CHAPTER 15 EATING DISORDERS Sociocultural and Psychological Factors Societal Pressures and Cultural Norms- linked historical and

d cross-cultural differences in prevalence of eating disorders to differences in standards of beauty for women at different historical times and in different cultures also certain groups within a culture may have standards for appearance that put them at greater risk for eating disorders Standards of Beauty o Ideal shape for women in North America and Europe has become thinner o Thinness more valued and encouraged in females than males o Thin-ideal promoted in womens magazines seems to have an effect on womens attitudes toward themselves o Adolescent girls and women can avoid pressures to be thin to some extent by avoiding fashion magazines and other media depictions of the thin-ideal but they cant avoid friends/family o Studies show interventions designed to get women to argue against thin-ideal and recognize pressures from media result in reductions in womens acceptance of this ideal and decreases in body dissatisfaction, dieting and bulimic pathology o Gay men at higher risk for eating disorders than heterosexual men because of focus on weight and physical appearance Athletes and Eating Disorders o Those in sports classified as aesthetic or weight-dependent most likely to have anorexia or bulimia nervosa o Female athletes said triggers for eating disorders were that they were trying to maintain their prepubescent figures o Female weightlifters often abused ephedrine, a stimulant that helps reduce body fat o Smolak, Murnen & Ruble concluded that although elite athletes show increased rates of eating disorders, amateur athletes, particularly those in high school sports in which thinness not emphasized, show lower rates of eating problems than non-athletes Bingeing and Emotion Regulation o Bingeing sometimes serves as maladaptive strategy for dealing with painful emotions. Depressive symptoms and negative affect have been found to predict onset or exacerbation of bulimic symptoms o Stice and colleagues identified 2 subtypes of disordered binge eating patterns o Dieting subtype: connected to excessive attempts at losing weight. Concerned about body shapes and sizes, try best to maintain strict, low-caloric diet but frequently fall off wagon and engage in binge eating. Use vomiting or exercise to purge selves of food or weight o Depressive subtype: concerned about weight and body size but plagued by feelings of depression and low self-esteem, often eat to quell these feelings. These women suffer greater social and psychological consequences over time, more difficulties in relationships, more likely to suffer psychiatric disorders and less likely to respond well to treatment Cognitive Models of Eating Disorders

Fairburn cognitive model of bulimia suggests overvaluation of appearance is important in development of disorder. People who consider body shape most important aspect of self-evaluation and believe achieving thinness will bring social and psychological benefits will engage in excessive dieting and purging to reduce weight o Vohs and colleagues suggested disordered eating especially likely to result when body dissatisfaction combined with perfectionism and low self-esteem. They found people with eating disorders more concerned with opinions of others are more conforming to others wishes and are more rigid in evaluations of selves and others o People with eating disorders have dichotomous thinking style, everything is either all good or all bad o Cognitions of women with eating disorders may be organized around issues of body size and control even at an unconscious level Family Dynamics o Hilde Bruch noted anorexia often occurs in girls who have been unusually good girls: high achievers, dutiful, compliant, trying to please parents and others by being perfect o Anorexia and bulimia consistently characterized by excessive perfectionism and obsessive-compulsive features. Tend to have parents who are overinvested in daughters compliance and achievements, over-controlling and wont allow expression of negative feelings o Salvadore Minuchin describes families of people with anorexia as enmeshed families: extreme interdependence and intensity occur in family interactions so boundaries between identities of individual family members are weak and easily crossed o Bruch argues that parents are ineffective and inappropriate in parenting, responding primarily to own needs rather than daughters needs for food or comfort. As a result daughters dont learn to identify and accept own feelings and desires. Instead they learn to monitor needs and desires of others and to comply with others demands o Girls with anorexia have fundamental deficits in senses of self and identities. Experience themselves as acting in response to others. dont accurately identify own feelings or desires and dont cope appropriately with distress o People so unaware of bodily sensations that they develop anorexia. People who are aware and cannot starve themselves but are prone to anxiety and impulsivity may develop binge-eating or bulimia o One important task of adolescence is separation and individuation from ones family. These girls deeply fear separation because they havent developed ability to act and think independently of their families. Also fear involvement with peers, especially sexual involvement. They harbour rage against parents for over-control, discover controlling food intake gives sense of control and elicits concern from parents o Rigid control of bodies provides sense of power over self and family that they never had before. It provides way of avoiding peer relationships o Other psychoanalytic theorists suggest girl with anorexia avoids sexual maturity and relationships by stopping pubertal maturation by self-starvation o Parents tend ot give boys freedom to separate. Enmeshed families parents terrified of girls independence. Mothers may need daughters to remain dependent because own

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identities tied too closely to daughters. Tremendous pressures on girls to remain enmeshed with families Families of girls with eating disorders have high levels of conflict, expression of negative emotions is discouraged, control and perfectionism are key family themes Mothers in these families are critical of daughters weight and more likely themselves to have disordered eating patterns Controlling nature of parents behaviours toward their children and the many personality characteristics of people with eating disorders may be consequences as well as causes of the disorder Controversial theory that eating disorders often result from experiences of sexual abuse. Stems from clinical reports of high rates of sexual abuse among persons seeking therapy rather than controlled studies. Led some therapists to urge clients with eating disorders to search through memories for childhood sexual abuse and hten take action against abusers as part of therapy Proponents of theory argue that survivors of sexual abuse develop eating disorders as symbol of self-loathing and way of making selves unattractive in attempt to prevent further sexual abuse Studies show history of sexual abuse common in several other disorders

TREATMENTS FOR EATING DISORDERS Psychotherapy for Anorexia Can be difficult to engage people with anorexia, they can be resistant to change and want to maintain their control First job of therapist is to help save individuals life Hospitalize patient and force them to ingest food to prevent death from starvation Individual therapy with people with anorexia focuses on inability to recognize and trust own feeling with goal of building self-awareness and independence from others o Only when clients learn to read their feelings will they also read sensations of hunger and fullness accurately and respond to them Behaviour therapies: make rewards contingent on eating. Teach relaxation techniques. Relapse rate alone is very high Techniques to help patients accept and value their emotions: use cognitive or supportiveexpressive techniques to help patients explore emotions and issues underlying behaviour Family systems therapy: raise familys concern about anorexic behaviour. Confront familys tendency to be over-controlling and to have excessive expectations Psychotherapy can help with anorexia but its typically a long process, many relapse and often continue to have self-esteem deficits, family problems, and periods of depression and anxiety

Psychotherapy for Bulimia For people with bulimia, psychological issues may involve learning to cope more effectively with emotions, learning to control binge and purge behaviours and learning more adaptive ways to think about food and ones body

Cognitive-behavioural therapy (CBT): based on view that extreme concerns about shape and weight are central features of the disorder. Involves teaching to recognize cognitions around eating and confront maladaptive cognitions. Introduce forbidden foods and regular diet and help client confront irrational cognitions about these Studies of CBT for bulimia show decrease in depression and anxiety, increase in social functioning, lessening concern about dieting and weight. Its more effective than drug therapies Interpersonal therapy (IPT): help identify interpersonal problems associated with bulimic behaviours (ex. marital problems) and deal with these problems more effectively Behaviour therapy: client taught how to monitor food intake, reinforced for introducing avoided food into diet and taught coping techniques for avoiding bingeing Dialectical behaviour therapy (DBT): focuses on deficits of emotion regulation as key to disordered eating behaviour Supportive-expressive psychodynamic therapy: provide support and encouragement for clients expression of feelings about problem associated with bulimia in a non-directive manner

Biological Therapies Many people with eating disorders are also depressed or have histories of depression in their families Monoamine oxidase (MAO) inhibitors: not typically prescribed because they require severe dietary restrictions to prevent dangerous side effects Tricyclic antidepressants and SSRIs: help reduce impulsive eating and negative emotions that drive bulimic behaviours Antidepressants dont appear to be as consistently effective in reducing binge eating as do CBTs

CHAPTER INTEGRATION Factors that contribute to eating disorders: Social pressures Negative body image Genetic predisposition Overvaluation of appearance (perfectionism, low self-esteem, etc.) Anxiety and depression

These factors can lead to excessive dieting which contributes to: If successful in losing weight, reinforced by society and sense of control leading to -> anorexia Impulsive binge eating which can lead to: o Binge-eating disorder or o Compensatory behaviours (purging, exercise) leading to -> bulimia