Chapter Nine

1. Chapter Nine Eating Disorders

2. Eating Disorders • Disturbed eating patterns are increasing in frequency • Types of eating disorders: • Anorexia nervosa • Bulimia nervosa • Binge-eating disorder (BED) • Eating conditions not elsewhere classified • Obesity is also discussed

3. Eating Disorders (cont’d.) • Eating disorders and disordered eating patterns are increasingly prevalent in U.S. • Linked to dissatisfaction with weight or body size • 13.4% of girls and 7.1% of boys have engaged in disordered eating patterns • Related factors: • Depression, substance use, and suicidal ideation

4. Eating Disorders (cont’d.)

5. Eating Disorders (cont’d.) • Paradox: as emphasis on thinness is increasing, so is the problem of obesity • 68% of adults and 17% of children and adolescents are overweight or obese • Body dissatisfaction becoming an increasing problem for men and boys • Muscle dysphoria: extreme dissatisfaction with one’s muscularity • Could be evidence of influence of unattainable body images prevalent in media

6. Anorexia Nervosa • Characterized by: • Low body weight • Intense fear of becoming obese • Body image distortion • Undue self-evaluation based on weight or body shape • Deny seriousness of physical effects • Occurs primarily in adolescent girls and young women, although now 25% are male

7. Anorexia Nervosa (cont’d.) • Subtypes: • Restricting: • Lose weight through severe dieting or exercising • Tend to be more introverted and deny feelings of hunger or psychological distress • Binge-eating/purging: • Lose weight through use of self-induced vomiting, laxatives, or diuretics, often after binge eating • Tend to be more extroverted and report anxiety, depression, guilt; admit stronger appetite; older

8. Anorexia Nervosa (cont’d.) • Physical complications: • Mortality rate is six times higher than general population due to suicide, substance abuse, and physiological effects of starvation • Irregular heart rate, low blood pressure, and weakened heart muscle • Extreme tiredness, dry skin, brittle hair, and low body temperature • Enlarged salivary glands and bone loss

9. Anorexia Nervosa (cont’d.) • Course and outcome: • Course is highly variable • Some recover fully after one episode • Others fluctuate between weight gain and relapse • Others have chronic and deteriorating course ending in death • Purging, vomiting, and obsessive-compulsive features are associated with unfavorable outcomes

10. Anorexia Nervosa (cont’d.) • Associated characteristics: • Depression, anxiety, impulse control problems, loss of sexual interest, and substance use • Obsessive-compulsive behaviors and thoughts • Personality disorders/characteristics: • Restricting: • Introversion, conformity, perfectionism, rigidity • Traits consistent with obsessive-compulsive personality • Binge eating/purging: • Extroverted, impulsive, or emotionally unstable personality

11. Bulimia Nervosa • Characterized by: • Recurrent episodes of binge eating (rapid consumption of large quantities of food) at least once a week for three months • Loss of control over eating followed by purging, excessive exercise, or fasting • Those with bulimia are aware that their eating habits are not normal • Become disgusted and ashamed, and hide it from others

12. Bulimia Nervosa (cont’d.) • More prevalent than anorexia: • Up to 2% of women suffer from bulimia, another 10% report some symptoms but do not meet all the criteria for the diagnosis • Up to 25% of bulimics are male • Especially prevalent in urban areas • Incidence seems to be increasing

13. Bulimia Nervosa (cont’d.) • Physical complications: • Effects of vomiting or excessive use of laxatives: • Erosion of tooth enamel, dehydration, swollen salivary glands, lower potassium (can weaken heart and cause heart irregularities and cardiac arrest) • Gastrointestinal disturbances • Inflammation of esophagus • Gastric and rectal irritation

14. Bulimia Nervosa (cont’d.) • Associated characteristics: • Eating can serve as coping response to stress • Highest rates of binge eating occur during negative emotional states, including anger and depression • A task-oriented approach may diminish stress and reduce need to use food to cope with stressful emotions

15. Bulimia Nervosa (cont’d.) • Course and outcome: • Generally begins in late adolescence or early adulthood • The mortality and suicide rates are relatively high, similar to those found in anorexia nervosa • Mixed, but better course than for anorexia • Better prognosis for those with better emotional functioning and positive social support • Poorer prognosis for those with high psychosocial stress and low social status

16. Binge-Eating Disorder • Involves a large consumption of food within a two-hour period, accompanying feeling of loss of control, and marked distress over excess eating • Unlike bulimia, BED does not involve use of compensatory behaviors, such as vomiting, fasting, or excessive exercise • Diagnosis: history of binge-eating episodes at least once a week for three months

17. Binge-Eating Disorder (cont’d.) • Lifetime prevalence: • 3.5% women; 2% of men • Percentages of African American and white women with BED are roughly equal in community samples • White women are more likely to seek treatment

18. Binge-Eating Disorder (cont’d.) Figure 9-1 Binge-Eating Disorder The comparison of scores on subscales of the Eating Disorder Questionnaire reveal differences between African American and white women with and without binge-eating disorder Source: Pike, Dohm, Striegel-Moore, Wilfley, & Fairburn (2001).

19. Binge-Eating Disorder (cont’d.) • Associated characteristics: • Likely to be overweight • 20-40% in weight control programs have BED • Binges are often preceded by poor mood, low alertness, feelings of poor eating control, and cravings for sweets • Complications due to medical conditions associated with obesity: • High blood pressure, high cholesterol, type 2 diabetes, and depression

20. Binge-Eating Disorder (cont’d.) • Course and outcome: • Begins in late adolescence or early adulthood • Limited information on natural course of BED • In one study, individuals made a full recovery over a five period • Weight remains high • Over time, 39% meet criteria for obesity

21. Eating Conditions Not Elsewhere Classified • Seriously disturbed eating patterns that do not fully meet criteria for anorexia, bulimia nervosa, or binge-eating disorder: • Normal weight individuals meeting other criteria of anorexia nervosa • Individuals meeting criteria for bulimia/BED except that binge eating occurs less than once per week or present for less than three months • Night-eating syndrome • Individuals who purge but do not binge

22. Eating Conditions Not Otherwise Specified (cont’d.) • Diagnosis received by 40-60% of individuals in eating disorder programs • Many continue on to develop bulimia nervosa or binge eating disorder • Display emotional and physiological problems • Increased mortality and higher risk of suicide

23. Etiology of Eating Disorders Figure 9-2 Multipath Model of Eating Disorders The dimensions interact with one another and combine in different ways to result in an eating disorder

24. Psychological Dimension • Risk factors: • Body dissatisfaction arises from discrepancy between perceived body versus imagined ideal • Perfectionism • Inflexible high standards • Negative self-evaluations following mistakes • Individuals appear to use food or weight control as a means of handling stress or anxiety

25. Psychological Dimension (cont’d.) • Other risk factors: • Perceived or actual inadequacies in interpersonal skills • Passive non-assertive interpersonal style • Dysfunctional beliefs • Mood disorders such as depression often accompany eating disorders • May represent an expression of mood disorders • Relationship is unknown (depression may be cause or result of eating disorder)

26. Social Dimension • Interpersonal interaction patterns with parents and peers, but difficult to interpret • Childhood maltreatment may produce a self-critical style that results in depression and body dissatisfaction • Childhood trauma appears to have the most impact on the purging type of anorexia nervosa • Peer and family pressures to be thin

27. Sociocultural Dimension • Unrealistic standards of beauty in mass media • Women are socialized to be conscious of body shape and weight • Exposure to thin-ideal: • Believe that primary value is to be attractive • Define themselves according to bodily standards in media • Become objectified rather than having capacity for independent action and decision making

28. Sociocultural Dimension (cont’d.) Figure 9-3 Objectification of Women and Girls In family films (those with a G, PG, or PG-13 rating), women and girls often are “scantily clad” and very attractive, and have an unrealistic body shape. Does this contribute to the objectification of girls and women? Source: S.L. Smith & Choueiti (2010)

29. Sociocultural Dimension (cont’d.) • Social comparison: • Evaluate self based on external standards, which are unattainable for most women • Body dissatisfaction: • Males see their bodies as smaller than what they believe is preferred • Females see their bodies as larger than what they believe is preferred

30. Sociocultural Dimension (cont’d.) Figure 9-4 Route to Eating Disorders Social comparison can lead to the development of eating disorders Source: Adapted from Stice (2001).

31. Sociocultural Dimension (cont’d.) • Ethnic minorities and eating disorders: • 2006 meta-analysis: • Body dissatisfaction not just a problem for white women; it exists for all ethnic minorities • Latina/Hispanic and Asian American women had body dissatisfaction levels equal to white women • African-American women had dissatisfaction, but at lower levels

32. Sociocultural Dimension (cont’d.) • Ethnic minorities and eating disorders: • Many African-Americans seem insulated from thinness standard, but equally as likely to have binge-eating disorder • Prevalence of eating conditions not elsewhere classified appears to be equivalent to white women • Ethnic minorities may become increasingly vulnerable to societal messages of beauty and thus may be at especially high risk of developing eating disorders

33. Sociocultural Dimension (cont’d.)

34. Sociocultural Dimension (cont’d.) • Cross-cultural studies on eating disorders: • Cultural values and norms affect views of body shape and size • Weight normalcy is influenced by cultural beliefs and practices • Exposure to Western media is linked with an increase in body shape concerns and distorted eating attitudes • Far fewer reports of eating disorders are found in Latin American, South American, and Asian countries than in European countries, Israel, and Australia

35. Biological Dimension • Gene-environment interaction • Genetics may contribute • Involves neurotransmitters or brain structures, such as hypothalamus • Dopamine levels control appetite • People with lower levels desire food more • Other brain regions and neurotransmitters (e.g., serotonin) also involved

36. Treatment of Anorexia Nervosa • Inpatient/outpatient depends on weight and health of individual • Treatment goals: • Restore healthy weight • Address physical complications • Enhance motivation to participate in program • Psychoeducation about healthy eating and nutrition

37. Treatment of Anorexia Nervosa (cont’d.) • Psychological interventions used to help client: • Understand and cooperate with nutritional and physical rehabilitation • Identify and understand dysfunctional attitudes • Improve interpersonal and social functioning • Address other psychological disorders or conflicts

38. Treatment of Anorexia Nervosa (cont’d.) • Family therapy: • Parents involved in meal planning • Reduce parental criticism (understanding seriousness of anorexia) • Learning new family relationship patterns • Important component in treatment • More effective than individual therapy alone

39. Treatment of Bulimia Nervosa • Treatment goals: • Treatment of conditions that result from purging • Need for an interdisciplinary team that includes a physician and a psychotherapist • One of primary goals is to normalize eating patterns and eliminate binge/purge cycle • Use of antidepressants: • Selective serotonin reuptake inhibitors

40. Treatment of Bulimia Nervosa (cont’d.) • Cognitive-behavioral approaches: • Encourage eating three or more balanced meals a day • Reduce rigid food rules and body image concerns • Identify triggers • Develop coping strategies • Only 50% fully recover • Adding exposure and response prevention improves long-term outcomes

41. Treatment of Eating Disorders • Preventing eating disorders: • Interventions focus on: • Increasing awareness of societal messages regarding being female • Develop positive body image • Develop healthier eating and exercise habits • Increase comfort in expressing feelings • Develop healthy coping strategies • Increase assertiveness skills • More focus on preventing eating disorders in men and boys

42. Treatment of Binge-Eating Disorder • Similar to treatments for bulimia with fewer physical complications • Because most are overweight, therapy programs try to help individual lose weight • Two phases: • Determine underlying triggering factors • Use strategies to reduce eating binges

43. Obesity • Defined as body mass index (BMI) greater than 30 • BMI: an estimate of body fat calculated on the basis of a person’s height and weight • Not recognized in DSM-5 • Some researchers believe that forms of obesity should be recognized as “food addiction”

44. Obesity (cont’d.) • Often accompanied by depression and anxiety disorders, low-self esteem, poor body image, and unhealthy eating patterns • 68% of American adults are overweight or obese • One-third of children or adolescents in U.S. are obese or overweight • Second only to tobacco in terms of preventable cause of disease and death

45. Obesity (cont’d.) Figure 9-5 State-Specific Increase in Obesity Prevalence among Adults, 2000 to 2009 These maps show the percentage of adults age 18 years and older considered obese, by state Source: Centers for Disease Control and Prevention (2010d).

46. Etiology of Obesity • Product of biological, psychological, and sociocultural influences • Interaction of these dimensions is still being investigated

47. Etiology of Obesity (cont’d.) Figure 9-6 Multipath Model for Obesity The dimensions interact with one another and combine in different ways to result in obesity

48. Etiology of Obesity (cont’d.) • Biological dimension: • Genes can influence eating behaviors through brain structures and neurochemistry • “thrifty genotype” • Brain regions that motivate and inhibit food consumption may be involved • Hormones such as leptin have been implicated • Low levels of dopamine and fewer dopamine receptors • Cause and effect relationship is unclear

49. Etiology of Obesity (cont’d.) • Psychological dimension: • Negative mood states and poor self-esteem • Anxiety and depression • Responses are likely affected by weight stigma • Cause-effect relationship of negative mood and weight still unclear

50. Etiology of Obesity (cont’d.) • Social dimension: • Family environments associated with obese children and adolescents • Stress within family • Poor maternal relationship • Teasing by family members about weight • Parental eating patterns and attitudes • Social networks also associated • People influence others in their social network regarding acceptability of weight gain