Bulimia

Bulimia Definition

Bulimia literally means “ox hunger” and is short for bulimia nervosa—an eating disorder characterized by binge eating episodes in which an individual feels a loss of control over eating and eats very large amounts of food. The individual reacts to binge episodes by using extreme measures to prevent weight gain, such as self-induced vomiting, laxative abuse, diuretic abuse, fasting, or excessive exercise. Within the United States, self-induced vomiting is the most common method for avoiding weight gain among individuals with bulimia nervosa. Importantly, research has shown that vomiting is not effective in getting rid of the calories consumed during binge-eating episodes. Vomiting only eliminates approximately 25% of the calories consumed during a typical binge-eating episode. Similar to individuals with anorexia nervosa, individuals with bulimia nervosa base their self-worth on their weight and shape. Like all eating disorders, bulimia nervosa is a form of mental disorder recognized by the fields of psychology, social work, nutrition, and medicine. Bulimia nervosa is an important subject in the field of social psychology because social factors play an important role in causing the disorder.

Bulimia nervosa most often occurs in adolescent and young adult females, affecting 0.5% to 3.0% of women (or 1 in 200 to 1 in 33) at some point in their lifetimes. Bulimia nervosa is far less common in males. Estimates suggest that 0.05% to 0.3% of men (or 1 in 2000 to 1 in 300) suffer from bulimia nervosa at some point in their lifetimes. Bulimia nervosa appears to be a modern problem. A British physician first used the term bulimia nervosa in 1979 to describe normal-weight female patients who regularly binged and vomited. Rates of bulimia nervosa increased dramatically over a very short period of time in the second half of the 20th century. In addition to being a modern problem, bulimia nervosa appears to be a problem restricted to Western cultures such as the United States and England or individuals who have been exposed to Western ideals.

Western Ideals and Bulimia Nervosa

The increasing idealization of thinness for women in Western culture provides one explanation for increasing rates of bulimia nervosa over the second half of the 20th century and the increased rates of the disorder in women compared to men. In modern, Western culture, being thin has been equated with being beautiful. The idealization of thinness has created associations between thinness and other positive qualities, such as success, intelligence, motivation, likeability, and strength. In contrast, fatness has been associated with many negative qualities, such as laziness, stupidity, loneliness, ineptitude, weakness, and dependence.

The thin ideal contrasts sharply with the reality of what most women’s bodies look like, leaving most women dissatisfied with their own body weight and shape. In bulimia nervosa, dissatisfaction with weight and shape influence self-esteem, and the potential impact of weight gain on self-esteem motivates extreme attempts to control weight. Ironically, extreme attempts to control weight may trigger binge-eating episodes, locking individuals with bulimia nervosa in a vicious cycle of dieting, binge eating, and purging. The processes by which attempts to control weight lead to behaviors that cause weight gain are similar to processes described in social psychology in the area of self-regulation. Further, work by Vohs and colleagues has shown that low self-esteem is directly linked to binge eating among individuals who perceive themselves as overweight and have high levels of perfectionism. Although binge eating would increase the chasm between actual weight and perfectionistic weight ideals, it temporarily reduces painful self-awareness in individuals with low self-esteem. This explanation is consistent with models put forth by Baumeister and colleagues for other self-destructive behaviors as being motivated by a desire to escape the self.

Given the widespread nature of body dissatisfaction among adolescent girls and young adult women, bulimia nervosa is actually quite rare. This means that within a culture that idealizes thinness there are factors that further increase risk for developing bulimia nervosa. Social environments that increase pressures to adhere to the thin ideal, such as ballet schools or social groups that model eating disorder behaviors, may further increase risk for developing bulimia nervosa. Peer influence may play an important role in causing the disorder.

Peer Influence and Bulimia

Researchers have hypothesized that peer influence is a likely causal factor in the development of bulimia nervosa during adolescence. As teenagers acquire more independence from their parents, peers become more important as a reference group. Peer influence is likely to increase dramatically when adolescents go away to college because they leave their homes to live among peers.

Researchers have examined the similarity of peer behaviors as one indicator of peer influence. According to the principle of homophily, social groups tend to share similar behavioral and interpersonal characteristics. Similar to results from studies of other health risk behaviors such as smoking, alcohol use, and drug use, research indicates that bulimic symptom levels are more similar within friendship groups than between friendship groups in high school girls. The process of socialization may cause this similarity.

Socialization and Bulimia

In the process of socialization, attitudes and behaviors spread from one group member to another. Social norms arise for characteristics that are important to the group. Individuals experience social rewards for adhering to these norms, such as an increase in popularity, and social punishments for deviating from them, such as a decrease in popularity or even rejection from the social group. Over time, this social pressure toward uniformity has a causal effect on an individual’s behavior. As group members spend more time together, their attitudes and behaviors should become more similar.

Evidence for the socialization of bulimic symptoms comes from Christian S. Crandall’s study of friendship groups in college sororities. Girls living in one of two sorority houses completed questionnaires that assessed binge eating and friendship groups in the fall and the spring of one academic year. Crandall hypothesized that socialization during the school year would lead to similarity on binge eating within peer groups in late spring (e.g., a few weeks before the sorority closed for the end of the term). As predicted, Crandall found that friends’ binge eating grew increasingly similar over the course of the academic year. In both sororities, popularity was related to the extent to which an individual’s binge eating was similar to the norm for her sorority. However, binge-eating patterns differed between the two sororities, suggesting that the “right” level of disordered eating depended upon local social norms— rather than reflecting college- or culture-wide norms. In an extension of this work, Zalta and Keel found socialization of bulimic symptoms in a general college sample, but this effect was specific to peers who had been selected on the basis of having similar levels of perfectionism and self-esteem.

Bulimia Treatment and Outcome

The most successful treatments for bulimia nervosa include cognitive-behavioral therapy and antidepressant medication. Cognitive-behavioral therapy directly challenges the association between self-worth and body weight/shape. Both treatments have produced higher rates of recovery compared to other forms of treatment used for the disorder. Overall, approximately half of women treated for bulimia nervosa achieve full recovery during treatment. Rates of recovery continue to increase over time such that 75% of women are recovered by 10 years following treatment. Although most women with bulimia nervosa will recover, a significant minority continues to struggle with their eating disorder into midlife. Bulimia nervosa is associated with significant health problems and problems in interpersonal relationships in these individuals. Treatment response and outcome for male patients or adolescent patients are not well described because most studies are restricted to adult female samples.

Other Influences on Bulimia

Although social factors play a crucial role in the development of bulimia nervosa, many other factors are involved as well. Biological factors, such as genes, contribute to risk for developing bulimia nervosa. In addition, personality factors play an important role in the development of the disorder. Finally, stressful life events may serve as triggers for the onset of bulimia nervosa in vulnerable individuals. For these reasons, bulimia nervosa is an important topic in many areas of psychology.