Worldwide, _____ percent of students report periodic binge eating or self-induced vomiting.

Eating Disorders

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TOPIC OVERVIEW

Anorexia Nervosa

The Clinical Picture

Medical Problems

Bulimia Nervosa

Binges

Compensatory Behaviors

Bulimia Nervosa Versus Anorexia Nervosa

Binge-Eating Disorder

What Causes Eating Disorders?

Psychodynamic Factors: Ego Deficiencies

Cognitive Factors

Depression

Biological Factors

Societal Pressures

Family Environment

Multicultural Factors: Racial and Ethnic Differences

Multicultural Factors: Gender Differences

How Are Eating Disorders Treated?

Treatments for Anorexia Nervosa

Treatments for Bulimia Nervosa

Treatments for Binge-eating Disorder

Putting It Together: A Standard for Integrating Perspectives

Shani, age 15 : While I was learning to resist the temptation of hunger, I walked into the kitchen when no one was around, took a slice of bread out the packet, toasted it, spread butter on it, took a deep breath and bit. Guilty. I spat it in the trash and tossed the rest of it in and walked away. Seconds later I longed for the toast, walked back to the trash, popped open the lid and sifted around in the debris. I found it and contemplated, for minutes, whether to eat it. I brought it close to my nose and inhaled the smell of melted butter. Guilty. Guilty for trashing it. Guilty for craving it. Guilty for tasting it. I threw it back in the trash and walked away. No is no, I told myself. No is no.

… And no matter how hard I would try to always have The Perfect Day in terms of my food, I would feel the guilt every second of every day. It reeked of shame, seeped with disgust and festered in disgrace. It was my desire to escape the guilt that perpetuated my compulsion to starve.

In time I formulated a more precise list of “can” and “can’t” in my head that dictated what I was allowed or forbidden to consume…. It became my way of life. My manual. My blueprint. But more than that, it gave me false reassurance that my life was under control. I was managing everything because I had this list in front of me telling me what—and what not—to do….

In the beginning, starving was hard work. It was not innate. Day by day I was slowly lured into another world, a world that was as isolating as it was intriguing, and as rewarding as it was challenging….

That summer, despite the fact that I had lost a lot of weight, my mother agreed to let me go to summer camp with my fifteen-year-old peers, after I swore to her that I would eat. I broke that promise as soon as I got there…. At breakfast time when all the teens raced into the dining hall to grab cereal boxes and bread loaves and jelly tins and peanut butter jars, I sat alone cocooned in my fear. I fingered the plastic packet of a loaf of white sliced bread, took out a piece and tore off a corner, like I was marking a page in a book, onto which I dabbed a blob of peanut butter and jelly the size of a Q-tip. That was my breakfast. Every day. For three weeks.

I tried to get to the showers when everyone else was at the beach so nobody would see me. I heard girls behind me whispering, “That’s the girl I told you about that looks so disgusting.” Someone invariably walked in on me showering and covered her mouth with her hand like I was a dead body. I wished I could disappear into the drain like my hair that was falling out in chunks….

While everyone else was out there swimming, tanning, making out, playing sports, volunteering and team building, I hid in my tent and wrote letters to my mother reassuring her that I was eating. I told her that I ate peanut butter and jelly sandwiches every morning for breakfast….

[Upon returning to school] I was labeled the “concentration camp victim.” On my return, over the months everyone watched my body shrink as though it were being vacuum packed in slow motion…. At my lowest weight my hipbones protruded like knuckle bones under my dress and I had to minimize the increments of the belt holes until there was so much extra belt material dangling down that I did away with the belt completely. My shoes were too big for my feet; my ankles were so thin that I wore three pairs of socks at a time and still my shoes would slide off my heels. And my panties were so baggy I secured them with safety pins on the sides so they wouldn’t fall down….

On the home front things were worse than ever. I moved to the downstairs room, which had a separate entrance and bathroom, and I locked my door and forbade anyone from entering. Even so, my mother and I had screaming matches every day, with her trying to convince me that “your body needs food as fuel” and me retaliating with “I’m not hungry.” But the more she tried to appeal to my rational side, the more stubborn I became in my conviction….

For nine months my mother stood by, forbidden to interfere, while I starved myself. She had no idea what was going on, nor did I. All she knew was that I had changed. She watched me transform from an innocent, soft, kind, loving girl into a reclusive, vicious, aggressive, defiant teenager. She had lost her little girl. And there was nothing she could say or do to stop me. She knew that if my weight continued to drop radically that she might lose me. But despite all her desperate attempts to reach out to me … she had no way of getting through to me, let alone helping me because, like with food, I slowly banned her from my life….

(Raviv, 2010)

BETWEEN THE LINES

In Their Words

“Girls should be encouraged to take an interest in their appearance when they are very young.”

Ladies’ Home Journal, 1940

It has not always done so, but Western society today equates thinness with health and beauty. In fact, in the United States thinness has become a national obsession. Most of us are as preoccupied with how much we eat as with the taste and nutritional value of our food. Thus it is not surprising that during the past three decades we have also witnessed an increase in two eating disorders that have at their core a morbid fear of gaining weight. Sufferers of anorexia nervosa, like Shani, are convinced that they need to be extremely thin, and they lose so much weight that they may starve themselves to death. People with bulimia nervosa go on frequent eating binges, during which they uncontrollably consume large quantities of food, and then force themselves to vomit or take other extreme steps to keep from gaining weight. A third eating disorder, binge-eating disorder, in which people frequently go on eating binges but do not force themselves to vomit or engage in other such behaviors, also appears to be on the rise. People with binge-eating disorder do not fear weight gain to the same degree as those with anorexia nervosa and bulimia nervosa, but they do have many of the other features found in those disorders (Alvarenga et al., 2014).

Are girls and women in Western society destined to struggle with at least some issues

of eating and appearance?

The news media have published many reports about eating disorders. One reason for the surge in public interest is the frightening medical consequences that can result from the disorders. The public first became aware of such consequences in 1983 when Karen Carpenter died from medical problems related to anorexia. Carpenter, the 32-year-old lead singer of the soft-rock brother-and-sister duo called the Carpenters, had been enormously successful and was admired by many as a wholesome and healthy model to young women everywhere. Another reason for the current concern is the disproportionate prevalence of anorexia nervosa and bulimia nervosa among adolescent girls and young women.

Anorexia Nervosa
Shani, 15 years old and in the ninth grade, displays many symptoms of anorexia nervosa (APA, 2013). She purposely maintains a significantly low body weight, intensely fears becoming overweight, has a distorted view of her weight and shape, and is excessively influenced by her weight and shape in her self-evaluations (see Table 11-1 ).

table: 11-1Dx Checklist

Anorexia Nervosa

1.

Individual purposely takes in too little nourishment, resulting in body weight that is very low and below that of other people of similar age and gender.

2.

Individual is very fearful of gaining weight, or repeatedly seeks to prevent weight gain despite low body weight.

3.

Individual has a distorted body perception, places inappropriate emphasis on weight or shape in judgments of herself or himself, or fails to appreciate the serious implications of her or his low weight.

(Information from: APA, 2013.)

Like Shani, at least half of the people with anorexia nervosa reduce their weight by restricting their intake of food, a pattern called restricting-type anorexia nervosa. First they tend to cut out sweets and fattening snacks; then, increasingly, they eliminate other foods. Eventually people with this kind of anorexia nervosa show almost no variability in diet. Others, however, lose weight by forcing themselves to vomit after meals or by abusing laxatives or diuretics, and they may even engage in eating binges, a pattern called binge-eating/purging-type anorexia nervosa, which you will read about in more detail in the section on bulimia nervosa.

Ninety to 95 percent of all cases of anorexia nervosa occur in females. Although the disorder can appear at any age, the peak age of onset is between 14 and 20 years. Between 0.5 and 4.0 percent of all females in Western countries develop the disorder in their lifetime, and many more display at least some of its symptoms (Ekern, 2014; Smink et al., 2013; Stice et al., 2013). It seems to be on the increase in North America, Europe, and Japan.

Typically the disorder begins after a person who is slightly overweight or of normal weight has been on a diet (Stice & Presnell, 2010). The escalation toward anorexia nervosa may follow a stressful event such as separation of parents, a move away from home, or an experience of personal failure (Wilson et al., 2003). Although most people with the disorder recover, between 2 and 6 percent of them become so seriously ill that they die, usually from medical problems brought about by starvation, or from suicide (Suokas et al., 2013; Forcano et al., 2010).

The Clinical Picture
Becoming thin is the key goal for people with anorexia nervosa, but fear provides their motivation. People with this disorder are afraid of becoming obese, of giving in to their growing desire to eat, and more generally of losing control over the size and shape of their bodies. In addition, despite their focus on thinness and the severe restrictions they may place on their food intake, people with anorexia are preoccupied with food. They may spend considerable time thinking and even reading about food and planning their limited meals (Herzig, 2004). Many report that their dreams are filled with images of food and eating (Knudson, 2006).

This preoccupation with food may in fact be a result of food deprivation rather than its cause. In a famous “starvation study” conducted in the late 1940s, 36 normal-weight conscientious objectors were put on a semistarvation diet for six months (Keys et al., 1950). Like people with anorexia nervosa, the volunteers became preoccupied with food and eating. They spent hours each day planning their small meals, talked more about food than about any other topic, studied cookbooks and recipes, mixed food in odd combinations, and dawdled over their meals. Many also had vivid dreams about food.

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Laboratory starvation Thirty-six conscientious objectors who were put on a semistarvation diet for six months developed many of the symptoms seen in anorexia nervosa and bulimia nervosa (Keys et al., 1950).

Persons with anorexia nervosa also think in distorted ways. They usually have a low opinion of their body shape, for example, and consider themselves unattractive (Boone et al., 2014; Siep et al., 2011). In addition, they are likely to overestimate their actual proportions. While most women in Western society overestimate their body size, the estimates of those with anorexia nervosa are particularly high. In one of her classic books on eating disorders, Hilde Bruch, a pioneer in this field, recalled the self-perceptions of a 23-year-old patient:

I look in a full-length mirror at least four or five times daily and I really cannot see myself as too thin. Sometimes after several days of strict dieting, I feel that my shape is tolerable, but most of the time, odd as it may seem, I look in the mirror and believe that I am too fat.

(Bruch, 1973)

This tendency to overestimate body size has been tested in the laboratory (Delinsky, 2011; Farrell, Lee, & Shafran, 2005). In a popular assessment technique, research participants look at a photograph of themselves through an adjustable lens. They are asked to adjust the lens until the image that they see matches their actual body size. The image can be made to vary from 20 percent thinner to 20 percent larger than actual appearance. In one study, more than half of the individuals with anorexia nervosa overestimated their body size, stopping the lens when the image was larger than they actually were.

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Seeing is deceiving In one research technique, people look at photographs of themselves through a special lens and adjust the lens until they see what they believe is their actual image. A research participant may change her actual image (left) from 20 percent thinner (middle) to 20 percent larger (right).

The distorted thinking of anorexia nervosa also takes the form of certain maladaptive attitudes and misperceptions (Alvarenga et al., 2014; Fairburn et al., 2008). Sufferers tend to hold such beliefs as “I must be perfect in every way”; “I will become a better person if I deprive myself “; and “I can avoid guilt by not eating.”

People with anorexia nervosa also have certain psychological problems, such as depression, anxiety, low self-esteem, and insomnia or other sleep disturbances (Forsén Mantilla, Bergsten, & Birgegård, 2014; Holm-Denoma et al., 2014). A number grapple with substance abuse (Mann et al., 2014; Steiger & Israel, 2010). And many display obsessive-compulsive patterns (Degortes et al., 2014; Friederich & Herzog, 2011). They may set rigid rules for food preparation or even cut food into specific shapes. Broader obsessive-compulsive patterns are common as well. Many, for example, exercise compulsively, prioritizing exercise over most other activities in their lives (Fairburn et al., 2008). In some research, people with anorexia nervosa and others with obsessive-compulsive disorder score equally high for obsessiveness and compulsiveness. Finally, persons with anorexia nervosa tend to be perfectionistic, a characteristic that typically precedes the onset of the disorder (Boone et al., 2014).