A Clinical Insight into Bulimia Nervosa – An Interview with Eugene Beresin

“This is a marathon, not a sprint”

Q1) Dr. Beresin, you are the executive director of The Clay Center for Young Healthy Minds at Massachusetts General Hospital (MGH). What are the questions that most frequently arise regarding Bulimia Nervosa?

There are a number of common questions about bulimia nervosa. I would list them as follows:

1. What is the typical course of the illness? How long does it last?
2. What are the most effective treatments for bulimia nervosa?
3. Are there other psychiatric disorders associated with bulimia nervosa, and if so, how do they interact?
4. What are the medical complications of bulimia nervosa?

Q2)Typically, how does Bulimia start?

Bulimia nervosa typically begins when a young woman (it is most common in women) is concerned about her weight and feels she needs to purge to get rid of the food and reduce her caloric intake. Often at the same time, there is a craving for eating foods such as carbohydrates and then throwing them up. Some people with bulimia will purge following most meals, others will have late night cravings for foods, eat them rapidly, often standing, and then feel bloated and purge.

Purging typically is accomplished by vomiting, but other times, purging may be done by using laxatives, diuretics, or even by excessive running.

Many feel that bulimia is like an addiction. There is an irresistible urge to eat and feel full. Then to rid the body of the food and calories, and often to get “relief” from feeling bloated the purging occurs.

Q3) As you explain in your article, shame plays a vital role in suffering from bulimia. How can those suffering from it stand up to their shame in order to reach out for help?

Shame is common in bulimia nervosa. The individual is terribly upset and embarrassed by excessive overeating and purging. Many have a very hard time reaching out for help as they feel too embarrassed by their behavior. The shame is not the cause of seeking help; in most cases, it actually prevents the individual from seeking help.

Individuals will seek help from bulimia for a number of reasons. First, the disorder feels like a terrible addiction, and it is so emotionally painful that help is sought to stop the pattern. Folks in this situation feel totally out of control. In other cases, help is sought because bulimia affects social or work life. Many cannot go out to dinner, parties or socialize without the need to purge. This is so disruptive to living a normal life that the individual seeks help.

Finally, and especially in younger individuals, help is sought because a family member or friend finds out about the bulimia and insists on getting help.

Q4) How do families react to the revelation of the “secret”? What is it that families need to do to help in the therapeutic process?

Most family members are shocked by the revelation of the secret. Many are concerned that there will be medical complications of the disorder. Emotionally the reactions typically are shock, and fear of more or other self-destructive behavior. Most family members will try to talk with the person who has bulimia nervosa and convince her to get help but find themselves pushed aside. Help rejection is very common. Most family members simply cannot understand why one would overeat to such a great extent and then purge. It is commonly viewed as “disgusting” by family member – only adding to the shame of the individual with the disorder.

Family members need to stay calm and try to understand the person with bulimia. This is not easy because folks with the disorder just do not want to talk about it. The best approach is trying to take an accepting, understanding and empathic approach. Attempts to force individuals into treatment often just don’t work, unless the person is very young and, as a minor, is forced into treatment by parents.

Another and very important role for family members is to see bulimia nervosa, as other eating disorders not simply as a problem of the individual but a sign that there is a family problem. When the family sees this as a family disorder and seeks help for “all of us” there is often a better response in the individual accepting help. And frankly, bulimia nervosa is often a psychosomatic disorder that does, in fact, represent hidden family conflicts, such as abuse, neglect or other family problems.

Q5) In your article, you talked about discontinuation being a risk factor in bulimia. Could you explain this further? 

I am not sure what you mean by discontinuation. If you mean that stopping bulimic behavior may lead to other psychiatric problems, it is not uncommon for other sources of tension relief to follow bulimia nervosa. While the disorder is a way of attempting to control weight, it is often a symptom of tension relief. This tension may be due to post-traumatic stress disorder, a mood or an anxiety disorder. The bulimic behavior is often a way of relieving tension, and when it stops, the tension may be relieved in other ways, such as cutting, substance misuse, or increase feelings of depression.

Q6) In which ways can meditation help in overcoming bulimia?

Many people with bulimia nervosa are driven by excessive anxiety or obsessions about their body image. Meditation is a very effective means of calming emotions, redirecting focus to healthy objectives, and providing effective control over impulses.

There are many forms of meditation, but the ones that I like are ones, like hypnosis, that encourages individuals to repeat a “mantra” or what we call a “hypnotic suggestion” that may help redirect thinking. So, when in a deep state of meditation, saying “I will not feel fat” or “I will not have an impulse to eat” or “I will eat normally” may make a big difference following regular meditation.

Meditation is a very effective technique to help control emotions, thoughts, and behavior. However, like many skills, it requires practice and regular use on a daily basis.

Q7) What do you tell patients who are skeptical towards medication?

The Selective Serotonin Reuptake Inhibitor antidepressants (SSRIs) are very effective in decreasing binge eating. It is estimated that medications such as Prozac, Zoloft, or others in this category decrease binging episodes by about 2/3, or 66%. The mechanism of action for this is not exactly known but it may be that the medications decrease impulsivity and this can then help the individual stop the need to binge. These medications also decrease anxiety, panic attacks, and depression that may be associated with bulimia.

While medications are extremely helpful for treating bulimia nervosa, they are not the only answer. The excessive focus on weight, on a distorted body image, and obsessions about food, purging and eating all require other means of help besides medications. However, effective psychotherapy such as Cognitive Behavior Therapy (which is often the most effective) can be helped tremendously if medications decrease binging impulses, anxiety and depression.

So, I tell patients that while medications are not a cure, they may be really valuable helpers in decreasing feelings and impulses so that effective psychotherapy and behavioral management can come along easier.

Q8) How can those who recovered from bulimia find their fuel to keep on track, or like you said, keep running the “marathon”?

Those who have recovered usually find new ways of seeking control in their life – controlling their emotions, impulses and behaviors in new ways. Being mindful on a regular basis of the new patterns they have adopted results in positive self-esteem and keeps many on track.

It is also incredibly important to stay on track through relationships. When an individual with bulimia nervosa has an open relationship with a friend, family member or partner and works through the problems with this important individual, recovery is “shared” and this helps tremendously.

Q9) Do you have any advice for mental health professionals in working with those suffering from bulimia?

Simply this: Hang in with your patients! This is, indeed, a marathon and not a sprint. Most of all, try to understand and empathize with your patients. They long for a caring relationship and need to be appreciated as an individual. Your relationship with them is critical for their well-being, and they need you to focus on them as people and not simply as patients with a disorder. Understanding them in the totality of their life – their identity, personality, interests, friends, passions, strengths and weaknesses are all crucial. Do not simply see them as someone with an eating disorder. Find out who they are and reflect this back to them. Overcoming bulimia nervosa is often the journey of self-discovery, and you are critical in this process.