Teen-agers suffering from bulimia may in fact be fighting a two-front war, coping with the effects of a devastating eating disorder while struggling with a chronic form of depression, reveals research by Texas A&M University psychologist Marisol Perez, who says the finding has critical implications for the way the disorder is treated.
Often masked by the bulimia itself, dysthymia - a lower-level, chronic form of depression - is often present in bulimics and may even predispose them to the eating disorder, shows the research by Perez and her colleagues Thomas E. Joiner Jr. of Florida State University and Peter M. Lewinsohn of the Oregon Research Institute.
Dysthymia, Perez explains, is different from the more familiar major depression in terms of its duration, severity and persistence of mood disturbance, all factors that can impact the course and treatment of eating disorders.
"As pernicious as major depression can be, it tends to remit, even if untreated," she notes. "By contrast, dysthymia is unrelenting, often lasting decades, with the average episode length lasting more than 10 years."
It's this long-lasting nature, Perez says, that makes dysthymia, rather than major depression, more likely to be associated with bulimia, which is characterized by unrelenting negative feelings about one's self.
Bulimics, she says, tend to have chronic low self-esteem. Previous models, she notes, have proposed that high perfectionism when dashed by low self-worth is predictive of bulimia. Because of this, the chronic and pervasive self-esteem problems associated with dysthymia may make dysthymic people vulnerable to bulimia, she says.
The relationship between bulimia and dysthymia might be the struggle to regulate unrelenting negative moods stemming from the depression and the feelings of low self-esteem associated with the eating disorder, Perez speculates.
Individuals who suffer from simultaneously existing disorders, such as bulimia and dysthymia, usually have a worse course and prognosis in treatment than those who only suffer from one disorder, Perez says. She believes that her findings can provide additional information to create more focused and effective treatments for teens with bulimia. Knowledge of the co-existence of bulimia and dysthymia in teens can help therapists assess specifically for dysthymia in bulimic patients and choose a treatment that will combat both disorders, she says.
Perez says that it is possible for adults to suffer from both disorders, but she notes that the patterns between bulimia and dysthymia may change from adolescence to adulthood, making major depression more likely to co-exist in adults than dysthymia.
She reasons that as the course of bulimia progresses, the social support network and resources of a bulimic person may start to diminish, making negative life events harder to overcome. The binges and purges that serve as a type of coping mechanism in the beginning of the disorder may, over time, lose their comforting aspects while their harmful ones continue to be amplified. This, in turn, may cause the intensity of the depression to increase, making the occurrence of major depression and bulimia more common in adults, she says.