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Are the existing criteria within the DSM IV culturally relevant to our diverse society?

  Kate Benedict

            As our society is bombarded with the images of manufactured beauty and “thinness”, conversations increasingly center on dieting and body dissatisfaction.  The media advertises weight loss products in the form of pills, drinks, surgery, fitness equipment and support groups to mold individuals into the proposed ideal form.  This evidence alone suggests a strong case for the possibility of a pathological fear of fat.  Is this fear, however, the driving force behind all cases of anorexia nervosa and bulimia?  According to the DSM IV, the fear of gaining weight is essential for these diagnoses to be made.  Strong arguments have been made both in favor and against modifying the existing criteria to allow for the diagnosis and treatment of individuals, regardless of whether or not a ‘fat phobia’ is present.  Is it culturally insensitive to retain this particular criterion, a fear of gaining weight, if a patient has not been exposed to the same cultural pressures and orientation towards being thin?

            Although western culture is thought to be the dominant culture, because of power and economics, non-western cultures make up eighty percent of the world’s population (Lee, 1995).  Many of these ‘sub-dominant’ cultures are present in the melting pot of the modern United States. Are these non-Westernized individuals being denied the necessary treatments and interventions merely because a fear of gaining weight is not expressed?  Such a strong focus on body dissatisfaction may cause one to overlook or disregard the pressures of societal systems, such as immigration or poverty, on the mental and physical well being of an individual.  If ‘fat phobia’ is indeed a culturally constructed definition of anorexia nervosa, it lacks a strong psychological and biological foundation, and is therefore questionable in the eyes of many researchers and clinicians.

            To observe the impact of culture on attitudes towards eating and perception of body shape, Lake, Staiger and Glowinski (1999) conducted a study using 140 female students from 2 Australian universities.  The students were divided into 2 groups – those who were born in Australia (98) and those who were born in Hong Kong (42).  The Students born in Hong Kong were further divided into 2 groups – a weak Chinese ethnic identity group (Western acculturized) and a strong Chinese ethnic identity group (Traditional) using the Ethnic Identity Scale (EIS). 

            All subjects were given the Eating Attitudes Test (EAT), a commonly used and well-validated measure (Garner et. al 1979; Garner et. al 1982), to assess attitudes towards eating. The Figure Rating Scale (FRS), used in similar research due to its high test-retest reliability (Thompson et. al, 1991), was used to determine perception of body shape.  The scores from these tests were then compared with the subjects’ cultural orientation.

            The results showed significantly higher scores on the EAT (indicating more negative attitudes toward eating) in the traditional Hong Kong born subjects than that of their acculturized counterparts, while the acculturized Hong Kong born subjects’ scores were significantly lower than those of the Australian born subjects.  In other words, between groups (Hong Kong born v. Australian born) there was no significant difference, but within-group (based on level of ethnic identity) significant differences were present. In addition, the FRS scores indicated a greater level of body dissatisfaction among the Australian born subjects. 

            The fact that greater body image distortion, in the absence of eating attitude differences, was present in the Australian born women, it may be inferred that body image is not a crucial factor contributing to eating disorders in Hong Kong born women.  It is not a ‘drive for thinness’ that leads to their eating pathology. Perhaps Hong Kong born subjects have not embraced ‘Western body figure preferences’.  These results support existing literature, which states that ‘attitudes toward eating and perceptions of one’s own body shape are influenced by cultural factors’ (Furnham, 1994; Hill et. al, 1995).  The authors of this study believe that the criteria for eating disorders should be more flexible in order to account for these cultural variations.  Based upon these results alone, can a decision be made as to whether or not diagnostic changes are necessary?  The measures that were used to obtain data for this study, despite their validity and reliability to date, are ‘Western’ questionnaires.  Whether these questionnaires can be applied to non-Western cultures has not been shown (King et. al, 1989).  Therefore, to search for a more culturally sensitive definition of eating disorders, a more culturally appropriate scale for aiding in the search is needed.

            Lending the perspective of Eastern culture, researchers from the Chinese University of Hong Kong conducted a study in their country.  The study was aimed at exposing and explaining the non fat phobic segment of anorexia nervosa.  It is their belief that anorexia nervosa may be conceptualized without ‘invoking the explanatory construct of fat phobia exclusively’ (Lee et. al, 1993).

            In this study, the subjects were 70 eating disordered patients (69 female; 1 male) with a mean age of 24 years.  To be included in the study, subjects had to meet the following criteria: (1) weight loss of 15% or more of weight expected for height; (2) the weight loss or maintenance of low body weight had to be induced by a restriction of food intake, which may have been accompanied by (a) excessive exercise, (b) self-induced vomiting, (c) self-induced purging, or (d) use of appetite suppressants and/or diuretics; (3) in response to others’ attempts to make him/her increase food intake, the patient used complaints such as fear of fatness, abdominal bloating, loss of appetite, no hunger, or distaste for food, to resist such attempts; (4) amenorrhoea in female or loss of libido in male; and (5) no other known disorder accounted for the weight loss.

            When the researchers examined reasons for food refusal, fat phobia did not emerge as a prevalent explanation.  In fact, only 29 patients (41.4 %) exhibited fat phobia at the onset or during the course of their illness.  41 patients (58.6 %) gave other reasons, such as stomach bloating (N=21), no appetite (N=11), fear of food (N=1), or no explanation at all (N=8).    The proportion of non fat phobic patients to fat phobic patients is thought to be even higher than what these numbers portray, because the former may seek other forms of treatment (i.e. medical care rather than psychiatric care).

  If such a large number of eating disordered patients lack a fear of fat, how are they to be categorized and treated.  Without a clinical diagnosis, which necessitates a fear of gaining weight, treatment becomes more complicated and uncertain.  Shouldn’t the terms ‘anorexia nervosa’ and ‘bulimia nervosa’ be expanded in order to accommodate the non fat phobic patients? 

The answer is still unclear.  Perhaps the absence of fat phobia in these patients can be explained by insufficient methodologies concerning the gathering of necessary data.  Human error can result in simply overlooking the presence of a phobia, and imperfect questioning can allow for a phobia to remain concealed.  If a fear of fat does indeed prevail, there is no need to change the current criteria.

Tilmann Habermas, from the Institute for Medical Psychology in Berlin, is a proponent of keeping the existing specific psychological criterion of fat phobia in the DSM IV.  He believes that this criterion creates a group of patients with sufficient similarity (Habermas, 1994).  To expand the diagnostic criteria would be detrimental to the patient population. A broad category for anorexia nervosa allows for food refusal of any type - be it a display of religious beliefs, of defiance, a political statement or any other non fat phobic behavior.  The existing definition of anorexia nervosa allows a doctor or clinician to clearly define the problem and treat it accordingly.

Perhaps a compromise can be made between the two schools of thought, without completely abolishing or completely adhering to the fear of fat criterion. Lee and his colleagues suggest the addition of a fat phobic - non fat phobic subtype distinction within the existing diagnosis of anorexia nervosa (1993).   Regardless of the DSM IV’s diagnostic flexibilities, research flexibility is needed to further understand and explore the nature of eating disorders.  The most critical element to keep in mind is the need for treatment.  However we decide to categorize them, eating disorders are disabling and can even be fatal. Treatments such as nutritional education, psychotherapy, medication, and various interventions will continue to illuminate the details and underlying causes that are still unknown.       














Furnham, A., & Baguma, P. (1994).  Cross cultural differences in the evaluation of male and female body shapes.  International Journal of Eating Disorders, 15, 81-89.

Garner, D.M., & Garfinkel, P.E. (1979).  The Eating Attitudes Test:  An index of the symptoms of anorexia nervosa.  Psychological Medicine, 9, 273-279.

Garner, D.M., Olmsted, M.P., Bohr, Y., & Garfinkel, P.E. (1982).  The Eating Attitudes Test:  Psychometric features and clinical correlates.  Psychological Medicine, 12, 871-878.

Habermas, T. (1996).  In Defense of Weight Phobia as the Central Organizing Motive in Anorexia Nervosa:  Historical and Cultural Arguments for a Culture-Sensitive Psychological Conception. International Journal of Eating Disorders, 19, 317-334.

Hill, A.J., & Bhatti, R. (1995).  Body shape perception and dieting in preadolescent British Asian girls:  Links with eating disorders.  International Journal of Eating Disorders, 17, 175-183.

King, M.B., & Bhugra, D. (1989).  Eating disorders:  Lessons from a cross-cultural study.  Psychological Medicine, 19, 955-958.

Lake, A.J. Staiger, P.K., & Glowinski, H. (2000).  Effect of Western Culture on Women’s Attitudes to Eating and Perceptions of Body Shape.  International Journal of Eating Disorders, 27, 83-89.

Lee, S. (1993).  How abnormal is the desire for slimness?  A survey of eating attitudes and behaviour among Chinese undergraduates in Hong Kong.  Psychological Medicine, 23, 437-451.

Lee, S. (1995).  Self-starvation in context:  Towards a culturally sensitive understanding of anorexia nervosa.  Social Science and Medicine, 41, 25-36.

Thompson, J.K. & Altabe, M.N (1991).  Psychometric qualities of the figure rating scale.  International Journal of Eating Disorders, 10, 615-619.


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