Case Analysis – Collaborating with Outside Providers

Bulimia Nervosa: A Comprehensive Analysis of Treatment, Policy, and Social Work Ethics

Dana Lynn Bernacchi

Bulimia nervosa is an often debilitating eating disorder with a biopsychosocial set of risk fac- tors. Those presenting are at an increased mortality rate and often have physical health com- plications as well as harmful cognitions related to self-esteem and overall self-concept. This article examines treatment, policy, and social work ethics as they relate to bulimia nervosa. A comprehensive cognitive–behavioral approach including psychoeducation, self-monitoring, exposure therapy, interpersonal therapy, body image therapy, energy balance training, and relapse prevention is recommended as evidence-based practice for treating bulimia nervosa. Authors identify health care policy and analyze it as a common barrier to treatment access. They also review ethical principles of competency and social justice as they relate to social work practitioners working with those diagnosed with bulimia nervosa.

KEY WORDS: adolescent mental health; evidence-based practice approaches; emotional and behavioral disorders; ethics; gender issues

Bulimia nervosa is an eating disorder affect-ing approximately 1 percent to 1.5 percentof the population within a 12-month period. The primary diagnostic characteristic of bulimia nervosa is experiencing recurrent episodes of binge eating followed by compensatory methods to pre- vent weight gain. Compensatory methods are often referred to as purging behaviors. The most common purging behavior is vomiting, but other methods such as misusing laxatives, restricting food intake, or excessive exercise are also common (American Psy- chiatric Association [APA], 2013; National Institute of Mental Health [NIMH], n.d.). Individuals with bulimia nervosa will exhibit bingeing and purging behaviors once a week minimally within the past three months and up to several times a day in severe cases. A secondary symptom of bulimia nervosa is an excessive emphasis on one’s body shape or weight when it comes to self-evaluation and overall self- esteem. Individuals with bulimia nervosa typically have an intense fear of weight gain and a distorted image of their body (APA, 2013). Bulimia nervosa typically develops in adolescence or early adult- hood, with the overwhelming majority of those affected being female. Bulimia nervosa can often go unrecognized as bingeing and purging behaviors are often conducted in secrecy and those suffering usually present at average or slightly above average weight (APA, 2013; NIMH, n.d.).

There are several risk factors for the development of bulimia nervosa, a biopsychosocial disorder with a biological and genetic component regarding risk for eating disorders in general. Individuals are more likely to develop this disorder if a direct family member has also experienced the specific sympto- mology. Furthermore, those who have experienced childhood obesity or an early onset of puberty are more likely to develop bulimia. Specific psychologi- cal patterns of thinking such as depressive thoughts, anxious thoughts, weight concerns, low self-esteem, and poor self-concept are also related to the devel- opment of bulimia nervosa (APA, 2013; Office on Women’s Health [OWH], 2010). Some environ- mental risk factors include attachment insecurity, childhood abuse, and trauma (APA, 2013; Demi- denko, Tasca, Kennedy, & Bissada, 2010; OWH, 2010). The cultural standard of female beauty being associated with an overly thin body type is also asso- ciated with the development of eating disorders such as bulimia nervosa. Countries that accept overly thin body types as the ideal tend to have higher rates of eating disorders (Kimmel, 2013). Individuals who internalize this cultural desirability of extreme thinness are at higher risk for developing eating disorders such as bulimia nervosa (APA, 2013).

Physical health complications are common with bulimia nervosa. Worn tooth enamel results in tooth decay, a common health problem with those

doi: 10.1093/sw/swx006 © 2017 National Association of Social Workers 174

diagnosed because of overexposure to stomach acid. Other gastrointestinal issues such as acid reflux and intestinal irritation are also common (NIMH, n.d.). Some physical complications of bulimia nervosa can be fatal. Fluid and electrolyte imbalances as a result of purging behaviors are common and are some- times serious enough to induce cardiac arrhythmia. Other fatal complications, though rare, include esoph- ageal and gastric ruptures. Individuals with bulimia nervosa have an elevated risk for mortality as a result of these complications, but also of suicide. Individuals presenting with bulimia nervosa symp- toms should always be assessed for suicidal ideation as they present an elevated risk for suicide attempts and completion (APA, 2013; NIMH, n.d.).

Comorbidity with bulimia nervosa and other mental disorders is more common than not. Most individuals with bulimia nervosa present with at least one other diagnosis and often times with sev- eral. The most common diagnoses seen along with bulimia nervosa are depression, bipolar depression, anxiety disorders, substance use disorders, and per- sonality disorders. Depressive disorders commonly occur along with or shortly after the onset of bulimia nervosa, and many individuals will con- tribute the development of their depressive symp- toms to bulimia. At least 30 percent of individuals with bulimia nervosa will experience substance use problems, with evidence showing a particularly strong link with alcohol and stimulants. Among personality disorders, borderline personality disorder diagnosis has the highest correlation with bulimia nervosa (APA, 2013).

LITERATURE REVIEW One aspect of research focuses on the social stigma and outsider’s perspective of those with eating dis- orders such as bulimia nervosa. Those with eating disorders are more likely to be viewed as fragile, responsible for their disorder, and attention seeking than those with other mental disorders such as depression (Roehrig & McLean, 2010). Further- more, purging behaviors associated with bulimia nervosa have been shown to be highly socially re- jected (Pyle, Neuman, Halvorson, & Mitchell, 1991). Modern society generally has the perspective that people can and should control their body image and weight. Therefore, eating disorders such as bulimia nervosa may be viewed as simply extreme efforts to control one’s weight. Furthermore, one study found that the large majority of a sample

population not diagnosed with any eating disorders admired certain characteristics of eating disorders such as extreme dieting and exercise (Roehrig & McLean, 2010). There is a sense that the public views those with eating disorders as personally responsible and that they should be able to “pull themselves together” (Crisp, Gelder, Rix, Meltzer, & Rowlands, 2000). These social stigmas regarding eating disorders support the notion that having an eating disorder is a conscious choice made by weighing costs and benefits. This notion signifi- cantly minimizes the serious nature and debilitating potential of eating disorders such as bulimia nervosa and may deter suffering individuals from seeking treatment as they feel they should be able to over- come their dysfunctions with food and body image on their own (Roehrig & McLean, 2010).

There is also a large body of research exploring treatment methods for bulimia nervosa. Major treat- ments researched are pharmacotherapy, cognitive– behavioral therapy (CBT), interpersonal therapy (IPT), and exposure therapy (Johnson, Tsoh, & Varnado, 1996; Koskina, Campbell, & Schmidt, 2013). Antidepressants such as tricylics, mono- amine oxidase inhibitors, and selective serotonin reuptake inhibitors (SSRIs) are recommended for treatment of bulimia nervosa. SSRIs are most com- monly prescribed due to minimal side effects. Anti- depressants do appear to significantly reduce bulimic symptoms of bingeing and purging through vomit- ing, but there is little research on the effectiveness of antidepressants with other purging behaviors such as abuse of laxatives or overexercising. It is also unclear whether antidepressants improve body image disturbances. The relief of bulimic symptoms through antidepressants appears to be independent of depressive symptoms. Research shows a reduc- tion in bulimic symptoms when using antidepres- sants even when there is an absence of depressive symptoms (Johnson et al., 1996). Using pharma- cotherapy as a sole treatment for bulimia nervosa is not recommended, as dropout and relapse rates following withdrawal are high. However, because pharmacotherapy is significantly cheaper than most psychotherapies, it may be a convenient option for some (Johnson et al., 1996).

CBT is a multifaceted intervention that aims at addressing negative cognitions to modify problem- atic behaviors. CBT is intended to cease dysfunc- tional eating patterns and address associated body image issues (Schlundt & Johnson, 1990). Common

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components of CBT for bulimia nervosa include die- tary monitoring, exposure with response prevention (ERP), energy balance training (EBT), cognitive in- terventions, IPT, education, body image therapy, and relapse prevention (Johnson et al., 1996; Schlundt & Johnson, 1990; Turner, Tatham, Lant, Mountford, & Waller, 2014). CBT is considered an evidence- based practice with high efficacy and is often the treatment of choice for those with bulimia nervosa (Johnson et al., 1996; Koskina et al., 2013; Raykos et al., 2014).

IPT targets personal stress and interpersonal rela- tionships in the rationale that anxiety and depression resulting from negative interpersonal situations trig- ger dysfunctional relationships with food. In essence, interpersonal events are viewed as triggers for bulimic symptoms. IPT does not put a strong focus on issues of diet, weight, or body image (Agras, 1991). IPT has shown to produce significant reductions in bulimic symptoms of binge eating and vomiting at a one year follow-up (Fairburn, Jones, Peveler, Hope, & O’Connor, 1993). However, it is not recom- mended that IPT be conducted in isolation but rather integrated as a component of CBT, which ad- dresses all of the known issues associated with bulimia nervosa (Johnson et al., 1996).

Exposure therapy involves exposure to stimuli that have a pattern of producing problematic re- sponses for an individual. The idea is that continual exposure in a controlled environment where the therapist can intervene will extinguish the problem- atic response. ERP is used in bulimia nervosa to address bingeing and purging behaviors as well as body image issues (Koskina et al., 2013). Exposure therapy can be used to reduce purging behaviors as patients are allowed to eat binge or trigger foods and then prevented from vomiting. The therapist stays with the client and challenges the cognitive distortions related to purging until the urge to purge has ceased (Leitenberg, Gross, Peterson, & Rosen, 1984).

Mirror exposure therapy addresses body image is- sues with those suffering from bulimia nervosa. Dur- ing therapy sessions, clients are often placed in front of a mirror that allows a wide view of their body while wearing minimal or tight-fitting clothing. Clients may be asked to describe their body and challenge cognitive distortions related to how they view their body (Koskina et al., 2013; Trentowska, Bender, & Tuschen-Caffier, 2012). The idea is that viewing their body activates negative thoughts about their body image that maintain their bulimia, and these

thoughts can be challenged in a therapeutic setting. It is thought that repeated exposure will weaken and eventually extinguish the automatic response of neg- ative thoughts about one’s body, leading to accep- tance of one’s body and decreased fear of weight gain (Trentowska et al., 2012; Vocks, Wachter, Wucherer, & Kosfelder, 2008). Research shows support for mirror exposure therapy in improvements in negative thoughts, body dissatisfaction, and self- esteem (Delinsky & Wilson, 2006; Trentowska et al., 2012). However, these studies are limited as there is no follow-up data, nondiagnosed control groups were used, and many participants had received inter- ventions for their bulimia before their participation (Koskina et al., 2013; Trentowska et al., 2012).

EVIDENCE-BASED PRACTICE IMPLICATIONS: CBT AND VARIOUS COMPONENTS CBT is considered to be the most effective treat- ment available for bulimia nervosa. CBT has been shown to reduce bingeing and purging behaviors, improve body image, and have other positive cog- nitive results (Johnson et al., 1996; Koskina et al., 2013; Raykos et al., 2014; Waller, Evans, & Pugh, 2013). It has been compared with other treatments and proved more efficacious. Administering CBT alone has been considered more successful than med- ication alone. Furthermore, no significant increase in treatment success is evident when combining CBT with medication, compared with CBT alone (Johnson et al., 1996). CBT has been shown to pro- duce faster treatment gains with lower dropout rates than IPT (Fairburn et al., 1993). CBT has also been shown to be more effective than exposure therapies alone (Koskina et al., 2013; Leitenberg et al., 1984). Clients who have received CBT as treatment for bulimia nervosa have reported several positive out- comes including higher energy levels, clearer think- ing, improved body image, increased self-liking, less anxiety, improved sleeping patterns, overall increased happiness, less concern about weight, and improved social relationships (Waller et al., 2013).

Cognitive interventions involve targeting harm- ful cognitive distortions and replacing them with cognitions conducive to recovery. Cognitive distor- tions are thoughts and beliefs that alter an indivi- dual’s perception of reality, usually in a harmful way (Test, 2015). Cognitive interventions are at the heart of CBT for the treatment of bulimia ner- vosa and are used throughout various components of CBT such as ERP, IPT, body image therapy,

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and relapse prevention (Johnson et al., 1996). The following examples describe cognitive distortions during the applications of various components of CBT for the treatment of bulimia nervosa. During ERP, a client may experience the cognitive distor- tion that if she does not purge, she will gain a lot of weight. During body image therapy, a client may express that she feels like she is so overweight, no one will love her. During IPT, a client may experi- ence the feeling that she is worthless if she cannot make her intimate partner happy. In practice, these distortions would be challenged and replaced with positive cognitions more conducive to recovery from bulimia nervosa.

It is important to note that components of CBT vary, and therefore it is necessary to analyze what specific components of CBT produce successful out- comes in the treatment of bulimia nervosa (Johnson et al., 1996). Self-monitoring is a component of CBT that asks clients to record problem behaviors such as bingeing and purging. This assists the client in making meaningful connections with situations or emotions that trigger these behaviors (Schlundt, 1989). Self-monitoring is important initially for ceasing behaviors and then later to prevent relapse. Incorporating ERP therapy as a component of CBT has been shown to elicit positive outcomes. ERP helps to reduce clients’ anxiety and increases their self-efficacy in resisting bingeing or purging even in high-risk situations (Wilson, Rossiter, Kleifield, & Lindholm, 1986). Challenging cognitive distortions surrounding bingeing and purging is key when implementing ERP, as the exposure component alone is likely not efficient enough to reduce bingeing and purging behaviors (Koskina et al., 2013). Incorporating ERP into CBT can initially be anxiety provoking for clients, but research shows that clients have acknowledged that the long-term benefits were worth the initial increase in anxiety (Waller et al., 2013).

EBT is another effective component of CBT used to treat bulimia nervosa (Johnson et al., 1996). Those with bulimia nervosa have problematic pat- terns of eating. Between bingeing and purging epi- sodes, those with bulimia commonly skip meals or are overly conscious of the foods that they eat (APA, 2013). Many clinicians feel that hunger from restricting food or skipping meals is a trigger for epi- sodes of bingeing and purging. EBT works to com- bat hunger and overeating that tend to maintain bulimia nervosa. The goal is regular intuitive eating

and long-term weight management: consuming food on a regular basis in moderate portions, eating when the individual is hungry, and stopping when the individual is full (Johnson et al., 1996).

Body image therapy is used as a component of CBT to remedy the symptom of intense fear of weight gain associated with bulimia nervosa (APA, 2013). Problematic thoughts and beliefs about an in- dividual’s body are challenged and ideally constructive perceptions are substituted (Johnson et al., 1996). Often this involves the client taking a close look at her or his body in a mirror. As this is anxiety provok- ing at first, many clinicians are hesitant to implement body image therapy for fear of distressing their cli- ents (Turner et al., 2014). However, research shows that body image therapy is successful in increasing positive thoughts about the bodies of those with bulimia nervosa, and therefore is a necessary com- ponent of CBT for bulimia nervosa (Trentowska et al., 2012).

Although psychoeducation is not explicitly a CBT-type intervention, it is commonly integrated into treatment and has proved beneficial when treating those with bulimia nervosa (Johnson et al., 1996). Many clients have reported it to be beneficial to gain an understanding of the development, risks, and psychopathology of their eating disorder (Wal- ler et al., 2013). Furthermore, clients need to be prepared for the possibility of relapse, common in bulimia nervosa. Identifying high-risk situations and developing coping strategies and plans for getting back on track after relapse are all necessary compo- nents of relapse prevention (Johnson et al., 1996).

ETHICAL IMPLICATIONS The issue of competency is an ethical issue to con- sider when treating clients diagnosed with bulimia nervosa. Competence is both a value and ethical principle of social work that requires professionals to only practice within their areas of competence and to continually strive to increase their com- petent knowledge base (National Association of Social Workers [NASW], 2015). Given the nature of bulimia nervosa to co-occur with other disor- ders, social work professionals treating bulimia ner- vosa should strive to gain a level of competency on treating the comorbid disorders and not just bulimia nervosa. Practitioners should seek to gain competency in disorders related to personality, anxiety, depression, and substance use as these are the most common comorbidities (APA, 2013).

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This is especially problematic in regard to issues of substance use in those diagnosed with bulimia nervo- sa as treatment facilities often discriminate between treating substance use disorders and other mental ill- ness, even though integrated care has been consid- ered more effective than treating comorbid disorders in isolation (Yeager, Cutler, Svendsen, & Grayce, 2013).

There is also evidence to suggest that clinicians are not carrying out evidence-based practice interven- tions in a competent manner (Turner et al., 2014). CBT is among the most effective treatments of bulimia nervosa (Johnson et al., 1996; Koskina et al., 2013; Raykos et al., 2014). However, many clini- cians are not focusing on key components of CBT, such as exposure therapy and body image work. Turner et al. (2014) found that not implementing these components was associated with the clinician’s fear of distressing the client as well as lack of expe- rience. Although clients will probably experience short-term distress during exposure therapy and body image work, evidence shows that these com- ponents have positive long-term outcomes (Tuner et al., 2014; Waller et al., 2013). To address this issue of competency in implementing CBT for treatment of bulimia nervosa, we need to focus on effective training and supervision of those with less clinical experience (Turner et al., 2014).

Social workers are called to carry out the ethical standard of social justice and “should act to prevent and eliminate domination of, exploitation of, and discrimination against any person, group, or class” (NASW, 2015, p. 27). Advocating for members of oppressed groups and changes in policy to elimi- nate such oppression is necessary to uphold our code of ethics (NASW, 2015). Bulimia nervosa may be facilitated and maintained partially by the unequal status of women when compared with that of men. Evidence of female inferiority can be found in numerous arenas including, but not lim- ited to, income level, employment rank, politics, media, and beauty standard (Kimmel, 2013).

Women in our society are held to a higher level of scrutiny when it comes to body image and over- all attractiveness. For women to be perceived as attractive by societal standards, they must undergo a rigorous routine of cosmetics, fashion, and diet regi- men to maintain the standard of an overly thin body type. The average contestant in the Miss America pageant is roughly 30 pounds underweight. Only in societies where being thin is of value are eating

disorders such as bulimia nervosa prevalent. It is esti- mated that between 5 percent and 10 percent of all postpubescent girls and women suffer from an eat- ing disorder in the United States (Kimmel, 2013). In a sense, this tyranny of slenderness in our society is causing women to fear weight gain to the extent that they sacrifice their physical and mental health. Women are held to this unattainable standard of beauty and body image to maintain their unequal status. It is an interesting coincidence that the very first Miss America pageant was held the same year that women gained the right to vote (Kimmel, 2013). To maintain our commitment to social jus- tice, we need to advocate for policies that support gender equality and work to unravel this unattain- able image of feminine beauty that holds many women as prisoners inside their own body.

POLICY CONCERNS Although we have seen improvements in mental health care policy over the years, coverage for treatment of eating disorders such as bulimia ner- vosa is still difficult. One reason for this is that cur- rent health care law allows insurance companies to discriminate among which diagnoses they cover and which ones they do not (Anthem Blue Cross, 2009). The National Eating Disorders Association (NEDA) (n.d.) has identified several reasons why individuals are often turned down for coverage or continuing coverage of their eating disorder treat- ment. The main reasons are lack of medical necessity, not showing improvement of symptoms, or a decline in symptoms. So either the individual is not exhibit- ing a dangerously low weight, they have not shown adequate treatment progress, or they show too much treatment progress (NEDA, n.d.).

An interview with Kate Fisch, a current LCSW specializing in eating disorder treatment at North- side Mental Health, Indianapolis, confirms that insurance coverage is a problem in everyday prac- tice. Fisch reported that many of her clients run across barriers to treatment because of lack of insurance coverage, specifically that their mental health coverage does not cover the treatment of eating disorders. She indicated that on one occa- sion she had been seeing a client for a period of time, all the while insurance was covering services. Seemingly out of the blue, she received notice from the client’s service provider that the client’s insurance policy does not and never did cover the treatment of eating disorders. The insurance company notified

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Kate that she would need to begin billing this client directly and that they may seek reimbursement from the client for prior services that were covered but should not have been. The client had been receiving services regularly for over a year (Kate Fisch, LCSW, Northside Mental Health, Indianapolis, personal communication, June 2015). One wonders of the legality of an insurance company forcing a client to pay for services that were mistakenly covered by fault of the insurance company, but the fact that this situation did happen is unsettling. It directs attention to the flaws in our health care system, specifically relating to mental health diagnosis discrimination in relation to insurance coverage.

Furthermore, insurance providers do not con- sider eating disorders such as bulimia nervosa to be a women’s health issue, even though they are highly discriminatory by gender (Kaiser Family Founda- tion, 2015); 90 percent of those affected by bulimia nervosa are women (APA, 2013). Women’s health care does address issues of mental health, but depres- sion is the only condition specifically mentioned (Kaiser Family Foundation, 2015). If eating disor- ders were recognized as a women’s health issue by insurance providers, it would help to break through barriers and provide easier access to treatment for those suffering from bulimia nervosa.

PRACTICE IMPLICATIONS, FUTURE RECOMMENDATIONS, AND CONCLUSIONS Given the research on various elements of CBT, it is recommended that psychoeducation, ERP, body image therapy, self-monitoring, relapse prevention, IPT, and ERT be incorporated into the CBT inter- vention for treatment of bulimia nervosa. These elements alone have been proven less effective than when combined together into a comprehensive CBT approach. Cognitive interventions should be incorporated throughout each of these elements, as challenging cognitive distortions and negative thinking have been shown to be an essential ele- ment of success when treating bulimia nervosa. Clinicians should not avoid anxiety-provoking components of CBT such as ERP and body image therapy as evidence shows and clients agree that long-term benefits are worth the initial distress. The addition of antidepressant medication, specifically SSRIs, can be beneficial for some but overall are not a necessity for treating bulimia nervosa. Given high comorbidity rates, it is recommended that those diagnosed with bulimia nervosa are screened

for depression, anxiety, personality, and substance use disorders. Integrated treatment when possible is recommended for co-occurring disorders. Suicide is a serious concern for those diagnosed with bulimia nervosa, therefore special attention to warning signs is vital. Civil commitment may be necessary if the client poses a severe risk.

Revisions to health care policy need to be made for treatment to become more accessible to those suffering from bulimia. One recommendation would be that disorders with significantly increased mortal- ity rates would not be allowed to be excluded from mental health coverage. Another recommendation would be to include the treatment of eating disorders under women’s health care. These would help to ensure better access to affordable treatment for bulimia nervosa.

Regarding stigma, it is important that we work to eliminate this public notion that those with bulimia nervosa are at fault, as this may deter those suffering from seeking treatment. Effective public health education may serve to remedy this problem. Education on eating disorders could be incorpo- rated into parenting classes, public school education, or relevant workplace environments. It is also clear that gender inequality presented by our cultural standard of an overly thin physique is a contributing factor to the prevalence of bulimia nervosa. Rec- ommendations for this problem include programs that emphasize the empowerment of girls and young women and policies that support gender equality and reduce oppression and discrimination based on gender.

Bulimia nervosa is a biopsychosocial disorder that is consuming and debilitating for many. Its exact course and development is not certain, but it is clear that both genetics and environment work together in various ways to create a perfect storm that allows its dysfunctions to take place. These individuals, mostly women, are not at fault, and evidence-based treat- ment is available. A tailored CBT approach aimed at altering the overt behaviors and the covert cogni- tions has helped many to recover. Those who suffer can be freed from the obsession with food and make peace with their bodies. SW

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Dana Lynn Bernacchi, MSW, is a mental health and sub- stance abuse counselor, Damien Center, 26 North Arsenal Ave- nue, Indianapolis, IN, 46201; e-mail: [email protected].

Original manuscript received February 8, 2016 Editorial decision April 12, 2016 Accepted April 15, 2016 Advance Access Publication February 6, 2017

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