For many of us, the first step toward recovery from an eating disorder is realizing and admitting that we have one. Knowing the process of defining bulimia nervosa can help us understand what it is and what it isn’t. Clarity and understanding can help us move away from stereotypes and toward understanding and effective treatment and support.

The Diagnostic Definition

Psychiatrists and other mental health professionals use the Diagnostic and Statistical Manual of Mental Disorders (DSM) in defining bulimia nervosa. According to the most recent version, DSM-5, the official diagnostic criteria include:

  • Recurrent episodes of binge eating. The DSM-5 defines binge eating as:
    • Eating a large amount of food (more than what most individuals would eat) within a two-hour period.
    • Having a feeling of loss of control.
  • Recurrent compensatory behaviors. Commonly known as “purging,” these behaviors can include self-induced vomiting, fasting, excessive exercise, or using laxatives and other medications.
  • Frequency. The cycle occurs once per week or more (on average) for three months.
  • Self-evaluation. Self-evaluation is heavily influenced by body shape and weight.

The episodes also should not occur during episodes of anorexia nervosa, which is a separate diagnosis. Those who don’t meet the exact criteria should still seek assistance if they are having episodes of binging and purging.

Understanding Binging

Since bulimia nervosa is a cycle, there is no true starting and ending point. Binge eating is one point on the cycle. Although the media tends to focus on the quantities of food, what truly sets a binge eating episode apart from overeating is the feeling of loss of control. Someone who is binge eating feels like they have to eat. It’s more than just a simple craving, and it’s not necessarily due to hunger.

Some binges have a “trigger,” which is a feeling or event that causes the binge. It could stem from an uncomfortable or painful emotion, such as sadness, loneliness, shame, or guilt. It could stem from an event, such as an argument or a break-up.

Bingeing could stem from food deprivation. A person can only ignore hunger for so long. Eating very little food or a limited variety of foods (in other words, dieting!), can lead to binge eating. The need to eat is primal and linked to survival. Restriction/dieting leads to an instinctive, natural need to eat and refuel.

After bingeing, someone with bulimia nervosa may feel painfully full, guilty, and ashamed. This leads to the next point in the cycle.

Understanding Purging and Other Compensatory Behaviors

In the media, self-induced vomiting is commonly used to compensate for a binge eating episode. In reality, that’s just one way people may compensate for bingeing. Some people may use excessive exercise or diuretics and laxatives to compensate. Others may severely restrict their food intake or fast to compensate. These behaviors are motivated by a need to “get rid of” the food and an attempt to avoid weight gain.

After the cycle, someone with bulimia nervosa may try to control their eating by restricting their food intake. They may feel back in control for a little while, until our biology kicks in and drives us to binge. Thus, the cycle continues.

What Causes Bulimia Nervosa?

No one is quite certain what causes bulimia nervosa. There may be a genetic component, as there is some evidence that eating disorders run in families. Emotional and mental health, societal expectations, and trauma may also play a role.

Risk Factors for Bulimia Nervosa

Anyone can be vulnerable to an eating disorder. There are some risk factors that make someone more likely to develop bulimia nervosa, but someone who doesn’t have these risk factors could still develop the disorder. Risk factors include:

  • Dieting/food restriction having a close relative with an eating disorder
  • Type one diabetes(According to the National Eating Disorders Association, about 25% of women diagnosed with type one diabetes develop an eating disorder.)
  • Body image dissatisfaction
  • Being bullied or teased due to weight
  • Isolation and loneliness

Body dissatisfaction is the most consistent risk factor for developing an eating disorder. The message that there is a certain size or shape that we are supposed to achieve and maintain is one we receive when we are very young. Although the media is slowly including more people with a variety of body types, progress is slow.

Recovering from Bulimia Nervosa

Learning the basics of bulimia nervosa is only a starting point. If you suspect that you or a loved one may have bulimia nervosa, it is important to talk to a specialist. Recovery is possible, but it typically requires professional assistance from a multi-disciplinary team. Recovery is a process, and it takes time and courage. No one has to go through it alone, though.

With time, people can break the cycle of binge and purge and learn to eat in a way that is nourishing. It’s a process of self-acceptance.

Melinda Sineriz is a freelance writer and fat acceptance advocate. Read more of her musings on Twitter or visit her website to learn more.