Bulimia

The revised DSM III criteria for bulimia are as follows:
•  Recurrent episodes of binge eating (rapid consumption of a large amount of food in a discrete period of time).
•  During the eating binges, there is a feeling of lack of control over the eating disorder.
•  The individual regularly engages in either self-induced vomiting, use of laxatives, strict dieting, fasting or vigorous exercise in order to     prevent weight gain.
•  A minimum average of two binge eating episodes per week for at least three months.
•  Persistent over concern with body shape and weight.

In bulimia the normal eating pattern of three or four meals a day is replaced by regular binge eating. Binge eating is compulsive and usually takes place in a frenzied and furtive manner. The first half of the binge is often pleasurable and exciting. The second half of the binge is experienced as being unpleasant and self-punishing. Because bingeing reduces anxiety in the short term it is highly addictive.

•  Commonly begins in late adolescence or early adulthood
•  The binge eating frequently begins during or after an episode of dieting

•  Depressive symptoms
•  Low self-esteem / self-loathing
•  Substance abuse or dependence
•  Over concern about weight and shape
•  Eating normally in front of others, secretly bingeing and purging
•  Guilt about bingeing
•  Fear of inability to stop eating voluntarily when bingeing
•  Secretive food foraging and hoarding
•  Constant feeling of being out of control
•  Lack of impulse control
•  Fear of fatness
•  Irregular periods
•  Vomiting and/or excessive use of laxatives

Bulimia is one of the fastest growing neuroses.

In the following article, Consultant Psychiatrist Dr Ann Leader describes the condition of bulimia, as she sees it, on a daily basis in her consulting practice.

Bulimia looks here to stay. It is one of the fastest growing neuroses in the western world, and its true incidence is hard to quantify. Unlike anorexia which is a very visible condition, bulimia is a master of disguise. I have seen women present for the first time with full-blown bulimic symptoms having kept their illness secret for up to twenty years. Because of increased media interest and coverage more bulimics are coming out of the closet and we are becoming aware just how prevalent a condition it is.

There is always a cultural component in the expression of neurotic symptoms and this is particularly true for bulimia. Present day society is not kind to the overweight woman. Thinness is overvalued and many women have an unhealthy pre-occupation with weight and shape. The slim woman is seen as sophisticated, active and in control of her life. Fat is equated with greed, laziness and failure. In every generation society creates its own idealised form of female beauty. Nowadays this beauty is embodied above all in a tall and slender physique. The insecure and those with low self-esteem are more likely to become obsessed with the pursuit of such perfection. Little girls as young as nine and ten are now inappropriately weight conscious and are presenting for treatment in eating disorder clinics.

The core symptoms of bulimia are recurrent binge eating, a phobia of becoming fat, vomiting or laxative abuse, a grossly disordered relationship with food and a constant pre-occupation with appearance.

Vomiting, laxative abuse, obsessive exercise and periods of starvation all serve to control weight gain and soon become as addictive and necessary as the binge itself. Obese bulimics resemble normal weight bulimics but tend not to vomit or abuse laxatives. Binge eating is an interesting phenomenon and it is important to understand its function and addictive properties. Food is a wonderful tranquilliser and bingeing guarantees large quantities at frequent intervals. Prior to the binge the sufferer feels increasingly restless, agitated and out of control. These feelings are intensified if there has been recent dietary restriction, which of course is often the case. There is evidence that carbohydrate deprivation decreases brain serotonin levels. Low brain serotonin levels are associated with anxiety and dysphoric states. One patient describes herself as resembling 'a cat on a hot tin roof' just prior to the binge. The compulsion to eat becomes unbearable and in some cases the longer the binge is postponed the more excessive the final binge becomes.

The binge itself is initially intensely pleasurable and exciting. As eating progresses the person feels more relaxed and settled.

However, guilt feelings then begin to set in and eating continues not for any additional relaxation, but as a form of punishment. The binge experience is thus complex and varied. At first it is thrilling, then it is relaxing and finally it is humiliating.

The experience of bingeing is very liberating for some people. The binger escapes not only from her dietary prison but symbolically breaks free from all the petty frustrations and tyrannies of normal life. Many of these are real, many are self imposed due to her perfectionistic and rigid personality. In everyday life she often feels 'cabinned, cribbed, confined.' The binge allows her to become unfettered and free. There are no limits, no holds are barred and she alone has full power to continue or call halt.

Company is not welcome when a binge is in full flight. Bingeing is also a potent method of releasing pent-up aggressive feelings which the bulimic is too polite to acknowledge in other ways. The language of bingeing is full of savagery and anger. Patients describe wolfing down food, devouring chocolates etc. Bingeing itself is a frenzied and undignified behaviour and patients are deeply ashamed of discussing its raw and animalistic nature. They sit in the surgery smiling and controlled - yet they describe how in private they tear their food apart, swallow it whole and indiscriminately consume what they consider to be the vilest and most forbidden of foods. Bingeing affords slim ladylike ladies a wonderful opportunity to vent their private fury and maintain their cool exteriors and phony bodies to the outside world.

Terrified women who cannot contain their compulsive eating and who cannot condone the inevitable weight gain face a dreadful dilemma. Vomiting seems to offer a seductive solution. Now the patient can continue to binge with all the attendant advantages and at the same time preserve her treasured thinness. She can indulge and not bulge. Vomiting, laxative abuse, obsessive exercise and periods of starvation all serve to control weight gain and soon become as addictive and necessary as the binge itself. These methods are not always exact and sometimes the person becomes excessively thin or even frankly anorectic. On other occasions weight gain is excessive and overweight become obvious. Depending on which phase the patient is in they are described as predominantly anorectic or bulimic.

As bulimia depends the patient's life revolves more and more around her addiction. Sooner or later work, hobbies and family are sacrificed at its altar. The patient's mood is governed by the scales and the degree of control she exerts over her eating. When 'in control' she feels powerful and successful. She bans from her diet a whole range of 'illegal foods' - which are seen as morally bad and strictly forbidden. When bingeing she is depressed, moody and inaccessible. Eventually the bulimic bogey has her totally ensnared and she 'cannot get out the grip of the grub' as one of my Kerry patients so aptly described it. At this stage the downside of bulimia far outweighs any possible benefits and she is now ready to seek help.

Bulimia

If anorexia and compulsive eating have long recorded histories, even though they might be infinitely more common now, what does appear to be quite new is the most painful and distressing of all eating disorders, bulimia - the bingeing and purging or vomiting that so many food mis-users find their way to. No one can keep anorexia or compulsive eating a secret for all that long; the physical effects become visible to anyone who cares to look. But bulimia is the most secret, the most shameful, the most isolating and desolate of all food misuse. Its effects can be very serious physically but are rarely seen by the outsider. It remains a private torment.

The concern is to try and understand what the misuse of food, whatever form it takes, might mean to the individual. The way we use food does have meaning, even though that meaning might be far from obvious, and not consciously known to the sufferer. It is instead of something; it is instead of feeling, or knowing, or understanding something that feels too difficult or frightening or unacceptable. It is designed to protect us from what we suspect about ourselves. Eating disorders are very preoccupying - we intend them to be; we need them to be, otherwise they would fail in their protective function. And the more frightening that hidden, unknown, suspected something is, the more resolutely we will cling on to our eating disorder. One of the terrible things about eating disorders is that it is very hard for the sufferer to believe that beginning to think and feel and understand what it might be about will not be worse than the pain of the condition itself. Often it seems as though, however painful and upsetting the eating disorder is, the prospect of reflecting upon its meaning is even more painful - in fact impossible. It is for that reason that eating disorders often go on for years and become a way of life.

What is more, it is probably true that there are some difficult things to be known or understood by the food misuser. There is something that needs attention, needs to be dealt with; some part of our experience, of our history, some unfinished business. It is unlikely to be very agreeable or very easy or we would not have needed to misuse food rather than let ourselves know about it. But we pay a very high price for the decision not to know. We stunt our development as people. We cheat ourselves of the human possibilities there might be for us.

Diana was a young woman brought up in conditions of extreme maltreatment and deprivation. Yet she had considerable talent as a dancer. Against all the odds she began to develop that talent but after three years of training she first developed anorexia and then bulimia. For her there were all sorts of terrible things about her past that she did not want to know. She could not keep them out of her dreams, but she could keep them out of her life during the day because she thought of nothing but food - how much, how little, when, what sort, how to get it out of her body once she had put it inside. Diana did not enjoy her eating disorder - it was a constant torment to her - but she resolutely maintained that the awful things that had happened to her, her present loneliness, her fear of people, were not important or worth thinking about. The only thing 'wrong' with her was her eating disorder. All she needed was some help with that. She got some help with that - nutritional advice, medical support - but nothing changed. She said sadly that she could not imagine ever being able to live without her preoccupation. But in: the meantime so great was her absorption in the ins and outs of food and eating and weight and body size that she stopped dancing. The one really good and positive thing in her life was being destroyed.

We most of us do not have so terrible a history to deal with as Diana, nor are we so totally absorbed in our food misuse that we bring our lives to a standstill, yet even so we waste our lives and our possibilities. Emma was a capable young woman in her late twenties who held down a responsible job and lived an energetic social life. However, she was very frightened of men and found it impossible to accept offers of dates from men although she would liked to have done so. Besides she had found a way of not worrying about that part of her life by worrying about her weight instead. Over a period of six years or so she steadily put on weight and was much heavier than she wanted to be. She had tried innumerable diets but had always abandoned them or put back the weight she had lost. When she began to dare to think through her feelings about men she also began to lose weight and to be freed from her preoccupation with it.

The thing about eating disorders is that they change the currency. Something that belongs to our emotional life, that is about feelings, is being expressed physically by means of behaviour. It is a symptom that simultaneously reveals and conceals. We are using a language that is difficult to translate, difficult for us and usually impossible for other people (or why would they say such things as 'I don't know why you don't eat a bit less/more/more sensibly'?). We believe somewhere inside our heads that we are protecting ourselves from something dreadful by our eating disorders; we think we have found a way of coping with what otherwise seems unmanageable. Instead we create for ourselves a much worse problem by creating a ritual behaviour whenever the world gets too frightening.

Initially the eating disorder is not the problem - we intend it to be the answer to the problem - but it can become the problem very quickly. After all, if you lose your job (or in some terrible cases your life) your solution to the problem is hardly brilliant. Even at a much less serious level staying at home counting calories and worrying about your weight and what you have eaten, what you are eating or what you intend to eat does not rate highly as a rewarding way to spend time.

Most of us long for a magic wand which will change the way things are for us. Unfortunately there are no magic wands and sooner or later we have to take responsibility for the way we live our lives. Sadly if we don't want to get better, at least with a bit of us, nobody can make us.

Information about the specific effects of bingeing and purging - vomiting or taking laxatives

As a preliminary to advising eating-disordered clients to give up bingeing and purging, the counselor needs to provide information about the damaging effects of these behaviours. Clients with eating disorders often have a variety of complaints, many of which may be a direct result either of their eating behaviour or of attempts to counter overeating such as vomiting or taking laxatives. These may include tiredness, muscle weakness, feeling faint or dizzy, abdominal pains, sore throats, diarrhoea or constipation. Many bulimics in particular experience swelling of the salivary glands, possibly due either to bingeing or to vomiting, which enhances their feeling of being fat. Clients who vomit frequently and have done so for several years are likely to have dental problems, in particular erosion of tooth enamel of the upper teeth. They may have increased sensitivity to temperature and be more prone to development of tooth decay. Clients are likely to suffer from dehydration as a result of vomiting or taking laxatives, which may partly explain feelings of dizziness, weakness and being light-headed. As a rebound effect, when they do allow themselves to eat and drink, they may experience fluid retention, which itself adds to the feelings of being fat and the belief that purging is necessary as a means of combating overeating.

Purging behaviour can lead to electrolyte imbalances caused by loss of essential minerals such as potassium, sodium, calcium, magnesium and chloride. These are reversed when purging stops, but can result in minor symptoms such as muscle weakness, and, at worst and rarely, can have serious medical consequences such as cardiac arrhythmias, even cardiac arrest or renal failure. In rare cases, bingeing itself can lead to acute gastric dilatation, even rupture; vomiting can cause tearing or rupture of the oesophagus.

Neither vomiting nor laxative abuse is an effective way of reversing the effects of binge eating. Vomiting may begin as a means of weight control, but can take on a life of its own. While a large proportion of calories taken in a binge may be ejected through vomiting, some are still absorbed, and the sufferer can still continue to gain weight. In fact, the knowledge that she has vomited can give the sufferer a false sense of security about having 'got rid of' a binge and hence lead to further eating. Feeling safe in the belief that she has apparently given herself a fresh start, the sufferer is free to begin overeating again, and binge eating is therefore to some extent justified and becomes more permissible. Also, some sufferers find it difficult to vomit unless they have consumed a large amount of food, so that they find themselves eating extra amounts of food in order to vomit. Hence, binges may become larger, with the result that the sufferer gains more weight and feels increasingly out of control and dependent on vomiting as her only means of controlling the binge eating.

Laxatives are equally ineffective as a means of weight control. They primarily affect the large intestine, whereas most nutrients are absorbed in the small intestine. By the time the food and digestive juices have traversed the stomach and small intestine and reached the colon, almost all the ingested foods that will be absorbed have been absorbed already, and any apparent weight loss is through dehydration. Clients may experience an immediate sense of weight loss, but the reflex fluid and therefore weight gain leads to further laxative abuse