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

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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.

Copyright © 2014. Wiley. All rights reserved.

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, 162 http://ebookcentral.proquest.com/lib/monash/detail.action?docID=5106408. Created from monash on 2021-09-05 15:15:11.

Copyright © 2014. Wiley. All rights reserved.

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 overprotective, 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 grades 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, http://ebookcentral.proquest.com/lib/monash/detail.action?docID=5106408. Created from monash on 2021-09-05 15:15:11.

Copyright © 2014. Wiley. All rights reserved.

164

Case Studies in Abnormal Psychology

however, and Randy eventually moved to another state. The divorce was finalized when Joan was 25 years old. Shortly after she and Randy were separated, Joan stopped working and went on welfare. With financial help from her father, she managed to keep up the mortgage payments on her house for several months. She and Charlie continued to live on their own, but Joan fell further into debt while she and Randy tried to work things out. She was forced to sell her home when the divorce became final. Although she came to regret the decision, she moved back into her parents’ home. Living there was stressful for Joan. Although she was 25 years old, she felt like a child. Her parents once again took care of Joan, and now also provided for her son. In this submissive role, Joan started to feel more like Charlie’s older sister than his mother. Joan lost some weight after she and Charlie were involved in a serious car accident, 6 months after moving back to live with her parents. Charlie was not hurt, but Joan’s left hip and leg were broken. She spent a month in the hospital. She was immobile when she came home, and her mother had to take even greater care of her and Charlie. Joan needed repeated surgery on her knee, as well as extensive physical therapy, and she had to relearn how to walk. During her recovery, she had little appetite, was nauseated, and did not eat much, but she was not consciously dieting. Joan’s weight went down to about 110 pounds, which she considered to be a reasonable weight. While recovering from her injuries, Joan became involved with a man named Jack, whom she met in one of the hospital’s rehabilitation programs. She was now 27 years old. To escape her parents’ overly protective home, she decided to take Charlie and move in with Jack. This move actually created more problems than it solved, in large part because Jack had a serious problem with alcohol. Joan had never been a heavy drinker. In the beginning of their relationship, she drank only during the weekend. After she started living with Jack, drinking became a daily activity. Much of their relationship and socializing revolved around alcohol. On the average weekday, Joan consumed a couple of beers and some wine, or perhaps a glass or two of bourbon. On weekends, she drank considerably more. Charlie was increasingly left at day-care centers and with babysitters. Joan eventually recognized the destructive nature of this relationship and ended it after a few months. She reluctantly moved back into her parents’ home. After leaving Jack, Joan stopped drinking, except occasionally when she was out socializing.

Onset of the Eating Disorder After breaking up with Jack, Joan lived with her parents for 2 more years. When she was 29 years old, almost 3 years after her accident, Joan returned to the hospital for more surgery on her leg. After being discharged, she began the diet that set the stage for 5 years of serious eating problems and nearly destroyed her life. Joan had gained a few pounds while she was drinking heavily and now weighed

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.

Copyright © 2014. Wiley. All rights reserved.

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 overwhelming 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 conflict

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.

Copyright © 2014. Wiley. All rights reserved.

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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 fluctuated 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, somewhere 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 benefits 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, http://ebookcentral.proquest.com/lib/monash/detail.action?docID=5106408. Created from monash on 2021-09-05 15:15:11.

Chapter 13

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Joan’s weight had fallen to 85 pounds. She ate reasonably well at first, trying to regain her strength. After 2 months, she was feeling better, returned to work, and went back on a restrictive diet. This time, however, Mitch and her friends would not let her continue this prolonged pattern of self-imposed starvation.

Copyright © 2014. Wiley. All rights reserved.

Conceptualization and Treatment Mitch and one of Joan’s friends from the medical school sought help for her. Realizing that she would never be free of her problems unless she faced them, Joan agreed to contact an eating-disorder specialist. Though it was one of the hardest decisions she ever made, Joan had herself committed to a 30-day stay in a psychiatric ward. She was now 34 years old. Joan’s diet was completely controlled in the hospital. She began a 1500calorie-per-day diet and was required to eat three meals a day in the presence of a staff member. Phone privileges, visitors, and outings were made contingent on eating. Specific goals were set for weight gain, and caloric intake was increased gradually. She had daily individual therapy sessions with a staff psychologist in which she explored how she felt about herself. At first, hospitalization was difficult for Joan. The amount of food that she was required to eat for breakfast (two pancakes, a bowl of cereal, a glass of milk, one piece of fruit, and a piece of toast) would previously have lasted her for several days. She was initially rebellious, refusing to eat or giving her food away to other patients. She didn’t earn any privileges in the first 10 days of her hospital stay. Unaccustomed to eating, she experienced severe constipation, bloating, and indigestion. At times she tried to vomit to get rid of the food, but she was not successful. She eventually accepted the fact that she had no choice and allowed herself to gain 15 pounds. She felt stronger physically but was still troubled. Joan convinced herself that she would lose that weight as soon as she was released from the hospital. An important turning point in her attitude came during the third week of treatment when Joan received a pass to go home. Outside the hospital, she felt out of control, as if she were too weak to take care of herself. She asked Mitch to take her back to the hospital immediately. Safely back in her hospital room, she cried and felt as though she would never get better. This wrenching experience helped Joan recognize that she needed to change her eating behavior as well as her attitudes regarding weight control and physical appearance. Somehow at the end of 30 days, Joan found the strength to leave the hospital. She was frightened at first, but with support from Mitch and her family, she was able to maintain a normal pattern of eating. She remained in therapy for 6 more months and was able to gain another 15 pounds. While she was in the hospital, Joan learned that her own attitudes about eating and her body were the principal problem, and she had become her own worst enemy. She learned that she could control her weight without becoming

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 15:15:1...