The following case study is connected to the questions below: Please assist with answering the following questions related to case study: What was the concern that Lilly had, along with many others who have bulimia nervosa? Describe Lilly's eating plan, including her "good" and "bad" eating habits. Do you think her eating plan was reasonable? When did Lilly's eating behaviors begin to become pathological? What prompted Lilly to decide to purge after her binges? What was Lilly's nonpurging activity to lose weight? According to the information provided in the text, how do individuals with bulimia generally perceive their body size compared to control subjects? How did Lilly's eating disorder affect her relationships with her coworkers? Why did Lilly finally decide to seek treatment? Describe the cognitive-behavioral theory of the maintenance of bulimia nervosa. Dr. Weinfurt asked Lilly to keep a record of her eating behaviors. What did Dr. Weinfurt see as advantages to this exercise, and why was Lilly reluctant to participate in this assignment? At what age do most cases of bulimia begin? From reading about Lilly, list all of the reasons she developed bulimia nervosa.

Lilly was a young woman who worked as a hostess at a modern farm-to-table local cuisine restaurant. She was born and raised in Southern California, in a small tourist town in the hills near Santa Barbara. Her childhood was not a happy one. Her parents divorced when she was 12 years old. She and her two older brothers remained with their mother, who often seemed overwhelmed and unable to run the household effectively. Lilly recalled her childhood as frenzied, chaotic, with little sense of control over week-to-week activities. Sometimes, she would tell her friends at school it seemed as if no one were in charge.

Despite these challenges, Lilly persevered with tenacity and poise. When her brothers went away to college, Lilly began high school, and alone with her mother and their cats Reuben and Cherise, the household was manageable. During those years, she developed a close relationship with her mother, indeed too close, Lilly would later come to realize. Her mother seemed like her closest friend, at times the entire focus of her social life. When her AP Psychology teacher described helicopter parenting, parents who hover all around their children's lives, it felt like an exact description of her relationship with her mother. They relied heavily on each other for comfort and support, which interfered with Lilly developing close friendships with girls her own age. They spent an excessive amount of time together, shopping, going out to eat, or running errands here and there. Lilly's mother was obsessed with keeping her appearance as young, thin, and fashionable looking as possible. She would talk to Lilly about the most recent fashion trends, "how important it is to look good and be put together," or how people wouldn't pay attention to you if you looked old, out of shape, or dressed matronly. Lilly loved her mom dearly and respected how she had managed to overcome a bitter divorce and raise three kids. She also respected how well her mother had aged. At 53, Lilly's mom looked more like a woman in her 30s. She practiced yoga, ate a strict plant-based diet, and kept her brown shoulder-length hair carefully styled. When Lilly and her mother went to restaurants, men would routinely turn their heads at her mother when she walked past them. She was attractive, and Lilly saw in her mother what she imagined she would strive to look like when she was older. So Lilly didn't mind when her mother gave her advice about makeup, clothes, or fitness. She knew her mother loved her, and mostly figured she just wanted the best for her. But her mother also was quite critical and judgmental of Lilly and her brothers, leading her to wonder sometimes if her mother's attention to Lilly's appearance was a way of telling her that she didn't think she looked good.

As many as 60% of elementary school girls express concern about their weight and about becoming overweight (Ekern, 2020; NEDA, 2020).

Lilly attended a nearby state university, majoring in hospitality. However, she dropped out of school her sophomore year to take a job at a restaurant. She had begun working in the restaurant part-time her freshman year and after a year was offered the position of daytime manager. It was a well-paying job, and since her interest was hospitality, Lilly figured it made sense to take this job, knowing it would add to her resume and that she might learn more on the job about hospitality than she could in the classroom. Her mother was unhappy about her decision to leave college, and let Lilly know about her displeasure. Lilly reassured her that she intended to go back and finish up after she had worked for a while and saved some money.

Soon after she started at her full-time job, Lilly began dating Stephen, a man she met at work. He also worked in the restaurant business and was introduced to her by a coworker. Her mother liked him at first, but after several months she began to turn on Stephen. Lilly was in love by then, and her mother couldn't hide her growing contempt for him. She openly criticized how he looked in front of others, commenting on his receding hairline and his "dad bod." She told Lilly that she could "do better." Lilly and Stephen met her mother for lunch one day. Stephen brought them both a rose from his garden. Lilly clasped his hand and kissed him on the cheek, thanking him. Her mother smiled with disdain, then began complaining about the weather and the table location at the restaurant. Lilly became agitated and told her mother she had had enough. "Why do you always ruin my day? He brought you a rose and you can't even be nice enough to thank him!" Her mother clapped back, "He isn't good enough for you dear, and everyone knows it. Sorry, Stephen, but it's true." Lilly grabbed his hand and stood up, tears streaming down her face, and left with Stephen.

Lilly and Stephen dated for another year, eventually becoming engaged. Everything seemed to be going well until Stephen began to behave differently. He went from being dependable and emotionally stable to being unpredictable and prone to emotional outbursts. Lilly would soon learn that he had developed a problem with alcohol and legally prescribed but misused painkillers. He was drinking at work, lying to Lilly about it, and taking oxycodone that he would buy from customers at his restaurant. Lilly was doing everything she could to hold it all together. She was working full-time, taking care of the apartment they shared, exercising and walking their dog every day, and staying close to her girlfriends. But she couldn't control Stephen's drinking and use of pills, and when he was admitted to an addiction treatment center, Lilly knew she may need to end their relationship. He was discharged and soon relapsed. Lilly felt like her world was spinning out of control, and she decided to end the engagement. She felt sad and angry, and she resented that her mother had been right about Stephen. It was time to pick up the pieces and go on without him.

A period of psychotherapy helped ease her grief and her adjustment following this tragedy, and eventually she was able to move on with her life and to resume dating again. However, serious relationships eluded her. Lilly knew that she was a moody person she judged people harshly and could be irrational and critical of herself or others easily and she believed this discouraged potential partners. She suspected that her employees didn't like her for more reasons than the fact that she was the boss, and she found it hard to make new close friends. Throughout her adolescence, Lilly had always been sensitive to people's opinions about her appearance and weight, particularly the opinions of other women. She recognized that this sensitivity likely came from the not-so-subtle messages from her mother about her appearance. She can still remember the day they went to a local pool with friends when she was 12 years old. She overheard her mother talking to the other mothers, telling them that she wondered if Lilly was going to have "hormonal problems" because she seemed to be chubbier than all of the other girls. Lilly didn't initially think of herself as chubby, but socially she always seemed to fall in with a group of women who were equally preoccupied with dieting and weight control. To Lilly, their preoccupation seemed to be based not on vanity but on anxiety. They lived under a cloud of concern that their weight and eating might somehow grow out of control. Typically, her acquaintances did not have significant weight problems, nor were they unusually vain or intent on being popular. In fact, most of them had serious academic interests and career goals. Thus she found it almost ironic that they in particular were so focused on their physical image. But focused they were, and Lilly became no exception.

Body dissatisfaction, depression, and self-reported dieting are important risk factors in the development of eating disorders (Cooper & Mitchell, 2020; McElroy et al., 2020).

From age 14 to 21 she always tried to keep her weight between 115 pounds and 118 pounds, a standard that began in the ninth grade after she thought she had a slightly overweight period. She would rigidly follow what she called her weight watcher plan, although she had never actually gone to the program of the same name. The eating plan consisted, when she was being "good," of a breakfast of toast with avocado and water, a lunch of salad with quinoa or lentils, and a low-fat, high-protein meal at dinnertime. On some days, when she was being "bad," it also included a couple of candy bars or two large gourmet chocolate chip cookies. She tried to keep "bad" days to a minimum, but there were probably three or four of them each week. Lilly felt she could tolerate such days, however, as she was a regular exerciser, attending spinning classes at the gym or doing Pilates at home at least 3 nights per week. During a particularly "bad" week, however, she might go to the gym a couple of extra times to exercise on her own.

In addition, she developed the habit of weighing herself several times a day to reassure herself that the reading did not exceed 118 pounds. When the scale showed that her weight was at or below 118, Lilly felt enormous satisfaction, similar to what other people might feel if their bank statement showed a comfortable balance. Lilly saw her 118 pounds as the well-earned reward for sustained and concentrated effort. And like a miser who counts her money over and over, she would get on the scale frequently to recapture that feeling of satisfaction, especially when other aspects of her life felt less than satisfying. One evening at home, when she saw that her weight was 114, she returned to the scale a dozen times to experience the pleasure at seeing that number.

Repeatedly engaging in body-checking behaviors (for example, weighing oneself, checking in the mirror, comparing one's body to that of others, measuring body size with clothes or other instruments) has been found to be a maintaining factor of eating disorders.

At the same time, the frequent weighing had its downside. Sometimes she would weigh 120 or more pounds and have a very negative reaction: Even though this was still a very healthy weight, she would feel fat and bloated and would resolve to limit her eating to a much stricter version of her weight watcher plan. In addition, she might throw in extra exercise sessions for good measure. In the meantime, to avoid anyone seeing her "fat" body, she would hide it under bulky sweaters and other concealing clothing. This way, at least other people would not gossip about her.

The more she felt upset about her body, the more she tended to check her body shape and size. She would try on different-sized clothes from her closet to see how they fit. She had one pair of "skinny jeans" that she fit into a few years prior, but only for a short time. She saved them, swearing that she would fit back into those again one day. She would stand in front of the mirror and suck her stomach in as far as she could and see if that made her feel any better. It tended to make her feel worse, but it did give her more motivation to have a really "good" day the next day. When she was 23, Lilly's eating habits became a major problem. She began to binge eat, sometimes two to three times per week. Typically she would become aware of the urge to binge in the afternoon while at work. Because she restricted her food intake during the day as much as she could, she would become very hungry, and the food in the restaurant at work would smell delicious. As the afternoon progressed, the urge would build into a sense of inevitability, and by the end of the workday, she knew she would binge that night. She would then start to fantasize about the foods she would bring home from the restaurant.

A binge is defined as consuming an objectively large amount of food during a relatively short time (less than 2 hours), a behavior accompanied by a feeling of loss of control.

Lilly's binges usually included food that she had labeled as "bad" foods that in her mind should never be eaten if she had any hopes of maintaining proper weight. On one binge day, for example, she got off of work and order a cheeseburger and fries to go. She said goodnight to her coworkers, then drove immediately to buy several scoops of ice cream with Oreo, Heath, and Kit-Kat toppings, all in her favorite chocolate coated waffle cone. The final stop was the grocery store, where she bought a box of donuts and bag of chocolate bars.

Once home, Lilly locked the door behind her and put her phone on silent. Something about the secrecy, the single-mindedness, and what Lilly called the depraved indifference of her binges made her feel as if she were committing a crime. Yet once the eating began, she felt powerless to stop it. After the first mouthful, the binge was destined to run its course.

On this particular evening, Lilly tore into the cheeseburger first while she sat in her kitchen checking Instagram, TikTok, and Snapchat on her phone. She ate rapidly, without pause, taking little notice of the stories or photos. After the cheeseburger and fries came the ice cream. Lilly changed out of her work clothes, then proceeded to the donuts and chocolates. This she ate in her living room at a slower, more leisurely pace while she watched a reality dating show on TV. Within about an hour and a half she eaten everything. In fact, within a 3-hour period, Lilly had consumed more than 4,000 calories.

Surveys find that adolescents and young adults who spend more time on social media and on fashion and music websites are more likely to display eating disorders, have a negative body image, eat in dysfunctional ways, and want to diet (Ioannidis et al., 2021; Latzer, Katz, & Spivak, 2011).

The young woman often felt as though she were in a changed state of consciousness during such binges. Nothing else in the world seemed to matter when she was eating like this. She would avoid answering texts or responding to social media posts. She didn't think about her mother or her difficulty dating. It was like a drug, she sometimes thought, that could take her away from her miseries for a short while, a time-out from the quotidian emotional distress of daily life.

Although Lilly viewed her binges with disgust in hindsight, she couldn't deny there was some pleasure in it when they were occurring. It was the only situation in which she could eat foods that she loved. Under normal conditions, eating was not a source of pleasure, because she would restrict herself to unappetizing foods. For her, normal eating meant dieting avoiding all foods that she enjoyed. She was convinced that if she regularly ate foods that she did like, she would set in motion a process that she couldn't stop. And now, indeed, her binges seemed to be bearing this theory out.

Once each binge ended, the next step, in Lilly's mind, was to repair the damage caused by the amount of calories consumed. Even though her binges started out feeling like a rush of adrenaline and could temporarily keep her from having to think about or deal with stressful things, by the time they ended she felt disgusted and sick. Physically she would feel bloated and heavy. The rest of the night she would feel gastroesophageal reflux from the volume and fatty content of what she had eaten. The blow to her sense of self was even more pronounced. Binge eating was so inconsistent with her usual style of behavior that she wondered if she was developing some sort of split personality: the competent, striving Lilly versus the irresponsible, out-of-control Lilly. She was becoming concerned for her mental health. Her mother would be very upset with her if she knew.

Typically, binges are followed by feelings of extreme self-blame, guilt, and depression, as well as fears of gaining weight and being discovered (APA, 2022, 2013).

Most important, the binge posed a severe threat to the one area of life which, in her mind, had become a measure of her success and worth as a human being: her weight. After a binge, she felt that if she didn't do something about it, she might see a 5-pound weight gain on the scale the next morning. During her first 2 or 3 months of binge eating, she would attempt to avoid weight gains by trying to fast for a day or two. Then she saw a documentary on YouTube featuring women with bulimia that examined purging behavior at length. The message of the documentary was to avoid this fate at all costs. However, with her binges becoming more extreme and her weight reaching an all-time high of 124 pounds, Lilly saw purging as the solution to her problem: a way of eating what she wanted while avoiding undesirable consequences.

She started to purge at home several times a week. She would stand over the toilet, touch her finger to the back of her throat, and throw up as much of the binge food as she could. The first time Lilly tried this, it was not so easy. Indeed, she was surprised at how hard it was to stimulate a gag reflex strong enough to bring up the food. Eventually, however, she often didn't have to use her finger at all; the food would seem to come up almost automatically as she bent over the toilet.

In the early stages of her disorder, Lilly's purging felt gratifying. It typically brought an immediate sense of release, as though some terrible wrong had been set right. The bloated feeling would go away, and Lilly would avoid seeing a weight gain the next day. But over the next few months, the need to purge grew and grew. Even after eating normal meals, Lilly would feel fat, and she couldn't get the thought of purging out of her mind.

Beyond purging, the young woman would try additional practices to undo the effects of binge eating. For example, she tried hitting the gym to exercise each day. Before going, however, she had to follow a particular ritual in front of the mirror. She had to convince herself that she looked thin enough to appear in a gym environment. She put on her workout clothes and inspected herself in the mirror from every angle. Lilly's weight was within the normal range: she was 5 feet 5 inches tall and weighed 125 pounds. Her body mass index (BMI) was 20.8, which was at the lower end of the normal range of 18.5 to 24.9. Anyone would have described her as slim. However, there were aspects of her body that caused her repeated concern. She felt that her center of gravity was too low, meaning she was heavy in her hips and thighs. If, after surveying herself in the mirror, she believed that she looked dumpy, she would abandon her plan to go to the gym. She just couldn't face going there "looking fat."

People with bulimia nervosa often have inaccurate and disturbed attitudes toward their body size and shape. Compared to individuals without an eating disorder, people with this disorder have a tendency to overestimate their body size in a laboratory setting (Artoni et al., 2020).

Usually, however, if Lilly spent enough time in front of the mirror, she was able to convince herself that her appearance was not entirely repulsive. Sometimes to do this she had to change outfits, moving to more concealing clothing. She would spend at least 2 hours at the gym, alternating between jogging on the treadmill and doing high intensity interval training. Going to the gym achieved two things in her mind. It burned calories and it kept her away from food. When she returned home, usually at about 9:30 p.m., she drank a couple of cans of coconut water and tried going to bed. Unfortunately, the long workout often left her ravenous, and frequently she found herself getting up again to binge and purge.

When she was not bingeing or skipping meals, Lilly would try to follow her diet plan. Sometimes she would allow herself a snack of fat-free cookies or vanilla frozen yogurt. When eating in this way, she felt she was in an odd harmony with the universe. The restrictive eating gave her a sense of control, competence, and success. She felt more worthy as a human being, and more at peace.

Most cases of bulimia nervosa begin during or after a period of intense dieting, often one that has been successful and earned praise from family members and friends (NEDA, 2020).

Unfortunately, the controlled feeling could not be sustained. Eventually, she would give in to periodic binges. And after bingeing she felt compelled to begin the cycle all over again. Even as Lilly's pattern of bingeing and purging at home was increasing month after month, she was able to keep it under control at her job. She sensed that allowing the pattern to enter her work life would mark the beginning of the end of her promising career. To be sure, there had been some slips. One afternoon, for example, she ate a whole order of lasagna in the break room. The full feeling that resulted was so intolerable that Lilly went to the employees' bathroom and purged. However, afterward, she felt horrified at the idea of someone observing or finding out about her purging, and she promised herself that she would try with all her might to limit the practice to home. It was not easy to do, but for the most part, she was able to keep her bingeing and purging out of the workplace.

That is not to say that Lilly's problems totally escaped the notice of people at work. Coworkers were increasingly able to tell that something was amiss, and some began to piece things together. Caitlin, a 22-year-old server and friend, was one such individual.

Working under Lilly in the restaurant for the past year, Caitlin had developed a cordial relationship with her manager. Although the two of them were not close friends outside of work, they had gone out after work to get a drink a number of times together. In recent months, however, Caitlin noticed that Lilly had become more distant and withdrawn at work, and she became concerned for her coworker's well-being. "I always knew that she wasn't the happiest person in the world and that she was certainly unhappy about not having any boyfriends," Caitlin later told another manager at the restaurant.

Of course, that was true of a lot of people, so at first I didn't give it much thought. However, after a while I started to notice a troubling pattern in Lilly. She would be very cheerful and friendly for her when I'd first arrive for my shift around 11:30 a.m., but as the day wore on her mood would turn distant and sour. From about 3:00 onward, she would hardly talk to me or anyone else, and she often seemed to be staring into space as though she was thinking about something far away.

Not long after this started Lilly stopped making plans to see me outside of work. Since we didn't get together all that often, at first it didn't seem that unusual. She was always "busy," too busy to spend time with me outside of the restaurant. A couple of times, I asked her what she was so busy with. Not that I was prying, but I was curious about what she was up to, since I really didn't think she had anything going on besides work. But when I would ask her, she would suddenly seem nervous and say something like, "Oh, just a few things I'm working on. Stuff for friends, you know."

I didn't know, but her tone made it clear to me that I shouldn't pry further. After about 2 months of this, it was apparent that she didn't want to spend any time with me outside of work. She never had any time to get together. And if I said, "Well, we really should find time to get together soon," she would brush the whole issue aside. Her moodiness at work was getting worse, too, and I wasn't the only one who noticed it. Of course, we all knew that she's not the most jovial of managers, but now she seemed totally distant and nervous at work. And she always was in a tremendous hurry to get out of the restaurant at the end of the day. I kept wondering what was going on in her personal life what was she so desperate to get to after work and why she wanted to shut me out of her life altogether.

Individuals with bulimia nervosa are more likely than other people to have symptoms of depression, including sadness, low self-esteem, shame, pessimism, and errors in logic (ANAD, 2020; Cooper & Mitchell, 2020; McElroy et al., 2020).

Her appearance was also suffering. Her skin started to look dry and irritated, and her hair was damaged and frizzy. Her face, especially around the ees, seemed kind of puffy, like she wasn't getting enough sleep. Her eyes were also red. It looked as if unhappiness was showing in her face. She also seemed very tired at work. I knew something was wrong, but I was afraid of asking her what was going on.

Finally, I decided that I was worried enough about her to go ahead and ask what was going wrong, regardless of what her reaction was. It seemed more important than maintaining our friendship. So I just asked one day, "Lilly, I can tell that you're very upset about something. You seem like you're very unhappy and secretive all the time, and you don't look very healthy. Is there something you want to talk about with me? I am worried about you. You know, I do consider you a friend, whatever you think of me, and I do care about you."

She just looked at me very coldly and said, "I don't know what you're talking about. You have some tables to bus." But her coldness led me to believe that she knew very well what I was talking about. Then I noticed that her weight, while generally on the increase, seemed to be going up and down every few days. I started to suspect that there was some kind of eating disorder going on. Of course, I'm no expert, but I had a feeling that maybe she was so depressed about something that she'd taken to binge eating or something. I knew that this was dangerous, but what could I do? She was uninterested in pursuing our friendship or in responding appreciatively to any offers of support. Eventually, her responses to me became downright nasty. So finally I decided that I had no choice but to wash my hands of the whole situation and stop trying to lend my hand. I had done what I could. fter 6 months of bingeing, Lilly found that she was falling further and further behind. As the binges and snacking had become more regular, she gradually gained weight, "ballooning," as she called it, to 133 pounds. She had never been this heavy before, and she felt desperate to lose the weight. All the purging, dieting, and exercise was failing. Her mother had noticed and commented multiple times that Lilly had gained weight and looked unhealthy.

Approximately 1% of all individuals meet the diagnostic criteria for bulimia nervosa in their lifetime. Around 75% of cases occur in women and adolescent girls (NIMH, 2021b, 2017e; ANAD, 2020).

Lilly was becoming increasingly worried that she might resort to more extreme measures, such as purging at work, to lose weight. Ironically, her only temporary relief from these anxieties was achieved through bingeing. But after the binge and purge were over, Lilly would often find herself sobbing. Overwhelmed, she contacted the eating disorders clinic at the local university hospital. They suggested she come in for an evaluation. She was ambivalent, but after reading online about the clinic, she decided to begin treatment. She figured she could always just go once, and if she didn't like it, she could decide to stop whenever she needed. Now resolute in her decision, she clicked on the link for new patients at the eating disorder clinic Website.

After waiting a few days for a response and not receiving one, she called the clinic. The person answering the phone sounded so young, she thought, a young woman with a high-pitched voice. Lilly was anxious. She felt exposed. Feelings of helplessness emerged. She answered some basic questions about name, number, and so on, and was gearing up willingness to tell her story. The woman on the phone finally asked the question. "What are you hoping to get out of treatment in our clinic?" Lilly took in a breath, and readied herself for her story. After what seemed like only a few sentences, the woman on the phone gently interrupted, her voice squeaking a bit as she said thank you, that is all we need to know for now. Something about having a lot more time when she comes in to tell the therapist more details. Lilly felt an uncomfortable mix of relief and agitation. She wrote down the date and time of the clinic appointment. She was going to meet with Dr. Nancy Weinfurt, a nationally renowned expert in eating disorders and director of the eating disorders program at the clinic.

During her first interview with Lilly, Dr. Weinfurt concluded that her eating behavior and related attitudes about food and weight fit the DSM-5-TR criteria for a diagnosis of bulimia nervosa. First, Lilly reported recurrent episodes of binge eating, over which she felt little or no control. Second, she engaged in inappropriate compensatory behavior in response to the binges mainly purging and occasional fasting, but some inappropriate exercising as well. Finally, Lilly's self-concept was largely influenced by her body shape and weight.

In most cases, bulimia nervosa begins in adolescence or young adulthood, most often at age 15 to 20 years (NIMH, 2021b, 2017e; ANAD, 2020).

Many therapists tend to use a combination of approaches in the family of treatments called cognitive-behavioral therapies (CBTs) to treat persons with this disorder, and, indeed, this was Dr. Weinfurt's approach to treating Lilly. The treatment plan had two main components: (1) changing Lilly's bingeing and compensatory behaviors and (2) changing her distorted thinking patterns her assumptions, interpretations, and beliefs, for example about weight, body shape, and other concerns that might cause distress and lead to bingeing. The techniques she would use from CBT included educating Lilly about her eating disorder, helping her perform more appropriate weighing and eating behaviors, teaching her how to control binges and eliminate purges, and leading her, through cognitive interventions, to identify and change dysfunctional ways of thinking.

Session 1

Lilly framed her problem mainly in terms of the bingeing. She stated that the binges were increasing in frequency and were causing her to gain weight. What was most upsetting, she didn't seem to have any control over the binges at this point. Her weight was inching up, and she felt helpless to stop it.

Dr. Weinfurt listened sympathetically and expressed optimism that Lilly's problem could be solved. She then showed the client a diagram that depicted a model of bulimia nervosa (see Figure 9-1), explaining to Lilly that although bingeing was her main complaint, it was really just one element in a system of interconnected parts. That is, the bingeing was the result of such elements as unpleasant emotions, concerns about shape and weight, and strict dieting. Furthermore, in a vicious cycle, the bingeing was also helping to intensify these other parts of the system. Similarly, it was both causing and being caused by purging, another element in the system. To stop a bingeing pattern, treatment had to bring about changes in all of the system's elements. It could not focus on bingeing alone.

Figure 9-1 Cognitive-behavioral theory of the maintenance of bulimia nervosa

Dr. Weinfurt then outlined the treatment approach. First, she explained that certain steps usually help to reduce the urge to binge. Chief among these is structuring eating in a manner that keeps physical and behavioral deprivation to a minimum. In addition, the therapist noted, it is usually helpful to develop certain measures for heading off binges should the urge arise. Finally and this is where Dr. Weinfurt felt it advisable to tread lightly initially it is usually helpful with this kind of problem to become less preoccupied with eating and weight matters. She explained that when people have a problem with binges, it is sometimes because such matters have assumed a greater role in the person's thinking than is desirable.

The psychologist also told Lilly that she would like her to start keeping track of her eating and related stresses. Dr. Weinfurt allowed Lilly to choose whichever method felt most comfortable to her: using one of the apps that she recommended, keeping detailed notes in her phone, or writing everything down on a record form which she could then scan and e-mail to Dr. Weinfurt. Lilly expressed some reluctance about such record keeping. She explained that she had tried keeping records of her eating in the past and had not found it helpful. If anything, it had increased her focus on her eating. Dr. Weinfurt acknowledged that Lilly's past record keeping might not have been helpful but suggested that it would be used more constructively now. Now the record keeping would be part of an overall strategy, and clinical experience showed that it was quite important. It would allow the therapist to understand Lilly's eating better and help the young woman make appropriate changes.

Around 43% of those with bulimia nervosa receive treatment (NIMH, 2021b, 2017e).

Dr. Weinfurt did acknowledge that, as Lilly suspected, the record keeping might initially increase her preoccupation with her eating and weight but said that such increases would be temporary. Over time the client would become less focused on the whole problem. Lilly agreed to download the recommended app and give it a try for the coming week.