Bulimia Nervosa is an eating disorder characterized by binge eating followed by purging. Binge eating refers to eating a large amount of food in a short amount of time. Purging refers to the attempts to get rid of the food consumed. Bulimia means to ‘eat like an ox’, although people have been known to ‘eat like an ox‘ from antiquity, it was not until 1979 that a London psychiatrist, Gerald Russell, identified 40% of his Anorexia Nervosa patients with an ‘ominous variation’ of the disorder – the variation being that they from time to time went on binges.
In this case study I sought to give an insight into Cognitive Behavioural Therapy (CBT) treatment for Bulimia Nervosa (BN). It was important to back up my assessment in the first session with a G.P report which contained Complete blood count;
Chem-20 panel which measures electrolytes, vitamins, liver and pancreatic function, adrenal glands, (levels of cortisol and adrenaline produced in times of stress);
Thyroid and parathyroid panel which indicates level of metabolic functions.
**Ask permission from your client to get the report.
Suitability for treatment was formally measured using the Safron and Segal (1990) Suitability for Short–term Cognitive Therapy Rating Scale. (aspects of the cognitive therapy process are rated on a scale of 0-5). High Rating indicate a good prognosis and low ratings indicate a poor one.
Client History
Jessica (pseudonym) aged 22 presented to the centre with a four-year history of binge eating, vomiting and laxative use. Jessica stated that at the age of 18, following the break-up of a one-year relationship with her boyfriend (she did not want to become intimate with him). She had begun to eat excessively at times (comfort eating) as a way of coping with the heartache it caused.
Jessica put on some extra weight, approximately 4 kg over the course of a few months and was very upset when she discovered that some of her outfits were not fitting her, especially in the run up to a summer holiday.
Jessica had known about people vomiting as a means of weight control and recalled some of her school friends telling her it was a handy way not to put on weight. However, she had never really considered doing this herself, as she thought it was a ‘disgusting thing to do’.
She stated that one evening after a particularly large bout of over eating, she felt very uncomfortable and thought that if she could only vomit it would at least relieve the discomfort. Using her forefinger, she stuck it down the back of her throat and began vomiting.
Afterwards she felt unwell, her throat was raw and her stomach sore, but she admitted feeling some relief from the feeling of guilt and regret of having eaten too much. She vowed at the time never to do it again. A few evenings later after a night out with friends and having consumed ‘a few too many‘ alcoholic beverages she engaged in what she described as a ‘feeding frenzy ‘, eating almost anything she could get her hands on in the fridge and cupboard.
It seemed easier to vomit this time and the next day she bought a packet of laxatives, to clear out the system, taking 3 times the recommended dose.
Jessica tried starving herself over the next few days, feeling determined to try and get her weight under control and start a ‘new chapter in her life’. This lasted until day 3 when weak with hunger and coming home from a late night at work, she could not resist the temptation to stop off at a local Chinese restaurant as she passed by it. They had a buffet–style service that meant she could keep going back up to eat whatever she wanted. Having left feeling stuffed and very guilty, vomiting seemed the obvious option and laxatives were used the following day.
Over the course of the next few months a pattern developed whereby she would attempt any and every new diet, she lasted 2 to 4 days and this would end up in bingeing and purging behaviour.
Jessica Weight was 9st-8lbs and her Height was 5ft-3ins
None of Jessica’s family or friends were aware of her difficulties, although they know she was constantly dieting. Jessica felt very unhappy with life, the thought of suicide had occasionally crossed her mind but it always occurred after a night out drinking followed by a binge and purging episode. Jessica was taking 40 mg of Fluoxetine (Prozac) when she attended therapy.
Personal background
Jessica was raised the eldest the eldest of 5 children. She had 1 sister and 3 brothers, her parents divorced when she was aged 16 yrs, mainly due to her father’s drinking.
Jessica felt close to her Mum who had a history of been treated for depression by her G.P.
Jessica disclosed that from the age of 12 to 14 she was sexually abused by a neighbour, she never told her parents until she reached the age of sixteen after they moved back to Ireland. Leaving school at sixteen she managed to secure employment in a marketing company and had worked her way up the firm, taking several professional examinations along the way.
Diagnosis
The main DSM-V criteria for Bulimia Nervosa that Jessica was displaying were as follows;
- Eating a large amount of food with a short space of time
- Bingeing three to four times per week
- She also experiences a sense of lack of control over eating, a feeling that she cannot stop.
- She was taking laxatives at least twice a week
- Over-evaluation or concern about shape, weight and appearance
- Secretive behaviour
- Vomiting three to four times per week
- Co-morbidity features – depression, alcohol misuse
CBT Treatment
Phase 1: Sessions 1 to 4
Establishing a sound therapeutic relationship. Setting treatment goals, setting homework. Explaining the CBT model of Bulimia Nervosa, including discussing predisposing, precipitating and perpetuating factors which resulted in an initial formulation been established. Motivation for Change (Pros and Cons of changing)
Psychoeducation, educating Jessica on the adverse consequences of bingeing and purging behaviour and explained the blood sugar imbalance, glycemic index (GI), foods that have high and low GI and how neurotransmitters influence hunger and mood.
Explaining the importance of introducing a regular eating pattern of 3 meals and 2 snacks/day (gave her a detailed specific food dairy). Disrupting the vicious cycle of bingeing and purging behaviour, noting particular triggers. Identifying the connection between thoughts, feelings and behaviour within the context of the Eating Disorder.
Phase 2: Sessions 5 to 15
This phase is at the heart of therapy for Jessica. It involved addressing the maintaining factors listed below:
- Negative Body Image
- Cognitive Distortions
- Feelings, (regret, guilt, low mood, shame etc.)
- Lifestyle activities, Self –Esteem
- Physiology (blood sugar, stimulants)
- Relationships
- Food Scripts
- Stress
- Habit
- Addictive Process (bingeing/purging alcohol misuse)
Interventions and homework worksheets in treating the above was carried out in the sessions.
Phase 3 (Final): Sessions 16 -19
Relapse Management Skills discussed.
- What made her vulnerable to developing the problem in the first place?
- What has she learned in Treatment?
- What areas leave her vulnerable?
- What strategies can undermine these vulnerabilities?
- Dealing with a setback
- What are her personal strengths?
