The “Double Life” of Bulimia Nervosa: Patients’ Perspectives

My psychiatrist once compared my life to Dexter. He said I was living a double life. It was the summer before my final year in undergrad and I was working in a neuroscience lab. Yet things were so bad that at one point I was very close to quitting and doing Day Program treatment. (I didn’t, and things ended up getting better, thankfully.)

This post is going to be more personal than most. One, I can relate well to the topic. Two, I feel that I can give voice to it under my real name. (As opposed to just discuss it abstractly, or anonymously. There’s nothing wrong with being anonymous, but I feel that, for many reasons I am in a position where I don’t feel I have to be anonymous anymore.)

I think this is important because there are a lot of myths that surround eating disorders and those who suffer from them, and I want to do my part in crushing those myths. Moreover, while restrictive anorexia nervosa is often, at least partly, associated with positive traits like self-control, bulimia nervosa (rather, bingeing and purging more broadly) is never associated with anything positive. Not eating is one thing, but eating and throwing up is quite another. It is dirty. Wasteful. 

Bulimia comes with  huge stigma. This stigma is a huge barrier to treatment. Hepworth and Paxton (2007) found that “fear of stigma is the main barrier for help-seeking individuals  with bulimia nervosa” (emphasis mine).

Bingeing and purging is shameful, but it is also invisible: most bulimia nervosa patients are at a normal weight. It is easier to hide than anorexia, too. (Eating and purging is often easier than not eating and making excuses for it.)

There’s also this idea that you can just stop. Hey, just eat and don’t throw up. Aren’t you smarter than that? Why can’t you do something more productive with your time. Stop being so selfish and wasting money, you arrogant girl. The world is not perfect, get over it. 

There is so much stigma that in one of the studies I’ll talk about, for more than half of the participants, the study was the first time they disclosed to anyone that they had bulimia. They struggled with bulimia from 1 to 9 years (average 4). Imagine, nine years in secrecy.

Remember, too, that “bulimia occurs in all age groups, ethnic backgrounds, and social classes” (Broussard, 2005).

What I am about to write, I’m not writing to brag. It is to illustrate that there were many times I was both very functional and very sick. What I am about to write, I’m writing because I want to help end the myths that those who binge and purge are lazy, obsessed with being thin, stupid, greedy, self-centered, or arrogant. I’m writing because although someone once told me I didn’t look like someone who would have an eating disorder, I did.

(Side-note, purging often refers to vomiting as well as any other methods commonly used to compensate for bingeing, such as exercise, laxatives, diuretics, and fasting. In talking about myself, when I say “purging” I mean “vomiting.”)

I started purging at the very end of my first year in undergrad. It was at its worst in the summer before my final year and during the middle of my final year. But, I managed to finish my degree in Neuroscience with a high GPA. In that final year, I was the Review Board Manager at my University’s undergraduate journal in life science, and a News & Features Editor at JYI. That year I also applied to graduate schools in the US. I got into five schools, including two Ivy League Neuroscience PhD programs. (And then decided I didn’t want a PhD and I didn’t want to be in a long-distance relationship.)

I’ll be defending my Masters in the next 2-3 months and NSERC (Natural Sciences and Engineering Research Council, a major funding body, probably most similar to the National Science Foundation in the US) decided I was in the top 24 Masters level applicants across all fields in 2012. (I’m not, I guarantee you, but I’ll accept their scholarship.) And guess what, I was bingeing and purging a lot during the start of grad school.

If people did think something was wrong, few probably suspected how bad it was. I doubt anyone actually thought I spent most of the night bingeing and purging, and then went to the lab in the morning and did experiments all day. Few probably suspected that I purged between experiments in undergrad.

I wasn’t lazy, stupid, greedy, self-centred, or arrogant. And no one is just because they are struggling with an eating disorder. No one.

I was just sick. I didn’t know how to eat normally. I didn’t know how to eat without eating a lot. I didn’t know how to stop bingeing and purging without severely restricting. Purging was extremely calming. I liked it. A lot. It wasn’t something I could just stop by myself.

I was science student by day, bulimic, well, the rest of the time.

My experiences though, they are just an anecdote  So, what I want to do is share two good papers exploring the experiences and perspectives of bulimia nervosa patients. Prior to these papers though, there was a study by Orbanic (2001) that described the experiences of six women living with bulimia.

Five themes surfaced:

1. A LIVING HELL: Thoughts were overwhelming about when, what, and how much they were going to eat and how they would avoid being caught. They were emotionally and physically exhausted.
2. THE PERPETUAL CYCLE: Bingeing and purging became “habitual, automatic, self-perpetuating.”
3. THE RIGHT TO EXIST: Felt justified to exist only if they were thin, need for approval and self-criticism were powerful drivers of the pursuit of thinness.
4. FOOD AS ANAESTHETIC: Bingeing and purging was a way to “detach from feelings and emotions”
5. LIVING A FAÇADE: A lot of time and thought went into how to maintain the façade of normalcy.

I can definitely relate to all of those, perhaps with the exception of number three. Number one, and especially number two, four, and five very accurately describe my experiences with bulimia. Spot on. 

Orbanic also found “that bulimic women often experience a sense of “satisfaction,” “completion,” and “calm” following vomiting.”

I’m so glad to see this written. There is a common assumption that bulimia nervosa patients like bingeing but feel guilty for the food and vomit. The assumption is that they don’t like vomiting, it is just to get rid of the gluttonous binge. For me, while that was true sometimes, I actually began to like vomiting and often binged to vomit precisely because it left me feeling incredibly calm and tranquil. There were times purging was something I felt compelled to do in order to actually fall asleep. I wanted to go to bed, but, I felt I had to binge and purge, otherwise, I wouldn’t fall asleep. I would be too anxious. 

Brenda Broussard, in her 2005 paper, and Gunn Pettersen and colleagues in their 2008 paper found very similar results to Orbanic. Instead of writing too much, I thought I’d make figures illustrating the main findings of the two qualitative papers (click on image to enlarge).

Broussard (2005):

SUMMARY OF IMPORTANT FINDINGS

Broussard (2005): 

• Many thought their behaviours were “normal” or weren’t a big deal, but that they were afraid others would think otherwise.
• Participant thought they were often perceived as being “gross,” “disgusting,” “sick,” “repulsive” or that there was something mentally “wrong” with them.
• After vomiting, “rather than guilt, [many] actually felt “relief” or “good.” (This is similar to Orbanic’s findings.)
• The participants faced a huge internal struggle, and attempts to rationalize the irrational but overwhelming desire to binge and purge.

Pettersen et al. (2008) found different, but similar, subthemes (note the differences between the participants):

SUMMARY OF IMPORTANT FINDINGS

Pettersen et al. (2008):

• Thought often seen as being “manipulative” patients are often just trying to preserve their dignity and concealing their bingeing and purging is a way to accomplish this.
• Participants hid their behaviour for fear of shame, stigma, and negative sanctions
• Individuals who were less ashamed of bingeing and purging, and did not put as much daily effort into hiding it “may be judged as better off” (because mentally it is less exhausting).

Severity of bulimia is then not only related to psychiatric status, frequency of symptoms, or objective somatic conditions. Severity is equally a question about emotional fragmentation between shame and dignity, as well as whether the distance between the overt and the covert hampers daily life functioning.

What do these findings mean for therapy and treatment?

Pettersen writes that time should be spent both on reducing symptom frequency *and* reducing the same that it is associated with bulimia, as well as addressing the costs of the “double life.” 

Broussard (a nurse) recommends studies that “involve bulimic women in a discussion about treatment strategies.” She suggests further studies should address “How can health care providers effectively address the issue of eating disorders with clients?” and “What do bulimic women think would be most helpful?”

Wouldn’t it be great if all therapists and treatment teams asked you how you feel you can be helped (particularly if you are an adult, perhaps in your mid-20’s, and have a lot of other things going on in your life, like school and work)? I can’t wait for that day.

I’m sure a lot of readers who have struggled with bingeing and purging can relate to some of themes discussed in these papers. Feel free to share your experiences, and perhaps how treatment helped or hindered recovery. (As always, you can do so completely anonymously.)

References

Broussard, B. (2005). Women’s experiences of bulimia nervosa Journal of Advanced Nursing, 49 (1), 43-50 DOI: 10.1111/j.1365-2648.2004.03262.x

Orbanic S (2001). Understanding bulimia. Signs, symptoms and the human experience. The American journal of nursing, 101 (3) PMID: 11279994

Pettersen, G., Rosenvinge, J., & Ytterhus, B. (2008). The “Double Life” of Bulimia: Patients’ Experiences in Daily Life Interactions Eating Disorders, 16 (3), 204-211 DOI: 10.1080/10640260802016696