Lesson 1: Clinical Disorders - Part A

Description

After watching a television show relating to eating disorders, a 23 year-old woman requested admittance to the treatment program highlighted on the TV show. To be admitted, she had to describe her eating behaviour. She began her story describing her desire to lose weight in college. She started to use a few laxatives but, with continued use, her current dose became ineffective. She gradually increased the dosage until she was taking 250-300 pills at one time, downing 20 pills with one swallow of water. She lost weight – as much as 20 pounds in a 24-hour period (mostly water), but became so dehydrated that she could not stand and could barely talk. Sometimes the woman would not eat for days. Then, with the first bite of food, she would be so overcome with guilt and hunger that she would binge. After speaking with a friend from the same dormitory at college, she learned that vomiting after the binges would prevent weight gain. She learned that she could eat large amounts of food, then induce vomiting, and still lose weight. Her weight dropped to 90 pounds. At this time her hair started to come out in handfuls and her teeth were loose.

Despite how she looked to others, the patient never felt happier about her appearance. She was flat everywhere and each rib and back vertebra could be seen when she bent over. The more weight she lost, the more worried she became about becoming fat. She was afraid of drinking water for days at a time because it added pounds on the scale. She did drink, however, to help her vomit after a binge. Binging was so successful that she stopped using the laxatives despite complaining of constipation. In fact, the mere sight of laxatives made her nauseated.

The patient exercised for many hours each day to tone her figure. She even joined the college track team, but she had to quit because she could not complete one lap. She vomited before practice which made her too dizzy to run. At this time she had not menstruated in two years. During her last semester before she dropped out of college she read an article on anorexia nervosa. The article scared her into trying to eat and digest healthy food.

While she loathed eating nutritious food items, she forced herself to do so and accepted a new attitude regarding food. At 5’6” and fighting panic, she inched her weight to a range of 105 and 115 pounds. She would only eat nutritious food (no junk food or sweets) but became reclusive in her home as she was embarrassed to be “so fat.” She also began to push away friends and activities that used to make her life complete. The patient, however, was able to hold a job despite binging, purging, and feeling sick all the time.

Her binging and purging was harder to perform each time, and the act took longer to complete. She needed to use different instruments (e.g., electric cords) to help her vomit as well as six to ten doses of ipecac (a substance that induces vomiting). Her knees became calloused from the time she spent kneeling while throwing up. Sometime a session of vomiting would last two to three hours but could also last as long as eight hours. A vomiting session left her dehydrated, cold, and shaking with broken blood vessels in her eyes.

In her letter to the treatment centre, the patient described her desire to break free from her overwhelming eating disorder. She cried for help from behaviours such as isolation, taking Aspirin® for the pain in her hands, taking potassium supplements (to counteract the diuretics she took), shoving cords down her throat, and spending hours heaving into the toilet. It was easily decided that she was a suitable candidate for treatment.

Upon her inclusion in the treatment program it was learned that her eating disorder began during her teen years. At 14 years-old, and at her adult height of 5’6”, she believed she was fat at 128 pounds. She began to diet, unsuccessfully, soon reaching 165 pounds. Not wanting to gain any more weight, she began to diet seriously and dropped to 130 pounds. At this time she felt depressed, overwhelmed, and insignificant. She also wanted to maintain an “A” average at school, so she avoided difficult classes and began to lie to avoid humiliation. She had extreme anxiety regarding the opposite sex and thus transferred to a girls’ school for her last year of high school. As attested to in her letter, her eating and dieting became drastically worse in college. Although she decided to gain weight from her low of 88 pounds, her binging and purging got worse and she dropped out of college. The patient is the only daughter of four children. She comes from an upper-middle-class family with an alcoholic father. The parents have a strained relationship, and the relationships between her parents and her brothers are strained. No other family member has had psychiatric treatment.

Diagnosis

The patient obviously displayed the features of anorexia nervosa. She had an intense and irrational fear of becoming fat although she was dramatically underweight. Her self-perceived body image was so unrealistic that while she thought she was fat, others thought she was normal. When she thought she was beautiful, others saw a grotesquely thin skeleton. Despite being hungry, the woman lost 30% of her body weight through dieting, vomiting, excessive exercise, and the use of drugs. This information resulted in a diagnosis of anorexia nervosa. Because she also binged and purged at least twice a week for three months, the additional diagnosis of bulimia nervosa was made.

Her DSM diagnosis is as follows:

Axis I: Anorexia Nervosa, Severe
          Bulimia Nervosa, Severe

Follow Up

During her treatment the patient was able to give up diuretics and other medication completely. After returning home, she continued psychiatric treatment for about six months until her family withdrew their support. During that period she had made some progress, but she was unable to change most of her behaviour. Two years after leaving treatment, she wrote to the hospital saying that she was “much better”, that she had returned to college and was seeing a nutritionist and counsellor. Her weight was normal and she was menstruating regularly despite the occasional episode of binging and purging. She was no longer using diuretics or laxatives.