Bulimia may arise from anorexia; half or more of bulimics have a history of self-starvation. A traumatic event, such as a severe loss or change, may trigger the bulimic cycle. So too can an episode of dieting.
Binge eating is pretty common. Between 60 and 80 percent of American women report that they binge once in a while. Another 10 to 20 percent have weekly binge episodes. With statistics like these, we have to conclude that the occasional act of eating a lot of food in a short time is actually normal. Making a diagnosis of bulimia requires much more than that the person experiences an occasional binge.
As we have seen, different events can trigger increased bingeing. There may be a change in the chemical balance in the brain. We know that such changes occur in some types of depression and lead to the symptom of increased eating.
Psychologically, someone may use bingeing to control unpleasant or overwhelming feelings. Bingeing shifts one’s mental focus. Eating a pound of cookies makes it easier to tolerate the anger one feels when denied a raise, for example. But bingeing then stirs up feelings of shame and inadequacy: “I shouldn’t have done that.” The binger thus takes the anger she feels toward her boss and redirects it toward herself. Eating also represents an act of revenge against the world; the binger knows she is doing something both forbidden and gratifying.
The intense sensory pleasure of (over)eating removes-or at least covers up-anxiety, such as dread of an upcoming school examination. Bingeing thus relieves tension in the same way as drugs or alcohol. Furthermore, bingeing produces chemical changes in the brain, changes that may have some direct anxiety-reducing effect.
Loss of control during a binge leads to self-disgust. Strangely, that self-disgust may also serve to reduce anxiety. Before the binge, the woman is haunted by the thought: “I may fail.” Afterward, though, a new thought dominates: “I have already failed.” Her burden is lifted; now she has little left to lose.
Bingeing also provides a familiar and dependable mental state, an escape from the emotional roller coaster. Many patients tell me they originally needed such an escape because of their chaotic family situation-for example, because the father came home drunk and abusive night after night. Others report that a binge provides “company” during times of painful loneliness.
Purging (vomiting, laxative abuse) or excessive exercise also has psychological meaning. Purging acts as “damage control”- a way of canceling out excessive calories. It also offers a way for the “child” part of the personality to return the good graces of the “parent” part by accepting punishment for being naughty.
Purging lets a woman think, “I can do something bad but it doesn’t really count.” In some patients, this thought comes to dominate the pattern-in other words, purging, not bingeing, becomes the goal. At first a woman may purge to “cancel out” her binge. Over time, however, she finds she must binge in order to purge. Calories are seen as “bad”; therefore, the emptiness produced by vomiting or laxative abuse is “good.” Purging restores control to a life that feels out of control.
Often a bulimic sees her “discovery” of purging as a positive thing. At first it makes her feel calmer or better able to cope with stress. She may even feel happy because she loses some weight in the early stages of her illness. Such weight loss, however, is unstable. The metabolic and nutritional chaos that comes with bulimia usually leads to more bingeing, which in turn may lead to weight gain. (Even when someone vomits immediately, the body retains as much as 25 percent of the calories contained in the meal.) Moreover, many bulimics interpret purging as “permission” to engage in more bingeing.
Bulimics keep their binge-purge habits secret because they feel ashamed. What may initially have begun as a response to upsetting feelings now produces upsetting feelings. The pattern becomes a habit. Thoughts and feelings about bingeing and purging occupy more and more of the patient’s time. In fact, she may structure her entire day around her habit. Some make an after-work ritual out of buying binge food, eating it, and purging. As with drug abuse, such devotion to ritual may increase the patient’s isolation from other people and keep her from taking part in a more normal social life. This in turn leaves her with more empty time on her hands; usually she fills that time with even more bingeing and purging. If something happens to prevent her from indulging her habit—social obligations, work pressure—she grows increasingly anxious.
In severe cases, a bulimic purges so frequently that the mere feeling of having food in her stomach produces the overwhelming desire to get rid of it. Similarly, anxiety caused by the very act of eating may be severe enough to promote purging. Frequently, the bulimic tries to distract herself as she eats by reading, watching TV, and so on. Doing so just makes it easier to eat large amounts without being aware of it.
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