Motivation and emotion/Book/2019/Bulimia nervosa and extrinsic motivation

Overview
Sage is a 26 year old university student. Sage has struggled with her weight since she was in the sixth grade when she was teased for experiencing puberty earlier than the other girls. She began dieting in the seventh grade however, and would stock up on high calorie foods during the night. In freshman year she began binging late at night followed by self-induced vomiting. Sage participated in this cycle 6 nights per week, feeling out of control during the binge, and feeling in control after the purge. Sage stresses the pressure to look thin like the other girls takes control of her. She recently experiences episodes of binging and purging when stress from university increases or when she fights with her boyfriend (Society of Clinical Psychology, 2019).

The case study above provides an example of bulimia nervosa and how external sources can lead to impact an individual's formation and maintenance of this eating disorder. The beginning of Sage's eating disorder began through emotional eating as a result of bullying at school. The formation of an unhealthy body image continued to progress the disorder whilst, external stressors maintained the bulimia nervosa.

The focus of this current chapter will examine the extrinsic motivations which contribute to the development and maintenance of bulimia nervosa. By understanding the extrinsic motivators of bulimia nervosa, strategies can be formed to help manage and prevent this disorder.

Bulimia nervosa vs anorexia nervosa


Anorexia can be characterised via restricted energy intake which leads to low body weight of an individual in comparison to their health trajectory, age, sex and development. Alternatively, bulimia does not specify restricting energy intake however, includes episodes of binging and purging. The behaviour of purging is how an individual attempts to counteract the binging behaviours and obtain lower body weight. Furthermore, bulimia does not lead to the formation of an intense fear of gaining weight like anorexia does. Another difference between the two disorders is the visibility of the disorder. Anorexic individuals are visibly underweight however, bulimic individuals are typically a healthy weight or overweight. This is due to the binging sessions that occur compared to constant food restriction. Though these eating disorders do differ, similarities are presented as well. Anorexic and bulimic individuals both perceive a distorted body weight and shape which is heavily influenced through critical self-evaluation (American Psychiatric Association, 2013).

Bulimia nervosa
The Diagnostic and Statistic Manual of Mental Disorders 5th Edition (DSM V) characterises bulimia as recurrent episodes of binge eating which involve eating within a discrete amount of time (2 hour period) and consuming a large amount of food. As well as a lack of control over eating during an episode. Bulimia also involves recurrent inappropriate compensatory behaviour/s to prevent weight gain also known as purging. Lastly, self-evaluation is solely influenced by body weight and shape. The table provided below ( See Table 1) categorises the severity of the bulimia diagnosis (American Psychiatric Association, 2013).

Table 1. Severity of bulimia diagnosis

Purging


Compensatory behaviour is a defining feature of the bulimia nervosa disorder. Compensatory behaviour also known as purging can be defined as any behaviour in which the goal is to compensate for the amount of calories previously consumed during a binge. Purging can be accomplished via self induced vomiting, laxatives, excessive exercise, diuretics, fasting, restriction of food intake or any drugs inappropriately used for weight control (Anderson & Bulik, 2004). In the bulimic cycle purging is where an individual can establish a level of control after the frenzy of binge eating. This control is crucial in bulimia as it establishes a pattern of purging further motivating the individual to participate in the compensatory behaviour (Marsh et al., 2009).

Dangers of bulimia nervosa
Bulimia can be suggested to be one of the most dangerous eating disorders due to the impact which the disorder has on the body and internal body systems (see figure 2). Many bulimic sufferers experience lifelong damaging effects to major internal organs due to the stress the body is put under during binging and purging episodes (Johnson, Spitzer & Williams, 2001). Health implications from bulimia can be split into two main categories of self-induced vomiting effects and laxative abuse. Self-induced vomiting is an extremely dangerous behaviour in which acid from the stomach causes severe inflammation and erosion. While self-induced vomiting persists chronic pain of the pharyngeal can occur. This inflammation can cause discomfort while breathing and lung damage can occur as a result of gastric acid from the stomach. Esophagitis also occurs through acid and bile which can lead to tearing and rupturing of the esophagus. Erosion of the teeth occurs as stomach acid erodes the enamel over time resulting in an unnatural glossy finish to the teeth. Through enamel loss teeth become highly sensitive to hot and cold food resulting in discomfort whilst eating. Gingivitis (gum disease) is also common in those suffering from bulimia. This decay can cause bleeding of the gums as well as an influx of mouth ulcers. The majority of these detrimental side effects typically emerge months or even years into the disorder.

The damage of persistent laxative abuse, effects predominately{{sp} two main categories within the body being the gastrointestinal system as well as electrolyte and hypovolemia disturbances. Gastrointestinal issues include melanosis coli, chronic constipation and chronic irregular bowel movements thus enforcing reliance on the substance. Laxatives can also cause cathartic colon syndrome whereby there is an involuntary constriction and relaxation of the colon. Side effects of cathartic colon syndrome include bloating, abdominal pain and incomplete evacuation of the bowels resulting in further issues (Mehler, 2011). Electrolyte disturbances can lead to cardiac complications such as irregular heartbeat and heart failure. Through purging episodes, the body has no food to breakdown to produce energy. As a result the body begins to breakdown muscles to continue functioning. In bulimic individuals the breakdown of the heart if untreated can lead to death (Mehler & Rylander, 2015).

Quiz
Choose the correct answers and click "Submit": {Which of the following is not part of the DSM V diagnosis for Bulimia? - distorted body image + restricted calorie intake - eating in a discrete period of time (2 hr period) - compensatory behaviour
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{Is it usual for bulimic individuals to be underweight?. - yes + no
 * type=""}

Comorbid disorders
With many eating disorders the co-emergence of other disorders is increasingly common. Bulimia has been associated with depression which can be related to the constant feelings of inadequacy and worthlessness in relation to body image (Stankovska, Osmani, Pandilovska & Dimitrovski, 2015). Anxiety, social anxiety and obsessive compulsive disorder have also been positively correlated with bulimia prior and post diagnosis. The social pressure and feelings to be “thin” can push an individual to withdraw from social situations. Alternately, the incessant need to binge and purge can also cause individuals anxiety if the binge and purge cycle is altered or interrupted due to others or social situations (Kaye, Bulik, Thornton, Barbarich & Masters, 2004).

Extrinsic motivation
Extrinsic motivation can be defined as a behaviour which is motivated via solely external objects. These objects can be viewed in the terms of rewards which continue to motivate us to preform a certain behaviour. In contrast, intrinsic motivation is behaviour which is motivated by ourselves and our intrinsic need to participate in the behaviour (Ryan & Deci, 2000). Several social influences can extrinsically motivate individuals in developing bulimia and other eating disorders (see Table 2).

Table 2. Social Influences

Social comparison theory
The social comparison theory postulates that individuals compare themselves to others to gauge their own attitudes and behaviours when comparison norms are absent. Two kinds of comparisons can be identified being upward and downward. Downward comparisons can be defined as comparing oneself to another who is failing in the given behaviour. This makes the individual feel superior in the situation further protecting their self-worth. Alternatively, upward comparisons occurs when comparing oneself to another who is excelling in the behaviour which motivates individual’s for self-improvement. However, when self-improvement is unattainable intense damage to the self-esteem via body dissatisfaction occurs.

It has been concluded that when viewing images of peers and models, bulimic individuals participate increasingly more in upward comparisons rather than downward. It was further noted that body satisfaction decreased in bulimic individuals however, increased in the healthy control when viewing the images. The motivation for an individual to engage in binging and purging cycles can be concluded to be the result of constant social comparison. As the individual consistently makes upward comparison the assumption of inferiority occurs based off their physical characteristics and idealisation. It was also concluded that those images which portrayed women with lower body mass were more attended to via people suffering from bulimia (Blechert, Nickert, Caffier & Tuschen-Caffier, 2009). It can be suggested that bulimic suffers are predisposed to attend to images where only upward comparisons can be made. It can also be concluded that bulimic individuals seek out upward comparisons which subconsciously motivates them to engage in the binge and purge cycle. The extrinsic motivation from peers and models further encourages body dissatisfaction which leads to the maintenance of the eating disorder. The pressure to conform to thin idealisation from both social media and real life is extremely motivating with only negative effects (Hesse-Biber, Leavy, Quinn & Zoino, 2006). This pressure is exhibited in the case of Sage when the feeling the pressure to be thin like the other girls she knows of. Furthermore, a study by Slevec & Triggermann (2011) concluded that when viewing television social comparisons occurred. Thus, resulting in a positive correlation between disordered eating, body dissatisfaction and television viewing. These results are in accordance with Levine & Murnen (2009); Dittmar (2009) suggesting that cultural ideals of perceived beauty, one which is severely unattainable for most is modelled through media. This modelling then becomes increasingly salient as individuals utilise social comparisons.



Body image
Body image can be referred to as an individual’s perception of their self, regarding their attractiveness, weight or shape (Cash & Deagle, 1997). Although this is an internal factor, mainly external factors influence an individual’s self-perception. In the diagnosis of bulimia nervosa a criteria which must be met is the severe distortion of an individual’s body image. It is evident that external stimuli which can influence an individual’s perception on their body does not have to be from others. In a study conducted by Mohr et al. (2011) 16 bulimic patients were asked to arrange the distorted images of themselves in a sequence of thin to big. After arranging the images individuals had to pick an image which closely represented their body and one image which was their ideal body size. Bulimic individuals had a considerable discrepancy with their actual body size compared to their ideal body size. This lowered participants{{gr body satisfaction and increased negative attitudes towards their body image. Bulimic individuals throughout the trials maintained the notion of wanting to be thinner and were satisfied with their accurate representation of their body. It can be concluded that images which display thin ideals cause certain individuals to become self-critical and increasingly unsatisfied. Although this study focuses on showcasing the negative perceptions of individuals with bulimia it also does display how external stimuli can affect body image. The viewing of distorted images provides evidence of how external stimuli can have an adverse effect on body image. If a person is subjected to this constantly their negative body image could influence them to take extreme measures such as engaging in bulimia. Body image can be viewed a motivating factor towards an eating disorder and an extreme factor in the maintenance of the disorder.

Thinspiration
“Thinspiration” is defined as images, lyrics or poems shared on various media outlets which are clustered together in order to promote thinness ideals on an unhealthy level. On avenues such as Pinterest, these images are banned as they are harm provoking. However, this thinspiration movement still exists on platforms such as Tumblr and can often be disguised as “fitspiration” across social media platforms (Lewallen & Behm-Morawitz, 2016). Similarly, 'pro-ana' (pro anorexia) and 'pro-mia' (pro-bulimia) blogs continue to circulate despite tighter content restrictions. These outlets utilise social norms and social comparison theory to enable eating disorders (Custers, 2015). Social norms are set in order to motivate and guide behaviour. On sites which encourage bulimia a social norm is set in which individuals are motivated to adhere to. This norm encourages the maintenance of bulimia but also the development of eating disorders (Zalta & Keel, 2006).



A study conducted by Zalta & Keel (2006) examined the influence of socialisation of bulimia symptomology in college students. The study concluded that those individuals who share similar personality traits were able to socialise their disordered eating. It can be suggested that chat rooms which utilise a pro-bulimia stance are effective motivators, as those individuals who access these forums are similar in a variety of ways. This allows for socialisation of bulimia symptomology to occur. This socialisation further motivates individuals to participate in the binge and purge act. As this socialisation occurs a social norm is created within the group. Group membership is maintained through the display of an eating disorder. These sites can be significant motivators in the maintenance of eating disorders as it provides a platform for tips and tricks to be exchanged through like-minded individuals. This phenomenon has been additionally supported by research from Csipke & Horne (2007) when examining the motivation behind eating disorder sites. The study concluded that individuals visited the sites to motivate themselves to commence and continue disordered eating. After viewing these pro-disordered eating websites individuals reported a negative mood and then preceded to engage in these websites more often. Through this negative mood, participants reported a worsening of their body image from visiting the sites. Ultimately participants admitted these pro-eating disorder sites motivated themselves to maintain their disorder and discourage them from recovery.

Cultivation theory
The Cultivation theory examines the long-term effects of various media outlets through the dispersion of cumulative content and regularity of messages. This theory suggests that the more an individual is subjected to media, the higher the probability that the individual will view mass media as realistic. The constant display of endorsements which promote an unobtainable view of beauty, that is typically related to thinness is closely associated with eating disorders (Hesse-Biber, Leavy, Quinn & Zoino, 2006). This relationship can be concluded to be a mediating factor of the beginning of bulimia but also the maintenance of the disorder. By viewing thin ideals constantly, those individuals who already experience bulimic symptoms would be motivated further to continue their disorder rather than seek treatment (Eisend & Möller, 2006). It can be suggested that for an individual to develop an eating disorder such as bulimia, an extrinsic motivation must first occur. The influx of thin ideals can be viewed as a mediating factor which further becomes internalised by the individual. Thus, this internalisation may not occur in the absence of long-term effects of media or social comparison (Hendriks, 2002). The viewing of mass media can prime an individual to experience feelings of inadequacy. As this internalisation remains a high media presence further initiates feelings of body dissatisfaction. However, it is noted not all individuals develop eating disorders from being exposed to an array of thin ideals in the media. According to Lawler & Nixon (2011) the internalisation of cumulative media content can be displayed as a mediating factor in the progression of body dissatisfaction, especially in critical and self-conscious individuals. Furthermore, this internal body dissatisfaction in addition to other extrinsic measures can increase the prevalence of eating disorders like bulimia.

Conclusion
Bulimia nervosa is a serious disorder which can have severe implications both psychologically and physically. Although it should be noted that intrinsic motivation for bulimia does occur, extrinsic motivation can be classified as the foundation of the disorder. Social media appears to play a mediating role in the development and maintenance of this disorder. Social comparison is inevitable through life, however it is amplified through avenues of social media. Websites which promote pro-bulimia behaviours are detrimental and motivate individuals to continue their disorder. The continuous display of thin ideals can act as a mediating factor which can significantly deteriorate an individual’s body image. To conclude, as technology advances avenues in which people stay connected {{gr} must be monitored in order to limit the levels of body dissatisfaction within individuals. Numerous theories provide evidence on how bulimia can be mediated and maintained. However, further research should be posed into the motivation of forming pro-eating disorder websites and hand accounts of reasons individuals may engage in the behaviour.