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Eating Disorders
Chapter 22
Eric Stice and Cara Bohon
HISTORICAL CONTEXT
 Anorexia nervosa was first recognized as a psychiatric
disorder more than a century ago.
 Stunkard (1959) first described binge eating disorder
half a century ago among overweight individuals.
 Binge eating disorder has not yet been recognized as
a diagnostic entity but considerable research has led to
the likely inclusion of the disorder in the next edition of
the DSM.
 Bulimia nervosa was recognized as a psychiatric
disorder in the late 1970s.
DIAGNOSTIC ISSUES AND DSMIV CRITERIA
 Anorexia Nervosa
 Weight loss or failure to gain weight (with weight less than 85% of what
would be expected for height, age, and developmental level)
 Intense fear of gaining weight or of becoming fat despite a low body
weight
 Disturbed perception of weight and shape
 An undue influence of weight or shape on self-evaluation or a denial of
the seriousness of the illness
 Amenorrhea in postmenarcheal females
 Bulimia Nervosa
 Marked by recurrent episodes (at least twice weekly for 3 months) of
consumption of unusually large amounts of food (coupled with a sense
that the eating is out of control)
 Recurrent (at least twice weekly for 3 months) compensatory behaviors
to prevent weight gain (e.g., self-induced vomiting, laxative/diuretic
abuse, fasting, or excessive exercise)
 Undue influence of weight and shape on self-evaluation
DIAGNOSTIC ISSUES AND DSMIV CRITERIA
 Binge Eating Disorder
 Binge eating disorder is listed in the DSM-IV (American
Psychiatric Association, 2000) as a provisional eating disorder
requiring further study, exemplifying an eating disorder
not otherwise specified (EDNOS).
 This eating disorder involves:
• Repeated episodes (at least 2 days per week for 6 months) of
uncontrollable binge eating characterized by certain features (e.g.,
rapid eating, eating until uncomfortably full, eating alone because of
embarrassment, and feeling guilty or depressed after overeating)
• Marked distress regarding binge eating
• The absence of regular compensatory behaviors (e.g., monthly
vomiting for weight control)
DIAGNOSTIC ISSUES AND DSMIV CRITERIA
 Eating Disorder Not Otherwise Specified (ED-
NOS)
 The DSM-IV currently describes five symptom
presentations in addition to binge-eating disorder as
examples of Eating Disorder Not Otherwise Specified
(EDNOS):
•
•
•
•
•
Anorexia nervosa with menses present
Anorexia nervosa with normal weight
Low-binge frequency bulimia nervosa
Chewing and spitting food repeatedly
Purging disorder (the regular use of inappropriate compensatory
behavior after eating food that would not be considered a binge
episode)
PREVALENCE
 Between 0.9% and 2.0% of girls and women and
between 0.1% and 0.3% of boys and men experience
anorexia nervosa during their lifetimes (Hudson, Hiripi, Pope, &
Kessler, 2007; Lewinsohn Striegel-Moore, & Seeley, 2000).
 Bulimia nervosa afflicts between 1.1% and 4.6% of
girls and women and between 0.1% and 0.5% of boys
and men during their lifetimes (Garfinkel et al., 1995; Hudson et al.,
2007).
 Binge eating disorder afflicts between 0.2% and 3.5%
of girls and between 0.9% and 2.0% of boys and men
during their lifetimes (Hoek & van Hoeken, 2003; Hudson et al., 2007).
RISK FACTORS, PROTECTIVE FACTORS,
AND ETIOLOGIC FORMULATIONS
 Anorexia Nervosa
 Picky eating and digestive problems in early childhood
 Premature birth and cephalhematoma
 Infant feeding problems
 Maternal depressive symptoms
 Thin-ideal internalization and body dissatisfaction
 Depressive symptoms and psychological disturbances
 High self-esteem and higher maternal body mass index
appear to be protective factors.
RISK FACTORS, PROTECTIVE FACTORS,
AND ETIOLOGIC FORMULATIONS
Bulimia Nervosa
Binge Eating Disorder
 Body dissatisfaction
 Initial elevations in body mass
 Preoccupation with thinness
 Perceived pressure for
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
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

by family members and peers
Dietary restraint
Negative affect
Deficits in social support
Substance abuse
Elevated body mass
Early feeding problems

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thinness
Body dissatisfaction
Dietary restraint
Negative affect
Tendency to eat in response
to negative emotions
Depressive symptoms
GENETIC AND OTHER
BIOLOGICAL FACTORS
 Heritability
 Relatives of individuals with eating disorders are at
elevated risk for eating pathology (Strober et al., 2000).
 Genetic studies
 Evidence suggesting a genetic basis for anorexia and
bulimia nervosa has emerged from molecular genetics
studies but almost no reliable findings have emerged
from genetic research on eating disorders.
GENETIC AND OTHER
BIOLOGICAL FACTORS
 Neuroendocrine and neurohormonal factors
 Serotonergic
 Histamergic
 Various peptidergic systems
 Brain structure and functioning studies
 Gray and white matter loss
 Increased ventricular size
 Increased cerebrospinal fluid volume
 Enlarged sulci
DEVELOPMENTAL
PROGRESSION
 Anorexia Nervosa
 Two peak periods of risk for anorexia nervosa onset: Around ages 14
and 18 (APA, 2000).
 Among adolescents with anorexia nervosa:
• 50% to 70% will recover
• 20% will show improvement but will exhibit residual symptoms
• 10% to 20% will develop a chronic course (Berkman et al., 2006; Wilson et al., 2003).
 Course of illness is on average 10 years (Strober, Freeman, & Morrell, 1997).
 Approximately 6% of patients diagnosed with this disorder die per
decade of illness.
 The suicide rate for anorexia nervosa is 57 times higher than in the
general population (Keel et al., 1997).
DEVELOPMENTAL
PROGRESSION
 Bulimia Nervosa
 Peak period of risk for onset for bulimia nervosa is between 14 and 19
years of age for females (Lewinsohn et al., 2000; Stice et al., 2009).
 Community-recruited samples suggest that bulimia nervosa typically shows
a chronic course characterized by periods of recovery and relapse
(Bohon,
Stice, & Burton, 2009).
 Studies have suggested that both diagnosable and subthreshold bulimia
nervosa are associated with future onset of:
•
•
•
•
•
•
Depression
Suicide attempts
Anxiety disorders
Substance abuse
Obesity
Health problems
(Fairburn, 2000; Johnson et al., 2002; Stice, Cameron, Killen, Hayward, & Taylor, 1999; Stice,
Hayward, Cameron, Killen, & Taylor, 2000; Striegel-Moore, Seeley, & Lewinsohn, 2003).
COMORBIDITY
 Anorexia Nervosa
 Adolescent comorbidity:
• Dysthymia, bipolar disorder, agoraphobia, simple phobia, marijuana
dependence, and oppositional defiant disorder
 Anxiety disorders often predate the eating disorder, and
depression often persists postrecovery (Kaye, Bulik, Thornton, et al., 2004;
Sullivan, Bulik, Fear & Pickering, 1998).
 Bulimia Nervosa
 Adolescent comorbidity:
• Major depression, dysthymia, bipolar disorder, agoraphobia, social
phobia, alcohol dependence, marijuana dependence, and conduct
disorder, but not with current simple phobia, overanxious disorder, panic
disorder, posttraumatic stress disorder, generalized anxiety disorder,
obsessive-compulsive disorder, oppositional defiant disorder, attention
deficit hyperactivity disorder, or other substance use disorders (Stice &
Peterson, 2007).
COMORBIDITY
 Binge Eating Disorder
 The National Comorbidity Survey Replication found that
78.9% of respondents with binge eating disorder met
criteria for at least one DSM-IV disorder, although no
particular disorder stood out as being more common than
others among those with binge eating disorder (Hudson et al.,
2007)
SEX DIFFERENCES and
CULTURAL CONSIDERATIONS
 Female to male sex ratios of the prevalence of anorexia nervosa
and bulimia nervosa are approximately 10:1
(APA, 2000).
 Striegel-Moore et al. (2005) noted different patterns of eating
disorder symptoms across ethnic/racial groups, reporting that binge
eating in the absence of purging was more common in African
American women, whereas purging in the absence of binge eating
was more common in Caucasian women.
 Several studies have found no racial or ethnic differences in the
prevalence of recurrent binge eating, eating disorder symptoms, or
risk factors for eating disorders (Smith et al., 1998).
 One consistent difference is that African Americans report less body
image dissatisfaction than their white counterparts.(Kronenfeld, RebaHarrelson, Von Holle, Reyes, & Bulik, 2010).
SYNTHESIS AND FUTURE
DIRECTIONS
 Developmental processes that give rise to eating
disorders are currently incomplete.
 Another key gap in the literature regards maintaining
factors—either psychosocial or biological—that
perpetuate eating-disordered behaviors once they
emerge.
 An improved understanding of risk factors is essential
for the design of more effective prevention programs,
and improved understanding of maintenance factors is
vital for the development of more effective treatment
interventions.