Case Study of an Adopted Chinese Woman with Bulimia Nervosa: A Cultural and Transcultural Approach

By De Montgremier, Marion Vu-Augier; Chen, Liangliang et al. | Shanghai Archives of Psychiatry, August 2017 | Go to article overview

Case Study of an Adopted Chinese Woman with Bulimia Nervosa: A Cultural and Transcultural Approach


De Montgremier, Marion Vu-Augier, Chen, Liangliang, Chen, Jue, Moro, Marie Rose, Shanghai Archives of Psychiatry


1. Transcultural conceptualization of eating disorders

A lot of studies have shown that bulimia is mainly present in Western countries and urbanized areas. Keel & Klump suggested that bulimia exists only in countries with food opulence and where purging occurs in the context of fear of weight gain. [1] Bulimia could therefore be a culture-bound syndrome (CBS), or according to Ritenbaugh (1982) - "a constellation of symptoms which has been categorized as a dysfunction or disease. It is characterized by meeting one or more of the following: it cannot be understood outside its specific cultural or subcultural context, the aetiology summarizes and symbolizes core meanings and behavioural norms of that culture, diagnosis relies on culture-specific technology as well as ideology, successful treatment is accomplished only by participants in that culture. [2] Anorexia nervosa has also been viewed as a CBS in Western countries, but this theory has been refuted. [3] DiNicola believed that anorexia nervosa was a culture-change syndrome (CCS), a syndrome appearing during rapid socio-cultural changes occurring in a person or in a society. [4] Witzum went further by claiming that bulimia was also a CCS. [5] Results have corroborated this hypothesis, as an increase of the prevalence of bulimia in developing countries has been observed. [6] A systematic review of the literature reported significant links between EDs and cultural change. [7]

We analysed the clinical case of a bulimic Chinese patient, observed during an internship of a French assistant at Shanghai Mental Health Center (SMHC) with the transcultural method detailed in our transcultural psychiatry section. Diagnosis was set by a Chinese doctor using the ICD-10 and DSM-4.

2. Clinical case

Ai was 23 years old when she was hospitalized for the second time because of her bulimia at SMHC. She asked for her hospitalization in order to "readapt her treatment, renew her motivation, and reduce the feeling of weariness".

Her disorder had begun a year and a half before, with a depression related to her father's car accident. This event had a dramatic impact on her family's life. Ai's father became addicted to alcohol, and many family conflicts ensued. Ai had to discontinue her studies. She had insomnia, a reduced appetite, loss of interest, suicidal thoughts and regularly cried.

Her mood worsened which led her to go to the SMHC counseling unit where she was prescribed fluoxetine, six months after it all began. Her depression improved, but she began to eat compulsively. The compulsive eating habits progressively occurred on a daily basis, as well as induced vomiting and mood instability. She was never preoccupied with her appearance, and her BMI oscillated between 18 and 20. She returned to SMHC and was diagnosed with an ED. The dosage of fluoxetine was increased. With no sign of improvement, she was hospitalized for the first time for three months.

After her first hospitalization, there was no resurgence of the bulimic symptomatology for a few months. However, her relationship with her parents was difficult, and in addition her mother told her at that point that she had been adopted and suggested that she leave the family. She could not concentrate at school any more and her mood worsened. The compulsive eating and vomiting reappeared, so she was hospitalized again. She then benefited from individual psychotherapy but she was strongly reluctant at first. When it allowed her to improve the relationship in her family, she started to show some progress. After a month of being hospitalized, the symptomatology regressed, and she started to plan for the future. When we saw Ai again, two years after her second hospitalization, she was completely asymptomatic.

3. Discussion

3.1 Atypical symptomatology

Ai had never neither been preoccupied by her appearance, nor was her self-esteem affected by her weight. …

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