What influence do you think Andreas boyfriend had on the development and maintenance of her eating problems? ?Would involving her boyfriend in the therapy process be a good idea? ?Why

Chapter 5

✵

Eating Disorders

SYMPTOMS

AndreaWeston was a 17-year-old Caucasian female referred to a clinical psychologist who specialized in anxiety, depressive, and eating disorders. Andrea was a senior in high school at the time of her initial assessment. Her parents, Mr. and Mrs. Weston, referred Andrea for what they described as “very unusual behavior.” Mr. Weston had an initial telephone conversation with the psychologist and said Andrea was caught eating a large amount of sweet foods by her sister. The incident was especially worrisome because Andrea then struck her sister in the face, an act she had never done before. Mr. Weston also claimed Andrea was becoming more irritable, withdrawn, and argumentative. Her relationship with her boyfriend was tempestuous and a source of tension between Andrea and her parents. Mr. Weston also said Andrea was reluctant to enter therapy and agreed to do so only if the entire family was involved.

The psychologist found Andrea to be somewhat gaunt and diminutive, but not seriously underweight during the initial interview. Her major symptoms initially seemed depressive. Andrea said she experienced several stressful events that felt overwhelming during the school year (it was now early February). She said her parents were constantly interfering with her life, giving her advice on how to look, act, and work toward the future. Her mother often “poked her nose” into Andrea’s affairs, especially her appearance, schoolwork, social life, and dating. Andrea said she was doing poorly at school, claiming a severe case of “senioritis.” She also felt lonely and rejected because many of her friends were joining other social groups.

The psychologist asked Andrea about recent events that triggered her father’s call. Andrea said her parents were unhappy with her boyfriend of the past 5 months. Both objected to his older age (20 years), rough demeanor, and ques- tionable status, characteristics Andrea seemed to relish. When asked for more details, Andrea simply said this was her first real boyfriend and that her parents “just don’t want me to have any independence.” Andrea did not openly admit that annoying her parents was a fringe benefit of dating her boyfriend, but her tone led the psychologist to this conclusion.

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The psychologist also asked Andrea about various depressive symptoms and she appeared to have several. She was sad, often felt tired, had low self-esteem, and occasionally thought about suicide. The psychologist developed a contract with Andrea in which she promised to contact the psychologist following suicidal ideation or before any suicide attempt. Andrea was also concerned about her weight and body size, which she described as “chubby” and unappealing to others. The psychologist saw that Andrea was a bit thin but her weight was generally appropriate for her age, gender, and height. Andrea said her parents, especially her mother, made frequent comments about her weight as she grew up. They sometimes said she needed to watch her figure if she was going to fit in with her social group. Andrea was thus sensitive about her weight and either felt bad whenever she gained a few pounds or “felt fat.”

When asked about her recent episode of binge eating, Andrea became tearful and spoke softly. She said she began dieting about 3 months earlier while dating her current boyfriend. Andrea’s boyfriend made an offhand comment about her weight that Andrea took immediately as a threat that he would not see her unless she lost weight. She then lost weight by eliminating certain foods from her diet and eating substantially less than before. Andrea lost about 20 pounds, reaching her current weight of 100 pounds, and said she felt more attractive but still inadequate. She also felt insecure about her relationship with her boyfriend and other friends. Andrea felt they were becoming more distant from her and she tended to blame this on her weight.

As Andrea lost weight, however, her sense of sadness and anxiety did not go away and she often felt hungry. She began to binge secretly about 2 months ago. The binges usually consisted of sweet foods such as ice cream, cake, candy bars, and soft drinks. Andrea said the binges occurred only once every other week, but the psychologist suspected they occurred more frequently. Andrea also said the binges made her feel “gross and fat,” so she started vomiting afterward. Andrea said she vomited only twice and that she no longer binged or vomited, but again the psychologist found this doubtful.

The psychologist then interviewed Mr. and Mrs. Weston, who confirmed much of Andrea’s report, but made the situation sound more dire. Mrs. Weston revealed that Andrea was hospitalized for a suicide attempt the previous year and continued to show signs of depression. Further questioning revealed that the “suicide attempt” was actually a car accident involving Andrea as the driver. Andrea said afterward that she wished she died in the accident, but whether she actually tried to kill herself was unclear. The psychologist noted Mrs. Weston’s tendency to make events such as these sound dramatic.

Mr. and Mrs. Weston also described some recently upsetting events regarding Andrea. At the top of their list was her relationship with her boyfriend, whom the parents described as a “bad seed.” Andrea’s boyfriend had a history of drug use and was arrested for theft twice in the past 4 years. Mr. and Mrs. Weston also felt Andrea was now sexually active with her boyfriend and worried about the possible consequences. They said their attempts to dissuade Andrea from dating the man were unsuccessful. Mr. and Mrs. Weston also said Andrea’s grades were suffering, her social life was shrinking, and her participation in family activities was declining.

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Both parents argued vehemently with Andrea about these issues in the past few months but their concern produced no change in their daughter’s behavior. Both, however, described their relationship with Andrea as excellent.

The psychologist also asked about Andrea’s weight and eating habits. Mrs. Weston repeated the “binge” story given earlier by her husband and said she felt Andrea was too fussy about the way she looked. Mrs. Weston said her daughter always had a weight problem and that she, Mrs. Weston, tried to control Andrea’s diet. Mrs. Weston said Andrea’s weight “fluctuated like a yo-yo” as her moods changed. (The psychologist noted the paradox in Mrs. Weston’s behavior: she claimed Andrea was too fussy about appearances, but emphasized such appear- ances herself.) Both parents became more concerned when Andrea revealed her recent pattern of binge eating and believed she was vomiting as well. Their primary treatment goal, however, was to “help Andrea overcome feelings of inadequacy.”

The psychologist also spoke with Andrea’s schoolteachers with Mr. and Mrs. Weston’s permission. All said Andrea was normally a good student, but her grades slipped recently because of incomplete homework. They also said Andrea seemed preoccupied with other matters and speculated that her home life caused her recent academic problems. Based on this early information from Andrea, her par- ents, and her teachers, the psychologist preliminarily concluded that Andrea had subclinical anorexia nervosa of the binging/purging subtype as well as subclinical depression.

ASSESSMENT

The essential features of anorexia nervosa are [American Psychiatric Association (APA), 2000, p. 583]:

■ Refusal to maintain a minimally normal body weight ■ Intense fear of gaining weight ■ Significant perceptual disturbance regarding one’s body shape or size ■ Amenorrhea in postmenarcheal females

People with anorexia maintain their body weight at less than 85% of normal weight for age and height. They commonly fear weight gain even when they are underweight, base their self-worth on weight, and/or deny that a problem exists. Female amenorrhea in anorexia refers to the absence of three consecutive men- strual cycles.

Anorexia nervosa may be of (1) the restricting type, in which a person has lost weight but is not binging or purging, or (2) the binge eating/purging type, in which a person engages in binge eating as well as purging through vomiting, laxative abuse, or excessive exercise. A binge refers to “eating in a discrete period of time an amount of food that is definitely larger than most individuals would eat under similar circumstances” (APA, 2000, p. 589).

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Andrea’s diagnosis was difficult. The psychologist tentatively refrained from a diagnosis of bulimia nervosa because Andrea’s binge eating and purging occurred too infrequently to meet diagnostic criteria. DSM-IV-TR criteria for bulimia nervosa mandate an average of 2 binge/purge episodes a week for 3 months. This left a possible diagnosis of anorexia nervosa with binge eating/purging features, a common finding in those with eating disorders. Andrea was not amenorrheic or more than 15% underweight but had lost 20 pounds in the past several weeks. If she continued on this path, as she seemed inclined to do, then she would be seriously underweight in a short period.

The psychologist also preferred a diagnosis of anorexia nervosa because of Andrea’s fear of weight gain and worry about losing her boyfriend. Andrea was convinced her boyfriend and other friends would abandon her if she gained weight and her parents would comment on her “obesity.” She also felt she would look “ugly.” The psychologist also noticed that Andrea was oblivious to negative consequences of losing more weight and judged her self-worth almost solely on the way she looked. People who meet most but not all symptoms of anorexia nervosa, like Andrea, may receive a diagnosis of “eating disorder not otherwise specified.” The psychologist also thought Andrea had depressive symptoms that needed treatment but she did not meet criteria for a major depressive episode.

Assessing people with anorexia nervosa should begin with a medical exami- nation because severe physical complications and even death can result. Anorexia may result in several physical problems: gastrointestinal distress, bloating, dizziness, dehydration, electrolyte imbalances, lethargy, dry skin, edema, anemia, cardio- vascular abnormalities, renal dysfunction, and atypical neurological patterns. Ero- sion of dental enamel may also occur in people who induce vomiting (Fairburn & Harrison, 2003). Andrea had no major physical symptoms and received no medical examination, however.

A psychological assessment or interview of those with eating disorders should concentrate on the following (Anderson, Lundgren, Shapiro, & Paulosky, 2004):

■ Attitudes toward weight and body shape ■ Characteristics of binging and purging and current weight ■ Feelings of loss of control, drive for thinness, distress, anxiety, and depression ■ Dieting behaviors ■ Body image disturbance ■ Maladaptive personality traits such as impulsivity ■ Social and family functioning ■ Reasons for seeking treatment and motivation for change

Andrea said she and her mother always paid close attention to weight and that Andrea’s self-worth closely matched her weight. Andrea kept daily records of her weight and eating habits and agreed to provide the psychologist with this infor- mation. Keeping such a diary is a common form of assessment in this population.

Assessment should focus on what a person eats, length of a binge, related emotions, and conditions that precede and follow a binge. The psychologist found

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that Andrea’s binges usually came after school and before she saw her boyfriend. Andrea would come home from school sometimes feeling isolated, inadequate, or hungry and would occasionally binge on easily bought and quickly eaten items such as cake. No one was usually home at this time. Following this binge and dinner with the family, Andrea worried the ingested food would cause her to gain weight and look inferior to her boyfriend. She then purged before dates with him. The psychologist instructed Andrea to keep a record of her binges and purges.

Andrea’s moods often related to food. She ate and binged when anxious or depressed and purged when feeling guilty, fat, or ugly. Andrea had few moods not tied to eating and often ate impulsively and with little control. The psychologist found no major patterns of borderline personality traits, aggression, or substance abuse, however. No history of physical or sexual abuse was reported either. These findings support the belief that no one pattern of symptoms necessarily fits all those with anorexia nervosa.

The psychologist also focused on the link between Andrea’s social and family interactions and her eating. Andrea had distorted thoughts of abandonment by others if she gained weight and popularity if she lost enough weight. An in-depth discussion with Andrea and her parents also revealed vacillating enmeshment and conflict. Andrea and her parents would become overinvolved in one another’s lives and then fight about this. Andrea and her mother spent hours shopping and talking about Andrea’s appearance. Andrea would then complain her mother was “trying to control me.” Similar patterns were evident with respect to Andrea’s girlfriends, but not her boyfriend.

The psychologist also explored the family’s reasons for seeking treatment and their motivation for change. An interesting observation was that no one focused much on Andrea’s eating habits, preferring to complain instead about each other’s role in the family. Mr. and Mrs. Weston did eventually acknowledge their con- cern about Andrea’s weight following a prompt from the psychologist and the issue became a centerpiece of family therapy conducted later.

Interviews for those with eating disorders also focus on social skills, sexual behavior, and menstrual history, but these were not discussed at length in Andrea’s case. Assessment in this area may also include rating scales such as the Eating Attitudes Test (Garner, 1997), cognitive and family measures (Cooper, 2005; Treasure et al., 2008), and a consideration of cultural factors that impinge on a case (Alegria et al., 2007). Sample items from the Eating Attitudes Test* include:

■ Am terrified about being overweight. ■ Find myself preoccupied with food. ■ Am preoccupied with a desire to be thinner. ■ Feel that others pressure me to eat. ■ Have the impulse to vomit after meals.

*Reproduced with permission by Dr. D. Garner (Garner et al., 1982. The eating attitudes test: Psychometric features and clinical correlates. Psychological Medicine, 12, 871–878). Further information on the EAT-26 can be obtained from www.river-centre.org.

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R ISK FACTORS AND MAINTAIN ING VARIABLES

Factors that lead to eating disorders in general and anorexia nervosa in particular involve a mixture of physical, psychological, and sociocultural variables. The causes of eating disorders may overlap with those for depression. Anorexia nervosa and depression are associated with changes in cortisol and the neurotransmitters serotonin and norepinephrine (Bailer & Kaye, 2003). A noteworthy finding in Andrea’s case was Mrs. Weston’s report that several of her relatives were depressed.

Other biological causes of eating disorders include genetics and sensory response. The concordance rate for anorexia nervosa in identical twins is sub- stantially higher than for fraternal twins. Family members of people with eating disorders are also more likely to have eating disorders themselves compared to the general population (Bulik, Slof-Op’t Landt, van Furth, & Sullivan, 2007). Those who binge also tend to have a greater sensory response such as salivation to food (Legenbauer, Vogele, & Ruddel, 2004). These factors did not seem pertinent to Andrea’s case, however.

Several individual psychological characteristics have also been associated with anorexia nervosa. People with anorexia tend to be perfectionistic, obsessive, and compliant. Those who binge and purge show depression and anxiety and impul- sivity, require approval from others, and like novel stimuli (Anderluh, Tchanturia, Rabe-Hesketh, & Treasure, 2003; Stein et al., 2002; Troisi, Massroni, & Cuzzolaro, 2005; Vervaet, Audenaert, & van Heeringen, 2003). Some of these characteristics were evident in Andrea but others were not. Andrea was dramatic in her behavior, a characteristic not typical of those with anorexia. She was also moderately non- compliant and enjoyed irritating her parents.

On the other hand, Andrea clearly needed approval from others, especially her friends and boyfriend. The opinion of her parents, despite her objections, seemed important to Andrea as well. Andrea had mood swings and impulsive behavior, a fact that greatly concerned her parents. She sometimes said and did things with little thought, such as driving fast and buying clothes impetuously. Andrea was clearly obsessed about her relationships with other people and about her weight. She also had perceptual and cognitive distortions regarding her weight, insisting she was “ugly and fat” even as she lost weight and claiming other people were often talking about her weight behind her back.

Cognitive-behavioral models of eating disorders, especially binge eating, focus on cycles of emotions and obsessional thinking (Wilson, Fairburn, Agras, Walsh, & Kraemer, 2002). One possible scenario is that stressful situations, low self-esteem, and worries about body shape and weight lead to general feelings of apprehension. Binge eating temporarily reduces this anxiety and tension. Guilt and shame gradually develop after a binge, however, so a person purges to reduce these emotions. Unfortunately, stressful events and a sense of low self-esteem remain in the person’s life and the cycle repeats. This scenario applied to some extent to Andrea, who sometimes binged following a stressful day at school. She then felt regret and distress over the binge, including possible weight gain, and purged by vomiting.

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Other psychological theories of eating disorders emphasize family variables. A classic developmental/psychodynamic/object relations view holds that anorexia nervosa is a manifestation of internal conflict. Anorexia is a compensatory behavior for satiation or separation problems during the oral stage of psychosexual devel- opment. A related view is that anorexia results from a problematic mother-child attachment. A mother may gratify the physiological but not emotional needs of her child. This may derive from the mother’s insecurity or hostility toward the child, but the result is a child who feels insecure, rejected, and possibly vulnerable to depression and eating disorders.

Other family theories of eating disorders focus on interactions among all family members. Some families of adolescents with anorexia are enmeshed. This means family members are overinvolved in one another’s lives to the point that even minor events, such as daily dress, become a source of great attention. Perhaps an adolescent, feeling dominated by her parents, rebels by overcontrolling a very personal aspect – weight. An adolescent may also draw extra attention from an enmeshed family by exploiting weight loss and related medical complications.

Andrea certainly had a strange and contradictory relationship with her parents:

■ She valued their opinions, but then claimed to reject them. ■ She sought advice from her parents, but then complained of being over-

controlled. ■ She professed love for her parents, but greatly enjoyed needling them.

Mrs. Weston also gave Andrea mixed messages:

■ She dismissed the importance of appearance and weight, but then gave Andrea extensive advice in this area.

■ She told Andrea she loved her while avoiding eye contact. ■ She blended criticisms of Andrea with compliments.

Andrea was probably confused about how her parents and others felt about her. She then developed low self-esteem and the mistaken belief that weight loss was a key way to get affection from others.

Some families of adolescents with anorexia nervosa display overprotective- ness, avoidance of conflict, poor problem-solving skills, and negative communi- cation and hostility. These characteristics were present to some degree in Andrea’s case. Her family was often sarcastic, critical, and reluctant to discuss certain pro- blems. Some theorists hold that children model a parent’s preoccupation with weight reduction (Wilson, Becker, & Heffernan, 2003). Andrea’s mother was particular about her own appearance and the psychologist discovered that Mrs. Weston also weighed herself and dieted regularly. Andrea imitated this behavior as she grew up.

Another popular model of eating disorders is a sociocultural one. The glori- fication of thinness in the media provokes many young women to diet. The image of the “ideal” female body size in popular literature has gradually become thinner in past decades. This could lead to anorexia in 2 ways. First, as more young women feel pressured to diet, more could trigger a biological predisposition to anorexia

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nervosa. Second, failure to meet societal demands for thinness could lead to de- pression, low self-esteem, and unusual eating patterns (Andrist, 2003).

A sociocultural perspective might explain why patterns of bulimia occur more in females from Western countries such as Andrea. The psychologist in this case also noted that Andrea and her mother subscribed to several women’s fashion magazines. Both often matched their appearance to the models in the magazines as well.

DEVELOPMENTAL ASPECTS

Several developmental variables influence the onset, course, and treatment of adolescents with eating disorders. One developmental variable may explain why girls show anorexia nervosa more than boys: physical development. Females tend to increase their amount of fat tissue at a greater rate than males during adoles- cence, and this obviously moves them away from the “ideal” body size portrayed in the media. This may also explain why anorexia and bulimia nervosa occur more in adolescents than children. Other physical factors related to onset of eating dis- orders include early menarche and breast development (Fairburn & Harrison, 2003). Parental reactions to these events are also critical.

The psychologist found that Andrea was an “early developer” and teased by her classmates for being so. Andrea found this humiliating and became sensitive about her weight and figure. This attitude, combined with her mother’s com- ments noted earlier, led Andrea to be self-conscious about her appearance. She was nearly obsessed with how others looked at her and catastrophized even minor flaws in her appearance such as wrinkles and skin blotches. When the psychologist asked Andrea to list her positive aspects, Andrea mentioned her figure, weight, height, and others’ reactions to her appearance. She made little mention of her role as student, daughter, or girlfriend.

Dieting is also a key developmental aspect of eating disorders. Dieting is a “rigid and unhealthy restriction of overall caloric intake, skipping meals, and excessive avoidance of specific foods in order to influence body weight and shape” (Wilson et al., 2003, p. 703). Chronic dieting actually induces some people to eat more high-calorie foods, which can then trigger binging and other eating disturbances. Eating alone often precedes dieting and may set the stage for the secretive nature of later eating disorder (Martinez-Gonzalez et al., 2003).

As people diet, their metabolic rates are reduced and weight loss becomes more difficult (Wilson et al., 2003). Subsequently, they may diet even more vigorously and become more vulnerable to binge eating. Biological and psychological vulnerabilities to eating disorders are then triggered. The dieters may feel increa- singly “out of control” and decide purging is the only way to moderate effects of binging. The cognitive-behavioral cycle described earlier can then serve to maintain the disorder. For those with restrictive anorexia, dieting may start by eliminating certain foods from their daily menu, such as sweets. As the disorder progresses, however, more and more foods such as meat or bread are added to the “forbidden” list and the person’s daily caloric intake and weight decline steadily.

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Andrea and her mother had a long history of dieting. Andrea was frustrated over the yo-yo effect of dieting, often losing weight to fit into certain clothes or attend social functions, then putting the weight back on in subsequent weeks. The addition of her boyfriend to her life and his comment about her weight, however, gave her dieting a new sense of urgency. Andrea lost 20 pounds in the past several weeks and was now terrified the lost weight would return. This fear caused her to restrict her diet even more than in the past but this aggravated feelings of social isolation, depression, and hunger. Her binging and purging thus began.

Depression can also influence eating disorders over time. The most consistent predictor of poor outcome in those with bulimia nervosa is depression (Berkman, Lohr, & Bulik, 2007). Andrea’s level of depression, though not severe, did extend the length of treatment. Her low self-esteem and general feelings of worthlessness led to cognitive distortions about her “ugly” body size and weight. Andrea also mused about suicide, which required its own intervention. Finally, Andrea’s depression prevented her from interacting with girlfriends, which ironically led to Andrea’s impression that no one wanted to socialize with her. Her subsequent feelings of rejection later increased her desire to diet, binge, and purge.

What is the long-term future of those with eating disorders? Some people with anorexia have only one episode of weight loss and soon return to normal patterns of eating and weight control. Others experience a gradual and ongoing course of weight loss and gain. About 7% of those with anorexia, however, eventually die from the disorder because of medical complications or suicide (Korndorfer et al., 2003).

The long-term pattern of bulimia is slightly different because the disorder usually develops later in life. Symptoms of bulimia alternately improve and worsen over time. The course of the disorder appears to change favorably after treatment but relapse is common. Many people with bulimia continue to show low-level eating disturbances such as extensive dieting, laxative use, and exercise. Outcome for eating disorders is better if a person has less severe depression, good family and social relationships, and improved impulse control (Berkman et al., 2007).

What about Andrea? Her long-term outcome is probably good and almost certainly better than most people with eating disorders. This is largely because she received treatment relatively early in her disorder; many with anorexia or bulimia nervosa hide their behavior for several years before entering therapy. Andrea’s therapist was also experienced in treating eating disorders and utilized cognitive-behavioral methods. Andrea’s eating disorder was also rather limited in scope and her family, though problematic, was motivated to resolve their difficulties. Andrea’s level of depression was not clinical either and generally dissipated during individual and family therapy for her eating problems.

TREATMENT

Treating people with eating disorders can involve inpatient and outpatient therapy. Inpatient treatment applies usually to severe cases of eating disorders,

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especially anorexia nervosa. Inpatient treatment is best when medical compli- cations of anorexia are dire or when a person’s behavior is life threatening. Major medical complications include substantial loss of ideal body weight (>25%), electrolyte imbalance, cardiac problems, and severe dehydration. Severe symptoms of depression and suicidal behavior must sometimes be addressed as well.

A main goal of hospitalization is to stabilize a person’s health and increase weight and nutrition. Staff members set a target weight to meet before discharge. Interventions can include (Guarda, 2008):

■ Structured eating sessions with staff and family members ■ Education about eating disorders ■ Reconstruction of proper eating and nutritional habits ■ Group and milieu therapy ■ Medication for physical complications or depression

Hospitalization was not necessary for Andrea given her relatively moderate eating problem.

Outpatient therapy for anorexia nervosa often involves drug, group, individual, and family therapy. Drug therapy includes antidepressants such as amitriptyline or fluoxetine (Prozac). These are sometimes effective because the drugs successfully reduce obsessive-compulsive and depressive behaviors that trigger or aggravate anorexia. Anti-anxiety drugs sometimes reduce tension and the temptation to binge and purge. Relevant family members should be educated about the use of medication and side effects should be monitored. The use of antidepressants was initially discussed, but later abandoned for Andrea. An emphasis was placed instead on individual and family therapy.

Treatment within a cognitive-behavioral framework is usually recommended. Important goals of individual therapy for those with anorexia nervosa involve:

■ Developing rapport with the client ■ Increasing motiv

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