DSM-III, draft DSM-III-R, and the diagnosis and prevalence of bulimia in Australia

A self-report questionnaire for bulimic symptoms was administered to three different groups of community residents and to patients in a hospital's weight disorders unit and its dietetics department. The prevalence of DSM-III bulimia was 12.7% among female community residents, while the prevalence of draft DSM-III-R bulimia was 1.7%. The questionnaire, scored to reflect DSM-III, categorized as bulimic large numbers of patients who were not given that diagnosis by clinicians. The draft DSM-III-R criteria seemed more closely aligned to clinical experience.     

Axis II comorbidity of normal-weight bulimia

The axis II comorbidity of 34 women with active bulimia, 18 women with remitted bulimia, and 20 women with a history of major depression was assessed blind to axis I diagnosis using the Diagnostic Interview for Personality Disorders (DIPD), a semistructured interview of demonstrated reliability. Fifty percent of the active bulimic subjects, 44% of the remitted bulimic subjects, and 35% of the depressed controls met DSM-III criteria for at least one axis II disorder. Despite the generally higher prevalence of axis II pathology in both bulimic groups than depressed controls, these between-group differences did not reach significance. The clinical implications of these findings are discussed.     

"Hidden" eating disorders in Scottish psychiatric inpatients

The authors designed a study to determine the prevalence of "hidden" eating disorders among a large group of hospitalized psychiatric patients. Of 146 patients surveyed, 13.8% currently had eating disorders diagnosed according to DSM-III criteria: 7.3% had bulimia, 3.6% had anorexia nervosa, and 2.9% had an atypical disorder. Eighty percent of the bulimic patients and all of the patients with an atypical disorder had not been so identified by hospital diagnosis. Eating-disordered patients tended to have concurrent diagnoses of affective or personality disorders.     

Bulimia in obese individuals. Relationship to normal-weight bulimia

We compared 23 obese subjects meeting DSM-III criteria for bulimia with 47 obese nonbulimic subjects and 47 normal-weight bulimic subjects using structured diagnostic interviews. The obese bulimic subjects were similar to the normal-weight bulimic subjects but different from the nonbulimic obese subjects in exhibiting a high lifetime rate of major affective disorder. However, the obese bulimic subjects were much less likely than the normal-weight bulimic subjects to use self-induced vomiting as a method of purging. These results suggest that obese individuals with bulimic symptoms may constitute a sizable but little-recognized population. Further studies will be required, however, to assess whether the syndrome of bulimia in obesity represents a valid diagnostic entity.     

Comorbidity of bulimia nervosa and personality disorder

Thirty patients meeting DSM-III-R criteria for bulimia nervosa with at least three bingeing episodes a week were compared with 30 age- and sex-matched controls on DSM-III personality measures. The bulimic patients were more likely to display cluster B (histrionic, narcissistic, antisocial, and borderline) personality abnormalities (odds ratio 15.0) and cluster C (avoidant, dependent, compulsive, and passive-aggressive) personality abnormalities (odds ratio 4.3) than were the community controls. This study supports the finding that personality disorder is a possible risk factor for bulimia.     

Depression in bulimia at 2- to 5-year followup

Previous research has indicated a strong association between bulimia and affective disorder at the time of initial clinical assessment. To investigate this relationship from a long-term perspective, 30 normal weight female bulimics were evaluated 2 to 5 years posthospital admission with psychometric measures and clinical interviews. Contrary to previous reports, the depression scores of the bulimics were surprisingly low, even though 26 of the 30 continued to fulfill DSM-III criteria for bulimia. Higher depression scores were associated with more intense bulimic symptomatology and attitudes, and greater psychiatric disturbance at followup. Although these data demonstrate a relationship between bulimic symptomatology and depression at long-term followup, they do not support recent assertions that bulimia is a variant of an underlying affective disorder.     

A controlled study of lifetime prevalence of affective and other psychiatric disorders in bulimic outpatients

The authors used structured diagnostic interviews to assess the lifetime prevalence of psychiatric disorders, by DSM-III criteria, among 70 women: 51 outpatients with active bulimia and 19 nonpatient subjects with remitted bulimia. Comparison groups consisted of 24 female outpatients with major depression and 28 nonpsychiatric control subjects. The active and remitted bulimic subjects closely resembled each other, with high lifetime rates of major affective disorder, anxiety disorders, and substance use disorders. Atypical depression was equally common among subjects with major affective disorder in all groups. These results are consistent with previous studies suggesting a phenomenologic relationship between bulimia and major affective disorder.     

A 20-month follow-up study of 628 women with eating disorders, I: Course and severity

A national sample of 628 women with eating disorders completed questionnaires in 1982 and again in 1984. According to initial simulated DSM-III diagnoses, 34 had anorexia nervosa with bulimic features, 392 had normal-weight bulimia, and 202 had a subdiagnostic eating disorder. Most respondents in the latter two groups met some criteria for alternative eating disorders. At follow-up, 29% of the anorexia nervosa group and 43% of the normal-weight bulimia group had improved enough to be classified as having a subdiagnostic disorder. Respondents who sought professional help between the initial survey and follow-up reported no more improvement than those who did not seek help.     

Brief report: psychological characteristics of less severe forms of eating disorders: an epidemiological study among 259 female adolescents

We screened a sample of 259 female students, aged 17-20 years old, by means of the Eating Disorder Inventory 2 (EDI 2) and the General Health Questionnaire (GHQ-28). Those students identified to be at risk for an eating disorder underwent a semi-structured interview to provide a diagnosis according to DSM-IV criteria. We also considered the prevalence of "not full-blown diagnosis". We found two cases of full-syndrome (0.77%), both bulimics, 9 partial-syndrome bulimia nervosa (3.47%) and 1 of partial-syndrome binge eating disorder (0.38%). Moreover, 18 (6.94%) girls met the criteria for subclinical-syndrome, of which the majority was subclinical anorexia (5.79%). We did not find statistically relevant differences between the anorexic and the bulimic samples on the psychological characteristics measured by the EDI 2 subscales. These findings suggest the hypothesis that anorexia and bulimia could have the same psychopathological core and bulimia could be considered as a "failed" anorexia.     

The validity of the distinction between bulimia with and without anorexia nervosa

The purpose of this study was to examine the relationship between bulimia in women with anorexia nervosa and bulimia of a similar severity in normal-weight women and to determine the support for the distinction between these two groups according to DSM-III criteria. Results indicated that bulimic women with anorexia nervosa (N = 59) and bulimic normal-weight women (N = 59) resembled each other on most variables and were more similar to each other than to women with anorexia nervosa who rigidly restricted food intake (N = 59). The results failed to support the diagnostic distinction between bulimia in anorexic women and bulimia of equal severity in normal-weight women.     

Sleep EEG in bulimia

To evaluate the sleep electroencephalogram (EEG) characteristics of bulimia, all-night sleep EEGs were performed on 11 women meeting DSM-III criteria for bulimia. Comparison groups consisted of young women outpatients with major depression (n = 44) and young normal women (n = 20). The sleep EEGs of the bulimic patients were largely indistinguishable from those of the normal controls, except for a trend toward increased rapid eye movement (REM) density in the first REM period among the bulimic subjects. No differences in any sleep EEG measure were observed between bulimic patients with major depression and those without affective disorder. By contrast, the outpatients with major depression displayed marked sleep continuity disturbances, as well as significantly increased REM intensity and REM density, as compared to normal controls. Implications of these results with respect to the hypothesis that bulimia is related to major affective disorder are discussed.     

Short-term prospective study of recovery in bulimia nervosa

Thirty women who sought treatment at an eating disorders clinic in a general hospital and were diagnosed as having a current episode of bulimia nervosa were followed prospectively to assess the course of eating behaviors and other psychopathology. At intake, all 30 met DSM-III criteria for bulimia nervosa, and 57% met Research Diagnostic Criteria for an affective disorder. After 6 months of followup, 33% had recovered from the bulimic episode, and 24% had recovered from the affective disorder. One subject had recovered from both disorders. In subjects with an affective disorder at intake, the affective disorder had little effect on the time to recovery from bulimia nervosa, and recovery from bulimia nervosa had little effect on the time to recovery from the affective disorder.     

High rates of comorbid OCD in patients with bulimia nervosa

There have been several suggestions in the literature that anorexia nervosa and bulimia nervosa, and obsessive-compulsive disorder (OCD) may be related. To assess in a controlled fashion the incidence and lifetime prevalence of OCD in patients with bulimia nervosa, we administered portions of the Structured Clinical Interview for DSM-III-R (SCID) to 25 females with a primary diagnosis of bulimia nervosa. We also assessed current obsessive-compulsive symptomatology using the YBOCS, Symptom Checklist 90-R, and the Maudsley Obsessive Compulsive Inventory. After excluding core bulimic symptoms, the lifetime prevalence of OCD was 32%; an additional 24% met Subthreshold criteria for OCD at some point in their lives. Core anorexia/bulimia nervosa symptoms to ensure that bulimic symptoms would not create a false-positive for OCD. Again, After excluding core bulimic symptoms, the mean score on the YBOCS score on the YBOCS obsessions subscale was 12.0 ± 11.6 and on the compulsions subscale was 5.04 ± 4.75. Scores for both YBOC scales range from 0 to 20. While this is somewhat less than that reported previously for OCD patients, it is considerably greater than that found in normals. These data provide further support for the link between OCD and the eating disorders.     

Is childhood sexual abuse a risk factor for bulimia nervosa?

OBJECTIVE: It is of considerable theoretical and clinical importance to assess whether childhood sexual abuse is a risk factor for the development of bulimia nervosa. The authors reviewed the scientific literature bearing on this issue. METHOD: Since prospective studies on this question have not been done, they assessed 1) controlled retrospective studies comparing the prevalence of childhood sexual abuse among bulimic and control groups, 2) uncontrolled retrospective studies of the prevalence of childhood sexual abuse in samples of 10 or more bulimic subjects, and 3) studies of the prevalence of childhood sexual abuse in the general population, which were chosen to match as closely as possible in methodology the available studies of bulimia nervosa (i.e., in geographic location, age and ethnicity of subjects, interview method, and criteria for defining childhood sexual abuse). RESULTS: Controlled studies generally did not find that bulimic patients show a significantly higher prevalence of childhood sexual abuse than control groups, especially when allowance is made for possible methodologic effects. Furthermore, neither controlled nor uncontrolled studies of bulimia nervosa found higher rates of childhood sexual abuse than were found in studies of the general population that used comparable methods. When it is taken into consideration that several methodologic factors might have exaggerated the rates of childhood sexual abuse among subjects with bulimia nervosa relative to rates in the general population, the absence of actual observed differences becomes particularly striking. CONCLUSIONS: Current evidence does support the hypothesis that childhood sexual abuse is a risk factor for bulimia nervosa.     

Anorexia nervosa and bulimia: a prevalence study.

We determined the prevalence of anorexia nervosa and bulimia in a large sample of students attending a secondary school on the island of São Miguel (Azores) using the Diagnostic Interview for Children and Adolescents, which enabled us to collect the information necessary to make DSM-III diagnoses. Although the prevalence of anorectic and bulimic behaviour was rather high, the partial syndrome of anorexia nervosa was found in only 0.48% of the students (0.76% for girls and 0.17% for boys) and the syndrome of bulimia in only 0.16% (0.30% of the girls; there were no boys with bulimia). The overall prevalence of eating disorders, including partial syndromes, was rather low (0.64%). These results stand in sharp contrast to reports that eating disorders are common and probably getting more common. The low prevalence found in the present survey is probably due to the absence of sociocultural pressures to control eating and weight.     

The use of a self-report instrument for eating disorders diagnoses: how different are DSM-III-R vs. DSM-III?

In response to a 1982 magazine article 641 women completed self report instruments concerning their eating disorders. Simulated DSM-III and DSM-III-R diagnoses were generated from these responses. Rediagnosis of 397 DSM-III normal weight bulimics (NWB) yielded 93.7% with DSM-III-R bulimia nervosa (BN) and 6.3% with DSM-III-R anorexia nervosa with bulimic features (ANB). Rediagnosis of 30 DSM-III ANB, yielded 66.7% with DSM-III-R ANB, 13.3% with DSM-III-R BN and 20% with subdiagnostic eating disorders (SDED). Rediagnosis of 214 DSM-III SDEDs yielded 93.5% DSM-III-R SDEDs, and 6.5% DSM-III-R BNs a relatively small shift. No Eating Disorders Inventory Scale Score or eating disorders behavioral symptom differences were noted between DSM-III and DSM-III-R ANB, or between DSM-III NBW and DSM-III-R and BN in 1982 or 20 months later. Although DSM-III-R diagnostic criteria for eating disorders are more specific than those in DSM-III, our findings suggest they may ultimately make little difference clinically. Self report instruments may be useful in approximating clinical diagnoses in large surveys. They may be especially useful for syndromes such as eating disorders, in which measureable physical criteria and observable behaviors are prominent.     

Prevalence of bulimia among secondary school students in Casablanca]

During the two last decades, several epidemiological studies have been conducted on bulimia nervosa. According to recent studies, prevalence rates were estimated to be 1%. There are a very few studies on eating behaviour conducted in Arab countries. The aims of the current study were to assess prospectively the prevalence of Bulimia Nervosa and its characteristics in a Moroccan context in a randomly selected and representative sample of students attending six secondary schools in Casablanca. A second group composed of the students of the French secondary school of Casablanca was included in the survey in order to verify the influence of socio-cultural factors. Subjects completed a sociodemographic questionnaire and the Bulimic Investigatory Test of Edinburgh (BITE), a 33-item self-report measure of both the symptoms and severity of bulimia nervosa. A score of 25 or higher suggests a bulimic syndrome; 2,044 subjects returned their questionnaires (participation rate = 75.8%). The group of Moroccan school included 1,887 subjects and the French school 157 subjects. Females were preponderant (59%). The mean age was 18.3 +/- 1.2 years (15-22 years). For the first group, at least one substance was taken by 290 (15.3%) students: 12.7% were addicted to tobacco and 5.7% consumed occasionally alcohol. 16.3% reported a familial history of disturbed eating behaviour. According to the BITE, the overall prevalence of bulimia was 0.8% (1.2% in female and 0.1 in male subjects). The mean age of bulimic subjects was 18.6 +/- 1.7 years (16-24 years). The only male case in our sample was aged 24 years, without personal nor familial psychiatric history, consumed regularly tobacco and alcohol. His BITE symptoms score was 20 and severity score was 17, the highest score in our sample. Analyses of correlates of bulimia nervosa in the Moroccan sample showed that the group of bulimic subjects did not differ from the non bulimic with regard to any sociodemographic characteristics except sex: the female sex was predominant (p < 0.005) with 14 cases, the prevalence of bulimic syndrome was 1.2% among girls. This prevalence was 0.1% among boys. The bulimic subjects have regularly used different compensatory behaviours to control their weight: 6 (33.3%) used appetite suppressants, 3 (16.6%) used diuretics and 4 (22.2%) were engaged in self-induced vomiting. In the group of the french school, the prevalence of bulimia was 1.9% in the whole sample (3.4% among girls and no case among boys). These results are comparable to those reported recently in occidental countries and in an Egyptian study. However, the prevalence of bulimic syndrome in our sample was lower to those reported in countries with similar culture. The elevated prevalence of 10% reported in a tunisian study could be explained by the composition of the sample (medical students, aged 22-28 years) and the cut-off point for the BITE was determined to be 20 without taking into account severity criteria. A South African survey, conducted on 1,435 college students representing South Africa's ethnically and culturally diverse population comparable to our sample regarding the age (17-25 years), found a prevalence of 5% with a cut-off of 25 in the BITE. The majority of epidemiological community-based studies estimated the prevalence of bulimia nervosa to be 1 to 3% according to the diagnostic instruments used (self-report questionnaires versus clinical interviews) and the diagnostic criterias operationalized (DSM III, III-R or IV). The rate of occurrence of this disorder in males usually one-tenth of that in females was more decreased among our sample. However, the prevalence among males was comparable to the data of literature. Except the sex, we did not find other risk factors identified in the previous papers. Although in the bulimic group, we noted a higher rate of substance abuse (26.6% versus 15.2%, p > 0.5), familial histories of disturbed eating behaviour (26.6% versus 16.2%, p > 0.3) and less regular practice of sportive activity (72.2% versus 92.3%, p > 0.1), these differences are not statistically significant. The review of the literature identified at least 5 domains associated to bulimic disorder: parental problems (lower parental contact or separation, disruptive events), vulnerability to obesity, parental psychiatric disorder (alcoholism, depression), sexual or physical abuse and a premorbid psychiatric disorder. With the enormous media coverage and the globalisation of the media, cultural differences are disappearing. In order to estimate the prevalence of bulimia nervosa in the Moroccan population and to identify the risk factors, further epidemiological community-based studies using structured psychiatric interviews are required.     

Frequency of bulimic behaviors and associated social maladjustment in female graduate students

A questionnaire survey of 550 female medical, business and law students revealed that 12% met criteria for bulimia. The bulimic students reported significantly more social maladjustment than their non-eating disordered peers. Frequency of binging and purging was associated with the degree of social impairment, with significant social dysfunction being noted on the overall scale at a minimum binging/purging frequency of once weekly. This finding suggests that the proposed DSM-III frequency criterion may be too restrictive.     

Eating disorders in female adolescents with insulin dependent diabetes mellitus

Recent case reports have suggested an association between anorexia nervosa and/or bulimia with insulin-dependent diabetes mellitus (IDDM). Fifty-eight females aged fifteen to twenty-two with IDDM for more than one year were assessed for the presence of eating disorders. Patients were screened for eating and weight pathology using the Eating Disorder Inventory (EDI) and Eating Attitudes Test-26 (EAT-26). Glycosylated hemoglobin (HbA1) was measured to assess metabolic control. Subjects who scored above the cut-off points associated with eating and weight pathology were interviewed. Clinically significant eating and weight pathology was found in 20.7 percent of the population. Of these subjects, anorexia nervosa was found in 6.9 percent and the syndrome of bulimia, based on DSM-III criteria, was found in 6.9 percent. In patients with bulimia, there was a strong inverse correlation between bulimic symptoms and metabolic control. These findings suggest that anorexia nervosa may be more common in female adolescents with IDDM than in nondiabetic populations and that bulimic symptoms may be a risk factor for poor metabolic control.