A 35-year-old woman with obesity presents with binge eating.
“Ms. Z,” a 35-year-old African American single woman with a body mass index (BMI) of 38.4 (height 5 feet, 6 inches, weight 238 lb), presents for an evaluation for bulimia nervosa. She was referred to the eating disorders program by her primary care physician, who knew about her eating disorder but was primarily concerned about her weight and blood pressure. Ms. Z has an advanced degree and is employed full time. She has struggled with her eating, weight, and body image since childhood and began binge eating regularly (one to two times per week) at age 15. Fasting and self-induced vomiting began in her early twenties, when she achieved her lowest adult BMI of 21.0 (weight 130 lb at age 23). She has gained 100 pounds in the past 7 years and currently binges and purges one to two times a day. A typical binge consists of a box of cookies, a pint of ice cream, 7 ounces of cheese, two bowls of cereal with 2 cups of milk, and four pickles. Ms. Z has seen five therapists to address her eating behaviors and weight concerns and has participated in numerous commercial weight loss programs. She states that binge eating has always served a self-soothing purpose for her. She has a demanding university-related job that absorbs most of her time. She has few friends and has not been in a romantic relationship for the past 5 years, believing that no one would be interested in a woman of her size. She remarks that food is more reliable than any man because “it’s always there when you need it and you don’t have to take care of it or stoke its ego.” She spends evenings at home working until she is completely exhausted, then heads to the kitchen for an all-out binge, after which she vomits everything up and then cries herself to sleep. She has never smoked and does not drink alcohol. Current medications prescribed by her primary care physician include fluoxetine (20 mg/day), amlodipine (5 mg/day), and clonazepam (as needed).
What are Ms. Z’s treatment goals? What are her primary care physician’s? Is her medication for bulimia nervosa adequate? How well would cognitive-behavioral therapy (CBT) for bulimia nervosa address her personal treatment goals? Her physician’s? What challenges might a therapist face having Ms. Z in group therapy for bulimia nervosa?
Ms. Z sought consultation with a psychiatrist who discussed treatment options. The psychiatrist offered the option of increasing the fluoxetine dosage to the recommended level (60 mg/day) or joining a CBT group. She explained that although fluoxetine does lead to short-term reduction in binge eating, the evidence for CBT was stronger in terms of long-term outcome. She also made it clear that they could adjust the medication dosage later if necessary, but recommended commencing one intervention at a time, rather than starting therapy and increasing medication dosage simultaneously. Ms. Z opted for group therapy. The majority of the CBT sessions were led by a clinical psychologist, and four sessions were led by a registered dietitian. The group was anchored in the principles of CBT and enriched with elements of dialectical behavior therapy. The group began with psychoeducation; reviewed the language of CBT, focusing on behaviors, thoughts, and feelings; emphasized successful self-monitoring and normalization of meals; and transitioned through challenging automatic thoughts, thought restructuring, chaining, and relapse prevention.
The group started with five participants, four of whom were overweight or obese. During the first session, weight was a central topic. Patients discussed all of the diet programs they had tried, and they discussed wanting to get their blood pressure or “sugar” levels under control. When the therapist included the general caveat that CBT for bulimia nervosa does not necessarily lead to weight change, the four overweight participants immediately spoke up, remarking that they expected to achieve weight loss from treatment in addition to getting over their bulimia nervosa. After this first session, the fifth participant, who had a history of anorexia nervosa and was on the low end of normal weight range, opted not to continue with group, stating that she felt out of place with the four other women, who were facing different recovery challenges. The other group members felt for her but agreed that the issues that they faced were different.
Rather than follow the standard CBT curriculum, the therapist decided to work with this group of patients to adapt CBT to address their bulimia nervosa and their weight concerns. For example, Ms. Z initially wanted to lose 50 pounds and stop binge eating and purging. The therapist worked with her to develop more realistic goals and indicated that the first and most important step toward recovery was normalization of eating. The therapist explained to the group that the treatment would borrow from CBT for binge eating disorder and include elements of appetite awareness, portion control, mindful eating, development of strategies other than eating for emotion regulation, and regular physical activity and exercise. She also focused their attention more on other health parameters (e.g. blood pressure and glucose and triglyceride levels) rather than the number on the scale. The patients decided as a group that they wanted to incorporate more physical activity and exercise goals into their treatment plan. The psychologist identified an exercise physiology practicum student who worked with the therapist to incorporate appropriate physical activity and exercise into the overall treatment plan.
Ms. Z was an active group participant, self-monitored regularly, and fought against her tendency to want to fix everything at once. Her expectations were for immediate and linear recovery and rapid and sustained weight loss to get her health under control. In the past when she had high treatment expectations and then failed to meet them, her disappointment resulted in a full-blown relapse of bulimia nervosa symptoms and a sense that she was a failure. When she had entered exercise programs in the past, she had overdone it, gotten injured, and then dropped out. Modulating her expectations and developing realistic goals and timelines became her primary issue in the group.
The dietitian taught the group how to work with the exchange system and how to self-monitor. She emphasized moderation rather than restriction, and she reinforced the CBT sessions using mindful eating techniques, portion control, and appetite awareness training.
The exercise physiology intern developed a home-based aerobic and resistance training intervention plan. Group members were instructed to engage in the exercise intervention five times a week, starting with 30 minutes of moderate exercise per day for the first 4 weeks and gradually increasing. The intern was careful to ensure that exercise did not become obsessive and made it clear that exercise was for health, not specifically for weight loss. He encouraged patients to look beyond the scale for success and to pay more attention to the blood test results, the sphygmomanometer readings, and their self-reports of mood and well-being than to the scale.
By week 16, Ms. Z was abstinent from binge eating and purging. She joined a yoga class for “large women,” where she found comfort in not having to compare herself with the other “teeny yoga bunnies.” She lost 10 pounds during CBT without dieting, which she admits fell far short of her original expectations, but her blood pressure had normalized to the point where her primary care physician tapered her amlodipine. Her intention was to enjoy a “planned plateau” and to consolidate her abstinence and new weight and blood pressure before engaging in the next step of her health reform plan (which included getting more fit).
She developed healthier approaches to stress tolerance and better solutions to boredom than binge eating and purging. She could identify warning signs of an impending binge and knew that her tendency to skip breakfast and boost her energy with caffeine set her up for evening binges. Her binge “hangover” the next morning would then facilitate skipping breakfast and lunch, thereby perpetuating the cycle. Rather than succumbing to work stress, she began to predict times of high stress and planned in advance to ensure that she would continue eating healthful breakfasts and lunches to avoid those strong evening urges. She also benefited from the technique of opposite action. On evenings when all she wanted to do was binge and purge, she learned how to avoid putting on her “binge sweats” and instead changing into casual clothes and getting out of the house—to a book reading, a movie, or some other non-food-related activity. All in all, she was pleased with the outcome of abstinence from binge eating and purging but needed considerable work to adjust her weight loss expectations.
A year after treatment, she remained abstinent from binge eating and purging and continued to reap the medical benefits of her healthier lifestyle. Her fluoxetine had been discontinued, which was sensible given her abstinence from bulimic behavior and prolonged underdosing. She worked hard to maintain a focus on health rather than on weight but occasionally still felt the pull toward a drive for thinness. Small upward weight fluctuations still triggered urges to purge, but she recognized that this was a trap for her and that she would continue to have to apply active strategies to combat this urge.