Anorexia and Bulimia Risk Factors

Exploring Eating Disorders

It is nearly impossible to walk past the aisles in stores without seeing headlines promising secrets to weight loss. Our cell phones are full of advertisements and videos of exercise routines. In the United States being thin has become a national obsession and places unrealistic expectations on what makes a female beautiful. To keep up with these expectations, females become dissatisfied with their bodies. With body dissatisfaction being the single most powerful contributor to the development of eating disorders, it is not surprising that these disorders continue to rise (Comer, 2015). The common eating disorders recognized by the Diagnostic and Statistical Manual are anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED) (APA, 2013). The focus of this paper is on the formally recognized eating disorders, anorexia and bulimia.  Briefly, these disorders are characterized by disturbances in body image and abnormal eating patterns. While the cause is elusive, today’s theorists and researchers believe eating disorders arise from the interaction of multiple risk factors. The more of these factors that are present, the likelier they will develop an eating disorder. Among these factors include biological, psychological, and sociocultural (Rikani, 2013).

Etiology

Biological Factors

Studies have shown a genetic contribution to developing eating disorders (Fairburn & Harrison, 2003). Certain genes may leave some people more susceptible to the development of eating disorders and researchers suggest that these diseases are biologically based forms of severe mental illnesses. This has been further supported by twin and family studies. For each disorder the estimated heritability ranges between 50% and 83%, therefore there is a possibility of genetic contribution to eating disorders (Treasure et al, 2003).

Studies have also suggested role of serotonin levels since this specific neurotransmitter is important in the regulation of eating and mood (Fairburn & Harrison, 2003). Several studies have confirmed those suffering from anorexia nervosa measured lower serotonin levels and may be an indirect effect of eating disorders (Rikani, 2013).

Psychological factors

Around 73% of girls and females have a negative body image, compared with 56% of boys and men (Comer, 2013). Body dissatisfaction has been defined as “discontent with some aspect of one’s physical appearance” (Cash, 2012) and is a risk factor for developing an eating disorder (Stice, 2001). Furthermore, it “encompasses one’s body-related self-perceptions and self-attitudes, including thoughts, beliefs, feelings, and behaviors” (Cash, 2012). Research has measured as far back to adolescent years and how the onset of puberty could set the stage for their body image perceptions (Rikani, 2013). According to Treasure, Claudina, and Zucker (2003), most eating disorders occur during adolescence.  While females are more concerned about losing weight, their male counterparts are focused on the body image of needing to gain muscle. Additionally, female perceptions have been linked to negative body image and adolescent boys are likelier to have positive feelings about their bodies (Ata et al, 2007). Females ultimately feel discontent with the shape and size of their body at such an early age when they are forming their identities. Specifically, females are trying to fit into the image society has described as the ideal beauty of a woman, thus they become increasingly obsessed with disordered eating (Dittmar et al, 2009). In turn, they can suffer psychologically from low self-esteem, feelings of helplessness, and intense dissatisfaction with the way they look” (APA, 2013).

Body image and body dissatisfaction have been measured by examining cognitive components, such as negative attitudes about the body or unrealistic expectations for appearance and behavioral components, such as avoiding perceived body scrutiny from others (e.g., avoiding swimming) (Thompson et al., 1999b). Ata, Ludden, and Lally (2007) also found strong links between eating disorders and feelings of depression and low self-esteem.  

Sociocultural factors

Many sociocultural factors like friends and family can influence the development of eating disorders. “Research focusing on the particular effects of teasing on female adolescents found that those who are teased about their weight, body shape, and appearance tend to exhibit poorer body image and are more likely to diet” (Ata et al., 2007). Furthermore, adolescents who have a relationship with their parents that are less supportive and filled with conflict are more likely to choose disordered eating behaviors and have poor body image. In a survey of individuals with eating disorders, they included family factors such as, poor parental control, controlling parents, poor relationship with parent, critical family environment as causal factors with eating disorders (Salafia et al., 2015). Swarr and Richards (1996) found that adolescents who have a healthy relationship with both parents are less likely to have concerns about their weight. During this vulnerable stage of development, adolescents place a high regard to the approval of their peers. Supported evidence shows that those with lower peer acceptance and social support may be linked to negative body image  (Ata et al., 2007).

It is not surprising that body image has been an obsession in Western society for decades. The media has portrayed the continually changing concept of beauty through advertisements, social media, magazines, and television, in turn shaping society’s standard of beauty. Mulvey (1998) looked at the history of female beauty and the major changes in the female image over the years. The cinched waist was popular in the 1900’s, while being flat chested without curves were emphasized in the 1920’s. Throughout the 1930’s women were encouraged by societal standards to have curves and this emphasis continued through the 1950’s. Images of full figured women like Marilyn Monroe, Audrey Hepburn and Elizabeth Taylor influenced the way women wanted to look (Mulvey, 1998). It was not until the end of this decade that the thin ideal began to decrease in shape (Rumsey). Women began to alter their bodies through plastic surgery in the 1960’s to reach society’s standards. It was during this time that the body type drastically changed into the depiction of being extremely thin and “boyish.” The immense pressure to be thin carried throughout the 1970’s and the rail thin image resulted in an increase in eating disorders, especially anorexia (Mulvey, 1998). Fortunately, that image did not last long and women were advertised as being fit and sporty throughout the early 90s, yet thin models and anorexia became rampant again at the end of this decade. Sadly, this image of thinness has continued throughout the 21^st century.

Prevalence

Measuring the prevalence of eating disorders is complex since countless numbers of people with the disorders do not seek treatment (Treasure et al., 2010). Research suggests that the stigma society has placed on eating disorders as being self-inflictive may factor in to why they do not seek help (Salafia et al., 2015). While eating disorders affect both genders, the prevalence among women and girls are 2 ½ times greater for females (NIMH, 2013). Additionally, Wade, Keski-Rahkonen, and Hudson (2011) found that 20 million women and 10 million men suffer from an eating disorder at some point in their life.  According to the National Institute of Mental Health (NIMH), the lifetime prevalence among adults with eating disorders have measured to be 0.6% for both anorexia nervosa and bulimia nervosa for the adult population.

The main risk factors that have been linked to anorexia nervosa and bulimia nervosa are general factors such as, being female, adolescent/young adult, and living in Western society (NIMH, ). The National Institute of Mental Health reports of suicide being very common in women who suffer from anorexia nervosa and has the highest mortality rate around 10% among all mental disorders.

As mentioned earlier, adolescent females are at a higher risk of developing eating disorders, which were related to low self-esteem, social support, and negative attitudes of their body image. While the age of onset frequently appears during teen years and young adulthood for both disorders, bulimia nervosa has a slightly later age of onset, however can begin the same way as anorexia nervosa (Fairburn & Harrison, 2003). A study found one-third of patients who had an initial diagnosis of anorexia nervosa crossed over to bulimia nervosa during 7 years of follow up (Eddy et al., 2008). Between .3 and .9% of this population are diagnosed with anorexia nervosa and .5 and 5% with bulimia nervosa (Salafia et al., 2015). Furthermore, the NIMH reported the lifetime prevalence of 13-18 year olds to be 2.7% for both eating disorders.

Certain professions and subcultures have a higher prevalence of developing eating disorders. These include professions where bodyweight is highly valued, such as athletes, models, performers, and dancers. In studies with female athletes the prevalence rate of eating disorders ranged from 0% and 8%, which is higher than that of the general population. Among these athletes, 33% engage in eating behaviors that put them at risk for such disorders, such as vomiting and using laxatives. Additional factors that increase the risk for this population have been shown to be the transition into the college setting and moving away from home.

Cultural Factors/Issues  

Historically, there has been a stereotype of eating disorders to effect young, female Caucasians, who are educated and from an upper socio-economic class. However, research increasingly shows that this disorder does not discriminate and is being reported in other race/ethnicities of both upper and lower classes. The prevalence of eating disorders is similar among Non-Hispanic Whites, Hispanics, African-Americans, and Asians in the United States, with the exception that anorexia nervosa is more common among Non-Hispanic Whites (Hudson et al., 2007; Wade et al., 2011).

One report found that views about body image and eating disorders varies among cultures and Caucasian women have the lowest body satisfaction and self esteem while Latina women score in the middle in terms of self-esteem and body satisfaction (Eating Disorder Hope, 2013). The literature among African American women is scarce, however Lee & Lock (2007) found that this group had the highest level of self-esteem and body satisfaction.

With more and more studies comcluding that eating disorders are occurring in other ethnic groups, it becomes imperative to note different cultural views and beliefs may influence this disorder. Common barriers among minority groups regarding treatment resistance, include language difficulties, lack of health insurance or transportation and lack of resources. Barriers can be present in all ethnicities with eating disorders, but ultimately their cultural beliefs tends to be the greatest influence  in their decision to whether they seek treatment (McCaslin, 2014).

Clinical picture

Mental disorders have been portrayed throughout movies and literature. While most do not portray a clear clinical picture of those disorders, a compelling illustration is of actress, Portia de Rossi, is able to show what it looks like and a raw mage of the eating disorder in her book, Unbearable Lightness: A Story of Loss and Gain. She writes about her personal struggle with body image and testimony of her eating disorder. Her struggle with anorexia and bulimia began when she was modeling at the age of 12 after her agents informed her she needed to go on a diet. She was influenced by her older colleagues to vomit to maintain the rail-thin figure directors favored. The actress discussed her disordered eating behaviors, such as taking 20 laxatives a day and restricting her caloric intake to 300 calories a day. She explained the overwhelming desire for perfectionism. Her personal account of her struggle with an eating disorder and illustrates the clinical picture of what it looks like to live through anorexia. From the competitiveness, obsessions, and distorted thoughts, she reveals a life of trying to measure up to the relentless pursuit to measure up to society’s standards of beauty.

Ronald Comer’s text, Abnormal Psychology, also gives a clinical insight into the nature of eating disorders. Sufferers have dysfunctional eating attitudes towards food. The main goal for people who suffer from anorexia nervosa is to become thin. They are fearful of gaining weight and the loss of control over the size and shape of their body. People with this disorder are so preoccupied with food that it results in food deprivation. Their thinking becomes distorted and are likely to have negative perceptions and poor body image. Distorted thinking can lead to psychological problems, such as depression, anxiety low self-esteem, and insomnia in those who suffer from anorexia nervosa. Comer (2015) provides research that suggests sufferers may also display symptoms of obsessive-compulsive patterns. The American Psychiatric Association (APA) confirms this finding of eating disorders being linked to other mental health issues. The APA reported 50-70% suffer from depression, 42-75% have a present personality disorder, 30-37% of bulimic sufferers engage in substance abuse as well as 12-18% of anorexic sufferers. Approximately 25% have OCD and 4-6% suffer from bipolar disorder.

 It is common for sufferers to engage in over exercising, misusage of laxatives and diuretics, and a decreased interest in the outside world (Fairburn & Harrison, 2003). Research has considered the main physical features of anorexia nervosa. The physical symptoms have included, heightened sensitivity to cold, gastrointestinal problems, dizziness, amenorrhea, and insomnia. The physical signs of a sufferer of this disorder may show signs of emaciation, dry skin, erosion of teeth, and cardiac arrhythmias (Fairburn & Harrison, 2003).

Bulimia Nervosa is defined by the DSM-V as eating behaviors that involve binging and purging to avoid weight gain (APA, 2013). Similar to anorexia nervosa, symptoms of depression and anxiety are often seen and sufferers may also engage in substance misuse or self-injury, or both (Fairburn & Harrison, 2003). Mitchell et al. (1983) found physiological electrolyte abnormalities in patients with bulimia nervosa, which can lead to irregular heartbeat and seizures. Other health complications of this eating disorder may include edema/swelling, dehydration, vitamin/mineral deficiencies, gastrointestinal problems, inflammation or possible rupture of the esophagus, tooth decay, and even chronic kidney problems/failure (Alliance for Eating Disorders Awareness, 2013).

Evaluating the prevelance of having eating disorders is fairly new for researchers and health care providers, however, continues to be challenging with the major gap in literature. Eating disorders are severe conditions and often associated with comorbidity and adverse medical conditions, as described earlier. Therefore, a large part of research only focuses on the psychiatric comorbidity in eating disorders, including depression, personality disorder, substance abuse, and obsessive compulsive disorder.

The stigma society has placed on eating disorders also influences the accuracy regarding the costs of these disorders, whether they are impacted directly or indirectly. The lack of reporting within the health care sector continues to make it difficult to estimate costs and prevalence. It is very common for sufferers to seek treatment for the physical problems than the eating disorder itself and one in four individuals actually seek treatment specifically directed at improving their eating disorder symptoms (Striegel-Moore et al., 2003). In past research that reviewed insurance claims regarding eating disorders, it was found that many insurance companies did not cover treatment for these disorders, which often resulted in the treatment providers to use different diagnostic codes when submitting the claims (Striegel-Moore et al., 2003).  One clinical trial that reviewed health records and insurance codes found that 42% of the claims related to weight or eating disorders, however, only 4% had an actual eating disorder diagnosis (Rosselli, 2016).

Samnaliev et al. (2015) measured the impact of eating disorders on health care costs, employment status, and income in the United States. Their evaluation indicated that individuals with eating disorders had more health care costs than those who did not have an eating disorder. In addition, if one had a comorbid then they saw an increase in annual costs, compared to those with no comorbidities. Another impact of the disease that they found during their analysis was lower rates of employment for those with eating disorders. The study also found a link between higher hospitalization costs for sufferers of anorexia nervosa compared to those with bulimia nervosa. Another study (Agras, 2001) found the average cost for inpatient treatment for female anorexics was $17,384 compared to the cost of $9088 for bulimic patients. The same study found treatment for outpatient settings for treatment of anorexia and bulimia to average around $2344. The costs of treating eating disorders were compared to schizophrenia and OCD and indicated costs for anorexia were not significantly different from schizophrenia, however much more expensive than treatment for OCD (Agras, 2001).

Research

While there has been a significant amount of research speculating the factors that influence the development to eating disorders, it continues to remain challenging. Questions remain unanswered regarding the etiology, prevelance cross-culturally, and effective treatment approaches. The only promising finding in current research has been the evidence that heritable factors make a significant contribution to the etiology of these disorders. (Walsh, 2004).

Another issue regarding the research is that a considerable amount is focuses on the eating disorders of Caucasian females in Western society in part due to the stigma placed on eating disorders. Past studies found that eating behaviors of young African American women were more positive than those of young white American women. However, over the past decade research has suggested that body image concerns/dissatisfaction, and disordered eating behaviors have increased for young African American women, as well as women of other minority groups. Despite these trends, society continues to believe that it is likelier for a white American female to develop an eating disorder, rather than a woman of a minority group (Comer, 2015).  It is clear that eating disorders are happening within other cultures, however, the prevelance continues to be an issue to measure. There are also issues regarding treatment. There is ongoing research on the efficacy of treatment for bulimia nervosa, but not for sufferers of anorexia nervosa, which suggests that future research should focus on interventions and treatments for this type of eating disorder. Furthermore, with culture being a risk factor in eating disorders, the development of culturally specific interventions and their efficacy could be beneficial for  future research (Walsh, 2004).

Prevention

It would be helpful for clinicians to hold a multidemensial risk perspective regarding eating disorders until findings point to the exact etiology of the disorder. With new research and data strongly suggesting genetic influence, it is promising that the etiology may eventually be explained. It is importance to understand that all eating disorders occur in all races and ethnicities. Sala et al. (2014) made suggestions for prevention of the disorders, such as public health campaigns to increase awareness and peer recognition since adolescents place a higher value to what their peers think of them. If awareness is brought about in schools than earlier detection may prevent eating disorders among adolescents. Also, since studies suggest that the family has an influence on the younger population, they could be used to inform prevention approaches at the family level (Langdon-Daly & Serpell, 2017).

Treatment

Being familiar with the factors invluencing the development of the eating disorder is imperative in order to understand and adequately help the person suffering from anorexia or bulimia. With that being said, the lack of empirical research regarding the treatment of anorexia nervosa is scarce, thus making it difficult to treat. Studies have shown a strong emphasis on a multidisciplinary approach for sufferers of anorexia is helpful. This approach involves a team of medical, nutritional, social, and psycholological professionals. Therpists typically use a combination of psychotherapy and family therapyto overcome the underlying issue of anorexia nervosa sufferers ( Comer, 2015).

Treatment for bulimia nervosa is often in clinic settings with the goals of eliminating the binge-purge patterns, developing healthier eating behaviors, and removing the underlying influence (Comer, 2015) A large amount of research concerning the treatment of bulimia nervosa suggests that Cognitive Behavioral Therapy is the treatment of choice, while other data suggests CBT being unsuccessful for anorexia. This proves of the need for new interventions and treatment models for eating disorders, specifically anorexia. Strong evidence from pharmacological trials have found that Pharmacotherapy is effective in treatment for bulimia in the short term. Other models of treatment regarding bulimia focus on emotional regulation, such as dialectical behavior therapy (Treasure et al., 2010).

A new approach that has gained preliminary support is Acceptance and Commitment Therapy (ACT). ACT focuses on accepting unwanted feelings/thoughts and seeing them as part of being human. One study suggested that ACT could be neneficial with patients of eating disorders. Treatment interventions that target negative body image may be beneficial when developing newer interventions and approaches towards treatment since both eating disorders have a strong desire to control their urges, thoughts, and feelings (Butryn et al., 2013).

Conclusion

Eating disorders are complex and various factors can influence the development of an eating disorder. These disorders cross all cultural and social backgrounds. While the exact etiology is unknown the overlapping theories help in understanding the combination of factors that influence the causes of eating disorders, It is important to understand they are severe mental disorders and have serious medical consequences.  The advancement in today’s research is encouraging and may eventually offer better treatment options and specific links to the development of an eating disorders.

References

Agras, W. S. (2001). THE CONSEQUENCES AND COSTS OF THE EATING DISORDERS. Psychiatric Clinics, 24(2), 371–379

Alliance for Eating Disorders Awareness. (2013). Eating Disorders. Retrieved from https://www.allianceforeatingdisorders

Alvarenga, M. S., Koritar, P., Pisciolaro, F., Mancini, M., Cordás, T. A., & Scagliusi, F. B. (2014). Eating attitudes of anorexia nervosa, bulimia nervosa, binge eating disorder and obesity without eating disorder female patients: differences and similarities. Physiology & behavior, 131, 99-104.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5^th ed.). Washington, DC.

Ata, R. N., Ludden, A. B., & Lally, M. M. (2007). The effects of gender and family, friend, and media influences on eating behaviors and body image during adolescence. Journal of Youth and Adolescence, 36(8), 1024-1037.

Barth, D. F., & Starkman, H. (2016). Introduction to Body Meets Mind: Eating Disorders and Body Image – A Twenty First Century Perspective. Clinical Social Work Journal , 44 (1), 1-3.

Brown, J. M., Selth, S., Stretton, A., & Simpson, S. (2016). Do dysfunctional coping modes mediate the relationship between perceived parenting style and disordered eating behaviors? Journal of eating disorders, 4(1), 27.

Butryn, M. L., Juarascio, A., Shaw, J., Kerrigan, S. G., Clark, V., O’Planick, A., & Forman, E. M. (2013). Mindfulness and its relationship with eating disorders symptomatology in women receiving residential treatment. Eating Behaviors, 14(1), 13–16.

Cash TF, Pruzinsky T, editors. Body Image: A Handbook of Theory, Research, and Clinical Practice. New York: Guilford Press; 2002.

Comer, R. J. (2015). Abnormal Psychology. New York, New York: Worth Publishers.

Cui, H., Moore, J., Ashimi, S. S., Mason, B. L., Drawbridge, J. N., Han, S., … & Pieper, A. A. (2013). Eating disorder predisposition is associated with ESRRA and HDAC4 mutations. The Journal of clinical investigation, 123(11).

Dittmar, Helga, Emma Halliwell, and Emma Striling. “Understanding the Impact of Thin Media Models on Women’s Body-Focused Affect: The Roles of thin-Ideal Internalization and Weight-Related Self-Discrepancy Activation in Experimental Exposure Effects.” Journal of Social and Clinical Psychology 28.1, 43-72, 2009.

Easter, M. M. (2012). Not all my fault”: Genetics, stigma, and personal responsibility for women with eating disorders. Social Science & Medicine (1982), 75(8), 1408–1416.

Eating Disorder Hope. (2013, July 26). Retrieved April 25, 2017, from https://www.eatingdisorderhope.com/information/eating-disorder/ethnic-minorities

Eddy KT, Dorer DJ, Franko DL, Tahilani K, Thompson-Brenner H, Herzog DB. Diagnostic crossover in anorexia nervosa and bulimia nervosa: implications for DSM-V.  Am J Psychiatry. 2008;165(2):245-250

Fairburn, C. G., & Harrison, P. J. (2003). Eating disorders. The Lancet, 361(9355), 407-416.

Fogelkvist, M., Parling, T., Kjellin, L., & Gustafsson, S. A. (2016). A qualitative analysis of participants’ reflections on body image during participation in a randomized controlled trial of acceptance and commitment therapy. Journal of Eating Disorders, 4(1), 29.

Heaner, M. K., & Walsh, B. T. (2013). A history of the identification of the characteristic eating disturbances of Bulimia Nervosa, Binge Eating Disorder and Anorexia Nervosa. Appetite, 65, 185-188.

Hoek HW. Classification, epidemiology and treatment of DSM-5 feeding and eating disorders. Curr Opin Psychiatry. 2013;26(5):529–31.

Hoek, H. W., & van Hoeken, D. (2003). Review of the prevalence and incidence of eating disorders. International Journal of Eating Disorders, 34(4), 383-396

Kaye, Walter. “Eating Disorders: Hope Despite Mortal Risk.” Am J Psychiatry 166.23, 2009.

Kelly, Amy M., Melanie Wall, Marle E. Eisenberg, Mary Story, and Dianne Neumark-Sztainer. “Adolescent Girls with High Body Satisfaction: Who are they and what can they teach us?” Journal of Adolescent Health 37.5, 391-396, 2005.

Langdon-Daly, J., & Serpell, L. (2017). Protective factors against disordered eating in family systems: a systematic review of research. Journal of Eating Disorders, 5(1), 12.

Lee HY and Lock, J: Anorexia nervosa in Asian-American adolescents: do they differ from their non-Asian peers? International Journal of Eating Disorders 2007;40:227-231.

McCaslin, K. K. (2014). Eating Disorders in Women Across Cultures (Master’s thesis, University of Redlands). Retrieved from h p://inspire.redlands.edu/proudian/1.

Miller, KJ et al: Comparisons of body image dimensions by racve/ethnicity and gender in a university population. International Journal of Eating Disorders 2000;27:310-316.

Mitchell, J. E., Pyle, R. L., Eckert, E. D., Hatsukami, D., & Lentz, R. (1983). Electrolyte and other physiological abnormalities in patients with bulimia. Psychological Medicine, 13(2), 273-278.

National Institute of Mental Health (2013). Eating Disorders. Retrieved April 20, 20157, from https://www.nimh.nih.gov/health/topics/eating-disorders/index.shtml

Rikani, A. e. (2013). A critique of the literature on etiology of eating disorders. Annals of Neurosciences , 20 (4), 157-161.

Rosselli, F. (2017). Reducing the burden of suffering from eating disorders: Unmet treatment needs, cost of illness, and the quest for cost-effectiveness. Behavior Research and Therapy, 88, 49-64.

Sala, M., Reyes-Rodríguez, M. L., Bulik, C. M., & Bardone-Cone, A. (2013). Race, Ethnicity, and Eating Disorder Recognition by Peers. Eating Disorders, 21(5), 423–436.

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), 32.

Samnaliev, M., Noh, H. L., Sonneville, K. R., & Austin, S. B. (2015). The economic burden of eating disorders and related mental health comorbidities: An exploratory analysis using the US Medical Expenditures Panel Survey. Preventive medicine reports, 2, 32-34.

Sharan, P., & Sundar, A. S. (2015). Eating disorders in women. Indian Journal of Psychiatry, 57(Suppl 2), S286–S295.

Soh, N. L. W., & Walter, G. (2013). Publications on cross-cultural aspects of eating disorders. Journal of eating disorders, 1(1), 4.

Striegel-Moore, R. H., Dohm, F. A., Kraemer, H. C., Taylor, C. B., Daniels, S., Crawford, P. B., & Schreiber, G. B. (2003). Eating disorders in white and black

women. American Journal of Psychiatry, 160(7), 1326e1331.

Stice E. Risk and maintenance factors for eating pathology: a meta-analytic review. Psychol Bull. 2002;128:825–48.

Surgenor, L. J., & Maguire, S. (2013). Assessment of anorexia nervosa: an overview of universal issues and contextual challenges. Journal of eating disorders, 1(1), 29.

Swarr AE, Richards MH (1996) Longitudinal effects of adolescent girls’ pubertal development, perceptions of pubertal timing, and parental relations on eating problems. Dev Psychol 32(4):636–646.

Thompson JK, Heinberg LJ, Altabe M, Tantleff-Dunn S (1999b) Exacting beauty: Theory, assessment, and treatment of body image disturbance. American Psychological Association, Washington, DC.

Treasure, J., Claudino, A. M., & Zucker, N. (13). Eating disorders. The Lancet, 375(9714), 583–593.

Walsh, B. T. (2004). The future of research on eating disorders. Appetite, 42(1), 5–10.