Functional Behavior Analysis of Anorexia Nervosa: Applications to Clinical Practice
Lappalainen, Raimo, Tuomisto, Martti T., The Behavior Analyst Today
Anorexia nervosa is a difficult and often life-threatening eating disorder with a prevalence of about one per cent of young women. Our intention in this article is to present facts, possibilities, and hypotheses for clinical applications of functional behavioral analysis in anorexic clients. Many clinical applications based on behavioral principles and processes for a functional analysis of "anorectic behavior" are presented. These principles include respondent, operant, and rule-governed behavior as well as Relational Frame Theory. Also, behavioral processes categorized through aversion learning, and complex schedules of reinforcement could be applied during the analysis. Further, the behavior analytic view helps us to understand problems with actual eating behavior and problems with the initiation of eating, as well as how physiological states of the body may be included in the behavioral analysis. In addition, contingencies of survival may have produced genetic tendencies for some behaviors to emerge more easily than others. Understanding the functions of "anorectic behavior" is a challenge, because it is a result of a multi-faceted interaction between genetically influenced and learned behaviors affected by a cultural context.
Key words: anorexia nervosa, functional analysis, behavior analysis, eating behavior, clinical applications
Anorexia nervosa is a severe and often life-threatening eating disorder that is difficult to treat. The clinical features of anorexia presented in DSM-IV (American Psychiatric Association, 1994) include refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected). Further, anorexia is associated with intense fear of gaining weight or becoming fat, even though underweight is part of the problem; disturbance in the way, in which body weight or shape is experienced; undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight. In females, the absences of at least three consecutive menstrual cycles are included in the criteria of anorexia. An anorexic client can also engage in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).
The prevalence of anorexia nervosa is 0.5-1.0% among young women (Crisp, Palmer, & Kalucy, 1976; Pope, Hudson, & Yurgelun-Todd, 1984; Roth & Fonagy, 2005), but other, less severe, eating disordered, behaviors are much more common (Drewnowski, Hopkins, & Kessler, 1988; Mintz & Betz, 1988). Approximately 1000 adults, from 15 European Union (EU) member states were selected to complete an interview-assisted face-to-face questionnaire. Overall the results suggested that only half of the European population is within the normal weight range. The number of respondents who were at least slightly underweight (defined as Body Mass Index less than 20) was approximately 10% (A Pan-EU survey on consumer attitudes to physical activity, body-weight, and health, 1998). This figure is an estimate since the measurements were self-reported. However, the study points to a fairly alarming tendency that almost a fifth of underweight people are in the process of losing more weight (Lappalainen, Tuomisto, Giachetti, Damicis, & Paquet, 1999). Thus, several million people in Europe have anorectic behavioral tendencies. Because the number of people having anorectic responses is large, and the number of people seeking treatment for these problems is also large, it is important to understand the phenomenon of anorexia.
From the functional or behavioral point of view there are several problems with using diagnoses in clinical practice. Although a diagnosis is often needed when transferring information between professionals within the health care system or for the clients to be able to receive reimbursement from health care authorities, it does not give enough information for understanding and treating the disorder effectively. …