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Family Functioning and Eating Disorders

Annalisa Jenner




          The association of family dynamics and the relationship to eating disorders has been studied frequently in hopes of determining the effect of one on the other. Eating disorders encroach on every aspect of a family’s life (Dimitropoulos, 2008); however, it is difficult to scientifically prove that the distress is caused directly by the eating disorder. It is also difficult to pin point which is the original stressor, the eating disorder or the conflict within the family. Despite numerous studies that have examined various precipitating events or family dynamics, there are no generalized explanations for the cause of an eating disorder.


            Anorexia Nervosa is a disease that involves self-starvation with thinness being a main goal. Bulimia Nervosa is a disorder that includes overeating and is followed by some sort of compensatory behavior (Patching & Lawler, 2009). Kluck (2008) found the prevalence of anorexia and bulimia to be one to five percent total, but much higher on college campuses. Some significant experiences, such as peer teasing, emotional predispositions, culture, family ideals, family interactions and advertising, can play a role in the development and maintenance of an eating disorder. Bulimia is often associated with impulsiveness and helplessness (Haslam, Mountford, Meyer & Waller, 2008), while anorexia is known for obsessiveness and compulsiveness. The key purpose of eating disorders is to gain some sort of control within the person’s life (Waller, 1994). This feeling commonly is a response to an overprotective family or high expectations within that family. Some researches believe that there is a natural course that leads up to an eating disorder. Understanding this path would assist in prevention rather than treatment (Patching & Lawler, 2009).

Influences of the family on the eating disorder patient

          Understanding the possible causes of an eating disorder is key in determining the best process for recovery (Patching & Lawler, 2009). Since an eating disorder leads to many unhealthy psychological reactions, it is difficult to correctly measure a patient’s attitude and perception of their family interaction (Waller, 1994).

            A family can have an effect on the patients disorder before and during the diagnosis. Anorexia Nervosa has frequently been associated with an enmeshed, conflict avoidant and rigid family, where Bulimia Nervosa has been linked to families presenting conflict, disorganization and poor communication skills (Ciccolo, 2008). Day to day interactions can also increase risk for an eating disorder. Declarations of high expectations and negative comments from friends and family members are frequent with eating disorder patients. Eating disorder patients often claim that strong emotion was looked down upon as a child, consequently, they commonly never learn how to properly deal with their emotions and use their eating disorder as an outlet for their negative emotions (Haslam, Mountford, Meyer & Waller, 2008). A questionnaire completed by 581 college women involving the level of criticism of weight, food habits and appearance they felt in their family related to the body image and eating tendencies that they have now, concluded that negative body image due to family disapproval may lead to depressive symptoms. These depressive symptoms tend to initiate poor dieting and binging habits (Meno, Hannum, Espelage & Douglas Low, 2008).  Even if family interaction does not play a significant role on the development of the eating disorder, it may have an effect in maintaining it (Patching & Lawler, 2009).

            The family of a patient can also have very positive results on their eating disorder. Family therapy has become very popular (Cook-Darzens, Doyen & Mouren, 2008).

Studies involving the impact of family interactions on patients

            Many studies have been performed involving the influence of family dynamics on the cause and maintenance of an eating disorder. It is difficult to perform an unbiased study on this subject because opinion can be factored into the results and most patients are aware of the study being executed and have the ability to generate new insights (Ciccolo, 2008).

            A study performed by Glenn Waller (1994) focused on women with Bulimia Nervosa and their perception of their family interactions in relation to their eating disorder. This study did not focus on whether family interactions were a cause of their eating disorder, but a factor in their intensity of their disorder.


            Eighty-one purging bulimic women who attended an eating disorders clinic were assessed on their perception of interaction with their family and their attitudes on eating. The women took the Eating Attitudes Test and the Family Assessment Device. Along with these two self-assessments, the women kept diaries on their eating behavior for two weeks after the self-assessments.


            The self-assessments along with the eating diary did not make it possible to associate the perceived family interaction with the eating disorder. Women who claimed to have more agreeable families binged less. The result did suggest a possible connection between the perceived interaction of the patient and their family with their binging pattern.


            The woman’s binging frequency was higher if she perceived her family to be poor at resolving problems, yet the frequency of binges was lower when the patient perceived her family to be poor at expression emotions towards each other. Waller (1994) concludes that family interactions could be a predisposing factor only if certain interactions are made. Family interactions could also be considered a protective factor against eating disorders if the family was poor at expressing concern for other family members.


            This test was very sound. It concentrated on only two variables, attitudes about eating and family. Also, it was clear that it was a study on the perception of the interactions; therefore, it takes into consideration that it is difficult to measure ones feelings without factoring in opinion. Waller (1994) continues to report on the woman’s attitudes over the next two weeks, which is important because attitudes can change daily and it is imperative to look for consistency in these feelings. It is also crucial that Waller focused on bulimia instead of eating disorders as a whole because Bulimia Nervosa and Anorexia Nervosa are two very different diseases. It would have been interesting to compare the results from this study to a new Waller study with anorexic patients.

            Erica Ciccolo (2008) researched a similar study. She studied 21 anorexic patients and 16 bulimic patients. She also performed the test on 30 undergraduate students from a university in Sweden. All of the patients were females around 22 years old. The patients were interviewed on their background and family history. Each patient completed the Trio Family test, where they were briefly shown a picture of a family. After viewing the picture, Ciccolo (2008) conducted an interview asking about the patients’ perception of the family in the picture and responding to different scenarios. Next, self-assessments including the Eating Disorder Inventory-2 and the Karolinska Scales of Personality were given to the patients. The patient group and control group showed significantly different values on certain areas of the self-assessments and the Trio Family Test. The control group scored lower on scales dealing with impulsiveness, aggression and negative family themes, where the variable group showed common themes of loneliness and lack of importance (Ciccolo, 2008). The study does not just concentrate on self-assessments, which usually focuses on themes of past experiences, but the Trio Family Test, which explores current feelings (Ciccolo, 2008). This test is more effective than others because it gives the ability to compare the results of the eating disorder patients with a control group; however, it would be useful to have more subjects studied. Ciccolo (2008) mentions that it would be meaningful to have a control group consisting of patients with other mental disorders to have the capability to distinguish between the effects of an eating disorder or just a mental disorder in general. More separation between the anorexic patients and the bulimic patients would be beneficial since they are very different disorders. Also, it is difficult to differentiate real family patterns from individual expression (Ciccolo, 2008).

            A study performed by Patching and Lawler (2009) involved interviewing 20 women with both anorexia and bulimia and evaluating their life history by multiple researchers. Some of the women were recovered and all of the women had different experiences with their eating disorder, yet the three common themes were found to be control, connectedness and conflict (Patching & Lawler, 2009). Some of the interviews discussed the families unrealistic expectations, dysfunctional eating of other family members, abuse within the family and a sense of not belonging. The study did not involve a control group, and the group that was studied was so diverse that many confounding variables may distort the results. Although a person’s entire life experience plays a role in their development of an eating disorder, it is difficult to determine what issues in their life are the most significant factors. The participants had the ability to respond to the interview questions with whatever they saw as important and the researchers took from it what they saw as important.

Negative effects of the eating disorder on the family

          Patients of eating disorders commonly depend on their family members for financial and emotional support (Diamantopoulos, 2008). The family of an eating disorder patient spends countless hours in distress over the family member. It becomes difficult for the caregiver to continue to deliver financial support since supporting an eating disorder patient and holding a full time job often becomes overwhelming. Providing continuous emotional support can also strain the caregivers who may not be emotionally content themselves (Diamantopoulos, 2008).  Many negative personality traits may come out because of an eating disorder, this could strain the relationship of the patient and their primary resource for help (Kyriacou, 2008). The family commonly has a difficult time understanding the patients reasoning behind the eating disorder and why they are not able to recover. This is made more difficult by the fact that an eating disorder is one of the few mental illnesses that needs the patients’ willingness to recover before any progress can be made (Patching & Lawler, 2009).

Whitney and Eisler (2005) discuss the reorganization of families after the diagnosis of an eating disorder.  Due to the lack of information, Whitney and Eisler (2005) were unable to differentiate between Anorexia Nervosa and Bulimia Nervosa. Family life begins to revolve around the patient and family members suffer mentally and physically. New responsibilities arise and the day-to-day routine is discontinued, replaced with a constant feeling of abnormality (Whitney & Eisler, 2005). The parents own life seems to be put on hold in order to take control of their child’s disease, while some parents cannot take the guilt and try to avoid the situation all together (Whitney & Eisler, 2005). Whether or not there are serious issues within the family, an eating disorder can amplify any dilemma in the household. The family is often unfairly blamed and family members frequently ask, “What did I do?” and “What didn’t I do?” (Whitney & Eisler, 2005).

A study found that families with an Anorexic family member suffered more distress then families with a Bulimic family member (Diamantopoulos, 2008). Another study concluded that caregivers of individuals with Anorexia Nervosa had higher scores on anxiety and depression tests than a carer of an individual with Alzheimer’s disease (Diamantopoulos, 2008). This could be due to the fact that caregivers of eating disorder patients are not given many resources for health services and also because the caregivers are often blamed for the illness of the patient (Kyriacou, 2008). The average duration of Anorexia Nervosa is about six years, meaning that the support of a caregiver is almost always long-term. It can be very disheartening to the family when giving so much support to the patient who may be unwilling to accept their help. This exhaustion of meeting the patients’ needs allows the caretakers very little time for themselves and eventually lowers their quality of life.

Andersen (2007) advises the families of his patients that although they need to be accepting of their child, for no reason do they need to accept the eating disorder. The suffering can affect every family member (Andersen, 2007); therefore, more time should be spent connecting the caregivers and the therapists (Sepulveda, Whitney, Hankins & Treasure, 2008).

Studies involving the consequences of an eating disorder on the family

          There are fewer studies on the impact of an eating disorder on the family compared to the amount of knowledge on the consequences of family interactions on a developing eating disorder. Also, there is minimal knowledge on the interaction of patients specifically with Bulimia Nervosa and their families.

            The study performed by PhD Gina Dimitropoulos (2008) was done to determine the impact that Anorexia Nervosa has on family functioning and the possible distress it may cause.


Dimitropoulos (2008) used a cross sectional study, which is a study where subjects were assessed at one point in their lives, with 63 family members of an inpatient suffering with Anorexia Nervosa. The stress process model measured the amount of stress experienced by the primary care giver. The stress process model focused on primary stressors, such as direct burdens to the primary caregiver, and secondary stressors, such as family conflict and the attitude towards the Anorexic patient. The primary care giver was made up of mothers, fathers, siblings and husbands.  Dimitropoulos (2008) used the Family Assessment Device, the Family Conflict Scale, the Burden Assessment Scale, the Devaluation of Consumers and Consumer Families, the Professional Support Instrument and the General Health Questionnaire to determine distress of the caregivers. These are both self-report standardized questionnaires that evaluate families, current health state, level of stress and support received (Dimitropoulos, 2008). The study was conducted at the Inpatient Eating Disorder Program at the Toronto General Hospital.


Certain assessments showed significant high scores with the eating disordered families. The Family Conflict Scale gave the strongest correlation, meaning that the eating disorder does cause added distress and conflict within the family. Primary caregivers that lived with the patients scored higher on the Burden Assessment Scale compared to a primary caregiver that did not live with the patient. The data also showed that female caregivers, 36 of the 63 studied, showed more distress than male caregivers. Emotional support was the most common form of help needed from the primary carer. The strongest predictors of family functioning were burden and social support.


            The results of the study concluded that many aspects of caring for an anorexic patient take a toll on family functioning and individual distress. The biggest finding showed that family conflict, burden and need for social support impacted the family the most. Although family conflict was considered a secondary stressor, next to the primary stressor of the day-to-day burden of the disease, conflict demonstrated to be the most influential variable on family functioning. The results of the study were similar to studies conducted with caretakers of other severe mental illnesses. The amount of time needed for care giving and the scores on many of the self-assessments showed many similarities.


            The study is one of the few that focuses on the family instead of the patient. Since it was a cross sectional study, reports could be very different if the caregivers were assessed at multiple times. At least three assessments would give better results to both of the questionnaires and would show changes in family functioning throughout the illness. Feeling of distress and depression can easily be perceived from different evaluations, but assessing the family members multiple times would show that the feelings of distress were long term and originated from the eating disorder. Also, a bigger pool and more variety of ethnicity and location of caregivers would earn this study more credibility. It would also allow the study to be more generalized. A control group is not addressed in the study and the statistics of stress within a family without the burden of an eating disorder would be helpful. When researching the three main variables, burden, family conflict and level of social support, there is an individual opinion of the level of burden, conflict, and support needed. This also makes the results hard to generalize. Although there are factors that would make this study more dependable, it is important to investigate the caregivers side of the disease to eventually have the ability to help the carer cope with the distress.

            Olivia Kyriacou (2008) performed a study in almost the exact same manner as Dimitropoulos.


This study was also a cross-sectional study that used self-report questionnaires. Parents of patients were found on the Carers Volunteer Database, resulting in 151 subjects studied. Kyriacou (2008) used the Caregiving Stress Scale, the Hospital Anxiety and Depression Scale, the Experience of Caregiving Inventory and the Anorectic Behavior Observation Scale.


            The mothers involved in the study showed higher levers of depression and anxiety than the fathers studied (Kyriacou, 2008). The mothers also seemed to have more personal strain than fathers did. The mothers scored higher on tests that focused on work overload and loss of self. Female carers are all together more emotionally involved in the care giving.


            Over 50 percent of the caregivers scored over the clinical threshold for anxiety and 13 percent scored over the clinical threshold for depression. The three most significant variables in the study were self-related strains, carer sex and interpersonal strains.


            This study was more reliable due to the fact that it included almost 100 more subjects that previous studies. There was no control group in this study, which makes it more difficult to analyze the results. This study took many variables and then studied the ones that they found to be significant. It would be more influential if they study took a few variables and then concentrated on the effects of these few factors throughout the whole study.

            A study was conducted using the Eating Disorders Symptom Impact Scale in order to measure the amount of stress of carers of eating disorder patients and measure the ability of this stress level to change. A sample of 190 caregivers of eating disorder patients were given a newly developed questionnaire that focused on guilt, dysregulated behavior, nutrition and social isolation. Caregivers of bulimic patients were shown to suffer from more difficulties than those that care for anorexic patients and there was little change shown in distress when caregivers were involved in an intervention (Sepulveda, Whitney, Hankins & Treasure, 2008). The caregivers should have been separated into those who care for an anorexic and those who care for a bulimic, along with factoring in those who care for a patient that lives in the same home as the caregiver. Depending on if the patient lives at home or not would change how much time is consumed caring for the patient. Since the test involved is new, it would enhance the study to include a second trial.

Family Therapy

            Family therapy is used to develop a healthy form of emotional expression, which is shown to be a predictor of mental health in family members (Meno, Hannum, Espelage & Douglas Low, 2008), so that an eating disorder can be prevented or treated. Realizing and resolving these anxieties of family pressure and criticism has shown to reduce the dependence on the controlling behaviors of an eating disorder (Meno, Hannum, Espelage & Douglas Low, 2008). A study conducted on family therapy incorporated in the recovery process of eating disorders showed an 86 percent success rate (Cook-Darzens, Doyen & Mouren, 2008). Family therapy may not just solve the problems that possibly created the eating disorder, but a positive family relationship is involved in a healthier recovery (Cook-Darzens, Doyen & Mouren, 2008). After examining the research on the effects of an eating disorder on the family, it is apparent that the family needs to be included in the therapy and should be treated with equal sensitivity as the patient (Whitney & Eisler, 2005). It is unclear if family interactions can directly lead to an eating disorder; however, personality characteristics such as self-esteem are influenced by the family and play a large role in the prevention of an eating disorder (Meno, Hannum, Espelage & Douglas Low, 2008).


          Studying family interactions in relation to an eating disorder may be helpful in determining therapy for both the patient and the caregiver. Ultimately, the studies performed will depend on the perception of the function of the family by the family member (Waller, 1994).

The negative family interactions could be caused by the common theme shown in many of the studies where the patient lacks the appropriate skills to communicate (Ciccolo, 2008). Poor body image, self esteem and emotional problems can be related to the establishment of an eating disorder, yet these are not necessarily issues caused by the family. Even if the family is not definitely a cause of an eating disorder, it should be considered a top responsibility of parents to install feelings of confidence and strong self esteem in their children. Focusing on a healthy diet, body and lifestyle instead of body negativity and a thin-ideal stereotype would be extremely constructive in developing these habits (Meno, Hannum, Espelage & Douglas Low, 2008).

The possible risk factors for an eating disorder are endless and each case cannot be placed on the same exact scale (Patching & Lawler, 2009). Some interactions can be seen as risky (Waller, 1994), but they cannot yet be concluded to be a cause of an eating disorder. All of the reviewed studies had some limitations that made them unable to be generalized to the entire population. Negative family dynamics could be a common occurrence in families with an eating disorder patient, or misperceptions of family interactions could be a frequent incidence with eating disorder patients (Ciccolo, 2008). Current findings may suggest consequences with family interaction and the symptoms of an eating disorder, but there is not enough information to establish family interactions as the cause of the disorder.


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Cook-Darzens, S., Doyen, C., Mouren, MC., (2008). Family Theraphy in the Treatment

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