LETtERS
TO THE
EDITOR
Dr.
REFERENCES 1. Cruzan v Harmon, 2.
Steinbock
760 SW 2d 408, 416-417
B: Recovery
ofCarrie
Coons.
from
Hastings
persistent
Cent
(Mo
vegetative
Rep 1989;
1988) state?
the
case
19(4):14-1S
DAVID
E. RASKIN, Wilmington,
M.D. Del.
of the Term
“Bulimia”
SIR: Albert Stunkard, M.D., presented the translation of a description of bulimic patients by M. Wulff in 1932 (1) and, referring also to earlier case descriptions, argued for the histonical continuity of “bulimia.” Although the reconstruction of the historical development of syndromes suffers from haying a weak database, it is nevertheless a possible and menitorious argument. My comment concerns the meaning of the term “bulimia,” an issue that Dr. Stunkard did not directly address. If bulimia is to
mean
some
form
of neurotic,
impulsive
overeating,
then
the assumption of historical continuity is plausible. Used in this sense, bulimia was described up to the end of the nineteenth century, usually grouped together with polyphagia, pica, and anorexia (i.e., loss of appetite) as disorders of the appetite; they are present in a large portion of books on internal medicine, especially on gastrointestinal disorders (2). If, in contrast, bulimia is to include cognitions related to body weight and practices such as self-induced vomiting, dieting, etc., as has been the tendency in the 1980s, then it must be considered
of bulimia in history
as
a new
nervosa (one
patient
syndrome,
must
and
be considered feared
becoming
Wulff’s
case
as almost overweight,
the
of eating disorders in 1932. Am J Psychiatry 1990; 147:263-268 2. Ziolko HU, Schrader HC: Bulimie. Fortschr Neurol Psychiatr 1985; 53:23 1-258 3. Habermas T: The psychiatric history of anorexia nervosa and bulimia nervosa: weight concerns and bulimic symptoms in early case reports. Int J Eating Disorders 1989; 3:259-273 4. Habermas T: Heif?hunger: Historische Bedingungen der Bulimia nervosa. Frankfurt, Germany, Fischer, 1990
1274
the
more
restricted
meaning
associated
with
ALBERT
J. STUNKARD, Philadelphia,
M.D. Pa.
two
REFERENCES
HABERMAS,
and
earliest and
A: A description
DR. TILMANN
eating
“bulimia nenvosa,” which has been closely associated with concerns about body image. His writings provide strong cvidence that although bulimia as bouts of impulsive (binge) eating appears to have a long history, bulimia as binge eating with associated body image disturbance and purging behavior is of relatively recent origin. As he suggests, the 1932 paper by Wulff that appeared in translation may well be the first description of this latter disorder. Recent developments have provided gratifying confirmation of Dr. Habermas’s emphasis on the plasticity and changing combinations of neurotic symptoms. For a number of years, binge eating has been considered in the medical litematune primarily as a component of bulimia nervosa, in association with disturbed body image and purging. It now appears that binge eating together with body image concerns, but without purging, constitutes a clearly defined clinical entity, with a prevalence as high as 20%-46% ofobese persons. A descniption of this new syn&ome should appear shortly (manuscript on binge eating disorder by R.L. Spitzem et al., submitted for publication).
description
were ashamed of their bodies), since in all other cases referred to by Dr. Stunkard the patients lacked the fear oF being or becoming overweight, with the exception, of course, of Janet’s one anorexic patient. Historically, in fact, among patients with eating disorders, the fear of being overweight first emerged in the context of anorexia nervosa (3, 4). The history of bulimia, I would suggest, forces us to acknowledge the plasticity of neurotic symptoms and the histonical relativity of attempts to define “syndromes” in a precise manner. Today the symptom of bulimia, on impulsive overeating, usually is organized around the cognition of being relatively overweight, but there are still many cases of patients with the symptom of bulimia that fall into the category of atypical eating disorders. To sum up, I wish to add to Dr. Stunkard’s contribution a concern for historically changing combinations of symptoms, which results in considering the symptom of bulimia (overeating) as very old, but makes it clean that weight-related fears, typical for modern bulimia ncrvosa (and anorexia nervosa), are distinctly modern.
1. Stunkard
Replies
SIR: I am indebted to Dr. Habermas for his comments on my article, for his scholarly historical review of the concept of bulimia nenvosa, and for his paper (his reference 3), which will be more accessible to non-German-speaking audiences. Dr. Habermas correctly distinguishes between bulimia as bouts of binge
Meaning
Stunkard
DIPL.PSYCH. Berlin, Germany
Dissociative
Experiences
and
Eating
Disorders
SIR: We read with interest the findings in the article “Relation ofClinical Variables to Dissociative Phenomena in Eating Disorders” by Mark A. Demitrack, M.D., and associates (1). In a similar study of the relation between dissociative expeniences and eating disorders (2), we compared the Dissociative Experiences Scale scores of 25 women with eating disorders to those of a group of 25 age-matched women. Our findings support those reported by Dr. Demitrack and associates that subjects with eating disorders had significantly higher scores. The mean total scale scone was 17.8 for the group with eating disorders and 3.7 for the comparison group (Dr. Demitrack and associates reported mean total scale scores of 16.7 and 6.4, respectively). As in the study by Dr. Demitmack and colleagues, our grgup with eating disorders reported a significantly higher rate of self-mutilation and shoplifting. We were particularly interested in Dr. Demitrack and associates’ discussion of the possible relation of eating disorders and dissociation to childhood sexual abuse. In our study, we investigated the prevalence of childhood sexual abuse in the subjects with eating disorders and in the comparison subjects. The subjects with eating disorders had a significantly higher rate. Furthermore, we categorized the data by the type of sexual abuse, i.e., sexual abuse restricted to touching, oral intercourse, or genital intercourse. The subjects with eating disordens reported significantly higher rates of childhood sexual abuse involving both oral intercourse and genital intercourse. However, there was no statistically significant difference between these subjects and the comparison subjects in reported rates of sexual abuse restricted to touching. These findings suggest that the subjects with eating disorders experienced more severe forms of childhood sexual abuse than did the comparison subjects.
Am
J
Psychiatry
1 48:9,
September
1991
TO THE
EDITOR
Dr.
REFERENCES 1. Cruzan v Harmon, 2.
Steinbock
760 SW 2d 408, 416-417
B: Recovery
ofCarrie
Coons.
from
Hastings
persistent
Cent
(Mo
vegetative
Rep 1989;
1988) state?
the
case
19(4):14-1S
DAVID
E. RASKIN, Wilmington,
M.D. Del.
of the Term
“Bulimia”
SIR: Albert Stunkard, M.D., presented the translation of a description of bulimic patients by M. Wulff in 1932 (1) and, referring also to earlier case descriptions, argued for the histonical continuity of “bulimia.” Although the reconstruction of the historical development of syndromes suffers from haying a weak database, it is nevertheless a possible and menitorious argument. My comment concerns the meaning of the term “bulimia,” an issue that Dr. Stunkard did not directly address. If bulimia is to
mean
some
form
of neurotic,
impulsive
overeating,
then
the assumption of historical continuity is plausible. Used in this sense, bulimia was described up to the end of the nineteenth century, usually grouped together with polyphagia, pica, and anorexia (i.e., loss of appetite) as disorders of the appetite; they are present in a large portion of books on internal medicine, especially on gastrointestinal disorders (2). If, in contrast, bulimia is to include cognitions related to body weight and practices such as self-induced vomiting, dieting, etc., as has been the tendency in the 1980s, then it must be considered
of bulimia in history
as
a new
nervosa (one
patient
syndrome,
must
and
be considered feared
becoming
Wulff’s
case
as almost overweight,
the
of eating disorders in 1932. Am J Psychiatry 1990; 147:263-268 2. Ziolko HU, Schrader HC: Bulimie. Fortschr Neurol Psychiatr 1985; 53:23 1-258 3. Habermas T: The psychiatric history of anorexia nervosa and bulimia nervosa: weight concerns and bulimic symptoms in early case reports. Int J Eating Disorders 1989; 3:259-273 4. Habermas T: Heif?hunger: Historische Bedingungen der Bulimia nervosa. Frankfurt, Germany, Fischer, 1990
1274
the
more
restricted
meaning
associated
with
ALBERT
J. STUNKARD, Philadelphia,
M.D. Pa.
two
REFERENCES
HABERMAS,
and
earliest and
A: A description
DR. TILMANN
eating
“bulimia nenvosa,” which has been closely associated with concerns about body image. His writings provide strong cvidence that although bulimia as bouts of impulsive (binge) eating appears to have a long history, bulimia as binge eating with associated body image disturbance and purging behavior is of relatively recent origin. As he suggests, the 1932 paper by Wulff that appeared in translation may well be the first description of this latter disorder. Recent developments have provided gratifying confirmation of Dr. Habermas’s emphasis on the plasticity and changing combinations of neurotic symptoms. For a number of years, binge eating has been considered in the medical litematune primarily as a component of bulimia nervosa, in association with disturbed body image and purging. It now appears that binge eating together with body image concerns, but without purging, constitutes a clearly defined clinical entity, with a prevalence as high as 20%-46% ofobese persons. A descniption of this new syn&ome should appear shortly (manuscript on binge eating disorder by R.L. Spitzem et al., submitted for publication).
description
were ashamed of their bodies), since in all other cases referred to by Dr. Stunkard the patients lacked the fear oF being or becoming overweight, with the exception, of course, of Janet’s one anorexic patient. Historically, in fact, among patients with eating disorders, the fear of being overweight first emerged in the context of anorexia nervosa (3, 4). The history of bulimia, I would suggest, forces us to acknowledge the plasticity of neurotic symptoms and the histonical relativity of attempts to define “syndromes” in a precise manner. Today the symptom of bulimia, on impulsive overeating, usually is organized around the cognition of being relatively overweight, but there are still many cases of patients with the symptom of bulimia that fall into the category of atypical eating disorders. To sum up, I wish to add to Dr. Stunkard’s contribution a concern for historically changing combinations of symptoms, which results in considering the symptom of bulimia (overeating) as very old, but makes it clean that weight-related fears, typical for modern bulimia ncrvosa (and anorexia nervosa), are distinctly modern.
1. Stunkard
Replies
SIR: I am indebted to Dr. Habermas for his comments on my article, for his scholarly historical review of the concept of bulimia nenvosa, and for his paper (his reference 3), which will be more accessible to non-German-speaking audiences. Dr. Habermas correctly distinguishes between bulimia as bouts of binge
Meaning
Stunkard
DIPL.PSYCH. Berlin, Germany
Dissociative
Experiences
and
Eating
Disorders
SIR: We read with interest the findings in the article “Relation ofClinical Variables to Dissociative Phenomena in Eating Disorders” by Mark A. Demitrack, M.D., and associates (1). In a similar study of the relation between dissociative expeniences and eating disorders (2), we compared the Dissociative Experiences Scale scores of 25 women with eating disorders to those of a group of 25 age-matched women. Our findings support those reported by Dr. Demitrack and associates that subjects with eating disorders had significantly higher scores. The mean total scale scone was 17.8 for the group with eating disorders and 3.7 for the comparison group (Dr. Demitrack and associates reported mean total scale scores of 16.7 and 6.4, respectively). As in the study by Dr. Demitmack and colleagues, our grgup with eating disorders reported a significantly higher rate of self-mutilation and shoplifting. We were particularly interested in Dr. Demitrack and associates’ discussion of the possible relation of eating disorders and dissociation to childhood sexual abuse. In our study, we investigated the prevalence of childhood sexual abuse in the subjects with eating disorders and in the comparison subjects. The subjects with eating disorders had a significantly higher rate. Furthermore, we categorized the data by the type of sexual abuse, i.e., sexual abuse restricted to touching, oral intercourse, or genital intercourse. The subjects with eating disordens reported significantly higher rates of childhood sexual abuse involving both oral intercourse and genital intercourse. However, there was no statistically significant difference between these subjects and the comparison subjects in reported rates of sexual abuse restricted to touching. These findings suggest that the subjects with eating disorders experienced more severe forms of childhood sexual abuse than did the comparison subjects.
Am
J
Psychiatry
1 48:9,
September
1991
