08 May Why do you think people with anorexia nervosa and bulimia nervosa continue their self-defeating behaviors despite the medical?complications?of these conditions? Explai
Ch 10 – Eating Disorders
Why do you think people with anorexia nervosa and bulimia nervosa continue their self-defeating behaviors despite the medical complications of these conditions? Explain. What role do sociocultural factors play in eating disorders? How might we change societal attitudes and social pressures placed on young men and/or women that may lead to disordered eating habits?
Please answer in a minimum of 500 words and use only your textbook and notes/memory from the in-class lecture to complete this assignment. Your word count should be included at the end of your writing. This assignment will not be accepted if it is in the form of a screen shot or jpeg file.
Fundamentals of Psychology – Ch.10 Eating Disorders – Page 203
Feeding and Eating Disorders
Chapter 10
But first..
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Feeding and Eating Disorders
Within the DSM 5-TR (APA, 2022), six disorders are classified under the Feeding and Eating Disorders chapter:
Pica – an eating disorder in which a person eats things not usually considered food
Rumination disorder – A condition where a person spits up food from the stomach, rechews it, and either swallows it again or spits it out. It tends to occur within 30 minutes of every meal. The cause is unknown.
Avoidant/restrictive food intake disorder – (ARFID) is a fairly new eating disorder. Children with ARFID are extremely selective eaters and sometimes have little interest in eating food. They may eat a limited variety of preferred foods, which can lead to poor growth and poor nutrition (Possibly related to neurodivergence)
Anorexia nervosa
Bulimia nervosa
Binge-eating disorder
We will cover the latter three whose diagnostic criteria are mutually exclusive, meaning that only one of these diagnoses can be assigned at any given time due to substantial differences in their clinical course, outcome, and treatment needs, despite a number of common psychological and behavioral features
Feeding and Eating Disorders
Feeding and eating disorders are “…characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning” (APA, 2022, pg. 371).
They are very serious, yet relatively common mental health disorders, particularly in Western society, where there is a heavy emphasis on thinness and physical appearance
13% of adolescents will be diagnosed with at least one eating disorder by their 20th birthday (Stice, Marti, & Rohde, 2013)
Furthermore, a large number of adolescents will engage in significant disordered eating behaviors just below the clinical threshold (Culbert, Burt, McGue, Iacono & Klump, 2009)
While there is no exact cause for eating disorders, the combination of biological, psychological, and sociocultural factors has been identified as major contributors in both the development and maintenance of eating disorders.
Clinical Presentation
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Anorexia Nervosa
Anorexia nervosa involves the restriction of energy intake, which leads to significantly low body weight relative to the individual's age, sex, and development.
This restriction is often secondary to an intense fear of gaining weight or becoming fat, despite the individual's low body weight
Altered perception of self and an over-evaluation of one's body weight and shape contribute to this disturbance of body size.
Typical warning signs and symptoms are divided into two different categories:
Emotional/Behavioral
Physical
Anorexia Nervosa: Warning Signs and Symptoms
Some emotional and behavioral symptoms include:
Dramatic weight loss
Preoccupation with food, weight, calories, etc.
Frequent comments about feeling "fat"
Eating a restricted range of foods
Making excuses to avoid mealtimes
Not eating in public
Physical changes may include”
Dizziness
Difficulty concentrating
Feeling cold
Sleep problems
Thinning hair/hair loss
Muscle weakness
Anorexia Nervosa (Cont.)
When the individual loses weight, they view this as an impressive achievement and a sign of extraordinary discipline, while weight gain is seen as an unacceptable failure of self-control (APA, 2022).
The onset of the disorder typically begins with mild dietary restrictions such as eliminating carbs or specific fatty foods
As weight loss is achieved, the dietary restrictions progress to more severe, e.g., under 500 calories/day
Symptoms present in adolescence or young adulthood and rarely before puberty or after age 40
The onset of the disorder typically is preceded by a stressful life event such as leaving home for college
Bulimia Nervosa
Unlike anorexia nervosa where there is solely restriction of food, bulimia nervosa involves a pattern of recurrent binge eating behaviors
Binge eating can be defined as a discrete period of time where the amount of food consumed is significantly more than most people would eat during a similar time period
Individuals with bulimia nervosa often report a sense of lack of control over-eating during these binge-eating episodes
Bulimia Nervosa (Cont.)
While not always the case, these binge-eating episodes are followed by a feeling of disgust with oneself, which leads to a compensatory behavior to rid the body of the excessive calories.
These compensatory behaviors include
Vomiting
Use of laxatives
Fasting (or severe restriction)
Diuretics or other medications
Excessive exercise
This cycle of binge eating and compensatory behaviors occurs on average, at least once a week for three months (National Eating Disorder Association website; APA, 2022)
Bulimia Nervosa Signs and Symptoms
Signs and symptoms of bulimia nervosa are similar to anorexia nervosa.
These symptoms include but are not limited to:
Hiding food wrappers or containers after a bingeing episode
Feeling uncomfortable eating in public
Developing food rituals
Limited diet
Disappearing to the bathroom after eating a meal
Drinking excessive amounts of water or non-caloric beverages
Additional physical changes include:
Weight fluctuations both up and down
Difficulty concentrating
Dizziness
Sleep disturbance
Possible dental problems due to purging post binge eating episode
Bulimia Nervosa (Cont.)
Symptoms of bulimia nervosa typically present later in development – adolescence or early adulthood.
Like anorexia nervosa, bulimia nervosa initially presents with mild restrictive dietary behaviors
However, episodes of binge eating interrupt the dietary restriction, causing bodyweight to rise around normal levels
In response to weight gain, patients engage in compensatory behaviors or purging episodes to reduce body weight.
This cycle of restriction, binge eating, and calorie reduction often occurs for years before seeking help.
Additionally, those with bulimia are often ashamed of their eating problems and attempt to hide the symptoms. The binge eating occurs in secrecy or as inconspicuously as possible.
Common antecedents of binge eating include negative affect; interpersonal stressors; dietary restraint; boredom; and negative feelings linked to body weight, shape, and food.
Binge-Eating Disorder
Binge-eating disorder is similar to bulimia nervosa in that it involves recurrent binge eating episodes along with feelings of lack of control during the binge-eating episode.
The binge-eating episodes are associated with at least three of the following:
eating quicker than usual
Eating until uncomfortably full
Eating large amounts even if not hungry
Eating alone
Feeling disgust with oneself or being depressed
Despite the feelings of shame and guilt post-binge, individuals with BED will not engage in vomiting, excessive exercise, or other compensatory behaviors
These binge eating episodes occur on average, at least once a week for 3 months.
Binge-Eating Disorder (Cont.)
Because these binge-eating episodes occur without compensatory behaviors, individuals with BED are at risk for obesity and related health disorders
Individuals with BED report feelings of embarrassment at the quantity of food consumed, and thus will often refuse to eat in public
Due to the restriction of eating around others, individuals with BED often engage in secret binge eating episodes in private, followed by discrete disposal of wrappers and containers.
While much is still being researched about binge-eating disorder, current research indicates that the onset of BED is adolescence to early adulthood but can begin later in life.
Those who seek treatment tend to be older than those with either bulimia or anorexia
Binge eating has been found to be common in adolescent and college-age samples and for all, is associated with social role adjustment issues, impaired health-related quality of life and life satisfaction, and increased medical morbidity and mortality (APA, 2022).
Epidemiology
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Anorexia Nervosa
According to the National Eating Disorder Alliance (NEDA) website, at any point in time more women (0.3-0.4%) than men (0.1%) will be diagnosed with anorexia
Anorexia nervosa is most prevalent in post industrialized, high-income countries such as the United States, Australia, New Zealand, Japan, and many European countries
In the U.S., prevalence is lower among Latinx and non-Latinx Black Americans than non-Latinx Whites (APA, 2022).
Bulimia Nervosa
According to the NEDA website, at any point in time, 1.0% of women and 0.1% of men will meet the diagnostic criteria for bulimia nervosa
A study by Stice and Bohon (2012) found that between 1.1% and 4.6% of females and 0.1% to 0.5% of males will develop bulimia and that subthreshold bulimia occurs in 2.0% to 5.4% of adolescent females.
The DSM reports that the 12-month prevalence ranges from 0.14% to 0.3% with higher rates in females and high-income countries
Rates are similar across ethnoracial groups across the U.S. (APA, 2022)
Binge-Eating Disorder
Hudson et al. (2007) reports that BED is three times more common than anorexia and bulimia and is more common than breast cancer, HIV, and schizophrenia
It has also been found that between 0.2% and 3.5% of females and 0.9% and 2.0% of males will develop binge eating disorder with subthreshold binge eating disorder occurring in 1.6% of adolescent females (Stice & Bohon, 2012)
The DSM reports a 12-month prevalence of 0.44% to 1.2% with rates 2-3 times higher in women, similar rates across ethnoracial groups in the United States and between most high-income industrialized countries (APA, 2022)
Comorbidity
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Anorexia Nervosa
Anorexia is rarely a single diagnosis
High rates of bipolar, depressive, and anxiety disorders are common among individuals with anorexia nervosa
Obsessive-compulsive disorder is more often seen in those with the restricting type of anorexia nervosa, whereas alcohol use disorder and other substance use disorders are more commonly seen in those with anorexia who engage in binge-eating/purging behaviors.
Unfortunately, there is also a high rate of suicidality, with rates reported to be 18 times greater than in an age- and gender-matched comparison group.
It is also estimated that between 9% and 25% of individuals with anorexia have attempted suicide (APA, 2022)
Bulimia Nervosa
The majority of individuals diagnosed with bulimia nervosa also present with at least one other mental disorder.
Similar to anorexia nervosa, there is a high frequency of depressive symptoms (i.e., low self-esteem), as well as bipolar and depressive disorders
While some experience mood fluctuations because of their eating pattern (occurring at the same time or following the development of bulimia), some individuals will identify mood symptoms prior to the onset of bulimia nervosa (APA, 2022)
Bulimia Nervosa (Cont.)
Anxiety, particularly social anxiety, is often present in those with bulimia nervosa
However, most mood and anxiety symptoms resolve once an effective treatment of bulimia is established
Substance use disorder, and in particular alcohol use disorder, is also prevalent in those with bulimia, with about a 30% prevalence among those with bulimia.
The substance abuse begins as a compensatory behavior (e.g., stimulant use is used to control appetite and weight) and over time, as the eating disorder progresses, so does the substance abuse.
There is also a percentage of individuals with bulimia nervosa who display personality features that meet the criteria for at least one personality disorder, most often borderline personality disorder.
Finally, about one-quarter to one-third of individuals with bulimia have had suicidal ideation and a comparable amount have attempted suicide
Binge-eating Disorder
Research shows that BED shares similar comorbidities with anorexia nervosa and bulimia nervosa
Common comorbidities include major depressive disorder and alcohol use disorder
About 25% of those with BED have shown suicidal ideation (APA, 2022)
Etiology
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Etiology of Eating Disorders
What causes eating disorders?
While researchers have yet to identify a specific cause of eating disorders, the most compelling argument to date is that eating disorders are multidimensional disorders
This means many contributing factors lead to the development of an eating disorder
While there is likely a genetic predisposition, there are also environmental, or external factors, such as family dynamics and cultural influences that impact their presentation.
Research supporting these influences is well documented for anorexia nervosa and bulimia nervosa
Seeing as BED has only just recently been established as a formal diagnosis, research on the evolvement of BED is ongoing.
Biological
There is some evidence of a genetic predisposition for eating disorders, with relatives of those diagnosed with an eating disorder being up to six times more likely than other individuals to be diagnosed also
Twin concordance studies also support the gene theory
If an identical twin is diagnosed with anorexia, there is a 70% percent chance the other twin will develop anorexia in their lifetime
The concordance rate for fraternal twins (who share less genes) is 20%.
While not as strong for bulimia, identical twins still display a 23% concordance rate, compared to the 9% rate for fraternal twins.
Biological (Cont.)
In addition to hereditary causes, disruption in the neuroendocrine system is common in those with eating disorders (Culbert, Racine, & Klump, 2015)
Unfortunately, it’s difficult for researchers to determine if these disruptions caused the disorder or have been caused by the disorder, as manipulation of eating patterns is known to trigger changes in hormone production.
With that said, researchers have explored the hypothalamus as a potential contributing factor.
The hypothalamus is responsible for regulating body functions, particularly hunger and thirst
Within the hypothalamus, the lateral hypothalamus is responsible for initiating hunger cues that cause the organism to eat, whereas the ventromedial hypothalamus is responsible for sending signals of satiation, telling the organism to stop eating.
Clearly, a disruption in either of these structures could explain why an individual may not take in enough calories or experience periods of overeating
Cognitive
Some argue that eating disorders are, in fact, a variant of obsessive-compulsive disorder (OCD)
The obsession with body shape and weight—the hallmark of an eating disorder—is likely a driving factor in anorexia nervosa
Distorted thought patterns and an over-evaluation of body size likely contribute to this obsession and one’s desire for thinness
Research has identified high levels of impulsivity, particularly in those with binge eating episodes, suggesting a temporary lack of control is responsible for these episodes
Post binge-eating episode, many individuals report feelings of disgust or even thoughts of failure
These strong cognitive factors are indicative as to why cognitive-behavioral therapy is the preferred treatment for eating disorders
Sociocultural
Eating disorders are overwhelmingly found in Western countries where there is a heavy emphasis on thinness—a core feature of eating disorders
It is also found in countries where food is in abundance, as in places of deprivation, round figures are viewed as more desirable (Polivy & Herman, 2002)
While eating disorders were once thought of as disorders of higher SES, recent research suggests that as our country becomes more homogenized, the more universal eating disorders become
Sociocultural: Media
One commonly discussed contributor to eating disorders is the media
The idealization of thin models and actresses sends the message to young women (and adolescents) that to be popular and attractive, you must be thin
These images are not isolated to magazines, but are also seen in television shows, movies, commercials, and large advertisements on billboards and hanging in store windows
With the emergence of social media (e.g., Facebook, Snapchat, Instagram), exposure to media images and celebrities is even easier
Couple this with the ability to alter images to make individuals even thinner, it is no wonder many young people become dissatisfied with their body (Polivy & Herman, 2004)
Sociocultural: Ethnicity
While eating disorders are not solely a “white woman” disorder, there are significant discrepancies when it comes to race, especially for anorexia nervosa
Why is this?
Research indicates that black men prefer heavier women than do white men (Greenberg & Laporte, 1996)
Given this preference, it should not be surprising that black women and children have larger ideal physiques than their white peers (Polivy & Herman, 2000)
Since black women are less driven to thinness, black women would appear to be less likely to develop anorexia; however, findings suggest this is not the case
Caldwell and colleagues (1997) found that high-income black women were equally as dissatisfied as high-income white women with their physique, suggesting body image issues may be more closely related to SES than that of race
The race discrepancies are also less significant in BED, where the prominent feature of the eating disorder is not thinness (Polivy & Herman, 2002)
Sociocultural: Gender
Males account for only a small percentage of eating disorders
While it is unclear as to why there is such a discrepancy, it is likely somewhat related to cultural desires of women being “thin” and men being “muscular” or “strong”
Of men diagnosed with an eating disorder, the overwhelming percentage of them identified a job or sport as the primary reason for their eating behaviors (Strother, Lemberg, Stanford, & Turberville, 2012)
Jockeys, distance runners, wrestlers, and bodybuilders are some of the professions identified as most restrictive regarding body weight
There is some speculation that males are not diagnosed as frequently as women due to the stigma attached to eating disorders
Eating disorders have routinely been characterized as a “white, adolescent female” problem
Due to this bias, young men may not seek help for their eating disorder in efforts to prevent labeling
Sociocultural: Family
Family influences are one of the strongest external contributors to maintaining eating disorders
Often family members are praised for their slenderness
Think about the last time you saw a family member or close friend- how often have you said, “You look great!” or commented on their appearance in some way?
The odds are likely high
While the intent of the family member is not to maintain maladaptive eating behaviors by praising the physical appearance of someone struggling with an eating disorder, they are indirectly perpetuating the disorder
Sociocultural: Family (Cont.)
While family involvement can help maintain the disorder, it can also contribute to the development of an eating disorder
Families that emphasize thinness or place a large emphasis on physical appearance are more likely to have a child diagnosed with an eating disorder (Zerbe, 2008)
In fact, mothers with eating disorders are more likely to have children who develop a feeding/eating disorder than mothers without eating disorders (Whelan & Cooper, 2000).
Additional family characteristics that are common among patients receiving treatment for eating disorders are enmeshed, intrusive, critical, hostile, or overly concerned with parenting (Polivy & Herman, 2002)
While there has been some correlation between these family dynamics and eating disorders, they are not evident in all families of people with eating disorders.
Personality
There are many personality characteristics that are common in individuals with eating disorders
While it is unknown if these characteristics are inherent in the individual’s personality or a product of personal experiences, the thought is eating disorders develop due to the combination of the two
Personality: Perfectionism
It should come as no surprise that perfectionism, or the belief that one must be perfect, is a contributing factor to disorders related to eating, weight, and body shape (particularly anorexia nervosa)
While an exact mechanism is unknown, it is believed that perfectionism magnifies normal body imperfections, leading an individual to go to extreme (i.e., restrictive) behaviors to remedy the flaw (Hewitt, Flett & Ediger, 1995)
Personality: Self-Esteem
Self-esteem, or one’s belief in their worth or ability, has routinely been identified as a moderator of many psychological disorders, and eating disorders are no exception
Low self-esteem not only contributes to the development of an eating disorder but is also likely involved in the maintenance of the disorder
One theory, the transdiagnostic model of eating disorders, suggests that overall low self-esteem increases the risk for over-evaluation of body, which in turn, leads to negative eating behaviors that could lead to an eating disorder (Fairburn, Cooper & Shafran, 2003).
Treatment
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Anorexia Nervosa
The immediate goal for the treatment of anorexia nervosa is weight gain and recovery from malnourishment
This is often established via an intensive outpatient program, or if needed, through an inpatient hospitalization program where caloric intake can be managed and controlled
Both the inpatient and outpatient programs use a combination of therapies and support to help restore proper eating habits
Of the most common (and successful) treatments are Cognitive-Behavioral Therapy (CBT) and Family-Based Therapy (FBT)
Anorexia Nervosa: CBT
Because anorexia nervosa requires changes to both eating behaviors as well as thought patterns, CBT strategies have been very effective in producing lasting changes to those suffering from anorexia nervosa
Some of the behavioral strategies include recording eating behaviors—hunger pains, quality and quantity of food—and emotional behaviors—feelings related to the food
In addition to these behavioral strategies, it is also important to address the maladaptive thought patterns associated with their negative body image and desire to control their physical characteristics
Changing the fear related to gaining weight is essential in recovery
Anorexia Nervosa: Family Based Therapy
FTB is also an effective treatment approach, often used as a component of individual CBT, especially for children and adolescents with the disorder
FBT has been shown to elicit 50-60% of weight restoration in one year, as well as weight maintenance 2-4 years post-treatment (Campbell & Peebles, 2014; LeGrange, Lock, Accurso, Agras, Darcy, Forsberg, et al, 2014)
Additionally, FBT has been shown to improve rapid weight gain, produce fewer hospitalizations, and is more cost-effective than other types of therapies with family involvement (Agras, Lock, Brandt, Bryson, Dodge, Halmi, et al., 2014).
Anorexia Nervosa: Family Based Therapy
FBT typically involves 16-18 sessions which are divided into 3 phases:
Parents take charge of weight restoration
Client’s gradual control of overeating
Addressing developmental issues including fostering autonomy from parents (Chen, et al., 2016)
While FBT has shown to be effective in treating adolescents with anorexia nervosa, the application for older eating patients (i.e., college-aged students and above) is still undetermined
As with adolescents, the goal for a family-based treatment program should center around helping the patient separate their feelings and needs from that of their family
Bulimia Nervosa
Just as anorexia nervosa treatment initially focuses on weight gain, the first goal of bulimia nervosa treatment is to eliminate binge eating episodes and compensatory behaviors
The aim is to replace both negative behaviors with positive eating habits
One of the most effective ways to establish this is through Cognitive Behavioral Therapy (CBT)
Bulimia Nervosa: CBT
Similar to anorexia nervosa, individuals with bulimia nervosa are expected to keep a journal of their eating habits
However, with bulimia nervosa, it is also important that the journal include changes in sensations of hunger and fullness, as well as other feelings surrounding their eating patterns in efforts to identify triggers to their binging episodes (Agras, Fitzsimmons-Craft & Wilfley, 2017)
Once these triggers are identified, psychologists will utilize specific behavioral or cognitive techniques to prevent the in
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