About Bulimia

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By: Melissa Gerson, LCSW

Alex starts her day with the intention to “be good.” As she navigates through her day, burdened by negative body thoughts, she feels down but hopeful that she will eat “clean” and with control. By mid-afternoon she’s starving and preoccupied with thoughts about food. When a co-worker puts out a tray of desserts for everyone to partake, Alex tries to resist but then can’t get the treats out of her mind. So she has one. Then another.   She’s on autopilot, out-of-body.   After too many cookies to count she’s despondent, miserable, stuffed.   She purges in the office bathroom since the full feeling is intolerable… and of course, the threat of absorbing all the calories is equally terrifying. Alex is resolved to make this her last binge/purge.   She’s “back on track.” But before you know, a food “mistake” or unexpected temptation gets in the way and the rest is history.

The pattern I just described is the classic bulimic cycle. There is restriction, deprivation, rules about what is on or off limits… Then a temptation, giving in, a food “mistake…” The binge means freedom from the exhausting control – at least for a short while. But then remorse, self-hatred. The purge is supposed to “undo” the binge but at the same time, without realizing it, the purge forgives the binge, actually opening the door for more binges in the future.

Most individuals with bulimia, will relate to some element – if not every element – of this cycle.*   The problem is that intuitively, it seems like more control and restraint are needed. The reality is that the exact opposite is true: over-control, deprivation, rigid rules are to blame. Because of this misguided effort to increase control, many who struggle with bulimia try and try again to end the cyclical pattern but find themselves frustrated in the process – and left with more shame, self-loathing, isolation.

What you should know about bulimia:

  1. Frequent purging – either by self-induced vomiting or laxatives – can lead to dangerous medical complications. The most common concern relates to cardiac health since minerals essential for proper cardiac function like sodium, magnesium, phosphorous get depleted through fluid loss. The only way to know if you have imbalance of these minerals is through a blood test. Your health status can change quickly so frequent labs are essential if purging is happening regularly. You could absolutely be at risk for a serious cardiac event but physically, feel no indication that anything is wrong.
  2. It is so important to consider a behavioral therapy like CBT-E, a treatment designed – and proven – to treat bulimia nervosa. CBT-E is so successful because of its laser focus on the factors that are keeping the cycle going – things like chronic dieting or restriction, rigid food rules (i.e. good and bad foods)… and also factors like intense focus on weight/shape, harsh comparisons to others and body checking like frequent weighing or body checking (mirror, pinching etc).
  3. CBT-E focuses on guiding you to a pattern of regular, consistent and flexible eating – an eating style that tends to reduce one’s vulnerability to binge eating and purging.   The treatment works to change your relationship with food (and thus your control!) by integrating:
    1. Flexibility: encouraging an approach to eating that allows for last minute changes, social eating, managing with the food available to you.
    2. Variety: balanced, satisfying meals. Moving away from having “off limit” foods since those tend to be the very things people consume in excess later.
    3. Adequacy: under-eating, delaying eating for long periods makes you more vulnerable to over-eating. If you’re starving, it’s harder to stay in control.
    4. Awareness: being present, aware of what is happening in the moment is key to maintaining control over eating behavior.
    5. Planning: you mustn’t under-estimate the power of being prepared. For many who struggle with BN, decisions on the fly lead to trouble. We want to move away from impulsive decision-making.
  4. Treatment must also address your current coping strategies since binge eating and purging for many are actually methods for relieving stress, numbing out, escaping….   To recover, you will likely need to establish alternative methods of coping – skills and strategies so you can care for yourself and manage feelings without defaulting to food-related behaviors.

Bulimia: The Bottom Line

There are many factors that contribute to the development of bulimia – biological/genetic, cultural/social, emotional…. But often what caused the problem in the first place is less important to focus on that the factors that are keeping the problem going now.

Bulimia is highly treatable. With the right intervention, people are able to make significant changes very early on in treatment. It is so important to seek help if you’re stuck in a destructive cycle with your eating.

* Please note that every individual is different. The pattern described in this post is among the more common presentations but there are many who have a very different “clinical picture.” Regardless, it’s essential to understand your pattern so that you can target the factors that are keeping it going.


About the Author: Melissa Gerson, LCSW is the Founder and Clinical Director of Columbus Park, Manhattan’s leading outpatient center for the treatment of eating disorders. As a comprehensive outpatient resource for individuals of all ages, they offer individual therapy, targeted groups, daily supported meals and an Intensive Outpatient Program (IOP). Columbus Park uses the most effective, evidence-based treatments like Enhanced CBT and Dialectical Behavior Therapy (DBT) to treat binge eating, emotional eating, bulimia, anorexia and other food or weight-related struggles. They track patient outcomes closely so they can speak concretely about their success in guiding our patients to recovery.

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