Abnormal Psychology
Fifth Edition
Oltmanns and Emery
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Chapter Ten
Eating Disorders
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Chapter Outline
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Symptoms of Anorexia
Symptoms of Bulimia
Diagnosis of Eating Disorders
Frequency of Eating Disorders
Causes of Eating Disorders
Treatment of Anorexia Nervosa
Treatment of Bulimia Nervosa
Prevention of Eating Disorders
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Overview
• Eating disorders are severe disturbances in
eating behavior that result from the sufferer’s
obsessive fear of gaining weight.
• DSM-IV-TR lists two major types of eating
disorders: anorexia nervosa and bulimia
nervosa.
• The most obvious characteristic of anorexia
nervosa is extreme emaciation, or more
technically, the refusal to maintain a minimally
normal body weight.
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Overview
• Bulimia nervosa is characterized by
repeated episodes of binge eating, followed
by inappropriate compensatory behaviors
such as self-induced vomiting, misuse of
laxatives, or excessive exercise.
• Both anorexia and bulimia are about 10
times more common among females than
males, and they develop most commonly
among women in their teens and early
twenties.
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Symptoms of Anorexia
Refusal to Maintain a Normal Weight
• The most obvious and most dangerous symptom
of anorexia nervosa is a refusal to maintain a
minimally normal body weight.
• Anorexia nervosa often begins with a diet to lose
just a few pounds.
• The young woman weighs near her healthy body
weight, and she decides to lose a little weight,
perhaps to fit into some new clothes.
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Symptoms of Anorexia
Refusal to Maintain a Normal Weight (continued)
• The diet goes awry, however, and losing
weight eventually becomes the key focus.
• Weight falls well below the normal range, and
often plummets to dangerously low levels.
• DSM-IV-TR contains no formal cutoff as to
how thin is too thin, but suggests 85 percent of
expected body weight as a rough guideline.
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Symptoms of Anorexia
Disturbance in Evaluating Weight or Shape
• A second defining symptom of anorexia
nervosa is a perceptual, cognitive, or
affective disturbance in evaluating one’s
weight and shape.
• Many individuals steadfastly deny problems
with their weight.
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Symptoms of Anorexia
Disturbance in Evaluating Weight or Shape
(continued)
• Other people with the disorder suffer from a
disturbance in the way body weight or
shape is experienced.
• Sometimes this may include a distorted
body image, an inaccurate perception of
body size and shape.
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Symptoms of Anorexia
Disturbance in Evaluating Weight or Shape
(continued)
• All people with the disorder are unduly
influenced by their body weight or shape in
self-evaluation.
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Symptoms of Anorexia
Fear of Gaining Weight
• An intense fear of becoming fat is a third
central characteristic of anorexia.
• The fear may grow more intense as the
individual loses more weight.
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Symptoms of Anorexia
Cessation of Menstruation
• Amenorrhea, the absence of at least three
consecutive menstrual cycles, is the fourth and
final defining symptom of anorexia nervosa in
females.
• The amenorrhea has led to speculation about the
role of sexuality and sexual maturation in causing
anorexia nervosa.
• However, the amenorrhea typically is a reaction to
the physiological changes produced by anorexia
nervosa, specifically a low level of estrogen
secretion, and not a symptom that precedes the
disorder.
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Symptoms of Anorexia
Medical Complications
• People with anorexia commonly complain about
constipation, abdominal pain, intolerance to cold,
and lethargy.
• In addition, the skin can become dry and cracked,
and some people develop lanugo, a fine, downy
hair, on their face or trunk of their body.
• Broader medical difficulties may include anemia,
infertility, impaired kidney functioning,
cardiovascular difficulties, dental erosion, and
osteopenia (bone loss).
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Symptoms of Anorexia
Medical Complications (continued)
• A particularly dangerous medical
complication is an electrolyte imbalance, a
disturbance in the levels of potassium,
sodium, calcium, and other vital elements
found in bodily fluids.
• Electrolyte imbalance can lead to cardiac
arrest or kidney failure.
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Symptoms of Anorexia
Struggle for Control
• People with anorexia nervosa often take great
pride in their self-denial, feeling like masters of
control.
• Some theorists speculate that the disorder actually
develops out of a desperate sense of having no
control.
• Excessively compliant “good girls” may find that
obsessively regulating their diet allows them to be
in charge of at least one area of their lives.
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Symptoms of Anorexia
Comorbid Psychological Disorders
• Anorexia nervosa may be associated with other
psychological problems, particularly obsessive–
compulsive disorder, obsessive–compulsive
personality disorder, and depression.
• In many cases, however, these comorbid
psychological problems may be reactions to
anorexia, not causes of it.
• Anorexia often co-occurs with the symptoms of
bulimia.
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Symptoms of Bulimia
• Many people with bulimia nervosa have a
history of anorexia nervosa.
• Depression also is commonly associated
with the disorder.
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Symptoms of Bulimia
Binge Eating
• Binge eating is defined in DSM-IV-TR as
eating an amount of food in a fixed period
of time, for example, less than 2 hours, that
is clearly larger than most people would eat
under similar circumstances.
• Binges may be planned in advance, or they
may begin spontaneously.
• In either case, binges typically are secret.
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Symptoms of Bulimia
Binge Eating (continued)
• Binge eating is commonly triggered by an
unhappy mood, which may begin with an
interpersonal conflict, self-criticism about
weight or appearance, or intense hunger
following a period of fasting.
• A key feature of binge eating is a sense of
lack of control during a binge.
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Symptoms of Bulimia
Inappropriate Compensatory Behavior
• Almost all people with bulimia nervosa engage in
purging, designed to eliminate the consumed food
from the body.
• The most common form of purging is self-induced
vomiting; as many as 90 percent of people with
bulimia nervosa engage in this behavior.
• Other less common forms of purging include the
misuse of laxatives, diuretics (which increase the
frequency of urination), and, most rarely, enemas.
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Symptoms of Bulimia
Inappropriate Compensatory Behavior
(continued)
• Ironically, purging has only limited effectiveness
in reducing caloric intake.
• Vomiting prevents the absorption of only about
half the calories consumed during a binge, and
laxatives, diuretics, and enemas have few lasting
effects on calories or weight.
• Inappropriate compensatory behaviors other than
purging include extreme exercise or rigid fasting
following a binge.
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Symptoms of Bulimia
Excessive Emphasis on Weight and Shape
• People with bulimia nervosa place excessive
emphasis on body shape and weight in
evaluating themselves.
• Their self-esteem, and much of their daily
routine, center around weight and diet.
• The individual’s sense of self is linked too
closely to appearance instead of personality,
relationships, or achievements.
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Symptoms of Bulimia
Comorbid Psychological Disorders
• Depression is common among individuals with
bulimia nervosa, especially those who self-induce
vomiting.
• Other disorders that may co-occur with bulimia
nervosa include anxiety disorders, personality
disorders (particularly borderline personality
disorder), and substance abuse, particularly
excessive use of alcohol and/or stimulants.
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Symptoms of Bulimia
Medical Complications
• Repeated vomiting can erode dental enamel,
particularly on the front teeth, and in severe cases
teeth can become chipped and ragged looking.
• Repeated vomiting can also produce a gag reflex
that is triggered too easily and perhaps
unintentionally.
• One consequence of the sensitized gag reflex—
one that is just beginning to be reported in the
scientific literature—is rumination: the
regurgitation and rechewing of food.
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Symptoms of Bulimia
Medical Complications (continued)
• Another possible medical complication is
the enlargement of the salivary glands, a
consequence that has the ironic effect of
making the sufferer’s face appear puffy.
• Potentially serious medical complications
can result from electrolyte imbalances.
• Finally, rupture of the esophagus or stomach
has been reported in rare cases, sometimes
leading to death.
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Diagnosis of Eating Disorders
Brief Historical Perspective
• Isolated cases of eating disorders have been reported
throughout history.
• In fact, the term anorexia nervosa was coined in
1874 by a British physician, Sir William Withey
Gull.
• Still, the history of professional concern with the
disorders is very brief.
• References to eating disorders were rare in the
literature prior to 1960, and the disorders have
received scientific attention only in recent decades.
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Diagnosis of Eating Disorders
Brief Historical Perspective (continued)
• The term bulimia nervosa was used for the first
time only in 1979.
• The diagnoses of anorexia nervosa and bulimia
nervosa first appeared in DSM in 1980 (DSM-III).
• Although the diagnostic criteria have changed
somewhat, the same eating behaviors remain as
the central features of these disorders.
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Diagnosis of Eating Disorders
Contemporary Classification
• DSM-IV-TR includes two subtypes of
anorexia nervosa.
• The restricting type includes people who
rarely engage in binge eating or purging.
• In contrast, the binge eating/purging type is
defined by regular binge eating and purging
during the course of the disorder.
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Diagnosis of Eating Disorders
Contemporary Classification (continued)
• Bulimia nervosa is divided into two subtypes in
DSM-IV-TR.
• The purging type is characterized by the regular
use of self-induced vomiting or the misuse of
laxatives, diuretics, or enemas.
• The individual with the nonpurging type of
bulimia nervosa does not regularly purge but
instead attempts to compensate for binge eating
with fasting or excessive exercise.
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Diagnosis of Eating Disorders
Contemporary Classification (continued)
• There has been some debate about whether other
eating problems should be included in the DSMIV-TR list of eating disorders.
• Binge eating disorder is one problem that was
given extensive consideration.
• The proposed disorder involves episodes of binge
eating much like those found in bulimia nervosa
but without compensatory behavior.
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Diagnosis of Eating Disorders
Contemporary Classification (continued)
• Research has demonstrated that binge eating is
associated with a number of psychological and
physical difficulties other than anorexia nervosa
and bulimia nervosa.
• Among these problems is obesity, or excess body
fat, a circumstance that roughly corresponds with
a body weight 20 percent above the expected
weight.
• Calling obesity a “mental disorder” is
controversial, especially given the high prevalence
of overweight individuals in the United States and
throughout the world.
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Frequency of Eating Disorders
• Estimates of the epidemiology of anorexia
and bulimia vary, but it is clear that the
prevalence of both disorders has increased
dramatically since the 1960s and 1970s.
• DSM-IV-TR indicates that lifetime
prevalence of anorexia nervosa is 0.5
among females, a figure that is consistent
with other estimates.
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Frequency of Eating Disorders
• Recent decades also seem to have witnessed a
torrent of new cases of bulimia nervosa.
• Bulimia nervosa is far more common than
anorexia nervosa.
• According to DSM-IV-TR, bulimia nervosa occurs
among 1 to 3 percent of women, a rate that is two
to six times the number of cases of anorexia
nervosa.
• Moreover, the prevalence of subclinical bulimia—
occasional binge eating and/or purging—is far
greater than the number of cases that meet DSMIV-TR criteria for bulimia nervosa.
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Frequency of Eating Disorders
Standards of Beauty
• Popular attitudes about women in the
United States tell us that “looks are
everything,” and thinness is essential to
good looks.
• In contrast, young men are valued as much
for their achievements as for their
appearance, and, the ideal body type for
men is considerably larger than for women.
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Frequency of Eating Disorders
Standards of Beauty (continued)
• The growing prevalence of eating disorders
may be explained by changing standards of
beauty.
• Marilyn Monroe, the movie idol of the
1950s, is chunky by today’s standards.
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Frequency of Eating Disorders
Age of Onset
• Both anorexia and bulimia nervosa typically
begin in late adolescence or early
adulthood.
• A significant minority of cases of anorexia
nervosa begin during early adolescence,
particularly as girls approach puberty.
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Causes of Eating Disorders
Social Factors
• Standards of beauty and the premium
placed on young women’s appearance
contribute to causing eating disorders.
• Troubled family relationships may be
another factor that increases vulnerability.
• Young people with bulimia nervosa report
considerable conflict and rejection in their
families, difficulties that also may
contribute to their depression.
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Causes of Eating Disorders
Social Factors (continued)
• In contrast, young people with anorexia
generally perceive their families as cohesive
and nonconflictual.
• Although the families of young people with
anorexia nervosa appear to be well
functioning, some theorists see the families
as being too close—as enmeshed families,
families whose members are overly
involved in one another’s lives.
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Causes of Eating Disorders
Social Factors (continued)
• According to the enmeshment hypothesis,
young people with anorexia nervosa are
obsessed with controlling their eating,
because eating is the only thing they can
control in their intrusive families.
• Child sexual abuse is another family
difficulty that might contribute to the
development of eating disorders.
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Causes of Eating Disorders
Psychological Factors
• Hilde Bruch viewed a struggle for control as
the central psychological issue in the
development of eating disorders.
• Perfectionism is another term for the endless
pursuit of control described by Bruch.
• Perfectionists set unrealistically high
standards, are self critical, and demand a
nearly flawless performance from themselves.
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Causes of Eating Disorders
Psychological Factors (continued)
• Young people with eating disorders may
also try to control their own emotions
excessively, perhaps as a result of their
constant attempt to please others instead of
themselves.
• The result may be a lack of introceptive
awareness—recognition of internal cues,
including various emotional states as well
as hunger.
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Causes of Eating Disorders
Psychological Factors (continued)
• Depression is commonly comorbid with
eating disorders, particularly bulimia
nervosa.
• Research also shows that antidepressant
medications reduce some symptoms of
bulimia nervosa.
• Bulimia thus appears to be a reaction to
depression in some cases.
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Causes of Eating Disorders
Psychological Factors (continued)
• In other cases, however, depression may
instead be a reaction to bulimia nervosa and
especially to anorexia nervosa.
• Some experts suggest that depressive
symptoms, and not necessarily clinical
depression, play a role in the onset of eating
disorders.
• Low self-esteem is a particular concern.
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Causes of Eating Disorders
Psychological Factors (continued)
• Depressive symptoms also clearly play a
role in maintaining problematic eating
behaviors.
• Dysphoria or negative mood states
commonly trigger episodes of binge eating
in bulimia nervosa and in the bingeeating/purging subtype of anorexia nervosa.
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Causes of Eating Disorders
Psychological Factors (continued)
• A negative body image, a highly critical
evaluation of one’s weight and shape, has
long been thought to contribute to the
development of eating disorders.
• Several longitudinal studies have found
negative evaluations of weight, shape, and
appearance to predict the subsequent
development of disordered eating.
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Causes of Eating Disorders
Psychological Factors (continued)
• Some symptoms of eating disorders may be
effects of dietary restraint, that is, direct
consequences of restricted eating.
• These symptoms include binge eating,
preoccupation with food, and perhaps outof-control feelings of hunger.
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Causes of Eating Disorders
Biological Factors
• Weight regulation is a result of the interplay
among behavior (e.g., energy expenditure,
eating), peripheral physiological activity
(e.g., digestion, metabolism), and central
physiological activity (e.g., neurotransmitter
release).
• The body strives to maintain weight around
certain weight set points, fixed weights or
small ranges of weight.
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Causes of Eating Disorders
Biological Factors (continued)
• If weight declines, hunger increases and food
consumption goes up.
• There is a slowing of the metabolic rate, the rate
at which the body expends energy, and movement
toward hyperlipogenesis, the storage of
abnormally large amounts of fat in fat cells
throughout the body.
• The body does not distinguish between intentional
attempts to lose weight and potential starvation.
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Causes of Eating Disorders
Biological Factors (continued)
• Other evidence suggests that genetic factors
contribute to eating disorders.
• Finally, several neurophysiological measures are
correlated with eating disorders, including
elevations in endogenous opioids, low levels of
serotonin, and diminished neuroendocrine
functioning.
• Most of these differences in brain functioning,
however, appear to be effects of eating disorders
and not causes of them.
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Causes of Eating Disorders
Integration and Alternative Pathways
• Research on the etiology of eating disorders
underscores the importance of equifinality.
• There are many pathways to developing an
eating disorder.
• Eating disorders are best understood in
terms of a systems approach.
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Causes of Eating Disorders
Integration and Alternative Pathways
(continued)
• A key issue that remains unresolved is why
some women develop anorexia nervosa and
others develop bulimia nervosa.
• Many social, psychological, and biological
factors in the development of the two
disorders are similar.
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Treatment of Anorexia Nervosa
• The treatment of anorexia nervosa usually
focuses on two goals.
• The first goal is to help the patient gain at
least a minimal amount of weight.
• The second goal in treating anorexia
nervosa is more general—to address the
broader difficulties that may have caused or
are maintaining the disorder.
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Treatment of Anorexia Nervosa
• Many different forms of treatment may be
used to achieve this goal.
• The clinical literature commonly advocates
family therapy.
• Some evidence indicates that family therapy
for anorexia nervosa is more effective than
treating the client individually, at least when
the client is an adolescent.
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Treatment of Anorexia Nervosa
• Clinicians have also tried a number of
different individual therapies for anorexia
nervosa.
• There is currently little, if any, evidence to
show that any of these treatments is
effective.
• Similarly, medications such as
antidepressants seem to offer little relief for
victims of anorexia nervosa.
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Treatment of Anorexia Nervosa
Course and Outcome of Anorexia Nervosa
• Evidence on the course and outcome of
anorexia nervosa demonstrates that
contemporary treatments are not very
effective.
• Perhaps as many as 10 percent starve
themselves to death or die of related
complications, including suicide.
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Treatment of Anorexia Nervosa
Course and Outcome of Anorexia Nervosa
(continued)
• Predictors of a better prognosis include an
early age of onset, conflict-free parent–child
relationships, early treatment, less weight
loss, and the absence of binge eating and
purging.
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Treatment of Bulimia Nervosa
• All classes of antidepressant medications
are somewhat effective in treating bulimia
nervosa; however, medication alone is not
the treatment of choice.
• The most thoroughly researched
psychotherapy for bulimia nervosa is
cognitive behavior therapy.
• Overall, cognitive behavior therapy leads to
a 70 to 80 percent reduction in binge eating
and purging across people in treatment.
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Treatment of Bulimia Nervosa
• Interpersonal psychotherapy, which was
originally developed for the treatment of
depression, also may be an effective
treatment for bulimia nervosa.
• Cognitive behavior therapy clearly is the
first-line treatment for bulimia nervosa, but
interpersonal therapy and antidepressant
medication may be useful supplemental or
alternative treatments.
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Treatment of Bulimia Nervosa
Course and Outcome of Bulimia Nervosa
• Bulimia nervosa also has a persistent
course, although the outcome is more
positive than for anorexia nervosa,
especially with treatment.
• Without treatment, one third to one half of
women with bulimia have an eating
disorder 5 years later, many continuing to
meet diagnostic criteria for bulimia nervosa.
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Treatment of Bulimia Nervosa
Course and Outcome of Bulimia Nervosa
(continued)
• Following treatment, in contrast, about half
of clients are free of all symptoms, about
one in five continue to meet the diagnostic
criteria for bulimia nervosa, and the
remainder have occasional relapses or
subclinical levels of binge eating and
compensatory behavior.
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Treatment of Bulimia Nervosa
Course and Outcome of Bulimia Nervosa
(continued)
• Predictors of continued binge eating include
a longer duration, greater emphasis on
shape and weight, childhood obesity, poorer
social adjustment, and persistent
compensatory behavior.
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Prevention of Eating Disorders
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•
The content of effective programs appears to
matter less than the style of delivery.
Whether a prevention program focuses on
promoting healthy weight control, a critical view
of the thin ideal, increasing self-esteem, or stress
management matters less than whether it:
1) targets at-risk individuals instead of an unselected
group;
2) involves an interactive component rather than
being purely didactic;
3) includes more than one session; and
4) is directed toward women (exclusively) in their
late teens and older.
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Prevention of Eating Disorders
• More successful programs also may be
covert, that is, their stated goal is to
increase acceptance of one’s body rather
than reduce disordered eating, a strategy
that may get around defensiveness about
body image.
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