Most of today’s theorists and researchers use a multidimensional risk perspective to explain eating disorders. That is, they identify several key factors that place a person at risk for these disorders (Jacobi & Fittig, 2010). The more of these factors that are present, the more likely it is that a person will develop an eating disorder. The most common of these are psychological, biological, and sociocultural factors. As you will see, most of the factors that have been cited and investigated center on anorexia nervosa and bulimia nervosa. Binge-eating disorder, identified as a clinical syndrome more recently, is only now being broadly investigated. Which of these factors are also at work in this “newer” disorder will probably become clearer in the coming years.

Hilde Bruch, a pioneer in the study and treatment of eating disorders, was mentioned earlier in this chapter. Bruch developed a largely psychodynamic theory of the disorders. She argued that disturbed mother–child interactions lead to serious ego deficiencies in the child (including a poor sense of independence and control) and to severe perceptual disturbances that jointly help produce disordered eating (Bruch, 2001, 1991, 1962).

According to Bruch, parents may respond to their children either effectively or ineffectively. Effective parents accurately attend to their children’s biological and emotional needs, giving them food when they are crying from hunger and comfort when they are crying out of fear. Ineffective parents, by contrast, fail to attend to their children’s needs, deciding that their children are hungry, cold, or tired without correctly interpreting the children’s actual condition. They may feed their children when their children are anxious rather than hungry, or comfort them when they are tired rather than anxious. Children who receive such parenting may grow up confused and unaware of their own internal needs, not knowing for themselves when they are hungry or full and unable to identify their own emotions.

Because they cannot rely on internal signals, these children turn instead to external guides, such as their parents. They seem to be “model children,” but they fail to develop genuine self-reliance and “experience themselves as not being in control of their behavior, needs, and impulses, as not owning their own bodies” (Bruch, 1973, p. 55). Adolescence increases their basic desire to establish independence, yet they feel unable to do so. To overcome their sense of helplessness, they seek excessive control over their body size and shape and over their eating habits. Helen, an 18-year-old patient of Bruch’s, described such needs and efforts:

Clinical reports and research have provided some support for Bruch’s theory (Holtom-Viesel & Allan, 2014; Schultz & Laessle, 2012; Zerbe, 2010). Clinicians have observed that the parents of teenagers with eating disorders do tend to define their children’s needs rather than allow the children to define their own needs (Ihle et al., 2005; Steiner et al., 1991). When Bruch interviewed the mothers of 51 children with anorexia nervosa, many proudly recalled that they had always “anticipated” their young child’s needs, never permitting the child to “feel hungry” (Bruch, 1973).

Research has also supported Bruch’s belief that people with eating disorders perceive internal cues, including emotional cues, inaccurately (Lavender et al., 2014; Siep et al., 2011; Fairburn et al., 2008). When research participants with an eating disorder are anxious or upset, for example, many of them mistakenly think they are also hungry (see Figure 11-2), and they respond as they might respond to hunger—by eating. In fact, people with eating disorders are often described by clinicians as alexithymic, meaning they have great difficulty putting descriptive labels on their feelings (Zerbe, 2010, 2008). And finally, studies support Bruch’s argument that people with eating disorders rely excessively on the opinions, wishes, and views of others (see MindTech below). They are more likely than other people to worry about how others view them, to seek approval, to be conforming, and to feel a lack of control over their lives (Amianto et al., 2011; Travis & Meltzer, 2008).

If you look closely at Bruch’s explanation of eating disorders, you’ll see that it contains several cognitive ideas. She held, for example, that as a result of ineffective parenting, people with eating disorders improperly label their internal sensations and needs, generally feel little control over their lives, and in turn, want to have excessive levels of control over their body size, shape, and eating habits. According to cognitive theorists, these deficiencies contribute to a broad cognitive distortion that lies at the center of disordered eating, namely, people with anorexia nervosa and bulimia nervosa judge themselves—often exclusively—based on their shape and weight and their ability to control them (Murphy et al., 2010; Fairburn et al., 2008). This “core pathology,” say cognitive theorists, gives rise to all other aspects of the disorders, including the repeated efforts to lose weight and the preoccupation with thoughts about shape, weight, and eating.

As you saw earlier in the chapter, research indicates that people with eating disorders do indeed display such cognitive deficiencies (Siep et al., 2011; Eifert et al., 2007). Although studies have not clarified that such deficiencies are the cause of eating disorders, many cognitive-behavioral therapists proceed from this assumption and center their treatment for the disorders on correcting the clients’ cognitive distortions and their accompanying behaviors. As you’ll soon see, cognitive-behavioral therapies of this kind are among the most widely used of all treatments for eating disorders (Fairburn et al., 2008).

Many people with eating disorders, particularly those with bulimia nervosa, have symptoms of depression (Vögele & Gibson, 2010). This finding has led some theorists to suggest that depressive disorders set the stage for eating disorders.

Their claim is supported by four kinds of evidence. First, many more people with an eating disorder qualify for a clinical diagnosis of major depressive disorder than do people in the general population. Second, the close relatives of people with eating disorders seem to have a higher rate of depressive disorders than do close relatives of people without such disorders. Third, as you will soon see, many people with eating disorders, particularly bulimia nervosa, have low activity of the neurotransmitter serotonin, similar to the serotonin abnormalities found in people with depression. And finally, people with eating disorders are often helped by some of the same antidepressant drugs that reduce depression. Of course, although such findings suggest that depression may help cause eating disorders, other explanations are possible. For example, the pressure and pain of having an eating disorder may cause depression.

Biological theorists suspect that certain genes may leave some people particularly susceptible to eating disorders (Starr & Kreipe, 2014; Helder & Collier, 2011). Consistent with this idea, relatives of people with eating disorders are up to six times more likely than other people to develop the disorders themselves (Thornton et al., 2011; Strober et al., 2001, 2000). Moreover, if one identical twin has anorexia nervosa, the other twin also develops the disorder in as many as 70 percent of cases; in contrast, the rate for fraternal twins, who are genetically less similar, is 20 percent. Similarly, in the case of bulimia nervosa, identical twins display a concordance rate of 23 percent, compared with a rate of 9 percent among fraternal twins (Thornton et al., 2011; Kendler et al., 1995, 1991).

One factor that has interested investigators is the possible role of serotonin. Several research teams have found a link between eating disorders and the genes responsible for the production of this neurotransmitter, and still others have measured low serotonin activity in many people with eating disorders (Phillips et al., 2014; Starr & Kreipe, 2014; Kaye, 2011). Given serotonin’s role in depression and obsessive-compulsive disorder—problems that often accompany eating disorders—it is possible that low serotonin activity has more to do with those other disorders than with the eating disorders per se. On the other hand, perhaps low serotonin activity contributes directly to eating disorders—for example, by causing the body to crave and binge on high-carbohydrate foods (Kaye et al., 2012, 2011, 2005, 2002, 2000).

Other biological researchers explain eating disorders by pointing to the hypothalamus, a part of the brain that regulates many bodily functions (Berthoud, 2012; Fetissov & Meguid, 2010; Higgins & George, 2007). Researchers have located two separate areas in the hypothalamus that help control eating. One, the lateral hypothalamus (LH), consisting of the side areas of the hypothalamus, produces hunger when it is activated. When the LH of a laboratory animal is stimulated electrically, the animal eats, even if it has been fed recently. In contrast, another area, the ventromedial hypothalamus (VMH), consisting of the bottom and middle of the hypothalamus, reduces hunger when it is activated. When the VMH is electrically stimulated, laboratory animals stop eating.

These areas of the hypothalamus and related brain structures are apparently activated by chemicals from the brain and body, depending on whether the person is eating or fasting (Schwartz, 2014; Petrovich, 2011). Two such brain chemicals are the natural appetite suppressants cholecystokinin (CCK) and glucagon-like peptide-1 (GLP-1) (Dossat et al., 2014; Tortorella et al., 2014; Turton et al., 1996). When one team of researchers collected and injected GLP-1 into the brains of rats, the chemical traveled to receptors in the hypothalamus and caused the rats to reduce their food intake almost entirely even though they had not eaten for 24 hours. Conversely, when “full” rats were injected with a substance that blocked the reception of GLP-1 in the hypothalamus, they more than doubled their food intake.

Some researchers believe that the hypothalamus, related brain areas, and chemicals such as CCK and GLP-1, working together, comprise a “weight thermostat” of sorts in the body, which is responsible for keeping an individual at a particular weight level called the weight set point. Genetic inheritance and early eating practices seem to determine each person’s weight set point (Sullivan et al., 2011; Levin, 2010). When a person’s weight falls below his or her particular set point, the LH and certain other brain areas are activated and seek to restore the lost weight by producing hunger and lowering the body’s metabolic rate, the rate at which the body expends energy. When a person’s weight rises above his or her set point, the VMH and certain other brain areas are activated, and they try to remove the excess weight by reducing hunger and increasing the body’s metabolic rate.

According to the weight set point theory, when people diet and fall to a weight below their weight set point, their brain starts trying to restore the lost weight. Hypothalamic and related brain activity produce a preoccupation with food and a desire to binge. They also trigger bodily changes that make it harder to lose weight and easier to gain weight, however little is eaten (Monteleone, 2011; Higgins & George, 2007). Once the brain and body begin conspiring to raise weight in this way, dieters actually enter into a battle against themselves. Some people apparently manage to shut down the inner “thermostat” and control their eating almost completely. These people move toward restricting-type anorexia nervosa. For others, the battle spirals toward a binge-purge or binge-only pattern. Although the weight set point explanation has received considerable debate in the clinical field, it remains widely accepted by theorists and practitioners.

Eating disorders are more common in Western countries than in other parts of the world (see PsychWatch below). Thus, many theorists believe that Western standards of female attractiveness are partly responsible for the emergence of the disorders (Levine & Maine, 2010; Russo & Tartaro, 2008). Western standards of female beauty have changed throughout history, with a noticeable shift in preference toward a thin female frame in recent decades (Gilbert et al., 2005). One study that tracked the height, weight, and age of contestants in the Miss America Pageant from 1959 through 1978 found an average decline of 0.28 pound per year among the contestants and 0.37 pound per year among winners (Garner et al., 1980). The researchers also examined data on all Playboy magazine centerfold models over the same time period and found that the average weight, bust, and hip measurements of these women had decreased steadily. More recent studies of Miss America contestants and Playboy centerfolds indicate that these trends have continued (Rubinstein & Caballero, 2000).

Because thinness is especially valued in the subcultures of performers, fashion models, and certain athletes, members of these groups are likely to be particularly concerned and/or criticized about their weight. For example, after undergoing an inpatient treatment program for eating disorders, the popular singer and rapper Kesha recently wrote, “The music industry has set unrealistic expectations for what a body is supposed to look like, and I started becoming overly critical of my own body because of that” (Sebert, 2014).

Studies have found that performers, models, and athletes are indeed more prone than others to anorexia nervosa and bulimia nervosa (Arcelus, Witcomb, & Mitchell, 2014; Martinsen & Sundgot-Borgen, 2013). In fact, many famous young women from these fields have publicly acknowledged grossly disordered eating patterns over the years. Surveys of athletes at colleges around the United States reveal that more than 9 percent of female college athletes suffer from an eating disorder and at least another 33 percent display eating behaviors that put them at risk for such disorders (Ekern, 2014; Kerr et al., 2007; Johnson, 1995). A full 20 percent of surveyed gymnasts appear to have an eating disorder (see Figure 11-3 below).

Attitudes toward thinness may also help explain economic differences in the rates of eating disorders. In the past, women in the upper socioeconomic classes expressed more concern about thinness and dieting than women of the lower socioeconomic classes (Margo, 1985; Stunkard, 1975). Correspondingly, anorexia nervosa and bulimia nervosa were more common among women higher on the socioeconomic scale (Foreyt et al., 1996; Rosen et al., 1991). In recent years, however, dieting and preoccupation with thinness have increased to some degree in all socioeconomic classes, as has the prevalence of these eating disorders (Starr & Kreipe, 2014; Ernsberger, 2009).

Western society not only glorifies thinness but also creates a climate of prejudice against overweight people (Levine & Maine, 2010; Goode & Vail, 2008). Whereas slurs based on ethnicity, race, and gender are considered unacceptable, cruel jokes about obesity are standard fare on the Web and television and in movies, books, and magazines. Research indicates that the prejudice against obese people is deep-rooted (Grilo et al., 2005). Prospective parents who were shown pictures of a chubby child and a medium-weight or thin child rated the former as less friendly, energetic, intelligent, and desirable than the latter. In another study, preschool children who were given a choice between a chubby and a thin rag doll chose the thin one, although they could not say why. It is small wonder that as many as half of elementary school girls have tried to lose weight and 61 percent of middle school girls are currently dieting (Ekern, 2014; Hill, 2006; Stewart, 2004).

Given these trends, it is not totally surprising that a recent survey of 248 adolescent girls directly tied eating disorders and body dissatisfaction to social networking, Internet activity, and television browsing (Latzer, Katz, & Spivak, 2011). The survey found that the respondents who spent more time on Facebook were more likely to display eating disorders, have negative body image, eat in dysfunctional ways, and want to diet. Those who spent more time on fashion and music Web sites and those who viewed more gossip- and leisure-related television programs showed similar tendencies.

Families may play an important role in the development and maintenance of eating disorders (Holtom-Viesel & Allan, 2014; Hoste, Lebow, & Le Grange, 2014). Research suggests that as many as half of the families of people with anorexia nervosa or bulimia nervosa have a long history of emphasizing thinness, physical appearance, and dieting. In fact, the mothers in these families are more likely to diet themselves and to be generally perfectionistic than are the mothers in other families (Zerbe, 2008; Woodside et al., 2002). Tina, a 16-year-old, describes her view of the roots of her eating disorder:

Abnormal interactions and forms of communication within a family may also set the stage for an eating disorder (Holtom-Viesel, & Allan, 2014; Hoste et al., 2014). Family systems theorists argue that the families of people who develop eating disorders are often dysfunctional to begin with and that the eating disorder of one member is a reflection of the larger problem. Influential family theorist Salvador Minuchin, for example, believes that what he calls an enmeshed family pattern often leads to eating disorders (Olson, 2011; Minuchin et al., 2006).

In an enmeshed system, family members are overinvolved in each other’s affairs and overconcerned with the details of each other’s lives. On the positive side, enmeshed families can be affectionate and loyal. On the negative side, they can be clingy and foster dependency. Parents are too involved in the lives of their children, allowing little room for individuality and independence. Minuchin argues that adolescence poses a special problem for these families. The teenager’s normal push for independence threatens the family’s apparent harmony and closeness. In response, the family may subtly force the child to take on a “sick” role—to develop an eating disorder or some other illness. The child’s disorder enables the family to maintain its appearance of harmony. A sick child needs her family, and family members can rally to protect her. Some case studies have supported such family systems explanations, but systematic research fails to show that particular family patterns consistently set the stage for the development of eating disorders (Holtom-Viesel & Allan, 2014; Konstantellou et al., 2011). In fact, the families of people with either anorexia nervosa or bulimia nervosa vary widely.

In the popular 1995 movie Clueless, Cher and Dionne, wealthy teenage friends of different races, have similar tastes, beliefs, and values about everything from boys to schoolwork. In particular, they have the same kinds of eating habits and beauty ideals, and they are even similar in weight and physical form. But does the story of these young women reflect the realities of white American and African American females in our society?

In the early 1990s, the answer to this question appeared to be a resounding no. Most studies conducted up to the time of the movie’s release indicated that the eating behaviors, values, and goals of young African American women were considerably healthier than those of young white American women (Lovejoy, 2001; Cash & Henry, 1995; Parker et al., 1995). A widely publicized 1995 study at the University of Arizona, for example, found that the eating behaviors and attitudes of young African American women were more positive than those of young white American women. It found, specifically, that nearly 90 percent of the white American respondents were dissatisfied with their weight and body shape, compared with around 70 percent of the African American teens.

The study also suggested that white American and African American adolescent girls had different ideals of beauty. The white American teens, asked to define the “perfect girl,” described a girl of 5'7" weighing between 100 and 110 pounds—proportions that mirror those of so-called supermodels. Attaining a perfect weight, many said, was the key to being happy and popular. In contrast, the African American respondents emphasized personality traits over physical characteristics. They defined the “perfect” African American girl as smart, fun, easy to talk to, not conceited, and funny; she did not necessarily need to be “pretty,” as long as she was well groomed. The body dimensions the African American teens described were more attainable for the typical girl; they favored fuller hips, for example. Moreover, the African American respondents were less likely than the white American respondents to diet for extended periods.

Unfortunately, research conducted over the past decade suggests that body image concerns, dysfunctional eating patterns, and anorexia nervosa and bulimia nervosa are on the rise among young African American women as well as among women of other minority groups (Starr & Kreipe, 2014; Gilbert, 2011; Levine & Smolak, 2010). For example, a survey conducted by Essence—the largest-circulation magazine geared toward African Americans—and studies by several teams of researchers have found that the risk of today’s African American women developing these eating disorders is approaching that of white American women. Similarly, African American women’s attitudes about body image, weight, and eating are closing in on those of white American women (Annunziato et al., 2007). In the Essence survey, 65 percent of African American respondents reported dieting, 39 percent said that food controlled their lives, 19 percent avoided eating when hungry, 17 percent used laxatives, and 4 percent vomited to lose weight.

The shift in the eating behaviors and eating problems of African American women appears to be partly related to their acculturation (Kroon Van Diest et al., 2014; Gilbert, 2011). One study compared African American women at a predominately white American university with those at a predominately African American university. Those at the former school had significantly higher depression scores, and those scores were positively correlated with eating problems (Ford, 2000).

Still other studies indicate that Hispanic American female adolescents and young adults engage in disordered eating behaviors and express body dissatisfaction at rates about equal to those of white American women (Levine & Smolak, 2010; Germer, 2005). Moreover, those who consider themselves more oriented to white American culture have particularly high rates of anorexia nervosa and bulimia nervosa (Cachelin et al., 2006). These eating disorders also appear to be on the increase among young Asian American women and young women in several Asian countries (Pike et al., 2013; Stewart & Williamson, 2008). In one Taiwanese study, for example, 65 percent of the underweight girls aged 10 to 14 years said they wished they were thinner (Wong & Huang, 2000).

Despite these trends, the public apparently still believes that women from minority groups are relatively unlikely to develop anorexia nervosa and bulimia nervosa. In one study, 160 undergraduates read the diary of a 16-year-old girl, including passages that revealed disturbed patterns of eating (Gordon, Perez, & Joiner, 2002). The participants who were told that the diarist was white American were much more likely to recognize that she had an eating disorder than were those who were told she was African American or Hispanic American.

One would expect clinical professionals to be wiser in such assessments, and they are—about Hispanic Americans, but not about African Americans. Several years after conducting the study just mentioned, the research team ran the same design, except that they used mental health professionals and clinical psychology graduate students as participants (Gordon et al., 2006). These participants were more likely to believe that the diarist had an eating disorder if she were labeled white American or Hispanic American than if she were labeled African American.

Males account for only 5 to 10 percent of all people with anorexia nervosa and bulimia nervosa. The reasons for this striking gender difference are not entirely clear, but Western society’s double standard for attractiveness is, at the very least, one reason. Our society’s emphasis on a thin appearance is clearly aimed at women much more than men, and some theorists believe that this difference has made women much more inclined to diet and more prone to eating disorders. Surveys of college men have, for example, found that the majority select “muscular, strong and broad shoulders” to describe the ideal male body and “thin, slim, slightly underweight” to describe the ideal female body (Mayo & George, 2014; Toro et al., 2005).

A second reason for the different rates of anorexia nervosa and bulimia nervosa between men and women may be the different methods of weight loss favored by the two genders. According to some clinical observations, men are more likely to use exercise to lose weight, whereas women more often diet (Gadalla, 2009; Toro et al., 2005). And, as you have read, dieting often precedes the onset of these eating disorders.

Why do some men develop anorexia nervosa or bulimia nervosa? In a number of cases, the disorder is linked to the requirements and pressures of a job or sport (Morgan, 2012; Thompson & Sherman, 2011). According to one study, 37 percent of men with these eating disorders had jobs or played sports for which weight control was important, compared with 13 percent of women with such disorders (Braun, 1996). The highest rates of male eating disorders have been found among jockeys, wrestlers, distance runners, body builders, and swimmers. Jockeys commonly spend hours before a race in a sauna, shedding up to seven pounds of weight, and may restrict their food intake, abuse laxatives and diuretics, and force vomiting (Kerr et al., 2007). Herb McCauley, a top jockey who competed in more than 20,000 races and earned $70 million in winnings, suffered from an eating disorder for 20 years, until after his career ended. Using the laxative Ex-Lax and the diuretic Lasix to help him purge, he now says, “I took so many slabs of Ex-Lax that to this day I can’t eat a Hershey bar” (Fountaine, 2000, p. 2). Similarly, male wrestlers in high school and college commonly restrict their food for up to three days before a match in order to “make weight.” Some lose up to five pounds of water weight by practicing or running in several layers of warm or rubber clothing before weighing in for a match.

For other men who develop anorexia nervosa or bulimia nervosa, body image ap-pears to be a key factor, just as it is in women (Mayo & George, 2014; Mond et al., 2014). Many report that they want a “lean, toned, thin” shape similar to the ideal female body, rather than the muscular, broad-shouldered shape of the typical male ideal (Morgan, 2012; Hildebrandt & Alfano, 2009; Soban, 2006).

Still other men seem to be caught up in a different kind of eating disorder, called reverse anorexia nervosa or muscle dysmorphobia. Men with this disorder are very muscular but still see themselves as scrawny and small and therefore continue to strive for a “perfect” body through extreme measures such as excessive weight lifting or the abuse of steroids (Morgan, 2012; Stewart & Williamson, 2008). People with muscle dysmorphobia typically feel shame about their bodies, and many have a history of depression, anxiety, and self-destructive compulsive behavior. About one-third of them also engage in related dysfunctional behaviors such as binge eating.