Answer: Watching the cake come out of the girl.
Ok I am sorry for the joke and here is what I know about a serious subject.
The Diagnostic and Statistical Manual of Mental Disorders, third edition, revised(DSM-III-R) defines eating disorders as a subclass of disorders "characterized by gross disturbances in eating behaviours". It is a problem mainly with young women who are overly concerned about gaining weight. Bulimia Nervosa is characterized by recurrent episodes of binge-eating and purging. The disorder can be associated with other disorders such as Anorexia Nervosa or depression but many otherwise well adapted woman of normal weight suffer from it.(Steiger, Fraenkel and Leichner,1989:62) DSM-III-R states that Anorexia Nervosa and Bulimia Nervosa are "apparently related disorders, typically beginning in adolescence or early adult life."(DSM-III-R, 1987:65) In this paper, I will review the DSM-III-R criteria for Bulimia Nervosa and then look at a number of recent articles that deal with the various aspects of this particular subclass of eating disorder. In particular, I shall discuss two studies that examine the prevalence and family composition of persons with Bulimia Nervosa. I also look at four studies that examine the physiological aspects of people with Bulimia Nervosa and conclude with five papers that discuss treatment of this type of eating disorder.
Although the practice of self purging by vomiting or laxatives has been recorded since the days of the ancient Greeks and Romans, Bulimia Nervosa was only recognized as a separate eating disorder in the United States in 1979 when DSM-III was released.
The DSM-III outlines for Bulimia Nervosa, when first published, were very broad but this was corrected with DSM-III-R which set specific criteria for diagnosis. DSM-III-R (1987) states that all of the following diagnostic criteria must be present to warrent a diagnosis of Bulimia Nervosa:
A. Recurrent episodes of binge eating.
B. A feeling of lack of control over eating behaviour during the eating binges.
C. The person regularly engages in either self induced vomiting, use of laxatives or diuretics, strict dieting or fasting, or vigorous exercise in order to prevent weight gain.
D. A minimum average of two binge eating episodes a week for at least three months.
E. Persistent overconcern with body shape and weight.
The criteria for Bulimia Nervosa in DSM-III-R which set out specific frequencies aided doctors in diagnosis and also aided researchers in estimating the prevalence of this disorder in the population. DSM-III-R cites a college study which found prevalence and sex ratio of 4.5% of the females and 0.4% of the males (DSM-III-R, 1987:68). Other researchers have found the prevalence of Bulimia among young suburban women or college students to be from 3.8% to 13% (Siegel, 1989:123). Ben-Tovim, et al (1989) conducted a study which surveyed the eating habits of an Adelaide, Australia suburb. The residents of the area studied consisted of white middle class families and was judged to be a typical metropolitan suburb. The a sample of the residents were surveyed by asking them to fill out a questionnaire in a shopping mall over a one week period. The survey was also administered to a consecutive series of woman who attended a general health clinic and to all the students at the local high school. From the results of their study they estimated the prevalence of Bulimia Nervosa in the general population of Australia to be 1-2 percent which is similar to rates found in North America and the United Kingdom.(Ben-Tovim, et al, 1989:79)
Dolan, Evans and Lacey (1989) reported a study which compared the backgrounds of 50 Bulimic women with 40 non-eating disordered woman who were all from the same geographical area. Their results showed that the distribution of Bulimia Nervosa subjects was equally spread across the various social classes. That the disorder is rarely seen in non-caucasians.
A comparison of the family structure showed that "there is no special effect of sibling size, sibling sex ratio, or birth order in Bulimia Nervosa. (Dolan, Evans and Lacey, 1989:271) A significant difference was found in that the ages of both parents of the women with Bulimia Nervosa were, an average, older than the parents of the control group. While the authors note that this is "...not evidence of causality, it appears consistent with the psychodynamic and family dynamic theories of anorexia." (Dolan, Evans and Lacey, 1989:271)
This disorder received national attention when movies stars such as Jane Fonda admitted that they had been treated for it. With all the publicity and public awareness, more people are recognizing that they or their children have a problem and they finally seek treatment. Most cases can be treated through counselling on an outpatient basis but when the disorder becomes acute or is accompanied by other problems, then they are admitted to a hospital. Even in a hospital, patients with Bulimia are notoriously difficult to treat. An good example is that of the case of a 29 year old female who had a eight year history of bingeing on rich food but either spitting out the food, inducing vomiting or using laxatives to purge herself. Her laxative use was curtailed when she was admitted to a hospital. After two months in hospital she discovered that by chewing 10 packages of sugar free gum acted like a powerful laxative. (1)(Ohlrich, Aughey and Dixon,1989:451)
Jansen, Klaver, Merckelbach and Van den Hout (1989) conducted a study to determine if there is a relationship between eating disorders and the addiction model. The noted that both are characterized by craving, preoccupation and a loss of control over intake. Research has shown that addicts score higher on scales that measure sensation seeking and they also "habituated more rapidly to neutral stimuli than normal controls". (Jansen, et al, 1989:247) Research has also shown that people with Bulimia Nervosa have faster habituation rates of skin conductance responses. The results of their study showed that restrained eaters, such as people with Bulimia Nervosa, score higher than controls on sensation seeking scales. It was also demonstrated that these people do habituate quicker to a series of neutral stimuli than unrestrained eaters. (2) The authors point out that both restrained eaters and addicts can lose control after being preloaded. A preload is an amount of food or substance which sets the person off on a binge. A Bulimic person might start out by eating a small amount of a "forbidden food" or an alcoholic might have just one drink. This can set the person off on a binge.
The authors state that rapid habituating sensation seekers need a great deal of stimulation to reach an optimum level of stimulation. This can lead to overconsumption that is perceived as a negative consequence therefore they practice restraint. Restraint, such as dieting, vomiting or abusing laxatives is a consequence of rapid habituation. "Breaking the restraint leads to overconsumption, and has thus much more to do with the rapid habituation rates and need for stimulation than with a biologically predetermined set-point for body weight.(Jansen, et al 1989:251) This is shown schematically at figure 1.
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(Jansen, et al 1989:251)
The above study is interesting since if it is indeed true that all people with Bulimia Nervosa are rapidly habituating sensation seekers, then this would have implications for current treatment programs. Treatment of Bulimia, to date, has meet with mixed results. One study reported that patients who participated in a "inpatient eating control program and received psychodynamic psychotherapy were no better off at the 2 to 3 years follow up than those who received other treatments".(Sohlberg et al, 1987)
Two forms of behaviourial treatment were examined by Schmidt and Marks (1989). They compared the results of one exposure and response prevention of bingeing (ERPB) to exposure to eating and response prevention of vomiting (ERPV). ERPV is a treatment that has the subject eating until they feel sick and then prevent them from vomiting. ERPB, on the other hand, has the subject eat a small amount of a "forbidden" food. The subject then is exposed to the right smell and texture of desirable food but is not allowed to eat it (binge). ERPV had been tested successfully by various researchers but the authors thought that this treatment might be aversive to too many patients and have a high drop out rate. They thought that ERPB might be just as effective but be more acceptable as a treatment by the patients. They used a cross over design with six subjects in one group and five subjects in the other. The subjects underwent six sessions of ERPB/V over a three week period and then crossed over to do six sessions of the other treatment over a similar period of time. The subjects had a mean age of 24 (range 17-44). They had been Bulimic for 4.6 years on average. Five of the subjects abused laxatives as well as inducing vomiting.
Four of the 2 subjects also had a problem with substance abuse. Eight of the subjects had previously been received some form of treatment for Bulimia Nervosa. (Schmidt and Marks, 1989:265) The results of this study showed no difference in the results between the two treatments. Eight of the 11 subjects improved in that the frequency of their binge-vomit episodes had been reduced after the treatment and at the six month follow up point. Previous research had shown that ERPV plus cognitive restructuring alone. The authors suggest that since ERPB seems to be less time consuming and less aversive to the subjects, that it may be preferable to ERPV treatment. I think that this study could have been improved by the adding of placebo or "do nothing and wait" control group. We do not know if the improvements were derived from the treatment or from other factors.
Elise Rossiter et al (1989:465) state that "Cognitive - behaviourial treatment programs frequently presuppose excessive caloric restriction and a primary focus of these programs is reducing restraint by helping diets to consume three well-balanced meals per day and challenging overvalued ideals of slenderness." Research has suggested that people who are obsessed with their physical appearances try various diets to control their weights. This leads to their metabolism requiring less nourishment to survive on. This also leads to weight gain once the person drops the diet. These types of people with a history of prolonged dieting are at risk of developing Bulimia Nervosa. Rossiter et al (1989:465) tried to identify the distinctive psychological and pathological process of Bulimia Nervosa by "controlling for normative restraint with both restrained and unrestrained control groups". The found that there was no difference between people with Bulimia Nervosa and restrained eaters when surveyed about their preoccupation with food, and their concepts about their body weight, shape and restrained eating. This is interesting as some researchers have stated that this preoccupation with body weight and shape is the central psychopathological core of Bulimia Nervosa. (Rossiter et al, 1989:466)
Some researchers state that a Bulimic's bingeing and resulting depression may be related to their intake of carbohydrates and the level of central serotonergic functioning (5HT) in the brains. People who diet, supposedly eat more protein and less carbohydrates in order to lose weight. This type of diet is thought to lower the brain's serotonergic activity. Therefore when a Bulimic person binges it may be an attempt to rectify this imbalance. The results of Rossiter's study showed that there was no difference in the level of carbohydrates during a subjects' binges than any other eating episode. Also, there was no difference between the groups in fat intake.
The results are shown at figure 2.
(Rossiter, et al, 1989:557)
Robinson (1989) studied the relationship between the gastric contents of a Bulimic's stomach and then reported changes and satiety. He tested 10 Bulimic subjects with 10 controls by giving them a meal labelled with technetium-99m and then scanning them with an IGE Maxicamera gamma camera at various intervals along with filling out hunger and satiety questionnaires. The results showed a difference on the hunger scales between the two groups but the subjects "with Bulimia reported more `bloating' and less `contentment' after the meal." (Robinson, 1989:402) Subjects with fast gastric emptying showed no difference in rating scales than subjects with slow gastric emptying. Slow gastric emptying was defined as greater than 50% retention of the meal in the stomach at 100 minutes. Subjects with Bulimia, though, "had higher overall scores for nausea, urge to be sick, sadness, fatness, tension and drowsiness." (Robinson, 1989:402) The author states that "while the perception of gastric afferent signals in intact, further processing into behaviourial strategy (the urges to eat) does not occur normally. There is an apparent misidentification of gastric signals as feeling states that represent morbid symptoms." (Robinson, 1989:405)
As noted above, Psychodynamic Psychotherapy for people with Bulimia has not be successful. (3) Howard Steiger acknowledges this and suggests that an integrated treatment is required to respond to the biological, psychological and social maintaining factors. He states that the therapist must take an active and confrontational role in attempting to achieve the "limiting of maladaptive defense, and the fostering of more mature ones, which amount ultimately to changing coping behaviour and thinking styles. Unlike traditional psychotherapy, regression in limited rather than fostered, through the confrontation of depending or passivity." (Steiger, 1989:231)
He describes the case of a 29 year old Bulimic female who had been bingeing one to several times daily for about 10 years and used laxatives to purge herself several times a week. She used this purging to control her weight so she would be attractive to men. She blamed men for her depression and as revenge refused to go out with anyone for the past six years. The therapist confronted her irrational thoughts and eventually broke down her defences. The counselling sessions continued over the period of one month and gradually she reduced her binges and purges to the point where she quit bingeing completely. She also decided to move our of her parents house. The authors does not say whether she started dating again or not. The author states that the therapist must "directly challenge the patients irrational thinking patterns around (and other issues) that underline unpleasant affects and maladaptive behaviourial patterns and be directive in encouraging the patient to consider alternative, less aversive conceptualizations." (Steiger, 1989:235) He points out that by informing the patient about a weight report when purging stops will head off any panic when they start to gain weight. This paper was interesting in that it is a direct appeal to psychiatrists to refrain from becoming unidimensional in their thinking and consider developing integrated treatments. He does not discuss, at any length, the depression that is usually associated with Bulimia.
Chandarana and Malla (1989) report a chase where the patient initially is treated for Bulimia and then later developed dissociative states. The case involved a 17 year old female who was admitted to a hospital with symptoms of Bulimia along with a one year history of major depression. She had been a good student until her depression began which lead to a decline in her school performance. In the hospital, she was tested on a variety of psychometric tests such as the Minnisota Multiphasic Personality Inventory (MMPI), Millon Clinical Multiaxial Inventory(MCMI), Eating Attitudes Tests (EAT-26), and the Eating Disorders Inventory (EDI). The patients depression, hypochondriasis, and pschoasthemia scales were elevated on the MMPI and "the MCMI profile was markedly elevated on dependent, passive-aggressive, and borderline personality disorders and anxiety, somatoform, and dysthymia symptoms scales. Both the EAT and EDI showed elevation in the range for Anorexia Nervosa and Bulimia." (Chandarana and Malla, 1989:137) She was treated using a multidimensional approach which involved individual psychotherapy, occupational therapy, diet counselling and pharmacotherapy. The authors do not state which drugs were administered but I assume it would be something for her depressions such as a tricyclic antidepressant of which I will discuss later. She remained under this treatment in hospital for six weeks. She seemed to have been greatly improved when she was discharged but six weeks later she was readmitted. This time she admitted bingeing and purging which included vomiting and the abuse of laxatives. She had gained 11 kg and was very depressed. She had cut her leg and abdomen but the lacerations were superficial. She was reported five different personalities which took over her body and argued among themselves. The authors point out that her testing was not characteristic of a person suffering from a Multiple Personality Disorder and describe these episodes as multiple disassociative states. She remained in the hospital for a further six weeks. Her behaviour gradually improved and she was discharged. The authors state that:
"The dissociative phenomena, in association with Bulimia, pervasive depression, anxiety, and the non specific abnormalities seen in the personality profile, can be viewed as a desperate, unconscious attempt by the patient to deal with reverse anxiety associated with self-destructive and aggressive impulses which would otherwise become intolerable."
(Chandarana and Malla 1989:138)
I do not agree with the authors that the dissociative states are "indications of increasing severity of psychopathology and the patient's desperate attempts to cope with severe distress." (Chandarana and Malla 1989:138) The dissociative states did not begin until after the patient had been in the hospital for two weeks. It is likely that she was treated for her depression with a tricyclic antidepressant. The following case reported by Siegel (1989) contains many similarities with the above case.
Psychopharmacologic agents have been used with various degrees of success on treating the depression that is usually present with cases of Bulimia Nervosa. Tricyclic antidepressants such as Imipramine have become the treatment of choice due to several studies which showed that patients "had a significant reduction in their binge-eating behaviour and an improvement in mood compared to a placebo control group."(Siegel,1989:123) There is evidence that patients treated with tricyclics can suddenly switch from a state of depression to that of mania. The author states that "The mechanism may involve the blocking of serotonin or norepinephrine at the presynaptic terminal."(Siegel,1989:124) He reports the case of a 12 year old girl who was brought to an Adolescent Clinic after displaying symptoms of Bulimia Nervosa over a period of seven months. She was given counselling every two to three weeks for a period of two months. At the end of this period she had improved enough to be discharged but six months later she returned with a two month history of bingeing/purging and increasing symptoms of depression. It was decided to treat her with 125mg of imipramine daily. This seemed to be effective since her symptoms improved to a point where after one month she had stopped bingeing and her symptoms of depression where gone. Two months later, she was seen at the clinic and was doing so well that it was planned to take her off medication on her next visit. Nine days later she was admitted to an adolescent psychiatric inpatient facility due to a three day history of bizarre behaviour. She was "quite agitated and had an abnormal mental status with hallucinations, flight of ideas, grandiosity, and pressured speech." (Siegel,1989:125) She spent 2.5 months in the hospital where she was treated with 40mg daily of haloperidol. Haloperidol, commonly referred to as Haldol is one of the major tranquillizers usually used to treat persons with schizophrenia. (Rosenhan and Seligman,1984:498) The Haloperidol provided some relief from her agitation and disorganization. After six weeks, she was started on a lithium treatment and gradually taken off the haloperidol. She is still on lithium but is back in school and doing well. She still binges on occasion but there has been "no significant weight fluctuations or mood cycling." (Siegel,1989:125)
Researchers have found an 8.6 percent rate of tricyclic antidepressant-induced mania or hypomania. This is a significant rate of incidence but it may be misleading. Walsh(1989) quotes a study which found that 20 percent of 60 adolescents hospitalized for depression developed manic episodes within 4 years. He suggests that this could lead to the conclusion that the Siegel case of mania was not related to imipramine. He also points out that no one would even risk using these types of drugs if they did not think they were effective. Walsh states that:
"in 10 of 12 double-blind, placebo-controlled trials there was a statistically significant advantage for drug over placebo...(with)one-fourth of the patients treated with active medication ceased binge-eating entirely at the conclusion of the studies, and over one-half were significantly improved."(Walsh,1989:127)
Walsh cautions that the subjects in these studies were adults, none of the studies lasted more than four months and the long-term effects are not known and there is no data on the treatment of Bulimia Nervosa in paediatric populations. There are also other side effects that are associated with tricyclic antidepressants such as constipation, irritability, forgetfulness, changes in blood pressure and changes in the electrocardiogram(EKG). Walsh makes the comment that "possibly the most important `side effect' is the fact that tricyclic antidepressants are frequently fatal in overdose, so their administration to a disturbed and perhaps impulsive adolescent should be undertaken only after due consideration." (Walsh,1989:128)
Bulimia Nervosa has proven in the past to be a difficult disorder to treat. It is not as life threatening as Anorexia Nervosa in that a Bulimic person rarely dies. It does seem to affect a significant portion of the female population and more incidents of this disorder are being reported each year. Researchers have estimated the prevalence of Bulimia Nervosa to be 1 - 2 percent of the North American population with the majority of the cases appearing with the white female young adult and adolescent populations. There seems to be no relationship between eating disorders and socioeconomic classes and no other predictor other than an indication that the parents of Bulimics are older than average.
People with Bulimia Nervosa were found to have normal physiological responses, compared to controls, in regards to hunger, satiety and rates of gastric emptying. The results of the study by Rossiter el al showed that Bulimic subjects did not differ significantly from non-Bulimic restrained eaters on measures of fear of weight gain, dietary restraint or drive for thinness and body dissatisfaction. Also, the theory that people with Bulimia Nervosa binge in order to consume carbohydrates to relieve depression was shown to be false as Bulimics were found to consume no more carbohydrates during bingeing episodes than during non-binge episodes. The results of the study by Jansen et al shows evidence that links Bulimia Nervosa to the addiction model and that Bulimics are rapidly habituating sensation seekers.
Various methods of treatment have been used with mixed results. The behaviourial methods described by Schmidt and Marks achieved some success but the cognitive-behaviourial methods described by Steiger seemed to be more effective but requires a longer treatment period. Antidepressant drugs have been used with good results but these treatments include the risk of side effects which range from being mildly discomforting to possibly inducing symptoms of mania or being fatal in overdose.
Females in our society are impaled on the horns of a dilemma. They are expected to be thin to be attractive but to do so they have to restrict their consumption in a society that seems to also glorify the consumption of fast foods that are high in saturated fats, carbohydrates and sodium. Some women can maintain their weight by matching their caloric intake to their level of energy expenditures. Other woman become obese but can live with it. There seems to be something more to Bulimia Nervosa than just it merely being a maladaptive way of weight control. It may well be that rapid habituation contributes to the development of this disorder but more research is necessary to confirm this theory. If this line of research is fruitful then perhaps an intervention can be devised that will be 100% successful.
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