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Done by: Justina Osorio and Azennette Aldana

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People with bulimia nervosa—also known as binge-purge syndrome—experience recurring episodes of uncontrollable overeating, known as binges. These binges typically happen over a short period, often around two hours, during which they consume far more food than most people would in the same amount of time. The binges often occur in response to increasing tension and are followed by feelings of guilt and self-blame. Afterward, they engage in inappropriate compensatory behaviors, such as self-induced vomiting, misuse of laxatives, diuretics, or enemas, extreme fasting, or excessive exercise. Additionally, their self-worth is heavily tied to their body shape and weight.

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Binge Eating Episodes - repeatedly eating unusual large amounts of food in one setting. Feeling a loss of control during binge eating, you may feel like you can't stop eating or can't control what you eat. For example someone might eat an entire pizza, a box of cookies, and a tub of ice cream within 2 hours without feeling able to stop.

Compensatory Behaviors - engaging in activities to prevent weight gain after bingeing for example, forcing yourself to vomit right after eating or exercising for hours to burn off the calories, using medicines that make you urinate, called water pills or diuretics, or laxatives or enemas to pass stool when they're not needed.

Preoccupation with Body Shape and Weight - living in fear of gaining weight, constantly thinking about body image, dieting and trying to lose weight in unhealthy ways. For example, being very unhappy with your body shape and weight, letting your body shape and weight guide how you feel about yourself and your worth.

Secretive Behavior Around Food - this is when a person is hiding how much they eat or being very private about eating habits. For example, stashing food in their room or making excuses to eat alone, making frequent trips to the bathroom when others aren't around.

Mood Swings and Emotional Distress - feeling intense guilt, shame, or sadness after bingeing or purging. For example, after a binge, someone might cry, withdraw from others, or punish themselves emotionally.

Sense of lack of control - During these binge eating Episodes, one feels a profound sense of lack of control over her eating. It is described as the feeling of being driven to eat and unable to stop, even when one knows they are already full.

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

1. Eating, in a discrete period of time, for example, within any 2- hour period, an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.

2. A sense of lack of control over eating during the episode, for example, a feeling that one cannot stop eating or control what or how much one is eating.

B. Recurrent inappropriate compensatory Behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.

C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.

D. Self-evaluation is unduly influenced by body shape and weight.

E. The disturbance does not occur exclusively during episodes of anorexia Nervosa.

Specified criteria for Bulimia Nervosa severity: The DSM-5 also provides specified criteria for the severity of Bulimia Nervosa, based on the frequency of inappropriate compensatory behaviors:

Mild: An average of 1-3 episodes of inappropriate compensatory behaviors per week.

Moderate: An average of 4-7 episodes of inappropriate compensatory behaviors per week.

Severe: An average of 8-13 episodes of inappropriate compensatory behaviors per week.

Extreme: An average of 14 or more episodes of inappropriate compensatory behaviors per week.

Teenagers and more females are prone to Bulimia Nervosa than Males

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1. Psycho-dynamic Approach: This approach emphasizes unconscious conflicts and unresolved issues from early childhood as the root cause of Bulimia Nervosa. It suggests that individuals with Bulimia may use bingeing and purging as a way to cope with emotional distress or to regain a sense of control. For example, a person might unconsciously associate food with comfort due to early experiences, leading to binge eating as a coping mechanism.

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2. Biological Approach: This approach focuses on genetic, neurochemical, and physiological factors contributing to Bulimia Nervosa. It suggests that there may be a genetic predisposition to developing the disorder, such as family and twins studies suggest a hereditary component like those with a family history of eating disorders are at higher risk. As well as abnormalities in brain chemistry and neurotransmitter imbalances (e.g., serotonin and dopamine). For example, alterations in serotonin and dopamine levels could affect mood and impulse control, contributing to binge eating.

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3. Sociocultural Approach: This approach emphasizes the influence of cultural and social factors on the development of Bulimia Nervosa. It suggests that societal pressures to conform to a certain body image, particularly thinness, can lead to body dissatisfaction, low self-esteem and disordered eating behaviors. Media portrayals, peer pressure, and societal ideals of unrealistic body standards to development of Bulimia Nervosa, especially in cultures where thinness is highly valued. Frequent comparisons and negative body image are key contributors as well.

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1. Psychodynamic Psychotherapy: The focus on this treatment is to explore unconscious conflicts, past trauma, and emotional patterns leading to the eating disorder. Some of the methods used can be exploring early childhood relationships, understanding how Bulimia may serve as a coping mechanism, working through unresolved emotional issues, it can be longer-term but may offer deep emotional insight and healing. Some of the techniques used include free association which is a technique where the therapist encourages the person to talk openly about whatever comes to mind, without filtering or censoring their thoughts. This helps bring out hidden feelings, memories, or patterns that may be connected to their eating behaviors. Another technique is interpretation meaning the therapist helps the person understand how things from their past (like childhood experiences) might be influencing how they think, feel, or act today, especially around eating and self-image.

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2. Pharmacotherapy/Medication (SSRIs): This treatment focuses on addressing underlying neurochemical imbalances, particularly with serotonin. Common medication is Fluoxetine (Prozac), the only FDA approved SSRI for Bulimia Nervosa. This is an antidepressant that helps improve mood, reduce obsessive thoughts about food or body, and decreases the urge to binge and purge. People who have moderate to severe Bulimia might benefit from Prozac, it can be especially helpful when combined with therapy, like CBT.

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3. Psycho education and Media Literacy Programs: This treatment focuses on changing harmful beliefs about beauty, weight, and appearance that come from outside influences. The media literacy programs teach people to critically think about what they see in ads, movies, magazines, and social media, help them understand that most images are edited or unrealistic, and encourage them to challenge the "thin ideal" promoted by society. Body image therapy helps people accept and appreciate their bodies, no matter the shape or size, focuses on self-love, body respect, and building confidence that is not based on appearances and this may include journaling about body positives, avoiding comparison with other, and practicing self-care and self-compassion. More therapy could be group therapy and support groups which involves talking with others who have similar struggles, it helps reduce feelings of isolation and pressure to look a certain way but by sharing it encourages and learn healthy ways to cope with body image and food concerns. All of these treatments helps them unlearn harmful messages and replace them with healthier, more realistic beliefs about beauty and self-worth.

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Sage has a history of excessive binge-eating as well as self-induced vomiting which is her method in order not to gain weight. She constantly over analyzes her weight and criticizes her body. She believes she is overweight but her BMI seems rather unusual. The diagnostic criteria for the DSM-5 states that there must be a lack of control of excessive eating which is evident in Sage’s case. As the case concludes, it is mentioned that she engages in the binge-purge method at least 4 times a week. The criterion for Bulimia Nervosa requires that it occurs at least once a week for three months. An example of this is when she consumed 7 candy bars over a time span of 15 minutes, which is rather unusual in regular eating time frames. It is clearly depicted that she can’t control her excessive consumption within the episodes. In accordance to the DSM-5, the patient must be eating in a discrete period of time with an amount typically larger than what most people would eat during a similar period of time. These symptoms are significantly evident in the case of the 26-year-old patient. She added that though she wants to end this behavior, she is concerned about her possible weight gain thereafter.

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In the case of Sage, a possible differtial diagnosis could be Anorexia Nervosa. This is supported due to her binge-purge episodes that she engages in. These symptoms are evident in Anorexia as well as the leading diagnosis, Bulimia Nervosa. Another symptom in the criterion for Anorexia is the disturbance about their body weight/shape and how it influences their self-evaluation. In addition to that, there is an intense fear of gaining weight even when significantly underweight or not even close to physically being fat. All of this is clearly evident in Sage’s case. However, Anorexia Nervosa is dismissed as a possible diagnosis due to the patient’s BMI results that confirmed that her weight is regular. Lastly, although she displays symptoms related to Anorexia, majority of her symptoms correlated more to Bulimia. The difference that confirms the proper diagnosis is the time frame. Therefore, Sage is being diagnosed with Bulimia Nervosa.

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Sage, a 26-year-old student, has struggled with a negative body image since childhood. This resulted from teasing related to early physical development. By the 7th grade, she alternated between restrictive dieting and binge eating. She expressed that binge eating helped her cope with negative emotions. According to the DSM-5, a diagnosis of Bulimia Nervosa requires a lack of control of overeating during the episode (whether that may be not being able to stop eating uncontrollably or what/how much you are eating). In college, this developed into a pattern of binge-purge behavior. Her purging method is self-induced vomiting to aid with the relief of not gaining weight. Currently, she engages in this cycle approximately 4 times per week. The diagnostic criteria also states that a symptom of Bulimia is that the binge eating and inappropriate compensatory behaviors both occur at least once a week for three months. To add to this, she consumes 7 candy bars within a time period of 15 minutes. In relation to the DSM-5, eating in a discrete period of time with an amount of food that is larger than most people would consume during a similar period of time, is a key symptom to diagnose a patient with Bulimia Nervosa. These episodes are typical triggered by academic stress or relationship conflict. Although her BMI seems ordinary, Sage perceives herself as overweight. A common symptom in the criteria for diagnosis is that the patient’s self-evaluation highly relies by their body shape and weight. She wishes to end the cycle to keep her boyfriend from discovering her behavior but is conflicted by her weight concerns. A differential diagnosis to be considered for this case is Anorexia Nervosa, binge-eating/purge type. A supportive symptom to justify this considerable diagnosis is the binge-purging behavior that is also evident in Anorexia. A factor that disregards this as a possible diagnosis is the patient’s BMI. To consider Anorexia, it requires a significantly low weight, while Sage’s BMI is relatively normal.

Some basic questions to ask in order to increase the accuracy of the diagnosis:

1.) Is your daily functioning disrupted by thoughts about food and weight gain? If so, how often do they occur?

2.) Does your purging method have a positive effect after you’ve finished?

3.) Are there any specific types/amounts of food you typically consume during a binge episode ?

4.) Are there any other inappropriate compensatory methods that you engage in?

5.) Do you feel that your immune system is weaker since you’ve been engaging in this behavior?

6.) Are there any medical issues that you’ve faced ever since?

7.) How do you manage to be discrete about your binge-purging episodes?

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The recommended treatment for Sage, who has been diagnosed with Bulimia Nervosa, should begin with Cognitive Behavioral Therapy which is considered the gold standard for treating this disorder which focuses on breaking the binge-purge cycle, addressing dysfunctional thoughts about body shape/weight, and developing healthier eating patterns, this treatment usually involves 20 sessions over 5 months. Nutritional/ healthy-weight support program is also very important, a registered dietitian can help Sage plan regularly meals and understand how purging harms the body. Along with therapy, a doctor may prescribe medicine like Fluoxetine (Prozac) to help reduce bingeing and purging. Sage should also have regular medical check-ups to watch for any health problems caused by purging, like low potassium or heart issues. Family-based treatment for Sage can be very helpful as well. Learning more about Bulimia can help Sage understand the illness and feel more motivated to get better. Also this therapy involves the family- especially parents and her immediate family. Support groups are also a good way for Sage to connect with others who have similar experiences and feel less alone. Lastly, it's important to make a plan to prevent relapse by helping Sage deal with stress, avoid triggers, and stay on track with recovery.

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Due to the motivation that Sage had, her prognosis will more than likely have a positive outcome. As mentioned in the case study, she functions well in her academic life while maintaining a romantic connection. This can indicate that she can overcome challenges that may arise in the course of her life. Clinically, the treatment that she has received may also positively influence her ability to cope or overcome with this behavior that she struggles with.

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Video explaining more about Bulimia Nervosa for better understanding

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Video explaining more about Bulimia Nervosa for better understanding

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Bulimia Nervosa: Causes, Health Risks, and Treatment | Mass General Brigham

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Society of Clinical Psychology | Division 12 of the American Psychological Association

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Sage is a 26-year-old doctoral candidate in English literature at the local university. She is in good standing in her program and has plans to enter the job market in the fall. In your intake, she tells you she thinks she is "fat" and has been self-conscious about her body since the sixth grade, at which time she began menstruating and developing breasts earlier than the other girls in her class. She was teased for needing a bra and remembers feeling "chubby, too big, and just wanting to be small like [her] younger sister." She started dieting in the seventh grade, following strict rules for weeks (e.g., she recalls the grapefruit only diet), then transitioning into what she called "bad" weeks. During these times, she would stock up on candy bars and other snack foods and eat them, often in her bedroom late at night. Her parents became concerned and tried to strictly limit her dieting. This led to eating "normal" during the day and binging on those candy bars she kept hidden in her bedroom at night if she felt sad, scared, or mad. She grew into a habit of eating to feel better - relief that was only temporary, as she would feel ashamed about what she had done and resolve to not do it again. In college, her pattern of emotional eating continued, which felt more distressing to her because of the pressure to look "as pretty and thin as the other girls." In spring of her freshman year she experimented with throwing up after the late-night eating and found that, at least in the minutes that followed, she felt like she had much more control and believed this would help her to prevent the weight gain she so dreaded. She fell into a vicious cycle of late-night binges (typically consuming about 7 candy bars in 15 minutes, during which times Sage described feeling very out of control) followed by making herself throw up. In college, she engaged in these binge-purge episodes about 6 nights/week. At present, she is having a harder time hiding the episodes because she lives with her boyfriend; she estimates that they occur about 4 nights per week. The times when she feels the most compelled to binge and purge are when she has a major presentation coming up in her doctoral program and when she gets in a fight with her boyfriend. Her BMI is in the normal range, but she says she needs to lose weight. She wants to stop binging and purging because she does not want her boyfriend to find out, but she is also afraid that if she stops, she will gain weight.

Symptoms

Binges and Purging

Body Image

Emotion Dysregulation

Disordered Eating

Diagnoses and Related Treatments

The following treatments have empirical support for individuals with Bulimia Nervosa:

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Sage (bulimia nervosa) | Society of Clinical Psychology

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Division 12 of the American Psychological Association