14
Feeding and Eating Disorders
Eric J. Mash
A. Wolfe
©David
Cengage Learning
2016
© Cengage Learning 2016
Overview
• What is peculiar about eating disorders is
that they are linked to Western culture,
where food is plentiful and physical
appearance is highly valued
– In Western society, eating disorders are the
third most common illness in adolescent
females
© Cengage Learning 2016
How Eating Patterns Develop
• Normal development
– Problematic eating habits and picky eating are
common in early childhood
– Societal norms and expectations affect girls
more than boys
• Beginning around age 9, girls are more anxious
than boys about losing weight
• Most important impact on fundamental biological
processes is early parent-child relationship
• Entering school comes with pressure to conform to
perceptions of desirable body type
© Cengage Learning 2016
Developmental Risk Factors
• Early eating habits, attitudes, and
behaviors
– Western sociocultural values and
preoccupation with weight and dieting
• May be internalized and expressed in children as
young as age 7-10
– A constellation of physical and psychological
factors are linked to early eating problems
and distorted beliefs
© Cengage Learning 2016
Developmental Continuum of Eating Habits
and Disorders
© Cengage Learning 2016
Transition into Adolescence
• Anorexia and bulimia typically occur during
adolescence
• Girls place greater emphasis on selfperceptions of their physical appearance
more than boys
© Cengage Learning 2016
Transition into Adolescence (cont’d.)
• Contradictory social messages imply that
women must be successful in traditional
feminine and masculine roles
• Changes encourage smoking and other
substance use to prevent impulse to binge
eat and consequences of weight gain
© Cengage Learning 2016
Dieting and Weight Concerns
• Restrictive dieting is common in North
America, even among elementary school
children
• Chronic dieting is associated with gender
and developmental factors
© Cengage Learning 2016
Dieting and Weight Concerns (cont’d.)
• Dieting may lead to a vicious cycle of
weight loss and weight gain, overeating,
and the “false hope syndrome,” as well as
binge eating and subsequent purging
• Many young people diet, but only a small
minority develop eating disorders
© Cengage Learning 2016
The Binge-Purge Cycle
© Cengage Learning 2016
Biological Regulators
• Metabolic rate
• Body weight
• Growth
– Major hormonal determinants of physical
growth rate during childhood are the growth
hormone (GH) and thyroid hormone
– Additional gonadal steroids kick in during
adolescence to produce a further growth spurt
and skeletal maturation
© Cengage Learning 2016
Obesity
• Approximately one in six children and
adolescents (aged 2-19) in North America
are obese
• Childhood obesity is a chronic medical
condition
– Is severely stigmatized in North American
society and carries many social and health
hazards
– Significantly affects children’s psychological
and physical development
© Cengage Learning 2016
Calculation of a Child’s BMI
© Cengage Learning 2016
Prevalence and Development
• In U.S. and Canada, obesity rate nearly
tripled for boys age 7-13 and more than
doubled for girls between the early 1980s
to mid-2000s
• Worldwide, prevalence of childhood
overweight and obesity has increased
from 4.2% in 1990 to 6.7% in 2010
© Cengage Learning 2016
Risks
• Risks include cardiovascular problems,
diabetes, and elevated cholesterol and
triglycerides
– Obesity is a major factor in reducing life
expectancy in North America
– Preadolescent obesity is a risk factor in the
later emergence of eating disorders
© Cengage Learning 2016
Prevalence of Obese Children in the U.S.
© Cengage Learning 2016
Culture and Socioeconomic Status
• Among U.S. children and adolescents
– Hispanic boys are significantly more likely to
be obese than non-Hispanic White boys
– Non-Hispanic black girls are significantly more
likely to be obese than non-Hispanic White
girls
• U.S. has the highest percentage of
overweight children in data comparing 15
industrialized countries
© Cengage Learning 2016
Culture and Socioeconomic Status (cont’d.)
• Problems for low-income populations
– Low cost and availability of fast food and junk
food
– Diminished physical activities due to living in
unsafe neighborhoods
© Cengage Learning 2016
Causes
• Heritability accounts for a substantial
portion of the variance in obesity
– Leptin hormone carries instructions to the
brain to regulate energy and appetite
• Parents determine food availability, and
they model an approach to exercise and
diet
• Family disorganization plays a role
– Poor communication, lack of perceived family
support, and sexual and physical abuse
© Cengage Learning 2016
Treatment
• Prevention or intervention of childhood
obesity involves the individual’s health and
family resources
– Restricting diets are not usually
recommended
• Treatment should:
– Address the parents’ knowledge of nutrition
– Increase the child’s physical activity
– Should instill active, less sedentary routines
for both parents and child
© Cengage Learning 2016
Feeding and Eating Disorders
• Feeding and eating disorders that occur
during infancy or early childhood constitute
a general diagnostic category
– Avoidant/restrictive food intake disorder
– Pica
© Cengage Learning 2016
Avoidant/Restrictive Food Intake Disorder
• Characterized by a sudden or marked
deceleration of weight gain and a slowing
or disruption of emotional and social
development prior to age 6
• Prevalence and development
– Affects up to one-third of young children
– Equally common among boys and girls
– Many factors lead to the initial problem
• There is no typical developmental outcome
© Cengage Learning 2016
Causes and Treatment
• Many interacting risk factors influence a
child’s adaptation to a certain level of
caloric intake
• Failure to thrive (FTT) may result from
deprivation of maternal stimulation and
love
© Cengage Learning 2016
Causes and Treatment (cont’d.)
• Avoidant/restrictive food intake disorder is
associated with:
– Family disadvantage, poverty, unemployment,
social isolation, parental mental illness, and
maternal eating disorders (specific risk factor)
• Treatment involves detailed assessment of
feeding behavior and parent-child
interactions, while allowing parents to play
a role in the infant’s recovery
© Cengage Learning 2016
Pica
• Ingestion of inedible, nonnutritive
substances (e.g., hair, insects, and paint)
for a period of at least one month
• Affects mostly very young children and
those with intellectual disability
• May be life-threatening if it continues into
adolescence
© Cengage Learning 2016
Prevalence and Development
• Pica is more prevalent among
institutionalized children and adults
– Especially those with severe impairments and
mental retardation
• Affects 0.3-14.4% of children and adults
with intellectual disabilities
– 9-25% of those in institutions
© Cengage Learning 2016
Causes and Treatment
•
•
•
•
Specific causes have not been isolated
Vitamin or mineral deficiency
No evidence of genetic factors
Can be a serious and substantial problem
– Risk of lead poisoning or intestinal obstruction
• Treatments are based on operant
conditioning procedures and teaching
caregivers to keep the child’s environment
tidy and removing dangerous substances
© Cengage Learning 2016
Eating Disorders of Adolescence
• Two important periods of adolescence for
eating disorders
– Early passage into adolescence
– Transition from later adolescence to young
adulthood
• Childhood risk factors (eating problems,
dieting patterns, and negative body image)
– May cause teens to exert excessive control
over their eating as a way to manage stress
and physical changes
© Cengage Learning 2016
Anorexia Nervosa
• Characterized by refusal to maintain
minimally normal body weight; intense fear
of gaining weight; and significant
disturbance in perception and experiences
of body size
• DSM-5 subtypes
– Restricting type - individual loses weight
through diet, fasting, or excessive exercise
– Binge-eating/purging type
© Cengage Learning 2016
Diagnostic Criteria for Anorexia Nervosa
© Cengage Learning 2016
Bulimia Nervosa
• Much more common than anorexia
• Primary feature is recurrent binge eating
• Binges are followed by compensatory
behaviors (intended to prevent weight
gain) in the form of two subtypes:
– Purging
– Non-purging
© Cengage Learning 2016
Diagnostic Criteria for Bulimia Nervosa
© Cengage Learning 2016
Diagnostic Criteria for Bulimia Nervosa
(cont’d.)
© Cengage Learning 2016
Bulimia Nervosa (cont’d.)
• Thinking is rigid and absolutistic (all or
nothing attitude)
– The individual either feels completely in
control or completely out of control
• Medical consequences are severe, but not
as severe as consequences resulting from
anorexia
© Cengage Learning 2016
Binge Eating Disorder
• Similar to bulimia without the
compensatory behaviors
– Involves periods of eating more than other
people would, accompanied by feeling of loss
of control
– Affects 1.5%-3% of adolescents
– Has negative health correlates
© Cengage Learning 2016
Diagnostic Criteria for Binge Eating
Disorder
© Cengage Learning 2016
Prevalence and Development
• Prevalence of anorexia nervosa and
bulimia among adolescents is 0.3% and
0.9%, respectively
• Persons with anorexia are 15% or more
below normal weight and engage in binge
eating only occasionally
• Those with bulimia are within 10% of
normal weight and binge frequently; then
purge to control their weight
© Cengage Learning 2016
Prevalence and Development (cont'd.)
• Eating disorders among boys
– More common than originally believed
– Young men place emphasis being muscular
• Sexual orientation and eating disorders
– Gay men are at greater risk for behavioral
symptoms of eating disorders compared to
heterosexual men
© Cengage Learning 2016
Ethnic and Cross-Cultural Considerations
• Anorexia occurs around the world,
although it may manifest differently
• Bulimia is a culture-bound syndrome
– Arising predominately in Western regions of
the world
• Higher SES for women was considered a
risk factor in the past
– Upon reaching a certain level of affluence, the
association between high SES and eating
disorders may no longer exist
© Cengage Learning 2016
Developmental Course
• Onset of anorexia is usually between ages
14 and 18
– Often begins with dieting - gradually leads to
life-threatening starvation (5% mortality rate)
– Fewer than one-half show full recovery; onethird show fair improvement, and one-fifth
continue on a chronic course
• Worse outcomes are correlated with:
– Longer illness duration; bingeing and purging;
and comorbid affective or anxiety disorders
© Cengage Learning 2016
Developmental Course (cont’d.)
• Onset of bulimia is in late adolescence
and young adulthood
• Binge eating often develops during or after
a period of restrictive dieting
• May follow a chronic course or occur
intermittently
© Cengage Learning 2016
Developmental Course (cont’d.)
• Between 50-75% of patients with bulimia
show full recovery over several years
• Disordered eating tends to decline in early
adulthood
– Body dissatisfaction remains an issue for
many young adults
© Cengage Learning 2016
Causes
• Single best predictor or risk for developing
an eating disorder is being an adolescent
female
• Biological and environmental variables are
inextricably linked
• Biological dimension - may contribute to
the maintenance of the disorder
• Genetic and constitutional factors
– Eating disorders run in families
© Cengage Learning 2016
Causes (cont’d.)
• Neurobiological factors
– Imbalances of serotonin, which regulates
hunger and appetite, may be implicated
– Biochemical similarities have been found
between people with eating disorders and
those with OCD
• Social dimension
– Features of contemporary Western culture
may be implicated in eating disorders
© Cengage Learning 2016
Causes (cont’d.)
• Sociocultural factors
– Western culture self-worth, happiness, and
success are determined primarily by physical
appearance
– Teenage girls - weight loss and being skinny
are more important than sexual issues,
alcohol and drug abuse, mental health,
disease, and environmental issues
– Mass media influences perceptions of body
dissatisfaction
© Cengage Learning 2016
Causes (cont’d.)
• Family influences
– Teen’s eating disorder may be functional
• Directing attention away from basic family conflicts
– Family processes may contribute to an
overemphasis on weight and dietary control
– Child sexual abuse may be a risk factor for
eating disorders, especially bulimia
• General risk factor for psychopathology, rather
than specific risk factor for eating disorders
© Cengage Learning 2016
Causes (cont’d.)
• Psychological dimension
– Hilda Bruch stated that eating disorders are
related to struggle for autonomy, competence,
control, and self-respect
– Arthur Crisp considers anorexia to be a type
of phobic avoidance disorder, in which the
phobic objects are normal adult body weight
and shape
– Mood disorder is often comorbid with anorexia
© Cengage Learning 2016
Psychological Dimension (cont'd.)
• Bulimia is associated with:
– Mood swings, poor impulse control,
obsessive-compulsive behaviors, major
depression, anxiety disorders, and substance
abuse
• Almost 90% of persons with eating
disorders have other Axis I disorders
– Usually depression, anxiety, or OCD
© Cengage Learning 2016
Psychological Dimension (cont'd.)
• Discrepancy between one’s actual self and
one’s ideal self increases the likelihood of
eating problems, especially among women
• The adolescent with bulimia or anorexia
feels:
– Efforts to restrict diet and lose weight are
ways of gaining control over her life and of
becoming a better person
© Cengage Learning 2016
A Dynamic Perspective on the Determinants
of Eating Disorders
© Cengage Learning 2016
Treatment
• Psychological interventions: individual
and/or family-based psychotherapy,
sometimes accompanied by medical
interventions
– Effectiveness is weak, especially for anorexia
nervosa
– Efficacy of cognitive-behavioral approaches
focusing on modifying abnormal eating
behaviors underlying bulimia
– Most can be managed as outpatients
© Cengage Learning 2016
Treatment (cont'd.)
• Hospitalization (usually brief) is necessary
for those who:
– Have serious complications due to comorbid
diagnosis or
– Are at high physical and/or psychiatric risk
• Pharmacological antidepressants (not for
initial treatment) and SSRIs may be helpful
for bulimia, but not anorexia
– Should be used in conjunction with CBT, not
just medication by itself
© Cengage Learning 2016
Treatment (cont’d.)
• Psychosocial interventions
– Comprehensive treatment plans with an
internist, a psychotherapist, a nutritionist, and
a psychopharmacologist are more effective
than medications alone
– Resolution of family and interpersonal
problems are crucial to recovery from an
eating disorder
© Cengage Learning 2016
Treatment (cont’d.)
• Anorexia is generally less responsive to
treatment than bulimia
– Initial phase - restoring weight and monitoring
of any medical complications
– In a study comparing CBT and specialist
supportive clinical management treatments
• Both groups reported improvements in quality of
life and social adjustment
– Family interventions are often required to
restore healthy communication patterns
© Cengage Learning 2016
Treatment (cont’d.)
• Bulimia
– Individual or family oriented CBT works to
change eating behaviors with rewards and
modeling
• Helps patients change distorted or rigid thinking
patterns
• Addresses underlying interpersonal issues
– Interpersonal therapy addresses situational
and personal issues contributing to the
development and maintenance of the disorder
© Cengage Learning 2016