“Ox Hunger”: Psychoanalytic Explorations of Bulimia Nervosa

Bulimia, a term derived from Greek words meaning ox and hunger, is a food obsession characterized by repeated overeating binges followed by purges of forced vomiting, prolonged fasting, or abuse of laxatives, enemas, diuretics and amphetamines. It provides temporary relief to emotional pain. If untreated, bulimia causes serious medical and dental problems. In this paper, I first present an overview of the historical development of bulimia nervosa as a clinical entity and then explore the syndrome from a psychoanalytic perspective, focusing on the Freudian drive-conflict model, the pathology of early object relations, and attachment theory. A case is presented and treatment implications are discussed.     

Treating bulimia: A combined therapy approach

Bulimia is an increasingly common eating disorder which is separate and distinct from anorexia nervosa. The disorder is characterized by ingestion of large volumes of food, usually followed by self-induced vomiting or laxative abuse. Although sometimes seen as a symptom accompanying obesity or anorexia nervosa, bulimia is often associated with a normal weight and nutritional state. This paper includes a case study which describes 3 years of treatment and illustrates the personality characteristics common to bulimic patients, demonstrating a marked contrast with the classic anorexia nervosa patient. A combined treatment approach is illustrated which (1) emphasizes individual therapy as the means by which long-term changes in personality can be attained and sustained; (2) uses group therapy to provide peer support and behavioral intervention; and (3) utilizes imipramine to decrease panic and alleviate anxiety and depression.     

Bulimia: A new perspective

The incidence of bulimia is on the rise, while its knowledge base is presently limited. The author attempts to contribute to our knowledge by sharing clinical case material which highlights characteristics of the disorder. Bulimia has been connected with anorexia nervosa as well as being considered a separate diagnostic category. Such differences of opinion reflect the newness of the knowledge and account for the variation of prognostic judgments about the disorder. Etiology of the disorder is still under investigation by researchers. Possible etiological factors are suggested. The cluster of these psychosocial factors in the patient's history include reinforcement at an early age by a parent for self care, other directedness, and the overevaluation of food in the family.     

A Description of Disordered Eating Behaviors in Latino Males

Abstract

Objective: To explore disordered eating and eating disorders (EDs) in Latino males. Participants: Participants are 722 male college students from a larger prevalence study conducted in the University of Puerto Rico system. Methods: Participants were selected from a list of sections of required courses for first-year students on each campus. Self-report instruments were used to explore ED symptoms (the Eating Attitudes Test [EAT-26] and the Bulimia Test–Revised [BULIT-26-R] and the Beck Depression Inventory depression (BDI). Results: Overall, 2.26% scored above the cut-off point on the BULIT-R and 5.08% score above the cut-off point on the EAT-26. Of the males, 4.43% reported sufficient frequency and severity to approximate DSM-IV criteria for bulimia nervosa. Depression symptomatology was found in those who scored above the cut-off point on both instruments of EDs. Conclusion: College health practitioners should be aware of disordered eating in Latino males and include them in efforts to detect disordered eating behaviors in college students.     

Disordered eating in college freshman women: a prospective study

The authors assessed eating behaviors and attitudes of 225 college freshman women on the bulimia and restraint scales at the beginning of the year. Seven months later, they reassessed 104 of the original students. Concurrent data regression analyses found that symptoms of eating pathology were associated with figure dissatisfaction, ineffectiveness, public self-consciousness, and vigor on the Profile of Mood States, and for bulimia, self-efficacy to control eating when experiencing negative feelings, and reward conditions. Both bulimia and restraint were highly stable across the 7 months. Prospective analyses, controlling for the initial level of eating pathology in hierarchical regressions, found that figure dissatisfaction, ineffectiveness, and alcohol use/abuse over the past year were significant predictors of worsening symptoms. Beginning levels of bulimia and restraint were the best predictors of eating pathology at the end of the study. The roles that self-image and alcohol use may play as vulnerabilities for eating pathology are also considered.     

Problem behaviors,substance abuse and sexual abuse in psychiatrically hospitalized adolescents with bulimia nervosa

Twenty-eight adolescent bulimics were compared to 201 psychiatrically hospitalized non-eating disordered patients. Non-eating disordered patients were found to be reliably more aggressive, delinquent, and under-controlled than patients with bulimia nervosa. Sexual abuse was found to be less prevalent among bulimic adolescents than comparison adolescents. No significant between group differences were achieved on any measure of alcohol/drug abuse. The behavioral profiles of substance abusing bulimics were highly similar to those of non-eating disordered patients. Three months follow-up of bulimic patients found that they were less depressed, had less somatization, and were less overcontrolled; however, they showed no reliable improvements in eating attitudes/behaviours or drug/alcohol use.     

Conflict-Oriented Cognitive Behavioral Therapy (CO-CBT): An Integrative Approach to the Treatment of Bulimia Nervosa Patients

The paper describes an integrative approach to the treatment of Bulimia Nervosa that combines Cognitive Behavioral Treatment (CBT) with short-term dynamic treatment, called conflict-oriented cognitive behavioral treatment (CO-CBT). The need to develop an integrative model emerges from the lack of focus on the underlying emotional dynamics in the traditional CBT approach. This article provides a brief literature review of CBT and short-term dynamic therapy as applied to Bulimia Nervosa patients. It describes the CO-CBT treatment model, followed by clinical examples, and a discussion of the importance of incorporating this additional dimension in order to most successfully treat Bulimia Nervosa.

BULIMIA: THE TRANSGENERATIONAL VIEW*

Within families presenting with bulimia, there exist interactional patterns that can be said to enable, and perpetuate, the binge-eating and purging symptoms of the identified patient. A transgenerational treatment method is proposed, which not only intervenes in ongoing dysfunctional patterns, but also provides a frame for creating a therapeutic metaphor (“legacy”) to direct the therapy. Rationale and stages of the treatment process are outlined, and a case example is given to illustrate use of the transgenerational frame.     

2012 JSS Award Winner: Book Division “Recovery” from Eating Disorders: Narrative-Based Clinical Sociology: A Summary by the Author

In recent years people with eating disorders have begun to discuss their experiences on the Internet. While attempts to explain eating disorders in contemporary society have concentrated on their etiology as problems of individuals, the family or society, in their postings on the Internet, some people who have recovered discuss eating disorders as “eating problems” caused by excessively strict dieting. Further, they believe they overcame their disorders by consuming regular meals. The present research attempts to shed light on both the conditions surrounding sufferers of eating disorders and the direction that some have taken to affect their recovery. In this article I focus on the narratives of two people who have recovered from bulimia nervosa. I examine why they refer to their illness as an eating problem, rather than accepting conventional explanations. Further, I consider what they are trying to achieve in doing so. Two results were obtained. First, it was determined that, though both of the subjects of this research were familiar with the conventional etiological explanations of eating disorders, they both also criticize the individual, familial and societal interpretations for providing no solution. Second, it became clear, through narratives explaining eating disorders as eating problems that can be solved via eating exercises, that the subjects were attempting to reclaim the means of ending their binging and regurgitation and, more broadly, the right to solve their own problems.     

Implicit Family Process Rules in Eating-Disordered and Non-Eating-Disordered Families

Family environment has been shown to be one of the factors related to the presence of eating disorders among young-adult females. Clinical experience and theories about eating disorders postulate that implicit family rules are an intricate part of family process that may have a great effect on the creation and maintenance of such problems. This study compared implicit family process rules (specifically rules pertaining to kindness; expressiveness and connection; constraining thoughts, feelings, and self; inappropriate caretaking; and monitoring) in families with a young-adult female diagnosed with an eating disorder—either anorexia nervosa, bulimia nervosa, or eating disorder not otherwise specified—and families with a young-adult female without an eating disorder diagnosis. One hundred two families (51 eating disordered and 51 comparison) participated in the study. Mothers, fathers, young-adult female children, and siblings completed the Family Implicit Rules Profile ( Harper, Stoll, & Larson, 2007 ). Results indicated that eating-disordered families are governed by a greater proportion of constraining family rules than are non-eating-disordered families. Additionally, eating-disordered youth reported a lower proportion of facilitative family rules and a higher proportion of constraining family rules than did parents and siblings. Theoretical, research, and clinical implications are discussed.     

The health of university athletes: attitudes, behaviors, and stressors

This study examined several aspects of the health of university athletes. Five areas of concern were targeted for investigation: general health background, use of drugs and alcohol, weight and eating behaviors, stress, and use of helping resources. The authors developed a questionnaire and used it to survey 27 varsity athletic teams at a major private university. The incidence of injuries was high; one third of the 247 student athletes surveyed reported sport-related injuries. Alcohol was much more frequently used than other drugs, and use tended to decrease during the competitive season. Significant differences between men and women athletes were found in off-season alcohol and marijuana use. Anabolic steroid abuse did not appear to be a major problem for this athlete population. Issues of diet, weight, and body image were found to be significantly different for women than for men. Although the incidence of bulimia and anorexia was low for both female and male athletes, it was clear that female athletes brought to their sport heightened concern for body image. The authors discuss the psychological and interpersonal implications that these findings have for the adjustment of female athletes. Injury and academics were perceived as the most stressful factors for both men and women, whereas weight and diet issues were a major stress factor for one third of the women. Given these data, specific recommendations are made for health professionals who work with college athletes.     

U.S. trends in feminine beauty and overadaptation

Men place more importance on the physical attractiveness of women than women do on the physical attractiveness of men. As a result, women's social opportunities are more affected by their physical beauty than are men's, so that women are under more pressure to conform to an ideal of beauty. Although standards of female beauty are not as arbitrary as is sometimes claimed, they do vary greatly over time and across cultures. Modern institutions of advertising, retailing, and entertainment now produce vivid notions of beauty that change from year to year, placing stress upon women to conform to the body image currently in vogue. The best known of these beauty standards are the “bosom mania” of the 1950s and 1960s and the current trend toward slenderization. As women attempt to adapt to each of these changes, a minority overadapt, sometimes to the point of incapacitation. Among these over‐adaptations have been hysteria, early in the century, which was an exaggeration of the fragile feminine ideal of that time; bosom anxieties of the 1950s and 1960s, when women worried if their breasts were sufficiently large; and anorexia and bulimia today.     

Suicide among elderly white men: development of a profile.

1. Older white men have the highest suicide rate in the nation; a linear increase of suicide occurs with each passing year of chronological age. 2. Elderly who attempt suicide are more likely to communicate their intentions less frequently and to use violent and lethal means. 3. Chronic sleep problems, pain, degenerative illness, or clinical depression may be experienced by older white men at suicidal risk; somatic complaints including imaginary symptoms can mask depression. 4. Educational programs, outreach mental health programs, and enhanced consultation/coordination improve case findings and early intervention. Holistic nursing care, including pain alleviation, depression assessment, and simple comfort measures, are imperative in suicide prevention in the elderly.     

The Group Treatment of Bulimia

Abstract

The incidence of bulimia in college populations is increasing, but an understanding of the syndrome remains sketchy. The authors describe an approach of group psychotherapeutic treatment that has evolved over four years and offer a theoretical formulation of the psychodynamics that may underlie the development of bulimia.     

Gender Differences among Adolescents with Gambling-Related Problems

Data from five recent studies using self-reports were merged to explore gender differences in the characteristics of adolescent problem gambling, including comorbidity with other youth problems. The sample consisted of 2,750 male and 2,563 female participants. Male problem gamblers were more likely than females to report signs of psychological difficulties while females were more likely to note behavioural problems as a consequence of their gambling problems. Males and females with severe gambling problems had remarkably similar prevalence rates of depression, substance use and weekly gambling. In the non-problem gambling group, depression was more likely to afflict females whereas substance use and frequent gambling were more prevalent among males.     

Sex differences in psychosocial consequences of alcohol and drug abuse

This paper reports analyses of the 1985 National Household Survey on Drug Abuse to evaluate three perspectives on sex differences in the relationship of psychosocial problems to levels of substance use. The results are more consistent with a styles of deviance perspective than with either the generalized feminine vulnerability or the convergence theses. Compared to women, men report higher levels of alcohol and drug abuse during the past year and are more likely than women to have experienced each of 17 psychosocial problems resulting from alcohol or drug use. Significant sex by substance use interaction tests for problem indices and for individual problems suggest that substance abuse is related more strongly to intrapsychic problems among women and to problems in social functioning among men. Decompositions of the sex differences in mean levels of psychological and social/behavioral problems suggest that most of the differences can be explained by males' greater frequency of intoxication and drug use.     

A review of environmental-based community interventions

Alcohol use and related problems can be influenced by a wide variety of prevention interventions, including efforts that focus on changing the community alcohol environment-for example, by reducing underage access to alcohol, decreasing alcohol availability among adults, and increasing awareness of alcohol-related issues. Examples of environmental-based community interventions that focus on reducing alcohol use and related problems are Communities Mobilizing for Change on Alcohol, the Community Prevention Trial, the Sacramento Neighborhood Alcohol Prevention Project, Saving Lives, Operation Safe Crossing, and Fighting Back. Evaluations of these programs found that programs that change the community environment can reduce alcohol use and related problems among both youth and adults, even in communities with relatively low readiness to address alcohol issues. Research also has identified particular settings and situations where alcohol environmental changes are particularly needed as well as factors influencing the effectiveness of certain strategies. Despite the progress made, additional questions still need to be addressed in future research to maximize the benefits associated with environmental-based community interventions.     

Hidden Eating Disorders: Attachment and Affect Regulation in the Therapeutic Relationship

From the time I began working at a clinic that specialized in therapy with individuals with eating disorders, I have repeatedly encountered cases of clients hiding these symptoms from their therapists. When they finally do reveal the disorder, their therapists often worry that their clients are more disturbed than they thought and that, they, the therapists, did something wrong in the therapy. Although some therapeutic rupture can be part of the picture, I have found that these disclosures often reflect a client’s growing trust in the therapist’s presence and ability to help with feelings that have been, until now, dealt with through the eating behaviors themselves. In my attempts to understand what happens before and after an individual shares a hidden eating disorder with a therapist, I have found ideas from attachment theory, in particular those that explore links between attachment, affect regulation, and self-reflection, to be very helpful. Many authors have noted that eating disorders are related to problems with attachment, loss and separation, and affect regulation. Difficulties in these areas make it hard for clients to be self-reflective or use insight productively. In this article, I discuss my experience with the integration of these dynamics, which I have found to be key to successful psychotherapy with clients who hide their eating disorders.

Economy,Society and Welfare: A Study in Social Economics. Joseph S. Berliner. New York,Praeger Publishers, 1972. 216 Pages, $13.50. Hardbound

This paper calls on schools of social work to provide more workers for practice in rural settings. It reviews the basic character of rural areas and the need for systematic intervention and program development to alter the disproportionate amount of social and economic problems existing there. The use of rural settings for student practice is reviewed, including concepts such as the community of communities, models for designing practice experiences, the role of the educator, and positive features and barriers found in providing social services.