Eating Disorders 445
Problems With the DSM-IV-TR Diagnostic Criteria
Like that of anorexia, the DSM-IV-TR diagnosis of bulimia has received criticism.
Specifi c criticisms focus on the defi nition of the term binge eating, the two types of
bulimia that DSM-IV-TR specifi es, and the issue of whether bulimia is suffi ciently
distinct from anorexia. Let’s examine these criticisms.
Problems Defi ning Binge Eating
DSM-IV-TR’s defi nition of binge eating (see Criterion A in Table 10.3) is subjective:
Who determines whether the amount of food is larger than most people would eat,
the patient or the therapist? In fact, research has found that calories consumed during
“binge episodes” vary widely from episode to episode and person to person (Rossiter &
Agras, 1990); thus, what some consider to be a binge, others might view as an
unexceptional meal.
In addition, the elements of the DSM-IV-TR criteria that focus on the timing ofbinge eating (episodes occur within a 2-hour period and twice weekly for at least
3 months) are not based on research results and don’t predict the course of the
disorder or its prognosis (Franko et al., 2004; Garfi nkel et al., 1995; Kendler et al.,
1991). To see the implications of this criticism, let’s compare two women,
Tess, whose symptoms meet the timing criteria, and Jen, whose symptoms do not. Tess
binges three times a week for 4 months and has enough of the other symptoms to
be diagnosed with bulimia. Jen binges and purges once a week, usually in a 3-hour
stint; however, twice every semester, during midterms and fi nals weeks, she binges
and purges almost every day. She’s been doing it since she was a freshman in high
school, 7 years ago. Her bingeing and purging do not meet the timing criteria, and
thus she would not be diagnosed with bulimia; however, her bingeing and purging
cannot be considered “normal.”
Problems With the Types of Bulimia
The classifi cation of purging versus nonpurging types of bulimia doesn’t appear
to be useful: Comparisons of people who have the two types have not been able to
document meaningful differences between the two groups, other than the specifi c
compensatory behaviors used to prevent weight gain (Gleaves, Lowe, Green, et al.,
2000; Gleaves, Lowe, Snow, et al., 2000; Williamson et al., 2002). That is, the two
groups are similar in terms of the disorder’s onset, course, outcome, and other vari-
ables. In fact, research has found that whether or not someone with bulimia is im-
pulsive is the characteristic that best predicts course and prognosis, not whether
her diagnosis is the purging or nonpurging type (Favaro et al., 2005). Examples of
behaviors that indicate impulsivity include stealing, running away, and seeking out
dangerous situations, as well as abusing substances (Fischer, Smith, & Anderson,
2003; Wonderlich & Mitchell, 2001).
Is Bulimia Distinct From Anorexia?
About half of people with anorexia go on to develop bulimia (Bulik et al., 1997;
Tozzi et al., 2005), which may indicate that anorexia and bulimia are not distinct
but rather represent phases of the same eating disorder, with the symptoms shift-
ing over time. A person’s diagnosis may better refl ect where she is in the course of
Everyone around me is terrifi ed that I may die from this, and it has put a lot of stress on
my marriage. I have no bedroom life anymore because I refuse to let my husband touch me or
even look at my body. My kids are affected greatly by it because I usually have no energy to do
anything with them, and when I do have energy, I am staying busy to burn the calories I have
put in my body.
(Anonymous, 2003, p. 382)