307.52 Bulimia Nervosa

DSM-IV-TR Diagnostic Criteria for Bulmia Nervosa:

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

(1) Eating, in a fixed period of time, an amount of food that is definitely larger than most people would eat under similar circumstances. Mainly eating binge foods.

(2) A lack of control over eating during the episode: a feeling that one cannot stop eating or control what or how much one is eating.

B.Recurrent inappropriate compensatory behavior to prevent weight gain, such as: self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; excessive exercise.

C. The binge eating and compensatory behaviors both occur, on average, at least twice a week for 3 months.

D. Self-evaluation is unduly influenced by body shape and weight.

E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa.

Specify type:

Purging Type: during the current episode of Bulimia Nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas

Nonpurging Type: during the current episode of Bulimia Nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

Sometimes I am out of control, but most of the time I know how much I will eat, and plan accordingly. It is better when I choose foods specifically. I am not secretive about binges. I have not hidden any aspect of the behaviour from either of my two long-term partners. I have managed over the years to greatly reduce episodes, but if I don't think I can manage, I will make an effort to plan a binge, so as to get the most out of it, rather than feel completely out of control.

At present, my binge eating and compensatory behaviours have not occurred on average at least twice a week for 3 months for a very long time, so technically I may have been in a partial remission for a very long time. Sometimes I will have a few weeks in which episodes increase for a while, but normally there is no more than one episode per week, and sometimes I go for weeks without an episode.

I have never used laxatives, diuretics (aside from caffeine, which is not used for diuretic effect, but for 'energy' or a 'high') or enemas.

Before age 21, I had never fasted regularly - probably only a few times in total in my life. I may have engaged in long exercise sessions to compensate for food intake, but maybe not often enough to have been considered bulimic. At age 21, I lost 30 lbs through eating a 1200 calorie a day diet, and exercising 6 days a week. I started out at one hour of exercise per day, eventually doing 2.5 or so hours per day. This phase lasted 3 months, and then I reduced the amount of exercise.

A couple of months later, I began bingeing. I first became a nonpurging bulimic (regularly fasting 2-4 days per week), and later that same year a purging bulimic (self-induced vomiting on a daily basis. I had managed to live on my own at age 21 for approximately 6 months. Almost immediately after I returned to the family home, I began self-induced vomiting for the first time. At age 22 it was up to 14 times a day at the worst point). In my 20s, when living alone, I combined self-induced vomiting with much fasting, and exercise. I may eat one day (a huge binge), attempt to vomit, then fast for several days, and this pattern would go on for months, with lengths of fasts increasing. I would exercise during the first few days of the fast until it became more difficult.

Through the years I have had a few years of complete remission (no self-induced vomiting for an entire year). The first occurred while living with my first long-term partner, who accepted me when I gained a bit of weight.

At present, my main reason for vomiting is that I am so full I am in pain, and it makes sense to get rid of the discomfort. Any episode of vomiting results in a feeling of being bloated and disgusting, and it takes time for that feeling to abate. I actually gain weight while b/p if I'm doing it a lot. It's important to point out that I am more likely to go out of the house when I have an extended period of reducing calories and exercising regularly, and that when I am going through a phase of b/p, binge/vomiting behaviour, I am less likely to be going outside. The times in my life associated with the most social activity followed 'diets', in which I reduced calories and exercised in preparation. Any self-induced vomiting would cause me to feel 'off track' and 'out of control', and would reduce the tenuous feeling of confidence. Vomiting is not for me associated with weightloss, but may help to maintain weight or at least prevent gain from occurring too rapidly.

I think that binge/purge behaviour is in large part a coping mechanism. It can be triggered by stress, boredom, anger or other 'negative' emotions - it can be a way to act out 'unacceptable' feelings that it is not appropriate to express. It may be about a wish for nurturing or for sex, or about having no outlets for such.

For me, episodes do increase after a period in which I have deliberately lost weight through reducing caloric intake and exercising. I can only maintain naturally for so long before my underlying 'nature' kicks in. Once my weight stabilizes in a more 'normal' range for me, the bingeing seems to slow down again. At that point, it becomes more normal to binge/purge on hangover day, but usually not every hangover day, just occasionally. It is also possible that the entire response relates in part to an evolutionary adaptation: in times of plenty, it is good to eat as much as possible so as to save up for times of famine.

There was a period in my 20s when on a few occasions I vomited 14 times in a day (all in the family home - I was not going out at the time, and I was in a period of severe depression), but for me it was never an after-meal thing, and especially not an after-restaurant- meal thing. It was an after-recognizable-binge thing. Most frequently through the years, I have had periods when I have needed to binge more than others. There were times in the past when I needed to b/p once per day for an entire year, or thereabout.

My symptoms:

I often have ended up with enlarged glands in the neck under the jaw line - this only occurs during times when there has been more than one b/p session per day for a while, and it often takes a week for this to go away. I also have constant weight fluctuations or have for most of my life. As for the dental issues, I do not apparently have erosion of enamel, or any cavities at all. It may be that I have never had a problem with calluses or scars on my hands because ichthyosis results in rapid skin cell production. I do not actually know if I have experienced cardiac arrythmia.

I do think that bulimia has a lot in common with addiction.

I am suprised that in so many places online that when it comes to bulimia they focus so much on weight and don't mention that it is a way of relieving stress - a way that people with a particular genetic background and environment might be drawn to. It feels considerably better to experience the 'empty' feeling after vomiting than it does to suffer through hours of digestion (even if there is residual bloating and in my case a feeling of self-disgust, this is preferable to the long, uncomfortable hours of digestion), and in addition there might actually be a kind of endorphin release. For people obsessed with size and weight and shape, sitting around with the feeling that comes from eating an extreme amount of food is psychologically difficult - at that time you feel fatter than you actually are, and it can be a source of distress. Purging does help to control weight somewhat, but part of the benefit is psychological.

When I have a look at recovery models, I can't shake the impression that while well-meaning, they are not looking at some of the realities. I don't think that disordered eating is only about emotional or social issues - I think that part of it is about food itself, about the availability of food, and genetic pressure. Part of the reason some people are more affected by food and body issues relates to an inability to adapt to the environment, possibly on account of their combination of genes. A lot of it honestly looks like an inability to compete. The sensitivity involved with this could very well be positive in some circumstances. Many females with eating disorders are not or do not start off as more vain or less sensible - I think the point is that if you are perceptive or aware enough, you begin to realize that appearance not only is more important than what is 'inside', it actually does represent what is inside. At present, certain 'insides' are valued more than others. Mating is still a very important part of human life, finding acceptance and partners is still key to well-being. People are going 'crazy' when it comes to food and body issues because what they have been taught to believe about what to value in a person, and what willpower is, are wrong. Some people figure out that it is annoying when someone focuses on their body and weight all the time, and are strong enough to hide their own preoccupation - and this improves their chances. I did that for as long as I could, and there is no pretending anything now.

A really big problem relates not only to the attitudes and behaviour of family members, but to all the mixed messages that come from all the people in the world we live in.

When a therapy 'works', it is likely to work because the person involved can find ways of attaching to the framework of life - and this will depend on her previous experiences and mindset.

For elaboration, (some of which may no longer be current), see: my retired eating disorder site.