Journal of Substance AbusE.

', 2, 38J-388 (J990)

BRIEF REPORT

Treatment of Laxative Abuse in a Female

with Bulimia Nervosa Using
an Operant Extinction Paradigm

Cynthia M. Hulik
Leonard H. Epstein
Walter Kaye
University of Pittsburgh School of Medicine
Western Psychiatric Institute and Clinic

Chronic laxative abuse was treated using an operant extinction paradigm in

a 29-year-old woman with bulimia nervosa. Access to self-adm inistration of
laxative and placebo were alternated in an ABAB design. Outcome was measured
by self-reported craving for laxatives and rates of drug self-administration. During
baseline, the subject exhibited high rates of both craving and self-administration.
During placebo phases, cravings and drug self-administration dec lined. Both
measures increased when active drug was reinstated. The final return to placebo
led to a decrease in craving and extinction of drug self-administration to zero
doses per day. This paper introduces the concept of laxatives as reinforcers and
provides a new approach to the treatment of laxative abuse in women with
bulimia nervosa.

Women with bulimia nervosa utilize a wide range of drugs to achieve

weight loss and to induce purgation (Harris, 1983; Mitchell, Boutacoff, Hat-
sukami, Pyle, & Eckert, 1986). Estimates of the prevalence of laxative abuse
in this population range between 38-75% (Abraham & Beumont, 1982;
Casper, Eckert, Halmi, Goldberg, & Davis, 1980; Johnson & Berndt, 1983;
Mitchell et al., 1986; Pyle, Mitchell, & Eckert, 1981). While little research
has been conducted on the pattern of self-administration of laxatives, patient
reports suggest that recommended doses are taken initially in response to
perceived constipation and bloatedness, or with the belief that they will aid
in weight loss, but that the amount of drug self-administered is rapidly
increased to achieve the desired laxative effects.
We have found that individuals with eating disorders who abuse laxatives
report difficulty with normal bowel function, water retention, and irritability
during periods of laxative abstinence or withdrawal (Bulik, Epstein, McKee,
& Kaye, 1990). Likewise, these individuals continue to self-administer laxatives
despite adverse effects such as cramping and diarrhea. The high rates of self-
Correspondence and requests for reprints should be sent to Cynthia M. Bulik, University of
Pittsburgh School of Medicine, Department of Psychiatry, Western Psychiatric Institute & Clinic,
3811 O'Hara Street, Pittsburgh, PA 15213.

381
382 CM. Sulik, LH. Epstein, and W. Kaye

administration suggest that laxative use is reinforcing to the individual with

an eating disorder. Likewise, the gradual need to take greater quantities of
the drug to achieve the same effect suggests that tolerance may develop to
the cathartic effects of laxative agents.
Despite the frequency of laxative abuse in the eating disorder population
and its potential adverse health consequences (Cummings, 1974; Harris, 1983;
Oster, Materson, & Rogers, 1980), effective treatments have not been pub-
lished. Similarly, dependence, craving, and withdrawal have not been ad-
dressed systematically. The treatment presented below uses an operant ex-
tinction paradigm that has been reported to be effective in the reduction of
craving and rates of self-administration of both opiates and cocaine in de-
pendent populations (O'Brien et aI., 1988).
This procedure is based on the premise that laxatives, like many other
drugs of abuse, are reinforcers and that various exteroceptive and intero-
ceptive stimuli prompt self-administration. The act of drug self-administration
thus comes to be under the control of these stimulus cues. Treatment involves
the continued presentation of the stimulus cues in the presence of drug self-
administration without presenting the pharmacological reinforcers, which
should lead to decreased craving and extinction of rates of self-administration
of the drug. We utilized an ABAB design alternating active drug with placebo
in a double-blind fashion.

METHOD
Subject
Ms. A. is a 29-year-old single white female with a 5-year history of bulimia
nervosa. The subject was diagnosed at the time of admission using semi-
structured interview techniques. Upon admission, she also met DSM III-R
(AP A, 1987) criteria for alcohol dependence, recurrent major depression,
and borderline personality disorder. Prior to admission she was binging 2-3
times per day. She had a 3-year history of laxative abuse which began at age
26 in response to perceived constipation and bloatedness. She reported that
she experienced a rapid increase in the number of laxatives needed to achieve
laxation. During her 3 years of abuse, the patient's stated purpose of ingesting
laxatives shifted from the treatment of constipation to the removal of post-
prandial sensations of fullness and bloatedness.
Two years prior to admission, she self-administered 25-30 stimulant lax-
atives (Correctol) per day despite adverse side effects such as cramping and
diarrhea. She achieved a year of partial remission from laxative use concurrent
with detoxification for alcohol abuse, but began using them again 6 months
prior to the present admission. At that time she initially took one pill per
week, but rapidly escalated to 15-25 tablets, 2-3 times per week at the time
of admission. She reported high laxative cravings. While she was not con-
stipated during the early phases of hospitalization, she frequently voiced the
desire for larger and smoother stools to decrease her postprandial discomfort.
Laxative Abuse 383

During inpatient treatment, Ms. A was treated with a cognitive-behavioral

treatment program focused on the eating disturbance and 20 mg of fluoxetine
per day to target her depressive symptoms. She was maintained on a steady
diet of 1200 kcal per day and she remained binge-free throughout the
treatment period. At admission she was 110% of average body weight (ABW)
according to the Metropolitan Life Tables (1959).
The patient recognized the dangers of laxative abuse but reported an
inability to stop on her own due to fears of constipation and weight gain.
This particular patient was asked to participate in the treatment protocol as
laxatives were her primary mode of purging. Vomiting 'was not included in
the symptom profile of her bulimia nervosa, She was offered the opportunity
to participate in a behavioral program to treat laxative abuse. She was
informed that she could receive placebo during the course of the study;
however, she was not informed of the design or the hypothesis of the
investigation.

Laxative Agent and Placebo

The orange-flavored bulk-forming laxative, CitruceI, was chosen for the
study. We chose the bulk laxative for this first study to introduce the procedure
to the staff with the intention of using stimulant laxatives in later trials if
the approach was successful. Citrucel contains 2g of Methylcellulose per 199
dose. The recommended dosage is one tablespoon three times per day when
constipated. The drJg was administered in 199 doses stirred briskly into 80z
of citrus-flavored Crystal Light to avoid adding any additional calories to the
patient's diet.
The placebo consisted of five parts of lactose, one part of low calorie Tang
for flavoring, and a pinch of unflavored gelatin for consistency also stirred
into 8 oz of Crystal Light. The active drug and placebo were indistinguishable
to the patient by retrospective self-report and to three blind tasters who were
unable to identify differences in taste or consistency on taste test trials.

Procedure
The treatment alternated active drug and placebo in an ABAB design.
Both the subject and all clinical staff were blind to both the drug versus
placebo condition and to the hypothesis of the study. Across all four phases
the subject was allowed to self-administer up to six doses per day of the
medicine provided. The upper limit was set to avoid potential uncomfortable
side effects such as bloating, difficulty swallowing, or cramping. Six individually
wrapped doses were supplied by the pharmacy each day. Unused doses were
returned at the end of each day. When a dose was desired, the subject asked
her nurse, who promptly mixed the dose with the Crystal Light in the
patient's absence and impartially administered the drug.
After each meal, Ms. A rated the following two questions on a 1-7 Likert
scale: (I) How much do you crave a laxative?; and (2) How full are you
384 C.M. Sulik, LH. Epstein, and W. Kaye

feeling now? Each night before bed, she rated how effective the drug was
and the number of bowel movements she had that day. The number of doses
requested per day provided a behavioral measure of drug self-administration.
The criterion for changing phases was based on four stable postmeal craving
ratings. The final placebo phase was extended until extinction was complete.
It is important to note that there were no changes in her prescribed daily
caloric intake throughout the study period. The subject ate 100% of her
meals throughout the protocol period.

RESULTS
Figure 1 presents the daily number of laxative doses requested. The mean
number of doses requested per day during the active drug baseline was 3.6.
This decreased to 2.5 doses/day during the placebo phase and increased to
2.8 during the second active drug phase. Drug self-administration rates
declined to an average of 1.1 doses/day during the final placebo phase with
no doses requested on the final two days of the study.
Figure 2 displays the mean daily craving and fullness ratings averaged
across daily meals. During the baseline active drug phase, craving and fullness
ratings were relatively high, but craving was decreasing. Craving ratings
continued to decrease during the first placebo phase with no observable
changes in fullness. During the second active drug phase, both craving and
fullness ratings increased. Finally, both craving and fullness decreased during
the final placebo phase.

6
Active Drug Placebo Active Placebo
1 Drug
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Figure 1. Daily doses of laxatives or placebo self-administered.
Laxative Abuse 385

Figure 3 (p. 386) presents the nightly ratings of drug effectiveness. Par-
adoxically, these ratings were lower during the active drug than placebo
phases of the study. The patient did not become constipated at any time
during the study and continued to have 1-2 bowel movements per day during
both active drug and placebo days.

DISCUSSION
This case report documents a novel approach to the inpatient treatment
of laxative abuse in a patient with bulimia nervosa. Using an ABAB design,
we demonstrated that the presentation of stimulus cues associated with laxative
use in the absence of the reinforcer (active laxative) led to extinction of both
self-reported craving and rates of drug self-administration in the inpatient
setting. The systematic changes in both craving ratings and rates of self-
administration in the active drug versus placebo phases suggest that the
experimental manipulation was the active ingredient in producing the change.
These predictions are based on the appetitive model of drug use (Stewart,
deWit, & Eikelboom, 1984) and the associated notion that reactivity to cues
associated with drug use plays a crucial role in continued use and relapse.
This model posits that cues associated with drug self-administration prime
reinitiation of drug use and elicit a "positive motivational state" similar to
that elicited by the drug itself (Niaura et al., 1988). This suggests that the
presentation of the drug or related cues directly stimulates the desire for

8.,--------,----------,r-----__T---------,
Active Drug I Placebo I Active I Placebo

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DAY
Figure 2. Mean daily craving and fullness ratings. (Average of four daily postmeal
ratings.)
386 C.M. Bulik, LH. Epstein, and W. Kaye

Active Drug,I Placebo I Active I Placebo

I Drug I
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Figure 3. Nightly drug effectiveness ratings.

more drug. According to this theory, successful treatment requires extinction

of cue reactivity to the stimuli usually associated with drug use in order to
decrease craving or urges to take the drug (Niaura et al., 1988) . Mere
abstinence from the drug does not suffice to reduce craving in the presence
of drug cues, as cue reactivity would remain strong, thereby increasing the
likelihood of cue-induced drug craving and a return to drug self-administra-
tion.
These results suggest that principles associated with more traditional drugs
of abuse can also be applied successfully to the understanding and treatment
of laxative abuse. To achieve maximum generalizability to laxative abuse
patterns seen outside the hospital situation, the operant extinction approach
should be extended to the use of laxatives habitually self-administered by the
patient such -as stimulant laxatives. Finally, complete treatment of laxative
abuse should also include exposure to other cues that trigger laxative taking
behavior such as drugstores, television commercials, and laxative-abusing
peers.
Interestingly, daily ratings of effectiveness of the laxative were higher
during the placebo phases than during the active drug phases. This finding
appears to be somewhat paradoxical, especially given that there were no
differences in the number of bowel movements the patient had across phases.
After breaking the blind, the patient recalled that on those active drug days,
despite regular bowel movements, she felt a greater urge to "cleanse her
system." She stated that according to the number of bowel movements, there
was no difference in effectiveness, but that she desired even more effectiveness
on active drug days and therefore rated the overall effectiveness as lower.
Laxative Abuse 387

This report is consistent with our hypothesis that self-administration of the

laxative is highly reinforcing and that taking the active laxative leads to even
greater craving and ultimately higher rates of self-administration. Alterna-
tively, the bulk laxatives themselves may have created a full or bloated feeling,
thereby contributing to the increased laxative craving in the active drug
phase. Replication of this procedure with stimulant laxatives will aid in
addressing this issue.
Finally, it is important to note that the patient was treated with 20 mg of
fluoxetine per day throughout the study period. If the decrease in laxative
taking had been secondary to the antidepressant effects of the drug, we would
have expected a more linear decline in both craving and rates of self-
administration. Given the observed changes concurrent with the phase switches,
we expect that the effect was due to the experimental manipulation and not
simply secondary to treatment with antidepressant agents.
The traditional and negative reinforcement model of drug use suggests
that laxatives may be the final reinforcers in a chain of eating-disordered
behaviors that begins with food deprivation. In that chain, individuals begin
by exhibiting restrictive dieting behavior which eventually gives way to bing-
ing. The physical discomfort, guilt, and fear of weight gain subsequent to
the binge are then removed via purging with laxatives. The sensation of
emptiness or cleanliness produced by the laxative abuse then promotes ad-
ditional food restriction, thus perpetuating the cycle. It is conceivable, how-
ever, that the major motivation for laxative use may be the positively rein-
forcing effects for the individual with an eating disorder and that they are
not self-administered exclusively to remove negative affective or physical states.
Given the frequency of laxative abuse in women with eating disorders and
the potential harmful physiological effects such as dehydration, electrolyte
disturbances, and loss of normal bowel function, programs for eating disorders
should not neglect specific treatment for laxative abuse. Failure to extinguish
craving and self-administration may allow laxative use to remain a significant
liability for slips and relapses in bulimic behavior.

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