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Section 2
Depression in Bulimic Clients

CEU Question 2 | CEU Test | Table of Contents | Eating Disorders
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In the last section, we discussed four motives clients have for binging.  These four binging motives included: avoiding failure; handling stress; postponing sexual relations; and eliciting attention

In this section, we will examine three manifestations of depression in binging and purging clients.  These three manifestations of depression include:  guilt; worthlessness; and social withdrawal.

Clients diagnosed with bulimia nearly always enter into treatment manifesting at least some symptoms of depression. Many feel quite desperate at times. They hate what they’re doing, they despise themselves, and they can see little, if any, prospect of their situation improving.  About five percent of clients who are diagnosed with bulimia have taken an overdose of pills in a suicide attempt. Sometimes, once the binge eating comes under control, the depressive symptoms disappear. In other cases, the depression is acting independently of the eating disorder and requires further treatment. 

3 Manifestations of Depression

♦ Manifestation #1 - Guilt
The first manifestation of depression in bulimic clients is guilt.  This guilt primarily precipitates from the shame resulting from binge-eating and vomiting.  Most bulimic clients understand that their eating habits are socially and mentally unacceptable, which is a far cry from the other major eating disorder, anorexia.  In one group of bulimic clients polled about their depressive symptoms, ninety-four percent reported feelings of guilt.  These feelings of guilt will often confirm or augment the client’s already established belief in his or her worthlessness.

Cindy, age 18, was actually excited about discovering vomiting as a way of relieving her binging symptoms. Cindy stated, "It was such a burden off my shoulders to realize that I didn’t have to feel so bloated or fat after every episode!  But after a while, I started eating more so I would have to vomit more. I felt like a freak, always running to the bathroom and never hanging around with my friends. I felt like I was doing something wrong, something I shouldn’t be doing!" 

The ever increasingly severe cycle of binging and purging can only worsen a client’s depression.  Although clients may use vomiting or laxatives as a means to compensate for their overeating, they still experience feelings of guilt and shame.  We will discuss the technique I used to treat Cindy, called "Exploding with Exaggeration", later on in the section.  Think of your Cindy.  What feelings of guilt is he or she harboring? 

♦ Manifestation #2 - Worthlessness
The second manifestation of depression in bulimic clients is feelings of worthlessness. At the core of many clients’ depression is a strong belief that he or she is a failure. When the client does not succeed in following the strict rules of dieting, he or she begins to develop a sense that nothing else is worthwhile either. Their image and body shape have already become an all-consuming obsession, and the inability to achieve the almost impossible goal of perfection leaves many clients with a feeling of disappointment in themselves. About seventy-four percent of bulimic clients report feelings of worthlessness. 

Bethany, age 17, had been a talented gymnast since the age of four. Her ambitious personality and rigid self-discipline, however, had begun to take a toll on her eating behaviors.

Bethany stated, "I have been driven since I was very young. Some of that was the encouragement of my coaches and parents, but most of it was myself!  By the time I was 16, I realized that I didn’t really know how to interact with other normal people around me. Gym was my life, and high school didn’t really conform to the rules of the gym!  I felt out of control and I started eating more. I was so afraid of gaining weight and ruining my routine that I started using laxatives and diuretics to maintain my weight. I feel like a complete waste of air!  All my hard work down the drain because I couldn’t socialize in the hall way." 

Because Bethany already had had high standards for herself prior to the onset of her eating disorder, the inability to stop herself caused an even more acute feeling of failure and worthlessness. Think of your Bethany. What personality traits could have contributed to her feelings of worthlessness?

♦ Manifestation #3 - Social Withdrawal
In addition to guilt and worthlessness, the third manifestation of depression in bulimic clients is social withdrawal. Often, this social withdrawal results from a loss in self-confidence which subsequently arises from feeling unable to eat in company. Also, clients may harbor the belief that their body shape and weight are socially unacceptable and avoid company if possible. As we will discuss in a later section, social gatherings may be a trigger for a binge as the stress of performing for the masses becomes too much of a strain. 

Craig, age 23, had completely withdrawn from his previous group of friends. He stated, "I don’t feel like myself anymore! I can’t seem to be happy enough to go out and be a normal person.  I’m never happy with how I look and I’m always comparing myself to other people. Not to mention the mood swings! I can’t seem to find ground zero and that absolutely frustrates me!" 

Think of your Craig.  How has he or she withdrawn him or herself from social interaction?

♦ 2-Step Cognitive Behavior Therapy Technique:  Exploding with Exaggeration
To help clients like Cindy, Bethany, and Craig, I ask that they try the "Exploding with Exaggeration" CBT exercise. 

--Step 1: I asked all three clients to think of their worst-case scenario regarding their weight.  For instance, Cindy worried that her parents would find out about her binging. Bethany had been worried that she would become too overweight to do gymnastics; and Craig worried that his friends would find him too repulsive to socialize with. 

--Step 2: Then I asked them to exaggerate their fears to such proportions that the idea of the worry became ridiculous.  Bethany pictured herself becoming so large that she had to be wheeled out on a forklift to the bars, which then broke as soon as she laid her hands on them.  Bethany then stated, "I thought it was actually so funny that I told my best friend, and we both had a laugh about it!  It feels really good to be able to laugh at your fears!"  By replacing actual anxiety about weight with exaggerated worries, the client can better assess his or her reality. 

Think about your bulimic client.  Could he or she benefit from the CBT technique "Exploding with Exaggeration"?

In this section, we discussed three manifestations of depression in bulimic clients.  These three manifestations of depression included:  guilt; worthlessness; and social withdrawal.

In the next section, we will examine three concepts related to self-image distortion in bulimic clients.  These three concepts related to self-image distortion in bulimic clients include:  weight-obsessive thoughts; overestimating size; and unrealistic standards.

Peer-Reviewed Journal Article References:
Fischer, S., & Peterson, C. (2015). Dialectical behavior therapy for adolescent binge eating, purging, suicidal behavior, and non-suicidal self-injury: A pilot study. Psychotherapy, 52(1), 78–92.

Levinson, C. A., Zerwas, S., Calebs, B., Forbush, K., Kordy, H., Watson, H., Hofmeier, S., Levine, M., Crosby, R. D., Peat, C., Runfola, C. D., Zimmer, B., Moesner, M., Marcus, M. D., & Bulik, C. M. (2017). The core symptoms of bulimia nervosa, anxiety, and depression: A network analysis. Journal of Abnormal Psychology, 126(3), 340–354.

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.

Lowe, M. R., Marmorstein, N., Iacono, W., Rosenbaum, D., EspelHuynh, H., Muratore, A. F., Lantz, E. L., & Zhang, F. (2019). Body concerns and BMI as predictors of disordered eating and body mass in girls: An 18year longitudinal investigation. Journal of Abnormal Psychology, 128(1), 32–43.

Pearl, R. L., Wadden, T. A., Bach, C., Gruber, K., Leonard, S., Walsh, O. A., Tronieri, J. S., & Berkowitz, R. I. (2020). Effects of a cognitivebehavioral intervention targeting weight stigma: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 88(5), 470–480.

Tasca, G., Balfour, L., Ritchie, K., & Bissada, H. (2007). Change in attachment anxiety is associated with improved depression among women with binge eating disorder. Psychotherapy: Theory, Research, Practice, Training, 44(4), 423–433.

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