Eating Disorders 443
- Thepurging type includes vomiting or using
diuretics, laxatives, or enemas.- Thenonpurging type involves other behaviors
to prevent weight gain, such as fasting or ex-
cessive exercise. Exercise is considered exces-
sive by mental health clinicians if the individual
feels high levels of guilt when she postpones or
misses a workout (Mond et al., 2006).As noted in the section on anorexia, a person
with anorexia may purge or fast. In those cases,
according to DSM-IV-TR, the symptoms that
distinguish anorexia from bulimia are the low
weight and related amenorrhea. Because women
with bulimia nervosa are in the normal weight
range—or possibly overweight—they generally
continue to menstruate. Bulimia is twice as prev-
alent as anorexia (American Psychiatric Asso-
ciation, 2000) and, like anorexia, is much more
prevalent among females (Keel et al., 2006). The
DSM-IV-TR criteria for bulimia nervosa are pre-
sented in Table 10.3, and additional facts about
the disorder are listed in Table 10.4.
Table 10.3 • DSM-IV-TR Diagnostic Criteria for Bulimia Nervosa
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both
of the following:
(1) eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food
that is defi nitely larger than most people would eat during a similar period of time and
under similar circumstances
(2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot
stop eating or control what or how much one is eating)B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as
self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fast-
ing; or excessive exercise.C. The binge eating and inappropriate compensatory behaviors both occur, on average, at
least twice a week for 3 months.D. Self-evaluation is unduly infl uenced by body shape and weight.E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa.
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Text
Revision, Fourth Edition, (Copyright 2000) American Psychiatric Association.Table 10.4 • Bulimia Nervosa Facts at a Glance
Prevalence- Over the course of a lifetime, 1–2% of women and 0.1–0.5% of men are likely to develop the disorder (Hoek & van Hoeken, 2003; Hudson et al., 2007).
Comorbidity- Up to 75% of people with bulimia have at least one other disorder, often an anxiety disorder (Godart et al., 2003; Hinrichsen et al., 2003; Kaye et al.,
2004; Keck et al., 1990; Milos et al., 2002; Schwalberg et al., 1992) or depression (American Psychiatric Association, 2000). - About 30% of those with bulimia will also develop substance abuse or dependence at some point during their lifetime, which may evolve from initial
use of stimulants for weight loss (American Psychiatric Association, 2000).
Onset- Bulimia usually begins in late adolescence or early adulthood (American Psychiatric Association, 2000). It may develop in older adults, however (Beck
et al., 1996). - Those in more recent birth cohorts (that is, those born more recently) have a higher risk for developing bulimia (Hudson et al., 2007).
Course- At a 15-month follow-up, almost a third of those diagnosed with bulimia still met the criteria for the diagnosis; at a 5-year follow-up, that proportion
dropped to 15% (Fairburn et al., 2000). However, people who no longer meet the DSM-IV-TR criteria for the disorder may nevertheless continue to
have persistent symptoms of bulimia, although not the number, frequency, or intensity specifi ed by the criteria (Ben-Tovim, 2003; Keel & Mitchell,
1997; Keel et al., 1999; Wade et al., 2006). - People who have less intense negative attitudes about their bodies and who function better in daily life are more likely to have a healthier outcome
(Ben-Tovim, 2003; Collings & King, 1994; Keel et al., 1999). - People with bulimia who also have or have had a substance use disorder generally do not fare as well as those without this comorbid disorder (Keel
et al., 1999).
Gender Differences- Approximately 75–90% of those with bulimia nervosa are female (Hoek & van Hoeken, 2003; Hudson et al., 2007).
Cultural Differences- Some studies fi nd signifi cant differences in prevalence, frequency, and symptoms of eating disorders across ethnic groups within the United States.
Specifi cally, black and Hispanic American women are less likely to be diagnosed with bulimia than are Asian American or white American women
(Alegria et al., 2007; Nicdao et al., 2007; Striegel-Moore et al., 2003; Taylor et al., 2007). Other studies fi nd fewer meaningful differences in symptoms
and prevalence rates across ethnic groups (see Arriaza & Mann, 2001; Franko et al., 2007; Walcott, Pratt, & Patel, 2003).