Bulimia Recovery

The reason that most clients reach out to me is because they’ve had enough. Before it used to feel like there was a real benefit to what they were doing with food and exercise. 

Even if they could recognise that it was disordered, it was “working” for them. But now, that’s changed.

This is especially true for the clients I work with who are suffering from bulimia. The honeymoon phase has truly passed and now they’re just stuck, not knowing how to change. 

And even when they try to make choices that are recovery focused, they still find themselves having binge/purge episodes. They’re confused and feel trapped.

If this is where you find yourself, I want to assure you that this isn’t a permanent situation. Full recovery from bulimia is possible and is something I have helped many clients achieve.

So as part of this article, I want to describe what bulimia is, some of the misconceptions about it, how it can shift over time and how to get the support that you need so bulimia is a thing of the past.

Definition of Bulimia

Bulimia nervosa (typically shortened to just bulimia) is an eating disorder and mental health condition characterised by regular, often secretive episodes of overeating or “bingeing” followed by some form of purging. And this is occurring alongside a persistent concern about body weight and shape. 

Bulimia is diagnosed using the DSM-5, which is the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. To receive a diagnosis of bulimia nervosa you need to meet the following criteria:

1. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
2. Eating, in a discrete period of time (e.g., within a two hour period), an amount of food that is definitely larger than what most people would eat during a similar period of time and under similar circumstances.
3. Lack of control over eating during the episode (e.g. a feeling that you cannot stop eating, or control what or how much you are eating).
4. Recurrent inappropriate compensatory behaviour to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.
5. The binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for three months.
6. Self-evaluation is unduly influenced by body shape and weight.
7. Bingeing or purging does not occur exclusively during episodes of behaviour that would be common in those with anorexia nervosa.

Purging means more than vomiting 

Bulimia, like other eating disorders, has a stereotype associated with it. Many people believe that purging means vomiting and that without vomiting it can’t be bulimia. But as the criteria shows, this is clearly not the case. 

Eating disorders morph over time and people have phases where their eating disorder looks one way and then shifts to something else. 

It’s common for someone, who has once used vomiting as a way of purging to stop this behaviour. But now they have transitioned to some other form of compensation.

Their exercise has increased. They restrict for greater periods of the day, saving up the majority of their eating for the evening. While they don’t vomit anymore, they have started chewing and spitting their food.

So, while the method has changed and they may not now meet the stereotype of what society thinks bulimia means, purging in the true sense is still occurring.   

Is It Bulimia Or Anorexia?

Just like there is a stereotype of bulimia, there is also one associated with anorexia. This idea of someone who is emaciated and never eats. That if you were looking at someone with anorexia, you’d instantly know. In reality, this is not true. 

As I cover in this article, there are technically three subtypes of anorexia:

Restricting type

This is the subtype that is most stereotypical of anorexia. Where someone consistently restricts without engaging in “binge eating”.

Binge/Purge type 

This subtype is where someone has regular instances of bingeing and/or purging. 

Atypical type 

This final subtype is where someone meets the criteria for anorexia, except they aren’t living with what is considered a “low body weight”.  

The fifth criteria listed in the DSM for bulimia is “Bingeing or purging does not occur exclusively during episodes of behaviour that would be common in those with anorexia nervosa.”

Given that you can have bingeing and purging with anorexia and that both anorexia and bulimia are associated with persistent concerns about body weight and shape, what’s the difference?

I would argue that there isn’t any difference. And I suspect that someone’s weight is the determiner of the diagnosis one receives.

If someone is low weight they will be diagnosed with anorexia binge/purge subtype. If their weight isn’t low, they’ll be diagnosed with bulimia. While there is this third category of atypical anorexia, where low weight isn’t a requirement, it seems like this is totally forgotten about when making a diagnosis of bulimia.

While this can seem like semantics, I don’t think it is. Because the label that someone receives can determine where it is believed that the problem lies and the kind of treatment that is received. 

For anorexia the problem is seen in the restriction and the undereating.  

For bulimia the problem is seen as the binge/purge episodes.

For binge eating disorder (BED) the problem is seen as the binges.

But the reality is that all these eating disorders have restriction in common. And if this isn’t the focus, true recovery is not going to occur.

[Note: If you want to understand more about restriction, you can check out this podcast on the topic]

The frequency of occurrence

The third criterion in the DSM states that “The binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for three months.” 

Don’t get hung up on the frequency as a cut off point. It’s very common for this to be happening less frequently than the diagnostic criteria. 

Or there can be months where it doesn’t happen and then there is a bad period for a number of weeks and then another period of abstinence before it happens again. 

So I don’t want you to read the above criteria and have it colour how big of an issue you believe this is. If this is happening at all, it’s a cause for concern and warrants seeking help. 

Planned episodes and unintentional episodes

When I think about binge/purges, they can roughly fall into two categories. This isn’t anything official, like from the DSM, but is based on my own observation from working with clients. 

The first is the planned episode. This is where someone intentionally starts a binge, knowing it will end in a purge and will prepare for this by buying specific foods.

This planning may start spur of the moment; so they’re in the shops and suddenly the desire hits and they start buying the specific foods. Or it could start as a thought that over a number of days builds up until they make the decision to buy these foods in advance. 

The first step isn’t always going out shopping. They may plan to do it and recognise that there are already appropriate foods in the house. 

But the hallmark of this type is that prior to the binge occurring, there is a decision to do it and knowing it will end with a purge (of some description, it doesn’t have to be vomiting).

The second type of binge/purge is an unintentional episode. This is where the binge isn’t planned but feels more like it “just happened”. 

So, they’re eating a meal but notice that what they’ve prepared for themselves isn’t leading to a feeling of fullness and/or satisfaction. It just isn’t hitting the spot the way they hoped it would.

Because of this, often the speed of eating can start to increase and they’re noticing that they’re now thinking about other foods and what else to eat.

At some point, this feeling of not being satisfied reaches an intensity and/or they’ve eaten past what is deemed an “appropriate” amount of food. There’s often a thought of “well I’ve blown it now anyway” and it’s at this point that the binge then occurs.

So, before the meal, there was no intention to binge/purge but because of what happened while eating, an episode occurred.

The Reason For Purges 

The second criterion for the bulimia diagnosis is “Recurrent inappropriate compensatory behaviour to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.” 

In this criteria, it is stated that the role of the “compensatory behaviour” is to “prevent weight gain” which I completely agree with. 

But I would add that there is a second reason for the compensatory behaviour, or even the whole binge/purge episodes, and this is to change one’s state. 

For many clients, the binge/purge becomes the go-to coping mechanism for dealing with the challenges of life. It’s an experience that allows them to numb out, dissociate or push the pause button.

So when something triggers uncomfortable thoughts, feelings and emotions to arise, the way of responding to this is a binge/purge episode.

Even though there can be shame associated with it, this shift in state can become important, especially if other coping skills are lacking. Because if there is no other method that can deliver this kind of instant change, it can be hard to give up.

Unfortunately, at some point, this stops “working”. The upside from the binge/purge becomes outweighed by the downside.

This downside can be that it doesn’t change one’s state in the moment to the extent it used to.   

Or that how one feels the next is so bad (physically, mentally and emotionally) that it doesn’t feel worth it. 

Or that there is a realisation of how this is impacting life more generally. The shame and isolation it causes. The reduction in the overall quality of life.    

Unintentional Binges and Recovery 

When I think about the trajectory of recovery, for most clients, it is the planned binge/purges that cease before the unintentional ones do. As I just mentioned, at some point they realise that it isn’t working as it used to and so there is a desire to stop.

But what’s most common when this happens is that the unintentional binges start to increase.

One of the reasons for this can be because the planned binge/purges were actually bringing in much-needed energy for the body. Even with the compensatory behaviour, the body was still getting more energy than was being expended from the binge/purge. And now with these episodes ceasing, total food intake has reduced and hence the increased unintentional episodes. 

But another reason this can occur is because more food has started to come in. And this can be rather confusing. “I’m now eating more than a was before, I don’t understand why these binges are happening!!”

As I mentioned earlier on, eating disorders are about restriction and this is true of bulimia. When food is restricted, the body doesn’t get everything it needs to be able to function properly. It has to turn down certain functions and turn off others. It means that many of the ongoing repairs that it should have been doing weren’t happening.

Part of recovery, therefore, is reversing this situation. It’s helping the body to climb out of the energy debt that it has accrued.

And when more energy starts to come in, this turns something on in the body. The body realises that food is now available and it wants to make the most of it. And this can lead to more occurrences of unintentional binges. 

[Note: I’ve previously covered how expectations connected to eating can have an impact on binges. You can read that here.] 

Moving From Binges/Purges To Just Binges

One of the comments I hear most often is that “I want to stop purging, but for that to happen, the binges have to stop first.” 

There is this idea that if a binge happens then a purge must occur. That the two are intimately connected and if one happens, the other must follow.

But for recovery, there needs to be an untangling of these separate acts. It needs to be ok for a large amount of food to be eaten and for it not to be followed by some form of compensation. 

This means learning to sit with the discomfort of a binge occurring. The physical discomfort but also the psychological discomfort. And it’s actually this second part, the psychological part, that is the more challenging of the two.

Because as uncomfortable as the physical sensations may be, all the thoughts and future tripping and resistance to what just happened is much more painful.

Would you like help?

I’m a leading expert and advocate for full recovery. I’ve been working with clients for over 15 years and understand what needs to happen to recover.

I truly believe that you can reach a place where the eating disorder is a thing of the past and I want to help you get there. If you want to fully recover and drastically increase the quality of your life, I’d love to help.

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