9 Flashcards

Question

BiNge-eatiNg DisorDer

Answer 1

Recent research has focused on a group of individuals who experience marked distress from binge eating but do not engage in extreme compensatory behaviours and therefore cannot be diagnosed with bulimia. - These individuals have binge-eating disorder (BED). After classification in the DSM-IV as a disorder needing further study, BED is now included as a full-fledged disorder in the DSM-5 (see DSM Table 9.3). - Evidence that supports its elevation to disorder status includes somewhat different patterns of heritability compared with other eating disorders (Bulik et al., 2000), as well as a greater likelihood of occurring in males and a later age of onset. - There is also a greater likelihood of remission and a better response to treatment of BED compared with other eating disorders Individuals who meet preliminary criteria for BED are often found in weight-control programs. - For example, Brody, Walsh, and Devlin (1994) studied mildly obese participants in a weight-control program and identified 19 percent who met the criteria for BED. - In other programs, with participants ranging in degree of obesity, close to 30 percent met the criteria (Spitzer et al., 1993). But Hudson and colleagues (2006) concluded that BED is a disorder caused by a separate set of factors from obesity without BED and is associated with more severe obesity. - The general consensus is that about 20 percent of obese individuals in weight-loss programs engage in binge eating, with the number rising to approximately 50 percent among candidates for bariatric surgery (stomach surgery to correct severe or morbid obesity). Fairburn, Cooper, Doll, Norman, and O’Connor (2000) identified 48 individuals with BED and were able to prospectively follow 40 of them for five years. - The prognosis was relatively good for this group, with only 18 percent retaining the full diagnostic criteria for BED. - The percentage of this group who were obese, however, increased from 21 to 39 percent at the five-year mark. Crossing over to bulimia is very common among individuals with BED About half of individuals with BED try dieting before bingeing, and half start with bingeing and then attempt to diet - those who begin bingeing first become more severely affected by BED and are more likely to have additional disorders It’s also increasingly clear that individuals with BED have some of the same concerns about shape and weight as people with anorexia and bulimia, which distinguishes them from individuals who are obese without BED It seems that approximately 33 percent of those with BED binge to alleviate “bad moods” or negative affect - These individuals are more psychologically disturbed than the 67 percent who do not use bingeing to regulate mood

Answer 2

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances. 2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating). B. The binge-eating episodes are associated with three (or more) of the following: 1. Eating much more rapidly than normal. 2. Eating until feeling uncomfortably full. 3. Eating large amounts of food when not feeling physically hungry. 4. Eating alone because of feeling embarrassed by how much one is eating. 5. Feeling disgusted with oneself, depressed, or very guilty afterward. C. Marked distress regarding binge eating is present. D. The binge eating occurs, on average, at least once a week for 3 months. E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.

Answer 3

Bulimia nervosa was recognized as a distinct psychological disorder only in the 1970s The majority (90 to 95 percent) of individuals with bulimia are women - The 5 to 10 percent of cases who are male have a slightly later age of onset, and a large minority are predominantly males of minority sexual orientation Research by D. Blake Woodside and colleagues in Toronto indi- cates that men with eating disorders are similar in most respects to women with eating disorders (Woodside et al., 2001). - One place that men and women with eating disorders may differ, however, is in personality risk factors, such as perfectionism In addition to men with a gay or bisexual orientation, male athletes in sports that require weight regulation, such as wrestling, are another group of males with eating disorders. More recent studies suggest that the incidence among males is increasing The gender imbalance in bulimia was not always present. - Historians of psychopathology note that for hundreds of years, the vast majority of (unsystematically) recorded cases were male - Because women with bulimia are overwhelmingly preponderant today, most of our examples are of women.

Answer 4

Age of onset for bulimia is typically 16 to 19 years, although signs of impending bulimic behaviour can occur much earlier Among women, adolescent girls are most at risk. - A prospective eight-year survey of 496 adolescent girls reported that more than 13 percent experienced some form of eating disorder by the time they were 20 In another elegant prospective study, the eating-related problems of 1498 freshmen women at a large university were studied over the four-year college experience. - Only 28 to 34 percent had no eating-related concerns. - But 29 to 34 percent consistently attempted to limit their food intake because of weight/shape concerns; 14 to 18 percent engaged in overeating and binge eating; another 14 to 17 percent combined attempts to limit intake with binge eating; and 6 to 7 percent had pervasive bulimic-like concerns. These tendencies were stable for the most part throughout their four years of college In an important prevalence study by Kendler and colleagues (1991), 2163 twins (more than 1000 sets of twins) were interviewed, and the lifetime prevalence of bulimia nervosa was found to be 2.8 percent, increasing to 5.3 percent when marked bulimic symptoms that did not meet full criteria for the disorder were included. - Once again, the prevalence was greatest in younger women. The risk was much higher for females born after 1960 than for females born before 1960. - Nevertheless, estimates are probably low because many individuals with eating disorders refuse to participate in studies. Therefore, the percentages represent only those individuals who consented to participate in the survey.

Answer 5

A somewhat different view of the prevalence of bulimia comes from studies of the population as a whole rather than of specific groups of adolescents. In one comprehensive study, sampling more than 8000 individuals between the ages of 15 and 64 in Ontario, the lifetime prevalence was 1.46 percent for women and 0.13 percent for men (Woodside et al., 2001). - Another 1.70 percent of women and 0.95 percent of men showed partial syndromes in which they displayed some of the symptoms of bulimia nervosa, but not enough to meet the full DSM-5 diagnostic criteria In a study in New Zealand (Bushnell et al., 1990), the lifetime prevalence of bulimia nervosa among women ages 18 to 44 years was 1.6 percent. - However, the rate was substantially higher among younger women. - For instance, among women ages 18 to 24, the prevalence was 4.5 percent. - Among women ages 25 to 44, the prevalence was 2 percent, but it was only 0.4 percent among women ages 45 to 64. Numbers seem to be highest in urban areas

Answer 6

After bulimia develops, it tends to be chronic if untreated One study by Todd Heatherton and colleagues shows the drive for thinness and accompanying symptoms were still present in a group of women ten years after diagnosis In an important study of the course of bulimia, referred to earlier, Fairburn and colleagues identified a group of 102 females with bulimia nervosa and followed 92 of them prospectively for five years. - About one-third improved to the point where they no longer met diagnostic criteria each year, but another third who had improved previously had then relapsed. - Between 50 and 67 percent evidenced serious eating disorder symptoms at the end of each year of the five-year study, indicating that this disorder has a relatively poor prognosis. In a follow- up study, Fairburn et al. (2003) reported that the strongest predictors of persistence were a history of childhood obesity and a continuing overemphasis on the importance of being thin. - In addition, individuals tend to retain their bulimic symptoms instead of shifting to other eating disorder symptomatology The same high percentage (90 to 95 percent) of individuals with anorexia are female, with onset also in adolescence, usually around the age of 15 - The increase in rates of anorexia, particularly in the 1960s and 1970s. Walters and Kendler (1995) have analyzed data from the 2163 twins to determine the prevalence of anorexia nervosa. - The results indicate that 1.6 percent met criteria for lifetime prevalence and this figure increased to 3.7 percent with the inclusion of marked anorexic symptoms that did not meet full criteria for the disorder. The comprehensive study of house- holds in the province of Ontario (Woodside et al., 2001) reported lifetime prevalence of 0.66 percent for women and 0.16 percent for men, with an additional 1.15 percent of women and 0.76 percent of men having partial syndromes (i.e., most but not all symptoms required for a diagnosis). Once anorexia develops, its course seems chronic—although not so chronic as bulimia, particularly if it is identified early and treated. But individuals with anorexia tend to maintain a low BMI over a long period, along with distorted perceptions of shape and weight, indicating that even if they no longer meet criteria for anorexia they continue to restrict their eating Perhaps for this reason, anorexia is thought to be more resistant to treatment than bulimia, based on clinical studies - In one seven-year study following individuals who had received treatment, 33 percent of those with anorexia versus 66 percent of those with bulimia reached full remission at some point during the follow-up

Answer 7

About one million Canadians have an eating disorder according to Canada’s National Institute for Eating Disorders (NIED, 2019). In the 2012 CCHS—Mental Health, 0.4 percent of Canadians over 15 years of age reported that they have a diagnosed eating disorder (Statistics Canada, 2019). For the years 2017–2018, CIHI estimates that 5.77 in every 100 000 Canadians were discharged from hospital with a primary diagnosis of an eating disorder, and this rate is 10 times as high in women than in men.

Answer 8

For anorexia and bulimia, a particularly striking finding is that these disorders develop in immigrants who have recently moved to Western countries One of the more interesting classic studies is Nasser’s survey of 50 Egyptian women in London universities and 60 Egyptian women in Cairo universities. - None of the women studied in Cairo had eating disorders, but 12 percent of the Egyptian women in England had developed eating disorders. - Mumford, Whitehouse, and Platts (1991) found the same result with Asian women living in North America. The prevalence of eating disorders varies somewhat among most North American minority populations. Earlier surveys revealed that black adolescent girls have less body dissatisfaction, fewer weight concerns, and a more positive self-image, and perceive themselves to be thinner than they actually are, compared with Caucasian adolescent girls Major risk factors for eating disorders in all groups include being overweight, being in a higher social class, and acculturating to the Western majority One culturally determined difference in criteria for eating disorders has been reported by Lee, Leung, Wing, Chiu, and Chen (1991). - In traditional Chinese cultures, it has been widely assumed that being slightly plump is highly valued, with ideals of beauty focused on the face rather than the body. - Therefore, in this group, acne was more often reported as a precipitant for anorexia nervosa than was a fear of being fat, and body image disturbance was rare - Patients said they refused to eat because of feelings of fullness or pain, although it is possible they related food intake to their skin conditions. Beyond that, they met all criteria for anorexia. - More recent studies, however, call into question these affirmations (Kawamura, 2002). Leung, Lam, and Sze (2001) analyzed data from the Miss Hong Kong Beauty Pageant from 1975 to 1999 and found that winners were taller and thinner than the average Chinese woman, with a curvaceous narrow-waist-and-full-hip body shape. They note that this ideal matches depictions of beauty in classical Chinese literature, and it challenges the notion that plumpness is valued, at least in Hong Kong. In Japan, the prevalence of anorexia nervosa among teenage girls is still lower than the rate in North America but, as mentioned previously, it seems to be increasing. - The need to be thin or the fear of becoming overweight has not been as important in Japanese culture as it is in North America, although this may be changing as cultures around the world become more Westernized - Body image distortion and denial that a problem exists are clearly present in Japanese patients who have the disorder An interesting study by Madhulika Gupta and colleagues at the University of Western Ontario compared weight-related body image concerns in young women ages 18 to 24 years in Canada and in India - This cross-cultural study found that women’s overall levels of the core eating disorder features of drive for thinness and body dissatisfaction did not differ between the two cultures. - However, body image concerns presented slightly differently in the two samples. - In the Canadian women, body dissatisfaction was related to concerns about the weight of the abdomen, hips, thighs, and legs. - In the Indian women, in contrast, body dissatisfaction was related to concerns about the weight of the face, neck, shoulders, and chest (i.e., upper torso). In conclusion, anorexia and bulimia are relatively homogeneous, and both—particularly bulimia—were overwhelmingly associated with Western cultures until recently. - In addition, the frequency and pattern of occurrence among minority Western cultures differed somewhat in the past, but those differences seem to be diminishing

Answer 9

Because the overwhelming majority of cases begin in adolescence, it is very clear that anorexia and bulimia are strongly related to development Differential patterns of physical development in girls and boys interact with cultural influences to create eating disorders. After puberty, girls gain weight primarily in fat tissue, whereas boys develop muscle and lean tissue. - As the ideal look in Western countries is muscular for men and thin for women, physical development brings boys closer to the ideal and takes girls farther away. Eating disorders, particularly anorexia nervosa, occasionally occur in children under the age of 11 - In those rare cases of young children developing anorexia, they are likely to restrict fluid intake, as well as food intake, perhaps not understanding the difference - This is particularly dangerous. - Concerns about weight are somewhat less common in young children. Nevertheless, negative attitude toward being over- weight emerges as early as three years of age, and more than half of girls ages six to eight would like to be thinner - By nine years of age, 20 percent of girls reported trying to lose weight, and by age 14, 40 percent were trying to lose weight (Field et al., 1999). Another study followed girls and boys for 10 years starting around age 12 and found that about 55 percent of the girls at age 12 were dieting and about 59 percent were dieting at age 22. - Further, they found that extreme weight-control behaviours increased over time in this group with a particular increase between adolescence and young adult- hood Both bulimia and anorexia can occur in later years, particularly after the age of 55. - Hsu and Zimmer (1988) reported that most of these individuals had had an eating disorder for decades with little change in their behaviour. - In a few cases, however, onset did not occur until later years, and it is not yet clear what factors were involved. Generally, concerns about body image decrease with age A new eating disorder listed in DSM-5 does not involve concerns about appearance: avoidant/restrictive food intake disorder (ARFID). - It involves a lack of interest in eating food, oversensitivity to certain aspects of food (e.g., smell, taste, colour), or concerns about consequences of eating (e.g., chok- ing). - It is usually detected in infants and children and may persist in adulthood. - This is a dangerous condition because children may experience weight loss and nutritional deficiencies, leading to growth delay and problems with learning. - This disorder can also lead to other eating disorders later in life Debra Katzman, at the Hospital for Sick Children in Toronto, conducted important research on restrictive eating in children - Using the Canadian Paediatric Surveillance Program survey, she and her colleagues reported that restrictive eating (which would include a diagnosis of anorexia) was seen by pediatricians in 2.6 cases per 100 000 people, six times more often in girls than in boys. - About half of children showed growth delay, and many required hospital admission (Pinhas et al., 2011). - Many of these children appeared to have typical anorexia (62 percent), but the researchers noted that some of these children did not have concerns about their body image and would likely meet a diagnosis of ARFID after the DSM-5 was in use. - More recently, Katzman and colleagues (2018) used the Surveillance Program specifically to study ARFID. Almost 40 percent of the patients identified were male—a proportion much higher than is usually found among those with eating disorders.

Answer 10

Biological, psychological, and social factors contribute to the development of these serious eating disorders, but the evidence is increasingly clear that the most dramatic factors are social and cultural.

Answer 11

Anorexia and particularly bulimia are the most culturally specific psychological disorders yet diagnosed. What drives so many young people into a punishing and life-threatening routine of semistarvation or purging? - For many young women, looking good is more important than being healthy. - In fact, for young females in competitive environments, self-worth, happiness, and success are determined to a large extent by body measurements and percentage of body fat, factors that have little or no correlation with personal happiness and success in the long run. - The cultural imperative for thinness directly results in dieting, the first dangerous step down the slippery slope to anorexia and bulimia What makes the modern emphasis on thinness in women even more puzzling is that standards of desirable body sizes change much like fashion styles in clothes, if not as quickly - Garner, Garfinkel, Schwartz, and Thompson (1980) collected data from Playboy magazine centrefolds and from contestants in major beauty pageants from 1959 to 1978. During this period, both Playboy centrefolds and the beauty pageant contestants became significantly thinner. Bust and hip measurements became smaller, although waists became somewhat larger, suggesting a change in what is considered desirable in the shape of the body in addition to weight. - The preferred shape during the 1960s and 1970s was thinner and more tubular than before (Agras & Kirkley, 1986). - Wiseman, Gray, Mosimann, and Ahrens (1992) updated the research, collecting data from 1979 to 1988, and reported that 69 percent of the Playboy centrefolds and 60 percent of the beauty pageant contestants weighed 15 percent or more below normal for their age and height, actually meeting one of the criteria for anorexia. - More recently, Rubinstein and Caballero (2000) compiled data on weight and height from beauty pageant winners from 1922 through 1999 and found that most of these winners since the 1970s would be considered undernourished. Levine and Smolak (1996) referred over 20 years ago to “the glorification of slenderness” in magazines and on television, where the vast majority of females are thinner than the average North American woman. - Because overweight men are two to five times more common as television characters than overweight women, the message from the media to be thin is clearly aimed at women; the message got through loud and clear and is still getting through. Grabe, Ward, and Hyde (2008) reviewed 77 studies and demonstrated a strong relationship between exposure to media images depicting the thin-ideal body and body image concerns in women. An analysis of prime-time situation comedies revealed that 12 percent of female characters were dieting and many were making disparaging comments about their body image (Tiggemann, 2002). Interestingly, a recent analysis of images of women in Ebony magazine, which has a wide African-American readership, generally does not show this thin-ideal body image, seemingly reflecting the somewhat lower prevalence of body image disturbances in African-American women (Thompson- Brenner et al., 2011). Stice, Schupak-Neuberg, Shaw, and Stein (1994) established a strong relationship between amount of media exposure and eating disorder symptomatology in university women. In another study, girls who watched eight or more hours of TV per week reported significantly greater body dissatisfaction than girls who watched less TV (Gonzalez-Lavin & Smolak, 1995; Levine & Smolak, 1996). Finally, Thompson and Stice (2001) found that risk for developing eating disorders was directly related to the extent to which women internalize or buy in to media messages and images glorifying thinness, a finding also confirmed by Cafri, Yamamiya, Brannick, and Thompson (2005) and Keel and Forney (2013). During the 1920s, the ideal female body was similar in shape to the ideal today (Agras & Kirkley, 1986) - however, this shape was achieved through fashion (e.g., through the use of girdles) rather than dieting. - In fact, no diet articles appeared in the magazines of the period that were sampled, whereas today we see what Brownell and Rodin (1994) have called “the dieting maelstrom,” in which health professionals, the media, and a powerful diet and food industry all have stakes. The problem with today’s standards is that they are increasingly difficult to achieve, because the size and weight of the average woman has increased over the years with improved nutrition; size has also generally increased throughout history (Brownell, 1991; Brownell & Rodin, 1994). - Whatever the cause, the collision between our culture and our physiology has had some very negative effects, one of which is that women are no longer satisfied with their bodies. A second clear effect is the dramatic increase, especially among women, in dieting and exercise to achieve what may, in fact, be an impossible goal. - Look at the increase in dieting since the 1950s. - Dwyer, Feldman, Seltzer, and Mayer reported in 1969 that more than 80 percent of female high school students in Grade 12 wanted to lose weight and that 30 percent were dieting. - Among their male counterparts, fewer than 20 percent wanted to lose weight and only 6 percent were dieting. - Hunicutt and Newman (1993) surveyed a sample of 3632 students in Grades 8 and 10 and found that 61 percent of females and 28 percent of males were dieting. - Although these studies are not directly comparable, younger girls typically diet less than older girls, suggesting that the increase in dieting is even more dramatic. In a classic case study, Fallon and Rozin (1985) studied male and female undergraduates and found that men rated their current size, their ideal size, and the size they figured would be most attractive to the opposite sex as approximately equal; indeed, they rated their ideal body weight as heavier than the weight females thought most attractive in men (see ■ Figure 9.3). - Women, however, rated their current figures as much heavier than the most attractive, which, in turn, was rated as heavier than the ideal. A study by Forestell, Humphrey, and Stewart (2004) showed that undergraduate women are particularly critical of women’s hip size when making evaluations of physical attractiveness. An additional interesting finding from the Fallon and Rozin (1985) study was that women’s judgment of ideal female body weight was less than the weight that men thought was most attractive. - This conflict between reality and fashion seems most closely related to the current epidemic of eating disorders. - In fact, the efforts of some people to maintain thin, athletic shapes are almost superhuman. - Contestants in major beauty pageants work out an average of 14 hours per week, with some exercising 35 hours per week We have information on how these attitudes about body image are socially transmitted in adolescent girls. - Paxton, Schutz, Wertheim, and Muir (1999) explored the influence of close friendship groups on attitudes concerning body image, dietary restraint, and extreme weight-loss behaviours. - In a very clever study, the authors identified 79 different friendship cliques in a group of 523 adolescent girls. They found that these friendship cliques tended to share the same attitudes toward body image, dietary restraint, and the importance of attempts to lose weight. - In other words, if your friends tend to use extreme dieting or other weight-loss techniques, there is a greater chance that you will, too (Hutchinson & Rapee, 2007). A recent, more definitive study concludes that while young girls do tend to share body image concerns, these friendship cliques do not necessarily cause these attitudes or the disordered eating that follows. - Rather, adolescent girls simply tend to choose friends who already share these attitudes (Rayner et al., 2012). - Nevertheless, any attempts to treat eating disorders must take into account the influence of the social network in maintaining these attitudes. Most people who diet don’t develop eating disorders, but Patton, Johnson-Sabine, Wood, Mann, and Wakeling (1990) determined in a prospective study that adolescent girls who dieted were eight times as likely to develop an eating disorder one year later as those who weren’t dieting. Telch and Agras (1993) noted marked increases in bingeing during and after rigorous dieting in 201 obese women. Stice, Cameron, Killen, Hayward, and Taylor (1999) demonstrated that one of the reasons that attempts to lose weight may lead to eating disorders is that weight reduction efforts in adolescent girls are more likely to result in weight gain than weight loss. - To establish this finding, 692 girls, initially the same weight, were followed for four years. Girls who attempted dieting faced a more than 300 percent greater risk of obesity than those who did not diet. Why does dieting cause weight gain? - Cottone and colleagues (2009) began feeding rats junk food, which the rats came to love, instead of a boring diet of pellets. They then withdrew the junk food but not the pellets. - Based on observations of brain function compared with rats that never had junk food, it was clear that these rats became extremely stressed and anxious. - Furthermore, the junk food rats began eating more of the pellets than the control group, and this behaviour then seemed to relieve the stress. - Thus, repeated cycles of “dieting” seem to produce stress-related withdrawal symptoms in the brain, much like other addictive substances, resulting in more eating than would have occurred without dieting. It is not yet entirely clear why dieting leads to bingeing in some people but not all. - A daily diary study by Howard Steiger and colleagues at the Douglas Hospital Eating Disorders Unit in Montréal showed that patients’ attempts to limit and control their dietary intake contributed to binge cravings but were not direct antecedents to binge-eating episodes (Engelberg et al., 2005). - The researchers concluded that dietary restraint sets the stage for binge eating (Urbszat et al., 2002) but does not necessarily trigger its occurrence. - Instead, factors like negative affect may operate to trigger individual binge-eating episodes (as discussed earlier) among those who are currently restricting their dietary intake. The work of Janet Polivy and C. Peter Herman at the Univer- sity of Toronto has contributed much to our understanding of the negative consequences of chronic dieting. - Their early lab-based work showed how a broken diet can readily lead to a binge in women who chronically restrict their diets (Polivy & Herman, 1985). - Their more recent work focuses on the more general negative psychological impacts of dieting, such as low self-esteem, food preoccupation, and negative mood—a phenomenon they have labelled the “false hope syndrome” (Polivy, 2001; Polivy & Herman, 2002; Trottier et al., 2005). - In brief, this perspective asserts that people’s false hopes about self-change attempts are initially strongly reinforced. - Recall the praise that Julie received from her friends and her mother when she first started to lose weight. Unfortunately, the positive feelings and sense of control that people feel with their initial successes at self-change lead them to continue to pursue unrealistic or even impossible goals for weight loss that ultimately result in extreme disappointment and a decline in self-esteem The conflict over body image would be bad enough if size were infinitely malleable, but it is not. - Increasing evidence indicates a strong genetic contribution to body size (e.g., Livesley et al., 2005; Rutherford et al., 1993); that is, some of us are born to be heavier than others, and we are all shaped differently. - Although most of us can be physically fit, very few can achieve the levels of fitness and shape so highly valued today. It is biologi- cally nearly impossible (Brownell, 1991; Brownell & Fairburn, 2002). - Nevertheless, many young people in our society fight biology to the point of starvation. - In adolescence, cultural standards are often experienced as peer pressure and are much more influential than reason and fact. The high number of gay men among the relatively small numbers of males with eating disorders has also been attributed to pressures in the gay culture to be physically trim. - Conversely, pressure to appear more fit and muscular are also very apparent for a substantial proportion of men If cultural pressures to be thin are as important as they seem to be in triggering eating disorders, then such disorders would be expected to occur where these pressures are particularly severe, which is the case with ballet dancers, who are under extraordinary pressures to be thin. - In an important study, Garner, Garfinkel, Rockert, and Olmsted (1987) followed a group of 11- to 14-year-old female students in an internationally acclaimed ballet school in Toronto. - Their conservative estimate was that at least 25 percent of these girls developed eating disorders during the two years of the study. In another study, Szmukler, Eisler, Gillis, and Haywood (1985) examined 100 adolescent female ballet students in London, England. - Seven percent were diagnosed with anorexia nervosa, and an additional 3 percent were borderline cases. - Another 20 percent had lost a significant amount of weight, and 30 percent were clearly afraid of becoming fat, although they were actually below normal weight Similar results are apparent among athletes, particularly females, such as gymnasts, figure skaters, and tennis players (Davis & Strachan, 2001). - For example, in a study of 41 female Canadian competitive figure skaters, Gail Taylor and Diane Ste-Marie of the University of Ottawa found that all the figure skaters had used weight-control measures at some point in their lives. - About 93 percent reported that they perceived weight-loss pressures to be associated with the sport of figure skating (Taylor & Ste-Marie, 2001). And in a study of female gymnasts, Gretchen Kerr and colleagues at the University of Toronto found that disordered eating patterns were particularly common among those gymnasts who had received negative comments about their weight The case of Canadian tennis player Carling Bassett illustrates how weight-loss pressures in competitive athletics can serve as triggers for an eating disorder. - Bassett was Canada’s leading female tennis player in the 1980s and was inducted into Canada’s Sports Hall of Fame. - She experienced a three-year bout of bulimia, which she developed as a teenager while she was competing professionally. - Bassett was introduced to self-induced vomiting as a weight-control strategy at age 16 by an older female tennis player. - Her mother recalls the negative impact the eating disorder had on Bassett and her family: “She became skeletal. You’d try to force food on her, and she’d just throw up. We screamed and yelled.” - Bassett kept her eating disorder hidden from other tennis players, even from her husband, tennis star Robert Seguso, until her symptoms became so disruptive that she attempted recovery with Seguso’s help Family matters too. - Several clinicians and investigators in decades past observed that the “typical” anorexic’s family is successful, hard driving, concerned about external appearances, and eager to maintain harmony. - To accomplish these goals, family members often deny or ignore conflicts or negative feelings and tend to attribute their problems to other people at the expense of frank communication among themselves Pike and Rodin (1991) confirmed some differences in interactions within the families of girls with disordered eating in comparison with other families. - Mothers of girls with disordered eating seemed to act as “society’s messengers” in wanting their daughters to be thin, at least initially (Steinberg & Phares, 2001). They were very likely to be dieting themselves and, generally, were more perfectionistic than other mothers in that they were less satisfied with their families and family cohesion A study by D. Blake Woodside and colleagues reported similar findings from data collected in the international Price Foundation family study of eating disorders. - Mothers of those girls with eating disorders showed elevated levels of perfectionism and more concerns about weight and shape than did other mothers (Woodside et al., 2002). Other family studies by Howard Steiger and colleagues demonstrated that a link exists between the abnormal eating attitudes of daughters and their mothers (Steiger et al., 1996) and that family preoccupation with appearance had a direct influence on body dissatisfaction and eating disorder symptoms (Leung et al., 1996). - Caroline Davis and colleagues in Toronto and Hamilton have shown that family preoccupation with appearance exerts its greatest negative effects in influencing weight preoccupation in more anxiety-prone young women Lynn Carpenter is the mother of the late Sheena Carpenter—a young woman who died of starvation in Toronto at age 22. - Lynn has spoken about the role of parents’ attitudes toward weight and shape in inadvertently triggering eating disorder behaviours in their children. - Sheena had wanted to be a model or an actor. When she died, she weighed only 23 kilograms. - In a candid interview, Lynn Carpenter talked about the role she believes she had in initiating her daughter’s illness: “Sheena didn’t stand a chance. I always had body issues, so she grew up with me always griping about my cellulite. Always negative.” - These messages about the importance of being thin reportedly had an effect on Sheena quite early in life. - Lynn recalled an event that took place when Sheena was only six years old. - On a hot summer day, Lynn found Sheena dressed in a snowsuit and doing jumping jacks. “Look, Mom,” Sheena said, “This way I won’t put on any weight.” - But Lynn Carpenter was not the sole messenger in relaying society’s message about the importance of low body weight to her daughter. - Apparently, when Sheena was 14 years old, a modelling agency told her a thinner face would make her more photogenic. - Sheena Carpenter’s tragic story led to her mother establishing a refuge in Toronto called Sheena’s Place, which offers support programs and group sessions to women with eating disorders Whatever the pre-existing relationships, after the onset of an eating disorder, particularly anorexia, family relationships can deteriorate quickly. - Nothing is more frustrating than watching your daughter starve herself at a dinner table where food is plentiful Educated and knowledgeable parents, including psychologists and psychiatrists with full understanding of the disorder, have reported resorting to physical violence (e.g., hitting or slapping) in moments of extreme frustration, in a vain attempt to get their daughters to put some food, however little, in their mouths. - The parents’ guilt and anguish, very evident in the interview with Lynn Carpenter (Strobel, 2002), often exceed the levels of anxiety and depression present in the children with the disorder and is associated with poorer outcomes of the eating disorder

Answer 12

Eating disorders seem to have a genetic component - Relatives of patients with eating disorders are four to five times as likely as the general population to develop eating disorders themselves, with the risks for female relatives of patients with anorexia higher In important twin studies of bulimia by Kendler and colleagues (1991) and of anorexia by Walters and Kendler (1995), researchers used structured interviews to ascertain the prevalence of the disorders among 2163 female twins. - In 23 percent of identical twin pairs, both twins had bulimia, as compared with 9 percent of fraternal twins. Because no adoption studies have yet been reported, strong sociocultural influences cannot be ruled out, and other studies have produced inconsistent results (Fairburn, Cowen, & Harrison, 1999). - For anorexia, numbers were too small for precise estimates, but the disorder in one twin did seem to confer a significant risk for both anorexia and bulimia in the co-twin. In a large twin study, Bulik and colleagues (2006) estimated heritability at 0.56. - However, once again, no clear agreement exists on just what (if anything) is inherited Hsu (1990) and Steiger and colleagues (2013) speculated that nonspecific personality traits, such as emotional instability and, perhaps, poor impulse control, might be inherited. - In other words, a person might inherit a tendency to be emotionally responsive to stressful life events and, as one consequence, might eat impulsively in an attempt to relieve stress and anxiety (Pearson et al., 2015). Klump, Kaye, and Strober (2001) mentioned perfectionist traits with negative affect. - This biological vulnerability might then interact with social and psychological factors to produce an eating disorder. A twin study by Vancouver-based researchers Livesley and colleagues (2005) suggests that some symptoms of eating disorders may themselves have a partially genetic basis. - In a community-recruited sample of 221 twin pairs, they estimated that heritability for BMI is 0.57, 0.42 for purging, and 0.20 for concern for overeating. - The rest of the variance in these eating disorder domains is attributable to environmental influences. Obviously, biological processes are quite active in the regulation of eating and thus of eating disorders, and substantial evidence points to the hypothalamus as playing an important role. - Investigators have studied the hypothalamus and the major neurotransmitter systems—including norepinephrine, dopamine, and, particularly, serotonin—that pass through it to determine whether something is malfunctioning when eating disorders occur - Low levels of serotonergic activity, the system most often associated with eating disorders (Russell, 2009; Steiger et al., 2011), are associated with impulsivity in general and binge eating specifically. - Thus, most drugs currently under study as treatments for eating diorders target the serotonin system Biological investigators are also interested in the influence of hormones on eating behaviour, particularly binge eating, which is an important component of bulimia. - In an impressive program of research, Kelly Klump and colleagues (2014) found strong associations between ovarian hormones and dysregulated or impulsive eating in women prone to binge-eating episodes. - Furthermore, emotional eating behaviour (eating to relieve stress or anxiety) and binge-eating frequencies peaked in the postovulatory phases of the menstrual cycle for all women whether they binged or not during other phases of their cycle. High levels of hormones at least partially accounted for these peaks. Some interesting research also points to the role of exercise in causing or maintaining anorexia nervosa. - According to the work of John Pinel and colleagues at the University of British Columbia, individuals with anorexia differ from most people who are starving because food lacks “positive incentive value” for them in terms of their desire to actually eat it - Julie’s reported loss of positive incentive to eat can be explained by the fact that she was exercising excessively— completing a workout videotape after every meal—phenomenon called “activity anorexia” where excessive physical activity can paradoxically cause a loss of appetite (Belke et al., 2006; Epling & Pierce, 1992; Pierce & Epling, 1996) for reasons that are not yet well understood. If investigators do find a strong association between neurobiological functions and eating disorders, the question of cause or effect remains. - At present, the consensus is that some neurobiological abnormalities do exist in people with eating disorders (e.g., Mainz et al., 2012) but that they may be a result of semi- starvation or a binge-purge cycle rather than a cause, although they may well contribute to the maintenance of the disorder once it is established.

Answer 13

Clinical observations over the years have indicated that many young women with eating disorders have a diminished sense of personal control and confidence in their own abilities and talents (Bruch, 1973, 1985; Striegal-Moore et al., 1993; Walters & Kendler, 1995). - They also display more perfectionistic attitudes learned, perhaps, from their families, which may reflect attempts to exert control over important events in their lives However, perfectionism alone is only weakly associated with the development of an eating disorder, because individuals must first consider themselves overweight and also manifest low self-esteem before the trait of perfectionism makes a contribution, as indicated by the work of Kathleen Vohs at the University of British Columbia. Similarly, a study by McGee, Hewitt, Sherry, Parkin, and Flett (2005) showed that perfectionism predicted eating disorder symptoms, but only among women who were dissatisfied with their bodies. Specific distortions in perception of body shape change frequently, depending on day-to-day experience. McKenzie, Williamson, and Cubic (1993) found that bulimic women judged their body size to be larger than, and their ideal weight to be less than, same-size comparison women did. - Indeed, women with bulimia judged that their bodies were larger after they ate a choco- late bar and soft drink, whereas the judgments of other women were unaffected by snacks. - Thus, rather minor events related to eating may activate fear of gaining weight, further distortions in body image, and corrective schemes, such as purging. Another important observation is that at least a subgroup of these patients has difficulty tolerating any negative emotion (mood intolerance) and may binge or engage in other behaviours, such as self-induced vomiting or intense exercise, in an attempt to regulate their mood (reduce their anxiety or distress by doing something they think will help them avoid being fat) (Haynos & Fruzzetti, 2011; Paul et al., 2002). For example, Mauler, Hamm, Weike, and Tuschen- Caffier (2006) investigated reaction to food cues in women with bulimia and other women who had been food deprived. - They discovered that women with bulimia, when hungry, had more intense negative emotional reactions (distress, anxiety, and depression) when viewing pictures of food and subsequently ate more at a buffet, presumably to decrease their anxiety and distress and make themselves feel better, even though this overeating would cause problems in the long run. - These individuals, understandably, then evidenced even more intense negative affect after overeating and seemed threatened by food cues, which could lead to the extreme food restriction or intense exercise noted above. Fairburn and Cooper (2014) also noted the importance in treatment of countering the tendency to overly restrict food intake and the associated negative attitudes about body image that lead to bingeing and purging. What all of these studies have in common is the role of intense emotions triggered by food cues and fear of becoming fat, and faulty attempts to regulate these emotions as factors driving eating disorders.

Answer 14

Although the three major eating disorders are identifiable based on their unique characteristics, and the specific diagnoses have some validity, it is becoming increasingly clear that all eating disorders have much in common in terms of causal factors (Fairburn et al., 2007; Fairburn & Cooper, 2014). In putting together what we know about eating disorders, it is important to remember, once again, that no one factor seems sufficient to cause them Individuals with eating disorders may have some of the same biological vulnerabilities (such as being highly responsive to stressful life events) as individuals with anxiety disorders Anxiety and mood disorders are also common in the families of individuals with eating disorders (Steiger et al., 2013), and negative emotions and “mood intolerance” seem to trigger binge eating in many patients In addition, as we will see, drug and psychosocial treatments with proven effectiveness for anxiety disorders are also the treatments of choice for eating disorders. - Indeed, we could conceptualize eating disorders as anxiety disorders focused exclusively on becoming overweight. In any case, it is clear that social and cultural pressures to be thin motivate significant restriction of eating, usually through severe dieting. - Many people go on strict diets, however, including adolescent females, but only a minority develops eating disorders, so dieting alone does not explain eating disorders. An emphasis on looks and achievement, and perfectionistic tendencies, in higher-achieving families may also help establish very strong attitudes about the overriding importance of physical appearance to popularity and success, attitudes reinforced in peer groups. - These attitudes result in an exaggerated focus on body shape and weight. Lastly, there is the question of why a minority of individuals with eating disorders can successfully control their intake through dietary restraint, resulting in alarming weight loss, whereas the majority are unsuccessful at losing weight and compensate in a cycle of bingeing and purging (bulimia). - These differences may be determined by biology or physiology, such as a genetically determined disposition to be somewhat thinner to begin with. Then again, perhaps pre-existing personality characteristics, such as a tendency to be overcontrolling or a tendency to act impulsively, are important determinants of which disorder a girl develops—anorexia nervosa or bulimia nervosa, respectively In any case, most individuals with anorexia do go on to bingeing and purging at some point.

Answer 15

Only since the 1980s have there been treatments for bulimia; treatments for anorexia had been around much longer but were not initially well developed. Rapidly accumulating evidence indicates that at least one, possibly two, psychological treatments are effective, particularly for bulimia nervosa. Certain drugs may also help, although the evidence is not strong. 1. Drug treatmeNts 2. Psychosocial treatmeNts a. Bulimia Nervosa b. Binge-Eating Disorder c. Anorexia Nervosa 3. PreveNtiNg eatiNg DisorDers

Answer 16

At present, drug treatments have generally not been found to be effective in the treatment of anorexia nervosa - For example, one definitive study reported that fluoxetine (Prozac) had no benefit in preventing relapse in patients with anorexia after weight has been restored There is some evidence that drugs may be useful for some people with bulimia, particularly during the bingeing and purging cycle. - The drugs generally considered the most effective for bulimia (e.g., Prozac) are the same antidepressant medications used for mood disorders and anxiety disorders - Effectiveness is usually measured by reductions in the frequency of binge eating as well as by the percentage of patients who stop binge eating and purging In two studies, one using tricyclic antidepressant drugs and the other using fluoxetine (Prozac), researchers found the average reduction in binge eating and purging was, respectively, 47 percent and 65 percent (Walsh, 1991; Walsh et al., 1991). A more recent review (meta-analysis) suggested that selective serotonin reuptake inhibitors are helpful in the treatment of bulimia (Tortorella et al., 2014). - However, although antidepressants are more effective than placebo in the short term, and they may enhance the effects of psychological treatment somewhat (Whittal et al., 1999; Wilson et al., 1999), the available evidence suggests that antidepressant drugs alone do not have substantial long-lasting effects on bulimia nervosa and current expert opinions suggest that medications are likely most useful in conjunction with psychological treatments (Reas & Grilo, 2014; Walsh, 1995; Wilson & Fairburn, 2007), as suggested in the work by Maureen Whittal and colleagues at the University of British Columbia

Answer 17

Until recently, psychosocial treatments were directed at the patient’s low self-esteem and difficulties in developing an individual identity. - Disordered patterns of family interaction and communication were also targeted for treatment. - These treat- ments alone, however, have not had the effectiveness that clini- cians had hoped they might Short-term cognitive-behavioural treatments target problem eating behaviour and associated attitudes about the overriding importance and significance of body weight and shape, and these strategies became the treatment of choice for bulimia More recently, this approach has been updated and improved in two major ways based on more than a decade of experience. - First, a variety of new procedures intended to improve outcome have been added. - Second, noting the common concern with body shape and weight at the core of all eating disorders, the treatment has become transdiagnostic in that it is applicable with minor alterations to all eating disorders. This is an important development because eating disorders in the DSM-IV were, for the most part, considered to be mutually exclusive. - For example, according to DSM-IV guidelines, a person could not meet criteria for both anorexia and bulimia. But investigators working in this area discovered that features of the various eating disorders overlapped considerably (Fairburn, 2008; Keel et al., 2012). - Furthermore, a large portion of patients, perhaps as many as 50 percent or more, who met the criteria for a clinically severe eating disorder in the DSM-IV did not meet the criteria for anorexia or bulimia and were diagnosed with “eating disorder not otherwise specified” (eating disorder NOS) (Fairburn & Bohn, 2005). As described earlier in the chapter, some of these patients would now meet criteria for BED, which is included as a full-fledged diagnostic category in the DSM-5. As we have noted, these eating disorders have very similar causal influences, including similar inherited biological vulnerabilities, similar social influences (primarily cultural influences glorifying thinness), and a strong family influence toward perfectionism in all things. - Finally, all eating disorders seem to share anxiety focused on one’s appearance and presentation to others, as well as distorted body image. In this treatment protocol, the essential components of cognitive-behavioural therapy (CBT) directed at causal factors common to all eating disorders are targeted in an integrated way. - Individuals with anorexia and a very low weight—BMI of 17.5 or less—who would need inpatient treatment would be excluded until their weight was restored to an adequate level when they could then benefit from the program. - The principal focus of this protocol is on the distorted evaluation of body shape and weight, and maladaptive attempts to control weight in the form of strict dieting, possibly accompanied by binge eating, and methods to compensate for overeating, such as purging, laxative misuse, and so forth. - Fairburn refers to this treatment as cognitive-behavioural therapy-enhanced (CBT-E; Fairburn & Cooper, 2014). - Nevertheless, since there are some differences in outcome across the eating disorders, we will review treatment of each separately.

Answer 18

In the CBT-E approach pioneered by British psychologist Christopher Fairburn (2008), the first stage is teaching the patient the physical consequences of binge eating and purging, as well as the ineffectiveness of vomiting and laxative abuse for weight control. - The adverse effects of dieting are also described. Patients are scheduled to eat small, manageable amounts of food five or six times per day with no more than a three-hour interval between any planned meals and snacks, which eliminates the alternating periods of overeating and dietary restriction that are hallmarks of bulimia. In later stages of treatment, CBT-E focuses on altering dysfunctional thoughts and attitudes about body shape, weight, and eating. - Coping strategies for resisting the impulse to binge and/or purge are also developed, including arranging activities so the individual will not spend time alone after eating during the early stages of treatment (Fairburn & Cooper, 2014). Evaluations of the earlier versions of short-term (approximately three months) cognitive-behavioural treatments for bulimia have been good, showing a mean reduction in purging of 79 percent; 57 percent of the patients eliminated bingeing and purging altogether (Craighead & Agras, 1991). Furthermore, these results seem to last In a thorough, carefully conducted study, Fairburn and colleagues (1993) evaluated three different treatments. - CBT focused on changing eating habits and changing attitudes about weight and shape; behaviour therapy focused only on changing eating habits; and interpersonal psychotherapy (IPT) focused on improving interpersonal functioning. - For patients receiving CBT, both binge eating and purging declined by more than 90 percent at a one-year follow-up. In addition, 36 percent of the patients had ceased all binge eating and purging; the others had occasional episodes. Attitudes toward body shape and weight also improved. These results were significantly better than the results from BT. - Even more interesting was the finding that IPT did as well as CBT at the one-year follow-up, although CBT was more effective at the assessment immediately after treatment was completed. This result indicates that IPT caught up with CBT in terms of effective- ness by the end of the one-year follow-up. This is particularly interesting because IPT does not concentrate directly on disordered eating patterns or dysfunctional attitudes about eating but rather on improving interpersonal functioning, a focus that may, in turn, promote changes in eating habits and attitudes. - Both treatments were more effective than BT. - Patients in the two effective treatments had retained their gains at a six-year follow-up (Fairburn et al., 1995). Very similar results were found in a study by Agras, Walsh, Fairburn, Wilson, and Kraemer (2000), compar- ing the effectiveness of CBT and IPT in the treatment of bulimia nervosa. More recent evaluations of CBT-E are very promising, particularly since a wider range of patients with bulimia-like symptoms can be included (e.g. Fairburn et al., 2009). - Results from a major clinical trial comparing 20 weeks of CBT-E with two years of weekly long-term psychoanalytic psychotherapy (PPT) in 70 patients with bulimia revealed that patients in each group were comfortable with their treatment, but at five months (when the CBT-E treatment concluded), 42 percent of CBT-E patients were recovered compared with 6 percent of PPT patients. - After two years (when the PPT treatment concluded), the comparable figures were 44 percent and 15 percent (Poulsen et al., 2014). - Thus, CBT-E was more efficient in terms of the number of sessions required and more effective at each time point assessed, with evidence for the durability in improvement among those who responded to CBT-E. - Now, results from a major clinical trial similar to the Agras at al. (2000) study described above, but comparing the transdiagnostic version of CBT (CBT-E) with interpersonal psychotherapy (IPT) in 130 patients with any form of eating disorder have been reported (Fairburn et al., 2015). Just after treatment 66 percent of the CBT-E participants met criteria for remission compared with 33 percent of the IPT participants. One year later, the figures were 69 percent for CBT-E compared with 49 percent for IPT, with IPT catching up somewhat but still less effective. - Therefore, currently, CBT-E would seem to be the treatment of choice for adults based on these studies. There is also good evidence that family therapy directed at the painful conflicts present in families with an adolescent who has an eating disorder can be helpful (le Grange et al., 2007). - Integrat- ing family and interpersonal strategies into CBT is a promising new direction (Sysko & Wilson, 2011). Clearly, we need to under- stand more about how to improve such treatments to deal more successfully with the growing number of patients with eating disorders. One of the problems with the best treatment, CBT-E, is that access to the treatment is limited because trained therapists are not always available. - Guided self-help programs that use CBT principles also seem to be effective, at least for less severe cases Another variant of CBT, developed by Ron Davis of Lakehead University and his colleagues in Toronto, is brief group psychoeducation for bulimia nervosa. - The main goal of psychoeducation is to help bulimic individuals normalize their eating and reduce their body image disturbance. - This goal is achieved through providing them with information relevant to bulimia nervosa and with useful strategies, such as meal planning, problem solving, and self-monitoring. - The main differences from CBT are that psychoeducation is briefer, is delivered in a lecture-type format, and is not tailored to the unique needs of individual patients (Davis & Olmsted, 1992). R - esearch has shown this approach to be better than a wait list control in helping bulimic individuals reduce their symptoms (Davis et al., 1990). - The intervention is particularly effective for those with less severe bulimia (Davis et al., 1992). - Nonetheless, improvements in bulimia are even better when the psychoeducation approach is followed by 16 weeks of CBT than when patients receive the psychoeducation approach alone

Answer 19

Early studies adapting CBT treatments for bulimia to obese binge eaters were quite successful (Smith et al., 1992). - Agras, Telch, Arnow, Eldredge, and Marnell (1997) followed 93 obese individuals with BED for one year and found that immediately after treatment 41 percent of the participants abstained from bingeing and 72 percent binged less frequently. - After one year, binge eating was reduced by 64 percent, and 33 percent of the group remained abstinent. - Importantly, those who had stopped binge eating during CBT maintained a weight loss of approximately four kilograms over the follow-up period; those who continued to binge gained almost three kilograms. - Thus, stopping binge eating is critical to sustaining weight loss in obese patients, a finding consistent with other studies of weight- loss procedures Widely available behavioural weight-loss programs for obese patients with BED, such as Weight Watchers, do have some positive effect on bingeing but not nearly so much as CBT Self-help procedures may be useful in the treatment of BED (Carter & Fairburn, 1998; Wilson & Zandberg, 2012). - For example, CBT delivered as guided self-help was demonstrated to be more effective than a standard behavioural weight-loss program for BED both after treatment and at a two-year follow- up (Wilson, Wilfley, et al., 2010), and this same program is effective when delivered out of a doctor’s office in a primary care setting (Striegel-Moore et al., 2010). - In view of these results, it would seem a self-help approach should probably be the first treatment offered for BED before engaging in more expensive and time-consuming therapist-led treatments. - Much as with bulimia, however, more severe cases may need the more intensive treatment delivered by a therapist, particularly when people have multiple (comorbid) disorders in addition to BED, as well as low self-esteem (Wilson et al., 2010). A recent report following up the Wilson et al. (2010) study indicated that rapid response (at least 70 percent reduction in binge eating by week 4) was a specific positive indicator of greater rates of remission compared with nonrapid responders up to two years later in the CBT guided self-help treatment but not in the IPT or the behavioural weight-loss group (Hilbert, Hildebrandt, Agras, Wilfley, and Wilson, 2015). - The authors suggest that since IPT was effective for both rapid and nonrapid responders that participants who do not show a rapid response to CBT might be switched over to IPT. - Matching treatment to individuals based on their personal characteristics or patterns of responding (personalized medicine) is regarded by many as the next important step for improving success rates of our treatments. - It is also important to emphasize again that if an obese person is bingeing, standard weight-loss procedures will be ineffective without treatment directed at bingeing.

Answer 20

In anorexia, of course, the most important initial goal is to restore the patient’s weight to a point that is at least within the low- normal range. - If body weight is below 85 percent of the average healthy body weight for a given individual or if weight has been lost rapidly and the individual continues to refuse food, inpatient treatment is recommended (American Psychiatric Association, 2010b; Russell, 2009) because severe medical complications, particularly acute cardiac failure, could occur if weight is not restored immediately. - If the weight loss has been more gradual and seems to have stabilized, weight restoration can be accomplished on an outpatient basis. Restoring weight, although often a difficult task, is probably the easiest part of treatment. - Clinicians who treat patients in different settings, as reported in a variety of studies, find that at least 85 percent will be able to gain weight. - The gain is often as much as one-quarter to a half a kilogram a day until weight is within the normal range. - In fact, knowing they cannot leave the hospital until their weight gain is adequate is often sufficient to motivate adolescents with anorexia. Weight gain is very important, since starvation induces loss of grey matter and hormonal dysregulation in the brain (Mainz et al., 2012), changes that are reversible when normal weight is restored. Then the more difficult stage begins. As Hsu (1988) and others have demonstrated, initial weight gain is a poor predictor of long- term outcome in anorexia. - Without attention to the patient’s underlying dysfunctional attitudes about body shape, she will almost always relapse. - For restricting anorexics, the focus of treatment must shift to their marked anxiety over becoming obese and losing control of eating, as well as to their undue emphasis on thinness as a determinant of self-worth, happiness, and success. - In this regard, effective treatments for restricting anorexics are similar to those for patients with bulimia nervosa, particu- larly in the transdiagnostic approach (CBT-E) described earlier (Fairburn & Cooper, 2014). In one earlier study (Pike et al., 2003), extended (one-year) outpatient CBT was found to be significantly better than continued nutritional counselling in preventing relapse after weight restoration, with only 22 percent failing (relapsing or dropping out) with CBT versus 73 percent failing with nutritional counselling. Carter and colleagues (2009) reported similar findings and both studies demonstrate the ineffectiveness of nutritional counselling alone. More recently, results from 99 adults with anorexia treated with CBT-E suggest the efficiency of this transdiagnostic treatment (only “suggest” because there was no control or comparison group). - In the 64 percent who completed treatment after 40 sessions, weight increased substantially and eating disorder features improved markedly. - This improvement was stable at a 60-week follow-up Other research highlights the importance of assessing clients with eating disorders’ readiness for change, since patients with anorexia nervosa are often difficult to treat (Goldner, 1989). - Interventions derived from those used in the treatment of substance abuse disorders are being developed that focus on enhancing the patient’s motivation to change (Kaplan & Garfinkel, 1999). - For example, a study by Joanne Gusella and colleagues at the IWK Health Centre in Halifax administered a motivational measure to 34 adolescents with eating disorders before the commencement of an eating disorder group. Those girls who reported being more ready to change at treatment outset showed greater improvements in their eating disorder symptoms over the course of the group. The group also assisted the girls in earlier stages to be more ready to change by the end of the group (Gusella et al., 2003). A similar study by Josie Geller at the St. Paul’s Hospital Eating Disorders Program in Vancouver examined motivation to change in 56 adult women with anorexia. - Like the findings in Gusella’s study, Geller (2002) found that patients who were at a more advanced stage of readiness to change were more likely to complete assigned behavioural recovery activities (e.g., increasing caloric intake) and to accept intensive treatment for their anorexia. Given the clear importance of motivation to change in recovery from anorexia, new treatments that target motivational enhancement are promising innovations in eating disorder treatment In addition, every effort is made to include the family to accomplish two goals. - First, the negative and dysfunctional communication regarding food and eating must be eliminated and meals made more structured and reinforcing. - Second, attitudes toward body shape and image distortion are discussed at some length in family sessions. - Unless the therapist attends to these attitudes, individuals with anorexia are likely to face a lifetime preoccupation with weight and body shape, struggle to maintain marginal weight and social adjustment, and be subject to repeated hospitalization. - Family therapy seems effective, particularly with young girls with a short history of the disorder (Eisler et al., 2000). - Recent research by a team at the Hospital for Sick Children in Toronto showed that a substantially less costly family group psychoeducation approach was just as effective as a more traditional family therapy approach in assisting hospitalized adolescents with anorexia and their families, at least in the short term Until recently, the long-term results of treatment for anorexia have been less encouraging than for bulimia, with substantially lower rates of full recovery than for bulimia over a 7.5-year period (Eddy et al., 2008; Herzog et al., 1999). - But this may be changing. - In a recent important clinical trial, 121 adolescents with anorexia received 24 sessions of either family-based treatment (FBT) in which the parents became intimately involved in the treatment program with a focus on facilitating weight gain, or individual psychotherapy. - At treatment conclusion, 42 percent met criteria for remission in the FBT condition and 49 percent at a one-year follow-up, compared with 23 percent at both points in time in the individual psychotherapy condition (Lock et al., 2010). A subsequent study demonstrated that FBT was at least as effective as and was less costly than other forms of family therapy addressing general family processes (Agras et al., 2014). As in some studies with bulimia, a positive early response (gaining at least two kilograms or five pounds in the first four weeks) predicts a better outcome in the long run (Lock et al. 2015). - At present FBT has the most support from clinical trials for treating adolescents with anorexia, but there is some support for its efficacy in treating bulimia (Le Grange et al., 2015). - Promising results have also recently been reported with CBT-E for adolescents with anorexia University of Ottawa psychologist George Tasca, his Ph.D. student Renee Grenon, and their colleagues recently conducted meta-analyses on the efficacy of psychological treatments for eating disorders. - Meta-analyses involve analyzing the results of many studies to arrive at a general conclusion. - The general conclusion from his work is that people with eating disorders who undergo psychological treatment experience much improvement in their symptoms, compared with people with eating disorders who are on a waitlist. - Interestingly, the type of treatment is not related to the size of the improvement: treatment based on CBT principles, treatments not based on CBT principles (e.g., short-term psychodynamic treatment), individual treatments, and group treatments produce similar outcomes Probably one of the most talked-about stories of the treat- ment of anorexia nervosa in Canadian history involves the Montreux Clinic—an expensive and exclusive private clinic for women and adolescents with anorexia nervosa in Victoria, British Columbia. - Montreux was directed by Peggy Claude- Pierre—a mother who had helped her own two teenage daugh- ters overcome eating disorders. - Claude-Pierre received a good deal of media attention, including interviews by Oprah Winfrey and Pamela Wallin, given her claims of a striking 90 percent recovery rate for clinic patients and the message of hope contained in her reported treatment philosophy of unconditional love. - The clinic came under investigation when a former employee made allegations that the staff was inadequately trained and the clients not properly screened. - More serious allegations were made that clients were being force-fed and held against their will. - Although, as mentioned earlier, it is essential for very emaciated patients with anorexia to be hospitalized to prevent potentially severe medical complications, these clients were admitted to Montreux with no medical supervision. - In fact, the director Claude-Pierre did not have a graduate degree in psychology or any medical training. - In spite of strong protests from her supporters, the residential clinic was eventually closed in December 1999 on the order of the local health officer

Answer 21

Attempts are being made to prevent the development of eating disorders. If successful methods are confirmed, they will be very important, because many cases of eating disorders are resistant to treatment and most individuals who do not receive treatment suffer for many years, in some cases all their lives (Eddy et al., 2008; Killen, 1996). The development of eating disorders during adolescence is a risk factor for a variety of additional problems and disorders during adulthood, including cardiovascular symp- toms, chronic fatigue and infectious diseases, binge drinking and drug use, and anxiety and mood disorders (Field et al., 2012; Johnson et al., 2002). Before implementing a prevention program, however, it is necessary to target specific behaviours to change. Stice, Shaw, and Marti (2007) concluded after a review of prevention programs that selecting girls age 15 or over, focusing on eliminating an exaggerated focus on body shape or weight, and encouraging acceptance of one’s body stood the best chance of success in preventing eating disorders. - This finding is similar to results from prevention efforts for depression, where a selec- tive approach of targeting high-risk individuals was more successful rather than a universal approach targeting everyone in a certain age range (Stice & Shaw, 2004). Using this selective approach, a program developed by Stice, Rohde, Shaw, and colleagues (2012) called Healthy Weight was compared with just handing out educational material in 398 college women at risk for developing eating disorders because of weight and shape concerns. During four weekly hour-long group sessions, the women were educated about food and eating habits (and moti- vated to alter these habits using motivational enhancement procedures). - Eating disorder risk factors and symptoms were substantially reduced in the Healthy Weight group compared with the comparison group, particularly for the most severely at risk women, and the effect was durable at a six-month follow-up. In Canada, Gail McVey and Ron Davis have examined the effectiveness of a program aimed at girls in Grade 6 that is designed to promote a healthy body image and ultimately prevent the development of eating disorders. - The program was tested on 258 girls, who were assigned to either the intervention or to a control group. - The intervention focused on countering the effects of the media portrayals of the desirability of being thin as well as training the girls in self-esteem enhancement, stress management, and peer relationship skills. - Relative to the control group, the six- session intervention was successful in improving body image satisfaction and self-esteem and in reducing dieting attitudes immediately following the intervention. - Unfortunately, these benefits were not maintained one year following the intervention Niva Piran of the Ontario Institute for Studies in Education ran a prevention program for young women that emphasized changes in the school culture at a well-known ballet school in Toronto (Piran, 1998). - In focus groups, students explored their experi- ences of body image dissatisfaction at the school and outside school. - They each formed an action plan to implement changes in the school culture (Piran, 2001). - Specific changes included moving away from a focus on a body shape and toward an increased focus on body conditioning and physical stamina, and not permitting teachers to make comments about students’ body shape (recall the impact of Phoebe’s experiences with her ballet instructor’s comments about her body weight and shape). - This prevention program has been very successful: dysfunctional eating attitudes have decreased among girls in the school, as have rates of bingeing, vomiting, and laxative abuse (Piran, 1999). In view of the severity and chronicity of eating disorders, preventing these disorders through widespread educational and intervention efforts would be clearly preferable to waiting until the disorders develop

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