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Eating Disorders: Techniques for Treating Binging & Purging
Bulimia continuing education counselor CEUs

Section 18
Bulimia Nervosa, Part IV: Diagnosis and Treatment

CEU Question 18 | CEU Test | Table of Contents | Eating Disorders
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What Will Confirm a Diagnosis of Eating Disorders? Admitting the Problem
The first step toward a diagnosis is to admit the existence of an eating disorder. Often, the patient needs to be compelled by a parent or others to see a doctor because the patient may deny and resist the problem. Some patients may even self-diagnose their condition as an allergy to carbohydrates, because after being on a restricted diet, eating carbohydrates can produce gastrointestinal problems, dizziness, weakness, and palpitations. This may lead such people to restrict carbohydrates even more severely.

It is often extremely difficult for parents as well as the patient to admit that a problem is present. For example, because food is such an intrinsic part of the mother/child relationship, a child's eating disorder might seem like a terrible parental failure. Parents themselves may have their own emotional issues with weight gain and loss and perceive no problem in having a "thin" child.

Interview Tests
It is recommended that a supportive companion be present during part of the initial medical interview to offer additional information on the patient's eating history and to help offset any resistance or denial the patient may express. Various questionnaires are available for assessing patients.

Diagnosing Bulimia Nervosa
In spite of the prevalence of bulimia, in one study only 30% of Midwest family physicians had ever diagnosed bulimia in a patient. Younger and female physicians are more likely to detect bulimia. A physician should make a diagnosis of bulimia if there are at least two bulimic episodes per week for three months. Because people with bulimia tend to have complications with their teeth and gums, dentists could play a crucial role in identifying and diagnosing bulimia.

Diagnosing Complications of Eating Disorders
Once a diagnosis is made, physicians should immediately check for any serious complications of starvation. They should also rule out other medical disorders that might be causing the anorexia. Tests should include the following:

• A complete blood count.
• Tests for electrolyte imbalances. Low potassium levels indicate that the disorder is more likely to be accompanied by the binge-purge syndrome.
• Test for protein levels.
• An electrocardiogram and a chest x-ray.
• Tests for liver, kidney, and thyroid problems.
• A bone density test.

What Are the General Guidelines for Treating Eating Disorders?
Overcoming Resistance to Initial Treatment
The first major difficulty in treating eating disorders is often the resistance by everyone involved:

• The anorexic patient often believes that the emaciation is normal and even attractive.
• The bulimic patient may feel that purging is the only way to prevent obesity.
• Even worse, the anorexic condition may be encouraged by friends who envy thinness or by dance or athletic coaches who encourage low body fat.
• The family itself may deny the problem and be obstructive or manipulative, adding to the difficulties of treatment.
It is very important that the patient and any close friends and relatives be informed about the serious potential of these conditions and the importance of receiving immediate help.

Getting Rid of Unrealistic Expectations
Patients may drop out of programs if they have unrealistic expectations of being "cured" simply through the therapists' insights. Before a program begins, the following possibilities should be made clear:

• The process is painful and requires hard work on the part of the patient and family.
• A number of therapeutic methods are likely to be tried until the patient succeeds in overcoming these difficult disorders.
• Relapse is common but should not be greeted with despair. (In one study, about 90% of bulimic patients responded to treatments after six years.)

Although outcome in bulimia is generally more favorable than in anorexia, long-term studies are showing recovery in most people treated for anorexia.

General Treatment Approaches
Psychotherapies. All eating disorders are nearly always treated with some form of psychiatric or psychologic treatment. Depending on the problem, different psychologic approaches may work better than others. A recent study reported that patients at greater risk for not completing therapy are those with a history of childhood trauma (e.g., divorce, abuse). Drop-out rates were not related to the severity or duration of the disorder.

Medications. A number of medications may be valuable for these patients depending on the type of eating disorder, psychiatric state, and severity of the condition.

What Are the General Psychologic Approaches Used in Eating Disorders?
Eating disorders are nearly always treated with some form of psychiatric or psychologic treatment. Depending on the problem, different psychologic approaches may work better than others.

Cognitive-Behavioral Therapy
Cognitive-behavioral therapy (CBT) works on the principle that a pattern of false thinking and belief about one's body can be recognized objectively and altered, thereby changing the response and eliminating the unhealthy reaction to food. One approach for bulimia is the following:

• Over a period of four to six months the patient builds up to three meals a day, including foods that the patient has previously avoided.
• During this period, the patient monitors and records the daily dietary intake along with any habitual unhealthy reactions and negative thoughts toward eating while they are occurring.
• The patient also records any relapses (binges or purging). Such lapses are reported objectively and without self-criticism and judgment.
• The patient discusses the responses with a cognitive therapist at regular sessions. Eventually the patient is able to discover the false attitudes about body image and the unattainable perfectionism that underlies the opposition to food and health.
• Once these habits are recognized, food choices are broadened and the patient begins to challenge any entrenched and automatic ideas and responses and replaces them with a set of realistic beliefs along with actions based on reasonable self-expectations.

Dialectical Behavioral Therapy (DBT). This approach uses cognitive techniques but was developed specifically for people with borderline personality disorder. It is now showing promise for patients with bulimia. It employs four goals for the patient:

• Becoming aware of emotions.
• Regulating the emotions.
• Learning how to identify painful feelings.
• Learning how to relate to other people.

Interpersonal Therapy
Interpersonal therapy deals with depression or anxiety that might underlie the eating disorders along with social factors that influence eating behavior. This therapy does not deal with weight, food, or body image at all.

The goals are the following:

• To express feelings.
• To discover how to tolerate uncertainty and change.
• To develop a strong sense of individuality and independence.
• To address any relevant sexual issues or traumatic or abusive event in the past that might be a contributor of the eating disorder.

Studies generally report that it is not as effective as cognitive therapy for bulimia and binge-eating, but may be useful for some patients with anorexia. The skill of the therapist plays a strong role in its success.

Family Therapy
Because of the major role family attitudes play in eating disorders, one of the first steps in treating the patient with early-onset anorexia is to also treat the family. Family therapy is certainly useful for both younger and older patients.

If the patient is hospitalized, experts recommend that family therapy start after the patient has gained weight, but before discharge. It should usually continue after the patient has left the hospital.

The feelings of intense guilt and anxiety that caregivers experience are probably similar to those produced by living with a person who is suicidal. An over-involved parent may even support the patient's eating disorder for various reasons:

• Some parents may be afraid of releasing some underlying anger or grief directed at the patient.
• Other parents may identify with the goal of thinness and not even perceive that their child is unhealthily underweight.
In such cases, it is extremely important that the family fully understand the danger of this disorder and that they are collaborating in their child's illness, or even death, by encouraging this state.
- Eating Disorders; Eating Disorders: Anorexia and Bulimia; (A.D.A.M.); 2002.

Personal Reflection Exercise #4
The preceding section contained information about diagnosis and treatment of bulimia nervosa. Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Cotter, E. W., & Kelly, N. R. (2018). Stress-related eating, mindfulness, and obesity. Health Psychology, 37(6), 516–525.

Gunstad, J., Sanborn, V., & Hawkins, M. (2020). Cognitive dysfunction is a risk factor for overeating and obesity. American Psychologist, 75(2), 219–234.

Luo, X., Nuttall, A. K., Locke, K. D., & Hopwood, C. J. (2018). Dynamic longitudinal relations between binge eating symptoms and severity and style of interpersonal problems. Journal of Abnormal Psychology, 127(1), 30–42.

Online Continuing Education QUESTION 18
What are the four goals of Dialectical Behavioral Therapy with bulimic clients? Record the letter of the correct answer the CEU Test.

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