Yeah, but what about bulimia?

There is a well-justified complaint out there that I and others pay more attention to anorexia than we do bulimia. For myself, this is influenced by my own experience: my daughter had a mostly restrictive eating disorder and I can't speak from experience in the same way. I don't like to presume that I know what a family experiences around it.

But, there are other reasons. Anorexia is better studied, as the clinical presentation is more uniform. Anorexics are forced into care when symptoms are extreme, while bulimia can be hidden even in life-threatening severity. Bulimia is often experienced with more shame, and family members often buy into or share that reaction. People are less sympathetic to bulimia and don't imbue it with the same romantic analogies and narratives.

We don't seem to be very clear about the differences and similarities between the conditions, either. There is a crossover population, so we know they are related, but the risk factors and pre-existing personality traits differ. Treatment seems to be different, too: there are drug approaches for bulimia, and different psychological therapies.

We need to understand bulimia better. This is interesting: High-fat, High-sugar Foods Alter Brain Receptors


  1. Alas, also looking through the lens of AN:

    Thanks Laura. I find it interesting that when my AN d. went through the "binge phase" that some people experience during recovery, what she wanted was simple carbs like boxed cereal and sweet baked goods. Her particular favorite was bakery icing which is essentially shortening and powdered sugar. My d. seemed to have some combo of genuine extra hunger coupled with a strong craving for these type foods.

    By sheer dumb luck and gut feeling, we fought our own way through this phase by increasing structure, allowing the craved foods, but balancing them with protein and, in some cases, extra fat. We also had several months of refeeding and monitoring behind us, so this approach wasn't new to us, really. She had a history of purging with anorexia, and I was very afraid of allowing the b/p cycle a chance to become established. This seemed to work. After three weeks or a month this discrete phase passed, though for some time after she was prone to stay on the carby side of the fence in her general choices if not prompted to include adequate protein.

    I've noted since then that the Kartini clinic's meal plan leaves off frank sweets for the first year. I suspect they do that, at least in part, to dodge this phase and it's potentially viscious cycle. We happened on a method that accomplished the same thing. The findings in the article you linked helps me make sense of this.

    I think that anorexia and bulimia are more than just related, I think we'll ultimately find that they represent different phases in the same process. And like any disease, some people experience some symptoms more than others. You mentioned that pre-existing personality and risk-factors are different, and I understand that, but I also now see the "ED personalities" as early mild symptoms--expressions of the internal chemistry. But there will always be differences in environment that impact symptom expression and the individual's response to it. We now know that even identical twins each experience slightly different environments in the womb for a variety of reasons. I'll also say that when my d. moved from frank malnutrition into "better but not yet well", her outward personality was less AN-perfectionistic (to over-generalize) and more BN-like-
    impulsive (ditto). Here, at least, that coincided with the extra hunger and craving phase.

    I don't think our individual brain chemistry is necessarily our fate or that we aren't able to steer ourselves most of the time while healthy and reasonably balanced. I do, however, think that our biochemistry determines our own personal cruise control settings--with the usual variations.


  2. And can I just add from experience as a person who suffers from bulimia how AWFUL it is to be in treatment groups with anorexics? God, the jealousy. It's torture. And I know it is in part because of lack of research on how to treat bulimia, they group us all together. Not good.

  3. So true -- as the mother of a daughter who is in (tenuous) recovery from bulimia, it is frustrating and terrifying to find so little consensus on treatment. Medication in the form of an SSRI is the only part of the treatment protocol that everyone seems to agree on. The rest is a mixture of advice and therapy to regulate eating ("but don't be the food police, Mom"), distract her from bulimic behaviors by encouraging engagement in age-appropriate school, work & social activities ("but don't be controlling, Mom") and allowing for maturation and individuation to take place ("be supportive but let her separate, Mom".) Add to that the fact that many bulimics are close to or have already reached majority age by the time the disorder is admitted/discovered. It is heartbreaking and terrifying and confusing. I am in awe of the parents on ATDT who are heroically re-feeding their children; but I admit to sometimes wishing that I had such a concrete task to do to help my daughter.

  4. Interesting post but...

    As someone who developed bulimia at 15 and did not have an interruption in the binge-purge cycle until 25 when I entered treatment and finally put the disorder to rest a few years after that I have to disagree with a few things that were said.

    I do believe that someone with bulimia can recover in an environment with people with anorexia. Of course at the time I felt some jealousy and envy. At the same time, I was given support by the very same people I was envious of and learned that the problem was that we let emotions dictate the pattern of our eating.

    It was me who thought I was unlovable by anyone. When I heard people with anorexia make the same comments about themselves that I did about me, and learned that they did not judge me. I felt more judged outside the walls of "treatment." We bonded in our mission of healthy eating. We learned that we all had perfectionistic patterns of thinking and were high achievers.

    Last point, it seemed as if anorexia was being painted as this clear cut known entity and bulimia was a wild card, when in fact we are lacking data on both disorders. What also happens when we don't give equal attention is that we set up "hierarchies" where people including sufferers, families, physicians and perhaps even insurance providers see that the pecking order of things are anorexia then bulimia then binge eating disorder.

    Best to you.

  5. I definitely have felt (and heard other people express) the "hierarchy" of eating disorders.

    We certainly glamorize stick thin women in our culture, and for some reason it's way more socially acceptable to be seen as that thin girl (or woman) than the maybe slightly overweight one who we know eats an entire carton of ice cream and sticks her finger down her throat.

    As a recovered bulimic, I remember feeling more shame during my bulimic phases contrasted with the feeling of superiority and the high of "I don't even need food. Look at you silly people shoveling it in," during my restricting cycles.

    Sick, right? I don't think this concept is rare, even if it may not be as extreme in other people.

    As for treatment of A and B together? Well, anorexic girls can be maddening to binge eaters and bulimics-- jealousy at their restraint tinged with pity. And for anorexics, looking at a bulimic is like seeing your worst fears embodied: complete lack of control and actual experience of all of life.

    Relationships between the two can be instructive, though perhaps later on in the path of recovery.

    As for the connection between brain and nutrition, check out "Gut-Psychology Syndrome," the book by Natasha Campbell-McBride, a British pediatrician whose research implicates digestive disbyosis in most mental illness including bipolar, schizophrenia, even autism and ADD, as well as eating disorders and general depression.

  6. Anorexia may win more cultural approval than bulimia but it is not better studied. Sensational popular media coverage of adolescent AN might skew perceptions that the disorder gets more than its fair share of the pie, but BN studies outnumber AN. There also seems to be a misperception that more attention is given to teens with eating disorders than adults. But there are more studies of adults than adolescents.

    Management of Eating Disorders from the Agency for Healthcare Research and Quality U.S. Department of Health and Human Services summarizes the available research.

    It's unfortunate for a few reasons:

    1. It's difficult to do good research on adult AN. Drop out rates are so high that it's hard to draw conclusions from outcome.

    2. AN is usually an early adolescent onset disorder. A research focus on effective treatment near age of onset has potential to save years of suffering.

    3. Much of the attention given to AN in the media is useless, not any sort of "advantage" for people with the disorder.

    For Anon #2. I think there is a consensus that cognitive behavioral therapy can be useful in BN. Christopher Fairburn's Overcoming Binge Eating is a good resource (In spite of the name, it does address bulimia.) This self-help website has a CBT-type approach too:

  7. I find this all very interesting ... and at least in my case, AN and BN are very much linked. I started out as a bulimic at 14, and the shame and secrecy was really overwhelming. I think it true that BN encompasses a lot more shame ...
    anyway - when I first entered into treatment and I began to slowly stop my purging behaviors, I started restricting. It wasn't entirely unhealthy at first, but it became pattern and habit ... I was in OP treatment, and when my treatment team realized what was going on, I technically "qualified" as an anorexic. I met all the criteria for AN, but not for BN ...
    I still don't know how to classify myself (not that it matters), but I do not think they are completely separated. At least they have not been in my case ...

  8. I started anorexic, and when I was finally diagnosed was diagnosed as an anorexic with highly bulimic tendencies...

    uring the patches of my life where I wouldn't eat, I was living a minimalistic life... I needed a lot of things that I wasn't getting... I was deprived of a lot of things... some self-deprived... I wasn't very sexual at all... I was isolated..

    During the patches where I would binge and purge... or just purge... I was living a life of excess... I had excess money, excess friends, excess men... excess everything...

    I don't believe the lifestyle morphed because of the needs/wants/ed behaviors at the time either, but that the behaviors were symptomatic of my lifestyle...

    I say that based on myself
    No doubt.

    It was in college that I transitioned from one set of ed behaviors to the other.

    The moment I got to college my life became so full of stuff it was insane... for the first bit I clung to my anorexic behaviors, then after awhile was a full fledged bulimic... later when I went home I morphed back (though not completely)

  9. It seems to me that as parents and family members we have a role to play AFTER weight restoration that is just as important as the one during: structure.

    I believe we can continue to provide balanced and thoughtful meals and snacks FOREVER, continue to eat as a family, continue our loving involvement with loved ones in our homes. I believe our role in preventing a transition to binging (and/or purging) is an important stage in recovery. We can do this with love, with authority, and with confidence.

    Getting someone to healthy weight is only the first step. If we go back to eating from the fridge on the run with a different menu for every family member I think we do our kids a disservice.

  10. I think one of the big differences between AN and BN is in my experience those suffering from bulimia have a greater awareness that their behavior is self-destructive. That's likely why the recovery rate is higher than for anorexics. Binging and purging is scary in a way that reducing one's food intake isn't.


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