Illustrative Case
A 20-year-old woman sought outpatient treatment for her binge eating and vomiting behavior. Her symptoms began at age 17, when she was a college freshman. Although very bright and attractive, she worried about whether men would like her. Her weight was normal for height and age, but she decided to lose a few pounds in the spring to “be prepared for bathing suit season.” She went on a diet together with her roommate, who suggested vomiting after meals.

The patient reported binging three or four times a week, usually in the evening and always when alone. She usually felt depressed and anxious when the urge to binge became overwhelming. She typically binged on breads and sweets. It was not unusual for her to eat a half-gallon of ice cream, a box of cookies, and a loaf of bread during a binge, which typically lasted about 30-45 minutes. She felt relief from her depression and anxiety during binges and reported sensations of warmth, safety, security, and unconditional acceptance. She ended the binges when her stomach ached, at which time she induced vomiting mechanically. After vomiting, she felt guilty and angry at herself for giving in to her impulses and being out of control.

The patient was 5 feet 6 inches tall. Her weight had fluctuated between 110 and 150 pounds since the onset of her bulimia. Although she weighed 122 pounds at the start of treatment, she reported wishing she weighed 15-20 pounds less. She took large doses of laxatives daily and occasionally used diuretics. She had taken amphetamines in the past and was worried about her increasing dependence on alcohol. She complained of spending up to $60 on a single binge and reported stealing food from grocery stores.

She described self-hatred as a result of her behavior and told of superficially cutting her wrists on two occasions, which she characterized as “semisuicide attempts.” She had been too embarrassed to discuss her symptoms and felt she might be the only person in the world with such a bizarre disorder. The patient decided to seek treatment after reading an article about the medical dangers of bulimia. She was surprised by the article, which reported that the disorder had a high incidence.

She entered individual psychotherapy and attended a support group for women with bulimia. Her symptoms improved during the first 6 months of treatment, with the frequency of binges dropping to once a week. A trial of fluoxetine was begun and resulted in complete remission of binge eating and purging behavior. She decided to continue in therapy, not only to better understand her eating disorder but also to work on long-standing problems related to low self-esteem and difficulty in social relationships.