DR.

RAM MANOHAR LOHIYA NATIONAL LAW UNIVERSITY

PSYCHOLOGY PROJECT

ON

CASE STUDIES: EATING DISORDERS

Submitted by: Submitted to:

Janvi Dorwal Ms. Isha Yadav
Enrollment no.210101134 Assistant professor
BA-LLB (hons.) Psychology
1 st year, 2nd sem (section- B) RMLNLU, Lucknow

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 TABLE OF CONTENTS

INTRODUCTION…………………………………………………….5-10

ANOREXIA NERVOSA……………………………………………...10

CASE STUDY (A)……………………………………………………..10-16

BULIMIA NERVOSA………………………………………………...16-17

CASE STUDY (B)……………………………………………………..17-21

BINGE EATING DISORDER (BED)…………………………………21-22

CASE STUDY (C)……………………………………………………...23-25

CONCLUSION…………………………………………………………26

REFERENCES………………………………………………………….27

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 DECLARATION

I, Janvi Dorwal, hereby declare that this project titled “Eating Disorders” is based on the
original research work carried out by me under the guidance of Ms. Isha Yadav.

The interpretations put forth are based on my reading and understanding of the original texts.
The books, articles and websites etc. which have been relied upon by me have been duly
acknowledged at the respective places in the text.

For the present project which I am submitting to this university, no degree or diploma has
been conferred on me before, either in this or in any other university.

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 ACKNOWLEDGEMENT

The work that I have done for this would not have been possible without the kind support of
many individuals and mentors.

I would like to extend my sincere gratitude to all of them. I am highly indebted to Asst. Prof.
Ms. Isha Yadav for her guidance and constant supervision as well as for providing
information regarding the project and support in completing it.

I would extend my gratitude to my seniors of my course, who constantly helped me find the
best resources for research.

I would like to thank my parents, siblings and my fellow batch-mates for their kind
cooperation and encouragement that helped me in completing this project.

Finally, I would like to acknowledge the books, journals and articles through remote access
facilities and access to reference materials required to complete the project.

Janvi Dorwal

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 INTRODUCTION

Eating disorders represent significant mental and physical health conditions characterized by
intricate and harmful associations with food, eating habits, exercise, and body perception. These
disorders impact an estimated 20 million women and 10 million men in the United States across
diverse demographics, regardless of gender, race, or ethnicity.
Individuals grappling with eating disorders face substantial clinical and psychological
challenges. They may experience enduring disruptions in social functioning and daily activities,
along with a spectrum of psychiatric and behavioral issues, medical complications, social
isolation, disability, and an elevated risk of mortality due to medical complications or suicide.
Indeed, suicide rates among individuals with eating disorders are alarmingly high, with those
with anorexia nervosa facing a 31-fold increase and those with bulimia nervosa facing a 7.5-
fold increase compared to the general population. The impact of an eating disorder reverberates
beyond the individual, affecting their entire family circle. This ripple effect can manifest in
heightened stress, diminished social connections, financial instability, strained personal
relationships, and a heightened risk of suicide.
The mortality risk associated with eating disorders is staggering, with individuals affected
facing up to six times higher mortality rates compared to those without such disorders. While
this increased risk applies across all types of eating disorders, individuals with anorexia nervosa
exhibit the highest mortality rates among all psychiatric conditions, attributed to a combination
of psychological and physiological complications.

DSM AND EATING DISORDERS:

The criteria of eating disorders evolved over time. In the Diagnostic and statistical Manual of
Mental Disorders, 4th edition (DSM-IV), eating disorders include anorexia nervosa (AN),
bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS). EDNOS is a
complex diagnosis recognized as all eating disorders that do not meet the diagnostic criteria
of AN or BN or cannot be categorized into either of the two. Binge eating disorder (BED) is
also classified into EDNOS and is listed in appendix. However, recent studies found that the
impact of physical and psychological damage caused by EDNOS is no less than that caused
by the classic eating disorders. In the DSM-5 issued in 2013, the diagnostic categories of
eating disorders were expanded to “feeding and eating disorders”, in which feeding and

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eating disorders first seen in infants and early childhood were included. Binge eating disorder
(BED) was listed individually in the diagnostic criteria. OSFED refers to eating disorders that
can lead to patients' clinical suffering or damage to social function, such as atypical AN,
atypical BN, atypical BED, purging disorder, and night eating syndrome, which do not meet
the criteria for AN, BN or BED. Apart from the changes in classification, the diagnostic
criteria of all types of eating disorders were relaxed in DSM-5. The weight loss requirement
has been relaxed, and the requirement of “amenorrhea” has been removed in AN. In the
diagnosis of BN, the frequency of binge eating or unduly compensational behavior was also
lowered similarly with BED.

The DSM-5 (Diagnostic & Statistical Manual of Mental Disorders, Fifth Edition) lists eating
disorders under the category of “Feeding & Eating Disorders” and describes that they are
“characterized by a persistent disturbance of eating or eating-related behavior that results in
the altered consumption or absorption of food that significantly impairs physical health or
psychosocial functioning.

Eating disorders are serious, complex and potentially life-threatening mental illnesses. They
are characterised by disturbances in behaviours, thoughts and attitudes to food, eating, and
body weight or shape. Eating disorders have detrimental impacts upon a person’s life and
result in serious medical, psychiatric and psychosocial consequences. They are common and
increasing in prevalence. There is a lifetime estimated prevalence of 8.4% for women and
2.2% for men.

Classification of Eating Disorders

Eating disorders are classified into different types, according to the Diagnostic and Statistical
Manual of Mental Disorders (DSM-5), Fifth Edition. Classifications are made based on the
presenting symptoms and how often these occur, and include:

• Binge eating disorder (BED)

• Other specified feeding or eating disorders (OSFED)
• Bulimia nervosa
• Anorexia nervosa
• Avoidant/restrictive food intake disorder (ARFID)
• Unspecified feeding or eating disorder (UFED)

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 • Pica
• Rumination disorder

EPIDEMIOLOGY

PREVALENCE

(Anorexia Nervosa) Galmiche et al. have performed an extensive systematic review of 94

studies published between 2000 and 2018 that addressed the prevalence of formally
diagnosed eating disorders in the general population. They explained the high variability of
prevalence rates by the use of different diagnostic instruments [most commonly used:
Structured Clinical Interview for DSM (13%), Composite International Diagnostic Interview
(12%) and Eating Disorder Examination (11%)], diagnostic criteria [DSM-IV (78%), DSM-5
(14%) and DSM-III-R (4%)] and clinical investigation methods [face-to-face interview
(51%), paper-and-pencil questionnaire (27%) or online or by telephone (22%)]. Weighted
means were constructed from the prevalence rates and the population sizes of each study
included, but were most likely not stratified for age. We therefore reproduce only the ranges
of lifetime prevalence rates of anorexia nervosa, which were 0.1% to 3.6% in females and 0%
to 0.3% in males.

(Bulimia Nervosa) Qian et al. reported an overall lifetime prevalence rate for bulimia nervosa
of 0.6% (95% CI 0.3–1.0). This review included a relatively large (40%) proportion of Asian
studies. For bulimia nervosa the lifetime prevalence in Western countries was 7.3 times
higher than that in Asian countries. The lifetime prevalence rates in females and males (Table
1) were close to the rates described by Galmiche et al. The pooled overall lifetime prevalence
rate rose up to 1.4% (95% CI 0.0–6.3), when using only studies that applied DSM-5 criteria
(18%; all in Western countries)

These elevated figures highlight importance of timely diagnosis and appropriate treatment of
BPD patients in all clinical settings.

SOCIODEMOGRAPHIC FACTORS

The most commonly studied correlates were age, sex, ethnicity, education level,
socioeconomic status, urbanicity, and marital status. As can be seen, many null effects were

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observed; however, this may be expected due to studies that conducted multiple analyses for
each ED diagnosis. Overall, EDs appear to be clearly associated with being female and
younger overall. On a specific diagnostic level, however, this relationship was not so robust
for BED, with most age-related effects being null. Less clear was an association between ED
epidemiology and ethnicity, education, socioeconomic status, urbanicity, or marital status.
The vast majority of ethnicity analyses were null, and of those analyses that found an effect,
one ethnicity did not tend to dominate in its association with EDs. On a diagnostic level,
however, BN tended to have a higher prevalence amongst minority ethnicities. An equal
number of analyses found a significant association between lower and higher education level
with ED epidemiology. Most analyses reported a null effect of socioeconomic status;
however, of the six effects found, four were for an association with lower socioeconomic
status. In terms of the impact of urbanicity and marital status, the majority of effects were
null.

DIAGNOSIS/ TREATMENT

Various types of treatments and therapies including healthy food with a balanced diet and
medical care can be used to cure eating disorders in a variety of ways, discussed below:

For people with bulimia nervosa or binge eating disorder, if you also have another mental
health condition such as depression, anxiety, impulse control or substance use disorder, your
doctor may prescribe antidepressant or mood-stabiliser medications. These medications may
also be useful alongside psychological treatment, even if you don’t have one of these
conditions.

Cognitive Behavioural Therapy (CBT)/ Enhanced (E)-CBT

CBT is used for a variety of mental health conditions, and people receiving CBT for eating
disorders experience improvements in other related symptoms like depression and anxiety. In
this, strategies and coping techniques to identify with beliefs and emotions such as body
shape, weight and appearance are taught to manage with. On the other hand, CBT-Enhanced
is used for all types of eating disorders.

Interpersonal Psychotherapy

It focuses on the link between when and how your symptoms started and on problems you
have relating to other people. Four different “problem areas” are used in IPT. These include:

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 • Interpersonal deficits: This often includes feelings of isolation or a lack of close,
fulfilling relationships. The relationships in question don’t have to be romantic, but
can also be related to those with friends or family.

• Role disputes: This often involves a difference in expectations between yourself and
one or more important people in your life, such as parents, friends, or employers.

• Role transitions: This is typically concerned with big life changes, such as being on
your own for the first time, starting a new job, or being in a new relationship.

• Grief: This can include feelings of loss due to the death of a loved one or the end of a
relationship.

Family-Based Treatment (FBT)

This kind of therapy is also called as Maudsley method. The individuals’ family is the biggest
force behind this technique as it helps to fasten the pace of recovery process with the support
of uninterrupted healthy behavior, maintaining a positive lifestyle while also restoring proper
eating patterns and healthy weight. It is considered as a vital therapy for dealing with eating
disorders in children and adolescents.

Dialectal Behavior Therapy (DBT)

DBT focuses on managing difficult emotions in addition to changing behaviors associated

with the dysfunctional consumption disorder. Some specific skills that it aims to build and
develop include interpersonal skills, openness, coping distress, defense mechanisms and
emotional expression. DBT has been prominently used in the treatment of some of the main
eating disorders of binge eating disorder, anorexia nervosa, and bulimia nervosa.

Cognitive Remediation Therapy (CRT)

CRT focuses on promoting big-picture thinking and mental flexibility. It’s currently used in
the treatment of anorexia nervosa. In CRT, a variety of exercises and tasks are used to help
address the rigid thinking patterns that are often associated with anorexia nervosa. Some
examples of tasks are, working with non-dominant hand, alternative ways to find solution to a
problem.

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Psychodynamic Psychotherapy

This is the core therapy which aims to uncover the underlying thoughts and causes which
leads to one’s eating disorders by diving deeper into the conflicts and motives of the mind. In
these cases the therapist, discovers that the ailment happens due to unwanted needs and
unresolved wants. This is how the root cause is addressed to reduce the risk of relapsing the
disorder.

ANOREXIA NERVOSA

Anorexia, officially called anorexia nervosa, is an ingesting disorder. People with anorexia
restrict the quantity of energy and the varieties of meals they consume. Eventually, they shed
pounds or cannot keep the appropriate frame weight primarily based on their height, age,
stature and bodily fitness. They can also additionally exercise compulsively and/or purge the
meals they consume through intentional vomiting and/or misuse of laxatives. Individuals with
anorexia even have a distorted self-photograph in their frame and feature an extreme worry of
gaining weight. Anorexia is an extreme situation that calls for treatment. Extreme weight
reduction in humans with anorexia can result in risky fitness troubles or even death.

Eating disorders affect at least 9% of the worldwide population, and anorexia affects
approximately 1% to 2% of the population. It affects 0.3% of adolescents. Anorexia most
commonly affects adolescents and young adult women, although it also occurs in men and is
increasing in numbers in children and older adults.

CASE STUDY: (A)

A 14-year-old girl, student of class 9, from a Sikh extended family of urban background
presented with 2 years history of decreased food intake. Patient was initially a thin built girl,
but as per family members, she started to gain weight when she turned 12. Though she did
not appear very fat, but was criticized by family members and peers for the weight gain
which prompted her to join a gymnasium. In addition, in the quest to lose weight she started
imposing dietary restrictions on herself. Gradually food intake decreased from 3 proper meals
and frequent snacking in between to mere 2-3 bowls of vegetables per day. Repeated efforts
by parents to make her eat failed miserably and were attended by crying spells and anger
outbursts. She started to lose weight and developed amenorrhoea within a year but continued

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with the dietary restrictions. A month before presentation she also started to remain sad
throughout the day, lost interest in previously enjoyable activities and started to have poor
sleep along with decreased attention and concentration. At the time of presentation her food
intake consisted of a few biscuits per day only. Anthropometric measures revealed
weight=39.5kg, height=162 cm and BMI= 15.05 Kg/m. She appeared cachectic, pale, with
lanugo hair over her face. She had prominent bones with a maxillary prominence. Her
secondary sexual characteristics were poorly developed. Patient was hospitalized and relevant
investigations were carried out to rule out any endocrine, metabolic or any other medical
disorder which could explain the weight loss and amenorrhea. In addition, careful psychiatric
evaluation was done to rule out any co-morbid psychiatric disorders. Patient initially reported
decreased appetite and food sticking in her throat as the reason for not eating. However, once
rapport was established she gradually revealed fear of becoming fat as the reason for her
dietary restrictions. Interestingly, patient equated being thin with successful. Further
assessment revealed that since her early child hood her paternal grandmother had been the
dominating figure in their family to the extent that parents could not make any independent
decisions for themselves or for the patient. Due to the same patient’s grandmother took the
role of the head of the household which patient’s father should have ideally taken. In
addition, patterns of communication in the family had been faulty with no direct
communication between patient and her mother; and between the parents. These indirect
communication patterns led to marked inconsistencies in parental handling, accentuated by
patient’s grandfather’s liberal attitude and grandmother’s strict notions which conflicted with
each other. Over time patient gradually learned whom to approach in order to fulfill her
demands. Patient also revealed the presence of bias on the basis of gender in the family. She
reported that extra care, attention and praise given to her brother by the grandmother was a
source of continuous stress for the patient, and she wanted to become successful in order to
earn the same. This attitude was further reinforced by the over expecting attitude of family
members. Sessions with the family revealed that patient had always had a difficult
temperament and she would throw temper tantrums when her demands were not met. She in
addition was egoist, was very sensitive, had a perfectionist attitude and was highly ambitious.
Psychometry revealed disturbed relations with prominent conflicts with mother and brother,
poor self esteem and affective instability. Initial attempts at increasing her food intake in
graded manner were met with resistance. She would repeatedly indulge in anger outbursts
and self harming behavior. Behavioral measures like contingency management, token
economy, positive reinforcement, activity scheduling, and externalization of interests were
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used to decrease the maladaptive behaviors and eventually it was possible to engage her in a
meaningful conversation. She was educated about balanced diet, anthropometry, ideal body
weight and symptoms of malnutrition. Gradually eating specific amount foods, increasing
food items in diet was made contingent with the activities she liked. Psychotherapeutic
measures were instituted in the form of supportive sessions and family therapy. During
supportive psychotherapy sessions with the patient her fears, apprehensions, day to day
problems were addressed. Emphasis was laid on building up her skills, equating success with
leading a good personal and academic life. During family therapy sessions, which 235
involved patient’s parents and grandparents, aforementioned issues like abnormal
communication patterns amongst family members, inconsistencies in parenting, critical and
over expecting attitude were addressed and they were asked to be patient. Patient was also
started on T. Mirtazapine 30mg for depressive symptoms and continued for 6 months. Patient
gradually increased daily food intake, initially added few sweets to her diet and over one year
started to take fruits, rice and curd. She started to gain weight and her menstrual cycle
resumed after a year or so. Gradually her diet intake further improved and she eventually
included breads and vegetables in the diet after one and a half year. Her interpersonal
relationships improved and she started to perform better at school. She was maintaining
improvement at the time of last follow-up, 2 years after discharge.

THERAPEUTIC MEASURES (BEHAVIOURAL THERAPY)

(A)BEHAVIORAL MEASURES

Those in which some other aspect of participants’ behaviour is observed and recorded.
This is an extremely broad category that includes the observation of people’s behavior
both in highly structured laboratory tasks and in more natural settings. In our case, the
following behavioral strategies are used-

Contingency Management: Contingency management (CM) is a type of behavioral therapy

rooted in the basis of operant/behavioral conditioning. Contingency management in
stipulating weight gain and to reinforce behaviors consistent with treatment goals, is routinely
used. It is not only is not explicitly limited to managing substance use, but is used also in the
context of other psychiatric treatments, for example, it can involve promoting regular follow-
ups in treatment settings or increasing adherence to medications. Gradually eating specific
amount foods, increasing food items in diet was made contingent with the activities she liked.

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Token Economy: A token economy is a system of contingency management based on the
systematic reinforcement of target behavior with the help of behavior inducing reinforcers
called as token. Our subject’s attempts at maladaptive behavior, and resistance to perform
any meaningful conversation were dealt with the same.

Positive Reinforcement: At last, the behavioral technique of positively reinforcing and

establishing a pattern of behavior with the patient by offering those rewards was taken into
part and parcel. The patient was expected to perform in a particular manner by the family
members, due to which she became very sensitive, but the therapy improved her condition.

(B) PSYCHOTHERAPY

This approach focuses on changing problematic behaviors, feelings, and thoughts by

discovering their unconscious meanings and motivations. Psychoanalytically oriented
therapies are characterized by a close working partnership between therapist and patient.
Patients learn about themselves by exploring their interactions in the therapeutic
relationship.

Cognitive Behavioral Therapy: (CBT) is the leading evidence-based treatment for mental
symptoms including, eating disorders. The cognitive model of eating disorders posits that the
core maintaining problem in all eating disorders is overconcern with shape and weight. Our
subject valued the sense of control that they derived from undereating leading to self-induced
vomiting, laxative and/or diuretic misuse, especially (but not exclusively) those who
experience episodes of loss of control over eating called subjective binges.
Psychodynamic Therapy: It presents a model describing how attachment insecurities lead to
negative affect or anxiety, which in turn may result in maladaptive defense mechanisms
and/or eating disorder symptoms. For example, the patient has her whims and fantasies about
the misconception of being slim, in order to attain a successful career and earn money. The
research supports this conceptual model by showing how early experiences lead to
attachment insecurity that subsequently leads to affect deregulation and eating disorder
symptoms like anorexia.

DIAGNOSIS

A healthcare issuer can diagnose someone with anorexia primarily based on the standards for
anorexia nervosa indexed within side the Diagnostic and Statistical Manual of Mental

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Disorders (DSM-five) posted with the aid of using the American Psychiatric Association. The
3 standards for anorexia nervosa beneath the DSM-five include:

1. Restriction of calorie intake main to weight reduction or a failure to advantage weight

ensuing in a substantially low frame weigh dependent on that person’s age, sex, top
and level of growth.
2. Intense worry of gaining weight or becoming “fat.”
3. Having a distorted view of themselves and their condition. In different words, the man
or woman is not able to realistically verify their weight and form believes their look
has a robust impact on their self-confidence and denies the clinical seriousness in their
contemporary low frame weight and/or meals restriction.

Even if all the DSM-five standards for anorexia aren’t met, someone can nonetheless have a
critical consumption disorder. DSM-five standards classifies the severity of anorexia in
keeping with frame mass index (BMI). Individuals who meet the standards for anorexia
however who aren’t underweight notwithstanding sizeable weight reduction have what’s
called peculiar anorexia.

PROCEDURE

The treatment followed the protocol of typical eating disorder of Anorexia Nervosa in an
impatient setting, suggesting its onset from childhood and reaching unto any level of
development inclusive of adolescence and adulthood. The patients are analyzed on the lines
of the Diagnostic and Statistical Manual (DSM)-5 criteria. In the current case series, the
patient is facing neurotic traits with poor parenting and child management in presence of
anger outbursts. It was ensured that the nutrition and diet were maintained due to the
worsening conditions of the patient. All in all, a possible multi disciplinary approach
including medical, nutritional, social, and psychological components was recommended.

MAIN ELEMENTS OF THERAPY

(1) To develop a positive insight about body positivity while rejecting the disturbing
social norms of body image tightly linked to overvalued beliefs, primarily the
overvaluation of thinness.
(2) To focus on the physiological component that is the presence of medical signs and
symptoms resulting from starvation, i.e, severe loss of muscle mass, fatigue,
exhaustion, insomnia and others. Also the patient may associate food and eating with

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 guilt. They may seem unaware that anything is wrong or be unwilling to recognize
their issues around eating.
(3) To analyze the distorted relationship of the patient with the family members in
accordance of Psychometry and reinforcing her attitude-aggressive behavior
(contingency management, token economy, activity rescheduling) to decrease the
maladaptive behavior.
(4) To gain the support of friends and family in the form of Psychotherapeutic measures
and therapy. During sessions with the patient her fears, apprehensions, day to day
problems were addressed. Emphasis was laid on building up her skills, equating
success with leading a smooth life.

RESULTS

(1) Being a classic historical form of anorexia nervosa, the food intake is highly
restricted, and the patient may be relentlessly and compulsively overactive, but they
got a grasp on such restrictive diet.
(2) The patient initially showed resistance to treatment, however later responded to
combination of behavioural and psychological measure leading to a clearer clinical
picture and the risks associated with Anorexia Nervosa.
(3) After the subject was diagnosed, medications of T. Mirtazapine 30mg for depressive
symptoms which continued for 6 months, and a balanced diet with 3 proper meals a
day, good sleep improved their plummeting BMI of 15.05 Kg/m2 (weight=39.5kg,
height=162 cm)
(4) One of the most interesting finding after the treatment was that the subject gradually
improved her interpersonal relationship with her family members which were
inconsistent with strict notions and lacked communication. Over a period of time our
patient understood whom to approach for fulfilling her demands.

IMPLICATIONS AND DISCUSSION

The results of the preliminary case series of multiple therapies for patients with the ailment of
Anorexia show that patient attained clinically gains, and that the gains are not attributed to
spontaneous recovery, but improved systematically during the therapy, and most importantly,
the gains of treatment had maintained for over a long span of time.

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One of the elements of the treatment, the patients reported to have been among the most
helpful, was the psychotherapy sessions where the patient was comfortable and open to
interact with the therapist about their personal matters of apprehensions, day-to-day activities,
fear, anxiety and discernment. The content and dynamics of the therapeutical measures were
easily conveyed to the patients, and they can easily identify with the model. Also, addressing
the emotional deprivation of the patient, and providing a nurturing base by the therapist
through limited re-parenting, combined with developing skills for coping with her
perfectionist attitude towards weight loss, seemed as the crucial elements.

The study has at least three limitations:

(1) Lack of a control group, which would allow evaluating the genuine impact of
CBT-E on weight gain and eating disorder pathology, Moreover, during the
follow-up period, most patients received outpatient treatment, which probably
influenced long-term outcome.
(2) The problem of ‘generalization. Any generalization of the effects of schema
therapy in a single case trial is limited due to the small number of patients
included, thus the feasibility of the treatment by other therapists is uncertain.
(3) Randomization of patients to different treatments seems necessary in order to
prevent a selection of highly motivated patients, which may bias outcome
interpretation.

The present study should be considered as an indication and a preliminary test of the effects
of therapies made for patient suffering from eating disorders like that of Anorexia. The
results of the present study indicate that the following stated therapeutical measures could
both be a suitable and an effective approach to the challenging task of treating patients with
Anorexia Nervosa.

BULIMIA NERVOSA

Bulimia is a psychological eating disorder where individuals tend to indulge in episodic

binge eating i.e, consuming a large quantity of food in one go without having any control
over it. This result in choosing inappropriate ways like vomiting, compulsive
exercising/workout, overuse of laxatives and diuretics to lose weight.

Bulimia, also known as bulimia nervosa, usually begins in late adolescence or early
adulthood. Normally, you binge and purge in private. When you binge, you feel humiliated
and ashamed,

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and when you purge, you feel relieved. Bulimics typically weigh within the normal weight
range for their age and height. They may, however, be afraid of gaining weight, desire to
reduce weight, and be unsatisfied with their physique. Some of the risk factors (Co-
Morbidities) along the lines
of bulimia include:

• Stress and Anxiety disorders

• Substance use disorders
• Traumatic experience
• Depression
• Frequent Dieting

The goal of any treatment is to break the pattern of binge-purge behavior, correct distorted
thinking patterns, and develop long-term behavioral changes. Typical treatment consists of
medications plus psychological counseling and nutritional counseling.

CASE STUDY: (B)

Jessica (pseudonym) was 22 years old and had a four-year history of binge eating, vomiting,
and laxative usage when she came to the centre. Jessica revealed that she was 18 years old
when she broke up from a relationship with her partner. As a way of coping with the pain, she
began to eat excessively at times (comfort eating). Jessica gained about 4 kg over the course
of a few months and was distraught when she learned that some of her garments no longer fit
her, especially as she approached vacation. She remembered hearing people and some of her
classmates about losing weight by vomiting and it being a means of weight control and
keeping it controlled.

She, on the other hand, had never contemplated doing it herself since she believed it was a
"disgusting thing to do” and added that she felt really uncomfortable one evening after a
particularly significant round of overeating and believed that if she could only vomit, it
would at least lessen the discomfort. She inserted her forefinger into the back of her throat
and began vomiting. She felt ill afterwards, her throat was raw, and her stomach hurt, but
she admitted to feeling relieved from the shame and regret of overeating.

She pledged at the time that she would never do it again. After a night out with friends and
after "a few too many" alcoholic beverages a few evenings later, she went on a 'feeding
frenzy' eating practically anything she could get her hands on. It felt easier to vomit this
time, so the next day she bought a packet of laxatives and took three times the suggested
quantity to clear her system.
Jessica tried starvation over the next few days, desperate to lose weight and begin a 'new
chapter in her life.' This continued until day 3, when, hungry and tired from a late night at
work, she couldn't resist the temptation to stop by a nearby Chinese restaurant, who’s buffet
system attracted her attention leaving her stuffed and with a feeling of guilt, and vomiting
along laxative use.

Over the next few months, she created a pattern in which she would try any and every new
diet, last 2 to 4 days, and then engages in bingeing and purging behavior. Jessica weighed 9st
8lbs and stood 5ft 3ins tall. Jessica's family and friends were unaware of her problems,
despite the fact that they were aware of her frequent dieting. Jessica was dissatisfied with her
life and had considered suicide on few occasions, but only after a night of drinking followed
by a binge and purge episode. When Jessica went to treatment, she was on 40 mg of
Fluoxetine (Prozac) when she attended the therapy.

PERSONAL BACKGROUND

Jessica was raised as the eldest of five children. She had 1 sister and 3 brothers, her dad and
mom divorced while she become elderly sixteen yrs, specifically because of her father’s
drinking. Jessica felt near her Mum who had a records of been dealt with for despair via way
of means of her G.P.

Jessica disclosed that from the age of 12 to fourteen she become sexually abused via way of
means of a neighbor, she in no way informed her dad and mom till she reached the age of 16
when they moved lower back to Ireland. Leaving college at 16 she controlled to stable
employment in an advertising and marketing agency and had labored her manner up the firm,
taking numerous expert examinations alongside the manner.

ETIOLOGY

The exact cause of bulimia nervosa is unknown, however it is most likely complex.
Abnormalities in interoceptive function, particularly of the insula, may play a role in the
binging behaviour that comes with this illness. Patients with anorexia and bulimia nervosa
exhibit significant abnormalities in white matter structural and useful connectivity, notably
within appetite-regulating and taste-reward pathways, according to a 2016 study. Other
research has suggested that intrinsic functional brain architecture may be altered.

EPIDEMIOLOGY

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Bulimia nervosa can afflict both men and women, however it is more common in women. The
average onset age is roughly 12.4 years. In the United States, the prevalence of bulimia
nervosa is estimated to be 0.9 percent among teenagers, 1.5 percent among women in general,
and 0.5 percent among men in general. While the prevalence of bulimia nervosa in
developing nations is not established much, prevalence estimates for males and females in
North America, Australia, and Europe range from 0.1 percent to 1.3 percent for males and 0.5
percent to 2.0 percent for females.

DIAGNOSIS/TREATMENT

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes the following
diagnostic criteria for bulimia nervosa:

• Recurrent episodes of binge eating. An episode of binge eating is characterized by

both of the following:
o Eating, in a discrete period of time (e.g., within a two hour period), an amount
of food that is definitely larger than what most people would eat during a
similar period of time and under similar circumstances.
o Lack of control over eating during the episode (e.g., a feeling that you cannot
stop eating, or control what or how much you are eating).
• Recurrent inappropriate compensatory behavior to prevent weight gain, such as self-
induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or
excessive exercise.
• The binge eating and inappropriate compensatory behaviors both occur, on average, at
least once a week for three months.
• Self-evaluation is unduly influenced by body shape and weight.
• Binging or purging does not occur exclusively during episodes of behavior that would
be common in those with anorexia nervosa.

TREATMENT THERAPIES USED

Chem-20 Panel

Also called as Comprehensive Metabolic Panel, test is a screening panel of 14 tests that look
at your metabolism.

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The patients’ body gets energy from food through a process called metabolism. The tests in
this panel help see how well your liver and kidneys are working and these are the two major
organs involved in metabolism.

These tests also measure the electrolyte and acid/base balance, your blood sugar, and your
blood proteins. Electrolytes are mineral salts that are involved in many cellular processes,
including maintaining your body's fluid and acidity (pH) levels. It also measures vitamins,
and pancreatic function, adrenal glands, (levels of cortisol and adrenaline produced in times
of stress).

Thyroid and parathyroid panel which indicates level of metabolic functions.

Therapy Rating Adherence Scale, Safran, J.D. and Segal, Z.V. (1990); short-term
cognitive therapy rating scale (on a measure of 0-5) to formally measure the suitability of the
treatment. A high scale is considered as a good prognosis while low ratings indicate a poor
performance of the cognitive treatment.

Cognitive Behavioral Therapy (CBT)

Phase 1: Session 1 to 4

Creating a healthy therapeutic connection, setting treatment objectives and assigning work
was done in the 1st session. Explaining the CBT model of Bulimia Nervosa, including
predisposing, precipitating, and perpetuating elements that led to the establishment of an
original formulation and the Will to Change (Pros and Cons of changing).

Jessica received psychoeducation about the negative consequences of bingeing and purging
behaviour, as well as information about blood sugar imbalance, the glycemic index (GI),
foods with high and low GI, and how neurotransmitters affect hunger and mood.

Explaining the necessity of establishing a daily eating schedule consisting of three meals and
two snacks (gave her a detailed specific food dairy). Identifying and interrupting the vicious
cycle of bingeing and purging behaviour. Within the setting of an Eating Disorder,
identifying the link between thoughts, feelings, and behaviour.

Phase 2: Session 5 to 15

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This phase is at the heart of therapy for Jessica. It involved addressing the maintaining
factors listed below:

• Negative Body Image

• Cognitive Distortions
• Lifestyle activities
• Physiology (blood sugar, stimulants)
• Food Scripts
• Stress
• Addictive Process (bingeing/purging alcohol misuse)

Phase 3: Session 16-19 (final)

Relapse Management Skills discussed.

• What made her vulnerable to developing the problem in the first place?
• What has she learned in Treatment?
• What areas leave her vulnerable and what strategies undermine them?
• What are her personal strengths?

RESULTS AND DISCUSSIONS

Our subject Jessica, fought with the notions of distorted body image which led her to
establish an initial formulation on predisposing, precipitating and perpetuating factors.
She was able to create a sound and interactive connection with the therapies and cognitive
treatments used upon her.
As observed naturally in cases of bulimia, patient use to die of any co-morbidities or suicide,
the subject came out as a successful and healthy individual with proper hunger and dietary
habits.
Unlike in anorexia nervosa, in which complications are due to weight loss and malnutrition,
the type and severity of medical complications of bulimia nervosa can be determined based
on the frequency and the method the patient uses to purge, where Jessica, came over with
reduced symptoms and secured life.

BINGE EATING DISORDER

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Binge Eating Disorders (BEED) is a clinical syndrome that was recently recognised as an
independent diagnostic in the DSM-5. When compared to the non-BED obese population,
those with Binge Eating Disorder (BED) have significantly inferior quality of life, perceived
health, and psychological discomfort. Treatment for BED is difficult for a variety of reasons,
including clinical and psychological factors, as well as a high rate of drop-out and low goal
stability. The goal of this study is to look into the existing data on this subject and summarise
the current state of knowledge on both diagnostic concerns and the most successful treatment
options.

DIAGNOSIS/TREATMENT

According to the DSM-5, diagnostic criteria for binge eating disorder include:

• Recurrent episodes of binge eating. An episode of binge eating is characterized by

both of the following:
o Eating, in a discrete period of time (for example, within any two-hour period),
an amount of food that is definitely larger than most people would eat in a
similar period of time under similar circumstances
o A sense of lack of control over eating during the episode (for example, a
feeling that one cannot stop eating or control what or how much one is eating)
• The binge-eating episodes are associated with three (or more) of the following:
o Eating much more rapidly than normal
o Eating until feeling uncomfortably full
o Eating large amounts of food when not feeling physically hungry
o Eating alone because of feeling embarrassed by how much one is eating
o Feeling disgusted with oneself, depressed, or very guilty afterwards
• Marked distress regarding binge eating is present.
• The binge eating occurs, on average, at least once a week for three months.
• The binge eating is not associated with the recurrent use of inappropriate
compensatory behavior (for example, purging) and does not occur exclusively during
the course of anorexia nervosa, bulimia nervosa, or avoidant/restrictive food intake
disorder.

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 CASE STUDY: (C)

Maria is a divorced 38-year-old lady who works for a huge government agency in a higher-
level administrative role. She has a successful career and a number of close friends with
whom she enjoys spending time. She came to get therapy after years of failing to seek proper
treatment for her binge eating disorder. She mentions a previous counselling session she had
during college when she was sexually assaulted. She expressed her concerns about binge
eating to her counsellor, but she was informed that they needed to stay focused on issues
directly related to the sexual assault. She waited years to seek therapy again, embarrassed for
bringing up her binge eating behaviour, and when she did on two subsequent occasions, she
was told to meet a dietitian to learn ‘how to eat healthy’.

She explains to you that she wishes to assist with binge ingesting and that it’s now no longer
a count of knowledge – “I understand what to do. I simply can’t do it. I can't manage my
ingesting.” She describes a sample in which she works difficult to “get on track” together
along with her ingesting, however unearths it hard to maintain. She is 5’4” and weighs 180
lbs. Furthermore, she first began out binging in university, and her weight fast elevated from
135 lbs as a freshman to 160 lbs. via way graduation. Not only that, but she has been handled
for high blood pressure and hypertension, and high cholesterol for the last five years, now
she comes to get advice of her medical doctor after a recent go to in which she suggested
growing issues with returned back and knee ache because of her extra weight.

ETIOLOGY

1. Disordered Eating
2. Obesity/ Overweight
3. Trauma
4. Anxiety, Depression (Co-morbidity)

EPIDEMIOLOGY

A systematic seek of 3 digital databases (PubMed, EMBASE, and PsycINFO) located 32

studies assembly GBD inclusion criteria. The worldwide pooled incidence of BED changed
into 0.9% (95% self belief intervals: 0.7–1.0%). Although women (1.4%, 1.1–1.7%) had
better incidence than men (0.4%, 0.3–0.6%), no good sized distinction in incidence changed

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into located among high-earnings countries (0.9%, 0.8–1.1%) and low- and middle-earnings
countries (0.7%, 0.3–1.1%).

THERAPIES

Two of the following treatments have an empirical support for individuals with Binge Eating
Disorder (BED):

Cognitive Behavioral Therapy (CBT)

The most researched and developed psychological strategy for treating BED is Cognitive-
Behavioral Therapy (CBT). The study focuses on the etiological basis of bingeing and its link
to a self-esteem that is overly reliant on body type. The most extensively utilised CBT models
are modifications of those established for BN, with a focus on weight loss and consideration
of BED's lower restriction levels and cognitive distortions when compared to BN. CBT is a
practical and adaptable intervention, with setting and duration that can be tailored on clinical
needs and the possibility of being carried out independently or in combination with, it have
yet showed high efficacy when administered alone, with BED remission rates around 50-
60%. Long term effects of CBT approaches include, in fact, a gradual normalization of eating
patterns and reduced relapse occurrence, these effects are coupled with the improvement of
disinhibition, hunger, negative feelings .

Interpersonal Psychotherapy

Interpersonal Psychotherapy is another evidence-based psychological treatment (IPT). In

order to improve social interactions and manage with interpersonal problems, this strategy
focuses on personal relationships and role transitions that may have a predisposing and
sustaining role in EDs. In fact, this disease frequently manifests in adolescence, often in the
context of interpersonal and maturational difficulties, and its persistence over time can be
linked to dysfunctional relational styles that trigger depression, anxiety, and anger feelings,
which in turn underpin eating impulsivity. It has been theorised that IPT, when delivered in a
psychodynamic framework with an emphasis on cyclical dysfunctional patterns, could be
particularly useful for people who overeat because of unpleasant moods. In any event, it
appears to be beneficial against depression and psychosocial distress. CBT and IPT have been
found to have equivalent efficacy in binge reduction, both at the conclusion of therapy and at
a one-year follow-up, with a considerable reduction in psychiatric comorbidities and, in some
cases, a significant decrease in weight.

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RESULT AND DISCUSSION

The therapy went successful and the patient was dealt with major Psychotherapeutic
approaches to BED, mostly based on Cognitive- Behavioral Therapy (CBT) models, which
are recommendable as first-line treatments with the wider evidences of efficacy also at long-
term follow-up, along the lines of Interpersonal Psychotherapy with a multidisciplinary
treatment choice that seem to emerge as the best treatment strategy for long-term
management of this disease, with primary goals on binge abstinence and at a second time a
sustainable weight loss.

The subject also lost the etiological symptoms in regards of her co-morbidities i.e, mental
stress, anxiety, fear of gaining weight, unmanaged eating schedules, and phases of depression
by way of explanation and cognitive factors at a deep level in order to promote a
comprehensive condition.

In addition to this, patient was treated on pathogenic mechanisms of the disease and about
strategies suitable to establish a stable change. Interventions are focused on lifestyle
modification to promote a general improvement of health and quality of life, rather than on
weight loss itself.

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 CONCLUSION

Eating problems are probably lifestyles threatening, ensuing in loss of life for as many as 10
percentages of folks who broaden them. They also can purpose vast mental misery and main
bodily complications. Important relationships are eroded because the consumption disease
takes up time and energy, brings approximately self-absorption, and impairs self-esteem. This
attitude is beginning to (and should) change since it allows such patients to become informed
consumers of cognitive health services

Treatment need to be initiated as quickly as possible, consciousness upon the on the spot
misery skilled with the aid of using the individual, and intention to assist the affected person
and own circle of relatives come to be effective sufficient to triumph over the ingesting
disease.

Eating issues are a first rate supply of morbidity, and it's far acknowledged that only a
handiest minority of patients are considered for treatment. Primary prevention has regarded
elusive, even though tries are being made inclusive of the complete instructional applications
in numerous institutes and clinical fitness centers. Until now, the most broadly effective
treatments are the psychotherapeutic approaches, especially CBT, which not only has a solid
empirical basis but also has been widely accepted by consumers and clinicians around the
globe.

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 REFERENCES

Dr. Savita M, Dr. Nidhi M, Dr. Basant P. (2014) Anorexia nervosa in Indian adolescents: a
report of two cases. J. Indian Assoc. Child Adolesc. Ment. Health, 10(3), 230-243.

Molloy, M. (2021, June 22). Case study of bulimia nervosa (BN). Mind & Body Works.
Retrieved March 12, 2024, from https://mindandbodyworks.com/case-study-of-bulimia-
nervosa-bn/

Case Study (Binge Eating Disorder) (2016) Division 12, Society of Clinical Psychology,
American Psychological Association, https://div12.org/case_study/maria-binge-eating-
disorder/

Galmiche M, Dechelotte P, Lambert G, Tavolacci MP. Prevalence of eating disorders over

the 2000–2018 period: a systematic literature review. Am J Clin Nutr 2019; 109:1402–1413.

Qian J, Wu Y, Liu F, et al. . An update on the prevalence of eating disorders in the general
population: a systematic review and meta-analysis. Eat Weight Disord 2021; Published online
8 April 2021. doi: 10.1007/s40519-021-01162-z.