 MODULE OUTLINE
may maintain disordered eating patterns.
A. Anorexia Nervosa
B. Bulimia Nervosa
C. Binge-eating disorder
D. Other Feeding and Eating Disorders
E. Etiology
F. Treatment
 ANOREXIA NERVOSA
Descriptions
Anorexia nervosa is a condition
characterized by extreme weight loss and
one of its most obvious symptoms is
extreme thinness. In anorexia nervosa, the
person eats only minimal amounts of food
or exercises vigorously to offset food
intake so body weight sometimes drops
dangerously.
A very frightening characteristic of
anorexia nervosa is that most people with
the disorder, even when clearly emaciated,
continue to insist they are overweight.
Some may acknowledge that they are thin
but maintain that some parts of their
bodies are too fat. Ninety to ninety-five
percent of anorexics are female.
In anorexia nervosa, deaths also occur
from physical complications of the illness
and from suicide. Complications such as
osteoporosis, cardiovascular problems,
anemia, and compromised immune
function are common.
Associated Characteristics
Depression, anxiety, impulse control
problems, loss of sexual interest, and
substance use often occur concurrently
with anorexia nervosa. Many individuals
with anorexia nervosa have difficulty
regulating their emotions, a factor that
Obsessive-compulsive behaviors and
thoughts that may or may not involve food
are common in those with anorexia
nervosa.
Anorexia nervosa is often comorbid with
several other disorders, including
substance abuse, obsessive-compulsive
disorder (OCD), several personality
disorders, and especially with major
depression
Diagnostic Criteria
A. Restriction of energy intake relative to
requirements, leading to a significantly
low body weight in the context of age,
sex, developmental trajectory, and
physical health.
o Significantly low weight is
defined as a weight that is less
than minimally normal or, for
children and adolescents, less
than that minimally expected.
B. Intense fear of gaining weight or of
becoming fat, or persistent behavior that
interferes with weight gain, even though at
a significantly low weight.
C. Disturbance in the way in which one’s
body weight or shape is experienced,
undue influence of body weight or shape
on self-evaluation, or persistent lack of
recognition of the seriousness of the
current low body weight.
Subtypes
 Restricting type: During the last 3
months, the individual has not engaged in
recurrent episodes of binge eating or
purging behavior (i.e., self-induced
vomiting or the misuse of laxatives,
diuretics, or enemas). This subtype
describes presentations in which weight
loss is accomplished primarily through
dieting, fasting, and/or excessive exercise.
Binge-eating/purging type: During the
last 3 months, the individual has engaged
in recurrent episodes of binge eating or
purging behavior (i.e., self-induced
vomiting or the misuse of laxatives,
diuretics, or enemas).
 BULIMIA NERVOSA
Descriptions
Individuals diagnosed with bulimia
nervosa realize that they have abnormal
eating patterns and are distressed by that
knowledge. Sometimes, their eating
episodes continue until they experience
abdominal pain or induce vomiting. They
also feel disgusted or ashamed of their
eating and hide it from others.
Some individuals with this disorder
consume nothing during the day but lose
control and binge in the late afternoon or
evening. For those who vomit or use
laxatives to compensate for overeating, the
temporary relief (from physical discomfort
or fear of weight gain) is followed by
feelings of shame and despair. Binge-
eating episodes may be followed by a
commitment to fasting, severely
restricting eating, or engaging in excessive
exercising or other physical activity.
Compared to anorexia nervosa, bulimia is
much more prevalent. People with bulimia
use a variety of measures—fasting, self-
induced vomiting, diet pills, laxatives, and
exercise—to control the weight gain that
accompanies binge eating. Side effects
from self-induced vomiting or from
excessive use of laxatives include erosion
of tooth enamel from vomited stomach
acid; dehydration; swollen salivary glands;
and lowered potassium, which can weaken
the heart and cause heart irregularities and
cardiac arrest.
Associated Characteristics
Individuals with bulimia often use eating
as a way of coping with distressing
thoughts or external stressors. There is
also a close relationship between
emotional states and disturbed eating. By
and large, bulimic behaviors may
represent maladaptive attempts at
emotional regulation.
Diagnostic Criteria
A. Recurrent episodes of binge eating. An
episode of binge eating is characterized by
both of the following:
o 1. Eating, in a discrete period of
time (e.g., within any 2-hour
period), an amount of food that is
definitely larger than what most
individuals would eat in a similar
period of time under similar
circumstances.
o 2. A sense of lack of control over
eating during the episode (e.g., a
feeling that one cannot stop
eating or control what or how
much one is eating).
B. Recurrent inappropriate compensatory
behaviors in order to prevent weight gain,
such as self-induced vomiting; misuse of
laxatives, diuretics, or other medications;
fasting; or excessive exercise.
C. The binge eating and inappropriate
compensatory behaviors both occur, on
average, at least once a week for 3
months.
D. Self-evaluation is unduly influenced by
body shape and weight.
 E. The disturbance does not occur
exclusively during episodes of anorexia
nervosa.
 BINGE-EATING DISORDER
Description
The essential feature of binge-eating
disorder is recurrent episodes binge eating
that must occur, on average, at least once
per week for 3 months. An "episode of
binge eating" is defined as eating, in a
discrete period of time, an amount of food
that is definitely larger than most people
would eat in a similar period of time under
similar circumstances.
An occurrence of excessive food
consumption must be accompanied by a
sense of lack of control to be considered
an episode of binge eating. An indicator of
loss of control is the inability to refrain
from eating or to stop eating once started.
Some individuals describe a dissociative
quality during, or following, the binge-
eating episodes.
The type of food consumed during binges
varies both across individuals and for a
given individual. Binge eating appears to
be characterized more by an abnormality
in the amount of food consumed than by a
craving for a specific nutrient.
Associated Characteristics
In contrast to those with bulimia nervosa,
individuals with BED are often
overweight. Binges are often preceded by
poor mood, decreased alertness, feelings
of poor eating control, and cravings for
sweets. Many with this condition are
unduly influenced by their weight or
shape, a factor associated with feelings of
depression, anxiety, and low self-esteem.
Those who expect that eating will help
relieve emotional distress are more likely
to engage in binge eating.
Diagnostic Criteria
A. Recurrent episodes of binge eating. An
episode of binge eating is characterized by
both of the following:
o 1. Eating, in a discrete period of
time (e.g., within any 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.
o 2. A sense of lack of control over
eating during the episode (e.g., a
feeling that one cannot stop
eating or control what or how
much one is eating).
B. The binge-eating episodes are
associated with three (or more) of the
following:
o 1. Eating much more rapidly than
normal.
o 2. Eating until feeling
uncomfortably full.
o 3. Eating large amounts of food
when not feeling physically
hungry.
o 4. Eating alone because of feeling
embarrassed by how much one is
eating. 5. Feeling disgusted with
oneself, depressed, or very guilty
afterward.
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.
 OTHER SPECIFIED FEEDING OR
EATING DISORDERS
 Description
The category other specified feeding or
eating disorders includes seriously
disturbed eating patterns that do not fully
meet the criteria for anorexia nervosa,
bulimia nervosa, or binge-eating disorder.
This is the most commonly diagnosed
eating disorder and accounts for up to 30
percent of eating disorder diagnoses.
Examples of people who fit in this
category include the following:
o Individuals of normal weight who
meet the other criteria for
anorexia nervosa
o Individuals who meet the criteria
for bulimia nervosa or binge-
eating disorder except that binge
eating occurs less than once a
week or has been present for less
than 3 months
o Individuals with night-eating
syndrome, a distressing pattern of
binge eating late at night or after
awakening from sleep
o Individuals who do not binge but
frequently purge (self-induced
vomiting, misuse of laxatives,
diuretics, or enemas) as a means
to control weight.
Many individuals who receive this
diagnosis have emotional problems and
later develop bulimia nervosa or binge-
eating disorder.
 ETIOLOGICAL
CONSIDERATIONS
Psychological Factors
Body dissatisfaction arises when
someone’s weight or body shape differs
significantly from an imagined ideal.
People who are highly dissatisfied with
their bodies are more likely to compare
their bodies to those of other people and
report lower self-satisfaction. Men who
highly value personal attractiveness and
appearance report lower body satisfaction
when exposed to TV commercials
featuring muscular men.
Maladaptive perfectionism is also a risk
factor; it may interact with body
dissatisfaction to influence the
development of anorexia nervosa and
other eating disorders. Maladaptive
perfectionism is composed of two
dimensions: (a) inflexible high standards
and (b) negative self-evaluations
following mistakes. Imposing perfectionist
standards on someone’s weight, shape, or
dieting may cause disordered eating.
Individuals with eating disorders also
appear to use food or weight regulation
as a means of handling stress or anxiety.
Dieting may represent an effort to
demonstrate self-control or to improve
self-esteem and body image. people who
binge often view eating as a source of
comfort and a way to counteract
depression and other negative emotions.
Individuals who believe eating will relieve
negative affect such as depression are
more likely to binge.
Perceived or actual inadequacies in
interpersonal skills are also associated
with eating disorders, particularly when
combined with maladaptive perfectionism.
Individuals with eating disorders often
perceive low levels of social support,
which may be due to a passive
interpersonal style. They also possess
“self-uncertainty,” which involves a low
self-concept and limited sense of self.
Mood disorders such as depression often
accompany eating disorders. In some
cases, disordered eating may be a
symptom of depression. However,
research studies are still being done to
determine if depression could be the
result, not the cause, of having an eating
disorder.
Social Factors
People with anorexia nervosa have often
had childhoods characterized by social
discomfort, anxiety, and insecure
attachments to others. As adults, they are
more likely to report no significant
attachments to others, and as mothers,
they are more likely to have difficulty
reading the interpersonal cues of their
infants.
Some individuals coping with eating
disorders report that their parents or
family members frequently criticized
them, had a negative reaction to their
eating issues, or blamed them for their
condition. Childhood maltreatment and
negative family relationships possibly
produce a self-critical style that causes
depression and body dissatisfaction.
Peers can also produce pressure to lose
weight, particularly when exposure to the
ideal of thinness occurs during a critical
period of development such as
adolescence or early adulthood.
Sociocultural Factors
Cultural attitudes and standards are
also thought to play an important role in
the development of anorexia nervosa.
Culture has a strong influence on
standards for what is considered to be the
ideal female shape. In Western culture,
thinness is perceived as the standard of
beauty as well as an indicator of success
and self-control.
At the same time that contemporary
cultural standards have emphasized
thinness, women’s body weight has been
increasing as a result of improved health
and nutrition. These circumstances have
created a conflict between the ideal shape
and many women’s actual shape. The
conflict often leads to prolonged or
obsessive dieting, which can be a prelude
to the development of anorexia nervosa.
The prevalence of anorexia nervosa is
especially high among women who are
under intense pressure to be thin, such as
dancers and models.
Women are socialized to be conscious of
their body shape and weight. At an early
age, girls are sexualized and objectified
through television, music videos, song
lyrics, magazines, and advertising.
A process of social comparison occurs in
which women and girls begin to evaluate
themselves according to external
standards. Because these standards are
unattainable for most women, body
dissatisfaction occurs. Self-consciousness
and frequent monitoring of one’s external
appearance can lead to anxiety or shame
about the body. When women compare
their body shape or weight with other
women’s, those with high body
dissatisfaction report increased feelings of
guilt and depression. Thoughts of
“solutions” such as dieting, purging, and
extreme exercise increase, especially
among those with the greatest body
dissatisfaction. Thus, social comparison
appears to be a strong risk factor for eating
disorders, especially among women who
are dissatisfied with their bodies.
Biological Factors
o Disordered eating appears to run
in families, especially among
female relatives.
 o Genetic influences may be
triggered by physical changes
such as puberty.
o Differences in dopamine levels
may explain why those with
bulimia nervosa are more
attentive to food stimuli and why
individuals with anorexia nervosa
show less appetitive response to
food images .
o Low levels of dopamine can
increase hunger, whereas
increased dopamine
concentrations can decrease
appetite
o Having genes associated with
lower dopamine availability may
interact with adverse childhood
rearing experiences to result in
emotional eating patterns
o Altered functioning of the
appetitive neural circuitry (brain
structures and processes that
mediate appetite) also appears to
influence disordered eating
patterns.
o Abnormalities in ghrelin and
leptin, gastrointestinal hormones,
have been found in those with
eating disorders.
 TREATMENT
Treatment of Anorexia Nervosa
Because anorexia nervosa is a complex
disorder, there is a need for teamwork
among physicians, psychiatrists, and
therapists. Because an individual being
treated for anorexia nervosa is starving,
the initial goal is to restore weight and
address the physical complications
associated with starvation. During the
weight restoration period, new foods are
introduced to supplement food choices
that are not sufficiently high in calories.
Family therapy is often an important
component of the treatment plan. This
therapy may involve (a) having parents
assist in the re-feeding process by
planning meals, (b) learning new family
relationship patterns, (c) and reducing
parental criticism by helping them
understand that anorexia nervosa is a
serious disease. Parents are encouraged to
help their children develop skills,
attitudes, and activities appropriate to their
developmental stage.
Treatment of Bulimia Nervosa
Treatment involves an interdisciplinary
team that includes a physician and a
psychotherapist. To normalize eating
patterns and eliminate the binge/purge
cycle is a primary goal of treatment.
Cognitive-behavioral approaches can help
individuals with bulimia develop a sense
of self-control. Common components of
cognitive-behavioral treatment involve
encouraging the consumption of three or
more balanced meals a day, reducing rigid
food rules and body image concerns,
identifying triggers for bingeing, and
developing strategies for coping with
emotional distress. Adding exposure and
response prevention procedures to therapy
(i.e., exposure to cues associated with
bingeing and prevention of purging
following a binge) appears to improve
long-term outcomes for individuals with
bulimia nervosa). Antidepressant
medications such as selective serotonin
reuptake inhibitors are sometimes helpful
in treating bulimia.
Treatment of Binge-Eating Disorder

In general, treatment follows two phases.

First, factors that trigger overeating are
determined; then clients learn strategies to
reduce eating binges.

Medications are sometimes effective in

reducing or stopping binge eating;
however, psychological interventions tend
to produce the best long-term results.

Although cognitive-behavioral therapy

(CBT) can produce significant reductions
in binge eating, it has less effect on weight
reduction. A newer form of CBT
incorporates ways to address interpersonal
difficulties and strategies for regulating
negative emotions that can trigger
bingeing and purging, a focus similar to
the emotional regulation and distress
tolerance skills taught in dialectical
behavior therapy.