Bulimia Nervosa
how often she exercises and Sarah’s answer was surprising. According to Sarah, she exercises two or three times a day. She suggests that “at least I can control my weight.” Sarah’s choice of the word “control” piqued Ms. Chu’s interest. Although it may have meant nothing, Ms. Chu tends to take her clients’ word choices seri-ously. She decided to explore the issue of control further.
Ms. Chu showed good use of her critical thinking skills by actively listening to not only the meaning of what Sarah said but the particular words she chose to use. Notice that Sarah did not suggest she could use exercising to “maintain,”
“manage,” “keep a handle on,” or “reduce” her weight. Ms. Chu used logical inference processes (critical thinking) to select the most important aspects of what Sarah was saying and how she was saying it. This is a very important skill, especially during the assessment and interview process.
As part of her routine initial diagnostic interview, Ms. Chu asked Sarah if she has ever received treatment for eating problems or other disorders, or ever thought she might have a problem involving eating. Sarah suggested that she has a healthy appetite and mentioned her particular fondness for junk food but was otherwise evasive about answering the question. Ms. Chu noticed that Sarah did not directly answer the question, so she persisted with further questions about eating. The more uncomfortable Sarah became, the more deliberate and patient Ms. Chu was with her questioning. Before long, Sarah completely dissolved in tears of frustration and helplessness. Between sobs, she expressed her exaspera-tion over a serious inability to control her preoccupaexaspera-tion with her weight or her eating binges. She discussed how miserable she was and how medically and psychologically damaging her eating problems have become.
Sarah revealed that bingeing and purging had become a cycle for her more than 7 years prior to the meeting with Ms. Chu. Sarah said she realized she was becoming increasingly frustrated as her control over her eating weakened and weakened. It seemed the harder she tried to control the cycle, the more control it began to exert over her and her life. Several close friends and even Sarah’s mother had begun to notice her unusual patterns and had been asking her ques-tions about them.
Upon further coaxing from Ms. Chu, Sarah described what has become a fairly typical day for her: “I get up in the morning three hours before I have to be anywhere. I start out by eating breakfast and tell myself that I won’t exercise. As I get dressed and plan my day, though, nagging thoughts about gaining weight keep occurring to me. Before long, I will be absolutely convinced that I will gain too much weight from having eaten that breakfast. Moments after thinking this, I hit the exercise machines. Exercising makes me feel good about myself and I stop worrying for a while about gaining weight. But exercising makes me hungry, too. If I eat another meal, though, I know I will have to deal with my worries about gaining weight. Sometimes I can control the concerns and have a pretty normal day. But good days have their price. I may suddenly have an over-whelming urge to eat and when I give in to that, I really give in. At one sitting,
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I have actually eaten an entire bucket of fried chicken, a box of Twinkies, several pints of ice cream, a bag of peanut M&M’s, and several diet drinks. While I am stuffing myself with food, I feel great. But, once I am done, the reality of what I have done hits me and I immediately start worrying about my weight again.
I get really concerned and all I can think about is getting that junk food out of me. Those days are total hell.”
Assessment
Sarah had been secretly hiding her disorder for more than 7 years. It is not obvious from looking at her that Sarah has bulimia. Unlike anorexia, where one would expect obvious physical signs, Sarah appeared to be of normal weight, and in between her episodes of bingeing and purging, she ate normally. Ms. Chu needed to verify the binge-purge cycle, which would not be easy since Sarah had con-siderable practice in hiding her aberrant eating behavior. Sarah had learned to use mouthwash after a purge to cover up any odor, and she could easily give the appearance of eating healthy amounts of food. As long as she could hide the binge-and-purge cycles, no one was the wiser. In addition, until recently, the episodes of bingeing and purging were somewhat isolated. But Sarah reported experiencing more stress in her life over the past year—and with an increase in her experiences of stress came an increase in the frequency of the binge-purge cycles.
Sarah demonstrated the most common pattern of symptomatology in bulimia, which involves the cycle of bingeing and purging. In an attempt to cope with stress and feelings of lack of control in her life, she engaged in bouts of overeating—
usually involving huge amounts of junk food—and followed this with purges that are intended to compensate for all of the calories and fat consumed. Sarah’s binge-ing and purgbinge-ing occurred several times per week, a frequency that was more than sufficient to meet DSM-5 criteria for Bulimia Nervosa. In addition, she clearly displayed a lack of control over her eating during these episodes, and presented a self-evaluation that is excessively influenced by body shape and weight.
Ms. Chu posed a careful series of questions about Sarah’s lifetime history of binge eating, induced vomiting, use of laxatives, food preferences, self-perceptions regarding her appearance, exercise habits, and understanding of factors that may be related to her binge-purge episodes. Ms. Chu was interested in understanding any potential relationships between events in Sarah’s life and the tendency to binge and purge. It might be the case, for example, that Sarah was more likely to binge and purge after certain types of stressful events than others. If she was able to resist the binge-purge cycle in response to certain stress-ors, then Ms. Chu could illuminate that and show Sarah how she was effectively coping with some stressors and not others.
Ms. Chu also asked Sarah about other symptoms she may have experienced, such as anxiety, mood disturbances, use of substances, suicidal thoughts and behaviors, and impulse-control problems. She asked Sarah about her history
of sexual activity (including unwanted sexual experiences). Ms. Chu inquired whether eating problems (including obesity), mood disturbances, or substance abuse have been problems for any other members of her family, and what Sarah perceived the attitudes of members of her family to be regarding eating, exercise, and appearance. Sarah was referred for physical and dental checkups. The physi-cal exam included a test for electrolyte imbalances.
A CRITICAL THINKING AND QUESTIONING PAUSE
Why is Ms. Chu so concerned about documenting family perceptions about eating, exercise, and appearance? How could family perceptions be related to the perceptions that Sarah has for these same issues? Ms. Chu knows that many of our attitudes derive from the attitudes of family mem-bers. If Sarah’s parents, for example, constantly questioned her about her weight, or mentioned to her that boys do not like “chubby” girls, this could establish in Sarah’s mind that her body weight and appearance should be of great concern. In addition, though, such comments and questions can convince Sarah that her appearance, whatever it happens to be, is not
“good enough.”
Some sports, such as gymnastics and wrestling, also emphasize a par-ticular body image that is difficult for some young people to attain. Have you ever known someone who was on the wrestling team, for example, who had to go on a crash diet to “come in at a certain weight” or had been asked by coaches to quickly put on weight to move to a new weight class?
Without passing judgment on these sports, suffice it to say that this heavy emphasis on an ideal body weight places a lot of pressure on those individu-als who want to be a part of that sport.
Sarah’s parents may have inadvertently reinforced any weight loss that she did experience. Comments such as, “you look great,” in response to a weight loss can be very reinforcing. In order to maintain this highly desired weight, then, Sarah may adopt some fairly unhealthy practices. Over time, these habits can become extremely difficult to break and Sarah may find herself involved in a vicious cycle that she knows is unhealthy. (Why else would she work so hard to hide her bingeing and purging if she did not realize that there was something “wrong” with it?) This is the state she is in when she first sees Ms. Chu.
Why would Ms. Chu refer Sarah for a dental checkup when her “prob-lem” involves disordered eating? You may have heard that one of the warning signs of bulimia is damaged teeth. This comes from the frequent vomiting. Stomach acid eventually begins to destroy the enamel of the teeth, making teeth vulnerable to cavities and other problems.
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Sarah’s History
Sarah’s mother recalled that Sarah was always somewhat “particular about her weight.” She displayed some chubbiness as a youngster, and after her parents once kidded her about her big appetite, Sarah would often ask for reassurance that she was “not as fat as Jane,” her best friend. As she moved from childhood to adoles-cence, Sarah’s concerns about her body image escalated. She began to show some athletic prowess, and by the time she was a junior in high school, she had lost most of her “baby fat” and developed into a strong competitive swimmer. Her friend Jane was not athletic and had become noticeably overweight by the time they entered high school. Sarah and Jane began spending less time together, and Sarah agreed with her parents and her other friends that Jane was to blame for the fact her weight made her unattractive and unpopular.
This is a fairly typical case history for a young woman suffering from bulimia.
Other life history factors sometimes related to bulimia include medical illnesses and surgeries as a child, deaths of significant loved ones or other forms of sepa-rations (divorce, etc.), and childhood sexual abuse. More often than not, these incidents are related to feelings that the world is “out of control” or unpredict-able. Food can sometimes be perceived by the person as something that she or he can control. This perception that control can be gained through food may lead to the kind of patterns indicative of bulimia. Additionally, at least in Western society, images of physical attractiveness and self-worth are often associated with thinness.
Sarah’s first binge episode came after a disappointing end to the swimming season during her sophomore year of high school. She had trained hard during the season and consciously restrained herself from eating to minimize her body fat. In spite of all this, Sarah did not improve on her top performances of the previous year and failed to qualify for the conference championships. Her swim-ming career seeswim-mingly over, she consoled herself alone later that night by eating an entire large box of chocolates. When she was finished, Sarah felt bloated and very guilty. As her anxiety and agitation increased, she decided to force herself to vomit, which she was able to do without much effort. Although rather disgusted by what she had done, Sarah was also somewhat intrigued that she had been able to consume such a heavy overdose of fattening food and then completely “undo”
this act, apparently paying no price at all for what would have been a very serious transgression in her training regimen.
Over the next 2 months Sarah repeated the overeating and purging several more times, always in secret. She would eat little or nothing during most of the day, at most nibbling occasionally if food was around, but by afternoon would become increasingly preoccupied with thoughts of food and eating. For Sarah, feelings of fullness brought relief, not the taste of food or reducing hunger pangs.
Her goal was to fill herself quickly, so food that was easy to swallow was what she preferred.
Sarah quit the swim team feeling her athletic career was finished almost before it got started. Without the swim team, school held little interest for Sarah and she withdrew from most contact with her friends, preferring to spend most evenings alone in her room at home. These times were not happy ones, however, and frequent arguments with her mother increased the temptation Sarah felt to overeat. Each day as school wound down, Sarah spent more and more time pre-occupied with thoughts about eating.
Those evenings she spent away from home most often involved serving as a nanny for a local lawyer’s children. On the way home, she would stop at a con-venience store, spending most of the money she earned on junk food that she would wolf down in the car before entering her house. On evenings when she was at home, and no one in her family was paying much attention, Sarah would sometimes sneak large bowls of ice cream or potato chips from the kitchen and eat them in her room. Once she began eating, it was almost impossible for her to stop until the food was all gone. Only if someone knocked on the door and seemed about to enter would Sarah interrupt her eating. She always managed to purge what she had eaten by throwing up in the bathroom, and masked the noise she made by turning both faucets in the sink on full blast.
Over time, Sarah’s mother became puzzled by Sarah’s lack of spending money (in spite of frequent employment as a nanny) and by the occasional disappearance of significant amounts of food. The couple for whom Sarah worked commented to Sarah’s mother that a whole half gallon of ice cream had disappeared from their freezer each of the last two times Sarah had taken care of the kids. Sarah’s closest call came when she and her mother and brother went out one Sunday to an “all you can eat” smorgasbord restaurant. After quickly eating several plates of food, Sarah became visibly uncomfortable and suddenly excused herself to use the restroom. A few minutes later, her mother went to the rest room and was startled to discover that Sarah had been throwing up.
Upon further assessment, Ms. Chu discovered that Sarah’s parents were divorced. Her mother divorced her father when Sarah was in ninth grade and her brother was in the sixth grade. Sarah explains that her father was an alcoholic and what her mother referred to as a “mean drunk.” With coaxing, Sarah describes one of her father’s drinking episodes. Her mother called all over town trying to discover which bar Sarah’s dad was “holed up in.” When she finally found him, he was furious that she had disturbed him in front of his friends. She told him to come home because it was Father’s Day and Sarah and Billy wanted to give him his presents. Sarah suggested to Ms. Chu that it would have been better if her mother had just let her father drink and hadn’t harped about it. “It only made things worse,” Sarah reasoned.
Sarah continued to share the memory with Ms. Chu. As she listened to the details, Ms. Chu experienced a sense of déjà vú. The story sounded too familiar.
She had heard similar memories recalled by many of the clients she worked with.
Sarah’s father did come home from the bar but not to celebrate the special day
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with the children. He had a point to prove. He was going to teach his wife not to call and embarrass him in front of his friends anymore. When he entered the house, he was obviously very intoxicated and extremely upset. Sarah remem-bered running to him and showing him the new lunch box she had gotten him for Father’s Day. To Sarah’s surprise, her father grabbed the lunch box from her and threw it out the front door. When it hit the sidewalk, it broke right in half.
Sarah burst into tears and ran to her room. Her mother tried to get her father to calm down by mentioning that she and the children had gotten him a new char-coal grill too, but Sarah’s father was beyond reason. He demanded that Sarah come out of her room, grabbed Billy by the arm and went outside. Sarah and her mother followed. Fred had Billy pull the grill out into the driveway. Sarah, Billy, and their mother watched in uncertainty as Fred started the car. Sarah recalled to Ms. Chu simply feeling numb as her father took the car and backed it over the new grill. As if to add insult to injury, he pulled forward and ran over the twisted metal again, and backed over it one more time for good measure. When he seemed satisfied that he had made his point, he drove away and rejoined his friends at the bar.
Sarah revealed to Ms. Chu that much of her anxiety over feeling “out of con-trol” started to skyrocket at that point in her life. Control became an important issue with her. She could not seem to control the chaotic nature of her fam-ily environment but she could control other things. She joined the swim team because she could lose herself in the regimen of training and the rigors of compe-tition. Sarah also discovered that she was good at swimming. With each increase in her performance came a parallel boost in her feelings of self-control. As long as she could continue to perform better, it convinced her that she was in control.
Ms. Chu recognized Sarah’s pattern of placing increasing demands for perfor-mance on herself. Ms. Chu also knew, as Sarah had discovered, it was a coping mechanism destined to fail. When Sarah’s performance on the swim team her sophomore year was worse than her freshman year and not even good enough to qualify her for the conference championships, she felt out of control again. She quit the swim team to regain control, but losing the focus that had come from having such a well-defined sense of purpose caused her feelings of chaos and loss of control to skyrocket again.
Sarah managed to finish high school and move on to college, but her struggles with feelings of control and constant thoughts of eating continued to plague her.
Whenever things in college seemed to be getting out of control, Sarah experi-enced an overwhelming urge to binge and purge. She reported to Ms. Chu that she has felt down and lethargic most of her college career—except when bingeing and purging. Sarah seemed disgusted with herself when she reported to Ms. Chu that during the binges and purges, she felt elated. Only after purging and realizing that the food has controlled her once again did she feel guilt and disgust.
Once again, Ms. Chu recognized the pattern. She suspected that Sarah is suf-fering from at least a mild depression related to her feelings of lack of control in life, among other things. If Sarah experienced an adrenaline rush while she