Features and Symptoms: Impulsivity, Compulsivity, Ambivalence and Body Dissatisfaction

**3**

**Chapter 1**

**Abstract**

Perspective

impulsivity, compulsivity

**1. Introduction**

*Samantha Jane Brooks and Helgi Schiöth*

a model of appetite restraint to improve treatment interventions.

**Keywords:** RDoC, cognitive systems, anorexia nervosa, appetite restraint,

The Diagnostic and Statistical Manual version 5 (DSM-5), published in 2013 after a decade of edition 4, has progressed nomenclature for the psychiatric eating disorder anorexia nervosa (AN), according to three main criteria, focusing on the behaviours and cognitions underlying weight restriction and body perception [1]. Moreover, while continuing to be categorical in scope, the DSM-5 also recognises the transdiagnostic nature of AN, with the inclusion of body mass index (BMI) severity clauses: mild,

Impulsivity and Compulsivity

in Anorexia Nervosa: Cognitive

Systems Underlying Variation in

Appetite Restraint from an RDoC

Contemporary nomenclature for anorexia nervosa (AN) describes the eating disorder as transdiagnostic, with overlapping facets of impulsivity and compulsivity contributing to variations in binge-purge, restrictive eating and maladaptive cognitions. It is important to understand how these facets interact, given that those diagnosed with AN often fluctuate and relapse–as opposed to maintaining a stable diagnosis—between Diagnostic and Statistical Manual version 5 (DSM-5) categories, over the life course. The National Institute of Health's Research Domain Criteria (NIH RDoC) subscribes to the transdiagnostic view of mental disorders and provides progressive guidelines for neuroscience research. As such, using the RDoC guidelines may help to pinpoint how impulsivity and compulsivity contribute to the cognitive mechanisms underlying variations in appetite restraint in eating disorders and common psychiatric comorbidities such as anxiety and obsessivecompulsive disorder. Exploring impulsivity and compulsivity in AN from the perspective of the RDoC cognitive systems domain is aided by measures of genetic, molecular, cellular, neural, physiological, behavioural and cognitive task paradigms. Thus, from the standpoint of the RDoC measures, this chapter will describe some of the ways in which impulsivity and compulsivity contribute to the cognitive systems associated with appetite restraint in AN, with the aim of further clarifying

#### **Chapter 1**

## Impulsivity and Compulsivity in Anorexia Nervosa: Cognitive Systems Underlying Variation in Appetite Restraint from an RDoC Perspective

*Samantha Jane Brooks and Helgi Schiöth*

### **Abstract**

Contemporary nomenclature for anorexia nervosa (AN) describes the eating disorder as transdiagnostic, with overlapping facets of impulsivity and compulsivity contributing to variations in binge-purge, restrictive eating and maladaptive cognitions. It is important to understand how these facets interact, given that those diagnosed with AN often fluctuate and relapse–as opposed to maintaining a stable diagnosis—between Diagnostic and Statistical Manual version 5 (DSM-5) categories, over the life course. The National Institute of Health's Research Domain Criteria (NIH RDoC) subscribes to the transdiagnostic view of mental disorders and provides progressive guidelines for neuroscience research. As such, using the RDoC guidelines may help to pinpoint how impulsivity and compulsivity contribute to the cognitive mechanisms underlying variations in appetite restraint in eating disorders and common psychiatric comorbidities such as anxiety and obsessivecompulsive disorder. Exploring impulsivity and compulsivity in AN from the perspective of the RDoC cognitive systems domain is aided by measures of genetic, molecular, cellular, neural, physiological, behavioural and cognitive task paradigms. Thus, from the standpoint of the RDoC measures, this chapter will describe some of the ways in which impulsivity and compulsivity contribute to the cognitive systems associated with appetite restraint in AN, with the aim of further clarifying a model of appetite restraint to improve treatment interventions.

**Keywords:** RDoC, cognitive systems, anorexia nervosa, appetite restraint, impulsivity, compulsivity

#### **1. Introduction**

The Diagnostic and Statistical Manual version 5 (DSM-5), published in 2013 after a decade of edition 4, has progressed nomenclature for the psychiatric eating disorder anorexia nervosa (AN), according to three main criteria, focusing on the behaviours and cognitions underlying weight restriction and body perception [1]. Moreover, while continuing to be categorical in scope, the DSM-5 also recognises the transdiagnostic nature of AN, with the inclusion of body mass index (BMI) severity clauses: mild,

moderate, severe and extreme. The BMI severity inclusion incorporates the overlapping impulsive and compulsive facets of weight dysregulation in eating disorders. For example, compulsive energy restriction relative to body weight requirements is an important diagnostic feature of AN, as is the intense fear of weight gain, and persistence in behaviour that interferes with weight gain. The third criterion includes disturbance in body perception, with undue influence of self-evaluation and persistent denial of the seriousness of reduced body weight. Restrictive and binge-purge are two subtype classifications of AN determined over the course of 3 months. The former holds if an individual has achieved weight loss by compulsive dieting, fasting or excessive exercise; the latter holds if an individual has engaged in impulsive binge-purge behaviour, including the use of diuretics, enemas, laxatives or self-induced vomiting.

The fifth edition of DSM further clarifies eating disorders and their underlying impulsive and compulsive features, incorporating additional categories such as avoidant/restrictive food intake disorder, rumination disorder, pica (compulsive consumption of non-nutritional substances) and binge eating disorder [2]. In terms of AN in particular, the behavioural (e.g. weight dysregulation) and cognitive (e.g. inflexible thinking and misperception) traits are significantly linked to genetic and environmental vulnerabilities, and more recently, to alterations in brain structure and function, particularly within the hypothalamus, hippocampus, insular cortex, parietal cortex and prefrontal cortex [3]. Furthermore, neuroinflammatory processes that contribute to the "leaky gut-brain" hypothesis of eating disorders may interact with these brain regions, via over-expression of cytokines, such as leukotrienes. Recently, theories about the involvement of neuroinflammatory processes in AN may bridge the gap between genetic susceptibility, environmental causes and changes in brain function, especially with regard to altered hypothalamic leptin and serotonin function. Moreover, memory and evaluative processes associated with dysfunction in the hippocampus and prefrontal cortex may contribute to the compulsive overvaluation of thinness, body dissatisfaction and excessive appetite restriction in AN [4], whereas the link to binge eating appears to overlap with striatal dysfunction and impulsivity [5].

The current understanding of eating disorders in general, and of AN in particular, reflects a view that impulsivity and compulsivity are significant diagnostic personality facets underlying the disorder [6]. While some propose that impulsivity and compulsivity are opposite extremes of a single personality dimension, others view impulsivity as a trait vulnerability that drives compulsivity, with repetitive behaviours that emerge as maladaptive, coping strategies to regulate arousal [7]. In addition, while both impulsive and compulsive traits appear to map onto binge eating, persistent drive for thinness and appetite restraint, with some fluctuation between these conditions [3], research suggests that impulsivity and compulsivity are entirely separate constructs that can present, to varying degrees, in unison [6]. Thus, there is still debate in the eating disorders field as to how impulsivity and compulsivity interact and correspond to the DSM criteria. In an attempt to better understand the roles, and to consider potential mechanisms, here we take the *cognitive systems* RDoC domain and its measurement, to examine the presentation of impulsivity and compulsivity and the link to cognitive processes underlying appetite restraint in AN. Prior to the examination of the RDoC domain and its measurement, next follows a brief summary of the definitions of impulsivity and compulsivity.

#### **2. Impulsivity and compulsivity**

Traditional views posit that impulsivity and compulsivity are dissociable states, reflecting neural processes within corticolimbic circuitry that underlie

**5**

*Impulsivity and Compulsivity in Anorexia Nervosa: Cognitive Systems Underlying Variation…*

high arousal and maladaptive aversion avoidance, respectively [8, 9]. However, with the advancement of neuroimaging data within transdiagnostic phenotypes, influenced in part by the updated DSM-5 nomenclature in 2013, and the publication of the RDoC, there appears to be common corticolimbic neural functions that when activated in a certain pattern, correspond to high levels of automaticity, impaired cognitive inhibition, lack of self-control and maladaptive self-regulation [10]. It remains to be elucidated, however, why certain variations in impulsivity and compulsivity present as discrete types of psychiatric disorder. In addition, while common psychiatric comorbidities exist between disorders, as highlighted by the RDoC enterprise, the DSM clearly demonstrates discrete boundaries that also exist between various phenotypes. Thus, examining impulsivity and compulsivity from the transdiagnostic measurement of the RDoC cognitive systems domain may clarify how these constructs merge to form a diagnosis of restrictive

The International Society for Research on Impulsivity (ISRI: http://www. impulsivity.org) defines impulsivity as: *behaviours or tendencies to act with less forethought than do most individuals of equal ability and knowledge, or a predisposition towards rapid, unplanned reactions to internal or external stimuli without regard to the negative consequences of these reactions*. Research defines impulsivity broadly as part of a normal range of functioning (as opposed to compulsivity that may reflect a maladaptive coping strategy), and yet it is the frequency of impulsivity that determines whether disorder exists [7, 11]. Moreover, neuropsychological research over the last decade has clarified the multi-faceted nature of impulsivity and its neural correlates [11] that are broadly associated with inattention or narrow/ inflexible thinking (cognitive impulsivity) and hyperactivity (behavioural or motor impulsivity). Within these broad definitions, nuances of impulsivity occur [11], highlighted by research studies that deserve additional consideration. For example, choice versus rapid response impulsivity have been identified; the former concerns the preference for immediate over delayed rewards (e.g. temporal or delay discounting), the latter concerns the tendency to act without forethought and out of context with immediate demands [12, 13]. Further distinctions of impulsivity within choice versus response impulsivity have been developed [9]. For example, motor impulsivity reflects an inability to inhibit an inappropriate or misplaced response. Disadvantageous decision-making involves cognitions that underlie risk-taking behaviours, and an inability to avoid danger, threat or some form of personal loss. Choice impulsivity determines a person, who cannot delay the experience of reward (e.g. temporal or delay discounting). Finally, reflection impulsivity refers to an

inability to deliberate on the potential outcome of one's actions.

Impulsivity appears related to a natural, arousal response, with some adaptive qualities that are widely researched and effectively defined [11], whereas conversely, there is a lack of consensus about compulsivity – both in terms of its definition and function. However, deficits in attention, perception and repetition of motor or cognitive responses appear to be key facets [9]. A recent formal definition based on neuroscientific research states that compulsivity is *a tendency towards repetitive, habitual actions, repeated despite adverse consequences* [14]*.* Compulsive, perpetual and ritualised behaviours and cognitions may be attempts to neutralise high levels of arousal and negative affect (e.g., fear, anxiety and perceived threat)

*DOI: http://dx.doi.org/10.5772/intechopen.83702*

or binge purge AN.

**2.1 Definitions of impulsivity**

**2.2 Definitions of compulsivity**

*Impulsivity and Compulsivity in Anorexia Nervosa: Cognitive Systems Underlying Variation… DOI: http://dx.doi.org/10.5772/intechopen.83702*

high arousal and maladaptive aversion avoidance, respectively [8, 9]. However, with the advancement of neuroimaging data within transdiagnostic phenotypes, influenced in part by the updated DSM-5 nomenclature in 2013, and the publication of the RDoC, there appears to be common corticolimbic neural functions that when activated in a certain pattern, correspond to high levels of automaticity, impaired cognitive inhibition, lack of self-control and maladaptive self-regulation [10]. It remains to be elucidated, however, why certain variations in impulsivity and compulsivity present as discrete types of psychiatric disorder. In addition, while common psychiatric comorbidities exist between disorders, as highlighted by the RDoC enterprise, the DSM clearly demonstrates discrete boundaries that also exist between various phenotypes. Thus, examining impulsivity and compulsivity from the transdiagnostic measurement of the RDoC cognitive systems domain may clarify how these constructs merge to form a diagnosis of restrictive or binge purge AN.

#### **2.1 Definitions of impulsivity**

*Anorexia and Bulimia Nervosa*

moderate, severe and extreme. The BMI severity inclusion incorporates the overlapping impulsive and compulsive facets of weight dysregulation in eating disorders. For example, compulsive energy restriction relative to body weight requirements is an important diagnostic feature of AN, as is the intense fear of weight gain, and persistence in behaviour that interferes with weight gain. The third criterion includes disturbance in body perception, with undue influence of self-evaluation and persistent denial of the seriousness of reduced body weight. Restrictive and binge-purge are two subtype classifications of AN determined over the course of 3 months. The former holds if an individual has achieved weight loss by compulsive dieting, fasting or excessive exercise; the latter holds if an individual has engaged in impulsive binge-purge behaviour, including the use of diuretics, enemas, laxatives or self-induced vomiting. The fifth edition of DSM further clarifies eating disorders and their underlying impulsive and compulsive features, incorporating additional categories such as avoidant/restrictive food intake disorder, rumination disorder, pica (compulsive consumption of non-nutritional substances) and binge eating disorder [2]. In terms of AN in particular, the behavioural (e.g. weight dysregulation) and cognitive (e.g. inflexible thinking and misperception) traits are significantly linked to genetic and environmental vulnerabilities, and more recently, to alterations in brain structure and function, particularly within the hypothalamus, hippocampus, insular cortex, parietal cortex and prefrontal cortex [3]. Furthermore, neuroinflammatory processes that contribute to the "leaky gut-brain" hypothesis of eating disorders may interact with these brain regions, via over-expression of cytokines, such as leukotrienes. Recently, theories about the involvement of neuroinflammatory processes in AN may bridge the gap between genetic susceptibility, environmental causes and changes in brain function, especially with regard to altered hypothalamic leptin and serotonin function. Moreover, memory and evaluative processes associated with dysfunction in the hippocampus and prefrontal cortex may contribute to the compulsive overvaluation of thinness, body dissatisfaction and excessive appetite restriction in AN [4], whereas the link to binge eating appears to overlap with striatal dysfunction and impulsivity [5]. The current understanding of eating disorders in general, and of AN in particular, reflects a view that impulsivity and compulsivity are significant diagnostic personality facets underlying the disorder [6]. While some propose that impulsivity and compulsivity are opposite extremes of a single personality dimension, others view impulsivity as a trait vulnerability that drives compulsivity, with repetitive behaviours that emerge as maladaptive, coping strategies to regulate arousal [7]. In addition, while both impulsive and compulsive traits appear to map onto binge eating, persistent drive for thinness and appetite restraint, with some fluctuation between these conditions [3], research suggests that impulsivity and compulsivity are entirely separate constructs that can present, to varying degrees, in unison [6]. Thus, there is still debate in the eating disorders field as to how impulsivity and compulsivity interact and correspond to the DSM criteria. In an attempt to better understand the roles, and to consider potential mechanisms, here we take the *cognitive systems* RDoC domain and its measurement, to examine the presentation of impulsivity and compulsivity and the link to cognitive processes underlying appetite restraint in AN. Prior to the examination of the RDoC domain and its measurement, next follows a brief summary of the definitions of impulsivity and

**4**

compulsivity.

**2. Impulsivity and compulsivity**

Traditional views posit that impulsivity and compulsivity are dissociable states, reflecting neural processes within corticolimbic circuitry that underlie

The International Society for Research on Impulsivity (ISRI: http://www. impulsivity.org) defines impulsivity as: *behaviours or tendencies to act with less forethought than do most individuals of equal ability and knowledge, or a predisposition towards rapid, unplanned reactions to internal or external stimuli without regard to the negative consequences of these reactions*. Research defines impulsivity broadly as part of a normal range of functioning (as opposed to compulsivity that may reflect a maladaptive coping strategy), and yet it is the frequency of impulsivity that determines whether disorder exists [7, 11]. Moreover, neuropsychological research over the last decade has clarified the multi-faceted nature of impulsivity and its neural correlates [11] that are broadly associated with inattention or narrow/ inflexible thinking (cognitive impulsivity) and hyperactivity (behavioural or motor impulsivity). Within these broad definitions, nuances of impulsivity occur [11], highlighted by research studies that deserve additional consideration. For example, choice versus rapid response impulsivity have been identified; the former concerns the preference for immediate over delayed rewards (e.g. temporal or delay discounting), the latter concerns the tendency to act without forethought and out of context with immediate demands [12, 13]. Further distinctions of impulsivity within choice versus response impulsivity have been developed [9]. For example, motor impulsivity reflects an inability to inhibit an inappropriate or misplaced response. Disadvantageous decision-making involves cognitions that underlie risk-taking behaviours, and an inability to avoid danger, threat or some form of personal loss. Choice impulsivity determines a person, who cannot delay the experience of reward (e.g. temporal or delay discounting). Finally, reflection impulsivity refers to an inability to deliberate on the potential outcome of one's actions.

#### **2.2 Definitions of compulsivity**

Impulsivity appears related to a natural, arousal response, with some adaptive qualities that are widely researched and effectively defined [11], whereas conversely, there is a lack of consensus about compulsivity – both in terms of its definition and function. However, deficits in attention, perception and repetition of motor or cognitive responses appear to be key facets [9]. A recent formal definition based on neuroscientific research states that compulsivity is *a tendency towards repetitive, habitual actions, repeated despite adverse consequences* [14]*.* Compulsive, perpetual and ritualised behaviours and cognitions may be attempts to neutralise high levels of arousal and negative affect (e.g., fear, anxiety and perceived threat)

and for the individual to gain a rewarding sense of control. However, in recent years, there have been various attempts to better conceptualise the nuances of compulsivity, and to date four discrete definitions have been emerged [9]. First, contingency-related cognitive inflexibility refers to heightened perseverance, especially in anticipation of receipt of a previously experienced reward. Second, task/attentional set-shifting deficits refer to an inability to alter cognitive strategies as the task/attentional demands change. Third, attentional bias/disengagement concerns the phenomenon of disorder salience, where certain stimuli bias processing resources, which may delay the completion of concurrent cognitive tasks (e.g. the "Food Stroop" task for eating disorders [15]). Finally, habit learning describes repetitive automaticity of behaviours and cognitions that correspond to a previously experienced reward.

#### **2.3 Interactions between impulsivity and compulsivity**

A diathesis model has held for many years, whereby the constructs of impulsivity and compulsivity are at opposing ends of a spectrum [9]. Such a model suggests that compulsive, maladaptive coping strategies manage excessively impulsive, automatic arousal reactions to internal and external stimuli. In support of the diathesis model, the Pavlovian Instrumental Transfer (PIT) theory [16] describes a switch from deliberative, controlled, ventral striatal (nucleus accumbens-driven) activation to habitual, repetitive, uncontrolled, dorsal striatal (caudate, putamen-driven) activation associated with reward. Furthermore, psychiatric compulsive cognitions and behaviours may be attempts to reduce high levels of impulsivity, arousal, tension and negative affect [8]. In this vein, trait vulnerability for high levels of impulsivity is associated with the advent and maintenance of psychiatric disorder, whereas the role of compulsivity is less clear, but may provide the individual with a semblance of respite from psychological distress, which is rewarding from an opponent process perspective [17]. Support for this notion comes from the repetitive nature of compulsivity – in that, an element of reward must be present for a cognition or behaviour to be repeated. Furthermore, by repeating the process of tension/stress reduction, an allostatic load alteration occurs to maintain stability within neural circuits, which ultimately contributes to psychiatric disorder [18]. Interestingly, the allostatic load hypothesis of AN is related to changes in basal ganglia dopaminergic and hypothalamic pituitary adrenal (HPA) axis systems [19] that are influenced by elevated inflammatory molecules (e.g. leukotrienes).

#### **3. Impulsivity and compulsivity in AN**

Impulsivity is typically associated with the loss-of-control over eating, which is characteristic of the binge-purge AN subtype, bulimia nervosa and binge eating disorder [20]. In contrast, the restrictive AN subtype is associated with disproportionate belief systems about self-control (e.g. preferring the goal of future thinness to present eating), whereas binge eating subtypes have steeper delay discounting rates and disinhibition over rapid eating [20]. Additionally, higher levels of impulsivity in those with bingeing subtypes of eating disorder show lower goal-drive persistence [21]. Interestingly, the bingeing subtypes, including binge-purge AN, also tend to present with other impulse control disorders, such as gambling disorder, which have a higher preponderance for impulsivity, suicidality and cognitive distortions [22]. Higher levels of impulsivity in binge-purge AN subtypes also

**7**

and compulsivity in AN.

*Impulsivity and Compulsivity in Anorexia Nervosa: Cognitive Systems Underlying Variation…*

correspond to increased difficulties in emotion regulation that may worsen with older age [23]. Finally, perhaps most pertinent to the role of impulsivity in bingeing subtypes of eating disorder is the concept of negative urgency, which is the dispositional tendency to engage in rash action during the experience of negative affect. Women with AN, who score higher on negative urgency, with an experience of negative affect, are significantly more likely to engage in binge eating behaviour [24]. Thus, in the same vein that trait vulnerability for impulsivity underlies a switch from deliberative to compulsive drug taking [25], it might be that a similar vulnerability occurs in AN, underlying a switch – or fluctuation – between impul-

Compulsivity in AN refers to the relentless pursuit of appetite restraint and weight loss, which appears to be transdiagnostic and related to obsessive-compulsive and addictive disorders [26]. In fact, obsessive-compulsive personality disorder, and addictive processes are common comorbidities in restrictive AN, alongside anxiety and depression [27, 28]. The compulsive relationship between initially rewarding deliberative behaviours and the relentless pursuit of thinness, supported by excessive exercise, starvation and purging, is associated with aberrant corticostriatal dysfunction and rigid, inflexible cognitive ruminations [25]. Moreover, the physiological effects of excessive weight loss may encourage the development of compulsive traits by altering neuroinflammatory processes within the gut-brain axis that interfere with memory consolidation physiology in the hippocampus and prefrontal cortex, and appetite dysregulation in the hypothalamus. A neural shift within corticolimbic brain areas underlying compulsive behaviour may explain why not all people who experiment with illicit substances become addicted, and not all people who experiment with dieting develop an eating disorder. However, the switch to a compulsive pursuit of thinness and appetite restraint in AN appears rewarding similar to the addictive process [28]. The cause of the switch to compulsive behaviour is not yet elucidated. However, it encompasses trait vulnerability for anxiety and impulsivity, and an initial controlled experience of reward (e.g. the pleasure of self-control and social praise alongside dieting), the development of incentive salience to motivate the continuance of the behaviour, and finally the seeking, or habitual behaviour necessary to repeat the learned reward [29]. Additionally, aberrant opponent processes in corticolimbic circuitry underlying reward deficits and stress surfeits drive compulsivity [29], which for those with AN would mean increasingly dangerous, yet still rewarding, weight loss attempts.

**3.1 Multi-faceted elements of impulsivity and compulsivity in AN**

Impulsivity and compulsivity may both uniquely contribute, in varying degrees, to certain aspects of AN. Compelling evidence suggests that both facets of impulsivity and compulsivity contribute to eating concerns and restraint in AN [6]. In a recent study of adults with AN by Lavender and colleagues [6], extensive self-report measures were used to confirm that impulsivity was linked to eating concerns and the frequency of loss of control eating. Conversely, compulsivity was associated with the lack of perseverance and restraint, as well as eating and weight concerns. Previously, the RDoC criteria reinforce the notion that anxiety drives the compulsive tendency to engage in repetitive self-starvation in those with AN [28]. This is in line with recent suggestions that impulsivity is associated with heightened anxiety, or negative urgency, which appears to drive maladaptive compulsive strategies in those with eating disorders [30]. **Figure 1** provides a schematic diagram of the link between arousal, anxiety, binge eating, restraint, impulsivity

*DOI: http://dx.doi.org/10.5772/intechopen.83702*

sive binge eating and compulsive appetite restraint.

#### *Impulsivity and Compulsivity in Anorexia Nervosa: Cognitive Systems Underlying Variation… DOI: http://dx.doi.org/10.5772/intechopen.83702*

correspond to increased difficulties in emotion regulation that may worsen with older age [23]. Finally, perhaps most pertinent to the role of impulsivity in bingeing subtypes of eating disorder is the concept of negative urgency, which is the dispositional tendency to engage in rash action during the experience of negative affect. Women with AN, who score higher on negative urgency, with an experience of negative affect, are significantly more likely to engage in binge eating behaviour [24]. Thus, in the same vein that trait vulnerability for impulsivity underlies a switch from deliberative to compulsive drug taking [25], it might be that a similar vulnerability occurs in AN, underlying a switch – or fluctuation – between impulsive binge eating and compulsive appetite restraint.

Compulsivity in AN refers to the relentless pursuit of appetite restraint and weight loss, which appears to be transdiagnostic and related to obsessive-compulsive and addictive disorders [26]. In fact, obsessive-compulsive personality disorder, and addictive processes are common comorbidities in restrictive AN, alongside anxiety and depression [27, 28]. The compulsive relationship between initially rewarding deliberative behaviours and the relentless pursuit of thinness, supported by excessive exercise, starvation and purging, is associated with aberrant corticostriatal dysfunction and rigid, inflexible cognitive ruminations [25]. Moreover, the physiological effects of excessive weight loss may encourage the development of compulsive traits by altering neuroinflammatory processes within the gut-brain axis that interfere with memory consolidation physiology in the hippocampus and prefrontal cortex, and appetite dysregulation in the hypothalamus. A neural shift within corticolimbic brain areas underlying compulsive behaviour may explain why not all people who experiment with illicit substances become addicted, and not all people who experiment with dieting develop an eating disorder. However, the switch to a compulsive pursuit of thinness and appetite restraint in AN appears rewarding similar to the addictive process [28]. The cause of the switch to compulsive behaviour is not yet elucidated. However, it encompasses trait vulnerability for anxiety and impulsivity, and an initial controlled experience of reward (e.g. the pleasure of self-control and social praise alongside dieting), the development of incentive salience to motivate the continuance of the behaviour, and finally the seeking, or habitual behaviour necessary to repeat the learned reward [29]. Additionally, aberrant opponent processes in corticolimbic circuitry underlying reward deficits and stress surfeits drive compulsivity [29], which for those with AN would mean increasingly dangerous, yet still rewarding, weight loss attempts.

#### **3.1 Multi-faceted elements of impulsivity and compulsivity in AN**

Impulsivity and compulsivity may both uniquely contribute, in varying degrees, to certain aspects of AN. Compelling evidence suggests that both facets of impulsivity and compulsivity contribute to eating concerns and restraint in AN [6]. In a recent study of adults with AN by Lavender and colleagues [6], extensive self-report measures were used to confirm that impulsivity was linked to eating concerns and the frequency of loss of control eating. Conversely, compulsivity was associated with the lack of perseverance and restraint, as well as eating and weight concerns. Previously, the RDoC criteria reinforce the notion that anxiety drives the compulsive tendency to engage in repetitive self-starvation in those with AN [28]. This is in line with recent suggestions that impulsivity is associated with heightened anxiety, or negative urgency, which appears to drive maladaptive compulsive strategies in those with eating disorders [30]. **Figure 1** provides a schematic diagram of the link between arousal, anxiety, binge eating, restraint, impulsivity and compulsivity in AN.

*Anorexia and Bulimia Nervosa*

previously experienced reward.

**2.3 Interactions between impulsivity and compulsivity**

inflammatory molecules (e.g. leukotrienes).

**3. Impulsivity and compulsivity in AN**

and for the individual to gain a rewarding sense of control. However, in recent years, there have been various attempts to better conceptualise the nuances of compulsivity, and to date four discrete definitions have been emerged [9].

First, contingency-related cognitive inflexibility refers to heightened perseverance, especially in anticipation of receipt of a previously experienced reward. Second, task/attentional set-shifting deficits refer to an inability to alter cognitive strategies as the task/attentional demands change. Third, attentional bias/disengagement concerns the phenomenon of disorder salience, where certain stimuli bias processing resources, which may delay the completion of concurrent cognitive tasks (e.g. the "Food Stroop" task for eating disorders [15]). Finally, habit learning describes repetitive automaticity of behaviours and cognitions that correspond to a

A diathesis model has held for many years, whereby the constructs of impulsivity and compulsivity are at opposing ends of a spectrum [9]. Such a model suggests that compulsive, maladaptive coping strategies manage excessively impulsive, automatic arousal reactions to internal and external stimuli. In support of the diathesis model, the Pavlovian Instrumental Transfer (PIT) theory [16] describes a switch from deliberative, controlled, ventral striatal (nucleus accumbens-driven) activation to habitual, repetitive, uncontrolled, dorsal striatal (caudate, putamen-driven) activation associated with reward. Furthermore, psychiatric compulsive cognitions and behaviours may be attempts to reduce high levels of impulsivity, arousal, tension and negative affect [8]. In this vein, trait vulnerability for high levels of impulsivity is associated with the advent and maintenance of psychiatric disorder, whereas the role of compulsivity is less clear, but may provide the individual with a semblance of respite from psychological distress, which is rewarding from an opponent process perspective [17]. Support for this notion comes from the repetitive nature of compulsivity – in that, an element of reward must be present for a cognition or behaviour to be repeated. Furthermore, by repeating the process of tension/stress reduction, an allostatic load alteration occurs to maintain stability within neural circuits, which ultimately contributes to psychiatric disorder [18]. Interestingly, the allostatic load hypothesis of AN is related to changes in basal ganglia dopaminergic and hypothalamic pituitary adrenal (HPA) axis systems [19] that are influenced by elevated

Impulsivity is typically associated with the loss-of-control over eating, which is characteristic of the binge-purge AN subtype, bulimia nervosa and binge eating disorder [20]. In contrast, the restrictive AN subtype is associated with disproportionate belief systems about self-control (e.g. preferring the goal of future thinness to present eating), whereas binge eating subtypes have steeper delay discounting rates and disinhibition over rapid eating [20]. Additionally, higher levels of impulsivity in those with bingeing subtypes of eating disorder show lower goal-drive persistence [21]. Interestingly, the bingeing subtypes, including binge-purge AN, also tend to present with other impulse control disorders, such as gambling disorder, which have a higher preponderance for impulsivity, suicidality and cognitive distortions [22]. Higher levels of impulsivity in binge-purge AN subtypes also

**6**

**Figure 1.**

*A schematic diagram describing how impulsivity and compulsivity may interact with bodily sensations (bottom up) and belief systems (top-down) in binge-eating and restricting anorexia nervosa (AN).*

#### **4. The RDoC research domains and suggested units of measurement**

Some consensus appears in the eating disorder literature as to the role of impulsivity and compulsivity in binge eating and restrictive eating subtypes, respectively. However, there is still debate as to whether these are separate constructs, extremes on a diathesis model, or functioning concomitantly in varying degrees to derive a fluctuating eating disorder phenotype. Moreover, there are other nuances to eating disorders – such as body and self-image distortion, denial of disorder, cognitive deficits including excessive attention to detail, set-shifting abnormalities – that are still not fully elucidated by theories of the neural processes of impulsivity and compulsivity. As such, it is useful to consider the transdiagnostic scope of the RDoC domains and suggested units of measurement, in an attempt to further clarify how impulsivity and compulsivity might contribute to symptoms of the subtypes of AN.

#### **4.1 Five RDoC domains**

RDoC comprises of five domains for suggested neuroscientific research areas (see: https://www.nimh.nih.gov/research-priorities/rdoc/constructs/rdoc-matrix. shtml). These are: (i) negative valence systems; (ii) positive valence systems; (iii) cognitive systems; (iv) social processes and (v) arousal and regulatory systems.

**9**

*4.2.1 Attention*

*Impulsivity and Compulsivity in Anorexia Nervosa: Cognitive Systems Underlying Variation…*

Negative valence systems include fear, anxiety, sustained threat, loss and frustrative non-reward. Positive valence systems include reward responsiveness, reward learning and reward valuation. Cognitive systems include attention, perception, declarative memory, language, cognitive control and working memory. Social processes include attachment, social communication, perception and understanding of the self, perception and understanding of others. Finally, arousal and regulatory systems include circadian rhythms and sleep/wakefulness. Against the background of the RDoC domains, given the scope of this article, the cognitive systems domain, linking impulsivity and compulsivity to varying degrees of appetite restraint in AN,

To measure the cognitive systems domain, the RDoC suggests eight neuroscientific genres. These are: (i) genes; (ii) molecules (neurotransmitters); (iii) cells; (iv) neural circuits; (v) physiology; (vi) behaviour; (vii) self-report; and (viii) paradigms. Before considering how cognitive systems and their measurement might aid the understanding of the role of impulsivity and compulsivity in appetite-restraint variations characteristic of AN, the measurement of the cognitive systems domain will be defined below. As a brief introduction, attention may be related to cognitive biases (particularly toward food and body-image stimuli) that maintain cognitive restraint in AN. Perception can be linked to non-conscious sensory mechanisms that may drive maladaptive conscious evaluations of the environment in those with AN. Declarative memories may underlie the AN narrative of the self and the world. Language processing may support the development of the internal narrative associated with AN-related cognitions, particularly in line with becoming and staying thin and in control. Cognitive control refers to the ability of people with AN to excessively regulate their appetite and eating behaviours with cognitive ruminations of goals to stay underweight. Finally, working memory likely underpins the flexible updating of excessively detailed cognitive strategies to achieve the future goal of thinness, and to avoid immediate distractions (e.g. food-related stimuli). Next follows a detailed account of the RDoC definitions of the sub-constructs (attention, perception, declarative memory, language, cognitive control and work-

ing memory) and the measurement of the cognitive systems domain.

According to the RDoC, attention refers to the regulation of capacity-limited systems such as awareness, higher order perception and motor function (e.g. response inhibition). Additionally, the RDoC clarifies that capacity limitation and competition are synonymous with selective and divided attention, respectively, which relate to attentional bias and distraction. The measurement of genes associated with attention has yielded inconclusive findings. However, in terms of neurotransmitters, the RDoC highlights that a balance between GABAergic and glutamatergic systems within the prefrontal cortex is a key to implement attention. Specifically, the control of attention is associated with acetylcholine, dopamine, glutamate, histamine and serotonin. In terms of cells, the RDoC recognises parvalbumin-positive interneurons as linked to the process of attention. Brain circuits associated with the initiation of attention include a balance between the resting state default mode and task positive networks, whereas the subsequent control of attention links to descending and ascending networks with the corticolimbic circuitry. Additionally, the dorsal "where" and ventral "what" visual processing pathways are implicated in attentional neural networks. Physiological measures of attention have yielded most

*DOI: http://dx.doi.org/10.5772/intechopen.83702*

will be the focus of the remaining sections.

**4.2 Eight RDoC measures**

*Impulsivity and Compulsivity in Anorexia Nervosa: Cognitive Systems Underlying Variation… DOI: http://dx.doi.org/10.5772/intechopen.83702*

Negative valence systems include fear, anxiety, sustained threat, loss and frustrative non-reward. Positive valence systems include reward responsiveness, reward learning and reward valuation. Cognitive systems include attention, perception, declarative memory, language, cognitive control and working memory. Social processes include attachment, social communication, perception and understanding of the self, perception and understanding of others. Finally, arousal and regulatory systems include circadian rhythms and sleep/wakefulness. Against the background of the RDoC domains, given the scope of this article, the cognitive systems domain, linking impulsivity and compulsivity to varying degrees of appetite restraint in AN, will be the focus of the remaining sections.

#### **4.2 Eight RDoC measures**

*Anorexia and Bulimia Nervosa*

**4. The RDoC research domains and suggested units of measurement**

*up) and belief systems (top-down) in binge-eating and restricting anorexia nervosa (AN).*

Some consensus appears in the eating disorder literature as to the role of impulsivity and compulsivity in binge eating and restrictive eating subtypes, respectively. However, there is still debate as to whether these are separate constructs, extremes on a diathesis model, or functioning concomitantly in varying degrees to derive a fluctuating eating disorder phenotype. Moreover, there are other nuances to eating disorders – such as body and self-image distortion, denial of disorder, cognitive deficits including excessive attention to detail, set-shifting abnormalities – that are still not fully elucidated by theories of the neural processes of impulsivity and compulsivity. As such, it is useful to consider the transdiagnostic scope of the RDoC domains and suggested units of measurement, in an attempt to further clarify how impulsivity and compulsivity might contribute to symptoms of the subtypes of AN.

*A schematic diagram describing how impulsivity and compulsivity may interact with bodily sensations (bottom* 

RDoC comprises of five domains for suggested neuroscientific research areas (see: https://www.nimh.nih.gov/research-priorities/rdoc/constructs/rdoc-matrix. shtml). These are: (i) negative valence systems; (ii) positive valence systems; (iii) cognitive systems; (iv) social processes and (v) arousal and regulatory systems.

**8**

**Figure 1.**

**4.1 Five RDoC domains**

To measure the cognitive systems domain, the RDoC suggests eight neuroscientific genres. These are: (i) genes; (ii) molecules (neurotransmitters); (iii) cells; (iv) neural circuits; (v) physiology; (vi) behaviour; (vii) self-report; and (viii) paradigms. Before considering how cognitive systems and their measurement might aid the understanding of the role of impulsivity and compulsivity in appetite-restraint variations characteristic of AN, the measurement of the cognitive systems domain will be defined below. As a brief introduction, attention may be related to cognitive biases (particularly toward food and body-image stimuli) that maintain cognitive restraint in AN. Perception can be linked to non-conscious sensory mechanisms that may drive maladaptive conscious evaluations of the environment in those with AN. Declarative memories may underlie the AN narrative of the self and the world. Language processing may support the development of the internal narrative associated with AN-related cognitions, particularly in line with becoming and staying thin and in control. Cognitive control refers to the ability of people with AN to excessively regulate their appetite and eating behaviours with cognitive ruminations of goals to stay underweight. Finally, working memory likely underpins the flexible updating of excessively detailed cognitive strategies to achieve the future goal of thinness, and to avoid immediate distractions (e.g. food-related stimuli). Next follows a detailed account of the RDoC definitions of the sub-constructs (attention, perception, declarative memory, language, cognitive control and working memory) and the measurement of the cognitive systems domain.

#### *4.2.1 Attention*

According to the RDoC, attention refers to the regulation of capacity-limited systems such as awareness, higher order perception and motor function (e.g. response inhibition). Additionally, the RDoC clarifies that capacity limitation and competition are synonymous with selective and divided attention, respectively, which relate to attentional bias and distraction. The measurement of genes associated with attention has yielded inconclusive findings. However, in terms of neurotransmitters, the RDoC highlights that a balance between GABAergic and glutamatergic systems within the prefrontal cortex is a key to implement attention. Specifically, the control of attention is associated with acetylcholine, dopamine, glutamate, histamine and serotonin. In terms of cells, the RDoC recognises parvalbumin-positive interneurons as linked to the process of attention. Brain circuits associated with the initiation of attention include a balance between the resting state default mode and task positive networks, whereas the subsequent control of attention links to descending and ascending networks with the corticolimbic circuitry. Additionally, the dorsal "where" and ventral "what" visual processing pathways are implicated in attentional neural networks. Physiological measures of attention have yielded most

#### *Anorexia and Bulimia Nervosa*

consistent results according to the RDoC, with functional MRI (fMRI), auditory/ visual event-related potentials (ERPs) and peripheral measures such as heart rate and pupillometry. The RDoC goes on to list that behavioural measures associated with attention include task distractibility, attentional lapses versus sustained attention, distractibility, object/feature detection, psychophysics and spatial attention. Finally, in terms of paradigms that measure attention, these include attentional blink, dichotic listening, dual-task paradigms, cueing paradigms, time-series responses and visual search.

#### *4.2.2 Perception*

Perception is the process by which computations in the brain extract sensory information to construct a model of the environment, making predictions about the world and guiding action, according to the RDoC. Visual and auditory perception involves various neurotransmitter systems, such as acetylcholine, catecholamines, GABA, glutamate, NMDA, peptides and serotonin. The cells involved in visual perception are magno and parvo cells, parvalbumin-positive interneurons and pyramidal cells, whereas for auditory perception, the cells include cochlear hair cells, cortical and limbic interneurons and ribbon synapses. In terms of neural circuits, subcortical vision involves konio-, magno- and parvo-cells, cortically the supra- and infra-granular layers are involved, and also the dorsal and ventral visual streams. Additionally, the suprachiasmatic nucleus and superior colliculus control saccadic and other visual actions. Additionally, auditory perception includes brain regions such as the anterior insula, brainstem, cochlear, inferior colliculus and the superior temporal gyrus. In terms of physiology, adaption and habituation are measured via fMRI, EEG and ERPs. Behavioural experiments to incorporate visual and auditory perception include discrimination, identification and localisation, learning, priming, reading, stimulus detection and visual acuity. Commonly used paradigms in visual perception research include backward masking (subliminal processing), motion processing, contrast sensitivity, emotion expression identification, face identification, object recognition, reading and visual illusion susceptibility. Commonly used paradigms in auditory perception research include auditory masking, streaming, detection of speech in noise, gating, inhibitory control, the McGurk effect (multisensory), oddball detection, self-monitoring and tone detection. Additionally, olfactory research is an emerging area of interest, with different odours eliciting different perceptual and cognitive systems.

#### *4.2.3 Declarative memory*

Declarative memory refers to the acquisition, encoding, storage and retrieval of information gained from the environment. This type of memory, as opposed to non-conscious, non-declarative memory, is important for spatial, temporal and contextual information, which represents a timeframe of events (e.g. episodic), and the organisation of items of memories into facts (semantic). Inferential and flexible extraction occurs from memories in order to update novel sensory information (e.g. Bayesian Inference). According to the RDoC, the neurotransmitters involved in declarative memory include acetylcholine, glutamate, noradrenalin and opioids. In terms on neuronal cell types that support declarative memory, these are glia, granule cells, inhibitory and excitatory interneurons and pyramidal cells. Brain circuitry for memory involves the hippocampus, and connections between the prefrontal and parietal cortices, as well as various other association areas. The physiology that supports declarative memory includes AMPA-related synaptic plasticity, coordinated fronto-temporal oscillatory activity, long-term potentiation and

**11**

*4.2.6 Working memory*

*Impulsivity and Compulsivity in Anorexia Nervosa: Cognitive Systems Underlying Variation…*

long-term depression and changes in the fMRI, EEG or other spatial and temporal brain imaging measures. Behaviour associated with declarative memory is measured by discrimination and familiarity tests, or learning, recall and recognition tasks. Finally, various paradigms exist to test declarative memory, including delayed recall, acquired equivalence, list and story learning, paired associative learning and

The RDoC describes cognitive processes underlying language as a system of shared symbolic representations of the external environment, incorporating abstract and self-related notions that aid thought and communication. Currently, there are no conclusive data regarding the genes, neurotransmitters or cells that contribute to language. However, the neural circuitry involves the inferior frontotemporo-parietal cortices, superior and middle temporal cortices, with considerable involvement of the limbic system, motor and sensory cortices. Behaviour is measured in the form of coherent discourse and sentences, and incorporates Wernicke (temporal cortex) and Broca's (frontal cortex) areas for speech comprehension and production, respectively. Experimental paradigms include discourse analyses and

The RDoC defines cognitive control as the processes that modulate the operation of other cognitive and affective systems in the brain. Cognitive control processes enable the achievement of goal-oriented behaviour, when pre-potent responses are not adequate for current demands. Control processes are also important under conditions of uncertainty, or novelty, where appropriate responses are selected from various competing options. Cognitive control involves three sub-processes, according to the RDoC: goal selection (updating, representation and maintenance),

response selection (inhibition/suppression), and performance monitoring.

insula and measured by conflict monitoring tasks.

Firstly, goal selection involves dorsolateral prefrontal and parietal cortex function, as well as inhibition of the default mode network. The neurotransmitter systems involved include cholinergic, dopaminergic, GABAergic, glutamatergic and norepinephrine. Gamma synchrony and pupillometry are some physiological measures used to detect goal-oriented cognitive control, alongside behavioural measures of distractibility. Experimental paradigms include cued stimulus-response reversal tasks, task switching and tower tasks (e.g. Hanoi, London). In addition, response selection tasks measure impulsive behaviour, using paradigms such as the Flanker, Simon and Stroop tests. Furthermore, response inhibition typically involves the parietal cortex, pre-supplementary motor area and ventro-fronto-striatal circuitry. Physiology of response inhibition is probed using, for example, pupillometry, eye-blink startle paradigms and transcranial magnetic stimulation. Tasks associated with response inhibition include Go/No-Go and Stop-Signal Reaction Time tasks. Finally, performance monitoring appears to involve serotonergic and dopaminergic systems within the anterior cingulate cortex, pre-supplementary motor area and

The RDoC definition states that working memory is active maintenance and flexible updating of goal or task relevant information (e.g. holding in mind bits of information, strategies and plans) in a limited capacity store that resists

*DOI: http://dx.doi.org/10.5772/intechopen.83702*

transitive inference.

eye-tracking equipment.

*4.2.5 Cognitive control*

*4.2.4 Language*

#### *Impulsivity and Compulsivity in Anorexia Nervosa: Cognitive Systems Underlying Variation… DOI: http://dx.doi.org/10.5772/intechopen.83702*

long-term depression and changes in the fMRI, EEG or other spatial and temporal brain imaging measures. Behaviour associated with declarative memory is measured by discrimination and familiarity tests, or learning, recall and recognition tasks. Finally, various paradigms exist to test declarative memory, including delayed recall, acquired equivalence, list and story learning, paired associative learning and transitive inference.

#### *4.2.4 Language*

*Anorexia and Bulimia Nervosa*

responses and visual search.

*4.2.2 Perception*

consistent results according to the RDoC, with functional MRI (fMRI), auditory/ visual event-related potentials (ERPs) and peripheral measures such as heart rate and pupillometry. The RDoC goes on to list that behavioural measures associated with attention include task distractibility, attentional lapses versus sustained attention, distractibility, object/feature detection, psychophysics and spatial attention. Finally, in terms of paradigms that measure attention, these include attentional blink, dichotic listening, dual-task paradigms, cueing paradigms, time-series

Perception is the process by which computations in the brain extract sensory information to construct a model of the environment, making predictions about the world and guiding action, according to the RDoC. Visual and auditory perception involves various neurotransmitter systems, such as acetylcholine, catecholamines, GABA, glutamate, NMDA, peptides and serotonin. The cells involved in visual perception are magno and parvo cells, parvalbumin-positive interneurons and pyramidal cells, whereas for auditory perception, the cells include cochlear hair cells, cortical and limbic interneurons and ribbon synapses. In terms of neural circuits, subcortical vision involves konio-, magno- and parvo-cells, cortically the supra- and infra-granular layers are involved, and also the dorsal and ventral visual streams. Additionally, the suprachiasmatic nucleus and superior colliculus control saccadic and other visual actions. Additionally, auditory perception includes brain regions such as the anterior insula, brainstem, cochlear, inferior colliculus and the superior temporal gyrus. In terms of physiology, adaption and habituation are measured via fMRI, EEG and ERPs. Behavioural experiments to incorporate visual and auditory perception include discrimination, identification and localisation, learning, priming, reading, stimulus detection and visual acuity. Commonly used paradigms in visual perception research include backward masking (subliminal processing), motion processing, contrast sensitivity, emotion expression identification, face identification, object recognition, reading and visual illusion susceptibility. Commonly used paradigms in auditory perception research include auditory masking, streaming, detection of speech in noise, gating, inhibitory control, the McGurk effect (multisensory), oddball detection, self-monitoring and tone detection. Additionally, olfactory research is an emerging area of interest, with different

odours eliciting different perceptual and cognitive systems.

Declarative memory refers to the acquisition, encoding, storage and retrieval of information gained from the environment. This type of memory, as opposed to non-conscious, non-declarative memory, is important for spatial, temporal and contextual information, which represents a timeframe of events (e.g. episodic), and the organisation of items of memories into facts (semantic). Inferential and flexible extraction occurs from memories in order to update novel sensory information (e.g. Bayesian Inference). According to the RDoC, the neurotransmitters involved in declarative memory include acetylcholine, glutamate, noradrenalin and opioids. In terms on neuronal cell types that support declarative memory, these are glia, granule cells, inhibitory and excitatory interneurons and pyramidal cells. Brain circuitry for memory involves the hippocampus, and connections between the prefrontal and parietal cortices, as well as various other association areas. The physiology that supports declarative memory includes AMPA-related synaptic plasticity, coordinated fronto-temporal oscillatory activity, long-term potentiation and

*4.2.3 Declarative memory*

**10**

The RDoC describes cognitive processes underlying language as a system of shared symbolic representations of the external environment, incorporating abstract and self-related notions that aid thought and communication. Currently, there are no conclusive data regarding the genes, neurotransmitters or cells that contribute to language. However, the neural circuitry involves the inferior frontotemporo-parietal cortices, superior and middle temporal cortices, with considerable involvement of the limbic system, motor and sensory cortices. Behaviour is measured in the form of coherent discourse and sentences, and incorporates Wernicke (temporal cortex) and Broca's (frontal cortex) areas for speech comprehension and production, respectively. Experimental paradigms include discourse analyses and eye-tracking equipment.

#### *4.2.5 Cognitive control*

The RDoC defines cognitive control as the processes that modulate the operation of other cognitive and affective systems in the brain. Cognitive control processes enable the achievement of goal-oriented behaviour, when pre-potent responses are not adequate for current demands. Control processes are also important under conditions of uncertainty, or novelty, where appropriate responses are selected from various competing options. Cognitive control involves three sub-processes, according to the RDoC: goal selection (updating, representation and maintenance), response selection (inhibition/suppression), and performance monitoring. Firstly, goal selection involves dorsolateral prefrontal and parietal cortex function, as well as inhibition of the default mode network. The neurotransmitter systems involved include cholinergic, dopaminergic, GABAergic, glutamatergic and norepinephrine. Gamma synchrony and pupillometry are some physiological measures used to detect goal-oriented cognitive control, alongside behavioural measures of distractibility. Experimental paradigms include cued stimulus-response reversal tasks, task switching and tower tasks (e.g. Hanoi, London). In addition, response selection tasks measure impulsive behaviour, using paradigms such as the Flanker, Simon and Stroop tests. Furthermore, response inhibition typically involves the parietal cortex, pre-supplementary motor area and ventro-fronto-striatal circuitry. Physiology of response inhibition is probed using, for example, pupillometry, eye-blink startle paradigms and transcranial magnetic stimulation. Tasks associated with response inhibition include Go/No-Go and Stop-Signal Reaction Time tasks. Finally, performance monitoring appears to involve serotonergic and dopaminergic systems within the anterior cingulate cortex, pre-supplementary motor area and insula and measured by conflict monitoring tasks.

#### *4.2.6 Working memory*

The RDoC definition states that working memory is active maintenance and flexible updating of goal or task relevant information (e.g. holding in mind bits of information, strategies and plans) in a limited capacity store that resists

interference. This active maintenance could involve flexible binding together of bits of information, may be internally represented despite external cues and holding in mind may be temporary, although this could be a function of interference. As such, according to the RDoC, working memory constitutes four sub-components: active maintenance, flexible updating, limited capacity and interference control. Active maintenance involves D1 dopamine receptor function, dopamine, GABA, glutamate and NMDA within inhibitory and pyramidal neuron populations. Furthermore, the cells responsible for inhibitory control include calbindin, calretinin, parvalbumin and distinct types of inhibitory neurons. Neural circuitry for active maintenance includes dorsolateral and ventrolateral prefrontal-parietal cortex and cingulatethalamo-limbic networks. Additionally, medium spiny neurons in the basal ganglia enable flexible updating. Delta, theta and gamma waves are also implicated with the use of EEG recordings. Working memory cognitive paradigms include change detection tasks, complex span tasks, delayed match to sample and non-sample, letter-number sequencing, N-Back, self-ordered pointing, sequence encoding and reproduction and Sternberg item recognition.

#### **4.3 RDoC measures of cognitive systems and the role of impulsivity and compulsivity in AN**

See **Table 1** for the summary of the RDoC cognitive systems sub-domains and their link to impulsivity and compulsivity in AN. The RDoC cognitive systems domain includes the constructs attention, perception, declarative memory, language, cognitive control and working memory, and all are pertinent in the processes of appetite control in AN. Before considering the RDoC measures of these constructs in relation to AN phenotypes, the broad links to these constructs are summarised. First, attentional processes are associated with regulatory control and response inhibition, and underlie the conscious and non-conscious processes of attentional bias to food stimuli [15, 31]. For example, attention is influenced by incentive salience as reflected in eye-blink startle responses to disorder-specific cues [32], which could drive the cognitive tendency for delayed reporting of disorder-specific stimuli [15]. Second, perception is related to this, and encompasses Bayesian Inference and epistemic foraging, or in AN-related terms, excessive cognitive sampling (e.g. of internal or external stimuli), to create rigid, inflexible cognitive models about the self, world and others, especially under conditions of uncertainty [4]. Third, declarative memory links to perception, in that episodic memory for recent food consumption for example, alters semantic memory regarding the metabolic and hedonic need for food [33]. However, recent research has not been able to replicate the finding that focused attention during eating improves later appetite control, and so, more research is required to determine under what conditions attention is associated with appetite control [34]. Fourth, language processes may support the internal narrative that contributes to ruminations underlying a distorted view of self and of body image [35]. Cognitive control may explain the compulsive nature of cognitive ruminations in AN, which bias decision-making and contribute to affect dysregulation [36]. Fifth, cognitive control of appetite may involve either goaloriented cognitive inhibition of distracting stimuli, or pre-potent motor response inhibition [33]. Finally, working memory may contribute to the cognitive control of appetite by keeping in mind, for delayed periods, independent of the initial stimulus (e.g. food), detailed and complex strategies to avoid eating [4]. Next follows a more detailed account of how the RDoC measures of cognitive systems might contribute to an updated understanding of the role of impulsivity and compulsivity in AN.

**13**

*Impulsivity and Compulsivity in Anorexia Nervosa: Cognitive Systems Underlying Variation…*

Binge-eating AN phenotypes are typically associated with trait impulsivity [5, 8, 9]. As such, the level of distraction (by food or body images for example) caused attention, as well as deficits in response inhibition (e.g. go/no-go, Stop Signal tasks and pre-pulse inhibition tasks), is likely to be a predictor of disorder severity reflected in distinct neural functioning [37]. Specifically, the function of acetylcholine, dopamine, glutamate, histamine and serotonin, and related stress hormones, particularly in the prefrontal-basal ganglia circuitry, are likely to be significantly indicative of the degree of impulsivity, and the likelihood that a binge-eating AN phenotype is present [38]. Similarly, neuronal variability in the ventral attentional resting state network may well reflect a greater propensity for impulsivity, and deficits in appetite control [39]. Heart rate variability and pupillometry may also highlight non-consciously derived arousal subserving impulsive tendencies and the

Restrictive subtypes of AN are typically associated with compulsivity, for example, inflexible ruminations and excessive attention to detail that appear to regulate anxiety and maintain complex self-concepts about weight loss [35]. Moreover, altered perceptual processes are associated with specific central

coherence and empathy deficits, such as an inability to perceive a global view [42], read the mind in the eyes [43] and alexithymia–an inability to recognise one's own or others' internal states [44]. Ineffective affect regulation, particularly in terms of anxiety and depression, may drive the compulsive tendency to rely on cognitive evaluations for environmental navigation and decision-making in those with restrictive AN [4]. Furthermore, studies of subliminal priming demonstrate that restrictive AN patients, particularly those with high levels of anxiety, experience

> Binge-purge severity is significantly associated with impulsivity, and is predicted by the level of distraction (by food or body images for example) caused to attention, as well as deficits in response inhibition (e.g. go/no-go, Stop Signal tasks and pre-pulse inhibition tasks). This is reflected in distinct neural functioning within fronto-striatal

circuitry [37].

is present [38].

Acetylcholine, dopamine, glutamate, histamine and serotonin function, and related stress hormones, particularly in the prefrontal-basal ganglia circuitry, are related to the degree of impulsivity, and the likelihood that a binge-eating AN phenotype

**Measures of impulsivity Measures of compulsivity**

Restrictive subtypes of AN are typically associated with compulsivity, for example, inflexible obsessive-compulsive ruminations and excessive attention to detail that appear to regulate anxiety and maintain complex self-concepts about

Task distractibility, attentional lapses versus sustained attention, distractibility, object/feature detection, psychophysics and spatial attention are common cognitive tasks used to measure attentional compulsivity.

weight loss [35]. An imbalance between GABAergic and glutamatergic systems within the prefrontal cortex is key to the compulsive function of attention (e.g. towards food and body stimuli)

in AN.

*DOI: http://dx.doi.org/10.5772/intechopen.83702*

binge-eating subtypes [40, 41].

*4.3.2 Compulsivity*

**RDoC cognitive systems sub-domain with definition**

*The regulation of capacitylimited systems such as awareness, higher-order perception and motor function (e.g. response inhibition).*

**Attention:**

*4.3.1 Impulsivity*

*Impulsivity and Compulsivity in Anorexia Nervosa: Cognitive Systems Underlying Variation… DOI: http://dx.doi.org/10.5772/intechopen.83702*

#### *4.3.1 Impulsivity*

*Anorexia and Bulimia Nervosa*

reproduction and Sternberg item recognition.

**compulsivity in AN**

interference. This active maintenance could involve flexible binding together of bits of information, may be internally represented despite external cues and holding in mind may be temporary, although this could be a function of interference. As such, according to the RDoC, working memory constitutes four sub-components: active maintenance, flexible updating, limited capacity and interference control. Active maintenance involves D1 dopamine receptor function, dopamine, GABA, glutamate and NMDA within inhibitory and pyramidal neuron populations. Furthermore, the cells responsible for inhibitory control include calbindin, calretinin, parvalbumin and distinct types of inhibitory neurons. Neural circuitry for active maintenance includes dorsolateral and ventrolateral prefrontal-parietal cortex and cingulatethalamo-limbic networks. Additionally, medium spiny neurons in the basal ganglia enable flexible updating. Delta, theta and gamma waves are also implicated with the use of EEG recordings. Working memory cognitive paradigms include change detection tasks, complex span tasks, delayed match to sample and non-sample, letter-number sequencing, N-Back, self-ordered pointing, sequence encoding and

**4.3 RDoC measures of cognitive systems and the role of impulsivity and** 

See **Table 1** for the summary of the RDoC cognitive systems sub-domains and their link to impulsivity and compulsivity in AN. The RDoC cognitive systems domain includes the constructs attention, perception, declarative memory, language, cognitive control and working memory, and all are pertinent in the processes of appetite control in AN. Before considering the RDoC measures of these constructs in relation to AN phenotypes, the broad links to these constructs are summarised. First, attentional processes are associated with regulatory control and response inhibition, and underlie the conscious and non-conscious processes of attentional bias to food stimuli [15, 31]. For example, attention is influenced by incentive salience as reflected in eye-blink startle responses to disorder-specific cues [32], which could drive the cognitive tendency for delayed reporting of disorder-specific stimuli [15]. Second, perception is related to this, and encompasses Bayesian Inference and epistemic foraging, or in AN-related terms, excessive cognitive sampling (e.g. of internal or external stimuli), to create rigid, inflexible cognitive models about the self, world and others, especially under conditions of uncertainty [4]. Third, declarative memory links to perception, in that episodic memory for recent food consumption for example, alters semantic memory regarding the metabolic and hedonic need for food [33]. However, recent research has not been able to replicate the finding that focused attention during eating improves later appetite control, and so, more research is required to determine under what conditions attention is associated with appetite control [34]. Fourth, language processes may support the internal narrative that contributes to ruminations underlying a distorted view of self and of body image [35]. Cognitive control may explain the compulsive nature of cognitive ruminations in AN, which bias decision-making and contribute to affect dysregulation [36]. Fifth, cognitive control of appetite may involve either goaloriented cognitive inhibition of distracting stimuli, or pre-potent motor response inhibition [33]. Finally, working memory may contribute to the cognitive control of appetite by keeping in mind, for delayed periods, independent of the initial stimulus (e.g. food), detailed and complex strategies to avoid eating [4]. Next follows a more detailed account of how the RDoC measures of cognitive systems might contribute to an updated understanding of the role of impulsivity and

**12**

compulsivity in AN.

Binge-eating AN phenotypes are typically associated with trait impulsivity [5, 8, 9]. As such, the level of distraction (by food or body images for example) caused attention, as well as deficits in response inhibition (e.g. go/no-go, Stop Signal tasks and pre-pulse inhibition tasks), is likely to be a predictor of disorder severity reflected in distinct neural functioning [37]. Specifically, the function of acetylcholine, dopamine, glutamate, histamine and serotonin, and related stress hormones, particularly in the prefrontal-basal ganglia circuitry, are likely to be significantly indicative of the degree of impulsivity, and the likelihood that a binge-eating AN phenotype is present [38]. Similarly, neuronal variability in the ventral attentional resting state network may well reflect a greater propensity for impulsivity, and deficits in appetite control [39]. Heart rate variability and pupillometry may also highlight non-consciously derived arousal subserving impulsive tendencies and the binge-eating subtypes [40, 41].

#### *4.3.2 Compulsivity*

Restrictive subtypes of AN are typically associated with compulsivity, for example, inflexible ruminations and excessive attention to detail that appear to regulate anxiety and maintain complex self-concepts about weight loss [35]. Moreover, altered perceptual processes are associated with specific central coherence and empathy deficits, such as an inability to perceive a global view [42], read the mind in the eyes [43] and alexithymia–an inability to recognise one's own or others' internal states [44]. Ineffective affect regulation, particularly in terms of anxiety and depression, may drive the compulsive tendency to rely on cognitive evaluations for environmental navigation and decision-making in those with restrictive AN [4]. Furthermore, studies of subliminal priming demonstrate that restrictive AN patients, particularly those with high levels of anxiety, experience


#### **RDoC cognitive systems sub-domain with definition**

#### **Perception:**

*The process by which computations in the brain extract sensory information to construct a model of the environment, making predictions about the world and guiding action.*

#### **Declarative memory:**

*The acquisition, encoding, storage and retrieval of information gained from the environment.*

#### **Language:**

*A system of shared symbolic representations of the external environment, incorporating abstract and self-related notions that aid thought and communication.*

Heart-rate variability and pupillometry may highlight nonconsciously derived perceptual processes sub-serving impulsive tendencies and the binge-eating subtypes [40, 41]. The dorsal 'where' and ventral 'what' visual processing pathways are implicated in rapid responses to environmental stimuli. Backward masking (subliminal processing), motion processing, contrast sensitivity, emotion expression identification, face identification, object recognition, reading, and visual illusion susceptibility. See also the McGurk effect (multisensory), oddball detection, selfmonitoring and tone detection.

Declarative memory is important for spatial, temporal and contextual information, which represents a timeframe of events (e.g. episodic), and the organisation of items of memories into facts (semantic). Inferential and flexible extraction occurs from memories in order to update novel sensory information (e.g. Bayesian Inference). This may underlie conditioned fear and threat-related impulsive responses to food, eating

and the environment.

Fluctuating levels of acetylcholine, glutamate, noradrenalin and opioids. In terms on neuronal cell types that support declarative memory, these are glia, granule cells, inhibitory and excitatory interneurons and pyramidal cells.

#### **Measures of impulsivity Measures of compulsivity**

Altered perceptual processes are associated with specific central coherence and empathy deficits, such as an inability to perceive a global view [42], read the mind in the eyes [43] and alexithymia - an inefficiency in perceiving one's own or others' internal states [44].

A switch from deliberative dieting to compulsive appetite restriction may involve a switch from activation of incentive salience networks within nucleus accumbens systems in favour of dorsal striatum networks associated with Pavlovian Instrumental Transfer [25]. The suprachiasmatic nucleus and superior colliculus control saccadic and other visual actions associated with excessive epistemic foraging of the environment, measured by eye-tracking equipment.

Compulsive cognitive ruminations and biases, which reflect in eye-tracking studies of vigilance and avoidance [46] may therefore become more deeply conditioned and consolidated in connected regions such as hippocampal, prefrontal cortex, and cholinergic and striatal dopaminergic neurons [47]. This may alter non-conscious memory formation and increase the probability of cognitive biases to disorder-relevant stimuli [48].

Inferior fronto-temporoparietal cortices, superior and middle temporal cortices, with considerable involvement of the limbic system, motor and sensory cortices. This may underlie the negative self-talk and phonological loop activation associated with impulsive responses to perceived threat and subsequent binge eating, which acts as a maladaptive coping strategy to suppress negative affect.

Coherent discourse analysis, which is reflected in neural function of Wernicke (temporal cortex) and Broca's (frontal cortex) areas for speech comprehension and production, respectively could measure restrictive eating behaviour that may be driven by cognitive ruminations. Experimental paradigms include discourse analyses and eye-tracking equipment.

**15**

**Table 1.**

*anorexia nervosa (binge-purge and restraint subtypes).*

*Impulsivity and Compulsivity in Anorexia Nervosa: Cognitive Systems Underlying Variation…*

Neuronal variability in the ventral attentional resting state network may well reflect a greater propensity for impulsivity, and deficits in appetite control [39]. Varying levels of control of attention is associated with levels of fluctuating acetylcholine, dopamine, glutamate, histamine

A balance between the resting state default mode and task positive networks underlies the maintenance of working memory and the subsequent control of attention links to descending and ascending networks with the corticolimbic and parietal cortex circuitry.

and serotonin. Parvalbumin-positive interneurons are linked to the process of attentional control.

**Measures of impulsivity Measures of compulsivity**

Ineffective affect regulation, particularly in terms of anxiety and depression, may drive the compulsive tendency to rely on cognitive evaluations for environmental navigation and decision-making in those with

restrictive AN [4]. A discrete balance between GABAergic and glutamatergic neurotransmitter function in the prefrontal cortex may underpin excessive cognitive control of appetite in restrictive AN, and superior performance on

planning tasks [4].

Studies of subliminal priming (with food images for e.g.) demonstrate that restrictive AN patients, particularly those with high levels of anxiety, experience the greatest interference to cognitive processes such as working memory [31, 45]. Greater working memory capacity may in turn contribute to the holding in mind of excessively detailed cognitive ruminations (e.g. epistemic foraging) in the absence of food stimuli, which subsequently resists interference (e.g. from interoceptive or exteroceptive stimuli).

interference to cognitive processes, such as working memory [31, 45]. Greater working memory capacity may in turn contribute to the holding in mind of

*RDoC cognitive systems sub-domain definitions and measures of impulsivity and compulsivity in relation to* 

excessively detailed cognitive ruminations in the absence of food stimuli. As such, a discrete balance between GABAergic and glutamatergic neurotransmitter function in the prefrontal cortex may underpin excessive cognitive control of appetite in restrictive AN, and superior performance on working memory and planning tasks [4]. Moreover, a switch from deliberative dieting to compulsive appetite restriction may involve a switch from activation of incentive salience networks within nucleus accumbens systems in favour of dorsal striatum networks associated with Pavlovian Instrumental Transfer [25]. Compulsive cognitive ruminations and biases, which reflect in eye-tracking studies of vigilance and avoidance [46] may therefore become more deeply engrained and consolidated in connected regions such as hippocampal, cholinergic and striatal dopaminergic neurons [47]. This may alter non-conscious memory formation and increase the probability of cognitive biases to disorder-relevant stimuli [48]. Finally, a propensity to higher levels of anxiety is associated with compulsive ruminations in AN, as well as the common presentation of obsessive-compulsive and other psychiatric disorders [49].

*DOI: http://dx.doi.org/10.5772/intechopen.83702*

**RDoC cognitive systems sub-domain with definition**

**Cognitive control:** *The processes that modulate the operation of other cognitive and affective systems in the brain. Cognitive control processes enable the achievement of goal-oriented behaviour, when pre-potent responses are not adequate for* 

*current demands.*

**Working memory:** *The active maintenance and flexible updating of goal or task relevant information (e.g. holding in mind bits of information, strategies, and plans) in a limited capacity store that resists interference.*

*Impulsivity and Compulsivity in Anorexia Nervosa: Cognitive Systems Underlying Variation… DOI: http://dx.doi.org/10.5772/intechopen.83702*


#### **Table 1.**

*Anorexia and Bulimia Nervosa*

**RDoC cognitive systems sub-domain with definition**

**Declarative memory:** *The acquisition, encoding, storage and retrieval of information gained from the* 

*environment.*

**Language:**

*communication.*

*A system of shared symbolic representations of the external environment, incorporating abstract and self-related notions that aid thought and* 

**Perception:** *The process by which computations in the brain extract sensory information to construct a model of the environment, making predictions about the world and guiding action.*

**Measures of impulsivity Measures of compulsivity**

[44].

Altered perceptual processes are associated with specific central coherence and empathy deficits, such as an inability to perceive a global view [42], read the mind in the eyes [43] and alexithymia - an inefficiency in perceiving one's own or others' internal states

A switch from deliberative dieting to compulsive appetite restriction may involve a switch from activation of incentive salience networks within nucleus accumbens systems in favour of dorsal striatum networks associated with Pavlovian Instrumental Transfer [25]. The suprachiasmatic nucleus and superior colliculus control saccadic and other visual actions associated with excessive epistemic foraging of the environment, measured by eye-tracking equipment.

Compulsive cognitive ruminations and biases, which reflect in eye-tracking studies of vigilance and avoidance [46] may therefore become more deeply conditioned and consolidated in connected regions such as hippocampal, prefrontal cortex, and cholinergic and striatal dopaminergic neurons [47]. This may alter non-conscious memory formation and increase the probability of cognitive biases to disorder-relevant stimuli [48].

Coherent discourse analysis, which is reflected in neural function of Wernicke (temporal cortex) and Broca's (frontal cortex) areas for speech comprehension and production, respectively could measure restrictive eating behaviour that may be driven by cognitive ruminations. Experimental paradigms include discourse analyses and eye-tracking

equipment.

Heart-rate variability and pupillometry may highlight nonconsciously derived perceptual processes sub-serving impulsive tendencies and the binge-eating

The dorsal 'where' and ventral 'what' visual processing pathways are implicated in rapid responses to environmental stimuli. Backward masking (subliminal processing), motion processing, contrast sensitivity, emotion expression identification, face identification, object recognition, reading, and visual illusion susceptibility. See also the McGurk effect (multisensory), oddball detection, selfmonitoring and tone detection.

Declarative memory is important for spatial, temporal and contextual information, which represents a timeframe of events (e.g. episodic), and the organisation of items of memories into facts (semantic). Inferential and flexible extraction occurs from memories in order to update novel sensory information (e.g. Bayesian Inference). This may underlie conditioned fear and threat-related impulsive responses to food, eating

and the environment.

Inferior fronto-temporoparietal cortices, superior and middle temporal cortices, with considerable involvement of the limbic system, motor and sensory cortices. This may underlie the negative self-talk and phonological loop activation associated with impulsive responses to perceived threat and subsequent binge eating, which acts as a maladaptive coping strategy to suppress

negative affect.

Fluctuating levels of acetylcholine, glutamate, noradrenalin and opioids. In terms on neuronal cell types that support declarative memory, these are glia, granule cells, inhibitory and excitatory interneurons and pyramidal cells.

subtypes [40, 41].

**14**

*RDoC cognitive systems sub-domain definitions and measures of impulsivity and compulsivity in relation to anorexia nervosa (binge-purge and restraint subtypes).*

interference to cognitive processes, such as working memory [31, 45]. Greater working memory capacity may in turn contribute to the holding in mind of excessively detailed cognitive ruminations in the absence of food stimuli. As such, a discrete balance between GABAergic and glutamatergic neurotransmitter function in the prefrontal cortex may underpin excessive cognitive control of appetite in restrictive AN, and superior performance on working memory and planning tasks [4]. Moreover, a switch from deliberative dieting to compulsive appetite restriction may involve a switch from activation of incentive salience networks within nucleus accumbens systems in favour of dorsal striatum networks associated with Pavlovian Instrumental Transfer [25]. Compulsive cognitive ruminations and biases, which reflect in eye-tracking studies of vigilance and avoidance [46] may therefore become more deeply engrained and consolidated in connected regions such as hippocampal, cholinergic and striatal dopaminergic neurons [47]. This may alter non-conscious memory formation and increase the probability of cognitive biases to disorder-relevant stimuli [48]. Finally, a propensity to higher levels of anxiety is associated with compulsive ruminations in AN, as well as the common presentation of obsessive-compulsive and other psychiatric disorders [49].

#### **5. Conclusions**

Considering the facets of impulsivity and compulsivity in AN from the perspective of the cognitive systems, RDoC domain may aid understanding of the nuances of appetite control in eating disorders. Traditionally, impulsivity is associated with binge-eating subtypes, which incorporates response inhibition deficits, craving, errors of perception, deficits in affect regulation and decision-making. In contrast, compulsivity appears to underlie the drive for thinness and excessive cognitive ruminations about food, eating, shape and weight concerns, and the control of eating in restrictive AN. As such, attention, declarative memory systems, perceptual processes, language and internal narratives, cognitive control processes and working memory–to hold consciously in mind complex strategies and detailed plans–appear significantly associated with restrictive AN. Moreover, heightened anxiety and altered incentive salience, non-consciously represented by mesolimbic function, appear to drive the compulsive maladaptive coping strategies. Thus, impulsivity and compulsivity may not form a diathesis model in AN, but they may rather overlap. Given this potential overlap, it might be that treatment interventions effectively treat one and not the other, which could form a basis for relapse. For example, altering maladaptive, compulsive cognitions during cognitive-behavioural therapy treatment without sufficiently altering impulsive, non-consciously-derived appetitive arousal and anxiety (to food or body images, for example), could drive the eventual re-emergence of maladaptive cognitions and relapse.

The popularity and relative efficacy of cognitive behavioural therapy for eating disorders may be due, in part, to the effective measurement of conscious, compulsive restraint cognitions – with self-report or neurocognitive paradigms for example – that may be easier to measure than non-consciously derived impulsive tendencies. Despite this, standard treatments for eating disorders continue to be subject to high relapse rates. However, the RD0C provides suggestions for other measures, such as cellular systems, genes, molecules (neurotransmitters) and neural systems that may well influence conscious compulsions, but are themselves functioning nonconsciously within biological systems. With this in mind, measures of impulsivity (e.g. anxiety, appetitive and non-conscious responses to food) may help to inform treatment efficacy, alongside more deliberative, psychological measures of compulsivity (e.g. self-report, neurocognitive tasks). Measuring the overlap between impulsivity and compulsivity in AN, from the perspective of the RDoC cognitive systems domain, may enable a more accurate model of appetite restraint that can improve relapse rates post-treatment.

**17**

**Author details**

Samantha Jane Brooks1

Liverpool, United Kingdom

provided the original work is properly cited.

Uppsala University, BMC, Uppsala, Sweden

\*Address all correspondence to: s.j.brooks@ljmu.ac.uk

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

1 School of Natural Sciences and Psychology, Liverpool John Moores University,

2 Head of Section of Functional Pharmacology, Department of Neuroscience,

\* and Helgi Schiöth2

*Impulsivity and Compulsivity in Anorexia Nervosa: Cognitive Systems Underlying Variation…*

*DOI: http://dx.doi.org/10.5772/intechopen.83702*

#### **Conflict of interest**

The author declares no conflict of interest.

*Impulsivity and Compulsivity in Anorexia Nervosa: Cognitive Systems Underlying Variation… DOI: http://dx.doi.org/10.5772/intechopen.83702*

### **Author details**

*Anorexia and Bulimia Nervosa*

Considering the facets of impulsivity and compulsivity in AN from the perspective of the cognitive systems, RDoC domain may aid understanding of the nuances of appetite control in eating disorders. Traditionally, impulsivity is associated with binge-eating subtypes, which incorporates response inhibition deficits, craving, errors of perception, deficits in affect regulation and decision-making. In contrast, compulsivity appears to underlie the drive for thinness and excessive cognitive ruminations about food, eating, shape and weight concerns, and the control of eating in restrictive AN. As such, attention, declarative memory systems, perceptual processes, language and internal narratives, cognitive control processes and working memory–to hold consciously in mind complex strategies and detailed plans–appear significantly associated with restrictive AN. Moreover, heightened anxiety and altered incentive salience, non-consciously represented by mesolimbic function, appear to drive the compulsive maladaptive coping strategies. Thus, impulsivity and compulsivity may not form a diathesis model in AN, but they may rather overlap. Given this potential overlap, it might be that treatment interventions effectively treat one and not the other, which could form a basis for relapse. For example, altering maladaptive, compulsive cognitions during cognitive-behavioural therapy treatment without sufficiently altering impulsive, non-consciously-derived appetitive arousal and anxiety (to food or body images, for example), could drive

the eventual re-emergence of maladaptive cognitions and relapse.

improve relapse rates post-treatment.

The author declares no conflict of interest.

**Conflict of interest**

The popularity and relative efficacy of cognitive behavioural therapy for eating disorders may be due, in part, to the effective measurement of conscious, compulsive restraint cognitions – with self-report or neurocognitive paradigms for example – that may be easier to measure than non-consciously derived impulsive tendencies. Despite this, standard treatments for eating disorders continue to be subject to high relapse rates. However, the RD0C provides suggestions for other measures, such as cellular systems, genes, molecules (neurotransmitters) and neural systems that may well influence conscious compulsions, but are themselves functioning nonconsciously within biological systems. With this in mind, measures of impulsivity (e.g. anxiety, appetitive and non-conscious responses to food) may help to inform treatment efficacy, alongside more deliberative, psychological measures of compulsivity (e.g. self-report, neurocognitive tasks). Measuring the overlap between impulsivity and compulsivity in AN, from the perspective of the RDoC cognitive systems domain, may enable a more accurate model of appetite restraint that can

**5. Conclusions**

**16**

Samantha Jane Brooks1 \* and Helgi Schiöth2

1 School of Natural Sciences and Psychology, Liverpool John Moores University, Liverpool, United Kingdom

2 Head of Section of Functional Pharmacology, Department of Neuroscience, Uppsala University, BMC, Uppsala, Sweden

\*Address all correspondence to: s.j.brooks@ljmu.ac.uk

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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**19**

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[17] Koob GF, Le MMR. Neurobiological mechanisms for opponent motivational processes in addiction. Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences. 2008;**363**(1507):3113-3123

[18] George O, Le Moal M, Koob GF. Allostasis and addiction: Role of the dopamine and corticotropin-releasing factor systems. Physiology & Behavior. 2012;**106**(1):58-64

[19] Woods SC, Begg DP. Regulation of the motivation to eat. Current Topics in Behavioral Neurosciences. 2016;**27**:15-34

[20] Steward T, Mestre-Bach G, Vintro-Alcaraz C, Aguera Z, Jimenez-Murcia S, Granero R, et al. Delay discounting of reward and impulsivity in eating disorders: From anorexia nervosa to binge eating disorder. European Eating Disorders Review. 2017;**25**(6):601-606

[21] Wilson DR, Loxton NJ, O'Shannessy D, Sheeran N, Morgan A. Similarities and differences in revised reinforcement sensitivities across eating disorder subtypes. Appetite. 2018;**133**:70-76

[22] Kim HS, von Ranson KM, Hodgins DC, McGrath DS, Tavares H. Demographic, psychiatric, and personality correlates of adults seeking treatment for disordered gambling with a comorbid binge/purge type eating disorder. European Eating Disorders Review. 2018;**26**(5):508-518

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in women with anorexia nervosa: Considering the role of negative urgency. Comprehensive Psychiatry. 2016;**66**:104-112

[25] Everitt BJ. Neural and psychological mechanisms underlying compulsive drug seeking habits and drug memories–indications for novel treatments of addiction. The European Journal of Neuroscience. 2014;**40**(1):2163-2182

[26] Godier LR, Park RJ. Compulsivity in anorexia nervosa: A transdiagnostic concept. Frontiers in Psychology. 2014;**5**:778

[27] Gillan CM, Fineberg NA, Robbins TW. A trans-diagnostic perspective on obsessive-compulsive disorder. Psychological Medicine. 2017;**47**(9):1528-1548

[28] O'Hara CB, Campbell IC, Schmidt U. A reward-centred model of anorexia nervosa: A focussed narrative review of the neurological and psychophysiological literature. Neuroscience and Biobehavioral Reviews. 2015;**52**:131-152

[29] Koob GF, Volkow ND. Neurobiology of addiction: A neurocircuitry analysis. Lancet Psychiatry. 2016;**3**(8):760-773

[30] Fischer S, Smith GT, Cyders MA. Another look at impulsivity: A metaanalytic review comparing specific dispositions to rash action in their relationship to bulimic symptoms. Clinical Psychology Review. 2008;**28**(8):1413-1425

[31] Brooks SJ, O'Daly OG, Uher R, Schioth HB, Treasure J, Campbell IC. Subliminal food images compromise superior working memory performance in women with restricting anorexia nervosa. Consciousness and Cognition. 2012;**21**(2):751-763

[32] O'Hara CB, Keyes A, Renwick B, Giel KE, Campbell IC, Schmidt U.

**18**

*Anorexia and Bulimia Nervosa*

[1] First MB. Diagnostic and statistical manual of mental disorders, 5th edition, and clinical utility. The Journal correlates of impulsivity and compulsivity. CNS Spectrums.

[10] Brooks SJ, Lochner C, Shoptaw S, Stein DJ. Using the research domain criteria (RDoC) to conceptualise

impulsivity and compulsivity in relation to addiction. Progress in Brain Research.

2014;**19**(1):69-89

2017;**235**:177-218

2017;**18**(3):158-171

2015;**6**(2):182-198

37-51

[14] Chamberlain SR, Stochl J, Redden SA, Grant JE. Latent traits of impulsivity and compulsivity: Toward dimensional psychiatry. Psychological

Medicine. 2018;**48**(5):810-821

[15] Brooks S, Prince A, Stahl D, Campbell IC, Treasure J. A systematic review and meta-analysis of cognitive bias to food stimuli in people with disordered eating behaviour. Clinical Psychology Review. 2011;**31**(1):

[16] Cartoni E, Balleine B, Baldassarre G. Appetitive Pavlovian-instrumental transfer: A review. Neuroscience and Biobehavioral Reviews. 2016;**71**:829-848

[11] Dalley JW, Robbins

TW. Fractionating impulsivity: Neuropsychiatric implications. Nature Reviews Neuroscience.

[12] Hamilton KR, Littlefield AK, Anastasio NC, Cunningham KA, Fink LHL, Wing VC, et al. Rapid-response impulsivity: Definitions, measurement issues, and clinical implications.

Personality Disorders: Theory, Research, and Treatment. 2015;**6**(2):168-181

[13] Hamilton KR, Mitchell MR, Wing VC, Balodis IM, Bickel WK, Fillmore M, et al. Choice impulsivity: Definitions, measurement issues, and clinical implications. Personality Disorders: Theory, Research, and Treatment.

of Nervous and Mental Disease.

[2] Call C, Walsh BT, Attia E. From DSM-IV to DSM-5: Changes to eating disorder diagnoses. Current Opinion in

[3] Treasure J, Zipfel S, Micali N, Wade T, Stice E, Claudino A, et al. Anorexia nervosa. Nature Reviews Disease

[4] Brooks SJ, Funk SG, Young SY, Schioth HB. The role of working memory for cognitive control in anorexia nervosa versus substance use disorder. Frontiers in Psychology.

[5] Collier DA, Treasure JL. The

Review. 2017;**25**(4):309-313

2017;**235**:177-218

2011;**69**(4):680-694

aetiology of eating disorders. The British Journal of Psychiatry. 2004;**185**:363-365

[6] Lavender JM, Goodman EL, Culbert KM, Wonderlich SA, Crosby RD, Engel SG, et al. Facets of impulsivity and compulsivity in women with anorexia nervosa. European Eating Disorders

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[8] Dalley JW, Everitt BJ, Robbins TW. Impulsivity, compulsivity, and top-down cognitive control. Neuron.

[9] Fineberg NA, Chamberlain SR, Goudriaan AE, Stein DJ, Vanderschuren LJ, Gillan CM, et al. New developments

Clinical, genetic, and brain imaging

in human neurocognition:

Psychiatry. 2013;**26**(6):532-536

2013;**201**(9):727-729

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[42] Fonville L, Lao-Kaim NP, Giampietro V, Van den Eynde F, Davies H, Lounes N, et al. Evaluation of enhanced attention to local detail in anorexia nervosa using the embedded figures test; an FMRI study. PLoS One. 2013;**8**(5):e63964

[43] Warrier V, Grasby KL, Uzefovsky F, Toro R, Smith P, Chakrabarti B, et al. Genome-wide meta-analysis of cognitive empathy: Heritability, and correlates with sex, neuropsychiatric conditions and cognition. Molecular Psychiatry. 2018;**23**(6):1402-1409

[44] Rozenstein MH, Latzer Y, Stein D, Eviatar Z. Perception of emotion and bilateral advantage in women with eating disorders, their healthy sisters, and nonrelated healthy controls. Journal of Affective Disorders. 2011;**134**(1-3):386-395

[45] Dickson H, Brooks S, Uher R, Tchanturia K, Treasure J, Campbell IC. The inability to ignore: Distractibility in women with restricting anorexia nervosa. Psychological Medicine. 2008;**38**(12):1741-1748

[46] Bauer A, Schneider S, Waldorf M, Cordes M, Huber TJ, Braks K, et al. Visual processing of one's own body over the course of time: Evidence for the vigilance-avoidance theory in adolescents with anorexia nervosa? The International Journal of Eating Disorders. 2017;**50**(10):1205-1213

**21**

*Impulsivity and Compulsivity in Anorexia Nervosa: Cognitive Systems Underlying Variation…*

*DOI: http://dx.doi.org/10.5772/intechopen.83702*

[47] Steward T, Menchon JM, Jimenez-Murcia S, Soriano-Mas C, Fernandez-Aranda F. Neural network alterations across eating disorders: A narrative review of fMRI studies. Current Neuropharmacology.

[48] Renwick B, Campbell IC, Schmidt U. Review of attentional bias modification: A brain-directed treatment for eating disorders. European Eating Disorders Review.

[49] Marucci S, Ragione LD, De Iaco G, Mococci T, Vicini M, Guastamacchia E, et al. Anorexia nervosa and comorbid psychopathology. Endocrine, Metabolic & Immune Disorders Drug Targets.

2018;**16**(8):1150-1163

2013;**21**(6):464-474

2018;**18**(4):316-324

*Impulsivity and Compulsivity in Anorexia Nervosa: Cognitive Systems Underlying Variation… DOI: http://dx.doi.org/10.5772/intechopen.83702*

[47] Steward T, Menchon JM, Jimenez-Murcia S, Soriano-Mas C, Fernandez-Aranda F. Neural network alterations across eating disorders: A narrative review of fMRI studies. Current Neuropharmacology. 2018;**16**(8):1150-1163

*Anorexia and Bulimia Nervosa*

2016;**11**(10):e0165104

2018;**128**:188-196

2018;**61**:9-23

2016;**239**:39-46

2013;**46**(5):425-432

2018;**9**:64-73

2018;**55**:10-17

Evidence that illness-compatible cues are rewarding in women recovered from anorexia nervosa: A study of the effects of dopamine depletion on eye-blink startle responses. PLoS One. [40] Peschel SK, Feeling NR, Vogele C, Kaess M, Thayer JF, Koenig J. A systematic review on heart rate variability in bulimia nervosa. Neuroscience and Biobehavioral

[41] Puviani L, Rama S, Vitetta GM. Computational psychiatry and

[42] Fonville L, Lao-Kaim NP,

2013;**8**(5):e63964

psychometrics based on non-conscious stimuli input and pupil response output. Frontiers in Psychiatry. 2016;**7**:190

Giampietro V, Van den Eynde F, Davies H, Lounes N, et al. Evaluation of enhanced attention to local detail in anorexia nervosa using the embedded figures test; an FMRI study. PLoS One.

[43] Warrier V, Grasby KL, Uzefovsky F, Toro R, Smith P, Chakrabarti B, et al. Genome-wide meta-analysis of cognitive empathy: Heritability, and correlates with sex, neuropsychiatric conditions and cognition. Molecular Psychiatry. 2018;**23**(6):1402-1409

[44] Rozenstein MH, Latzer Y, Stein D, Eviatar Z. Perception of emotion and bilateral advantage in women with eating disorders, their healthy sisters, and nonrelated healthy

controls. Journal of Affective Disorders.

2011;**134**(1-3):386-395

[45] Dickson H, Brooks S, Uher R, Tchanturia K, Treasure J,

anorexia nervosa. Psychological Medicine. 2008;**38**(12):1741-1748

Campbell IC. The inability to ignore: Distractibility in women with restricting

[46] Bauer A, Schneider S, Waldorf M, Cordes M, Huber TJ, Braks K, et al. Visual processing of one's own body over the course of time: Evidence for the vigilance-avoidance theory in adolescents with anorexia nervosa? The International Journal of Eating Disorders. 2017;**50**(10):1205-1213

Reviews. 2016;**63**:78-97

[33] Higgs S, Spetter MS. Cognitive control of eating: The role of memory in appetite and weight gain. Current Obesity Reports. 2018;**7**(1):50-59

[34] Whitelock V, Higgs S, Brunstrom JM, Halford JCG, Robinson E. No effect of focused attention whilst eating on later snack food intake: Two laboratory experiments. Appetite.

[35] Smith KE, Mason TB, Lavender JM. Rumination and eating disorder psychopathology: A meta-analysis. Clinical Psychology Review.

[36] Danner UN, Sternheim L,

Bijsterbosch JM, Dingemans AE, Evers C, van Elburg AA. Influence of negative affect on decision making in women with restrictive and binge-purge type anorexia nervosa. Psychiatry Research.

[37] Friederich HC, Wu M, Simon JJ, Herzog W. Neurocircuit function in eating disorders. The International Journal of Eating Disorders.

[38] Wierenga CE, Lavender JM, Hays CC. The potential of calibrated fMRI in the understanding of stress in eating disorders. Neurobiology of Stress.

[39] Spalatro AV, Amianto F, Huang Z, D'Agata F, Bergui M, Abbate Daga G, et al. Neuronal variability of resting state activity in eating disorders: Increase and decoupling in ventral attention network and relation with clinical symptoms. European Psychiatry.

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[48] Renwick B, Campbell IC, Schmidt U. Review of attentional bias modification: A brain-directed treatment for eating disorders. European Eating Disorders Review. 2013;**21**(6):464-474

[49] Marucci S, Ragione LD, De Iaco G, Mococci T, Vicini M, Guastamacchia E, et al. Anorexia nervosa and comorbid psychopathology. Endocrine, Metabolic & Immune Disorders Drug Targets. 2018;**18**(4):316-324

**23**

**Chapter 2**

**Abstract**

**1. Introduction**

Bulimia Nervosa and Body

Dissatisfaction in Terms of

*Hessah Ibrahim Alsuwedan, Hessa Faleh Alnefaie,*

*Layam Anitha, Asma Abdulaziz Alhussaini,*

will lead to eating disorders in adolescents.

**Keywords:** self-perception, body image, misperception, BMI

Self-Perception of Body Image

*Rehab Abduallah Almubrek and Shima Abdulaziz Aldaweesh*

Bulimia nervosa is characterized by disturbed body image, repetitive binge eating, and compensatory behaviours such as self-induced vomiting, laxative abuse, or fasting. Body image dissatisfaction and eating disordered behaviours (e.g. food restriction, purging, and binge eating) can affect men and women of varied ages, races, and cultural backgrounds. Body dissatisfaction is defined as a negative subjective evaluation of the weight and shape of one's own body. Body dissatisfaction predicts the onset, severity, and treatment outcomes of eating disorders. A core component of body dissatisfaction is appearance-based social comparisons. In this context a study on self-perception of body image of women in Riyadh in 2018 revealed that a sudden spurt in obesity after marriage is leading to shift of higher percentage of women from positive to negative perception. Overall, an underestimation of body weight in terms of BMI was found among the participants. Such misconceptions should be addressed in view of the high obesity prevalence. It was also evident that positive and negative body image perception

The diagnostic and statistical manual (DSM) [1] defines bulimia nervosa as characterised by disturbed body image, repetitive binge eating and compensatory behaviours such as laxative abuse, self-induced vomiting or fasting. Bulimia nervosa was ranked as 12th leading cause of disability adjusted life years (DALYs) in females aged 15–19 years in high income group countries out of 306 mental and physical disorders [2, 3]. Although this ranking did not change globally to a great extent between 1990 and 2013, ranking has been increased from 58th in 1990 to 46th in 2013 in low-income and middle income countries [2]. The review articles of eating disorders showed that it occurred mostly in the high-risk group of young western females [4, 5]. In 2014 Pike et al. found that eating disorders appear to be increasing in Asian and Arab countries in conjunction with increasing industrialization, urbanization and globalization [6]. In Europe, anorexia nervosa is reported

#### **Chapter 2**

## Bulimia Nervosa and Body Dissatisfaction in Terms of Self-Perception of Body Image

*Layam Anitha, Asma Abdulaziz Alhussaini, Hessah Ibrahim Alsuwedan, Hessa Faleh Alnefaie, Rehab Abduallah Almubrek and Shima Abdulaziz Aldaweesh*

#### **Abstract**

Bulimia nervosa is characterized by disturbed body image, repetitive binge eating, and compensatory behaviours such as self-induced vomiting, laxative abuse, or fasting. Body image dissatisfaction and eating disordered behaviours (e.g. food restriction, purging, and binge eating) can affect men and women of varied ages, races, and cultural backgrounds. Body dissatisfaction is defined as a negative subjective evaluation of the weight and shape of one's own body. Body dissatisfaction predicts the onset, severity, and treatment outcomes of eating disorders. A core component of body dissatisfaction is appearance-based social comparisons. In this context a study on self-perception of body image of women in Riyadh in 2018 revealed that a sudden spurt in obesity after marriage is leading to shift of higher percentage of women from positive to negative perception. Overall, an underestimation of body weight in terms of BMI was found among the participants. Such misconceptions should be addressed in view of the high obesity prevalence. It was also evident that positive and negative body image perception will lead to eating disorders in adolescents.

**Keywords:** self-perception, body image, misperception, BMI

#### **1. Introduction**

The diagnostic and statistical manual (DSM) [1] defines bulimia nervosa as characterised by disturbed body image, repetitive binge eating and compensatory behaviours such as laxative abuse, self-induced vomiting or fasting. Bulimia nervosa was ranked as 12th leading cause of disability adjusted life years (DALYs) in females aged 15–19 years in high income group countries out of 306 mental and physical disorders [2, 3]. Although this ranking did not change globally to a great extent between 1990 and 2013, ranking has been increased from 58th in 1990 to 46th in 2013 in low-income and middle income countries [2]. The review articles of eating disorders showed that it occurred mostly in the high-risk group of young western females [4, 5]. In 2014 Pike et al. found that eating disorders appear to be increasing in Asian and Arab countries in conjunction with increasing industrialization, urbanization and globalization [6]. In Europe, anorexia nervosa is reported by 1–4%, bulimia nervosa by 1–2% and Binge eating disorders (BED) by 1–4% of women [7]. The highest contributions of total DALY's caused by eating disorders among women aged 15–49 years was observed in India with over 1.32 billion, China over 1.38 billion along with United States [8]. Eating disorders have global distribution and are associated with increasing health burdens in Asia [9].

#### **1.1 Association between bulimia nervosa, body image and body dissatisfaction**

Body image has been studied extensively in patients with bulimia nervosa. Body image has been identified as an important factor in eating disorders but little research has been successfully carried out to have meaningful conclusions. Body image dissatisfaction and eating disordered behaviours can affect men and women of varied ages, races, and cultural backgrounds; however psychologists indicate that body image is one of the strongest gender differences in social sciences. Several studies have empirically investigated the role of social influence on body image and dissatisfaction [10]. Factors such as body-image dissatisfaction, the adoption of a perfectionistic attitude towards the body, the restrictive pursuit of thinness, and the development of bulimic tendencies are often indicated in scientific research as predictors of eating disorders [11–15]. However, most researchers focus on selected risk factors and indicate that the risk factors of eating disorders should not be considered separately. These factors seem to constitute the specific syndrome, related to the culture of thinness.

Body image is a multidimensional construct that represents body image evaluation that comprises perceptions, attitudes, and feelings about body size, shape and related behaviours [16]. The attitudinal dimension, also called as body satisfaction, reflects individuals' feeling about their body appearance, and the perceptual dimension is also called as body perception, which reflects individuals' subjective expectancy of their body image [17, 18]. Disturbances of body image perception are considered to be one of the central aspects of anorexia nervosa (AN) and bulimia nervosa (BN) [19]. According to Garner and Garfinkel [20], body image disturbances consist of two separate aspects, i.e. perceptual disturbance and body dissatisfaction. Perceptual disturbance involves the inability to assess the size of one's body accurately. Body dissatisfaction includes affective or attitudinal perceptions of one's body [20].

Body image disturbance (BID) refers to an overvaluation of one's appearance, possibly combined with difficulties in correctly gauging one's size and with pronounced body avoidance or checking behaviour. It is a transdiagnostic feature of AN and BN and assumed to be the core psychopathology of eating and weight disorders [21]. The distinction between body size distortion and body dissatisfaction has been studied in bulimic patients [12]. Although these two concepts have not been included in the DSM-III diagnostic criteria for bulimia nervosa, it has been postulated that a disturbance in body image plays a role in the disorder aetiology. Self-report procedures in the form of semi-structured interviews or questionnaires have been established for the assessment of BID, but experimental setups using specific devices are also commonly used [22, 23]. The different measures of BID are assumed to capture different aspects of BID.

Research has revealed associations between sociocultural aspects and women's perception towards body image. In some cultures, especially for women thinness is accepted as an icon of women whereas in other a medium body mass index (BMI) is accepted. It has been proposed that pressure to be thin from one's environment increases body dissatisfaction because the message to be thin via media or family fraternity will make the individual to feel discontent with their body image in terms of physical appearance. This view has been supported by perceived pressure leading

**25**

program.

**2. Methodology**

*Bulimia Nervosa and Body Dissatisfaction in Terms of Self-Perception of Body Image*

dissatisfaction appears to be influenced both by social factors and BMI.

Previous research has reported both positive and negative aspects of body image as a psychological construct. A satisfactory body image has been linked to long term mental health and wellbeing [28, 29]. However body image dissatisfaction has been associated with a variety of disturbances that affect psychological functioning and quality of life which has led to unhealthy weight control behaviours and suicidal ideation [30, 31]. In general, people either have a positive or negative impression on the way they look. Some have learned how to be proud and tend to accept the way they look and feel about themselves regardless of what others might say or judge. On the other hand, people with a negative body image usually are dissatisfied. Thus, they tend to exaggerate the evaluation of their whole body or some parts whether

Based on the western study, women perceived themselves as '62% of overestimation' and '33% just right', while '5% of underestimation' compared with actual weight [33]. Furthermore, Saudi studies reported that only (23.3%) of the students had an agreement between their actual and perceived weight in which ideal body image discrepancies were found among the participants who wanted to be thinner (44.1%) or heavier (19.7%) than their perceived Body image [34]. Preference for a particular body weight and attitudes towards it may be mediated by cultural, personal and familial factors as well as an individual's own weight status [35].

Overall, the focus on ideal body size rather than on a range of acceptable body sizes has contributed to a literature that emphasizes female body size dissatisfactions [42]. Most of recent studies are conducted from western society. Since the issue of weight and weight perception are universal, the influence of social norms cannot be denied. Furthermore, there is a lack of information on how the misperception might affect Saudi women [43]. So, to understand self-perception, it is a demand to understand how people might feel about themselves as they definitely experience physical changes over their lifespan [46]. Study in south western in Saudi Arabia clarified that 76.7% had a disagreement in relation to misperception of body image [34]. Since it was highly significant in Saudi Arabia, where eating disorders and obesity is on increasing pace, it is incumbent to fill the gap and provide a reliable baseline data that might help the policy makers to develop an intervention

A cross-sectional study was conducted in a university, located in Riyadh, Saudi Arabia. Participants are Saudi female from non-health college students and employees ranging in age from 18 to 50 years. The sample size was selected from open EPI website, based on confidence interval 95%. This study included 336 respondents out of which 269 (80%) were students and 67 (20%) were employees. Data was collected by structured self-administered questionnaire and close-ended questions. Some of the questions collected from previous studies and has been modified to be in line of Saudi culture. It includes socio-demographic information (ID, age, marital status, etc.), as well as, questions related to assessment of self-perception of body

to subsequent increase in body dissatisfaction [24] and in turn risk of development of an eating disorder [25]. A study was conducted by Massidda et al. [26] to analyse the relations between perceptual body distortion, body dissatisfaction, social influence and body Mass Index and the desire to change in a sample of young women. Results of this study revealed that participants tend to perceive their body as larger than real and they desire their body to be thinner than real which has been supported by Mikolajczyk et al. study [27]. Finally the results revealed that body

*DOI: http://dx.doi.org/10.5772/intechopen.84948*

bigger or smaller than what they actually are [32].

#### *Bulimia Nervosa and Body Dissatisfaction in Terms of Self-Perception of Body Image DOI: http://dx.doi.org/10.5772/intechopen.84948*

to subsequent increase in body dissatisfaction [24] and in turn risk of development of an eating disorder [25]. A study was conducted by Massidda et al. [26] to analyse the relations between perceptual body distortion, body dissatisfaction, social influence and body Mass Index and the desire to change in a sample of young women. Results of this study revealed that participants tend to perceive their body as larger than real and they desire their body to be thinner than real which has been supported by Mikolajczyk et al. study [27]. Finally the results revealed that body dissatisfaction appears to be influenced both by social factors and BMI.

Previous research has reported both positive and negative aspects of body image as a psychological construct. A satisfactory body image has been linked to long term mental health and wellbeing [28, 29]. However body image dissatisfaction has been associated with a variety of disturbances that affect psychological functioning and quality of life which has led to unhealthy weight control behaviours and suicidal ideation [30, 31]. In general, people either have a positive or negative impression on the way they look. Some have learned how to be proud and tend to accept the way they look and feel about themselves regardless of what others might say or judge. On the other hand, people with a negative body image usually are dissatisfied. Thus, they tend to exaggerate the evaluation of their whole body or some parts whether bigger or smaller than what they actually are [32].

Based on the western study, women perceived themselves as '62% of overestimation' and '33% just right', while '5% of underestimation' compared with actual weight [33]. Furthermore, Saudi studies reported that only (23.3%) of the students had an agreement between their actual and perceived weight in which ideal body image discrepancies were found among the participants who wanted to be thinner (44.1%) or heavier (19.7%) than their perceived Body image [34]. Preference for a particular body weight and attitudes towards it may be mediated by cultural, personal and familial factors as well as an individual's own weight status [35].

Overall, the focus on ideal body size rather than on a range of acceptable body sizes has contributed to a literature that emphasizes female body size dissatisfactions [42]. Most of recent studies are conducted from western society. Since the issue of weight and weight perception are universal, the influence of social norms cannot be denied. Furthermore, there is a lack of information on how the misperception might affect Saudi women [43]. So, to understand self-perception, it is a demand to understand how people might feel about themselves as they definitely experience physical changes over their lifespan [46]. Study in south western in Saudi Arabia clarified that 76.7% had a disagreement in relation to misperception of body image [34]. Since it was highly significant in Saudi Arabia, where eating disorders and obesity is on increasing pace, it is incumbent to fill the gap and provide a reliable baseline data that might help the policy makers to develop an intervention program.

#### **2. Methodology**

A cross-sectional study was conducted in a university, located in Riyadh, Saudi Arabia. Participants are Saudi female from non-health college students and employees ranging in age from 18 to 50 years. The sample size was selected from open EPI website, based on confidence interval 95%. This study included 336 respondents out of which 269 (80%) were students and 67 (20%) were employees. Data was collected by structured self-administered questionnaire and close-ended questions. Some of the questions collected from previous studies and has been modified to be in line of Saudi culture. It includes socio-demographic information (ID, age, marital status, etc.), as well as, questions related to assessment of self-perception of body

*Anorexia and Bulimia Nervosa*

to the culture of thinness.

one's body [20].

assumed to capture different aspects of BID.

by 1–4%, bulimia nervosa by 1–2% and Binge eating disorders (BED) by 1–4% of women [7]. The highest contributions of total DALY's caused by eating disorders among women aged 15–49 years was observed in India with over 1.32 billion, China over 1.38 billion along with United States [8]. Eating disorders have global distribu-

**1.1 Association between bulimia nervosa, body image and body dissatisfaction**

Body image has been studied extensively in patients with bulimia nervosa. Body image has been identified as an important factor in eating disorders but little research has been successfully carried out to have meaningful conclusions. Body image dissatisfaction and eating disordered behaviours can affect men and women of varied ages, races, and cultural backgrounds; however psychologists indicate that body image is one of the strongest gender differences in social sciences. Several studies have empirically investigated the role of social influence on body image and dissatisfaction [10]. Factors such as body-image dissatisfaction, the adoption of a perfectionistic attitude towards the body, the restrictive pursuit of thinness, and the development of bulimic tendencies are often indicated in scientific research as predictors of eating disorders [11–15]. However, most researchers focus on selected risk factors and indicate that the risk factors of eating disorders should not be considered separately. These factors seem to constitute the specific syndrome, related

Body image is a multidimensional construct that represents body image evaluation that comprises perceptions, attitudes, and feelings about body size, shape and related behaviours [16]. The attitudinal dimension, also called as body satisfaction, reflects individuals' feeling about their body appearance, and the perceptual dimension is also called as body perception, which reflects individuals' subjective expectancy of their body image [17, 18]. Disturbances of body image perception are considered to be one of the central aspects of anorexia nervosa (AN) and bulimia nervosa (BN) [19]. According to Garner and Garfinkel [20], body image disturbances consist of two separate aspects, i.e. perceptual disturbance and body dissatisfaction. Perceptual disturbance involves the inability to assess the size of one's body accurately. Body dissatisfaction includes affective or attitudinal perceptions of

Body image disturbance (BID) refers to an overvaluation of one's appearance, possibly combined with difficulties in correctly gauging one's size and with pronounced body avoidance or checking behaviour. It is a transdiagnostic feature of AN and BN and assumed to be the core psychopathology of eating and weight disorders [21]. The distinction between body size distortion and body dissatisfaction has been studied in bulimic patients [12]. Although these two concepts have not been included in the DSM-III diagnostic criteria for bulimia nervosa, it has been postulated that a disturbance in body image plays a role in the disorder aetiology. Self-report procedures in the form of semi-structured interviews or questionnaires have been established for the assessment of BID, but experimental setups using specific devices are also commonly used [22, 23]. The different measures of BID are

Research has revealed associations between sociocultural aspects and women's perception towards body image. In some cultures, especially for women thinness is accepted as an icon of women whereas in other a medium body mass index (BMI) is accepted. It has been proposed that pressure to be thin from one's environment increases body dissatisfaction because the message to be thin via media or family fraternity will make the individual to feel discontent with their body image in terms of physical appearance. This view has been supported by perceived pressure leading

tion and are associated with increasing health burdens in Asia [9].

**24**

image, weight perception, socio-cultural factors affecting body image, lifestyle habits, body satisfaction and media influencers. The data was collected after receiving the approval from ethical committee of university.

#### **3. Results and discussion**

Results of the study are presented in terms of perceived and actual BMI (**Table 1**). According to actual measurement in students, the mean BMI was 23.72 = 8.63 (Mean = SD) which belong to normal and in employees, the mean was 27.27 + 5.69) which comes under the overweight category. The perceived mean BMI for students was 22.68 + 9.70, belong to normal and in employees, the mean was 25.74 + 6.05) which comes under the overweight category. The mean for BMI was less to students when compared to employees, though 47.8% of employees belong to 18–29 years of age. In the present study assessing body image self-perception BMI has been used as an indicator of nutritional status associated with determinants of body weight related behaviours. The mean actual BMI was more than the mean perceived BMI both in students and employees. When the perceived BMI is less than the actual and hence this can lead to increase in the obesity incidence in a long run. For preventing and reducing excess weight, the efficacy relies on one's realistic perception and self-awareness of their own body based on a real body size.

Body image was perceived as positive and negative in comparison with actual BMI of students. Out of 269 students, 71.6% have positive body image perception and 28.4% has negative body image perception. The difference between positive and negative body image perception was statistically significant at *x2* (3) = 43.37, *p* < 0.001. Out of 66 employees, 56.1% have positive body image perception and 43.9% has negative body image perception and was statistically significant at *x2* (3) = 8.50, *p* = 0.03. Percentage of positive perception towards body image was more when compared with negative perception in both the students and employees (**Figure 1**).

The question regarding the sociocultural view towards body image was asked as 'From 1 to 10 where you think the ideal BI rank according to your sociocultural perspective'. From the mentioned question 1–4 was represented as thin, 5–6 represented moderate and 7–10 as fat. According to actual BMI categories, 132 (40.6%) in normal weight responded that moderate weight is the ideal body in their society. Fat weight was the ideal body image responded by 27 (8.3%) participants of normal


**27**

**Figure 1.**

**Figure 2.**

*Bulimia Nervosa and Body Dissatisfaction in Terms of Self-Perception of Body Image*

*Positive and negative perception towards body image among students and employees in PNU.*

weight category. Of normal weight category, thin weight was opted by 32 (9.9%) as ideal weight and only about 4 (1.2%) individuals from underweight category considered their weight as ideal weight (**Figure 2**). An interesting aspect observed from this study was 24.5% (55 in number) of overweight subjects rated that they

*Sociocultural view towards body image according to actual BMI categories among females.*

It is evident that 81% of students and 94% of employees felt that it appearance is very important, towards the perceptions of body image. Most of the percentage of the students that is 43.1–61.2% in employees wants to change their abdominal part and the good choice to change is through lose weight (48.7% in students and 68.7% in employees) (**Table 2**). 52% of students responded that media sometimes affect the perception of body image and 53.7% of employees responded the same. According to social pressure 49.8% of students responded that it never affects the body image. But 47.8% of employees responded that sometimes social pressure

About 63.9% of students and 53.7% of employees responded that sometimes they compared their body shape with others. Lowered self-esteem is the highest (49.8%) consequence related to the negative perception of body image by students. Lowered self-esteem (37.3%) and gaining motivation to exercise, eat healthier, etc.

belong to moderate scale of body image.

affects their body image (**Table 3**).

*DOI: http://dx.doi.org/10.5772/intechopen.84948*

**Table 1.**

*Actual and perceived anthropometric measurements of students and employees.*

*Bulimia Nervosa and Body Dissatisfaction in Terms of Self-Perception of Body Image DOI: http://dx.doi.org/10.5772/intechopen.84948*

#### **Figure 1.**

*Anorexia and Bulimia Nervosa*

**3. Results and discussion**

image, weight perception, socio-cultural factors affecting body image, lifestyle habits, body satisfaction and media influencers. The data was collected after receiv-

According to actual measurement in students, the mean BMI was 23.72 = 8.63 (Mean = SD) which belong to normal and in employees, the mean was 27.27 + 5.69) which comes under the overweight category. The perceived mean BMI for students was 22.68 + 9.70, belong to normal and in employees, the mean was 25.74 + 6.05) which comes under the overweight category. The mean for BMI was less to students when compared to employees, though 47.8% of employees belong to 18–29 years of age. In the present study assessing body image self-perception BMI has been used as an indicator of nutritional status associated with determinants of body weight related behaviours. The mean actual BMI was more than the mean perceived BMI both in students and employees. When the perceived BMI is less than the actual and hence this can lead to increase in the obesity incidence in a long run. For preventing and reducing excess weight, the efficacy relies on one's realistic perception and

Results of the study are presented in terms of perceived and actual BMI (**Table 1**).

Body image was perceived as positive and negative in comparison with actual BMI of students. Out of 269 students, 71.6% have positive body image perception and 28.4% has negative body image perception. The difference between positive

*p* < 0.001. Out of 66 employees, 56.1% have positive body image perception and 43.9% has negative body image perception and was statistically significant at

(3) = 8.50, *p* = 0.03. Percentage of positive perception towards body image was more when compared with negative perception in both the students and employees

The question regarding the sociocultural view towards body image was asked as 'From 1 to 10 where you think the ideal BI rank according to your sociocultural perspective'. From the mentioned question 1–4 was represented as thin, 5–6 represented moderate and 7–10 as fat. According to actual BMI categories, 132 (40.6%) in normal weight responded that moderate weight is the ideal body in their society. Fat weight was the ideal body image responded by 27 (8.3%) participants of normal

**Actual measurements Students (N = 269) Employees (N = 67)**

Height 156.86 8.03 155.65 5.42 Weight 56.89 11.51 66.05 14.27 Waist circumference 71.89 8.86 82.06 12.14 BMI 23.42 8.63 27.27 5.69

Height 158.7 8.77 157.52 7.23 Weight 56.07 11.01 63.79 14.87 BMI 22.68 9.7 25.74 6.05

*Actual and perceived anthropometric measurements of students and employees.*

**M SD M SD**

(3) = 43.37,

ing the approval from ethical committee of university.

self-awareness of their own body based on a real body size.

and negative body image perception was statistically significant at *x2*

**26**

**Table 1.**

*x2*

(**Figure 1**).

**Perceived measurements**

*Positive and negative perception towards body image among students and employees in PNU.*

#### **Figure 2.**

weight category. Of normal weight category, thin weight was opted by 32 (9.9%) as ideal weight and only about 4 (1.2%) individuals from underweight category considered their weight as ideal weight (**Figure 2**). An interesting aspect observed from this study was 24.5% (55 in number) of overweight subjects rated that they belong to moderate scale of body image.

It is evident that 81% of students and 94% of employees felt that it appearance is very important, towards the perceptions of body image. Most of the percentage of the students that is 43.1–61.2% in employees wants to change their abdominal part and the good choice to change is through lose weight (48.7% in students and 68.7% in employees) (**Table 2**). 52% of students responded that media sometimes affect the perception of body image and 53.7% of employees responded the same. According to social pressure 49.8% of students responded that it never affects the body image. But 47.8% of employees responded that sometimes social pressure affects their body image (**Table 3**).

About 63.9% of students and 53.7% of employees responded that sometimes they compared their body shape with others. Lowered self-esteem is the highest (49.8%) consequence related to the negative perception of body image by students. Lowered self-esteem (37.3%) and gaining motivation to exercise, eat healthier, etc.

*Sociocultural view towards body image according to actual BMI categories among females.*

(35.8%) are the highest consequences reported by the employees. Both the students and the employees sometimes have negative thoughts about their bodies which is 59.9 and 58.2% respectively (**Table 4**).

Throughout the adult lifespan, women are experienced to various stages on how they perceive their body which is important to examine the implicit and explicit attitude of self-perception toward body image such as age, education level, marriage,


#### **Table 2.**

*Descriptive statistics to assess the change towards their appearance of university students and employees.*


**29**

**Table 4.**

*Bulimia Nervosa and Body Dissatisfaction in Terms of Self-Perception of Body Image*

**Comparing body shape with others Students Employees**

Always 23 8.6 13 19.4 Sometimes 172 63.9 36 53.7 Never 73 27.1 17 25.4 Total 268 99.6 66 98.5

Being insecure around people 95 35.3 17 25.4 Embarrassment 37 13.8 9 13.4 General unhappiness 58 21.6 10 14.9 Lowered self –esteem 134 49.8 25 37.3 Undesirable to the opposite sex 13 4.8 2 3 Gaining motivation to exercise, eat healthier, etc. 94 34.9 24 35.8

Always 18 6.7 13 19.4 Sometimes 161 59.9 39 58.2 Never 89 33.1 13 19.4 Total 268 99.6 66 97

**N % N %**

pregnancy, social role changes, retirement, and menopause which can influence one's perceived level of body satisfaction [36, 37]. From social and psychological dimension, civilized and western societies are increasing the focus on female body image. They are inordinately emphasizing thinness as an ideal standard for beauty. Thus, women receive more social pressure to be beautiful than ever before [38, 39]. Regarding to social pressure, there was a study concerned about social factors and lifestyle associated with obesity among Arab women in Bahrain discovered that the ideal body is the middleweight, which found to be preferred more than thinness and fatness for women that are less socially accepted [34]. The revolution of mass media and fashion models has played an essential role on women perception towards their body image. The media is a powerful channel for transmission and reinforcement of cultural beliefs and values among all ages and ethnicities and other varieties, while it may not be exclusively responsible for determining the standards for physical attractiveness. Advertising, in particular creates a seductive and toxic mix of messages that can be taken seriously for both genders [40]. Nowadays, magazines, celebrities, idols all these agents contributes to make a difference in shaping our lives, changing beliefs and cultures in an imprescriptible way that we cannot even figure. Along with the ideal body image aspect which is being everywhere. A study investigated the satisfaction level in regard to BI among 10-year-old girls and boys. Unfortunately, they were dissatisfied with their bodies after watching their favourite

*Descriptive statistics indicate psychological effect of body image of students and employees.*

actor or singer in a music video or clip from TV shows [41].

'Misperception of own weight status refers to the discordance between an individual's actual weight status and the perception of his/her weight status' [42]. The discoveries of misperception from a study conducted in Hail about body weight perception, among female university students has shown that, one-third of students misclassifying themselves when compared with actual weight [43]. Several

*DOI: http://dx.doi.org/10.5772/intechopen.84948*

**Consequences relate to negative perception of BI**

**How often do you think a negative thought about your body**

#### **Table 3.**

*Descriptive statistics for social affect the body image perception of students and employees.*


*Bulimia Nervosa and Body Dissatisfaction in Terms of Self-Perception of Body Image DOI: http://dx.doi.org/10.5772/intechopen.84948*

#### **Table 4.**

*Anorexia and Bulimia Nervosa*

**Body part wants to change**

**Prefer to**

**Table 2.**

59.9 and 58.2% respectively (**Table 4**).

(35.8%) are the highest consequences reported by the employees. Both the students and the employees sometimes have negative thoughts about their bodies which is

Throughout the adult lifespan, women are experienced to various stages on how they perceive their body which is important to examine the implicit and explicit attitude of self-perception toward body image such as age, education level, marriage,

**N % N %**

**Importance of appearance Students Employees**

Very important 81 63 94 Moderately important 45 16.7 3 4.5 Slightly important 5 1.9 0 0 Not important 1 0.4 0 0 Total 269 100 66 98.5

Upper part 38 14.1 8 11.9 Abdominal part 116 43.1 41 61.2 Lower part 73 27.1 12 17.9 Nothing 40 14.9 5 7.5 Total 267 99.3 66 98.5

Do nothing 21 7.8 2 3 Lose weight 131 48.7 46 68.7 Gain weight 40 14.9 4 6 Maintain as it is 77 28.6 14 20.9 Total 269 100 66 98.5

**Media affect Students Employees**

*Descriptive statistics to assess the change towards their appearance of university students and employees.*

*Descriptive statistics for social affect the body image perception of students and employees.*

Always 86 32 20 29.9 Sometimes 140 52 36 53.7 Never 42 15.6 10 14.9 Total 268 99.6 66 98.5

Always 37 13.8 21 31.3 Sometimes 97 36.1 32 47.8 Never 134 49.8 13 19.4 Total 268 99.6 66 98.5

**N % N %**

**28**

**Table 3.**

**Social pressure**

*Descriptive statistics indicate psychological effect of body image of students and employees.*

pregnancy, social role changes, retirement, and menopause which can influence one's perceived level of body satisfaction [36, 37]. From social and psychological dimension, civilized and western societies are increasing the focus on female body image. They are inordinately emphasizing thinness as an ideal standard for beauty. Thus, women receive more social pressure to be beautiful than ever before [38, 39]. Regarding to social pressure, there was a study concerned about social factors and lifestyle associated with obesity among Arab women in Bahrain discovered that the ideal body is the middleweight, which found to be preferred more than thinness and fatness for women that are less socially accepted [34]. The revolution of mass media and fashion models has played an essential role on women perception towards their body image. The media is a powerful channel for transmission and reinforcement of cultural beliefs and values among all ages and ethnicities and other varieties, while it may not be exclusively responsible for determining the standards for physical attractiveness. Advertising, in particular creates a seductive and toxic mix of messages that can be taken seriously for both genders [40]. Nowadays, magazines, celebrities, idols all these agents contributes to make a difference in shaping our lives, changing beliefs and cultures in an imprescriptible way that we cannot even figure. Along with the ideal body image aspect which is being everywhere. A study investigated the satisfaction level in regard to BI among 10-year-old girls and boys. Unfortunately, they were dissatisfied with their bodies after watching their favourite actor or singer in a music video or clip from TV shows [41].

'Misperception of own weight status refers to the discordance between an individual's actual weight status and the perception of his/her weight status' [42]. The discoveries of misperception from a study conducted in Hail about body weight perception, among female university students has shown that, one-third of students misclassifying themselves when compared with actual weight [43]. Several

studies show that female has a lot of curiosity about their body image and worried regarding it more than men. In 2014, a study conducted among Malaysian men and women found a misperception of own weight status and was higher among females (34.5%) compared to males (26.7%) [42]. According to the study, possible consequences might result in restrictive dieting and unhealthy weight control methods which may lead to increase the risk for the development of eating disorders, such as anorexia and bulimia nervosa [44]. Otherwise, underestimating one's own weight is associated with an increase of developing overweight prevalence [45]. Also, it is associated with depression, low self-esteem, feeling of shame, body surveillance, anxious and social isolation [40]. Additionally, Women's perception may shape into interpersonal relationship satisfaction [37].

### **4. Conclusions**

Researchers believe that the body image of AN and BN individuals are characterised by distortion and disorder. BN is correlated largely with body image. In females due to high obesity percentages in some countries, characterized by more food intake, followed by depression, anxiety and hypochondriacally neurosis has led to body image distortion. Socio cultural factors largely contribute individual's perception in terms of body attractiveness which leads to more body self-image satisfaction or dissatisfaction. There is a statistically significant difference in students and employees towards their self-perception in terms of BMI and body image. Individuals with negative BI perception have functional correlations between the level of eating disorders and BI satisfaction.

### **Author details**

Layam Anitha\*, Asma Abdulaziz Alhussaini, Hessah Ibrahim Alsuwedan, Hessa Faleh Alnefaie, Rehab Abduallah Almubrek and Shima Abdulaziz Aldaweesh Department of Health Sciences, College of Health and Rehabilitation Sciences, Princess Nourah University, Riyadh, KSA

\*Address all correspondence to: layamanitha@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**31**

*Bulimia Nervosa and Body Dissatisfaction in Terms of Self-Perception of Body Image*

[10] Zydorczyk B, Sitnik-Warchulska K. Sociocultural appearance standards and risk factors for eating disorders in adolescents and women of various ages. Frontiers in Psychology. 2018;**9**:429. DOI: 10.3389/fpsyg.2018.00429

[11] Izydorczyk B. A psychological typology of females diagnosed with anorexia nervosa, bulimia nervosa or binge eating disorder. Health Psychology Report. 2015;**3**:312-325. DOI: 10.5114/hpr.2015.55169

[12] Stice E, Marti CN, Rohde P. Prevalence, incidence, and

10.1037/a0030679

10.1002/eat.20625

s10964-005-9006-5

[16] Pruzinsky T, Cash

TF. Understanding body images: Historical and contemporary

perspectives. In: Cash TF, Pruzinsky T, editors. Body Image: A Handbook of Theory, Research, and Clinical Practice.

[14] Zechowski C. Polska wersja

Kwestionariusza Zaburzenì od zywiania (EDI)–Adaptacja i normalizacja [polish version of eating disorder inventory– Adaptation and normalization]. Psychiatria Polska. 2008;**42**:179-193

[15] Jones DC, Crawford JK. The peer appearance culture during adolescence: Gender and body mass variations. Journal of Youth and Adolescence. 2006;**35**:257-269. DOI: 10.1007/

impairment a course of the proposed DSM-V eating disorder diagnoses in 8-year prospective community study of young women. Journal of Abnormal Psychology. 2013;**122**:445-457. DOI:

[13] Striegel-Moore RH, Roselli F, Perrin N, DeBar L, Wilson GT, Mag A, et al. Gender diferrence in the prevalaence of eating disorder symptoms. The International Journal of Eating Disorders. 2009;**42**:471-474. DOI:

*DOI: http://dx.doi.org/10.5772/intechopen.84948*

[1] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. Arlington, VA, USA: American Psychiatric Publishing; 2013

[2] Erskine HE, Whiteford HA, Pike KM. The global burden of eating disorders. Current Opinion in Psychiatry. 2016;**29**(6):346-353

[3] Murray CJL, Barber RM, Foreman KJ, et al. Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990-2013: Quantifying the epidemiological transition. Lancet.

[4] Smink FRE, Van Hoeken D, Hoek HW. Epidemiology, course and outcome of eating disorders. Current Opinion in

[5] Hoek HW. Epidemiology of eating disorders in persons other than the high risk group of young Western females. Current Opinion in Psychiatry.

[6] Pike K, Hoek HW, Dunne PE. Recent cultural trends and eating disorders. Current Opinion in Psychiatry.

[8] Thomas JJ, Lee S, Becker AE. Updates in the epidemiology of eating disorders in Asia and the Pacific. Current Opinion in Psychiatry. 2016;**29**(6):354-362

[9] Van Hoeken D, Burns JK, Hoek HW. Epidemiology of eating disorders

in Africa. Current Opinion in Psychiatry. 2016;**29**(6):372-377

[7] Keski-Rahkonen A, Mustelin L. Epidemiology of eating disorders in Europe: Prevalence, incidence, comorbidity, course, consequences and risk factors. Current Opinion in Psychiatry. 2016;**29**(6):340-345

Psychiatry. 2013;**26**:543-548

2015;**386**:2145-2191

2014;**27**:423-425

2014;**27**:436-442

**References**

*Bulimia Nervosa and Body Dissatisfaction in Terms of Self-Perception of Body Image DOI: http://dx.doi.org/10.5772/intechopen.84948*

#### **References**

*Anorexia and Bulimia Nervosa*

**4. Conclusions**

interpersonal relationship satisfaction [37].

level of eating disorders and BI satisfaction.

**30**

**Author details**

provided the original work is properly cited.

Princess Nourah University, Riyadh, KSA

\*Address all correspondence to: layamanitha@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Hessa Faleh Alnefaie, Rehab Abduallah Almubrek and Shima Abdulaziz Aldaweesh Department of Health Sciences, College of Health and Rehabilitation Sciences,

studies show that female has a lot of curiosity about their body image and worried regarding it more than men. In 2014, a study conducted among Malaysian men and women found a misperception of own weight status and was higher among females (34.5%) compared to males (26.7%) [42]. According to the study, possible consequences might result in restrictive dieting and unhealthy weight control methods which may lead to increase the risk for the development of eating disorders, such as anorexia and bulimia nervosa [44]. Otherwise, underestimating one's own weight is associated with an increase of developing overweight prevalence [45]. Also, it is associated with depression, low self-esteem, feeling of shame, body surveillance, anxious and social isolation [40]. Additionally, Women's perception may shape into

Researchers believe that the body image of AN and BN individuals are characterised by distortion and disorder. BN is correlated largely with body image. In females due to high obesity percentages in some countries, characterized by more food intake, followed by depression, anxiety and hypochondriacally neurosis has led to body image distortion. Socio cultural factors largely contribute individual's perception in terms of body attractiveness which leads to more body self-image satisfaction or dissatisfaction. There is a statistically significant difference in students and employees towards their self-perception in terms of BMI and body image. Individuals with negative BI perception have functional correlations between the

Layam Anitha\*, Asma Abdulaziz Alhussaini, Hessah Ibrahim Alsuwedan,

[1] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. Arlington, VA, USA: American Psychiatric Publishing; 2013

[2] Erskine HE, Whiteford HA, Pike KM. The global burden of eating disorders. Current Opinion in Psychiatry. 2016;**29**(6):346-353

[3] Murray CJL, Barber RM, Foreman KJ, et al. Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990-2013: Quantifying the epidemiological transition. Lancet. 2015;**386**:2145-2191

[4] Smink FRE, Van Hoeken D, Hoek HW. Epidemiology, course and outcome of eating disorders. Current Opinion in Psychiatry. 2013;**26**:543-548

[5] Hoek HW. Epidemiology of eating disorders in persons other than the high risk group of young Western females. Current Opinion in Psychiatry. 2014;**27**:423-425

[6] Pike K, Hoek HW, Dunne PE. Recent cultural trends and eating disorders. Current Opinion in Psychiatry. 2014;**27**:436-442

[7] Keski-Rahkonen A, Mustelin L. Epidemiology of eating disorders in Europe: Prevalence, incidence, comorbidity, course, consequences and risk factors. Current Opinion in Psychiatry. 2016;**29**(6):340-345

[8] Thomas JJ, Lee S, Becker AE. Updates in the epidemiology of eating disorders in Asia and the Pacific. Current Opinion in Psychiatry. 2016;**29**(6):354-362

[9] Van Hoeken D, Burns JK, Hoek HW. Epidemiology of eating disorders in Africa. Current Opinion in Psychiatry. 2016;**29**(6):372-377

[10] Zydorczyk B, Sitnik-Warchulska K. Sociocultural appearance standards and risk factors for eating disorders in adolescents and women of various ages. Frontiers in Psychology. 2018;**9**:429. DOI: 10.3389/fpsyg.2018.00429

[11] Izydorczyk B. A psychological typology of females diagnosed with anorexia nervosa, bulimia nervosa or binge eating disorder. Health Psychology Report. 2015;**3**:312-325. DOI: 10.5114/hpr.2015.55169

[12] Stice E, Marti CN, Rohde P. Prevalence, incidence, and impairment a course of the proposed DSM-V eating disorder diagnoses in 8-year prospective community study of young women. Journal of Abnormal Psychology. 2013;**122**:445-457. DOI: 10.1037/a0030679

[13] Striegel-Moore RH, Roselli F, Perrin N, DeBar L, Wilson GT, Mag A, et al. Gender diferrence in the prevalaence of eating disorder symptoms. The International Journal of Eating Disorders. 2009;**42**:471-474. DOI: 10.1002/eat.20625

[14] Zechowski C. Polska wersja Kwestionariusza Zaburzenì od zywiania (EDI)–Adaptacja i normalizacja [polish version of eating disorder inventory– Adaptation and normalization]. Psychiatria Polska. 2008;**42**:179-193

[15] Jones DC, Crawford JK. The peer appearance culture during adolescence: Gender and body mass variations. Journal of Youth and Adolescence. 2006;**35**:257-269. DOI: 10.1007/ s10964-005-9006-5

[16] Pruzinsky T, Cash TF. Understanding body images: Historical and contemporary perspectives. In: Cash TF, Pruzinsky T, editors. Body Image: A Handbook of Theory, Research, and Clinical Practice. New York, NY: Guilford Press; 2002. pp. 3-12

[17] Ozmen D, Ozmen E, Ergin D, Cetinkaya AC, Sen N, Dundar PE, et al. The association of self-esteem, depression and body satisfaction with obesity among Turkish adolescents. BMC Public Health. 2007;**7**(80):1-7

[18] Gardner RM. Assessing body image disturbance in children and adolescents. In: Thompson JK, Smolak L, editors. Body Image, Eating Disorders, and Obesity in Children and Adolescents: Theory, Assessment, Treatment and Prevention. Washington D.C.: American Psychological Association; 2001. pp. 193-214

[19] Yamamotova A, Bulant J, Bocek V, Papezova H. Dissatisfaction with own body makes patients with eating disorders more sensitive to pain. Journal of Pain Research. 2017;**10**:1667-1675. DOI: 10.2147/JPR.S133425

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[22] Steinfeld B, Bauer A, Waldorf M, Hartmann AS, Vocks S. Diagnostik der Körperbildstörung. Psychotherapeut. 2017;**62**(3):164-182. DOI: 10.1007/ s00278-017-0188-6

[23] Gaudio S, Brooks SJ, Riva G. Nonvisual multisensory impairment of 687 body perception in anorexia nervosa: A systematic review of 688 neuropsychological studies. PLoS ONE. 2014;**9**(10):e110087. DOI: 10.1371/ journal.pone.0110087

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2002. pp. 3-12

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[29] Kirkcaldy BD, Shephard RJ, Siefen RG. The relationship between physical activity and self-image and problem behaviour among adolescents. Social Psychiatry and Psychiatric Epidemiology. 2002;**37**(11):544-550

[30] Cash TF, Morrow JA, Hrabosky JI, Perry AA. How has body image changed? A cross-sectional investigation of college women and men from 1983 to 2001. Journal of Consulting and Clinical Psychology. 2004;**72**(6):1081-1089

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2001;**37**:597-607

Press; 2011. pp. 129-137

Public Health. 2010;**10**:40

2004;**19**(4):357-372

Padova; 2010

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[18] Gardner RM. Assessing body image disturbance in children and adolescents. In: Thompson JK, Smolak L, editors. Body Image, Eating Disorders, and Obesity in Children and Adolescents: Theory, Assessment, Treatment and Prevention. Washington D.C.: American Psychological

Association; 2001. pp. 193-214

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image in anorexia nervosa: Measurement, theory and clinical implications. International Journal of Psychiatry in Medicine. 1981;**11**:263-284

[19] Yamamotova A, Bulant J, Bocek V, Papezova H. Dissatisfaction with own body makes patients with eating disorders more sensitive to pain. Journal of Pain Research. 2017;**10**:1667-1675.

[20] Garner DM, Garfinkel PE. Body

[21] Fairburn CG, Cooper Z, Shafran R. Cognitive behaviour therapy for 640 eating disorders: A "trans diagnostic" theory and treatment. Behaviour Research and Therapy. 2003;**41**:509-528. DOI: 10.1016/ s0005-6427967(02)00088-8

[22] Steinfeld B, Bauer A, Waldorf M, Hartmann AS, Vocks S. Diagnostik der Körperbildstörung. Psychotherapeut. 2017;**62**(3):164-182. DOI: 10.1007/

G. Nonvisual multisensory impairment of 687 body perception in anorexia nervosa: A systematic review of 688 neuropsychological studies. PLoS ONE. 2014;**9**(10):e110087. DOI: 10.1371/

s00278-017-0188-6

journal.pone.0110087

[23] Gaudio S, Brooks SJ, Riva

**32**

[32] Planned parenthood. Positive and Negative Body Image Improving Self Esteem. Planned parenthood, 2016. Available at: https://www. plannedparenthood.org/learn/body-image

[33] El-Ansari W, Clausen S, Mabhala A, Stock C. How do I look? Body image perceptions among university students from England and Denmark. International Journal of Environmental Research and Public Health. 2010;**7**(2):583-595

[34] Khalaf A, Westergren A, Berggren V, Ekblom O, Alhazzaa H. Perceived and ideal body image in among women in south western in Saudi Arabia. Journal of Obesity. 2015;**2015**:7. DOI: 10.1155/2015/697163

[35] Chang V, Christakis N. Selfperception of weight appropriateness in the United States. American Journal of Preventive Medicine. 2003;**24**(4):332-339

[36] Lee M. Women's body image throughout the adult life span: Latent growth modeling and qualitative approaches. Graduate Theses and Dissertations. 2013:13212. https://lib. dr.iastate.edu/etd/13212

[37] Howard T. Skin deep: Body image and interpersonal relationship quality in college women. Journal of Interdisciplinary Undergraduate Research. 2014;**6**(5):2

[38] Field A, Austin S, Camargo C, Tailor C, Striegel-Moore R, Loud K, et al. Exposure to the mass media, body shape concerns, and use of supplements to improve weight and shape among male and female adolescents. AAP News and Journals. 2005;**116**(2):e214-e220

[39] Wykes M, Gunter B. The Media and Body Image. Vol. 6. London: Sage Publications; 2005

[40] University of California Santa Crus. Student health outreach and promotion. University of California Santa Crus; 2015. Available from: http://shop.ucsc. edu/general-health-wellness/bodyimage.html.bodyimageimportant

[41] Long P, wall T. Media Studies, Texts, Production, Context, Producing Audiences: What Do Media Do to People? 2nd ed. London and New York: Routledge Taylor and Francis Group; 2012

[42] Shagar P, Shakiba N, Rahmah M. Factors associated with misperception of own weight status among 18-21 year old university students. IOSR Journal of Nursing and Health Science. 2014;**3**(5):25-31

[43] Epuru S, Eideh A, Shamsuddeen S, Al Shamarry S. Self-reported weight patterns and perceptions among female students of Saudi Arabia: A cross sectional survey. International Journal of Nutrition and Food Sciences. 2013;**2**(6):360

[44] Rand C, Resnick J. The "good enough" body size as judged by people of varying age and weight. Obesity Research. 2000;**8**(4):309-316

[45] Alwan H, Viswanathan B, Paccaud F, Bovet P. Is accurate perception of body image associated with appropriate weight-control behavior among adolescents of the Seychelles. Journal of Obesity. 2011;**2011**:8. DOI: 10.1155/2011/817242

[46] Slee P, Campbell M, Child SB. Adolescent and Family Development. 3rd ed. New York: Cambridge university press; 2012. p. 472

**35**

**Chapter 3**

**Abstract**

**1. Introduction**

*Raquel Fernández-Cézar*

Bulimia Nervosa: Is Body

Dissatisfaction a Risk Factor?

Eating disorder studies are often carried out with adolescents. However, having a normal weight and the appearance of a seemingly healthy body makes many young people wait for years before seeking out professional consultation with a specialist. Therefore, after a review of the literature we will reflect on the role of body dissatisfaction in the development and persistence that occur in bulimia nervosa. It will be linked to the data found by our research group, both in samples of adolescents and adult women. Results on risk scores in purgative behaviors associated with bulimia nervosa, dieting, eating habits, physical activity, self-esteem, social skills, and body dissatisfaction will be described. They will be contrasted in a descriptive way with data from clinical study participants diagnosed with bulimia nervosa, leading to a predictive model of the role body dissatisfaction plays as a risk factor in the development of bulimia nervosa.

**Keywords:** body dissatisfaction, risk factor, predictive model, adolescents, adults

*"After a lifetime of wanting to lose weight or 1 cm more around the waist, now I have other things to think about. My mind is out of jail and has many things to do".*

The first definition of the term "body image" is attributed to Schilder who defines it as follows: "the picture of our own body which we form in our own mind" ([1], p. 11). This author alludes to the mental representation of one's own body as a definition of body image. Currently, there is a general consensus that there is a multifactorial connotation attributed to this interpretation of body image in which cognitive, emotional, perceptive, and behavioral factors are interrelated [2]. Furthermore, the mental representation of the body is built on a basis of personal experience and the relationships with peer and adults, all of which are immersed in a specific sociocultural and historic context [3, 4]. In other words, the personal experience of one's own physical appearance is part of how we relate to others [5, 6]. The development of a positive body image is considered to be a public health issue by linking it to human well-being [7]. In fact, the existing research suggests that a negative development of body image constitutes a risk factor for psychological problems such as depression, suicidal thinking, low self-esteem, unhealthy behavior in order to control one's weight, and eating disorders [8]. Furthermore,

*"A woman fighting to overcome her illness."*

*Natalia Solano-Pinto, Miriam Valles-Casas and* 

#### **Chapter 3**

## Bulimia Nervosa: Is Body Dissatisfaction a Risk Factor?

*Natalia Solano-Pinto, Miriam Valles-Casas and Raquel Fernández-Cézar*

#### **Abstract**

Eating disorder studies are often carried out with adolescents. However, having a normal weight and the appearance of a seemingly healthy body makes many young people wait for years before seeking out professional consultation with a specialist. Therefore, after a review of the literature we will reflect on the role of body dissatisfaction in the development and persistence that occur in bulimia nervosa. It will be linked to the data found by our research group, both in samples of adolescents and adult women. Results on risk scores in purgative behaviors associated with bulimia nervosa, dieting, eating habits, physical activity, self-esteem, social skills, and body dissatisfaction will be described. They will be contrasted in a descriptive way with data from clinical study participants diagnosed with bulimia nervosa, leading to a predictive model of the role body dissatisfaction plays as a risk factor in the development of bulimia nervosa.

**Keywords:** body dissatisfaction, risk factor, predictive model, adolescents, adults

*"After a lifetime of wanting to lose weight or 1 cm more around the waist, now I have other things to think about. My mind is out of jail and has many things to do".*

*"A woman fighting to overcome her illness."*

#### **1. Introduction**

The first definition of the term "body image" is attributed to Schilder who defines it as follows: "the picture of our own body which we form in our own mind" ([1], p. 11). This author alludes to the mental representation of one's own body as a definition of body image. Currently, there is a general consensus that there is a multifactorial connotation attributed to this interpretation of body image in which cognitive, emotional, perceptive, and behavioral factors are interrelated [2]. Furthermore, the mental representation of the body is built on a basis of personal experience and the relationships with peer and adults, all of which are immersed in a specific sociocultural and historic context [3, 4]. In other words, the personal experience of one's own physical appearance is part of how we relate to others [5, 6].

The development of a positive body image is considered to be a public health issue by linking it to human well-being [7]. In fact, the existing research suggests that a negative development of body image constitutes a risk factor for psychological problems such as depression, suicidal thinking, low self-esteem, unhealthy behavior in order to control one's weight, and eating disorders [8]. Furthermore,

body dissatisfaction is considered to be a predictor of physical inactivity and weight gain [9, 10]. It is also suggested that it is one of the most important factors for determining the persistence of eating disorders [11]. The prevalence of body dissatisfaction has been mainly studied in adolescence, considering people at this vital stage the main risk group for its development [12]. Thus, research places the prevalence among girls to be between 57 and 87% and among boys between 49 and 82% [13, 14]. However, in recent years, studies indicate an increase in the desire of boys to lose weight [15]. Along this line, [16] the silhouette scale was used with 1082 participants between 3 and 18 years of age and found that 61.2% presented dissatisfaction with their body with 44.7% of boys and 46% of girls expressing a desire to be thinner. Other research carried out with adults reported that body dissatisfaction is present in 60% of women and 40% of men [17].

The following will provide evidence to support the hypothesis that body dissatisfaction could be a risk factor for eating disorders, especially for bulimia nervosa.

#### **2. Body dissatisfaction and associated factors**

Over the past few years, researchers have focused their efforts on identifying the variables associated with the development of body dissatisfaction. Dion et al. [18] conducted a longitudinal study using an adapted version of the silhouettes scale with 413 participants between the ages of 14 and 18, obtaining the following results: one out of two girls wants to be thinner, and one in every five boys makes an attempt to lose weight. The factors that are mostly associated with body dissatisfaction in girls are: a desire to be thinner; the body mass index; exhibiting behaviors for losing weight; and negative comments about their weight. In the case of boys, some factors are: wanting to be thinner or bigger; the body mass index; having had sexual intercourse experiences; and negative comments about their own weight. Other authors, in an attempt to create predictive models in the development of body dissatisfaction, point out the effects that variables such as self-objectification, social comparison, internalization of what is considered to be "ideal beauty," and the perception that others have of the body and whether it will be accepted or rejected by them [19] have.

A key issue regarding body dissatisfaction is the standard of beauty. Previous studies have reported a positive correlation between the internalization of thinness ideal and the body dissatisfaction and symptoms of eating disorders, mainly in adolescents. In the work of Barajas-Iglesias et al. [21], carried out with a clinical sample of 104 patients aged 13–18 and diagnosed of anorexia nervosa (AN, n = 66) or bulimia nervosa (BN, n = 38), the authors claim that the influence of the esthetic body shape model is a relevant variable in eating disorders. In addition, they conclude that BN and AN patients are influenced by that model, but BN patients to a higher extent (94.74% BN vs. 68.18% AN). To sum up, the authors report that the esthetic body shape model relates to body dissatisfaction, and acts as a predictor of BN symptoms, especially purging behaviors (vomits, laxatives, or diuretics).

This canon of beauty is also associated with social, professional, and even personal success [20], and has the purpose of encouraging the consumption of esthetic treatments causing discrepancies between ideal beauty and the real body. As Vygotsky, the classic of evolutionary psychology indicates, the people, women and men as part of a given society, appropriate and internalize sociocultural norms making them their own, and normalize them as "appropriate" or expected [22]. In this vein, when a certain type of beauty is internalized, it becomes one's own ideal and becomes a need, rejecting other body forms that are far from that ideal.

**37**

*Bulimia Nervosa: Is Body Dissatisfaction a Risk Factor? DOI: http://dx.doi.org/10.5772/intechopen.84169*

of beauty that is associated with success [25, 26].

the development of body image based on dissatisfaction [31].

fashion is assumed.

and peers [27, 28].

In general, individuals immersed in a culture do not question the beauty guidelines offered in that culture; simply, and in a standardized way, the canon dictated by

This ideal-real body discrepancy is associated with body dissatisfaction in both, young people and adults [23]. In this sense, the internalization of an "ideal beauty" is accompanied by the rejection of any difference, being overweight or obese, and the mobilization of a plan to achieve a certain type of beauty. Aligned with that, a peculiar thinness is attributed to women, which is at odds with the biological and expected shapes of adult women: a sunken stomach, a disproportionately small waist in relation to the hips, large breasts in relation to the body's dimensions, etc. Also, in recent decades, men have exhibited their own contradictions in the attainment of the "ideal body" through a variety of means aimed at promoting muscle growth and thinness, with the most obvious discrepancies in having a full head of hair, muscular abs, and an absence of body hair [24]. In this line, people are educated to pay attention to their body shape, placing emphasis on what is supposedly deemed physically attractive, even if it means sacrificing functionality and competence. They are educated to consume and mold the body following a certain canon

These aspects, among others, are transmitted through media and technology, stories, toys, fashion, and the main educational and social agents: family, school,

In the described context, social relationships are mediated by body image and awareness of weight [3]. Thus, when levels of dissatisfaction are high, the relationship with peers and the appreciation of friendship could be damaged by centering the conversation on the body, and making continuous comparisons between one's own body and that of others [14, 29]. In this respect, the person will relate addressing the desire to be liked, to be admired, with the fear of being rejected, and even with the risk of classifying and selecting friends based on body shapes [30]. In short, the individual internalizes that only through a certain body do they achieve success in their lives: have more friends, better jobs, more social or affective relationships. In addition, during childhood and adolescence, unfortunately, it is common to be the object of critical comments and ridicule toward the body, both in appearance and body competence. Having been the object of ridicule contributes to

As previously mentioned, the family also contributes, explicitly or implicitly, to the development of body dissatisfaction: explicitly and directly, by comments and labels addressed to the body of their children, and implicitly, vicariously, or indirectly, through the treatment of their own body, as well as through dieting, doing exercise with the purpose of losing weight, flattery toward thin people, etc. [23, 32–34]. In the Critical Eye Research Group of Castilla La Mancha University, various researches in which the central theme has been body dissatisfaction have been carried out. In all the cases, the participants' informed consent has been obtained, under the principles of the Declaration of Helsinki. Fundamentally, the stages of life evaluated have been adolescence and adulthood. The project to assess body dissatisfaction in adults was performed with a non-probabilistic-intentional sample (233 adults, average age 32.4, 126 women and 107 men) composed by families from schools of Castilla La Mancha (España). The research has included the following instruments: a questionnaire to assess body dissatisfaction [35]; questions about having suffered teasing in childhood; items about muscle-building desire; and anthropometric measurements. Among the most relevant results are the following: 9.9% have marked or severe levels of body dissatisfaction. Compared to those with moderate levels, this group is characterized by being more overweight, having a greater desire for bodybuilding and a greater concern for physical appearance [36].

*Anorexia and Bulimia Nervosa*

body dissatisfaction is considered to be a predictor of physical inactivity and weight gain [9, 10]. It is also suggested that it is one of the most important factors for determining the persistence of eating disorders [11]. The prevalence of body dissatisfaction has been mainly studied in adolescence, considering people at this vital stage the main risk group for its development [12]. Thus, research places the prevalence among girls to be between 57 and 87% and among boys between 49 and 82% [13, 14]. However, in recent years, studies indicate an increase in the desire of boys to lose weight [15]. Along this line, [16] the silhouette scale was used with 1082 participants between 3 and 18 years of age and found that 61.2% presented dissatisfaction with their body with 44.7% of boys and 46% of girls expressing a desire to be thinner. Other research carried out with adults reported that body dissatisfaction

The following will provide evidence to support the hypothesis that body dissatisfaction could be a risk factor for eating disorders, especially for bulimia nervosa.

Over the past few years, researchers have focused their efforts on identifying the variables associated with the development of body dissatisfaction. Dion et al. [18] conducted a longitudinal study using an adapted version of the silhouettes scale with 413 participants between the ages of 14 and 18, obtaining the following results: one out of two girls wants to be thinner, and one in every five boys makes an attempt to lose weight. The factors that are mostly associated with body dissatisfaction in girls are: a desire to be thinner; the body mass index; exhibiting behaviors for losing weight; and negative comments about their weight. In the case of boys, some factors are: wanting to be thinner or bigger; the body mass index; having had sexual intercourse experiences; and negative comments about their own weight. Other authors, in an attempt to create predictive models in the development of body dissatisfaction, point out the effects that variables such as self-objectification, social comparison, internalization of what is considered to be "ideal beauty," and the perception that others have of the body and whether it will be accepted or rejected

A key issue regarding body dissatisfaction is the standard of beauty. Previous studies have reported a positive correlation between the internalization of thinness ideal and the body dissatisfaction and symptoms of eating disorders, mainly in adolescents. In the work of Barajas-Iglesias et al. [21], carried out with a clinical sample of 104 patients aged 13–18 and diagnosed of anorexia nervosa (AN, n = 66) or bulimia nervosa (BN, n = 38), the authors claim that the influence of the esthetic body shape model is a relevant variable in eating disorders. In addition, they conclude that BN and AN patients are influenced by that model, but BN patients to a higher extent (94.74% BN vs. 68.18% AN). To sum up, the authors report that the esthetic body shape model relates to body dissatisfaction, and acts as a predictor of BN symptoms, especially purging behaviors (vomits, laxatives, or

This canon of beauty is also associated with social, professional, and even personal success [20], and has the purpose of encouraging the consumption of esthetic treatments causing discrepancies between ideal beauty and the real body. As Vygotsky, the classic of evolutionary psychology indicates, the people, women and men as part of a given society, appropriate and internalize sociocultural norms making them their own, and normalize them as "appropriate" or expected [22]. In this vein, when a certain type of beauty is internalized, it becomes one's own ideal and becomes a need, rejecting other body forms that are far from that ideal.

is present in 60% of women and 40% of men [17].

**2. Body dissatisfaction and associated factors**

**36**

diuretics).

by them [19] have.

In general, individuals immersed in a culture do not question the beauty guidelines offered in that culture; simply, and in a standardized way, the canon dictated by fashion is assumed.

This ideal-real body discrepancy is associated with body dissatisfaction in both, young people and adults [23]. In this sense, the internalization of an "ideal beauty" is accompanied by the rejection of any difference, being overweight or obese, and the mobilization of a plan to achieve a certain type of beauty. Aligned with that, a peculiar thinness is attributed to women, which is at odds with the biological and expected shapes of adult women: a sunken stomach, a disproportionately small waist in relation to the hips, large breasts in relation to the body's dimensions, etc. Also, in recent decades, men have exhibited their own contradictions in the attainment of the "ideal body" through a variety of means aimed at promoting muscle growth and thinness, with the most obvious discrepancies in having a full head of hair, muscular abs, and an absence of body hair [24]. In this line, people are educated to pay attention to their body shape, placing emphasis on what is supposedly deemed physically attractive, even if it means sacrificing functionality and competence. They are educated to consume and mold the body following a certain canon of beauty that is associated with success [25, 26].

These aspects, among others, are transmitted through media and technology, stories, toys, fashion, and the main educational and social agents: family, school, and peers [27, 28].

In the described context, social relationships are mediated by body image and awareness of weight [3]. Thus, when levels of dissatisfaction are high, the relationship with peers and the appreciation of friendship could be damaged by centering the conversation on the body, and making continuous comparisons between one's own body and that of others [14, 29]. In this respect, the person will relate addressing the desire to be liked, to be admired, with the fear of being rejected, and even with the risk of classifying and selecting friends based on body shapes [30]. In short, the individual internalizes that only through a certain body do they achieve success in their lives: have more friends, better jobs, more social or affective relationships. In addition, during childhood and adolescence, unfortunately, it is common to be the object of critical comments and ridicule toward the body, both in appearance and body competence. Having been the object of ridicule contributes to the development of body image based on dissatisfaction [31].

As previously mentioned, the family also contributes, explicitly or implicitly, to the development of body dissatisfaction: explicitly and directly, by comments and labels addressed to the body of their children, and implicitly, vicariously, or indirectly, through the treatment of their own body, as well as through dieting, doing exercise with the purpose of losing weight, flattery toward thin people, etc. [23, 32–34].

In the Critical Eye Research Group of Castilla La Mancha University, various researches in which the central theme has been body dissatisfaction have been carried out. In all the cases, the participants' informed consent has been obtained, under the principles of the Declaration of Helsinki. Fundamentally, the stages of life evaluated have been adolescence and adulthood. The project to assess body dissatisfaction in adults was performed with a non-probabilistic-intentional sample (233 adults, average age 32.4, 126 women and 107 men) composed by families from schools of Castilla La Mancha (España). The research has included the following instruments: a questionnaire to assess body dissatisfaction [35]; questions about having suffered teasing in childhood; items about muscle-building desire; and anthropometric measurements. Among the most relevant results are the following: 9.9% have marked or severe levels of body dissatisfaction. Compared to those with moderate levels, this group is characterized by being more overweight, having a greater desire for bodybuilding and a greater concern for physical appearance [36].

Along with that, 22.4% of the surveyed men report having been teased in their childhood, although this group is not characterized by high levels of dissatisfaction. In contrast, among women, 25.4% claim having suffered teasing, this group being characterized by high levels of dissatisfaction [37]. The results also indicate that in 22% of the families, at least one parent shows marked or severe levels of body dissatisfaction, a higher desire to be more muscular and a higher concern for health care [38].

Therefore, these results in adults indicate that body dissatisfaction is present in both men and women, and it has been noted that these data should be taken into account in health programs, as other research has also proposed. Similarly, the results obtained in adolescents indicate that body dissatisfaction should be a factor to consider in programs for the prevention of eating disorders and health promotion. This conclusion is reached by several authors. On the one hand, Valles and Solano-Pinto [39] who worked with a sample of 1040 young people, secondary education students from Castilla La Mancha (Spain) between the ages of 14 and 17 (55.7% women and 44.2% men), obtained results showing that 163 participants exhibited high levels of body dissatisfaction, out of which 110 were women and 53 were men, representing about 16% of the sample. On the other, Garner [40] worked with 406 participants with an average age of 12.2, early adolescence. Among this sample, 129 were men and 214 were women, evaluated with the EDI-2. In this case, 28 young people were considered as a group at risk of having severe levels of body dissatisfaction [41].

It seems, therefore, that the sociocultural pressure and the internalization of the desire to have a certain body type are so common that it is considered normal to feel dissatisfaction toward one's body, mainly in women, and increasingly in men. Such dissatisfaction, at moderate levels, is probably present because of the discrepancy between the proposed ideal body and the real one, for both men and women, in our society. The crucial aspect, in the context of eating disorders, is to detect the threshold: when the levels of body dissatisfaction are so high that one becomes obsessive and a possible risk factor for unhealthy behaviors and eating disorders such as bulimia nervosa [42]. If the desire for having a certain body is internalized in such a way that it becomes a necessity, the level of obsessiveness increases, the level of body dissatisfaction becomes so high that it could constitute a risk to one's health, triggering eating disorders.

#### **3. Body dissatisfaction in bulimia nervosa**

In light of this information, it seems that among the identified risks associated with body dissatisfaction is the development of eating disorders such as anorexia nervosa, bulimia nervosa, binge eating disorder, which primarily begin in adolescence, although they may also be present or triggered at other ages. In this sense, when the different components of body dissatisfaction in the adolescent population are evaluated through self-reporting [34], it has been shown that the probability of having an eating disorder is 32.2 times higher in young people with high scores in the behavioral component, compared to those with lower scores. For the perceptual component, the risk is 12.7 times higher, and for the cognitive-emotional component, the risk is 13.4 times higher [43].

Similar percentages are obtained in samples of adult women, for whom the risk of suffering the disorder increases by 22.5 when high scores are obtained from the IMAGE questionnaire. Additionally, 106 adult women were evaluated in the same study (55 diagnosed of eating disorders at a Spanish university hospital and 51 as a control group, estudiantes universitarias españolas), and it was observed that those

**39**

*Bulimia Nervosa: Is Body Dissatisfaction a Risk Factor? DOI: http://dx.doi.org/10.5772/intechopen.84169*

as predictive factors [47].

of the behavior to modify their body.

cation of the body [48].

diagnosed with bulimia nervosa obtained the highest scores in all the components of body dissatisfaction, that is, levels of body dissatisfaction in contrast to the diagnostic categories of anorexia nervosa, binge eating disorder or restrictive food intake disorder [44]. For this reason, some authors have emphasized the need to create differentiating profiles for each diagnostic category, considering high levels of internalization of sociocultural norms, social pressure toward the ideal body, and high levels of fear of maturity [21, 45, 46] as important factors for the onset of bulimia, along with body dissatisfaction. Parents' perception of their children's weight throughout childhood, concern about body weight and appearance in middle adolescence, and uncontrolled eating in late adolescence are also considered

In the case of bulimia nervosa, in most people, the manifestations are activated

Occasionally, weight loss may have been accidental, due to a disease, or a situation that made it difficult to eat. But whether one starts from being overweight or from having a normal weight, social flattery occurs almost automatically. In addition, body dissatisfaction, which is at the heart of the decision, causes emotional malaise due to the anxiety that their body produces. As a result, in behavioral terms, a negative reinforcement is created when the anxiety is reduced through the modifi-

As already mentioned, all these situations are more critical in adolescence, which is considered a vital stage in the development of one's body image. This stage is characterized by strong biological, psychological, and social changes; identity is reaffirmed through the search for identification with a group that, in turn, identifies with role models, ways of spending their free time, ways of dressing, selfexpression, etc., and in which the influence of the media and sociocultural aspects are of greater relevance. It is also the time when comments from their family and their peer group have the greatest impact on the person, because they are continually going back and forth between the need to be accepted, rule breaking, and group identification, all the while searching for their own individual identity. And in this search, teenagers have to choose how they want to be, what to believe in, who to relate to and how to relate to them, and whether they want to study and what they want to study. They are afraid, very afraid, of making mistakes, feeling rejected, or not feeling accepted. Sometimes, they do not build an identity, feeling out of control, or that they are incapable of facing life problems, and it is at these moments when the sociocultural influence overwhelms them and they can view the changes in their bodies, brought on by normal development, as undesirable. They selectively look at certain body areas as imperfect, compare their body shapes with those of their peers or social models, and feel insecure. They may resolve these conflicts provided that everything they have learned during childhood allows them to develop a protective shield, making them feel they have personal competence. This will depend, in part, on a positive development of body image in childhood. However, the feeling of insecurity or inferiority may also end up winning and make them

with the decision to follow a strict diet that aims to modify the body quickly. According to some authors, such a decision would not occur if there were not a feeling of body dissatisfaction, that is, an experience of the body that implied discomfort and the desire to modify body forms [45, 46]. Thus, in general, the person varies their diet expecting a miraculous outcome, which will lead to a situation of imbalance, making the appearance of binge eating and vomiting likely. When there is a decrease in weight, and sometimes even without it, one receives a social compliment from the immediate environment that presumably interprets their weight loss or body change as an interest in taking care of their health. That compliment is seen as a reward for their efforts, a positive reinforcement, allowing for the persistence

*Anorexia and Bulimia Nervosa*

care [38].

dissatisfaction [41].

health, triggering eating disorders.

nent, the risk is 13.4 times higher [43].

**3. Body dissatisfaction in bulimia nervosa**

Along with that, 22.4% of the surveyed men report having been teased in their childhood, although this group is not characterized by high levels of dissatisfaction. In contrast, among women, 25.4% claim having suffered teasing, this group being characterized by high levels of dissatisfaction [37]. The results also indicate that in 22% of the families, at least one parent shows marked or severe levels of body dissatisfaction, a higher desire to be more muscular and a higher concern for health

Therefore, these results in adults indicate that body dissatisfaction is present in both men and women, and it has been noted that these data should be taken into account in health programs, as other research has also proposed. Similarly, the results obtained in adolescents indicate that body dissatisfaction should be a factor to consider in programs for the prevention of eating disorders and health promotion. This conclusion is reached by several authors. On the one hand, Valles and Solano-Pinto [39] who worked with a sample of 1040 young people, secondary education students from Castilla La Mancha (Spain) between the ages of 14 and 17 (55.7% women and 44.2% men), obtained results showing that 163 participants exhibited high levels of body dissatisfaction, out of which 110 were women and 53 were men, representing about 16% of the sample. On the other, Garner [40] worked with 406 participants with an average age of 12.2, early adolescence. Among this sample, 129 were men and 214 were women, evaluated with the EDI-2. In this case, 28 young people were considered as a group at risk of having severe levels of body

It seems, therefore, that the sociocultural pressure and the internalization of the desire to have a certain body type are so common that it is considered normal to feel dissatisfaction toward one's body, mainly in women, and increasingly in men. Such dissatisfaction, at moderate levels, is probably present because of the discrepancy between the proposed ideal body and the real one, for both men and women, in our society. The crucial aspect, in the context of eating disorders, is to detect the threshold: when the levels of body dissatisfaction are so high that one becomes obsessive and a possible risk factor for unhealthy behaviors and eating disorders such as bulimia nervosa [42]. If the desire for having a certain body is internalized in such a way that it becomes a necessity, the level of obsessiveness increases, the level of body dissatisfaction becomes so high that it could constitute a risk to one's

In light of this information, it seems that among the identified risks associated with body dissatisfaction is the development of eating disorders such as anorexia nervosa, bulimia nervosa, binge eating disorder, which primarily begin in adolescence, although they may also be present or triggered at other ages. In this sense, when the different components of body dissatisfaction in the adolescent population are evaluated through self-reporting [34], it has been shown that the probability of having an eating disorder is 32.2 times higher in young people with high scores in the behavioral component, compared to those with lower scores. For the perceptual component, the risk is 12.7 times higher, and for the cognitive-emotional compo-

Similar percentages are obtained in samples of adult women, for whom the risk of suffering the disorder increases by 22.5 when high scores are obtained from the IMAGE questionnaire. Additionally, 106 adult women were evaluated in the same study (55 diagnosed of eating disorders at a Spanish university hospital and 51 as a control group, estudiantes universitarias españolas), and it was observed that those

**38**

diagnosed with bulimia nervosa obtained the highest scores in all the components of body dissatisfaction, that is, levels of body dissatisfaction in contrast to the diagnostic categories of anorexia nervosa, binge eating disorder or restrictive food intake disorder [44]. For this reason, some authors have emphasized the need to create differentiating profiles for each diagnostic category, considering high levels of internalization of sociocultural norms, social pressure toward the ideal body, and high levels of fear of maturity [21, 45, 46] as important factors for the onset of bulimia, along with body dissatisfaction. Parents' perception of their children's weight throughout childhood, concern about body weight and appearance in middle adolescence, and uncontrolled eating in late adolescence are also considered as predictive factors [47].

In the case of bulimia nervosa, in most people, the manifestations are activated with the decision to follow a strict diet that aims to modify the body quickly. According to some authors, such a decision would not occur if there were not a feeling of body dissatisfaction, that is, an experience of the body that implied discomfort and the desire to modify body forms [45, 46]. Thus, in general, the person varies their diet expecting a miraculous outcome, which will lead to a situation of imbalance, making the appearance of binge eating and vomiting likely. When there is a decrease in weight, and sometimes even without it, one receives a social compliment from the immediate environment that presumably interprets their weight loss or body change as an interest in taking care of their health. That compliment is seen as a reward for their efforts, a positive reinforcement, allowing for the persistence of the behavior to modify their body.

Occasionally, weight loss may have been accidental, due to a disease, or a situation that made it difficult to eat. But whether one starts from being overweight or from having a normal weight, social flattery occurs almost automatically. In addition, body dissatisfaction, which is at the heart of the decision, causes emotional malaise due to the anxiety that their body produces. As a result, in behavioral terms, a negative reinforcement is created when the anxiety is reduced through the modification of the body [48].

As already mentioned, all these situations are more critical in adolescence, which is considered a vital stage in the development of one's body image. This stage is characterized by strong biological, psychological, and social changes; identity is reaffirmed through the search for identification with a group that, in turn, identifies with role models, ways of spending their free time, ways of dressing, selfexpression, etc., and in which the influence of the media and sociocultural aspects are of greater relevance. It is also the time when comments from their family and their peer group have the greatest impact on the person, because they are continually going back and forth between the need to be accepted, rule breaking, and group identification, all the while searching for their own individual identity. And in this search, teenagers have to choose how they want to be, what to believe in, who to relate to and how to relate to them, and whether they want to study and what they want to study. They are afraid, very afraid, of making mistakes, feeling rejected, or not feeling accepted. Sometimes, they do not build an identity, feeling out of control, or that they are incapable of facing life problems, and it is at these moments when the sociocultural influence overwhelms them and they can view the changes in their bodies, brought on by normal development, as undesirable. They selectively look at certain body areas as imperfect, compare their body shapes with those of their peers or social models, and feel insecure. They may resolve these conflicts provided that everything they have learned during childhood allows them to develop a protective shield, making them feel they have personal competence. This will depend, in part, on a positive development of body image in childhood. However, the feeling of insecurity or inferiority may also end up winning and make them

#### *Anorexia and Bulimia Nervosa*

feel that they are not good enough or worthy of being loved and accepted, and, as a result, this feeling of body inadequacy opens the door for unhealthy behaviors [31].

Therefore, some event that has made them feel especially bad about their body, or an occasional loss of weight (e.g. as a result of a mild illness such as the flu), may trigger the decision to diet or maintain weight loss, blaming their body for all their angst, and considering it to be the source of their problems. Now, with this new goal of modifying their body, they finally feel special; they feel that they are in control by building communication with and through the body and manipulating it. They turn this into their "project": a path to security and self-acceptance that they could not achieve through self-confirmation of their identity, even creating a sense of superiority over "all those people who don't have enough discipline to control themselves" [49].

The aspects commented so far on the role of body dissatisfaction in the development of bulimia nervosa are collected in **Figure 1**.

As indicated in **Figure 2**, thoughts and emotions about the body become progressively more repetitive, and negative beliefs about the body and weight are reactivated. It will become increasingly obsessive and generalized to different situations and in all areas of their life. That is, dissatisfaction with body image increases, and with it, the fear of gaining weight, which compels them to continue the diet. In this sense, the emotional angst caused by body dissatisfaction causes the person to develop an enormous fear of their body, which becomes predominant and augments the fear of gaining weight or of losing control [50].

As shown in **Figure 3**, as the disease takes hold, it is likely that there will be an excessive need for food, binge eating, real or perceived, which may be caused by an imbalance in the body as well as other factors. Such binge eating will initially be assessed as a situation of pleasure, of "forbidden taste" for food, which is also generally forbidden, and a negative reinforcement led by the reduction of the organic imbalance, of hunger [51]. However, after that, the binge eating is seen as

**41**

**Figure 3.**

*The role of dissatisfaction. Part III.*

**Figure 2.**

*The role of dissatisfaction. Part II.*

*Bulimia Nervosa: Is Body Dissatisfaction a Risk Factor? DOI: http://dx.doi.org/10.5772/intechopen.84169*

an attack on the body: the obsessive beliefs about the body will be activated, and with them the emotional malaise. They are the insistent beliefs that one imposes on oneself regarding slimness, bodybuilding, and the rejection of obesity, all of which are greatly reinforced by current society and further compel the person to purge with the aim of reducing the anxiety and fear associated with weight gain [52]. The elements shown in **Figure 4** reflect that through the vicious circle of binge eating and purgative behaviors, one begins to formulate the erroneous belief that this is the only way that they can eat and not gain weight. Therefore, binge eating and purging will become more frequent and planned. Thoughts revolve around the need for having a certain body, and beliefs begin to emerge centering on the fact that eating a balanced diet will, irremediably, move them away from their goals. Given this, the role of stress must be considered. Whether caused or not caused

**Figure 1.** *The role of dissatisfaction. Part I.*

#### **Figure 2.**

*Anorexia and Bulimia Nervosa*

themselves" [49].

ment of bulimia nervosa are collected in **Figure 1**.

the fear of gaining weight or of losing control [50].

feel that they are not good enough or worthy of being loved and accepted, and, as a result, this feeling of body inadequacy opens the door for unhealthy behaviors [31]. Therefore, some event that has made them feel especially bad about their body, or an occasional loss of weight (e.g. as a result of a mild illness such as the flu), may trigger the decision to diet or maintain weight loss, blaming their body for all their angst, and considering it to be the source of their problems. Now, with this new goal of modifying their body, they finally feel special; they feel that they are in control by building communication with and through the body and manipulating it. They turn this into their "project": a path to security and self-acceptance that they could not achieve through self-confirmation of their identity, even creating a sense of superiority over "all those people who don't have enough discipline to control

The aspects commented so far on the role of body dissatisfaction in the develop-

As shown in **Figure 3**, as the disease takes hold, it is likely that there will be an excessive need for food, binge eating, real or perceived, which may be caused by an imbalance in the body as well as other factors. Such binge eating will initially be assessed as a situation of pleasure, of "forbidden taste" for food, which is also generally forbidden, and a negative reinforcement led by the reduction of the organic imbalance, of hunger [51]. However, after that, the binge eating is seen as

As indicated in **Figure 2**, thoughts and emotions about the body become progressively more repetitive, and negative beliefs about the body and weight are reactivated. It will become increasingly obsessive and generalized to different situations and in all areas of their life. That is, dissatisfaction with body image increases, and with it, the fear of gaining weight, which compels them to continue the diet. In this sense, the emotional angst caused by body dissatisfaction causes the person to develop an enormous fear of their body, which becomes predominant and augments

**40**

**Figure 1.**

*The role of dissatisfaction. Part I.*

*The role of dissatisfaction. Part II.*

**Figure 3.** *The role of dissatisfaction. Part III.*

an attack on the body: the obsessive beliefs about the body will be activated, and with them the emotional malaise. They are the insistent beliefs that one imposes on oneself regarding slimness, bodybuilding, and the rejection of obesity, all of which are greatly reinforced by current society and further compel the person to purge with the aim of reducing the anxiety and fear associated with weight gain [52].

The elements shown in **Figure 4** reflect that through the vicious circle of binge eating and purgative behaviors, one begins to formulate the erroneous belief that this is the only way that they can eat and not gain weight. Therefore, binge eating and purging will become more frequent and planned. Thoughts revolve around the need for having a certain body, and beliefs begin to emerge centering on the fact that eating a balanced diet will, irremediably, move them away from their goals. Given this, the role of stress must be considered. Whether caused or not caused

by the body, it is capable of generating anxiety that will increase the need to seek out other mechanisms for resolving the issue. Consequently, at different times, the problematic situation, whether or not it is related to the body, will be interpreted "through" the body. In this way, and depending on these interpretations, emotions of dissatisfaction, anxiety, sadness, and behaviors that sometimes become ritualistic will be awakened [53]. At the same time, emotions and behaviors reinforce distorted beliefs, being able to perceive suffering and pain as a source of pride, living in a dualism between mind and body: the body is undisciplined and must be controlled and the mind is fragmented in a dissociation between "a good me, and a bad me" [54]. In short, they live in ambivalence. What does the word ambivalence mean in this context? It is the internal debate between the desire to continue with one's objective of controlling the body, or to learn to live by accepting oneself.

In this ambivalence, family, friends, their boyfriends or girlfriends, teachers and professionals can accompany them by encouraging reflection on the suffering and loneliness of living through trying to control the body, and encouraging them to discover their identity, that they can be independent and live in their body in a healthy way. Following the interventions for improving body image which call for decreasing the internalization of sociocultural norms and social comparisons all the while learning to be unique (Stand-Alone), adolescents must be guided well by helping them to listen and interpret corporal sensations, accept their body shape and constitution, be critical of social pressure, confront comments that criticize the body or food, to block obsessive thoughts and to learn to look at themselves in a global way [55–57].

#### **4. Conclusion**

By living in a society, all people are exposed to sociocultural norms related to the body, aspects that influence and normalize a certain level of body dissatisfaction. As body dissatisfaction increases, it puts people at risk and moves them away from healthy behaviors. Fortunately, it only affects some people. There are those who will feel ill at ease with their body, but nothing else; others will learn to live with it; while others will intermittently follow restrictive diets. Only a small percentage will

**43**

Spain

**Author details**

Natalia Solano-Pinto1

provided the original work is properly cited.

*Bulimia Nervosa: Is Body Dissatisfaction a Risk Factor? DOI: http://dx.doi.org/10.5772/intechopen.84169*

men have been found to have with their own bodies.

everyday problems.

develop an eating disorder. Bulimia nervosa is, unquestionably, a disease with many factors that interact with one another and that, in a vital moment of vulnerability, increase the probability of developing the disease. In this chapter, a hypothetical model has been proposed that needs to be contrasted with future research. The role of body dissatisfaction in bulimia nervosa has been described, reflecting on the four phases of development of the disease, from the decision to lose weight to the use of binging and purging in an (unfortunate) attempt to self-regulate when facing

Given the results provided in the studies, it seems clear that body dissatisfaction can be considered a risk factor. It is also present once the disease has been developed, and it seems to maintain the typical manifestations of bulimia nervosa. But more research is needed, mainly longitudinal studies, to determine the role of different variables (anthropometric measurements, age, sex, anxiety, mood and personality traits, among others) in the development of body dissatisfaction. It is also necessary to know exactly what the relationship between body dissatisfaction and the manifestations of bulimia nervosa is in all phases of the disease, and if this dissatisfaction persists in people in clinical remission with respect to control groups. Such research should not be restricted to women, given the growing concern that

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

2 Castilla La Mancha University, Faculty of Social Sciences, Talavera de la Reina,

and Raquel Fernández-Cézar1

\*

, Miriam Valles-Casas2

\*Address all correspondence to: raquel.fcezar@uclm.es

1 Castilla La Mancha University, Faculty of Education, Toledo, Spain

#### *Bulimia Nervosa: Is Body Dissatisfaction a Risk Factor? DOI: http://dx.doi.org/10.5772/intechopen.84169*

*Anorexia and Bulimia Nervosa*

by the body, it is capable of generating anxiety that will increase the need to seek out other mechanisms for resolving the issue. Consequently, at different times, the problematic situation, whether or not it is related to the body, will be interpreted "through" the body. In this way, and depending on these interpretations, emotions of dissatisfaction, anxiety, sadness, and behaviors that sometimes become ritualistic will be awakened [53]. At the same time, emotions and behaviors reinforce distorted beliefs, being able to perceive suffering and pain as a source of pride, living in a dualism between mind and body: the body is undisciplined and must be controlled and the mind is fragmented in a dissociation between "a good me, and a bad me" [54]. In short, they live in ambivalence. What does the word ambivalence mean in this context? It is the internal debate between the desire to continue with one's objective of controlling the body, or to learn to live by accepting oneself. In this ambivalence, family, friends, their boyfriends or girlfriends, teachers and professionals can accompany them by encouraging reflection on the suffering and loneliness of living through trying to control the body, and encouraging them to discover their identity, that they can be independent and live in their body in a healthy way. Following the interventions for improving body image which call for decreasing the internalization of sociocultural norms and social comparisons all the while learning to be unique (Stand-Alone), adolescents must be guided well by helping them to listen and interpret corporal sensations, accept their body shape and constitution, be critical of social pressure, confront comments that criticize the body or food, to block obsessive thoughts and to learn to look at themselves in a

By living in a society, all people are exposed to sociocultural norms related to the body, aspects that influence and normalize a certain level of body dissatisfaction. As body dissatisfaction increases, it puts people at risk and moves them away from healthy behaviors. Fortunately, it only affects some people. There are those who will feel ill at ease with their body, but nothing else; others will learn to live with it; while others will intermittently follow restrictive diets. Only a small percentage will

**42**

global way [55–57].

**Figure 4.**

*The role of dissatisfaction. Part IV.*

**4. Conclusion**

develop an eating disorder. Bulimia nervosa is, unquestionably, a disease with many factors that interact with one another and that, in a vital moment of vulnerability, increase the probability of developing the disease. In this chapter, a hypothetical model has been proposed that needs to be contrasted with future research. The role of body dissatisfaction in bulimia nervosa has been described, reflecting on the four phases of development of the disease, from the decision to lose weight to the use of binging and purging in an (unfortunate) attempt to self-regulate when facing everyday problems.

Given the results provided in the studies, it seems clear that body dissatisfaction can be considered a risk factor. It is also present once the disease has been developed, and it seems to maintain the typical manifestations of bulimia nervosa. But more research is needed, mainly longitudinal studies, to determine the role of different variables (anthropometric measurements, age, sex, anxiety, mood and personality traits, among others) in the development of body dissatisfaction. It is also necessary to know exactly what the relationship between body dissatisfaction and the manifestations of bulimia nervosa is in all phases of the disease, and if this dissatisfaction persists in people in clinical remission with respect to control groups. Such research should not be restricted to women, given the growing concern that men have been found to have with their own bodies.

### **Author details**

Natalia Solano-Pinto1 , Miriam Valles-Casas2 and Raquel Fernández-Cézar1 \*

1 Castilla La Mancha University, Faculty of Education, Toledo, Spain

2 Castilla La Mancha University, Faculty of Social Sciences, Talavera de la Reina, Spain

\*Address all correspondence to: raquel.fcezar@uclm.es

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[10] Van den Berg P, Neumark-Sztainer D. Fat on happy 5 years later: Is it bad for overweight girls to like their bodies? Journal of Adolescent Health. 2007;**41**(4):415-417

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Developmental Psychology. 2002;**38**:669-678

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[14] Lawler M, Nixon E. Body dissatisfaction among adolescent boys and girls: The effects of body mass, peer appearance culture and internalization of appearance ideals. Journal of Youth and Adolescent. 2011;**40**:51-71

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[17] Tiggemann M. Body image across the adult life span: Stability and change. Body Image. 2004;**1**(1):29-41

[18] Dion J, Blackburn ME, Auclair J, Laberge L, Veillette S, Gaudreault M, et al. Development and etiology of body dissatisfaction in adolescent boys and girls. International Journal of Adolescence and Youth. 2015;**20**(2):151-166. DOI: 10.1080/02673843.2014.985320

[19] Andrew R, Tiggemann M, Clark L. Predicting body appreciation in young women: An integrated model of positive body image. Body Image. 2016;**18**:34-42

**45**

*Bulimia Nervosa: Is Body Dissatisfaction a Risk Factor? DOI: http://dx.doi.org/10.5772/intechopen.84169*

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[27] Jiménez-Moral JA, Zagalaz-Sánchez ML, Molero D, Pulido-Martos M, Ruiz JR. Capacidad aeróbica, felicidad y satisfacción con la vida en adolescentes españoles. Revista de psicología del deporte. 2013;**22**(2):429-436

2014;**16**(2):19-30

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Psychology Press; 2008

*Bulimia Nervosa: Is Body Dissatisfaction a Risk Factor? DOI: http://dx.doi.org/10.5772/intechopen.84169*

[20] Evans PC. "If only I were think like her, maybe I could be happy like her": The self-implications of associating a thin female ideal with life success. Psychology of Women Quarterly. 2003;**27**:209-214

[21] Barajas-Iglesias B, Jáuregui-Lobera I, Laporta-Herrero I, Santed-Germán MÁ. The influence of the aesthetic body shape model on adolescents with eating disorders. Nutrición Hospitalaria. 2018;**35**(5):1131-1137

[22] Da Silva R, Calvo S. La actividad infantil y el desarrollo emocional en la infancia. Revista Intercontinental de Psicología y Educación. 2014;**16**(2):19-30

[23] Lowes J, Tiggemann M. Body dissatisfaction, dieting awareness and the impact of parental influence in young children. British Journal of Health Psychology. 2003;**8**:135-147

[24] Silva DAS, Da Silva RC, Gonçalves ECA. Body image among men who practice body building: Comparison by age, economic statys and city size. Perceptual & Motor Skills: Perception. 2015;**121**(2):537-547

[25] O'Dea JA, Abraham S. Improving the body image, eating attitudes, and behaviors of young male and female adolescents: A new educational approach that focuses on self-esteem. International Journal of Eating Disorders. 2000;**28**(1):43-57

[26] Grogan S. Body Image. Understanding Body Dissatisfaction in Men, Women, and Children. London, New York: Routlege Psychology Press; 2008

[27] Jiménez-Moral JA, Zagalaz-Sánchez ML, Molero D, Pulido-Martos M, Ruiz JR. Capacidad aeróbica, felicidad y satisfacción con la vida en adolescentes españoles. Revista de psicología del deporte. 2013;**22**(2):429-436

[28] Mancilla-Medina A, Vázquez-Arévalo R, Mancilla-Díaz JM, Amaya-Hernández A, Alvarez Rayón G. Body dissatisfaction in children and preadolescents: A systematic review. Mexican Journal of Eating Disorders. 2012;**3**:62-79

[29] Chen LJ, Fox KR, Haase AM, Ku PW. Correlates of body dissatisfaction among Taiwanese adolescents. Asia Pacific Journal of Clinical Nutrition. 2010;**19**:172-179

[30] Jones DC. Interpersonal and familial influences on the development of body image. In: Cash TF, Smolak L, editors. Body Image. A Handbook of Science, Practice and Prevention. New York. London: The Guilford Press; 2011. pp. 110-119

[31] Toro J. El Adolescente Ante Su Cuerpo. Madrid: Pirámide; 2013

[32] Haines J, Neumark-Sztainer D, Hannan PJ, Robinson-O'Brien R. Child versus parent report of parental influences on children's weight-related attitudes and behaviors. Journal of Pediatric Psychology. 2008;**33**:783-788

[33] Smolak L. Body image development in childhood. In: Cash TF, Smolak L, editors. Body Image. A Handbook of Science, Practice and Prevention. New York, London: The Guilford Press; 2011. pp. 67-76

[34] Rodgers RF, Chabrol H. Parental attitudes, body image disturbance and disordered eating amongst adolescents and young adults: A review. European Eating Disorders Review. 2009;**17**:137-151

[35] Solano-Pinto N, Cano-Vindel A. IMAGEN. Evaluación de la insatisfacción con la imagen corporal. Madrid: TEA Ediciones; 2010

[36] Solano-Pinto N, Solbes-Canales I, Fernández-Cézar R, Calderón López

**44**

2007;**41**(4):415-417

*Anorexia and Bulimia Nervosa*

[1] Schilder P. The Image and Appearance of the human body. Abingdon, OX (Oxon): Routledge; Developmental Psychology.

[12] Cash T. A negative body image: Evaluating epidemiological evidence. In: Cash T, Pruzinsky T, editors. Body Image: A Handbook of Theory, Research, and Clinical Practice.

New York, London: The Guilford Press;

[13] Almeida S, Severo M, Arau'jo J, Lopes C, Ramos E. Body image and depressive symptoms in 13-year-old adolescents. Journal of Paediatrics and Child Health. 2012;**48**:E165-E171

[14] Lawler M, Nixon E. Body

and Adolescent. 2011;**40**:51-71

[15] Arrayás MJ, Tornero I, Díaz

dissatisfaction among adolescent boys and girls: The effects of body mass, peer appearance culture and internalization of appearance ideals. Journal of Youth

MS. Percepción de la imagen corporal de los adolescentes de Huelva atendiendo al género y a la edad. Retos. 2018;**34**:40-43

[16] López GL, Díaz A, Smith L. Análisis de imagen corporal y obesidad mediante las siluetas de Stunkard en niños y adolescentes españoles de 3 a 18 años. Anales de Psicología. 2018;**34**(1):167-172

[17] Tiggemann M. Body image across the adult life span: Stability and change.

[18] Dion J, Blackburn ME, Auclair J, Laberge L, Veillette S, Gaudreault M, et al. Development and etiology of body dissatisfaction in adolescent

[19] Andrew R, Tiggemann M, Clark L. Predicting body appreciation in young women: An integrated model of positive body image. Body Image. 2016;**18**:34-42

Body Image. 2004;**1**(1):29-41

boys and girls. International Journal of Adolescence and Youth. 2015;**20**(2):151-166. DOI: 10.1080/02673843.2014.985320

2002;**38**:669-678

2002. pp. 269-276

[2] Wertheim EH, Paxton SJ. Body image development in adolescent girls. In: Cash TF, Pruzinsky T, editors. Body Image: A Handbook of Theory, Research, and Clinical Practice.

New York, NY: The Guilford Press; 2011

[3] Raich RM. Imagen Corporal: Conocer y Valorar el Propio Cuerpo. Madrid:

[4] Salazar Z. Adolescencia e imagen corporal en la época de la delgadez.

[5] Bulik C. The Woman in the Mirror. New York: Walker & Company; 2012

[6] Sidoli M. When the Body Speaks. London. Philadelphia: Routledge; 2000

[7] Molero D, Zagalaz-Sánchez ML, Cachón-Zagalaz JA. Comparative study of the physical self-concept across the life span. Revista de Psicología del

[8] Stice E, Marti CN, Durant S. Risk factors for onset of eating disorders: Evidence of multiple risk pathways from an 8-year prospective study. Behaviour Research and Therapy. 2011;**49**:622-627

[9] Grogan S. Body image and health: Contemporary perspectives. Journal of Health Psychology. 2006;**11**(4):523-530

[10] Van den Berg P, Neumark-Sztainer D. Fat on happy 5 years later: Is it bad for overweight girls to like their bodies? Journal of Adolescent Health.

[11] Stice E, Whitenton K. Risk factors for body dissatisfaction in adolescent girls: A longitudinal investigation.

Deporte. 2013;**22**(1):135-142

Reflexiones. 2008;**87**:67-80

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Pirámide; 2000

S, Pozo-Bardera C. Hábitos saludables en la primera infancia y en sus familias. Una invitación a la reflexión. DEMETRA. Food, Nutrition & Health. 2017;**12**(4):803-821. DOI: 10.12957/ demetra.2017.28657

[37] Pozo C, Solano-Pinto N, Navarro C. Burlas in childhood and body dissatisfaction in adults. In: I International Congress of Intervention and Research in Health, 28 y 29 Septiembre 2017; Toledo. ISBN: 978-84-697-5272-2

[38] Solano-Pinto N, Solbes I, Calderón S, Fernández-Cézar R, Body dissatisfaction in families of children between 3 and 8 years. In: 3rd International Congress of Clinical and Health Psychology on children and adolescents; 16-18 Noviembre 2017; Sevilla. ISBN: 84-217-2848-5832

[39] Valles M, Solano-Pinto N (dir). Evaluación de actitudes y comportamientos asociados a los trastornos de conducta alimentaria. Memoria Para la obtencion de estudios avanzados. Albacete: Universidad de Castilla La Mancha; 2010

[40] Garner DM. Inventario de trastornos de la conducta alimentaria (EDI-2). Madrid: TEA Ediciones; 1998

[41] Valles M, Solano-Pinto N (dir). La imagen corporal: Proyecto preventivo sobre los trastornos de la conducta alimentaria [Tesis doctoral]. Albacete: Universidad de Castilla La Mancha; 2013

[42] Sepúlveda AR, Calado M. Westernization: The role of mass media on body image and eating disorders. In: Jáuregui-Lobera I, editor. Relevant Topics in Eating Disorders. InTech; 2012. pp. 47-64

[43] Solano-Pinto N, Cano-Vindel A, Blanco Vega H, Fernández Cézar R. Datos psicométricos de la versión abreviada del cuestionario IMAGEN; evaluación de la insatisfacción corporal. Nutrición Hospitalaria. 2017;**34**: 952-960. DOI: 10.20960/nh.695

[44] Solano-Pinto N, Cano-Vindel A, Bustamante E, Gómez del Barrio A. Evaluation of body dissatisfaction in the adult population with and without eating disorder with the IMAGEN questionnaire. In: Oral Communication Presented at IX Congreso Internacional de la Sociedad Española Para el Estudio de la Ansiedad y el Estrés; 6-8 Septiembre 2012; Valencia

[45] Izydorczyk B. A psychological profile of the bodily self-characteristics in women suffering from bulimia nervosa. In: Hay P, editor. New Insights into the Prevention and Treatment of Bulimia Nervosa. Croatia: InTech-Open Access Publisher; 2011. pp. 147-167

[46] Izydorczyk B. A psychological typology of females diagnosed with anorexia nervosa, bulimia nervosa or binge eating disorder. Health Psychology Report. 2015;**3**(4):312-325. DOI: 10.5114/hpr.2015.55169

[47] Allen KL, Byrne SM, Crosby RD. Distinguishing between risk factors for bulimia nervosa, binge eating disorder, and purging disorder. Journal of Youth and Adolescence. 2015;**44**:1580-1591. DOI: 10.1007/s10964-014-0186-8

[48] Stice E, Ng J, Shaw H. Risk factors and prodromal eating pathology. Journal of Child Psychology and Psychiatry. 2010;**51**:518-525

[49] Treasure J, Claudino AM, Zucker N. Eating disorders. Lancet. 2010;**375**:583-593

[50] Baker-Pitts. 'Look at me… What am I supposed to be?' Women, culture, and cosmetic plitting. In: Petrucelli J, editor. Body-States: Interpersonal/Relational Perspectives on the Treatment of Eating Disorders. London: Routledge; 2015. pp. 104-119

**47**

*Bulimia Nervosa: Is Body Dissatisfaction a Risk Factor? DOI: http://dx.doi.org/10.5772/intechopen.84169*

[51] Chernyak Y, Lowe MR. Motivations

[52] Peñas-Lledó E, Aguera Z, Sánchez I,

[53] Stice E, Bohon C, Marti CN, Fischer K. Subtyping women with bulimia nervosa along dietary and negative affect dimensions: Further evidence of reliability and validity. Journal of Consulting and Clinical Psychology.

[54] Hallings-Pott C, Waller G, Watson D, Scragg P. State dissociation in bulimic eating disorders: An experimental study. International Journal of Eating

[55] Alleva JM, Sheeran P, Webb TL, Martijn C, Miles E. A Meta-analytic review of Stand-Alone interventions to improve Body Image. PLoS ONE. 2015;**10**(9):e0139177. doi:10.1371/

[56] Grabe S, Ward LM, Hyde JS. The role of the media in body image concerns among women: A metaanalysis of experimental and correlational studies. Psychol Bull. 2008;**134**(3):460- 76. doi: 10.1037/0033-2909.134.3.460

[57] Irving LM, Berel SR. Comparison

strengthen college women's resistance to media images. Psychol Women Q,

of media-literacy programs to

2001;**25**(2):103-11

for dieting: Drive for thinness is different from drive for objective thinness. Journal of Abnormal Psychology. 2010;**119**:276-281

Gunnard K, Jiménez-Murcia S, Fernández-Aranda F. Differences in cognitive behavioral therapy dropout rates between bulimia nervosa subtypes based on drive for thinness and depression. Psychotherapy and Psychosomatics. 2013;**82**:125-126

2008;**76**:1022-1033

Disorders. 2005;**38**:37-41

journal.pone.0139177

*Bulimia Nervosa: Is Body Dissatisfaction a Risk Factor? DOI: http://dx.doi.org/10.5772/intechopen.84169*

[51] Chernyak Y, Lowe MR. Motivations for dieting: Drive for thinness is different from drive for objective thinness. Journal of Abnormal Psychology. 2010;**119**:276-281

*Anorexia and Bulimia Nervosa*

demetra.2017.28657

978-84-697-5272-2

S, Pozo-Bardera C. Hábitos saludables

evaluación de la insatisfacción corporal.

[44] Solano-Pinto N, Cano-Vindel A, Bustamante E, Gómez del Barrio A. Evaluation of body dissatisfaction in the adult population with and without eating disorder with the IMAGEN questionnaire. In: Oral Communication Presented at IX Congreso Internacional

Nutrición Hospitalaria. 2017;**34**: 952-960. DOI: 10.20960/nh.695

de la Sociedad Española Para el Estudio de la Ansiedad y el Estrés; 6-8

[45] Izydorczyk B. A psychological profile of the bodily self-characteristics in women suffering from bulimia nervosa. In: Hay P, editor. New Insights into the Prevention and Treatment of Bulimia Nervosa. Croatia: InTech-Open Access Publisher; 2011. pp. 147-167

[46] Izydorczyk B. A psychological typology of females diagnosed with anorexia nervosa, bulimia nervosa or binge eating disorder. Health Psychology Report. 2015;**3**(4):312-325.

[47] Allen KL, Byrne SM, Crosby RD. Distinguishing between risk factors for bulimia nervosa, binge eating disorder, and purging disorder. Journal of Youth and Adolescence. 2015;**44**:1580-1591. DOI: 10.1007/s10964-014-0186-8

[48] Stice E, Ng J, Shaw H. Risk factors and prodromal eating pathology. Journal of Child Psychology and Psychiatry. 2010;**51**:518-525

[50] Baker-Pitts. 'Look at me… What am I supposed to be?' Women, culture, and cosmetic plitting. In: Petrucelli J, editor. Body-States: Interpersonal/Relational Perspectives on the Treatment of Eating Disorders. London: Routledge; 2015.

[49] Treasure J, Claudino AM, Zucker N. Eating disorders. Lancet.

2010;**375**:583-593

pp. 104-119

DOI: 10.5114/hpr.2015.55169

Septiembre 2012; Valencia

familias. Una invitación a la reflexión. DEMETRA. Food, Nutrition & Health. 2017;**12**(4):803-821. DOI: 10.12957/

en la primera infancia y en sus

[37] Pozo C, Solano-Pinto N, Navarro C. Burlas in childhood and body dissatisfaction in adults. In: I International Congress of Intervention and Research in Health, 28 y 29 Septiembre 2017; Toledo. ISBN:

[38] Solano-Pinto N, Solbes I, Calderón S, Fernández-Cézar R, Body dissatisfaction in families of children between 3 and 8 years. In: 3rd International Congress of Clinical and Health Psychology on children and adolescents; 16-18 Noviembre 2017; Sevilla. ISBN: 84-217-2848-5832

[39] Valles M, Solano-Pinto N (dir). Evaluación de actitudes y comportamientos asociados a los trastornos de conducta alimentaria. Memoria Para la obtencion de estudios avanzados. Albacete: Universidad de

Castilla La Mancha; 2010

[40] Garner DM. Inventario de trastornos de la conducta alimentaria (EDI-2). Madrid: TEA Ediciones; 1998

[42] Sepúlveda AR, Calado M.

2012. pp. 47-64

[41] Valles M, Solano-Pinto N (dir). La imagen corporal: Proyecto preventivo sobre los trastornos de la conducta alimentaria [Tesis doctoral]. Albacete: Universidad de Castilla La Mancha; 2013

Westernization: The role of mass media on body image and eating disorders. In: Jáuregui-Lobera I, editor. Relevant Topics in Eating Disorders. InTech;

[43] Solano-Pinto N, Cano-Vindel A, Blanco Vega H, Fernández Cézar R. Datos psicométricos de la versión abreviada del cuestionario IMAGEN;

**46**

[52] Peñas-Lledó E, Aguera Z, Sánchez I, Gunnard K, Jiménez-Murcia S, Fernández-Aranda F. Differences in cognitive behavioral therapy dropout rates between bulimia nervosa subtypes based on drive for thinness and depression. Psychotherapy and Psychosomatics. 2013;**82**:125-126

[53] Stice E, Bohon C, Marti CN, Fischer K. Subtyping women with bulimia nervosa along dietary and negative affect dimensions: Further evidence of reliability and validity. Journal of Consulting and Clinical Psychology. 2008;**76**:1022-1033

[54] Hallings-Pott C, Waller G, Watson D, Scragg P. State dissociation in bulimic eating disorders: An experimental study. International Journal of Eating Disorders. 2005;**38**:37-41

[55] Alleva JM, Sheeran P, Webb TL, Martijn C, Miles E. A Meta-analytic review of Stand-Alone interventions to improve Body Image. PLoS ONE. 2015;**10**(9):e0139177. doi:10.1371/ journal.pone.0139177

[56] Grabe S, Ward LM, Hyde JS. The role of the media in body image concerns among women: A metaanalysis of experimental and correlational studies. Psychol Bull. 2008;**134**(3):460- 76. doi: 10.1037/0033-2909.134.3.460

[57] Irving LM, Berel SR. Comparison of media-literacy programs to strengthen college women's resistance to media images. Psychol Women Q, 2001;**25**(2):103-11

**49**

Section 2

The Neurobiology of

Anorexia Nervosa: Insights

into Pathophysiology and

Novel Drug Targets

### Section 2
