Eating Disorders

Eating Disorders Chapter 11 Slides & Handouts by Karen Clay Rhines, Ph.D. American Public University System

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: • Anorexia nervosa • Bulimia nervosa Comer, Abnormal Psychology, 8e DSM-5 Update

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

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

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

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

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

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

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

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

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

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 Comer, Abnormal Psychology, 8e DSM-5 Update

Bulimia Nervosa • Bulimia nervosa, also known as “binge-purge 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

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

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

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

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 self-induced vomiting • Only some of these individuals qualify for a diagnosis of bulimia nervosa Comer, Abnormal Psychology, 8e DSM-5 Update

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

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

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

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

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

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

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

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

Binge Eating Disorder Comer, Abnormal Psychology, 8e DSM-5 Update • 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

Binge Eating Disorder Comer, Abnormal Psychology, 8e DSM-5 Update 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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Eating Disorders