Eating Disorders

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Chapter 11
Slides Handouts by Karen Clay Rhines,
Ph.D. Seton Hall University

• Eating Disorders

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Eating Disorders

• Although not historically true, current Western
  beauty standards equate 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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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

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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

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Anorexia Nervosa

• About 9095 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

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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

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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

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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

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Anorexia Nervosa The Clinical Picture

• People with anorexia nervosa also think in
  distorted ways
• Often 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

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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

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

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Bulimia Nervosa

• The disorder is also characterized by
  compensatory behaviors, which mark the subtype of
  the disorder
• Purging-type bulimia nervosa
• Vomiting
• Misusing laxatives, diuretics, or enemas
• Nonpurging-type bulimia nervosa
• Fasting
• Exercising excessively

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Bulimia Nervosa

• Like anorexia nervosa, about 9095 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 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 condition is not yet listed in the DSM-IV-TR

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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 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

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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 1000
  calories (often more than 3000 calories) per
  binge episode

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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

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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

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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
  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

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

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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

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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

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

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What Causes Eating Disorders? Societal Pressures

• Many theorists believe 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

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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

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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

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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

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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 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 members lives

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What Causes Eating Disorders? Ego Deficiencies
and Cognitive Disturbances

• Bruch argues that eating disorders are the result
  of disturbed motherchild interactions which lead
  to serious ego deficiencies in the child and to
  severe cognitive disturbances

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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 childs
  biological and emotional needs
• Ineffective parents fail to attend to childs
  internal needs they feed when the child is
  anxious, comfort when the child is tired, etc.
• There is some empirical support for Bruchs
  theory from clinical reports

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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

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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 low levels of
  serotonin
• 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 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

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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)

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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, ?
  metabolism ? binges
• If weight rises above set point ? hunger, ?
  metabolism
• Dieters end up in a fight against themselves to
  lose weight

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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

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Treatments for Anorexia Nervosa

• The initial aims of treatment for anorexia
  nervosa are to
• Restore proper weight
• Recover from malnourishment
• Restore proper eating

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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
• 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

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Treatments for Anorexia Nervosa

• Researchers have found that people with anorexia
  must overcome their underlying psychological
  problems in order to achieve lasting improvement

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Treatments for Anorexia Nervosa

• Therapists use a mixture of therapy and education
  to achieve this broader goal, using a combination
  of individual, group, and family approaches
• 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

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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

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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

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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

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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

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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 behaviors recur in at least one-third of
  recovered patients, usually triggered by stress
• Many patients still express concerns about body
  shape and weight
• Lingering emotional problems are common

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Treatments for Bulimia Nervosa

• Treatment programs are relatively new but have
  risen in popularity
• Treatment is frequently offered in specialized
  eating disorder clinics

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Treatments for Bulimia Nervosa

• The initial 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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Treatments for Bulimia Nervosa

• Several treatment strategies
• Individual insight therapy
• The insight approach receiving the most attention
  is cognitive therapy, which helps clients
  recognize and change their maladaptive attitudes
  toward food, eating, weight, and shape
• As many as 65 stop their binge-purge cycle

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Treatments for Bulimia Nervosa

• Several treatment strategies
• Individual insight therapy
• If cognitive therapy isnt effective,
  interpersonal therapy (IPT), a treatment that
  seeks to improve interpersonal functioning, may
  be tried
• A number of clinicians also suggest self-help
  groups or self-care manuals

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Treatments for Bulimia Nervosa

• Several treatment strategies
• Behavioral therapy
• Behavioral techniques are often included in
  treatment as a supplement to cognitive therapy
• 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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Treatments for Bulimia Nervosa

• Several treatment strategies
• Antidepressant medications
• During the past decade, antidepressant drugs have
  been used in bulimia treatment
• Most common is fluoxetine (Prozac), an SSRI
• Drugs help as many as 40 of patients
• Medications are best when used in combination
  with other forms of therapy

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Treatments for Bulimia Nervosa

• Several treatment strategies
• Group therapy
• Provides an opportunity for patients to express
  their thoughts, concerns, and experiences with
  one another
• Helpful in as many as 75 of cases, especially
  when combined with individual insight therapy

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Treatments for Bulimia Nervosa

• Left untreated, bulimia can last for years
• Treatment provides immediate, significant
  improvement in about 40 of cases
• An additional 40 show moderate improvement
• Follow-up studies suggest that 10 years after
  treatment about 90 of patients have fully or
  partially recovered

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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

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Treatments for Bulimia Nervosa

• Finally, treatment may also help improve overall
  psychological and social functioning