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�*�,/�] ���1�1���2������������������������������������������������������������������������{7vZ�:Breaking down Bulimia: The importance of positive aspects attributed to the disorder


Dimitris V. Bekiaris 1*and Marsha Koletsi b
a University of Bolton, Department of Psychology, UK
b New York College, Department of Psychology, Athens, Greece

Correspondence Author: Dimitris V. Bekiaris, 21 Larissis Str.,11523, Ampelokipoi, Athens, Greece. E-mail: dimitrisbekiaris@hotmail.com


Abstract
Background: Beneficial aspects of Bulimia Nervosa (BN) are rarely the focus of research and investigation.
Aims: Exploration of positive notions attributed to BN which contribute to its perpetuation, resilience and maintenance of the bulimic cycle.
Method: Interpretative Phenomenological Analysis was used to analyze data collected through semi-structured interviews with 5 women diagnosed with BN and were undergoing treatment for their disorder
Results: Freedom, a sense of normalcy and companionship were positive notions linked to BN as a concept. Binge eating was associated with filling an existential void created by the absence of positive emotions and transforming unbearable negative emotions and situations into something concrete and manageable. Self-induced vomiting provided immediate relief from excess food consumption and an optimistic stance for future terminating endeavors regarding the disorder.

Keywords: bulimia nervosa, positive emotions eating disorders.

1. Introduction
Despite the fact that disordered eating behaviors are mostly associated with negative affective states, growing evidence support the pivotal role of both positive and negative emotions not only in the development and maintenance of BN [1] but also in its overall course and treatment outcome [2]. Different parts of the bulimic cycle have been associated with a number of positive attributes. Extreme dietary restrains and their successive outcome may be heralds of positive emotions such as mastery, control [3], pride [4] and a sense of self-worth [5]. Binge eating is often utilized as a mean to alleviate negative affect [6], a dissociating mechanism for painful emotions [7] and facilitates reduction of aversive emotional self-awareness [8]. It also generate feelings of happiness, relaxation, relief and oblivion [9]. Self-induced vomiting offers instant relief from excessive food consumption and a sense of euphoria for getting away with something forbidden [10]. Feelings of happiness and relaxation are also attributed to self-induced vomiting, while relief was the dominant positive emotion [9]. �� as a concept provides resources to deal with personal, social and familial crisis, a somehow coherent sense of self, [11, 12] and a valuable companion over the years [10].

2. Method
Five participants volunteered for this study, Caucasian female of Greek ethnicity and residency, aged ranging from 29 - 40 years old, undergoing treatment for BN. Knowledge mobilization was achieved through Interpretative Phenomenological Analysis. Ethical approval was gained through the Research Ethics Committee by both University of Bolton and New York College while all necessary actions took place in order to safeguard anonymity, confidentiality and absence of harm.

3. Results

Three master themes emerged concerning the positive aspects attributed to the disorder: 
Positive aspects of participants regarding food consumption and binge-eating 
The role of self induced vomiting, in both present and the future.
The impact of the disorder on participants' sense of normality and feelings of loneliness (Table1) [13].






Table 1: Master Themes and Superordinate Themes


Master Themes
Superordinate Themes


Perception of food consumption and
binge eating

Absence of positive emotions - Filling the void
Replacing negative emotions and situations into a manageable problem


The role of self-induced vomiting in both present and the future

Positive aspects with immediate effect

Positive aspects related to future expectations



Positive attributes of BN as a concept

Freedom � release from �perfect self�
Perception of normality to self and others through BN
BN as companion
Strict family dietary rules and obsession with healthy lifestyles, was a common theme shared by almost all participants and binge eating served as a way to counterbalance the aforementioned excessive pressure and strict familiar demands. The act of binge-eating created a feeling of numbness and helped them overcome the sense of "void" that were experiencing and was manifested in feelings of boredom, dissatisfaction and lack of motivation. In addition, food consumption and binge-eating was conceptualized by participants as a means to anticipate and tolerate past negative life experiences such as loss, abandonment, (perceived or real), neglect, strict rules and high expectations into a manageable situation. Through binge-eating, external negative situations (family obligations, heavy workload, interpersonal difficulties) were transformed from "out of their reach and beyond "their control situations", into manageable problems, in which the responsibility resided with them, confirming once more the strong role of the concept of control in played in the development and maintenance of eating disorders.

Despite the fact that binge-eating brought many positive attributes in participants' life was also accompanied by a sense of shame and an array of negative emotions due to the lack of control exhibited by them in keeping the dietary schedule. As a result, purging was viewed as the immediate solution that alleviated painful emotions, doubts and self criticisms and served as a weight controlling strategy. Self-induced vomiting provided comfort and catharsis to both physical and psychological symptoms and effects and also restored hope and a more optimistic future of a new found strength for the abolishment of bulimic practices. For the participants, the opportunity to obtain the ideal self with the ideal shape and size could easier become a reality since self induced vomiting served as a corrective experience to extreme dietary schedule or extraneous exercising regime slips. 

Finally, bulimia was conceptualized as a rebellious act that provided freedom and independence to release participants'' selves from societal standards, familiar expectations concerning their own body shape, weight but also decisions about their education, relationships and everyday choices. It was described as a "safe place", in which they could enjoy in secrecy the privilege of expressing their real self and their own feelings. At the same time, it offered them power, control and a unique opportunity to appear in the outside word as being "normal' and not inadequate compared to other people. Furthermore, bulimia was described as a stable and timeless companion, always present and loyal in their hardships of life and everyday struggles to help them overcome them.




4. Discussion

Findings strongly support that bulimic behavior offer certain benefits reflected on people�s view of self, emotional regulation and everyday functioning. Future treatment protocols should aim on providing the resources and skills for people living with BN to acquire the sense of "normalcy" in order to live in the outside world without being in need of the advantages offered by the disorder. Focusing on building internal locus of control to define one�s self and provide insight on the benefits of the disorder, while building recourses to replace those "gains" with functional ones, are key aspects in reducing eating symptomatology and compensatory behavior through eating.



Acknowledgements
Sincere thanks and gratitude goes to the women who agreed to share their experiences and took part in this research, this study would not be able to materialize without their contribution. Great thanks to Konstantinos Zervos and Dimitris Athanasiadis for their valuable contribution to the recruitment process and facilitation of contact with participants. 

Conflict of interest statement
We declare that we have no conflict of interest



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9 Hsu LG. Experiential aspects of bulimia nervosa: Implications for cognitive behavioral therapy. Behavior Modification. 1990 Jan;14(1):50-65.

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12 Troop NA. Eating disorders as coping strategies: a critique. European Eating Disorders Review. 1998 Dec;6(4):229-37.

13 Bekiaris DV, Koletsi M. Subjective experience of positive emotions and impact of disordered eating behaviors in individuals with bulimia nervosa. Dialogues in Clinical Neuroscience & Mental Health [Internet]. 2019 May 16;2(1):37-54. Table 2, Master Themes and Superordinate Themes, p. 42. Available from: https://www.obrela-journal.gr/index.php/obrela/article/view/108/129

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