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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 2 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 3 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 4 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 5 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 6 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 7 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 8 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 9 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 10 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 11 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 12 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 13 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 14 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 15 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 16 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 17 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 18 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 19 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 20 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 21 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 22 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 23 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 24 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 25 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 26 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 27 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 28 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 29 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 30 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 31 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 32 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 33 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 34 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 35 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 36 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 37 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 38 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 39 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 40 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 41 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 42 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 43 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 44 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 45 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 46 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 47 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 48 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 49 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 50 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 52 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 57 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 58 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 60 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 62 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 65