Introduction

Biological and environmental factors have been found to play an important role in the development of anorexia nervosa (AN) [1]. When studying the epidemiology of AN (incidence and prevalence in different cultures) the influence of socio-cultural factors need to be considered [2]. Until recently, socio-cultural theories have considered AN as “Western culture-bound syndromes” specific to Caucasian women from industrialized societies [3]. Recent studies have suggested that the Westernization of society (i.e. globalization and exposure to Western media in non-Western countries) contributes to the development of AN in non-Western cultures [4–7]. However, other studies have found the presence of AN in societies where there is an absence of Western influence [3].

In the last few years there has been a growing interest in the clinical presentation of AN across different non-Western societies. This has been reflected by an increased number of studies, describing the prevalence and manifestation of AN, particularly from African and Latin American/Hispanic groups [8] with few studies from Asian individuals [8]. These studies have been part of the debate regarding whether the clinical manifestation of AN differ across cultures [3]. As many of the cross-cultural studies analysing AN in non-Western societies have been carried out within Western countries [9] these studies have been inconclusive.

In spite of this, some studies have found that Chinese patients with AN report less body dissatisfaction, absence of fat phobia and different weight control behaviours than Western cultures [10,11], while others suggest a similar symptomatic profile to Western eating disorder (ED) patients [12]. An increase of fat phobia among Chinese ED patients in the last years has also been suggested [13]. The difference in the manifestation of symptomatology across cultures may not be unique to AN, as differences in the expression of psychopathology (such as depression or anxiety) have also been reported [14,15]. For example, Chinese people tend to present more self-control and emotional restraint and less externalization of their emotions [16–18]. Kleinman [19] reported that in Chinese societies the experience of depression is physical rather than psychological.

Cultures in all the above studies have been divided into Western or non-Western. However, the values and attitudes regarding the individual´s relation to their social group can also divide cultures into Collectivistic and Individualistic [20]. Collectivist cultures put emphasis on the individual´s behaviour for the whole group, focusing on cooperative tasks. Conversely, individualistic societies are characterized by an emphasis on what makes the individual distinct, focusing in competitive tasks [21–23]. According to the cultural dimensions considered by Hofstede [24] some Western countries, like Spain, will be closer to the Non-Western countries, like China, than to other Western countries, like the United Kingdom (UK). The individualism (vs. collectivism) index (IDV) classifies both China and Spain as collectivistic societies while Anglo-Saxon countries as individualistic cultures [20,24–26]. In fact, China is considered as one of the highest collectivist society (IDV: 20) whereas UK presents amongst the highest of the individualist scores (IDV: 89). Spain, by contrast, in comparison with the rest of the European countries (except for Portugal) is the highest collectivistic society (IDV: 51) [27]. Literature on individualism and collectivism provides a framework for exploring the association between cultural values and psychological processes or mental health [28]. Although we have not been able to find researches regarding IDV and ED, studies analyzing psychopathological traits, much of them co-morbid and/or related with EDs, found that individuals from collectivistic societies reported greater levels of social anxiety [29,30], lower self-esteem [17], maladaptive perfectionism (mainly high parental expectations) and depression symptoms [31]; but also less emotional expression or suppression of emotions in order to keep the group harmony [32,33], than those from individualistic countries. Likewise, some of the characteristics of collectivistic society, such as high levels of parental overprotection, have been found to be directly associated with eating pathology in both Chinese [34,35] and Spanish culture [36] and may influence the manifestation of these disorders. Besides, Katzman and Lee [37] have theorized that women in collectivistic societies which are in a changing cultural environment (i.e. modern exposure and experimentation with individualistic models) might develop an ED as a reaction to socio-cultural disconnection and transition.

With the aim of adding into the cultural debate this study will compare ED symptomatology, including co-morbid psychopathology, in a large sample of individuals diagnosed with AN from China, Spain, and UK. This will provide an opportunity to assess eating psychopathology for a set of cultures with different collectivist/individualist values as well as Western/Eastern orientations. Specifically, UK represents Western/high Individualist culture, China has been identified as Eastern/ high Collectivist, and Spain has been described as Western/ intermediate Collectivist [27]. Greater differences between Spain and UK would be indicative that collectivist attitudes play a more significant role in the clinical symptomatology and comorbid psychopathology of patients with AN. Alternatively, greater differences between Spain and China would suggest the primary role of the Eastern/Western division. As the big majority of patients with EDs attending the Chinese services present with AN, and other disorders are rare, the study has focused on patients with AN only.

The present study tries to overcome the limitations of the previous literature. Although some studies have investigated EDs among different cultures, most of them have used non-Western ethnic groups living in Western countries, and they may be biased by not taking into account the process of acculturation. To our knowledge, this is the first cross-cultural study assessing whether ED are more influenced across Western/Eastern or Collectivism/Individualism cultural attitudes. Thus, the findings of this study could provide useful information in the understanding of the manifestation of EDs, which may help the identification and prevention of these conditions. The knowledge of cross-cultural influences may help to design targeted interventions (e.g. if the collectivist values are more influential than Western/Eastern orientations, the patients of collectivist cultures probably would benefit more of group therapy, family therapy or family meetings).

The study’s aims are twofold: 1) to compare the clinical presentation, including co-morbid psychopathology, between patients with AN from Western (UK and Spain) and Non-Western (People´s Republic of China (PRC)) cultures, and 2) to compare the clinical presentation, including co-morbid psychopathology, between patients with AN from the UK, PRC and Spain in order study the differences according to the country’s IDV.

Taking into account the existing literature, we expect to find psychopathological differences between groups. However, we hypothesized that these differences may not be due only to Western vs. Non-Western influence, but Collectivist/Individualist values may shape the psychopathology expression (e.g. the group wellbeing encourages the suppression of emotions and individual psychopathology in favor of the group in collectivist cultures).

Materials and methods

Results

Discussion

The current study assessed clinical and comorbid psychopathological differences between patients with AN patients from China, UK and Spain. These three countries were chosen as they offer differences in the levels of individualism and collectivism as well as being Western and Eastern countries. According to the Individualism (vs. collectivism) Index, China and Spain can be classified as collectivistic societies while Anglo-Saxon countries, such as the UK, as individualistic cultures [20,24–26]. At the same time UK and Spain are Western countries while China is not. This study not only extend previous research comparing non-Western versus Western populations living in their respective countries [9], but also identifies whether abnormal eating patterns, anorexic cognitions and general psychopathology are more influenced by Western/Eastern or Collectivism/Individualism cultural attitudes.

The study found that people attending services in the different countries differed by age, with older people attending services in Western countries. This could be explained by the increase in pathological eating and body dissatisfaction among middle aged and older women reported in recent Western studies [49]. These societies have started to move away from AN being seen as illness affecting young people only [50,51]. However, this may not be the case in Non Western countries and stigma regarding access of older people to eating disorders services may still exist [52]. Non-Western societies may still see AN as an illness occurring only in young females [53,54].

In terms of eating psychopathology the study also found clear differences in the clinical presentation of EDs between the three countries. Western countries presented with higher levels of drive for thinness and body dissatisfaction, and Chinese patients appeared less clinically ill. These results are in line with other studies that have shown that female subjects from China were less likely to have fear of fatness or fat phobia [10], or score lower on restraint and weight concern subscales of Eating Disorder Examination (EDE) [55]. The high levels of body dissatisfaction among Western patients were mainly influenced by scores in the Spanish group. This may be less to do with Westernization or collectivist society and more influenced by the local culture of a coastal Mediterranean city. In line with this hypothesis, the study of Jaeger et al. [56] comparing 12 countries found the most extreme body dissatisfaction in northern Mediterranean countries, followed by other European countries, and finally non-Western countries [56]. Likewise, the high levels of drive for thinness in both Western and individualist societies were determined by the high scores of the UK patients. Although these results are not completely in accordance with previous studies arguing that the thin ideal is due to the Western influence [57], they would support the hypothesis that collectivist values could minimize the expression of eating symptoms in patients with AN, such as drive for thinness, to avoid the strain on the family that could cause the illness.

Regarding general psychopathology, the study found significant differences in most of the psychopathological indices between the three countries. Overall, Western countries presented with higher scores in comorbid psychopathology. Surprisingly, the IDV value only influenced the scores of interpersonal sensitivity scale. This dimension focuses on feelings of personal inadequacy and inferiority, particularly in comparison to others. Self-consciousness, uneasiness and marked discomfort during interpersonal interactions are hallmark features of interpersonal sensitivity [43]. Patients with AN from individualistic societies were found to present higher scores on interpersonal sensitivity (i.e. more negative expectations concerning interpersonal behavior) than those from collectivistic ones. This may be due to collectivistic societies being highly interdependent and concerned with interpersonal harmony, while individualistic ones being more independent societies. Patients from the Western society (UK + Spain) showed the highest scores of comorbid somatization, interpersonal sensitivity, and overall psychopathology. Our findings show that patients from both Spain and UK are more similar regarding psychopathology than those from China. As noted above, greater differences between Spain and China would suggest the primary role of the Western division. Therefore, these results suggest that psychopathology expression is better explained by belonging to Western society than for individualist/collectivist values. These results are in line with previous studies reporting how Chinese symptom patterns might differ from those found in the West, and how Chinese people tend to deny depression, anxiety or other psychopathological symptoms [16,58]. Denial or minimization of symptoms may be more common in Chinese patients with AN, as they are culturally encouraged to use denial and minimization to cope with conditions deemed taboo, particularly mental and terminal illnesses [59]. Our results are also in line with other previous studies that failed to find association between social anxiety and individualism/collectivism [60,29].

Patients from China presented with surprisingly low levels of psychopathology, including depression and anxiety. This could be explained by the fact that eating disorders services are relatively new in non-Western societies and patients with comorbid conditions may access other mental health services, leaving the more “pure” and less comorbid individuals, whose weight is substantially and dangerously low, accessing ED services. This may also have explained the differences in BMI between the three groups.

Conclusions

In conclusion, our findings showed a clear pattern where Western influence, and not individualist values, best explains the psychopathological expression comorbid to the eating disorder according to countries. This can suggest that treatments targeting the comorbid psychopathology may need to be adapted to take cultural aspects into consideration as some evidenced based treatments may not be suitable for all cultures. When discussing treatments for EDs, culture and the adaptation to a specific culture should be considered.