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Major Types of Eating Disorders

From 20% to 30% of anorexia-related deaths are suicides, which is 50 times higher than the risk of death
from suicide in the general population.

Increased dramatically in Western countries from about 1960 to 1995, before seeming to level off

Between 1975 and 1986, the referral rates for anorexia rose slowly but the rates for bulimia rose
dramaticallyfrom virtually none to more than 140 per year. Similar findings have been reported from
other parts of the world

Although more recent surveys suggest that rates for bulimia may be leveling off or even beginning to
drop from highs reached in the 1990s

The figures on mortality mentioned above represent six times the increase in death rates from eating
disorders compared with death rates in the normal population

Eating disorders were included for the first time as a separate group of disorders in the fourth edition of
the Diagnostic and Statistical Manual (DSM-IV), published by the American Psychiatric Association in

Estimates of prevalence in China and Japan are approaching those in the United States and other
Western countries

More than 90% of the severe cases are young females who live in a socially competitive environment.

The strongest contributions to etiology seem to be sociocultural rather than psychological or biological

70% of adults in the United States are overweight, and more than 35% meet criteria for obesity. they
may now be leveling off, at least in North America

Clear cases of bulimia have been described for thousands of years (Parry-Jones & Parry-Jones, 2002), but
bulimia nervosa was recognized as a distinct psychological disorder only in the 1970s (Boskind-Lodahl,
1976; Russell, 1979). Therefore, information on prevalence has been acquired relatively recently.

Among those who present for treatment, the overwhelming majority (90% to 95%) of individuals with
bulimia are women. Males with bulimia have a slightly later age of onset, and a large minority are
predominantly gay males or bisexual (Rothblum, 2002). For example, Carlat, Camargo, and Herzog
(1997) accumulated information on 135 male patients with eating disorders who were seen over 13
years and found that 42% were either gay males or bisexual, a far higher rate of eating disorders than
found in heterosexual males (Feldman & Meyer, 2007). Male athletes in sports that require weight
regulation, such as wrestling, are another large group of males with eating disorders (Ricciardelli &
McCabe, 2004). During 1998, stories were widely published about the deaths of three wrestlers from
complications of eating disorders. More recent studies suggest the incidence among males is increasing
(Domin, Berchtold, Akr, Michaud, & Suris, 2009). Interestingly, the gender imbalance in bulimia was
not always present. Historians of psychopathology note that for hundreds of years the vast majority of
(unsystematically) recorded cases were male (Parry-Jones & Parry-Jones, 1994, 2002). Because women
with bulimia are more common today, most of our examples are women. Among women, adolescent
girls are most at risk. A recent prospective 8-year survey of 496 adolescent girls reported that more than
12% experienced some form of eating disorder by the time they were 20 (Stice, Marti, Shaw, & Jaconis,
2009). In another elegant prospective study, eating-related problems of 1,498 freshmen women at a
large university were studied over the 4-year college experience. Only 28% to 34% had no eating-related
concerns. But 29% to 34% consistently attempted to limit their food intake because of weight/shape
concerns; 14% to 18% engaged in overeating and binge eating; another 14% to 17% combined attempts
to limit intake with binge eating; and 6% to 7% had pervasive bulimic-like concerns. And these
tendencies were stable for the most part throughout their 4 years of college (Cain, Epler, Steinley, &
Sher, 2010).

A somewhat different view of the prevalence of bulimia comes from studies of the population rather
than of specific groups of adolescents, with the most definitive study appearing in 2007 (Hudson et al.,
2007). These results from the National Comorbidity Survey reflect lifetime and 12-month prevalence,
not only for the three major eating disorders described here but also for subthreshold BED, where
binge eating occurred at a high-enough frequency but some additional criteria, such as marked
distress regarding the binge eating, were not met. Therefore, the disorder did not meet the diagnostic
threshold for BED. Although the study was conducted prior to the publication of DSM-5, the 3-month
duration required for BED (or subthreshold BED), found in DSM-5, rather than the 6 months required in
DSM-IV-TR, was used. Finally, if binge eating occurred at least twice a week for 3 monthseven if it was
just a symptom of the four other disorders in Table 8.2 rather than a separate condition the case was
listed under Any binge eating. This latter category provides an overall picture of the prevalence
of binge eating. As you can see, lifetime prevalence was consistently 2 to 3 times greater for females,
with the exception of sub threshold BED.

So it is possible that the prevalence of anorexia is underrepresented in some surveys. In the adolescent
supplement to the National Comorbidity Survey that reports results just for adolescents from ages 13 to
18, lifetime prevalence rates were 0.3% for anorexia (compared with 0.6% for the full age range in Table
8.2), 0.9 % for bulimia (compared with 1.0 % in Table 8.2), and 1.6% for BED (compared with 2.8 % in
Table 8.2) (Swanson et al., 2011). This suggests that many cases of anorexia and BED, but not bulimia,
begin after age 18.

The median age of onset for all eating-related disorders occurred in a narrow range of 18 to 21 years
(Hudson et al., 2007). For anorexia, this age of onset was fairly consistent, with younger cases tending to
begin at age 15, but it was more common for cases of bulimia to begin as early as age 10, as it did for
Phoebe. Once bulimia develops, it tends to be chronic if untreated

In an important study of the course of bulimia, referred to earlier, Fairburn and colleagues (2000)
identified a group of 102 females with bulimia nervosa and followed 92 of them prospectively for 5
years. About a third improved to the point where they no longer met diagnostic criteria each year, but
another third who had improved previously relapsed. Between 50% and 67% exhibited serious eating
disorder symptoms at the end of each year of the 5-year study, indicating this disorder has a relatively
poor prognosis.

In a follow-up study, Fairburn, Stice, et al. (2003) reported that the strongest predictors of persistent
bulimia were a history of childhood obesity and a continuing overemphasis on the importance of being
thin. In addition, individuals tend to retain their bulimic symptoms instead of shifting to symptoms of
other eating disorders (Eddy et al., 2008; Keel et al., 2000).
Similarly, once anorexia develops, its course seems chronicalthough not so chronic as bulimia, based
on data from Hudson and colleagues (2007), particularly if it is caught early and treated. But individuals
with anorexia tend to maintain a low BMI over a long period, along with distorted perceptions of shape
and weight, indicating that even if they no longer meet criteria for anorexia they continue to restrict
their eating (Fairburn & Cooper, in press). Perhaps for this reason, anorexia is thought to be more
resistant to treatment than bulimia, based on clinical studies (Vitiello & Lederhendler, 2000). In one 7-
year study following individuals who had received treatment, 33% of those with anorexia versus 66% of
those with bulimia reached full remission at some point during the follow-up (Eddy et al., 2008).

Cross-Cultural Considerations
A particularly striking finding is that these disorders develop in immigrants who have recently moved to
Western countries (Anderson-Fye, 2009). One of the more interesting classic studies is Nassers survey
of 50 Egyptian women in London universities and 60 Egyptian women in Cairo universities (Nasser,
1988). There were no instances of eating disorders in Cairo, but 12% of the Egyptian women in England
had developed eating disorders. Mumford, Whitehouse, and Platts (1991) found comparable results
with Asian women living in the United States.

The prevalence of eating disorders varies somewhat among most North American minority populations,
including African Americans, Hispanics, Native Americans, and Asians. Earlier surveys revealed that
African American adolescent girls have less body dissatisfaction, fewer weight concerns, a more positive
self-image, and perceive themselves to be thinner than they are, compared with the attitudes of
Caucasian adolescent girls (Celio, Zabinski, & Wilfley, 2002). Another study (Hoek et al., 2005) on the
small relatively isolated Caribbean island of Curacao in the Netherlands Antilles, where the population is
only approximately 150,000, found that the incidence of anorexia from 1995 to 1998 was zero among
the majority black population but approached levels observed in the Netherlands and United States for
the minority white and mixed population.

Several years ago, Striegel-Moore and colleagues (2003) surveyed 985 white women and 1,061 black
women who had participated in a 10-year government study on growth and health and who were now
21 years old on average. The number in each group who developed anorexia, bulimia, or BED during
that 10-year period is presented in Figure 8.1. Major risk factors for eating disorders in all groups
included being overweight, higher social class, and acculturation to the majority (Crago et al.,
1997;Grabe & Hyde, 2006; Wilfley & Rodin, 1995). Greenberg and LaPorte (1996) observed in an
experiment that young white males preferred somewhat thinner figures in women than African
American males, which may contribute to the somewhat lower incidence of eating disorders in African
American women. But a more recent survey suggests some of these ethnic differences may be changing.
Marques et al. (2011) found that the prevalence of eating disorders is now more similar among non-
Hispanic whites, African American, Asian American, and Hispanic females. Eating disorders are generally
more common among Native Americans than other ethnic groups (Crago, Shisslak, & Estes, 1997).

In conclusion, anorexia and bulimia are relatively homogeneous, and bothparticularly bulimiawere
overwhelmingly associated with Western cultures until recently. In addition, the frequency and pattern
of occurrence among minority Western cultures differed somewhat in the past, but those differences
seem to be diminishing (Marques et al., 2011).

Developmental Considerations
Because the overwhelming majority of cases begin in adolescence, it is clear that anorexia and bulimia
are strongly related to development (Smith, Simmons, Flory, Annus, & Hill, 2007; Steiger et al., 2013).
As pointed out in classic studies by Striegel-Moore, Silberstein, and Rodin (1986) and Attie and Brooks-
Gunn (1995). cultural influences to create eating disorders. After puberty, girls gain weight primarily in
fat tissue, whereas boys develop muscle and lean tissue. As the ideal look in Western countries is tall
and muscular for men and thin and prepubertal for women, physical development brings boys closer to
the ideal and takes girls further away.

Eating disorders, particularly anorexia nervosa, occasionally occur in children under the age of 11
(Walsh, 2010). In those rare cases of young children developing anorexia, they are likely to restrict fluid
intake, as well as food intake, perhaps not understanding the difference (Gislason, 1988; Walsh, 2010).
This is particularly dangerous. Concerns about weight are somewhat less common in young children.
Nevertheless, negative attitude toward being overweight emerges as early as 3 years of age, and more
than half of girls age 68 would like to be thinner (Striegel-Moore & Franko, 2002). By 9 years of age,
20% of girls reported trying to lose weight, and by 14, 40% were trying to lose weight (Field et al., 1999).

Both bulimia and anorexia can occur in later years, particularly after the age of 55. Hsu and Zimmer
(1988) reported that most of these individuals had had an eating disorder for decades with little change
in their behavior. In a few cases, however, onset did not occur until later years, and it is not yet clear
what factors were involved. Generally, concerns about body image decrease with age (Tiggemann &
Lynch, 2001; Whitbourne & Skultety, 2002).

Causes of Eating Disorders
As with all disorders discussed in this book, biological, psychological, and social factors contribute to the
development of these serious eating disorders. The evidence is increasingly clear, however, that the
most dramatic factors are social and cultural.

Social Dimensions
Remember that anorexia and particularly bulimia are the most culturally specific psychological disorders
yet identified.

The cultural imperative for thinness directly results in dieting, the first dangerous step down the slippery
slope to anorexia and bulimia. Levine and Smolak (1996) refer to the glorification of slenderness in
magazines and on television, where most females are thinner than the average American woman.
Because overweight men are 2 to 5 times more common as television characters than overweight

Grabe, Ward, and Hyde (2008), reviewing 77 studies, demonstrated a strong relationship between
exposure to media images depicting the thin-ideal body and body image concerns in women. An analysis
of prime-time situation comedies revealed that 12% of female characters were dieting and many were
making disparaging comments about their body image (Tiggemann, 2002). Interestingly, a recent
analysis of images of women in Ebony magazine, which has wide African-American readership, generally
does not show this thin-ideal body image, seemingly reflecting the somewhat lower prevalence of body
image disturbances in African-American women (Thompson-Brenner, Boisseau, & St. Paul, 2011). Finally,
Thompson and Stice (2001) found that risk for developing eating disorders was directly related to the
extent to which women internalize or buy in to media messages and images glorifying thinness, a
finding also confirmed by Cafri, Yamamiya, Brannick, and Thompson (2005).

In a case study, Fallon and Rozin (1985), studying male and female undergraduates, found that men
rated their current size, their ideal size, and the size they figured would be most attractive to the
opposite sex as approximately equal; indeed, they rated their ideal body weight as heavier than the
weight females thought most attractive in men. Women, however, rated their current figures as much
heavier than what they judged the most attractive, which in turn, was rated as heavier than what they
thought was ideal. This conflict between reality and fashion seems most closely related to the current
epidemic of eating disorders.

Pope and colleagues (2000) confirmed that men generally desire to be heavier and more muscular than
they are. The authors measured the height, weight, and body fat of college-age men in three
countriesAustria, France, and the United States. They asked the men to choose the body image that
they felt represented (1) their own body, (2) the body they ideally would like to have, (3) the body of an
average man of their age, and (4) the male body they believed was preferred by women. In all three
countries, men chose an ideal body weight that was approximately 28 pounds more muscular than their
current one. They also estimated that women would prefer a male body about 30 pounds more
muscular than their current one. In contradiction to the impression, Pope and colleagues (2000)
demonstrated, in a pilot study, that most women preferred an ordinary male body without the added
muscle. Men who abuse anabolicandrogenic steroids to increase muscle mass and bulk up possess
these distorted attitudes toward muscles, weight, and the ideal man to a greater degree than men
who dont use steroids.

We have some specific information on how these attitudes are socially transmitted in adolescent girls. In
an early study, Paxton, Schutz, Wertheim, and Muir (1999) explored the influence of close friendship
groups on attitudes concerning body image, dietary restraint, and extreme weight-loss behaviors. In a
clever experiment, the authors identified 79 different friendship cliques in a group of 523 adolescent
girls. They found that these friendship cliques tended to share the same attitudes toward body image,
dietary restraint, and the importance of attempts to lose weight. They assumed from the study that
these friendship cliques are significantly associated with individual body image concerns and eating

A recent, more definitive study concludes that while young girls do tend to share body image concerns,
these friendship cliques do not necessarily cause these attitudes or the disordered easting that follows.
Rather, adolescent girls simply tend to choose friends who already share these attitudes (Rayner,
Schniering, Rapee, Taylor, & Hutchinson, 2012).

Kelly Brownell documented the collision between culture and physiology that results in overwhelming
pressure to be thinner.

Mothers who have anorexia restrict food intake in not only themselves but also their children,
sometimes to the detriment of their childrens health (Russell, 2009).

Preventing Eating Disorders
Attempts are being made to prevent the development of eating disorders (Field et al., 2012; Stice,
Rohde, Shaw, & Marti, 2012). If successful methods are confirmed, they will be important, because
many cases of eating disorders are resistant to treatment and most individuals who do not receive
treatment suffer for years, in some cases all of their lives (Eddy et al., 2008). The development of eating
disorders during adolescence is a risk factor for a variety of additional problems and disorders during
adulthood, including cardiovascular symptoms, chronic fatigue and infectious diseases, binge drinking
and drug use, and anxiety and mood disorders (Field et al., 2012; Johnson, Cohen, Kasen, & Brook,
2002). Before implementing a prevention program, however, it is necessary to target specific behaviors
to change. Stice, Shaw, and Marti (2007) concluded after a review of prevention programs that selecting
girls age 15 or over and focusing on eliminating an exaggerated focus on body shape or weight and
encouraging acceptance of ones body stood the best chance of success in preventing eating disorders.
This finding is similar to results from prevention efforts for depression, where a selective approach of
targeting high-risk individuals was most successful rather than a universal approach targeting
everyone in a certain age range (Stice & Shaw, 2004). Using this selective approach, a program
developed by Stice et al. (2012) called Healthy Weight was compared with just handing out
educational material in 398 college women at risk for developing eating disorders because of weight and
shape concerns. During 4 weekly hour-long group sessions with 6210 participants, the women were
educated about food and eating habits (and motivated to alter these habits using motivational
enhancement procedures). Eating disorder risk factors and symptoms were substantially reduced in the
Healthy Weight group compared with the comparison group, particularly for the most severely at risk
women, and the effect was durable at a 6-month follow-up.

Could these preventive programs be delivered over the Internet? It seems they can! Winzelberg and
colleagues (2000) studied a group of university women who did not have eating disorders at the time of
the study but were concerned about their body image and the possibility of being overweight. College
women in general are a high-risk group, and sorority women in particular are at higher risk than non-
sorority women (Becker, Smith, & Ciao, 2005). The investigators developed the student bodies
program (Winzelberg et al., 1998), a structured, interactive health education program designed to
improve body image satisfaction and delivered through the Internet. The results indicated this program
was markedly successful, because participants, compared to controls, reported a significant
improvement in body image and a decrease in drive for thinness. Subsequently, these investigators
developed innovations to improve compliance with this program to levels of 85% (Celio, Winzelberg,
Dev, & Taylor, 2002). A briefer and more efficient program termed The Body Project has now been
adapted as a standalone intervention delivered over the Internet (eBody Project; Stice, Rohde, Durant,
and Shaw, 2012) with no clinician required. Initial results indicate that this program is just as good as the
program delivered in groups by a clinician.

In view of the severity and chronicity of eating disorders, preventing these disorders through
widespread educational and intervention efforts would be clearly preferable to waiting until the
disorders develop.