case study example of bulimia nervosa

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Case Study of Bulimia Nervosa (BN)

• By : Maggie Molloy

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 pane l 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.

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
• 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?

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CASE REPORT article

Case report: unexpected remission from extreme and enduring bulimia nervosa with repeated ketamine assisted psychotherapy.

• 1 Department of Psychology, University of Utah, Salt Lake City, UT, United States
• 2 Behavioral Science Department, Utah Valley University, Orem, UT, United States
• 3 Division of Public Health, University of Utah School of Medicine, Salt Lake City, UT, United States
• 4 Marriage and Family Therapy Program, Capella University, Minneapolis, MN, United States
• 5 Riverwoods Behavioral Health, Provo, UT, United States
• 6 Department of Educational Psychology, University of Utah, Salt Lake City, UT, United States

Background: Bulimia nervosa is a disabling psychiatric disorder that considerably impairs physical health, disrupts psychosocial functioning, and reduces overall quality of life. Despite available treatment, less than half of sufferers achieve recovery and approximately a third become chronically ill. Extreme and enduring cases are particularly resistant to first-line treatment, namely antidepressants and cognitive behavioral therapy, and have the highest rate of premature mortality. Here, we demonstrate that in such cases, repeated sessions of ketamine assisted psychotherapy (KAP) is an effective treatment alternative for improving symptoms.

Case Presentation: A 21-year-old woman presented with extreme and enduring bulimia nervosa. She reported recurrent binge-eating and purging by self-induced vomiting 40 episodes per day, which proved refractory to both pharmacological and behavioral treatment at the outpatient, residential, and inpatient level. Provided this, her physician recommended repeated KAP as an exploratory and off-label intervention for her eating disorder. The patient underwent three courses of KAP over 3 months, with each course consisting of six sessions scheduled twice weekly. She showed dramatic reductions in binge-eating and purging following the first course of treatment that continued with the second and third. Complete cessation of behavioral symptoms was achieved 3 months post-treatment. Her remission has sustained for over 1 year to date.

Conclusions: To our knowledge, this is the first report of repeated KAP used to treat bulimia nervosa that led to complete and sustained remission, a rare outcome for severe and enduring cases, let alone extreme ones. Additionally, it highlights the degree to which KAP can be tailored at the individual level based on symptom severity and treatment response. While its mechanism of action is unclear, repeated KAP is a promising intervention for bulimia nervosa that warrants future research and clinical practice consideration.

Introduction

Bulimia nervosa (BN) is a disabling psychiatric disorder characterized by recurrent binge-eating (consuming objectively large amounts of food with a sense of lost control) and inappropriate compensatory behaviors (self-induced vomiting; laxative, diuretic, or medication misuse; and fasting or excessive exercise) aimed at preventing weight gain ( 1 , 2 ). Overtime, the severity of these patterns significantly disrupts physical health and psychosocial functioning, as well as impacts families and communities at large ( 3 ). Approximately 50 million people worldwide will develop BN at some point in their life ( 4 ). Moreover, studies have found BN to be associated with concomitant psychiatric comorbidity [e.g., mood disorders and substance abuse; ( 5 , 6 )] in addition to premature mortality due to medical complications ( 7 – 9 ). Death by suicide is also eight times more likely to occur among individuals with BN compared to the general population, with more than a third experiencing lifetime rates of non-suicidal self-injury ( 10 , 11 ).

While pharmacological (e.g., selective serotonin reuptake inhibitors) and behavioral (e.g., cognitive behavioral therapy) interventions are effective in managing BN ( 12 , 13 ), many individuals do not respond to first-line treatment, are unsuccessful in later attempts, and fail to change over protracted periods ( 14 , 15 ). Nearly 30% of sufferers become chronically ill as a result ( 16 ). For such chronic refractory cases, the paucity of evidence-based treatments has prompted paradigm shifts toward harm reduction and palliative care over recovery ( 17 , 18 ).

Ketamine, a non-competitive N-methyl-D-aspartate receptor (NMDAr) antagonist, is an emerging therapy for treatment-resistant mood disorders ( 19 , 20 ). Single-dose studies have consistently shown rapid antidepressant and anti-suicidal effects following ketamine treatment, though are relatively short-lived (1–4 weeks) ( 21 – 28 ). Ketamine assisted psychotherapy (KAP) has therefore been utilized to prolong ketamine's efficacy and maximize therapeutic outcomes ( 29 – 34 ). To date, few studies have used ketamine for the treatment of eating disorders, including one open-label study ( 35 ), two case reports ( 36 , 37 ), and one longitudinal case series ( 38 ), all of which administered ketamine without a psychotherapeutic component. Nonetheless, the results are encouraging. Here, we report the case of a young woman suffering from extreme and enduring BN, according to CARE (CAse REport) guidelines ( 39 ), who demonstrated remarkable symptom improvement following repeated sessions of KAP.

Case Presentation

A 21-year-old woman with BN of 9 years presented to the outpatient clinic, Forum Health. She was first diagnosed with BN, binge-eating/purging type, at 12.5 years of age to which the severity of her symptoms steadily increased overtime. On presentation, she reported alarming rates of binge-eating and purging by self-induced vomiting, averaging ~40 episodes per day for the last 12 months. Based on this frequency, her BN was categorized as “extreme” according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criterion (14 or more episodes per week). Clinical assessment and scoring on the Eating Disorder Examination Questionnaire [EDE-Q; ( 40 , 41 )] additionally confirmed the severity of her illness. No laxative or diuretic abuse was reported. While not active in psychiatric treatment, the patient was taking potassium chloride 20 mEq extended-release twice daily for hypokalemia as well as trazodone 100 mg once daily in the evenings for sleep. At 161.92 cm tall and 46.26 kg in weight [body mass index (BMI) = 17.6 kg per m 2 ], the patient was amenorrheic and described body image disturbances, intense fear of gaining weight, and obsessive-compulsive tendencies around food (counting calories, binging by order of food group, and inability to discard uneaten items). She further displayed pronounced bilateral parotid sialadenosis (enlargement of the salivary glands) and pseudo-idiopathic edema, otherwise known as pseudo-bartter's syndrome (PBS): a rare and painful complication of BN characterized by hyperaldosteronism, metabolic alkalosis, and hypokalemia ( 42 ). As a University student studying cognitive neuroscience, the patient was obliged to take a medical leave due functional decline. “I lost all ability to take care of myself. I could not think clearly or show up for classes. I stopped socializing and running errands. I could hardly maintain basic hygiene.”

Her psychiatric history included an adolescent sexual assault by a treating physician (13 years of age [2011]); a suicide attempt by cut throat injury at the level of the hyoid bone, which required emergency transportation and thyroid cartilage repair as well as inpatient hospitalization (13 years of age [2011]); a second suicide attempt by drug overdose involving mixed opioids, barbiturates, and antidepressants that resulted in emergency room hospitalization (15 years of age [2013]); and a blitz rape (surprise attack) by an unknown assailant (19 years of age [2017]). The patient's history also contained reports of major depression, general anxiety, and obsessive-compulsive disorder. There was no family history of eating disorders, including BN.

As an outpatient, she was treated with various pharmacotherapies (fluoxetine 40 mg once daily, citalopram 20 mg once daily, and naltrexone 50 mg twice daily), behavioral interventions (cognitive behavioral therapy, mindfulness-based stress reduction, and eye movement desensitization and reprocessing), and nutritional counseling (dietary modification and time-based feeding). She additionally was prescribed spironolactone 25 mg twice daily, a potassium-sparing diuretic, on multiple occasions to treat PBS following attempts at purging cessation. However, the patient's binge-purge patterns continued. Finally, she received inpatient, residential, and intensive-outpatient eating disorder care (15–16 years of age [2013–2014]), which the patient described as a “traumatic experience” that resulted in immediate relapse upon discharge.

“My parents pulled me out of class and dropped me off at a center, leaving me there for almost 10 months. It was like being in prison. I was completely cut off from my friends and family. I was forced to eat unreasonable amounts of food at each meal. And I learned new [eating disorder] tricks from other patients that I tried later on. It was not a place conducive to recovery, at least for me. It just made my condition worse.”

Her medical history detailed emergency room hospitalizations for hypokalemia (16, 19, and 20 years of age [2014, 2017, 2018]), gastroesophageal reflux disorder (17–21 years of age [2015–2019]), gastric and duodenal ulcers (19 and 21 years of age [2017, 2019]), hypothyroidism (20–21 years of age [2018–2019]), and adrenocortical insufficiency (20–21 years of age [2018–2019]). Porcelain-laminate veneers were also placed on 10 of her teeth due to dental caries and enamel erosion from chronic purging (21 years of age [2019]).

Given the patient's extreme and chronic refractory state, her physician recommended repeated KAP, with the understanding it constituted an exploratory and off-label intervention for her eating disorder. She consented to treatment following a comprehensive medical evaluation and in-depth review of the procedures, risks, and possible side effects. A signed consent form was obtained. Prior to treatment, she met with a clinical psychologist to establish rapport and therapeutic alliance. The patient then underwent one course of repeated KAP, consisting of six sessions scheduled twice weekly for 3 weeks, with a minimum interval between sessions of 48 h ( Figure 1 ). Each KAP session involved guided psychotherapy combined with racemic ketamine hydrochloride (0.5 mg per kg bodyweight suspended in 0.9% normal saline) administered intravenously over 40 min. The drug regimen was standard practice in the clinic for sub-anesthetic ketamine infusions, which is most commonly used for treating psychiatric disorders and is supported by a substantial body of literature ( 43 , 44 ). A person-centered, humanistic approach to psychotherapy was employed to facilitate the process of self-actualization and therapeutic change. KAP sessions were preceded by 30 min of preparatory psychotherapy and delivered in a private room with dimmed lights, ambient music, and textile art on the ceiling. The intervention components and ketamine regimen remained the same for all five consecutive sessions; and blood pressure, heart rate, and oxygen saturation were continuously monitored. Due to the severity of her eating disorder, however, the patient returned to the clinic 1 month later for a second course of repeated KAP and then again 1 month later for a third.

Figure 1 . Timeline of clinical events. The patient received three courses of repeated KAP for extreme and enduring BN, consisting of six sessions per course scheduled twice weekly for 3 weeks. KAP, ketamine assisted psychotherapy; BN, bulimia nervosa; B/P, binge-eating and purging.

Dissociation, ego dissolution, and perceptual distortions were present during all KAP sessions, as evidenced by the patient's description of “being disconnected from reality,” “losing [her] sense of identity and self,” and “seeing abstract geometric patterns.” She further exhibited mild diplopia (double vision), nystagmus (involuntary oscillations of the eyes), and alogia (lack of speech) during treatment that resolved completely. No other side effects or adverse events were reported. The patient's eating disorder symptoms remitted over the course of treatments, as measured by change in scoring on the EDE-Q as well as entries from a daily tracking log that recorded frequency of binge-eating and purging. On the EDE-Q, her global score dropped from 31.8 at baseline to 15.0 by the end of all three courses (18 sessions), with similar patterns recorded across all four subscales: “Restraint” ( M = 5.0, SD = 2.2 to M = 1.8, SD = 1.3), “Eating Concern” ( M = 5.8, SD = 0.5 to M = 2.2, SD = 1.5), “Weight Concern” ( M = 5.8, SD = 0.5 to M = 4.0, SD = 1.9), and “Shape Concern” ( M = 5.5, SD = 0.8 to M = 2.5, SD = 1.6) ( Figure 2 ). Additionally, the patient's tracking log showed decreases in binge-eating and purging from 40 to 18 episodes per day after the first course of treatment (6 sessions), 18 to 13 episodes per day after the second course of treatment (12 sessions), and 13 to 4 episodes per day after the third course of treatment (18 sessions) ( Figure 3 ).

Figure 2 . Change in scoring on the Eating Disorder Examination Questionnaire (EDE-Q).

Figure 3 . Frequency of daily binge-eating and purging following repeated ketamine assisted psychotherapy.

Most notably, the patient stopped her binge-eating and purging behaviors 3 months post-treatment. Given her initial severity and chronic refractory state, this degree of improvement was striking. The patient's daily tracking log additionally showed no signs of relapse 1 year later, accompanied by marked improvement in psychosocial functioning. Specifically, she reported feeling “free” from intrusive BN thoughts and compulsions, “less impulsive” when faced with the urge to binge and purge, and “more confident” about her body in general. The patient has since resumed her academic studies in preparation for a doctoral program.

Severe, chronic, and refractory eating disorder symptoms are unfortunately common among patients with BN. In this case, we describe a young woman with extreme and enduring BN, who remained unresponsive to first-line treatment for nearly a decade, despite care at the outpatient, residential, and inpatient level. Her eating disorder was extreme, insofar as she engaged in recurrent binge-eating and purging by self-induced vomiting 40 episodes per day, which significantly exceeds DSM-5 criterion (14 or more episodes per week). Given the severity of her illness, complete and sustained remission with three courses of repeated KAP (18 sessions) was both remarkable and unanticipated. These findings are more robust provided the patient was not active in psychiatric treatment for 1 year prior to clinic admission, excluding her long-standing prescription of potassium chloride for hypokalemia and trazodone for sleep. If ketamine and psychotherapy act synergistically, with therapy priming and enhancing the response to treatment, then its combined effect may explain the striking improvements in symptoms. Serial treatments likely account for the durability of response necessary for sustained remission, which is consistent with literature ( 45 – 48 ).

Provided this is the first report of repeated KAP used as an exploratory and off-label intervention for BN, it is important to consider the a-priori context. Clinical recommendation to pursue repeated KAP was prompted by three factors. First, the patient's psychiatric and medical history that detailed unsuccessful treatment attempts, including pharmacotherapies, behavioral treatments, and nutritional counseling—even at higher levels of eating disorder care; and significant trauma to which accumulating evidence has shown ketamine to yield positive effects for ( 49 – 51 ). Second, her severe functional impairment in three major life domains, including academic work, social and family engagement, and personal responsibilities. The patient was binge-eating and purging nearly to the exclusion of all other activities, spending more time “alone in the bathroom than with [her] friends or family.” Finally, an open-label case series on repeated ketamine in severe and enduring anorexia nervosa, showing modest improvements in eating disorder symptoms ( 38 ).

The patient's impetus for treatment was largely driven by fear of premature mortality—that if she did not attempt something new, she was going to “eat [herself] to death,” quite literally. Serious degradation in the patient's physical and mental health status were particularly motivating. Apart from transient psychological (dissociation, ego dissolution, and perceptual distortions) and physiological (mild diplopia, nystagmus, and alogia) side effects of ketamine that resolved completely after each session, the treatment was well-tolerated. Following all three courses of treatment, the patient dramatically reduced her binge-eating and purging behaviors by 90% compared to baseline, as measured by the EDE-Q and daily tracking logs. She also demonstrated considerable improvements in disordered eating psychopathology that were captured by the subscales of the EDE-Q, most notably “Restraint” (e.g., dietary rules and avoidance of food) and “Eating Concerns” (e.g., preoccupation with calories and fear of losing control over eating). Moreover, the patient regained control of her impulsive eating as well as resolved her obsessive-compulsive neurosis, which align with previous BN-specific findings from a study on intermittent ketamine infusions in eating disorders ( 35 ). At 3 months follow-up, she achieved complete cessation of binge-eating and purging and no longer met diagnostic criteria for BN. The magnitude of response neither diminished over time, with no signs of relapse at 15 months follow-up, contrary to studies showing rapid decline of effects after treatment ( 28 , 52 , 53 ). With sustained remission, the patient has adopted a healthier relationship with food, established psychosocial stability in her life, and resumed her academic studies in preparation for graduate school.

This is a single case report with inherent limitations in generalizing the findings to other patients with BN. The lack of polypharmacy or medication washout is an additional limitation that may have unknowingly mediated improvements. Furthermore, it is unclear as to whether ketamine or psychotherapy produced greater clinical benefit, if both are coadjuvant and necessary, or if the treatment would have been as effective without psychotherapy and/or fewer sessions. Finally, a person-centered, humanistic approach to psychotherapy was employed, differing from more traditional methods, such as cognitive-behavioral, interpersonal, and psychodynamic therapy. Open pilot studies as well as fully-powered randomized controlled trials with longitudinal assessment are thus required to establish whether the outcome of this case can be replicated, to what degree ketamine and psychotherapy contribute to the overall success of the treatment, and the comparative efficacy of different psychotherapeutic interventions. Further research is also warranted to optimize KAP duration and frequency for this patient population.

Conclusions

This study provides compelling evidence that repeated KAP is an effective treatment for extreme and enduring BN, which is exceedingly resistant to first-line therapies and associated with poor prognosis. It further highlights the utility of combined strategies that may prolong ketamine's efficacy, and subsequently maximize therapeutic outcomes at the individual level.

Data Availability Statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

Ethics Statement

Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Author Contributions

PH-B assessed, treated, and followed-up with the patient. AR interviewed the patient, conceptualized the case report, drafted the manuscript, and developed all figures. LKJ and SC contributed to the literature review and assisted with manuscript preparation. LG, QT, and MR provided substantial contributions to the interpretation of data as well as manuscript revisions. All authors have read and approved the final manuscript.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments

We thank Dr. Andrew Petersen, the lead physician on this case, for his contributions to this study and continued innovation in the field.

Abbreviations

BMI, body mass index; BN, bulimia nervosa; DSM-5, diagnostics and statistical manual of mental disorders, 5th edition; EDE-Q, eating disorder examination questionnaire; KAP, ketamine assisted psychotherapy; NMDAr, N-methyl-D-aspartate receptor; PBS, pseudo-bartter's syndrome.

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Keywords: bulimia nervosa, eating disorder, binge-eating, purging, ketamine, ketamine assisted psychotherapy, psychopharmacology, case report

Citation: Ragnhildstveit A, Jackson LK, Cunningham S, Good L, Tanner Q, Roughan M and Henrie-Barrus P (2021) Case Report: Unexpected Remission From Extreme and Enduring Bulimia Nervosa With Repeated Ketamine Assisted Psychotherapy. Front. Psychiatry 12:764112. doi: 10.3389/fpsyt.2021.764112

Received: 25 August 2021; Accepted: 27 October 2021; Published: 17 November 2021.

Reviewed by:

Copyright © 2021 Ragnhildstveit, Jackson, Cunningham, Good, Tanner, Roughan and Henrie-Barrus. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Anya Ragnhildstveit, anya.ragnhildstveit@utah.edu

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Bulimia Nervosa Clinical Presentation

• Author: Guido Klaus Wilhelm Frank, MD; Chief Editor: David Bienenfeld, MD  more...
• Sections Bulimia Nervosa
• Practice Essentials
• Pathophysiology
• Epidemiology
• Mortality/Morbidity
• Patient Education
• Diagnostic Criteria
• Physical Examination
• Comorbidities
• Complications
• Laboratory Studies
• Imaging Studies
• Other Tests
• Approach Considerations
• Medical Care
• Nonpharmacologic Interventions
• Pharmacologic Treatments
• Surgical Care
• Consultations
• Long-Term Monitoring
• Media Gallery

Bulimia nervosa (BN) is often not diagnosed for many months or even years after onset because of patients' secretiveness about their symptoms, usually associated with a great deal of shame. These patients often see physicians for other problems, such as anxiety, depression, infertility, bowel irregularities, fatigue, or palpitations. Similarly, they may see mental health professionals for mood and anxiety problems, personality issues, relationship issues, histories of childhood or adolescent trauma, or substance abuse, without revealing the presence of an eating disorder.

One common presenting scenario is that of a patient who is concerned about their weight who seeks help with weight loss. Symptoms may include bloating, constipation, and menstrual irregularities. Far less often, people may present with palpitations resulting from arrhythmias, which are often associated with electrolyte abnormalities and dehydration. BN is also often, but not always, characterized by an inappropriate premium placed on slender physical appearance. It is important to note that the diagnostic criteria do not necessarily require an individual to express a desire to lose weight or change their appearance to meet criteria for BN. Some, especially younger patients, may not be able or willing to articulate why they engage in eating disorder behaviors. Others may express a motivation for control, a fear of fullness, or other reasons for their disordered eating behaviors. Failure to make an appropriate eating disorder diagnosis that an individual would otherwise meet criteria for, whether it be anorexia nervosa (AN), BN, or other specified feeding or eating disorder (OSFED), because of a lack of expressed concern or denial of concern about body weight/shape is dangerous for patients’ physical and mental health due to causing delays in diagnosis that can contribute to significant morbidity and mortality. 

A dietary history may reveal attempts to control weight by dieting and abstaining entirely from high-calorie foods at all times except during binge eating episodes. Often, an all-encompassing preoccupation with food and eating is present, and recurring cycles of extreme dieting and/or fasting may alternate with gorging behavior. The clinician should inquire further about types of foods and quantities of foods consumed when a patient endorses binging behavior. A binge eating episode, by definition, must constitute consumption of more food than would typically be consumed in a single setting by an individual, so there is some subjectivity in what is a binge. Some patients with AN or with periods of very restrictive eating patterns may endorse a “binge,” but on further inquiry may be describing an episode that would be either less than or normative for typical eating for a non-eating-disordered individual but perceived subjectively as a binge eating episode. In the context of highly restrictive eating, any instance of normative eating, such as consuming a dessert, eating high-calorie snacks, or even allowing oneself to eat until feeling full, might appear to be binge eating to an individual who is used to eating very little amounts of food most of the time. 

Most patients self-induce vomiting by gagging themselves with their fingers or a toothbrush. Some patients are able to regurgitate reflexively, without requiring external stimulation of the pharynx. [ 34 ] A minority of patients will chew, then regurgitate, without actually swallowing the food. One particularly dangerous form of vomiting is via induction through the use of emetics (eg, ipecac). Ipecac is a tightly binding and slowly released mycotoxin that may lead to fatal cardiomyopathy in habitual users. Up to 40% of patients misuse laxatives, thinking that their use will help them lose weight. In fact, laxative misuse results in additional dehydration and often electrolyte abnormalities as well. Screening for laxative use should be a routine topic of assessment. 

For children and adolescents, the parents/guardians of the patient should be asked to check for signs of vomiting and laxative misuse in the home when the patient is denying purging behavior but there is a strong suspicion of purging behaviors occurring. Indications of surreptitious purging behaviors that parents/guardians should be instructed to look for in the home include hidden vomitus in concealed places in the home (eg, closets, floorboards), concealed laxatives in the patients’ room or belongings, clogged drains with vomit, vomit in trash cans, and so on. The parents/guardians should also be instructed to be observant for other signs of purging behavior both for diagnostic and preventative purposes such as unusual online orders (which could be for laxatives or other emetics) and unusually long periods of time spent in the bathroom or shower, which may or may not be after meals and may or may not be accompanied by retching noises. For both children and adults, collateral informants can be very useful sources of information for the clinician about surreptitious purging or other eating disorder behaviors. 

Clinicians should be aware of misconceptions that eating disorders are almost exclusively present in young women to avoid missing diagnoses of BN or other eating disorders in male patients or older patients. Additionally, it is a misconception that eating disorders, including BN, mostly occur in White women and people from Western cultures. While research is still evolving on the epidemiology of BN and other eating disorders in males, older individuals, people in developing countries, and so on, in the authors’ clinical experiences, we have encountered a great many patients with BN and other eating disorders who are male, not White, and of a great many different ethnic and racial backgrounds. 

Patients with BN may experience the following symptoms:

General - Dizziness, lightheadedness, palpitations (due to dehydration, orthostatic hypotension, possibly hypokalemia)

Gastrointestinal symptoms - Pharyngeal irritation, abdominal pain (more common among persons who self-induce vomiting), blood in vomitus (from esophageal irritation and more rarely actual tears, which may be fatal), difficulty swallowing, bloating, flatulence, constipation, and obstipation

Pulmonary symptoms - Uncommonly aspiration pneumonitis or, more rarely, pneumomediastinum

A high index of suspicion is required in any depressed or anxious weight-conscious young woman.

A set of screening questions, such as the SCOFF mnemonic questionnaire, [ 35 ]  is useful to obtain a quick impression as to the potential need for further in-depth questioning. The SCOFF questionnaire includes the following 5 questions:

Do you make yourself  S ick because you feel uncomfortably full?

Do you worry you have lost  Co ntrol over how much you eat?

Have you recently lost more than  O ne stone (about 14 lbs or 6.35 kg) in a 3-month period?

Do you believe yourself to be  F at when others say you are too thin?

Would you say that  F ood dominates your life?

The Eating Disorder Screen for Primary Care (ESP) questionnaire is an alternative screening tool. [ 36 ] It contains the following 5 questions:

Are you satisfied with your eating patterns?

Do you ever eat in secret?

Does your weight affect the way you feel about yourself?

Have family members suffered from an eating disorder?

Do you currently suffer with or have you in the past suffered with an eating disorder?

The Eating Attitudes Test (EAT) is a self-report population-based screening instrument that patients can complete in the waiting room prior to seeing the health care provider. [ 37 ] (See  Psych Central  for more information.)

Family history of eating disorders, anxiety, mood disorders, and alcohol and/or substance abuse/dependence may contribute to the risk of BN and should be investigated.

Generally, patients with BN are more likely than controls to view their families as conflicted, badly organized, non-cohesive, and lacking in nurturance and caring. These patients have also been shown to more often appear to be angrily submissive to hostile and neglectful parents.

Perceptions of appearance-related teasing by family members may be present. [ 38 ]

For individuals still living with their parents, careful assessment of the family’s dynamics should be undertaken.

Physiological abnormalities

Many physiological abnormalities may be seen in association with eating disorders, but virtually all appear to be consequences of the abnormal behaviors, not their causes. In most cases of BN, laboratory abnormalities are relatively minor. In cases of very frequent purging (eg, daily or multiple times per day), abnormalities in electrolyte and serum amylase levels occur, but these and most other laboratory abnormalities are reversible with weight restoration and cessation of compensatory behaviors. 

Among the identified metabolic consequences sometimes seen in BN are low plasma insulin, C peptide, triiodothyronine, and glucose values, as well as increased beta-hydroxybutyrate and free fatty acid levels. Both fasting and post-binge/post-vomiting hypoglycemia are sometimes seen in some patients with BN. Some studies suggest increased secretory diurnal amplitudes in cortisol and adrenocorticotropic hormone (ACTH) in BN as well as blunted responses to corticotrophin-releasing hormone (CRH). However, these findings have been inconsistent among research studies.

Reports have also suggested abnormal responses to dexamethasone suppression like those seen in AN and major depressive disorder, more common among individuals with significant dietary restriction. Some authors have attributed these abnormalities to impaired dexamethasone absorption, which is demonstrated in some patients with BN. Similar to findings in AN, patients with BN tend to have higher growth hormone levels at night, while nocturnal prolactin levels tend to be less than those seen in controls.

About half of women with BN have anovulatory cycles, while about 20% have luteal phase defects. Patients with anovulatory cycles generally have impaired luteinizing hormone pulsatile secretion patterns and associated reduced estradiol and progesterone pulse amplitudes. [ 39 , 40 ]

Although the implications of many research findings are still unclear, and none of the following offer clinical tests of any merit, reports suggest involvement of the serotonin transporter, [ 41 , 42 ]  autoantibodies against neuropeptides, [ 43 ]  various chromosome regions, [ 44 ] brain-derived neurotrophic factor, [ 45 ]  and peptides leptin and ghrelin. [ 46 ] In a few instances, cerebral hemispheric lesions may be involved in pathogenesis. [ 47 ] Regional cerebral blood flow abnormalities have been noted in adolescents. [ 48 ] Endogenous opioids and beta-endorphins have been implicated in the maintenance of binge eating. Therefore, diagnosis of BN and other eating disorders should be made mostly on the basis of interview with the patient and their collateral informants as well as behavioral observation at times (eg, purging witnessed by family or a staff member). Laboratory tests and physical examination can provide important information about comorbid medical sequelae of BN, but diagnosis requires a thorough diagnostic interview and clinical history. 

The underlying causes for buimia nervosa (BN) remain elusive. However, a variety of biological and psychological factors have been suggested to be involved the development of BN.

Behavioral traits

BN has long been associated with inadequate mechanisms to control food intake beyond ones physiological needs, and behavioral traits could contribute. [ 183 , 184 , 185 , 186 , 187 ]  

Emotion regulation has been defined as the “extrinsic and intrinsic process responsible for monitoring, evaluating, and modifying emotional reactions, to accomplish one’s goals." [ 188 ] A disturbance in emotion regulation has been found in eating disorders. [ 189 ] Individuals with BN have difficulties modulating strong emotions and controlling rash, impulsive response. [ 190 ] Most but not all studies suggest that negative affect precedes binge eating episodes, [ 191 ] followed by initial relief. [ 192 , 193 ]  

Impulsivity, the “opposite to aspects of executive function,” [ 194 ] is a tendency to act with insufficient forethought, or a predisposition toward rapid, unplanned reactions to internal or external stimuli without regard for the negative consequences of these reactions. Impulsivity has relevance for binge eating behaviors, as those episodes typically occur impulsively in response to an external or internal trigger. Increased impulsivity had been found across BN. [ 195 , 196 ] Overall, the literature on executive function in BN is limited, but there is evidence that altered impulsivity and executive function distinguish binge eating individuals from normal weight or obese controls.

Negative urgency, the tendency to experience strong impulses under the influence of negative emotions, or to act rashly when distressed, is related to emotion regulation and impulsivity and has been associated with binge eating. [ 197 , 198 ] Negative urgency is a trait that is triggered by negative affect and may result in binge eating in vulnerable individuals. [ 199 , 200 , 201 , 202 , 203 , 204 ] Interestingly, negative urgency and affect seem to be more relevant than impulsivity, at least for some with binge eating. [ 205 ]  

Sensitivity to reward and punishment described in the reinforcement sensitivity theory (RST) provides a framework for how differences in brain systems' responsiveness to reward and punishment are reflected in individual personality. [ 206 , 207 ] Reward sensitivity influences decision making in eating disorders. [ 208 ] Sensitivity to reward was found elevated in BN and it has been hypothesized that an imbalance between reward sensitivity, impulsivity and inhibition are mechanistically involved in binge eating. [ 209 , 210 , 211 ] In addition, individuals with binge eating behaviors showed greater risk taking, and obese binge eating disorder has been associated with altered value computation and discrimination of salient stimuli. [ 212 ]

Taken together, emotion regulation, impulsivity, negative affect, negative urgency, and sensitivity to reward have been linked to binge eating and may create a vulnerability for developing or perpetuation BN behaviors. [ 213 ] However, we do not have a transdiagnostic model for their underlying neurobiology.

Neurocircuitry of emotion regulation, impulsiveness, and cognitive control in BN

A complex interplay exists between emotion regulation and cognitive control. Emotions affect attention, drive cognitive bias, and may interrupt proper decision making; on the other hand, attention to specific goals can control emotions and override strong feelings. [ 214 , 215 , 216 ] Control of food cravings is thought to involve prefrontal cortical areas, whereas greater caloric intake has been related to higher activation in gustatory cortex and brain regions for reward computation. [ 217 , 218 , 219 ] Little is known about how emotion regulation and cognitive control circuits affect binge eating. One study found reduced prefrontal cortical activity in BN when viewing food pictures. [ 220 ] BN showed hypoactivity in brain areas involved in self-regulation and impulse control, such as the prefrontal cortex or insula. [ 221 , 222 , 223 , 224 ] Only one study directly investigated negative affect in relation to binge eating in BN, finding a positive correlation between negative affect and striatal brain response during anticipation of a milkshake. [ 225 ] Altogether, studies suggest altered brain function related to emotion regulation in individuals with binge eating, but the literature is inconsistent.

Neurotransmitters and hormones

Animal models have shown that dopamine, serotonin, acetylcholine, and norepinephrine have all been associated with cognitive control and impulse control in frontal cortical circuits. [ 226 , 227 ] For instance, dopamine D2 and serotonin 2A and 2C receptor signaling can modulate impulsivity. [ 228 , 229 ] Human studies in BN found that serotonin 1A or dopamine D2/3 receptor binding correlated with harm avoidance or behavior inhibition. [ 230 , 231 ] Endocrine factors such as ghrelin, leptin, sex hormones, and cortisol can influence food intake behaviors, [ 232 ] but how they contribute to eating disorders is still elusive. [ 233 , 234 ] Basic research on the gut–brain axis showed how leptin or ghrelin activate brain stem and ventral striatum to activate dopamine circuits and motivation to eat. [ 231 , 234 ] Stress, via cortisol and gut hormone activation, leads to dopamine-mediated decreased food intake in animals, although in humans stress often leads to increased food intake, suggesting a different pathophysiology. [ 235 ] Dopamine drives motivation and food approach, while hedonic aspects of food intake (“liking”) are processed by opioids. [ 236 , 237 ] Those systems could be altered premorbidly as a vulnerability factor but also change in response to extremes of eating, which is an important part of our overall model of eating disorder pathophysiology. [ 238 ] Dopamine has a unique position. It is the only neurotransmitter that we have a mathematical understanding of neuronal function for, which can be used for computational modeling of brain function. Dopamine mediates reward learning [ 239 ] and has been implicated in the pathophysiology of taste and reward processing in eating disorders using the so-called prediction error model, which provides a very strong framework to study reward function in eating disorders. [ 240 , 241 , 242 , 243 , 244 ]

Although patients with bulimia nervosa (BN) are often unremarkable in general appearance and frequently have no signs of illness on physical examination, several characteristic findings may occur.

Physical findings may include the following:

• Bilateral parotid enlargement, largely consequent to noninflammatory stimulation of the salivary glands, may be seen. [ 65 ]  See parotid gland swelling in following image.

Parotid hypertrophy. Reprinted with permission from Mandel, L and Siamak, A. Diagnosing bulimia nervosa with parotid gland swelling. J Am Dent Assoc 2004, Vol 135, No 5, 613-616.

See the list below:

• In patients with significant self-induced vomiting, erosions of the lingual surface of the teeth, loss of enamel, periodontal disease, and extensive dental caries may be observed, as in the following image. [ 66 ]

Dental caries. Reprinted with permission from Wolcott, RB, Yager, J, Gordon, G. Dental sequelae to the binge-purge syndrome (bulimia): report of cases. JADA. 1984; 109:723-725.

• Russell sign (one of the few physical examination findings in psychiatry) manifests as callosities, scarring, and abrasions on the knuckles secondary to repeated self-induced vomiting. [ 67 ]

Russell sign. Reprinted with permission from Glorio R, et al. Prevalence of cutaneous manifestations in 200 patients with eating disorders. Int J Derm, 2000, 39(5), 348-353.

Other cutaneous manifestations can include telogen effluvium (sudden, diffuse hair loss), acne, xerosis (dry skin), nail dystrophy (degeneration), and scarring resulting from cutting, burning, and other self-induced trauma. [ 68 ]

Other nonspecific but suggestive findings that may reflect the severity of the disease include bradycardia or tachycardia, hypothermia, and hypotension (often associated with dehydration). Edema, particularly of the feet (and less commonly the hands), is found more often among patients with a history of diuretic abuse, laxative abuse, or both or in patients with significant protein malnourishment causing hypoalbuminemia.

Some patients may be clinically obese, but morbid obesity is rare. Patients with BN who are overweight may have excessive fat folds that favor humidity and maceration with bacterial and fungal overgrowth, striae due to skin overextension, stasis pigmentation related to peripheral vascular disease, and plantar hyperkeratosis due to increased weight. [ 68 ]

A community-based household survey involving 52,095 adults in 19 countries found, after adjustment for pertinent comorbidities, that the rate of BN among the 2580 identified cases of adult-onset diabetes mellitus was twice that of non-diabetic individuals. [ 69 ]

A typical Mental Status Examination for a patient with BN is detailed below. (The formal Folstein Mini-Mental Status Examination [MMSE] is usually unnecessary in the evaluation of patients with BN because symptoms of dementia and delirium are not common in these patients.)

Appearance: Patients are typically neat, well dressed, and show attention to detail. Grooming is often meticulous and may further demonstrate a patient's concern about personal appearance.

Behavior: Patients usually do not have kinetic abnormalities, but anxious feelings may heighten psychomotor agitation. Movements are spontaneous, and patients generally are cooperative and able to carry out requested tasks.

Cooperation: Patients generally avoid eye contact due to shame and embarrassment.

Mood and affect: Patients often demonstrate a depressed mood but may also have significant anxiety.

Speech: Content and articulation are generally normal.

Thought process: Patients likely have a linear thought process that is goal-directed.

Thought content: Thoughts tend to revolve around food and concerns regarding body image and weight.

Perceptual disturbances: Delusions and hallucinations are typically absent.

Suicidal ideation: Suicidal ideation is a significant consideration, especially in patients with depressed moo. Although suicidal ideation is often restricted to thoughts rather than concrete plans, suicidal thinking should be taken very seriously.

Homicidal ideations: Homicidal ideation is not typically associated with those diagnosed with BN.

Cognition: Patients are generally alert, and oriented to their surroundings. Attention and concentration typically measured by serial sevens and digit span are generally normal. Immediate memory is normal, as is recent and remote memory recall. Intellect is usually judged as normal, and in some cases, intellect ability may surpass average. Capacity to read and write is within normal limits. Visuospatial functions are also intact.

Judgment: Patients generally demonstrate poor judgment regarding self-care and treatment. Weight-reducing strategies such as induced vomiting, laxative, and diuretic ingestion are often perceived as legitimate and appropriate methods of weight management.

Insight: Insight regarding the presence and significance of disturbances is variable. While patients typically admit to episodes of binge eating, they often do not appreciate their inappropriate fixation on eating or their distorted ideas of body image and weight.

A national comorbidity study examined lifetime comorbidities of other psychiatric diagnoses in conjunction with bulimia nervosa (BN). [ 10 ] In general, the lifetime comorbidity of any psychiatric disorder is 94.5%.

Affective disorders

The common co-occurrence of eating disorders with affective disorders suggests a possible relationship between them. [ 49 ]   Major depressive disorder (MDD) is particularly common (approximately 50%) in this regard. Whether the association is causative (primary), secondary to the BN itself, or represents a common set of risk factors for BN and MDD is still unclear. Depressive symptoms can occur during pregnancy and postpartum in women with BN. [ 50 ]  Bipolar II disorder also appears to be more common in patients with BN than in patients without eating disorders. The lifetime comorbidity for bipolar I or II is 17.7%.

Anxiety disorders

Obsessive-compulsive disorder (OCD) is more common in persons with BN (17.4% lifetime comorbidity) than in controls. Panic disorder , social phobia , specific phobias , generalized anxiety disorder (GAD), and posttraumatic stress disorder (PTSD) significantly contribute to comorbidity. Lifetime comorbidities have been reported at approximately 17.4% for OCD, 16.2% for panic disorder, 41.3% for social phobia, 50.1% for specific phobias, 11.8% for GAD, and 45.4% for PTSD.

One study suggests that baseline clinical predictors such as female gender and family history of eating disorders might be specific to the later development of eating disorders in the context of childhood OCD. [ 51 ]

Substance use disorders

Some evidence suggested a relationship between disorders of substance abuse and dependence and BN, including alcohol dependence, [ 52 ]  nicotine dependence, [ 53 ]  and drug dependence. [ 54 ]  For example, with regard to smoking in healthy controls, there were significantly more smokers among people with bulimia (lifetime OR = 2.165) and BED (lifetime OR = 1.792), but not for those with AN (lifetime OR = 0.927). Studies on caffeine intake are mixed. [ 55 ]  Alcohol abuse or dependence has a lifetime comorbidity with BN of 33.7%, whereas illicit drug abuse or dependence has a lifetime comorbidity of 26%.

Impulse control disorders

In a study of lifetime prevalence of impulse control disorders in patients with BN, compulsive buying, and intermittent explosive disorder were the most frequently reported disorders, at 17.6% and 13.2%, respectively. Higher than expected rates of kleptomania, pathological gambling, and trichotillomania have also been reported in patients with BN. [ 56 ]

Attention deficit hyperactivity disorder (ADHD)

ADHD may be associated with BN. [ 57 ]  In one study of more than 2000 female inpatients treated for BN, 9% were also diagnosed with ADHD. The average rate of ADHD in the general population of young women is approximately 3.4%. [ 58 ]  Lifetime comorbidity with ADHD and BN has been reported to be as high as 34.9%.

Other psychopathology

The role of sexual abuse in the development of eating disorders is controversial. [ 59 ]  Some reports suggest a strong association, while others detect no increased association. Borderline personality disorder is found frequently. [ 60 ]  These patients usually have histories of trauma and abuse and may represent a distinct subgroup. Pathologic narcissism [ 61 ]  and identity impairment [ 62 ]  may be present. Features of obsessive-compulsive personality disorder (OCPD), particularly perfectionism, may be increased among patients with BN.

Suicidal behavior

BN is associated with increased risk of suicide attempts and suicidal ideations. [ 63 ]  In one study, all-cause mortality rate for BN was 3.9%, higher than other studies reported in the past. [ 64 ]  However, the standardized mortality ratio with respect to suicide was 6.51, a much higher than expected rate.

Psychiatric complications

Studies suggest that patients with bulimia nervosa (BN) have increased rates of major depressive disorder, substance abuse, anxiety disorders, bipolar II disorder, and sexual abuse; these conditions should be considered and managed as necessary. Mortality and morbidity associated with depression (suicidal thoughts or self-injury) and poor impulse control (eg, substance abuse, sexually transmitted diseases, unintended pregnancy, accidental injuries) should always be anticipated and assessed. Patients with BN who are depressed and who have concurrent alcohol dependence are at exceptionally high risk of suicide, particularly those who overexercise. Studies have shown that in people with eating disorders, excessive exercise appears to be linked to an increased prevalence of acquired capability for suicide (ACS) and suicide attempts. [ 75 , 76 ]

Medical complications

The all-cause mortality rate for BN per se is slightly lower than for anorexia nervosa (AN) (3.9% vs 4.0%, respectively). [ 64 ]  Medical complications do arise and should be assessed carefully.

While the results of formal gastric emptying studies in patients with BN have yielded variable results (some suggesting delayed emptying time and others suggesting normal emptying time), acute gastric dilatation is a rare but concerning risk. This complication may result in gastric rupture, which may be fatal.

Among other rare potential complications are Mallory-Weiss tears of the esophagus, esophageal rupture, reflux esophagitis, and cardiomyopathies secondary to ipecac use.

Ipecac toxicity may be associated with skeletal myopathy, while chronic hypokalemia may also be associated with intestinal ileus, abdominal distension, exertional rhabdomyolysis, or both.

Hypokalemia-related distal renal tubulopathy is very rarely associated with BN.

Xerosis (dry skin) is a common finding in bulimia nervosa, which appears to be related to the chronic dehydration to which persons with BN are often prone.

Skin health usually requires an overall healthy nutritional status. Dermatological treatment is ordinarily topical.

Patients who chronically overuse and abuse laxatives risk chronic constipation, cathartic colon with pseudo-Hirschsprung syndrome, melanosis coli with increased risk for colon cancer, steatorrhea, and/or protein-losing enteropathy and metabolic consequences of hypophosphatemia and hypomagnesemia.

Other potential complications include osteopenia or osteoporosis, menstrual irregularity and infertility, and, less commonly, cognitive changes associated with dehydration and electrolyte and metabolic abnormalities.

A 21-year-old woman is brought into an outpatient clinic by her mother, who complains that her daughter has been demonstrating unusual eating patterns since she moved back home 6 months ago. Her mother observes her to eat large amounts of food, such as desserts, when she is alone, often finding food wrappers hidden in her daughter’s room. She is worried that her daughter may be engaging in vomiting after these episodes of heavy eating. She often isolates herself in the bathroom for 10–20 minutes after a large meal.

When the patient was asked about her eating habits, she admitted to a “loss of control.” She described feeling deep remorse when she eats more than she would like. Furthermore, she described feeling so laden with guilt about her eating binges that she purposefully induces vomiting at least once every other day. This act gives her tremendous relief. She admits that she is unhappy with her overall appearance and feels that she is “fat” and “out of shape.” She is preoccupied with her appearance and says that she compares herself to other women “all day long.” She also admits to feeling sad most days. She endorses experiencing occasional missed menstrual periods, low libido, low energy, and intermittent sore throat.

Historically, the patient has memories of a chaotic childhood. She is an only child whose parents fought often and finally divorced when she was 9 years old. The patient remembers the first time she induced vomiting at 10 years old, after she felt “too full after a large meal.” The mother describes her daughter as having few friends and as tending to isolate herself. However, the mother describes her as very bright; in fact, she was valedictorian of her high school.

On physical examination, the patient’s blood pressure is 90/60, heart rate is 100, and BMI is 19. Her oropharynx appears injected without areas of erosion, and multiple dental caries are seen. Bilateral parotid enlargement with minor tenderness is present. The patient is tachycardic and bowel sounds are hyperactive. The abdomen is soft, nontender, and nondistended. Skin turgor is poor.

On mental status examination, the patient presents as a young White woman with average body habitus and pale skin. She is meticulously dressed and groomed. She answers questions curtly, makes poor eye contact, and demonstrates mild foot tapping throughout the interview. Her mood is anxious, and her affect is mood congruent but restricted to negative emotionality. She is highly articulate. Thought process is linear and goal directed. Methodical about her statements, she often takes time to clarify what she “really means.”

Thought content displays themes of shame and self-reproach, [ 33 ] though it is unclear whether shame is a risk factor for the development of the eating problems or a consequence of these difficulties; while guilt may be present, its role is unclear. No active delusions or hallucinations are present. Her cognition is grossly intact. She denies suicidal thoughts, but sometimes wishes she was “invisible.” She has no violent or homicidal thoughts. Insight is limited regarding her ability to acknowledge her psychiatric illness. Her judgment is impaired considering her inability to recognize the potential negative health consequences of her eating behaviors.

Prior to entering the clinic, laboratory assessment obtained at the suggestion of the patient's primary care doctor reveals a serum potassium level of 3.8 Meq/L and serum amylase level of 140 Units/L.

Take-home points

• The differential diagnosis of BN includes depression, anxiety and age-appropriate developmental problems (eg, lack of esteem). These issues are common comorbidities.
• A biopsychosocial treatment plan will be necessary to provide the patient with the care she needs.
• Developing a treatment team and collaboration with primary care providers and psychotherapist is often necessary for the short term and sometimes for the long term.

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• Parotid hypertrophy. Reprinted with permission [Mandel L, Siamak A. Diagnosing bulimia nervosa with parotid gland swelling. J Am Dent Assoc. 2004 May;135 (5):613-16.]
• Dental caries. Reprinted with permission [Wolcott RB, Yager J, Gordon G. Dental sequelae to the binge-purge syndrome (bulimia): report of cases. J Am Dent Assoc. 1984 Nov;109(5):723-25.].
• Russell sign. Reprinted with permission [Glorio R, Allevato M, De Pablo A, et al. Prevalence of cutaneous manifestations in 200 patients with eating disorders. Int J Derm. 2001 Dec;39(5):348-53.].
• This chest radiograph demonstrates pneumomediastinum, which can occur in association with esophageal rupture from forceful vomiting.
• Water-soluble contrast esophagram from a patient with esophageal perforation after esophageal dilation shows contrast leak (arrowheads) and normal esophageal lumen (arrows).
• Mallory-Weiss tear. Typical longitudinal mucosal tear with overlying fibrinous exudate extending from the distal esophagus to the gastric cardia. Courtesy of Christopher J Gostout, MD.

Contributor Information and Disclosures

Guido Klaus Wilhelm Frank, MD Professor, Department of Psychiatry, University of California, San Diego, School of Medicine; Director of Psychiatry, Medical Behavioral Unit, Rady Children’s Hospital-San Diego Guido Klaus Wilhelm Frank, MD is a member of the following medical societies: Academy for Eating Disorders, American Academy of Child and Adolescent Psychiatry , American College of Neuropsychopharmacology , Eating Disorders Research Society, German Medical Association , Society of Biological Psychiatry Disclosure: Nothing to disclose.

Lisa D Adler, MD Assistant Professor of Clinical Health Sciences, Department of Psychiatry, University of California San Diego Health Sciences, UCSD Eating Disorder Center for Treatment and Research, Medical Behavioral Unit, Rady Children’s Hospital Lisa D Adler, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape.

David Bienenfeld, MD Professor, Departments of Psychiatry and Geriatric Medicine, Wright State University, Boonshoft School of Medicine David Bienenfeld, MD is a member of the following medical societies: American Medical Association , American Psychiatric Association , Association for Academic Psychiatry Disclosure: Nothing to disclose.

Donald M Hilty, MD, MBA Associate Chief of Staff, Mental Health, Northern California VA Healthcare System; Professor of Psychiatry, Department of Psychiatry and Behavioral Sciences, University of California, Davis, School of Medicine Donald M Hilty, MD, MBA is a member of the following medical societies: American Association for Technology in Psychiatry , American Psychiatric Association , American Telemedicine Association , Association for Academic Psychiatry Disclosure: Nothing to disclose.

Christine I Osterhout, MD Resident Physician, Department of Psychiatry and Behavioral Sciences, University of California, Davis Health System Christine I Osterhout, MD is a member of the following medical societies: Alpha Omega Alpha , American Academy of Child and Adolescent Psychiatry , American Academy of Psychiatry and the Law , American Medical Association , American Psychiatric Association Disclosure: Nothing to disclose.

Lorin M Scher, MD, FACLP Clinical Professor of Psychiatry and Behavioral Sciences, Vice-Chair for Education, Roy T Brophy Endowed Chair, Director, Integrated Behavioral Health Services, Medical Director, Government and Community Relations, UC Davis Health Lorin M Scher, MD, FACLP is a member of the following medical societies: Academy of Consultation-Liaison Psychiatry, Alpha Omega Alpha , American Medical Association , American Psychiatric Association , Association of Directors of Medical Student Education in Psychiatry, California Medical Association , Central California Psychiatric Society, Sierra Sacramento Valley Medical Society Disclosure: Nothing to disclose.

Joel Yager, MD Professor of Psychiatry, University of Colorado Health Sciences Center; Professor of Psychiatry Emeritus, University of California, Los Angeles, David Geffen School of Medicine; Professor of Psychiatry Emeritus, University of New Mexico School of Medicine Joel Yager, MD is a member of the following medical societies: Alpha Omega Alpha , American Association for the Advancement of Science , American Medical Association , American Psychiatric Association , Association for Academic Psychiatry Disclosure: Nothing to disclose.

Gagandeep Randhawa, MBBS Resident Physician, Department of Psychiatry, Kaweah Delta Medical Center, University of California, Irvine, School of Medicine Gagandeep Randhawa, MBBS is a member of the following medical societies: American Psychiatric Association , Indian Doctors for Peace and Development Disclosure: Nothing to disclose.

Robert C Daly, MB, ChB, MPH Senior Fellow, Department of Behavioral Endocrinology, National Institute of Mental Health, National Institutes of Health

Disclosure: Nothing to disclose.

Raj K Kalapatapu, MD Fellow, Addiction Psychiatry, Columbia University College of Physicians and Surgeons

Raj K Kalapatapu is a member of the following medical societies: American Academy of Addiction Psychiatry, American Academy of Child and Adolescent Psychiatry, American Association for Geriatric Psychiatry, American Medical Association, and American Psychiatric Association.

Gabriel I Uwaifo, MD Associate Professor, Section of Endocrinology, Diabetes and Metabolism, Louisiana State University School of Medicine in New Orleans; Adjunct Professor, Joint Program on Diabetes, Endocrinology and Metabolism, Pennington Biomedical Research Center in Baton Rouge

Gabriel I Uwaifo, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians-American Society of Internal Medicine, American Diabetes Association, American Medical Association, American Society of Hypertension, and The Endocrine Society

Kelda Harris Walsh, MD Assistant Professor of Clinical Psychiatry, Section of Child and Adolescent Psychiatry, Department of Psychiatry, Indiana University School of Medicine; Chief, Obsessive-Compulsive/Tourette/Anxiety Disorders Clinic, Riley Hospital for Children

Acknowledgments

The authors would also like to acknowledge the contributions of Rebecca Davis, Librarian at the University of California (UC), Davis and Dr. Eric Rickin, Director for the Center for Overcoming Problem Eating (COPE) at the Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center. Finally, the authors thank the Department of Psychiatry and Behavioral Sciences at UC Davis.

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Psychological Intervention in a Case of Bulimia Nervosa: A Case Report

• Published: 20 February 2014
• Volume 59 , pages 68–75, ( 2014 )

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• Paakhi Srivastava 1 ,
• Piyali Mandal 1 ,
• Manju Mehta 1 &
• Rajesh Sagar 1  

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This paper presents a case report detailing the use of an enhanced form of enhanced cognitive behavior therapy (CBT) and other techniques that were employed when faced with impediments in adhering to manualized CBT-E. Ms. S, 22 years old unmarried female pursuing MBBS final year, belonging to upper middle socioeconomic status and urban domicile was provided with 28 weekly sessions of psychotherapy to simultaneously address the patient’s symptoms and try to effect change across multiple domains. A single case design was adopted. Therapy was conducted over 9 months. A total of 28 sessions were taken, with the frequency of two sessions/week initially, and then moving onto one session/week. Pre and Post assessments using Binge Eating Scale, BDI-II, height and weight measurements and frequency of binging episodes using visual analogue scale were done. On measures of pre and post assessment there was 87 % improvement in Binging Episodes, 82 % improvement on Binge Eating Scale and client had 3 kg weight gain with reduction in depression as assessed on BDI-II. The gains were maintained at 1 month follow up. The use and deviations from CBT E, therapy process, role of family and challenges to intervention will be discussed in this case report.

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It has been an invaluable learning experience for the therapist to understand phenomenology of eating disorders, role of family and the process of therapy including preparation of this manuscript.

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Department of Psychiatry, All India Institute of Medical Sciences, Room No 4089, Fourth Floor, Teaching Block, New Delhi, 110029, India

Paakhi Srivastava, Piyali Mandal, Manju Mehta & Rajesh Sagar

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Srivastava, P., Mandal, P., Mehta, M. et al. Psychological Intervention in a Case of Bulimia Nervosa: A Case Report. Psychol Stud 59 , 68–75 (2014). https://doi.org/10.1007/s12646-014-0242-1

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DOI : https://doi.org/10.1007/s12646-014-0242-1

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• Barlow, D. H., Durand, V. M., Lalumiere, M. L., & Hofmann, S. G. (2018). ​Abnormal psychology: An integrative approach​ (8th ed.). Toronto, ON: Nelson Education.
• Egan, S., Watson, H., Kane, R., McEvoy, P., Fursland, A., & Nathan, P. (2013). Anxiety as a mediator between perfectionism and eating disorders. ​Cognitive Therapy & Research​, 37​(5), 905–913. https://doi.org/10.1007/s10608-012-9516-x
• Peterson, C. B., Berg, K. C., Crosby, R. D., Lavender, J. M., Accurso, E. C., Ciao, A. C., … Wonderlich, S. A. (2017). The effects of psychotherapy treatment on outcome in bulimia nervosa: Examining indirect effects through emotion regulation, self-directed behavior, and self-discrepancy within the mediation model. International Journal of Eating Disorders, 50(6), 636–647. https://doi.org/10.1002/eat.22669
• Waller, G., Gray, E., Hinrichsen, H., Mountford, V., Lawson, R., & Patient, E. (2014). Cognitive-behavioral therapy for bulimia nervosa and atypical bulimic nervosa: Effectiveness in clinical settings. ​International Journal of Eating Disorders​, ​47​(1), 13–17. https://doi.org/10.1002/eat.22181 <a>https://doi.org/10.1037/a0015003</a>

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Bulimia Nervosa Analysis: Patient Care Case Study

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Introduction

Case analysis.

Bulimia Nervosa is an eating ailment caused by uncontrollably eating large amounts of food and then using unsafe methods to eliminate excess calories. Notably, the disorder is more prone to females than male teens. Jessica Johns, who has lived with her mother Marie since her two brothers live overseas in the UK and USA, was first diagnosed with Bulimia Nervosa when she was sixteen. Jessica, now eighteen years old, has been working in a logistics company as a receptionist since she deferred to join the university. Lately, Jessica’s behaviors started changing during the last six months, when she has been displaying strange behaviors, such as preferring to eat alone and avoiding people at mealtimes. Jessica has been more antisocial and withdrawn and would return to the bathroom after eating. Due to the unusual changes in Jessica’s routines, she was taken to a General Practice nurse who referred her to a hospital.

Jessica was admitted to a cardiac unit for cardiac monitoring and treatment of hypokalemia. Her serum potassium concentration was <2.5 mEq/L, which is below the normal range of 3.5–5.0 mEq/L. The low level is dangerous since it can result in abnormal heart rhythms, fatigue, and muscle cramps. Hypokalemia is caused by diarrhea, low intake of potassium in the diet, and vomiting. Bulimia nervosa patients would force themselves to vomit to get rid of the excess calories. In vomiting, one gets rid of essential potassium ions necessary for maintaining stable potassium ion concentration in the body. Since the condition has troubled Jessica mentally, the mental health practitioners performed a SCOFF questionnaire to review her health status (Ossenber et al., 2020). Jessica has been submitted to treatment, though she seems uncomfortable with the decision, making her less willing to comply.

Based on the scenario presented above, the priority for Registered Nurses when managing Jessica’s situation would be to ensure that she receives evidence-based patient care to improve her condition. In particular, nurses would focus on providing care based on the latest scientific evidence and best practices (Jacobs et al., 2018). This would include ensuring Jessica receives the appropriate medications and treatments and monitoring her condition closely to ensure that it does not worsen. Additionally, nurses would educate and support Jessica and her family members to help them cope with her condition and make the necessary lifestyle changes (Driscoll et al., 2019). The study aims to outline practices that RN should prioritize when handling patients with acute and chronic conditions like Jessica’s. Such practices include Recognising and diagnosing the condition, Investigating the condition, Treating the condition, Rehabilitating the patient, Preventing the condition from recurring, educating the patient, and monitoring the condition.

Evaluate how effective the actions taken in the course of the patient’s treatment process are. All the other components are biased and depend on a variety of circumstances. The only evaluation that will show the importance of the nurse’s influence in the treatment process is the patient’s recovery. Then, the fact of how necessary and accessible the treatment became clear. In addition, the specific observations that would be made of her would include her vital signs, weight, and height (Driscoll et al., 2019). The outcomes would be referred to depict whether she suffered from complications such as hypokalaemia, hypernatraemia, and any cardiac arrhythmias (Jacobs et al., 2018). Her vital signs would be monitored closely, and her weight and height would be measured to calculate her body mass index.

The care plan for Jessica should focus on three main areas: her physical health, her mental issues and her eating disorder. Regarding her physical health, the main goal should be to correct her electrolyte imbalance and stabilize her heart rate (Morris & Atkinson, 2018). Regarding her mental health, the primary goal should be to help her cope with her feelings of regret, guilt, and shame (Ossenberg et al., 2020). As with any nurse, when confronted with a problem, it is necessary to establish the root of the problem and provide all possible services to help improve the patient’s condition. In the case of bulimia, it is essential to provide not only an initial examination and observation but also the help of a psychologist. Often, a mental health professional is required because, with the proper morals, one can guide the patient by acting on his subconscious mind (Australian College of Mental Health Nurse, 2013). The nurse must provide a specialist and accompany the patient in recovery.

After assessing Jessica’s problem and developing a strategic care plan, the RN should administer hypokalaemia and hypernatraemia treatment. In essence, the RN should give Jessica potassium supplements and continuous cardiac monitoring, refer Jessica to a dietician, and ensure she gets enough fluids. In addition, the RN should ensure that Jessica is on bed rest with supervised toilet privileges before meals and 1 hour after meals and that she has 1:1 nursing (Driscoll et al., 2019). Referral to a dietician will help to ensure that Jessica is getting the proper nutrition that she needs, and the supervised toilet privileges will help to prevent her from purging or using laxatives. Finally, the 1:1 nursing will help ensure that Jessica gets the care and attention that she needs.

To guarantee Jessica’s successful treatment process, the application of specific nursing standards, code of conduct, code of ethics, and legalities must be made. Such nursing standards include the standards of care for managing hypokalaemia and hypernatraemia, the standards of care for managing cardiac arrhythmias, and the standards of care for managing eating disorders (Daly, 2018). The code of conduct for nurses is relevant as it sets out the professional standards nurses must adhere to. It is also worth understanding that in the medical field, the key concept is the morality of choice made. Each employee should be guided by what results from it will lead to, not only now but also in the future. It is also worth noting that it is about human health and life, and these values are essential not only in health care but also in everyone’s social life. Often, these principles go against the principles of legal norms, as their application in the treatment process can lead to harmful consequences in the future. That is why it is essential to start from the condition of the patient but also from the requirements of current medicine.

The relevance of contemporary nursing practice is unchanged and at the same high level as before. It is now only possible to imagine life with quality treatment and care for the individual because these standards have stayed the same after a great deal of time and are fundamental in this branch (Nursing and Midwifery Board of Australia, 2016). The same goes for cultural designation because all patients are individuals who need a different approach (Department of Health Victoria, 2014). Often there are significant cultural differences between people and in order for the patient to feel comfortable, it is necessary to be aware of ethnic and not only ethnic differences.

The RN can apply a patient-centered care approach to focus on Jessica as an individual and her specific needs. This approach would involve creating a care plan tailored to her situation and working closely with her to ensure that she complies with her treatment plan. A recovery-oriented approach would focus on helping Jessica to recover from her eating disorder and laxative abuse. This would involve working with her to establish healthy eating habits and helping her overcome any psychological barriers preventing her from recovery. A trauma-informed approach would focus on the fact that Jessica has a history of trauma and abuse (Tebes et al., 2019). This approach would involve working with her to address any unresolved trauma and helping her to develop healthy coping mechanisms (Jacobs et al., 2018). Ultimately, the most important thing is ensuring Jessica receives the care and treatment she needs to recover from her eating disorder and laxative abuse. An example of this method would be any influence on a subsonic activity that resulted in a positive outcome. This includes conversation, which is also capable of changing people’s lives through indirect influence.

It is fundamental to note that patients with irregular vital signs should be immediately referred to an experienced doctor for further assessment. Jessica’s low blood pressure, irregular pulse, and feeling dizzy at times were indicative of an underlying cardiac condition. After being admitted to the cardiac unit, her potassium levels were found to be low, and she was also suffering from hypernatremia. These electrolyte abnormalities can lead to cardiac arrhythmias, which can be life-threatening. Therefore, Jessica needed to be closely monitored and treated for her hypokalaemia and hypernatraemia (Daly, 2018). In addition, her history of binge eating, purging, and laxative abuse put her at risk for developing eating disorders, which can be life-threatening. As such, the Mental Health Team was consulted, and a care plan was developed that included potassium supplements, continuous cardiac monitoring, referral to a dietician, and supervision at all meals. Although Jessica was initially angry at the rules and plan of care, she eventually accepted them and complied with the treatment plan.

Australian College of Mental Health Nurse. (2013). ); Recovery Focused Principles; Trauma Informed Care; Strengths Based Practice; The Mental Health Nursing Standards . Australian College of Mental Health Nurse.

Borthwick, A., & Higgs, P. (2020). The Medical Treatment Planning and Decisions Act 2016: what is the role for allied health professionals? . Australian Journal of Primary Health , 26 (5), 383-387. Web.

Daly, P. (2018). A concise guide to clinical reasoning . Journal of evaluation in clinical practice , 24 (5), 966-972. Web.

Department of Health Victoria. (2014). Mental Health Act 2014 . Web.

Driscoll, J., Stacey, G., Harrison-Dening, K., Boyd, C., & Shaw, T. (2019). Enhancing the quality of clinical supervision in nursing practice . Nursing standard , 34 (5), 43–50. Web.

Jacobs, S., Taylor, C., Dixon, K. A., & Wilkes, L. M. (2018). The consensus of the characteristics of clinical judgement utilised by nurses in their practice: Results of a survey. Open Journal of Nursing , 4 (12), 746-757. Web.

Langberg, E. M., Dyhr, L., & Davidsen, A. S. (2019). Development of the concept of patient-centredness–A systematic review . Patient education and counseling , 102 (7), 1228-1236. Web.

Medical Treatment Planning and Decisions Act 2016 . (2016). Web.

Morris, R., & Atkinson, C. (2018). How can educational psychologists work within further education to support young people’s mental health? An appreciative inquiry . Research in Post-Compulsory Education , 23 (3), 285-313. Web.

Nursing and Midwifery Board of Australia. (2016). Registered nurse standards for practice . Web.

Ossenberg, C., Mitchell, M., & Henderson, A. (2020). Adoption of new practice standards in nursing: revalidation of a tool to measure performance using the Australian registered nurse standards for practice . Collegian , 27 (4), 352-360. Web.

Tebes, J. K., Champine, R. B., Matlin, S. L., & Strambler, M. J. (2019). Population health and trauma‐informed practice: Implications for programs, systems, and policies . American Journal of Community Psychology , 64 (3-4), 494-508. Web.

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Clinical Case Discussion: Binge Eating Disorder, Obesity and Tobacco Smoking

Marney a. white.

1 Department of Psychiatry, Yale University School of Medicine

Carlos M. Grilo

2 Department of Psychology, Yale University School of Medicine

Stephanie S. O'Malley

Marc n. potenza.

3 Child Study Center, Yale University School of Medicine

This clinical case involves an obese woman requesting treatment for her binge eating and obesity. The information is presented to expert clinicians who provide their thoughts regarding the case, assessment, treatment formulation, and associated clinical and research issues.

Case Description

A 48-year old African American woman presented for treatment for binge eating and weight loss. She presented for treatment following a recent routine physical examination during which her primary care physician noted concerns about her increasing weight. The physician recommended that she try to lose weight but did not provide any specific or further guidance. In light of her previous “failed” experiences with commercial weight loss programs, she decided to seek treatment at a university-based program. At initial evaluation, she was 64 inches tall and weighed 230 pounds yielding a body mass index (BMI) of 39.5, which reflects obesity. She had moderately elevated blood pressure and high cholesterol but was otherwise in good health. The patient completed college and a master's degree in education and had been employed as a special education teacher in the same job for 11 years. She lived with her husband of 24 years, and one of her two adult children. She reported that her relationships with her husband and family were good, that her job was enjoyable and rewarding, and that she had a good circle of close relationships.

Weight and dieting history

The patient reported an onset of overweight during adulthood. She reported having been involved in sports throughout childhood, and although she viewed herself as ‘big-boned’, she did not have body image concerns nor did she recall feeling dissatisfied with her weight or shape when younger. She denied any significant dieting behaviors until age 29. She reported maintaining a weight of approximately 150 pounds (BMI = 25.7) until age 28, at which age she became pregnant with her second child. She reported that she never fully lost the ‘baby weight’ and subsequently began to gradually gain weight throughout her 30s despite numerous dieting efforts. She reported a rapid weight gain of approximately 25 pounds in the past 6 months.

Binge eating

The patient reported an onset of “eating binges” at approximately age 16. The binge eating began soon after she began babysitting for neighborhood children. She estimated that she would engage in binge eating approximately 1-2 times per month which occurred during times that she babysat at night and had access to assorted snack foods. During those times she would ‘load up on junk food’ that the family had provided. She recalled that she would eat chips, cookies, and brownies “non-stop,” and that these eating episodes often lasted throughout the evening. She recalled feeling a loss of control during these episodes and stated that she would continue to eat despite not feeling physically hungry and that she would not stop until feeling physically ill. She reported that she was very embarrassed and secretive about these eating behaviors. She also recalled feeling embarrassed when worried that it was likely that the missing food was apparent to the family for whom she was babysitting. She denied any history of extreme inappropriate weight control or purging behaviors such as self-inducing vomiting or misusing laxatives.

The patient reported infrequent and sporadic binge eating throughout her late teens and early 20s, estimating a frequency of once per month which tended to correspond with social functions. During her 30s, however, the frequency of her binge eating increased considerably and became more regular except during periods of dieting efforts. The patient reported that she had enrolled in commercial weight loss programs approximately five different times, and had, in addition, tried to follow multiple self-help diets. She reported that when she was following a weight loss plan, she could successfully lose approximately 10 pounds, but that she would ‘hit a wall’ and discontinue after about one month of dieting. She reported that in-between diets, her binge eating would resume at a frequency of 2 to 3 times per week, and persist at that level until the next dieting attempt. The patient reported that she had not engaged any formal dieting in the past 18 months, although she frequently skipped meals in an effort to reduce her weight.

Recent course

The patient noted an increase in binge eating frequency approximately six months ago, corresponding with her mother's hospitalization and rapid physical decline. The patient was the primary caregiver for her mother, and noted that the months preceding her mother's death were extremely stressful. She reported that her binge eating increased in frequency to 3 to 4 times per week during her mother's illness, and increased to 6 to 7 times per week following her mother's death.

The patient described her typical binge episode as starting with an evening meal and extending for several hours. Her daily pattern of eating was to skip breakfast, and to consume a standard school cafeteria lunch at 11:30 a.m. She would then not eat again until preparing the evening meal, at which point she would ‘graze’ while cooking. The patient reported that most nights she would eat a ‘normal’ meal with her family, consisting of 5-6 ounces of meat, 2 or 3 types of vegetables, and bread. However, she would then eat the ‘leftovers’ while cleaning up after the meal, such that overall she would have consumed the equivalent of two full meals. She would then eat various foods throughout the rest of the evening until bedtime. During these episodes, she would alternate between salty and sweet snacks. One example binge episode, occurring approximately 30 minutes after the evening meal and spanning the two hours before bedtime, included: a roll of Ritz crackers with 6 ounces of cheese, 2 doughnuts, 4 handfuls of Chex mix, and ½ of a large (12 oz.) Cadbury candy bar.

Smoking History and Cessation

The patient reported that she had recently quit smoking ‘cold turkey’ and had successfully maintained abstinence for four months. She reported quitting smoking following the death of her mother because she died of cancer. She quit smoking without any professional help and without the use of any nicotine replacements or medications to assist with the smoking cessation.

In terms of her smoking history, the patient reported that she began smoking at age 18, that she had successfully quit smoking upon becoming pregnant at age 24, but resumed when she returned to work 11 years ago. She reported a daily smoking frequency of 15 to 20 cigarettes per day. She reported no serious efforts to stop smoking during the past 11 years prior to this recent period of complete abstinence. The patient reported that since quitting smoking, she has experienced more frequent and intense urges to binge eat, and that in the few weeks prior to intake the urges to smoke had increased in frequency and intensity. She reported urges to smoke primarily in the evenings.

Diagnostic Instrument

In addition to a standard intake history, the patient was administered the Eating Disorder Examination (EDE; Fairburn and Cooper, 1993 ). The EDE is a semi-structured investigator-based interview that evaluates current eating behaviors and eating disorder psychopathology. The EDE focuses on the previous 28 days, except for diagnostic items – such as binge eating behaviors - which are assessed for the duration stipulations for each ED. More specifically, the EDE assesses the frequency of different forms of overeating, including objective bulimic episodes (binge eating defined as unusually large amounts of food with a subjective sense of loss of control) and various inappropriate weight control methods (e.g., purging, laxative abuse, etc). The EDE contains four scales reflecting different aspects of ED psychopathology (dietary restraint, eating concerns, weight concern, and shape concern). The EDE is considered the best-established method for assessing and tracking over time the behavioral and cognitive features of EDs and has psychometric support specifically with BED ( Grilo, Masheb, Lozano-Blanco, & Barry, 2004 ; Grilo, Masheb, & Wilson, 2001 ). The interview was administered before treatment and at treatment conclusion to evaluate treatment gains.

The patient was treated with 12 weekly individual sessions of cognitive behavioral therapy (CBT) for binge eating. Expert opinion ( Wilson, Grilo, & Vitousek, 2007 ) and quantitative meta-analytic reviews ( NICE, 2004 ) conclude CBT is the best-established and treatment-of-choice for BED. CBT, a focal and structured treatment, consists of three overlapping phases conducted in a collaborative and interactive method with patients. The first phase focused on educating the patient about the nature of binge eating. Standard behavioral strategies such as self-monitoring and record keeping were used to help the patient identify better her disordered eating patterns while working towards the central goal of normalizing and achieving a structured regular pattern of eating (i.e., not skipping meals). The second phase integrated cognitive procedures to help the patient identify and challenge maladaptive cognitions regarding her eating, possible triggers for dyscontrol, and associated eating/shape concerns. The final phase focuses on consolidating and maintaining the changes and relapse prevention issues.

During the overview of treatment and the ‘meal pattern prescription,’ the patient became tearful, stating that she is not organized enough to follow a meal pattern consisting of three meals and three snacks. She expressed a fear that eating more frequent meals would result in more weight gain, and stated that she was fearful of failing at another weight loss effort. The patient was encouraged to follow the meal and snack pattern as an ‘experiment’ for the first week of treatment. When the patient's fears were alleviated (i.e., disproved owing to weight maintenance during the first week of treatment), she moved through the treatment steps without difficulty. Although she initially voiced concern about the self-monitoring she eventually regarded it as one of the most essential tools that she gained during the treatment.

Overall, at treatment completion the patient's binge eating had remitted fully. She reported no objective bulimic episodes in the last 4 weeks of treatment. Her weight remained relatively stable, with a post-treatment weight loss of five pounds (final weight = 225; BMI = 38.6). Although the patient was pleased to have stopped binge eating, she reported continued distress over her weight and a persisting desire to lose weight.

Carlos M. Grilo, Ph.D.

This clinical case involves a combination of a behavioral (BED) and a physical medical problem (obesity) that often co-occur. This case is also notable for a positive lifetime history of a pharmacological addiction (nicotine) despite not being “active” at the time of presentation for treatment for the eating/weight concerns might nonetheless have important implications. In several respects, this case is fairly typical of BED in obese persons and serves to illustrate a number of important issues facing clinicians and researchers.

Background: Diagnosis, Distribution, and Clinical Features of BED

BED is a specific example of eating disorder not-otherwise-specified (EDNOS) and was included as a “research category” with provisional research diagnostic criteria in Appendix B of the DSM-IV ( American Psychiatric Association, 1994 ). BED is defined primarily by recurrent episodes of binge eating without the regular use of inappropriate compensatory weight control methods (such as purging) that characterize bulimia nervosa (BN). Binge eating is defined as eating unusually large amounts of food while experiencing a subjective sense of loss of control. The research criteria require marked distress about the binge eating and that the binge eating occurs on at least two days per week over the past six months. Unlike the two “formal” eating disorders (anorexia nervosa and bulimia nervosa), the DSM-IV does not include a cognitive criterion pertaining to disturbed body image (i.e., overvaluation of shape or weight) for the diagnosis of BED although such disturbances are present in many patients with BED ( Grilo, Hrabosky, White, Allison, Stunkard, & Masheb, 2008 ). Research has supported the distinctiveness of BED from both other eating disorders (BN) and from obesity without co-existing binge eating (Grilo, Crosby et al., in press; Grilo, Masheb, & White, in press ). A recent critical review of the literature concluded that there exists sufficient empirical evidence to support the inclusion of BED as a distinct and formal ED diagnosis in the DSM-V ( Striegel-Moore & Franko, 2008 ).

Recent epidemiological research has reported a prevalence rate for BED of roughly 3.5% in adult women, which is greater than anorexia nervosa and bulimia nervosa combined ( Hudson, Hiripi, Pope, & Kessler, 2007 ). The distribution of BED is much broader and more diverse than that of the other eating disorders. BED is evenly distributed throughout adulthood and is common in both men and women as well as across ethnic and racial groups ( Hudson et al., 2007 ; Grilo, Lozano, & Masheb, 2005 ). BED is strongly associated with obesity (which is not a required criterion) ( Hudson et al., 2007 ) and therefore with substantially increased morbidity associated with excess weight (e.g., diabetes, metabolic problems). The excess weight in patients with BED is attributable to a combination of binge eating in the absence of weight compensatory behaviors in addition to a general lack of dietary “restraint” that is salient and characteristic of the other eating disorders ( Grilo, 2010 ). Patients with BED who seek treatment are typically older than patients with other eating disorders despite the fact that many report a longstanding duration of the binge eating often dating back to adolescence ( Reas & Grilo, 2007 ). Moreover, unlike the case for the other eating disorders, which most frequently begin following intensive dieting attempts, nearly half of patients with BED report that the onset of their binge eating preceded their first diet ( Reas & Grilo, 2007 ). Regardless of the exact longitudinal sequence, the binge eating and the associated weight gain over time motivate multiple diet attempts over time many of which are not successful ( Reas & Grilo, 2007 ; Roehrig, Masheb, White, & Grilo, 2009 ).

Observations About the Specific Case

I will offer a number of observations regarding this specific case that are illustrative regarding selected issues of relevance to clinicians and researchers. This case is typical in a number of important respects yet it differs in several important ways that I will note with a view of characterizing the heterogeneity of this behavioral disorder. Evolving research has identified a number of treatments that have efficacy for a majority of such patients although two major challenges remain. First, many patients with BED do not get accurately identified, and few receive empirically-supported treatments ( Wilson, Grilo, & Vitousek, 2007 ).

Treatment-Seeking

Although obese patients with BED have elevated psychiatric and medical problems and greater health care utilization patterns relative to their obese peers who do not binge eat, they infrequently seek specialized psychological or psychiatric care for their binge eating. Obese persons who binge eat, along with many generalist health care providers, frequently see the binge eating problem as merely reflecting their obesity and need for better diet and weight loss. In this case, the patient and her physician discussed the need for weight loss, although her binge eating problem was not specifically addressed. Despite not being able to provide the patient with specific guidance, this interaction nonetheless represents an important first step. Many health care providers are uncomfortable in raising or discussing excess weight issues with their patients. This is likely due to a many reasons including, for example, negative biases or views about obesity, personal discomfort, perceived lack of expertise, and concerns about “harming” the therapeutic relationship ( Puhl & Heuer, 2009 ). The patient-physician interaction in this case seemed positive enough to support and motivate the patient to seek more specialized care. It is critically important for generalist health care providers to be receptive and open when discussing their patients' excess weight and potential treatment avenues.

Clinical Presenting Picture

This patient presented with co-occurring obesity and BED. Although she had moderately elevated blood pressure and high cholesterol, she had not yet developed metabolic syndrome although she was clearly at risk to do so along with other medical problems. Thus, her proactive treatment-seeking is certainly a very positive step. This is noteworthy because some research has suggested that black women who are obese and who binge eat are less likely to seek treatment than their white peers until both problems are substantially worse ( Grilo, Lozano, & Masheb, 2005 ; Pike, Dohm, Striegel-Moore, Wilfley, Fairburn, 2001 ). Her primary concern was her increasingly weight gain that started in her 30s despite numerous dieting attempts. More recently, her weight gain had increased markedly and this seemed related, in part, to her increased binge eating behaviors. Based on her clinical history, she did not seem to suffer from body image dissatisfaction or from body image disturbance that are characteristic of eating disorders. The EDE interview provides specific quantification of different aspects of body image disturbance and would yield detailed information regarding behavioral, affective, and cognitive aspects of body image to inform both treatment interventions and to assess changes over time ( Grilo et al., 2001 ). Although the absence of such body image problems in this specific patient signals a less disturbed variant of BED ( Grilo et al., 2008 ) with a positive prognosis ( Masheb & Grilo, 2008a ), treating the obese patient with BED will still remain challenging relative to treating obesity only ( Grilo et al., 2008 ). She did not appear to have significant psychosocial problems either independent or associated with the obesity and BED. Her psychosocial functioning seemed rather positive and this is not uncharacteristic of many patients with BED. Conversely, since it is not uncommon for many patients to have associated psychosocial problems, clinicians should routinely assess for any on-going difficulties as context for formulating and implementing treatment. Importantly, the patient did report a specific life stressor (her mother's death) which seemed associated with an intensification of her binge eating.

Psychiatrically, no additional lifetime or current problems were reported, although no formal structured diagnostic interview was administered. Patients with BED have elevated lifetime rates of psychiatric disorders, including most notably mood, anxiety, and substance use disorders ( Grilo, White, & Masheb, 2009 ), although roughly 25% have never experienced another psychiatric problem. For comprehensive treatment formulation and planning, the presence of other psychiatric disorders should be carefully ascertained. However, it is noteworthy that psychiatric co-morbidity has not emerged as a significant predictor or moderator of outcomes for BED treatments that have empirical support ( Masheb & Grilo, 2008b ; see Wilson et al., 2007 ).

The positive smoking history is especially noteworthy in this patient. Unfortunately, the significance of smoking in this patient group is still poorly understood and is often overlooked by clinicians and researchers alike. This case suggests some potentially important associations among smoking, eating, and weight domains. First, preliminary research suggests that smoking histories are not uncommon in patients with BED and, if present, signal increased risk for psychiatric problems, most notably anxiety disorders ( White & Grilo, 2006 ). Although this patient was not determined to have anxiety disorder co-morbidity, both binge eating and smoking may serve to regulate affect. The exacerbation of the patient's binge eating immediately following her mother's death and her smoking quit attempt can perhaps be conceptualized in this way (i.e., increased binge eating to cope with increased negative affect). Second, preliminary research also suggests that BED patients with smoking histories are characterized by heightened levels of maladaptive and rigid eating and dieting behaviors as well as heightened food “cravings” that must be addressed along with the binge eating ( White & Grilo, 2007 ). Third, weight gain following smoking cessation is common and may be especially problematic for obese patients with BED. A recent study found that obese patients with BED reported gaining significantly more weight following a smoking quit attempt than their non-binge-eating obese peers ( White, Masheb, & Grilo, in press ). This patient's rapid recent weight gain following her most recent smoking quit attempt is consistent with this finding and represents an important clinical challenge because it potentially represents a challenge to continued abstinence.

This patient's eating behavior and patterns are fairly representative of patients with BED. First, binge eating occurs most frequently during evenings, although many patients report having episodes at varying times throughout the day. The large amount consisting of mixed foods often based on availability and ease is typical. Also typical in this patient group is that the binge eating often follows eating behaviors or episodes that are occurring without a sense loss of control. Unlike bulimia nervosa where the binge eating episodes are very clear episodes following excessive restraint, patients with BED are characterized by a more chaotic and amorphous eating pattern. This patient attempts some dietary restraint (skipping breakfast, not eating for long period following lunch) but her eating is fairly continuous throughout the evening. Rather than eating a clear meal (dinner), she appears to eat continuously and during part of this time also experiences a sense of loss of control. Thus, these patients require assistance in several complex tasks including: normalizing and scheduling their eating (i.e., not skipping meals), lessening certain maladaptive restraint behaviors (i.e., not going long periods without eating), increasing certain adaptive restraint behaviors (i.e., not overeating during meals, not grazing or nibbling at odd times), in addition to eliminating the binge eating episodes (Allison, Grilo, Masheb, & Stunkard, 2006; Masheb & Grilo, 2006 ).

Treatment Options

Critical meta-analytic ( NICE, 2004 ) and qualitative reviews ( Wilson et al., 2007 ) of the treatment literature have concluded that cognitive behavioral therapy is the treatment of choice for BED. Studies of CBT for BED consistently report remission rates of 50% or greater along with broad improvements in associated psychological and psychosocial functioning, although weight loss tends to be minimal ( Wilson et al., 2007 ). Different research groups have documented that CBT is superior to other active treatments, including behavioral weight loss therapy ( Grilo & Masheb, 2005 ; Wilson et al., in press ) and pharmacotherapy with fluoxetine ( Grilo et al., 2005 ; Ricca et al., 2001 ), and that the benefits of CBT for BED are well-maintained through 24-months (Wilfley, Wilson, & Agras, 2008) following treatment. There is also some empirical support for two alternative psychotherapies (interpersonal psychotherapy and dialectical behavior therapy) which also produce substantial reductions in binge eating but, like CBT, fail to reduce weight ( Wilson et al., 2007 ). Finally, there is also empirical support for behavioral weight control therapy (structured manualized treatment delivered by professionals but not necessarily for the widely-available commercial programs or self-help diets) for reducing binge eating although findings regarding weight losses are also surprisingly mixed ( Grilo & Masheb, 2005 ; Wilson et al., 2007 ). Lastly, a critical meta-analysis of pharmacotherapy treatment research concluded that certain medications have a clinically significant advantage over placebo for producing short-term remission from binge eating and for reducing weight, although the weight losses tend to be quite modest and of uncertain clinical significance ( Reas & Grilo, 2008 ). The meta-analysis highlighted the potential efficacy of an anti-obesity agent (sibutramine) and anti-epileptic medications (particularly topiramate) but suggested more limited utility of SSRIs given their smaller effects on binge eating and essentially no effect on weight. Unlike the psychosocial treatments, the longer-term effects of these medications are unknown. The few available data from blinded ( Grilo, Masheb, & Wilson, 2005 ) and open-label ( Ricca et al., 2001 ) trials directly comparing the effectiveness of pharmacotherapy and psychological treatments indicate that CBT is significantly superior to SSRIs. In terms of combining approaches, most studies have found that adding pharmacotherapy to psychological approaches has generally not enhanced outcomes ( Reas & Grilo, 2008 ). Noteworthy exceptions are studies that reported adding orlistat ( Grilo, Masheb, & Salant, 2005 ) or topiramate ( Claudino et al., 2007 ) to CBT significantly enhanced the weight losses.

Treatment Course

Thus, it is fortunate that this patient sought treatment at a university-based program where she was offered an empirically-supported treatment. This patient's response to CBT was fairly typical in that she experienced an early and rapid response to the treatment ( Grilo, Masheb, & Wilson, 2006 ; Masheb & Grilo, 2007 ), stopped binge eating entirely by the end of treatment, but unfortunately did not lose weight. Many obese patients with BED fail to lose clinically meaningful amounts of weight despite the substantial reductions in binge eating achieved via CBT, which is not unlike the case for other psychological ( Wilson et al., 2007 ) and pharmacological treatments ( Reas & Grilo, 2008 ). Although the patient failed to lose significant weight (only five pounds), the CBT and presumably the cessation of binge eating were associated with a stabilization of weight. The patient entered treatment following a period of rapid and marked weight gain so the weight stabilization does represent a potentially important first step. Unfortunately, the failure to produce weight loss does leave this patient at risk for developing medical problems and given her frustration and distress about the weight may put her at heightened risk for relapse in both the binge eating and the smoking domains.

Future Directions

Finding ways to produce or enhance weight loss in obese patients with BED represents a major research priority ( Grilo, 2010 ). Interestingly, research has found that combining treatments, for example combining pharmacotherapy, has generally not enhanced outcomes ( Reas & Grilo, 2008 ). Possible notable exceptions have included findings from controlled trials suggesting that adding orlistat ( Grilo, Masheb, & Salant, 2005 ) or topiramate ( Claudino et al., 2007 ) may enhance weight losses achieved with CBT for BED. It has been suggested that greater attention to non-normative eating behaviors and patterns ( Masheb & Grilo, 2006 ) in addition to the CBT focus on normalization of eating meals and reducing binge eating may facilitate greater weight loss. Future treatment studies should include analyses of mediators of outcomes in order to guide the process of improving further our existing treatments ( Wilson et al., 2007 ).

Stephanie S. O'Malley, Ph.D.

This case history highlights the important interface between smoking and binge eating behavior and suggests how treatment of binge eating may have beneficial effects on maintenance of smoking abstinence.

Co-occurring Conditions and Complicating Factors

While smokers tend to be leaner compared to nonsmokers, a significant proportion of obese individuals smoke, placing them at increased risk of attendant health consequences such as diabetes and cardiovascular disease. Smoking related health consequences, experienced by the smoker or another family member, often motivate a smoker to quit as was the case for this patient. However, women compared to men are less likely to remain abstinent from smoking despite a motivating “health shock” for a variety of reasons, including concerns about weight gain. Smoking cessation can result in weight gain at one year of about 11 pounds on average, due to decreased energy expenditure, increased appetite and greater food intake. The degree of weight gain, however, is variable. Binge eating appears to be an important risk factor. In a retrospective study of overweight individuals who had quit smoking, those with significant binge eating problems gained substantially more weight in the year following smoking cessation (24.6 pounds) compared to those without binge eating (11 pounds) ( White, Masheb & Grilo, in press ).

Consistent with this report, this patient recently experienced rapid weight gain that initially began during the stressful period of her mother's illness and coincided with a four-month period of smoking abstinence. Her weight gain of 25 pounds over the recent six months, four of which followed smoking cessation, suggests that without intervention her binge eating is a major risk factor for continued weight gain.

Her maladaptive eating may also place her at risk of smoking relapse. Indeed, she reports that her urges to smoke had increased in recent weeks and were more intense in the evenings. Her pattern of depriving herself of food during the day and then binge eating in the evening could undermine maintenance of smoking abstinence in several ways. Food deprivation can increase the reinforcing effects of drugs, including nicotine, making any lapses to smoking more likely to promote continued smoking. Her efforts to resist eating may also tax her self-control resources and undermine her ability to resist smoking. The evening binge eating episodes she reports follow restricted eating during the day and may result in abstinence violation effects in which she experiences demoralizing recriminations over her loss of control. The resulting increase in negative affect and decreased self-efficacy could promote smoking urges and place her at risk of resorting to smoking to cope with negative affect, a common risk factor for smoking relapse. Finally, the expectation that smoking can limit binge eating is another risk factor for smoking relapse.

Treatment Considerations

Given this conceptualization, the treatment plan for her binge eating may help her also remain abstinent from smoking. The “meal prescription” of regular meals and several small snacks should prevent periods of food deprivation that could increase smoking urges, and diminished frequency of binge eating should increase feelings of self-efficacy and remove the compensatory need for smoking to limit binge eating. The remission of her binge eating and the resulting stabilization of her weight may remove the motivation to resume smoking in an effort to manage her weight.

Cognitive behavioral therapy for eating disorders, including binge eating, also addresses the development of alternative coping skills for handling negative affective states and other triggers of maladaptive eating patterns. Given that many smokers use smoking to cope with negative affective states, teaching her alternative coping skills for handling negative affect is likely to have benefits that generalize and help her maintain abstinence from smoking. The therapist could make this connection explicit by examining the circumstances that elicit the urge to smoke, noting any parallels with the circumstances that provoke binge eating as a coping strategy and emphasizing that the new coping skills learned as alternatives to maladaptive eating could serve as alternatives to smoking as a coping response. Evidence for coping skills therapy targeted to one maladaptive behavior generalizing to another behavior is evident in a study of cognitive behavioral therapy for alcoholism, in which improvements in eating disturbances occurred in addition to reductions in alcohol intake ( O'Malley et al., 2007 ). Learning new coping skills and introducing a regular pattern of eating during the day could ultimately minimize stress, a major precipitant of binge eating and smoking.

In the smoking literature, a recent meta-analysis concluded that smoking interventions that incorporate a weight control component result in short-term (< 3 months) improvements in smoking abstinence and reduced weight gain compared to smoking cessation interventions alone ( Spring et al., 2009 ). In one study, for example, a cognitive behavioral intervention designed to reduce over-concern with weight gain improved smoking quit rates and reduce weight gain compared to standard care or a weight control intervention ( Perkins et al., 2001 ). Further development of CBT interventions for weight concerned smokers may be well served by incorporating additional elements of CBT for binge eating, such as meal patterning, especially for those with a history of binge eating or other eating disorder that may predispose for the development or worsening of eating problems during a quit attempt. Likewise, the clinician should consider smoking history in the management of obese patients who present for treatment of binge eating disorder. As a group, these individuals have higher overall psychiatric co-morbidity and more severe binge eating pathology than overweight individuals without a history of smoking and may require specialized care ( White & Grilo, 2006 , 2007 ).

Marc N. Potenza, M.D., Ph.D.

Diagnostic considerations.

The current case describes the treatment of an individual who has demonstrated seemingly excessive engagement in two domains – tobacco use and food consumption. In anticipation of DSM-V, there exist discussions about how best to define and categorize disorders seemingly addictive in nature, and whether excessive engagement in non-drug behaviors (e.g., pathological gambling) might be grouped together with substance use disorders as addictions ( Petry, 2006 ; Potenza, 2006 ). The current case raises questions about whether excessive eating behaviors manifesting in BED and/or obesity might similarly be considered within an addiction framework, and, if so, how such a conceptualization might influence studies into the etiology, prevention and treatment of “behavioral” and drug addictions ( Grant et al., 2006 ; Holden, 2001 ).

Historically, the term “addiction” has undergone multiple changes in usage. Derived from the Latin word meaning “bound to” or “enslaved by”, the term was originally used independent of drug use. However, several hundred years ago the term became linked to excessive patterns of alcohol use and more recently drug use such that by the time when DSM-III-R was being generated, expert consensus was that “addiction” referred to compulsive drug-taking ( O'Brien et al., 2006 ). More recently researchers have proposed core elements of addiction (continued engagement despite adverse consequences, a compulsive quality, an appetitive urge typically preceding engagement in the behavior, and diminished self-control over the behavior) ( Potenza, 2006 ; Shaffer, 1999 ). If these features are seen as the defining qualities of addiction, then conditions like BED and obesity might be considered as addictions ( Volkow and O'Brien, 2007 ; Volkow and Wise, 2005 ).

Mechanisms and Treatment

Obesity, like addictions, appears to have multiple environmental and biological factors contributing to the disorder ( Gearhardt, Corbin, & Brownell, 2009 ; Gold et al., 2009 ). For example, food availability and advertising may increase the societal rates of obesity ( Brownell, 2004 ), and individual difference factors (e.g., specific genetic allelic variants) may predispose people to greater risks for obesity ( Paracchini et al., 2005 ; van Deneen et al., 2009 ). Arguably, a historical focus on the biological mechanisms underlying obesity has involved metabolism and imbalanced energy homeostasis (i.e., “energy in” and “energy out”) ( Abizaid et al., 2006 ). However, the application of motivational behavioral models to food consumption, like those that have been applied to drug use ( Chambers et al., 2003 ; Everitt and Robbins, 2005 ), may lead to identification of novel factors involved in the pathophysiology of obesity and BED ( Volkow and Wise, 2005 ; Hoebel et al.., 2009 ). Given that neurocircuity implicated in drug abuse appears similarly implicated in obesity (e.g., relatively diminished dopamine D2-like receptor availability in the striatum ( Wang et al., 2004 ; Wang et al., 2009 )), additional research is warranted to understand more completely the biological similarities and differences between drug addictions and obesity. The more complete and precise identification of these similarities and differences could help advance prevention and treatment strategies across disorders. Such a strategy has proven fruitful for pathological gambling, where proposed mechanisms underlying pathological gambling and substance addictions led to the hypothesis that opioid antagonists such as naltrexone, approved for the treatments of alcohol dependence and opioid dependence, would be efficacious in the treatment of pathological gambling ( Brewer et al., 2008 ; Grant et al., 2008 ; Tamminga and Nestler, 2006 ). Analogously, glutamatergic agents (e.g, N-acetyl cysteine) have demonstrated initial promise with respect to weight loss, tobacco smoking, pathological gambling and cocaine dependence ( Souza et al., 2008 ; Knackstadt et al., 2009; Grant et al., 2007 ; LaRowe et al., 2006 ), and further research is needed to further evaluate their efficacies and tolerabilities, particularly amongst dually diagnoses populations.

Specific aspects of the case also warrant mention as they relate to the relationship between disorders, like drug dependence, typically have been conceptualized as addictions and others, like obesity and BED, that typically have not. For example, it is noteworthy that the patient reports having recently quit smoking prior to entering treatment, as well as having had several periods of time of time when she was smoking regularly and others when she had quit for prolonged durations. This pattern raises questions about the natural history of smoking and eating behaviors, both individually and in conjunction. Addictions have historically been considered chronic relapsing conditions, a conceptualization based in considerable part on clinical samples. Epidemiological data suggest that both “behavioral” and drug addictions might follow less pernicious natural histories than originally thought, with many individuals recovering without formal interventions ( Slutske, 2006 ; Tamminga et al., 2006 ). Nonetheless, many individuals do require formal interventions, often on multiple occasions. Furthermore, how one behavioral domain might influence the other is incompletely understood. The phenomenon of “switching addictions”, as is suggested in other domains (e.g., alcoholism and problem gambling ( Potenza et al., 2005 )), may be reflected here in increased food cravings, food consumption and weight gain following smoking cessation, with multiple possible contributing mechanisms related to motivation, metabolic changes, stress reduction, or coping with uncomfortable or dysphoric states, as Dr. O'Malley indicates.

Life stressors appear to play an important role in the patient's clinical course, both with respect to smoking and eating. As such, therapies like CBT that include instruction in healthy coping strategies might be particularly relevant for the patient. From a biological perspective, the neural mechanisms underlying stress responses overlap with those implicated in impulse control and addiction ( Kalivas and Duffy, 1989 ; Piazza and Le Moal, 1996 ). Consistently, identification of specific intermediary phenotypes or endophenotypes in the domains of stress responsiveness and impulsivity would appear to have important implications across a broad range of disorders, including obesity, BED and nicotine dependence ( Blanco et al., 2009 ). As Dr. Grilo notes, combinations of pharmacological and behavioral therapies might be most helpful for BED, and consideration of pharmacological agents that target important intermediary phenotypes will represent important areas of future development.

Concluding Comments and Future Directions

The changes over time in the patient's smoking and eating behaviors highlight the importance of considering behaviors with addictive potential within a developmental framework, particularly as early problems have important implications for adult functioning ( Chambers et al., 2003 ). Early life interventions aimed at developing healthy eating, exercise, stress-coping skills, emotional regulation and general health behaviors at early ages, and particularly involving youth who might be considered high-risk, will be important in preventing the development of a broad range of addictive disorders including obesity ( Merlo et al., 2009 ). Public health interventions like those that appear effective in reducing youth smoking (e.g., increased taxation of cigarettes) warrant consideration for foods associated with obesity ( Brownell et al., 2009 ). It is likely that only through multiple interdisciplinary approaches will we be able to effectively target the public health concerns of obesity and drug addictions, ones that currently are estimated to cost US society hundreds of billions of dollars annually and impart significant personal and familial suffering ( Surgeon General, 2001 ; Uhl and Grow, 2004 ; Potenza and Taylor, 2009 ).

Acknowledgments

Acknowledgments and Disclosures: This work was supported by the NIH grants RL1 AA017539, UL1 DE19586, K23 KD071646, K24 DK070052, R01 DK49587, RC1 DA028279, P50 AA015632, NIH Roadmap for Medical Research/Common Fund, and the VA VISN1 MIRECC. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of any of the funding agencies. Dr. Potenza has received financial support or compensation for the following: Dr. Potenza consults for and is an advisor to Boehringer Ingelheim; has consulted for and has financial interests in Somaxon; has received research support from the National Institutes of Health, Veteran's Administration, Mohegan Sun Casino, the National Center for Responsible Gaming and its affiliated Institute for Research on Gambling Disorders, and Forest Laboratories, Ortho-McNeil, Oy-Control/Biotie and Glaxo-SmithKline pharmaceuticals; has participated in surveys, mailings or telephone consultations related to drug addiction, impulse control disorders or other health topics; has consulted for law offices and the federal public defender's office in issues related to impulse control disorders; provides clinical care in the Connecticut Department of Mental Health and Addiction Services Problem Gambling Services Program; has performed grant reviews for the National Institutes of Health and other agencies; has given academic lectures in grand rounds, CME events and other clinical or scientific venues; and has generated books or book chapters for publishers of mental health texts. Dr. Grilo has received research support from the National Institutes of Health, medical research foundations (Donaghue Foundation, American Heart Association, Borderline Personality Research Foundation), has delivered lectures and papers at scientific conferences, and has generated books and chapters for academic book publishers. Dr. O'Malley is a member of the ACNP workgroup, the Alcohol Clinical Trial Initiative, sponsored by Eli Lilly, Janssen, Schering Plough, Lundbeck, Glaxo-Smith Kline and Alkermes; a partner in Applied Behavioral Research; a Scientific Panel member, Butler Center for Research at Hazelden. Dr. O'Malley participates in studies in which Nabi Biopharmaceuticals and Sanofi Aventis donated medications, has given academic lectures at professional societies and has received grant support form the National Institutes of Health.

All authors report no conflicts of interest with the current manuscript.

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Bulimia nervosa and treatment-related disparities: a review

Affiliation.

• 1 College of Health Sciences, Utah Tech University, St. George, UT, United States.
• PMID: 39205982
• PMCID: PMC11349707
• DOI: 10.3389/fpsyg.2024.1386347

Introduction: Bulimia nervosa (BN) is a type of eating disorder disease usually manifesting between adolescence and early adulthood with 12 as median age of onset. BN is characterized by individuals' episodes of excessive eating of food followed by engaging in unusual compensatory behaviors to control weight gain in BN. Approximately 94% of those with BN never seek or delay treatment. While there are available treatments, some populations do not have access. Left untreated, BN can become severe and lead to other serious comorbidities. This study is a review of randomized controlled trials to explore available treatments and related treatment disparities. The objective of this review was to identify differences among treatment modalities of BN and aide in the further treatment and research of bulimia nervosa.

Methods: This study followed narrative overview guidelines to review BN treatment studies published between 2010 and 2021. The authors used PubMed and PsychInfo databases to search for articles meeting the inclusion criteria. Search terms included phrases such as, BN treatment, BN and clinical trials, and BN and randomized clinical trials.

Results: Most of the reviewed studies had their sample sizes between 80 and 100% female with age range between 18 and 60 years old. Sample sizes were mostly between 80 and 100% white. Treatment practices included both pharmacological and psychosocial interventions, such as cognitive behavioral therapy (CBT) and limited motivational interviewing (MI). Most studies were in outpatient settings.

Conclusion: Reviewed research shows that certain populations face disparities in BN treatment. Generally, individuals older than 60, males and racial minorities are excluded from research. Researchers and practitioners need to include these vulnerable groups to improve BN treatment-related disparities.

Keywords: bulimia nervosa and clinical trials; bulimia nervosa diagnosis and treatment; bulimia nervosa research; bulimia nervosa treatment; bulimia nervosa treatment-related disparities.

Copyright © 2024 Wilson and Kagabo.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Flow chart of studies reviewed.

• American Psychiatric Association (2022). Diagnostic and statistical manual of mental disorders. 5th Edn: APA Press.
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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.

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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.

• Agras, W. S. (1995). “Treatment of eating disorders.” In A. Schatzberg & C. Nemeroff (Eds.), Textbook of pyschopharmacology. Washington, DC: American Psychiatric Press.
• 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.
• Hsu, M. Y. (1990). Schizophrenia and comorbid conditions: Diagnosis and treatment. Washngton, DC: American Psychiatric Press.
• Silverstein, S. M., Rodin, L. (2006). Identifying and addressing cognitive barriers to rehabilitation readiness. Psychiatric Services, 49(1), 34–36.
• 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.
• Striegel-Moore, R., Silberstein, L., & Rodin, J. (1986). “Toward an understanding of risk factors for bulimia.” American Psychologist, 43, 246–263.

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