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Eating Disorders: Anorexia Nervosa, Bulimia Nervosa, and Binge Eating

Annelaure Nguyen, Mahrukh Jilani, Angelly Vindas, Elizabeth Beserra, Forrest Floyd, Tamantha

Rodriguez

Department of Psychology, The University of Houston

PSYC 2301: Intro to Methods of Psychology

Dr. Pamela Harlan

March 7, 2021
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Eating Disorders: Anorexia Nervosa, Bulimia Nervosa, and Binge Eating

Eating disorders currently affect millions of people worldwide and have one of the

highest death rates among mental illnesses. Anorexia Nervosa and Bulimia Nervosa have

emerged as the predominant eating disorders, specifically among adolescent girls. This paper

will explore the severity and the onset of eating disorders, specifically focusing on Anorexia,

Bulimia, Binge Eating, and the medical complications and psychological effects associated with

each disorder. We will explore peer-reviewed literature on the prevalence and treatment of these

disorders.

Anorexia Nervosa is one of the most common types of eating disorders, characterized by

an “abnormally low body weight with an intense fear of gaining weight” (Mayo Clinic 2018).

Those with this disorder tend to overvalue their weight and body shape and, as a result, resort to

extreme efforts as a means of maintaining that specific image. Another eating disorder is Binge

Eating; binge eating is characterized by an individual’s desire to consume an abnormally large

amount of food. Though overeating occasionally (such as on popular holidays like Thanksgiving

and Christmas) is typical, people with this disorder make binge-eating a regular occurrence due

to their inability to control the amount of food they consume. Lastly, Bulimia Nervosa is

described as an individual’s tendency to binge-eat a large amount of food in one sitting, and then

purge as a means of decreasing the extra calories gained. To prevent weight gain, individuals’

resort to extremely unhealthy methods such as self-induced vomiting and strict dieting, which is

why eating disorders are life-threatening.

Anorexia Nervosa

Anorexia Nervosa is a serious psychiatric disorder with its principal feature being a

relentless pursuit of thinness. “Anorexia Nervosa is one of the deadliest of psychiatric disorders,
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with an estimated mortality rate at least five times higher than that expected” (Walsh, 2013).

Anorexia falls under the (DSM) classification of feeding and eating disorders. Feeding and

eating disorders are characterized as an unusual eating pattern that could significantly damage a

person’s physical and psychosocial functions. More specifically, it involves the avoidance or

restriction of food consumption through uncontrollable physical means. Dieting and weight loss

dominate mental life for years, and seriously impair one's physical health and social

development. The onset of Anorexia Nervosa typically begins during a period of stress, usually

encountered during adolescence. For many individuals, these dieting behaviors help to cope with

emotional difficulties. Both rodent and human studies have demonstrated that behaviors learned

during a period of stress are more likely to become habitual than those learned at other times.

The study provided gives reasonable evidence that the significant weight loss associated with

Anorexia Nervosa increases the tendency to develop compulsive patterns of behavior. (Walsh,

2013). For decades, Anorexia Nervosa has been targeted among specific demographics.

Anorexia and other excessive dieting concerns were seen to be overrepresented in dance and

modelling students the most, suggesting that the pressures of having to be slim to exceed

expectations are significant factors in the development of the disorder. Anorexia is substantially

more common in females and usually develops in adolescence, it’s also commonly

overrepresented in the upper social classes since it serves as a symbol of modern time’s outlook

of beauty and success. Therefore, any increase in the frequency of the disorder can be linked to

the increased emphasis for women to appear slim and to diet/exercise as a means of maintaining

that ideal body shape. Regarding body sizes, even though the ideal body form has varied over

time and between cultures, the ideal body shape/standard in the Western hemisphere is generally

thin with a small waist-to-hip ratio. This standard comes with dire consequences as indicated by
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the prevalence of dieting among women in the United States (most notably among teenagers and

young adults). Women feel the need to maintain traditional attractiveness standards while at the

same time having to assimilate to the heightened demands for performance and success. For

instance, dancers and models epitomize these very consequences since their careers require them

to have the utmost control over their body shapes. The competitive nature of their jobs

additionally catalyzes this ubiquity of Anorexia Nervosa.

Although the factors that contribute to anorexia include stress, social class, and

expectations held by an individual's career, many people experience this disorder because of the

influence of social media. People on social media and television are usually represented as being

the ideal body type. Due to the increase in internet usage, social networking has made it easier to

promote businesses and expand advertisement for beauty brands. As people see the ideal body

through social media and television, it “... permanently distort[s] self-perceptions of the body”

and “it has been suggested that the consequent fear of rejection based on physical appearance is

behind the increase in the number of persons suffering from eating disorders.” (Costa-Font

2013). As more people become dissatisfied with their bodies and appearance, they start to

undertake diets and psychologically construct the idea of a “perfect body”. From here, the

symptoms of anorexia begin as it causes individuals to be fearful of gaining weight as they

continuously envy the standardized beauty figure that they see on social media. Younger

individuals are more likely to be easily influenced by social media, so they fall into the belief

that beauty is an extremely important factor of life. This study shows how social networking has

affected individuals' body image and, in turn, where they stand within society. Even after

recovering from eating disorders, many continue to struggle with its long-term effects.
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Treatment Research

Like many disorders, suffering from Anorexia Nervosa can be seen throughout the rest of

one's life. Those who achieve the convalescent status still have a lifelong fight ahead of them. A

team led by Kamryn T. Eddy, PhD., wanted to learn what long-term recovery for both Anorexia

Nervosa and Bulimia Nervosa looked like; they conducted a longitudinal study consisting of

patient follow-ups at the 9, 20, and 25-year marks. The study was made of 246 women, ages 12

and up, living within 200 miles of the study site, and not showing any signs of an organic brain

syndrome or terminal illness. Out of the 246 women who took part in the study, 18 died by 20-25

years after the study. The study showed that the longer a patient stays within the ideal recovery

state, the less likely a relapse will occur; This is shown by comparing the recovery rates of

62.8% at the 22-year mark and 31.4% at the 9-year mark. Furthermore, the study found that

patients who followed through with each follow-up had a higher recovery rate. (Eddy, et al.

2017).

Binge Eating Disorder

Binge eating disorder (BED) is generally characterized by recurrent episodes of binge

eating and includes features such as eating until uncomfortably full, eating even when not

physically hungry, or eating alone with feelings of depression/guilt. These negative emotional

states (in addition to anger/frustration/or anxiety) appear to be a strong trigger for BED. This

disorder is increasingly associated with depression and personality disorders. The current

prevalence of binge eating disorder is said to be between 2 and 5 percent and is more equal in

gender ratio (65% female, 35% male) than Bulimia Nervosa. When it comes to weight, there

seems to be a positive correlation between binge severity and the degree of obesity; suggesting

there is evidence that binge eating does affect early-onset obesity. There are two basic kinds of
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binge eating episodes. One involves either having a feeling of lack of control in the amount eaten

or the inability to stop eating; the other episode involves meeting a ratio of food eaten to the

amount of time it takes to eat the same food under similar circumstances normally. When an

individual is experiencing an episode, specifically a lack of control with extreme consumption of

food, they can easily lose focus of things going on around them and become so over-engrossed

with eating that they don’t acknowledge their surroundings. All of this can put a tremendous

emotional toll on individuals experiencing BED.

Research on Binge Eating Disorder

A group based out of Switzerland led by Alexandra Dingemans wanted to learn more

about how people who have BED regulate their emotions, and if BED was associated with self-

harm or substance abuse. They found out that poor mood appears to happen before an episode of

excessive eating or drinking in a short time, which could be an attempt to regulate their high

emotions of worry and depression. This could also be because people with BED appear to lack a

healthy and effective regulation system of feelings involving love, hate, guilt, Etc. They also run

into difficulty with planning out situations or reaching set goals successfully. These attempts to

push away their unwanted feelings can lead to unhealthy behaviors such as self-harm or

substance abuse. (Dingemans, 2017).

Binge eating disorder is not only associated with physical health hazards, but it has also

been linked to observable emotional anxieties, such as shame and the concept of cognitive body

image fusion. Shame creates a negative effect on an individual, causing them to become self-

conscious and socially focused on evaluations of themselves by others, such as believing they are

“defective, inferior, inadequate and unattractive.” (Duarte et al., p. 196). Cognitive body image
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fusion is described as a mental entanglement with the obsessive belief that the physical

appearance of self is under constant scrutiny by society, and one must attempt to satisfy that

expectation at all times. In their study published in Clinical Psychology and Psychotherapy,

Duarte et al (2017) sought to find the correlation between binge eating disorder and shame/body

image fusion, as well as the effect each has on the severity of the condition. Their study included

73 women of various ages, diagnosed with BED, who were given surveys and agreed to have

their answers investigated. Some tests used in the study were eating disorder examinations, a

binge eating scale, a depression-anxiety stress scale, and a questionnaire based on cognitive

fusion body image. The results concluded that, “binge eating severity presented a strong positive

association with external shame and with body image-related cognitive fusion” (Duarte et al. p.

199). The study also revealed positive correlations between binge eating, depressive symptoms,

and shape/eating concerns. It was found that external shame has a direct influence on the

intensity of binge eating. (Durate et al. 2017). This finding suggests that individuals struggling

with binge eating disorder can become overly dissatisfied with their shape/weight and try to

control these anxieties through the consumption of food. Following these behaviors, one may

feel embarrassment, humiliation, or discomfort due to their participation in binge eating and

eating disorder-like behaviors. Likewise, both shame and cognitive body image fusion can

ultimately lead to feelings of loss of self-control, as well as a sense of self-worthlessness which

can lead to a continuation, or even an acceleration in, the severity of binge-eating behavior.

Treatment

Treatment for BED should target eating behavior, associated psychopathology, and

weight and psychiatric symptomatology. Cognitive behavior therapy (CBT) and interpersonal

psychotherapy (IPT) are most successful in the short-term reduction of binge eating. However,
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reduction of binge eating through these methods usually only result in modest weight loss, and it

is often costly and intensive for many individuals.

Bulimia Nervosa

Self-induced vomiting is the most frequently used method that patients with Bulimia

Nervosa use in order to purge their unwanted weight; The medical complications of self-induced

vomiting are severe and can cause irreversible damage. Repetitive self-induced binging and

vomiting can result in: Cutaneous manifestations, abnormalities in the oral cavity (dental erosion,

tooth hypersensitivity, periodontal disease), acid reflux, GERD, dehydration, cardiac disease, a

higher risk of miscarriages, and more. (Mehler & Rylander, 2015). While less prevalent than

self-induced vomiting, laxative abuse is the second most commonly utilized method of purging

weight in patients with bulimia. Laxative abuse can lead to gastrointestinal effects and electrolyte

disturbance.

Like anorexia, bulimia is especially common among adolescent females within the 15-16

year old age range. Young girls “are subject to stricter parental control, are less satisfied with

their appearance, and made to feel inferior in social interactions, and have a lower self-esteem”

(Scodellaro, 2017). These stressors tend to make them feel like they have no control over their

lives, which results in them forming unhealthy habits in order to regain that loss of control.

Along with gender and age, a person's social class also plays a vital role in those affected with

bulimia. “The highest prevalence is observed among upper-class girls.. and remains the lowest

among working-class girls.” (Scodellaro, 2017). Struggling with this at any point in a person’s

life takes a significant toll on their mental health, so many people turn to therapy.

Treatment Methodology
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Bulimia is not only associated with a multitude of medical complications, but also a poor

quality of life and an alarmingly high death rate. Although many treatments continue to remain

grim, there has been some effectiveness with the use of an unconventional route: therapeutic

rapport. According to Jaqueline Patmore (2019), “One means of facilitating a heightened sense

of alliance between the patient and provider is through therapist self‐disclosure” (p. 266). This

therapy can assist the patient’s responsiveness to the treatment due to feeling a sense of security

without judgement. The patient will not feel alone or isolated due to their condition, and will be

more likely to engage in the therapy. Patmore (2019) supports the effectiveness of this theory

with respect to individuals suffering from eating disorders like bulimia when she writes: “Eating

disordered individuals may be particularly sensitive to the effects of strong provider rapport

given the nature of the illness and the underlying mechanisms... Eating disorders become

emotional regulation systems that provide a sense of control over tension states and resolve

feelings of disconnectedness.” (p. 267). Patmore also explains that although patients with eating

disorders can be quite defensive when discussing their condition, they can significantly benefit

from the comfort of knowing that the provider is acting from a place of understanding,

compassion, and sensitivity for the patient’s situation.

There are many schools of thought when it comes to treating a patient. Some are very

precise and methodical, while others are more free-flowing. There are numerous points of reason

when it comes to determining which method is best for the longevity of a patient’s health. The

team led by Stig Poulsen, Ph.D., specifically wanted to compare Psychoanalytic Psychotherapy

and Cognitive Behavioral Therapy (CBT) to determine which of them would produce the most

desired outcome when treating someone who is suffering from Bulimia Nervosa. To be

diagnosed with Bulimia Nervosa, the patient would need to have at least one episode per week
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for three months; the episode may consist of “self-induced vomiting, the misuse of laxative,

diuretics/other medications, or excessive fasting/exercise” to achieve an ideal look. (DSM-5. p

345). For the study, the researchers used a randomized control trial consisting of 70 patients

diagnosed with Bulimia Nervosa, ages 18 and up, who had no other treatments that could hinder

the results of the study. The study lasted for two years. Within the study, the patient’s either

received a weekly 50-minute session of psychoanalytic psychotherapy, consisting of the patient

being able to freely talk while reflecting on the circumstances triggering their symptoms, or 20

50-minute sessions of CBT that are preceded by one 90-minute preparatory session and followed

by one review session 20 weeks after treatment. In conclusion, patient improvement was greater

among those who received Cognitive Behavioral Therapy; “42% of the patients in CBT had

ceased to binge eat and purge compared with 15% of the patients in psychoanalytic

psychotherapy.” (Poulsen, et al. 2014).

Correlation Between the Internet and Eating Disorders

Although there is no precise cause of eating disorders, countless studies have been

performed surrounding how internet and app usage affect individuals with eating disorders. A

study done in Singapore assessed a group of patients using a self-reported questionnaire to

investigate patterns surrounding the usage of internet and smartphone applications. The research

was conducted with 55 participants- 41.8% had Anorexia Nervosa, 34.5% had Bulimia Nervosa,

and 9.1% were ED-NOS (Eating Disorder Not Otherwise Specified). Results showed that 41.8%

of the participants felt that internet usage helped continue their illness, and 32.7% of the

participants felt that the internet helped with their recovery. It was concluded in the research that

the internet and mobile apps have a significant correlation to eating disorders. (Tan, 2016).
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Conclusion

Each eating disorder has varying psychological, biological, and sociocultural causes. For

example, binge eating disorder is commonly associated with traumatic life events, while anorexia

and bulimia are not. (Salafia et al., 2015). Each type of disorder is unique, with potentially

unique causes attributed to the disorder. Future research should continue to explore these

differences and focus on the individual nature of each type of eating disorder. The seriousness of

eating disorders is more evident now than ever, primarily due to their adverse psychological

effects. Eating disorder treatments have evolved over time and continue to do so; further research

will develop more effective and promising treatments.

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental

Disorders, Fifth Edition. Psychiatry Online. 329, 345, and 350-351.

https://doi.org/10.1176/appi.books.9780890425596.

Clinic Staff, M. (2018, February 20). Anorexia Nervosa.

https://www.mayoclinic.org/diseases-conditions/anorexia-nervosa/symptoms-causes/syc-

20353591.

Costa-Font, J., & Jofre-Bonet, M. (2013). Anorexia, Body Image and Peer Effects:

Evidence from a Sample of European Women. Economica, 80(317), 44-64.

http://www.jstor.org/stable/24029761

Dingemans, A. (2017, November 22). Emotion Regulation in Binge Eating Disorder: A

Review. MDPI. https://doi.org/10.3390/nu9111274.

Duarte, C., Pinto, G. J., & Ferreira, C. (2017). Ashamed and Fused with Body Image and

Eating: Binge Eating as an Avoidance Strategy. Clinical Psychology & Psychotherapy,

24(1), 195–202. https://doi-org.ezproxy.lib.uh.edu/10.1002/cpp.1996

Eddy, K., Tabri, N., Thomas, J. J., Murrary, H. B., Keshaviah, A., Hastings, E., Edkins, K.,

Krishns, M., Herzog, D. B., Keel, P. K., & Franko, D. L. (2017). Recovery From

Anorexia Nervosa and Bulimia Nervosa at 22-Year Follow-Up. The Journal of

clinical psychiatry, 78(2), 184-189.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7883487/.
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Mehler, P. S., & Rylander, M. (2015, April 3). Bulimia Nervosa – medical complications.

Journal of Eating Disorders.

https://jeatdisord.biomedcentral.com/articles/10.1186/s40337-015-0044-4?report=reader.

Patmore, J. (2020). Therapist self-disclosure in the treatment of eating disorders: A

personal perspective. Journal of Clinical Psychology, 76(2), 266-276.

http://ezproxy.lib.uh.edu/login?url=http://search.ebscohost.com/login.aspx?

direct=true&db=psyh&AN=2019-72756-001&site=ehost-live

Poulsen, S., Lunn, S., Daniel, S., Folke, S., Mathiesen, B., Katznlson, H., & Fairburn, C.

(2014). A Randomized Controlled Trial of Psychoanalytic Psychotherapy or

Cognitive-Behavioral Therapy for Bulimia Nervosa. The American Journal of

Psychiatry, 171(1), 109-116. https://doi.org/10.1176/appi.ajp.2013.12121511

Salafia, E. H. B., Jones, M. E., Haugen, E. C., & Schaefer, M. K. (2015). Perceptions of

the causes of eating disorders: a comparison of individuals with and without eating

disorders. Journal of eating disorders, 3(1), 1-10.

https://jeatdisord.biomedcentral.com/articles/10.1186/s40337-015-0069-8

Scodellaro, C., Pan Ké Shon, J., Legleye, S., & Hamilton, P. (2017). Disorders in Social

Relationships: The Case of Anorexia and Bulimia. Revue Française De Sociologie

(English Edition), 58(1), 1-30. Retrieved February 13, 2021

https://www.jstor.org/stable/26605190

Tan, T. (2016, February). Internet and Smartphone Application usage in eating disorders:

A descriptive study in Singapore. Science Direct. https://doi-

org.ezproxy.lib.uh.edu/10.1016/j.ajp.2015.11.007.
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Walsh, T. B. (2013, May 1). The Enigmatic Persistence of Anorexia Nervosa. American

Journal of Psychiatry.

https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2012.12081074#_i8.