Case Example

SESSION 1 Presenting Problem

Intake assessment

Jenna was a 26-year-old newlywed who presented for treatment after more than 6 years of bingeing and purging. She had no prior psychological or psychiatric treatment. For the 2 years prior to intake, since completing business school, she was employed at a prestigious firm in her “dream job.” At intake, Jenna reported concern about the effect her eating disorder was having on her concentration at work, prompting her to seek treatment. She reported that thoughts of food, her appearance, and her weight consumed nearly all her mental energy. She was also concerned about trust issues and the impact her eating disorder was having on her relationship with her husband, from whom she kept her bingeing and purging secret. Jenna and her husband were planning to start a family in the coming year, and Jenna reported concern about purging during pregnancy, handling pregnancy weight gain, and being a good role model as a mother.

Symptoms of Bulimia Nervosa

Assessment of BN symptoms

Jenna started bingeing and purging 6 years prior to intake following a 6-month period of strict dieting and significant weight loss. The frequency of bingeing and purging increased over the years and, at the time of intake, occurred approximately twice daily. During a typical day, Jenna reported that she ate a piece of fruit for breakfast, a small salad (no dressing) with grilled chicken and broccoli as a late lunch, and a small platter of assorted sushi for dinner. She tried not to eat in between meals and believed that doing so is a sign of “weakness.” Her diet was not at all varied, and these were the only foods she considered “safe” to eat. Jenna occasionally vomited after a meal if she ate a “bad food” or a portion she considered “excessive.” Almost every evening, while working late, Jenna binged at her desk. Tempting binge foods were readily available in her office kitchen. a typical binge was 15 cookies, a handful of potato chips, and 10 miniature candy bars. Jenna reported that she “hid” in

This case example is completely fictionalized. While the descriptions of symptoms and interventions are based on Rene Zweig’s experience working with many patients, the case material presented here does not reflect a real case.

her office while bingeing. She ate the food very rapidly, felt out of control, and subsequently felt ashamed and bloated. She then immediately vomited to ease her guilt and physical discomfort.

At 5'4" and 110 pounds, Jenna’s BMI at intake was 19, indicating that she was borderline underweight. Her highest adult weight was 140 pounds, which immediately preceded her strict diet 6 years ago. Her lowest adult weight was 103 pounds 2 years earlier when she was exercising intensely. Jenna’s scores were highly elevated on the Restraint, Eating Concern, and Shape Concern subscales of the EDE-Q. At intake, Jenna reported strong motivation to discontinue binge- ing and purging, although she felt her current diet was otherwise healthy. She described feeling unattractive and “too flabby” at her current weight, and she was intensely afraid of weight gain.

Assessment of Comorbid Conditions

Assessment of depression, anxiety, alcohol use, and substance abuse

Jenna reported feeling significant anxiety most days, characterized by worry about the future, work, and her relationship. Her Beck Anxiety Inventory (BAI) score was high (27) at intake. She exhibited no compulsive behaviors and denied experiencing panic attacks. She denied depressive symptoms and any past depressive episodes. Her BDI score was low (5). She denied any current or past substance abuse, and she reported drinking only occasionally. At intake, Jenna disclosed that she is quite regimented in her routines, in completing tasks, and in organization and cleanliness. She reported having difficulty being flexible when collaborating with others on team projects. She also found it difficult to relax until all of her work was complete. The SCID-II confirmed that Jenna met diagnostic criteria for obsessive- compulsive personality disorder. Jenna reported having a fulfilling and supportive relationship with her husband, and her Dyadic Adjustment Scale score was in the satisfied range (109). Jenna’s diagnoses include:


Axis I: Bulimia nervosa (307.51); generalized anxiety disorder (300.02)

Axis II: Obsessive-compulsive personality disorder (301.4)

Axis III: Slightly underweight; no other medical conditions reported Axis IV: Stressors related to employment, recent marriage, family, recent move, and reduced social support network Axis V: Current: GAF = 55

Highest past year: GAF = 55

Evaluation of Suicide Risk

Assessment of suicidal risk

Jenna reported significant frustration with her eating disorder and worried about how it would affect her future. However, she reported feeling otherwise hopeful and denied any suicidal thoughts or intent. Jenna denied any past suicidal attempts or gestures. She reported no familial history of mood disorders or suicidality.

Psychotropic Medications

Jenna had never seen a psychiatrist or been prescribed psychotropic medication. She was open to the idea of medications to improve her anxiety and eating disorder.

Socialization to Treatment

During the initial session, the therapist described the cognitive-behavioral model for BN to Jenna, showing how her obsession with her weight and shape set off a desire to diet, to carefully control her food intake, and to deprive herself of seemingly “bad” foods. This ongoing pattern of dietary restriction, hypervigilence about food choices, and strict food rules led to deprivation and hunger. The deprivation and hunger, when combined with an emotional trigger and/or the accessibility of “trigger” foods, immediately precipitated a binge. Jenna related well to this model and recognized having feelings of guilt and disgust following a binge. Her inability to tolerate physical discomfort and negative affect, combined with a fear of weight gain following the binge, triggered vomiting. Jenna also recognized that she would then vow to be “good” the following morning, which included resuming her strict dietary control and perfectionistic standards (see Figure 5.1). The therapist recommended that Jenna begin reading Overcoming Binge Eating by christopher fairburn to better understand Bn, and also provided Jenna with a copy of the Information for Patients about Bulimia Nervosa (form 3.1).

Jenna and the therapist discussed the potential medical consequences of BN, particularly purging. The therapist requested that Jenna see her physician as soon as possible for blood work to assess for electrolyte imbalance. The therapist also requested that Jenna schedule a consultation for a psychotropic medication evaluation and provided her with psychiatric referrals.

At the end of the initial session, the therapist asked Jenna to describe her goals for treatment, ensuring that her treatment goals were realistic and well defined:

Orientation to CBT for BN

Case conceptualization

Referral to internist

Referral to psychiatrist

Set treatment goals

  • 1. Stop bingeing and purging.
  • 2. Become less obsessive about food.
  • 3. Improve body image.
  • 4. Learn to exercise moderately.
  • 5. learn to better manage anxiety and stress.

In light of the cognitive-behavioral model of BN, the therapist suggested Jenna add the following to her treatment goals:

  • 6. Reduce dietary restriction.
  • 7. Modify perfectionistic beliefs.
  • 8. Improve work performance and concentration.
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