Abnormal Psychology Fifth Edition Oltmanns and Emery Power

Abnormal Psychology Fifth Edition Oltmanns and Emery Power. Point Presentations Prepared by: Cynthia K. Shinabarger Reed This multimedia product and its contents are protected under copyright law. The following are prohibited by law: any public performance or display, including transmission of any image over a network; preparation of any derivative work, including the extraction, in whole or in part, of any images; any rental, lease, or lending of the program. Copyright © Prentice Hall 2007

Chapter Ten Eating Disorders Copyright © Prentice Hall 2007

Chapter Outline • • Symptoms of Anorexia Symptoms of Bulimia Diagnosis of Eating Disorders Frequency of Eating Disorders Causes of Eating Disorders Treatment of Anorexia Nervosa Treatment of Bulimia Nervosa Prevention of Eating Disorders Copyright © Prentice Hall 2007

Overview • • • Eating disorders are severe disturbances in eating behavior that result from the sufferer’s obsessive fear of gaining weight. DSM-IV-TR lists two major types of eating disorders: anorexia nervosa and bulimia nervosa. The most obvious characteristic of anorexia nervosa is extreme emaciation, or more technically, the refusal to maintain a minimally normal body weight. Copyright © Prentice Hall 2007

Overview • • Bulimia nervosa is characterized by repeated episodes of binge eating, followed by inappropriate compensatory behaviors such as self-induced vomiting, misuse of laxatives, or excessive exercise. Both anorexia and bulimia are about 10 times more common among females than males, and they develop most commonly among women in their teens and early twenties. Copyright © Prentice Hall 2007

Symptoms of Anorexia Refusal to Maintain a Normal Weight • • • The most obvious and most dangerous symptom of anorexia nervosa is a refusal to maintain a minimally normal body weight. Anorexia nervosa often begins with a diet to lose just a few pounds. The young woman weighs near healthy body weight, and she decides to lose a little weight, perhaps to fit into some new clothes. Copyright © Prentice Hall 2007

Symptoms of Anorexia Refusal to Maintain a Normal Weight (continued) • • • The diet goes awry, however, and losing weight eventually becomes the key focus. Weight falls well below the normal range, and often plummets to dangerously low levels. DSM-IV-TR contains no formal cutoff as to how thin is too thin, but suggests 85 percent of expected body weight as a rough guideline. Copyright © Prentice Hall 2007

Symptoms of Anorexia Disturbance in Evaluating Weight or Shape • • A second defining symptom of anorexia nervosa is a perceptual, cognitive, or affective disturbance in evaluating one’s weight and shape. Many individuals steadfastly deny problems with their weight. Copyright © Prentice Hall 2007

Symptoms of Anorexia Disturbance in Evaluating Weight or Shape (continued) • • Other people with the disorder suffer from a disturbance in the way body weight or shape is experienced. Sometimes this may include a distorted body image, an inaccurate perception of body size and shape. Copyright © Prentice Hall 2007

Symptoms of Anorexia Disturbance in Evaluating Weight or Shape (continued) • All people with the disorder are unduly influenced by their body weight or shape in self-evaluation. Copyright © Prentice Hall 2007

Symptoms of Anorexia Fear of Gaining Weight • • An intense fear of becoming fat is a third central characteristic of anorexia. The fear may grow more intense as the individual loses more weight. Copyright © Prentice Hall 2007

Symptoms of Anorexia Cessation of Menstruation • Amenorrhea, the absence of at least three consecutive menstrual cycles, is the fourth and final defining symptom of anorexia nervosa in females. • The amenorrhea has led to speculation about the role of sexuality and sexual maturation in causing anorexia nervosa. • However, the amenorrhea typically is a reaction to the physiological changes produced by anorexia nervosa, specifically a low level of estrogen secretion, and not a symptom that precedes the disorder. Copyright © Prentice Hall 2007

Symptoms of Anorexia Medical Complications • • • People with anorexia commonly complain about constipation, abdominal pain, intolerance to cold, and lethargy. In addition, the skin can become dry and cracked, and some people develop lanugo, a fine, downy hair, on their face or trunk of their body. Broader medical difficulties may include anemia, infertility, impaired kidney functioning, cardiovascular difficulties, dental erosion, and osteopenia (bone loss). Copyright © Prentice Hall 2007

Symptoms of Anorexia Medical Complications (continued) • • A particularly dangerous medical complication is an electrolyte imbalance, a disturbance in the levels of potassium, sodium, calcium, and other vital elements found in bodily fluids. Electrolyte imbalance can lead to cardiac arrest or kidney failure. Copyright © Prentice Hall 2007

Symptoms of Anorexia Struggle for Control • • • People with anorexia nervosa often take great pride in their self-denial, feeling like masters of control. Some theorists speculate that the disorder actually develops out of a desperate sense of having no control. Excessively compliant “good girls” may find that obsessively regulating their diet allows them to be in charge of at least one area of their lives. Copyright © Prentice Hall 2007

Symptoms of Anorexia Comorbid Psychological Disorders • • • Anorexia nervosa may be associated with other psychological problems, particularly obsessive– compulsive disorder, obsessive–compulsive personality disorder, and depression. In many cases, however, these comorbid psychological problems may be reactions to anorexia, not causes of it. Anorexia often co-occurs with the symptoms of bulimia. Copyright © Prentice Hall 2007

Symptoms of Bulimia • • Many people with bulimia nervosa have a history of

Symptoms of Bulimia Binge Eating • • • Binge eating is defined in DSM-IV-TR as eating an amount of food in a fixed period of time, for example, less than 2 hours, that is clearly larger than most people would eat under similar circumstances. Binges may be planned in advance, or they may begin spontaneously. In either case, binges typically are secret. Copyright © Prentice Hall 2007

Symptoms of Bulimia Binge Eating (continued) • • Binge eating is commonly triggered by an unhappy mood, which may begin with an interpersonal conflict, self-criticism about weight or appearance, or intense hunger following a period of fasting. A key feature of binge eating is a sense of lack of control during a binge. Copyright © Prentice Hall 2007

Symptoms of Bulimia Inappropriate Compensatory Behavior • • • Almost all people with bulimia nervosa engage in purging, designed to eliminate the consumed food from the body. The most common form of purging is self-induced vomiting; as many as 90 percent of people with bulimia nervosa engage in this behavior. Other less common forms of purging include the misuse of laxatives, diuretics (which increase the frequency of urination), and, most rarely, enemas. Copyright © Prentice Hall 2007

Symptoms of Bulimia Inappropriate Compensatory Behavior (continued) • • • Ironically, purging has only limited effectiveness in reducing caloric intake. Vomiting prevents the absorption of only about half the calories consumed during a binge, and laxatives, diuretics, and enemas have few lasting effects on calories or weight. Inappropriate compensatory behaviors other than purging include extreme exercise or rigid fasting following a binge. Copyright © Prentice Hall 2007

Symptoms of Bulimia Excessive Emphasis on Weight and Shape • • • People with bulimia nervosa place excessive emphasis on body shape and weight in evaluating themselves. Their self-esteem, and much of their daily routine, center around weight and diet. The individual’s sense of self is linked too closely to appearance instead of personality, relationships, or achievements. Copyright © Prentice Hall 2007

Symptoms of Bulimia Comorbid Psychological Disorders • • Depression is common among individuals with bulimia nervosa, especially those who self-induce vomiting. Other disorders that may co-occur with bulimia nervosa include anxiety disorders, personality disorders (particularly borderline personality disorder), and substance abuse, particularly excessive use of alcohol and/or stimulants. Copyright © Prentice Hall 2007

Symptoms of Bulimia Medical Complications • • • Repeated vomiting can erode dental enamel, particularly on the front teeth, and in severe cases teeth can become chipped and ragged looking. Repeated vomiting can also produce a gag reflex that is triggered too easily and perhaps unintentionally. One consequence of the sensitized gag reflex— one that is just beginning to be reported in the scientific literature—is rumination: the regurgitation and rechewing of food. Copyright © Prentice Hall 2007

Symptoms of Bulimia Medical Complications (continued) • • • Another possible medical complication is the enlargement of the salivary glands, a consequence that has the ironic effect of making the sufferer’s face appear puffy. Potentially serious medical complications can result from electrolyte imbalances. Finally, rupture of the esophagus or stomach has been reported in rare cases, sometimes leading to death. Copyright © Prentice Hall 2007

Diagnosis of Eating Disorders Brief Historical Perspective • • Isolated cases of eating disorders have been reported throughout history. In fact, the term anorexia nervosa was coined in 1874 by a British physician, Sir William Withey Gull. Still, the history of professional concern with the disorders is very brief. References to eating disorders were rare in the literature prior to 1960, and the disorders have received scientific attention only in recent decades. Copyright © Prentice Hall 2007

Diagnosis of Eating Disorders Brief Historical Perspective (continued) • • • The term bulimia nervosa was used for the first time only in 1979. The diagnoses of anorexia nervosa and bulimia nervosa first appeared in DSM in 1980 (DSM-III). Although the diagnostic criteria have changed somewhat, the same eating behaviors remain as the central features of these disorders. Copyright © Prentice Hall 2007

Diagnosis of Eating Disorders Contemporary Classification • • • DSM-IV-TR includes two subtypes of anorexia nervosa. The restricting type includes people who rarely engage in binge eating or purging. In contrast, the binge eating/purging type is defined by regular binge eating and purging during the course of the disorder. Copyright © Prentice Hall 2007

Diagnosis of Eating Disorders Contemporary Classification (continued) • • • Bulimia nervosa is divided into two subtypes in DSM-IV-TR. The purging type is characterized by the regular use of self-induced vomiting or the misuse of laxatives, diuretics, or enemas. The individual with the nonpurging type of bulimia nervosa does not regularly purge but instead attempts to compensate for binge eating with fasting or excessive exercise. Copyright © Prentice Hall 2007

Diagnosis of Eating Disorders Contemporary Classification (continued) • • • There has been some debate about whether other eating problems should be included in the DSMIV-TR list of eating disorders. Binge eating disorder is one problem that was given extensive consideration. The proposed disorder involves episodes of binge eating much like those found in bulimia nervosa but without compensatory behavior. Copyright © Prentice Hall 2007

Diagnosis of Eating Disorders Contemporary Classification (continued) • • • Research has demonstrated that binge eating is associated with a number of psychological and physical difficulties other than anorexia nervosa and bulimia nervosa. Among these problems is obesity, or excess body fat, a circumstance that roughly corresponds with a body weight 20 percent above the expected weight. Calling obesity a “mental disorder” is controversial, especially given the high prevalence of overweight individuals in the United States and throughout the world. Copyright © Prentice Hall 2007

Frequency of Eating Disorders • • Estimates of the epidemiology of anorexia and bulimia vary, but it is clear that the prevalence of both disorders has increased dramatically since the 1960 s and 1970 s. DSM-IV-TR indicates that lifetime prevalence of anorexia nervosa is 0. 5 among females, a figure that is consistent with other estimates. Copyright © Prentice Hall 2007

Frequency of Eating Disorders • • Recent decades also seem to have witnessed a torrent of new cases of bulimia nervosa. Bulimia nervosa is far more common than anorexia nervosa. According to DSM-IV-TR, bulimia nervosa occurs among 1 to 3 percent of women, a rate that is two to six times the number of cases of anorexia nervosa. Moreover, the prevalence of subclinical bulimia— occasional binge eating and/or purging—is far greater than the number of cases that meet DSMIV-TR criteria for bulimia nervosa. Copyright © Prentice Hall 2007

Frequency of Eating Disorders Standards of Beauty • • Popular attitudes about women in the United States tell us that “looks are everything, ” and thinness is essential to good looks. In contrast, young men are valued as much for their achievements as for their appearance, and, the ideal body type for men is considerably larger than for women. Copyright © Prentice Hall 2007

Frequency of Eating Disorders Standards of Beauty (continued) • • The growing prevalence of eating disorders may be explained by changing standards of beauty. Marilyn Monroe, the movie idol of the 1950 s, is chunky by today’s standards. Copyright © Prentice Hall 2007

Frequency of Eating Disorders Age of Onset • • Both anorexia and bulimia nervosa typically begin in late adolescence or early adulthood. A significant minority of cases of anorexia nervosa begin during early adolescence, particularly as girls approach puberty. Copyright © Prentice Hall 2007

Causes of Eating Disorders Social Factors • • • Standards of beauty and the premium placed on young women’s appearance contribute to causing eating disorders. Troubled family relationships may be another factor that increases vulnerability. Young people with bulimia nervosa report considerable conflict and rejection in their families, difficulties that also may contribute to their depression. Copyright © Prentice Hall 2007

Causes of Eating Disorders Social Factors (continued) • • In contrast, young people with anorexia generally perceive their families as cohesive and nonconflictual. Although the families of young people with anorexia nervosa appear to be well functioning, some theorists see the families as being too close—as enmeshed families, families whose members are overly involved in one another’s lives. Copyright © Prentice Hall 2007

Causes of Eating Disorders Social Factors (continued) • • According to the enmeshment hypothesis, young people with anorexia nervosa are obsessed with controlling their eating, because eating is the only thing they can control in their intrusive families. Child sexual abuse is another family difficulty that might contribute to the development of eating disorders. Copyright © Prentice Hall 2007

Causes of Eating Disorders Psychological Factors • • • Hilde Bruch viewed a struggle for control as the central psychological issue in the development of eating disorders. Perfectionism is another term for the endless pursuit of control described by Bruch. Perfectionists set unrealistically high standards, are self critical, and demand a nearly flawless performance from themselves. Copyright © Prentice Hall 2007

Causes of Eating Disorders Psychological Factors (continued) • • Young people with eating disorders may also try to control their own emotions excessively, perhaps as a result of their constant attempt to please others instead of themselves. The result may be a lack of introceptive awareness—recognition of internal cues, including various emotional states as well as hunger. Copyright © Prentice Hall 2007

Causes of Eating Disorders Psychological Factors (continued) • • • Depression is commonly comorbid with eating disorders, particularly bulimia nervosa. Research also shows that antidepressant medications reduce some symptoms of bulimia nervosa. Bulimia thus appears to be a reaction to depression in some cases. Copyright © Prentice Hall 2007

Causes of Eating Disorders Psychological Factors (continued) • • • In other cases, however, depression may instead be a reaction to bulimia nervosa and especially to anorexia nervosa. Some experts suggest that depressive symptoms, and not necessarily clinical depression, play a role in the onset of eating disorders. Low self-esteem is a particular concern. Copyright © Prentice Hall 2007

Causes of Eating Disorders Psychological Factors (continued) • • Depressive symptoms also clearly play a role in maintaining problematic eating behaviors. Dysphoria or negative mood states commonly trigger episodes of binge eating in bulimia nervosa and in the bingeeating/purging subtype of anorexia nervosa. Copyright © Prentice Hall 2007

Causes of Eating Disorders Psychological Factors (continued) • • A negative body image, a highly critical evaluation of one’s weight and shape, has long been thought to contribute to the development of eating disorders. Several longitudinal studies have found negative evaluations of weight, shape, and appearance to predict the subsequent development of disordered eating. Copyright © Prentice Hall 2007

Causes of Eating Disorders Psychological Factors (continued) • • Some symptoms of eating disorders may be effects of dietary restraint, that is, direct consequences of restricted eating. These symptoms include binge eating, preoccupation with food, and perhaps out-of -control feelings of hunger. Copyright © Prentice Hall 2007

Causes of Eating Disorders Biological Factors • • Weight regulation is a result of the interplay among behavior (e. g. , energy expenditure, eating), peripheral physiological activity (e. g. , digestion, metabolism), and central physiological activity (e. g. , neurotransmitter release). The body strives to maintain weight around certain weight set points, fixed weights or small ranges of weight. Copyright © Prentice Hall 2007

Causes of Eating Disorders Biological Factors (continued) • • • If weight declines, hunger increases and food consumption goes up. There is a slowing of the metabolic rate, the rate at which the body expends energy, and movement toward hyperlipogenesis, the storage of abnormally large amounts of fat in fat cells throughout the body. The body does not distinguish between intentional attempts to lose weight and potential starvation. Copyright © Prentice Hall 2007

Causes of Eating Disorders Biological Factors (continued) • • • Other evidence suggests that genetic factors contribute to eating disorders. Finally, several neurophysiological measures are correlated with eating disorders, including elevations in endogenous opioids, low levels of serotonin, and diminished neuroendocrine functioning. Most of these differences in brain functioning, however, appear to be effects of eating disorders and not causes of them. Copyright © Prentice Hall 2007

Causes of Eating Disorders Integration and Alternative Pathways • • • Research on the etiology of eating disorders underscores the importance of equifinality. There are many pathways to developing an eating disorder. Eating disorders are best understood in terms of a systems approach. Copyright © Prentice Hall 2007

Causes of Eating Disorders Integration and Alternative Pathways (continued) • • A key issue that remains unresolved is why some women develop anorexia nervosa and others develop bulimia nervosa. Many social, psychological, and biological factors in the development of the two disorders are similar. Copyright © Prentice Hall 2007

Treatment of Anorexia Nervosa • • • The treatment of anorexia nervosa usually focuses on two goals. The first goal is to help the patient gain at least a minimal amount of weight. The second goal in treating anorexia nervosa is more general—to address the broader difficulties that may have caused or are maintaining the disorder. Copyright © Prentice Hall 2007

Treatment of Anorexia Nervosa • • • Many different forms of treatment may be used to achieve this goal. The clinical literature commonly advocates family therapy. Some evidence indicates that family therapy for anorexia nervosa is more effective than treating the client individually, at least when the client is an adolescent. Copyright © Prentice Hall 2007

Treatment of Anorexia Nervosa • • • Clinicians have also tried a number of different individual therapies for anorexia nervosa. There is currently little, if any, evidence to show that any of these treatments is effective. Similarly, medications such as antidepressants seem to offer little relief for victims of anorexia nervosa. Copyright © Prentice Hall 2007

Treatment of Anorexia Nervosa Course and Outcome of Anorexia Nervosa • • Evidence on the course and outcome of anorexia nervosa demonstrates that contemporary treatments are not very effective. Perhaps as many as 10 percent starve themselves to death or die of related complications, including suicide. Copyright © Prentice Hall 2007

Treatment of Anorexia Nervosa Course and Outcome of Anorexia Nervosa (continued) • Predictors of a better prognosis include an early age of onset, conflict-free parent–child relationships, early treatment, less weight loss, and the absence of binge eating and purging. Copyright © Prentice Hall 2007

Treatment of Bulimia Nervosa • • • All classes of antidepressant medications are somewhat effective in treating bulimia nervosa; however, medication alone is not the treatment of choice. The most thoroughly researched psychotherapy for bulimia nervosa is cognitive behavior therapy. Overall, cognitive behavior therapy leads to a 70 to 80 percent reduction in binge eating and purging across people in treatment. Copyright © Prentice Hall 2007

Treatment of Bulimia Nervosa • • Interpersonal psychotherapy, which was originally developed for the treatment of depression, also may be an effective treatment for bulimia nervosa. Cognitive behavior therapy clearly is the first-line treatment for bulimia nervosa, but interpersonal therapy and antidepressant medication may be useful supplemental or alternative treatments. Copyright © Prentice Hall 2007

Treatment of Bulimia Nervosa Course and Outcome of Bulimia Nervosa • • Bulimia nervosa also has a persistent course, although the outcome is more positive than for anorexia nervosa, especially with treatment. Without treatment, one third to one half of women with bulimia have an eating disorder 5 years later, many continuing to meet diagnostic criteria for bulimia nervosa. Copyright © Prentice Hall 2007

Treatment of Bulimia Nervosa Course and Outcome of Bulimia Nervosa (continued) • Following treatment, in contrast, about half of clients are free of all symptoms, about one in five continue to meet the diagnostic criteria for bulimia nervosa, and the remainder have occasional relapses or subclinical levels of binge eating and compensatory behavior. Copyright © Prentice Hall 2007

Treatment of Bulimia Nervosa Course and Outcome of Bulimia Nervosa (continued) • Predictors of continued binge eating include a longer duration, greater emphasis on shape and weight, childhood obesity, poorer social adjustment, and persistent compensatory behavior. Copyright © Prentice Hall 2007

Prevention of Eating Disorders • • The content of effective programs appears to matter less than the style of delivery. Whether a prevention program focuses on promoting healthy weight control, a critical view of the thin ideal, increasing self-esteem, or stress management matters less than whether it: 1) targets at-risk individuals instead of an unselected group; 2) involves an interactive component rather than being purely didactic; 3) includes more than one session; and 4) is directed toward women (exclusively) in their late teens and older. Copyright © Prentice Hall 2007

Prevention of Eating Disorders • More successful programs also may be covert, that is, their stated goal is to increase acceptance of one’s body rather than reduce disordered eating, a strategy that may get around defensiveness about body image. Copyright © Prentice Hall 2007