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. 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 since 2007.  The percentage of people who report being Bulimarexic has doubled in that time. At the end of the first year that the survey was up, the percentage of individuals reporting being Bulimarexic was 24.9%, now it is 48.2%. (Part of this is likely due to increased familiarity with the term.)

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 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 1,965 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.

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. 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.

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.

Resting Metabolism Rate (RMR)

One of the most common fears the Bulimarexic has is uncontrolled weight gain.  There is actually some basis for this fear of uncontrolled weight gain from a biological perspective. Victims of Bulimarexia have often suppressed their metabolism, by restricting for years, to the point that rapid weight gain may begin with relatively low caloric intake. This is, of course, part of another very vicious cycle. The less they eat, the less they can eat without gaining weight. If left unaddressed, this underlying assumption, which is based on a biological reality, will undermine recovery.

Research demonstrates that rapid weight gain is counterproductive with this population. I find that re-feeding goes much better when it begins with my client’s current resting metabolism rate (RMR) and systematically, but very slowly, steps up the calories over a period of 12 to 18 months, which also improves a sluggish metabolic rate. I am comfortable with one or two pounds of weight gain per month, as long as my patient is medically stable and the calories are consistently going up each month. It helps that I know the food is clean and loaded with good nutrition.

The focus is on increasing the calories each week with clean, nutritious food. The focus is not on the weight gain per se.  In fact, most of my patients are eating 2 to 3 times the number of calories within the first month with little or sometimes even no weight gain, because their metabolism rate improves almost immediately on a clean diet.   

Of course, ultimately there is weight gain, but it is reassuringly slow from the patient’s perspective, despite the fact that the calories are going up fairly quickly. A typical scenario is that of patient LL.  For this particular patient, her initial RMR was 693 calories per day, and her weight was 79 pounds, while her RMR at the end of eleven months was 1940 calories per day and her weight was 99 pounds.[5] Another patient had even more dramatic reaction.  Her beginning weight was 98 pounds, and her calories were 300-400 per day.  After only 3 months her RMR was 2500 /day and her weight was 103.

I often see such dramatic changes in the resting metabolism rate, which I track for every patient that is re-feeding. The graphs are both convincing, as well as reassuring to the client and her loved ones. The value of this approach is that it does not ask for a change that would challenge all of the patient’s underlying assumptions and create resistance (by triggering tremendous anxiety). Instead, it accepts the patient’s underlying assumptions, and leverages them into progressively more healthy behavior. As a result, there is less danger of setting up resistance (not eating), which often leads to rebounding (weight loss).

Unfortunately, this is exactly what happens in residential treatment centers. Even in outpatient therapy, many therapists communicate a similar expectation to their patients, i.e. that s/he should gain weight rapidly. To this end, the patient is weighed every visit and the criteria for a successful week is based solely upon his/her weight gain. It may have the unintended side effect of forcing the patient to lie to avoid the negative consequences of telling the truth.



Whether the issue is restricting or bingeing and purging, learning how to eat without fear and dread is the key to recovery. Dieting doesn’t work, restricting can lead to death and bingeing and purging do not control weight and may also cause serious medical complications, some of which are irreversible.

What works is learning to eat clean nutritious foods that do not pollute the body or cause unnecessary weight gain.  Assuming that the client is medically stable, weight-bearing and light aerobic exercise 3 to 4 times per week is essential to good health. When regular exercise is combined with eating clean foods, a healthy relationship with food and eating can be established.

Re-feeding addresses several issues, food phobias, food allergies/sensitivities and the quality of the food.  Food phobias are usually based upon misperceptions and/or mistaken beliefs about fat and carbohydrates. A critical component of treatment is debunking the myths and fears about foods and desensitizing the individual to the ingestion of healthy foods. When the client is ready, analyzing her current food intake is the first step towards managing this component of the eating disorder.

Food allergies and sensitivities are also of critical importance as they may attack the gut or the thyroid.  If this is happening it increases the anxiety that my patient is experiencing making it even more important to hang on to her coping mechanism, restricting. I recommend a comprehensive medical assessment to rule out thyroid disorders, vitamin D deficiencies, esophageal tears from purging, osteopedia or osteoporosis, heart arrhythmias, upper or lower GI problems from laxative abuse, which are very common among those with an eating disorder, and food sensitivities that may be a contributing factor to food aversion.

Finally re-feeding focuses on understanding and learning to enjoy “clean” food.  The following is a clean eating/re-feeding protocol that should be standard for anyone who is recovering from Anorexia.

Link: Re-feeding Protocol

Protein– Six servings of protein /day = 3 meals + 3 snacks.  Have 4 to 6 oz. servings of protein for meals and 2 to 4 oz. servings for snacks of:

  • 100% grass-fed beef, bison, pork, game or poultry  
  • 100% grass-fed dairy, including eggs, cheese, yogurt, cottage cheese, milk, ice cream
  • wild-caught fish
  • organic nuts – ½ cup
  • Sacha Inchi powder – 1 serving

Complex carbohydrates – 7 servings of organic fruits and vegetables each day 

A serving is an entire fruit such as an apple or a pear, or a cup of vegetables (peas) or fruit (strawberries.) It is ok to eat more than a serving.

Fats – Coconut oil (the more the better) for veggies and for frying; Moderate amounts of 100%grass-fed butter, ghee, or duck fat for cooking; Olive oil (limited amounts – use for salad dressings)

Grains – In general we do not need grains and most people do not do well with them, but 1 serving a day is ok if you are not intolerant or allergic. However, stick with these: 

  • Sourdough bread (2 slices)- the only bread to eat 
  • Hemp-seed florettes – high in protein and fiber, great rice & cereal substitute
  • Quinoa – some people cannot eat even this very ancient and relatively safe grain
  • Steel-cut gluten-free organic oats

Snacks – all fruits, humus and vegies, popcorn made with coconut oil, organic gluten free brownies, chocolate covered bananas or strawberries, apples and cashew butter, gluten-free crackers and cheese, raw or seasoned roasted nuts

Does someone you love suffer from an eating disorder?

Dr. Renae Norton specializes in the treatment of eating disorders. Located in Cincinnati, Ohio. Call 513-205-6543 to schedule an appointment or fill out our online contact form for someone to call you to discuss your concerns. Tele-therapy sessions available. Individual and family sessions also available.

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