Bulimia | Introduction
In recent years the incidence of bulimia in the United States has increased: The American Psychiatric Association estimates that today 1.1 to 4.2 percent of females will have bulimia in their lifetime. Many health professionals have expressed concern that bulimia, together with anorexia, binge eating, and other eating disorders may soon reach epidemic proportions. The Washington-based National Eating Disorders Association, which claims to be the largest advocacy and prevention organization in the world, estimates that 5 to 10 million girls and women and 1 million boys and men are battling some form of eating disorder in the United States.
Of those suffering from bulimia in the country, 90 to 95 percent are female. Most troubled are college-age women, teens, middle-aged women, and more recently, children. Among men, the most vulnerable are athletes, fitness enthusiasts, and those who have experienced various kinds of abuse, causing them to succumb to anxiety and, oftentimes, low self-esteem.
The fourth edition of the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, published in 1994, defines bulimia as an eating disorder that involves episodes of binge eating and purging and lack of control over eating. To avoid gaining weight from huge food intakes, a bulimic person engages in self-induced vomiting and often misuses laxatives, diuretics, enemas, or other medications. He or she may also engage in fasting and compulsive exercise. The binge eating and the compensatory behavior occur at least twice a week for three months. Bulimics generally have normal body weights, but they are never satisfied with them. Having an ideal weight in mind, their overriding goal is to become thinner.
Bulimics usually binge on high-calorie junk foods like fast food, ice cream, french fries, sweets, and cookies, with calorie intake per binge running from one thousand to twenty thousand—way over the standard. One school of thought suggests that bulimia occurs more in developed countries because of higher intakes of processed carbohydrates. In contrast, developing and poorer countries mostly rely on whole grains and vegetables, which are always more healthful.
Most of a bulimic’s routine is spent in finding the time and place to indulge in his or her uncontrollable habit. The person caught up in the disorder follows the cycle of bingeing and purging at home, at work, in a college dorm, at parties, during the day, and at night. The bulimic often feels shame, loneliness, isolation, guilt, and terror but finds it hard to break the cycle of eating and disgorging, eating and fasting, eating and laxatives, eating and compulsive exercise. The habit can even lead the individual to periodic lying and, in many cases, stealing; after all, mounds of food could cost a lot of money. Avoiding social activities, the bulimic rarely has meaningful friendships and intimate relationships.
The initial signs and symptoms of bulimia are sometimes misleading: vomiting, diarrhea, scarring of the fingers and hands, constipation, and menstrual irregularities. Often, this delays proper detection, which brings further harm to a suffering individual. Many health providers also note that many sufferers tend to deny the symptoms of the disorder. Repeated vomiting could lead to erosion of tooth enamel, dehydration, stomach ulcers, and eventually an imbalance in electrolytes, which could be lifethreatening. Serious consequences include kidney damage, ruptured stomach or esophagus, irregular heartbeat, and seizures. Finally, bulimia can cause death from a damaged heart or loss of body chemicals. Author Debbie Stanley observes in her book Understanding Bulimia Nervosa that together with other eating disorders, bulimia and its twin, anorexia (which involves avoiding food to the point of starvation), account for more deaths than any other psychiatric condition.
Indeed, while its manifestations are physical, bulimia—again, like anorexia—is a mental disorder. A bulimic person suffers from abnormally low self-esteem, a desire for perfection, heightened loneliness and isolation, and an obsession with food. He or she is also prone to depression and anxiety. A bulimic shares several similarities with an anorexic: an obsession with diet, a distorted body image, a lack of self-esteem, and a sense of inadequacy. Both are likely young women who come from middle-class families with dominant mothers and uninvolved fathers. Hungry for approval, both bulimics and anorexics tend to become “dutiful daughters” and comply with family rules. Yet whereas an anorexic avoids food and is always starved, a bulimic is always on a cycle of bingeing and purging. A bulimic is also capable of a social and work life while an anorexic often is not.
The causes of bulimia in women—like anorexia and other eating disorders for that matter—have been initially attributed to a culture that stresses and rewards female thinness as well as to the mass media, which promote irrational standards of beauty. The Harvard Eating Disorders Center (HEDC) cites a study of children aged eight to ten wherein half of the girls and one-third of the boys reported being dissatisfied with their body size. The most dissatisfied among the girls wanted to be thinner, and the dissatisfied boys wanted to be heavier. Another study showed that expectations regarding thinness among young girls are evident as early as six and seven years old. In terms of actual dieting, HEDC cites a study of 457 fourth graders in which 40 percent reported dieting “very often” or “sometimes.” Another study on dieting indicated that 31 to 46 percent of nine-year-olds and 46 to 81 percent of ten-year-olds reported dieting, fear of fatness, and binge eating.
It is disturbing that eating disorders may soon be afflicting more and more children and teens, and recent research on the nature of eating disorders does not offer relief either. Most studies point out that eating disorders are much more complex than a simple obsession with weight expressed in the misuse of food. Often the disorder is a mask for—if not a response to—deeper, far more serious psychological pathologies. Various research surveys have found sufferers to be dealing painfully with issues of self-worth, dysfunctional family relationships, unresolved conflicts, and traumatic childhood experiences. In many ways, bulimia is a coping mechanism employed during times of duress. Jennifer Redford, writing in Physician Assistant in March 2001, cites numerous studies that link bulimia and sexual abuse in childhood.
Initially, studies have pointed to the most vulnerable group as young white middle-class women who are inclined toward traditional values such as successful careers and marriage. Marlene Boskind-White, a professional counselor who has helped thousands of bulimia sufferers on college campuses, observes that bulimic women are often attractive, bright, talented, and have potential for creative activity such as writing, dancing, painting, and acting. Also, they are able to pursue careers and often become overachievers. In Bulimia Anorexia: The Binge/Purge Cycle and Self-Starvation, Boskind-White and coauthor William C. White Jr. explain the sufferer’s drive as a compensation for her shortcomings. Based on their practice, the two authors note that a bulimic’s pursuit of success is not for the joy of achievement but for the expected rewards, particularly from men.
More recent research shows that sufferers are no longer confined to the white middle-class female population. Growing evidence suggests that bulimia among non-Caucasians—including Native Americans, Hispanics, African Americans, and Asians—is on the rise. Kathryn Zerbe, a psychoanalyst and a former faculty member at the Karl Menninger School of Psychiatry, attributes this to the aforementioned groups’ improved socioeconomic conditions, exposure to media stereotypes, and, more importantly, their vulnerability to destabilizing life change such as immigration, acculturation, and westernization.
Merry N. Miller and Andres J. Pumariega, both professors of the department of psychiatry at the James H. Quillen College of Medicine, Eastern Tennessee State University, echo the link between bulimia and sociocultural change. Writing in Psychiatry in the summer of 2001, they note that eating disorders such as bulimia occur when traditional ideas of physical attractiveness are threatened and supplanted with something else. The two authors also identify the changing role of women as a major factor. Supporting this contention, Karin Kratina, a dietician and consultant for Renfrew Center, which treats eating disorders, is quoted by Jim McCaffree in the Journal of the American Dietetic Association as saying, “Cultures that experience oppression of women in conjunction with increased expectations of women tend to have more incidences of eating disorders.”
Becky Thompson, a sociologist and author, refutes the common contention that eating disorders are about women’s vanity. Through in-depth interviews with a group composed of African Americans, Hispanics, and lesbians, she found that women resorted to eating disorders as a way of dealing with poverty, racism, alienation, sexism, and sexual abuse. Regarding the alienation that some groups may be experiencing, the HDEC cites a study involving 135 males with eating disorders that indicated that 42 percent of those diagnosed as bulimic were either gay or bisexual.
Another group that has been succumbing recently to eating disorders in bigger numbers is immigrant girls and women. Quoted in the March 6, 2000, issue of the Washington Post, Catherine Steiner-Adair of Harvard University’s Eating Disorder Center says that one-fourth of her clients have been American teenagers whose parents were born in Latin America, Africa, the Middle East, and Asia. In their desire to blend into their communities, these women may be trying too hard to fit into the American ideal of thin- ness. To respond to the phenomenon, youth centers in places like Los Angeles and New York have started support groups for immigrants.
Acknowledging that eating disorders are, for the most part, a social problem, scholars like Miller and Pumariega propose that care providers should offer more carefully crafted programs of prevention and treatment. They stress that strategies have to strengthen personal identity, reach out more strongly to women of color and other disenfranchised groups, promote rational ideals of beauty, and reinforce adaptive practices. A meaningful program would also require clinicians to work across cultural differences and include the influence of traditional beliefs in their interventions.
While modes of treatment continue to evolve with the recognition that eating disorders are both medical and psychiatric concerns, researchers continue to unravel new information. A recent study in Britain found that bulimia springs partly from a deficiency in tryptophan, a chemical in the brain. Tryptophan, an amino acid that occurs naturally in many foods, is used by the body to make serotonin, which in turn regulates mood and appetite. In a 1999 New York Times article, lead researcher Katharine A. Smith of Oxford University said that the finding suggests that “lowered brain serotonin function can trigger some of the clinical features of bulimia nervosa in individuals vulnerable to the disorder.” (In the same manner, anorexia nervosa is being studied on its possible link to a gene. The Eating Disorder Program of the University of Pittsburgh Medical Center Health Systems is participating in an international study that seeks to determine whether a gene or a set of genes might predispose individuals to develop anorexia nervosa.)
As eating disorders continue to spark more attention, as new research sheds new light on their nature, and as professionals continue to search for effective strategies for prevention, advocacy, and treatment, a better understanding of the issue may emerge, resulting in positive responses from various sectors. When this happens, more suffering individuals may come forward and seek help. Hopefully, millions of suffering women, children, and men—not to mention their families and communities—will be able to find solace and relief.
