Psychological Medicine, 1979, 9, 429-448 Printed in Great Britain

Bulimia nervosa: an ominous variant of anorexia nervosa GERALD RUSSELL1 From the Academic Department of Psychiatry, Royal Free Hospital, London

Thirty patients were selected for a prospective study according to two criteria: (i) an irresistible urge to overeat (bulimia nervosa), followed by self-induced vomiting or purging; (ii) a morbid fear of becoming fat. The majority of the patients had a previous history of true or cryptic anorexia nervosa. Self-induced vomiting and purging are secondary devices used by the patients to counteract the effects of overeating and prevent a gain in weight. These devices are dangerous for they are habit-forming and lead to potassium loss and other physical complications. In common with true anorexia nervosa, the patients were determined to keep their weight below a self-imposed threshold. Its level was set below the patient's healthy weight, defined as the weight reached before the onset of the eating disorder. In contrast with true anorexia nervosa, the patients tended to be heavier, more active sexually, and more likely to menstruate regularly and remain fertile. Depressive symptoms were often severe and distressing and led to a high risk of suicide. A theoretical model is described to emphasize the interdependence of the various symptoms and the role of self-perpetuating mechanisms in the maintenance of the disorder. The main aims of treatment are (i) to interrupt the vicious circle of overeating and self-induced vomiting (or purging), (ii) to persuade the patients to accept a higher weight. Prognosis appears less favourable than in uncomplicated anorexia nervosa.

SYNOPSIS

t i e r inia e

' ' ^ °f food. Indeed, episodes of overeating constituted the most constant feature of Anorexia nervosa has in recent years become the disorder. Sometimes the overeating alteraccepted as a psychiatric disorder with well- nated with periods of abstinence. Overeating defined diagnostic criteria (Russell, 1970; Bruch, was often overshadowed by more dramatic 1974; Garrow et al. 1976). Although there is clinical phenomena - intractable self-induced still no specific treatment, the general manage- vomiting or purgation. At least one of these ment of anorexia nervosa yields gratifying results habits was always present, and they were some(Crisp, 1974; Russell, 1977a). A natural course times combined. The episodes of overeating for the typical illness has also been discerned, the were the immediate precursor of self-induced majority of patients making a substantial recovery vomiting or purgation which should be regarded even though this may require the lapse of some as the patients' attempts to counteract the effects years (Morgan & Russell, 1975; Hsu et al. 1979). of the ingestion of excessive food. The constancy The purpose of this article is to report a series and significance of overeating invite a new of 30 patients whose illness bears a close terminology for the description of this symptom resemblance to anorexia nervosa, but does not - bulimia nervosa - even though it would be conform fully to its diagnostic criteria. In this premature to think of the disorder described in series the patients did not necessarily reduce this article as constituting a distinct syndrome. It will be seen still to be related to anorexia Address for correspondence: Professor Gerald Russell, Academic Department of Psychiatry, Royal Free Hospital, nervosa. , . , _ , . . , . London NW3 2QG.

Apart from the nature of their eating distur429 0033-2917/79/2828-4520 $01.00 © 1979 Cambridge University Press

Sex

M M F F F F F F F F F F F F F F F F F F F F F F F F F F F F

Pt.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 18-8 21-2

18 20 17 17 23 15 21 22 37 13 14 15 23 17 21 17 31 37 24 19 16 16 16 31 25 17 19 22 19 34

18 20 16 13 20 15 19 16 36 13 14 14 22 17 20 17 21 35 18 14 14 13 14 24 25 16 13 17 18 33

Mean

Onset bulimia vomiting purging

Onset eating disorder

Age (years)

22-8

21 22 16 23 20 20 25 17 38 16 17 17 23 27 22 17 32 36 25 19 23 18 17 26 26 21 20 22 22 36

* First* referral for treatment

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

Yes

X

X

X

X

X

X

X

' Cryptic'

X

X

X

X

X

X

No

Previous anorexia nervosa

P V VP VP VP V p V V V V V VP V VP VP VP p V V V V VP V V V V VP VP

V

Devices used after bulimiaf

Table 1. Summary of principal clinical data

66-5 73 0 520 540 540 570 540 540 44 0 480 550 48 0 540 600 500 7 58 0 7 570 540 63 0 600 51 0 64 0 540 550 550 570 760 490

41 0 540 35-5 38 0 38 0 7 380 300 35 0 35-0 33-5 390 43-5 43 0 450 350 510 35-5 390 440 43-5 500 340 440 380 440 490 440 630 380

Minimum (B)

4903

43 0 65-5 531 44-8 36-7 700 41 0 73 0 420 44-4 33-6 44-7 43-5 43 0 470 460 58-6 360 46 0 540 550 63 0 46-5 500 400 54-4 590 46-5 63 0 380

When treated for bulimia (C)

Mean (females only)

'Healthy ' (A)

Weight (kg)

So

M M F F F F F F F F F F F F F F F F F F F F F F F F F F F F

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 X

X X X

X X X X

X

X

X X

X

X

X

X

X

X

X

X

X X

X

X

Married

X

X

X

X

X

X

X

Experienced

Sexual activity

B

D

B D

B D

B

N.a. N.a. D D

Fertility ||

-1-5 60

120 0-6

-30

9-5 90

6-3; 9-2; 16-8; 0-9

140; 14-0 -9-5

-9-0 -20

19-7; 7-4; 10-7

Weight gain during admission(s) (kg)H

represents severe abuse of purgatives. N.a. = not applicable. Refers to first treatment of eating disorder: in some patients with true anorexia nervosa it preceded the onset of bulimia. V = vomiting, P = purging. Desired weight is the patient's own definition of the weight she will not exceed. A = amenorrhoea, M(p) = menses on the pill. Before (B), during (D) eating disorder. Weight loss shown by minus sign.

N.a. N.a. M A A M M(p) M A A A M A M A A M A M M M M M M A M M(p) M(p) M(p) A

7 690 41-5 42-5 47-5 7 7 540 41 0 44 0 440 470 520 44 0 48-5 7 550 45 0 480 54 0 470 54 0 51 0 460 7 51 0 540 49 0 60-5 48 0

Sex

Pt.

P * •f j § || II

Menstrua tion§

Desired weigh tj (kg) (D)

Table 1 (cont.)

a

;•>

5

??

g |5

432

G. Russell

bance, the patients in the present series differed in other ways from those with true anorexia nervosa. The latter are required to satisfy 3 essential diagnostic criteria: self-induced loss of weight with severe inanition, persistent amenorrhoea (or an equivalent endocrine disturbance in the male), and a psychopathology characterized by a dread of losing control of eating and becoming fat (Russell, 1970). In contrast, several of the patients described were only slightly underweight, and some were of normal or even excessive weight. Neither was amenorrhoea a constant or persistent feature. Some of the patients experienced only transient amenorrhoea; others maintained regular menstrual cycles throughout, in spite of their eating pattern being severely disturbed. The one feature that held fast for both bulimia nervosa and anorexia nervosa was the characteristic psychopathology whereby the patients were abnormally concerned with their body size, fearing fatness which they described in excessively harsh terms out of keeping with sensible standards. Patients with true anorexia nervosa may also make themselves sick or abuse purgatives; they differ, however, from the present series of patients in that they do not resort to these devices after _ episodes of overeating, but mainly in order to prevent the absorption of an already reduced intake of food. Moreover, the vomiting and purging in true anorexia nervosa are generally less frequent and habitual. Thus, the 30 patients presented in this article all experienced episodes of overeating, immediately followed by self-induced vomiting or purging or both, and they betrayed a morbid fear of becoming fat. The clinical features of bulimia nervosa will be described, and a distinction made between the primary symptoms and the secondary complications. The relationship of this disorder with true anorexia nervosa will be discussed, as will the differences in the response to treatment and the prognosis.

referral was as follows: 1972 (1 patient), 1973 (2), 1974 (3), 1975 (5), 1976 (2), 1977 (9) and 1978 (January-June: 8). The episodes of overeating had become frequent, usually at least daily, causing the patients much distress. They sought to counteract the increased calorie intake by self-induced vomiting (27 patients), purging only (2 patients), purging and vigorous running (1 patient). Sixteen of the 27 patients who vomited also took purgatives, but this proportion was probably an underestimate as, at first, I was not sufficiently alerted to this possibility. In every patient the vomiting and/or purging had become frequent, habitual, and established over a period of months or even years. The intractability of these habits was remarkable in view of the patients' deep sense of shame and common awareness of their harmful effects. Table 1 summarizes the principal clinical data on the 30 patients, and includes 3 landmarks in the course of the illness: (1) the age of onset of the eating disorder (whether it was undereating or overeating) (mean 18-8 years; S.D. ±6-18); (2) the age at which the patient first experienced the urge to overeat (followed by vomiting or purging) (mean 21-2 years; S.D.+ 6-52); (3) the age at which she first sought treatment (at the Royal Free Hospital or elsewhere) (mean 22-8 years; S.D. ±5-90). In the case of 5 patients (3, 5, 8, 18, 24), the bulimic episodes developed after the patient had first sought treatment, and this was usually the reason for seeking treatment again. CONTROL GROUP OF PATIENTS WITH ANOREXIA NERVOSA

In order to permit comparisons with the patients who had sought treatment for episodes of overeating and vomiting (or purging), data were extracted from the case-notes of 30 patients with true anorexia nervosa who had been treated around the same time. This group consisted of 30 patients who met the diagnostic criteria of THE SELECTION OF PATIENTS anorexia nervosa but did not overeat or vomit, The 30 patients (28 females and 2 males) were and who had been admitted consecutively to seen consecutively by the author over a period the psychiatric unit of the Royal Free Hospital of 6 | years (1972-8) and studied prospectively. during 1975-6. The group included one male They were selected from other patients with patient. The mean age of onset of their illness eating disorders if they revealed a history of was 18-2 years (S.D.+ 6-24) and did not differ episodes of overeating, followed by self-induced significantly from the corresponding age of the vomiting or purging, or both. The frequency of bulimic patients.

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Bulimia nervosa

ILLUSTRATIVE CASE HISTORIES Patient 8 This patient illustrates the transition from true anorexia nervosa to bulimia nervosa. At the age of 16, while at boarding school in Switzerland and feeling lonely, the patient reduced her intake of food and menstruation ceased. Her weight fell from 54 to 41 kg, and she was diagnosed as suffering from anorexia nervosa. Between the ages of 16 and 18 she was admitted to hospital 6 times in order to treat her loss of weight: twice she had sunk to 30 kg. At last she improved but without resumption of menstruation. At 21 she began to feel plagued by the urge to keep on eating, at the same time denying that she felt hungry. For the next 7 years the pattern was as follows: she would eat little during the day but would overeat during the evening. She said that if she allowed some carbohydrate-rich food to cross her lips she was bound to continue eating until she had consumed 15000 to 20000 calories, according to her estimate. She added,' there is an empty aloneness inside me which is usually relieved by food'. After the eating orgy she felt revolted. She then swallowed 10-20 purgative tablets (Senokot). She never resorted to vomiting. Over the course of years her weight rose. At 22 she became severely depressed and after admission to hospital made a serious suicidal attempt with amitriptyline tablets. It was not until she was aged 25 and weighed 76 kg that menstruation was resumed. She reacted to it with dismay. She led a lonely life, without a boyfriend, cut off from her family, and immersed in her work as a secretary. At 28 she was admitted to the Royal Free Hospital with the aim of interrupting the cycle of bulimia and purging. She was also encouraged to accept being heavier than she wished, but was permitted to reduce her mild degree of obesity by losing weight from 74 kg to 64 kg in the course of 12 weeks. She did not benefit from antidepressant treatment but welcomed thrice weekly brief supportive psychotherapeutic sessions. At follow-up one year later she was more cheerful and weighed 60'2 kg but had resumed the overeating and purging. Patient 4 This patient became bulimic several years after an episode of weight loss that can be viewed as a cryptic form of anorexia nervosa. At 13 (one year after menarche) the patient's weight fell from 55 to 40 kg, but she continued to menstruate regularly. At 17 when she weighed 47 kg she had a love affair, became pregnant and obtained an abortion. It was then that she began to overeat and make herself vomit. There was a respite between the ages of 18 29

and 20 after her marriage, when her weight rose to 56 kg. She again became pregnant, and again had her pregnancy terminated. Subsequently, and with a deterioration of her marriage, the bouts of overeating and vomiting were resumed. They continued intermittently for the next 4 years and it was only at the end of this period that menstruation ceased when she weighed 42 kg. The patient was much preoccupied with food and derived great pleasure from eating. During a bout of eating she might consume 7 pounds of food, including half a loaf, cakes and yoghurt, until she could hardly stand. She would then make herself sick by pushing the handle of a toothbrush down her throat. After vomiting she would induce 35-40 retchings, which would be followed by a sense of relief at having got rid of all the food eaten. The cycle might be repeated, up to 4 times daily. She spoke of this as an ingrained habit, akin to an addiction. She was able to desist from overeating and vomiting for weeks at a time, but only by reducing her intake of food to 800 calories daily, an amount which she imagined would suffice to keep her weight constant. At other times she abused purgatives. She set a sharp upper limit of 45 kg for her weight, declaring that she would be unattractive above this weight. She was admitted to the Royal Free Hospital when she was vomiting frequently and weighed 42 kg. She temporarily ceased vomiting, but would not accept the treatment aimed at increasing her weight. After discharge she entered a phase of undereating and lost more weight (40 kg); the amenorrhoea has persisted during a follow-up of one year. Patient 29 This patient became bulimic after having dieted. She is considered not to have previously suffered from anorexia nervosa, because she has not been underweight and there has been no interruption of menses. The patient was a tall young woman (height 1 m 79; 5'10i") who weighed 76 kg at the age of 14 and 86 kg at the age of 18. She entered a teacher's training college where she felt unhappy, began dieting and reduced her weight to 62 kg. She continued to menstruate regularly. She made herself vomit for the first time after a large Christmas lunch. For the next 3 years she continued to overeat and vomit intermittently. The patient described her overeating as an involuntary, almost unconscious, habit which felt quite unlike eating in response to normal hunger. She said she tried to avoid food altogether when she felt 'strong enough'. For the first 9 months she induced vomiting by pushing her ringers down her PSM

9

434

G. Russell

throat. Thereafter, vomiting became effortless regurgitation prompted by adopting a special posture. She would stand with one foot on the lavatory bowl, the thigh exerting slight pressure on the abdomen, and would also gently press it with the opposite forearm. After vomiting she felt vastly relieved: 'It is like the first few puffs of a cigarette'. There were times, however, when the vomiting became a mechanical habit: 'I feel nothing, it's just a bore, as routine as cleaning one's teeth'. She only took purgatives when it was not possible for her to vomit for social reasons. She would then take a large amount over a couple of weeks. The patient declared that this behaviour was due to her unwillingness to weigh more than 60-62 kg. She said that above this weight she would be prone to sweating and feel large, unfeminine and unattractive to the opposite sex. Yet she was otherwise well adjusted: she felt happier since transferring to a new college, had a supportive boyfriend and enjoyed a satisfactory sexual relationship. The patient first sought treatment at the age of 22, when she weighed 60 kg and looked moderately slender. She was admitted to hospital where she ceased to overeat or vomit. She was most careful not to let her weight rise above 60-5 kg. She relapsed soon after returning home. When last seen 3 months later, she weighed 57-5 kg and had resumed the regular overeating and vomiting. PREVIOUS OCCURRENCE OR ABSENCE OF ANOREXIA NERVOSA In each patient the history of the eating disorder was studied from its beginning to determine its possible relationship to anorexia nervosa. (i) Previous unequivocal anorexia nervosa In 17 of the 30 patients there had been a previous history of anorexia nervosa meeting all the necessary criteria including severe loss of weight and prolonged amenorrhoea (see Table 1). Eleven of them had previously received treatment for anorexia nervosa aimed at encouraging a gain in weight, including one or more admissions to hospital. Their clinical histories resembled that of patient 8. By the time the remaining 6 patients had presented themselves for treatment, the episodes of overeating and self-induced vomiting had become established, having begun soon after the onset of the anorexia nervosa. (ii) An unusual cryptic form of anorexia nervosa In 7 of the 30 patients there had been only a moderate loss of weight and only a few months

of amenorrhoea (see Table 1). Weight was usually maintained well above 40 kg except in the case of one patient (30) of slender build, whose weight fell to 38 kg. The clinical histories of these patients corresponded to that of patient 4. Their illnesses can be classified as milder forms of anorexia nervosa, the early symptoms having caused little concern until the bouts of overeating and self-induced vomiting became established. (iii) Not classifiable as anorexia nervosa Six patients could not be considered as suffering from anorexia nervosa (see Table 1). Three of them had remained consistently overweight (patients 6 and 17, and patient 29 already described). Only one of them (17) had experienced amenorrhoea. The remaining 3 patients (14, 22, and 27) had no history of amenorrhoea and had shown only slight loss of weight (not below 43 kg) which did not persist. Interval between the onset of the eating disorder and the overeating Table 1 shows a variable interval between the onset of the original symptoms (usually food restriction and weight loss) and the bouts of overeating, self-induced vomiting or purgation. In 18 of the 30 patients, the overeating commenced within one year of the onset of the eating disorder. In the other 12 patients, the interval was 2-3 years (3 patients), 4-5 years (5 patients), 6-7 years (3 patients), over 7 years (1 patient). CLINICAL ASPECTS OF THE EATING DISORDER The urge to eat Several patients volunteered that their minds were filled almost constantly with thoughts of food with resulting impairment of concentration. A few mentioned recurrent dreams about food, waking in an agitated state if they had dreamed that they had given way to eating. Yet most patients declared that the urge to overeat differed from sensations of true hunger. Patient 11 said: 'It is not hunger. Hunger is a feeling of a gap inside you. You eat something small to stop that feeling. I go on eating after I've satisfied that hunger. I want to keep on eating until I feel full-it's the final limit-you can then

Bulimia nervosa

435

eat no more.' Another patient said that eating to 7 pounds. Patient 14 said she would eat fulfilled an emotional need. One patient said £5-worth of food at one sitting. Patient 6 said she obtained real pleasure from the food but she would spend her entire week's wages on others implied that the initial pleasure was soon food, leaving no money for other necessities. overwhelmed by the feelings of guilt or disgust. Patient 8 thought the food she consumed during Patients frequently said that a bout of over- the evening frequently amounted to 15000-20000 eating would be the sequel to allowing even a calories. small amount of a favourite food to be ingested. The frequency of overeating varied a great This applied especially to food which the patients deal. Some patients imposed a harsh control over considered fattening-carbohydrate-rich foods. eating for as long as possible. They might sucThe description of the chain-reaction that fol- ceed for several days on end but succumb to lowed the ingestion of a mere morsel was sug- overeating every week or two. Others overate gestive of a failure of a satiety mechanism, the daily, especially during the late evening or at patient being unable to stop eating once she night. This diurnal pattern might partly be the had commenced. During intervening periods result of a greater opportunity for solitary eating patients attempted to reduce their food intake, during the late hours. Overeating might even abstaining especially from carbohydrate-rich occur several times daily. food. Thus, there was often an all-or-none pattern to the sequences of eating. It was also observed that overeating and its sequel of Devices to prevent weight gain (i) Self-induced vomiting vomiting were more likely to occur when the patient felt most intensively that she was fat or Self-induced vomiting can be so closely associin danger of becoming fat. A corollary was that ated in the patient's mind with the preceding patients would strive to lose weight as a safe- bout of overeating that it is often difficult to guard against overeating. distinguish between them in the course of the The social setting in which the patient found patient's introspection. A few of the patients or placed herself was also important. Overeating could remember distinctly the precipitants of tended to be a solitary and secretive habit. It the first incident of overeating and vomiting. was unlikely to happen when the patient ate One remembered that it followed a large Christan ordinary meal in the presence of others. Yet mas dinner; another that it resulted after her these patients tended to eat erratic snacks and brother's birthday party celebrations. A third to shun the company of others. If a patient specifically blamed her doctor who, in the course planned an eating orgy she would choose a time of his enquiries, had asked if she had ever made and a place which ensured privacy. One patient herself vomit. She blamed him for putting the described her anger when her preparations for idea in her mind. Yet another said the idea a bout of overeating were interrupted by the of making herself sick occurred after an attack ringing of the doorbell. Food shops were of genuine gastro-enteritis which had caused her described as places of temptation. The shopping to vomit involuntarily. itself might become ritualized with the patient As with overeating, the act of vomiting itself buying confectionery from several shops to may be susceptible to the social setting in which avoid the embarrassment of buying large the patient finds herself. She is least likely to quantities at a time. The shopping expedition risk being discovered vomiting when in a strange acquired overtones of anxiety or excitement. Two house or in the company of friends. Patients patients described buying large amounts of food, frequently say that the temptation to vomit is becoming frightened, and throwing it away to greatest when they are in their parents' home. their annoyance for wasting money. Patient 28 regularly overate and vomited when The amounts of food consumed at one sitting she lived with her parents; when she stayed at could be extraordinarily large, e.g. 10 bars of her boyfriend's home she almost starved herself chocolate, or 6 cartons of cottage cheese, or in order to control the vomiting which would 5 packets of biscuits were examples given by have caused him displeasure. Two patients (26, different patients. Patient 4 thought the total 29) earnestly asked to come into hospital even weight of food and drink consumed was close though they were told that this was not necessary. 29-2

436

G. Russell

Their motive was to arrest the vomiting as a result of external control. Patients vary in the preferred method of making themselves vomit. The commonest way, and certainly that used most often to initiate the habit, is by inserting the fingers in the mouth and throat and inducing the gag-reflex. Two patients (12 and 24) who had continued to rely on this method developed caMuses over the dorsum of the hand as a result of repeated rubbing of the skin against the upper incisors. In the case of patient 12 this rubbing had led to ulceration of the skin, the cause of which she concealed from her mother by claiming that she was suffering from boils (Fig. 1, facing p. 448). Patient 24 actually found it difficult and painful to make herself vomit (but found it easier if she covered her fingers with salt beforehand). The use of an emetic is surprisingly rare (one other instance was encountered in a patient not featured in the present series who once drank a bottle of Ipecac: the effects were so unpleasant that she did not repeat the experiment). Patients 4 and 18 had graduated from using their fingers to inserting the handle of a toothbrush. They both attributed special magical qualities to the toothbrush itself. Patient 18 one day presented her toothbrush wrapped in tissues to her husband as a gesture that she was abandoning the habit. She relapsed a few days later. Patient 4 made a similar gesture, breaking her toothbrush in two and presenting me with the pieces. She mentioned how incensed she had felt when her husband had once attempted to confiscate the toothbrush. When questioned about the specificity of the sacrificed toothbrush, she rather grudgingly admitted that she could after all buy another one. Patient 22 was unusual in that she preferred to press tightly on the front of her throat above the level of the hyoid until the discomfort caused her to vomit. This sometimes led to local bruising. If the method failed, she would insert her fingers into her throat. Of the 27 patients who induced vomiting, 21 did so by the insertion of their fingers or a toothbrush. The remaining 6 patients found it no longer necessary to stimulate their throats in order to induce vomiting. They described the vomiting as often effortless: ' I can just make myself sick'. They qualified this by saying that vomiting was eased by the large quantities of food and fluid they had consumed. Patient 21 could demonstrate

how she vomited. She stood on a chair and bent over a bucket placed on a table: the gastric contents appeared simply to pour out as a result of slight hand pressure over the abdomen. Other patients actually spat out food, or described a process of partial ingestion when 'gagging' or 'burping' would lead to regurgitation. There may be a variety of ritualistic accompaniments. Patient 4 counted 35-40 retchings before being satisfied that she had completely rid herself of all ingested food. Patient 26, a nurse, used a more sophisticated approach: in between vomits she would drink a large amount of water and repeated the vomiting 'until the washings returned clear'. The frequency of vomiting varied a great deal - from once every 2 weeks in a patient trying to stop the habit, to several times a day after each meal. One patient (26) said she vomited up to 15 times daily. The habit-forming aspects of self-induced vomiting were often stressed, especially by patients who had tried to stop. They drew analogies with addiction to smoking, alcohol or even drugs. The affective accompaniments of the vomiting also varied. Many patients spoke of relief after vomiting, partly because the abdominal distension had been corrected, but more because they felt that overeating would not lead to fatness. No patient claimed that the vomiting was pleasurable, although one (3) said that in retrospect vomiting was so closely associated with pleasurable eating that the process as a whole was remembered pleasantly. Patient 24 who found it difficult to vomit described how ill she felt: ' I nearly pass out'. Otherwise patients tended to regret feeling compelled to vomit and expressed shame. Patient 29, on the other hand, said it had become a routine habit. The secretive nature of the vomiting has already been alluded to, patients trying to conceal the habit from parents or husband, often with prolonged success. Yet by the time they sought medical help, most patients were ready to discuss the habit they often found distressing. Only 4 out of the 27 vomiters tried at first to conceal this habit. When questioning the patient, it is advisable to use a series of graduated questions avoiding guesses about a specific method of inducing vomiting. This is all the more important with patients who can vomit 'at will' without resorting to mechanical aids. Thus, after having first confirmed that the

Bulimia nervosa

patient is prone to vomiting, the interviewer might enquire if the vomiting occurs especially after large meals or provides relief. If the last question is answered affirmatively, she might be asked whether the promise of relief sometimes leads her to encourage vomiting in some way. It will eventually be possible to question the patient directly about her customary method of inducing vomiting. (ii) Purgative abuse A close parallel was found between the abuse of purgatives and self-induced vomiting: they were both means of trying to get rid of food which the patient regretted having ingested. There were variations on this theme: one patient (14) enjoyed the sensation of a 'flat stomach' after having had a vigorous purge. Senokot was the most popular laxative among the patients of this series. Four patients took daily doses of 12-20 tablets (7-5 mg sennoside B per tablet), usually during the late evening. Nine patients also took large amounts but less often (e.g. 8-10 Senokot tablets every 2 weeks). These 13 patients were considered to be gross abusers of purgatives and are shown (P) in Table 1. Another 6 patients took only moderate doses of purgatives but so frequently that they too can be considered to have become excessively reliant on them. Three of the gross abusers (2, 8, 19) did not resort to vomiting. The remainder turned to purgatives when social circumstances precluded vomiting; they looked on them as a second-best attempt to interfere with the absorption of food.

(iii) Other methods of preventing weight gain Prolonged starvation between eating orgies was common. Less frequent means of trying to avoid the consequences of overeating were excessive exercise, the taking of amphetamine tablets or diuretics. Of these, excessive exercising was encountered to a striking degree in patients 2 (a male) and 28. Lesser degrees of exercising were probably common but not systematically enquired into. Patient 14 took 15 mg amphetamine daily for 5 years. Patient 22 misappropriated her mother's diuretic tablets.

437

Physical complications of self-induced vomiting or purging

In several patients, vomiting and purging were combined but it seemed that repeated vomiting was the more dangerous in causing complications. (i) Potassium depletion Twenty-four of the 30 patients had their serum levels of potassium estimated on at least one occasion. Thirteen of them were found to have low levels (3-6 mmol/1 or less); 3 patients had borderline levels (3-8 mmol/1). In the remaining 8 patients normal levels were recorded (above 3-8 mmol/1). (ii) Urinary infections and renal failure One patient (5) developed renal failure and hypertension after 8 years of self-induced vomiting and purging. A renal biopsy1 showed severe destruction of both glomerular and tubular units which was interpreted as due to chronic pyelonephritis. One year later she required intermittent haemodialysis, and was subsequently given a renal transplant. Her immediate postoperative progress was good and her weight rose from 35 kg to 40 kg, but she still had occasional bouts of vomiting. Three patients in the series required treatment for urinary infections. Four patients were found to have low creatinine clearances on at least two tests, the cause of which was uncertain; in 3 it may have been due to a low body weight rather than impaired renal function. (iii) Epileptic seizures Both male patients and 2 of the female patients (23 and 25) had suffered from attacks of unconsciousness accompanied by tonic and clonic convulsions. The frequency of these attacks was low. Electroencephalograms on these patients seldom showed frank epileptic discharges, but poorly formed alpha rhythm, small sharp waves and irregular theta components were reported. (iv) Tetany In addition to the patient with renal failure, one patient (7) reported attacks of carpo-pedal spasm and acroparasthesiae. She was found to have a low serum potassium (2-2 mmol/1) and 1 While under the care of Dr J. P. Bingle, The County Hospital, York.

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an elevated serum bicarbonate (42 mmol/1), but a normal serum calcium.

weights of the patients with true anorexia nervosa ranged from 25-2 to 51 kg.

(v) Swollen salivary glands One patient showed a painless chronic swelling of all her salivary glands. She reported that the swellings subsided when she could bring the vomiting under control.

Psychopathology The principal abnormalities in the patients' mental state, revealed at the height of the illness, will now be considered.

(vi) Loss of weight Loss of weight is another complication of the patient's repeated vomiting and abuse of purgatives. It may also result from food avoidance in between the bouts of overeating. An individual patient's weight will be the resultant of these variables - food avoidance, overeating and vomiting (or purging, or exercising). Clinical observation suggests that the balance between these factors was highly variable, some patients being underweight as in true anorexia nervosa, others having a normal or even excessive weight. This series of bulimic patients was compared with the control group of patients with true anorexia nervosa. The mean weight of the 28 female patients with bulimia nervosa was 49-03 kg (S.D. ±9-89 kg). The mean weight of the 29 control patients with true anorexia nervosa was 37-8 kg (S.D. ±5-18 kg). This difference in weight between the two series was highly significant statistically (P < 0-005). Fig. 2 shows the distribution of the weights of the two series of patients with an overlap in the middle range. The weights of the bulimic patients ranged from 33-6 to 73 kg: 11 of them weighed 50 kg or more. The

(i) Preoccupations with food Several patients were distressed by almost constant thoughts about food. Patient 20 was a university student who was keen to perform well in her examinations. At the height of her eating disorder she was due to sit two examinations on the same day. During the morning examination she could not concentrate on the question paper because she kept on thinking about having lunch with a friend who had prevailed on her to accept this invitation. During the afternoon examination she felt she could not do justice to the paper because her thoughts wandered back to the meal and its possible fattening effects. (ii) Preoccupation with weight and body size It has already been shown that the patients resorted to vomiting, purgation or exercise in an attempt to counteract the dreaded fattening effects of ingested food, especially after a bout of overeating. The preoccupations with body size and fatness consisted of overvalued ideas rather than obsessional ruminations, for the patients usually remained convinced of the danger and odiousness of fatness.

10987654c

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o 6

1

Weight groupings (kg) FIG. 2. Distribution curves of weights of patients with bulimia nervosa and control patients with anorexia nervosa. The dark area represents the number of patients whose weights overlap. QH, Number of anorexic patients in each weight group; § , number of bulimic patients in each weight group.

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Xc 'Healthy' 1 weight

FIG. 3. Schematic representation of variations in the weights of patients with bulimia nervosa in the course of the disorder (see text).

(a) Variations in weight during the course of the illness. The patients could recall variations in their body weight over the passage of years, and referred to these weights when expressing their ideas of fatness and normality. In discussions with patients suffering from anorexia nervosa it is advisable to equate 'normal' with 'healthy' body weight, rather than refer to tables of weights based on statistical averages or actuarial norms. These tables do not take into account the wide range of individual variation of height, body build and constitution. It is preferable, therefore, to identify the 'healthy weight' of an individual patient as her weight during her early 'teens, when she was still in good health and unconcerned with dieting and weight. It was possible to elicit the 'healthy' weight during history-taking in 28 of the 30 patients, and the levels are shown in Table 1. Fig. 3 illustrates schematically the variations in the patients' weights over the course of their feeding disorder. 1 is the 'healthy' weight as defined above; 2 is the change in weight at the onset of the feeding disorder. In a there is an early weight gain followed by a sharp fall in weight. In b there is a weight loss from the very onset. In the present series, 11 patients followed course a and 19 course b. 3 represents the patient's lowest weight, a loss of weight having occurred in all but one (no. 6) of the patients; 4 indicates the return to a more normal weight with the passage of months or years. In c the patient exceeds her premorbid 'healthy' weight.

In d her weight remains below the 'healthy' level. In the present series, 8 patients followed course c and 20 course d (2 patients returned to their 'healthy'weight). 5 is the time when the patient seeks treatment for the episodes of overeating (and vomiting/or purgation), sometimes several years after the onset of the eating disorder. In e the patient's weight is well above the premorbid 'healthy' weight. In / the patient's weight remains below her 'healthy' weight. Only 4 patients in this series followed course 5e (one of whom (patient 8) had earlier suffered from typical anorexia nervosa; the other three (6, 22, 27) were considered not to have had anorexia nervosa). Two patients had weights close to their 'healthy' weights. The majority of patients (24 out of 30) were still underweight when they presented themselves for treatment (5/), but weighed more than at the earlier trough in their weight chart. Table 1 shows the patients' weights at these different stages: 'healthy' weights (column A), minimum weights (B) and weights when seeking treatment for overeating and vomiting (or purgation) (C). (b) Discrepancy between 'healthy' weight and desired weight. It was informative to elicit the patient's view of her desired weight. She expressed it usually in terms of a ceiling weight which she would be reluctant to exceed. An appropriate way of posing the question is to ask' If I advised you to put on some weight, what weight would you be willing to reach?' A clear answer, usually

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expressed in stones and pounds, was obtained from 25 patients. Five other patients declared themselves in other ways, either by refusing to cooperate further with treatment once they reached the weight which they had set themselves, or by self-deprecatory statements such as ' I feel obscene, my thighs are too fat.' A measure of each patient's reluctance to return to a healthy weight is provided by comparing her desired weight (column D in Table 1) with her premorbid 'healthy' weight (column A). In only 3 of the 24 patients in whom the comparison was possible was the desired weight the same as the 'healthy' weight. In the remaining 21 patients, the desired weight was significantly lower than the 'healthy' weight, the discrepancy ranging from 1 to 18 kg, with a mean of 6-2 kg. No patient was willing to exceed her premorbid 'healthy' weight. Even more impressive than these data was the strength of feeling expressed by patients when they were urged to consider returning to their original weight. This is all the more remarkable when it is remembered that the mean premorbid weight for the 28 female patients was only 55-1 kg (121-2 lb), and that they had all suffered much as a result of their illness. The arguments put forward by patient 29 in terms of her femininity and her attractiveness were perhaps the most colourful, but not the most intense. Patient 20 remarked: 'If I can see my ribs it makes me feel happier.' When patient 21 reached 55 kg, she said that her stomach constantly felt too fat. For patient 24 'to be thin means I feel more attractive and cleaner. I have more energy and I feel happy; if I gain weight, I feel ashamed.' (c) Poor response to admission to hospital. Additional proof of the patients' determination to defend their thinness was provided by their relatively poor response to hospital treatment aimed at encouraging weight gain. (The reverse policy was adopted with patient 8 who was moderately obese.) Table 1 shows that 7 out of the 12 patients admitted for weight gain did succeed in gaining weight ranging from 9 to 19-7 kg; the weight of one patient remained virtually the same (26); 4 patients actually lost weight (3, 4, 16, 29). These last results are to be contrasted with the marked gains in weight that are predictable when patients with typical

anorexia nervosa are treated with appropriate nursing measures (Russell, 1977 a). (iii) Depression Next to the preoccupations directly concerned with eating and weight, depressive symptoms were the most prominent feature of the patients' mental state. Although these symptoms were often severe, they could seldom be considered part of an 'endogenous' depressive illness. This was due to the rarity of symptoms usually considered characteristic of 'endogenous' depression, e.g. psychomotor retardation, diurnal variation of mood, ideas of self-blame, or general impairment of daily activities. The patients had usually coped with their work and their domestic responsibilities, albeit in a somewhat restricted manner. Their outward appearance usually failed to portray the severe misery they described. Thus, depressive features consisted mainly of subjective feelings of gloom and recurrent suicidal thoughts. Impaired mental concentration was reported especially by patients who were required to study. Marked irritability was often present and expressed towards friends or relatives who would find the patient difficult to live with. Eleven patients had made at least one suicidal attempt. In the case of 5 of them the suicidal attempt was serious, and one succeeded in killing herself. A second patient died after returning to her country of origin, as the result of crashing the car she was driving. Further enquiries failed to clarify whether this death was suicidal or accidental. The frequency and severity of depressive symptoms are best summarized by means of a simple 3-point clinical scale. The assessment covered the whole duration of the eating disorder since its onset, and was not necessarily confined to the examination of the current mental state. The 30 patients were divided into the following groups as regards their depressive symptoms: Grade 1. No severe or sustained symptoms of depression: 4 patients. Grade 2. One or more of the following: complaints of severe and persistent gloom with suicidal ideas, minor suicidal acts, marked irritability, severe impairment of concentration: 13 patients.

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Grade 3. One or more of the following: severe depressive symptoms leading to inability to work or cope with daily activities, a previous course of electro-convulsive treatment, a serious suicidal act: 13 patients. Thus, few of the patients escaped depressive symptoms of at least moderate severity, which contributed in large measure to the distress they had experienced in the course of their protracted illness. On the other hand, it did not appear that the patients had a primary depressive illness of which the eating disorder was a secondary manifestation. Treatment with antidepressants or electro-convulsive therapy was effective in relieving depressive symptoms in 7 patients, but in no case was there relief of the urge to overeat or induce vomiting. (iv) Hysterical features The curious phenomenon of self-induced vomiting often elicits the term 'hysterical' to qualify the patient's behaviour, her attitudes, or the disorder itself. This may be because the patient adopts a mode of behaviour that carries obvious detrimental effects, and because she attempts to veil it with secrecy. But the secrecy is mainly to conceal the embarrassment of a habit that she finds disgusting. She knows, moreover, that to reveal it would lead to relatives' censure. It has been remarked that the patient is often prepared to discuss freely the self-induced vomiting with her general practitioner or psychiatrist. This behaviour therefore differs from the dissimulation found in dermatitis artefacta, or the sick role assumed by patients with conversion hysteria or dissociative states. In any case, the self-induced vomiting is merely the method used by the patient to protect herself against the effects of overeating. In the present series of patients conversion hysteria or dissociative states had occurred in only 2 patients. Patient 25 was found in the course of a physical examination to have a glove and stocking anaesthesia of all 4 limbs which may have been suggested unwittingly by the examining doctor. It disappeared within a few days. Patient 20 was described as having entered into a trance-like state after a bout of overeating: she had walked into the garden on a cold May night and sat on a bench for 2 hours barefoot and clad only in her night attire. When

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discovered by her parents she said ' I was not aware of what was going on.' She had 2 further episodes of a similar nature before being referred for treatment. In view of the rarity of those manifestations most appropriately recognized as hysterical, it would appear that there are no strong grounds for generally invoking hysterical mechanisms in the genesis of the disorder under discussion. Nevertheless, a proportion of the patients betrayed minor dissociative mechanisms. They would show an evasion or a denial of the significance of their acts. This was elicited principally in relation to the episodes of overeating or self-induced vomiting. Patient 8 would say she was hardly aware of eating the large amounts of food which she subsequently estimated as totalling 15000-20000 calories. Patient 29 described the self-induced vomiting as a habit which she hardly noticed - as if it had become a routine. A similar mechanism might be invoked for the patients' common denial that their overeating was prompted by severe hunger: patient 8 petulantly protested against taking an appetitesuppressant because she declared that she never felt hungry. It has been said that hysterical disorders represent the adoption of a sick role to escape from situations that patients find intolerable (Kendell, 1974). Evidence of such a mechanism was found in 2 patients who were facing stressful examinations, and who succeeded in avoiding them by engineering their admission to hospital. But the majority of patients appeared to struggle valiantly in trying, for example, to remain at work in spite of distressing depression or tiredness. Indeed, they gave the impression to their doctors, nurses and relatives of a great deal of personal suffering. Premorbid personality

No attempt was made in this study to investigate systematically the patients' premorbid personality. This task would have been rendered particularly difficult by the inextricable merging of personality traits with the symptoms and disturbances caused by the illness, especially when its onset was in early adolescence before full maturation of the personality. The assessment of premorbid personality was a clinical one, based on informants' reports (parents and/or spouses as appropriate). Bearing in mind these limitations,

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the premorbid personality was considered to be 'normal' in 8 out of the 30 patients and to show definite deviations from normal in 8 patients. In the remaining patients, at least minor disturbances were elicited which were considered possibly to have contributed to the subsequent illness or coloured its manifestations. The following abnormal traits appeared to occur with relative frequency: anxiety, especially in social relationships or with school work (8 patients); depression (4 patients); difficult personal relationships with parents or at school (9 patients); marked dependence on parents (4 parents); antisocial behaviour such as abusing drugs, stealing or promiscuity (4 patients). There was no regularity in the way these abnormal traits were clustered, so that no characteristic type of personality could be said to have preceded the illness. On the positive side, it is noteworthy that the group as a whole showed a high level of achievement scholastically and occupationally. Fourteen out of the 30 patients obtained at least one pass at the GCE A-level examination or its equivalent, and had embarked upon or completed courses of higher education. The series included 2 qualified doctors, 1 medical student, 2 teachers and 2 nurses. Five patients were exceptions and had a record of irregular employment that could not simply be attributed to their illness. Menstruation, sexual adjustment and fertility

Menstruation One patient (4) had been noted to menstruate regularly when she weighed only 40 kg. She remained sexually active and had even conceived when she weighed 47 kg. These and other observations suggested that patients with episodic overeating and vomiting might not become amenorrhoeic as constantly as patients with true anorexia nervosa. This question was examined for the series as a whole by comparing the mean weights of the patients whose periods had persisted up to the time they sought treatment with those who had become amenorrhoeic. Among the 28 female patients, 11 had amenorrhoea and their mean weight was 41-1 kg. In 4 patients menstrual function was difficult to assess for it may have been maintained artificially by taking an oral contraceptive; their mean weight was 52-4 kg. The remaining 13 patients had continued to menstruate spontaneously; their mean weight was 54-8 kg. This mean weight is admittedly

near normal, but among this group were 4 patients (12, 14, 19, 23) who were still menstruating regularly in spite of weighing only 45, 43, 46 and 46 kg respectively. Sexual adjustment Ten of the 28 female patients were married. Four of them had precarious marriages or were actually separated from their husbands. In the other 6 marriages the husbands showed remarkable tolerance towards their wives' peculiar eating habits. Twenty-three of the 30 patients were sexually experienced, including both male patients. Among the 21 female patients, 14 reported achieving satisfactory sexual relationships including orgasm - a surprisingly good adjustment. The level of sexual experience was extremely limited in 4 patients including both males: one explained that she was much more interested in food than in boyfriends. Two of the married women had lost their capacity for orgasm after the onset of the eating disorder. The absence of sexual experience in 7 patients might be attributable to their youth, but there was some evidence of undue apprehension at coming into contact with the opposite sex. Fertility Nine patients had conceived, but in the case of 4 of them the pregnancies had occurred before the onset of their eating disorder. Three of these 4 patients had allowed their pregnancies to go to term: one had had 3 children; another had had 2 children and 1 miscarriage. These last 2 patients had been sterilized after their last pregnancy, and their eating disorder started soon after. Five patients had conceived in spite of already being prone to frequent bouts of overeating and self-induced vomiting. Two of them were undergoing treatment and ceased to vomit or abuse purgatives; their pregnancies were successfully brought to term. One patient had her child without any special treatment for the eating disorder. The remaining 2 patients had their pregnancies terminated. The 10 married patients' attitudes to the prospect of future pregnancies were elicited and in 7 of them they were strongly negative. Indeed, 2 of them had been sterilized, as previously mentioned. In spite of having been sterilized, one experienced for several months recurring terrifying nightmares of having become pregnant. A third patient who suffered from

Bulimia nervosa

intense fear that she might become pregnant had requested sterilization but it was refused as she was only 17 years old. One patient had adopted 2 children, largely to satisfy her husband. Among the reasons given by patients who were adamant that they did not want children might be quoted the following two: ' I am a woman's lib., career-type woman', and 'women have the right to withhold their maternal instincts'. DISCUSSION The basis for the selection of patients in the present study was two-fold. First, they were victims of powerful and irresistible urges to overeat, to which they reacted by inducing vomiting or abusing purgatives, or both. Secondly, they were morbidly fearful of becoming fat. It was found that this fear expressed itself most clearly in a grim determination to maintain their body weight below a specific level they had set themselves. The other features of typical anorexia nervosa, marked loss of weight and amenorrhoea, might or might not have been present: they were not requirements for inclusion in this study. Previous investigators have been struck by the frequency of occurrence of self-induced vomiting and purging in anorexia nervosa (Crisp etalA 977; Hsu, 1978). It has also been proposed by some authors that anorexia nervosa might be considered as consisting of two different clinical forms according to whether the presenting symptom was abstinence of food or self-induced vomiting (Beumont et al. 1976). Bouts of overeating have been identified in the course of anorexia nervosa by most clinicians, and Dally (1969) suggested that they usually occurred in patients with obsessional personalities, this combination carrying a more favourable prognosis. But the close relationship between bulimia, on the one hand, and vomiting or purging, on the other, has not previously been stressed. Beumont et al, whose patients were primarily selected as satisfying the 3 diagnostic criteria of anorexia nervosa, did find a higher incidence of overeating in the group of patients they termed 'vomiters and purgers' in comparison with their 'dieters'. But, in contrast with the present study, the occurrence of bulimic episodes was not the basis for the selection of their patients. Nevertheless, their study is the one which invites the most immediate comparison with the present

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findings, and will be returned to later in this article. The psychological aspects of overeating, vomiting and purging as found in the present study, will now be summarized. Overeating was often associated with obtrusive preoccupations about food. Patients tended to deny that overeating was due to hunger and the descriptions of their rapid and grotesque eating orgies were more in keeping with a failure to achieve normal satiety. Overeating could at times be interpreted as meeting an unfulfilled emotional need. The frequency of the bouts of overeating was often influenced by opportunities for privacy, particular social settings and a tendency for repetition once the patient had succumbed to the first orgy. But it must be said that the social settings were often contrived by the patient herself, in order to facilitate the overeating and the vomiting. Vomiting soon followed overeating and formed part of an established pattern, the venue being carefully selected so as to allow the patient to vomit when she wished. Vomiting and purging were methods adopted by the patients to prevent the fattening effects of the ingested food because of the second feature of the disorder - an overvalued idea that it is essential to keep below a self-imposed and specific weight threshold. To exceed this weight would be odious and reprehensible. The series of patients, taken as a whole, weighed more than a comparable series of patients with typical anorexia nervosa. At first glance several of the patients appeared reasonably well-covered and had unexceptional weights. A closer examination of the course of each patient's weight history, however, revealed that they were nearly all struggling to maintain a weight at a level significantly below that which had prevailed before the onset of ill-health, a level which has been defined as the 'healthy' weight,even though it sometimes amounted to a slight degree of obesity. This observation, together with the resolve to keep below a self-imposed weight threshold, indicates a sharp discrepancy between the weight desired by the patient and that which appears to be determined by her earlier constitution. On average, this difference amounted to over 6 kg. It may be this discrepancy that triggers off physiological responses which find expression in the powerful urges to overeat. It is clearly the patient's refusal to accept her constitutional weight that leads her to counteract the eating

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orgies by means of vomiting or purging or both. The term 'bulimia' has been chosen to do justice to the bouts of gross overeating which constitute the central clinical feature from which many of the other clinical phenomena are derived. The alternative term, 'compulsive eating', does not commend itself, for it leads to the faulty interpretation that the disorder is obsessional in nature or that the patients are usually overweight. Although self-induced vomiting and purging are secondary features of the disorder described, they become ingrained habits and result in dangerous complications. The patients report that, with repeated practice, the act of vomiting becomes effortless and it is likely therefore that the upper alimentary tract undergoes adaptive changes. Three patients in the present series resorted to purgatives rather than vomiting, but over half the patients combined the two. The abuse of anthracene purgatives carries the risk of injuring the myenteric plexuses in the gut wall (Smith, 1968) with consequent permanent loss of normal bowel reactivity (Avery Jones & Godding, 1973). Both vomiting and purging lead to losses of body fluid and electrolytes, of which hypokalaemia is the commonest result. Of the two habits, vomiting is the more harmful from this point of view. Multiple routes of electrolyte loss have been shown to lead to an increase in the secretion rate of aldosterone with a worsening of potassium depletion (Wolff et al. 1968). Hypokalaemia may give rise to vacuolar degeneration of the renal tubules (Wigley, 1960), urinary infection and impaired renal function. This may account for the urinary infection and reduced glomerular filtration rates in some of the patients studied, and renal failure in one of them. The epileptic seizures experienced by 4 of the patients were probably also due to the electrolyte disturbance as previously proposed by Crisp et al. (1968). Rarer complications of self-induced vomiting are tetany due to alkalosis found in one patient, and chronically swollen salivary glands in another. Psychiatric disturbances also constitute important aspects of the disorder studied. Of these, depressive symptoms were the most distressing and potentially dangerous. The depression did not resemble 'endogenous' depression, for the

patients appeared to cope with their day-to-day responsibilities, but it was nevertheless found to be treacherous as regards the risk of suicide. Depressive symptoms tended to parallel the overall severity of the eating disorder, but also tended to fluctuate with changes in personal relationships which often deteriorated as a result of the patients' altered way of life. The relief provided by antidepressant medication tended to be confined to the depressive symptoms. It is thus unlikely that a primary depressive illness could account for the disorder of bulimia nervosa. Hysterical dissociative mechanisms were detected in several patients. They can be interpreted as a method of coping in patients inclined to such devices by the nature of their personality structure. Indeed, a wide variety of abnormal personality traits were found in the majority of patients. It must be conceded, however, that in a minority of the patients studied there was a reasonably good level of personal adjustment before the onset of the eating disorder. The disorder of bulimia nervosa invites comparison with true anorexia nervosa. The majority of the patients studied had experienced a previous typical episode of the illness. In many this episode had been severe and prolonged; in others the weight loss had been slight and the amenorrhoea transient, so that they can be considered to have gone through a cryptic form of anorexia nervosa. Bulimia nervosa may therefore be viewed as an aftermath or chronic phase of anorexia nervosa. As regards the clinical resemblances between the two disorders, the basic psychopathology is similar. The patients reported expressed the same morbid fear of fatness as patients with true anorexia nervosa. Whereas anorexic patients are capable of starving themselves, bulimic patients can only resist eating for so long before succumbing to a bout of overeating. Bulimic patients may be said to exemplify the worst fears of the anorexic patients come true. In both disorders body weight is reduced below the optimum level. In anorexia nervosa the loss of weight is extreme, to the point of severe emaciation. In bulimia nervosa the reduction in weight is less severe: some patients are indeed thin, but others are of average or even apparently elevated weight. The two disorders also differ as regards the frequency of amenorrhoea, the level of sexual activity and the preservation of fertility. The diagnosis of

Bulimia nervosa

true anorexia nervosa requires that menstruation ceases and fertility be suspended. Most anorexic patients show an arrest or loss of sexual activity. In contrast, several of the patients in this study continued to menstruate regularly, even at relatively low weights, although amenorrhoea became more likely as weight was reduced. Their level of sexual activity was also often surprisingly good. These differences are in keeping with the distinction found by Beumont et al. (1976, 1980) between their groups of ' vomiters and purgers' and 'dieters'. Finally, 2 of the patients studied became pregnant while receiving treatment, indicating that, in contrast with anorexia nervosa, fertility may be preserved during the course of bulimia nervosa. Out of the 30 patients included in the present study, 6 had no history of preceding anorexia nervosa. This observation leaves open the possibility that bulimia nervosa may be a disturbance reached through a number of different pathways. Indeed, the preponderance of patients with previous episodes of anorexia nervosa may reflect a bias in patient self-selection, the Royal Free Hospital having become known as a centre specializing in the treatment of anorexia nervosa. A. J. Stunkard has suggested (personal communication) that overeating and self-induced vomiting may be a common practice among otherwise normal young female students of American universities. This observation requires amplification, but it is possible that future studies from other centres may reveal a greater proportion of patients in whom bulimia nervosa arises without antecedent anorexia nervosa. It is appropriate to anticipate a question which psychiatrists have a disconcerting tendency to ask whenever it is proposed that a constellation of symptoms and disturbances of behaviour might have diagnostic value. Does bulimia nervosa constitute a separate 'syndrome'? The question itself is ambiguous unless the term 'syndrome' is defined; all too often it remains unclear whether the term refers simply to a set of intertwined symptoms or goes further and carries implications as regards aetiology. Kendell (1975) has pointed out that 'the defining characteristic of every non-organic psychiatric diagnosis is simply its syndrome, the constellation of symptoms and signs typically associated with that diagnosis'. In this narrower sense, bulimia nervosa may be thought of as a syndrome, no

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claim whatever being made about its possible cause or causes, which remain largely unknown. There are far more important aspects to the diagnosis of bulimia nervosa than mere concern about its status within systems of classification. First, it is important to set out clear diagnostic criteria which enable other clinicians and researchers to identify the disorder with consistency. The criteria which should all be satisfied in bulimia nervosa are that: (1) the patients suffer from powerful and intractible urges to overeat; (2) they seek to avoid the 'fattening' effects of food by inducing vomiting or abusing purgatives or both; (3) they have a morbid fear of becoming fat. The last criterion is shared with uncomplicated anorexia nervosa. The boundary between bulimia nervosa and anorexia nervosa has already been delineated. As previously indicated, most of the patients described in this article went through an earlier phase of anorexia nervosa. Future investigators may report patients who overeat and induce vomiting or purging without having followed this pathway: they may have been of excessive weight or average weight. They too might be considered as suffering from bulimia nervosa so long as they satisfy all 3 essential criteria. The second important aspect of the diagnosis of bulimia nervosa in patients with the characteristic constellation of symptoms and behavioural disturbances is that there would follow vital clinical consequences such as the risk of secondary metabolic complications and the danger of depressive suicide. The implications as regards treatment and prognosis are crucial, and will be further discussed later. This part of the discussion on bulimia nervosa will be concluded speculatively. Fig. 4 is an attempt to represent the complex interactions which exist between the psychological disorder, the loss of weight and the disturbances of eating behaviour. Inevitably such a representation runs the risk of over-simplification. The thickness of the lines in the diagram reflects the strength of the evidence favouring each interaction. Two principal mechanisms are postulated: a mental disorder which is incontrovertible, and a hypothalamic disorder which is more questionable. Firmly established are the pathways that attribute to the psychological disorder the reduced

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Psychological mechanisms

Mental disorder

Rejection of a healthy weight

Self-induced vomiting &/or purging

Hypothalamic disorder

I Amenorrhoca [—•