1Slides & Handouts by Karen Clay Rhines, Ph.D.Northampton Community College

Fundamentals of Abnormal Psychology, 6e

Ronald Comer

Eating DisordersEating DisordersChapter 9

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Eating DisordersEating Disorders

Although not historically true, current Western beauty standards equate thinness with health and beauty

◦ Thinness has become a national obsession

There has been an increase in eating disorders in the past three decades

◦ The core issue is a morbid fear of weight gain

Two main diagnoses:

◦ Anorexia nervosa

◦ Bulimia nervosa

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Anorexia NervosaAnorexia Nervosa

There are two main subtypes:

◦Restricting type

Lose weight by cutting out sweets and fattening snacks, eventually restricting nearly all food

Show almost no variability in diet

◦Binge-eating/purging type

Lose weight by vomiting after meals, abusing laxatives or diuretics, or engaging in excessive exercise

Like those with bulimia nervosa, people with this subtype may engage in eating binges

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Anorexia NervosaAnorexia NervosaAbout 90%–95% of cases occur in females

The peak age of onset is between 14 and 18 years

Between 0.5% and 2% of females in Western countries develop the disorder

◦ Many more display some symptoms

Rates of anorexia nervosa are increasing in North America, Europe, and Japan

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Anorexia NervosaAnorexia 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 or life transition

Experience of personal failure

◦ Most victims recover However, about 2% to 6% become seriously ill

and die as a result of medical complications or suicide

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Anorexia Nervosa: Anorexia Nervosa: The Clinical PictureThe Clinical PictureThe 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 shape and weight

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Anorexia Nervosa: Anorexia Nervosa: The Clinical PictureThe Clinical PictureDespite their dietary restrictions,

people with anorexia nervosa are extremely 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

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Anorexia Nervosa: Anorexia Nervosa: The Clinical PictureThe Clinical PicturePersons 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”

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Anorexia Nervosa: Anorexia Nervosa: The Clinical PictureThe Clinical PicturePeople with anorexia nervosa may

also display certain psychological problems:◦Depression (usually mild)

◦Anxiety

◦Low self-esteem

◦ Insomnia or other sleep disturbances

◦Substance abuse

◦Obsessive-compulsive patterns

◦Perfectionism

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Anorexia Nervosa: Anorexia Nervosa: Medical ProblemsMedical ProblemsCaused 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

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Bulimia NervosaBulimia Nervosa

Bulimia nervosa, also known as “binge-purge syndrome,” is characterized by binges:

◦Bouts of uncontrolled overeating during a limited period of time

Eat more than most people would/could eat in a similar period

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Bulimia NervosaBulimia Nervosa

The disorder is also characterized by inappropriate compensatory behaviors, such as:

◦Vomiting

◦Misusing laxatives, diuretics, or enemas

◦Fasting

◦Exercising excessively

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Bulimia NervosaBulimia 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

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Bulimia NervosaBulimia NervosaPatients are generally of normal weight

◦Often experience marked weight fluctuations

◦Some may also qualify for a diagnosis of anorexia

“Binge-eating disorder” may be a related diagnosis

◦Symptoms include a pattern of binge eating with NO compensatory behaviors (such as vomiting)

◦This pattern is not yet listed in the DSM

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Bulimia NervosaBulimia NervosaMany teens and young adults go on

eating binges or experiment with vomiting or laxatives after hearing about these behaviors from friends or the media

According to global studies, 25 to 50% of students report periodic binge-eating or self-induced vomiting

◦Surveys suggests that as many as 5% develop the full syndrome

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Bulimia Nervosa: BingesBulimia 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 rapidly with little chewing

Usually sweet foods with soft texture

Binge-eaters commonly consume more than 1000 calories (often more than 3000 calories) per binge episode

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Bulimia Nervosa: BingesBulimia 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

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Bulimia Nervosa: Bulimia Nervosa: Compensatory BehaviorsCompensatory BehaviorsAfter a binge, people with bulimia

nervosa try to compensate for and “undo” the caloric effects

The most common compensatory behavior is vomiting

Fails to prevent the absorption of half the calories consumed during a binge

Affects ability to feel satiated greater hunger and bingeing

◦ Laxatives and diuretics

Also almost completely fail to reduce the number of calories consumed

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Bulimia Nervosa: Bulimia Nervosa: Compensatory BehaviorsCompensatory BehaviorsCompensatory behaviors may

temporarily relieve the negative feelings attached to binge eating

◦Over time, however, a cycle develops in which purging bingeing purging…

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Bulimia NervosaBulimia Nervosa

The “typical” case:

◦A normal to slightly overweight female has been on an intense diet

◦Research suggests that even among normal subjects, bingeing often occurs after strict dieting

For example, a study of binge-eating behavior in a low-calorie weight loss program found that 62% of patients reported binge-eating episodes during treatment

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Bulimia Nervosa vs. Bulimia Nervosa vs. Anorexia NervosaAnorexia NervosaSimilarities:

◦ Onset after a period of dieting

◦ Fear of becoming obese

◦ Drive to become thin

◦ Preoccupation with food, weight, appearance

◦ Feelings of anxiety, depression, obsessiveness, perfectionism

◦ Substance abuse

◦ Distorted body perception

◦ Disturbed attitudes toward eating

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Bulimia Nervosa vs. Bulimia Nervosa vs. Anorexia NervosaAnorexia NervosaDifferences:

◦People with bulimia nervosa are more worried 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

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Bulimia Nervosa vs. Bulimia Nervosa vs. Anorexia NervosaAnorexia Nervosa

Differences:

◦ People with bulimia nervosa tend to be controlled by emotion – may change friendships easily

◦ People with bulimia nervosa are more likely to display characteristics of a 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

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What Causes Eating What Causes Eating Disorders?Disorders?Most theorists use a

multidimensional risk perspective:◦Several key factors place individuals at

risk

◦More factors = greater risk

◦Leading factors: Psychological problems (ego, cognitive, and

mood disturbances)

Biological factors

Sociocultural conditions (societal, family, and multicultural pressures)

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What Causes Eating Disorders? What Causes Eating Disorders? Psychodynamic Factors: Ego Psychodynamic Factors: Ego DeficienciesDeficienciesHilde Bruch developed a largely

psychodynamic theory of eating disorders

Bruch argues that eating disorders are the result of disturbed mother–child interactions, which lead to serious ego deficiencies in the child and to severe cognitive disturbances

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What Causes Eating Disorders? What Causes Eating Disorders? Psychodynamic Factors: Ego Psychodynamic Factors: Ego DeficienciesDeficienciesBruch 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 internal needs; they feed when the child is anxious, comfort when the child is tired, etc.

These children then turn to external guides and feel unable to establish independence

There is some empirical support for Bruch’s theory from clinical reports

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What Causes Eating What Causes Eating Disorders? Disorders? Cognitive FactorsCognitive FactorsBruch’s theory also contains

several cognitive factors

◦According to cognitive theorists, such deficiencies contribute to a broad cognitive distortion that is at the center of disordered eating (e.g., disproportionate concerns about body shape and weight)

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What Causes Eating What Causes Eating Disorders? Disorders? Mood DisordersMood DisordersMany people with eating

disorders, particularly those with bulimia nervosa, experience symptoms of depression

◦Theorists believe mood disorders may “set the stage” for eating disorders

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What Causes Eating What Causes Eating Disorders? Disorders? Mood DisordersMood DisordersThere 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

◦ People with eating disorders are helped by antidepressant medications

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What Causes Eating What Causes Eating Disorders? Biological FactorsDisorders? Biological FactorsBiological theorists suspect certain genes

may leave some people particularly susceptible to eating disorders

◦ Consistent with this model: 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

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What Causes Eating What Causes Eating Disorders? Biological FactorsDisorders? Biological FactorsOther 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)

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What Causes Eating What Causes Eating Disorders? Biological FactorsDisorders? Biological FactorsSome theorists believe that the LH and

VMH are, in part, 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

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What Causes Eating What Causes Eating Disorders? Disorders? Societal PressuresSocietal PressuresMany theorists believe that current

Western standards of female attractiveness are partly responsible for the emergence of eating disorders

◦ 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

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What Causes Eating What Causes Eating Disorders? Disorders? Societal PressuresSocietal PressuresMembers 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

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What Causes Eating What Causes Eating Disorders? Disorders? Societal PressuresSocietal Pressures

Societal attitudes may explain economic 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 food, along with rates of eating disorders, are increasing in all socioeconomic classes

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What Causes Eating What Causes Eating Disorders? Disorders? Societal PressuresSocietal PressuresThe socially accepted prejudice

against overweight people may also add to the “fear” and preoccupation about weight

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What Causes Eating What Causes Eating Disorders? Disorders? Family EnvironmentFamily EnvironmentFamilies 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, physical appearance, and dieting

◦Mothers of those with eating disorders are more likely to be dieters and perfectionistic themselves

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What Causes Eating What Causes Eating Disorders? Disorders? Family EnvironmentFamily EnvironmentAbnormal interactions and forms of

communication within a family may also set the stage for an eating disorder

◦Influential family theorist Salvador Minuchin believes that “enmeshed family patterns” often lead to eating disorders

These patterns include overinvolvement in, and overconcern about, family member’s lives

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What Causes Eating Disorders? What Causes Eating Disorders? Multicultural Factors: Racial and Ethnic Multicultural Factors: Racial and Ethnic DifferencesDifferences

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

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What Causes Eating Disorders? What Causes Eating Disorders? Multicultural Factors: Racial and Ethnic Multicultural Factors: Racial and Ethnic DifferencesDifferences

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

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What Causes Eating Disorders? What Causes Eating Disorders? Multicultural Factors: Racial and Ethnic Multicultural Factors: Racial and Ethnic DifferencesDifferences

Other studies indicate that Hispanic American female adolescents now engage in disordered eating behaviors at rates 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

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What Causes Eating Disorders? What Causes Eating Disorders? Multicultural Factors: Gender Multicultural Factors: Gender DifferencesDifferencesMales account for only 5% to 10%

of all cases of eating disordersThe reasons for this striking

difference are not entirely clear, but Western society’s double standard 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

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What Causes Eating Disorders? What Causes Eating Disorders? Multicultural Factors: Gender Multicultural Factors: Gender DifferencesDifferencesIt 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

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What Causes Eating Disorders? What Causes Eating Disorders? Multicultural Factors: Gender Multicultural Factors: Gender DifferencesDifferences

For other men, body image appears to be a key factor

Additionally, a new kind of eating disorder has emerged and is found almost exclusively among men – reverse anorexia nervosa or muscle dysmorphobia

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How Are Eating Disorders How Are Eating Disorders Treated?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

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Treatments for Anorexia Treatments for Anorexia NervosaNervosaThe initial aims of treatment for

anorexia nervosa are to:

◦Regain lost weight

◦Recover from malnourishment

◦Eat normally again

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Treatments for Anorexia Treatments for Anorexia NervosaNervosaIn the past, treatment took place in

a hospital; it is now often offered in 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

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Treatments for Anorexia Treatments for Anorexia NervosaNervosaThe 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

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Treatments for Anorexia Treatments for Anorexia NervosaNervosaResearchers have found that

people with anorexia nervosa must overcome their underlying psychological problems to achieve lasting improvement

Therapists use a combination of education, psychotherapy, and family approaches to achieve this broader goal; psychotropic drugs have been helpful in some cases

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Treatments for Anorexia Treatments for Anorexia NervosaNervosaIn most treatment programs, a

combination of behavioral and cognitive interventions are applied

◦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”

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Treatments for Anorexia Treatments for Anorexia NervosaNervosaTherapists help patients recognize

their need for independence and control

Therapists help patients identify and trust their internal feelings

Therapists also help clients change their attitudes about eating and weight

◦Using cognitive approaches, therapists correct disturbed cognitions and educate about body distortions

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Treatments for Anorexia Treatments for Anorexia NervosaNervosaAnother focus of treatment is

changing family interactions

◦Family therapy is important for anorexia nervosa treatment

◦The main issues are often separation and boundaries

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Treatments for Anorexia Treatments for Anorexia NervosaNervosaThe 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

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Treatments for Anorexia Treatments for Anorexia NervosaNervosaPositives of treatment:

◦Weight gain is often quickly restored

83% 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

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Treatments for Anorexia Treatments for Anorexia NervosaNervosaNegatives of treatment:

◦Close to 20% of patients remain seriously 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

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Treatments for Bulimia Treatments for Bulimia NervosaNervosaTreatment 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

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Treatments for Bulimia Treatments for Bulimia NervosaNervosaCognitive-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

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Treatments for Bulimia Treatments for Bulimia NervosaNervosaCognitive-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

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Treatments for Bulimia Treatments for Bulimia NervosaNervosaOther 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

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Treatments for Bulimia Treatments for Bulimia NervosaNervosaOther 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 therapy provides 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

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Treatments for Bulimia Treatments for Bulimia NervosaNervosaAntidepressant medications

◦During the past decade, 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, particularly cognitive-behavioral therapy

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Treatments for Bulimia Treatments for Bulimia NervosaNervosaLeft 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 90% of patients have fully or partially recovered

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Treatments for Bulimia Treatments for Bulimia NervosaNervosaRelapse 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