232 Eating Disorders
constipation, diarrhea, and pancreatitis; may have sore throats; and often
have dental caries and abscesses. They show muscle cramps and have skin
problems such as dry flaky skin and calluses on the backs of their hands
and fingers from induced vomiting (Treasure and Szmukler, 1995).
Psychological complicationsBulimia is also associated with a wide range of psychological complications.
Neurotic symptoms are particularly common. For example, one study
reported that pathological guilt, worrying, poor concentration, obsessional
ideas, rumination, and nervous tension were present in over 80 percent of
a sample of patients, and that hopelessness and inefficient thinking were
present in over 60 percent of the sample (Fairburn and Cooper, 1984).
Depression and anxiety are also frequently associated with bulimia. For
example, in the original paper describing bulimia nervosa, Russell (1979)
reported that 43 percent of his female patients showed signs of severe depres-
sion. Subsequent studies have supported this finding. Using larger sample
sizes and structured interviews, the lifetime rate of major depression among
patients with bulimia has been reported to range from 36 percent to 70
percent (Piran et al., 1985; Laessle et al., 1987). These studies also show
that at the time of presentation for treatment between one-third and one-
half of patients fulfill the criteria for depression. However, depression does
not always co-occur with bulimia. It sometimes precedes bulimia and at
times follows the onset of the eating disorder, suggesting that although there
is a close relationship between bulimia and depression, neither is simply a
secondary disorder to the other. Suicide attempts are also high among patients
with bulimia. Of Russell’s patients, 11 out of the 30 had made a suicide
attempt, and Hatsukami et al. (1984) reported a suicide attempt rate of 16
percent. Actual suicide rates have also been shown to be higher than in
the normal healthy population (Favaro and Santonastaso, 1997). In terms
of anxiety, the majority of bulimic patients report anxiety symptoms
(Fairburn and Cooper, 1984). However, many of these symptoms appear
to be related to the specific psychopathology of bulimia. For example,
bulimics feel anxious about eating in public and getting undressed in a com-
munal area, and suffer anxiety-related symptoms when thinking about food,
weight, or shape (Cooper and Cooper, 1987). Bulimia is also associated with
other less common psychological problems. In particular, rates of alcohol
and substance abuse are higher in bulimics than in control subjects
(Hatsukami et al., 1984; Bulik, 1987), and bulimia is also associated with