Must include a separate references page that is formatted according to APA style as outlined in the Ashford Writing Center.Case 9: Bulimia Nervosa in Gorenstein and Comer (2014)
Rita was a 26-year-old manager of a local Italian restaurant and lived in the same city as her parents. Her childhood was not a happy one. Her parents divorced when she was about 5 years of age. She and her three older brothers remained with their mother, who often seemed overwhelmed with her situation and unable to run the household effectively. Rita would often refer to her childhood as utterly chaotic, as if no one were in charge. Within a 12-month period, 1 percent to 1.5 percent of individuals will meet the diagnostic criteria for bulimia nervosa; at least 90 percent of cases occur in females (APA, 2013). She nevertheless muddled through. When her brothers were finally all off to college or beyond, Rita entered high school, and the household seemed more manageable. Ultimately, she developed a close relationship with her mother, indeed too close, Rita suspected. Her mother seemed like her closest friend, at times the entire focus of her social life. They were both women alone, so to speak, and relied heavily on one another for comfort and support, preventing Rita from developing serious friendships. The two often went shopping together. Rita would give her mother an update on the most recent fashion trends, and her mother would talk to Rita about “how important it is to look good and be put together in this day and age.” Rita didn’t mind the advice, but sometimes she did wonder if her mother kept saying that as a way of telling her that she didn’t think she looked good. Rita later attended a local public college, majoring in business. However, she quit after 3 years to take a job at the restaurant. She had begun working in the restaurant part-time while a sophomore and after 2 years was offered the position of daytime manager. It was a well-paying job, and since her interest was business anyway, Rita figured it made sense to seize an attractive business opportunity. Her mother was not very supportive of her decision to leave college, but Rita reassured her that she intended to go back and finish up after she had worked for a while and saved some money. Just before leaving college, Rita began a serious relationship with a man whom she met at school. Their interest in each other grew, and they eventually got engaged. Everything seemed to be going well when out of the blue, her fiancé’s mental state began to deteriorate. Ultimately he manifested a pattern of schizophrenia and had to be hospitalized. As his impairment extended from days to months and then to more than a year, Rita finally had to end the engagement; she had to pick up the pieces and go on without him. She felt as if he had died. A period of psychotherapy helped ease her grief and her adjustment following this tragedy, and eventually she was able to move on with her life and to resume dating again. However, serious relationships 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 her employees didn’t like her for more reasons than the fact that she was the boss, and she found it hard to make close friends. Rita Fundamental Concerns About Weight and Appearance Throughout her adolescence and young adulthood, Rita had always been sensitive to people’s opinions about her appearance and weight, particularly the opinions of other women. She recognized that this sensitivity likely came from the not-so-subtle messages from her mother about her appearance. She can still remember the day they went to a local pool with friends when she was 12 years old. She overheard her mother talking to the other mothers, telling them that she wondered if Rita was going to have “hormonal problems” because she seemed to be chubbier than all of the other girls. Rita didn’t initially think of herself as chubby, but socially she always seemed to fall in with a group of women who were equally preoccupied with dieting and weight control. To Rita, their preoccupation seemed to be based not on vanity but on anxiety. They lived under a cloud of concern that their weight and eating might somehow grow out of control. Typically, her acquaintances did not have significant weight problems, nor were they unusually vain or intent on being popular. In fact, most of them had serious academic interests and career goals. Thus she found it almost ironic that they in particular were so focused on their physical image. But focused they were, and Rita became no exception. Body dissatisfaction, depression, and self-reported dieting are important risk factors in the development of eating disorders (Stice, Marti, & Durant, 2011). From age 14 to 25 she always tried to keep her weight between 121 pounds and 123 pounds, a standard that began in the ninth grade, after she had a slightly overweight period. She would rigidly follow what she called her weight watcher plan, although she had never actually gone to the program of the same name. The eating plan consisted, when she was being “good,” of a breakfast of dry toast and juice, a lunch of turkey or dry tuna on diet bread, and a low-fat frozen meal at dinnertime. On some days, when she was being “bad,” it also included a couple of candy bars or two large gourmet chocolate chip cookies. She tried to keep “bad” days to a minimum, but there were probably three or four of them each week. Rita felt she could tolerate such days, however, as she was a regular exerciser, attending spinning classes at the gym or doing Pilates at home at least 3 nights per week. During a particularly bad week, however, she might go to the gym a couple of extra times to exercise on her own. In addition, she developed the habit of weighing herself several times a day to reassure herself that the reading did not exceed 123 pounds. When the scale showed that her weight was at or below 121, the young woman felt enormous satisfaction, similar to what other people might feel if their bank statement showed a comfortable balance. Rita saw her 121 pounds as the well-earned reward for sustained and concentrated effort. And like a miser who counts her money over and over, she would get on the scale frequently to recapture that feeling of satisfaction, especially when other aspects of her life felt less than satisfying. One evening at home, when she saw that her weight was 119, she returned to the scale a dozen times to experience the pleasure at seeing that number. At the same time, the frequent weighing had its downside. Sometimes she would weigh 124 or 125 pounds and 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 plan. In addition, she might throw in extra exercise sessions for good measure. In the meantime, to avoid anyone seeing her “fat” body, she would hide it under bulky sweaters and other concealing clothing. This way, at least other people would not gossip about her. The more she felt upset about her body, the more she tended to check her body shape and size. She would try on different-sized clothes from her closet to see how they fit. She had one pair of “skinny jeans” that she fit into a few years prior, but only for a short time. She saved them, swearing that she would fit back into those again one day. She would stand in front of the mirror and suck her stomach in as far as she could and see if that made her feel any better. It tended to make her feel worse, but it did give her more motivation to have a really “good” day the next day. Repeatedly engaging in body-checking behaviors (e.g., weighing self, checking in the mirror, comparing body to others, measuring body size with clothes or other instruments) has been found to be a maintaining factor of eating disorders (Shafran, Fairburn, Robinson, & Lask, 2004). Rita: Caught in a Binge-Purge Cycle Shortly after her 26th birthday, Rita’s eating habits became much more troubled. First she began to have eating binges, perhaps two to three times per week. Typically she would become aware of the urge to binge sometime in the afternoon while at work. Because she restricted her food intake during the day as much as she could, she was hungry, and the food smelled so good. As the afternoon progressed, the urge would build into a sense of inevitability, and by the end of the workday, she knew she would be spending her evening on a food binge. She would then start to fantasize about the foods she would be buying on the way home. A binge is defined as consuming an objectively large amount of food during a relatively short time (less than 2 hours) and is accompanied by a feeling of loss of control (APA, 2013). The foods that figured in Rita’s binges were items that she had labeled as “bad”—foods that in her mind should never be eaten if she had any hopes of maintaining proper weight. On one binge day, for example, the young woman made three stops on the way home from work. The first was a fast food drive-through, where she ordered an extra-large combo cheeseburger meal. The next stop was a gourmet cookie shop, where she bought three large super chunk chocolate chip cookies. The final stop was the grocery store, where she bought half a gallon of ice cream, which, as usual, was heavily laden with chocolate chips and nuts. Once home, Rita locked the door behind her and put her phone on silent. Something about the secrecy, the single-mindedness, and what Rita called the depraved indifference of her binges made her feel as if she were committing a crime. Yet once the eating began, she felt powerless to stop it. After the first mouthful, the binge was destined to run its course. On this particular evening, Rita tore into the cheeseburger first while she sat in her kitchen checking Facebook, Instagram, and Twitter on her iPad. She ate rapidly, without pause, taking little notice of the stories or photos. After the cheeseburger came the cookies; these were gone in a matter of minutes. After about a 20-minute break, during which Rita changed out of her work clothes, she proceeded to the ice cream. This she ate in her living room at a slower, more leisurely pace while she watched the food network on TV. Within about an hour and a half she was scraping the bottom of the carton. Spoonful by spoonful, she had devoured all of it. In fact, within a 3-hour period, Rita had consumed more than 4,000 calories. The young woman often felt as though she were in a changed state of consciousness during such binges. Nothing else in the world seemed to matter when she was eating like this. She would avoid answering the phone or doorbell. Although Rita viewed the binge overall with disgust, she couldn’t deny there was some pleasure in it. It was the only situation in which she could eat foods that appealed to her. Under normal conditions, eating was not a source of pleasure, because she would restrict herself to unappetizing foods. For her, normal eating meant dieting—avoiding all foods that she enjoyed. She was convinced that if she regularly ate foods that she did like, she would set in motion a process that she couldn’t stop. And now, indeed, her binges seemed to be bearing this theory out. Once the binge was over, the next step, in Rita’s mind, was to repair the damage. By the time she was through, she was left with feelings of both physical and psychological revulsion. Physically she would feel bloated. The blow to her self-esteem was even more pronounced. Binge eating was so inconsistent with her usual style of behavior that she wondered if she was developing some sort of split personality: the competent, striving Rita versus the irresponsible, out-of-control Rita. She was becoming concerned for her mental health. Typically, binges are followed by feelings of extreme self-blame, guilt, and depression, as well as fears of gaining weight and being discovered (APA, 2013). Most important, the binge posed a severe threat to the one area of life by which she measured most of her success and worth as a human being: her weight. After a binge, she felt that if she didn’t do something about it, she might see a 5-pound weight gain on the scale the next morning. During her first 2 or 3 months of binge eating, she would attempt to avoid weight gains by trying to fast for a day or two. Then she came across a documentary on YouTube featuring women with bulimia that examined purging behavior at length. The message of the documentary was to avoid this fate at all costs. However, with her binges becoming more extreme and her weight reaching an all-time high of 127 pounds, Rita saw purging as the solution to her problem: a way of eating what she wanted while avoiding undesirable consequences. She started to purge at home several times a week. She would stand over the toilet, touch her finger to the back of her throat, and throw up as much of the binge food as she could. The first time Rita tried this, it was not so easy. Indeed, she was surprised at how hard it was to stimulate a gag reflex strong enough to bring up the food. Eventually, however, she often didn’t have to use her finger at all; the food would seem to come up almost automatically as she bent over the toilet. In the early stages of her disorder, Rita’s purging felt gratifying. It typically brought an immediate sense of release, as though some terrible wrong had been set right. The bloated feeling would go away, and Rita would avoid seeing a weight gain the next day. But over the next few months, the need to purge grew and grew. Even after eating normal meals, Rita would feel fat, and she couldn’t get the thought of purging out of her mind. Beyond purging, the young woman would try additional practices to undo the effects of binge eating. For example, she tried hitting the gym to exercise each day. Before going, however, she had to follow a particular ritual in front of the mirror. She had to convince herself that she looked thin enough to appear in a gym environment. She put on her workout clothes and inspected herself in the mirror from every angle. Rita’s weight was within the normal range: she was 5 feet 5 inches tall and weighed 125 pounds. Her body mass index (BMI) was 20.8, which was at the lower end of the normal range of 18.5 to 24.9. Anyone would have described her as slim. However, there were aspects of her body that caused her repeated concern. She felt that her center of gravity was too low, meaning she was heavy in her hips and thighs. If, after surveying herself in the mirror, she believed that she looked dumpy, she would abandon her plan to go to the gym. She just couldn’t face going there “looking fat.” People with bulimia nervosa often have numerous inaccurate and disturbed attitudes toward their body size and shape. Compared to individuals without an eating disorder, people with bulimia have a tendency to overestimate their body size in a laboratory setting (Delinsky, 2011; Farrell, Lee, & Shafran, 2005). Usually, however, if Rita spent enough time in front of the mirror, she was able to convince herself that her appearance was not entirely repulsive. Sometimes to do this she had to change outfits, moving to more concealing clothing. She would spend at least 2 hours at the gym, alternating between jogging on the treadmill and baking in the sauna. Going to the gym achieved two things in her mind. It burned calories and it kept her away from food. When she returned home, usually at about 9:30 P.M., she drank a couple of cans of diet soda and tried going to bed. Unfortunately, the long workout often left her ravenous, and frequently she found herself getting up again to binge and purge. When she was not bingeing or skipping meals, Rita would try to follow her diet plan: a breakfast of dry toast and juice, a lunch of half a sandwich of dry turkey or tuna on diet bread, and a dinner of a low-calorie frozen meal. Sometimes she would allow herself a snack of fat-free cookies or vanilla frozen yogurt. When eating in this way, she felt she was in an odd harmony with the universe. The restrictive eating gave her a sense of control, competence, and success. She felt more worthy as a human being, and more at peace. Unfortunately, the controlled feeling could not be sustained. Eventually, she would give in to periodic binges. And after bingeing she felt compelled to begin the cycle all over again. A Coworker’s Perspective: Piecing Things Together Even as Rita’s pattern of bingeing and purging at home was increasing month after month, she was able to keep it under control at her job. She sensed that allowing the pattern to enter her work life would mark the beginning of the end of her promising career. To be sure, there had been some slips. One afternoon, for example, she ate a whole order of lasagna in the break room. The full feeling that resulted was so intolerable that Rita went to the employees’ bathroom and purged. However, afterward, she felt horrified at the idea of someone observing or finding out about her purging, and she promised herself that she would try with all her might to limit the practice to home. It was not easy to do, but for the most part, she was able to keep her bingeing and purging out of the workplace. That is not to say that Rita’s problems totally escaped the notice of people at work. Coworkers were increasingly able to tell that something was amiss, and some began to piece things together. Kate, a 22-year-old server and friend, was one such individual. Working under Rita in the restaurant for the past year, Kate had developed a cordial relationship with her manager. Although the two of them were not close friends outside of work, they had gone to an occasional movie or out to a bar together. In recent months, however, Kate noticed that Rita had become more distant and withdrawn at work, and she became concerned for her coworker’s well-being. “I always knew that she wasn’t the happiest person in the world and that she was certainly unhappy about not having any boyfriends,” Kate later told another manager at the restaurant. People with bulimia nervosa are more likely than other people to be diagnosed with comorbid depressive disorders and/or anxiety disorders. Approximately 30 percent of people with bulimia struggle with a problem with substance use (particularly alcohol or stimulant use) (APA, 2013). Of course, that was true of a lot of people, so at first I didn’t give it much thought. However, after a while I started to notice a troubling pattern in Rita. She would be very cheerful and friendly—for her—when I’d first arrive for my shift around 11:30 A.M., but as the day wore on her mood would turn distant and sour. From about 3:00 onward, she would hardly talk to me or anyone else, and she often seemed to be staring into space as though she was thinking about something far away. Not long after this started Rita stopped making plans to see me outside of work. Since we didn’t get together all that often, at first it didn’t seem that unusual. She was always “busy,” too busy to spend time with me outside of the restaurant. A couple of times, I asked her what she was so busy with. Not that I was prying, but I was curious about what she was up to, since I really didn’t think she had anything going on besides work. But when I would ask her, she would suddenly seem nervous and say something like, “Oh, just a few things I’m working on. Stuff for friends, you know.” I didn’t know, but her tone made it clear to me that I shouldn’t pry further. After about 2 months of this, it was apparent that she didn’t want to spend any time with me outside of work. She never had any time to get together. And if I said, “Well, we really should find time to get together soon,” she would brush the whole issue aside. Her moodiness at work was getting worse, too, and I wasn’t the only one who noticed it. Of course, we all knew that she’s not the most jovial of managers, but now she seemed totally distant and nervous at work. And she always was in a tremendous hurry to get out of the restaurant at the end of the day. I kept wondering what was going on in her personal life—what was she so desperate to get to after work—and why she wanted to shut me out of her life altogether. Her appearance was also suffering. She seemed to be gaining some weight, nothing too alarming. But the way she carried the extra weight was a bit disturbing. Her face, especially around the eyes, seemed kind of puffy, like she wasn’t getting enough sleep. Her eyes were also red. It looked as if some extreme upset or unhappiness was showing in her face. She also seemed very tired at work. I knew something was wrong, but I was afraid of asking her what was going on. Finally, I decided that I was worried enough about her to go ahead and ask what was going wrong, regardless of what her reaction was. It seemed more important than maintaining our friendship. So I just asked one day, “Rita, I can tell that you’re very upset about something. You seem like you’re very unhappy and secretive all the time, and frankly you don’t look very healthy. Is there something that I should know about? Or something you’d like to get off your chest? You know, I do consider you a friend, whatever you think of me, and I do care about you.” She just looked at me very coldly and said, “I don’t know what you’re talking about. You have some tables to bus.” But her coldness led me to believe that she knew very well what I was talking about. Then I noticed that her weight, while generally on the increase, seemed to be going up and down every few days. I started to suspect that there was some kind of eating disorder going on. Of course, I’m no expert, but I had a feeling that maybe she was so depressed about something that she’d taken to binge eating or something. I knew that this was dangerous, but what could I do? She was uninterested in pursuing our friendship or in responding appreciatively to any offers of support. Eventually, her responses to me became downright nasty. So finally I decided that I had no choice but to wash my hands of the whole situation and stop trying to lend my hand. I had done what I could. Americans spend more than $60 billion each year on weight-reduction products and services (Marketdata Enterprises Inc., 2011). Rita in Treatment: Gaining Real Control After 6 months of bingeing, Rita found that she was falling further and further behind. As the binges and snacking had become more regular, she gradually gained 10 pounds, ballooning, as she called it, from 123 pounds to 133 pounds. She had never been this heavy before, and she felt desperate to lose the weight. All the purging, dieting, and exercise were adding up to nothing. Rita was also becoming increasingly worried that she might resort to more extreme measures, such as purging at work, to lose weight. Ironically, her only temporary relief from these anxieties was achieved through bingeing. But after the binge and purge were over, Rita would often find herself sobbing. Overwhelmed, she contacted a behavior therapy program for weight management at a nearby medical center. There she was directed to Dr. Francine Heston, a psychologist with expertise in the treatment of eating disorders. During her first interview with Rita, Dr. Heston concluded that the 26-year-old woman’s eating behavior and related attitudes about food and weight fit the DSM-5 criteria for a diagnosis of bulimia nervosa. First, the client had recurrent episodes of binge eating, over which she felt little or no control. Second, she engaged in inappropriate compensatory behavior in response to the binges—mainly purging and occasional fasting, but some inappropriate exercising as well. Finally, Rita’s self-concept was largely influenced by her body shape and weight. Most therapists tend to use a combination of approaches—primarily cognitive and behavioral—to treat persons with this disorder, and Dr. Heston was no exception. Her treatment program had two main components: (a) changing the patient’s bingeing and compensatory behaviors; and (b) changing the patient’s distorted attitudes about weight and shape and any other thinking patterns that might cause distress and hence lead to bingeing. Her techniques included educating patients about their eating disorder; helping them perform more appropriate weighing and eating behaviors; teaching them how to control binges and eliminate purges; and leading them, through cognitive therapy, to identify dysfunctional ways of thinking and to develop more accurate cognitions. Dr. Heston’s combination of cognitive and behavioral therapies for bulimia nervosa is similar to the successful approach developed by Fairburn (2008). Session 1 Rita framed her problem mainly in terms of the bingeing. She stated that the binges were increasing in frequency and were causing her to gain weight. What was most upsetting, she didn’t seem to have any control over the binges at this point. Her weight was inching up and she felt helpless to stop it. Dr. Heston listened sympathetically and expressed optimism that Rita’s problem could be solved. She then showed the client a diagram that depicted a model of bulimia nervosa (Figure 9-1), explaining to Rita that although bingeing was her main complaint, it was really just one element in a system of interconnected parts. That is, the bingeing was the result of such elements as unpleasant emotions, concerns about shape and weight, and strict dieting. Furthermore, in a vicious cycle, the bingeing was also helping to intensify these other parts of the system. Similarly, it was both causing and being caused by purging, another element in the system. To stop a bingeing pattern, treatment had to bring about changes in all of the system’s elements. It could not focus on bingeing alone. Dr. Heston then outlined the treatment approach. First, she explained that certain steps usually help to reduce the urge to binge. Chief among these is structuring eating in a manner that keeps physical and behavioral deprivation to a minimum. In addition, the therapist noted, it is usually helpful to develop certain measures for heading off binges should the urge arise. Finally—and this is where Dr. Heston felt it advisable to tread lightly initially—it is usually helpful with this kind of problem to become less preoccupied with eating and weight matters. She explained that when people have a problem with binges, it is sometimes because such matters have assumed a greater role in the person’s thinking than is desirable. Figure 9-1 Cognitive-behavioral theory of the maintenance of bulimia nervosa The psychologist also told Rita that she would like her to start keeping track of her eating and related stresses. Dr. Heston allowed Rita to choose whichever method felt most comfortable to her: using one of the apps that she recommended, keeping detailed notes in her phone, or writing everything down on a record form which she could then scan and email to her. Rita expressed some reluctance about such record keeping. She explained that she had tried keeping records of her eating in the past and had not found it helpful. If anything, it had increased her focus on her eating. Dr. Heston acknowledged that Rita’s past record keeping might not have been helpful, but suggested that it would be used more constructively now. Now the record keeping would be part of an overall strategy, and clinical experience showed that it was quite important. It would allow the therapist to understand Rita’s eating better and help the young woman make appropriate changes. Dr. Heston did acknowledge that, as Rita suspected, the record keeping might initially increase her preoccupation with her eating and weight but said that such increases would be temporary. Over time the client would become less focused on the whole problem. Rita agreed to download the recommended app and give it a try for the coming week. Session 2 Rita’s food records indicated that during the week, she had binged on 3 evenings after work. Each consisted of a cheeseburger meal followed by some cookies or cake; then, later in the evening, a pint or two of ice cream. Rita always purged afterward. During the day, her eating was severely restricted; on one of the days she was virtually fasting, consuming only no-calorie beverages (coffee, tea, diet soda) before surrendering to several large cookies in the late afternoon. On the 3 postbinge days, Rita reported skipping lunch and later having an apple and a couple of rice cakes before once again surrendering to high-calorie snacks. On days when she followed her “normal” weight-watching diet, her total calorie intake was around 800, about half the requirement for someone of Rita’s weight and activity level. In contrast, on binge days, Rita was consuming 4,000 to 5,000 calories. Dr. Heston did not discuss the specific calorie values with Rita, knowing that it can be counterproductive for patients with bulimia to monitor calories too closely. It creates a dieting mentality that the treatment is trying to discourage. Instead, the psychologist simply noted that soon they would begin the process of trying to fashion a more regular eating pattern for Rita, one that might lower some of her urges to binge. They spent most of the session reviewing basic facts about weight and eating. Dr. Heston explained that it would be important for Rita to recognize first that her current weight of 133 was not considered excessive according to standard criteria and second that the deprivation needed to maintain the very low weight of 121, her “ideal” weight, could in fact lead to physically overpowering food cravings. The weight of people with bulimia nervosa is typically within a normal to overweight range (i.e., body mass index [BMI] between 18.5 and 29.9) (APA, 2013). Rita said she understood that 121 was on the low side but voiced strong reservations about accepting anything higher, particularly 133, as a weight for her. Dr. Heston suggested that there was no need to decide on an appropriate body weight for Rita now, only to recognize that her assumptions about proper body weight might call for some reexamination sooner or later. The psychologist then recommended that the client stop weighing herself more than once per week, explaining that frequent weighing was fueling Rita’s preoccupation with her weight. Moreover, frequent weighing gives false feedback, as day-to-day scale fluctuations often reflect water retention or a particular state of the excretion cycle, rather than true weight gain or loss based on body fat. Rita replied that this would be a big change for her, but on the other hand, she liked the idea of not being a slave to the scale. Dr. Heston made one additional recommendation, that Rita stop skipping lunch at work, a habit that she had developed. The therapist said she understood Rita’s motivation—concern about weight gain—but explained that skipping meals ultimately produces overeating. Research has found that normal subjects on very restrictive diets develop a tendency to binge. For example, after participating in a very low calorie weight loss program, 62 percent of the subjects, who had not previously been binge eaters, reported binge-eating episodes (Teich & Agras, 1993). Similar results have been found in animal studies; they appear to be related to increased stress as a result of caloric restriction (Pankevich, Teegarden, Hedin, Jensen, & Bale, 2010). Rita: I just don’t see how I can do what you’re proposing. If I don’t skip some meals, I’ll turn into a blimp. As it is, I’ve gained 10 pounds in the past 6 months. The only thing that is keeping me from gaining another 10 is skipping lunch now and then. Wouldn’t it make more sense for you to tell me to stop bingeing? Dr. Heston: Yes, I could tell you to stop bingeing. But bingeing is probably the thing that you have the least control over right now. Instead, it’s better to focus on something that you have more control over, such as whether you eat lunch or not. I know you feel that skipping lunch is helping you to maintain your weight, but skipping meals actually produces the urge to snack or binge. Not skipping meals will eventually help you to stop overeating. Rita: It makes me nervous to think of eating lunch every day. Dr. Heston: I know this will take some getting used to. But let’s try it out this week, and we’ll review how you feel about it next time. Rita: OK, I’ll try it. Dr. Heston closed by giving Rita three main instructions for the week: (a) continue to keep the food records, (b) weigh herself only once, and (c) eat lunch every day. Session 3 Rita’s records indicated that she had had two binge nights during the preceding week. As instructed, she had made an effort to eat a lunch every day, which for her, was still the “diet” meal: for example, half a sandwich of dry tuna on diet bread. In addition, the client had limited weighing herself to only once during the week. Dr. Heston asked how Rita felt making these changes. Rita: To tell you the truth, it’s making me very nervous. I feel I must be gaining weight. Not only am I still snacking and bingeing, but I’ve added regular lunches. Dr. Heston: What does the scale say? Rita: 132 pounds. Dr. Heston: So your weight is basically the same. Even if it were higher, it wouldn’t mean that you were necessarily gaining weight. As we’ve discussed, one week’s weight reading doesn’t tell much about the overall trend. Rita: Well, it just feels wrong not to skip lunch occasionally. Dr. Heston: I know how difficult this must have been, and I appreciate the effort you’ve made. However, you will eventually benefit from this change. I’m afraid, though, that what I’m going to ask you to do next will not be any easier. However, I think you’re ready for it, and it’s important that we keep moving forward. Rita: Don’t tell me you want me to start eating even more! Dr. Heston: Yes. That’s exactly it. As we discussed in the beginning, your calorie intake on your so-called normal days is too restricted and is therefore producing binges. You need to start consuming more calories in the course of your regular meals. Rita: But how do I do it? I have no idea what else to eat. I’ve been eating this way for so long. Dr. Heston: One way is to match your eating to what others eat, perhaps even take your cue from friends, coworkers, or even recipe books. Right now you seem to be having half a sandwich for lunch. As you probably know, most people eat the whole sandwich; therefore, I’d encourage you to do the same. For breakfast, most people have some cereal, fruit, or eggs in addition to toast and juice, so you could add that as well. Rita: I guess I could try it. Most cases of bulimia nervosa begin after a period of dieting. Session 4 Rita reported having made the suggested meal changes, adding cereal to her breakfast and eating a whole sandwich for lunch, although complaining that eating the whole sandwich made her feel fat for the rest of the afternoon. Dr. Heston praised the client for these changes and reminded her that there was a difference between feeling fat and actually gaining body fat. The psychologist suggested that Rita relabel the feeling that she got after a regular meal as feeling full, which has nothing to do with a true weight gain. Rita’s food records during the week indicated two episodes that the client labeled as binges, each consisting of two slices of pizza and a pint of ice cream. This amount of food was less than in her past binges, yet she still described them this way because of the frame of mind she had been in at the time: She was focused only on the eating and afterward felt the usual guilt and shame. And she purged afterward. Dr. Heston observed that nevertheless, eating somewhat more during the day had seemed to promote less ravenous eating in the evening. Individuals with bulimia nervosa are more likely than other people to have symptoms of depression, including sadness, low self-esteem, shame, pessimism, and errors in logic (Burney & Irwin, 2000; Paxton & Diggens, 1997). The psychologist now suggested a two-pronged approach, in which Rita would further normalize her meals and would also develop some strategies for eliminating binges at night. With respect to meals, Dr. Heston observed that Rita was still limiting herself to a diet frozen dinner in the evening. She suggested that instead she start to have a regular dinner: meat with rice or potatoes, plus a vegetable. It had been a while since Rita had prepared a regular dinner, and so the client was concerned that the sheer effort might force her back to the frozen meals. Thus the therapist suggested that she at least eat conventional frozen dinners, rather than the dietetic ones. Next, Rita and Dr. Heston discussed some measures for avoiding binges, should the urge arise. First, the psychologist advised that she plan an evening activity at least 3 nights a week: a movie, a dinner out, or a moderate exercise class. Second, Rita should buy all of the food for the week in one or two shopping trips, preferably on the weekend; she should shop from a list and go to the store on a full stomach. Third, Rita should change her route home from work so as to bypass the stores in which her binge foods were usually purchased. Finally, Dr. Heston said she thought the time was right for Rita to start refraining from purging. The client’s better eating habits had already reduced the severity of her binges, and so she was better off just accepting the full caloric consequences of those binges, as opposed to purging. The psychologist emphasized that purging was actually helping to produce bingeing by making Rita feel that she could protect herself from the consequences of a binge. In other words, knowing she could purge, she was feeling freer to binge. Rejecting purging, on the other hand, would help Rita to try to control her bingeing. Dr. Heston also pointed out that if Rita retained the calories from the binge, she would be less likely to feel deprived afterward, thus reducing the need to binge later. Vomiting fails to prevent the absorption of at least half the calories consumed during a binge (Garner et al., 1985; Wooley & Wooley, 1985). Rita expressed agreement with the goal of not purging, saying it made her feel disgusting. But once again she was concerned about gaining weight. Dr. Heston reminded the client that the proposed measures did not, according to experience, cause people to gain weight. That is, the increased calories that might result occasionally from not purging would be offset over time by a reduction in overeating. This could be verified by keeping track of Rita’s weight. Rita said she would do her best not to purge. Session 5 Rita reported that she had followed the new meal plan, eating a regular breakfast, a whole sandwich for lunch, and on most nights, a complete dinner—sometimes frozen, sometimes a meal she prepared. Snacks consisted of fruit and rice cakes. Also, as advised, the client had scheduled activities for herself on several nights. Still, there were two episodes that Rita described as binges: a pint of ice cream on one night and a couple of large chocolate doughnuts on another night. The quantities of these “binges” were not really extraordinary—it now appeared that her more regular meals were holding down her cravings—but Rita considered them intolerable, and she purged on both occasions. She said that she had decided to purge because she just felt so fat after eating those foods. Still, she asserted, “I really want to stop purging,” and she asked for another chance to try during the coming week. Dr. Heston encouraged the client to try again but asked that she bring some so-called bad foods to the next session. The psychologist explained that they could do a practice exercise in which Rita would eat the foods with Dr. Heston and then practice tolerating the feeling of fullness. Session 6 Rita reported having purged after two episodes of “overeating” at home in the evening. In one case, she purged two large chocolate chip cookies that she had bought in a gourmet shop; in another, she purged two pieces of chocolate cake. She had intended not to do any purging this week, but once she ate those foods and felt as if she had gained weight, she couldn’t stand it. Most cases of bulimia nervosa begin in adolescence or young adulthood (most often at age 15 to 19 years) (Smink, van Hoeken, & Hoek, 2012). Dr. Heston asked the client whether she had brought any “bad” foods, as advised. Rita at first stated that she had forgotten, but then admitted that she had deliberately not brought the foods in the hope of avoiding the eating exercise. The psychologist, having anticipated this complication, informed Rita that she had brought some chocolate doughnuts to the session herself. The client reluctantly agreed to do the eating-without-purging exercise during the session. She said she might as well get it over with, as it appeared she could not do the exercise on her own right now. Dr. Heston brought out two large chocolate doughnuts and suggested that they each eat one. Rita balked, saying she hadn’t expected the doughnuts to be so large, and she asked whether she could just eat half. The psychologist explained that the exercise would be of no value if Rita restricted her eating to an amount that felt safe. “I know,” Rita replied, “but I’m afraid of gaining weight.” Dr. Heston then asked Rita to estimate how much weight she would gain by eating the doughnut. “I don’t know; 2 pounds?” she guessed. In response, the psychologist gave Rita some facts on eating and weight gain. First, the doughnuts themselves did not weigh more than 3 ounces each; so ingesting one of them could not increase her weight by more than 3 ounces. Moreover, like all foods, some of the doughnuts’ weight reflected their water content, which would be excreted eventually; most of the rest would be burned off in the natural course of events. Dr. Heston suggested they conduct an experiment in which the client would weigh herself on the office scale just prior to eating the doughnut and then immediately afterward. Rita agreed to eat the doughnut, first weighing herself on the office scale; her weight was 132. She then ate her doughnut slowly, as if taking a bitter herb, but at the same time she admitted that she liked it. After finishing, the young woman remarked that she felt really fat and had a strong desire to purge. The psychologist suggested that she return to the scale. Rita discovered that her weight did not show any increase. Dr. Heston used the finding to make the point that feeling fat after eating and actually being fat or gaining weight are not the same. The therapist also noted that sometimes eating a large quantity of food will indeed produce a considerable weight gain immediately afterward, but most of this gain is water and will be excreted eventually. In order to get used to this, however, Rita would have to stop purging. The behavioral technique that requires clients to confront their fears by eating taboo foods to show that eating can be harmless and even constructive is similar to the exposure and response prevention therapy used in cases of obsessive-compulsive disorder (Steinglass et al., 2012). For the remainder of the session, Rita and Dr. Heston focused on other matters, reviewing Rita’s meal plan, binge control strategies, and evening activities. All three areas seemed to be going smoothly. At the end of the session, the psychologist asked Rita how she felt about having eaten the doughnut. The client replied that she still felt fat, but not as much as before. She said it had been a long time since she had let such a feeling stand without purging afterward. Dr. Heston repeated the importance of Rita’s not purging after she left the office or undertaking any other compensatory measures. The young woman indicated she thought she could comply. Finally, the psychologist asked Rita what the prospects were of her refraining from all purging during the coming week, should she get the “fat” feeling after eating. Rita replied that she thought the prospects were better now. If she could keep this doughnut down for the rest of the night, she thought the experience would help her resist purging on future occasions. Session 7 Rita reported that she had gone the full week without purging. There were a couple of occasions when she had been sorely tempted—once after she ate a whole pint of ice cream at night and another after eating a couple of large chocolate chip cookies. When she first selected those foods, she had in fact planned to purge afterward. However, she later willed herself not to do it, recalling her success in the therapist’s office. Dr. Heston praised Rita for this accomplishment and said she wanted to help the client lock in these gains by once again eating some “bad” foods together. Today, the psychologist explained, she had brought some large chocolate chip cookies. “I was afraid of that,” Rita replied, but she was clearly more willing to conduct the exercise this week. Once again, they ate together and Rita agreed not to purge either these cookies or any other foods in the coming week. As usual, she was to continue eating regular meals, observing the binge control strategies, and scheduling activities at night. Sessions 8 to 11 During the next four sessions, Dr. Heston and Rita continued to eat foods that the young woman would normally have avoided—potato chips, pizza, and cake—and again Rita refrained from purging. In fact, she succeeded in not purging throughout the 3-week period, despite several occasions when she ate “bad” foods at home. Many individuals with bulimia nervosa have severe oral and dental problems, including dental erosions, dental cavities, periodontal disease, and gum disease. Esophageal complications, some of which can be life-threatening, are fairly common (Mehler, 2011). During this period, the combination of regular meals plus the lack of purging seemed to be naturally reducing the client’s desire to binge. By the 11th session, she reported bingeing only occasionally, and the quantities were actually rather modest. Also during this period, Dr. Heston had Rita add some taboo foods to her diet. By the 11th session, the client was deliberately eating such items as pizza or a sausage-and-peppers hero for lunch, chips or candy bars for afternoon snacks, and barbecued chicken for dinner. Throughout this whole period, Rita worried about gaining weight, but the scale indicated that her weight was remaining the same—131 to 134 pounds. Still, she complained that this eating pattern made her feel fat. Rita: I know the scale says my weight is the same. But when I eat such large meals during the day, I feel fat and bloated. My clothes are tight, I feel that people can tell I’m fat. Before, I didn’t have this feeling. I miss that feeling of being in control. Dr. Heston: How were you in control before? Rita: By dieting, by following my weight watcher plan. Dr. Heston: But what about the binges? Rita: Well, except for the binges I was in control. Dr. Heston: I don’t think you can separate one from the other. Your dieting was causing binges. Besides, the term control doesn’t really describe what you were doing when you dieted. You weren’t controlling your food, you were being controlled by a vicious cycle of dieting, bingeing, and purging. Rita: Well, I had a feeling of control when I dieted. It made me feel good—like I was accomplishing something. Dr. Heston: You seem to be equating control over food—or what you thought was control—with accomplishment. Does that stand up? Rita: Well, maybe it’s not the control part. I mean, I can see that the idea of controlling food is sort of dumb by itself. It doesn’t make you accomplished or anything. It’s more my weight that matters. Maybe I wasn’t going about it in the best way, but 133 pounds is fat as far as I’m concerned, and nothing in the world is going to convince me not to lose that weight. Dr. Heston: What’s wrong with 133 pounds? Rita: It’s more than I should be weighing. Dr. Heston: But we’ve seen that 133 is normal for your height. Rita: I don’t care. I am fat at 133. Dr. Heston: I’d like you to consider the possibility that your thinking on this matter is really groundless. For example, what evidence do you have to support the idea that you’re fat? Rita: I feel fat. Dr. Heston: That’s just a feeling. We’re trying to see if the feeling is justified. What evidence do you have? Rita: Well, I used to weigh less—that’s evidence—but I suppose you would say I used to be too thin. How about the fact that my love life is nonexistent? I haven’t had a date in months. Dr. Heston: What was your love life like when you weighed 121 pounds? Rita: Not that great either, I suppose. People don’t want to go out with me because I’m so miserable more than because I’m fat. Dr. Heston: But you still believe you’re fat. Rita: Well, I guess I’m not actually obese. I just look heavy at this weight. As many as half of elementary school girls have tried to lose weight, and 61 percent of middle school girls are currently dieting (Hill, 2006). This discussion seemed to shift Rita’s view of her weight slightly: She moved from declaring she was fat to thinking that maybe she just looked heavy. Still, Dr. Heston felt that her client’s thoughts had not yet shifted far enough. It was critical that she arrive at a more neutral view of her weight. Thus, the psychologist asked Rita to consider all the ways in which her current behavior differed from the way she had behaved at 121 pounds. Rita noted that at her current weight she tended to: (a) wear a bulky sweater or jacket at the office, (b) check her body shape for extended periods in a full-length mirror before leaving the apartment, (c) wear concealing clothing at her gym, (d) avoid swimming, (e) spend most of her time alone in her office at work, and (f) rarely accept dates. Dr. Heston explained that these actions were actually all serving to strengthen Rita’s belief that her weight was terrible. The therapist thus suggested behavioral exercises to help Rita change such behaviors, and they agreed to devise the first set of exercises at the next session. Sessions 12 to 15 Rita and Dr. Heston devoted the next four sessions to planning and carrying out behavioral exposure exercises and cognitive reinterpretation exercises to help eliminate Rita’s fear and avoidance of various activities. In these exercises, Dr. Heston systematically guided her client to perform and reinterpret those activities that, according to the previous week’s list, Rita had been avoiding or eliminating from her life. Research indicates that individuals with bulimia nervosa are extremely focused on weight matters and virtually define their self-worth in these terms (Fairburn et al., 2003; Fairburn, 2008). The first exercise was for the young woman to remove her sweater at work and venture around the restaurant for a minimum of I hour—later 2 hours—each day. When she carried out the plan initially, Rita felt enormous anxiety. As instructed, the client recorded her negative thoughts and then tried to refute them in writing. In one instance, for example, Terry, a “slim” coworker, had seen Rita and had given her a critical look. Rita’s first impression was that Terry must be thinking that she had grown fat. As part of her written exercise, Rita also considered contrary evidence—for example, that Terry had not actually said anything about her appearance. Rita then produced an alternative interpretation of her interaction with the coworker—namely, that Terry’s so-called critical look could just as easily have been a meaningless glance or a reflection of some other concern. At first, such counterarguments didn’t feel very convincing to Rita. But after continued written thought exercises, coupled with the behavioral exposure, her thinking and feelings started to shift. In fact, after 2 weeks of not concealing her shape, Rita was no longer feeling self-conscious in this activity. The client’s anxiety was also reduced following repeated exposure to other activities, coupled with the thought exercise. By the 15th session, she no longer felt the need to wear concealing clothing at work or at the gym, and she was leaving her apartment with just a quick glance at the mirror. Rita had even gone swimming several times at her gym and felt pretty comfortable doing so by the fourth venture. Rita: By doing these things over and over I’m getting used to them. I’m back to doing normal things in spite of my weight. People don’t really seem to view me any differently. More likely, they simply don’t care one way or the other. I guess I need to consider why I care so much. Dr. Heston: What thoughts do you have? Rita: I guess I’ve been equating my weight with some sense of worthiness, like I don’t deserve anything unless I’m thin. Where do you think I got that? Dr. Heston: I don’t know, but obviously our culture promotes that concept to some extent. In any case, the important thing is to recognize that you’ve fallen prey to that idea and need to counteract it. Rita: I think these exercises have helped to some extent. But I can’t help feeling that being successful or worthwhile is tied to being thinner. Dr. Heston had Rita consider arguments both for and against the belief that thinness is a sign of success. Rita concluded that being thinner might be desirable from an appearance standpoint but that it did not represent any form of merit. To further this, the psychologist had Rita carry out a new exercise. The client agreed to survey the appearance of women whom she considered attractive or successful, particularly at the gym and the swimming pool. Rita was to attend specifically to the flaws in body shape they might each possess. Such observations would help her recognize that she might have given her own flaws in body shape unfair emphasis. Sessions 16 and 17 By the 16th session, Rita had been almost binge-free and purge-free for 8 weeks. She was continuing to eat regular meals, including formerly forbidden foods. And she had eliminated most of the behaviors that had been inspired by anxiety over her weight and shape. By the 17th session, the client had spent 2 weeks carrying out the exercise of noticing other women’s body shapes. She noted that the exercise was very different from the way she normally directed her attention to other women. Usually, she would focus on their most flattering attributes. If one had a small waist, she would focus on that; if another had toned legs, she would look at them, all the while making unfavorable comparisons with herself. With this new exercise, she was forcing herself to do the opposite, and it was quite an eye-opener. She learned, for example, that Terry, the coworker Rita had always considered the epitome of thinness, was actually quite thick in the calves and had large feet. Similarly, she noted that a woman at the pool, one Rita had consistently admired, had dimpled thighs. These observations, in combination with the ongoing behavioral exposure exercises, were helping her to see her own situation in a different light. She was starting to consider that maybe her dissatisfaction with 132 pounds was overblown. Although she still would prefer to weigh 120 to 125, she was now thinking of postponing any further weight loss; the effort might not justify the result. Dr. Heston was very supportive, suggesting that it would be best to put the whole weight loss question on hold for at least several months. This would give Rita time to lock in her more realistic views on weight and body shape. Then the client could consider the question of weight reduction objectively. Sessions 18 to 22 The next five sessions were devoted to the consolidation of Rita’s behavior and attitude changes and to relapse prevention. During this period, she had been instructed to stop her daily food records and behavioral exercises. In addition, the sessions were spread more and more apart, to give the client practice in functioning for longer periods without supervision. All continued to go very well, and treatment ended after the 22nd session. In the final session, Dr. Heston advised Rita to keep on the lookout for any signs of slipping into old habits: for example, skipping meals, avoiding many foods, excessive weighing, and of course purging. If she were to detect any such signs, she was to counteract them right away; if this proved too hard to do on her own, she was to contact Dr. Heston for booster sessions. Cognitive-behavioral treatments for bulimia nervosa produce significant improvement in 40 percent to 60 percent of clients. Differences in outcome statistics depend on when the treatment outcome is assessed and how it is defined (reduction in symptoms versus complete remission) (Mitchell et al., 2011; Poulson et al., 2014). Epilogue Six months after the final session, Rita contacted Dr. Heston. She said that she had successfully maintained her progress, although there had been one occasion, about a month after the treatment ended, when she purged. Rita said she regretted the purging immediately afterward and had been purge-free for the past 5 months. She continued to follow a regular meal plan, although she had to admit that her old dieting habits were often tempting. Her weight remained about the same throughout this period. Her main reason for getting in touch, she told Dr. Heston, was that she was not doing well in her dating relationships: on more than a few occasions, she had driven off guys by being too critical and moody. She asked Dr. Heston for the name of a therapist who was experienced in interpersonal problems. The psychologist suggested a colleague and asked Rita to continue to keep in touch. The therapist was of course not pleased that her former client was still struggling with relationships, but she was very pleased indeed with her continued success in the realm of eating and appearance. With those problems under control, Rita’s chances of addressing her interpersonal problems, or any other problems for that matter, were greatly improved. One follow-up study indicated that patients who received either cognitive-behavioral therapy or exposure with response prevention treatment for bulimia continued to improve over a 5-year period. By 5 years after treatment, 83 percent of individuals no longer met the criteria for bulimia nervosa, but only 36 percent had been abstinent from bulimic behaviors for the past year (McIntosh, Carter, Bulik, Frampton, & Joyce, 2011). Assessment Questions 1. What was the concern that Rita had, along with many others who have bulimia nervosa? 2. Describe Rita’s eating plan, including her “good” and “bad” eating habits. Do you think her diet plan was reasonable? 3. When did Rita’s eating behaviors begin to become pathological? 4. What prompted Rita to decide to purge after her binges? 5. What was Rita’s nonpurging activity to lose weight? 6. According to the information provided in the text, how do individuals with bulimia generally perceive their body size compared to control subjects? 7. How did Rita’s eating disorder affect her relationships with her coworkers? 8. Why did Rita finally decide to seek treatment? 9. Describe the cognitive-behavioral model of the maintenance of bulimia nervosa. 10. Dr. Heston asked Rita to keep a record of her eating behaviors. What did Dr. Heston see as advantages to this exercise, and why was Rita reluctant to participate in this assignment? 11. At what age do most cases of bulimia begin? 12. Describe at least two medical problems that may occur with continued bingeing and purging. 13. From reading about Rita, list all of the reasons you think were factored in to why she developed bulimia nervosa. 14. For clients seeking treatment for bulimia, what are the statistics regarding improvement in behaviors?
and Case 9: Bulimia Nervosa in Gorenstein and Comer (2014)(attached). Please also read the Waller, Gray, Hinrichsen, Mounford, Lawson, and Patient (2014) “Cognitive-Behavioral Therapy for Bulimia Nervosa and Atypical Bulimic Nervosa: Effectiveness in Clinical Settings,”Halmi (2013) “Perplexities of Treatment Resistance in Eating Disorders,” and DeJesse and Zelman (2013) “Promoting Optimal Collaboration Between Mental Health Providers and Nutritionists in the Treatment of Eating Disorders” articles.
