Abnormal lecture ch09

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  • 1. Chapter 9 Eating DisordersComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 1Slides & Handouts by Karen Clay Rhines, Ph.D.
  • 2. Eating Disorders  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 nervosaComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 2
  • 3. Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 3
  • 4. Anorexia Nervosa  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 bingesComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 4
  • 5. Anorexia Nervosa  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 EuropeComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 5
  • 6. Anorexia Nervosa  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 suicideComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 6
  • 7. Anorexia Nervosa: The Clinical Picture  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 weightComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 7
  • 8. Anorexia Nervosa: The Clinical Picture  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 objectorsComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 8
  • 9. Anorexia Nervosa: The Clinical Picture  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”Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 9
  • 10. Anorexia Nervosa: The Clinical Picture  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  PerfectionismComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 10
  • 11. Anorexia Nervosa: Medical Problems  Caused by starvation:  Amenorrhea  Slow heart rate  Low body temperature  Metabolic and electrolyte imbalances  Low blood pressure  Dry skin, brittle nails  Body swelling  Poor circulation  Reduced bone density  LanugoComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 11
  • 12. Bulimia Nervosa  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 periodComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 12
  • 13. Bulimia Nervosa  The disorder is also characterized by compensatory behaviors, such as:  Vomiting  Misusing laxatives, diuretics, or enemas  Fasting  Exercising excessivelyComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 13
  • 14. Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 14
  • 15. Bulimia Nervosa  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 letupComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 15
  • 16. Bulimia Nervosa  Patients are generally of normal weight  Often experience weight fluctuations  Some may also qualify for a diagnosis of anorexiaComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 16
  • 17. Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 17
  • 18. Bulimia Nervosa  “Binge-eating disorder” may be a related diagnosis  Symptoms include a pattern of binge eating with NO compensatory behaviors (such as vomiting)  This condition is not yet listed in the DSM-IV-TRComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 18
  • 19. Bulimia Nervosa  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 syndromeComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 19
  • 20. Bulimia Nervosa: Binges  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 episodeComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 20
  • 21. Bulimia Nervosa: Binges  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”Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 21
  • 22. Bulimia Nervosa: Compensatory Behaviors  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 ⇒ greater hunger and bingeing  Laxatives and diuretics  Also almost completely fail to reduce the number of calories consumedComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 22
  • 23. Bulimia Nervosa: Compensatory Behaviors  Compensatory behaviors may temporarily relieve the negative feelings attached to binge eating  Over time, however, a cycle develops in which purging ⇒ bingeing ⇒ purgingComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 23
  • 24. Bulimia Nervosa  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 treatmentComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 24
  • 25. Bulimia Nervosa vs. Anorexia Nervosa  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 eatingComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 25
  • 26. Bulimia Nervosa vs. Anorexia Nervosa  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 copingComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 26
  • 27. Bulimia Nervosa vs. Anorexia Nervosa  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 laxativesComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 27
  • 28. What Causes Eating Disorders?  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 factorsComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 28
  • 29. What Causes Eating Disorders? Societal Pressures  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 pastComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 29
  • 30. What Causes Eating Disorders? Societal Pressures  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 disorderComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 30
  • 31. What Causes Eating Disorders? Societal Pressures  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 groupsComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 31
  • 32. What Causes Eating Disorders? Societal Pressures  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 dietingComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 32
  • 33. What Causes Eating Disorders? Family Environment  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 themselvesComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 33
  • 34. What Causes Eating Disorders? Family Environment  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 livesComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 34
  • 35. What Causes Eating Disorders? Ego Deficiencies and Cognitive Disturbances  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 disturbancesComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 35
  • 36. What Causes Eating Disorders? Ego Deficiencies and Cognitive Disturbances  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 reportsComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 36
  • 37. What Causes Eating Disorders? Mood Disorders  Many people with eating disorders, particularly those with bulimia nervosa, experience symptoms of depression  Theorists believe mood disorders may “set the stage” for eating disordersComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 37
  • 38. What Causes Eating Disorders? Mood Disorders  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 medicationsComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 38
  • 39. What Causes Eating Disorders? Biological Factors  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 serotoninComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 39
  • 40. What Causes Eating Disorders? Biological Factors  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)Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 40
  • 41. What Causes Eating Disorders? Biological Factors  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: ⇑ hunger, ⇓ metabolism ⇒ binges  If weight rises above set point: ⇓ hunger, ⇑ metabolism  Dieters end up in a fight against themselves to lose weightComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 41
  • 42. Treatments for Eating Disorders  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 friendsComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 42
  • 43. Treatments for Anorexia Nervosa  The initial aims of treatment for anorexia nervosa are to:  Restore proper weight  Recover from malnourishment  Restore proper eatingComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 43
  • 44. Treatments for Anorexia Nervosa  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 weeksComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 44
  • 45. Treatments for Anorexia Nervosa  Researchers have found that people with anorexia must overcome their underlying psychological problems to achieve lasting improvementComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 45
  • 46. Treatments for Anorexia Nervosa  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 feelingsComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 46
  • 47. Treatments for Anorexia Nervosa  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 distortionsComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 47
  • 48. Treatments for Anorexia Nervosa  Another focus of treatment is changing family interactions  Family therapy is important for anorexia  The main issue is often separationComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 48
  • 49. Treatments for Anorexia Nervosa  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 personComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 49
  • 50. Treatments for Anorexia Nervosa  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 decliningComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 50
  • 51. Treatments for Anorexia Nervosa  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 commonComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 51
  • 52. Treatments for Bulimia Nervosa  Treatment is frequently offered in specialized eating disorder clinicsComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 52
  • 53. Treatments for Bulimia Nervosa  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 therapyComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 53
  • 54. Treatments for Bulimia Nervosa  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 cycleComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 54
  • 55. Treatments for Bulimia Nervosa  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 manualsComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 55
  • 56. Treatments for Bulimia Nervosa  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 cycleComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 56
  • 57. Treatments for Bulimia Nervosa  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 therapyComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 57
  • 58. Treatments for Bulimia Nervosa  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 therapyComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 58
  • 59. Treatments for Bulimia Nervosa  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 recoveredComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 59
  • 60. Treatments for Bulimia Nervosa  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 problemsComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 60
  • 61. Treatments for Bulimia Nervosa  Finally, treatment may also help improve overall psychological and social functioningComer, Fundamentals of Abnormal Psychology, 5e – Chapter 9 61