Many–myself included–assume that emphasizing the biological basis of mental disorders will reduce mental health stigma. The idea is that it will place less blame and personal responsibility on the affected individual.
Still, when it comes to raising awareness and reducing stigma, we need to make sure that our assumptions hold up to the evidence, otherwise we run the risk of playing a game of broken telephone. Given that this is Eating Disorder Awareness Week in the United States, the topic is particularly timely. Those of us involved in some aspect of mental health awareness don’t want to be saying “x” only to have be interpreted as “y.”
So, the question is–does a biological or genetic framing of eating disorders lead individuals to hold more positive views of eating disorder sufferers and place less blame on “weak will”?
This is precisely what Matthias Angermeyer and colleagues asked almost 1,350 individuals from two German cities. Angermeyer had them read two vignettes about a woman with either anorexia nervosa or bulimia nervosa (see below) and answer a series of questions aimed at probing the participants’ views on causal factors of EDs and their reactions toward ED sufferers.
The vignettes were:
In the last weeks 15-year-old Anna has lost a lot of weight with a strict diet and lots of sports. Her parents’ attempts to persuade her to eat are rejected vehemently by Anna. She herself has the feeling that she is overweight, even though she is significantly underweight in the meantime. Additionally, she is very afraid of putting on weight again.
15-year-old Bianca is very unhappy with her physique, even though her body weight is normal. She diets all the time because she wants to lose weight at all costs. Several times a week she experiences sudden cravings for food, then she eats big amounts of food in a short time. After that Bianca secretly vomits by putting a finger down her throat.
I cringed at the vignettes, but, I’ll put my criticisms on hold for a second and present what the researchers found (* = % that responded “somewhat true” and “completely true” and ** = % that responded “somewhat untrue” and “not true at all”):
As you can see, there were few differences between attitudes toward anorexia nervosa and bulimia nervosa patients. What’s interesting, however, is that when Angermeyer and colleagues analysed the data further, the found that for both anorexia and bulimia nervosa, attribution to “brain disease” was positively associated with attribution to weak will. In other words, those that endorsed the “brain disease” as a causal explanation for EDs also held that individuals were more responsible for their condition.
This is both surprising and not at the same time. It is not surprising because this seems to be the case for other mental disorders, namely schizophrenia and depression. Studies have found that attribution to biological and genetic wasn’t particularly beneficial. On the other hand, it is surprising because unlike schizophrenia (though I don’t know about depression), eating disorder sufferers are not perceived as being dangerous and “crazy,” usually just vain, selfish, narcissistic and immature. In which cause, attributing the ED to biological causes should (as we commonly assume) give it more legitimacy, as opposed to make it seem “hard-wired”? (I think, anyway.)
The authors were at a loss for explanations, but they speculated:
Instead of conceiving brain disease and weak will to be in a reciprocal relationship, as proposed by attribution theory, in the sense that a stronger endorsement of the first is accompanied by a weaker endorsement of the latter, respondents may have perceived weak will as a consequence of rather than an alternative to brain disease, in the sense that people with this disorder are less able to exert control over their behavior.
Yeaaah this might be the case. I can think of some other reasons for these results, though.
First, the vignettes. Ugh, right? I mean, I get it, they are textbook/DSM-style blurbs. But they make Anna and Bianca look like vain, selfish, narcassitic and immature teenagers, don’t they? So much so that brain “disease” or not, their perceived psychological attributes still dominate our perception of them (at least this could be the case for many study participants). After all, what’s the point of presenting a very symptom-based and superficial description and then studying the effects of attributing EDs to biogenetic factors?
If I were to do the study, I’d do it differently. I would write up several different blurbs, each of which would have varying hints of biological and hereditary causal factors (mentioning anxiety, perfectionism, OCPD, family history, that restricting was anxiety-reducing, etc..), then split up my participants and give each group one a different blurb to read. Then I would ask them about their opinions and attitudes. Basically, my question is: To what extent do the responses depend on the content and wording of vignettes themselves? I bet substantially.
Second, “brain disease”? Would responses be different if Angermeyer said “brain disorder” or “brain-based disorder”? When I think brain disease, I think neurodegenerative diseases, encephalitis, brain trauma. Medical problems where there is a clear disruption in normal processes, either a particular group of neurons are dying (as in neurodegenerative diseases) or brain region is physical damaged, for example. The causes might be purely environmental (accident) or genetic (Huntingdon’s disease), but there’s a clear disruption in brain function.
Eating disorders don’t fit that in my opinion. The way I view it is that factors that predispose individuals to develop eating disorders aren’t inherently negative, they can just become maladaptive as a result of environmental factors. The personality and temperamental traits that commonly occur in those with eating disorders (and other mental health disorders) seem to me to be on one end of the normal distribution as opposed being on a whole different spectrum entirely. I think maladaptive behaviours are different from purely physiological diseases whose causes do not depend on the social environment (at least not much).
Finally, we don’t really know what the participants in this study thought when they read “brain disease” or “hereditary factors.” As someone with a neuroscience degree, it is particularly difficult for me to gauge public understanding and perception of biological phenomena. It would be nice to see, in future studies, more exploration (using semi-structured interviews) of what participants think of when they hear “brain disease” or “hereditary factors”. What does it mean to them?
In any case, I firmly believe that–although it is difficult, and it doesn’t fit nicely into a headline–we HAVE to emphasize and explain the complex causal factors that lead to eating disorders (and that means explaining a lot of biology, too). We don’t know them all yet, but we know enough to begin to paint a complex picture for the public. It is tempting to cut corners and make slogans that fit onto T-shirts, but I doubt that will get us where we want to be.
Epidemiology&rft_id=info%3Adoi%2F10.1007%2Fs00127-012-0648-9&rfr_id=info%3Asid%2Fresearchblogging.org&rft.atitle=Biogenetic+explanations+and+public+acceptance+of+people+with+eating+disorders&rft.issn=0933-7954&rft.date=2013&rft.volume=&rft.issue=&rft.spage=&rft.epage=&rft.artnum=http%3A%2F%2Fwww.springerlink.com%2Findex%2F10.1007%2Fs00127-012-0648-9&rft.au=Angermeyer%2C+M.&rft.au=Mnich%2C+E.&rft.au=Daubmann%2C+A.&rft.au=Herich%2C+L.&rft.au=Wegscheider%2C+K.&rft.au=Kofahl%2C+C.&rft.au=Knesebeck%2C+O.&rfe_dat=bpr3.included=1;bpr3.tags=Medicine%2CPsychology%2CPsychiatry%2C+Eating+Disorders%2C+Anorexia+Nervosa%2C+Bulimia+Nervosa%2C+Public+Understanding%2C+Causal+Attributions%2C+Social+Psychiatry">Angermeyer, M., Mnich, E., Daubmann, A., Herich, L., Wegscheider, K., Kofahl, C., & Knesebeck, O. (2013). Biogenetic explanations and public acceptance of people with eating disorders Social Psychiatry and Psychiatric Epidemiology DOI: 10.1007/s00127-012-0648-9