Bulimia

I have been trying to write a post summarizing my thought on bulimia since I started this blog. Suffice it to say, coherent and concise are not the words I would use to describe my attempt thus far. So I am going to try again and post whatever comes out. My apologies if this dissolves into epic rant territory.

*I should note that I am not addressing common misconceptions about bulimia or eating disorders in general (eg they stem from controlling mothers, etc). This post is really about the misconceptions I still see within the well educated community.

1. Bulimia is less serious than anorexia.

I’ve heard (read) this statement and variation on the theme from far too many clinicians to count, including some who I greatly respect. I assume that what they mean is that bulimia has a lower mortality rate than anorexia. Putting aside the fact that I don’t think we have very good stats on  mortality rates for eating disorders, I wasn’t aware that mortality rates were the be all end all definition of severity in mental illness. What about the people who don’t die but who suffer for decades in the hell that is life with an ED?

But lets say for arguments sake that anorexia is more serious than bulimia, however you want to define severity. Does telling parents and sufferers that do any good? I think not. I think it actually has the potential to do great harm. If a parent find out their child is bulimic, looks at a website/reads a book/talks to a clinician, and one of the first things they hear is “at least he/she is not anorexic” (or some comment to that effect), is that parent better educated about about the illness? No. Are they more likely to aggressively pursue treatment for their child? No. What that parent needed to hear/read is that bulimia is serious, that people do die from it, that they need to get their child into treatment. And of course that they did not cause it and their child did not choose it.

2. Bulimia is culture-bound while anorexia is a biological illness.

This bothers me for a bunch of reasons. First off, I’m not sure we have conclusive evidence that bulimia is only found in western cultures/first world countries. Maybe researchers have not found instances of bulimia in other cultures because bulimia is so much easier for the sufferer to hide. The physical side effects of bulimia are not usually visible (ie severe weigh loss) like they are with anorexia. And bulimics are not likely to voluntarily identify themselves since they usually feel a huge amount of shame about their behaviors.

Secondly people tend to use the phrase “culture-bound” to mean “a reaction to a culture that overvalues thinness”. Just as anorexia is not “about” being thin, neither is bulimia. Anorexia is not a diet gone too far and bulimia is not someone wanting to eat whatever they want and not gain weight. If bulimia is in fact culture-bound, I think it is more likely that that has to do with the amounts and types of foods that are readily available in different cultures.

3. Refeeding is for anorexia. Bulimics are already at normal or above normal weights.

Laura blogged about this here.

What the fuck is a “normal” weight? Its true that bulimics are not usually visibly underweight. But I would advise anyone treating a bulimic patient to plot their growth chart the same way you should to determine the target weight of an anorexic. Often bulimics are under their own individual ideal weight range. If that is the case then weight gain is just as necessary as it is for an anorexic.

Refeeding is not just about weight gain. It is about restoring a nutritional balance and normalizing eating patterns. Even is the bulimic patient is not underweight (on the charts or for their individual body) I guarantee you that they are not eating a balanced, sufficient diet outside of their binge/purge episodes. Restriction and poor nutrition keep them trapped in the binge/purge cycle. They need 3 meals and 3 snacks with sufficient calories and high percentages of proteins and fats. They probably need a parents (or someone else) to select their foods, determine portions, and supervise eating for quite a while before they will be able to do it on their own. And of course they need to be monitored for purging (not just for an hour either as bulimics digestive systems kind of shut down allowing them to purge long after eating). In fact they probably need to be monitored just about all the damn time. It will take a significant amount of time of eating proper amounts and nutrition before the urge to binge will subside.

4. Bulimics are ashamed of their illness and want to stop binging and purging and will cooperate with FBT style interventions.

So many things here that drive me crazy!

Are bulimics ashamed of binging and purging? Usually, yes. God knows I was. But when exactly was the last time shame was a good basis for open communication and cooperation? I would hazard a guess and say never. Is someone who is deeply, deeply ashamed of binging and purging really going to keep a detailed record of their behaviors and sit down with parents and/or treatment providers to discuss it which is what Locke and Legrang suggest in their manual? [On a side not, I also think that constantly noting how ashamed bulimics feel of their behavior in all the literature just serves to reinforce for the patient that their behavior is in fact shameful.]

Secondly, people misguidedly equate feeling ashamed of their behaviors with actively wanting to stop the behaviors. In my case at least, I was definitely ashamed and disgusted with myself for binging and purging but that in no way translated into wanting to stop. I told my friends and treatment providers that I wanted to stop because admitting that I in anyway even remotely “enjoyed” binging and purging added a whole other level of humiliation. I mean who likes eating until their stomach is so distended that they can’t breathe and then vomiting it all back up? Doing it meant I was messed up but liking it probably meant that I was beyond redemption. So I told everyone I wanted to stop and played along with writing out plans to prevent behaviors and making listing of coping strategies to use when I wanted to binge. But the whole time I was just counting the minutes until I could leave and go binge and purge.

I put ‘enjoy’ in quotes above because its not exactly that I derived pleasure from binging and purging as it is that binging and purging was the only thing that afforded me any relief from the crippling anxiety and sheer panic that I felt the rest of the time. And that’s why I think expecting bulimic patients to be compliant with interventions that prevent them from binging and purging is not only unrealistic but also downright cruel. I cannot accurately describe what “needing” to binge/purge felt like but it was pretty fucking horrendous and god help you if you were trying to stand in my way. We don’t expect anorexic patients to be compliant because we understand the amount of anxiety that eating provokes. Well for bulimics being required to eat normal amounts and not purge provokes that same level of intense anxiety.

Yes, some bulimics are going to be cooperative and compliant with treatment. But some anorexics are too. Presenting that as the norm is not only inaccurate but I think its downright harmful. If parents start the process of refeeding/nutritional restoration/symptom interruption expecting compliance they are much less likely to be successful.

Okay I think I should wrap this up although there is quite a bit more I could say on the topic. I hope I don’t come across as claiming to know more than all the experts. Its just that what the experts say does not mesh with my experience of bulimia at all and I have to assume that my experience was not all that unique.