Case study: Anorexia Nervosa
I began my study into Anorexia Nervosa by reading a general overview of eating disorders. Eating Disorders and Adolescents: An Overview of a Maladaptive Behavior" gave the basic facts on Anorexia Nervosa (AN) and some the key indicators. The four diagnostic criteria as presented in the DSM-IV were cited.
Refusal to gain weight and maintain a healthy body weight
Extreme fear of gaining weight or becoming "fat"
Disturbances in body image - Inability to see one's true body size
Amenorrhea - cessation of menstruation
Anorexia is divided into two subgroups. The restrictive type is the first group. Clients in this category do not engage in purging behavior, rather they severely limit food intake. The second subgroup is the binge-eating/purging category. Clients in this category do engage in binging and purging. This occurs in episodes between periods of restricting food intake.
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This disorder is most common among white females under the age of 25 who belong to the middle to upper classes of Western Culture. These cultures are industrialized. The eating disorder is likely to begin between the ages of 12 to 18 years of age. This disorder can continue into adulthood if left untreated of if the treatment fails. It is estimated that 1% of teenage and collage aged women suffer from Anorexia.
Grothaus (1998) discusses the many commonly given etiologies for the disorder such as a poorly functioning familial relationship, a history of traumatic experiences, such as sexual abuse. Additional causes for anorexia are identity formation/separation difficulties, as well as a biological and genetic propensity. One of the main issues focused on was the cultural influence. The media depiction of the ideal woman as being very thin can be extremely detrimental to individuals with low self esteem and a tendency toward perfectionism.
A person with anorexia will most likely not seek treatment on their own. The family is most likely to be the ones to initiate treatment due to the loved ones increasing weight loss over the previous few months. According to the article a person presenting Anorexia is likely to exhibit the following behaviors.
Total dependence on parents
Feelings of helplessness and powerlessness
Belief that by controlling food intake will gain power
Cling to early childhood concepts and thinking patterns, preoperational and concrete thinking
Abstract thinking and concept development seems to be delayed
Grothaus (1998) not only profiles an individual with anorexia, but also the typical family of an anorexia client emphasizing the impact and role of the family in the disorders development. A typical family in this case would be highly enmeshed. The separation of individuals within the family would appear to be blurred. Resistance to discussing and dealing with family issues will be present, prompting the parents to request the therapist "to fix" their child. The family is likely to lack conflict-resolutions skills relying heavily on denial. The patient will most likely have not developed a sense of self or independence. She/he will be unable to express anger. And interesting, the biological parents are likely to still be married, but that marriage is likely to be troubled.
There are many medical complications that result from Anorexia. A patient will need to have medical treatment. Some of these complications due to malnutrition include cardiac dysrhythmias, esophageal tear, and renal failure. Disruptions in the endocrine system can lead to amenorrhea, abnormal thyroid function, and potential sterility.
The treatment of anorexia nervosa varies dependent upon the therapy approach utilized. The most effective treatment presented involves the use a team of professionals consisting of a pediatrician or internist, nutritionist, psychotherapist and psychiatrist. A combination of treatment therapies including cognitive restructuring therapy, meal planning, regular weighing and re-introduction of restricted foods is suggested in the author's research. In general the goal is to find balance in attending to the physical and psychological treatments.
My second article I "Fathers, Daughters, and Anorexia Nervosa" by J. Carol Elliot. While there are many different causes and contributing factors for AN, I am very interested in the impact of family dynamics and relationships on this disorder.
Children whose father is supportive, engaged, and nurturing tend to be more successful academically, athletically and socially. They tend have well adjusted personalities and higher self-esteem. In Elliot's research, a strong relationship was noted between fathers and daughters with AN. Unfortunately, while the bond was strong, it was also found to be extremely stressful.
The following father/daughter relationship characteristics reportedly emerged during the study. The fathers of anorexic teens were found to be "narcissistic perfectionists, emotionally constricted, and depressed" (38). The father was viewed by the daughter as more influential than the mother. Ambition, achievement, self control and thinness were all valued by the father. He tended to be more judgmental of others, including his daughter. The fathers self-reported the relationship with their daughters to be warm and understanding. This did not match with self-reports from the daughters. Based on further research, it was noted that the daughter's perceptions of the father's disapproval and family functioning tended to be more accurate.
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Several patterns in the father-daughter relationships emerged in reviewing the data from the daughters with AN.
The need to grow up quickly - The participants reported the need to grow up very fast. This increased the anxiety and confusion of an already stressful period in their lives.
Uncertainty - The daughters report being uncertain as to whether they were loved by their fathers. This lead to approval seeking behavior. The family unit tended to be marked by marital conflict and sporadic absences of the father. It was interesting to note that the daughters internalized this conflict and took the blame. Several reported that the parents would have been happier without the daughter.
Fear of Abandonment - This fear was fed by the absences of the father, marital conflicts, and the chaotic home environment.
Father like daughter - The participants reported they tended to be like their fathers in temperament. They also reported their fathers' defense mechanisms were denial, avoidance, and withdrawal. The daughters seem to have copied these same defenses.
Relationship pattern - The daughters reported being very close to their fathers early in the relationship. Idolizing the father and copying quite a lot of his behavior. When the daughters became older, the fathers became less accessible.
The absences themselves were not necessarily the contributing factor here. It was noted that it was more the daughter's perception of the father's availability that is most important. The daughters with AN did not have confidence of the father's willingness to be involved. Therefore, he was considered absent.
Body Changes - The participants reported that puberty was a hard and stressful time. During this time, they report that the father didn't understand. "I don't think he ever got it, the girl thing" (40). As a result, the daughter reports pulling away as a coping technique.
In the treatment of AN, the author suggests in the early stages of treatment, an assessment of the father-daughter relationship be completed. Changes in the father-daughter dynamic seem to be a key factor in the recovery. Researchers found that if the woman developed a more self-sufficient self image that was not reliant upon her father's approval, developed healthier coping techniques and was able to reinterpret the father-daughter relationship, she had a greater chance for a more successful recovery.
For my third article, I chose "Ten-year Follow-up of Adolescent-onset Anorexia Nervosa: Psychiatric Disorders and Overall Functioning Scales". This article studied treatment outcome over a ten year period for individuals presenting with AN. The research had a fairly small subject group of 51 participants with AN and 51 participants in a control group. Due to the small number of participants, I do think follow up research would be warranted.
In general, after 10 years the prognosis for teenage-onset AN was good. Most of the participants had recovered from the eating disorder for the most part. However, it was found that all seemed to still have an extreme preoccupation with thoughts of food, weight, and body image. It was also found that many of the individuals with AN reported poor psychosocial skills meaning that issues were present in their employment, family dynamics, or with lack of social interaction outside the family unit. The authors argue that the lack of social skills might be caused by the isolation created while in treatment during a critical social development phase. Based on this, it was felt that it was not only an immediate need to restore the patient's weight but also to address the social aspects of her/his development.
I began my study into Bulimia Nervosa by reading a general overview of eating disorders. "Eating Disorders and Adolescents: An Overview of a Maladaptive Behavior" gave the basic facts on Bulimia Nervosa (BN) and some the key indicators. While this is the same article used to begin my study into Anorexia. The information included was very useful, giving me a good foundation to begin further study.
The four diagnostic criteria as presented in the DSM-IV were cited.
Recurrent episodes of eating excessively large amounts of food in a small time frame
Lack of control over eating during these episodes.
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Recurrent compensatory behaviors to prevent weight gain.
The binge-eating episodes occur at least two times a week for at least 3 months
Bulimia is divided into two subgroups. The first group is a person who purges, meaning the person induces vomiting or uses other chemical means to expel the unwanted food. The second is a non-purging individual who attempts to rid her body of the food through excessive exercise, fasting, etc.
A Bulimic person is likely to seek treatment on her/his own. The patient may not appear emaciated. She will have a history of binging and purging. Like the anorexic, she will most likely have started dieting due to feelings of being fat. According to the article a person presenting Bulimia is likely to exhibit the following behaviors.
Impulsive and rebellious
Been arrested for shoplifting (typically food, laxatives or diet pills)
Cross-addicted to drugs or alcohol
May have been sexually abused
The family of a person presenting with Bulimia is likely to have the following characteristics.
Higher social class
Close relatives are likely to have eating disorders, affective disorders and a history of substance abuse.
Controlling family interactions
Strong emotional dependence
Poor conflict resolution - Conflicts are not openly discussed.
The family tends to no encourage independence or expression.
The family tends to focus more on achievement than recreational pursuits.
As Bulimia is more subtle than anorexia in a presenting patient's appearance, I looked for am more detailed description of the medical complications associated with the disorder in my second article, "Bulimia: Medical Complications".
The most common symptoms reported women with bulimia were as follows:
The physical effects of Bulimia are affected by the mode and frequency of purging. For individuals who vomit and/or use laxatives there is a high incidence of renal disruptions and electrolyte abnormalities. The use of either method severely depleted potassium from the body. Cardiovascular complications can result in heart palpitations, low blood pressure and weakness.
For individuals who induce vomiting, oral complications arise. The most common is the erosion of dental enamel which is typically seen within 6 months of the behavior. Tooth enamel does not regenerate. As a result, the patient will require dental procedures to correct. Enlargement of the Parotid Gland occurs after the patient has been purging for some time. The enlargement is not life threatening but is very bothersome to a bulimic as can be disfiguring. This can be treated by stopping the purging. Tears in the esophagus can also occur and are life threatening. The mortality rate is 20%.
Patients who abuse laxatives are likely to have colon issues. The excessive amount of pill ingestion can be up to as many as 50 pills a day. This behavior leads to a malfunctioning colon. The result is severe constipation or a cathartic colon.
The article recommends a multidisciplinary approach to treatment of individuals with BN. The primary care providers should treat the physical symptoms while working with a psychologist or psychiatrist and a nutritionist. The authors also stressed the need to have a non-judgmental approach to the patient when trying to determine if the diagnosis should be BN. This approach is more likely to elicit more accurate historical information and self-disclosure.
The third article chosen was "Treatment of Bulimia Nervosa: Where Are We and Where Are We Going?" This article outlined some of the current and newly developing therapies being used to combat BN.
The use of medication has been found to be useful. In some cases, the use of antidepressants helped to control symptoms and to reduce the occurrence of comorbid conditions. While the use of drugs is useful in the short term, it was not found to be effective long term. As a result, drug therapy can only play a limited role and should be paired with additional treatment.
The most common psychotherapy for those suffering from BN is still Cognitive Behavioral Therapy (CBT). Recent modifications to CBT have been suggested. This newly enhanced CBT includes an additional four areas of focus during counseling sessions, clinical perfectionism, interpersonal difficulties, core low self-esteem, and mood intolerance. The enhanced CBT involves 4 phases.
Focus on engaging patient in treatment, determining formation of the disorder, and attempting early behavior changes.
Review of the patient's information and a treatment plan is made based on the four areas of focus.
Treatment to modify the eating disorder psychopathology with modules to cover the 4 areas of focus.
Relapse prevention and follow up to ensure continued treatment
Interpersonal Therapy (IPT) has also shown to be as effective as CBT in 1 year follow-up studies. IPT is the theory that interpersonal problems have a role in BN. As a result, IPT focus on interpersonal deficits, interpersonal role disputes, role transitions, and grief. As a lot of individuals experience the onset of BN during adolescence, I could see the importance of looking at how our personal roles and expectations change during the difference phases of our lives. Learning healthy ways to negotiate these changes would be very beneficial to prevent future relapses. The techniques utilized in IPT are as follows:
Feedback on problematic interactive styles
Exploration of feelings
Grief related emotional processing
The other treatment discussed in the article is Dialectical Behavior Therapy (DBT). The approach we originally used to treat suicidal or self-harming individuals. DBT uses weekly group sessions, telephone consultations and regular meetings of a team of therapists. Treatment seeks to change behaviors by focusing on the dynamic relationship between change and self-growth and self-acceptance. The four primary skills focused on are as follows:
While this approach is seen as more emotion based, it is viewed as effective because it targets emotion dysregulation which is thought to contribute to continuing BN.
To further understand dysregulation, I chose my fourth article, "Negative Reinforcement Eating Expectancies, Emotion Dysregulation, and Symptoms of Bulimia Nervosa". Research presented argued that people with BN engage in binge behavior in an attempt to avoid the negative emotional experiences. It was found in their research that binge eaters tend to have alexithymia, difficulty indentifying and describing feelings as well as the inability to distinguish feelings from physical sensations. The results of the study confirmed previous research stating that BN is a result of using eating to avoid or gain relief from negative emotions. With this in mind, I could see how learning emotional regulation as suggested in the previous article in the DBT approach would be most beneficial.
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