Bulimia nervosa, moderate
Binge-purge cycle 4-6x/week, dietary restriction during the day driving the cycle; medical workup stable.
Presenting concern
EDE-Q at intake: global 4.2. Binge-purge episodes 4-6x/week for 3 years. Heavy daytime dietary restriction. Body image distress. Medically cleared, no electrolyte abnormalities currently. PHQ-9: 11.
History
Dieting started age 14. Binge-purge cycle established by 17. Never disclosed to family or prior providers. Triggered to seek help by roommate noticing.
- Long-standing pattern
- Continued restriction maintaining binge cycle
- Secrecy and shame
- Body image disturbance
- Medically stable
- Self-presenting
- Bright, capable of doing the work
- Willing to track
Conceptualization across modalities
Over-evaluation of shape and weight as defining self-worth drives dietary restriction. Restriction (physical and cognitive) sets up the binge. Binge produces guilt and compensatory behavior (purging). The cycle maintains via mood regulation function and avoidance of body distress.
- Regular eating pattern (3 meals + 2 snacks, regardless of binge)
- Real-time self-monitoring
- Behavioral experiments to break dietary rules
- Address over-evaluation of shape/weight in stage 3
Binge-purge serves emotion regulation. Skills deficits in distress tolerance and emotion regulation drive episode use. Mindful eating and urge surfing replace dysfunctional skills.
- Diary card with urges and behaviors
- Distress tolerance skills
- Emotion regulation skills
- Mindful eating practice
Treatment plan
Engagement (1–4)
Formulation, real-time monitoring, regular eating.
Stage 2 — early change (5–12)
Address dietary rules, behavioral experiments, weight stabilization.
Stage 3 — maintenance mechanisms (13–18)
Shape/weight over-evaluation, mood-driven eating.
Stage 4 — relapse prevention (19–20)
Plan for high-risk situations.
Binge-purge frequency dropped to <1/week by session 14. Regular eating pattern was the hardest behavioral target. Body image work continued past symptom remission.