Case Study: Sofia Alvarez (DSM-5-TR: Bulimia Nervosa, Moderate Severity)

Demographics

• Name: Sofia Alvarez

• Age: 21

• Gender: Female

• Occupation: Junior at a large university, majoring in Kinesiology

• Background: Former competitive soccer player; currently works part-time at a campus café

Clinical Presentation

Course of Symptoms

Sofia was referred to counseling by her academic advisor after multiple class absences and reports of fainting during practice. In therapy, she reveals a two-year history of recurrent binge-eating episodes followed by compensatory behaviors, primarily self-induced vomiting and excessive exercise.

She describes cycles of “feeling completely out of control” while eating—consuming large quantities of food (entire pizzas, multiple pints of ice cream)—followed by panic, disgust, and purging.

Episodes occur at least three to four times per week, typically in the evening or after social events involving food.

DSM-5-TR Diagnostic Features

Criterion A:

Recurrent episodes of binge eating, characterized by:

1. Eating, in a discrete period (≤2 hours), an amount of food larger than what most people would eat in a similar period.

2. A sense of lack of control over eating during the episode.

Sofia reports episodes where she “zones out” and keeps eating despite fullness or nausea, often describing them as “blackouts with food.”

Criterion B:

Recurrent inappropriate compensatory behaviors to prevent weight gain, such as vomiting, misuse of laxatives, fasting, or excessive exercise.

Sofia vomits after nearly every binge and sometimes engages in intense cardio sessions lasting 90+ minutes to “undo the damage.”

Criterion C:

Both binge eating and compensatory behaviors occur, on average, at least once a week for three months.

Sofia’s pattern—three to four binge-purge cycles weekly for the past two years—exceeds this threshold.

Criterion D:

Self-evaluation unduly influenced by body shape and weight.

She constantly compares her body to athletes and fitness influencers, checking mirrors up to 30 times daily. Her self-worth is tied to “feeling lean.”

Criterion E:

Disturbance does not occur exclusively during episodes of anorexia nervosa.

Although Sofia’s weight is slightly below average (BMI 20.1), it is not significantly low, and she maintains regular menstrual cycles.

Severity (DSM-5-TR Classification)

• Moderate: Average of 4–7 inappropriate compensatory behaviors per week.

Psychological and Behavioral Features

• Cognitive distortions: “I can’t trust myself around food.”

• Mood instability: Periods of anxiety, guilt, and brief relief after purging.

• Social secrecy: Eats “normally” with others but binge eats in private.

• Interpersonal distress: Avoids dating and social meals due to shame.

• Physical symptoms: Electrolyte imbalance, dental erosion, calloused knuckles (“Russell’s sign”), and frequent sore throats.

Differential Diagnosis (DSM-5-TR Guidance)

Functional Impairment

• Academic: Declining grades, missed classes due to fatigue and dehydration.

• Social: Avoids roommates; lies about having “stomach bugs.”

• Medical: Frequent dizziness and low potassium; advised to suspend physical activity temporarily.

• Emotional: Shame, self-disgust, and fear of being discovered dominate daily life.

Treatment Considerations (DSM-5-TR Aligned)

• Cognitive-Behavioral Therapy (CBT-E): Address binge-purge cycle, body-image distortion, and perfectionism.

• Nutritional rehabilitation: Work with dietitian to restore balanced eating patterns and normalize metabolism.

• SSRIs (e.g., fluoxetine): Shown effective for reducing binge-purge frequency.

• Family involvement: Especially helpful for young adults still financially or emotionally dependent on parents.

• Monitoring: Ongoing medical supervision for electrolyte levels and cardiac health.

Cultural Context and Contributing Factors

• Sofia describes being raised in a family where food was tied to celebration but also appearance was heavily scrutinized (“We always talked about who gained weight after holidays”).

• Her identity as a former athlete fuels perfectionism and fear of “letting herself go.”

• Social media exposure intensifies her drive for an idealized body image.