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

Chapter 11

Comer, Abnormal Psychology, 8eDSM-5 Update

Slides & Handouts by Karen Clay Rhines, Ph.D.American Public University System

2Comer, Abnormal Psychology, 8e

DSM-5 Update

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

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


DSM-5 Update

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


DSM-5 Update


DSM-5 Update

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


DSM-5 Update

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


DSM-5 Update

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

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


DSM-5 Update


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


DSM-5 Update


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”


DSM-5 Update


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


DSM-5 Update

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


DSM-5 Update

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


DSM-5 Update

Bulimia Nervosa

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

Misusing laxatives, diuretics, or enemas

Fasting

Exercising excessively


DSM-5 Update

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


DSM-5 Update

Bulimia Nervosa

Patients are generally of normal weight Often experience marked weight

fluctuations

Some may also qualify for a diagnosis of anorexia


DSM-5 Update

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


DSM-5 Update

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


DSM-5 Update

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


DSM-5 Update

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


DSM-5 Update

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…


DSM-5 Update

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


DSM-5 Update

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


DSM-5 Update


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


DSM-5 Update


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


DSM-5 Update

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


DSM-5 Update

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 doesn’t start following a diet, and there are not large gender differences in the prevalence of this disorder


DSM-5 Update

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


DSM-5 Update

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 mother–child interactions, which lead to serious ego deficiencies in the child and to severe perceptual disturbances


DSM-5 Update

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 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


DSM-5 Update


Cognitive Factors Bruch’s 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)


DSM-5 Update

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


DSM-5 Update

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


DSM-5 Update

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


DSM-5 Update


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)


DSM-5 Update


Factors 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


DSM-5 Update


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


DSM-5 Update


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


DSM-5 Update


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


DSM-5 Update


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 A recent survey of adolescent girls tied

eating disorders and body dissatisfaction to social networking, Internet activities, and television browsing


DSM-5 Update


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


DSM-5 Update


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


DSM-5 Update

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


DSM-5 Update



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


DSM-5 Update



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


DSM-5 Update


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 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


DSM-5 Update


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


DSM-5 Update


Gender Differences

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


DSM-5 Update

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


DSM-5 Update

Treatments for Anorexia Nervosa

The immediate aims of treatment for anorexia nervosa are to: Regain lost weight

Recover from malnourishment

Eat normally again


DSM-5 Update


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


DSM-5 Update


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


DSM-5 Update


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


DSM-5 Update


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”


DSM-5 Update


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


DSM-5 Update


Family therapy is important for anorexia nervosa treatment The main issues are often separation

and boundaries


DSM-5 Update


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


DSM-5 Update


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


DSM-5 Update


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


DSM-5 Update

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


DSM-5 Update


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


DSM-5 Update


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


DSM-5 Update


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


DSM-5 Update


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


DSM-5 Update


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


DSM-5 Update


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


DSM-5 Update


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


DSM-5 Update

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


DSM-5 Update

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


DSM-5 Update

Documents

Eating Disorders Chapter 11 Comer, Abnormal Psychology, 8e DSM-5 Update Slides & Handouts by Karen Clay Rhines, Ph.D. American Public University System