The fact that it took Russell(1) more than 6years (1972-1978) to collect 30 cases of bulimia nervosa suggested that the disorder was not common. Therefore it is remarkable that within a few years of the publication of Russell's paper it was evident that bulimia nervosa was an important source of psychiatric morbidity among women.
In the early 1980s large numbers of previously undetected cases were identified using the media. (3,3J These were remarkably similar to Russell's cases, except that almost all were female and a small proportion had a history of anorexia nervosa. Most had kept their eating disorder secret for many years, and because of shame and hopelessness few had sought help. Many thought that they were the only person with this type of eating disorder. Simultaneously, however, and doubtless partly as a result of the media attention, there was also a sharp increase in the number of people requesting treatment for bulimia nervosa ( Fig 3) such that it was soon the most common type of eating disorder seen in clinical practice. This remains true today. (35,36)
Fig. 3 Rates of referral to a major eating disorder centre in Toronto (1975-1986). (Reproduced with permission from D.M. Garner and C.G. Fairburn (1988). Relationship between anorexia nervosa and bulimia nervosa: diagnostic implications. In Diagnostic issues in anorexia nervosa and bulimia nervosa (ed. D.M. Garner and P.E. Garfinkel). Brunner-Mazel, New York.)
The marked increase in the number of patients with bulimia nervosa stimulated interest in the prevalence of the disorder. By 1989 over 50 prevalence studies had been conducted, many of which had yielded unrealistically high prevalence figures as a result of using weak assessment and sampling procedures. Gradually methods improved with the result that estimates of the prevalence of bulimia nervosa decreased to more modest and consistent levels with the point prevalence among young adult women (aged 16 to 35years) being in the region of 1 per cent.(3 38) A similar figure has been obtained for lifetime prevalence. (39> The prevalence of bulimia nervosa among men is not known. Among patient samples, male cases are most unusual. Little is known about the presence of bulimia nervosa in non-Western cultures although it is thought to be uncommon.
There have been few estimates of the incidence of bulimia nervosa, and since these have been based upon clinic rather than community samples, they are likely to underestimate the true figures. Even today, many people with bulimia nervosa do not seek help. The lack of reliable community-based incidence figures also makes it impossible to know whether the disorder has become more common since the 1970s or whether the upsurge in cases in the early 1980s was as a result of undetected cases being more likely to seek treatment. Data from the assessment of women in different birth cohorts(40> suggest that the disorder has become much more common (Fig, 4), although other explanations for the apparent increase cannot be ruled out. It is of note that systematic searches of the psychiatric literature prior to the mid-1970s have uncovered very few cases of the disorder. (41>
Fig. 4 Lifetime cumulative risk of bulimia nervosa among different birth cohorts of female twins. (Reproduced with permission from K.S. Kendler et al. (1991). The genetic epidemiology of bulimia nervosa. American Journal of Psychiatry, 148, 1627-37.)
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