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Allan Schwartz, Ph.D.Allan Schwartz, Ph.D.
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Bulimia Nervosa

Allan N. Schwartz, LCSW, Ph.D. Updated: Nov 17th 2006

Perhaps one of the most daunting, frustrating and frightening types of behavioral disorders is Bulimia Nervosa. According to the DSM IV of the American Psychiatric Association, Bulimia Nervosa is an Eating Disorder characterized by:

Diagnostic Criteria for Bulimia Nervosa:

1. Repeated episodes of binge eating.

a. Binge eating is defined as eating amounts of food far larger than most people would eat and within a short period of time, often two hours or less.

b. Experiencing the feeling that there is no control over the bingeing while it is happening.

2. To compensate for the huge amounts of calories taken in and in the hope of avoiding weight gain, the person does some of the following:

a. Induces self vomiting

b. Induces diarrhea by taking laxatives or using enemas or other diuretics

c. Engages in fasting

d. Engages in excessive exercise

By far the largest number of bulimics is young women. The DSM IV reports that 1% to 3% of the population engages in this disorder. In addition, 90% of those diagnosed with this disorder are women while only 10% are male. The numbers of women are probably higher than that since studies of college women show that large numbers admit having binged and purged at least once during their lives.

In my experience as a therapist there are many dysfunctional behaviors associated with this disorder. For example, many of the bulimic young women with whom I have worked admitted to stealing small items from stores and/or engaging in drug abuse. Many of them were extremely depressed, particularly after purging.

What is so interesting about this disorder are the combination of feelings and behaviors during and after the cycle bingeing and purging ends. During the binge, as stated above, there is the complete inability to control, limit or stop the bingeing. Some people have stated that they were almost in a hypnotic state while the bingeing was occurring. Also, almost everyone I have treated reported that they knew they wanted to binge before the cycle began. Very much like the alcoholic, they experienced a craving for the binge. However, it is important to note that the urge or desire to binge had nothing to do with hunger. In most cases, these people did not feel at all hungry. Something else was driving the need to stuff themselves with food.

The foods of choice for the binge were always carbohydrates. Foods such as massive amounts muffins, cookies, candies, breads, bagels, ice cream, etc. were the foods of choice for the binge. Flavor and quality of the foods were of no importance to the binger. More important than anything else was the need of the binger to stuff themselves as quickly as possible with as much as possible until they felt the drive to binge decrease and end.

Following the binge was the need to purge and/or induce diarrhea as soon as possible. When the purge is over there is a sense of relief, similar to the glow experienced by the drug abuser. Once the bulimic no longer feels the glow or relief from the binge-purge she experiences extraordinary amounts of shame and self hatred. The feelings of shame, self hatred and self attack for having purged ends in the patient feeling extremely depressed.

Because of the shame and embarrassment felt by the bulimic there is a huge need to keep the entire cycle and problem a strict secret from everyone. It is not unusual for the families of teenage bulimics to be totally unaware of the binge/purge cycle. At most, there may be joking about the amount of time spent in the bathroom (where the purging is taking place).

There can be terrible health consequences to purging and using laxatives. Among the health consequences are:

  • Dehydration
  • Damage to tooth enamel resulting in the possible loss of teeth.
  • Electrolytes can become totally unbalanced.
  • Damage to the esophagus result caused by stomach acid moving upward through the esophagus during purging.
  • Ultimately, the bulimic's health can become so damaged that death results.

Treatment for Bulimia Nervosa includes a combination of psychotherapy, anti depressant medication and regular visits with a nutritionist that includes such things as weigh-ins, diaries of food intake each day of the wake, including whether or not the individual felt tempted to purge or did purge. Sometimes group therapy is included in the treatment process. The groups are made up of young women suffering from the same bulimic disorder and led by a therapist who is oftentimes a woman. However, many young women are reluctant to enter such a group for fear of feeling jealous that others in the group may be thinner than they are.

Sometimes it is necessary to hospitalize a person with Bulimia in order to save their lives, prevent further damage to their health and learn new ways of coping with emotional issues without binging and purging. Behavior Modification and Cognitive Behavioral Therapy are usually part of these hospitalizations.

It would be a mistake to believe that all bulimics are thin. There are those who binge but do not purge. These patients are plagued by obesity and self hate for their inability to control their eating habits and their weight.

There are also those bulimics who alternate between anorexia and bulimia. These are, in my words, anorexic-bulimics. A complication factor in all of these eating disorders is the insistence on denying that there is a problem. Those who are anorectic of the bulimic variety or the pure anorectic type insist on their being fat and on the idea that they do not have a problem, except for their weight.

The next weblog on the issue of Eating Disorders will center on the family relationships and societal pressures that cause so many young women to become anorectic or bulimic.

Your responses to this important topic are welcome and encouraged.

Allan Schwartz, LCSW, Ph.D.

Readers who live in the Boulder, Colorado metro area, or in Southwest Florida may contact Dr. Schwartz for face-to-face consultation. He is also available for psychotherapy through Skype video for those who are not in Florida or Colorado. He can be reached via email at for details.

Reader Comments
Discuss this issue below or in our forums.

personal experience - YoungDoc - Nov 29th 2006
Thanks for starting this blog. I am a 27 year old Doctor, SHO in psychiatry and have suffered from Bulimia for about 13 years. I have experienced first hand the devastation bulimia can have on oneself both psychologically, physically and emotionally. Binging and purging for me has become for me a way of life - albeit an expensive one. Externally however I maintain a 'normal' sociable way of life. I have a good job, friends etc... but I would say that bulimia is my best friend - always reliable... with the power to always make me feel better (in the short term)... I would say that for me modifying my behaviour would take a huge upheaval in my life - and a good supportive network ... neither which are immediately conceivable at the current time.. unfortunately the reality of bulimia often goes hidden - with less media coverage than some of the other eating disorders... I would like this to change..

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