The dietary chaos syndrome: a useful new term?

Les troubles de l'alimentation dans une population étudiante

De nombreuses études récentes montrent que la boulimie est une perturbation fréquente des conduites alimentaires de l’adulte dont la prévalence dans la population féminine avoisinerait 10 %. Il reste cependant difficile d’être plus précis, car les critères diagnostiques, les instruments d’évaluation et les populations varient beaucoup entre eux.

A titre d’exemple, la définition du DSM III ne retient pas la présence des vomissements comme critére obligatoire, contrairement à d’autres.

Les auteurs présentent également les premiers résultats d’une enquête effectuée auprès de l’ensemble des étudiants de l’Université de Genève. A partir de 4200 des 12000 questionnaires qui ont été retournés, la representativité selon le sexe et l’âge a été obtenue en sélectionnant un groupe de 3102 questionnaires valides, soit 25.7 % du total. Au moment de l’étude, 20.5 % des femmes et 8.6 % des hommes utilisaient l’un des moyens de contrôle du poids, régime inclus, et 2.6 % des femmes et 0.5 % des hommes recouraient aux vomissements. Concernant la boulimie, si ce travail ne permet pas de conclusions définitives, il permet néanmoins d’approcher un groupe à risque boulimique avoisinant 4 à 6 % des femmes et 0.5 à 0.8 % des hommes. Ces résultats ainsi que les ratios F/H et les âges de début sont superposables aux valeurs des études de référence. Les rapports que la boulimie entretient avec la dépression, les conduites toxicomaniaques ou d’alcoolisation, voire les troubles paniques, phobiques et obsessifs-compulsifs devraient être mieux étudiés afin d’éviter les erreurs de diagnostic. La recherche d’un poids idéal est une caractéristique de ce syndrome. Un traitement visant à modifier la représentation de ce paramétre constituerait un des éléments utiles d’une thérapie cognitive et informative.

Bulimia: A Review of the Medical, Behavioural and Psychodynamic Models of Treatment

Current treatment approaches for bulimia are reviewed. The use of hospitalisation and drug therapy is examined. The behavioural and psychodynamic models of treatment, including cognitive-behavioural therapy, behaviour therapy, group therapy and family therapy, and counselling and educational approaches are discussed.

Bulimia: A Literature Review

This article provides a literature review of bulimia. It examines the condition and its prevalence, features and complications.

The Talking Disease: Hilda Bruch and Anorexia Nervosa

In this note on anorexia nervosa, it is assumed that the sociology of health and illness must adopt a three-level model of explanation. We have to understand the phenomenology of illness within the world of the patient. The problem with 'positivistic' approaches (based upon a medical model) is that they examine the condition independently of its constitution by a knowledgeable agent. Anorexia is not just a question of having anorexia; it is fundamentally about being anorexic. Secondly, there is the sociology of illness behaviour which examines the sick role. Finally, there is a political economy of health which is broadly concerned with the distribution of resources (including health) in a society. It can also be argued that a'condition' as complex as anorexia requires a multidisciplinary perspective to understand the various levels in which this disorder can be conceptualised in terms of its various social and cultural mean ings. Existing approaches to anorexia are typically under developed because they adopt uncritically an unidimensional view of the etiology of anorexia behaviour. Hilda Bruch's clinical work is important in this context as a multi-discipli nary interpretative approach. As a supplementary theoretical strategy, this note extends the therapeutic insights of Bruch by considering anorexia in terms of a phenomenology of the mouth as a 'talking disease' about familial interaction in societies which place an emphasis on individual competition. Being sick involves a special type of linguistic membership through socialisation in a sick role. The understanding of the meaning of sickness in medical practice can be seen consequently as a version of the methodology of verstehende soziologie.

A tale of corruption

The multi-disciplinary team of Becker and colleagues elegantly present their findings addressing aspects of the impact on Fijian schoolgirls of exposure to Western television (Beckeret al, 2002, this issue). These findings support the notion that such exposure has generated disordered eating, underlying body dissatisfaction and intergenerational conflicts within the family that may, in part, be fuelling the process. Focusing on the expected escalation of such disordered eating in this population under these circumstances, their study was naturalistic in capitalising on the recent introduction of television to Fiji, with the first survey of these schoolgirls taking place within 1 month of its advent. The second survey was 3 years later in 1998. The authors point out that the traditional Fijian culture has ‘supported robust appetites and body shapes'.

Differential dynamic responses of luteinizing hormone to gonadotropin releasing hormone in patients affected by bulimia nervosa-purging versus non-purging type

OBJECTIVE

Aim of the study was to investigate the presence of underlying abnormalities affecting the hypothalamus-pituitary-gonadal axis in 13 normal weight eumenhorreic bulimics as expressed by a different gonadotropin response to gonadotropin releasing hormone (GnRH), comparing patients with (n = 6) and without (n = 7) purging behaviours to controls (n = 5).

METHOD

Subjects were administered an intravenous GnRH infusion for four hours, with an additional bolus at first and third hour.

RESULTS

Non-purging bulimics showed a significantly reduced luteinizing hormone (LH) response to GnRH compared to controls; purging bulimics, following the second bolus, demonstrated a statistically reduced peak, in comparison to both controls and non-purging bulimics.

DISCUSSION

even in the absence of overt menstrual disturbances, an altered LH secretion elicited by pulsatile stimulation of endogenous GnRH was found, with a more severe impairment in purging than in non-purging bulimics, possibly related to their greater psychopathological and physical burden.

Emergence of bulimia nervosa as a separate diagnostic entity: review of the literature from 1960 to 1979

With Russell's description of bulimia nervosa in 1979, followed by the DSM-III diagnosis of bulimia, a "new" eating syndrome found its official acceptance in the scientific world. In the two preceding decades clinicians and researchers gradually payed more attention to special forms of overeating. In the 1970s the nosographic conceptualizations of binge eating, bulimia, compulsive eating, or hyperorexia clearly shifted from a symptom level--closely connected to anorexia nervosa and/or obesity--to a syndrome level. Around the same time and independently from one another, clinicians from different countries proposed various descriptive labels for this new diagnostic entity, which, finally, became accepted as bulimia nervosa.

Women and eating disorders, Part I: Significance and sociocultural risk factors

Eating disorders are a significant health problem for women today and therefore are a concern for the health professionals who work with women. The significance of this problem is addressed through epidemiological data from a Western cultural perspective. Many risk factors contribute to the development of these disorders. Broad categories including sociocultural, developmental, familial, and biological factors have been identified by clinicians and researchers. The sociocultural risk factors are the norms, standards, or values of a society. The sociocultural risk factors explored in this article are (a) the value of a thin physique, (b) the value of perfection, (c) the norm of dieting, (d) the influence of the media on these values, and (e) the choice of certain professions. The role of the health professional in prevention with respect to sociocultural factors is discussed.

[Eating disorders in a population of students of a college environment: correlation with 2 psychosocial characteristics]

The aims of this study were to measure the extent of severe eating disorders among female college students, to verify if there is a correlation with two indicators of "pressure to perform" while evaluating a screening instrument. Of 1144 female students, 16.3% scored 20 or above on the EAT-26 scale. Interviews allowed to determine that the positive predictive value of the EAT-26 when coupled with a low self-reported weight is considerably heightened. It was possible to estimate that over the last three years one girl out of 12 has presented severe eating disorders and one in 65 has suffered from anorexia nervosa. The EAT score was significantly correlated with the mother's level of schooling but not with the student's academic discipline.

Family correlates of bulimic characteristics in college females

This article provides a short review of the literature that relates family characteristics to anorexia nervosa and bulimia nervosa. In addition, a quantitative analysis of the relationship between family variables and level of eating disturbance was performed on self-reported responses of 175 normal weight females in an attempt to verify an expansion of the continuum hypothesis outlined by Kagan and Squires (1985). Consistent with the continuum hypothesis, moderate relationships were found between level of family dysfunction and bulimic symptomatology. Among several family variables, inconsistent expression of affection by the mother best predicted severity of eating disturbance.

An empirical assessment of bulimic patients using multiple measures

This paper examines personality and clinical assessment data from bulimic patients and from a control group of normal volunteer subjects. Thirty-eight bulimic females representing consecutive admissions to an outpatient treatment program were administered a battery of tests including the MMPI, FIRO-B, Beck Depression Inventory, Moos Family Environment Scale, Bem Sex Role Inventory, and Conte Borderline Syndrome Index. Twenty-six normal females also completed this testing battery. As expected, bulimics differed from normals on several clinical scales, including the MMPI, Beck Depression Inventory, and Conte Borderline Syndrome Index. More importantly, however, were the results of the cluster analysis of the bulimic MMPI scores which demonstrated two clearly defined subtypes of bulimia: a mildly disturbed group that shows developmental conflicts and adjustment difficulties, and a severely disturbed group that displays low ego strength and characteristics suggesting an Axis II personality disturbance. The other testing measures failed to reach significance levels. Implications for assessment and treatment are explored in the context of these results.

Eating pattern disturbances among women medical and graduate students

In this study, the Eating Disorder Inventory (EDI) was used to determine the incidence of disturbed eating patterns and other characteristics of anorexia nervosa and bulimia among women graduate and medical students. The EDI was given to 219 female graduate students and 132 female medical students by mail questionnaire (61% return rate). Excessive dieting concerns, as measured by the Drive for Thinness subscale, were significantly more common in medical students compared to graduate students (18.7% versus 12.9%; p less than 0.05). The incidence of bulimic eating patterns was also insignificantly higher in the medical students. The prevalence of bulimia estimated from this survey is similar to that reported in undergraduate women, but the estimated prevalence of anorexia nervosa in both medical and graduate students is lower than reported for younger students. Our data suggest that a competitive environment alone does not appear to lead to greater expression of anorexia nervosa and bulimia.

Bulimia: an entity in search of definition

A review of research literature that addresses personality correlates of bulimia revealed a major problem which affects that research and its interpretation: Criteria used to define this disorder have not been consistent across investigators. A related issue is that this disorder has been described by a variety of names, such as dietary chaos syndrome, binge-eating syndrome, bulimia nervosa, etc. The second major problem that contributes to the uncertainty about the personality of bulimics is methodology. Among these have been the inclusion of individuals with a history of anorexia nervosa, the use of researcher-specific self-reports and questionnaires (primarily within a narrow population), and a lack of consistency in the testing measures used to assess personality. This very basic issue needs to be resolved if the findings in bulimia research are to be cumulative and generalizable across studies. Suggestions are offered as to how this resolution should occur.

The treatment of bulimia nervosa

We review treatment approaches to bulimia nervosa, with particular emphasis on methodology and research design. The following treatments are considered: behaviour therapy, cognitive behaviour therapy, pharmacological treatment, group therapy, psychoanalytic psychotherapy, self-help and support groups, hypnosis and miscellaneous (family therapy and nutritional approaches). Several directions for future research and methodological recommendations are suggested.

A self-rating scale for bulimia. The 'BITE'

A new brief questionnaire, the Bulimic Investigatory Test, Edinburgh (BITE), for the detection and description of binge-eating is described. Data from two separate populations demonstrate satisfactory reliability and validity. The scale has measures of both symptoms and severity. All items in the DSM-III definition of bulimia and Russell's definition of bulimia nervosa are covered but the questionnaire is more than just an operationalised checklist of these diagnostic criteria.

Physical and psychological characteristics of five male bulimics

The case histories of five men who met DSM-III criteria for bulimia and details of their physical characteristics are given. Various eating disorder questionnaires were administered and the results indicated that most of these instruments would not have identified the men as suffering from an eating disorder. The necessity of caution in asserting the prevalence of bulimia using these measures is emphasised.

Bulimia nervosa: treatment and short-term outcome

Fifty-six bulimia nervosa patients were treated by means of a behavioural approach and followed for at least one year after completion or dropping out of treatment. Outcome was encouraging in about half of the patients and several psychiatric indicators, such as duration of illness and response to treatment, were identified. The significance of the findings and unresolved methodological issues are discussed.

Diagnostic issues in eating disorders: two cases of atypical eating disorder

Two cases with significant eating disturbances are described. Both possess several characteristic symptoms of anorexia but lack a primary drive for thinness or body image disturbances. Similarly, neither engaged in recurrent episodes of binge eating which is typical of bulimia. The authors propose the differential diagnoses of atypical eating disorder rather than conversion disorder as a more descriptive and accurate diagnostic label.

Bulimia. Growing 'epidemic' among women

Bulimia is a serious eating disorder that appears to be increasing in frequency among young females. It is characterized by uncontrolled binge eating that may be followed by purging. Serious medical complications may result if bulimia is not diagnosed and treated effectively. Evidence indicates that bulimia may be closely related to affective disorder, and therefore antidepressant drugs should be considered in therapy.

Evaluating a group treatment for bulimia

A multifaceted group-based approach to the treatment of bulimia is described, that focuses on recovering a sense of control by examining how control is relinquished, and can be regained by developing adaptive attitudes and behaviour about food and eating, the body, and interpersonal relationships. Results from an end of programme assessment and then at six month, 12 month and 18 month follow-ups indicate that a successful reduction in bingeing and vomiting and a variety of other changes was achieved and maintained by 36 of the 40 participants.

The TRH test in bulimia and anorexia nervosa: a controlled study

TSH responsiveness to 500 micrograms TRH given intravenously was examined in ten bulimic outpatients, nine anorexic in-patients and a group of age matched healthy subjects. Serum TSH levels were measured by means of a sensitive radioimmune assay. There were no group differences between bulimic subjects and the healthy comparison group. Anorexic subjects at low weight showed a delayed response to TRH, which tended to normalize with weight gain. Bulimic subjects showed varied patterns of response and it remains possible that a sub-group of bulimic patients may have an abnormality of response to TRH.

Empirical assessment of identity in anorexia and bulimia nervosa

Researchers have neglected the study of the self concept of individuals who develop anorexia and bulimia nervosa. Towards rectifying this situation, Identity Structure Analysis (ISA) is introduced as an appropriate framework allowing the specification and empirical testing of postulates regarding disturbed identity development in anorexic disorders. The data presented distinguish a common constellation of identity characteristics in those suffering from anorexia and bulimia nervosa that differentiate them from normal and psychiatric control groups. Their identity pattern tends to be anti-developmental and in a state of 'identity crisis', in which identification conflicts with the maternal metaperspective of self (me as my mother sees me) are especially significant. Further analysis suggest that anorexics are in a phase of 'plummeting' identity crisis, whilst the patients in the sample with bulimia nervosa are in a 'sustained' phase. Future directions for research are noted.

The prevalence of binge-eating and bulimia in 1063 college students

We used a purpose-designed questionnaire to survey the prevalence of binge-eating and bulimia in a sample of 1063 Dublin third-level students aged 17-25 yr. There were 361 males and 701 females. The questionnaire was based on DSM-III, and included a written definition of a binge and cross-check questions. Although 17.7% of males and 37% of females claimed to have had an eating binge, cross-check items reduced this to 1.1% of males and 10.8% of females who met the DSM-III definition. No male and only 7.7% of females also met the behavioural criteria under item B of DSM-III, and only 5% of females reported dysphoric mood. Excluding those experiencing fewer than one episode per week gave a prevalence of 2.8% in females and 0% on males. Previously-reported prevalences using questionnaire may be inflated due to poor respondent understanding of the psychiatric terms being used.

Bulimia: the emergence of a syndrome

The literature on bulimia, which has regarded it as a psychiatric entity or as a form of disordered eating, suggests that this behaviour is now widespread among the obese, among those with anorexia nervosa and those of normal weight. While physiological, psychological and sociocultural explanations and forms of treatment have been proposed, a holistic perspective on the context in which it occurs can distinguish bulimia nervosa and bulimarexia from 'simple' bulimia.

Binge-eating, self-induced vomiting and laxative abuse: a community study

Following a television documentary on bulimia nervosa, people who thought that they had this type of eating problem were asked to complete a confidential questionnaire. 579 women who fulfilled self-report diagnostic criteria for bulimia nervosa were thereby identified. These women closely resembled patients with bulimia nervosa, although the age range was wider. They had grossly disturbed eating habits and almost half vomited at least daily. Laxative abuse was also common. Although almost two-thirds had been overweight in the past, the majority had a weight within the normal range. A minority had previously fulfilled diagnostic criteria for anorexia nervosa. On standardized measures, these women had abnormal attitudes to their weight and shape, as well as significant levels of psychiatric symptomatology. Nearly three-quarters thought that they definitely needed professional help, yet only a third had ever been referred for psychiatric treatment. Using data from this sample and an independent sample of 499 probable bulimia nervosa cases, the significance of three issues relating to the diagnosis of bulimia nervosa were examined: laxative abuse, the frequency of self-induced vomiting, and a history of anorexia nervosa.

Bulimia nervosa, binge eating, and psychogenic vomiting: a controlled treatment study and long term outcome

An "epidemic" prevalence of binge eating and vomiting (bulimia nervosa) has been reported, and treatment has been claimed to be difficult. This paper describes a short term outpatient treatment programme of eclectic orientation capable of being conducted by non-specialist staff, under medical supervision, in local centres. The treatment programme was evaluated in a controlled trial and in long term follow up. In 30 women with severe bulimia the treatment programme significantly reduced their incidence of dietary manipulation without producing weight gain, weight disorder, or neurotic illness. After treatment all the women had fewer symptoms; 24 stopped binge eating and vomiting at the end of treatment, and a further four stopped shortly afterwards. During formal follow up 20 showed no dietary abuse and a further eight reduced their attacks to an average of three episodes a year: all judged treatment to be a success. Pretreatment indicators of poorer prognosis include alcohol abuse and a history of anorexia nervosa. Married patients experienced marital difficulties or illness in the spouse.

Eating attitudes and neurotic symptoms in university students

A postal survey of male and female university students is reported, using the Eating Attitude Test (EAT) and the Crown Crisp Experiential Index (CCEI). Eleven per cent of the 156 female respondents but none of 120 males scored above 30 on the EAT, thereby declaring eating attitudes comparable to anorexic subjects. Of those interviewed, none fulfilled diagnostic criteria for anorexia nervosa, but half showed eating disorder of clinical severity. There was a clear association between high EAT scores and higher scores on all the subscales of the CCEI except the phobic scale. The results are discussed in relation to ideas about the possible origins of clinical eating disorders.

Hypothalamic-pituitary-adrenal-axis hyperactivity in bulimia

Hyperactivity of the hypothalamic-pituitary-adrenal axis, demonstrated by nonsuppression of plasma cortisol in the dexamethasone suppression test (DST), has been found in about 50% of patients with major depression. We administered the DST to 47 patients with bulimia and to 22 age- and sex-matched normal controls. Among the bulimics, 47% were nonsuppressors, significantly higher than the 9% prevalence of nonsuppressors in the controls, but similar to the prevalence reported for patients with major depression in other studies. This finding is consistent with evidence from studies of phenomenology, family history, and treatment response which suggest that bulimia may be related to affective disorder.

Binge eating and its management

It is well recognized that bouts of uncontrolled and excessive eating (binges) occur in both a small proportion of patients who are overweight and in about 50 per cent of patients with anorexia nervosa. However, it has only recently been appreciated that many people who fall into neither category also have an eating disorder which is principally characterized by episodes of binge-eating. These people experience a profound and distressing loss of control over eating which results in a grossly disturbed eating pattern. Despite this, their body weight tends to lie within the normal range. The disorder has attracted various names including ‘the dietary chaos syndrome’ (Palmer, 1979), ‘the abnormal normal weight control syndrome’ (Crisp, 1979), ‘bulimia nervosa’ (Russell, 1979), and simply ‘bulimia’ (DSM III, 1980). The term bulimia nervosa is probably the most satisfactory since it conveys the links with anorexia nervosa and emphasises the central role of binge-eating. Russell (1979) proposed the following diagnostic criteria for this syndrome:

Subclinical anorexia nervosa

The Eating Attitudes Test (Garner & Garfinkel, 1979) was administered to 578 students (446 females and 132 males) at a College of Technology and to 14 "control" subjects fulfilling strict diagnostic criteria for anorexia nervosa. Although no male students scored highly, a total of 28 female students (6.3% of the female student sample) scored in the "anorexic" range. These "high scorers", together with a random control group of 28 "non-high scorers", were subsequently interviewed. Interview revealed that the symptoms of anorexia nervosa were common in the high scoring group but virtually absent in the student control group. It is concluded that a substantial proportion of post-pubertal females (approximately 5%) develop a subclinical form of anorexia nervosa. The implications of these findings are discussed in relation to the aetiology, prevention and treatment of disturbances in eating behaviour.

Anorexia nervosa at normal body weight!--The abnormal normal weight control syndrome

Disgust with "fatness" and a consequent preoccupation with body weight, coupled with an inability to reduce it to or sustain it at the desired low level, characterizes the abnormal normal weight control syndrome. Individuals remain sexually active in a biological sense and often also socially. Indeed their sexual behaviour may be as impulse ridden as is their eating behaviour, which often comprises phases of massive bingeing coupled with vomiting and/or purgation. The syndrome is unlike frank anorexia nervosa in that the latter involves a regression to a position of phobic avoidance of normal body weight and consequent low body weight control with inhibition of both biological and social sexual activity. In abnormal normal weight control there is a strong and sometimes desperate hedonistic and extrovert element that will often not be denied so long as body weight does not get too low. Individuals nevertheless feel desperately "out of control" and insecure beneath their bravura. The syndrome is much more common in females than in males. There is a clinical overlap with anorexia nervosa and obesity in many cases as the disorder evolves. Depression, stealing, drug dependence (including alcohol) and acute self-poisoning and self-mutilation are common complications. Clinic cases probably only represent the tip of the iceberg of the much more widespread morbidity within the general population. Like anorexia nervosa and for the same reasons the disorder is probably more common than it used to be.