People with bulimia nervosa—a disorder also known as binge-purge syndrome—engage in repeated episodes of uncontrollable overeating, or binges. A binge episode takes place over a limited period of time, often two hours, during which the person eats much more food than most people would eat during a similar time span (APA, 2013). In addition, people with this disorder repeatedly perform inappropriate compensatory behaviors, such as forcing themselves to vomit; misusing laxatives, diuretics, or enemas; fasting; or exercising excessively (see Table 11-2). Lindsey, a woman who has since recovered from bulimia nervosa, describes a morning during her disorder:

Like anorexia nervosa, bulimia nervosa usually occurs in females, again in 90 to 95 percent of the cases (Sanftner & Tantillo, 2011). It begins in adolescence or young adulthood (most often between 15 and 20 years of age) and often lasts for years, with periodic letup (Stice et al., 2013). The weight of people with bulimia nervosa usually stays within a normal range, although it may fluctuate markedly within that range. Some people with this disorder, however, become seriously underweight and may eventually qualify for a diagnosis of anorexia nervosa instead (see Figure 11-1).

Many teenagers and young adults go on occasional eating binges or experiment with vomiting or laxatives after they hear about these behaviors from their friends or the media. Indeed, according to global studies, 25 to 50 percent of all students report periodic binge eating or self-induced vomiting (Ekern, 2014; Zerbe, 2008; McDermott & Jaffa, 2005). Only some of these individuals, however, qualify for a diagnosis of bulimia nervosa. Surveys in several Western countries suggest that as many as 5 percent of women develop the full syndrome (Ekern, 2014; Touchette et al., 2011). Among college students the rate may be much higher (Zerbe, 2008).

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People with bulimia nervosa may have between 1 and 30 binge episodes per week (Fairburn et al., 2008). In most cases, they carry out the binges in secret. The person eats massive amounts of food very rapidly, with minimal chewing—usually sweet, high-calorie foods with a soft texture, such as ice cream, cookies, doughnuts, and sandwiches. The food is hardly tasted or thought about. Binge eaters consume an average of 3400 calories during an episode. Some individuals consume as many as 10,000 calories.

Binges are usually preceded by feelings of great tension. The person feels irritable, “unreal,” and powerless to control an overwhelming need to eat “forbidden” foods. During the binge, the person feels unable to stop eating (APA, 2013). Although the binge itself may be experienced as pleasurable in the sense that it relieves the unbearable tension, it is followed by feelings of extreme self-blame, shame, guilt, and depression, as well as fears of gaining weight and being discovered (Sanftner & Tantillo, 2011; Goss & Allan, 2009).

After a binge, people with bulimia nervosa try to compensate for and undo its effects. Many resort to vomiting, for example. But vomiting actually fails to prevent the absorption of half of the calories consumed during a binge. Furthermore, repeated vomiting affects one’s general ability to feel satiated; thus it leads to greater hunger and more frequent and intense binges. Similarly, the use of laxatives or diuretics largely fails to undo the caloric effects of bingeing (Fairburn et al., 2008).

Vomiting and other compensatory behaviors may temporarily relieve the uncomfortable physical feelings of fullness or reduce the feelings of anxiety and self-disgust attached to binge eating (Stewart & Williamson, 2008). Over time, however, a cycle develops in which purging allows more bingeing, and bingeing necessitates more purging. The cycle eventually causes people with the disorder to feel powerless and disgusted with themselves (Sanftner & Tantillo, 2011; Hayaki et al., 2002). Most recognize fully that they have an eating disorder. Lindsey, the woman we met earlier, recalls how the pattern of binge eating, purging, and self-disgust took hold while she was a teenager in boarding school.

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As with anorexia nervosa, a bulimic pattern typically begins during or after a period of intense dieting, often one that has been successful and earned praise from family members and friends (Stice & Pressnell, 2010; Couturier & Lock, 2006). Studies of both animals and humans have found that normal research participants placed on very strict diets also develop a tendency to binge (Pankevich et al., 2010; Eifert et al., 2007). Some of the participants in the conscientious objector “starvation study,” for example, later binged when they were allowed to return to regular eating, and a number of them continued to be hungry even after large meals (Keys et al., 1950).

Bulimia nervosa is similar to anorexia nervosa in many ways. Both disorders typically begin after a period of dieting by people who are fearful of becoming obese; driven to become thin; preoccupied with food, weight, and appearance; and struggling with depression, anxiety, obsessiveness, and the need to be perfect (Boone et al., 2014; Holm-Denoma et al., 2014). People with either of the disorders have a heightened risk of suicide attempts (Suokas et al., 2014; Keel & McCormick, 2010). Substance abuse may accompany either disorder, perhaps beginning with the excessive use of diet pills (Mann et al., 2014; Steiger & Israel, 2010). People with either disorder believe that they weigh too much and look too heavy regardless of their actual weight or appearance (Boone et al., 2014; Siep et al., 2011) (see InfoCentral below). And both disorders are marked by disturbed attitudes toward eating (Alvarenga et al., 2014).

Yet the two disorders also differ in important ways. Although people with either disorder worry about the opinions of others, those with bulimia nervosa tend to be more concerned about pleasing others, being attractive to others, and having intimate relationships (Zerbe, 2010, 2008; Eddy et al., 2004). They also tend to be more sexually experienced and active than people with anorexia nervosa (Gonidakis et al., 2014). Particularly troublesome, they are more likely to have long histories of mood swings, become easily frustrated or bored, and have trouble coping effectively or controlling their impulses and strong emotions (Boone et al., 2014; Lilenfeld, 2011; Halmi, 2010). As many as one-third of those with bulimia nervosa display the characteristics of a personality disorder, particularly borderline personality disorder, which you will be looking at more closely in Chapter 16 (Reas et al., 2013; Rowe et al., 2011, 2010).

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Another difference is the nature of the medical complications that accompany the two disorders (Corega et al., 2014; Birmingham, 2011; Mitchell & Crow, 2010). Only half of women with bulimia nervosa are amenorrheic or have very irregular menstrual periods, compared with almost all of those with anorexia nervosa. On the other hand, repeated vomiting bathes teeth and gums in hydrochloric acid, leading some women with bulimia nervosa to have serious dental problems, such as breakdown of enamel and even loss of teeth. Moreover, frequent vomiting or chronic diarrhea (from the use of laxatives) can cause dangerous potassium deficiencies, which may lead to weakness, intestinal disorders, kidney disease, or heart damage.