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.
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