Download Comer, Abnormal Psychology, 7th edition

Eating Disorders
Chapter 11
Slides & Handouts by Karen Clay Rhines, Ph.D.
Northampton Community College
Comer, Abnormal Psychology, 7e
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, 7e
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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

Disturbed body perception

Amenorrhea
Comer, Abnormal Psychology, 7e
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Anorexia Nervosa

There are two main subtypes:


Restricting type

Lose weight by cutting out sweets and fattening
snacks, 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, 7e
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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, 7e
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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 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, 7e
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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
Comer, Abnormal Psychology, 7e
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Anorexia Nervosa:
The Clinical Picture

Despite their dietary restrictions, people
with anorexia nervosa 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, 7e
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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


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”
Comer, Abnormal Psychology, 7e
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Anorexia Nervosa:
The Clinical Picture

People with anorexia nervosa may also
display certain psychological problems:

Depression (usually mild)

Anxiety

Low self-esteem

Insomnia or other sleep disturbances

Substance abuse

Obsessive-compulsive patterns

Perfectionism
Comer, Abnormal Psychology, 7e
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Anorexia Nervosa:
Medical Problems

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
Comer, Abnormal Psychology, 7e
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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, 7e
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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

Eat objectively more than most people
would/could eat in a similar period
Comer, Abnormal Psychology, 7e
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Bulimia Nervosa

The disorder is also characterized by
inappropriate compensatory behaviors,
which mark the subtype of the condition:


Purging-type bulimia nervosa

Vomiting

Misusing laxatives, diuretics, or enemas
Nonpurging-type bulimia nervosa

Fasting

Exercising frantically
Comer, Abnormal Psychology, 7e
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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, 7e
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Bulimia Nervosa


Patients are generally of normal weight

Often experience marked 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 pattern is not yet listed in the DSM-IV-TR
Comer, Abnormal Psychology, 7e
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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
nervosa from friends or the media

According to global studies, 50% of
students report periodic binge-eating
or self-induced vomiting
Comer, Abnormal Psychology, 7e
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Bulimia Nervosa: Binges

For people with bulimia nervosa, the
number of binges per week can range from
1 to 30

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
Comer, Abnormal Psychology, 7e
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Bulimia Nervosa: Binges

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 self-blame, guilt,
depression, and fears of weight gain
and “discovery”
Comer, Abnormal Psychology, 7e
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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, 7e
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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, 7e
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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 low-calorie weight loss program found
that 62% of patients reported binge-eating
episodes during treatment
Comer, Abnormal Psychology, 7e
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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

Feelings of anxiety, depression, obsessiveness,
perfectionism

Substance abuse

Distorted body perception

Disturbed attitudes toward eating
Comer, Abnormal Psychology, 7e
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Bulimia Nervosa vs.
Anorexia Nervosa

Differences:

People with bulimia nervosa are more
worried 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, 7e
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Bulimia Nervosa vs.
Anorexia Nervosa

Differences:

People with bulimia nervosa tend to be controlled
by emotion – may change friendships easily

People with bulimia nervosa are more likely to
display characteristics of a 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, 7e
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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:

Psychological problems (ego, cognitive, and mood
disturbances)

Biological factors

Sociocultural conditions (societal and family pressures)
Comer, Abnormal Psychology, 7e
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What Causes Eating Disorders?
Psychodynamic Factors: Ego Deficiencies

Hilde Bruch developed a largely
psychodynamic theory of eating
disorders

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
Comer, Abnormal Psychology, 7e
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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
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
Comer, Abnormal Psychology, 7e
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What Causes Eating Disorders?
Cognitive Factors

Bruch’s theory also contains several
cognitive factors

According to cognitive theorists, such
deficiencies contribute to a broad
cognitive distortion that is at the center of
disordered eating (e.g., disproportionate
concerns about body shape and weight)
Comer, Abnormal Psychology, 7e
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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
Comer, Abnormal Psychology, 7e
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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 serotonin abnormalities

Symptoms of eating disorders are helped by
antidepressant medications
Comer, Abnormal Psychology, 7e
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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 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, 7e
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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)
Comer, Abnormal Psychology, 7e
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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,  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, 7e
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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

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, 7e
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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, 7e
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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 food,
along with rates of eating disorders, are
increasing in all groups
Comer, Abnormal Psychology, 7e
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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
Comer, Abnormal Psychology, 7e
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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
Comer, Abnormal Psychology, 7e
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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, 7e
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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
Comer, Abnormal Psychology, 7e
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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, 7e
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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, 7e
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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 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, 7e
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What Causes Eating Disorders?
Multicultural Factors:
Gender Differences

For other men, body image appears to
be a key factor

A new kind of eating disorder has
emerged and is found almost exclusively
among men – reverse anorexia nervosa or
muscle dysmorphobia
Comer, Abnormal Psychology, 7e
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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, 7e
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How Are Eating Disorders
Treated?

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, 7e
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Treatments for
Anorexia Nervosa

The initial aims of treatment for
anorexia nervosa are to:

Regain lost weight

Recover from malnourishment

Eat normally again
Comer, Abnormal Psychology, 7e
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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
In contrast, behavioral weight-restoration
approaches have clinicians use rewards
whenever patients eat properly or gain weight
Comer, Abnormal Psychology, 7e
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Treatments for
Anorexia Nervosa

The most popular weight-restoration
technique has been the combination of
supportive nursing care, nutritional
counseling, and high-calorie diets


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
Comer, Abnormal Psychology, 7e
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Treatments for
Anorexia Nervosa

Therapists use a combination of
therapy and education to achieve this
broader goal, using a combination of
individual, group, and family
approaches; psychotropic drugs have
been helpful in some cases
Comer, Abnormal Psychology, 7e
51
Treatments for
Anorexia Nervosa

In most treatment programs, a combination
of behavioral and cognitive interventions
are applied

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”

Such approaches can take place in either
individual or group therapy formats
Comer, Abnormal Psychology, 7e
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Treatments for
Anorexia Nervosa



Therapists help patients recognize their
need for independence and control
Therapists help patients recognize and trust
their internal feelings
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, 7e
53
Treatments for
Anorexia Nervosa

Another focus of treatment is
changing family interactions

Family therapy is important for anorexia
nervosa treatment

The main issues are often separation and
boundaries
Comer, Abnormal Psychology, 7e
54
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, 7e
55
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 nervosa is
declining
Comer, Abnormal Psychology, 7e
56
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 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
Comer, Abnormal Psychology, 7e
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Treatments for
Bulimia Nervosa


Treatment is frequently offered in
specialized eating disorder clinics
The immediate 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
Comer, Abnormal Psychology, 7e
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Treatments for
Bulimia Nervosa

Cognitive-behavioral therapy is
particularly helpful:

Behavioral techniques

Diaries are often a useful component of
treatment

Exposure and response prevention (ERP) is
used to break the binge-purge cycle
Comer, Abnormal Psychology, 7e
59
Treatments for
Bulimia Nervosa

Cognitive-behavioral therapy is
particularly helpful:

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
Comer, Abnormal Psychology, 7e
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Treatments for
Bulimia Nervosa

Cognitive-behavioral therapy is particularly
helpful:

Other forms of psychotherapy

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
Comer, Abnormal Psychology, 7e
61
Treatments for
Bulimia Nervosa

Cognitive-behavioral therapy is particularly
helpful:

Other forms of psychotherapy

Various forms of psychotherapy are often
supplemented by family therapy and may be offered in
either individual or group therapy format

Group therapy provides 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,
especially when combined with individual insight therapy
Comer, Abnormal Psychology, 7e
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Treatments for
Bulimia Nervosa

Antidepressant medications

During the past decade, all groups of
antidepressant drugs have been used in
bulimia nervosa treatment


Drugs help as many as 40% of patients
Medications are best when used in
combination with other forms of therapy
Comer, Abnormal Psychology, 7e
63
Treatments for
Bulimia Nervosa

Left untreated, bulimia nervosa can last for
years

Treatment provides immediate, significant
improvement in about 40% of cases


An additional 40% show moderate response
Follow-up studies suggest that 10 years
after treatment about 90% of patients have
fully or partially recovered
Comer, Abnormal Psychology, 7e
64
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
Comer, Abnormal Psychology, 7e
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