Chapter 11

1. Chapter 11 Eating Disorders

2. Eating Disorders • Although not historically true, current Western beauty standards equate 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: • Anorexia nervosa • Bulimia nervosa

3. Eating Disorders During the past 3 decades there has been an increase in two eating disorders • Anorexia Nervosa • Bulimia Nervosa • Both are characterized with a morbid fear of gaining weight According to surveys on body image, people in our society are much more dissatisfied with their bodies now than they were a generation ago.

4. 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 • A distorted view of body weight and shape • Amenorrhea

5. Anorexia Nervosa • There are two main subtypes: • Restricting type • Lose weight by restricting “bad” foods, 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

6. 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 2% of females in Western countries develop the disorder • Many more display some symptoms • Rates of anorexia nervosa are increasing in North America, Japan, and Europe

7. Anorexia Nervosa • The “typical” case: • A normal to slightly overweight female has been on a diet • Escalation to anorexia nervosa may follow a stressful event • Separation of parents • Move or life transition • 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

8. 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 shape and weight • Not being perfect

9. Anorexia Nervosa: The Clinical Picture • Despite their dietary restrictions, people with anorexia 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.

10. Anorexia Nervosa: The Clinical Picture • People with anorexia nervosa also think in distorted ways: • Often 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”

12. Anorexia Nervosa: The Clinical Picture • People with anorexia may also display certain psychological problems: • Depression (usually mild) • Anxiety • Low self-esteem • Insomnia or other sleep disturbances • Substance abuse • Obsessive-compulsive patterns • Perfectionism

13. Caused by starvation: Amenorrhea Low body temperature Low blood pressure Body swelling Reduced bone density Slow heart rate Metabolic and electrolyte imbalances Dry skin, brittle nails Poor circulation Lanugo Anorexia Nervosa: Medical Problems

17. The Vicious Cycle of Anorexia • Fear of obesity and distorted body image lead to… Starvation Preoccupation with food Harder attempts at thinness Increased anxiety & depression Greater feelings of fear & loss of control Medical problems

18. Bulimia Nervosa • Bulimia nervosa, also known as “binge-purge syndrome,” is characterized by binges: • Bouts of uncontrolled overeating during a limited period of time • Eats objectively more than most people would/could eat in a similar period

19. Bulimia Nervosa • The disorder is also characterized by compensatory behaviors, which mark the subtype of the disorder: • Purging-type bulimia nervosa • Vomiting • Misusing laxatives, diuretics, or enemas • Nonpurging-type bulimia nervosa • Fasting • Exercising excessively

20. 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

21. Bulimia Nervosa • Patients are generally of normal weight • Often experience 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 condition is not yet listed in the DSM-IV-TR

22. Bulimia Nervosa • Teens and young adults have frequently attempted binge-purge patterns as a means of weight loss, often after hearing accounts of bulimia from friends or the media • In one study: • 50% of college students reported periodic binges • 6% tried vomiting • 8% experimented with laxatives at least once

23. Bulimia Nervosa: Binges • For people with bulimia nervosa, the number of binges per week can range from 2 to 40 • Average: 10 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

24. Bulimia Nervosa: Binges • Binges are usually preceded by feelings of 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 “discovery”

25. 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 • Affects ability to feel satiated  greater hunger and bingeing • Laxatives and diuretics • Also almost completely fail to reduce the number of calories consumed

26. 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…

27. Bulimia 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

28. Bulimia Nervosa vs. Anorexia Nervosa • Similarities: • Onset after a period of dieting • Fear of becoming obese • Drive to become thin • Preoccupation with food, weight, appearance • Elevated risk of self-harm or attempts at suicide • Feelings of anxiety, depression, perfectionism • Substance abuse • Disturbed attitudes toward eating

29. Bulimia Nervosa vs. Anorexia Nervosa • Differences: • People with bulimia are more worried about pleasing others, being attractive to others, and having intimate relationships • People with bulimia tend to be more sexually experienced • People with bulimia display fewer of the obsessive qualities that drive restricting-type anorexia • People with bulimia are more likely to have histories of mood swings, low frustration tolerance, and poor coping

30. Bulimia Nervosa vs. Anorexia Nervosa • Differences: • People with bulimia tend to be controlled by emotion – may change friendships easily • People with bulimia are more likely to display characteristics of a personality disorder • Different medical complications: • Only half of women with bulimia experience amenorrhea vs. almost all women with anorexia • People with bulimia suffer damage caused by purging, especially from vomiting and laxatives

31. Medical Problems • Repeated vomiting can cause serious dental problems • Vomiting and laxative abuse can cause dangerous potassium deficiencies • Weakness • Intestinal disorders • Kidney disease • Heart damage • Half of women who are bulimic have amenorrhea (compared to almost all anorexic women)

32. What Causes Eating Disorders? • Most theorists subscribe to a multidimensional risk perspective: • Several key factors place individuals at risk • More factors = greater risk • Leading factors: • Sociocultural conditions (societal and family pressures) • Psychological problems (ego, cognitive, and mood disturbances) • Biological factors

33. What Causes Eating Disorders? Societal Pressures • Many theorists believe that current Western standards of female attractiveness have contributed to the rise 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

34. What Causes Eating Disorders? Societal Pressures • Certain groups 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 met full criteria for an eating disorder

35. What Causes Eating Disorders? Societal Pressures • Societal attitudes may explain economic and racial differences seen in prevalence rates • In the past, Caucasian women of higher SES expressed more concern about thinness and dieting • These women had higher rates of eating disorders than African American women or Caucasian women of lower SES • Recently, dieting and preoccupation with food, along with rates of eating disorders, are increasing in all groups

36. 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

37. 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

38. What Causes Eating Disorders? Family Environment • Abnormal family interactions and forms of communication within a family may also set the stage for an eating disorder • Minuchin cites “enmeshed family patterns” as causal factors of eating disorders • These patterns include overinvolvement in, and overconcern about, family member’s lives

39. What Causes Eating Disorders? Mood Disorders • There is empirical support for the claim that mood disorders set the stage for eating disorders: • Many more people with an eating disorder qualify for a clinical diagnosis of major depressive disorder than do people in the general population • Close relatives of those with eating disorders seem to have higher rates of mood disorders • People with eating disorders, especially those with bulimia nervosa, have low levels of serotonin • Symptoms of eating disorders are helped by antidepressant medications

40. What Causes Eating Disorders? Biological Factors • Biological theorists suspect certain genes may leave some people particularly susceptible to eating disorders • Consistent with this model: • Relatives of people with eating disorders are 6 times more likely to develop the disorder themselves • Identical (MZ) twins with bulimia: 23% • Fraternal (DZ) twins with bulimia: 9%

41. 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)

42. What Causes Eating Disorders? Biological Factors • Some theorists believe that the LH and VMH 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,  metabolism  binges • If weight rises above set point:  hunger,  metabolism • Dieters end up in a fight against themselves to lose weight

43. Treatments for Eating Disorders • Eating disorder treatments have two main goals: • Correct abnormal 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

44. Treatments for Anorexia Nervosa • In the past, treatment took place in a hospital setting; it is now often offered in an outpatient setting • 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 • Most common technique now is the use of supportive nursing care and high-calorie diets • Necessary weight gain is often achieved in 8 to 12 weeks

45. Treatments for Anorexia Nervosa • Researchers have found that people with anorexia must overcome their underlying psychological problems in order to achieve lasting improvement

46. Treatments for Anorexia Nervosa • Therapists use a mixture of therapy and education to achieve this broader goal, using a combination of individual, group, and family approaches • One focus of treatment is building autonomy and self-awareness • Therapists help patients recognize their need for independence and control • Therapists help patients recognize and trust their internal feelings

47. Treatments for Anorexia Nervosa • Another focus of treatment is correcting disturbed cognitions, especially client misperceptions and attitudes about eating and weight • Using cognitive approaches, therapists correct disturbed cognitions and educate about body distortions

48. Treatments for Anorexia Nervosa • Another focus of treatment is changing family interactions • Family therapy is important for anorexia • The main issues are often separation and boundaries

49. 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

50. Treatments for Anorexia Nervosa • Positives 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 is declining