Running

head: EATING DISORDERS: ROLE OF FAMILY AND SENSE OF SELF

EDPS 651
Eating Disorders: The Role of Family and the Development of Sense of Self
Review Paper
Alison Lessard
University of Calgary

EATING DISORDERS: ROLE OF FAMILY AND SENSE OF SELF

Eating Disorders: The Role of the Family and the Development of Sense of Self
There are profound physical and psychological impacts upon the health of those
diagnosed with eating disorders (Loth, Neumark-Sztainer & Croll, 2009). In industrialized
countries, the incidence of eating disorders in young females has increased significantly over the
past thirty years (Ringer & Crittenden, 2007). Research into the causes of eating disorders has
examined biological, social, and psychological factors. No single reason or specific combination
of factors has been determined. Eating disorders appear to be the result of an interaction
between existing vulnerabilities, experiences, and genetic predispositions (Le Grange, Lock,
Loeb & Nicholls, 2010). The complexity and seriousness of eating disorders has resulted in
research efforts to identify why some individuals develop eating disorders and others do not. A
greater understanding of eating disorders would support appropriate treatment decisions and
assist in identifying high-risk populations for prevention purposes (Striegel-Moore & Bulik,
2007). Two factors that have been associated with eating disorders are family influences and the
development of the sense of self. The purpose of this paper is to review current research related
to the role of the family and self-concept of individuals diagnosed with eating disorders.
Eating Disorders
Children and adolescents with eating disorders possess abnormal views of their body
weight, demonstrate disturbances of eating behavior, and go to extreme lengths to control
weight. (Andrews & Instanffy, 2012; Wilson, Becker & Heffernan, 2003). Anorexia Nervosa
(AN) and Bulimia Nervosa (BN) are the two most commonly referred to eating disorders and
occur most frequently in females (Le Grange et al., 2010). AN is characterized by a refusal to
maintain healthy body weight, being overly focused upon weight and shape, and exhibiting

EATING DISORDERS: ROLE OF FAMILY AND SENSE OF SELF

extreme exercise regimens to control weight (Wilson, Becker & Heffernan, 2003). Individuals
who present with BN, experience repeated cycles of eating larger than normal amounts of food
followed by efforts such as vomiting and the misuse of laxatives to control their weight. The
effects of both AN and BN are serious, difficult to treat, and have high rates of mortality (Le
Grange et al., 2010). Hence the study of eating disorders has focused upon attempts to identify
which individuals are at risk, causative factors and appropriate therapies to support rehabilitation.
Role of the Family
Historically, studies of the role of the family in eating disorders tended to highlight
dysfunction within the family unit. In 1978, Minuchin, Rosman and Bakers model of the
psychosomatic family indicated four distinct characteristics present in those affected by AN (as
cited in Aragona, Catapano, Loriedo, & Alliani, 2011). Enmeshment, overprotectiveness,
rigidity, and avoidance of conflict were identified as principle characteristics of families of
anorexics. Minuchin and colleagues suggested that the interaction style of a family unit
perpetuated and caused the development of eating disorders by focusing upon the disorder in
order to avoid conflict or other familial problems (as cited in Aragona et al., 2011). This
psychosomatic model had significant influence suggesting family members, specifically parents,
were an integral piece of the pathological process of AN (Le Grange et al., 2010). This model
also identified the family member with an eating disorder as being overly involved in conflict
within the family. The eating disorder thereby acted as a means of diverting attention away from
the conflicts of the parents or in forming an alliance with one parent against the other (Wilson,
Becker & Heffernan, 2003).
The psychosomatic family model has remained popular among therapists. However,
growing awareness between professionals and the public has resulted in a demand for further

EATING DISORDERS: ROLE OF FAMILY AND SENSE OF SELF

research into familial causes of eating disorders. Subsequent research has led to insight of the
many elements involved in the development of eating disorders, and relieving the blame off of
the shoulders of families and patients themselves (Herpertz-Dahlmann, Seitz & Konrad, 2011).
Polivy and Herman (2002) suggested that there are many possible variable causes of eating
disorders and their presentation in each case is unique.
The focus over the past 25 years has gradually shifted from accusation of families to
supporting them in prevention and treatment of loved ones with eating disorders (Loth,
Neumark-Sztainer & Croll, 2009). Aragona et al. (2011) posited that the basic premise of
Minuchins model was a result of observations of severe cases during the 1970s within clinical
settings in North America. Such cases may be less likely in todays world where early treatment
and intervention occur more frequently. Family models that are more strength-based and flexible
are gradually becoming a focus of treatment (Aragona et al., 2011). The perspective of the
family unit dealing with an eating disorder has also received increased attention. Treasure et al.
(2008) indicated that the stressfulness of living with a loved one with an eating disorder has
profound effects upon family life. Eating disorders often leave a family feeling helpless and
frustrated as they deal with related behaviors and obvious visible signs of the illness.
Maudsley Model
During the same era of Minuchins psychosomatic family model, another theory was
developed. Maudsley Hospital in London was instrumental in developing a framework for
treatment of ED related to the family (Le Grange et al., 2009). The Maudsley model provided a
framework for assessing the needs of the family as well as the person with an eating disorder.
This model is based on the presumption that parenting behaviors or styles exist that may
encourage the maintenance of an eating disorder (Treasure et al., 2008). Interpersonal factors

EATING DISORDERS: ROLE OF FAMILY AND SENSE OF SELF

within families, such as overprotection and criticism are believed to impact treatment and
recovery (Treasure et al., 2008). Families may unwittingly enable an eating disorder by
tolerating it in order to keep the peace or out of fear of consequences or resistance (Treasure et
al., 2008). Feelings of anxiety, anger, frustration, and shame may also perpetuate the disorder.
Anderson (2009) indicated high levels of emotional reactions such as arguments at meal times,
could result in an unhealthy power struggles within families dealing with eating disorders.
Current family therapy is focused on emotional communication and developing skills within
families to successfully deal with behaviors and emotions that often accompany eating disorders
(Le Grange et al., 2010).
Family Factors
In 2010 the Academy of Eating Disorders presented a position paper related to the role
of the family in eating disorders (Le Grange et al., 2010). While agreeing that factors such as
genetics and maintenance exist within families, the Academy of Eating Disorders was strongly
opposed to models where families are viewed as the primary cause of eating disorders (Le
Grange et al., 2010). Wilson et al. (2003) reported that genetic studies of families and twins
reflected a genetic component, however the extent to which genetics are involved is still not
entirely clear. A study by Herpertz-Dahlmann et al. (2011) indicated a risk of 7-12 times greater
for first-degree relatives of eating disordered patients than healthy families. Le Grange et al.
(2010) suggested that rather than a specific hereditary cause a combination of genetic, cultural,
developmental and psychological risk factors could increase an individuals susceptibility to
developing an eating disorder.
Family interaction characteristics and parenting behaviors have been the focus of
numerous studies related to eating disorders (Aragona et al., 2011; Le Grange et al., 2010; Loth

EATING DISORDERS: ROLE OF FAMILY AND SENSE OF SELF

et al., 2009). Individuals with eating disorders experienced more parental difficulties such as
separation, arguments, high expectations, over-involvement, low affection, and critical
comments about weight (Le Grange et al., 2010). In light of the results of these studies,
researchers caution that more work needs to be done surrounding the effects of families. It is
likely that no one specific factor is responsible for the onset of an eating disorder. (Le Grange et
al., 2010; Loth et al., 2009). Le Grange et al. (2010) further suggested that negative family
experiences are risk factors that could interact with genetic and inherent vulnerabilities and result
in the development of eating disorders.
Development of the Sense of Self
Deficits of identity have been examined to determine whether there is a link between
eating disorders and low self-concept (Vartanian, 2009). In the 1980s Hilde Bruch suggested
that eating disorders were the result of impairments in overall identity and the failure to develop
multiple constructs of self-definition (as cited in Stein & Corte, 2007). Stein & Corte (2007)
defined self-concept as a set of knowledge structures about the self (p.59). Negative beliefs,
attitudes, and thoughts about the self are some of the core symptoms of eating disorders (Senra et
al., 2007). Stein and Corte (2007) indicated their research results demonstrated people diagnosed
with eating disorders had fewer positive and more negative self-schemas. In addition, Stein and
Corte (2007) stated that the development of a fat body concept along with a negative self-schema
could increase ones vulnerability for developing an eating disorder. Vartanian (2009) also
reported that women who do not possess a clear self-concept have a tendency to compare their
self-worth based on body weight. Others have noted that girls who do not possess a secure
identity are overly concerned about the perception of others and use their external appearance to
build an identity (Wilson, Becker & Heffernan, 2003).

EATING DISORDERS: ROLE OF FAMILY AND SENSE OF SELF

A sense of self that is lovable, valuable and worthwhile is believed to develop from
secure attachments that begin in infancy (Demidenko, Tasca, Kennedy & Bissada, 2010).
Insecure or unpredictable attachment is thought to increase reliance upon external sources to
determine self-worth. There is a significant amount of evidence that people with eating disorders
struggle with low self-esteem (Bardone-Cone et al., 2010; Senra, Sanchez-Cao, Seoane & Leung,
2007, Vartanian, 2009). Not surprisingly, girls are particularly at risk for developing eating
disorders during adolescence during this phase of identity development (Demidenko et al.,
2010).
Societal standards of attractiveness and ideal body weight are prominent in the Western
world. The media has been frequently implicated for its role in perpetuating standards of
thinness that are unachievable. Females are more likely than males to value an idealization of
thinness (Polivy & Herman, 2002). Vartanian (2009) indicated that while most girls and women
are exposed to the same media images, not everyone internalizes them to the same degree.
Vartanian (2009) found that women who have a diminished sense of self-concept are more apt to
internalize societal standards, and as a result develop body image and dieting concerns. In turn,
negative body image and dieting could lead to unhealthy methods of weight control. Other
variables of self-concept were identified by Vartanian (2009), such as conformist tendencies,
self-consciousness in public, and basing ones self worth on weight. Such variables could make
females vulnerable to internalizing external sources related to attractiveness.
Qualitative studies of women in recovery have been helpful in assisting researchers to
determine the relationship between a poor of self-concept and eating disorders. Reaching selfacceptance and developing a sense of self-worth were identified as being crucial components of
achieving and maintaining recovery (Bardone-Cone et al., 2010). In contrast, those at risk for

EATING DISORDERS: ROLE OF FAMILY AND SENSE OF SELF

relapse indicated self-criticism and feelings of worthlessness as factors that interfered with their
recovery (Bardone-Cone et al., 2010).
Family and Self-Concept
Without placing sole responsibility upon families for their role in the development of
eating disorders, it would be remiss not to connect self-concept surrounding weight to family
functioning and relationships. A number of studies have indicated parental pressures
differentiate eating disordered families from normal controls (Le Grange et al., 2010; Polivy &
Herman, 2002; Senra et al., 2007). The family acts as the first socialization agent where
modeling and reinforcement of weight loss behaviors are established (Senra et al., 2007).
Individuals with eating disorders have reported that they received more family criticism about
shape, weight, or eating prior to the onset of the disorder (Le Grange et al., 2010). In particular,
mothers who directly criticize their daughter seem to have more influence on self-esteem than
those who express a general concern about weight and shape (Senra et al., 2007). Mothers who
have had eating disorders themselves can perpetuate negative experiences regarding food, eating
behaviors, and may express concern about their daughters weight at an early age (Polivy &
Herman, 2002). These influential factors of weight-related self-concept are not necessarily
Indicators of dysfunctional families, but can offer important insight into prevention and
treatment.
Conclusion
Eating disorders have high morbidity and mortality rates and significantly impact
functioning (Herpertz-Dahlmann et al., 2010). Increased awareness of the incidence and severity
of eating disorders has resulted in numerous research studies aimed at identifying related causes.
Most current studies lean toward a model of multiple triggers, risk factors, vulnerabilities, and

EATING DISORDERS: ROLE OF FAMILY AND SENSE OF SELF

hereditary characteristics. Family life has a long history of being in the spotlight of eating
disorder research. More than 25 years ago, research suggested that eating disorders developed as
a result of overprotective families who avoided conflict. Suspected dysfunction in the home
resulted in the stigmatization of families who were attempting to deal with an often distressing
and fatal disorder. There is no question that family life plays an important role in any childs
psychological and emotional well-being. However, more value has recently been placed upon
the inclusion of family members in therapy and in the recovery process of eating disorders (Le
Grange et al., 2010). Family needs and those of the individual with an eating disorder need to
be acknowledged. As Treasure et al. (2008) suggested the common enemy of the family is the
eating disorder.
Research has shed light upon a variety of factors such as genetics, societal pressures, and
inherent personality traits that render a person vulnerable to eating disorders. Treasure et al.,
(2008) suggested that the family should be in the forefront of care to build capacity in managing
very challenging behaviors and their own emotional reactions. Secure attachments that support a
strong sense of self-concept and image have been identified as protective mechanisms against
eating disorders. Research has demonstrated that without a positive self-concept, females in
particular are more likely to turn toward external sources for approval. Sensitivities regarding
weight, shape and body image often accompany low self-esteem and increase the likelihood of
eating disorders. Future research regarding the role of families and the development of selfesteem in preventing eating disorders is necessary. Many parents would be interested to know
how to provide an environment in the home that supports the healthy development children.
Those who have battled AN and BN could also provide essential information for families on how
to best avoid such distressing disorders. As we parent our daughters in particular, we need to

EATING DISORDERS: ROLE OF FAMILY AND SENSE OF SELF

10

fully understand how ones sense of self is connected to the need for external sources of
approval. Research surrounding families and the development of self-concept has shown that
there is no specific formula for the development of eating disorders. The goal in reducing eating
disorders should be to highlight vulnerabilities and risk factors as well as possible negative
family and societal influences. The future of the fight against eating disorders is dependent upon
effective prevention, support for families, continued genetic and development study, and
treatment options that are guided by well-designed research.

EATING DISORDERS: ROLE OF FAMILY AND SENSE OF SELF

11

References
Anderson, Natalya. (2009). The maudsley maintenance model for anorexia nervosa. Irish
Medical Times, 43(38), 48.
Aragona, M., Catapano, R., Loriedo, C., Alliani, D. (2011). The psychosomatic family
system: Are families with eating disorders more enmeshed and rigid than normal
controls? Dialogues in Philosophy, Mental and Neuro Sciences, 4(1), 10-15
Bardone-Cone, A.M., Schaefer, L.M., Maldonado, C.R., Fitzsimmons, E.E., Harney, M.B.,
Lawson, M.A.,.Smith, R. (2010). Aspects of self-concept and eating disorder
recovery: What does the sense of self look like when an individual recovers from an
eating disorder? Journal of Social and Clinical Psychology, 29(7), 821-846. doi:
10.1521/jscp.2010.29.7.821
Demidenko, N., Tasca, G.A., Kennedy, N., & Bissada, H. (2010). The mediating role of selfconcept in the relationship between attachment insecurity and identity differentiation
among women with an eating disorder. Journal of Social and Clinical Psychology,
29(10), 1131-1152. doi: 10/1521/jscp.2010.29.10.1131
Herpertz-Dahlmann, B., Seitz, J., & Konrad, K. (2011). Aetiology of anorexia nervosa: From a
psychosomatic family model to a neuropsychiatric disorder? European Archives of
Psychiatry and Clinical Neuroscience, 261 Suppl 2(2), S177-181. doi: 10.1007/s00406011-0246-y
Le Grange, D., Lock, J., Loeb, K., & Nicholls, D. (2010). Academy for eating disorders position
paper: The role of family in eating disorders. The International Journal of Eating
Disorders, 4(1), 1-NA. doi: 10.1002/eat.20751

EATING DISORDERS: ROLE OF FAMILY AND SENSE OF SELF

12

Loth, K.A., Neumark-Sztainer, D., & Croll, J.K. (2009). Informing family approaches to eating
disorder prevention: Perspectives of those who have been there. The International
Journal of Eating Disorders, 42(2), 146-152. doi: 10.1002/eat.20586
Polivy, J., & Herman, C.P. (2002). Causes of eating disorders. Annual Review of Psychology,
53(1), 187-213. doi: 10.1146/annurev.psych.53.100901.135103
Senra, C., Sanchez-Cao, E., Seoane, G., & Leung, F.Y.K. (2007). Evolution of self-concept
deficits in patients with eating disorders: The role of family concern about weight and
appearance. European Eating Disorders Review: The Journal of the Eating Disorders
Association, 15(2), 131-138. doi: 10.1002/erv.733
Stein, K.F., & Corte, C. (2007). Identity impairment and the eating disorders: Content and
organization of the self-concept in women with anorexia nervosa and bulimia nervosa.
European Eating Disorders Review: The Journal of the Eating Disorders Association,
58-69. doi: 10.1002/erv.726
Striegel-Moore, R. H., & Bulik, C. M. (2007). Risk factors for eating disorders. The American
Psychologist, 62(3), 181-198. doi: 10.1037/0003-066X.62.3.181
Treasure, J., Sepulveda, A.R., MadDonald, P., Whitaker, W., Lopez, C., Zabala, M.,.Todd, G.
(2008). The assessment of the family of people with eating disorders. European
Eating Disorders Review: The Journal of Eating Disorders Association, 16(4), 247-255.
doi: 10.1002/erv.859
Vartanian, L.R. (2009). When the body defines the self: Self-concept clarity, internalization, and
body image. Journal of Social and Clinical Psychology, 28(1), 94-126. doi:
10.1521/jscp.2009.28.1.94

EATING DISORDERS: ROLE OF FAMILY AND SENSE OF SELF

Wilson, G., Becker, C., Heffernan, K. (2003) Eating disorders. In E.J. Mash & R. Barkley
(Eds). Child Psychopathology (pp. 687-715). New York, NY: Guilford Press.

13