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Slides & Handouts by Karen Clay Rhines, Ph.D.
Seton Hall University
Chapter 11
Eating Disorders
Comer, Abnormal Psychology, 6e – Chapter 11
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Eating Disorders

Although not historically true, current Western beauty
standards equate thinness with health and beauty


There has been a rise in eating disorders in the past
three decades


Thinness has become a national obsession!
The core issue is a morbid fear of weight gain
Two main diagnoses:

Anorexia nervosa

Bulimia nervosa
Comer, Abnormal Psychology, 6e – Chapter 11
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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

A distorted view of body weight and shape

Amenorrhea
Comer, Abnormal Psychology, 6e – Chapter 11
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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
Comer, Abnormal Psychology, 6e – Chapter 11
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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
Comer, Abnormal Psychology, 6e – Chapter 11
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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
Comer, Abnormal Psychology, 6e – Chapter 11
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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 shape and weight
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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, as evidenced by
the famous 1940s “starvation study” with conscientious
objectors
Comer, Abnormal Psychology, 6e – Chapter 11
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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”
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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
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Anorexia Nervosa: Medical Problems

Caused by starvation:

Amenorrhea

Slow heart rate

Low body temperature


Low blood pressure
Metabolic and electrolyte
imbalances

Dry skin, brittle nails

Poor circulation

Lanugo


Body swelling
Reduced bone density
Comer, Abnormal Psychology, 6e – Chapter 11
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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
Comer, Abnormal Psychology, 6e – Chapter 11
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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

Eats objectively more than most people would/could eat
in a similar period
Comer, Abnormal Psychology, 6e – Chapter 11
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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
Comer, Abnormal Psychology, 6e – Chapter 11
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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, 6e – Chapter 11
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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
Comer, Abnormal Psychology, 6e – Chapter 11
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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
Comer, Abnormal Psychology, 6e – Chapter 11
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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
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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 selfblame, guilt, depression, and fears of weight
gain and “discovery”
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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
Affects ability to feel satiated  greater hunger and bingeing
Laxatives and diuretics

Also almost completely fail to reduce the number of calories
consumed
Comer, Abnormal Psychology, 6e – Chapter 11
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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…
Comer, Abnormal Psychology, 6e – Chapter 11
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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 subjects,
bingeing often occurs after strict dieting

For example, a study of binge-eating behavior in a lowcalorie weight loss program found that 62% of patients
reported binge-eating episodes during treatment
Comer, Abnormal Psychology, 6e – Chapter 11
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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
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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
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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
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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
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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
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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
Comer, Abnormal Psychology, 6e – Chapter 11
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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
Comer, Abnormal Psychology, 6e – Chapter 11
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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
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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
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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
Comer, Abnormal Psychology, 6e – Chapter 11
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What Causes Eating Disorders?
Ego Deficiencies and Cognitive Disturbances

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?
Ego Deficiencies and Cognitive Disturbances


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 internal needs; they
feed when the child is anxious, comfort when the child is
tired, etc.
There is some empirical support for Bruch’s theory
from clinical reports
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What Causes Eating Disorders?
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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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
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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%
These findings may be related to low serotonin
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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)
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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
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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
Comer, Abnormal Psychology, 6e – Chapter 11
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Treatments for Anorexia Nervosa

The initial aims of treatment for anorexia
nervosa are to:

Restore proper weight

Recover from malnourishment

Restore proper eating
Comer, Abnormal Psychology, 6e – Chapter 11
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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
Comer, Abnormal Psychology, 6e – Chapter 11
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Treatments for Anorexia Nervosa

Researchers have found that people with
anorexia must overcome their underlying
psychological problems in order to achieve
lasting improvement
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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 selfawareness

Therapists help patients recognize their need for
independence and control

Therapists help patients recognize and trust their internal
feelings
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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
Comer, Abnormal Psychology, 6e – Chapter 11
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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
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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
Comer, Abnormal Psychology, 6e – Chapter 11
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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
Comer, Abnormal Psychology, 6e – Chapter 11
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Treatments for Anorexia Nervosa

Negatives of treatment:

Close to 20% of patients remain troubled for years

Even when it occurs, recovery is not always
permanent


Anorexic behaviors recur in at least one-third of
recovered patients, usually triggered by stress

Many patients still express concerns about body shape
and weight
Lingering emotional problems are common
Comer, Abnormal Psychology, 6e – Chapter 11
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Treatments for Bulimia Nervosa

Treatment programs are relatively new but have
risen in popularity

Treatment is frequently offered in specialized
eating disorder clinics
Comer, Abnormal Psychology, 6e – Chapter 11
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Treatments for Bulimia Nervosa


The initial 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

Several treatment strategies:

Individual insight therapy

The insight approach receiving the most attention is
cognitive therapy, which helps clients recognize and
change their maladaptive attitudes toward food, eating,
weight, and shape

As many as 65% stop their binge-purge cycle
Comer, Abnormal Psychology, 6e – Chapter 11
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Treatments for Bulimia Nervosa

Several treatment strategies:

Individual insight therapy

If cognitive therapy isn’t effective, interpersonal therapy
(IPT), a treatment that seeks to improve interpersonal
functioning, may be tried

A number of clinicians also suggest self-help groups or
self-care manuals
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Treatments for Bulimia Nervosa

Several treatment strategies:

Behavioral therapy

Behavioral techniques are often included in treatment as a
supplement to cognitive therapy


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 Nervosa

Several treatment strategies:

Antidepressant medications


During the past decade, antidepressant drugs have been
used in bulimia treatment

Most common is fluoxetine (Prozac), an SSRI

Drugs help as many as 40% of patients
Medications are best when used in combination with
other forms of therapy
Comer, Abnormal Psychology, 6e – Chapter 11
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Treatments for Bulimia Nervosa

Several treatment strategies:

Group therapy

Provides an opportunity for patients to express their
thoughts, concerns, and experiences with one another

Helpful in as many as 75% of cases, especially when
combined with individual insight therapy
Comer, Abnormal Psychology, 6e – Chapter 11
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Treatments for Bulimia Nervosa

Left untreated, bulimia can last for years

Treatment provides immediate, significant
improvement in about 40% of cases


An additional 40% show moderate improvement
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 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
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Treatments for Bulimia Nervosa

Finally, treatment may also help improve overall
psychological and social functioning
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