Bulimia is the most common eating disorder in young women. It starts as a strategy to control weight, but soon it develops a life of its own. Life for bulimic young women becomes a relentless preoccupation with eating, purging and weight. Pleasure is replaced by despair, frenzy and guilt. Like all addictions, bulimia is a compulsive, self-destructive and progressive disorder. Bingeing and purging are the addictive behaviors; food is the narcotic.

Over time young women with bulimia are at risk for serious health problems: Often they have dental problems, esophageal tears, gastrointestinal problems and sometimes dangerous electrolytic imbalances that can trigger heart attacks.

They experience personality changes as they grow to love bingeing more than anything else. They become obsessed and secretive, driven for another binge and guilty about their habit. They experience a loss of control that leads to depression. Often they are irritable and withdrawn, especially with family members.

While anorexia often begins in junior high, bulimia tends to develop in later adolescence. It's called the college girl's disease because so many young women develop it in sororities and dorms. While anorexic girls are perfectionist and controlled, bulimic young women are impulsive and they experience themselves as chronically out of control. They are more vulnerable to alcoholism than their anorexic peers. Unlike anorexic girls, bulimic young women come in all shapes and sizes.

Estimates of the incidence of bulimia run as high as one-fifth of all college-age women. Bulimic young women, like their anorexic sisters, are oversocialized to the feminine role. They are the ultimate people pleasers. Most are attractive, with good social skills. Often they are the cheerleaders and homecoming queens, the straight-A students and pride of their families.

Bulimic young women have lost their true selves. In their eagerness to please, they have developed an addiction that destroys their central core. They have sold their souls in an attempt to have the perfect body. They have a long road back.

Anorexia is a problem of Western civilization, a problem for the prosperous. It is, to quote Peter Rowen, a question of "being thirsty in the rain." Anorexia is both the result of and a protest against the cultural rule that young women must be beautiful. In the beginning, a young woman strives to be thin and beautiful, but after a time, anorexia takes on a life of its own. By her behavior as an anorexic girl tells the world: "Look, see how thin I am, even thinner than you wanted me to be. You can't make me eat more. I am in control of my fate, even if my fate is starving." Once entrenched, anorexia is among the most difficult disorders to treat. Of all the psychiatric illnesses, it has the highest fatality rate.

Its victims are often the brightest and the best young women. In my experience, it is the good girls, the dutiful daughters and high achievers who are at the greatest risk for anorexia. Anorexia often begins in early adolescence with ordinary teenage dieting. But instead of stopping the diet, perfectionist young women continue. They become progressively obsessed with weight and increasingly rigid in their thinking about food. They see themselves in a competition to be the thinnest girl around, the fairest of the fair.

The word "anorexia" implies an absence of hunger, but in fact anorexic girls are constantly hungry. They are as obsessed with food as any starving people. They have many of the physical symptoms of starvation- their bellies are distended, their hair dull and brittle, their periods stop and they are weak and vulnerable to infections. They also have the psychological characteristics of the starving. They are depressed, irritable, pessimistic, apathetic, and preoccupied with food. They dream of feasts.

Anorexic girls are great at self-denial. They are obsessed with weight, which becomes their one important and all-defining attribute. They feel confident if they are losing weight and worthless and guilty if they are not.

By the time anorexia is full-blown, family members are terrified. They try everything to make their daughters eat- pleading, threatening, reasoning and tricking. But they fail because the one thing in life that anorexic girls can control is their eating. No one can make them gain weight. Their thinness has become a source of pride, a badge of honor.

Anorexic young women tend to be popular with the opposite sex. They epitomize our cultural definitions of feminine: thin, passive, weak and eager to please. Oftentimes young women report that they are complimented on their appearance right up until they are admitted to hospitals for emergency feeding.

I think anorexia is a metaphor. It is a young woman's statement that she will become what the culture asks of its women, which is that they be thin and nonthreatening. Anorexia signifies that a young woman is so delicate that, like the women of China with their tiny broken feet, she needs a man to shelter and protect her from a world she cannot handle. Anorexic women signal with their bodies "I will take up only a small amount of space. I won't get in the way." They signal "I wont' be intimidating or threatening." (Who is afraid of a seventy-pound adult?)

Beauty is the defining characteristic for American women. It's the necessary and often sufficient condition for social success. It is important for women of all ages, but the pressure to beautiful is most intense in early adolescence. Girls worry about their clothes, makeup, skin and hair. But most of all they worry about their weight. Peers place an enormous value on thinness.

This emphasis on appearance was present when I was a girl. Our high school had a "gauntlet" that we girls walked through every morning. It consisted of all the boys lined up by their cars along the sidewalk that led into the front doors. We walked past them to catcalls and remarks about our breasts and legs. I wore a girdle made of thick rubber to flatten my stomach on days I dressed in straight skirts.

But appearance is even more important today. Three things account for the increased pressure to be thin in the 1990s. We have moved from communities of primary relationships in which people know each other to cities full of secondary relationships. In a community of primary relationships, appearance is only one of the many dimensions that define people. Everyone knows everyone else in different ways over time. In a city of strangers, appearance is the only dimension available for the rapid assessment of others. Thus it becomes incredibly important in defining value.

Secondly, the omnipresent media consistently portrays desirable women as thin. Thirdly, even as real women grow heavier, models and beautiful women are portrayed as thinner. In the last two decades we have developed a national cult of thinness. What is considered beautiful has become slimmer and slimmer. For example, in 1950 the White Rock mineral water girl was 5 feet 4 inches tall and weighed 140 pounds. Today she is 5 feet 10 and weighs 110 pounds.

Girls compare their own bodies to our cultural ideals and find them wanting. Dieting and dissatisfaction with bodies have become normal reactions to puberty. Girls developed eating disorders when our culture developed a standard of beauty that they couldn't obtain by being healthy. When unnatural thinness became attractive, girls did unnatural things to be thin.

In all of the years I've been a therapist, I've yet to meet one girl who likes her body. Girls as skinny as chopsticks complain that their thighs are flabby or their stomachs puff out. And not only do girls dislike their bodies, they often loathe their fat. They have been culturally conditioned to hate their bodies, which are after all themselves. When I speak to classes, I ask any woman in the audience who feels good about her body to come up afterward. I want to hear about her success experience. I have yet to have a woman come up.

Unfortunately girls are not irrational to worry about their bodies. Looks do matter. Girls who are chubby or plain miss much of the American dream. The social desirability research in psychology documents our prejudices against the unattractive, particularly the obese, who are the social lepers of our culture. A recent study found that 11 percent of Americans would abort a fetus if they were told that it had a tendency to obesity. By age five, children select pictures of thin people when asked to identify good-looking others. Elementary school children have more negative attitudes toward the obese than toward bullies, the handicapped or children of different races. Teachers underestimated the intelligence of the obese and overestimate the intelligence of the slender. Obese students are less likely to be granted scholarships.

Girls are terrified of being fat, as well they should be. Being fat means being left out, scorned and vilified. Girls hear the remarks make about heavy girls in the halls of their schools. No one feels thin enough. Because of guilt and shame about their bodies, young women are constantly on the defensive. Young women with eating disorders are not all that different from their peers. It's a matter of degree. Almost all adolescent girls feel fat, worry about their weight, diet and feel guilty when they eat. In fact, the girls with eating disorders are often the girls who have bought the cultural messages about women and attractiveness hook, line and scales. To conform they are willing to make themselves sick.

Particularly in the 1980s and 1990s, there's been an explosion of girls with eating disorders. When I speak at high schools, girls surround me with confessions about their eating disorders. When I speak at colleges, I ask if any of the students have friends with eating disorders. Everyone's hand goes up. Studies report that on any given day in American, half our teenage girls are dieting and that one in five young women has an eating disorder. Eating disorders are not currently the media-featured problem they were in the 1980s, but incidence rates are not going down. Eight million women have eating disorders in America.