Eating Disorders

It has not always done so, but Western society
today equates thinness with health and beauty


There has been a rise in eating disorders in the
past three decades


Thinness has become a national obsession
The core issue is a morbid fear of weight gain
Two main diagnoses:
Anorexia
nervosa
Bulimia
nervosa
Anorexia Nervosa

The main symptoms of
anorexia nervosa are:
A refusal to maintain more
than 85% of normal body
weight
 Intense fears of becoming
overweight
 Distorted view of weight and
shape
 Amenorrhea

Anorexia Nervosa

There are two main subtypes:

Restricting type



Lose weight by cutting out sweets and fattening snacks,
eventually eliminating nearly all food
Show almost no variability in diet
Binge-eating/purging type


Lose weight by forcing themselves to vomit after meals or by
abusing laxatives or diuretics
Like those with bulimia nervosa, people with this subtype may
engage in eating binges
Anorexia Nervosa

The “typical” case:
A normal to slightly overweight female has been on a
diet
 Escalation toward anorexia nervosa may follow a
stressful event





Separation of parents
Move away from home
Experience of personal failure
Most patients recover

However, about 2% to 6% become seriously ill and die as a
result of medical complications or suicide
Anorexia Nervosa: The Clinical Picture

The key goal for people with anorexia nervosa is
becoming thin

The driving motivation is fear:



Of becoming obese
Of giving in to the desire to eat
Of losing control of body size and shape
Anorexia Nervosa: The Clinical Picture

Despite their dietary restrictions, people with
anorexia nervosa are preoccupied with food
This includes thinking and reading about food and
planning for meals
 This relationship is not necessarily causal


It may be the result of food deprivation, as evidenced by the
famous 1940s “starvation study” with conscientious objectors
Anorexia Nervosa: The Clinical Picture

Persons with anorexia nervosa also think in
distorted ways:
Usually have a low opinion of their body shape
 Tend to overestimate their actual proportions



Adjustable lens assessment technique
Hold maladaptive attitudes and misperceptions



“I must be perfect in every way”
“I will be a better person if I deprive myself”
“I can avoid guilt by not eating”
Anorexia Nervosa: The Clinical Picture

People with anorexia nervosa also display certain
psychological problems:
Depression (usually mild)
Anxiety
Low self-esteem
Insomnia or other sleep disturbances
Substance abuse
Obsessive-compulsive patterns
Perfectionism
Anorexia Nervosa: Medical Problems

Caused by starvation:
Amenorrhea
Low body
temperature
Low blood
pressure
Body swelling
Reduced
bone density
Slow heart
rate
Metabolic and
electrolyte
imbalances
Dry skin,
brittle nails
Poor
circulation
Lanugo
Bulimia Nervosa

Bulimia nervosa, also known as “binge-purge
syndrome,” is characterized by binges:

Bouts of uncontrolled overeating during a limited period
of time

Eat objectively more than most people would/could eat in a
similar period
Bulimia Nervosa

The “typical” case:
A normal to slightly overweight female has been on an
intense diet
 Research suggests that even among normal
participants, bingeing often occurs after strict dieting




Like anorexia nervosa, about 90%–95% of
bulimia nervosa cases occur in females
The peak age of onset is between 15 and 21
years
Symptoms may last for several years with
periodic letup
Bulimia Nervosa

The disorder is also
characterized by
inappropriate compensatory
behaviors, which mark the
subtype of the condition:

Purging-type bulimia nervosa



Forced vomiting
Misusing laxatives, diuretics, or
enemas
Nonpurging-type bulimia
nervosa


Fasting
Exercising frantically
Bulimia Nervosa

Patients are generally of normal weight
Often experience marked weight fluctuations
 Some may also qualify for a diagnosis of anorexia


“Binge-eating disorder” is a related diagnosis

Symptoms include a pattern of binge eating with NO
compensatory behaviors (such as vomiting)
Bulimia Nervosa: Binges


People with bulimia nervosa may have between 1
and 30 binge episodes per week
Binges are often carried out in secret

Binges involve eating massive amounts of food very
rapidly with little chewing


Usually sweet, high-calorie foods with soft texture
Binge-eaters commonly consume between 1,000 and
10,000 calories per binge episode
Overlapping Patterns Of Anorexia Nervosa,
Bulimia Nervosa, And Obesity
Bulimia Nervosa: Binges


Binges are usually preceded by feelings of great
tension and/or powerlessness
Although the binge itself may be pleasurable, it is
usually followed by feelings of extreme selfblame, guilt, depression, and fears of weight gain
and being discovered
Bulimia Nervosa: Compensatory Behaviors


After a binge, people with bulimia nervosa try to
compensate for and “undo” the caloric effects
The most common compensatory behaviors:

Vomiting



Fails to prevent the absorption of half the calories consumed
during a binge
Repeated vomiting affects the ability to feel satiated  greater
hunger and bingeing
Laxatives and diuretics

Also largely fails to reduce the number of calories consumed
Bulimia Nervosa: Compensatory Behaviors

Compensatory behaviors may temporarily relieve
the negative feelings attached to binge eating

Over time, however, a cycle develops in which purging
 bingeing  purging…
Bulimia Nervosa vs. Anorexia Nervosa
Similarities:
•
•
•
•
•
•
•
•
•
Begin after a period of dieting
Fear of becoming obese
Drive to become thin
Preoccupation with food, weight, appearance
Feelings of anxiety, depression, obsessiveness,
perfectionism
Heighted risk of suicide attempts
Substance abuse
Distorted body perception
Disturbed attitudes toward eating
Bulimia Nervosa vs. Anorexia Nervosa
Differences:
• People with bulimia nervosa are more
concerned about pleasing others, being
attractive to others, and having intimate
relationships
• People with bulimia nervosa tend to be more
sexually experienced and active
• People with bulimia nervosa are more likely
to have histories of mood swings, low
frustration tolerance, and poor coping
Bulimia Nervosa vs. Anorexia Nervosa
Differences:
• More than one-third of people with bulimia
display characteristics of a personality disorder,
particularly borderline personality disorder
• Different medical complications:
• Only half of women with bulimia nervosa
experience amenorrhea vs. almost all women
with anorexia nervosa
• People with bulimia nervosa suffer damage
caused by purging, especially from vomiting
and laxatives
Binge Eating Disorder



Repeated eating binges
during which they feel no
control over their eating
These individuals do not
perform inappropriate
compensatory behavior
As a result of their
frequent binges, around
two-thirds of people with
binge eating disorder
become overweight or
even obese
What Causes Eating Disorders?

Most theorists and researchers use a
multidimensional risk perspective to explain
eating disorders:
Several key factors place individuals at risk
 More factors = greater likelihood of developing a
disorder
 Leading factors:




Psychological problems (ego, cognitive, and mood disturbances)
Biological factors
Sociocultural conditions (societal, family, and multicultural
pressures)
Psychodynamic Factors: Ego Deficiencies

Hilde Bruch developed a largely psychodynamic
theory of eating disorders

Argued that eating disorders are the result of disturbed
mother–child interactions, which lead to serious ego
deficiencies in the child and to severe perceptual
disturbances
Psychodynamic Factors: Ego Deficiencies

Bruch argues that parents may respond to their
children either effectively or ineffectively
Effective parents accurately attend to a child's biological
and emotional needs
 Ineffective parents fail to attend to child's needs; they
feed when the child is anxious, comfort when the child
is tired, etc.



Such children may grow up confused and unaware of their own
internal needs and turn, instead, to external guides
Clinical reports and research have provided some
empirical support for this theory
Cognitive Factors

Bruch's theory also contains several cognitive
factors, like improper labeling of internal
sensations and needs

According to cognitive theorists, these deficiencies
contribute to a broad cognitive distortion that lies at the
center of disordered eating (e.g., negative selfjudgment based on body shape and weight)
Mood Disorders

Many people with eating disorders, particularly
those with bulimia nervosa, experience symptoms
of depression

Theorists believe mood disorders may “set the stage”
for eating disorders
Mood Disorders

There is empirical support for the claim that mood
disorders set the stage for eating disorders:
Many more people with an eating disorder qualify for a
clinical diagnosis of major depressive disorder than do
people in the general population
 Close relatives of those with eating disorders seem to
have higher rates of mood disorders
 People with eating disorders, especially those with
bulimia nervosa, have serotonin abnormalities
 Symptoms of eating disorders are helped by
antidepressant medications

Biological Factors

Biological theorists suspect certain genes may
leave some people particularly susceptible to
eating disorders

Consistent with this idea:






Relatives of people with eating disorders are up to 6 times more
likely to develop the disorder themselves
Identical (MZ) twins with anorexia: 70%
Fraternal (DZ) twins with anorexia: 20%
Identical (MZ) twins with bulimia: 23%
Fraternal (DZ) twins with bulimia: 9%
These findings may be related to low serotonin
Biological Factors

Other theorists believe that eating disorders may
be related to dysfunction of the hypothalamus

Researchers have identified two separate areas that
control eating:


Lateral hypothalamus (LH)
Ventromedial hypothalamus (VMH)
Biological Factors

Some theorists believe that the hypothalamus,
related brain areas, and chemicals together are
responsible for weight set point – a “weight
thermostat” of sorts

Set by genetic inheritance and early eating practices,
this mechanism is responsible for keeping an individual
at a particular weight level



If weight falls below set point:  hunger,  metabolic rate 
binges
If weight rises above set point:  hunger,  metabolic rate
Dieters end up in a battle against themselves to lose
weight
Societal Pressures

Many theorists believe that current Western
standards of female attractiveness are partly
responsible for the emergence of eating disorders

Western standards have changed throughout history
toward a thinner ideal


Miss America contestants have declined in weight by 0.28 lbs/yr;
winners have declined by 0.37 lbs/yr
Playboy centerfolds have lower average weight, bust, and hip
measurements than in the past
Societal Pressures

Members of certain subcultures are at greater risk
from these pressures:

Models, actors, dancers, and certain athletes


Of college athletes surveyed, 9% met full criteria for an eating
disorder while another 50% had symptoms
20% of surveyed gymnasts appear to have an eating disorder
Societal Pressures

Societal attitudes may explain economic and
racial differences seen in prevalence rates

Historically, women of higher SES expressed more
concern about thinness and dieting


These women had higher rates of eating disorders than women
of the lower socioeconomic classes
Recently, dieting and preoccupation with thinness,
along with rates of eating disorders, are increasing in all
groups
Societal Pressures

The socially accepted prejudice against
overweight people may also add to the “fear” and
preoccupation about weight
About 50% of elementary and 61% of middle school
girls are currently dieting
 A recent survey of adolescent girls tied eating disorders
and body dissatisfaction to social networking, Internet
activities, and television browsing

Family Environment

Families may play an important role in the
development of eating disorders
As many as half of the families of those with eating
disorders have a long history of emphasizing thinness,
appearance, and dieting
 Mothers of those with eating disorders are more likely
to be dieters and perfectionistic themselves

Family Environment

Abnormal interactions and forms of
communication within a family may also set the
stage for an eating disorder

Influential family theorist Salvador Minuchin cites
“enmeshed family patterns” as causal factors of eating
disorders

These patterns include overinvolvement in, and overconcern
about, family member's lives
Multicultural Factors: Racial and Ethnic
Differences

A widely publicized 1995 study found that eating
behaviors and attitudes of young African
American women were more positive than those
of young white American women
Specifically, nearly 90% of the white American
respondents were dissatisfied with their weight and
body shape, compared to around 70% of the African
American teens
 The study also suggested that the groups had different
ideals of beauty

Multicultural Factors: Racial and Ethnic
Differences


Eating disorders among Hispanic American
female adolescents are about equal to those of
white American women
Eating disorders also appear to be on the
increase among Asian American women and
young women in several Asian countries
Multicultural Factors: Racial and Ethnic
Differences



Males account for only 5% to 10% of all cases of
eating disorders
The reasons for this striking difference are not
entirely clear, but Western society's double
standard for attractiveness is, at the very least,
one reason
A second reason may be the different methods of
weight loss favored:
Men are more likely to exercise
 Women more often diet

Multicultural Factors: Racial and Ethnic
Differences

It seems that some men develop eating disorders
as linked to the requirements and pressures of a
job or sport

The highest rates of male eating disorders have been
found among:





Jockeys
Wrestlers
Distance runners
Body builders
Swimmers
Multicultural Factors: Racial and Ethnic
Differences


For other men, body image appears to be a key
factor
Last, some men seem to be caught up in a new
kind of eating disorder – reverse anorexia
nervosa or muscle dysmorphobia
How Are Eating Disorders Treated?

Eating disorder treatments have two main goals:
Correct dangerous eating patterns
 Address broader psychological and situational factors
that have led to, and are maintaining, the eating
problem


This often requires the participation of family and friends
Treatments for Anorexia Nervosa

The immediate aims of treatment for anorexia
nervosa are to:
Regain lost weight
 Recover from malnourishment
 Eat normally again

Treatments for Anorexia Nervosa


In the past, treatment took place in a hospital
setting; it is now often offered in day hospitals or
outpatient settings
In life-threatening cases, clinicians may need to
force tube and intravenous feedings on the
patient
This may breed distrust in the patient and create a
power struggle
 In contrast, behavioral weight-restoration approaches
have clinicians use rewards whenever patients eat
properly or gain weight

Treatments for Anorexia Nervosa

The most popular weight-restoration technique
has been the combination of supportive nursing
care, nutritional counseling, and high-calorie diets


Necessary weight gain is often achieved in 8 to 12
weeks
Researchers have found that people with
anorexia nervosa must overcome their underlying
psychological problems to achieve lasting
improvement
Treatments for Anorexia Nervosa

In most treatment programs, a combination of
behavioral and cognitive interventions are
included
On the behavioral side, clients are required to monitor
feelings, hunger levels, and food intake and the ties
among those variables
 On the cognitive sides, they are taught to identify their
“core pathology”

Treatments for Anorexia Nervosa



Therapists help patients recognize their need for
independence and control
Therapists help patients recognize and trust their
internal feelings
A final focus of treatment is helping clients
change their attitudes about eating and weight


Using cognitive approaches, therapists correct
disturbed cognitions and educate about body distortions
Family therapy is important for anorexia nervosa
treatment

The main issues are often separation and boundaries
Treatments for Anorexia Nervosa

The use of combined treatment approaches has
greatly improved the outlook for people with
anorexia nervosa


But even with combined treatment, recovery is difficult
The course and outcome of the disorder vary
from person to person
Treatments for Anorexia Nervosa
Positives of treatment:
Negatives of treatment:
• Weight gain is often quickly
restored
• As many as 90% of patients
still showed improvements
after several years
• Menstruation often returns
with return to normal weight
• The death rate from anorexia
nervosa is declining
• As many as 25% of patients
remain troubled for years
• Even when it occurs, recovery
is not always permanent
• Anorexic behavior recurs in
at least one-third of
recovered patients, usually
triggered by new stresses
• Many patients still express
concerns about their weight
and appearance
• Lingering emotional problems
are common
Treatments for Bulimia Nervosa


Treatment is frequently offered in eating disorder
clinics
The immediate aims of treatment for bulimia
nervosa are to:
Eliminate binge-purge patterns
 Establish good eating habits
 Eliminate the underlying cause of bulimic patterns


Programs emphasize education as much as
therapy
Treatments for Bulimia Nervosa

Cognitive-behavioral therapy is particularly
helpful:

Behavioral techniques



Diaries are often a useful component of treatment
Exposure and response prevention (ERP) is used to break the
binge-purge cycle
Cognitive techniques


Help clients recognize and change their maladaptive attitudes
toward food, eating, weight, and shape
Typically teach individuals to identify and challenge the negative
thoughts that precede the urge to binge
Treatments for Bulimia Nervosa

Other forms of psychotherapy
If clients do not respond to cognitive-behavioral therapy,
other approaches may be tried
 A common alternative is interpersonal therapy (IPT); a
treatment that seeks to improve interpersonal
functioning may be tried
 Psychodynamic therapy has also been used

Treatments for Bulimia Nervosa

Other forms of psychotherapy

Various forms of psychotherapy are often supplemented
by family therapy and may be offered in either individual
or group therapy format


Group formats provide an opportunity for patients to express
their thoughts, concerns, and experiences with one another
Group therapy is helpful in as many as 75% of cases
Treatments for Bulimia Nervosa

Antidepressant medications

During the past 15 years, all groups of antidepressant
drugs have been used in bulimia nervosa treatment


Drugs help as many as 40% of patients
Medications are best when used in combination with
other forms of therapy
Treatments for Bulimia Nervosa


Left untreated, bulimia nervosa can last for years
Treatment provides immediate, significant
improvement in about 40% of cases


An additional 40% show moderate response
Follow-up studies suggest that 10 years after
treatment about 75% of patients have fully or
partially recovered
Treatments for Bulimia Nervosa

Relapse can be a significant problem, even
among those who respond successfully to
treatment
Relapses are usually triggered by stress
 Relapses are more likely among persons who:





Had a longer history of symptoms
Vomited frequently
Had histories of substance use
Have lingering interpersonal problems