Eating disorders as “brain-based mental illnesses”: An antidote to stigma?

Individuals with eating disorders, like individuals with other mental disorders, are subject to stigmatizing attitudes and beliefs on the part of the public. Thus, many members of the public appear to believe that individuals with eating disorders are vain, self-centred, fragile, unreliable, attention-seeking, or even annoying, that these individuals “have only themselves to blame” and that these individuals should “pull themselves together” (Crisp et al., 2000; Easter, 2012; Mond et al., 2006). There may also be a perception that eating disorders are not “real” or serious mental health problems or that these disorders are either serious but uncommon or common but trivial (Easter, 2012; Mond et al., 2009). Attitudes and beliefs of this kind reduce the likelihood that help is sought by sufferers when needed and compound feelings of helplessness and isolation (Hepworth & Paxton, 2007). Hence, there is a need to identify health promotion strategies that have the potential to counteract these and other misconceptions.

Recently, it has been suggested that stigma toward individuals with eating disorders might be reduced through the inclusion in health promotion campaigns of messages to the effect that eating disorders are “brain-based”, “biological”, “genetic”, or whatever other term one might want to use to convey that factors outside the individual's control are involved (Crisafulli et al., 2008; Crisafulli et al., 2010). Promoting greater awareness of the role of biogenetic factors in the etiology of eating disorders might also be conducive to greater recognition of the severity and public health significance of these conditions (Klump et al., 2009; Mond et al., 2009) as well as greater acceptance by sufferers of the need for medically oriented interventions, such as treatment from a psychiatrist and/or the use of psychotropic medication, where this is indicated (Angermeyer et al., 2011; Mond et al., 2008).

The notion that promoting greater awareness of the uncontrollability of mental illness might be beneficial in reducing stigma is not new (Weiner et al., 1988). In recent years, however, with growing optimism about developments in neuroscience, promoting awareness of the biogenetic bases of mental disorders as a strategy for reducing stigma has gained momentum (Angermeyer et al., 2011; Pescosolido et al., 2010). Hence, in the past decade, there has been a concerted effort on the part of influential public health agencies, such as the US National Institutes of Mental Health, to “reconceptualise disorders of the mind as disorders of the brain” and messages to this effect have been featured in various mental health promotion campaigns (Angermeyer et al., 2011; Insel & Wang, 2010; Pescosolido et al., 2010). In the eating disorders field, this approach has been endorsed by various professional and consumer representative organizations, including the Academy for Eating Disorders (Klump et al., 2009).

Of course, it is not that simple. For one thing, there is no guarantee that greater adherence to a biogenetic model of mental illness is in fact conducive to reduced stigma. Empirical support for an association of this kind, as this relates to schizophrenia, depression and alcohol dependence at least, has been found to be equivocal and the effects dependent upon the particular illness investigated (Angermeyer et al., 2011; Easter, 2012). For disorders that are associated with dangerousness and unpredictability, such as schizophrenia, promoting public awareness of biogenetic factors may be more likely to have the effect of increasing stigma than reducing it (Angermeyer et al., 2011; Easter, 2012). For depression and other disorders for which stigma is more likely to focus on personal responsibility or weakness of character, benefits may be more likely (Angermeyer et al., 2011; Easter, 2012).

Although research addressing associations between beliefs about etiology and stigmatization of individuals with eating disorders is limited, findings from recent studies, in college students, do suggest that eating disorders fall into this latter category, perhaps because individuals with eating disorders are particularly liable to be seen to be responsible for their condition (Crisp et al., 2000; Easter, 2012; Roehrig & McLean, 2010). Thus, in each of the studies concerned (Crisafulli et al., 2008, 2010; Wingfield et al., 2011), participants who believed that eating disorders have a biogenetic basis were less likely to attribute blame to sufferers and, in turn, more likely to be sympathetic to their plight.

These findings await replication in a larger, more representative sample. Even given evidence of this kind, however, I am not convinced that promoting the biogenetic bases of eating disorders in health promotion programs is a good idea, for at least three reasons. First, circumstances can be imagined in which casting eating disorders as “brain-based” illnesses might be conducive to greater, rather than lower, levels of stigma. In particular, attribution to biogenetic factors might reinforce the notion that the eating disorder is an essential, defining and, perhaps, immutable characteristic of the person, thereby marking sufferers as fundamentally different from other, “normal” people by virtue of their condition (Easter, 2012).

Second, there may be a trade-off between reinforcing the message that individuals are not responsible for their mental health problems, with a view to reducing stigma, and reducing individuals' motivation to address those problems. For example, attribution of eating-disordered behavior to biogenetic factors, on the part of sufferers, those with whom they interact, and the community as a whole, might have the effect of overshadowing the role of developmental and/or psycho-social factors in the etiology of disordered eating and the need to address these factors in treatment and recovery (Crisafulli et al., 2010; Easter, 2012). Findings from a recent, qualitative study suggest that at least some individuals with eating disorders share the concern that promoting biogenetic accounts of etiology may have the effect of reducing motivation for change and, perhaps, engendering a sense of helplessness by highlighting the need for a treatment that is not currently and may never be available (Easter, 2012).

Last, but not least, I am not sure that it is ethical to include information concerning the putative biogenetic bases of eating disorders, or of mental health problems more generally, in health promotion campaigns, at least not without qualification. For me, this qualification would need to include, at a minimum, reference to: (i) evidence concerning the role of psycho-social factors in the etiology and maintenance of eating-disordered behavior; and (ii) the shortcomings of reductionist “explanations” of mental health problems; for example, information to the effect that all behavior is “brain-based”, that correlates and causes are two different things and that genes for specific mental disorders have not and may never be identified, particularly if the mental disorders described in current classification schemes are viewed as hypothetical constructs rather than “carving nature at its joints” (Frances & Widiger, 2012; Mond, 2012).

For all these reasons, promoting adherence to a biogenetic model of mental illness is not, in my opinion, a good way to go about reducing stigma toward individuals with eating disorders. A better approach would be to focus on improving awareness and understanding of the spectrum of disordered eating that occurs at the population level and levels of distress and disability associated with this (Mond et al., 2009). A strategy of this kind has the potential to both reduce the stigma of sufferers and improve awareness of the public health significance of eating-disordered behavior, without engendering concerns about potential untoward effects or the integrity of the information presented.

Declaration of Interest: The authors report no conflict of interest.