A Guide to Recovery

25th Anniversary Edition

by Lindsey Hall and Leigh Cohn

What is Bulimia?

Excerpt from Bulimia: A Guide to Recovery 25th Anniversary Edition

Bulimia is an obsession with food and weight characterized by repeated overeating binges followed by compensatory behavior, such as self-induced vomiting or excessive exercise. This book primarily uses the term "bulimia," but "bulimia nervosa" is also correct, though more formal. In my first publication in 1980 I used "bulimarexia," which is rarely used today.

In 1980, the American Psychiatric Association formally recognized "bulimia nervosa" in Diagnostic and Statistical Manual of Mental Disorders (DSM), a publication that has been updated various times. The diagnostic criteria for bulimia have been only slightly revised in subsequent DSM editions. They include:

A. Recurrent episodes of binge eating, with an episode characterized by (1) eating in a discrete period of time, usually less than two hours, an amount of food that is significantly larger than most people would eat during a similar period of time and under similar circumstances; and, (2) a sense of lack of control over eating during the episode, such as a feeling that one cannot stop eating.

B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, enemas, fasting, or excessive exercise.

C. Behaviors occur at least once a week for at least three months.

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

E. Behavior occurs separate from anorexia nervosa.

The above list was created to help clinicians diagnose and treat this complex disorder, and there are other, similar definitions used internationally. Also, there are many individuals with "subclinical" bulimia, who fulfill only some of the criteria. Whether these people technically have bulimia or another classification (see the next question on other eating disorders) their behaviors are also life damaging and need to be taken seriously. For example, someone may binge and purge less often than once a week, but still have all the concerns as someone who exhibits this behavior daily.

Although the overt symptoms of bulimia revolve around food behaviors and a fear of gaining weight, bulimia is actually a way to cope with personal distress, emotional pain, and chemical imbalance. An eating disorder takes time and focus away from painful feelings such as anxiety, fear, depression, inferiority, etc. Binges can be a form of self-medication that satisfies cravings for particular nutrients or neurochemicals that are lacking. A purge is an effective way to regain the control and feelings of safety lost during the binge and to prevent dreaded weight gain.

While bulimic behavior may start as a seemingly quick way to lose weight, it soon becomes addictive. Dieting behaviors naturally lead to hunger, which is followed by eating, guilt, bingeing, purging, relief, and then the cycle begins again. Additionally, there is a physical "high" that accompanies the whole act. This vicious cycle becomes a diversion from all kinds of other problems.

Most individuals with bulimia are ashamed and secretive, sometimes going to great lengths to maintain the appearance of normal eating around other people. Many describe feeling like two people—one who wants to give it up and be healthy, and another who constantly sabotages. Lying and sneaking are common traits. Many people describe stealing food that they know belongs to other people or digging through the trash during particularly desperate episodes.

Although a typical binge represents a tremendously large quantity of food, a binge is uniquely defined by the person who is eating. Even a "normal" meal might feel like "too much" to someone who is terrified of getting fat, and a single bite of something "bad" might be too much for some individuals. I once spoke to a woman who felt compelled to throw up after drinking one can of diet cola.

Binges can be triggered by a number of things: a high number on a scale, eating something that is normally "forbidden," taking one bite more than "allowed," a traumatic event, or something as innocuous as thinking about food. Many people describe their feelings during binges as completely out of control, driven by a desperate desire to escape or numb out. While they might feel ugly, unworthy, hopeless, and helpless before and during a binge-purge episode, after, they might feel a mix of control, shame, relief, disgust, high, dizziness, exhaustion, and resolution. Part of the cycle often includes the promise that each incidence will be the last.

*At the time of this writing, the DSM-IV-TR was in use, and we also consulted the proposed DSM-V.