She came into my office frail, rigid, and pale. Although she carried reminiscence of a once beautifully muscular figure, my new 20-year-old client now appeared predominantly sick and weak. She immediately smiled and greeted herself in a customary fashion. Subsequently thereafter, she found her place in the room and sat down. Although physically underweight and malnourished, the client took acceptional care of her appearance in regard to dress, hygiene, and grooming. She reported her height to be 5�3� and her current weight to be 93 pounds. My clients overall complexion could be described as relatively pale and sickly, worn, and her face a bit pimply. During our initial discussion, her facial expressions (aside from the initial hello smile) varied between tense, sad, preoccupied, worried, and at times flat and rigid.
Despite her frail appearance, my client expressed her feelings rather explicitly. She predominantly feels out of control and helpless. She feels that normal life opportunities will be granted to her only if she is �lucky.� She especially worried over ever being able to find a mate and if she did �manage� to do this she �would be lucky to ever become pregnant.� She feels trapped because she feels that she will lose herself if she rids herself of the eating disorder. However, if she doesn�t she believes she could possibly die. She doesn�t see any possibility of ever letting go of it, but acknowledges that a part of her does believe that she can move on and wants to live a normal life. She describes this tiny hope as a faint �light� indicative of the �real her.� My client feels that she is constantly fighting for control, but never quite seems to grasp it. She feels confused. She really can�t explain why she can�t eat. By making the disorder her only focus, she can block out all other sources of anguish going on in her life. �It is the thing that makes me strong so I don�t want, don�t need, don�t feel.� She also believes that it is the only thing holding her together. But then counters that point with stating that it is the thing pulling her apart. The phrase �but, I don�t know,� is used after most attempts at describing her behavior and feelings. She describes herself as fat, useless, unworthy, unlovable, and weak. My client genuinely believes that by losing weight, it will somehow make things better, �but I don�t know,� she adds. �I know that I am being stupid I guess.�
�Eating disorders are diseases of silence. We are all silently screaming for something: attention, love, help, escape or forgiveness. Although we might be looking to fill different voids, we never ask for the things we need. We feel unworthy, that for some reason we don�t deserve them. So we play the game of guess what I need from you. Your inability to guess just feeds our feelings of worthlessness,� (something-fishy.org)
��The day goes on, nothing is good enough, so we push ourselves to eat less, run faster, dance harder, whatever we are doing we must be the best,� (something-fishy.org).
�Although we say we hate the eating disorder, we can�t hate it all�we love the high that comes with seeing the numbers go down, we long for that empty, numb feeling that comes with starvation. We thrive on what begins as compliments and turns to worry about our weight loss,�(something-fishy.org).
Day to day functioning of my client is rigid and standard in terms of daily routines. She wakes up, having already planned her day. A typical day consists of about 9 hours of manual labor at her food service job, an hour of running, and any project at home that exerts energy. These can include cleaning the house, taking the dog for a walk etc. However, interpersonal relations are unstable emotionally and psychologically. Her anguish and continual self-torment effect not only her self-cognition, but those around her as well. Her mother is in a continual state of worry, and feels helpless. Her sister is supportive, but tends to ignore the situation. Aside from a friend from high school, she remains relatively introverted and reclusive.
The mental disorders in the DSM are grouped into five distinct categories making up the multiaxial model. �The multiaxial model exist because some means is required whereby the various symptoms and personality characteristics of a given patient can be brought together to paint a picture that reflects the functioning of the whole person,� (Milton and Davis, 5). Axis I, which consists of the clinical syndromes, is a hierarchical arrangement of classical mental disorders. I would diagnose my client with an eating disorder, specifically, anorexia nervosa, the restricting type. Each of the following criteria have been met:
1. Refusal to maintain body weight at or above a minimally normal weight for age ad height.
2. Intense fear of gaining weight or becoming fat, even though underweight
3. Disturbance in the way in which one�s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness or the current low body weight.
4. In postmenarcheal females, anemorrhea, ie, the absence of at least three consecutive menstrual cycles.
5. During the current episode of Anorexia Nervosa, the person has not regularly engaged in binge-eating or purging behavior.
(DSM-IV: American Psychiatric Association)
Axis II is the personality disorders. My client shows specific obsessive- compulsive personality disorder characteristics with regard to self-cognition. Specifically, doubting, weighing pros and cons, �thinks too much�, indecisive, preoccupation with details, fears the loss of control, perfectionism, �never good enough�, and attention is rigidly and narrowly focused on own interests are examples found in relation to my client, (Clinicians thesaurus, 97). However, it is still premature to diagnose a personality disorder because physiological abnormalities resulting from anorexia may be, in part, responsible for these characteristics and could diminish with recovering health. There is evidence indicating that inheriting a predisposition to heightened emotionality would contribute to Obsessive-Compulsive Personality Disorder, eating disorders, and, mood disorders characterized by excessive anxiety. A study conducted by a Division of Neurogenetics found that �a region on a rats chromosome number 4 strongly reflected a behavior thought to reflect emotionality or anxiety,� (Ramos, A. 453-462). Further, Folic acid and the B vitamins are found to play a role in the onset of depression and anxiety, (something-fishy.org). This would indicate the possibility for remittance of anxiety-like symptoms and thus obsessive-compulsive personality traits presented above. Therefore, it is uncertain whether these obsessive-compulsive tendencies have persisted or will persist for an extended period after recovering from the eating disorder.
Axis III consists of any physical or medical conditions that may affect the psychological functioning of the patient. I have recommended that my patient receive a comprehensive blood analysis. Of primary concern, a complete blood cell counts (CBC), and her electrolyte balance. Additionally, ketones should be screened for in a urinary analysis (something-fishy.org). The CBC is a comprehensive blood examination and will test for factors such as low iron, infections, immune system functionality, etc. Electrolyte balance refers to the highly specific balance of certain minerals in your blood stream. Potassium and Calcium are of primary concern amongst anorexics. An imbalance can lead to kidney failure, heart attack and death, (something-fishy.org). The presence of ketones in the urine indicates that the body is �eating its own fat� for energy. An excessive accumulation of these can lead to ketoacidosis, which can cause coma and/or death, (something-fishy.org). Presently, no known diagnosis for my client can be listed in this axis.
Axis IV consists of psychosocial stressors, which focus on social and cultural factor as well as psychological influences. Two primary factors affecting my client include her familial experience and her lack of a strong social network. Although the emotional bond between my client and her mother appears to be strong, growing up with an alcoholic mother was highly emotionally damaging. Additionally, her family appears highly addictive in personality and unstable emotionally. Although no one else is reported to have an eating disorder in her family, clinical depression and substance abuse are relatively prevalent on her mother�s side of the family. The alcohol abuse by her mother was reported to have begun in 1987, just after her parent�s divorce. Since then, relatively little contact has occurred between her and her father. The lack of social support by her peers intensifies her feelings of worthlessness.
Finally, Axis V is a global rating of level of psychological, social, and occupational functioning, referred to as the Global Assessment of Functioning, (GAF). Generally, the 5th axis functions as an overall index of psychological health and pathology, (Milton & Davis, 7). On the 100-point scale, I would diagnose my patient to be around 55. This indicates that her symptoms are in between moderate and severe. She does have marked impairments in social, occupational, or school functioning that persistently effects her day to day functioning.
The following summery exemplifies my client�s progressive conflict with the eating disorder and depicts its development through multiple factors. These factors include biological, psychological, and social dimensions. I hypothesize that a predominant genetic disposition regarding sensitivity and anxiety are the primary biological contributions. The primary psychological contributions facilitating and retaining the disorder include the negative self-cognition associated with her mothers verbal abuse growing up and her ability to catastrophes minor self-inadequacies. Socially, her father leaving, living in a dysfunctional household, and inadequate social relations with her peers were the major contributing factors. In summation, the eating disorder developed.
My patient has sought therapy before. Although her senior year of high school was the first time others noticed her anorexia, she has felt physically inadequate since her doctor check-up in 7th grade. �You�re a little over weight, but nothing to worry about. Otherwise your are perfectly healthy.� As a result of her highly sensitive personality and over-awareness of what others perceive her to be, this statement resonated in her mind. A few months later, while swimming, a friend mentioned the bit of chub on her belly. At this point, the social pressure to fit in was felt. The anxiety, hypersensitivity, and strong will pasted down to her genetically now found a physically expressed identity. Later, remembering this statement (amongst other negative self-thoughts) during one of her mother�s frequent alcoholic outbursts, irrationality superseded reality. Combining all her current problems and worries into one�the eating disorder was born.
Initially, she was unhappy and decided to lose weight in order to feel better about herself, become more socially acceptable, and (unconscious to her at first) to feel in control of some aspect in her existence. Her plan consisted of skipping breakfast, skipping lunch (except sometimes begging for 1 or 2 french fries or part of left over pizza crust from her friends) and allowing herself � (or less if possible) of her moms dinner each night until the weight came off. Although she was unable to follow the plan perfectly, eventually the weight began to come off. School ended and summer started. A few months later a couple of her friends (including the one who previously called her chubby) commented on how thin she had gotten. She interpreted the comments as complements because for once (she felt) all the attention of her peers was drawn to her. Now 15 pounds lighter, she decided to maintain that weight and continued to do so thereafter for the first few of years of high school.
Briefly, she became diagnostically anorexic toward the middle of her senior year. The catalyst for this first real episode was her overwhelming feelings of losing control of her life. Although an exceptional student, she was terrified to be on her own. Her mother would compensate for her excessive drinking by doing just about everything for her when sober. Her mother bought her a car, paid for the insurance, filled out most all forms, made doctor/dentist appointments for her, etc. All her mom asked for in return was that she maintains good grades. Additionally, she was perceived as the �good one� in the family who was possibly planning on going to medical school. This intensified her anxieties about being on her own because she felt that she had to live up to these expectations��after all, she and her sister were all mom had to live for, (as she put it drunkenly many times,) right?�
She struggled to put on weight that summer before college because her mother threatened placing her in a hospital. Although outwardly she began to look healthy toward the end of the summer, inwardly she was afraid and disgusted with herself. It wasn�t until the following summer, after a freshman year of bingeing and purging, did she finally decide to seek help. Concurrent counseling with a clinical psychologist and a nutritionist put her back on track. She even managed to convince herself that she was �fixed.� Although the clinical psychologist did an exceptional job with the little time they spent together, it wasn�t quite enough.
Once she was back in college, she felt lonelier than ever. She quite socializing with her �party friends� from the previous year and found herself feeling alone and socially inadequate. At this time, her only sense of relief from these depressive feelings was her running. Having initially begun running the previous year as one of a few calorie-purging tactics, she now genuinely loved to run. She eventually became compulsive about her running, however, and in addition, preoccupied with the �perfect� eating habits taught to her by the nutritionist.
Finals in the fall were overwhelming and she felt that she could not possibly study all she needed to. Her newly founded compulsive behavior alongside immense feelings of loneliness reached an unbearable point. Now barely above 100 pounds, she realized that she was no longer in control.
Once the school year was over, she moved home. She became worse before finally conceding to see me. A few months later she walked into my office, another 7 or 8 pounds lighter, and this is where we are presently.
I would treat my patient following an eclectic approach to therapy. The eclectic approach combines many aspects of the following theories: Psychoanalytic Therapy, Nonpsychoanalytic (Jungian) Therapy, and Cognitive-Behavioral Therapy. Eclectic Therapy enables the therapist to �attack many different issues over the course of recovery including self-esteem, past and present emotional issues, and day-to-day coping strategies, (something-fishy.org). Of particular focus for my client are the following: Working on repressed conflicts that lead to the development of the eating disorder (psychoanalytic). Learning to accept herself for the individual she is by connecting to her inner feelings/motivations (Jungian). Finally, learning to change the way she thinks about herself and thus, the way she treats herself by thinking, questioning and practicing these skills, (cognitive-behavioral).
