1. LEIGH FALLS, PH.D., LPCS, RPTS, ACS, NCC
1
Eating Disorders

2. Eating Disorders:
How much is enough?

3. Why is this so important?
3
 81% of 10 year olds are afraid of being fat
 51% of 9 & 10 year old girls feel better about themselves if they are
on a diet
 91% college women who had attempted to control their weight
through dieting
 22% dieted "often" or "always“
 95% of all dieters will regain their lost weight in 1-5 years
 55% of "normal dieters" progress to pathological dieting
 35% of these progress to partial or full-syndrome eating disorders
 Americans spend over $50 billion on dieting and products each
year
 58 million of the adult U.S. population are overweight or obese
 up from 25% of American adults in 1980 to 33% today
Adapted from: http://www.divorcedoc.com/psychotherapy/statistics.htm

4. What Causes Eating Disorders?
4
Most theorists subscribe to a multidimensional
risk perspective:
 Several key factors place individuals at risk
 More factors = greater risk
 Leading factors:
 Sociocultural conditions (societal and family pressures)
 Psychological problems (ego, cognitive, and mood disturbances)
 Biological factors

5. Eating Disorders:Etiology
5
• Genetics
– Relatives of patients with anorexia are eight times more
likely to develop an eating disorder
– Twin studies:
• Monozygotic twins have a 58-76% concordance, while dizygotic
twins with 35-45% concordance
• Monozygotic twins have a 46%-56% concordance, while dizygotic
twins with 18%-35% concordance for bulimia
• Neurochemical
– Serotonin precursor (5-HIAA) reduced in anorexia when
ill and normalize upon recovery
– Recovery from bulima associated with high levels of
serotonin

6. Eating Disorders:Etiology
Psychosocial
6
 Difficulty with transition to adulthood
 Changes of body associated with puberty
 Adult autonomy
 Stressful times of transition
 Family conflicts
 Ineffective attempts to cope with stress

7. What Causes Eating Disorders?
Societal Pressures
7
Many theorists believe that current Western
standards of female attractiveness have contributed
to increases in eating disorders
 Standards have changed throughout history toward a thinner
ideal
 Miss America contestants have declined in weight by 0.28 lbs/yr;
winners have declined by 0.37 lbs/yr
 Playboy centerfolds have lower average weight, bust, and hip
measurements than in the past

8. What Causes Eating Disorders? Societal Pressures
8
Certain groups are at greater risk from these
pressures:
 Models, actors, dancers, and certain athletes
 Of college athletes surveyed, 9% met full criteria for an eating
disorder while another 50% had symptoms
 20% of surveyed gymnasts met full criteria for an eating disorder

9. What Causes Eating Disorders? Societal Pressures
9
Societal attitudes may explain economic and racial
differences seen in prevalence rates
 In the past, white women of higher SES expressed more
concern about thinness and dieting
 These women had higher rates of eating disorders than African
American women or white women of lower SES
 Recently, dieting and preoccupation with food, along with rates
of eating disorders, are increasing in all groups

10. What Causes Eating Disorders? Societal Pressures
10
The socially accepted prejudice against overweight
people may also add to the “fear” and preoccupation
about weight
 About 50% of elementary and 61% of middle school girls are
currently dieting

11. Eating Disorders: Sociocultural Factors
11
Changes in Body Image over Time

12. Did you know that…
12
15% of young women in the United States (who are
NOT diagnosed with an eating disorder), have
disordered eating attitudes and behavior, according
to the National Institute of Mental Health.

13. Eating Disorders:
Sociocultural Factors
13
• Anne Becker, Harvard researcher, studied the influence of
American television on eating patterns in Fiji
– Fiji had traditionally been a nation that has cherished the fuller figure
• Since the arrival of TV to the island of Fiji in 1995, the
percentage of eating disorders among young girls aged 15-19
years increased from 3% to 15%
• The number of girls dieting (62 per cent) and girls feeling "too
big or fat" (74 per cent) has also increased since 1995.
• It is believed that the sudden infusion of Western cultural images
and values through TV changed the way Fijian girls view
themselves and their bodies

14. What Causes Eating Disorders? Family Environment
14
Families may play an important role in the
development of eating disorders
 As many as half of the families of those with eating disorders
have a long history of emphasizing thinness, appearance, and
dieting
 Mothers of those with eating disorders are more likely to be
dieters and perfectionistic themselves

15. What Causes Eating Disorders? Family Environment
15
Abnormal family interactions and forms of
communication within a family may also set the
stage for an eating disorder
 Minuchin cites “enmeshed family patterns” as causal
factors of eating disorders
 These patterns include overinvolvement in, and overconcern
about, family member’s lives

16. What Causes Eating Disorders?
Ego Deficiencies and Cognitive Disturbances
16
Bruch argues that eating disorders are the result of
disturbed mother–child interactions, which lead to
serious ego deficiencies in the child and to severe
cognitive disturbances

17. What Causes Eating Disorders?
Ego Deficiencies and Cognitive Disturbances
17
According to Bruch, parents may respond to their
children either effectively or ineffectively
 Effective parents accurately attend to a child’s biological
and emotional needs
 Ineffective parents fail to attend to child’s internal needs;
they feed when the child is anxious, comfort when the
child is tired, etc.
There is some empirical support for Bruch’s theory
from clinical reports

18. What Causes Eating Disorders? Mood Disorders
18
Many people with eating disorders, particularly
those with bulimia nervosa, experience symptoms of
depression
 Theorists believe mood disorders may “set the stage” for eating
disorders

19. What Causes Eating Disorders? Mood Disorders
19
There is empirical support for the claim that mood
disorders set the stage for eating disorders:
 Many more people with an eating disorder qualify for a
clinical diagnosis of major depressive disorder than do
people in the general population
 Close relatives of those with eating disorders seem to
have higher rates of mood disorders
 People with eating disorders, especially those with
bulimia nervosa, have low levels of serotonin
 Symptoms of eating disorders are helped by
antidepressant medications

20. What Causes Eating Disorders? BiologicalFactors
20
Biological theorists suspect certain genes may leave
some people particularly susceptible to eating
disorders
 Consistent with this model:
 Relatives of people with eating disorders are 6 times more likely to
develop the disorder themselves
 Identical (MZ) twins with bulimia: 23%
 Fraternal (DZ) twins with bulimia: 9%
 These findings may be related to low serotonin

21. What Causes Eating Disorders? Biological Factors
21
Other theorists believe that eating disorders may be
related to dysfunction of the hypothalamus
 Researchers have identified two separate areas that control
eating:
 Lateral hypothalamus (LH)
 Ventromedial hypothalamus (VMH)

22. What Causes Eating Disorders? Biological Factors
22
Some theorists believe that the LH and VMH are
responsible for weight set point – a “weight
thermostat” of sorts
 Set by genetic inheritance and early eating practices, this
mechanism is responsible for keeping an individual at a
particular weight level
 If weight falls below set point: Ý hunger, ß metabolism Þ binges
 If weight rises above set point: ß hunger, Ý metabolism
 Dieters end up in a fight against themselves to lose weight

23. Eating Disorders: Risk Factors
23
Activities with
heightened
weight/shape demands
Childhood obesity
Familial psychiatric
history and/or obesity
Diabetes
Routine Dieting or
restrained eating
Premorbid personality
disorder(s)

24. Eating Disorders
24
Although not historically true, current Western
beauty standards equate thinness with health and
beauty
 Thinness has become a national obsession!
There has been a rise in eating disorders in the
past three decades
Two main diagnoses:
 Anorexia nervosa
 Bulimia nervosa

25. Eating Disorders: DSM-5
Eating Disorders
25
 Anorexia Nervosa
 Bulimia Nervosa
 Binge Eating Disorder
DSM-5

26. ED Changes from DSM IV TR- DSM 5
DSM IV TR
Pica, Rumination, and
Avoidant/Restrictive in
chapter of disorders
usually 1st diagnosed in
infancy, childhood, or
adolescence
No Binge Eating
Disorder
DSM 5
Pica Rumination, &
Avoidant/Restrictive in
ED chapter
Recognition of Binge
Eating Disorder
Anorexia Nervosa &
Bulimia Nervosa
criteria updated

27. Eating Disorders
Can only be diagnosed with one of the following at
any given time:
 Rumination Disorder
 Avoidant/Restrictive Food Intake Disorder
 Anorexia Nervosa
 Bulimia Nervosa
 Binge Eating Disorder

28. EDs: (307.51/F50.8)Binge Eating Disorder (p. 380)
DSM IV TR:
 Appendix B: Criteria Sets and Axes Provided for Further
Study
 Diagnosed as ED NOS
DSM 5:
 Added BED to Feeding and Eating Disorders chapter
 Recognition that a large percentage of ED NOS diagnoses
could be attributed to BED
 More severe and less common than overeating and
associated with significant physical and psychological
problems
 Criteria A-E will must be met

29. Binge Eating Disorder Criteria (p. 350)
A.Recurrent episodes of binge eating. An episode of
binge eating is characterized by both of the
following:
1. Eating, in a discrete period of time (w/in 2-hour
period), an amount of food that is definitely larger
than what most people would eat in a similar
period of time under similar circumstances.
1. A sense of lack of control over eating during the
episode (e.g. feeling that one cannot stop eating
or control what or how much one is eating).

30. Binge Eating Disorder Criteria (p. 350)
B. The binge-eating episodes are associated with
3/more of the following:
1. Eating much more rapidly than normal.
2. Eating until feeling uncomfortably full.
3. Eating large amounts of food when not feeling
physically hungry.
4. Eating alone because of feeling embarrassed by
how much one is eating.
5. Feeling disgusted with oneself, depressed or very
guilty afterward.

31. Binge Eating Disorder Criteria (p. 350)
C. Marked distress regarding binge eating is
present.
D. The binge eating occurs, on average, at least
once a week for 3 months.
E. The binge eating is not associated with the
recurrent use of inappropriate compensatory
behavior as in bulimia nervosa and does not
occur exclusively during the course of bulimia
nervosa or anorexia nervosa.

32. Binge Eating Disorder Specifiers (p. 350)
Partial/Full Remission After full criteria for
BED were met, binge-eating disorder were
previously met,
Partial: Binge eating occurs at an average frequency of less
than one episode per week for a sustained period of time.
Full: none of the criteria have been met for a sustained
period of time.
Severity
Mild: 1-3 episodes of binge eating each week
Moderate: 4-7 episodes of binge eating each
week
Severe: 8-13 episodes of binge eating each week
Extreme: 14/more episodes of binge eating each
week

33. BED: Associated Features
Prevalence: (p. 351)
 12 month prevalence among adults:
 Female: 1.6%
 Males: .8%
Development & Course : (p. 352)
 Binge eating usually precedes BED whereas dieting usually
precedes onset of binge eating in bulimia nervosa)
 Treatment seeking BED clients are usually older than AN/BN
treatment seeking clients
 Course: persistent, similar to BN in severity & duration
Risk and Prognostic Factors: Indication of
Genetic predisposition

34. BED: Associated Features
Culture-Related Diagnostic Issues
 Similar across industrialized countries
 Similar across ethnicities
Functional Consequences
 Social role adjustment problems
 Impaired health-related quality of life & life satisfaction
 Increased medical morbidity & mortality
 Increased health care utilization compared with BMI-matched
control subjects

35. BED: Associated Features
Differential Diagnosis
 Bulimia Nervosa:
 BED doesn’t have recurrent compensatory (purge/exercise) behavior
 BED consistently higher rates of improvement than BN
 Obesity:
 BED higher rates of overvaluation of body weight and shape
 BED rates of psychiatric comorbidity are significantly higher
 BED better outcomes
 Bipolar & MDD can be given in addition to BED if meet full criteria for
both
 Borderline PD & BED can be given if meet full criteria for both
Comorbidity *linked to severity of BED not degree of
obesity*
 Most common: bipolar, depressive, & anxiety disorders
 Less common: substance use disorders

36. EDs: Anorexia Nervosa
Several minor but important changes in criteria:
 Criterion A DSM 5:
 Focuses on behaviors indicating AN like restricting calorie intake
 No longer includes the word “refusal” in terms of weight
maintenance – implies intention – hard to assess
 Elimination of Criterion D DSM IV TR: Amenorrhea
required
 Cannot be applied to males, premenstrual females, females taking
oral contraceptives, and post-menopausal females
 May have other AN criteria and still have some menstrual activity

37. Anorexia Nervosa
37
There are two main subtypes:
 Restricting type
 Lose weight by restricting “bad” foods, eventually restricting
nearly all food
 Show almost no variability in diet
 Binge-eating/purging type
 Lose weight by vomiting after meals, abusing laxatives or
diuretics, or engaging in excessive exercise
 Like those with bulimia nervosa, people with this subtype may
engage in eating binges

38. Anorexia Nervosa
38
About 90%–95% of cases occur in females
The peak age of onset is between 14 and 18 years
Between 0.5% and 2% of females in Western
countries develop the disorder
 Many more display some symptoms
Rates of anorexia nervosa are increasing in North
America, Japan, and Europe

39. Anorexia Nervosa
39
The “typical” case:
 A normal to slightly overweight female has been on a diet
 Escalation to anorexia nervosa may follow a stressful
event
 Separation of parents
 Move or life transition
 Experience of personal failure
 Most patients recover
 However, about 2% to 6% become seriously ill and die as a result
of medical complications or suicide

40. Anorexia Nervosa: The Clinical Picture
40
The key goal for people with anorexia nervosa is
becoming thin
 The driving motivation is fear:
 Of becoming obese
 Of giving in to the desire to eat
 Of losing control of body shape and weight

41. Anorexia Nervosa: The Clinical Picture
41
Despite their dietary restrictions, people with
anorexia are preoccupied with food
 This includes thinking and reading about food and planning
for meals
 This preoccupation may be the result of food deprivation
rather than its cause
 Famous 1940s “starvation study” with conscientious objectors

42. Anorexia Nervosa: The Clinical Picture
42
People with anorexia nervosa also think in
distorted ways:
 Often have a low opinion of their body shape
 Tend to overestimate their actual proportions
 Adjustable lens assessment technique
 Hold maladaptive attitudes and misperceptions
 “I must be perfect in every way”
 “I will be a better person if I deprive myself”
 “I can avoid guilt by not eating”

43. Anorexia Nervosa: The Clinical Picture
43
People with anorexia may also display certain
psychological problems:
 Depression (usually mild)
 Anxiety
 Low self-esteem
 Insomnia or other sleep disturbances
 Substance abuse
 Obsessive-compulsive patterns
 Perfectionism

44. Anorexia Nervosa: Medical Problems
44
Caused by starvation:
 Amenorrhea
 Low body temperature
 Low blood pressure
 Body swelling
 Reduced bone density
 Slow heart rate
 Metabolic and electrolyte
imbalances
 Dry skin, brittle nails
 Poor circulation
 Lanugo

45. EDs: Bulimia Nervosa
Basically the same criteria EXCEPT
Compensatory behaviors:
DSM IV TR 2x/week
DSM 5 1 time/week

46. Bulimia Nervosa
46
Bulimia nervosa, also known as “binge-purge
syndrome,” is characterized by binges:
 Bouts of uncontrolled overeating during a limited period
 Eats more than most people would/could eat in a similar period

47. Bulimia Nervosa
47
The disorder is also characterized by compensatory
behaviors, such as:
 Vomiting
 Misusing laxatives, diuretics, or enemas
 Fasting
 Exercising excessively

48. Bulimia Nervosa
48
Like anorexia nervosa, about 90%–95% of bulimia
nervosa cases occur in females
The peak age of onset is between 15 and 21 years
Symptoms may last for several years with periodic
letup

49. Bulimia Nervosa
49
Patients are generally of normal weight
 Often experience weight fluctuations
 Some may also qualify for a diagnosis of anorexia

50. 50

51. Bulimia Nervosa
51
Teens and young adults have frequently attempted
binge-purge patterns as a means of weight loss,
often after hearing accounts of bulimia from
friends or the media
In one study:
 50% of college students reported periodic binges
 6% tried vomiting
 8% experimented with laxatives at least once
Surveys suggest that as many as 5% of women
develop the full syndrome

52. Bulimia Nervosa: Binges
52
For people with bulimia nervosa, the number of
binges per week can range from 2 to 40
 Average: 10 per week
Binges are often carried out in secret
 Binges involve eating massive amounts of food rapidly
with little chewing
 Usually sweet foods with soft texture
 Binge-eaters commonly consume more than 1000
calories (often more than 3000 calories) per binge
episode

53. Bulimia Nervosa: Binges
53
Binges are usually preceded by feelings of tension
and/or powerlessness
Although the binge itself may be pleasurable, it is
usually followed by feelings of extreme self-blame,
guilt, depression, and fears of weight gain and
“discovery”

54. Bulimia Nervosa:
Compensatory Behaviors
54
After a binge, people with bulimia nervosa try to
compensate for and “undo” the caloric effects
The most common compensatory behaviors:
 Vomiting
 Fails to prevent the absorption of half the calories consumed
during a binge
 Affects ability to feel satiated Þ greater hunger and bingeing
 Laxatives and diuretics
 Also almost completely fail to reduce the number of calories
consumed

55. Bulimia Nervosa: Compensatory Behaviors
55
Compensatory behaviors may temporarily relieve the
negative feelings attached to binge eating
 Over time, however, a cycle develops in which purging Þ
bingeing Þ purging

56. Bulimia Nervosa
56
The “typical” case:
 A normal to slightly overweight female has been on an intense
diet
 Research suggests that even among normal subjects, bingeing
often occurs after strict dieting
 For example, a study of binge-eating behavior in a low-calorie
weight loss program found that 62% of patients reported binge-eating
episodes during treatment

57. Bulimia Nervosa vs. Anorexia Nervosa
57
Similarities:
 Onset after a period of dieting
 Fear of becoming obese
 Drive to become thin
 Preoccupation with food, weight, appearance
 Elevated risk of self-harm or attempts at suicide
 Feelings of anxiety, depression, perfectionism
 Substance abuse
 Disturbed attitudes toward eating

58. Bulimia Nervosa vs. Anorexia Nervosa
58
Differences:
 People with bulimia are more worried about pleasing
others, being attractive to others, and having intimate
relationships
 People with bulimia tend to be more sexually experienced
 People with bulimia display fewer of the obsessive
qualities that drive restricting-type anorexia
 People with bulimia are more likely to have histories of
mood swings, low frustration tolerance, and poor coping

59. Bulimia Nervosa vs. Anorexia Nervosa
59
Differences:
 People with bulimia tend to be controlled by emotion –
may change friendships easily
 People with bulimia are more likely to display
characteristics of a personality disorder
 Different medical complications:
 Only half of women with bulimia experience amenorrhea vs.
almost all women with anorexia
 People with bulimia suffer damage caused by purging, especially
from vomiting and laxatives

60. Treatments for Eating Disorders
60
Eating disorder treatments have two main goals:
 Correct abnormal eating patterns
 Address broader psychological and situational factors that
have led to and are maintaining the eating problem
 This often requires the participation of family and friends

61. Treatments for Anorexia Nervosa
61
The initial aims of treatment for anorexia nervosa
are to:
 Restore proper weight
 Recover from malnourishment
 Restore proper eating

62. Treatments for Anorexia Nervosa
62
In the past, treatment took place in a hospital
setting; it is now often offered in an outpatient
setting
In life-threatening cases, clinicians may need to
force tube and intravenous feedings on the patient
 This may breed distrust in the patient and create a power
struggle
Most common technique now is the use of
supportive nursing care and high-calorie diets
 Necessary weight gain is often achieved in 8 to 12 weeks

63. Treatments for Anorexia Nervosa
63
Researchers have found that people with anorexia
must overcome their underlying psychological
problems to achieve lasting improvement

64. Treatments for Anorexia Nervosa
64
Therapists use a mixture of therapy and education
to achieve this broader goal, using a combination
of individual, group, and family approaches
 One focus of treatment is building autonomy and self-awareness
 Therapists help patients recognize their need for independence
and control
 Therapists help patients recognize and trust their internal feelings

65. Treatments for Anorexia Nervosa
65
Another focus of treatment is correcting disturbed
cognitions, especially client misperceptions and
attitudes about eating and weight
 Using cognitive approaches, therapists correct disturbed
cognitions and educate about body distortions

66. Treatments for Anorexia Nervosa
66
Another focus of treatment is changing family
interactions
 Family therapy is important for anorexia
 The main issue is often separation

67. Treatments for Anorexia Nervosa
67
The use of combined treatment approaches has
greatly improved the outlook for people with
anorexia nervosa
 But even with combined treatment, recovery is difficult
The course and outcome of the disorder vary from
person to person

68. Treatments for Anorexia Nervosa
68
Positives of treatment:
 Weight gain is often quickly restored
 83% of patients still showed improvements
after several years
 Menstruation often returns with return to normal weight
 The death rate from anorexia is declining

69. Treatments for Anorexia Nervosa
69
Negatives of treatment:
 Close to 20% of patients remain troubled for years
 Even when it occurs, recovery is not always permanent
 Anorexic behaviors recur in at least one-third of recovered
patients, usually triggered by stress
 Many patients still express concerns about body shape and weight
 Lingering emotional problems are common

70. Treatments for Bulimia Nervosa
70
Treatment is frequently offered in specialized eating
disorder clinics

71. Treatments for Bulimia Nervosa
71
The initial aims of treatment for bulimia nervosa are
to:
 Eliminate binge-purge patterns
 Establish good eating habits
 Eliminate the underlying cause of bulimic patterns
Programs emphasize education as much as therapy

72. Treatments for Bulimia Nervosa
72
Several treatment strategies:
 Individual insight therapy
 The insight approach receiving the most attention is cognitive
therapy, which helps clients recognize and change their
maladaptive attitudes toward food, eating, weight, and shape
As many as 65% stop their binge-purge cycle

73. Treatments for Bulimia Nervosa
73
Several treatment strategies:
 Individual insight therapy
 If cognitive therapy isn’t effective, interpersonal therapy (IPT), a
treatment that seeks to improve interpersonal functioning, may be
tried
 A number of clinicians also suggest self-help groups or self-care
manuals

74. Treatments for Bulimia Nervosa
74
Several treatment strategies:
 Behavioral therapy
 Behavioral techniques are often included in treatment as a
supplement to cognitive therapy
Diaries are often a useful component of treatment
 Exposure and response prevention (ERP) is used to break the
binge-purge cycle

75. Treatments for Bulimia Nervosa
75
Several treatment strategies:
 Antidepressant medications
 During the past decade, antidepressant drugs have been used in
bulimia treatment
 Most common is fluoxetine (Prozac), an SSRI
 Drugs help as many as 40% of patients
 Medications are best when used in combination with other forms
of therapy

76. Treatments for Bulimia Nervosa
76
Several treatment strategies:
 Group therapy
 Provides an opportunity for patients to express their thoughts,
concerns, and experiences with one another
 Helpful in as many as 75% of cases, especially when combined
with individual insight therapy

77. Treatments for Bulimia Nervosa
77
Left untreated, bulimia can last for years
Treatment provides immediate, significant
improvement in about 40% of cases
 An additional 40% show moderate improvement
Follow-up studies suggest that 10 years after
treatment about 90% of patients have fully or
partially recovered

78. Treatments for Bulimia Nervosa
78
Relapse can be a significant problem, even among
those who respond successfully to treatment
 Relapses are usually triggered by stress
 Relapses are more likely among persons who:
 Had a longer history of symptoms
 Vomited frequently
 Had histories of substance use
 Have lingering interpersonal problems

79. Treatments for Bulimia Nervosa
79
Finally, treatment may also help improve overall
psychological and social functioning