the incidence of bulimia in freshman college students

The Incidence of Bulimia in Freshman College Students

Richard 1. Pyle, M.D., James E. Mitchell, M.D., Elke D. Eckert, M.D., Patricia A. Halvorson, Ph.D.,

Patricia A. Neuman, Ed& Gretchen M. Goff, M.P.H.

D I ABSTRACT

This paper reports the results of a questionnaire survey administered to 1355 college freshman (98.3 % response rate) and to a comparison group of 37 female bulimic patients. Questions were contructed to elicit information which would allow identification of those respondents who would meet DSM-Ill requirements for diagnosis of bulimia. 2.7 % of the student population (4.5 % of females, 0.4 % of males) met these modified criteria and the ad- ditional criterion of weekly binge-eating. The identified ddbulimic” female students differed from female bulimic patients in their use of fasting instead of self-induced vomiting for weight control, and in their tendency to be overweight. “Bulimic” female students are also compared with nonbulimic students.

D I Bulimia is an eating disorder characterized by a pattern of episodic binge-

eating (DSM-111, 1980). While symptoms of bulimia have been described in overweight individuals (Stunkard, 1959) and in a subgroup of patients with anorexia nervosa (Casper et al., 1980) attention to the syndrome of bulimia in normal-weight individuals has been relatively recent (Boskind-Lodahl, 1976; Russell, 1979; Pyle et al., 1981.)

Bulimia as defined in the DSM-I11 (1980), has as the essential features “episodic binge-eating accompanied by an awareness that the eating pattern is abnormal, fear of not being able to stop eating voluntarily, and depressed

~

Richard L. Pyle, M.D., James E. Mitchell, M.D., Elke D. Eckert, M.D., 81 Gretchen M. Goff, M.P.H., are at the Department of Psychiatry of the Unviersity of Minnesota Medical School, Minneapolis, Minnesota. Patrica A. Halvorson, Ph.D., is at North Dakota State University, Fargo, North Dakota. Patricia A. Neuman, Ed.S., is at Moorhead State University, Moorhead, Minnesota. Please address reprint requests and cor- respondence to: Dr. Richard L. Pyre, Department of Psychiatry, University Hospitals, Box 393, Mayo Memorial Bldg., 420 Delaware Street, S . E., Minneapolis, Minnesota 55455.

~

INT’LJOURNALOF EATING DISORDERSIVOL.2 N0.3/SPRINC 1983 75

Bulimia in Collegestudents

mood and self-deprecating thoughts following the eating binges." In addition to binge-eating, patients with this disorder frequently employ other behaviors designed to rid themselves of either real or imagined excess food and weight; these behaviors include self-induced vomiting, laxative abuse, and diuretic abuse.

There has been little published research regarding the epidemiology of bulimia. Stangler and Prince (1980) reported that 3.8% of 500 consecutive students seen for emotional problems at a university health service met the DSM-I11 diagnostic criteria for bulimia. This diagnosis was made for 5.3% of the females in the series. Hawkins and Clement (1980) administered a questionnaire to a sample of 247 psychology students. They found that 79% of the females and 49% of the males responding admitted to having had binge-eating episodes. In the largest study reported to date, Halmi et al., (1981) reported the responses of 355 summer school students to a questionnaire designed to study eating behaviors. Thirteen percent of those responding reported having ex- perienced all the major symptoms of bulimia as outlined in DSM-111. This included 19% of the females and 5% of the males. Purging behavior, defined as vomiting or laxative use, occurred in 10% of the respondents. These studies suggest a high prevalence of this problem in young adults.

This paper presents the results of a survey using a questionnaire based on the DSM-I11 criteria for bulimia. Our objective was to assess the prevalence of bulimia in a population of university students.

METHOD

A &item questionnaire (available on request) was developed to elicit information relative to a) basic demographic data, b) the DSM-I11 diagnostic criteria for bulimia, c) frequency of certain behaviors used to control weight, d) weight and food attitudes, and e) history of treatment for psychiatric or eating disorders. Questions related to DSM-I11 criteria were developed by simplification of criteria language used in DSM-111.

The survey population consisted of students attending required freshman English classes on a given day at a state university in the midwest. This population had previously been used by the university for information gather- ing purposes. Student counseling center staff explained the purpose of the questionnaire to the teachers of the course who then cooperated in handing out the questionnaires. The questionnaire contained a cover paragraph ex- plaining the purpose of the study and that cooperation was voluntary. Anonymity was assurred. We obtained completed questionnaires from 1355 of the 1379 students surveyed (response rate 98.3%).

The questionnaire was also administered to 37 outpatients who were found to meet the DSM-I11 criteria for bulimia at the time of evaluation in our eating disorders clinic. This group will be referred to as the bulimic patient group in this paper.

DSM-I11 criteria for bulimia are shown in Table 1 and the questionnaire

76 INT'L IOURNALOF EATING DISORDERSIVOL.2 N0.3ISPRINC 1983

Bulimia in College Students

items designed to elicit information related to those criteria are listed in the left-hand column of Table 2. Criterion C (Table 1) was omitted from the inclusion criteria because our clinical experience indicated that it would not be valuable in identifying questionnaire responses by bulimic individuals. Those students who responded affirmatively to all the items required for our inclusion criteria for the diagnosis of bulimia (A, B, and D in Table 2) will subse- quently be referred to as the "bulimic" student group.

One section of the questionnaire asked questions concerning weight. For purposes of data analysis, respondents were classified as overweight if their reported weight exceeded the maximum weight for a person of their height, assuming a large frame, using the Metropolitan Life Insurance tables. Those respondents who reported weighing below the minimum for their height, assuming a small frame, were defined as underweight.

Data analysis for comparisons between groups utilized the Chi-square test with OSL adjustment for multiple comparisons.

RESULTS

The results are presented in three sections: 1) The first section examines the incidence of bulimia in the population surveyed. The other sections compare 2) female bulimic patients and female "bulimic" students, and 3) female "bulimic" students and nonbulimic female students. Eleven "bulimic" male students were identified by the survey (Table 2) but were excluded from subse- quent statistical comparison because of the small number in this group and because no males were included in the group of bulimic patient controls.

Frequency of Bulimia in the College Population

The responses of "bulimic" students, nonbulimic students and bulimic patients are shown in Table 2. The three criteria required for inclusion (A, B, and D) were responded to affirmatively by 100% of the group of female bulimic patients who answered the questionnaire. Fifty-six students (45 females and 11 males) met our inclusion criteria for bulimia. This "bulimic" student group included 4.1% of the total population, 7.8% of the females and 1.4% of the males surveyed.

As shown in Table 2, the results indicate that many of the nonbulimic students (41% of males and 57.4% of females) admitted to binge-eating episodes and that over one-third of the students (34.6%) including nearly one- half of the women (47%) admitted to having attempted specific weight-control methods.

To further define groups of students with abnormal eating patterns two ad- ditional sets of criteria were considered empirically: I) a history of at least weekly binge-eating behavior in addition to criteria A, B, and D, and 2) a history of at least weekly binge-eating behavior accompanied by either at least weekly self-induced vomiting and/or at least weekly laxative use in addition

INT'LJOURNALOF EATING DISORDERSIVOL.2 N0.3iSPRING 1983 77

Bulimia in CollegeStudents

TABLE 1

Diagnostic Criteria for Bulimia

Recurrent episodes of binge-eating (rapid consumption of a large amount of food in a discrete period of time, usually less than 2 hours) At least 3 of the following: (1) (2) (3)

(4)

(5)

Awareness that the eating pattern is abnormal and fear of not being able to stop eating voluntarily Depressed mood and self-deprecating thoughts following eating binges Bulimic episodes are not due to anorexia nervosa or any known physical disorder

consumption of high caloric, easily ingested food during a binge. inconspicuous eating during a binge termination of such eating episodes by abdominal pain, sleep, social interruption, or self-induced vomiting repeated attempts to lose weight by severely restrictive diets, self-induced vomiting, or use of cathartics and/or diuretics frequent weight fluctuations greater than 10 pounds due to alternating binges and fasts

A.

B.

C.

D. E.

to criteria A, B, and D. These data are shown in Table 3. The addition of the criterion of at least weekly binge-eating identified a smaller number of both male and female students. The use of the criteria of at least weekly binge- eating accompanied by at least weekly self-induced vomiting or laxative use identified only 8 students. However, all 37 bulimic patients met the first alternative set of criteria, and all but 3 met the second set of alternative criteria.

Another group of students examined relative to the question of the prevalence of bulimia were those who admitted to a history of previous treatment for eating disorders. Fifteen students (11 females and 4 males) reported previous treatment for either anorexia nervosa or bulimia. This represented 1% of the total population and approximately 2% of the females surveyed.

Female “Bulimic” Students vs. Female Bulimic Patients

While the binge-eating criterion A was required of both groups, the bulimic patients reported daily binge-eating significantly more often than the ”bulimic” students reported this pattern (Table 4). Bulimic patients also reported a significantly higher incidence and frequency of self-induced vomiting and laxative use. There was no significant difference in the fasting behavior reported by these two groups. The bulimic patients had a significantly higher frequency of responding affirmatively to the inclusion criterion question regarding binging until interrupted by pain, other people, sleep, or self- induced vomiting. The female bulimic patient group also reported a significantly higher frequency of previous treatment for eating disorders, depression, and a higher rate of stealing behavior compared to female ”bulimic” students.

78 INT’1)OURNALOF EATING DISORDERS/VOL.2 N0.3 / SPRING 1983

A.

Adm

it to

hav

ing

"had

the

ex

peri

ence

of r

apid

ly e

atin

g a

larg

e am

ount

of

food

at

one

time

in a

way

that

w

ould

be

emba

rras

sing

if

othe

rs s

aw y

ou."

8.

(Adm

it to

at l

east

3 o

f th

e fo

llow

ing

5 st

atem

ents

):

1.

''I te

nd t

o ea

t hig

h-

calo

rie,

eas

y-to

-dig

est

food

in la

rge

quan

titie

s."

2.

''I do

n't

like

to h

ave

peop

le p

rese

nt w

hen

I ea

t."

3.

''I fr

eque

ntly

eat

unt

il m

y st

omac

h hu

rts

too

bad

to c

ontin

ue,

or I

am in

terr

upte

d by

oth

er

peop

le, o

r I f

all a

slee

p,

or v

omit.

"

cont

rol w

eigh

t by

self-

in

duce

d vo

miti

ng, l

ax-

ativ

e use, d

iure

tics,

en

emas

, or

fast

ing

5.

''I ha

ve h

ad m

any

fluc-

tu

atio

ns in

wei

ght o

f 10

po

unds

or m

ore.

"

4.

Adm

it to

atte

mpt

s to

C.

"Fee

l dep

ress

ed a

nd d

own

on m

ysel

f af

ter I

eat

la

rge

quan

titie

s of

food

."

I

TABL

E 2

Incl

usio

n C

rite

ria

for S

elec

tion of "

Bul

imic

" S

tude

nts

Non

bulim

ic S

tude

nts

"Bul

imic

" St

uden

ts

Tot

al

n =

1299

(%

n)

619

(47.

7)

37

(2.8

)

266

(17.

4)

46

(3.5

)

40

(3.1

)

450

(34.

6)

165

(12.

7)

285

(21.

9)

Mal

e n =

769

(% n

) 31

5 (4

1.0)

30

(3.9

)

147

(19.

1)

27

(3.5

)

27

(3.5

)

201

(26.

1)

85

(11.1)

78

(10.1)

Fem

ale

Tot

al

n =

530

n=56

(%

n)

(% n

) 30

4 56

(5

7.4)

(1

00.0

)

7 (1

.3)

79

(14.

9)

19

(3.6

)

13

(2.5

)

56

(100

.0)

44

(78.

6)

36

(64.

3)

15

(26.

8)

249

52

(47.

0)

(92.

9)

80

40

(15.

1)

(71.

4)

207

56

(39.

1)

(100

.0)

Mal

e n

=ll

(%

n)

11

(100

.0)

11

(100

.0)

(81.

8)

9 9 (8

1.8)

2 (1

8.2)

7

(63.

7)

7 (6

3.7)

11

(100.0)

Fem

ale

n=45

(%

n)

45

(100

.0)

45

(100

.0)

(77.

8)

35

27

(60.

0)

13

(28.

9)

45

(100.0)

33

(73.

3)

45

(100

.0)

B u 1 i m

i c

Patie

nts

Fem

ale

n=37

(%

n)

37

(100

.0)

37

(100

.0)

28

(75.

7)

23

(62.

2)

28

(75.

7)

37

(100.0)

18

(48.

6)

37

(100.0)

Mee

t Inc

lusi

on C

rite

ria

for

"Bul

imic

" St

uden

ts

m

TABL

E 3

Prev

alen

ce o

f "B

ulim

ia"

in th

e C

olle

ge P

opul

atio

n Fe

mal

e T

otal

Stu

dent

s M

ale

Fem

ale

Bul

imic

Pat

ient

s n=1355

n=780

n=575

n=37

n

n n

(%) (%)

n

__

_

_

__

_

_

(%) (a)

56

(4.1)

11

(1.4

45

(7.8

) 37

(100)

Mee

t Inc

lusi

on C

rite

ria

plus

29

(2.1)

3 (0

.4)

25

(4.5)

37

(100)

a hi

stor

y of

wee

kly

bing

e-ea

ting

Mee

t Inc

lusi

on C

rite

ria

plus

8

(0.6)

2 (0.3)

6 (1

.0)

34

(91.9)

a hi

stor

y of

wee

kly

bing

e-ea

ting

and

wee

kly

self-

indu

ced

vom

iting

or

laxa

tive

use

- TABL

E 4

Bul

imic

Beh

avio

rs a

nd A

ttitu

des

in "

Bul

imic

" Stu

dent

s an

d B

ulim

ic P

atie

nts

Bin

ge E

atin

g12

At

any

time

At l

east

wee

kly

At l

east

dai

ly

At a

ny ti

me

At

leas

t wee

kly

At l

east

dai

ly

Self-

Indu

ced

Vom

iting

]

"Bul

imic

" Fe

mal

e St

uden

ts

Bul

imic

Fem

ale

Patie

nts

P N =

45

n =

37

n 70

n 70

45

(100.0)

37

(100.0)

26

(57.7)

37

(100.0)

NS

-

7 (15.5)

33

(89.

2)

<.001

8

(17.8)

36

(97.3)

<.001

5 (11.1)

32

(86.5)

<.001

4 (8.9)

29

(78.4)

<.001

v

W

r_

_.

Lax

ativ

e Use

1 A

t any

tim

e A

t lea

st w

eekl

y A

t lea

st d

aily

At

any

time

At

leas

t wee

kly

At

leas

t dai

ly

24-H

our F

astin

g1

At a

ny ti

me

At l

east

wee

kly

Bin

ge o

n H

igh-

Cal

orie

, Eas

y-to

-Dig

est F

ood3

Pr

efer

to E

at A

lone

3 B

inge

unt

il In

terr

upte

d by

Pai

n, P

eopl

e, S

leep

or

Vom

iting

3 C

ontr

ol W

eigh

t by

Vom

iting

, Lax

ativ

es, D

iure

tics,

or

Fas

ting3

Fr

eque

nt W

eigh

t Flu

ctua

tions

3 Fe

ar o

f B

eing

Fat

Tre

atm

ent f

or A

nore

xia

Ner

vosa

or B

ulim

ia

His

tory

of

Alc

ohol

or D

rug

Abu

se2

Tre

atm

ent f

or A

lcoh

ol A

buse

T

reat

men

t for

Oth

er D

rug

Abu

se

Tre

atm

ent f

or D

epre

ssio

n T

reat

men

t for

Oth

er E

mot

iona

l Dis

orde

rs

His

tory

of

Stea

ling

Beh

avio

r

Ove

rwei

ght

Und

erw

eigh

t

Diu

retic

Use

1

10

4 2 7 5 2 34

12

35

27

13

45

33

35 4 6 3 4 4 6 6 18 0

(22.

1)

(8.8)

(4.4

)

(15.

5)

(14.

1)

(4.4

)

(75.

6)

(26.

6)

(77.

8)

(60.

0)

(28.

9)

(100

.0)

(73.

3)

(77.

8)

(8.8)

(13.

3)

(6.7

) (8.9)

(8.9)

(13.

3)

(13.

3)

(45.

0)

(0.0)

21

10

8 15

10

8 24

12

28

23

28

37

18

37

18

10

8 4 15

6 21 5 1

(56.

8)

(27.

0)

(21.

6)

(40.

5)

(27.

0)

(21.

6)

(64.

9)

(32.

4)

(62.

2)

(75.

7)

(75.

7)

(100

.0)

(100.0)

(48.

6)

(48.

6)

(27.

0)

(21.

6)

(10.

8)

(40.

5)

(16.

2)

(56.

8)

(13.

5)

(2.7

)

<.05

N

S

NS

NS

NS

NS

NS

NS

<.01

NS

NS

<.05

N

S

<.05

NS

<.01

NS

1 A

nsw

ered

the

follo

win

g: F

or e

ach

of t

he b

ehav

iors

list

ed b

elow

, sel

ect t

he o

ne m

onth

per

iod

in y

our l

ife w

hen

that

beh

avio

r occ

urre

d mos

t of

ten

and

chec

k th

e ap

prop

riat

e co

lum

n. R

espo

nses

wer

e nev

er, less

than

onc

e a w

eek,

mor

e th

an o

nce a

wee

k, a

bout

onc

e dai

ly, a

nd m

ore

than

onc

e da

ily (e

xcep

t for

24-h

our

fast

s).

Ans

wer

ed y

es to

"H

ave

you

ever

had

pro

blem

s with

alc

ohol

or d

rug

abus

e or

bee

n to

ld th

at y

ou s

houl

d se

ek h

elp

for s

uch

prob

lem

s?

Atti

tude

s and

beh

avio

rs re

late

d to

incl

usio

n cr

iteri

a fro

m T

able

2.

2 3


The "Bulimic" Female Student Groups vs. the Nonbulimic Female Students

A comparison between the female "bulimic" students and the nonbulimic female students is shown in Table 5. "Bulimic" female students reported significantly higher prevalence and frequency for 24-hour fasting than nonbulimic female students reported. "Bulimic" female students also were significantly more likely to report having had treatment for alcohol and drug- related problems, and were also significantly more likely to report having engaged in stealing behavior compared to nonbulimic female students. They were also more likely to be overweight than nonbulimic female students. Non- bulimic female students were significantly more likely to report being underweight than "bulimic" female students.

DISCUSSION

The reliability and validity of using self-report questionnaires to elicit data is always of concern. The high response rate in the present study (98.3%) strengthens the validity of the findings, however. The 100% response of the 37 bulimic female patients to inclusion criteria A, B, and D, reduced our concern about false negatives.

A second consideration is our formulation of the questions for this instru- ment. In light of our previous experiences using the DSM-I11 criteria, several questions relating to the inclusion criteria for "bulimic" students were made more stringent. For example, criterion A regarding binge-eating was restricted by using the qualifying terms "in a way that would be embarrassing if others saw you." Conversely, criterion B5 on weight fluctuations was broadened by omitting "as a result of alternating binges and fasts," since it was felt that a judgment regarding causality might be too restrictive. Questions were also simplified so that they could be easily understood. For example, in criterion B1, the word "ingest" was changed to "digest." These changes introduced the risk of changing the meaning or allowing for alternative interpretations of a given question.

While omission of Criterion C, "awareness that the eating pattern is abnormal and fear of not being able to stop eating voluntarily" seemed indicated on the basis of our clinical experience with the questionnaire responses of bulimic patients, this criterion should not be rejected as a diagnostic criterion for clinical interviews. Future investigators may wish to include this criterion to deter- mine its usefulness in distinguishing bulimic patients from other patients with eating problems.

Four percent of all students (8 % of females and 1.4% of males) met our inclusion criteria for bulimia which did not include DSM-I11 criterion C or require recurrent binge-eating (only binge-eating). The group of "bulimic" females who have engaged in binge-eating at least weekly (4.5% of females) may approximate more closely the DSM-111 criteria for bulimia since recurrent

a2 INT'L IOURNALOF EATING OlSOROERSl VOL.2 N0.3 / SPRING 1983

Bulimia in CollegeStudents

TABLE 5 Bulimic Behaviors and Attitudes in "Bulimic" and Nonbulimic Female Shtdents

Binge Eating1r3 At any time At least weekly At least daily

At any time At least weekly At least daily

Laxative Use1 At any time At least weekly At least daily

At any time At least weekly At least daily

24 Hour Fasts1 At any time At least weekly

Self-Induced Vomiting1

Diuretic Use1

Depressed and Self-Deprecatory after a Binge3 Binge on High-Caloric, Easy-to-Digest Food3 Prefer to Eat Alone3 Binge Until Interrupted by Pain, People, Sleep or

Control Weight by Vomiting, Laxatives, Diuretics,

Frequent Weight FluctuationsJ Criterion B (3 of 5 Item@ Fear of Being Fat Treatment for Anorexia Nervosa or Bulimia History of Alcohol or Drug Abuse2 Treatment for Alcohol Abuse Treatment for Other Drug Abuse Treatment for Depression Treatment for Other Emotional Problems History of Stealing Behavior2 Overweight Underweight

Vomiting3

or Fasting3

Nonbulimic Students -

n = 530 % ___-

304 (57.6) 73 (17.2) 7 (1.3)

34 (6.4) 7 (1.3) 1 (0.2)

50 (9.5) 3 (0.6) 1 (0.2)

29 (5.6) 7 (1.3) 2 (0.4)

161 (30.4) 23 (4.4)

207 (39.1) 79 (14.9) 19 (3.6) 13 (2.5)

249 (47.0)

80 (15.1 7 (1.31

329 (62.1)

7 (1.3) 19 (3.6) 10 (1.9) 9 (1.7)

19 (3.6) 29 (5.5)

18 (3.1) 68 (14.3)

105 (22.0)

"Bulimic" Students P

n = 4 5 % --__

45 26 7

8 5 4

10 4 2

7 5 2

34 12

45 35 27 13

45

33 45 35 4 6 3 4 4 6 6

18 0

(100.0) <.001 (57.7) <.001 (15.5)

(17.8) NS (11.1) (8.9)

(22.1) NS (8.8) (4.4)

(15.5) NS (11.1) (4.4)

(75.6) <.001 (26.6) <.001

(100.0) <.001 (77.8) <.001 (60.0) <.001 (28.9) <.001

(100.0) <.001

<.001 (iE:;I <.001 (77.8) NS

(13.3) <.05 (8.8)

(6.7) (8.9) (8.9) NS

(13.3) NS (13.3) <.05 (45.0) <.001 (0.0) <.05

1 Answered the following: For each of the behaviors listed below, select the one month period in your life when that behavior occurred most often and check the appropriate column. Responses were never, less than once a week, more than once a week, about once daily, and more than once daily (except for 24-hour fasts).

2 Answered yes to "Have you ever had problems with alcohol or drug abuse or been told that you should seek help for such problems?

3 Attitudes and behaviors related to inclusion criteria from Table 2.

INT'L IOURNALOF EATING DISORDERSIVOL.2 NO.3/ SPRING 1983 83


binge-eating is established in this group. "Bulimic" female students who admitted to at least weekly self-induced vomiting or laxative use, as well as at least weekly binge-eating, most closely resembled the bulimic patients that we evaluate in our clinic. They comprised 1 % of the female student population.

This study identified a smaller percentage of "bulimic" students than the percentage identified by Halmi et al., (1981) who found that 13% of the population studied reported all the major symptoms of bulimia as outlined in DSM-111. This variation may reflect the difference between the two popula- tions. Halmi's population, selected to represent a cross section of the general population, consisted of summer school students close to a large metropolitan area. Our population consisted of students from a state university in the midwest.

"Bulimic" students clearly are different from the bulimic patients that we see in their use of fasting rather than self-induced vomiting or laxative use to control weight. These data suggest the possibility of a high proportion of overeaters in the "bulimic" group of students identified by this questionnaire, and that this group of students may not closely resemble the bulimics we see clinically. These data also suggest the possibility that fasting and being overweight are common in the earlier stage of the bulimic syndrome, or are typical features of milder cases of this problem. "Bulimic" female students cer- tainly resemble bulimic patients in their history of alcohol and drug abuse, and stealing behavior, all of which are significantly higher than in nonbulimic female students.

More bulimic patients seek treatment for depression than "bulimic" students. It may be that this more symptomatic group has a higher frequency of secondary depression or that they are more likely to seek professional help for symptoms of depression. It is also possible that there is an association between primary affective disorders and the development of more severe symptoms of bulimia. The occurrence of a significantly higher percentage of daily binge-eating behavior, self-induced vomiting and laxative use for weight control, and stealing behavior may represent a basic impulse control problem in those bulimic patients who develop the more severe symptoms which lead them to seek treatment.

The responses from the nonbulimic student population related to incidence of binge-eating, weight-control measures, and attitudes about eating and weight largely agree with previous findings. The incidence of binge-eating in our survey (57% females and 41% males) was somewhat less than that found by Hawkins and Clement (79% females and 49% males).

The 4 to 1 ratio of females over males responding affirmatively to the inclusion criteria D for being depressed and self-deprecatory after binge-eating may explain the preponderance of females over males in the "bulimic" student group (see Table 2). Halmi et al., (1981) also found this difference to be significant. This attitude among females may be a reflection of their concern over their weight and physical appearance which has been associated with the predominance of females with this syndrome (Boskind-Lodahl, 1976). Results

84 INT'L JOURNALOF EATING DISORDERS/ VOL.2 N0.3 / SPRING 1983


of the survey indicate that the fear of being fat is common in a college population which greatly limits the usefulness of this variable in identifying individuals with eating disorders.

In summary, our data would indicate that one percent of the female students surveyed reported abnormal eating behaviors similar to the eating behaviors reported by bulimic patients coming to our clinic. While similar to the bulimic patient, the female "bulimic" student professes to use fasting as a frequent weight-control measure. The bulimic patient, on the other hand, has more frequently weekly binge-eating, tends to control weight by self-induced vomiting or laxative abuse, is more likely to be treated for depression, and to engage in stealing behavior. The results of this study indicate that DSM-111 criteria, as we have applied them to a self-report questionnaire, are not effective criteria for identifying a group of people who closely resemble the patients we have evaluated and diagnosed as bulimic. The use of more stringent criteria such as a history of binge-eating and self-induced vomiting and/or laxative use on at least a weekly basis identified a group which is more similar clinically to our patients, but this group is much smaller than the group identified by the DSM- 111-based inclusion criteria used in this study.

The results of this study must be viewed with the knowledge that DSM-111 criteria were developed for clinical diagnostic interviews and not specifically for inclusion in questionnaires. While the addition of quantitative parameters to the DSM-111-based questionnaire responses was helpful in identifying a group of students who more closely resembled bulimic patients, the possible assumption that DSM-I11 criteria would be more useful if they were quantified will require further study.

U REFERENCES

Diagnostic and Statistical Manual of Mental Disorders. Washington, D.C.: American Psychiatric Associa- tion, 1980, 3rd edition.

Boskind-Lodahl, M. Cinderella's stepsisters: A feminist perspective on anorexia nervosa and bulimia. Journal of Women in Culture and Society, 1976. 2. 342-356.

Casper, R.C., Eckert, E.D., & Halmi, K.A. Bulimia: Its incidence and clinical importance in patients with anorexia nervosa. Arch Gen Psychiatry, 1980, 37, 1030-1035.

Halmi, K.A., Falk, J . R . , & Schwartz, E . Binge-eatingand vomiting: A survey of a college population. Psycho1 Med, 1981, 11, 697-706.

Hawkins, R.C., & Clement, P.F. Development and construct validation of a self-report measure of binge- eating tendencies. Addicitue Behaviors, 1980, 5, 219-226.

Pyle, R.L. . Mitchell, J.E., & Eckert, E D . Bulimia: A report of 34 cases. Clin Psychiatry, 1981, 42, 60-64. Russell, G. Bulimia nervosa: An ominous variant of anorexia nervosa. PsycholMed, 1979, 9, 429-448. Stangler, R.S., & Printz, A.M. DSM-111: Psychiatric diagnosis in a university population. A m JPsychiatry,

Stunkard, A.J. Eating patterns and obesity. Psych Quart, 1959, 33, 284-295. 1980, 137, 937-940.

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the incidence of bulimia in freshman college students

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