Handbook of Psychology

Mental Health Issues 521

constitute more than 90% of reported AN and BN cases
(American Psychiatric Association, 1994) with lifetime
prevalence rates estimated to be approximately 0.5% for AN,
1% to 3% for BN, and 0.7% to 4% for BED in community
samples (American Psychiatric Association, 2000).
The impact of eating disorders on women•s health in-
volves both physical and psychological consequences. One
of the most common physical effects on women is primary or
secondary amenorrhea (i.e., absence of menstruation)„a
symptom required to receive a Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (DSM-IV;
American Psychiatric Association, 1994), diagnosis of AN.
Although absence of menses is not a core requirement for
BN, about one-third of bulimic women report amenorrhea
(Mitchell, Seim, Colon, & Pomeroy, 1987). This hormone
disturbance reduces, but does not eliminate, the chance for
reproduction; however, there is fetal risk associated with
pregnancy in the presence of AN (Goldbloom & Kennedy,
1995). Later in this chapter, we discuss the psychological
impact of infertility on women; consequently, it is important
to consider that women with eating disorders present twice
as often as women in the general population for treatment at
infertility clinics (Stewart, 1992). Women with eating disor-
ders are at increased risk for osteoporosis (Goldbloom &
Kennedy, 1995) and for developing stress fractures and other
bone-related problems because of low bone-mineral density
associated with amenorrhea (Putukian, 1994). Vomiting or
purging, a frequent symptom of eating disorders, has been as-
sociated with various medical problems, including salivary
gland hypotrophy (Mitchell, 1995) and electrolyte imbalance
with 50% of bulimic women experiencing electrolyte abnor-
mality. Cardiovascular problems such as bradycardia and
hypotension (Stewart, 1992), as well as cardiomyopathy
(Mitchell, 1995), are common in AN and BN. It is equally
important to examine the physical health problems associated
with being obese, a common symptom in women with BED,
as obesity has been associated with type 2 diabetes mellitus
(noninsulin dependent), hypertension, stroke, cardiovascular
disease, gallbladder disease, cancer, and arthritis (Pike &
Striegel-Moore, 1997; Pi-Sunyer, 1995).
Eating disorders also have been linked to increased risk for
comorbid psychological disorders. Pike and Striegel-Moore
(1997) suggest that rates of depression in individuals with eat-
ing disorders (including AN, BN, and BED) are higher than
those in the general population. Approximately 45% of those
with AN have a lifetime history of an affective disorder
(Santonastaso, Pantano, Panarotto, & Silvestri, 1991), as do
43% to 88% of those with BN (Kendler et al., 1991) and 32%
to 50% of those with BED (Yanovski, Nelson, Dubbert, &

Spitzer, 1993). Cooper (1995) reported that approximately half

of those individuals seen in a clinic for an eating disorder also

have a lifetime history of major depressive disorder. Eating dis-

orders have been linked to anxiety disorders, with obsessive-

compulsive disorder disproportionately found among those

with eating disorders (Kaye, Weltzin, & Hsu, 1993). Eating

disorders also have been linked to personality disorders, with

30% to 50% of bulimic individuals having a personality disor-

der„the majority of these in theDSM-IVCluster B category

(i.e., antisocial, borderline, histrionic, and narcissistic; Sokol

& Gray, 1998). Eating disorders have a strong sociocultural

component as women face unique pressures to be thin,

exacerbating the numerous detrimental effects on women•s

physical and psychological health documented in this section.

Substance Use

Cigarette Smoking

Approximately 22 million women in the United States

(22.6%) smoke cigarettes (Husten & Malarcher, 2000). Ciga-

rette smoking kills approximately 152,000 women each year

because of resulting cardiovascular disease, cancer, and res-

piratory diseases (CDC, 1997). More speci“cally, cigarette

smoking accounts for an estimated 85% of CHD deaths and

79% of COPD deaths among women ages 45 to 49 years

(CDC, 1997; Davis & Novotny, 1989). Cigarette smoking is

also associated with increased risk of stroke, infertility, and

low birth weight infants. Cigarette smoking among women

typically starts in adolescence. Various risk factors have been

linked to the initial smoking behaviors among adolescent

girls such as peer pressure, depression, drug abuse, poor aca-

demic achievement, familial smoking behaviors, and the be-

lief that smoking helps control weight gain (see Husten &

Malarcher, 2000). Because smoking results in a variety

of physical health problems and is the •leading pre-

ventable cause of death among women in the United StatesŽ

(Husten & Malarcher, 2000), prevention efforts should focus

on educating women of all ages about the health conse-

quences of smoking, especially in populations where preva-

lence rates are particularly high (e.g., among women who

live below the poverty level and women who have less than

12 years of education (Adler & Coriell, 1997).

Alcohol

A national study in the United States revealed that approxi-

mately four million women above the age of 18 years could

be considered •alcoholicŽ or •problem drinkersŽ„with 58%