Somerset and Wessex Eating Disorders Association
"Serving those affected by eating disorders"
Here you will find a research paper by Andy Fox and Dr. Neuman Leung. The aim of the research is to show that anorectic behaviour may be an attempt to introduce control into a chaotic environment, and that the need for stability and meaning in life is an important factor in the development of psychopathologies, as indicated in previous studies.
Although this research is concerned with anorexia only, it is interesting to compare it to the eating disorders as 'coping mechanisms' view (as in 'A sufferer's View' for example).
The document is by nature fairly technical.
The Role of Existential Anxiety in Anorexia Nervosa
Andy P. Fox1, and Newman Leung1,2
1Department of Psychology, University of Birmingham, Birmingham, UK.
2 Eating Disorders Service, Queen Elizabeth Psychiatric Hospital, Birmingham, UK.
Abstract: Objective: Previous research suggests that anorectic behaviour may be an attempt to introduce control into a chaotic environment, and that the need for stability and meaning in life is an important factor in the development of psychopathologies. The phenomenon of ‘existential anxiety’ is a characteristic reaction to a lack of meaning in the life of an individual. This study attempted to identify whether existential anxiety is associated with anorexic tendencies. Method: 44 participants completed 4 questionnaires: the Eating Disorder Inventory, the Beck Depression Inventory, the Anorectic Cognition Scale, and the McGill Quality of Life Scale. Results: A negative relationship was found between the existential wellbeing subscale of the McGill and anorexic symptoms and beliefs. This relationship persisted when the influence of depression was statistically removed. Discussion: The results suggest that existential anxiety may be a possible factor in the development and maintenance of anorexia. Suggestions are made regarding the possible mechanism through which anorexia may develop existential meaning for the individual, and the therapeutic implications of this are discussed. Possible directions for further research are also considered.
The prevalence of eating disorders is continuing to rise, despite the increased amount of research that is being conducted into the causes and possible areas of treatment (Fairburn & Harrison, 2003). Of the different types of eating disorders, anorexia nervosa presents clinicians and researchers the most difficult challenge, partly due to the potentially fatal medical complications, but also due to the complexity of the underlying causes. Historically, models of treatment for anorexia have varied from traditional psychodynamic perspectives (with a focus upon the mother as a cause of the disorder) to the more scientifically rigorous approach of cognitive behaviour therapy. While all the approaches have achieved some certain measure of success (Treasure, Todd & Szmukler, 1995), there is still a gap within the literature for further treatment regimes, and one area in-particular that has been overlooked is the existential domain.
Treatment programmes for eating disorders initially focussed on dealing with the physical symptoms of the disorder through increasing the patient’s weight to a level which is less severe (Gull, 1874). Although this approach deals effectively with the physical manifestations of the illness, such as low weight, arrhythmias, hypotension, and endocrine abnormalities, it neglects the psychological aspects which cause an individual to lose the weight in the first place, and invariably leads to them relapsing into the disorder once they leave the confines of the medical establishment. It was established quite early that removing an anorexic from her immediate social and physical surroundings may be the most effective way to treat her illness (Gull, 1874). However, this is only partly the case, as unless the recovery is total (in both the physical and psychological sense) she will return to these places and/or people and relapse (Treasure, Todd & Szmukler, 1995). A change in life-style and psychological functioning is therefore what should ultimately be sought by eating disorders treatment programmes.
One important aspect of anorexia that has been examined more recently is that of the maladaptive thoughts and behaviours of patients suffering from an eating disorder. There are several models of the cognitive-behavioural dimension in anorexia nervosa (e.g., Fairburn, Shafran & Cooper, 1999; Garner & Bemis, 1982; Guidano & Liotti, 1983; Slade, 1982) with their own strengths and limitations. One such model, Slade (1982) also included psychosocial, physiological and endocrinological dimensions. According to this theory, there are certain underlying conditions that mediate the onset of anorexia nervosa, including a general dissatisfaction with life, low self esteem, and perfectionist tendencies. Adolescence (the typical period of onset for anorexia nervosa; Crisp, 1965) is a troublesome time for most individuals, but if it is complicated with other factors (such as divorce of parents, death in the family, or bullying), as Slade suggests, this may place added strain on established coping methods, and other solutions may be sought. This, in conjunction with pressures from peers and general society, may cause experimentation with dieting to improve self-esteem. When judged in the light of perfectionist tendencies, it becomes apparent that weight loss can provide a clear, objective measure as to how ‘well’ an individual is performing. If current weight is taken as a measure of general life functioning, this can be monitored by simply stepping on the scales. The pleasure from losing weight then takes on a personal significance and the rewarding properties of dieting become all the more salient. Within certain individuals, this may be taken to a pathological extreme and eventually result in anorexia nervosa.
This theory, although extensive, does not take into account all the possible determinants of anorexia. For example, it does not discuss the possible impact of genetics or underlying neurological mechanisms that are currently thought to be implicated in the psychopathology of anorexia nervosa (Lilenfield & Kaye, 1998). Garner and Bemis (1982) provide a thorough outline of the factors that may mediate the onset of anorexia nervosa, and discuss the personal profile and underlying characteristics of anorexic individuals. This profile fits with the outline initially proposed by early writers, such as Crisp (1965) and Bruch (1973), emphasising a conscientious and hard-working individual who appears to be particularly sensitive to the needs and desires of others. Garner and Bemis report that just prior to the onset of the illness, individuals become withdrawn and self-occupied, which is in stark contrast to their usual other-directed selves. It is suggested that this may be in response to a stressor, and is marked by an acute sense of loss of control within the individual. Thus, losing weight is perceived as a mechanism that serves to alleviate this distress, and anorexia may be viewed as a functional response to the feelings of loss of control, and low self-esteem.
This concept of the illness as a functional response to an adverse environment suggests that anorexia may serve to relieve anxiety and re-introduce a sense of control. This observation has been empirically supported by Serpell, Treasure, Teasdale and Sullivan (1999) who studied the highly valued nature of anorexic symptoms and the positive beliefs about the illness within sufferers. One of their main findings, while studying letters written by anorexic patients to their illness, was that the anorexia served as a form of control. Further, this was manifested in a sense that it was their ‘guardian’ and helped them to avoid negative states. These positive themes were taken as important factors that may maintain anorexia and explain the reluctance within anorexic clients to give up their illness. However, if anorexia has such value associated with it, then why do more individuals not make use of it as a method of dealing with their lives? Why is it that some people see dieting as the solution to their problems, and then go on to develop anorexia?
Vitousek and Manke (1994) argue that anorexia only develops functional value in the presence of specific dispositional traits within the individual, and go on to review the importance of personality factors in anorexia. They conclude that restrictive anorectic behaviour is consistently associated with limited coping mechanisms and withdrawn, compliant personality profiles. Thus, the weight-loss and compensatory behaviours have value in that they provide a mechanism for dealing with upsetting or traumatic events, feelings, or beliefs.
This is not a new concept, and it is argued that there are many mechanisms that may be employed in clinical and non-clinical populations to either avoid the initial cause of anxiety provoking states, or avoid the resulting state itself. Miller, Brody and Summerton (1988) noted that two main styles of coping, avoidant and active, had been identified in the literature. When actively coping, individuals attempt to minimise stress and anxiety by eliminating the cause directly. People who use avoidant coping, however, attempt to avoid the stressor rather than attempt to deal with it, and methods of achieving this include drinking, sleeping, socialising, or drug abuse (Lewis & Brown; 2002). One could argue that behaviours associated with anorexia (such as preoccupation with food and weight) may serve as such an avoidant mechanism which enables the individual to reduce negative emotions resulting from the anxiety provoking situation, without actually dealing with the cause itself. Alternatively, anorexia may not serve to reduce anxiety associated with the current stressor or anxiety-provoking situation, but it may serve to reduce anxiety associated with other concepts important to the individual. An obvious example would be anxiety associated with psychosocial pressures to be thinner or more attractive, and thus weight-loss behaviour gains functional value by reducing this more general anxiety. This would fit with the Serpell et al (1999) conclusion that anorexia serves the purpose of a ‘guardian’ or protector: it protects the individual by reducing anxiety in their lives.
Holahan and Moos (1987a) found that people who primarily use avoidant coping are more vulnerable to the effects of anxiety and stress, due to their inability to effectively deal with the cause. Individuals whose personality style leads them to use avoidant coping strategies may be more likely to develop maladaptive coping forms to a pathological extreme in an attempt to deal with the acute anxiety they experience. It could be argued that in some cases this may take the form of anorexic behaviours, depending on other variables such as the dispositional traits suggested by Vitousek and Manke (1994).
Another way of classifying coping strategies was initially outlined by Folkman and Lazarus (1980) and this model focuses upon the negative affect that often results from stress and anxiety. They propose that individuals in stressful circumstances either do something to remove the stressor (which will then result in reduced negative affect) or that they do something to remove the negative affect without eliminating the cause. This is ‘problem focussed’ and ‘emotion focussed’ coping, respectively. Individuals tend to use both, but the decision to use one over the other depends on the event itself. If a person perceives that they have the resources to deal with the aversive event, they will use a problem focussed coping style, otherwise they will use avoidant mechanisms and seek to reduce the resulting emotions without tackling the cause.Clearly, this is based upon the same premise as Miller, Brody and Summerton’s (1988) observations, and they both share a similar characteristic: that stress and anxiety will lead to different forms of coping in different people, and this is dependent on factors within the individual.
Kenyon (2000) argues that the main anxiety-provoking condition humans have to face is the realisation that an individual is born into a world free from any inherent meaning and that one day that individual will cease to be. This is an unalterable truth that all humans have to come to terms with, and no amount of ‘active’ or ‘problem-focussed’ coping can resolve the fact that one day our lives will end. Thus we must either repress or come to terms with this anxiety rather than deal with the cause of it, and many authors have speculated on the importance of this ‘existential anxiety’ dynamic.
As biological organisms, humans have physical bodies that exist only for a limited time. However, what separates humans from other organisms is the perspective that we have on our bodies, and the meaning we place upon them. Merleau-Ponty (1963) observes that our physical body initially creates, but then becomes the focus of, our consciousness. The fact that we are self aware and thus realise we can impact upon our environment is one of the first steps to becoming fully aware of the complete breadth of our own existence.
Frankl (1973) suggests that purpose for the individual is present in the world whether we are aware of our existence or not; it is simply a case of finding this purpose and attaching meaning to it. Finding a purpose for existence is important to any individual as demonstrated by those who experience none, and suffer what he terms ‘noögenic neurosis’ - which is typified by boredom and general apathy. From his perspective, existential meaning is less created and more discovered - yet there is only one true meaning to each situation, and it is up to the individual to discover this for themselves. His view breaks with the traditional existential view that humans impose meaning upon the world: Frankl agrees that humans cannot adequately function without meaning, but suggests that true meaning is inherent in all situations - the individual discovers this meaning rather than imposes it.
Maslow (1962) takes a slightly different perspective, and theorises that existential meaning is a property that exists within each person. Once the lower levels of the needs-hierarchy are satisfied, the need for personal meaning begins to require fulfilment. If the person chooses meanings that fulfil their inner nature, then they will be healthier – mental illness results when people choose to explain their lives with a meaning that does not fit with their inner nature. If their need for existential meaning is left unfulfilled, then they will, as Frankl suggested, become ill.
While Maslow and Frankl agree that meaning exists in the world, May and Yalom (1995) take the view that there is no meaning that exists outside of the individual. Psychopathology results when one has ineffective methods of dealing with the ultimate concerns of life: death, freedom, and meaninglessness. Thus, Yalom (1980) agrees that personal meaning is important to a healthy mental state, but it is how we deal with and resolve our own concepts of meaning that is particularly important. Individuals suffering from mental illness may be using ineffective methods of dealing with the ‘angst’ caused by these ultimate concerns.
In order to understand the impact of existential meaning upon the lives of adolescents, and why it may be a factor in such maladaptive coping mechanisms such as anorexia, it may be wise to understand the properties of the need for personal meaning. Battista & Almond (1973) identified 4 basic characteristics of existential meaning from Yalom, Maslow and Frankl’s theories.
Firstly, once an individual states that their life is meaningful, this implies that they are committed to some concept of the meaning of life. In effect, they are adhering to some form of paradigm that they use to view and explain the world around them. Thus, this concept or paradigm affords them a framework from which life events can be interpreted in a coherent fashion, and this second characteristic (the notion of a framework) helps them identify goals or purposes for their lives. Thirdly, it follows that if individuals can see that their lives are in some way meaningful, they must be in the process of fulfilling these goals set by the framework, or have met them already. Lastly, the actual process of meeting these goals leads to the experience that ones life and existence have significance. This suggests that commitment to any system of beliefs can serve as a framework for the development of meaning in an individual’s life. Reker and Wong (1988) went on to identify three interrelated components of personal meaning: the cognitive, the motivational, and the affective.
The cognitive component of personal meaning in life refers to the interpretations we make of the world and our belief systems that influence this interpretation. A framework is developed through which experiences can be interpreted.
The motivational component is associated with the pursuit and attainment of personal goals that are consistent with an individual’s values, needs, and desires. This affords their daily actions a sense of meaning, and may be hierarchical, with pre-occupation with pleasure and comfort at the bottom, and the realisation of ones potential at the top.
The affective component refers to feelings of fulfilment, satisfaction, and happiness that accompany the belief that life is worth living.
Clearly, the cognitive component will determine that which an individual sees as important – their values and goals to be attained, and the affective component will then be influenced by how effectively they achieve these goals. If these goals are not achieved, then the cognitive component will adjust to cater for the new information and new beliefs will be formed. This will then change the motivational component, and new goals shall be set. This feedback loop illustrates the importance of meaning in a person’s life and behaviour.
Relating these concepts to anorexia, the illness may serve to introduce some personal meaning into a life that has little or none, and in this sense reduces the perception of existential anxiety. If, as Slade (1982) suggests, that dissatisfaction with life and interpersonal factors contribute to a feeling of loss of control, anorexia may offer a framework to restructure and organise the meanings in life to offer back that sense of control that was lost, albeit via a self-destructive framework. Predisposing factors such as personality (Vitousek & Manke; 1994), may work in conjunction with adolescent or interpersonal conflicts and social pressures to cause the individual to experiment with new forms of control. In the anorexics case, new motivational meaning is discovered in the form of dieting and, more importantly, the loss of weight. Whereas previous goals could not be met, these new, easily defined targets can be, and this then leads to a sense of satisfaction (the affective component). In this way, anorexia provides meaning, structure, and reward, and thus serves to provide that which was lost (or never even present) preceding the illness. Previous beliefs are bolstered or attenuated to match with this new framework, and events are interpreted in the context of the new meaning that this system of beliefs now provides. In this way, anorexia serves as an attempt to reduce the experience of existential anxiety through the creation of personal meaning. However, it does not tackle the fundamental roots of this anxiety, and in effect does not serve to reduce it, rather, it merely hides it. The result of this is that anorexia may serve as a framework for personal meaning and although it is maladaptive and self-destructive, it is the only meaning that the individual has to construct their world. To give this up through the process of ‘recovery’ is to give up the only thing that provides any meaning and any structure for interpreting ones experiences.
As O’Connor, Simmons, and Cooper (2003) have demonstrated that eating disordered thought patterns and behaviours occur in non-clinical samples, it is suggested that a sample population will contain individuals with anorexic tendencies sufficient to test the hypothesis that existential anxiety is associated with anorexia. Additionally, Halmi (1995) noted that anorexia is associated with depression in almost 70% of clients, and as such it would be pertinent to measure depressive symptoms in order to ascertain whether these are related to existential anxiety, and if so, to what extent. Thus, we hypothesise that individuals with anorexic tendencies may be more sensitive to the need for meaning in life due to a number of predisposing factors, and this sensitivity should result in them scoring more highly on measures of existential anxiety than individuals without these anorexic tendencies, regardless of depressive symptomology.
Anorexic participants were recruited from several eating disorder units around the UK. The inclusion criteria stipulated that they should speak English as a first language due to the complexity of the questionnaires, and be currently under treatment for anorexia nervosa. This was validated before they were included in the study. Any participants who did not meet the screening criteria were removed from the study. All other participants were current undergraduates and postgraduates not currently being treated for an eating disorder, recruited using the University of Birmingham’s psychology participation credit scheme, and followed the same procedure as the anorexic group.
All participants were provided with an information sheet outlining the present study and the concepts involved, and asked to read this prior to deciding whether to participate or not. Those that indicated they wished to participate were asked to sign a consent form outlining their role in the research and the procedure involved, and told they could keep the information booklet along with the main researchers contact details should they wish to ask any questions after the study.
Participants then completed 4 self-report measures: the Eating Disorder Inventory (EDI; Garner, Olmsted, & Polivy, 1983); the Anorectic Cognition Scale (MAC; Mizes & Klesges, 1989); the Beck Depression Inventory (BDI; Beck, Ward, Mendelsohn, Mock & Erbaugh, 1961); and the McGill Quality of Life Scale (McGill; Cohen, Mount, Tomas & Mount, 1996). Participants were asked to return the completed questionnaires in stamped, addressed, self-seal envelopes for analysis.
Eating Disorders Inventory (EDI).
The Mizes Anorectic Questionnaire (MAC)
The Beck Depression Inventory (BDI)
The McGill Quality of Life Questionnaire (McGill)
Raw scores were transformed according to the established original author methodology, as outlined in the Method. The scores from the student group (n = 37) and the anorexic group (n = 7) were then combined into one data set (n = 44) and all calculations were performed on this set unless otherwise stated. Means and standard deviations are shown in Table 1. For the EDI, the three eating-related subscales (Drive for Thinness, EDI-DT; Body Dissatisfaction, EDI-BD; and Bulimia, EDI-B) were used in the analysis, in order to separate out anorexic from bulimic tendencies.
Table 1: Means and standard deviations
EDI subscales: EDI-DT = Drive for Thinness; EDI-BD = Body Dissatisfaction; EDI-B = Bulimia.
A Spearman’s rho correlation demonstrated that several factors within the questionnaires were found to be significantly related, and these can be seen in Table 2. Scatter-plots of the relationship between the existential well-being subscale of the McGill and the other questionnaire scores can be seen in Graphs 1-5.
Table 2: Spearman’ Rho correlations between questionnaire measures
All correlations significant at p < 0.01 level.
Graph 1: Relationship between existential well-being and MAC scores
Graph 2: Relationship between existential well-being and EDI-DT subscale scores
Graph 3: Relationship between existential well-being and EDI-BD subscale scores
Graph 4: Relationship between existential well-being and EDI-B subscale scores
Graph 5: Relationship between existential well-being and BDI scores
Significant relationships between existential well-being and EDI-DT (r = -.710; p < 0.01), EDI-B (r = -.494; p < 0.01), EDI-BD (r = -.688; p < 0.01), MAC (r = -.785; p < 0.01), and BDI (r = -.774; p < 0.01) scales were found. To assess the impact of depression upon the existential well-being subscale, a Partial Correlation was conducted, with BDI scores partialled out. Results of this analysis significant to the p < 0.01 level can be found in Table 3. As the EDI was found to significantly correlate with the existential well-being subscale, and in order to separate anorexic from bulimic tendencies, the subscales of the EDI were separated and also entered into the partial correlation.
Table 3: Correlations between eating disorder scales and existential well-being, with BDI partialled out
The hypothesis of the current study was that there is a relationship between existential anxiety and anorexic psychopathology, which is supported by the findings. From the initial results it appears that the more existentially anxious individuals show a higher occurrence of anorexic symptoms or thoughts, even after the effect of depression has been controlled for.
Clearly, however, this study is only correlational in nature, and as such cannot infer cause and effect about the nature of the observed relationship. It is not clear whether anorexic tendencies lead to existential anxiety or whether existential anxiety influences the development of anorexia. Previous research and traditional existential theory (Frankl, 1973; Yalom, 1980) state that all individuals develop some form of existential anxiety at some point in their lives. From this view, the current study suggests that individuals who are vulnerable to anorexic thoughts and behaviours may be more prone to existential anxiety. When taken in the context of the conclusions of Vitousek and Manke (1994), it may be that factors that predispose someone to developing a maladaptive coping strategy such as anorexia may also predispose them to suffering more existential anxiety. They argue that restrictive anorexics have limited resources for dealing with the strains of adolescence and other anxiety provoking situations or events. Similarly, these types of individuals would have limited mechanisms for dealing with existential anxiety, and anorexia may be one form of imposing meaning upon their world. Although cause and effect cannot be directly inferred purely from the results gained in this study, previous research and established theory, as discussed in the Introduction, point to a number of dispositional traits that predispose an individual to anorexic tendencies and thus an acute sense of existential anxiety.
This study looks at anorexic symptoms within a predominantly non-clinical population, thus the interpretation should take into account the possibility that there may be some qualitative difference between an individual who is diagnosed as having anorexia nervosa, and one who is not. However, the EDI and MAC showed levels of anorexic behaviours in the non-clinical portion of the group that were, at times, comparable to the clinical levels of anorexic scoring. Graphs 1-4 demonstrate that for both the EDI and the MAC, a number of individuals not currently diagnosed with an eating disorder were scoring at levels diagnostic of eating disturbance. Although this is no substitute for clinical data, it does suggest that anorexic behaviours and symptoms exist within a
non-clinical population, supporting previous research by O’Connor, Simmons, and Cooper (2003).
The proposed relationship between existential anxiety and anorexia is also associated with increased levels of depression, as measured by the BDI. It is already well known that anorexic individuals tend to suffer from a variety of co-morbid symptoms, including depression, anxiety and self-harm behaviour. The current study analysed the possibility that the relationship is exclusively between depression and existential anxiety, and found that once depression was partialled out, there was still significant contribution from the MAC and EDI scores to suggest an association with anorexia and existential anxiety. More specifically, it was the drive for thinness and body dissatisfaction scales within the EDI that contributed to explaining most of the variance in the data, rather than the other eating disorder subscales. This suggests that it is anorexic beliefs and behaviours that are associated with existential anxiety rather than bulimic or other eating disorder tendencies – indeed, there was no significant link found between bulimic symptoms and existential anxiety.
The current notion of anorexia being related to existential anxiety can be incorporated into existing cognitive-behavioural constructions of anorexia (e.g., Fairburn, Shafran & Cooper, 1999; Garner & Bemis, 1982; Guidano & Liotti, 1983; Slade, 1982). It has been argued that anorexia is based upon an attempt to regain control over ones life when it is perceived as out of control (Slade, 1982) and disruption in the developing years of adolescence is known to precipitate anorexia nervosa. If anorexic tendencies are an attempt to re-introduce control and structure to a chaotic life, it can be argued that the need for control and structure may develop from existential anxiety. One possible mechanism of action is that dieting rapidly becomes perceived as a form of control – if not of some-ones life, then at least of their body and weight. Within certain individuals this may be taken to its logical conclusion and the exclusion of all other activities. In this way it may develop to provide a framework to interpret the world based upon previous experiences (Reker and Wong, 1988), and would require only a few set patterns of beliefs to acquire salience. For example, if the beliefs of an individual centre around feelings of worthlessness, then in an environment where other mechanisms for measuring self-worth have broken down, weight loss could rapidly become the primary motivational system as a highly valued achievement. The loss of weight would be a physical demonstration of the individuals’ ability to achieve a measure of self-worth and would also provide future goals and targets: losing weight becomes a worthwhile pursuit. Importantly, in a chaotic environment, where few things are stable, one thing that can be reliably and easily measured is weight loss, and by definition, the individuals self-worth. This imbues the life with a sense of meaning – actions take on the higher purpose of achieving the ultimate goal of losing weight to feel worthwhile. Upon achieving this, the sense of satisfaction further reinforces the system of beliefs and behaviours. Additionally, the sense of hunger following dietary restraint can be used as an indicator that an individual is losing weight. As hunger is associated with weight loss, and weight loss is associated with feeling good about one-self, the feeling of hunger may develop a level of motivational salience. The cognitive decline that develops with continued weight-loss would likely serve to compound matters further. In this example, the need for stability, control and meaning may serve to augment a rigidly held set of beliefs and cognitions that motivate the individual to engage in maladaptive (anorectic) behaviours.
Several studies may illustrate the above assertions of the role existential anxiety, in light of the current research. Macleod (1981) argued that starvation itself may be viewed, from the anorexic point of view, as an art-form. She has herself recovered from anorexia and suggests that the denial of food is itself related to an existential crisis of identity. She argues that anorexics must learn to live in the world as it is, and accept that they are as much a part of the world as it is a creation of their own minds. One point embraced by Macleod, but initially outlined by Palozzoli (1974) is that anorexic clients must be made aware that growth and change is a necessary factor of ‘being-in-the-world’. Death is an inevitable part of life, and growth is necessary for death – we must except that life is a process that will eventually cease upon non-existence. In her example of a case study, Palozzoli reports that when she proposed this existential concept to an anorexic, the woman reacted initially with shock, but then progressed steadily to a recovery. She suggests that that naming and confronting the anxiety was an important step in her client’s progression through the illness.
If anorexia is viewed as a coping strategy that provides a sense of meaning and identity, then it is important to provide other strategies or frameworks to replace this and facilitate change. MacSween’s (1993) work on the anorexic narrative suggests that this may be difficult due to the perfectionist tendencies that anorexics typically possess, which often leads them into dichotomous or ‘black and white’ thinking. Even so, education and an occupation are suggested as areas where obvious targets, goals and rewards can be identified and achieved with reasonable success. This would serve to re-introduce alternative motivational aspects to an individual’s life, which could then become incorporated into the cognitive component of personal meaning, eventually replacing the anorexic tendencies.
Many factors are involved in the development of anorexia and it is apparent that the illness may serve a functional role by alleviating distress caused by a lack of structure and meaning. However, this is an avoidant strategy that does not tackle the cause of the distress in an individual’s life, and until the cause is tackled, the distress is likely to persist. According to theorists such as Maslow and Frankl, the maladaptive framework will not solve the need for meaning in the long term, does not satisfy the individuals’ inner nature, and will therefore lead to further psychopathology. Although to the individual, anorexic traits and behaviours appear to provide structure, meaning and, to many extents, a way of life, they are rather a mechanism for avoiding dealing with their true need for existential meaning.
Although these results are promising, several points about the present study should be borne in mind. The study is based upon questionnaire data, which relies upon respondents taking time to complete and return information – thus, the type of people who participate may not be a representative sample from the population. This criticism is particularly pertinent with regards to the anorexic component of the data, as these participants are selected primarily from eating disorder units, and the data do not reflect out-patient, or partially recovered anorexic individuals. However, the tendency towards existential anxiety was observed within the entire (combined) group as anorexic tendencies increased, demonstrating that this trend occurs across the entire group - not just the anorexic component, despite the obvious selectiveness of the anorexic sample.
There is also a more general problem with self-report methodology itself and its use within the context of an illness such as anorexia. Although well established as the first line of diagnosis of someone with an eating disorder, recent research suggests that interviews may be significantly more accurate in measuring eating disorder pathology (Passi, Bryson, and Lock, 2002). Questions may be interpreted differently by different individuals, and the nature of the illness means that some people may not report (consciously or unconsciously) certain aspects of their lives. However, although interviews are obviously the ‘gold standard’, in practical terms it is simply neither cost nor time-effective to interview all individuals who participate in the study, and as such, questionnaires are an effective alternative. Evidence suggests that although not the best form of assessment, questionnaires are by no means useless, and they have been demonstrated to be an effective and quick form of evaluating participants. Further to this, as links appear to have been established, structured interviews may prove useful in illuminating the specific dynamic between anorexic thoughts and behaviours and the need for meaning and existential anxiety. An experimental design that compared existential anxiety in clinical and non-clinical samples would allow the dynamic to be explored further, however, time and careful thought would be required to set up and properly control such an investigation. One possible route would be to analyse the relationship between anorexia and existential anxiety compared to other psychopathologies such as obsessive compulsive disorder and depression. However, a control group would have to be comprised of anorexic individuals with no other mental health problems - yet as has been discussed (Halmi, 1995), this would be a difficult group to assemble. Alternatively, a study that measured existential anxiety in patients with mental health problems other than anorexia, such as clinical depression or obsessive compulsive disorder, would also allow some analysis of the specificity of the relationship currently observed between anorexia and existential anxiety. Clearly however, obtaining participants would be a large task requiring extensive resources and access to a large variety and number of willing volunteers; and the validity of a comparison of existential anxiety across such different groups may be questionable.
In conclusion, it seems that the current study provides evidence that anorexic tendencies and existential anxiety are linked. It would be surprising if anorexic behaviours developed purely out of a specific need for meaning, but it is possible that it is a factor in their development. The structure and meaning that anorexic thoughts and behaviours provide may go some way to explaining the low recovery rates that are typically observed within the illness and the high incidence rates of relapse (Fairburn and Harrison, 2003). The introduction of techniques that deal with existential issues (such as those proposed by May and Yalom, 1995) may serve to increase individual self-awareness and reduce the need for maladaptive coping strategies such as the pursuit of the thin-ideal observed in anorexia. Regardless, there is a definite need to offer alternative goals and targets for the anorexic individual besides the pursuit of weight-loss. In order to effectively remove the existential salience of anorexic behaviours, a viable alternative must be offered, as no matter how unappealing starving one-self is, ultimately it is better than nothing.
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