BULIMIA NERVOSA

Bulimia is a condition in which the sufferer binges (eats exceptionally large amounts of food) and then purges herself by use of starvation, vomiting, laxatives, or diuretics. It is a lifestyle which completely controls the sufferer's every waking hour, an existence in which almost every day, to some extent, is spent thinking about shopping, cooking, bingeing, and finally getting rid of food.

Bulimia usually begins between the ages 15 and 20, although before this time many bulimics will have had problems with eating habits or weight, anorexia nervosa, childhood obesity, adolescent weight in the high-normal range, or lifelong fluctuations in weight. In many cases bulimia begins with the institution of a diet following a distressing event (e.g. the break-up of a romance), a challenge (e.g. making the gymnastics team), or any situation that encourages the person to think about body shape and its links with control, popularity, and achievement.

It is probably not coincidental that the peak age of the onset for bulimia, 16 to 18, is a time of transition from high school to college, from the family to independent living. Sufferers of bulimia nervosa become trapped in a cycle which reinforces their already highly developed feelings of guilt, shame, disgust, and self-hatred. They feel great guilt about their bulimia and, while they are often social people to begin with, they are forced into increasingly private lives to avoid the possibility of being found out. This shame and isolation only increase their feelings of inadequacy and unattractiveness.

Because sufferers tend generally to present a public image of self assurance, happiness, and success, bulimia nervosa is a condition which may go undetected for years. The sad fact is that sufferers are desperately unhappy, have an appallingly low self-esteem, and may be exceedingly depressed. Sufferers of bulimia nervosa are usually normal weight, unless the condition has been preceded by anorexia nervosa, and they seem to eat normally when they are with other people.

Causes

Much of what has been said about the anorexic and her family is also true of the bulimic. The bulimic is likely to be a good student or employee and desire a high level of achievement, but at the same time has many self-doubts and feels insecure about her ability to handle life's demands and difficulties. She fears she is inadequate and does not have the tools to reach the goals she has set for herself. She believes she does not measure up in looks or accomplishment to other people, and may experience problems interacting with them because of this sense of inferiority. She wants to be part of the crowd but fears she will not be accepted.

Stress, anxiety, loneliness, and depression, may cause her to eat large quantities of food as a way of releasing the tension. She cannot control her desire for food, but she can control whether it remains in her body. Some people turn to alcohol or drugs when they are under stress, upset, or depressed - bulimics turn to food.

Many bulimics fear that once they start eating, they will not be able to stop. They binge and then purge as a means of giving in to their desire for food and then controlling it.

A binge

A binge is what happens when eating becomes wholly out of control. Enormous quantities of food are consumed in a frenzy, so much so that food may be eaten uncooked or even straight from the freezer. A binge almost exclusively consists of high calorie foods. These are usually carbohydrates and fats in the form of sweets, chocolate, biscuits, bread, pastry, butter, and cheese. There are, of course, many other variations, and food may have been previously selected on a shopping expedition with the binge in mind.

Bulimics loathe the cycle of bingeing and then ridding themselves of food. The purgation, or "cleansing procedure", is frequently perceived by sufferers as a self-inflicted punishment for the gap which separates their public image from their private selves. The latter, already desolate and stricken by feelings of guilt, comes to be regarded with even greater revulsion. Many sufferers have reported that their behaviour, when bingeing, is to them like a hidden side of their personality, a demonic voice which will not release them. They are totally out of control because the "voice" controls them wholly. So powerful can be the compulsion to binge that there are times when quite literally nothing will prevent sufferers from so doing. As a result, regardless of resolution on the part of sufferers to change, the vicious circle can seem to them to be impossible to break.

If sufferers rely heavily on vomiting to rid themselves of food, then teeth are rapidly affected. The constant acidic action erodes the enamel on the teeth and extensive tooth decay soon follows. Other dangers associated with bulimia include: ulcers; stomach and bowel disorders; mouth and throat irritations; and gum disease. Loss of hair is common to bulimics, as is a general feeling of total apathy after a binge. For those using laxatives or diuretics, there may be serious, even fatal, results.

Constant purging and/or vomiting creates severe mineral imbalances in the body, as the delicate balance of many mineral salts (absolutely vital for the body to function) becomes deranged. Fatigue or complete exhaustion follow, and in the most severe cases stupor, coma, and eventually death. This is because the correct balance of mineral salts is vital for the proper functioning of organs such as the heart and kidneys.

Symptoms

The central features are:

• recurrent episodes of uncontrollable overeating
• efforts to undo the effects of binge-eating by self-induced vomiting, severe caloric restriction, excessive exercising, use of legal or illegal appetite suppressants, and/or use of laxatives or diuretics
• chronic anxiety, guilt, depression, and tension

Commonly associated characteristics are:

• drastic weight fluctuation
• impulsivity and emotional instability
• acting-out via substance abuse, theft, self-mutilation and/or promiscuity
• problems with social adjustment
• depression
• a high need to achieve in order to obtain the approval of others
• shop-lifting

Bulimics have periods of over-eating which become out of control. These may follow excessively long periods of starvation. The process of starvation leads to cravings for food, which become so strong the sufferer loses control and "binges". After a binge a bulimic may resort to laxatives or diuretics, as well as vomiting, to get rid of the effects of bingeing. Many bulimics have a previous history of anorexia nervosa and either "discover" bulimia nervosa, or turn to bulimia nervosa, believing it will solve their dilemma of wanting to eat whilst remaining thin. Initially, bulimia nervosa may seem to hold the answer for people who are dissatisfied with their lives and dislike what they are. However, the answer is superficial, and sufferers rapidly find themselves trapped in a dangerous cycle which reinforces self degradation, guilt, and shame. Although some bulimics never experience a real anorexic episode, they nevertheless share the anorexic's abnormal concern about weight and shape, control and lack of control, and fundamental need to accept their imperfections as possible strengths.

Occasionally there are bulimics whose weight swings from high to low over a period of years, a reminder that anorexia nervosa and bulimia nervosa are not mutually exclusive.

Treatment

As with anorexia nervosa, there is no one way of offering help to bulimics. What suits one woman might not suit another, and anyway not everyone has access to all forms of treatment. One of the greatest difficulties facing women wanting help at present is the sheer lack of resources available.

Bulimic women generally experience extreme ambivalence about giving up the symptom, and this is a profound problem for those offering help. In some situations when the sufferer is in a life-threatening condition, or there are other problems involved as well as bulimia, she is admitted to an in-patient hospital programme. But this is not the case for most bulimics.

Unlike anorexics, most bulimics recognise their eating disorder and desperately want help. In another sense however, the bulimic woman's ambivalence about allowing herself to take in anything good can make it difficult to receive help.

Self-help programmes or self-help groups, combined with back up counselling support or therapy, and the motivation of the bulimic herself, can prove a successful way of tackling this very difficult problem.

Neither anorexia nor bulimia can be cured overnight. Recovery is a long hard process, which often requires the bulimic to face those painful issues she has been avoiding by being bulimic. She will experience all sorts of difficult feelings (depression, anger, frustration, rage). She may also need help in re-learning about "normal" eating. The recovered bulimic should also be aware that she needs to develop ways, other than bulimia, of coping with stress.

The impact of society

Our society emphasises thinness. To be thin is thought to be healthy, attractive, and self-disciplined. To be overweight is thought to be lazy, dull, unattractive, and probably incompetent. Thinness is admired, and interpreted by many to mean the person has value for others and values herself. Fatness is frowned on, and interpreted to mean the person has little respect for herself and is not really worthy of respect from others.

Some experts see a connection between our society's ever-increasing emphasis on thinness over the last 20 or 30 years and the dramatic increase in the number of anorexics in that same period. People who are normal weight want to be thin, like the models they see daily in print and on television. People who are thin want to be thinner, like the 14 year old "sex symbol" in the films and on the magazine cover.

To some extent it is true that a person's physical fitness can be an indication of their personality, values, and interests, but when simply being thin is a determining factor in self-analysis or social success, something has gone wrong. When what a person looks like is confused with who that person is, then the values and ideals of a society are being misplaced.

Women sufferers

Some experts on eating disorders think there are social causes for a disproportionate number of sufferers being women. Anorexics tend to be overly concerned with the opinions other people have about them, such as whether they think she is attractive, well dressed, informed, intelligent, and successful. Our society teaches us that we are not "good" people unless someone else says we are; women, in particular, feel this way. All of us are taught that we are not the best judge of our own value, it is other people who determine our worth.

Unfortunately, if your self-worth is based solely on the opinions of others, then you are always seeking their praise, and never getting enough. You are forced into doing things you do not like to do, or that do not make you happy, as that is the only way you can win or maintain their favour and commendation (or, you ignore or mistreat those around you out of the fear of being judged and the desire to maintain distance so that judgement cannot take place).

Women are told that they must be emotionally sensitive and supportive of others. Men are told that they must be the providers of material benefits. Women are brought up believing they will be accepted by men on the basis of their looks and their personalities. Men are brought up believing they will be accepted by women on the basis of their achievements and personalities. Men often become workaholics, women have eating disorders. They are both extremes of very normal desires, desires our society values highly.

Conflicting messages about food and eating put an additional strain on women who, because of their nurturing role in society, have to think about food a great deal. On the one hand they are told they have a right to derive pleasure for themselves and to meet their needs through food, and on the other they are being warned continually to guard against food' s potential for making them unhappy, unfit, and unwanted.

Exciting, new, and miraculous diets, promising weight loss with minimum effort or discomfort are featured every week in various women's magazines, followed by pictures and recipes for delightful, easy to bake treats. As a result, many women worry continually about what they can and cannot eat, and it is not surprising that so many turn to dieting.

Eating disorders are more likely to occur during periods in a person's life that require adjustments or acknowledgement of significant changes. The beginning of menstruation signals the beginning of the transformation from childhood to womanhood. The prospect of leaving home or school at 17 or 18 signals the change from dependence to independence. These are the two most likely times that the illness might develop, though other pressures (including a divorce, the death of a loved one, or any destabilising event) may incline a person to this illness at any age.

Anorexia usually occurs in women after the beginning of menstruation. Since menstruation requires an emotional as well as physical adjustment, it is not surprising that its onset can be a difficult stage in a woman's life. She may feel she is not in control of her body, or that her body is imposing its will on her. This seeming loss of self-control and self-direction can be very disconcerting. Some anorexics fear their femininity and doubt their ability to be adult women.

Anorexia not only removes menstruation, it removes the other physical symbols of womanhood (hips, buttocks, breasts). Some anorexics do not like being female. They believe that our society gives males more opportunities to feel worthwhile and valuable. Being female is looked on as an unfair burden, which is only complicated by a body that menstruates and seems unmanageable. To overcome these "disadvantages", anorexics may attempt to excel in academic work or athletics as a way of covering up the fact (from themselves and others) that they do not feel very good about themselves. When these successes are not enough, the decision not to eat becomes, in the anorexic's mind, the decision to live a life that is totally self-directed and self-sufficient.

In modem society women often find themselves in a dilemma. On the one hand they may feel committed to traditional feminine values, and on the other to desire vocational career success and achievement. Trying to reconcile these opposing ideologies places great strain on women, leading to the sort of inner turmoil and confusion often expressed by bulimic women.

Pre-menstrual tension can also be a trigger for bulimic binges. Hormonal changes during the pre-menstrual phase cause the amount of sugar in the blood to fall to abnormally low levels. Women who are particularly sensitive to these changes may experience cravings for sweet, high-calorie foods a few days before a period. In addition, the body's own protective mechanism for correcting the blood sugar levels may predispose individuals to binge-eating.

Adrenalin is the hormone which is rapidly secreted to release sugar from the body's stores of glucose in order to restore the blood sugar to its normal levels. As it is also responsible for the "fight and flight" reaction in humans, it may trigger off feelings of panic, tension, and irritability. If this happens, eating may be a way of providing physiological as well as psychological relief, by helping to temporarily blot out these distressing mental symptoms. Pre-menstrual physical discomfort in the form of headaches and a general feeling of bloatedness may also make some people seek solace by eating sweet carbohydrate-rich foods.

Male sufferers

The misconception that anorexia and bulimia nervosa are disorders affecting exclusively young women must be almost as widespread as the view of anorexia as a "slimming disease". Despite greater media interest in recent years and public awareness of eating disorders as a serious health problem, a considerable number of male sufferers of the estimated 5 to 10 per cent of all cases remain unknown to the medical profession, self-help groups, and other support structures. A reluctance on the sufferers' part to seek help, together with a strong denial that anything might be wrong, could excuse some professionals who show a hint of surprise when it is suggested that male anorexics do actually exist.

Even boys as young as eleven or twelve can get it, though it is an illness to which women are very much more vulnerable.

Marilyn Lawrence of the Women's Therapy Centre puts it well when she says: "Anorexia is a problem crucially related to women's psychology, which in turn is related to women's way of being in the world. The fact that it sometimes affects men only indicates that the psychology of women and men is not wholly distinct. Issues problematic for most women can also be so for some men".

Recent research has shown that male and female sufferers have similar personalities and symptoms except that men seem more achievement-oriented and show more sexual anxiety. In general, they appear also to be excessively athletic and over-value physical fitness, body appearance, and muscle strength.

As with female sufferers, the first step toward recovery is to recognise the problem and realise one has to start where one is. During the course of therapy (used in the general sense), there has to be a genuine desire to experience perhaps profound change in lifestyle and circumstance, of which attitude to food and weight is but one, and the need to have realistic expectations of the pace ground can be covered. The work of rebuilding can be lengthy as well as an emotionally-charged process.