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

For a long time, eating disorders were considered as culture-bound syndromes, specific to Western countries. This theory has been refuted for anorexia, but few transcultural studies have been carried out on bulimia nervosa. As a result, knowledge concerning this disorder is limited. On the basis of a clinical case involving a bulimic Chinese girl, we attempt to demonstrate the impact of cultural factors on the disorder. We discuss the atypical characteristics of her symptom profile, in particular the absence of preoccupations concerning her appearance and the psycho-pathological impact of the secrecy surrounding her adoption. In this particular case, bulimia triggered a search for filiation and identity that could have later enabled her to restore harmonious family ties and to gain autonomy. We also examine the case in the context of adoption in China. This clinical case points out how important it is to take cultural factors into account and how useful a transcultural approach is in order to understand bulimia, and suggest effective methods of care.

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.[ 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.[ Anorexia nervosa has also been viewed as a CBS in Western countries, but this theory has been refuted.[ 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.[ Witzum went further by claiming that bulimia was also a CCS.[ Results have corroborated this hypothesis, as an increase of the prevalence of bulimia in developing countries has been observed.[ A systematic review of the literature reported significant links between EDs and cultural change.[

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. Criterion D in DSM-5 (self-esteem influenced by weight and body shape) was not met.[ She justified vomiting as a way of regaining control, and not of avoiding weight gain. An Indian study described a similar case of bulimia without weight concern, and where vomiting was intended to control and reduce heaviness in the chest or discomfort in the abdomen.[ The cultural variability of body preoccupations in clinical practice has been well established for anorexia.[

Fat phobia was not observed to be common among female patients with anorexia in a study in Hong-Kong.[ Lee and Ngai believe that fat phobia is a culturally coded symptom.[11] In the DSM-5, it is actually stipulated that body preoccupations vary, depending on the cultural context, especially in Asia, where the absence of fat phobia is common.[ Body preoccupations in bulimia could also be influenced by culture.

3.2 Bulimia in a context of secrecy

In Ai’s bulimia, the secrecy around her adoption seemed to be central.

Tisseron described the conditions in which a secret can develop: when things go unsaid, when knowledge of certain things is forbidden, and when family secrets concern a painful event.[ When parents try to hide a secret that worries them, their child always senses it. Children are then torn between a desire to understand their parents and a fear of reviving their pain. When the content of a secret surfaces in the parent holding the secret, they experience particular emotions and body states whereby the secret seeps out. Tisseron also called on the idea of rebound, when poorly elaborated traumas cause strange behaviours that the children witness, or of which they are the object, without being given any explanation. Children internalize their parents’ attitudes, they may display learning disorders, and especially somatic signs, as the body is the privileged stage for the unspeakable.[

Ai’s bulimia could have enabled the revelation of the secret and favoured the appeasement of relationships in her family.

3.3 Difficulties in becoming psychologically autonomous

Ai presented difficulties in becoming psychologically autonomous, linked to her low self-esteem that could be a consequence of the fallout from the secret among other things. When she was offered help to develop autonomy, there was much resistance on her part, as well as a loss of compliance with care. However, Ai showed total adherence to any suggestion for restoring a harmonious family relationship.

In traditional Chinese culture, there is an interdependence among family members, collective needs are more important than individual ones. Filial piety is a Confucian principle of obedience to the elders taught to all Chinese children. There are three concepts in filial piety: being grateful towards your parents, respect and love for your parents, being attentive and considering your parents’ wishes before your own.[ The autonomy process could be more problematic for Chinese teenagers and young adults because of their filial piety, especially now that they are exposed to Western values of independence. There are significant inter-generational differences that could create family issues. These complications, along with rapid social change, could be risk factors for developing eating disorders.[

Ai thought that her parents were too intrusive and in control of her life. Vomiting enabled her to control her emotions and increase her sense of control over herself. Faiburn suggests that there is a higher rate of eating disorders with no body preoccupations in non-Western countries, because of difficulties in self-control.[

Bulimia enabled Ai to develop her self-determination and to decrease parental control. Bulimia probably fulfilled a function of protest against her lack of freedom, given that open conflicts with parents are impossible in China, due to filial piety.

3.4 Adoption and filiation

Ai got to know a little more about her adoption. Her parents found her on the road when she was three months old. They were not able to have children of their own, so “they were lucky to find me”.

Adoption raises universal questions about filiation, and in such a situation, there cannot be any biological reassurance. The process of individuation gives rise to a fear of abandonment, which is made worse in cases of adoption because a loss has already occurred. Ai’s mother considered the family to be responsible for her illness. Ai’s father however did not wish this secret to be revealed, perhaps fearing that Ai could leave the family.

The process of separation-individuation, made more complex by adoption, is very important here. Bulimia might have enabled the symbolization and resolution of these different conflicts. It also might have helped Ai to regain her identity, and to reaffirm her filiation to her adopting parents.

3.5 Adoption in China

The context of adoption in China can be used to shed more light on this clinical case. Firstly, “there is a long history of abandonment of girls in China” (Johnson), in a society that is mainly patriarchal, in which sons are more valued than daughters, and are considered as a support for their ageing parents, whereas girls leave home to go and live with their husbands’ family. Secondly, in order to stop a demographic explosion and promote the country’s modernization, the One-child policy was initiated. Consequently, a significant number of abortions, clandestine births and unrecorded deaths happened in China. 92% of the children abandoned between 1986 and 1990 were girls, on account of the quota for children and the fact that only sons were wanted.[ Socio-economical reasons are therefore at the core of this Chinese demographic characteristic, which is nonetheless evolving since a new law is now authorizing two children per couple.

3.6 Transcultural psychiatry

Transcultural psychotherapy relies on anthropology and psychoanalysis and is based on the theory of complementarism. Complementarism consists in the non-simultaneous use of anthropology and psychoanalysis. Anthropology helps to better understand the different cultural representations and cultural coding; illness and disease are also affected by this cultural coding. Moving abroad enables the therapist to start a decentering process and to build an inner position that allows him/her not to assimilate what is unfamiliar to what is familiar. The therapist is thereby able to accommodate different cultural coding in order to enhance the provided care. The analysis of cultural counter-transfer is primordial. According to Moro, “cultural counter-transfer is about the way the therapist positions him/herself in relation to the patient’s otherness (ways of saying, doing things, ways of representing the world, of thinking about his/her illness, which are all culturally coded)”.[

In this case, the decentering process of the French psychiatrist led to the comparison of bulimia in France and in China, and could have helped in the restoration of harmonious family relationships according to traditional Chinese culture, which might have allowed an improvement.

4. Conclusion

This case report of bulimia has illustrated how the cultural, social, personal and family context was essential to provide better understanding. The transcultural approach enabled the identification of cultural factors specific to China implicated in this case of bulimia. It also enabled the identification of transcultural factors such as secrecy, difficulties in becoming psychologically autonomous, filiation in the setting of adoption and rapid social change. The therapeutic alliance and symptomatology improved with the help in restoring harmonious interdependent family relationships. Cultural and transcultural factors have demonstrated their efficacy throughout this case to understand eating disorders and set up efficient medical care.