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Chapter 5

Eating Disorders


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 Weston also claimed Andrea wasbecoming more irritable, withdrawn, and argumentative.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

The psychologist found Andrea to be somewhat gaunt and diminutive, but notseriously underweight during the initial interview. Her major symptoms initiallyseemed depressive. Andrea said she experienced several stressful events that feltoverwhelming during the school year (it was now early February). She said herparents were constantly interfering with her life, giving her advice on how to look,act, and work toward the future. Her mother often “poked her nose” into Andrea’saffairs, especially her appearance, schoolwork, social life, and dating. Andrea saidshe was doing poorly at school, claiming a severe case of “senioritis.” She also feltlonely and rejected because many of her friends were joining other social groups.

The psychologist asked Andrea about recent events that triggered her father’scall. Andrea said her parents were unhappy with her boyfriend of the past5 months. Both objected to his older age (20 years), rough demeanor, and ques-tionable status, characteristics Andrea seemed to relish. When asked for moredetails, Andrea simply said this was her first real boyfriend and that her parents“just don’t want me to have any independence.” Andrea did not openly admitthat annoying her parents was a fringe benefit of dating her boyfriend, but hertone led the psychologist to this conclusion.


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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

Andrea’s moods often related to food. She ate and binged when anxious ordepressed and purged when feeling guilty, fat, or ugly. Andrea had few moods nottied to eating and often ate impulsively and with little control. The psychologistfound no major patterns of borderline personality traits, aggression, or substanceabuse, however. No history of physical or sexual abuse was reported either. Thesefindings support the belief that no one pattern of symptoms necessarily fits all thosewith anorexia nervosa.

The psychologist also focused on the link between Andrea’s social and familyinteractions and her eating. Andrea had distorted thoughts of abandonment byothers if she gained weight and popularity if she lost enough weight. An in-depthdiscussion with Andrea and her parents also revealed vacillating enmeshment andconflict. Andrea and her parents would become overinvolved in one another’slives and then fight about this. Andrea and her mother spent hours shopping andtalking about Andrea’s appearance. Andrea would then complain her mother was“trying to control me.” Similar patterns were evident with respect to Andrea’sgirlfriends, but not her boyfriend.

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

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

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

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

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Factors that lead to eating disorders in general and anorexia nervosa in particularinvolve a mixture of physical, psychological, and sociocultural variables. Thecauses of eating disorders may overlap with those for depression. Anorexia nervosaand depression are associated with changes in cortisol and the neurotransmittersserotonin and norepinephrine (Bailer & Kaye, 2003). A noteworthy finding inAndrea’s case was Mrs. Weston’s report that several of her relatives weredepressed.

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

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

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

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

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

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

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

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

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

Mrs. Weston also gave Andrea mixed messages:

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

What about Andrea? Her long-term outcome is probably good and almostcertainly better than most people with eating disorders. This is largely becauseshe received treatment relatively early in her disorder; many with anorexia orbulimia nervosa hide their behavior for several years before entering therapy.Andrea’s therapist was also experienced in treating eating disorders and utilizedcognitive-behavioral methods. Andrea’s eating disorder was also rather limitedin scope and her family, though problematic, was motivated to resolve theirdifficulties. Andrea’s level of depression was not clinical either and generallydissipated during individual and family therapy for her eating problems.


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

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

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

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

Hospitalization was not necessary for Andrea given her relatively moderate eatingproblem.

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

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

■ Developing rapport with the client■ Increasing motivation for behavior change■ Normalizing weight and eliminating binging and purging■ Modifying cognitive distortions about weight and body size■ Addressing other conditions such as depression

The psychologist spent considerable time developing a positive therapeuticrelationship with Andrea. Andrea felt isolated and sometimes distrustful ofothers so the therapist recognized her concerns and did not judge her behavior.The first 3 sessions concentrated on developing a positive working relationshipas well as education about proper eating habits. The psychologist and Andreadesigned a daily eating schedule that was largely fat-free but also nutritious.They agreed Andrea’s weight could fluctuate between 100 and 110 pounds,but no lower. Andrea also agreed to weigh herself before the psychologistduring each weekly visit. Andrea’s response to this treatment was rapid – sherigorously adhered to her new diet and did not lose more weight. Her

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motivation to address her binging, purging, and social and family problems alsoseemed to increase.

The tougher part of individual therapy is to eliminate binging and purgingand modify cognitive distortions about body size. A reduction in binging andpurging may occur if the behavior is out in the open and the person and thosearound her actively monitor the behavior. This was the case with Andrea, whobinged and vomited only 3 times since her parents became more aware of theproblem. A therapeutic method of eliminating binging and purging is to have aperson eat high-calorie foods in a therapist’s office and then prevent subsequentpurging (Carter, McIntosh, Joyce, Sullivan, & Bulik, 2003). This approach issimilar to one used for obsessive-compulsive symptoms and assumes a person’sanxiety will eventually decrease as she refrains from purging. The person realizesthe binge/purge cycle is unnecessary to reduce stress.

The psychologist outlined this therapy technique to Andrea, who agreed totry it. Andrea consumed a fair amount of ice cream, candy bars, and cupcakeswithin a half-hour and then waited. She could not use the bathroom and thepsychologist taught Andrea how to relax. The psychologist also reminded Andreathat self-induced vomiting is an ineffective way of negating a binge because thebody quickly absorbs many of the calories anyway. Andrea reported some anxietyfollowing this process, but was able to relax. She said she did not want to try itagain, however, out of fear of weight gain. She instead agreed to have her familymembers closely monitor her behavior for signs of binging and purging. Theyreported no such incidents over the next several weeks.

Individual therapy for people with eating disorders may also address cog-nitive distortions. Such distortions may involve food, weight, and body size aswell as themes of abandonment, loss of autonomy, and guilt (Cooper, 2005).The psychologist helped Andrea develop more realistic thoughts about con-sequences of weight gain and loss, her ideal and real body size, and isolationfrom others.

The psychologist explored the probable consequences of weight loss and gain.Andrea learned that her friends would not notice much or change their opinion ofher as her weight fluctuated slightly. Andrea also received feedback about the wayshe perceived her body and the effect her negative thoughts had on her socialrelationships. Andrea realized that her fears of abandonment by others led to herwithdrawal and even greater feelings of isolation. Andrea engaged in severalplanned outdoor activities with her friends to dispel these beliefs, increase hersocial interaction, and reduce her depression.

Family therapy is also an important treatment component for youths witheating disorders and focuses on developing cohesion, consistency, communi-cation, and conflict resolution (Eisler et al., 2005). Andrea’s therapist exploredenmeshed family patterns, concentrating especially on Mrs. Weston’s tendencyto overcontrol her daughter’s appearance and social life. Fortunately, Mrs.Weston was responsive to this and allowed Andrea substantial free time withher friends and boyfriend under certain conditions such as curfew. Andrea alsoagreed to eat dinner with her family at least 5 times per week and allow herparents to monitor her weight and possible binging and purging.

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The psychologist also addressed issues related to Andrea’s boyfriend, schoolperformance, and future educational status. Mr. and Mrs. Weston relayed theirconcerns about Andrea’s dating and Andrea admitted she saw her boyfriend in partto annoy her parents. Andrea did start dating other people as therapy progressed.Mr. and Mrs. Weston also encouraged Andrea to put more effort into her classes,which she did, and develop a plan for attending college.

Andrea and her family participated in therapy for 4 months. Andrea’s overallfunctioning was good following therapy. Some issues remained unresolved, suchas Andrea’s sexual activity. Her eating problems were no longer evident and hermood greatly improved since the beginning of therapy, however. The psycho-logist also thought the family developed improved insight into their dynamicsand their effects on one another. Family members were also more motivated towork together to solve future problems. Informal telephone contact with Andrea6 months later indicated no recurrence of eating problems or depression.


1. What distinguishes people with anorexia nervosa (the binge eating/purgingtype) from those with bulimia nervosa? Explore not just diagnostic criteria butalso social, family, and other variables.

2. Bulimia appears to be largely specific to Western societies. Why do you thinkthis is so? What societal changes could lead to less anorexia and bulimianervosa in the general population? What might be done to prevent thedisorders?

3. Eating disorders also appear to be largely specific to females. Why do youthink this is so? Give specific examples of messages from the media, familymembers, and peers that might promote this disorder in young women.

4. Do you feel your eating behavior is linked to your emotional state? How so?What changes in how you handle stress, if any, could lead to an improvementin your eating habits?

5. Devise a treatment plan for someone who wanted to lose weight responsibly.What foods, shopping and food preparation behaviors, eating times andplaces, activities during eating, and other variables would you focus on?

6. Would you say anything to someone who appeared dangerously under-weight? If so, what might you say to that person? What prejudgments wouldyou want to avoid?

7. What influence do you think Andrea’s boyfriend had on the developmentand maintenance of her eating problems? Would involving her boyfriend inthe therapy process be a good idea? Why or why not? If yes, how might youdo so?

8. What is the danger in placing someone treated for anorexia back with familymembers? What could be done to prevent a relapse in this situation?

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9. What could or would you do if a person were in danger of losing her life fromanorexia but refused treatment?

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