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Eating Disorders

Chapter 11

Slides & Handouts by Karen Clay Rhines, Ph.D.


American Public University System

Comer, Abnormal
Psychology, 8e
DSM-5 Update

Eating Disorders
It has not always done so, but Western society today
equates thinness with health and beauty
Thinness has become a national obsession

There has been a rise in eating disorders in the past


three decades
The core issue is a morbid fear of weight gain

Two main diagnoses:


Anorexia nervosa
Bulimia nervosa

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Eating Disorders
A third disorder binge eating disorder also
appears to be on the rise
Fear of weight gain is not to the same degree as
with anorexia or bulimia
People with this disorder display many of the
other features found in those disorders

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Anorexia Nervosa
The main symptoms of anorexia nervosa are:
A refusal to maintain more than 85% of normal
body weight
Intense fears of becoming overweight
Distorted view of weight and shape
Amenorrhea

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Anorexia Nervosa
There are two main subtypes:
Restricting type
Lose weight by cutting out sweets and fattening snacks, eventually
eliminating nearly all food
Show almost no variability in diet

Binge-eating/purging type
Lose weight by forcing themselves to vomit after meals or by
abusing laxatives or diuretics
Like those with bulimia nervosa, people with this subtype may
engage in eating binges

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Anorexia Nervosa
About 90%95% of cases occur in females
The peak age of onset is between 14 and 18 years
Between 0.5% and 3.5% of females in Western
countries develop the disorder
Many more display at least some symptoms

Rates of anorexia nervosa are increasing in North


America, Europe, and Japan

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Anorexia Nervosa
The typical case:
A normal to slightly overweight female has been on a diet
Escalation toward anorexia nervosa may follow a stressful
event
Separation of parents
Move away from home
Experience of personal failure

Most patients recover


However, about 2% to 6% become seriously ill and die as a result
of medical complications or suicide

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Anorexia Nervosa:
The Clinical Picture
The key goal for people with anorexia nervosa
is becoming thin
The driving motivation is fear:
Of becoming obese
Of giving in to the desire to eat
Of losing control of body size and shape

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Anorexia Nervosa:
The Clinical Picture
Despite their dietary restrictions, people with
anorexia nervosa are preoccupied with food
This includes thinking and reading about food and
planning for meals
This relationship is not necessarily causal
It may be the result of food deprivation, as evidenced
by the famous 1940s starvation study with
conscientious objectors

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Anorexia Nervosa:
The Clinical Picture
Persons with anorexia nervosa also think in
distorted ways:
Usually have a low opinion of their body shape
Tend to overestimate their actual proportions
Assessed using an adjustable lens technique

Hold maladaptive attitudes and misperceptions


I must be perfect in every way
I will be a better person if I deprive myself
I can avoid guilt by not eating

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Anorexia Nervosa:
The Clinical Picture
People with anorexia nervosa also display certain
psychological problems:

Depression
Anxiety
Low self-esteem
Insomnia or other sleep disturbances
Substance abuse
Obsessive-compulsive patterns
Perfectionism

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Anorexia Nervosa:
Medical Problems
Caused by starvation:

Amenorrhea
Low body temperature
Low blood pressure
Body swelling
Reduced bone density

Slow heart rate


Metabolic and
electrolyte imbalances
Dry skin, brittle nails
Poor circulation
Lanugo

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Bulimia Nervosa
Bulimia nervosa, also known as binge-purge
syndrome, is characterized by binges:
Repeated bouts of uncontrolled overeating during
a limited period of time
Eat objectively more than most people would/could eat
in a similar period

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Bulimia Nervosa
The disorder is also characterized by
inappropriate compensatory behaviors,
including:
Forced vomiting
Misusing laxatives, diuretics, or enemas
Fasting
Exercising excessively

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Bulimia Nervosa
Like anorexia nervosa, about 90%95% of
bulimia nervosa cases occur in females
The peak age of onset is between 15 and 21
years
Symptoms may last for several years with
periodic letup

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Bulimia Nervosa
Patients are generally of normal weight
Often experience marked weight fluctuations
Some may also qualify for a diagnosis of anorexia

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Bulimia Nervosa
Many teenagers and young adults go on
occasional binges or experiment with vomiting or
laxatives after hearing about these behaviors
from friends or the media
According to global studies, 25-50% of students
report periodic binge-eating or self-induced
vomiting
Only some of these individuals qualify for a diagnosis
of bulimia nervosa

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Bulimia Nervosa: Binges


People with bulimia nervosa may have
between 1 and 30 binge episodes per week
Binges are often carried out in secret
Binges involve eating massive amounts of food
very rapidly with little chewing
Usually sweet, high-calorie foods with soft texture

Binge-eaters commonly consume between as


many as 10,000 calories per binge episode
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Bulimia Nervosa: Binges


Binges are usually preceded by feelings of
great tension
Although the binge itself may be pleasurable,
it is usually followed by feelings of extreme
self-blame, guilt, depression, and fears of
weight gain and being discovered

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Bulimia Nervosa:
Compensatory Behaviors
After a binge, people with bulimia nervosa try
to compensate for and undo the caloric
effects
Many resort to vomiting
Fails to prevent the absorption of half the calories
consumed during a binge
Repeated vomiting affects the ability to feel satiated
greater hunger and bingeing

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Bulimia Nervosa:
Compensatory Behaviors
Compensatory behaviors may temporarily
relieve the negative feelings attached to binge
eating
Over time, however, a cycle develops in which
purging bingeing purging

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Bulimia Nervosa
The typical case:
A normal to slightly overweight female has been
on an intense diet
Research suggests that even among normal
participants, bingeing often occurs after strict
dieting

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Bulimia Nervosa vs.


Anorexia Nervosa
Similarities:

Begin after a period of dieting


Fear of becoming obese
Drive to become thin
Preoccupation with food, weight, appearance
Feelings of anxiety, depression, obsessiveness, perfectionism
Heighted risk of suicide attempts
Substance abuse
Distorted body perception
Disturbed attitudes toward eating

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Bulimia Nervosa vs.


Anorexia Nervosa
Differences:
People with bulimia nervosa are more concerned
about pleasing others, being attractive to others, and
having intimate relationships
People with bulimia nervosa tend to be more sexually
experienced and active
People with bulimia nervosa are more likely to have
histories of mood swings, low frustration tolerance,
and poor coping

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Bulimia Nervosa vs.


Anorexia Nervosa
Differences:
More than one-third of people with bulimia display
characteristics of a personality disorder, particularly
borderline personality disorder
Different medical complications:
Only half of women with bulimia nervosa experience
amenorrhea vs. almost all women with anorexia nervosa
People with bulimia nervosa suffer damage caused by
purging, especially from vomiting and laxatives

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Binge Eating Disorder


Like those with bulimia, individuals with binge eating
disorder engage in repeated eating binges during which
they feel no control
These individuals do not perform inappropriate
compensatory behaviors

As a result of their binges, two-thirds of people with


this disorder become overweight or obese
It is important to recognize, however, that most
overweight people do not engage in repeated binges

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Binge Eating Disorder


Between 2 and 7% of the population display
binge eating disorder
The binges and many other symptoms that
characterize this pattern are similar to those seen
in bulimia
On the other hand, those with binge eating
disorder are not driven to thinness, the disorder
doesnt start following a diet, and there are not
large gender differences in the prevalence of this
disorder
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What Causes Eating Disorders?


Most theorists and researchers use a
multidimensional risk perspective to explain
eating disorders:
Several key factors place individuals at risk
More factors = greater likelihood of developing a
disorder
Leading factors:
Psychological problems
Biological factors
Sociocultural conditions

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What Causes Eating Disorders?


Psychodynamic Factors: Ego Deficiencies
Hilde Bruch developed a largely
psychodynamic theory of eating disorders
Bruch argued that eating disorders are the
result of disturbed motherchild interactions,
which lead to serious ego deficiencies in the
child and to severe perceptual disturbances

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What Causes Eating Disorders?


Psychodynamic Factors: Ego Deficiencies
Bruch argues that parents may respond to their
children either effectively or ineffectively
Effective parents accurately attend to a childs biological
and emotional needs
Ineffective parents fail to attend to childs needs; they feed
when the child is anxious, comfort when the child is tired,
etc.
Such children may grow up confused and unaware of their own
internal needs and turn, instead, to external guides

Clinical reports and research have provided some


empirical support for this theory
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What Causes Eating Disorders?


Cognitive Factors
Bruchs theory also contains several cognitive
factors, like improper labeling of internal
sensations and needs
According to cognitive theorists, these deficiencies
contribute to a broad cognitive distortion that lies
at the center of disordered eating (e.g., negative
self-judgment based on body shape and weight)

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What Causes Eating Disorders?


Depression
Many people with eating disorders,
particularly those with bulimia nervosa,
experience symptoms of depression
Theorists believe depressive disorders may set
the stage for eating disorders

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What Causes Eating Disorders?


Depression
There is empirical support for the claim that mood
disorders set the stage for eating disorders:
Many more people with an eating disorder qualify for a
clinical diagnosis of major depressive disorder than do
people in the general population
Close relatives of those with eating disorders seem to have
higher rates of depressive disorders
People with eating disorders, especially those with bulimia
nervosa, have serotonin abnormalities
Symptoms of eating disorders are helped by
antidepressant medications

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What Causes Eating Disorders?


Biological Factors
Biological theorists suspect certain genes may leave
some people particularly susceptible to eating
disorders
Consistent with this idea:
Relatives of people with eating disorders are up to 6 times more
likely to develop the disorder themselves
Identical (MZ) twins with anorexia: 70%
Fraternal (DZ) twins with anorexia: 20%
Identical (MZ) twins with bulimia: 23%
Fraternal (DZ) twins with bulimia: 9%

These findings may be related to low serotonin

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What Causes Eating Disorders?


Biological Factors
Other theorists believe that eating disorders
may be related to dysfunction of the
hypothalamus
Researchers have identified two separate areas
that control eating:
Lateral hypothalamus (LH)
Ventromedial hypothalamus (VMH)

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What Causes Eating Disorders?


Biological Factors
Some theorists believe that the hypothalamus, related
brain areas, and chemicals together are responsible for
weight set point a weight thermostat of sorts
Set by genetic inheritance and early eating practices, this
mechanism is responsible for keeping an individual at a
particular weight level
If weight falls below set point: hunger, metabolic rate
binges
If weight rises above set point: hunger, metabolic rate

Dieters end up in a battle against themselves to lose


weight

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What Causes Eating Disorders?


Societal Pressures
Many theorists believe that current Western
standards of female attractiveness are partly
responsible for the emergence of eating disorders
Western standards have changed throughout history
toward a thinner ideal
Miss America contestants have declined in weight by 0.28
lbs/yr; winners have declined by 0.37 lbs/yr
Playboy centerfolds have lower average weight, bust, and
hip measurements than in the past

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What Causes Eating Disorders?


Societal Pressures
Members of certain subcultures are at greater
risk from these pressures:
Models, actors, dancers, and certain athletes
Of college athletes surveyed, 9% met full criteria for an
eating disorder while another 50% had symptoms
20% of surveyed gymnasts appear to have an eating
disorder

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What Causes Eating Disorders?


Societal Pressures
Societal attitudes may explain economic and
racial differences seen in prevalence rates
Historically, women of higher SES expressed more
concern about thinness and dieting
These women had higher rates of eating disorders than
women of the lower socioeconomic classes

Recently, dieting and preoccupation with thinness,


along with rates of eating disorders, are increasing in
all groups

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What Causes Eating Disorders?


Societal Pressures
The socially accepted prejudice against
overweight people may also add to the fear
and preoccupation about weight
About 50% of elementary and 61% of middle
school girls are currently dieting
A recent survey of adolescent girls tied eating
disorders and body dissatisfaction to social
networking, Internet activities, and television
browsing

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What Causes Eating Disorders?


Family Environment
Families may play an important role in the
development of eating disorders
As many as half of the families of those with
eating disorders have a long history of
emphasizing thinness, appearance, and dieting
Mothers of those with eating disorders are more
likely to be dieters and perfectionistic themselves

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What Causes Eating Disorders?


Family Environment
Abnormal interactions and forms of
communication within a family may also set
the stage for an eating disorder
Influential family theorist Salvador Minuchin cites
enmeshed family patterns as causal factors of
eating disorders
These patterns include overinvolvement in, and
overconcern about, family members lives

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What Causes Eating Disorders?


Multicultural Factors:
Racial and Ethnic Differences
A widely publicized 1995 study found that eating
behaviors and attitudes of young African
American women were more positive than those
of young white American women
Specifically, nearly 90% of the white American
respondents were dissatisfied with their weight and
body shape, compared to around 70% of the African
American teens
The study also suggested that the groups had different
ideals of beauty
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What Causes Eating Disorders?


Multicultural Factors:
Racial and Ethnic Differences

Unfortunately, research conducted over the


past decade suggests that body image
concerns, dysfunctional eating patterns, and
eating disorders are on the rise among young
African American women as well as among
women of other minority groups
The shift appears to be partly related to
acculturation
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What Causes Eating Disorders?


Multicultural Factors:
Racial and Ethnic Differences

Eating disorders among Hispanic American


female adolescents are about equal to those
of white American women
Eating disorders also appear to be on the
increase among Asian American women and
young women in several Asian countries

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What Causes Eating Disorders?


Multicultural Factors:
Gender Differences
Males account for only 5% to 10% of all cases of
eating disorders
The reasons for this striking difference are not
entirely clear, but Western societys double
standard for attractiveness is, at the very least,
one reason
A second reason may be the different methods of
weight loss favored:
Men are more likely to exercise
Women more often diet

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What Causes Eating Disorders?


Multicultural Factors:
Gender Differences
It seems that some men develop eating disorders
as linked to the requirements and pressures of a
job or sport
The highest rates of male eating disorders have been
found among:

Jockeys
Wrestlers
Distance runners
Body builders
Swimmers

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What Causes Eating Disorders?


Multicultural Factors:
Gender Differences

For other men, body image appears to be a


key factor
Last, some men seem to be caught up in a
new kind of eating disorder reverse anorexia
nervosa or muscle dysmorphobia

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How Are Eating Disorders Treated?


Eating disorder treatments have two main
goals:
Correct dangerous eating patterns
Address broader psychological and situational
factors that have led to, and are maintaining, the
eating problem
This often requires the participation of family and
friends

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Treatments for
Anorexia Nervosa
The immediate aims of treatment for anorexia
nervosa are to:
Regain lost weight
Recover from malnourishment
Eat normally again

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Treatments for
Anorexia Nervosa
In the past, treatment took place in a hospital setting;
it is now often offered in day hospitals or outpatient
settings
In life-threatening cases, clinicians may need to force
tube and intravenous feedings on the patient
This may breed distrust in the patient and create a power
struggle
In contrast, behavioral weight-restoration approaches have
clinicians use rewards whenever patients eat properly or
gain weight

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Treatments for
Anorexia Nervosa
The most popular weight-restoration technique
has been the combination of supportive nursing
care, nutritional counseling, and high-calorie
diets
Necessary weight gain is often achieved in 8 to 12
weeks

Researchers have found that people with


anorexia nervosa must overcome their underlying
psychological problems to achieve lasting
improvement

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Treatments for
Anorexia Nervosa
Therapists use a combination of therapy and
education to achieve this broader goal, using a
combination of individual, group, and family
approaches; psychotropic drugs have been
helpful in some cases

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Treatments for
Anorexia Nervosa
In most treatment programs, a combination of
behavioral and cognitive interventions are
included
On the behavioral side, clients are required to
monitor feelings, hunger levels, and food intake
and the ties among those variables
On the cognitive sides, they are taught to identify
their core pathology

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Treatments for
Anorexia Nervosa
Therapists help patients recognize their need for
independence and control
Therapists help patients recognize and trust their
internal feelings
A final focus of treatment is helping clients
change their attitudes about eating and weight
Using cognitive approaches, therapists correct
disturbed cognitions and educate about body
distortions

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Treatments for
Anorexia Nervosa
Family therapy is important for anorexia
nervosa treatment
The main issues are often separation and
boundaries

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Treatments for
Anorexia Nervosa
The use of combined treatment approaches
has greatly improved the outlook for people
with anorexia nervosa
But even with combined treatment, recovery is
difficult

The course and outcome of the disorder vary


from person to person

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Treatments for
Anorexia Nervosa
Positives of treatment:
Weight gain is often quickly restored
As many as 90% of patients still showed improvements
after several years

Menstruation often returns with return to normal


weight
The death rate from anorexia nervosa seems to be
falling

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Treatments for
Anorexia Nervosa
Negatives of treatment:
As many as 25% of patients remain troubled for years
Even when it occurs, recovery is not always
permanent
Anorexic behavior recurs in at least one-third of recovered
patients, usually triggered by new stresses
Many patients still express concerns about their weight and
appearance

Lingering emotional problems are common

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Treatments for
Bulimia Nervosa
Treatment is frequently offered in eating disorder
clinics
The immediate aims of treatment for bulimia
nervosa are to:
Eliminate binge-purge patterns
Establish good eating habits
Eliminate the underlying cause of bulimic patterns

Programs emphasize education as much as


therapy

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Treatments for
Bulimia Nervosa
Cognitive-behavioral therapy is particularly
helpful:
Behavioral techniques
Diaries are often a useful component of treatment
Exposure and response prevention (ERP) is used to
break the binge-purge cycle

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Treatments for
Bulimia Nervosa
Cognitive-behavioral therapy is particularly
helpful:
Cognitive techniques
Help clients recognize and change their maladaptive
attitudes toward food, eating, weight, and shape
Typically teach individuals to identify and challenge the
negative thoughts that precede the urge to binge

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Treatments for
Bulimia Nervosa
Other forms of psychotherapy
If clients do not respond to cognitive-behavioral
therapy, other approaches may be tried
A common alternative is interpersonal therapy
(IPT); a treatment that seeks to improve
interpersonal functioning may be tried
Psychodynamic therapy has also been used

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Treatments for
Bulimia Nervosa
Other forms of psychotherapy
Various forms of psychotherapy are often
supplemented by family therapy and may be
offered in either individual or group therapy
format
Group formats provide an opportunity for patients to
express their thoughts, concerns, and experiences with
one another
Group therapy is helpful in as many as 75% of cases

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Treatments for
Bulimia Nervosa
Antidepressant medications
During the past 15 years, all groups of
antidepressant drugs have been used in bulimia
nervosa treatment
Drugs help as many as 40% of patients

Medications are best when used in combination


with other forms of therapy

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Treatments for
Bulimia Nervosa
Left untreated, bulimia nervosa can last for
years
Treatment provides immediate, significant
improvement in about 40% of cases
An additional 40% show moderate response

Follow-up studies suggest that 10 years after


treatment about 75% of patients have fully or
partially recovered
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Treatments for
Bulimia Nervosa
Relapse can be a significant problem, even among
those who respond successfully to treatment
Relapses are usually triggered by stress
Relapses are more likely among persons who:

Had a longer history of symptoms


Vomited frequently
Had histories of substance use
Have lingering interpersonal problems

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Treatments for Binge Eating


Disorder
Given the key role of binges in both bulimia and
binge eating disorder, treatments, too, are often
similar
Cognitive-behavior therapy, other forms of
psychotherapy, and, in some cases, antidepressant
medications are provided to reduce or eliminate binge
patterns and to change disturbed thinking

People with binge eating disorder who are


overweight require additional intervention
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Treatments for Binge Eating


Disorder
Now that binge eating disorder has been
identified and is receiving considerable study,
it is likely that specialized treatment programs
will be emerging
In the meantime, little is known about the
aftermath of the disorder

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