Bulimia Nervosa

AS and A Level Healthcare

- -

EATING DISORDERS:

Bulimia Nervosa

Name: A.L.B

Module: Lifespan Developmental Psychology

Module Leader(s): Jeff Edwards / Margaret Ferrario

Submission Date: Monday 10th May 2004

Within developmental lifespan psychology, eating disorders are often categorised under the heading of ‘adolescence problems’ along with suicide, delinquency, substance misuse and pregnancy. They are particularly associated with females, especially during the development stage of adolescence when one’s physical, cognitive and social development leaves childhood and enters adulthood (Seifert et al, 1997: 333). It appears that young women are more dissatisfied with weight than women at any other stage of the female lifespan. This is due to an increase in awareness of their body shape and weight, therefore accounting for the large majority of eating disorder cases being adolescent females (90%) (Kayrooz 2001: 20). Problematic eating behaviours are becoming a growing concern as the number of cases increase (especially in the last 20-30 years) and especially as younger age groups are being affected. Bulimia nervosa (bulimia) is the most common eating disorder today. However it was only identified as a disorder in 1979 when a rapid increase in the condition was established (Gross, 2001: 657). Bulimia shall now be studied in relation to psychological aspects, definitions, prevalence, symptoms, complications, treatment and possible causes.

“Bulimia is a syndrome characterised by episodes of binge eating followed by compensatory behaviour such as vomiting and purging, along with other techniques to compensate for over eating” (Banyard, 2001: 88). Bulimia affects 1-2.8% of the population, yet it is estimated that 20% of adolescent girls (2.5 million) exhibit less extreme bulimic behaviours (Graber et al, 1994). However, Morris & Summers (1995) highlight the difficulty in identifying the prevalence of eating disorders due to the diversity in which these disorders are defined and measured in research. The bulimic sufferer periodically consumes huge amounts of food in short time spans, with little control over consumption and with fearful thoughts about their inability to stop. An average bulimia sufferer performs secret binges of 2,500 calories or more within a two-hour period, although reports range from 1,200 to 55,000 calories (Johnson et al, 1982). These binges produce feelings of guilt, leading the person to purge, with this behaviour often affecting work, social life, family and health. Other psychologically straining problems include constant worry of being discovered, continuing feelings of shame and the fatigue associated with this particular eating pattern. According to Pinel (2003) bulimia is considered to be a psychiatric, rather than medical condition, characterised by abnormal eating patterns and obsessions with food and weight. However, DSM-IV (1994) states four specific symptoms needed to diagnose bulimia. They are recurrent episodes of binge eating, recurrent inappropriate compensatory behaviour to prevent weight gain, the behaviour must occur approximately twice a week for at least three months, and finally disturbance must not occur during anorexia. The diagnostic criteria also notes specific types of bulimia (purging and non-purging), with severity and frequency of symptoms varying, as some sufferers infrequently use compensatory behaviours, whereas some spend days continuously displaying bulimic behaviour to the extent of exhaustion.

Until 1979, both anorexia and bulimia were classified as one disorder, however they are now classed as separate disorders, although bulimia is often associated with anorexia as both disorders are accompanied by disturbance in self-perception (Cardwell et al, 1996: 236). However, the key difference with bulimia is that the person is usually within 10% of normal weight range, whereas anorexic patients are at least 15% below normal weight range (Eysenck, 2001: 696). Also the extreme lack of control over eating distinguishes bulimia from anorexia (Gross, 2001: 658). However, despite these differences some researchers have questioned whether they are separate disorders, as many of the symptomatic/psychological features, causes and history is very similar (Mitchell & McCarthy, 2000).

Bulimia accompanies many medical complications; most associated with weight control efforts, with vomiting being the main technique used. The most common problem associated with vomiting is dental erosion. Rytomaa et al (2004) compared 35 bulimic patients against a control group of 105 in relation to tooth erosion. It was revealed that severe dental erosion was significantly more common among bulimics than controls. However, the sample is culturally bias, with experimental groups not equal in participant numbers, thus affecting reliability/validity of the study. In addition to vomiting, many eating disordered patients may resort to laxatives to control weight. Mitchell et al (1985) reported that 60% of bulimic individuals used laxatives at some time during the disorder, with 20% on a daily basis, thus leading to digestive and metabolic complications. The use of diuretics is another method used to prevent weight gain as they help eliminate water from the body, but again can lead to many problems, including cognitive changes such as concentration difficulties, confusion and delirium. Bulimia sufferers also control weight via stimulants, as most stimulants stimulate the body’s metabolism or suppress appetite. However, stimulants can lead to nervousness, insomnia, palpitations, and increased heart rate and blood pressure. In addition, psychotic reactions such as hallucinations, as well as seizures and cerebral haemorrhage have been reported. In terms of cognition these stimulants can lead to poor concentration, psychosis with grandise and paranoid features (Renner, 1987). Finally, individuals with bulimia can engage in strenuous exercise or may fast for a day or more in an attempt to compensate for extensive calorie intake, leading to amenorrhea, brittle bones, concentration problems and depression (Cardwell, 1996: 237).

This is a preview of the whole essay

It is possible to see that bulimia has many negative implications regarding ones physiological and psychological state. Anderson et al (2004) revealed that those bulimics who report more drug abuse as a means of controlling weight are significantly more likely to resort to suicide. Bulimia can lead to life threatening consequences, making it interesting to discover why so many bulimic suffers pursue this behaviour. Therefore the causes shall now be discussed. According to APA (1994) a possible cause of bulimia is the increased overabundance of food in Western industrialised societies and the influences of societal norms that link attractiveness to being thin. Thompson & Sherman (1993) agree and use sport to demonstrate. They found athletes are more likely than non-athletes to develop an eating disorder due to the sports’ emphasis on low body fat and acknowledge that ‘thinness demand sports’ such as gymnastics account for the greatest proportion of eating disorders. Gross (2001) claims that bulimia is a cultural rather than universal disorder. Evidence to support this idea comes from Nasser (1986). Nasser compared Egyptian women studying in Cairo and London. None of the women in Cairo developed an eating disorder, in contrast to 12% of those studying in London, therefore suggesting Western cultural surroundings may account for the onset of the disorder. On the other hand, a study by Mumford & Whitehouse (1988) compared 204 Asians and 355 white schoolgirls in Northern England. Findings revealed that 3.4% of the Asians and 0.8% of white girls met the DSM-III-R (1987) criteria for bulimia. Therefore, Asian girls from traditional families were more likely to develop an eating disorder than those from Westernised families, suggesting the tensions of living in a traditional Asian family could be responsible for bulimia. However the sample does not prove equal in terms of participants. Nevertheless, Bhugra & Bhui (2002) agree, as they too revealed Asians were more likely to indulge in compulsive eating, again providing evidence against the idea that eating disorders are specifically related to Westernised culture. However, all who participated were East London students, making findings difficult to generalise. In addition, validity of these two studies can be questioned, as although Asian, they were living in England and therefore were not entirely free from Westernised society.

Streigel-Moore et al (1986) specifically studied bulimia in relation to gender, claiming bulimia is a predominantly female disorder because women rather than men accept and internalise cultural norms. Hayes & Ross (1987) suggest that the traditional housewife role can be used as an explanation for women’s disturbed body image and their vulnerability to eating disorders. As for women at home, physical appearance is a more important contribution to self-esteem than for women who work. Therefore this suggests those women who stay at home are more likely to suffer from bulimia. However if this was true then the prevalence of bulimia should be expected to have decreased in society, as more women are now choosing to go to work than ever before. Silverstein et al (1986) also studied gender differences, relating them to the mass media. Their study suggested thinness in society is promoted by the mass media and that popular female characters in TV shows and magazines are more likely than male characters to be exceedingly thin, thus justifying the reason for more women suffering from eating disorders. Stice et al (2003) carried out a further study, focusing on the exposure of media-portrayed thin-ideal images and their effects on girls. The sample consisted of 219 adolescent girls. The experimental condition made use of a 15-month subscription to a fashion magazine. The control group did not. Results revealed no main effects of long-term exposure to thin images, however findings revealed that vulnerable adolescents within the sample were at more risk of being subjected to lasting negative effects as a result of exposure to the magazine, thus suggesting vulnerable girls in society are at most risk of developing bulimia. Tiggemann (2003) also studied media exposure, suggesting magazines have a greater impact in relation to eating disorders than television. However this study cannot be generalised as the sample were Australian students and could be culturally bias. However in conclusion, cultural factors cannot be the sole reason for the occurrence of eating disorders as the majority who are exposed to cultural pressures, especially regarding weight and appearance do not develop eating disorders.

There is increasing evidence to suggest genetic/heredity factors play a part in the development of eating disorders (Eysenck, 2001: 696). There is an increased risk of bulimia among first-degree biological relatives of sufferers, approximately 4/5 times more probability (Cardwell et al, 1996: 236). Much research related to the genetic components of eating disorders make use of the twin study approach, however these studies often use small samples, thus limiting findings. However, findings are fairly consistent, with concordance rate for monozygotic twins (Mz) at roughly 40% compared to 10% or less for dizygotic twins (Dz) (Eysenck, 2001: 696). A twin study that looked specifically at bulimia (in 2163 female twins) was carried out by Kendler et al (1991). Findings revealed concordance rate for Mz twins was 23% compared to only 9% for Dz twins. This study appears to be more valid than the majority of twin studies as it makes use of a large sample, and focuses solely on bulimia. However, genetic accounts of eating disorders are limited. They do not make clear what is inherited that increases vulnerability to eating disorders. Also the fact that concordance rate for Mz twins is below 100% and since relatives usually share the same environment strongly suggests non-genetic factors must also be important. In addition, the recent dramatic increase in sufferers of eating disorders cannot be explained in genetic terms, as it is almost impossible that there have been major genetic changes in the short space of 20-30 years.

Little is known as to whether depression plays a part in producing eating disorders or whether eating disorders cause depression. Piran et al (1985) attempted to study this causality issue by sampling anorexic patients who had suffered depression. The symptoms of depression occurred before those of anorexia in 44% of patients, and after in 34%. The final 22% started suffering with the symptoms of both anorexia and depression within the same year. Therefore these results do not help enlighten us of the order in which depression and eating disorders occur. The findings are also specifically accumulated by anorexic patients and so cannot be applied to bulimia. However, most people who become depressed do not go on to develop an eating disorder, nor do all patients suffering from eating disorders get depressed and so depression cannot be the direct cause. Nevertheless, there is some link between the two.

Bulimia has been linked to family dynamics and traumatic experiences such as childhood abuse. One suggestion for this link is that such experiences are repressed into the unconscious and express themselves in adolescence in the form of bulimia. For example, sexual abuse in childhood can lead to a rejection by victims of their own bodies, with this rejection turning to disgust, leading to an unconscious desire to destroy their bodies. However, there is some difficulty in gaining evidence due to the unconscious aspect of this claim. Family relationships themselves are associated to bulimia, particularly with a mother-daughter relationship that is over protective (Attie et al, 1990). Cardwell et al (1996) also suggests they particularly relate to family relationships when an adolescent within the family struggles to gain a sense of individual identity as a result of too much parental control. This control by parents is usually maintained via family roles, such as the mother cooking meals and the daughter dutifully eating them. As in this example, the daughter may struggle for her identity by refusing to eat as this gives her some control over her own body, although this can be linked more closely to anorexia than bulimia. This lack of personal identity in family members is known as enmeshment (Eysenck, 2001: 698). In addition, parental and family conflict is often apparent in families where an adolescent is suffering from bulimia. However, this is not always the case and it is not clear whether poor family interactions help cause the disorder or are a reaction to it. Another psychodynamic approach suggests bulimia occurs as a result of fear due to increasing sexual desires, a desire to remain pre-pubescent or even oral impregnation. For example, semi-starvation by bulimics may reflect desire to avoid pregnancy, as one of the symptoms of starvation is the elimination of menstrual periods (Eysenck, 2001: 698). Other risk factors/theories of bulimia include learning theory, cognitive biases, biochemical imbalances, anxiety and borderline personalities.

The aim of treatment for bulimia is to reduce/eliminate binge eating and purging behaviour. Treatments include nutritional therapy, psychotherapy and medication. These three major treatments can be used individually but are often combined to produce the most successful approach, with different treatments working for different sufferers. Establishment of a pattern of non-binge meals, improvement of attitudes, encouragement of healthy levels of exercise, and resolution of other problems such as anxiety and depression are among the specific aims of the three major treatments. The most effective form of treatment tends to be cognitive behavioural therapy (CBT), a form of psychotherapy (Wilson, 1999), ranging from a 50%-90% decrease rate in binge-eating behaviour (Alexander-Mott, 1994: 215). CBT usually involves identifying distorted negative thoughts about appearance and body image and helps a sufferer to learn to identify the cues that trigger a bingeing episode. However, antidepressants have been found to be effective at the beginning of treatment and can also be used as an on-going treatment to prevent relapse. However, Wilson (1999) found that the most effective strategy for treating bulimia was to combine CBT with medication, as adding antidepressant drugs to CBT enhances the improvement in co-morbid conditions. However, the specific patient determines the effectiveness of treatment, with success rates for treatment at 50-70%, with relapse rates of between 30-50%.

In conclusion, no one specific cause for bulimia has been found, although many factors have been linked to the onset of the disorder. Bulimia can vary in terms of its severity, medical complications and treatment methods, with the disorder predominantly affecting female adolescents, with numbers significantly increasing.

REFERENCES

Alexander-Mott, L., & Lumsden, D.B. (1994), Understanding Eating Disorders, Taylor and Francis, London, P. 215

Anderson, C.B., Carter, F.A., McIntosh, V.V., Joyce, P.R., & Bulik, C.M. (2004), Self-Harm and Suicide Attempts in Individuals with Bulimia Nervosa, Eating Disorders, Vol.10, 227-243

APA, American Psychiatric Association (1994), Diagnostic and Statistical Manual of Mental Disorders (4th edn), American Psychiatric Association, Washington, cited in Gross, R. (2001), Psychology, The Science of Mind and Behaviour, 4th edn, Hodder and Sloughton, London P.656

Attie, I., Brooks-Gunn, J., & Petersen, A. (1990), A Developmental Perspective on Eating Disorders and Eating Problems, In Lewis, M., & Miller, S.M. (Eds.), Handbook of Developmental Psychopathology, Pienum Press, cited in Seifert, K.L., Hoffung, R.J., & Hoffung, M. (1997), Lifespan Development, Houghton Mifflin Company, Boston, P.350

Banyard, P. (2001), Applying Psychology to Health, Hodder & Stoughton, London, P.87, 88

Benowitz, N.L., (1990), Clinical Pharmacology of Caffeine, Annual Review of Medicine, 41, 277-288, cited in Alexander-Mott, L., & Lumsden, D.B. (1994), Understanding Eating Disorders, Taylor and Francis, London, P.197

Bhugra, D., & Bhui, K. (1988), Eating Disorders in Teenagers in East London: A Survey, cited in European Eating Disorders Review, Vol 11 (1), 46-57

Cardwell, M., Clark, L., & Meldrum, C. (1996), Psychology for A-Level, Collins Educational, London, P.236, 237, 239

DSM-IV. (1994), (Diagnostic and Statistical Manual of Mental Disorders), DSM-IV, 4th Edn, American Psychiatric Association, Washington, P.549-550

Edlund, B., Halvarsson, K., & Sjoden, P. (1996), Eating Behaviours & Attitudes to Eating, Dieting and Body Image in 7 year old Swedish Girls, cited in European Eating Disorders Review, Vol 4, Wiley & Sons, London, P.40 – 53

Eysenck, M.W. (2001), Psychology, A Student’s Handbook, Psychology Press – Taylor & Francis Groups, East Sussex, P.696, 698

Graber, J.A., Brooks-Gunn, J., Paikoff, R.L., & Warren, M.P. (1994), Prediction of Eating Problems: An 8 year study of Adolescent Girls, Developmental Psychology, 30, 823 – 834, cited in Seifert, K.L., Hoffung, R.J., & Hoffung, M. (1997), Lifespan Development, Houghton Mifflin Company, Boston, P.350

Gross, R. (2001), Psychology, The Science of Mind and Behaviour, 4th edn, Hodder and Sloughton, London P.656, 657, 658

Hayes, D., & Ross, C.E. (1987), Concern with Appearance, Health Beliefs, and Eating Habits, Journal of Health and Social Behaviour, 28, 120-30, cited in Trew, K., & Kremer, J. (1998), Gender and Psychology, Arnold Publishers, London, P.174

Johnson, C.L., Stuckey, M.K., Lewis, L.D., & Schwartz, D.M. (1982), Bulimia: A descriptive study of 316 cases, cited in International Journal of Eating Disorders, 2, 3-16

Kayrooz, C. (2001), A Systematic Treatment Of bulimia Nervosa: Women In Transition, Jessica Kingsley Publishers, London, P.20

Kendler, K.S., Maclean, C., Neale, M., Kessler, R., Heath, A., & Eaves, L. (1991), The Genetic Epidemiology of Bulimia Nervosa, American Journal of Psychiatry, 148, 1627-1637, cited in Eysenck, M.W. (2001), Psychology, A Student’s Handbook, Psychology Press – Taylor & Francis Groups, East Sussex, P.696

Mitchell, J.E., Hatsukami, D., Eckert, E.D., & Pyle, R.L. (1985), Characteristics of 275 patients with bulimia, American Journal of Psychiatry, 142, 482-485, cited in Alexander-Mott, L., & Lumsden, D.B. (1994), Understanding Eating Disorders, Taylor and Francis, London, P. 190

Mitchell, J., & McCarthy, H. (2000), Eating Disorders. In Champion, L., & Power, M. (Eds), Adult Psychological Problems: An introduction, 2nd edn, Psychology Press, Hove, cited in Gross, R. (2001), Psychology, The Science of Mind and Behaviour, 4th edn, Hodder and Sloughton, London P.658

Morris, T., & Summers, J. (1995), Sport Psychology: Theory, Applications and Issues, John Wiley and Sons, Australia, P.556

Mumford, D.B., & Whitehouse, A.M. (1988), Increased Prevalence of Bulimia Nervosa Among Asian Schoolgirls, British Medical Journal, 297, 718, cited in Gross, R. (2001), Psychology, The Science of Mind and Behaviour, 4th edn, Hodder and Sloughton, London P.659

Nasser, M. (1986), Eating Disorders: The Cultural Dimension, Social Psychiatry and Psychiatric Epidemiology, 23, 184 – 187, cited in Eysenck, M.W. (2001), Psychology, A Student’s Handbook, Psychology Press – Taylor & Francis Groups, East Sussex, P.700

Pinel, J.P.J. (2003), Biopsychology, 5th edn, Allyn and Bacon, Boston, P.302, 307,

Piran, N., Kennedy, S., Garfinkel, P.E., & Owens, M. (1985), Affective Disturbance in Eating Disorders, Journal of Nervous and Mental Disease, 173, 395-400, cited in Eysenck, M.W. (2001), Psychology, A Student’s Handbook, Psychology Press – Taylor & Francis Groups, East Sussex, P.701

Renner, J.A. (1987), Drug Addiction, In Hackett, T.P., & Cassem, H.H. (Eds.), Massachusetts General Hospital Handbook of General Hospital Psychiatry, PSG Publishing, Littleton, cited in Alexander-Mott, L., & Lumsden, D.B. (1994), Understanding Eating Disorders, Taylor and Francis, London, P. 195

Rytomaa, I., Jarvinen, V., Kanerva, R., & Heinonen, O.P. (2004), Bulimia and Tooth Erosion, Acta Odontologica Scandinavica, 56, 36 - 40

Seifert, K.L., Hoffung, R.J., & Hoffung, M. (1997), Lifespan Development, Houghton Mifflin Company, Boston, P.333

Silverstein, B., Perdue, L., Peterson, B., & Kelly, E. (1986), The Role of the Mass Media in Promoting a Thin Standard of Bodily Attractiveness for Women, Sex Roles, 14, 519-532, cited in Brehm, S.S., & Kassin, S.M. (1996), Social Psychology, 3rd edn, Houghton Mifflin Company, Boston, P.180

Stice, E., Spangler, D., & Agras, S.W. (2003), Exposure to Media-Portrayed Thin-Ideal Images Adversely Affects Vulnerable Girls: A Longitudinal Experiment, cited in Journal of Social and Clinical Psychology, Vol 20 (3), 270-288

Streigel-Moore, R.H., Silberstein, L.R., & Rodin, J. (1986), Toward an Understanding of Risk Factors for Bulimia, American Psychologist, 41, 246-263, cited in Seifert, K.L., Hoffung, R.J., & Hoffung, M. (1997), Lifespan Development, Houghton Mifflin Company, Boston, P.350

Tiggemann, M. (2003), Media Exposure, Body Dissatisfaction & Disordered Eating: Television & Magazines are not the Same, Volume 11 (5), 418-430, cited in European Eating Disorders Review (1996), Wiley & Sons, London, P.40-53

Thompson, R.A., & Sherman, R.T. (1993), Helping Athletes with Eating Disorders, Human Kinetics, Champaign, cited in Trew, K & Kremer, J. (1998), Gender and Psychology, Arnold Publishers, London, P.214

Wilson, G.T. (1999), Treatment Of Bulimia Nervosa: The Next Decade, European Eating Disorders Review, 7, 77, 81