Bulimia Nervosa With and Without a History of Anorexia Nervosa James E. Mitchell, Richard L. Pyle, Elke D. Eckert, Dorothy Hatsukami, and Elizabeth Sol1 This study compared two subgroups of women of normal weight with bulimia nervosa: those with a history of anorexia nervosa and those without such a history. Those with a history of anorexia nervosa indicated a desired body weight significantly lower than those without the history. Those with a history of anorexia nervosa were more likely to abuse laxatives and fess likely to self-induce vomiting. Both groups reported feeling fat and worrying a great deal about weight and shape issues. 0 1990 by W.B. Saunders Company.
T
HERE IS CONSIDERABLE OVERLAP between bulimia nervosa and anorexia nervosa, as reflected in the DSM-III-R criteria for eating disorders. The prevalence of concomitant problems with bulimia among individuals diagnosed as having anorexia nervosa is approximately 40% to 50%, and a subgroup of patients with bulimia nervosa have a prior history of anorexia nervosa.is3 Patients who originally developed bulimia nervosa and later developed anorexia nervosa have also been reported.4 Therefore, the relationship between these two conditions is complex. The available scientific literature clearly demonstrates important differences between anorexia nervosa patients who have concomitant problems with bulimia nervosa and those who do not.5-7 Very little is known, however, about the possible similarities and differences between bulimia nervosa patients who have a history of anorexia nervosa and those who do not. Although in his original description of bulimia nervosa Russell’ stressed that most of his patients had a history of actual or “cryptic” anorexia nervosa, treatment centers working with these disorders frequently encounter patients without this history. To examine this area further, we compared two subgroups of bulimia nervosa patients who were of normal weight when they presented for treatment. One subgroup was composed of patients who had a history of anorexia nervosa before onset or during the course of bulimia nervosa but who had maintained a normal adult weight for height for at least 6 months. The other subgroup was composed of individuals with bulimia nervosa who had never had a period of significant weight loss sufficient to qualify for a diagnosis of anorexia nervosa. In particular, we were interested in examining bulimic symptom severity in these two subgroups and such other variables as desire for weight loss, strategies to achieve weight loss, and prevalence of other associated problems. METHOD Patients with bulimia nervosa evaluated in the eating disorders clinic at the University of Minnesota routinely complete several forms before evaluation, including the Eating Disorders Questionnaire From the Eating Disorders Program, Department of Psychiatry, Minneapolis, MN. Supported in part by Grants No. MH40377 and MH43296 from the National Institute of Mental Health. Address reprint requests to James E. Mitchell, M.D.. Box 393 Mayo. 420 Delaware St. S.E., Minneapolis, MN 55455. o 1990 by W.B. Saunders Company. 0010-440X/90/3102~008~03.00/0 Comprehensive
Psychiatry,
Vol. 3 1, No. 2 (March/April),
1990: pp 17 l-l 75
171
172
MITCHELL ET AL
(EDQ)? a detailed self-report instrument which asks questions about eating patterns and bulimia-related behaviors, and a psychiatric database which asks questions about other psychiatric problems and medical problems. During the evaluation, an eating disorders staff member establishes diagnoses using a checkoff sheet designed to assess axis I DSM-III-R psychopathology based on the clinical interview and a review of the records. Two cohorts of 50 subjects each were selected. Subjects were selected for inclusion if they were female, met DSM-III-R criteria for bulimia nervosa, and satisfied one of the following two sets of criteria: (a) prior diagnosis of anorexia nervosa, with this diagnosis confirmed retrospectively through examination of DSM-III-R criteria and when possible by obtaining prior records, and weight within 10% of ideal body weight at the time of evaluation for bulimia nervosa; and (b) weight within 10% of ideal body weight at the time of evaluation with no history of low weight or anorexia nervosa. The data were derived from the EDQ, the psychiatric database, the evaluation summary dictated by the eating disorders staff members, and the diagnostic checkoff sheet completed at evaluation. Data were analyzed using chi-square and paired t tests.
RESULTS
In the cohort with a history of anorexia nervosa (HAN) all 50 subjects were white. Forty-nine of the subjects in the group with no history of anorexia nervosa (NHAN) were white and one was American Indian. Although a majority of subjects in both groups were single, there was a trend suggesting a higher rate of marriage in the NHAN group (HAN, single = 43, 86%; divorced = 3, 6%; married = 4,8%; NHAN, single = 32,64%; divorced = 5, lo%, divorced-remarried = 1,2%, married = 12,24%; x2 = 7.113, & = 3, P = .068). Social class distribution according to the Hollingshead and Redlich two-factor index of social position was very similar between the two groups.” Age, age of onset, and weight data are shown in Table 1. The two groups were essentially identical as to age at presentation and age of onset of binge-eating. Although subjects in the NHAN group were numerically slightly heavier in terms of percentage of ideal body weight, this difference did not reach statistical significance. Subjects in the HAN group desired a lower percentage of ideal body weight, however, and wanted to lose more weight than did subjects in the NHAN group. There were some significant differences between the two groups in pattern of bulimic behaviors, as shown in Table 2. Those without a history of anorexia nervosa were significantly more likely to use self-induced vomiting as a weight-control technique, and those with a history of anorexia nervosa were more likely to report laxative abuse and chewing and spitting out food as bulimic symptoms. Binge-eating frequencies also were fairly similar between the two groups, with 18 (37.5%) of the Table 1. Age, Age of Onset, and Weight Data in Bulimic Subjects With and Without a History of Anorexia Nervosa Variable Age Age of onset Binge-eating Vomiting Laxatives Weight (% l8W) Desired weight loss (lb)
HAN 24.7 17.5 17.8 18.6 100.4 12.4
NHAN
k 5.9 + f f f +
Abbreviation: IBW, ideal body weight.
3.9 4.0 4.2 14.5 10.4
24.9 18.3 18.7 21.5 103.1 6.3
f 5.0 f 4.0 + 5.0 + 5.4 + 11.2 _+ 8.0
t
df
P
0
98
.OOO
0.983 1.120 4.149 1.156 9.960
98 93 46 99 91
.324 .296 .048 .285 .002
BULIMIA NERVOSA
Table 2. Associated
Eating Problem Vomiting Laxatives Oiet pills Chew and spit
173
Eating Problems in Bulimic Subjects With and Without Anorexia Nervosa
a History of
N (%) HAN 44 35 31 26
NHAN
(88) (70) (62) (52)
50 20 29 15
(100) (40) (58) (30)
X2 4.433 7.395 0.109 4.133
df
P
1 1 1 1
.035 .006 .741 .042
HAN subjects reporting binge-eating more than once a day and 21 (42.0%) of the NHAN group reporting binge-eating more than once a day (x2 = 3.956, d’= 2, P = .138). Those in the NHAN group were more likely to be vomiting frequently, however (HAN daily vomiting = 4, 8.5%; more than daily = 19, 40.4%; NHAN daily = 13, 26%; more than daily = 24, 48%; x2 = 16.269, df = 5, P = .006). The frequencies of laxative abuse were similar, and the majority in both groups who abused laxatives did so less than once a day. Subjects were also asked certain questions on the EDQ that examined concerns about shape and weight (Table 3). Asked how they felt about their current weight, most subjects in both groups indicated that they felt “fat,” were afraid of becoming fat, and disliked their body proportions. Data on other problems associated with bulimia nervosa are summarized in Table 4. There were no significant differences between the two groups with regard to a history of alcohol or drug abuse problems or stealing behavior. Those in the HAN group were numerically but not statistically more likely to report a history of self-injurious behavior such as cutting, burning, or hitting themselves and suicide attempts. Those in the HAN group were more likely to report previous treatment for depression and hospitalization for their eating disorder. As expected, those in the Table 3.
Concerns
About Weight and Shape Among Bulimic Subjects With and Without a History of Anorexia Nervosa
N (%) Concern Feel fat Extremely Very Moderately Somewhat Not at all Fear of fat Extremely Very Moderately Somewhat Not at all Dislike proportions Extremely VerY Moderately Somewhat Not at all
HAN
NHAN
X2
df
P
3 4 5 12 6
(10) (13) (17) (40) (20)
3 11 14 16 6
(6) (22) (28) (32) (12)
3.308
4
.507
33 11 3 2 0
(67) (22) (6) (4) (0)
32 13 4 1 0
(64) (26) (8) (20) (0)
0.648
4
,885
4 4 11 9 2
(13) (13) (37) (30) (7)
9 14 12 12 3
(18) (28) (24) (24) (6)
3.308
4
,507
174
MITCHELL ET AL
Table 4. Associated
Problems Among Bulimic Subjects With and Without Anorexia Nervosa
a History of
N (%I History Alcohol/drug abuse Stealing Self-injury Suicide attempt(s) Treatment for depression Inpatient ED
HAN 14 27 12 13 16 14
(29) (54) (25) (32) (32) (28)
NHAN 12 22 7 6 6 5
(24) (44) (14) (12) (12) (10)
X2
df
P
0.083 0.640 1.145 2.205 4.720 4.159
1 1 1 1 1 1
.773 .424 .265 .137 .030 .041
Abbreviations: ED, emergency department.
HAN reported a longer mean period of amenorrhea associated with their eating disorders (HAN = 18.5 + 20.9 months; NHAN = 6.8 + 9.5 months; F ratio = 11.287, df = 83, P = .OOl). DISCUSSION
Previous research has shown clearly that patients with anorexia nervosa who rigidly restrict food intake as their only weight control technique differ significantly from those who engage in bulimic behaviors. ‘-’ Much less is known, however, about the two subgroups of bulimia nervosa examined in the current study. Katzman and Wolchik” previously reported a comparison of five subjects who fulfilled operationalized criteria for DSM-III bulimia and reported a history of anorexia nervosa and nine women who fulfilled these criteria but had no history of anorexia nervosa. The results indicated that the bulimic subjects with a history of anorexia nervosa were significantly more depressed, but the two groups did not differ significantly on the other personality measurements used. Our current data also suggests significant differences and some interesting trends toward differences between these two subgroups. In our samples, individuals with no history of anorexia nervosa were three times as likely to be married, although the marriage rate was low in both groups. Additional measures of social performance and impairment were not used. It would be interesting to examine psychosocial functioning in more detail in these two subgroups. Although the mean weights of both subgroups did not differ significantly, subjects with a history of anorexia nervosa gave a desired body weight twice as far below their current body weight as those with no history of anorexia nervosa, suggesting more exaggerated concerns about shape and weight. On our other measures of concerns about shape and weight, such as fear of becoming fat, seeing oneself as being fat, and the effects a 2-pound weight gain would have on the individual, however, the two groups were quite similar, suggesting exaggerated concern about such issues in most subjects in both groups. These measures are admittedly crude, however, and further examination of these cognitive variables might expose significant differences. Most subjects in both groups self-induced vomiting, with a significantly higher percentage among those with no history of anorexia nervosa. A higher rate of laxative abuse in those with a history of anorexia nervosa is of interest and fits with previous data that persons who abuse laxatives tend to have more associated
BULIMIA NERVOSA
175
problems,12 but runs counter to the observations of Lacey and Gibson13 that laxative abusers tend to eat less and weigh more than person who self-induce vomiting. This may result from our requirement of a body weight within 10% of ideal body weight for inclusion in the study. There was some suggestion that the patients with a history of anorexia nervosa were more likely to have other problems, such as a history of a treatment for depression, hospitalization for their eating disorder, and self-injurious or suicidal behavioral, but most of these variables did not reach statistical significance. Overall, the results suggest that some mean differences probably exist between the two groups on the variables examined, but the similarities between the two groups were as dramatic as the differences, and the preoccupation with issues of shape and weight and the desire to lose weight was not only a concern of subjects with a history of anorexia nervosa, but also of most subjects in both groups. REFERENCES 1. Beaumont PJV, George GCW, Smart DE: “Dieters” and “vomiters and purgers” in anorexia nervosa. Psycho1 Med 6:617-622.1976 2. Casper RC, Eckert ED, Halmi KA, et al: Bulimia: Its incidence and clinical importance in patients with anorexia nervosa. Arch Gen Psychiatry 37:1030-1035, 1980 3. Garfinkel PE, Moldofsky H, Garner DM: The heterogeneity of anorexia nervosa: Bulimia as a distinct subgroup. Arch Gen Psychiatry 37:1036-1040,198O 4. Kasset JA, Gwirtsman HE, Kaye WH, et al: Pattern of onset of bulimic symptoms in anorexia nervosa. Am J Psychiatry 145:1287-1288, 1988 5. Garner DM, Gartinkel PE, G’Shaughnessy M: The validity of the distinction between bulimia with and without anorexia nervosa. Am J Psychiatry 142:581-587.1985 6. Yellowlees AJ: Anorexia and bulimia in anorexia nervosa: A study of psychosocial functioning and associated psychiatric symptomatology. Br J Psychiatry 146:648-652, 1985 7. Vandereycken W, Pierloot R: The significance of subclassification in anorexia nervosa: A comparative study of clinical features in 141 patients. Psycho1 Med 13:543-549, 1983 8. Russell G: Bulimia nervosa: An ominousvariant of anorexia nervosa. Psycho1 Med 7:173-193, 1972 9. Mitchell JE, Hatsukami D, Eckert ED, et al: Eating disorders questionnaire. Int J Eating Dis 21:1025-1043,1985 10. Hollingshead AB, Redlich FC: Social class and mental illness. New York, Wiley, 1958 11. Katzman MA, Wolchik SA: Bulimics with and without prior anorexia nervosa: A comparison of personality characteristics. Presented to the Rocky Mountain Psychological Association, April 29, 1983 12. Mitchell JE, Boutacoff LI, Hatsukami D, et al: Laxative abuse as a variant of bulimia. J Nerv Ment Dis 174:174-176,1986 13. Lacey JH, Gibson E: Controlling weight by purgation and vomiting: A comparative study of bulimics. J Psychiatr Res 19:337-341, 1985
T
HERE IS CONSIDERABLE OVERLAP between bulimia nervosa and anorexia nervosa, as reflected in the DSM-III-R criteria for eating disorders. The prevalence of concomitant problems with bulimia among individuals diagnosed as having anorexia nervosa is approximately 40% to 50%, and a subgroup of patients with bulimia nervosa have a prior history of anorexia nervosa.is3 Patients who originally developed bulimia nervosa and later developed anorexia nervosa have also been reported.4 Therefore, the relationship between these two conditions is complex. The available scientific literature clearly demonstrates important differences between anorexia nervosa patients who have concomitant problems with bulimia nervosa and those who do not.5-7 Very little is known, however, about the possible similarities and differences between bulimia nervosa patients who have a history of anorexia nervosa and those who do not. Although in his original description of bulimia nervosa Russell’ stressed that most of his patients had a history of actual or “cryptic” anorexia nervosa, treatment centers working with these disorders frequently encounter patients without this history. To examine this area further, we compared two subgroups of bulimia nervosa patients who were of normal weight when they presented for treatment. One subgroup was composed of patients who had a history of anorexia nervosa before onset or during the course of bulimia nervosa but who had maintained a normal adult weight for height for at least 6 months. The other subgroup was composed of individuals with bulimia nervosa who had never had a period of significant weight loss sufficient to qualify for a diagnosis of anorexia nervosa. In particular, we were interested in examining bulimic symptom severity in these two subgroups and such other variables as desire for weight loss, strategies to achieve weight loss, and prevalence of other associated problems. METHOD Patients with bulimia nervosa evaluated in the eating disorders clinic at the University of Minnesota routinely complete several forms before evaluation, including the Eating Disorders Questionnaire From the Eating Disorders Program, Department of Psychiatry, Minneapolis, MN. Supported in part by Grants No. MH40377 and MH43296 from the National Institute of Mental Health. Address reprint requests to James E. Mitchell, M.D.. Box 393 Mayo. 420 Delaware St. S.E., Minneapolis, MN 55455. o 1990 by W.B. Saunders Company. 0010-440X/90/3102~008~03.00/0 Comprehensive
Psychiatry,
Vol. 3 1, No. 2 (March/April),
1990: pp 17 l-l 75
171
172
MITCHELL ET AL
(EDQ)? a detailed self-report instrument which asks questions about eating patterns and bulimia-related behaviors, and a psychiatric database which asks questions about other psychiatric problems and medical problems. During the evaluation, an eating disorders staff member establishes diagnoses using a checkoff sheet designed to assess axis I DSM-III-R psychopathology based on the clinical interview and a review of the records. Two cohorts of 50 subjects each were selected. Subjects were selected for inclusion if they were female, met DSM-III-R criteria for bulimia nervosa, and satisfied one of the following two sets of criteria: (a) prior diagnosis of anorexia nervosa, with this diagnosis confirmed retrospectively through examination of DSM-III-R criteria and when possible by obtaining prior records, and weight within 10% of ideal body weight at the time of evaluation for bulimia nervosa; and (b) weight within 10% of ideal body weight at the time of evaluation with no history of low weight or anorexia nervosa. The data were derived from the EDQ, the psychiatric database, the evaluation summary dictated by the eating disorders staff members, and the diagnostic checkoff sheet completed at evaluation. Data were analyzed using chi-square and paired t tests.
RESULTS
In the cohort with a history of anorexia nervosa (HAN) all 50 subjects were white. Forty-nine of the subjects in the group with no history of anorexia nervosa (NHAN) were white and one was American Indian. Although a majority of subjects in both groups were single, there was a trend suggesting a higher rate of marriage in the NHAN group (HAN, single = 43, 86%; divorced = 3, 6%; married = 4,8%; NHAN, single = 32,64%; divorced = 5, lo%, divorced-remarried = 1,2%, married = 12,24%; x2 = 7.113, & = 3, P = .068). Social class distribution according to the Hollingshead and Redlich two-factor index of social position was very similar between the two groups.” Age, age of onset, and weight data are shown in Table 1. The two groups were essentially identical as to age at presentation and age of onset of binge-eating. Although subjects in the NHAN group were numerically slightly heavier in terms of percentage of ideal body weight, this difference did not reach statistical significance. Subjects in the HAN group desired a lower percentage of ideal body weight, however, and wanted to lose more weight than did subjects in the NHAN group. There were some significant differences between the two groups in pattern of bulimic behaviors, as shown in Table 2. Those without a history of anorexia nervosa were significantly more likely to use self-induced vomiting as a weight-control technique, and those with a history of anorexia nervosa were more likely to report laxative abuse and chewing and spitting out food as bulimic symptoms. Binge-eating frequencies also were fairly similar between the two groups, with 18 (37.5%) of the Table 1. Age, Age of Onset, and Weight Data in Bulimic Subjects With and Without a History of Anorexia Nervosa Variable Age Age of onset Binge-eating Vomiting Laxatives Weight (% l8W) Desired weight loss (lb)
HAN 24.7 17.5 17.8 18.6 100.4 12.4
NHAN
k 5.9 + f f f +
Abbreviation: IBW, ideal body weight.
3.9 4.0 4.2 14.5 10.4
24.9 18.3 18.7 21.5 103.1 6.3
f 5.0 f 4.0 + 5.0 + 5.4 + 11.2 _+ 8.0
t
df
P
0
98
.OOO
0.983 1.120 4.149 1.156 9.960
98 93 46 99 91
.324 .296 .048 .285 .002
BULIMIA NERVOSA
Table 2. Associated
Eating Problem Vomiting Laxatives Oiet pills Chew and spit
173
Eating Problems in Bulimic Subjects With and Without Anorexia Nervosa
a History of
N (%) HAN 44 35 31 26
NHAN
(88) (70) (62) (52)
50 20 29 15
(100) (40) (58) (30)
X2 4.433 7.395 0.109 4.133
df
P
1 1 1 1
.035 .006 .741 .042
HAN subjects reporting binge-eating more than once a day and 21 (42.0%) of the NHAN group reporting binge-eating more than once a day (x2 = 3.956, d’= 2, P = .138). Those in the NHAN group were more likely to be vomiting frequently, however (HAN daily vomiting = 4, 8.5%; more than daily = 19, 40.4%; NHAN daily = 13, 26%; more than daily = 24, 48%; x2 = 16.269, df = 5, P = .006). The frequencies of laxative abuse were similar, and the majority in both groups who abused laxatives did so less than once a day. Subjects were also asked certain questions on the EDQ that examined concerns about shape and weight (Table 3). Asked how they felt about their current weight, most subjects in both groups indicated that they felt “fat,” were afraid of becoming fat, and disliked their body proportions. Data on other problems associated with bulimia nervosa are summarized in Table 4. There were no significant differences between the two groups with regard to a history of alcohol or drug abuse problems or stealing behavior. Those in the HAN group were numerically but not statistically more likely to report a history of self-injurious behavior such as cutting, burning, or hitting themselves and suicide attempts. Those in the HAN group were more likely to report previous treatment for depression and hospitalization for their eating disorder. As expected, those in the Table 3.
Concerns
About Weight and Shape Among Bulimic Subjects With and Without a History of Anorexia Nervosa
N (%) Concern Feel fat Extremely Very Moderately Somewhat Not at all Fear of fat Extremely Very Moderately Somewhat Not at all Dislike proportions Extremely VerY Moderately Somewhat Not at all
HAN
NHAN
X2
df
P
3 4 5 12 6
(10) (13) (17) (40) (20)
3 11 14 16 6
(6) (22) (28) (32) (12)
3.308
4
.507
33 11 3 2 0
(67) (22) (6) (4) (0)
32 13 4 1 0
(64) (26) (8) (20) (0)
0.648
4
,885
4 4 11 9 2
(13) (13) (37) (30) (7)
9 14 12 12 3
(18) (28) (24) (24) (6)
3.308
4
,507
174
MITCHELL ET AL
Table 4. Associated
Problems Among Bulimic Subjects With and Without Anorexia Nervosa
a History of
N (%I History Alcohol/drug abuse Stealing Self-injury Suicide attempt(s) Treatment for depression Inpatient ED
HAN 14 27 12 13 16 14
(29) (54) (25) (32) (32) (28)
NHAN 12 22 7 6 6 5
(24) (44) (14) (12) (12) (10)
X2
df
P
0.083 0.640 1.145 2.205 4.720 4.159
1 1 1 1 1 1
.773 .424 .265 .137 .030 .041
Abbreviations: ED, emergency department.
HAN reported a longer mean period of amenorrhea associated with their eating disorders (HAN = 18.5 + 20.9 months; NHAN = 6.8 + 9.5 months; F ratio = 11.287, df = 83, P = .OOl). DISCUSSION
Previous research has shown clearly that patients with anorexia nervosa who rigidly restrict food intake as their only weight control technique differ significantly from those who engage in bulimic behaviors. ‘-’ Much less is known, however, about the two subgroups of bulimia nervosa examined in the current study. Katzman and Wolchik” previously reported a comparison of five subjects who fulfilled operationalized criteria for DSM-III bulimia and reported a history of anorexia nervosa and nine women who fulfilled these criteria but had no history of anorexia nervosa. The results indicated that the bulimic subjects with a history of anorexia nervosa were significantly more depressed, but the two groups did not differ significantly on the other personality measurements used. Our current data also suggests significant differences and some interesting trends toward differences between these two subgroups. In our samples, individuals with no history of anorexia nervosa were three times as likely to be married, although the marriage rate was low in both groups. Additional measures of social performance and impairment were not used. It would be interesting to examine psychosocial functioning in more detail in these two subgroups. Although the mean weights of both subgroups did not differ significantly, subjects with a history of anorexia nervosa gave a desired body weight twice as far below their current body weight as those with no history of anorexia nervosa, suggesting more exaggerated concerns about shape and weight. On our other measures of concerns about shape and weight, such as fear of becoming fat, seeing oneself as being fat, and the effects a 2-pound weight gain would have on the individual, however, the two groups were quite similar, suggesting exaggerated concern about such issues in most subjects in both groups. These measures are admittedly crude, however, and further examination of these cognitive variables might expose significant differences. Most subjects in both groups self-induced vomiting, with a significantly higher percentage among those with no history of anorexia nervosa. A higher rate of laxative abuse in those with a history of anorexia nervosa is of interest and fits with previous data that persons who abuse laxatives tend to have more associated
BULIMIA NERVOSA
175
problems,12 but runs counter to the observations of Lacey and Gibson13 that laxative abusers tend to eat less and weigh more than person who self-induce vomiting. This may result from our requirement of a body weight within 10% of ideal body weight for inclusion in the study. There was some suggestion that the patients with a history of anorexia nervosa were more likely to have other problems, such as a history of a treatment for depression, hospitalization for their eating disorder, and self-injurious or suicidal behavioral, but most of these variables did not reach statistical significance. Overall, the results suggest that some mean differences probably exist between the two groups on the variables examined, but the similarities between the two groups were as dramatic as the differences, and the preoccupation with issues of shape and weight and the desire to lose weight was not only a concern of subjects with a history of anorexia nervosa, but also of most subjects in both groups. REFERENCES 1. Beaumont PJV, George GCW, Smart DE: “Dieters” and “vomiters and purgers” in anorexia nervosa. Psycho1 Med 6:617-622.1976 2. Casper RC, Eckert ED, Halmi KA, et al: Bulimia: Its incidence and clinical importance in patients with anorexia nervosa. Arch Gen Psychiatry 37:1030-1035, 1980 3. Garfinkel PE, Moldofsky H, Garner DM: The heterogeneity of anorexia nervosa: Bulimia as a distinct subgroup. Arch Gen Psychiatry 37:1036-1040,198O 4. Kasset JA, Gwirtsman HE, Kaye WH, et al: Pattern of onset of bulimic symptoms in anorexia nervosa. Am J Psychiatry 145:1287-1288, 1988 5. Garner DM, Gartinkel PE, G’Shaughnessy M: The validity of the distinction between bulimia with and without anorexia nervosa. Am J Psychiatry 142:581-587.1985 6. Yellowlees AJ: Anorexia and bulimia in anorexia nervosa: A study of psychosocial functioning and associated psychiatric symptomatology. Br J Psychiatry 146:648-652, 1985 7. Vandereycken W, Pierloot R: The significance of subclassification in anorexia nervosa: A comparative study of clinical features in 141 patients. Psycho1 Med 13:543-549, 1983 8. Russell G: Bulimia nervosa: An ominousvariant of anorexia nervosa. Psycho1 Med 7:173-193, 1972 9. Mitchell JE, Hatsukami D, Eckert ED, et al: Eating disorders questionnaire. Int J Eating Dis 21:1025-1043,1985 10. Hollingshead AB, Redlich FC: Social class and mental illness. New York, Wiley, 1958 11. Katzman MA, Wolchik SA: Bulimics with and without prior anorexia nervosa: A comparison of personality characteristics. Presented to the Rocky Mountain Psychological Association, April 29, 1983 12. Mitchell JE, Boutacoff LI, Hatsukami D, et al: Laxative abuse as a variant of bulimia. J Nerv Ment Dis 174:174-176,1986 13. Lacey JH, Gibson E: Controlling weight by purgation and vomiting: A comparative study of bulimics. J Psychiatr Res 19:337-341, 1985
