Motivation and emotion/Book/2018/Anorexia nervosa and intrinsic motivation

Overview
Around 4% of the Australian population suffers from an eating disorder (Eating Disorders in Australia, 2018). The diagnoses for eating disorders has expanded significantly in recent years with symptoms ranging from extremely low dietary intake to excessive consumption of foods, both of which are caused by psychological disturbances relative to body image and/or weight. The motives behind eating disorder behaviours are independent to the individual with the illness, however are central to perceived control.

Intrinsically (or internally) driven desires are those which are driven by personal incentives rather than external rewards. Common intrinsic motivators would be things such as achievement, enjoyment, and mastery of skill; feelings not typically associated with a psychological disorder. Yet it is these internal feelings which drive individuals with eating disorders to take action in losing weight and restricting their diets no matter the detriments to their health. This chapter explains intrinsic motivations behind the specific eating disorder of Anorexia nervosa (AN). The chapter will identify and examine the intrinsic motivators that lead to food avoidance behaviours in those with eating disorders such as AN. For more information about extrinsic motivators involved in AN, see anorexia nervosa and extrinsic motivation (Book chapter, 2016).

Focus questions
 * What is anorexia?
 * What motivates anorexia?
 * What is motivation?
 * What is intrinsic motivation?
 * What intrinsically motivates anorexia?

Anorexia nervosa
Anorexia nervosa is a mental illness characterised by fear of gaining weight, over-exercising, low caloric intake often accompanied by an abnormally low body weight (The Butterfly Foundation, 2018). Compared to other eating disorders such as bulimia and BED (binge-eating disorder), sufferers of the illness are at higher risk of severe malnourishment, hair loss, bone damage, and organ damage. Causes for the disorder were unknown up until the second half of the 19th century, with majority of empirical findings being inconclusive or inadequate as the desire for weight loss was and still is considered relatively normal (Vandereycken, 2002). Since developing research and understanding more about the disorder, the diagnostic statistic manual for psychological disorders has also included more sub types of eating disorders as well as expanded the diagnosis criteria for many of the related disorders ("DSM-V Diagnostic Criteria for Eating Disorders", 2018).



There is however, no one set criteria for eating disorders, meaning anorexia affects individuals in very personal and unique ways which are subject to cultural, social and environmental differences. One of the most common misconceptions about the development of anorexia is the notion that it is the individuals choice to engage in weight-loss promotion behaviour due to having a high amount of body fat or simply lacking self-esteem, however there are no predictable causes for the disease nor is it a choice. Some of the most typical motivators for weight-loss behaviour such as dieting, exercise and lifestyle change, are factors like reversing possible weight-gain, improving health and fitness, and increasing self-esteem (Brink & Ferguson, 1998). All of these incentives are intrinsically motivated as they offer a sense of gained control, power and independence over oneself and their body.

History of anorexia nervosa
Over time, the amount of diagnosable eating disorders has increased as well as the symptoms, treatments, and prevention's used. An important factor to consider is the large role that the health and wellness industry has played in diminishing individuals self-esteem and emphasising the importance of body image. What is most concerning about this is the significant fluctuations in the motivations, causes and repercussions which come from specific society's perception of ideal beauty. The perceived standard of the ideal body shape differs from culture to culture. Yet it seems to be the Westernised ideal of thinness which is spreading culturally, with statistics showing the rise of eating disorders in Asian countries with women reporting they have low self-esteem about their ethnically defined features (Bordo, 2004). The widespread concept of a thin waist, tall shapely legs and a gap between one's thighs, is a look common within the fashion industry and is often perceived as beautiful and ideal. This body type is depicted in Figure 1.

Another crucial factor to consider when looking further at the increase of eating disorders like AN is the amplification of modern diet culture. Diet culture refers to the concept that being thin equals being healthy, as well as the overemphasis on the importance of size and shape (Gremillion, 2002). Fad diets such as low fat, no sugar, and no carbs are common examples of diet culture, as they promote a continuous cycle of weight loss and gain which keeps a person pursuing better health and ultimately investing more time and money into that goal. This cultural aspect plays a crucial role in the development of eating disorders as it takes various platforms, and can mask as a solution to a better and happier life.

Who is at risk?


It is often said that those with AN also suffer from symptoms like anxiety disorder or obsessive-compulsive disorder (OCD) (Zandian, 2007). This is often true and will be discussed further, however there is a large range of influences that can trigger eating disorders or related behaviour that are more complex. Evidently there are the social influences as spoken about previously in regards to diet culture. Furthermore, to this there are environmental factors such as media representation, perception of beauty and marketing of diet products which may have the ability to evoke body conscious thoughts into an individual. In contrast to this, heritability of anorexia has been studied judiciously with one study finding that the heritability of anorexia is around 70% (Gorwood, Kipman, & Foulon, 2003). Studies conducted in 2000 on causes of weight concern also concluded that young females with mothers more concerned with body image and diet, are more likely to develop those same body concerns which can easily trigger an eating disorder (Ogden & Steward, 2000). This common relationship between mothers and daughters is also why family therapy is commonly used for treatment.

Another biological predisposition to eating disorders is gender. A large amount of studies done in comparing the prevalence of eating disorders among genders have found females more vulnerable to have or develop eating disorders, often sitting at a 70%-30% ratio, with females taking the larger percent (Whiteman, 2016). In an Australian study in 2008, results indicated 1% of participants within the study that were male had an eating disorder, whereas 6.4% of female participants had an eating disorder (Smink, Van Hoeken, & Hoek, 2012). There are a number of reasons as to why more females suffer from eating disorders than men, mostly relating to culture and beauty standards placed upon women. The emphasis put on women to control their shape and body size is a large contributor to their deeper awareness of their physical appearance. Research conducted in 1989 found that women had higher awareness of their body image because of role confusion and possible unresolved teenage conflict (Hsu, 1989). The heritability however can be more unpredictable and variable especially when paired with the environmental and social influences that have been known to motivate disordered eating behaviours.

Comorbidity in eating disorders
Comorbidity refers to the presence of an additional disorder with an already existing disorder (Department of Health, 2003). For example, having both anxiety and OCD simultaneously. Individuals suffering from an eating disorder have a 56 to 97% chance of having an additional psychiatric disorder, this further pressure is likely to explain why eating disorders have the highest rates of fatality of all psychiatric disorders (NEDC, 2018).

Intrinsic motivation
Motivation refers to the broad range of reasons behind an individuals actions or belief. A motive is an individual reason for the doing of something, which is often caused by desires, drives, and needs. Motives consist of either an intrinsic or extrinsic influence or a combination of both. An extrinsic reward is one that is physical or has some physical benefit such as money (refer to Figure 3). An intrinsic reward is an internal reward such as a feeling of accomplishment from completing a task or goal (Ryan & Deci, 2000). Intrinsic motivation is most often prompted by a person's desire to engage in a behaviour for enjoyment, pleasure and/or personal gain. When considering the actions and behaviours commonly seen in anorexia, it is difficult to determine why an individual suffering from an eating disorder may put in large amounts of effort to be thin despite negative psychological and physiological outcomes and risks, however it can be understood better when examined in reference to psychological theories of motivation, which will be discussed further within this chapter.

Research
The first identification of intrinsic (and extrinsic) motivation was discovered by Robert White in 1959 when studying animal behaviour and the drives in which motivated them to act despite having no external reward or incentive (Ryan & Deci, 2000). Intrinsic motivation has played a crucial part in the contribution to workplace and education management research, as well as studying psychiatric disorders and motivation behind certain behaviours within those disorders (Harter, 1981). Because intrinsic motivation is internal, it has understandably been difficult to measure and research. Yet because the relationship lies between the task at hand and the individual, self-report inventories have become a highly beneficial way of reporting whether or not intrinsic motivation has occurred. For example, an individual who enjoys painting reports feelings of joy and peace when painting (Elliot & Harackiewicz, 1996). These kinds of measures are useful in that individual emotions can be difficult to record and study, so having an individual report them gives the researcher more insight into what emotions are being felt and why.

Applications of intrinsic motivation study


Most modern researchers refer to intrinsic motivation as motivation by which there is no drive for (Ryan & Deci, 2000). However, there is still a large debate behind whether intrinsic motivation merely stems from every human's desire to be competent and self-motivated. Intrinsically motivated behaviours are seen often in learning, mastery and completion of enjoyable tasks. Typically the pattern of behaviour occurs in this order, meaning that when an individual acquires a task, completes it with the right amount of challenge and succeeds, they will most likely continue to gain enjoyment from completing that task again in the future. An example of a combination of both intrinsic and extrinsic motivation is if a student studies very hard to achieve good grades, but also to feel a sense of achievement within oneself and gratification in their skill. A more general and every-day application of intrinsically motivated behaviour is when an individual simply partakes in an activity which they have a liking for, interest in, or desire to learn more about in order to become more skilled at it.

Drive theory
Two significant theories about human drive came from renowned psychologists Sigmund Freud and Clarke Hull. Both theories focus on the theme that human behaviour is the result of a drive - or motivation, yet have some distinct differences such as what initiates drive. Hull's theory differs from Freud's in that it can be caused by more disturbances such as thirst, hunger, avoidance of pain, and sex, whereas Freud believed humans had two central drives which were sex and aggression. As sex and aggression may not seem relevant to eating disorder motivation, it is to be noted that Freud's theory branched further into drives more common to a typical person. (Ryan & Deci, 2000). Both Freud and Hull's drive theories support the notion that a deficiency in a need, whether it be psychological or physiological, becomes so uncomfortable to a person that they must do something to relieve tension in order to feel a sense of balance or homeostasis (Weiner, 1996). A homeostatic disturbance is a physiological state of imbalance which motivates drives such as eating when one is hungry and stopping when full (Atkinson, 1964).

For an individual suffering from AN, the fine line between hunger and fullness can become incredibly blurred as one of the most prevalent and central symptoms of the disorder is restricting dietary intake. Various studies have shown those with AN to have highly distorted understandings of satiety and fullness, especially surrounding mealtimes (Garfinkel, 2009). Findings like this lean more towards Hull's theory in that an individual with anorexia may reject feelings of hunger, yet become so used to it in the future that they eat less automatically. Freud's theory however, does still highlight the importance of relieving internal imbalances which may cause discomfort either physiologically or psychologically. Examining Clark Hull's drive reduction theory further, it is evident he believed drive influenced behaviour completely, which often resulted in the learning of a behaviour. The influences which drive one to engage in disordered behaviour seem to stem mostly from intrinsic drives, but have extrinsic outcomes that are often negative (Refer to Table 1). Consequences from the intrinsic motivations as seen in Table 1 may include an extremely low body weight, extreme feelings of hunger, focused attention on food and diet, as well as social isolation that can occur from the extensive pursue of weight loss. It is perhaps through this combination of psychological motivation paired with physiological feelings that AN can be so dangerous and difficult to treat.

Self-determination theory
The self-determination theory is centred around feeding our intrinsic motivations in beneficial ways to create a feeling of personal accomplishment. The three fundamental desires which come from the self-determination model are autonomy, competence and relatedness (Ryan & Deci, 2000). The relationship between these 3 aspects and AN can be explained in Figure 5, and explained further below.

Autonomy
"Freedom from external control or influence; independence." (Ryan & Deci, 2000). Autonomy within the self-determination theory is one of the strongest factors which contribute to human behaviour. Autonomy within anorexia is doubly as important considering the disorder is strongly linked with control over oneself (Cameron, 1985). Motivationally speaking, autonomy is highly intrinsic in that once gained, it can create a feeling of self-accomplishment and pride. A person with anorexia may attain autonomy for a number of reasons including creating diet rules, choosing to defy/follow hunger signals and choosing to engage in over-exercising. The loss of autonomy however can cause great psychological disturbances especially for one dealing with AN. These disturbances come from a deep feeling of loss of control such as accidentally breaking a dietary rule, eating mindlessly or gaining weight despite efforts not to. Furthermore, a dangerous aspect of AN that arises from autonomy is the defiance of recovery, for example refusing to regain weight, follow a treatment or seek help when it is needed (Bruch, 1974).

Competence
"The ability to do something successfully or efficiently." (Ryan & Deci, 2000). Competence refers to the ability of being able to do something well and/or with ease. In AN, competence is evident in the social expectation of the ideal body shape and how one can achieve it. Weight loss is often regarded as a symbol of personal success, ultimate will-power, and control, both throughout history and in today's society (Wright, O’Flynn, & Macdonald, 2006). Majority of this thought behind accomplishment in weight loss comes from the notion that losing weight and keeping it off is very difficult; a notion promoted by the diet and health industry. Within eating disorders, competition similarly creates a sense of competence in that it drives an individual to be better or perhaps lose more weight than someone else in order to feel superior, especially considering sufferers often feel highly inferior and self-doubtful (Bers & Quinlan,1992). The feeling of inferiority is one of the stronger drives in someone with AN as it motivates them either be better than someone else or to be better than their past self, for example, losing an extra kilo on top of their previous weight loss and/or eating less calories than the day prior.



Relatedness
"The need to feel belongingness and connectedness with others." (Ryan & Deci, 2000). The feeling of relatedness is one that is highly beneficial to one's mental well-being as it represents a connection with another person. Typically, relatedness can be achieved by growing and nurturing positive relationships with others often through identifying common interests and goals. Depending on the level of self-determination that an individual with AN has, their sense of relatedness can be detrimental or highly therapeutic in regards to their disorder. A common practice of treatment for those with eating disorders is family therapy, as it encourages sufferers and their families to understand and relate to one another (Palazzoli,1985). In addition to family therapy, group therapy is also common in treatment for those with eating disorders as it allows individuals to feel a sense of relatedness to others who share similar struggles. This same sense of relatedness is crucial to recovery and is often why individuals in recovery have support teams made up of health professionals, friends, family and other supportive influences (Tozzi, Sullivan, Fear, McKenzie, & Bulik, 2003).

Quiz questions
Choose the correct answers and click submit. {What percentage of the Australian public suffer from an eating disorder? - 24% + 16% - 4% - 43%
 * type=""}

{What is the most common eating disorder? - Other specified feeding or eating disorders (OSFED) - Bulimia Nervosa + Binge Eating Disorder - Anorexia Nervosa
 * type=""}

{Who is more likely to develop an eating disorder? - A young male + A female with family history of anorexia - A middle-aged female with children - A father of 3 daughters
 * type=""}

For more information, see Help:Quiz.

Conclusion
The development of an eating disorder such as AN has multiple causes that are environmental, cultural and social. However, it is the intrapersonal influences that reinforce the detrimental behaviours and symptoms that come from eating disorders. Anorexia is driven by an extreme desire for self-control, power, and sense of personal achievement - all of which are types of intrinsic motivation. The self-determination theory sheds light on the human desire to feel accepted, independent and needed as well as powerful enough to govern one's own actions with skill. It also explains why those with eating disorders are often perfectionists, with a longing to control aspects of their lives (Bastiani, Rao, Weltzin, & Kaye, 1995).

Similarly, the drive theory's offers insight as to why individuals with eating disorders suffer from hunger disturbances and altered perceptions of hunger and satiety. Hull's theory in particular gives most clarification to the manifestation of negative behaviours which an anorexic person displays, such as denying internal hunger cues and relentless exercise. When combined with the self-determination theory, the development of an eating disorder can easily be explained as it is the intrinsic drives which motivate one to pursue weight-loss, giving them a sense of personal gain and satisfaction which continues the cycle of learned reward and reinforcement of those behaviours and outcomes.