1. Anorexia Nervosa (AN) Drive for Thinness, intense fear of gaining weight >= 15% below expected weight Body image distortion (feel fat) Preoccupation with food Amenorrhea (>=3 cycles) Many anorexics also binge (they feel starved) These tend to be less introverted, more impulsive, than the non-binge anorexics)

2. Bulimia Nervosa (BN) Recurrent episodes of binge eating (at least twice a week for 3 months) Feel a loss of control during binge Binge on high-caloric foods (i.e. not carrots) Usually perceive binges as shameful, keep them secretive Typically engage in purging—vomiting, laxatives, diuretics; also, intense exercise or dieting is common Preoccupied with body shape and weight

3. Prevalence of AN and BN Increased prevalence in past half-century, with biggest increases in younger women (ages 15-24), ethnic minority groups (although still most predominant in Whites) Prevalence for Anorexia ages 15-24 (AN): 14.6 females/100,000 (approx 1%), 1.8 males/100,000 Rates for Bulimia (BN) higher, roughly 2% of female teens (5x as many females as males) AN & BN rare in non-Western countries

4. Subclinical Problems Approximately 40-60% of h.s. girls diet to lose weight. Approximately 10-15% ‘purge’ or compensate for eating by vomiting, laxatives, diuretics, or use dieting pills

5. Precursors In early childhood: picky eaters, digestive problems predict later anorexia Pica, conflict regarding eating predict bulimia. In school age children: Approx 1/3 of those with later eating disorders try to lose weight, and many of those children have distortions in body image (see themselves as fat).

6. Precursors, c’t’d Early adolescence: Disliking one’s body during pubertal development Mood swings, and problems regulating (coping with) moods, especially in BN Inhibited, overcontrolled personality (AN) Difficult communication with parents (although research findings are inconsistent): High conflict associated with BN Enmeshed/overprotected, overcontrolled in AN Parents who are preoccupied with diets

7. Other risk factors Other factors: Media and cultural over-emphasis on thinness in women History of sexual abuse (esp for BN) Heritability – modest

8. Treatment of Anorexia First, weight gain (in consultation with nutritionist) Hospitalization (brief) may be necessary for weight gain, other health concerns Family therapy – best results Family insists on weight gain in supportive way, mutual communication and problem-solving Medication – especially if depressed Individual therapy: cognitive-behavioral, as well as other modalities, more widely studied in adults than adolescents.

9. Cognitive-Behavioral Therapy Focus on ‘cognitive errors’, e.g. Selective abstraction (over-focusing on one aspect): “I cannot eat any carbohydrates, or I will become obese” Magnification: “I’ve gained 2 pounds, so now I look so horrible I cannot wear a pair of shorts anymore” Dichotomous (black/white) thought: “If I am not in complete control, I lose all control”; “If I cannot master being thin, my whole life will be a failure”. Superstitious thought: “If I eat a sweet, it is instantly converted to fat on my stomach”. Personalization: “I know I look horrible, and you are looking at me, thinking how horrible I look”

10. Treatment of Cognitive Errors Have adolescent state their beliefs out loud Decentering: Ask if she is as aware of others as she thinks others are of her Question the “shoulds” Decatastrophizing: Questioning what would happen if the feared event were to occur Reattribution: point out that these are automatic, re- occurring thoughts, and they cannot be trusted Challenge cultural drive for ‘thinness’ Teach self-soothing Assertiveness training