chapter 11 eating disorders slides & handouts by karen clay rhines, ph.d. seton hall university
TRANSCRIPT
Chapter 11
Eating Disorders
Slides & Handouts by Karen Clay Rhines, Ph.D.Seton Hall University
Slide 2
Eating Disorders
Although not historically true, current Western beauty standards equate thinness with health and beauty
There has been a rise in eating disorders in the past three decades• The core issue is a morbid fear of weight gain
Two main diagnoses:• Anorexia nervosa
• Bulimia nervosa
Slide 3
Anorexia Nervosa
The main symptoms of anorexia nervosa are:
• A refusal to maintain more than 85% of normal body weight
• Intense fears of becoming overweight
• A distorted view of body weight and shape
• Amenorrhea
Slide 4
Anorexia 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
Slide 5
Anorexia Nervosa
About 90–95% of cases occur in females
The peak age of onset is between 14 and 18 years
Around 0.5% 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
Slide 6
Anorexia Nervosa
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
Slide 7
Anorexia Nervosa: The Clinical Picture
The key goal for people with anorexia nervosa is thinness
• The driving motivation is FEAR:
• Of becoming obese
• Of losing control of body shape and weight
Slide 8
Anorexia Nervosa: The Clinical Picture
Despite their dietary restrictions, people with anorexia are extremely preoccupied with food
• This includes thinking and reading about food and planning for meals
• This relationship is not necessarily causal
• It may be the result of food deprivation, as evidenced by the famous 1940s “starvation study” with conscientious objectors
Slide 9
Anorexia Nervosa: The Clinical Picture
People with anorexia nervosa also demonstrate distorted thinking:
• Often have a low opinion of their body shape
• Tend to overestimate their actual proportions
• Adjustable lens assessment technique – overestimate size by 20%
• Hold maladaptive attitudes and beliefs
• “I must be perfect in every way”
• “I will be a better person if I deprive myself”
• “I can avoid guilt by not eating”
Slide 10
Anorexia Nervosa: The Clinical Picture
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
Slide 11
Anorexia Nervosa: Medical Problems
Caused by starvation:
• Amenorrhea
• Low body temperature
• Low blood pressure
• Body swelling
• Reduced bone density
• Slow heart rate
• Metabolic and electrolyte imbalance
• Dry skin, brittle nails
• Poor circulation
• Lanugo
Slide 12
The Vicious Cycle of Anorexia
Fear of obesity and distorted body image lead to…
Preoccupation with food
Increased anxiety & depression
Medical problems
Greater feelings of fear & loss of control
Harder attempts at thinness
Starvation
Slide 13
Bulimia Nervosa
Bulimia nervosa, also known as “binge-purge syndrome,” is characterized by binges:
• Bouts of uncontrolled overeating during a limited period of time
• Often objectively more than most people would/could eat in a similar period
Slide 14
Bulimia Nervosa
The disorder is also characterized by compensatory behaviors, which mark the subtype of the condition:
• Purging-type bulimia nervosa• Vomiting
• Misusing laxatives, diuretics, or enemas
• Nonpurging-type bulimia nervosa• Fasting
• Exercising excessively
Slide 15
Bulimia Nervosa
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
Slide 16
Bulimia Nervosa
Patients are generally of normal weight
• May be slightly overweight
• Often experience weight fluctuations
“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
Slide 17
Bulimia Nervosa
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
Slide 18
Bulimia Nervosa: Binges
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 1500 calories (often more than 3000 calories) per binge episode
Slide 19
Bulimia Nervosa: Binges
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”
Slide 20
Bulimia Nervosa: Compensatory Behaviors
After a binge, people with bulimia nervosa try to compensate for and “undo” the caloric effects
The most common compensatory behaviors:
• Vomiting
• Affects ability to feel satiated greater hunger and bingeing
• Laxatives and diuretics
• Almost completely fail to reduce the number of calories consumed
Slide 21
Bulimia Nervosa: Compensatory Behaviors
Compensatory behaviors may temporarily relieve the negative feelings attached to binge eating
• Over time, however, a cycle develops in which purging bingeing purging…
Slide 22
Bulimia Nervosa
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
Slide 23
Bulimia Nervosa vs. Anorexia 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
Slide 24
Bulimia Nervosa vs. Anorexia Nervosa
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
Slide 25
Bulimia Nervosa vs. Anorexia Nervosa
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
Slide 26
What Causes Eating 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
Slide 27
What Causes Eating Disorders? Societal Pressures
Many theorists argue that current Western standards of female attractiveness have contributed to the rise of 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
Slide 28
What Causes Eating Disorders? Societal 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
Slide 29
What Causes Eating Disorders? Societal Pressures
Societal attitudes may explain economic and racial differences seen in prevalence rates
• In the past, Caucasian women of higher SES expressed more concern about thinness and dieting
• These women had higher rates of eating disorders than African American women or Caucasian women of lower SES
• Recently, dieting and preoccupation with food, along with rates of eating disorders, are increasing in all groups
Slide 30
What Causes Eating Disorders? Societal 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
Slide 31
What Causes Eating Disorders? Family Environment
Families may play a critical 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
Slide 32
What Causes Eating Disorders? Family 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
• Such families can be affectionate and loyal but can also foster clinginess and dependency
• Children are allowed little room for individuality and independence
Slide 33
What Causes Eating Disorders? Ego Deficiencies and Cognitive Disturbances
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
Slide 34
What Causes Eating Disorders? Ego Deficiencies and Cognitive Disturbances
Bruch argues that 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.
• Children who receive such parenting may grow up confused and unaware of their own internal needs; they are unable to identify their own emotions
• They turn to external guides (often parents) and fail to develop genuine self-reliance (i.e., they are not in control of their lives)
Slide 35
What Causes Eating Disorders? Ego Deficiencies and Cognitive Disturbances
There is some empirical support for Bruch’s theory from clinical sources
• People with bulimia eat in response to emotions; many mistakenly think they are also hungry
• People with eating disorders rely excessively on the opinions, wishes, and views of others
• They are more likely to worry about how they are viewed, to seek approval, to be conforming, and to feel a lack of life control
Slide 36
What Causes Eating Disorders? Mood 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
Slide 37
What Causes Eating Disorders? Mood Disorders
There is some 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
Slide 38
What Causes Eating Disorders? Biological Factors
Biological theorists suspect that some people inherit a genetic tendency to develop an eating disorder
• 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
Slide 39
What Causes Eating Disorders? Biological Factors
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)
Slide 40
What Causes Eating Disorders? Biological Factors
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
Slide 41
Treatments for Eating Disorders
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
Slide 42
Treatments for Anorexia Nervosa
The initial aims of treatment for anorexia nervosa are to:
• Restore proper weight
• Recover from malnourishment
• Restore proper eating
Slide 43
Treatments for Anorexia Nervosa
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 force tube and intravenous feeding
• 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
Slide 44
Treatments for Anorexia Nervosa
Researchers have found that people with anorexia must overcome their underlying psychological problems in order to achieve lasting improvement
Slide 45
Treatments for Anorexia Nervosa
Therapists use a mixture of therapy and education to achieve this broader goal
• 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
Slide 46
Treatments for Anorexia Nervosa
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
Slide 47
Treatments for Anorexia Nervosa
Another focus of treatment is changing family interactions
• Family therapy is important for anorexia
• The main issues are often separation and boundaries
Slide 48
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
Treatments for Anorexia Nervosa
Slide 49
Treatments for Anorexia Nervosa
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
Slide 50
Treatments for Anorexia Nervosa
Negatives of treatment:
• Close to 20% of patients remain troubled for years
• Even when it occurs, recovery is not always permanent
• Relapses are usually triggered by stress
• Many patients still express concerns about body shape and weight
• Lingering emotional problems are common
Slide 51
Treatments for Bulimia Nervosa
Treatment programs are relatively new but have risen in popularity
Treatment is frequently offered in specialized eating disorder clinics
Slide 52
Treatments for Bulimia Nervosa
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
Slide 53
Treatments for Bulimia Nervosa
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
• 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
Slide 54
Treatments for Bulimia Nervosa
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
Slide 55
Treatments for Bulimia Nervosa
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 25 to 40% of patients
• Medications are best when used in combination with other forms of therapy
Slide 56
Treatments for Bulimia Nervosa
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
Slide 57
Treatments for Bulimia Nervosa
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
Slide 58
Treatments for Bulimia Nervosa
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