The DSM-III-R, published in 1987, substantially improved the definition of bulimia, largely because physicians had had time to study many more Patients with the condition. The revised definition reads as follows:
Diagnostic criteria for bulimia nervosa
A. Recurrent episodes of binge eating (rapid consumption of a large amount of food in a
discrete period of time).
B. A feeling of lack of control over eating behavior during the eating binges.
C. The person regularly engages in either self-induced vomiting, use of laxatives or
diuretics, strict dieting or fasting, or vigorous exercise in order to prevent weight gain.
D. A minimum average of two binge eating episodes a week for at least three months.
E. Persistent over-concern with body shape and weight.
One subtle but significant change appears in the very name given to the illness: from bulimia to bulimia nervosa. Such a change, never made lightly, was the result of intense debate by experts on both sides of the Atlantic.
When the disorder first attracted notice, experts focused attention on the single symptom of bulimia-”ox hunger,” or uncontrolled bouts of overeating. Bulimics resemble anorexics in many ways, especially in their attitudes about body shape and weight. The main difference, however, is that a bulimic’s weight is more likely to fluctuate-sometimes wildly-yet on the average it tends to stay within the normal range. An anorexic, by contrast, falls considerably below even a minimal normal weight.
Different experts proposed a variety of terms to identify these patients. A British physician, Gerald Russell, introduced the term bulimia nervosa in 1979. The name identifies more than just the symptom of overeating and helps forge a link with anorexia nervosa. Of course, you can’t please all the people all the time, especially when those people are doctors. The controversy over the name continues.
The first criterion in the DSM-IH-R attempts to define an eating binge. Even so, the definition is somewhat vague: What exactly constitutes “a large amount of food”? How rapid is “rapid”? And what qualifies as a “discrete period of time”?
Actually, this vagueness is purposeful and has its advantages. It grants physicians some leeway in applying the standard to different patients.
“Rapid” simply suggests that the food is consumed quickly. A normal person might eat a normal meal in, say, half an hour. At a formal dinner she might eat a larger amount of food, but that dinner might stretch out over the entire evening. In contrast, a bulimic will often gorge herself as quickly as she can, sometimes eating a day’s worth of food within fifteen minutes.
“Discrete time” sidesteps the need to specify the period over which the patient eats. This is an improvement over the 1980 version of the DSM, which stated that the binge usually takes “less than two hours.” True, most binges occur within that time, but I treat patients who get home from work around six o’clock and begin eating whatever they can find. When that’s gone they send out for pizza. Finally, around ten o’clock they make a bee-line for the convenience store, where they buy as much ice cream and as many cookies as they have money for, then dash home and continue eating. These people qualify as bulimics, even if their eating binge doesn’t quite match the original guideline.
The second criterion makes the crucial point that the bulimic feels her eating behavior is out of control. In this way she resembles alcoholics or drug addicts who also can’t control their behavior. Her lack of control produces strong feelings of shame and inadequacy. To compensate she goes to extreme lengths to regain mastery, but as we have seen, such actions just perpetuate the vicious cycle.
The third criterion identifies the flip side of binge eating: weight control through extraordinary means. The authors of these revised guidelines felt that purging or other similar behavior was such a cardinal feature of the syndrome of bulimia that it deserved a listing of its own. The guideline also helps differentiate between bulimics, who tend to be of normal weight, and people who just overeat. This latter group may be overweight, a problem that requires a different therapeutic approach.
The fourth criterion specifies that the pattern of bingeing and purging must reach a certain severity before medical intervention becomes necessary. By stating the frequency with which binges occur and by indicating that the behavior must persist for a certain period of time, the DSM-IH-R helps differentiate those people with a severe disorder from those who might binge only occasionally. The actual figures (at least two episodes a week for three months) are useful but somewhat arbitrary.
The last criterion, addressing the bulimic’s distorted attitudes about her body, appeared in the manual only after a lot of wrangling. Some physicians felt that bulimics showed their “over-concern” about the body simply through the extraordinary measures they use to control weight. Surely, they argued, self-induced vomiting by itself reflects over-concern about the effect of food; another criterion would just be redundant.
However, other experts felt that the extreme importance bulimics (and anorexics, for that matter) attach to body shape and weight is an essential feature of the illness. In fact, without evidence of these distorted attitudes, some physicians are reluctant to enter a diagnosis of bulimia, choosing to classify the problem as a type of depression or some other variety of disturbed eating.
Almost all of the people I see for bulimia express concern about body shape to one degree or another. If a patient doesn’t appear to have these attitudes, I attribute their absence to my inability to perceive them, or to the patient’s skillful ability at disguising them.
The 1980 criteria stated that depressed mood was an essential component of the illness. The new version drops that requirement. Many patients do have depressive symptoms. The strong association between eating disorders and depression suggests a possible link somewhere in the brain: The cause of one may be the cause of the other. In the past, some experts thought of eating disorders as just one subtype of depression.