PSY3032 Week 11: Body Image and Eating Disorders

Preventive Interventions for Eating Disorders

A different approach to treating eating disorders involves prevention. Intervening with children or adolescents before the onset of eating disorders may help to prevent these disorders from ever developing. Broadly speaking, three different types of preventive interventions have been developed and implemented: 1. Psychoeducational approaches. The focus is on educating children and adolescents about eating disorders in order to prevent them from developing the symptoms. 2. Deemphasizing sociocultural influences. The focus here is on helping children and adolescents resist or reject sociocultural pressures to be thin. 3. Risk factor approach. The focus here is on identifying people with known risk factors for developing eating disorders (e.g., weight and body-image concern, dietary restraint) and intervening to alter these factors. Research has found that the most effective prevention programs are those that are interactive rather than didactic, include adolescents age 15 or older, include girls only, and involve multiple sessions rather than just one session. Some effects appear to last as long as two years.

A group of researchers developed this questionnaire to measure concerns about dieting and overeating in a laboratory setting, studying people who are dieting and have distorted attitudes about eating.

The restraint scale

anorexia nervosa

The term anorexia refers to loss of appetite, and nervosa indicates that the loss is due to emotional reasons. The term is something of a misnomer because most people with anorexia nervosa actually do not lose their appetite or interest in food. On the contrary, while starving themselves, most people with the disorder become preoccupied with food; they may read cookbooks constantly and prepare gourmet meals for their families.

Eating disorders first appeared in the DSM in __________ as one subcategory of disorders beginning in childhood or adolescence.

1980

Currently, nearly __________ percent of Americans are obese, setting the stage for greater conflict between the cultural ideal and reality.

30

Do eating disorders and weight concerns go away as women get older?

A large, 20-year prospective study of over 600 men and women reported important differences in dieting and other eating disorder risk factors for men and women The men and women were first surveyed about dieting, BMI, weight, body image, and eating disorder symptoms when they were in college. Follow-up surveys were completed 10 and 20 years after college. Thus, the men and women were around age 40 at the 20-year follow-up assessment. The researchers found that after 20 years, women dieted less and were less concerned about their weight and body image compared to when they were in college, even though they actually weighed more. In addition, eating disorder symptoms decreased over the 20 years for women, as did the risk factors for eating disorders (concern about body image, frequency of dieting). Changes in life roles—having a life partner, having a child—were also associated with decreases in eating disorder symptoms for women. By contrast, men were more concerned about their weight and were dieting more. Like women, they weighed more in their early forties than when they were in college. Decreases in risk factors such as concern about body image and dieting frequency were also associated with decreases in eating disorder symptoms for men.

prevalence of bulimia

About 90 percent of cases are women, and prevalence among women is thought to be about 1 to 2 percent of the population (Hoek & van Hoeken, 2003). Many people with bulimia nervosa were somewhat overweight before the onset of the disorder, and the binge eating often started during an episode of dieting. Although both anorexia nervosa and bulimia nervosa among women begin in adolescence, they can persist into adulthood and middle age (Keel et al., 2010; Slevec & Tiggemann, 2011).

Psychological Treatment of Binge Eating Disorder

Although not as extensively studied as with bulimia nervosa, cognitive behavior therapy has been shown to be effective for binge eating disorder in several studies ( CBT for binge eating disorder targets binges as well as restrained eating by emphasizing self-monitoring, self-control, and problem solving as regards eating. Gains from CBT appear to last for up to 1 year after treatment. CBT also appears to be more effective than treatment with fluoxetine Randomized controlled clinical trial have shown that interpersonal therapy (IPT) is equally effective as CBT and guided self-help CBT for binge eating disorder. These three treatments are more effective than behavioral weight-loss programs, which are often used to treat obesity. More specifically, CBT and IPT reduce binge eating (but not necessarily weight), whereas behavioral weight-loss programs may promote weight loss but do not curb binge eating. One recent study compared three treatments for binge eating disorder: (1) therapist-led group CBT, (2) therapist-assisted group CBT, and (3) structured self-help group CBT with no therapist. Results showed that people in the therapist-led group CBT had the greatest reduction in binge eating at 6-month and 12-month follow-ups but that all groups had a greater reduction in binges than a group of people assigned to a wait-list control group (Peterson et al., 2009). Fewer people dropped out of the therapist-led group as well. Thus, having a therapist lead a CBT group may help keep people in treatment and help reduce binges, but, importantly, people in the therapist-assisted and "therapist-free" groups also showed reductions in binges. Given that therapist cost and/or availability may limit treatment for some people, having options such as these available is promising.

medication

Because bulimia nervosa is often comorbid with depression, it has been treated with various antidepressants, such as fluoxetine (Prozac). In one multicenter study, 387 women with bulimia were treated as outpatients for 8 weeks. Fluoxetine was shown to be superior to a placebo in reducing binge eating and vomiting; it also decreased depression and lessened distorted attitudes toward food and eating. Findings from most studies, including double-blind studies with placebo controls, confirm the efficacy of a variety of antidepressants in reducing purging and binge eating, even among people who had not responded to prior psychological treatment On the negative side, many people with bulimia drop out of drug treatment. In the multicenter fluoxetine study cited, almost one-third of the women dropped out before the end of the 8-week treatment, primarily because of the side effects of the medication. In contrast, fewer than 5 percent of women dropped out of cognitive behavior therapy. Moreover, most people relapse when various kinds of antidepressant medication are withdrawn, as is the case with many psychoactive drugs. There is some evidence that this tendency to relapse is reduced if antidepressants are given in the context of cognitive behavior therapy. Medications have also been used to treat anorexia nervosa. Unfortunately, they have not been very successful in improving weight or other core features of anorexia. Medication treatment for binge eating disorder has not been as well studied. Limited evidence suggests that antidepressant medications are not effective in reducing binges or weight loss. Recent trials of antiobesity drugs, such as sibutramine and atomoxetine, show some promise in binge eating disorder, but additional clinical trials are needed.

prognosis

Between 50 and 70 percent of people with anorexia eventually recover. (Keel & Brown, 2010). However, recovery often takes 6 or 7 years, and relapses are common before a stable pattern of eating and weight maintenance is achieved (Strober, Freeman, & Morrell, 1997). As we discuss later, changing peoples' distorted views of themselves is very difficult, particularly in cultures that value thinness. Anorexia nervosa is a life-threatening illness; death rates are 10 times higher among people with the disorder than among the general population and twice as high as among people with other psychological disorders. Mortality rates among women with anorexia range from 3 to 5 percent (Crow et al., 2009; Keel & Brown, 2010). Death most often results from physical complications of the illness—for example, congestive heart failure—and from suicide (Herzog et al., 2000; Sullivan, 1995).

prevalence of BED

Binge eating disorder appears to be more prevalent than either anorexia nervosa or bulimia nervosa (Hudson et al., 2007). In the National Comorbidity Survey—Replication study, the prevalence was 3.5 percent for women and 2 percent for men. Research suggests that binge eating disorder is more common in women than men, although the gender difference is not as great as it is in anorexia or bulimia. Though only a few epidemiological studies have been done, binge eating disorder appears to be equally prevalent among European, African, Asian, and Hispanic Americans (Striegel-Moore & Franco, 2008). Binge eating disorder is comorbid with depression and anxiety disorders (Wonderlich et al., 2009).

genetic factors

Both anorexia nervosa and bulimia nervosa run in families. First-degree relatives of young women with anorexia nervosa are more than ten times more likely than average to have the disorder themselves. Similar results are found for bulimia nervosa, where first-degree relatives of women with bulimia nervosa are about four times more likely than average to have the disorder Furthermore, first-degree relatives of women with eating disorders appear to be at higher risk for anorexia or bulimia. Although eating disorders are quite rare among men, one study found that first-degree relatives of men with anorexia nervosa were at greater risk for having anorexia nervosa (though not bulimia) than relatives of men without anorexia Finally, relatives of people with eating disorders are more likely than average to have symptoms of eating disorders that do not meet the complete criteria for a diagnosis. Twin studies of eating disorders also suggest a genetic influence. Most studies of both anorexia and bulimia report higher MZ than DZ concordance rates and that genes account for a portion of the variance among twins with eating disorders On the other hand, research has shown that nonshared/unique environmental factors, like different interactions with parents or different peer groups, also contribute to the development of eating disorders. For example, a study of more than 1,200 twin pairs found that 42 percent of the variance in bulimia symptoms was attributable to genetic factors but 58 percent of the variance was attributable to unique environmental factors. Research also suggests that key features of the eating disorders, such as dissatisfaction with one's body, a strong desire to be thin, binge eating, and preoccupation with weight, are heritable Additional evidence suggests that common genetic factors may account for the relationship between certain personality characteristics, such as negative emotionality and constraint, and eating disorders. The results of these studies are consistent with the possibility that genes play a role in eating disorders, but studies showing how genetic factors interact with the environment are needed.

bulimia nervosa

Bulimia is from a Greek word meaning "ox hunger." This disorder involves episodes of rapid consumption of a large amount of food, followed by compensatory behavior, such as vomiting, fasting, or excessive exercise, to prevent weight gain. The DSM defines a binge as having two characteristics. First it involves eating an excessive amount of food, that is, much more than most people would eat, within a short period of time (e.g., 2 hours). Second, it involves a feeling of losing control over eating—as if one cannot stop. Bulimia nervosa is not diagnosed if the bingeing and purging occur only in the context of anorexia nervosa and its extreme weight loss; the diagnosis in such a case is anorexia nervosa, binge-eating/purging type. The key difference between anorexia and bulimia is weight loss: people with anorexia nervosa lose a tremendous amount of weight, whereas people with bulimia nervosa do not. In bulimia, binges typically occur in secret; they may be triggered by stress and the negative emotions they arouse, and they continue until the person is uncomfortably full Research suggests that people with bulimia nervosa sometimes ingest enormous quantities of food during binges, often more than what a person eats in an entire day; however, binges are not always as large as the DSM implies, and there is wide variation in the caloric content consumed by people with bulimia nervosa during binges (e.g., Rossiter & Agras, 1990). People report that they lose control during a binge, even to the point of experiencing something akin to a trancelike state, perhaps losing awareness of their behavior or feeling that it is not really they who are bingeing. They are usually ashamed of their binges and try to conceal them. After the binge is over, feelings of discomfort, disgust, and fear of weight gain lead to the second step of bulimia nervosa—the inappropriate compensatory behavior (also known as purging) to attempt to undo the caloric effects of the binge. People with bulimia most often stick fingers down their throats to cause gagging, but after a time many can induce vomiting at will without gagging themselves. Laxative and diuretic abuse (which do little to reduce body weight) as well as fasting and excessive exercise are also used to prevent weight gain. The DSM-5 diagnosis of bulimia nervosa requires that the episodes of bingeing and compensatory behavior occur at least once a week for 3 months.

onset of bulimia

Bulimia nervosa typically begins in late adolescence or early adulthood.

psychological treatment of bulimia

Cognitive behavior therapy (CBT) is the best-validated and most current standard for the treatment of bulimia. In CBT, people with bulimia are encouraged to question society's standards for physical attractiveness. People with bulimia must also uncover and then change beliefs that encourage them to starve themselves to avoid becoming overweight. They must be helped to see that normal body weight can be maintained without severe dieting and that unrealistic restriction of food intake can often trigger a binge. They are taught that all is not lost with just one bite of high-calorie food and that snacking need not trigger a binge, which will be followed by induced vomiting or taking laxatives, which in turn will lead to still lower self-esteem and depression. Altering this all-or-nothing thinking can help people begin to eat more moderately. They also learn assertiveness skills, which help them cope with unreasonable demands placed on them by others, as well as more satisfying ways of relating to people. The overall goal of treatment in bulimia nervosa is to develop normal eating patterns. People with bulimia need to learn to eat three meals a day and even some snacks between meals without sliding back into bingeing and purging. Regular meals control hunger and thereby, it is hoped, the urge to eat enormous amounts of food, the effects of which are counteracted by purging. To help people with bulimia develop less extreme beliefs about themselves, the cognitive behavior therapist gently but firmly challenges such irrational beliefs. A generalized assumption underlying these and related cognitions for women might be that a woman has value only if she is a few pounds underweight—a belief that is presented in the media and advertisements. One intervention that is sometimes used in the cognitive behavioral treatment approach has the patient bring small amounts of forbidden food to eat in the session. Relaxation is employed to control the urge to induce vomiting. Unrealistic demands and other cognitive distortions—such as the belief that eating a small amount of high-calorie food means that the patient is an utter failure and doomed never to improve—are continually challenged. The therapist and patient work together to identify events, thoughts, and feelings that trigger an urge to binge and then to learn more adaptive ways to cope with these situations. The outcomes of cognitive behavioral therapies are rather promising, both in the short term and over time. A meta-analysis showed that CBT yielded better results than antidepressant drug treatments, and therapeutic gains were maintained at 1-year follow-up, nearly 6 years later, and 10 years later. Findings from a number of studies indicate that CBT often results in less frequent bingeing and purging, with reductions ranging from 70 to more than 90 percent. Extreme dietary restraint is also reduced significantly, and there is improvement in attitudes toward body shape and weight. However, if we focus on the people themselves rather than on numbers of binges and purges across people, we find that at least half of those treated with CBT improve very little. Clearly, while CBT may be the most effective treatment available for bulimia, it still has room for improvement. Some studies have examined whether adding exposure and ritual prevention (ERP) to CBT for bulimia might boost the treatment effects of CBT. This ERP component involves discouraging the person from purging after eating foods that usually elicit an urge to vomit. In one study, the combination of ERP and CBT was more effective than CBT without ERP, at least in the short term. ERP may not continue to be an advantage over the long term, however. One study examined outcome 3 years after treatment for people with bulimia who had received CBT either with or without ERP. 85 percent of people with bulimia did not meet criteria for bulimia 3 years after treatment, regardless of which treatment they had received. People with bulimia who are successful in overcoming their urge to binge and purge also improve in associated problem areas such as depression and low self-esteem. CBT alone is more effective than any available drug treatment. Adding antidepressant drugs, however, may be useful in alleviating the depression that often occurs with bulimia. Another form of CBT, called guided self-help CBT, has also shown promise for some people. In this type of treatment, people receive self-help books on topics like perfectionism, body image, negative thinking, and food and health. Patients meet for a small number of sessions with a therapist who helps guide them through the self-help material. Preliminary results suggest that this is an effective treatment compared to a wait-list control group and to traditional CBT for bulimia. In addition, greater confidence in one's ability to change is associated with better outcomes In several other studies, interpersonal therapy (IPT) fared well in comparisons with CBT, though it did not produce results as quickly. Family therapy is also effective for bulimia, though it has been studied less frequently than either CBT or IPT. A recent randomized clinical trial demonstrated that family-based therapy was superior to supportive psychotherapy for adolescents with bulimia with respect to decreasing bingeing and purging up to 6 months after treatment was completed.

cognitive behavioural factors- anorexia

Cognitive behavioral theories of anorexia nervosa emphasize fear of fatness and body-image disturbance as the motivating factors that powerfully reinforce weight loss. Many who develop anorexia symptoms report that the onset followed a period of weight loss and dieting. Behaviors that achieve or maintain thinness are negatively reinforced by the reduction of anxiety about becoming fat. Furthermore, dieting and weight loss may be positively reinforced by the sense of mastery or self-control they create. Some theories also include personality and sociocultural variables in an attempt to explain how fear of fatness and body-image disturbances develop. For example, perfectionism and a sense of personal inadequacy may lead a person to become especially concerned with his or her appearance, making dieting a potent reinforcer. Similarly, seeing portrayals in the media of thinness as an ideal, being overweight, and tending to compare oneself with especially attractive others all contribute to dissatisfaction with one's body. Another important factor in producing a strong drive for thinness and a disturbed body image is criticism from peers and parents about being overweight. In one study supporting this conclusion, adolescent girls aged 10 to 15 were evaluated twice, with a 3-year interval between assessments. Obesity at the first assessment was related to being teased by peers and at the second assessment was linked to dissatisfaction with their bodies. Dissatisfaction was in turn related to symptoms of an eating disorder. It is known that bingeing frequently results when diets are broken. Thus, when a lapse occurs in the strict dieting of a person with anorexia nervosa, the lapse is likely to escalate into a binge. The purging after an episode of binge eating can again be seen as motivated by the fear of weight gain that the binge elicited. People with anorexia who do not have episodes of bingeing and purging may have a more intense preoccupation with and fear of weight gain or may be more able to exercise self-control.

This component of CBT (Cognitive Behavior Therapy) involves discouraging the patient from purging after eating foods that usually elicit an urge to vomit.

ERP

Distorted body image or sense of body shape

Even when emaciated, those with anorexia nervosa maintain that they are overweight and that certain parts of their bodies, particularly the abdomen, hips, and thighs, are too fat. To check on their body size, they typically weigh themselves frequently, measure the size of different parts of the body, and gaze critically at their reflections in mirrors. Their self-esteem is closely linked to maintaining thinness.

cross-cultural studies

Evidence for eating disorders across cultures depends on the disorder. Anorexia has been observed in a number of cultures and countries besides the United States; for example, in Hong Kong, China, Taiwan, England, Korea, Japan, Denmark, Nigeria, South Africa, Zimbabwe, Ethiopia, Iran, Malaysia, India, Pakistan, Australia, the Netherlands, and Egypt. Furthermore, cases of anorexia have been documented in cultures with very little Western cultural influence. An important caveat must be made, however. The anorexia observed in these diverse cultures does not always include the intense fear of gaining weight or being fat that is part of the DSM criteria, at least initially. Thus, intense fear of fat likely reflects an ideal more widely espoused in more Westernized cultures. A 20-year study of eating disorders in Hong Kong found evidence of Western influence in both the prevalence and presentation of eating disorders (Lee et al., 2010). First, both anorexia and bulimia were twice as common in 2007 than they were in 1987. Second, 25 percent more women reported body dissatisfaction and fear of fat in 2007 than in 1987. Thus, in a fairly short period of time, eating disorders in Hong Kong appear to have become more Western. Another feature of eating disorders that may be heavily influenced by Western ideals of beauty and thinness is body image. In a study supporting the notion of cross-cultural differences in body-image perception, Ugandan and British college students rated the attractiveness of drawings of nudes ranging from very emaciated to very obese. Ugandan students rated the obese females as more attractive than did the British students. Bulimia nervosa appears to be more common in industrialized societies, such as the United States, Canada, Japan, Australia, and Europe, than in nonindustrialized nations. However, as cultures undergo social changes associated with adopting the practices of more Westernized cultures, particularly the United States (Watters, 2010), the incidence of bulimia appears to increase. A comprehensive review of research on culture and eating disorders conducted nearly 10 years ago could not find evidence of bulimia outside of a Westernized culture

neurotransmitters and eating disorders

Finally, some research has focused on neurotransmitters related to eating and satiety (feeling full). Animal research has shown that serotonin promotes satiety. Therefore, it could be that the binges of people with bulimia result from a serotonin deficit that causes them not to feel satiated as they eat. Animal research has also shown that food restriction interferes with serotonin synthesis in the brain. Thus, among people with anorexia, the severe food intake restrictions could interfere with the serotonin system. Researchers have examined levels of serotonin metabolites among people with anorexia and bulimia. Several studies have reported low levels of serotonin metabolites among people with anorexia and bulimia. Lower levels of a neurotransmitter's metabolites are one indicator that the neurotransmitter activity is underactive. In addition, people with anorexia who have not been restored to a healthy weight show a poorer response to serotonin agonists (i.e., drugs that stimulate serotonin receptors) than those people who have regained a good portion of their weight, again suggesting an underactive serotonin system. People with bulimia also show smaller responses to serotonin agonists The antidepressant drugs that are often effective treatments for anorexia and bulimia (discussed later) are known to increase serotonin activity, adding to the possible importance of serotonin. Serotonin, though, could also be linked to the comorbid depression often found in anorexia and bulimia. More recently, researchers have examined the role of the neurotransmitter dopamine in eating behavior. Studies with animals have shown that dopamine is linked to the pleasurable aspects of food that compel an animal to go after food, and brain imaging studies in humans have shown how dopamine is linked to the motivation to obtain food and other pleasurable or rewarding things. In one study with healthy people, participants were presented with smells and tastes of food while undergoing a PET scan. The participants also filled out a measure of dietary restraint. People who scored higher on dietary restraint exhibited greater dopamine activity in the dorsal striatum area of the brain during the presentation of food. This finding suggests that restrained eaters may be more sensitive to food cues, since one of the functions of dopamine is to signal the salience of particular stimuli. Whether or not these findings will be relevant to people with eating disorders remains to be seen. A small fMRI study of 14 women with anorexia nervosa and 14 women without an eating disorder found that women with anorexia reported feeling more positively about pictures of underweight women compared to pictures of normal or overweight women (Fladung et al., 2010). The women without anorexia felt more positively when viewing pictures of normal-weight women. Brain activation matched these ratings of feelings: women with anorexia showed greater activation in the ventral striatum, an area of the brain linked to dopamine and reward, than women without anorexia when viewing pictures of underweight women. Another study found that women with either anorexia nervosa or bulimia nervosa had greater expression of the dopamine transporter gene DAT The expression of DAT influences the release of a protein that regulates the reuptake of dopamine back into the synapse. This study also found that women with either eating disorder exhibited less expression of another dopamine gene called DRD2. Other studies have found disturbances in the DRD2 gene only among women with anorexia These findings point to the role of dopamine in eating disorders and will need to be replicated in future studies.

ethnic differences

Indeed, there is a somewhat greater incidence of eating disturbances and body dissatisfaction among white women than black women, but differences in actual eating disorders, particularly bulimia, do not appear to be as great. In addition, the greatest differences between white and black women in eating disorder pathology appear to be most pronounced in college student samples; fewer differences are observed in either high school or nonclinical community samples. Finally, a meta-analysis found more similarities than differences in body dissatisfaction among ethnic groups in the United States. White women and Hispanic women reported greater body dissatisfaction than African American women, but no other ethnic differences were reliably found. Studies show that white teenage girls diet more frequently than do African American teenage girls and are more likely to be dissatisfied with their bodies. The relationship between BMI and body dissatisfaction also differs by ethnicity. Compared with African American adolescents, white adolescents become more dissatisfied with their bodies as their BMI rises. Socioeconomic status is also important to consider. The emphasis on thinness and dieting has spread beyond white women of upper and middle socioeconomic status to women of lower socioeconomic status, as has the prevalence of eating disorder pathology. In addition, acculturation, the extent to which someone assimilates their own culture with a new culture, may be another important variable to consider. This process can at times be quite stressful. A recent study found that the relationship between body dissatisfaction and bulimia symptoms was stronger for African American and Hispanic college students who reported higher levels of acculturative stress compared to those students who reported lower levels of this type of stress. The diagnosis of bulimia was more likely for women who had lived in the United States for several years than for women who had recently immigrated, indicating that acculturation may play a role. In contrast to other eating disorders, anorexia nervosa was very rare among Latina women (only 2 out of over 2,500 women had a lifetime history of anorexia).

subtypes of anorexia nervosa

Initial research indicated a number of differences between these two subtypes, thus supporting the validity of this distinction. For example, studies have shown that people with the binge-eating/purging subtype exhibit more personality disorders, impulsive behavior, stealing, alcohol and drug abuse, social withdrawal, and suicide attempts than do people with the restricting type of anorexia (e.g., Herzog et al., 2000; Pryor, Wiederman, & McGilley, 1996). Longitudinal research, however, suggests the distinction between subtypes may not be all that useful (Eddy et al., 2002). Nearly two-thirds of women who initially met criteria for the restricting subtype had switched over to the binge-eating/purging type 8 years later. Furthermore, this study found few differences in substance abuse or personality disturbances between the two subtypes. A review of the subtype literature for the preparation of DSM-5 concluded that the subtypes had limited predictive validity even though clinicians found them useful

Intense fear of gaining weight and being fat.

Intense fear of gaining weight and being fat. This fear is not reduced by weight loss. There is no such thing as "too thin."

personality influences

It is also important to keep in mind that an eating disorder itself can affect personality. A study of semistarvation in male conscientious objectors conducted in the late 1940s supports the idea that the personality of people with eating disorders, particularly those with anorexia, is affected by their weight loss. For a period of 6 weeks, the men were given two meals a day, totaling 1,500 calories, to simulate the meals in a concentration camp. On average, the men lost 25 percent of their body weight. They all soon became preoccupied with food; they also reported increased fatigue, poor concentration, lack of sexual interest, irritability, moodiness, and insomnia. Four became depressed, and one developed bipolar disorder. This research shows vividly how severe restriction of food intake can have powerful effects on personality and behavior, which we need to consider when evaluating the personalities of people with anorexia and bulimia. In part as a response to the findings just mentioned, some researchers have collected retrospective reports of personality before the onset of an eating disorder. This research describes people with anorexia as having been perfectionistic, shy, and compliant before the onset of the disorder. The description of people with bulimia includes the additional characteristics of histrionic features, affective instability, and an outgoing social disposition. Prospective studies examine personality characteristics before an eating disorder is present. One study found that perfectionism prospectively predicted the onset of anorexia in young adult women. Additional research has taken a closer look at the link between perfectionism and anorexia. Perfectionism is multifaceted and may be self-oriented (setting high standards for oneself), other-oriented (setting high standards for others), or socially oriented (trying to conform to the high standards imposed by others). A recent review of many studies concludes that perfectionism, no matter how it is measured, is higher among girls with anorexia than girls without anorexia and that perfectionism remains high even after successful treatment for anorexia. A multinational study found that people with anorexia scored higher on self- and other-oriented types of perfectionism than people without anorexia. Finally, mothers of girls with anorexia scored higher on perfectionism than mothers of girls without anorexia. This intriguing finding needs to be replicated, but it suggests that what is genetically transmitted in anorexia could be a personality characteristic, such as perfectionism, that increases the vulnerability for the disorder rather than the disorder per se.

Risk factors- BED

It is linked to impaired work and social functioning, depression, low self-esteem, substance use disorders, and dissatisfaction with body shape (Spitzer et al., 1993; Striegel-Moore et al., 1998, 2001). Risk factors for developing binge eating disorder include childhood obesity, critical comments regarding being overweight, weight-loss attempts in childhood, low self-concept, depression, and childhood physical or sexual abuse (Fairburn et al., 1998; Rubinstein et al., 2010). One behavior genetics study (Hudson et al., 2006) found that relatives of obese people with binge eating disorder were more likely to have binge eating disorder themselves (20 percent) than were relatives of obese people without binge eating disorder (9 percent).

prevalence

Lifetime prevalence of anorexia is less than 1 percent, and it is at least 10 times more frequent in women than in men (Hoek & van Hoeken, 2003). When anorexia nervosa does occur in men, symptomatology and other characteristics, such as reports of family conflict, are generally similar to those reported by women with the disorder (Olivardia et al., 1995) The gender difference in the prevalence of anorexia most likely reflects the greater cultural emphasis on women's beauty, which has promoted a thin shape as the ideal over the past several decades.

physical consequences of bulimia nervosa

Like anorexia, bulimia is associated with several physical side effects. Although less common than in anorexia, menstrual irregularities, including amenorrhea, can occur, even though people with bulimia typically have a normal body mass index (BMI) (Gendall et al., 2000). The BMI is calculated by dividing weight in kilograms by height in meters squared and is considered a more valid estimate of body fat than many others. For women, a normal BMI is between 20 and 25. To calculate your own BMI. Bulimia nervosa, like anorexia, is a serious disorder with many unfortunate medical consequences (Mehler, 2011). For example, frequent purging can cause potassium depletion. Heavy use of laxatives induces diarrhea, which can also lead to changes in electrolytes and cause irregularities in the heartbeat. Recurrent vomiting has been linked to menstrual problems and may lead to tearing of tissue in the stomach and throat and to loss of dental enamel as stomach acids eat away at the teeth, which become ragged. The salivary glands may become swollen. Death from bulimia nervosa was once thought to be less common than from anorexia nervosa (Herzog et al., 2000; Keel & Brown, 2010; Keel & Mitchell, 1997), but a recent study of nearly 1000 women with bulimia nervosa found the mortality rate to be nearly 4 percent (Crow et al., 2009).

physical consequences of binge eating disorder

Like the other eating disorders, there are physical consequences of binge eating disorder. Many of the physical consequences are likely a function of associated obesity, including increased risk of type 2 diabetes, cardiovascular problems, breathing problems, insomnia, and joint/muscle problems. However, research shows that a number of physical problems are present among people with binge eating disorder that are independent from co-occurring obesity, including sleep problems, anxiety, depression, irritable bowel syndrome, and, for women, early onset of menstruation (Bulik &. Reichborn-Kjennerud, 2003).

prognosis bulimia nervosa

Long-term follow-ups of people with bulimia nervosa reveal that close to 75 percent recover, although about 10 to 20 percent remain fully symptomatic (Keel et al., 1999; 2010; Reas et al., 2000; Steinhausen & Weber, 2009). Intervening soon after a diagnosis is made (i.e., within the first few years) is linked with an even better prognosis (Reas et al., 2000). People with bulimia nervosa who binge and vomit more and who have comorbid substance use or a history of depression have a poorer prognosis than people without these factors (Wilson et al., 1999).

DSM 5 changes to bulimia

Minimum frequency of bingeing/purging once/week instead of twice/week for at least 3 months Subtypes removed

DSM 5 changes to BED

New category in DSM-5 This was in the Appendix in DSM-IV-TR as a category in need of further study; additional research supports its addition to the DSM-5

gender influences

One primary reason for the greater prevalence of eating disorders among women is likely due to the fact that Western cultural standards about thinness have changed over the past 50 years, today reinforcing the desirability of being thin for women more than for men. Another sociocultural factor, though, has remained remarkably resilient to change—namely, the objectification of women's bodies. Women's bodies are often viewed through a sexual lens; in effect, women are defined by their bodies, whereas men are esteemed more for their accomplishments. According to objectification theory, the prevalence of objectification messages in Western culture (in television, advertisements, and so forth) has led some women to "self-objectify," which means that they see their own bodies through the eyes of others. Research has shown that self-objectification causes women to feel more shame about their bodies. Shame is most often elicited in situations where an individual's ideal falls short of a cultural ideal or standard. Thus, women likely experience body shame when they observe a mismatch between their ideal self and the cultural (objectified) view of women. Research has also shown that both self-objectification and body shame are associated with disordered eating

cognitive factors- bulimia and BED

People with bulimia nervosa are also thought to be overconcerned with weight gain and body appearance; indeed, they judge their self-worth mainly by their weight and shape. They also have low self-esteem, and because weight and shape are somewhat more controllable than are other features of the self, they tend to focus on weight and shape, hoping their efforts in this area will make them feel better generally. They try to follow a pattern of restrictive eating that is very rigid, with strict rules regarding how much to eat, what kinds of food to eat, and when to eat. These strict rules are inevitably broken, and the lapse escalates into a binge. After the binge, feelings of disgust and fear of becoming fat build up, leading to compensatory actions such as vomiting. Although purging temporarily reduces the anxiety from having eaten too much, this cycle lowers the person's self-esteem, which triggers still more bingeing and purging, a vicious circle that maintains desired body weight but has serious medical consequences. One group of researchers developed the Restraint Scale, a questionnaire measure of concerns about dieting and overeating. These researchers have conducted a series of laboratory studies on people with high scores on this measure. These studies are generally conducted under the guise of being taste tests. One such study was described as an assessment of the effects of temperature on taste. To achieve a "cold" condition, some participants first drank a 15-ounce chocolate milk shake (termed a preload by the investigators) and were then given three bowls of ice cream to taste and rate for flavor. Participants were told that once they had completed their ratings, they could eat as much of the ice cream as they wanted. The researchers then measured the amount of ice cream eaten. In laboratory studies following this general design, people who scored high on the Restraint Scale ate more than nondieters after a fattening preload, even when the preload was perceived as fattening but was actually low in calories and even when the food was relatively unpalatable. Thus, people who score high on the Restraint Scale show a pattern similar to that of people with bulimia nervosa, albeit at a much less intense level. Several additional conditions have been found to further increase the eating of restrained eaters after a preload, most notably various negative mood states, such as anxiety and depression. The increased consumption of restrained eaters is especially pronounced when their self-image is threatened and if they have low self-esteem. Finally, when restrained eaters are given false feedback indicating that their weight is high, they respond with increases in negative emotion and increased food consumption. The eating pattern of people with bulimia or binge eating disorder is similar to, but more extreme than, the behavior highlighted in the studies of restrained eaters. People with bulimia nervosa or binge eating disorder typically binge when they encounter stress and experience negative affect, as has been shown in several studies. In ecological momentary assessment (EMA), the investigators are able to show how specific binge-and-purge events are linked to changes in emotions and stress in the course of daily life. A meta-analysis of 82 EMA studies found that negative affect preceded the onset of a binge among people with bulimia or binge eating disorder, but the effect sizes were stronger for binge eating disorder. The binge may therefore function as a means of regulating negative affect. However, the meta-analysis of EMA studies also showed that people with bulimia or binge eating disorder experienced more negative affect after the binge, so the use of bingeing as a way to regulate affect appears not to be very successful. Evidence also supports the idea that stress and negative affect are relieved by purging. That is, negative affect levels decline and positive affect levels increase after a purge event, supporting the idea that purging is reinforced by negative affect reduction. Given the similarities between people who score high on the Restraint Scale and people with bulimia nervosa, we might expect that restrained eating would play a central role in bulimia. In fact, a study of the naturalistic course of bulimia (i.e., the course of bulimia left untreated) has found that the relationship between concern over shape and weight and binge eating was partially mediated by restrained eating. In other words, concerns about body shape and weight predicted restrained eating, which in turn predicted an increase in binge eating across 5 years of follow-up assessments. Research methods from cognitive science have been used to study how attention, memory, and problem solving are impacted in people with eating disorders. Using cognitive tasks such as the Stroop task and the dot probe test, research shows that people with anorexia and bulimia focus their attention on food-related words or images more than other images. People with anorexia nervosa and people who score high on restrained eating remember food words better when they are full but not when they are hungry. Other studies have found that college women with eating disorder symptoms pay attention to and better remember images depicting other people's body size more than images depicting emotion. Thus, women with eating disorders pay greater attention not only to their own bodies, food, and weight but also to other women's bodies, food, and shapes. This bias toward food and body image may make it harder for women with eating disorders to change their thinking patterns.

prognosis of binge eating disorder

Perhaps because it is a relatively new diagnosis, fewer studies have assessed the prognosis of binge eating disorder. Research so far suggests that between 25 and 82 percent of people recover (Keel & Brown, 2010; Striegel-Moore & Franco, 2008). One retrospective study found that people reported having their binge eating disorder for an average of 14.4 years, which is much longer than people with anorexia or bulimia report having their disorders (Pope et al., 2006).

binge eating disorder DSM

Recurrent binge eating episodes Binge eating episodes include at least three of the following: eating more quickly than usual eating until over full eating large amounts even if not hungry eating alone due to embarrassment about large food quantity feeling bad (e.g., disgusted, guilty, or depressed) after the binge No compensatory behavior is present

bulimia nervosa DSM

Recurrent episodes of binge eating Recurrent compensatory behaviors to prevent weight gain, for example, vomiting Body shape and weight are extremely important for self-evaluation

DSM 5 changes to anorexia

Restriction of food that leads to very low body weight rather than "refusal to maintain weight" as a criterion A focus on low weight rather than normal weight Loss of menstrual period no longer required for diagnosis. It was removed, however, in DSM-5 because there are many reasons why women can stop having their menstrual period that do not have anything to do with weight loss. In addition, few differences have been found between women who have amenorrhea and the other three features of anorexia nervosa and those women who have the other three features but do not have amenorrhea Subtypes specified for past 3 months rather than just current episode

anorexia nervosa DSM

Restriction of food that leads to very low body weight; body weight is significantly below normal Intense fear of weight gain Body image disturbance

physical consequences of anorexia

Self-starvation and use of laxatives produce numerous undesirable biological consequences in people with anorexia nervosa. Blood pressure often falls, heart rate slows, kidney and gastrointestinal problems develop, bone mass declines, the skin dries out, nails become brittle, hormone levels change, and mild anemia may occur. Some people lose hair from the scalp, and they may develop lanugo—a fine, soft hair—on their bodies. As in Lynne's case, levels of electrolytes, such as potassium and sodium, are altered. These ionized salts, present in various bodily fluids, are essential to neural transmission, and lowered levels can lead to tiredness, weakness, cardiac arrhythmias, and even sudden death.

child abuse and eating disorders

Some studies have indicated that self-reports of childhood sexual abuse are higher among people with eating disorders than among people without eating disorders, especially those with bulimia nervosa some research indicates that memories of abuse may be created in therapy, it is notable that high rates of sexual abuse have been found among people with eating disorders who have not been in treatment as well as those who have. Still, the role of childhood sexual abuse in the etiology of eating disorders remains uncertain. Furthermore, high rates of childhood sexual abuse are found among people with different diagnoses, so if it plays some role, it may not be highly specific to eating disorders Research has also found higher rates of childhood physical abuse among people with eating disorders. These data suggest that future studies should focus on a broad range of abusive experiences. Furthermore, it has been suggested that the presence or absence of abuse may be too general a variable. Abuse at a very early age, involving force and by a family member, may bear a stronger relationship to eating disorders than abuse of any other type.

characteristics of families

Studies of the characteristics of families of people with eating disorders have yielded variable results. Some of the variation stems, in part, from the different methods used to collect the data and from the sources of the information. For example, self-reports of people with eating disorders consistently reveal high levels of conflict in the family. Reports of parents, however, do not necessarily indicate high levels of family problems. Family characteristics may contribute to the risk for developing an eating disorder; however, eating disorders also likely have an impact on family functioning. One study assessed both people with eating disorders and their parents on tests designed to measure rigidity, closeness, emotional overinvolvement, critical comments, and hostility. The families showed considerable variation in whether parents were overinvolved with their children; the families were also quite low in conflict (low levels of criticism and hostility). A family study in which assessments were conducted before and after treatment of the patient found that ratings of family functioning improved after treatment. Finally, one study examined identical twins discordant for bulimia (i.e., one twin had the disorder; the other didn't). The twin who developed bulimia reported greater family discord than the twin who did not develop the disorder. Because these studies rely on retrospective self-reports, it remains unclear whether the family discord was a contributory factor or consequence of the eating disorder. Although an adolescent's perception of his or her family's characteristics is important, we also need to know how much of reported family discord is perceived and how much is consistent with others' perceptions. In one of the few observational studies conducted thus far, parents of children with eating disorders did not appear to be very different from control parents. The two groups did not differ in the frequency of positive and negative messages given to their children, and the parents of children with eating disorders were more self-disclosing than were the controls. The parents of children with eating disorders did lack some communication skills, however, such as the ability to request clarification of vague statements. Observational studies such as this, coupled with data on perceived family characteristics, would help determine whether actual or perceived family characteristics are related to eating disorders.

assessments of distorted body image in anorexia

The distorted body image that accompanies anorexia nervosa has been assessed in several ways, most frequently by a questionnaire such as the Eating Disorders Inventory (Garner, Olmsted, & Polivy, 1983). In another type of assessment, people with anorexia nervosa are shown line drawings of women with varying body weights and asked to pick the one closest to their own and the one that represents their ideal shape. People with anorexia overestimate their own body size and choose a thin figure as their ideal. Despite this distortion in body size, people with anorexia nervosa are fairly accurate when reporting their actual weight (McCabe et al., 2001), perhaps because they weigh themselves frequently. One interesting study found a slightly different pattern for men with eating disorders. Men with eating disorders didn't differ from men without eating disorders when pointing to their ideal male body type. However, the men with eating disorders overestimated their own body size considerably, thus demonstrating a distortion in their own body images.

neurobiological factors

The hypothalamus is a key brain center for regulating hunger and eating. Research on animals with lesions to the lateral hypothalamus indicates that they lose weight and have no appetite. Thus, it is not surprising that the hypothalamus has been proposed to play a role in anorexia. The level of some hormones regulated by the hypothalamus, such as cortisol, is indeed abnormal in people with anorexia. Rather than causing the disorder, however, these hormonal abnormalities occur as a result of self-starvation, and levels return to normal after weight gain. Furthermore, the weight loss of animals with hypothalamic lesions does not parallel what we know about anorexia. These animals appear to have no hunger and to become indifferent to food, whereas people with anorexia continue to starve themselves despite being hungry and having an interest in food. Nor does the hypothalamic model account for body-image disturbance or fear of becoming fat. A dysfunctional hypothalamus thus does not seem highly likely as a factor in anorexia nervosa. Endogenous opioids are substances produced by the body that reduce pain sensations, enhance mood, and suppress appetite. Opioids are released during starvation and have been hypothesized to play a role in both anorexia and bulimia. Starvation among people with anorexia may increase the levels of endogenous opioids, resulting in a positively reinforcing euphoric state. Furthermore, the excessive exercise seen among some people with eating disorders would increase opioids and thus be reinforcing. Some research supports the theory that endogenous opioids play a role in eating disorders, at least in bulimia. For example, two studies found low levels of the endogenous opioid beta-endorphin in people with bulimia. In one of these studies, the researchers observed that the people with more severe cases of bulimia had the lowest levels of beta-endorphin. It is important to note, however, that these findings demonstrate that low levels of opioids are seen concurrently with bulimia, not that such levels are seen before the onset of the disorder. In other words, we don't know if the low levels of opioids are a cause of bulimia or an effect of changes in food intake or purging

treatment- psychological anorexia

Therapy for anorexia is generally believed to be a two-tiered process. The immediate goal is to help the person gain weight in order to avoid medical complications and the possibility of death. The person is often so weak and physiological functioning so disturbed that hospital treatment is medically imperative (in addition to being needed to ensure that the patient ingests some food). Operant conditioning behavior therapy programs (e.g., providing reinforcers for weight gain) have been somewhat successful in achieving weight gain in the short term (Hsu, 1990). However, the second goal of treatment—long-term maintenance of weight gain—remains a challenge for the field. Beyond immediate weight gain, psychological treatment for anorexia can also involve cognitive behavior therapy (CBT). One study that combined hospital treatment with CBT found that reductions in many anorexia symptoms persisted up to 1 year after treatment (Bowers & Ansher, 2008). Family therapy is the principal form of psychological treatment for anorexia, based on the notion that interactions among members of the patient's family can play a role in treating the disorder (Le Grange & Lock, 2005). In one kind of family therapy, anorexia is cast as an interpersonal rather than an individual issue, and attempts are made to bring the family conflict to the fore. How is this accomplished? The therapist holds family lunch sessions, since conflicts related to anorexia are believed to be most evident at mealtime. These lunch sessions have three major goals: 1. Changing the patient role of the person with anorexia 2. Redefining the eating problem as an interpersonal problem 3. Preventing the parents from using their child's anorexia as a means of avoiding conflict One strategy is to instruct each parent to try individually to force the child to eat. The other parent may leave the room. The individual efforts are expected to fail. But because of this failure and frustration, the mother and father may now work together to persuade the child to eat. Thus, rather than being a focus of conflict, the child's eating will produce cooperation and increase parental effectiveness in dealing with the child (Rosman, Minuchin, & Liebman, 1975).

Restriction of behaviors that promote healthy body weight.

This is usually taken to mean that the person weighs much less than is considered normal [e.g., body mass index (BMI) less than 18.5 for adults] for that person's age and height. Weight loss is typically achieved through dieting, although purging (self-induced vomiting, heavy use of laxatives or diuretics) and excessive exercise can also be part of the picture.

socio-cultural influences

Throughout history, the standards societies have set for the ideal body—especially the ideal female body—have varied greatly. Over the past 50 years, the American cultural ideal has progressed steadily toward increasing thinness. For men, the situation appears somewhat different. In a study parallel to the studies examining Playboy centerfolds, researchers analyzed the BMI of Playgirl male centerfolds from 1973 to 1997. They found that the centerfolds' BMI increased over the period and that their muscularity, assessed using a fat-to-muscle estimate, increased even more. Thus for men, magazines focus attention on the masculine ideal of normal body weight or on increased muscle mass Somewhat paradoxically, as cultural standards were moving in the direction of thinness over the later part of the twentieth century, more and more people were becoming overweight. The prevalence of obesity has doubled since 1900 Currently, over two-thirds of Americans are overweight (and over a third are obese), setting the stage for greater conflict between the cultural ideal and reality. As society has become more health and fat conscious, dieting to lose weight has become more common; the number of dieters increased from 7 percent of men and 14 percent of women in 1950 to 29 percent of men and 44 percent of women in 1999. The focus on cutting carbohydrates, so widespread during the past few years, added yet another craze to dieting. Like many diet fads, the low-carb craze has quieted since 2004. In fact, a 2009 study in the New England Journal of Medicine reported that diets were equally effective, whether carbs, fat, or protein is cut, as long as the total number of calories is reduced. Surgeries such as liposuction (vacuuming out fat deposits just under the skin) and gastroplasty (surgically changing the stomach so it cannot digest as much food) are becoming more common despite their risk. The percentages above indicate that women are more likely than men to be dieters. The onset of eating disorders is typically preceded by dieting and other concerns about weight, supporting the idea that social standards stressing the importance of thinness play a role in the development of these disorders. It is likely that women who either are actually overweight or fear being fat are also dissatisfied with their bodies. Not surprisingly, studies have found that people with both a high BMI and body dissatisfaction are at higher risk for developing eating disorders. Body dissatisfaction is also a robust predictor of the development of eating disorders among adolescent girls. In addition, preoccupation with being thin or feeling pressure to be thin predicts an increase in body dissatisfaction among adolescent girls, which in turn predicts more dieting and negative emotions. Preoccupation with thinness and body dissatisfaction both predict greater eating disorder pathology. Finally, exposure to media portrayals of unrealistically thin models can influence reports of body dissatisfaction. One study reviewed results from 25 experiments that presented images of thin models to women and then asked the women to report on their body satisfaction. Perhaps not surprisingly, results from these studies showed that women reported a decline in body satisfaction after viewing these images The sociocultural ideal of thinness is a likely vehicle through which people learn to fear being or even feeling fat. In addition to creating an undesired physical shape, being fat has negative connotations, such as being unsuccessful and having little self-control. Obese people are viewed by others as less smart and are stereotyped as lonely, shy, and greedy for the affection of others. Even more disturbing, health professionals who specialize in obesity have also exhibited beliefs that obese people are lazy, stupid, or worthless. Reducing the stigma associated with being overweight will be beneficial to those with eating disorders as well as those who are obese. Not only does the fear of being fat contribute to eating pathology, but more recently the celebration of extreme thinness via websites, blogs, and magazines may also play a role. Websites that are "pro-ana" (short for anorexia) or "pro-mia" (short for bulimia) and other "thinsperation" websites and blogs have developed a following of women who seek support and encouragement for losing weight, often to a dangerously low level. These sites often post photos of female celebrities who are extremely thin as inspiration (hence, the term thinsperation). A recent review of the impact of these "pro-eating disorder" websites noted that the evidence suggests that women who visited these sites were more dissatisfied with their bodies, had more eating disorder symptoms, and had more prior hospitalizations for eating disorders. To tease apart causation from correlation, researchers have randomly assigned healthy women to view either pro-eating disorder or other health-related or tourist websites (Jett, La Perte, & Wanchism, 2010), supposedly as part of a website evaluation survey. Women completed food diaries for one week before and one week after viewing these websites. Women assigned to the pro-eating disorder website condition restricted their eating more the following week than did the women assigned to the other website conditions. These results suggest that viewing these websites has the potential to cause unhealthful changes in eating behavior.

comorbidity - anorexia

Women with anorexia nervosa are frequently diagnosed with depression, obsessive-compulsive disorder, phobias, panic disorder, substance use disorders, and various personality disorders (Baker et al., 2010; Godart et al., 2000; Ivarsson et al., 2000; Root et al., 2010). Men with anorexia nervosa are also likely to have a diagnosis of a mood disorder, schizophrenia, or substance use disorder (Striegel-Moore et al., 1999). Suicide rates are quite high for people with anorexia, with as many as 5 percent completing suicide and 20 percent attempting suicide (Franko & Keel, 2006).

normal eating

a pattern of eating behaviours which: maintains normal weight ensures adequate nutrition, conforms with cultural/requirements/enjoyable

onset of anorexia nervosa

anorexia nervosa typically begins in the early to middle teenage years, often after an episode of dieting and the occurrence of a life stress

body dysmorphic disorder description

body dysmorphic is less well known, but has at least double the prevalence of anorexia- about 2%- and a higher level of psychological impairment

treatment for body dysmorphic disorder

cognitive behavioural therapy - reduce fusion between looks and self-esteem, develop identity independent of looks SSRI

These two subtypes of bulimia appear to have greater validity than the purging/nonpurging types.

dietary/ dietary-depression

People with bulimia report that they lose control during a binge, even to the point of experiencing something akin to a __________ state.

dissociative

Studies with animals have shown that __________ is linked to the pleasurable aspects of food that compels an animal to go after food.

dopamine

This theory proposes that the symptoms of an eating disorder are best understood by considering both the person and how the symptoms are embedded in a dysfunctional family structure.

family systems

This is the principal form of treatment for anorexia nervosa

family therapy

binge eating disorder

his disorder includes recurrent binges (one time per week for at least 3 months), lack of control during the bingeing episode, and distress about bingeing, as well as other characteristics, such as rapid eating and eating alone. It is distinguished from anorexia nervosa by the absence of weight loss and from bulimia nervosa by the absence of compensatory behaviors (purging, fasting, or excessive exercise). Most often, people with binge eating disorder are obese. A person with a BMI greater than 30 is considered obese. not all obese people meet criteria for binge eating disorder. Indeed, only those who have binge episodes and report feeling a loss of control over their eating will qualify, which amounts to anywhere from 2 to 25 percent of obese people

A sociocultural factor that has remained resilient to change is the __________ of women's bodies.

objectification

what are the two types of anorexia nervosa?

restricting type- weightless is achieved by severely limiting food intake binge-eating/purging type- the person has also regularly engaged in binge eating and purging

__________ status and __________ stress are two other influences on the development of eating disorder.

socioeconomic/ acculturative

features of concern for men and women- body dysmorphic disorder

women: facial, breasts, size,weight, legs men: baldness, body hair, penis size, build