CHAPTER 5

Eating Disorders, Gender and Sexual Disorders

Objectives
a.) To identify the different types of eating disorder
b.) To give the importance of having a knowledge with different
eating disorder
c.) To analyze the different gender and sexual disorder

Eating Disorders
❖ Anorexia Nervosa
Anorexia nervosa (often referred to simply as anorexia) is that the person
will not maintain at least a low normal weight and employs various methods to prevent
weight gain.
To be diagnosed with anorexia nervosa according to DSM-IV-TR,
symptoms must meet four criteria:
1. A refusal to obtain or maintain a healthy weight (at least 85% of expected
body weight, based on age and height).
2. An intense fear of becoming fat or gaining weight, despite being significantly
underweight.
3. Distortions of body image (the individual’s view of her body).
4. The suppression of menstruation, called amenorrhea, which is diagnosed
after three consecutive missed menstrual cycles in females who have already
begun menstruating
Types of Anorexia Nervosa
1. Restricting - Low weight is achieved and maintained through severe
undereating; there is no binge eating or purging.
2. Binge-eating/purging type- Some people with anorexia may engage in binge
eating—eating much more food at one time than most people would eat in the
same context, for example, a “snack” might consist of a pint or two of ice cream
with a whole jar of hot fudge sauce.
Anorexia can lead to significant medical problems, most importantly muscle wasting
(particularly of heart muscle), as well as low heart rate, low blood pressure, loss of bone
density, and decreased metabolism. Other symptoms include irritability, headaches,
fatigue, and restlessness. All methods of purging—vomiting, diuretics, laxatives, and
enemas—can cause dehydration because they primarily eliminate water, not calories,
from the body.
Starvation also leads to various psychological and social problems,
including a heightened sensitivity to light, cold, and noise, poor sleep and mood, irritability,
anxiety, and preoccupation with food.
Critics of the DSM-IV-TR diagnostic criteria for anorexia point out that the criteria
of low weight and amenorrhea aren’t highly associated with general medical status,
prognosis, or outcome. Also, the two types of anorexia—restricting and binge-eating/
purging—may better represent stages of the disorder rather than distinct paths it can take.
❖ Bulimia Nervosa
A key feature of bulimia nervosa (often simply referred to as bulimia) is
repeated episodes of binge eating followed by inappropriate efforts to prevent weight
gain. Such inappropriate efforts to prevent weight gain are categorized by DSM-IV-TR as
either purging or non purging.
The purging type includes vomiting or using diuretics, laxatives, or
enemas.
The nonpurging type involves other behaviors to prevent weight gain, such
as fasting or excessive exercise. Exercise is considered excessive by
mental health clinicians if the individual feels high levels of guilt when she
postpones or misses a workout.
Bulimia is twice as prevalent as anorexia, and much more common among
women than men.
All purging methods can cause dehydration, which leads to electrolyte
imbalances and possibly death. Chronic vomiting can lead to enlarged parotid and
salivary glands and can erode dental enamel. Chronic laxative use can lead to permanent
loss of intestinal functioning.
Aspects of the DSM-IV-TR criteria for a diagnosis of bulimia have been criticized:
The defi nition of “binge eating” is subjective, the purging/nonpurging distinction does not
correlate meaningfully with course or prognosis, and bulimia and anorexia do not appear
to be distinct disorders but rather may be different phases of the same disorder.
Problems with the criteria for anorexia and bulimia are apparent in the
prevalence of eating disorder not otherwise specified (EDNOS), which is greater than
anorexia and bulimia combined. One subset of patients with EDNOS have binge-eating
disorder.
❖ Understanding Eating Disorders
It is particularly difficult for researchers to establish causeand-effect
relationships among the factors associated with eating disorders. This diffi culty
arises because the symptoms themselves—restricting, bingeing, purging,
excessive exercise, malnourishment—create neurological (and other biological),
psychological, and social changes.
Neurological factors associated with eating disorders include:
• unusually low activity in the frontal, temporal, and parietal lobes, as
well as the anterior cingulate cortex, the basal ganglia, and the
cerebellum. However, these neural patterns may vary for specifi c
types of anorexia, and may be affected by dieting. Patients with
anorexia also have reduced gray and white matter;
• reduced responsiveness to serotonin, a neurotransmitter involved in
mood, anxiety, and binge eating. One theory about the role of
serotonin in bulimia involves tryptophan, a building block of
serotonin;
• a tendency for eating disorders tend to run in families, as well as
evidence of substantial heritability, which indicates that genes play a
role.
Psychological factors related to eating disorders include:
• irrational thoughts and excessive concerns about weight,
appearance, and food;
• binge eating as a result of the abstinence violation effect;
• positive and negative reinforcement of symptoms of eating disorders
(restricting, bingeing, and purging);
• certain personality traits: perfectionism, harm avoidance,
neuroticism, and low self-esteem;
• disinhibited eating, triggered by the last supper effect, especially in
restrained eaters; and
• comorbid psychological disorders in female adolescents, particularly
depression.

Social factors related to eating disorders include:

• family members and friends who provide a model for eating,
concerns about weight, and focus on appearance through their own
behaviors and responses to others;
• cultural factors, which play a key role, as evidenced by the increased
prevalence over time of bulimia and concern about weight that is part
of anorexia. Specific cultural factors include a cultural ideal of
 thinness and repeated exposure—through the media—to this ideal,
as well as the individual’s assimilation of this ideal. People in
Western and Westernized countries are more likely to develop eating
disorders than are people from non-Western and developing
countries;
• confl icting gender roles in Western societies and a tendency to view
women’s bodies as objects and search for bodily fl aws (objectifi
cation theory).

❖ Treating Eating Disorders

The treatments that target neurological and other biological factors include:
• nutritional counseling to improve eating (and can also correct
erroneous information about food and weight);
• medical hospitalization for significant medical problems related to the
disorder; and
• medication to address some symptoms of the eating disorder and of
anxiety and depression. Specifically, SSRIs may help prevent
relapse in those with anorexia and can decrease symptoms of
bingeing and purging in those with bulimia.
The primary treatment that targets psychological factors is CBT, which is the
treatment of choice for eating disorders. CBT addresses maladaptive thoughts, feelings,
and behaviors that impede normal eating, promote bingeing and purging, and lead to
body image dissatisfaction. CBT may include exposure with response prevention and
help patients develop new coping strategies.
Treatments that target social factors include:
• interpersonal therapy, which is designed to improve the patient’s
relationships; as relationships become more satisfying, the eating
disorder symptoms diminish;
• Family therapy, particularly the Maudsley approach, which can be
helpful for adolescents with anorexia who live at home. Parents
figure out how to feed their child, despite her protests, until she eats
normally and without a struggle;
• psychiatric hospitalization, which provides supervised mealtimes to
increase normal eating, and a range of therapeutic groups to address
various psychological and social factors (such as irrational beliefs
about food and weight and social problems), plus individual therapy
and possibly medication;
• prevention programs, which have the goal of preventing eating
disorders from developing, particularly in high-risk individuals.
 Gender and Sexual Disorder
❖ Gender Identity Disorder
Gender identity disorder is characterized by a persistent cross gender
identification that leads to chronic discomfort with one’s biological sex. Symptoms of
gender identity disorder often emerge in childhood, but most children diagnosed with the
disorder no longer have the disorder by the time they become adults. However, most
adults with gender identity disorder report that their symptoms began in childhood.
In children, symptoms of gender identity disorder include cross-dressing and
otherwise behaving in ways typical of the other sex, such as engaging in other-sex types
of play, choosing other-sex playmates, and even claiming to be the other sex. In adults,
symptoms include persistent and extreme discomfort from living publicly as their
biological sex, which leads many to live (at least some of the time) as someone of the
other sex.
In children, symptoms of gender identity disorder include cross-dressing and
otherwise behaving in ways typical of the other sex, such as engaging in other-sex types
of play, choosing other-sex playmates, and even claiming to be the other sex. In adults,
symptoms include persistent and extreme discomfort from living publicly as their
biological sex, which leads many to live (at least some of the time) as someone of the
other sex.
Criticisms of the diagnostic criteria in DSM-IV-TR for this disorder point to the
overly narrow concept of gender and appropriate behavior (particularly for males) and the
ambiguous requirement about distress. With gender identity disorder, the person’s
distress often arises because of other people’s reactions to the cross-gender behaviors.
Some brain areas in adults with gender identity disorder are more similar to the
corresponding brain areas of members of their desired sex than they are to those of their
biological sex. Results from animal studies suggest that one explanation for this disorder
is that prenatal exposure to hormones causes the brain to develop in ways more similar
to the other sex, although the sexual characteristics of the body are unchanged. Beyond
symptoms that are part of the diagnostic criteria for the disorder, no psychological or
social factors are clearly associated with the disorder
Treatments may target neurological (and other biological), psychological, or
social factors:
• Treatments that target neurological (and other biological) factors include
hormone treatments and sex reassignment surgery.
• Treatments that target psychological factors include psychoeducation,
helping the patient choose among gender- related lifestyle options, and
problem solving about potential difficulties.
• Treatments that target social factors include family education, support
groups, and group therapy.
❖ Paraphilias
Paraphilias are characterized by a predictable sexual arousal pattern
regarding “deviant” fantasies, objects, or behaviors. Paraphilias can involve
(1) nonconsenting partners or children (exhibitionism, voyeurism,
frotteurism, and pedophilia),
(2) suffering or humiliating oneself or one’s partner (sexual masochism and
sexual sadism), or
(3) arousal by nonhuman objects (fetishism and transvestic fetishism). To
be diagnosed with a paraphilia, either the person must have acted on these
sexual urges and fantasies, or these arousal patterns must cause the patient
significant distress.

Assessments of paraphilias may involve the use of a penile

plethysmograph to determine the sorts of stimuli that arouse a man, as well as
self-reports of arousing stimuli and reports from partners and from the criminal
justice system for those apprehended for sexual crimes.
Criticisms of the DSM-IV-TR paraphilia classification include the
following: What is determined to be sexually “deviant” varies across cultures and
over time; the diagnostic criteria are overly broad (e.g., fantasies or behavior,
distress or no distress) and thereby lead clinicians to group together very
different disorders (that is, to create a heterogeneous group); and the criteria do
not address the ability to control the paraphilic urges.
Most frequently, men who receive treatment for paraphilias were
ordered to do so by the criminal justice system. Treatments that target
neurological factors decrease paraphilic behaviors through medication;
however, although the behaviors may decrease, the interests often do not.
Treatments that target psychological factors are designed to change cognitive
distortions about the predatory sexual behaviors, especially the false belief that
the behavior is not harmful to the nonconsenting victims. A goal of such
treatments is to change sexual arousal patterns using behavioral methods, as
well as to prevent relapse. Although social factors may be the target of treatment
for sex offenders, they have not generally been successful.

❖ Sexual Dysfunctions
Sexual dysfunctions are characterized by problems in the sexual response
cycle. Let’s fi rst examine this cycle and then consider various ways in which it can
go awry for men and women.

What is a normal sexual response?

1. Excitement. Excitement occurs in response to sensory-motor, cognitive, and
emotional stimulation that leads to erotic sensations or feelings. Such arousal
includes muscle tension throughout the body and engorged blood vessels,
 especially in the genital area. In men, this means that the penis swells; in
women, this means that the clitoris and external genital area swell and
vaginal lubrication occurs.
2. Plateau. Bodily changes that began in the excitement phase become more
intense and then level off when the person reaches the highest level of
arousal.
3. Orgasm. The arousal triggers involuntary contractions of internal genital
organs, followed by ejaculation in men. In women, responses range from
extended or multiple orgasms (without falling below the plateau level) to
resolution.
4. Resolution. Following orgasm is a period of relaxation, of release from
tension. For men, this period is often referred to as a refractory period, during
which it is impossible to have an additional orgasm. Women rarely have such
limitations and can often return to the excitement phase with effective sexual
stimulation.
 Hypoactive sexual desire disorder .A sexual dysfunction characterized by a
persistent or recurrent lack of sexual fantasies or an absence of desire for sexual activity.
Sexual aversion disorder, whose hallmark is a persistent or recurrent extreme
aversion to and avoidance of most genital sexual contact with a partner.
Sexual arousal disorders occur when a person cannot become aroused or
cannot maintain arousal during a sexual encounter.
Female sexual arousal disorder. A sexual dysfunction marked by a woman’s
persistent or recurrent difficulty attaining or maintaining engorged genital blood vessels
in response to adequate stimulation; formerly referred to as frigidity.
Male erectile disorder A sexual dysfunction characterized by a man’s
persistent or recurrent inability to attain or maintain an adequate erection until the end of
sexual activity; sometimes referred to as impotence.
Orgasmic disorder is diagnosed when a clinician determines that the individual
has experienced normal excitement and adequate stimulation for orgasm in normal
circumstances (based on the person’s age and other factors)—but fails to have an
orgasm.
Female Orgasmic Disorder Female orgasmic disorder is diagnosed when a
woman’s normal sexual excitement does not lead to orgasm or when orgasm is delayed
following a normal amount of stimulation.
Male orgasmic disorder. A sexual dysfunction characterized by a man’s delay
or absence of orgasm.
Premature ejaculation. A sexual dysfunction characterized by orgasm and
ejaculation that occur earlier than the man expects, usually before, immediately during,
or shortly after penetration.
Sexual Pain Disorders
Dyspareunia is characterized by recurrent or persistent genital pain that is
associated with sexual intercourse (see Table 11.5). In men, dyspareunia is rare
(Bancroft, 1989; Sadock, 1995).
Vaginismus consists of recurrent or persistent involuntary spasms of the
musculature of the outer third of the vagina, which interfere with sexual intercourse.
Criticisms of the DSM-IV-TR sexual dysfunction disorders include the following:
(1) The sexual response cycle may not apply equally well to women;
(2) the criteria focus almost exclusively on the neurological (and other biological)
components;
(3) the end goal is orgasm, not satisfaction;
 (4) the criteria rest on a particular definition of normal sexual functioning that
doesn’t encompass normal aging;
(5) there are no duration criteria;
(6) the definition of distress or interpersonal diffi ulty caused by the sexual
dysfunction is vague;
(7) the DSM-IV-TR definitions of the sexual dysfunctions for women aren’t
necessarily the ones used by specialists in human sexuality;
(8) dyspareunia should be considered a pain disorder, not a sexual disorder
Various factors contribute to sexual dysfunctions. Neurological (and other
biological) factors include disease, illness, surgery or medications, and the normal aging
process.
Psychological factors can be divided into three types: predisposing factors, such
as negative attitudes toward sex, negative conditioning experiences, and a history of
sexual abuse; precipitating factors, such as anxiety about sex and distraction because of
sexual or nonsexual matters; and maintaining factors, such as worrying about future
sexual problems.
Social factors include: the quality of the partners’ relationship (how stress,
conflict, and communication are handled, and how attracted the partners are to one
another); the partner’s sexual functioning; a history of abuse; and sexual mores in the
individual’s subculture (e.g., religious teachings)
Neurological (and other biological) factors that may contribute to sexual
dysfunctions are assessed through tests of endocrine and hormone levels and of the
functioning of sensory nerves, internal organs, and the genitals. Psychological factors are
sometimes assessed through personality tests and inventories; a clinician will also
consider possible comorbid disorders and assess a patient’s thoughts and feelings about
sexual activities. Social factors include the ways that sexual problems interact with any
relationship problems a couple may have.
Treatments that target neurological (and other biological) are medications for
erectile dysfunction and for analogous arousal problems in women
Treatments that target psychological factors include psycho education, sensate
focus exercises, and CBT to counter negative thoughts, beliefs, and behaviors associated
with sexual dysfunction. For certain sexual dysfunctions, specific techniques may be
particularly helpful.
Treatments that target social factors address problematic issues in a couple’s
relationship as well as teach the couple specific sex-related cognitive or behavioral
strategies
 Treatments that focus on one type of factor for a given patient can create
complex feedback loops, which sometimes have unexpected—and perhaps negative—
consequences for the couple. Successful treatment for a patient might create problems
for the partner.