Bulimia nervosa affects between 1 and 3 per cent of the young female population in the western world, which makes it 2 to 3 times more common than anorexia nervosa. The peak age of onset is in the late teens to early twenties. Compare this with anorexia, which typically arises in the early to mid-teens, as in my own case. I believe that this is a highly significant pointer to the meaning that bulimia nervosa carries, as distinct from anorexia nervosa.
Moreover, in contrast to anorexia, bulimics tend to maintain their weight within the normal range. True, some are overweight, and others inhabit the grey area between normal weight and the anorexic range. But a bulimic, almost by definition, is rarely emaciated. She looks like she is a part of the normal adult world. She may well hold down a good job and enjoy an active social life, as well as engaging in romantic relationships. Her public facade is often attractive, lively and successful. No one would know just by looking at her that she is suffering from an eating disorder, though the trained eye might spot tell-tale callouses on her hand, swollen cheeks, and her rather frequent visits to the toilet.
Bulimia Nervosa as Distinct from Anorexia
It is thought by some clinicians that a typical bulimia nervosa sufferer is more emotionally mature than sufferers of anorexia nervosa. She tends to occupy the adult world, the symbolic concomitant of which is her maintenance of a viable weight. She probably has a career, social life and sexual relationships. Indeed, she has at least on a superficial level been through the process of adolescence - something that the anorexic has almost certainly avoided. But she has not quite emerged as an independent adult - i.e., she has not acquired all the skills that are necessary to survive in the adult world.
Bulimia nervosa sufferers sometimes characterise their bingeing and compensatory behaviour as an 'emotional dustbin'. I myself referred to it as 'a dustbin for our sorrows' in one of my own poems. Just as with the anorexic, we are dealing with certain negative emotions and feelings here - anger, sadness, grief, disappointment - and an inadequate sense of self, supported by low self-esteem. But this in the context of the adult world, as opposed to a protective retreat into childhood.
The Bulimic Experience
Bingeing is a very intense experience. When you feel the urge to binge, it is extremely difficult to concentrate on anything else. Anxiety, verging on panic, will arise if you don't have access to food and privacy. A trip to the supermarket will be accompanied by immense anticipation, and the bulimic will have the urge to purchase almost everything she sees. In my own bulimic days, I could end up with a trolley overflowing with binge food (think cakes, biscuits, chocolate, crisps and bread in massive quantities) plus a couple of boxes of laxatives for good measure; I used to feel pretty self-conscious when I got to the checkout! The length of time that it takes to get home is almost unbearable; one friend told me how it looked like I was avoiding the cracks in the pavement. Sometimes, I would be chomping en route. Once in the privacy of my own room, I would devour the food with terrifying urgency, barely pausing to taste and swallow. The aftermath would be a very messy bedroom and me feeling like a beached whale - so bloated that I could hardly move.
Contrary to popular belief, not all bulimics purge - though the majority do. A diagnosis of bulimia nervosa is given if the binger regularly engages in one or more of any of the following: vomiting, use of laxatives, diuretics or diet pills, enemas, fasting, excessive exercising, or even bloodletting. The point is that she takes desperate measures to try and counteract the effects of her binge. Although at the start of a binge there is a release of tension, this will mount up again to fever pitch if the bulimic cannot compensate afterwards. A bulimic who induces vomiting will often feel relaxed once she has flushed everything out of her system; the symbolic ritual is thereby completed. Non-vomiters are more likely to feel sad - desperate even - after their binges. Whatever the pattern though, most bulimics feel a sense of guilt, shame and disgust over their habits, and keep their whole disorder very much secret. I'm not entirely sure how they do this, as with me, people tended to notice my bulimia even more than my anorexia, but it seems that many bulimics are masters of discretion.
Why On Earth...?
To an outsider, bulimic behaviour must seem extraordinarily bizarre. I would contend that a binge-purge episode is highly symbolic on an emotional level.
Bingeing can be seen in several ways. Firstly, and most obviously, it is a means of self-soothing. Food is a ready source of comfort in times of distress. When you don't know how else to take care of yourself and cope with difficult feelings, a bar of chocolate can make things feel easier. It is both distracting and rewarding. And it is not difficult to see why a person with inadequate coping resources might turn to food excessively as a source of comfort. It is also a way of burying emotion, on a symbolic level. Anger and sadness are quite literally *swallowed* by the bulimic. Perhaps a deeper symbol is that the bulimic is acknowledging her need - she just doesn't know what her needs are. In a sense, she is acknowledging her need for food, however much she may try to deny herself between binges. But she also feels a deeper hunger, which is emotional in origin. Food is obviously not going to meet an emotional need, but this is effectively what the bulimic is trying to do. Like the anorexic, she is trying to reduce the scope of her problem to the domain of food. And also like the anorexic, she does not know how to get her needs met.
The compensatory behaviours that follow a binge are clear attempts to negate it on various levels. With vomiting and laxative abuse, this negation is particularly violent. On the most superficial level, it is a way of avoiding weight gain - a thought which inspires terror in a bulimic, just as it does in sufferers of anorexia. The actual calorie intake of bulimics varies widely, both in terms of what they eat between binges (though this is typically not very much) and how much they consume within a binge, as well as the level of effectiveness of their purging techniques. Given that most bulimics maintain a normal weight, we can infer that their mean calorie intake is close to normal, though of course some bulimics are overweight, and some are underweight. However, studies indicate that the majority of bulimics will in fact lose a small amount of weight once they stop bingeing and purging. Following a binge episode however, purging, in whatever form, provides immense relief for the bulimic.
Many bulimics talk of feeling 'purified' or 'empty' after purging. Why would they need to feel 'pure'? Food is a symbol of 'bad' or unmanageable aspects of the bulimic person and her life. It's all about forbidden feelings and the needs that she doesn't know how to meet. By purging out the food, she rejects both her needs and her feelings - her 'bad' self. So she swallows her anger, then purges it out. She attempts to meet her need for love with food, then rejects that need. If she views her binges as a lapse into weak indulgence, through purging, she is reasserting her 'strong' self.
The Control Issue
Again, like anorexia, bulimia is an attempt to impose order on a life which feels out of control. It might seem a strange way of doing it, but bulimia nervosa is a way of achieving mastery over the self. For most sufferers, there is the restriction inbetween binges which functions much like the restraint of the anorexic in providing a sense of control. Binge episodes might be seen as symbolic of the general feeling of being out of control that the bulimic experiences, and purging as the attempt to reassert that control. Furthermore, the bulimic is in a sense *choosing* to engage in binge-purge episodes - though don't be deceived into thinking that she can relinquish them easily as a matter of will. The point is that, through bingeing and purging, she creates her own private world upon which no one else can intrude. If the doorbell rings while she is bingeing, the bulimic will essentially move into autopilot mode and will suspend bingeing all the time that the other person is present, only to launch straight back into it when alone once more.
The overriding impression that one receives of bulimia nervosa sufferers is of a group of people desperately trying to exercise some autonomy over their lives in the only way that they know how. Anorexics and bulimics both create for themselves a secret, food-centered world, in which *they* make the decisions, and no one else.
There is another component in the binge-purge cycle which is purely biological. This is that bulimics binge, at least in part, because they are starving hungry! Many bulimics diet rigorously in between binges, so that when they come to binge, they are ravenously hungry. The types of food that they binge on may also serve to increase feelings of hunger if they are high in simple sugars (leading subsequently to a drop in blood sugar levels). Purging also leads to hunger, especially vomiting and, surprisingly, laxative abuse. One of the first objectives of a treatment programme for bulimia nervosa sufferers is to establish a regular eating pattern characterised by small, well balanced meals. It is essential to eliminate extreme food cravings due to physical hunger if bingeing and purging is to stop.
How does this relate to bingeing/purging anorexia? The key distinction between the two disorders is based on weight: the anorexic-bulimic is, by definition, severely underweight, whereas the bulimic is not. Little is known about the binges of anorexics, but it seems that they vary widely in terms of size and frequency. Some anorexics consume vast amounts of food daily, whereas for others, a 'binge' is a purely subjective affair, which may consist of eating an extra unplanned apple.
Those anorexics with prominent bulimic features have a disorder that is very similar to bulimia nervosa, and are similarly driven by hunger and fear of weight gain. However, my contention is that again, weight signifies emotional maturity of the sufferer, and thus to an extent shapes the meaning of the eating disordered behaviours. For some anorexics, bingeing and purging is part of the price that they pay for maintaining their low weight. For others, it may also constitute the 'emotional dustbin' referred to earlier. It is a violent act that can express all of the *forbidden* emotions - especially anger - and it is also an act of choice.
Purging varies a great deal in the degree to which it is effective. Mostly, it is not very effective. Vomiting is the preferred method for many bulimics, but it has been found that, on average, less than half the calories consumed are actually expelled. This varies though from person to person.
Unsurprisingly, laxatives are not an effective method of weight control. It is possible that, when taken in large quantities, laxatives remove about 10% of the calories consumed. You can read more about what laxatives do and don't do on my anorexia page. I personally was aware of the ineffectiveness of laxatives while I was taking them, but took them mainly as a means of self-punishment and 'cleansing', and I deliberately sought to dehydrate myself.
Diuretics have no impact on calorie absorption whatsoever. Like laxatives, they have the effect of dehydrating the person. This can result in rapid apparent weight loss - which is of course only water. Rebound fluid retention and weight gain are common in both laxatives and diuretics.
Exercise is clearly not going to compensate wholly for a full-blown binge, though it may mitigate the effects. Likewise, starvation will not totally cancel out the effects of binge - rather, it sets you up for the next one. Bulimics who binge and starve probably eat as many calories on balance as a non-dieting individual.
The truth about purging is that, besides being physically dangerous, it doesn't work. It simply sets you up for further bingeing.
Many people tend to assume that it's just the extreme underweights who die from eating disorders. Well, I'm sorry to shatter the comfy illusion, but this just isn't the case. People can die from an eating disorder at any weight. Yes, severe emaciation is dangerous and life-threatening - but so is an electrolyte imbalance, which can arise from purging, particularly if you combine more than one method. A combination of laxatives and diuretics is especially dangerous. Bulimics have died from heart failure as a result of electrolyte imbalance. Occasionally, death is occurs following a stomach rupture from bingeing.
Death as a direct result of bulimia nervosa is probably not as common as those related to anorexia, though there has been no comprehensive study of mortality to demonstrate this. But the fact is, that people can and do die from the effects of bulimia nervosa, even though they look healthy enough on the outside. Bulimia is a very insidious disease. One startling finding is that more bulimics do in fact meet a premature end than anorexics - due to suicide. Bulimia nervosa is a ghastly thing to be trapped in, and the misery of it is sufficient to induce a sufferer to take her own life. In fact, many bulimics have a comorbid diagnosis of depression.
My aim here is not to terrify you, as studies have indicated that about 70% of bulimics do go on to make some sort of a recovery. However, the physical consequences of all eating disorders are for real. People need to realise that weight is only one indicator of the severity of the disorder and the amount of physical danger that the sufferer is in. Anyone who regularly engages in vomiting or the abuse of laxatives and diuretics should have regular, comprehensive blood tests to establish electrolyte levels. You can read about other, less serious physical complications of bulimia nervosa by following the links at the top of the page, and by clicking here.
Recovery from any eating disorder is hard. Help and support is usually necessary, though the form and amount may vary. The first step is to institute regular meals and eliminate dieting. Until this happens, it is unlikely that the bingeing will stop. You may object that this will cause you to gain weight: in fact, research has shown that when bulimics stops bingeing, many of them actually lose a small amount of weight. The key is to eat little and often when emerging from a bulimic phase. The cravings for food can be more easily satisfied if the sufferer knows that she is going to eat something every two hours. It's a good idea to stick to 'safe' foods at first in order to minimise the desire to purge after meals, and to try and incorporate some protein and carbohydrate in every main meal. For more advice on how to do this, consult a good guide to recovery from bulimia nervosa.
Of course, recovery is not just a matter of regularising the eating pattern, although this is clearly a crucial component. Medical monitoring may be necessary, and antidepressant medication may be helpful, along with a supportive friend or confidante with whom to share the journey of recovery. Counselling or psychotherapy can also help to heal past hurts and conflicts which have metamorphosed into an eating disorder. It may be that excessive concern about weight and shape will not diminish until this has taken place. Techniques can also be taught on how to manage the eating disorder symptoms themselves.
Whatever the pathway that one takes through the eating disorder, then end result needs to be that the sufferer has learned how to deal with difficult situations and feelings. It's about being able to take care of yourself, as an adult.
The binge monster is evil.