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234 Chapter 12 Depressive Disorders, Bipolar Disorders, and Suicidality
Box 12.2 Clinical Perspectives
Self-Harm in Adolescence and Emerging Adulthood
Nonsuicidal self-injury (NSSI), also called self-harm or selfinjurious behavior, is the deliberate, self-inflicted destruction
of body tissue, outside of cultural norms, and without
suicidal intent (Cha & Nock, 2014; Oppenheimer et al.,
2022). Self-injurious behaviors include cutting, scratching,
and burning. Broadly conceived, NSSI is conceptualized as a
compensatory strategy for regulating intense emotional states
and a maladaptive coping skill displayed in response to stress.
NSSI likely serves a variety of psychological functions, such as
reducing or blocking painful emotions. Research and clinical
attention is often focused on the immediate relief experienced
by youth who engage in NSSI (Cha & Nock, 2014).
Although incidence rates vary considerably, NSSI is a
surprisingly common clinical problem. NSSI typically begins
between 12 and 15 years of age and peaks in late adolescence
and early adulthood (Buelens et al., 2019). Individuals d iagnosed
with anxiety and depressive disorders, bipolar disorders,
dissociative disorders, eating disorders, ADHD, and individuals
with histories of maltreatment exhibit higher rates of NSSI
(Crowell & Kaufman, 2016; Hinshaw et al., 2021; Vaughn et
al., 2015). LGBTQ+, nonbinary, and other gender-diverse
individuals are at much higher risk (Cummings et al., 2021).
Girls are disproportionately affected (Beauchaine et al., 2019).
Multiple interacting factors contribute to NSSI pathways,
including genetics, psychological characteristics, sociocultural
influences, and environmental events. Emotion dysregulation,
impulsivity, and rumination have significant impacts on the
emergence and maintenance of NSSI, involving ongoing
cascades of distress and maladaptive emotion dysregulation
(Beauchaine et al., 2019; Buelens et al., 2019; Selby et al.,
2016). Child maltreatment and experiences of trauma are
powerful risk factors (Brown et al., 2018; Vaughn et al., 2015;
Yates, 2009). Suicidal ideation sometimes accompanies NSSI,
and NSSI sometimes precedes suicidal planning and attempts
(Oppenheimer et al., 2022).
NSSI is often discussed in the context of self and identity.
Researchers have hypothesized that NSSI may counteract
identify confusion and distress in some youth while also
connecting them with others who also engage in NSSI (Glenn
et al., 2016; Verschueren et al., 2020). It is important to note
that the most common methods of NSSI leave scars, and the
consequences of scarring for self-image and others’ perceptions
and/or judgments are often difficult for youth to manage
(Buelens et al., 2019).
The appearance of NSSI in early to middle adolescence is
often tied to developmental transitions that involve increased
sensitivity to socioaffective pain and reward. Socioaffective
pain is the result of “affective experiences associated with
social rejection, social exclusion, and other forms of noninclusion in adolescence (e.g., the sting of social rejection,
heartache, hurt feelings)” (Cummings et al., 2021). Across
typically developing and atypically developing youth, brainbehavior processes are associated with increases in the
frequency and intensity of socioaffective pain. In addition,
amplified reward sensitivity contributes to NSSI persistence
(with decreases in distressing emotion following NSSI
experienced by many as a rewarding behavior). NSSI often
declines after early adulthood. It is possible that other agerelated events occur that influence the intense distress
experienced by individuals who exhibit NSSI or that other
maladaptive behaviors such as substance use take the place of
NSSI to manage distress (Oppenheimer et al., 2022).
The dynamics of the pain experience during NSSI are
complex. Several pain processes have been described (Selby
et al., 2019). The pain analgesia effect involves little to no pain
during NSSI episodes. The pain onset effect involves eliciting
physical pain to distract from intense emotion or unpleasant
thoug hts. The pain of fset effec t involves relief (and reinforcement)
when pain subsides following NSSI. Research suggests that
pain experiences vary by individual and episodes of NSSI
(Kranzler et al., 2020; Selby et al., 2019).
In recognition of how widespread and varied the clinical
presentation of NSSI is, therapeutic approaches are becoming
more targeted and differentiated. One of the most meaningful
prevention priorities is decreasing maltreatment and
psychological disorders that increase the risk of self-harm
(Beauchaine et al., 2019). More specific prevention programs
are aimed at preadolescent girls and focus on developing skills
to manage intense emotion and emotion dysregulation. Other
programs focus on decreasing peer rejection and social
difficulties and on helping parents, teachers, and peers identify
and support youth who display NSSI (Beauchaine et al., 2019).
Psychological factors are among the most frequently
investigated. As noted in the genetics information, youth
psychopathology is a significant risk factor. Both internalizing
and externalizing disorders increase the likelihood of suicidality,
including depressive disorders, bipolar disorders, anxiety
disorders, ADHD, conduct disorders, and substance use
disorders (Derbidge & Beauchaine, 2014; Meza et al., 2020).
Factors related to identity, self-image, and self-esteem are
also noteworthy contributors to increased risk, particularly with
respect to a lack of self-efficacy and hopelessness. Hopelessness
is significant both for the development and maintenance of
suicidality. Shame and guilt, as well as a sense of being a burden
to others, often exacerbate hopelessness ( Liu et al., 2021). To
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
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the extent that adolescents cannot envision their own conti nuity
through time, or that they believe that their continued existence
will involve unremitting psychological pain, extreme decisions
may be made. Adolescents’ inability to communicate their
ongoing struggles and their deeply felt pain, combined with
hesitation about seeking help from others, further complicates
difficult situations (Derbidge & Beauchaine, 2014).
Peer factors are al so important. Adolescents are incre asingly
embedded in social networks that provide a range of positive
and negative experiences. Social skills deficits, problematic
peer relationships, and romantic breakups increase suicidality
risk (Van Meter et al., 2019; Xiao & Lindsey, 2021). In
addition, adolescents who turn to peers during crises may
Suicidality 235
atypical active suicidal ideation. Principle 2 depicts how expression of SITBs and risk factors may change depending on developmental
Principle 4 depicts how there are multiple possible prevention and intervention points leading up to more severe forms of SITBs. These
principles are presented separately but operate in concert with one another.
not always receive appropriate help. Peers may misperceive
intent or misjudge lethality. Even when a friend is clearly
struggling, peers do not always try to connect with a friend’s
parents, teachers, or mental health professionals.
Other environmental, familial, and sociocultura l contexts
may also increase risk. Negative life events, such as trauma,
loss, maltreatment, or failing academic performance, may
require immed iate attention. Poverty, racism, discri mination,
and other sociocultural adversities all likely contribute to
increased risk (Derbridge & Beauchaine, 2014; Hatchel
et al., 2021; Robinson et al., 2022). Access to lethal means
is a preventable risk factor. Overall, the accumulation of
multiple risk factors and adverse experiences predicts youth
suicidality (Oppenheimer et al., 2022; Ruch et al., 2021).
The presence of suicidal models must also be considered.
Models of SITBs and/or parasuicidal behavior may include
close relatives, a peer, or a celebrity. The role of the media
in presenting information on suicide, particularly when
news reports include details about specific individuals or
methods, requires scrutiny (Shoval et al., 2005; Stack,
2005). Peer contagion and the fact that “impulsive and
dysregulated individuals are likely to affiliate with deviant
peer groups” make social reinforcement of SITBs important
to counteract (Derbridge & Beauchaine, 2014). Changes in
the accessibility of suicide information on the internet and
(in some cases) support for suicidal behavior is a real concern
(Biddle et al., 2016).
Previous suicidal behavior is a strong predictor of future
suicidality (Derbidge & Beauchaine, 2014; Oppenheimer et
al., 2022). Past behavior appears to habituate individuals to the
fear and pain of self-injury and underlies Joiner’s (2002, 2005)
interpersonal–psychological theory of suicidality. The
theory proposes two general categories of risk: dysregulated
impulse control and intense psychological pain. The idea is
that adolescents “gradually acquire the ability to enact lethal
self-injury through prior experience with self-injury (which
in turn is encouraged by impulsive behavior underlain by
serotonergic dysregulation)” (Joiner et al., 2005, p. 305). In
other words, in the context of adolescent impulsivity and
psychological anguish, self-destructive behavior may escalate
over time, culminating in suicide.
Several principles of the developmental psychopathology
framework provide important perspectives on youth
suicidality (Oppenheimer et al., 2022; refer to Figure 12.8).
Figure 12.8 Four principles of developmental psychopathology help to focus research and clinical
work related to self-injurious thoughts and behaviors
Principle 1: All Behavior Ranges from Typical to Atypical Principle 2: Changes Across Development
Active
suicidal
Few
ideation
Passive suicidal
ideation
Preoccupation with death
Many
Death related thoughts
Principle 3: Movement of SITBs Across Development
NSSI
Suicidal Ideation
Suicidal Behavior
Hypothetical within-person trajectory showing progressively
Incidence Time Established link
more severe SITBs
Changes in expressions of SITBs
Wishing not to be here Wishing was never born Active thoughts of killing self
Changes in risk factors
Exposure to family
conicts
Early childhood Preteen Adolescence
Principle 4: Early Intervention and Prevention
Suicidal Ideation Emerges
Potential
Intervention
Points
Bullying & social
isolation
NSSI
Suicidal Ideation
NSSI
Relational victimisation &
strained parent-adolescent
relationships
Suicidal Ideation
Suicidal Behavior
Four key principles of developmental psychopathology that can guide future directions in research on self-injurious thoughts
and behaviors (SITBs) in youth. Principle 1 depicts a hypothetical example of a continuum from typical death related thoughts to
stage. Principle 3 provides a hypothetical example of an individual’s nonlinear, dynamic shifts in SITBs across time in development.
Source: Oppenheimer et al. (2022). Future directions in suicide and self-injury revisited: Integrating a developmental psychopathology perspective.
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236 Chapter 12 Depressive Disorders, Bipolar Disorders, and Suicidality
First, there is a continuum of typical to atypical behaviors.
We need to better understand SITBs across development
in clinical and nonclinical samples of youth. Second,
youth display SITBs in developmental and environmental
contexts. We need to improve understanding of the risk and
protective factors across time and also investigate patterns
of risk and resilience in youth of varied backgrounds and
circumstances. Third, individual trajectories of suicidality
must be examined with attention paid to transition periods
where risk may increase or intervention may be especially
useful. Finally, the importance of early intervention and
prevention efforts cannot be overstated (Oppenheimer
et al., 2022).
Reducing adolescent suicidality involves multiple,
coordinated efforts designed to identify at-risk individuals
so that (1) suicide attempts and deaths decline in frequency,
and (2) youth who do attempt suicide receive immediate
and ongoing treatment. With respect to prevention,
school-based education programs and staff training often
focus on risk factors, coping skills, youth support, and
early referrals. Decreasing help-seeking stigma is also
important (Asarnow & Miranda, 2014; Oppenheimer
et al., 2022).
Dialectical behavior therapy for adolescents is an
evidence-based treatment with significant support. Social
skills training, cognitive behavior therapy, and family
centered approaches are also empirically supported
treatments (Glenn et al., 2019; Oppenheimer et al., 2022).
The focus of these interventions is often stress management,
distress tolerance, coping skills, and resilience training.
Interventions also involve the treatment of disorders
associated with suicidality (Glenn et al., 2019; Khan &
Ungar, 2021).
Informational campaigns that raise adult and youth
awareness are also essential and may include lists of behaviors
that increase adolescent risk (refer to Table 12.4). Projects
designed to scale up effective programs and to address the
individual, family, and sociocultural factors that limit access
to mental health services are critical components of any
Table 12.4 Warning Signs of Suicidality
●
Stressful life event or loss
●
Withdrawal from friends, family, and regular
activities
●
Violent actions, rebellious behavior, or running
away
●
Drug and alcohol use
●
Unusual neglect of personal appearance
●
Marked personality change
●
Changes related to psychological distress or
dysfunction
●
Loss of interest in pleasurable activities
●
Easy access to lethal methods
●
Exposure to suicidality of others
Adapted from the American Academy of Child and Adolescent Psychiatry
(2000) and the Centers for Disease Control and Prevention (2020).
prevention planning (Asarnow & Miranda, 2014; Glenn et
al., 2019). These types of resources are absolutely necessary,
given that many studies report rates of up to 50 percent for
suicide-related fatalities on a first attempt (Joiner, Conwell
et al., 2005).
Emergency management plans for adolescents who do
attempt suicide are a priority. Inpatient admission is an
option that should be considered. Successful outpatient
treatments that bridge the crisis and recovery stages have
been documented for both physiological and psychosocial
therapies (Asarnow & Miranda, 2014). Lack of long-term
treatment plans and noncompliance with treatment plans
are problems that seriously hinder positive outcomes.
Adolescents who repeatedly attempt suicide require even
more aggressive care. Compared to those who attempt suicide
only once, those who attempt more than once experience
more anger, depression, and emotional dysregulation. These
symptoms must be specifically targeted in treatment plans
(Asarnow & Miranda, 2014).
Key Terms
Major depressive disorder (218)
Persistent depressive disorder (219)
Disruptive mood dysregulation disorder (219)
Gender dysphoria (222)
Bipolar disorder (222)
Mania (222)
Hypomania (223)
Rumination (227)
Reinforcement model (228)
Negative life events (229)
Chronic hassles (229)
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Cognitive-behavioral therapies (232)
Interpersonal therapies (232)
Suicidal ideation (233)
Parasuicide (233)
Nonsuicidal self-injury (NSSI)/self-harm (233)
Self-injurious thoughts and behaviors (SITBs) (233)
Suicide (233)
Suicidality (233)
Interpersonal–psychological theory
of suicidality (235)
Chapter Summary
Suicidality 237
●
Depression in children and adolescents is a frequent
phenomenon, can have long-term consequences, and is
generally underrecognized and undertreated.
●
The transition from childhood to adolescence is marked
by the development of a coherent psychological identity
that includes a sense of competence and self-esteem.
These are among the core domains adversely affected by
child and adolescent depression.
●
Major depressive disorder in childhood and adolescence
is characterized by sadness and loss of pleasure and is
accompanied by cognitive, behavioral, and somatic
symptoms.
●
Persistent depressive disorder is a long-standing
disturbance of mood and places the child or teen
at significantly greater risk for developing major
depression.
●
Disruptive mood dysregulation disorder involves
developmentally atypical and severe temper tantrums
and chronic negative mood and irritability.
●
In children, depression often manife sts itself in a depressed
appearance, somatic complaints, anxiety symptoms, and
externalizing behaviors. In adolescents, hopelessness,
substance abuse, suicidality, and other serious symptoms
are more common.
●
Before adolescence, the rate of depressive disorders is
generally the same for boys and girls. Beginning in
adolescence, however, the rate of depression is much
greater for girls.
●
Higher rates of depression are also observed for youth
experiencing multiple adversities, including LGBTQ+,
nonbinary, and other gender-diverse individuals.
●
Bipolar disorders are severe forms of mood disorder
involving alternating periods of depression and mania.
The clinical presentation of bipolar disorders in
adolescence is mostly similar to the clinical presentation
of bipolar disorders in adults.
●
There is significant developmental continuity of
depressive disorders occurring in childhood, through
adolescence, and into adulthood.
●
A mix of genetic, physiological, psychological, parentrelated, and sociocultural risk factors contribute to the
development of depressive disorders.
●
The genetic impact on the development of depressive
disorders increases as children get older, most likely due
to gene-by-environment-by-time processes.
●
Parent depression is an especially important risk factor
for the development of depression in childhood.
●
Many children and adolescents with major depression
have other psychopathologies as well, including both
internalizing and externalizing disorders.
●
Research suggests that the combination of cognitivebehavioral therapy and medication is generally the most
effective intervention approach in the treatment of more
severe mood disorders in childhood and adolescence.
●
Suicidality is a complex phenomenon in youth. Increased
rates require intervention and prevention efforts.
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13
Eating Disorders
Chapter Outline
Developmental Tasks and Challenges
Related to Eating and Appearance 239
Eating Disorders 240
The Case of Elizabeth
The Case of Sierra
The Case of Kenji
Developmental Course 245
Etiology 246
Genes and Heredity
Learning Objectives
1. Summarize the components and processes related to body
image, body esteem, and body dissatisfaction.
2. Critically analyze the information related to body
dissatisfaction across childhood, adolescence, and early
adulthood.
3. Summarize the core characteristics of anorexia nervosa.
4. Summarize the core characteristics of bulimia nervosa.
5. Summarize the core characteristics of binge eating disorder.
6. Summarize the core characteristics of avoidant/restrictive
food intake disorder.
Physiological Factors
Psychological Factors
Parent and Family Factors
Environmental Factors
Assessment and Diagnosis 248
Intervention 248
Prevention
Treatment
7. Describe several developmental pathways for youth
diagnosed with eating disorders.
8. Integrate the findings related to genes, heredity,
physiological factors, psychological factors, parent and
family factors, and environmental factors that contribute to
the emergence and maintenance of eating disorders.
9. Summarize the best practices for the assessment and
diagnosis of eating disorders in youth.
10. Provide a critical analysis of the data related to family-based
and individual treatments for eating disorders.
238
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Developmental Tasks and Challenges Related to Eating and Appearance 239
In previous chapters, we have considered how biological,
psychological, and sociocultural processes interact and
how they contribute to the challenges and achievements of
typical development as well as to the nature, progression,
and treatment of disorders. This interplay among biology,
psychology, and culture is particularly salient as we
focus our attention on the relations between healthy
and unhealthy eating, safe and dangerous practices for
weight management, and eating disorders. Because of the
developmental status of older children and adolescents,
their increasing independence, increased autonomy in food
choice, and still not fully mature emotional and cognitive
abilities, they are vulnerable to an array of eating problems.
Because struggles with eating disorders involve ongoing
distress and impairment as well as life-threatening crises,
it is crucial to understand the unique circumstances of
adolescence and the ways in which eating disorders emerge
and are maintained.
Developmental Tasks and Challenges Related to Eating and Appearance
The physical development that occurs across later childhood
and adolescence has multiple impacts on psychological
development and functioning, with the onset of puberty
signaling many of the most dramatic changes. Among
the most noticeable changes are that children get taller
and heavier. There are, of course, individual and group
differences related to the timing and tempo of puberty and
accompanying transitions. These include differences related
to race/ethnicity and country of origin as well as sociocultural
factors related to maturity and appearance (Deardorff et al.,
2021). Many of these changes are associated with increases in
concerns about body shape, weight, and appearance. Bodyrelated concerns do not appear suddenly in adolescence.
Body image and body esteem are important developmental
issues across childhood, adolescence, and early adulthood.
These concerns are present in elementary school and
persist, often increasing, from late childhood through early
adulthood (Lacroix et al., 2022).
Understanding the continuum from healthy eating to
eating disorders depends, in part, on knowledge related to
body image and body esteem/satisfaction. Body image is a
complex construct that is focused on “how individua ls think,
feel, and behave in relation to their own bodies” (Lacroix
et al., 2022). Body image is an important component of
identity, contributing to identity development in childhood,
adolescence, and adulthood (Nelson et al., 2018). The body
image construct overlaps others, including body esteem.
Body esteem (or body satisfaction) has to do with the
degree to which individuals accept or are pleased with their
physical appearance. Body esteem includes satisfaction
with one’s weight, satisfaction with one’s appearance, and
attribution esteem (satisfaction with others’ evaluations of
one’s body and appearance) (Nelson et al., 2018). Body
dissatisfaction involves a negative attitude toward one’s
body and appearance. There are multiple components
of body dissatisfaction, including thinness-oriented
dissatisfaction and muscularity-oriented dissatisfaction.
Body esteem is relatively similar in younger girls and boys,
with most children satisfied with themselves. By early
adolescence, many youth become preoccupied, upset, and
unhappy with their body, appearance, and weight (Patalay
et al., 2015). Body dissatisfaction is often associated with
unhealthy eating, dieting, and other problematic weightcontrol measures. In addition, negative body image and
body dissatisfaction predict long-term difficulties related to
well-being (Sharpe et al., 2018).
Several relatively stable developmental trajectories of
body image and body esteem have been described. These
include high body esteem across late childhood through
early adolescence, moderate body esteem across time, and
low body esteem across time. General trends may mask
important individual differences, however, with some
younger adolescents exhibiting stable pathways, others with
moderate declines, and others with more significant declines
in body image and esteem over time (LaCroix et al., 2022;
Nelson et al., 2018).
Girls and women experience more negative body
image and lower levels of body esteem. Adolescents
in the low body esteem pathways are mostly girls
(Lacroix et al., 2022). Girls with higher body-mass
indices (BMIs) are more likely to exhibit declines in
weight- and appearance-esteem over adolescence. These
declines are coupled with negative impacts on identity
and psychological functioning (Nelson et al., 2018).
With respect to sex/gender and body concerns, girls
are more typically focused on thinness, and boys are
more focused on muscularity (although there is overlap)
(Lacroix et al., 2022). For sexual and gender minority
(SGM) individuals, SGM males report higher rates
iStock.com/Electravk
of body dissatisfaction. The data for SGM females is
mixed, with some findings related to more positive body
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
240 Chapter 13 Eating Disorders
image and other findings related to higher levels of body
dissatisfaction (Jones et al., 2019; Miller & Luk, 2019).
Regarding race and ethnicity, many Black girls report less
body dissatisfaction than White girls throughout the high
school years. Asian American youth report more body
dissatisfaction (Bucchianeri et al., 2016; de Guzman &
Nishina, 2014). Although differences in degree of body
dissatisfaction are observed, body dissatisfaction may be
experienced by individuals of all ethnic backgrounds.
Risk factors for body dissatisfaction are varied and
accumulate over time (often beginning in childhood)
for many youth. Parent factors include intrusive
concerns, pressure to manage weight, and modeling of
body dissatisfaction. Family teasing related to weight
and appearance is associated with decreased esteem
and higher rates of depression. These associations
are documented in LGBTQ+ youth and in Hispanic
American, Hmong American, and Somali American
youth (Eisenberg et al., 2019; 2020). Peer factors
include teasing and shaming, peer comparisons, and
peer dieting. Weight victimization and bullying have
also been observed, with LGBTQ+ and gender diverse
youth at much higher risk (Day et al., 2021; Puhl
et al., 2016; 2019). Contemporary research also highlights
the importance of genetic and physiological factors as
well as psychological factors such as negative emotion,
depressive symptoms, and low self-esteem (Lacroix et al.,
2022; O’Connor et al., 2020; Rodgers et al., 2014; Wang
et al., 2019).
The influence of society and the media on body
image and body attitudes has been extensively
studied, and researchers have described the ways in
which television, movies, the internet, and social
media present specific, narrow, and often unrealistic
versions of attractiveness (e.g., very slender women’s
bodies and muscular men’s bodies). 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 healthcompromising behaviors” (Harrison & Hefner, 2008,
p. 381). Social media use, involving both commercial
and user-generated content, increases appearance
comparisons and internalization of body ideals. Social
media use also increases body dissatisfaction, eating
concerns, problematic behaviors, and negative outcomes
related to well-being (Clay et al., 2005; Paterna et
al., 2021; Rodgers et al., 2020; refer to Figure 13.1).
Sociocultural shifts related to body diversity and
acceptance are increasing and may balance some of the
problematic media effects (Karazsia et al., 2017).
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,
Figure 13.1 A model of proposed mediators
of age trends in body satisfaction and
self-esteem
Age
Awareness of
societal attitudes
Internalization of
societal attitudes
Social
comparison
Source: Clay, Vignoles, & Dittmar (2005). Body image and self-esteem
among adolescent girls: Testing the influence of sociocultural factors.
Body
satisfaction
Self-esteem
Tibet, and Turkey (Canpolat et al., 2005; Latzer, 2003;
Li et al., 2005; McArthur et al., 2005; Nobakht &
Dezhkam, 2000; Page et al., 2005; Ricciardelli et al.,
2004; Shroff & Thompson, 2004; Storvoll et al., 2005;
Waaddegaard & Petersen, 2002; Wang et al., 2005; Ying
& Hong, 2005). Findings from a large-scale comparative
study in 26 countries across 10 world regions suggested
that a combination of body-mass index and exposure to
Western media predicted body dissatisfaction among
women. Noteworthy cross-cultural 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 non-Western cultures but
between high-SES and low-SES regions. The hypothesis
is that both modernization and Westernization “bring
cultural changes that promote a thin ideal” (Swami,
2015, p. 41).
Eating Disorders
The Case of Elizabeth
Elizabeth is 17 years old and in eleventh grade. She is
a successful student, has leadership positions in several
service clubs, and is the 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
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Eating Disorders 241
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. Even though 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 parents 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.
The Case of Sierra
Sierra 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. Sierra’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
Sierra’s mother made the transition to working full
time while continuing to care for Sierra 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 Sierra’s promising start in high school, her
guidance counselor became concerned about her missed
classes and falling grades and met with Sierra and her
mother toward the end of the year. That meeting
led to a referral to her family physician and a mental
health counselor. Sierra 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, Sierra 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, Sierra became
concerned about her body size and shape. She was slightly
overweight, and a boy she was dating made an insensitive
comment about her “full and curvy” appearance. Sierra
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 Sierra was vomiting
several times a day, generally at home but occasionally at
school as well.
Sierra found herself th inking about food of ten. 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, Sierra was repeating
a cycle in which she would binge on foods high in
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242 Chapter 13 Eating Disorders
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), Sierra kept her behavior secret.
Her weight fluctuated considerably, although it always
returned to approximately the same as it was when Sierra’s
difficulties began. Although Sierra 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, Sierra 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 Sierra that she herself was
currently being treated for bulimia in a group program
at the college. She encouraged Sierra to meet with an
eating disorders specialist in the counseling department.
Eventually, Sierra agreed and began both individual and
group therapy.
The Case of Kenji
Kenji is a 9-year-old boy. His third-grade teacher notes
that he does well in the classroom but is reluctant to speak
in class and seems uncomfortable in group activities.
Since he began elementary school, there have been several
incidents in which Kenji was bullied, and he now tends
to keep to himself during lunch and recess. While Kenji’s
parents describe him as generally cooperative and engaged
at home, they also recognize that mealtimes have been
distressing and frustrating for several years.
They report that Kenji was an extremely picky eater
throughout his childhood. They note that, for as long as
they can recall, he has been quite sensitive and reactive
to varied textures and tastes of food. Consequently,
Kenji has an extremely restricted diet based on the few
foods he finds acceptable, primarily yogurt and oatmeal.
Family meals have become increasingly unpleasant and
a source of tension for Kenji’s parents who fluctuate
between times when they try to force him to eat the same
foods as the rest of the family and times when they give
in and serve him small portions of the few foods he is
willing to eat (hoping that if he is hungry enough, he
will eat other foods).
This stressful situation worsened recently when Kenji
reluctantly agreed to eat chicken at a restaurant while on
a family vacation. Encouraged by his parents to try a few
bites, he tearfully attempted to comply. However, a piece
of chicken briefly became stuck in his throat. Although
he quickly coughed this up, he became extremely upset,
coughing and crying and insisting that he had “almost
choked to death.” Following this incident, Kenji often
refused to eat during meals at all, though when very
hungry he would eat yogurt. In addition to his previous
taste and texture aversions, Kenji was now quite frightened
of choking and told his parents that he could no longer
chew or swallow any solid food.
While Kenji had been markedly small for his age
prior to the choking incident, he was obviously losing
weight following it. Alarmed, his parents brought him
in to see the family’s pediatrician, who noted that Kenji
was beginning to fall off his previous growth trajectory
and expressed concern that Kenji’s body mass index had
dropped dramatically compared to his last office visit.
In response to this feedback, Kenji acknowledged feeling
self-conscious about becoming “too skinny” but was also
fearful of any plan that required him to eat a wider variety
of foods. Kenji’s parents told the pediatrician that they
felt defeated by Kenji’s resistance to eating and frustration
with the extent to which so much of the family’s mealtime
routine centered on his now severely restricted diet, as well
as the daily arguments about food.
Their pediatrician explained to the parents that while
Kenji’s challenges may not fit their general assumptions
about what constitutes an eating disorder, such as anorexia
or bulimia, Kenji’s pattern of distress and dysfunction was,
in fact, consistent with an eating disorder diagnosis. The
pediatrician told them that because the problem was causing
signif icant and potentially ha rmful weight loss and interfering
with Kenji’s and the family’s well-being, a diagnosis of
avoidant/restrictive food intake disorder (ARFID) was
warranted and a referral to a psychologist with experience
treating these issues was made. The parents felt more hopeful
knowing that their situation with Kenji was not unique and
eagerly scheduled an intake with the psychologist.
Eating disorders are disorders characterized by serious
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). DSM-5-TR provides summaries
of several types of eating disorders. Among the most
common are anorexia nervosa (illustrated in the case of
Elizabeth; refer to Table 13.1), bulimia nervosa (described
in the case of Sierra; refer to Table 13.2), 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). As presented in Chapter 5, the DSM-5-TR section
on eating disorders also includes avoidant/restrictive
food intake disorder, a diagnosis that can be made across
childhood and adolescence (described in the case of Kenji;
refer to Table 13.3). DSM-5-TR also provides a category for
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Both bulimia nervosa and binge eating disorder include
episodes of binge eating.
eating disorders with atypical, mixed, or below-threshold
presentations.
Problematic eating behaviors include severe restriction of
food intake or limiting food to particular types. Distorted
body image includes body dissatisfaction, overvaluation
(assigning excessive importance to weight and/or shape in
terms of self-worth) and preoccupation (excessive thinking
about weight or shape) (Mitchison et al., 2017; Sharpe et al.,
2018). Distorted b ody image also may i nvolve the denia l 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.
Even though 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 (AN) is characterized by restriction of
food and energy intake and significantly low weight, an
intense fear of gaining weight and compensatory behaviors,
Table 13.1 Anorexia Nervosa: Summary of
DSM-5-TR Diagnostic Criteria
A. Restriction of energy intake, relative to
requirements, leading to significantly low body
weight in the context of age, sex, developmental
trajectory, and physical health.
B. Intense fear of gaining weight or becoming fat,
or persistent behavior interfering with weight
gain, despite significantly low weight.
C. Disturbance in the way in which body weight or
shape is experienced, undue influence of body
weight or shape on self-evaluation, or persistent
lack of recognition of the seriousness of the
current low body weight.
Eating Disorders 243
Table 13.2 Bulimia Nervosa: Summary of
DSM-5-TR Diagnostic Criteria
A. Recurrent episodes of binge eating. An episode
of binge eating is characterized by both of the
following:
1. Eating, in a discrete period of time, an amount
of food that is much larger than what most
individuals would eat in a similar period of
time under similar circumstances.
2. A sense of lack of control over eating during
the episode (e.g., a feeling that one cannot
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B. Recurrent inappropriate compensatory
behaviors in order to prevent weight gain, such
as self-induced vomiting; misuse of laxatives;
fasting; or excessive exercise.
C. The binge eating and inappropriate
compensatory behaviors both occur, on average,
at least once a week for three months.
D. Self-evaluation is unduly influenced by body
shape and weight.
E. The disturbance does not occur exclusively
during episodes of anorexia.
Table 13.3 Avoidant/Restrictive Food Intake
Disorder: Summary of DSM-5-TR Diagnostic
Criteria
A. An eating or feeding disturbance (e.g., lack of
interest in eating or in food; avoidance based
on the sensory characteristics of food; concern
about aversive consequences of eating) as
manifested by persistent failure to meet
appropriate nutritional needs associated with
one (or more) of the following:
1. Significant weight loss (or failure to achieve
expected weight gain for full-term growth in
children).
2. Significant nutritional deficiency.
3. Dependence on enteral (tube) feeding or oral
nutritional supplements.
4. Marked interference with psychosocial
functioning.
B. Disturbance is not better explained by a lack
of available food or by an associated culturally
sanctioned practice.
C. The eating disturbance does not occur exclusively
during the course of anorexia nervosa or bulimia
nervosa, and no evidence of disturbance in the
way in which body weight or shape is experienced.
D. The eating disturbance is not attributable to a
concurrent medical condition or better explained
by another mental disorder.
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.