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Case Studies in Abnormal Psychology 10th Edition - (Chapter 13 Eating Disorder Anorexia Nervosa )

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CHAPTER 13

Eating Disorder:

Anorexia Nervosa

Joan was a 38-year-old woman with a good job and family life. She lived with her second husband, Mitch; her 16-year-old son, Charlie, from her first marriage; and her husband’s 18-year-old daughter from a previous marriage. Joan was employed as a secretary at a university, and Mitch was a temporary federal employee. Joan was 5′ 3 ′′and weighed approximately 125 pounds. Although she was concerned about her weight, her current attitudes and behaviors were much more reasonable than they had been a few years earlier, when she had been diagnosed with anorexia nervosa. Joan had struggled with a serious eating disorder from the ages of 29 to 34. She was eventually hospitalized for 30 days. The treatment she received during that hospital stay finally helped her overcome her eating problems. Four years later, her condition continued to be much improved.

Social History

Joan was born in a suburb on the outskirts of a large northeastern city. Her one brother was 2 years younger. Her father worked as a supervisor for an aircraft subcontractor. Joan’s mother stayed at home while the children were young and then worked part time as a waitress and bookkeeper. Both parents were of average weight. Joan’s early childhood was ordinary. She was an above-average student and enjoyed school. She and her brother bickered, but their disagreements did not extend beyond the usual sibling rivalry. Her family lived in a large neighborhood filled with lots of children. Joan was somewhat overweight during elementary school. She had high personal standards and strove to be a perfect child. She always tried to do what was right and conformed completely to her parents’ wishes. When Joan was 14 and entering the ninth grade, tragedy struck her family and forever changed her home life. She and her 12-year-old brother were home while her parents were at work. Although her brother was too old to require babysitting,

Oltmanns, Thomas F., et al. Case Studies in Abnormal Psychology, 10th Edition, Wiley, 2014. ProQuest Ebook Central, ebookcentral.proquest/lib/monash/detail.action?docID=5106408. 162

Chapter 13 Eating Disorder: Anorexia Nervosa 163

she was supposed to keep an eye on him. Joan had a friend over, and the two girls were upstairs in her room. Joan heard some loud noise outside and looked out the window. She saw her brother lying dead in the road. He had been run over by a car. Although the feeling became less intense as years passed, Joan continued to feel guilty about her brother’s death well into adulthood. After the accident, Joan’s parents changed. They became extremely overpro- tective, and Joan felt as if she “had a leash on all of the time.” From age 14 on, she no longer had a normal childhood. She could not hang out with friends, be away from the house for long periods of time, or go out in cars. Her parents wanted to know where she was and what she was doing, and they set a strict curfew. Joan knew her parents would worry if she were late, so she always tried to be home early. She made a special effort to do exactly as she was told. She did not go out much because she felt the need to stay near her parents so they would know that she was alive and well. The rest of high school was unremarkable. Joan earned reasonably good gra- des and got along well with everyone. During the summer after her brother’s death, when Joan was 15, she met and began to date a 17-year-old boy. Joan’s parents were initially unhappy with this relationship, in part because Randy owned a car, and they didn’t want her to ride around with him. Joan had to meet Randy secretly for the first few months. As her parents got to know him better, they began to like him, and they could date openly. During this time, Joan continued to feel guilty when she was in cars because she was reminded of her brother’s death. She frequently stayed home because she knew that her parents would suffer horribly if anything happened to her. After high school, Joan attended a two-year business school and was engaged to Randy. They married after Joan graduated. She was 19 years old as she began her marriage and her first full-time job as a secretary in a medical office. Prior to this time, Joan’s father had never allowed her to hold even a part-time job. He insisted on providing for all of her needs. Although this marriage lasted legally for 6 years, it became clear within 9 months that the relationship was in trouble. Joan cared for her husband, but she did not love him. She soon realized that she had used Randy as an escape route from her parents’ home. She felt as if she had simply jumped from one dependent relationship into another. When she had been at home, her parents provided everything. Now Randy was taking care of her. Joan worried that she did not know how to take care of herself. Despite these negative feelings, Joan and Randy tried to make the marriage work. They bought a home 1 year after their wedding. Two years later, Joan accidentally became pregnant. Joan gained 80 pounds during the course of her pregnancy. When Charlie was born, she weighed 200 pounds. Over the next few months, Joan found it difficult to lose weight but eventually got down to 140 pounds. Although it was hard for her to adjust to this weight gain, she did not try to change her weight because it felt “safe” to her. Joan and Randy were legally separated 2 years after Charlie was born. They continued to see each other occasionally and sought marital counseling at various times during the next couple of years. They could not reconcile their differences,

Oltmanns, Thomas F., et al. Case Studies in Abnormal Psychology, 10th Edition, Wiley, 2014. ProQuest Ebook Central, ebookcentral.proquest/lib/monash/detail.action?docID=5106408.

Chapter 13 Eating Disorder: Anorexia Nervosa 165

125 pounds. She was concerned that she would gain more weight while she was inactive, recovering from surgery. Joan’s diet was strict from the beginning: She measured and weighed all her food. Within a year, she weighed less than 100 pounds. Her food intake was severely restricted. During the day she consumed only coffee with skim milk and an artificial sweetener. Occasionally, she ate a piece of fruit or a bran muffin. When she and Charlie ate dinner with her parents, Joan took a normal amount of food on her plate but played with it rather than eating it. After dinner, she usually excused herself to go to the bathroom where she took laxatives in an effort to get rid of what little food she had eaten. Joan hardly ate any meats, breads, or starches. She preferred fruits and vegetables because they were mostly water and fiber. Although she did not let herself eat, Joan still felt hungry; in fact, she was starving most of the time. She thought about food constantly, spent all her time reading recipe and health books, and cooked elaborate meals for the family. Although she weighed less than 100 pounds, Joan still felt overweight and believed that she would look better if she lost more weight. She had an overwhelm- ing fear of getting fat because she believed that gaining weight would mean that she was not perfect. She tried to be an exemplary person and struggled to be what she imagined everybody else wanted. She gave little thought to what she would want for herself. She felt like everything in her life was out of her control except for her weight and body. She felt proud and accomplished by having such strict self-control over her eating. As she lost weight, Joan experienced several of the physical effects that accompany starvation. Her periods stopped; she had problems with her liver; her skin became dry and lost its elasticity; her hair was no longer healthy; and she would often get dizzy when she stood up. At this time, Joan was working as a secretary in a university medical school. Some of her coworkers noticed the drastic change in her appearance and became concerned. An internist in her department recognized her symptoms as those of anorexia nervosa and tried to get Joan to seek help. Joan agreed to attend an eating disorders support group and even went to some outpatient therapy sessions, mostly in an attempt to appease her friends. She also consulted a dietician at the university hospital and worked on an eating plan. There were moments when Joan considered the possibility that her behavior was not normal, but most of the time she viewed her ability to control her weight and appetite as a sign of strength. When she was transferred to a different department within the university, she left therapy and returned to her restrictive dieting. Joan’s parents were also acutely aware of their daughter’s abnormal patterns of eating and excessive weight loss. They were extremely worried about her health. The more they tried to talk to her about it, the more resistant she became to their pleadings. Arguments about eating became frequent, and the level of tension in the home escalated dramatically. A year and a half after the onset of her eating disorder, Joan moved with Charlie into her own apartment. Her decision was prompted mostly by the conict

Oltmanns, Thomas F., et al. Case Studies in Abnormal Psychology, 10th Edition, Wiley, 2014. ProQuest Ebook Central, ebookcentral.proquest/lib/monash/detail.action?docID=5106408.

166 Case Studies in Abnormal Psychology

with her parents. She continued to diet and now weighed about 90 pounds. Charlie’s diet had also become restricted, in part because there was very little food in the house. Joan could hardly bring herself to go to the grocery store. Once there, she made an effort to behave normally and went through the store putting food into her shopping cart. When it came time to pay, however, she would not actually buy much. She believed that food was bad and that it was a waste of money. Instead of purchasing anything, she would wander up and down the aisles, eating much of what was in her shopping cart. Her reasoning was that it made no sense to pay for food that could be eaten while you were in the store. She engaged in binge eating whenever she did manage to buy something. In one afternoon, she would occasionally eat two dozen donuts, a five-pound box of candy, and some ice cream. After this, Joan took 20 to 30 laxatives to get rid of the food. At times she made herself vomit by sticking a toothbrush down her throat, but she preferred to take laxatives. Some weeks she did not binge at all, others once or twice. On the days in between binges, she ate only a little fruit and drank some liquids. Joan’s eating problems persisted for the next 5 years. Her weight uctuated between 90 and 105 pounds during this period. At times she ate more normally, but then she would eat practically nothing for months. She tried therapy, though she was not seriously or consistently committed to changing her behavior. Her life seemed like a roller coaster, as she cycled back and forth between relatively healthy patterns of eating, severe restricting, and bingeing and purging. Most of her diet consisted of liquids such as diet soda, water, and coffee. Occasionally she drank beer, seeking the numbing effect it had on her appetite. She was pleased with her weight when it was very low, but she felt horrible physically. She was weak most of the time, and other people constantly told her that she was too thin. In Joan’s mind, however, she was still too heavy. When she was 32 years old, almost 3 years after the onset of her eating problems, Joan met Mitch at a church gathering. They began to date. Mitch was different from all of the other men in Joan’s past. He genuinely cared about her, and he also liked her son. Her weight was at one of its peaks when they met, some- where between 100 and 105 pounds, so her eating problems were not immediately obvious to him. Unfortunately, soon after they began dating, Joan once again began to restrict her eating, and her weight quickly dropped to another low point. Mitch noticed the obvious change in her behavior and appearance. His reaction was sympathetic. As their relationship grew stronger, Mitch seemed to help Joan feel differently about herself. They talked frequently about her weight and how little she ate. Mitch expressed great concern about her health, pleading gently with her to gain weight, but her restrictive patterns of eating persisted despite the other psychological ben- efits that accompanied the development of this relationship. One year after she started dating Mitch, Joan needed major abdominal surgery to remove two cysts from her small intestine. During the operation, the surgeon saw that she had other problems and reconstructed her entire bowel system. When she left the hospital,

Oltmanns, Thomas F., et al. Case Studies in Abnormal Psychology, 10th Edition, Wiley, 2014. ProQuest Ebook Central, ebookcentral.proquest/lib/monash/detail.action?docID=5106408.

168 Case Studies in Abnormal Psychology

extremely restrictive in her eating. She began to feel differently about herself and food. Joan could not pinpoint exactly what had happened, but she had become a different person who was no longer preoccupied with dieting and weight control.

Discussion

Anorexia nervosa is one of the feeding and eating disorders described in DSM- (APA, 2013). Anorexia nervosa is characterized by extreme weight loss, fear of gaining weight, and problems with thinking about one’s weight. About 90– percent of anorexics are female. Lifetime prevalence rates for white women range from 1 to 2 percent (Wade, Bergin, Tiggemann, Bulik, & Fairburn, 2006). Over time, about half of people with the disorder stop having any symptoms, and another 25 percent are improved. However, its course can be chronic, and 5 percent of patients with anorexia nervosa starve to death (Steinhausen, 2002). Deaths also occur from physical complications of the illness and from suicide. Careful medi- cal supervision of weight gain for severely malnourished patients is necessary to prevent refeeding syndrome, another cause of death and other serious complica- tions, caused by too-rapid changes in phosphorus and electrolyte levels when food is reintroduced (Katzman, 2005). Complications such as osteoporosis, anemia, and compromised immune function are common (Misra et al., 2004). The DSM-5 (APA, 2013) specifies two types of anorexia nervosa. Individ- uals are considered to be the restricting type if during the episode of anorexia nervosa, they do not regularly engage in eating binges or purge themselves of the food they have eaten during a binge (whether through vomiting or laxative misuse). The binge-eating/purging type , which is consistent with Joan’s behav- ior, involves the regular occurrence of binge eating or purging behavior during the episode of anorexia. Approximately one-half of people with anorexia nervosa also have bulimic symptoms, and roughly one-third of those with bulimia nervosa have a history of anorexia. When followed over a period of several years, many people who originally fit the description for restricting type have changed over to the binge-eating/purging type (Eddy et al., 2002). Research has revealed some important differences between the two subtypes of anorexia nervosa. Anorexics who also binge and purge tend to have weighed more before their illness, are more sexually experienced, are more outgoing, tend to have less impulse control, are more likely to abuse drugs or steal, and have more variable moods than restrictors (Casper & Troiani, 2001). The presence of binge- ing and purging is also thought to be a sign of greater psychological disturbance and an indication of a poorer prognosis (Van der Ham, 1997). Anorexia nervosa is often comorbid with several other disorders, including substance abuse, obsessive compulsive disorder (OCD), several personality disorders, and especially with major depression (O’Brien & Vincent, 2003).

Oltmanns, Thomas F., et al. Case Studies in Abnormal Psychology, 10th Edition, Wiley, 2014. ProQuest Ebook Central, ebookcentral.proquest/lib/monash/detail.action?docID=5106408.

Chapter 13 Eating Disorder: Anorexia Nervosa 169

Relatives of patients with anorexia are more likely to have mood disorders. People with the bingeing-purging subtype of anorexia nervosa are more likely to have personality disorders, especially borderline personality disorder (Jordan et al., 2008). Comorbid disorders may not be as common among anorexics who do not seek treatment, so studies may have overestimated comorbidity because they have often relied on clinical samples (Perkins, Klump, Iacono, & McGue, 2005). People with anorexia nervosa are often characterized as being obses- sional, conforming, and emotionally reserved (Thornton & Russell, 1997). Many researchers and clinicians have described perfectionism as common among people with anorexia (Franco-Paredes, Mancilla-Díaz, Vázquez-Arévalo, López-Aguilar, & Álvarez-Rayón, 2005). A frequent feature of anorexia is overactivity. People with the disorder are often restless, fidgety, and engage in excessive exercise (Klein & Walsh, 2004). Joan met the diagnostic criteria for anorexia nervosa, binge-eating/purging type. She experienced a drastic, self-induced loss of weight; was intensely afraid of becoming fat; and could not recognize the true size of her body or the seri- ousness of her condition. In addition to her severe restriction of food intake, Joan would also periodically eat large amounts of food and then try to rid herself of the unwanted calories through vomiting and laxatives. She also experienced many of the physical side effects that accompany starvation, such as loss of menstruation, skin changes, constipation, hypotension, bloating, abdominal pains, dehydration, and lanugo (downy hair growth). It is important to recognize that some of the psychological symptoms of anorexia nervosa are produced by the lack of food and are not necessarily inherent aspects of the anorexic’s personality. For example, people who are starving become preoccupied with food and eating. Like Joan, they will often cook for others, read recipe books, and may even develop peculiar food rituals. While people with anorexia nervosa may become preoccupied with interacting with food, they lose their motivational orientation toward eating it (Veenstra & de Jong, 2011). This lack of desire to approach and consume food is what enables them to so severely restrict their food intake. Obsessive behaviors, such as hoarding, may also appear. There is often an exaggeration of previous personality traits, such as increased irritability, avoidance and social withdrawal, and a narrowing of interests (Kaye, Strober, & Rhodes, 2002).

Etiological Considerations

Biological factors have been considered in the search for the causes of anorexia nervosa. It seems likely that biological factors—including hormones and neu- rotransmitters that regulate metabolism and mediate perceptions of satiety—are involved in the etiology of anorexia nervosa. The exact factors and their role in the disorder have not been determined (Ferguson & Pigott, 2000). But there is compelling evidence that genetic factors are implicated in disordered eating.

Oltmanns, Thomas F., et al. Case Studies in Abnormal Psychology, 10th Edition, Wiley, 2014. ProQuest Ebook Central, ebookcentral.proquest/lib/monash/detail.action?docID=5106408.

Chapter 13 Eating Disorder: Anorexia Nervosa 171

At the same time that contemporary cultural standards have emphasized thinness, the average woman’s body weight has been increasing, creating a conict between the ideal shape and many women’s actual shape. This conict often leads to prolonged or obsessive dieting, which can be a prelude to the development of anorexia nervosa (Hsu, 1996). About 12 percent of adolescent girls have some form of eating pathology (Stice, Marti, Shaw, & Jaconis, 2009). The prevalence of anorexia nervosa has increased as the thin feminine ideal took hold, and the prevalence of anorexia nervosa is especially high among women who are under intense pressure to be thin, such as dancers and models. Of course, not all dieting develops into an eating disorder. The evidence specifically linking media exposure to body dissatisfaction is contradictory and at best shows modest effects; there is more evidence that peer pressure impacts body dissatisfaction, perhaps due to female competition for potential mates (Ferguson, Winegard, & Winegard, 2011). It is hypothesized that sociocultural pressures are part of a larger model of development, which includes other predisposing factors such as problems with autonomy, rapid physical change at puberty, premorbid obesity, personality traits, cognitive style, perceptual disturbances, and interpersonal and familial difficulties (Polivy & Herman, 2002). The role of sexuality in the development of anorexia is not clear (Ghizzani & Montomoli, 2000). Although some experienced clinicians have described the disorder as a retreat from maturity, sexual issues are not necessarily the central problem. Rather, the patient with anorexia may be focused more specifically on achieving control of her body and diet. For some women, sexual abuse is an impor- tant factor in the development of an eating disorder. Nevertheless, there does not appear to be a specific relation between eating disorders and exposure to sex- ual trauma (Wonderlich, Brewerton, Jocic, & Dansky, 1997). About 30 percent of women with eating disorders report being sexually abused as children, but this seems to be a more important risk factor for bulimia nervosa than for anorexia ner- vosa (Jacobi, Hayward, de Zwaan, Kraemer, & Agras, 2004). Sexual abuse does not explain the development of most cases of anorexia nervosa, but it is one impor- tant risk factor for eating disorders and other forms of psychological disturbance. The adapted to ee famine hypothesis proposes that anorexia nervosa symp- toms are an adaptive mechanism that evolved to protect our ancestors from starva- tion in famine conditions (Guisinger, 2003). This mechanism would occur when body weight became too low (which now would be due to a diet rather than famine) and only among certain individuals with the genes for it, and would then trigger restlessness, energy, and cognitive distortions about the emaciated state of one’s body to enable the starving individual to have both the courage and energy to travel to new locations where food might be more plentiful. This hypothesis could explain the persistent denial of the eating disorder that is a common feature of anorexic patients, a phenomenon that can be hard for clinicians to understand and to overcome (Gatward, 2007). More research is needed to evaluate this interesting hypothesis.

Oltmanns, Thomas F., et al. Case Studies in Abnormal Psychology, 10th Edition, Wiley, 2014. ProQuest Ebook Central, ebookcentral.proquest/lib/monash/detail.action?docID=5106408.

172 Case Studies in Abnormal Psychology

Treatment

Treating anorexia nervosa is extremely difficult. One form of treatment has not been found to be consistently more effective than others. Various forms of psychotherapy are employed by clinicians, with most using cognitive-behavioral therapy (CBT) or a combination of cognitive-behavioral and psychodynamic techniques (Peterson & Mitchell, 1999), but none of these treatments has been conclusively shown to work (Fairburn, 2005). The most effective treatment is family therapy for adolescents with a short history of the disorder (Wilson, Grilo, & Vitousek, 2007). The first step in the treatment of anorexia nervosa is often hospitalization, which may be necessary when weight loss is extreme, suicidal thoughts are present, the patient is still denying her illness, or previous outpatient therapy has been ineffective (Andersen, 1997). Weight restoration is necessary, both to alleviate the symptoms of starvation and to confront the patient with the body size that she fears. Although there is no single best way to restore weight, the key is to elicit as much cooperation as possible and to be sensitive to the patient’s concerns. It is important to work with the patient to set a target weight, usually 90 percent of the average weight for a particular age and height. Behavioral techniques, such as those used with Joan, are often used to facilitate immediate weight gain. Although inpatient hospitalization seems warranted, there is no research evidence to show that it is more effective than outpatient treatment (Fairburn, 2005). Various medications are used to treat patients with eating disorders, espe- cially antidepressants, because anorexic and bulimic patients are often depressed. However, studies have not shown them to be any more effective than placebo for anorexia nervosa (Wilson et al., 2007). Dysfunctional attitudes toward food and body shape are addressed in psycho- therapy. This aspect of treatment can be especially challenging because patients with anorexia are usually not self-referred, and most are resistant to treatment. Establishing a connection with the patient and building a therapeutic relationship are particularly important in working with severe cases (Strober, 1997). The ther- apist’s goal is to build a trusting relationship within which other interventions can be employed. Cognitive distortions, superstitious thinking, trouble with express- ing emotion, body-image misperceptions, self-esteem, and autonomy are some of the issues that need to be addressed (Cooper, Todd, & Wells, 2002). Joan’s treatment followed parts of this approach. During her hospitalization, various behavioral techniques were used to restore her weight to a healthy level. Because Joan was older and living on her own, she was treated individually, rather than in family therapy. Consistent with a cognitive approach, Joan’s ways of view- ing the world and herself were challenged directly. Cognitive therapy involves several steps: (a) learning to be more aware of thoughts and beliefs; (b) exploring and clarifying the connection between the dysfunctional beliefs and maladap- tive behaviors; (c) examining the truth of those beliefs; (d) learning to replace the dysfunctional beliefs with more realistic ones; and (e) eventually changing

Oltmanns, Thomas F., et al. Case Studies in Abnormal Psychology, 10th Edition, Wiley, 2014. ProQuest Ebook Central, ebookcentral.proquest/lib/monash/detail.action?docID=5106408.

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Case Studies in Abnormal Psychology 10th Edition - (Chapter 13 Eating Disorder Anorexia Nervosa )

Course: abnormal psychology (PSY 3032)

48 Documents

Students shared 48 documents in this course

University: Monash University Malaysia

Was this document helpful?

CHAPTER 13

Eating Disorder:

Anorexia Nervosa

Joan was a 38-year-old woman with a good job and family life. She lived with her

second husband, Mitch; her 16-year-old son, Charlie, from her first marriage; and

her husband’s 18-year-old daughter from a previous marriage. Joan was employed

as a secretary at a university, and Mitch was a temporary federal employee. Joan

was 5′3′′ and weighed approximately 125 pounds. Although she was concerned

about her weight, her current attitudes and behaviors were much more reasonable

than they had been a few years earlier, when she had been diagnosed with anorexia

nervosa.

Joan had struggled with a serious eating disorder from the ages of 29 to 34.

She was eventually hospitalized for 30 days. The treatment she received during

that hospital stay finally helped her overcome her eating problems. Four years

later, her condition continued to be much improved.

Social History

Joan was born in a suburb on the outskirts of a large northeastern city. Her one

brother was 2 years younger. Her father worked as a supervisor for an aircraft

subcontractor. Joan’s mother stayed at home while the children were young and

then worked part time as a waitress and bookkeeper. Both parents were of average

weight.

Joan’s early childhood was ordinary. She was an above-average student and

enjoyed school. She and her brother bickered, but their disagreements did not

extend beyond the usual sibling rivalry. Her family lived in a large neighborhood

filled with lots of children. Joan was somewhat overweight during elementary

school. She had high personal standards and strove to be a perfect child. She always

tried to do what was right and conformed completely to her parents’ wishes.

When Joan was 14 and entering the ninth grade, tragedy struck her family and

forever changed her home life. She and her 12-year-old brother were home while

her parents were at work. Although her brother was too old to require babysitting,

162

Oltmanns, Thomas F., et al. Case Studies in Abnormal Psychology, 10th Edition, Wiley, 2014. ProQuest Ebook Central,

http://ebookcentral.proquest.com/lib/monash/detail.action?docID=5106408.

Created from monash on 2021-09-05 15:15:11.

Case Studies in Abnormal Psychology 10th Edition - (Chapter 13 Eating Disorder Anorexia Nervosa )

abnormal psychology (PSY 3032)

Monash University Malaysia

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CHAPTER 13

Eating Disorder:

Anorexia Nervosa

Social History

Discussion

Etiological Considerations

Treatment

Case Studies in Abnormal Psychology 10th Edition - (Chapter 13 Eating Disorder Anorexia Nervosa )

Course: abnormal psychology (PSY 3032)

University: Monash University Malaysia

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