Bulimarexia: Why Are We Seeing More of It?

Bulimarexia Treatment Cincinnati

There is definitely an increase in the number of patients coming my way who are Bulimarexic, or suffering from symptoms of both Anorexia and Bulimia.  This is consistent with the information we have seen from our online survey. Please take the survey if you haven’t already done so!

Check out the chart for percentages of individuals reporting the type of Eating Disorder from which they are suffering.


The survey has been up for approximately two years.  The number of people reporting being Bulimarexic has tripled in that time. One year ago the percentage for Bulimarexia was only 24.9%, now it is nearly 48%!(Part of this is likely due to increased familiarity with the term.)

The question is why? According to our survey at the Norton Center of more than 200 individuals who report having been in treatment for an eating disorder, 16% of those suffering exclusively from Anorexia upon entering an inpatient program report being discharged with symptoms of Bulimia that they acquired during their inpatient stay. Likewise, 11% of those surveyed, report that they entered in-patient treatment suffering exclusively from symptoms of Bulimia and exited with symptoms of Anorexia as well.

Anyone treating this population knows that the most difficult group to treat by far is the group suffering from symptoms of both Anorexia and Bulimia, or Bulimarexia.  Likewise the risk of mortality is greater with this group than that of either group alone. If it isn’t apparent, the medical consequences of cycling between restricting sufficiently to be at an extremely low weight, followed by periods of bingeing and purging, are dramatic and often deadly. Thus, a treatment approach that may actually increase the likelihood of the development of Bulimarexia is a serious problem.

Obviously not all patients with Bulimarexia have developed the disorder while in an in-patient program. However, I am finding that an alarmingly high number of individuals “graduating” from inpatient treatment end up with Bulimarexia. Since I often see patients that other practitioners will not take into their practice because they are so sick, the number of Bulimarexic patients I see is probably higher than it would be in most practice settings.  None-the-less, this issue doesn’t appear to be on the radar of researchers and many practitioner groups which is a serious problem in my opinion.

To date, there is not even a diagnostic code specifically for Bulimarexia in the Diagnostic and Statistical Manual, Fourth Edition (DSM IV).

In the DSM-IV, the closest thing we have is a code for two types of Anorexia:

Restricting Type: During the current episode of Anorexia Nervosa, the person has not regularly engaged in binge-eating or purging behavior (self-induced vomiting or misuse of laxatives, diuretics, or enemas).
Binge Eating/Purging Type: During the current episode of Anorexia Nervosa, the person has regularly engaged in binge-eating or purging behavior.

These definitions do not capture the nature of Bulimarexia. For example, whether the individual started as Anorexic or Bulimic makes a difference in terms of their current symptoms.  The more Anorexic Type restricts most of the time and may or may not binge, but purges almost everything she does eat.  In other words, she is more likely to have “subjective” binges, i.e. a small amount of food seems like a binge to her so she is forced to purge it.

The more Bulimic Type of Bulimarexic can keep some food down, and/or has more flexibility in terms of what she allows herself to eat, i.e. she may eliminate fat altogether from her diet but allow foods with carbohydrates. She will have some criteria that she uses to establish a “good” day versus a “bad” day.  “Bad” days trigger the need to binge and purge whereas a “good” day allows her to skip this part of the cycle. These distinctions may not seem important, but they are critically important when it comes to treatment effectiveness.  The therapist that does not understand such subtleties is going to be much less effective treating these disorders and could end up doing more harm than good.

More attention needs to be paid to this problem, we need better in-patient alternatives and we need more research on outcomes in general, i.e. we need to look at the impact that both inpatient and outpatient therapy has on the incidence of Bulimarexia. Graduate students looking for research opportunities contact me at drnorton@eatingdisorderpro.com.

My experience treating this population has been that treatment effectiveness is driven by customizing strategies to the individual and not using a One Size Fits All © approach. In general, I believe that inpatient approaches have tended to lump all eating disorders together in terms of treatment. The upshot is often an increase in the type of symptoms during or following discharge, or crossover from one disorder to another.  This is a serious problem given the increased medical and psychological complications that result.

Excerpt from Dr. Norton’s upcoming book One Size Fits All Copyright Dr. J. Renae Norton 2010 All rights reserved.

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