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Unformatted text preview: COMER CH11_Cb.qxp 3/9/06 1:37 PM Page 308 COMER CH11_Cb.qxp 3/9/06 1:37 PM Page 309 C H A P T E R 11 Eating Disorders 11 TOPIC OVERVIEW anorexia nervosa The Clinical Picture Medical Problems bulimia nervosa Binges Compensatory Behaviors Bulimia Nervosa vs. Anorexia Nervosa what causes eating disorders? Societal Pressures Family Environment Ego Deficiencies and Cognitive Disturbances Mood Disorders Biological Factors how are eating disorders treated? Treatments for Anorexia Nervosa Treatments for Bulimia Nervosa putting it together: a standard for integrating perspectives J anet Caldwell was . . . five feet, two inches tall and weighed 62 pounds. . . . Janet began dieting at the age of 12 when she weighed 115 pounds and was chided by her family and friends for being “pudgy.” She continued to restrict her food intake over a two-year period, and as she grew thinner, her parents became increasingly more concerned about her eating behavior. . . . Janet . . . felt that her weight problem began at the time of puberty. She said that her family and friends had supported her efforts to achieve a ten-pound weight loss when she first began dieting at age 12. Janet did not go on any special kind of diet. Instead, she restricted her food intake at meals, generally cut down on carbohydrates and protein intake, tended to eat a lot of salads, and completely stopped snacking between meals. At first, she was quite pleased with her progressive weight reduction, and she was able to ignore her feelings of hunger by remembering the weight loss goal she had set for herself. However, each time she lost the number of pounds she had set for her goal she decided to lose just a few more pounds. Therefore she continued to set new weight goals for herself. In this manner, her weight dropped from 115 pounds to 88 pounds during the first year of her weight loss regimen. Janet felt that, in her second year of dieting, her weight loss had continued beyond her control. . . . She became convinced that there was something inside of her that would not let her gain weight. . . . Janet commented that although there had been occasions over the past few years when she had been fairly “down” or unhappy, she still felt driven to keep on dieting. As a result, she frequently went for walks, ran errands for her family, and spent a great deal of time cleaning her room and keeping it in a meticulously neat and unaltered arrangement. When Janet’s weight loss continued beyond the first year, her parents insisted that she see their family physician, and Mrs. Caldwell accompanied Janet to her appointment. Their family practitioner was quite alarmed at Janet’s appearance and prescribed a high-calorie diet. Janet said that her mother spent a great deal of time pleading with her to eat, and Mrs. Caldwell planned various types of meals that she thought would be appealing to Janet. Mrs. Caldwell also talked a great deal to Janet about the importance of good nutrition. Mr. Caldwell, on the other hand, became quite impatient with these discussions and tended to order Janet to eat. Janet then would try to eat something, but often became tearful and ran out of the room because she could not swallow the food she had been ordered to eat. The youngster said that she often responded to her parents’ entreaties that she eat by telling them that she indeed had eaten but they had not seen her do so. She often listed foods that she said she had consumed which in fact she had flushed down the toilet. She estimated that she only was eating about 300 calories a day. (Leon, 1984, pp. 179–184) It has not always done so, but Western society today equates thinness with health and beauty (see Figure 11-1). In fact, in the United States thinness has become a national obsession. Most of us are as preoccupied with how much we eat as with COMER CH11_Cb.qxp 310 3/9/06 1:37 PM Page 310 chapter 11 Percentage Dissatisfied with Their: 1972 1997 25% 15% 48% 30% 66% 52% 57% Muscle tone 25% 26% Breasts/Chest 18% 50% 45% 34% 38% 71% Abdomen 63% 36% 49% 12% Hips and upper thighs Males 43% Weight 35% Females 56% Overall body 61% 29% figure 11-1 Body dissatisfaction on the rise According to surveys on body image, people in our society are much more dissatisfied with their bodies now than they were a generation ago. Women are still more dissatisfied than men, but today’s men are more dissatisfied with their bodies than the men of a generation past. (Adapted from Garner, Cooke, & Marano, 1997, p. 42; Rodin, 1992, p. 57.) Table 11-1 DSM Checklist the taste and nutritional value of our food.Thus it is not surprising that during the past three decades we have also witnessed an increase in two eating disorders that have at their core a morbid fear of gaining weight. Sufferers of anorexia nervosa, like Janet Caldwell, are convinced that they need to be extremely thin, and they lose so much weight that they may starve themselves to death. People with bulimia nervosa go on frequent eating binges, during which they uncontrollably consume large quantities of food, then force themselves to vomit or take other extreme steps to keep from gaining weight. The news media have published many reports about anorexic or bulimic behavior. One reason for the surge in public interest is the frightening medical consequences that can result.The death in 1983 of Karen Carpenter, a popular singer and entertainer, from medical problems related to anorexia nervosa serves as a reminder (see Box 11-1). Another reason for concern is the disproportionate prevalence of these disorders among adolescent girls and young women (Russell, 1995). Clinicians now understand that the similarities between anorexia nervosa and bulimia nervosa can be as important as the differences between them (Serpell & Treasure, 2002). For example, many people with anorexia nervosa binge as they persist in losing dangerous amounts of weight; some later develop bulimia nervosa (Tozzi et al., 2005; APA, 2000). Conversely, people with bulimia nervosa sometimes develop anorexia nervosa as time goes on. anorexia nervosa 1. Refusal to maintain body weight above a minimally normal weight for age and height. 2. Intense fear of gaining weight, even though underweight. 3. Disturbed body perception, undue influence of weight or shape on self-evaluation, or denial of the seriousness of the current low weight. 4. In postmenarcheal females, amenorrhea. Based on APA, 2000. Anorexia Nervosa Janet Caldwell, 14 years old and in the eighth grade, displays many symptoms of anorexia nervosa: she refuses to maintain more than 85 percent of her normal body weight, intensely fears becoming overweight, has a distorted view of her weight and shape, and has stopped menstruating (see Table 11-1). Like Janet, at least half of the people with anorexia nervosa reduce their weight by restricting their intake of food, a pattern called restricting-type anorexia nervosa. At first they tend to cut out sweets and fattening snacks and then, increasingly, other foods (APA, 2000, 1994). Eventually people with this kind of anorexia nervosa show almost no variability in diet. Others, however, lose weight by forcing themselves to vomit after meals or by abusing laxatives or diuretics, and they may even engage in eating binges, a pattern called binge-eating/purging-type anorexia nervosa, which we shall observe in more detail when we turn to bulimia nervosa (APA, 2000, 1994). COMER CH11_Cb.qxp 3/9/06 1:37 PM Page 311 Eating Disorders 311 [ BOX 11-1 ] G iven the hard-living, substanceabusing, risk-taking image cultivated by many pop music artists, we are no longer shocked to read about the untimely death of one of them, from Elvis Presley, Jimi Hendrix, or Sid Vicious to Kurt Cobain, Tupac Shakur, Notorious B.I.G., or Russell Jones (Ol’ Dirty Bastard). The 1983 death of Karen Carpenter, from the effects of anorexia nervosa, in contrast, stunned the country. Karen, the 32-year-old velvetvoiced lead singer of the soft-rock brotherand-sister duo The Carpenters, did not drink, take drugs, drive fast cars, or tear up the roadside on a motorcycle. She never appeared in the pages of the tabloids. Until her late twenties—well into her fame—she even continued to live at home with her parents and brother, Richard, in suburban Downey, California. Indeed, she and Richard were icons of unrebellious, quiet youthful virtue. The pressure to maintain this wholesome image may have contributed to Karen’s destruction. After reading an early concert review describing her as “chubby,” Karen began a downward spiral into anorexia nervosa. Always a dutiful family member and content to let Richard make all the management and artistic decisions for their group, Karen seemed to have little control over her fame. One friend and fellow sufferer later said about Karen’s eating disorder, “When you start denying yourself food, and begin feeling you have control over a life that has been pretty much controlled for you, it’s exhilarating” (O’Neill, as cited in Levin, 1983). For nine years Karen starved herself, abused laxatives and thyroid pills, and purged by repeatedly swallowing drugs that induce vomiting. Her weight dropped from a high of 140 pounds at the beginning of her singing career to a devastating low of 80 pounds. Ironically, in the last year of her life, it looked as though she had gotten a handle on her disorder. She had increased her weight to an almost-normal 108 pounds after a year of therapy. Yet on a visit home to her parents’ house in California, on February 4, 1983, she collapsed. Paramedics could not revive her, and she died an hour later of cardiac arrest. Traces of a vomit-inducing drug were found in her bloodstream. Until Karen’s death, the public knew little about anorexia nervosa, and what it knew did not sound serious—more like the latest celebrity fad diet than a dangerous, potentially fatal condition. But that lighthearted view changed dramatically with her death, as scores of articles in newspapers and magazines detailed not only the tragically short life of Karen Car- Approximately 90 to 95 percent of all cases of anorexia nervosa occur in females (Freeman, 2005). Although the disorder can appear at any age, the peak age of onset is between 14 and 18 years (APA, 2000). Between 0.5 and 2 percent of all females in Western countries develop the disorder in their lifetime, and many more display at least some of its symptoms (Kjelsas et al., 2004; Favaro et al., 2003). It seems to be on the increase in North America, Europe, and Japan. Typically the disorder begins after a person who is slightly overweight or of normal weight has been on a diet.The escalation toward anorexia nervosa may follow a stressful event such as separation of parents, a move away from home, or an experience of personal failure (Wilson et al., 2003; Gowers et al., 1996). Although most victims recover, between 2 and 6 percent of them become so seriously ill that they die, usually from medical problems brought about by starvation or from suicide (Millar et al., 2005; Nielsen et al., 1998; Slade, 1995). B. Schiffman/Gamma Liaison We’ve Only Just Begun penter but also the disorder that killed her. Anorexia nervosa was no longer something to be taken casually. Since then numerous other famous personalities in diverse fields have gone public about their own struggles with eating disorders. •anorexia nervosa•A disorder marked by the pursuit of extreme thinness and by extreme loss of weight. COMER CH11_Cb.qxp 1:37 PM Page 312 chapter 11 Wallace Kirkland, Life ©Time Warner, Inc. 312 3/9/06 The Clinical Picture Laboratory starvation Thirty-six conscientious objectors who were put on a semistarvation diet for six months developed many of the symptoms seen in anorexia nervosa and bulimia nervosa (Keys et al., 1950). Becoming thin is the key goal for people with anorexia nervosa, but fear provides their motivation (Russell, 1995). People with this disorder are afraid of becoming obese, of giving in to their growing desire to eat, and more generally of losing control over the size and shape of their bodies. In addition, despite their focus on thinness and the severe restrictions they may place on their food intake, people with anorexia are preoccupied with food. They may spend considerable time thinking and even reading about food and planning their limited meals (King, Polivy, & Herman, 1991). Many report that their dreams are filled with images of food and eating (Schredl & Montasser, 1999; Levitan, 1981). This preoccupation with food may in fact be a result of food deprivation rather than its cause. In a famous “starvation study” conducted in the late 1940s, 36 normal-weight conscientious objectors were put on a semistarvation diet for six months (Keys et al., 1950). Like people with anorexia nervosa, the volunteers became preoccupied with food and eating. They spent hours each day planning their small meals, talked more about food than about any other topic, studied cookbooks and recipes, mixed food in odd combinations, and dawdled over their meals. Many also had vivid dreams about food. Persons with anorexia nervosa also think in distorted ways. They usually have a low opinion of their body shape, for example, and consider themselves unattractive (Kaye et al., 2002). In addition, they are likely to overestimate their actual proportions.While most women in Western society overestimate their body size, the estimates of those with anorexia nervosa are particularly high. A 23-year-old patient said: I look in a full-length mirror at least four or five times daily and I really cannot see myself as too thin. Sometimes after several days of strict dieting, I feel that my shape is tolerable, but most of the time, odd as it may seem, I look in the mirror and believe that I am too fat. (Bruch, 1973) Seeing is deceiving In one research technique, David Garner people look at photographs of themselves through a special lens and adjust the lens until they see what they believe is their actual image. A subject may change her actual image (left) from 20 percent thinner (middle) to 20 percent larger (right). This tendency to overestimate body size has been tested in the laboratory (Farrell, Lee, & Shafran, 2005). In a popular assessment technique, subjects look at a photograph of themselves through an adjustable lens. They are asked to adjust the lens until the image that they see matches their actual body size.The image can be made to vary from 20 percent thinner to 20 percent larger than actual appearance. In one study, more than half of the subjects with anorexia nervosa were found to overestimate their body size, stopping the lens when the image was larger than they actually were. The distorted thinking of anorexia nervosa also takes the form of certain maladaptive attitudes and misperceptions (Gilo et al., 2005; Garner & Bemis, 1985, 1982). Sufferers tend to hold such beliefs as “I must be perfect in every way”; “I will become a better person if I deprive myself ”; and “I can avoid guilt by not eating.” Gertrude, who recovered from anorexia nervosa, recalls that at age 15 “my thought processes became very unrealistic. I felt I had to do something I didn’t want to do for a higher purpose.That took over my life. It all went haywire” (Bruch, 1978, p. 17). People with anorexia nervosa also display certain psychological problems, such as depression and anxiety and low self-esteem (Godart et al., 2005; O’Brien & Vincent, 2003). Some also experience insomnia or other sleep disturbances. A number grapple with substance abuse. And many display obsessive-compulsive patterns.They may set rigid rules for food preparation or even cut food into specific shapes. Broader obsessive-compulsive patterns are common as well (Sansone et al., 2005; Shafran, 2002). In one study, people with anorexia nervosa and others with obsessive-compulsive disorder scored equally high for obsessiveness and compulsiveness (Bastiani et al., COMER CH11_Cb.qxp 3/9/06 1:37 PM Page 313 Eating Disorders 1996). Finally, persons with anorexia nervosa tend to be perfectionistic, a characteristic that typically precedes the onset of the disorder (Rousset et al., 2004; Shafran, Cooper, & Fairburn, 2002). Medical Problems The starvation habits of anorexia nervosa cause medical problems (Katzman, 2005;Tyre, 2005).Women develop amenorrhea, the absence of menstrual cycles. Other problems include lowered body temperature, low blood pressure, body swelling, reduced bone mineral density, and slow heart rate. Metabolic and electrolyte imbalances also may occur and can lead to death by heart failure or circulatory collapse (Froelich et al., 2001). The poor nutrition of people with anorexia nervosa may also cause skin to become rough, dry, and cracked; nails to become brittle; and hands and feet to be cold and blue. Some people lose hair from the scalp and some grow lanugo (the fine, silky hair that covers some newborns) on their trunk, extremities, and face. Clearly, people with this disorder are caught in a vicious cycle.Their fear of obesity and distorted body image lead them to starve themselves. Starvation in turn leads to a preoccupation with food, increased anxiety and depression, and medical problems, causing them to feel even more afraid that they will lose control over their weight, their eating, and themselves.They then try still harder to achieve thinness by not eating. 313 •amenorrhea•The cessation of menstrual cycles. nervosa•A disorder marked by frequent eating binges that are followed by forced vomiting or other extreme compensatory behaviors to avoid gaining weight.Also known as binge-purge syndrome. •bulimia •binge•An episode of uncontrollable eating during which a person ingests a very large quantity of food. Bulimia Nervosa People with bulimia nervosa—a disorder also known as binge-purge syndrome— engage in repeated episodes of uncontrollable overeating, or binges. A binge occurs over a limited period of time, often an hour, during which the person eats much more food than most people would eat during a similar time span (APA, 2000, 1994). In addition, people with this disorder repeatedly perform inappropriate compensatory behaviors, such as forcing themselves to vomit; misusing laxatives, diuretics, or enemas; fasting; or exercising excessively (see Table 11-2). If the compensatory behaviors regularly include forced vomiting or misuse of laxatives, diuretics, or enemas, the specific diagnosis is purging-type bulimia nervosa. If individuals instead compensate by fasting or exercising frantically, the specific diagnosis is nonpurging-type bulimia nervosa. A married woman with the former pattern, since recovered, describes a morning during her disorder: Today I am going to be really good and that means eating certain predetermined portions of food and not taking one more bite than I think I am allowed. I am very careful to see that I don’t take more than Doug does. I judge by his body. I can feel the tension building. I wish Doug would hurry up and leave so I can get going! As soon as he shuts the door, I try to get involved with one of the myriad of responsibilities on the list. I hate them all! I just want to crawl into a hole. I don’t want to do anything. I’d rather eat. I am alone, I am nervous, I am no good, I always do everything wrong anyway, I am not in control, I can’t make it through the day, I just know it. It has been the same for so long. I remember the starchy cereal I ate for breakfast. I am into the bathroom and onto the scale. It measures the same, BUT I DON’T WANT TO STAY THE SAME! I want to be thinner! I look in the mirror, I think my thighs are ugly and deformed looking. I see a lumpy, clumsy, pear-shaped wimp. There is always something wrong with what I see. I feel frustrated trapped in this body and I don’t know what to do about it. I float to the refrigerator knowing exactly what is there. I begin with last night’s brownies. I always begin with the sweets. At first I try to make it look like nothing is missing, but my appetite is huge and I resolve to make another batch of brownies. I know there is half of a bag of cookies in the bathroom, thrown out the night before, and I polish them off immediately. I take some milk so my vomiting will be smoother. I like the full feeling I get after downing a big glass. I get Table 11-2 DSM Checklist bulimia nervosa 1. Recurrent episodes of binge eating. 2. Recurrent inappropriate compensatory behavior in order to prevent weight gain. 3. Symptoms continuing, on average, at least twice a week for three months. 4. Undue influence of weight or shape on self-evaluation. Based on APA, 2000. COMER CH11_Cb.qxp 314 3/9/06 1:37 PM Page 314 chapter 11 >>LOOKING BACK Bulimia and Royalty During her three years as queen of England, Anne Boleyn, King Henry VIII’s second wife, displayed a habit, first observed during her coronation banquet, of vomiting during meals. In fact, she assigned a lady-in-waiting the task of holding up a sheet when the queen looked likely to vomit. (Shaw, 2004) << out six pieces of bread and toast one side in the broiler, turn them over and load them with patties of butter and put them under the broiler again till they are bubbling. I take all six pieces on a plate to the television and go back for a bowl of cereal and a banana to have along with them. Before the last toast is finished, I am already preparing the next batch of six more pieces. Maybe another brownie or five, and a couple of large bowlfuls of ice cream, yogurt or cottage cheese. My stomach is stretched into a huge ball below my ribcage. I know I’ll have to go into the bathroom soon, but I want to postpone it. I am in never-never land. I am waiting, feeling the pressure, pacing the floor in and out of the rooms. Time is passing. Time is passing. It is getting to be time. I wander aimlessly through each of the rooms again tidying, making the whole house neat and put back together. I finally make the turn into the bathroom. I brace my feet, pull my hair back and stick my finger down my throat, stroking twice, and get up a huge pile of food. Three times, four and another pile of food. I can see everything come back. I am glad to see those brownies because they are SO fattening. The rhythm of the emptying is broken and my head is beginning to hurt. I stand up feeling dizzy, empty and weak. The whole episode has taken about an hour. (Hall, 1980, pp. 5–6) Normal-weight bulimia nervosa Binge-eating/purging-type anorexia nervosa Restricting-type anorexia nervosa figure 11-2 Overlapping patterns of anorexia nervosa, bulimia nervosa, and obesity Some people with anorexia nervosa binge and purge their way to weight loss, and some obese persons binge-eat. However, most people with bulimia nervosa are not obese, and most overweight people do not binge-eat. (Adapted from APA, 2000, 1994; Garner & Fairburn, 1988; Russell, 1979.) Like anorexia nervosa, bulimia nervosa usually occurs in females, again in 90 to 95 percent of the cases (Freeman, 2005) (see Box 11-2 on page 316). It begins in adolescence or young adulthood (most often between 15 and 21 years of age) and often lasts for several years, with periodic letup. The weight of people with bulimia nervosa usually stays within a normal range, although it may fluctuate markedly within that range (APA, 2000, 1994). Some people with this disorder, however, become seriously underweight and may eventually qualify for a diagnosis of anorexia nervosa instead (see Figure 11-2). Clinicians Bulimic have also observed that certain people, a number of obesity them overweight, display a pattern of binge eating without vomiting or other inappropriate compensatory behaviors. This pattern, often called binge-eating disorder, is not yet listed in the DSM, although it is being considered for inclusion in the next edition (Striegel-Moore et al., 2005; Wilson, 2005). Between 2 and 7 percent of the population and as many as onequarter of severely overweight people are thought to have this disorder (Pull, 2004; Hoek et al., 2003). Many teenagers and young adults go on occasional eating binges or experiment with vomiting or laxatives after they hear about these behaviors from their friends or the media (McDermott & Jaffa, 2005; Pyle, Obesity 1999). In one study, half of the college students surveyed reported periodic binges, 6 percent had tried vomiting, and 8 percent had experimented with laxatives at least once (Mitchell et al., 1982). Only some of these individuals, however, qualify for a diagnosis of bulimia nervosa. Surveys in several Western countries suggest that as many as 5 percent of women develop the full syndrome (Kjelsas et al, 2004; Favaro et al., 2003). Binges People with bulimia nervosa may have 2 to 40 binge episodes per week, although the number is usually closer to 10 (Mizes, 1995, 1993). In most cases, the binges are carried out in secret.The person eats massive amounts of food very rapidly, with minimal chewing—usually sweet, high-calorie foods with a soft texture, such as ice cream, cookies, doughnuts, and sandwiches. The food is hardly tasted or thought about. Binge-eaters COMER CH11_Cb.qxp 3/9/06 1:37 PM Page 315 315 Rosaria Esposito/AP Photo Eating Disorders commonly consume more than 1,000 calories (often more than 3,000) during an episode (Guertin, 1999;Agras, 1995). Binges are usually preceded by feelings of great tension (Crowther et al., 2001).The person feels irritable, “unreal,” and powerless to control an overwhelming need to eat “forbidden” foods. During the binge, the person feels unable to stop eating. Although the binge itself may be experienced as pleasurable in the sense that it relieves the unbearable tension, it is followed by feelings of extreme self-blame, shame, guilt, and depression, as well as fears of gaining weight and being discovered (Hayaki et al., 2002). Compensatory Behaviors After a binge, people with bulimia nervosa try to compensate for and undo its effects. Many resort to vomiting. But vomiting actually fails to prevent the absorption of half of the calories consumed during a binge. Furthermore, repeated vomiting affects one’s general ability to feel satiated; thus it leads to greater hunger and more frequent and intense binges (Wooley & Wooley, 1985). Similarly, the use of laxatives or diuretics largely fails to undo the caloric effects of bingeing (Garner et al., 1985). Vomiting and other compensatory behaviors may temporarily relieve the uncomfortable physical feelings of fullness or reduce the feelings of anxiety and self-disgust attached to binge eating. Over time, however, a cycle develops in which purging allows more bingeing, and bingeing necessitates more purging. The cycle eventually causes people with this disorder to feel powerless and disgusted with themselves (Hayaki et al., 2002). Most recognize fully that they have an eating disorder.The woman we met earlier recalls how the pattern of bingeing, purging, and self-disgust took hold while she was a teenager in boarding school: Every bite that went into my mouth was a naughty and selfish indulgence, and I became more and more disgusted with myself. . . . The first time I stuck my fingers down my throat was during the last week of school. I saw a girl come out of the bathroom with her face all red and her eyes puffy. She had always talked about her weight and how she should be dieting even though her body was really shapely. I knew instantly what she had just done and I had to try it. . . . I began with breakfasts which were served buffet-style on the main floor of the dorm. I learned which foods I could eat that would come back up easily. When I woke in the morning, I had to make the decision whether to stuff myself for half an hour and throw up before class, or whether to try and make it through the whole day without overeating. . . . I always thought people noticed when I took huge portions at mealtimes, but I figured they assumed that because I was an athlete, I burned it off. . . . Once a binge was under way, I did not stop until my stomach looked pregnant and I felt like I could not swallow one more time. That year was the first of my nine years of obsessive eating and throwing up. . . . I didn’t want to tell anyone what I was doing, and I didn’t want to stop. . . . [Though] being in love or other distractions occasionally lessened the cravings, I always returned to the food. (Hall, 1980, pp. 9–12) As with anorexia nervosa, a bulimic pattern typically begins during or after a period of intense dieting, often one that has been successful and earned praise from family members and friends (Helgeson, 2002). Research has found that normal subjects placed on very strict diets also develop a tendency to binge. Some of the subjects in the conscientious objector “starvation study,” for example, later binged when they were allowed to return to regular eating, and a number of them continued to be hungry even after Eating for sport Many people go on occasional eating binges, particularly teenagers and young adults. In fact, sometimes binges are officially endorsed, as we see in this photo from the World Pizza Eating Championships in New York City. However, individuals are considered to have an eating disorder only when the binges recur and the pattern endures, and the issues of weight or shape dominate self-evaluation. >>LOOKING AROUND Dietary Triggers Although most dieters do not develop an eating disorder, female teenagers who follow a severely restrictive diet are 18 times more likely than nondieters to develop an eating disorder within one year of the diet (Patton et al., 1999). << The Diet Business Americans spend $31 billion each year on weight-reduction products and services, including $500 million on prescription and over-the-counter diet drugs (National Task Force on the Prevention and Treatment of Obesity). << COMER CH11_Cb.qxp 316 3/9/06 1:37 PM Page 316 chapter 11 [ BOX 11-2 ] Not for Women Only T he number of young men with eating disorders appears to be on the rise, and more men are now seeking treatment for these disorders (Drummond, 2002; Robb & Dadson, 2002). Nevertheless, males account for only 5 to 10 percent of all cases of eating disorders. The reasons for this striking gender difference are not entirely clear. One possible explanation is that men and women are subject to different sociocultural pressures (Toro et al., 2005). For example, a survey of college men found that the majority selected “muscular, strong and broad shoulders” to describe the ideal male body and “thin, slim, slightly underweight” to describe the ideal female body (Kearney-Cooke & Steichen-Ash, 1990). A second reason for the different rates of eating disorders may be the different methods of weight loss favored by men and women. According to some clinical observations, men are more likely to use exercise to lose weight, whereas women more often diet (Toro et al. 2005; Braun, 1996; Mickalide, 1990). And dieting often precedes the onset of eating disorders. Perhaps a third reason for the difference in reported cases is that eating disorders in men may be underdiagnosed (Freeman, 2005). Some men do not want to admit that they have what many consider a “female problem.” In addition, it may be more difficult for clinicians to identify eating disorders in men because the clinical manifestations are different. For example, amenorrhea, an obvious symptom of anorexia nervosa among females, does not occur in men. Why do men develop eating disorders? For some the disorder is linked to the requirements and pressures of a job or sport (Thompson & Sherman, 1993). In fact, such factors are more likely to trigger eating disorders in men than in women. According to one study, 37 percent of males with eating disorders had jobs or played sports for which weight control was important, compared to 13 percent of women (Braun, 1996). The highest rates have been found among jockeys, wrestlers, distance runners, body builders, and swimmers. Jockeys commonly spend hours before a race in a sauna, shedding up to seven pounds of weight, and may restrict their food intake, abuse laxatives and diuretics, and force vomiting (King & Mezey, 1987). Similarly, male wrestlers in high school and college commonly restrict their food for up to three days before a match in order to “make weight.” Some lose up to five pounds of water weight by practicing or running in several layers of warm or rubber clothing before weighing in for a match (Thompson & Sherman, 1993). Whereas most women with eating disorders are obsessed with thinness at all times, wrestlers and jockeys are usually preoccupied with weight reduction only during their active season. After “making weight,” many wrestlers go on eating and drinking binges in order to gain strength for the upcoming match, only to return to a weight-loss strategy after the match in preparation for the next weigh-in. A cycle of losing and regaining weight each season changes metabolic activity and jeopar- Schindler Family Photo/AP Photo large meals (Keys et al., 1950).A later study examined the binge-eating behavior of subjects at the end of a very low-calorie weight-loss program (Telch & Agras, 1993). Immediately after the program, 62 percent of the subjects, who had not previously been binge eaters, reported binge-eating episodes, although the episodes did decrease during the three months after treatment stopped. Was bulimia nervosa the cause? One of the most publicized and tragic cases of 2005 was that of Terri Schiavo, shown in this photo shortly after she collapsed and suffered an apparent heart attack in 1990. After experiencing cardiac arrest, she suffered extensive brain damage and was left in what was termed a “persistent vegetative state.” Following a series of legal battles, a court ordered in 2005 that Schiavo’s feeding tube be removed, and she died a week later. One question at the center of this case was whether Schiavo’s heart dysfunction had been the result of bulimia nervosa. Blood tests revealed that she had a potassium deficiency (a dangerous medical complication of bulimia nervosa); her weight had fluctuated significantly during the years prior to her collapse; a number of friends reported observing bulimia-like patterns of behavior; and, in fact, a jury eventually awarded Schiavo more than $1 million in a malpractice suit against the obstetrician who had been treating her for infertility prior to her collapse, contending that he had failed to test her for or diagnose an eating disorder. On the other hand, Schiavo’s autopsy offered no direct proof of an eating disorder, and alternative explanations for her collapse and cardiac arrest have been proposed. COMER CH11_Cb.qxp 3/9/06 1:37 PM Page 317 J. Polleross/The Stock Market Eating Disorders The weigh-in Although this jockey does not have an eating disorder, his prerace weigh-in illustrates the weight standards and pressures to which such athletes are subjected. dizes the person’s health and future efforts at weight control (Mickalide, 1990; Steen et al., 1988). Beyond job or sport pressures, body image appears to be a strong predictor of eating disorders in men, just as it is in women. Some men who develop eating disorders report that they want a “lean, toned, thin” shape similar to the ideal female body, rather than the muscular, broad-shouldered shape of the typical male ideal (Kearney-Cooke & Steichen-Ash, 1990). However, those who aspire to the typical male ideal are also at risk. A study of 548 males—both young and old— revealed that 43 percent of them were dissatisfied with their bodies to some degree, with many of them expressing a desire to increase their muscle mass, especially in their abdomen and chest (Garner & KearneyCooke, 1997). The most dissatisfied men were those in their 30s and 50s; the least dissatisfied were men in their 20s. Given such concerns, it may not be surprising that a new kind of eating disorder has been emerging, found almost exclu- 317 sively among men, called reverse anorexia nervosa or muscle dysmorphobia. This disorder is displayed by men who are very muscular but still see themselves as scrawny and small and therefore continue to strive for a perfect body through extreme measures such as excessive weight lifting or the abuse of steroids (Robb & Dadson, 2002; Olivardia, Pope, & Phillips, 2000). Individuals with muscle dysmorphobia typically experience shame about their body image, and many have a history of depression, anxiety, or selfdestructive complusive behavior. About one-third of them also display related dysfunctional behaviors such as bingeing. As the number of males with eating disturbances increases, researchers are increasing their efforts to understand both the similarities and the differences between males and females with these disorders. Since eating disturbances cause problems for both men and women, investigators must unravel the important factors that operate across the gender divide. Bulimia Nervosa vs. Anorexia Nervosa Bulimia nervosa is similar to anorexia nervosa in many ways. Both disorders typically begin after a period of dieting by people who are fearful of becoming obese; driven to become thin; preoccupied with food, weight, and appearance; and struggling with feelings of depression, anxiety, and the need to be perfect (Thompson-Brenner & Westen, 2005; Fairburn et al., 2003). Individuals with either of the disorders have a heightened risk of self-harm or attempts at suicide (Ruuska et al., 2005; Levitt et al., 2004). Substance abuse may accompany either disorder, perhaps beginning with the excessive use of diet pills. People with either disorder believe that they weigh too much and look too heavy regardless of their actual weight or appearance (Kaye et al., 2002). And both disorders are marked by disturbed attitudes toward eating (Walker et al., 2002). Yet the two disorders also differ in important ways (see Table 11-3 on the next page). Although people with either disorder worry about the opinions of others, those with bulimia nervosa tend to be more concerned about pleasing others, being attractive to others, and having intimate relationships (Striegel-Moore, Silberstein, & Rodin, 1993). They also tend to be more sexually experienced and active than people with anorexia nervosa. On the positive side, people with bulimia nervosa display fewer of the obsessive qualities that drive people with restricting-type anorexia nervosa to control their caloric intake so rigidly (Halmi, 1995; Andersen, 1985). On the negative side, they are more likely to have long histories of mood swings, become easily frustrated or bored, and have trouble coping effectively or controlling their impulses (Claes et al., 2002;APA, 2000). Individuals with bulimia nervosa also tend to be ruled by strong emotions and >>LOOKING BACK Poetic Concerns The famed poet Lord Byron (1788–1824), author of Don Juan, wrote: “A woman should never be seen eating and drinking unless it be lobster salad and champagne.” Friends of Byron noted that the poet himself had “a horror of fat.” He regularly abstained from eating, believing that he would lose his creativity if he ate normally (Brumberg, 1988). << COMER CH11_Cb.qxp 318 3/9/06 1:37 PM Page 318 chapter 11 Table 11-3 Anorexia Nervosa vs. Bulimia Nervosa Restricting-type Anorexia Nervosa Bulimia Nervosa Refusal to maintain a minimum body weight for healthy functioning Underweight, normal weight, near-normal weight, or overweight Hunger and disorder denied; often proud of weight management and more satisfied with body Intense hunger experienced; binge-purge experienced as abnormal; greater body dissatisfaction Less antisocial behavior Greater tendency to antisocial behavior and alcohol abuse Amenorrhea of at least 3 months’ duration common Irregular menstrual periods common; amenorrhea uncommon unless body weight is low Mistrust of others, particularly professionals More trusting of people who wish to help Tend to be obsessional Tend to be dramatic Greater self-control, but emotionally overcontrolled, with problems experiencing and expressing feelings More impulsivity and emotional instability More likely to be sexually immature and inexperienced More sexually experienced and sexually active Females more likely to reject traditional feminine role Females more likely to embrace traditional feminine role Age of onset often around 14–18 Age of onset around 15–21 Greater tendency for maximum pre-disorder weight to be near normal for age Greater tendency for maximum pre-disorder weight to be slightly greater than normal Lesser familial predisposition to obesity Greater familial predisposition to obesity Greater tendency toward pre-disorder compliance with parents Greater tendency toward pre-disorder conflict with parents Tendency to deny family conflict Tendency to perceive intense family conflict Source: APA, 2000, 1994; Levine, 1987; Andersen, 1985; Garner et al., 1985; Neuman & Halvorson, 1983. may change friends and relationships frequently. And more than one-third of them display the characteristics of a personality disorder, particularly borderline personality disorder, which we shall examine more closely in Chapter 16 (Sansone, Levitt, & Sansone, 2005; Maranon et al., 2004). Another difference is the nature of the medical complications that accompany the two disorders (Birmingham & Beaumont, 2004; Mickley, 2001). Only half of women with bulimia nervosa are amenorrheic or have very irregular menstrual periods, compared to almost all of those with anorexia nervosa (Crow et al., 2002). On the other hand, repeated vomiting bathes teeth and gums in hydrochloric acid, leading some women with bulimia nervosa to experience serious dental problems, such as breakdown of enamel and even loss of teeth (Helgeson, 2002; Casper, 1995). Moreover, frequent vomiting or chronic diarrhea (from the use of laxatives) can cause dangerous potassium deficiencies, which may lead to weakness, intestinal disorders, kidney disease, or heart damage (Turner et al., 2000; Halmi et al., 1994). What Causes Eating Disorders? •multidimensional risk perspective• A theory that identifies several kinds of risk factors that are thought to combine to help cause a disorder.The more factors present, the greater the risk of developing the disorder. Most of today’s theorists and researchers use a multidimensional risk perspective to explain eating disorders. That is, they identify several key factors that place individuals at risk for these disorders (Rousset et al., 2004; Lyon et al., 1997). The more of these factors that are present, the greater the likelihood that a person will develop an eating disorder.The factors cited most often include sociocultural conditions (societal and family pressures), psychological problems (ego, cognitive, and mood disturbances), and biological factors. COMER CH11_Cb.qxp 3/9/06 1:37 PM Page 319 Eating Disorders 319 Societal Pressures Image courtesy of The Advertising Archives Many theorists believe that the current Western standards of Engage in at least 32% one self-destructive female attractiveness have contributed to increases in eating weight-control 62% disorders (Jambor, 2001). These standards have changed behavior throughout history, with a noticeable shift toward preference for a thin female frame in recent decades (Gilbert et al., 25% Ingest diet pills 2005). One study that tracked the height, weight, and age of 24% contestants in the Miss America Pageant from 1959 through 1978 found an average decline of 0.28 pound per year 14% among the contestants and 0.37 pound per year among winInduce vomiting ners (Garner et al., 1980).The researchers also examined data 26% on all Playboy magazine centerfold models over the same time period and found that the average weight, bust, and hip 16% measurements of these women had decreased steadily. More Use laxatives recent studies of Miss America contestants and Playboy cen7% terfolds indicate that these trends have continued (Rubinstein & Caballero, 2000;Wiseman et al., 1992). 5% Because thinness is especially valued in the subcultures of Use diuretics All female athletes 12% fashion models, actors, dancers, and certain athletes, members Female gymnasts of these groups are likely to be particularly concerned about their weight (Taylor & Ste-Marie, 2001). As sociocultural Percentage Who Display Behavior theorists would predict, studies have found that people in these professions are more prone than others to eating disorders (Thompson & Sherman, 2005, 1999). In fact, many famous young women from these figure 11-3 Dangerous shortcuts According to surveys, in sports ranging from field hockey to gymfields have publicly acknowledged grossly disordered eating patterns in recent years. One nastics, numerous female athletes engage in one or survey of 1,443 athletes at 10 colleges around the United States revealed that more than more self-destructive behaviors to control their 9 percent of female college athletes suffer from an eating disorder and another 50 percent weight (Taylor & Ste-Marie, 2001). One study found that close to two-thirds of female college gymnasts admit to eating behaviors that put them at risk for such disorders (Johnson, 1995). A full engage in at least one such behavior. (Adapted from 20 percent of the gymnasts surveyed had an eating disorder (see Figure 11-3). Rosen & Hough, 1988; Rosen et al., 1986.) Attitudes toward thinness may also help explain economic and racial differences in the rates of eating disorders (see Box 11-3 on the next page). In the past, white American women in the upper socioeconomic classes expressed more concern about thinness and dieting than African American women or white American women of the lower socioeconomic classes (Margo, 1985; Stunkard, 1975). Correspondingly, eating disorders were more common among white American women higher on the socioeconomic scale (Foreyt et al., 1996; Rosen et al., 1991). In more recent years, however, dieting and preoccupation with thinness have increased to some degree in all classes and minority groups, as has the prevalence of eating disorders (Germer, 2005; StriegelMoore et al., 2005). The ad! An advertising campaign that created an enormous stir in 2005 was the “Dove girls” ad. The manufacturer of Dove Firming products recruited six young women with no prior modeling experience, had them pose in their underwear, and displayed the ad in magazines and on billboards across the country. Many people praised Dove for “courageously” using less than perfectly shaped women in the ad, while others had a decidedly less positive reaction. The point that both sides overlooked is that the women, while not ultra-thin models, were far from overweight, with dress sizes ranging from 6 to 12 (the average American woman is size 14). Thus, the controversy reflected once again the predominant belief in Western society that extreme—typically unattainable—thinness is the aesthetic ideal for women. COMER CH11_Cb.qxp 320 3/9/06 1:37 PM Page 320 chapter 11 [ BOX 11-3 ] Sociocultural Landscape: Is Body Image a Matter of Race? I n the popular 1995 movie Clueless, Cher and Dionne, wealthy teenage friends of different races, have similar tastes, beliefs, and values about everything from boys to schoolwork. In particular, they have the same kinds of eating habits and beauty ideals, and they are even similar in weight and physical form. But does the story of these young women reflect the realities of white and African American females in our society? In the early 1990s, the answer to this question appeared to be a resounding no. Most studies conducted up to the time of the movie’s release indicated that the eating behaviors, values, and goals of young African American women were considerably healthier than those of young white American women (Lovejoy, 2001; Cash & Henry, 1995; Parker et al., 1995). However, it turns out that the movie and the later television show of the same name were in fact clued in to changes ocurring in the United States. Most studies conducted since 1995 suggest that African American women, as well as women of other minority groups, are becoming more and more like white American women in their worries about weight and appearance, their inclination to diet, and their vulnerability to eating disorders. Let’s look first at the situation before 1995 and then at the clinical picture that has been unfolding since then. pre-1995 A widely publicized 1995 study at the University of Arizona offered findings and conclusions consistent with other research in the early 1990s (Parker et al., 1995). The study found that the eating behaviors and attitudes of young African American women were more positive than those of young white American women. It found, specifically, that nearly 90 percent of the white respondents were dissatisfied with their weight and body shape, compared to around 70 percent of the African American teens. The African American teens expressed satisfaction regardless of their actual weight; even those who were overweight described themselves as happy. The study also suggested that white and African American adolescent girls had very different ideals of beauty. The white teens, asked to define the “perfect girl,” described a girl of 5Ј7Љ weighing between 100 and 110 pounds—proportions that mirror those of so-called supermodels. Attaining a perfect weight, many said, was the key to being “totally happy,” and they indicated that thinness was a requirement for popularity. In contrast, the African American respondents tended to emphasize personality traits over physical characteristics when they described the ideal girl. They defined the “perfect” African American girl as smart, fun, easy to talk to, not conceited, and funny; she did not necessarily need to be “pretty,” as long as she was well groomed. The body dimensions the African American teens described were more attainable for the typical girl; they favored fuller hips, for example. In addition, two-thirds of them defined beauty as “the right attitude.” Given such definitions of beauty, it was not surprising that the African American subjects were less likely than the white American respondents to diet for extended periods. Despite the findings of this and related studies in the early 1990s, the University of Arizona investigators and other clinical theorists warned that problems might lie ahead for young African American women in the areas of self-image and eating behaviors. They observed, “It remains to be seen whether they will be able to maintain these self-perceptions. . . . [They] may be more likely to deemphasize their black identities in order to get ahead. . . . Will this translate into body discipline in the form of dieting to obtain a thin body by girls who aspire to make it?” (Parker et al., 1995, p. 111). post-1995 Unfortunately, the concerns of the University of Arizona investigators seem to have been borne out in the years since their study. Research conducted over the past decade suggests that body image concerns, dysfunctional eating patterns, and eating disorders are on the upswing among young African American women as well as among women of other minority groups. Here are some of the most striking findings: Surveys conducted by Essence, the largest-circulation African American magazine, and by several teams of researchers have found that African American women today have about the same risk for developing eating disorders as white American women, along with similar attitudes regarding body image, weight, and eating (Walcott et al., 2003; Mulholland & Mintz, Cultural differences may also help explain the striking gender gap for eating disorders. Our society’s emphasis on a thin appearance is aimed at women much more than men. Some theorists believe that this double standard has made women much more inclined to diet and more prone to eating disorders (Cole & Daniel, 2005; Rand & Kuldau, 1991). Western society not only glorifies thinness but creates a climate of prejudice against overweight people.Whereas slurs based on ethnicity, race, and gender are considered unacceptable, cruel jokes about obesity are standard fare on television and in movies, books, COMER CH11_Cb.qxp 3/9/06 1:38 PM Page 321 Courtesy of Everett Collection Eating Disorders Fact or fiction? In the movie Clueless, best friends Dionne and Cher think, act, dress, and look alike and hold identical values and concerns. Here they talk to each other on cell phones while walking side by side. 2001; Pumariega et al., 1994). In the Essence survey, 65 percent of African American respondents reported dieting behavior, 39 percent said that food controlled their lives, 19 percent avoided eating when hungry, 17 percent used laxatives, and 4 percent vomited to lose weight. African American women may be at particular risk for binge eating. In one study, African American women reported more bingeing than did white American women when they tried to lose weight through extreme methods (Striegel-Moore et al., 2000). Many African American subjects also reported using overeating to fill an emotional void in their lives, to cope with hardships such as racism, and to deal with fear and anger in their daily lives. In a study of more than 2,000 girls aged 9 to 10 years, 40 percent of the respondents—African American and white American subjects in equal measure—reported wanting to lose weight (Schreiber et al., 1996). The shift in the eating behaviors and eating problems of African American women appears to be partly related to their acculturation (Striegel-Moore & Smolak, 1997). One study compared African and magazines (Gilbert et al., 2005). Research indicates that the prejudice against obese people is deep-rooted (Tiggeman & Wilson-Barrett, 1998). Prospective parents who were shown pictures of a chubby child and a medium-weight or thin child rated the former as less friendly, energetic, intelligent, and desirable than the latter. In another study, preschool children who were given a choice between a chubby and a thin rag doll chose the thin one, although they could not say why. It is small wonder that as many as half of elementary school girls have tried to lose weight and 61 percent of middle school girls are currently dieting (Stewart, 2004; Shisslak et al., 1998; Hunnicut & Newman, 1993). American women at a predominately white university with those at a predominately African American university. Those at the former school had significantly higher depression scores, and those scores were positively correlated with eating problems (Ford, 2000). Studies indicate that Hispanic American women also engage in disordered eating behaviors and express body dissatisfaction at rates similar to those of white American women (Germer, 2005; Granillo et al., 2005). Moreover, one study found that Hispanic American subjects who were dissatisfied with their weight tended to display more severe binge-eating behavior than white American or African American subjects with similar concerns (Fitzgibbon et al., 1998). Eating disorders also appear to be on the increase among young Asian American women and young women in several Asian countries (Pike & Borovoy, 2004; Walcott et al., 2003; Efron, 1997). Indeed, a study in Taiwan surveyed 843 schoolgirls, aged 10 to 14 years, and found that 8 percent were severely underweight and 10 percent were somewhat underweight (Wong & Huang, 2000). Around 65 percent of the underweight girls nevertheless wished they were thinner. Altogether, 38 percent of the participants had intentionally tried to lose weight, including 13 percent of underweight girls and 35 percent of girls whose weight was appropriate for their height. Clearly the “protections” of race or culture that once seemed to operate in the realms of weight control and eating disorders no longer apply. 321 COMER CH11_Cb.qxp 1:38 PM Page 322 chapter 11 Donna Terek, Michigan magazine, The Detroit News/Free Press 322 3/9/06 Family Environment Pierre August Renoir, Seated Bather, 1903–1906, Detroit Institute of the Arts, bequest of Robert H. Tannahill Models and mannequins Mannequins were once made extra-thin to show the lines of the clothing for sale to best advantage. Today the shape of the ideal woman is indistinguishable from that of a mannequin, and a growing number of young women try to achieve this ideal. Families may play an important role in the development of eating disorders (Reich, 2005; Moorhead et al., 2003). Research suggests that as many as half of the families of people with eating disorders have a long history of emphasizing thinness, physical appearance, and dieting. In fact, the mothers in these families are more likely to diet themselves and to be generally perfectionistic than are the mothers in other families (Woodside et al., 2002; Pike & Rodin, 1991). Abnormal interactions and forms of communication within a family may also set the stage for an eating disorder (Reich, 2005;Vidovic et al., 2005). Family systems theorists argue that the families of people who develop eating disorders are often dysfunctional to begin with and that the eating disorder of one member is a reflection of the larger problem (Rowa et al., 2001). The influential family theorist Salvador Minuchin, for example, believes that what he calls an enmeshed family pattern often leads to eating disorders (Minuchin, Rosman, & Baker, 1978). In an enmeshed system, family members are overinvolved in each other’s affairs and overconcerned with the details of each other’s lives. On the positive side, enmeshed families can be affectionate and loyal. On the negative side, they can be cling and foster dependency. Parents are too involved in the lives of their children, allowing little room for individuality and independence. Minuchin argues that adolescence poses a special problem for these families. The teenager’s normal push for independence threatens the family’s apparent harmony and closeness. In response, the family may subtly force the child to take on a “sick” role—to develop an eating disorder or some other illness.The child’s disorder enables the family to maintain its appearance of harmony.A sick child needs her family, and family members can rally to protect her. Some case studies have supported such family systems explanations, but systematic research fails to show that particular family patterns consistently set the stage for the development of eating disorders (Wilson et al., 2003, 1996). In fact, the families of people with either anorexia nervosa or bulimia nervosa vary widely. Ego Deficiencies and Cognitive Disturbances Hilde Bruch, a pioneer in the study and treatment of eating disorders, developed a theory built on both psychodynamic and cognitive notions. She argued that disturbed mother–child interactions lead to serious ego deficiencies in the child (including a poor sense of independence and control) and to severe cognitive disturbances that jointly help produce disordered eating patterns (Bruch, 2001, 1991, 1983, 1962). According to Bruch, parents may respond to their children either effectively or ineffectively. Effective parents accurately attend to their children’s biological and emotional needs, giving them food when they are crying from hunger and comfort when they are crying out of fear. Ineffective parents, by contrast, fail to attend to their children’s needs, deciding that their children are hungry, cold, or tired without correctly interpreting the children’s actual condition.They may feed the children at times of anxiety rather than hunger, or comfort them at times of tiredness rather than anxiety. Children who receive such parenting may grow up confused and unaware of their own internal needs, not knowing for themselves when they are hungry or full and unable to identify their own emotions. Changing times Seated Bather, by Pierre-Auguste Renoir (1841–1919), shows that the aesthetically ideal woman of the past was considerably larger than today’s ideal. COMER CH11_Cb.qxp 3/9/06 1:38 PM Page 323 Eating Disorders Unable to rely on internal signals, these children turn instead to external guides, such as their parents. They seem to be “model children,” but they fail to develop genuine self-reliance and “experience themselves as not being in control of their behavior, needs, and impulses, as not owning their own bodies” (Bruch, 1973, p. 55).Adolescence increases their basic desire to establish independence, yet they feel unable to do so. To overcome their sense of helplessness, they seek excessive control over their body size and shape and over their eating habits. Helen, an 18-year-old, describes her experience: 323 family pattern•A family system in which members are overinvolved with each other’s affairs and overconcerned about each other’s welfare. •enmeshed There is a peculiar contradiction—everybody thinks you’re doing so well and everybody thinks you’re great, but your real problem is that you think that you are not good enough. You are afraid of not living up to what you think you are expected to do. You have one great fear, namely that of being ordinary, or average, or common—just not good enough. This peculiar dieting begins with such anxiety. You want to prove that you have control, that you can do it. The peculiar part of it is that it makes you feel good about yourself, makes you feel “I can accomplish something.” It makes you feel “I can do something nobody else can do.” (Bruch, 1978, p. 128) Clinical reports and research have provided some support for Bruch’s theory (Pearlman, 2005). Clinicians have observed that the parents of teenagers with eating disorders do tend to define their children’s needs rather than allow the children to define their own needs (Ihle et al., 2005; Steiner et al., 1991).When Bruch interviewed the mothers of 51 children with anorexia nervosa, many proudly recalled that they had always “anticipated” their young child’s needs, never permitting the child to “feel hungry” (Bruch, 1973). Research has also supported Bruch’s belief that people with eating disorders perceive internal cues, including emotional cues, inaccurately (Bydlowski et al., 2005; Speranza et al., 2005). When subjects with an eating disorder are anxious or upset, for example, many of them mistakenly think they are also hungry (see Figure 11-4), and they respond as they might respond to hunger—by eating. Finally, studies support Bruch’s argument that people with eating disorders rely excessively on the opinions, wishes, and views of others.They are more likely than other people to worry about how 69% Boredom 23% 47% Feeling That Triggers Eating Depression 29% 44% Anxiety 33% Eat junk food Eat nutritional food only 36% Love 35% 33% Happiness 53% Selfconfidence 23% figure 11-4 When do people seek junk food? 62% Percentage Who Eat the Food Apparently, when they feel bad. People who eat junk food when they are feeling bad outnumber those who eat nutritional food under similar circumstances. In contrast, more people seek nutritional food when they are feeling good. (Adapted from Lyman, 1982.) COMER CH11_Cb.qxp 1:38 PM Page 324 chapter 11 Courtesy of Everett Collection 324 3/9/06 others view them, to seek approval, to be conforming, and to feel a lack of control over their lives (Button & Warren, 2001;Walters & Kendler, 1995). Mood Disorders Unfair game As we are reminded by one of the leading characters in the highly successful film Austin Powers 2: The Spy Who Shagged Me, overweight people in Western society are typically treated with insensitivity. They are the targets of humor in magazines, books, television shows, and movies. >>BY THE NUMBERS Weighing In 5% Percentage of Americans who weigh themselves more than once per day << 8% Those who weigh in once per day << 10% Those who weigh in twice per week << 36% Those who weigh themselves twice per month << 75% Percentage of scale-checkers who are women << (Kanner, 1995) Many people with eating disorders, particularly those with bulimia nervosa, experience symptoms of depression (Speranza et al., 2005; LeGrange & Lock, 2002). This finding has led some theorists to suggest that mood disorders set the stage for eating disorders. Their claim is supported by four kinds of evidence. First, many more people with an eating disorder qualify for a clinical diagnosis of major depressive disorder than do people in the general population (Duncan et al., 2005; Brewerton et al., 1995). Second, the close relatives of people with eating disorders seem to have a higher rate of mood disorders than do close relatives of people without such disorders (Moorhead et al., 2003;APA, 2000).Third, as we shall see, many people with eating disorders, particularly bulimia nervosa, have low activity of the neurotransmitter serotonin, similar to the serotonin abnormalities found in depressed people. And finally, people with eating disorders are often helped by some of the same antidepressant drugs that reduce depression. Although such findings suggest that depression may be linked to eating disorders, other explanations are possible (Stice & Bearman, 2001). For example, the pressure and pain of having an eating disorder may cause a mood disorder.Whatever the correct interpretation, many people struggling with eating disorders also suffer from depression, among other psychological problems. Biological Factors Biological theorists suspect that certain genes may leave some persons particularly susceptible to eating disorders (Kaplan, 2005; Steiger et al., 2005;Vink et al., 2001). Consistent with this idea, relatives of people with eating disorders are up to six times more likely than other individuals to develop the disorders themselves (Strober et al., 2001, 2000; Gorwood et al., 1998). Moreover, if one identical twin has bulimia nervosa, the other twin also develops the disorder in 23 percent of cases; in contrast, the rate for fraternal twins, who are genetically less similar, is 9 percent (Kendler et al., 1995, 1991).Although such family and twin findings do not rule out environmental explanations, they have encouraged biological researchers to look further still for specific biological causes. One factor that has interested investigators is the possible role of serotonin. Several research teams have found a link between eating disorders and the genes responsible for the production of this neurotransmitter, and still others have measured low serotonin activity in many people with eating disorders (Kuhn et al., 2004; Enoch et al., 1998; Carrasco et al., 2000). Given serotonin’s role in depression and obsessive-compulsive disorder—problems that often accompany eating disorders—it is possible that low serotonin activity has more to do with those other disorders than with the eating disorders per se. On the other hand, perhaps low serotonin activity contributes directly to eating disorders—for example, by causing the body to crave and binge on high-carbohydrate foods (Kaye et al., 2005, 2002, 2000). Some researchers even believe that persons with eating disorders are born with excessively high levels of serotonin activity, which they instinctively try to reduce by starving or purging themselves (Kay et al., 2005, 1998). Other biological researchers explain eating disorders by pointing to the hypothalamus, a part of the brain that regulates many bodily functions (Uher & Treasure, 2005; Leibowitz & Hoebel, 1998). Researchers have located two separate areas in the hypothalamus that help control eating. One, the lateral hypothalamus (LH), consisting of the side areas of the hypothalamus, produces hunger when it is activated.When the LH of a laboratory animal is stimulated electrically, the animal eats, even if it has been fed recently. In contrast, another area, the ventromedial hypothalamus (VMH), consisting of the bottom and middle of the hypothalamus, reduces hunger when it is activated. When the VMH is electrically stimulated, laboratory animals stop eating (Duggan & Booth, 1986) (see Box 11-4 on page 326). These different centers of the hypothalamus are apparently activated by chemicals from the brain and body, depending on whether the person is eating or fasting. One COMER CH11_Cb.qxp 3/9/06 1:38 PM Page 325 such brain chemical is glucagon-like peptide-1 (GLP-1), a natural appetite suppressant. When a team of researchers collected and injected GLP-1 into the brains of rats, the chemical traveled to receptors in the hypothalamus and caused the rats to reduce their food intake almost entirely even though they had not eaten for 24 hours (Turton et al., 1996). Conversely, when “full” rats were injected with a substance that blocked the reception of GLP-1 in the hypothalamus, they more than doubled their food intake. Some researchers believe that the LH and VMH and chemicals such as GLP-1, working together, comprise a “weight thermostat” of sorts in the body, responsible for keeping an individual at a particular weight level called the weight set point (Hallschmid et al. 2004; Garner et al., 1985; Keesey & Corbett, 1983). Genetic inheritance and early eating practices seem to determine each person’s weight set point. When a person’s weight falls below his or her particular set point, the LH is activated and seeks to restore the lost weight by producing hunger and lowering the body’s metabolic rate, the rate at which the body expends energy. When a person’s weight rises above his or her set point, the VMH is activated, and it seeks to remove the excess weight by reducing hunger and increasing the body’s metabolic rate. According to the weight set point theory, when people diet and fall to a weight below their weight set point, their brain starts trying to restore the lost weight. Hypothalamic activity produces a preoccupation with food and a desire to binge. It also triggers bodily changes that make it harder to lose weight and easier to gain weight, however little is eaten (Spalter et al., 1993; Hill & Robinson, 1991). Once the brain and body begin conspiring to raise weight in this way, dieters actually enter into a battle against themselves. Some people apparently manage to shut down the inner “thermostat” and control their eating almost completely.These people move toward restrictingtype anorexia nervosa. For others, the battle spirals toward a binge-purge pattern. Although the weight set point explanation has received considerable debate in the clinical field, it remains widely accepted by theorists and practitioners (Pinel et al., 2000). 325 Richard Howard ©1991 Discover Eating Disorders Laboratory obesity By electrically stimulating parts of a rodent’s hypothalamus, researchers can induce overeating and massive weight gain. How Are Eating Disorders Treated? Today’s treatments for eating disorders have two goals.The first is to correct as quickly as possible the dangerous eating pattern. The second is to address the broader psychological and situational factors that have led to and now maintain the eating problem. Family and friends can also play an important role in helping to overcome the disorder. Treatments for Anorexia Nervosa The immediate aims of treatment for anorexia nervosa are to help individuals regain their lost weight, recover from malnourishment, and eat normally again.Therapists must then help them to make psychological and perhaps family changes to lock in those gains. How Are Proper Weight and Normal Eating Restored? A variety of treatment methods are used to help patients with anorexia nervosa gain weight quickly and return to health within weeks. In the past, treatment almost always took place in a hospital, but now it is often offered in outpatient settings (Gowers et al., 2000; Pyle, 1999). In life-threatening cases, clinicians may need to force tube and intravenous feedings on a patient who refuses to eat (Tyre, 2005). Unfortunately, this use of force may breed distrust in the patient (Robb et al., 2002;Treasure,Todd, & Szmuckler, 1995). In contrast, behavioral weight-restoration approaches have clinicians use rewards whenever patients eat properly or gain weight and offer no rewards when they eat improperly or fail to gain weight (Tacon & Caldera, 2001; Griffiths et al., 1998). Perhaps the most popular weight-restoration technique of recent years has been a combination of supportive nursing care, nutritional counseling, and a relatively highcalorie diet (Sorrentino et al., 2005; Roloff, 2001; Treasure et al., 1995). Here nurses gradually increase a patient’s diet over the course of several weeks to more than 2,500 calories a day (Herzog et al., 2004).The nurses educate patients about the program, track their progress, provide encouragement, and help them recognize that their weight gain •hypothalamus•A part of the brain that helps regulate various bodily functions, including eating and hunger. •lateral hypothalamus (LH)•A brain region that produces hunger when activated. •ventromedial hypothalamus (VMH)•A brain region that depresses hunger when activated. •weight set point•The weight level that a person is predisposed to maintain, controlled in part by the hypothalamus. COMER CH11_Cb.qxp 1:38 PM Page 326 chapter 11 [ BOX 11-4 ] Obesity: To Lose or Not to Lose B y medical standards, one-third of adults in the United States and Canada weigh at least 20 percent more than people of their height should (Birmingham & Jones, 2003; Stice, 2002). In fact, despite the public’s focus on thinness, obesity has become increasingly common in these and many other countries (Johnston, 2004). Being overweight is not a mental disorder, nor in most cases is it the result of abnormal psychological processes. Nevertheless, it causes great anguish, and not just because of its physical effects. The media, people on the streets, and even many health professionals treat obesity as shameful. Obese people are often the unrecognized victims of discrimination in efforts to gain admission to college, jobs, and promotions (Rothblum, 1992). Mounting evidence indicates that overweight persons are not to be sneered at as weak and that obesity results from multiple factors. First, genetic and biological factors seem to play large roles. Researchers have found that children of obese biological parents are more likely to be obese than children whose biological parents are not obese, whether or not the people who raise those children are obese (Stunkard et al., 1986). Other researchers have identified several genes that seem to be linked to obesity (Nagle et al., 1999; Halaas et al., 1995). And still others have identified chemicals in the body, including a hormone called leptin and a protein called glucagon-like peptide-1 (GLP-1), that apparently act as natural appetite suppressants (Costa et al., 2002; Tartaglia et al., 1995). Suspicion is growing that the brain receptors for these chemicals may be defective in overweight persons. Environment also plays a causal role in obesity. Studies have shown that people eat Never too young? A Head Start teacher leads two preschoolers in a yoga exercise as part of a pilot program aimed at preventing childhood obesity. is under control and will not lead to obesity. Studies find that patients in nursing-care programs usually gain the necessary weight over 8 to 12 weeks (Treasure et al., 1995). How Are Lasting Changes Achieved? Clinical researchers have found that individuals with anorexia nervosa must overcome their underlying psychological problems in order to achieve lasting improvement.Therapists typically provide both therapy and education to achieve this broader goal, using a combination of individual, group, and family approaches (Hechler et al., 2005; Kalodner & Coughlin, 2004). building independence and self-awareness One focus of treatment is to help patients with anorexia nervosa recognize their need for independence and teach them more appropriate ways to exercise control (Dare & Crowther, 1995; Robin et al., 1995). Therapists may also teach them to better identify and trust their internal sensations and feelings (Kaplan & Garfinkel, 1999). In the following session, a therapist tries to help a 15-year-old client recognize and share her feelings: Patient: Therapist: Patient: Therapist: I don’t talk about my feelings; I never did. Do you think I’ll respond like others? What do you mean? I think you may be afraid that I won’t pay close attention to what you feel inside, or that I’ll tell you not to feel the way you do—that it’s Frank Franklin II/AP Photo 326 3/9/06 COMER CH11_Cb.qxp 3/9/06 2:45 PM Page 327 Eating Disorders more when they are in the company of others, particularly if the other people are eating (Logue, 1991). In addition, research finds that people in low socioeconomic environments are more likely to be obese than those of high socioeconomic background (Ernst & Harlan, 1991). health risk? Do mildly to moderately obese people have a greater risk of coronary disease, cancer, or other disease? Investigations into this question have produced conflicting results (Bender et al., 1999; Lean, Han, & Seidell, 1999). One long-term study found that while moderately overweight subjects had a 30 percent higher risk of early death, underweight subjects had a low likelihood of dying at an early age as long as their thinness could not be attributed to smoking or illness (Manson et al., 1995). However, another study found that the mortality rate of underweight subjects was as high as that of overweight subjects regardless of smoking behavior or illness (Troiano et al., 1996). These findings suggest that the jury is still out on this issue. Patient: Therapist: Patient: Therapist: does dieting work? There are scores of diets and diet pills. There is almost no evidence, however, that any diet yet devised can ensure longterm weight loss (Wilson, 1994). In fact, long-term studies reveal a rebound effect, a net gain in weight in obese people who have lost weight on very low-calorie diets. Research also suggests that the feelings of failure that accompany diet rebounds may lead to dysfunctional eating patterns, including binge eating (Venditti et al., 1996). Efforts are now under way to develop new kinds of drugs that will operate directly on the genes, hormones, proteins, and brain regions that have been linked to obesity (Marchione, 2005; Carek & Dickerson, 1999). Theoretically, these drugs will counteract the bodily reactions that undermine efforts at dieting. Whether such interventions can provide safe and permanent weight loss remains to be seen. what is the proper goal? Some researchers argue that attempts to reduce obesity should focus less on weight loss and more on improving gen- 327 eral health and attitudes (Painot et al., 2001; Rosen et al., 1995). If poor eating habits can be corrected, if a poor selfconcept and distorted body image can be improved, and if overweight people can be educated about the myths and truths regarding obesity, perhaps everyone will be better off. Most experts agree that extreme obesity is indeed a clear health hazard and that weight loss is advisable in such cases. For these individuals, the most promising path to long-term weight loss may be to set realistic, attainable goals rather than unrealistic ideals (Brownell & O’Neil, 1993; Brownell & Wadden, 1992). As for people who are mildly and even moderately overweight, a growing number of experts now suggest that perhaps they should be left alone, or, at the very least, encouraged to set more modest and realistic goals (Butryn & Wadden, 2005). In addition, it is critical that the public overcome its prejudice against people who are overweight and come to appreciate that obesity is, at worst, a problem that requires treatment, and perhaps simply another version of the normal human condition. foolish to feel frightened, to feel fat, to doubt yourself, considering how well you do in school, how you’re appreciated by teachers, how pretty you are. (Looking somewhat tense and agitated) Well, I was always told to be polite and respect other people, just like a stupid, faceless doll. (Affecting a vacant, doll-like pose) Do I give you the impression that it would be disrespectful for you to share your feelings, whatever they may be? Not really; I don’t know. I can’t, and won’t, tell you that this is easy for you to do. . . . But I can promise you that you are free to speak your mind, and that I won’t turn away. (Strober & Yager, 1985, pp. 368–369) >>LAB•NOTES Upsetting Ads correcting disturbed cognitions Another focus of treatment is to help people with anorexia nervosa change their attitudes about eating and weight (McFarlane, Carter, & Olmsted, 2005; Garner & Magana, 2002) (see Table 11-4 on the next page). Using cognitive approaches, therapists may guide clients to identify, challenge, and change maladaptive assumptions, such as “I must always be perfect” or “My weight and Immediately after looking at ads in fashion magazines and the models in those ads, undergraduate female subjects showed a greater rise in depression and hostility than did women exposed to ads without pictures of people (Pinhas et al., 1999). << COMER CH11_Cb.qxp 328 3/9/06 1:38 PM Page 328 chapter 11 Table 11-4 Sample Items from the Eating Disorder Inventory For each item, decide if the item is true about you ALWAYS (A), USUALLY (U), OFTEN (O), SOMETIMES (S), RARELY (R), or NEVER (N). Circle the letter that corresponds to your rating. A U O S R N I think that my stomach is too big. A U O S R N I eat when I am upset. A U O S R N I stuff myself with food. A U O S R N I think about dieting. A U O S R N I think that my thighs are too large. A U O S R N I feel extremely guilty after overeating. A U O S R N I am terrified of gaining weight. A U O S R N I get confused about what emotion I am feeling. A U O S R N I feel inadequate. A U O S R N I have gone on eating binges where I felt that I could not stop. A U O S R N I have trouble expressing my emotions to others. A U O S R N I get confused as to whether or not I am hungry. A U O S R N I think my hips are too big. A U O S R N If I gain a pound, I worry that I will keep gaining. A U O S R N I have the thought of trying to vomit in order to lose weight. A U O S R N I think my buttocks are too large. A U O S R N I eat or drink in secrecy. A U O S R N I would like to be in total control of my bodily urges. Source: Garner, 2005; Garner, Olmsted, & Polivy, 1991, 1984. shape determine my value” (Lask & Bryant-Waugh, 2000; Freeman, 1995). Therapists may also educate clients about the body distortions typical of anorexia nervosa and help them see that their own assessments of their size are incorrect (Wegner & Wegner, 2001). Even if a client never learns to judge her body shape accurately, she may at least reach a point where she says, “I know that a key feature of anorexia nervosa is a misperception of my own size, so I can expect to feel fat regardless of my actual size.” >>IN THEIR WORDS “Girls should be encouraged to take an interest in their appearance when they are very young.” << Ladies’ Home Journal, 1940 “All philosophy in two words—sustain and abstain.” << Epictetus (A.D. c. 55–c. 135) “To be born woman is to know—Although they do not speak of it at school—Women must labor to be beautiful.” << W. B.Yeats changing family interactions Family therapy is often part of the treatment program for anorexia nervosa (Lock & le Grange, 2005; Reich, 2005).As in other family therapy situations, the therapist meets with the family as a whole, points out troublesome family patterns, and helps the members make appropriate changes. In particular, family therapists may try to help the person with anorexia nervosa separate her feelings and needs from those of other family members. Although the role of family in the development of anorexia nervosa is not yet clear, research strongly suggests that family therapy (or at least parent counseling) can be helpful in the treatment of this disorder (McDermott & Jaffa, 2005; Robin, 2003). Mother: I think I know what [Susan] is going through: all the doubt and insecurity of growing up and establishing her own identity. (Turning to the patient, with tears) If you just place trust in yourself, with the support of those around you who care, everything will turn out for the better. Therapist: Are you making yourself available to her? Should she turn to you, rely on you for guidance and emotional support? COMER CH11_Cb.qxp 3/9/06 1:38 PM Page 329 Eating Disorders Mother: Well, that’s what parents are for. Therapist: (Turning to patient) What do you think? Susan: (To mother) I can’t keep depending on you, Mom, or everyone else. That’s what I’ve been doing, and it gave me anorexia. . . . Therapist: Do you think your mom would prefer that there be no secrets between her and the kids—an open door, so to speak? Older sister: Sometimes I do. Therapist: (To patient and younger sister) How about you two? Susan: Yeah. Sometimes it’s like whatever I feel, she has to feel. Younger sister: Yeah. (Strober & Yager, 1985, pp. 381–382) What Is the Aftermath of Anorexia Nervosa? The use of combined treat- 329 >>LOOKING AROUND The Lure of “Ana” Eating disorder specialists are concerned about a widespread underground movement that actively promotes self-starvation, often using the fictitious character “Ana” to give advice on the Web about what to eat and to mock people who do not lose weight. Many followers of Ana (short for anorexia) wear red Ana bracelets, follow the “Ana creed” of control and self-starvation, and offer each other words of “thinspiration” on Web pages and blogs. A Stanford University survey of teens with eating disorders found that 40 percent had visited Web sites that promote eating disorders (Irvine, 2005). << Les Stone/Sygma ment approaches has greatly improved the outlook for people with anorexia nervosa, although the road to recovery can be difficult and research findings are sometimes mixed (Fairburn, 2005).The course and outcome of this disorder vary from person to person, but researchers have noted certain trends. On the positive side, weight is often quickly restored once treatment for the disorder begins (McDermott & Jaffa, 2005), and treatment gains may continue for years (Haliburn, 2005; Ro et al., 2005). In one study, 83 percent of patients continued to show improvement when they were interviewed several years or more after their initial recovery: around 33 percent were fully recovered and 50 percent partially improved (Herzog et al., 1999; Treasure et al., 1995). Other studies have found that most individuals perform effectively at their jobs and express job satisfaction years after their recovery (Fombonne, 1995;Theander, 1970). Another positive note is that most females with anorexia nervosa menstruate again when they regain their weight (Fombonne, 1995; Crisp, 1981), and other medical improvements follow (Iketani et al., 1995). Also encouraging is that the death rate from anorexia nervosa seems to be declining (Neumarker, 1997;Treasure & Szmukler, 1995). Earlier diagnosis and safer and faster weight-restoration techniques may account for this trend. Deaths that do occur are usually caused by suicide, starvation, infection, gastrointestinal problems, or electrolyte imbalance. On the negative side, close to 20 percent of persons with anorexia nervosa remain seriously troubled for years (Haliburn, 2005; Steinhausen, 2002; APA, 2000). Furthermore, recovery, when it does occur, is not always permanent (Richard et al., 2005). Anorexic behavior recurs in at least one-third of recovered patients, usually triggered by new stresses, such as marriage, pregnancy, or a major relocation (Fennig et al., 2002; Lay et al., 2002). Even years later, many recovered individuals continue to express concerns about their weight and appearance. Some continue to restrict their diets to a degree, Harmful advertising When Calvin Klein posed young teenagers in sexually suggestive clothing ads in 1995, the public protested and the ads were halted. However, what some researchers consider even more damaging—the use of very thin young models who influence the body ideals and dietary habits of millions of teenage girls—continued uninterrupted. COMER CH11_Cb.qxp 1:38 PM Page 330 chapter 11 Lara Jo Regan/The Gamma Liaison Network 330 3/9/06 Daily record A teenager with anorexia nervosa writes in her journal as part of an inpatient treatment program. The writing helps her identify the fears, emotions, and needs that have contributed to her disorder. experience anxiety when they eat with other people, or hold some distorted ideas about food, eating, and weight (Fichter & Pirke, 1995). About half of those who have suffered from anorexia nervosa continue to experience certain emotional problems—particularly depression, social anxiety, and obsessiveness—years after treatment. Such problems are particularly common in those who have not succeeded in reaching a fully normal weight (Steinhausen, 2002; Halmi, 1995). The more weight persons have lost and the more time that has passed before they entered treatment, the poorer the recovery rate (Richard, 2005; Finfgeld, 2002). Individuals who had psychological or sexual problems before the onset of the disorder tend to have a poorer recovery rate than those without such a history (Finfgeld, 2002; Lewis & Chatoor, 1994). Teenagers seem to have a better recovery rate than older patients (Richard, 2005; Steinhausen et al., 2000). Females have a better recovery rate than males. Treatments for Bulimia Nervosa Treatment programs for bulimia nervosa are often offered in eating disorder clinics. Such programs share the immediate goal of helping clients to eliminate their binge-purge patterns and establish good eating habits and the more general goal of eliminating the underlying causes of bulimic patterns. The programs emphasize education as much as therapy (Davis et al., 1997; Button, 1993). Like programs for anorexia nervosa, they often combine several treatment strategies, including individual insight therapy, behavioral therapy, antidepressant drug therapy, and group therapy (Wilson, 2005; Narash et al., 2002;Tobin, 2000). Individual Insight Therapy The insight approach that is now receiving the most >>LOOKING BACK Saintly Restraint During the Middle Ages, restrained eating, prolonged fasting, or purging by a number of female saints was greatly admired and was even counted among their miracles. Catherine of Siena sometimes pushed twigs down her throat to bring up food; Mary of Oignes and Beatrice of Nazareth vomited from the mere smell of meat; and Columba of Rieti died of self-starvation (Brumberg, 1988). << attention in cases of bulimia nervosa is cognitive therapy, which tries to help clients recognize and change their maladaptive attitudes toward food, eating, weight, and shape (McFarlane et al., 2005; Wilson, 2005; Mitchell et al., 2002). Cognitive therapists typically teach the individuals to identify and challenge the negative thoughts that regularly precede their urge to binge—“I have no self-control,”“I might as well give up,”“I look fat” (Fairburn, 1985).They may also guide clients to recognize, question, and eventually change their perfectionistic standards, sense of helplessness, and low self-concept (see Box 11-5). Cognitive therapy seems to help as many as 65 percent of patients to stop bingeing and purging (Mitchell et al., 2002). Because of its effectiveness in the treatment of bulimia nervosa, cognitive therapy is often tried first, before other individual insight therapies are considered. If clients do not respond to the cognitive approach, approaches with promising but less impressive track records may then be tried. A common alternative is interpersonal psychotherapy, the treat- COMER CH11_Cb.qxp 3/9/06 1:38 PM Page 331 Eating Disorders 331 [ BOX 11-5 ] And She Lived Happily Ever After? Marcus/Sipa Press I n May 1996 Alicia Machado, a 19-year-old woman from Venezuela, was crowned Miss Universe. Then her problems began. During the first eight months of her reign, her weight rose from 118 to 160 pounds, angering pageant officials and sparking rumors that she was about to be relieved of her crown. The “problem” received broad newspaper and television coverage and much ridicule on talk radio programs around the world. Ms. Machado explained, “I was a normal girl, but my life has had big changes. I travel to many countries, eat different foods.” Nevertheless, in response to all the pressure, she undertook a special diet and an extensive exercise program to lose at least some of the weight she had gained. Her trainer claimed that a weight of 118 pounds was too low for her frame and explained that she had originally attained it by taking diet pills. In the meantime, the whole episode served to demonstrate once again the powerful role of society in defining female beauty, acceptable weight, and “proper” eating. Ironically, many of the individuals who harshly criticized Ms. Machado or made fun of her—that is, the female critics—are themselves victims of the demanding and unrealistic standards of Western cultures that drive so many individuals toward dysfunctional patterns of eating. ment that seeks to improve interpersonal functioning (Phillips et al., 2003; Mitchell et al., 2002).A number of clinicians also suggest self-care manuals for clients, which describe numerous education and treatment strategies for sufferers (Wilson, 2005; Palmer et al., 2002). Psychodynamic therapy has also been used in cases of bulimia nervosa, but only a few research studies have tested and supported its effectiveness (Valbak, 2001; Zerbe, 2001). nervosa, particularly as a supplement to cognitive therapy (Wilson, 2005; Mizes & Bonifazi, 2002). Clients may, for example, be asked to keep diaries of their eating behavior, changes in sensations of hunger and fullness, and the ebb and flow of other feelings (Latner & Wilson, 2002).This helps them to observe their eating patterns more objectively and recognize the emotions that trigger their desire to binge. Some behaviorists use the technique of exposure and response prevention to help break the binge-purge cycle. As we saw in Chapter 5, this approach consists of exposing people to situations that would ordinarily raise anxiety and then preventing them from performing their usual compulsive responses until they learn that the situations are actually harmless and their compulsive acts unnecessary. For bulimia nervosa, the therapists require clients to eat particular kinds and amounts of food and then prevent them from vomiting, to show that eating can be a harmless and even constructive activity that needs no undoing (Toro et al., 2003; Rosen & Leitenberg, 1985, 1982).Typically the therapist sits with the client during the eating of forbidden foods and stays until the urge to purge New dolls for a new generation After nearly 50 years of Barbie and her extremely thin waistline dominating the doll industry, a number of manufacturers are now introducing very different-looking dolls to the marketplace. The new dolls, such as these “Get Real Girls” dolls, often emphasize fitness and health, multicultural appearance, and sports, business, and other professional roles for females. Observers hope that such products will have a positive effect on the body satisfaction, self-image, and goals of young girls and also help prevent eating disorders. Aynsley Floyd/AP Photo Behavioral Therapy Behavioral techniques are often applied in cases of bulimia COMER CH11_Cb.qxp 1:38 PM Page 332 chapter 11 Eric Young/Winona Daily News/AP Photo LM Otero/AP Photo 332 3/9/06 New efforts at prevention A number of innovative educational programs have been developed in recent years to help promote healthy body images and prevent eating disorders among females ranging from preteens to young adults. (Above) An instructor helps two 11-year-old girls with their stretching exercises as part of “Girls in Motion,” a nutrition and exercise program offered by Southern Methodist University. (Left) A Winona State University freshman swings a maul over her shoulder and into bathroom scales, as part of Eating Disorders Awareness Week. The scale smashing is an annual event. has passed. Studies find that this treatment often helps reduce eating-related anxieties, bingeing, and vomiting (Bulik et al., 1998). Antidepressant Medications During the past decade, antidepressant drugs such as fluoxetine, or Prozac, have been used to help treat bulimia nervosa (Sloan et al., 2004; Mitchell, 2001).According to research, the drugs help as many as 40 percent of patients, reducing their binges by an average of 67 percent and vomiting by 56 percent. Once again, drug therapy seems to work best in combination with other forms of therapy. Alternatively, some therapists wait to see whether cognitive therapy or another insight approach is effective before trying antidepressants (Wilson, 2005; Mitchell et al., 2002). Group Therapy Finally, bulimia nervosa programs now often feature group therapy, including self-help groups to give clients an opportunity to share their concerns and experiences with one another (Kalodner & Coughlin, 2005; Riess, 2002). Group members learn that their disorder is not unique or shameful, and they receive support from one another, along with honest feedback and insights. In the group they can also work directly on underlying fears of displeasing others or being criticized. Research suggests that group therapy is at least somewhat helpful in as many as 75 percent of bulimia nervosa cases, particularly when it is combined with individual insight therapy (Valbak, 2001; McKisack & Waller, 1997). >>Q & A Is prevention possible? Apparently so. In a psychoeducation program, 11- to 13-year-old girls who were extremely worried about gaining weight were taught that female weight gain after puberty is normal and that excessive restriction of food can actually lead to weight gain. The concerns of the girls lessened markedly, in contrast to those of similar subjects who did not receive the instruction (Killen, 1996; Killen et al., 1994). << The Aftermath of Bulimia Nervosa Left untreated, bulimia nervosa can last for years, sometimes improving temporarily but then returning (APA, 2000).Treatment, however, produces immediate, significant improvement in approximately 40 percent of clients: they stop or greatly reduce their bingeing and purging, eat properly, and maintain a normal weight (Richard, 2005).Another 40 percent show a moderate response— at least some decrease in bingeing and purging. As many as 20 percent show little immediate improvement (Keel & Mitchell, 1997; Button, 1993). Follow-up studies suggest that by 10 years after treatment, 89 percent of persons with bulimia nervosa have recovered either fully (70 percent) or partially (19 percent) (Herzog et al., 1999; Keel et al., 1999).Those with partial recoveries continue to have recurrent binges or purges. Relapse can be a problem even among people who respond successfully to treatment (Olmsted et al., 2005; Herzog et al., 1999). As with anorexia nervosa, relapses are COMER CH11_Cb.qxp 3/9/06 1:38 PM Page 333 Eating Disorders usually triggered by a new life stress, such as an upcoming exam, job change, marriage, or divorce (Abraham & Llewellyn-Jones, 1985). One study found that close to one-third of persons who had recovered from bulimia nervosa relapsed within two years of treatment, usually within six months (Olmsted, Kaplan, & Rockert, 1994). Relapse is more likely among persons who had longer histories of bulimia nervosa before treatment, had vomited more frequently during their disorder, had histories of substance abuse, made slower progress in the early stages of treatment, and continue to be lonely or to distrust others after treatment (Fairburn et al., 2004; Stewart, 2004; Keel et al., 2002, 2000, 1999). Research also indicates that treatment helps many, but not all, people with bulimia nervosa attain lasting improvements in their overall psychological and social functioning (Keel et al., 2002, 2000; Stein et al., 2002). Follow-up studies find former patients to be less depressed than they had been at the time of diagnosis (Halmi, 1995). Approximately one-third of former patients interact in healthier ways at work, at home, and in social settings, while another third interact effectively in two of these areas (Hsu & Holder, 1986). >>PSYCH•LISTINGS Celebrities Who Acknowledge Having Had Eating Disorders Mary-Kate Olsen, actress << Tracey Gold, actress << Cynthia French, singer << Jane Fonda, actress << Jamie-Lynn Sigler, actress << Paula Abdul, singer, dancer << Victoria Beckham (“Posh Spice”), singer << Princess Diana, British royalty << putting it together A Standard for Integrating Perspectives We have observed throughout this book that it is often useful to consider sociocultural, psychological, and biological factors jointly when one tries to explain or treat various forms of abnormal functioning. Nowhere is the argument for combining these perspectives more powerful than in the case of eating disorders. According to the multidimensional risk perspective, embraced by many theorists, varied factors act together to encourage the development of eating disorders. One case may be the result of societal pressures, autonomy problems, the changes of adolescence, and hypothalamic overactivity, while another case may result from family pressures, depression, and the effects of dieting. No wonder that the most helpful treatment programs for eating disorders combine sociocultural, psychological, and biological approaches. When the multidimensional risk perspective is applied to eating disorders, it demonstrates that scientists and practitioners who follow very different models can work together productively in an atmosphere of mutual respect. Today’s many investigations of eating disorders keep revealing new surprises that force clinicians to adjust their theories and treatment programs. For example, in recent times researchers have learned that people with bulimia nervosa sometimes feel strangely positive about their symptoms (Serpell & Treasure, 2002). A recovered patient said, “I still miss my bulimia as I would an old friend who has died” (Cauwels, 1983, p. 173). Only when feelings like these are understood will treatment become fully effective—another reason why the cooperative efforts of different kinds of theorists, clinicians, and researchers are so important. While clinicians and researchers seek more answers about eating disorders, clients themselves have begun to take an active role. A number of patient-run organizations now provide information, education, and support through national telephone hot lines, Web sites, professional referrals, newsletters, workshops, and conferences. For example, the National Eating Disorders Association, the American Anorexia and Bulimia Association, and the National Association of Anorexia Nervosa and Associated Disorders help fight the feelings of isolation and shame experienced by people with eating disorders. They show countless sufferers that they are hardly alone or powerless. Kate Beckinsdale, actress << Zina Garrison, tennis star << Cathy Rigby, Olympic gymnast << Kathy Johnson, Olympic gymnast << Nadia Comaneci, Olympic gymnast << Magali Amadei, supermodel << >>LOOKING AROUND A small step in the right direction? [ summary and review ] ■ Eating disorders Rates of eating disorders have increased dramatically as thinness has become a national obsession.The two leading disorders in this category, anorexia nervosa and bulimia nervosa, share many similarities, as well as key differences. pp. 309–310 ■ Anorexia nervosa People with anorexia nervosa pursue extreme thinness and lose dangerous amounts of weight. They may follow a pattern of restricting-type anorexia The manufacturer of king-sized Mars and Snickers chocolate bars, oversized snacks weighing as much as 3.5 ounces and containing 387 calories, recently decided to re-package the snacks in “two shareable portions.” The decision came as a result of Britain’s Food and Drink Federation’s manifesto to the food industry to reduce portion sizes (Reuters, 2004). << 333 COMER CH11_Cb.qxp 334 3/9/06 1:38 PM Page 334 chapter 11 >>LOOKING AROUND Fashion Downsizing In 1968, the average fashion model was 8 percent thinner than the typical woman. Today, models are 20 percent thinner (Halls & Hanson, 2003; Van Rossen & Associates, 2002; Zerbe, 1993). << nervosa or binge-eating/purging-type anorexia nervosa. The central features of anorexia nervosa are a drive for thinness, fear of weight, preoccupation with food, cognitive disturbances, psychological problems such as depressed feelings or obsessive functioning, and consequent medical problems, including amenorrhea. Approximately 90 to 95 percent of all cases of anorexia nervosa occur among females. Typically the disorder begins after a person who is slightly overweight or of normal weight has been on a diet. pp. 310–313 ■ Bulimia nervosa Individuals with bulimia nervosa go on frequent eating binges and then force themselves to vomit or perform other inappropriate compensatory behaviors. They may follow a pattern of purging-type bulimia nervosa or nonpurging-type bulimia nervosa. The binges often occur in response to increasing tension and are followed by feelings of guilt and self-blame. Compensatory behavior is at first reinforced by the temporary relief from uncomfortable feelings of fullness or the reduction of feelings of anxiety, self-disgust, and loss of control attached to bingeing. Over time, however, people come to feel generally disgusted with themselves, depressed, and guilty. People with bulimia nervosa may experience mood swings or have difficulty controlling their impulses. Some display a personality disorder.Around half are amenorrheic, a number develop dental problems, and some develop a potassium deficiency. Clinicians have also observed that certain people display a pattern of binge eating without vomiting or other inappropriate compensatory behaviors.This pattern, often called binge-eating disorder, is not yet listed in the DSM, although it is being considered for inclusion in the next edition. pp. 313–318 ■ Explanations Most theorists now apply a multidimensional risk perspective to explain eating disorders and identify several key contributing factors. Principal among these are society’s emphasis on thinness and bias against obesity; family environment, including, perhaps, an enmeshed family pattern; ego and cognitive disturbances, including a poor sense of autonomy and control, the result, perhaps, of parents incorrectly identifying and reacting to their young children’s internal needs and cues; a mood disorder; and biological factors, such as activity of the hypothalamus, biochemical activity, and the body’s weight set point. pp. 318–325 ■ Treatments Therapists aim first to help people with eating disorders resume nor- >>LOOKING AROUND Children’s Playthings Barbie During the 1990s clinical researchers noted that Barbie, the doll with whom so many women grew up, had unattainable proportions. A 5؅2؆ 125-pound woman who aspired to Barbie’s size would have to grow to be 7؅2؆, add 5 inches to her chest and 3.2 inches to the length of her neck, and lose 6 inches from her waist (Brownell & Napolitano, 1995). << GI Joe Contemporary male action figures, such as GI Joe and Luke Skywalker, have acquired the physiques of body builders in recent years, with sharp muscle definition in the chest, shoulders, and abdominals (Pope et al., 1999). If GI Joe were a real man, he would have larger biceps than any body builder in history, with a 5؅10؆ frame and 29-inch biceps, a 32-inch waist, and a 55-inch chest. << mal eating and regain their health; then they tackle the broader problems that led to the disorder.The first step in treating anorexia nervosa, for example, is to increase calorie intake and quickly restore the person’s weight, using a strategy such as supportive nursing care. The second step is to deal with the underlying psychological and family problems, often using a combination of individual, group, and family approaches, and education. Therapists try to help clients build independence and self-awareness, correct their disturbed cognitions, and change dysfunctional family interactions, among other goals. About 83 percent of people who receive successful treatment for anorexia nervosa continue to show full or partial improvements years later. However, some of them relapse along the way, many continue to worry about their weight and appearance, and half continue to experience some emotional or family problems. Most menstruate again when they regain weight. Most of those who recover are later found to enjoy work and perform effectively at their jobs and to marry or have intimate relationships at the usual rates. pp. 325–330 Treatments for bulimia nervosa focus first on stopping the binge-purge pattern and then on addressing the underlying causes of the disorder. Often several treatment strategies are combined, including individual insight therapy (particularly cognitive therapy and, at times, interpersonal psychotherapy, self-care manuals, and psychodynamic therapy), group therapy (including self-help groups), behavioral therapy (including exposure and response prevention and keeping a food intake diary), and antidepressant medications. Approximately 89 percent of those who receive treatment eventually improve either fully or partially.While relapse can be a problem and may be precipitated by a new stress, treatment leads to lasting improvements in psychological and social functioning for many individuals. pp. 330–333 COMER CH11_Cb.qxp 3/9/06 1:38 PM Page 335 Eating Disorders >>> critical thoughts 1. Many, perhaps most, women in Western society feel as if they are dieting or between diets their entire adult lives. Is it possible to be a woman in this society and not struggle with at least some issues of eating and appearance? Who is responsible for the standards and pressures that affect so many women? pp. 309–310, 319–321 2. The most successful of today’s fashion models, often referred to as supermodels, have a celebrity status that was not conferred upon models 335 <<< in the past. Why do you think the fame and status of models have risen in this way? pp. 319–324 3. The prevalence of eating disorders is particularly low in cultures that restrict female social roles and reduce a woman’s freedom to make decisions about her life (Miller & Pumariega, 1999; Bemporad, 1997). How might you explain this relationship? pp. 319–324 4. What does the 1996 Miss Universe flap suggest about the role of societal factors in the development of [ cyberstudy ] >>> search the abnormal psychology CD-ROM for ▲ Chapter 11 Video Cases and Discussions Witness the feelings behind bingeing and purging. How does an eating disorder begin? How do individuals feel toward their eating disorders? ▲ Chapter 11 Practical, Research, and Decision-Making Exercises Uncovering attitudes toward eating, food, and weight Tracing the media’s role in eating behaviors and disorders ▲ Chapter 11 Practice Test and Feedback log on to the comer web page for ▲ Suggested Web links, exercises, FAQ page, additional Chapter 11 practice test questions <www.worthpublishers.com/comer> <<< eating problems? Why do you think so many people held such strong, often critical, opinions about Ms. Machado’s weight? p. 331 5. Relapse is a problem for some people who recover from anorexia nervosa and bulimia nervosa. Why might people remain vulnerable even after recovery? How might they and their therapists reduce the chances of relapse? pp. 325–333 ...
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