Bulimia: Factors Associated

with its Etiology and

Maintenance

J. Hubert Lacey, M.B., Ch.B., M. Phil, F.R.C. Psych.

Sian Coker, B.Sc. (Hons)
S. A. Birtchnell, M.B., B.S., M.R.C. Psych.

Fifty female patients with bulimia at normal body weight were examined
in a prospective study to determine factors associated with the onset and
maintenance of their disorder. Factors given by patients and interpretations
drawn by the psychiatrist for the underlying, precipitating, and mainte-
nance factors of bulimia were recorded. Bulimic patients describe a re-
markably similar and consistent series of underlying factors, particularly
centered on doubts concerning femininity but also including a poor rela-
tionship with parents, academic striving, parental marital conflict, and poor
peer group relationships. All patients described at least one and usuallv
two or three major groups of life events: sexual conflicts, major changes in
life circumstances, and ”loss” acting upon the above underlying factors
which together with carbohydrate-abstinent dieting precipitated the onset
of the condition. Maintenance factors included carbohydrate craving,
binge eating for its sedative qualities or, alternatively, as a stimulant to
replace loneliness or boredom.

In 1979, Russell used the term bulimia neruosu to describe a condition in

which patients suffer from powerful and intractable urges to overeat

j. Hubert Lacey, M.B., Ch.B., M.Phil. F.R.C. Psych., is Senior Lecturer, St. George‘s Hospital
Medical Sc-hool, The UniverGty of London, and Honorary Consultant, EatinR Disorders
Clinic, St. George’s Hospital, London. Sian Coker, B.Sc. (Hons), is Kesearch Assistant to I>r.
L a w y . Dr. S. A. Birtchnell, M.B., B.S., M.R.C. Psych. is Senior Registrar at the same affilia-
tion. Addrecs a / / correspondence to Dr. 1. / fubert Lacey, A( ddernk I k p d r f r n c v f of I’cychiafry,
SI. George’s Horpifal Medicdl School. Cranrner Terrace, London SW J 7 O R € Unifcd Kinsdon,.

International lournal of Eating Dlrorder,, Vol 5. No 3 , 475-487 (19861

0 1986 by john Wiley & Sons, Inc. ccc 0276 ~ 7 8 / 8 6 / 0 3 0 4 7 5 -3804
i no
476 Lacey, Coker, and Birtchnell

while at normal body weight. A similar syndrome, termed bulimia, has

been described in the United States although its diagnostic criteria are
broader. To date, only clinical impressions or anecdotal reports of its
etiology exist (Lacey, 1982; Johnson, Lewis, & Hagman, 1984; Lacey &
Birtchnell, 1985). However, Strober (1984) has examined the incidence
of life events in a population of anorexia nervosa patients and deter-
mined that bulimics at low body weight experienced significantly more
life stress than abstaining anorectics; also Garner, Garfinkel, and
O'Shaughnessy (1983) found that normal-weight bulimic families had
more disturbed life styles and interaction than a comparison group of
patients with anorexia nervosa with no history of bulimic symptoms.
The aim of this paper is to systematically investigate factors associ-
ated with the onset and maintenance of bulimia at normal body
weight.

METHODS

A prospective study was carried out on 50 female consecutive refer-

rals to the Eating Disorders Clinic who met DSM 111 (American Psychi-
atric Association, 1980) and Russell's (1979) criteria for the diagnosis of
bulimia and bulimia nervosa, respectively. Unfortunately, these criteria
have a number of confusing, if not conflicting, aspects (Lacey, 1985).
For this reason and because we believe that until standardized research
criteria are established, research teams should clarify their diagnostic
procedures, we state below our own diagnostic criteria.
These were that each patient:
1. Described severe (Lacey & Gibson, 1985) and distressful binge
eating while being within a normal range of weight (as deter-
mined by Kemsley, 1953; and OPCS Monitor, 1981).
2. Declared both overtly and covertly an absence of an irrational
fear (phobia) of normal body weight; further, while the patient
may wish to lose weight her desired target weight is within a
normal range.
3. While the bulimic episodes may have developed within the con-
text of anorexia nervosa (Type I1 bulimia, see below), massive
obesity (Type 111 bulimia) or physical illness (secondary bulimia;
see Lacey, 1984), they were not maintained by these pathologies.
4. Felt that her eating pattern was out of control: a feeling that may
transcend the food abuse and be appreciated in other areas of
her life, such as her interpersonal relationships, alcohol or street
drug abuse, sexual disinhibition, etc.
5. Will show at least two of the following six clinical features asso-
ciated with binge eatings: (a) intermittent periods of starvation,
purgation or self-induced vomiting with the desired aim of re-
Bulimia: Etiology and Maintenance 477

ducing the effects of the binge eating or its associated edema; (b)
fluctuation of body weight (though within a normal range; (c)
frequent attempts to lose weight (but see (2) above); (d) secret
binge eating; (e) eating of large amounts of food within a short
period of time (but see Lacey & Gibson, 1985); (f) physical com-
plications such as erosion of the palatal surfaces of the molar
teeth (Hurst, Lacey, & Crisp, 1977) or enlargement of salivary
glands, etc.
6. Depressed and angry moods and self-depreciatory thoughts such
as humiliation are usually associated with the binge eating, but
the removal of the binge eating does not necessarily lead, at least
in the short term, to a normal mood state.
The subject population were divided into three subgroups, namely:
Type I Bulimia: In this neither the patient nor her family describe a
history of previous anorexia nervosa, weight phobia, or massive
weight loss although weight fluctuation was common. This has
been referred to as the bulimic syndrome (Lacey, 1980) and its
prognosis with treatment is very good (Lacey, 1983).
Type II Bulimia: In this the patient with previous anorexia nervosa
has "recovered" to normal body weight. This is somewhat similar
to the concept of bulimia nervosa (Russell, 1979). The patient no
longer expresses a fear of normal body weight. Prognosis is not as
good as Type I bulimia (Lacey, 1984).
Type III Bulimia: These patients enter bulimia from massive obesity
and, as such, give a history of being at least 50% above mean
matched population weight in the past and are usually in excess
of 10% above mean matched population weight on presentation.
Long-term prognosis is poor (Lacey, 1985).
Information for this study was obtained from an interview using a
semistructured schedule and conducted by a psychiatrist. Reasons
given by the patients and the interpretations drawn by the psychiatrist
for the precipitating, underlying, and maintenance factors of bulimia
were examined. The precipitant was defined as an event occurring
within the six months prior to the development of the symptoms and
which the patient and the psychiatrist felt had precipitated the disor-
der. An underlying factor was a chronic difficulty of emotional signifi-
cance which was present in the previous 18 months to the precipitation
of the disorder.

RESULTS

The majority of patients in this study (70%) were classified as Type I

bulimics. The remaining 30% were Type I1 bulimic, there were no Type
111 bulimics in this study. Type I11 bulimics make up some 6% of our
478 Lacey, Coker, and Birtchnell

clinic population and so the proportions of Type I and Type I1 bulimics

in this study broadly represent the total patient population at the St.
George‘s Eating Disorders Clinic. The mean age of presentation was 25
years and the mean age of onset of binge eating was 18.5 years. Vom-
iting was currently described at initial consultation by 39 patients and
another 5 had used it in the recent past. Twenty eight patients reported
current or recent laxative abuse.
”Dieting” was evident in all subjects. Type I patients described a
longer history of ”normal dieting” that is, dieting indistinguishable
from that frequently reported in normal populations while dieting in
Type I1 patients tended to be more severe and associated with emo-
tional distress.

Precipitants
In all cases the patients and psychiatrist determined an event or
events in the six months prior to bulimia which both considered was
associated with the onset of the disorder. Binge eating was precipitated
by the interaction of at least two of the following:
(i) Sexual conflict: Particularly those surrounding the beginning or
termination of a major sexual relationship. Reported by 72% of
patients.
(ii) A major change in life circumstance: That is a change in occupation
or geographical location such that the patient feels markedly
rootless and insecure. Reported by 70% of patients.
(iii) “Loss”: Broadly defined and involving bereavement, estrange-
ment, or separation from a significant family member or close
friend. Reported by 20% of patients.
Of these 50 patients, 56% reported more than one precipitant factor
in operation. An example of sexual conflict given by one patient was
the ending of an intense sexual relationship when the patient was told
by her boyfriend that she ”did not even rate as a woman.” Example of
a change in geographical location or occupation was given by a patient
who moved from South Africa to England with her mother after her
parents divorced. An example of loss given by a patient was the es-
trangement from her family after a violent row and subsequent access
to the family was prevented.
Full details of the precipitant factors described by patients are shown
in Table 1 .

Immediate Circumstances
The majority of patients, some 74%, reported that the immediate cir-
cumstance prior to the first bulimic episode was the inability to main-
Table 1 Factors associated with the precipitation of bulimia nervosa.
Factor 1: Sexual Conflict Factor 11: Move a Change in
Geographical Location/
Terminations Beginnings Occupation Factor
111: “Loss”
c;
3
Type I 3
Bulimia 3
Left home. Started new job E.
1. Termination of major 3
relationship in context h
0
of boyfriend’s 2
infidelity. c,
2. Left school. Began college.
3. Left husband in context Moved to London from home
of his infidelity and town.
frequent rows.
4. 1st Major Left home as a result of
Relationship. First discovering father’s affair.
sexual VC. Father
having affair with
16 yr. old friend.
5. Changed school. Out of place as
a ‘working class’ girl in a
‘middle class’ school.
6. Mother hospitalized. Loss
of maternal relationship.
7. Change in status from
girlfriend to co-
habitee. Boyfriend
refused sex if she
overate.
8. Left home. Started 1st job.
(Food related, waitressing)
P
U
 P
0,
0

Table 1. Continued.
Factor I: Sexual Conflict Factor 11: Move a Change in
Geographical Location/
Terminations Beginnings Occupation Factor 111: ”Loss”

9. Termination of 1st major

relationshp. Refusal
to have UC
precipitated the
breakdown.
10. 1st major relationship. Left home.
Sexual uncertainty
expressed.
11. 1st major relationship. Left school. Started first job. Parents’ divorce
1st sexual UC. Felt
prematurely
pressured into sex,
fear of pregnancy.
12. Terminating of major Left home as result of poor Swift remarriage of mother.
rela tionship. relationship with new Stepfather not accepted.
stepfather. Loss maternal and
paternal relationship.
13. 1st major relationship.
1st sexual UC. Fear
of pregnancy.
14. Termination of major Left school. Visited New
relationship. Zealand. 3
w
15. 1st major relationship. P
Sexual uncertainty
expressed.
16. Termination of major
relationshp.
17. Termination of major Left university. Moved to a;
relationship. Told she France. c
was “not even rated 3:
F!
as a woman.” rn
18. 1st major relationship -.
-2
1st sexual VC. Fear 0
of sexual 9
disinhibition.
19. Termination of 1st major
relationship. 1st
sexual relationship.
20. Rape. 1st sexual I/C Left school. Mother hospitalized for
depressive illness. Loss
of maternal relationship.
21. Moved to England from S. Parents’ divorce. Loss of
Afnca with mother after paternal relationship.
parents’ divorce. Father remains in S.
Africa.
22. Left home to live in hostel at Remarriage of mother.
stepfather’s request. Asked to leave by new
stepfather. Loss of
maternal relationship.
23. 1st major relationship. Changed school. Only female in
all boys school.
24. Changed school. Private to State
Sector.
25. 1st major relationship. Left school. Started first job.
1st sexual UC. Maternal pressure to be a
Repercussions in secretary.
family.
26. Termination of 1st major
relationship. 1st
sexualized
relationship.
P
c”
Table 1. Continued.
P
0)
N
Factor I: Sexual Conflict Factor11: Move a Change in
Geographical Location/
Terminations Beginnings Occupation Factor 111: "Loss"

27. 1st major relationship Left school. Started first job.

1st sexual UC. Felt
prematurely
pressured into sex.
28. Termination of 1st major
relationship. 1st
sexual relationship.
29. Termination of 1st major Moved from England to Canada,
relationship. Rivalry then Canada to England with
between patient, boyfriend and his sister.
boyfriend, and sister.
30. Left school. Started first job. Father hospitalized. Then
chronic invalid. Loss of
paternal relationship.
31. Termination of 1st major Left school. Started first job. Death of mother. Sudden
relationship. 1st Very unhappy in first job. after row with patient.
sexualized
relationship.
32. Terminatoin of major Moved house. Changed job.
relationship.
33. Termination of major Left university. Started job. r
relationship. n
b y f n e n d afraid of c
commitment.
34. Start of several Termination of pregnancy.
concurrent sexual
relationships. Fear
of deeper
commitment.
35 ]oined escort agency.
Traumatic
experience with
client.
Tvpe II
Bulimia W
36. Estrangement from family. 5.
Prevented access to 3
younger brother. F:
37. Termination of major Moved house. Changed job.
relationship.
38. Changed school.
39. Left school. Started college. CI
40. 1st sexual UC. Left home. Left school. Started CL
first job in context of 3
difficulties with parents. Y.
41. 1st major relationship. Left home. Left school. Started 3
1st sexual UC. first job. 3
W

42. 1st sexual I/C in Left job (as Nanny). Lost h

13
context of affair accommodation.
with married man.
43. Termination of 1st major Moved from London to
rela tionship. Portsmouth. Changed school
Private to State Sector.
44. 1st sexual I/C Left home. Moved to London.
Started first job.
45. 1st sexual UC. Changed school.
46. Termination of major
relationship. 1st
sexualized
relationship.
47 Left home. Started university. Remarriage of father. Two
sisters marry. Loss of
family relationship.
48. 1st sexual V C .
49. Changed schools. Boarding to
Day School.
50. Termination of a major Left school. Moved town.
heterosexual and a Started college.
homosexual
relationship. e
a
N = 50 18 18 35 10 ir
36(72%) (70%) (20%)
484 Lacey, Coker, and Birtchnell

tain a carbohydrate-restricted diet with associated carbohydrate

craving. A substantial minority (18%)reported the development of self-
induced vomiting as a dietary aid prior to the onset of binge eating.
The knowledge that this technique was available encouraged the de-
velopment of the bulimia. This was particularly common in Type I1
patients (47%).

Underlying Factors
The immediate circumstances and precipitating events described
above were superimposed on a background of underlying factors
which represented long and chronic emotional difficulties. Patients de-
scribed at least and usually three or four of the following:
(a) Doubts concerning femininity: Involving the patient questioning
her desirability and attractiveness. She reports a major discrep-
ancy between her concept of herself as a woman and her idea of
a stereotypic ideal woman. Reported by 78% of patients.
(b) Poor relations with parents: Reported by 60% of patients.
(c) Academic striving: Many patients, though on paper high achiev-
ers, nevertheless were struggling to achieve better results. Thus,
paradoxically, high achievement was coupled with low self-es-
teem. Reported by 46% of patients.
(d) Parental marital conflict: This was reported by 44% of patients and
involved long-standing difficulties in the parents’ relationship in-
cluding arguments, violence, infidelity, separation, and divorce.
(e) Poor peer group relationships: This was reported by 28% of patients
and involved a failure to establish adequate relationships with
peers of both sexes.
The majority of patients (76%) reported more than one underlying
factor in operation. Thus many patients were concurrently experienc-
ing a number of emotional difficulties.

Maintenance Factors
Once bulimia has become established the cycle is maintained by a
number of factors, usually acting in concert. Again, carbohydrate crav-
ing is the most commonly reported trigger described by 96% of pa-
tients. In addition, bulimic episodes were triggered by emotional
distress. Forty-six patients reported that food was used for its sedative
or tranquilizer-like qualities to dampen down unpleasant emotional
states, particularly anger and frustration. Alternatively, patients dis-
placed negative emotional feelings such as loneliness or boredom by
the abuse of food and this was reported by 78% of patients.
Bulimia: Etiology and Maintenance 485

DISCUSSION

In our study we have been impressed by the consistency of the pa-

tients own reports of factors associated with their binge eating and
vomiting. They describe a series of factors which, usually in combina-
tion, underline their disorder. These factors come under three head-
ings-sociocultural, familial, and individual factors (Fig. 1). The family
difficulties usually manifest in patients having a poor relationship with
one or the other parent. This often stems from parental marital conflict
or the parents’ judgement, usually an unfavorable one, of their daugh-
ter’s interpersonal relationships. These family difficulties interact with
individual emotional problems. The most important of these being
doubts that the future patient may have of her attractiveness to men,
although poor peer group relationships and intense academic striving
are commonly reported. Although these personal and familial prob-
lems are important this is not to deny the role of sociocultural factors
such as western society’s present emphasis on thinness. The combina-
tion of these provide the bedrock of the disorder.
While these underlying factors are fairly commonly experienced
among young women, the precipitating factors of bulimia are more
specific. It is the action of certain life events on these underlying factors
in an already dieting woman which precipitates out the disorder. It
should be emphasized that it is when these life events act in combina-
tion and at the same time that they are most potent. In particular, we
have found that stresses associated with the beginning or end of the
patient’s first major emotional relationship and usually that relation-
ship in which sexual intercourse first occurred, are powerful and im-
portant. Environmental changes, usually a change of job or leaving
home for the first time, or alternatively the loss of a parent or close
friend (particularly when acting in concert with the above) provide the
three precipitant factors described by our patients. We would suggest
that the patient lacks the necessary adult coping skills necessary to deal
with these difficulties. Food and its manipulation becomes a readily
available defense mechanism, particularly as the patient’s attention is
already focused on food through dieting and the belief that a slimmer
body shape is the answer to her problems.
The question arises as to whether a similar pattern of factors would
have been found in a general psychoneurotic population or perhaps in
another group of eating disordered patients. In a study of 50 anorexia
nervosa patients, Hsu (1979) determined events suggestive of overt
sexual conflict in only 36% of patients and this included events up to
a year before the illness; we found double this incidence in a period of
just six months before onset of symptoms in our population of normal
weight bulimics. Hsu found exactly the same (20%) number of patients
486 Lacev, Cokw, and Birtchnell

. - .- __
j PRECIPITANTS I

A '.' ,
...
I
VOMITING'
li
//
I

M clii bol ic tlisturbdiiLe

i iii
S e n s c of being O I I ! ol control

i G ~ l arid
t stitline
D i I f i c it I t i 1; s t n soc I J I ii nd p rofcss to r i r i I
D Y SPH OR I A;
I
I Ii f e c.1 I I s e d b y t i 11I I ni t :iivo m I t I11cj

Figtire 1. Interacting factors in the etiology of bulimia.

report a "loss" which is perhaps similar to that found in many neurotic

disorders. Only 14% of anorectics reported a major change in life and
home circumstances which is perhaps a function of the different age of
onset of the two disorders, dieting beginning in Hsu's group at an
average age of 17.1 years while the mean age of onset of binge eating
in ours was 18.5 years (Lacey, 1984).
For methodological reasons, it is not possible to compare our find-
ings with those reported in Strober's excellent study (1984) in an ano-
rectic population. His patients were at low body weight, had a mean
Hulimia: Etiology and Maintenance 487

age of 15.6 years and had been ill for seven months. Our population
presented at a mean age of 25 years and described an average of eight
years of illness. Many of the life events described by our patients could
not possibly have occurred to a mid-teenage population. These differ-
ences-and many others-show the fallacy of comparing bulimic ano-
rectics with normal body weight bulimic women. However, it is
noteworthy that Strober found that two or more life events of “negative
emotional impact” were experienced by 68% of his bulimic anorectics
compared with only 24% of abstaining anorectics.
Finally, this account should not be construed as representing a
causal model. The absence of a control group makes it impossible to
claim that these factors have more than an associative role. However,
the picture that emerged was very consistent both within and between
patients and forms a useful starting point for more in-depth research.

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