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Chapter 9
Eating Disorders
Abnormal Psychology, Eleventh Edition
Ann M. Kring, Gerald C. Davison, John M. Neale,
& Sheri L. Johnson
Anorexia Nervosa
Diagnostic criteria
» Refusal to maintain normal body weight
– Less than 85%
» Intense fear of gaining weight and being fat
– Can’t be ‘too thin’
» Distorted body image
– Feel “fat” even when emaciated
» Amenorrhea
– Loss of menstrual period
Two types:
» Restricting
» Binge-eating-purging
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Table 9.1 Sample Items from Eating
Disorders Inventory (EDI)
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Figure 9.1Assessment
of Body Image
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Anorexia Nervosa
Onset early to middle teen years
Usually triggered by dieting and stress
Women 10x as likely to develop disorder as men
» Symptomatology in men similar to that of women
Often comorbid with depression, OCD, phobias,
panic, alcoholism & PDs
» In men, comorbid with substance dependence, mood
disorders, or schizophrenia
Suicide rates high in anorexia
» 5% completing
» 20% attempting
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Physical Changes in Anorexia
Low blood pressure, heart rate decrease,
kidney & gastrointestinal problems
Loss of bone mass
Brittle nails, dry skin, hair loss
» Soft, downy body hair
Depletion of potassium & sodium
» Can cause tiredness, weakness, and death
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70% recover
» May take several years
» Relapse common
Difficult to modify distorted view of self,
especially in cultures that highly value
 Death rates 10x higher then general
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Bulimia Nervosa
Uncontrollable eating binges followed by
compensatory behavior to prevent weight gain
» Binge
– An excessive amount of food consumed in under 2 hours
– Occur at least 2x per week for 3 months, often in secret
Two types:
» Purging (vomiting, laxatives)
» Non-purging (fasting, excessive exercise)
Other proposed subtypes:
» dietary subtype - dietary restraint
» dietary-depressive - dietary restraint, negative
Bulimia vs. Anorexia, binge-eating-purging type
» Extreme weight loss in anorexia
» At or above normal weight in bulimia
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Bulimia Nervosa
Binges often triggered by stress and negative
Typical food choices:
» Cakes, cookies, ice cream, other easily consumed,
high calorie foods
Avoiding a craved food can increase
likelihood of binge
Loss of control during binge
» Reports of losing awareness or dissociation
» Shame and remorse often follow
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Bulimia Nervosa
Onset late adolescence or early
 Prevalence 1 – 2%
 90% women
 Comorbid with depression, PDs, anxiety,
substance abuse, conduct disorder
 Suicide attempts & completions higher
than in general population but lower
than in anorexia nervosa
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Physical Changes in Bulimia
Menstrual irregularities
 Potassium depletion from purging
 Laxative use depletes electrolytes which
can cause cardiac irregularities
 Loss of dental enamel from vomiting
» Teeth appear “jagged”
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70% recover
 10% remain fully symptomatic
 Early intervention linked with improved
 Poorer prognosis when depression and
substance abuse are comorbid
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Binge Eating Disorder
Diagnosis in need of further study
Associated with obesity and history of dieting
» Recurrent binges
– 2x per week for at least 6 months
» Loss of control during binge
» Binge causes distress
No loss of weight or purging
Often accompanied by obesity
» Body mass index (BMI) > 30
Equally prevalent among Euro-, African-, Asian-,
and Hispanic-Americans
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Etiology of Eating Disorders:
Family and twin studies support genetic link
» First degree relatives of individuals with both disorders
more likely to have the disorder
» Higher MZ concordance rates for both anorexia and
Body dissatisfaction, desire for thinness, binge
eating, and weight preoccupation all heritable
Adoption studies needed
Linkage on chromosome 1 (Grice et al., 2002)
» Need for replication
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Etiology of Eating Disorders:
Neurobiological Factors
Hypothalamus not directly involved
Low levels of endogenous opioids
» Substances that reduce pain, enhance mood, &
suppress appetite
» Released during starvation
– May reinforce restricted eating of anorexia
» Excessive exercise increases opioids
» Low levels of opioids (beta-endorphins) in bulimia
promote craving
– Reinforce binging
Serotonin & dopamine may also play a role
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Table 9.3 The Restraint Scale
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Etiology of Eating Disorders:
Psychodynamic View
Disturbed parent-child relationship
» Over-controlling parent
– Dieting a means to gain control and identity (Baruch,
» Conflicted mother-daughter relationship
– Bulimia creates a sense of self (Goodsitt, 1997)
Personality characteristics
» Body dissatisfaction, lack of interoceptive
awareness, and negative emotions (Leon et al.,
» Perfectionism (Tyrka et al., 2002)
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Etiology of Eating Disorders:
Cognitive Behavioral View
» Focus on body dissatisfaction and fear of fatness
» Certain behaviors (e.g., restrictive eating, excessive
exercise) negatively reinforcing
– Reduce anxiety about weight gain
» Perfectionism and personal inadequacy lead to
excessive concern about weight
» Feelings of self control brought about by weight loss are
positively reinforcing
» Criticism from family & peers regarding weight can also
play a role
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Etiology of Eating Disorders:
Cognitive Behavioral View
» Self-worth strongly influenced by weight
» Low self-esteem
» Rigid restrictive eating triggers lapses which can
become binges
– Many “off-limit” foods
– Restraint Scale measures dieting and overeating
» Disgust with oneself and fear of gaining weight
lead to compensatory behavior
– e.g., vomiting, laxative use
» Stress, negative affect trigger binges
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Figure 9.3 Schematic of Cognitive
Behavior Theory of Bulimia Nervosa
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Etiology of Eating Disorders:
Sociocultural Factors
Society values thinness
Dieting, especially among women, has
become more prevalent
» Often precedes onset
Body dissatisfaction and preoccupation with
thinness also predict eating disorders
Societal objectification of women
» Women viewed as sexual objects
Unrealistic media portrayals
» Women may feel shame when they don’t match
the ideal
Overweight individuals are viewed with
disdain, creating more pressure to be thin
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Etiology of Eating Disorders:
Cross Cultural Factors
Anorexia found in many cultures
» Even those not under western influence
» May not include fears of getting fat
As countries become more like western
cultures, bulimia increases
 Body image and preoccupation with
thinness also culturally influenced
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Etiology of Eating Disorders:
Ethnic Factors
White teens as compared to African American
» More body dissatisfaction
– BMI increases linked to greater body dissatisfaction
» Greater eating disturbances
» Differences in eating disorders rates not as great
» Body dissatisfaction and symptoms of bulimia more
strongly correlated when acculturation stress is high
White and Hispanic college students exhibit more
body dissatisfaction than African American
Prevalence of binge eating disorder and bulimia
in Latina women comparable to Caucasian
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Etiology of Eating Disorders:
Other Factors
Personality characteristics:
» Perfectionism, lack of interoceptive awareness,
and negative affect predicted disordered eating.
– Perfectionism remains high even after treatment
Family characteristics
» Self report indicates high levels of family conflict
– Parental reports don’t always indicate family problems
» One observational study showed parents
had no greater levels of negative statement
than controls.
» More observational studies needed
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Etiology of Eating Disorders:
Child Abuse
Self reports of high rates of childhood
sexual and physical abuse
 Reports of abuse not specific to eating
» Also found in other diagnostic categories
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Treatment of Eating Disorders
Most individuals don’t receive treatment
» Denial common
» Effective for bulimia but not anorexia
» Drop out and relapse rates high
CBT for bulimia
» Challenge societal ideals of thinness
» Challenge beliefs about weight and dieting
» CBT more effective than medication
Limited evidence suggests that antidepressant
medications are not effective in reducing binges
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Treatment of Eating Disorders
» Immediate goal is to increase weight to avoid
medical complications and avoid death
» Second goal is long term maintenance of weight
» Alter all-or-nothing thinking
» Reductions in symptoms through1 year
» Also effective for binge-eating disorder
Family-based therapy (FBT) found to be
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Prevention of Eating Disorders
Psychoeducational approaches
» Dissonance reduction intervention
» Healthy weight intervention
De-emphasize sociocultural influences
 Risk Factor Approach
» Identify those most at risk and intervene
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