General psychopathology

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General psychiatric symptoms are prominent in bulimia nervosa, more so than in anorexia nervosa.(!. 19) The nature of the comorbid symptoms also differs. Depressive features are particularly striking: indeed, the level of depressive symptoms in bulimia nervosa is equivalent to that seen in major depressive disorder. Depressed mood, feelings of hopelessness and worthlessness, poor concentration, guilt, and suicidal ideation are seen. Anxiety symptoms are also encountered, many of which are directly related to the eating disorder; for example, there is often pronounced anxiety about eating in public. Obsessive- compulsive features are sometimes present, although they are less common than in anorexia nervosa. Similarly, social functioning is less impaired.

A subgroup of patients with bulimia nervosa have 'impulse-control' problems, such as the overconsumption of alcohol or drugs, or repeated self-harm. Some of these patients also meet diagnostic criteria for borderline personality disorder. The prevalence of such features varies according to treatment setting: they are unusual in community samples/20 whereas they are more frequent among patients seen in specialist treatment centres.

Much more common than frank personality disorders are two traits which are also seen in anorexia nervosa.(22) The first is low self-esteem. This generally antedates the eating disorder, although it is often exaggerated by it. Many patients with bulimia nervosa describe long-standing doubts about their worth and ability, irrespective of their accomplishments. The second is perfectionism, that is, imposing on oneself inordinately high personal standards in a range of domains (e.g. work, sport, personal conduct). Since many of these standards are unachievable, it is common for these patients to give long histories of having viewed themselves as perpetually failing.

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