Ongoing design and publication of this site is completed by Shane R. Jimerson, Jeff R. Klein and Angela D. Whipple. Please forward comments regarding this site to Shane R. Jimerson. This page was last updated 1.11.02. © 2002
Symptoms
Epidemiology
Etiology
Assessment
Treatment
Authors
Shane R. Jimerson, Renee Pavelski, Micah Orliss & Hallie D’Agruma
University of California, Santa Barbara
EATING DISORDERS
The eating disorders section of the developmental
psychopathology website provides important information regarding the epidemiology,
etiology, assessment, and treatment of eating disorders in children and
adolescents. The site takes up a comprehensive review of the recent
research and relevant literature that reflects the current knowledge regarding
anorexia nervosa and bulimia nervosa during childhood and adolescence.
Additionally, after a thorough review of web-based information, this site
suggests the top ten reference websites on eating disorders. The
site emphasizes the importance of understanding the multidimensional nature
of eating disorders. From a developmental perspective, this section
explores the emergence of eating disorder symptomatology, considering sociocultural,
biogenetic, personality, family, emotional, cognitive and behavioral domains.
The research proves the necessity of seriously examining the manifestation
of eating disorders among children and adolescent populations as
the age range of eating disorders now extends to early elementary school
(age 7 years), with increasing prevalence in children and adolescents (Bryant-Waugh
& Lask, 1995; Phelps & Bajorek, 1991). Furthermore, the incidence
of eating disorders has risen dramatically over the past two decades with
no evidence of abatement (Lucas, Beard, O’Fallon, & Kurland, 1991;
Steiner & Lock, 1998). The prevalence of anorexia nervosa and bulimia
nervosa among girls between the ages of 10 and 19 (approximately 2% and
4%, respectively) places eating disorders among the most common chronic
illnesses of adolescent girls (Lucas et al., 1991; Stice & Agras, 1998).
With the increased scope and significance of eating disorders, psychologists,
health care professionals, school teachers and administrators, parents,
and friends are in a critical position to facilitate the healthy development
of individuals of children and adolescents, with an eye towards the prevention,
assessment, treatment of eating disorders in these populations.
Broadly, eating disorders include rumination,
pica, obesity, anorexia, and bulimia. In this section, the focus
is on both anorexia nervosa and bulimia nervosa. The Diagnostic and Statistical
Manual of Mental Disorders - Fourth Edition Revised(DSM-IV-TR) (American
Psychological Association, 2000) definition of anorexia includes symptoms
of low body weight, fear of gaining weight, distorted body image, and the
absence of menstruation in females (see below). The DSM-IV-TR symptoms
of bulimia nervosa include recurrent episodes of binge eating, inappropriate
compensatory behavior (purging), and a self evaluation unduly influenced
by body weight (see below). A primary difference between the disorders
is that anorexics are significantly underweight, while bulimics generally
are within normal weight ranges or only slightly underweight.
Diagnostic criteria according to the DSM-IV-TR (American Psychiatric Association, 2000) for Anorexia Nervosa:
A. Refusal to maintain body weight at or above a minimally
normal weight for age and height (e.g., weight loss leading to maintenance
of body weight less than 85% of that expected; or failure to make expected
weight gain during period of growth, leading to body weight less than 85%
of that expected).
B. Intense fear of gaining weight or becoming fat, even
though underweight.
C. Disturbance in the way in which one's body weight or
shape is experienced, undue influence of body weight or shape on self-evaluation,
or denial of the seriousness of the current low body weight.
D. In postmenarcheal females, amenorrhea, i.e., the absence
of at least three consecutive menstrual cycles. (A woman is considered
to have amenorrhea if her periods occur only following hormone, e.g., estrogen,
administration).
Specify type:
Restricting Type: during the current episode of Anorexia Nervosa,
the person has not regularly engaged in binge-eating or purging behavior
(i.e., self-induced vomiting or the misuse of laxatives, diuretics, or
enemas).
Binge-Eating/Purging Type: during the current episode of Anorexia Nervosa,
the person has regularly engaged in binge-eating or purging behavior (i.e.,
self-induced vomiting or the misuse of laxatives, diuretics, or enemas.
Diagnostic criteria according to the DSM-IV-TR (American Psychiatric Association, 2000) for Bulimia Nervosa:
A. Recurrent episodes of binge eating. An episode of binge
eating is characterized by both of the following:
1. eating, in a discrete period of time (e.g., within any 2-hour period),
an amount of food that is definitely larger than most people would eat
during a similar period of time and under similar circumstances.
2. a sense of lack of control over eating during the episode (e.g.,
a feeling that one cannot stop eating or control what or how much one is
eating).
B. Recurrent inappropriate compensatory behavior in order to prevent
weight gain, such as self-induced vomiting; misuse of laxatives, diuretics,
enemas, or other medications; fasting; or excessive exercise.
C. The binge eating and inappropriate compensatory behaviors
both occur, on average, at least twice a week for 3 months.
D. Self-evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes
of Anorexia Nervosa.
Specify type:
Purging type: during the current episode of Bulimia Nervosa,
the person has regularly engaged in self-induced vomiting or the misuse
of laxatives, diuretics, or enemas.
Nonpurging type: during the current episode of Bulimia Nervosa, the
person has used other inappropriate compensatory behaviors, such as fasting
or excessive exercise, but has not regularly engaged in self-induced vomiting
or the misuse of laxatives, diuretics, or enemas.
EPIDEMIOLOGY
Anorexia Nervosa
Anorexia nervosa is an important health problem
to address. In addition to impairing normal bodily functioning in
individuals, it has been linked to severe long-term morbidity and substantial
mortality; 10% of cases end in death (American Psychiatric Association,
1994). Most estimates have indicated that the incidence of anorexia
nervosa has increased since 1950(Lucas, Beard, O'Fallon, & Kurland,
1991); thus, it is becoming a more pressing concern. In particular,
the high rate among girls between the ages of 10 and 19 makes anorexia
nervosa the third most common chronic illness among adolescent girls after
obesity and asthma (Lucas et al., 1991). Significant medical problems,
such as the potential for significant growth retardation, pubertal delay
or interruption, and peak bone mass reduction, are all associated with
this illness (Steiner & Lock, 1998). In addition to impairing normal
bodily functioning in individuals, it has been linked to severe long-term
morbidity and substantial mortality; 3% to 10% of cases end in death (Steiner
& Lock, 1998; American Psychiatric Association, 1994). Suicide
has been reported in up to 5% of patients with chronic anorexia nervosa
(Steiner & Lock, 1998). Moreover, although anorexia nervosa has been
primarily seen as an illness specific to adolescent girls, the research
shows that both sexes suffer from this condition and that onset ages range
from childhood to late adulthood. Additionally, a near threefold increase
was observed over the past 40 years among women in their 20's and 30's
(Pawluck & Gorey, 1998). Recent research has also suggested that
there may be a common familial vulnerability for anorexia nervosa (Lilenfeld,
Kaye, Greeno, et al., 1998).
In general, it appears that the prevalence
of anorexia nervosa may be on the rise. Currently, studies of females
in late adolescence and early adulthood indicate prevalence rates of between
.5% and 1% using DSM-IV criteria (American Psychiatric Association, 1994).
Studies suggest that females comprise the majority of cases, but males
may make up 5% to 10% of the overall anorexic population. In studies
of childhood-onset anorexia (before age 14), studies show that boys may
represent 20% to 30% of anorexia nervosa cases (Attie & Brooks-Gunn,
1995; Lask & Bryant-Waugh, 1991; Maloney & Klykylo, 1983; Ross,
1977). The age of onset for anorexia nervosa appears to be bimodally
distributed at ages 14 and 18 years and is often associated with a significant
life event such as the onset of puberty or leaving home for college (Attie
& Brooks-Gunn, 1995). Important to note is that over one-third of the
adolescent female population report participating in such aggressive methods
of weight control and reduction as chronic dieting, excessive exercise,
and diet medications (Phelps, Augustyniak, Nelson, & Nathanson, 1997).
Some evidence shows that the majority of anorexics are women who are Caucasian
and from higher socioeconomic backgrounds. These demographic trends,
however, may be shifting towards including more ethnic minorities and those
from lower social classes (Attie & Brooks-Gunn, 1995; Lask & Bryant-Waugh,
1991).
Doyle & Bryant-Waugh (2000) present a
discussion of critical issues in the epidemiological study of eating disorders,
focusing specifically on problems with methodology in the study of eating
disorders of children, the lack of epidemiological studies of eating disorders
in children, and assessment challenges with the increased rates of eating
disorders among children. Additionally, the chapter addresses issues
of gender differences, developmental age, high risk groups, and cultural
issues highly relevant to the epidemiology of eating disorders in youth.
Lask & Bryant-Waugh (1992) focus
mainly on literature about anorexia in the age group 8-14 years, while
providing comprehensive information that is applicable to eating disorders
in the general population. The authors review a considerable number
of studies, taking an international approach that provides information
for research being done all over the world. The first section of
the review covering epidemiology and demography provides a good summary
of prevalence studies and also addresses such issues as eating disorders
in various ethnic groups and the usefulness of diagnostic criteria.
The article goes on to present information on the possible pathogenesis
of anorexia, its biological correlates, the psychometric assessment of
the illness, other psychological aspects, and possible outcomes of treatment.
The authors conclude that the pathogenesis of eating disorders is likely
the result of a complex interaction of genetic, biological, personality,
and family factors. As a result, multi-focal assessment of children
with eating disorders is recommended.
Lewinsohn, Striegel-Moore, & Seeley (2000)
investigate the epidemiology of eating disorders in a community sample
of adolescent girls, looking at the continuity between adolescent and young
adult psychopathology. The study also compared the characteristics
of full-syndrome and partial-syndrome cases. The researchers found
a relatively younger age of onset for anorexia than for bulimia, consistent
with the current literature, and discovered that eating disorders occur
most frequently within adolescent populations, with the incidence of eating
disorders less than 2.8 % by the age of 18 and as 1.3 % for ages 19-23.
They found a high comorbidity with other psychopathology (89.5%), especially
depression, even when the acute eating disorder episode has remitted; thus,
suggesting the necessity of a broad-based diagnostic assessment and treatment
plan. The full-syndrome and partial-syndrome groups did not differ
from each other, yet each group differed significantly from a no-disorder
group. Consequently, the clinical implications of this study point
towards the routine assessment and treatment of both full-syndrome and
partial-syndrome eating disorders for adolescent girls.
Lilenfeld, Kaye, Greeno, et al. (1998) use
family-epidemiological methods to examine patterns of comorbidity and familial
aggregation of psychiatric disorders for anorexia nervosa and bulimia nervosa.
Subjects included females with restricting-type anorexia nervosa or bulimia
nervosa, a control group, and first-degree biological relatives.
Results suggest that the relatives of anorexic and bulimic subjects had
increased risk of clinically subthreshold forms of an eating disorder,
major depressive disorder, and obsessive-compulsive disorder. This
study sheds light on the myriad of problems associated with eating disorders,
and helps to clarify the transmission patterns of other psychiatric disorders
among family members. Additionally, the results suggest a shared
familial transmission of anorexia nervosa and obsessive-compulsive disorder.
This raises the possibility that it is necessary to have a risk for both
obsessive-compulsive disorder and eating disorder to develop restricting-type
anorexia nervosa.
In this comprehensive study spanning a fifty
year period, Lucas, Beard, O'Fallon, & Kurland (1991) examined
incidence and prevalence rates of anorexia nervosa by studying all persons
residing in Rochester, Minnesota from 1935 to 1984. For girls aged
10-19, the incidence fell from 16.6 per 100,000 person-years during the
1935-1939 period to a low of 7.0 in 1950-1954. However, in recent
years (1980-1984), this figure has increased to 26.3. The authors
concluded that the rate of anorexia nervosa is more common than previously
recognized; in particular, for girls aged 15-19, it is a very common chronic
illness. The incidence of anorexia nervosa has increased among females
aged 15-24, but not among older women or among males. In this article,
the authors also discuss other international studies on the incidence and
prevalence rates of anorexia nervosa.
Maloney & Klykylo (1983) review information
on epidemiology and both short-term and long-term treatment of anorexia,
bulimia, and obesity in children in adolescents. It indicates that anorexia
nervosa and other eating disorders are reaching epidemic proportions in
teenage populations. Long-term follow-up studies report a fall of
mortality rates but no improvement in morbidity rates for these illnesses.
The article also includes information on outcomes, mortality rates, and
possible psychological and physical consequences of the illness.
Treatments reviewed include psychodynamic approaches, cognitive behavioral
approaches, and family therapy approaches as well as psychopharmacology.
The authors recommend a biopsychosocial approach to treatment and indicate
that long-term treatment is likely to be necessary.
Steiner & Lock (1998) highlight recent
advances in normal development as it pertains to anorexia nervosa and bulimia
nervosa, their diagnosis, prevention, and treatment. The authors
review the changes in the DSM, recent epidemiological data, studies of
risk factors, and treatment effectiveness studies in children and adolescents.
From their review, the authors conclude that most of the literature focuses
on risk, and very little focuses on protective factors. This article
points to several persistent methodological problems in the current literature:
most studies involve mixed samples of adults and juveniles, and age at
onset of illness and duration of illness are rarely controlled for and
thus may confound treatment results. They assert that research is
needed addressing normative data on the development of eating behavior
and specific risk and resilience factors for pathology in specific developmental
periods. Especially lacking are studies regarding the continuities
and discontinuities of eating disturbances across the life span.
This article states that to establish risks and causal models, any developmental
model of eating disorders must account for the normal development of complex
factors in multiple domains and their interactions. Finally, the
authors also point to the need for longitudinal data.
Walters & Kendler (1995) study the epidemiologic
characteristics and risk factors of anorexia nervosa. They also examined
the relationship between anorexia and anorexia-like syndromes, noting that
partial-syndrome anorexia nervosa is probably more common than anorexia
nervosa and that there may be a continuumof pathology on which classic
anorexia nervosa represents the furthest extreme. Thus, although
the prevalence of classic, narrowly defined anorexia nervosa was relatively
rare (.5%), there also seemed to be a higher percentage (1%) of women who
exhibited anorexia-like symptoms but did not meet full criteria for class
anorexia nervosa; moreover, over 3% of women reported an anorexic-like
episode at one or more times in their lives. In this study, a significant
relationship is reported between anorexia nervosa and dieting status, greater
number of years of parental education, low self-esteem, high levels of
neuroticism, and maternal overprotectiveness. The authors also reported
comorbidity between anorexia nervosa and major depression, bulimia nervosa,
generalized anxiety disorder, alcoholism, phobias, and panic disorder.
This study also concluded that the co-twin of a twin with anorexia nervosa
was at a significantly higher risk for anorexia nervosa.
The study of anorexia nervosa is still in
its infancy and further research needs to be done, especially with ethnic
minorities and samples from lower socioeconomic classes. Researchers
have noted that the relatively low prevalence rate makes this condition
hard to study. In addition, diagnostic criteria have changed over
the years which adds to the difficulty in diagnosing and studying this
condition. Recent research points to the importance of assessing familial
factors that could aid in the diagnosis of anorexia nervosa. Utilizing
an etiological model, it is recommended that prevention programs be directed
toward female and male young adolescents with an orientation toward increasing
factors which attenuate risk status while reducing elements placing teens
in jeopardy. Nevertheless, the facts that the prevalence of anorexia nervosa
appears to be on the rise and that the consequences of this illness can
be fatal cause this to be an area of research deserving of considerable
attention.
Bulimia Nervosa
Bulimia nervosa is an important psychological
disorder, yet has been the subject of less research than the other major
eating disorder, anorexia nervosa. However, incidence rates indicate
that it is more common than anorexia nervosa and, indeed, is most likely
underreported, as individuals suffering from the disorder tend to be secretive
about its existence and do not necessarily exhibit symptoms such as dramatically
reduced body weight (Turnbull, Ward, Treasure, Jick, & Derby, 1996).
Given this, it is important to be as aware and well-informed about bulimia
nervosa as possible. This page will present some of the most current
information and studies regarding bulimia nervosa in order to highlight
the recent developments and new knowledge that has been gained about this
historically overlooked disorder.
Various estimates of the prevalence of bulimia
nervosa exist. According to a study by Turnbull et al. (1996) the
prevalence of the disorder is 12.2 cases per 100,000 population, adjusted
for age and gender, which was consistent with other research they reviewed.
Bulimia nervosa is most common among female adolescents and young adults
(American Psychiatric Association, 1994). It is estimated to occur
in 1%-3% of this population. Some controversy exists as to whether
the incidence of bulimia nervosa is increasing. While it does seem
to be being diagnosed more frequently, it remains to be seen whether this
reflects an increasing prevalence of the disease or a wider recognition
of the symptoms of the disorder and therefore a higher rate of diagnosis
(Turnbull et al., 1996). As mentioned earlier, bulimia nervosa occurs
more often in females than males. This difference is striking: at
least 90% of bulimics are women (Wilson, O’Leary, & Nathan, 1992).
Bulimia nervosa typically has its onset during adolescence (American Psychiatric
Association, 1994). It occurs most often, but not exclusively, in
Caucasians (American Psychiatric Association, 1994).
Johnson, Powers, & Dick (1999) look at
the prevalence of disordered eating among study athletes through a collaboration
with the National College Athletic Association. The researchers found
that 1.1 % of the females met DSM-IV criteria for bulimia nervosa and 9.2
% of the females showed clinically significant problems with bulimia.
For example, 10.85 % of the females reported binge eating on a weekly or
greater basis, and 5.52 % of the females also reported purging behavior
(vomiting, laxatives, diuretics) on a weekly or greater basis. Despite
the fact that symptomatic eating behaviors and attitudes are significantly
lower in this study than in previous studies of athletes, a disturbing
finding surfaced nonetheless, pointing towards a drive for both performance
and appearance thinness among athletes that significantly increases the
risk for developing eating disordered thoughts and behaviors.
Neumark-Sztainer, Story, Faulkner, Beuhring,
& Resnick (1999) seek to determine prevalence reates of behaviors aimed
at weight loss and weight/muscle gain among adolescents across sociodemographic
and personal variables. The results show that exercise followed by
dieting was the most frequently reported weight control measure.
Significantly, 7.4 % of adolescent girls reported disordered eating (vomiting,
diet pills, laxatives, or diuretics) over the previous week, and 3.1 %
of adolescent boys reported these behaviors. Girls with the highest
body mass index showed the greatest risk for these behaviors, while boys
with the lowest body mass index were at the greatest risk for steroid use.
Caucasian girls were the most likely to diet and exercise, and older girls
reported slightly more dieting and disordered eating and less exercise
than younger girls. African American and Hispanic girls reported
more behaviors aimed at weight gain. African American and Hispanic
boys presented high rates of diordered eating behaviors as well as youth
from low socioeconomic backgrounds. The diverse results of this study suggest
a need to broaden our investigation across multiple groups to determine
who is most at risk for developing eating disorders.
Sullivan, Bulik, & Kendler (1998) present
interesting findings regarding the relative genetic and environmental influences
of bulimia nervosa. The study additionally examines the validity
of the DSM-IV diagnostic criteria for the disorder. Using a study
of 1897 female twins, the authors determine that 46% of binging variance
and 72% of vomiting variance was accounted for by genetic factors.
Individual-specific environmental factors accounted for the rest of the
variance. The authors also determined that there was a significant
overlap between the genetic factors accounting for binging and the genetic
factors accounting for vomiting behaviors. The results also indicate
that the DSM-IV criteria for bulimia nervosa are valid. This study
is an important step forward in understanding the genetic and environmental
epidemiology of bulimia nervosa, an issue which remains unresolved.
Turnbull, Ward, Treasure, Jick, & Derby (1996) provide a very good
epidemiological study of both bulimia nervosa and anorexia nervosa.
The authors made use of the General Practice Research Database, which holds
the records of 550 general practitioners in the United Kingdom. This
results in a database of over 4 million patients and is therefore a very
broad and representative sample to examine. The authors examine the
incidence rates of bulimia nervosa and anorexia nervosa in this sample
over a six year period. Results are compared by gender and age.
Frequency of diagnosis is also examined over this period. The authors
conclude that the incidence of bulimia nervosa is increasing, which therefore
necessitates a greater dissemination of information regarding the disorder
and an increased knowledge of treatments.
While less is known about bulimia nervosa
than other similar disorders, an influx of new research is changing that.
At the moment, incidence rates indicate that it is the most prevalent eating
disorder. Like other eating disorders, it occurs strikingly more
often in women and is most common during adolescence and young adulthood.
The current DSM-IV-TR conception of bulimia nervosa has been independently
validated and seems appropriate. However, controversy still exists
over whether or not the incidence is increasing. Additionally, there
is still disagreement over the specific genetic and environmental influences
of the disorder (Sullivan, 1998). It seems then, that while researchers
are gaining a greater understanding of bulimia nervosa, many specific details
of the disorder remain to be seen.
I. ETIOLOGY
Biological models of eating disorders look at the genetic predisposition to the diseases (e.g., twin studies; Brooks-Gunn & Reiter, 1990; Ericsson, Poston, & Foreyt, 1996; Sullivan, Bulik, & Kendler, 1998; Walters & Kendler, 1995; Young 1991). Specifically, proponents of the biological viewpoint cite evidence of abnormalities in the serotonergic functioning of individuals who possess the symptoms of bulimia (Walsh & Delvin, 1998). They also note evidence to an abnormal satiety system for these individuals (Walsh & Delvin, 1998). Psychological models of anorexia have focused on the importance of family interactions (e.g., individuation-separation difficulties) and the patient’s view of self (e.g., intrapsychic paranoia) as important factors (Altman & Lock, 1997). Psychological theories of bulimia point to binge eating as a coping mechanism for those suffering from mood disorders (Stice & Agras, 1998) and for those dealing with a high degree of stress and negative affect. Additionally, the association between dieting and binge eating has been emphasized (Walsh & Devlin, 1998; Lowe, Gleaves, & Murphy-Eberenz, 1998). From a sociocultural perspective, the influence of social and culture standards of beauty, often impossible to attain for most women, puts women at significant risk for the development of dysfuntional thoughts and behaviors.(Stice and Agras, 1998) In recent years, researchers and practitioners have begun to view the etiology of anorexia and bulimia as multifactorial rather than resulting from a single cause (Szmukler, Dare, & Treasure, 1995; Wren & Lask, 1993). Accordingly, etiology is being viewed in terms of the interactions between various risk factors, and there is a growing consensus that biological vulnerability, psychological predisposition, family situation and social climate all contribute to the risk of developing an eating disorder (Stoylen & Laberg, 1990).
II. DEVELOPMENTAL PERSPECTIVE
The developmental perspective provides a conceptual
framework for understanding disordered behavior in relation to the course
of normal development. This framework also considers multiple factors that
contribute to adaptive success as well as the origins and developmental
course of disordered behavior (Smolak, Levine, & Striegel-Moore, 1996;
Wicks-Nelson & Israel, 1997). With regard to eating disorders, the
developmental perspective considers how these conditions arise out of sociocultural,
biogenetic, personality, family, and behavioral domains. This paradigm
also emphasizes the interaction between these different factors (Attie
& Brooks-Gunn, 1995).
Researchers have not reached a consensus about
which single factor is most responsible for eating disorders. Thus, in
recent years, professionals in the field have increasingly looked to a
developmental perspective for understanding the etiology of eating disorders.
In addition, developmental psychopathology provides a means for conceptualizing
how pathways of risk may lead to anorexia as opposed to other pathology
or how pathways of resilience may prevent the onset of this illness.
Keel, Leon, & Fulkerson (2001) discuss the ways in which developmental
transitions serve as a context in which various biological, psychological,
and social risk factors increase vulnerability to eating disorders.
They present an overview of the biological factors (i.e. negative
affectivity, genetic predisposition, anxiety disorders, and serotonin dysregulation)
that may lead to eating disorders. They analyze the etiological role
of psychological factors such as alexithymia, dieting, body dissatisfaction,
emotion regulation, and self-esteem. Additionally, the authors examine
the impact of social factors, including the sociocultural ideals of beauty
and morality as well as family and peer attitudes, on the etiology of eating
disorders.
Sociocultural
Modell and Goodman (1990) provide a compelling
historical perspective on adolescent development and eating disorders from
the early nineteenth century through the 1990s. One common thread tying
this developmental perspective through time is the powerful influence of
society on disordered eating.
Stoylen and Laberg (1990) also provide a historical
introduction to eating disorders, from a sociocultural perspective. The
authors point out that none of the common theories of etiology are complete
on their own and that the question is not which of these factors is the
cause but rather which of these factors is primary. According to this article,
the current social norms that emphasize unrealistic slimness have more
to do with the etiology of eating disorders than any other single factor.
Thus, this article approaches etiological issues from a developmental,
multifactorial perspective.
Streigel-Moore & Smolak (1996) use prevalence
data to prove that eating disorders are not limited to White women and
illustrates the limitations associated with a “White model of eating disorders.”
The article makes an important contribution to research on the etiology
of eating disorders by showing how scholarship with a focus on Black women
increases the understanding of eating problems in women of all racial/ethnic
backgrounds. The article examines the ways in which diverse American
cultures or subcultures contribute to different patterns of disordered
eating, considers how a culture servers to protects itself against specific
forms of eating disorders while fostering others, and hypothesizes about
the differences in the rates and patterns of eating disorders between Black
and White females.
Biological
Fairburn (1999) evaluated the empirical data
used to suggest that eating disorders, especially bulimia nervosa, may
be attributed to genetic causation. In his thorough review of twin
studies, Fairburn (1999) found inconsistent results, with estimates of
heritability ranging from 0% to 83% for bulimia nervosa and from 0% to
70% for anorexia nervosa. The extreme variability of the estimates
highlights the methodological problems in the majority of studies in this
field. Thus, Fairburn suggests a broad view of the etiology of eating
disorders, with a focus on environmental mechanisms, gene-environment interactions,
and more research in genetic studies.
Brooks-Gunn and Reiter (1990) provide a thorough
review of the role of the pubertal process in development and the association
with eating disorders. Specific focus is given to how hormonal changes
influence growth. Specifically, the authors review how levels of hormonal
secretions are suppressed when women experience a considerable loss of
weight. This results in lack of menstrual cycles in which fertility is
impaired.
Young (1991) examines how levels of estrogen
contribute to anorexic symptoms. Young discusses evidence that estrogen
contributes to the symptoms seen in anorexia and suggests that estrogen
may underlie sex differences in the incidence rate. The author posits that
an abnormal response to estrogen may be implicated in the manifestation
of anorexia and suggests that progesterone, which blocks estrogen, may
be a promising treatment in the future. Biological factors associated with
eating disorders warrant further investigation.
Davis (1997) proposes that physical activity
plays a role in the pathogenesis and progression of eating disorders, specifically
with anorexia, as physical activity and starvation may potentiate each
other, with alterations in the serotonergic system underlying this cycle.
The author states that while psychosocial factors contribute significantly
to the etiology of eating disorders, it is highly probable that severe
malnutrition and overexercising work to maintain eating disorders.
Psychological
Altman and Lock (1997) review psychological
and behavioral factors associated with eating disorders. Specifically,
they discuss how children’s feeding difficulties at very young ages are
associated with later eating problems. The authors also discuss how certain
personality traits, such as being compliant, perfectionistic, goal oriented,
shy, and obsessive, can sometimes be associated with patients with anorexia.
Additionally, children who are depressed and who have been exposed to a
greater number of stressful life events than is normal are also more likely
to develop eating disorders. Finally, insecure attachment styles are also
discussed as recognized characteristics in individuals with eating disorders.
O’Kearney (1996) presents a review of the literature detailing
the connection between attachment disruption and eating disorders.
The author cites evidence for the presence of attachment disturbances in
eating disordered subjects and for the asssociation of the attachment difficulties
with aspects of eating disorder psychopathology. Despite this apparent
link, the author makes no claim as to direct causation and insists on the
development of multifactorial and process-orientated models, which consider
the role of attachment functions, in the pathogenesis of eating disorders.
General
Keel, Fulkerson, and Leon (1997) completed
an empirical study of the precursors of eating disorders, including both
males and females in the sample. The researchers assessed fifth and sixth
grade boys and girls in terms of depression, body image, self-esteem, eating
behaviors and attitudes, weight, height, and pubertal development over
two years. For girls, year one body mass index and pubertal development
predicted year two disordered eating, while for boys, year two disordered
eating was predicted by poor body image in year one. This is a carefully
conducted study that provides a thorough background of the problem as well
as a discussion of the implications of the findings.
Wren and Lask (1993) emphasize the importance
of viewing eating disorders as multi-factored syndromes and of understanding
how various factors interact and develop over time to produce the eating
disorder. This is an excellent overview of etiology that discusses biological
factors, psychodynamic models, adverse sexual experiences, family models,
and cultural explanations. The authors conclude with a discussion of how
these theories of etiology may be integrated.
In examining the research and literature on
the etiology of eating disorders, it appears that psychological, sociocultural,
and biological theories all play some role in contributing to the onset
of this condition and that no single factor alone can explain the development
of this disorder. Accordingly, it is critical that future research and
literature acknowledges and explores multifactorial explanations for the
onset of anorexia and bulimia. Utilizing an etiological model, it is recommended
that prevention efforts be directed toward female and male young adolescents
with an orientation toward increasing factors which attenuate risk status
while reducing elements that place teens in jeopardy.
ASSESSMENT
The assessment of eating disorders is a complex area of clinical activity because eating disorders present with a range of disturbances in multiple domains. Anorexia and bulimia may cause disturbances in the cultural, social, behavioral, familial, and physical dimensions of a person’s life. Therefore, diagnostic assessment materials must address each of these domains. During the typical assessment process, individuals are asked to complete a series of questionnaires. Selecting appropriate instruments facilitates treatment recommendations and creates a database that allows for the evaluation of treatment effectiveness across time. Structured and semistructured interviews, clinical and self-reports, and physiological measures are all utilized in this process.
Interviews
Numerous semi-structured interviews for eating
disorders have been described in the research literature: Eating Disorder
Examination (EDE), Interview for Diagnosis of Eating Disorders (IDED),
Structured Interview for Anorexic and Bulimic Disorders (SIAB-EX), Schedule
for Affective Disorders and Schizophrenia for School-Age Children-Present
and Lifetime version (K-SADS-PL), and Clinical Eating Disorder Rating Instrument
(CEDRI).
Bryant-Waugh, Cooper, Taylor, and Lask (1996)
report the results of a recent study using a slightly modified EDE. The
two main modifications to the EDE were: the inclusion of a sort task to
assess overvalued ideas about weight and shape, and the reformulation of
certain items to assess intent rather than actual behavior. Results indicate
that it may be a useful assessment tool for not only adolescents and adults,
but also for children (aged 7-14 years). However, only 16 subjects were
utilized in this study, thus, results should be interpreted with caution.
Fichter, Herpertz, Quadflieg, and Herpertz-Dahlmann
(1998) provide a review of the recently revised Structured Interview for
Anorexic and Bulimic Disorders (SIAB-EX) including a discussion of the
validity of the SIAB-EX. Specifically, a five-factor solution was shown
to have good internal consistency and interrater reliability. Additionally,
DSM-IV diagnoses for eating disorders can be derived directly or by using
a computer algorithm from the SIAB-EX.
Kauffman, Birmaher, Brent, and Rao (1997)
present reliability and validity data regarding a general interview for
psychiatric diagnosis, the Schedule for Affective Disorders and Schizophrenia
for School-Age Children-Present and Lifetime version (K-SADS-PL). This
measure includes sections for the assessment of eating disorders and all
other DSM-IV childhood diagnoses and may therefore be especially useful
if comorbidity is a concern. It has been found to have adequate reliability
and validity.
Kempa & Thomas (2000) offer an important
perspective on the culturally sensitive assessment and treatment of eating
disorders. They explain how the erroneous belief that eating disorders
exist primarily in young White American women complicates the assessment,
diagnosis, and treatment of eating disorders in culturally diverse clients.
They maintain that a culturally sensitive approach to assessment and treatment
is essential and outline the relationship of acculturation, immigration,
and ethnic identity to eating disorders. Specifically, they look
at culturally specific symptoms, worldviews, and values across diverse
ethnic groups in the United States. Finally, the researchers stress
the significance of attuning to the influence of culture on the developmental
of eating disorders.
Kutlesic and colleagues (1998) tested the
most recent version of the IDED (IDED-IV) for the purpose of differential
diagnosis of eating disorders. Evidence for internal consistency was found
for symptom ratings relevant to bulimia nervosa, anorexia nervosa, and
binge eating disorder. Additionally, support was found for the content,
concurrent, and discriminant validity of the IDED-IV. Interrater reliability
for differential diagnosis of eating disorders was also high. Therefore,
it can be concluded that the IDED-IV yields sufficiently valid and reliable
data.
Palmer, Robertson, Cain, and Black (1996)
outline the many uses of the Clinical Eating Disorders Rating Instrument
(CEDRI) in assessing many of the behaviors associated with clinical eating
disorders. A recent study confirmed the pattern of results that provides
evidence for the validity and reliability of this instrument. Specifically,
the ability of the CEDRI to discriminate between a weight concerned comparison
group and a sample of subjects with clinical eating disorders could be
seen as a particularly exacting test of validity.
Rizvi, Peterson, Crow, & Agras (2000)
investigate the test-retest and interrater reliability of the Eating Disorder
Examination (EDE) in women with varied eating disorder symptomology.
They found test-retest correlations as .7 or greater for all the subscales
and measures of eating disorder behaviors except for subjective bulimic
episodes and subjective bulimic days. Additionally, they found correlations
above .9 for interrater reliability. In conclusion, the researchers
found significant support for the reliability of the EDE, but suggest that
smaller binge episodes may not indicate eating pathology.
Clinical and Self-Report Assessments
An assortment of clinical and self-report
measures related to eating disorders are outlined in the literature. What
follows is a summary of the most highly utilized assessments.
Beebe, Holmbeck, & Grzeskiewicz
(1999) examine the Body Image Assessment-Revised (BIA), an adapted silhouette
body-size estimation (BSE), in light of the current need for psychometrically
sound, well normed, inexpensive, and/or straightforward body image assessments,
which are lacking at present in the eating disorders literature.
The researchers gathered comprehensive normative data on college women’s
cognitively and affectively based body-size estimates, their desired body
size, and related discrepancy indexes. The results indicate that
the indexes from the adapted measure are moderately reliable over time
and consistent with theory relating them to fluctuations in body
related attitudes. The results also show convergent validity.
Finally, the researchers found a strong relationship between the
affectively based BSE (alone or part of discrepancey measure with desired
body size) and measures of eating pathology, body focus, body dissatisfaction,
and depressed affect.
Garner, Olmsted, Bohr, and Garfinkel (1982)
describe the Eating Attitudes Test (EAT) which is commonly used as a measure
of attitudes regarding eating and weight. A factor analysis conducted with
the EAT identified three factors including: Dieting, Bulimia, and Food
Preoccupation, and Oral Control. The EAT has been found to yield reliable
and valid data.
Geller, Srikameswaran, Cockell, &
Zaitsoff (2000) examine the psychometric properties of the Adolescent version
of the Shape and Weight-Based Self-Esteem Inventory (SAWBS-A) in adolescent
females and compared the self-concept of symptomatic and assymptomatic
individuals. The Adult version of the SAWBS inventory has already
proven psychometric properties. The SAWBS-A provides a contextual
measure of the importance of shape and weight to overall feelings of self
worth. The results of their study indicate that SAWBS-A scores were
stable over 1 week and correlated with other measures of eating disorders
symptomatology. They also found that symptomatic and asymptomatic
individuals differed in the extent to which body and facial appearance
predicted self-worth.
Keel, Fulkerson, and Leon (1997) provide information
on the Self-Image Questionnaire for Young Adolescents (SIQYA), which asks
adolescents to rate how much they like and are comfortable with their bodies.
This article suggests that the psychometric properties of this measure
are strong.
Kutlesic and colleagues (1998) also report
information about the Eating Disorders Inventory-2 (EDI-2). The authors
suggest that it has been found to yield data with moderate-to-high levels
of internal consistency, test-retest reliability, and convergent and discriminant
validity. The entire EDI-2 has 11 subscales that measure cognitive and
behavioral dimensions of both anorexia and bulimia nervosa.
Sunday, Halmi, and Einhorn (1995) describe
the Yale-Brown-Cornell Eating Disorder Scale (YBC-EDS) which can be used
to assess the preoccupation with rituals associated with eating disorders.
This article suggests that results confirm the reliability and validity
of the YBC-EDS. Additionally, the authors state that this measure characterizes
and quantifies preoccupations and rituals associated with eating disorders.
It is useful both for research and clinical purposes.
Williamson, Davis, Bennerr, and Goreczny (1989)
provide on overview of the Body Image Assessment procedure (BIA) which
may be used to examine body image disturbances. The BIA measures perceived
current body size, preferred body size, and the discrepancy between these
two. Evidence for adequate test-retest reliability, and construct validity
has been reported in this article.
Thelan and colleagues (1991) describe the
development of the revised Bulimia Test (BULIT-R). The BULIT-R is
based on DSM-III-R criteria for bulimia, but has been shown to be accurate
in its diagnoses even when using DSM-IV criteria (Hohlstein, Smith &
Atlas, 1998). The test itself is a 32 item, Likert-type scale that
classifies individuals not only as bulimic or non-bulimic, but also provides
information as to the degree of their symptomatology. The authors
present high sensitivity and specificity scores for the BULIT-R.
Mintz and colleagues (1997) describe the development
of the Q-EDD. This is a very promising new eating disorder assessment
tool that claims to have improved on other existing questionnaires.
One of its greatest benefits is its recent development, a fact that allows
it to make use of the current DSM-IV diagnostic criteria as well as the
current understanding of the disorder. The Q-EDD has the ability
to diagnose an individual into numerous categories, the most broad being
eating disordered or non-eating-disordered. Available reliability
and validity data support the use of the Q-EDD. However, due to its recent
development, there has not been a great deal of research that has conclusively
demonstrated its validity.
Physiological Measures
Casper (1998) suggests that physical exams
should include weight and height measurements, body mass index, a record
of menstrual cyclicity and regularity, and an endocrine profile. However,
it should be noted that there are no biological measures with proven specificity
for anorexia nervosa or bulimia nervosa.
Grant (2001) explains the characteristics of stress inventories
used in clinical and nonclinical settings, including stimulus-event measures,
response-oriented measures, and interactional measures, some of which aid
in the assessment of stress as it relates to eating disorders.
Hamilton (2001) discusses the role of nutrition
in the assessment and treatment of eating disorders. She outlines
the physiological markers in eating disorders such as eating patterns and
biochemistry assessment. Furthermore, the chapter looks at the ways
in which the chemistry associated with eating disorders contributes to
additional appetite decline and decreased nutritional intake.
Assessing eating disorders requires a multifactored
approach. One must take the many cultural, societal, behavioral, familial,
and biological factors into consideration. Interviews, clinical and self-reports,
and physiological measures are all important in this process. Utilizing
a developmental model is most useful in gaining a full picture of these
various factors and how they interact. Ideally, an assessment should include
a full physical exam, a general diagnostic interview, and a specific interview
that goes into more detail regarding symptoms. It is crucial that this
specific interview is based on the most recent changes in diagnostic criteria.
I. TREATMENT
Individuals with eating disorders rarely seek
treatment voluntarily. Most enter treatment under duress from alarmed relatives,
friends, or school professionals who have cajoled them into the therapist’s
office. The few true volunteers are typically seeking relief from food
preoccupation, depression, or anxiety rather than eating disorder symptoms.
Often, the first job of the counselor is to help the patient overcome their
resistance to change. The goals of treatment for anorexics and bulimics
apply to the medical, nutritional, psychological and familial aspects of
their lives. Specifically, there must be adequate weight gain and return
to physical health, a resumption of nutritionally balanced eating habits,
resolution of distorted cognitions, body image problems, self-image and
comorbid conditions, and a focus on individuation, family relationships,
and parent-child conflict issues (Robin, Gilroy, & Dennis, 1998).
Considering the multiple goals, a variety
of different therapies have been proposed. However, research has not determined
one treatment of choice for adolescent patients with eating disorders.
Additionally, no well-controlled psychopharmacological studies of adolescent
patients with eating disorders have been performed (Gillberg & Rastam,
1998). Individual psychotherapy, group therapy, family therapy, cognitive
behavioral therapy, and multidimensional approaches have all been acknowledged
as acceptable forms of treatment. However, there is no conclusive research
that specifies the efficacy rates of these various forms of therapy.
Individual Psychotherapy
Robin and colleagues (1998) review the treatment
of eating disorders in children and adolescents. The authors state that
long-term psychodynamic therapies are probably the most frequently utilized
outpatient treatment for anorexia nervosa in the United States. They point
to evidence that suggests an ego-oriented, self psychology approach has
proven clinically useful. This approach has been subjected to rigorous
evaluation in a randomly assigned, controlled comparison to Behavioral
Family Systems Therapy. Additionally, individual therapy was found to be
superior to family therapy on weight gain (but not psychosexual functioning
or nutritional status) for those who became anorexic at age 19 or later.
Crisp (1997) provides a detailed rationale
for seeing anorexia as a “flight from growth.” He then offers specific
and detailed suggestions for working with patients, including psychotherapy
and dietary advice. Although Crisp focuses on individual therapy, he also
provides some information about family and group therapies.
Eisler and colleagues (1997) conducted a 5-year
follow-up study on anorexics that participated in a previous trial of family
and individual therapy. Results suggest that individual supportive therapy
works best for patients with late-onset anorexia nervosa as compared to
early onset. Although it was possible to detect long-term benefits of individual
psychotherapy, some of these improvements can be attributed to the natural
outcome of the illness.
Family Therapy
Eisler and colleagues (1997) also suggest that
family therapy is most effective with a particular group of individuals
with anorexia nervosa: those with early onset and short history. Sargent,
Liebman, and Silver (1985) describe the rationale for family therapy for
anorexics. The authors provide specific treatment steps and addresses special
problems that might arise (e.g., lack of progress, single parent families).
This chapter is part of a classic text on anorexia and is an important
resource even though it is somewhat dated.
Robin, Gilroy, and Dennis (1998) report that
Dare and Szmukler’s (1991) approach to family therapy for adolescents with
anorexia nervosa emphasizes the family as a resource that has to be mobilized
to help the starving youngster. The therapist refrains from expressing
views about the etiology of the condition, but suggests that the family
is presented with a problem of unknown origin which is not their fault,
but that will require all of their resources to overcome. When this therapy
was compared to a supportive individual therapy, family therapy had a more
favorable outcome for the early onset (before aged 18), short duration
(less than three years) type of anorexia (similar to the results found
in the Eisler [1997] article). In general, their research supports the
effectiveness of family-oriented treatments. The authors suggest a number
of important issues to remember: use nonblaming terms, direct parents to
take charge of their child’s eating routines, maintain a structured behavioral
weight gain program, after weight gain give gradual control of eating back
to the child, and once the patient begins to gain weight, focus treatment
on broader topics such as autonomy, parent-child conflicts and family interactions.
Mitchell and Carr (2000) review 7 studies
of the effects of psychological interventions for 12-30 year old women
suffering from anorexia nervosa or bulimia. The results of this study
suggest that for patients with anorexia nervosa, outpatient family therapy
or family-based treatment programs involving concurrent therapy for parents
and adolescents lead to sustained weight gain and improvement in psychosocial
adjustment. In this study, effective family therapy included psychoeducation
about risks associated with dysfunctional eating and emphasized parent’s
involvement in monitoring their children’s eating habits.
Scholz & Asen (2001) look at therapeutic
work with eating disordered adolescents and their families in a multiple
family setting. They explain the definition and theory behind multiple
family therapy. The results of the 18 month follow-up study show
that multiple family therapy may bring about significant positive changes
in the patient’s symptomology and recovery rates.
Group Therapy
Garfinkel and Garner (1982) provide a thorough
overview of the multidimensional aspects of anorexia nervosa. It suggests
that group therapy be instituted when the starvation symptoms have begun
to be reduced. Their research has found that assertive training groups
are beneficial to patients because they allow them to display a more direct
expression of appropriate affect in a controlled setting. They state that
the purpose of these groups is to provide a setting in which patients may
discuss their feelings connected with the disorder and how it has affected
them, in a setting where they can be accepted and understood. Additionally,
the group should provide support, models of coping, peer feedback and education.
The authors also note the benefits of group therapy for parents.
Fernandez-Aranda (2000) study the efficacy
of group psychoeducational therapy for the treatment of bulimia in 64 female
adolescents and adults in Spain. The treatment group receives information
on bulimia pathology and associated health conditions, nutritional advice,
and instruction on methods of coping with their disordered eating and other
problems. In contrast to the control group, the treatment group shows
improvement in 24 % of the patients, suggesting the importance of developing
group psychoeducational programs to help treat eating disorders.
Cognitive-Behavior Therapy
Robin, Gilroy, and Dennis (1998) state that
in the cognitive-behavioral approach to the treatment of anorexia nervosa
(Garner, 1986), the therapist should focus on using cognitive restructuring
to modify distorted beliefs and attitudes about the meaning of weight,
shape and appearance, which are believed to underlie dieting and fear of
weight gain. The authors state that little empirical work has been done
with cognitive-behavioral approaches to anorexia nervosa, and that none
of this work has been done with children or adolescents. They report the
results from a study that found no significant differences between cognitive-behavioral
therapy, behavior therapy, or a no-treatment control group with patients
presenting with anorexia. Given the perfectionistic characteristics of
the majority of individuals with anorexia, the use of cognitive-behavioral
treatment would appear to have promise with this population. However, issues
have been raised about the minimum age and level of cognitive development
necessary for implementing this type of treatment.
Wilfley and Cohen (1997) describe a typical
example of cognitive behavioral treatment for bulimia nervosa. They divide
treatment into three phases. The first phase consists of behavioral interventions
designed to interrupt the bingeing/purging cycle. Next, cognitive
strategies are used to challenge the disordered thought patterns that influence
the disordered eating. Distorted body image is an example of something
that might be targeted in this stage. Treatment concludes with relapse
prevention techniques that help ensure the patient will not resume his
or her old thoughts and behaviors. Cognitive behavioral therapy is
generally considered the therapeutic treatment of choice for bulimia nervosa.
Schmidt (1998) outlines that even though cognitive-behavioral
therapy is the gold standard treatment for bulimia nervosa, the evidence
supporting its usefulness with anorexic patients is much more mixed. The
authors suggest that basic cognitive-behavior therapy may need to be supplemented
with other measures to achieve better outcomes for individuals with anorexia.
Mitchell and Carr (2000), in reviewing 7 studies
of the effects of psychological interventions for 12-30 year olds with
bulimia, find that either Cognitive-Behavioral Therapy (CBT) or Interpersonal
Psychotherapy (IPT) lead to sustained improvement in bulimic symptoms as
well as psychosocial adjustment. They saw rapid improvement with
CBT combined with psychoeducation and relapse prevention training, whereas
with IPT improvement takes a slower course, with the focus on resolving
interpersonal difficulties instead of changing eating behaviors and thoughts.
Johnson, Tsoh, and Varnado (1996) review the
efficacy of pharmacological and psychological interventions with eating
disorders. This article provides valuable information about and a comparison
of two types of treatment: medication versus cognitive behavioral. For
example, the authors discuss different types of medication and give an
overview of the different components of cognitive behavior therapy. These
authors conclude that medications are often helpful in the management of
the psychopathology associated with anorexia nervosa however, no pharmacological
compound has been shown to reliably assist weight gain or alter other core
features of eating disorders. Antidepressants were found to reduce bingeing
and purging in bulimia nervosa and binge eating disorder, although this
action appeared to be independent of any antidepressant effect. Contingency
management and other behavior therapy procedures were found to be effective
in promoting weight gain in anorexics. The limited effectiveness of cognitive
interventions for anorexia nervosa was postulated to be a result of the
complex physical symptoms associated with low body weight. Additionally,
cognitive/behavioral interventions also reduce bingeing and purging. Comparisons
of cognitive/behavioral therapy and medication/pharmacological interventions
indicate that psychotherapy alone is more effective than medication alone.
Moreover, changes produced by cognitive/behavioral interventions endure
longer than medication where higher relapse rates are common. Finally,
most studies also revealed no advantage of medication over cognitive/behavioral
therapy alone in the reduction of bulimic symptoms.
Kotler and Walsh (2000) presents an overview
of the current literature dealing with the pharmacological treatment of
anorexia nervosa and bulimia nervosa in child and adolescent populations.
They summarize the current research trends in the study of pharmacological
treatment with adult populations, such as the efficacy of of anitdepressant
medications with bulimia nervosa and the possible usefulness of medication
for relapse-prevention stage of anorexia nervosa. Then they look
at the very limited research on pharmacological interventions with children
and adolescents suffering from anorexia nervosa and bulimia nervosa and
conclude that more research is needed to determine the most effective treatments
of eating disorders in youth.
Multidimensional Approach
Tate (2000) argues that there are multiple
causal factors for childhood onset eating disorder and inevitably involve
and/or affect the child’s school work. Thus, the school environment
plays an important role in the multidimensional approach to the treatment
of eating disorders in youth. The article discusses many issues relevant
to eating disorders and school such as identifying pupils with eating disorders,
professional boundaries, liason between the treatment team and the school,
the role of teachers in the treatment team, eating at school, dealing with
perfectionism, and social withdrawl. The article puts forth a compelling
argument for the inclusion of school-based interventions in a multidimensional
approach to the treatment of eating disorders.
Mantero, Giovanni, Raffaele, and Gaetano (1998)
outline the importance of utilizing an integrated treatment of anorexia.
This effective treatment entails some guidelines for cooperation among
specialists involved in the management of such patients. The authors outline
the importance of utilizing a problem-solving approach in this type of
treatment.
Shekter-Wolfson, Woodside, and Lackstrom (1997)
provide a brief and comprehensive overview of both anorexia and bulimia.
This article discusses issues related to etiology, assessment, and treatment
options. The authors advocate a multidisciplinary, multidimensional approach
to treating anorexia, including psychoeducation, medication, cognitive-behavior
therapy, individual, and family therapy. This is a good resource in providing
practitioners with different treatment options but does not provide enough
detailed information with regard to specific treatment plans.
Bryant-Waugh and Lask (1996) discuss childhood
onset anorexia nervosa and present a case study of a 12 year old girl with
anorexia disorder. After describing her background and results of
her assessments, they put together a multidimensional treatment plan.
The multidimensional treatment plan included providing information to the
parents about their daughter’s illness, empowering the parents to take
control of their daughter’s eating, gentle refeeding, setting a target
weight, providing parental counseling, family therapy, and individual counseling
for the child, creating a liason with her school, and considering the use
of medication.
Golder and Birmingham (1994) focus not on
a specific type of treatment but instead, on a set of primary treatment
components (e.g., medical stabilization, establishment of therapeutic alliance,
weight restoration). The authors allude to different types of treatment,
such as cognitive behavioral, family, and psychodynamic therapies. Rather
than endorsing one type of treatment, this chapter acknowledges the validity
of multiple types of therapies and emphasizes the need to focus on key
components of treatment.
Eating disorders can be seen as a process.
There are continuous interactions between the individual and his/her external
world, the symptoms and his/her attempts to deal with the symptoms, that
result in an elaboration of the disorder in a variety of forms for each
person. Because the development of eating disorders is influenced by these
different factors for each individual, a multidimensional approach is recommended
as the treatment of choice. This type of therapy allows the practitioners
to tailor the treatment to the individual patient. In addition, the multidimensional
approach recognizes that treatment must address biological, familial, sociocultural,
and psychological components of the individual’s recovery. Individuals
with anorexia nervosa and bulimia nervosa may come to treatment at various
stages in the course of their disorder. Some may require immediate medical
attention while others may be in a condition to benefit more from insight-oriented
therapy. Thus, depending on the individual (including age) and the stage
of their disorder, the multidimensional treatment allows for a focus on
whichever aspects are most salient at that time.
II. OPTIMAL TREATMENT
Optimal treatment within this multidimensional
framework should include a clinical team of different professionals including
school psychologists and other educational professionals. This allows the
patient to receive specific interventions from individuals with the most
training and knowledge of the issues at hand. It is in this type of environment
where the patient and his/her family can be fully understood.
Because eating disorders, especially in its
childhood-onset form, are known to be an extremely difficult disorder to
treat, many different kinds of therapies should be considered. There are
few controlled studies of interventions for eating disorders in children,
so treatment recommendations must be based for the most part on uncontrolled
studies, clinical case reports, and extrapolation downward from controlled
studies with adolescents and adults. A multidimensional approach offers
the most flexibility and options for the practitioner or team of health
care providers. Most importantly, it provides the most specific and personalized
type of treatment to individuals and families suffering from an eating
disorder.
III. SUMMARY
Eating disorders have many deleterious,
morbid, and even mortal consequences. More than three decades of research
on anorexia and bulimia has clearly underscored its public health importance.
However, the most basic questions in the field, those concerned with the
problem’s prevalence and incidence, have not yet been unequivocally answered.
With the increased significance and scope of eating disorders, professionals
are in a pivotal position to better understand and assist youth who are
suffering with anorexia or bulimia.
It is necessary to account for the normal
development of many factors in multiple domains and their interaction within
this developmental model. Considering the cumulative nature of development
and acknowledging that early events impact subsequent adjustment, it is
essential that efforts target prevention, early identification, and treatment
for children and adolescents. The school environment is a critical, but
often overlooked, domain to consider.
Thus, researchers and practitioners are encouraged
to approach eating disorders and their treatment from a developmental and
multidimensional perspective. Further research should include the critical
perspective of educational professionals, and investigate the efficacy
of integrated approaches as opposed to traditional treatments.
IV. TOP TEN EATING DISORDERS WEBSITES
About.com Eating Disorders
http://eatingdisorders.about.com/health/eatingdisorders
A very thorough website, the About.com Eating Disorders page is a resource
for both professionals and lay people interested in learning about anorexia,
bulimia, binge-eating behavior, and body image issues. It has a section
dedicated to symptoms, risk factors, causes, prevention, treatment, recovery,
and relapse. It also has information related to associated pathology,
such as depression, substance abuse, etc…. Interestingly, it provides
detailed information regarding the gender and cultural components of eating
disorders across different age groups. It also has sections that
look at the impact of eating disorders on pregnancy. Additionally,
it provides a chatroom, frequently asked question area, personal stories,
and information about therapists and referral links.
American Anorexia Bulimia Association
http://www.aabainc.org
The American Anorexia Bulimia Association (AABA) is a national, non-profit
organization dedicated to the prevention and treatment of eating disorders.
Through advocacy, research, and education, AABA serves as a national authority
on eating disorders and related concerns. Their mission is carried
out through many different services: help-lines, referral networks, public
information, school outreach, media support, professional training, support
groups, and prevention programs. This site is most useful because
it promotes social attitudes that enhance healthy body image and works
to overcome the idealization of thinness that contributes to disordered
attitudes and behaviors. It also includes a list of "professional
members of AABA" who are qualified to treat clients with eating disorders.
Anorexia Nervosa and Related Eating Disorders, Inc.
http://www.anred.com
The Anorexia Nervosa and Related Eating Disorders, Inc website
includes definitions and descriptions, statistic, warning signs, and background
information of eating disorders. The site offers information on helping
friends and loved ones suffering from the symptoms of an eating disorder
and provides opportunities for the reader to assess his/her thoughts and
behaviors. There are sections devoted to both treatment and recovery.
Furthermore, the site provides information on athletes, males, and
diabetics with eating disorders.
Eating Disorders Awareness and Prevention
http://www.edap.org
The Eating Disorders Awareness and Prevention website is dedicated
to the elimination of eating disorders and body dissatisfaction through
prevention efforts, education, referral and support services, advocacy,
training, and research. The site contains information about eating
disorders, education and prevention programs, referral and treatment
services, materials, and links to other online resources.
Eating Disorder Referral and Information Center
http://www.edreferral.com
The Eating Disorder Referral and Information Center provides referrals
to eating disorder professionals for diagnosis and treatment and information
for the lay person about the types, symptoms, associated pathology, and
treatment of eating disorders. The Eating Attitudes Test is available
on this site for self-assessment. In addition, there is information
about insurance, events, advocacy, and employment opportunities in the
field. It is a very comprehensive source of information.
Eating Disorders Shared Awareness
http://www.mirror-mirror.org/eatdis.htm
This comprehensive and well-organized page links two web sites through
a group called Eating Disorders Shared Awareness. The same information
can be found whether you go to the Mirror-Mirror site based from Canada
or the Something Fishy site based from New York. Topics covered range
from "Finding a Therapist" to "Surviving Holidays" to a "Survivor's Wall"
with personal messages from those recovered or recovering. Clinicians
also might benefit from readings on eating disorders in different populations
such as athletes and older women.
National Association of Anorexia Nervosa and Associated Disorders
http://www.anad.org/about.htm
The National Association of Anorexia and Associated Disorders provides
services such as counseling, referrals, early detection, education, prevention
and research programs, support groups, newsletter and publications, advocacy,
and conferences/seminars. The site also contains an overview of information
on eating disorders, insurance information, and legislative news.
Links to other eating disorder online resources are available as well.
National Eating Disorder Screeing Program
http://www.nmisp.org/eat.htm
The National Eating Disorder Screening Program website provides information
on the annual screening program for eating disorders, targeted at the general
population as well as college and high school students. The site
includes information on the screening process and offers a sample screening
test. It includes a comprehensive list of eating disorder organizations
involved in the assessment, treatment, and prevention of eating disorders.
Something Fishy
http://www.somethingfishy.org
The Something Fishy website is a great resource for the description
of eating disorder pathology and associated issues. At this
site, there is information about the manifestation, treatment, and prevention
of eating disorders. The site also provides an up-to-date news bulletin,
personal stories, recovery facts, a discussion of cultural issues, treatment
referrals, online support, and resources such as reading materials, cd-roms,
etc…In addition, the site contains questionnaires, information about current
events and programs, and links to other eating disorder webpages, organizations,
and resources.
Support Concern and Resources for Eating Disorders
http://www.eating-disorder.org
The Support Concern and Resources for Eating Disorders website provides
information about the types, symptoms, and dangers of eating disorders.
The site provides resources such as reading materials, assessments such
as the Eating Attitudes Test, personal narratives, information for teenagers
and parents, and links to associated organizations and treatment centers.
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ASSESSMENT REFERENCE
Body Image Assessment-Revised (BIA) Beebe, D., Holmbeck, G. N.,
Grzeskiewicz, C. J. (1999)
Bulimia Test-Revised (BULIT) Thelan, M. H., Farmer, J., Wonderlich,
S., & Smith, M. (1991)
The Clinical Eating Disorders Rating Instrument (CEDRI) Palmer, R.,
Robertson, D., Cain, M., & Black, S. (1996)
Eating Attitudes Test (EAT) Garner D. M. (1997)
Eating Disorders Examination (EDE) Fairburn C. G. & Cooper Z.(1993)
Eating Disorders Inventory (EDI) Garner, D. M. (1991)
The Interview for the Diagnosis of Eating Disorders-IV (IDED) Kutlesic,
V., Williamson, D. A., Gleaves, D. H., Barbin, J. M., & Murphy-Eberenz,
K. P. (1998)
Questionnaire for Eating Disorder Diagnosis (Q-EDD) Mintz, L. B., O'Halloran,
M. S., Mulholland, A. M., & Schneider, P. A. (1997)
Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present
and Lifetime version (K-SADS-PL) Kauffman, J., Birmaher, B., Brent, D.,
& Rao, U. (1997)
The Self-Image Questionnaire for Young Adolescents (SIQYA) Peterson,
A. (1984)
The Shape and Weight Based Self-Esteem Inventory (SAWBS-A) Geller,
J., Johnston, C., Madsen, K. (1997)
The Structured Interview for Anorexic and Bulimic Disorders-Revised
(SIAB-EX) Fichter, M. M., Herpertz, S., Quadflieg, N., & Herpertz-Dahlmann,
B. (1998)
The Yale-Brown-Cornell Eating Disorder Scale (YBC-EDS) Sunday, S. R.,
Halmi, K. A., & Einhorn, A. (1995)