abnormal lecture ch09

1Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 9Slides & Handouts by Karen Clay Rhines, Ph.D.

Chapter 9Chapter 9

Eating DisordersEating Disorders

2Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 9

Eating DisordersEating Disorders

Although not historically true, current Western beauty standards equate thinness with health and beauty Thinness has become a national obsession!

There has been a rise in eating disorders in the past three decades

Two main diagnoses: Anorexia nervosa

Bulimia nervosa


Anorexia NervosaAnorexia Nervosa

There are two main subtypes: Restricting type

Lose weight by restricting “bad” foods, eventually restricting nearly all food

Show almost no variability in diet

Binge-eating/purging type Lose weight by vomiting after meals, abusing

laxatives or diuretics, or engaging in excessive exercise

Like those with bulimia nervosa, people with this subtype may engage in eating binges



About 90%–95% of cases occur in females The peak age of onset is between 14 and

18 years Between 0.5% and 2% of females in

Western countries develop the disorder Many more display some symptoms

Rates of anorexia nervosa are increasing in North America, Japan, and Europe



The “typical” case: A normal to slightly overweight female has been on

a diet

Escalation to anorexia nervosa may follow a stressful event

Separation of parents

Move or life transition

Experience of personal failure

Most patients recover However, about 2% to 6% become seriously ill and die as

a result of medical complications or suicide


Anorexia Nervosa: The Anorexia Nervosa: The Clinical PictureClinical Picture

The key goal for people with anorexia nervosa is becoming thin The driving motivation is fear:

Of becoming obese

Of giving in to the desire to eat

Of losing control of body shape and weight



Despite their dietary restrictions, people with anorexia are preoccupied with food This includes thinking and reading

about food and planning for meals

This preoccupation may be the result of food deprivation rather than its cause

Famous 1940s “starvation study” with conscientious objectors



People with anorexia nervosa also think in distorted ways: Often have a low opinion of their body shape

Tend to overestimate their actual proportions Adjustable lens assessment technique

Hold maladaptive attitudes and misperceptions “I must be perfect in every way”

“I will be a better person if I deprive myself”

“I can avoid guilt by not eating”



People with anorexia may also display certain psychological problems: Depression (usually mild) Anxiety Low self-esteem Insomnia or other sleep disturbances Substance abuse Obsessive-compulsive patterns Perfectionism


Anorexia Nervosa: Medical Anorexia Nervosa: Medical ProblemsProblems

Caused by starvation: Amenorrhea

Low body temperature

Low blood pressure

Body swelling

Reduced bone density

Slow heart rate

Metabolic and electrolyte imbalances

Dry skin, brittle nails

Poor circulation

Lanugo


Bulimia NervosaBulimia Nervosa

Bulimia nervosa, also known as “binge-purge syndrome,” is characterized by binges: Bouts of uncontrolled overeating during

a limited period Eats more than most people would/could eat

in a similar period



The disorder is also characterized by compensatory behaviors, such as: Vomiting

Misusing laxatives, diuretics, or enemas

Fasting

Exercising excessively



Like anorexia nervosa, about 90%–95% of bulimia nervosa cases occur in females

The peak age of onset is between 15 and 21 years

Symptoms may last for several years with periodic letup



Patients are generally of normal weight Often experience weight fluctuations

Some may also qualify for a diagnosis of anorexia



“Binge-eating disorder” may be a related diagnosis Symptoms include a pattern of binge

eating with NO compensatory behaviors (such as vomiting)

This condition is not yet listed in the DSM-IV-TR



Teens and young adults have frequently attempted binge-purge patterns as a means of weight loss, often after hearing accounts of bulimia from friends or the media

In one study: 50% of college students reported periodic binges 6% tried vomiting 8% experimented with laxatives at least once

Surveys suggest that as many as 5% of women develop the full syndrome


Bulimia Nervosa: Bulimia Nervosa: BingesBinges

For people with bulimia nervosa, the number of binges per week can range from 2 to 40 Average: 10 per week

Binges are often carried out in secret Binges involve eating massive amounts of food

rapidly with little chewing Usually sweet foods with soft texture

Binge-eaters commonly consume more than 1000 calories (often more than 3000 calories) per binge episode


Bulimia Nervosa: Bulimia Nervosa: BingesBinges

Binges are usually preceded by feelings of tension and/or powerlessness

Although the binge itself may be pleasurable, it is usually followed by feelings of extreme self-blame, guilt, depression, and fears of weight gain and “discovery”


Bulimia Nervosa: Bulimia Nervosa: Compensatory BehaviorsCompensatory Behaviors

After a binge, people with bulimia nervosa try to compensate for and “undo” the caloric effects

The most common compensatory behaviors: Vomiting

Fails to prevent the absorption of half the calories consumed during a binge

Affects ability to feel satiated greater hunger and bingeing

Laxatives and diuretics Also almost completely fail to reduce the number of

calories consumed


Bulimia Nervosa: Bulimia Nervosa: Compensatory BehaviorsCompensatory Behaviors

Compensatory behaviors may temporarily relieve the negative feelings attached to binge eating Over time, however, a cycle develops in

which purging bingeing purging



The “typical” case: A normal to slightly overweight female has

been on an intense diet

Research suggests that even among normal subjects, bingeing often occurs after strict dieting

For example, a study of binge-eating behavior in a low-calorie weight loss program found that 62% of patients reported binge-eating episodes during treatment


Bulimia Nervosa vs. Bulimia Nervosa vs. Anorexia NervosaAnorexia Nervosa

Similarities: Onset after a period of dieting Fear of becoming obese Drive to become thin Preoccupation with food, weight, appearance Elevated risk of self-harm or attempts at suicide Feelings of anxiety, depression, perfectionism Substance abuse Disturbed attitudes toward eating



Differences: People with bulimia are more worried about

pleasing others, being attractive to others, and having intimate relationships

People with bulimia tend to be more sexually experienced

People with bulimia display fewer of the obsessive qualities that drive restricting-type anorexia

People with bulimia are more likely to have histories of mood swings, low frustration tolerance, and poor coping



Differences: People with bulimia tend to be controlled by

emotion – may change friendships easily

People with bulimia are more likely to display characteristics of a personality disorder

Different medical complications: Only half of women with bulimia experience

amenorrhea vs. almost all women with anorexia

People with bulimia suffer damage caused by purging, especially from vomiting and laxatives


What Causes Eating What Causes Eating Disorders?Disorders?

Most theorists subscribe to a multidimensional risk perspective: Several key factors place individuals at risk

More factors = greater risk

Leading factors: Sociocultural conditions (societal and family

pressures)

Psychological problems (ego, cognitive, and mood disturbances)

Biological factors


What Causes Eating What Causes Eating Disorders? Disorders?

Societal PressuresSocietal Pressures Many theorists believe that current

Western standards of female attractiveness have contributed to increases in eating disorders Standards have changed throughout history

toward a thinner ideal Miss America contestants have declined in weight

by 0.28 lbs/yr; winners have declined by 0.37 lbs/yr

Playboy centerfolds have lower average weight, bust, and hip measurements than in the past



Societal PressuresSocietal Pressures Certain groups are at greater risk

from these pressures: Models, actors, dancers, and certain

athletes Of college athletes surveyed, 9% met full

criteria for an eating disorder while another 50% had symptoms

20% of surveyed gymnasts met full criteria for an eating disorder



Societal PressuresSocietal Pressures Societal attitudes may explain economic

and racial differences seen in prevalence rates In the past, white women of higher SES

expressed more concern about thinness and dieting

These women had higher rates of eating disorders than African American women or white women of lower SES

Recently, dieting and preoccupation with food, along with rates of eating disorders, are increasing in all groups



Societal PressuresSocietal Pressures The socially accepted prejudice

against overweight people may also add to the “fear” and preoccupation about weight About 50% of elementary and 61% of

middle school girls are currently dieting



Family EnvironmentFamily Environment Families may play an important role in

the development of eating disorders As many as half of the families of those

with eating disorders have a long history of emphasizing thinness, appearance, and dieting

Mothers of those with eating disorders are more likely to be dieters and perfectionistic themselves



Family EnvironmentFamily Environment Abnormal family interactions and forms of

communication within a family may also set the stage for an eating disorder Minuchin cites “enmeshed family patterns” as

causal factors of eating disorders These patterns include overinvolvement in, and

overconcern about, family member’s lives


What Causes Eating Disorders? What Causes Eating Disorders? Ego Deficiencies and Cognitive Ego Deficiencies and Cognitive

DisturbancesDisturbances Bruch argues that eating disorders

are the result of disturbed mother–child interactions, which lead to serious ego deficiencies in the child and to severe cognitive disturbances


What Causes Eating Disorders? What Causes Eating Disorders? Ego Deficiencies and Cognitive Ego Deficiencies and Cognitive

DisturbancesDisturbances According to Bruch, parents may respond

to their children either effectively or ineffectively Effective parents accurately attend to a child’s

biological and emotional needs Ineffective parents fail to attend to child’s

internal needs; they feed when the child is anxious, comfort when the child is tired, etc.

There is some empirical support for Bruch’s theory from clinical reports



Mood DisordersMood Disorders Many people with eating disorders,

particularly those with bulimia nervosa, experience symptoms of depression Theorists believe mood disorders may

“set the stage” for eating disorders



Mood DisordersMood Disorders There is empirical support for the claim that

mood disorders set the stage for eating disorders: Many more people with an eating disorder qualify

for a clinical diagnosis of major depressive disorder than do people in the general population

Close relatives of those with eating disorders seem to have higher rates of mood disorders

People with eating disorders, especially those with bulimia nervosa, have low levels of serotonin

Symptoms of eating disorders are helped by antidepressant medications


What Causes Eating What Causes Eating Disorders? Biological Disorders? Biological

FactorsFactors Biological theorists suspect certain genes

may leave some people particularly susceptible to eating disorders Consistent with this model:

Relatives of people with eating disorders are 6 times more likely to develop the disorder themselves

Identical (MZ) twins with bulimia: 23% Fraternal (DZ) twins with bulimia: 9%

These findings may be related to low serotonin



FactorsFactors Other theorists believe that eating

disorders may be related to dysfunction of the hypothalamus Researchers have identified two

separate areas that control eating: Lateral hypothalamus (LH)

Ventromedial hypothalamus (VMH)



FactorsFactors Some theorists believe that the LH and VMH

are responsible for weight set point – a “weight thermostat” of sorts Set by genetic inheritance and early eating

practices, this mechanism is responsible for keeping an individual at a particular weight level

If weight falls below set point: hunger, metabolism binges

If weight rises above set point: hunger, metabolism

Dieters end up in a fight against themselves to lose weight


Treatments for Eating Treatments for Eating DisordersDisorders

Eating disorder treatments have two main goals: Correct abnormal eating patterns

Address broader psychological and situational factors that have led to and are maintaining the eating problem

This often requires the participation of family and friends


Treatments for Anorexia Treatments for Anorexia NervosaNervosa

The initial aims of treatment for anorexia nervosa are to: Restore proper weight

Recover from malnourishment

Restore proper eating



In the past, treatment took place in a hospital setting; it is now often offered in an outpatient setting

In life-threatening cases, clinicians may need to force tube and intravenous feedings on the patient This may breed distrust in the patient and create a

power struggle

Most common technique now is the use of supportive nursing care and high-calorie diets Necessary weight gain is often achieved in 8 to 12

weeks



Researchers have found that people with anorexia must overcome their underlying psychological problems to achieve lasting improvement



Therapists use a mixture of therapy and education to achieve this broader goal, using a combination of individual, group, and family approaches One focus of treatment is building autonomy

and self-awareness

Therapists help patients recognize their need for independence and control

Therapists help patients recognize and trust their internal feelings



Another focus of treatment is correcting disturbed cognitions, especially client misperceptions and attitudes about eating and weight Using cognitive approaches, therapists

correct disturbed cognitions and educate about body distortions



Another focus of treatment is changing family interactions Family therapy is important for

anorexia

The main issue is often separation


The use of combined treatment approaches has greatly improved the outlook for people with anorexia nervosa But even with combined treatment,

recovery is difficult

The course and outcome of the disorder vary from person to person




Positives of treatment: Weight gain is often quickly restored

83% of patients still showed improvements after several years

Menstruation often returns with return to normal weight

The death rate from anorexia is declining



Negatives of treatment: Close to 20% of patients remain troubled

for years Even when it occurs, recovery is not

always permanent Anorexic behaviors recur in at least one-third of

recovered patients, usually triggered by stress Many patients still express concerns about

body shape and weight

Lingering emotional problems are common


Treatments for Bulimia Treatments for Bulimia NervosaNervosa

Treatment is frequently offered in specialized eating disorder clinics



The initial aims of treatment for bulimia nervosa are to: Eliminate binge-purge patterns

Establish good eating habits

Eliminate the underlying cause of bulimic patterns

Programs emphasize education as much as therapy



Several treatment strategies: Individual insight therapy

The insight approach receiving the most attention is cognitive therapy, which helps clients recognize and change their maladaptive attitudes toward food, eating, weight, and shape

As many as 65% stop their binge-purge cycle



Several treatment strategies: Individual insight therapy

If cognitive therapy isn’t effective, interpersonal therapy (IPT), a treatment that seeks to improve interpersonal functioning, may be tried

A number of clinicians also suggest self-help groups or self-care manuals



Several treatment strategies: Behavioral therapy

Behavioral techniques are often included in treatment as a supplement to cognitive therapy

Diaries are often a useful component of treatment

Exposure and response prevention (ERP) is used to break the binge-purge cycle



Several treatment strategies: Antidepressant medications

During the past decade, antidepressant drugs have been used in bulimia treatment

Most common is fluoxetine (Prozac), an SSRI

Drugs help as many as 40% of patients

Medications are best when used in combination with other forms of therapy



Several treatment strategies: Group therapy

Provides an opportunity for patients to express their thoughts, concerns, and experiences with one another

Helpful in as many as 75% of cases, especially when combined with individual insight therapy



Left untreated, bulimia can last for years

Treatment provides immediate, significant improvement in about 40% of cases An additional 40% show moderate

improvement

Follow-up studies suggest that 10 years after treatment about 90% of patients have fully or partially recovered



Relapse can be a significant problem, even among those who respond successfully to treatment Relapses are usually triggered by stress

Relapses are more likely among persons who: Had a longer history of symptoms

Vomited frequently

Had histories of substance use

Have lingering interpersonal problems



Finally, treatment may also help improve overall psychological and social functioning

abnormal lecture ch09

Education