Testing the Hypothesis of the Multidimensional Model of Anorexia Nervosa in Adolescents
Lyon, Maureen, Chatoor, Irene, Atkins, Darlene, Silber, Tomas, Mosimann, James, Gray, James, Adolescence
While there is general agreement that anorexia nervosa is multidetermined, few studies (Nygaard, 1990; Martin, 1990; Nagel & Jones, 1992) have examined anorexia nervosa in a multidimensional way. Three sets of factors - biogenetic predisposition, individual characteristics, and family functioning - have usually been examined separately.
A family aggregation of eating disorders and affective disorders among patients with anorexia nervosa has led some investigators to hypothesize the existence of biogenetic vulnerability to anorexia nervosa (McCarthy, 1990). Strober et al. (1990) in a study of 97 anorexic patients found that the lifetime rate of anorexia nervosa among first-degree relatives of anorexic patients (4.1%) was significantly greater than among relatives of depressed patients and relatives of nondepressed psychiatric patients (9%). Strober and Humphrey (1987) reported that the prevalence of eating disorders among sisters of anorexics ranged from 3 to 10%, and a lifetime risk of eating disorders in relatives of patients was six to seven times greater than in matched controls. Differential concordance for anorexia nervosa among monozygotic twin pairs was higher at a rate of .66 to .71 as compared to dizygotic twins at. 10 to .25 (Holland, Sicotte, & Treasure, 1988). However, not all studies have found such increased prevalence of eating disorders in the family histories of anorexic patients (Logue, Crowe, & Bean, 1989; Waters, Beumont, Touyz, & Kennedy, 1990).
Strober et al. (1990) found an increased prevalence of family history of depression among anorexic patients who were not depressed (18% vs. 5.1%). Other studies with smaller samples had shown similar findings (Logue et al., 1989; Piran, Kennedy, & Garfinkel, 1985; Smith & Steiner, 1992).
Personality features have also been considered to be predisposing factors to anorexia nervosa (Shapiro, Blinder, Hagman, & Pituck, 1993; Soukup, Bailer, & Terrell, 1990). These include exceptionally "easy" temperament, feelings of personal ineffectiveness (Bers & Quinlan, 1992), and poor interceptive awareness (Bruch, 1973; Johnson & Connors, 1987; Palazzoli, 1978; Zerbe, 1993). Adolescents with anorexia nervosa have been clinically described as "model children" with implied deficits in self-assertion and autonomous strivings. However, no empirical test of this construct is available.
Bruch (1973, 1978) identified a developmental deficit, the ability to accurately identify and discriminate proprioceptive states such as hunger, satiety, and emotions. She postulated that these disturbances occur whenever the mother's reading of the infant's cues is inaccurate (e.g., fear or fatigue confused with hunger) or the mother's response is noncontingent (feeding a fearful infant). Validation for this model has been provided by observations of infants with feeding problems (Chatoor et al., 1988).
Johnson highlighted a family variable: low independence within the family (Johnson & Connors, 1987; Williams, Chamove, & Millar, 1990). Indeed, difficulty with separation, individuation, and dependency appear to be typical (Bruch, 1978). The patient's anorexic behavior has also been thought to function as a protection of the family homeostasis (Minuchin, Rosman, & Baker, 1978). Others have found no support for a typical anorexia nervosa family (R'astam & Gillberg, 1991; Stern et al. (1989).
The purpose of this study was to test the multidimensional nature of anorexia nervosa. It was hypothesized that three sets of variables would provide the best model for anorexia nervosa among adolescents.
Biogenetic: family history of anorexia nervosa or affective disorder; Individual Personality Features: feelings of ineffectiveness, low interoceptive awareness, and being a "perfect child"; Family Characteristic: low independence
The subjects were 43 female patients (inpatient and outpatient), aged 11 to 19, admitted to an Eating Disorders Program during a 14-month period in an urban pediatric hospital. …