A Treatment Plan for

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					                          A Treatment Plan for
                          Bulimia Nervosa

Bulimia Nervosa DSM-IV Criteria
        It is estimated that 1-3% of female adolescents and young adult women suffer
from Bulimia Nervosa. Bulimia is classified as an Eating Disorder in the DSM-IV. All
eating disorders are characterized by severe disturbances in eating behavior. Bulimia is a
disorder in which the affected individual displays repeated episodes of binge eating
followed by inappropriate compensatory behaviors to avoid weight gain. Most often, the
behavior is self-induced vomiting accompanied by one or more of the following
behaviors: misuse of laxatives, diuretics, or other medications; fasting; and/or excessive
exercise. The following is a summary of the criteria for a Bulimia Nervosa diagnosis as
outlined in the DSM-IV:
        A. Recurrent episodes of binge eating. An episode of binge eating is
             characterized by both of the following:
                                (1) Eating in a 2-hour or less time period large amounts of
                                    food that is definitely larger than most would eat in the
                                    same amount of time or under the same circumstances
                                (2) A feeling of loss of control while consuming the food

       B. Regular use of inappropriate behaviors in order to prevent weight gain, such
          as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other
          medications; fasting; or excessive exercise.

       C. The binge eating and inappropriate behaviors both occur, on average, at least
          twice a week for 3 months.

       D. Self-evaluation focuses primarily on body shape and weight.

       E. The disturbance does not occur exclusively during episodes of Anorexia

       Specify type:

               Purging Type: during the current episode of Bulimia Nervosa, the person
       has regularly engaged in self-induced vomiting or the misuse of laxatives,
       diuretics, or enemas
               Nonpurging Type: during the current episode of Bulimia Nervosa, the
       person has used other inappropriate compensatory behaviors, such as fasting or
       excessive exercise, but has not regularly engaged in self-induced vomiting or the
       misuse of laxatives, diuretics, or enemas
Long-term Goals for Treating Bulimia Nervosa
 Restore normal eating patterns, body weight, balanced fluid and electrolytes, and a
  realistic perception of body size.
 Terminate pattern of binge eating and purging behavior with a return to normal eating
  of enough nutritious foods to maintain healthy weight.
 Restructure the distorted thoughts, beliefs, and values that contribute to eating
  disorder development.
 Develop alternate coping strategies to deal with underlying emotional issues, making
  the eating disorder unnecessary.

Short-term Objectives for Treating Bulimia Nervosa
   Accept personal responsibility for adequate nutrition as evidenced by consumption of
    necessary daily calories to progressively gain weight and balance body fluids and
   Terminate purging behavior, hoarding of food, and excessive physical exercise.
   Develop a realistic appraisal of weight status and body size, and identify irrational
    beliefs about eating.
   Process the role of passive-aggressive control in bingeing and purging behaviors.
   Identify and verbalize acceptance of shortcomings and improve self-esteem and
    assertive behaviors that allow for healthy expression of needs and emotions.

Treatment Plan for Objective 1: Accept personal responsibility for
adequate nutrition.
   Refer for inpatient hospitalization if client’s weight loss becomes severe and physical
    health is jeopardized.
   Educate client through direct instruction and/or video and printed material about the
    physical and emotional side effects of eating disorder behavior.
   Monitor weight and give realistic feedback about body weight and size.
   Establish minimal daily caloric intake.
   Assist in meal planning and/or refer the client to a dietitian for education in healthy
    eating and nutritional concerns.
   Reinforce weight gain and acceptance of personal responsibility for normal food
   Discuss issues of food control as related to fear of losing control of eating or weight.

Treatment Plan for Objective 2: Terminate purging behavior, food
hoarding, and excessive exercise.
   Monitor vomiting frequency, food hoarding, exercise levels, and laxative usage.
   Work with the client to develop a Relapse Prevention Plan (www.mirror-
    mirror.org/relplan.htm). This plan focuses on identifying triggers that may cause a
    relapse of binging and purging as well as allows the client to suggest alternative ways
    of dealing with the temptation to relapse.
   Get a verbal commitment each session from client that s/he will not engage in purging
    behavior or excessive exercise until the next session.
   Discuss fear of failure and role of perfectionism in search for control and avoidance
    of failure.
   Group therapy with other children/adolescents who have eating disorders to build
    social support as well as social, conversational, and problem-solving skills.

Treatment Plan for Objective 3: Develop realistic appraisal of weight
status and identify irrational beliefs about eating.
   Assist in identification of negative cognitive messages that mediate avoidance of food
    intake. Assist client in disputing negative and irrational thoughts and replacing them
    with more realistic, positive thoughts.
   Reinforce client’s qualities and successes to reduce fear of failure and build a positive
    sense of self.
   Assign client to keep a daily journal of food intake, activities, thoughts, and feelings.
   Process journal information each session.
   Confront the client’s unrealistic assessment of his/her body image and assign
    exercises (e.g., positive self-talk in the mirror, shopping for clothes that flatter the
    appearance) that reinforce a healthy, realistic body appraisal.
   Assign the client the book Body Traps (Rodin) and process the key ideas regarding
    obsessing over body image.
   Probe the client’s emotional struggles as related to feelings of low self-esteem,
    depression, loneliness, anger, need for nurturance, or lack of trust that underlie the
    eating disorder.

Treatment Plan for Objective 4: Process the role of passive-aggressive
control in bingeing and purging behaviors.
 Process issue of passive-aggressive control (refusal to accept guidance) in rebellion
  against authority figures.
 Recommend that the client’s parents or friends read Surviving an Eating Disorder
  (Siegel, et al.) and process the concepts in a family therapy session.
 Teach parents how to successfully detach from taking responsibility for the client’s
  eating behavior without becoming hostile or indifferent.
 Assist the client in choosing activities s/he can do each day for 20-30 minutes for
  enjoyment: bubble bath, read a magazine, go to his/her “special place,” etc.
 Confront the client regarding the impact of bingeing and purging behavior on
  household members and the need for consideration of their feelings and rights.
 To give the client an element of control and help them become less selfish, instruct
  the client the value of kindness to others and encourage him/her to do a random act of
  kindness for someone each week.
 Assist the parents in developing a behavioral contract with the client in which the
  client pays a consequence (e.g., added household chores or loss of money, privilege,
  or curfew time) for bingeing on family food, hoarding food, or failing to clean up
  after purging.
 Encourage parents to spend quality time with the client on a regular basis doing
  something relaxing or fun that the client chooses.
 Educate parents how to listen to the child without trying to “fix him/her.”
 Treatment Plan for Objective 5: Accept shortcomings and improve
  self-esteem and assertive behaviors.
   Facilitate family therapy sessions that focus on owning feelings, clarifying messages,
    identifying control conflicts, and fear related to separation.
   Discuss fears related to emancipation from parent figures in individual sessions.
   Assist the client in identifying a basis for self-worth apart from body image by
    reviewing his/her talents, positive traits, importance to others, and intrinsic spiritual
   Reinforce assertiveness behaviors in session and reports of successful assertiveness
    between sessions.
   Conduct assertiveness training through direct instruction/ discussion and drama/role
   Use appropriate activities to enhance self-esteem such as What Do You Want? (Frey
    & Carlock, 1989). This activity encourages clients to focus on what they want
    specific to a given situation. Gear it to increasing self-esteem by asking them to
    visualize themselves having, being, or doing what they want in terms of how they feel
    about themselves. Then have them fill in the details and answer what they can
    realistically do to bring about what they want. Have them focus on this activity
    whenever they feel their self-esteem decreasing.
   Acknowledgments (Carter-Scott, 1989). Make a list of the client’s accomplishments
    for the day. First, list the big items, then the medium ones, and finally, the small
    ones. Put the spotlight on what was accomplished. Have the client acknowledge the
    accomplishments as a success.

Developed by: Karen Collins and Marsha Hubbs, Graduate Counseling Students, Eastern
Kentucky University.
                   The Warning Signs of Bulimia
Bulimia is a disorder that most young women (and men) want to keep a
secret. They rarely seek out help for the disorder until loved ones notice the
warning signs of the disorder and confront them about it. The following list
will help you identify whether or not someone you care about may be
suffering from bulimia.

Bulimia Warning Signs

    Binge eating                               Avoidance of restaurants, planned
                                                 meals or social events
    Secretive eating (food missing)
                                                Complains of sore throat
    Bathroom visits after eating
                                                Need for approval from others
    Vomiting
                                                Substance abuse
    Laxative, diet pill or diuretic abuse
                                                Ipecac abuse
    Weight fluctuations (usually with 10-15
     lb range)                                  Amenorrhea (loss of menstruation) and
                                                 irregular menstruation
    Swollen glands
                                                Dizziness
    Broken blood vessels, usually in the
     face or eyes                               Headaches

    Harsh exercise regimes                     Dehydration

    Fasting                                    Constipation and diarrhea

    Mood swings                                Shortness of breath

    Depression                                 Tears of esophagus

    Severe self-criticism                      Hair loss

    Self-worth determined by weight            Stomach pain and bloating

    Fear of not being able to stop eating      Edema (swelling of hands and feet)
                                                Low blood pressure
    Self-deprecating thoughts following
     eating                                     Chest pains

    Fatigue                                    Abrasions on back of hands and
    Muscle weakness
                                                Anemias
    Tooth decay
                                                Cardiac arrest and death
    Irregular heartbeats
              By the International Eating Disorder Referral Organization
    1. Focus on feelings and interpersonal relationships - not on food and weight.
       Family members are often the forgotten members, especially other children. It is
       important that they talk about their feelings.
    2. Do not let the eating disordered family member disrupt the entire household. The
       family should go on with their lives as normally as possible.
    3. Do not allow the eating disordered family member to shop, cook or feed the
       family. Do not let the eating disordered family member dominate the rest of the
       families eating patterns. In nurturing others, eating disorder sufferers are denying
       their own need for food. Families should go on with normal eating patterns.
       These details will need to be worked out with the therapist.
    4. Set limits in a caring, reasonable, but firm manner.
    5. Help the family show affection and appreciation for each other. Underneath
       disordered eating is a lack of self-worth; thus unconditional love goes a long way.
    6. Work on how to avoid power struggles and find alternative ways of dealing with
       problems as they arrive. Let the therapist and/or physician deal with "highly-
       charged" issues such as weight.
    7. Realize that there are no quick solutions. Demanding change, and/or berating the
       eating disordered family member will not bring about change or a positive result.
       Be patient.
    8. Avoid having the eating disordered family member make too many decisions
       about food and other issues. Control is a big issue that must be addressed in
       therapy. One cannot attempt to over control the eating disordered family
       member. The therapist can help balance out these issues.
    9. Parents will need to examine alternatives to their current behaviors (i.e. yelling,
       pleading, etc). Family members should write in journals, write letters to each
       other, call the therapist, and write down situations that they need assistance with
       and provide these to the therapist during family sessions.
    10. The family needs to talk about all kinds of issues - not just focus on the problems
        or the eating disorder.
Your Dieting Daughter: Is She Dying for Attention? By Carolyn Costin, M.A., M.Ed. MFT published by
Brunner/Mazel, New York, New York (1997).

                       http://www.edreferral.com /for_the_family.htm

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