Eating disorders (EDs) are characterized by chronicity and relapse and are some of the most common psychiatric disorders faced by girls and women. The two most common eating disorders are anorexia nervosa and bulimia nervosa. According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM—TV—TR), the criteria for anorexia nervosa include emaciation (i.e., a body mass index < 17.5), an intense fear of becoming fat, disturbed perception of body shape, denial of the seriousness of low body weight, and for postmenarcheal women, the absence of at least three consecutive menstrual cycles. Criteria for bulimia nervosa include uncontrollable binge eating followed by compensatory behavior to prevent weight gain (e.g., vomiting, excessive exercise, misuse of laxatives, fasting), occurring at least twice a week for a minimum duration of 3 months. People with anorexia or bulimia evaluate themselves primarily by their body shape and weight.
Individuals who have some, but not all, of the specific characteristics of anorexia or bulimia may meet the DSM—TV—TR criteria for eating disorder not otherwise specified (EDNOS). One example of EDNOS is binge eating disorder, which is marked by uncontrollable binge eating in the absence of compensatory behaviors. It is important to note that obesity is not recognized as an ED by the DSM—TV—TR, because it has not been associated with a psychological or behavioral syndrome.
Disordered eating behaviors include starvation, inadequate nutrient intake, bingeing, frequent vomiting, and abusing laxatives and diuretics. These behaviors can result in numerous negative health consequences. Cardiovascular complications such as a loss of heart muscle mass, abnormal heart beat and rhythm, and cardiac failure can result from the common ED symptoms of emaciation, electrolyte disturbances, dehydration, and weight cycling. These complications can range from being relatively benign to life threatening.
Lowered bone mineral density or osteoporosis affects a large number of individuals with anorexia due to their chronic inadequate intake of nutrients such as calcium and vitamin D. Gastrointestinal difficulties such as constipation, ulcers, tears in the esophagus, and gastrointestinal bleeding can result from purging via laxatives and vomiting. Hormone functioning can be altered as a result of malnutrition and purging, which could lead to reduced fertility, increased miscarriage, and premature/underweight births. Other biochemical abnormalities from inadequate nutrient intake and purging can affect energy levels and overall physical functioning (e.g., headaches, general muscle weakness) and psychological functioning (e.g., lower well-being, elevated depression).
Individuals who chronically engage in ED behaviors are at a higher risk for these deleterious health conditions. Yet, many others participate in ED behaviors less frequently, but may still be at a significant risk for these conditions. Periodic malnutrition (i.e., from fasting, skipping meals), electrolyte disturbances, and weight cycling are common among those who meet some, but not all, of the criteria for clinical eating disorders. This finding highlights the importance of attending to all individuals who display ED symptoms and not solely focusing on those who meet the threshold for a clinical ED diagnosis.
The Spectrum of Eating Behavior
Eating behavior may be conceptualized along a continuum, with one pole representing clinical EDs and the opposite pole reflecting adaptive eating. The intermediate range is characterized by the use of harmful weight control strategies and food preoccupation, but at a less severe level than that of a diagnosable ED. However, because individuals in the intermediate range may jeopardize their physical and psychological health via maladaptive weight control techniques, it is crucial for counselors to focus on preventing and treating all degrees of ED symptomatology.
Eating Disorders and Less Severe Eating Disturbances
Clinical criteria for EDs are quite strict. Despite a popular belief that a high percentage of adolescent girls and young adult women have bona fide EDs, only a small number are diagnosed with anorexia (0.5%), bulimia (l%-3%), or EDNOS (2%-5%). Yet, an overwhelming number of young adult women report engaging in the unhealthy weight regulation practices that fall in the intermediate category on the eating behavior continuum. In their research, Tracy Tylka and Linda Subich uncovered large percentages of high school and college women who skipped meals (59%), ate fewer than 1,200 calories a day (36.7%), eliminated fats (30.1%) and carbohydrates (26.5%) from their diet, and fasted for more than 24 hours (25.9%).
Individuals may not display ED symptomatology per se, but may eat maladaptively by habitually eating in the absence of hunger or eating everything on their plate with no regard to satiety level. Therefore, it is important to articulate, define, and promote adaptive eating. Studying adaptive eating is important for counselors, as it could (a) reveal how to best foster and maintain this eating style, (b) highlight behaviors to help people strive toward in order to enhance their well-being rather than solely pinpointing maladaptive behaviors to avoid, and (c) facilitate understanding of how to prevent and treat disordered eating, as these efforts should result in an increase in adaptive eating behaviors alongside a reduction in maladaptive symptoms. Recently, Tylka supported the adaptive properties of intuitive eating, defined as eating in response to internal physiological hunger and satiety cues in lieu of situational and emotional cues. Although the study of adaptive eating has gained momentum, most theory and research on eating behavior has focused on ED symptomatology.
Assessment of Eating Behavior
Eating behavior often is assessed via interviews or several psychometrically sound instruments. The Eating Disorder Examination by Christopher Fairburn and Zafra Cooper is a popular standardized interview schedule that measures dietary restraint and concern with eating, shape, and weight. Some self-report assessment instruments that measure ED symptomatology are scored according to decision rules that determine whether a person meets ED diagnostic criteria and, if so, provides the diagnosis. The Questionnaire for Eating Disorder Diagnoses (Q-EDD) by Laurie Mintz, Sean O’Halloran, Amy Mulholland, and Paxton Schneider differentiates between ED, symptomatic, and asymptomatic individuals and between those with anorexia, bulimia, and EDNOS diagnoses. The Eating Disorder Diagnostic Scale (EDDS) by Eric Stice, Christy Telch, and Shireen Rizvi diagnoses anorexia, bulimia, and binge eating disorder. A continuous ED composite score also can be calculated from the EDDS.
Other self-report instruments are scored along a gradient to reveal the degree of eating disturbance. The Eating Attitudes Test-26 (EAT-26) by David Garner, Marion Olmsted, Yvonne Bohr, and Paul Garfinkel measures dieting, bulimia, food preoccupation, and oral control and is often used as a general measure of ED symptomatology. The Eating Disorder Inventory-3 (EDI-3) by Garner measures many behavioral characteristics of EDs, such as drive for thinness and bulimia, as well as many psychological correlates of EDs (e.g., low self-esteem, perfectionism); an overall ED risk composite score can be computed. The Bulimia Test-Revised (BULIT-R) by Mark Thelen, Janet Farmer, Stephen Wonderlich, and Marcia Smith assesses levels of bulimic symptomatology. In terms of adaptive eating behavior, the Intuitive Eating Scale (IES) by Tylka measures unconditional permission to eat, eating for physical rather than emotional reasons, and reliance on internal hunger/satiety cues to determine when and how much to eat. An overall score also can be computed.
Eating Disorders Risk Factors
There is no single cause of EDs. Rather, researchers suggest that sociocultural variables (e.g., cultural pressures for thinness), personal variables (e.g., personality, physical, behavioral, cognitive, and affective variables), and relational variables (e.g., lack of social support) are associated with the development and maintenance of eating disorders.
Cultural and environmental factors that encourage individuals to focus on the appearance of their bodies in lieu of internal characteristics such as personality and intellect can lead to increased body dissatisfaction. Consequently, individuals attempt to employ maladaptive weight control strategies to conform to the cultural thin-ideal prototype. Women constitute roughly 90% of individuals with diagnosable EDs. Thus, ED symptomatology could be related to the cultural sexual objectification of women’s bodies. One form of sexual objectification is the pressure to be thin that women face from family, friends, partners, and the media. Sociocultural variables are thought to play a more important role in fostering eating pathology than in maintaining it, as they are the backdrop against which individual development occurs.
In 2002, Stice conducted a meta-analysis of longitudinal studies of eating pathology. He noted that pressure for thinness leads to ED symptomatology as well as internalization of the thin-ideal societal standard, body dissatisfaction, dieting, and negative affect (i.e., a combination of anxiety, depression, and low self-esteem). He concluded that the adverse effects of pressure to be thin are more pronounced for individuals with specific maladaptive personal and relational characteristics, such as those presented next.
Stice highlighted how several personal variables may combine with other variables to increase women’s risk of disordered eating. First, elevated body mass leads to pressure for thinness and body dissatisfaction, but does not directly lead to or maintain ED symptomatology. Second, internalization of the thin-ideal societal standard leads to body dissatisfaction and negative affect, both of which lead to and maintain ED symptomatology. Third, body dissatisfaction and negative affect appear to influence each other. Fourth, maladaptive perfectionism, a personality trait characterized by unrealistically high expectations coupled with severe criticism for falling short of these expectations, leads to and maintains ED symptomatology. Although not investigated in Stice’s meta-analysis, poor awareness of internal states (i.e., hunger, satiety, emotions) also has been found to contribute to ED symptomatology within several models of disordered eating.
High levels of social support from family and friends may buffer the effects of stress on ED symptomatology, as feeling accepted and appreciated by others is believed to help people feel more positively about themselves and their bodies. Therefore, low levels of social support could contribute to negative affect as well as intensify the negative effects of stress on ED symptomatology.
Prediction of Eating Disorder Symptomatology
According to Barbara Fredrickson and Tomi-Ann Roberts, sexually objectifying encounters socialize girls and women to self-objectify, or treat themselves as objects to be looked at and evaluated (e.g., by habitually monitoring their bodies and internalizing the societal thinness standard as the only attractive body type). Self-objectification, then, directly leads to consequences such as body shame and decreased awareness of internal bodily states (e.g., hunger, satiety, emotions). These consequent variables are believed to directly contribute to women’s eating pathology. Many researchers have demonstrated support for the pathways of objectification theory and found that sexual objectification only influences women’s ED symptomatology indirectly through its associations with personal variables (i.e., self-objectification, body shame, decreased internal awareness).
Dual Pathway Model
In 1996, Stice, Carol Nemeroff, and Heather Shaw proposed the dual pathway model to explain the development of bulimic symptomatology. This model asserted that sociocultural pressures to be thin foster body dissatisfaction, as repeated messages that one is not thin enough likely encourages dissatisfaction with one’s body. Internalization of the thin-ideal societal standard additionally contributes to body dissatisfaction because this ideal is difficult to attain. Body dissatisfaction in turn promotes dieting (in an attempt to achieve the thin-ideal) and negative affect (as low body esteem is equated with low self-esteem). Dieting and negative affect are the two pathways that connect body dissatisfaction to bulimic symptomatology. Dieting encourages bulimic symptomatology because the violation of strict dietary rules results in disinhibited eating, and negative affect promotes bulimic symptomatology as binge eating temporarily provides comfort and distraction from negative emotions. This model has been supported in several longitudinal studies with adolescent girls.
The confluence of several risk factors places individuals even more at risk for ED symptomatology. For instance, many women may experience body dissatisfaction, but of these women, only those with high levels of other variables (e.g., maladaptive perfectionism, low self-esteem, body surveillance, negative affect, or having a family member or friend with an ED) have an increased likelihood of displaying ED symptoms. These findings underscore the importance of examining how variables interact in their prediction of ED symptomatology.
Eating Disorders Prevention and Treatment
Less than 25% of individuals with EDs receive treatment; of these individuals, only 30% of clients show symptom remission that persists for at least 4 weeks. In light of the limited success in the treatment of diagnosed eating disorders, extensive efforts have been directed toward developing prevention and treatment programs designed to curb maladaptive eating practices before they develop into eating disorders. However, when evaluated (e.g., typically with female high school or college students in a school or university setting), only a few of the many extant programs have produced lasting symptom reduction at follow-up, ranging from 1 month to 2 years.
Prevention of Disordered Eating
Based on research documenting the multidimensional nature of ED risk factors, prevention programs focus on one or more of the identified risk factors. Programs that have produced lasting effects such as improvements in body dissatisfaction and amelioration of ED symptomatology typically were several hours in length (ranging from 4 to 10 hours); promoted healthy weight control behaviors, body acceptance, resistance of cultural pressures for thinness, self-esteem enhancement, and stress management; and presented information on EDs and the effects of cognitions (i.e., thoughts) on emotions. Several programs that demonstrated significant improvements had women actively challenge their beliefs about their bodies or the thin-ideal body type promoted by society. In one 4-hour program, girls who were at high-risk for ED symptomatology actively replaced their negative appearance self-statements with positive statements. Systematic desensitization (i.e., an intervention that pairs muscle relaxation with anxiety-producing objects arranged along a gradient from low to high anxiety) also was used to reduce body anxiety.
Counterattitudinal exercises in which participants actively critiqued the cultural thin-ideal body were used to reduce participants’ endorsement of the thin-ideal. Women receiving this intervention showed greater reduction in ED risk factors and bulimic symptoms at the end of the program and lower binge eating through a 12-month follow-up than women who did not receive this intervention. Moreover, women in another intervention group (i.e., where a healthy-ideal weight was defined, the thin-ideal societal standard was refuted, and public commitments to follow an individualized plan that included a balanced diet and increased exercise were encouraged) achieved similar benefits.
Treatment of Disordered Eating
Treatment of EDs is challenging. Clients who were once reinforced for losing weight may be reluctant to relinquish their fantasy of attaining the thin-ideal body shape. As such, many clients only enter treatment because of significant others’ pleas. Clients may not yet be contemplating change.
Treatment of individuals with EDs is multidisciplinary and may involve counselors (e.g., psychologists, social workers), physicians, and dieticians. Treatment setting is determined by the severity of ED symptomatology; medical danger from extreme emaciation or severe bingeing and purging may warrant inpatient hospitalization. Settings include outpatient treatment (e.g., weekly therapy sessions), partial hospitalization (i.e., consisting of 4-8 hours per day of treatment for 8-14 weeks), or inpatient treatment at a hospital or ED treatment facility. Regardless of the setting, intense psychotherapy and strict attention to the medical needs of the clients are imperative, and therapy may include a combination of psychoeducation (e.g., media literacy, information on healthy eating) and individual, family, and group psychotherapy. Certain antidepressant medications (i.e., Prozac) may also be used to treat bulimia and binge eating disorder, but they appear to be less effective for treating anorexia.
There are various types of psychotherapy for treating ED symptomatology. Many counselors choose to integrate aspects of these approaches and tailor the treatment to the client’s individual needs. Cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), feminist therapy, and family therapy are common treatment frameworks. Much empirical research has supported CBT and IPT in the treatment of ED symptomatology; more research needs to be conducted on the other approaches to determine their effectiveness.
One of the most popular approaches for treating ED symptomatology is CBT. First, in a psychoeducational component, clients are given information regarding EDs, the role of thinking in maintaining EDs, and nutrition information. They monitor their eating behaviors during this phase. For instance, individuals with bulimia may note that they binge after fasting for 8 hours. They are encouraged to begin a pattern of regular eating (e.g., three planned meals plus two or three planned snacks each day), to identify triggers for their ED symptomatology, and to generate a list of adaptive coping strategies and use these strategies (in lieu of binge or restricted eating) to deal with stress. Second, in a cognitive-restructuring phase, clients are taught to identify, question, and restructure their maladaptive general thought patterns (e.g., dichotomous, black-or-white thinking) and irrational thoughts specific to food and weight that maintain their ED and negative affect. Last, in a relapse prevention phase, clients learn how to anticipate events that may impede their continued progress and make plans to deal effectively with these events.
The focus of IPT is on addressing clients’ current interpersonal relationships and how to make them more satisfactory. The first phase is geared toward establishing rapport, explaining the treatment approach, and assessing client problem areas with careful attention to interpersonal difficulties (e.g., interpersonal deficits, grief, disputes). The second phase addresses interpersonal difficulties identified in the first phase and may include a psychoeducational component about negative affect, EDs, and how to effectively solve problems. In the last phase, clients are prepared to deal with future problems and therapeutic progress is reviewed.
Feminist therapy highlights how environmental factors such as objectification and cultural pressures to be thin contribute to ED symptomatology. After establishing an egalitarian relationship, counselors often help clients pinpoint the connection between their eating problems and the deleterious environment that maintains these problems. For instance, clients’ body dissatisfaction emanating from their belief that the thin-ideal is the only attractive body shape is connected to cultural messages that espouse this unrealistic body shape. This strategy is referred to as “making the personal political.” Clients are encouraged to disentangle themselves from self-objectification, and interventions are designed to foster body acceptance and appreciation by focusing on how the body functions rather than its appearance. Strategies to critically evaluate media portrayals of women and men are discussed (i.e., media literacy efforts). Assertiveness skills help clients find their voice within interpersonal encounters. Sex-role analysis helps clients identify messages they have been taught with regard to their gender that serve to maintain their ED behaviors (e.g., women should be passive and thin, men should be muscular). Clients are prompted to express their emotions within the safe therapy environment.
Because a family member’s ED may be a manifestation of a problem within the entire family system, family therapy often is used to treat ED symptomatology. In structural family therapy, counselors focus on identifying roles, alliances, conflicts, and interaction patterns within the family that are related to the ED. Once these patterns are acknowledged, counselors tailor their interventions to facilitate appropriate and healthy expression from each family member and enhance the well-being of the entire family system.
Most theory and research on ED symptomatology has focused on women who are young, Caucasian, and heterosexual. As a result, ED symptomatology may be different for other individuals and therefore not reflected in DSM-IV-TR criteria for EDs. For instance, anorexia is much less prevalent among men than women, and only about 10% of the individuals with bulimia are men. Yet, one third of all men desire a leaner body and approximately one quarter of all men want a more muscular body. Some of these men may internalize environmental pressures to become more muscular, become dissatisfied with their bodies, and go to extreme efforts to gain muscle mass by using anabolic steroids and eating maladaptively (e.g., eating excessive amounts of protein, becoming preoccupied with eating 20 grams of protein in 2-hour intervals). Indeed, contemporary American men display substantial body dissatisfaction, which is often expressed as muscle belittlement (i.e., believing they are less muscular than they are). This dissatisfaction is closely associated with depression, ED symptomatology, use of performance-enhancing substances, and low self-esteem.
Although body dysmorphic disorder may reflect men’s muscle dysmorphia, the associated maladaptive eating behaviors are not recognized in the DSM-IV-TR. This neglect has clinical implications, as it may lead to counselors overlooking these deleterious behaviors in their clients. Furthermore, because many ED instruments were designed to assess only diagnostic criteria for EDs and not other maladaptive eating behaviors, counselors may miss maladaptive eating behaviors when they exist, leading to some clients not being appropriately identified or treated for an eating disturbance.
Future efforts also need to be directed toward exploring extant models of ED symptomatology with diverse samples and developing models that more appropriately reflect the experiences of other groups of individuals. Ethnic identity (e.g., expressing positive ethnic attitudes; identification with, affirmation of, and belonging to an ethnic group) has been asserted to protect individuals of color from internalizing Western cultural standards of attractiveness and developing body dissatisfaction and ED symptomatology. However, preliminary findings suggest that a strong ethnic identity may not directly protect women of color from internalizing the Western thin-ideal body type, having a negative body image, or displaying ED symptomatology. Instead, ethnic identity appears to positively influence the self-esteem of women of color, and self-esteem then protects these women from internalizing the thin-ideal body type, body dissatisfaction, and ED symptomatology.
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