Abstract
This paper will evaluate contemporary approaches used to
assess and diagnose Bulimia Nervosa.
Rationale for the diagnosis will be presented, as well as
the advantages and limitations of using
the DSM for diagnosis. I will apply the 5-axis diagnostic
system of the DSM-IV-TR to a client of record
who presented with Bulimia Nervosa. I will present a
treatment plan based upon best-practice research
regarding treating of Bulimia. Additionally, I will
evaluate the social systems of the client and assess what
impact these will have upon treatment planning for the
client. Lastly, I will discuss how managed care
health insurance might influence the treatment process.
Prevalence of Eating Disorders
The DSM-5 shows the following prevalence
rates for Bulimia Nervosa (BN): “The
lifetime prevalence
was
0.8% for AN, 2.6% for BN, 3.0% for BED, 2.8% for atypical AN, 4.4% for sub
threshold BN, 3.6% for sub threshold BED, and 3.4% for PD based on the newly
proposed diagnostic criteria. The overall lifetime prevalence of any eating
disorder by age 20 was 13.1%” (Stice, Marti, & Rohde, 2013).
Additionally, Newman et al. (1996)
state, “Eating disorders (ED) show stronger relations to suicide attempts,
outpatient and inpatient treatment, and functional impairment than virtually
all other psychiatric disorders.” Stice, Marti, & Rohde (2013) confirm
this: “Participants with DSM-5 BN, BED, and sub threshold BN reported
significantly greater functional impairment, emotional distress, suicidality,
and elevated treatment seeking than participants without an eating disorder.” Since
1987, hospitalizations for ED in Canada have increased by 34% among adolescents
females under the age of 15 (Public Health Agency of Canada, 2002) making it
likely that clinicians may encounter these complex and potentially lethal
illnesses more frequently. “ED pose particular treatment challenges and it is
important to intervene early in the illness development to prevent more chronic
and treatment-resistant forms of AN and BN from developing” (leGrange &
Loeb, 2007).
Contemporary Approaches to Assessment
and Diagnosis of Eating Disorders
Tobin et al. (1991) state, “Despite
attempts in the DSM-III-R to improve diagnosis of bulimia nervosa
over criteria in the DSM-III
(American Psychiatric Association, 1980), there remains considerable
subjectivity in diagnosis of this disorder.” In light of the subjective nature of
using the DSM to diagnose,
the “Interview for
Diagnosis of Eating Disorders, IDED-IV” (Kutlesic et al.,1998) can aid
clinicians in
more accurate
assessment. Several studies have found that the EDE yields reliable and valid data
when
used to assess the
symptoms of anorexia and bulimia (Fairburn & Cooper, 1993).
Advantages and Limitations of DSM
Diagnosis
Using
a combination of the DSM for client self-report of symptoms combined with a
formal assessment
instrument
seems to be best-practice delivery of mental health services. Using the DSM to
exclusively
diagnose is advantageous to the clinician in that it allows the clinician flexibility
in structuring
questions based
upon client self-report. However, it limits the accuracy of diagnosis, as leGrange,
&
Loeb
(2007) discovered: “More
than 90% of the total sample (of general psychologists and ED
psychologists) indicated that they encountered
child or adolescent patients who presented with ED who
they were unable to treat.” Both
groups of clinicians rated themselves as low on ability to treat ED, siting
lack of skills, case complexity, and
lack of resources as being problematic. This leads to the conclusion
that “formal training opportunities in
the area of pediatric ED during medical school and doctoral studies”
should be increased (leGrange & Loeb, 2007).
Rationale for Diagnosis
According to the DSM-lV-TR (2000) diagnostic
criteria for BN is:
A.
Binge Eating
B.
Recurrent compensatory behavior (such as: vomiting, fasting, excessive
exercise, laxatives, enemas or diet medications)
C.
Binge Eating and Compensatory behaviors both occur at least twice a week for 3
months
D.
Self-evaluation is unduly influenced by weight
E.
Disturbance does not occur during episodes of Anorexia Nervosa.
The
case study I presented of the “Case of the Bulimic Model” meets all criteria
established by the DSM for BN.
Applying the 5-axis Diagnostic System
The Bulimic client is a 23 year old female model named
Stephanie who reports having suffered with Bulimia since the age of 19. The
triggering event was her ex-boyfriend’s comment that he broke off the
relationship because she had “gained a few pounds.” Stephanie suffers from low
self-esteem and body dysmorphia. In applying the DSM 5-axis diagnostic system,
I would assign the following:
l) Clinical
Syndromes/Disorders-Bulimia Nervosa is classed by the DSM as a mental disorder.
Body Dysmorphia is also a mental disorder.
II)
Personality Disorders/Mental Retardation-Client has no symptoms of personality
disorder nor deficiencies in intelligence.
lll)
Medical Conditions-Client reports no present medical conditions, though in the
past experienced amenorrhea due to restricting and purging.
lV)
Psychosocial and Environmental Stressors-Client is a professional model. Her
only social contacts are other models who also admit to having eating
disorders. Client’s family and boyfriend live out of state, and she is no
longer attending church where she used to find spiritual support. Client
reports having made no friends outside of models at her agency. She is having financial difficulties
due to lack of work.
V) Global Assessment of Functioning
(GAF)-Client has poor insight regarding her choice of modeling career which
maintains BN. She is socially isolated and her family does not know about her
eating disorder. Client has medium-level depression and experiences high
anxiety due to body dysmorphia. While client presents in counseling
well-groomed, she is frequently tearful and makes self-deprecating remarks.
GAF Score of: 43, due to: Serious
impairment in relationship with friends (no current friends), serious
impairment in thinking (distorted body image and preoccupation with weight),
and serious impairment due to anxiety (overwhelming anxiety).
Treatment Plan for Bulimia Nervosa
Evidence-based
treatment approaches for BN indicate Cognitive-Behavioral Therapy as the
standard
psychotherapeutic approach for eating disorders. However,
a new model of therapy known as Integrative
Cognitive-Affective
Therapy for the treatment of bulimia nervosa is an emotion-focused treatment
that
emphasizes
emotion regulation skills in clients with BN (Basada, 2011). Combining
elements
from Dialectical Behavioral Therapy (DBT) and
Cognitive-Behavioral Therapy, Integrative
Cognitive-
Affective Therapy
offers the emotional-regulation skills of DBT in addition to the
empirically-proven CBT
Model which
emphasizes cognition and resulting behaviors.
Social Systems and Diagnosis
In a large study of multifactorial assessment of bulimia nervosa, Tobin
et al. (1991) concluded, “Factors
that promote depression and affective
instability, whether biologic, systemic, or psychological, represent
another complicating dimension of
bulimic symptoms.” It is clear that the systemic or environmental
influences upon the client will impact
treatment outcome and must be accounted for. The client’s only
social influences are the modeling
agency and the models she refers to as “friends.” She has hidden her
BN since the age of 19 and may have
moved out of state from her family to keep her disorder a secret.
Because the modeling agency encourages
anorexic-like body types, and because her modeling friends
have admitted having the same problem
as the client, treatment planning for her becomes challenging, as
this is her only means of income; to
change jobs would mean a loss of all income. These factors must be
topics for discussion with the client
when considering treatment planning.
Managed Care Health Insurance and Treatment
In order for the client to enter an in-patient treatment
facility, authorization (approval) must be obtained prior to admittance. This
process can take time and certain criteria must be met. Clients who are
needing hospitalization for eating disorders should find out what their
insurance covers and how long the process takes should hospitalization become
necessary. Often, clients whose disorders are not critical prefer a course of
psychotherapy to in-patient care. Because ED are complex and a specialization
within mental health, families should not delay in seeking a second opinion if
they believe the healthcare professional is not treating the eating disorder
seriously as the life-threatening situation it is.
References:
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(2000). Diagnostic and Statistical Manual of Mental Disorders (DSM-
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Stice, E., Marti, C. N., Rohde,
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proposed
DSM-5 eating disorder diagnoses in an 8-year prospective community study of young women.
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Public Health Agency of Canada.
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