This report details the recommended psychological treatment plan for Simón, a 19-year-old Latin-American student in his second year at university in the UK.
Case Overview – Symptoms and Diagnosis
Simón is displaying the primary symptoms of bulimia nervosa, such as frequent bouts of binge eating, in which he cannot regulate the quantity of food he consumes in a certain length of time (A Keski-Rahkonen, 2021). After these binge events, improper compensatory behaviours like self-induced vomiting and excessive exercise—which had happened at least once a week for the previous three months—occur to prevent weight gain (Keski-Rahkonen, 2021; Christian et al., 2020). Simon’s primary means of controlling his weight are purging and binge eating (Werlang et al., 2021).
Simón exhibits excessive anxiety and obsession with body form and weight in addition to binge-purge behaviours (NICE, 2020). He measures his muscles obsessively, weighs his physique often and examines himself in the mirror (Werlang et al., 2021). In addition, Simon deliberately abstains from meals he fears are harmful or would make him gain weight, which might leave him malnourished or isolate him from peers when these items are consumed (Christian et al., 2020).
Simón has extreme anxiety as a result of the binge-purge cycle because he feels guilty and worries that he is losing control over his food cravings (Levinson et al., 2020). He makes an effort to hide his symptoms from his peers, which is typical of eating problem sufferers (NICE, 2020). Simon believes that stress from the outside world is what sets off binge cravings and the self-induced vomiting that follows (Keski-Rahkonen, 2021). When combined, his eating habits, worries about his weight and appearance, coping mechanisms, and level of distress meet the criteria outlined in ICD-11 for bulimia nervosa.
Relevant Background
Simón’s bulimia nervosa treatment strategy needs to take into account several factors from his past. Initially, his sports participation and role model status seemed to support restricted diet regimens. Since he was young, Simón has been committed to sports; he moved into competitive sports and joined varsity teams, both of which need the highest level of physical fitness (Keski-Rahkonen, 2021). Along with semi-starvation meals devoid of calories from fats or carbohydrates that do not “fuel” his training, he exhibits an intense workout schedule designed to regulate weight. Simón’s father and brother share a similar commitment to a strict diet and fitness regimen, which may indicate an underlying family message that a man’s identity and self-worth depend on his ability to follow a regimented diet and exercise schedule (Christian et al., 2020). Exercise and proper diet may promote healthy embodiment. However, when pushed too far, they can also encourage disordered eating habits and an excessive emphasis on body image or weight as markers of identity.
Second, Simón’s bulimic symptoms and binge cravings are probably exacerbated by several stresses and mental health issues. According to the case report, Simón had a tough time adjusting to life abroad when he first started college. However, his involvement in extracurricular activities and sports helped ease the transition. Even if it is not a visible stressor right now, case formulation and treatment planning should take lingering acculturation challenges—which often lead to mental health issues—into account (Keski-Rahkonen, 2021). Furthermore, Simon notes that stressful times may cause a person to feel as if they are losing control when they binge, indicating that therapy for eating disorders must include stress management techniques. Furthermore, given that unfavourable life events often precede the emergence of eating disorders (NICE, 2020), Simon’s mother’s recent passing could represent a trauma background deserving of evaluation; grieving concerns might also need attention. It is also necessary to screen for co-occurring disorders such as anxiety, OCD, or body dysmorphia that may contribute to bulimic episodes (Werlang et al., 2021).
Thirdly, the aims, values, and social supports of Simón need to inform the course of treatment. While Simon has a strong desire to overcome binge cravings and rebuild a positive connection with food and his body, his athletic aspirations may stand in the way of his development if his weight loss objectives take priority over his mental health (Werlang et al., 2021). Examining Simón’s rehabilitation goals and guiding principles together might reveal both possible roadblocks—such as continued sports participation—and enablers—such as supportive social networks. Although Simon keeps his eating issue a secret from his friends, his links to the academic community may improve therapy by lowering stigma and isolation via peer support and normalising asking for assistance (Beintner et al., 2020). Utilising the social and community resources that are accessible and tailoring treatments to Simón’s recovery objectives and past strengths should maximise adherence and effectiveness.
Putting Simón’s background into consideration while developing a case concept and treatment plan guarantees that interventions specifically address factors like social isolation, stress reactivity, and familial pressures that may have caused or continued his bulimia nervosa (Christian et al., 2020). Analysing his particular goals, assets, and coping mechanisms all at once makes it possible to uniquely customise evidence-based treatments to increase their potency and relevance and ensure that improvement extends outside therapy (NICE, 2020). Examining Simón’s distinct biopsychosocial background helps identify critical intervention points while leveraging innate strengths, supports, and values that can counteract disorder persistence. This is because the aetiology and maintenance of bulimia nervosa involve complex bidirectional interactions between biological, psychological, and social-contextual factors.
Treatment Suggestion.
Considering Simón’s symptoms and history, I recommend individual cognitive behavioural therapy (CBT) with exposure therapy components as the main course of treatment for his bulimia nervosa. With a wealth of studies demonstrating its efficacy in lowering binge-purge behaviours and related psychopathology, cognitive behavioural therapy (CBT) is recognised as the most effective evidence-based treatment for bulimia nervosa (NICE, 2020; Riva et al., 2021). To lessen food restriction and anxiety, the CBT protocol should prioritise psychoeducation, normalising eating via regular meals, a cognitive restructuring that targets my overvaluation of weight and form, developing emotion management skills, and exposure treatment (Butler et al., 2023). In order to address bulimic symptoms and contributors noted in Simón’s case formulation, I would suggest 20 weekly CBT sessions spread over 5 months.
By focusing on maintenance mechanisms, CBT reduces the symptoms of bulimia nervosa, according to several theoretical theories. According to the cognitive-behavioural hypothesis, eating disorders are triggered by unhealthy beliefs about food, eating, and body image, which in turn lead to bulimia (Werlang et al., 2021). For Simón, stringent weight/leanness objectives and the perception of failure to limit consumption may cause binges to get out of control, while beliefs about what meals are “good” or “bad” encourage avoidance. Through guided discovery, reality testing, and behavioural trials, CBT directly addresses distorted cognitions, improving self-efficacy to normalise eating despite illogical beliefs (Levinson et al., 2020).
Furthermore, the affect regulation model indicates that people with bulimia binge eat to control or avoid bad feelings, underscoring the need for feeling tolerance skills in therapy. Emotional and interpersonal vulnerabilities may intensify cognitive distortion (Keski-Rahkonen, 2021). For Simón, heightened tensions in life may be too much to handle, which would cause binge eating as a way to let off steam. Teaching different coping mechanisms for challenging emotions may reduce this maintenance element. Simón’s family may promote his dietary discipline and physical aspirations via his father and brother’s robust fitness modelling. In addition to cognitive-behavioral therapies, it is necessary to address these possible family implications on his eating disease based on the interpersonal psychotherapy paradigm.
Using a mix of cognitive, behavioural, and emotional regulation strategies, there is substantial empirical evidence for the effectiveness of CBT in lowering the frequency of binges and purges associated with bulimia nervosa, which is consistent with these theoretical theories (NICE, 2020). In terms of empirical data, a recent study that modified CBT to concentrate on exposure treatment for eating disorder anxieties discovered decreased anxiety and depression as well as decreased symptomology (Butler et al., 2023). In order to address Simón’s weight/shape worries, which are shown in his food avoidance, body checking, and compensatory behaviours after binges, I advise strongly emphasising imagination and in vivo exposure treatment.
In addition to CBT, I suggest referring to a dietician or nutritional counsellor since these services have been linked to better adherence to eating disorder treatments and are effective at stabilising disordered eating habits via group meal planning (Werlang et al., 2021). Given that research shows that a mixed strategy improves motivation and offers additional skill improvement compared to outpatient-only models, group-based day treatment programmes are also recommended to complement his therapy (Beintner et al., 2020). To lessen the isolating behaviours associated with eating disorders, group therapy might strengthen Simón’s social support. As an emerging technique for lowering eating disorder anxieties underlying cognitive-emotional triggers for bingeing and purging, integrating virtual reality exposure treatment after early symptom management is established may heighten Simón’s level of participation.
References
Beintner, I., Hütter, K., Gramatke, K., & Jacobi, C. (2020). Combining day treatment and outpatient treatment for eating disorders: findings from a naturalistic setting. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity, 25, 519-530.
Butler, R. M., Crumby, E. K., Christian, C., Brosof, L. C., Vanzhula, I. A., & Levinson, C. A. (2023). Facing Eating Disorder Fears: An Open Trial Adapting Prolonged Exposure to the Treatment of Eating Disorders. Behavior Therapy.
Christian, C., Perko, V. L., Vanzhula, I. A., Tregarthen, J. P., Forbush, K. T., & Levinson, C. A. (2020). Eating disorder core symptoms and symptom pathways across developmental stages: A network analysis. Journal of abnormal psychology, 129(2), 177.
Keski-Rahkonen, A. (2021). Epidemiology of binge eating disorder: prevalence, course, comorbidity, and risk factors. Current opinion in psychiatry, 34(6), 525-531.
Levinson, C. A., Christian, C., Ram, S. S., Vanzhula, I., Brosof, L. C., Michelson, L. P., & Williams, B. M. (2020). Eating disorder symptoms and core eating disorder fears decrease during online imaginal exposure therapy for eating disorders. Journal of Affective Disorders, 276, 585-591.
Levitan, M. N., Papelbaum, M., Carta, M. G., Appolinario, J. C., & Nardi, A. E. (2021). Binge eating disorder: A 5-year retrospective study on experimental drugs. Journal of Experimental Pharmacology, 33-47.
Low, T. L., Ho, R., Ho, C., & Tam, W. (2021). The efficacy of virtual reality in the treatment of binge‐purging eating disorders: A meta‐analysis. European Eating Disorders Review, 29(1), 52-59.
NICE. (2020). Overview: Eating disorders: Recognition and treatment: Guidance. https://www.nice.org.uk/guidance/ng69
Riva, G., Malighetti, C., & Serino, S. (2021). Virtual reality in the treatment of eating disorders. Clinical psychology & psychotherapy, 28(3), 477-488.
Werlang, M. E., Sim, L. A., Lebow, J. R., & Lacy, B. E. (2021). Assessing for eating disorders: a primer for gastroenterologists. Official journal of the American College of Gastroenterology| ACG, 116(1), 68-76.
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