Imagery as a Trigger of Self-Induced Vomiting in Bulimic Behaviors

Although many studies have examined the role of imagery among people with anxiety disorders, little research has been done into the frequency and nature of images experienced by patients with eating disorders.

A group of researchers at the Institute of Psychiatry, King’s College, London, investigated the possible role of core beliefs and imagery in triggering self-induced vomiting. Thirty bulimic women first participated in a semi-structured interview focusing on their thoughts prior to vomiting, and then completed a self-report measure of core beliefs. Before taking part in the interview, participants were asked to complete a measure of core beliefs. The Schema Identification Scale for Clients with Eating Disorders is a seven-item report questionnaire specifically developed for this study (see table).

Seeking memories and core beliefs

The participants were then asked to identify a recent time when they had vomited and to describe any thoughts they remembered experiencing immediately before vomiting. They were then asked to indicate if they felt that any of the core beliefs they had previously identified on the questionnaire were reflected in those beliefs, and to rate the strength of the beliefs. They were also asked if they had noticed any feelings before vomiting, including loneliness, boredom, shame, and guilt, and, if so, to describe the feelings. In addition, the women were asked whether any images had passed through their minds prior to the vomiting episode; if not, they were asked about any sensory impressions, including smells, tastes, feelings, or sounds. Finally, they were asked if they had a memory that seemed linked to the image.

Feelings of defectiveness and shame were common

As Dr. Hendrik Hinrichsen and colleagues reported, a significant proportion of the subjects had thoughts relating to defectiveness/shame, failure, and social isolation before a vomiting episode (J Cognitive Psychother. 2007; 21:261). Seventy-three percent believed that the thoughts they experienced before vomiting were related to feelings of defectiveness and shame; 67% of the women reported feelings of failure before the vomiting episode. More than half of the women reported having thoughts relating to social isolation.

Two overall themes emerged among the women who could identify a recurrent image linked to a specific memory. These were: (1) being humiliated or abused, for example, being laughed at by a teacher, being bullied because of being overweight, or being forced to have sex while drunk, and (2) being abandoned, such as when their father left the family after a divorce, or when they saw a sibling dying.

The results of this study have several implications for clinical practice. First, it seems important to identify patients’ feelings of defectiveness and shame in therapy. These beliefs might then be modified using positive data logs, verbally challenging belief content, and reattribution of the origins of the core belief. These steps would be especially helpful, according to the authors, for bulimic patients with a history of childhood trauma or abuse.