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Eating Disorders: Techniques for Treating Binging & Purging
Bulimia continuing education psychologist CEUs

Section 16
Bulimia Nervosa, Part II: Underlying Emotional
& Personality Disorders

CEU Question 16 | CEU Answer Booklet | Table of Contents | Eating Disorders
Psychologist CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs

There is no single cause for eating disorders. Although concerns about weight and body shape underlie all eating disorders, the actual cause of these disorders appear to result from a convergence of many factors, including cultural and family pressures and emotional and personality disorders. Genetics and biologic factors may also play a role.

Personality Disorders
A 2000 study reported that people with eating disorders tended to share similar personality traits, including low self-esteem, dependency, and problems with self-direction. Researchers have been attempting to determine specific personality disorders or behavioral characteristics that might put people at higher risk for one or both of the eating disorders. Some studies have reported the following personality disorders linked to particular eating disorders:

• Avoidant personalities, mostly in anorexia. Such people are generally high functioning, persistent, and perfectionists.
• Dependent personalities, mostly seen in anorexia. (This group is usually overcontrolled and withdrawn.)
• Borderline and histrionic personalities, mostly seen in bulimia. (Such individuals are emotionally uncontrolled and impulsive.)
• Narcissism in both anorexia and bulimia.

It should be noted that any of these personality traits can appear in either patients with bulimia or anorexia; some experts believe that the patient's specific personality disorders, rather than whether they are anorexic or bulimic, may be the more important factor in determining treatment choices.

Borderline Personalities. Studies indicate that almost 40% of people who are diagnosed with bulimic anorexia (who lose weight by bingeing and purging) may have borderline personalities. Such people tend to have the following characteristics:

• Having unstable moods, thought patterns, behavior, and self-images. People with borderline personalities have been described as causing chaos around them by using emotional weapons such as temper tantrums, suicide threats, and hypochondriasis.
• Being frantically fearful of being abandoned.
• Being unable to be alone.
• Having difficulty controlling their anger and impulses. (In fact, between one-quarter and one-third of people with bulimia have impulsive symptoms.)
• Being prone to idealize other people. Frequently this is followed by rejection and by disappointment.

Some research has suggested that the severity of this personality disorder predicts difficulty in treating bulimia, and it might be more important than the presence of psychological problems, such as depression.

Narcissism. Studies have also found that people with bulimia or anorexia are often highly narcissistic and manifest the following personality traits:

• Having an inability to soothe oneself.
• Having an inability to empathize with others.
• Having a need for admiration.
• Being hypersensitive to criticism or defeat.

Accompanying Emotional Disorders
Between 40% and 96% of all eating-disordered patients experience depression and anxiety disorders. It is not clear if emotional disorders, particularly obsessive-compulsive disorder (OCD), are actual causes of the eating disorders, increase susceptibility to them, or share common biologic cause.

Obsessive-Compulsive Disorder (OCD). Obsessive-compulsive disorder is an anxiety disorder that occurs in up to 69% of patients with anorexia and up to 33% of patients with bulimia. In fact, some experts believe that eating disorders are just variants of OCD. Obsessions are recurrent or persistent mental images, thoughts, or ideas, which may result in compulsive behavior, repetitive, rigid, and self-prescribed routines that are intended to prevent the manifestation of the obsession. Women with anorexia and OCD may become obsessed with exercise, dieting, and food. They often develop compulsive rituals, eg, weighing every bit of food, cutting it into tiny pieces, or putting it into tiny containers. The presence of OCD with either anorexia or bulimia does not, however, appear to have any effect on whether a patient improves or not.

Other Anxiety Disorders. A number of other anxiety disorders have been associated with both bulimia and anorexia.

• Phobias. Phobias often precede the onset of the eating disorder. Social phobias, in which a person is fearful about being humiliated in public, are common in both eating disorders.
• Panic Disorder. Panic disorder often follows the onset of an eating disorder. It is characterized by periodic attacks of anxiety or terror (panic attacks).
• Post-Traumatic Stress Disorder. One study of 294 women with serious eating disorders reported that 74% of them recalled a traumatic event and more than half exhibited symptoms of post-traumatic stress disorder (PTSD), which is an anxiety disorder that occurs in response to violent circumstances.

Depression. Depression is common in people with eating disorders, particularly anorexia. Depression and eating disorders are also linked to a similar seasonal pattern, as indicated by the following observations:

• In many people, depression is more severe in darker winter months. Similarly; a subgroup of bulimic patients suffers from a specific form of bulimia that worsens in winter and fall. Such patients are more apt to have started bingeing at an earlier age and to binge more frequently than those whose bulimia is more consistent year round.
• Onset of anorexia appears to peak in May, which is also the peak month for suicide.

Major depression is unlikely to be a cause of eating disorders, however, because treating and relieving depression rarely cures an eating disorder. The severity of the eating disorder is also not correlated with the severity of any existing depression. In addition, depression often improves after anorexic patients begin to gain weight.

Body Image Disorders
Body Dysmorphic Disorder. Body dysmorphic disorder involves a distorted view of one's body that is caused by social, psychologic, or possibly biologic factors. It is often associated with anorexia or bulimia, but it can also occur without any eating disorder. People with this disorder also commonly suffer from emotional disorders, including obsessive-compulsive disorder and depression.

Muscle Dysmorphia. Experts are also increasingly reporting a disorder in which people have distorted body images involving their muscles. It tends to occur in men who perceive themselves as being "puny" and results in excessive body building, preoccupation with diet, and social problems.

Cultural Pressures
One interesting anthropologic study reported the following observations:

• During historical periods or in cultures where women are financially dependent and marital ties are stronger, the standard is toward being curvaceous, possibly reflecting a cultural or economic need for greater reproduction.
• During periods or in cultures where female independence has been possible, the standard of female attractiveness tends toward thinness.
Whether or not the current Western cultural pressure is for fewer children, the response of the media to both the cultural drive for thinness and overproduction of food play major roles in triggering obesity and eating disorders.
• On the one hand, advertisers heavily market weight-reduction programs and present anorexic young models as the paradigm of sexual desirability. Clothes are designed and displayed for thin bodies in spite of the fact that few women could wear them successfully.
• One study reported that teenage boys and girls who made strong efforts to look like celebrities of the same sex were more likely to be constant dieters.
• On the other hand, food is overproduced, and the media floods the public, and particularly women and children, with attractive ads for consuming foods, both at home and out of the home. And, the emphasis is on junk foods.

In a country where obesity is epidemic, young women who achieve thinness believe they have accomplished a major cultural and personal victory; they have overcome the temptations of junk food and, at the same time, created body images idealized by the media. Weight loss brings a feeling of triumph over helplessness. This sense of accomplishment is often reinforced by the envy of heavier companions who perceive the anorexic friend as being emotionally stronger and more sexually attractive than they are.

Excessive Athleticism and the Female Athlete Triad
The cultural attitude toward physical activity is a fitting companion to the general disordered attitude regarding eating. Americans are encouraged to admire physical activity only as an intense competitive effort that few can attain, leaving most people in their armchairs as spectators.

In the small community of athletes, excessive exercise plays a major role in many cases of anorexia (and, to a lesser degree, bulimia). In young female athletes, anorexia postpones puberty, allowing them to retain a muscular boyish shape without the normal accumulation of fatty tissues in breasts and hips that may blunt their competitive edge. Many coaches and teachers compound the problem by overstressing calorie counting and loss of body fat. Some over-control the athletes' lives and are even abusive to an athlete that goes over the weight limit. (Male athletes are also vulnerable to their coaches' influence and anorexia is also a problem among this group.)

In response, people who are vulnerable to such criticism may lose excessive weight, which has been known to be deadly even for famous athletes. The term "female athlete triad" in fact, is now a common and serious disorder facing young female athletes and dancers and describes the combined presence of the following problems:

• Eating disorders. • Amenorrhea (absence or irregular menstruation). Evidence is mounting that overly restricting calories may be more important than low weight in causing menstrual problems. Studies suggest that amenorrhea occurs even in women with normal weight if they severely diet.
• Osteoporosis. Bone loss, on the other hand, appears to be related to low weight. The more severe the weight loss, the more bone is lost.

In one study, female athletes who consumed a high-fat diet (35% of daily calories) performed longer and with greater intensity than those with a standard athletic low-fat diet (27% of daily calories). And such a diet appeared to be more estrogen-protective.
- Eating Disorders; Eating Disorders: Anorexia and Bulimia; (A.D.A.M.); 2002.
The article above contains foundational information. Articles below contain optional updates.

Personal Reflection Exercise #2
The preceding section contained information about underlying emotional and personality disorders in bulimic clients.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 16
What three personality disorders are linked to bulimia nervosa? Record the letter of the correct answer the CEU Answer Booklet.

 
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The article above contains foundational information. Articles below contain optional updates.
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