1. Disorders of Eating &
Body Image
Perception in Young Athletes
Bonnie Marks, PsyD

2. Background Information
• Body Image
• Body satisfaction vs. body dissatisfaction
• Disordered Eating (precursor to ED)
• Eating Disorders
• Anorexia Nervosa
• Bulimia Nervosa
• Eating Disorder NOS
• Binge-Eating Disorder

3. Body Image
• The subjective picture or mental image of one’s
body
• Body Image linked to self-esteem (Abel & Richards, 1994)
• Body dissatisfied: Low Self-esteem
• Body satisfied: High self-esteem
• Body dissatisfaction is related to disordered eating
behavior

4. Anorexia Nervosa (DSM-IV)
Criteria:
A. Refusal to maintain body weight
at or above a minimally normal
weight for age and height
• Body weight less than 85% of that expected
B. Intense fear of weight gain
C. Disturbance of self body image
and denial of weight problem
D. Amenorrhea (in females)

5. Anorexia Nervosa
Types:
1. Restricting Type
2. Binge Eating/Purging Type

6. DSM-IV vs. DSM-V
• Anorexia Nervosa:
• Criterion A – has been replaced with:
“Persistent restriction of energy intake leading to
significantly low body weight (in context of what is
minimally expected for age, sex, developmental trajectory,
and physical health)”
• Criterion D – (requiring amenorrhea) has been removed

7. Bulimia Nervosa (DSM-IV)
• Criteria:
A. Recurrent episodes of binge-eating
B. Recurrent, inappropriate
compensatory behavior
C. On average, criteria A & B both occur
at least twice a week for 3-months
D. Undue self evaluation
E. Disturbance of self body image

8. Bulimia Nervosa
Types:
1. Purging Type
2. Nonpurging Type

9. DSM-IV vs. DSM-V
• Bulimia Nervosa:
• Frequency of binge eating and compensatory behaviors
have been reduced from twice a week to once weekly.
(As stated in Criterion C.)

10. Women in Athletics
• More girls are placed in organized sports at a young
age (Hofferth & Sandberg, 2001)
• Starting as early as infant and preschool training
(Committees on Sports Medicine and School Health, 1989)

11. Women in Athletics
• ~149% more female collegiate athletes over the last 25
years
(2008 NCAA Sports Sponsorship and Participation Rates Report)
• Athletics influence females across all
developmental stages
• Female athletes are the product of “athletic
development”
• Being an athlete affects women at all stages of life

12. Body Image and Athletics
• Conflicting Research
• Athletics = Body Satisfaction
(Reinking & Alexander, 2005; Kirk, Singh, & Getz, 2001; Schwarz, Gairrett, Aruguete, & Gold,
2005)
• Athletics = Body Dissatisfaction
(George, 2005; Storch, Storch, Killiany, & Roberti, 2005)

13. Over-exercising
(Exercise Bulimia)
http://www.youtube.com/watch?v=0vG9Ixcp06A

14. Psychological Theories Impacting
Body Image and Eating Disorders
• Social Comparison Theory
• Body evaluation compared to
similar others
• Who do athletes compare to?
• Thin-Ideal Internalization
• Psychological acceptance of
societal standard for thinness
• Average Model: 5’11” and 117lbs
(National Eating Disorders
Association)
• Average athlete?

15. Lean Sports vs Non-Lean
Sports
Is Thin Ideal?
Lean Sports:
• Cross country running
• Track and Field (select events)
• Lightweight crew
• Gymnastics
• Dance
Non-Lean Sports
• Basketball
• Volleyball
• Soccer
• Field Hockey
• Hockey
• Softball
• Body ideals differ by sport
• Social Comparison?
• Thin ideal internalization?

16. Athlete Body Types
Shalane Flanagan
5’5”, 113lbs
American Record
Holder: 3,000m;
5,000m; 10,000m
Courtney Paris
6’4”, 250lbs
2-Time Collegiate All-
American; Former AP
Player of the Year
Hope Solo
5’9”, 152lbs
Starting goalie, US
Women’s National
Team

17. Athlete Body Types
Serena Williams
5’9”, 155lbs
No.1 ranked women’s
tennis player
Gabby Douglas
4’11”, 90lbs
Gold Medal Gymnast
Gabrielle Reece
6’3”, 170 lbs
Women’s Volleyball

18. Biological Factors and Body
Image among Athletes
• Body Mass Index (BMI)
• Higher BMI = Body Dissatisfaction
• BMI influenced by athletic participation
• Lean sport BMI? Non-lean sport BMI?
• Past vs. Present
• 1976 average gymnast: 5’3” ; 105lbs
• 1992 average gymnast: 4’9” ; 88 lbs

19. Biological Factors and Body
Image among Athletes
• Pubertal Timing
• Early maturation (early-onset menstruation)
associated with increased body dissatisfaction
• Athletics can lead to delayed menstruation
(Dusek, 2001; Kelntrou & Plyley, 2003)

20. Psychosocial Factors and
Body Image among Athletes
• Salience of minority body ideals
• African American females are typically less body dissatisfied and less concerned about
weight than their Caucasian peers (Compian, Gowen, & Hayward, 2004; Halpern, Udry,
Campbell, & Suchindran, 1999).
• According to the 2005-2006 NCAA student athlete race and ethnicity report (2008), 29%
of all female basketball players and 20% of all females running in track and field events
for NCAA Divisions I, II, and III are African American. At the Division I level, these
percentages rise to approximately 45% for basketball and 28% for track.
• Sexual Activity
• Early sexual activity, emphasis on relationships, early dating linked to body
dissatisfaction, disordered eating
• Athletics associated with lower rates of/engagement in sexual behavior
• Homosexuality
• Homosexual women tend to exhibit higher body satisfaction (Herzog et al, 1990;
Morrison, Morrison, & Sager, 2004; Conner, Johnson, & Grogan, 2004)
• Increased acceptability for lesbians in sport (O’Reilley & Cahn, 2007)

21. Eating Disorders and
Athletics
• Study 2009: Greenleaf, Petrie, Carter & Reel
• 204 college athletes from 17 sports
• Results:
• 2% Diagnosed Eating Disorder
• 25.5% symptomatic
• Exercise used for weight control
• 72.5% asymptomatic

22. Eating Disorders and
Athletics
• Study 2010: Martinsen, Bratland-Sanda Eriksson &
Borgen
• Adolescent elite athletes vs. non-athlete controls
• Results:
• Higher prevalence of non-athletes dieting and classified with
disordered eating
• Differences in motivation:
• Non-athletes: appearance-based
• Athletes: performance-based
• No differences between lean sport and non-lean sport athletes

23. Personality Similarities:
Elite Athletes and Anorexics
Anorexics
• Asceticism
• Excessive Exercise
• Perfectionism
• Overcompliance
• Selflessness
• Denial of Discomfort
Athletes
• Mental Toughness
• Commitment to Training
• Pursuit of Excellence
• Coachability
• Unselfishness
• Performance Despite Pain
Body Dissatisfied Athletes may be at higher
risk for Disordered Eating

24. Unique Concerns for Athletes
• “Win At All Cost Mentality”
• “If losing a few pounds is good for performance,
losing a lot of pounds will be amazing” ~Sarah
Sumpter: HS cross country standout, diagnosed with
Anorexia Nervosa

25. Unique Concerns for Athletes
• Competitive Thinness
• Social Comparison with teammates
• Pressure of athletic performance
• Increase in competition level is associated with
increased disordered eating (Thompson)
• Sports anxiety levels were predictive of levels of
bulimic symptoms and drive for thinness.
(Holm-Denoma, Scaringi, Gordon, Van Orden & Joiner, 2009)

26. Blurred Lines:
Athletes as Sex Symbols
Maria Sharapova
6’2’’, 130 lbs
Women’s Tennis
Association
Alex Morgan
5’8”, 137 lbs
U.S. Women’s
SoccerKerri Walsh Jennings
6’2”, 157lbs
Gold Medalist,
Women’s Beach Volleyball

27. Symptoms of ED
Physical/Medical
• Malnourished
• Dehydrated
• Fatigued
• Difficulty sleeping
• Medically compromised
Psychological
• Depressed
• Distracted
• Obsessed
• Anxious
• Difficulty relaxing
• Lack of concentration
• Drop in motivation

28. Providing Treatment
• Can never be subordinate to sport
• Cannot be skipped in order to train or compete
• Cannot be rushed
• Message: “sport performance is more important
than health of athlete”
• b/c sport is more important in the patient’s mind.
With their low self-esteem, convincing them that the
Tx is geared towards improving performance will
fulfill self-worth

29. Important
The therapist must understand the patient and learn
to value oneself for who the patient is rather than for
what she does, or looks like or weighs

30. Treatment to improve
athleticism?
• Goal: to attain and maintain a healthy weight that
allows the body to avoid typical medical and
psychological consequences of ED
• Improved performance
• Improved endurance
• Improved emotional state resulting in a greater
emotional connection with athletic performance
• More effective use of time

31. Treatment Methods
• Individual Therapy
• Group Therapy
• Family Therapy
• Self-Help
• Outpatient
• Pharmacotherapy
• Partial Hospitalization
• Inpatient
• Residential
• Inpatient Hospitalization
• Cognitive Behavioral
Therapy
• Involvement of coaches
and other sports personnel

32. Before treatment
• Must first be evaluated by a physician
• Teach the pt to gain the satisfaction of the ED by
other means that don’t involve food, weight or
exercise.
• Psychotherapist should have expertise in ED
• Psychotherapist should have experience with
athletes
• Must understand/value importance of sports in pt’s life
• Understands risk factors & pressures inherent in the sport

33. Individual Therapy
• Focuses on the individual patient
• Takes consideration of unique and specific issues
that predisposed, precipitated, and perpetuated
the eating disorder of the individual

34. Group Therapy
• Opportunity to participate and learn from other pts
• Opportunity for improving interpersonal
communication and relationships
• Group support – beneficial to recovery
• Immediate acceptance and comfort from other
group members

35. Family Therapy
• One or more family members are involved
• Parents become agents of change
• For child or adolescent; family is crucial
• More effective than for adults

36. Psychoeducation
• Information to pts with a psychological problem or
eating disorder
• Prevent relapse
• Provided to individuals, groups, and families
• Risk factors:
• Genetics, medical issues, exercise, and nutrition

37. Self-Help
• Improve outcome by teaching patients skills
necessary to overcome and manage difficulties
• Use self-help materials
• Books, videos, etc.
• Used in adjunct with other treatment methods

38. Outpatient
• Ideal method
• Allows person to maintain as normal a life as
possible while being in treatment
• Allows pt to live at home and continue school/work
• Intensive outpatient: 2-3 hrs/day, 2-4 days/wk

39. Pharmacotherapy (AN)
• Use of medications
• May be useful in adjuct with
psychotherapy
• Antidepressants – varying degrees of
success
• Not too effective during acute low weight
stages of anorexia
• Fluoxetine has been beneficial towards
relapse prevention
• Atypical antipsychotics (olanzapine) may
help promote weight gain with less fear and
resistance

40. Pharmacotherapy (BN)
• Anticonvulsants
• Antidepressants
• Medications involved with reducing binge eating and
vomiting, as well as related mood and anxiety
symptoms associated with BN
• Not the most effective treatments
• Often use meds designed to decrease frequency of
binge eating and facilitate weight loss for overweight
pts

41. Partial Hospitalization
• Designed for pts who do not need 24 hour care of
supervision and not ready for outpatient Tx
• 5 days/wk, 6-8 hrs/day
• Groups that are either therapy, psychoed., or
nutritional in nature
• Involves pharmacotherapy
• Cost effective compared to 24 hr care
• Allows patients to live outside of the hospital
• Lower dropout rates compared to inpatient
hospitalization

42. Inpatient Tx
• Disorder becomes out of control or so severe as
to result in dire medical psychological
consequences
• Weight is less than 85% minimal avg body wt
• Of expected, or significant rapid weight loss, low
heart rate, low BP, electrolyte abnormalities,
unstable vital signs, suicidal risk
• Lack of progress in outpatient program
• Require supervision during meals and bathroom
use

43. Residential Tx
• 24 hour supervision
• Home or dorm
• Not medically compromised
• All meals & snacks are monitored
• Nutritional guidance provided
• Complete bed rest

44. Cognitive Behavioral Therapy
• May reduce relapse risk for adults after weight is
restored
• Less known about efficacy during underwt state
• Decreased symptoms in the short term and long term
• Manual-based CBT had most empirical support for
treatment of BN

45. CBT
• Interpersonal psychotherapy (IP) –
• For depression
• Emphasis on relationships
• Dialectical behavior therapy
• For borderline disorder
• Adapted to ED
• Integrative cognitive affective therapy (ICAT) –
• For self-discrepancy
• The disparity btwn how a pt views himself and an ideal
self

46. Coach/Sport Personnel
Involvement
• Coach/sport personnel participate in therapy
sessions
• “sport family”
• Can play critical role in precipitating, perpetuating
or preventing EDs
• Increase likelihood of their power and influence
having a positive impact

47. Dietary Nutritional
Counseling and
Rehabilitation
• Involves the patient’s most feared object: FOOD
• Pt most often avoids or resists
• Semi-starvation affects all aspects of normal
functioning:
• Concentration, mood, personality, social behavior, sexual
interest, hunger, eating, metabolism, and health
• All conditions necessary for training/competition

48. Conclusion