Case Study of Bulimia Nervosa

Case History

Background Information

The client, Rita is a 26-year-old manager of the women’s dress department in a large department store. Her childhood was not a happy one since her parents divorced when she was about 5 years of age. She would often describe her childhood as utterly chaotic, as if no one were in charge though when she entered high school, the household seemed more manageable. Ultimately, she developed a “too close” relationship with her mother, that she was the entire focus of her social life and thus preventing her from developing serious friendships.

She attended college but quit after 3 years to take a job in the department store which was a well-paying job. Just before leaving college, Rita began a serious relationship with a man who became his fiancé but sadly developed schizophrenia and had to be hospitalized and which eventually forced her to end their relationship with her feeling as if her boyfriend has died.

But she had she had eventually coped with this tragedy, and eventually she was able to move on with her life and to resume dating again. However, a serious relationship eluded her. Rita knew that she was a moody person-she judged people harshly and displayed irritation easily-and, she believed, this discouraged potential suitors. She suspected that she was known as a “crank” at work, and she found it hard to make close friends.

In addition, throughout her adolescence and young adulthood, Rita had always been sensitive to people’s opinions about her appearance and weight thus she developed the habit of weighing herself several times a day, to assure herself that her weight did not exceed her expectations.  At the same time, the frequent weighing had its downside since when she observed a slight weight increase she would have a very negative reaction:

She would feel fat and bloated and would resolve to limit her eating to a much stricter version of her weight watcher’s plan and thus would throw in extra exercise sessions for good measure and would avoid anyone seeing her “fat” body, she would hide it under bulky sweaters and other concealing clothing.

Description of the Presenting Problem

The problem or symptoms presented by Rita includes:

• 6 months of bingeing which had become more regular which she felt little or no control;
• she experienced a gradual weight gain, “ballooning,” as she called it, and she  felt desperate to lose the weight;
• becoming increasingly worried that she might resort to more extreme measures,
•   such as purging at work, in order to lose weight

In addition to all these, pressure from society to be thin is believed to be the most immediate triggers for the onset of bulimia include unusual or extreme stressors and feelings of loss of control (Agras, 1995).  In addition, several researchers (Stice, Burton, & Shaw, 2004; Striegel-Moore, Silberstein, & Rodin, 2006) have noted a number of other specific factors that increase the tendency to develop a bulimic pattern:

• higher stress;
• tendencies toward depression;
• a prolonged history of dieting attempts;
• family isolation;
• a high valuing of appearance and thinness,
• attendance away at college or a boarding school;
• early physical maturation;
• a lower metabolic rate;
• participation in a sport such as gymnastics or an activity such as ballet that reinforces significant weight loss, or a sport such as wresting that encourages rapid weight loss, especially fluids, followed by bingeing;
• a high belief in the ability to use one’s will to control the self and the world. Rita’s history includes most of these factors.

Another explanation is that bulimia may be related to continuous dietary restriction. The “natural weight” of many women is higher than what is required to match society’s ideal image. While the body naturally seeks one weight, the woman struggles with long-term dieting to maintain a different one. Bingeing may occur when food intake is constantly restricted over a long period of time. The binge brings satisfaction, but guilt soon follows. Purging then relieves the guilt. This becomes a self-perpetuating cycle that allows the bulimic to satisfy food cravings without suffering the consequences.

Rita especially seemed to fit Hilde Bruch’s pioneering descriptions and Agras’s (1995) later explanation of predisposing variables of eating disorders and specifically of bulimia. Privately, problems are either not dealt with or are handled poorly.

Your Diagnosis

The three main clinical features which characterize bulimia nervosa were present in Rita’s case. First, the keystone behavior of bulimia nervosa is binge eating. Bingeing is defined as the consumption of large amounts of food that most people would not eat under similar circumstances. This excessive amount of eating is accompanied by a feeling of loss of control. Rita attempts to compensate for these episodes with purgative behaviors, which is the second feature of bulimia nervosa. These include techniques such as self-induced vomiting, laxative abuse, diuretic abuse, stimulant abuse, rigorous dieting or fasting, or vigorous exercise.

The third criteria required for the diagnosis of bulimia nervosa is a self-evaluation that is unduly influenced by body shape and weight. Weight regulation and evaluation of one’s body are important factors in determining self-esteem in bulimic individuals. To qualify for the diagnosis of bulimia nervosa binge eating and purging behaviors must be present an average of at least twice weekly for 3 months which is the case of Rita. Hence, there is not much difficulty in diagnosing Rita’s eating disorder.

The DSM-IV-TR diagnostic criteria for bulimia nervosa are listed in Table 1 below.  As you can see, the DSM-IV-TR further subtypes bulimia nervosa into purging and non-purging types. The purging subtype distinguishes those who engage in self-induced vomiting or the misuse of laxatives or diuretics, while the non-purging subtype refers to those individuals who use alternative compensatory behaviors such as excessive fasting or exercise. Approximately two-thirds of individuals diagnosed with bulimia nervosa are purging type, while the remaining one-third is subtype non-purging (Hsu, 1990).

Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

• eating in a discrete period of time (e.g., within any 2 hour period, an amount of food that is definitely larger than most people would eat in a similar period of time in similar circumstances; and,
• a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).

Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as: self-induced vomiting; misuse of laxatives, diuretics or other medications; fasting; or excessive exercise. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months. Self-evaluation is unduly influenced by body shape and weight. The disturbance does not occur exclusively during episodes of Anorexia Nervosa.

Specify type

• Purging type: The person regularly engages in self-induced vomiting or the misuse of laxatives or diuretics.
• Non-purging type: The person uses other inappropriate compensatory behaviors, such as fasting or excessive exercise, but does not regularly engage in self-induced vomiting or the misuse of laxatives or diuretics.
• Source: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Copyright 2000 American Psychiatric Association

Intervention

The best intervention for Rita’s case is the Cognitive-Behavioral Approach. Cognitive-behavioral psychotherapy even in group settings, has shown positive results in treating bulimia (Stice, Burton, & Shaw, 2004). This involves assessing dysfunctional beliefs that perpetuate bingeing and purging. Examples of beliefs frequently found in those with bulimia is Rita’s sensitivity to people’s opinions about her appearance and weight, particularly the opinions of other women. So, she always fall in with a group of women who were equally preoccupied with dieting and weight control.

Behaviorists have not spent much effort trying to formulate the etiology of bulimia. Rather, they have focused on devising token economy, aversion therapy, and contracting programs that have been useful in an overall treatment package (Bongar & Beutler, 1995). Family therapy, which includes an acknowledgment that this disorder at least in part reflects a disturbed family system, is usually necessary if the bulimic is to recover. A particularly difficult task here is to get family members to see that they are not doing this for the bulimic; rather, that the bulimic’s disorder is in large part the natural evolutionary result of a specific system of family expectations, values, and controls (Agras, 1995).

Another treatment model for Rita focuses on the anxiety that occurs after bingeing due to the client’s fear of gaining weight. Vomiting is reinforced by relieving the anxiety. The client brings food to a therapy session that is used to binge and then eats it to the point at which he or she would normally vomit. Then, instead of vomiting, the client deals with the anxiety and is able to observe that the anxiety declines over time. This treatment is thought to break the connection between vomiting and the relief of anxiety.

It is difficult to determine which therapy is most effective because there are different ways to define improvement. Some believe that a higher self-esteem through more functional cognitions is the goal, whereas others believe the actual number of binge-pur cycles is the only way to determine improvement. Most likely, a successful recovery will involve elements of all the different conceptualizations of this disorder.

Bulimia is difficult to treat effectively. Because of its secretive nature, the disorder is usually well entrenched before help is sought just like the case of Rita. Thus, a major problem encountered with treatment is the dropout rate. Characteristics of bulimics that are associated with successful outcome include late-age onset, lack of prior hospitalization, shorter duration of the illness, less serious nature of the illness, fewer social stressors, and a good social or work history.

Because bulimia can be life-threatening, it is important to be aware of how a focus on dieting and physical attractiveness, and conflict over self-expression, can meld into this disorder, particularly in middle- and upper-class women.

References

1. Agras, W. S. (1995). “Treatment of eating disorders.” In A. Schatzberg & C. Nemeroff (Eds.), Textbook of pyschopharmacology. Washington, DC: American Psychiatric Press.
2. Bongar, B., & Beutler, L. (Eds.). (1995). Comprehensive textbook of psychotherapy. New York: Oxford University Press. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Copyright 2000 American Psychiatric Association.
3. Hsu, M. Y. (1990). Schizophrenia and comorbid conditions: Diagnosis and treatment. Washngton, DC: American Psychiatric Press.
4. Silverstein, S. M., Rodin, L. (2006). Identifying and addressing cognitive barriers to rehabilitation readiness. Psychiatric Services, 49(1), 34–36.
5. Stice, E., Burton, E., & Shaw, H. (2004). “Prospective relations between bulimic pathology, depression, and substance abuse.” Journal of Consulting and Clinical sychology, 72, 62–71.
6. Striegel-Moore, R., Silberstein, L., & Rodin, J. (1986). “Toward an understanding of risk factors for bulimia.” American Psychologist, 43, 246–263.