Eating Disorders
Chapter 11
Slides & Handouts by Karen Clay Rhines, Ph.D.
American Public University System
Comer, Abnormal Psychology, 8e
DSM-5 Update
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
Comer, Abnormal Psychology, 8e
DSM-5 Update
2
Eating Disorders

A third disorder – binge eating disorder –
also appears to be on the rise

Fear of weight gain is not to the same degree as
with anorexia or bulimia

People with this disorder display many of the
other features found in those disorders
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Anorexia Nervosa

About 90%–95% of cases occur in females

The peak age of onset is between 14 and 18 years

Between 0.5% and 3.5% of females in Western
countries develop the disorder


Many more display at least some symptoms
Rates of anorexia nervosa are increasing in North
America, Europe, and Japan
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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


Assessed using an adjustable lens 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”
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Anorexia Nervosa:
The Clinical Picture

People with anorexia nervosa also display
certain psychological problems:







Depression
Anxiety
Low self-esteem
Insomnia or other sleep disturbances
Substance abuse
Obsessive-compulsive patterns
Perfectionism
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Anorexia Nervosa:
Medical Problems

Caused by starvation:

Amenorrhea

Slow heart rate

Low body temperature


Low blood pressure
Metabolic and
electrolyte imbalances

Dry skin, brittle nails

Poor circulation

Lanugo


Body swelling
Reduced bone density
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Bulimia Nervosa

Bulimia nervosa, also known as “bingepurge syndrome,” is characterized by
binges:

Repeated bouts of uncontrolled overeating
during a limited period of time

Eat objectively more than most people would/could
eat in a similar period
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Bulimia Nervosa

The disorder is also characterized by
inappropriate compensatory behaviors,
including:

Forced vomiting

Misusing laxatives, diuretics, or enemas

Fasting

Exercising excessively
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Bulimia Nervosa

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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Bulimia Nervosa

Patients are generally of normal weight

Often experience marked weight fluctuations

Some may also qualify for a diagnosis of
anorexia
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Bulimia Nervosa

Many teenagers and young adults go on
occasional binges or experiment with
vomiting or laxatives after hearing about these
behaviors from friends or the media

According to global studies, 25-50% of
students report periodic binge-eating or selfinduced vomiting

Only some of these individuals qualify for a
diagnosis of bulimia nervosa
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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 as
many as 10,000 calories per binge episode
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Bulimia Nervosa: Binges

Binges are usually preceded by feelings of
great tension

Although the binge itself may be
pleasurable, it is usually followed by
feelings of extreme self-blame, guilt,
depression, and fears of weight gain and
being discovered
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Bulimia Nervosa:
Compensatory Behaviors

After a binge, people with bulimia nervosa
try to compensate for and “undo” the
caloric effects

Many resort to 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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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…
Comer, Abnormal Psychology, 8e
DSM-5 Update
21
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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Binge Eating Disorder

Like those with bulimia, individuals with binge
eating disorder engage in repeated eating binges
during which they feel no control


These individuals do not perform inappropriate
compensatory behaviors
As a result of their binges, two-thirds of people
with this disorder become overweight or obese

It is important to recognize, however, that most
overweight people do not engage in repeated binges
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Binge Eating Disorder



Between 2 and 7% of the population display
binge eating disorder
The binges and many other symptoms that
characterize this pattern are similar to those
seen in bulimia
On the other hand, those with binge eating
disorder are not driven to thinness, the
disorder doesn’t start following a diet, and
there are not large gender differences in the
prevalence of this disorder
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Biological factors
Sociocultural conditions
Comer, Abnormal Psychology, 8e
DSM-5 Update
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What Causes Eating Disorders?
Psychodynamic Factors: Ego Deficiencies

Hilde Bruch developed a largely
psychodynamic theory of eating disorders

Bruch 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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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What Causes Eating Disorders?
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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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What Causes Eating Disorders?
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 self-judgment based on
body shape and weight)
Comer, Abnormal Psychology, 8e
DSM-5 Update
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What Causes Eating Disorders?
Depression

Many people with eating disorders,
particularly those with bulimia nervosa,
experience symptoms of depression

Theorists believe depressive disorders may “set
the stage” for eating disorders
Comer, Abnormal Psychology, 8e
DSM-5 Update
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What Causes Eating Disorders?
Depression

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 depressive disorders
People with eating disorders, especially those with
bulimia nervosa, have serotonin abnormalities
Symptoms of eating disorders are helped by
antidepressant medications
Comer, Abnormal Psychology, 8e
DSM-5 Update
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What Causes Eating Disorders?
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
Comer, Abnormal Psychology, 8e
DSM-5 Update
34
What Causes Eating Disorders?
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)
Comer, Abnormal Psychology, 8e
DSM-5 Update
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What Causes Eating Disorders?
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
Comer, Abnormal Psychology, 8e
DSM-5 Update
36
What Causes Eating Disorders?
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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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What Causes Eating Disorders?
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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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What Causes Eating Disorders?
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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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What Causes Eating Disorders?
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
Comer, Abnormal Psychology, 8e
DSM-5 Update
40
What Causes Eating Disorders?
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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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What Causes Eating Disorders?
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
Comer, Abnormal Psychology, 8e
DSM-5 Update
42
What Causes Eating Disorders?
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
Comer, Abnormal Psychology, 8e
DSM-5 Update
43
What Causes Eating Disorders?
Multicultural Factors:
Racial and Ethnic Differences

Unfortunately, research conducted over the
past decade suggests that body image
concerns, dysfunctional eating patterns,
and eating disorders are on the rise among
young African American women as well as
among women of other minority groups

The shift appears to be partly related to
acculturation
Comer, Abnormal Psychology, 8e
DSM-5 Update
44
What Causes Eating Disorders?
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
Comer, Abnormal Psychology, 8e
DSM-5 Update
45
What Causes Eating Disorders?
Multicultural Factors:
Gender 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
Comer, Abnormal Psychology, 8e
DSM-5 Update
46
What Causes Eating Disorders?
Multicultural Factors:
Gender 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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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What Causes Eating Disorders?
Multicultural Factors:
Gender 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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
49
Treatments for
Anorexia Nervosa

The immediate aims of treatment for
anorexia nervosa are to:

Regain lost weight

Recover from malnourishment

Eat normally again
Comer, Abnormal Psychology, 8e
DSM-5 Update
50
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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Treatments for
Anorexia Nervosa

Therapists use a combination of therapy
and education to achieve this broader goal,
using a combination of individual, group,
and family approaches; psychotropic drugs
have been helpful in some cases
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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”
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Treatments for
Anorexia Nervosa

Family therapy is important for anorexia
nervosa treatment

The main issues are often separation and
boundaries
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Treatments for
Anorexia Nervosa

Positives 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 seems to
be falling
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Treatments for
Anorexia Nervosa

Negatives of treatment:

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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Treatments for
Bulimia Nervosa

Cognitive-behavioral therapy is particularly
helpful:

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
Comer, Abnormal Psychology, 8e
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Treatments for
Bulimia Nervosa

Other forms of psychotherapy

If clients do not respond to cognitivebehavioral 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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
65
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
Comer, Abnormal Psychology, 8e
DSM-5 Update
66
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
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DSM-5 Update
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Treatments for Binge Eating
Disorder

Given the key role of binges in both bulimia
and binge eating disorder, treatments, too, are
often similar


Cognitive-behavior therapy, other forms of
psychotherapy, and, in some cases, antidepressant
medications are provided to reduce or eliminate
binge patterns and to change disturbed thinking
People with binge eating disorder who are
overweight require additional intervention
Comer, Abnormal Psychology, 8e
DSM-5 Update
68
Treatments for Binge Eating
Disorder

Now that binge eating disorder has been
identified and is receiving considerable
study, it is likely that specialized treatment
programs will be emerging

In the meantime, little is known about the
aftermath of the disorder
Comer, Abnormal Psychology, 8e
DSM-5 Update
69