For our second week of eating disorders (prompted by my current short-story) I’m tackling bulimia nervosa. Of the two eating disorders we’re discussing, bulimia is actually more common than anorexia, and there is certainly some overlap between the two (which is why they can get confused). Seeing as both of these diagnoses come under the banner of ‘eating disorders’, they are characterized by a persistent disturbance of eating that results in the altered consumption of food, so much so that it significantly impairs physical health or psychosocial functioning. Most people know that bulimia is defined by bingeing and purging, but if you’re going to include a character experiencing bulimia, then understanding the behaviours and nuances of this disorder is important. Which is exactly what this post is for!
In essence, there are three essential features of bulimia nervosa: recurrent episodes of binge eating, recurrent inappropriate compensatory behaviours to prevent weight gain, and self-evaluation that is powerfully defined by body shape and weight. Let’s look at each of these and then understand the differences between bulimia and anorexia.
An episode of binge eating is defined as eating, in a discrete period of time, an amount of food that is definitely larger than most individuals would eat in a similar period of time. It’s valuable to note that a single episode of binge eating need not be restricted to one setting. For example, your character may begin a binge in a restaurant and then continue to eat on returning home. The binge eating often continues until the individual is uncomfortably, or even painfully, full.
Useful to note for your plotting, is that the most common antecedent of binge eating is negative affect. Triggers include interpersonal stressors, dietary restraint, boredom and negative feelings related to body weight, body shape, and food (which sadly creates a vicious cycle). Binge eating can minimize or mitigate the emotions that precipitated the episode in the short-term (it acts as a form of mental anaesthesia), but negative self-evaluation frequently follows.
This excessive food consumption is accompanied by a sense of lack of control. Your character is likely to feel an inability to stop eating once they’ve started. Some individuals describe a dissociative quality during, or following, the binge-eating episodes (which can become reinforcing). Many individuals minimise the severity of their behaviours.
The type of food consumed during binges varies, and appears to be characterized more by an abnormality in the amount of food consumed than by a craving for a specific nutrient. However, during binges, individuals tend to eat foods they would otherwise avoid.
A Sense of Shame
Individuals with bulimia nervosa are typically ashamed of their eating problems and attempt to conceal their symptoms. Binge eating usually occurs in secrecy or as inconspicuously as possible. Your character may turn off their phone, cancel appointments or time their bingeing and purging to avoid getting caught. Unlike anorexia, which is associated with a sense of self-control, many individuals feel out of control, and that they have poor willpower. Your character may feel others would perceive them as being gross and disgusting, or that there was something mentally wrong with them. It is this sense of shame that can be a significant barrier to help seeking (many individuals live with bulimia for years before accessing help).
Another essential feature of bulimia nervosa is the recurrent use of inappropriate compensatory behaviours to prevent weight gain. Many individuals with bulimia nervosa employ several methods to compensate for binge eating, with vomiting as the most common. The immediate effects of vomiting include relief from physical discomfort and reduction of fear of gaining weight. In some cases, vomiting becomes a goal in itself, and the individual will binge eat in order to vomit or will vomit after eating a small amount of food. As already noted, bingeing and purging becomes a way to detach from feelings and emotions, which creates a vicious cycle if the negative emotions are related to body-image or the shame of living with bulimia.
Individuals with bulimia nervosa may use a variety of methods to induce vomiting, including the use of fingers or instruments to stimulate the gag reflex. Individuals generally become adept at inducing vomiting and are eventually able to vomit at will. Other purging behaviours include the misuse of laxatives and diuretics, misuse of enemas, thyroid medication or omitting insulin doses. Individuals with bulimia nervosa may fast for a day or more or exercise excessively in an attempt to prevent weight gain.
Excessive Emphasis on Body Shape/Weight
Your character will place an excessive emphasis on body shape or weight in their self-evaluation, and these factors are typically extremely important in determining self-esteem. Weight, appearance and overall self-worth are deeply inter-woven. Some individuals living with bulimia have stated they felt justified to exist only if they were thin, and the need for approval and self-criticism were powerful drivers of the pursuit of thinness. Individuals with this disorder may closely resemble those with anorexia nervosa in their fear of gaining weight, in their desire to lose weight, and in the level of dissatisfaction with their bodies. Which nicely leads to the next sub-heading…
The Difference between Anorexia and Bulimia Nervosa
Bulimia and anorexia have several similarities, particularly the purging type of anorexia. Both eating disorders are typified by an overpowering sense of self that is determined by their weight and their perceptions of it. They both place all their achievements and successes as the result of their body, and for this reason are often depressed as they feel they are consistently failing to achieve what they consider to be the perfect body.
The main criteria difference between these two eating disorders involves weight, as an individual with anorexia must technically be classified as underweight. Individuals with bulimia are often slightly overweight as the calorie intake of bingeing isn’t completely expelled by purging.
In addition, generally those suffering anorexia do not engage in regular binging and purging sessions. Purging for those with anorexia will follow eating even small amounts, whilst for those with bulimia, purging follows bingeing large amounts of food as a habitual cycle.
Characteristically, those with bulimia nervosa feel more shame and out of control with their behaviours, as those with anorexia meticulously control their intake. The latter are more likely to believe they are in control of their eating.
When writing my short story and getting to really understand my character (her thinking patterns and choices), understanding these similarities and differences was extremely useful. What about you? Do you have a character with an eating disorder? Have you ever confused anorexia and bulimia (I had a friend who self-diagnosed her adolescent self with bulimia (because she purged) until I explained the differences – she, in fact, had purging type anorexia)?
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