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Shebanova Vitaliya Ihorivna, Taras Shevchenko National University of Kyiv, doctoral student, the Faculty of Рsychology, the department of psycho-diagnostics and clinical psychology
E-mail: vitaliap@mail.ru
The present state of the problem of anorexia nervosa and bulimia nervosa
Abstract: The article describes the analysis of scientific sources on the study of clinical forms of eating disorders (anorexia nervosa and bulimia nervosa). Close relationship of pathological patterns of eating behavior to bulimic and anorectic type is determined. There is a lack of accurate data on the therapeutic methods of treatment for people using pathological forms of eating behavior to correct their figures (anorexic and bulimic strategies).
Keywords: eating disorders, anorexia nervosa, bulimia nervosa, psychological prophylaxis, therapy, rehabilitation.
The problem of clinical eating disorders is important today due to the disease expansion in the last decade, its earlier onset, the difficulties in diagnosis and treatment of patients with a tendency to dissimulation, time-lag reference to specialists. Over the last decade epidemiological and statistical data on anorexia nervosa point out some changes in the direction of significant growth of: 1) the total number of cases among the population, 2) male anorexia, 3) bulimic manifestation of symptoms in patients with anorexia nervosa (M. O. Tsyvilko, M. V. Korkina, V. I. Skvortsov, et al., 2001; N. I. Dolyshnya, 2009, I. V Babenko-Sorokopud, 2010, V. A. Mityukov, N. V Knyazeva, N. V Hrebelna, et al., 2011) [1; 2; 3; 4]. All that makes it necessary to clarify not only the diagnostic criteria, but the peculiarities of pathological eating behavior.
Anorexia nervosa is a behavioral syndrome, a form of pathological eating behavior, characterized by immoderate food restriction (of conscious and unconscious nature) for the purpose of body slimming (or appearance correction). This destructive (disadaptive) type of behavior is based on dysmorphophobic — dysmorphomanic disturbances. A striking feature of the first ones is a «morbid fear of fatness» or real or imaginary overweight. Dysmorphomanic disturbances are associated with an excessive overvaluation of the individual’s weight and body fat. Behavioral patterns caused by an extreme concern about weight and shape lead to physical and mental exhaustion, severe somatic endocrine disorders.
Anorexia nervosa is treated as a behavioral syndrome, which refers to «non-specific» pathology in pubertal and adolescent age (more than 75 % of patients are teens)
(N. I. Dolyshnia, I. V Babenko-Sorokopud, V. O. Mitiukov, N. V. Kniazeva, N. V. Hre-belna, D. N. Isaev, B. D. Karvasarskiy, E. K. Kislova, M. V Korkina, M. A. Tsivilko, V. V Kovalev and others) [2; 3; 4; 5; 6; 9].
It should be noted that the first diagnostic criteria used in determining the features of bulimic eating behavior (binge eating followed by induced vomiting) are: a «special variant of eating behavior» (M. V Korkina, M. A. Tsyvilko, V V Marilov, 1975), the «syndrome of dietary chaos» (dietary chaossyndrome, R. L. Palmer, 1979), the «syndrome of abnormal control of normal weight» (A. N. Crisp, 1979), «bulimia nervos» (bulimia nervosa, F. M. Russellg, 1979, DSM — III — R, 1987). C. G. Fair-burn (1982) characterizes bulimia nervosa as a «disturbance of eating behavior with periods of uncontrolled binging, keeping to a strict diet excluding fat food and an extensive concern for a certain body weight».
The question ofwhether bulimia nervosa is an independent pathological behavior (disorder), or a stage in the development of anorexia nervosa remains controversial for a long time. Accordingly, a lack of unity of views on diagnostic criteria and about the features of forming pathological eating behavior doesn’t allow achieving unity in the prevention, treatment and rehabilitation. Solution of these issues is an important task in clinical psychology.
At the present stage of scientific development a lot of foreign researchers stand up for the idea of nosological independence of bulimia nervosa, emphasizing the necessity of delimitation of anorexia nervosa and bulimia nervosa (R. L. Palmerr, 1979;
C. G. Fairburn 1982; B.J. Blinder, 1991; J. E. Mitchell, 1992; T. B. Walsh, M. J. Devlin, 1998 and others).
At the same time, many foreign researchers point to the «common roots» (a certain unity, commonality) of anorexia nervosa and bulimia nervosa (A. Z. Guiora, 1967; R. C. Casper, 1990; G. F. M. Russell, et al., 1992; D. M. Gamer, et al., 1997; V Pudel, N. Maus, 1990; C. Costin, 2007 and others). In particular, A. Z. Guiora (1967) considers «anorexia nervosa and bulimia nervosa» as one disease «dysorexia» which manifests itself in two ways. G. F. M. Russell (1992) defines bulimia nervosa as an «ominous variant of anorexia nervosa». An important argument of the followers of this point of view is the possibility of mutual transformation of anorexia nervosa and bulimia nervosa (H. Bruch, 1961; W. S. Agras, et al., 1986, 1987; J. J. Brumberg, 1988; D. B. Herzog, et al., 1991,-J. E. Mitchell, et al., 1990; G. F. M. Russell et al., 1992; M. Boskind-White, W. C. White, 2001; J. Kirkpatrick, et al., 2004 and others).Thus, many authors believe that bulimia is a variant of anorexic behavior, but with a deeper level of pathology.
O. K. Kislova notes that despite the distinguishing AN and BN in a separate group of disorders in DSM — IV (1994) and ICD — 10 (1995) not only their similarity but also indissoluble connection between bulimic and anorexic behavior are emphasized at
the same time in nosologic manuals mentioned [7, 15]. Thus, according to ICD — 10: «... the term (bulimia) should be restricted to the form of the disorder that is related to anorexia nervosa by virtue of sharing the same psychopathology. The age and sex distribution is similar to that of anorexia nervosa, but the age of presentation tends to be slightly later. The disorder may be viewed as a sequel to persistent anorexia nervosa (although the reverse sequence may also occur)» [10, 175].
Among Ukrainian researchers in the field of eating behavior pathology, a number of leading experts also prejudice the relevance of delimitation of anorexia nervosa and bulimia nervosa (M. V. Korkina, M. O. Tsyvilko, V. V. Marilov, 1986, 1988, 1990, 1991, B. B. Kovalev, 1990; M. O. Tsyvilko, 2000, 2001; O. K. Kislova, 2004, V. A. Mi-tiukov, N. V Knyazeva, N. V Hrebelna et al., 2011 and others) [8; 9; 10; 16; 18]. At the same time the attention is paid to the fact that anorexia nervosa and bulimia nervosa have «common psychopathological core — dysmorphophobic and dysmorphoman-ic ideas». The researchers deny nosologic independence of bulimia nervosa, noting that it is an unfavorable course of anorexia nervosa, emphasizing the indissoluble connection between bulimic and anorexic behavior.
The analysis of scientific papers devoted to the problem of eating behavior disorders (both foreign and domestic authors) allows to notice that the early publications in 70s had tendency to delimitation of anorexia nervosa and bulimia nervosa, but more recent studies (XX — XXI c.) emphasize the idea of their unity and tendency to connection (quoted in O. K. Kislova) [7, 15].
The studies review in terms of nosologic belonging to eating disorders also reveals the variety of specialists’ views on the subject. Some foreign investigators include anorexia nervosa to the «circle of schizophrenic forms (K. Lingyarde, 1949; N. Bassoe, 1998, and others), considering it as an initial manifestation of schizophrenia (A. Buge, 1966; Theander, 1969 and others). ICD — 10 lays out guidelines that anorexia nervosa may be a syndrome of schizophrenia [10]. To confirm the schizophrenic nature of AN the authors suggest the following common features for these diseases as a breakdown of thought processes (presence of delusions), abnormal social contacts, impaired emotional responses with a lack of desire to form relationships, obsessive — compulsive behavior accompanied by multiple protective rituals, maladaptive behavior, a distortion of the body image.
The analysis of comorbid anorexic and bulimic strategies of eating behavior with symptoms of other non-psychotic disorders, premorbid characterological features of individuals, specific features of dynamics of pathological forms of eating behavior (clinical picture of AN and BN, expressiveness of the secondary somatoendocrine disorders, results of disease), confirms an idea about a close relationship and unity of eating behavior disorders and allows to consider that differentiation of these two types of eating behavior is artificial.
Thus, the analysis of works devoted to the pathological forms of eating behavior enables to make the following conclusions:
1. Evaluating eating behavior features, the results of researches often have controversial character. There is a lack of unity in nosologic belonging of bulimic symptoms and the abnormal psychology structure of AN and BN syndromes. One researches define bulimia nervosa as an independent pathological form of eating behavior, the others consider BN a symptom, stage, variant of anorexia nervosa.
2. A close relationship of pathological patterns of eating behavior on bulimic and anorexic type is specified by:
- strong desire (of conscious and unconscious character) for body slimming (or appearance correction) by certain maladaptive (irrational, destructive) behavioral strategies;
- a general mechanism for initializing maladaptive behavioral strategies — dysmorphophobic and dysmorphomanic ideas;
- general psychopathological symptoms (similar psychotic syndromes structure of AN and Bn);
- possible mutual transformation of anorexia nervosa and bulimia nervosa, while changing anorexic strategies for bulimic or their interchanging may be regarded as an unfavorable dynamics of anorexia nervosa (its «ominous variant») or is considered prognostically unfavorable symptom;
- similar comorbidness of AN and BN with symptoms of other non-psychotic disorders (symptoms of anxious-phobic and affective disorders);
- similar premorbid characterological features (according to anankastic, anxious, hysterical personality disorders).
3. There is a lack of accurate data on the therapeutic methods of treatment for people using pathological forms of eating behavior to correct their figures (anorexic and bulimic strategies). However, there is an obvious necessity to explore these issues for conducting adequate psychological prophylaxis, therapy and rehabilitation.
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