Comer, Abnormal Psychology, 8th edition

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Eating Disorders

• It has not always done so, but Western society
  today equates thinness with health and beauty
• Thinness has become a national obsession
• There has been a rise in eating disorders in the
  past three decades
• The core issue is a morbid fear of weight gain
• Two main diagnoses

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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

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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

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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

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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

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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

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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
• 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 The Clinical Picture

• People with anorexia nervosa also display certain
  psychological problems

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Anorexia Nervosa Medical Problems

• Caused by starvation

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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

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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 9095 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 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

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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
• Binge-eating disorder is a related diagnosis
• Symptoms include a pattern of binge eating with
  NO compensatory behaviors (such as vomiting)

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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 1,000 and
  10,000 calories per binge episode

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Overlapping Patterns Of Anorexia Nervosa, Bulimia
Nervosa, And Obesity
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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
  self-blame, guilt, depression, and fears of
  weight gain and being discovered

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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

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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

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Bulimia Nervosa vs. Anorexia Nervosa
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Bulimia Nervosa vs. Anorexia Nervosa
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Bulimia Nervosa vs. Anorexia Nervosa
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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

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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 (ego, cognitive, and mood
  disturbances)
• Biological factors
• Sociocultural conditions (societal, family, and
  multicultural pressures)

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Psychodynamic Factors Ego Deficiencies

• Hilde Bruch developed a largely psychodynamic
  theory of eating disorders
• Argued that eating disorders are the result of
  disturbed motherchild interactions, which lead
  to serious ego deficiencies in the child and to
  severe perceptual disturbances

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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

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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)

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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

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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

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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

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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)

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Treatments for Anorexia Nervosa

• The immediate aims of treatment for anorexia
  nervosa are to
• Regain lost weight
• Recover from malnourishment
• Eat normally again

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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

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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

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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

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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
• Family therapy is important for anorexia nervosa
  treatment
• The main issues are often separation and
  boundaries

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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

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Treatments for Anorexia Nervosa
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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

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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
• 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 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

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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

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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

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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

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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