TREATMENT OF EATING DISORDERS pot

TREATMENT
OF EATING
DISORDERS
Bridging the Research - Practice Gap
Edited by
MARGO MAINE
BETH HARTMAN MCGILLEY
DOUGLAS W. BUNNELL
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Biographies
Senior Editor
Margo Maine, PhD, FAED, cofounder of
the Maine & Weinstein Specialty Group, is
a clinical psychologist who has specialized
in eating disorders and related issues for 30
years. Author of: Effective Clinical Practice in
the Treatment of Eating Disorders: The Heart of
the Matter, co-edited with William Davis
and Jane Shure (Routledge, 2009); The Body
Myth: Adult Women and the Pressure to Be
Perfect (with Joe Kelly, John Wiley, 2005);
Father Hunger: Fathers, Daughters and the
Pursuit of Thinness (Gurze, 2004); and Body
Wars: Making Peace With Women’s Bodies
(Gurze, 2000), she is a senior editor of Eating
Disorders: The Journal of Treatment and Preven-
tion and vice president of the Eating Disor-
ders Coalition for Research, Policy, and

Action. A Founding Member and Fellow of
the Academy for Eating Disorders and
a member of the Founder’s Council and
past president of the National Eating Disor-
ders Association, she is a member of the
psychiatry departments at the Institute of
Living/Hartford Hospital’s Mental Health
Network and at Connecticut Children’s
Medical Center, having previously directed
their eating disorder programs. Dr Maine is
the 2007 recipient of The Lori Irving Award
for Excellence in Eating Disorders Aware-
ness and Prevention, given by the National
Eating Disorders Association. She lectures
nationally and internationally on topics
related to the treatment and prevention of
eating disorders, female development, and
women’s health.
Editors
Douglas W. Bunnell, PhD, FAED, is
a graduate of Yale University and received
his doctoral degree from Northwestern
University. He is a clini cal psychologist and
Vice President and Director of Outpatient
Clinical Services for The Ren frew Center,
overseeing the clinical programming and
training for Renfrew’s eight outpatient treat-
ment centers. He is the editor of Renfrew’s
professional newsletter, Perspectives, and co-
chairs their research committee. He serves

on the editorial board of Eating Disorders:
The Journal of Treatment and Prevention.A
Fellow of the Academy for Eating Disorders,
he is a former board president of the
National Eating Disorders Association,
a member of National Eating Disorder Asso-
ciation’s Founders Council, and is the clin-
ical advisor for the National Eating
Disorder Association’s Navigator program
which trains parents and family members
as resources for newly diagnosed patients
and families. Dr. Bunnell also remains active
in eating disorders advocacy and awareness.
He has written and lectured, nationally and
internationally, on eating disorders treat-
ment, research, professional training, eating
disorders in men, and the challenges of inte-
grating science and practice. He is also
a member of the Academy for Eating Disor-
ders credentialing committee, working to
develop practice standards for residential
treatment of patients with eating disorders.
In addition to his work with Renfrew, the
Academy for Eating Disorders and National
ix
Eating Disorder Association, Dr. Bunnell
maintains a private practice in Wilton, Con-
necticut specializing in the treatment of
eating disorders, chronic illness, and the
psychological aspects of Lyme Dis ease.

Beth Hartman McGilley, PhD, FAED,
Associate Professor, University of Kansas
School of Me dicine-Wichita, is a psychologist
in private practice, speci alizing in the treat-
ment of eating and related disorders, body
image, athletes, trauma, and grief. A Fellow
of the Academy for Eating Disorders, she
has practiced for 25 years, writing, lecturing,
supervising, directing an inpatient eating
disorders program, and providing indi-
vidual, family and group therapy. She has
published in academic journals and the
popular media, as well as having contrib-
uted chapters to several books. She is an
editor for Eating Disorders: The Journal of
Treatment & Prevention, and is working on
her first book, a tribute to the patients she
has served over the course of her career.
Dr. McGilley also specializes in applica-
tions of sports psychology and performance
enhancement techniques with athletes at the
high school, collegiate, and professional
levels. She was the sports psychology consul-
tant for the Wichita State University Wom-
en’s Basketball team from 2005 to 2008, and
serves as the co-chair of the Association for
Applied Sports Psyc hology (AASP) Eating
Disorders Special Interest Group.
Dr.McGilley co-founded and is the current
President of the Healing Path Foundation,

a non-profit foundation dedicated to the
prevention and treatment of eating disorders
in Kansas. She is a recent graduate of the
Kansas Health Fou ndation Le aders hip Fell ows
Training program. Her hobbies include
competitive cy cling, hiking, and writing.
Contributors
Diann M. Ackard, PhD, LP, FAED, is
passionate about helping us be the best that
we can be. She is a licensed psychologist in
private practice, and is an Adjunct Assistant
Professor in the Division of Epidemiology
and Community Health at the University
of Minnesota, and a Research Scientist at
Melrose Institute in St Louis Park, Minnesota.
She sits on the Boards for the Academy for
Eating Disorders and Break the Cycle, and
co-founded the Trauma and Eating Disor-
ders Special Interest Group of the Academy
for Eating Disorders. She regularly publishes
articles in peer-reviewed journals and
frequently contributes at meetings and
conferences.
Drew Anderson, PhD, is an Associate
Professor in the Department of Psychology
at the University at Albany, State University
of New York. His research focuses on assess-
ment and treatment of eating disorders,
body image disturbance, and psychological
and medical problems associated with

obesity.
Amy Baker Dennis, PhD, FAED, is a clin-
ical and research psychologist who has
maintained a clinical practice over 36 years.
She was the founding Board Secretary and
served on the Board of the Academy for
Eating Disorders (AED) for 11 years. She is
also a founding member of the Eating
Disorder Research Society (EDRS), founding
Board President of the Eating Disorder
Awareness and Prevention (EDAP) and a
member of the Founders Council, and
currently serves on the Board of the Natio nal
Eating Disorder Association (NEDA). She
has published and lectured extensively and
received numerous awards for her contrib u-
tions to the field, including the Lifetime
BIOGRAPHIESx
Achievement Award givn by NEDA. She is
a certified cognitive therapist and has served
on the faculties of University of South Flor-
ida, Department of Psychiatry and Behav-
ioral Sciences, the Hamilton Holt graduate
school at Rollins College in Orlando, Florida,
and Wayne State University Department of
Psychiatry in Detroit.
Judith Banker, MA, LLP, FAED, is the
founder and executive director of the Center
for Eating Disorders, a non-profit outpatient
treatment center in Ann Arbor, Michigan.

She is a Past President of the Academy for
Eating Disorders and served as chair of the
Academy for Eating Disorders Psychody-
namic Psychotherapy Special Interest Group
for 10 years. With over 35 years of clinical
and training experience, Judith’s teaching
and writing focuses on the integrative clin-
ical treatment of eating disorders and on
research-practice integration in the eating
disorders field.
Michael E. Berrett, PhD, received his PhD
in Counseling Psychology in 1986 from
Brigham Young University. He is CEO,
Director, and Co-founder of Center For
Change in Orem, Utah. Dr. Berrett has served
as Chief of Psychology at Utah Valley
Regional Medical Center and as Clinical
Director of Aspen Achievement Academy.
He has 25 years experience in the treatment
of those struggling with eating disorders.
He is co-author of the American Psycholog-
ical Association book Spiritual Approaches in
the Treatment of Women With Eating Disorders
and multiple articles in professional journals.
Timothy D. Brewerton, MD, DFAPA,
FAED, is Clinical Professor of Psychiatry
and Behavioral Sciences at the Medical
University of South Carolina in Charleston.
He is triple board certified in general psychi-
atry, child/adolescent psychiatry and

forensic psychiatry, Distinguished Fellow of
the Am erican Psychiatric Association and
Founding Fellow of the Academy of Eating
Disorders. Dr. Brewerton has published
over 115 articles and book chapters, is editor
of the book, Clinical Handbook of Eating Disor-
ders: An Integrated Approach, and serves on
the Editorial Boards of the International Jour-
nal of Eating Disorders and Eating Disorders:
The Journal of Treatment and Prevention.
Judith Brisman, PhD, is Director and
Co-Founder of the Eating Disorder Resource
Center in New York City. She is co -author of
Surviving an Eating Disorder: Strategies for
Family and Friends (Collins Living, 2009, third
edn), is an associate editor of Contemporary
Psychoanalysis and is on the editorial board
of the journal Eating Disorders: The Journal of
Treatment and Prevention. Dr. Brisman is
a supervisor of psychotherapy and a member
of the teaching faculty of the William
Alanson White Institute. She has published
and lectured extensively regarding the inter-
personal treatment of eating disorders and
currently maintains a private practice in
Manhattan, New York.
Deborah Burgard, PhD, specializes in the
treatment of eating disorders and body
image. She created www.BodyPositive.com
and is one of the founding proponents of

the Health at Every Size model. She co-wrote
Great Shape: The First Fitness Guide for Large
Women, and chapters in Effective Clinical
Practice in the Treatment of Eating Disorders:
The Heart of the Matter, Feminist Perspectives
on Eating Disorders, and The Fat Studies
Reader. Dr. Burgard is also a co-author of
the Academy for Eating Disorder’s “Guide-
lines for Childhood Obesity Programs” and
co-leads the Sustainable Health Practices
Registry, research on how people create
ongoing practices that support their health.
BIOGRAPHIES xi
Rachel Calogero, PhD, completed her
M.A. at The College of William and Mary,
and her doctoral and postdoctoral work in
social psychology at the University of Kent
in Canterbury, England. Currently, she is
Assistant Professor of Psychology at Virginia
Wesleyan College. Her primary interests
cover a spectrum of socio-cultural factors
that affect women’s health and well-being,
including the role of exercise in eating disor-
ders treatment and recovery, the impact of
sexual and self-objectification in girls’ and
women’s daily lives, and the perpetuation
of fat prejudice and stigmatization. She has
published her research widely in peer-
reviewed journals and book chapters, and
is senior editor of the book, Self-Objectifica-

tion in Women: Causes, Consequences, and
Counteractions (APA, 2010). She presents
her research frequently in Europe and North
America, and offers workshops on mindful
excercise in various clinical and community
contexts.
Nancy Cloak, MD, attended medical
school at the University of South Florida
and did her psychiatric residency at the
Menninger Clinic, where she was also
a candidate in the Topeka Institute for
Psychoanalysis. Following residency, she
worked with eating disorder patients in
a university health center, and then
completed a fellowship in eating disorders
at Sheppard-Pratt Hospital, after which she
returned to Oregon to become the medical
director of RainRock Treatment Center. Her
professional interests include psychody-
namic psychotherapy with eating disorder
patients, the neurobiology of weight, appe-
tite, and eating disorders, and medical
complications of eating disorders.
Jillian Croll, PhD, MPH, RD, LD, is the
Director of Communications, Outreach, and
Research for the Emily Program. She is an
Adjunct Assistant Professor in Department
of Food Science and Nutrition at the Univer-
sity of Minnesota. She completed her MPH
and PhD in Public Health Nutrition and

Epidemiology at the University of Minne-
sota, and her MS in Nutritional Science at
the University of Vermont. Her work in
eating disorders includes program develop-
ment, community education, teaching,
research, clinical work, and advocacy.
Kimberly Dennis, MD, is the Medical
Director at Timberline Knolls Residential
Center for women with eating disorders
and co-occurring disorders, and has a private
practice with Working Sobriety Chicago. She
specializes in group and individual treat-
ment for patients with co-occurring eating
and substance use disorders. She maintains
a holistic perspective, and brings an aware-
ness of the benefits of storytelling, creativity,
and play in the recovery process. Dr. Dennis
is a member of IAEDP, Academy for Eating
Disorders, and ASAM. She is an editor ial
board member for Eating Disorders: The Jour-
nal of Treatment & Prevention.
Kyle P. De Young, MA, is currently an
advanced graduate student in clinical
psychology at the University at Albany, State
University of New York. His research inter-
ests include the course and outcome of eating
disorders, exercise, and assessment of eating
and exercise-related constructs.
Richard A. Gordon, PhD, is Professor of
Psychology at Bard College and a clinical

psychologist in independent practice. He
has treated patients with eating disorders
for over 25 years. He is author of Eating Disor-
ders: Anatomy of a Social Epidemic, Second
Edition (Blackwell, 2000), and with Melanie
Katzman and Mervat Nasser, Eating Disorders
and Cultures in Transition (Brunner Routledge,
2001). He was made Honorary Fellow of the
American Psychiatric Association for his
BIOGRAPHIESxii
contributions to the social understanding of
eating disorders.
Randy K. Hardman, PhD, worked as
a psychologist for 26 years. He was
a co-founder and director of Center for
Change, where he worked for 11 years. Dr.
Hardman is currently working with students
in the Counseling Center at Brigham Young
University-Idaho in Rexburg, Idaho. He is
a co-author of the book, Spiritual Approaches
in the Treatment of Women with Eating Disor-
ders (American Psychological Association,
2007). He has written and published articles
on spirituality and other related eating
disorder topics.
Bethany Helfman, PsyD, is a clinical
psychologist who has practiced in the field
for over 18 years. She is currently at Dennis &
Moye & Associates in Bloomfield Hills,
Michigan where she specializes in the treat-

ment of adolescents, adults, and families
affected by eating disorders and their comor-
bidities. She is a member of the Academy for
Eating Disorders and the National Eating
Disorder Association. Dr. Helfman super-
vises other professionals in the field, writes,
lectures, and advocates for change related
to the factors that make recovery from
mental illness more difficult.
Anita Johnston, PhD, is Director of the
Anorexia & Bulimia Center of Hawaii, which
she co-founded in 1982, Clinical Director and
Founder of Ai Pono Eating Disorders
Programs in Honolulu, and Senior Advisor
and Clinical Consultant for Foc us Center
for Eating Disorders in Tennessee. In 1986,
she developed Hawaii’s first in-patient
eating disorders treatment program at Kahi
Mohala Hospital. Dr. Johnston is the author
of Eating in the Light of the Moon: How Women
Can Transform Their Relationships with Food
Through Myth, Metaphor, and Storytelling
(Gurze, 2000) and an international speaker
and workshop leader with a private practice
in Kailua, Hawaii.
Kathy Kater, LICSW, is a St. Paul, Minn e-
sota psychotherapist and an internationally
known author, speaker, and consultant
with over 30 years of experience specializing
in the treatment and prevention of body

image and eating-related disorders. Frus-
trated that progress in understanding these
problems has not been matched by effective
prevention, she authored Healthy Body Image:
Teaching Kids to Eat and Love Their Bodies Too,
a primary prevention curriculum for upper
elementary school children, and Real Kids
Come in All Sizes; Ten Essential Lessons to Build
Your Child’s Body Esteem, a companion guide
for parents.
Susan Kleinman, MA, BC-DMT, NCC, is
the dance/movement therapist for The Ren-
frew Center of Florid a. She is a trustee of the
Marian Chace Foundation, a past president
of the American Dance Therapy Association,
and a past Chair of The National Coalition
for Creative Arts Therapies. She is a co-
editor of The Renfrew Center Foundation’s
Healing Through Relationship, serves on the
editorial board of the Journal of Creativity in
Mental Health, and has published exte nsively
on the use of dance/movement therapy in
the treatment of eating disorders. She was
the American Dance Therapy Association
recipient of the 2009 Outstanding Achieve-
ment Award.
Kelly L. Klump, PhD, FAED, is an Asso-
ciate Professor of Psychology at Michigan
State University. Her research focuses on
genetic and biological risk factors for eating

disorders. Dr. Klump has published over 90
papers and has received a number of federal
grants for her work. She has been honored
with several awards including the David
Shakow Award for Early Career Contribu-
tions to Clinical Psychology from the
BIOGRAPHIES xiii
American Psychological Association and
New Investigator Awards from the World
Congress on Psychiatric Genetics and the
Eating Disorders Research Society. Dr.
Klump is a Past President of the Academy
for Eating Disorders.
Francine Lapides, MFT, writes and
teaches from attachment and psycho-
neurobiological theories (including the
arousal and regulation of affect) and their
applications to relational and psychody-
namic psychotherapy and adult romantic
relationships. She supervised and taught
psychotherapy through the 1970s and has
been in pri vate practice in Santa Cruz,
California since 1980. She has trained with
Daniel Siegel, is a member of Allan Schore’s
Berkeley study group, and has been strongly
influenced by relational principl es devel-
oped at The Stone Center at Wellesley
College. She teaches workshops and confer-
ences across the United States and provides
an online seminar at www.PsyBC.com.

Jason M. Lavender, MA, is currently an
advanced graduate student in clinical
psychology at the University at Albany. His
research interests include the functions of
eating disorder behaviors, the course and
outcome of eating disorders, and the assess-
ment of body image and eating disorder
behaviors.
Martha M. Peaslee Levine, MD, is Assis-
tant Professor of Pediatrics, Psychiatry, and
Humanities and the Director of the Partial
Hospitalization and Intensive Outpatient
Programs at Penn State Milton S. Hershey
Medical Center.
Michael P. Levine, PhD, FAED, is Samuel
B. Cummings Jr. Professor of Psychology at
Kenyon College in Gambier, Ohio. His
special interest is body image and eating
problems and their links with preventive
education, developmental psychology, and
community psychology. His most recent
book is Levine and Smolak’s (2006) The
Prevention of Eating Problems and Eating Disor-
ders: Theory, Research, and Practice (Lawrence
Erlbaum). Dr. Levine is a Fell ow of the
Academy for Eating Disorders. In June
2006 he received the Meehan-Hartley Award
for Leadership in Public Awareness and
Advocacy from the Academy for Eating
Disorders.

Richard L. Levine, MD, is Professor of
Pediatrics and Psychiatry and is the Chief
of the Division of Adolescent Medicine and
Eating Disorders at Penn Stat e Milton S.
Hershey Medical Center.
Kimberli McCallum, MD, CEDS, is
a Fellow of the American Psychiatric Associ-
ation and Associate Professor of Clinical
Psychiatry at Washington University Scho ol
of Medicine. She is a psychotherapist with
a broad range of therapy skills, including
dialectic behavior therapy, cognitive
behavior therapy, family-based treatment,
Family Systems Therapy, and psychoanal-
ysis. She received her MD from Yale, general
psychiatric training at UCLA, and child/
adolescent training at Washington Univer-
sity. Dr. McCallum has co-founded several
specialized eating disorders units, including
inpatient, partial hospital, residential, and
intensive outpatient programs. Her current
programs include McCallum Place Treat-
ment Center in St. Louis, MO, and Cedar
Springs Treatment Center in Austin, TX.
Elisa Mott, MEd/EdS, a certified yoga
teacher and graduate of University of Flori-
da’s Counselor Education program, also
holds a Spirituality in Health Certificate.
She was awarded an International Excel-
lence in Counseling Research Grant from

Chi Sigma Iota honor society for her study
evaluating the use of yoga to improve well-
ness among females and presented this
BIOGRAPHIESxiv
research at the 2010 ACA conference. She
served as CSI’s Wellness Committee chair
and has presented on the use of yoga in the
treatment of eating disorders at the Interna-
tional Association for Eating Disorder
Professionals Conference and the University
of Florida’s Professional Development Day.
Robbie Munn, MA, MSW, is a clinical
social worker who has spoken and written
widely about the chaotic impact of eating
disorders upon families and the challenges
families face in obtaining appropriate treat-
ment. Many women in her family have
been affected by eating disorders, including
her mother and daughter, nieces, and
cousins. In 2000 she joined the Board of the
National Eating Disorders Association
(NEDA) as one of its first family members.
In 2003 she helped to create and co-chair
the first conference in the field to include
families and individuals along with clini-
cians. This has become the esteemed annual
conference hosted by NEDA.
Kelly N. Pedrotty-Stump, MS, is a high-
school guidance counselor and an Exercise
Consultant at the Renfrew Center. She co-

developed the exercise program at Renfrew.
Kelly is an experienced speaker on exercise
and the treatment of eating disorders and
has presented at national conferences
including National Eating Disorder Associa-
tion, Academy for Eating Disorders, and
MEDA. She has taught workshops on
various topics at West Chester University,
Temple University and Philadelphia College
of Osteopathic Medicine. She has published
on the topic of exercise abuse and eating
disorders. Kelly is also a certified yoga
instructor.
Pauline Powers, MD, FAED, graduated
from the University of Iowa College of Medi-
cine and completed her residency at the
University of California at Davis. She is
Professor of Psychiatry and Behavioral
Medicine in the Clinical and Translational
Science Institute at the University of South
Florida, Tampa, Florida. She was the Found-
ing President of the Academy for Eating
Disorders and was President of the National
Eating Disorders Association 2005e2006.
She has published three books on eating
disorders and has reported research in
several journals. She is currently Director of
the University of South Florida Center for
Eating and Weight Disorders and the
Director of the USF Hope House for Eating

Disorders.
Adrienne Ressler, MA, LMSW, CEDS,
the National Training Director for The Ren-
frew Center Foundation, is the 2008e2010
president of the International Association
for Eating Disorder Professionals board.
She attended the University of Michigan
and served as a faculty member in the School
of Education. Her nationally renowned
seminars reflect her background in gestalt,
transactional analysis, psychodrama, bio-
energetic analysis, and Alexander technique.
She is published in the International Journal of
Fertility and Women’s Medic ine, Social Work
Today and authored the chapter BodyMind
Treatment in Effective Clinical Practice in the
Treatment of Eating Disorders. She is the
featured body-image expert for documen-
taries on both cosmetic surgery and
menopause.
P. Scott Richards, PhD, is a Professor of
Counseling Psychology at Brigham Young
University. He received his PhD in Coun-
seling Psyc hology in 1988 from the Univer-
sity of Minnesota. He is the co-author of
the book, Spiritual Approaches in the Treatment
of Woman with Eating Disorders (American
Psychological Association, 2007). He is also
co-author of the book, A Spiritual Strategy
for Counseling and Psychotherapy, which was

BIOGRAPHIES xv
published in 1997 and 2005 (2nd ed.) by the
American Psychological Association. Dr.
Richards has published on the topics of spir-
ituality and eating disorders, religion and
mental health, and spiritual issues in
psychotherapy.
Jennifer Sanftner, PhD, is a Clinical
Psychologist and tenured Associate
Professor of Psychology at Slippery Rock
University. She has been teaching in the areas
of abnormal, clinical, health, and gender
psychology, and directing the undergraduate
practicum program at SRU for the last 8½
years. She has researched eating disorders
for 19 years, resulting in publications in
peer-reviewed journals and chapters. Her
research focuses on the application of Rela-
tional Cultural Theory to understanding the
etiology and maintenance of eating disor-
ders. She is interested in using RCT to under-
stand women’s relationships with their
bodies, with others, and with food, and to
applying our understanding of RCT to
treatment.
Lori A. Sansone, MD, is a civilian family
medicine physician and the Medical Director
for the Primary Care Clinic at Wright-
Patterson Air Force Base in Dayton, Ohio.
She has published over 100 refereed articles

and 24 book chapters; co-authored the
book, Borderline Personality Disorder in the
Medical Setting; co-developed the Self-Harm
Inventory; co-authors a professional column,
The Interface, for the journal Psychiatry, and
co-authors a local monthly newsletter,
Mental Health Issues in Primary Care.
Randy A. Sansone, MD, is a professor
at Wright State University School of Medi-
cine in Dayton, Ohio, and Director of
Psychiatry Education at Kettering Medical
Center. He has published over 225
refereed articles and 33 book chapters;
co-edited the books, Self-Harm Behavior
and Eating Disorders and Personality Disor-
ders an d Eating Disorders; co-authored the
book, Borderline Personality Disorder in
the Medical Setting ;co-developedthe
Self-Harm Inventory; and co-authors
a professional column, The Interface,for
the journal Psychiatry.Dr.Sansoneisalso
the editor of the borderline personality
module for the Physician Information and
Education Resource and is on six journal
editorial boards, including Eating Disor-
ders: The Journal of Treatment and
Prevention.
Doris and Tom Smeltzer, are career
educators with master’s degrees in educa -
tion and counseling psychology, respec-

tively. Tom is a college professor and Doris
has taught throughout the K-12 spectrum.
When their 19-year-old daughter Andrea
died after 13 months of bulimic behaviors,
Doris chose to leave her teaching position
and has devoted her life to eating disorder
prevention through Andrea’s Voice Founda-
tion, the non-profit organization she and
Tom co-founded. Doris is the author of
Andrea’s Voice: Silenced by Bulimia and Gurze
Books’ “Advice for Parents” blog and is devel-
oping an educational curriculum for the ED
field based on her Internet radio show.
Jacqueline Szablewski, MTS, MAC,
LAC, is a psychotherapist and licensed
addictions counselor who resides in Boulder,
Colorado. Combining study in psychology,
counseling, and world religions with a self-
designed concentration in pastoral coun-
seling, Jackie earned her Masters degree in
Theological Studies from Harvard Univer-
sity. She has worked along the continuum
of care in agency and hospital settings.
Specializing in eating disorders, addiction
recovery, and life transitions, particularly
with individuals challenged by concomitant
mood disorders, trauma, and grief issues,
BIOGRAPHIESxvi
Jackie has worked in the field for nearly two
decades. She has maintained a private prac-

tice in Boulder, Colorado for the last
14 years.
Mary Tantillo, PhD, RN, CS, FAED, is the
Director of the Western New York Compre-
hensive Care Center for Eating Disorders,
an Associate Professor of Clinical Nursing
at the University of Rochester School of
Nursing, a Clinical Associate Professor in
the Department of Psyc hiatry at the Un iver-
sity of Rochester School of Medicine, and
CEO/Clinical Director of a free-standing
Eating Disorders Partial Hospitalization
Program, The Healing Connection, LLC.
She is a fellow of the Academy for Eating
Disorders, as well as a previous board
member, present chairperson for the
Academy for Eating Disorders Credentialing
Task Force, and co-chairperson for the
Patient/Carer Task Force.
Edward P. Tyson, MD, has been treating
eating disorders for more than 20 years and
is board certified in both Family Medicine
and Adolescent Medicine. After serving as
Director of Adolescent Clinics for the
Department of Pediatrics at Children’s
Hospital of Oklahoma, he opened a private
practice in Austin, Texas specializing in
eating disorders. Dr. Tyson is an active
member and frequent presenter at the
professional eating disorder organizations.

He is an advocate for those with eating disor-
ders and teaches residents and medical
students, as well as undergraduate and
graduate classes, at the University of Texas
about eating disorders.
Kitty Westin is the founder and former
President of the Anna Westin Foundation,
which has now merged with the Emily
Program Foundation. The Anna Westin Foun-
dation was started by Anna’s family after
Anna died in 2000 as a direct result of
anorexia. The Westins also started the first
and only residential program to treat people
with eating disorders in Minnesota. Kitty is
also the past President of the Eating Disorders
Coalition for Research, Policy & Action and
she serves on the Academy for Eating Disor-
ders Patient/Carer Task Force, and is the
Co-chair of the Academy for Eating Disorders
Advocacy/Communications Committee.
Jancey Wickstrom, AM, LCSW, is the
Milieu Manager and DBT Specialist at
Timberline Knolls Residential Center for
women with eating disorders and co-
occurring disorders. While a student at
University of Chicago, she received training
in DBT at the Emotion Management
Program, and maintains a group and indi-
vidual DBT practice there. Ms. Wickstrom
firmly believes in the powerful effects of

mindfulness meditation to help every
person create a meaningful life.
BIOGRAPHIES xvii
Abbreviations
AA, Alcoholics An onymous
ACC, anterior cingulate cortex
ACT, acceptance co mmitment therapies
ACTH, adrenocorticotropic hormone
ADHD, attention-deficit/hyperactivity
disorder
AN, anorexia nervosa
ANBP, anorexia nervosa, binge purge
subtype of anorexia nervosa
ANS, autonomic nervous system
BED, binge eating disorder
BMI, body mass index
BN, bulimia nervosa
BPD, borderline personality disorder
CAT, cognitive analytic psychotherapy
CBC, complete blood cells
CBT, cog nitive behavior therapy
CPT, cognitive processing therapy
CRF, corticotrophin releasing factor
DBT, dialectical behavior thera py
DE, disordered eating
DEX, dysfunctional exercise
DEXA, dual energy X-ray absorptiometry
DMT, dance/movement therapy
DSM, Diagnostic and Statistical Manual
EBP, evidence-based practice

EBT, evidence-based treatment
ED, eating disorder
EDI, Eating Disorder Inventory
EDNOS, eating disorder not otherwise
specified
EST, empirically supported treatments
FBT, family-based treatment
fMRI, functional magnetic resonance
imaging
fNIRS functional near-infrared spectroscopy
FTT, failure to thrive
GABA, gamma-aminobutyric acid
GERD, gastroesophageal reflux disease
HPA, hypothalamic pituitary axis
IFT, intern al family therapy
IPT, interpersonal psychotherapy
LH, left hemisphere
MAOI, monoamine oxidase inhibitors
MBCT, mindfulness-based cognitive
therapy
MB-EAT, mindfulness-based eating disorder
training
MBSR, mindfulness-based stress reduction
MET, motivational enhancement therapy
MI, motivational interviewing
MPC, me dial prefrontal cortex
NA, narcotics anonymous
NES, night eating syndrome
OA,
overeaters anonymous

OCD,
obsessive-compulsive disorder
OFC, orbital frontal cortex
OTC, over the counter
PET, positron emission tomography
PFC, prefrontal cortex
PM, perceived mutuality
PPI, proton pump inhibitors
PTSD, post-traumatic stress disorder
RBC, red blood cells
R/M, relational/motivational approach
RCT, relational-cultural theory
RCTs, randomized controlled trials
RFS, refeeding syndrome
RH, right hemisphere
SD, standard deviation
SIV, self-inflicted violence
SMA, superior mesenteric artery
xix
SOC, stage of change
SOCT, stages of change theory
SNRI, serotonin and norepinephrine
reuptake inhibitors
SRED, sleep-related eating disorder
SSRI, selective serotonin reuptake inhibitor
SUD, subjective units of distress
TCA, tricyclic antidepressants
WBC, white blood cells
ABBREVIATIONSxx
Introduction

Eating Disorders as Biopsychosocial Illnesses
The point is that profound but contradictory
ideas may exist side by side, if they are con-
structed from different materials and methods
and have different purposes. Each tells us
something important about where we stand in
the universe and it is foolish to insist that they
must despise each other. Postman, 1995, p. 107
The idea for this volume, Treatment of
Eating Disorders: Bridging the Research/Practice
Gap, emanated from our experiences as clini-
cians facing the challenge of helping patients
and their loved ones back from the precipice
of self-destruction brought on by eating
disorders (EDs). While we are each very
active in our professional devel opment and
ongoing education, every day we experience
the impact of the significant gap bet ween
what the research in journals, books, and
conference presentations provides and how
our patients present clinically. Their needs
rarely match the theories or studies intended
to explain them.
For example, although Eating Disorders
Not Otherwise Specified (EDNOS) is the
most commonly diagnosed ED in clinical
settings, ranging from 50 to 70% of all ED
cases (Walsh & Sysko, 2009), research studies
rarely include this diagnostic category.
While more recent research is beginning to

explore the complexities of EDNOS (Agras,
Crow, Mitchell, Halmi & Bryson, 2010;
Walsh, 2009; Wildes & Marcus, 2010), little
is yet known about how this largest
subgroup of ED patients progresses through
the illness, responds to treatment, and fares
in terms of outcome. Recent data seem to
confirm what we have known clinically:
many patients with EDNOS actually have
poorer outcomes and higher mortality rates
than patients with AN or BN (Crow, Peter-
son, Swanson, Raymond & Specker, 2009).
A multitude of other factors contribute to
the research/practice gap. Despite the fact
that many of our patients suffer from comor-
bid conditions, treatment research in our
field tends to look at these problems
more singularly (Haas & Clopton, 2003;
Thompson-Brenner & Westen, 2005; Tobin,
2007). In clinical practice, it is often these
comorbid factors, including depression,
anxiety, and post-traumatic stress disorder,
that dominate the process of therapeutic
engagement. The process of engagement is
known to be difficult in patients with ED,
and adapting to the special demands of
a patient’s comorbidities makes each treat-
ment relationship unique. This sense of
uniqueness can create the perception that
research does not easily, or often, apply to

the individual patient with whom we sit.
Furthermore, in clinical research trials, “rela-
tively ‘pure’ groups of homogenous patients
are selected for study, and are offered stan-
dardized treatment based on structured
manuals. Everyone knows that therapy in
the real world is far messier” (Herbert,
Neeren & Lowe, 2007, p. 15). We designed
this book with the clear intention of trying
to bridge such gaps so that research can
better inform clinical work, and clinical
work can better inform the research agenda
and process.
xxi
A historical view may help us to create the
most-informed approaches to the field’s
current dilemmas. In her review of four
decades of work, Hilda Bruch (1985), the
pioneer to whom the field owes great respect
and gratitude, identified the nature/nurture
debate as a concerning gap. In her hopeful
assessment, the two dimensions had finally
found common ground. “Recent explora-
tions of the neurochemical processes of the
brain have revealed the close association of
psychological experiences with alterations
in brain metabolism, rendering the old
dichotomy between physiological and
psychological events untenable” (Bruch,
1985, pp. 8e9). The biopsychosocial model

(Johnson & Connors, 1987; Lucas, 1981;
Yager, 1982; Yager, Rudnick & Metzner,
1981) advanced this perspective and our
understanding of ED, laying the groundwork
for prolific empirical contributions in the
subsequent decades. The field rigorously
researched areas of pressing concern
including, but not limited to: prevention;
medical and psychiatric management; thera-
peutic tools and approaches; neuroscience
and epigenetics; and the essential role of the
family in the ED treatment and recovery
process. In the clinical realm, innovative
treatment approaches began to yield more
positive outcomes.
The dialectic of the past decade, the
science/practice gap, parallels, if not harks
back to, that of Bruch’s generation of ED
specialists. Despite Bruch’s prescient respect
for the neuroscientific basis of psychological
experience, integration of this work, and its
implications for the therapeutic process, is
relatively recent in the ED field. Although
we cannot expect neuroscience to be the ulti-
mate mediator for researchers and clinicians
of discrepant viewpoints, it has undoubtedly
provided a language and medium for profes-
sionals in both “camps” to appreciate the
other’s contributions to the understanding
of the etiology and treatment of ED. Nearly

30 years have passed since Bruch’s review,
and the resurgence of interest in neuroscien-
tific applications/understandings of ED, and
in patients’ subjective experiences, provides
rich opportunities for collaboration between
researchers and clinicians.
Today, we have the advantage of a knowl-
edge base built on many more years of
inquiry than Dr. Bruch and the other early
writers had available to them. There are
three scholarly journals dedicated solely to
ED: Eating Disorders: The Journal of Treatment
and Prevention (EDJTP), the International
Journal of Eating Disorders (IJED), and the
European Eating Disorders Review. Since the
1980s, approximately 1000 books have been
published specifically regarding ED or
closely related illnesses. EDJTP has pub-
lished about 750 articles, and IJED has pub-
lished approximately 1200 (L. Cohn,
personal communication, January 28, 2010).
Broadening the topic to body image, health
psychology, obesity, or related areas, these
numbers would vastly increase, but still do
not reflect publications in a wide variety of
basic science, psychiatric, medic al, nutri-
tional, and psychological journals. The point
is that the ED field is relatively young and
rapidly developing, with many talented
clinicians and researchers wh ose contribu-

tions have the potential to bridge the current
gaps, better serving the needs of our
patients.
Helene Deutsch, the first psychoanalyst to
specialize in the treatment of women, has
been credited with saying, “after all, the ulti-
mate goal of all research is not objectivity,
but truth” (retrieved from: http://www.
brainyquote.com/quotes/authors/h/helene_
deutsch.html). Treatment of Eating Disorders:
Bridging the Re search/Practice Gap brings
together the expertise of scientists and prac-
titioners in an effort to further describe the
truth about ED. Readers will find an
INTRODUCTIONxxii
unexpected irony: the effect of closing gaps
also expands the realm of influence, infor-
mation, and expertise across disciplines.
Researchers will find accounts of the prac-
ticed experience and wisdom of clinicians
who have been operating with skills and
perspectives only partially informed by
science. Likewise, clinicians will be exposed
to scientific advances that have enriched our
understanding of the biopsychosocial
complexity of ED. Some of this research
has substantiated the central role of the ther-
apeutic relationship (American Psychiatric
Association, 2006), and qualitative research
is now giving the patient/subject an active

voice and presence in the empirical process.
Readers will have access to chapters
across a variety of topics where research
and clinical work must come together to
better shape the understanding, treatment,
and outcome of ED. In light of the significant
proportion of EDNOS cases, we encouraged
our contributors to take a trans diagnostic
approach (Fairburn & Cooper, 2007)when
possible. We are also intrigued by the
proposed alternative system for classifica-
tion, Broad Categories for the Diagnosis of
Eating Disorders (Walsh & Sysko, 2009).
While the American Psychiatric Association
refines its work on the DSM-V, many diag-
nostic issues are being considered, and it is
premature to discuss the changes; however,
we deeply appreciate the efforts of the ED
work group.
The collaborative spirit of this book
reflects our view that EDs are complex, mul-
tidetermined illnesses that must be under-
stood and treated in the sociopolitical
context. Effective treatment takes a team that
includes the patient, the family, and a multi-
disciplinary group of clinicians working in
concert. Successful recovery takes a village,
interlocking communities of support (e.g.
extended family, peers, team-mates, social
networks, professional support) in which

patients practice their recovery skills, and
find vital sources of commonality, connec-
tion, optimism, and accountability. We hope
that this book conveys respect for the
daunting power of these illness processes,
as well as the healing power of clinicians,
researchers, patients, and families combining
forces toward a common goal.
Readers will note recurring references to
the importance of the clinical relationship,
based on empathy, connection, compassion,
respect, and affection, as well as the impor-
tance of using that relationship to best imple-
ment interventions that have demonstrated
effectiveness (Zerbe, 2008). Furthermore,
we hope a spirit of partnership emerges
from this bookdpartnership between fami-
lies and professionals, and between
researchers and practitioners. Ideally,
Treatment of Eating Disorders: Bridging the
Research/Practice Gap, will help us to tran-
scend the historical tensions and competitive
relationships between researchers and prac-
titioners in our field (Banker & Klump,
2007), and inspire us to proceed with collab-
orative efforts that appreciate and integrate
the best from each domain’s perspective. A
paradigmatic shift of this magnitude,
involving change in attitude and practice
both within and between disciplines, will

require more than an academic tome
devoted to its necessity. As the final chapter
of this book illustrates, we are called to action
or we will remain a field destructively
divided.
As editors, we also are aware of the limits
of this volume. For example, the diversity, or
the evolving face, of ED, is a critical issue
beyond the scope of this book. Once the
purview of young Caucasian women
from higher socio-economic strata in the
advanced technological nations, EDs are
now global conditions occurr ing in over
40 countries, many of which are developing
nations (Gordon, 2001). In their examination
INTRODUCTION xxiii
of how culture, ethnicity, difference, and EDs
affect minority and non-western females,
Nasser and Malson (2009) state:
The spread of thinness as a master signifier of
feminine beauty, promulgated by the mass media
and the post-colonial operations of transnational
capital, across all sections of western societies
and across the world has been devastatingly
effective in the ‘globalisation’ of ‘eating disor-
dered’ subjectivities and practices.Thinness as
a gendered body ‘ideal’ and a signifier of
a multiplicity of positively construed ‘attributes’
can clearly no longer be considered exclusively
western or white (p. 82).

Confirming this significant change in the
face of ED, Grabe and Hyde (2006) con-
ducted a meta-analysis of 98 studies, finding
no significant differences in body dissatisfac-
tion between Caucasian, Hispanic, and
Asian women in the USA. Also, Bisaga et
al. (2005) found similar rates of disordered
eating (DE) across ethnicities in adolescent
girls. Despite clinical impressions clearly
confirmed by research, regarding the diverse
presentation of ED, minority women experi-
ence worrisome barriers to their access to
care, especially due to lack of recognition
by providers (Cachelin & Striegel-Moore,
2006). Many of these same issues are factors
in the underdiagnosis and treatment of men
with ED. We must challenge these outdated
stereotypes so all patients will be able to
receive appropriate diagnosis and care.
Clearly, the field has much to learn about
how EDs present across culture, country,
ethnicity, and other divisions. We must begin
to acknowledge that EDs no longer belong to
a place, but instead inhabit many different
and constantly evolving global social
spheres. Nasser and Malson (2009) advise
us to attend to both global and local factors
in our attempts to understand ED. They
explain that the “gendered aesthetics of thin-
ness” are not always central to the DE or self

starvation and that other “locally-specific
discursive constructions of self-starvation
may be more relevant” (p. 82).
The above findings remind us that our
culture continues to drive vulnerable men
and women into DE and ED. Although there
seems to be a decreased appreciation for
these sociocultural forces, enduring gender
role stereotypes remain influential. Culture
and diversity are enormously complex
issues and, while we believe strongly in their
importance in a discussion about ED, we
could not do them full justice in this volume.
Despite this noted limitation, Treatment of
Eating Disorders: Bridging the Research/Practice
Gap, presents a range of topics critically
illuminating the challenge of clinical work
with ED patients. The informed clinician
needs to be conversant with multiple litera-
tures including research on the cultural,
psychological, behavioral, medical, genetic,
neurological, and spiritual dimensions of
ED. If nothing else, this volume should put
to rest the notion that there is any real
dichotomy between the biology and the
psychology of lived experience. We believe,
also, that there is no validity to the dichotomy
between clinical practice and research; it is,
rather, the lack of resources, inadequate dia-
logue, disparate languages, and varied

systems of inquiry that create this divisive
impression (Banker & Klump, 2007). Clini-
cians collect data every day informing their
sense of what does and does not help partic-
ular patients and families. Meanwhile,
researchers are developing and refining
methods of inquiry that allow for more rele-
vant applications of evidence-based practices
into naturalistic settings (Lowe, Bunnell,
Neeren, Chernyak & Greberman, 2010).
Historical differences between the two camps
regarding what constitutes meaningful
“evidence,” or sources of information (e.g.,
clinical vs. empirical data) have impeded in-
tegrative, clinically driven investigations.Ad-
vances in qualitative and phenomenological
INTRODUCTIONxxiv
research have begun to mediate this imp-
asse and should be further incorporated into
formal quantitative explorations (Jarman &
Walsh, 1999; Kazdin, 2009). As Banker and
Klump (2007) aptly state, it is time
for a “researcher-clinician rapprochement”
(p. 14).
Finally, the need to bridge the science/
practice gap does not devalue either
domain’s distinct and relative merits, nor
does it negate the necessity for interdisci-
plinary debate. In fact, as Nobel prize winner
Ilya Prigogine has asserted, a certain degree

of friction is vital for growth:
It is precisely the quality of fragility, the
capacity for being ‘shaken up,’ that is paradoxi-
cally the key to growth. Any structuredwhether
at the molecular, chemical, physical, social, or
psychological leveldthat is insulated from
disturbance is also protected from change (Levoy,
1997, p. 8).
Change, and exchangedin perspectives,
attitudes, and practicesdis the bridge this
volume endeavors to create. It is no longer
acceptable to rely on research that does not
reflect clinical realities; thanks to the efforts
of our authors and many other colleagues,
we see promising signs that this gap is
closing. Nor is it acceptable for therapists to
base their treatment approaches solely on
their own clinical intuition (Herbert et al.,
2007). The research cited in this volume sup-
porting innovative clinical work demon-
strates the merits of Evidence Based
Treatment (EBT) and the importance of incor-
porating EBT into treatment plans (Haas &
Clopton 2003; Mussell, Crosby, Crow,
Knopke & Peterson, 2000; Tobin, Banker,
Weisberg & Bowers, 2007). Working from
one theoretical perspective because that is
how you were trained is no longer defensible.
Clinicians need to be able to explain their
rationale for their treatment approach and

recommendations, and those explanations
need to incorporate both science and clinical
intuition. The following contributions seek to
insure that researchers and clinicians are
cross-trained in the best practices of ED treat-
ment, building bridges that can withstand
the inherent friction required for growth,
and paving the way for future advances.
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INTRODUCTIONxxvi
CHAPTER
1
A Perfect Biopsychosocial Storm
Gender, Culture, and Eating Disorders
Margo Maine and Douglas W. Bunnell
Although eating disorder(s) (ED) are multidetermined, biopsychosocial disorders, gender
alone remains the single-best predictor of their risk (Striegel-Moore & Bulik, 2007). Most
research asserts that anorexia nervosa (AN) and bulimia nervosa (BN) are 10 times more
common in females than males, and binge-eating disorder (BED) is three times more
common (Treasure, 2007). While some have argued that one in six cases occurs in males
(Andersen, 2002), the gender disparity is still glaring. Furthermore, while ED is not the
only gendered psychiatric condition, the degree of gender disparity is much greater than

in most diagnoses (Levine & Smolak, 2006 ).
Now the third most common illness in adolescent females (Fisher et al., 1995), superseded
only by diabetes and asthma, ED have become a major public health issue, affecting more and
more women of all ages. Today they appear in every stratum of American culture and, with
the impact of globalization, in more than 40 countries worldwide (Gordon, 2001). This expo-
nential increase in a condition disproportionate ly affecting women must have its roots in the
interplay of culture and gender, as a genetic mutation has not swept the globe. But media
images of perfectly crafted female bodies and unprecedented role change have, in fact, swept
the globe. The increased access to education and involvement in the workplace have trans -
formed women’s social roles dramatically, with rapid technological and market changes
introducing a powerful global consumer culture and relentless expectations about appear-
ance and beauty (Gordon, 2001). As the social changes accelerate, many women seek solace
and mastery by controlling their bodies (Maine & Kelly, 2005).
Quite simply, gender creates risk. The World Health Organization’s (WHO) evidence-
based review of women’s mental health (World Health Organization, 2000) concludes that
gender is the strongest determinant of mental health, soc ial position, and status, as well as
the strongest determinant of exposure to events and conditions endangering mental health
and stability. Furthermore, the WHO notes a positive relationship between the frequency
and severity of social stressors and the frequency and severity of mental health problems
in women. Despite the importance of gender disparities in mental health and risk for ED,
the recent emphasis on biogenetic research risks minimizing the importance of the role of
3Treatment of Eating D isorders doi: 10.1016/B978-0-12-375668-8.10001-4 Ó 2010 Elsevier Inc.
culture and gender in their etiology. As clinicians, we understand that the biopsychosocial
whole is greater than the sum of its parts, despite the challenges this presents to the tradi-
tional research paradigms. This chapter explores the interplay of biopsychosocial factors
contributing to the perfect storm of ED, especially examining culture and gender.
NATURE VERSUS NURTURE: A FALSE DICHOTOMY
Delineations between the biol ogical, psychological, and social forces underlying ED are
false distinctions, as nature and nurture always go hand in hand. Genes code RN A and
DNA, the building blocks of cells, creating variations associated with risk. While they do

not code behavior or disease, genes create vulnerabilities which wi ll be tempered or intensi-
fied by other factors (Chavez & Insel, 2007), such as the family, early development, social
experiences and expectations, physical conditions, and gender. Increasingly sophisticated
research models investigate the complicated interactions in which environmental experience
can alter gene expression (Hunter, 2005). Although they are not destiny, genes shape vulner-
ability and resilience, affecting how we perceive, organize, and respond to experiences, and
contributing to the perfect storm of ED.
The rapid dec line in the age at which girls enter puberty is an apt example of such a bio-
psychosocial storm. A century ago, the average age for menarche was 14.2 and now it is 12.3.
In the 1970s, the average age of breast development was 11.5, but by 1997, it was less than 10
years old for Caucasian girls and 9 years old for African American girls, with a significant
number developing even before age 8 (Steingraber, 2009). Girls who enter puberty earlier
than peers have more self-esteem issues, anxiety, depression, adjustment reactions, eating
disorders, and suicide attempts (Graber, Seeley, Brooks-Gunn & Lewinsohn, 2004). They
are more likely to use drugs, alcohol, and tobacco, have earlier sexual experiences, be at
increased risk of physical violence, and, due to prolonged estrogen exposure, have a higher
incidence of breast cancer (Steingraber, 2009).
Early puberty may be best understood as an ecological disorder, an interaction of psycho-
social, nutritional and environmental triggers, such as pollutants or chemical exposure; while
family stress or trauma may also play a part. Aptly describing the false dichotomy between
nature and nurture, Steingr aber states: “The entire hormonal system has been subtly rewired
by modern stimuli.female sexual maturation is not controlled by a ticking clock. It’s more
like a musical performance with girls’ bodies as the keyboards and the environment as the
pianist’s hands” (2009, p. 52).
Sexual maturation brings increased attention to the body, sexuality, and the develop-
mental pressures of adolescence, enhancing the impact of other ED risk-factors. Nature
and nurture interact as girls’ lives unfold.
GENDER: DIFFERENCE OR SIMILARITY?
Culturally constructed sexism has led to intense divisions between men and women , as
expressed in common concepts such as “the war of the sexes,” as if gender creates virtually

different species with no hope of understanding each other. The media systematically
1. A PERFECT BIOPSYCHOSOCIAL STORM4
I. BRIDGING THE GAP: THE OVERVIEW
promulgate gender differences, just as they have contributed to the objectification of women
and sexism. Despite the popularity of books like Men Are from Mars, Women Are from Venus
(Gray, 1995) and You Just Don’t Understand: Men and Women in Conversation (Tannen, 2001),
decades of psychological research suggest that men and women and boys and girls are
much more alike than different (Hyde, 2005).
In their epic work, The Psychology of Sex Differences, Maccoby and Jacklin (1974) reviewed
more than 2000 studies, dismissing many popular beliefs and identifying only four areas of
difference: (i) verbal ability; (ii) visual-spatial ability; (iii) mathematical ability; and (iv) aggres-
sion. In 2005, Hyde’s meta-analysis of the gender difference literature found that 78% of the
differences are very small, actually close to zero, even in areas where gender differences
have been consistently considered strong. The greatest gender difference is in motor perfor-
mance, due to post-puberty differences in muscle mass and bone size. Measures of sexuality,
especially the frequency of masturbation and attitudes toward “casual sex,” also reveal signif-
icant gender differences, but virtually no difference in reported sexual satisfaction. The meta-
analysis of aggression indicates a strong gender difference in physical parameters, but less so
with verbal aggression. Despite the suggestion in the popular press and media that girls have
a higher level of relational aggression, the evidence is mixed.
As gender differences fluctuate over the course of development, Hyde (2005) suggests that
they are not as fixed as many believe. She also notes that the surrounding context, such as the
written instructions, interacti ons between participant and experimenter, or expectations of
gender differences, significantly affect results. The fact that both their strength and their
direction depends on context challenges the notion of strong, stable gender differences.
NATURE, NURTURE, AND THE BRAIN
Research on the brain indicates important gender differences, despite the behavioral simi-
larities noted above. In a thorough review of gender, Cahill (2006) no ted significant gendered
patterns in brain structure and neurochemistry associated with a wide range of emotional
and cognitive functions including learning, emotional and social processing, memory

storage, and decision-making. Male and female brains react differently to stress. Chronic
stress is more damaging to the male brain, particularly to the hippocampal area thought to
be central to memory and learning, while transitory interpersonal stressors result in
a stronger adrenocortical response in women’s brains (Stroud, 1999). At the neurochemical
level, gender influences the ways in which our brains synthesize, metabolize, and respond
to neurotransmitters such as serotonin, possibly helping to explain differential rates of
mood disorders and substance addiction.
Brain differences have been disproportionately attributed to sex hormones, but research
has now established that other distinctions exist. For example, the denser corpus callosum
(the band of fibers bridging the brain’s hemispheres) in the female brain allows greater
connection between the two hemispheres, so women have less lateral specialization, whereas
men have more of a division between the brain hemispheres. These neuroanatomical differ-
ences may explain women’s superior language skills and men’s superior visual-spatial skills.
The neuroanatomy of the hypothalamus, instrumental in hormonal functions and reproduc-
tion, is also different, resulting in neurophysiological differences that in turn affect behavior.
NATURE, NURTURE, AND THE BRAIN 5
I. BRIDGING THE GAP: THE OVERVIEW
The anterior cingulate gyrus, more active in women, is linked to nurturant social behaviors,
while the amygdyla (more active in men) is linked to anger and rage. Although statistically
significant, these differences are small (Solms & Turnbull, 2002). The environment and
culture often intensify these differences with gend er-laden messages, attitudes, and expecta-
tions, and thereby multiply their expression (Lee, 2007).
While the study of brain gender differences has been enhanced by technological develop-
ments, it has, perhaps, been retarded by the viewpoint that differences somehow imply defi-
ciency. In a patriarchic culture, an androcentric bias may affect how scientific findings and
models of psychopathology are interpreted.
GENDERING: A BIOPSYCHOSOCIAL PROCESS
Is it a boy or a girl? This is often the first question asked about the birth or pending birth of
a baby. The answer shapes our reaction and expectations and impacts the child’s life story
and experience in countless ways. Simply put, the impact of gender occurs early and often.

According to social scientists, “gendering” is “the sum of all influences. that channel
females and males into divergent life situations,” which are then intern alized into the self,
leading to certain “sex-linked characteristics, cognitions, and interpersonal transactions”
(Worell & Todd, 1996, p.135). By age 2, gender identity begins to emerge, with the child con-
structing a sense of self as either male or femal e (Worell & Todd, 1996).
Gender experiences interact with the gendered features of the brain to create a gendered self,
and relationships with caregivers are the key arenas for these experiences to play out. Illus-
trating the intersections of culture, biology, and psychology, parental responses to an infant
are driven by the parent’s biology, by their cultural and psychological experiences, and by
the gendered biology of the infant. According to Weinberg, Tronick, Cohn & Olson (1999),
male and female infants display markedly different levels of emotional expressivity and
arousal and evoke differ ent parental reactions. Boys, who are less regulated, are actually
more sociable than girls a t this age. They seem to pull for more physical touch and perhaps
greater relational involvement from their mothers due to the challenge of maintaining emotional
regulation. Weinberg and he r colleagues also found that bo ys and mothers stayed in attachment
synchrony more t han motheredaughter dyads but also took longer times to re-establish that
synchrony after it ha d been disrupted. Gi rls, b y c ompariso n, r equi re less soothing but also
seem to pr ese nt more subtle c ues to their caregivers. Perhaps our belief tha t girls and women
are more relational is rooted, at least in part, in the need for closer attention to these subtle
expressions. Boys may be less relational because their emotions are so obviou s.
In order to develop a sense of self, boys mu st psychologically separate from their primary
attachment, usually their mother, and connect to the same sex figure, the father. Girls, on the
other hand, must retain the connection to mother as the same sex identificatory figure but
connect to the father in a new affective relationship. This developmental challenge places
a premium on relational, as opposed to self-containing and separating, capabilities. Girls
begin to explore who they are and who they want to be by comparing themselves with peers,
parents, siblings, and the cultural images available to them (like characters in books or
movies). Boys learn to harden themselves into self-sufficiency, fearful that dependence is
shameful.
1. A PERFECT BIOPSYCHOSOCIAL STORM6

I. BRIDGING THE GAP: THE OVERVIEW
In optim al circumstances, these developmental challenges inter-twine with biological
endowments and social values in ways that enhance and support healthy maturation. The
environment can be more or less gendered, either reinforcing stereotypic behavior or allow-
ing more room for difference or exploration. Individuals can also adjust their gender-typed
behaviors in order to present in a certain way. For example, girls may act more typically femi-
nine to get approval or attention pending the cues and demands they perceive. When
psychopathology develops, it may reflect disruptions in this complicated process. When
the psychopathology occurs at vastly different rates in men and women, the biopsychosocial
construction of gender may be the source.
PSYCHOLOGICAL DEVELOPMENT IN A GENDERED ENVIRONMENT
Western culture is still androcentric, based on a patriarchy, as seen in our common
language forms (think “chairman” of the board). Such gendered environments exert subtle,
subliminal, but constant pressures on both sexes to act in certain ways. Gender stereotypes
evolve based on a culture’s belief systems regarding the attitudes, behaviors, and other char-
acteristics that seem to differentiate the two sexes. This section focuses primarily on how
gendering affects females, while Chapter 18 (Bunnell) examines the male experience and
consequent risks for ED.
Frequent references to “the opposite sex” show our polarizing views of gender. Western
culture usually emphasizes socio-emotional and body image (BI) issues when defining
stereotypic femininity, and competence and autonomy when defining masculinity. These
stereotypes prescribe certain behaviors: women are to take care of others and attend to their
appearance, while men are to take risks, assume leadership, and focus on success and work.
Such dichotomous views of gender give men public power and influence, while limiting
them to women, with far-reaching consequences.
The impact of a gendered environment may intensify in the face of biopsychosocial devel-
opmental stressors. Puberty heralds both internal and external changes, clear markers of
gender. For girls, it brings dramatic hormonal changes resulting in menstrual periods, breast
development, and increased body fat. Bet ween the ages of 10 and 14, in fact, the average girl
gains 10 inches of height and between 40 and 50 pounds. Most double their weight by the

time they finish puberty (Friedman, 1997). In addition to the physical events, puberty
involves an increased attention to the demands and expectations of the dominant culture,
as, emotionally ready or not, girls move from the safety of childhood into a universe increas-
ingly driven by factors outside the family such as peers, school, and the media.
This heightened attunement to sociocultural demands or norms creates significant conflict
for girls. Absorbing the external message that they need to control their weight and maintain
an attractive, sculpted look, girls may feel unhappy about their body’s natural changes.
While body fat may be necessary to physical development, it contradicts the female ideals
they have been taught, so it seems invalidating and frightening.
For some girls, this transition into puberty feels like the proverbial fall down a rabbit-hole,
just like Alice in Wonderland, landing in a place where things may look the same but feel very,
very different. One young woman in recovery from bulimia described that she went to bed at
night after playing with dolls, then woke up with breasts, and everyone treated herdifferently.
PSYCHOLOGICAL DEVELOPMENT IN A GENDERED ENVIRONMENT 7
I. BRIDGING THE GAP: THE OVERVIEW