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In this paper I describe some aspects of the psychopathology of a bulimic patient who was 19 when she started treatment. I treated her in psychotherapy three times a week for three and a half years. In particular, I wish to stress the contribution made by this patient's extreme intolerance, both of psychic emptiness and, as importantly, of mental pain. This may indicate a phenomenon of general importance in bulimia. For clarity I have concentrated on the first year of the therapy, where the gradual unfolding of her difficulties, and of the ways in which she had tried to cope with them can be seen.
Anorexia nervosa has received a good deal of psycho-analytic attention (see particularly Tustin 1958; Pines, M. 1973; Kalucy 1973; and Thomä 1977); its counterpart, bulimia, (Fairburn 1982, 1983) somewhat less (notable exceptions being Sprince 1984 and Thorner 1969). In connection with both syndromes, psycho-analytic writers have stressed the patients' experience of emptiness, apparently resulting from traumatic experiences of separation from, and inconstancy in, the primary caring object. As will be seen, this was certainly evident in my patient. Indeed “emptiness” seems an inadequate word to describe the piercing and biting quality of the experience in which, as Bion (1962) and O'Shaughnessy (1964) observe, an absent object can be experienced as a very present and persecuting one. But in addition to that, and arising from it, my patient showed an inability to tolerate or think about any pain, including that arising from separation. I hope to show that, in order to understand the nature of the gorging and vomiting in bulimia, both the search to fill an inner emptiness and the extreme intolerance of mental pain need to be taken into account.