18 EATINGDISORDERS 439
About 50% of clients with bulimia recover fully,
20% continue to meet all the criteria for the disease,
and 30% have episodic bouts of bulimia. One-third of
fully recovered clients have a relapse. Clients with a
comorbid personality disorder tend to have poorer
outcomes than those without. The death rate from
bulimia is estimated at 3% or less.Related Disorders
Eating disorders usually first diagnosed in infancy and
childhood include rumination disorder, pica,and feed-
ing disorder(see Chap. 20). Common elements in
clients with these disorders are family dysfunction and
parent–child conflicts (Patel, Phillips & Pratt, 1998).
Binge eating disorderis listed as a research cat-
egory in DSM-IV-TR,2000; it is being investigated
to determine its classification as a mental disorder.
The essential features are recurrent episodes of binge
eating; no regular use of inappropriate compensatory
behaviors such as purging or excessive exercise or
abuse of laxatives; guilt, shame, and disgust about
eating behaviors; and marked psychological distress
(Costin, 2002). Clients are more likely to be overweight
or obese, overweight as children, and teased about
their weight at an early age. Thirty-five percent re-
ported that binge eating preceded dieting; 65% re-
ported dieting before binge eating (Grilo & Masheb,
2000).
Night eating syndrome (NES)is characterized by
morning anorexia, evening hyperphagia (consuming
50% of daily calories after the last evening meal),
and nighttime awakenings (at least once a night) to
consume snacks. It is associated with life stress, low
self-esteem, anxiety, depression, and adverse reac-
tions to weight loss. Most people with NES are obese
(Gluck, 2002).
Comorbid psychiatric disorders are common in
clients with anorexia nervosa and bulimia nervosa.
Clients with anorexia nervosa have a high rate of
major depression (68%), anxiety disorders (65%),
obsessive-compulsive disorder (26%), and social phobia
(34%). Personality disorders also are prevalent: 25%
of clients with the restricting type of anorexia have
cluster C anxious personality traits, and 40% of clients
with the binge and purge type have cluster B impulsive
personality traits. Clients with bulimia have comor-
bid psychiatric diagnoses of major depressive disorder
(36% to 70%), substance abuse (18% to 32%), and per-
sonality disorders (28% to 77%) that are primarily
cluster B impulsive personality traits (Halmi, 2000).
Eating disorders, particularly bulimia, often are
linked to a history of sexual abuse (Redford, 2001).
Such a history may be a factor contributing to prob-
lems with intimacy, sexual attractiveness, and low
interest in sexual activity. Matsunaga et al. (1999)
studied women recovering from bulimia and found
that those with a history of physical or sexual abuse
had increased rates of borderline personality dis-
order and posttraumatic stress disorder and more
severe core eating disorder symptoms such as drive
for thinness, body dissatisfaction, and ineffectiveness.
Whether or not sexual abuse has a cause-and-effect
relationship with the development of eating dis-
orders, however, remains unclear.ETIOLOGY
A specific cause for eating disorders is unknown. Ini-
tially dieting may be the stimulus that leads to their
development. Biologic vulnerability, developmental
problems, and family and social influences can turn
dieting into an eating disorder (Table 18-2). Psycho-
logical and physiologic reinforcement of maladaptive
eating behavior sustains the cycle (Halmi, 2000).Biologic Factors
Studies of anorexia nervosa and bulimia nervosa have
shown that these disorders tend to run in families.
Grise & Kaye (2002) found a genetic susceptibility forSusan is driving home from the grocery store and eat-
ing from the grocery bags as she drives. In the 15-minute
trip, she has already consumed a package of cookies,
a large bag of potato chips, and a pound of ham from
the deli. She thinks “I have to hurry, I’ll be home soon.
No one can see me like this!” She knew when she
bought these food items that she would never get home
with them.
Susan hurriedly drops the groceries on the kitchen
counter and races for the bathroom. Tears are streaming
down her face as she vomits to get rid of what she hasCLINICALVIGNETTE: BULIMIANERVOSA
just eaten. She feels guilty and ashamed, and does not
understand why she cannot stop her behavior. If only she
did not eat those things. She thinks, “I’m 30 years old,
married with two beautiful daughters and a successful
interior design consultant. What would my clients say if
they could see me now? If my husband and daughters
saw me, they would be disgusted.” As Susan leaves the
bathroom to put away the remainder of the groceries, she
promises herself to stay away from all those bad foods.
If she just does not eat them, this won’t happen. This is
a promise she has made many times before.