|
Questions Most Often Asked About Bulimia Reprinted from Bulimia: A Guide to Recovery Find out more about Bulimia from one of the helpful links below Bulimia is an obsession with food and weight characterized by repeated overeating binges followed by compensatory behavior, such as forced vomiting or excessive exercise. For an epidemic number of women and men, bulimia is a secret addiction that dominates their thoughts, undercuts their self-esteem, and threatens their lives. The symptoms are described by the Egyptians and in the Hebrew Talmud; and bulimia (Greek for “oxhunger”) was widely practiced during Greek and Roman times. In the later half of the twentieth century, though, eating disorders, and particularly bulimia, have been identified as widespread cultural phenomena. Bulimia is also termed bulimia nervosa and bulimarexia. In 1980, the American Psychiatric Association formally recognized bulimia. In its fourth edition, the Diagnostic and Statistical Manual of Mental Disorders (APA, 1994) lists the following criteria that an individual must meet to be diagnosed: 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, or enemas (purging type); or, through fasting or excessive exercise (nonpurging type). C. These behaviors occur at least twice a week for at least three months. D. Self-evaluation is unduly influenced by body shape and weight. E. The behavior does not only occur during episodes of anorexia nervosa. The above list was created to help clinicians diagnose and treat this complex disorder. However, many individuals, termed “subclinical,” fulfill only some of the criteria. These cases are also life-damaging and need to be taken seriously. 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 and emotional pain. Eating binges take time and focus away from more disturbing issues, and purges are an effective way to regain the control and feelings of safety lost during the binge. Also, while bulimic behavior may have started as a seemingly-innocent way to lose weight, the cycle of bingeing and purging usually becomes an addictive escape from all kinds of other problems. Most individuals with bulimia are extremely secretive about their behavior, sometimes going to great lengths to maintain the appearance of normal eating around other people. They are ashamed of their behavior and what it has done to their lives. 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 large quantity of food, usually between 1500 and 3000 calories and primarily high carbohydrates, a binge is uniquely defined by the person doing it. Even a “normal” meal might feel like “too much” to someone who is terrified of getting fat. Binges can be triggered in a number of ways: by higher numbers on a scale, eating something that is normally forbidden or taking one bite more than allowed, difficult feelings, 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 feel even a little bit better. 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, dizziness, exhaustion, and resolution. Part of the cycle often includes the promise that each time will be the last. It is difficult to say how many people have bulimia. Statistics may not truly reflect the total numbers because, as we said, bulimics generally hide their behavior. In fact, one study showed that college students answered questionnaires more truthfully when told to put a dab of their saliva on the survey paper, because they believed it could be chemically analyzed to determine if they were bulimic! Of the research done on the prevalence of eating disorders, the most reliable statistics indicate that about 5% of college-aged women meet the strict clinical criteria for bulimia. However, some studies offer much higher numbers. A recent one of female high school and college students reported that 15% met the criteria for bulimia (Cavanaugh, 1999), and some experts suggest that as many as one of every three women have engaged in some bulimic behavior. Men account for at least 10% of cases, although, this number has seemed to increase in recent years. There is also evidence that—unlike anorexia nervosa, which has remained fairly constant in the past few decades—the incidence of bulimia rose significantly in the early 1980’s (Russell, 1997). Whatever the actual figures, a significant number of both women and men are engaging in this self-destructive behavior. There is no easy answer to this question. Just as the life of every individual is unique, so are the reasons why they become bulimic and the paths they must take to overcome it. Bulimia is generally considered to be a psychological and emotional disorder, which sometimes coexists with other psychiatric disorders, such as depression or obsessive compulsive disorder. Some studies show that bulimia is related to major affective disorder, (Johnson, 1987) and therefore influenced by heredity and chemical imbalances in the body. (See “Can medication help in recovery?” in this chapter.) In some cases, therefore, medication can alleviate the binge-purge behavior or the blanket of depression, making psychotherapy and other avenues for recovery more effective. Other studies have linked lowered brain serotonin function to bulimia (Kaye, 1999). However, the underlying reasons most people give for their eating disorder are a complex mix of low self-esteem, childhood conflicts, and cultural pressures. In general, people become addicted to substances and behaviors to avoid painful feelings—past as well as present. Some of these feelings have their origins in childhood, such as feeling unloved and unlovable, ashamed, afraid, or incompetent. Others come from the pressure to conform or to be accepted by peers. Most devastating of all are the feelings associated with low selfesteem—that we have no worth, that our lives have no value or purpose, and that we will never be fulfilled or happy. Paradoxically, an eating disorder in the early stages can raise self-esteem when it provides someone with a sense of success— in this case by achieving the cultural ideal of thinness. Indeed, many individuals turn to purging when they have failed at a diet and fear that there is no other way for them to lose weight. However, once the bingeing and purging cycle begins, the resulting metabolic imbalances and habitual escape become an ever-deepening pit, eventually eroding any initial sense of self-worth and control. It is important for those who are reading this book to remember that the rewards for thinness are only implied, and although diets and a thinner body promise a happier life, they don’t deliver! The question remains as to why bulimia is the chosen escape, and there appear to be similarities in the backgrounds, personalities and experiences of eating disordered individuals which will help clarify this. All of these characteristics will not apply to everyone, but certainly some will. Most bulimics come from families in which the emotional, physical, or spiritual needs of family members are not met in some way. In some of these households, feelings are not verbally expressed and communication skills are lacking. There may be a history of depression, alcoholism, drug abuse, or eating disorders; and, the child might unconsciously recognize that escape is an appropriate thing to do. In this context, food becomes a “good” drug, something which does not have the negative connotations of alcohol or drug abuse. Bulimics are often considered “ideal” children, and will go out of their way to be “people pleasers.” They present an acceptable facade—seeming outgoing, confident, and independent— while anxious feelings bubble underneath. They may be valued for not needing to be nurtured, for taking care of themselves, and for growing up early. 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 “Will you love me as I am?” Sometimes, people use bulimia to postpone growing up. The child who has looked to others for validation and feelings of selfworth and who has assumed a “perfect little girl” role because it works at home may experience tremendous fear at having to trust herself and face the outside world alone. This insecurity is sometimes unconsciously reinforced by parents who also do not want to let go. Often parents and children fall into roles that limit the relationships and personal growth within the family. Mothers may reinforce the idea that it is important for women to be thin. Fathers may be relegated to the role of economic provider and dis ciplinarian rather than taking part in a son’s or daughter’s emotional life. Girls, in particular, can develop insecurities about their appearance, competence, and ability to be loved if they are not valued for their own unique strengths. In a society where roles for women are changing, strong relationships with parents of both sexes based on the child’s uniqueness will give him or her the confidence and ability to make smart decisions and negotiate healthy relationships in the future. Bulimics tend to be overly judgmental of themselves and others, have difficulty expressing emotions through language, fear criticism, avoid disagreements, and have low self-esteem—all traits which make having relationships with others difficult. In fact, many people in our survey of 392 recovered and recovering bulimics indicated that they were uncomfortable with intimate relationships, and that bulimia was their predictable, reliable, unquestioning ally. Many had been sexually or emotionally abused as children and had difficulty trusting others. The bulimic rituals and thoughts protected them from what might be rejection, abandonment, or other potential pain. The bulimia had become the only relationship, albeit an empty one, which also prevented them from experiencing deep love—described on one woman’s survey as “The Great Filler.” The bulimics from our survey identified various causes for their disorder. Many remembered specific reasons for their initial binges, as well as how the behavior subsequently served them. Few women thought it would become addictive. In addition to the original causes which still existed, they were faced with guilt, secrecy, physical side-effects, and an increasing number of reasons to want to escape. Frequently mentioned were: boredom, the influences of media and culture, family dynamics, mental “numbness,” the irresistible taste of food, pressure to lose weight, the “high” experienced after purging, overwhelming bouts of anxiety, the release of physical and sexual tension. Most bulimics have been preoccupied with eating and diet for years, but the initial binge-purge episodes might be triggered by specific events, such as: traumatic change (graduation, moving away from home, marriage, death of a loved one, etc.), unresolved grief, career changes, a failed diet, and rejection by a lover or wished-for lover. These survey comments were among the several specific reasons offered for starting the bulimic behavior: I started because I was rejected by a boy at age 15. I thought the only 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 be there. I never thought about trying it until I read about it. 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 at junior high. Looking back, she didn’t do me any favors! No matter what 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 we allow with our own bodies. 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. Since bulimia is falsely perceived as less dangerous than alcoholism or drug abuse, it is especially insidious and captivating. Food is always available for a “fix,” and eating in public, even if on the run, is accepted and not unusual. Also, nothing gives a bulimic away, because her weight usually appears close to normal. Food gives life, heals, nurtures, and means love. The safety, relief, availability, pleasure, and companionship represented by food appear to outweigh any immediate drawbacks. Bulimia becomes a short-term solution for pain, which in the long term can be devastating. Hopefully, everyone reading this book now understands that an eating disorder is a painful, exhausting illness. Anyone suffering through it deserves tremendous compassion and empathy. Judging them as wasteful, self-centered, vain or spoiled, invalidates that person’s feelings, ignores underlying issues, and increases the individual’s shame. Remember, an eating disorder is not just about food. Why are bulimics mainly women? In the most simple terms, we live in a society which is fundamentally unsatisfying to an enormous number of women, and eating disorders are a symbol of this inner emptiness. Many of our institutions, corporations, systems and roles are set up in a male-oriented, hierarchical structure. This type of environment, which favors independence and competition, alienates those women who feel more comfortable in cooperative, interdependent settings. Women’s sexuality is exploited, their intelligence questioned, their roles limited and often confusing. They are bombarded with promises of a “better self” through the dieting, fashion, cosmetics and anti-aging industries. Most women feel unsupported by a culture with such shallow values! They want and deserve something more—something that gives their lives meaning in a deeper way. It is this role within this society which is at different times limiting, confusing, frightening, and unfulfilling, that propels enormous numbers of women into the safety and numbness of food problems. • Women are socialized in specific ways. Generally speaking, in the course of growing up, women are taught to relate and behave in ways which are specific to our culture. This is called being “socialized” or “acculturated.” Although strides have been made, many archaic ideas remain. Four of the most harmful lessons which can contribute to eating disorders are the following: (Buckroyd, 1996)
These lessons teach women that they have cultural “limitations.” They become afraid to express themselves freely, and deny their own needs, strengths, opinions, and inherent beauty. Bulimia can be a distraction from feeling disconnected from one’s own self. • Adolescent women are particularly vulnerable. The message that women should be concerned with their appearance is communicated to both sexes starting at birth, along the path through childhood, adolescence, and right into adulthood. Particularly when kids enter puberty, however, becoming more independent from their families and facing the culture at large, young girls are bombarded with images of female bodies as objects which are scrutinized unmercifully. They also become aware of stereotypical “feminine” traits, such as cleanliness, docility, unselfishness, politeness, and sometimes being a tease. By the time sexual game-playing starts, most of them already know that their bodies are tools for popularity and power, and that there is appropriate and inappropriate behavior associated with being a girl. Also, a strange thing happens to girls at this age. Their sure sense of self, strong opinions, and unabashed involvement give way to powerlessness, insecurity, and doubts about their appearance. They are no longer cute little girls, they are budding sexual women. From a girl’s perspective, this puts her in a vulnerable position with regard to men, and a competitive one with women. At a time when she is forging an identity, altering her body to fit everyone’s expectations, including those of her culture, seems to be a reasonable way to please everyone. Many young women develop eating disorders when they fail their initial attempts at dieting and are faced with the fear that they will never be an “ideal” woman. • Having a female body in this society can be frightening. Men, for the most part, are more sexually driven than women, whether this trait is biologically inherited or learned from their environment. Women, on the other hand, are driven more by a deep desire to maintain connections with others. These two factors have created an environment of pervasive sexual abuse and harassment against women, both young and old, within our society which we are just beginning to face. Recent statistics of sexual abuse and violence against women are staggeringly high. An eating disorder is a way of coping with the pain of that experience, “My body is my own. I am in control of what goes in and out of it.” It can be an unconscious reenactment of the original abuse or a way to punish the body which was “to blame” for the assault. It can also be a way to distance one’s self from one’s body or numb the feelings associated with abuse or harassment. Ultimately, an eating disorder is a safe place to hide from the pain and fear of mistreatment. • Contemporary society denies the natural variety and function of women’s bodies. “Becoming a woman” is for many an embarrassing, self-conscious affair, requiring daily self-scrutiny. Most feel required to shave their legs and underarms, hide their periods, and control body odors. Even women who have experienced the miracle of giving birth are driven to quickly flatten their stomachs afterwards, as though it had never happened! Denying women’s deepest biological truth trivializes their lives. An eating disorder can ease the pain of being disconnected from this inner source of strength and meaning. • Women are expected to control their emotions. Many women with bulimia report fearing the intensity of bottled-up feelings. Consequently, many have little experience with their emotions or appetites for sex, food, or living. Some say that they cannot distinguish one feeling from another or that they swing back and forth from extreme highs to lows. Letting out their emotions would mean being engulfed by them or engulfing others. Females are expected to keep their anger in check—not even talk too much! Controlling their bodies, specifically food intake, becomes a concrete way to feel in control of this inner instability. Thinness becomes a measure of emotional control, and bulimia a way to insure it. • Women are frustrated in the work place. Although the women’s movement has provided new opportunities for some fortunate women who have taken advantage, the majority of today’s working women continue to be discriminated against in the male-dominated marketplace and political arena. Those who are able to land jobs in the areas of their interest and expertise are often paid less than men and are under tremendous pressure to perform. Also, as we said earlier, jobs which require a high degree of competition and supervision can be unsatisfying for many women who are more apt to thrive in an atmosphere of cooperation and mutuality. In these cases, bulimia can be a symptom of a life devoid of meaning, creativity, or rewarding work. It can also help let off steam or provide a way to self-sabotage in order to avoid failure or intimacy in the workplace. • The media and money perpetuate the status quo. The extensive influence of the media is unquestionable. Images of women as sexual objects are endlessly reinforced via television, movies, magazines, newspapers, billboards, and consumer products, conveying to both sexes that women should be thin, pretty, and sexy. Billion dollar businesses depend on women feeling insecure about their appearance. While a cover girl’s photo or cosmetics advertisement does not cause a binge, these constant reminders that thinner equals better establishes values that lead to distorted ways of viewing food and the self. How can a woman feel good about who she is on the inside if everyone else seems to focus on the outside? Ironically, many of the thin actresses and models, who are paid enormous sums for their “look” and skinny bodies, are themselves struggling with eating disorders in an effort to remain marketable. What special issues are faced by men with bulimia? While the actual numbers of men with bulimia are unknown and are certainly less than for women, more men have bulimia than anyone thought in the early 80s, when information about this eating disorder first emerged. Current estimates are that at least 10% of individuals with eating disorders are males. However, much of the latest research on prevalence is based on small studies and lacks conclusive findings. Men can also develop anorexia nervosa; and unlike women, some become obsessed with getting larger and more muscular—a condition called “reverse anorexia” or “body dysmorphia” which can also become addictive. Considering the issues that surround bulimia, such as guilt, shame, and low self-esteem, it is understandable that men might feel these emotions even more intensely when they have what has been generally regarded as a “women’s” disease. For this reason, many bulimic men may have been reluctant to seek professional help. Those who use exercise addiction as a type of purge generally deny that they have a problem with food. Perfectionistic “low-fat eaters” hide their obsession behind a facade of health and fitness. For the most part, men appear to become bulimic for the same kinds of reasons that women do. Some male athletes, such as wrestlers, jockeys and gymnasts, use bulimia to maintain or lose weight and become hooked on it, just as is the case for female athletes. Although contemporary thought suggests that more women are bulimic than men because society has traditionally placed more of an emphasis on women’s appearance, men are increasingly encouraged to conform to a narrow range of body types. The gay community, in particular, is concerned with “lookism” and roughly 20% of male bulimics are gay (Andersen, 1999). Heavy male models are as rare as full-figured females, and men are encouraged to diet, undergo plastic surgery and alter their hair just like women. Men are also under pressure to appear strong, in control, and independent, and as such, their roles in our culture have limitations and drawbacks, just like women’s. Many have difficulty expressing feelings and have had little experience in emotionally intimate relationships. Most feel tremendous pressure to be in charge, to shoulder financial worries and be the foundation for their families and other responsibilities. Few would want to be labelled as obsessed with their appearance. All these situations might make them more susceptible to using bulimia as a coping mechanism, as well as extremely reluctant to seek help. Most research concludes that there are far more similarities than differences when comparing men and women with bulimia. In addition to our pervasive, cultural diet-consciousness, other factors such as dysfunctional families, sexual abuse, low self-esteem, and lack of meaning in one’s life contribute to the causes for becoming bulimic, regardless of gender. Recovery outcomes for each are also parallel. Finding adequate therapy has its own unique concerns for men. Treatment options for women are plentiful and diverse, and only in recent years have programs been developed that are available solely for men. Therefore, finding professional support may require a lot of searching and may mean settling for a general men’s or mixed bulimia support group. Men might find it necessary to step outside the roles they’ve defined for themselves, and to interpret feminist recovery literature to meet their own needs. For instance, one aspect of feminism is valuing relationships between people rather than being separate from them. This might well apply to men who are encouraged to be so independent and competitive that they feel isolated from others and drawn to bulimia. As a society, both men and women perpetuate negative stereotypes, and it is up to both sexes to learn how to relate to each other in fulfilling, nurturing ways. As you know, the language of this book primarily addresses women, but most of the underlying messages and suggested activities are also worthwhile for men. How is bulimia related to sexual trauma? Clinical studies are inconsistent in reporting the numbers of eating disorders patients that have been sexually abused, and there is some controversy about this. Figures for bulimics with a history of sexual abuse range from an astounding 7% to 70%, with a majority reporting that roughly 60% of bulimics have experienced some form of sexual abuse (Vanderlinden, 1996). Since all of these figures do not include individuals who have repressed the memories of their abuse, the actual incidence is undoubtedly higher than much of the research has shown. It is important to be aware of the extremely sensitive nature of this topic, and that a self-help book such as this is not adequate “therapy” for healing these issues. With the understanding that victims need to work with a qualified therapist who has experience treating individuals suffering with both eating disorders and sexual trauma, I will present an overview on this subject. Also, although I am using the pronoun “she,” incest and sexual abuse occur with startlingly high incidence among males, with similar consequences. Being sexually assaulted, especially by a “trusted” adult, parent, or sibling, is a terrifying, confusing, horrific experience for anyone. It is an act of violence and betrayal so intense that just remembering it is agonizingly painful. In order to survive not only the trauma itself but also the memory of it, a victim might dissociate from the event and from those parts of herself which were present at that time. She may even consider the person being raped to be separate from herself, because the pain is too much for her to bear. Her emotional and physical survival depend on her not remembering the events or her feelings connected with what happened. An eating disorder works to protect, repress, complete, divert, numb, or confuse these feelings and memories. Certainly it is not within a child’s realm of possibility to blame the abuser for what happened, but even an adult will tend to blame herself for the attack, making her body the focus for hatred and control. Stuffing down food will stuff down the anger and silence the voice that cries out, “Don’t do this to me!” Planning and executing a binge will numb anxieties and deny physical needs, such as hunger or affection. Being in charge of what does, and does not, go into the body is a way to symbolically regain that control which was lost during the original trauma. The relationship with food makes it difficult to have full relationships with others, thus eliminating the risk of another betrayal. Depending on the individual’s internal survival tools, being extremely large or thin, or even perceiving one’s self as too large or too thin, is a way of keeping potential abusers at a distance. Finally, the painful and violent act of vomiting is a way of expressing and releasing rage and self-loathing. Many victims of sexual abuse become promiscuous, masochistic, or even fantasize about rape during consenting lovemaking without realizing that they are hooked on the “high” of relief they experience by blocking out their assault. Likewise, they can repeat this “forbidden high” by bingeing and purging. Some bulimics compulsively follow rituals which might mirror repeated incidents, such as molestation from a babysitter every Saturday night or visits from a sibling when parents are out of the house. Forced eating and vomiting also parallel the act of forced oral sex. These repetitive behaviors may be an attempt on the part of the unconscious to complete the original abuse in the present. An even more upsetting eating pattern may be the result of Satanic rituals, which could involve swallowing excrement or blood. Given the appalling scope of sexual trauma within this context, it is apparent that an eating disorder can be a crucial mechanism for survival. Although we are defining sexual abuse here in terms of more extreme behaviors, practically every woman has suffered sexual humiliation in some form or another. Their breasts have been “accidentally” brushed up against, their virginity has been the subject of male gossip, and they have been whistled or jeered at by strangers. In all of these cases, the female is victimized by the standard line, “She was asking for it.” It is no coincidence that epidemic numbers of women also suffer from some type of food/ weight conflict, the most common of which is dieting. Sadly, women’s bodies have become their enemies instead of the natural wonder that they are. Sexual trauma must be treated in a safe, trusted environment. Coming to terms with the experience, repressed or not, and returning the inner child to an experience of unconditional love and acceptance is a tremendous undertaking. It requires gentle understanding and patience by therapist and patient alike. Keep in mind that eliminating the binge-purge behavior without introducing healthy coping skills can result in a reliving of the original horror. Making some kind of peace with the nightmare that lies beneath the bulimic surface is best achieved with the guidance of a trained and skilled professional (Schwartz, 1996). Working and uncovering the truth about my family, and the fact that I was incested, helped everything make sense. I saw how wounded I was, and how much pain and anger I worked dutifully to deny. I began to see that I had value, and that I was lovable and competent, but that I had not been treated that way by my parents. I realized that my eating disorder was motivated by my archaic need to protect my family, and that I was actually recreating my abuse. When I was 12, my brother began sexually abusing me. I was overwhelmed with confusion and believed if I became fat, he might leave me alone. I think gaining 40 pounds in three months was also my way of saying, “Hey, there’s something wrong here,” without having to verbalize it. My physical and sexual abuse began at an early age. Much of the abuse centered around food, with my father demanding favors for desserts. Some days, it was all right to leave food on my plate, others it wasn’t. Food became my lasting enemy. My Dad used to tell dirty jokes. At the time, we all laughed, but they were all demeaning to women. I wondered if he really thought about women, my mother, in that way, but I never asked him. I had a swallowing problem due to being forced into oral sex. I would spit out all of my food, even liquids. I had been through every medical test in the book because the doctors thought there was something wrong with my throat. After four years of therapy, that problem is finally gone; but, it comes back at times of high stress or when memories surface. It’s important for parents, therapists, doctors, and the public to know that women who were sexually abused are in a lot of pain. Their eating disorder is a way of dealing with all of the feelings— rage, anger, secrecy, fear, betrayal, powerlessness and many others. An eating disorder is a feeling disorder because it helps you handle your feelings. How does bulimia affect my relationships? Bulimia is sometimes referred to as a relationship disorder because it does, to a large degree, disrupt normal, healthy relationships. Individuals with bulimia gradually withdraw from others until their obsession with food becomes practically the sole one. Also, most of our beliefs about ourselves, like whether or not we are good people or if we have to be thin to be loved, are born in our most important relationships. The eating disorder primarily serves as a protective device which insures that past hurts on these intimate issues are not remembered or repeated in the present. As children, the ways in which we are treated by our parents, other adults, our peers and our community-at-large tell us something about us. These relationships are the foundation for our feelings of significance, competence, and ability to be loved. Unfortunately, many of us have been abused emotionally and physically by the very people entrusted with our lives. With our child’s mind, we cannot believe that the fault lies with our caretakers, so we blame ourselves. We even have a hard time believing that our culture, the largest family of all, might not be such a good one. This is not to imply that eating disorders develop only in households where there is violence or physical abuse. Being repeatedly ignored or undervalued can be as damaging to a child’s self-image as being incested. Children who do not feel loved or safe in any type of family don’t trust their own actions. They will then look outside themselves for cues on how to behave. As a result, their relationships will be “other-directed” and founded in low self-esteem. Bulimia, which often begins as an innocent attempt to gain thinness and thus please others, is an example of this other-directed behavior. The person with bulimia is not following her own heart, she is reacting to what is going on around her. While it appears to be protecting her by preserving a false front and a sense of safety, it also keeps people at a distance. Bulimics interact with people knowing that they can withdraw at any time to their familiar, repetitive behaviors. Even when a bulimic appears to be present in conversation, her mind can be light years away, in the last or next binge. Certain aspects of bulimia are particularly detrimental to forming honest, fulfilling relationships. Obviously, maintaining a happy, competent facade on the outside, while feeling anxious or depressed on the inside, is an effort and a distraction. The binge and purge behaviors are done secretly, usually shrouded by feelings of guilt and shame. Mood swings and lying are common characteristics. Stealing, which was mentioned by 37% of the people who answered our survey, reinforces low self-esteem and hiding. Focusing on thinness encourages competition between women instead of support, and emphasizes the sexual nature of relationships with men instead of affection or respect. Over time, a bulimic’s relationship with food will come to supersede all other relationships. As one person who responded to our survey said, “Bulimia is a friend who does not criticize, judge, compete, or reject.” However, bulimic behavior cannot love us the way we need to be loved. It does not nurture, support, or fulfill us and the deepest inner level, as anyone who has gorged and purged themselves over and over will testify. It is a tenuous short-term solution for buried long-term pain, creating loneliness and isolation in its wake. Giving up bulimic behavior is extremely frightening for someone who has little experience being close to others. It means risking rejection and facing feelings of worthlessness, but the payoffs are obvious—honesty, trust, fun, intimacy, and love. As the section in this book on getting support emphasizes, an open, trusting relationship with even one person can be a crucial factor in recovery. Many people found this trust in therapy; others found it with parents, lovers, spouses, and friends. The very nature of an eating disorder prevents the development of relationships. How could I have a relationship with someone based on honesty and truth if I was constantly lying about how much I ate, didn’t eat, exercised, or purged? When I am in love or working on intimacy, my eating habits normalize, but when I have no close relationships or involvement with others, I feel like I am starving. Food reduces the anxiety, and masks the feelings. Only working on intimacy stops this pattern. For me, relationship-building is essential to recovery. Basically, my life became a massive cover-up. Any lie or deception that protected my freedom to binge-purge was okay, and I’d always placed a high value on honesty prior to this! My relationships with my family members deteriorated as they caught me in numerous lies. They couldn’t trust most of what I said. I actually believed that the reason my sisters were tracking me around the house, in an attempt to stop my vomiting, was because they were jealous that I was finally thinner than they were! When I went out with friends, I was so detached from what was going on that all I could do was calculate how fast I needed to get to the bathroom to vomit. I had no real interest in the people around me; but, through therapy, that’s all changing now. I recall on many occasions, turning on my answering machine, settling down to plates of my favorite binge foods, and listening to friends leave messages, while I frantically shoveled in food. Food had become more important than my friends. Food was my BEST friend. As I became more comfortable with myself, I saw my life change in many ways. I found myself surrounded by friends who really liked me. And they were happy people, not miserable and depressed like my old friends. I have learned how to say “no” to people, and earned a lot of respect for doing so. I was always afraid of what would happen if I disagreed or wanted something to be different. Now I feel worth having an opinion. Is it the same as anorexia nervosa? For many years bulimia was considered to be one type of anorexic behavior. Certainly, in both cases, the relationship with food is a symptom of other serious problems and many other similarities do exist. By recognizing bulimia as a separate disorder in 1980, however, the American Psychiatric Association identified a much larger group than those who could be clinically classified as strictly anorexic. The fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (APA, 1994) lists four criteria that an individual must meet in order to be diagnosed as anorexic, generalized as follows: A. The individual maintains a body weight that is about 15% below normal for age, height, and body type. B. The individual has an intense fear of gaining weight or becoming fat, even though they are underweight. Paradoxically, losing weight can make this fear of gaining even worse. C. The individual has a distorted body image. Some may feel fat all over, others recognize that they are generally thin but see specific body parts (particularly the stomach and thighs) as being too fat. Their self-worth is based on their body size and shape. They deny that their low body weight is serious cause for concern. D. In women, there is an absence of at least three consecutive menstrual cycles. A woman also meets this criteria if her period occurs only while she is taking a hormone pill (including, but not limited to, oral contraceptives). The DSM-IV also differentiates between two specific types of anorexia nervosa. “Restricting Type” denotes individuals who lose weight primarily by reducing their overall food intake through dieting, fasting and/or exercising excessively. “Binge-Eating/Purging Type” describes those who regularly binge (consume large amounts of food in short periods of time), and purge through self-induced vomiting, excessive exercise, fasting, the abuse of diuretics, laxatives, and enemas, or any combination of these measures (Hall and Ostroff, 1998). Although some anorexics also purge after eating, anorexia nervosa is generally characterized by self-starvation. In general, anorexics reject food, have lower body weight, often begin younger, and are socially and sexually less mature. In contrast, the majority of bulimics’ weight appears closer to normal, most began purging in their late teens or early twenties (many anorexics turn to bulimia), and are more socially outgoing. Also, as noted, the DSM-IV criteria includes amenorrhea, which is generally rare amongst bulimics, who nevertheless, frequently report irregular menses. Hospitalization is often necessary for anorexics, who have a higher fatality rate: 5-20% of anorexics die from complications related to the disease (Zerbe, 1995). There is no definitive data for bulimia fatality statistics, but the clinical impression is that they are low, and not as high as for anorexia nervosa. There are, as mentioned above, similarities in the issues underlying anorexia nervosa and bulimia. Individuals with the disorders share an overconcern with the size of their bodies and what they have or have not eaten. They are focused on an inner empty place, which can be viewed in physical, emotional, social or spiritual terms. Both use the control of food to handle intense feelings of different kinds, such as depression, anger, rejection, loneliness, selfishness, fear of independence or dependence, and love. Each also uses food to avoid situations where there is a potential for conflict, disapproval, or failure. Ultimately, both use food to express something that they feel is unacceptable or they are unable to express directly. However, while a binge and purge can give a bulimic the courage to face the world, not-eating is empowering to an anorexic. Although some anorexics engage in purges if they eat more than they consider safe, not-eating remains their primary tool for self-preservation. Recovery for these individuals is less a matter of avoiding a binge than it is eating enough to be healthy. But the bottom line for both remains to be able and willing to care for themselves with appropriate amounts of food (not starving or stuffing) in a healthy, self-nurturing way. “Typical” depends entirely on the individual. The size and frequency can vary as well as the type of purge and the length of time between sessions. A binge is really whatever causes a person to feel guilty. Typical binges, however, share two characteristics—the consumption of an excessive amount of food and feelings of being out of control. Many bulimics have said that they can “relate to” my binges, one of which I’ve described in the Introduction. Frequently I started a binge while in the course of eating what I thought to be a “good” or “safe” meal. For example, I may have gone to a salad bar and carefully allowed myself a moderate portion. As I ate the salad, I would begin to feel guilty about the calories in the salad dressing or the fact that I had taken croutons. At one point in the meal, I would decide I had eaten one bite too many. Rather than stop eating, I’d think, “What’s the difference. I’ve already gone too far. I’ll do a binge, and none of the calories will matter after I vomit.” It never occurred to me that there were “issues” driving this bizarre behavior. If I had my choice, I would eat sweets and refined carbohydrates. A single binge might include: a quart of ice cream, a bag of cookies, a couple of batches of brownies, a dozen donuts, and a few candy bars. When I was desperate, though, I would binge on anything: oatmeal, cottage cheese, carrots, or day-old rolls that I fished out of the trash from what was to be my last-ever binge. My stomach stretched so much that I looked pregnant, and I usually postponed vomiting for about 30 minutes of numbness.Then I’d stick my fingers down my throat until I had vomited everything that would come up. The whole episode lasted about an hour, and I often felt very weak and dizzy afterwards. I did not abuse laxatives, enemas, or diuretics, although some others with bulimia do. Although bulimia rarely results in death, it can occur. Excessive vomiting leads to electrolyte imbalance. Electrolytes, which are chemicals in the body like potassium, chloride and sodium, help regulate heart beat. When they are depleted by purging or dehydration, heart arrhythmia—irregular heart beat—often takes place. Sometimes this is not serious and subsides when proper health and nutrition is restored, but for others it can lead to death from cardiac arrest. Kidney failure is another possible life-threatening side-effect of low potassium. Vomiting can be fatal due to choking or if the esophagus or bronchial passage is ruptured. The most common medical problems for bulimics include rotten teeth, constipation, bloating and other digestive disorders, infected or swollen glands known as “chipmunk cheeks,” blisters in the throat, icy hands and feet, and fluid depletion. Other potentially serious, though generally rare, complications are abnormalities in the endocrine and gastrointestinal systems, anemia, internal bleeding, hypoglycemia, irregular menstrual periods or amenorrhea, osteoporosis, myopathy, and irregularities in brain imaging. Some bulimics use syrup of ipecac, detergents, or foreign objects to induce vomiting—all of which are extremely dangerous. Ipecac, a horrible tasting liquid, is used to treat poison victims, and its abuse can produce muscle weakness or cardiac arrest (Mitchell, 1997; Mickley, 1999). Laxative abuse can irritate intestinal nerve endings, which can inhibit them from triggering contractions. Heavy use of laxatives or enemas removes protective mucus from the intestinal lining, which can result in bowel infections. The lower bowel can lose muscle tone, becoming limp and unable to produce contractions. Dehydration and fluid imbalances can occur with the same sideeffects as listed above. Also, laxative abusers can have rectal pain, gas, constipation or diarrhea (or both), and bowel tumors. Although not directly linked, individuals with eating disorders may tend to have other medical illnesses, including diabetes mellitus, cystic fibrosis, inflammatory bowel diseases such as Crohn’s disease, and thyroid disease. Diabetics with bulimia often misuse their insulin, which can be life-threatening (Bock, 1999; Zerbe, 1995). It is difficult, if not impossible, to know which bulimics are at greatest risk for developing any of these specific conditions. Certainly, the longer someone has bulimia, the more likely they are to experience associated medical problems. However, even someone who has only started to purge faces the possibility of serious physical consequences, even death. Many bulimics have concerns about getting or being pregnant. Some fear that their vomiting will harm the child or that they will get too fat. Although information on pregnancy and eating disorders is limited, what we do know is: 1. Although women with disordered eating are more likely to deliver babies that are small, major birth defects do not accompany bulimia or anorexia nervosa. 2. Since a mother who purges has a separate digestive system than her fetus, the child is generally not harmed. However, poor nutrition and negative frame of mind are unhealthy for mother and child. 3. For women in treatment, some antidepressants can be used but others should be avoided. In any case, they should check with their doctors about the specific medications that they are taking. 4. A large percentage of women experience remission of their bulimic symptoms while they are pregnant. They may feel that their bodies belong to their babies during pregnancy, and thus eliminate unhealthy behaviors. However during the postpartum period they are likely to return to their bulimia, especially faced with their added weight. 5. The birth of a child also brings up other emotional issues for bulimic women, which include mother/child relationships, how the eating disorder will affect parenting, sexuality and attractiveness, separation conflicts, and worries over proper feeding for baby. These should all be addressed for the welfare of the mother and child (Yager, 1997; Zerbe, 1995). What thoughts and feelings are associated with it? Eating disorders are feeling disorders. The rigid rules and rituals of bulimic behavior are a definite way to distance one’s self from feelings that seem unmanageable, overwhelming, or just plain terrifying. These can be as nightmarish as the fear that comes from memories of abuse, the quiet pain of being unloved or considered unimportant, or feelings that are buried in past events or fresh from one’s daily life. A binge pushes away all feelings by providing something else on which to focus. Eventually, bulimics use no other way of handling their feelings except to binge and purge. This is what they describe when they say they feel powerless. What’s more, the illness brings with it a whole new set of complications that mask the old feelings and often make them worse. For example, a person who is afraid of others may use bulimia to keep her distance by hiding her embarrassing thoughts and rituals. Or someone who feels incompetent may perfect the art of throwing up, while attempting little else. In this way, whatever precipitated the binge-purge behavior is effectively denied, and in the long run, buried beneath fresh shame and guilt. Most initial lessons about feelings are acquired at an early age and have a profound impact. Some families do not express or know how to handle a free range of emotions, especially “negative” ones, such as anger, disappointment or even disagreement. Others have strict rules for controlling which emotions can be expressed and what modes of expression are permitted. Children in these types of families learn that they should monitor and protect their feelings, and in many cases deny them altogether. With no experience identifying and talking about them, a bulimic may not even know exactly what she is feeling, or might assume that her feelings are bad and she is bad for having them. She might fear other people’s feelings, as well, and work hard to insure that they are not upset in any way. Eventually these unvoiced feelings will find expression in other ways, such as through an eating disorder. In fact, many bulimics misinterpret a wide range of emotions as hunger. Most say that they feel depressed, disconnected and powerless most of the time. The cyclical nature of the bulimic binges also applies to feelings which, in the space of a few hours, can move from worthlessness (low self-esteem), to powerlessness (I have no control over my life), effectiveness (I can get rid of these feelings), a “high” from the release of the purge, hope (that this binge might be the last), and finally the return to feelings of worthlessness. Bulimia is also a thinking disorder in that sufferers are trapped in harmful thought patterns. One example is “black and white thinking,” where everything is divided into extreme categories. For example, foods are either “good” or “bad,” bodies are either “fat” or “thin,” and not being in-control means being completely out-of-control. Other patterns are magnifying problems, magical and dramatic thinking, constantly comparing one’s self to others, and taking remarks or situations too personally. Some bulimics also seem to hold a generally negative attitude towards life, which influences all aspects of their experience. Most think that they are worthless, as evidenced by the size of their bodies. Individuals with bulimia typically harbor a set of deeply-held core ideas upon which other harmful conclusions are drawn. For instance, the belief that being fat is bad will also mean that food is bad, that having a large body is a sign of failure, and that self indulgence is a sign of weakness. Believing that “I am a bad person,” to which many bulimics adhere, makes possible the thoughts “There is no reason to take care of myself,” and “No one can love me.” This sets up an entire system of values and ideas upon which they are constantly monitoring and judging themselves, and sometimes others. Their minds do what is referred to as “spinning,” or going over and over the same negative thoughts. These endless, automatic “tapes” in the mind make it impossible for bulimics to hear anything else, much less their own inner wisdom. All these negative feelings and thoughts must be brought to light and challenged in recovery. This can be at once a frightening, rejuvenating, exhausting, rewarding experience, which is why it is best done with the guidance of a therapist. I can easily see how, during stressful times of your life, you seek some kind of comfort. I found this in food. Others find it in drugs and alcohol. Before I started therapy, I never associated my desire to binge with my emotions. I always felt it was an uncontrollable desire for huge amounts of food. Now I understand the binge takes the place of allowing myself to feel any emotions. When I feel sad, troubled, panic, anger or loneliness, this disease jumps out on me like a Jack-in-the-box. I find it scary because I also feel helpless and not in control. Then again, the mental “numbness” blocks out all the emotions and makes me forget about all my problems. It’s not worth it, though. What other behaviors do bulimics share? People with eating disorders have compulsive personalities; the rituals they create are safe and familiar places to reside. Many of the rituals revolve around food and body image, such as arranging food on their plates, excessive exercise, eating systematically, looking in the mirror, and obsessive calorie counting. Some behaviors are not related to food, such as always knowing where the nearest bathroom is, avoiding people, lying, keeping secrets, kleptomania, and compulsive shopping. Most bulimics take exhaustive steps to cover up their symptoms. During the five years of my first marriage, my husband never found out about my closely-guarded secrets. No one knew! Covering my tracks was part of my daily routine. Lying about food was second nature to me. For example, if I went to the same grocery two days in a row to buy large quantities of binge food, I would tell the checker that I was a nursery school teacher buying snacks for the children. My rituals included a preoccupation with scales, mirrors, and trying on clothes. I used to weigh myself before and after binges to be sure that I gained no weight. (At one point in my recovery, I took a hammer to the scale!) I could not pass a mirror without judging every slight bulge or hair out of place. In our survey, 37% of the bulimics mentioned kleptomania as a symptom. Obviously, stealing is one way to offset the cost of food, but there is more to kleptomania than just basic economics. Both compulsive shopping and stealing are ways to “fill up” without eating, as well as to symbolically fulfill unmet emotional needs. Also, stealing from other people can be a way to communicate negative feelings without using words. In my case, I felt unworthy and incapable of affording “nice” things, although I spent vast amounts on food. I wanted love and attention, and not knowing how to get those emotional rewards, I settled for the temporary satisfaction of new things. Sometimes I just wanted the rush of doing something I shouldn’t. The women in our survey had similar experiences. Their stealing ranged from candy bars to larger, more expensive items. Most of those who stole also indicated that it was not too difficult a pattern to change. A few women were arrested, then stopped immediately, such as this one: I stopped stealing after I got caught with a chicken in my purse! What does it feel like to binge-vomit? In answering this question, it is important to remember that bulimia serves a purpose for the person using it. In other words, they would not be binge eating and purging if it made them feel worse rather than better. Particularly in the early stages, when purging is excused as a way to lose weight or maintain low weight, bulimia provides a false sense of self-esteem, competence, and control. In the later stages, giving it up means understanding the difference between what is real and true and what is not. It also means choosing what is real. The mental “numbness” and physical “high” are important reasons that the binge-vomiting behavior itself becomes so addictive. In fact, many women from our survey who were compulsive about food were also alcoholics, or came from families where substance abuse existed. There have been several studies on the comorbidity of eating disorders and other addictions, and they have shown that between 9% and 55% of bulimics are also alcoholic or abuse drugs. They also become addicted to diet pills, diuretics, and laxatives (Mitchell, 1997). Friends and loved-ones should know that vomiting from a binge is not the same thing as vomiting when you are sick. The person with bulimia doesn’t feel sick, she feels desperate, driven. Bingeing and purging temporarily removes stress, like a drug. All focus is on the cycle, from trying to avoid a binge, giving in to the urge, planning, and execution. After a vomiting purge, there is also a physical “high” from the pressure of being upside down and exhausting physical effort. Feelings of cleanliness, renewal, relaxation, mindlessness, and emotional numbness are common. There may be sexual feelings from the emerging, private excitement, complete involvement, fullness, stroking, and sudden release. In my case, in the calm after the purging storm, I promised myself that I would never binge again, adding feelings of hope and renewal to the cycle. But shortly thereafter, I always started anew. For more than five years, I binged and vomited four or five times—and more—practically every day. Several surveyed women commented about the drug-like aspect of bulimia: I like the high and then the numbness. Once I begin a binge, there is no stopping me. When I first tried to give up my bulimic behaviors, I began to drink more alcohol. I was substituting one escape for another. I would get so depressed over my drinking that I would finally binge. I joined Alcoholics Anonymous, have been sober five months, and find my bulimia much more manageable. Until I quit drinking I kept having recurrent episodes of my old bulimic behavior. No matter how down and depressed you feel, think of food as a temporary filling or “high.” Find something permanent, because after you purge, you’ll feel the same or even worse. Why waste your time? How do I know if I have bulimia? Have we been talking about you? I binged and vomited daily for nine years without thinking I had a problem, although that was before bulimia had been given a name. I came across the very first magazine article about “bulimarexia” and was shocked to discover that there were other people who had the same eating behavior as mine. Whether you binge and purge daily or only occasionally, or if you overeat and then exercise compulsively or engage in strict dieting, you are still abusing your body in a bulimic manner. Actually, even if you are only obsessive in your thoughts about weight, diet, and food, you still have a problem with food, even if you do not meet the clinical definition for anorexia or bulimia. To address the problems of individuals who do not fit the strict criteria, the American Psychiatric Association established a new category in the DSM-IV, “Eating Disorders Not Otherwise Specified” (EDNOS). Some of the symptoms of EDNOS include binge eating without purging, meeting all of the criteria for anorexia except the individual has regular menses or is close to normal weight, having bulimic symptoms with less frequency than twice a week or for a duration of less than three months, purging after eating relatively small portions, or chewing and spitting out the food rather than swallowing. Just about everyone enjoys an occasional large meal (holiday binges!), but an obsession is an escape. If you have constant negative thoughts about food and your body, you have a problem regardless of its clinical classification, and I urge you to face it. How long does it take to get better? That’s up to you. The behavior does not suddenly stop without an effort. In fact, it is addictive enough to continue as a lifelong obsession. I have corresponded with a woman in her sixties who has been bulimic for more than forty years! In the past, so little was known about bulimia that people commonly continued for years before seeking help. Now, there are national and local organizations, treatment facilities, private therapists, support groups, and books solely devoted to eating disorders. There are a few necessary steps to recovery. The first is acknowledging that you have a problem and making the decision to change. For some people, prolonged therapy, or even hospitalization, is necessary. Generally, overcoming bulimia takes time and a firm commitment, and increased time, effort and determination will make it happen faster. The time it takes to stop the bingeing behavior varies with each individual. I have heard of people who have gone “cold turkey,” stopping instantly, and of others who have decreased the number of binges slowly over a period of months or years while they worked on the underlying issues. Stopping the binge-purge behavior is like opening Pandora’s box. Within are the reasons why the bulimia began and took hold, as well as those it has created anew. These all need to be resolved. I am often asked how long it took me to recover. I spent a year and a half working to stop the actual binge-purge behavior. There was a time when only one binge each day seemed like an impossible goal, but days extended into weeks, and eventually my goal was to not binge for a month at a time. Ridding myself of the obsessive thoughts about food and my body took longer because I had to confront the issues that led me to become bulimic in the first place. Stopping the behavior was only one aspect of recovery, though. I had goals related to my emotional life as well, such as improving my relationship with my parents, making more friends, being able to handle conflicts, and knowing what I needed and being able to articulate that to the people closest to me. I also had goals related to my body image, because I wanted to be able to love the body that I was born with no matter what its size or shape, and I wanted to stop being judgemental about other people’s bodies. It was three or four years before I considered myself able to do that. A few years after that, I had stopped all bulimic behavior and had moved from being a basically negative person to a basically happy one. I didn’t expect to ever go back to the way it was again, and called myself completely “cured.” So, there were many aspects to my recovery. Now, when someone asks me how long it took me to get better, I say that I am always working on my “betterment,” primarily my spiritual life at this point. However, I have had no bulimic symptoms, thoughts or feelings whatsoever for many years. These days, I find it difficult to even remember my struggle with bulimia. I have not binged for about twenty years, and I do not think about returning to it. There are times, especially during menstruation, when I crave and eat more food than usual, especially chocolate. This is nothing like the eating binges when I was bulimic, either in content or quality. Also, I was recently diagnosed with hyperthyroidism. At first, I didn’t know why my body was speeded up or why I lost some weight and was hungry all the time. I just went with it, often consuming five meals a day until my condition was finally discovered. After treatment, I am gaining the weight back, and I feel ecstatic to be back in what feels like my “old, familiar” body. I can tell when I am at a healthy weight (not a particular weight!) and it feels good. Not everyone agrees that you can be “cured” of an eating disorder. Some experts believe that bulimia is an addiction and that abstinence is the only way to prevent future relapse. They stress the addictive nature of certain types of foods which trigger responses that lead to bingeing. Like alcoholism, a complete cure is not possible because you will always be prone to bulimia, even if you do not practice the binge-purge behavior again. They would say that you are always “in recovery.” I know that this abstinence approach does work for many people, but I personally wanted to lessen food’s power over me. I wanted to be completely free to eat anything I wanted. And so, my recovery focused on what is called the “legalized” approach to food. Instead of restricting, advocates of this approach stress differentiating stomach hunger from emotional hunger and fulfilling both accordingly. They emphasize getting satisfaction from eating what your body wants and suggest that when a preoccupation with eating and weight ends, bingeing stops as well. In spite of my personal experience, I recommend many therapists and facilities who promote the abstinence approach, as well as those which do not. The information in this book applies to bulimics interested in recovery regardless of their stance on this issue. I do not advocate any specific modality of treatment—whatever works for you, do it! It may be necessary to depend on another behavior, such as regularly-scheduled phone conversations with friends, or going to support group meetings to relieve tension or distract yourself. There is always the possibility that you will just trade one compulsivity for another. However, if you continually ask yourself if the steps you are taking are in a more positive direction, gradually you will be able to let go of all compulsivity. There will come a time when days pass without any fears associated with what you eat or look like. Remember, you are a worthwhile and important soul whose bulimia has served you in many ways. Be patient and gentle, work hard, and let it go. Can medication help in recovery? Even the strongest proponents of drug therapy do not recommend treatment based entirely on medication. No “magic pill” can fully resolve the emotional and spiritual issues underlying their bulimic behavior. Still, recent scientific data does support the use of antidepressants for the treatment of select patients with bulimia as part of a complete program administered by a treatment team. A consistent finding of many studies is that cognitivebehavioral psychotherapy alone is superior to solely using antidepressants, and sometimes the combination of medication and psychotherapy is even more effective (Garfinkel, 1997). This is a controversial subject among clinicians. Most agree that individuals with eating disorders have mood disturbances, and many argue that bulimia is related to major affective disorder, the psychiatric family under which major depression is classified. Evidence also suggests that the cause of eating disorders might be traced to hereditary, genetic, and biological factors, including abnormalities of the hypothalamus, a gland in the brain which regulates many bodily functions. Fluoxetine (brand name Prozac®) is the most widely-used antidepressant for bulimia, and many patients and therapists report good results from it as well as others, such as tricyclics (TCA’s) and monoamine oxidase inhibitors (MAO’s). However, antidepressants do not work for everyone, nor will any kind of treatment. Mood stabilizers, such as lithium carbonate, anxiolytics, and opiate antagonists have generally not been found to be effective in the treatment of bulimia (Garfinkel, 1997). Some bulimics have responded well to drug treatment and have reduced the cravings to binge within weeks. Many of these patients have a history of depression, although being caught in the cycle of bulimic behavior can certainly cause depression as well. Some bulimics benefit from these medications because of chemical changes in their bodies related to hunger and satiety. Draw your own conclusions by consulting with a professional trained in the pharmacological treatment of bulimia. Many people in our survey had experience with drug therapy. Close to 60% of those who had used antidepressants found them helpful in recovery. Several women indicated that drug therapy decreased their cravings to binge, allowing the issues that fueled the binge-purge behavior to surface. Two of many psychiatrists I tried were biochemically oriented, and willing to modify pharmaceutical rules based on their own experience. We kept trying different doses and medicines until something worked. I started using Prozac, and it really helped me. My urge to binge lessened practically overnight. It made me feel more ready for therapy. I am being treated with Parnate (an MAO inhibitor) which has changed my life. It offers a “normal” mood, as well as freedom from binges. Of course, therapy in conjunction with medication is the ideal situation, and I’m trying that too. I don’t think one without the other would do. How do I learn to eat correctly? Just as there is no one road to recovery, there is no one way to eat correctly. Every individual body is different, and deciding what and how much to eat will ultimately be up to you. In the early stages of recovery, however, when emotions are high and thoughts are spinning, food decisions are extremely difficult, sometimes immobilizing. It is helpful to have some plan with which you feel comfortable as you embark on new eating patterns. A qualified dietician or nutritionist, working in conjunction with your therapist, can help you with this. (See Chapter Six, “Healthy Eating and Healthy Weight.”) As I indicated earlier, there are two main approaches to the food behaviors in recovery from bulimia. People who use the abstinence approach eliminate certain foods from their diet and stick to a food plan. This enables them to avoid those foods which might trigger fears about weight gain or binges, such as sweets, processed, or fried foods. One common practice is to have three, well-planned meals each day and up to three healthy snacks. The other orientation encourages people to eat whatever food they want, in moderate portions, when they are physically hungry. This is a more spontaneous approach and for this reason can be extremely difficult for someone new to recovery, requiring a new awareness of hunger cues and permission to eat that which was previously considered “bad,” without guilt or loss of control. Most therapists recommend a more externally-structured eating plan at first, and a slow introduction to a more internally-guided plan. It is hard even for a normal eater to make choices these days. The four food groups appear to be fast, frozen, fat, and fried— poor choices for anyone! Many restaurants serve overly large portions of fatty, sugary, processed food. With rare exceptions, fruits and vegetables are chemically treated, poultry and livestock are pumped with growth hormones, and much of our seafood swims in polluted waters. Finally, millions of dollars are spent promoting diet plans with powdery meal-substitutes or brand-name processed foods. What is considered healthy one week has warnings the next. Recovering bulimics have a particularly difficult time wading through this muck in order to learn how to eat nutritious meals. Eating correctly obviously means not binge-eating or feeling badly about what you have eaten. It does mean following a relatively healthy, nutritious diet, allowing one’s self the freedom to eat occasional treats without guilt or fear. A healthy, well-balanced diet includes complex carbohydrates, protein, fat, vitamins, and minerals. Carbohydrates are the body’s primary energy source and are crucial to the functioning of the red blood cells, brain, and central nervous system. Therefore, whole grains are an excellent source, as is pasta, rice, and starchy vegetables, such as potatoes. Protein also provides energy, and if enough carbohydrates are eaten, protein is used to build and repair tissue and help maintain adequate immune system function. Animal products provide “complete” proteins, but grains and legumes (such as rice and beans) can be adequately combined within a 24 hour period to form “complementary” proteins, which are essential for vegetarian diets. The body also needs fat to provide and absorb fat-soluble vitamins, fatty acids, and to slow the emptying of food from the stomach, which gives a feeling of fullness. Good sources are seeds (such as sunflower seeds) and unsaturated oils. A balanced diet, with plenty of variety, will provide the vitamins and minerals needed, although supplements may be appropriate. For more information, consult a professional or books on nutrition (not diet books). Often, individuals with eating problems are well aware of these basic nutritional facts, but have difficulty acting upon them. This is because food represents much more than fuel and the act of eating symbolic of deeper issues. Changing your eating behavior may require trial and error over time in order to find what changes you are ready to make at the different stages of your progress. Eating normally means enjoying what I eat. It also means loving myself enough to nourish my body with healthy, adequate nutrition. To normal eaters, food is just food; it’s not a substitute for something missing in your life, or a way to stuff feelings. There are no more “good” or “bad” foods. I eat when I’m physically hungry, and stop when I’m comfortably satisfied. I can eat the foods I enjoy whenever I am hungry for them, and I am more aware of the taste and texture. I no longer binge as a result of deprivation. I no longer binge or purge, but I also have to watch how much I eat, and I abstain from certain foods such as wheat, flour, hard cheese, and crispy, salty things like potato chips or rice cakes. Eating normally is being able to eat anything I want, in moderation, with anyone I want. Now, I enjoy going out to eat with my husband and friends. If I quit purging, will I gain weight? There is no single answer to this question that is true for everyone. Some people gain weight when they stop purging, others lose or stay the same. This question is of obvious concern for most people with bulimia, but it brings up another, more relevant question: Why do you care? Whether you gain or lose weight is not as important as whether you can become self-accepting regardless of your weight or shape. (See Chapter Six, “Healthy Eating and Healthy Weight.”) Currently, the harmful message that thinness has innate value permeates every level of our society, although this has not always been the case. While there have been societal standards of beauty within every culture and time, emphasis has been increasingly placed on thinness in Westernized countries since the late ’60s, particularly for women. Contemporary actresses and models, who represent the “ideal” woman are the thinnest 5-10% of the general public. Consequently, 90-95% of women are pressured to lose weight (Seid, 1994). So ingrained is the value of thinness that dieting has become an accepted part of their lives. One study showed that 42% of girls in the 1st through 3rd grades want to be thinner (Collins, 1991). Another showed that 51% of nine and ten year-old girls feel better about themselves when they are dieting; 9% of nine years olds have vomited to lose weight; 81% of ten year olds are afraid of being fat (Mellin, 1992). A thin body has become a panacea, with both implied and actual rewards. We asked people who have had food problems to list their gut reactions to the words “thin” and “fat.” “Thin” was associated with goodness, power, success, glamor, comfort, control, happiness, approval, attraction, friendship, love, and perfection. “Fat” indicated the opposite: panic, anger, self-hate, inferiority, unworthiness, unhappiness, loneliness, frustration, disgust, desperation, laziness, rejection, lack of control, ugliness, sloppiness, and failure! As a culture, we have been brainwashed. So much so that we can no longer separate the uniqueness of a person from the meanings connoted by the size of their bodies. This creates prejudice, the ultimate result of which is discrimination against people with large bodies. Naturally, you are worried about gaining weight! The fact is that bodies come in all shapes and sizes and every person has a genetically programmed “natural” weight which is most healthy for them. This is called “set point.” It is the weight at which they feel best, are neither eating too much or too little, and have a balanced metabolism. This ideal weight is a lot different than the one that is found on a standardized table. It is unique to every person. Actually, one’s set point is a range of between about five to ten pounds. (See Chapter Seven, “Healthy Eating and Healthy Weight.”) Even a large body can be fit when it is at its set point—getting healthy food and regular, moderate exercise. You can find your body on your family tree and there is not much you can do about it! Research has consistently shown that fat people, on the average, do not eat more than those who are thin. Biologically thin, adopted children in households with large adoptive parents do not grow up fat, or visa versa. Genetically thin people who are overfed do not become fat (Ellis-Ordway, 1999). In adoptive families, there is no relationship between the weights of the parents and children. Studies of twins also demonstrates that heredity accounts for about 70% of fatness (Foreyt, 1992). In answer to the original question, frightening though it may be, many bulimics who resume normal eating do gain some weight while their metabolism adjusts to normal and they replenish their cellular water supply. Eventually, they will level off at the weight that is genetically correct for their particular body. At the same time, they are making the commitment to gain happiness, peace of mind, feelings of wholeness and integrity, as well as take care of themselves emotionally and physically. Interestingly, many individuals from our survey discovered that when they gave up dieting and the need to be thin, their bodies came to rest at weights that were acceptable, comfortable, beautiful, and unique. They were not necessarily thin. I used to weigh myself at least 25 times a day. Now, I have not been on a scale for over two years. Eating disordered people like myself are so hung up on numbers. What should count is how you feel, not a number on the scale. It’s hard to break the scale habit, but my advice to anyone is, don’t weigh yourself at all! I’m content with myself and realize I don’t have to be skinny any longer. My health is more important to me than the image of “model thin.” Nothing could hurt me as much as being called “fat.” It’s only now, with definite steps toward recovery, that I’m able to understand how I used food and weight problems to hide from the real issues: relationship problems, loneliness, and shyness. Only when I took recovery as serious business was I able to understand that all of life does not revolve around fat or thin. My weight stays within a five-pound range. I will admit that I would like to weigh about five pounds less, but I consider stopping bulimia much more important than being “thin.” This increase (eight pounds) was right after I stopped vomiting every day, but I have stayed at that weight ever since. I am at peace with my body image. I learned the way I look doesn’t count half as much as how I act and my attitude toward myself. I get more compliments on my appearance when I am feeling really good about myself than when I struggled to be thinner. How should I choose a therapist? Most bulimics should consider entering professional therapy. I’m often asked for referrals for therapists, and at one lecture, I recommended a psychiatrist who was considered a national expert on eating disorders. From the back of the room, a woman immediately cried out, “Oh no, that man is horrible.” She went on to describe her experiences with him, which were indeed terrible. Yet I know that he has helped others. It is important to find the therapist that is right for you. Would you buy a car without a test drive? Some people spend an hour trying to decide which ice cream to pick in a supermarket. Choosing a therapist should certainly take more consideration than that. Put in time and effort to find a therapist that will help you. Local health agencies usually provide lists of doctors and counselors who treat bulimia, and hospitals and medical clinics often have specialties in this area. Some hospitals that have inpatient units also have outpatient or day treatment programs, as well as groups available to the public. There are quite a few residential facilities devoted entirely to treating eating disorders. For some bulimics, hospitalization is an effective part of their treatment. (See the “Resources” section.) As I’ve mentioned, there are different approaches to recovery. You must decide for yourself which approach best suits your needs. When you investigate therapy options, come with a list of questions. Does he or she emphasize the “abstinence” or “legalized” approach? Do they focus on changing thought patterns and expressing feelings? Do they give homework? How will they handle your anxiety level? Will they expect you to stop the bingeing right away, or allow you to improve at your own pace? How much experience do they have with this type of problem? Ask those questions which are important you to personally, remaining flexible enough to reevaluate your beliefs. Do what will work for you! A “therapist” usually refers to a psychiatrist, psychologist, or marriage and family counselor, but can refer to other professionals, such as: licensed social workers, dieticians, or nutritionists. Also, some registered nurses, clergymen, acupuncturists, chiropractors, or those who practice therapeutic touch can provide invaluable services. A multidisciplinary approach combines several professionals as a treatment team. If drug therapy is a consideration, a qualified physician must be part of that team. Check in the phone book and make some calls asking for references. Referrals are a good place to start, but you have to kick their tires! Call their offices and ask for a short appointment to meet them. Let them know that you are also interviewing other therapists—they’ll appreciate your effort. Come prepared with a list of questions. This will not be a therapy session, so your questions can be hypothetical or direct—it’s up to you. Some things you might ask are: What is their treatment approach to bulimia? How often would you need to see them? How quickly might you see results? How long would they expect therapy to last? What will the charges be and do they have a sliding fee, based upon income and need? Do they accept your insurance? In evaluating the interviews, use criteria that are meaningful to you. These are subjective measures. Probably the most important area to consider is how you felt during the interviews. If you were comfortable with the therapist and felt that you could honestly work with him or her, that’s a good indication. Other things to notice: Do you like the office? Does the staff seem friendly? Does the therapist answer you directly and invite you to express yourself? Finally, you can always change therapists. Once you’ve picked out someone, try at least a few sessions. Give therapy a chance. You might decide together on a reasonable time period before evaluating your progress. If therapy with your first choice proves unsatisfactory, find someone else! What can I do to help someone who has bulimia? The support of a spouse, parent, sibling, or friend is one of the most valuable tools a person with an eating disorder can have. If someone close to you has bulimia, you can face it together in many different ways, but remember that they are the one with the problem. Loved ones can research treatment options, read appropriate books, attend lectures, talk to experts, and lend a supportive ear, but only the bulimic herself can do the work. (See Chapter Eight, “Advice for Loved Ones.”) Keep in mind that bulimia is a way to feel in control of one’s life. Sometimes, what is intended to be helpful and considerate can be interpreted as controlling by the person with the disorder. Communicate that you are available to help, but that it is not your job to patrol their behavior. You are there to support and encourage them in their struggle to get well, but only if that is what they want. Bulimia is a protective device used to handle pain. If it was easy to give up, the person would have done so already. Someone who uses food as a coping mechanism needs understanding and compassion. The reality of bulimia may shock or disgust you, but separate the individual from her binge-purge behavior. She deserves love and appreciation for who she is apart from the bulimia, and compassion for the pain that has driven her to it. If a loved-one became disabled or ill, you would still be there for them—bulimia is disabling and life-threatening. At the same time, do not be manipulated or lied to for the sake of binges. Do not “enable” the disorder by looking the other way or pretending that the problem is not serious. If you stock the refrigerator with food only to have it flushed down the toilet, be honest and assertive about your rights and needs. Bulimics should not be allowed to abuse your trust or pocketbook; having bulimia is not justification for treating loved ones poorly. Also, don’t turn meals into battles—food is not the issue. Parents of bulimics especially need to be aware of their limitations in helping their children. Often, the relationship is too close for objective evaluation. Let your daughter open up to you with her feelings, and if she does not make progress with your support within a short time, encourage professional therapy. It may also be appropriate for parents to seek out professional advice or a support group for help with their own feelings of frustration and helplessness. Parents usually play a part in the development of their child’s behavior, and in many instances, may have to face issues and make adjustments of their own. This is not to say that they are the cause of the eating disorder, but rather that they may have contributed to it in some way and need to acknowledge that. Parents may need to reevaluate their values, ways of communicating, family rules about food, ways of handling feelings, parenting roles, and the family’s decision-making process. Guilt, anger, frustration, denial, and cynicism are all likely sentiments. As hard as this all sounds, family therapy has proved to be one of the most successful methods of overcoming eating disorders. With better communication, increased self-knowledge and mutual acceptance of what has happened in the past, parents and children can focus on the important task of recovery in the present. What can be done to prevent eating disorders? In the past twenty years, since I wrote the first publication in print about bulimia (Hall, 1980) and began working to increase education about eating disorders, I’ve come across hundreds of books written on the subject, countless newspaper and magazine articles, television programs, movies, radio talk shows, and public lectures. Numerous eating disorders organizations and treatment facilities have come in and out of existence, there have been informative conferences and workshops, and a whole new specialty has developed for health-care professionals. My efforts and those of other writers, speakers, organizers, therapists, administrators, and educators have helped real people. Also, due to increased public awareness, individuals with eating disorders are today able to find help more readily available and know that they are not alone with their problem. Sadly, there are still millions of people who suffer with eating disorders and countless others who are preoccupied with weight and body dissatisfaction. In fact, after a brief rise and decline in the incidence of bulimia in the early ’80s, which may have been due to the early public awareness of this condition, the prevalence of this eating disorder has not diminished despite our educational efforts. It is apparent that although we have defined bulimia and developed a variety of successful treatment programs for it and other eating problems, our long term goal must be to prevent these disorders altogether. Healthy eating and the dangers of dieting must be incorporated into every elementary, junior high, and high school curriculum. We should further educate parents, prospective parents, teachers, the medical community, fitness instructors, physical educators, clergy, the media at large, and others about the symptoms, causes, and consequences of eating disorders, with early detection and intervention in mind. However, in order to be successful, prevention programs must go beyond the presentation of basic information, which has shown to be largely ineffective (Piran, 1998). Despite our best intentions, an hour lecture about bulimia, for example, may only teach listeners how to become bulimic! For prevention to truly work, the approach must be participatory, systemic, and long-term. It is ineffective to solely teach a student about the hazards of eating disorders without also educating her teachers, parents, and peers. Too frequently, a health instructor will offer information on healthy eating and the futility of dieting, only to have the student attend a next class with a teacher who is on a diet, then have lunch with friends who only eat carrots and celery, return home to a family that is weight prejudiced, and look at magazines and television commercials that advocate the false promise of thinness. To actualize prevention, the message must permeate an individual’s whole life; it must be integrated into all areas of our culture. In a perfect world, free from eating disorders, all people would appreciate that love and self-esteem are their birthright regardless of shape or weight. Families, aware of the causes and consequences of eating disorders, would be a constant source of communication and sharing. Women would be safe from victimization in their homes, in the work place, on public streets, and in the media. Inner beauty and competence would be recognized and rewarded without regards to age, color, or body shape. Food would be a symbol of life rather than a tool for abuse. In other words, people would be allowed to be themselves without conforming to tight-fitting roles based on artificial limits. There are so many different factors which contribute to an eating disorder that all contributing factors, whether they are cultural, social, biological, familial, emotional, sexual or other, must be addressed in order to achieve real prevention. This is a lofty goal that would require a revolution of contemporary thought. But I believe that every person who recovers from an eating disorder, every person who even embarks on recovery or who refuses to diet is just that—a revolutionary. And the repercussions of that person’s actions can be far-reaching. Certainly, institutional change is crucial, but even those are made up of individuals capable of transformation. Obviously, we have a long way to go, but we must each move in the right direction. Striving for far-reaching goals means that we must first face weight prejudice in our own lives and learn to embrace ourselves and others, regardless of differences. It is only within an atmosphere of mutual love and respect that we will fully realize eating disorders prevention on an individual, and ultimately a societal, level.
Additional Resources: |
No items in cart
Eating Disorders Resources
Books, DVD's,
& More |
NEWSLETTERS |
Enews |
For Parents |
Related Products |
NEDA Products |
Blogs |
Organizations |
Free Articles |
Recovery Stories |
Treatment
Therapist Directory | Treatment Facilities | Support Groups |
For Professionals
Resources | Conferences | For & About Authors |
Helpful Links
Other Websites | Gürze Affiliates | Participants Wanted |
Book Categories
Anorexia Nervosa | Bulimia | Binge Eating | Body Image | General Eating Disorders | For Parents | For Professionals | New Releases | More... |
|
Treatment Facilities Complete List |