Chapter 10 Eating Disorders

Which statement BEST describes the current thinking about treatment for binge-eating disorder?

Psychotherapy is typically more helpful than antidepressant medications.

Who is MORE worried about pleasing others and being attractive to others?

a person with bulimia nervosa

Research has found that _____ therapy can be invaluable in the treatment of anorexia nervosa, although the exact nature of why this effect is seen is not yet clear.

family

Carla suffers from bulimia nervosa and has dental complications. Why is this the case?

The hydrochloric acid that coats the teeth during self-induced vomiting is very damaging to the gums and tooth enamel.

A 1995 survey found that _____ of African American respondents were dissatisfied with their weight and body shape, compared with _____ of white American teens.

70 percent; 90 percent

When people binge eat, they consume on average _____ calories during an episode.

2,000-3,400

Around _____ percent of the population have binge-eating disorder.

2.8

Approximately _____ percent of cases of anorexia nervosa and bulimia nervosa are diagnosed in men.

25

summary

- eating disorders: Rates of eating disorders have increased dramatically as thinness has become a national obsession. Two leading disorders in this category, anorexia nervosa and bulimia nervosa, share many similarities, as well as key differences. A third eating disorder, binge-eating disorder, also seems to be on the rise - anorexia nervosa: People with anorexia nervosa pursue extreme thinness and lose dangerous amounts of weight. They may follow a pattern of restricting-type anorexia nervosa or binge-eating/purging-type anorexia nervosa. The central features of anorexia nervosa are a drive for thinness, intense fear of weight gain, and disturbed body perception and other cognitive disturbances. People with this disorder develop various medical problems, particularly amenorrhea. Approximately 0.6 percent of all people develop the disorder during their lives. Around 75 percent of all cases occur among females. Typically the disorder begins after a person who is slightly overweight or of normal weight has been on a diet - bulimia nervosa: People with bulimia nervosa go on frequent eating binges and then force themselves to vomit or perform other inappropriate compensatory behaviors. Around 1 percent of the population manifest bulimia nervosa in their lifetime. The binges are often in response to increasing tension and are followed by feelings of guilt and self-blame. Compensatory behavior is at first reinforced by the temporary relief from uncomfortable feelings of fullness or the reduction of feelings of anxiety, self-disgust, and loss of control attached to bingeing. Over time, however, sufferers generally feel disgusted with themselves, depressed, and guilty. Once again, 75 percent of all cases of bulimia nervosa occur among females. People with the disorder may have mood swings or have difficulty controlling their impulses. Some display a personality disorder. Around half are amenorrheic, a number develop dental problems, and some develop a potassium deficiency - binge eating disorder: People with binge-eating disorder have frequent binge eating episodes but do not display inappropriate compensatory behaviors. Although most overweight people do not have binge-eating disorder, many individuals with binge-eating disorder become overweight. Around 2.8 percent of the population develops binge-eating disorder during their lives. Approximately 64 percent of people with this disorder are female - explanations for eating disorders: Most theorists now use a multidimensional risk perspective to explain eating disorders and to identify several key contributing factors. Principal among these are ego deficiencies; cognitive factors; depression; biological factors such as dysfunctional brain circuits, problematic activity of the hypothalamus, and disturbances of the body's weight set point; society's emphasis on thinness and bias against obesity; family environment; racial and ethnic factors; and gender differences - treatments for eating disorders: The first step in treating anorexia nervosa is to increase calorie intake and quickly restore the person's weight, a part of treatment called nutritional rehabilitation. The second step is to deal with the underlying psychological and family problems, often using a combination of education, cognitive-behavioral approaches, and family therapy. As many as 75 percent of people who are successfully treated for anorexia nervosa continue to show full or partial improvements years later. However, some of them relapse along the way, many continue to worry about their weight and appearance, and half continue to have some emotional problems. Most menstruate again when they regain weight. Treatments for bulimia nervosa focus first on stopping the binge-purge pattern (nutritional rehabilitation) and then on addressing the underlying causes of the disorder. Often several treatment strategies are combined, including education, psychotherapy (particularly cognitive-behavioral therapy), and, in some cases, antidepressant medications. As many as 75 percent of those who receive treatment eventually improve either fully or partially. While relapse can be a problem and may be precipitated by a new stress, treatment leads to lasting improvements in psychological and social functioning for many people. Similar treatments are used to help people with binge-eating disorder. Some of these individuals, however, may also require interventions to address their excessive weight. Prevention programs are becoming more common and more effective in addressing anorexia nervosa and bulimia nervosa

binge eating disorder

- LIKE THOSE WITH bulimia nervosa, people with binge-eating disorder engage in repeated eating binges during which they feel no control over their eating (APA, 2013). However, they do not perform inappropriate compensatory behavior (see Table 10-3). As a result of their frequent binges, around half of those with this disorder become overweight or even obese - Although binge-eating disorder was not formally listed as a clinical category until the publication of DSM-5 in 2013, the syndrome was first recognized 60 years ago as a pattern common among many overweight people (Stunkard, 1959). It is important to recognize, however, that most overweight people do not engage in repeated binges; their excess weight results from frequent overeating and/or a combination of biological, psychological, and sociocultural factors (ANAD, 2020). Around 2.8 percent of the population have binge-eating disorder, making it the most prevalent eating disorder (NEDA, 2020; Sysko & Devlin, 2019a, 2019b). As with the other eating disorders, women with this problem outnumber men; 64 percent of reported sufferers are female (see Table 10-4). The binges that characterize this pattern are similar to those seen in bulimia nervosa, particularly the amount of food eaten and the sense of loss of control experienced by individuals during the binge. Moreover, like people with bulimia nervosa and anorexia nervosa, those with binge-eating disorder typically are preoccupied with food, weight, and appearance; tend to base evaluation of themselves largely on their weight and shape; often misperceive their body size and are extremely dissatisfied with their body; may struggle with feelings of depression, anxiety, self-disgust, and perfectionism; and sometimes abuse substances. - On the other hand, people with binge-eating disorder are not as driven to thinness as those with anorexia nervosa and bulimia nervosa, although they do aspire to limit their eating. In the cognitive realm, they are more likely than those with the other eating disorders to perceive large portions of food as moderate in size (Chao et al., 2019). In addition, unlike those disorders, this problem does not necessarily begin with efforts at extreme dieting. People typically first develop the pattern later than those with the other eating disorders; most often they are in their twenties (NEDA, 2020; NIMH, 2020j, 2017h). One population that seems particularly at risk for binge-eating disorder are individuals who live with food insecurity — that is, a limited, uncertain, or unreliable availability of needed food due to limited financial means (Lydecker & Grilo, 2019; Rasmusson et al., 2019). People with binge-eating disorder have an increased risk of developing certain medical problems. Because they do not lose excessive weight or perform unhealthy compensatory behaviors, their medical problems are different from the ones that characterize anorexia nervosa and bulimia nervosa (Mitchell & Zunker, 2020). Those whose disorder includes obesity are — like other overweight people — more likely than the general population to develop diabetes, high blood pressure, heart disease, high cholesterol, and strokes, among other medical problems (Perreault, 2019). Even those whose binge-eating disorder does not include obesity may develop certain health problems, such as joint pain, headaches, gastrointestinal problems, and shortness of breath (Mitchell & Zunker, 2020). In addition, many people with this disorder describe their general health as poor

Adult females and males report the MOST body dissatisfaction with:

the stomach.

Which musician died because of the effects of anorexia nervosa on his or her body?

Karen Carpenter

Niles, a 22-year-old college student and a member of the school wrestling team, occasionally makes himself vomit after a meal, in order to remain in his preferred weight class. He has been doing this for six months. Would a therapist classify Niles as having bulimia nervosa?

No, because Niles's actions do not stem from inappropriate self-appraisal.

Relapse is a major problem for those suffering from bulimia nervosa. Researchers have identified certain factors that more accurately predict future relapse after successful treatment. Which is NOT one of those factors?

There was at least one other diagnosable mental illness that co-occurred with the bulimia nervosa.

Both anorexia nervosa and bulimia nervosa have a similar pattern of development; both disorders typically begin:

after a period of dieting by people who are fearful of becoming obese.

The peak age of onset for anorexia nervosa is:

between 14 and 20 years of age.

Susan's weight loss is a result of her forcing herself to vomit after eating excessively. She abuses laxatives and diuretics. Susan is exhibiting a pattern called _____.

binge-eating /purging-type anorexia nervosa

The MOST powerful contributor to dieting and to the development of eating disorders is:

body dissatisfaction.

Research studies exploring the effectiveness of treatment for those with _____ have found that, years after treatment, as many as 75 percent of clients have maintained either complete or partial recovery.

bulimia nervosa

Gregg has recently been hospitalized for an eating disorder, and his therapist prescribes an antidepressant. Gregg MOST likely has:

bulimia nervosa.

Meredith's friends are always surprised by how thin she always seems to stay, but her friends have never been concerned about her being unhealthily thin. She always seems to eat a lot whenever she goes out with them and people always seem to ask her "where she puts all that food." Her friends have never heard her talk about going to the gym, and after she finishes eating she always seems to excuse herself to the bathroom. Meredith's friends are starting to suspect that she has:

bulimia nervosa.

According to Hilde Bruch, _____ parents accurately attend to their children's biological and emotional needs, giving them food when they are crying from hunger and comfort when they are crying out of fear.

effective

Unlike the other eating disorders, binge-eating disorder does NOT necessarily begin with:

efforts at extreme dieting.

According to Hilde Bruch, a child who has developed a poor sense of control and independence has:

ego deficiencies.

When members of a family system are overinvolved with each other's affairs and are overconcerned with the details of each other's lives, they are said to be:

enmeshed

Corbin and Willow are fraternal twins attending the same university. They have made a pact to get healthy, motivate each other, and stay in shape. In order to achieve their weight goals, Corbin is more likely to _____, and Willow is more likely to _____.

exercise; diet

Mark is worried that his brother, who suffers from anorexia nervosa, will take his own life. The suicide rate for people suffering anorexia nervosa is ____ times the suicide rate found in the general population.

five

Research indicates that each of the brain circuits linked to ______ disorder(s) are also acting dysfunctionally in individuals with eating disorders.

generalized anxiety, obsessive-compulsive, and depressive

The _____, the part of the brain that regulates many bodily functions, has been identified as a possible contributor to the development of eating disorders.

hypothalamus

In addition to repeated episodes of bingeing, followed by compensatory behaviors lasting three months, the Diagnostic and Statistical Manual of Mental Disorders (DSM) also requires _____ to qualify for a diagnosis of bulimia nervosa.

inappropriate influence of weight and shape on appraisal of oneself

As a result of their frequent binges, around _____ of people with binge-eating disorder become overweight or even obese.

one-half

If a person with anorexia is given the opportunity to take a picture of herself and then "adjust" the picture to best represent her body, she will _____ her body size.

overestimate

The majority of body-dissatisfied females believe they are _____, and body-dissatisfied males believe themselves to be _____.

overweight; either overweight or underweight

This theory of eating disorders is supported by the research finding that when individuals with eating disorders are upset or anxious, they mistakenly think they are also hungry.

psychodynamic

Research conducted over the past two decades has found that _____.

rates of anorexia nervosa and bulimia nervosa are increasing among young African American women.

At least half of those suffering from anorexia nervosa reduce their weight by ______.

restricting their intake of food

Repeatedly vomiting after bingeing will affect one's ability to feel _____; this causes greater hunger.

satiated

When people with bulimia nervosa have a binge episode, they are the LEAST likely to eat:

steak

In this program, individuals attend group sessions in which they are guided through verbal, written, role-playing, and behavioral exercises that critique Western society's ultra-thin ideal.

the Body Project

Which prevention program has resulted in lower rates of eating disorders and higher rates of body satisfaction in individuals when compared to those who received no prevention program?

the Body Project

Leandra has anorexia nervosa and has developed amenorrhea, which is ______.

the absence of a menstrual cycle

According to the text, a variety of techniques are used in the treatment of bulimia nervosa, but if just one form of therapy is used, _____ is most effective.

the cognitive-behavioral approach

Activating this area of the hypothalamus produces feelings of hunger.

the lateral hypothalamus

In individuals with eating disorders, which brain structure is unusually small?

the prefrontal cortex

A "weight thermostat" that is responsible for keeping an individual at a particular weight level is called:

the weight set point.

During a violent assault, Noel suffered damage to his _____. Damage to this structure has caused an increase in his food intake.

ventromedial hypothalamus

Who would be the MOST likely man to develop an eating disorder?

Jorge, a professional boxer

cognitive behavioral therapy

- A combination of cognitive and behavioral interventions are included in most treatment programs for anorexia nervosa. These techniques are designed to help clients appreciate and change the behaviors and thought processes that keep their restrictive eating going (Hay, 2020; Grave et al., 2019). On the behavioral side, clients are typically required to monitor (by written diaries or smartphone apps) their feelings, hunger levels, and food intake and the ties between these variables. On the cognitive side, they are taught to identify their "core pathology" — the deep-seated belief that they should in fact be judged by their shape and weight and by their ability to control these physical characteristics. The clients may also be taught alternative ways of coping with stress and of solving problems. Cognitive-behavioral therapists are particularly careful to help patients with anorexia nervosa recognize their need for independence and teach them more appropriate ways to exercise control (Pike, 2019). The therapists may also teach them to better identify and trust their internal sensations and feelings. Finally, cognitive-behavioral therapists seek to help clients with anorexia nervosa change their attitudes about eating and weight (Pike, 2019) (see Table 10-5). The therapists may guide the clients to identify, challenge, and change maladaptive assumptions, such as "I must always be perfect" or "My weight and shape determine my value." They may also educate the clients about the body distortions typical of anorexia nervosa and help them see that their assessments of their own size are incorrect (Artoni et al., 2020). Even if the clients never learn to judge their body shape accurately, they may reach a point where they say, "I know that a key feature of this disorder is a misperception of my own size, so I can expect to feel fat regardless of my actual size." - According to research, cognitive-behavioral techniques are often effective in cases of anorexia nervosa, more so than psychodynamic therapies, psychoeducation, or supportive therapy alone (Hay, 2020; Pike, 2019). The approach helps many individuals to restore their weight, overcome their fear of becoming overweight, develop greater self-esteem, correct their body distortions and dissatisfaction, adopt more adaptive eating attitudes, acquire more appropriate eating and exercise habits, and develop better problem-solving skills. The treatment is most successful at preventing relapses when it continues for at least a year beyond a patient's recovery — a maintenance, or preventative, therapy strategy that you read about in Chapter 7 (see pages 196, 209). At the same time, studies suggest that the cognitive-behavioral approach brings the best results when it is supplemented by other approaches. In particular, family therapy is often included in treatment.

how are proper weight and normal eating restored?

- A variety of treatment methods are used to help patients with anorexia nervosa gain weight quickly and return to health within weeks, a phase of treatment called nutritional rehabilitation (Steinglass, 2019). In the past, treatment almost always took place in a hospital, but now it is often offered in day hospitals or outpatient settings. - In life-threatening cases, clinicians may need to force tube and intravenous feedings on a patient who refuses to eat (Mitchell & Peterson, 2020). Unfortunately, this use of force may cause the client to distrust the treatment team. In contrast, clinicians using behavioral weight-restoration approaches offer rewards whenever patients eat properly or gain weight and offer no rewards when they eat improperly or fail to gain weight. Perhaps the most popular nutritional rehabilitation approach is a combination of supportive nursing care, nutritional counseling, and a relatively high-calorie diet (Steinglass, 2019). Here nurses and other staff members gradually increase a patient's diet over the course of several weeks, to between 2,500 and 3,000 calories a day (Grubiak, 2019). The nurses educate patients about the program, track their progress, provide encouragement, and help them appreciate that their weight gain is under control and will not lead to obesity. In some programs, the nurses also use motivational interviewing, an intervention that uses a mixture of empathy and inquiring review to help motivate clients to recognize they have a serious eating problem and commit to making constructive choices and behavior changes (Pike, 2019; Yager, 2019). Studies find that patients in nutritional rehabilitation programs usually gain the necessary weight over 8 to 12 weeks.

compensatory behaviors

- After a binge, people with bulimia nervosa try to compensate for and undo its effects. Many resort to vomiting, for example. But vomiting actually fails to prevent the absorption of half of the calories consumed during a binge. Furthermore, because repeated vomiting affects one's general ability to feel satiated, it leads to greater hunger and more frequent and intense binges. Similarly, the use of laxatives or diuretics largely fails to undo the caloric effects of bingeing - Vomiting and other compensatory behaviors may temporarily relieve the uncomfortable physical feelings of fullness or reduce the feelings of anxiety and self-disgust attached to binge eating. Over time, however, a cycle develops in which purging allows more bingeing, and bingeing necessitates more purging (Mitchell, 2019). The cycle eventually causes people with the disorder to feel powerless and disgusted with themselves (Engel et al., 2019). Most recognize fully that they have an eating disorder. Lindsey, the woman we met earlier, recalls how the pattern of binge eating, purging, and self-disgust took hold while she was a teenager in boarding school. - As with anorexia nervosa, a bulimic pattern typically begins during or after a period of intense dieting, often one that has been successful and earned praise from family members and friends (NEDA, 2020). Studies of both animals and humans have found that normal research participants placed on very strict diets also develop a tendency to binge. Some of the participants in the starvation study described earlier, for example, later binged when they returned to regular eating, and a number of them continued to be hungry even after large meals

multicultural factors: gender differences

- Although men are as likely as women to eat in unhealthy ways, males account for only 25 percent of all people with reported anorexia nervosa and bulimia nervosa (ANAD, 2020). The reasons for this striking gender difference are not entirely clear, but Western society's double standard for attractiveness is, at the very least, one reason. Our society's emphasis on a thin appearance is clearly aimed at women much more than men, and some theorists believe that this difference has made women much more inclined to diet and more prone to eating disorders. Surveys of college men have, for example, found that the majority select "muscular, strong and broad shoulders" to describe the ideal male body and "thin, slim, slightly underweight" to describe the ideal female body (Baker & Blanchard, 2018; Mayo & George, 2014). A second reason for the different rates of anorexia nervosa and bulimia nervosa between men and women may be the different methods of weight loss favored by the two genders. According to some clinical observations and studies, men are more likely to use exercise to lose weight, whereas women more often diet (NEDA, 2020; Thackray et al., 2016). And, as you have read, dieting often precedes the onset of these eating disorders. Why do some men develop anorexia nervosa or bulimia nervosa? In a number of cases, the disorder is linked to the requirements and pressures of a job or sport (NEDA, 2020; Cottrell & Williams, 2016). According to one study, 37 percent of men with these eating disorders had jobs or played sports for which weight control was important, compared with 13 percent of women with such disorders. The highest rates of male eating disorders have been found among jockeys, wrestlers, distance runners, body builders, and swimmers. For other men who develop anorexia nervosa or bulimia nervosa, body image appears to be a key factor, just as it is in women (Linardon et al., 2020). Many report that they want a "lean, toned, thin" shape similar to the ideal female body, rather than the muscular, broad-shouldered shape of the typical male ideal. Studies indicate that as many as 42 percent of all men with eating disorders identify as gay, and many of them — although not the majority — endorse a very lean ideal (NEDA, 2018). A number of men seem to be ensnared in different patterns of dysfunctional eating. Some young men who consider themselves too thin increasingly perform muscularity-oriented disordered eating behaviors in which they eat excessively in order to gain weight and "bulk up." This pattern is particularly common among young African American men (Nagata et al., 2019). In some cases the pattern escalates into a disorder called muscle dysmorphia, or reverse anorexia nervosa, in which men who are actually quite muscular perceive themselves as scrawny and small and so continue to strive for a "perfect" body through excessive weight lifting, abuse of steroids, or other excessive measures (Badenes-Ribera et al., 2019). Individuals with this disorder typically feel shame about their bodies, and many have a history of depression, anxiety, and self-destructive compulsive behavior. About one-third of them also engage in binge eating.

treatments for bulimia nervosa

- Around 43 percent of those with bulimia nervosa receive treatment (NIMH, 2020j, 2017h). Treatment programs for the disorder are often offered in eating disorder clinics. Such programs offer (1) nutritional rehabilitation, which, for bulimia nervosa, means helping clients eliminate their binge-purge patterns and establish good eating habits; and (2) a combination of therapies aimed at eliminating the underlying causes of bulimic patterns (Crow, 2019; Mitchell, 2019). The programs emphasize education as much as therapy. Cognitive-behavioral therapy is particularly helpful in cases of bulimia nervosa (Svaldi et al., 2019; Yager, 2019) — perhaps even more helpful than in cases of anorexia nervosa. And antidepressant drug therapy, which is of limited help to people with anorexia nervosa, appears to be quite effective in many cases of bulimia nervosa.

treatments for anorexia nervosa

- Around one-third of those with anorexia nervosa receive treatment (NIMH, 2020j, 2017h). The immediate aims of treatment for anorexia nervosa are to help people regain their lost weight, recover from malnourishment, and eat normally again (Mehler, 2019a, 2019b). Therapists must then help them to make psychological and perhaps family changes to lock in those gains.

depression

- As many as half of people with eating disorders, particularly those with bulimia nervosa, have symptoms of depression (ANAD, 2020; Klein & Attia, 2019). This finding has led some theorists to suggest that depressive disorders help set the stage for eating disorders. Their claim is supported by four kinds of evidence. First, many more people with an eating disorder qualify for a clinical diagnosis of major depressive disorder than do people in the general population. Second, the close relatives of people with eating disorders seem to have a higher rate of depressive disorders than do close relatives of people without such disorders. Third, as you will see, the depression-related brain circuit of many people with eating disorders shows abnormalities that are similar to those of people with depression. And finally, people with eating disorders are sometimes helped by the same antidepressant drugs that reduce depression. Of course, although such findings suggest that depression may help cause eating disorders, other explanations are possible. For example, the pressure and pain of having an eating disorder may cause depression.

other forms of psychotherapy

- Because of its effectiveness in cases of bulimia nervosa, cognitive-behavioral therapy is often tried first, before other therapies are considered. If clients do not respond to it, other approaches with promising but less impressive track records may then be tried (Crow, 2019). A common alternative is interpersonal psychotherapy, the treatment that is used to help improve interpersonal functioning (Gomez Penedo et al., 2019). Psychodynamic therapy has also been used in cases of bulimia nervosa, but relatively few research studies have tested and supported its effectiveness (Wooldridge, 2018; Thompson-Brenner, 2016). The various forms of psychotherapy — cognitive-behavioral, interpersonal, and psychodynamic — are often supplemented by family therapy (Spettigue et al., 2020). Cognitive-behavioral, interpersonal, and psychodynamic therapy may each be offered in either an individual or a group therapy format. Group formats, including self-help groups, give clients with bulimia nervosa an opportunity to share their concerns and experiences with one another. Group members learn that their disorder is not unique or shameful, and they receive support from one another, along with honest feedback and insights. In the group they can also work directly on underlying fears of displeasing others or being criticized. Research suggests that group formats are at least somewhat helpful for as many as 75 percent of people with bulimia nervosa

the clinical picture

- Becoming thin is the key goal for people with anorexia nervosa, but fear provides their motivation. People with this disorder are afraid of becoming obese, of giving in to their growing desire to eat, and more generally of losing control over the size and shape of their bodies. In addition, despite their focus on thinness and the severe restrictions they may place on their food intake, people with anorexia are preoccupied with food. They may spend considerable time thinking and even reading about food and planning their limited meals (Ekern, 2020; Klein & Attia, 2019). Many report that their dreams are filled with images of food and eating - This preoccupation with food may in fact be a result of food deprivation rather than its cause. In a famous "starvation study" conducted in the late 1940s, 36 normal-weight men volunteered to be on a semistarvation diet for 6 months (Keys et al., 1950). Like people with anorexia nervosa, the volunteers became preoccupied with food and eating. They spent hours each day planning their small meals, talked more about food than about any other topic, studied cookbooks and recipes, mixed food in odd combinations, and dawdled over their meals. Many also had vivid dreams about food. Persons with anorexia nervosa also think in distorted ways. They usually have a low opinion of their body shape, for example, and consider themselves unattractive (Klein & Attia, 2019). In addition, they are likely to overestimate their actual proportions (Artoni et al., 2020; Beilharz et al., 2019). While most women in Western society overestimate their body size, the estimates of those with anorexia nervosa are particularly high. In one of her classic books on eating disorders, Hilde Bruch, a pioneer in this field, recalled the self-perceptions of a 23-year-old patient: - This tendency to overestimate body size has been tested in the laboratory (Artoni et al., 2020; Klein & Attia, 2019). In a popular assessment technique, research participants look at a photograph of themselves through an adjustable lens. They are asked to adjust the lens until the image that they see matches their actual body size. The image can be made to vary from 20 percent thinner to 20 percent larger than actual appearance. In one study, more than half of the individuals with anorexia nervosa overestimated their body size, stopping the lens when the image was larger than they actually were. - The distorted thinking of anorexia nervosa also takes the form of certain maladaptive attitudes and misperceptions (Treasure, Duarte, & Schmidt, 2020; Yager, 2020). Sufferers tend to hold such beliefs as "I must be perfect in every way," "I will become a better person if I deprive myself," and "I can avoid guilt by not eating." People with anorexia nervosa also have certain psychological problems, such as depression, anxiety, low self-esteem, and insomnia or other sleep disturbances (ANAD, 2020; Marzola et al., 2020). A number grapple with substance abuse. And many display obsessive-compulsive patterns. They may set rigid rules for food preparation or even cut food into specific shapes. Broader obsessive-compulsive patterns are common as well (Bang et al., 2020). Many, for example, exercise compulsively, prioritizing exercise over most other activities in their lives. In some research, people with anorexia nervosa and others with obsessive-compulsive disorder score equally high for obsessiveness and compulsiveness (NEDA, 2020). Finally, persons with anorexia nervosa tend to be perfectionistic, a characteristic that typically precedes the onset of the disorder

biological factors

- Biological theorists suspect that certain genes may leave some people particularly susceptible to eating disorders (Mitchell & Peterson, 2020; Yao et al., 2019). Consistent with this idea, relatives of people with eating disorders are up to six times more likely than other people to develop the disorders themselves. Moreover, if one identical twin has anorexia nervosa, the other twin also develops the disorder in as many as 70 percent of cases; in contrast, the rate for fraternal twins, who are genetically less similar, is 20 percent. Similarly, in the case of bulimia nervosa, identical twins display a concordance rate of 23 percent, compared with a rate of 9 percent among fraternal twins - One factor that has captured the attention of biological investigators is the possible role of dysfunctional brain circuits in people with eating disorders (Oliva et al., 2020; Gaudio et al., 2019; Seidel et al., 2019). As you have read throughout this book, a brain circuit is a network of particular brain structures and their connecting pathways that work together, triggering each other into action to produce a distinct kind of behavioral, cognitive, or emotional reaction (see pages 50-51). Research suggests that each of the circuits linked to generalized anxiety, obsessive-compulsive, and depressive disorders also acts dysfunctionally to some degree in people with eating disorders (Mele et al., 2020; Donnelly et al., 2018; Frank et al., 2013). For example, among individuals with eating disorders, the insula (a structure in the fear circuit) is abnormally large and active, the orbitofrontal cortex (a structure in the obsessive-compulsive-related circuit) is uncommonly large, the striatum (another structure in the obsessive-compulsive-related circuit) is hyperactive, and the prefrontal cortex (a structure in the fear, obsessive-compulsive-related, and depression-related circuits) is unusually small. Similarly, the activity levels of serotonin, dopamine, and glutamate (key neurotransmitters in the fear, obsessive-compulsive-related, and depression-related circuits) are abnormal in people with eating disorders (Boehm et al., 2019; Yokokura et al., 2019). Given such findings, some researchers believe that dysfunctions across or within those various brain circuits collectively help cause eating disorders. However, at this early stage of research, it is just as possible that the dysfunctions in those circuits are actually the result of eating disorders. Alternatively, the observed circuit dysfunctions may simply reflect the fact that many people with eating disorders also suffer from anxiety, obsessive-compulsive, and/or depressive disorders (ANAD, 2020; Engel et al., 2019). Finally, a number of biological theorists focus their explanation of eating disorders on one part of the brain in particular, the hypothalamus, a structure that regulates many bodily functions (Marino et al., 2020; Gao et al., 2017). The hypothalamus plays a central role in how the brain processes pleasurable and rewarding experiences, so it is not surprising that it helps control our appetite and govern our fluctuating desires for food intake. Researchers have located two separate areas in the hypothalamus that help control eating. One, the lateral hypothalamus (LH), produces hunger when it is activated. When the LH of a laboratory animal is stimulated electrically, the animal eats, even if it has been fed recently. In contrast, another area, the ventromedial hypothalamus (VMH), reduces hunger when it is activated. When the VMH is electrically stimulated, laboratory animals stop eating. - These areas of the hypothalamus and related brain structures are apparently activated by chemicals from the brain and body, depending on whether the person is eating or fasting. One such brain chemical is the natural appetite suppressant glucagon-like peptide-1 (GLP-1) (Hengist et al., 2020; Thom et al., 2020; Dossat et al., 2014). When one team of researchers collected and injected GLP-1 into the brains of rats, the chemical traveled to receptors in the hypothalamus and caused the rats to reduce their food intake almost entirely even though they had not eaten for 24 hours. Conversely, when "full" rats were injected with a substance that blocked the reception of GLP-1 in the hypothalamus, they more than doubled their food intake. Some researchers believe that the hypothalamus, related brain structures, and chemicals such as GLP-1, working together, comprise a "weight thermostat" in the body, which is responsible for keeping an individual at a particular weight level called the weight set point. Genetic inheritance and early eating practices seem to determine each person's weight set point (Liao et al., 2020). When a person's weight falls below their particular set point, the LH and certain other brain areas are activated and seek to restore the lost weight by producing hunger and lowering the body's metabolic rate, the rate at which the body expends energy. When a person's weight rises above their set point, the VMH and certain other brain areas are activated, and they try to remove the excess weight by reducing hunger and increasing the body's metabolic rate. - According to the weight set point theory, when people diet and fall to a weight below their weight set point, their brain starts trying to restore the lost weight. Hypothalamic and related brain activity produce a preoccupation with food and a desire to binge. They also trigger bodily changes that make it harder to lose weight and easier to gain weight, however little is eaten (Liao et al., 2020; Yu, 2017; Chhabra et al., 2016). Once the brain and body begin conspiring to raise weight in this way, dieters actually enter into a battle against themselves. Some people apparently manage to shut down the inner "thermostat" and control their eating almost completely. These people move toward restricting-type anorexia nervosa. For others, the battle spirals toward a binge-purge or binge-only pattern. Although the weight set point explanation has received considerable debate in the clinical field, it continues to be embraced by many theorists and practitioners.

bulimia nervosa versus anorexia nervosa

- Bulimia nervosa is similar to anorexia nervosa in many ways. Both disorders typically begin after a period of dieting by people who are fearful of becoming obese; driven to become thin; preoccupied with food, weight, and appearance; and struggling with depression, anxiety, obsessiveness, and the need to be perfect (Engel et al., 2019; Klein & Attia, 2019). People with either of the disorders have a heightened risk of suicide attempts and fatalities. Substance abuse may accompany either disorder, perhaps beginning with the excessive use of diet pills. People with either disorder believe that they weigh too much and look too heavy regardless of their actual weight or appearance (see InfoCentral). And both disorders are marked by disturbed attitudes toward eating - Yet the two disorders also differ in important ways. Although people with either disorder worry about the opinions of others, those with bulimia nervosa tend to be more concerned about pleasing others, being attractive to others, and having intimate relationships (Zerbe, 2017, 2010, 2008). They also tend to be more sexually active than people with anorexia nervosa (Gonidakis et al., 2015). Particularly troublesome, they are more likely to have long histories of mood swings, become easily frustrated or bored, and have trouble coping effectively or controlling their impulses and strong emotions (Engel et al., 2019). More than one-third of those with bulimia nervosa display the characteristics of a personality disorder, particularly borderline or avoidant personality disorder, which you will be looking at more closely in Chapter 15 (NEDA, 2020). Another difference is the nature of the medical complications that accompany the two disorders (Mitchell & Zunker, 2020). Only half of women with bulimia nervosa are amenorrheic or have very irregular menstrual periods, compared with almost all of those with anorexia nervosa. On the other hand, repeated vomiting bathes teeth and gums in hydrochloric acid, leading some women with bulimia nervosa to have serious dental problems, such as breakdown of enamel and even loss of teeth. Long-term cardiovascular disease is also not uncommon among individuals with bulimia nervosa (Tith et al., 2020). Moreover, frequent vomiting or chronic diarrhea (from the use of laxatives) can cause a host of serious medical problems, including dangerous potassium deficiencies, which may lead to weakness, intestinal disorders, kidney disease, or heart damage.

prevention of eating disorders: wave of the future

- CLEARLY, EATING DISORDERS are profoundly destructive. Moreover, the various treatments for these disorders, while improving greatly in recent years, do not bring about a full recovery (or, in some instances, any recovery) for many people with these disorders. Thus, some clinical theorists believe that researchers must invest more work into the development of programs that prevent the onset of eating disorders. One of today's promising prevention programs is called Body Project, a program developed and expanded by psychologists Eric Stice and Carolyn Black Becker and their colleagues (Stice et al., 2020, 2017b, 2013; Becker et al., 2017). Keeping in mind the key factors that predispose people to the development of eating disorders, Body Project offers a total of four weekly group sessions for high school and college-age women. In these sessions, group members are guided through a range of intense verbal, written, role-playing, and behavioral exercises that critique Western society's ultra-thin ideal. The participants also engage in body acceptance exercises, eating and related activities that run counter to the ultra-thin ideal, motivation enhancement techniques, skill-building training, and social support exercises. The principle behind this program is cognitive dissonance theory. According to this social psychology theory, when people adopt new attitudes (in this case, anti-thinness attitudes) that contradict their other attitudes and behaviors (for example, pro-thinness and pro-weight-loss attitudes), they will experience emotional discomfort — a state of dissonance that they implicitly seek to eliminate by changing their old attitudes and behaviors. Encouragingly, the Body Project prevention program has performed well in research (Stice et al., 2020, 2017b, 2015). In comparison to other young women who received education-only prevention programs or no prevention programs at all, participants in Body Project develop fewer eating disorders, hold more realistic and healthful appearance ideals, display fewer maladaptive eating attitudes and behaviors, have greater body satisfaction, and experience more positive emotions in follow-up studies conducted a year or more after the program. - Clearly, this program is promising and important. Whether in the form of Body Project or other such undertakings, prevention programs address a critical need in the clinical field's commitment to overcome eating disorders and are likely to increase in the years to come.

antidepressant medications

- During the past 15 years, antidepressant drugs have been used to help treat bulimia nervosa. In contrast to people with anorexia nervosa, those with bulimia nervosa are often helped considerably by these drugs (Crow, 2019). According to research, the drugs help as many as 40 percent of patients, reducing their binges by an average of 67 percent and vomiting by 56 percent. Studies suggest that antidepressants are less effective than psychotherapy, particularly cognitive-behavioral therapy, but that a combination of the two is more effective than either form of treatment alone

societal pressures

- Eating disorders are more common in Western countries than in other parts of the world. Thus, many theorists believe that Western standards of female attractiveness are partly responsible for the emergence of the disorders (NEDA, 2020). Western standards of female beauty have changed throughout history, with a noticeable shift in preference toward a thin female frame over the past 60 years or so. For example, some "pioneering" studies conducted throughout the second half of the twentieth century tracked the weight, bust, and hip measurements of Playboy magazine centerfold models and Miss America Pageant contestants and found a steady year-by-year decrease in those measurements that has continued into the current century (Gilbert et al., 2005; Garner et al., 1980). Because thinness is especially valued in the subcultures of performers, fashion models, and certain athletes, members of these groups are likely to be particularly concerned and/or criticized about their weight. For example, after undergoing an inpatient treatment program for eating disorders, the popular singer and rapper Kesha wrote, "The music industry has set unrealistic expectations for what a body is supposed to look like, and I started becoming overly critical of my own body because of that" (Sebert, 2014). Studies have found that performers, models, and athletes are indeed more prone than others to develop anorexia nervosa and bulimia nervosa (Caceres, 2020). In fact, many famous young women from these fields have publicly acknowledged grossly disordered eating patterns over the years. Surveys of athletes at colleges around the United States reveal that more than 9 percent of female college athletes suffer from an eating disorder and at least another 33 percent display eating behaviors that put them at risk for such disorders (Levine, 2020; NEDA, 2020). Attitudes toward thinness also help explain what used to be striking economic differences in the rates of eating disorders. For most of the twentieth century, women in the upper socioeconomic classes expressed more concern about thinness and dieting than women of the lower socioeconomic classes (Margo, 1985). Correspondingly, anorexia nervosa and bulimia nervosa were more common among women higher on the socioeconomic scale (Foreyt et al., 1996). In recent years, however, preoccupation with thinness and dieting has increased in all socioeconomic classes, as has the prevalence of eating disorders. In fact, according to some research, teenage girls from low-income families are now more likely than those from wealthier families to binge and display bulimia nervosa and binge-eating disorder - Western society not only glorifies thinness but also creates a climate of prejudice against excess weight (Cohen & Shikora, 2020). Whereas slurs based on ethnicity, race, and gender are considered unacceptable, cruel jokes about overweight people are standard fare on the Web and television and in movies, books, and magazines. Research indicates that the prejudice against overweight people is deep-rooted (Tomiyama et al., 2018). Prospective parents who were shown pictures of a chubby child and a medium-weight or thin child rated the former as less friendly, energetic, intelligent, and desirable than the latter. In another study, preschool children who were given a choice between a chubby and a thin rag doll chose the thin one, although they could not say why. Thus it is small wonder that as many as 60 percent of elementary school girls express concern about their weight and becoming overweight and that the number of girls under 12 years who develop a full eating disorder is growing - Consistent with these trends, one survey of 248 adolescent girls directly tied eating disorders and body dissatisfaction to social networking, Internet activity, and television browsing (Latzer, Katz, & Spivak, 2011). The survey found that the respondents who spent more time on social media were more likely to display eating disorders, have negative body image, eat in dysfunctional ways, and want to diet (see Figure 10-2). Those who spent more time on fashion and music websites and those who viewed more gossip- and leisure-related television programs showed similar tendencies. And in one study 69 percent of young girls said that the pictures of women they see in magazines and social media influence their notions of ideal body shape and make them want to lose weight

family environment

- Families may play an important role in the development and maintenance of eating disorders (Cerniglia et al., 2017). Research suggests that as many as half of the families of people with anorexia nervosa or bulimia nervosa have a long history of emphasizing thinness, physical appearance, and dieting. In fact, the mothers in these families are more likely to diet themselves and to be generally perfectionistic than are the mothers in other families (NEDA, 2020; Woodside et al., 2002). Tina, a 16-year-old, describes her view of the roots of her eating disorder: - Abnormal interactions and forms of communication within a family may also set the stage for an eating disorder. Family systems theorists argue that the families of people who develop eating disorders are often dysfunctional to begin with and that the eating disorder of one member is a reflection of the larger problem. Influential family theorist Salvador Minuchin, for example, believed that an enmeshed family pattern often leads to eating disorders (Villines, 2019a; Minuchin et al., 2017, 2006). In an enmeshed system, family members are overinvolved in each other's affairs and overconcerned with the details of each other's lives. On the positive side, enmeshed families can be affectionate and loyal. On the negative side, they can be clingy and foster dependency. Parents are too involved in the lives of their children, allowing little room for individuality and independence. Minuchin argued that adolescence poses a special problem for these families. The teenager's normal push for independence threatens the family's apparent harmony and closeness. In response, the family may subtly force the child to take on a "sick" role — to develop an eating disorder or some other illness. The child's disorder enables the family to maintain its appearance of harmony. A sick child needs her family, and family members can rally to protect her. Although some studies have supported such family systems explanations (MHN, 2020c; Cerniglia et al., 2017), they have failed to show that particular family patterns consistently set the stage for the development of eating disorders.

changing family interactions

- Family therapy can be a valuable part of treatment for anorexia nervosa, particularly for children and adolescents with the disorder (Hay, 2020; Mitchell & Peterson, 2020). As in other family therapy situations, the therapist meets with the family as a whole, points out troublesome family patterns, and helps the members make appropriate changes. In particular, family therapists may try to help the persons with anorexia nervosa separate their feelings and needs from those of other family members. Although the role of family in the development of anorexia nervosa is not yet clear, research strongly suggests that family therapy (or at least parent counseling) can be helpful in the treatment of this disorder

psychodynamic factors: ego deficiencies

- Hilde Bruch, a pioneer in the study and treatment of eating disorders, was mentioned earlier in this chapter. Bruch developed a largely psychodynamic theory of the disorders. She argued that disturbed mother-child interactions lead to serious ego deficiencies in the child (including a poor sense of independence and control) and to severe perceptual disturbances that jointly help produce disordered eating - According to Bruch, parents may respond to their children either effectively or ineffectively. Effective parents accurately attend to their children's biological and emotional needs, giving them food when they are crying from hunger and comfort when they are crying out of fear. Ineffective parents, by contrast, fail to attend to their children's needs, deciding that their children are hungry, cold, or tired without correctly interpreting the children's actual condition. They may feed their children when their children are anxious rather than hungry, or comfort them when they are tired rather than anxious. Children who receive such parenting may grow up confused and unaware of their own internal needs, not knowing for themselves when they are hungry or full and unable to identify their own emotions. - Because they cannot rely on internal signals, these children turn instead to external guides, such as their parents. They seem to be "model children," but they fail to develop genuine self-reliance and they "experience themselves as not being in control of their behavior, needs, and impulses, as not owning their own bodies" (Bruch, 1973, p. 55). Adolescence increases their basic desire to establish independence, yet they feel unable to do so. To overcome their sense of helplessness, they seek excessive control over their body size and shape and over their eating habits. Helen, an 18-year-old patient of Bruch's, described such needs and efforts: - Clinical reports and research have provided some support for Bruch's theory. Clinicians have observed that the parents of teenagers with eating disorders do tend to define their children's needs rather than allow the children to define their own needs (MHN, 2020c; Ihle et al., 2005). When Bruch interviewed the mothers of 51 children with anorexia nervosa, many proudly recalled that they had always "anticipated" their young child's needs, never permitting the child to "feel hungry" (Bruch, 1973). Research has also supported Bruch's belief that people with eating disorders perceive internal cues, including emotional cues, inaccurately (Oldershaw, Startup, & Lavender, 2019). When research participants with an eating disorder are anxious or upset, for example, many of them mistakenly think they are also hungry, and they respond as they might respond to hunger — by eating. And finally, studies support Bruch's argument that people with eating disorders rely excessively on the opinions, wishes, and views of others

cognitive behavioral factors

- If you look closely at Bruch's explanation of eating disorders, you'll see that it contains several cognitive-behavioral ideas. She held, for example, that as a result of ineffective parenting, people with eating disorders improperly label their internal sensations and needs, generally feel little control over their lives, and in turn, want to have excessive levels of control over their body size, shape, and eating habits. According to cognitive-behavioral theorists, these deficiencies contribute to a broad cognitive distortion that lies at the center of disordered eating, namely, people with anorexia nervosa and bulimia nervosa judge themselves — often exclusively — based on their shape and weight and their ability to control them (Mitchell, 2019; Fairburn et al., 2015, 2008). This "core pathology," say cognitive-behavioral theorists, contributes to all other aspects of the disorders, including the repeated efforts to lose weight and the preoccupation with shape, weight, and eating. - As you saw earlier in the chapter, research indicates that people with eating disorders do indeed display such cognitive deficiencies (Klein & Attia, 2019). Although studies have not clarified that the deficiencies are the cause of eating disorders, many cognitive-behavioral therapists proceed from this assumption and center their treatment for the disorders on correcting the clients' cognitive distortions and their accompanying behaviors. As you'll soon see, cognitive-behavioral therapies are among the most widely used of all treatments for eating disorders.

introduction

- It has not always done so, but Western society today equates thinness with health and beauty. In fact, in the United States thinness has become a national obsession. Most of us are as preoccupied with how much we eat as with the taste and nutritional value of our food. Thus it is not surprising that during the past three decades we have also witnessed an increase in two eating disorders that have at their core a morbid fear of gaining weight. Sufferers of anorexia nervosa, like Shani, are convinced that they need to be extremely thin, and they lose so much weight that they may starve themselves to death. People with bulimia nervosa go on frequent eating binges, during which they uncontrollably consume large quantities of food, and then force themselves to vomit or take other extreme steps to keep from gaining weight. A third eating disorder, binge-eating disorder, in which people frequently go on eating binges but do not force themselves to vomit or engage in other such behaviors, also is on the rise. People with binge-eating disorder do not fear weight gain to the same degree as those with anorexia nervosa and bulimia nervosa, but they do have many of the other features found in those disorders - The news media have published many reports about eating disorders. One reason for the surge in public interest is the frightening medical consequences that can result from the disorders (Gibson et al., 2019). The public first became aware of such consequences in 1983 when Karen Carpenter died from medical problems related to anorexia. Carpenter, the 32-year-old lead singer of the soft-rock brother-and-sister duo called the Carpenters, had been enormously successful and was admired by many as a wholesome and healthy model to young women everywhere. Another reason for the current concern is the disproportionate prevalence of two of the disorders, anorexia nervosa and bulimia nervosa, among adolescent girls and young women

what causes eating disorders?

- MOST OF TODAY'S theorists and researchers use a multidimensional risk perspective to explain eating disorders. That is, they identify several key factors that place a person at risk for these disorders (Stice, Johnson, & Turgon, 2019). Generally, the more of these factors that are present, the more likely it is that a person will develop an eating disorder. The multidimensional risk perspective for eating disorders is not as specific as the developmental psychopathology perspective, but it does share many principles with the latter perspective. That is, it too contends that the risk factors for eating disorders unfold over the course of development, that interactions between these factors are key, and that different risk factors and combinations of factors may lead to the same eating disorders. As you will see, most of the risk factors that have been cited and investigated center on anorexia nervosa and bulimia nervosa. Binge-eating disorder, formally identified as a clinical syndrome more recently, is only now being broadly investigated. The factors that are also at work in this disorder will probably become clear in the coming years.

how are lasting changes achieved?

- Most people in treatment for anorexia nervosa gain weight successfully in the short term, but clinical researchers have found that those individuals must overcome their underlying psychological problems in order to create lasting improvement (Murray et al., 2019). Therapists typically use a combination of education, psychotherapy, and family therapy to reach this broader goal (Mitchell & Peterson, 2020). Psychotropic drugs, particularly antipsychotic drugs, are sometimes used when patients do not respond to those other forms of treatments. Studies suggest that such medications may help with weight gain, but typically not with an individual's anorexia-related cognitive and emotional symptoms

binges

- Most people with bulimia nervosa have multiple binge episodes per week. Typically, they carry out the binges in secret. The person eats massive amounts of food very rapidly, with minimal chewing — usually sweet, high-calorie foods with a soft texture, such as ice cream, cookies, doughnuts, and sandwiches. The food is hardly tasted or thought about. Binge eaters consume an average of 2,000 to 3,400 calories during an episode (Engel et al., 2019). Some individuals consume as many as 10,000 calories. Binges are usually preceded by feelings of great tension. The person feels irritable, "unreal," and powerless to control an overwhelming need to eat "forbidden" foods. During the binge, the person feels unable to stop eating (APA, 2013). Although the binge itself may be experienced as pleasurable in the sense that it relieves the unbearable tension the individual has been experiencing, it is followed by feelings of extreme self-blame, shame, guilt, and depression, as well as fears of gaining weight and being discovered

bulimia nervosa

- PEOPLE WITH BULIMIA NERVOSA — a disorder also known as binge-purge syndrome — engage in repeated episodes of uncontrollable overeating, or binges. A binge episode takes place over a limited period of time, often 2 hours, during which the person eats much more food than most people would eat during a similar time span (APA, 2013). In addition, people with this disorder repeatedly perform inappropriate compensatory behaviors, such as forcing themselves to vomit; misusing laxatives, diuretics, or enemas; fasting; or exercising excessively (see Table 10-2). Lindsey, a woman who has since recovered from bulimia nervosa, describes a morning during her disorder: - Around 1 percent of all people develop bulimia nervosa in their lifetime. Like anorexia nervosa, this disorder occurs most frequently in females, again in 75 percent of reported cases (ANAD, 2020; NIMH, 2020j, 2017h). It begins in adolescence or young adulthood (most often between 15 and 20 years of age) and often lasts for years, with periodic letup. The weight of people with bulimia nervosa usually stays within a normal range, although it may fluctuate markedly within that range. Some people with this disorder, however, become seriously underweight and may eventually qualify for a diagnosis of anorexia nervosa instead -Many teenagers and young adults go on occasional eating binges or experiment with vomiting or laxatives after they hear about these behaviors from their friends or the media. Indeed, according to global studies, 25 to 50 percent of all students report periodic binge eating or self-induced vomiting (Ekern, 2020). Only some of these individuals, however, qualify for a diagnosis of bulimia nervosa. Surveys in several Western countries suggest that as many as 5 percent of adolescent girls may develop the full syndrome (NEDA, 2020; Engel, Steffen, & Mitchell, 2019). The rate seems to be particularly high among college students

multicultural factors: racial and ethnic differences

- Prior to this century, studies indicated that the eating behaviors, values, and goals of women in minority groups in the United States were considerably healthier than those of non-Hispanic white American women (Lovejoy, 2001; Cash & Henry, 1995; Parker et al., 1995). A widely publicized 1995 survey, for example, found that 70 percent of the African American teenage respondents were dissatisfied with their weight and body shape, compared to nearly 90 percent of the non-Hispanic white American respondents. The study also found that the respondents had different ideals of beauty. When asked to define the "perfect girl," the non-Hispanic white American teens described a girl of 5'7" weighing between 100 and 110 pounds — proportions that mirror those of supermodels. In contrast, the African American teens described body dimensions that were more attainable for the typical girl; they favored fuller hips, for example. In addition, the African American respondents were less likely to diet for extended periods. - However, research conducted over the past two decades suggests that body image concerns, dysfunctional eating patterns, and eating disorders are on the rise among young women in minority groups in today's society. In fact, studies now suggest that young women of color in the United States express body dissatisfaction to the same degree as young non-Hispanic white American women; are even more likely to engage in disordered eating behaviors (particularly binge eating); and may actually have a higher prevalence of eating disorders, including binge-purge disorder (Goode et al., 2020; NEDA, 2020). Eating disorders also appear to be rising among young Asian American women (Javier & Belgrave, 2019). These shifts appear to be partly related to the acculturation displayed by many minority group women (Warren & Akoury, 2020; Ford, 2000). One study compared African American women at a predominately non-Hispanic white American university with those at a predominately African American university. Those at the former school had significantly higher depression and more eating problems. The general public and, indeed, clinical professionals have been slow to recognize these changing racial and ethnic trends. In one study, for example, clinicians were presented with identical case studies in which women of different races and ethnicity displayed disordered eating symptoms. When the woman in the case study was African American or Hispanic American, as opposed to non-Hispanic white American, the clinicians were less likely to assess her symptoms as problematic or to recommend treatment (NEDA, 2020; Gordon et al., 2006). Given such research, it is small wonder that in the United States, people of color are less likely to receive treatment for their eating disorders than non-Hispanic white Americans

anorexia nervosa

- SHANI, 15 YEARS OLD and in the ninth grade, displays many symptoms of anorexia nervosa (APA, 2013). She purposely maintains a significantly low body weight, intensely fears becoming overweight, has a distorted view of her weight and shape, and is excessively influenced by her weight and shape in her self-evaluations - Like Shani, at least half of the people with anorexia nervosa reduce their weight by restricting their intake of food, a pattern called restricting-type anorexia nervosa. First they tend to cut out sweets and fattening snacks; then, increasingly, they eliminate other foods. Eventually people with this kind of anorexia nervosa show almost no variability in diet. Others, however, lose weight by forcing themselves to vomit after meals or by abusing laxatives or diuretics, and they may even engage in eating binges, a pattern called binge-eating/purging-type anorexia nervosa, which you will read about in more detail in the section on bulimia nervosa. Around 75 percent of reported cases of anorexia nervosa occur in females (ANAD, 2020). Although the disorder can appear at any age, the peak age of onset is between 14 and 20 years. Approximately 0.6 percent of all people in Western countries develop this problem in their lifetime, and many more display at least some of its symptoms (NEDA, 2020; NIMH, 2020j, 2017h). Typically the disorder begins after a person who is slightly overweight or of normal weight has been on a diet (Mitchell & Peterson, 2020; NEDA, 2020). The escalation toward anorexia nervosa may follow a stressful event such as separation of parents, a move away from home, or an experience of personal failure (Moreno-Encinas et al., 2020). Although most people with the disorder recover, as many as 6 percent of them become so seriously ill that they die, usually from medical problems brought about by starvation, or from suicide (Mehler, 2019a, 2019b). The suicide rate among people with anorexia nervosa is five times the rate found in the general population (Klein & Attia, 2019). Around 20 percent of individuals with this disorder continue to display severe eating disturbances for decades

how are eating disorders treated?

- TODAY'S TREATMENTS FOR eating disorders have two goals. The first is to correct the dangerous eating pattern as quickly as possible. The second is to address the broader psychological and situational factors that have led to and maintain the eating problem. Family and friends can also play an important role in helping to overcome the disorder.

what is the aftermath of anorexia nervosa?

- The average lifetime duration of anorexia nervosa is 6 years (Yager, 2019, 2018). The use of combined treatment approaches, with cognitive-behavioral therapy typically at the center, has greatly improved the outlook for people with this disorder, although the road to recovery can be difficult. The course and outcome of this disorder vary from person to person, but researchers have noted certain trends. - On the positive side, as you read earlier, weight is often quickly restored once treatment for the disorder begins, and treatment gains may continue for years. As many as 75 percent of patients continue to show improvement — either full or partial — when interviewed several years or more after their initial recovery (Klein & Attia, 2019). Another positive note is that most females with anorexia nervosa menstruate again when they regain their weight, and other medical improvements follow (Mehler, 2019a, 2019b). Also encouraging is that the death rate from anorexia nervosa seems to be falling. Earlier diagnosis and safer and faster weight-restoration techniques may account for this trend. Deaths that do occur are usually caused by suicide, starvation, infection, gastrointestinal problems, or electrolyte imbalance (Mehler, 2019a, 2019b). On the negative side, at least 20 percent of persons with anorexia nervosa remain seriously troubled for years (Dobrescu et al., 2020; Klein & Attia, 2019). Furthermore, recovery, when it does occur, is not always permanent. At least one-third of recovered patients have recurrences of anorexic behavior, usually triggered by new stresses, such as marriage, pregnancy, or a major relocation (Steinglass et al., 2020; Stice et al., 2017a, 2013). Even years later, many who have recovered continue to express concerns about their weight and appearance (Klein & Attia, 2019). Some still restrict their diets to a degree, feel anxiety when they eat with other people, or hold distorted ideas about food, eating, and weight (Isomaa & Isomaa, 2014). About half of those who have suffered from anorexia nervosa continue to have certain psychological problems — particularly depression, obsessiveness, and social anxiety — years after treatment. Such problems are particularly common in those who had not reached a fully normal weight by the end of treatment -The more weight persons have lost and the more time that passes before they enter treatment, the poorer the recovery rate (Klein & Attia, 2019; Zerwas et al., 2013). People who had psychological or sexual problems before the onset of the disorder tend to have a poorer recovery rate than those without such a history. People whose family or interpersonal relationships are troubled have less positive treatment outcomes. Younger sufferers seem to have a better recovery rate than older patients.

treatments for binge eating disorder

- The average lifetime duration of binge-eating disorder is 14 years (Yager, 2019, 2018). Approximately 44 percent of people with this problem receive treatment (NIMH, 2020j, 2017h). Given the key role of binges in this disorder (bingeing without purging), today's treatments for binge-eating disorder are often similar to those for bulimia nervosa. In particular, cognitive-behavioral therapy, certain other forms of psychotherapy, and in some cases, antidepressant medications are provided to help reduce or eliminate the binge-eating patterns and to change disturbed thinking such as being overly concerned with weight and shape (Scott, 2020; Hilbert et al., 2019). According to research, psychotherapy is generally more helpful than antidepressants. Evidence indicates that these various interventions are indeed often effective, at least in the short run. As many as 60 percent of clients no longer fit the criteria for binge-eating disorder by the end of treatment (Sysko & Devlin, 2019a, 2019b). Many of their early gains may continue for years. However, only around one-third of the recovered individuals showed total improvement in those follow-up studies. As with the other eating disorders, many of those who initially recover from binge-eating disorder continue to have a relatively high risk of relapse (Sysko & Devlin, 2019a, 2019b). For reasons that are not yet clear, some studies find that African Americans with this disorder have better treatment outcomes than non-Hispanic white Americans (Lydecker et al., 2019). Of course, many people with binge-eating disorder also are overweight, and that part of their problem requires additional kinds of intervention. Their weight difficulties are often resistant to long-term improvement, even if their binge eating is reduced or eliminated (Sysko & Devlin, 2019a, 2019b). In one follow-up study of hospitalized patients with severe symptoms of binge-eating disorder, 36 percent of those who had been treated were still significantly overweight 12 years after hospitalization

what is the aftermath of bulimia nervosa?

- The average lifetime duration of bulimia nervosa is 6 years (Yager, 2019, 2018). Left untreated, the disorder is more likely to last longer, sometimes improving temporarily but then returning. Treatment, however, produces immediate, significant improvement in approximately 40 percent of clients: they stop or greatly reduce their bingeing and purging, eat properly, and maintain a normal weight (Mitchell, 2019; Isomaa & Isomaa, 2014). Another 40 percent show a moderate response — at least some decrease in binge eating and purging. Follow-up studies, conducted years after treatment, suggest that around 75 percent of people with bulimia nervosa have recovered, either fully or partially (Engel et al., 2019). Relapse can be a problem even among people who respond successfully to treatment. Studies suggest that 31 percent of those who recover from bulimia nervosa may relapse within 2 years (Muhlheim, 2020). As with anorexia nervosa, relapses are usually triggered by a new life stress, such as an upcoming exam, a job change, marriage, or divorce. Relapse is more likely among people who had longer histories of bulimia nervosa before treatment, had vomited more frequently during their disorder, continued to vomit at the end of treatment, had histories of substance abuse, and continue to be lonely or to distrust others after treatment

medical problems

- The starvation habits of anorexia nervosa cause medical problems (Lawson & Miller, 2019; Mehler, 2019a, 2019b). Women develop amenorrhea, the absence of menstrual cycles. Other problems include lowered body temperature, low blood pressure, body swelling, reduced bone mineral density, and slow heart rate. Metabolic and electrolyte imbalances also may occur and can lead to death by heart failure or circulatory collapse. The poor nutrition of people with anorexia nervosa may also cause skin to become rough, dry, and cracked; nails to become brittle; and hands and feet to be cold and blue. Some people lose hair from the scalp, and some grow lanugo (the fine, silky hair that covers some newborns) on their trunk, extremities, and face. Shani, the young woman whose self-description opened this chapter, recalls how her body deteriorated as her disorder was progressing: "Nobody knew that I was always cold no matter how many layers I wore, that my hair came out in thick wads whenever I wet it or washed it, that I stopped menstruating, [and] that my hipbones hurt to lie on my stomach and my coccyx hurt to sit on the floor"

cognitive-behavioral therapy

- When treating clients with bulimia nervosa, cognitive-behavioral therapists employ many of the same techniques that they use to help treat people with anorexia nervosa. However, they tailor the techniques to the unique features of bulimia (for example, bingeing and purging) and to the specific beliefs at work in bulimia nervosa. The therapists often instruct clients with bulimia nervosa to keep diaries of their eating behavior, changes in sensations of hunger and fullness, and the ebb and flow of other feelings (Mitchell, 2019). This helps the clients to observe their eating patterns more objectively and recognize the emotions and situations that trigger their desire to binge. Smartphone apps have been particularly useful in keeping track of such changes throughout the day. One team of researchers studied the effectiveness of an online diary (Shapiro et al., 2010). They had 31 clients with bulimia nervosa, each a participant in a 12-week cognitive-behavioral therapy program, send nightly texts to their therapists, reporting on their bingeing and purging urges and episodes. The clients received feedback messages, including reinforcement and encouragement for the treatment goals they had been able to reach that day. The clinical researchers reported that by the end of therapy, the clients showed significant decreases in binges, purges, other bulimic symptoms, and feelings of depression. - Cognitive-behavioral therapists may also use the behavioral technique of exposure and response prevention to help break the binge-purge cycle. As you read in Chapter 5, this approach consists of exposing people to situations that would ordinarily raise anxiety and then preventing them from performing their usual compulsive responses until they learn that the situations are actually harmless and their compulsive acts unnecessary. For bulimia nervosa, the therapists require clients to eat particular kinds and amounts of food and then prevent them from vomiting to show that eating can be a harmless and even constructive activity that needs no undoing (Butler & Heimberg, 2020; Mitchell, 2019). Typically the therapist sits with the client while the client eats the forbidden foods and stays until the urge to purge has passed. Studies find that this treatment often helps reduce eating-related anxieties, bingeing, and vomiting. Beyond such behavioral techniques, a primary focus of cognitive-behavioral therapists is to help clients with bulimia nervosa recognize and change their maladaptive attitudes toward food, eating, weight, and shape. The therapists typically teach the clients to identify and challenge the negative thoughts that regularly precede their urge to binge — I have no self-control; I might as well give up; I look fat. They may also guide clients to recognize, question, and eventually change their perfectionistic standards, sense of helplessness, and low self-concept (see Trending). Cognitive-behavioral approaches help as many as 75 percent of patients stop or reduce bingeing and purging

anorexia nervosa checklist

1. Individual purposely takes in too little nourishment, resulting in body weight that is very low and below that of other people of similar age and gender. 2. Individual is very fearful of gaining weight, or repeatedly seeks to prevent weight gain despite low body weight 3. Individual has a distorted body perception, places inappropriate emphasis on weight or shape in self-judgments, or fails to appreciate the serious implications of their low weight

binge eating disorder checklist

1. Recurrent binge-eating episodes 2. Binge-eating episodes include at least three of these features: Unusually fast eating Absence of hunger Uncomfortable fullness Secret eating due to sense of shame Subsequent feelings of self-disgust, depression, or severe guilt 3. Significant distress. 4. Binge-eating episodes take place at least weekly over the course of 3 months 5. Absence of excessive compensatory behaviors

bulimia nervosa checklist

1. Repeated binge-eating episodes. 2. Repeated performance of ill-advised compensatory behaviors (e.g., forced vomiting) to prevent weight gain 3. Symptoms take place at least weekly for a period of 3 months 4. Inappropriate influence of weight and shape on appraisal of oneself.

The average lifetime duration of binge-eating disorder is _____ years.

14

Although most people with anorexia nervosa recover, about _____ percent of people with the disorder become so seriously ill that they die, usually from medical problems brought about by starvation, or from suicide.

6

About _____ percent of individuals with binge-eating disorder are female.

64

Biological research into the cause of eating disorders has found that, in as many as _____ percent of cases, if one identical twin suffers from anorexia nervosa, the other twin will also develop this disorder.

70

As many as _____ percent of clients with anorexia nervosa continue to show improvement, either full or partial, post-treatment.

75

At most, ____ percent of reported cases of anorexia nervosa occur in females.

75

For reasons that according to the text are still unclear, one minority population group in the United States has better outcomes with treatment for binge eating than non-Hispanic white Americans do. Which group is that?

African Americans

Which statement is true regarding menstruation in women with bulimia nervosa?

Half of all women with bulimia nervosa experience absent or irregular menstrual periods.

Researcher _____ suggested that enmeshed family patterns, where there is a lack of appropriate boundaries between family members, often contribute to the development of eating disorders.

Salvador Minuchin

Marlon, a 22-year-old college student, has recently discovered that if he makes himself vomit after every other meal, he will lose weight and become more slender. After doing this for three weeks, he shares this revelation with his friend Duane, and Duane tells him, "Man, I never thought of you as bulimic!" Which of the following is an accurate assessment of Duane's statement?

The binge-purge cycles of bulimia nervosa must be present for at least 3 months in order to be diagnosed.

Christina decided that she wanted to lose weight to look better, but now it seems to have gotten out of control. She has lost 30 pounds in the last few months, she cannot seem to stop thinking about her body and weight, and she has also stopped getting her period. Christina would MOST likely be diagnosed with _____.

anorexia nervosa

This psychological disorder is marked by the pursuit of extreme thinness and by extreme weight loss.

anorexia nervosa

Quinn intensely fears gaining weight. He restricts his food intake, and his body perception is distorted. Quinn MOST likely suffers from:

anorexia nervosa.

Zeekal has recently been hospitalized. She is severely underweight, her body temperature is low, her heart rate is below normal, and her feet are swollen. All of Zeekal's physiological symptoms could be associated with:

anorexia nervosa.

Which eating disorder is found in equal numbers of males and females?

anorexia-binge disorder

Both Devon and Marissa are concerned about their weight. Devon has begun restricting her diet, only eating one small meal a day. Marissa, on the other hand, eats several meals a day; however, she sometimes will binge and then exercise obsessively and purge. Devon MOST likely has _____ nervosa, while Marissa MOST likely has _____.

anorexia; bulimia nervosa

People with _____ frequently go on eating binges but do not force themselves to vomit or engage in other such compensatory behaviors.

binge-eating disorder

Which of the eating disorders has the LEAST successful long-term recovery after treatment?

binge-eating disorder

A person who displays many of the behaviors of bulimia nervosa but does not engage in compensatory behaviors would MOST likely be diagnosed with:

binge-eating disorder.

Bernice is 26 years old, weighs about 250 pounds, and is extremely dissatisfied with her body. She finds herself stuck in a pattern of, at least four times a week, secretly and within minutes devouring several dozen doughnuts, even if she's not all that hungry. After consuming the doughnuts, Bernice feels shame and disgust at what she has just done. Bernice would MOST likely be diagnosed with:

binge-eating disorder.

Sometimes, Edna vomits her meal soon after she eats. At other times, she takes an excessive amount of diuretics and laxatives. Edna MOST likely suffers from _____ anorexia nervosa.

binge-eating/purging-type

Binge-purge syndrome is also referred to as _____.

bulimia nervosa

Of the following therapies, which one is particularly careful to help clients with anorexia nervosa identify their need for independence and better identify and trust their internal sensations and feelings?

cognitive-behavioral

A therapist has worked with a patient of anorexia nervosa to identify her "core pathology." As part of that, the patient must identify maladaptive assumptions in order to challenge and to change them. The therapist is MOST likely using a:

cognitive-behavioral approach.

At a recent multidisciplinary psychology conference, a leading researcher spoke on using the multidimensional risk perspective to explain eating disorders, identifying _____ such as ineffective parenting and _____ factors such as ego deficiency.

cognitive-behavioral factors; psychodynamic

Hannah has never really gotten along with her mother. This may be one reason that she has never developed an adequate sense of control and independence. According to Hilde Bruch, this would be an example of:

deficiencies

For females, the biggest jump in body dissatisfaction occurs when girls transition from:

early adolescence to mid-adolescence.

According to Hilde Bruch, a parent who incorrectly feeds a fearful child and comforts a hungry child is:

ineffective

Britta has recently been diagnosed with anorexia nervosa, and she is seeing a therapist to start the process of recovery. As the therapist does his initial assessment, he notices that Britta has developed _____, which is fine, silky hair that is covering her arms.

lanugo

Martin was recently diagnosed with anorexia nervosa and is now seeing a therapist. As the therapist conducts her initial assessment, she notices that Martin has developed _____, a fine, silky hair covering his face and arms.

lanugo

The main goal for people with anorexia nervosa is to ______, and ______ is their motivation to do so.

look good; looking good

One perspective identified several kinds of risk factors associated with an eating disorder. Adherents suggested that the more risk factors that are present, the MORE likely that the eating disorder will develop. This is known as the _____ perspective.

multidimensional risk

Thalia has been hospitalized for anorexia nervosa. As part of her treatment program, her caloric intake is being gradually increased, she is being educated about the proper way to maintain weight, and she has received encouragement about her appropriate weight gain. Right now, Thalia is MOST undergoing:

nutritional rehabilitation.

Kate suffers from anorexia nervosa. Kate is likely to experience all of the following EXCEPT:

phobias