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Chapter 11
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Eating Disorders
Eating Disorders
• It has not always done so, but Western society
today equates thinness with health and beauty
• 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
Bulimia
nervosa
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– Thinness has become a national obsession
Anorexia Nervosa
– A refusal to maintain more than 85% of normal body
weight
– Intense fears of becoming overweight
– Distorted view of weight and shape
– Amenorrhea
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• The main symptoms of anorexia nervosa are:
Anorexia Nervosa
• There are two main subtypes:
– Restricting type
– 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Lose weight by cutting out sweets and fattening snacks,
eventually eliminating nearly all food
• Show almost no variability in diet
Anorexia Nervosa
• The “typical” case:
• 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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– A normal to slightly overweight female has been on a
diet
– Escalation toward anorexia nervosa may follow a
stressful event
Anorexia Nervosa: The Clinical Picture
• The key goal for people with anorexia nervosa is
becoming thin
• Of becoming obese
• Of giving in to the desire to eat
• Of losing control of body size and shape
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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– The driving motivation is fear:
Anorexia Nervosa: The Clinical Picture
• Despite their dietary restrictions, people with
anorexia nervosa are preoccupied with food
• It may be the result of food deprivation, as evidenced by the
famous 1940s “starvation study” with conscientious
objectors
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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– This includes thinking and reading about food and
planning for meals
– This relationship is not necessarily causal
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
– 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”
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Adjustable lens assessment technique
• People with anorexia nervosa also display
certain psychological problems:
• Depression (usually mild)
• Anxiety
• Low self-esteem
• Insomnia or other sleep disturbances
• Substance abuse
• Obsessive-compulsive patterns
• Perfectionism
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Anorexia Nervosa: The Clinical Picture
Anorexia Nervosa: Medical Problems
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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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Caused by starvation:
Bulimia Nervosa
• Bulimia nervosa, also known as “binge-purge
syndrome,” is characterized by binges:
• Eat objectively more than most people would/could eat in a
similar period
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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– Bouts of uncontrolled overeating during a limited
period of time
Bulimia Nervosa
• The “typical” case:
• 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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– 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
Bulimia Nervosa
– Purging-type bulimia nervosa
• Forced vomiting
• Misusing laxatives, diuretics, or
enemas
– Nonpurging-type bulimia
nervosa
• Fasting
• Exercising frantically
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• The disorder is also
characterized by
inappropriate compensatory
behaviors, which mark the
subtype of the condition:
Bulimia Nervosa
• Patients are generally of normal weight
– Often experience marked weight fluctuations
– Some may also qualify for a diagnosis of anorexia
– Symptoms include a pattern of binge eating with NO
compensatory behaviors (such as vomiting)
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• “Binge-eating disorder” is a related diagnosis
Bulimia Nervosa: Binges
– 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• People with bulimia nervosa may have between
1 and 30 binge episodes per week
• Binges are often carried out in secret
• 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 selfblame, guilt, depression, and fears of weight
gain and being discovered
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Bulimia Nervosa: Binges
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:
• 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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– Vomiting
Bulimia Nervosa: Compensatory Behaviors
• Compensatory behaviors may temporarily
relieve the negative feelings attached to binge
eating
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– Over time, however, a cycle develops in which
purging  bingeing  purging…
Abnormal Psychology | Ronald J. Comer | Ninth Edition
Bulimia Nervosa vs. Anorexia Nervosa
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•
•
•
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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Similarities:
Bulimia Nervosa vs. Anorexia Nervosa
• 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Differences:
Bulimia Nervosa vs. Anorexia Nervosa
• 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Differences:
• 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 twothirds of people with binge eating disorder
become overweight or even obese
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Binge Eating Disorder
What Causes 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)
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Most theorists and researchers use a
multidimensional risk perspective to explain
eating disorders:
Psychodynamic Factors: Ego Deficiencies
– 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Hilde Bruch developed a largely psychodynamic
theory of eating disorders
Psychodynamic Factors: Ego Deficiencies
– 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Bruch argues that parents may respond to their
children either effectively or ineffectively
Cognitive Factors
– According to cognitive theorists, these deficiencies
contribute to a broad cognitive distortion that lies at
the center of disordered eating (e.g., negative selfjudgment based on body shape and weight)
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Bruch's theory also contains several cognitive
factors, like improper labeling of internal
sensations and needs
• Dark sites of the Internet—sites with the goal of
promoting behaviors that the clinical community,
and most of society, consider abnormal and
destructive
• Eating Disorders Association reports that there
are more than 500 pro-anorexia Internet sites,
with names such as “Dying to Be Thin” and
“Starving for Perfection”
• Besides promoting eating disorders, might there
be other ways in which pro-Ana sites are
potentially harmful to regular visitors?
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Dark Sites of the Internet
Biological Factors
• Biological theorists suspect certain genes may
leave some people particularly susceptible to
eating disorders
• 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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– Consistent with this idea:
Biological Factors
• Other theorists believe that eating disorders may
be related to dysfunction of the hypothalamus
• Lateral hypothalamus (LH)
• Ventromedial hypothalamus (VMH)
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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– Researchers have identified two separate areas that
control eating:
Biological Factors
– 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Some theorists believe that the hypothalamus,
related brain areas, and chemicals together are
responsible for weight set point – a “weight
thermostat” of sorts
Societal Pressures
– 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Many theorists believe that current Western
standards of female attractiveness are partly
responsible for the emergence of eating
disorders
Societal Pressures
• Members of certain subcultures are at greater
risk from these pressures:
• 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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– Models, actors, dancers, and certain athletes
Societal Pressures
• Societal attitudes may explain economic and
racial differences seen in prevalence rates
• 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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– Historically, women of higher SES expressed more
concern about thinness and dieting
Societal Pressures
– 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• The socially accepted prejudice against
overweight people may also add to the “fear”
and preoccupation about weight
Family Environment
– 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Families may play an important role in the
development of eating disorders
Family Environment
– 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Abnormal interactions and forms of
communication within a family may also set the
stage for an eating disorder
Multicultural Factors: Racial and Ethnic
Differences
– 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• 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
• 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Multicultural Factors: Racial and Ethnic
Differences
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
•
•
•
•
•
Jockeys
Wrestlers
Distance runners
Body builders
Swimmers
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– The highest rates of male eating disorders have been
found among:
• 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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Multicultural Factors: Racial and Ethnic
Differences
How Are Eating Disorders Treated?
• Eating disorder treatments have two main goals:
• This often requires the participation of family and friends
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– Correct dangerous eating patterns
– Address broader psychological and situational factors
that have led to, and are maintaining, the eating
problem
Treatments for Anorexia Nervosa
– Regain lost weight
– Recover from malnourishment
– Eat normally again
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• The immediate aims of treatment for anorexia
nervosa are to:
• 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Treatments for Anorexia Nervosa
Treatments for Anorexia Nervosa
– 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• The most popular weight-restoration technique
has been the combination of supportive nursing
care, nutritional counseling, and high-calorie
diets
Treatments for Anorexia Nervosa
– 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”
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• In most treatment programs, a combination of
behavioral and cognitive interventions are
included
• 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
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Treatments for Anorexia Nervosa
Treatments for Anorexia Nervosa
• The use of combined treatment approaches has
greatly improved the outlook for people with
anorexia nervosa
• The course and outcome of the disorder vary
from person to person
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– But even with combined treatment, recovery is difficult
Treatments for Anorexia Nervosa
• Positives of treatment:
– Weight gain is often quickly restored
• As many as 90% of patients still showed improvements after
several years
• Negatives of treatment:
– As many as 25% of patients remain 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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– Menstruation often returns with return to normal weight
– The death rate from anorexia nervosa is declining
Treatments for Bulimia Nervosa
– Eliminate binge-purge patterns
– Establish good eating habits
– Eliminate the underlying cause of bulimic patterns
• Programs emphasize education as much as
therapy
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Treatment is frequently offered in eating disorder
clinics
• The immediate aims of treatment for bulimia
nervosa are to:
Treatments for Bulimia Nervosa
• Cognitive-behavioral therapy is particularly
helpful:
• 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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– Behavioral techniques
Treatments for Bulimia Nervosa
– 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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• Other forms of psychotherapy
Treatments for Bulimia Nervosa
• Other forms of psychotherapy
• 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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– Various forms of psychotherapy are often
supplemented by family therapy and may be offered
in either individual or group therapy format
Treatments for Bulimia Nervosa
• Antidepressant medications
– During the past 15 years, all groups of antidepressant
drugs have been used in bulimia nervosa treatment
– Medications are best when used in combination with
other forms of therapy
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• Drugs help as many as 40% of patients
Treatments for Bulimia Nervosa
• Left untreated, bulimia nervosa can last for years
• Treatment provides immediate, significant
improvement in about 40% of cases
• Follow-up studies suggest that 10 years after
treatment about 75% of patients have fully or
partially recovered
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– An additional 40% show moderate response
Treatments for Bulimia Nervosa
– 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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• Relapse can be a significant problem, even
among those who respond successfully to
treatment
• Today’s treatments for binge-eating disorder are
often similar to those for bulimia nervosa
• Cognitive-behavioral therapy, other forms of
psychotherapy, and in some cases,
antidepressant medications are provided to help
reduce or eliminate the binge-eating patterns
and to change disturbed thinking such as being
overly concerned with weight and shape
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Treatments for Binge-Eating Disorder