CASE STUDY
Sage (bulimia nervosa)

Sage is a 26-year-old doctoral candidate in English literature at the local university. She is in good standing in her program and has plans to enter the job market in the fall. In your intake, she tells you she thinks she is “fat” and has been self-conscious about her body since the sixth grade, at which time she began menstruating and developing breasts earlier than the other girls in her class. She was teased for needing a bra and remembers feeling “chubby, too big, and just wanting to be small like [her] younger sister.” She started dieting in the seventh grade, following strict rules for weeks (e.g., she recalls the grapefruit only diet), then transitioning into what she called “bad” weeks.  During these times, she would stock up on candy bars and other snack foods and eat them, often in her bedroom late at night. Her parents became concerned and tried to strictly limit her dieting.  This led to eating “normal” during the day and binging on those candy bars she kept hidden in her bedroom at night if she felt sad, scared, or mad. She grew into a habit of eating to feel better – relief that was only temporary, as she would feel ashamed about what she had done and resolve to not do it again. In college, her pattern of emotional eating continued, which felt more distressing to her because of the pressure to look “as pretty and thin as the other girls.” In spring of her freshman year she experimented with throwing up after the late-night eating and found that, at least in the minutes that followed, she felt like she had much more control and believed this would help her to prevent the weight gain she so dreaded. She fell into a vicious cycle of late-night binges (typically consuming about 7 candy bars in 15 minutes, during which times Sage described feeling very out of control) followed by making herself throw up. In college, she engaged in these binge-purge episodes about 6 nights/week. At present, she is having a harder time hiding the episodes because she lives with her boyfriend; she estimates that they occur about 4 nights per week. The times when she feels the most compelled to binge and purge are when she has a major presentation coming up in her doctoral program and when she gets in a fight with her boyfriend. Her BMI is in the normal range, but she says she needs to lose weight. She wants to stop binging and purging because she does not want her boyfriend to find out, but she is also afraid that if she stops, she will gain weight.