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Question 1

Overview of Eating Disorders

Answer 1

There are three prevalent eating disorders:
- In bulimia nervosa, dieting results in out-of-control binge-eating episodes that are often followed by purging the food through vomiting or other means.
- In anorexia nervosa, food intake is cut down dramatically, resulting in substantial weight loss and sometimes dangerously low body weight.
- In binge-eating disorder, a pattern of binge eating is not followed by purging.

Without treatment, eating disorders become chronic and can, on occasion, result in death.

An increase in the cases of eating disorders over last few decades
- Increase is culturally specific; going global
- Young females in a socially competitive environment

Question 2

Bulimia nervosa

Answer 2

Binging (out-of-control) eating episodes followed by self-induced vomiting

Clinical Description
- Large amounts of food consumed
- Eating out of control
- Several purging techniques to compensate:
— Self-induced vomiting
— Using laxatives and diuretics
— Excessive exercising
— Fasting

Medical Consequences
- Enlargement of salivary glands
- Erosion of dental enamel
- Electrolyte imbalance [ Electrolyte imbalance can result in serious medical complications if unattended, including cardiac arrhythmia (disrupted heartbeat) and renal (kidney) failure, both of which can be fatal. ]
- Disrupted heartbeat, kidney failure
- Intestinal problems [ Intestinal problems resulting from laxative abuse are also potentially serious; they can include severe constipation or permanent colon damage. ]
- Marked calluses on fingers or back of hand

Associated Psychological Disorders
- Anxiety and mood disorders, GAD
- Depression, borderline personality disorder
- Impulsivity (compulsive shoplifting)

In a study by Kristin von Ranson at the University of Calgary and colleagues, eating disorders were associated with nicotine dependence in adolescent girls and with alcohol abuse in adult women (von Ranson et al., 2002).

Question 3

Anorexia nervosa

Answer 3

Person eats minimal amounts or exercises vigorously

Clinical Description
- Bulimics have a history of anorexia
- Fear of obesity: severe caloric restriction
- Two subtypes:
— Restricting type
— Binge eating/purging type

In the restricting type, individuals diet to limit calorie intake; in the binge-eating/purging type, they rely on purging.
- Unlike individuals with bulimia, individuals with binge-eating/purging binge on relatively small amounts of food and purge more consistently, in some cases each time they eat.

Clinical Description
- About half of anorexics engage in binge eating and purging
- Comorbidity with anxiety disorders
- Body mass index (BMI) close to 16 when treatment is sought
- Disturbance in body image

In the restricting type, individuals diet to limit calorie intake; in the binge-eating/purging type, they rely on purging. Unlike individuals with bulimia, individuals with binge-eating/purging binge on relatively small amounts of food and purge more consistently, in some cases each time they eat.

Medical Consequences
- Cessation of menstruation (amenorrhea)
- Dry skin, brittle hair or nails, and sensitivity to or intolerance of cold temperatures
- Lanugo, downy hair on the limbs and cheeks
- Cardiovascular problems
- Electrolyte imbalance

Cardiovascular problems, such as chronically low blood pressure and heart rate, can also result. If vomiting is part of the anorexia, electrolyte imbalance and cardiac and kidney problems can result, as in bulimia (Mehler et al., 2010).

Associated Psychological Disorders
- Anxiety disorder
- Mood disorders
- OCD
- Substance abuse
- Suicide

Question 4

Binge-Eating Disorder

Answer 4

• Associated with obesity
• Males; later age of onset
• 20% of individuals in weight-loss programs engage in binge eating
• 50% of those in stomach surgery (bariatric surgery)
• Many cross over to bulimia
• Binge to alleviate bad moods

Binge-Eating Disorder (BED): full-fledged disorder in DSM-5

It seems that approximately 33 percent of those with BED binge to alleviate “bad moods” or negative affect (Grilo et al., 2001; Steiger et al., 2013; Stice et al., 2000). These individuals are more psychologically disturbed than the 67 percent who do not use bingeing to regulate mood (Grilo et al., 2001).

Question 5

Statistics of eating disorders

Answer 5

• 90%–95% of bulimics are women
• The rest male: predominantly minority sexual orientation
• Age of onset: 16–19 years; girls at most risk
• Urban areas
• Becomes chronic if left untreated

Cross-Cultural Considerations
- Immigrants who recently moved to Western countries
- Higher social class
- Acculturating to the Western majority
- Eastern cultures deny having eating disorders

Developmental Considerations
- Girls have concerns of gain weight gain at puberty
- Found in children and older adults too
- Concerns about body image
- ARFID

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.

In Japan, the prevalence of anorexia nervosa among teenage girls is still lower than the rate in North America but it seems to be increasing.

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., choking). This disorder can also lead to other eating disorders later in life (Katzman et al., 2016).

Question 6

Social Dimensions - Causes of Eating Disorders

Answer 6

• Sociocultural pressures
• Magazines, beauty pageants glorify “slenderness”
• Collision between culture and physiology
• Increase in exercise programs
• Dieting produces stress-related withdrawal symptoms in brain
• Men rated their ideal body weight as heavier than the weight females thought most attractive in men
• Conflict between reality and fashion closely related to the current epidemic of eating disorders
• Weight reduction efforts in adolescent girls are more likely to result in weight gain than weight loss
• Dieting produces stress-related withdrawal symptoms in brain
  — Result in more eating than without dieting
• Fighting biology
• Pressure from family
  — Anorexia leads to deteriorating relationships with family
• Chronic dieting leads to preoccupation with food
  — Athletes, dancers, models

In addition to sociocultural pressures, causal factors include possible biological and genetic vulnerabilities (the disorders tend to run in families), psychological factors (low self-esteem), social anxiety (fears of rejection), and distorted body image (relatively normal-weight individuals view themselves as fat and ugly).

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

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 (Fairburn et al., 1999).

Question 7

Biological Dimensions
- Causes of Eating Disorders

Answer 7

• Biological and genetic vulnerabilities
• Heritability is estimated at 0.56
• Low levels of serotonergic activity
• High levels of postovulatory hormones lead to impulsive eating

Biological vulnerability might interact with social and psychological factors to produce an eating disorder.

Question 8

Psychological Dimensions
- Causes of Eating Disorders

Answer 8

Young women with eating disorders have
- Diminished sense of personal control
- Lack of confidence in their own abilities and talents
- Perfectionist attitudes
- Low self-esteem
- Intense negative emotional reactions
- Distorted body image

In addition to sociocultural pressures, causal factors include possible biological and genetic vulnerabilities (the disorders tend to run in families), psychological factors (low self-esteem), social anxiety (fears of rejection), and distorted body image (relatively normal-weight individuals view themselves as fat and ugly).

Question 9

An Integrative Model
- Causes of eating disorders

Answer 9

An Integrative Model

Eating disorders influenced by
- Biological, social, and psychological factors

Restriction on eating results in
- Anorexia
- Bulimia
- BED

Question 10

Treatment of Eating Disorders

Answer 10

Drug Treatments
- Antidepressants, Prozac

Psychosocial Treatments
- Short-term CBT
- CBT-E (cognitive-behavioural therapy-enhanced)

Several psychosocial treatments are effective, including cognitive-behavioural approaches combined with family therapy and interpersonal psychotherapy. Drug treatments are less effective at the current time.

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.

Question 11

Bulimia Nervosa - Psychosocial Treatments

Answer 11

CBT-E: alter dysfunctional thoughts, attitudes about body shape, weight, eating

IPT (interpersonal psychotherapy): improve interpersonal functioning

CBT (cognitive-behavioural therapy-enhanced): change eating habits and attitudes about food

Behaviour therapy: change eating habits

Family therapy

Question 12

Binge-Eating Disorder - Psychosocial Treatments

Answer 12

CBT

Weight-loss programs

Self-help procedures

Treatment to be directed toward bingeing

Question 13

Anorexia Nervosa - Psychosocial Treatments

Answer 13

Hospitalization for weight gain

Fear of relapse

CBT-E (cognitive-behavioural therapy-enhanced)

Outpatient CBT: nutritional counselling

Motivational enhancement techniques

Family therapy

Question 14

Preventing Eating Disorders

Answer 14

Eliminating exaggerated focus on body shape, weight

Educating about food and eating habits

Promoting a healthy body image

Countering the effects of the media portrayals of desirability of being thin

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.

Question 15

Overview Of Eating Disorders

Answer 15

In bulimia nervosa, out-of- control eating episodes, or binges, are followed by self-induced vomiting, excessive use of laxatives, or other attempts to purge (get rid of) the food.
- In anorexia nervosa, the person eats only minimal amounts of food or exercises vigorously to offset food intake, so body weight sometimes drops dangerously.
- The chief characteristic of these related disorders is an overwhelming, all- encompassing drive to be thin.

Of the people with anorexia nervosa who are followed over an extended time, up to 20 percent die as a result of their disorder, with slightly more than 5 percent dying within ten years
- anorexia nervosa has the highest mortality rate of any psychological disorder reviewed in this book, including depression
- From 20 to 30 percent of anorexia-related deaths are suicides, which is 50 times as high as the risk of death from suicide in the general population

Suicide attempts are very common in people with eating disorders, occurring in from 30 to 40 percent of patients at least once during their lifetime

Garner and Fairburn (1988) reviewed rates of referral to a major eating disorder centre in Toronto.
- Between 1975 and 1986, the referral rates for anorexia rose slowly, but the rates for bulimia rose dramatically—from virtually none to more than 140 per year.
- Similar findings have been reported from other parts of the world (Hay & Hall, 1991; Lacey, 1992).
- The reason for this increase is not known. Toronto researchers Paul Garfinkel and Barbara Dorian (2001) have suggested that it may relate to the increased prevalence of dieting and preoccupation with the body among young women who are simultaneously being exposed to social pressures toward consumption and incredible food availability

Although reports of cases of eating disorders are documented throughout history, eating problems were not recognized as psychological disorders until relatively recently.
- In 1872, Sir William Withey Gull, a British physician, was the first to use the term anorexia nervosa.
- According to Canadian psychiatrists Sidney Kennedy and David Goldbloom (1996), the first Canadian description of anorexia nervosa appeared in the Maritime Medical Journal in 1895.
- The recognition of bulimia nervosa as a separate entity did not occur until much later, when the condition was described in the 1970s (e.g., Russell, 1979).
- Eating disorders were included for the first time as a separate group of disorders in the DSM-IV; before then, they had been classified as one of the disorders usually first diagnosed in infancy, childhood, or adolescence because of their typical onset in adolescence.

Until recently, eating disorders, particularly bulimia, were not found in developing countries, where access to sufficient food is so often a daily struggle; only in the West, where food is generally plentiful, have they been rampant.
- Now this has changed; evidence suggests that eating disorders are going global.
- China and Japan is approaching those in Canada, the United States, and other Western countries

Eating disorders tend to occur in a relatively small segment of the population.
- More than 90% of the severe cases are young females who live in a socially competitive environment.

Perhaps the most visible example is the late Diana, Princess of Wales, who recounted her seven-year battle with bulimia
- she was bingeing and vomiting four or more times a day during her honeymoon

The strongest contributions to etiology seem to be sociocultural rather than psychological or biological factors.

Question 16

Bulimia Nervosa - Clinical Description

Answer 16

The hallmark of bulimia nervosa is eating a large amount of food—typically, junk food rather than fruits and vegetables—and more than most people would eat under similar circumstances
- Patients with bulimia readily identify with this description, even though the actual caloric intake for binges varies significantly from person to person
- Just as important as the amount of food eaten is the fact that the eating is experienced as out of control, a criterion that is an integral part of the definition of binge eating.

The individual attempts to compensate for the binge eating and potential weight gain, usually by purging techniques.
- Techniques include self-induced vomiting immediately after eating, and using laxatives (drugs that relieve constipation) and diuretics (drugs that result in loss of fluids through greatly increased frequency of urination).
- Some fast for long periods between binges.
- Others exercise excessively. However, rigorous exercising is usually characteristic of anorexia nervosa. Caroline Davis and colleagues at York University (Davis et al., 1997) found that 81 percent of a group of patients with anorexia nervosa exercised excessively, compared with 57 percent of a group of patients with bulimia nervosa. Activity levels increase at least a year before the development of full-blown anorexia nervosa, suggesting that excessive exercise may be an early warning sign for anorexia nervosa development

Bulimia nervosa was subtyped in the DSM-IV-TR into purging type and nonpurging type (exercise or fasting).
- But the nonpurging type has turned out to be rare, accounting for only 6 to 8 percent of patients with bulimia

A study by Paul Garfinkel and colleagues in Toronto compared purging versus nonpurging bulimics (Garfinkel et al., 1996).
- In comparison with nonpurging bulimics, those who purged developed their eating disorder at a younger age and had higher rates of comorbid depression, anxiety disorders, and alcohol abuse, as well as higher rates of earlier sexual abuse.
- However, other studies have found little evidence of any differences between purging and nonpurging types of bulimia, leading some to question whether this manner of subtyping is useful. As a result, this distinction was dropped in the DSM-5.

Purging is not a particularly efficient method of reducing caloric intake (Fairburn, 2013).
- Vomiting reduces approximately 50 percent of the calories that were just consumed, less if it is delayed at all (Kaye et al., 1993); laxatives and related procedures have very little effect, acting, as they do, so long after the binge

One of the more important additions to the DSM-IV-TR that was maintained in the DSM-5 is the specification of a psychological characteristic
- Despite accomplishments and success, people feel that their continuing popularity and self-esteem would be determined largely by the weight and shape of their body.
- Paul Garfinkel (1992) noted that, of 107 women seeking treatment for bulimia nervosa, only 3 percent did not share this attitude.
- Recent investigations confirm the construct validity of the diagnostic category of bulimia nervosa, suggesting that the major features of the disorder (binge- ing, purging, overconcern with body shape, etc.) cluster together in someone with this problem

Question 17

Diagnostic Criteria for Bulimia Nervosa

Answer 17

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 most people would eat during a similar period of time and 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. Recurrent inappropriate compensatory behaviors in order to pre- vent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics or other medications; fasting; or excessive exercise.

C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.

D. Self-evaluation is unduly influenced by body shape and weight.

E. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Question 18

Medical Consequences - Bulimia Nervosa

Answer 18

Chronic bulimia with purging has a number of medical consequences (Russell, 2009).

One is salivary gland enlargement caused by repeated vomiting, which gives the face a chubby appearance.

Repeated vomiting also may erode the dental enamel on the inner surface of the front teeth.

More important, continued vomiting may upset the chemical balance of bodily fluids, including sodium and potassium levels.
- This condition, called an electrolyte imbalance, can result in serious medical complications if unattended, including cardiac arrhythmia (disrupted heartbeat) and renal (kidney) failure, both of which can be fatal.

Surprisingly, young women with bulimia also develop more body fat than age- and weight- matched healthy controls (Ludescher et al., 2009), the very effect they are trying to avoid.
- Normalization of eating habits will quickly reverse the imbalance.

Intestinal problems resulting from laxative abuse are also potentially serious; they can include severe constipation or permanent colon damage.

Finally, some individuals with bulimia have marked calluses on their fingers or the backs of their hands caused by the friction of contact with the teeth and throat when repeatedly using their fingers to stimulate the gag reflex.

Question 19

Associated Psychological Disorders - Bulimia Nervosa

Answer 19

Both men and women with bulimia usually present with additional psychological disorders, particularly anxiety and mood disorders

In the 2002 Canadian Community Health Survey (CCHS), about half of people who met the criteria for eating problems (which include bulimia) had an anxiety or mood disorder as well

We compared 20 patients with bulimia nervosa to 20 individuals with panic disorder and another 20 with social phobia (Schwalberg et al., 1992).
- The most striking finding was that 75 percent of the patients with bulimia also presented with an anxiety disorder, such as social phobia or generalized anxiety disorder
- patients with anxiety disorders, in contrast, did not necessarily have an elevated rate of eating dis-orders.
- Mood disorders, particularly depression, also commonly co-occur with eating disorders
- For several years, one prominent theory suggested that eating disorders are simply a way of expressing depression. But almost all evidence indicates that depression follows bulimia and may be a reaction to it

Some research suggests a high prevalence of borderline personality disorder in patients with bulimia (e.g., Cassin & von Ranson, 2005).

Researchers at Simon Fraser University noted an association between eating disorder symptoms and non-suicidal self-injury in their online survey (Turner et al., 2015).

Substance abuse commonly accompanies bulimia nervosa and vice versa (Stewart & Brown, 2007).
- Seventy-one percent of the alcoholic women reported binge eating, with 91 percent of those displaying binge- eating patterns that clinicians would consider severe.

In a study by Kristin von Ranson at the University of Calgary and colleagues, eating disorders were associated with nicotine dependence in adolescent girls and with alcohol abuse in adult women (von Ranson et al., 2002).

Those with binge-purge types of eating disorders smoke the most and that smoking is related to impulsive personality traits

Research by Elliot Goldner and colleagues in Vancouver suggests that bulimia may also be related to other behaviours suggesting poor impulse control, such as compulsive shoplifting (Goldner et al., 2000).

In sum, bulimia seems related to anxiety disorders, mood disorders, substance use disorders, borderline personality, and impulsivity.

Question 20

aNorexia Nervosa - general

Answer 20

Majority of individuals with bulimia are within 10 percent of their normal weight
- In contrast, individuals with anorexia nervosa (which literally means a “nervous loss of appetite,” an incorrect name because appetite often remains healthy) are so successful at losing weight that they put their lives in considerable danger.

Both anorexia and bulimia are characterized by a morbid fear of gaining weight and losing control over eating.
- The major difference seems to be whether the individual is successful at losing weight.

People with anorexia are proud of both their diets and their extraordinary control, and they usually do not see themselves as having an illness.
- People with bulimia are ashamed of both the problem itself and their lack of control, and they tend to be secretive about their bulimic symptoms.

The denial of illness in anorexia and the shame and secrecy in bulimia mean that people with eating disorders do not seek treatment as early as they should.

Responses to the current physical fitness and exercise craze can become extreme for female athletes
- Perhaps the best-known example was world-class gymnast Christy Henrich, who died of kidney failure at the age of 22. During repeated hospitalizations for anorexia, Christy had to be physically restrained to prevent excessive exercise; she exercised to the point of exhaustion if given half a chance. When she died in 1994, Christy weighed only 30 kilograms.
- Elaine Tanner, who represented Canada in swim- ming at the Commonwealth Games, the Pan-Am Games, and the Olympics in the 1960s (winning 15 medals and setting new records), also developed anorexia after competing in the Olym- pics at age 17 (Bornath, 2002). She was finally able to overcome her disorder, but it took 19 years.

The tragic consequences of anorexia among young performers and athletes and within the modelling world have also been well publicized in the media. In November 2006, 21-year-old Brazilian model Ana Carolina Reston died, weighing just 40 kilograms.

Question 21

Anorexia - Clinical Description

Answer 21

Bulimia nervosa is more common than anorexia, but they have a great deal of overlap.
- For example, many individuals with bulimia have a history of anorexia; that is, they once used fasting to reduce their body weight below desirable levels

Although decreased body weight is the most notable feature of anorexia nervosa, it is not the core of the disorder.
- Many people lose weight because of a medical condition, but people with anorexia have an intense fear of obesity and relentlessly pursue thinness

The disorder most commonly begins in an adolescent who is actually overweight or who perceives herself to be.
- She then starts a diet that escalates into an obsessive preoccupation with being thin.
- She continues to see herself as over- weight despite her weight loss.
- A study by Randi McCabe at McMaster University showed that patients with anorexia nervosa have a tendency to overestimate their body weight (McCabe et al., 2001).

Dramatic weight loss is achieved through severe caloric restriction or by combining caloric restriction and purging.

The DSM-5 specifies two subtypes of anorexia nervosa
- In the restricting type, individuals diet to limit calorie intake
- in the binge-eating/purging type, they rely on purging.

Unlike individuals with bulimia, individuals with binge-eating/purging binge on relatively small amounts of food and purge more consistently, in some cases each time they eat.
- Approximately half the individuals who meet the criteria for anorexia engage in binge eating and purging

Prospective data collected over eight years on 136 individuals with anorexia reveal few differences between these two subtypes on severity of symptoms or personality
- At that time, 62 percent of the restricting subtype had begun bingeing or purging.
- Another study showed few differences between these subtypes and comorbidity with anxiety disorders
- Thus, subtyping may not be useful in predicting the future course of the disorder but rather may reflect a certain phase or stage of anorexia. For this reason, DSM-5 criteria specify that subtyping refers only to the last three months

An individual with anorexia is never satisfied with his or her weight loss.
- Staying the same weight from one day to the next or gaining any weight is likely to cause intense panic, anxiety, and depression.
- Only continued weight loss every day for weeks on end is satisfactory.

Although DSM-5 criteria specify only “significantly low weight,” one study suggests that body mass index (BMI) averages close to 16 by the time treatment is sought

Another key criterion of anorexia is a marked disturbance in body image—the way a person sees and feels about her body.
- may focus on certain body parts

After seeing numerous doctors, people become good at saying what others expect to hear.
- They may agree they are underweight and need to gain a few kilograms—but they don’t really believe it themselves.
- Question them further and they will tell you that the person in the mirror is fat.
- For this reason, individuals with anorexia seldom seek treatment on their own. Usually, pressure from somebody in the family leads to the initial visit

Some anorexic individuals show increased interest in cooking and food. Some have become expert chefs, preparing all the food for the family. Others hoard food in their rooms, looking at it periodically.

Question 22

Diagnostic Criteria for Anorexia Nervosa

Answer 22

A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, develop- mental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for chil- dren and adolescents, less than that minimally expected.

B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a signifi- cantly low weight.

C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self- evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

Specify whether:

1. Restricting type: During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise.
2. Binge-eating/purging type: During the last 3 months, the indi- vidual has engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

Question 23

Anorexia - Medical Consequences

Answer 23

One common medical complication of anorexia nervosa is cessation of menstruation (amenorrhea), which also occurs relatively often in bulimia - This feature can be an objective physical index of the degree of food restriction but is inconsistent because it does not occur in all cases (Franko et al., 2004).
- Because of this inconsistency, amenorrhea was dropped as a diagnostic criterion in the DSM-5.

Other medical
signs and symptoms of anorexia include dry skin, brittle hair or nails, and sensitivity to or intolerance of cold temperatures.
- Also, it is relatively common to see lanugo, downy hair on the limbs and cheeks.

Cardiovascular problems, such as chronically low blood pressure and heart rate, can also result.

If vomiting is part of the anorexia, electrolyte imbalance and resulting cardiac and kidney problems can result, as in bulimia

Question 24

Anorexia - Associated Psychological Disorders

Answer 24

As with bulimia nervosa, anxiety disorders and mood disorders are often present in individuals with anorexia
- One that seems to co-occur frequently is obsessive-compulsive disorder

In anorexia nervosa, unpleasant thoughts are focused on gaining weight and the individual engages in a variety of behaviours, some of them ritualistic, to rid herself of such thoughts.
- Future research will determine whether anorexia and OCD are truly similar or simply resemble each other.

Substance abuse is also common in individuals with anorexia nervosa and, in conjunction with anorexia, is a strong predic- tor of mortality, particularly by suicide.

Question 25

BiNge-eatiNg DisorDer

Answer 25

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

Question 26

Diagnostic Criteria for Binge-Eating Disorder

Answer 26

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.

Question 27

statistics - sex

Answer 27

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.

Question 28

Statistics - Age

Answer 28

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.

Question 29

Statistics - whole populations

Answer 29

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

Question 30

Statistics long term

Answer 30

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

Question 31

statistics - Canada

Answer 31

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.

Question 32

Statistics - Cross-Cultural Considerations

Answer 32

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

Question 33

Statistics - Developmental Considerations

Answer 33

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.

Question 34

CAusEs Of EATing DisOrDErs

Answer 34

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.

Question 35

Social Dimensions

Answer 35

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

Question 36

Biological DimeNsioNs

Answer 36

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.

Question 37

Psychological DimeNsioNs

Answer 37

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.

Question 38

aN iNtegrative moDel

Answer 38

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.

Question 39

TrEATmEnT Of EATing DisOrDErs

Answer 39

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

Question 40

Drug treatmeNts

Answer 40

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

Question 41

Psychosocial treatmeNts

Answer 41

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.

Question 42

Bulimia Nervosa - psychological treatment

Answer 42

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

Question 43

Binge-Eating Disorder - psychological treatment

Answer 43

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.

Question 44

Anorexia Nervosa - Psychological treatment

Answer 44

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

Question 45

PreveNtiNg eatiNg DisorDers

Answer 45

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