Barton J. Blinder, M.D. and Karin H. Chao, B.S., M.A.
Department of Psychiatry and Human Behavior
University of California Irvine

in [Understanding Eating Disorders]
Alexander-Mot Ed.
Taylor and Frances, Washington, D.C.1994

Bulimia is derived from the Greek meaning ravenous hunger. Teenage or young women are most likely to suffer from this eating disorder. The patient practices binge eating which consists of uncontrollable, recurrent overfeeding most often outside of normal meal tme in a driven pre-emptory pattern-disrupting routine daily activity. The compensatory behavior which occurs subsequent to binge eating can include purging (mechanical or chemical self-induced vomiting, ruminatory reguigitation, laxative and diuretic abuse) and non-purging (prolonged abstinence from food, extreme vigorous exercise and the use or abuse of anorexic medication) techniques. The patient's weight fluctuates, and unlike anorexia nervosa, a bulimic may not necessarily be underweight. Studies show 70% of bulimics are within the normal weight range while 15% are overweight, and 15% are underweight (De Zwaan and Mitchell, 1991).

Historical accounts of bulimia nervosa

Bulimia nervosa was not a new disorder. (Russell, 1979). There were scattered historical references suggested bulimia and there have been detailed case histories over the last 60 years. (Casper, 1983; Ziolko & Shrader, 1985; Blinder and Cadenhead, 1986).

Entries compatible with bulimia could be seen in the Latin writings of Aulus Gellius and Sextus Pompeius Festus, grammarians of the 2nd and 4th A>D> respectively; and with the description of "canine hunger" in the works of Theodorus Priscianus, a physician in the 5th century (Smith, 1866; Lewis $ Short, 1900). Romans were known to tickle their throats with feathers after each meal to induce vomiting thus allowing them to return to gluttonous feasting (Fischer, 1976). The Romans did so to enhance the enjoyment of a wider selection of palatable foods. (In contrast Bulimis patients have a narrow sterotyped food selection usually carbohydrates with the repetitive eating of the same item). Galen, a 2nd century greek physician noted that an abnormal acid humor in the stomach was the cause of "bulimis". Bulimis gave an exaggerated but false signal of hunger (Siegel, 1973; Stein & Laakso, 1988). Powdermaker (1973) noted gluttony was an acceptable behavior for primitive cultures. After months of hunger, hunting for food and finally preparing the feast, one Trobriand Islander declared:"We shall be glad, we shall eat until we vomit." (Boskind-White and White, 1986). In the Talmud (400-500 A.D.) the term "boolmut" was used to describe an overwhelming hunger which impaired a person's judgment about food and on external event (Kaplan & Garfinkel, 1984; van der Eycken, 1985; Blinde & Cadenhead, 1986).

The earliest English language example of bulimia occurred in the English translation in 1398 by John Trevisa of Bartholomeus in Glanville's encyclopaedic thirteenth century work, De Proprietativus Rerum (Parry-Jones, 1991). James (1743) described "true boulimus" which was characterized by intense preoccupation with food and over eating at very short intervals, terminated by vomiting (Stein & Laakso, 1988). Motherby (1785) studied three types of bulimia: bulimia of pure hunger, bulimia associated with "swooning;" and bulimia terminated by vomiting (Stunkard, 1990). Bulimia was recognized in the 1797 edition of the Encyclopedia Britannica (Stunkard, 1990).

Case histories of bulimia before 1900's

In the 18th and 19th century binge eating and vomiting was considered worthy of medical attention only if the over eating could be seen as a symptom of other disease. Gull (1873) noted in one anorexic patient who "occasionally for a day or two, her appetite was voracious, but this was rare and exceptional." He also saw another anorexic patient who, in order to induce vomiting, would think of "putrid cat pudding." (Blinder & Cadenhead, 1986).

Lasegue (1873) noted that many anorexics reactively vomited after they had been forced to eat. Janet (1919) commented that Lasegue's second phase of illness was when the period patient learned to vomit what she swallowed. Briquet (1859) studied a woman who for months ate normally, but then went into a phase of ovmiting everything she ate (Habermas, 1989). Casper (1980) and Garfinkel and Garner (1980) noted that significant occurrence of bulimic behaviors and symptoms, approximately 40%, in anorexia nervosa patients.

During this period, different terms were coined to described the overwhelming urge to overeat and vomit (Habermas, 1989). However, none of them associated binging and purging with weight control (Ziolko and Schrader, 1985). Blanchez (1869) termed "cynorexia" as a cycle of overeating and vomiting. The cynorexic was literally possessed by the thought of food, and insatiable hunger. Stiller (1884) described "hyperorexia" as a constant eating of small amounts of food in order to counteract feelings of faintness. Soltmann (1894) documented a 17-year-old boy whoa te massively when he returned ome from schoo. He was outraged when kept from eating. Soltmann called such symptom "polyphagia" in which there was an absence of a feeling of fullness, leading to a rather constant devouring of huge amounts of food. Speculatively, this might have been Klein-Levin syndrome (Orlowsky, 1982; Sugar, Khandelwal, Gupta, 1990).

Secret eating and food stealing

Binging in secrecy and food stealing has been patterns seen frequently in bulimics (Habermas, 1989; De Zwaan and Mitchell, 1991). Janet (1908) noted his patient Nadia "from time to time forgets herself to the point of devouring gluttonously anything she can get hold of. At other times, she cannot resist the urge to eat something; she then secretly eats biscuits." Wulff's patient A (1932) claimed she secretly binged on fodds such as sweets, pastries, and bread that were restricted because of her obesity (Stunkard, 1990). She categorized foods by saying "This is good; the worst, the better" (Habermas, 1989). Bergmann (1934) documented a young thin woman who hoarded food from the pantry at night. Stunkard, Grace Wolff (1955) coined the term "night feeders" to describe obese patients who consumed large amounts of food during the night. Other authors noted secret eating and food stealing often associated with binge eating, and they suggested such activities fell in the same category of binge eating (Casper, Ecker, Halmi, Goldberg, and DAvis, 1980; Densmore, 1988). Secret eating was usually planned in advance, and carried out late in the day. It was all part of the isolating nature of bulimia nervosa. From a developmental and psychodynamic perspective, secret eating and food stealing were suspected to express impulsiveness, ambivalence or rebelliousness (Habermas, 1989; Schwartz, 1990; De Zwann and Mitchell, 1991; Wilson, Hogan, Mintz, 1992).

1990-1940's

During the first half of this century, many of the studies on eating disorders wer eovershadowed by Simmond's observation of pituitary insufficiency. Nevertheless, in a paper presented to the German Psychoanalytic Society in 1932, Moshe Wulff described four cases of an eating disorder in women characaterized by uncontrollable, recurrent overeating, prolonged fasting, hypersomnia, depressed mood, and irritability (Blinder and Cadenhead, 1986; Stunkard, 1990; Habermas, 1989). All four went through the phase of binge eating, and two of the four vomited. Patient B described the binge episodes as "circumstances of animal eating" in that she devoured everything in sight, including orange peels and scraps of paper. Usually the patients binged on snacks or dessert foods which were avoided at other times because these foods were fattening and calorie-rich. This phase alternated with the phase of prolonged fasting. Patient D often went through 3- to 6-day-long fasts that could extend to complete abstincence from food for the entire day. Patient C noted her motivation to fast was to lose weight. During fasting, these patients selected fruits, vegetable, and milk - a constricted cuisine. The fasting phase often ended with the onset of yet another phase of prolonged binge eating episodes; such cycles brought these women a strong sense of disgust with their own bodies, and the broken promises to never do it again.

Wulff characterized binge eating as "oral symptom-complex" in which the paient regressed to obtain a "pure oral erotic satisfaction . . . almost a sexual perversion." He placed bulimia between melancholia and addiction. From a psychoanalytic perspective what bulimia had in common with above mental states was they all encompass a sense of loss or detachment leading to an "insult to narcissim," the reaction to which culminated in binge eating (Blinder and Cadenhead, 1986; Stunkard, 1990; HAbermas, 1989).

Binswanger (1944) described the case of Ellen WEst who was a partially remitted anorexia who began to struggle with bulimia. Her symptoms included binge eating, violent vomiting, and laxative abuse. West's diary detailed her struggle for control over her emotions and her body weight (Britt and Bloom, 1982; Casper, 1983; Blinder and Cadenhead, 1986; Stunkard, 1990; Beumont, 1991).

Selling and Ferraro (1945) observed bulimia in refugee children between 1933 and 1939. Many of these children came to the United States from Europe without their parents, and they fed themselves frantically and excessively when they felt insecure. However, when these children found new homes, they reduced their food intake (Casper, 1983). Waller and Kaufman (1940) described two women who overate on candies, and then starved themselves in a defensive reaction to an incestuous pregnancy fantasy involving father. Berkman of the Mayo Clinic (1930) reported that out of 177 anorexia patients, 66% vomited. Most said they did it to relief the sensation of fullness. Schottky (1932) noted a female patient who used a hose to empty out what she atehan inducing vomiting (Habermas, 1989). It was also around this time that Nogue (1913) researched the prescriptive use of laxatives or thyroid for the purpose of weight control. This brought about the changes in the kind of laxatives used to lose weight; earlier, anorexics used vinegar to control weight (Gungl and Stichl, 1892; Wallet, 1982; Janet, 1908).

Bulimia nervosa and anorexia nervosa

Many authors have described bulimia in nonanorexic patients. some characterized it as a rare neurotic condition. Janet (1908) studied a 26-year-old male who was "withdrawn with a bizarre character." This man's self-induced vomiting, as Janet noted, was a form of tic, and not as part of anorexia (Habermas, 1989). Abraham (1916) described a patient who, instead of vomiting, binged only on vegetables during bulimic attacks to counteract the weight gain. Abraham called it a "neurotic hunger" in which the feeding and satiety signals originate from anxiety and internal psychological conflict, not the emptiness or fullness of the stomach (Blinder, 1980; Blinder and Cadenhead, 1986; Habermas, 1989). Abraham associated the bulimic condition with repression of libido and likened it to an addiction dipsomania (alcoholism,) or morphinism (Blinder, 1980). Wulff (1932) characterized the somnolence that followed the binges as a kind of "sleep drunkenness" completing the bulimic cycle during which patients sought and fulfilled "oral erotic stimulation." Lindner (1955) noted the case of Laura who binged but did not vomit. Laura's father abandoned her and the family when she was young; Lindner suggested Laura's distended stomach represented her secret wish to be impregnated by her father (Blinder and Cadenhead, 1986). Kirshbaum (1951) used the term "Hyperorexia" as a manifestation to signifiy hypothalamic insufficiencies.

However, modern history of bulimia first appeared in connection with patients who also suffered from anorexia. Nemiah (1950) reported the case histories of 14 patients with this condition in Massachusetts General Hospital (Stunkard, 1990). Four of 14 patients were suspected of bulimia due to their abnormal eating pattern and vomiting. Many authors were aware of overeating, laxative abuse, and self-inducted vomiting in anorexics, but considered bulimia as a variant of anorexia nervosa, rather than a distinct syndrome (Bond, 1949; Nemiah, 1950; Bruch, 1962). Abraham and Beumont (1982) viewed bulimia and anorexia as extremes of the same disorder; whereas Russell (1979) described bulimia as an indicator of chronicity of anorexia. In separate studies done by Casper (1980) and Garfinkel, Moldofsky, and Garner (1980) about half of patients with anorexia demonstrated bulimic behavior; and in Mitchell's study (1985) 30 to 80% of patients with bulimia had a history of anorexia. Blinder, Chaitin, and Hagman (1987) reported an increased history of anorexia nervosa preceding bulimia and more extensive current eating disorder symptoms in those bulimic patients who had co-morbidity for depression. Katz and Stinick (1982) considered bulimia as a manifestation of the constant core syndrome of eating disorder. Comparing bulimia and anorexia, a bulimic patient may not necessarily be underweight, and about 15% of the time, she is overweight. Too, unlike anorexics, a bulimic patient may or may not have amenorrhea (although oligomenorrhea, anovulatory cycles and occasional missed periods are common); a bulimc patient possessed a greater premorbid weight, more affective instability, greater interpersonal sensitivity; a bulimic patient is more extroverted, and was more likely to have a personality disorder diagnosis (Russell, 1979; Casper, 1980; Garfinkel, 1980; Strober, 1980, 1981).

After 1940's

Some cases of bulimia before the 1940's mentioned the patient's concern with body shape and body weight. Janet (1908) noted one of Charcot's cases of a young girl who wore a rose-colored ribbon around her waist. She did this to ensure that her waist size never exceeded what she thought and measured it to be (Brumberg, 1988). However, not until after the 1940's did the overconcern of patients with body shape and self-image become a usual and constant feature (Casper, 1983). The "desire and pursuit of thinness" theme started appearing more frequently in literatures, culminating in the 1970's with what Bruch called "the pursuit of thinness," and Selvini-Palazzoli termed "the desperate need to grow thinner." The idea of thinness was becoming a virtue, and it was a symbol of independence, autonomy, self-control, and a moral grace. A combination of cultural, economic, and psychological factors may have contributed to the vast and rapid emergency of bulimia nervosa (Gordon, 1992). Culturally, following the Depression years, prosperity and increase in the availability of foods led more girls to worry about overeating, being overweight, and being plump (Casper, 1983). Fat was deemed disgraceful and indicative of a lack of self-control. Waller (1940) saw patients who were "ashamed of being fat." Casper (1981) noted this dread of fatness came from critical self-image which drove the patient to develop bulimia, and "escape into a controlled, desirable, however, distorted and isolated thin existence." Bruch (1973) saw this development as a compensatory mode of action covering over feelings of pervasive inadequacy.

Bulimia nervosa as a distinct syndrome

Toward the end of the 1970's, more focus was put on the occurrence of gorging in patients who were at a normal weight. Bruch (1957) described a case of a patient who binged and vomited, but he was neither obese nor emaciated (anorexia). Because these patients did not have an obvious weight disturbance, it seemed necessary to define a new syndrome to encompass their disorder. Boskind-White (1976) termed this "bulimarexia." This term described an eating disorder usually in young women at a normal weight who alternated between binging and strict fasting. Bulimarexics had low self-esteem, poor body image, and the fear of not being successful in heterosexual relationships. Boskind-Lodahl and White (1978) noted "the importance of sociocultural factors in female role definition and the view of bulimarexia as related to the struggle to achieve a 'perfect' female image in which women surrended their self-defining powers to others."

with some initial caution, the concept of a distinct syndrome of bulimia nervosa came to be accepted in DSM-III in 1980. Russell (1979) designated the term "bulimia nervosa" to describe a subgroup of patients who, in contrast to eating restricts, have been foundt ohave an older age of onset, a more chronic outcome, and a higher incidence of premorbid and family obesity (Beumont, George, Smart, 1976; Casper, Eckert, Halmi, Goldberg, Davis, 1980; Garfinkel, Moldofsky, Garner, 1980; Strober, 1981; Strober, Salkin, Burroughs, Morrel, 1982). These patients manifest greater anxiety and depression, report a higher incidence of impulsive behavior (substance abuse and kelptomania), more evidence of premorbid instability, a greater body image distortion, and a more extensive family conflict (Casper, et al., 1980; Garfinkel, et al., 1980; Katzman, Wolchik, 1984; Strober, 1980). According to DSM-IV (1993) the essential features of bulimia nervosa are recurrent and unctrollable episodes of binge eating; self-induced vomiting, the use of laxatives or fiuretics, strict dieting, fasting, or vigorous exercise to prevent weight gain; and persistent overconcern with body shape and weight. Binging usually precedes vomiting by about one year. Bulimia is usually diagnosed in teenage or young women with the age of onset between 16 and 19. Less than 10% of men are affected by bulimia (Zwaan and Mitchell, 1991). In surveys of college and high school populations (Halmi, Falk, and Schwartz, 1981; Hawkins and Clement, 1980; Johnson, Lewis, Love, Lewis, and Stuckey, 1984; Nagelberg, Hale, and Ware, 1984; Pyle, Mitchell, and Eckert, 1981; Russell, 1979), a range of 4.1% to 13% of students met the criteria for bulimia. Kendler, MacLean, Neale, Kessler, Heath, Eaves, in 1991 reported a 4% lifetime incidence of bulimia nervosa in all women. In the long run, this disease is not easily cured, of the 45 patients with eating disorders reported by Bruch in 1973, 25% suffered from bulimic attacks; however 12 years later, the number went up to 50% (Bruch, 1985).

OBESITY

Obesity is a condition characterized by the excessive accumulation of fat (when the body weight exceeds by 20% of the standard weight listed in the usual height-weight tables) (Kaplan and Saddock, 1991). Step variations in the magnitude of excessive weight have been delineated according to increases in total body mass index (weight in kg/(height in m)2). The latter statistic may be placed on a continuum so that a result over 25 (25 to 45) may signify the degree of obesity from moderate to morbid, and reflect the level of accelerated mortality risk as a consequence of the morbidity of anticipated medical complications (hypertension, cardiac and circulatory disease, diabetes, orthopedic disorders). Fundamentally, it is a result of overnutrition. Obesity existed in the most primitive and ancient societies. Portrayals of human forms during the Aurignacian era, which dated some 20,000 years ago, showed rather plump and obese women. Some supposed fat was admired during this period; obesity in a woman was looked upon as a sign of fertility, her capacity to bear children, and her ability to endure the extremes of weather conditions (Beumonth, 1991; Bruch, 1973).

Attitudes toward obesity changed in the classical times as it was recognized as a problem. Aristophanes, a fifth century B.C. Greek comedy writer, described in his work Plutus that obese men were "bloated, gross, and pre-seniled . . . they are fat rogues with big bellies and dropsical legs, whose toes by the gout are tormented." The Greek goddesses such as Venus and Diana were plump and matronly with round bodices. They glorified and portrayed the "mother earth" image (Boskind-White and White, 1986). However, in their own daughters and wives the Greeks emphasized slimness, and beauty in order to look seductive in revealing clothes. Greek physician Dioscorides described radish, caper, and vinegar as substances that disturbed the bowel system. These were prescribed as diuretics and emetics. Hippocrates described obesity in detail and advocated for slimming exercise along with punitive measures such as sleeping on hard beds. The Cretans also had drugs which allowed one to drink and to eat as much as one wished and remain slender. In Sparta, people were customarily trained to survive in its military society. A spartan writer, Xenophane, described diets as being sparse, strict at best, so its people could survive war times and could enjoy better heath. Obese people were punished for their adiposity; youths were examined in the nude for excess weight gain, and those who gained weight were subjected to compulsory diets and scourging. The Romans frowned on obesity, and they were accredited for inventing the vomitorium which allowed them to binge and to relieve themselves of the feeling of fullness. To preserve their youthful figures, Roman wives and daughters often starved themselves to the point of death. Galen prescribed diuretics to "make them thin as reeds" (Boskind-White and White, 1986). The Egyptian men also chose wives who were young and slender.

In some religious circles, gluttony was considered a sin. For example, in the painting "The Last Judgment," the sinners were fat and heavy but the disciples were slender. Bible verses also discredited gluttony. Examples include the following, in Proverbs 23:21 "For the drunkard and the glutton will come to poverty;" Deuteronomy 21:20 "He is a glutton and a drinkard, then all the men stoned him to purge evil from mist;" Matthew 11:19 "Behold a glutton and a drunkard - a friend of tax collectors and sinners. However, in an overtly ambivalent perspective, obesity was also viewed as the "Grace of God." In works throughout the Renaissance, scenes of merry feastings were depicted with great joy and vitality. Botticelli's Venus and De Vinci's works portrayed women who round bodices and full figures (Bruch, 1973).

In other non-western cultures, obesity was looked upon as a favored trait. For some Plynesian people, it was a privilege to be so well-fed and pampered tha tone could be at such leisure to get fat. Some Malayan kings were noted to be very large, and they were specially cared for with massages and exercises to preserve their good health (Bruch, 1973). The girls of Banyankole of East Africa underwent regimens to gain weight in preparation for marriage. It was a compliment to the men who married plump women; it showed the men off as good providers (Boskind-White and White, 1986).

Throughout the Victorian Age, obesity was associated with lower class status and poverty. Dress designs of their period stressed full breasts and tiny waistlines; for instance, the "Gibson girl" image of the last 19th century America. Women stayed away from food in order to be slim and to create the hourglass shape. In 1864 Ebstein distinguished three types of obesity: stout, comical, and severe (Beumont, 1991). Some poor immigrant mothers during the 1930's who suffered from hunger in their childhood and youth did not see overweight in their children as negative. To them plumpness meant security and success. Slenderness was at its peak during the 1960's with the arrival of "Twiggy" (5'7", 92 pounds). Severe abstinence from food and various forms of weight control were used to achieve a type of malnourished figure which was heralded as the standard of beauty. It was of no surprise that during this time there was both an increase in medical and psychaitric recognition of eating disorders and more women diagnosed as anorexic or bulimic.

Cross-cultural sutides of white's and minorities' views on body type showed that blacks and other minorities do not prefer the ultrathin body type (Huenemann, Shapiro, Hampton, et al., 1966; Levinson, Powell, Steelman, 1986; Maddox, Black, Liederman, 1968; Stern, Pugh, Gaskill, et al., 1982). Studies showed that black girls and their families were not as obsessed over being think or losing weight (Wadden, Stunkard, Rich, et al., 1990; Dornbusch, Smith, Duncan, et al., 1984; Sobal, Stunkard, 1989; Striegel-Moore, Silberstein, Rodin, 1986; Wadden, Foster, Stunkard, et al., 1989). The latter attitudes contributed to a two fold increased prevalence of obesity in blacks compared to Caucasian women (Van Itallie, 1985). Contributing to the latter difference in addition to attitudinal and social value determinants would be differences in informed nutrition practices, opportunities for regular exercise, and poverty-determined adverse health practices. Higher socioeconomic status in females correlated to ower body weight and a less chance of becoming obese (Sobal, Stankard, 1989). Other studies showed that decline in educational level was related to an increasing amount of body fat and obesity (Teasdale, Sorensen, Stunkard, 1992; Sonne-Holm, Sorensen, 1986).

Obesity through the ages has been clearly influenced by prevailing social custom with both over-valuation of its presence and severe derision and social osterocism. A plethera of methods for slimming have been attempted and early observations were made of the adverse health consequences of morbid obesity.