Much of what has been said about the anorexic and her family is also true of the bulimic. The bulimic is likely to be a good student or employee and desire a high level of achievement, but at the same time has many self-doubts and feels insecure about her ability to handle life's demands and difficulties. She fears she is inadequate and does not have the tools to reach the goals she has set for herself. She believes she does not measure up in looks or accomplishment to other people, and may experience problems interacting with them because of this sense of inferiority. She wants to be part of the crowd but fears she will not be accepted.

Stress, anxiety, loneliness, and depression, may cause her to eat large quantities of food as a way of releasing the tension. She cannot control her desire for food, but she can control whether it remains in her body. Some people turn to alcohol or drugs when they are under stress, upset, or depressed - bulimics turn to food.

Many bulimics fear that once they start eating, they will not be able to stop. They binge and then purge as a means of giving in to their desire for food and then controlling it.

The central features are:

• recurrent episodes of uncontrollable overeating
  
  
• efforts to undo the effects of binge-eating by self-induced vomiting, severe caloric restriction, excessive exercising, use of legal or illegal appetite suppressants, and/or use of laxatives or diuretics
  
  
• chronic anxiety, guilt, depression, and tension
  
  

Commonly associated characteristics are:

• drastic weight fluctuation
  
  
• impulsivity and emotional instability
  
  
• acting-out via substance abuse, theft, self-mutilation and/or promiscuity
  
  
• problems with social adjustment
  
  
• depression
  
  
• a high need to achieve in order to obtain the approval of others
  
  
• shop-lifting

Bulimics have periods of over-eating which become out of control. These may follow excessively long periods of starvation. The process of starvation leads to cravings for food, which become so strong the sufferer loses control and "binges". After a binge a bulimic may resort to laxatives or diuretics, as well as vomiting, to get rid of the effects of bingeing. Many bulimics have a previous history of anorexia nervosa and either "discover" bulimia nervosa, or turn to bulimia nervosa, believing it will solve their dilemma of wanting to eat whilst remaining thin. Initially, bulimia nervosa may seem to hold the answer for people who are dissatisfied with their lives and dislike what they are. However, the answer is superficial, and sufferers rapidly find themselves trapped in a dangerous cycle which reinforces self degradation, guilt, and shame. Although some bulimics never experience a real anorexic episode, they nevertheless share the anorexic's abnormal concern about weight and shape, control and lack of control, and fundamental need to accept their imperfections as possible strengths.

Occasionally there are bulimics whose weight swings from high to low over a period of years, a reminder that anorexia nervosa and bulimia nervosa are not mutually exclusive.

As with anorexia nervosa, there is no one way of offering help to bulimics. What suits one woman might not suit another, and anyway not everyone has access to all forms of treatment. One of the greatest difficulties facing women wanting help at present is the sheer lack of resources available.

Bulimic women generally experience extreme ambivalence about giving up the symptom, and this is a profound problem for those offering help. In some situations when the sufferer is in a life-threatening condition, or there are other problems involved as well as bulimia, she is admitted to an in-patient hospital programme. But this is not the case for most bulimics.

Unlike anorexics, most bulimics recognise their eating disorder and desperately want help. In another sense however, the bulimic woman's ambivalence about allowing herself to take in anything good can make it difficult to receive help.

Self-help programmes or self-help groups, combined with back up counselling support or therapy, and the motivation of the bulimic herself, can prove a successful way of tackling this very difficult problem.

Neither anorexia nor bulimia can be cured overnight. Recovery is a long hard process, which often requires the bulimic to face those painful issues she has been avoiding by being bulimic. She will experience all sorts of difficult feelings (depression, anger, frustration, rage). She may also need help in re-learning about "normal" eating. The recovered bulimic should also be aware that she needs to develop ways, other than bulimia, of coping with stress.