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Section 3
Self-Discrepancy in Bulimic Clients

CEU Question 3 | CEU Test | Table of Contents | Eating Disorders
Social Worker CEUs, Psychologist CEs, Counselor CEUs, MFT CEUs

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On the last track, we examined three manifestations of depression in bulimic clients.  These three manifestations of depression included:  guilt; worthlessness; and social withdrawal.

On this track, we will discuss three concepts related to self-image distortion in bulimic clients.  These three concepts related to self-image distortion in bulimic clients include: weight-obsessive thoughts; overestimating size; and unrealistic standards.

As you are aware, body image and the desire to be a certain size is at the core of eating disorders.  Bulimic and anorexic clients both have an unhealthy standard of weight which leads to unhealthy eating habits.  While both bulimic and anorexic clients experience obsessive thoughts about weight and body image, anorexic clients also accept the disorder as another identity while binging and purging clients can more easily dissociate themselves from the disorder. 

3 Concepts Related to Self-Image Distortion

Concept #1 - Weight-Obsessive Thoughts
The first concept related to self-image distortion in bulimic clients is weight-obsessive thoughts.  Clients diagnosed with bulimia regularly worry about their shape and weight. Many of these thoughts consume most of their day and the client rarely thinks about anything else. In addition, the client will regularly check him or herself in order to determine how much weight he or she has gained or lost. Some clients report weighing themselves up to 25 times a day. 

Others use a tape measure or estimate their attractiveness by the tightness of their clothes. In many ways, these obsessive thoughts resemble those of clients with OCD. As you know, OCD clients will obsess over a situation or object until he or she can perform a ritual to expel the thoughts from the mind. In the same way, bulimic clients will obsess over their weight and appearance until they can binge or purge, their own form of ritual. For this reason, it is difficult for bulimic clients to accept not dieting any more. They fear becoming overweight and cannot adapt to another way of life.

Milly, age 21, was in a constant cycle of weight and image checking that caused her to feel more distressed than assured. Milly stated, "My confidence and feelings of self-worth are deeply rooted in the idea that I must be physically attractive, meaning thin. When I put on weight, even one pound, I risk being unattractive, and I see my future as bleak and lonely! This thought fills me with despair so I force myself to eat as little as possible. I weigh myself over and over again, sometimes up to fifteen times a day! When I haven’t lost the weight I wanted, I get depressed and want to eat again!" 

I asked Milly to remove the scales in her house and to throw them out in the garbage. Also, I suggested that she rethink her wardrobe and buy clothes that are slightly looser fitting so the tightness does not distract her into thinking she is overweight. Think of your Milly. What other strategies could help prevent weight-obsessive thoughts?

3-Step Cognitive Behavior Therapy Technique:  Accepting New Habits
To help Milly accept the new behavior of non-dieting, I asked her to try the "Accepting New Habits" CBT exercise. I stated to Milly, "I want you to think of everything that needs to be changed for you to be happy, especially those thoughts that relate to your weight. For instance, do you say to yourself, ‘I need to lose twenty pounds"? 

-- Step 1. Then I want you to write this list down in a notebook and underline the word ‘need’ in those phrases. 

-- Step 2. Next, go through that list and, one by one, ask yourself if you can let go of the need or demand to change it. Then, once you have those written down, write out items that you have trouble accepting, for example, not dieting. Write down the reasons you can’t accept it. 

-- Step 3. Then, look at each reason and say out loud that you choose to accept it." One of Milly’s "need phrases" was "I need to be thin" and the item that she could not accept was "stop dieting." 

One of the reasons she gave for not being able to accept this was "it’s not slimming." Her new "acceptance" phrase, then, was "I accept that it’s not slimming."  These new phrases can help clients like Milly reverse his or her obsessive thoughts.

Think of your Milly. Could he or she benefit from "Accepting New Habits?"

Concept #2 - Overestimating Size
The second concept related to self-image in bulimic clients is overestimating size.  Bulimic clients will often believe themselves to be approximately twenty percent larger than they actually are.  While overestimating size is common in even healthy individuals, the overestimation is only about five percent over actual size. 

This extreme overestimation... that occurs in bulimic clients is the driving force behind the guilt and shame of overeating.  Bulimic clients desperately want to "cure" themselves of being overweight, but cannot accomplish such a task because of their binging habits. 

Lola, age 19, was a normal weight client who experienced self-image distortion.  While she felt much pride in her accomplishments in her grades and other school activities, Lola’s physical self-image did not correspond with her actual outward appearance. Lola stated, "I am confident in many ways, yet I hate my body and can’t bear to look at it! I feel bloated, wobbly, and huge all over!  I cannot put into words how repulsed I am with my body!  I wish it were possible to wear clothes that disguised one’s shape completely!  I take showers instead of baths to avoid having to look at myself!" 

While other students constantly compliment her on her appearance, Lola cannot accept herself as a person of physical attractiveness.  Think of your Lola.  How does he or she overestimate his or her size or weight?

Concept #3 - Unrealistic Standards
In addition to weight-obsessive thoughts and overestimating size, the third concept related to self-image distortion in bulimic clients is unrealistic standards. Clients who experience self-image distortion and bulimia have unrealistic standards in regards to healthy or optimal weight. Coupled with the belief that they are larger than they truly are, the client’s discrepancy between their perceived reality and their perceived standard becomes greater and even harder to accomplish. 

Holly, age 18, had cut out pictures of super models and pre-adolescent actresses and pasted them on her walls. When I asked her why she did this, she stated, "It reminds me of what I’m working towards! Those women are beautiful and successful. It’s just more motivation for me to keep on track!" I asked Holly how she felt when she compared herself to these women. She stated, "Well, I feel fatter and slightly depressed." I then asked if she had ever had a binging episode after one of these comparisons. 

She stated, "Actually, yes. Almost every time, really."  I then stated, "So the pictures of the infinitesimally small women doesn’t really keep you on track at all. In fact, it derails you into an overeating episode. Perhaps if you did not have such an unreachable goal, you might be able to feel less depressed and more able to control your habits." Think of your Holly. What unrealistic standards has he or she set?

On this track, we discussed three concepts related to self-image distortion in bulimic clients.  These three concepts related to self-image distortion in bulimic clients included:  weight-obsessive thoughts; overestimating size; and unrealistic standards.

On the next track, we will examine three binge trigger categories.  These three binge trigger categories include:  food and eating; body weight and shape; and negative emotions.

Peer-Reviewed Journal Article References:
Landa, C. E., & Bybee, J. A. (2007). Adaptive elements of aging: Self-image discrepancy, perfectionism, and eating problems. Developmental Psychology, 43(1), 83–93.

Lowe, M. R., Marmorstein, N., Iacono, W., Rosenbaum, D., Espel-Huynh, H., Muratore, A. F., Lantz, E. L., & Zhang, F. (2019). Body concerns and BMI as predictors of disordered eating and body mass in girls: An 18-year longitudinal investigation. Journal of Abnormal Psychology, 128(1), 32–43.

Williamson, D. A., Cubic, B. A., & Gleaves, D. H. (1993). Equivalence of body image disturbances in anorexia and bulimia nervosa. Journal of Abnormal Psychology, 102(1), 177–180.

Online Continuing Education QUESTION 3
What are three concepts related to self-image distortion in bulimic clients? To select and enter your answer go to CEU Test.

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