A Guide to Recovery
25th Anniversary Edition
by Lindsey Hall and Leigh Cohn
Why do People Become Bulimic?
Excerpt from Bulimia: A Guide to Recovery 25th Anniversary Edition
There is no easy answer to this question, because bulimia is a multidimensional disorder. It is caused by a combination of factors including, but not limited to, culture, family, personality, genetics, biology, and trauma. Although there is evidence that every one of these factors can play a significant role, none singly is a predictor of who will be afflicted.
The Culture of Dieting
In the first sentence of her book, The Religion of Thinness, Michelle Lelwica writes, "We live in a culture that worships thinness." She exposes the intersection between the all-pervasive media and $60 billion per year weight-loss industry. We are constantly bombarded with digitally enhanced images of models selling concepts of happiness, success, and intimacy. Whether the product is a diamond ring or diet, the message is the same: Your life would be better if you were thinner.
A widely published study of Fiji Islanders illustrates this point. Prior to the introduction of television in 1995, the island had no reported cases of anorexia nervosa, bulimia, or weight concerns; but, within three years of American and British TV programming, more than two-thirds of Fijian girls had attempted dieting, and three-quarters of them felt "too fat." The thin ideal had crept into their lives.
Dieting, so normalized in our culture, is often referred to as a "gateway" to eating disorders. Most people with bulimia began restricting or purging as the result of a failed diet. However, 95% of diet attempts end in failure, and clearly not all of those people develop serious eating disorders. So, while dieting is a risk factor, it alone does not "cause" bulimia.
While bulimia was a secretive disease 30 years ago, it is now a well-publicized, almost glorified, condition. Descriptions of binges and purges can easily be found on the web, as can encouragement for the eating-disordered "lifestyle." Celebrities with anorexia nervosa are sensationalized throughout popular culture, and eating disorders are essentially "taught" to innocent teens. College residence assistants have complained that serial vomiting damages dormitory plumbing, and some students binge and purge in groups. When I started telling my story, few people had ever heard of bulimia, but now everyone knows someone who has had some kind of eating disorder. Sadly, public awareness focuses on the symptoms rather than the devastating consequences, so large numbers of people continue to experiment with bulimia with the hope of getting thinner.
In the '80s, people believed that bulimia primarily affected white, upper middle class girls whose mothers were controlling. However, we now know that eating disorders do not discriminate by race, age, gender, or socio-economic class, and are global problems. The tendency to blame parents is also outdated, because all types of families are susceptible.
That said, bulimia often manifests in families where the emotional, physical, or spiritual needs of its members are not met and attachments are tenuous. In some of these households, feelings are not verbally expressed, and communication skills are lacking. There may be a history of depression, substance abuse, or eating disorders; the child might unconsciously recognize that escape is an appropriate, and necessary, thing to do.
Oftentimes, parents are unaware of problems. For example, a girl who hides her bulimia might appear to be an "ideal" child, presenting an acceptable facade—outgoing, confident, and independent—while anxious feelings bubble underneath. She may be valued for not needing to be nurtured, for taking care of herself, and for growing up early, all the while feeling guilty and unlovable. Bulimia is a way of expressing what cannot be said directly in words, in this case something like, "I want to be taken care of" or, "Would you love me if you really knew me?"
Sometimes, young people use bulimia to postpone growing up, and parents—especially those who don't want to let go—can be unaware of how they reinforce their child's insecurities. A "perfect little girl" who always looks to her parents for validation might be ill equipped to trust herself and face the outside world alone. This may explain why college students away from home for the first time are prime candidates for developing bulimia.
Families that emphasize weight and appearance, or have rigid rules about food, can also promote eating disorders. Kids who grow up watching their mothers and fathers go on diets and over-exercise are likely to do the same. If parents are judgmental and gossip about how so-and-so has gained a few pounds, their children will learn that body size is a measure of worth and will themselves feel judged and be prone to a poor body image.
Furthermore, parents who do not communicate openly and honestly foster poor relationship skills in their children. Also, daughters whose fathers are physically and emotionally absent experience "father hunger," which can contribute to problems with body image, self-esteem, and food (Maine, 2004). Finally, emotional, physical, or sexual abuses by family members are obvious risk factors.
Compared to the general population, the risk of developing bulimia is 4.4 times greater for women with a female relative who has experienced an eating disorder (Crow, 2010). Whether that is a result of nature or nurture is unclear, and, regardless, families are only part of the equation.
The complex relationship between personality and susceptibility to eating disorders has been of interest to researchers and clinicians for a long time. Certain personality traits—perfectionism, sensitivity, compulsivity, impulsivity, and inflexibility—appear to predispose a person to developing an eating disorder. Some may be genetically hard- wired into our biology, some the result of co-occurring conditions, and others shaped by individual experience.
In general, people with bulimia are attempting to avoid painful feelings, which may be the result of these personality traits, such as a naturally sensitive person feeling unloved and anxious, or a perfectionist feeling overwhelmed. Most devastating of all are the feelings associated with low self-esteem—that we have no worth, that our lives have no value or purpose, and that we will never be fulfilled or happy. These kinds of feelings, no matter what their source, often lead to eating disorders.
Genetics and Biology
Genes, hormones, and biochemistry influence personality and behavior. Researchers are just beginning to uncover the genes—or groups of genes— involved with depression, anxiety, and other mental disorders. Twenty years ago, the conventional wisdom was that culture and dysfunctional families caused eating disorders, but in recent years, genetics has been recognized as a substantial factor. Some experts attribute 50 to 80% of a person's risk being due to genetic predisposition (Bulik, 2007).
Genetic research for eating disorders is only emerging and, thus far, has concentrated more on anorexia nervosa. However, it is already widely accepted that there is a genetic component to bulimia, the exact nature of which is still unknown. If a specific bulimia gene exists, then why has bulimia only been known for the past 30 years? The way researchers explain this contradiction is that someone may be born with a genetic predisposition for an eating disorder, but that the behaviors only develop as a result of cultural and environmental triggers—for example, mass media, the diet mentality, and increased availability of food.
Research advances are also finding connections between eating disorders and biochemistry. For example, abnormal levels of the brain chemical serotonin are common in individuals with bulimia. Also, evidence suggests that changes in sex gland hormone status, both in puberty and adulthood, may impact eating behavior (Crow, 2010). Studies in this area indicate that biology may play a greater role than previously thought and deserve further inquiry.
The consequences of malnutrition have long been studied, and the harmful effects of disordered eating are well established. Subjecting the body to the nutritional toll of restricting or purging has significant physical and mental repercussions. The medical complications of bulimia are described later in this chapter, but for our purposes here, suffice it to say that starving your brain can cause psychological problems—including misguided thinking. After all, why else might someone who has been dieting think it would be a good idea to try bingeing and purging?
Finally, normal, biological weight gain during puberty, a time when body image becomes so important to both boys and girls, is often interpreted negatively. Especially in today's society, when tremendous emphasis is placed on the "obesity epidemic," teens feel the pressure to be thin. Large kids are often teased for their size or put on diets by well- meaning parents, which can alienate them from their bodies for the rest of their lives.
Most individuals with bulimia have been preoccupied with food and dieting for years, but the onset of binge-purge episodes may be triggered by trauma (abuse, an accident, extreme stress) or major life events, such as: moving away from home or beginning college, graduation or career change, rejection by a lover or wished-for lover, marriage, or death of a loved one. (The link between bulimia and sexual abuse is addressed on page 43.)
One reason that trauma causes the onset of bulimia might be that severe or prolonged stress creates alterations in the brain and neuroendocrine system, including abnormalities of neurotransmitter levels and cortisol production. This can disrupt crucial physiological functions, contributing to depression and fatigue, both risk factors for an eating disorder (Woolsey, 2002).
Individuals with bulimia identify various causes for their disorder. Many remember specific reasons for their initial binges, as well as how the behavior subsequently served them. Few thought it would become addictive. Once the binge-purge cycle is begun, the original causes— which still exist—are blanketed with guilt, secrecy, physical side-effects, and an increasing number of reasons to want to escape.
Regardless of the underlying reasons, bulimia "works" on many different levels. Binge eating provides instant relief. It replaces all other actions, thoughts, and emotions. The mind ceases to dwell on anything but food and how to get it down. Feelings are on hold. Even vomiting can be pleasurable when it is the most intimate contact allowed with the body. When the whole binge-purge episode is over, for a brief moment, the bulimic regains control. No longer feeling guilty for having eaten so many calories, she is drained, relaxed, and high. Soon, these feelings are replaced by negative ones, and the cycle of this painful, debilitating, exhausting illness begins again.
No two people are the same, so everyone's reason for developing bulimia is unique. Here are some quotes from actual sufferers:
I started because I was rejected by a boy at age 15. I thought the main thing wrong with me was my weight.
I developed my eating disorder the night before my first college finals. My father had passed away a month earlier, and I was nervous about my tests and about returning home and having him not there.
I started throwing up during my fourth month of pregnancy when I could not handle my changing body, and dieting away the calories became impossible.
One of my friends showed me how to do it when we were in junior high. Looking back, she didn't do me any favors!