Read Case Vignette on Eating Disorder – Please answer questions that follow below:
Susan is a 16-year-old, Caucasian female who resided in a small town on the West Coast. Her previous psychologist referred her for treatment at the Eating Disorders Clinic in Child and Adolescent Psychiatry at a university medical center.
3 Presenting Complaints
Susan’s eating disorder symptomatology began one and a half years prior to the onset of the treatment described in this case report. Her first symptom was a desire to lose weight, which was followed by food restriction and overexercise. A few months later, binge and purge symptoms began. Her main form of purging was self-induced vomiting. She had tried
laxatives and diuretics for a short time but discontinued them in light of unpleasant effects. One year after the binge–purge behaviors began, she was referred for the current treatment. Upon referral, she presented with fear of weight gain, body image distortion, binge eating, food restriction, self-induced vomiting, and overexercise (i.e., excessive engagement in dance, volleyball, and kickboxing). Her binge–purge cycles occurred at the frequency of two to three times per day.
Susan resided with her mother and one sibling in a single-family dwelling in a midsize town on the West Coast. Her parents had divorced six years prior to treatment, and she had sporadic contact with her father, which was becoming more regular at the onset of treatment. She and her mother enjoyed a close and mutually supportive relationship.
Susan was in the 10th grade a local private high school. She was doing quite well academically, obtaining mainly A’s for grades. She was highly involved in her school, and in particular enjoyed participating in the photography club. She had won several awards for her photography skills.
Susan was a sociable young woman, with several close friends. She had a boyfriend of several years, with whom she felt very close. She was not involved in illegal behaviors, such as substance use or other delinquent behaviors. She reported experiencing some harassment from a group of female peers at school, the source of which she did not understand.
Medical and Mental Health
Susan had an insignificant medical history. She had never experienced a major medical illness, nor was there a history of major medical illness in the family. Family history was significant for depression, however. Her first psychological symptomatology emerged six years prior to treatment, when her parents got divorced. At this time, she was feeling emotional distress and sought therapy. When the eating disorder symptoms emerged one and a half years ago, her prior therapist attempted to treat them. Furthermore, her primary care physician prescribed an antidepressant, which Susan only took on a couple of occasions. When symptoms continued, her prior therapist made a referral to the Eating Disorders Clinic. In the past, Susan had experienced passing suicidal ideation and had engaged in cut- ting behaviors, although these symptoms were not present at the onset or for the duration of the current treatment.
Susan and her mother completed a thorough evaluation in the Eating Disorders Clinic. First, they participated in clinical and semi-structured diagnostic interviews in the Department of Psychiatry and Behavioral Sciences. In particular, Susan and her mother engaged in separate clinical interviews with a psychiatrist who is an expert in the area of adolescent eating disorders (JL). During these interviews, history of presenting symptomatology; frequency, severity, and type of eating disorder symptoms; and current functioning across multiple domains (i.e., school, family, social, etc.) were assessed. Results of this clinical interviewing suggested a remarkable concordance between parent and youth reports, and data suggested that Susan met criteria for BN based on the parameters set forth in the Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition (American Psychological Association, 1994).
In terms of semi-structured diagnostic interviewing, Susan completed the Eating Disorders Examination (EDE) (i.e., Cooper & Fairburn, 1987) with a postdoctoral fellow in eating disorders (ASW). The EDE is the most widely used semi-structured interview for the assessment of eating disorder pathology. It contains 62 questions that are divided into four subscales: dietary restraint (DR), eating concern (EC), shape concern (SC), and weight concern (WC). Research suggests that the EDE has adequate reliability and valid- ity (Cooper, Cooper, & Fairburn, 1989; Wilfley, Schwartz, Spurrell, & Fairburn, 2000). Results for the EDE interview indicated scores of 3.4 on DR, 2.8 on EC, 5.13 on SC, and 4.2 on WC. Based on normative data, Susan’s responses were typical (i.e., within one standard deviation of the mean) of an adult with BN on the DR and WC subscales. Her scores on the EC and SC subscales, however, were much higher than the typical scores of a sample of adults with BN.
After completing clinical and semi-structured interviews, Susan participated in a medical evaluation at the Eating Disorders Medical Clinic at Stanford. Results of this evaluation suggested that Susan had severe orthostatic hypotension, borderline hypothermia, and bradycardia as a result of her eating dysfunction. Her physical status resulted in an inpatient hospitalization prior to the commencement of outpatient treatment. This inpatient stay lasted two weeks and was primarily geared toward Susan’s medical stabilization. Once she was medically able to be discharged, she began the course of outpatient psychotherapy dis- cussed in this manuscript.
6 Case Conceptualization
As a standard protocol in the Eating Disorders Clinic, after assessing and diagnosing the patient, practitioners convey what the research has shown to be efficacious interventions for the diagnosis at hand. In this case, Susan and her mother were presented with the two types of psychotherapy that have been shown to be efficacious in treating BN: CBT and IPT. These two treatments were described to them, and Susan and her mother were able to pick the intervention with which they felt the most comfortable. They overwhelmingly agreed that CBT would be the best option for Susan’s symptoms. The therapist (ASW) felt that this was a good idea as well, given that assessment data suggested a preponderance of maladaptive cognitions contributing to the behavioral symptoms of her eating disorder.
|During the initial session of CBT, the common interplay of thoughts, behaviors, and emotions in the context of BN was conveyed to Susan. In particular, the therapist conveyed that often, the cycle of BN involved individuals having negative thoughts about their shape or weight, which led to dietary restriction, which in turn created excessive hunger cues, and then binge eating. Following the binge eating, patients tended to feel guilty and regretful, and then engaged in purging. Purging often led to guilt and shame, which served as catalysts for the BN cycle to commence recurrently. Susan was asked if this pattern seemed typical of her experience, to which she responded affirmatively.
The therapist and Susan went on to further discuss the specific interplay of thoughts, behaviors, and feelings in her life, in a sense to tailor the BN conceptualization to Susan’s specific experience. Susan identified two thoughts that tended to incite her binge–purge cycle. First, she believed that “Men will like me if I’m skinny.” Susan identified that this thought was a product of her relationship with her father, as she felt her father never really liked her given the sporadic contact that he had with her. Her second thought lead- ing to restriction was “My life is out of control, so I will control my eating.” Susan iden- tified that this thought stemmed from the fact that she was a highly involved student. She worked hard in her studies and engaged in many extracurriculars, in addition to having a boyfriend and several good friends. These two thoughts, Susan identified, led to dietary restriction.
Susan identified that her dietary restriction then led to increased hunger cues, which in turn became unbearable to her. These intense hunger pangs would trigger binge eating. Susan identified another precursor to binge eating was the thought that “No one loves me,” leading to feelings of loneliness and then binge eating. Susan stated that the thought of no one loving her also related to a sporadic relationship with her father, as she often questioned if he loved her.
After binge eating, Susan reported thinking that “I’ll gain weight, and no one will like me.” This thought led to anxiety, which in turn led to overexercise. After overexercise, Susan reported thinking, “Now I won’t gain any weight,” which led to relief (and positive reinforcement for her overexercise). Susan indicated that her anxiety also led to self- induced vomiting, which in turn made her feel guilty and depressed, leading to crying spells. She identified that feelings of guilt and depression also resulted in dietary restriction, thereby reinstating her binge–purge cycle.
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