"Not all my fault": genetics, stigma, and personal responsibility for women with eating disorders

Exploring perceptions of genetic risk and the transmission of substance use disorders

BACKGROUND

Substance use disorders (SUDs) have been consistently shown to exhibit moderate intergenerational continuity (1-3). While much research has examined genetic and social influences on addiction, less attention has been paid to clients' and lay persons' perceptions of genetic influences on the heritability of SUD (4) and implications for treatment.

METHODS

For this qualitative study, twenty-six structured Working Model of the Child Interviews (WMCI) were conducted with mothers receiving inpatient SUD treatment. These interviews were thematically analyzed for themes related to maternal perceptions around intergenerational transmission of substance use behaviours.

RESULTS

Findings show that over half of the mothers in this sample were preoccupied with their children's risk factors for addictions. Among this group, 29% spontaneously expressed concerns about their children's genetic risk for addiction, 54% shared worries about their children's propensity for addiction without mentioning the word gene or genetic. Additionally, 37% had challenges in even discussing their children's future when prompted. These concerns mapped onto internal working models of attachment in unexpected ways, with parents who were coded with balanced working models being more likely to discuss intergenerational risk factors and parents with disengaged working models displaying difficulties in discussing their child's future.

CONCLUSION

This research suggests that the dominant discourse around the brain-disease model of addictions, in its effort to reduce stigma and self-blame, may have unintended downstream consequences for parents' mental models about their children's risks for future addiction. Parents receiving SUD treatment, and the staff who deliver it, may benefit from psychoeducation about the intergenerational transmission of SUD as part of treatment.

Stigma of Binge-Eating Disorder in Hong Kong Chinese Adults: Effects of Weight Status, Diagnostic Labeling, and Etiological Explanations

OBJECTIVE

Binge-eating disorder (BED) is a strongly stigmatized condition and is often complicated by weight stigma. Research on the intersection between BED and weight stigma is scarce especially in Chinese populations. The present study examined BED stigma in Chinese, whether BED stigma was independent from weight stigma, and whether diagnostic labeling and etiological explanations influenced the degree of BED stigma.

METHOD

Using a between-subject experimental vignette study, 642 participants (mean age = 29.74 years, SD = 11.34) were randomly assigned to read one of the 18 vignettes, describing a character with information on BED symptoms, weight status, diagnostic labeling, and etiological explanations, followed by measures of stigma and help-seeking intentions.

RESULTS

The character with BED symptoms was ascribed more negative personality characteristics, elicited more negative affective reactions, and triggered greater desired social distance compared to the character without BED symptoms. No evidence for weight stigma was found nor for its interaction with BED stigma. The Cantonese diagnostic label of BED, kwong sik zing, was associated with lower levels of volitional stigma and greater help-seeking intentions than the diagnostic label of eating disorders, jam sik sat tiu, and the absence of labeling. The effect of etiological explanations was only significant in the univariate test, indicating that providing either a psychosocial or a biogenetic etiological explanation lessened the negative evaluations of personality characteristics.

DISCUSSION

The present study provided first evidence for BED stigma in Chinese. BED stigma appeared to be attributable to the presence of disordered eating behavior rather than the BED diagnosis.

Teaching gene-environment interaction concepts with narrative vignettes: Effects on knowledge, stigma, and behavior motivation

Gene-environment interaction (GxE) concepts underlie a proper understanding of complex disease risk and risk-reducing behavior. Communicating GxE concepts is a challenge. This study designed an educational intervention that communicated GxE concepts in the context of eating behavior and its impact on weight, and tested its efficacy in changing knowledge, stigma, and behavior motivation. The study also explored whether different framings of GxE education and matching frames with individual eating tendencies would result in stronger intervention impact. The experiment included four GxE education conditions and a control condition unrelated to GxE concepts. In the education conditions, participants watched a video introducing GxE concepts then one of four narrative vignettes depicting how a character's experience with eating hyperpalatable or bitter tasting food (reward-based eating drive vs. bitter taste perception scenario) is influenced by genetic or environmental variations (genetic vs. environmental framings). The education intervention increased GxE knowledge, genetic causal attributions, and empathetic concern. Mediation analyses suggest that causal attributions, particularly to genetics and willpower, are key factors that drive downstream stigma and eating behavior outcomes and could be targeted in future interventions. Tailoring GxE education frames to individual traits may lead to more meaningful outcomes. For example, genetic (vs. environmental) framed GxE education may reduce stigma toward individuals with certain eating tendencies among individuals without such tendencies. GxE education interventions would be most likely to achieve desired outcomes such as reducing stigma if they target certain causal beliefs and are strategically tailored to individual attributes.

Public perceptions of people with eating disorders: Commentary on results from the 2022 Australian national survey of mental health-related stigma and discrimination

Mental illness is highly prevalent in the community. As such, significant attention has been paid in recent years to raising awareness of the mental health disorders (including eating disorders). This includes efforts to normalise help-seeking, campaigns to reduce stigma and discrimination, targeted research funding and advocacy for improved and accessible mental health service provision. But have these initiatives changed public attitude? The 2022 National Survey of Mental Health-Related Stigma and Discrimination is the first of four national surveys canvassing the general public's perceptions of people with mental health disorders (including stigmatising and discriminatory beliefs) conducted since 1995 to include eating disorders. It finds significant prejudice against those with mental health disorders still exists within the community, particularly among younger Australians. For eating disorders, this is primarily related to attributions of blame and personal weakness. Findings from the survey are discussed in this commentary.

White as milk: Biocentric bias in the framing of lactose intolerance and lactase persistence

The majority of the world population is lactose intolerant, as 65%-70% of people lose the enzymes to digest lactose after infancy. Yet, in the United States, where lactose intolerance is predicted to affect only 36% of people, this phenomenon is often framed as a deficiency as opposed to the norm. This is because the United States has a higher prevalence of people who are lactase persistent. Lactase persistence is a genetic trait most common among Europeans and some African, Middle Eastern and southern Asian groups with a history of animal domestication and milk consumption. In this study, we take the case of lactose intolerance to examine how popular media maintains biocentric biases. Analysing relevant articles published in The New York Times and Scientific American between 1971 and 2020, we document how ideas about milk, health and race evolve over time. Over this fifty-year period, writers shifted from framing lactose intolerance as racial difference to lactase persistence as evolutionary genetics. Yet, articles on the osteoporosis 'epidemic' and vitamin D deficiency worked to perpetuate lactose intolerance as a health concern and standardise the dairy-heavy American diet. Studying media portrayals of lactose intolerance and lactase persistence, we argue that popular discourses normalise biocentric biases through messages about eating behaviours and health.

Ethical concerns relating to genetic risk scores for suicide

Genome-wide association studies (GWAS) provide valuable information in research contexts regarding genomic changes that contribute to risks for complex psychiatric conditions like major depressive disorder. GWAS results can be used to calculate polygenic risk scores (PRS) for psychiatric conditions, such as bipolar disorder or schizophrenia, as well as for other traits, such as obesity or hypertension. Private companies that provide direct-to-consumer (DTC) genetic testing sometimes report PRS for a variety of traits. Recently, the first well-powered GWAS study for suicide death was published. PRS reports that claim to assess suicide risk are therefore likely to appear soon in the DTC setting. We describe ethical concerns regarding the commercial use of GWAS results related to suicide. We identify several issues that must be addressed before PRS for suicide risk is made available to the public through DTC: (a) the potential for misinterpretation of results, (b) consumers' perceptions about determinism and behavior change, (c) potential contributions to stigma, discrimination, and health disparities; and (d) ethical problems regarding the testing of children and vulnerable adults. Tests for genetic prediction of suicidality may eventually have clinical significance, but until then, the potential for individual and public harm significantly outweighs any potential benefit. Even if genetic prediction of suicidality improves significantly, information about genetic risk scores must be distributed cautiously, with genetic counseling, and with adequate safeguards.

Healthcare providers' engagement with eating disorder recovery narratives: opening to complexity and diversity

Interdisciplinary healthcare providers (HCPs) receive only minimal training in identifying, referring for and treating eating disorders and may feel ill-prepared to manage them. There is a need for brief interventions that prepare HCPs for work with people with eating disorders, particularly when they do not fit stereotypes about who might experience an eating disorder. One method for enacting brief interventions that make change in this realm is using digital stories (short videos) to generate awareness and knowledge. In this article, we discuss the results of a pilot study exploring the impact of viewing digital stories created by people in eating disorder recovery and their supporters on an interdisciplinary group of HCPs. We showed five stories to 22 HCPs who filled out qualitative prequestionnaires and postquestionnaires about their experiences of viewing the films and how they conceptualised recovery. Providers found the stories evocative; the stories appear to have complexified their perspectives on recovery. HCPs desired more diverse, detailed and lengthy stories, indicating that pursuing digital storytelling for HCP education and awareness may hold promise. Through centring the voices of people with eating disorders and in recovery, digital stories may also provide new ways of talking about recovery that open up possibilities for embracing difference.

Using Network Theory for Psychoeducation in Eating Disorders

Background

Negative illness representations such as self-blame impede treatment-seeking behavior and therapy motivation in individuals with eating disorders (EDs). However, only one study so far has investigated how different explanatory models influence these beliefs in EDs. We aimed to expand these findings by introducing an explanatory model based on network theory (NT).

Methods

We presented three explanatory models to a diverse web-recruited sample (n = 290, 141 females, 149 males) with clinically elevated ED symptomatology. Participants either watched a video with a biological-genetic (BG), cognitive-behavioral (CB) or an NT explanatory model and were asked about illness representations before and after watching the video.

Results

The BG group showed significantly greater reductions in self-blame but a significant decrease in personal control and less optimistic expectation regarding timeline compared to the CB and NT groups. There were no group differences regarding the perception of the clinician, comprehensibility of the explanatory model and credibility of a CBT intervention.

Conclusions

Given the increasing popularity of biological-genetic explanatory models of EDs, it is important to note the disadvantages we found to be associated with these models. Our findings indicate that explanatory models emphasizing cognitive-behavioral (CB) principles and/or network theoretical (NT) underpinnings of EDs may serve to promote optimism and greater perceptions of personal agency in affected populations.

This trial's registration number is 316.

Online imagery rescripting among young women at risk of developing an eating disorder: A randomized controlled trial

OBJECTIVE

This study compared the effectiveness of two approaches to imagery rescripting (body versus general) among young women with an elevated risk of developing an eating disorder.

METHOD

University students (N = 130 females) were randomly assigned to one of the four conditions: body or general imagery rescripting, psychoeducation, control. After initial brief laboratory training delivered online, participants in the imagery rescripting conditions were asked to practice imagery rescripting for 5 min each day for a week. Primary (global eating psychopathology, eating disorder behaviors, and body image acceptance) and secondary outcomes (self-compassion, fear of self-compassion, and dysfunctional attitudes) were measured at baseline and one-week follow up.

RESULTS

Completer analyses showed both imagery rescripting conditions and psychoeducation had significant impact on global eating psychopathology and body acceptance (d = 0.60-0.78). Psychoeducation did not impact secondary variables, whereas body imagery rescripting improved self-compassion and fear of self-compassion (d = 0.61-0.80) and general imagery rescripting improved dysfunctional attitudes (d = 0.82) compared to control. Intent to treat analyses had similar but slightly less robust results.

DISCUSSION

While three active groups had significant impact on the primary variables, imagery rescripting approaches had impact on other variables that maintain disordered eating. Future research should investigate the impact of combining psychoeducation and imagery rescripting in terms of impact on disordered eating.

Revisiting the relationship between perceived discrimination and health: Evidence from sibling models with multiple health measures

Perceived discrimination (PD) is known to be significantly related to health outcomes. This link, however, warrants further scrutiny due to the possibility of unobserved family-level confounding. Using the Add Health and sibling fixed-effect approach, we examine whether the relationship between PD and health is confounded by family background characteristics such as genetics, family environment, and childhood social context (school and neighborhood effects). While the naive OLS models exhibit significant associations between PD and both physical and psychological health outcomes, our preferred sibling fixed-effect estimates reveal that the observed associations between PD and physical health outcomes are confounded by shared family background. In contrast, the observed associations for psychological health, self-reported health, and some of health behavior outcomes are robust to adjustment for sibling fixed-effects. Furthermore, we find similar overall patterns in the link between PD and health across races/ethnicities.

Expanding boundaries in psychiatry: uncertainty in the context of diagnosis-seeking and negotiation

Psychiatric diagnosis has become pervasive in modern culture, exerting an increasing influence on notions of personhood, identity practices and forms of self-governing. The broadening of diagnostic categories and increasing awareness regarding popular diagnostic categories has led to an increased demand for formal diagnosis within clinical encounters. However, there is continuing 'epistemological uncertainty' (Fox 2000) surrounding these entities, in part due to their lack of associated clinical biomarkers and their 'fuzzy boundaries'. Meanwhile, this diagnostic expansion has encountered resistance from those concerned with the alleged 'over-pathologisation' of emotional distress. Drawing upon the concepts of 'diagnostic cultures' (Brinkmann 2016) and the 'looping effects of human kinds' (Hacking 1995), this article considers some of the competing forces acting upon the contested boundaries of diagnostic categories as they play out within diagnostic interactions. The study involved ethnographic observations of diagnostic encounters within several UK-based mental health clinics. By focusing on interactions where diagnosis is negotiated, findings illustrate the role played by different kinds of diagnostic uncertainty in shaping these negotiations. It is argued that diagnostic reification plays a key role in the moral categorisation of patients, particularly where there is uncertainty regarding individual diagnostic status.

Understanding and managing uncertainty in health care: revisiting and advancing sociological contributions

In this collection we revisit the enduring phenomenon of uncertainty in health care, and demonstrate how it still offers coherence and significance as an analytic concept. Through empirical studies of contemporary examples of health care related uncertainties and their management, our collection explores the different ways in which uncertainty may be articulated, enacted and experienced. The papers address a diverse range of healthcare contexts - Alzheimer's disease, neonatal surgery, cardiovascular disease prevention, cancer, addiction (use of alcohol and other drugs during pregnancy), mental health/disorders and medical education - and many tackle issues of contemporary relevance, such as an ageing population, and novel medical interventions and their sequelae. These empirical papers are complemented by a further theoretical contribution, which considers the role of 'implicit normativity' in masking and containing potential ethical uncertainty. By mapping themes across the collection, in this introduction we present a number of core analytical strands: (1) conceptualising uncertainty; (2) intersections of uncertainty with aspects of care; (3) managing uncertainty; and (4) structural constraints, economic austerity and uncertainty work. We reflect on the methodological and theoretical stances used to think sociologically about uncertainty in health care, and the strengths, silences and gaps we observe in the collection. We conclude by considering the implications of the insights gained for 'synthesising certainty' in practice and for future research in this area.

Psychological correlates of biological and non-biological explanations for stuttering

Purpose: This study examined whether people who stutter would associate biological and non-biological explanations of stuttering with the endorsement of stereotypes about people who stutter, prognostic expectations for the reduction of stuttering, feelings of guilt, self-blame, and shame about stuttering, and agency for speech modification.Method: This was a cross-sectional study including 372 adults who stutter. Participants completed a web survey with scales that measured their agreement with biological and non-biological models of stuttering; their endorsement of common stereotypes for people who stutter; prognostic expectations for reduced stuttering; feelings of guilt, self-blame, and shame about stuttering; and feelings of agency in their ability to modify their speech.Result: Biological explanations for stuttering were significantly correlated with reduced stereotype endorsement about people who stutter, lower prognostic expectations for reducing stuttering, and reduced feelings of guilt and self-blame regarding stuttering. Non-biological explanations for stuttering were significantly correlated with increased endorsement of negative stereotypes about people who stutter, increased prognostic expectations for reducing stuttering, and increased feelings of guilt, self-blame, and shame about stuttering.Conclusion: It is concluded that the implications of biological framing of stuttering among people who stutter are complex and should be well thought out by professionals. Explaining stuttering as biological, but responsive to personal and environmental influences, may lead to reduced guilt and self-blame, while at the same time fostering feelings of agency for speech modification.

Eating disorders "mental health literacy": a scoping review

Background: While it is apparent that much has been learned about "mental health literacy" (MHL) relating to certain mental health problems, such as depression, in recent years, what has been learned about MHL relating to eating disorders (ED-MHL) is unclear.Aims: A scoping review was conducted to inform the current state of knowledge in this field.Methods: A systematic search of relevant literature published between 1997 and 2017 was followed by a narrative synthesis of the findings.Results: The number of eligible studies increased from 32 in 1997-2001 to 98 in 2012-2017 (total = 264). Most studies originated from North America or Europe, recruited individuals with EDs receiving treatment or college students and included both female and male or only female participants. The majority of studies examined MHL relating to anorexia nervosa or bulimia nervosa and examined attitudes which facilitate recognition and appropriate help-seeking and knowledge and beliefs about professional help available.Conclusion: Interest in ED-MHL is increasing and there is now a considerable body of research addressing some aspects of ED-MHL in a range of study populations. Notable gaps in the literature exist, including a paucity of information about ED-MHL relating to EDs other than anorexia nervosa and bulimia nervosa, ED behaviour in males and the use of self-help interventions. We hope the findings will provide an incentive to further research in these and other aspects of ED-MHL.

COVID19, the pandemic which may exemplify a need for harm-reduction approaches to eating disorders: a reflection from a person living with an eating disorder

This reflective piece, written by a woman with an eating disorder aims to identify the impact of COVID-19 on persons living with eating disorders and provide a social justice approach as a resolution. The author identifies that eating disorder behaviors may be the only coping tool available for many persons with eating disorders during this time of uncertainty. While she acknowledges the risks associated with eating disorder behaviors, she identifies that this time of uncertainty may be a time to embrace harm-reduction in approaching the health and wellness of persons with eating disorders.

Eating Disorder Recovery: A Metaethnography

BACKGROUND: Eating disorders seriously affect both physical health and psychosocial functioning. Breaking the confines of an eating disorder requires engagement in a multifaceted recovery process. OBJECTIVE: This article provides a synthesis of 12 qualitative research studies with various eating disordered populations (anorexia nervosa, bulimia nervosa, binge eating disorder, eating disorder not otherwise specified, and other specified feeding and eating disorders) to elucidate the recovery process from the perspective of those who have overcome the disease. METHOD: A metasynthesis of qualitative studies was conducted using Noblit and Hare's metaethnographic methodology. RESULTS: Five overarching themes emerged from the data: (1) the eating disorder as a life jacket, (2) drowning: recognizing consequences, (3) treading the surface: contemplating recovery, (4) swimming: the path toward recovery, and (5) reaching recovery: a sense of freedom. CONCLUSIONS: Eating disorder treatment often entails a cycle of transitions before recovery occurs. Synthesizing the experiences from the perspective of individuals who have overcome an eating disorder presents a unique understanding of the treatment and recovery process.

The ethics of global psychiatric genomics: Multilayered challenges to integrating genomics in global mental health and disability-A position paper of the Oxford Global Initiative in Neuropsychiatric GenEthics (NeuroGenE)

Psychiatric genomics has the potential to radically improve the prevention and early intervention of serious mental and neurodevelopmental disorders worldwide. However, little work has been done on the ethics of psychiatric genomics-an oversight that could result in poor local uptake, reduced practical/clinical application, and ethical violations in this rapidly developing area of scientific research. As part of the Global Project of the Stanley Center for Psychiatric Research, the Global Initiative in Neuropsychiatric GenEthics (NeuroGenE) based at the University of Oxford aims to embed ethical inquiry within scientific investigation and engage with fundamental ethical questions around a psychiatric genomics approach to mental and neurodevelopmental disorder. This position paper sets out the core aims of the NeuroGenE research programme and explores the importance of a crosscutting research orientation in this field based on multidisciplinary methodologies which can ensure that efforts to translate and apply global psychiatric genomics in public policy and clinical practice are ethically grounded strategies, respectful of different cultures and contexts.

How do people with eating disorders experience the stigma associated with their condition? A mixed-methods systematic review

BACKGROUND

Public opinion research shows that eating disorders (EDs) are a major target of stigmatisation. To understand the implications of this stigma, research investigating how stigma is experienced by individuals with EDs is critical.

AIM

This paper aims to collate, evaluate and synthesise the extant empirical research illuminating how people with EDs experience the stigma associated with their condition.

METHOD

A systematic mixed-methods literature search was performed. Articles that met a specified set of inclusion criteria underwent a quality assessment and thematic synthesis.

RESULTS

Twenty-nine articles were included in the review. Studies were mostly qualitative and of reasonable methodological quality. The literature was characterised by five research themes, illuminating (i) the nature and prevalence of stigma experienced, (ii) stigma in families, (iii) stigma in healthcare contexts, (iv) self-stigmatisation and illness concealment, and (v) stigma resistance.

CONCLUSIONS

The reviewed research showed that people with EDs have extensive experience of stigma in diverse settings. They report that stigma has negative implications for their psychological wellbeing and likelihood of help-seeking. However, research also shows that people with EDs actively seek to resist and challenge stigma. The review identifies the outstanding gaps and weaknesses in this literature.

Making a murderer: Media renderings of brain injury and Aaron Hernandez as a medical and sporting subject

This paper examines the entanglement of medicine, brain injury, and subjectivity within newspaper discourse and through the case of ex-American footballer Aaron Hernandez. In 2017, two years after being found guilty of murder and five years after scoring in the Super Bowl, Aaron Hernandez died by suicide in his prison cell. Hernandez was posthumously diagnosed with Chronic Traumatic Encephalopathy (CTE), a neurodegenerative disease associated with violence, depression, and dementia-like symptoms. I examine newspaper coverage of the Hernandez case, focusing upon the murder, arrests, conviction, suicide, and diagnosis of CTE in order to examine understandings of Hernandez's subjectivity. I make three conclusions: First, the disease is not mentioned prior to diagnosis with family instability, friendship groups, individual psychology, and the entitlement of celebrity foregrounded. Second, CTE is foregrounded after the diagnosis and is used to explain much of Hernandez's behaviour. Third, the diagnosis of CTE goes someway to normalizing the behaviour of Hernandez, rendering his behaviours comprehensible. I conclude by considering how the specific narrative of CTE-as-acquired-dementia shapes depictions of Hernandez's subjectivity and discuss how this case troubles existing literatures on the neurologization of selfhood.

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CTE is a neurodegenerative disease popularly associated with contact sport.

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Aaron Hernandez was convicted of murder, died by suicide, and diagnosed with CTE.

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Through media analysis, I ask if Hernandez's actions were seen as shaped by CTE.

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CTE is not mentioned prior to suicide and rarely prior to formal diagnosis.

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After diagnosis CTE is used to explain and normalize much of Hernandez's behaviour.

Does genetics matter for disease-related stigma? The impact of genetic attribution on stigma associated with rheumatic heart disease in the Western Cape, South Africa

INTRODUCTION

A common concern in African genomic research is that such work may cause, or increase, stigma associated with particular diseases or population groups. While there is some evidence suggesting that genetic attribution of disease might impact stigma, there exists no evidence for the situation in African populations. With increasing genomic research in African populations, questions about the effect of genetic attribution on disease-related stigma are salient for stakeholders involved in implementation and regulation. To understand better the relationship between stigma and genetic attribution, we interviewed people with Rheumatic Heart Disease (RHD) in the Western Cape of South Africa.

METHOD

We conducted 11 focus group discussions with RHD patients of mixed-ancestry in the Western Cape, exploring the impact of genetic attribution on stigma. Participants had previously consented to participate in genomic research, attending information sessions on genetics. We explored the impact of genetic attribution by introducing both genetic and environmental causes to RHD and by specifically probing how these various causes would likely impact selected features of disease stigma.

RESULTS

Participants reported varying experiences of stigma relating to RHD, such as labelling, social exclusion and discrimination at the workplace. They had some understanding of genetics, either in general, or in relation to their illness. Participants' understanding depicted multiple causal models to explain RHD including genetic, environmental and bacterial causation. Overall, participants did not make a connection between genetics as a cause of RHD and their experiences of stigma.

DISCUSSION

In this study we found no support for the concern that genetic attribution of RHD, understood by participants in our study as a genetic predisposition to developing the disease, would impact stigma associated with it. Our findings provide some reassurance that genomic research may be unlikely to cause an increase in disease-related stigma in the South African context.

The Role of Puberty and Ovarian Hormones in the Genetic Diathesis of Eating Disorders in Females

Puberty is a critical risk period for eating disorders (EDs). ED incidence increases across the pubertal period and becomes female predominant, and genetic influences on disordered eating significantly increase. Surges of ovarian hormones, particularly estrogen, may drive this increasing genetic effect for EDs in pubertal girls and contribute to differential phenotypic presentations beyond puberty. In this article, we explain phenotypic associations between puberty and disordered eating and present evidence showing underlying genetic and hormonal influence. Potential benefits of communicating roles of genetic influence to people with or at risk for EDs are also discussed.

Compulsory treatment in eating disorders: Control, provocation, and the coercion paradox

In eating disorders, the denial of the illness is a central phenomenon. In the most severe forms of anorexia, compulsory treatment may be necessary. The professional acceptance of involuntary treatment is controversial due to the fact that the autonomy of the patient is juxtaposed with the obligation of the health care practitioner to save lives. This paper discusses the major practical and ethical considerations surrounding this controversy. In addition, case vignettes are used to illustrate various strategies to diminish client resistance and enhance motivation toward treatment. Involving the family is nearly always essential for the treatment of patients with eating disorders. In some cases, parental consultation (i.e., treatment without the client) can also be an option. Home visits, though rarely used, can reframe the therapeutic relationship and provide information about family functioning. In general, a lower level of treatment coercion can be achieved through transparent client-parent and client-therapist communication.

Evaluating the effectiveness of an evidence-based online training program for health professionals in eating disorders

BACKGROUND

Early detection and treatment are essential to ensuring the best possible health outcomes for people with eating disorders (EDs). However, low diagnostic accuracy and a lack of specific ED training are common workforce challenges in Australia and internationally. Online learning provides a potential solution in facilitating the access to evidence-based training programs. The InsideOut Institute has developed the first online clinical training program in EDs to assist with educating health professionals in the identification, assessment, and management of EDs. The aim of the study is to evaluate the effectiveness of the online training program, The Essentials, in mitigating barriers to health professionals treating patients with EDs.

METHODS

Pre and post training questionnaires assessed participants' attitudes, knowledge, and skills in relation to treating people with EDs. Demographic and work-related information (gender, discipline, work setting, practice length and remoteness) and participants' ratings of the online learning experience and satisfaction on completion were collected. The Wilcoxon signed rank test was applied to test for changes in learning outcomes before and after completion of the program. A multivariate linear regression model was estimated for each of the learning outcomes with personal and work-related characteristics as covariates.

RESULTS

Among 1813 health professionals who registered for The Essentials program between 1 October 2013 and 31 July 2018, 1160 completed at least 80% of the five learning modules. There were significant improvements in confidence, knowledge, skills to treat EDs and a reduction in stigmatised beliefs among the 480 participants who completed both pre and post assessments. Results from the regression models suggest that psychologists, dieticians, and those working in rural areas were more willing to treat EDs after completing the program. Additionally, those working in hospitals and regional or rural areas experienced the largest improvement in confidence for treating patients with EDs.

CONCLUSIONS

The Essentials program represents a new and effective way of meeting the educational needs of partaking health professionals working with ED patients. Greater investment in the development and testing of evidence-based online training programs for EDs may help to address some of the considerable workforce development challenges in EDs.

Biomedical Explanations of Psychopathology and Their Implications for Attitudes and Beliefs About Mental Disorders

Mental disorders are increasingly conceptualized as biomedical diseases, explained as manifestations of genetic and neurobiological abnormalities. Here, we discuss changes in the dominant explanatory accounts of psychopathology that have occurred over time and the driving forces behind these shifts, lay out some real-world evidence for the increasing ascendancy of biomedical explanations, and provide an overview of the types of attitudes and beliefs that may be affected by them. We examine theoretical and conceptual models that are relevant to understanding how biomedical conceptualizations might affect attitudes and beliefs about mental disorders, and we review some empirical evidence that bears on this question. Finally, we examine possible strategies for combatting potential negative effects of biomedical explanations and discuss important conclusions and directions for future research.

A qualitative study: experiences of stigma by people with mental health problems

OBJECTIVES

Prior research has examined various components involved in the impact of public and internalized stigma on people with mental health problems. However, studies have not previously investigated the subjective experiences of mental health stigma by those affected in a non-statutory treatment-seeking population.

DESIGN

An in-depth qualitative study was conducted using thematic analysis to investigate the experiences of stigma in people with mental health problems.

METHODS

Eligible participants were recruited through a local mental health charity in the North West of England. The topic of stigma was examined using two focus groups of thirteen people with experience of mental health problems and stigma.

RESULTS

Two main themes and five subthemes were identified. Participants believed that (1) the 'hierarchy of labels' has a profound cyclical impact on several levels of society: people who experience mental health problems, their friends and family, and institutional stigma. Furthermore, participants suggested (2) ways in which they have developed psychological resilience towards mental health stigma.

CONCLUSIONS

It is essential to utilize the views and experiences gained in this study to aid understanding and, therefore, develop ways to reduce the negative impact of public and internal stigma.

PRACTITIONER POINTS

People referred to their mental health diagnosis as a label and associated that label with stigmatizing views. Promote awareness and develop improved strategies (e.g., training) to tackle the cyclical impact of the 'hierarchy of labels' on people with mental health problems, their friends and family, and institutional stigma. Ensure the implementation of clinical guidelines in providing peer support to help people to combat feeling stigmatized. Talking about mental health in psychological therapy or health care professional training helped people to take control and develop psychological resilience.

Feminist approaches to Anorexia Nervosa: a qualitative study of a treatment group

BACKGROUND

Eating disorders (EDs) are now often approached as biopsychosocial problems. But it has been suggested by scholars interested in sociocultural factors that all is not equal within this biospsychosocial framework, with the 'social' aspects of the equation relegated to secondary factors within ED treatment contexts. Although sociocultural influences are well-established as risk factors for EDs, the exploration of whether or how such perspectives are useful in treatment has been little explored. In responding to this context, this article seeks to discuss and evaluate a 10 week closed group intervention based on feminist approaches to EDs at a residential eating disorder clinic in the East of England.

METHODS

The data was collected via one-to-one qualitative interviews and then analysed using thematic discourse analysis.

RESULTS

The participants suggested that the groups were helpful in enabling them to situate their problem within a broader cultural and group context, that they could operate as a form of 'protection' from ideologies regarding femininity, and that a focus on the societal contexts for EDs could potentially reduce feelings of self-blame. At the same time, the research pointed to the complexities of participants considering societal rather than individualised explanations for their problems, whilst it also confronted the implications of ambivalent responses toward feminism.

CONCLUSIONS

Highly visible sociocultural factors in EDs - such as gender - may often be overlooked in ED clinical contexts. Although based on limited data, this research raises questions about the marginalisation of sociocultural factors in treatment, and the benefits and challenges including the latter may involve.

Genetics of Anorexia Nervosa

PURPOSE OF REVIEW

Genetic factors contribute to the etiology of anorexia nervosa (AN). This review synthesizes the current state of knowledge about the genetic etiology of AN, provides directions for future research, and discusses clinical implications for this research.

RECENT FINDINGS

Candidate gene meta-analyses indicate serotonin genes may be involved in the genetic etiology of AN. Three genome-wide association studies have been conducted and one genome-wide significant locus was identified. Cross-disorder analyses suggest shared genetic risk between AN and several psychiatric, educational, and medical phenotypes. Much has been learned about the genetic etiology of AN over the past 3 decades. However, to fully understand the genetic architecture, we must consider all aspects including common variation, cross-disorder analysis, rare variation, copy number variation, and gene-environment interplay. Findings have important implications for the development of treatment and prevention approaches and for how AN, and psychiatric and medical diseases in general, are conceptualized.

Psychiatric Genomics and Mental Health Treatment: Setting the Ethical Agenda

Realizing the benefits of translating psychiatric genomics research into mental health care is not straightforward. The translation process gives rise to ethical challenges that are distinctive from challenges posed within psychiatric genomics research itself, or that form part of the delivery of clinical psychiatric genetics services. This article outlines and considers three distinct ethical concerns posed by the process of translating genomic research into frontline psychiatric practice and policy making. First, the genetic essentialism that is commonly associated with the genomics revolution in health care might inadvertently exacerbate stigma towards people with mental disorders. Secondly, the promises of genomic medicine advance a narrative of individual empowerment. This narrative could promote a fatalism towards patients' biology in ways that function in practice to undermine patients' agency and autonomy, or, alternatively, a heightened sense of subjective genetic responsibility could become embedded within mental health services that leads to psychosocial therapeutic approaches and the clinician-patient therapeutic alliance being undermined. Finally, adopting a genomics-focused approach to public mental health risks shifting attention away from the complex causal relationships between inequitable socio-economic, political, and cultural structures and negative mental health outcomes. The article concludes by outlining a number of potential pathways for future ethics research that emphasizes the importance of examining appropriate translation mechanisms, the complementarity between genetic and psychosocial models of mental disorder, the implications of genomic information for the clinician-patient relationship, and funding priorities and resource allocation decision making in mental health.

Interventions to reduce the stigma of eating disorders: A systematic review and meta-analysis

Stigma is a problem for individuals with eating disorders (EDs), forming a barrier to disclosure and help-seeking. Interventions to reduce ED stigma may help remove these barriers; however, it is not known which strategies (e.g., explaining etiology to reduce blame, contact with a person with an ED, or educating about ED) are effective in reducing stigma and related outcomes. This review described effectiveness of intervention strategies, and identified gaps in the literature. A search of four databases was performed using the terms (eating disorder* OR bulimi* OR anorexi* OR binge-eating disorder) AND (stigma* OR stereotyp* OR beliefs OR negative attitudes) AND (program OR experiment OR intervention OR education), with additional texts sought through LISTSERVs. Two raters screened papers, extracted data, and assessed quality. Stigma reduction strategies and study characteristics were examined in critical narrative synthesis. Exploratory meta-analysis compared the effects of biological and sociocultural explanations of EDs on attitudinal stigma. Eighteen papers were eligible for narrative synthesis, with four also eligible for inclusion in a meta-analysis. Biological explanations reduced stigma relative to other explanations, including sociocultural explanations in meta-analysis (g = .47, p < .001). Combined education and contact interventions improved stigma relative to control groups or over time. Most studies examined Anorexia Nervosa (AN) stigma and had mostly female, undergraduate participants. Despite apparent effectiveness, research should verify that biological explanations do not cause unintentional harm. Future research should evaluate in vivo contact, directly compare education and contact strategies, and aim to generalize findings across community populations.

Stigmatizing Attitudes and Beliefs About Anorexia and Bulimia Nervosa Among Italian Undergraduates

Stigmatizing attitudes toward eating disorders (EDs) may lead to reduced treatment seeking. We aimed to estimate the prevalence of stigmatizing trends and beliefs related to anorexia nervosa (AN) and bulimia nervosa (BN), and the associations with the experiential knowledge of the problem, in a large sample of Italian undergraduates. A total of 2109 participants completed an online survey including questionnaires related to stigmatizing beliefs toward AN and BN, and personal contacts with people with EDs. Undergraduates reported almost overlapping low levels of stigmatizing trends for AN and BN, apart from personal responsibility and social distance. Those aged 18 to 25 and living with family held higher stigmatizing attitudes. Stigma was lower in underweight participants and in those (12%) reporting a previous ED diagnosis. Although not improving stigmatizing attitudes, 83% of the sample was familiar with people with an ED. Antistigma actions to increase awareness on EDs and to improve treatment-seeking behaviors are needed.

Genetic explanations, discrimination and chronic illness: A qualitative study on hereditary haemochromatosis in Germany

OBJECTIVE

The objective of this study is to explore the discriminatory impacts of genetic diagnosis for people living with the chronic illness of hereditary haemochromatosis in Germany.

METHODS

Semi-structured interviews with 15 patients; all had tested positive for a genetic mutation associated with haemochromatosis and already displayed symptoms of the disease. Inductive approach, with interviews collaboratively interpreted by the research group in a vertical and horizontal analysis informed by a multi-person perspective.

RESULTS

First, as the genetic diagnosis of the disease holds the promise of therapeutic intervention, the interviewees perceived it as leading to relief. Second, the interviewees felt stigmatized by their family members, they complained of social isolation and a lack of acknowledgement of their health problems. Third, they feared disadvantages for themselves or their children at their place of work, when buying insurance coverage, and when attempting to donate blood.

DISCUSSION

The findings point to the need for an expanded view on genetic discrimination. Besides institutional discrimination, it appears necessary to systematically address interactional stigmatization and take anxieties and fears into account. Here we see starting points for providing essential support through specialist and self-help groups to those faced with the genetic diagnosis of haemochromatosis in addition to and beyond the legal protection against genetic discrimination that already exists.

The Effects of Stigma on Recovery Attitudes in People With Anorexia Nervosa in Intensive Treatment

Self-stigma in individuals with anorexia nervosa (AN) may affect engagement in intensive treatment. The objective of this study was to test a Model of Self-Stigma to identify the influence of public stigma, internalized stigma, self-esteem, and self-efficacy on recovery attitudes in individuals in inpatient treatment for AN. Using a cross-sectional design, 36 female participants with AN completed questionnaires during the first week of intensive inpatient treatment. Better attitude towards recovery was positively correlated with higher self-esteem and self-efficacy and negatively correlated with greater internalized stigma and perceptions of others devaluing families of individuals with AN. Together, these factors accounted for 63% of the variance in recovery attitudes. Findings demonstrate the adverse effects perceived stigma towards families, self-stigma, and self-esteem have on recovery attitudes in individuals with AN. Clinical interventions are needed to challenge internalized stigma and bolster self-esteem to enhance individuals' recovery efforts.

Drawing on Accounts of Long-Term Urinary Catheter Use: Design for the "Seemingly Mundane"

The design of the Foley catheter has not changed since 1937. Scientists interested in medical technology tend to focus on state-of-the-art designs for newsworthy specialties rather than the more mundane technologies of daily life. We interviewed 36 people living with a long-term urinary catheter in the United Kingdom, who described limitations of the current catheter design, including infections and complications and consequences for social life and relationships, and their perceptions of whose responsibility it was to improve the design. All took steps to hide the urine bag, but the need to use a catheter and urine bag had, for some, a very detrimental effect on social life and relationships. People living with long-term catheters are relatively isolated at home and dealing with many different underlying health problems, undermining opportunities to speak with a collective patient voice. Qualitative health researchers could act as a conduit to help stimulate new designs.

Stigma and treatment of eating disorders in Ireland: healthcare professionals’ knowledge and attitudes

Objectives

This study examines aspects of healthcare professionals’ knowledge and attitudes about eating disorders (EDs), which might impede the effective detection or treatment of EDs in Ireland.

Methods

A total of 1,916 healthcare professionals were invited to participate in a web-based survey. Participants were randomly allocated to view one of five vignettes depicting a young person with symptoms consistent with anorexia nervosa, bulimia nervosa, binge-eating disorder, depression or type 1 diabetes. Study-specific questions examined participants’ responses to the vignettes and ED knowledge and experience.

Results

In total, 171 clinicians responded (9% response rate). Participants had an average of 15.8 years of clinical experience (s.d.=9.2) and included psychiatrists, GPs, psychologists and counsellors. Although participants’ knowledge of EDs was moderately good overall, responses showed poor recognition of the symptoms of EDs compared with depression [χ2 (4, n=127)=20.17, p<0.001]. Participants viewed EDs as chronic disorders that primarily affected females. Participants believed that clinicians like working with patients with depression and diabetes more than with AN patients [F (4,101)=5.11, p=0.001]. Among the professionals surveyed, psychiatrists were the most knowledgeable about EDs [F (4,82)=9.18, p<0.001], and were more confident in their ability to diagnose and treat EDs than professionals of all other disciplines, except psychologists [F (4,85)=8.99, p<0.001]. Psychiatrists were also the most pessimistic about ED patients’ long-term life prospects [χ2 (4, n=65)=15.84, p=0.003].

Conclusions

This study recommends that specific attention should be given to EDs in professional educational programmes across healthcare disciplines. This training should not be restricted to improving healthcare professionals’ knowledge of EDs, but should also strive to increase service-providers’ awareness of how their own potentially stigmatising attitudes can undermine engagement with treatment.

Educating medical students about anorexia nervosa: a potential method for reducing the volitional stigma associated with the disorder

It is frequently reported that clinicians across a range of professional disciplines experience strong negative reactions toward patients with anorexia nervosa (AN). The present study aimed to develop, evaluate, and compare the effectiveness of two different educational programs, based on an etiological framing model. Participants were medical students (N = 41) from an Australian University, who were randomly assigned to one of three conditions (biogenetic intervention vs. multifactorial intervention vs. control). Outcome attitudinal/stigma data were collected pre- and post-intervention, and at 8 weeks follow-up. Results indicated intervention participations exhibited significantly lower volitional stigma scores compared to the control group, who exhibited no change in attitudes or stigma. Specifically, intervention participants had significantly lower total ED stigma scores, levels of blame, perceptions of AN as a selfish/vain illness, and viewed sufferers as less responsible for their illness at post-intervention. These reductions were maintained at follow-up. Overall, the study provides preliminary evidence that brief targeted interventions can assist in reducing levels of volitional stigma toward AN.

Sex differences in attitudes towards females with eating disorders

BACKGROUND

This study aims to examine the public's attitudes and predictors of social distance towards women afflicted by eating disorders (anorexia nervosa [AN] and bulimia nervosa [BN]) under specific consideration of the respondents' sex. Eating disorders are still often seen as a women's health issue, and those afflicted remain stigmatized in Western societies. The concept of social distance is a frequently used indicator in awareness campaigns. Sex-specific results could add important information to destigmatization programs.

METHODS

Data originate from a German telephone survey which was conducted in 2011. Vignettes with signs and symptoms either suggestive of AN or BN were presented to the respondents randomly, who subsequently answered questions regarding beliefs about causes, contact to persons afflicted as well as desire for social distance. Stratified multiple linear regression analyses according to disorder under study were performed to examine associations between different predictors and desire for social distance.

RESULTS

There were significant sex differences in desire for social distance, causal attributions, and emotional reactions towards women with eating disorders. E.g., with respect to AN, women exhibited a significantly greater desire for social distance than men (p<.001), and more frequently believed that AN could be caused by sexual abuse during childhood. Regarding predictors of social distance, there was a significant positive association between age and desire for social distance equally among men and women. However, distinct sex differences came into effect concerning other predictors depending on the eating disorder under study. In BN, attribution of brain disease emerged as significant predictor of social distance among men. This is not true for women, where the attribution of weak will significantly predicted the desire for social distance.

CONCLUSION

Sex-dependent differences in attitudes and predictors of social distance towards females afflicted should be met with tailored measures in anti-stigma campaigns, addressing women and men on different levels.

Perceptions of the causes of eating disorders: a comparison of individuals with and without eating disorders

BACKGROUND

In this study, we examined perceptions regarding the causes of eating disorders, both among those with eating disorders as well as those without. By understanding the differences in perceived causes between the two groups, better educational programs for lay people and those suffering from eating disorders can be developed.

METHOD

This study used open-ended questions to assess the beliefs of 57 individuals with self-reported eating disorders and 220 without. Participants responded to the questions, "What do you think was (were) the cause(s) of your eating disorder?" and "What do you think is (are) the cause(s) of eating disorders?".

RESULTS

A list of possible codes for the causes of eating disorders was created based on a thorough review of the literature. A manually-generated set of eight codes was then created from individuals' actual responses. Frequencies and chi square analyses demonstrated differences in rates of endorsement between those with eating disorders and those without. Participants with eating disorders most frequently endorsed psychological/emotional and social problems, with genetics/biology and media/culture ideals least endorsed. Participants without eating disorders most frequently endorsed psychological/emotional problems and media/culture ideals, with traumatic life events and sports/health least endorsed. There was a difference between groups in the endorsement of the media as a cause of eating disorders, suggesting that those without eating disorders may overly attribute the media as the main cause while those with eating disorders may not be fully aware of the media's impact. Additionally, while both groups highly endorsed psychological/emotional problems, there was a noticeable stigma about eating disorders among those without eating disorders.

CONCLUSIONS

There were noteworthy differences between samples; such differences suggest that there is a need for more education on the topic of eating disorders. Furthermore, despite empirical support for the effects of genetics, sports, and family factors, these were infrequently endorsed as causes of eating disorders by both groups. Our results suggest that there is a need for more education regarding the factors associated with eating disorders, in order to reduce the stigma surrounding these disorders and to potentially aid the treatment process.

Interpreting genetics in the context of eating disorders: evidence of disease, not diversity

How is genetic involvement interpreted for disorders whose medicalisation is contested? Framing psychiatric and behavioural disorders in terms of genetics is expected to make them seem more medical. Yet a genetic aetiology can also be used to frame behaviour as acceptable human variation, rather than a medical problem (for example, sexual orientation). I analyse responses to the idea that there is a genetic component in anorexia and bulimia nervosa (AN or BN) via semi-structured interviews with a sample of 50 women diagnosed with an eating disorder (25 had recovered). All but three volunteered that genetics would medicalise AN or BN by (i) making eating disorders seem more like 'real diseases'; implying that these disorders need (ii) professional treatment or (iii) a biologically based treatment. The results also indicate there are several counter-logics by which genetic framing could support non-medical definitions of AN or BN. I argue that genetic framing reduces perceived individual responsibility, which can support definitions of behaviour as either a reflection of disease (which entails intervention) or a reflection of normal human diversity (which does not). In the context of public scepticism as to the 'reality' of AN or BN, genetic involvement was taken as evidence of disease in ongoing negotiations about the medical and moral status of people with eating disorders.

The ethics of neuromodulation for anorexia nervosa: a focus on rTMS

OBJECTIVE

Recently there has been emerging clinical and research interest in the application of deep brain stimulation (DBS) and repetitive transcranial magnetic stimulation (rTMS) to the treatment of anorexia nervosa (AN). To our knowledge, few studies have discussed ethical aspects associated with the increased use of neuromodulation in AN, some of which are quite specific to AN, despite the rapid development and dissemination of these new technologies.

METHOD

We provide a brief overview of three published rTMS studies for AN and discuss ethical issues involved in the use of neuromodulation for AN.

RESULTS

In contrast to neurosurgery or DBS, rTMS is a less invasive technique, with less associated risk, and thus has greater potential to become a more widespread augmentation or add-on therapy for AN. New therapeutic procedures are promising, yet they raise ethical questions regarding informed consent and patient selection. Illness-specific issues surrounding authenticity and autonomy are important to consider, ensuring an ethical approach to treatment for patients with AN.

DISCUSSION

We argue that ethical investigations for neuromodulation techniques are timely and important, and discussions should go beyond the immediate goals of patient safety, consent, and risk and benefit, to consider broader ethical concepts such as authenticity and autonomy.