Cover Story

At any given time, more than 10 million Americans report symptoms of an eating disorder, such as anorexia nervosa or bulimia nervosa, according to the National Association of Eating Disorders. Millions more struggle with binge-eating disorder.

Psychologists know well the havoc these serious mental illnesses wreak on the body, including osteoporosis, gastrointestinal complications and dental problems, among other significant health problems. But fewer psychologists may know that eating disorders have become one of the nation's deadliest psychological conditions. One out of every five people with anorexia eventually die of causes related to the disorder, and it boasts one the highest suicide rates of any psychiatric condition: A 2003 Archives of General Psychiatry (Vol. 60, No. 2) study found that those with the condition are 56 times more likely to take their own lives than their healthy peers.

"Eating disorders are debilitating and can be fatal," says Joslyn Smith, APA's senior legislative assistant for public interest policy. "But in general, recognition of the seriousness and burden of these illnesses is lacking."

In fact, only half of those with anorexia and bulimia recover fully, and even among those who have recovered from anorexia, many continue to maintain low body weights and experience depression, according to the Academy for Eating Disorders, a global professional organization dedicated to eating-disorders research, education, treatment and prevention.

To combat these numbers and encourage Americans to lead healthier lives, psychologists are leading battles on several fronts to eradicate eating disorders, help those diagnosed with or at risk for these disorders and debunk myths about these conditions.

Genes at work

Some of the most groundbreaking research is examining the genetic risk factors for eating disorders. Although for years experts believed anorexia and bulimia were caused solely by such environmental influences as peer pressure and societal expectations, recent work has shown that many genetic and biological risk factors are at play as well.

"It's not uncommon even in this day and age to see eating disorders referred to as 'choices by vain girls who just want to be skinny,'" says Michigan State University's Kelly Klump, PhD. "What we now know is that just like any other psychiatric condition, such as schizophrenia and bipolar disorder, eating disorders have a strong genetic component."

In her work examining the effects of genes on eating disorders, Klump conducted a series of developmental studies with data from the Minnesota Twin Family Study. She found that the heritability of eating disorder symptoms increases during puberty, from zero risk before puberty to 50 percent or greater after puberty (Psychological Medicine, Vol. 37, No. 5). Along with Florida State University psychology professor Pamela Keel, PhD, Klump is now using those findings to examine how natural changes in ovarian hormone levels may contribute to bulimic behaviors in twins. Preliminary analyses suggest that heritability influences disordered eating most when estrogen levels are at their highest.

Klump is also involved with a study of the genetic underpinnings of anorexia conducted by University of North Carolina at Chapel Hill psychologist Cynthia Bulik, PhD, and other researchers from around the world. As part of a 13-country Genetic Consortium for Anorexia Nervosa, they plan to conduct the largest ever genomewide association study for the disorder, pulling together resources and DNA samples of more than 4,000 females with anorexia and 4,000 controls.

"The name of the game in genetics is large samples, and what we've seen in other disorders, such as autism, obesity and depression, is that researchers are really joining forces to get the numbers," Bulik notes. "The hope is that the consortium will help us unlock the biology underlying the illness, an important step in developing biologically based interventions."

Meanwhile, new and as-yet-unpublished fMRI brain imaging work by Oregon Research Institute psychologist Eric Stice, PhD, suggests that in some females, bulimia may be hard-wired. Stice examined brain activation among 33 female adolescents and 43 young women after they tasted a chocolate milkshake. Over a one-year follow-up period, he found that those who showed greater activation of key reward regions in the brain—particularly the gustatory cortex, somatosensory cortex and striatum—reported increases in bulimic behavior.

"What I think we're learning is that if children are exposed to a high-fat, high-sugar diet early in development, they develop a strong preference for and craving for these foods that doesn't otherwise emerge, and that this is what sets people up for bulimia," he says.

Similar research by Columbia University's Rachel Marsh, PhD, shows that the brains of women with bulimia may react more impulsively than those without an eating disorder. Researchers compared fMRI images from 20 women with bulimia to 20 similar-aged aged healthy controls while the participants identified the direction of a series of arrows viewed on a computer screen. They found that the women with bulimia tended to be more impulsive during the task, responding faster and making more mistakes than healthy women. They also found that the women with bulimia did not show as much activity in brain areas involved in self-regulation and impulse control. Marsh is now studying adolescents with bulimia to determine whether these functional brain abnormalities arise early in the course of the illness, possibly predicting its development and persistence.

Innovative treatments

Psychologists are also at the forefront of several innovative treatments for eating disorders that target hard-to-reach populations, such as adult women and those in rural areas.

UNC's Bulik, in collaboration with researchers at the University of Pittsburgh Medical Center, is conducting a novel clinical trial to compare the efficacy and cost-effectiveness of an online cognitive behavioral therapy augmented with therapist-moderated, weekly online chat sessions with that of traditional face-to-face group therapy. The trial and follow-up will not be complete until next year, but Bulik hopes the online program proves effective so it could help those in rural areas who suffer from the disorder.

Bulik is also partnering with fellow UNC clinical psychologist Donald H. Baucom, PhD, to test a couples-based anorexia treatment. Building on similar cognitive-behavioral couples' interventions for depression, anxiety disorders, smoking cessation and cancer, the program guides the healthy partner in how best to assist in recovery.

"The partners are so grateful [for the intervention] because, by and large, they want to help but they don't know what to do when their partner just stops eating," Bulik says.

Twenty-four couples are taking part in the yearlong clinical trial comparing the "UCAN—Uniting Couples in the treatment of Anorexia Nervosa" intervention to traditional family supportive therapy. If the treatment is successful, the psychologists plan to conduct a multi-site trial of the intervention and develop similar programs for bulimia and binge-eating disorder among older adults.

Clinical psychologist Margo Maine, PhD, co-founder of Maine and Weinstein Specialty Group, based in Hartford, Conn., is also working with older adult women with eating disorders. Most of these women feel shame about their disorder, she says, thinking that they should have outgrown such "teenage" problems. Through individual therapy, Maine helps validate their experiences as women by discussing the many cultural and societal pressures women face in terms of perfectionism and weight and shape, and she encourages her clients to learn how to take time for themselves.

In 2005, Maine co-wrote the book "The Body Myth," (Wiley) about adult women and the pressure they feel to be perfect. She's now working on a chapter on adult women and eating disorders for an edited anthology that explores the disparities between research and treatment of the conditions.

"This is the forgotten story in eating disorders," Maine says. "I think we've gotten so used to putting pressure on women to look young and be something for other people that we don't pay attention to them as they get older."

Evidence-based prevention

Other innovative work is seeking to thwart the development of eating disorders.

Stice, of the Oregon Research Institute, for example, developed an eating-disorder prevention program based on social psychology's theory of cognitive dissonance, in which participants critique the thin-ideal standard of female beauty through a series of verbal, written and behavioral group exercises. A 2008 Journal of Consulting and Clinical Psychology (Vol. 76, No. 2) study with 481 adolescent girls who were dissatisfied with their bodies found that those who participated in the dissonance intervention showed a 60 percent reduction in eating disorder onset compared with controls who had no intervention.

Researchers are now testing the program's effectiveness when it's delivered by high school guidance counselors and physical education teachers.

"It all boils down to one simple premise—that if you take a critical analysis of [the thin ideal], you can talk yourself out of pursuing it," Stice says.

Adapting Stice's model, Trinity University psychology professor Carolyn Black Becker, PhD, has developed a peer-led eating-disorders prevention program that has significantly improved body-image perceptions and decreased disordered eating on college campuses. A study led by Becker also published in JCCP (Vol. 76, No. 2) suggests that participants who attended two two-hour cognitive dissonance-based workshops showed less desire to be thin and were less dissatisfied with their bodies. This year, the sorority Tri Delta and others will implement the program on 28 college campuses nationwide.

Another prevention effort is using the power of the Web. A team of mental health professionals led by Gail McVey, PhD, a health systems scientist at Toronto's Hospital for Sick Children, has created a Web-based program of learning modules that promote health and help prevent eating disorders among children. A study with 78 Toronto elementary school teachers and 89 public health practitioners found that those who took part in the program reported an overall improvement in their awareness of how their own weight biases can come across in their teaching practices (Eating Disorders, Vol. 17, No. 1).

McVey is also working with obesity-prevention researchers to ensure that their programs don't unintentionally lead to eating-disorder development.

"We're trying to find a way to encourage all children to have healthy lifestyles, but we don't want to do it at the cost of triggering weight and shape preoccupation and disordered eating," McVey says.

In a more widespread effort, clinical psychologist and eating disorder specialist Ann Kearney-Cooke, PhD, collaborated last spring with the Dove Self-Esteem Fund to interview 3,344 girls age 8 to 17 in 20 major U.S. cities to get a better sense of girls' self-esteem. They found that seven in 10 girls feel they do not measure up in some way and that 75 percent of girls with low self-esteem report engaging in negative and potentially harmful activities, such as disordered eating, cutting, bullying, smoking or drinking, compared with 25 percent of girls with high self-esteem.

Based on these data, Kearney-Cooke has created a daylong workshop to help girls develop skills to cope with their emotions, healthy relationships with others and a positive body image to reduce their risk for developing an eating disorder. Her approach goes against older notions that the way to boost self-esteem is pointing out each person's uniqueness, Kearney-Cooke says. Instead, she teaches girls how to take more control over their lives.

"Self-esteem is not about being special," Kearney-Cooke says. "It's about mastery and competence and feeling like you can handle the demands of being a teenager."

To date, she's led six workshops on the topic throughout the country, and she now plans to test the curriculum in schools.

Disparities continue

In spite of the growing research and innovative treatments, eating disorders are often undiagnosed, especially among ethnic minorities and men, researchers say.

"There is a paradox of elevated health services use on the one hand and underutilization of appropriate health services," says Wesleyan University psychology professor Ruth Striegel-Moore, PhD, who has examined health services use for eating disorders in large databases of insured populations. Only a minority of people with an eating disorder receive treatment specifically for it. Yet, as she found in a 2008 study in Psychological Medicine (Vol. 38, No. 10), adults who are diagnosed with eating disorders use significantly more health services and incur higher health services costs than individuals who do not have an eating disorder—and they are not getting the mental health services they need.

"The average number of mental health visits was four, which is half of what's recommended in the most minimum of evidence-based psychotherapy interventions for eating disorders," Striegel-Moore says.

In addition, because primary care was the setting in which more than 50 percent of the study's eating-disorder diagnoses were given, the research points to the key role primary-care providers play in screening for the disorders.

In other research, bulimia and binge eating appear to be more prevalent among minority populations than once thought. In a series of articles in the November 2007 special issue of the International Journal of Eating Disorders (Vol. 40, No. S3), researchers reported that Latinos who spent more than 70 percent of their lives in the United States had significantly higher rates of eating disorders than those who had spent more of their lives in their native countries. They also found that blacks who reported higher levels of acculturated stress were at greater risk for body image dissatisfaction and bulimia.

Overall, the study authors say, minorities often do not seek treatment for eating disorders, and they warn that the standard criteria for eating-disorder diagnoses may need to be revised for these populations. Latinos, for example, often exhibit binge-eating behavior rather than restricting their food intake and often will not appear skinny despite their irregular eating patterns, says Margarita Alegria, PhD, director of the Center for Multicultural Mental Health Research at Cambridge Health Alliance.

"We might just be asking the wrong questions," she says.

Another set of research suggests that binge eating during pregnancy may be on the rise, particularly among the economically disadvantaged, based on data gathered by Bulik from an ongoing child and mother cohort study of 100,000 new births in Norway and published in 2007 in Psychological Medicine (Vol. 37, No. 8).

"We hadn't expected that, and we don't really know why that's happening," Bulik says, adding that these results warrant ongoing vigilance by health-care professionals for continuation and emergence of eating disorders in pregnancy.

Other areas of the eating-disorders field are beginning to get more attention. One is purging disorder, in which individuals feel a sense of loss of control after eating only a small amount of food and purge, or people who purge but don't binge. Research by Florida State's Keel has found that people with the condition showed a significantly greater release of cholecystokinin, a hormone that controls feelings of fullness, than people who have bulimia (Archives of General Psychiatry, Vol. 64, No. 9). Study participants also reported greater levels of gastrointestinal distress compared to those with bulimia and the control participants.

These findings suggest the disorder may be worthy of specific delineation in the Diagnostic and Statistical Manual of Mental Disorders as a provisional category for further study, Keel notes, which "would allow for a commonly accepted name and definition for the condition, promote greater progress in researching the psychological and biological features of the disorder and lead to more specific evidence-based treatments." (See "Revamping our definitions of eating disorders".)

Psychologists are also exploring eating disorders among men. In the book "The Muscular Ideal" (APA, 2007), University of South Florida's J. Kevin Thompson, PhD, who co-edited the book with graduate student Guy Cafri, reports a 700 percent increase in the number of journal articles on male body image and eating disorders among men since 2000. In a 2008 Comprehensive Psychiatry article (Vol. 49, No. 4), Thompson and Cafri investigated the symptoms and psychiatric conditions associated with muscle dysmorphia, in which individuals—mainly males—become pathologically preoccupied with their muscularity. He found that those who meet the criteria for the disorder exhibited rigid adherence to dietary regimens, such as carbohydrate restriction and protein overload, in efforts to enhance their appearance of muscularity. Thompson also found that these people reported increased dissatisfaction with their appearances, as well as higher rates of mood and anxiety disorders.

However, these disorders are underdiagnosed, mainly because the men's weights may be normal and they may look healthy, unlike many women with clinically diagnosable eating disorders, Thompson says.

"It would be very easy not to recognize an eating dysfunction that might require clinical attention if you restrict yourself to the DSM criteria or if you look at men and women in the same way," he says.

To reduce such barriers and get men into treatment for eating disorders, psychologist Thomas Hildebrandt, PsyD, and colleagues at New York's Mount Sinai School of Medicine have developed a male-specific questionnaire that could be used in conjunction with the Body Checking Questionnaire that has been used for years to test women for eating disorders. An article in press in the International Journal of Eating Disorders suggests the questionnaire may be a reliable tool indicating eating-disorder psychopathology in males, and if widely adapted, may help in the development of male-specific treatments for eating disorders.

All of these efforts may help save lives and lead to a healthier nation, says Kenyon College psychologist Michael Levine, PhD, an expert in eating-disorders prevention.

"Creating a world in which there will be fewer eating disorders will be one in which both men and women will be healthier because there won't be as much objectification and materialism, or as much emphasis on and preoccupation with thin and fat and control of appetite, shape and weight," Levine says. "I'm really excited about what the next 10 years hold."

Further reading

  • Maine, M., Davis, W.N. & Shure, J. (Eds). (2009). Effective Clinical Practice in the Treatment of Eating Disorders: The Heart of the Matter. New York, NY: Routledge.

  • Maine, M. & Kelly, J. (2005). The Body Myth: Adult Women and the Pressure to be Perfect. Hoboken, NJ: Wiley.

  • Smolak, L. & Thompson, J.K. (Eds). (2009). Body Image, Eating Disorders, and Obesity in Youth: Assessment, Prevention, and Treatment, Second Edition. Washington, DC: APA.

  •  Thompson, J.K. & Cafri, G. (Eds). (2007). The Muscular Ideal: Psychological, Social, and Medical Perspectives. Washington, DC: APA.

  • Thompson, J.K. (Ed). (2003). Body Image, Eating Disorders, and Obesity: An Integrative Guide for Assessment and Treatment. Washington, DC: APA.