The description of body image disturbance that is central to both anorexia and bulimia nervosa has undergone revision. A distinction has been argued for between dissatisfaction with body shape and overvalued ideas about weight and shape. Although body shape dissatisfactions are commonly found in these patients, it is their overvalued ideas about weight and shape that are the necessary diagnostic feature. In other words, concern should go beyond simply feeling fat to a point where a person's life is dominated by their feelings about body weight and shape.

If these overvalued ideas are accepted as the core psychopathology of bulimia nervosa, then the chaotic eating that typifies the condition can be seen as a behavioral consequence. Binges are often interspersed between periods of intense dieting, even fasting, themselves strategies to control weight. Purging always follows a binge and is a way of expelling the food ingested or compensating for the food energy intake. Binges are secretive, planned, often expensive, and emotionally self-destructive. Paired with purging, they are cyclical and self-perpetuating, although their frequency may wax and wane. In addition, this behavior may have a long history before treatment is considered and clinical attention sought.

Bulimic episodes may be triggered by a variety of factors, including anxiety, boredom, tension, or breaking the self-imposed dietary rules necessary to maintain rigid control over eating (see Figure 1). Only rarely is hunger identified as precipitating a binge, even though the person may not have eaten for 24 h or more.

Sustained depressive and anxiety symptoms are common and are part of a range of psychological

Psychopathophysiology Bulimia Nervosa
Figure 1 The cognitive behavioral view of the maintenance of bulimia nervosa (adapted from Fairburn & Brownell, 2002).

and social problems characteristic of bulimia nervosa. Impulsivity is also characteristic, with sexual promiscuity, self-harm, drug use, and stealing frequently noted. One suggestion is that impulsivity is a personality trait that favors bingeing over restriction, and so predisposes a person to bulimia nervosa rather than anorexia nervosa.

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