This is a review of various literature sources and does not contain statistics or in-report references. A sample of sources from which this information is drawn is given at the end of this article.
Bulimia: A Definition
Bulimia Nervosa (literally, ox like hunger of nervous origin) is a condition usually arising in females in late adolescence, characterised by recurrent episodes of binge eating with compensatory behaviours such as vomiting, taking laxatives or diuretics in order to prevent weight gain. Among bulimics, self-esteem is significantly influenced by ideas about weight and shape. A feature of the illness is that the sufferer is either normal weight or overweight; in underweight individuals a diagnosis of anorexia will usually prevail.
People with bulimia may be highly attached to their illness for a variety of reasons, but it is less valued than anorexia; also it is usually hidden due to shame about the behaviours of binge eating and purging. Like anorexia and binge eating disorder, it tends to arise in the context of dieting to lose weight. However, the dieting strategy fails due to a breakdown of restraint. In this respect the illness is said to be ego-dystonic with sufferers wishing to be rid of their symptoms. Thus they are more likely to seek help. There are many ways of being bulimic; binges vary in quantity both among individuals and for the same individual over time; purges may occur several times a day or more infrequently; eating may be chaotic or there may be many eating occasions which are normal.
Before 1980, the illness bulimia just did not exist – at least in the eyes of the medical profession. However, doctors involved in the study of eating disorders had noticed that there were significant numbers of people who confessed to regularly and secretly eating large quantities of food in a short period of time. Unable to stop eating when physically full, they would attempt to control their weight (especially after bingeing) by self induced vomiting, by dietary restraint and/or by using laxatives. Most of them were repulsed by their own behaviour and were aware that it could not be normal.
There has been confusion in the past regarding what bulimia really is. The term has been used to describe the eating patterns of people who are overweight, and also to describe episodes of binge eating in patients with anorexia.
Whilst bulimia nervosa was first believed to be a rare disorder, recent studies show that it is strikingly common among younger women. In the 1980s, famous personalities such as Jane Fonda and the Princess of Wales admitted to having this illness and this encouraged others to come forward for help. More recently a number of male celebrities and sportsmen (Elton John, Paul Gascoigne), admitting to bulimia make it clear that men get eating disorders too.
Bulimia describes an illness which contains a range of behaviours. There are regular episodes of “binge” eating, usually in private, of foods believed to be fattening and therefore in some way “forbidden” to someone wanting to control their weight. Foods typically eaten during a binge will include biscuits, chocolate, crisps, bowls of cereal, large amounts of toast with butter, chips, cakes, tubs of ice cream etc. Eating continues until the urge to eat is gone, tension is reduced, physical satiation is reached, often to the point of pain, or the person is interrupted.
Sometimes the food is enjoyed, but it is more likely to be eaten quickly and without tasting, and our definition requires that this kind of eating will be accompanied by feelings of anxiety, guilt and remorse. Following a binge, but not always immediately afterwards, there will be an attempt to get rid of the calories absorbed by making oneself sick, and/or by taking laxatives. Some bulimics try to contain their weight by indulging in excessive exercise and additionally by starving for periods of time. In rare cases there is more extreme “compensatory” behaviour such as blood letting or eating cotton wool.
In its most severe form, the sufferer eats vast amounts of food sometimes resulting in physical damage – rupture of the stomach for example – followed by self-induced vomiting to the point of causing life-threatening chemical imbalance. Cases are known where someone has eaten raw meat, dog food, or food from other people’s rubbish bins. The cycles of bingeing and purging can occur many times each day.
There is no standard definition of the word “binge” in bulimia. It is well known that normal eaters periodically overeat. 86% of college women responded “yes” to the question “do you ever binge eat?” However this figure dropped to under 10% when stricter definitions of a binge were applied. The key is that normal eaters are less disturbed by their eating habits than bulimics. For a true bulimic one mouthful too much of a meal may be regarded as a binge. Purging may be provoked simply by the feeling that they must get rid of the calories that they have eaten at all costs and without any regard to the consequences.
There is also disagreement about the frequency of binge eating which satisfies the definition of bulimia. Some people binge and purge several times a day and some only once or twice each month. Research shows that the frequency of binge eating episodes among bulimics varies from 1 per week to 46 times. The average is once daily, with the number of calories consumed in the binge ranging from 1,200 to 11,500.
Overall, bulimia can be said to exist when several but not necessarily all of these symptoms exist TOGETHER – i.e. episodes of overeating, accompanied by guilt and self hatred, secrecy, excessive fear of gaining weight, over concern with body size, failure to eat in a systematic way and attempts to remove unwanted calories by purging. In between episodes of overeating, most bulimics restrict their eating, sometimes very severely. In atypical cases, the bulimic might not overeat in an objective sense, but may vomit a normal meal as a means of weight control. The use of purging to lose weight as opposed to prevent weight gain is an ominous variant of bulimia.
The Development of Bulimia
Most bulimics see their condition as a breakdown of self control, indicating that they are at best morally weak (lacking willpower), and at worst mentally ill. This is likely to be felt most powerfully by people who either dieted very successfully in the past or who were anorexic, and who therefore once felt totally in control around food. Whilst research suggests a high incidence of mood or personality disorder among bulimics, it is not really helpful to view oneself as amoral or psychologically ill.
Bulimia as an Outcome of Dieting
A series of experiments run by Ancel Keys in the 1950s (The Minnesota Starvation Studies) demonstrated the relationship between food restriction and binge eating. Following a diet, and irrespective of whether fat or thin, most people are unable to stop eating when full, and develop marked preferences for foods rich in sugar and fats – the very foods which someone concerned with body size will be anxious to avoid. Another side effect of dieting is an immediate tendency to gain weight easily. This results from changes in metabolic functioning and will normalise over time. People are particularly susceptible to weight gain if their diet has been nutritionally unsound or, where weight loss has been too fast or, the individual has used methods such as diet pills, or liquid meal replacements.
Many people with bulimia are successful at dieting in the short term and may even have been anorexic for a while, but this is not true of all bulimics. But eventually their control is undermined by binge eating. If particularly dismayed about their lack of control they may attempt to purge after a bout of overeating. Some people begin purging because they have heard or read about it. Not all people who try to vomit can do it, but if they are able, vomiting becomes a secret tool, a way of dealing with guilt and a way of “having one’s cake and eating it”. Purging is hiding the secret greedy person inside, while on the outside you appear to be in control.
The Bulimic Progression
Initially, purging is viewed as useful. The bulimic doesn’t have to worry anymore about overeating. But as time goes on, what happens if someone has eaten just a little bit too much? Such a person says to himself “This has got to go, but at least let’s make it worth my while. They then go on to eat a large amount of food, and eat to bursting point or until they are interrupted.
What then sets in is a more sinister process. In the early stages of the illness, purging is just about staying safe with food. But it slowly becomes a way to manage feelings. Everything that is part of the bulimic process – going from full and awful to empty and relieved becomes a different way of being. Bulimia now becomes what we describe as “adaptive”.
In later stages of bulimia, binges may be planned well in advance, or may become a necessary part of the daily routine, with time being specifically set aside for the ritual of eating and purging. People may spend enormous amounts of time shopping for food, planning where to eat it and planning how to purge so that no one will find out. Some people have an unbearable urge to binge and purge whenever they are angry, tired or alone. Others cannot get on with their lives at all unless they have had their binge.
In some respects the disorder has become an addiction, with preoccupation and a loss of control over it; a need to use the behaviour in secrecy to cope with stress or feelings;. Bulimics in the throes of their condition may behave compulsively despite negative legal and social consequences. Some resort to stealing or shoplifting to support their habit. Normal and healthy coping responses have been replaced by bulimic ones. It is these healthy, adaptive coping skills that are to be reclaimed in therapy.
Many bulimics gain weight, since about 1200 calories are absorbed in each binge event prior to purging even if purging is immediate.
Tanya was a 21 year old student who dieted to be attractive and compete, as she saw it, with the more popular girls in her class at school. She had suffered in secret with bulimia for 5 years. In the early stages she binged and vomited occasionally and managed to complete her A-Levels and go on to University. But the binges and the hungers became worse. She would wait until everyone in her family went to bed and then she started on her binge of specially bought and hidden foods, eating mechanically until she felt ready to sleep. The process of vomiting, which she would occasionally delay because it was painful, took a further hour or two, and then she slept until late next day. She would suffer from paralysing depression and tension if circumstances prevented her from bingeing, and by the time she came along for treatment she believed that it was only by having her nightly binge that she could get through the next day at all. In reality the long nocturnal sessions meant that she could not work and was unable to complete her degree.
It is not known how widespread bulimia is but it typically emerges in young women in late adolescence. It may follow a period of anorexia although most bulimics have never been anorexic. Once present, it may continue throughout adult life unless treated. Only 1 in 5 bulimics are male, and most male bulimics have a history of weight problems. The illness favours, but is not confined to, higher social grades and greater educational attainment. Thus bulimia is more commonly found in girls’ boarding schools, and among women at college or university. Statistics suggest a lifetime incidence of 1 in 10 women in higher education and 3 per 100 female adolescents in the population at large.
Factors influencing both the severity of the condition and its prognosis include:-
- The ability to vomit with relative ease
- A history of personal trauma
- Personality disorder, such as borderline or avoidant presentation
- Co-occurring or pre-morbid alcohol or drug abuse
- Why Women ?
There is great pressure on women in our society to control their weight. There is also a higher value placed on a slim body shape with increasing social status. Perhaps also, educated women hold more perfectionist attitudes, making them more critical of how they look.
Psychoanalytic literature describes factors in the rearing of females and in the relationship between mothers and daughters which make them susceptible to bulimia. Women are socialised to suppress their needs in favour of attending to the needs of others and they are more likely to inhibit their feelings -particularly anger. Such dynamics may lead to body insecurity – which is a risk factor for an eating disorder of any type.
Bulimia in men is more likely to be associated with conflicts over sexual identity. However there may be many hidden cases among men who are completely heterosexual. Going to the gym and exercising obsessively might simply be another way of “purging” for males who have become extremely body conscious. This may be accompanied by eating disordered behaviour and the use of steroids and other supplements designed to build muscle and reduce fat. Many young men, unconfident in their masculinity, try to emulate sporting “masculine” role models such as famous cyclists or track athletes.
Risk Factors for Bulimia
The Link Between Anorexia & Bulimia
- About 1 in 2 anorexics develop bulimic patterns and the term anorexia, bulimic subtype is coined for people of low body weight who also binge and purge. The “true bulimic” differs from the anorexic bulimic in some respects. While both value weight loss, the true bulimic does not share the anorexic’s terror of normal body weight. In addition, some bulimics can eat normally in between episodes of bingeing.
The Link Between Mood, Personality & Bulimia
- Low self esteem is a risk factor for bulimia, and may present in perfectionist attitudes, a fear of inadequacy, fear of rejection and a high need to gain the approval of others. Bulimics will typically define themselves as kind, lacking in confidence and unassertive.
- Attachment Literature suggests a strong association of bulimia with Insecure Attachment styles typified by Avoidant or Ambivalent presentation. A typical Avoidant might say “I don’t really trust others so it is safer to keep away” or “I would love to get close but do not feel that people will want to be with me”.
- The question of whether bulimia is a sign of psychological disturbance is controversial. Bulimics tend to be depressed, anxious, guilty, impulsive and obsessional, but this may change when the illness is treated. Many of these symptoms are “state dependent”, which means that emotions are disrupted simply because the brain is not getting the nutrients it needs. Antidepressants, in particular serotonergic drugs such as Prozac have some impact on bulimia; although there is a tendency to relapse when medication is discontinued unless the treatment is combined with appropriate psychotherapy.
- Personality features associated with poor impulse control such as Borderline Personality Disorder can be associated with bulimia. The core problem with this presentation is one of regulating and tolerating powerful feelings from which the person must escape, or which must be denied and blocked.
- Character traits, such as fear of harmful situations, the need for instant gratification, and novelty seeking.
The Link Between Trauma & Bulimia; Sexual abuse in childhood or later sexual trauma
- The effects of sexual abuse are complex and may lead to a variety of ways in which food may be misused, e.g. to perpetuate the abuse, to suppress memories, express anger, or to console oneself. Abuse in itself is not a risk factor, rather how that particular individual has dealt with the event. Where there is evidence of Post Traumatic Stress Disorder (suffering as a result of the abuse which persists) the risk of bulimia is heightened.
- Emotional trauma which arises from more subtle forms of abuse such as physical or emotional neglect is deemed of equal significance in risk for bulimia. As with sexual abuse, the risk is strongly mediated by the presence of PTSD in later life.
Bulimia & Families
- Bulimia is not caused by families, although comparisons between anorexics, bulimics and normal eaters indicate that bulimics are more likely to come from families in which there are high levels of hostility, expressed as arguments, marital breakdown, physical violence, or abandonment. There is also a high correlation between addiction within families, such as alcoholism, and bulimia, although it is not fully proven whether there is a direct physiological connection, or whether the child learns through example to deal with stress by using substances.
- Family Weight Issues are a risk factor for body dissatisfaction, dieting and bulimia especially in females.
- Teasing or comments about weight are tantamount to bullying for vulnerable individuals. Of particular importance:-
- A mother who is overly concerned with weight and dieting is associated with eating disorders in daughters. Here it is probable that body dissatisfaction is readily transmitted to vulnerable young women.
- A father, brother or uncle who comments about female shape and weight, who tease the individual, make weight related comments, shame a child, or even reward a child for weight loss, pose a risk for bulimic behaviour. Grandparents are sometimes accountable for causing worries about weight.
- Loss, such as divorce or bereavement in the family may provoke bulimia in a vulnerable person who finds it hard to cope AND is sensitive about their weight. Bulimia may be a sign that this individual lacks the skills to adjust to new challenges and situations.
Bulimic Biology – Before & After
- Food restraint is so common among bulimics that many exist in a state of perpetual hunger, which increases the risk of losing control. Some bulimics go without food for long periods to maximise the pleasure they get from bingeing. Others develop a fear of food; much like anorexics they feel unhealthy if they have food inside them. And there are many who avoid eating in case it triggers a binge. Most people with bulimia have a magnified experience of hunger because their blood glucose levels are in disarray.
- Negative emotions such as anger, boredom, tiredness, loneliness or anxiety are common triggers for bulimic events. Sometimes the purpose of the bulimia is to regulate the feelings, which are experienced as overwhelming and undeserved. Sometimes the purpose of the bulimia is to block awareness of the bad self-beliefs which are triggered by emotional change. Core beliefs among bulimics are invariably poor, such as “I am unattractive, I am a bad person, and I am unworthy of respect”.
- Eating a forbidden food, or even thinking about doing so can provoke a thinking shift psychologists call “thought shape fusion (TSF)”. Typical thinking in TSF is “I am fat” or, “I will definitely gain weight”, or “I am a horrible person”. Perhaps they catch sight of themselves in a mirror, or they are in the company of someone thinner. A bulimic may feel inadequate if the “someone” perceived as thinner/more attractive is admired (like a successful elder sister) or is in competition with the bulimic for attention, social popularity, or romance. What happens in these instances is that the sufferer “translates” all their negative ideas about themselves into feelings of disgust toward their body.
- Catastrophic feelings can arise if someone wakes in the morning and finds that clothes are tight, or they go on a shopping trip and try on outfits, becoming increasingly aggravated with their appearance.
- Bulimic behaviour may relieve these horrible feelings of fatness, since many people describe feeling instantly thin after they have purged.
- Typical situation triggers include being alone, or following a visit to a restaurant or dinner party, if the person feels that they have eaten too much. The bulimic becomes hypersensitive about the amounts and types of food they eat, with “all or nothing” ideas about eating. Foods may be either good or bad, amounts eaten may be safe or “too much and it will have to go”. When is that moment when they have had one bite too many? The bulimic can never be sure. If dietary rules are breached, the bulimic typically thinks “I’ve blown it now; I may as well keep eating and then get rid of it all”. Breaking dietary rules, however small, is a very common trigger for bulimia.
Before a Binge
- There is usually a heightened sense of tension just before a binge, which is released as soon as the first mouthful is taken. It may feel as if one has been taken over by another presence, like an alien, or a devil inside. The initial relief of tension may be followed by a sense of despair – “here we go again” and worry about the purging episode ahead.
- Purging is a way of giving in to the binge and then controlling it. The methods of purging vary in technique, duration and how they are experienced. Some people find vomiting easy and spontaneous, lasting only seconds. Some prolong the process with frequent drinks of water, and emerge from the process drained and exhausted.
- Some people also use laxatives to ensure that the body is fully cleansed and drained. Laxatives, like vomiting, are ineffective for weight control. Most ingested calories have been absorbed by the time laxatives start to work because they largely affect the large intestine after digestion has been completed. Ingesting large amounts of laxatives creates a lot of pain, which is felt to be deserved. Eating disorder professionals regard the excessive use of laxatives as a form of self-harming behaviour, whose intention is as much about regulating feelings as it is a way of controlling weight.
After a Binge
- People vary in what they experience immediately after a binge. For some there is initial relief, they feel full of energy, released from the pre-binge tension, and able to continue with their lives. Some people feel depressed and guilty or go to sleep. How a person reacts after bingeing provides us with clues about what they are findinguseful about the illness. Either it is a way of regulating difficult emotions or bulimia has become a way of returning someone to a general motivated state.
- Bulimic episodes may be followed by fervent promises that this will never happen again and that tomorrow will be different. In practice, such promises cannot be kept and this makes the bulimic feel even more hopeless.
Sufferer Accounts of Bulimia
Here is what some people say about bulimia
- Constant thoughts about food – how to avoid eating it, how to get a binge food, how to get people out of the way so that you can overeat, thoughts and images about food which lead to fear and distress.
- Constant thoughts about weight, feeling fat and ugly. Often purging will help you to feel instantly thin even though in reality they are not.
- A sense of fear and foreboding, uncertainty and anxiety about everyday food occasions that other people can deal with – such as going to restaurants or social occasions.
- Eating normally in public, only for this control to break down when you are alone.
- Food feeling like a constant threat, both a friend and a foe, having to be constantly vigilant, not knowing when you have had “one bite too many” and will have to get rid of it.
- A sense of being different from others, carrying a guilty secret around with you.
- Feeling lonely, different and insane.
- Bingeing feels as if you have been taken over and possessed by someone else and not even remembering all that you have eaten.
- Bingeing and purging changes your mood, you may find unbearable tension before binge purging, and may be sleepy and calm or elated afterwards as if you can “get on with things”.
- Bulimic behaviour being something you have to do ritually and get over with just to feel normal.
- Feeling angry and stupid that you can’t stop; letting yourself down over and over again.
- A sense of life being a constant struggle.
- Guilt and shame about all the behaviour that supports bulimic behaviour, such as spending too much money, wasting food, stealing money or taking food from other people’s food supplies.
- In someone without bulimia, trying to resist purging would feel as if you had knowingly eaten poisoned food that would slowly rot you from the inside, and your life depended on getting it out of you.
The Medical Complications of Bulimia
The complications of bulimia are of profound importance to the family and friends of the bulimic as well as to the sufferer who must be made aware of their significance. Binge/purge behaviour affects major biochemical and hormonal systems in the body.
Disturbance of the essential chemical balance of body fluids (which we call the electrolyte balance). Abnormalities of potassium levels are of particular concern since these are most affected by vomiting and by laxative abuse, causing dehydration and causing irreversible damage to heart, kidney and brain.
Fatigue, depression, sore muscles, faintness, sensitivity to the cold, and a tendency to gain weight easily are also common symptoms which can be attributed to large fluctuations in blood glucose levels as a result of bingeing on foods high in refined carbohydrates.
Vomiting disrupts the complex message system – the satiety messages- which normally bring eating to an end.
Disruption of brain chemistry influencing appetite and mood. Binge purging depresses levels of serotonin in the brain which is an important regulator of cravings for carbohydrate and which also regulates our mood. Binge-purging also affects the opioid (endorphins and dopamine) centres of the brain; this is a system governing self worth, pain control and emotional balance. After purging, there may be transient feelings of euphoria, which contribute to the addictive nature of the illness. But these feelings may be replaced by confusion and hunger as endorphin levels fall.
Binge eating, vomiting and laxative abuse cause irritation within the gastrointestinal tract, which may be potentially fatal. Swelling of the salivary glands and erosion of the teeth are common. Vomiting causes sore throats, severe bleeding of the oesophagus and destruction of the valve which stops ingested food from rising back into the mouth. The stomach could swell with fatal consequences, although this is rare. Finally, the gut wall may be irreparably damaged by laxative abuse. In this event, the gut becomes bloated, lazy and unable to work on its own. In extreme cases the person will need surgical removal of damaged sections of the gut and the use of a colostomy bag.
A famous model met her demise in 1996 after eating four raw cauliflowers, two pounds of raw liver, a loaf of bread all washed down with a litre of diet soda.
Bulimia is associated with hormonal irregularities and the development of polycystic ovary syndrome, which may lead to insulin resistance (promoting weight gain) and infertility in later life.
The long term effects of bulimia on health, reproduction and life expectancy may be dire. These are vital concerns for people who are contemplating bulimia as a weight control strategy or who are avoiding treatment.
Understanding The Illness
Bulimia it is not simply a psychological illness based on a fear of being fat. Nor is it a moral weakness, or a global failure of willpower.
Bulimic behaviour can be better understood when we see that the components of the illness – cravings, gorging, elimination of food, disgust and guilt and the experience of being out of control – exist in a unified whole giving meaning and expression to unresolved personal difficulties in the bulimic person. Another way of expressing this idea is to suggest that the bulimia represents what is hidden but active in the emotional world of the bulimic. For example, a bulimic girl may feel out of control because of difficulties at home, suppress her anger by binge eating, eliminate her feelings by vomiting, and experience her guilt at not being able to handle her parents better through her post-purging remorse.
Culture-Bound Syndrome? Bulimia does not exist in third world countries where food is scarce. It is therefore an outcome of conflict between the physiological tendency to gain weight when food is plentiful (which is biologically determined) and the cultural pressures to gain love and acceptability by being slim.
Un-met Needs. The excessive hunger for food with its subsequent rejection may be an expression of deeper needs that has not been met by others. Unlike anorexics, who deny that they have needs, bulimics acknowledge their neediness but often fail to identify their needs correctly. They know what they want, which is the next bar of chocolate, but not what they need.
If needs are not satisfied in early childhood, by parents who are too busy, too needy themselves, or abusive, those needs for validation and nurturing go underground and are regarded as undeserved. But they do not disappear. In being out of touch with their needs and unable to have them met, the bulimic experiences them as overwhelming and insatiable. By asking the simple question “what is it that I am really wanting?” the bulimic may get in touch with the need for love, acknowledgement, friendship, comfort and acceptance which lie beneath their surface level cravings for food.
By gorging food the bulimic says “I am a greedy (wanting) person” and then by getting rid of it later, says “I reject it all – that mustn’t be me”. This conflict resonates in many aspects of a bulimic’s life. For example, a bulimic may be drawn into relationships and then may push away the people who have come to love them.
Escape from Pressure. Many bulimics have good careers and hold positions of authority, revealing nothing of secret bulimic life. They have become good at hiding their secret doubts, feelings of inadequacy and their aching solitude. The bulimic ritual represents a splitting off and hiding of the feeble, unacceptable part. The bulimic needs a neat controlled exterior which conceals the turbulent messy part which must be hidden away.
Coping. Bulimics like to be regarded as people who can cope with life and may deal with forbidden feelings such as anger, resentment, hostility and even sexual desire by splitting these feelings off and hiding them away. In the isolation of the kitchen and bathroom, that hidden part can be expressed. Many people with bulimia share the experience of feeling that underneath a neat exterior lurks a “monster within”. This monster may be the part that is hard to say “I am angry and it is okay to be angry”. Rather, a bulimic will say “I am angry and so I’ve somehow failed”. Many normal women will identify with these particular difficulties of being both feminine and ladylike, and also wild, achievement seeking and demanding.
Rosie told me “I am really jealous because my sister is always flirting with my boyfriend. I couldn’t tell her to stop. It’s a terrible thing to be jealous and just proves what an awful person I really am”
Need for Control. Bulimia restricts life choices and that is useful for some people. Life feels more in control when you have fewer decisions about what to do or where to go. For example, Anna claimed that her bulimia had stopped her from going to work and looking for a boyfriend. But in actual fact it had protected her from having to make a painful decision about whether to leave home or stay to care for her disabled mother.
This issue of control is central to the experience of a bulimic, who is either in control and therefore okay, or who has abandoned it. We all have a need for control; this is human. But feeling out of control is terrible for individuals with perfectionist attitudes; who struggle to achieve demanding or unrealistic goals in life.
Trying to control yourself and other people all the time can be stressful, and in this respect a binge can be a temporary release. This helps us to make some sense of the irrational aspects of bulimia. For someone who generally feels out of control – self, life and other people – control of food and weight becomes the only way to prove that one is doing OK. But it is a type of control that cannot be maintained.
Response To Low Self Worth. Self-neglect, over- control or self-abuse are common outcomes of low self-worth. Bulimics neglect, control and abuse themselves with food. Food is a threat, a treacherous friend, an enemy and a punishment. In therapy they can learn again how to take care of themselves with food.
Bulimia is usually well concealed from family or friends and can remain undetected for many years. Many husbands, parents or friends will have no idea that anything is amiss. There are however, certain behaviour patterns which give clues to a possible problem. These include:
- Disappearing to the bathroom after a meal, running bathwater or playing the radio at high volume.
- Strange night bird behaviour, staying up and going to the kitchen after everyone else has gone to bed. Or going for unexpected walks or drives at night. A bulimic tries to get rid of people, or have them go to bed, so that they can binge.
- Disappearance of large quantities of food, or overeating, without apparent sign of weight gain.
- Finding food wrappers hidden behind chair cushions or under beds.
- Unexplained irritability and mood swings.
People with bulimia can return to healthy eating regardless of how long they have been suffering, and furthermore many of the physical side effects of the illness will disappear. It is crucial to find a therapist with an adequate training in – and understanding of – the eating disorders. Factors such as distance, availability and cost can make it harder to find adequate help once a person has accepted their need of help. For many bulimics the shame and embarrassment of their condition will have allowed it to go untreated for many years, by which time urgent assistance is needed.
For many people with bulimia the first port of call may be a doctor, although medical practitioners are not generally skilled in the treatment of bulimia. There is now good awareness of the disorder and doctors may be able to refer their patient to a suitable specialist service. Hospital in-patient treatment will be necessary for only the smallest minority of cases; usually those whose life is at risk, or who are also severely depressed or mentally chaotic.
What Needs To Change?
The goal of therapy is normalising eating behaviour and stopping unhealthy compensatory strategies such as purging, skipping meals, or trying to cheat the appetite with diet drinks and caffeine. The eating disorder therapist will help change a person’s attitudes toward food and weight. The recovered individual almost certainly will not be dieting to lose weight.
The first goal in therapy is to persuade the bulimic to stop trying to lose weight and start a programme of regular eating, ideally of foods which are nutritionally dense. Many bulimics fear that once they start eating they will never stop. Yet food restriction and the lack of essential nutrients perpetuate cravings so the bulimic will need empathetic help to step outside this vicious cycle of restraint and excess.
In the beginning, the client will need help to manage their fears of food, and to manage temporary feelings of bloating and distress after eating. The therapist can help in this respect by giving appropriate information, about hunger, the effects of bulimia and how much a person can safely eat without gaining weight. Many bulimics, especially after years of binge eating, are surprised at how quickly their hunger comes back to normal. As Jenny put it “I learned to trust my body again and found that I could eat three meals a day and not get fat”.
There may be immediate and gratifying changes in mood as the chemistry of the brain is regulated.
It would be a mistake to assume that bulimics are motivated to recover. Many are deeply ambivalent. The disorder is regarded by experts as “functional” or useful. It helps someone to avoid responsibility for what they eat; it is also a way to deal with feelings, for some it is even just a way to get by from one day to another. It is the task of therapy to acknowledge ambivalence to change and help someone be ready, willing and able to take on the tasks of letting go of the illness.
Changing the bulimia mindset and the emotional world
Therapy for bulimia acknowledges the integral relationship between thoughts and feelings and the effect of these on behaviour. This can be done with cognitive-behavioural therapy; a treatment first found useful for depression which has been adapted for use with the eating disorders. The behavioural aspect of this treatment aims to change unhelpful behaviour by observing patterns which are unhelpful and then negotiating changes, which can be viewed as experiments. The cognitive aspect of treatment targets unhelpful thoughts and feelings which maintain bulimic behaviour.
Therapy for bulimia targets thoughts about food, weight, and body image, and beliefs about the self which are unhelpful. This includes giving attention to ways of thinking which may have nothing to do with food but which find expression in the way that someone relates to food. The thinking that needs to be changed includes unhelpful patterns such as:-
- Having lots of food rules, shoulds and must nots.
- Black and white ideas, such as good and bad or binge and safe foods.
- Feeling fat if you eat a bad food
- Feeling as if you have failed if your eating is not perfect.
- Having obsessive and constant thoughts about food and weight.
- And much more…..
Treatment for bulimia will help a person to recognise their tubulent feelings and manage them effectively without needing to turn to food and purging.
Work on feelings may involve helping a bulimic to relate more effectively with other people. Aggression, placatory or avoidant ways of behaving toward others will be replaced by skills such as communication, assertiveness and conflict resolution, thereby enabling the person to maintain good boundaries and gain satisfaction from their interactions with others.
Deeper Issues – Self Esteem and Spiritual Growth
For recovery to be possible, a person must become happier otherwise why let go of bulimia? People with bulimia are usually kind, sensitive people with many skills which have become suppressed and they have given up their power to the illness. In some sense this power must be reclaimed, so that the individual can pursue a better and more meaningful way of life. This will involve exchanging eating disorder values such as “being a size 8″ and replacing them with more authentic values such as “making a difference in life”.
There are many ways to achieve these goals. Treatment starts with a therapist with a professional rather than a personal understanding of eating disorders. Such a therapist will be able to adapt the evidence- based treatment of eating disorders to the particular needs of the individual
The gold-standard treatment of bulimia is CBT adapted for eating disorders, and its variants CBT-E (Fairburn) and CEBT (Waller et al). Interpersonal Therapy (IPT) is also recommended for bulimia, based on the observation that bulimia tends to arise at times of inter personal stress. The evidence for other therapies such as hypnosis is weaker but some people could benefit.
- A therapist may add to their repertoire for bulimia any of the following:-
- Motivational Enhancement Therapy for ambivalence to change
- Mindfulness Kabat-Zinn,
- Positive Psychology Seligman and
- Schema Focussed Therapy Jeffrey Young for treatment resistant cases
- Group versus Individual Therapy
The value of group approaches is that it brings the bulimic individual in contact with a support system of recovering bulimics and ends the years of isolation.
However groups vary in the health and stability of group members. If a majority of members are abstinent from binge eating, vomiting and laxative-taking the group can be effective in promoting recovery among new members, if a majority are actively bulimic such a group may inadvertently encourage food abuse.
Similar care must be taken when selecting a counsellor, to ensure that their correct professional background in the treatment of eating problems. One very important predictor of success in personal treatment will be the strength of the bond which can be established between patient and counsellor. In the presence of trust, empathy and confidence, much can be achieved.
Drugs For Bulimia
The NICE Eating Disorder Guideline (2004) recommended a trial of an SSRI like Prozac at 60 mg per day. The dosage for depression is 20mg per day. This might be useful in controlling the symptoms and urges to purge, but is less successful in dealing with the “core problem” of bulimia, which is the importance of shape and weight and its relationship to self-esteem. There is a heightened risk of relapse if drugs are given without eating disorder therapy. Drugs are therefore of limited value but they can be useful in helping to stabilise an individual who has more severe symptoms.
Self help programmes for mild to moderate cases of bulimia are now available online but sufferers get better faster and are less likely to relapse with expert help.
We have come a long way since bulimia was first identified several years ago. It is important to get the message across to the many desperate, silent sufferers that they need not be ashamed to ask for help, and with appropriate treatment their prospects for recovery are good.
- Coping with Bulimia, Barbara French, Thorsons
- Bulimia Nervosa, a cognitive behaviour programme for Clients, Myra Cooper Todd and Wells, 2000 Jessica Kingsley Press
- Eating Disorders, Fairburn and Harrison , in the Lancet, 2002
- The Eating Sickness, Jill Welbourne, Harvesters Press
- Women’s Secret Disorder, Marilyn Lawrence and Mira Dana, Graftons.
- Counselling for Eating Disorders, Sara Gilbert , Sage Publications.
- The Hungry Self” Kim Chernin, Virago.
- A Review of Bulimia Nervosa, International Eating Disorders Review, G.Russell, Wiley Press Summer 2004.