 is a psychology fellow at Baylor College of Medicine.

Ronnie Lee, PsyD

Tales From the Clinic: The Art of Psychiatry

, we discuss a case of bulimia nervosa and the challenges of managing it in outpatient care. Eating disorders (EDs) include pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa (restricting type/binge-eating/purging type), bulimia nervosa (BN), and binge-eating disorder. Growing awareness of disordered eating is helpful in conceptualization and treatment, and it covers the gamut from grazing and excessive dieting to frequent weight fluctuations and other behaviors that do not warrant a diagnosis of eating disorder.

“Ms Georgina” was referred to the outpatient clinic following recurrent compensatory behaviors without remission. One look at Ms Georgina’s chart, and the complexity of her ED presentation became apparent and almost overwhelming. Diagnosed with BN at age 14, Ms Georgina had been unable to establish residential/inpatient care due to a plethora of barriers (ie, insurance denials, lack of resources, bed availability). She had a tumultuous clinical history of recovery (verbalized), relapse, hospitalization, and failed medication trials.

At the time of treatment initiation, Ms Georgina was living with her immediate family and working at a nearby community center. She endorsed a binge-purge cycle occurring 1 to 2 times per day (depending on mood) that began with purchasing large amounts of food on the way home from work, eating the food in her room, and vomiting it into a trash bag. As one can imagine, this presentation of BN is quite advanced and has deep-rooted anchors in personality and day-to-day functioning that appear to go far beyond body image and comparisons. During the first interaction, she appeared sullen and fatigued, attempting to hide much of her appearance during the session and subsequently remained relatively quiet. Ms Georgina was forthcoming and accepting of psychoeducation and clinical interview questions. She demonstrated an adequate amount of insight and voiced a need for help: “I am not an idiot. I know this cannot keep going much longer. I know this… trust me, I know.”

Ms Georgina described her childhood as “scattered” and discussed difficulty with familial interactions from an early age. She expressed a history of constant moving, divorce, and remarriage of both parents. She denied abuse of any type. Her anxiety symptoms began around this time, at age 9, with specific localization in her abdominal region. Ms Georgina said, “it would only go away when I ate and forgot about the feelings.” At age 13, she recalled a distinct memory of being called “chubby” by her family; shortly after, she had a relationship end due to her being overweight. She was highly emotional while speaking about this event and profusely stated, “this is where it all began. I do not know what it was about how he ended things, but looking back, this is where it turned to shit.”

Ms Georgina began restricting meals and increasing the frequency at which she worked out. A friend introduced laxatives to her, which also became a part of this almost daily routine. Binging/purging emerged as she entered high school, as a way to maintain relationships and enjoy outings, but also maintain control over her body image. She reported that her binge/purge episodes only occurred every weekend, but slowly increased in prevalence until the episodes were daily. Persistent laxative use led to gastroenteritis, hypokalemia, and esophagitis at age 18. Family members commented on her behaviors, but Ms Georgina described herself as so “engulfed” by her routine at this point, that she did not recall serious conversations about medical/psychiatric help.

However, she did recall an instance on a family trip in which her family caught her in the act of purging, and she was taken to a general practitioner upon returning. She was prescribed Zoloft and Xanax to help with her diagnosed generalized anxiety disorder, which led to a subsequent overdose at age 19 (accidental, per patient). Subsequently, Zoloft and Xanax were discontinued, psychiatry restarted Zoloft, and she maintained adherence for 1 year before stopping medications and disregarding follow-up appointments. She denied past individual psychotherapy, group therapy, or residential treatment. Ms Georgina stated that her insurance would not cover residential treatment, and she had been turned away previously at intake. Ms Georgina denied past or present suicidal ideation; however, she did endorse a sporadic history of passive thoughts of death.

BN diagnoses have steadily risen over the past decade, contributing to an estimated 6.3 million Americans currently meeting criteria. Moreover, if not thoroughly screened, BN is shown to be consistently underdiagnosed by mental health providers due to a myriad of reasons. Research indicates that initial screening and questionnaires use may be too rigid to accurately identify compensatory strategies, medical complications secondary to EDs, and differences in presentation (child/adolescent/adult).

Particularly with BN, studies demonstrate that weight changes may prove to be insignificant, which can allow BN to go undiagnosed for longer periods of time when compared to 

, avoidant/restrictive food intake disorder, and binge-eating disorder. This is particularly true for early detection and intervention, which may significantly impact prognosis and treatment for common medical comorbidities (low bone mineral density, growth retardation, disturbed metabolic rates).

 A combination of structured and unstructured questions may be useful in conjunction with a short screening tool, similar to the Sick, Control, One, Fat, Food (SCOFF) questionnaire.

 The SCOFF can be administered orally or in written form, and it provides simple, straightforward answers. Due to the generality of the questions, only 1 positive answer indicates that further information may be required.

If BN is suspected, structured interviews, following specific DSM-5 criteria is useful. These questions should most definitely encompass the mainstay of BN, which is binge eating, and accompanied by specific questions regarding self-control during binges; feelings of guilt, remorse, or shame; and other compensatory behaviors (over-exercising, laxatives, enemas, stimulant abuse). Further inquiry into specific patterns of binging/compensatory behaviors can provide determinants related to severity and duration of disorder. Mood states pre- and post-cycles, binge triggers, context-specific behaviors, family patterns/interactions, mental health history, and food perceptions are essential to gauge.

Treating advanced disordered eating on an outpatient basis requires in-depth background history and awareness of current literature. Differential diagnosis and clarification are imperative steps in this process, and many of the eating disorders outlined in the DSM-5 share similar criteria. Furthermore, compensatory behaviors and types of eating patterns have recently been identified as pervasive, albeit sub-clinical, disordered eating (ie, grazing, loss of control eating).

 Another consideration is identifying a medical presentation that may be indicative of BN. The following symptoms should warrant further consideration if identified in conjunction: energy despite cachexia, gastroesophageal reflux disease (GERD), dehydration, gastrointestinal distress, subconjunctival hemorrhages, Barrett’s esophagus, cavities/dental erosion, acrocyanosis, Russell’s signs, and abnormal lab values.

 Open communication with medical providers, nutritionists, and nurse case managers is highly encouraged to help streamline treatment protocol and recommendations. Most often, these are unavailable or patients may be unwilling to adhere to recommendations outside of psychiatric treatment.

Although BN is often construed as a “less severe” ED, mortality rates have been observed as equal to or slightly below 

. Moreover, an increased risk of suicide is positively correlated with the severity of presentation. These 2 considerations alone make this diagnosis difficult to treat from an outpatient perspective if a complete background and open line of communication are not established early in treatment. Safety planning, instillation of hope, and immediate introduction of adaptive coping skills are necessary components to the early treatment process and especially imperative when treating well-established eating disorders on an outpatient basis. This step clearly details safety concerns and ensures there is a mutual understanding of the medical risks associated with disordered eating.

Early sessions with Ms Georgina focused primarily on understanding core mechanisms and insight into presentation. Much focus was given toward empowering the patient to think critically about her life course and identify contributory factors to the development of BN. CBT-Enhanced (CBT-E) explicitly states to begin to narrow and personalize the treatment protocol toward the patient; in Ms Georgina’s case, this occurred rather quickly, as she had entered therapy highly motivated and fearless of retrospective analyses of behaviors, experiences, and thoughts. An internal diagram was constructed with Ms Georgina to concretely display a conceptualization of her ED, which was characterized by negative familial interactions, bullying, and forced body comparisons that led to an overall low self-esteem and dissatisfaction with self. Her shame toward self and eating patterns dominated the early sessions, and time was devoted to discussing the overlap between self-shame, culturally reinforced body shame, and the mediating factors of guilt, dysregulation with food, and binge-purge cycles.

As the function of Ms Georgina’s ED became increasingly clear, gentle challenging with complementary coping skills were introduced. Mindful eating and nutritional psychoeducation provided the framework for restructuring her relationship with food. Hunger/fullness cues, intention settings, breathing exercises, mindful distraction, and appropriate challenging were instrumental skills to master prior to collaborative reduction of 

. It is imperative to maintain open communication and consistent symptom/behavior tracking during this stage to appropriately gauge progress. Cognitive distortions were continuously brought to awareness and normalized, and a combination of rational thinking and behavioral experiments were utilized to help disconfirm distortions and birth new alternative beliefs. Ms Georgina is currently in the final phase of treatment, which is placated on preventing relapse and ensuring that changes are maintained over time. The focus is on the future, and it heavily reinforces the new belief system, mindful eating strategies, and coping skills to decrease distress/anxiety.

 can be quite challenging at each level of care—particularly in an outpatient clinic. Recent studies have sought to identify which modalities are effective and generalizable to a variety of presentations.

 Cognitive behavioral therapy-bulimia nervosa, cognitive behavioral therapy-enhanced, interpersonal psychotherapy, and dialectical behavior therapy, among others, have all had considerable attention and shown some effectiveness in decreasing problematic symptoms. The decision of which to use should factor in resources, time availability, level of care, and provider familiarity. CBT-E offers a time-limited directive approach that aims for improvements in severe ED psychopathology, body mass index, remission rates, and suicidality.

 Moreover, De Jong and colleagues speculated that CBT-E may be a cost-effective modality that provides the ability to offer treatment in settings with limited psychiatric resources, subsequently increasing the reach for specialized psychiatric treatment to underserved populations.

 Support and structure are critical for long-term remission, soothing painful feelings, and creating a stable sense of self over time.

 is a psychology fellow at Baylor College of Medicine. 

 is an assistant professor and licensed clinical psychologist at Harris Health System in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine in Houston, Texas.

1. Gravina G, Milano W, Nebbiai G, et al. 

Medical complications in anorexia nervosa and bulimia nervosa.

2. Westmoreland P, Krantz MJ, Mehler PS. 

Medical complications of anorexia nervosa and bulimia.

The SCOFF questionnaire: assessment of a new screening tool for eating disorders. 

Screening for symptoms of eating disorders: Reliability of the SCOFF screening tool with written compared to oral delivery. 

Emotion regulation and binge eating in children. 

Grazing and loss of control related to eating: two high-risk factors following bariatric surgery.

Eating disorders in children and adolescents: state of the art review.

8. Hay PP, Bacaltchuk J, Stefano S, Kashyap P. 

Psychological treatments for bulimia nervosa and binging.

A systematic review of enhanced cognitive behavioral therapy (CBT‐E) for eating disorders.

10. de Jong M, Korrelboom K, Van der Meer I, et al. 

Effectiveness of enhanced cognitive behavioral therapy (CBT-E) for eating disorders: study protocol for a randomized controlled trial.

Articles

How can you help patients with bulimia nervosa beyond residential programs?

Ronnie Lee, PsyD

Articles

Trust, Patience, and Communication: Treating Bulimia Nervosa When Residential Programs are Unavailable