“I feel so full, I should make myself throw up.” Hearing this phrase as a joke might draw some laughs, but the truth is that having bulimia is not a joke at all. This is part 3 of my series called “What is an eating disorder?” and I’m here today to take you through the ins and outs of this illness called bulimia.
Binge, purge, repeat — the vicious cycle
Bulimia is characterized by two things: episodes of binge eating followed by compensatory behaviors. According to the DSM-V, here’s what those mean.
- Bingeing: Eating, in a discrete period of time, an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances; characterized by a sense of lack of control over eating during the episode.
- Compensatory behaviors: Recurrent inappropriate behavior in order to prevent weight gain, such as self-induced vomiting (purging), misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.
These behaviors also have to be happening at least 1x/week for 3 months to qualify for the diagnosis. Additionally, the diagnosis includes a clause for body image — “Self-evaluation is unduly influenced by body shape and weight.”
There are tell-tale red flags that can give you a pretty good idea that something is up, such as:
- Disappearing after eating, often to the bathroom
- Being overly concerned with weight loss, dieting, and controlling food
- Evidence of bingeing — i.e. disappearance of large amounts of food, lots of empty wrappers or containers
- Evidence of purging — i.e. signs/smells of vomiting, packages of laxatives or diuretics
- Cutting out foods or food groups — i.e. going vegan, no sugar, etc
- Drinking excessive amounts of water
- Maintains rigid exercise regimen despite sickness or injury
- Unusual swelling of cheeks or jaw
- Discolored/stained teeth
- Calluses on backs of hands from self-induced vomiting
- Extreme mood swings
You’ll notice that significant weight loss/low body weight isn’t part of the diagnosis for bulimia; this is the main way bulimia is different from anorexia. However, the possible physical complications are not all that different:
- Stomach cramps, constipation, acid reflux
- Dizziness and fainting
- Cold intolerance
- Hair loss
- Dry skin, brittle nails
- Menstrual irregularities for females
- Impaired immune function
- Noticeable fluctuations in weight, both up and down
- Slowing of the heart rate (can lead to cardiac arrest)
- Severe electrolyte abnormalities (can also lead to cardiac arrest, often unexpectedly)
Myth #1: Bulimia is only about making yourself throw up. Although this is a common presentation, other means such as excessive exercise and food restriction can be used to compensate for binge episodes.
Myth #2: Purging actually helps someone lose weight. Even when someone does vomit, a good portion of food eaten is still absorbed by the body. Using laxatives and diuretics may temporarily reduce someone’s weight due to water loss, but these effects are temporary. Due to this, bulimia may not result in significant weight loss.
Myth #3: Only females struggle with bulimia. Although eating disorder treatment centers in general tend to have more females, this doesn’t mean that males aren’t susceptible. Males may be better at hiding their disorder, especially if they are using exercise as a form of purging.
Myth #4: Bulimia is not that dangerous. The kicker with self-induced vomiting as well as laxative/diuretic misuse is that both can put the body in an ultra-dehydrated state which could not be achieved from simple water deprivation and is extremely dangerous. Cardiac arrest can quickly occur if electrolyte imbalances are significant enough.
Myth #5: People with anorexia do not binge and purge. Actually, there is a subtype of anorexia called binge/purge — the only defining difference between anorexia and bulimia is the significant weight loss seen in anorexia. Interesting, huh?
How bulimia helps people
For anyone who doesn’t have this disorder, the thought of making yourself throw up on a regular basis might be unfathomable. But it is helpful to understand why the act of purging is the cornerstone of this disease.
For people with bulimia, purging is a means of release — both physical and emotional. They feel better because the uncomfortable fullness of eating too much food is gone, and often they will describe a sense of calm after purging. It actually does help to reduce their anxiety, and this is usually why they do it.
Of course, purging (in whatever form) is really hard on the body and not a good way of coping with feelings long-term. But we can probably all think of a time when we had overwhelming emotions and just had to do something to let it out. Multiply that by 100 and you might get an idea of what your friend is experiencing. With that in mind, you can step forward to offer support.
First steps toward recovery
The very first thing we work on when moving towards recovery with people with bulimia is to stop purging behaviors immediately. Of course, it is not so easy as to be done with a snap of the fingers, but beginning to learn alternative ways to cope with overwhelming feelings will help provide another way out.
The next thing we work on is making sure there is no restriction going on. Restriction fuels bingeing, which fuels purging, so we make sure that these people are getting regular and adequate food intake.
This process takes a lot of patience as there is a lot of un-learning going on, but it’s really neat to see the grace and strength people take on as they learn there is another way out.
One final note: There are diagnostic criteria that help us understand eating disorders. However, a diagnosis can never fully explain a human being, nor does it define them. For this reason, we say “person with bulimia” rather than “bulimic.” If you have or had the diagnosis of bulimia, and you feel this article doesn’t fully explain you, you will be correct. My intention is not to detail the beautiful complexities of one human being, but to give a simple framework to help others better understand in order to empathize.