Which Comes First in the Pathogenesis of Bulimia Nervosa: Dieting or Bingeing? Timothy D. Brewerton,* Bonnie S. Dansky, Dean G. Kilpatrick, and Patrick M. O’Neil Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina Accepted 21 March 2000 Abstract: Objective: Clinical experience has indicated that dieting usually precedes the onset of binge eating in the development of bulimia nervosa (BN). However, data confirming this in nonclinical, representative samples are lacking. Method: Using results obtained from the National Women’s Study (NWS), we were able to determine the chronological relationship between age of onset of significant dieting (attempting to lose 15 lbs) and onset of bingeing in 85 respondents who met DSM-III-R criteria for BN. These respondents were a subset of over 3,000 female adult U.S. women who completed a random telephone interview (aver- aging 40 min and including screenings for rape, sexual molestation, aggravated assault, posttraumatic stress disorder [PTSD], and BN). Results: We found that the age of first serious attempt to diet preceded the age of first binge in 46% of cases. There were no significant differences in histories of victimization experiences among the groups. First binge preceded first serious diet in 37% of cases, and these behaviors occurred during the same age in 17% of cases. Discussion: These data confirm that dieting is more likely to precede binge eating, although binge eating precedes significant dieting in a substantial proportion of bulimic respondents. © 2000 by John Wiley & Sons, Inc. Int J Eat Disord 28: 259–264, 2000. Key words: dieting; binge eating; eating disorder INTRODUCTION The relationship between dieting and eating disorders has been of major clinical re- search interest. According to Polivy and Herman (1993 page 194), “it seems to be generally agreed that dieting either contributes to or at the very least exacerbates binge eating.” In one large study of bulimic individuals, Mitchell, Hatsukami, Eckert, and Pyle (1985) reported that 85% of them began their illness with a crash diet. In Johnson and Connors’ This paper was previously presented at the Seventh Annual New York International Conference on Eating Disorders, April 26–28, 1996, New York, NY. *Correspondence to: Dr. Timothy D. Brewerton, Institute of Psychiatry, Medical University of South Carolina, 67 President Street, Suite 553, P.O. Box 250861, Charleston, SC 29425. © 2000 by John Wiley & Sons, Inc.