Case Study Analysis of Bulimia Nervosa

Brandy is a female college student who suffers with bulimia nervosa at 21 years old. Brandy’s constant anxiety about how she appears to others results in extreme levels of stress that she copes with by binging food uncontrollably, which are characteristics of bulimia nervosa. She also displays other bulimic traits like purging after her binge sessions multiple times a day in fear of gaining weight even though her body weight appears to be good. This research paper aims to discover the etiology of her disorder and the best method to treat it.

Brandy’s Background

Throughout all of Brandy’s life, she struggled to maintain the high standards set upon her by her parents. She believes the reason why they expect so much of her is because of how disappointed they are with her older sister Sarah, who did poorly in school, became overweight, and rebelled against the family. Brandy thinks that they want to remedy the failure of their parenting by making Brandy more successful than Sarah. This can be seen when Brandy was in middle school and her parents forced her to serve in their church, take advanced classes, and be on the track team. Brandy did not want to disappoint her parents like Sarah did and she strived to be the best in these activities so her parents would be proud. She stressed about being perfect in everything she did and felt anxiety when she made a minor mistake like receiving an A- on an assignment or placing second in track, causing her to think her parents wouldn’t love her anymore. Brandy was reinforced for her perfectionist behavior because her parents would constantly compare her to Sarah and say how proud they were of her whenever she reached a milestone. Brandy’s intensive focus on being perfect for her parents caused her so much stress that she could barely handle it. The opportunities to be impress them increased as she got older.

Causal Research

The etiological factor for Brandy’s bulimia nervosa is the perfectionist trait she acquired in her childhood while trying to please her parents. This caused her to stress enormously about how she appeared to her parents and later to others which transferred to almost all the areas of her life as she got older. The stress from trying and failing to be perfect caused her to binge food to relieve it, which she then followed by purging so that her health could stay perfect too. These first two empirical studies examine and support how the perfectionist trait can lead to bulimia nervosa.

The first etiological study was conducted by Bardone-Cone, Boyd, and Weishuhn (2009) which was determined to examine the relationship of maladaptive and adaptive perfectionism to bulimic symptoms in African American women that were college students. Another goal of this research study was to use an interactive model to discover how different levels of perfectionism and perceptions of weight interacted with each other and how they affected bulimic symptoms. To pursue both of these goals, the researchers recruited 97 African American women from a Midwestern university, who most of which were halfway through their bachelor’s degree and on average 19 years of age. The study was designed by having the 97 women take two questionnaires that were separated by 5 months, although only 70 of the original group took the second one (Bardone-Cone, et al., 2009). The questionnaires were designed to determine the traits of perfectionism and impulsivity within each participant, along with other behaviors that were linked to eating and substance abuse (Bardone-Cone, et al., 2009). The first test was used to determine the status of bulimic symptoms in the participants and the second test to evaluate and predict the change in their symptoms he measures used to test the goals of this research were the participants complete demographics, levels of maladaptive and adaptive perfectionism, perceived weight status, BMI, and bulimic symptoms. The results of this study showed that it was only maladaptive perfectionism that was linked to bulimic symptoms and increased the probability that those symptoms would worsen, not adaptive perfectionism. The study also highlighted the detrimental effects of maladaptive perfectionism mixing with the woman’s perception of being overweight, which predicted in increase of developing more extreme bulimic symptoms the more she thought she was overweight. This shows that perfectionism, at least the negative form of it, plays a crucial role in the chances of developing bulimia nervosa. Another discovery Bardone-Cone, et al., (2009) found was that higher levels of BMI interacting with the maladaptive perfectionist women also contributed to bulimic symptoms, but they concluded that perceptions of being overweight mixing with maladaptive perfectionism was more consequential. Lastly, Bardone-Cone, et al., (2009) conclude that in order to decrease bulimic symptoms for African American women, it is critical to counsel them on their negative perceptions of weight but more importantly on reducing their maladaptive perfectionism, which is considered a major maintenance factor for eating disorders among most women and is the preferred target for counseling.

The second etiological study was completed by Egan, Watson, Kane, McEvoy, Fursland, and Nathan (2013) which was determined to examine how anxiety is the mediator between the empirically strong relationship of perfectionism and eating disorders, such as bulimia nervosa, anorexia nervosa, and other eating disorders not specified. Egan, et al., (2013) conducted this experiment after examining that perfectionism plays a huge role in being a risk and maintenance factor for eating disorders, based on the large amount of empirical research they provided in their study. To determine this and how anxiety plays a part in this strong relationship, they recruited 370 patients that were associated with a specialist service for eating disorders in Australia, 18% of which were diagnosed with anorexia nervosa, 41% with bulimia nervosa, and 41% with eating disorders not specified. Those that were excluded from the study were people who did not meet the criteria for an eating disorder by the DSM-IV standards and those who were diagnosed with binge eating disorder (Egan, et al., 2013). The age of these participants was between 16 and 71 years old, with the average being 25.04 years (Egan, et al., 2013). The design of the study was for the participants to take eating disorder assessments from clinical psychologists for 2-3 sessions. Included in the assessments were clinical interviews, self reports, Eating Disorder Examinations (EDE), Mini International Neuropsychiatric Interviews (MINI), and a measuring of the participants body mass index. The measures used for this study were diagnostic interviews like the MINI and EDE which assessed, perfectionism, anxiety, eating disorder pathology, objective binge eating, and purging behaviors in the participants (Egan, et al., 2013). After comparing the results of the study in partially and fully mediated models used to determine the size of anxiety’s role, and ultimately choosing the partially mediated model’s data as evidence over the other, the results of the study showed that the strong relationship between perfectionism and eating disorders does have a partial role played by anxiety in mediating the two instead of a larger one.

Egan, et al., (2013) conclude that treating perfectionism and anxiety is important for effectively treating eating disorders, and by treating perfectionism specifically it can reduce not only eating disorders like bulimia nervosa but also disorders related to anxiety and eating pathology. Egan, et al., (2013) come to this conclusion even though anxiety was their focus for this research, which proved to be a small factor for eating disorders, and instead they found more on how much perfectionism plays a role in both eating and anxiety disorders. The researches Egan, et al., (2013) conclude that perfectionism was much more significant than expected and that it is a powerful transdiagnostic factor for many disorders, which their research proves why perfectionism is such a big contributor to bulimia nervosa.

Treatment Research

The treatment of choice for curing bulimia nervosa is Cognitive Behavioral Therapy, also known as CBT. This treatment is more effective than any type of medication that has been used to treat eating disorders, like antidepressants, and it is especially successful for bulimia nervosa that results in a better chance of improvement and possibly freedom from the disorder. According to the researchers Waller, Gray, Hinrichsen, Mountford, Lawson, and Patient (2014), CBT is comprised of three main areas when treating this disorder: education on the disorder, cognitive therapy, and coping strategies. For education, it focuses on teaching the physical consequences of binging and purging, ineffectiveness of purging techniques, bad effects of dieting, and a solid meal plan that has nutritious food every three hours for about five to six meals (Waller, et al., 2014). For cognitive therapy, it aims to correct highly dysfunctional thoughts, fix incorrect beliefs about body weight and shape, and restructure the view on eating since it is a huge contributor to the disorder.

Lastly, for coping strategies it focuses on learning how to resist the impulse to binge and the immediate drive to purge. This last stage is characterized by targeting the stressful cues that trigger binge eating and dealing with the anxiety and depression that results from the binge in order to prevent the impulse to purge (Barlow, et al., 2018). These stages are addressed in around 20 hour long sessions, which can be increased or decreased depending on the improvement rate of the patient (Waller, et al., 2014). These next two research studies will analyze CBT and show how effective it is in treating bulimia nervosa.

The first treatment study was conducted by Waller, Gray, Hinrichsen, Mountford, Lawson, and Patient (2014) which was determined to examine whether or not the effectiveness of using cognitive behavioral therapy (CBT) to treat bulimia nervosa in research trials can be transferred over to everyday clinics for the same results. Waller, et al., (2014) conducted this study because the evidence for CBT working on those with bulimia nervosa had only come from research studies that were highly controlled, specialized, and funded, which made them doubt how generalizable those findings were. The number of participants for this study was 78 women who suffered with bulimic disorders, 55 of which had bulimia nervosa and 23 had eating disorders not otherwise specified (EDNOS) but that had bulimic behaviors like purging and binging. It is also important to note that 9 of the women were taking antidepressants before undergoing CBT and a large amount of the participants had a comorbidity with other disorders. The average age of the women was 27.8 years.

The design of the study was for the women to undergo CBT, take eating pathology and depression assessments, and to journal the amount of times they binged and purged throughout the treatment. For CBT, Waller, et al., (2014) issued 20 supervised one hour CBT sessions, the average being 19.2, with experienced clinical psychologists that involved cognitive restructuring, education on their behavior and the disorder, behavioral experiments to fix coping strategies, a change in diet, and addressing the comorbidities they suffered once they began to improve. The measures used for the study were the Eating Disorders Inventory, Beck Depression Inventory, and CBT treatment with an analysis of the participants recovery of bulimia nervosa. The results of the study by Waller, et al., (2014) agreed with their hypothesis that CBT was an effective measure of treatment for bulimia nervosa and other forms of eating disorders in both a clinical practice and a research facility. They showed that in everyday clinical settings compared to research studies, CBT was just as effective for bulimic symptoms with a very low drop out rate, only half of the participants were remissioned, and there was significant reduction of eating disorder characteristics and depression. They also showed that through CBT, the participants improved in their mood, eating perceptions and behavior (Waller, et al., 2014).

However, Waller, et al., (2014) do note that the weakness of this study was that the CBT administered to the participants was done by clinicians who were specialized in eating disorder pathology and had high levels of training for its treatment. The researchers conclude that this, along with no control group and therapy validation to determine if clinicians were actually administering CBT, is due to the nature of the trial and that there was little they could do to fix it. Despite these limitations, their research study helps to solidify CBT as an effective treatment for bulimia nervosa regardless of where it is administered.

The second treatment study was conducted by Peterson, Berg, Crosby, Lavender, Accurso, Ciao, Smith, Klein, Mitchell, Crow, and Wonderlich (2017) which was determined to observe and compare how both Integrative Cognitive-Affective Therapy (ICAT) and Cognitive Behavioral Therapy-Enhanced (CBT-E) indirectly affected patients with bulimia nervosa. To compare which one was better for treating bulimia nervosa, Peterson, et al., (2017) assessed how both treatments impacted the patients emotional regulation, coping strategies, and view of themselves. In order to test this, Peterson, et al., (2017) recruited 80 participants who were on average 27.3 years old, had a BMI that was around 23.9 kg, and almost all of them were Caucasian females. They were acquired from communal and clinical environments in North Dakota and Minnesota, of which 72.5% of them were diagnosed with bulimia nervosa and 27.5% had bulimic symptoms that did not meet the full criteria of the DSM-IV for bulimia nervosa. The study was designed to place the participants randomly in either 21 sessions of CBT-E or ICAT, which lasted 50 minutes each and was taken in the course of 17 weeks. There was four methods used throughout the study to assess the participants as they went through either treatment.

The first method was the Eating Disorder Examination (EDE), an interview given by a researcher who was both trained to give it and blind to what group the interviewee was in, that determines the severity of the participant’s bulimic symptoms which Peterson, et al., (2017) used at the end of their treatment and in the 4 month follow up. The second method used was the Difficulties in Emotion Regulation Scale (DERS), a scale that participants used to indicate their emotional regulation difficulties, which Peterson, et al., (2017) used in the beginning, middle, and end of treatment. The third method used was the Structural Analysis of Social Behavior Intrex questionnaire that showed changes in both positive and negative self directed behaviors, which Peterson, et al., (2017) used in the beginning, middle, and end of treatment. The last method used was the Selves Interview, which determined how the participants viewed their ideal self and how others want them to be, which Peterson, et al., (2017) used in the beginning and end of treatment.

The results of the study show that there were no significant differences in the indirect effects on the participants psychology with ICAT or CBT-E. The study also showed that the future outcome of a patient’s bulimia nervosa while being treated by ICAT or CBT-E can be determined by how they’ve changed in emotional regulation and coping strategies by the middle of their treatment. Lastly, the study concluded that the outcomes were similar for both treatments and they proved to be equally effective in treating bulimia nervosa.

References

1. Bardone-Cone, A. M., Weishuhn, A. S., & Boyd, C. A. (2009). Perfectionism and bulimic symptoms in African American college women: Dimensions of perfectionism and their interactions with perceived weight status. ​Journal of Counseling Psychology​, ​56​(2), 266–275. ​https://doi.org/10.1037/a0015003
2. Barlow, D. H., Durand, V. M., Lalumiere, M. L., & Hofmann, S. G. (2018). ​Abnormal psychology: An integrative approach​ (8th ed.). Toronto, ON: Nelson Education.
3. 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
4. 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
5. 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>