This is the third of a series of articles on Eating Disorders, and is
Part 1 of two papers on Bulimia Nervosa. This first paper deals with the
background and etiology of this syndrome. Bulimia is an under-diagnosed
syndrome and the cause of significant morbidity especially in the female
adolescent and young adult population. As will be discussed later,
bulimia has both a historical and modern perspective. The authors
consider Bulimia Nervosa to be on a continuum of eating disorders
ranging from starvation syndromes to obesity.
"Uncontrolled recurring episodes of binge eating and self-induced
vomiting and/or abuse of laxatives and diuretics in order to prevent
weight gain" is the description used to describe the condition
Bulimia Nervosa. The term Bulimia is derived from the Greek words "bous"
meaning ox, and "limos" meaning hunger (Hsu 1990, pg 1, and
Brownell & Fairburn 1995, pg 145).
Like its counterpart, Anorexia Nervosa, individuals with bulimia are
excessively pre-occupied by their weight and body image. However, while
the anorexic generally restricts food intake and hence loses weight, the
bulimic patient, despite the cycle of bingeing and purging, may be at a
reasonable or above normal weight.
Bulimia has been described since ancient times. Greek authors described
the behaviors of cults as encouraging self-induced vomiting. (Giannini
& Slaby 1993, pg 18).
The Egyptians believed that diseases came from food, and purged on a
monthly basis, and the Romans had "vomitoriums". The wealthy
Romans gave elaborate banquets during which twenty or more courses were
consumed. To accommodate this, purging between courses was instituted as
socially acceptable behaviour. These vomitoriums had "fountains,
scented water, and flowers.…providing a pleasant environment for the
guests to purge themselves of previous courses". The guests were
then washed and cleaned by slaves and escorted back to continue with the
meal. (Giannini & Slaby 1993, pg 18).
During the Middle Ages, religious authorities considered gluttony a
mortal sin. Self-induced vomiting was allowed as penance. Forced emesis
was also practiced among monks to control sexual drives and sharpen
The first known clinically description of bulimia is that of James who
in 1743 defined "true boulimus, which was characterized by intense
pre-occupation with food and overeating at very short intervals
terminated by vomiting". Motherby (1785) distinguishes between
three types of bulimia. These include "bulimia of pure hunger,
bulimia associated with swooning, and bulimia terminated by
vomiting". (Alexander-Mott 1994, pg 17).
Cases of bulimia approximating modern day criteria did not begin to
appear in the literature until the 1930's. The word bulimia was re-
introduced by John Trevisa in 1938 (Giannini & Slaby 1993 and
Alenander-Mott & Lumsden 1994). The increased incidence of bulimic
behaviour in the 1970's finally warranted the acknowledgment of Bulimia
Nervosa as a distinct disorder in 1980 in the DSM III.
DIAGNOSIS OF BULIMIA NERVOSA
In the current issue of the Diagnostic Manual of the American Medical
Association, (DSM IV), the criteria for the diagnosis of Bulimia Nervosa
are as follows:
A) Recurrent episodes of binge eating. An episode of binge eating is
characterized by both of the following:
(1) Eating, in a discrete period of time (e.g. within any 2 hour
period), an amount of food that is definitely larger than most people
would eat during a similar period of time and under similar
(2) A sense of lack of control over eating during the episode (e.g. a
feeling that one cannot stop eating or control what or how much one is
B) Recurrent inappropriate compensatory behavior in order to prevent
weight gain, such as self-induced vomiting; misuse of laxatives,
diuretics, enemas, or other medications; fasting; or excessive exercise.
C) The binge eating and inappropriate compensatory behaviors both occur,
on average, at least twice a week for 3 months.
D) Body shape and weight unduly influence self-evaluation.
E) The disturbance does not occur exclusively during episodes of
Bulimia can also include two subtypes. Bulimia that includes the purging
type characterizes those individuals who engage in repeated episodes of
self-induced vomiting or misuse of laxatives and diuretics. Bulimia that
includes the nonpurging type characterizes those individuals who do not
engage in self-induced vomiting or the misuse of laxatives and diuretics
but actively engage in fasting or excessive exercise to prevent weight
Bulimia Nervosa usually begins in late adolescence or early adulthood.
Ninety percent of all individuals suffering from bulimia are women,
while only an estimated five to ten percent are men (Alexander-Mott
& Lumsden 1994). The frequency of Bulimia Nervosa ranges from 3.8%
to 19% among college-age women and from 3% to 8.3% among high school
women (Alexander-Mott & Lumsden 1994). The literature cautions,
however, that these prevalence rates may be an underestimation as many
sufferers of bulimia go for many years undiagnosed and undetected.
Furthermore, the incidence of Bulimia Nervosa appears to have increased
within the past several years It is unknown if this increase is a true
reflection in the rise of frequency or if it merely reflects better
Research findings suggest that individuals who suffer from Bulimia
Nervosa have associated personality and behavioral problems. Weiss and
Ebert (1983) compared fifteen individuals who met the DSM III criteria
for Bulimia Nervosa against fifteen individuals from a community sample.
They found that those individuals suffering from bulimia reported
significantly higher rates of psychopathology in a number of areas
including, "somatisation, obsession-compulsion, interpersonal
sensitivity, depression, anxiety, anger, phobic anxiety, paranoid
ideation, and psychotism". They also reported "greater
external loss of control, greater fear of fat, and more anxiety in
situations related to eating than controls" (Alexander-Mott &
Lumsden 1994, pg 167). Beumont (1995) also found preexisting personality
difficulties, and difficulties in interpersonal relations, impulse
control and substance abuse. Beaumont also differentiated bulimics from
anorexics who are characterized as "usually more reserved,
introverted, inhibited, and obsessional" (Brownell & Fairburn
1995, pg 157). However, both anorexics and bulimics have been found to
be perfectionists and to have high self-expectations.
In an attempt to prevent weight gain, bulimics usually follow a strict
diet and avoid high calorie foods. However, as their restrictive diet
becomes more difficult to follow and with their increasing preoccupation
with food, episodes of gorging soon become established. Soon after the
gorging behavior begins, self-induced vomiting begins as well as purging
with laxatives and diuretics. The usual method of inducing vomiting is
by inserting the finger down the throat but, as the bulimic purges on a
more regular basis, they learn to vomit at will. (Brownell &
Fairburn 1995, pg 156). Bulimic episodes are often planned to occur when
chance of discovery is remote. The binge foods are usually sweet, fatty,
high-calorie foods with the binge lasting anywhere from thirty minutes
to an hour. Some bulimics will ingest large amounts of food within
minutes while others may engage in "picking" behavior, taking
in small quantities at a time (i.e. a teaspoon of ice-cream, a small
piece of cake, or a portion of cheese), but continuing this
"picking" for hours until they have ingested thousands of
calories." (Brownell & Fairburn 1995, pg 156)
The binge-purge cycle affects every aspect of a bulimic's life. Not only
does it cause health problems, but it interferes with interpersonal
relationships and performance at school and/or work. The bulimic often
feels ashamed of the behavior and becomes overwhelmed with guilt, shame
and remorse. Because bulimics spend most of their time planning and
creating situations where they can be alone to binge, they isolate
themselves from family and friends which lead to further solitude.
(Alexander-Mott & Lumsden 1994, pg 169).
The specific etiology of bulimia is not yet known but, as in anorexia
and related food disorders, a multiplicity of factors appear to be
involved requiring the interaction of biological, psychological and
Biologically based theories hypothesize that bulimia is the result of
the dysfunctional regulation of neuroendocrine mechanisms in the
hypothalamus. Two important regions in the hypothalamus effect feeding
behaviors. The ventromedial hypothalamus contains a satiety center and a
feeding center exists in the lateral hypothalamus. In animal
experiments, stimulation of the ventromedial hypothalamus (satiety
center) suppresses eating while hyperphagia and obesity occurs if this
center is damaged. The opposite is true with the lateral hypothalamus.
When this center is stimulated, there is increased eating while eating
is suppressed once this center is damaged. Thus, "the satiety
center is thought to coordinate the stop-feeding response; the feeding
center integrates the start-feeding signal" (Giannini & Slaby
1993, pg 46).
The neurotransmitters Norepinephrine, Serotonin, and Dopamine are found
in the hypothalamus and have been identified as having an important role
in the regulation of food intake. When Norepinephrine is released in the
lateral hypothalamus (feeding center) eating is suppressed. The same is
true with Serotonin. When Serotonin is released in the ventromedial
hypothalamus (satiety center) eating is again suppressed. Depletion of
Serotonin results in hyperphagia and obesity, while Norepinephrine
inhibits the satiety center increasing eating behaviors. (Giannini &
Slaby 1993, pg 46).
It has also been hypothesized that bulimia has a biological basis by
examining the relationship between bulimia and affective disorders. Pope
and Hudson (1985) reported that "80% of the bulimic patients they
have studied have had major affective disorder at some point during
their lifetime" (Alexander-Mott & Lumsden 1994, pg 174). Some
authors report that higher rates of depression are found among family
members of bulimic patients and that some bulimics respond positively to
treatment using antidepressant medication. However, it is also possible
that the pathological eating behaviour leads either biologically or
psychologically to depression. (Brownell & Fairburn 1995, pg 157).
From a psychosocial perspective bulimia is related to a society which
stresses thinness and physical appearance related directly to
self-esteem. This is especially apparent amongst females. Whether as a
result of advertising that equates slimness with popularity or
identification with popular media figures, young girls are becoming more
and more preoccupied with their looks and body weight. Some authors have
maintained that this is due to problems especially in regards to women's
role in society while others do not see a sexual bias, but rather an
increase in narcissistic preoccupations.
Baskind-Lodahl (1985) maintains "that a central issue in the
development of eating disorders is the struggle in which women find
themselves immersed when attempting to live up to an ideal of femininity
that deprives them of an identity of their own" (Bendfeldt-Zachrisson
1992, pg 66). Thus, women's obsessions with their bodies are directly
related to the expectations that society has on physical appearance and
a "svelte figure has become an ideal to be anxiously pursued"
(Bendfeldt-Zachrisson 1992, pg 67).
Orbach (1985) attributes the increase in incidence of eating disorders
as a direct result to the development of the consumer society. Along
"with reification of products on the market, sexuality has been
made a commodity" (Bendfeldt-Zachrisson 1992, pg 67). The body has
become a "permissible form of self-expression and
self-involvement". (Bendfeldt-Zachrisson 1992, pg 68).
Psychological theories of bulimia reflect the full gamut of
psychological theories in general. Traditional psychoanalytic approaches
equate bulimia to repressed sexuality related to oedipal strivings.
Object relations theory stresses problems in early mother-child
separation individuation which leads to emotionally directed eating
patterns. The bulimic rebels against the mother by taking control of
Other psychodynamic theories are less symbolic and focus more on the
family dynamics. The belief is that the parents are not happy as a
couple and displace their dissatisfaction and disappointment onto their
child. The child is drawn into the conflict and is bombarded with
unrealistic expectations. "Their displaced and excessive
expectations with regard to the child also revolve around eating, food
and body appearance" (Bendfeldt-Zachrisson 1992, pg 65).
In summary, Bulimia Nervosa can be viewed as a modern syndrome with some
ancient origins. Bulimia has increased significantly in recent years
consistent with societal expectations equating positive self-esteem and
self worth with body size and shape and body weight. As distinct from
its sister syndrome, Anorexia Nervosa, bulmia is associated with more
affective disorder, and other personality disorders. Biological and
psychological explanations of both syndromes are essentially the same
and suffer from the same limitations, in that it is not really clear
whether the various problems found are the cause, or the result of the
syndrome. The very nature of bulimia and the fact that the bulimic
patient does obtain significant satisfaction from the behaviour makes
treatment extremely difficult and demanding on the professional and
warrants a separate discussion.
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