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Bulimia Nervosa: Dana’s story

Caitlyn Landry

ID#: 5663950

PSYC 3F20

Dr. Andrew Dane

TA: Ann Farrell

Seminar #4

Date submitted: February 7, 2017

Date due: February 7, 2017

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DSM-5 Diagnostic Criteria:

According to the DSM-5 the criteria from bulimia nervosa is as follows: A) the individual

must have repeated episodes of binge eating (DSM-5, pg. 345), B) be using preventative weight

gain behaviour (purging, excessive exercise, laxatives, etc.) (DSM-5, pg. 345), C) both

previously mentioned behaviours must occur together at least once a week for 3 months on

average (DSM-5, pg. 345), D) individuals must have excessive thoughts of evaluation that is

influenced by body shape and weight (DSM-5, pg. 345), and E) disturbances do not occur solely

during episodes of anorexia nervosa (DSM-5, pg. 345). For further clarification about the

criteria, the DSM-5 defined the parameters for a binge eating episode. This involves:

1. eating within any 2-hour period, the portion of food being eaten is substantially large than

what most individuals would eat in the same amount of time (DSM-5, pg. 345).

2. A lose of control over their binging episode and feeling like they cannot stop themselves

(DSM-5, pg. 345).

In Dana’s case, according to criterion A, she had exhibited repeated episodes of binging. The

day of her twenty second birthday dinner, she had partaken in 2 purging episodes leading up to

the dinner, purged again during the dinner despite not having ate very much and would later that

night partake in yet another purging episode, this time the episode consisted of a combination of

both binging and purging as per criterion A sub section 1. During the final episode of binging

and purging that day, she noted that she did not stop eating until she felt she was going to

explode which indicates a lose of control which fulfills criterion A sub section 2.

The DSM-5 states that an individual with bulimia nervosa must be using preventative weight

lose measures which includes but is not limited to; laxatives, purging, improper use of thyroid
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hormones, and/or excessive exercise as per criterion B. In Dana’s case her method of weight lost

is purging which involves her throwing up her food as soon as she has finished eating.

Dana’s binging and purging behaviours had begun around the age of sixteen when her

“friend” told her about a “diet” where she could eat whatever she wanted to and still lose weight.

As per the DSM-5 both binging and weight lose measures (ie. Purging) must occur at least once

a week for at least 3 weeks. Dana has been partaking in these behaviours for approximately 8

years and given that she purged 4 times in one day we can assume that this behaviour occurs

more then once a week is not more then once a day (depending on the level of stress Dana feels).

These behaviours that Dana exhibit far exceeds the minimum requirement for criterion C.

Dana had expressed her self-conscious feelings toward her body shape and weight on a

couple occasions. When Dana walked into the restaurant she felt as though everyone’s eyes were

on her, this caused her to feel anxious. She thought “My God! These people must think I’m so

fat” (Clipson& Steer, 1998) which indicate that she has aversive feelings towards her weight and

as such evaluates herself as lesser then others. On separate occasion that same night, her sister’s

boyfriend gave her a complement on her looks telling her that she looks great. Instead of the

typical reaction “thank you” Dana proceeded to think about how she thinks her hips are large and

could not fit into the seat and that her stomach was bulging from dinner (Clipson & Steer, 1998).

These feeling she has expressed are used as a way to put herself down and criticize everything

about her, which is indicative of criterion D.

As for criterion E, individuals can have recurring episodes of bulimia nervosa whilst being

diagnosed with anorexia nervosa however these two do not have to interconnect. Dana had never

been diagnosed with anorexia prior to her diagnosis of bulimia.

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Other then the key criterions discussed above, the DSM-5 discussed the overlap of

depression or depressive like symptoms.

Finally, there are specifiers to indicate the severity of the disorder. The DSM-5 states that if

the individual has on average a certain number of episodes per week they can be classified as

either mild, moderate, severe or extreme. An extreme severity is classified as having on average

14 or more episodes per week (DSM-5, pg. 345). Given that Dana has experienced at least 4

episodes in one day before and assuming this happens in a similar amount every day then Dana

would be classified as extreme.

Etiology:

Till this day there is no unknown cause or singular factor that can trigger bulimia. What

is known is that it is more prevalent in females (1.0% female, 0.1% males) and that it effects

approximately 4.5% of females ages 18-24. Although we do not know the cause of bulimia we

can infer and discus social, biological and psychological factors that can come into light when

evaluating an individual with bulimia.

Social

Bulimia is a disorder that anyone can develop, having said that bulimia is more prevalent

in wester society and cultures. This is most likely due to social media and body shape standards.

In countries like America, a skinny figure with blond hair is most desirable and this idea is

plastered all over magazines and tabloids. Whereas in other countries (eastern societies) they

celebrate curvy bodies and they also typically shame less even for those body shapes they don’t
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find desirable. In Dana’s case, however I feel that there may have been a media influence

however it was not as predominant compared to others such as family.

Dana’s mother is a very vein person, wrapped up in looks and fashion, and she tries to

place these ridiculous standards of looks on Dana. On several occasions, Dana, can recall her

mother telling her that if she were to enlarge her breast or change her clothing style or change her

hair, then her boyfriend Matt would be more interested in her. Strober and Humphry conducted a

study in 1987, to show family dynamics and how they effect bulimics. They noted that “Bulimia

has been strongly associated with a lack of parental affection” (Strober and Humphry, 1987).

They typically exhibit behaviours of neglect and belittlement. These behaviours are exhibited by

Dana’s mother via the constant picking at her look (ie. Hair, style and body shape). Strober and

Humphry also mentioned that “bulimic-anorexic daughters displayed greater ambivalence in

interaction with their parents and often fluctuated between resentful submission and active

assertion compared with normal control subjects” (Strober & Humphry, 1987). This idea can be

shown in the relationship dynamic between Dana and her father. Dana’s father is a very

successful man and with that he expects great achievements from his children, however, Dana

felt that she could never fully please her parents. Due to these behaviour Dana wasn’t very close

to her parents and resented their need to push expectations on her. These expectations caused her

stress which probably had an influence on her binging and purging behaviours. These behaviours

also cause her to be hesitant about her relationship with her family in general.

Along with Dana’s parents, Joanie (Dana’s older sister) is no help to Dana’s self-esteem. There

have been several occasions where Joanie has used “fat shaming” terms to put Dana down. This

also leads to an ambivalent relationship with her sister.

Biological
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Genetics:

Compared to the general population, individual who have relatives with bulimia are 4 to

5 times more likely to develop an eating disorder. Fichter and Noegel did a study in 1989 that

studied bulimia nervosa via a twin study. When comparing monozygotic twins and dizygotic

twins, the monozygotic twin results showed significantly higher frequencies in eating disorders.

They found that dizygotic twins were less then three times as likely then monozygotic twins

“among females was 83.3% for monozygotic twins and 26.7% for dizygotic twins” (Fichter &

Noegel, 1989). These results speak to the importance of biological vulnerabilities for bulimia

nervosa.

Serotonin Dysregulation:

Individuals with Bulimia tend to have irregular levels of serotonin transporters (5-HTT)

and serotonin receptors (5-HT1a and 5-HT2a). When there is a decrease in availability of

serotonin transporters and 5-HT1a, there seems to be an association with anxiety levels in that

anxiety levels would increase. When there is a decrease in 5-HT2a receptor availability, there

seems to be a connection with novelty seeking which involves making impulsive decision,

overindulgence to reward cues, quick loss of temper, and avoidance of frustration. We assume

that if they have a high level of novelty seeking personality trait then they are less able to inhibit

certain behaviours such as binge eating for individuals with bulimia. A study done by Culbert,

Racine and Klump (2015) took individuals with bulimia and did neuroimaging to study levels of

serotonin “Neuroimaging data also point to altered serotonin receptor activity in several cortical

and limbic regions in women recovered from anorexia nervosa and bulimia nervosa, and these

serotonin receptor alterations have been associated with co-occurring features of eating disorders

(i.e., increased drive for thinness and harm avoidance)”. Based on this study there seems to be a
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correlation between serotonin levels and bulimic behaviours and emotions. It would then make

sense in Dana’s case that she would most likely be lacking in these serotonin transporters and

receptors, which might be demonstrated by her lack of control and her depression like symptoms.

Set Point:

The “set point” theory is the idea that in order to stay in good health your body has a

genetically pre-determined ideal weight and body temperature that it tires to sustain. This body

weight may not necessarily uphold the ideal shape one might want or that it not widely accepted

by the media. This is especially hard for bulimics to accept. As such they try to deviate from the

set point which can throw their health through a loop. Not only do they defy the set point by

eating way more then needed (binging) but they also deviate by throwing it up the food or using

laxatives (purging). Dana is no exception, she has demonstrated the unconscious deviation when

she ate until she felt she was going to explode and then purged all the food thereafter. Because of

her deviation from the set point she is causing her body to deteriorate. There are not a lot of

studies involving set point theory and bulimia however a study done by Elran-Barak and

colleagues (2015) could bring some insight into binging and purging behaviours. They wrote

“this study provides preliminary support for the restraint model as well as the possibility that

some dietary restriction behaviors, particularly eating few meals per day, may be associated with

increased rates of binge eating among individuals with AN-BE/P and BN” (Elran-Barak et.al.,

2015), which helps to demonstrate the spiraling effect that binging and purging has on each other

which can be related to the deviation from the set point.

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Psychological

Individuals with bulimia have a distorted sense of reality when it come to their body

weight and shape. This idea of distortion of one’s body leads to feelings of anxiety. In order for

them to feel less anxious they purge and in doing so lessen their anxiety levels. This process

creates a connection of negative reinforcement between purging and lower anxiety levels. Along

with the negative reinforcement there are other ways that increase someone’s risk of

participating in binging and purging behaviours. Dana had talked about her feelings of relief

when she was finished purging. She felt an aversive feeling towards her body shape and eating

which caused anxiety but when she purged herself there was a moment of relief where the

aversive stimulus was removed which lead her to create a connection through the negative

reinforcement.

Pearson and colleagues (2014) discuss a state-based pathway and a personality-based

pathway that also increase risk of bulimic behaviours. They proposed “The first is state-based:

the experience of negative mood, in girls attempting to restrain eating, leads to the depletion of

self-control and thus increased risk for loss of control eating. The second is personality-based:

elevations on the trait of negative urgency, or the tendency to act rashly when distressed,

increase risk, particularly in conjunction with high-risk psychosocial learning” (Pearson et.al.,

2014). One personality trait highly linked with bulimia is perfectionism, they refuse to accept

their body if they do not think it is 100% perfect. While Dana did not seem to display any sever

traits of perfectionism in other aspects of her life, there may be an underlying need for perfection

in her body image which could augment the need to binge and purge.

Treatment Plan:
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A possible treatment could be a form of cognitive-behavioural therapy (CBT) that targets

bulimics shame and self critical mind set. A study done by Kelly and Carter in 2013, showed that

high levels of self-criticism is linked to elevated eating disorder pathology (Kelly & Carter,

2013). They concluded that “Interventions that target the shame of self-critical patients might

therefore facilitate their recovery” (Kelly & Carter, 2013), therefore if you help to create a new

outlook, about one’s self, for individuals with bulimia, then they will be better able to self reflect

with a less negative view. CBT will be able to facilitate a positive resource that may be able to be

used by the individual with little help from a psychiatrist which can be beneficial because

bulimics and other with disorders need to learn to become self sufficient.

Individuals that suffer from bulimia most often also suffer from depression on depressive

like symptoms. In order to help these individuals prescribing them antidepressants could help

eliminate the depression which could help with later outlooks on other treatment. Carolyn

Dukarm (2005) evaluated medication effects on bulimics. When evaluating how effective the

antidepressants where she found “the effectiveness of antidepressants, specifically SSRIs, and

TCAs have demonstrated some reduction in the frequency of binge eating and purging, remission

rates (complete abstinence from bulimic symptoms) were low.3,4 In addition, CBT has

demonstrated only partial reduction of bulimic symptoms” (Dukarm, 2005). In some ways, the

SSRI’s and TCA’s seemed to be the best option however for best results a combination of the

two could possibly be more beneficial.

When you combined both CBT and medication you are treating the individual’s

depression, that is usually accompanied by low self-esteem that leads to binging and purging

behaviours, and you are also giving them the ability to cognitively work around their disorder

through new coping techniques via the CBT. Bowers and Andersen (2007) said “Antidepressant
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medications decrease depressive symptoms, improve mood, and may have a role in relapse

prevention. Additionally, SSRIs have demonstrated their usefulness in reducing binge frequency

and ending binge-purge behavior” (Bowers and Andersen, 2007), therefore if you combined the

SSRI’s with CBT then the outcome could probably last longer given that the individual will be

able to cope long after treatments have been completed. This idea was also suggested by Bowers

and Andersen, that although there is not a lot of information in this area given that bulimia itself

is not 100% understood, we maybe be able to assume that “Combining CBT and medication may

enhance the maintenance of therapeutic gains after hospitalization” (Bowers and Andersen,

2007).

Treatment for Dana should be the SSRI and CBT combination. Dana suffered from

depression like symptoms and would benefit from SSRI’s. In order for her treatment to last

longer I would suggest that she go to a therapist to help cope with her new regimen and do so

through CBT.
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References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders

(5th ed.). Washington, DC:Author.

Bowers, W. A., & Andersen, A. E. (2007) Cognitive-Behavior Therapy with Eating Disorders:

The Role of Medications in Treatment. Journal of Cognitive Psychotherapy: An

International Quarterly. Vol. 21, No.1, 2007

Clipson, C. R., & Steer, J. M. (1998). Bulimia Nervosa: The Self-Destructive Diet. Case Studies

in Abnormal Psychology. Boston NY. 97-72455. Retrieved from

https://lms.brocku.ca/access/lessonbuilder/item/33492337/group/PSYC3F20D01FW2016

MAIN/Essay/Bulimia%20Nervosa%20Essay%20Case.pdf.

Culbert, K. M., Racine, S. E., & Klump, K. L. (2015) Research Review: What we have learned

about the causes of eating disorders – a synthesis of sociocultural, psychological, and

biological research. Journal of Child Psychology and Psychiatry. Doi: 10.

1111/jcpp.12441.

Dukarm, C. P. (2005). Bulimia Nervosa and Attention Deficit Hyperactivity Disorder: A

Possible Role for Stimulant Medication. Journal of Women’s Health. Vol.14, No.4, 2005.

Elran-Barak, R., et.al. (2015). Dietary Restriction Behaviors and Binge Eating in Anorexia

Nervosa, Bulimia Nervosa and Binge Eating Disorder: Trans-diagnostic Examination of

the Restraint Model. ElsevierLtd. Doi: 10.1016/j.eatbeh.2015.05.012.

Fichter, M. M., & Noegel, R. (1989). Concordance for Bulimia Nervosa in Twins. International

journal of Eating Disorders. Vol.9, No. 3, 255-263.

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Kelly, A. C., & Carter, J. C. (2013). Why self-critical patients present with more severe eating

disorder pathology: The mediating role of shame. British Journal of Clinical Psychology.

Doi: 10.1111/bjc.12006.

Pearson, C. M., Riley, E. N., Davis, H. A., & Smith, G. T. (2014). Research Review: Two

pathways toward impulsive action: an integrative risk model for bulimic behavior in

youth. Journal of Child Psychology and Psychiatry. Doi: 10.1111/jcpp.12214.

Strober, M., & Humphry, L.L. (1987). Familial Contributions to the Etiology and Course of

Anorexia Nervosa and Bulimia. Journal of Consulting and Clinical Psychology. Vol 55,

No. 5. 654-659.