Eating disorders (EDs) are complex biopsychosocial disorders that affect individuals of all demographic categories. EDs have the highest mortality rate of any mental illness due to the high risk of medical complications and suicidality (National Eating Disorder Association, n.d.). As many as 30 million individuals suffer from EDs in the United States and 1.5% of the female population meets the DSM-5 diagnostic criteria for bulimia, an ED marked for its binging and purging behaviors (National Eating Disorder Association, n.d.; National Association of Anorexia Nervosa and Associated Disorders, n.d.). EDs are covert disorders and there is still a great deal of mystery surrounding how they develop and the best ways to prevent and intervene with vulnerable populations. EDs are all-encompassing illnesses, which impact a person’s daily functioning including physical and mental health, social relationships, work or school and other aspects of a person’s life. Despite the recent surge in body positive movements, more and more restaurants display calorie counts, fashion company executives claim their clothing is not meant for ‘thicker’ individuals, people are praised when losing weight even if they do not need to and Photoshop is as rampant as ever. This paper will focus largely on bulimia, however, certain aspects of the assessment, impact and interventions can be applied to anorexia and related disorders. Unfortunately, EDs are not going away anytime soon and with the high incidence and prevalence rates, it is of the utmost importance that clinicians obtain a better understanding of the overarching dynamics.
Located under Feeding and Eating Disorders in the DSM-5, bulimia has three essential features: recurrent binge eating episodes, subsequent purging or inappropriate behaviors to avoid weight gain and self-evaluation influenced by body weight and shape (American Psychiatric Association, 2013). Individuals with bulimia also tend to share some personality traits. A few of these characteristics include severe impulsiveness, an inappropriate drive for thinness not relative to current body mass index, a fear of maturity and responsibilities, a desire to be perfect, low levels of self-efficacy and self-esteem, interpersonal distrust and difficulty with maintaining healthy relationships (Izydorczyk, 2014). Furthermore, patients with bulimia score high on harm avoidance behaviors and negative stress reactions (Peterson et al., 2010). Bulimia is highly comorbid with other disorders such as substance use disorders, anxiety disorders, mood disorders and personality disorders, with borderline personality found is an as many as 51.5% of patients entering treatment for bulimia (Carbaugh & Sias, 2010; Kaye, Bulik, Thornton, Barbarich & Masters, 2004; Marañon, Echeburúa & Grijalvo, 2004).
Bulimia is widespread and, due to stigma, true prevalence and incidence rates are unknown. Research suggests that bulimia has a lifetime prevalence of 1.5% in American women (National Association of Anorexia Nervosa and Associated Disorders, n.d.). Following the DSM-5 publication, a study found that the incidence rate for bulimia in 16 to 20 year old females was 300 per 100,000 (Smink, van Hoeken & Hoek, 2012). The age of onset for bulimia in females is decreasing to early teenage years as opposed to college years, however, this may also be in part due to earlier detection (Smink, van Hoeken & Hoek, 2012). The lifetime prevalence rate for bulimia in women has decreased significantly since the early 1980’s, where it was 4.2% as compared to today’s 1.5% (Smink, van Hoeken & Hoek, 2012). Another study conducted by Hoek and van Hoeken found that between 1988 and 1993, incidence rates or 10-39 year old women tripled (2003). This suggests bulimia is not as widespread today as it was a few decades ago, but clearly it is still a national problem.
Bulimia and other EDs do not discriminate based on any demographical information. Certain groups, however, are more prone to developing the ED. Bulimia is vastly more prevalent in adolescent and young adult females than males of any age (Nagl et al., 2016). Due to this statistic, males with bulimia face a great deal of stigma. They are often overlooked by clinicians or too ashamed to come forward, fearing they will be labeled as feminine. In reality, men account for one third of ED patients (National Eating Disorder Association, n.d.). Members of certain religious groups also present ED symptoms differently. Some religions like Judaism or Hinduism practice fasting and restrictive food intakes, which can obscure ED behaviors.
Unlike anorexia, bulimia is more common in Latinos (2%) and African Americans than non-Latino whites (0.51%) (Smink, van Hoeken & Hoek, 2012). Historically, anorexia is portrayed in the media as a ‘white upper-middle class’ disorder. Bulimia appears at higher rates in minorities and lower socioeconomic class individuals, thus creating a less sympathetic view. Moreover, clinicians are now facing the question of whether EDs like bulimia are developing at younger ages or if professionals are simply better at detecting them (National Eating Disorder Association, n.d.). Clinicians may interpret a minor displaying bulimic thoughts or behaviors as going through a phase. In actuality, ED behaviors should be taken seriously at any age. It is also important to understand that EDs do not vanish after a successful attempt at recovery; they often lay dormant and can re-emerge at any time (National Eating Disorder Association, n.d.).
Assessments are crucial to properly diagnose a client. They assist in identifying symptoms, collecting an in-depth history and understanding the client on a multidimensional level. Assessments also play a key role in treatment planning. Assessments always occur during the initial phase of treatment and should be intermittently reviewed and updated over time.
There are several unique symptoms to look for when assessing a client for bulimia. The client measures their perceived self-worth in weight and has a preoccupation with their physical appearance (American Psychiatric Association, 2013). A client engages in recurrent binge eating episodes; a binge is when an abnormally large amount of calories are consumed in a generally short period of time and is followed by a sense of guilt and lack of control over the episode (American Psychiatric Association, 2013). The main characteristic of bulimia, which distinguishes it from binge eating disorder, is that an individual engages in harmful compensatory behaviors after binging, such as laxative use, self-induced vomiting, fasting or over-exercising (American Psychiatric Association, 2013). It is important to note that these behaviors do not occur exclusively during anorexic episodes (a client may better fit the criteria for anorexia nervosa – purging subtype) and the binge-purge cycle occurs at least weekly for a minimum of three months (American Psychiatric Association, 2013).
It is common practice for individuals meeting the above criteria to be seen by a multidisciplinary team. This may vary depending on the intensity level of treatment, but when residential, inpatient or partial inpatient, the team often consists of a social worker, medical doctor, psychologist and dietitian. Each professional brings a unique perspective to the assessment and intervention process. A social worker would stress the importance of a biopsychosocial assessment and strengths perspective. Medical and nutritional assessments are crucial when assessing a client and creating a treatment plan and sometimes they take precedence when physical complications are a high risk. In such situations, recovery of the mind is forced to take a back seat. An effective social worker would ensure this not be the case. Although a client can be taught how to meal plan and maintain weight, the risk for relapse does not truly decrease until faulty cognitions and subsequent harmful and risky behaviors are addressed (Hoffman, Asnaani, Vonk, Sawyer & Fang, 2012). A social worker brings a unique perspective to the assessment by exploring the client’s entire history, systems and trends. Additionally, social workers utilize a strengths perspective and highlight the client’s abilities and potential. While other disciplines may focus on numbers and vitals, a social worker dives deeper to go beyond acute stabilization.
Social workers use a biopsychosocial framework in order to gather as much information as possible. Before this model came into practice, assessments were biomedical in nature and a great deal of crucial psychological and social information was left out (Engel, 1980). An all-encompassing and holistic approach, the biopsychosocial assessments ensure no stone is left unturned. EDs are deeply embedded in a client’s history and while no two EDs are the same, there are several trends in determinants that can be highlighted during a biopsychosocial assessment. While a biomedical one may catch a genetic history and disordered eating, an assessment that looks into trauma, personality traits, family dynamics, development and substance use accounts for all the missed connections and determinants (Engel, 1980).
A strictly biomedical model would not ask a client or family about personality traits developed in childhood. Additionally, bulimia is heavily rooted in Western society. Clinicians must be aware of sociological determinants and inquire about them during an assessment. The National Eating Disorder Association reports that in girls aged six to twelve, 40-60% report severe concerns regarding body shape and weight and this percentage continues to increase as they grow older and begin puberty (n.d.). Almost 70% of female elementary students in the United States report their self-worth, body image and understanding of the ideal body shape comes from magazines and advertisements, which are often altered through Photoshop technology (Martin, 2010). The great advantage of a biopsychosocial approach is that it captures the missing information in a biomedical assessment while also asking about physiological influences as well (Engel, 1980). Some studies have argued there is a biological determinant to bulimia, with as many as 9.6% of first-degree relatives also being clinically affected (Brambilla, 2001). On the other hand, other studies have found zero connections (Brambilla, 2001); this shows why the psychological and social influences are so important to include in an assessment.
A social work empowerment approach would influence the assessment by focusing on the client’s strengths and positive traits rather than strictly highlighting the problem areas. Clients with bulimia already present with low self-esteem and self-efficacy. An empowerment approach works around this to increase treatment compliance and success rates. Social workers often use a humanistic approach in assessments as well, which stresses empathy and the good in human behavior. Using these two approaches would help build rapport with the client and help combat thought processes that are barriers to the client’s treatment and recovery.
EDs are all-encompassing diseases that impact and are influenced by various systems, from the family system to society as a whole. Several studies have found a genetic and biological determinant to bulimia. In addition to genetic ties, EDs can be deeply rooted in family dynamics. For a child growing up in a home in which a certain physical appearance is stressed, perfectionism is expected. A home where the child is exposed to impulsive behaviors can influence that individual’s risk of developing bulimia as well (Izydorczyk, 2014). Conversely, bulimia can destroy a family. Bulimia revolves around compulsion and obsession; when a family member is actively living with bulimia it is difficult for that person to engage in healthy relationships. Parents grieve for their sick children and young members are seemingly neglected by their sick parent. Family members break at the seams trying to intervene with their loved one while attempting to live normal lives. Treatment is expensive, creating a financial strain on families. Siblings run the risk of being impacted by their sick brother or sister and developing disordered eating themselves. On the other hand, recovery efforts can positively impact the family system as a whole through joint therapy and by creating a healthier family relationship with food and weight.
The broader community also has a relationship with bulimia. Societal beliefs about beauty and thinness deeply impact the prevalence of EDs and overall disordered eating practices. Western culture has a preoccupation with physical appearance and beauty standards that are unattainable to most people (Schott & Langan, 2015). American citizens are bombarded with advertisements everywhere they go. Many of these advertisements display the ‘ideal’ body or are diet related, suggesting foods and programs one should incorporate into daily life to achieve such a beauty standard. Entire online communities exist that promote EDs and share tips and techniques, encouraging their members that bulimia is a lifestyle (Schott & Langan, 2015). Bulimia itself also impacts society. The more widespread it becomes, the more individuals are willing to take the behaviors for a test run, assuming they can quit at any time (National Association of Eating Disorders, n.d.). As its popularity remains steady or even surges, more people will see it as a socially acceptable behavior to combat weight issues.
Organizational and institutional systems are also important to assess when analyzing bulimia. Many non-specialized inpatient and residential settings are not well equipped or prepared to treat EDs the same way they are with mood, anxiety or substance use disorders. Meal planning with a dietitian and a therapeutic focus on body image and the relationship with food are not standard in such settings. Specialized treatment centers may not have a bed for months, are more expensive and far and few between in certain areas of the country. Additionally, since EDs have severe and fatal physical side effects, many patients will find themselves on primary care inpatient units as opposed to psychiatric ones. Primary care doctors and nurses have a general understanding of the health consequences related to bulimia, but are not well trained in the psychological aspects of the disorder and this can be a barrier to recovery for many clients. Some rehabilitation centers can do more harm than good, teaching clients additional behaviors such as calorie counting, requiring non-blind weights, exercise regimes and more.
Educational institutions also play a role in EDs. Many EDs develop in adolescent years, when there is more autonomy surrounding food and health behaviors (National Eating Disorder Association, n.d.). Some schools require weigh-ins and body mass index checks, silently allowing students to label each other as “good” or “bad” based on a number. High school aged individuals experience various physical changes during these years and are highly susceptible to peer pressure and societal ideals. Some students find it more difficult than others to manage these changes and external forces, placing them at risk for an ED.
Since 1979, there have been several proposed evidence-based practices (EBPs) for treating the disorder. Cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT) have consistently been the intervention front-runners. CBT has become the gold standard for treating a multitude of mental disorders and bulimia is no exception. CBT-BN is a modified version of CBT, created specifically for treating bulimia, which implements a strong focus on mood intolerance, perfectionism, interpersonal problems and low self-esteem in addition to standard CBT interventions (Lampard & Sharbanee, 2015). CBT-BN evaluations have shown that 30-50% of participants experience a complete remission in binging and purging behaviors upon completion of the intervention (Lampard & Sharbanee, 2015).
CBT interventions help the client to recognize and explore their distorted and maladaptive cognitions that lead to emotional distress and behavioral problems. For example, a CBT-BN approach would focus on the client’s belief that their self-worth is based in their physical appearance. The general assumption under CBT is that by reversing faulty cognitions, the client’s adverse behaviors will follow suit. If the client no longer believes their self-worth is measured in pounds, they are more likely to cease binging and purging behaviors (Hoffman, Asnaani, Vonk, Sawyer & Fang, 2012). When treating bulimia, CBT typically has three phases. The first phase focuses on developing and maintaining a normalized eating pattern (Schapman-Williams & Lock, 2007). The next stage addresses the maladaptive thoughts and triggers to engaging in bulimic behaviors (Schapman-Williams & Lock, 2007). The final stage of CBT addresses relapse prevention strategies (Schapman-Williams & Lock, 2007).
DBT is another popular intervention for bulimia. DBT was initially created by Marsha Linehan for treating borderline personality disorder. It has been well adapted for bulimia, which is no surprise due to the high comorbidity of bulimia with borderline personality. DBT focuses on distress tolerance, interpersonal effectiveness, regulating emotions and mindfulness. When applied to bulimia, DBT analyzes how binging and purging behaviors are maladaptive to mindfulness and how many ED sufferers struggle with managing emotions and label them as the problem (Safer, Telch & Agras, 2001). DBT also zeroes in on the client’s inability to handle distressing emotions and situations. This lack of distress tolerance leads to bulimic episodes, further imprinting the disordered thoughts and behaviors (Safer, Telch & Agras, 2001).
DBT is a highly effective treatment modality for bulimia not only based on a rapid decline in behaviors and maladaptive thoughts, but also because of its success in treating comorbid disorders. One study found that DBT, when applied for bulimia, showed abstinence rates after 12 sessions comparable to those reported after 20 CBT sessions (Hill, Craighead & Safer, 2011). A randomized control trial found that, when compared to a waitlist control group, DBT reduced purging behaviors by 98% on average and decreased urges to eat triggered by negative emotions; in other words, distress tolerance was improved (Linehan & Chen, 2005).
Issues of ethics and diversity should always be assessed when treating clients. EDs can be particularly tricky for various reasons, many rooted in client autonomy and the right to self-determination. The biggest ethical dilemma when treating EDs is determining when health professionals have the right to step in and go against a client’s wishes to refuse treatment (Matusek & O’Dougherty-Wright, 2010). Bulimia can be fatal disease in which the client may die slowly or suddenly, but always surely if left untreated. Professionals are bound to protecting the client but the question is when can they usurp a patient’s rights. The issue becomes even more perplexing when treating minors. Clinicians need to determine the client’s capacity for sound judgment in the face of starvation, binging, purging and the like. There is also the dilemma of when to use coercive tactics (bed rest, tube feeding, limited bathroom visits, etc.) with patients who are running the risk of dying (Matusek & O’Dougherty-Wright, 2010). Professionals would not confine a client with a depressive disorder to bed rest for experiencing dysphoria; however, low mood is not always cause for a fatality concern.
The best way to tackle these ethical dilemmas is consistently re-assessing clients with biopsychosocial assessments and mental status exams (Lipschutz, 2012). Using these assessments, the team can make a judgment on the client’s decision-making abilities and competency. Clinicians are bound to varies codes of ethics, all of which state that the professional has a duty to the client’s well-being. While treatment cannot be forced, if there is an issue of life or death, the treatment team can deem the client unfit to make medical decisions (Lipschutz, 2012; Matusek & O’Dougherty-Wright, 2010). Compulsory treatment is highly debated, with some clinicians believing it saves lives, while others argue it does more harm in the long run (Matusek & O’Dougherty-Wright, 2010). Ideally, a contract is created with the client at the beginning of services that explains treatment compliance and expectations. While punishments in treatment programs are frowned upon, consequences are not as long as they are incorporated into the contract and treatment plan.
Issues of diversity must be addressed when treating clients with EDs. Behaviors and thoughts surrounding food and weight are deeply rooted in family, gender roles, ethnic groups and religions. It is necessary to use a transcultural integrative model and for the clinician to understand their own attitudes and beliefs surrounding food (Matusek & O’Dougherty-Wright, 2010). Bulimia exists across the world and different groups view the behaviors in various ways. Some religious and ethnic groups practice fasting and break the fast with what could be considered a binge. In this case, it is crucial the treatment team understands beliefs around fasting and that they are respectful of religious practices. Different genders experience bulimia in different ways related to how society depicts male and female attractiveness. When addressing matters of diversity, clinicians should identify and leave at the door their own biases and values in order to fully understand the client and their experience.
<h2>Conclusions and Recommendations</h2>Bulimia is a complex mental illness with roots in biology, psychology and sociology. The treatment of bulimia requires a competent multidisciplinary team that utilizes EBPs. Various interventions show promise for treating the ED, however, CBT and DBT are the leaders in treatment compliance and effectiveness. Recovery is a full-time job and the client will need to be cognizant of their triggers and predispositions in order to achieve long term success. Clients with bulimia can experience full remission of behaviors, however, the cognitive processes may remain active for much longer. Medications can aid depression, anxiety and irregular mood symptoms as well as assist in treating comorbid disorders.
Great progress has been made regarding the inclusivity of EDs in the DSM-5, but more changes are still needed. Non-specialized clinicians still struggle with understanding that EDs can occur and be life threatening at any weight. Clients with bulimia, anorexia or binge-eating disorder can present as overweight, average weight or underweight no matter the diagnosis. I recommend weight requirements should be removed from the diagnostic criteria. If a patient lost 50 pounds in two months through restriction, but still has an average body mass, who are we to deny treatment and insurance coverage? Clients in need of treatment who are five pounds away from meeting an ‘anorexic weight’ are denied coverage and services despite their physical and mental status surpassing the criteria for inpatient treatment. It is consistently a strenuous fight to receive insurance coverage all because of something as small as a five-pound difference, which is also damaging to the client on many levels. Insurance companies and the health system as a whole are failing the 30 million individuals in this country who are fighting for their lives. I hope to see a great deal of progress in my professional career and I will fight for my clients to receive proper treatment and coverage regardless of weight.
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