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244 Chapter 13 Eating Disorders
Percent
Data from National Comorbidity Survey Adolescent Supplement (NCS–A)
ARFID involves avoidance of food resulting in problematic
medical and psychological outcomes.
and disturbed or distorted perceptions of weight or shape.
Bulimia nervosa (BN) involves recurrent episodes of
binge eating, a sense or perception that one lacks control
over binge eating, recurrent problematic compensatory
behaviors, and poor self-evaluations of body shape and
weight. Binge eating disorder (BED) is characterized by
repeated episodes of binge eating, a sense or perception
that one lacks control, and significant distress. Avoidant/
restrictive food intake disorder (ARFID) involves an
apparent lack of interest in eating or in food that is not
associated with weight or shape concerns. Individuals with
avoidant/restrictive food intake disorder either avoid food
or are anxious about the potentially adverse consequences
of eating (e.g., nausea, stomach pain, or vomiting).
Individuals with avoidant/restrictive food intake disorder
display significant weight loss, nutritional deficiencies,
and/or impaired psychosocial functioning (Becker et al.,
2018; Norris et al., 2014; 2016).
Atypical anorexia nervosa (AAN) is the focus of
significant research and clinical attention. Individuals
diagnosed with AAN meet the diagnostic criteria for
restricted eating observed for anorexia nervosa except that
their weight is within or above the normal range. Individuals
with AAN are frequently overlooked and underdiagnosed
(Harrop et al., 2021; Neumark-Szainer, 2015).
Research into the subtypes of eating disorders continues,
with important implications for identification, assessment,
and treatment. Key issues include whether eating disorder
subtypes are best understood as mostly dimensional or
iStock.com/Kool99
mostly categorical in nature, whether the number and
structure of subtypes are similar across adolescence and
adulthood, and/or whether subtypes are varied expressions
of a common underlying pathology (the transdiagnostic
approach) (Fairburn & Cooper, 2011; Swanson et al., 2014).
Overall, the data suggest that the common experiences,
symptoms, and impairment may be more salient than the
differences observed in individuals diagnosed with various
eating disorders.
Prevalence rates for eating disorders are relatively high,
despite the fact that many individuals with eating disorders
are likely not identified or treated. Available statistics from
the National Institute of Mental Health show overall
prevalence rates of 2.7% for eating disorders for 13- to
18-year-olds, with girls two and a half times as likely as boys
to have an eating disorder (Merikangas et al., 2010; refer to
Figure 13.2). Those rates are comparable to other estimates
for specific eating disorders: 1% for AN, 2.6% for BN,
1–3% for BED, and 2.8% for AAN (Bohon, 2019; Stice et al.,
2013). Individuals diagnosed with ARFID are somewhat
Figure 13.2 Prevalence of eating disorders in U.S. adolescents (2001–2004)
4
3
2
2.7
1
0
Overall Female Male 13–14 15–16 17–18
Source: National Institute of Mental Health: https://www.nimh.nih.gov/health/statistics/eating-disorders
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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.
3.8
2.4
1.5
Sex Age
2.8
3.0
Anorexia nervosa can lead to dangerous levels of weight loss.
younger than other individuals with eating disorders, with
a higher proportion of males (Murray et al., 2017; Norris et
al., 2014). Very low rates of eating disorders are observed in
children younger than 11, although subclinical patterns are
sometimes evident (Murray et al., 2022).
Binge eating disorder has the latest onset and is more
prevalent in overweight children and adolescents (Murray
et al., 2022). The average duration of an eating disorder
episode is approximately 3 months for bulimia and
11 months for anorexia (Stice et al., 2013). It is important
to note that crossover is common. For example, many
individuals are first diagnosed with bulimia and then cross
over to anorexia. Other frequent crossover patterns include
from binge-eating/purging disorders to restricting disorders
and between anorexia nervosa and atypical anorexia nervosa.
ARFID is the most stable diagnosis (Breithaupt et al., 2022).
Although much of the research on eating disorders
has focused on cisgender White girls and women, data
are increasingly available for boys, men, youth of color,
LGBTQ+ youth, and nonbinary and gender-diverse
individuals. Depending on the specific subtype, male youth
comprise between from 10 to 33 percent of individuals
diagnosed with eating disorders. Higher rates are observed
for BED and ARFID. Compared to female youth diagnosed
with anorexia, male youth with anorexia are more likely
to display muscularity-related concerns and compulsive
exercising. Compared to heterosexual male youth, gay and
bisexual male youth have higher rates of eating disorders
(Coelho et al., 2018; Murray et al., 2017; Parker & Harriger,
2020). Transgender and nonbinary youth also display
higher rates of disordered eating, more severe symptoms,
more severe depression, and higher rates of suicidality
(Riddle et al., 2022; Roberts et al., 2022). Eating disorders
are diagnosed across racial, ethnic, and SES groups, with
mixed data related to similar or slightly higher prevalence
rates in youth of color (Beccia et al., 2019; Burke et al.,
2022; Rodgers et al., 2017, 2018).
Adolescents diagnosed with eating disorders are
also frequently diagnosed with other psychopathologies.
Depression and anxiety are common comorbid disorders.
Developmental Course 245
The combination of an eating disorder and depression is
reflected in Elizabeth’s case. For individuals with eating
disorders, self-harm and suicidality are important concerns.
Connections between eating disorders and substance
use disorders are widely described, especially for older
adolescents and individuals diagnosed with bulimia (Halmi,
2009; Mann et al., 2014). The connections have led some
researchers to hypothesize that, for some, eating disorders
are addictions, with food as a mood-altering substance and
ongoing cycles of food preoccupation, craving, and abuse
despite negative consequences.
iStock.com/Motortion
Developmental Course
For many youth, eating disordered behavior in childhood
and adolescence predicts eating disordered behavior in
adulthood (Herpertz-Dahlmann & Dahmen, 2019).
Further, being diagnosed with an eating disorder in
childhood or adolescence is associated with increased
risk of negative physical and mental health outcomes in
adulthood (Grilo & Udo, 2021; Steinhausen et al., 2021).
Eating disorder onset is most common at two times: early
adolescence (11–13 years) and late adolescence (15–19 years).
These are two key developmental transition points. The first
one marks the transition from childhood to adolescence,
and the second is from early adolescence to late adolescence/
early adulthood. Younger adolescents are more likely to
present with symptoms of AN, and older adolescents
are more likely to present with symptoms of BN. A third
onset time, emerging adulthood, has also been described.
Emerging adulthood marks another transition involving
identity development, greater autonomy, more independent
functioning, and often less access to family and social
resources (Grilo & Udo, 2021; Potterton et al., 2020).
Data are somewhat mixed with respect to age of onset and
severity, but most data suggest that early onset is associated
with greater severity (lower BMIs and longer episodes) and
poorer outcomes. Although most eating disorders emerge
before age 25, midlife-onset disorders do occur (Grido &
Udo, 2021; Runfola et al., 2018).
The developmental pathways of eating disorders are
varied. With diagnosis in early or later adolescence, many
youth exhibit fluctuating courses of weight loss and gain,
while others deteriorate over time and are repeatedly
hospitalized. As noted, crossover from one type of eating
disorder to another is relatively common. For some
individuals diagnosed with AN or AAN, hospitalizations
for medical complications occur (although many youth
with AAN are overlooked) (Harrop et al., 2021; Matthews
et al., 2022). The medical consequences of eating disorders
can be life-threatening, and early identification and access
to treatment are essential. Help-seeking behaviors are less
frequently observed in youth with eating disorders and
are associated with denial of disorder as well as stigma
(Sonneville & Lipson, 2018).
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246 Chapter 13 Eating Disorders
Even those who recover or no longer meet the diagnostic
criteria for an eating disorder may continue to display
some kinds of disordered eating as well as medical and
psychological difficulties (Fichter et al., 2017; Quadflieg
& Fichter, 2019). The trajectories associated with the
diagnosis of eating disorders in emerging adulthood also
vary in terms of persistence and recovery. Across pathways,
there is a clear negative impact on psychosocial outcomes
(Potterton et al., 2021).
Long-term psychosocial outcomes frequently include
impairments in self-image, health, and social functioning as
well as the development of internalizing and externalizing
disorders such as depressive disorders, substance abuse, selfharm, and suicidality (Bohon, 2020; Micali et al., 2017).
Lower education attainment has also been documented
(Grilo & Udo, 2021).
Etiology
Two of the most well-known explanations of eating
disorders are related to family factors and sociocultural
factors. Critical analyses of these explanations (typically
focused on girls) are necessary to separate fact from
fiction and to examine empirical data that support or
refute these hypothetical processes. The idea that families
create or foster eating disorders is most fully explored in
psychodynamic explanations and is often associated with
the psychodynamic theorists Hilde Bruch (1973, 1982) and
Salvador Minuchin. Bruch observed eating disorders in
“good girls”—girls who were characteristically compliant,
achievement oriented, and attuned to pleasing others.
Bruch asserted that the daughters in these families with
indulgent, overinvolved parents lacked many of the basic
skills of childhood, such as the ability to distinguish among
physiological sensations (e.g., hunger vs. exhaustion), the
ability to differentiate emotional experiences (e.g., anxiety
vs. irritation), and the ability to feel confident in one’s body
and oneself.
Minuchin’s book Psychosomatic Families (Minuchin
et al., 1978) described families who were “enmeshed,” or
too closely involved and controlling of one another. These
families allowed little opportunity for child or adolescent
autonomy, a stressful situation made more difficult because
it was accompanied by an atmosphere of overt nurturing and
affection. With the developmental press for independence
and self-definition associated with early adolescence, crises
were inevitable. Without a well-defined sense of self and
without the ability to identify their own needs and desires
appropriately, daughters sought control over themselves in
any way possible. For some, the struggle played out in the
form of eating disorders.
As might be expected, parents of adolescent girls
diagnosed with eating disorders were “bewildered, blamed,
and broken-hearted” (MacDonald, 2000) as they sought
help for their children. And their confusion and upset was
warranted because there is little or no empirical support
in prospective studies for the causal impact of these
psychodynamic family factors. A position paper from the
Academy for Eating Disorders (Le Grange et al., 2010, p. 1)
is quite clear: “It is the position of the Academy for Eating
Disorders (AED) that whereas family factors can play a role
in the genesis and maintenance of eating disorders, current
knowledge refutes the idea that they are the exclusive or
even the primary mechanisms that underlie risk. Thus, the
AED stands firmly against any etiologic model of eating
disorders in which family influences are seen as the primary
cause of anorexia nervosa or bulimia nervosa, and condemns
generalizing statements that imply families are to blame for
their children’s illness.”
Sociocultural models of eating disorders have become
increasingly prominent. These explanations, briefly
discussed in the opening section of this chapter on the
developmental challenges associated with eating and
appearance, begin with the near-constant presentation of
images of actors, models, and Instagram celebrities with
impossibly thin bodies and shapes. Internalization of this
thin ideal, coupled with the pressure to be thin (coming
from oneself, family, peers, and society), leads to body
dissatisfaction, negative emotions, problematic dieting
behaviors, and eating pathology. Indeed, research suggests
that exposure to media images of the thin ideal, as well
as peer pressure to be thin immediately, increases levels of
body dissatisfaction. This is especially the case if youth are
vulnerable in terms of already-present body dissatisfaction,
perceived pressure to be thin, and lack of social support.
Given that the vast majority of youth and young adults do
not develop clinically significant eating disorders, however,
a single-factor model is unlikely to capture the real-life
complexity of eating disorders. A multifactorial risk model
provides a more nuanced explanation of the development of
eating disorders.
Genes and Heredity
Family and twin research suggests strong heritability for both
anorexia and bulimia, with genetic effects increasing across
puberty (Bulik et al., 2016; Culbert et al., 2015; O’Connor
et al., 2020). The data are consistent with explanations that
highlight common genetic factors underlying eating disorder
symptoms, anxiety and depression, and explanations that
emphasize distinct genetic factors for early symptoms of
eating disorders such as body dissatisfaction and weight/
shape concerns. The data also emphasize that nonshared
environmental factors (those factors that differentially
influence siblings) are much more important than shared
environmental factors.
Physiological Factors
Physiological studies provide additional perspective on
the brain structures and mechanisms involved in appetite,
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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.
Etiology 247
food intake and satiety, and associated pleasure and reward
(Culbert et al., 2015). Data suggest abnormal activity
in various regions of the brain, including the prefrontal
and temporal lobes. Related research focuses on the role
of the vagus nerve, dysregulation of the serotonin and
dopamine systems, and elevated pain thresholds observed
in adolescents with eating disorders (Culbert et al.,
2015). Some of the physiological factors that appear to
be implicated are similar to those observed in individuals
with certain mood disorders and substance abuse disorders,
including dysregulation of eating and mood, impulsivity,
and craving responses after exposure to food cues.
These factors may be particularly salient for those adolescents
and adults with more severe psychopathology. Halmi
describes a physiological model that emphasizes allostasis.
Extending a model originally designed to explain drug
addiction, it may be that individuals diagnosed with anorexia
or bulimia experience “a dysregulation of reward circuits
with activation of brain and hormonal stress responses”
and that these “changes in the entire brain-body system”
underlie ongoing risk, chronic distress and impairment, and
frequent relapses (Halmi, 2009, pp. 163-164).
As noted, the onset of puberty is associated with increased
risk. Part of that increased risk is linked to physiological
maturation and hormonal changes, with explanations
mostly focused on sex steroid hormones (Culbert et al.,
2018; Vo et al., 2021). Early-maturing girls are at higher
risk than later-maturing girls. For children who struggle
with obesity in childhood, there are increased risks for
restrictive eating disorders such as atypical anorexia nervosa
in adolescence. Even when weight loss is recommended,
careful attention to the extent of weight loss, as well as
potentially maladaptive outcomes, is necessary (Lebow
et al., 2015).
processes (Culbert et al., 2015; Dahlenburg et al., 2019). In
addition, fear of negative evaluation is a transdiagnostic risk
factor that increases the risk of developing eating disorders
and influences the persistence of eating disorders once they
are in place (Trompeter et al., 2019).
Another cluster of risk factors are personality
characteristics related to self and identity. For example, with
respect to levels of agency, reflectivity, differentiation, and
relatedness, individuals with anorexia nervosa described
lower levels of agency and relatedness as well as heightened
and harsh self-reflectivity. These self-descriptions
distinguish between individuals with anorexia and
individuals without anorexia, and between individuals with
anorexia and individuals with other disorders (Bers et al.,
2004; Potterton et al., 2020). Interactive processes related to
racial and gender identity in Black adolescents, for example,
provide additional perspective. Increased risk for eating
disorders differs depending on the degree to which Black
youth endorse feminine versus masculine gender identities
(Blazek & Carter, 2019).
Risk factors related to negative body image, weight and
shape concerns, and body dissatisfaction have already been
discussed as contributing to a cascade of disordered eating,
unhealthy dieting, and compensatory behaviors such as
overexercise. These risk factors are typically in place by
puberty and escalate in impact over adolescence (Rohde
et al., 2015; Sharpe et al., 2018). Individuals who participate
in athletic or arts activities where appearance or weight are
consequential (such as gymnastics, wrestling, or dance) are
at higher risk (Harriger et al., 2014; Van Durme et al., 2012;
Walter et al., 2022). As noted earlier in the chapter, these
risk factors may have even more negative impact for SGM
youth (Miller & Luk, 2019).
Psychological Factors
Individual factors that influence the emergence of
eating disorders have received a great deal of clinical and
empirical attention. A cluster of biologically influenced
personality characteristics have been identified that
increase vulnerability. These include temperament, negative
emotionality and emotion dysregulation, impulsivity,
stress reaction and harm avoidance, and reward and
punishment sensitivity (Brown et al., 2020; Culbert et al.,
2015; Henderson et al., 2021). The combination of negative
emotionality and impulsivity, in particular, is connected to
binge eating and purging (Culbert et al., 2015). In addition,
emotion dysregulation appears to be especially salient for
the association of eating disorders with suicidality (Rania
et al., 2021).
Perfectionism, involving setting impossibly high goals and
experiencing a sense of failure and worthlessness when those
goals are not met, appears to run in families and may lead
to the “relentless pursuit of the thin ideal” (Bruch, 1973).
Perfectionism is central to both etiology and maintenance
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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.
Parent and Family Factors
Parent and family factors have long been implicated in the
development and maintenance of eating disorders. As noted,
however, we need to be very careful how we evaluate these
factors. It may turn out that an appreciation of bidirectional
influences provides the most useful information. It is
also likely that specific family factors are more salient for
already vulnerable adolescents (Le Grange et al., 2010). One
basic risk variable involves general family dysfunction. For
instance, families with more problematic communication,
more psychopathology, and more financial difficulties have
adolescents at higher risk (Moorhead et al., 2003; Steinberg
& Phares, 2001).
Encouragement of dieting is related to body d issatisfaction
and drive for thinness (Cooley et al., 2008). Critical
comments about weight and shape and the frequency of
these comments, as well as family teasing, are associated
with eating pathology (Cooley et al., 2008; Hanna & Bond,
2006). There are, of course, protective family factors as well.
Family connectedness, positive family communication, and
248 Chapter 13 Eating Disorders
parental monitoring all decrease the risk of eating disorders
in adolescents (Fonseca et al., 2002).
Environmental Factors
Negative life events (e.g., school transitions, death of a family
member, relationship changes, home and job transitions,
illness/hospitalization, and maltreatment) increase the risk
for eating disorders and may trigger the onset of an eating
disorder (Berge et a l., 2012). Teasing experiences also increase
risk. Weight teasing and weight stigma are observed across
sex/gender, race/ethnicity, and SES backgrounds (Hooper
et al., 2021). Body discrimination and peer victimization
also increase risk (Sutin et al., 2020). As already described,
media-related influences are also important risk factors.
Media exposure clearly plays a role in increasing body
dissatisfaction and internalization of the thin ideal (Rohde
et al., 2015; Rodgers et al., 2015).
Assessment and Diagnosis
The assessment and diagnosis of eating disorders involves
the developmentally informed evaluation of a complicated
mix of somatic and psychological symptoms, especially
when considered in the context of the transition from
childhood to adolescence and from adolescence to early
adulthood (Huemer et al., 2012; Potterton et al., 2020).
It is, of course, absolutely necessary for a comprehensive
medical examination to be part of the assessment process.
Assessment may be especially problematic because most
adolescents with eating disorders deny difficulties (often
vehemently) and avoid contact with medical or mental
health professionals (Becker et al., 2009; Collins &
Ricciardelli, 2005). The development and maintenance of
therapeutic engagement and alliance, therefore, are of the
highest priority.
There are a number of well-validated structured
interview and self-report measures for screening and
diagnosis, although instruments need to be designed
and interpreted with regard for differences in the clinical
presentation of adolescents versus adults and with respect
to ethnicity and gender (Couturier & Van Blyderveen,
2012). In addition, since eating disorders are associated
with a wide range of clinical concerns, evaluation
measures designed for both broad-based screening and
more in-depth and disorder-specific assessment are
often utilized (Bardone-Cone & von Ranson, 2020).
For example, the Eating Disorders ExaminationQuestionnaire (Fairburn & Beglin, 2008) was developed
to screen for symptoms and and severity associated
with a wide array of eating disorders, while the Eating
Disturbances in Youth Questionnaire (Kurz et al., 2015)
assesses ARFID symptoms in 8 to 13-year-olds.
Because several of the diagnostic criteria for eating
disorders involve cognitive symptoms, the diagnostic
process must take into account age-related and cultural
considerations. For example, “body experience and weight
concerns may be difficult to formulate and express, in part
because they are highly subjective, and in part because they
are relative to social norms” (Becker et al., 2009, p. 616).
In addition, given the different perspectives of adolescents
and parents, parent reports should always be solicited
(Ford et al., 2021).
There is some momentum to include a quick screen for
eating disorders as part of well-child and other child and
adolescent appointments with physicians (Lock et al., 2015).
For those who respond to questions about eating behaviors,
weight concerns, and body satisfaction with answers that
raise concerns, more comprehensive evaluations can be
provided. In all cases, it is important to identify and rule out
multiple causes of weight loss, loss of appetite, and refusal
to eat. It is also important to keep in mind that outreach,
screening, and assessment may be particularly critical for
youth who may be overlooked or underserved including
boys and LGBTQ+, nonbinary, and transgender individuals
(Avila et al., 2019; Roberts et al., 2018).
Intervention
Prevention
Interventions for eating disorders include both prevention
and treatment. Effective prevention strategies depend on a
clear understanding of the risk factors for eating disorders
(Solmi et al., 2018) and focus on the more malleable of
these factors, including body dissatisfaction, internalization
of the thin ideal, and emotion dysregulation, and seek to
strengthen some of the protective factors, such as selfesteem and social support (Linardon et al., 2018; NeumarkSztainer et al., 2006). School-based programs in both
middle schools and high schools can be effective. These
may focus on components of healthy eating, self-esteem
and perfectionism, and critical analysis of media images
and may specifically address teasing and harassment
related to body weight and shape (Hooper et al., 2020).
Peer-led prevention programs for older adolescents and
college students have also received empirical support (Stice
et al., 2020). Prevention programs designed to reduce the
prevalence of eating disorders are one important example
of translational science. With information about effective
programs readily available, mental health and public
health advocates must identify opportunities to increase
awareness, encourage early intervention, and scale up
programming to meet the needs of diverse youth and
young adults with varied eating disorders (Austin, 2016;
refer to Figure 13.3).
Treatment
Treatment models include inpatient hospitalization,
partial hospitalization, intensive outpatient settings,
and traditional outpatient settings. Current approaches
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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.
Figure 13.3 Infographics provide information that increase knowledge and
decrease stigma
TM
Center for the Treatment of Eating Disorders
Changing the Standard of Care
EATING DISORDERS
Intervention 249
20M FEMALES
and 10M MALES
Suffer from clinically signicant eating
1
in their lifetime, making it more
disorders
common than breast cancer or Alzheimer’s
ANOREXIA
is the third most
common* chronic illness
among adolescent
FOUR IN 10 PEOPLE
Less than half of people with an
eating disorder receive treatment
1. Wade, Keski-Rahkonen, & Hudson (2011) 2. Public Health Service’s Office in Women’s Health (2000) 3. Substance Abuse and Mental Health Services Administration, The
Center for Mental Health Services, offices of the U.S. Department of Health and Human Services 4. The Eating Disorders Coalition (2014) 5. Noordenbox, International Journal
of Eating Disorders (2002) 6. The National Eating Disorder Collaboration (2012)
childrensMN.org/eating-disorders
2
95%
are between the
age of 12 and 25
5
3
EVERY HOUR
someone in the U.S. dies as
a result of an eating disorder
4
EATING
DISORDERS
are complex disorders, not a choice
or sign of poor parenting
The number of boys who
have eating disorders is
INCREASING
*following obesity and asthma
6
provide multidisciplinary, comprehensive, and integrated
treatments that address the medical and psychological
issues of children, adolescents, and their family and peer
contexts (Monteleone et al., 2019). Hospitalization remains
essential for those with severe and life-threatening disorders.
Both inpatient and partial hospitalization are intensive
forms of treatment that require considerable clinical skills
on the part of mental health professionals who work with
therapeutically challenging adolescents. With compelling
data on empirically supported outpatient treatments for
eating disorders, it is increasingly the case that the primary
function of hospitalization is medical stabilization. Beyond
stabilization, inpatient treatment tends to be used only
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.
when outpatient treatments have been unsuccessful or are
unavailable (Lock et al., 2015). Outpatient care is associated
with greater client and parent satisfaction as well as lower
cost (Gowers & Bullock, 2012).
As noted, adolescents rarely initiate or compliantly
accept treatment (Forrest et al., 2017). Even if treatment
begins, dropout rates are high, emphasizing the need to
proactively reach out to children or adolescents who seem
to be especially likely to resist, disengage, or drop out.
Characteristics of the therapist and the therapeutic alliance
also take on added significance. As with all therapists
working with children and adolescents with all kinds of
psychopathologies, therapists who are nonjudgmental,
250 Chapter 13 Eating Disorders
neutral, and accepting are more likely to engage their
clients with eating disorders. There are also other strategies
to more effectively engage adolescents in eating disorder
treatment such as better integration of treatment into
primary care settings (Thaler et al., 2018). Addressing
the stigma of eating disorders is another aspect of initial
treatment (Murray et al., 2017).
Although pharmacological treatments for adolescents
with eating disorders have received less attention than for
adults, it is an increasing area of focus (McElroy et al., 2018).
Most of the research is focused on the use of antidepressants
and mood stabilizers, especially when co-occurring disorders
are present. There is little evidence that pharmacological
treatments are effective for restoring weight for individuals
diagnosed with anorexia, and there are mixed data on the
role of pharmacological treatments for reducing relapse rates
and improving core features of eating disorders (Chavez &
Insel, 2007; Lock et al., 2015). Other research does suggest a
role for medication in addition to psychosocial interventions
in the treatment of binge eating disorder (Amodeo et al.,
2019).
Overall, psychosocial interventions, including individual
and family psychotherapies, remain the treatments of
choice (Datta et al., 2022; Lock et al., 2015). In general,
treatment trends include the use of family-based treatments
for older children and adolescents and the use of cognitivebehavioral therapy for young adults. Evidence-based
treatment options may be customized for individuals and
families (refer to Table 13.4). Family-based therapies are
especially effective for adolescents with both anorexia
Table 13.4 Evidence-Based Treatment Options for Individuals and Families
Treatment
Type Inpatient Care
Overview
●
For immediate
medical and
nutritional
stabilization;
patients receive
around-theclock care from
a full team of
specialists
Family-Based
Therapy (FBT)
●
Leading
therapy for
children and
adolescents
(also known as
the Maudsley
Approach)
Cognitive
Behavioral Therapy
-Enhanced (CBT-E)
●
Most
recommended
treatment for
adults, adapted
for use with
adolescent
Unified Protocol
(UP)
●
Developed to
treat emotional
disturbances
and adapted to
treat feeding
problems
caused by
anxiety,
textures, mood
disorders, etc.
Multi-Family
Partial Hospital
●
Fills the gap
between
hospitalization
and outpatient
treatment,
offering patients,
parents and
siblings intensive
skills training
tools
Best for
●
Young patients
up to college
age who are
experiencing
●
Youth with AN,
BN, ARFID, and
other eating
disorders
medical
complications of
eating disorders
or are in need
of nutritional
stabilization
Approach
●
Help the patient
return to health
as quickly as
possible so they
can move on to
an appropriate
outpatient
treatment
●
Parents play
an active role
in first helping
to restore
weight, then
transitioning
control of
eating back to
the patient
Frequency
●
Average length
of stay is 12–14
●
10–20 family
sessions
days
Source: Adapted from childrensmn.org/eating-disorders
●
Adolescents/teens
with all types of
eating disorder
●
Parents are
still involved
but treatment
engages the
patient more
independently
●
More intensive,
20–40 one-to-one
1 hr sessions
●
Youth with
ARFID or
other feeding
problems that
cause failure
to thrive and
weight loss
●
Personalized
therapy
applying
cognitive
behavioral
approaches
as well as
mindfulness
●
16–20
individual and
family sessions
●
Youth with all
types of eating
disorders
●
Families learn
from each
other while
developing skills
and techniques,
such as coping
strategies, parent
training, meal
coaching
●
1–3-week
sessions
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Intervention 251
and bulimia and for adolescents requiring higher levels of
care (Huryk et al., 2021; Lock et al., 2015). Family-based
treatment can also be adapted for youth with ARFID (Lock
et al., 2018; Shimshoni et al., 2020). Parent participation is
also associated with lower rates of dropout for adolescents
(Le Grange et al., 2010). Caregiver perspectives on eating
disorder recovery also provide valuable information
(Accurso et al., 2020).
The Maudsley model of family therapy, in which
parents have a central role in treatment, has been the focus
of much current research and has received much empirical
support (Lock & Le Grange, 2018; Treasure et al., 2021).
The Maudsley model is a practical approach focused on
problems related to improving eating and promoting
weight gain (Lock & Le Grange, 2018). In the early
phase of treatment, parents have significant control over
the adolescent’s eating. Problems in family structure that
make improvements in eating more difficult are addressed
quickly. When eating and weight have improved,
adolescents take more responsibility and control over
eating. The last part of treatment focuses on the typical
developmental challenges of adolescence (e.g., autonomy,
identity, sexuality) that may have an impact on continued
progress.
Compared to individual treatments for adolescents with
anorexia, family-based treatments are more effective in
maintaining full remission of symptoms over time. Also,
the more severe the clinical presentation, the greater the
benefit associated with family-based treatments compared
to individual treatments (Le Grange et al., 2012; Lock
et al., 2010). In addition to family-based treatments, groups
of parents whose adolescents are diagnosed with eating
disorders benefit from parent training programs that provide
both information and support for their own struggles
(Le Grange et al., 2010).
The most common empirically-supported individual
approach is cognitive-behavioral psychotherapy (Pellizer
et al., 2018). Most child- and adolescent-focused therapies
target the distorted cognitions, disordered eating patterns,
and self-efficacy concerns in specific developmental
contexts (Fitzpatrick, 2012; Lock et al., 2015). Keeping
in mind the role of body dissatisfaction in the etiology of
disorders, cognitive-behavioral treatments that include
specific techniques to reduce body dissatisfaction (such as
positive role playing, challenging negative cognitions, and
generating positive self-statements) have the most positive
outcomes (Rohde et al., 2015).
A specialized version, cognitive behavioral therapy
for eating disorders (CBT-E), is designed to address
various forms of eating disorders and to match adolescents’
and young adults’ personalities and psychopathologies
(Fairburn, 2008; Mulkins & Waller, 2021). The focus
of CBT-E treatment involves identifying factors that
maintain the eating disorder (in contrast to factors that
influenced the development of the disorder) and helping
individuals step back or distance themselves from their
disorder so they can understand it better. The initial stage
of treatment involves engaging the client, assessing the
nature and severity of the disorder, educating the client
about eating disorders, and working together to devise an
individualized treatment plan. The second and third stages
involve reviewing progress and compliance and identifying
ongoing barriers to change.
Examples of work in these stages might include exploring
the evaluation of shape and weight, developing strategies to
reduce the importance of shape and weight, and developing
other domains for self-evaluation. Additional work might
focus on dealing with dietary rules, dietary restraints, or
negative moods. The final phase emphasizes understanding
and minimizing relapse and devising plans for dealing with
setbacks.
Other common treatments for adolescents with bulimia
focus more specifically on restrictive eating patterns.
For those with bulimia, who often relapse and struggle
with repeat cycles of binge eating and purging, for those
with binge eating disorder, and for those with atypical
anorexia nervosa, dieting must be appreciated as a complex
phenomenon (Hagan & Walsh, 2021). Relapse prevention
can be addressed by having therapists pay special attention
to an adolescent’s higher level of initial preoccupation with
food, greater ritualization of eating, and lower motivation
for change (Halmi et al., 2002).
Interpersonal therapies, focused on changing the
problematic relationships that trigger or maintain eating
disorder symptoms, have also received empirical support
(Lock et al., 2015; Miniati et al., 2018). Dialectical behavior
therapy (DBT) is another treatment option (Bohon
et al., 2019). Telehealth programs provide increased access
and transitional support (Datta et al., 2020; Levinson
et al., 2021). Of course, it is essential to address comorbid
disorders, including depression, anxiety, substance use,
nonsuicidal self-injury, and suicidality (Jacobson & Luik,
2014; Mann et al., 2014).
Group interventions have also been widely used, with
both positive and negative outcomes (Dittmer et al.,
2018). Groups enable children and adolescents to explore
similar psychological factors underlying the emergence and
maintenance of eating disorders (e.g., related to dysregulated
emotion, distorted cognitions, and problematic behaviors),
as well as parent, peer, and media influences on eating
disorders. Peers in groups also provide specific kinds of
support for recovery and examples of successful treatment.
Group interventions may be especially helpful when
integrated into a multimodal treatment plan and focused
on eating disorder patients with similar symptom patterns
(Dittmer et al., 2018). In addition, research indicates that
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252 Chapter 13 Eating Disorders
groups with a high level of structure and clear thematic focus
(e.g., perfectionism) lead to greater engagement and efficacy
(Margherita et al., 2021). However, as with other forms of
psychopathology (e.g., conduct disorders, substance use
disorders), negative influences are also observed, with peers
providing information about noncompliance and strategies
for treatment sabotage (Dishion & Stormshak, 2007).
Similar issues arise from the increased intensity and scope
of social media on body image and related issues focused
on eating disorders (de Valle & Wade, 2022). This kind
of negative influence is especially important to counter
Key Terms
Body image (239)
Body esteem (239)
Body dissatisfaction (239)
Eating disorders (242)
Anorexia nervosa (242)
because it may be reinforced by numerous websites and
other forms of social media that promote eating-disordered
behavior as a lifestyle choice (Hilton, 2018; Mento et al.,
2021).
In the end, individual, family, and group treatments may
each contribute to improvements in clinical presentation and
better long-term outcomes. As with all psychopathologies,
the overriding goal of the treatment of eating disorders is
to enable children and adolescents to capitalize on their
strengths, cope with inevitable difficulties, and move
forward with confidence and hope.
Bulimia nervosa (242)
Binge eating disorder (242)
Avoidant/restrictive food intake disorder (242)
Atypical anorexia nervosa (244)
Maudsley model of family therapy (251)
Cognitive behavioral therapy for eating disorders (CBT-E)
(251)
Chapter Summary
●
Body image, body esteem, and body dissatisfaction are
developmental challenges across childhood, adolescence,
and adulthood.
●
Transitions from late childhood to early adolescence,
from mid-adolescence to late adolescence, and across
emerging adulthood are all periods where there is an
increased risk for eating disorders.
●
Core eating disorder symptoms include problematic
eating behaviors, body dissatisfaction and negative body
perceptions, and compensatory behaviors to lose weight
or prevent weight gain.
●
Key symptoms of anorexia nervosa include a desire for
thinness and extreme behaviors leading to weight loss.
Binge eating and compensatory behaviors to prevent
weight loss characterize bulimia nervosa, while binge
eating disorder does not include the compensatory
behaviors. Avoidant/restrictive food intake disorder
involves a lack of interest or aversion to food resulting
in nutritional deficiencies and other maladaptive
outcomes.
●
The prevalence of eating disorders varies depending
on family history, sex/gender, race/ethnicity, and other
demographic factors.
●
Depressive disorders, anxiety disorders, substance
use, and nonsuicidal self-injury may be diagnosed in
combination with eating disorders.
●
The biopsychosocial model of eating disorders emphasizes
the interaction of genetic, physiological, personality, and
family factors in the development and maintenance of
eating disorders.
●
Negative emotionality and emotional dysregulation are
personality characteristics with particular salience for
eating disorders.
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Intervention 253
●
Negative life events increase the risk for eating disorders
and may also precipitate the onset of an eating disorder.
●
Once established, many forms of eating disorders
are relatively resistant to treatment. Severe and lifethreatening forms often require hospital-based programs
for medical stabilization.
●
Current treatment trends include the use of family-based
treatments for older children and adolescents and the use
of cognitive-behavioral therapy for young adults.
●
An important component of all treatment models is a
focus on healthy attitudes toward food and eating as well
as improved coping skills.
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.