Eating Disorders TOPIC OVERVIEW Anorexia Nervosa The Clinical Picture Medical Problems Bulimia Nervosa Binges Compensatory Behaviors Bulimia Nervosa Versus Anorexia Nervosa Binge-Eating Disorder What Causes Eating Disorders? Psychodynamic Factors: Ego Deficiencies Cognitive Factors Depression Biological Factors Societal Pressures Family Environment Multicultural Factors: Racial and Ethnic Differences Multicultural Factors: Gender Differences How Are Eating Disorders Treated? Treatments for Anorexia Nervosa Treatments for Bulimia Nervosa Treatments for Binge-eating Disorder Putting It Together: A Standard for Integrating Perspectives Shani, age 15: While I was learning to resist the temptation of hunger, I walked into the kitchen when no one was around, took a slice of bread out the packet, toasted it, spread butter on it, took a deep breath and bit. Guilty. I spat it in the trash and tossed the rest of it in and walked away. Seconds later I longed for the toast, walked back to the trash, popped open the lid and sifted around in the debris. I found it and contemplated, for minutes, whether to eat it. I brought it close to my nose and inhaled the smell of melted butter. Guilty. Guilty for trashing it. Guilty for craving it. Guilty for tasting it. I threw it back in the trash and walked away. No is no, I told myself. No is no. … And no matter how hard I would try to always have The Perfect Day in terms of my food, I would feel the guilt every second of every day. It reeked of shame, seeped with disgust and festered in disgrace. It was my desire to escape the guilt that perpetuated my compulsion to starve. In time I formulated a more precise list of “can” and “can’t” in my head that dictated what I was allowed or forbidden to consume…. It became my way of life. My manual. My blueprint. But more than that, it gave me false reassurance that my life was under control. I was managing everything because I had this list in front of me telling me what—and what not—to do…. In the beginning, starving was hard work. It was not innate. Day by day I was slowly lured into another world, a world that was as isolating as it was intriguing, and as rewarding as it was challenging…. That summer, despite the fact that I had lost a lot of weight, my mother agreed to let me go to summer camp with my fifteen-year-old peers, after I swore to her that I would eat. I broke that promise as soon as I got there…. At breakfast time when all the teens raced into the dining hall to grab cereal boxes and bread loaves and jelly tins and peanut butter jars, I sat alone cocooned in my fear. I fingered the plastic packet of a loaf of white sliced bread, took out a piece and tore off a corner, like I was marking a page in a book, onto which I dabbed a blob of peanut butter and jelly the size of a Q-tip. That was my breakfast. Every day. For three weeks. I tried to get to the showers when everyone else was at the beach so nobody would see me. I heard girls behind me whispering, “Tha ...

1. Eating Disorders
TOPIC OVERVIEW
Anorexia Nervosa
The Clinical Picture
Medical Problems
Bulimia Nervosa
Binges
Compensatory Behaviors
Bulimia Nervosa Versus Anorexia Nervosa
Binge-Eating Disorder
What Causes Eating Disorders?
Psychodynamic Factors: Ego Deficiencies
Cognitive Factors
Depression
Biological Factors
Societal Pressures
Family Environment
Multicultural Factors: Racial and Ethnic Differences
Multicultural Factors: Gender Differences
How Are Eating Disorders Treated?
Treatments for Anorexia Nervosa
Treatments for Bulimia Nervosa
Treatments for Binge-eating Disorder
Putting It Together: A Standard for Integrating Perspectives
Shani, age 15: While I was learning to resist the temptation of
hunger, I walked into the kitchen when no one was around, took
a slice of bread out the packet, toasted it, spread butter on it,
took a deep breath and bit. Guilty. I spat it in the trash and
tossed the rest of it in and walked away. Seconds later I longed
for the toast, walked back to the trash, popped open the lid and
sifted around in the debris. I found it and contemplated, for
minutes, whether to eat it. I brought it close to my nose and

2. inhaled the smell of melted butter. Guilty. Guilty for trashing it.
Guilty for craving it. Guilty for tasting it. I threw it back in the
trash and walked away. No is no, I told myself. No is no.
… And no matter how hard I would try to always have The
Perfect Day in terms of my food, I would feel the guilt every
second of every day. It reeked of shame, seeped with disgust
and festered in disgrace. It was my desire to escape the guilt
that perpetuated my compulsion to starve.
In time I formulated a more precise list of “can” and “can’t” in
my head that dictated what I was allowed or forbidden to
consume…. It became my way of life. My manual. My
blueprint. But more than that, it gave me false reassurance that
my life was under control. I was managing everything because I
had this list in front of me telling me what—and what not—to
do….
In the beginning, starving was hard work. It was not innate. Day
by day I was slowly lured into another world, a world that was
as isolating as it was intriguing, and as rewarding as it was
challenging….
That summer, despite the fact that I had lost a lot of weight, my
mother agreed to let me go to summer camp with my fifteen-
year-old peers, after I swore to her that I would eat. I broke that
promise as soon as I got there…. At breakfast time when all the
teens raced into the dining hall to grab cereal boxes and bread
loaves and jelly tins and peanut butter jars, I sat alone cocooned
in my fear. I fingered the plastic packet of a loaf of white sliced
bread, took out a piece and tore off a corner, like I was marking
a page in a book, onto which I dabbed a blob of peanut butter
and jelly the size of a Q-tip. That was my breakfast. Every day.
For three weeks.
I tried to get to the showers when everyone else was at the
beach so nobody would see me. I heard girls behind me
whispering, “That’s the girl I told you about that looks so
disgusting.” Someone invariably walked in on me showering
and covered her mouth with her hand like I was a dead body. I
wished I could disappear into the drain like my hair that was

3. falling out in chunks….
While everyone else was out there swimming, tanning, making
out, playing sports, volunteering and team building, I hid in my
tent and wrote letters to my mother reassuring her that I was
eating. I told her that I ate peanut butter and jelly sandwiches
every morning for breakfast….
[Upon returning to school] I was labeled the “concentration
camp victim.” On my return, over the months everyone watched
my body shrink as though it were being vacuum packed in slow
motion…. At my lowest weight my hipbones protruded like
knuckle bones under my dress and I had to minimize the
increments of the belt holes until there was so much extra belt
material dangling down that I did away with the belt
completely. My shoes were too big for my feet; my ankles were
so thin that I wore three pairs of socks at a time and still my
shoes would slide off my heels. And my panties were so baggy I
secured them with safety pins on the sides so they wouldn’t fall
down….
On the home front things were worse than ever. I moved to the
downstairs room, which had a separate entrance and bathroom,
and I locked my door and forbade anyone from entering. Even
so, my mother and I had screaming matches every day, with her
trying to convince me that “your body needs food as fuel” and
me retaliating with “I’m not hungry.” But the more she tried to
appeal to my rational side, the more stubborn I became in my
conviction….
For nine months my mother stood by, forbidden to interfere,
while I starved myself. She had no idea what was going on, nor
did I. All she knew was that I had changed. She watched me
transform from an innocent, soft, kind, loving girl into a
reclusive, vicious, aggressive, defiant teenager. She had lost her
little girl. And there was nothing she could say or do to stop
me. She knew that if my weight continued to drop radically that
she might lose me. But despite all her desperate attempts to
reach out to me … she had no way of getting through to me, let
alone helping me because, like with food, I slowly banned her

4. from my life….
(Raviv, 2010)
BETWEEN THE LINES
In Their Words
“Girls should be encouraged to take an interest in their
appearance when they are very young.”
Ladies’ Home Journal, 1940
It has not always done so, but Western society today equates
thinness with health and beauty. In fact, in the United States
thinness has become a national obsession. Most of us are as
preoccupied with how much we eat as with the taste and
nutritional value of our food. Thus it is not surprising that
during the past three decades we have also witnessed an
increase in two eating disorders that have at their core a morbid
fear of gaining weight. Sufferers of anorexia nervosa, like
Shani, are convinced that they need to be extremely thin, and
they lose so much weight that they may starve themselves to
death. People with bulimia nervosa go on frequent eating
binges, during which they uncontrollably consume large
quantities of food, and then force themselves to vomit or take
other extreme steps to keep from gaining weight. A third eating
disorder, binge-eating disorder, in which people frequently go
on eating binges but do not force themselves to vomit or engage
in other such behaviors, also appears to be on the rise. People
with binge-eating disorder do not fear weight gain to the same
degree as those with anorexia nervosa and bulimia nervosa, but
they do have many of the other features found in those disorders
(Alvarenga et al., 2014).
Are girls and women in Western society destined to struggle
with at least some issues
of eating and appearance?
The news media have published many reports about eating
disorders. One reason for the surge in public interest is the
frightening medical consequences that can result from the
disorders. The public first became aware of such consequences
in 1983 when Karen Carpenter died from medical problems

5. related to anorexia. Carpenter, the 32-year-old lead singer of the
soft-rock brother-and-sister duo called the Carpenters, had been
enormously successful and was admired by many as a
wholesome and healthy model to young women everywhere.
Another reason for the current concern is the disproportionate
prevalence of anorexia nervosa and bulimia nervosa among
adolescent girls and young women.
Anorexia Nervosa
Shani, 15 years old and in the ninth grade, displays many
symptoms of anorexia nervosa (APA, 2013). She purposely
maintains a significantly low body weight, intensely fears
becoming overweight, has a distorted view of her weight and
shape, and is excessively influenced by her weight and shape in
her self-evaluations (see Table 11-1).
table: 11-1Dx Checklist
Anorexia Nervosa
1.
Individual purposely takes in too little nourishment, resulting in
body weight that is very low and below that of other people of
similar age and gender.
2.
Individual is very fearful of gaining weight, or repeatedly seeks
to prevent weight gain despite low body weight.
3.
Individual has a distorted body perception, places inappropriate
emphasis on weight or shape in judgments of herself or himself,
or fails to appreciate the serious implications of her or his low
weight.
(Information from: APA, 2013.)
Like Shani, at least half of the people with anorexia nervosa
reduce their weight by restricting their intake of food, a pattern
called restricting-type anorexia nervosa. First they tend to cut
out sweets and fattening snacks; then, increasingly, they
eliminate other foods. Eventually people with this kind of
anorexia nervosa show almost no variability in diet. Others,
however, lose weight by forcing themselves to vomit after meals

6. or by abusing laxatives or diuretics, and they may even engage
in eating binges, a pattern called binge-eating/purging-type
anorexia nervosa, which you will read about in more detail in
the section on bulimia nervosa.
Ninety to 95 percent of all cases of anorexia nervosa occur in
females. Although the disorder can appear at any age, the peak
age of onset is between 14 and 20 years. Between 0.5 and 4.0
percent of all females in Western countries develop the disorder
in their lifetime, and many more display at least some of its
symptoms (Ekern, 2014; Smink et al., 2013; Stice et al., 2013).
It seems to be on the increase in North America, Europe, and
Japan.
Typically the disorder begins after a person who is slightly
overweight or of normal weight has been on a diet (Stice &
Presnell, 2010). The escalation toward anorexia nervosa may
follow a stressful event such as separation of parents, a move
away from home, or an experience of personal failure (Wilson
et al., 2003). Although most people with the disorder recover,
between 2 and 6 percent of them become so seriously ill that
they die, usually from medical problems brought about by
starvation, or from suicide (Suokas et al., 2013; Forcano et al.,
2010).The Clinical Picture
Becoming thin is the key goal for people with anorexia nervosa,
but fear provides their motivation. People with this disorder are
afraid of becoming obese, of giving in to their growing desire to
eat, and more generally of losing control over the size and
shape of their bodies. In addition, despite their focus on
thinness and the severe restrictions they may place on their food
intake, people with anorexia are preoccupied with food. They
may spend considerable time thinking and even reading about
food and planning their limited meals (Herzig, 2004). Many
report that their dreams are filled with images of food and
eating (Knudson, 2006).
This preoccupation with food may in fact be a result of food
deprivation rather than its cause. In a famous “starvation study”
conducted in the late 1940s, 36 normal-weight conscientious

7. objectors were put on a semistarvation diet for six months
(Keys et al., 1950). Like people with anorexia nervosa, the
volunteers became preoccupied with food and eating. They
spent hours each day planning their small meals, talked more
about food than about any other topic, studied cookbooks and
recipes, mixed food in odd combinations, and dawdled over
their meals. Many also had vivid dreams about food.
Laboratory starvation Thirty-six conscientious objectors who
were put on a semistarvation diet for six months developed
many of the symptoms seen in anorexia nervosa and bulimia
nervosa (Keys et al., 1950).
Persons with anorexia nervosa also think in distorted ways.
They usually have a low opinion of their body shape, for
example, and consider themselves unattractive (Boone et al.,
2014; Siep et al., 2011). In addition, they are likely to
overestimate their actual proportions. While most women in
Western society overestimate their body size, the estimates of
those with anorexia nervosa are particularly high. In one of her
classic books on eating disorders, Hilde Bruch, a pioneer in this
field, recalled the self-perceptions of a 23-year-old patient:
I look in a full-length mirror at least four or five times daily
and I really cannot see myself as too thin. Sometimes after
several days of strict dieting, I feel that my shape is tolerable,
but most of the time, odd as it may seem, I look in the mirror
and believe that I am too fat.
(Bruch, 1973)
This tendency to overestimate body size has been tested in the
laboratory (Delinsky, 2011; Farrell, Lee, & Shafran, 2005). In a
popular assessment technique, research participants look at a
photograph of themselves through an adjustable lens. They are
asked to adjust the lens until the image that they see matches
their actual body size. The image can be made to vary from 20
percent thinner to 20 percent larger than actual appearance. In
one study, more than half of the individuals with anorexia
nervosa overestimated their body size, stopping the lens when

8. the image was larger than they actually were.
Seeing is deceiving In one research technique, people look at
photographs of themselves through a special lens and adjust the
lens until they see what they believe is their actual image. A
research participant may change her actual image (left) from 20
percent thinner (middle) to 20 percent larger (right).
The distorted thinking of anorexia nervosa also takes the form
of certain maladaptive attitudes and misperceptions (Alvarenga
et al., 2014; Fairburn et al., 2008). Sufferers tend to hold such
beliefs as “I must be perfect in every way”; “I will become a
better person if I deprive myself “; and “I can avoid guilt by not
eating.”
People with anorexia nervosa also have certain psychological
problems, such as depression, anxiety, low self-esteem, and
insomnia or other sleep disturbances (Forsén Mantilla,
Bergsten, & Birgegård, 2014; Holm-Denoma et al., 2014). A
number grapple with substance abuse (Mann et al., 2014;
Steiger & Israel, 2010). And many display obsessive-
compulsive patterns (Degortes et al., 2014; Friederich &
Herzog, 2011). They may set rigid rules for food preparation or
even cut food into specific shapes. Broader obsessive-
compulsive patterns are common as well. Many, for example,
exercise compulsively, prioritizing exercise over most other
activities in their lives (Fairburn et al., 2008). In some research,
people with anorexia nervosa and others with obsessive-
compulsive disorder score equally high for obsessiveness and
compulsiveness. Finally, persons with anorexia nervosa tend to
be perfectionistic, a characteristic that typically precedes the
onset of the disorder (Boone et al., 2014).Medical Problems
The starvation habits of anorexia nervosa cause medical
problems (Faje et al., 2014; Suokas et al., 2014; Oflaz et al.,
2013). Women develop amenorrhea, the absence of menstrual
cycles. Other problems include lowered body temperature, low
blood pressure, body swelling, reduced bone mineral density,
and slow heart rate. Metabolic and electrolyte imbalances also

9. may occur and can lead to death by heart failure or circulatory
collapse. The poor nutrition of people with anorexia nervosa
may also cause skin to become rough, dry, and cracked; nails to
become brittle; and hands and feet to be cold and blue. Some
people lose hair from the scalp, and some grow lanugo (the fine,
silky hair that covers some newborns) on their trunk,
extremities, and face. Shani, the young woman whose self-
description opened this chapter, recalls how her body
deteriorated as her disorder was progressing:
Nobody knew that I was always cold no matter how many layers
I wore. And that my hair came out in thick wads whenever I wet
it or washed it. That I stopped menstruating. That at night I lay
awake agonizing over thoughts of the day’s consumption. That
the guilt I carried every day weighed on me like lead. That my
hipbones hurt to lie on my stomach and my coccyx hurt to sit on
the floor. And that the concave feeling in my stomach of dying
hunger left in its place an anger that would destroy all feeling.
(Raviv, 2010)
Across the generations When famous television journalist Katie
Couric interviewed popular singer Demi Lovato in 2012, it
turned out that the two had an important thing in common—
eating disorders. Lovato has spoken openly for years about her
body image issues and eating struggles, but not until this
interview did Couric reveal that she had experienced similar
problems in the past. She noted, “I wrestled with bulimia all
through college and for two years after that.”Bulimia Nervosa
table: 11-2Dx Checklist
Bulimia Nervosa
1.
Repeated binge eating episodes.
2.
Repeated performance of ill-advised compensatory behaviors
(e.g., forced vomiting) to prevent weight gain.
3.
Symptoms take place at least weekly for a period of 3 months.

10. 4.
Inappropriate influence of weight and shape on appraisal of
oneself.
(Information from: APA, 2013.)
People with bulimia nervosa—a disorder also known as binge-
purge syndrome—engage in repeated episodes of uncontrollable
overeating, or binges. A binge episode takes place over a
limited period of time, often two hours, during which the person
eats much more food than most people would eat during a
similar time span (APA, 2013). In addition, people with this
disorder repeatedly perform inappropriate compensatory
behaviors, such as forcing themselves to vomit; misusing
laxatives, diuretics, or enemas; fasting; or exercising
excessively (see Table 11-2). Lindsey, a woman who has since
recovered from bulimia nervosa, describes a morning during her
disorder:
Today I am going to be really good and that means eating
certain predetermined portions of food and not taking one more
bite than I think I am allowed. I am very careful to see that I
don’t take more than Doug does. I judge by his body. I can feel
the tension building. I wish Doug would hurry up and leave so I
can get going!
As soon as he shuts the door, I try to get involved with one of
the myriad of responsibilities on the list. I hate them all! I just
want to crawl into a hole. I don’t want to do anything. I’d rather
eat. I am alone, I am nervous, I am no good, I always do
everything wrong anyway, I am not in control, I can’t make it
through the day, I just know it. It has been the same for so long.
I remember the starchy cereal I ate for breakfast. I am into the
bathroom and onto the scale. It measures the same, but I don’t
want to stay the same! I want to be thinner! I look in the mirror,
I think my thighs are ugly and deformed looking. I see a lumpy,
clumsy, pear-shaped wimp. There is always something wrong
with what I see. I feel frustrated trapped in this body and I don’t
know what to do about it.
I float to the refrigerator knowing exactly what is there. I begin

11. with last night’s brownies. I always begin with the sweets. At
first I try to make it look like nothing is missing, but my
appetite is huge and I resolve to make another batch of
brownies. I know there is half of a bag of cookies in the
bathroom, thrown out the night before, and I polish them off
immediately. I take some milk so my vomiting will be smoother.
I like the full feeling I get after downing a big glass. I get out
six pieces of bread and toast one side in the broiler, turn them
over and load them with patties of butter and put them under the
broiler again till they are bubbling. I take all six pieces on a
plate to the television and go back for a bowl of cereal and a
banana to have along with them. Before the last toast is
finished, I am already preparing the next batch of six more
pieces. Maybe another brownie or five, and a couple of large
bowlfuls of ice cream, yogurt or cottage cheese. My stomach is
stretched into a huge ball below my ribcage. I know I’ll have to
go into the bathroom soon, but I want to postpone it. I am in
never-never land. I am waiting, feeling the pressure, pacing the
floor in and out of the rooms. Time is passing. Time is passing.
It is getting to be time.
I wander aimlessly through each of the rooms again tidying,
making the whole house neat and put back together. I finally
make the turn into the bathroom. I brace my feet, pull my hair
back and stick my finger down my throat, stroking twice, and
get up a huge pile of food. Three times, four and another pile of
food. I can see everything come back. I am glad to see those
brownies because they are SO fattening. The rhythm of the
emptying is broken and my head is beginning to hurt. I stand up
feeling dizzy, empty and weak. The whole episode has taken
about an hour.
(Hall & Cohn, 2010, p. 1; Hall, 1980 pp. 5–6)
BETWEEN THE LINES
Royal Bulimia?
During her three years as queen of England, Anne Boleyn, King
Henry VIII’s second wife, displayed a habit, first observed

12. during her coronation banquet, of vomiting during meals. In
fact, she assigned a lady-in-waiting the task of holding up a
sheet when the queen looked likely to vomit (Shaw, 2004).
Like anorexia nervosa, bulimia nervosa usually occurs in
females, again in 90 to 95 percent of the cases (Sanftner &
Tantillo, 2011). It begins in adolescence or young adulthood
(most often between 15 and 20 years of age) and often lasts for
years, with periodic letup (Stice et al., 2013). The weight of
people with bulimia nervosa usually stays within a normal
range, although it may fluctuate markedly within that range.
Some people with this disorder, however, become seriously
underweight and may eventually qualify for a diagnosis of
anorexia nervosa instead (see Figure 11-1).
figure11-1Overlapping patterns of anorexia nervosa, bulimia
nervosa, and obesity
Some people with anorexia nervosa binge and purge their way
to weight loss, and some obese people binge eat. However, most
people with bulimia nervosa are not obese, and most overweight
people do not binge eat.
Many teenagers and young adults go on occasional eating
binges or experiment with vomiting or laxatives after they hear
about these behaviors from their friends or the media. Indeed,
according to global studies, 25 to 50 percent of all students
report periodic binge eating or self-induced vomiting (Ekern,
2014; Zerbe, 2008; McDermott & Jaffa, 2005). Only some of
these individuals, however, qualify for a diagnosis of bulimia
nervosa. Surveys in several Western countries suggest that as
many as 5 percent of women develop the full syndrome (Ekern,
2014; Touchette et al., 2011). Among college students the rate
may be much higher (Zerbe, 2008).
Eating for sport Many people go on occasional eating binges. In
fact, sometimes binges are officially endorsed, as you see in
this photo from the annual Nathan’s Famous International Hot
Dog Eating Contest in Brooklyn’s Coney Island, New York.

13. However, people are considered to have an eating disorder only
when the binges recur, the pattern endures, and the issues of
weight or shape dominate self-evaluation.Binges
People with bulimia nervosa may have between 1 and 30 binge
episodes per week (Fairburn et al., 2008). In most cases, they
carry out the binges in secret. The person eats massive amounts
of food very rapidly, with minimal chewing—usually sweet,
high-calorie foods with a soft texture, such as ice cream,
cookies, doughnuts, and sandwiches. The food is hardly tasted
or thought about. Binge eaters consume an average of 3400
calories during an episode. Some individuals consume as many
as 10,000 calories.
Binges are usually preceded by feelings of great tension. The
person feels irritable, “unreal,” and powerless to control an
overwhelming need to eat “forbidden” foods. During the binge,
the person feels unable to stop eating (APA, 2013). Although
the binge itself may be experienced as pleasurable in the sense
that it relieves the unbearable tension, it is followed by feelings
of extreme self-blame, shame, guilt, and depression, as well as
fears of gaining weight and being discovered (Sanftner &
Tantillo, 2011; Goss & Allan, 2009).Compensatory Behaviors
After a binge, people with bulimia nervosa try to compensate
for and undo its effects. Many resort to vomiting, for example.
But vomiting actually fails to prevent the absorption of half of
the calories consumed during a binge. Furthermore, repeated
vomiting affects one’s general ability to feel satiated; thus it
leads to greater hunger and more frequent and intense binges.
Similarly, the use of laxatives or diuretics largely fails to undo
the caloric effects of bingeing (Fairburn et al., 2008).
BETWEEN THE LINES
Climate Control
Women who live in warmer climates (where more revealing
clothing is worn) have lower weight, engage in more binge
eating and purging, and have more body image concerns than
women who live in cooler climates (Sloan, 2002).

14. Vomiting and other compensatory behaviors may temporarily
relieve the uncomfortable physical feelings of fullness or reduce
the feelings of anxiety and self-disgust attached to binge eating
(Stewart & Williamson, 2008). Over time, however, a cycle
develops in which purging allows more bingeing, and bingeing
necessitates more purging. The cycle eventually causes people
with the disorder to feel powerless and disgusted with
themselves (Sanftner & Tantillo, 2011; Hayaki et al., 2002).
Most recognize fully that they have an eating disorder. Lindsey,
the woman we met earlier, recalls how the pattern of binge
eating, purging, and self-disgust took hold while she was a
teenager in boarding school.
Every bite that went into my mouth was a naughty and selfish
indulgence, and I became more and more disgusted with
myself….
The first time I stuck my fingers down my throat was during the
last week of school. I saw a girl come out of the bathroom with
her face all red and her eyes puffy. She had always talked about
her weight and how she should be dieting even though her body
was really shapely. I knew instantly what she had just done and
I had to try it….
I began with breakfasts which were served buffet-style on the
main floor of the dorm. I learned which foods I could eat that
would come back up easily. When I woke in the morning, I had
to make the decision whether to stuff myself for half an hour
and throw up before class, or whether to try and make it through
the whole day without overeating…. I always thought people
noticed when I took huge portions at mealtimes, but I figured
they assumed that because I was an athlete, I burned it off….
Once a binge was under way, I did not stop until my stomach
looked pregnant and I felt like I could not swallow one more
time.
That year was the first of my nine years of obsessive eating and
throwing up…. I didn’t want to tell anyone what I was doing,
and I didn’t want to stop…. [Though] being in love or other
distractions occasionally lessened the cravings, I always

15. returned to the food.
(Hall & Cohn, 2010, p. 55; Hall, 1980, pp. 9–12)
As with anorexia nervosa, a bulimic pattern typically begins
during or after a period of intense dieting, often one that has
been successful and earned praise from family members and
friends (Stice & Pressnell, 2010; Couturier & Lock, 2006).
Studies of both animals and humans have found that normal
research participants placed on very strict diets also develop a
tendency to binge (Pankevich et al., 2010; Eifert et al., 2007).
Some of the participants in the conscientious objector
“starvation study,” for example, later binged when they were
allowed to return to regular eating, and a number of them
continued to be hungry even after large meals (Keys et al.,
1950).Bulimia Nervosa Versus Anorexia Nervosa
Miss America speaks out Kirsten Haglund is crowned Miss
America at the January 2008 pageant. During her one-year
reign, Haglund openly acknowledged her past struggles with
anorexia nervosa. In recent years, she has continued to travel
and speak about body-image issues and eating disorders. She
also has started a foundation to provide treatment services for
women who have eating disorders.
Bulimia nervosa is similar to anorexia nervosa in many ways.
Both disorders typically begin after a period of dieting by
people who are fearful of becoming obese; driven to become
thin; preoccupied with food, weight, and appearance; and
struggling with depression, anxiety, obsessiveness, and the need
to be perfect (Boone et al., 2014; Holm-Denoma et al., 2014).
People with either of the disorders have a heightened risk of
suicide attempts (Suokas et al., 2014; Keel & McCormick,
2010). Substance abuse may accompany either disorder, perhaps
beginning with the excessive use of diet pills (Mann et al.,
2014; Steiger & Israel, 2010). People with either disorder
believe that they weigh too much and look too heavy regardless
of their actual weight or appearance (Boone et al., 2014; Siep et
al., 2011) (see InfoCentral below). And both disorders are

16. marked by disturbed attitudes toward eating (Alvarenga et al.,
2014).
Yet the two disorders also differ in important ways. Although
people with either disorder worry about the opinions of others,
those with bulimia nervosa tend to be more concerned about
pleasing others, being attractive to others, and having intimate
relationships (Zerbe, 2010, 2008; Eddy et al., 2004). They also
tend to be more sexually experienced and active than people
with anorexia nervosa (Gonidakis et al., 2014). Particularly
troublesome, they are more likely to have long histories of
mood swings, become easily frustrated or bored, and have
trouble coping effectively or controlling their impulses and
strong emotions (Boone et al., 2014; Lilenfeld, 2011; Halmi,
2010). As many as one-third of those with bulimia nervosa
display the characteristics of a personality disorder, particularly
borderline personality disorder, which you will be looking at
more closely in Chapter 16 (Reas et al., 2013; Rowe et al.,
2011, 2010).
InfoCentral
BODY DISSATISFACTION
People who evaluate their weight and shape negatively are
experiencing body dissatisfaction. Around 73% of all girls and
women are dissatisfied with their bodies, compared with 56% of
all boys and men (Mintem et al., 2014). The vast majority of
dissatisfied females believe they are overweight; in contrast,
half of dissatisfied males consider themselves overweight and
half consider themselves underweight. The factors most closely
tied to body dissatisfaction are perfectionism and unrealistic
expectations (Wade & Tiggemann, 2013). Body dissatisfaction
is the single most powerful contributor to dieting and to the
development of eating disorders.
Another difference is the nature of the medical complications
that accompany the two disorders (Corega et al., 2014;
Birmingham, 2011; Mitchell & Crow, 2010). Only half of

17. women with bulimia nervosa are amenorrheic or have very
irregular menstrual periods, compared with almost all of those
with anorexia nervosa. On the other hand, repeated vomiting
bathes teeth and gums in hydrochloric acid, leading some
women with bulimia nervosa to have serious dental problems,
such as breakdown of enamel and even loss of teeth. Moreover,
frequent vomiting or chronic diarrhea (from the use of
laxatives) can cause dangerous potassium deficiencies, which
may lead to weakness, intestinal disorders, kidney disease, or
heart damage.
Turning point When soft-rock star Karen Carpenter (right)
received an award from fellow musician Emmylou Harris at the
1977 Billboard Music Awards, few people paid much attention
to her symptoms. Carpenter’s 1983 death helped change the
public’s view of anorexia nervosa.
Binge-Eating Disorder
Like those with bulimia nervosa, people with binge eating
disorder engage in repeated eating binges during which they
feel no control over their eating (APA, 2013). However, they
do not perform inappropriate compensatory behavior
(see Table 11-3). As a result of their frequent binges, around
two-thirds of people with binge-eating disorder become
overweight or even obese (Brauhardt et al., 2014; Claudino &
Morgan, 2012).
table: 11-3Dx Checklist
Binge-Eating Disorder
1.
Recurrent binge-eating episodes.
2.
Binge-eating episodes include at least three of these features: •
Unusually fast eating • Absence of hunger • Uncomfortable
fullness • Secret eating due to sense of shame • Subsequent
feelings of self-disgust, depression, or severe guilt.
3.
Significant distress.

18. 4.
Binge-eating episodes take place at least weekly over the course
of 3 months.
5.
Absence of excessive compensatory behaviors.
(Information from: APA, 2013.)
Binge-eating disorder was first recognized more than 50 years
ago as a pattern common among many overweight people
(Stunkard, 1959). It is important to recognize, however, that
most overweight people do not engage in repeated binges; their
weight results from frequent overeating and/or a combination of
biological, psychological, and sociocultural factors (ANAD,
2014; Claudino & Morgan 2012).
Between 2 and 7 percent of the population have binge-eating
disorder (Smink et al., 2013; Stice et al., 2013; Hudson et al.,
2007). The binges that characterize this pattern are similar to
those seen in bulimia nervosa, particularly the amount of food
eaten and the sense of loss of control experienced during the
binge. Moreover, like people with bulimia nervosa or anorexia
nervosa, those with binge-eating disorder typically are
preoccupied with food, weight, and appearance; base their
evaluation of themselves largely on their weight and shape;
misperceive their body size and are extremely dissatisfied with
their body; struggle with feelings of depression, anxiety, and
perfectionism; may abuse substances; and typically first develop
the disorder in adolescence or young adulthood (Brauhardt et
al., 2014; Pearl et al., 2014; Stice et al., 2013). On the other
hand, although they aspire to limit their eating, people with
binge-eating disorder are not as driven to thinness as those with
anorexia nervosa and bulimia nervosa. Also, unlike the other
eating disorders, binge-eating disorder does not necessarily
begin with efforts at extreme dieting. Nor are there large gender
differences in the prevalence of binge-eating disorder (ANAD,
2014; Grucza et al., 2007).