As one of the most well-known kinds of eating disorders, bulimia nervosa affects over 5 million men and women in the United States alone. Although the stereotype holds that only women have the disorder, almost 25 percent of cases are observed in men. Another stereotype surrounding bulimia nervosa is the misconception that it’s primarily about food.
On the contrary – bulimia nervosa’s notorious cycle of binge eating sessions followed by purging is a behavioral symptom, not the cause.
Many factors combine to cause bulimia nervosa in the (mostly) young men and women it commonly afflicts. There are genetic factors; people whose parents had bulimia nervosa are much more likely to develop the disorder themselves. Similarly, there are biological factors. Women and girls predominate the diagnosis of bulimia nervosa, although it’s becoming clearer that eating disorders are under-reported by men. Despite these potential causes, psychological and psychiatric factors are the best indicators of a burgeoning case of bulimia nervosa.
Parents and other caregivers, peers at school and work, and the media in all its forms all send conscious and unconscious signals about weight and expectations. They imply that a person’s body should meet an idealized form and appearance; in many cases, the media outright says so. Because of this, a large part of bulimia nervosa treatment programs focuses on rehabilitating body image and learning acceptance and self-love.
Body Image and Self-Esteem
So, bulimia nervosa isn’t really about food. What’s it all about, then?
In short, it’s about being dissatisfied with one’s body, especially one’s weight.
Most people feel negative about their bodies at some point in their lives. Body image is a central part of how we see ourselves, how we interact with others, and how attractive we feel. In most forms of eating disorders, the individual suffers from a not only negative but distorted body image. Regardless of their actual weight or body shape, they tend to perceive themselves as “fat” or “overweight.” People with bulimia nervosa are often at a “normal” weight, but still, perceive a need to diet or lose weight.
This results in disordered eating patterns that are designed to force weight loss, such as the self-starvation that accompanies anorexia nervosa. With bulimia nervosa, the defining behavioral symptom is a cycle of binge eating episodes, in which a person will eat a large amount of food in a short period, and then purge those calories through a variety of means. The most common method is self-induced vomiting, but abuse of laxatives and diuretics, excessive exercise, and abusing diet pills are also frequently observed.
In striving to lose weight (even if they are dangerously underweight in reality), people with bulimia nervosa are striving to improve their self-image.
Behavioral Symptoms of Bulimia Nervosa
As per the DSM-V (the official manual for diagnosing psychiatric illnesses), a diagnosis of bulimia nervosa includes the following criteria:
- Recurrent episodes of binge eating, as characterized by both:
- Eating, within any 2 hours, an amount of food that is definitively larger than what most individuals would eat in a similar period under similar circumstances.
- Recurrent inappropriate compensatory behaviors in order to prevent weight gain such as
self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting or excessive exercise.
- Binge eating and inappropriate compensatory behaviors occur, on average, at least twice a week for 3 months.
- Self-evaluation is unjustifiability influenced by body shape and weight.
The first three items describe the typical behaviors caused by bulimia nervosa, but for our purposes, item D is the most relevant. A central part of a bulimia nervosa diagnosis is the individual’s inability to accurately perceive their body weight. What’s worse, this distorted perception negatively influences their self-esteem and self-image.
Perfectionism and Reaching for Unattainable Goals
Disordered body image leading to a case of bulimia nervosa is often fueled by perfectionism. Perfectionism, in a clinical sense, isn’t the laudable trait many people assume it to be. Rather than a barista trying to make the perfect cup of coffee, for example, or a lawyer making an airtight closing argument, clinical perfectionism often leads to chronic self-esteem issues.
All too often, maladaptive perfectionism leads people to chase unattainable goals. In cases of bulimia nervosa, the individual is trying to achieve the “perfect body.” Despite the methods used to attain this kind of “perfection” being potentially harmful, with health consequences such as heart disease, malnutrition, and eroded teeth, people with bulimia nervosa will continue to lose weight.
Perfectionism also inspires negative feelings and exacerbates symptoms of depression. Since the goal of a “perfect” (skinny) body is not reachable or healthy, people with bulimia nervosa might feel like failures, inspiring more negative self-esteem issues and furthering the cycle.
How the Media Influences Self-Image
Add to this the presentation of “the perfect body” in films, TV, advertising, and even social media, there are constant assaults on their self-esteem. When caught in a cycle of shame about binging and purging (a common feeling for people with bulimia to have), and seeing what society presents as perfection, a feeling of hopelessness can set in. While their relationships with food are disordered, the root cause is more often than not driven by a sense that their body is flawed, and an overwhelming compulsion to somehow “fix” those flaws.
Advertising plays a key role, too. In ads for everything from cars to clothing, people are shown actors and models with skinny bodies, implying that the “best” people are those who have unattainable, “perfect” bodies. The subliminal, and sometimes overt message this carries to at-risk people is that only those with slim bodies deserve to be happy (i.e. buy those products).
This is even more explicit when it comes to advertisements for the diet industry. Products like diet soda, weight-loss pills, and services like gyms and diet programs all portray overweight people as unhappy and unfulfilled. Certainly, doctors recommend eating in moderation and regular exercise, but for someone with an eating disorder, these messages reinforce the desire to lose weight and “regain control” over their body. A multibillion-dollar industry focused on weight loss has an inherent interest in making people feel unhappy about their bodies – and take extreme measures to achieve what they present as the ideal.
Social Media’s Role in Promoting the “Perfect Body”
Although it’s hardly new media any longer, social media has had continuing effects on the diet & fitness industry and people’s self-image. It’s even more invasive than traditional media; virtually every in America checks their phone multiple times daily, and some apps like Instagram report 500 million daily users – more than the total population of the United States. Social media has a huge influence on the way we interact with the world around us.
It’s had an impact on the eating disorder community as well. The Senate hearings in 2021 just confirmed something that was already well-known in treatment circles: social media has a powerful negative influence on people’s self-esteem, especially adolescents’. This is especially crucial because the age of onset for bulimia nervosa and other eating disorders is usually during the teenage years for both boys and girls. At this age, teenagers are still impressionable and coping with their changing bodies and roles in society.
Social media also promotes the myth of a perfect body through its many fitness and beauty influencers. These models and content creators often use carefully staged or photoshopped images to promote products or boost their following. These altered images are literally unattainable body types; the quest to “perfect” their body can be exacerbated and continued by following them.
To be fair, social media can also provide support systems and positive communities for people with eating disorders. “recovery communities” are widespread, and most major eating disorder institutions like NEDA maintain a robust presence online. They can help counteract the negative influence weight-loss and beauty influences can exert.
The Perfect Body Isn’t Real. Eating Disorder Recovery Is.
Bulimia nervosa treatment can be very effective, although it’s never a “quick fix.” Months and often years of therapy are normally required. However, it can result in a full recovery if the underlying causes are properly addressed. One way to do so is to promote the concept of HAES, “Healthy At Every Size,” which helps people with flawed body image and perfectionism embrace their natural body shape and size and learn to accept themselves as they are.
A HAES mindset can be promoted through mindfulness and therapy techniques that promote it. By learning to accept emotions and disordered thoughts without acting on them, eating disorder recovery programs can help their clients manage the behaviors symptomatic to bulimia nervosa and other eating disorders. Very often, techniques like Dialectical Behavioral Therapy (DBT) and Cognitive Processing Therapy (CPT), both of which work on understanding negative emotions and replacing them with healthier reactions, can make the difference between recovery and continued disordered eating. If you or a loved one is struggling with bulimia nervosa or a distorted body image, don’t wait. Reach out for help and get started on a happier, healthier life.
Melissa Orshan Spann, PhD, LMHC, RTY 200, is Chief Clinical Officer at Monte Nido & Affiliates, overseeing the clinical operations and programming for over 50 programs across the U.S. Dr. Spann is a Certified Eating Disorder Specialist and clinical supervisor as well as an accomplished presenter and passionate clinician who has spent her career working in the eating disorder field in higher levels of care. She is a member of the Academy for Eating Disorders and the International Association of Eating Disorder Professionals where she serves on the national certification committee, supervision faculty, and is on the board of her local chapter. She received her doctoral degree from Drexel University, master’s degree from the University of Miami, and bachelor’s degree from the University of Florida.