ORIGINAL ARTICLE
Stigmatizing Attitudes and Beliefs Toward Bulimia Nervosa The Importance of Knowledge and Eating Disorder Symptoms Rachel Florence Rodgers, PhD,*† Susan J. Paxton, PhD,‡ Siân A. McLean, BSc (Hons),‡ Robin Massey, BA, PGDipPsych,‡ Jonathan M. Mond, PhD,§ Phillipa J. Hay, PhD,k¶ and Bryan Rodgers, PhD# Abstract: Widely held stigmatizing attitudes and beliefs toward bulimic eating disorders may lead to self-blame and reduced treatment seeking. Knowledge and familiarity with mental disorders may help decrease associated stigma. However, these relationships are not well understood in bulimia nervosa (BN). A community sample of 1828 adults aged 18 to 70 years completed a survey assessing stigmatizing attitudes and beliefs toward BN, knowledge and familiarity with the disorder, as well as levels of eating disorder symptoms. Knowledge of BN was negatively associated with three dimensions of stigmatization, personal responsibility (ρ = −0.28), unreliability (ρ = −0.19), and advantages of BN (ρ = −0.23). Familiarity revealed no association with stigmatization. Both men and women with high levels of eating disorder symptoms perceived BN as less serious than the participants with low levels of symptoms. Increasing community knowledge about bulimia may help mitigate stigmatization and perceived barriers to treatment. Key Words: Stigmatization, bulimia nervosa, knowledge, eating disorder symptoms (J Nerv Ment Dis 2015;203: 259–263)
B
ulimia nervosa (BN) affects a substantial proportion of the population and is associated with distress and role impairment (Hay, 2003; Hay and Mond, 2005). However, only a minority of individuals with BN seek appropriate professional treatment (Hudson et al., 2007; Swanson et al., 2011; Wade et al., 2006). It has been proposed that one of the main barriers to treatment seeking among individuals with these disorders is the fear of stigma (Becker et al., 2004; Hepworth and Paxton, 2007). Indeed, stigmatizing and negative attitudes toward eating disorders in general seem to be widespread (Mond et al., 2004b, 2004c; Stull et al., 2013). Such stigma results in the discrediting of individuals with these disorders and individuals with eating disorders being labeled as possessing undesirable and negative characteristics, which may, in turn, lead to social rejection (Jones et al., 1984). In relation to BN, individuals have reported fearing the judgment of others because their behaviors are considered disgusting and shameful (Hepworth and Paxton, 2007). In addition, eating disorders have been shown to be perceived as more under the control of the individual and associated with more blame directed toward the individual with an
*Department of Counseling and Applied Educational Psychology, Northeastern University, Boston, MA; †Laboratoire de Stress Traumatique, Université Paul Sabatier, Toulouse, France; ‡School of Psychological Science, La Trobe University, Melbourne, Victoria; §Research School of Psychology, Australian National University, Canberra, Australian Capital Territory; kCentre for Health Research, School of Medicine, University of Western Sydney, Sydney; ¶School of Medicine, James Cook University, Townsville; and #Australian Demographic & Social Research Institute, The Australian National University, Canberra, Australian Capital Territory, Australia. Send reprint requests to Rachel Florence Rodgers, PhD, 404, International Village, Northeastern University, 360 Huntington Ave, Boston, MA 02115. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0022-3018/15/20304–0259 DOI: 10.1097/NMD.0000000000000275
eating disorder than other mental health disorders (Ebneter and Latner, 2013). Furthermore, stigmatizing attitudes toward BN may affect the self-view of individuals with the disorder (Corrigan and Watson, 2002; Rüsch et al., 2010). This form of self-stigma could then be associated with heightened shame and self-blame. Consistent with this theory, among students with high levels of disordered eating, self-stigma predicted negative attitudes toward seeking counseling (Hackler et al., 2010). Furthermore, feelings of shame and that one should be able to help oneself have been identified as important barriers to treatment seeking among individuals with significant eating problems (Cachelin and Striegel-Moore, 2006). Individuals with high levels of eating disorder symptoms are also more likely to expect someone with BN to be discriminated against and less likely to seek help for a similar eating problem compared with individuals with low levels of eating disorder symptoms (Mond et al., 2010). The “contact hypothesis” of discrimination (Allport, 1954) posits that increased contact and familiarity with a stigmatized group will result in decreased discrimination. Consistent with this hypothesis, there is some evidence that greater contact with individuals with mental health issues decreases the stigmatization of these groups (Read and Harré, 2001). Similarly, individuals with higher levels of contact with those with eating disorders have reported lower levels of negative attitudes. In a study using 16 different scenarios depicting individuals presenting symptoms of either BN or anorexia nervosa, college students who reported having previous contact with eating disorders perceived the fictional characters as more similar to themselves compared with participants with no previous contact with eating disorders (Wingfield et al., 2011). In a similar study using a vignette depicting a young woman with anorexia nervosa, among undergraduate students, previous personal contact with an individual with anorexia nervosa was associated with greater reported comfort with interacting with the young woman depicted in the vignette (Stewart et al., 2008). However, other studies have found that college students acquainted with eating disorders through personal experience of knowing someone who had had such a disorder did not report decreased stigmatizing attitudes and beliefs regarding eating disorders compared with individuals who were not acquainted with the disorders (Ebneter et al., 2011). Knowledge about mental health disorders, specifically their origin, course, treatment options, and dangerousness, has been pinpointed as an important factor contributing to lower levels of stigmatizing attitudes and beliefs (Hinshaw and Stier, 2008; Jorm, 2012). In line with this hypothesis, one previous study has suggested that increased knowledge of BN was associated with lower levels of critical attitudes toward individuals with the disorder (Rancie, 2008). However, data regarding the relationship between knowledge of BN as well as stigmatizing attitudes and beliefs in community samples are lacking, and further investigations of community beliefs and attitudes are warranted. Moreover, this gap limits our understanding of the usefulness of targeting knowledge in interventions that aim to decrease stigma. The aims of the present study were therefore twofold. The first aim was to explore the relationships of stigmatizing attitudes and beliefs toward BN with knowledge of and familiarity with BN. We
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hypothesized that higher levels of familiarity with and knowledge of BN would be associated with lower levels of stigmatizing attitudes toward BN. The second aim was to explore the relationships between stigmatizing attitudes and beliefs toward BN and current self-reported eating disorder symptoms, in particular, to assess stigmatizing attitudes toward BN among individuals with higher levels of eating disorder symptoms. Increased familiarity and empathy with individuals with BN could lead to participants with high levels of eating disorder symptoms reporting lower levels of stigmatizing attitudes and beliefs. However, within a self-stigma framework, the converse would be expected, that is, that individuals with high levels of eating disorder symptoms would report high levels of stigmatizing attitudes toward BN. We therefore developed no specific hypothesis related to this second aim. In view of suggestions that stigmatizing attitudes and beliefs toward individuals with eating disorders might vary according to sex and age (Hudson et al., 2007; Mond and Arrighi, 2011; Mond et al., 2008), we also examined our hypotheses among men and women separately and among younger and older age groups.
METHODS Participants and Procedure A random sample from the Australian Electoral Roll for Victoria, Australia, was mailed a questionnaire, resulting in a sample of 1828 adult participants, aged 18 to 70 years (mean [SD] age, 44.63 [13.11]; response rate, 22.43%), similar to previous eating disorder postal surveys of community adults in the United States and Australia (Mond et al., 2004a; Striegel et al., 2009). The sample demographics were compared with similar samples from Australia with higher response rates (Hay et al., 2008) and found to be similar. The participants returned their completed surveys in a prepaid envelope and were compensated Aus$10 for their time. The sample was stratified according to basic demographics including sex, age group, socioeconomic status, and location. The distribution of participants by sex was relatively even (51.3% women); 25.9% of the sample was aged between 18 and 34 years, 27.2% of the sample was aged between 35 and 44 years, and 46.9% of the sample was aged between 45 and 65 years. Approximately a third of the sample (32.7%) came from rural areas; 31.9% of the sample reported low socioeconomic status (SES), 41.1% reported average SES, and 27% reported high SES. The majority of the sample was born in Australia (79.4%). Approval for the study was granted by the La Trobe University Human Ethics Committee. Study protocols were in accordance with the 2008 Declaration of Helsinki. (An additional detailed account of the methods used in this study is provided in McLean et al. [2014].)
A short definition of bulimia nervosa was provided to the participants to orient them to the salient features of the disorder. The definition was “Bulimia is an eating disorder (a type of mental illness) that involves binge eating and using extreme ways to control weight. Binge eating means eating more than normal in a short period of time and losing control of eating. Examples of extreme ways to control weight are excessive exercise, extreme dieting, vomiting and abuse of laxatives. People with bulimia usually have a normal body weight and do not need to gain weight to get better. You may have heard of other eating disorders, such as anorexia nervosa where people starve themselves in order to become very thin.”
Stigmatising Attitudes and Beliefs Towards Bulimia Nervosa Scale The Stigmatising Attitudes and Beliefs Towards Bulimia Nervosa scale is a 26-item scale developed for the present study assessing www.jonmd.com
Familiarity With BN Familiarity with BN was assessed using a modified version of the Level of Familiarity Questionnaire (Holmes et al., 1999; Mond et al., 2006b). The measure includes 10 dichotomous items describing increasing familiarity with BN from “I know/knew people in my school, university, workplace or social group who have/had bulimia” to “I currently have bulimia.” Statements were ranked in order of increasing social proximity by 10 independent experts, including 8 clinical psychologists and 2 academics in the field of eating disorders. The final ranking was developed from the mean of the rankings provided by these experts. In line with previous coding schemes for assessing familiarity and social distance (Holmes et al., 1999), the participants were attributed the score corresponding to the highest level of familiarity that they endorsed (for example, participants endorsing “I currently have bulimia” were attributed a score of 10).
Knowledge of BN
Measures
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stigmatizing attitudes and beliefs regarding BN, which includes five subscales: advantages of BN (seven items), minimisation/low seriousness (six items), unreliability (five items), social distance (three items), and personal responsibility (five items). Items are scored on a 6-point scale ranging from 1 (completely disagree) to 6 (completely agree). An example item from the advantages of BN subscale is “Bulimia is not that bad because you can eat what you like without putting on weight,” with high scores indicating greater perceived advantages of BN. Items from the minimisation/low seriousness subscale are reverse scored so that higher scores indicate a greater degree of minimization of the seriousness of the disease. An example item is “Bulimia with deliberate vomiting is a serious problem.” An example item from the unreliability subscale is “People with bulimia are unreliable,” with higher scores indicating a greater lack of trust in individuals with BN. An example item from the social distance subscale is “Deep down, I would be ashamed of a family member if they had bulimia,” with higher scores indicating greater levels of social distance. An example item from the personal responsibility subscale is “People with bulimia should work on their self-control,” with higher scores indicating higher levels of perceived personal responsibility of the individual with BN. The subscales were identified through principal component analysis, in which an unspecified factor solution was selected. This revealed a five-factor solution, which was confirmed with confirmatory factor analysis. Factors were correlated at small to moderate levels, and the subscales revealed satisfactory internal consistency (see McLean et al., 2014), with α = 0.75 for advantages of BN, α = 0.70 for minimisation/low seriousness, α = 0.86 for unreliability, α = 0.50 (mean interitem correlation, 0.25, indicating acceptable internal consistency) for social distance, and α = 0.78 for personal responsibility.
Knowledge of BN was assessed using 10 dichotomous questions focusing on knowledge of treatment options (5 questions) as well as etiological factors (2 questions), age of onset (1 question), treatment barriers (1 question), and outcomes (1 question). Item selection was guided by reference to the mental health literacy framework (Jorm, 2000) and consideration of low levels of appropriate treatment seeking found for BN (Hart et al., 2011). Thus, a large proportion of the items assessed treatment seeking in relation to other aspects of knowledge. An initial pool of 15 items was obtained from previous work examining knowledge of BN among a community sample in Victoria, Australia (Rancie, 2008), as well as additional items developed by the researchers for the purpose of the present study. The 15 items were pilot tested among a community sample (unpublished data), and items that were judged to be ambiguous or had a high rate of nonresponses were revised or removed, leading to 10 final items being retained. A total score was obtained from the sum of correct responses to the 10 items. An example item is “Psychologists and psychiatrists are unhelpful for treating bulimia.” © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Eating Disorder Symptoms Eating disorder symptoms were assessed using the Eating Disorders Examination Questionnaire (EDEQ; Fairburn and Beglin, 1994), which contains 22 items yielding 4 subscales: weight concern, shape concern, dietary restraint, and eating concerns. Items are scored on a 7-point scale representing the frequency with which eating disorder behaviors have occurred during the past 4 weeks, with higher scores indicating higher levels of eating disorder symptoms. This questionnaire has been shown to produce valid and reliable scores in Australian community samples, and a cutoff score of 56 on the total sum of the 22 items has been proposed to indicate potential eating disorder cases (Mond et al., 2004d). In the present study, the Cronbach's α values were α = 0.79 for the weight concerns, α = 0.90 for the shape concerns, α = 0.79 for the eating concerns, and α = 0.77 for the dietary restraint subscale.
Statistical Analyses Descriptive statistics for the study variables were examined. Because the distributions of the stigma dimensions of minimisation/low seriousness and advantages of BN were skewed, relationships between stigmatizing attitudes toward BN, familiarity, knowledge, and eating disorder symptoms were explored using Spearman's correlations. Analyses were first conducted in the total sample, then for each sex separately, and then within each sex split by age group (i.e., among six different subgroups). In view of the large sample size, and multiple comparisons conducted, effect sizes rather than p-values were used to evaluate the strength of the relationships, and only correlations of higher than ρ = 0.15 were deemed worth considering (which is slightly on the conservative side of the commonly used benchmark for a small effect size of r = 0.10; Ellis, 2010). The proposed cutoff score of 56 of the summed total score of the EDEQ was used to create low eating disorder and high eating disorder symptom groups. Independent sample Mann-Whitney's U tests were conducted to compare levels of stigmatizing attitudes toward BN in the high and low eating disorder symptom groups, with a p-value set at p = 0.025 to adjust for multiple comparisons. The probability of superiority (PS) was used as an index of effect size. There are no clear cutoff points for interpreting PS. However, the further away PS is from 0.5 (in either direction), the larger the effect (Ellis, 2010).
Stigma Toward Bulimia Nervosa
was not associated with levels of stigmatizing attitudes toward BN, with ρ values ranging between −0.06 and 0.05. However, knowledge of BN was negatively associated with three of the dimensions of stigmatizing attitudes toward BN, namely, personal responsibility (ρ = −0.28), unreliability (ρ = −0.19), and advantages of BN (ρ = −0.23). When the sample was split by sex, the pattern of correlations remained identical, with slightly stronger associations among men (personal responsibility: men, ρ = −0.29; women, ρ = −0.28; unreliability: men, ρ = −0.23; women, ρ = −0.15; advantages of BN: men, ρ = −0.27; women, ρ = −0.20). When the sample was further subdivided according to both sex and age, among men, the patterns remained consistent, with one additional relationship emerging among young men (18–34 years old) between knowledge and social distance (ρ = −0.16). Similarly, among women, no age variations emerged.
Stigmatizing Attitudes Toward BN Among Individuals With Higher Levels of Disordered Eating Results from the correlation analysis indicated no relationships between stigmatizing attitudes and beliefs toward BN and eating disorder symptom scores. With the use of the cutoff of 56, 21% (n = 447) of the sample reported high levels of eating disorder symptoms. Of these, 149 (33%) reported having previously sought professional help for a problem pertaining to weight or eating. In addition, 174 of these (39%) reported having eaten what other people would regard as an unusually large amount of food, 151 (34%) reported a sense of loss of control, 17 (4%) reported having used self-induced vomiting as a means of controlling shape and weight, 28 (6%) reported having used laxatives, 41 (9%) reported using diet pills, and 150 (33%) reported exercising hard to control shape or weight. Mann-Whitney's U tests revealed no differences in levels of stigmatizing attitudes toward BN between the participants with high and low levels of eating disorder symptoms when data from men and women were analyzed together. The analyses were repeated in men and women separately. In men, the high eating disorder symptoms group reported higher scores on minimisation/low seriousness (p = 0.003, PS = 0.42). Among women, the high eating disorder symptoms group reported higher scores on the advantages of BN subscale. However, this finding was on the threshold of significance (p = 0.025, PS = 0.54).
RESULTS DISCUSSION
Relationships of Stigmatizing Attitudes and Beliefs With Knowledge of and Familiarity With BN The means and standard deviations for the study variables are presented in Table 1. Contrary to our hypothesis, familiarity with BN
The aims of the present study were to explore the relationships of stigmatizing attitudes and beliefs toward BN with knowledge of and familiarity with BN as well as to explore the relationships between stigmatizing attitudes and beliefs toward BN and current self-reported
TABLE 1. Spearman's Correlations Between Stigmatizing Attitudes Toward BN and Familiarity, Knowledge, and Eating Disorder Symptoms Eating Disorder Symptoms
Stigmatization Personal responsibility Minimisation/low seriousness Unreliability Social distance Advantages of BN Mean (SD)
Mean (SD)
Familiarity
Knowledge
Weight Concerns
Shape Concerns
Eating Concerns
Dietary Restraint
2.93 (1.07) 1.83 (0.89)
−0.01 −0.05
−0.28 −0.10
−0.05 0.00
−0.04 0.01
−0.01 0.05
−0.05 −0.02
2.29 (1.01) 2.68 (.98) 1.64 (0.65)
−0.05 −0.04 −0.01 3.44 (1.91)
−0.19 0.10 −0.23 6.32 (1.42)
−0.02 0.01 0.00 1.42 (1.36)
−0.02 −0.01 0.00 1.76 (1.55)
0.04 0.05 0.05 0.56 (.91)
−0.03 0.00 −0.02 1.32 (1.36)
Correlations higher than ρ = 0.15 are in bold. High scores on the stigmatization subscales all indicate greater stigmatization of BN. High scores on the familiarity and knowledge scales indicate high familiarity and knowledge of BN, respectively. High scores on the eating disorder symptoms subscales indicate higher eating disturbance.
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eating disorder symptoms. Regarding the first aim, the findings revealed that greater knowledge of BN, for the purposes of this study predominantly conceptualized as knowledge of treatment of BN, was related to lower stigmatizing attitudes and beliefs toward BN, and few sex and age variations were found in these relationships, contrary to the contact hypothesis and previous findings (Allport, 1954; Ebneter et al., 2011; Wingfield et al., 2011); however, greater familiarity with BN, such as knowing someone with BN, was not associated with lower levels of stigmatizing attitudes and beliefs. For the second aim, our findings revealed that stigmatizing attitudes and beliefs toward BN were not associated with current self-reported eating disorder symptoms across the entire sample. In relation to consideration of possible differences across sex groups, interesting findings emerged. Men with high levels of eating disorder symptoms reported higher levels of minimisation/low seriousness stigmatizing beliefs, whereas women with high levels of eating disorder symptoms tended to report greater perceptions of the advantages of BN in comparison with their counterparts with low levels of symptoms. Consistent with previous findings (Rancie, 2008), greater knowledge of BN was associated with lower levels of stigmatizing attitudes and beliefs, specifically lower personal responsibility, unreliability, and advantages of BN. Although our findings are correlational, they are consistent with the theory that greater knowledge may lead to lower levels of stigmatizing attitudes and beliefs. As previously discussed, the belief that the individual with BN is personally responsible for his/her disorder and should merely pull himself/herself together to overcome the problem is an important dimension of stigma related to eating disorders (Ebneter and Latner, 2013), and identifying potential ways to decrease blaming of this kind is therefore important. In addition, minimization of symptoms, or the perception of potential advantages to maintaining symptoms, has been identified as a significant barrier to treatment seeking among women with an eating disorder (Cachelin and Striegel-Moore, 2006). Our results suggest that increasing knowledge about BN causes and treatment in the community at large might perhaps help reduce the tendency toward blaming people with BN for their disorder and to limit the perception of benefits or advantages to symptoms, which may, in turn, facilitate treatment seeking among individuals with BN. Our findings revealed that the perception of BN behaviors as desirable or acceptable was more frequent among the participants with high levels of eating disorder symptoms. This pattern was consistent with previous research. For example, similar to our finding that men with high levels of eating disorder symptoms reported perceiving BN as less serious, previous studies have also found that individuals with high levels of eating disorder symptoms have been more likely to rate bulimic behaviors as acceptable (Mond et al., 2010). In the current study, women with high levels of eating disorder symptoms tended to be more likely to express greater perceptions of advantages to BN compared with their healthy peers, which is consistent with findings that individuals with high levels of eating disorder symptoms report that it might not be “all that bad” to resemble the person in the vignette depicting BN (Mond et al., 2004c). Such attitudes might seem to reflect a certain reluctance to recognize symptoms as problematic and to imagine giving them up. Such attitudes have been documented in the literature (Fox et al., 2011) and may also serve to increase barriers to treatment because symptoms are normalized. Lack of recognition of eating disorder symptoms, which may stem from the normalizing of bulimic behaviors, constitutes a barrier to treatment seeking (Hepworth and Paxton, 2007). Interestingly, however, the prevalence of bulimic behaviors, in particular purging behaviors such as self-induced vomiting or laxative use, was relatively low among the participants in our high eating disorder symptom group. It may therefore also be that these participants did not identify strongly with BN and thought of individuals with this disorder as being quite different from themselves because it has previously been shown that self-induced vomiting is a key behavior 262
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in the self-recognition of bulimic-type eating disorders (Mond et al., 2006a). This may partly explain why no differences were found on the personal responsibility, unreliability, or social distance subscales between the high and low eating disorder symptom groups. Although attention has been paid to methods to reduce stigma associated with obesity and to highlight stigma as a social justice and primary public health issue (Puhl and Heuer, 2010; Puhl and Latner, 2007), similar efforts to reduce the stigma attached to eating disorders are lacking. In other psychological disorders such depression, in Australia, public health campaigns have been successful in changing attitudes and correcting widespread myths regarding the origins and treatment of the disorder (Jorm et al., 2006). Further efforts are required both at the national and the international level to identify and correct common misconceptions regarding BN and related disorders. Although longitudinal studies would help clarify the directionality of the relationships, the present findings provide preliminary evidence of cross-sectional relationships that suggest that improving knowledge about eating disorders, particularly in terms of origin, treatment options, and the seriousness of the disorder, may contribute to decreasing stigmatizing attitudes and beliefs toward BN and increase treatment seeking among affected individuals. Limitations to the study include the characteristics of the sample, which, although diverse in terms of sex, SES, age, and location, was not guaranteed to be representative of the Victorian population as a result of the low response rate, and this may limit generalizability of the findings. The low internal consistency of the social distance subscale was also a limitation. In addition, because of the nature of the study design, which provided the participants with a definition of BN, aspects of knowledge of the symptoms of the disorder could not be assessed. Furthermore, the knowledge items may have failed to assess other aspects such as the course of the disorder that have been shown to be an important aspect of mental health knowledge (Hinshaw and Stier, 2008). Nevertheless, this project represents a first attempt to develop a multifaceted scale exploring stigmatizing attitudes and beliefs toward BN. Moreover, our findings are based on strictly correlational data; therefore, causality should not be inferred. Finally, although we recruited a large community sample, our study included no adolescents. In the future, it would be interesting to extend these findings to younger members of the community.
CONCLUSIONS Knowledge of BN emerged as the main factor related to lower stigmatizing attitudes and beliefs toward the disorder. Stigmatizing attitudes were also held by individuals with high levels of eating disorder symptoms. Future research should continue to pursue this line of work by clarifying which information is most important in counteracting stereotypes and reducing stigma and thereby identifying targets for effective public health campaigns to improve mental health literacy related to BN and increase access to treatment. DISCLOSURES This research was funded by a grant from the Australian Research Council (DP1095656) to S. J. P., P. J. H., J. M. M., and B. R. The authors declare no conflict of interest. REFERENCES Allport GW (1954) The nature of prejudice. Cambridge, MA: Addison-Wesley. Becker AE, Franko DL, Nussbaum K, Herzog DB (2004) Secondary prevention for eating disorders: The impact of education, screening, and referral in a collegebased screening program. Int J Eat Disord. 36:157–162. Cachelin FM, Striegel-Moore RH (2006) Help seeking and barriers to treatment in a community sample of Mexican American and European American women with eating disorders. Int J Eat Disord. 39:154–161.
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Wade TD, Bergin JL, Tiggemann M, Bulik CM, Fairburn CG (2006) Prevalence and long-term course of lifetime eating disorders in an adult Australian twin cohort. Aust N Z J Psychiatry. 40:121–128.
Mond J, Hay P, Rodgers B, Owen C (2006a) Self-recognition of disordered eating among women with bulimic-type eating disorders: A community-based study. Int J Eat Disord. 39:747–753.
Wingfield N, Kelly N, Serdar K, Shivy VA, Mazzeo SE (2011) College students' perceptions of individuals with anorexia and bulimia nervosa. Int J Eat Disord. 44: 369–375.
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Stigmatizing Attitudes and Beliefs Toward Bulimia Nervosa The Importance of Knowledge and Eating Disorder Symptoms Rachel Florence Rodgers, PhD,*† Susan J. Paxton, PhD,‡ Siân A. McLean, BSc (Hons),‡ Robin Massey, BA, PGDipPsych,‡ Jonathan M. Mond, PhD,§ Phillipa J. Hay, PhD,k¶ and Bryan Rodgers, PhD# Abstract: Widely held stigmatizing attitudes and beliefs toward bulimic eating disorders may lead to self-blame and reduced treatment seeking. Knowledge and familiarity with mental disorders may help decrease associated stigma. However, these relationships are not well understood in bulimia nervosa (BN). A community sample of 1828 adults aged 18 to 70 years completed a survey assessing stigmatizing attitudes and beliefs toward BN, knowledge and familiarity with the disorder, as well as levels of eating disorder symptoms. Knowledge of BN was negatively associated with three dimensions of stigmatization, personal responsibility (ρ = −0.28), unreliability (ρ = −0.19), and advantages of BN (ρ = −0.23). Familiarity revealed no association with stigmatization. Both men and women with high levels of eating disorder symptoms perceived BN as less serious than the participants with low levels of symptoms. Increasing community knowledge about bulimia may help mitigate stigmatization and perceived barriers to treatment. Key Words: Stigmatization, bulimia nervosa, knowledge, eating disorder symptoms (J Nerv Ment Dis 2015;203: 259–263)
B
ulimia nervosa (BN) affects a substantial proportion of the population and is associated with distress and role impairment (Hay, 2003; Hay and Mond, 2005). However, only a minority of individuals with BN seek appropriate professional treatment (Hudson et al., 2007; Swanson et al., 2011; Wade et al., 2006). It has been proposed that one of the main barriers to treatment seeking among individuals with these disorders is the fear of stigma (Becker et al., 2004; Hepworth and Paxton, 2007). Indeed, stigmatizing and negative attitudes toward eating disorders in general seem to be widespread (Mond et al., 2004b, 2004c; Stull et al., 2013). Such stigma results in the discrediting of individuals with these disorders and individuals with eating disorders being labeled as possessing undesirable and negative characteristics, which may, in turn, lead to social rejection (Jones et al., 1984). In relation to BN, individuals have reported fearing the judgment of others because their behaviors are considered disgusting and shameful (Hepworth and Paxton, 2007). In addition, eating disorders have been shown to be perceived as more under the control of the individual and associated with more blame directed toward the individual with an
*Department of Counseling and Applied Educational Psychology, Northeastern University, Boston, MA; †Laboratoire de Stress Traumatique, Université Paul Sabatier, Toulouse, France; ‡School of Psychological Science, La Trobe University, Melbourne, Victoria; §Research School of Psychology, Australian National University, Canberra, Australian Capital Territory; kCentre for Health Research, School of Medicine, University of Western Sydney, Sydney; ¶School of Medicine, James Cook University, Townsville; and #Australian Demographic & Social Research Institute, The Australian National University, Canberra, Australian Capital Territory, Australia. Send reprint requests to Rachel Florence Rodgers, PhD, 404, International Village, Northeastern University, 360 Huntington Ave, Boston, MA 02115. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0022-3018/15/20304–0259 DOI: 10.1097/NMD.0000000000000275
eating disorder than other mental health disorders (Ebneter and Latner, 2013). Furthermore, stigmatizing attitudes toward BN may affect the self-view of individuals with the disorder (Corrigan and Watson, 2002; Rüsch et al., 2010). This form of self-stigma could then be associated with heightened shame and self-blame. Consistent with this theory, among students with high levels of disordered eating, self-stigma predicted negative attitudes toward seeking counseling (Hackler et al., 2010). Furthermore, feelings of shame and that one should be able to help oneself have been identified as important barriers to treatment seeking among individuals with significant eating problems (Cachelin and Striegel-Moore, 2006). Individuals with high levels of eating disorder symptoms are also more likely to expect someone with BN to be discriminated against and less likely to seek help for a similar eating problem compared with individuals with low levels of eating disorder symptoms (Mond et al., 2010). The “contact hypothesis” of discrimination (Allport, 1954) posits that increased contact and familiarity with a stigmatized group will result in decreased discrimination. Consistent with this hypothesis, there is some evidence that greater contact with individuals with mental health issues decreases the stigmatization of these groups (Read and Harré, 2001). Similarly, individuals with higher levels of contact with those with eating disorders have reported lower levels of negative attitudes. In a study using 16 different scenarios depicting individuals presenting symptoms of either BN or anorexia nervosa, college students who reported having previous contact with eating disorders perceived the fictional characters as more similar to themselves compared with participants with no previous contact with eating disorders (Wingfield et al., 2011). In a similar study using a vignette depicting a young woman with anorexia nervosa, among undergraduate students, previous personal contact with an individual with anorexia nervosa was associated with greater reported comfort with interacting with the young woman depicted in the vignette (Stewart et al., 2008). However, other studies have found that college students acquainted with eating disorders through personal experience of knowing someone who had had such a disorder did not report decreased stigmatizing attitudes and beliefs regarding eating disorders compared with individuals who were not acquainted with the disorders (Ebneter et al., 2011). Knowledge about mental health disorders, specifically their origin, course, treatment options, and dangerousness, has been pinpointed as an important factor contributing to lower levels of stigmatizing attitudes and beliefs (Hinshaw and Stier, 2008; Jorm, 2012). In line with this hypothesis, one previous study has suggested that increased knowledge of BN was associated with lower levels of critical attitudes toward individuals with the disorder (Rancie, 2008). However, data regarding the relationship between knowledge of BN as well as stigmatizing attitudes and beliefs in community samples are lacking, and further investigations of community beliefs and attitudes are warranted. Moreover, this gap limits our understanding of the usefulness of targeting knowledge in interventions that aim to decrease stigma. The aims of the present study were therefore twofold. The first aim was to explore the relationships of stigmatizing attitudes and beliefs toward BN with knowledge of and familiarity with BN. We
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hypothesized that higher levels of familiarity with and knowledge of BN would be associated with lower levels of stigmatizing attitudes toward BN. The second aim was to explore the relationships between stigmatizing attitudes and beliefs toward BN and current self-reported eating disorder symptoms, in particular, to assess stigmatizing attitudes toward BN among individuals with higher levels of eating disorder symptoms. Increased familiarity and empathy with individuals with BN could lead to participants with high levels of eating disorder symptoms reporting lower levels of stigmatizing attitudes and beliefs. However, within a self-stigma framework, the converse would be expected, that is, that individuals with high levels of eating disorder symptoms would report high levels of stigmatizing attitudes toward BN. We therefore developed no specific hypothesis related to this second aim. In view of suggestions that stigmatizing attitudes and beliefs toward individuals with eating disorders might vary according to sex and age (Hudson et al., 2007; Mond and Arrighi, 2011; Mond et al., 2008), we also examined our hypotheses among men and women separately and among younger and older age groups.
METHODS Participants and Procedure A random sample from the Australian Electoral Roll for Victoria, Australia, was mailed a questionnaire, resulting in a sample of 1828 adult participants, aged 18 to 70 years (mean [SD] age, 44.63 [13.11]; response rate, 22.43%), similar to previous eating disorder postal surveys of community adults in the United States and Australia (Mond et al., 2004a; Striegel et al., 2009). The sample demographics were compared with similar samples from Australia with higher response rates (Hay et al., 2008) and found to be similar. The participants returned their completed surveys in a prepaid envelope and were compensated Aus$10 for their time. The sample was stratified according to basic demographics including sex, age group, socioeconomic status, and location. The distribution of participants by sex was relatively even (51.3% women); 25.9% of the sample was aged between 18 and 34 years, 27.2% of the sample was aged between 35 and 44 years, and 46.9% of the sample was aged between 45 and 65 years. Approximately a third of the sample (32.7%) came from rural areas; 31.9% of the sample reported low socioeconomic status (SES), 41.1% reported average SES, and 27% reported high SES. The majority of the sample was born in Australia (79.4%). Approval for the study was granted by the La Trobe University Human Ethics Committee. Study protocols were in accordance with the 2008 Declaration of Helsinki. (An additional detailed account of the methods used in this study is provided in McLean et al. [2014].)
A short definition of bulimia nervosa was provided to the participants to orient them to the salient features of the disorder. The definition was “Bulimia is an eating disorder (a type of mental illness) that involves binge eating and using extreme ways to control weight. Binge eating means eating more than normal in a short period of time and losing control of eating. Examples of extreme ways to control weight are excessive exercise, extreme dieting, vomiting and abuse of laxatives. People with bulimia usually have a normal body weight and do not need to gain weight to get better. You may have heard of other eating disorders, such as anorexia nervosa where people starve themselves in order to become very thin.”
Stigmatising Attitudes and Beliefs Towards Bulimia Nervosa Scale The Stigmatising Attitudes and Beliefs Towards Bulimia Nervosa scale is a 26-item scale developed for the present study assessing www.jonmd.com
Familiarity With BN Familiarity with BN was assessed using a modified version of the Level of Familiarity Questionnaire (Holmes et al., 1999; Mond et al., 2006b). The measure includes 10 dichotomous items describing increasing familiarity with BN from “I know/knew people in my school, university, workplace or social group who have/had bulimia” to “I currently have bulimia.” Statements were ranked in order of increasing social proximity by 10 independent experts, including 8 clinical psychologists and 2 academics in the field of eating disorders. The final ranking was developed from the mean of the rankings provided by these experts. In line with previous coding schemes for assessing familiarity and social distance (Holmes et al., 1999), the participants were attributed the score corresponding to the highest level of familiarity that they endorsed (for example, participants endorsing “I currently have bulimia” were attributed a score of 10).
Knowledge of BN
Measures
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stigmatizing attitudes and beliefs regarding BN, which includes five subscales: advantages of BN (seven items), minimisation/low seriousness (six items), unreliability (five items), social distance (three items), and personal responsibility (five items). Items are scored on a 6-point scale ranging from 1 (completely disagree) to 6 (completely agree). An example item from the advantages of BN subscale is “Bulimia is not that bad because you can eat what you like without putting on weight,” with high scores indicating greater perceived advantages of BN. Items from the minimisation/low seriousness subscale are reverse scored so that higher scores indicate a greater degree of minimization of the seriousness of the disease. An example item is “Bulimia with deliberate vomiting is a serious problem.” An example item from the unreliability subscale is “People with bulimia are unreliable,” with higher scores indicating a greater lack of trust in individuals with BN. An example item from the social distance subscale is “Deep down, I would be ashamed of a family member if they had bulimia,” with higher scores indicating greater levels of social distance. An example item from the personal responsibility subscale is “People with bulimia should work on their self-control,” with higher scores indicating higher levels of perceived personal responsibility of the individual with BN. The subscales were identified through principal component analysis, in which an unspecified factor solution was selected. This revealed a five-factor solution, which was confirmed with confirmatory factor analysis. Factors were correlated at small to moderate levels, and the subscales revealed satisfactory internal consistency (see McLean et al., 2014), with α = 0.75 for advantages of BN, α = 0.70 for minimisation/low seriousness, α = 0.86 for unreliability, α = 0.50 (mean interitem correlation, 0.25, indicating acceptable internal consistency) for social distance, and α = 0.78 for personal responsibility.
Knowledge of BN was assessed using 10 dichotomous questions focusing on knowledge of treatment options (5 questions) as well as etiological factors (2 questions), age of onset (1 question), treatment barriers (1 question), and outcomes (1 question). Item selection was guided by reference to the mental health literacy framework (Jorm, 2000) and consideration of low levels of appropriate treatment seeking found for BN (Hart et al., 2011). Thus, a large proportion of the items assessed treatment seeking in relation to other aspects of knowledge. An initial pool of 15 items was obtained from previous work examining knowledge of BN among a community sample in Victoria, Australia (Rancie, 2008), as well as additional items developed by the researchers for the purpose of the present study. The 15 items were pilot tested among a community sample (unpublished data), and items that were judged to be ambiguous or had a high rate of nonresponses were revised or removed, leading to 10 final items being retained. A total score was obtained from the sum of correct responses to the 10 items. An example item is “Psychologists and psychiatrists are unhelpful for treating bulimia.” © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Eating Disorder Symptoms Eating disorder symptoms were assessed using the Eating Disorders Examination Questionnaire (EDEQ; Fairburn and Beglin, 1994), which contains 22 items yielding 4 subscales: weight concern, shape concern, dietary restraint, and eating concerns. Items are scored on a 7-point scale representing the frequency with which eating disorder behaviors have occurred during the past 4 weeks, with higher scores indicating higher levels of eating disorder symptoms. This questionnaire has been shown to produce valid and reliable scores in Australian community samples, and a cutoff score of 56 on the total sum of the 22 items has been proposed to indicate potential eating disorder cases (Mond et al., 2004d). In the present study, the Cronbach's α values were α = 0.79 for the weight concerns, α = 0.90 for the shape concerns, α = 0.79 for the eating concerns, and α = 0.77 for the dietary restraint subscale.
Statistical Analyses Descriptive statistics for the study variables were examined. Because the distributions of the stigma dimensions of minimisation/low seriousness and advantages of BN were skewed, relationships between stigmatizing attitudes toward BN, familiarity, knowledge, and eating disorder symptoms were explored using Spearman's correlations. Analyses were first conducted in the total sample, then for each sex separately, and then within each sex split by age group (i.e., among six different subgroups). In view of the large sample size, and multiple comparisons conducted, effect sizes rather than p-values were used to evaluate the strength of the relationships, and only correlations of higher than ρ = 0.15 were deemed worth considering (which is slightly on the conservative side of the commonly used benchmark for a small effect size of r = 0.10; Ellis, 2010). The proposed cutoff score of 56 of the summed total score of the EDEQ was used to create low eating disorder and high eating disorder symptom groups. Independent sample Mann-Whitney's U tests were conducted to compare levels of stigmatizing attitudes toward BN in the high and low eating disorder symptom groups, with a p-value set at p = 0.025 to adjust for multiple comparisons. The probability of superiority (PS) was used as an index of effect size. There are no clear cutoff points for interpreting PS. However, the further away PS is from 0.5 (in either direction), the larger the effect (Ellis, 2010).
Stigma Toward Bulimia Nervosa
was not associated with levels of stigmatizing attitudes toward BN, with ρ values ranging between −0.06 and 0.05. However, knowledge of BN was negatively associated with three of the dimensions of stigmatizing attitudes toward BN, namely, personal responsibility (ρ = −0.28), unreliability (ρ = −0.19), and advantages of BN (ρ = −0.23). When the sample was split by sex, the pattern of correlations remained identical, with slightly stronger associations among men (personal responsibility: men, ρ = −0.29; women, ρ = −0.28; unreliability: men, ρ = −0.23; women, ρ = −0.15; advantages of BN: men, ρ = −0.27; women, ρ = −0.20). When the sample was further subdivided according to both sex and age, among men, the patterns remained consistent, with one additional relationship emerging among young men (18–34 years old) between knowledge and social distance (ρ = −0.16). Similarly, among women, no age variations emerged.
Stigmatizing Attitudes Toward BN Among Individuals With Higher Levels of Disordered Eating Results from the correlation analysis indicated no relationships between stigmatizing attitudes and beliefs toward BN and eating disorder symptom scores. With the use of the cutoff of 56, 21% (n = 447) of the sample reported high levels of eating disorder symptoms. Of these, 149 (33%) reported having previously sought professional help for a problem pertaining to weight or eating. In addition, 174 of these (39%) reported having eaten what other people would regard as an unusually large amount of food, 151 (34%) reported a sense of loss of control, 17 (4%) reported having used self-induced vomiting as a means of controlling shape and weight, 28 (6%) reported having used laxatives, 41 (9%) reported using diet pills, and 150 (33%) reported exercising hard to control shape or weight. Mann-Whitney's U tests revealed no differences in levels of stigmatizing attitudes toward BN between the participants with high and low levels of eating disorder symptoms when data from men and women were analyzed together. The analyses were repeated in men and women separately. In men, the high eating disorder symptoms group reported higher scores on minimisation/low seriousness (p = 0.003, PS = 0.42). Among women, the high eating disorder symptoms group reported higher scores on the advantages of BN subscale. However, this finding was on the threshold of significance (p = 0.025, PS = 0.54).
RESULTS DISCUSSION
Relationships of Stigmatizing Attitudes and Beliefs With Knowledge of and Familiarity With BN The means and standard deviations for the study variables are presented in Table 1. Contrary to our hypothesis, familiarity with BN
The aims of the present study were to explore the relationships of stigmatizing attitudes and beliefs toward BN with knowledge of and familiarity with BN as well as to explore the relationships between stigmatizing attitudes and beliefs toward BN and current self-reported
TABLE 1. Spearman's Correlations Between Stigmatizing Attitudes Toward BN and Familiarity, Knowledge, and Eating Disorder Symptoms Eating Disorder Symptoms
Stigmatization Personal responsibility Minimisation/low seriousness Unreliability Social distance Advantages of BN Mean (SD)
Mean (SD)
Familiarity
Knowledge
Weight Concerns
Shape Concerns
Eating Concerns
Dietary Restraint
2.93 (1.07) 1.83 (0.89)
−0.01 −0.05
−0.28 −0.10
−0.05 0.00
−0.04 0.01
−0.01 0.05
−0.05 −0.02
2.29 (1.01) 2.68 (.98) 1.64 (0.65)
−0.05 −0.04 −0.01 3.44 (1.91)
−0.19 0.10 −0.23 6.32 (1.42)
−0.02 0.01 0.00 1.42 (1.36)
−0.02 −0.01 0.00 1.76 (1.55)
0.04 0.05 0.05 0.56 (.91)
−0.03 0.00 −0.02 1.32 (1.36)
Correlations higher than ρ = 0.15 are in bold. High scores on the stigmatization subscales all indicate greater stigmatization of BN. High scores on the familiarity and knowledge scales indicate high familiarity and knowledge of BN, respectively. High scores on the eating disorder symptoms subscales indicate higher eating disturbance.
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eating disorder symptoms. Regarding the first aim, the findings revealed that greater knowledge of BN, for the purposes of this study predominantly conceptualized as knowledge of treatment of BN, was related to lower stigmatizing attitudes and beliefs toward BN, and few sex and age variations were found in these relationships, contrary to the contact hypothesis and previous findings (Allport, 1954; Ebneter et al., 2011; Wingfield et al., 2011); however, greater familiarity with BN, such as knowing someone with BN, was not associated with lower levels of stigmatizing attitudes and beliefs. For the second aim, our findings revealed that stigmatizing attitudes and beliefs toward BN were not associated with current self-reported eating disorder symptoms across the entire sample. In relation to consideration of possible differences across sex groups, interesting findings emerged. Men with high levels of eating disorder symptoms reported higher levels of minimisation/low seriousness stigmatizing beliefs, whereas women with high levels of eating disorder symptoms tended to report greater perceptions of the advantages of BN in comparison with their counterparts with low levels of symptoms. Consistent with previous findings (Rancie, 2008), greater knowledge of BN was associated with lower levels of stigmatizing attitudes and beliefs, specifically lower personal responsibility, unreliability, and advantages of BN. Although our findings are correlational, they are consistent with the theory that greater knowledge may lead to lower levels of stigmatizing attitudes and beliefs. As previously discussed, the belief that the individual with BN is personally responsible for his/her disorder and should merely pull himself/herself together to overcome the problem is an important dimension of stigma related to eating disorders (Ebneter and Latner, 2013), and identifying potential ways to decrease blaming of this kind is therefore important. In addition, minimization of symptoms, or the perception of potential advantages to maintaining symptoms, has been identified as a significant barrier to treatment seeking among women with an eating disorder (Cachelin and Striegel-Moore, 2006). Our results suggest that increasing knowledge about BN causes and treatment in the community at large might perhaps help reduce the tendency toward blaming people with BN for their disorder and to limit the perception of benefits or advantages to symptoms, which may, in turn, facilitate treatment seeking among individuals with BN. Our findings revealed that the perception of BN behaviors as desirable or acceptable was more frequent among the participants with high levels of eating disorder symptoms. This pattern was consistent with previous research. For example, similar to our finding that men with high levels of eating disorder symptoms reported perceiving BN as less serious, previous studies have also found that individuals with high levels of eating disorder symptoms have been more likely to rate bulimic behaviors as acceptable (Mond et al., 2010). In the current study, women with high levels of eating disorder symptoms tended to be more likely to express greater perceptions of advantages to BN compared with their healthy peers, which is consistent with findings that individuals with high levels of eating disorder symptoms report that it might not be “all that bad” to resemble the person in the vignette depicting BN (Mond et al., 2004c). Such attitudes might seem to reflect a certain reluctance to recognize symptoms as problematic and to imagine giving them up. Such attitudes have been documented in the literature (Fox et al., 2011) and may also serve to increase barriers to treatment because symptoms are normalized. Lack of recognition of eating disorder symptoms, which may stem from the normalizing of bulimic behaviors, constitutes a barrier to treatment seeking (Hepworth and Paxton, 2007). Interestingly, however, the prevalence of bulimic behaviors, in particular purging behaviors such as self-induced vomiting or laxative use, was relatively low among the participants in our high eating disorder symptom group. It may therefore also be that these participants did not identify strongly with BN and thought of individuals with this disorder as being quite different from themselves because it has previously been shown that self-induced vomiting is a key behavior 262
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in the self-recognition of bulimic-type eating disorders (Mond et al., 2006a). This may partly explain why no differences were found on the personal responsibility, unreliability, or social distance subscales between the high and low eating disorder symptom groups. Although attention has been paid to methods to reduce stigma associated with obesity and to highlight stigma as a social justice and primary public health issue (Puhl and Heuer, 2010; Puhl and Latner, 2007), similar efforts to reduce the stigma attached to eating disorders are lacking. In other psychological disorders such depression, in Australia, public health campaigns have been successful in changing attitudes and correcting widespread myths regarding the origins and treatment of the disorder (Jorm et al., 2006). Further efforts are required both at the national and the international level to identify and correct common misconceptions regarding BN and related disorders. Although longitudinal studies would help clarify the directionality of the relationships, the present findings provide preliminary evidence of cross-sectional relationships that suggest that improving knowledge about eating disorders, particularly in terms of origin, treatment options, and the seriousness of the disorder, may contribute to decreasing stigmatizing attitudes and beliefs toward BN and increase treatment seeking among affected individuals. Limitations to the study include the characteristics of the sample, which, although diverse in terms of sex, SES, age, and location, was not guaranteed to be representative of the Victorian population as a result of the low response rate, and this may limit generalizability of the findings. The low internal consistency of the social distance subscale was also a limitation. In addition, because of the nature of the study design, which provided the participants with a definition of BN, aspects of knowledge of the symptoms of the disorder could not be assessed. Furthermore, the knowledge items may have failed to assess other aspects such as the course of the disorder that have been shown to be an important aspect of mental health knowledge (Hinshaw and Stier, 2008). Nevertheless, this project represents a first attempt to develop a multifaceted scale exploring stigmatizing attitudes and beliefs toward BN. Moreover, our findings are based on strictly correlational data; therefore, causality should not be inferred. Finally, although we recruited a large community sample, our study included no adolescents. In the future, it would be interesting to extend these findings to younger members of the community.
CONCLUSIONS Knowledge of BN emerged as the main factor related to lower stigmatizing attitudes and beliefs toward the disorder. Stigmatizing attitudes were also held by individuals with high levels of eating disorder symptoms. Future research should continue to pursue this line of work by clarifying which information is most important in counteracting stereotypes and reducing stigma and thereby identifying targets for effective public health campaigns to improve mental health literacy related to BN and increase access to treatment. DISCLOSURES This research was funded by a grant from the Australian Research Council (DP1095656) to S. J. P., P. J. H., J. M. M., and B. R. The authors declare no conflict of interest. REFERENCES Allport GW (1954) The nature of prejudice. Cambridge, MA: Addison-Wesley. Becker AE, Franko DL, Nussbaum K, Herzog DB (2004) Secondary prevention for eating disorders: The impact of education, screening, and referral in a collegebased screening program. Int J Eat Disord. 36:157–162. Cachelin FM, Striegel-Moore RH (2006) Help seeking and barriers to treatment in a community sample of Mexican American and European American women with eating disorders. Int J Eat Disord. 39:154–161.
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