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Bulimia (from the Greek boulima: hunger [limos] of an ox [bous]), a medical term that has entered common usage, refers to an eating disorder characterized by episodes.

A bulimic episode (a binge) is defined as a fit of frenzied overeating in which an excessive amount of food is consumed in a short time; this episode involves a sense of loss of control. It can occur several times in one day and can completely overwhelm the subject. Bulimia always entails a major and overwhelming event that is convulsive or ritualized, and violent. There is usually an awareness of the pathological nature of this behavior, combined with fear of an inability to avoid it, pleasure, shame, and self-denigration. In addition to bulimia relating to food, there is a form of bulimia that relates to various consumer items (medicines, pathological buying) and to sex.

There are descriptions of bulimic episodes dating from antiquity. Medical dictionaries, particularly in the English language, refer to this disorder from the beginning of the eighteenth century (Blankaart, 1708). Historically, bulimia was predominantly a male disorder and was akin to hyperphagia and gluttony. It was long considered a manifestation of the same order as neurotic symptoms (Janet, 1903); Sigmund Freud referred to it as one of the symptoms of anxiety neurosis and also recorded it as an eating compulsion motivated by a fear of starvation.

As a manifestation of orality in the broad sense, bulimia is generally a form of pathological behavior, a passage to the act that is often impulsive and bypasses any mentalization or psychic material. It then has a defensive function in warding off psychotic disorganization or depressive affects. Karl Abraham mentioned it in his work on melancholia and, in Fear of Breakdown (1974), Donald Winnicott described it as a form of defense against the frightening nature of the void.

Bulimia is also associated with the addictions (Radó, 1926). In 1945, Otto Fenichel classified it as a "drugless addiction." Marie-Claire Célérier regards it as a symptom on the boundary between a psychosomatic loss of meaning and a hysterical signifier (1977), while Joyce McDougall describes it in terms of a symptomatic act that substitutes for the undreamt dream.

Bulimia is a widespread phenomenon in Western societies that is both on the increase and more out in the open. It has gradually become a syndrome in its own right—bulimia nervosa—with a separate status from anorexia nervosa and obesity. Wermuth and Russell first established the diagnostic criteria for the bulimic syndrome. In addition to bulimic episodes, these include various strategies for controlling weight and a psychiatric co-morbidity that can be severe (thymic disorders and addictions). These criteria reflect the notions of loss of control, chaotic functioning, inadequate mentalization and relationships of dependency (Jeammet, 1991) that are observed in these patients.

Contemporary discussions of bulimia refer to a complex, multi-faceted disorder that combines eating binges with a range of strategies for maintaining a normal weight, distortions in cognitive functioning and body-image perception, and emotional disturbances (Vindreau, 1991). In the majority of cases, the origins of the disorder are traced back to adolescence and its physiological and psychodynamic transformations. As of 2004, ninety percent of bulimics are women but the bulimia rate is rising among men. Whereas the incidence of the syndrome is three percent in the general population, it rises to seven percent in some adolescent, student, and high-school groups.

The conception of bulimia has developed from a simple compulsive substitution for a repressed sexual drive, into the widely-recognized, contemporary bulimia nervosa. Throughout this development, its definition has closely reflected both sociological and cultural changes and the psychopathological theories that prevailed over time. Above all, both the recourse of acting out through eating behavior, and the perceived need for particular bodily sensations in order to produce a psychic effect (Brusset, 1991), pose questions relating to self-esteem, difficulty in controlling behavior and emotions, narcissistic difficulties, and the quest for identity.

CHRISTINE VINDREAU

See also: Anorexia nervosa; Self representation.