Module 8
Eating Disorders
a. Developmental Tasks and Challenges Related to Eating and Appearance
The physical development that occurs throughout later childhood and
adolescence has multiple impacts on psychological development and functioning,
with the onset of puberty signaling many of the most dramatic changes. Significant
growth involves proportional increases in the food intake of nutrients and energy
(Stang & Story, 2005). For girls, average weight gain is approximately 38 pounds
over the course of adolescence, with associated increases in body fat levels. For boys,
average weight gain is about 50 pounds, with a decrease in body fat levels. There are,
of course, individual and group (e.g., ethnicity, country of origin) differences related
to the beginning of puberty and weight gain; most black girls, for example, enter
puberty earlier than most white girls. Keep in mind, however, that the prevalence of
weight issues and dieting in ever-younger samples suggests that body-related
concerns are not exclusive to a particular age or stage of development.
One of the keys to understanding eating disorders depends on understanding
issues related to body image and body satisfaction. Body image has to do with
individuals’ perceptions of their own physical appearance. Body satisfaction has to do
with the degree to which individuals accept or are pleased with their physical
appearance. Concerns about body image do not appear suddenly in adolescence.
These concerns are present in elementary school and increase significantly from fifth
to eighth grade. Body image concerns have been studied mostly in girls and women;
more recent studies include boys and men. Body satisfaction is relatively similar in
younger girls and boys, with most children reporting satisfaction. By early
adolescence, however, body dissatisfaction increases. Girls become more
preoccupied, upset, and unhappy with their appearance and weight.
Girls who are underweight tend to report higher levels of satisfaction with
their bodies compared to their peers. This phenomenon can be attributed to various
societal pressures and beauty standards that often equate thinness with attractiveness.
These cultural norms can lead to a positive reinforcement loop, where underweight
girls receive more compliments and positive feedback about their appearance, thereby
enhancing their body satisfaction.
Conversely, boys who experience body dissatisfaction often find themselves
divided between two conflicting desires: the wish to lose weight and the aspiration to
gain weight or muscle mass. This dichotomy is influenced by differing societal
expectations placed upon males. On one hand, the pressure to conform to lean,
athletic body ideals leads some boys to strive for weight loss. On the other hand, the
cultural emphasis on strength and muscularity drives others to focus on gaining
muscle mass. This internal conflict can create a complex relationship with their
bodies, as they navigate between these competing goals.
For boys, the desire to lose weight often stems from the aim to achieve a more
defined and toned physique, which is highly prized in many social contexts. Media
representations of male celebrities and athletes frequently showcase lean, sculpted
bodies, reinforcing the notion that thinness is synonymous with health and
attractiveness.
In contrast, the desire to gain weight, particularly in the form of muscle mass,
is driven by the pursuit of a more robust and powerful appearance. This aspiration is
fueled by images of muscular male figures in movies, sports, and advertisements,
which celebrate strength and physical dominance. Boys seeking to build muscle often
engage in rigorous weight training and dietary regimens to achieve their ideal body
shape.
This duality in boys' body image goals highlights the complex interplay of
societal expectations, media influence, and personal aspirations. It underscores the
unique challenges boys face in navigating their body image, as they must reconcile
these often contradictory desires. Both boys and girls are significantly influenced by
external factors in their perceptions of their bodies, but their experiences and
responses to these pressures can differ markedly. Understanding these dynamics is
crucial in addressing body dissatisfaction and promoting healthier body image among
youth.
In a recent investigation of the relative impact of weight, race/ethnicity,
gender, and age on body dissatisfaction in fourth- to sixth-grade children, the
strongest predictor of body dissatisfaction was weight status. Obese children reported
the highest levels of dissatisfaction. Asian-American children and girls also reported
higher levels of dissatisfaction (Xanthopoulos et al., 2011). Another set of findings
from a longitudinal study identified various combinations of risk factors for body
dissatisfaction. In that study, both girls and boys who perceived themselves as late in
pubertal development were more likely to report body dissatisfaction. Black girls
reported less body dissatisfaction throughout the high school years; in contrast, Asian-
American girls reported more body dissatisfaction at the beginning of high school,
and that dissatisfaction increased over time (de Guzman & Nishina, 2014). Although
differences in degree of body dissatisfaction are observed, body dissatisfaction may
be experienced by individuals of all ethnic backgrounds.
Negative body image, body dissatisfaction, and concerns related to weight and
appearance are observed across many countries and cultures, including Argentina,
Australia, Chile, China, Cuba, Denmark, Guatemala, India, Iran, Israel, Norway,
Panama, Peru, Taiwan, Tibet, and Turkey. Findings from a large-scale comparative
study in 26 countries across 10 world regions suggested that a combination of
bodymass index and exposure to Western media predicted body dissatisfaction among
women. Noteworthy crosscultural differences were observed related to socioeconomic
status (SES), with body dissatisfaction and desire for thinness more frequently
reported in high-SES settings (Swami et al., 2010). Indeed, the largest differences in
body size ideals are no longer between Western and nonWestern cultures, but between
high-SES and low-SES regions.
The hypothesis suggests that both modernization and Westernization
contribute to cultural shifts that promote a thin ideal. This notion is grounded in the
observation that as societies undergo processes of modernization, including
technological advancement, urbanization, and increased access to global media, there
is a concurrent shift in cultural norms and values. Westernization, characterized by the
adoption of Western lifestyles, ideologies, and aesthetics, further amplifies this trend.
Modernization brings with it changes in socioeconomic structures, lifestyles,
and access to information. With increased urbanization, people move away from
traditional, agrarian lifestyles to more sedentary, urban living. This shift often results
in greater exposure to media and advertising, which frequently emphasize and glorify
thinness as a standard of beauty. The proliferation of digital media and social
networks allows for the rapid dissemination of Western beauty ideals, which typically
valorize slim, toned bodies.
Westernization, on the other hand, involves the spread of Western cultural
norms and values, often through media, entertainment, and global trade. The Western
ideal of beauty, which has historically celebrated a slim physique, becomes pervasive
in non-Western societies through movies, television shows, fashion magazines, and
social media platforms. This influence can lead to a shift in local beauty standards,
aligning them more closely with Western ideals.
As countries modernize and Westernize, traditional body ideals that may have
favored fuller, more robust figures can be overshadowed by the thin ideal. This
change is often driven by the media's portrayal of celebrities, models, and influencers
who exemplify slimness as a desirable trait. The impact of these images can be
profound, shaping individuals' perceptions of their own bodies and influencing
societal standards of attractiveness.
Moreover, the economic and social benefits associated with modernization can
also play a role. In many modern, Westernized societies, being thin is often equated
with being healthy, disciplined, and successful. These associations can create a strong
incentive for individuals to strive for a thinner body in order to align with these
positive attributes. The thin ideal can become a marker of social status and personal
achievement, further entrenching its desirability.
This hypothesis is supported by numerous studies that have documented the
relationship between modernization, Westernization, and body image. For instance,
research has shown that in countries undergoing rapid economic development and
increased exposure to Western media, there is a notable rise in the prevalence of
eating disorders and body dissatisfaction. This trend underscores the powerful
influence of cultural changes in shaping body ideals.
Understanding the dynamics of how modernization and Westernization
contribute to the promotion of a thin ideal is crucial for addressing the associated
negative consequences. These include increased rates of body dissatisfaction, eating
disorders, and mental health issues among populations exposed to these cultural
shifts. It highlights the need for culturally sensitive approaches to promoting positive
body image and well-being, taking into account the complex interplay of global and
local influences on beauty standards.
The influence of society and the media on body image and body attitudes has
been extensively researched and researchers have described the ways in which
television, movies, magazines, and Web sites glamorize specific, narrow, and often
unrealistic versions of beauty (e.g., very slender women’s bodies and muscular men’s
bodies). Harrison and Hefner (2008, p. 381) suggest that media exposure “(1)
normalizes dieting and excessive thinness, and (2) encourages young people to
repeatedly evaluate their bodies, to find them wanting, and to engage in extreme
dieting, overexercising, and other health-compromising behaviors.”
Many investigations have distinguished between the awareness of ideals and
attitudes about appearance, thinness, and beauty, and the internalization of such ideals
and attitudes. Studies of younger (11–12 years) and older girls (15–16 years) show
that both groups are aware of sociocultural images and ideals; the older girls,
however, are more likely to have internalized these images and ideals. According to
Sherwood and Neumark-Sztainer (2001, p. 228), “media exposure does not cause, but
reinforces, an unhealthy body image among vulnerable women.” In other words,
internalization is more important than awareness.
A recent investigation into the genetic and environmental influences on thin-
ideal internalization provides compelling evidence that environmental factors play a
predominant role in explaining the increase in thin-ideal internalization observed
during adolescence and continuing into young adulthood. This comprehensive study
delves into the relative contributions of genetic predispositions versus environmental
influences in shaping individuals' acceptance and internalization of societal standards
that favor thinness.
During adolescence, individuals are particularly susceptible to external
influences due to their developmental stage, characterized by identity formation and
heightened sensitivity to social feedback. The research indicates that environmental
factors, such as exposure to media, peer pressure, and cultural norms, significantly
outweigh genetic predispositions in shaping the thin ideal. Adolescents are constantly
bombarded with images and messages that glorify slimness through various media
channels, including television, magazines, social media, and advertisements. These
pervasive images create and reinforce the notion that being thin is synonymous with
beauty, success, and desirability.
Furthermore, the influence of peer groups during adolescence cannot be
underestimated. Friends and social circles often reinforce societal beauty standards,
with discussions about body image, dieting, and appearance becoming common.
Adolescents who are immersed in environments where thinness is highly valued are
more likely to internalize these ideals, striving to conform to the expectations of their
social groups. This peer influence is a powerful environmental factor contributing to
the internalization of the thin ideal.
As individuals transition into young adulthood, these environmental influences
continue to play a significant role. Young adults often experience new social
environments, such as college or the workforce, where appearance and body image
remain important. The study highlights that the pressure to adhere to thinness ideals
persists, driven by ongoing exposure to media portrayals of idealized bodies and
societal standards that equate thinness with professional and personal success.
Moreover, the study underscores that while genetic factors do contribute to
individual differences in body image and susceptibility to internalizing the thin ideal,
their impact is relatively minor compared to environmental factors. Genetic
predispositions may influence traits such as body composition, metabolism, and
temperament, which can affect how individuals respond to environmental pressures.
However, it is the consistent and pervasive environmental messaging that exerts the
most substantial influence on the development and reinforcement of thin-ideal
internalization.
The research also suggests that interventions aimed at reducing thin-ideal
internalization should focus on modifying environmental factors. This can include
promoting media literacy to help individuals critically analyze and resist harmful
beauty standards portrayed in the media, fostering supportive peer environments that
prioritize body positivity, and advocating for broader cultural shifts towards more
inclusive and diverse representations of beauty. By addressing the environmental
contributors to thin-ideal internalization, it is possible to mitigate its impact and
promote healthier body image attitudes among adolescents and young adults.
In conclusion, the investigation into genetic and environmental influences on
thin-ideal internalization provides robust evidence that environmental factors are the
primary drivers of the increase in thin-ideal internalization observed from adolescence
into young adulthood. This finding highlights the critical role of external influences,
such as media exposure and peer pressure, in shaping body image attitudes and
underscores the importance of addressing these factors to promote positive body
image and well-being.
b. Eating Disorders
Elizabeth is 17 years old and in eleventh grade. She is a successful student, has
leadership positions on several service clubs, and is student editor of her high school’s
literary magazine. Elizabeth’s grades have been outstanding, and her teachers consider
her a bright and extremely conscientious student. Elizabeth is the only child of two
affluent, professional parents who are both very involved in her academic and
extracurricular activities. Elizabeth reports that she gets along well with her parents,
but that she would like more independence than they seem comfortable with.
Elizabeth’s parents have noted that she has become increasingly withdrawn and even
secretive, especially toward them, in the past year.
Although Elizabeth has had a very successful high school career thus far,
junior high was a much more difficult time for her. Although she performed well
academically, she had few friends and described feeling lonely and alienated. Her
parents became concerned about her sad mood and noticeable weight gain in eighth
grade and brought her to her pediatrician, who started her on an antidepressant.
Within a few months of taking the medication and starting high school, Elizabeth was
clearly happier, more energetic, and making more friends. Because of lingering
concern over her weight, she began a very disciplined diet and program of running,
resulting in the loss of 30 pounds over several months. Elizabeth received
considerable attention and praise for these efforts from her parents and friends.
Elizabeth’s sophomore year was successful, and her parents described her as
happy and busy. The summer before her junior year, Elizabeth and her parents visited
several colleges and she enrolled in a course to help her prepare for the SAT and ACT
tests that she would be taking in her junior year. Her parents also hired a consultant to
begin working with Elizabeth in preparation for applying to colleges in the fall of her
senior year. The consultant helped Elizabeth plan her upcoming schedule, including
advising her on what extracurricular activities would look best to the selective
colleges that her parents were encouraging her to apply to.
Early in her junior year, Elizabeth’s parents began to notice that her diet was
increasingly restricted and that she seemed to avoid eating while out in public.
Already quite thin when the school year started, Elizabeth began to lose weight at an
alarming rate. She continued to run early in the morning before school and began to
miss most family dinners. Her parents became increasingly worried as Elizabeth’s
appearance became gaunt and she admitted to them that she had not had her period in
several months. Throughout this time, Elizabeth continued to excel in school and her
energy level seemed especially high. At home, however, Elizabeth was isolated,
seldom speaking to her parents except to argue about her refusal to eat the food that
her mother prepared. The only foods her parents ever saw her eat were yogurt and raw
vegetables such as carrots and cauliflower. Also, despite being told by her parents and
friends that she was too thin, she insisted that she was fat. Over Elizabeth’s
objections, her parents brought her to their physician for a checkup. There, they
learned that her weight had fallen to a dangerously low level and that she was
experiencing clinically significant anemia and cardiac symptoms. Elizabeth was
admitted directly to a medical inpatient unit for eating disorders.
Kayla is 19 years old and a first-year student at a local community college.
She lives in an apartment with several of her high school friends who are students at
the same college. Kayla’s time in high school was characterized by considerable
variability in her academic performance. She did well early in high school but,
following her parents’ divorce in the middle of her sophomore year, she began to
disengage from school. This was a stressful time for the family, as Kayla’s mother
made the transition to working full time while continuing to care for Kayla and her
two younger siblings. She began to skip classes occasionally, failed to complete
homework, and began hanging out with a new group of friends who smoked and
drank and did not value academic activities.
After Kayla’s promising start in high school, her guidance counselor became
concerned about her missed classes and falling grades and met with Kayla and her
mother toward the end of the year. That meeting led to a referral to her family
physician and a mental health counselor. Kayla was treated for depression with
medication and psychotherapy. She felt better, reconnected with old friends, and
returned to school in the fall feeling more settled and focused. Over the next two
years, Kayla did somewhat better, but she continued to have intermittent academic
and social problems, although never to the extent that she did in tenth grade. Early in
her senior year of high school, Kayla became concerned about her body size and
shape. She was slightly overweight, and a boy she was dating made some joking but
rude comments about her “full and curvy” appearance. Kayla was very upset and
made several unsuccessful attempts to lose weight. During this time, she also began to
induce vomiting after hearing several friends talk about this as a way of controlling
their weight. Soon Kayla was vomiting several times a day, generally at home but
occasionally at school as well.
Kayla found herself thinking about food often; this made her feel very
anxious. She found that the anxiety lessened considerably when she ate, although the
relief did not last. In fact, once the initial pleasure wore off, eating made her feel more
anxiety and shame. These feelings led her to induce vomiting to calm herself and keep
from gaining more weight. Multiple times per day, Kayla was repeating a cycle in
which she would binge on foods high in carbohydrates, such as cookies and ice
cream, feel anxiety and guilt, and vomit. She began to buy food and hide it in her
bedroom so that she could binge late at night, when everyone else was sleeping.
Although the girls at school often talked about various ways of purging (e.g.,
vomiting, using laxatives, exercising), Kayla kept her behavior secret. Her weight
fluctuated considerably, although it always returned to approximately the same as it
was when Kayla’s difficulties began. Although Kayla continued to meet periodically
with her therapist throughout high school to talk about her parents’ divorce and to get
help with symptoms of mild depression, she never mentioned her binge eating and
purging behaviors. Once she was living in an apartment, Kayla found it more difficult
to hide her binge eating and purging from her roommates. Although two of the
women she lived with pretty much ignored the unusual behavior, one roommate
expressed concern and told Kayla that she herself was currently being treated for
bulimia in a group program at the college. She encouraged Kayla to meet with an
eating disorders specialist in the counseling department. Eventually, Kayla agreed and
began both individual and group therapy.
Eating disorders are psychopathologies characterized by severe disturbances in
eating behaviors, disturbed perceptions of body size and shape, fear of being fat, and
compensatory behaviors to lose weight or to prevent weight gain. Eating disorders are
not a contemporary phenomenon; descriptions of eating-disordered behavior have
been documented for centuries. Halmi (2009) provides a number of examples of
notable historical figures (mostly women) whose severe food restrictions spiraled out
of control. DSM-5’s more current descriptions include several types of eating
disorders.
Among the most common are anorexia nervosa, bulimia nervosa and binge
eating disorder. Anorexia nervosa has two subtypes: a restricting type (without binge
eating or purging) and a binge eating/purging type (with recurrent episodes of binge
eating and purging) the DSM-5 section on eating disorders also includes
avoidant/restrictive food intake disorder, a diagnosis that can be made across
childhood and adolescence. DSM-5 also provides a residual category for eating
disorders with atypical, mixed, or below-threshold presentations.
Problematic eating behaviors include severe restricting of food intake or
limiting food to particular types. Distorted body perceptions involve distorted body
image or denial of the seriousness of weight loss. Compensatory behaviors include
excessive exercising, vomiting, and/or laxative use. Other symptoms, such as
obsessions and compulsive behaviors, are often displayed as well. Typical obsessions
include concerns with somatic functioning; typical compulsive behaviors include
rituals involving order and control. Although most of the research on the clinical
picture of eating disorders has involved girls and women, there are data indicating that
some aspects of the disorder may differ by gender. For instance, childhood body
dissatisfaction predicts negative food-related cognitions in girls, but only in boys with
high body-mass index.
Although there is both heterogeneity and considerable overlap in the clinical
presentations of the various eating disorders, there are distinctive patterns of
symptoms, developmental pathways, and outcomes. Anorexia nervosa is characterized
by restriction of food and energy intake and significantly low weight, an intense fear
of gaining weight, and disturbed or distorted perceptions of weight or shape. Bulimia
nervosa involves recurrent episodes of binge eating, a sense or perception that one
lacks control over binge eating, recurrent problematic compensatory behaviors, and
poor self-evaluations of body shape and weight. Binge eating disorder is characterized
by repeated episodes of binge eating, a sense or perception that one lacks control, and
significant distress. Avoidant/restrictive food intake disorder involves an apparent lack
of interest in eating or in food that is not associated with a drive for thinness.
Individuals with avoidant/restrictive food intake disorder either avoid food or appear
overly concerned with potentially adverse consequences of eating (e.g., nausea,
stomach pain, or vomiting). Food avoidance may involve aversion to the texture or
smell of food. Individuals with avoidant/restrictive food intake disorder display
significant weight loss, nutritional deficiencies, and/or impaired psychosocial
functioning.
Research into the subtypes of eating disorders continues, with important
implications for identification, assessment, and treatment. Key issues include whether
these subtypes are best understood as mostly dimensional or mostly categorical in
nature, whether the number and structure of subtypes are similar across adolescence
and adulthood, and/or whether subtypes are varied expressions of a common
underlying pathology (the transdiagnostic approach). At this point in time, the data
suggest that the common experiences, symptoms, and impairment may be more
salient than the differences observed in individuals diagnosed with various eating
disorders.
The prevalence of eating disorders has increased over the past several decades.
Prevalence rates are relatively high, despite the fact that many individuals with eating
disorders are likely not identified or treated. Available statistics from the National
Institute of Mental Health show overall prevalence rates of 2.7% for eating disorders
for 13- to 17-year-olds, with girls two and a half times as likely as boys to have an
eating disorder (Merikangas et al., 2010). Those rates are somewhat lower than other
recent estimates for specific eating disorders: 1% for anorexia, 2.6% for bulimia, 3%
for binge eating disorder, and 2.8% for atypical anorexia (Stice, Marti, & Rohde,
2013). Individuals diagnosed with avoidant/restrictive food intake disorder are
somewhat younger than other eating-disordered individuals, with a higher proportion
of males.
The average duration of an eating disorder episode was approximately three
months for bulimia and 11 months for anorexia (Stice et al., 2013). It is important to
note that crossover is common. For example, many individuals are first diagnosed
with bulimia, and then cross over to anorexia. The most frequent crossover pattern is
from binge eating disorder to bulimia (Stice et al., 2013). Individuals with
avoidant/restrictive food intake disorder often cross over to anorexia (Norris et al.,
2014). Adolescents diagnosed with eating disorders are also frequently diagnosed
with other psychopathologies. Depression and anxiety are common comorbid
disorders. The combination of an eating disorder and depression is reflected in
Elizabeth’s case. There is also considerable overlap between eating disorders and
bipolar disorder, and symptom similarities in terms of eating dysregulation, mood
dysregulation, impulsivity, and compulsions. Self-harm and suicidality are primary
concerns. Jacobson and Luik (2014) report that a majority of individuals diagnosed
with an eating disorder also display nonsuicidal self-injury, with the highest rates
observed in those with purging-type disorders.
Connections between eating disorders and substance abuse disorders have
been widely described in the literature, especially among older adolescents and
individuals diagnosed with bulimia nervosa. This association has led some researchers
to hypothesize that, for some individuals, eating disorders may function as addictions,
with food serving as a mood-altering substance. The ongoing cycles of food
preoccupation, craving, and abuse, despite negative consequences, mirror the patterns
observed in substance addiction.
Eating disorders, particularly bulimia nervosa, involve behaviors such as binge
eating and purging that closely resemble the compulsive use and subsequent
withdrawal seen in substance abuse disorders. For individuals with bulimia, episodes
of binge eating are often characterized by consuming large quantities of food in a
short period, followed by feelings of guilt, shame, and the use of compensatory
behaviors such as vomiting, excessive exercise, or laxative abuse. These behaviors
create a cycle of addiction-like patterns where food becomes a source of temporary
relief or euphoria, similar to how substances can alter mood and provide temporary
escape from negative emotions.
The preoccupation with food, weight, and body image in eating disorders also
parallels the obsessive thoughts and cravings experienced in substance addiction.
Individuals with eating disorders may spend an inordinate amount of time planning,
obtaining, and consuming food, similar to how those with substance use disorders
focus on acquiring and using their preferred substance. This preoccupation can
dominate their daily lives, interfering with social, academic, and occupational
functioning.
Furthermore, both eating disorders and substance use disorders share common
risk factors and underlying psychological mechanisms. These include genetic
predispositions, neurobiological alterations, and environmental influences such as
trauma, stress, and exposure to cultural pressures that emphasize thinness or substance
use. For instance, research has shown that individuals with a family history of
addiction or eating disorders are at increased risk for developing these conditions,
suggesting a genetic vulnerability that may manifest as different forms of compulsive
behavior depending on environmental triggers and individual experiences.
Neurobiological studies have revealed that the brain's reward pathways,
particularly those involving dopamine, are implicated in both eating disorders and
substance abuse. The consumption of highly palatable foods, especially those high in
sugar and fat, can stimulate the release of dopamine in the brain's reward centers,
creating a sense of pleasure and reinforcing the behavior. This mechanism is strikingly
similar to the way addictive substances, such as drugs and alcohol, act on the brain's
reward system, reinforcing their use and leading to addictive behaviors.
Additionally, psychological factors such as low self-esteem, emotional
dysregulation, and difficulties in coping with stress are common in both eating
disorders and substance use disorders. Individuals may turn to food or substances as
maladaptive coping mechanisms to manage negative emotions, leading to cycles of
dependency and addiction. The temporary relief provided by binge eating or
substance use reinforces these behaviors, despite the long-term negative consequences
on physical health, mental well-being, and overall quality of life.
The comorbidity of eating disorders and substance use disorders is well-
documented, with many individuals experiencing both conditions simultaneously.
This dual diagnosis presents significant challenges for treatment, as both disorders
need to be addressed concurrently to achieve lasting recovery. Integrated treatment
approaches that target both the eating disorder and the substance use disorder are
essential for effective intervention, focusing on underlying psychological issues,
developing healthy coping mechanisms, and addressing the addictive behaviors
associated with both conditions.
In summary, the connections between eating disorders and substance abuse
disorders are widely recognized, particularly among older adolescents and individuals
with bulimia nervosa. The hypothesis that eating disorders may function as
addictions, with food acting as a mood-altering substance, highlights the complex
interplay of genetic, neurobiological, and psychological factors that contribute to
these conditions. Understanding these connections is crucial for developing effective
treatment strategies that address the multifaceted nature of eating disorders and
substance use disorders, promoting recovery and improving the lives of those affected
by these challenging conditions.
c. Developmental Course
Eating disordered behavior in childhood and adolescence predicts eating
disordered behavior in adulthood, although there is a decline in prevalence and in
severity. Further, being diagnosed with an eating disorder in childhood or adolescence
is associated with later risk of being overweight and worse mental health outcomes.
Eating disorder onset is most common at two times: early adolescence and late
adolescence. These are two key developmental transition points. The first one marks
the transition from childhood to adolescence, and the second is from adolescence to
adulthood.
Although most eating disorders emerge during adolescence, recent reports
suggest that instances of middle- and late-life eating disorders are increasing. This
phenomenon warrants additional attention from both the medical community and
researchers, as it challenges the traditional understanding that eating disorders
predominantly affect younger populations.
The increasing prevalence of eating disorders among middle-aged and older
adults highlights several critical issues that need to be addressed. Firstly, the
recognition and diagnosis of eating disorders in these age groups can be more
complex. Healthcare providers might not always consider eating disorders as a
potential diagnosis for older adults, leading to underdiagnosis and undertreatment.
Older adults might also be less likely to seek help due to stigma or the misconception
that eating disorders only affect younger individuals.
Several factors contribute to the onset of eating disorders in middle and late
life. Life transitions and stressors, such as divorce, the death of a spouse, children
leaving home, retirement, and the physical and psychological changes associated with
aging, can act as triggers. For some individuals, these stressors may lead to increased
body dissatisfaction or the use of disordered eating behaviors as a coping mechanism.
Additionally, a history of disordered eating earlier in life can resurface or worsen in
response to these later-life stressors.
The societal pressure to maintain a youthful appearance can also play a role.
Despite the natural aging process, the cultural ideal of thinness and the valorization of
youthful looks persist across all ages. Older adults, particularly women, may feel
pressured to adhere to these ideals, leading to unhealthy eating behaviors and a
preoccupation with weight and body shape.
Hormonal changes that occur during menopause in women or andropause in
men can also influence body weight and shape, potentially contributing to the
development of eating disorders. For example, the decrease in estrogen levels during
menopause can lead to changes in fat distribution, which might cause distress for
women who are particularly concerned about their body image. In men, decreasing
testosterone levels can lead to changes in muscle mass and fat distribution, which
might similarly affect body image and lead to disordered eating behaviors.
Furthermore, chronic health conditions that are more prevalent in older adults,
such as diabetes, cardiovascular disease, and gastrointestinal disorders, can
complicate the presentation and treatment of eating disorders. The interplay between
managing these chronic conditions and maintaining a healthy relationship with food
can be challenging. For instance, dietary restrictions necessary for managing diabetes
can sometimes evolve into more restrictive eating patterns that resemble eating
disorders.
The impact of eating disorders on the physical health of middle-aged and older
adults can be particularly severe. These individuals may already face age-related
health challenges, and the presence of an eating disorder can exacerbate these issues.
Malnutrition, osteoporosis, cardiovascular problems, and weakened immune function
are among the potential health consequences that can be especially detrimental in
older populations. Additionally, the psychological toll of eating disorders, including
depression, anxiety, and social isolation, can significantly impair the quality of life.
Given the increasing prevalence of eating disorders in middle and late life,
there is a pressing need for greater awareness, improved diagnostic tools, and tailored
treatment approaches for this demographic. Healthcare professionals should be trained
to recognize the signs and symptoms of eating disorders in older adults and to
consider these conditions in their differential diagnoses. Treatment programs should
be adapted to address the unique needs of middle-aged and older adults, incorporating
strategies that consider the physical, psychological, and social aspects of aging.
In conclusion, while most eating disorders traditionally emerge during
adolescence, the rising incidence of eating disorders in middle and late life is a
growing concern that warrants significant attention. Understanding the unique factors
that contribute to the development of eating disorders in older adults is crucial for
providing effective care and support. As societal norms and the demographic
landscape continue to evolve, so too must the approaches to diagnosing, treating, and
preventing eating disorders across the lifespan.
Research suggests that multiple risk factors, including body dissatisfaction,
perceived pressure to be thin, thin-ideal internalization, and negative affectivity, are
already in place by puberty and escalate in impact over adolescence. These factors
will be discussed in more detail in the upcoming etiology section. The developmental
pathways of eating disorders are varied. Younger adolescents are more likely to
present with symptoms of anorexia nervosa, and older adolescents are more likely to
present with symptoms of bulimia. Many adolescents exhibit fluctuating courses of
weight loss and gain, whereas others deteriorate over time and are repeatedly
hospitalized (Peterson et al., 2012).
As noted, the crossover from one type of eating disorder to another is
common. For instance, individuals who initially present with anorexia nervosa may
later develop symptoms of bulimia nervosa or binge eating disorder, and vice versa.
This fluidity between different types of eating disorders underscores the complex and
dynamic nature of these conditions. It also highlights the importance of ongoing
assessment and monitoring, as the specific presentation of an eating disorder can
change over time, complicating both diagnosis and treatment.
When identification and intervention occur earlier in the course of an eating
disorder, the trajectory of the illness can often be significantly improved. Early
detection allows for prompt initiation of treatment, which can help mitigate the
severity and chronicity of the disorder. For example, early intervention can prevent
the entrenched patterns of disordered eating and the psychological and physiological
complications that often accompany prolonged illness. Research consistently shows
that individuals who receive treatment in the early stages of their eating disorder have
better outcomes compared to those whose treatment is delayed.
Early identification involves recognizing the subtle signs and symptoms of
eating disorders before they become more pronounced and difficult to treat. These
signs can include preoccupation with weight, food, and body image; changes in eating
patterns, such as skipping meals or avoiding certain foods; excessive exercise; and
physical symptoms like unexplained weight loss, fatigue, or gastrointestinal issues.
Family members, friends, teachers, and healthcare providers play a crucial role in
identifying these early warning signs and encouraging individuals to seek help.
Intervention at an early stage can encompass a variety of therapeutic
approaches tailored to the individual's specific needs. Cognitive-behavioral therapy
(CBT), for example, is a widely used and effective treatment for many types of eating
disorders. CBT helps individuals identify and challenge distorted thoughts and
behaviors related to food and body image, and develop healthier coping mechanisms.
Family-based therapy (FBT) is particularly effective for adolescents with eating
disorders, as it involves the family in supporting the individual's recovery.
Nutritional counseling is another critical component of early intervention.
Dietitians specializing in eating disorders can work with individuals to establish
balanced eating patterns and address any nutritional deficiencies. This can help restore
physical health and reduce the medical complications associated with eating
disorders.
Furthermore, early intervention often includes addressing any co-occurring
mental health conditions, such as depression, anxiety, or substance abuse, which are
common among individuals with eating disorders. Integrated treatment plans that
address both the eating disorder and any comorbid conditions can enhance overall
outcomes and support long-term recovery.
Preventive measures also play a vital role in early identification and
intervention. Educational programs that promote body positivity, healthy eating
habits, and resilience against societal pressures can help reduce the risk of developing
eating disorders. Schools, communities, and healthcare settings can implement these
programs to raise awareness and provide resources for individuals at risk.
In addition to improving individual outcomes, early identification and
intervention have broader implications for public health. Eating disorders are
associated with significant healthcare costs due to the need for medical and
psychological treatment, as well as the potential for long-term health complications.
By identifying and treating eating disorders early, these costs can be reduced, and the
burden on healthcare systems can be alleviated.
In conclusion, the crossover from one type of eating disorder to another is a
common occurrence that complicates the diagnosis and treatment of these conditions.
Early identification and intervention are crucial in altering the course of eating
disorders, making them less severe and chronic. By recognizing early warning signs,
providing timely and appropriate treatment, and implementing preventive measures,
we can improve outcomes for individuals with eating disorders and reduce the overall
impact of these conditions on individuals and society.
The psychological consequences of eating disorders include impairments in
self-image, health, and social functioning, and, as described, the development of
depressive disorders, substance abuse, and suicidality. The pathway from depression
to eating disorder has also been observed, more often for the restrictive eating
disorder subtypes (Herpertz-Dahlmann et al., 2015). In addition, there are immediate
and long-term medical complications, such as biochemical, endocrine, hematological,
and bone-related difficulties. The mortality rate for eating disorders is high.
d. Etiology
Two of the most well known explanations of eating disorders are related to
family factors and sociocultural factors. Critical analyses of these explanations are
necessary in order to separate fact from fiction and to examine empirical data that
support or refute these hypotheses. The idea that families create or foster eating
disorders is most fully explored in psychodynamic explanations and is often
associated with the psychodynamic theorists Hilde Bruch (1973, 1982) and Salvador
Minuchin. Bruch observed eating disorders in “good girls”—girls who were
characteristically compliant, achievement oriented, and attuned to pleasing others.
Bruch asserted that the daughters in these families with indulgent, overinvolved
parents lacked many of the basic skills of early childhood, such as the ability to
distinguish among physiological sensations (e.g., hunger vs. exhaustion), the ability to
differentiate emotional experiences (e.g., anxiety vs. irritation), and the ability to feel
confident in one’s body and oneself.
Minuchin’s book Psychosomatic Families (Minuchin, Rosman, & Baker,
1978) described families who were “enmeshed,” or too closely involved and
controlling of one another. These dysfunctional families allowed little opportunity for
child or adolescent autonomy, a stressful situation exacerbated by an atmosphere of
overt nurturing and affection. With the developmental press for independence and
self-definition associated with early adolescence, crises were inevitable. Without a
well-defined sense of self, and without the ability to identify their own needs and
desires appropriately, daughters sought control over themselves in any way possible.
For some, the struggle played out in the form of eating disorders.
As might be expected, parents of adolescent girls diagnosed with eating
disorders were “bewildered, blamed, and broken-hearted” (MacDonald, 2000) as they
sought help for their children. And their confusion and upset was warranted because
there is little or no empirical support in prospective studies for the causal impact of
these psychodynamic family factors (Stice, 2002). A recent position paper from the
Academy for Eating Disorders is quite clear: “It is the position of the Academy for
Eating Disorders (AED) that whereas family factors can play a role in the genesis and
maintenance of eating disorders, current knowledge refutes the idea that they are the
exclusive or even the primary mechanisms that underlie risk. Thus, the AED stands
firmly against any etiologic model of eating disorders in which family influences are
seen as the primary cause of anorexia nervosa or bulimia nervosa, and condemns
generalizing statements that imply families are to blame for their children’s illness.”
More recently, sociocultural models of eating disorders have become
prominent. These explanations, briefly discussed in the opening section on the
developmental challenges associated with eating and appearance, begin with the near-
constant presentation of images of actresses, fashion models, and Instagram
celebrities with impossibly thin bodies and shapes. Internalization of this thin ideal,
coupled with the pressure to be thin (coming from oneself, family, peers, and society),
leads to body dissatisfaction, negative emotions, problematic dieting behaviors, and
eating pathology. Indeed, research suggests that exposure to media images of the thin
ideal, as well as peer pressure to be thin immediately, increases levels of body
dissatisfaction. This is especially the case if girls are vulnerable in terms of already-
present body dissatisfaction, perceived pressure to be thin, and lack of social support.
According to Harrison and Hefner (2008, p. 381), the “thin-ideal media exposure may
coax body image disturbance and disordered eating into expression by activating
related cognitions and emotions.” Given that the vast majority of adolescent girls and
young women do not develop clinically significant eating disorders, however, a
single-factor model is unlikely to capture the real-life complexity of eating disorders.
A biopsychosocial, multifactorial risk model provides a more nuanced
explanation of the development of eating disorders (Le Grange et al., 2010). As we
review the genetic and environmental factors here, keep in mind that both the number
and pattern of risk factors likely influence an individual’s vulnerability. In addition, it
is important to know that many of the studies summarized here do not differentiate
among subtypes of eating disorders; given the distinct symptom profiles of the various
subtypes, it is likely that some of the patterns of risk and maintenance factors differ.
Family and twin research suggests strong heritability for both anorexia and
bulimia. The data are consistent with explanations that highlight common genetic
factors underlying eating disorder symptoms, anxiety and depression, as well as
explanations that emphasize distinct genetic factors for early symptoms of eating
disorder. The data also emphasize that nonshared environmental factors (i.e., those
factors that differentially influence siblings) are much more important than shared
environmental factors (Culbert et al., 2015). Future work in this area is likely going to
examine gene-by-environment effects and epigenetic processes.
Physiological studies provide additional perspective on the brain structures
and mechanisms involved in appetite, food intake and satiety, and associated pleasure
and reward. Data suggest abnormal activity in various regions of the brain, including
the prefrontal and temporal lobes. Related research focuses on the role of the vagus
nerve, dysregulation of the serotonin and dopamine systems, and elevated pain
thresholds observed in adolescents with eating disorders. Some of the physiological
factors that appear to be implicated are similar to those observed in individuals with
certain mood disorders and substance abuse disorders, including dysregulation of
eating and mood, impulsivity, and craving responses after exposure to food cues
(Berridge, 2009; Halmi, 2009). These factors may be particularly salient for those
adolescents and adults with more severe psychopathology. Halmi describes a
physiological model that emphasizes allostasis. Extending a model originally
designed to explain drug addiction, Halmi (2009, pp. 163–164) suggests that
individuals diagnosed with anorexia or bulimia experience “a dysregulation of reward
circuits with activation of brain and hormonal stress responses” and that these
“changes in the entire brain-body system” underlie ongoing risk, chronic distress and
impairment, and frequent relapses.
As noted, the onset of puberty is associated with increased risk. Part of that
increased risk is linked to physiological maturation and hormonal changes.
Earlymaturing girls are at higher risk than later-maturing girls. The data are mixed on
the impact of puberty timing for boys (Klump, 2014). For children who struggle with
obesity in childhood, there are increased risks for restrictive eating disorders in
adolescence. Even when weight loss is recommended, careful attention to the extent
of weight loss, as well as potentially maladaptive outcomes, is necessary.
Individual factors that influence the emergence of eating disorders have
received a great deal of clinical and empirical attention. A cluster of biologically
influenced personality characteristics have been identified that increase vulnerability.
These include temperament, negative emotionality and emotion dysregulation,
impulsivity, stress reaction and harm avoidance, and reward and punishment
sensitivity. The combination of negative emotionality and impulsivity, in particular, is
connected to binge eating and purging. With respect to distressing emotion
experience, an inflexible emotion regulation repertoire is an additional risk factor.
Perfectionism, involving setting impossibly high goals and experiencing a
sense of failure and worthlessness when those goals are not met, appears to run in
families and may lead to the “relentless pursuit of the thin ideal” (Bruch, 1973).
Perfectionism is central to both etiology and maintenance processes. Another cluster
of personality characteristics is more psychodynamically informed, including
variables related to self report that individuals with anorexia described lower levels
of agency and relatedness, as well as heightened and harsh self-reflectivity; these self-
descriptions distinguish between individuals with anorexia and individuals without
anorexia, as well as between individuals with anorexia and individuals with other
disorders. Other variables in the psychodynamic framework involve atypical
emotional development and functioning (such as a reluctance to express emotion or a
tendency to experience a restricted range of emotion), with difficulties often traced
back to early relationship interactions.
Body-related characteristics and attitudes are another set of risk factors, with
body dissatisfaction at the nexus. As described in the previous section on
developmental course, several risk factors are present before puberty and increase in
salience across adolescence: perceived pressure to be thin, thin-ideal internalization,
body-mass index, dieting, negative emotionality, and body dissatisfaction (Rohde et
al., 2015). Perceived pressure to be thin exhibits the largest increase over time.
General dissatisfaction with one’s body emerges before rather than after perceived
increases in the pressure to be thin, as well as before increases in body mass that
occur postpuberty. Body dissatisfaction is the most consistent and strongest predictor
of eating disorders later in life.
Teasing appears to be a particularly important factor for both girls and boys. A
different type of body risk factor involves participation in weight-focused sports, such
as gymnastics or running. The roles of gender identity and sexual orientation require
further exploration. Lesbian-gay-bisexual-transgender-questioning (LBGTQ)
adolescents are at increased risk for body dissatisfaction, problematic weight-related
behaviors, and eating disorders.
Parent and family factors have long been implicated in the development and
maintenance of eating disorders. As noted, however, we need to be very careful how
we evaluate these factors. It may turn out that an appreciation of bidirectional
influences provides the most useful information. It is also likely that specific family
factors are more salient for already vulnerable adolescents (Le Grange et al., 2010;
Stice, 2002). One basic risk variable involves general family dysfunction. For
instance, families with more problematic communication, more psychopathology, and
more financial difficulties have adolescents at higher risk.
Perceptions of family functioning (versus actual family functioning) provide
additional perspective. Daughters with eating disorders, for example, perceive more
family dysfunction than their mothers, and this may be because of their feelings of
inadequacy and distrust of others. Examining some of the specific aspects of maternal
and paternal behaviors may elucidate some of these more general findings. The
relationships of mothers and daughters are a frequent clinical focus. Mothers’ critical
comments about weight and shape and the frequency of such comments appear to be
more influential than family conflict.
Encouragement of dieting is also related to body dissatisfaction and drive for
thinness (Cooley et al., 2008). The data on mothers’ own modeling of eating
pathology (e.g., emotional eating or restrictive eating) and negative body image are
mixed. Fathers who emphasize attractiveness and control food intake increase the risk
of eating pathology (Dixon, Gill, & Adair, 2003). Fathers, as well as mothers and
siblings, who tease daughters increase the likelihood of negative outcomes. Paternal
rejection is an especially poignant risk factor. There are, of course, protective family
factors as well. Family connectedness, positive family communication, and parental
monitoring all decrease the risk of eating disorders in adolescents.
Negative life events (e.g., school transitions, death of a family member,
relationship changes, home and job transitions, illness/hospitalization, and
maltreatment) increase the risk for eating disorders and may trigger the onset of an
eating disorder. As already described, media influences are also important risk factors.
Media exposure clearly plays a role in increasing body dissatisfaction and
internalization of the thin ideal. Beyond media influence, a variety of culturerelated
factors likely influence the development of eating disorders. Anorexia nervosa is
observed over time and across cultures, whereas bulimia nervosa is only observed in
cultures with significant exposure to Western influences (Culbert et al., 2015). The
specific mechanisms by which various Western influences have an impact have yet to
be fully explained.
e. Assessment and Diagnosis
The assessment and diagnosis of eating disorders involves the
developmentally informed evaluation of a complicated mix of somatic and
psychological symptoms. Assessment may be especially problematic because most
adolescents with eating disorders deny difficulties (often vehemently) and avoid
contact with medical or mental health professionals. The development and
maintenance of therapeutic engagement and alliance, therefore, are of the highest
priority.
There are a number of well-validated structured interview and self-report
measures for screening and diagnosis, although instruments need to be designed and
interpreted with regard for differences in the clinical presentation of adolescents
versus adults and with respect to ethnicity and gender (. Because several of the
diagnostic criteria for eating disorders involve cognitive symptoms, the diagnostic
process must take into account age-related and cultural considerations. For example,
“body experience and weight concerns may be difficult to formulate and express, in
part because they are highly subjective, and in part because they are relative to social
norms”.
In addition, given the different perspectives of adolescents and parents,
particularly related to family functioning, it is crucial to solicit parent reports during
the assessment of eating disorders. Adolescents and their parents often have differing
views on various aspects of family dynamics, stressors, and interactions, which can
provide a more holistic understanding of the situation. Adolescents may not fully
recognize or may minimize the impact of certain behaviors or stressors, while parents
can offer insights into changes in behavior, family history, and other contextual
factors that adolescents might not report.
For example, parents can provide valuable information about the adolescent's
developmental history, eating habits, exercise routines, and emotional responses that
may be pertinent to understanding the onset and progression of the eating disorder.
They can also shed light on family patterns, such as parental attitudes toward weight
and diet, family conflicts, and the presence of other mental health issues within the
family. These insights can help clinicians identify underlying factors contributing to
the eating disorder and tailor treatment plans accordingly.
Parent reports are particularly important when considering family functioning
and dynamics, as these can significantly influence the development and maintenance
of eating disorders. Family functioning encompasses communication patterns,
problem-solving abilities, emotional support, and the overall emotional climate within
the family. Dysfunctional family dynamics, such as high levels of criticism, lack of
emotional support, or unresolved conflicts, can exacerbate disordered eating
behaviors. By obtaining parent reports, clinicians can better understand these
dynamics and address them in treatment.
Including parents in the assessment process also fosters a collaborative
approach to treatment, which can enhance the therapeutic alliance and improve
treatment outcomes. When parents are actively involved, they are more likely to
support their child's treatment plan, adhere to recommendations, and create a home
environment that promotes recovery. This collaborative approach can also empower
parents with the knowledge and skills needed to support their child effectively.
Furthermore, it is absolutely necessary for a comprehensive medical
examination to be part of the assessment process for eating disorders. Eating disorders
can have severe physical health consequences, and a thorough medical evaluation is
essential to identify and address these issues. A comprehensive medical examination
should include a detailed medical history, physical examination, and appropriate
laboratory tests to assess the individual's overall health and identify any medical
complications resulting from disordered eating behaviors.
For instance, individuals with anorexia nervosa may present with bradycardia,
hypotension, electrolyte imbalances, and other potentially life-threatening conditions.
Those with bulimia nervosa may suffer from electrolyte disturbances, gastrointestinal
problems, dental erosion, and esophageal tears. A medical examination can help detect
these complications early and guide the necessary medical interventions to stabilize
the individual's health.
The medical examination should also assess for co-occurring medical
conditions that might influence the treatment plan. For example, conditions such as
diabetes, gastrointestinal disorders, or endocrine abnormalities can interact with
eating disorder symptoms and require specific management strategies. By identifying
and addressing these conditions, healthcare providers can ensure a more
comprehensive and effective treatment approach.
Moreover, a medical examination provides an opportunity to educate the
individual and their family about the physical consequences of eating disorders,
emphasizing the importance of medical monitoring and adherence to treatment
recommendations. This education can enhance motivation for recovery and
compliance with the treatment plan.
In summary, incorporating parent reports into the assessment process is
essential due to the differing perspectives of adolescents and parents, particularly
regarding family functioning. Parent reports offer valuable insights that can inform
the understanding and treatment of eating disorders. Additionally, a comprehensive
medical examination is crucial for identifying and managing the physical health
consequences of eating disorders, ensuring a holistic approach to assessment and
treatment. By combining psychological and medical evaluations with family
involvement, clinicians can develop a more effective and individualized treatment
plan that addresses the complex needs of individuals with eating disorders.
There is some momentum to include a quick screen for eating disorders as part
of well-child and other child and adolescent appointments with physicians. For those
who respond to questions about eating behaviors, weight concerns, and body
satisfaction with answers that raise concerns, more comprehensive evaluations can be
provided. In all cases, it is important to identify and rule out multiple causes of weight
loss, loss of appetite, and refusal to eat.
f. Intervention
Interventions for eating disorders include both prevention and treatment.
Prevention strategies frequently target some of the more malleable risk factors,
including body dissatisfaction, negative emotion, and internalization of the thin ideal,
and seek to strengthen some of the protective factors, such as self-esteem and social
support. School-based programs in both middle schools and high schools, as well as
across ethnic groups, can be effective. These may focus on components of healthy
eating and healthy dieting, self-esteem and perfectionism, and critical analysis of
media images, and may specifically address teasing and harassment related to body
weight and shape. Age 14 appears to be the key age for prevention efforts (Rohde et
al., 2015). Peer-led prevention programs for older adolescents and college students
have also received empirical support. Prevention programs designed to reduce the
prevalence of eating disorders are one important example of translational science.
With information about effective programs readily available, mental health and public
health advocates must identify opportunities to scale up programming to meet the
increased need.
Treatment models include inpatient hospitalization, partial hospitalization,
intensive outpatient settings, and traditional outpatient settings. Current approaches
provide multidisciplinary, comprehensive, and integrated treatments that address the
medical and psychological issues of children, adolescents, and their family and peer
contexts. Hospitalization remains essential for those with severe and life-threatening
disorders. Both inpatient and partial hospitalization are aggressive forms of treatment
that require considerable clinical skills on the part of mental health professionals who
work with therapeutically challenging adolescents. With accumulating data on
empirically supported outpatient treatments for eating disorders, it is increasingly the
case that the primary function of hospitalization is medical stabilization. Beyond
stabilization, inpatient treatment tends to be used only when outpatient treatments
have been unsuccessful or are unavailable (Lock et al., 2015). Outpatient care is
associated with greater client and parent satisfaction, as well as lower cost.
As noted, adolescents rarely initiate or compliantly accept treatment (Halmi,
2009; Sommers-Flanagan, Richardson, & Sommers-Flanagan, 2011). Even if
treatment begins, dropout rates are high. Halmi et al. (2005) emphasize the need to
proactively reach out to children or adolescents who seem to be especially likely to
resist, disengage, or drop out. Characteristics of the therapist and the therapeutic
alliance also take on added significance (Constantino, Arnow, Blasey, & Agras, 2005).
As with all therapists working with children and adolescents with all kinds of
psychopathologies, Stewart (2004) suggests that therapists who are nonjudgmental,
neutral, and accepting are more likely to engage their eating-disordered clients.
Pharmacological treatments are relatively unexplored with adolescents (compared to
adults), but there are numerous research projects underway. Most of the research is
focused on the use of antidepressants and mood stabilizers. There is little evidence
that pharmacological treatments are effective for restoring weight for individuals
diagnosed with anorexia, and mixed data on the role of pharmacological treatments
for reducing relapse rates and improving core features of eating disorders.
Psychosocial interventions, including individual and family psychotherapies,
are the treatments of choice (Lock et al., 2015). In general, current treatment trends
include the use of family-based treatments for older children and adolescents and the
use of cognitive-behavioral therapy for young adults. Family therapies are effective
for adolescents with both anorexia and bulimia. In fact, “family involvement appears
to be useful in reducing both psychological and medical morbidity, especially for
younger patients with a short duration eating disorder” (Le Grange et al., 2010, p. 3).
Parent participation is also associated with lower rates of dropout for adolescents.
The Maudsley model of family therapy, in which parents have a central role in
treatment, has been the focus of much current research and has received much
empirical support. The Maudsley model is a “highly practical approach, which
initially focuses exclusively on problems related to improving eating and promoting
weight gain”. In the early phase of treatment, parents have significant control over the
adolescent’s eating; problems in family structure that make improvements in eating
more difficult are addressed quickly. When eating and weight have improved,
adolescents take more responsibility and control over eating. The last part of treatment
focuses on the typical developmental challenges of adolescence (e.g., autonomy,
sexuality) that may have an impact on continued progress.
Compared to individual treatments for adolescents with anorexia, family-
based treatments were more effective in maintaining full remission of symptoms over
time (Lock et al., 2010). Also, the more severe the clinical presentation, the greater
the benefit associated with family-based treatments compared to individual treatments
(Le Grange et al., 2012). In addition to familybased treatments, groups of parents
whose adolescents are diagnosed with eating disorders benefit from parent training
programs that provide both information and support for their own struggles, a recent
investigation of multifamily-based treatments examined the outcomes of immersive,
intense five-day programs focused on psychoeducation and skills training. The
positive outcomes suggest that effective family treatments may be able to be
disseminated more broadly.
The most common, empirically supported individual approach is cognitive-
behavioral psychotherapy. Most child- and adolescent-focused therapies target the
distorted cognitions, disordered eating patterns, and self-efficacy concerns in specific
developmental contexts (Fitzpatrick, 2012; Lock et al., 2015). Keeping in mind the
role of body dissatisfaction in the etiology of disorders, cognitive-behavioral
treatments that include specific techniques to reduce body dissatisfaction (e.g.,
positive role playing, challenging negative cognitions, generating positive self-
statements) have the most positive outcomes.
A specialized version, cognitive behavioral therapy for eating disorders (CBT-
E), is designed to address various forms of eating disorders and to match adolescents’
and young adults’ personalities and psychopathologies. The focus of CBT-E treatment
involves identifying factors that maintain the eating disorder (in contrast to factors
that influenced the development of the disorder), and helping individuals step back or
distance themselves from their disorder so that they can understand it better. The
initial stage of treatment involves engaging the patient, assessing the nature and
severity of the disorder, education about eating disorders, and working together to
devise an individualized treatment plan. The second and third stages involve
reviewing progress and compliance and identifying ongoing barriers to change.
Examples of work in these stages might include exploring the evaluation of
shape and weight and developing strategies to reduce the importance of shape and
weight and develop other domains for self-evaluation. Additional work might focus
on dealing with dietary rules, dietary restraint, or negative moods. The final phase
emphasizes understanding and minimizing relapse and devising plans for dealing with
setbacks. Other common treatments for adolescents with bulimia focus more
specifically on dieting and dietary restraint strategies. For those with bulimia, who
often relapse and struggle with repeat cycles of binge eating and purging, and for
those with binge eating disorder, dieting must be appreciated as a complex
phenomenon. Although once thought to exacerbate the symptoms of bulimia, dieting
actually improves the clinical picture. To the extent that early progress can be made,
initial improvement often predicts the eventual outcome. Relapse prevention can be
addressed by having therapists pay special attention to an adolescent’s higher level of
initial preoccupation with food, greater ritualization of eating, and lower motivation
for change.
Interpersonal therapies, focused on changing the problematic relationships that
trigger or maintain eating disorder symptoms, have received empirical support (Lock
et al., 2015). Less prevalent, with fewer data to support them, are psychodynamic
treatments for eating disorders. These tend to center on providing a safe space to
explore painful emotions, construct self and identity, and explore early and current
family relationships. Of course, it is essential to address comorbid disorders, including
depression, anxiety, substance abuse, nonsuicidal self-injury, and suicidality.
