Eating

Disorders
Joanne Chua
PSY 213: Advanced Abnormal Psych
February 27, 2021
 Anorexia Nervosa

“Anorexia”: Greek for loss of appetite

“Nervosa”: Latin for nervous

Diagnosis Criteria Two Subtypes (based on past 3 months’

1. Restriction of food intake relative to behavior):
energy requirements 1. Restricting Type
2. Intense fear of gaining weight or 2. Binge-Eating/Purging Type
persistent behavior that interferes with
weight gain
3. Distorted body image
 Bulimia Nervosa
“Bulimia”: Greek for ”ox hunger”
“Nervosa”: Latin for nervous
Diagnostic Criteria
1. Episodes of binge eating and
compensatory behaviors occur at least
once a week for 3 months
2. Self-evaluation unduly influenced by
body shape and weight
What constitutes a binge episode?
1. Eating an excessive amount of food
within a short period of time
2. Feeling a loss of control while eating
When do binge episodes happen?
● Binges usually happen in secret and may
occur due to stress or negative emotions
● Usually begins during a dieting episode
● Usually lead to feelings of disgust and
fear over weight gain, leading to
compensatory behaviors – in the form of
vomiting, laxatives and diuretics,
excessive exercise, or fasting
 Anorexia Nervosa vs. Bulimia Nervosa

People with Anorexia… Vs. People with Bulimia…

Lose a lot of weight Do not lose a lot of weight

Those with the binge-eating/purging Binge on inordinate amounts of

type of anorexia binge on relatively food at least once a week, with
small amounts of food and purge on compensatory behaviors
a more consistent basis
 Binge Eating Disorder

Diagnostic Criteria
1. Recurrent episodes of binge eating occurring at least once a week
for 3 months
2. Significant distress regarding binging

People with binge eating disorder are usually obese, with BMI > 30

Risk factors: childhood obesity, childhood attempts at weight loss,

depression, low self-concept, and childhood physical or sexual abuse
 Epidemiology and Prognoses
Anorexia Nervosa (AN) Bulimia Nervosa (BN) Binge Eating Disorder
Age of Onset Early to mid-teens Late adolescence or Later than for AN or BN
early adulthood
Gender 3x more frequent in ~90% female More common in women,
Occurrence women but smaller gender gap
than AN and BN
Lifetime < 1% 1-2% 0.2-4.7%
Prevalence
Recovery ~50-70% ~68-75% Better chances of recovery
and response to treatment
than AN and BN
Comorbidity Anxiety and mood Anxiety and mood Anxiety and mood
disorders, OCD, phobias, disorders, substance disorders, ADHD, conduct
panic disorder, personality abuse disorder, substance abuse
disorders, substance
abuse
 Physical Consequences
Anorexia Nervosa (AN) Bulimia Nervosa (BN)
Physical • amenorrhea (cessation of
Consequences menstruation)
• dry skin
• brittle hair or nails
• sensitivity to cold
temperature
• kidney and gastronomical
problems
• decline in bone mass
• lanugo (soft hair on limbs
and cheeks)
• mild anemia
• cardiovascular problems
such as low blood pressure
and low heart rate
• imbalances in electrolyte
levels
Binge Eating Disorder
• amenorrhea (though less (mostly associated with obesity)
common than in people
with anorexia) Increased risk of:
• electrolyte depletion • type 2 diabetes
• erosion of dental enamel • cardiovascular issues
• swollen salivary glands • chronic back pain
• tearing in stomach and • headaches
throat tissues
• intestinal issues
• calluses on one’s fingers
or back of hands
 Etiology of Eating Disorders

Sociocultural Biological Psychological

1. Female vs. male body 1. Eating disorders run 1. Perfectionism

ideals in families regarding distorted
2. Impact of friends and 2. Traits like body body image
social media dissatisfaction and 2. High social anxiety
3. Typical family profile: binge eating may be 3. Mood intolerance
high expectations, heritable
reputation-focused, 3. Correlated low
conflict-averse serotonin and high
dopamine levels
Case Study:
Reeya

Indian female university

student in her early 20s
living in Britain, diagnosed
with bulimia nervosa
 Social Case History: Childhood

● Moved around a lot

● Mother passed away when she was a toddler, so she and her sister
moved in with grandparents
● After father’s remarriage, moved back in with father and stepmother
● Did not have good relationship with parents, who throughout her
upbringing placed pressure and high expectations on her in terms of
education, marriage, career
● Went to competitive grade school, where she worked hard academically
but never felt proud of her achievements or felt she was ”doing
enough”
 Social Case History: Physical Perception

● Had healthy body image and eating behaviors until the age of 16
● Began monitoring weight and experimenting with dieting
● Compared herself to girls she saw on social media
● Subscribed to British ideal of thin female body, but also felt pressured
due to Indian cultural idea of “marriageability”
● Stepmother and grandmother contributed to her insecurities by
commenting on Indian women in saris: “bulging” bellies, or telling Reeya
“you can’t have a tire around your belly”
● Parents also compared her to her sister, saying she was “a lot bigger”
than her sister
 Social Case History: Associations with Food

● Positive associations with sweet foods during childhood at her

grandparents’ home
● Once she moved in with her father and stepmother, sweets were
forbidden
● Stepmother was a disciplinarian: made sure Reeya finished her food at
mealtimes, even if it made Reeya feel sick
● Reeya indulged in sweets to create her own space apart from her
stepmother
 Social Case History: University

● Went away to university at age 18 for a demanding medicine-related

course
● Body conscious, wanted to be judged favorably in new environment
● First year of university was the “hardest year of her life”
● Stressful and lonely living situation: housemates partied a lot while
Reeya preferred not to
● Also didn’t make good friends as her course mates didn’t want to
socialize after a full day of classes
● Combination of academic demands and loneliness caused her to turn
to food as a source of comfort
● Began to restrict daily food intake and binge in the evenings
 Social Case History: Lack of Family Support

● Lack of concern and involvement from parents while she was at

university
● “Hostile” relationship: couldn’t confide in them about her worries
● They expected her to deal with difficult situations on her own
● She finally sought out help with the support of her boyfriend
● Eventually referred to a psychiatrist, who diagnosed her with bulimia
nervosa, with restricting tendencies
 Symptomatology and Factors

Daily restricted food intake and evening binges

Factors affecting her disordered eating behavior:

1. Relational conflicts with and isolation from housemates, peers, family
2. Academic stresses
3. British thin female ideal and Indian concept of “marriageability”
4. Childhood association of “comfort” with sweet foods
 Difficulty Accepting Diagnosis

● Has yet to tell her parents about her diagnosis

● Cultural stigma in the family against mental health
“You just need to learn how to eat healthy and not gain weight”
They say a mentally ill person is just “making a big deal out of it”
● Received psychiatric medication but refuses to take it as it would make
her diagnosis ”real”
● Stepmother was diagnosed with depression and also refused to take her
medication due to stigma
 Diagnostic Impression

Axis I Bulimia nervosa

Axis 2 N/A

Axis 3 No notable medical conditions

Axis 4 Relational difficulties at home and in university setting

Academic stress

Axis 5 Global Assessment Functioning (GAF) Score of 60

Moderate symptoms of bulimia and moderate difficulty in
social/school functioning
Few close personal relationships
 Treatment Recommendations

Enhanced Cognitive Dialectical Behavior

Interpersonal
Behavioral Therapy Therapy for Bulimia
Therapy (IPT)
(CBT-E) Nervosa (DBT for BN)
Complex broad version Focus on role disputes Aims to improve skills in
(CBT-Eb) which addresses (relationship with interpersonal
additional maintaining parents and sister) and communication, distress
factors of mood interpersonal deficits (at tolerance, emotional
intolerance, interpersonal university) regulation, and
deficits, perfectionism and mindfulness
low self-esteem
Applied Research
 Applied Research 1: Eating Disorders in
the Philippines
● Preliminary study by Lorenzo et al. found both Filipino adolescent females and
males had rates of abnormal eating attitudes comparable to those found in
female adolescents in Western countries, using the Eating Attitudes Test (EAT)
● Rates found for Filipino high schoolers were higher than those found in other
studies in China, Pakistan and Malaysia

● A cross-cultural study by Kayano et al. that looked at a sample of Indian, Omani,

Filipino, Japanese, and Euro-American adolescents found that Filipino males
scored significantly higher on the EAT than all other cultural groups, while
Filipino females scored significantly higher than Euro-American females
● Euro-American males and females both had significantly higher Drive for Thinness
scores
(Lorenzo et al., 2002; Kayano et al., 2008)
 Applied Research 2: Multifamily Therapy
for Bulimia Nervosa (MFT-BN)
● Family Therapy for Bulimia Nervosa (FT-BN) found to be superior to
CBT for adolescents, but only for families with lower levels of conflict
● Unclear if appropriate for Reeya in terms of family conflict level and her
parents’ willingness

● Multifamily Therapy for Bulimia Nervosa is a variant

● Initially, groups for parents and adolescents are run in parallel
● Youth receive psychoeducation and motivation, parents learn to tackle
criticism, negativity, and communication skills in household
● May help Reeya’s parents work through their stigma

(Le Grange et al., 2015; Simic & Eisler, 2018)

 Theoretical and
Practical
Recommendations
 Theoretical Recommendations

● Tripartite Influence Model of body image and eating disturbances:

Parents, Peers, and Media

● Relationship between culture and eating disorders: Eating disorders are

not culture-specific or culture-bound, but culture-reactive, which means
certain cultural contexts result in social and environmental changes that
increase the risk for eating disorders
 Practical Recommendations

● Develop family-based treatments for young adults with eating

disorders, especially in countries with collectivist cultures

● Fight cultural stigma through psychoeducation and prevention

programs, both for children and adolescents, as well as their parents,
teachers, caregivers
Personal Insights
 Personal Insights

1. No experience with eating disorders but have witnessed the effects of

societal ideals and dieting culture in my family
2. Important for parents to promote and model body positivity and body
acceptance to their children. They need to be aware of what they say, as
even small comments they make, without mal intent, may have a huge
impact on their children
3. Remember that everyone is fighting a different battle, even the
celebrity or public figure you admire who seems to have a perfect life
A Picture Is Worth
Thank You!
a Thousand Words