Bulimia

Barbara G. Bauer, Wayne P. Anderson, Robert W. Hyatt

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135059606
• Edition: 1
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Bulimia: A Book for Therapist and Client, provides pertinent information to demystify the treatment process, to give clients more complete understanding of their eating disorder and to assist practitioners who treat clients with Bulimia. Questions answered include what are the causes, the primary identifying feature, medical complications, the team of professionals who can help and the process and treatment.

CHAPTER 1

EPIDEMIC OF THE 80s

The authors who work in three different settings have been impressed with the marked increase in recent years of clients with eating disorders. We have been at self-help meetings for persons with eating disorders where as many as 150 have attended, some frantic with fear because their behavior was out of control, and others disturbed because they were being asked to change behavior which they saw no need to modify. The extent of the problem nation wide is difficult to measure, partly because of different opinions as to the definition of an eating disorder. If we use periodic binging or gorging on food as a criteria, estimates are that as many as 67% of the female population have an eating disorder (Polivy & Herman, 1985). With a more restrictive definition Halmi, Falk, and Schwartz (1981) found that 13% of their sample of college students had all the major symptoms of bulimia. Of the 13% who reported symptoms of bulimia, 87% were women. Even if we are cautious and take the most conservative estimations in the literature as to the extent of this problem, 4% of college aged women are victims. This means that the number of people who are suffering from this disorder is still very large.

What is Bulimia?

In this book we will use the definition for bulimia developed by the American Psychiatric Association and published in the Diagnostic and Statistical Manual of Mental Disorders (third edition) in 1980. Their criteria for bulimia:

A.  Recurrent episodes of binge eating (rapid consumption of a large amount of food in a discrete period of time, usually less than two hours).

B.  At least three of the following:

1.  consumption of high-caloric, easily ingested food during a binge

2.  inconspicuous eating during a binge

3.  termination of such eating episodes by abdominal pain, sleep, social interruption, or self-induced vomiting

4.  repeated attempts to lose weight by severely restrictive diets, self-induced vomiting, or use of cathartics or diuretics

5.  frequent weight fluctuations greater than ten pounds due to alternating binges and fasts

C.  Awareness that the eating pattern is abnormal and fear of not being able to stop eating voluntarily.

D.  Depressed mood and self-deprecating thoughts following eating binges.

E.  The bulimic episodes are not due to Anorexia Nervosa or any known physical disorder.

Almost unheard of 10 years ago, bulimia has become a major social concern; so much so that an explosion of articles and books on the topic has occurred (e.g., see the list of references at the end of this book). So many women are seeking treatment for this disorder that the first author, who is in private practice, sees almost exclusively women with bulimia. The literature in the field often gives conflicting impressions as to the cause of this behavior and how it can best be treated. One group of authors tells us that bulimia is mostly caused by biologically based depression, probably genetically inherited, and that psychoactive drugs are the best treatment. Another group of writers defends the position that bulimia is a behavioral problem and that behavior modification will work best in curing it. Still others believe that bulimia is an addiction and should be treated as such. Our own experience based on work with our clients, investigation of case records, and study of the literature suggests that none of these explanations are complete in and of themselves. We feel another more integrative look needs to be taken at those factors that cause bulimia and at those treatment methods that produce long term changes in client behavior. In this book these issues are presented so therapists will gain guidance in dealing with clients with bulimia, but in addition it is written so that clients can read it to gain more knowledge about themselves and the treatment process.

What Causes Bulimia?

Three major factors underlie our theory of why people develop bulimia:

1.  The stress in our culture on weight control. In writing this book we have come to the conclusion that perhaps the disorder we should be trying to cure is America’s preoccupation with dieting. As a nation we have become almost schizophrenic in our treatment of food. Our ads encourage people to eat, we have richness of choice, the prices are cheap in comparison with other nations, we are, in short, a nation where becoming overweight is easy. Within seconds of being enticed to eat we can be confronted with the dangers of overweight, or with encouragement to be slim. The encouragement is coupled with a new diet or a new pill to relieve hunger. This worship of thinness is a major factor in creating bulimia.

2.  The cognitive control of the body’s natural need for food is limited in most people. People with anorexia may be an exception, but people with bulimia are not. The semi-starvation diets on which women with bulimia place themselves lead to problems with the innate control mechanisms which attempt to keep body weight within certain limits. When the cognitive controls break down bulimic behavior results.

3.  Not all people will feel the need to push their physical limits to the same extent. A certain type of personality and temperment, inherited perhaps from the family, will need to be present. The personalities of these individuals will have developed in the context of certain family and social structures. Those individuals who have the appropriate (inappropriate?) personality characteristics and who wish to be thin will be risking development of bulimic behavior.

All three of these factors must be present to some extent for the condition to develop. In the following chapters we will explore at some length these three factors. More importantly we present a structure for treatment with concrete suggestions of how to handle both the general problems these clients present to the therapist and the specific problems that arise with special cases. Our solutions are not easy ones to apply, and we have found no magic road to helping these clients. Our experience is that treatment takes time and involves working on a wide variety of family attitudes, and personal problems and necessitates teaching clients (patients) more effective ways of coping with their feelings and the stresses in their lives.

The case of Jane provides us with examples of many of the features of bulimia that we will be discussing in this book. We feel this case provides an overview of experiences and attitudes of a fairly typical client who seeks therapy for the treatment of bulimic symptoms.

Case of Jane

Jane comes from a family of professionals. Her father has a Ph.D. in biochemistry and her mother is working on her Ph.D. in the same field. Jane has completed a bachelors degree in geology and is considering graduate school.

Jane is the middle child of three children. She was born just ten months after her older sister. From the time she was little, Jane can remember being told she came too soon after her sister was born and how hard this was on her mother. She remembers feeling guilty over this as a little girl and wondering if she was wanted in her family. She states that her mother was always very occupied with her sister who was very timid and had some minor health problems and that her brother was “Dad’s boy” but that she never felt that she fit into the family very well.

Jane describes her mother as being very rational and intellectual. “I can never remember being hugged by my mother. She showed her caring by doing things for us like driving car pools and cooking.” Her father was very distant. “He did not become involved with me until high school when I became anorexic.”

Jane remembers her eating disorder as starting during the second year of high school. She returned to school after the summer vacation and saw the coach for whom she had run track the previous year. He made a comment that she wouldn’t be able to run as fast this year since she had put on a few pounds over the summer. Jane was crushed by his remark and vowed to diet. She continued to lose weight until she reached 89 pounds. She was hospitalized by the family’s pediatrician on a general pediatrics ward. No therapy was done. Her weight was restored to 100 pounds and she was released. For the next two years, Jane alternately gained and dieted with her weight fluctuating by ten or more pounds.

Jane developed bulimia when she went to college. She reports feeling very pressured by the work load in college and the emphasis on weight and attractiveness that was so prevalent in the sorority to which she belonged. She began self-induced vomiting in an attempt to lose five pounds. Jane thought she could stop vomiting at any time and was shocked to find that she could not break the cycle on her own.

When she first came to this therapist, Jane was vomiting 2 to 3 times a day. She rarely binged on large amounts of food but could not tolerate even a normal meal in her stomach. She used no laxatives, diuretics, diet pills, or other drugs. She exercised by running two miles three times a week. Her weight had stabilized at 105. She was 5’2” tall. Jane reported difficulty getting to sleep at night and had developed the habit of drinking one to two shots of whiskey to help her fall asleep.

Session 2. Jane talked about her feelings toward her family. Last Christmas, her sister talked to the family on the phone and announced that she no longer wished to be contacted by them. She has not been in contact with them since that time. We discussed the anger someone must feel to literally divorce her family. Jane cried and stated how hurt she was by this and how she felt she must make up for the hurt her sister caused her parents and be as good as possible so that she would not hurt them too.

Session 3. Today Jane talked about her relationships with men. She commented that she always seemed to lose herself in the relationship. When asked what she meant, Jane explained that she becomes so busy trying to be exactly what she thinks her boyfriend wants her to be that she loses touch with any wants or needs she may have. Jane has a pattern of dating men who are very demanding and critical. Her current boyfriend knows of her bulimia and attempts to “help” Jane by threatening her, physically restraining her after eating, and telling her how much her behavior upsets him.

Session 4. Jane came in depressed today. She was teary-eyed from the beginning of the session and sat slumped in her chair. She could not identify a cause for her sadness but said she had been feeling very down for several days. The therapist asked Jane to describe the physical sensations in her body that were connected with the depression. “It is an emptiness inside like catacombs—winding and dark and not leading anywhere.” The therapist had her close her eyes and go into the catacombs and try to find the part that was hurting. She reported it was like when she was growing up and her mother was not there for her. The therapist instructed her to light a candle in the catacombs and find the child. When she had done this she was encouraged to comfort the child, tell her that she loved her, and slowly lead her to a safe place where there was sunlight and warmth. The therapist told Jane that she was now the caring adult she had always needed as a little girl. When Jane opened her eyes, she reported feeling very tired but calm and no longer sad.

Session 5. Jane wanted to talk about her future today. She realizes that she has never made a career decision for herself. “I majored in journalism first because that’s what my boyfriend in high school went into. I switched to geology because that is what my next boyfriend was majoring in. Lately I have been leaning toward chemistry but I think I am just following my parents now.” The therapist asked Jane about past experiences she remembered as pleasurable and rewarding. Jane described two things with obvious enthusiasm: when she had spent a semester working in a pre-school and when she had volunteered as an aid in a nursing home. It was pointed ouf that both of these activities involved much interaction with people. Jane stated the appreciation and acceptance by the children and nursing home residents made her feel very good about herself. Arrangement was made for Jane to take vocational interest tests.

Session 6. Jane reported having a difficult week with her roommate. The roommate’s boyfriend had moved in with them without Jane’s permission. Jane stated that she did not like having him there but felt guilty because she was unhappy with the situation. The therapist and Jane discussed her need to please everyone at all times. This lead to a discussion of how uncomfortable Jane is with both her own anger and the feeling that someone is angry at her. Jane and the therapist discussed several alternative ways she might approach the roommate with her dissatisfaction.

For Whom Is This Book Intended?

For therapists, clients like Jane have become common place. By taking a broad view on causes and treatment from the points of view of psychology, medicine, and nutrition we hope that we can help professionals working in this area increase their ability to help individuals with this disorder. We also have written this book with intelligent lay readers in mind so that clients, their parents, and spouses can read it with profit. This book is not intended, however, as a self-help manual, and we encourage individuals with eating disorders to seek professional help.

Do Men Have Bulimia?

Up to this point in our discussion we have been referring to him and her, however, in the rest of the book whenever we are discussing bulimia we will refer to she/her. In the studies which are cited in this book, the reader will soon find that women are primarily the ones who develop symptoms of bulimia. Overall, the estimate is that women make up 90 to 95% of the population with this disorder. As we discuss the pressures in this culture for women to be thin and the personality dynamics of the families from which these women come, one can more clearly understand why women are the primary victims. Men with similar backgrounds usually respond with a different set of problems, drug abuse, work-aholism, or perhaps excessive exercise.

In summary the disorder of bulimia, which strikes mainly young women, is on the rise. Besides the cultural and family factors which primarily influence women, we will look at a number of other general factors such as biological and emotional factors which play a role in the development of this disorder. Therapy issues and stages will be described including specific techniques the therapist might use and the clients’ reactions and role in the therapy process.

CHAPTER 2

MEDICAL ASPECTS OF BULIMIA

The aim of the current chapter is to acquaint the reader with the clinical syndrome, medical complications, and medical treatment of bulimia. The evaluation of a client with an eating disorder should involve a multidisciplinary team approach. This should include a mental health professional to assess psychological and family status, and to provide individual, group, and family therapy as indicated. The team also should include a dietitian to evaluate nutritional status and needs and to offer assistance in establishing optimum nutrition to the patient and her family. Involvement of a health care provider, usually a physician or a physician-nurse team is necessary for appraisal of medical status, evaluation of complications, and direction of appropriate medical therapy.

A physician’s or health care provider’s first contact with a client with an eating disorder will probably stem from one or more medical complications. Most of the medical complications of bulimia result from behaviors practiced by the individual with the intention of losing weight or avoiding weight gain, including intentional malnourishment, binge eating, self-induced vomiting, cathartic abuse (emetic or laxative), diuretic abuse, and strenuous exercise. Since the client will not usually volunteer that she has an eating disorder, or associate the medical problem as a complication of bulimia, the physician or health care provider must be aware of the clinical conditions characteristic of bulimic syndro...