Chapter 12: Eating Disorders
What is the primary symptom that distinguishes individuals diagnosed with AN from those diagnosed with BN or binge eating disorder (BED)?
The primary symptom that distinguishes individuals with a diagnosis of AN from those with BN or BED is restriction of intake leading to a significantly low weight that is less than minimally normal or (in children or adolescents) less than minimally expected.
Polivy & German (2002)
-"(Bemporad, 1997) uncovered some interesting evidence of both anorexia nervosa and bulimia nervosa having existed since ancient times..." -"In the late 1960s, the previously obscure and extremely rare disorder AN became much more prevalent in Western societies. Young females from middle- and upper-class families were starving themselves, sometimes to death. The next decade saw the emergence of a new eating disorder, bulimia nervosa, wherein young women alternated self-starvation with binging, usually followed by purging (i.e. active attempts to rid the body of calories)."
When are binges most likely to occur and what are some common triggers for a binge?
-Clearly identifiable binge/purge episodes typically occur when the individual is alone, and evenings are especially high‐risk time. The behaviors are quite secretive and are usually associated with high levels of shame and embarrassment. Individuals with BN typically restrict their food intake, often severely, between binge/purge episodes. Many individuals binge primarily on the foods they otherwise restrict (e.g., high‐fat, high‐calorie foods), whereas others binge on whatever is available or eat large quantities of healthy foods. Individuals with BN frequently skip meals in an attempt to limit total intake and many feel at risk for bingeing or overeating whenever they do eat. Both type and amount of food may be severely limited by a set of rigid rules (e.g., no fat, no processed foods, no meat, no food after dinner or eating only at specified times). The most typical BN pattern is little or no breakfast or lunch, with intake postponed to as late as possible in the day. Early in the course of the disorder, binges are often unplanned (normal eating turns into overeating and then bingeing and purging). As the pattern crystallizes, it becomes more common that individuals fight the urge to binge and purge. -Common triggers for bingeing and purging include emotions (both positive and negative), lapses in self‐awareness, interpersonal stressors, the presence of tempting food, feeling that a dieting rule has been broken, body‐image dissatisfaction, and skipping meals or getting extremely hungry. Eating‐disordered behaviors often serve to distract individuals from unpleasant emotions, to comfort or soothe individuals, to numb unpleasant emotions, or to provide a sense of control. However, after bingeing and purging, individuals typically report feeling intense guilt and shame. Although binge episodes are intended to relieve negative mood, mood often worsens following them.
WHAT THE DIFFERENCE BETWEEN AN AND BN?
-Isn't bulimia nervosa the same as anorexia nervosa binge-purge type? --The critical difference is that only bulimic-type AN patients suppress their weight below normal limits, whereas BN tend to be at least of normal weight --In the DSM-IV-TR, AN had a cut-off of body weight less than 85% normal weight and amenorrhea. General thesis: -Anorexia and bulimia are the same disorder, expressed differently as a function of individual life experiences and temperament --e.g., Impulsivity/self-control --"Sexual promiscuity, suicide attempts, drug abuse, and stealing or shoplifting are frequently noted in BN patients (e.g., Matsunaga et al. 2000; Wiederman & Pryor 1996). Indeed, impulsiveness may be what makes an aspiring anorexic into a bulimic; if an individual intent on restricting her intake cannot resist food under certain circumstances, she may capitulate to temptation, binge, and then feel obliged to compensate afterward. This pattern would seem to characterize both BN and bulimic-type AN patients, the only difference being the weight level around which they fluctuate. "(Polivy & Herman, 2002; p. 189)
The family environment may foster eating disorders in that they fail to teach appropriate behaviors around eating; what other characteristics are common in families of eating disordered patients?
-Parental obesity is a risk factor for eating disorders, and in particular binge eating disorder. While this could be a result of shared genetic vulnerability to obesity (or impulsivity), it may also reflect more subtle environmental influences. Individuals with overweight family members are more likely to have been exposed to negative societal attitudes toward obesity and thus may impose pressure to exercise or diet on themselves. Similarly, parents who are overweight or concerned about weight or eating may exert excessive and unhelpful pressure on children to be thin in order to prevent them from developing weight problems. Families of individuals with eating disorders have been described as more chaotic, conflicted, and critical, and as lower in positive expressiveness, cohesion, and caring than other families. A negative family environment could increase anxiety and depression, which are in turn associated with the later development of eating disorders.
INTERNALIZING THE THIN IDEAL
-Person begins to assume seemingly dominant cultural perspective that equates adherence to certain physical standards with personal or social value -Individuals internalize attitudes that are approved of by significant or respected others (Kandel, 1980). -The socialization agents (e.g., media) reinforce the thin-ideal body image for women through comments or actions that serve to support and perpetuate this ideal (e.g., criticism or teasing regarding weight, encouragement to diet, and glorification of ultra-slender models) -These sources communicate expectations concerning the benefits of thinness, such as increased social acceptance, and these expectations likely play a key role in the propagation of this ideal (Hohlstein, Smith, & Atlas, 1998).
Bulimia: Symptoms profile
-Recurrent episodes of binge eating, characterized by both of the following: --Eating, in a discrete period of time, an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances. --A sense of lack of control over eating during the episodes (e.g., feeling that one cannot stop eating or control what or how much one is eating) -Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications; fasting, or excessive exercise. -The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for three months. -Self-evaluation is unduly influences by body shape and weight -The disturbance does not occur exclusively during episodes of anorexia nervosa. -Tracy: A typical binge would begin with a trip to the nearby grocery store. Tracy would buy a whole chicken and take it home to prepare. The process usually began with a glass of wine, which made her feel more relaxed (particularly on an empty stomach). As she sipped her wine, Tracy would bake the chicken and prepare a large batch of stuffing and mashed potatoes—almost like a Thanksgiving dinner. Then she would order two large sausage pizzas to be delivered from a local restaurant. While she was waiting for the chicken to bake and the pizzas to be delivered, she would eat cookies and potato chips while finishing her bottle of wine. Whenever she started to feel full, she would go in the bathroom and make herself throw up. This lengthy process of eating and regurgitation would continue until all the food was consumed. Tracy felt helpless and out of control during these binges, which often lasted 2 and sometimes as much as 3 hours. After the process started, it seemed to demand completion.
Anorexia Nervosa: Subtypes
-Restricting type: Person has not engaged in binge eating or purging. Weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise -Binge-purging type: Individual has engaged in recurrent episodes of binge eating or purging behavior (e.g., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). Joan: -This type of binge eating also happened whenever she did manage to buy something. In one afternoon, she would occasionally eat two dozen donuts, a five-pound box of candy, and some ice cream. After this, Joan took 20 to 30 laxatives to rid herself of the food. At times she made herself vomit by sticking a toothbrush down her throat, but she preferred to take laxatives. Some weeks she did not binge at all, others once or twice. On the days in between binges, she ate only a little fruit and drank some liquids. Tracy: -Tracy's notion of an appropriate diet bordered on the concept of starvation. She tried not to eat all day long. After skipping breakfast and lunch, she would invariably experience intense hunger pains during the afternoon. Not trusting these signals from her body, she would manage to fight them throughout the rest of the day. Tracy usually returned to her apartment around 7 or 8 o'clock at night after a hectic day of classes, meetings, and work. By that point, she would be starving. That was the point at which her binges were most likely to occur.
Anorexia Nervosa: DSM-V symptoms profile
-Restriction of energy intake(food) relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health --Significantly low weight defined as a weight that is less than minimally normal (more subjective than DSM-IV) -Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight -Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight Joan -Joan's diet was strict from the beginning: She measured and weighed all her food. Within a year, she weighed less than 100 pounds. Her food intake was severely restricted. During the day, she consumed only coffee with skim milk and an artificial sweetener. Occasionally, she ate a piece of fruit or a bran muffin. When she and Charlie [her son] ate dinner with her parents, Joan took a normal amount of food on her plate but played with it rather than eating it. After dinner, she usually excused herself to go to the bathroom where she took laxatives in an effort to get rid of what little food she had eaten. Joan hardly ate any meat, breads, or starches. She preferred fruits and vegetables because they consist mainly of water and fiber. Although she did not allow herself to eat, Joan still felt hungry; in fact, she was starving most of the time. She thought about food constantly, spent all her time reading recipes and health books, and cooked elaborate meals for the family.
PERSONALITY FACTORS
Bulimia-specific: -High impulsivity -Lack of forethought and failure to contemplate future consequences of current behavior -Sensation seeking: --Willingness to take personal/social risks to satisfy need for varied, novel and complex situations/experiences Humphrey (1991): -Genetic "self-soothing" deficits expressed through affective instability and impulsiveness TRACY -Like many of her peers, Tracy was rebellious as a teenager. Her father was lenient with her as she entered adolescence, allowing her to run with a crowd of wild boys and girls. Her friends were unconventional and viewed themselves as outsiders in their high school. Their group drank alcohol and smoked marijuana regularly, beginning in their early teens. Her father's house was occasionally the site for these gatherings because he was seldom around to supervise. After smoking marijuana, Tracy and her friends would get "the munchies" and consume large quantities of snacks and desserts (such as chips and cookies, which were in abundant supply at her father's house). This pattern of sporadic binge eating subverted more than one of her diet plans. Her weight increased noticeably.
What do genetic studies indicate with respect to genetic influences on eating disorders and gender differences? What does this findings suggest about the particular biological factors that might be implicated in the development of eating disorders in girls?
Developmental twin studies show that in females, overall levels of eating disorder symptoms exhibit no genetic influences before puberty, but significant genetic effects are observed from mid‐puberty on. The magnitude of genetic effects remains stable after puberty into middle adulthood, suggesting that all of the genetic risk becomes activated during puberty. However, in contrast to these findings in girls, results for male twins show no changes in genetic effects across pre‐ to early puberty, mid‐ to late puberty, or young adulthood. The heritability remains constant at approximately 50% in all age groups. These findings suggest that pubertal increases in genetic influences are specific to girls and point to the possibility that the ovarian hormones (estrogen and progesterone) that become activated during puberty and drive pubertal development in girls (e.g., breast development, increased adiposity) may be responsible.
EARLY PERSONALITY & TEMPERAMENTAL DIFFERENCES
Individuals with either disorder tend to be: -Perfectionistic: --Tendency to pursue unrealistically high standards despite aversive consequences --Note: Tends to be moderated by self-esteem -Obsessive-compulsive traits: --Doubting, checking, and need for symmetry and exactness -High levels of self-criticism and sensitivity to social approval and prone to rapid deflation of self-concept and self-denigration in responses to lack of recognition from others. Anorexia-specific: -High constraint -Low novelty seeking Strober (1991): -"the core of Anorexia Nervosa lies in genotypic personality structures that predispose...to rigid...avoidance behaviors with marked obsessional, anxious-depressive coloring" (p.11) Stereotypic presentation of anorectic restrictor: -Compliant, socially isolated, anxious female who gravitates towards orderliness and control -Crisp (1990): --Reserved, compliant child with marked conflicts around pubertal changes -Strober (1991): --Incompatibility between developmental imperatives surrounding puberty and temperament characterized by harm avoidance, hyper-reactivity to social approval, and preference for sameness.
CULTURAL & SOCIETAL FACTORS
Eating disorders do not occur at the same rate across cultures or time. -Ideals tend toward body shapes that are difficult to achieve under certain circumstances (e.g., an obsession with slimness in cultures where food is abundant) -Exposure to the "thin ideal" may underscore greater body dissatisfaction and, in turn, engagement in behaviors that are aimed at attaining this ideal. --The idealization of slimness and derogation of fatness in cultures of abundance is more intense for females than for males (Striegel-Moore 1993, 1997) --This sex-linked valuation of thinness is usually invoked to account for the fact that EDs are more than 10 times more prevalent in females than in males (Striegel-Moore 1997). If exposure to the thin ideal was the cause of eating disorders, then why don't we all have them? -Ubiquitous exposure to naturally thin (i/e/. The tail of the normal distribution of body weight) and un-naturally thin (i.e. products of exceptional efforts to maintain weight, photoshop, etc.) -Meta-analytic work suggests only small effects for media exposure to thin ideal --Could be that those preoccupied with weight seek out thin ideal media representations --Research shows risk of influence by thin ideals in the media moderated by other factors -Impact heightened in cultures that impede women's access to other means of self- definition -Contingencies in local social environment are often associated with eating disorders --Higher frequency in subcultures that place a special emphasis on slimness and weight control (e.g., ballet dancers, athletes, models, etc.)
What are the central tenets of Fairburn's transdiagnostic theory of eating disorders?
Fairburn's transdiagnostic theory identifies the centrality of overvaluation of eating, shape, and weight and their control across the range of eating pathology. Fairburn postulates that variations in eating symptomatology are all expressions of this overvaluation and argues that the mechanism of this core belief must be targeted in treatment. This transdiagnostic view of eating disorders is supported by data demonstrating similarities in risk factors, genetic mechanisms, neurobiological processes, and maintaining factors, as well as data showing significant diagnostic crossover over time.
FAMILY INFLUENCE
Families (and friends) often praise AN patients' slenderness, and envy the self-control and discipline required to achieve it (Branch & Eurman, 1980); this reinforcement frequently persists even when the anorexic becomes severely emaciated. Mothers of girls with EDs: -Think that their daughters should lose more weight and describe them as less attractive than do comparison mothers or the girls themselves (Hill & Franklin 1998, Pike & Rodin 1991). -Are more dissatisfied with the general functioning of the family system and are themselves more eating disordered than are mothers of girls who do not have EDs (Hill & Franklin 1998, Pike & Rodin 1991). -Direct maternal comments appear to be more powerful influences than is simple modeling of weight and shape concerns (Ogden & Steward 2000, Smolak et al. 1999), although even modeling does appear to affect elementary schoolchildren's weight and shape-related attitudes and behaviors (Smolak et al. 1999). -Mothers' critical comments prospectively predicted ED outcome for their daughters (Vanfurth et al. 1996). Tracy -When Tracy was 13 years old, her mother—who was now 36—suddenly reappeared...Tracy was initially struck by her mother's stunning appearance. She was beautiful—still very thin and exquisitely dressed. As they got to know each other better, however, Tracy's mother became more intrusive and critical of Tracy's behavior and appearance. She began to tell Tracy that it wouldn't hurt for her to lose a few pounds. Tracy's younger half-sister was also very thin, like their mother. She and Tracy soon found themselves competing for their mother's attention. -Tracy and her mother began to spend more time together on weekends and holidays. She admired her mother. It was fun to have a mom who would take her out to lunch and dote on her. As they got to know each other better, however, Tracy's mother became more intrusive and critical of Tracy's behavior and appearance. She began to tell Tracy that it wouldn't hurt for her to lose a few pounds. Tracy's younger half-sister was also very thin, like their mother. She and Tracy soon found themselves competing for their mother's attention. -At her mother's suggestion, Tracy started to experiment with various kinds of diets. Her mother recommended a sequence of diets that had worked for her. Unfortunately, nothing worked for very long when Tracy tried it. If she did manage to lose 10 pounds, she would gain it back within 3 months. Her weight fluctuated for the next few years between 120 and 145 pounds -Her half-sister seemed to be able to eat more than Tracy without gaining weight. Her half-sister and stepfather were always given bigger servings than Tracy, as her mother reminded her to watch what she ate. Whenever Tracy expressed an interest in having a light dessert, her mother would smile at her and ask, "Do you really think you should do that?"
What differentiates BED from BN?
For a diagnosis of BED, the OBEs must be characterized by three of the following five descriptors: eating more rapidly than normal; eating until uncomfortably full; eating large amounts when not hungry; eating alone due to embarrassment; and feeling disgusted, depressed, or very guilty after overeating. These descriptors have been added to help distinguish the problematic eating pattern of BED from the less pathological overeating that is problematic primarily because it contributes to obesity. While the binge behavior must be reported as distressing, the BED criteria do not require the display of overconcern with weight/shape that is a requirement for BN.
What are some physical consequences of continued binging/purging?
Individuals with BN may develop fluid or electrolyte abnormalities (leading to potentially fatal arrhythmias), esophageal complications, gastrointestinal (GI) symptoms, renal system problems, menstrual irregularities, and thyroid dysfunction. Medical complications related to prolonged laxative abuse, another common form of purging, include reflex constipation and the loss of normal colonic function (cathartic colon syndrome; Mehler, 2010). However, many individuals show few medical indicators for extended periods of time. Russell's sign (scarring or calluses on the tops of the hands from repeatedly inducing vomiting), dental problems (dental enamel erosion, gum disease), and enlarged parotid glands (chipmunk‐like cheeks) are often the only obvious signs of chronic vomiting. It is useful for dentists to ask about purging when atypical dental problems are evident. Laboratory tests (for salivary amylase) can be used as an indicator of inflammation of the parotid glands, and positive results may mean the person is purging; but this test is not a specific indicator, so it is not widely used.
Although restrictive behaviors can take many forms, which one is seen as most prominent in AN and what are some examples?
Intentional dieting that results in an unhealthy low weight is the hallmark of AN. Hours may be spent calculating calories and planning meals. Converting to vegetarianism in the context of dieting can be an early sign of disordered eating. Only certain foods come to be seen as safe to consume, and the list of permissible foods typically becomes smaller over time until often a patient eats the exact same thing every day. Some patients drink excessive amounts of water to control hunger, while others will consume very little water because it appears to increase their weight or makes them feel bloated. They may weigh themselves frequently and may feel the day is ruined if their weight has not decreased. Exercise may initially be fairly normal in quantity and quality, but compulsive exercise patterns develop where attempts to interrupt the behavior are met with extreme resistance. The patient may feel he or she must exercise in order to be allowed to eat, or may exercise after meals to burn off the calories consumed. Some patients will not miss a day despite illness or injury and will forgo almost any other activity to ensure they can exercise. Some individuals exercise at such a high level that their caloric intake may actually be in the normal range, referred to clinically as exercise anorexia. Such individuals refuse to eat "unhealthy" foods and to increase calories sufficiently to achieve or maintain a healthy weight. Alternatively, some individuals with AN may not engage in intense physical activity but may instead spend large amounts of time standing or fidgeting, behaviors that they appear to engage in more often than healthy controls do and that may contribute to relapse
What does interoceptive awareness have to do with eating disorders?
Interoceptive awareness refers to the ability to identify internal sensations, including both physiological and emotional states. Women with eating disorders report poor interoceptive awareness, and this inability to identify internal sensations prospectively predicts onset of eating disorder symptoms. Some research suggests that even after recovery these women continue to struggle with identifying their internal states. However, specific intervention to train appetite awareness has been shown to improve awareness of internal hunger and satiety cues.
CONSEQUENCES
Joan: -As she lost weight, Joan experienced several of the physical effects that accompany starvation. Her periods stopped; she had problems with her liver; her skin became dry and lost its elasticity; her hair was no longer healthy; and she would often get dizzy when she stood up. Tracy: -Unfortunately, Tracy also returned home in the early stages of an expanding eating disorder. She was already starting to experience some physical consequences from throwing up repeatedly. She had severe stomach pains. One of her friends commented on the fact that she frequently had very bad breath. As her secret problem escalated, she became more embarrassed and ashamed.
What are some of the physical consequences of malnutrition?
Malnutrition affects most organ systems, as the body responds to manage a starvation state and conserves energy by cutting back on all but the most essential functions. Blood flow to the periphery is decreased, leading to cold extremities. Skin becomes dry and hair falls out, while the body becomes coated with lanugo, a fine downy hair meant to conserve warmth. Menstruation stops or becomes irregular, and fertility is impaired. Along with these hormonal changes, calcium is lost from the bones, leading to osteopenia or in severe cases to osteoporosis. In children who are still growing, growth can be slowed or stopped. Heart and brain function are preserved for as long as possible but eventually the cardiac muscle weakens, leading to low heart rate, low blood pressure, and possible death. Brain scans have shown shrinkage of the brain during the illness that reverses with weight restoration. Of all these complications, the only one known to definitely persist after weight restoration is osteoporosis, the severity of which depends on the duration of the illness.
HOW DO EDS SERVE TO DEAL WITH CONTINUING EMOTIONAL OR IDENTITY PROBLEMS?
One can gain some emotional control by refocusing one's attention onto weight, shape, and eating -The AN patient achieves at least partial emotional gratification by avoiding food and achieving slimness (albeit never enough). -The BN patient gains emotional relief by bingeing (and then by purging). For both, obsessive focus on weight loss and its associated tactics provide a narrow, apparently viable way to channel identity concerns (and to avoid dealing with broader issues). -More recent theorists concur that an extreme need to control both eating and other aspects of behavior is a central feature of EDs (Fairburn et al. 1999). JOAN: -Although she weighed less than 100 pounds, Joan still felt overweight and believed that she would look better if she lost more weight. She had an overwhelming fear of getting fat because she believed that gaining weight would mean that she was not perfect. She tried to be a model young adult and struggled to be what she imagined everybody else wanted. She gave little thought to what she would want for herself. She felt like everything in her life was out of her control except for her weight and body. The demonstration of strict self-control over eating was a source of pride and accomplishment to Joan.
PEER INFLUENCE
Peer influences on body dissatisfaction appear stronger than media effects. Peers can influence body dissatisfaction by two main routes: -May actively influence women through verbal comments, communication of beauty norms, explicit verbal comparisons, and attributions of personal value based on beauty. -May passively influence body dissatisfaction by provoking internal or unconscious body comparisons.
BODY DISSATISFACTION
Sometimes operationalized as the gap between one's actual and ideal weight/shape; -However, one may see one's body as far from ideal and yet still be reasonably satisfied with it. -More direct assessment of BD involves asking people specifically how (dis)satisfied they are with their bodies or parts thereof. Viewed as final common pathway for social risk factors; however, not all of those dissatisfied with their body develop EDs: -"Why is it that of two dissatisfied people, one throws herself into (usually futile) attempts to achieve a satisfactory body, whereas the other remains dissatisfied but does not diet/starve, binge, or purge?" (Pivony & Herman, 2002)
AGE OF ONSET
Symptoms of ED or early vestiges of the disorder are evident in early adolescents, with actual emergence typical in early adulthood -Though AN tends to develop earlier than BN JOAN -Joan lost some weight after she and Charlie were involved in a serious car accident, 6 months after moving back to live with her parents. Charlie was not hurt, but Joan's left hip and leg were broken. She spent a month in the hospital. She was immobile when she came home, and her mother had to take even greater care of her and Charlie. Joan needed repeated surgery on her knee, as well as extensive physical therapy, and she had to relearn how to walk. During her recovery, she had little appetite, was nauseated, and did not eat much, but she was not consciously dieting. Joan's weight went down to about 110 pounds, which she considered to be a reasonable weight. After breaking up with Jack, Joan lived with her parents for 2 more years. When she was 29 years old, almost 3 years after her accident, Joan returned to the hospital for more surgery on her leg. After being discharged, she began the diet that set the stage for 5 years of serious eating problems and nearly destroyed her life... She was concerned that she would start to gain more weight while she was inactive, recovering from surgery. TRACY -Like most other teenagers, Tracy was self-conscious about her body and the changes that she was going through at this time. Whatever doubts she already had about her own figure and appearance were seriously exacerbated by these competitive interactions with her mother and half-sister.
In addition to anorexia nervosa (AN) and bulimia nervosa (BN), what additional diagnostic categories were added in the DSM-V and why?
The DSM‐5 maintained the historical distinction between AN and BN, which is based primarily on weight, but it greatly expanded the scope of eating disorder diagnoses. These changes were needed because more than half the individuals presenting for eating concerns failed to meet criteria for AN or BN. In DSM‐5, BED has been added as a distinct diagnosis and the criteria for AN and BN have been modified to be more inclusive. In addition, the category Other Specified Feeding or Eating Disorder (OSFED) was added, which identifies subthreshold variants of AN, BN, and BED, as well as the syndromes called purging disorder and night‐eating syndrome. The hope is that these changes will facilitate research to improve our understanding of different developmental pathways, encourage earlier detection and diagnosis, and promote the development of effective strategies that target specific presenting patterns.
On what critical symptom does the diagnosis of BN center? What is the difference between an objective binge episode and a subjective binge episode?
The diagnostic criteria for bulimia nervosa (BN) center around the presence of recurrent objective binge episodes (OBEs) and the various compensatory behaviors such as vomiting, laxative use, fasting, or excessive exercise that are intended to minimize the impact of the binges (i.e., to prevent weight gain). OBEs are defined as eating more than most people would eat in a similar situation and in a discrete period of time (e.g., 2 hours) and with a sense of loss of control over eating (i.e., feeling unable to control what or how much food is consumed). Assessing loss of control can be problematic as some individuals have difficultly reporting on their experience, and many in fact "plan" when they are going to binge eat. Episodes in which loss of control is endorsed but where normal or even small portions are reported are labeled subjective binge episodes (SBEs); these are common but do not count toward the frequency criterion required for diagnosis. The clinical guideline for determining large amounts is a portion at least 3 times the typical portion size for that food. The caloric value reported by Bartholome, Raymond, Lee, Peterson, and Warren (2006) for an objective binge episode averaged 1,900 calories and for a subjective binge episode about 700 calories. The OBEs and compensatory behaviors may be closely linked in time, forming a distinct binge/purge episode that is easily identifiable, but that is not necessarily the case. OBEs and compensatory behaviors are required to occur at least once per week for 3 months for a diagnosis of BN; these criteria represent a decrease from those in the DSM‐IV (twice per week for 6 months), allowing less severe and more recent onset cases to be diagnosed. Individuals who do not meet the weight criterion for AN but who purge only after SBEs or solely as a deliberate weight control strategy are diagnosed with purging disorder (which is in the OSFED category). This pattern is clinically significant as it may persist over considerable periods of time or may serve as a pathway to either AN or BN.
LIFE HISTORY
There does appear to be a connection between childhood sexual abuse (CSA) and bulimic symptomatology (Everill & Waller 1995), although CSA is also associated with depression and other psychological disturbances. -Kent & Waller (2000) maintain that childhood emotional abuse (CEA)—possibly through its profound influence on self-esteem and anxiety—is the only type of childhood trauma that predicts eating pathology in adults. -By refocusing one's attention onto weight, shape, and eating, one enters a domain in which one can gain some emotional control or by providing a stable sense of identity to guide behavior
Patients with AN tend to overestimate their body size relative to their true body size. From what process is this likely the result and how is this relevant to treatment avoidance?
This body‐image distortion likely results from a consistent and persistent overfocus on the body as a whole or on specific parts of the body (e.g., thighs, buttocks, cheeks) in an attempt to assess the success of efforts to lose weight or fat. Initially, this focus may be a source of limited reassurance, much in the way that constant checking of weight on a scale may be, because changes can be seen and measured. However, over time, the hyperfocus on the body leads to greater and greater distortions and misperceptions. This can also lead to a severe distortion in evaluating the medical consequences of being severely underweight. This denial of the seriousness of malnutrition is a major source of treatment avoidance and represents a significant psychological hazard for successful weight restoration.
What factors may associate with a person's adoption of the "thin ideal"?
With the obvious deluge of images of overly thin women in the mass media, one misperception is that eating disorders are largely due to misguided efforts (i.e., excessive dieting) to attain our culture's thin ideal. As noted above, it has been difficult to establish the degree to which dieting is a direct risk factor. Similarly, efforts to document a clear causal relationship between the level of media exposure and eating disorders have not shown consistent, strong effects. Rather, research suggests that the transmission of the thin ideal may be occurring more indirectly, given data that individuals who immigrate to a Western culture and those living in relatively more urban than rural areas are at increased risk for eating disorders. Two points are worth noting here. First, individuals clearly differ in the extent to which they personally adopt the predominant culture's thin ideal. The degree of internalization of the thin ideal and the degree to which a person personally feels pressured by others to be thin appear to be more closely associated with the development of other risk factors (i.e., body dissatisfaction) and eating pathology than simply with degree of media exposure. Furthermore, while media exposure appears to increase the risk of body dissatisfaction and subsequent dieting as well as binge eating, particularly among individuals already at increased risk for disordered eating, media exposure appears to play less of a role in maintaining already established eating disorder symptoms