The current clinical and social explanations of bulimia in the United Kingdom are based upon two premises: 1) that bulimia is a derivative of anorexia, and 2) that it is a hierarchically “lower” disorder, meaning that it is worse to have than anorexia. These explanations of bulimia revolve around the concept of “control” and conceptualize a particular bulimic “subjectivity.” By “subjectivity,” I mean the kind of person or subject that these techniques aim to create (Foucault 2004; Hacking 1986).
Ideas about bulimic “character traits” and the nature of bulimia reflect common ways of understanding bulimia and anorexia in psychiatric practice and literature (APA 2013; Cooper & Fairburn 2000; Schmidt et al. 1993). They are rooted in the following underlying premise: If the bulimic could, she would starve herself. This premise creates a hierarchical dichotomy between anorexia and bulimia in which anorexia becomes the “successful” eating disorder, and it creates a particular depiction of the bulimic: unlike her anorexic counterpart, she is “overwhelmed” by her “impulses.”
In this essay, I will show how that depiction is problematic. Based upon a year of fieldwork conducted in the UK (mostly in and around London), it draws on interviews with health professionals such as psychiatrists, psychologists, dietitians, nurses and researchers about bulimia. I analyze an interview excerpt from to highlight some important aspects of contemporary psychiatric “styles of thought,” a phrase that refers and draws attention to both discourses and practices, coined by sociologist Nikolas Rose following Ludwik Fleck (Rose 1999). In doing so, I wish to highlight current depictions of bulimic patients, and why these are important in the context of treatment.
According to the Diagnostic and Statistical Manual (DSM-V) and the International Classification of Diseases (ICD-11), bulimia is an eating disorder characterised by recurrent episodes of “binge eating,” during which the person swallows large amounts of food. Binges are followed by compensatory behaviours, such as purging, exercising, the use of laxatives, or dieting. Like other eating and feeding disorders, the DSM defines bulimia as a “severe mental illness” (APA 2013). In doing so, the classification moves from practice to identity: bulimia is described as an “act,” but being diagnosed with bulimia (as a “bulimic”) refers to a person who is bulimic.
Most work on eating disorders in psychiatry, psychology, and the social sciences have focused on anorexia. This might be due to the fact that bulimia is a “young” diagnosis: it was added to the DSM-III in 1981, a few years after the British psychiatrist Gerald Russell wrote his influential 1979 paper: “Bulimia Nervosa: an Ominous Variant of Anorexia.” Since the publication of Russell’s research, the conceptualisation of bulimia as a variant of anorexia has remained tenaciously persistent.
Take for example Sandra’s characterisation of “bulimics.” Sandra is a senior psychiatrist whom I interviewed during my research project. She works in a prestigious research unit in London. We were talking about the effectiveness of particular treatment models for bulimic patients and anorexic patients when she said:
[P]eople with bulimia are often a bit wilder [than anorexics] – especially when they’re bingeing. [A] treatment that helps them to develop a bit of a structure for regulating themselves, their lives, their impulses is helpful. […] Bulimia… it’s a terrible generalisation, but certainly there are some wilder people amongst them, some of them quite chaotic, some who are impulsive, some who are generally just a bit larger-than-life kind and like lots of new things, excitement of stuff. (TR 24.10.2018 (1) 62-75)
First, Sandra contrasts bulimia with anorexia by saying that, as opposed to anorexics, bulimics tend not to be so structured and organised (her answer is about why a particular treatment works “better” for bulimics than anorexics). Second, Sandra links this “wildness” and “lack of structure” to chaos and impulsivity. It is because of their presumed impulsivity that a “structured” form of psychotherapy (cognitive-behavioural therapy or CBT) can particularly help bulimics. This way of characterising bulimics and how treatment might help them, says a lot about how they are portrayed as opposed to anorexics.
Sandra paints a picture that consists of a spectrum with two “axes”: anorexia stands for control and structure and bulimia stands for impulsivity and “lack of structure.” As she has established experience in the field, Sandra is aware of this opposition between anorexia and bulimia that exists in psychological literature. She says that “it is a generalisation” (even a “terrible” one) to describe bulimics as “wild” and anorexics as “rigid.” Still, as her answer highlights, the idea of bulimics as more impulsive than anorexics plays a role in how Sandra thinks about treatment, and which treatment bulimics should – and do – receive.
This complicates common interpretations of bulimia and anorexia: although they are constantly compared with each other, clinicians like Sandra and many other interviewees describe bulimics as possessing particular character traits and even having a particular kind of “personality.” This personality is very different from the “anorexic” one, which complicates the interpretation of bulimia as “variant” of anorexia. Although it is based upon, as Sandra says, “a caricature,” contrasting anorexics with bulimics does divide them into different “kinds” of patients, just like the different diagnoses do. This labelling of patients does more than just describe them; it also puts forward some expectations on behaviour, character, and personality (cf. Hacking 1986).
Interpreting bulimic behaviour as a lack of control is problematic. First, it exclusively focuses on bingeing but does not pay attention to other symptoms of bulimia, such as the preceded restriction of food intake or compensatory behaviours (such as purging). Symptoms like purging, exercising, or dieting are difficult to fit into this logic, as they require quite some organisation (how and where to do it, and how often, which behaviour works best, etc.). Moreover, the binges are framed as failed attempts to restrict (as the bulimic is said to “lack control”). Hence, bulimia practitioners tend to describe bulimia as “failed anorexia.” The bulimic, they say, is “too impulsive” (or wild or chaotic) to persevere a strict restriction.
Next to the conceptualisation of bulimia as “failed anorexics.” which has been the focus of important research (Bordo 2004; Burns 2004; Eli 2016; Frey 2019; Tucker 2016), I found a different mechanism at work. Health professionals do conceptualise bulimia as the expression of a “bulimic self”: because of her “chaotic” eating patterns, the bulimic patient herself is often viewed to be chaotic and impulsive personal in general. As we have seen, Sandra linked bulimia and one’s susceptibility to develop it to particular “traits,” such as impulsivity.
This picture of a bulimic “personality” frames the bulimic patient not only in terms of her “behaviour,” but more fundamentally as a type of person. The conceptualisation of the bulimic as “impulsive” and “chaotic” risks reinforcing the stigmatisation of bulimic patients. How the notion of “control”, and the ability to discipline one’s self is used in descriptions of patients, and what styles of thought they originate from, are crucial to analyse. This is especially the case given how psychiatric patients are increasingly portrayed by clinicians and mental health institutions as active participants in their treatment who need to be “responsibilised” in order to make their treatment a success.
Leonie Mol is a PhD student in the Department of Global Health & Social Medicine at King’s College. She is carrying out an ethnographic analysis of bulimia nervosa.
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