Understanding and Dealing with Bulimia and Anorexia

By: Michael G. Conner, Psy.D

Revised: May 21, 2014

Bulimia and Anorexia are challenging and sometimes severe problems to treat in any mental health treatment setting. As many as five out of 100 females with Anorexia die from acute medical problems. Both of these disorders can produce profound and lasting damage to a person’s health.

Researchers have concluded that Bulimia and Anorexia are primarily the result of social influences and pressures in countries where a popularized body size and appearance can only be achieved through unhealthy diet and exercise. Bulimia and Anorexia are found almost exclusively in females and can be detected as early as middle to late adolescence. People who intentionally starve themselves to achieve an ideas or desirable body image suffer from anorexia (termed anorexia nervosa). The disorder, which usually begins in young people around the time of puberty, involves extreme weight loss--at least 15 percent below the individual's normal body weight. Many people with the disorder look emaciated but are convinced they are overweight. Sometimes they must be hospitalized to prevent starvation. People with Bulimia Nervosa consume food and then rid ("purge") their bodies of the excess calories by vomiting, abusing laxatives or diuretics, using enemas, or exercising obsessively. Some use a combination of all these forms of purging. Because many individuals with bulimia "binge and purge" in secret and maintain normal or above normal body weight, they can often successfully hide their problem from others for years.

According to the Diagnostic and Statistical Manual of Mental Disorders, Anorexia and Bulimia can be diagnosed at any age, but the disorder can be found in children as young 8 years old. The diagnostic criteria for these disorders have been established by the American Psychiatric Association and is very similar to the International Classification of Disorders (ICD). When a child or adult demonstrates symptoms associated with an eating disorder, a full evaluation and diagnosis is essential. The prognosis is better when Bulimia or Anorexia is detected early and it is less favorable the longer the disorder exists and the longer it has been reinforced.

In the early stages, the symptoms of Bulimia and Anorexia are very difficult for parents and friends to detect. As these disorders progress, parents, friends and care givers will usually become suspicious as they notice weight changes, preoccupations with weight and appearance, and a pattern of avoidance behaviors in which friends or family become concerned about adequate nutrition and eating patterns. In a few cases, children will demonstrate symptoms of Depression or Anxiety disorder, a Conduct Disorder (CD) or Oppositional and Defiant Disorder (ODD). Children who become involved in drug abuse, primarily stimulants, may evidence loss of appetite and other behaviors that frequently look like Bulimia and Anorexia.

People with Bulimia and Anorexia have four primary problem areas. These include,

  • Control

  • Argument and Debate

  • Secretive Behaviors

  • Guilt and Shame

  • Obsession over weight and appearances

The psychological and emotional needs of people with Bulimia and Anorexia usually involve their appearances and control, or more specifically, avoiding the perception of being overweight and out of control. People with Bulimia and Anorexia are prone to view their friends or caretakers as people who are attempting to control rather than help them. It is crucial that friends and caregivers avoid falling into the trap of trying to control the eating behaviors of people with Anorexia or Bulimia. People who attempt to reason, persuade or coerce food intake, proper nutrition and to prevent purging are met with debate, argument, deception, defiance, anger, or in some cases, self-destructive behavior. The general response toward friends and caregivers who attempt to reason and persuade people with an eating disorders is often resistance, avoidance or defiance. At the same time, a person with Bulimia or Anorexia will make efforts to engage parents and caregivers by asking questions that present the possibility of compromise, but in reality lead to arguments in which the person always wins. The resulting message is "I am willing to discuss my refusal to eat or my purging, but I am not going to let you stop me. I will always win the argument. I am in control of my eating and purging, not you!!" This mixed message produces frustration in peers, friends, family and caregivers who fail to understand the rigid and unwavering nature of the obsession.

Anorexia And Bulimic Behaviors

  • Hiding foods

  • Avoiding and arguing over certain foods they can or cannot eat.

  • Comments that they are fat, unattractive and need to loose weight despite evidence to the contrary.

  • A pattern of leaving or asking to leave the group (usually within 1 hour) with some excuse soon after eating an adequate or large meal and then purging their meal without staff awareness.

  • A recurrent and increasing pattern over time of emotionality, low frustration tolerance, mental dullness, physical weakness or complaints of being cold that are the result of insufficient nutrition.

  • Arguments and pleas to friends or parents to keep their bulimic behavior secret and to keep information about their disorder a secrete from others.

  • Asserting that they can be trusted to not hurt themselves while minimizing and referring to the health education and increasing concerns about their health as stupid or unnecessary in their case.

  • Shame and guilt expressed in withdrawn and avoidant behavior that may appear shy, indignant or controlling, and may become defiant, argumentative or aggressive if ignored or challenged.

  • Obsessed thinking that borders on a fixation that is contradictory, illogical and irrational with regard to nutrition, food choice, purging, weight loss, the method and risks.

  • Exercising unnecessarily or in a secrete manner when others are not watching.

  • Attempts to form a close and confiding relationship with a friend or staff person (usually a female) to enlist their aide in persuading others to allow their behavior to continue and to separate their Bulimic or Anorexic behavior and the impact of that behavior from all other aspects of their life or treatment program.

  • Using defiance in terms of a refusal to eat, and then offering to eat in order to negotiate permission  to continue partial starvation and purging.

  • Increasing motivation to purge when emotionally distressed, nervous or feeling out of control following limit setting, confrontation or feedback by friends, therapists or peers that interprets their  behavior in terms of manipulation, escape, or an avoidance.

Medical Problems

In patients with anorexia, starvation will eventually damage vital organs such as the heart and brain. To protect itself, the body shifts into "slow gear": monthly menstrual periods stop, breathing, pulse, and blood pressure rates drop, and thyroid function slows. Nails and hair become brittle; the skin dries, yellows, and becomes covered with soft hair called lanugo. Excessive thirst and frequent urination may occur. Dehydration contributes to constipation, and reduced body fat leads to lowered body temperature and the inability to withstand cold.

Mild anemia, swollen joints, reduced muscle mass, and light-headedness also commonly occur in anorexia. If the disorder becomes severe, patients may lose calcium from their bones, making them brittle and prone to breakage. They may also experience irregular heart rhythms and heart failure. In some patients, the brain shrinks, causing personality changes. Fortunately, the later condition can be reversed when normal weight is reestablished.

Bulimia nervosa patients--even those of normal weight--can severely damage their bodies by frequent binge eating and purging. In rare instances, binge eating causes the stomach to rupture; purging may result in heart failure due to loss of vital minerals, such as potassium. Vomiting causes other less deadly, but serious, problems--the acid in vomit wears down the outer layer of the teeth and can cause scarring on the backs of hands when fingers are pushed down the throat to induce vomiting. Further, the esophagus becomes inflamed and glands near the cheeks become swollen. As in anorexia, bulimia may lead to irregular menstrual periods. Interest in sex may also diminish. Many times these people require medical attention for associated health problems that are related to loss of electrolytes, ulceration of their esophagus, deterioration of the stomach lining, bone loss, or damage to their teeth.


Treatment can save the life of someone with an eating disorder. Friends, relatives, teachers, and physicians will often play an important role in helping the ill person start and stay with a treatment program. Encouragement, caring, and persistence, as well as information about eating disorders and their dangers, are usually needed to convince the ill person to accept help. In a wilderness treatment program, there are inherent advantages and disadvantages.

Individuals with Bulimia or Anorexia must learn how to tolerate unpleasant feelings associated with less than ideal self-image and appearance. They must also gain a sense of control and self –esteem in their life that is independent of their physical appearance. It is essential that their friends or caregivers set boundaries and not argue. Parents, friends and therapists must be supported to respond to the individuals obsession with patience, compassion and confidence. Parents, friends and caregivers should avoid discussing and debating efforts to monitor the student’s behavior. This will demonstrate to the student that the caregiver will not enter into or create power struggles. Argument will only serve to reinforce the obsession and rigid stance the student is taking. Individuals with Bulimia must slowly learn to overcome their belief that their value and importance as a person or friend does not depend on their weight, size and shape. This cannot be accomplished through lecture and reminders. The unplanned and unstaged behavior of a caring and firm therapist or treatment program or the individual's peer group can communicate this more than anything. A high degree of repeated confrontation or argument from will only reinforce defiant behavior. The children will always "win" and remain in "control" if they simply refuse to eat or agree, or they continue to purge. In many cases, a student with bulimia or anorexia will prefer the sensation of starvation and the possibility of health problems and medical harm over the feeling of losing an argument or the belief that they are fat.

The complex interaction of emotional and physiological problems in eating disorders will sometimes call for a comprehensive treatment plan, involving a variety of experts and approaches. Ideally, the treatment team for complex cases will include an internist, a nutritionist, an individual psychotherapist, and a psychopharmacologist--someone who is knowledgeable about psychoactive medications useful in treating these disorders. Complex or advanced disorders requiring this level of support are not realistic admissions to wilderness programs.

To help those with eating disorders deal with their illness and underlying emotional issues, some form of psychotherapy is usually needed. A psychiatrist, psychologist, or other mental health professional meets with the patient individually and provides ongoing emotional support, while the patient begins to understand and cope with the illness. Group therapy, in which people share their experiences with others who have similar problems, has been especially effective for individuals with bulimia.

Use of individual psychotherapy, family therapy, and cognitive-behavioral therapy--a form of psychotherapy that teaches patients how to change abnormal thoughts and behavior--is often the most productive. Cognitive-behavior therapists focus on changing eating behaviors usually by rewarding or modeling wanted behavior. These therapists also help patients work to change the distorted and rigid thinking patterns associated with eating disorders.

Crisis Hospitalization

A significant loss of weight or overall weight less than 15% of normal weight may constitute a significant health problem.  People with Bulimia who refuse to eat for an extended time will become medically and mentally compromised. Conditions warranting hospitalization include excessive and rapid weight loss, serious metabolic disturbances, severe depression (with neurovegetative signs), risk of suicide, repeated sycopal episodes, severe binge eating and purging, or psychosis. Most emergency departments that are medical and not psychiatric are able to recognize or respond with appropriate understanding of the needs of child or adult with Bulimia and Anorexia.  Primary treatment of Bulimia or Anorexia in a hospital setting is not the preferred first treatment method unless there is severe medical or behavioral instability.


The use of medications, especially an initial trial of a medication can be very appropriate. Starting an individual on a medication while in outpatient treatment reuires that staff be trained to recognize associated side-effects and to respond appropriately. The patient’s mental and medical status must be monitored. The use of antipsychotic drugs (e.g., haloperidol or respiridone) are not indicated. Monoamine oxidase inhibitors (MAOIs) have been used for people with Bulimia and Anorexia but with some success to address patients who are overly sensitive to rejection. However these drugs have potentially life threatening side effects if a student eats certain foods. Other antidepressants have also been found to be effective in reducing anxiety, depression and obsessive compulsive behavior. Brief use of antianxiety medication has been used to relieve episodic or intense anxiety. Long-term use of antianxiety medication should be considered with caution because of their propensity to reinforce medication seeking behavior and further escape and avoidance behavior. Scientists have examined the effectiveness of combining psychotherapy and medications. In a recent study of bulimia, researchers found that both intensive group therapy and antidepressant medications, combined or alone, benefited patients. In another study of bulimia, the combined use of cognitive-behavioral therapy and antidepressant medications was most beneficial. The combination treatment was particularly effective in preventing relapse once medications were discontinued. For patients who binge only, cognitive-behavioral therapy and antidepressant medications may also prove to be useful.

Copyright 1999 to 2008, Michael G. Conner