Chapter 11

1. Chapter 11 Eating Disorders Slides & Handouts by Karen Clay Rhines, Ph.D. Seton Hall University

2. 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 • The core issue is a morbid fear of weight gain • Two main diagnoses: • Anorexia nervosa • Bulimia nervosa

3. 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 • A distorted view of body weight and shape • Amenorrhea

4. Anorexia Nervosa • There are two main subtypes: • Restricting type • Lose weight by restricting “bad” foods, 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

5. Anorexia Nervosa • About 90–95% of cases occur in females • The peak age of onset is between 14 and 18 years • Around 0.5% 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

6. Anorexia Nervosa • The “typical” case: • A normal to slightly overweight female has been on a diet • Escalation to 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

7. Anorexia Nervosa: The Clinical Picture • The key goal for people with anorexia nervosa is thinness • The driving motivation is FEAR: • Of becoming obese • Of losing control of body shape and weight

8. Anorexia Nervosa: The Clinical Picture • Despite their dietary restrictions, people with anorexia 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

9. Anorexia Nervosa: The Clinical Picture • People with anorexia nervosa also demonstrate distorted thinking: • Often have a low opinion of their body shape • Tend to overestimate their actual proportions • Adjustable lens assessment technique – overestimate size by 20% • Hold maladaptive attitudes and beliefs • “I must be perfect in every way” • “I will be a better person if I deprive myself” • “I can avoid guilt by not eating”

10. Anorexia Nervosa: The Clinical Picture • People with anorexia may also display certain psychological problems: • Depression (usually mild) • Anxiety • Low self-esteem • Insomnia or other sleep disturbances • Substance abuse • Obsessive-compulsive patterns • Perfectionism

11. Caused by starvation: Amenorrhea Low body temperature Low blood pressure Body swelling Reduced bone density Slow heart rate Metabolic and electrolyte imbalance Dry skin, brittle nails Poor circulation Lanugo Anorexia Nervosa: Medical Problems

12. 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

13. Bulimia Nervosa • Bulimia nervosa, also known as “binge-purge syndrome,” is characterized by binges: • Bouts of uncontrolled overeating during a limited period of time • Often objectively more than most people would/could eat in a similar period

14. Bulimia Nervosa • The disorder is also characterized by 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 excessively

15. 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

16. Bulimia Nervosa • Patients are generally of normal weight • May be slightly overweight • Often experience weight fluctuations • “Binge-eating disorder” may be a related diagnosis • Symptoms include a pattern of binge eating with NO compensatory behaviors (such as vomiting) • This condition is not yet listed in the DSM

17. Bulimia Nervosa • Teens and young adults have frequently attempted binge-purge patterns as a means of weight loss, often after hearing accounts of bulimia from friends or the media • In one study: • 50% of college students reported periodic binges • 6% tried vomiting • 8% experimented with laxatives at least once

18. Bulimia Nervosa: Binges • For people with bulimia nervosa, the number of binges per week can range from 2 to 40 • Average: 10 per week • 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 1500 calories (often more than 3000 calories) per binge episode

19. Bulimia Nervosa: Binges • Binges are usually preceded by feelings of 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”

20. 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 • Affects ability to feel satiated  greater hunger and bingeing • Laxatives and diuretics • Almost completely fail to reduce the number of calories consumed

21. 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…

22. 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

23. 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 • Elevated risk of self-harm or attempts at suicide • Feelings of anxiety, depression, perfectionism • Substance abuse • Disturbed attitudes toward eating

24. Bulimia Nervosa vs. Anorexia Nervosa • Differences: • People with bulimia are more worried about pleasing others, being attractive to others, and having intimate relationships • People with bulimia tend to be more sexually experienced • People with bulimia display fewer of the obsessive qualities that drive restricting-type anorexia • People with bulimia are more likely to have histories of mood swings, low frustration tolerance, and poor coping

25. Bulimia Nervosa vs. Anorexia Nervosa • Differences: • People with bulimia tend to be controlled by emotion – may change friendships easily • People with bulimia are more likely to display characteristics of a personality disorder • Different medical complications: • Only half of women with bulimia experience amenorrhea vs. almost all women with anorexia • People with bulimia suffer damage caused by purging, especially from vomiting and laxatives

26. 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: • Sociocultural conditions (societal and family pressures) • Psychological problems (ego, cognitive, and mood disturbances) • Biological factors

27. What Causes Eating Disorders? Societal Pressures • Many theorists argue that current Western standards of female attractiveness have contributed to the rise 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

28. What Causes Eating Disorders? Societal Pressures • Certain groups 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 met full criteria for an eating disorder

29. What Causes Eating Disorders? Societal Pressures • Societal attitudes may explain economic and racial differences seen in prevalence rates • In the past, Caucasian women of higher SES expressed more concern about thinness and dieting • These women had higher rates of eating disorders than African American women or Caucasian women of lower SES • Recently, dieting and preoccupation with food, along with rates of eating disorders, are increasing in all groups

30. 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

31. What Causes Eating Disorders? Family Environment • Families may play a critical 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

32. What Causes Eating Disorders? Family Environment • Abnormal family interactions and forms of communication within a family may also set the stage for an eating disorder • Minuchin cites “enmeshed family patterns” as causal factors of eating disorders • These patterns include overinvolvement in, and overconcern about, family member’s lives • Such families can be affectionate and loyal but can also foster clinginess and dependency • Children are allowed little room for individuality and independence

33. What Causes Eating Disorders? Ego Deficiencies and Cognitive Disturbances • 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

34. What Causes Eating Disorders? Ego Deficiencies and Cognitive Disturbances • 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. • Children who receive such parenting may grow up confused and unaware of their own internal needs; they are unable to identify their own emotions • They turn to external guides (often parents) and fail to develop genuine self-reliance (i.e., they are not in control of their lives)

35. What Causes Eating Disorders? Ego Deficiencies and Cognitive Disturbances • There is some empirical support for Bruch’s theory from clinical sources • People with bulimia eat in response to emotions; many mistakenly think they are also hungry • People with eating disorders rely excessively on the opinions, wishes, and views of others • They are more likely to worry about how they are viewed, to seek approval, to be conforming, and to feel a lack of life control

36. 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

37. What Causes Eating Disorders? Mood Disorders • There is some 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 low levels of serotonin • Symptoms of eating disorders are helped by antidepressant medications

38. What Causes Eating Disorders? Biological Factors • Biological theorists suspect that some people inherit a genetic tendency to develop an eating disorder • Consistent with this model: • Relatives of people with eating disorders are 6 times more likely to develop the disorder themselves • Identical (MZ) twins with bulimia: 23% • Fraternal (DZ) twins with bulimia: 9% • These findings may be related to low serotonin

39. 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)

40. 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,  metabolism  binges • If weight rises above set point:  hunger,  metabolism • Dieters end up in a fight against themselves to lose weight

41. Treatments for Eating Disorders • 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

42. Treatments for Anorexia Nervosa • The initial aims of treatment for anorexia nervosa are to: • Restore proper weight • Recover from malnourishment • Restore proper eating

43. 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 force tube and intravenous feeding • This may breed distrust in the patient and create a power struggle • Most common technique now is the use of supportive nursing care and high calorie diets • Necessary weight gain is often achieved in 8 to 12 weeks

44. Treatments for Anorexia Nervosa • Researchers have found that people with anorexia must overcome their underlying psychological problems in order to achieve lasting improvement

45. Treatments for Anorexia Nervosa • Therapists use a mixture of therapy and education to achieve this broader goal • One focus of treatment is building autonomy and self-awareness • Therapists help patients recognize their need for independence and control • Therapists help patients recognize and trust their internal feelings

46. Treatments for Anorexia Nervosa • 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

47. Treatments for Anorexia Nervosa • Another focus of treatment is changing family interactions • Family therapy is important for anorexia • The main issues are often separation and boundaries

48. 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

49. 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 is declining

50. 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 • Relapses are usually triggered by stress • Many patients still express concerns about body shape and weight • Lingering emotional problems are common