Chapter Eleven: Eating Disorders

Anorexia Nervosa

• Anorexia Nervosa: A disorder marked by the pursuit of extreme thinness and by extreme weight loss

• A person with anorexia will

  • Purposely maintain a significantly low body weight
  • Have intense fears of becoming overweight
  • Have a distorted view of their weight and shape
  • Be excessively influenced by their weight and shape in their self-evaluations

• Restricting-type Anorexia Nervosa: A pattern of anorexia where one reduces their weight by restricting their intake of food

• Binge-eating/Purging-type Anorexia Nervosa: A pattern of anorexia where one reduces their weight by forcing themselves to vomit after meals or by abusing laxatives or diuretics

  • May also engage in eating binges

• 75-90% of cases of anorexia occurs in females

• Peak age of onset is 14-20 yrs

• Disorder typically begins after a person who is slightly overweight or of normal weight has been on a diet

• Escalation toward anorexia may follow a stressful event

• Most people with the disorder recover, but as many as 6% become so seriously ill that they die

  • Medical problems brought about by starvation
  • Suicide - suicide rate for anorexics is 5x the rate of the general population

The Clinical Picture

• Fear is the motivation
  • Fear of becoming obese
  • Fear of giving in to their desire to eat
• Preoccupied with food
  • Spend considerable time thinking about food
  • Plan their limited meals
  • Dreams are filled with images of food and eating
  • May be a result of food deprivation
• Think in distorted ways
  • Low opinion of their body shape
  • Consider themselves unattractive
  • Likely to overestimate their actual proportions
  • Maladaptive attitudes and misperceptions
• Psychological problems
  • Depression
  • Anxiety
  • ow self-esteem
  • Insomnia and other sleep disturbances
  • Substance abuse
  • Obsessive-compulsive patterns
  • Perfectionistic

Medical Problems

• Amenorrhea: The absence of menstrual cycles
• Lowered body temperature
• Low blood pressure
• Body swelling
• Reduced bone mineral density
• Slow heart rate
• Metabolic and electrolyte imbalances
  • Can lead to death by heart failure or circulatory collapse
• Skin can become rough, dry, and cracked
• Nails become brittle
• Hands and feet are cold and blue

Bulimia Nervosa

• Bulimia Nervosa: A disorder in which people engage in binges and compensatory behaviors

• Usually occurs in females

• Begins in adolescence or young adulthood and often lasts for years, with periodic letup

• Weight stays within a normal range, though it might fluctuate markedly within that range

• Some people with this disorder become seriously underweight and may eventually qualify for a diagnosis of anorexia instead

• 25-50% of all students report periodic binge eating or self-induced vomiting but only some qualify for a diagnosis

Binges

• Binge: A repeated episode of uncontrollable overeating
• Takes place over a limited period of time during which the person eats much more food than most people would eat during a similar time span
• May have between 1 and 30 binge episodes per week
• Carry out the binges in secret
• Consume an average of 2000-3400 calories during an episode
• During the binge the person feels unable to stop eating
• Feelings
  • Before: Feelings of great tension. feels irritable and powerless
  • During: Pleasurable bc it relieves the tension
  • After: Extreme self-blame, shame, guilt, depression, fears of gaining weight / being discovered

Compensatory Behaviors

• After a binge, ppl with bulimia try to compensate for and undo its effects
• ex: Forcing themselves to vomit, misusing laxatives, fasting, or exercising excessively
• Vomiting
  • Fails to prevent the absorption of half of the calories consumed during a binge
  • Repeated vomiting affects one’s general ability to feel satiated
  • Leads to greater hunger and more frequent and intense binges
• Use of laxatives/diuretics largely fails to undo the caloric effects of binging
• The Cycle
  • 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
  • Purging allows more binging
  • Binging necessitates more purging
  • Causes people with the disorder to feel powerless and disgusted with themselves
• Most fully recognize that they have an eating disorder
• 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

Bulimia Nervosa Versus Anorexia Nervosa

• Ppl with bulimia, compared to those with anorexia:
  • Tend to be more concerned about pleasing others, being attractive to others, and having intimate relationships
  • Tend to be more sexually experienced and active
  • More likely to have long histories of mood swings, become easily frustrated or bored, and have trouble coping effectively
  • More than ⅓ display the characteristics of a personality disorder
  • Only half are amenorrheic
  • Frequent vomiting can cause serious medical and dental problems

Binge-Eating Disorder

• Those with binge-eating disorder engage in repeated eating binges during which they feel no control over their eating, but don’t perform inappropriate compensatory behavior
• Around half of people with binge-eating become overweight or obese
• Most overweight people don’t engage in repeated binges
• 2-7% of the population have binge-eating disorder
  • 64% women
• Typically preoccupied with food, weight, and appearance, base their evaluation of themselves largely on weight, misperceive their body size and are extremely dissatisfied with their body
• Not as driven to thinness
• Doesn’t necessarily begin with efforts at extreme dieting
• Typically develop it later than those with the other eating disorders (most often in their twenties)

What Causes Eating Disorders?

• Multidimensional Risk Perspective: A theory that identifies several kinds of risk factors that are thought to combine to help cause a disorder. The more factors present, the greater the risk of developing the disorder

Psychodynamic Factors

• 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
• Parents may respond to their children either effectively or ineffectively
  • Effective parents
  • Accurately attend to their children’s biological and emotional needs
  • Give them food when they’re crying from hunger
  • Give them comfort when they’re crying out of fear
  • Ineffective parents
  • Fail to attend to their children’s needs
  • Decide that their children are hungry, cold, or tired without correctly interpreting the children’s actual condition
  • May feed their children when their children are anxious rather than hungry or comfort them when they’re tired rather than anxious
• Children may grow up confused and unaware of their own internal needs, not knowing for themselves when they’re hungry or full and unable to identify their own emotions
  • Turn to external guides, such as their parents
  • Fail to develop genuine self-reliance
  • Feel unable to establish independence
  • To overcome their sense of helplessness, they seek excessive control over their body size and shape and over their eating habits
• Parents of teens with eating disorders tend to define their children’s needs rather than allow the children to define their own needs
• People with eating disorders perceive internal cues, including emotional cues, inaccurately
• Alexithymic: A person who has great difficulty putting descriptive labels on their feelings

Cognitive-Behavioral Factors

• 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 want to have excessive levels of control over their body size and eating habits
• Cognitive-Behavioral Therapies are among the most widely used of all treatments for eating disorders

Depression

• Many people with eating disorders have symptoms of depression
• Depressive disorders help set the stage for eating disorders
  • Many more people with an eating disorder qualify for a clinical depressive disorder than do ppl in the general population
  • Close relatives of people with eating disorders have a higher rate of depressive disorders
  • Depression-related brain circuit of many people with eating disorders shows abnormalities similar to those of people with depression
  • Ppl with eating disorders are sometimes helped by the same antidepressant drugs that reduce depression

Biological Factors

• Certain genes may leave some people particularly susceptible to eating disorders
• Relatives of people with eating disorders are 6x more likely to develop those disorders themselves
• If one identical twin has anorexia, the other develops the disorder in 70% of cases
• Dysfunctional brain circuits in people with eating disorders
  • Circuits linked to generalized anxiety, obsessive-compulsive, and depressive disorders acts dysfunctionally in ppl with eating disorders
  • Insula is abnormally large and active
  • Orbitofrontal cortex is uncommonly large
  • Striatum is hyperactive
  • Prefrontal cortex is unusually small
  • Activity levels of serotonin, dopamine, and glutamate are abnormal
• Dysfunction across the brain circuits could
  • Help cause eating disorders
  • Be a result of eating disorders
  • Reflect the fact that many people with eating disorders also suffer from anxiety, obsessive-compulsive, and/or depressive disorders
• Hypothalamus: A part of the brain that helps regulate various bodily functions, including eating and hunger
  • Lateral Hypothalamus: Part of the hypothalamus that produces hunger when it’s activated
  • sides of the hypothalamus
  • Ventromedial Hypothalamus: Part of the hypothalamus that reduces hunger when it’s activated
  • Bottom and middle of the hypothalamus
  • GLP-1: Natural appetite suppressant
  • Weight Set Point: The weight level that a person is predisposed to maintain, controlled in part by the hypothalamus
  • Determined by genetic inheritance and early eating practices
  • When a person’s weight falls below their set point, the LH is activated
    • Produce hunger
    • Lower metabolic rate
  • When a person’s weight rises above their set point, the VMH is activated
    • Reduce hunger
    • Increase metabolic rate
  • Weight Set Point Theory: When people diet and fall to a weight below their weight set point, their brain starts trying to restore that lost weight
    • Produce a preoccupation with food and a desire to binge
    • Trigger bodily changes that make it harder to lose weight and easier to gain weight
  • Metabolic Rate: The rate at which the body expends energy

Societal Pressures

• Eating disorders are more common in Western countries
• Western standards of female attractiveness are partly responsible for the emergence of eating disorders
• Performers, models, and athletes are more prone than others to anorexia and bulimia
• Anorexia and Bulimia more common among women higher on the socioeconomic scale
• Western society glorifies thinness and prejudices overweight people
• People who spend more time on Facebook are more likely to display eating disorders, have negative body image, eat in dysfunctional ways, and want to diet

Family Environment

• Half the families of people with anorexia or bulimia have a history of emphasizing thinness, physical appearance, and dieting
• Mothers are more likely to diet and be perfectionistic
• Abnormal interactions and forms of communication within a family may set the stage for an eating disorder
• Enmeshed Family Pattern: A family system in which members are overinvolved with each other’s affairs and overly concerned about each other’s welfare
  • Can be affectionate and loyal
  • Can be clingy and foster dependency
  • Parents allow little room for individuality and independence

Multicultural Factors: Racial and Ethnic Differences

• 70% of African Americans were dissatisfied with their weight and body shape, compared with 90% of non-Hispanic white American teens
• Different ideals of beauty
  • Whites
  • Tall girls weighing 100-110 pounds
  • To be happy and popular, you have to be the perfect weight
  • African Americans
  • To be perfect, you have to have a good personality
  • Favored fuller hips
  • Less likely to diet
• Body image concerns are on the rise for minority groups
• Shift in eating disorders and eating problems is partly related to acculturation

Multicultural Factors: Gender Differences

• Males account for 10% of all people with anorexia and bulimia
• Men are more likely to exercise to lose weight and women are more likely to diet
• Why do men develop anorexia or bulimia?
  • Linked to the requirements and pressures of a job or sport
  • Jockeys, wrestlers, distance runners, body builders, swimmers
  • Body image
  • Want a lean, toned, thin shape rather than the muscular shape of the typical male ideal
  • Reverse Anorexia Nervosa / Muscle Dysmorphia
  • Very muscular but still see themselves as scrawny and small
  • Continue to strive for a perfect body through extreme measures
  • Feel shame about their bodies
  • Have a history of depression, anxiety, and self-destructive compulsive disorder
  • ⅓ also engage in related dysfunctional behaviors such as binge eating

How Are Eating Disorders Treated?

• Goals: Correct the dangerous eating pattern and address the broader psychological and situational factors that led to the eating problem

Treatments for Anorexia Nervosa

• ⅓ of those with anorexia receive treatment
• Restore proper weight and normal eating
  • Nutritional rehabilitation
  • Tube and intravenous feedings
  • Rewards as positive reinforcement
  • Supportive nursing care, nutritional counseling, and a relatively high-calorie diet
  • 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
  • Patients in nutritional rehab programs usually gain the necessary weight over 8-12 weeks
• Lasting changes
  • Combination of education, psychotherapy, and family therapy
  • Psychotropic drugs are limited in helping
  • Cognitive-Behavioral Therapy
  • Clients are required to monitor their feelings, hunger levels, and food intake
  • Taught to identity their core pathology
  • Taught alternative ways of coping with stress and of solving problems
  • Recognize their need for independence
  • Better identify and trust their internal sensations and feelings
  • Help clients change their attitudes about eating and weight
    • Identify, challenge, and change maladaptive assumptions
    • Educate clients about body distortions typical of anorexia
    • Help them see that their own assessments of their size are incorrect
  • Very effective
  • Most successful at preventing relapses when it continues for at least a year beyond a patient’s recovery
  • Changing family interactions
  • Try to help the person with anorexia separate her feelings and needs from those of other members of her family
  • Family therapy can be helpful in the treatment of this disorder
• Aftermath
  • Weight is often quickly restored once treatment begins
  • Treatment gains may continue for years
  • Most females with anorexia menstruate again when they regain their weight, and other medical improvements follow
  • Death rate from anorexia is falling
  • As many as 25% of ppl with anorexia remain seriously troubled for years
  • recovery isn’t always permanent
  • ½ of those who have suffered from anorexia continue to have certain psychological problems years after treatment
  • The more weight people have lost and the more time that passes before they enter treatment, the poorer the recovery rate

Treatments for Bulimia Nervosa

• 43% of those with bulimia receive treatment
• Nutritional Rehab: Helping clients to eliminate their binge-burge patterns and establish good eating habits
• A combination of therapies aimed at eliminating the underlying causes of bulimic patterns
• Emphasize education as much as therapy
• Cognitive-Behavioral Therapy is particularly helpful
• Antidepressant drug therapy is very effective
• Cognitive-Behavioral Therapy
  • Keep diaries of their eating behavior, changes in sensations of hunger and fullness, and the ebb and flow of other feelings
  • Exposure and Response Prevention: Require clients to eat particular kinds and amounts of food and then prevent them from vomiting
  • Help clients recognize and change their maladaptive attitudes
• Other forms of psychotherapy
  • Interpersonal Psychotherapy: Treatment that is used to help improve interpersonal functioning
  • Psychodynamic therapy
  • Group therapy formats
• Antidepressant Medications
  • Helps as many as 40% of patients
  • Reduces binges and vomiting
  • Seems to work best in combination with other forms of therapy
• Aftermath
  • Left untreated, bulimia can last for years, sometimes improving temporarily but then returning
  • Treatment produces immediate, significant improvement in 40% of patients
  • Another 40% show a moderate response
  • Around 75% of people with bulimia have recovered, either fully or partially
  • Relapses are usually triggered by a new life stress

Treatments for Binge-Eating Disorder

• 44% of people with binge-eating disorder receive treatment

• Psychotherapy is generally more helpful than antidepressants

• ⅓ of recovered individuals showed total improvement

• High risk of relapse

• Weight problems are often resistant to long-term improvement

• Body Project: A program that offers weekly group sessions where members are guided through exercises that critique Western society’s beauty ideals

  • Based on CDT
  • Cognitive Dissonance Theory (CDT): When people adopt new attitudes that contradict their other attitudes and behaviors, they’ll experience emotional discomfort that they seek to eliminate by changing their old attitudes and behaviors
  • Performed well in research

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