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]
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 There were scattered historical references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
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,
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).
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,
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
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 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
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,
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.