MENTAL
545
PLAY IN GTS AND OCD
as an obsessive—compulsivephenomenon. Further
PAULS, D. L. & LECKMAN,J. F. (1986) The inheritance of Gilles
de la Tourette's syndrome and associated behaviors. New
research is needed to elucidate the nature of differences and resemblances inrepetitive phenomena
EnglandJournalof Medicine,315, 993—997.
in GTS and OCD.
studyof Gillesde la Tourettesyndrome.AmericanJournal of
RAYMOND,C. L., Smvat.aoN, J. M., et al(1991) A family
Human Genetics,48, 154—163. ROBERTSON,M. M. (1989) The Gilles de Ia Tourette syndrome:
Acknowledgement
the
currentstatus.BritishJournalof Psychiatry,154, 147—169.
We are most grateful to M. M. Robertson,MiddlesexHospital, London; D. L. Pauls, Child Study Center, Yale University, New Haven, USA; and M. F. Niermeijer, University Hospital, Rouerdam for their useful comments on the manuscript.
TRIMBLE,
M.
M.
& Lms,
A.
J. (1989)
Self-injurious
behaviour and the Gilles de Ia Tourette syndrome: a clinical study and review of the literature. Psychological Medicine, 19,
611—625. & GOURDIE, A. (1990)FamilialTourette's syndromein a largeBritishpedigree.British Journalof Psychiatry,156,515-521. SHAPIRo,A. K., SHAPIRO,E. S., Yout'ic, J. 0., et al (1988) Gilles
References
de Ia Tourette Syndrome (2nd edn). New York: Raven Press.
Asnaic@ PsycuiAliuc Associ@iioN(1987)Diagnostic and Statistical Manual of Mental Disorders (3rd edn, revised) (DSM—III—R). *D. C. Cath, MD, Psychiatrist, Psychiatric Hospital Washington, BULLEN,
J. 0.
Endegeest,Oegstgeest,The Netherlands;B. J. M.
DC: APA. & HEMSLEY, R. (1983)
Sensory
experience
as a
van de Wetering, MD, Psychiatrist, Department of Psychiatry, University Hospital Rotterdam-Dijkzigt, Rotterdam; T. C. A. M. van Woerkom, PhD, Psy chiatrist, Department of Neurology, Municipal Hos CoMINos, D. E. & CoMINGs, B. 0. (1987) A controlled study of Tourette syndrome, 1-VIl. American Journal of Human pitals, The Hague; C. A. L. Hoogduin, MD, PhD, Genetics,41, 701—866. Professor of Psychiatry, Department of Psychiatry, FRANKEL, M., CUMMINGS, J. L., R0B!tRTsoN, M. M., et al (1986) Reinier de Graaf Gasthuis, Deift, also Catholic Obsessions and compulsions in Gilles de la Tourerte's syndrome. University, Nijmegen; R. A. C. Roos, MD, PhD, Neurology, 36, 378-382. H@w4,E. DE(1988)A manwithcountingrituals:a diagnostic Neurologist, Department of Neurology, University problem. DirectiveTherapie,8, 127—134. Hospital, Leiden; H. 0. M. Rooijmans, MD, PhD, HooGnuiN, C. A. L. (1986) On the diagnosis of obsessive Professor of Psychiatry, Department of Psychiatry, compulsive disorder. American Journal of Psychotherapy, 15, University Hospital, Leiden, The Netherlands 36—51. trigger in Gilles de Ia Tourette's syndrome. Journal of Behaviour Therapy and Experimental Psychiatry, 14, 197-201.
KURLAN, R., LIcHmR, D. & Hswrrr,
D. (1989) Sensory tics in
Toureue's syndrome. Neurology, 39, 731—734.
Correspondence
Bulimia Nervosa in Hong Kong Chinese Patients SING LEE, L. K. GEORGE HSU and V. K. WING
In contrastto the West, bulimicdisordersare rarerthan anorexia nervosaIn Hong Kong. Four female normal weight bulimic patients with mostly typical clinical features and conspicuousmorbidityare reported.The casehistoriessupportthe hypothesisthat binge-eating Is used to regulate unpleasantaffect.
Malaysia, and Hong Kong. Although emaciation,
food refusal and amenorrhoea are universal among
Chinese anorexics, body-image distortion, a core diagnostic feature among Western anorexics and the reason most commonly given for wilful starvation, is frequently absent among Chinese patients, some BritishJournalof Psychiatry(1992),161, 545—551 of whom may blame indigestion or fullness for their poor intake (Lee, 1991). Perhaps of significance is the report that body-image disturbance is also not
Although there is frequent mention of a modern ‘¿epi found among anorexics in India (Khandelwal & demic' of eating disorders, classic anorexia nervosa anorexia nervosa is almost unknown, and it remains
Saxena, 1990). If these findings are substantiated by future studies, then the diagnostic criteria for anorexia nervosa may need to be modified in non
very rare among the Chinese populations of Singapore,
Western cultures.
has remained rare (Whitaker eta!, 1990). In China,
546
LEE ET AL
In contrast,
bulimia nervosa, which has more
recently been distinguished from anorexia nervosa
critical remarks from others. On average she secretly consumed 800 g of bread and biscuits. Such episodes were
(American Psychiatric Association, 1987), is appar ently becoming more common among Western
was nausea but no vomiting. She took excessive laxatives
followedby abdominalbloating,guiltand dysphoria.There
females (Pyle et al, 1986), although this finding may
(usuallyprunejuice)to purgeand ‘¿calm' herself,restricted
be open to dispute. Nonetheless, it is clear that bulimia nervosa is at least three to four times more
Her body weight fluctuated by up to 4 kg per week, but her menseswere normal. There was no weight or mental
prevalent than anorexia nervosa (Patton et al, 1990; Whitaker et a!, 1990). Among anorexics reported from non-Western
food intake and exercisedexcessively in the next 1—2 days. disorder in the family.
Mental examinationrevealeda fullyconsciousgirl who felt helpless over the “¿attacks of overeating―.She desired
countries (Khandelwal& Saxena,1990;Lee,1991), a body weightof 45 kg and disparaged her waistlineand
however, typical bulimic symptoms are uncommon. Besides, using the Diagnostic Interview Schedule (DIS), the Shatin Psychiatric Epidemiological Survey conducted in 1984—86 in Hong Kong identified only one female with a lifetime DSM—III diagnosis of anorexia nervosa out of a community sample of 7229 subjects (3786 females, 3443 males, age range 18—64)(Chen et al, 1992), but apparently no
square
face, which
food dominated
made
her “¿look like a pig―. She found
her life, and likened her problem to heroin
addiction. There was a persistentrequest for laxatives, but
no significantdepressivefeatures.Laboratorytestsindicated a transient increase in serum free thyroxine because of the exogenous thyroxine used for weight reduction. The Minnesota Multiphasic Personality Inventory (MMPI; Hathaway & McKinley, 1967) revealed abnormal elevations
on the depression, hysteria, and psychaesthenia scales. Its
bulimia. Recently, a retrospective case review at the
profilesuggestedpoorpsychologicalintegration,denial,social
Department of Psychiatry of the University of Hong Kong indicated that there was only one case of
inadequacy and lack of drive. Her scores on the Eating Disorder Inventory (EDI; Garner et a!, 1983) were: drive forthinness=6, interoceptiveawareness= 13, bulimia= 11, body dissatisfaction =7, ineffectiveness =9, maturity fears = 2, perfectionism = 0, and interpersonal distrust = 3. Miss A received cognitive—behaviouraltherapy and a short course of imipramine. There were frequent relapses, and a transient episode of psychotic decompensation, during which she exhibited formal thought disorder, incongruous affect and the paranoid delusion that she had to work closely with the American Embassy for obscure reasons, but no major mood disturbance. This responded to neuroleptic treatment. A year later she stopped bingeing, but remained withdrawn and irregularly employed.
bulimia nervosa as compared with 42 anorexic patients treated over an eight-year (1980—88)period (Ho, personal communication) at a general teaching hospital which served a regional population of 0.6
million. Over 1984—91,our own unit at the Prince of Wales Hospital, which currently serves 0.5 million people, has treated 18 anorexics (Lee, 1991), but only
more recently (1989—91)four bulimic patients. As bulimia nervosa at normal weight has never been reported among the Hong Kong Chinese, we now describe them.
Case 2 Case reports
treatment
Case 1 Miss A was a 22-year-old single clerk, who was referred by
her doctor for treatment of ‘¿psychiatric problems'. She presented with a three-year history of uncontrolled over eating. Although she was not originallyobese (weight47 kg, height 152 cm, BMI (body mass index)= 20.34 kg/rn2), she disliked her “¿square face―,and developed a sensitive, moody and dependentpersonality.Her fatherwas rigidand avoidant, whereas her mother was nagging and dominating. As a result, they had frequent rows which caused feelings of helplessness in the patient. Since she failed in a public examination
Ms B (weight 47 kg, height 157cm, BMI = 19.07 kg/rn2) was a 34-year-old married clerk, who was referred for
and was unable to study graphics in a technical
school, she started to relieve boredom and comfort herself by overeating.She was upset to reacha maximumweightof 60kg (BMI = 25.97 kg/rn2), and abused slimming tablets.
This enabled her to lose 5—8 kg, but also increasedher urge to eat. Her binges occurred four times per week and lasted 1-3 hours each. Triggers included feelings of emptiness and
of anxiety neurosis. She presented with a 15-year
history of binge eating, which occurred 3-4 times per week. Each episode lasted 1-2 hours, and was precipitated by being alone at home, tension and exclusive thoughts of
food. On averageshe consumed600g of bread, but many other kinds of food (e.g. meat, fish, vegetables, and fruits) were ingested. A binge ended when a “¿sleepy feeling― occurred.
She was then
worried
about
her body
shape,
became guilty and demoralised. She did not induce vomiting, but used about five suppositories and exercised excessively by swimming up to three hours per day. Since
the age of 16, she had kept her weight remarkably stable at 47 kg. Ms B received 12 years of education. Since the age of six, she was attracted
towards the same sex, and frequently
caressed her younger sister while the latter was asleep. She dared not reveal this because of the severe stigmatisation of homosexualityin Chinesesociety. She neverhad a formal lesbianrelationship,and lived with persistentconflicts over her sexuality. She felt isolated, and started to cope with
547
BULIMIA IN HONG KONG her loneliness by overeating. At 26 she got marriedbecause her husband treated her “¿kindly―. However, her lesbian
became very moody. After repeated requests, 18 months later she was allowed to live with her grandmother in Hong
identity remained a secret, and their communicationwas
Kong again.
limited. She achieved sexual satisfaction by masturbation, which involved lesbian fantasy. There was also stress from the departureof a close female colleague (with whom she
a fitnessclub to lose weight. In the next few months, her
While in Hong Kong, Miss C found herself fat and joined
weight returned to 48 kg, but her binge episodes became
had an imaginaryrelationship),and the neonatal death of
more frequent than before. Typically, she consumed a
a prematurebaby. The lattercaused her to weep frequently for two monthsand fearfuturepregnancy.Heroccupational functioning, however, remained satisfactory. There was no family history of mental illness.
variety of snacks (e.g. biscuits, popcorn, dried cuttlefish)
Shelookedyoungerthan her age. Althoughnot strongly concerned with body shape, she felt that her abdomen could “¿perhaps be a little thinner―,and desired a body weight of 45 kg. Being preoccupied with food, she meticulously reported her daily caloric intake (this was unusual for a Hong Kong Chinese). There were repeated requests for laxatives because of constipation, and uncontrollable urges to overeatwhen she felt empty. Yet she also learnedto enjoy
a “¿sleep-like― feelingduring bingeing.She was not aware of any technique of self-induced vomiting, which she thoughtwas“¿difficult to carryout―. As rapport improved, she repeatedly sought reassurancethat her homosexuality was not a mental disease. MMPI revealed the typical
neurotic triad pattern with depression, multiple somatic complaints, and hysteroid features. Its profile suggested overcontrol of emotions, rebellion against the traditional feminine role, and a persistent identity crisis. The EDI
showed:drivefor thinness= 5, interoceptiveawareness= 4,
both at homeand in the streetuntil her stomachcouldhold no more. The binges involved a subjective loss of control, and weretriggeredby boredom, tensionand cravingspecific foods. They were followed by guilt and overconcern with
weightgain.Therewasno self-inducedvomitingor laxative abuse,
but
dietary
restriction
by skipping
most
regular
meals, and also attemptsto burn off calories by swimming and playing squash several times a week. Marked weight fluctuationswerenot noticed, and her menseswerenormal. Her school work deteriorated, and she became irritable, frequently tearful, yelled, and angrily tore photographs of her parents.Therewereno biological depressivesymptoms.
Examination showeda slim girl who was distressedby her constant preoccupation with food. She was upset by her previousweight gain, but acceptedhercurrentbody weight, which she maintained only with “¿a lot of self restraint over eating―.She was weepy because of her ambivalence over her school work and future career. She described herself to be “¿very Chinese―and had a recurrent nightmare about her recent visit to the UK. She could see that
bulimia= 3, body dissatisfaction = 5, ineffectiveness = 7, maturity fears= 2, perfectionism=10 and interpersonal distrust= 7. With out-patient psychotherapy, she was able to live with her clandestine lesbianism with less distress, but her binge-eating persisted as a means of soothing
herbingeeating wasa way ofdistracting herself fromher “¿insoluble problems―, andwasworried thatthis became addictive. MMPI revealedelevation only on the depression scale, and its profile suggestedhelplessnessand demoralisa tion. The EDI indicated:drivefor thinness= 8, interoceptive awareness = 12, bulimina =5, body dissatisfaction =7,
herself.
ineffectiveness=9, maturity fears=6, perfectionism=9,
Case 3 Miss C (weight 48 kg, height 161 cm, BMI = 18.5 kg/m2) was a 19-year-old A-level student, who was referred for “¿emotional problems―.She presented with a one-year history of binge-eating severaltimes a week. She was born in the UK in a Chinese family which ran a cafeteria in Bristol. When she was five, she was sent to Hong Kong by her parents to live with her grandparents, so that she could “¿learn to speak Chinese there―. Despite early separation from her family, she lived happily with her grandparents who were protective towards her. She developed a conservative, anxiety-prone personality, and was an above-average student who had high expectation of herself. Two years before presentation, after the death of her grandfather, she was reluctantly advised by her parents to return to the UK, so that she could enjoy free and ‘¿better' education there. After arrival,she experienced markedadjustmentdifficultiesin schooling, socialisolation, and conflicts with her “¿noisy― mother who showed favouritism towards her Westernised and academically
successful siblings. She learned to cope with her lonely feelings by overeating a variety of junk foods, as a result of which she was disappointed to reach 54kg (BMI = 20.8 kg/rn2). She lost interest in school work and
interpersonaldistrust= 6. Her binges decreased with out patient psychotherapy, but she later defaulted treatment despite frequent moodiness. Case 4 Miss D was a 25-year-old single primary school teacher, who first presented to a gynaecologist for transient secondary amenorrhoea. This recovered spontaneously after thorough investigations, and she was then referred for treatment of “¿abnormal eating habit and possible anorexia nervosa―. After beingcasuallyremarkedto be fat four years earlier,
she started
to diet by reduced
food intake
and 1-3
hours of aerobic exercise per day. Her weight decreased from 58 kg (height 158cm, BMI = 23.23 kg/rn2) to her desired body weight of 48 kg (EM! = 19.23 kg/rn2), which was also her ideal body weight according to the local Chinese norm. She became overconcerned with her body weight, and developed intense preoccupation with food. When she was bored and feeling empty in the past year, she consumed various kinds of food availablein the home, including bread, biscuits, Chinese soup, instant noodles, peanuts, and chicken wings. This involved “¿a loss of thinking―and usually lasted 1.5 hours in the evenings. It was followed by a sense of heaviness in the abdomen, tiredness, fear of weight gain, and guilt. There was
548
LEE ET AL
self-induced vomiting and subsequent throat discomfort. To her disappointment her weight returned to 56 kg.
(1979) puts it, the result of a “¿starved body rebeffing and demanding to be fed―.
Miss D was born in a traditional Chinese family, which showed obvious favouritism for her two brothers. Her
clinical features of bulimia nervosa in Hong Kong
father was emotionally distant, and she developed a dependent personality with low self-esteem and ambivalence
towards her domineering mother. Despite her parents'
If future studies confirm our observation that the resemble those in the West, two questions immediately present themselves: why is the disorder so rare in
Hong Kong, and why is it becoming more prevalent now? Our answers to these two questions must be as an achievement, and was naive in heterosexual relationships.Therewasno familyhistoryof mentalillness speculative because the aetiology of bulimia nervosa devaluation of the educational need for females, she obtained a diploma in college.Yet she did not regard this or obesity.
On mental
status
examination,
she was
preoccupied with food, and admitted that her body weight affected her self-esteem. She disliked her arms and hips, and her desired body weight was 47 kg. Although she recognised the harmful effects of her “¿irrational― eating,
she was unable to stop it. She likened herself to a goldfish,
whichate untilitsabdomenbecameswollen.Therewasguilt not only over becoming fat, but also wasting food, which “¿should be enjoyed―.She described how she
remains unclear. In the West, the following risk factors are associated with the development of an eating disorder: female gender, adolescence and young adulthood, Caucasian race, higher socio
economic status, higher premorbid percentile weight, family history of eating or mood disorder, and cultural emphasis on slimness. All the four cases that
spontaneously learned to induce vomiting by using her right
we have described are young females, but they did not all come from an upper social class background.
index and middle fingers. There was no significant depression. Physical and laboratory assessment was normal.
Higher premorbid body weight and dieting behaviour have been identified in several recent studies as
MMPI revealed elevated scores on the depression
and
powerful predictors for the onset of bulimic disorders (e.g. Patton et a!, 1990). This certainly seemed to operate in our patients since their mean premorbid thinness = 18, interoceptive awareness = 13, bulimia = 14, BMI (22.27 kg/m2) was high by Hong Kong Chinese body dissatisfaction = 18, ineffectiveness = 17, maturity standards, and mightcontribute totheir characteristic fears =6, perfectionism =6, and interpersonal distrust =6. fear of fatness which was frequently absent among Despite two years of psychotherapy, her binges persisted. Chinese anorexic patients in Hong Kong (Lee, 1991). We contend therefore that bulimic disorders are rare Discussion in Hong Kong because obesity (BMI >25 kg/m2) is The rarity of bulimic symptoms in Hong Kong may relatively rare among its indigenous population, and be reflected by our patients' non-specific reasons for dieting behaviour is uncommon. Compared to their referral, namely, ‘¿psychiatric problems', ‘¿anxiety Western counterparts, Chinese girls are slim, if not neurosis', ‘¿abnormal eating habits', and ‘¿emotional underweight. Although Western females commonly use ‘¿fear of fatness' as an idiom of distress, the problems', as bulimia is still unfamiliar to many Chinese have traditionally accepted and even valued medical practitioners. Nonetheless, their clinical features largely resembled those of Western bulimic a degree of fatness. Greeting someone with “¿You patients, and would meet criteria for the DSM-III-R have put on weight―, for example, is still regarded (American Psychiatric Association, 1987) diagnosis as a compliment. Although it is only understandable of bulimia nervosa without modification. In the first that modern Chinese girls also prefer not to be fat, three patients the binge-eating seemed to have there is less stigmatisation of obesity, which is not equated with physical, mental or moral impairment. occurred at a time of distress. The disorder could In contrast, thinness is associated with ill-health and thus represent a set of dysfunctional behaviours resulting from “¿a difficulty in coping with disturbed bad luck and not, as in the West, with self-discipline, feelings and thoughts― (Fairburn, 1985). This attractiveness, or economic well-being. paralleled Western bulimic patients, whose urge to The diet of the Chinese is generally low in fat and binge is typically triggered by emotional states such high in fibre content, and it is less common for as depression, boredom, anxiety, and anger, so that them to characterise fattening food as “¿bad and binge-eating may serve to regulate affect or induce forbidden―,as many in the West may apparently do. nurturance (Abraham & Beumont, 1982). The fourth While it may be an exaggeration to claim that “¿guilt patient was premorbidly heavier, had higher scores about ingestion has become a national political issue―(Schwartz et a!, 1982), it is nevertheless true on the ED!, and began binge-eating after a weight that many apparently normal Western women loss of 10 kg. Her onset is therefore consistent with the conceptualisation that bulimia is a response to experience guilt and shame after eating fattening chronic starvation and over-restraint, or as Russell foods. In contrast, the Chinese enjoy eating and use psychaesthenia scales. The profile suggested self-criticism, denial and reaction formation. The EDI showed: drive for
BULIMIA IN HONG KONG sophisticated
combinations
of food to promote
health and longevity. Eating is also a major channel for the development of interpersonal
549
This is considered tolead tolow self-esteem, poor body acceptance, a constant need to be slim, ambivalence
towards career achievement, and a morbid fear of
relationships, or even a tool of conducting diplomatic
negative evaluation and rejection, particularly from
intercourse. The Chinese commonly say “¿Have you eaten?―when others would say “¿Hello―, and believe
men (Boskind-Lodahl, 1976).According to Confucian precepts, however, self-esteem and happiness among Chinese females are based more on success in social
that “¿being able to eat is to have luck―.According to traditional Chinese belief, individuals who prevent others from eating good food may be reincarnated as “¿hungry demons―, which are the most abhorred of all demons. Confucius, whose ideology has a profound influence in shaping proper behaviour in Chinese society, wrote “¿Human nature naturally desires sex and food―.Chinese culture may therefore discourage restraint from eating, and the relative absence of obesity may obviate the need for weight
control, which predisposes to bulimia.
role performance, especially in the family (Bond, 1991), than physical appearance or career accom
plishment. Therefore, while there are no hard data to suggest that the role of Chinese women in Hong Kong is less conflictual, it is plausible that their role
is more straightforward in a society where gender roles are still under traditional influence. If so, this may be yet another factor that reduces bulimic disorders in Hong Kong. In the West, bulimics usually use vomiting as a method of weight control (Russell, 1979). Some of them are aware of a variety of techniques, and may even take medical precautions such as potassium supplement immediately after vomiting (Abraham
Among many Chinese, food is considered a source of energy (qi) for the body rather than a quantitative amount of proteins or vitamins. Therefore, although some foods may be classified as potentially bad for health, this is frequently in terms of “¿energy & Beumont, 1982). Accordingly, there is the imbalance―according to traditional Chinese medical suggestion that self-induced vomiting should be belief rather than with exclusive caloric connotations. included as a mandatory criterion for the diagnosis An excessive consumption of ‘¿hot' food, for example, of bulimia. However, our patients abused laxatives can be neutralised by taking more ‘¿cooling' food in predominantly. In fact, all except the last patient order to re-establish energy equilibrium. Therefore, seemed not to have ‘¿discovered' self-induced vom iting. Although not proven, it is possible that inducing vomiting to dispose of excessive ‘¿bad' food may be superfluous, and the mental mechanisms self-induced vomiting as a means of weight control (e.g. “¿Now that I have taken the first bite I might may be “¿socially contagious― (Chiodo & Latimer, as well go all the way―)that trigger a binge in 1983). In a survey of 647 Chinese female university Western females may not commonly operate in the students (mean age= 19.2 years, s.d. 1.16, mean Chinese consciousness. BMI= 19.5 kg/m2, s.d. 1.87) using the Eating Attitudes Test (Garner & Garfinkel, 1979), 1.2°loof Whereas behavioural restraint and social con formity are personality risk factors for restrictive them scored on item 13 (“vomitafter I have eaten―) anorexia nervosa (Casper, 1990), impulsivity has a and item 40 (“havethe impulse to vomit after known association with bulimia (Pyle et a!, 1981; meals―)respectively (Lee, unpublished). Because of the non-specific nature of these items, it is unclear Lacey & Evans, 1986). Although there is no emphasis on restraint from eating or pursuit of thinness, how many of these students vomit after eating for the purpose of controlling weight. However, the Chinese socialisation discourages impulsive behaviour apparentlymore so than in theWest, and values, figures are still lower than the 4.5°loof women who perhaps to an excessive degree, self-discipline and reported vomiting for the specific intention of weight interpersonal harmony (Bond, 1991). This, among control in a mid-Western university in the United other reasons, may explain the lack of alcohol abuse, States (Pyle eta!, 1986). Elsewhere, we have reported overdoses and other ‘¿borderline' behaviour (Lacey that self-induced vomiting is rare among a series of & Evans, 1986) in our patients. On the MMPI, they Chinese anorexic patients with slim premorbid body
also did not show elevated scores on the psychopathic deviant scale (Pyle et a!, 1981), which is a measure of impulsivity. However, the small number of patients precludes any definite conclusion about the personality of Chinese bulimic patients. Among feminist researchers in the West, the position is strongly held that the high prevalence of bulimia among women is related to their complex and conflicting roles in contemporary Western society.
shape (Lee, 1991), whereas up to 40% of anorexic (Hsu et a!, 1979) and 90% of bulimic patients (Chiodo & Latimer, 1983) may do so in the West. Understandably, since the media in Hong Kong have yet to publicise the eating disorders, the idea that self induced vomiting can be an effective method (at least in the short-term) of weight control (Chiodo & Latimer, 1983) has not become widely known. Among many Chinese, moreover, the belief is
LEE ET AL
550
perhaps still common that wasting food by vomiting may lead to bad luck and severe punishment by gods
or spirits. Describing somebody or something as “¿causing one to vomit― is a most severe way of expressing disapproval and shame. These beliefs may discourage, but certainly not prevent, the use of vomiting to control body weight among Chinese
Acknowledgement Weare gratefulto T. P. Ho, C. H. Hung, S. Chan and C. Tang. References ABRAHAM, S. & BEUMONT, P. J. V. (1982) How patients describe
bulimia or binge eating. Psychological Medicine, 12, 625—635. AMERICAN PSYCHIATRIC ASSOCiATION (1987)
females. We speculate therefore that the rarity of bulimia nervosa in Hong Kong is related mainly to the relative absence of relevant sociocultural risk factors. In doing so we are not ignoring the role of biological factors in the pathogenesis of the disorder. While decreased central noradrenergic activity has been
implicated as a trait-disturbance in bulimia nervosa (Kaye et a!, 1990), replications of the finding are still lacking. Similarly, the report remains unconfirmed that an impaired cholecystokinin response to eating occurs in acutely bulimic patients (Geracioti & Liddle, 1988). Even if primary biological disturbances are
identified in bulimia nervosa, our contention still standssincetheexisting datasuggest thattheonsetof a bulimic disorder is best explained by an interplay of biological and psychosocial factors. Finally, eating disorders (Strober et a!, 1985) and mood disorders (Hudson et a!, 1987) have been found to be more prevalent among the family members of bulimic patients. The absence of such family histories among our patients may be related
to the small sample size, the relatively young age of some family members who may still be at risk for
Diagnostic
and
Statistical Manual of Mental Disorders (3rd edn, revised)
(DSM-III-R). Washington,DC: APA. BOND, M. H. (1991) Beyond
the Chinese Face: Insights
From
Psychology. Oxford: Oxford University Press. BOSKIND-LODAHL,M. (1976) Cinderella's
step-sister:
A feminist
perspective on anorexia nervosa and bulirnia. Signs: Journal of Women in Culture and Society, 2, 342—356. CASPER, R. C. (1990) Personality
features
of women with good
outcome from restricting anorexia nervosa. Psychosomatic Medicine, 52,156—170. CHEN, C. N., Wor@io,J., Las, N., a: al (1992) The Shatin
community mental health survey in Hong Kong: II. Major
findings.Archivesof GeneralPsychiatry(in press). CHIODO, J. & LATIMER,P. R. (1983) Vomiting as a learned weight
control technique in bulimia. Journal of Behaviour Therapy& Experimental Psychiatry, 14,131—135. FMRBURN, C. G. (1985) Cognitive-behavioural treatment for bulimia. In Handbook of Psychotherapy for Anorexia Nervosa
and Bulimia(edsD. M. Garner&P. E. Garflnkel),pp. 160-192. New York: Guilford Press. GARNERD. M. & GARFINKEL,P. E. (1979) The eating attitudes test:
an indexof the symptomsof anorexianervosa.Psychological Medicine, 9, 273—279. Ou@eri@, M. A. & Pouvy, i. (1983) Development and vali dation of amukidimensional eating disorderinventory for anorexia
nervosa and bulimia. International Journal of Eating Disorders,
2, 15—34. Gsa*cJoTl, T. D. & LIDDLE,R. A. (1988) Impaired cholecystokinin
secretion inbulimia nervosa. New EnglandJournal ofMedicine,
319,683—688. thedevelopmentof a mood or eatingdisorder ata HAThAWAY S. R. & McKmaxy, J. C. (1967) Minnesota Mu!t@phasic Personality Inventory: Manualfor Administration and Scoring. later time in life, and the inability on our part to New York: Psychological Corporation. interview directly all their family members. Although Hsu, L. K. G., CRISP,A. H. & HARDISO, B. (1979)Outcomeof anorexianervosa. Lancet, i, 62-65. disturbedfamilydynamics were presentin three HUDSON,J., Pops, H., JoNAs, J., ci al (1987) A controlled family of our cases, their primary aetiological role in historystudyof bulimia.PsychologicalMedicine,17,883—890. the pathogenesis of an eating disorder remains KAYE,W. H., GWIRTEMAN, H. E., GEORGE,D. T., ci a! (1990) Disturbances of noradrenergic systems in normal-weight bulimia: speculative.
Why then has the disorder become apparently more prevalent among the Chinese in Hong Kong? We conjecture that the answer lies in the recent emergence of the relevant risk factors in the culture of Hong Kong. As obesity and attendant weight control become more widespread among Chinese adolescents, and as Westernised eating habits (e.g. eating fast foods) and ideals of female slimness become incorporated into the Hong Kong culture, bulimic disorders may increase in fre quency. Already anorexia and bulimia nervosa have become common in Japan, where their clinical features are virtually indistinguishable from those
in the West (Suematsu et a!, 1985). After all, culture
is at once continuous
and plastic;
as it
quietly transforms, novel disorders may find their expression.
relationship to diet and menses. Biological Psychiatry, 27,4—21. KHANDELWAL,S. K. & SAXENA, 5. (1990) Anorexia nervosa in
peopleof Asianextraction.BritishJournalof Psychiatry,157,784. LACEY, J. H. & EVANS, C. D. H. (1986) The impulsivist:
a
mukiimpulsive personality disorder. British Journal of Addiction,
81, 641—650. Lea, 5. (1991) Anorexia nervosa in Hong Kong- a Chinese perspective. Psychological Medicine, 21, 703—711. PATrON, G. C., JOHNSON-SABINE,E., WooD, K., ci al (1990)
Abnormal eating attitudes in London schoolgirls - a prospective epidemiological study: outcome at twelve month follow-up. Psychological Medicine, 20, 383—394. PYLE, R. L., MITCHELL, J. E. & ECKERT, E. D. (1981) Bulimia: a
report of 34 cases.Journal of ClinicalPsychiatry,42, 60—64. —¿,
HALVORSON,
P.
A.,
NEUMAN,
P.
A.,
ci
a!
(1986)
The
increasing prevalence of bulimia in freshman college students. International Journal ofEatingDisorders, 5,631—647. RUSSELL,G. F. M. (1979) Bulimia nervosa: an ominous variant of
anorexia nervosa. Psychological Medicine, 9,429—448. SCHWARTZ,D. N., THOMPSON, M. G. & JOHNSON, C. L. (1982)
Anorexia nervosa and bulimia: the sociocultural context. International Journal of Eating Disorders, 1, 20—36.
551
BULIMIA IN HONG KONG STROBER,M., MORRELL,W., BURROUGHS,J., ci a! (1985) A
controlled family study of anorexia nervosa. Journal of Psychiatric Research, 19, 239-246. SUEMATSU, H.. I5rnKAWA,H., KUBOKI,1., ci al (1985) Statistical studies on anorexia nervosa in Japan: detailed clinical data
on 1,011 patients. Psychotherapy & Psychosomatics, 43, 96—103. WHITAKER, A., JoHNSoN,
J., SHAFFER, D., ci al (1990)
Uncommon
troubles in young people: Prevalenceestimates of selected psychiatric disorders in a nonreferred adolescent population. Archives of General Psychiatry, 47, 487—496.
Chromosomal
Aberrations
5Sing Lee, MRCPsych,Senior Lecturer,
Department
of Psychiatry,ChineseUniversityof Hong Kong, il/F Princeof WalesHospita4Shatin,Hong Kong; L. K. George Hsu, MD, MRCPSyCh, Associate Professor
of Psychiatry, WesternPsychiatricInstitute and Clinic, Universityof Pittsburgh,USA; Y. K. Wing, MRCP, MRCPsych,Lecturer, Department of Psychiatry,
Chinese University of Hong Kong, Shatin, Hong Kong Correspondence
in a Patient with Severe Psychopathology
GUNNAR AKNER, KARL-HENRIKGUSTAVSON, EVA HAKANSSON, JAN SAAF, HANS KIESSLING,ARTHUR VUWILERand LENNARTWETTERBERG The case of a female patient showing aggressive, compulsive, destructive behaviour, ritualistic faecal smearing, and hyperactivity is presented. The behaviour Is long standing, therapy-resistant, and Its aetlology Is
unknown, although ft Is seemingly associated with chromosomal abnormalities plasmafactors.
secondary
to abnormal
BritishJournalof Psychiatry(1992),161, 551-555 An abstract on this patient has been previously presented (Wetterberg et al, 1988). This more detailed account is made in the hope of eliciting suggestions as to aetiology and treatment.
Case report The patient shows compulsive, violently aggressive and destructive
behaviour,
faecal
smearing,
and hyperactivity.
These have remained stable. Her daily routine is rigid and
ritualistic
and
it is nearly
impossible
to divert
her from it. She awakes, smears faeces on the wall, tears her underclothing,
and engages in postprandial
spitting and
vomiting. She walks for 4-5 hoursin an enclosedyardwhile
ordering minor changes in diet. She writes two or more letters a day, frequentlysignedwith her father's name or the namesof others. She is generallyless aggressiveat night, goes to bed early and sleeps well regardless of daily events. Her violent behaviour may be precededby frustration but often occurs without obvious cause. She shows unusual strength during outbursts, often requiring several men to restrain her. She has inflicted severe injuries, including fractures, on others. She rarely attacks her parents but
destroystheirpossessionswhenangry.Her behaviourseems under some control since she accepts some staff members
Her illness is of early onset and she has never been symptom-free. She has never shown symptoms of disturbed consciousness, confusion, disturbed speech, seizures or other focal neurological signs, hallucinations, autism, depression, or memory disturbance, nor has there been any sign of deterioration.
Her vision and hearing are normal
and she seldom complains of headaches. The age of onset is unclear. Her mother claims detecting abnormallydestructive,aggressive,and anxious behaviour asearly asherdaughter's eighth month,butotherreports suggest normal early behaviour except for impulsive aggressive behaviour towards children her own age or younger outside the home. Aggressive, destructive, unpredictable, and compulsive behaviour became more manifest at the age of three upon the birth of her eldest brother. She receivedpsychiatriccounselling the following year and was admitted
for diagnostic
evaluation
at the age
of 7. Her behaviour deteriorated and she has been an in patient since the age of 10. Eating disorders began at age 20 and included postprandialspitting and vomiting. These have persisted. Her height is 171cm and her bodyweight presentlyranges between 40 and 45 kg. Since the age of 20 she has tried a series of diets, avoiding meat, sugar, fat, wheat,etc., without benefit. The patient expresses interest in her problem, but lacks insight. She says “¿I cannot do anythingabout my impulses. Igeta feeling inmy stomach, a tension, a fear. I haveto get rid of that tension. My wits are unleashed at that moment―.When asked about a future outside the hospital she responds with a stereotypic desire for “¿a husband, a home and a poodle―. Family history
The fatherwas reportedlyaggressive,destructive,impulsive, and antisocial as a child. At the age of 38 he experienced care but she often requests to be restrained, lest she “¿get unconsciousnessand an electroencephalogramshowedepileptic inthefrontotemporal regions oftheleft cerebral an impulse―and injure someone, suggesting uncertain activity control of her emotions. hemisphere. He was treated with phenytoin and the
and is not violent during medicalexaminationsor dental
Bulimia nervosa in Hong Kong Chinese patients. S Lee, L K Hsu and Y K Wing BJP 1992, 161:545-551. Access the most recent version at DOI: 10.1192/bjp.161.4.545
References Reprints/ permissions You can respond to this article at Downloaded from
This article cites 0 articles, 0 of which you can access for free at: http://bjp.rcpsych.org/content/161/4/545#BIBL To obtain reprints or permission to reproduce material from this paper, please write to [email protected] /letters/submit/bjprcpsych;161/4/545 http://bjp.rcpsych.org/ on September 29, 2017 Published by The Royal College of Psychiatrists
To subscribe to The British Journal of Psychiatry go to: http://bjp.rcpsych.org/site/subscriptions/
545
PLAY IN GTS AND OCD
as an obsessive—compulsivephenomenon. Further
PAULS, D. L. & LECKMAN,J. F. (1986) The inheritance of Gilles
de la Tourette's syndrome and associated behaviors. New
research is needed to elucidate the nature of differences and resemblances inrepetitive phenomena
EnglandJournalof Medicine,315, 993—997.
in GTS and OCD.
studyof Gillesde la Tourettesyndrome.AmericanJournal of
RAYMOND,C. L., Smvat.aoN, J. M., et al(1991) A family
Human Genetics,48, 154—163. ROBERTSON,M. M. (1989) The Gilles de Ia Tourette syndrome:
Acknowledgement
the
currentstatus.BritishJournalof Psychiatry,154, 147—169.
We are most grateful to M. M. Robertson,MiddlesexHospital, London; D. L. Pauls, Child Study Center, Yale University, New Haven, USA; and M. F. Niermeijer, University Hospital, Rouerdam for their useful comments on the manuscript.
TRIMBLE,
M.
M.
& Lms,
A.
J. (1989)
Self-injurious
behaviour and the Gilles de Ia Tourette syndrome: a clinical study and review of the literature. Psychological Medicine, 19,
611—625. & GOURDIE, A. (1990)FamilialTourette's syndromein a largeBritishpedigree.British Journalof Psychiatry,156,515-521. SHAPIRo,A. K., SHAPIRO,E. S., Yout'ic, J. 0., et al (1988) Gilles
References
de Ia Tourette Syndrome (2nd edn). New York: Raven Press.
Asnaic@ PsycuiAliuc Associ@iioN(1987)Diagnostic and Statistical Manual of Mental Disorders (3rd edn, revised) (DSM—III—R). *D. C. Cath, MD, Psychiatrist, Psychiatric Hospital Washington, BULLEN,
J. 0.
Endegeest,Oegstgeest,The Netherlands;B. J. M.
DC: APA. & HEMSLEY, R. (1983)
Sensory
experience
as a
van de Wetering, MD, Psychiatrist, Department of Psychiatry, University Hospital Rotterdam-Dijkzigt, Rotterdam; T. C. A. M. van Woerkom, PhD, Psy chiatrist, Department of Neurology, Municipal Hos CoMINos, D. E. & CoMINGs, B. 0. (1987) A controlled study of Tourette syndrome, 1-VIl. American Journal of Human pitals, The Hague; C. A. L. Hoogduin, MD, PhD, Genetics,41, 701—866. Professor of Psychiatry, Department of Psychiatry, FRANKEL, M., CUMMINGS, J. L., R0B!tRTsoN, M. M., et al (1986) Reinier de Graaf Gasthuis, Deift, also Catholic Obsessions and compulsions in Gilles de la Tourerte's syndrome. University, Nijmegen; R. A. C. Roos, MD, PhD, Neurology, 36, 378-382. H@w4,E. DE(1988)A manwithcountingrituals:a diagnostic Neurologist, Department of Neurology, University problem. DirectiveTherapie,8, 127—134. Hospital, Leiden; H. 0. M. Rooijmans, MD, PhD, HooGnuiN, C. A. L. (1986) On the diagnosis of obsessive Professor of Psychiatry, Department of Psychiatry, compulsive disorder. American Journal of Psychotherapy, 15, University Hospital, Leiden, The Netherlands 36—51. trigger in Gilles de Ia Tourette's syndrome. Journal of Behaviour Therapy and Experimental Psychiatry, 14, 197-201.
KURLAN, R., LIcHmR, D. & Hswrrr,
D. (1989) Sensory tics in
Toureue's syndrome. Neurology, 39, 731—734.
Correspondence
Bulimia Nervosa in Hong Kong Chinese Patients SING LEE, L. K. GEORGE HSU and V. K. WING
In contrastto the West, bulimicdisordersare rarerthan anorexia nervosaIn Hong Kong. Four female normal weight bulimic patients with mostly typical clinical features and conspicuousmorbidityare reported.The casehistoriessupportthe hypothesisthat binge-eating Is used to regulate unpleasantaffect.
Malaysia, and Hong Kong. Although emaciation,
food refusal and amenorrhoea are universal among
Chinese anorexics, body-image distortion, a core diagnostic feature among Western anorexics and the reason most commonly given for wilful starvation, is frequently absent among Chinese patients, some BritishJournalof Psychiatry(1992),161, 545—551 of whom may blame indigestion or fullness for their poor intake (Lee, 1991). Perhaps of significance is the report that body-image disturbance is also not
Although there is frequent mention of a modern ‘¿epi found among anorexics in India (Khandelwal & demic' of eating disorders, classic anorexia nervosa anorexia nervosa is almost unknown, and it remains
Saxena, 1990). If these findings are substantiated by future studies, then the diagnostic criteria for anorexia nervosa may need to be modified in non
very rare among the Chinese populations of Singapore,
Western cultures.
has remained rare (Whitaker eta!, 1990). In China,
546
LEE ET AL
In contrast,
bulimia nervosa, which has more
recently been distinguished from anorexia nervosa
critical remarks from others. On average she secretly consumed 800 g of bread and biscuits. Such episodes were
(American Psychiatric Association, 1987), is appar ently becoming more common among Western
was nausea but no vomiting. She took excessive laxatives
followedby abdominalbloating,guiltand dysphoria.There
females (Pyle et al, 1986), although this finding may
(usuallyprunejuice)to purgeand ‘¿calm' herself,restricted
be open to dispute. Nonetheless, it is clear that bulimia nervosa is at least three to four times more
Her body weight fluctuated by up to 4 kg per week, but her menseswere normal. There was no weight or mental
prevalent than anorexia nervosa (Patton et al, 1990; Whitaker et a!, 1990). Among anorexics reported from non-Western
food intake and exercisedexcessively in the next 1—2 days. disorder in the family.
Mental examinationrevealeda fullyconsciousgirl who felt helpless over the “¿attacks of overeating―.She desired
countries (Khandelwal& Saxena,1990;Lee,1991), a body weightof 45 kg and disparaged her waistlineand
however, typical bulimic symptoms are uncommon. Besides, using the Diagnostic Interview Schedule (DIS), the Shatin Psychiatric Epidemiological Survey conducted in 1984—86 in Hong Kong identified only one female with a lifetime DSM—III diagnosis of anorexia nervosa out of a community sample of 7229 subjects (3786 females, 3443 males, age range 18—64)(Chen et al, 1992), but apparently no
square
face, which
food dominated
made
her “¿look like a pig―. She found
her life, and likened her problem to heroin
addiction. There was a persistentrequest for laxatives, but
no significantdepressivefeatures.Laboratorytestsindicated a transient increase in serum free thyroxine because of the exogenous thyroxine used for weight reduction. The Minnesota Multiphasic Personality Inventory (MMPI; Hathaway & McKinley, 1967) revealed abnormal elevations
on the depression, hysteria, and psychaesthenia scales. Its
bulimia. Recently, a retrospective case review at the
profilesuggestedpoorpsychologicalintegration,denial,social
Department of Psychiatry of the University of Hong Kong indicated that there was only one case of
inadequacy and lack of drive. Her scores on the Eating Disorder Inventory (EDI; Garner et a!, 1983) were: drive forthinness=6, interoceptiveawareness= 13, bulimia= 11, body dissatisfaction =7, ineffectiveness =9, maturity fears = 2, perfectionism = 0, and interpersonal distrust = 3. Miss A received cognitive—behaviouraltherapy and a short course of imipramine. There were frequent relapses, and a transient episode of psychotic decompensation, during which she exhibited formal thought disorder, incongruous affect and the paranoid delusion that she had to work closely with the American Embassy for obscure reasons, but no major mood disturbance. This responded to neuroleptic treatment. A year later she stopped bingeing, but remained withdrawn and irregularly employed.
bulimia nervosa as compared with 42 anorexic patients treated over an eight-year (1980—88)period (Ho, personal communication) at a general teaching hospital which served a regional population of 0.6
million. Over 1984—91,our own unit at the Prince of Wales Hospital, which currently serves 0.5 million people, has treated 18 anorexics (Lee, 1991), but only
more recently (1989—91)four bulimic patients. As bulimia nervosa at normal weight has never been reported among the Hong Kong Chinese, we now describe them.
Case 2 Case reports
treatment
Case 1 Miss A was a 22-year-old single clerk, who was referred by
her doctor for treatment of ‘¿psychiatric problems'. She presented with a three-year history of uncontrolled over eating. Although she was not originallyobese (weight47 kg, height 152 cm, BMI (body mass index)= 20.34 kg/rn2), she disliked her “¿square face―,and developed a sensitive, moody and dependentpersonality.Her fatherwas rigidand avoidant, whereas her mother was nagging and dominating. As a result, they had frequent rows which caused feelings of helplessness in the patient. Since she failed in a public examination
Ms B (weight 47 kg, height 157cm, BMI = 19.07 kg/rn2) was a 34-year-old married clerk, who was referred for
and was unable to study graphics in a technical
school, she started to relieve boredom and comfort herself by overeating.She was upset to reacha maximumweightof 60kg (BMI = 25.97 kg/rn2), and abused slimming tablets.
This enabled her to lose 5—8 kg, but also increasedher urge to eat. Her binges occurred four times per week and lasted 1-3 hours each. Triggers included feelings of emptiness and
of anxiety neurosis. She presented with a 15-year
history of binge eating, which occurred 3-4 times per week. Each episode lasted 1-2 hours, and was precipitated by being alone at home, tension and exclusive thoughts of
food. On averageshe consumed600g of bread, but many other kinds of food (e.g. meat, fish, vegetables, and fruits) were ingested. A binge ended when a “¿sleepy feeling― occurred.
She was then
worried
about
her body
shape,
became guilty and demoralised. She did not induce vomiting, but used about five suppositories and exercised excessively by swimming up to three hours per day. Since
the age of 16, she had kept her weight remarkably stable at 47 kg. Ms B received 12 years of education. Since the age of six, she was attracted
towards the same sex, and frequently
caressed her younger sister while the latter was asleep. She dared not reveal this because of the severe stigmatisation of homosexualityin Chinesesociety. She neverhad a formal lesbianrelationship,and lived with persistentconflicts over her sexuality. She felt isolated, and started to cope with
547
BULIMIA IN HONG KONG her loneliness by overeating. At 26 she got marriedbecause her husband treated her “¿kindly―. However, her lesbian
became very moody. After repeated requests, 18 months later she was allowed to live with her grandmother in Hong
identity remained a secret, and their communicationwas
Kong again.
limited. She achieved sexual satisfaction by masturbation, which involved lesbian fantasy. There was also stress from the departureof a close female colleague (with whom she
a fitnessclub to lose weight. In the next few months, her
While in Hong Kong, Miss C found herself fat and joined
weight returned to 48 kg, but her binge episodes became
had an imaginaryrelationship),and the neonatal death of
more frequent than before. Typically, she consumed a
a prematurebaby. The lattercaused her to weep frequently for two monthsand fearfuturepregnancy.Heroccupational functioning, however, remained satisfactory. There was no family history of mental illness.
variety of snacks (e.g. biscuits, popcorn, dried cuttlefish)
Shelookedyoungerthan her age. Althoughnot strongly concerned with body shape, she felt that her abdomen could “¿perhaps be a little thinner―,and desired a body weight of 45 kg. Being preoccupied with food, she meticulously reported her daily caloric intake (this was unusual for a Hong Kong Chinese). There were repeated requests for laxatives because of constipation, and uncontrollable urges to overeatwhen she felt empty. Yet she also learnedto enjoy
a “¿sleep-like― feelingduring bingeing.She was not aware of any technique of self-induced vomiting, which she thoughtwas“¿difficult to carryout―. As rapport improved, she repeatedly sought reassurancethat her homosexuality was not a mental disease. MMPI revealed the typical
neurotic triad pattern with depression, multiple somatic complaints, and hysteroid features. Its profile suggested overcontrol of emotions, rebellion against the traditional feminine role, and a persistent identity crisis. The EDI
showed:drivefor thinness= 5, interoceptiveawareness= 4,
both at homeand in the streetuntil her stomachcouldhold no more. The binges involved a subjective loss of control, and weretriggeredby boredom, tensionand cravingspecific foods. They were followed by guilt and overconcern with
weightgain.Therewasno self-inducedvomitingor laxative abuse,
but
dietary
restriction
by skipping
most
regular
meals, and also attemptsto burn off calories by swimming and playing squash several times a week. Marked weight fluctuationswerenot noticed, and her menseswerenormal. Her school work deteriorated, and she became irritable, frequently tearful, yelled, and angrily tore photographs of her parents.Therewereno biological depressivesymptoms.
Examination showeda slim girl who was distressedby her constant preoccupation with food. She was upset by her previousweight gain, but acceptedhercurrentbody weight, which she maintained only with “¿a lot of self restraint over eating―.She was weepy because of her ambivalence over her school work and future career. She described herself to be “¿very Chinese―and had a recurrent nightmare about her recent visit to the UK. She could see that
bulimia= 3, body dissatisfaction = 5, ineffectiveness = 7, maturity fears= 2, perfectionism=10 and interpersonal distrust= 7. With out-patient psychotherapy, she was able to live with her clandestine lesbianism with less distress, but her binge-eating persisted as a means of soothing
herbingeeating wasa way ofdistracting herself fromher “¿insoluble problems―, andwasworried thatthis became addictive. MMPI revealedelevation only on the depression scale, and its profile suggestedhelplessnessand demoralisa tion. The EDI indicated:drivefor thinness= 8, interoceptive awareness = 12, bulimina =5, body dissatisfaction =7,
herself.
ineffectiveness=9, maturity fears=6, perfectionism=9,
Case 3 Miss C (weight 48 kg, height 161 cm, BMI = 18.5 kg/m2) was a 19-year-old A-level student, who was referred for “¿emotional problems―.She presented with a one-year history of binge-eating severaltimes a week. She was born in the UK in a Chinese family which ran a cafeteria in Bristol. When she was five, she was sent to Hong Kong by her parents to live with her grandparents, so that she could “¿learn to speak Chinese there―. Despite early separation from her family, she lived happily with her grandparents who were protective towards her. She developed a conservative, anxiety-prone personality, and was an above-average student who had high expectation of herself. Two years before presentation, after the death of her grandfather, she was reluctantly advised by her parents to return to the UK, so that she could enjoy free and ‘¿better' education there. After arrival,she experienced markedadjustmentdifficultiesin schooling, socialisolation, and conflicts with her “¿noisy― mother who showed favouritism towards her Westernised and academically
successful siblings. She learned to cope with her lonely feelings by overeating a variety of junk foods, as a result of which she was disappointed to reach 54kg (BMI = 20.8 kg/rn2). She lost interest in school work and
interpersonaldistrust= 6. Her binges decreased with out patient psychotherapy, but she later defaulted treatment despite frequent moodiness. Case 4 Miss D was a 25-year-old single primary school teacher, who first presented to a gynaecologist for transient secondary amenorrhoea. This recovered spontaneously after thorough investigations, and she was then referred for treatment of “¿abnormal eating habit and possible anorexia nervosa―. After beingcasuallyremarkedto be fat four years earlier,
she started
to diet by reduced
food intake
and 1-3
hours of aerobic exercise per day. Her weight decreased from 58 kg (height 158cm, BMI = 23.23 kg/rn2) to her desired body weight of 48 kg (EM! = 19.23 kg/rn2), which was also her ideal body weight according to the local Chinese norm. She became overconcerned with her body weight, and developed intense preoccupation with food. When she was bored and feeling empty in the past year, she consumed various kinds of food availablein the home, including bread, biscuits, Chinese soup, instant noodles, peanuts, and chicken wings. This involved “¿a loss of thinking―and usually lasted 1.5 hours in the evenings. It was followed by a sense of heaviness in the abdomen, tiredness, fear of weight gain, and guilt. There was
548
LEE ET AL
self-induced vomiting and subsequent throat discomfort. To her disappointment her weight returned to 56 kg.
(1979) puts it, the result of a “¿starved body rebeffing and demanding to be fed―.
Miss D was born in a traditional Chinese family, which showed obvious favouritism for her two brothers. Her
clinical features of bulimia nervosa in Hong Kong
father was emotionally distant, and she developed a dependent personality with low self-esteem and ambivalence
towards her domineering mother. Despite her parents'
If future studies confirm our observation that the resemble those in the West, two questions immediately present themselves: why is the disorder so rare in
Hong Kong, and why is it becoming more prevalent now? Our answers to these two questions must be as an achievement, and was naive in heterosexual relationships.Therewasno familyhistoryof mentalillness speculative because the aetiology of bulimia nervosa devaluation of the educational need for females, she obtained a diploma in college.Yet she did not regard this or obesity.
On mental
status
examination,
she was
preoccupied with food, and admitted that her body weight affected her self-esteem. She disliked her arms and hips, and her desired body weight was 47 kg. Although she recognised the harmful effects of her “¿irrational― eating,
she was unable to stop it. She likened herself to a goldfish,
whichate untilitsabdomenbecameswollen.Therewasguilt not only over becoming fat, but also wasting food, which “¿should be enjoyed―.She described how she
remains unclear. In the West, the following risk factors are associated with the development of an eating disorder: female gender, adolescence and young adulthood, Caucasian race, higher socio
economic status, higher premorbid percentile weight, family history of eating or mood disorder, and cultural emphasis on slimness. All the four cases that
spontaneously learned to induce vomiting by using her right
we have described are young females, but they did not all come from an upper social class background.
index and middle fingers. There was no significant depression. Physical and laboratory assessment was normal.
Higher premorbid body weight and dieting behaviour have been identified in several recent studies as
MMPI revealed elevated scores on the depression
and
powerful predictors for the onset of bulimic disorders (e.g. Patton et a!, 1990). This certainly seemed to operate in our patients since their mean premorbid thinness = 18, interoceptive awareness = 13, bulimia = 14, BMI (22.27 kg/m2) was high by Hong Kong Chinese body dissatisfaction = 18, ineffectiveness = 17, maturity standards, and mightcontribute totheir characteristic fears =6, perfectionism =6, and interpersonal distrust =6. fear of fatness which was frequently absent among Despite two years of psychotherapy, her binges persisted. Chinese anorexic patients in Hong Kong (Lee, 1991). We contend therefore that bulimic disorders are rare Discussion in Hong Kong because obesity (BMI >25 kg/m2) is The rarity of bulimic symptoms in Hong Kong may relatively rare among its indigenous population, and be reflected by our patients' non-specific reasons for dieting behaviour is uncommon. Compared to their referral, namely, ‘¿psychiatric problems', ‘¿anxiety Western counterparts, Chinese girls are slim, if not neurosis', ‘¿abnormal eating habits', and ‘¿emotional underweight. Although Western females commonly use ‘¿fear of fatness' as an idiom of distress, the problems', as bulimia is still unfamiliar to many Chinese have traditionally accepted and even valued medical practitioners. Nonetheless, their clinical features largely resembled those of Western bulimic a degree of fatness. Greeting someone with “¿You patients, and would meet criteria for the DSM-III-R have put on weight―, for example, is still regarded (American Psychiatric Association, 1987) diagnosis as a compliment. Although it is only understandable of bulimia nervosa without modification. In the first that modern Chinese girls also prefer not to be fat, three patients the binge-eating seemed to have there is less stigmatisation of obesity, which is not equated with physical, mental or moral impairment. occurred at a time of distress. The disorder could In contrast, thinness is associated with ill-health and thus represent a set of dysfunctional behaviours resulting from “¿a difficulty in coping with disturbed bad luck and not, as in the West, with self-discipline, feelings and thoughts― (Fairburn, 1985). This attractiveness, or economic well-being. paralleled Western bulimic patients, whose urge to The diet of the Chinese is generally low in fat and binge is typically triggered by emotional states such high in fibre content, and it is less common for as depression, boredom, anxiety, and anger, so that them to characterise fattening food as “¿bad and binge-eating may serve to regulate affect or induce forbidden―,as many in the West may apparently do. nurturance (Abraham & Beumont, 1982). The fourth While it may be an exaggeration to claim that “¿guilt patient was premorbidly heavier, had higher scores about ingestion has become a national political issue―(Schwartz et a!, 1982), it is nevertheless true on the ED!, and began binge-eating after a weight that many apparently normal Western women loss of 10 kg. Her onset is therefore consistent with the conceptualisation that bulimia is a response to experience guilt and shame after eating fattening chronic starvation and over-restraint, or as Russell foods. In contrast, the Chinese enjoy eating and use psychaesthenia scales. The profile suggested self-criticism, denial and reaction formation. The EDI showed: drive for
BULIMIA IN HONG KONG sophisticated
combinations
of food to promote
health and longevity. Eating is also a major channel for the development of interpersonal
549
This is considered tolead tolow self-esteem, poor body acceptance, a constant need to be slim, ambivalence
towards career achievement, and a morbid fear of
relationships, or even a tool of conducting diplomatic
negative evaluation and rejection, particularly from
intercourse. The Chinese commonly say “¿Have you eaten?―when others would say “¿Hello―, and believe
men (Boskind-Lodahl, 1976).According to Confucian precepts, however, self-esteem and happiness among Chinese females are based more on success in social
that “¿being able to eat is to have luck―.According to traditional Chinese belief, individuals who prevent others from eating good food may be reincarnated as “¿hungry demons―, which are the most abhorred of all demons. Confucius, whose ideology has a profound influence in shaping proper behaviour in Chinese society, wrote “¿Human nature naturally desires sex and food―.Chinese culture may therefore discourage restraint from eating, and the relative absence of obesity may obviate the need for weight
control, which predisposes to bulimia.
role performance, especially in the family (Bond, 1991), than physical appearance or career accom
plishment. Therefore, while there are no hard data to suggest that the role of Chinese women in Hong Kong is less conflictual, it is plausible that their role
is more straightforward in a society where gender roles are still under traditional influence. If so, this may be yet another factor that reduces bulimic disorders in Hong Kong. In the West, bulimics usually use vomiting as a method of weight control (Russell, 1979). Some of them are aware of a variety of techniques, and may even take medical precautions such as potassium supplement immediately after vomiting (Abraham
Among many Chinese, food is considered a source of energy (qi) for the body rather than a quantitative amount of proteins or vitamins. Therefore, although some foods may be classified as potentially bad for health, this is frequently in terms of “¿energy & Beumont, 1982). Accordingly, there is the imbalance―according to traditional Chinese medical suggestion that self-induced vomiting should be belief rather than with exclusive caloric connotations. included as a mandatory criterion for the diagnosis An excessive consumption of ‘¿hot' food, for example, of bulimia. However, our patients abused laxatives can be neutralised by taking more ‘¿cooling' food in predominantly. In fact, all except the last patient order to re-establish energy equilibrium. Therefore, seemed not to have ‘¿discovered' self-induced vom iting. Although not proven, it is possible that inducing vomiting to dispose of excessive ‘¿bad' food may be superfluous, and the mental mechanisms self-induced vomiting as a means of weight control (e.g. “¿Now that I have taken the first bite I might may be “¿socially contagious― (Chiodo & Latimer, as well go all the way―)that trigger a binge in 1983). In a survey of 647 Chinese female university Western females may not commonly operate in the students (mean age= 19.2 years, s.d. 1.16, mean Chinese consciousness. BMI= 19.5 kg/m2, s.d. 1.87) using the Eating Attitudes Test (Garner & Garfinkel, 1979), 1.2°loof Whereas behavioural restraint and social con formity are personality risk factors for restrictive them scored on item 13 (“vomitafter I have eaten―) anorexia nervosa (Casper, 1990), impulsivity has a and item 40 (“havethe impulse to vomit after known association with bulimia (Pyle et a!, 1981; meals―)respectively (Lee, unpublished). Because of the non-specific nature of these items, it is unclear Lacey & Evans, 1986). Although there is no emphasis on restraint from eating or pursuit of thinness, how many of these students vomit after eating for the purpose of controlling weight. However, the Chinese socialisation discourages impulsive behaviour apparentlymore so than in theWest, and values, figures are still lower than the 4.5°loof women who perhaps to an excessive degree, self-discipline and reported vomiting for the specific intention of weight interpersonal harmony (Bond, 1991). This, among control in a mid-Western university in the United other reasons, may explain the lack of alcohol abuse, States (Pyle eta!, 1986). Elsewhere, we have reported overdoses and other ‘¿borderline' behaviour (Lacey that self-induced vomiting is rare among a series of & Evans, 1986) in our patients. On the MMPI, they Chinese anorexic patients with slim premorbid body
also did not show elevated scores on the psychopathic deviant scale (Pyle et a!, 1981), which is a measure of impulsivity. However, the small number of patients precludes any definite conclusion about the personality of Chinese bulimic patients. Among feminist researchers in the West, the position is strongly held that the high prevalence of bulimia among women is related to their complex and conflicting roles in contemporary Western society.
shape (Lee, 1991), whereas up to 40% of anorexic (Hsu et a!, 1979) and 90% of bulimic patients (Chiodo & Latimer, 1983) may do so in the West. Understandably, since the media in Hong Kong have yet to publicise the eating disorders, the idea that self induced vomiting can be an effective method (at least in the short-term) of weight control (Chiodo & Latimer, 1983) has not become widely known. Among many Chinese, moreover, the belief is
LEE ET AL
550
perhaps still common that wasting food by vomiting may lead to bad luck and severe punishment by gods
or spirits. Describing somebody or something as “¿causing one to vomit― is a most severe way of expressing disapproval and shame. These beliefs may discourage, but certainly not prevent, the use of vomiting to control body weight among Chinese
Acknowledgement Weare gratefulto T. P. Ho, C. H. Hung, S. Chan and C. Tang. References ABRAHAM, S. & BEUMONT, P. J. V. (1982) How patients describe
bulimia or binge eating. Psychological Medicine, 12, 625—635. AMERICAN PSYCHIATRIC ASSOCiATION (1987)
females. We speculate therefore that the rarity of bulimia nervosa in Hong Kong is related mainly to the relative absence of relevant sociocultural risk factors. In doing so we are not ignoring the role of biological factors in the pathogenesis of the disorder. While decreased central noradrenergic activity has been
implicated as a trait-disturbance in bulimia nervosa (Kaye et a!, 1990), replications of the finding are still lacking. Similarly, the report remains unconfirmed that an impaired cholecystokinin response to eating occurs in acutely bulimic patients (Geracioti & Liddle, 1988). Even if primary biological disturbances are
identified in bulimia nervosa, our contention still standssincetheexisting datasuggest thattheonsetof a bulimic disorder is best explained by an interplay of biological and psychosocial factors. Finally, eating disorders (Strober et a!, 1985) and mood disorders (Hudson et a!, 1987) have been found to be more prevalent among the family members of bulimic patients. The absence of such family histories among our patients may be related
to the small sample size, the relatively young age of some family members who may still be at risk for
Diagnostic
and
Statistical Manual of Mental Disorders (3rd edn, revised)
(DSM-III-R). Washington,DC: APA. BOND, M. H. (1991) Beyond
the Chinese Face: Insights
From
Psychology. Oxford: Oxford University Press. BOSKIND-LODAHL,M. (1976) Cinderella's
step-sister:
A feminist
perspective on anorexia nervosa and bulirnia. Signs: Journal of Women in Culture and Society, 2, 342—356. CASPER, R. C. (1990) Personality
features
of women with good
outcome from restricting anorexia nervosa. Psychosomatic Medicine, 52,156—170. CHEN, C. N., Wor@io,J., Las, N., a: al (1992) The Shatin
community mental health survey in Hong Kong: II. Major
findings.Archivesof GeneralPsychiatry(in press). CHIODO, J. & LATIMER,P. R. (1983) Vomiting as a learned weight
control technique in bulimia. Journal of Behaviour Therapy& Experimental Psychiatry, 14,131—135. FMRBURN, C. G. (1985) Cognitive-behavioural treatment for bulimia. In Handbook of Psychotherapy for Anorexia Nervosa
and Bulimia(edsD. M. Garner&P. E. Garflnkel),pp. 160-192. New York: Guilford Press. GARNERD. M. & GARFINKEL,P. E. (1979) The eating attitudes test:
an indexof the symptomsof anorexianervosa.Psychological Medicine, 9, 273—279. Ou@eri@, M. A. & Pouvy, i. (1983) Development and vali dation of amukidimensional eating disorderinventory for anorexia
nervosa and bulimia. International Journal of Eating Disorders,
2, 15—34. Gsa*cJoTl, T. D. & LIDDLE,R. A. (1988) Impaired cholecystokinin
secretion inbulimia nervosa. New EnglandJournal ofMedicine,
319,683—688. thedevelopmentof a mood or eatingdisorder ata HAThAWAY S. R. & McKmaxy, J. C. (1967) Minnesota Mu!t@phasic Personality Inventory: Manualfor Administration and Scoring. later time in life, and the inability on our part to New York: Psychological Corporation. interview directly all their family members. Although Hsu, L. K. G., CRISP,A. H. & HARDISO, B. (1979)Outcomeof anorexianervosa. Lancet, i, 62-65. disturbedfamilydynamics were presentin three HUDSON,J., Pops, H., JoNAs, J., ci al (1987) A controlled family of our cases, their primary aetiological role in historystudyof bulimia.PsychologicalMedicine,17,883—890. the pathogenesis of an eating disorder remains KAYE,W. H., GWIRTEMAN, H. E., GEORGE,D. T., ci a! (1990) Disturbances of noradrenergic systems in normal-weight bulimia: speculative.
Why then has the disorder become apparently more prevalent among the Chinese in Hong Kong? We conjecture that the answer lies in the recent emergence of the relevant risk factors in the culture of Hong Kong. As obesity and attendant weight control become more widespread among Chinese adolescents, and as Westernised eating habits (e.g. eating fast foods) and ideals of female slimness become incorporated into the Hong Kong culture, bulimic disorders may increase in fre quency. Already anorexia and bulimia nervosa have become common in Japan, where their clinical features are virtually indistinguishable from those
in the West (Suematsu et a!, 1985). After all, culture
is at once continuous
and plastic;
as it
quietly transforms, novel disorders may find their expression.
relationship to diet and menses. Biological Psychiatry, 27,4—21. KHANDELWAL,S. K. & SAXENA, 5. (1990) Anorexia nervosa in
peopleof Asianextraction.BritishJournalof Psychiatry,157,784. LACEY, J. H. & EVANS, C. D. H. (1986) The impulsivist:
a
mukiimpulsive personality disorder. British Journal of Addiction,
81, 641—650. Lea, 5. (1991) Anorexia nervosa in Hong Kong- a Chinese perspective. Psychological Medicine, 21, 703—711. PATrON, G. C., JOHNSON-SABINE,E., WooD, K., ci al (1990)
Abnormal eating attitudes in London schoolgirls - a prospective epidemiological study: outcome at twelve month follow-up. Psychological Medicine, 20, 383—394. PYLE, R. L., MITCHELL, J. E. & ECKERT, E. D. (1981) Bulimia: a
report of 34 cases.Journal of ClinicalPsychiatry,42, 60—64. —¿,
HALVORSON,
P.
A.,
NEUMAN,
P.
A.,
ci
a!
(1986)
The
increasing prevalence of bulimia in freshman college students. International Journal ofEatingDisorders, 5,631—647. RUSSELL,G. F. M. (1979) Bulimia nervosa: an ominous variant of
anorexia nervosa. Psychological Medicine, 9,429—448. SCHWARTZ,D. N., THOMPSON, M. G. & JOHNSON, C. L. (1982)
Anorexia nervosa and bulimia: the sociocultural context. International Journal of Eating Disorders, 1, 20—36.
551
BULIMIA IN HONG KONG STROBER,M., MORRELL,W., BURROUGHS,J., ci a! (1985) A
controlled family study of anorexia nervosa. Journal of Psychiatric Research, 19, 239-246. SUEMATSU, H.. I5rnKAWA,H., KUBOKI,1., ci al (1985) Statistical studies on anorexia nervosa in Japan: detailed clinical data
on 1,011 patients. Psychotherapy & Psychosomatics, 43, 96—103. WHITAKER, A., JoHNSoN,
J., SHAFFER, D., ci al (1990)
Uncommon
troubles in young people: Prevalenceestimates of selected psychiatric disorders in a nonreferred adolescent population. Archives of General Psychiatry, 47, 487—496.
Chromosomal
Aberrations
5Sing Lee, MRCPsych,Senior Lecturer,
Department
of Psychiatry,ChineseUniversityof Hong Kong, il/F Princeof WalesHospita4Shatin,Hong Kong; L. K. George Hsu, MD, MRCPSyCh, Associate Professor
of Psychiatry, WesternPsychiatricInstitute and Clinic, Universityof Pittsburgh,USA; Y. K. Wing, MRCP, MRCPsych,Lecturer, Department of Psychiatry,
Chinese University of Hong Kong, Shatin, Hong Kong Correspondence
in a Patient with Severe Psychopathology
GUNNAR AKNER, KARL-HENRIKGUSTAVSON, EVA HAKANSSON, JAN SAAF, HANS KIESSLING,ARTHUR VUWILERand LENNARTWETTERBERG The case of a female patient showing aggressive, compulsive, destructive behaviour, ritualistic faecal smearing, and hyperactivity is presented. The behaviour Is long standing, therapy-resistant, and Its aetlology Is
unknown, although ft Is seemingly associated with chromosomal abnormalities plasmafactors.
secondary
to abnormal
BritishJournalof Psychiatry(1992),161, 551-555 An abstract on this patient has been previously presented (Wetterberg et al, 1988). This more detailed account is made in the hope of eliciting suggestions as to aetiology and treatment.
Case report The patient shows compulsive, violently aggressive and destructive
behaviour,
faecal
smearing,
and hyperactivity.
These have remained stable. Her daily routine is rigid and
ritualistic
and
it is nearly
impossible
to divert
her from it. She awakes, smears faeces on the wall, tears her underclothing,
and engages in postprandial
spitting and
vomiting. She walks for 4-5 hoursin an enclosedyardwhile
ordering minor changes in diet. She writes two or more letters a day, frequentlysignedwith her father's name or the namesof others. She is generallyless aggressiveat night, goes to bed early and sleeps well regardless of daily events. Her violent behaviour may be precededby frustration but often occurs without obvious cause. She shows unusual strength during outbursts, often requiring several men to restrain her. She has inflicted severe injuries, including fractures, on others. She rarely attacks her parents but
destroystheirpossessionswhenangry.Her behaviourseems under some control since she accepts some staff members
Her illness is of early onset and she has never been symptom-free. She has never shown symptoms of disturbed consciousness, confusion, disturbed speech, seizures or other focal neurological signs, hallucinations, autism, depression, or memory disturbance, nor has there been any sign of deterioration.
Her vision and hearing are normal
and she seldom complains of headaches. The age of onset is unclear. Her mother claims detecting abnormallydestructive,aggressive,and anxious behaviour asearly asherdaughter's eighth month,butotherreports suggest normal early behaviour except for impulsive aggressive behaviour towards children her own age or younger outside the home. Aggressive, destructive, unpredictable, and compulsive behaviour became more manifest at the age of three upon the birth of her eldest brother. She receivedpsychiatriccounselling the following year and was admitted
for diagnostic
evaluation
at the age
of 7. Her behaviour deteriorated and she has been an in patient since the age of 10. Eating disorders began at age 20 and included postprandialspitting and vomiting. These have persisted. Her height is 171cm and her bodyweight presentlyranges between 40 and 45 kg. Since the age of 20 she has tried a series of diets, avoiding meat, sugar, fat, wheat,etc., without benefit. The patient expresses interest in her problem, but lacks insight. She says “¿I cannot do anythingabout my impulses. Igeta feeling inmy stomach, a tension, a fear. I haveto get rid of that tension. My wits are unleashed at that moment―.When asked about a future outside the hospital she responds with a stereotypic desire for “¿a husband, a home and a poodle―. Family history
The fatherwas reportedlyaggressive,destructive,impulsive, and antisocial as a child. At the age of 38 he experienced care but she often requests to be restrained, lest she “¿get unconsciousnessand an electroencephalogramshowedepileptic inthefrontotemporal regions oftheleft cerebral an impulse―and injure someone, suggesting uncertain activity control of her emotions. hemisphere. He was treated with phenytoin and the
and is not violent during medicalexaminationsor dental
Bulimia nervosa in Hong Kong Chinese patients. S Lee, L K Hsu and Y K Wing BJP 1992, 161:545-551. Access the most recent version at DOI: 10.1192/bjp.161.4.545
References Reprints/ permissions You can respond to this article at Downloaded from
This article cites 0 articles, 0 of which you can access for free at: http://bjp.rcpsych.org/content/161/4/545#BIBL To obtain reprints or permission to reproduce material from this paper, please write to [email protected] /letters/submit/bjprcpsych;161/4/545 http://bjp.rcpsych.org/ on September 29, 2017 Published by The Royal College of Psychiatrists
To subscribe to The British Journal of Psychiatry go to: http://bjp.rcpsych.org/site/subscriptions/
