Eating Disorders PDF

Eating Disorders LEARNING OBJECTIVES 1. Describe the various types of eating disorders. 2. Explain the etiology of eating disorders from a biopsychosocial perspective, including the role of the family. 3. Describe the treatment of eating disorders, including the role of cognitive-behavioural t her...

Eating Disorders LEARNING OBJECTIVES 1. Describe the various types of eating disorders. 2. Explain the etiology of eating disorders from a biopsychosocial perspective, including the role of the family. 3. Describe the treatment of eating disorders, including the role of cognitive-behavioural t herapy. 4. Discuss the need to prevent eating disorders. Brief Case Example Recovering from Anorexia Nervosa compulsive traits and depressive symptoms) and gained to a weight of 98 lb. At discharge, she was maintaining her weight on WHEN MS. A was first evaluated for admission to an inpatient eating food but remained concerned about her w eight and was particu- disorders program, she had been restricting her food in take for larly frightened of reaching "the triple digits" (i.e., 100 lb). After approximately 5 years and had been amenorrheic for 4 years. At the leaving the hospital, Ms. A continued with outpatient psychother- time of her admission, this 24-year-old, single, white woman weighed apy and fluoxetine for several months... 71 lb at a height of 5 feet 1.5 inches. In 12th grade, Ms. A menstruated About 3.5 years after discharge, at age 27 years, Ms. A again for the first time and also developed "very large breasts. She had a sought inpatient treatment. At admission, she weighed 83 lb but difficult first year at college, where she gained to her maximum weight still felt " fat." During hospitalization, she steadily gained weight of 120 lb. The following year, Ms. A transferred to a smaller college, and was prescribed sertraline at 100 mg/ day for feelings of low became a vegetarian for "ethical reasons," and began to significantly self-esteem, anxiety, and obsessional thinking. When she was dis- restrict her food intake. She limited herself to a total of 700 to 800 cal- charged five months later, at a weight of 108 lb, she noted men- ories per day, with a maximum of200 calories per meal, and gradually strual bleeding for the first time in more than 7 years. After leaving lost weight in the next 5 years. Ms. A did not binge, vomit, abuse laxa- the hospital, Ms. A contin ued taking medication and began outpa- tives, or engage in excessive exercise. She considered herself to be tient cognitive-behavioral psychotherapy. For the next year, she "obsessed with calories" and observed a variety of rituals regarding continued to struggle with eating and weight issues but managed food and food preparation (e.g., obsessively weighing her food)... to maintain her weight and successfully expand other aspects of During her first five-month hospitalization, Ms. A was treated her life by independently supporting herself with a full-time job, with a multi modal program (behavioural weight gain protocol, indi- making new friends, and becoming involved in her first romantic L ual and fami ly therapy, fluoxetine at 60- 80 mg for obsessive- relationship. (Walsh, 2003, pp. 1516-1517) Many cultures are preoccupied with eating. In North America often reflect transitions involving physiological processes (e.g., today, gourmet restaurants abound and numerous magazines puberty) and life transitions (e.g., going to university). and television shows are devoted to food preparation. At the Although clinical descriptions of eating disorders can be same time, many people are overweight. Dieting to lose weight traced back many years, these disorders appeared in the DSM is common, and the desire of many people, especially women, for the first time only in 1980, as one subcategory of disorders to be slimmer has created a multi-billion-dollar-a-year busi- beginning in childhood or adolescence. With the publication ness. Given this intense interest in food and eating, it is not of DSM-IV, the eating disorders anorexia nervosa and bulimia surprising that this aspect of human behaviour is subject to nervosa formed a distinct category, reflecting the increased disorder. The case of Ms. A in the brief case example illustrates attention they have received from clinicians and researchers several relevant themes, including how eating disorder symptoms over the past three decades. As will be discussed, binge eating 280  Eating Disorders 281 disorder is another distinct diagnostic category that is now offi- According to Statistics Canada's 2002 Mental Health and cially included in OSM-5. Improved criteria fo r anorexia nervosa Well-being Survey (CCHS, 1.2; see Government of Canada, and bulimia nervosa have also been introduced. 2006), 0.5% of Canadians 15 years of age or older reported an Just how common are eating disorders? The prevalence eating disorder diagnosis in the preceding 12 months. Women and correlates of eating disorders were assessed in a nation- were once again more likely than men to report an eating disor- ally representative household survey conducted in the United der: 0.8% vs. 0.2%, respectively. Among young women aged 15 States between 2001 and 2003 (see Hudson, Hiripi, Pope, & to 24, 1.5% reported that they had an eating disorder. Analyses Kessler, 2007). The lifetime prevalence estimates of anorexia of the CCHS data also determined that 1.7% of Canadians met nervosa were 0.9% for women and 0.3% for men. The lifetime 12-month criteria for an eating attitude problem. prevalence estimates of bulimia nervosa were 1.5% for women Particularly alarming is the growing tendency for children and 0.5% for men. Finally, the lifetime prevalence estimates between the ages of 5 and 9 years old to be admitted to a hos- of binge eating disorder were 3.5% for women and 2.0% for pital for an eating disorder. This was noted in a 2012 British sur- men. While there is a clear sex difference, it is still the case vey, which found that 197 children in the past three years had overall that 1 in 3 or 1 in 4 cases involve boys or young men. received treatment. Leora Pinhas confirmed that this is also A follow-up study of the prevalence of binge eating disorder taking place in Canada (see Chung, 2012). According to Pin has, around the world conducted by Kessler et al. (2013) used World the eating disorders program at Sick Kids Hospital provided Health Organization data gathered on over 24,000 participants treatment to 166 children (aged 5 to 12 years old) in the same from 14 countries. They found that the lifetime prevalence three-year period. of binge eating disorder was higher than the rate for bulimia Eating disorders can cause long-term psychological, social, nervosa (1.4% vs. 0.8%). The disorders were similar in terms and health problems. Hospitalization is sometimes necessary. of age of onset (late teen years to early 20s) but it was slightly Hospitalization rates are highest among young women in earlier for those with bulimia nervosa. Bulimia was also distin- the 15 to 19 age range (Government of Canada, 2006; see guished by having a longer persistence (6.5 years vs. 4.3 years). Figure 10.1). However, rates are also high among those aged 10 An extended analysis later showed that the two disorders had t o 14 and 20 to 24. comparable levels of role impairment associated with them (Kessler et al., 2014). 70...................................................................................................................................................................................................................................... § 60 Ir· 1 Women Men 0.,... 0 50 "- Q) c. 40 "'c0 +:: 30 cu.fl 20 ·a. :c"' 0 10 0 c.9 < c "' Cultural standards regarding the ideal feminine shape have changed over time. Even in the 1950s and 1960s, the feminine ideal was considerably heavier than what it has been since then. 2009, p. 407). Furthermore, the excessive exercise seen among gain, thus increasing the perceived need to engage in dieting some people with eating disorders would increase opioids and that may become excessive. thus be reinforcing (Davis, 1996; Epling & Pierce, 1992). Hardy and This model's initial emphasis on genetic polymorphisms is Waller {1988) hypothesized that bulimia is mediated by low levels in keeping with recent attempts by researchers to link the neu- of endogenous opioids, which are thought to promote craving; rotransmitters implicated in eating disorders with genetic dif- a euphoric state is then produced by the ingestion of food, thus ferences. Indeed, one meta-analysis of eight studies focusing on reinforcing bingeing. serotonin found strong evidence of a role in anorexia nervosa Some data support the theory that endogenous opioids do for genetic variance in the serotonin transporter gene promoter play a role in eating disorders, at least in bulimia (see Con nan & (Lee & Lin, 2010). However, there was no apparent link between Stanley, 2003). Waller et al. (1986) found low levels of the endog- genetic variance in the serotonin transporter for bulimia nervosa. enous opioid beta-endorphin in people with bulimia; the more Though we can expect further significant advances in bio- severe cases of bulimia had the lowest levels of beta-endorphin. chemical research in the future, keep in mind that this work Bencherif et al. (2005) used brain MRI techniques to establish focuses principally on brain mechanisms relevant to hunger, that clients with bulimia have decreased regional mu-opioid eating, and satiety and a key question is whether attempts are receptor binding in the insular cortex and this is Inversely corre- made to account for other key features of both disorders, par- lated with fasting behaviour. Perhaps low levels of endogenous ticularly the intense fear of becoming fat. Clearly, the social and opioids can help account, at least partly, for the intentional acts cultural environments appear to play a role in the faulty per- of self-harm expressed by those with eating disorders. Bresin ceptions and eating habits of those with eating disorders, and and Gordon (2013) reviewed evidence linking non-suicidal it is to these influences we now turn. self-injury with the release of opioids as well as evidence linking this release of opioids with regulation of negative affect. Finally, some research has focused on several neuro- Socio-Cultural Variables transmitters related to eating and satiety (feeling full). Several studies have identified low levels of serotonin metabolites Throughout history, the standards societies have set for the in people with bulimia (e.g., Steiger et al., 2003), and sero- ideal body-especially the ideal female body-have varied tonin metabolites have been linked with the negative mood greatly. Think of the famous nudes painted by Rubens in the and self-concept changes that precipitate binge episodes seventeenth century; according to modern standards, these (Steiger et al., 2005). Evidence has now accumulated and con- women are chubby (see images). In recent times in our cul- tinues to support the role of a serotonin deficit in bulimia ture, there has been a steady progression toward increasing nervosa (see Hildebrandt, Alfano, Tricamo, & Pfaff, 2010). In thinness as the ideal. Playboy magazine centrefolds became fact, Hildebrandt et al. (2010) have advanced a development thinner between 1959 and 1978 (Garner, Garfinkel, Schwartz, & model that links serotonin and estrogen in bulimia nervosa. Thompson, 1980). A follow-up investigation of Playboy centre- Key premises of this model are that genetic polymorphisms folds found the trend toward portrayals of increasing thinness at birth limit the serotonergic system, and associated genes has levelled off and may even be reversing somewhat (Sypeck may be further limited by exposure to harsh environments in et al., 2006). However, while the images have suggested increasing the form of maladaptive parenting styles. Subsequent envi- heaviness, the normative weight displayed is still considerably ronmental estrogens predispose female adolescents to weight lower than ls healthy. 292 CHAPTER 10 Ea t ing Disorders When it comes to the promotion of unrealistic images, females While she could not visually perceive unrealistic body images, consistently feel more pressure than males. Even toys reflect the appearance pressures were conveyed in other ways. How does unrealistic pressures on females; to achieve the same figure as Barbie come into this situation? This young woman with bulimia another ideal, the Barbie doll, the average American woman would nervosa said that she first became aware of unrealistic beauty have to increase her bust by 12 inches, reduce her waist by 10, standards when she first played with her Barbie doll when she was and grow to over seven feet in height {Moser, 1989)! {See photo.) 13 years old. She noted Barbie's "amazingly long legs, small waist, The insidious effects of exposing young girls to Barbie dolls with and small face" and that "she became incredibly angry with her unrealistic body images was shown in an experiment (see Dittmar, Barbie doll because she did not look like her" (p. 2). As she picked Halliwell, & Ive, 2006). Five- and six-year-old girts exposed to Barbie up on other cues via Internet searches and in conversations, this images suffered lower body esteem and greater desire to achieve young woman indicated that "she started to feel a pressure to be the thin ideal. The manufacturer of the Barbie doll responded to thin because she learned from the media that if she wanted to be public pressue by introducing several new versions of Barbie in accepted and successful, she needed to be perfect" (p. 2). 2016 in an effort to not only increase sales, but to also be more Body image pressures can contribute to restrictive eating realistic and inclusive and decrease the body image pressures on behaviours in various ways. Chaiken and Pliner (see Chaiken & girls. And now a contemporary analysis of the top 150 video games Plainer, 1987; Pliner & Chaiken, 1990) advanced the theory that has confirmed this tendency to portray female body types as being women respond to these socio-cultural pressures by eating too thin, especially in games geared toward children, as opposed lightly in an attempt to project images of femininity. Research in to games for adults (Martins, Williams, Harrison, & Ratan, 2009). laboratory and naturalistic settings has confirmed that women This same research team has established that males portrayed who are portrayed as eating heavily are indeed seen as less in video games are systematically large on every body dimension feminine and more masculine than women who are portrayed measured vs. the actual norms for males (Martins, Williams, Ratan, as eating light meals. Pliner and Chaiken have coined the term & Harrison, 2011). There is an increasing focus in the research lit- the Scarlett O'Hara effect to refer to this phenomenon of eat- erature on how many of the same issues that have been focused ing lightly to project femininity. In Gone with the Wind, Mammy on among females also tend to apply to males as well. There is admonishes Scarlett to eat a meal prior to going to a barbecue growing evidence of the role of body dissatisfaction and how the so that she would appear dainty by eating very little. idealization of a hyper-mesomorphic lean and muscular body While cultural standards and pressures to be thin were ideal for males is providing the kind of pressure and dissatisfaction increasing, more and more people were becoming overweight. that underscores problems in body image, eating behaviours, and The prevalence of obesity has doubled since 1900; currently 20 associated problems in health and well-being (see McFartand & to 30% of North Americans are overweight and there are con- Petrie, 2012). As a result, a measure of male body dissatisfaction tinuing references to an obesity epidemic. Pine!, Assanand, and has been created recently (McFarland & Petrie, 2012). Lehman (2000) attribute the increasing prevalence of obesity to The dangers inherent in trying to live up to the unrealistic an evolutionary tendency for humans to eat to excess to store Barbie image were illustrated in a unique case study reported energy in their bodies for a time when food may be less plenti- by Simeunovic Ostojic and Hansen (2013). They provided an ful. If so, this tendency to overconsume is clearly at odds with account of a 28-year-old Dutch woman with a 10-year history unrealistic pressures to maintain ideal body weights. of bulimia nervosa who was exceptionally sensitive to socio- Kevin Thompson and his associates have documented cultural pressures to be thin despite being congenitally blind. differences among females and males in the extent of their..g ] Q. "'0 The photographs above demonstrate what a woman would look like if her proportions were changed to match those of a Barbie doll (bust 39", waist 18", hips 33 "). Her neck and legs have also been elongated to match the doll's proportions.  10.2 Etiology of Eating Disorders 293 Sample Items from the Internalization As society has become more health and fat conscious, TAB LE 10.3 Subscale of the Sociocultural Attitudes dieting to lose weight has become more common. The number Towards Appearance Scale- 3 of dieters increased from 7% of men and 14% of women in I would like my body to look like the people who are in the movies. 1950 to 29% of men and 44% of women in 1999 (Serdula et al., 1999). An Ontario study found that among more than 2,000 girls I compare my body to the bodies of people who appear in magazines. aged 10 to 14, 29.3% were dieting and 1 in 10 had maladaptive I wish I looked like the models in music videos. eating attitudes, suggesting the presence of an eating disor- I try to look like the people on TV. der (Mcvey, Tweed, & Blackmore, 2004). Similarly, according I compare my appearance to the appearance of TV and movie stars. to the 2002 HBSC Canadian survey, by Grades 9 and 10, more than 25% of young women were on a diet when the survey was Source: Adapted from J. K. Thompson et al. (2003), pp. 293-304. Reprinted with permission from John Wiley & Sons, Inc. conducted (Government of Canada, 2006). The diet industry (books, pills, videos, special foods) is valued at more than $50 internalization and acceptance of prescribed body image stand- billion per year. Also, liposuction (vacuuming out fat deposits ards. Sample items from their measure (the Sociocultural Atti- just under the skin) is a very common (and sometimes risky) tudes Towards Appearance Scale-3) are shown in Table 10.3. procedure in plastic surgery (Brownell & Rodin, 1994). Growing evidence points to internalization of these standards The socio-cultural ideal of thinness shared by most West- as a key component of risk for eating disorder and related dys- ern industrialized nations is a likely vehicle through which peo- functional behaviours (see Thompson et al., 2003; Thompson & ple learn to fear being or even feeling fat. Excessive body fat has Stice, 2001). In fact, a recent analysis of developmental trajecto- negative connotations, such as being unsuccessful and having ries of disordered eating symptoms in adolescents showed that little self-control. Obese people are viewed by others as less escalating symptoms were predicted robustly by internalization smart and are stereotyped as being lazy. Investigations sug- of the thin ideal (Fairweather-Schmidt & Wade, 2016). gest this anti-fat bias is pervasive so that even the most obese According to the World Health Organization's 2013-2014 people tend to endorse these views; however, the bias seems Health Behaviour in School-Aged Children study, more than 1in4 more automatic among thinner people, according to measures Canadian girls felt they were too fat and by the time they reached of implicit cognitive processing (Schwartz et al., 2006). Unfor- the age of 15 years old, 43% indicated they were too fat (see Figure tunately, the media continue to promote these stereotypes. 10.3). It can be seen in Figure 10.3 that the percentage of fifteen A content analysis of 18 prime-time television situation com- year-old girls who felt they were too fat has increased from 2009. edies conducted by researchers in Calgary found that females with below average weights were overrepresented in these rI 45 40 1:-------------------------------------------------------------==-i --------------------------------------------------------- ------- I shows; also, the heavier the female character, the more likely she was to have negative comments directed toward her (Fouts & Burggraf, 2000). Moreover, these negative comments were i ---- --- :::::= I especially likely to be reinforced by audience laughter. Even worse than the media's promotion of thinness is the proliferation of pro-anorexia websites. These "pro-ana" websites glorify starvation and reinforce irrational beliefs £ 20 about the importance of thinness and the perceived rewards of being dangerously thin. While some people seem to turn 15 -- to these websites in a desperate search for coping advice, 10 others may simply be looking for tips and techniques to help 5 -- -I I become more anorexic (see Mulveen & Hepworth, 2006). A survey of 29 members of a French site found that they used 0 -- the site to gain social support and to get specific weight loss Eleven Thirteen Fifteen advice. A common theme among these people is they equated 25 32 thinness with happiness (Rodgers, Skowron, & Chabrol, 2012). Girls 38 2009 Increasingly, organizations representing psychologists and Boys 21 24 23 psychiatrists are issuing calls for a ban on these pro-an a sites. Girls 26 36 43 Such calls are well-founded in light of evidence confirming 2014 that exposure to these sites is reliably associated with body Boys 21 21 22 image dissatisfaction, dieting, and negative affect; however, Age these pro-eating-disorder sites were not linked with bulimia h'd'i;lf i ii Proportion of Canadian students who rated their 1 (Rodgers, Lowy, Halperin, & Franko, 2016). body image as too fat, 2013/2014 vs 2008/2009. The double-edged nature of the Internet was illustrated Source: Health Policy for Children and Adolescents, No. 7. Health further in a study conducted at the University of Waterloo on Behaviour in School-aged Children (HBSC) study: international report the functions of online forums for people with eating prob- from the 2013/2014 survey. lems (Ransom, LaGuardia, Woody, & Boyd, 2010). This survey 294 CHAPTER 10 Eating Disorders of 60 members of on line forums found that they can be good or bad for one's health. Online forum members reported that, relative to their peers, they get less "offline support" from fam- ily members and friends and that online forums help them get the social support they need. At the same time, on line forums encou raged adaptive and maladaptive behaviour and can actually encourage dysregulated eating behaviour because there was evidence that these forums do have an influence on their members. Gender Influences The primary reason for the greater prevalence of eating disor- ders among women than among men is that women appear to have been more heavily influenced by the cultural ideal of thin- ness. Women are typically valued more for their appearance, Standards of beauty vary cross-culturally as shown by Gauguin's whereas men gain esteem more for their accomplishments. painting ofTahitian women, Femmes de Tahiti (Sur la Plage). Women apparently are more concerned than men about being thin, are more likely to diet, and are thus more vulnerable to eating disorders. However, there is a growing belief that diagnostic criteria, so it is difficult to compare prevalence rates appearance pressures are increasing on young males as well. across cultures accurately or make definitive statements about These increasing pressures are reflected by a heightened drive cultural differences in symptom expression. for muscularity, which can take the extreme form of muscle A review concluded that at present, it is unclear whether dysmorphia (i.e., an obsession about not being as muscular as the presentation of eating disorder symptoms varies across desired). cultures (Soh, Touyz, & Surgenor, 2006). However, allowances Of course, everyone who diets will not develop an eating must still be made for possible cultural differences in the disorder. Other factors are described in subsequent sections. expression of symptoms. In China, for instance, th ere have been suggestions that the "fear of fat" criterion seen for many years as an i ndicatlon of anorexia nervosa may not apply to anorexic Cross-Cultural Studies females (see Wonderlich et al., 2007). Another example comes from a study of eating disorder symptoms among school girls in Eating disorders are far more common in industrialized socie- Fiji; here the researchers found a subtype of bulimia known as ties, such as the United States, Canada, Australia, and Europe, "the herbal purgative class," distinguished by the use of indige- than in non-industrialized nations, and it is also accepted that nous Fijian herbal purgatives (see Thomas et al., 2011). eating disorders are more evident in Western cultures (Keel Intriguing data were reported by Tucker (2004), who evalu- & Klump, 2003). However, it is also generally concluded that ated the effects of introducing television (and exposure to body the gap is closing, with rising levels of eating disorders in shape ideals via television) to a rural area of Fiji that had never non-Western cultures as well as rising levels of research inter- had television. This study showed that within three years, est, as reflected by an increasing number of publications (see there was a noticeable increase in preoccupation with weight Soh & Walter, 2013). To illustrate, while cases of eating disor- and body shape, purging behaviour, and negative evaluations der in Japan were once relatively rare, a review of research on of body characteristics. Interview data also indicated that the eating disorders in Japan by Chisuwa and O'Dea (2010) found Fijian girls acknowledged social learning and wishing to emu- a prevalence between 0.025% to 0.2% for AN and 1.9% to 2.9% late people they had seen on television. for BN. The researchers concluded that there are clear indica- tions that the prevalence of eating disorders has increased sub- stantially but ls still low relative to the prevalence in Western Cognitive-Behavioural Views countries. Moreover, according to a review conducted by Uni- versity of Windsor researchers (Geller & Thomas, 1999), young Cognitive-behavioural theories of anorexia nervosa emphasize women who emigrate to industrialized Western cultures may fear of fatness and body-image disturbance as the motivating be especially prone to developing eating disorders owing to factors that make self-starvation and weight loss powerful the experience of rapid cultural changes and pressures. reinforcers. Behaviours that achieve or maintain thinness are The wide variation in the prevalence of eating disorders negatively reinforced by the reduction of anxiety about becom- across cultures suggests the importance of culture in establish- ing fat. Furthermore, dieting and weight loss may be positively ing realistic vs. potentially disordered views of one's body (see reinforced by the sense of mastery or self-control they create painting). As yet, however, there have been no cross-cultural (Fairburn, Shafran, & Cooper, 1999; Garner, Vitousek, & Pike, 1997). epidemiological studies employing similar assessments and Some theories also Include personality and socio-cultural  10.2 Etiology of Eating Disorders 295 variables to explain how fear of fatness and body-image dis- (1999), early psychodynamic models interpreted symptoms turbances develop. For example, perfectionism and a sense of of anorexia from a conflict perspective (i.e., a defence against personal inadequacy may lead a person to become especially conflict drives, often of a sexual nature), while contemporary concerned with his or her appearance, making dieting a potent psychodynamic models interpret symptoms of anorexia from reinforcer. a deficit perspective, with a particular emphasis on anorexia Similarly, the media's portrayal of thinness as an ideal, as a way to compensate for defects in the self. being overweight, and a tendency to compare oneself with Several psychodynamic theories focus on family relation- especially attractive others all contribute to dissatisfaction ships. One view, proposed by influential theorist Hilde Bruch with one's body (Stormer & Thompson, 1996). As shown in (1980), is that anorexia nervosa is an attempt by children one Canadian study, even brief exposure to pictures of fash- who have been raised to feel ineffectual to gain competence ion models can instill negative moods in young women, and and respect and to ward off feelings of helplessness, ineffec- women who are dissatisfied with their bodies seem espe- tiveness, and powerlessness. This sense of ineffectiveness is cially vulnerable when exposed to these images (Pin has et al., created by a parenting style in which the parents' wishes are 1999). imposed on the child without considering the child's needs Somewhat ironically, research by Jennifer Mills from York or wishes. Children reared in this way do not learn to identify University and her associates showed that, initially, chronic their own internal states and do not become self-reliant. When dieters actually feel thinner after looking at idealized images faced with the demands of adolescence, the child seizes on the of the thin body and this motivates them to diet (Mills, Polivy, societal emphasis on thinness and turns dieting Into a means of Herman, & Tiggemann, 2002). This effect, labelled the thinspi- acquiring control and identity. ration effect, can begin a process of dietingthat can ultimately Steiger and Israel (1999) have a similar view of the origins lead to distress among dieters unable to attain unrealistic of anorexia, and they maintain that "obstinate, avoidant, or body-image standards. controlling reactions on the part of these clients often consti- Another important factor in producing a strong drive for tute adaptations, justified by past experiences of parental over- thinness and disturbed body image is criticism from peers and control" (p. 745). parents about being overweight (Paxton et al., 1991). In one Consider the case of Susie, a 23-year-old woman who study supporting this conclusion (Paxton et al., 1991), adoles- experienced anorexia following the death of her father from cent girls aged 10 to 15 were evaluated twice, with a three-year cancer. Below is an excerpt written by Susie's therapist to her interval between assessments. Obesity at the first assessment as part of her fourth treatment session: was related to being teased by peers and at the second assess- "You have an eating disorder that started at the ment to dissatisfaction with their bodies. Dissatisfaction was in unexpected death ofyour father two years ago. turn related to symptoms of eating disorder. Your eating disorder has helped you to feel in It is known that bingeing results frequently when diets control and your life has been both physically and are broken (Polivy & Herman, 1985). Thus, a lapse that occurs emotionally affected by this eating disorder. It is in the strict dieting of a person with anorexia nervosa is likely making you feel depressed and ashamed... to escalate into a binge. The purging following an episode You described to me a pleasant childhood, of binge eating can again be seen as motivated by the fear and also that you were told that you were a very of weight gain that the binge elicited. Clients with anorexia demanding baby who your mother found difficult who do not have episodes of bingeing and purging may have to cope with. When you started school you felt all a more intense preoccupation with and fear of weight gain ofyour demanding behaviour stopped and you (Schlundt & Johnson, 1990) or may be more able to exercise needed to control yourself, but often felt bad... self-control. As an adolescent you felt you couldn't rebel as you caused your father particular distress because you were so bad at maths. He used to tutor you Psychodynamic Views and shout at you because you were so bad at it. You again tried to control yourself emotionally and There are many psychodynamic theories of eating disorders. learn to do maths. But perhaps you were unable Most propose that the core cause lies in disturbed parent-child to express your fear, anger and shame at his relationships and agree that certain core personality traits, treatment and your inability to be good at maths. such as low self-esteem and perfectionism, are found among When your father died, perhaps such distressing individuals with eating disorders. Psychodynamic theories also emotions as fear, loss, anger and grief made you propose that the symptoms of an eating disorder fu lfill some feel ashamed again, as they did not seem able to be need, such as the need to increase one's sense of personal effec- expressed by your family. So again you went out of tiveness (the person succeeds in maintaining a strict diet) or to control, this time using control ofyour eating and avoid growing up sexually (by being very thin, the person does body as a way of managing your distress." not achieve the usual female shape) (Goodsitt, 1997). Accord- ing to Canadian researchers Howard Steiger and Mimi Israel (Tanner & Connon, 2003, p. 286) 296 CHAPTER 10 Eating Disorders Family Systems Theory 1994). Contrary to Minuchin's theory, the families showed considerable variation in enmeshment and were quite low in Salvador Minuchin and his colleagues proposed another influ- conflict (low levels of criticism and hostility). Though this latter ential position, known as the family systems theory, a theory finding could reflect the conflict-avoiding pattern Minuchin relevant to both anorexia and bulimia. This position holds has described, the parents' lack of overinvolvement is clearly that the symptoms of an eating disorder are best understood inconsistent with his clinical descriptions. Also inconsistent by considering both the afflicted person and how the symp- with Minuchin's theory is a family study conducted in Toronto toms are embedded in a dysfunctional family structure. In this in which assessments were conducted before and after treat- view, the child is seen as physiologically vulnerable (although ment of the client (Woodside et al., 1995). Ratings of family the precise nature of this vulnerability is unspecified), and functioning improved after treatment, contradicting the idea the child's family has several characteristics that promote the that improvement in the client should bring other family con- development of an eating disorder. Also, t he child's eating dis- flicts to light and supporting the idea that eating disorders may order plays an important role in helping the family avoid other cause family problems rather than the other way around. conflicts. Thus, the child's symptoms are a substitute for other To better understand the role of family functioning, we conflicts within the family. must begin to study these families directly, by observational According to Minuchin et al. (1975), the families of children measures, rather than by reports alone. Although a child's with eating disorders exhibit the following characteristics: perception of his or her family's characteristics is important, we also need to know how much of reported family disturbance is Enmeshment. Families have an extreme form of over perceived and how much is real. involvement and intimacy in which parents may speak for their children because they believe they know exactly how they feel. Child Abuse and Eating Disorders Overprotectiveness. Family members have an extreme level of concern for one another's welfare. Some studies have indicated that self-reports of childhood sexual abuse are higher than normal among people with eat- Rigidity. Families have a tendency to try to maintain the ing disorders. A study conducted in Toronto found that 25% of status quo and avoid dealing effectively with events that women with eating disorders reported the experience of pre· require change (e.g., the demand that adolescence creat es vious sexual abuse; it also correlated a history of sexual abuse for increased autonomy). with greater psychological disturbance (DeGroot, Kennedy, Lack of conflict resolution. Families either avoid conflict or Rodin, & McVey, 1992). Similarly, research conducted in Verdun, are in a state of chronic conflict (see photo). Quebec, confirmed that bulimic women, relative to normal eat- ers, had higher levels of childhood abuse and that the presence and the severity of abuse predicted more extreme psychopa- Characteristics of Families thology (Leonard, Steiger, & Kao, 2003). The most comprehen- sive recent study examined nationally representative data from Studies of the characteristics of families of people with eating the 2012 Canadian Community Health Survey (Afifi et al., 2014). disorders are relevant to both the family systems theory and Both physical abuse and sexual abuse were predictors of hav- the psychodynamic theory. Results have been variable. Some ing an eating disorder and having at least three types of abuse, of the variation stems, in part, from the different methods used relative to one or two types, amplified the risk of having an eat- to collect the data and from the sources of the information. For ing disorder. example, self-reports consistently reveal high levels of conflict in the family among people with eating disorders (e.g., Hodges, Cochrane, & Brewerton, 1998). However, reports of parents Personality and Eating Disorders do not necessarily indicate high levels of family problems. In one study in which the reports of parents of clients with eating Researchers study personality factors in the hope of identify- disorders differed from those of parents in the control group, ing vulnerability factors that may be involved in the etiology parents of clients reported high levels of isolation and lower of eating disorders. Enough evidence for the role of person- levels of mutual involvement and support (Humphrey, 1986). ality factors has now accumulated to support the conclusion Disturbed family relationships do seem to characterize some by Culbert, Racine, and Klump (2015) that factors such as trait families; however, the characteristics that have been observed, negative emotionality and perfectionism have achieved "risk such as low levels of support, only loosely fit the family systems status" along with other factors such as socio-cultural pres- theory. And again, these family characteristics could be a result sures for thinness and thin-ideal internalization. Another recent of the eating disorder and not a cause of it. meta-analysis conducted by Canadian researchers impli- A study more directly linked to Minuchin's family systems cated six personality factors as linked consistently with eating theory assessed both eating disorder clients and their parents disorders: avoidance motivation, lower extroversion and self- on tests designed to measure rigidity, closeness, emotional directedness, neuroticism, perfectionism, and sensitivity to overinvolvement, critical comments, and hostility (Dare et al., social rewards (Farstad, McGeown, & von Ransom, 2016).  10.2 Etiology of Eating Disorders 297 In assessing the role of personality, it is important to keep food and nutrients so they could study them. Up to 1,000 chil- in mind that the eating disorder itself can affect personality. A dren were kept malnourished and sometimes starved because study of semi-starvation in male conscientious objectors (who it suited research purposes. volunteered for the study instead of serving in the Second World In part as a response to the earlier findings about how star- War) conducted in the mid-1940s supports the idea that the vation can influence people, some researchers have collected personality of people with eating disorders, particularly those retrospective reports of personality before the onset of an with anorexia, is affected by their weight loss (Keys et al., 1950). eating disorder. This research described clients with anorexia For a period of six weeks, the men were given two meals a day, as having been perfectionistic, shy, and compliant before the totalling 1,500 calories, to simulate the meals in a concentration onset of the disorder. It described people with bulimia as hav- camp. On average, they lost 25% of their body weight. All the ing the additional characteristics of histrionic features, affec- men soon became preoccupied with food. They also reported tive instability, and an outgoing social disposition (Vitousek & increased fatigue, poor concentration, lack of sexual interest, irri- Manke, 1994). It is important to remember, however, that retro- tability, moodiness, and insomnia. Four became depressed, and spective reports that involve recalling what the person was like one developed bipolar disorder. This research shows vividly how before diagnosis can be inaccurate and biased by awareness of severe restriction of food intake can have powerful effects on per- the person's current problem. sonality and behaviour. We need to consider these effects when Numerous studies have also measured the current person- evaluating the personality of people with anorexia and bulimia. ality of people with eating disorders, relying on results from Of course, it is very unlikely that such a study involving star- established personality questionnaires such as the MMPI. Both vation would be permitted today. Still, people in Canada today people with anorexia and people with bulimia are high in neu- can be alarmed and outraged by research practices in the past. roticism and anxiety and low in self-esteem (Bulik et al., 2000). This was the case in 2013 following the publication of a report The role of neuroticism as a long-term predictor of anorexia written by Ian Mosby from the University of Guelph. Hunger was also confirmed in a twin study (Bulik et al., 2006). Those and malnutrition experiments had been conducted in Aborigi- people with AN or BN also score high on a measure of tradi - nal communities in the 1940s and 1950s by leading nutritional tionalism, indicating strong endorsement of family and social experts employed by the Government of Canada. According standards (Bulik et al., 2000). to Mosby (2013), unethical, controlled experiments involving Researchers have also examined the personality trait of lack of informed consent were conducted in various regions, narcissism in clients with eating disorders. Narcissists are char- including research on the Northern Cree people in Northern act erized by an excessive focus on the self and a heightened Manitoba. It is alleged that researchers identified people, both sense of self-importance and grandiosity. These individuals young and old, who were starving and denied some of them are believed to be overcompensating for a fragile sense of People with eating disorders consistently report that their family life was high in conflict. 298 CHAPTER 10 Eating Disofders self-esteem, however, and they are highly sensitive and reac- Follow-up research has linked eating disorders with the tive to criticism. Pathological narcissism at extreme levels tendency for some individuals to respond to social pressures can take the form of a narcissistic personality disorder (see to be perfect by engaging in a form of behaviour known as per- Chapter 13). Steiger and his associates have shown that AN and fectionistic self-presentation; that is, these individuals try to BN clients are characterized by high levels of narcissism that create an image of perfection and are highly focused on min- persist even when the eating disorder is in remission (Lehoux, imizing the mistakes they make in front of other people (see Steiger, & Jabalpurlawa, 2000; Steiger et al., 1997). Narcissism Hewitt, Flett, & Ediger, 1995; Hewitt et al., 2003). Perfectionistic is not always elevated among people with eating disorders self-presentation seems dominated by a focus on self-image (see Waller et al., 2007), but the use of a narcissistic defensive goals (Nepon, Flett, & Hewitt, in press), and, as such, it is not "poor me" style has treatment implications because it predicts surprising that evidence indicates that it is elevated among greatertreatment dropout (Campbell, Waller, & Pistrang, 2009). eating disorder clients (see Cockell et al., 2002; Geller, Cockell, As suggested earlier, perfectionism is believed to be Hewitt, Goldner, & Flett, 2000). highly relevant to an understanding of eating disorders. The A focus on perfectionistic self-presentation is in keeping initial research in this area was conducted with the perfec- with indications that women with eating disorders are high t ionism subscale of the Eating Disorders Inventory (EDI; see in public self-consciousness and overly concerned with how Table 10.1), and it confirmed that perfectionism is elevated in they are viewed by others, in part because they often feel individuals with eating disorders (Garner et al., 1983). The EDI like imposters and frauds who have not been detected yet by perfectionism subscale provides a single, global measure of other people and are mistakenly seen by them as competent perfectionism. Subsequent researchers, however, have found (Striegel-Moore, Silberstein, & Rodin, 1993). People who feel that the perfectionism construct is multi-dimensional, and like imposters and fear detection of their self-perceived inade- this was even demonstrated by a reanalysis of the EDI items quacies can respond defensively by trying to create an impres- that showed the perfectionism subscale actually consisted of sion of being perfect; this strategy can include attempts to two factors reflecting self-standards and external pressures portray their physical appearance in the best possible way. This imposed on the self (Sherry et al., 2005). need to seem perfect can go to very extreme lengths, especially Hewitt and Flett (1991b) created a multi-dimensional perfec- among university and college students. Research is now explor- tionism scale that assesses self-oriented perfectionism (setting ing the need for some people to seem "effortlessly perfect" (see high standards for oneself), other-oriented perfectionism (setting Flett et al., 2016; Travers et al., 2015). This tendency is believed high standards for others), and socially prescribed perfectionism to underscore such phenomena as "the Stanford Duck Syn- (the perception that high standards are imposed on the self by drome." This syndrome refers to the tendency for students at others). One possible manifestation of socially prescribed perfec- Stanford University to respond to strong social pressures and tionism of relevance here is a sense that there is social pressure to expectations by trying to seem very calm and collected on the attain unrealistic standards of physical perfection. surface when in public, while hiding their anxieties, fears, and Eating disorder research with the Hewitt and Flett (199l b) tendencies to work especially hard. Multidimensional Perfectionism Scale suggests that self- Overall, the studies outlined above suggest that diverse oriented and socially prescribed perfectionism are both ele- perfectionism dimensions are indeed elevated in the various vated in eating disorders. Bastiani et al. (1995) reported that eating disorders. However, one significant limitation of this weight-restored and underweight anorexics had elevated work is that the causal role of these dimensions of perfection- scores on self-oriented perfectionism. In addition, the under- ism has yet to be firmly established by longitudinal, prospective weight anorexics had higher scores on socially prescribed per- research on the role of these dimensions in the onset of eat- fectionism, relative to the control group. ing disorders. Such designs are critical to determine whether Other research conducted in Toronto found that self- perfectionism is a true risk factor for eating d isorders (see oriented and socially prescribed perfectionism were elevated Bardone-Cone et al., 2007). once again in people with eating disorders, and that anorexic individuals who engage in excessive exercise are distinguished by remarkably high levels of self-oriented perfectionism (Davis, Kaptein, Kaplan, Olmsted, & Woodside, 1998). Perfectio_nism is 10.3 Treatment of Eating relevant to both anorexia and bulimia. One line of investigation has provided support for a Disorders three-factor interactive model of perfectionism and bulimic symptom development (for a review, see Bardone-Cone et al., It is often difficult to get a person with an eating disorder into 2007). According to this interactive model, bu limic symptoms treatment because the person typically denies that he or she are elevated among females who are characterized not only has a problem. For this reason, the majority of people with by perfectionism, but also by body dissatisfaction and low eating disorders-up to 90% of them - are not in treatment self-esteem. Thus, they have exceptionally high standards yet (Fairburn, C. et al., 1996) and those who are in treatment are often recognize a sense of self-dissatisfaction for not attaining these resentful. Some people with bulimia only wind up in treatment impossible standards. because their dC!ntist has spotted one key indicator-the erosion  10.3 Treatment of Eating Disorders 299 of teeth enamel as a result of the stomach acid coming into to be the most promising approaches to this life-threatening contact with the teeth during vomiting. disorder. Hospitalization is required frequently to treat people Therapy for anorexia is generally believed to be a two- with anorexia so that their ingestion of food can be gradually tiered process. The immediate goal is to help each person increased and carefully monitored. Weight loss can be so severe gain weight in order to avoid medical complications and the that intravenous feeding is necessary to save the person's life. possibility of death. The client is often so weak and his or her Clearly, weight restoration is the immediate primary goal in the physiological functioning so disturbed that hospital treatment treatment of anorexia (for a discussion, see Attia, 2010). The is medically imperative (in addition to being needed to ensure medical complications of anorexia, such as electrolyte imbal- that the patient ingests some food). The second goal of treat- ances, also require treatment. For anorexia and bulimia, both ment is long-term maintenance of weight gain. biological and psychological interventions have been employed. Fairburn, Shafran, and Cooper {1999) proposed a cogni- In the sections below we provide an overview of available tive-behavioural theory of the maintenance of anorexia ner- treatments and their effectiveness. One vexing problem is a vosa. They argued that the central feature of the disorder is an high rate of relapse. For instance, a recent study of 100 ano- extreme need to control eating. A tendency to judge self-worth rexia nervosa clients in Toronto who were treated successfully in terms of shape and weight is assumed to be superimposed found that 41 % of them relapsed during the one-year follow-up on the need for self-control. According to Fairburn et al. {1999), period (Carter et al., 2012). Given this problem, the search the theory has two major treatment implications: is on for predictors of relapse and ways to mitigate it. Carter The issue of self-control should be the principal focus of et al. (2012) found in their study that relapse was more likely treatment, including "the use of eating, shape, and weight as for those clients who had the binge-purge anorexia subtype indices of self-control, and self-worth, the disturbed eating and who had more obsessive-compulsive disorder-like check- itself and the associated extreme weight behaviour, the body ing behaviours. Most notably, and perhaps not too surprisingly, checking and, of course, the low body weight" (Fairburn lower motivation to recover predicted subsequent relapse. et al., 1999, p. 10). They suggest that other targets for change in traditional cognitive-behavioural approaches {e.g., Garner, Vitousek, & Pike, 1997), such as low self-esteem, difficulty Biological Treatments recognizing and expressing emotions, and interpersonal and family difficulties, do not need to be addressed unless they Because bulimia nervosa is often comorbid with depression, it interfere with treatment progress. has been treated with various antidepressants in research con- ducted over the past 20 years. Interest has focused on fluox- Treatment should also focus on the person's need for etine (Prozac) (e.g., Fluoxetine Bulimia Nervosa Collaborative self-control in general. Thus, the "focus of control can be Study Group, 1992). In one mu Iti-centre study, 387 women with gradually shifted away from eating by helping clients derive bulimia were treated as outpatients for eight weeks. Fluoxetine satisfaction and a sense of achievement from other activi- was shown to be superior to a placebo in reducing binge eat- ties, and by demonstrating that control over eating does not ing and vomiting; it also decreased depression and lessened provide what they are seeking" (Fairburn et al., 1999, p. 10). distorted attitudes toward food and eating. Unfortunately, A non-randomized clinical trial conducted at Toronto however, optimism about the use of fluoxetine in treatment General Hospital found that relative to a no-treatment con- was reduced substantially by a well-designed study conducted trol group, cognitive-behavioural maintenance therapy for jointly in Toronto and New York City; this investigation of people with anorexia nervosa resulted In significant improve- patients with anorexia found no benefits following weight res- ments and it was significantly better at preventing relapse toration (Walsh et al., 2006). Thus, fluoxetine is not consistently (see Carter et al., 2009). Thus, cognitive-behavioural therapy effective. However, as noted by McElroy, Guerdjikova, Mori, and (CBT) has promise as a means of treating anorexia, and this Keck (2015), fluoxetine is the only medication approved for the was supported in more recent research comparing CBT with treatment of an eating disorder. Interpersonal therapy using a randomized control trial (RCT) Drugs have also been used in attempts to treat anorexia design; In this investigation, both kinds of treatment were nervosa and binge eating disorder, but there is only preliminary quite effective {see Carter et al., 2011). According to Wilson, evidence. McElroy et al. (2015) expressed their concern about Grllo, and Vltousek (2007). CBT is regarded as the treatment of the relative paucity of pharmacotherapy research given the choice for bulimia nervosa and binge eating disorder, while a magnitude of eating disorders as a public health problem. specific version of family therapy Is most favoured for treating anorexia nervosa. Let us take a closer look at the well-known family therapy Psychological Treatment of Salvador Minuchin and his colleagues, which is based on the of Anorexia Nervosa family systems theory described earlier. In Minuchin's view, the family member with an eating disorder deflects attention There is limited controlled research on psychological Interven- away from underlying conflicts in family relationships. To treat tions for anorexia nervosa, but we will present what appear the disorder, Minuchin attempts to redefine it as interpersonal 300 CHAPTER 10 Eating Disorders rather than individual and to bring the family conflict to the precedes anorexia; perhaps having a child develop anorexia fore. In this way, he theorizes, the symptomatic family member causes family dysfunction. is freed from having to maintain his or her problem, for it no longer deflects attention from the dysfunctional family. Although Minuchin provided the theoretical impetus for Psychological Treatment focusing on the family, his views have been rejected in recent of Bulimia Nervosa years. Why? Minuchin placed too much emphasis on a specific family type and this does not allow for the great heterogeneity People with bulimia nervosa, according to cognitive-behavioural among families that we discussed earlier. Also, it has been seen accounts (see Fairburn, 1997), are usually overconcerned with as an approach that places blame on the family. weight gain and body appearance; indeed, they judge their Current efforts focus on an intervention known as the self-worth mainly by their weight and shape. They also have Maudsley Approach (see Lock, Le Grange, Agras, & Dare, 2001). low self-esteem, and because weight and shape are somewhat The Maudsley Approach is a labour-intensive method that more controllable than other features of the self, they ten d recruits parents and requires them to find creative ways to feed to focus on weight and shape, hoping their efforts will make their children and restore them to a healthy weight. Parents are them feel better. They adhere to a rigid pattern of eating that taught that they are not to blame, but at the same time, they has st rict rules regarding how much to eat, what kinds of food are key "agents of change" who are taught new ways to be sup- to eat, and when to eat. These rules are inevitably broken, and portive and not critical. the lapse escalates into a binge. After the binge, feelings of More recent results continue to support the effective- disgust, shame, and fear of becoming fat build up, leading to ness of family therapy (see photo). A meta-analysis of 12 RCTs compensatory actions such as purging via vomiting. Although involving adolescents wit h either anorexia or bulimia and purging temporarily reduces t he anxiety from having eaten too their families found that family-based therapy and individual- much, this cycle lowers the person's self-esteem, which triggers focused therapy were equally effective at the end of treatment; still more bingeing and purging, a vicious circle that maintains however, family-based treatment yielded superior outcomes desired body weight but has serious medical consequences. assessed six t o 12 months post-treatment (Couturier, Kimber, (See Figure 10.4 for a summary of this theory.) & Szatmari, 2013). The cognitive-behavioural therapy approach of Fairburn While CBT studies have had the greatest impact and the (1985; Fairburn, Marcus, & Wilson, 1993) is the best-validated relevance of CBT is described in more detail below, a grow- and current standard for th e treatment of bulimia. In Fair- ing number of investigations have explored the effectiveness burn's therapy, which reflects his theoretical views, the client is of psychodynamic treatments for eating disorders. A survey encouraged to question society's standards for physical attrac- covering the years 1980 to 2015 identified 47 studies. These tiveness. They must also uncover and then change beliefs that studies, by and large, had significant methodological flaws encourage them to starve themselves to avoid becoming over- and RCTs are clearly needed. However, it was concluded t hat weight. They must be helped to see that normal body weight psychodynamic interventions yielded promising results both can be maintained without severe dieting and that unreal- post-intervention and at follow-up (Abbate-Daga, Marzola, istic restriction of food intake can often trigger a binge. They Amianto, & Fassino, in press). This is fitting given that it is Hilde are taught that all is not lost with just one bite of high-calorie Bruch's pioneering work from a psychodynamic perspective food and that snacking need not trigger a binge that would be that launched much of this field. followed by induced vomiting or taking laxatives. Altering this Finally, Lock and Couturier (2007) noted that there have all-or-nothing thinking can help clients begin to eat more mod- been no longitudinal studies showing that family dysfunction erately. They are also taught assertion skills to help them cope with unreasonable demands placed on them by others, and they learn more satisfying ways of relating to people, as well. The overall goal of treatment of bulimia nervosa is to develop normal eating patterns. People with BN need to learn to eat three meals a day and even to eat some snacks between meals without sliding back into bingeing and purging. Regu- lar meals control hunger and thereby, it is hoped, control the urge to eat enormous amounts of food, the effect of which- being overweight-is counteracted by purging. To help clients develop less extreme beliefs about themselves, the CBT ther- apist gently but firmly challenges such irrational beliefs as " No one will love or respect me if I am a few pounds heavier than I am now." A generalized assumption underlying such cognitions for female clients might be that a woman has value to a man only if she is a few pounds underweight-a belief that is put Family therapy is the main treatment for anorexia nervosa. forth in the media and advertisements.  10.4 Prevention of Eating Disorders 301 Low self-esteem Food intake is Dieting to feel and high negative restricted too better about self aff8ct.....ay Compensatory behaviours Diet is Binge (e.g., vomiting) to reduce broken fear8 gain This CBT approach has the client bring small amounts of Recall that CBT is regarded as the psychological treatment forbidden food to eat in the session. Relaxation is employed of choice for bulimia nervosa. In several other studies, Weiss- to control the urge to induce vomiting. Unrealistic demands man and Klerman's Interpersonal Therapy (IPT) fared well in and other cognitive distortions-such as the belief that eating comparisons with CBT (see Carter et al., 2011; Wilfley, Stein, & a small amount of high-calorie food means that the person is Welch, 2003). A contemporary comparison conducted by Fair- an utter failure and doomed never to improve-are continually burn et al. (2015) of people with various disorders including challenged. The therapist and client work together to deter- bulimia nervosa found that about two-thirds of the partici- mine the events, thoughts, and feelings that trigger an urge to pants who were treated with CBT achieved remission versus binge and then to learn more adaptive ways to cope with these about one-third who received IPT. Also, CBT appeared to work situations. For example, if the therapist and the client, usually quicker than IPT. It is noteworthy that IPT is effective at all, con- a young woman, discover that bingeing often takes place after sidering that it does not focus, as CBT does, on maladaptive the client has been criticized by her boyfriend, therapy could eating patterns, but focuses instead on improving interper- entail any or all of the following: sonal functioning. Such success suggests that, at least for some people, disordered-eating patterns might be caused by poor encouraging the client to assert herself if the criticism is interpersonal relationships and associated negative feelings unwarranted; about the self and the world. teaching her, a la Albert Ellis, that it is not a catastrophe to Although the outcomes from these two leading psycho- make a mistake and it is not necessary to be perfect, even if logical treatments, especially the cognitive-behavioural one, the boyfriend's criticism is valid; and appear to be superior to those from other modes of interven- desensitizing her to social evaluation and encouraging her to tion, including drugs, a good deal more remains to be learned question society's standards for ideal weight and the pres- about how best to treat bulimia nervosa. Part of the reason sures on women to be thin-not an easy task by any means. at least half of the clients in some controlled studies do not recover may be that significant numbers of the clients in these A 2006 review concluded that CBT is the most commonly studies have psychological disorders in addition to eating dis- used and empirically supported treatment for body image orders, such as borderline personality disorder, depression, disturbance in the normal population (Farrell, Shafran, & Lee, anxiety, and marital distress (Wilson, 1995). Another possibility 2006). These data and other recent developments have led is suggested by data indicating that those people who begin some authors to conclude that no other treatment has greater with negative self-efficacy judgements about their ability to efficacy than CBT (see Mitchell, Agras, & Wonderlich, 2007). recover actually tend to be the ones who are more treatment However, if we focus on the clients themselves rather than resistant and do indeed take longer to recover (Pinto et al., on numbers of binges and purges across clients, almost half 2008). This finding underscores the role of cognitive appraisal relapse after four months (Halmi et al., 2002). Predictors of in terms of beliefs about the expected benefits of treatment. relapse include less initial motivation for change and higher ini- tial levels of food and eating preoccupation (Halmi et al., 2002). Waller and associates have argued that if CBT is extended and takes the form of a schema-focused cognitive behaviour 10.4 Prevention of Eating therapy (SFCBT), it will prove to be more effective in treating bulimia (see Waller & Kennerley, 2003). The goal of this approach Disorders is to identify and modify deeply ingrained and painful core belief systems that reflect the individual's cognitive schemas (i.e., Given the possible difficulties associated with the treatment of mental filters). Waller argues that a negative core belief system individuals with eating disorders, serious consideration has to involving negative aspects of the self (e.g., "I am unlovable") be given to prevention of the disorders before onset. Efforts to must be replaced by positive core beliefs in order for improve- prevent eating disorders in Canada and elsewhere are summa- ments to occur. Research on SFCBT is still in its early stages. rized in Canadian Perspectives 10.1. 302 CHAPTER 10 Eating Disorders , Canadian Perspectives 10.1 Eating Disorders in Canada Issues involving eating disorders among people in Canada are quite salient right now as a result of a federal report that was published in 2014. "Eating Disorders Among Girls and Women in Canada" was presented to Parliament on behalf of the Standing Committee on the Status of Women (Government of Canada, 2014). The report was based on presentations and testimony from various stakehold- ers, Canadian citizens, and experts. Overall, the report paints a bleak picture of the prevalence of eating disorders and challenges in accessing effective treatment. The report calls on the federal government to respond to 25 rec- ommendations. Key recommendations include more research on the impact of media messaging and marketing that supports the thin ideal and "a narrow definition of beauty." The report also called for broad public education programs as well as programs designed to boost the knowledge of eating disorders among gen- eral medical practitioners. The report also recommends extending Gail McVey, shown with one of her mentors, Harvey Skinner, the the scope and quality of care, including the formation of multidis- founding Dean of York University's Faculty of Health, is one of ciplinary care teams (combining psychiatrists, psychologists, other Canada's leading experts on the prevention of eating disorders. necessary therapists, and dieticians), and having the various levels of government work together. Finally, the recommendations call employed by the Hospital for Sick Children; she is also the Director for increased funding for research and research training so that of the Ontario Community Outreach Program for Eating Disorders. we have more researchers in Canada focused on eating disorder She has also created a national prevention strategy group that is issues. Most notably, several recommendations address the need a research, practice, and policy group with members from across to develop and implement a preventive approach. Canada. The group's goal is to prevent eating disorders and obesity Why was such an emphasis placed on prevention? One reason and advance awareness of public health issues. McVey et al. (2010) is the results of a survey conducted with family doctors and psy- showed the effectiveness of an intervention for university women. chologists in Ontario that indicated low perceptions of competence Components of the intervention included media literacy training, and frustration with several barriers to practice, including lack of self-esteem enhancement strategies, stress management skills, and knowledge and lack of resources (Lafrance Robinson, Boachie, & Instruction on how to recognize healthy vs. unhealthy relationships. Lafrance, 2013). The reality is that the demand will always outpace McVey and Davis (2002) created a program designed to reduce available services in Canada and elsewhere. There is now exten- the Impact of media portrayals of unrealistic body images and to sive research on the prevention of eating disorders and the results promote a non-dieting approach to eating and exercise. This multi· are encouraging for only certain programs. Stice and Shaw (2004) faceted program also includes a focus on stress-management conducted a meta-analysis of 23 prevention studies and confirmed skills and social problem-solving strategies, along with strategies that the intervention effects have varied widely and have ranged to promote a positive self-image. An additional aspect is parent from no effect to significant effects. The overall effect of preven- education on the nature and prevention of eating problems. Initial tion was deemed to range from small to medium in magnitude. results have found no specific effects of the program because both Tests of mediator effects showed that larger effects occurred when the prevention and control groups In this study showed increases the prevention was aimed at high-risk participants vs. all partici- in body-image satisfaction and decreases In eating problems over pants. Stronger effects were also associated with an interactive time (Mcvey & Davis, 2002). program that was more engaging than a didactic, lecture-style pro- One prevention approach involves forming school-based peer gram. Multiple sessions also increased the effect, as did the use of support groups (McVey, Lieberman, Voorberg, Wardrope, & Black· well-validated measures. more, 2003). Thus far, McVey and colleagues have found mixed A more recent open access review of the prevention and treat· evidence for the impact of peer support groups, with one study ment of eating disorders in young people (see Bailey and associates, leading to improvements In Grade 7 and 8 girls and another study 2014) summarized 197 empirical trials and 22 systematic reviews. find ing no improvement. Regardless, this multi-faceted approach They noted that prevention research is dominated by psychoeduca· to prevention recognizes that a multitude of factors can contribute tion efforts and the evidence base is still not well-established. A recent to the development of eating disorders and that a complex preven· comprehensive review by Pennessi and Wade (2016) concluded that tion program is required to combat this problem. "there still remains a pressing need to develop more effective inter- More recent efforts focus on enlisting teachers in preventive ventions" (p. 175). A significant problem noted by these investlga· efforts. Initial results from a web-based training program for teach· tors was the lack of a close link in the eating disorder field between ers suggests that the program is effective in improving teachers' theoretical orientations and the interventions that are developed. knowledge and empowering them to monitor and address any Gail McVey is a leader In Canada when It comes to active weight-related biases that creep into teaching practices (McVey, attempts to prevent eating disorders (see photo). McVey Is Gusella, Tweed, & Ferrari, 2009).  Key Terms 303 Information on eating disorders can be obtained from the set up such a program for eating disorders, what would you National Eating Disorder Information Centre (www.nedic.ca) in emphasize? Toronto. 2. Governments have taken steps to make sure that there are warning labels on products such as cigarettes because they can Thinking Critically be harmful to your health. Do you think there is merit in includ- 1. Prevention efforts often take place under the auspices of ing warnings about television shows that promote unhealthy school boards. Do you think that all school boards should be body images and/or restricting ads that promote unhealthy required to include a focus on the prevention of disorders such body images? Or would this simply draw even more attention as eating disorders and depressive disorders? If you were to to these body images? Summary 10.1 The two main eating disorders in terms of awareness among standards changed to favour a thinner shape as the ideal for women, researchers and the general public are anorexia nervosa and bulimia the frequency of eating disorders increased. The prevalence of eating nervosa. The symptoms of anorexia nervosa include refusal to main- disorders is higher in industrialized countries, where the cultural pres- tain normal body weight, an intense fear of being fat, and a distorted sure to be thin is strongest. The prevalence of eating disorders is very sense of body shape. Amenorrhea in females is no longer a required high among people who are especially concerned with their weight, symptom in the DSM-5. Anorexia typically begins In the mid-teens, is such as models, dancers, and athletes. Initial psychodynamic theories 10 times more frequent in women than in men, and Is comorbid with of eating disorders emphasize parent-child relationships and person- several other disorders, notably depression. Its course is not favoura- ality characteristics. Bruch's theory, for example, proposes that the ble, and it can be life-threatening. The symptoms of bulimia nervosa parents of children who later develop eating disorders impose their include episodes of binge eating followed by purging, fear of being fat, wishes on their children without considering the children's needs. The and a distorted body image. Like anorexia, bulimia begins in adoles- family systems approach embeds dysfunction in the family dynamic. cence, is much more frequent in women than in men, and is comor- But research on the role of family factors is not consistent in terms of bid with other diagnoses, such as depression. Prognosis is somewhat pointing to the role of family characteristics. Contemporary interven- more favourable than for anorexia. Some people with an eating disor- tion approaches enlist the parents as key agents of positive change der have a clinical condition designated as EDNOS (I.e., eating disorder and support. not otherwise specified). This applies to people with less severe and 10.3 Cognitive-behavioural theories of eating disorders propose that overt symptoms or ones who do not meet the rigid criteria for anorexia fear of being fat and body-image distortion make weight loss a power- or bulimia. The other main eating disorder is binge eating disorder, ful reinforcer. Among people with bulimia nervosa, negative mood and which applies to people who have at least one binge episode every stress precipitate binges that create anxiety, which is then relieved by week for at least three months. The characteristics of a binge episode purging. Cognitive-behavioural treatment for bulimia focuses on ques- include eating more rapidly, eating past the point of being comfortably tioning society's standards for physical attractiveness, challenging full, eating alone out of shame and embarrassment, and feeling dis- beliefs that encourage severe food restriction, and developing normal gusted or depressed due to the amount eaten. eating patterns. Outcomes are promising. The main biological treat- 10.2 Biological research in the eating disorders has examined both ment of eating disorders is the use of antidepressants. There are not genetics and brain mechanisms. There is strong evidence of a role for extensive data indicating that drugs are effective. genetics but the specific genetic factors remain to be identified. Endog- 10.4 The need for services to treat people with eating disorders far enous opioids and serotonin, both of which play a role in mediating outweighs the available services in Canada, according to a recent fed- hunger and satiety, have been examined in eating disorders. Low levels eral report. The level of demand points to the clear need for preven- of both these br