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Family Structure and Eating Disorders

Cherilyn Hefter

Anorexia nervosa and bulimia nervosa are the two most common eating disorders. There are several theories that try to explain how and why these disorders affect so many people. I will look at how family structure contributes to the onset of both anorexia and bulimia. I will also examine possible ways to treat the two based on the assumption that the causes of the disorders are rooted in the family and its structure.

In an article entitled Fearing fat: A literature review of family systems understandings and treatments of anorexia and bulimia, Kyle Killian (Killian, 1994)addresses the family variables associated with anorexia and bulimia. Killian cites Yager as deriving family variables as relevant to eating disorders. Those variables are the presence of affective disorders in other family members, sociological factors (not discussed here), and family relationships. Killian then addresses these variables separately. It was found that there is a higher incidence of various forms of psychopathology in the families of persons with eating disorders. Relatives of those suffering from anorexia are almost six times as likely to develop an eating disorder (Killian, 1994). Strober et al concluded that anorexia is intergenerationally transmitted. Strober says, "It is roughly eight times as common in female first-degree relatives of anoretic probands as in the general population, and is absent in relatives of probands with other types of deviance(Killian, 1994)". It was also found that sisters of bulimics were four times as likely of developing bulimia than the general population (Killian, 1994).

The dynamics of a family are also related to the onset and continuity of anorexia and bulimia. Minuchin et al. found that enmeshment, rigidity, lack of conflict resolution, and overprotectiveness contribute to eating disorders. Heron and Leheup have found that anorectic families tend to be characterized by enmeshment. However, bulimic families report that they are less involved with one another as well as perceiving themselves as less cohesive. Kog and Vandereycken found that eating disordered families show more stability and less openness when discussing conflict between parents and children. Root et al. has identified three types of families that contribute to eating disorders. These families are the perfect family, the overprotective family, and the chaotic family (Killian, 1994).

Felker and Stivers (1994) did a study to examine the relationship between family environment and the risk of developing anorexia or bulimia in adolescents. They measured perceptions of family environment by using the Family Environment Scale , Form R. Seven of the ten subscales of the FES Form R relate to eating disorder research. Those subscales are cohesion, expressiveness, contact, independence, achievement orientation, organization, and control. Analysis of data revealed that there was a significant relationship between family environment and the risk of developing and eating disorder in adolescents. It was found that lower cohesion, lower expressiveness, and lower organization were significantly associated with the risk of developing an eating disorder. It is also true that lower independence is significantly associated with eating disorder risk. They also discovered that great conflict and control were significantly associated with an increased risk of developing an eating disorder.

Kent and Clopton (1992) did a study to examine the relationship between bulimia and family variables. They used 24 bulimics, 24 subclinical bulimics, and 24 symptom-free females from Texas Tech University as subjects. Each subject was given the following self-assessment measures: Personal History Questionnaire, the Bulimia Test (BULIT), the Eating Disorder Inventory (EDI), the Family Environment Scale (FES), and The Parental Bonding Instrument (PBI). The Personal History Questionnaire gathers information about bulimia related behavior, menstrual history, psychiatric history, and family information. The BULIT and EDI were used to determine how well the subjects met the DSM-III-R criteria for bulimia. The FES looked at interpersonal relations, directions of personal growth, and basic organizational structure. The PBI assessed the subject's perception of her relationship with her parents in regards to care and protection. Several significant findings emerged after statistical analysis of the questionnaire answers. Bulimics were found to score lower on the Cohesion and Active- Recreational Orientation subscales of the FES than the other two groups of subjects. When examining closeness to parents, it was found that 26% of the bulimics and 26% of the subclinical bulimics were currently closer to their fathers. No symptom free subjects reported closeness to their fathers. No symptom-free subjects were found to have eating problems withing the family. However, 29% of the bulimics and 20% of the subclinical bulimics were found to have members in their families that had eating problems. Based on these findings, it is reasonable to conclude that their is a significant correlation between family variables and bulimia (Kent and Clopton, 1992).

All of the above information tells us that there is a correlation between family structure and the onset and continuation of eating disorders. The evidence is not empirical and cannot point to the family as the cause of eating disorders.


Because it has been theorized that family structure is correlated with eating disorders, family systems therapies have sometimes been found to be beneficial in the treatment of eating disorders. Structural family therapy focuses on the current interaction within the family. Structural therapy aims at discovering the hierarchical organization of the family. A healthy family would have clear boundaries amongst family members. Therapy typically centers around the issue of control as it pertains to control of food intake. Strategic family therapy looks at the present but centers on having specific directives aimed at the patient. The goal of the therapist is "to interrupt the repetition of dysfunctional sequences and to introduce into the system more It constructive behavioral alternatives (Killian, 1994). Transgenerational therapy deals with the past of anorectic families. It is believed that anorexia can develop out of beliefs that a family has held over generations. In this type of family, daughters are expected to fulfill the role of a devoted and sensitive person. In bulimic systems, therapy centers on particular treatment for perfect, overprotective, and chaotic families. In this type of therapy, an alliance is created within the family (Killian, 1994). One model for treating bulimics is the transgenerational model. In this model, the family legacy is examined. Purging is seen as a symbol for rejection of the family's love or other intangible things. Object relations/family systems model looks at what is termed ego deficits. Ego deficits occur when the mother was insufficient in giving loving care. Therefore, this therapy aims at correcting the ego deficits. The internal family systems model looks at parallel interactions within the family. It examines the internal and external pieces of the family and the individual simultaneously (Killian, 1994).


Felkner and Stivers suggest that schools be involved in helping train students to cope. They suggest that schools teach children better interpersonal skills, self-concept, and organizational skills. In doing so, adolescents were be prepared to handle conflict within the family unit. Independence can be achieved by enhancing self-awareness and understanding. All these methods would benefit the individuals currently suffering from anorexia nervosa and bulimia nervosa as well as help to prevent the onset of either disorder.

The above treatment and prevention techniques are found to be effective if administered properly and consistently. More research needs to be done on the prevention techniques in order to determine their long-term effects.


Felker, Kenneth R., & Stivers, Cathie (1994). The relationship of gender and family environment to eating disorder risk in adolescents. Adolescence, 29, 821-830.

Kent, Jan S., & Clopton, James R. (1992). Bulimic Women's Perceptions of Their Famliy Relationships. Journal of Clinical Psychology, 48, 281-290.

Killian, Kyle D. (1994). Fearing fat: A literature review of family systems understandings and treatments of anorexia and bulimia. Family Relations, 43, 311-330.



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