The document discusses how eating disorders affect adolescent self-concept during and after recovery. It finds that relapse rates for bulimia nervosa and binge-eating disorder are high at 41% and 33% respectively, indicating unresolved self-concept issues. Recovery from binge-purge disorders is especially difficult due to lack of emotional regulation skills. Patients experience conflicting views of their identity and treatment facilities, which can influence relapse. Recovery tends to be slower for anorexia nervosa subtypes and those with high levels of thought-shape and thought-action fusion. The "self-talk" of eating disorders also challenges self-concept during recovery.

1. Running Head: SELF-CONCEPT AND EATING DISORDERS 1
Assessment of the Residual Issues Regarding Self-Concept in
Adolescents Recovering from an Eating Disorder
Chloe McDaniel
University of Georgia

2. SELF-CONCEPT AND EATING DISORDERS 2
Abstract
Eating disorders occur primarily in middle to upper class white females during middle
adolescence. The onset of these eating disorders is due mainly to biological and cognitive factors
that have to do with puberty. Eventually relapse rates, the speed at which recovery takes place,
and depression comorbidity all give way to the emotional effects on self-concept during the
recovery process and following an eating disorder.

3. SELF-CONCEPT AND EATING DISORDERS 3
Assessment of the Residual Issues Regarding Self-Concept in
Adolescents Recovering from an Eating Disorder
Most eating disorders occur in middle to upper class white females for a variety of
reasons. Adolescence is a time when young people, females especially, begin to look at their
bodies more critically because of all of the changes that are occurring during puberty combined
with new cognitive abilities that reveal judgments of other people. Specifically in Western
cultures, the ideal body type for women is a slim figure. Puberty leads to fuller and curvier
bodies which do not meet this ideal. Girls undergoing these physical and biological changes may
feel significant stress to hinder or reverse the effects of puberty by closely monitoring the foods
they eat (Arnett, 2013). Eventually, some young people develop an eating disorder and possibly
multiple eating disorders. Although the DSM-V has certain guidelines to define threshold eating
disorders, there are also adolescents that suffer from subthreshold and partial eating disorders.
The onset of these eating disorders is usually in middle to late adolescence, perhaps when
importance of peer and romantic relationships peak (Stice, Marti, Shaw, & Jaconis, 2009). This
review assesses how recovering from any form of eating disordered behaviors affects the way
these young women and a small portion of men think about themselves. These effects will be
considered with regards to relapse rates, the speed at which recovery takes place, and depression
comorbidity.
Literature Review
Much of the research dedicated to eating disorders centers on relapse rates for
adolescents. Because most eating disorders appear in the form of poor body image
compensation, it can be deduced that relapse occurs due to unresolved problems in the self
following the original eating disorder. Even after hospitalization and inpatient or outpatient

4. SELF-CONCEPT AND EATING DISORDERS 4
recovery programs, these young people still face the chance of relapse. In a study conducted by
Stice, Marti, Shaw & Jaconis (2009), relapse rates for bulimia nervosa and binge-eating disorder
emerged to be 41% and 33% respectively, the highest observed in their sample. This sample
included threshold as well as subthreshold eating disorders which sheds light on the seriousness
of adolescents exhibiting even a small number of eating disordered behaviors. The fact that there
is strong likelihood of subthreshold or partial disorders to develop into full-scale eating disorders
also lead researchers to further investigate the reasons for and prevention of relapse (Stice, Marti,
Shaw, & Jaconis, 2009). If these youth are spending extensive amounts of time in programs
designed to reduce the possibility of relapse, then why do rates remain so high, and who are the
people most at risk?
While struggling with recovery from an eating disorder, an adolescent can be in a very
vulnerable state physically, mentally, and emotionally. Emotional regulation and impulsivity are
affected in this position. When a sample of women with anorexia nervosa, subtype restrictive
(AN-R) and anorexia nervosa, subtype binge-purge (AN-BP) were inducted into an intensive
inpatient recovery program, patients with AN-R exhibited over controlled emotional regulation
and low impulsiveness, while patients with AN-BP lacked emotional regulatory strategies and
showed signs of high impulsivity (Roswell, MacDonald, & Carter, 2016). The impulsive nature
of adolescents with binge-purge disorders combined with inadequate emotional control leads
them to perceive feelings such as shame and incompetence in a deeper way. Little control of
emotion provokes them to act on their impulsive desires to eat more food and thus to purge the
food. This is strongest during recovery, so relapse is more likely to occur.
Lack of emotional regulation contributes to intensified sentiments of insecurity in one’s
self-concept. Both Thought-Shape Fusion (TSF) and Thought-Action Fusion (TAF) are related to

5. SELF-CONCEPT AND EATING DISORDERS 5
a belief that bad things will happen if one thinks about them. With regards to TSF, the belief that
thinking about food will cause a person to gain weight, and TAF, the belief that having thoughts
about a negative event increases the likelihood that it will occur, levels are higher in people who
have or have had eating disorders. More specifically, young people who suffer from AN-BP
display higher levels of TSF suggesting they are more susceptible to punishing themselves for
thinking about food, even after recovery (Coelho, Ouellette-Courtois, Purdon, & Steiger, 2015).
The trigger of food-related stimuli may set off a reaction in the person with an eating disorder
that causes him or her to become excessively shameful or guilty which gets out of control due to
lack of emotional regulation abilities. The person may then act on their overwhelming inclination
to revert to their eating disordered behavior. The more emotional distress the adolescent endures,
the higher the chance of regression.
These emotions seem to vary in the setting of an inpatient recovery facility. Eli (2014)
interviewed twelve Israeli women and one man in one of these facilities to study the aspects of
their stay that determined the self-image that the patients had developed throughout. In the
interviews, she discovered several common yet conflicting themes. She highlights battling
between the resisting and finding refuge in an identity of a person with an eating disorder,
deciding whether fellow patients at the ward provide support or risk of relapse, and lastly,
choosing to view the facility as a safe haven or a prison (Eli, 2014). Each of the interviewees felt
both sides of each argument to a different degree. In part, the patients feel that they are
negatively grouped and defined by their eating disorder, but they also feel that the label
legitimizes the sufferings they have undergone. Similarly, although the other patients provided
support and a feeling of belongingness, they had also experienced inklings of jealousy for
patients who had achieved low weights that they had never reached, therefore posing a threat to

6. SELF-CONCEPT AND EATING DISORDERS 6
each fragile recovery. Many of the patients interviewed had difficulty determining if the facility
took away too many freedoms or if it protected them from the outside world (Eli, 2014). The
attitudes of the patients varied depending on the length of their stays, the number of previous
hospitalizations, and other personal experiences within the facility. The patients who claimed to
have more negative experiences tended to have already relapsed from previous recoveries (Eli,
2014). Perhaps the way a facility encourages the patient to consider himself or herself
contributes to the relapse rate. When a patient has more negative feelings towards the treatment
at an inpatient recovery facility, he or she may be more likely to relapse. Although the study was
conducted in Israel, comparison to British studies of similar topics reveals that the sentiments of
Israeli patients coincide with those of British patients in these types of facilities (Eli, 2014).
A patient centered focal point in recovery from eating disorders leads to appraisal of how
the speed of recovery affects a patient’s personal self-concept. Patients recovering from the
restrictive and binge-purge subtypes of anorexia nervosa see more gradual improvements in their
eating disorder along with their personal body image and self-compassion compared to patients
with bulimia nervosa (BN) and eating disorders not otherwise specified (EDNOS) Additionally,
an adolescent with a case of AN-BP also faces lagging improvements in guilt, warmth of
relationships, and support from others (Kelly & Carter, 2014). Perhaps the findings in Coelho,
Ouellette-Courtois, Purdon, & Steiger’s article on higher TSF and TAF levels in patients with
AN-BP (2015) bestows support to the idea that AN-BP eating disorders often carry difficult
cognitive obstacles to overcome, hence the long recovery time. Subthreshold and partial eating
disorders, which mostly fall under the category of EDNOS, tend to last a shorter amount of time,
about four to five months, rather than the years that threshold eating disorders average to last
(Stice, Marti, Shaw, & Jaconis, 2009). This factor could relate however to the severity of the

7. SELF-CONCEPT AND EATING DISORDERS 7
eating disorder. When a disorder is more severe, it tends to take longer to recover. The milder
state of a partial or threshold eating disorder may factor into its short existence (Stice, Marti,
Shaw, & Jaconis, 2009).
Because the most severe eating disorders take the longest to recover generally, those
young people suffering from severe forms of anorexia nervosa, bulimia nervosa, or binge eating
disorder especially have faced many difficult cognitive battles against their illness (Stice, Marti,
Shaw, & Jaconis, 2009). Self-talk is the proverbial voice of the eating disorder. This voice takes
on several different personas, a few of which being a seducer, a disciplinarian or coach, a
mentor, and an abuser. Each voice plays a different role in triggering hatred for the body and an
enigmatic need for improvement. The seducer tells the victim of an eating disorder that if she
loses five more pounds, then she will be satisfied. The coach provides strict rules for food intake
and/or exercising and is the source of discipline. The mentor tells the person that being skinny is
morally valued. Having discipline and denying oneself builds character. Finally, the abuser
destroys self-esteem. The degree of self-talk is positively correlated with severity (Scott,
Hanstock, & Thornton, 2014). In other words, those who endure a very severe form of an eating
disorder are markedly more likely to hear stronger voices of their illness telling them that they
are never going to be skinny enough, worthy enough, or even self-sacrificing enough to be
valued by others even during recovery.
These feelings of worthlessness provide evidence that most internalized problems such as
eating disorders have high comorbidity rates with other internalizing issues. Diminished self
worth is a key depressive symptom observed in young people. Because body image and self-
esteem issues go hand in hand with eating disorders, it is almost conservative to state that most
adolescents who suffer from an eating disorder also experience some degree of depression. To

8. SELF-CONCEPT AND EATING DISORDERS 8
support this notion, one study assessed the success rates in interventions involving both eating
disorders and depressive symptoms (Rodgers & Paxton, 2014). The interventions saw a 92%
success rate in reducing symptoms of eating disorders, yet only 42% of the interventions were
able to relieve eating disorder symptoms as well as depressive symptoms. Because eating
disordered behaviors are nearly three times more prevalent in girls who reported depressive
symptoms in early adolescence, this is essential to the prevention and improvement of eating
disorder symptoms (Allen, Crosby, Oddy, & Byrne, 2013). Even if the eating disorder is
eliminated through treatment, often times, the depressive symptoms remain left behind for the
victim to deal with.
Overall, the suffering and lack of a positive self-concept that accompany an eating
disorder diagnosis do not cease upon recovery. The recovery process as well as the system of
resocialization in the outside world still carries with them feelings of inadequacy, hopelessness,
and shame. Sometimes, adolescents must undergo the course of recovery and relapse several
times before they can fully focus on the negative remnants that plague their minds. Many of
these studies focused on simply eliminating the symptoms of eating disorders alone.
Comorbidity factors rarely appear in the literature, and when they do, the information sheds little
light on possible solutions. Another issue encountered in many studies on eating disorders is
having too small of a sample size. Reliable and valid studies are scattered and scanty. Larger
samples should be selected, perhaps through the educational system, to get more accurate
prevalence and relapse rates and other statistics on adolescents and emerging adults who
experience eating disorders. Relapse back to old eating disordered behaviors is an extremely
serious issue. Yet, the scarcity of literature available on the topic raises the question that asks if
researchers are dedicating most of their efforts to prevention while ignoring intervention

9. SELF-CONCEPT AND EATING DISORDERS 9
strategies. Nonetheless, eating disorders are odd groupings of psychopathological illnesses that
stump many researchers and interventionists because of their unconventional prevalence in
predominantly middle to upper class white and female populations. They coincide with other
internalizing problems such as depression and anxiety, causing many to ponder which came first
and which should be addressed first. However baffling the issue of eating disorders may be, there
is much more research to be done to alleviate the victims of such a troubling illness.

10. SELF-CONCEPT AND EATING DISORDERS 10
References
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