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April – Anorexia Nervosa

The clinician noted a provisional diagnosis of 307. 1 Anorexia Nervosa (American Psychiatric Association [DSM-IV-TR], 2000), as she was fairly certain that April would meet the full diagnostic criteria for the disorder but currently lacked adequate information to support a firm diagnosis. Diagnosis and Differential Diagnosis Initially, April was subjected to both a physical and a neurological examination in order to rule out a primary medical condition as the reason for her weight loss and other reported symptoms. During the medical exam, April elaborated that she had not had her menstrual period for six months, thus indicating amenorrhea.

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She also informed the doctor that she had been having abdominal pains, was often very cold, and had developed a light, fluffy hair on her torso, which the doctor informed her was called lanugo. Most notably, April’s body weight was only 65% of what it should have been for a young woman of her age, height and build. It was determined that these issues were unrelated to a general medical condition and thus, the Axis III diagnosis was listed as “None. ” Based upon April’s symptoms and the absence of a general medical condition to explain her symptoms, it was believed that she had an Axis I clinical disorder.

She refused to maintain a minimally normal body weight, indicated an intense fear of gaining weight, and despite her emaciated condition, continued to believe that certain parts of her body were still “fat. ” She had been eating only 200 calories per day and would spend 4-5 hours on the treadmill each day. Although severe weight loss can occur with Major Depressive Disorder (MDD), April’s conscious desire to engage in extreme dieting and inordinate fear of weight gain were inconsistent with MDD (DSM-IV-TR, 2000).

Individuals with schizophrenia also occasionally experience massive weight loss, but April’s distorted self body image and fear of weight are rarely seen in schizophrenia (DSM-IV-TR, 2000). Social phobia was ruled out as April failed to demonstrate any social fears that were unrelated to eating behavior (DSM-IV-TR, 2000). She did not exhibit any obsessive-compulsive tendencies unrelated to food, such as an excessive fear of germs, and thus a potential diagnosis of Obsessive-Compulsive Disorder was dismissed as well.

She did not impart any distorted views of other parts of her body, such as the size of her head, so a diagnosis of Body Dysmorphic Disorder was not considered (DSM-IV-TR, 2000). Finally, a potential diagnosis of Bulimia Nervosa was disregarded as April had only maintained a body weight of 65% of what would be considered normal for a woman of her age, height, and build. These factors, along with the presence of amenorrhea, confirmed that April did indeed meet the full diagnostic criteria for the Axis I clinical disorder, 307. 1 Anorexia Nervosa, Restricting Type (DSM-IV-TR, 2000).

As the multiaxial evaluation progressed, it was determined that April did not meet the criteria for an Axis II diagnosis, which is concerned with personality disorders and mental retardation (DSM-IV-TR, 2000), and thus her Axis II diagnosis was recorded as “V71. 09 No diagnosis. ” However, her clinician did note problems with her primary support group, as indicated along Axis IV, which is concerned with psychosocial and environmental problems (DSM-IV-TR, 2000). Specifically, the clinician noted the death of her brother, Pete, and the consequential lack of attention and discipline supplied by her parents during her adolescence.

Although these issues occurred a little more than a year prior to the current evaluation, the clinician believed it was prudent to note them as they clearly played a role in the development of her disorder. Additionally, the clinician noted ongoing problems related to the social environment, as well as educational problems. April lacked a strong social support network. She had several casual romantic partners, but few, if any, real friends and her family was largely uninvolved in her life.

These social problems carried over into her school life as well, where she continued to experience tumultuous relationships with both her teachers and classmates. Her academic performance was poor and she had been cited for truancy on numerous occasions. Finally, the clinician assessed April’s overall level of functioning on Axis V via the Global Assessment of Functioning (GAF) scale (Endicott, Spitzer, Fleiss, & Cohen, 1976). Although April did not have a history of attempts at suicide, nor did she indicate any suicidal ideations, she was in a severely emaciated state and thus, her health was at serious risk.

Therefore, the clinician rated her symptom severity at 19, which indicated that she was in some danger of hurting herself or others (Endicott et al. , 1976). She fared slightly better on her level of functioning. She often got into fights at school and displayed serious impairment in relationships with both friends and family. She had few, if any, friends and had had virtually no involvement with her family since Pete committed suicide. She also displayed serious impairment in thinking in terms of her severely distorted body image. Despite being only 65% of normal weight, she continued to believe that she was “fat. However, she had a perfect attendance record at work and usually attended classes. Her judgment, aside from issues related to food consumption or her own body, appeared to be largely unimpaired and she was not suffering from any type of hallucinations. Accordingly, in terms of functioning, the clinician noted a rating of 39, which indicated major impairment in several areas of functioning (Endicott et al. , 1976). The final assessment recorded on Axis V was “GAF = 19 (current),” in order to reflect the lower of the two scores. History and Background

April grew up in a small, lower-middle-class New Jersey town with her two brothers, Pete and Chris. Pete was ten years older than April, whereas Chris was two years younger. Pete was a heroin addict who had contracted AIDS and was rarely ever home. Her mother worked in retail, whereas her father managed a local liquor store. Both parents were overweight. April had a fairly normal early childhood, but as she got older, problems began to develop. She did well in school and played several sports. She considered herself a perfectionist and always strove to be the best at everything she did.

However, at age 10, she experienced a considerable growth spurt, which resulted in her being the tallest person in her class. She was often picked on and referred to as the “jolly green giant. ” As a result, she stopped played sports and began getting in frequent fights at school with both boys and girls. She soon turned to food for comfort and before long, she was overweight. When April was 16, Pete committed suicide. He had called April’s father asking for money and a ride from New York City. Her father, tired of enabling his son’s addiction, declined. Pete’s body was found several days later.

Riddled with guilt, her father completely withdrew from his family and became completely uninvolved in April’s life. Her mother, overly fearful of making April unhappy, quickly adopted an extremely permissive parenting style. Feeling unwanted and neglected, April began seeking attention from boys in her class and other young men. By the time she turned 17, April’s academic performance had dropped off significantly and she was spending nearly all of her free time pursuing young men. Determined to remain attractive to these young men, she became intensely fearful of gaining weight and began engaging in extreme dieting and excessive exercise.

It wasn’t long before April had become noticeably emaciated and attracted the attention of her parents, who had become quite concerned with her physical condition. When they approached her about the issue, however, April denied that there was a problem and boasted about her recent, rapid weight loss. Shortly before her 18th birthday, April passed out in school, at which point she finally gave in and agreed to see a mental health professional. Etiological Considerations Biological factors, such as an abnormal serotonin metabolism, have been cited as potential contributors to the development of eating disorders, though heir precise role and the exact implications of the findings are unknown (Oltmanns, Martin, Neale, & Davison, 2009). It has also been suggested that genetic factors may play a role, with evidence specifically supporting a genetic predisposition to eating disorders for immediate female relatives and identical twins of individuals with a history of eating disorders (Striegel-Moore & Bulik). Mazzeo and Bulik (2008) proposed a scenario in which genetic factors may predispose individuals to seek out image-focused activities (e. g. modeling), a theory which is reminiscent of Ridley’s “nature via nurture” (as cited in Kring, Johnson, Davison, ; Neale, 2010, p. 29). Psychological risk factors for anorexia include negative affect, low self-esteem, and an intensely negative self body image (Stice, 2002), as well as a strong desire for perfectionism (Herpertz-Dahlmann et al. , 2001). April’s promiscuity and obsession with being thin both stem from a sense of low self-esteem, which is believed to be due, in part, to excessive teasing by her classmates during her childhood, as well as diminished parental support following the death of her brother.

Incidentally, family dysfunction itself plays a significant role in the development of eating disorders as well (American Psychological Association HealthCenter [APAHC], 1998). April’s maladaptive eating habits may have also developed, in part, in response to the traumatic death of her brother. Compared to the general population, individuals with eating disorders are more likely to have a history that involves one or more traumatic life events (American Dietetic Association [ADA], 2001).

Sociocultural influences, such as exposure to the tall and thin ideal female physique created by Western culture through multimedia, help individuals (especially women) to internalize the idealized body shape (Arnett, 2010). Dissatisfaction with one’s own body often results when individuals realize that their own body shape varies from the ideal (Striegel-Moore & Bulik, 2007). Additionally, objectification of the female body bolsters the importance of attaining an often unrealistic ideal (Moradi, Dirks, & Matteson, 2005).

Consequently, these factors most probably explain why anorexia and bulimia are most likely to occur amongst young women in their teens and early 20s (Reijonen, Pratt, Patel, & Greydanus, 2003). Case Conceptualization Cognitive behavioral theories (CBT) of anorexia nervosa focus on the excessive fear of weight gain and distorted body image as the primary factors behind the maladaptive behaviors that characterize the illness (Kring et al. , 2010). Behaviors that result in weight loss, such as extreme dieting and excessive exercise, help to reduce anxiety, as well as the fear of losing control (Murphy, Cowan & Sederer, 2001).

Perfectionism or cognitive rigidity have been purported to encourage individuals to become overly concerned with their weight and shape (Herpertz-Dahlmann et al. , 2001), as has the media portrayal of the ideal female form (Mazzeo & Bulik, 2009). Paxton also noted that overt criticism from peers can contribute to a distorted body image and consequently, to an overwhelming desire to be thin (as cited in Kring et al. , 2010). Any number of these factors may have contributed to the development of April’s disorder.

She may have feared becoming overweight like both of her parents or she may have needed to feel in control once again after the death of her brother. Alternately, she may have engaged in these behaviors in response to years of criticism or in order to achieve the perfect body she felt was necessary to maintain the attention of her romantic partners. The psychodynamic model of anorexia offers at least two divergent views of the disorder. Because the disorder most commonly occurs during adolescence, Shoebridge and Gowers purported that anorexia represents an unconscious desire by the female to remain prepubescent (as cited in Oltmanns et al. 2009). Conversely, Bruch perceived anorexia as being the product of low self-esteem and poor self-efficacy (as cited in Oltmanns et al. , 2009). The behaviors associated with the illness are therefore viewed as an attempt at regaining a sense of control. Bruch (1979) additionally indicated two childhood factors that she believed increased the likelihood of an individual developing anorexia nervosa: excessive concern with food and family problems that interfered with identity formation. The death of April’s brother and the resultant deficient parenting may have left April uncertain as to her role within the family system.

Knowing one’s role within the family system during adolescence is an essential component of proper identity formation (Arnett, 2010). Course of Treatment The goals of April’s treatment were to help her to: (1) attain a normal weight and establish healthy eating patterns, (2) learn to be more aware of the dysfunctional thoughts and beliefs that contributed to her illness and the related behaviors, (3) examine those thoughts and beliefs and replace them with more realistic ones, and (4) establish a sense of self-worth that was not dependent upon weight or body shape.

These goals were achieved through an interventional process that utilized a combination of cognitive-behavioral and psychodynamic techniques, which was chosen in order to provide the most effective form of treatment for April’s specific set of problems. Due to April’s emaciated state and continued denial of her illness, the first step in treatment was hospitalization. This was necessary in order to help her restore weight and confront her condition. During this time, she was provided with intravenous fluids and medically observed.

Willful cooperation is essential to weight restoration (Oltmanns et al. , 2009) and thus, doctors were pleased when April agreed to eat on her own rather than be subjected to tube-feeding. Over the course of the next several weeks, April made significant progress towards the target weight agreed upon by her and her physician. Once April’s condition had stabilized, she began individual psychotherapy with her clinician on an in-patient basis. Individual therapy was chosen over family therapy due to the unwillingness of her parents to devote the necessary time and effort to treatment.

Within these therapy sessions, she was educated about anorexia, the proposed course of treatment, and the prospective underlying cognitive processes that potentially contributed to the illness. The issues surrounding the death of her brother and the subsequent abatement of parental support were discussed as well. She was also encouraged to critically evaluate the beliefs that led to her maladaptive behaviors, with the intent of eventually replacing her dysfunctional thoughts with more realistic thoughts. Following her discharge from the hospital, April’s physician continued to monitor her weight and general physical condition.

Individual therapy progressed with her original clinician. During these sessions, the clinician explored several issues believed to be associated with the development of April’s illness, including her anger, low self-esteem, promiscuity, and difficulty in maintaining close relationships. April also discussed her strong desire for control and problems regarding relational aggression. Essentially, the goal of these sessions was to gain further insight into the precipitating factors (e. g. the death of her brother) and the perpetuating factors (e. g. her anger and low self-esteem) that contributed to the development of her illness.

This information could be used, in turn, to help restructure her thought processes and establish a feeling of self-worth that was independent of her weight or body shape. Despite the lack of a reliable family support system, April continued to move forward in her treatment. She persisted with individual therapy for the next two years and made slow but certain progress. At the conclusion of her final therapy session, April was at 95% of her normal body weight, engaging in healthy eating habits, had a considerably more accurate self body image, and demonstrated vastly improved social skills and psychological well-being.

Other Considerations Several other factors are believed to have portrayed a crucial role in the progression of April’s disorder. As an adolescent, white American female, the chances of April developing an eating disorder were fairly high comparatively speaking. According to the CDC, 60% of American adolescent girls believe they are overweight, although only 15% are actually overweight according to medical standards (as cited in Arnett, 2010). Incidentally, most eating disorders have their onset amongst adolescent or early adulthood females (Reijonen et al. , 2003).

In fact, 90% of all eating disorders occur amidst females (Reijonen et al. , 2003). Additionally, in comparison to other ethnic groups, the highest prevalence for eating disorders occurs among Caucasian Americans (Hock, 2006). The relatively high prevalence of eating disorders amongst young women is undoubtedly due in no small part to excessive cultural pressures within America for women to be thin. References American Dietetic Association. (2001). Position of the American Dietetic Association: nutrition intervention in the treatment of anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified.

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