In an episode of “The Crown” — ironically titled “Fairytale” — Diana Spencer, the future princess of Wales, is desperately lonely, anxious and restless in Buckingham Palace in the days before her wedding to Prince Charles.
The Netflix series shows her sneaking into the kitchen and urgently devouring huge spoonfuls of chocolate pastries, one after another, straight out of the fridge. Most viewers know what will happen next even without watching because the real Princess Diana was frank about her struggle with bulimia: the binge eating is followed by self-induced vomiting.
The purging scene is graphic and raw at the insistence of Emma Corrin, the actress who plays Diana in season four of “The Crown.”
“I was very determined that I didn’t want it just to be alluded to — I didn’t want it just to be a flushing of the toilet or her wiping her mouth,” Corrin told Vogue.
“I wanted you to see her experiencing it because she was so candid about her struggles with the media, which I think was incredibly ahead of her time.”
There’s been an increase in conversation about bulimia since the new episodes were released, said Cynthia Bulik, founding director of the University of North Carolina Center of Excellence for Eating Disorders.
She praised “The Crown” for accurately portraying the condition.
“It's real and I think for people who have the illness to not show it is almost disrespectful because it's as if it's like there's something that's too shameful about it,” Bulik told TODAY.
“The more honest we can be about how horrible this illness is — it's a great step toward destigmatizing it.”
Bulimia nervosa is a potentially life-threatening eating disorder that can affect the entire digestive system, lead to electrolyte and chemical imbalances, and impact the heart and other major organ functions, the National Eating Disorders Association warned.
Teen girls and women in their early 20s are most at risk, according to the Office on Women’s Health.
Up to 2% of young women and 0.1% of young men have bulimia, which is characterized by a cycle of eating large amounts of food in a short period of time, then trying to prevent weight gain through self-induced vomiting, laxatives, fasting or an extreme amount of exercise.
It can be a hidden illness because unlike anorexia nervosa — which leads to weight loss — people with bulimia often fall within a healthy weight range when they're ill.
Diana’s story line in “The Crown” is one of the most high-profile portrayals of bulimia in the last few years, said Lauren Smolar, senior director of programs for the National Eating Disorders Association.
“We've really seen this renewed interest in talking about eating disorders… and we're super grateful for that opportunity,” she said.
The organization didn’t provide input into the series, but episodes that show Diana binging and purging begin with a trigger warning that prepares the audience for “scenes of an eating disorder which some viewers may find troubling.” It also invites those struggling with the illness to visit a website with links to resources, including a link to NEDA.
Bulik was pleased with the trigger warning. She also praised the portrayal for showing Diana’s emotional turmoil, and her lack of resources to express her feelings.
“When she started eating the piece of chocolate cake at the refrigerator, it opened the door and sort of provided some release for all these pent-up emotions,” she said.
“That was actually very, very accurate because binge eating and purging is often a release for uncomfortable emotions when you don't have other methods of regulating them.”
The scenes could be tough to watch for people who may be struggling with bulimia or have recovered, both Bulik and Smolar said. For those who may be triggered, it could be a good idea to watch with a friend or family member, or just skip those episodes, Bulik advised.
The renewed conversation about bulimia comes as doctors have seen an increase in eating disorders associated with the coronavirus crisis.
The National Eating Disorders Association reported a 75% uptick in call volume to its help lines in March and April, with calls still very much above the norm this fall.
A study examining how the COVID-19 epidemic has impacted people with eating disorders found those with bulimia nervosa and binge-eating disorder reported increases in their binge-eating episodes and urges to binge.
Adding “The Crown” into the mix could be “almost like a double whammy” for some of them, Bulik said. “This is a really high-risk time for relapse because there's so much uncertainty and so much anxiety, and so this could be just something else.”
One of the biggest misconceptions about bulimia is that it’s a choice, both Bulik and Smolar emphasized. Experts believe it’s triggered by a person's biology and life events.
The disorder is a genetically-influenced illness — not something associated with vanity or wanting to look a certain way, Bulik noted. She leads an international consortium on the genetics of eating disorders and is seeking participants for the world’s largest study on the subject.
“People sometimes say, ‘Well, why don't you just stop?’ From my perspective, that's like telling someone with asthma, ‘Well, why don't you just breathe?’” she said.
The first step to get help can be talking with a primary care physician — now is an excellent time because telemedicine is widely available.
People can also reach out to an organization like the National Eating Disorders Association, which offers support and resources.
Bulimia patients usually need help to recover and the treatment of choice is cognitive behavioral therapy, Bulik said. Princess Diana underwent treatment in the late 1980s, which was not shown in the current season of “The Crown.”
“An eating disorder can be really isolating and it's sometimes something that people feel like they need to keep a secret because of stigma,” Smolar said.
“We're hopeful that when we're seeing conversations like this one, it’s going to raise awareness and help people recognize this is an opportunity to get help and that they aren't alone.”