Bulimarexia

A new eating disorder has emerged over the past 5-10 years. It combines Anorexia and Bulimia and in my opinion, is much more dangerous than the other two separately. 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.

 

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 s/he feels compelled to purge it.

The more Bulimic Type of Bulimarexic can keep some food down, and/or has more flexibility in terms of what s/he is allowed to eat, i.e. they may eliminate fat altogether from their diet but allow foods with carbohydrates. They will have some criteria that they use to establish a “good” day versus a “bad” day.  “Bad” days trigger the need to binge and purge whereas a “good” day allows them 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.

The question is why is this happening? The answer is complicated.  In my experience, the longer you have Anorexia, the more at risk you are for ending up with either Bulimia or Bulimarexia.  The reason for that is that the body, or brain, eventually stops behaving normally under the assault of the Anorexia. In other words, it has to suppress metabolism again and again to prevent the induced starvation from doing irreparable damage and eventually gives up or gives in and effectively stops burning calories, resulting in uncontrolled weight gain.  

This is obviously terrifying to the Anorexic who may now begin to purge through vomiting, abusing laxatives, or over exercising in desperation. It may help temporarily, but ultimately it just makes the problem worse. This is one path I have observed in numerous patient histories. In most cases I have been able to help my patient coax her brain into responding normally to food again. When that happens, and we are able to increase the number of calories s/he burns we often end up with an even higher metabolism than before the eating disorder. That is a good thing.

Another reason we are seeing more bulimarexia may be due to the impact of residential “treatment” on eating disorders.  According to our survey at the Norton Center of the roughly 2,000 respondents, 16% of those suffering exclusively from Anorexia upon entering a residential program reported being discharged with symptoms of Bulimia that they acquired during their inpatient stay. Likewise, 11% of those suffering exclusively from bulimia upon entering, reported being discharged with symptoms of Anorexia as well.

For more survey results click here.

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. Because I offer intensive outpatient treatment, I often see patients whose symptoms are more severe. Nonetheless, this issue doesn’t appear to be on the radar of researchers and many practitioner groups which is a serious problem in my opinion.

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 both Anorexia and Bulimia. 

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.