Behaviors. Vol. Il. pp. 603-607. Printed in the USA. i\ll rights reserved.
.dddicrrw
1992 Copyright
BRIEF
OCCURRENCE
0306~1603192 S5.00 A .OO C I992 Pergamon Press Ltd.
REPORT
BULIMIA SERVOSA: WITH PSYCHOACIIVE DISORDERS
SUBSTANCE
USE
JOEL R. WILSON North Dakota State Hospital. Jamestown. ND ,\bstrdct - The prevalence of bulimic symptomatology was determined in the female population ofa state-funded chemical dependent! treatment unit. Sixty women. 39 Caucasian and 2 I Native American. all diagnosed \Qith a psychoactive substance use disorder. uere evaluated using both the Bulit-R and the eating disorder section of the Structured Clinical Intervieu for the DSM III-R to diagnose bulimia nervosa. The prevalence of bulimia Has calculated to be I% of the total subject group. Additionally. 3 anorectics \\ere identified. resulting in a 17% rate of diagnosable eating disorders in the total group. Percentages of occurrence in the Caucasian group alone were 15%for bulimia and 23% for the combined eating disorders.
is a term that was derived from the Greek meaning of”Ox hunger” (French $2 Baker. 1984). The classic symptoms of this disorder include episodes of food binges followed by some type ofcompensatory behavior, such as self-induced vomiting. abuse of laxatives or diuretics, and periods of fasting or excessive esercise. While explanations appear to be as plentiful as theoretical orientations. similarities noted in the dynamics and characteristics ofbulimics and psychoactive substance abusers have lead some researchers to believe that bulimia may be a variation ofan addictive disorder (Brisman & Siegal, 1984: Bulik. 1987: Mule, 198 1). Addiction, a term that historically has been used to describe dependence upon some type of psychoactive substance. has increasingly been used to describe other habitual. repetitive behaviors. According to B&man and Siegal ( 1984). bulimic behavior can be considered a psychological addiction to binge eating and purging. Boskind-White and White ( 1983) suggest that the bulimics world revolves around food. much the same as the substance abusers life revolves around drugs. The repetitiveness and lack of control over the binge/purge cycle is evidenced in a report by Pyle, hlitchell, and Eckert ( 198 1) in which it was observed that binge eating and purging behavior persisted in spite of the development of significant life problems. General observations of psychological traits of bulimics and alcoholics made bq Jones. Cheshire. and Moorhouse (1985) indicate that both groups tend to be rather impulsive. with evidence of low self-esteem. guilt. and self-depreciating thinking. Comparisons of psychological characteristics. as measured by the Minnesota Multiphasic Personality Inventory (MMPI) tend to support these observations. A number of studies have noted similarities on MMPI scales when comparing bulimics and psychoactive substance abusers. Hatsukami. Oiven, Pyle. and Mitchell (1982) found similar elevations on scale 7 (depression) and scale 8 (schizophrenia). while Norman and Herzog ( 1983) noted similarities on scale -1(psychopathic deviate). Bulimia
603
604
JOEL R. WILSON
The incidence of psychoactive substance use disorders occurring in groups of bulimits has been noted to be significant when compared with normal groups. Pyle et al. ( 198 1) reported that 8 of 34 bulimic individuals had completed treatment for chemical dependency. In a later report by Mitchell. Hatsukami. Eckert. and Pyle (1985), 23% of the bulimics interviewed reported a history of alcohol abuse. A comparison of the incidence of psychoactive substance use disorders in bulimics to normal controls by Stern et al. ( 1984) revealed that 30% of the bulimics were diagnosed as having a psychoactive substance use disorder, while only 4% of the control group were diagnosed. Another study by Pyle et al. (1983) comparing characteristics of bulimic college students with their nonbulimic counterparts indicated significant differences in the occurrence of alcohol and drug abuse. Only 3.6% of the nonbulimic students had a history of alcohol or drug abuse as compared with 13.3% of the bulimic group. These aforementioned statistics represent a significant difference in the occurrence of psychoactive substance use disorders between bulimics and normal groups. According to Brisman and Seigal (1984). these data are suggestive of a cross-over of addictive behaviors, or symptom substitution. Unfortunately, little data has been found regarding the incidence of bulimia in a group of psychoactive substance abusers. The only published article available at the time ofthis writing investigated the incidence ofeating disorders in a group ofcocaine abusers. Jonas. Gold, Sweeny. and Pottash ( 1987) found that 32% of the cocaine abusers surveyed met the DSM-III criteria for an eating disorder. Ofthe women included in this survey, 56% were diagnosed with bulimia according to DSIM-III criteria (APA, 1980) and of those, 75% met the more stringent criteria for bulimia which included the presence of self-induced vomiting. The purpose of this study is to investigate the occurrence ofbulimic symptomatology in a population of females with a diagnosed psychoactive substance use disorder. METHOD
The subject population consisted of all women who were admitted to the Chemical Dependency Unit of the North Dakota State Hospital during the screening period. Generally, the subject group comes from lower socio-economic levels and is comprised of both Native Americans and Caucasians.
The Bulit-R (Smith & Thelen, 1984) is an instrument that was specifically developed to identify symptoms of bulimia nervosa, according to the diagnostic criteria outlined in the DSM-III-R. (APA, 1987). This instrument is an updated version of the Bulit, which was developed to diagnose bulimia nervosa according to the criteria in the DSIMIII (APA, 1980). No data regarding reliability and validity was available for the Bulit-R as ofthis writing. However, the Bulit had a test re-test reliability of .87 over a I-week period. It also has known group validity as evidenced by the ability to distinguish clinically identified bulimics from normals. It has excellent concurrent validity, correlating with other measures of eating disorders, such as the Eating Attitudes Test (Corcoran & Fisher, 1987). The Structured Clinical Interview for DSM-III-R (SCID) is an interview form based upon DSM-III-R criteria for psychiatric disorders. No statistical reliability coefficients were reported. but in general, the results of the SCID were similar to other instruments such as the Personality Disorders Examination
Bulimia nervosa
605
(PDE) and the Structured Interview for DSM-III-R: Personality (Spitzer, Williams. Gibbon, & First, 1988).
Disorders (SID-P)
Following admission and detoxification. each woman diagnosed with a psychoactive substance use disorder by the admitting physician was oriented to this research project. Following the orientation interview. those individuals who volunteered to participate signed the subject consent form and a release of information. which would allow the diagnosis and other demographic information to be taken from their medical record. Each subject was then given a copy of the Bulit-R and instructed to complete the test according to the directions. Upon completion, those participants whose scores exceeded the cutoff level were interviewed using the SCID to confirm or disprove a diagnosis of bulimia nervosa. RESULTS A total of 87 women diagnosed with a psychoactive substance use disorder were oriented to this research project. Sixty individuals. or 69% of those oriented, volunteered to participate. Thirty-nine (65%) were Caucasian and 2 1 (35%) were Native American. The mean age ofthe total group was 33.29 years, with a standard deviation of6.69 years. Twenty-one percent were married. 40% were single, 33% were either separated or divorced. and 6% were widovved. Fifty-eight percent reported being unemployed prior to their hospitalization, and the mean educational level vvas 1 I .73 years with a standard deviation of 1.22 years. The testing identified bulimia nervosa in 7 ofthe 60 subjects. Additionally, 3 subjects reported having been treated for anorexia nervosa. This was an unexpected finding, but it was considered significant and, therefore, was also included in the data presentation. Table 1 outlines the prevalence of bulimia and anorexia. with an additional presentation of the combination of both eating disorders. When the prevalence of eating disorders is calculated for the Caucasian subjects only. the percentage of bulimia is found to be 15% (6 of 39). with anorexia at 8% (3 of 39). Therefore, the total percentage ofeating disorders found in the Caucasian group was 23%. The Native American group was found to have only 1 bulimic in a total of 2 1, or 5% of that group.
DISCUSSION
The purpose ofthis research project has been to study the co-existence ofbulimia and psychoactive substance use disorders. The rates of occurrence found in this study are quite high when compared with data
Table I. The prevalence of eating disorders
Son-eat dis. Bulimic Anorexic Total eat dis. Total
Total group 11= 60
Native American n = 21
10 (83%) 7 (12%) 3 (5%) 10(17%) 60 ( 100%)
20 (95%)
I (5%) 0 (0%)
I (5%) ‘I (100%)
Caucasian )I = 30 30 (77%) 6 (15%) 3 (8%) 9 (23%) 39 ( I OO?b)
606
JOEL R. WILSON
provided by Thelen, Mann, Pruitt, and Smith (1987). which suggested that the actual rate of occurrence of bulimia in a normal population is between 2%-3.8%. Unfortunately, it is difficult to make a determination of significance due to the extreme variations noted in rates of occurrence of bulimia. Occurrence rates as high as 20% have been noted by Ordman and Kirschenbaum ( 1985) and Kirkley ( 1986). However, consideration must be given to the diagnostic criteria used in these studies. The Caucasian group in this study presented a higher than expected percentage of bulimia. Generally, bulimia is most often found in young, white. achievement-oriented females from upper middle class families (Balaa, 1985; Newman & Halvorson, 1983). Those identified with bulimia in this study were older and from lower socio-economic groups. A comparison of these findings with data from chemical dependency facilities that cater to clients from upper income groups would allow further testing of the premise that bulimia is primarily a disorder of the upper middle class. Bulimia was not found to be significant in the Native American group. While one article by Rosen, Schafer, Dummer, Cross, Deuman, and Malmberg (1988) reported evidence of bulimic-like behavior in a Native American group. this was minimally evident in this study. However, further research comparing Caucasian and Native American groups could provide opportunities to explore the socio-cultural influences often thought to be a causative factor of eating disorders. A major limitation of this study was the relatively small subject group. However. in spite of this limitation, this study has provided a different view of the relationship between bulimia and psychoactive substance abuse. REFERENCES American Psychiatric Association (APA). (1987).Diagnostic and stalislicu/ tnanua~ of me&z/ disorders. 3rd ed., revised. Washington DC. American Psychiatric Association (APA). ( 1980). Diannoslic and statistical manuz/ ofmental disorders. 3rd ed. Wa&ington DC. Balsa, M. (1985). Anorexia nervosa and bulimia: The eating disorders. Disease-a-,\/onlh. 31(6). I-52 Boskind-White. M.. & White. W. (1983). Bulimerexiu. New York: W.W. Norton. Brisman, J., & Siegal. M. (1984). Bulimia and alcoholism: Two sides of the same coin. Joltma/ ofSltbsrance Abuse Treatmen!. l(2). I I3- I IS. Bulik. C. (1987). Drug and alcohol abuse by bulimic women and their families. .-lnzericun Journal offs~~chiarrj..
144. I604-
1606.
Corcoran. K.. & Fischer, J. (1987). .~/eas~fres& clinicalpractice. New York: The Free Press. French, R.. & Baker. E. (1984). Anorexia nervosa and bulimia. Indiana .Uedicine. 77(d). 241-245. Hatsukami. D.. Owen. P.. Pyle, R.. & Mitchell, J. (1982). Similarities and differences on the MMPI between women with bulimia and women with alcohol or drug abuse problems. .4ddicrive Behaviors. 7,435~439. Jonas. J. M., Gold, M. S., Sweeney. D.. Pottash. A. L. C. (I 987). Eating disorders and cocaine abuse: A survey of 259 cocaine abusers. Journal ofClinical PsJ,chialry, 48(l). 47-50. Jones. D. A.. Cheshire. N.. & Moorhouse. H. (1985). Anorexia nervosa, bulimia and alcoholism-association ofeating disorders and alcohol. J. Pqchial. Res.. 19(2/3), 377-380. Kirkley. B. G. ( 1986). Bulimia: Clinical characteristics. development and etiology. Journal ofthe .-lnzericun Dieieris.-lssociarion.
86(4). 468-475.
Mitchell. 1.. Hatsukami, D.. Eckert. E.. & Pyle, R. (1985). Characteristics of 275 patients with bulimia. .4rnerican Journnl q/Psvchiatry. 142(4), 482-485. Mule. S. (198 I). Behaviorit1e_rcess:.4n esaminarion ofvolilionaldisorders. New York: Macmillan Publishing Co.. Inc. Sewman. N. A.. & Halvorson. P. A. (1983). Anore.ria nervosa and bulimia: .4 handbook/or counselors and rherapisrs. New York: Van Norstrand Reinhold Company. Norman. D. K.. & Herzog. D. B. (1983). Bulimia. anorexia nervosa. and anorexia nervosa with bulimia: A comparative analysis with MMPl profiles. fmernational Jorvnal qfEuring Duorders. 2,4 I-50. Ordman, A.. & Kirschenbaum. D. (1985). Cognitive-behavioral therapy for bulimia: An initial outcome study. Jolrrnnl yfCorisu/ting atld Clinical Psycho/og~~. 53(3). 305-3 13.
Bulimia nervosa
607
Pkle. R.. Mitchell, J.. & Eckett, E. (I 98 I ). Bulimia: A report of 34 cases. ./oumul~/ C/ir~~t~a/P~clr~orrJ~. 4?(2). 60-64. Pyle. R.. Mitchell, J.. Eckert, E.. Halvorson, P.. Neuman. P.. & Goff. G. ( 1983). The incidence bulimia in freshman college students. Inrrrnarionai Jownal oj‘thring Disorders. 2(3), 75-8.3. Rosen. L., Shafer. C.. Dummer. G.. Cross. L., Deuman. G.. & Malmberg. S. (1988). Prctalence ofpathogenic weight control behaviors among Native American women and girls. Inrrrnn~ionu~ Jcwrnul qt.Eniirrg Dis-
of
orders, 7(6). 807-8
I I.
Smith. M. C. and Thelen. XI. H. (195-1). Development suiting
and Clinical
Psjrlrolog~..
and validation
of a test for bulimia. Jommzl
yi‘Con-
52. 8634372.
Spitzer, R.. Williams. J.. Gibbon, ht.. 8: First. M. (1989). Instrcxfion tnnnual for r/w srriccrlrrc,d clrtlical inrerviebvfor DS.\f-III-R. New York: Biometrics Research Dept.. New York State Pqchiatric Institute. Stern. S. L.. Dixon. K. N.. Nemzer. E.. Lake, M. D.. Sansone. R. A.. Smeltzer, D. J.. Lantz. S.. & Schrier, S. S. (1984). Affective disorder in the families ofwomen with normal weight bulimia. .4mcvicxtr Jolrrnnlqf Psjrhiafry. 141, 1714-1217. Thelen. M.. Mann, L.. Pruitt. J.. & Smith. M. (1987). Bulimia: Prevalence and component factors in college women. Jotrrnal ql‘Ps!r/ioson~ali~. Rt~search. 31( I ). 73-78.
.dddicrrw
1992 Copyright
BRIEF
OCCURRENCE
0306~1603192 S5.00 A .OO C I992 Pergamon Press Ltd.
REPORT
BULIMIA SERVOSA: WITH PSYCHOACIIVE DISORDERS
SUBSTANCE
USE
JOEL R. WILSON North Dakota State Hospital. Jamestown. ND ,\bstrdct - The prevalence of bulimic symptomatology was determined in the female population ofa state-funded chemical dependent! treatment unit. Sixty women. 39 Caucasian and 2 I Native American. all diagnosed \Qith a psychoactive substance use disorder. uere evaluated using both the Bulit-R and the eating disorder section of the Structured Clinical Intervieu for the DSM III-R to diagnose bulimia nervosa. The prevalence of bulimia Has calculated to be I% of the total subject group. Additionally. 3 anorectics \\ere identified. resulting in a 17% rate of diagnosable eating disorders in the total group. Percentages of occurrence in the Caucasian group alone were 15%for bulimia and 23% for the combined eating disorders.
is a term that was derived from the Greek meaning of”Ox hunger” (French $2 Baker. 1984). The classic symptoms of this disorder include episodes of food binges followed by some type ofcompensatory behavior, such as self-induced vomiting. abuse of laxatives or diuretics, and periods of fasting or excessive esercise. While explanations appear to be as plentiful as theoretical orientations. similarities noted in the dynamics and characteristics ofbulimics and psychoactive substance abusers have lead some researchers to believe that bulimia may be a variation ofan addictive disorder (Brisman & Siegal, 1984: Bulik. 1987: Mule, 198 1). Addiction, a term that historically has been used to describe dependence upon some type of psychoactive substance. has increasingly been used to describe other habitual. repetitive behaviors. According to B&man and Siegal ( 1984). bulimic behavior can be considered a psychological addiction to binge eating and purging. Boskind-White and White ( 1983) suggest that the bulimics world revolves around food. much the same as the substance abusers life revolves around drugs. The repetitiveness and lack of control over the binge/purge cycle is evidenced in a report by Pyle, hlitchell, and Eckert ( 198 1) in which it was observed that binge eating and purging behavior persisted in spite of the development of significant life problems. General observations of psychological traits of bulimics and alcoholics made bq Jones. Cheshire. and Moorhouse (1985) indicate that both groups tend to be rather impulsive. with evidence of low self-esteem. guilt. and self-depreciating thinking. Comparisons of psychological characteristics. as measured by the Minnesota Multiphasic Personality Inventory (MMPI) tend to support these observations. A number of studies have noted similarities on MMPI scales when comparing bulimics and psychoactive substance abusers. Hatsukami. Oiven, Pyle. and Mitchell (1982) found similar elevations on scale 7 (depression) and scale 8 (schizophrenia). while Norman and Herzog ( 1983) noted similarities on scale -1(psychopathic deviate). Bulimia
603
604
JOEL R. WILSON
The incidence of psychoactive substance use disorders occurring in groups of bulimits has been noted to be significant when compared with normal groups. Pyle et al. ( 198 1) reported that 8 of 34 bulimic individuals had completed treatment for chemical dependency. In a later report by Mitchell. Hatsukami. Eckert. and Pyle (1985), 23% of the bulimics interviewed reported a history of alcohol abuse. A comparison of the incidence of psychoactive substance use disorders in bulimics to normal controls by Stern et al. ( 1984) revealed that 30% of the bulimics were diagnosed as having a psychoactive substance use disorder, while only 4% of the control group were diagnosed. Another study by Pyle et al. (1983) comparing characteristics of bulimic college students with their nonbulimic counterparts indicated significant differences in the occurrence of alcohol and drug abuse. Only 3.6% of the nonbulimic students had a history of alcohol or drug abuse as compared with 13.3% of the bulimic group. These aforementioned statistics represent a significant difference in the occurrence of psychoactive substance use disorders between bulimics and normal groups. According to Brisman and Seigal (1984). these data are suggestive of a cross-over of addictive behaviors, or symptom substitution. Unfortunately, little data has been found regarding the incidence of bulimia in a group of psychoactive substance abusers. The only published article available at the time ofthis writing investigated the incidence ofeating disorders in a group ofcocaine abusers. Jonas. Gold, Sweeny. and Pottash ( 1987) found that 32% of the cocaine abusers surveyed met the DSM-III criteria for an eating disorder. Ofthe women included in this survey, 56% were diagnosed with bulimia according to DSIM-III criteria (APA, 1980) and of those, 75% met the more stringent criteria for bulimia which included the presence of self-induced vomiting. The purpose of this study is to investigate the occurrence ofbulimic symptomatology in a population of females with a diagnosed psychoactive substance use disorder. METHOD
The subject population consisted of all women who were admitted to the Chemical Dependency Unit of the North Dakota State Hospital during the screening period. Generally, the subject group comes from lower socio-economic levels and is comprised of both Native Americans and Caucasians.
The Bulit-R (Smith & Thelen, 1984) is an instrument that was specifically developed to identify symptoms of bulimia nervosa, according to the diagnostic criteria outlined in the DSM-III-R. (APA, 1987). This instrument is an updated version of the Bulit, which was developed to diagnose bulimia nervosa according to the criteria in the DSIMIII (APA, 1980). No data regarding reliability and validity was available for the Bulit-R as ofthis writing. However, the Bulit had a test re-test reliability of .87 over a I-week period. It also has known group validity as evidenced by the ability to distinguish clinically identified bulimics from normals. It has excellent concurrent validity, correlating with other measures of eating disorders, such as the Eating Attitudes Test (Corcoran & Fisher, 1987). The Structured Clinical Interview for DSM-III-R (SCID) is an interview form based upon DSM-III-R criteria for psychiatric disorders. No statistical reliability coefficients were reported. but in general, the results of the SCID were similar to other instruments such as the Personality Disorders Examination
Bulimia nervosa
605
(PDE) and the Structured Interview for DSM-III-R: Personality (Spitzer, Williams. Gibbon, & First, 1988).
Disorders (SID-P)
Following admission and detoxification. each woman diagnosed with a psychoactive substance use disorder by the admitting physician was oriented to this research project. Following the orientation interview. those individuals who volunteered to participate signed the subject consent form and a release of information. which would allow the diagnosis and other demographic information to be taken from their medical record. Each subject was then given a copy of the Bulit-R and instructed to complete the test according to the directions. Upon completion, those participants whose scores exceeded the cutoff level were interviewed using the SCID to confirm or disprove a diagnosis of bulimia nervosa. RESULTS A total of 87 women diagnosed with a psychoactive substance use disorder were oriented to this research project. Sixty individuals. or 69% of those oriented, volunteered to participate. Thirty-nine (65%) were Caucasian and 2 1 (35%) were Native American. The mean age ofthe total group was 33.29 years, with a standard deviation of6.69 years. Twenty-one percent were married. 40% were single, 33% were either separated or divorced. and 6% were widovved. Fifty-eight percent reported being unemployed prior to their hospitalization, and the mean educational level vvas 1 I .73 years with a standard deviation of 1.22 years. The testing identified bulimia nervosa in 7 ofthe 60 subjects. Additionally, 3 subjects reported having been treated for anorexia nervosa. This was an unexpected finding, but it was considered significant and, therefore, was also included in the data presentation. Table 1 outlines the prevalence of bulimia and anorexia. with an additional presentation of the combination of both eating disorders. When the prevalence of eating disorders is calculated for the Caucasian subjects only. the percentage of bulimia is found to be 15% (6 of 39). with anorexia at 8% (3 of 39). Therefore, the total percentage ofeating disorders found in the Caucasian group was 23%. The Native American group was found to have only 1 bulimic in a total of 2 1, or 5% of that group.
DISCUSSION
The purpose ofthis research project has been to study the co-existence ofbulimia and psychoactive substance use disorders. The rates of occurrence found in this study are quite high when compared with data
Table I. The prevalence of eating disorders
Son-eat dis. Bulimic Anorexic Total eat dis. Total
Total group 11= 60
Native American n = 21
10 (83%) 7 (12%) 3 (5%) 10(17%) 60 ( 100%)
20 (95%)
I (5%) 0 (0%)
I (5%) ‘I (100%)
Caucasian )I = 30 30 (77%) 6 (15%) 3 (8%) 9 (23%) 39 ( I OO?b)
606
JOEL R. WILSON
provided by Thelen, Mann, Pruitt, and Smith (1987). which suggested that the actual rate of occurrence of bulimia in a normal population is between 2%-3.8%. Unfortunately, it is difficult to make a determination of significance due to the extreme variations noted in rates of occurrence of bulimia. Occurrence rates as high as 20% have been noted by Ordman and Kirschenbaum ( 1985) and Kirkley ( 1986). However, consideration must be given to the diagnostic criteria used in these studies. The Caucasian group in this study presented a higher than expected percentage of bulimia. Generally, bulimia is most often found in young, white. achievement-oriented females from upper middle class families (Balaa, 1985; Newman & Halvorson, 1983). Those identified with bulimia in this study were older and from lower socio-economic groups. A comparison of these findings with data from chemical dependency facilities that cater to clients from upper income groups would allow further testing of the premise that bulimia is primarily a disorder of the upper middle class. Bulimia was not found to be significant in the Native American group. While one article by Rosen, Schafer, Dummer, Cross, Deuman, and Malmberg (1988) reported evidence of bulimic-like behavior in a Native American group. this was minimally evident in this study. However, further research comparing Caucasian and Native American groups could provide opportunities to explore the socio-cultural influences often thought to be a causative factor of eating disorders. A major limitation of this study was the relatively small subject group. However. in spite of this limitation, this study has provided a different view of the relationship between bulimia and psychoactive substance abuse. REFERENCES American Psychiatric Association (APA). (1987).Diagnostic and stalislicu/ tnanua~ of me&z/ disorders. 3rd ed., revised. Washington DC. American Psychiatric Association (APA). ( 1980). Diannoslic and statistical manuz/ ofmental disorders. 3rd ed. Wa&ington DC. Balsa, M. (1985). Anorexia nervosa and bulimia: The eating disorders. Disease-a-,\/onlh. 31(6). I-52 Boskind-White. M.. & White. W. (1983). Bulimerexiu. New York: W.W. Norton. Brisman, J., & Siegal. M. (1984). Bulimia and alcoholism: Two sides of the same coin. Joltma/ ofSltbsrance Abuse Treatmen!. l(2). I I3- I IS. Bulik. C. (1987). Drug and alcohol abuse by bulimic women and their families. .-lnzericun Journal offs~~chiarrj..
144. I604-
1606.
Corcoran. K.. & Fischer, J. (1987). .~/eas~fres& clinicalpractice. New York: The Free Press. French, R.. & Baker. E. (1984). Anorexia nervosa and bulimia. Indiana .Uedicine. 77(d). 241-245. Hatsukami. D.. Owen. P.. Pyle, R.. & Mitchell, J. (1982). Similarities and differences on the MMPI between women with bulimia and women with alcohol or drug abuse problems. .4ddicrive Behaviors. 7,435~439. Jonas. J. M., Gold, M. S., Sweeney. D.. Pottash. A. L. C. (I 987). Eating disorders and cocaine abuse: A survey of 259 cocaine abusers. Journal ofClinical PsJ,chialry, 48(l). 47-50. Jones. D. A.. Cheshire. N.. & Moorhouse. H. (1985). Anorexia nervosa, bulimia and alcoholism-association ofeating disorders and alcohol. J. Pqchial. Res.. 19(2/3), 377-380. Kirkley. B. G. ( 1986). Bulimia: Clinical characteristics. development and etiology. Journal ofthe .-lnzericun Dieieris.-lssociarion.
86(4). 468-475.
Mitchell. 1.. Hatsukami, D.. Eckert. E.. & Pyle, R. (1985). Characteristics of 275 patients with bulimia. .4rnerican Journnl q/Psvchiatry. 142(4), 482-485. Mule. S. (198 I). Behaviorit1e_rcess:.4n esaminarion ofvolilionaldisorders. New York: Macmillan Publishing Co.. Inc. Sewman. N. A.. & Halvorson. P. A. (1983). Anore.ria nervosa and bulimia: .4 handbook/or counselors and rherapisrs. New York: Van Norstrand Reinhold Company. Norman. D. K.. & Herzog. D. B. (1983). Bulimia. anorexia nervosa. and anorexia nervosa with bulimia: A comparative analysis with MMPl profiles. fmernational Jorvnal qfEuring Duorders. 2,4 I-50. Ordman, A.. & Kirschenbaum. D. (1985). Cognitive-behavioral therapy for bulimia: An initial outcome study. Jolrrnnl yfCorisu/ting atld Clinical Psycho/og~~. 53(3). 305-3 13.
Bulimia nervosa
607
Pkle. R.. Mitchell, J.. & Eckett, E. (I 98 I ). Bulimia: A report of 34 cases. ./oumul~/ C/ir~~t~a/P~clr~orrJ~. 4?(2). 60-64. Pyle. R.. Mitchell, J.. Eckert, E.. Halvorson, P.. Neuman. P.. & Goff. G. ( 1983). The incidence bulimia in freshman college students. Inrrrnarionai Jownal oj‘thring Disorders. 2(3), 75-8.3. Rosen. L., Shafer. C.. Dummer. G.. Cross. L., Deuman. G.. & Malmberg. S. (1988). Prctalence ofpathogenic weight control behaviors among Native American women and girls. Inrrrnn~ionu~ Jcwrnul qt.Eniirrg Dis-
of
orders, 7(6). 807-8
I I.
Smith. M. C. and Thelen. XI. H. (195-1). Development suiting
and Clinical
Psjrlrolog~..
and validation
of a test for bulimia. Jommzl
yi‘Con-
52. 8634372.
Spitzer, R.. Williams. J.. Gibbon, ht.. 8: First. M. (1989). Instrcxfion tnnnual for r/w srriccrlrrc,d clrtlical inrerviebvfor DS.\f-III-R. New York: Biometrics Research Dept.. New York State Pqchiatric Institute. Stern. S. L.. Dixon. K. N.. Nemzer. E.. Lake, M. D.. Sansone. R. A.. Smeltzer, D. J.. Lantz. S.. & Schrier, S. S. (1984). Affective disorder in the families ofwomen with normal weight bulimia. .4mcvicxtr Jolrrnnlqf Psjrhiafry. 141, 1714-1217. Thelen. M.. Mann, L.. Pruitt. J.. & Smith. M. (1987). Bulimia: Prevalence and component factors in college women. Jotrrnal ql‘Ps!r/ioson~ali~. Rt~search. 31( I ). 73-78.
