abnormal psychology chapter 11

Eating Disorders

Chapter 11

Comer, Abnormal Psychology, 8e DSM-5 Update

Slides & Handouts by Karen Clay Rhines, Ph.D.

American Public University System

Eating Disorders

It has not always done so, but Western society today equates thinness with health and beauty Thinness has become a national obsession

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 Bulimia nervosa


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Eating Disorders

A third disorder binge eating disorder also appears to be on the rise

Fear of weight gain is not to the same degree as with anorexia or bulimia

People with this disorder display many of the other features found in those disorders


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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

Distorted view of weight and shape

Amenorrhea


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Anorexia Nervosa

There are two main subtypes:

Restricting type Lose weight by cutting out sweets and fattening snacks, eventually

eliminating nearly all food

Show almost no variability in diet

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


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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 3.5% of females in Western countries develop the disorder

Many more display at least some symptoms

Rates of anorexia nervosa are increasing in North America, Europe, and Japan


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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 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


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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 size and shape


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Despite their dietary restrictions, people with anorexia nervosa are 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


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Persons with anorexia nervosa also think in distorted ways: Usually have a low opinion of their body shape

Tend to overestimate their actual proportions Assessed using an adjustable lens 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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People with anorexia nervosa also display certain psychological problems: Depression 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

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


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Bulimia Nervosa

Bulimia nervosa, also known as binge-purge syndrome, is characterized by binges:

Repeated bouts of uncontrolled overeating during a limited period of time

Eat objectively more than most people would/could eat in a similar period


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Bulimia Nervosa

The disorder is also characterized by inappropriate compensatory behaviors, including:

Forced vomiting

Misusing laxatives, diuretics, or enemas

Fasting

Exercising excessively


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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


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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


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Bulimia Nervosa

Many teenagers and young adults go on occasional binges or experiment with vomiting or laxatives after hearing about these behaviors from friends or the media

According to global studies, 25-50% of students report periodic binge-eating or self-induced vomiting Only some of these individuals qualify for a diagnosis

of bulimia nervosa


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Bulimia Nervosa: Binges

People with bulimia nervosa may have between 1 and 30 binge episodes per week

Binges are often carried out in secret

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 as many as 10,000 calories per binge episode


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Bulimia Nervosa: Binges

Binges are usually preceded by feelings of great tension

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 being discovered


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Bulimia Nervosa: Compensatory Behaviors

After a binge, people with bulimia nervosa try to compensate for and undo the caloric effects

Many resort to vomiting

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


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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


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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 participants, bingeing often occurs after strict dieting


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Bulimia Nervosa vs. Anorexia Nervosa

Similarities: 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


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Differences:

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


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Differences:

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


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Binge Eating Disorder

Like those with bulimia, individuals with binge eating disorder engage in repeated eating binges during which they feel no control These individuals do not perform inappropriate

compensatory behaviors

As a result of their binges, two-thirds of people with this disorder become overweight or obese It is important to recognize, however, that most

overweight people do not engage in repeated binges


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Binge Eating Disorder

Between 2 and 7% of the population display binge eating disorder

The binges and many other symptoms that characterize this pattern are similar to those seen in bulimia

On the other hand, those with binge eating disorder are not driven to thinness, the disorder doesnt start following a diet, and there are not large gender differences in the prevalence of this disorder


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What Causes Eating Disorders?

Most theorists and researchers use a multidimensional risk perspective to explain eating disorders: Several key factors place individuals at risk More factors = greater likelihood of developing a

disorder Leading factors:

Psychological problems Biological factors Sociocultural conditions


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What Causes Eating Disorders? Psychodynamic Factors: Ego Deficiencies

Hilde Bruch developed a largely psychodynamic theory of eating disorders

Bruch argued that eating disorders are the result of disturbed motherchild interactions, which lead to serious ego deficiencies in the child and to severe perceptual disturbances


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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 childs biological

and emotional needs

Ineffective parents fail to attend to childs 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


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What Causes Eating Disorders? Cognitive Factors

Bruchs theory also contains several cognitive factors, like improper labeling of internal sensations and needs

According to cognitive theorists, these deficiencies contribute to a broad cognitive distortion that lies at the center of disordered eating (e.g., negative self-judgment based on body shape and weight)


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What Causes Eating Disorders? Depression

Many people with eating disorders, particularly those with bulimia nervosa, experience symptoms of depression

Theorists believe depressive disorders may set the stage for eating disorders


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What Causes Eating Disorders? Depression

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 depressive disorders

People with eating disorders, especially those with bulimia nervosa, have serotonin abnormalities

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 idea:

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


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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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Some theorists believe that the hypothalamus, related brain areas, and chemicals together 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


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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 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


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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


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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 thinness, along with rates of eating disorders, are increasing in all groups


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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

A recent survey of adolescent girls tied eating disorders and body dissatisfaction to social networking, Internet activities, and television browsing


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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 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 members lives


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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

The study also suggested that the groups had different ideals of beauty


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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


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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


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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 societys 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


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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


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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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How Are Eating Disorders Treated?

Eating disorder treatments have two main goals:

Correct dangerous 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


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Treatments for Anorexia Nervosa

The immediate aims of treatment for anorexia nervosa are to:

Regain lost weight

Recover from malnourishment

Eat normally again


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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


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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


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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


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In most treatment programs, a combination of behavioral and cognitive interventions are included

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


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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


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Family therapy is important for anorexia nervosa treatment

The main issues are often separation and boundaries


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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


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Positives of treatment:

Weight gain is often quickly restored

As many as 90% of patients still showed improvements after several years

Menstruation often returns with return to normal weight

The death rate from anorexia nervosa seems to be falling


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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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Treatments for Bulimia Nervosa

Treatment is frequently offered in 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


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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


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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


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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


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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 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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Antidepressant medications

During the past 15 years, 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


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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 75% of patients have fully or partially recovered


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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 Binge Eating Disorder

Given the key role of binges in both bulimia and binge eating disorder, treatments, too, are often similar

Cognitive-behavior therapy, other forms of psychotherapy, and, in some cases, antidepressant medications are provided to reduce or eliminate binge patterns and to change disturbed thinking

People with binge eating disorder who are overweight require additional intervention


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Treatments for Binge Eating Disorder

Now that binge eating disorder has been identified and is receiving considerable study, it is likely that specialized treatment programs will be emerging

In the meantime, little is known about the aftermath of the disorder


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