Chapter 1. Test1

Introduction

Written by Danae L. Hudson, Ph.D.

Missouri State University

(c) 2013 Worth Publishers (Photo Credit: John Knill / Getty Images)

1.1 Presenting Complaint

Carrie, a 24-year-old college student, woke up early one morning and thought to herself, “I can’t live like this anymore. I really think I might die.” Immediately, she also found herself thinking, “You’re just waking up and you are shaky and weak. Don’t overreact, once you work out you’ll feel so much better.” Carrie used to find it strange that she could have two seemingly contradictory thoughts at the same time, but after so many years, she was used to it.

Carrie got out of bed and began her morning routine. She nervously undressed and stepped on the scale. It was such a risk; she knew she hadn’t been perfect with her eating yesterday but still she hoped the scale would bring good news. The scale registered 98 pounds. At 5’5”, her body mass index (BMI) was a mere 16.3. Carrie breathed a sigh of relief. She hadn’t lost any more, but at least she hadn’t gained weight. It had been such a battle to get below the 100-pound mark that she vowed to never let herself get past that point again. She felt as though she just needed to lose about 5 more pounds and then she would be satisfied. She, of course, had thought that before, but when she reached her goal, still all she saw was fat. Intellectually she knew that she weighed less than most of her friends, but she couldn’t understand why people referred to her as skinny. Didn’t they see all the fat around her stomach and thighs? Carrie even began to wonder if she had some kind of strange medical condition where her body held onto fat and lost weight from other areas, like her muscles, or even worse, her brain.

Lately, Carrie has had such a difficult time concentrating and has noticed that her grades are slipping in her classes. She has always been a straight-A student, so she was not used to these kinds of difficulties. However, she viewed this as just one more challenge; she could easily stay up all night to study if it was necessary. She had always had difficulty sleeping and, lately, she had been waking up at 4:00 AM, unable to get back to sleep.

Carrie continued with her morning routine of writing down everything she was going to eat that day. She never ate breakfast, but after returning from the gym, if she had a successful workout, she would allow herself to eat lunch. A successful workout was defined as 90 minutes of cardiovascular exercise and at least 30 minutes of weight training. She was almost always successful with her exercise, except for the few times she nearly fainted and the manager of the gym suggested that she return home and rest. Today, lunch would consist of a plain salad with no salad dressing, ½ can of tuna, and a diet soda.

After class she would drink some coffee with her friends. She often brought a snack, such as an apple or some carrot sticks, with her and would leave it on the table so she could refer to it when her friends would offer her some of their snacks. Most of the time she didn’t want to eat it, but sometimes she felt as though everyone was staring at her, so she would just eat some carrots just to appease them. After doing so, though, Carrie found it very difficult to concentrate in her next class because she would obsess about how many calories she had consumed that day already. She swore she could feel the fat cells in her body enlarging after she ate. Sometimes in the evening, she would try not to eat anything at all, especially if she had eaten something during the day that she hadn’t planned on. She found that drinking a lot of water and diet soda could calm her hungry stomach. Carrie hated feeling hungry. She viewed it as a sign of weakness. She had always prided herself on how much willpower she had compared with other people. In some ways, she enjoyed watching other people eat because it made her feel even more powerful when she did not eat with them.

When she did eat dinner, it usually consisted of a low-calorie frozen meal or maybe a sandwich. Lately, she has been enjoying a mixture of fat-free cottage cheese, corn, and hot sauce. She is amazed at how a small amount can fill her up and give her the protein she needs for her workout the next morning. Carrie strives to eat no more than 500 calories per day. If she ever does eat more than her allotted amount, she worries about gaining weight. A few times in the past few months she has wished she could force herself to vomit after what she calls overeating. She reports that she is unable to self-induce vomiting and wishes that she could just “make it happen like so many other people can.”

After dinner, Carrie often searches the internet for new recipes. She has always enjoyed cooking and now she finds it even more satisfying to cook for others and watch them eat her food. Sometimes she will eat some of the food with them, but most of the time she tells people that she has eaten already and wouldn’t have time to sit and enjoy her meal during the dinner because she needs to be preparing to serve the next course.

Although she has a lot of friends, Carrie doesn’t socialize as much as she did when she was younger. She tries to tell herself that it is because she is very busy with classes, but sometimes she feels sad and recognizes that she has pushed many of her friends away because she has been so focused on losing weight. Nowadays, dieting has become her only true friend.

1.2 Social/Family History

Carrie is an only child and was raised by both her mother and father. Her father, an emergency room physician, worked very long hours and was often not home. He provided for the family financially and Carrie always had everything she had wanted, but many times their big house felt very lonely. Carrie wishes she had a closer relationship with her father but she doubts that will ever happen; she thinks she can never do enough to make him proud of her. For example, after graduating high school with 3.96 GPA Carrie elected to attend a local community college with her friends. Her father was mortified by her decision and told her that he had always pictured her going away to an Ivy League school. She overheard her father one day at church telling another member that she had been accepted to a couple of Ivy Leagues, but the family thought is was best for her to stay at home for one more year to clarify her academic goals and choose the school the best suited her needs.

Both Carrie’s mother and father were very concerned with appearances. Everyone always thought they were the perfect family, but no one really knew what things were like. Carrie had an extremely close relationship with her mother. They had always been more like friends than like mother and daughter. Carrie told her mom everything and often her mother confided in her, too, since her father was always working. Carrie could see that her mother tried to be perfect in everything she did and would get very depressed if she did not live up to her own standards. Many nights she stayed up with her mother who would cry about how she had failed in life. Sometimes, Carrie struggled with her mother’s over-involvement in her life. On one hand, she believed she needed her mother for support, but on the other hand, she often felt smothered and as though she had no privacy. She felt especially uncomfortable when her mother would comment on her changing body or clothes.

Carrie had learned at a very early age that what you looked like was very important. She had been heavily involved with figure skating since the age of 3 years. She skated competitively for almost 14 years and had reached a point where she needed to decide if she was going to train to compete at the highest levels. She never actually had to make that decision, however, because of an injury that ended her skating career.

Life as a skater was grueling. Carrie practiced for hours each day and when she wasn’t practicing she was in the gym or studying. She can remember from an early age how much emphasis was placed on having to “look good” and have “the right kind of body.” When Carrie was in the 3^rd grade, her mother caught her eating a bag of potato chips and told Carrie that she hadn’t been blessed with a naturally thin body and if she wanted to continue skating she could not afford to eat like most people. When Carrie was 14 years old her body changed and she experienced some difficulty adjusting her skating to her new body. At that point, her coach told her that she was beginning to get “too chubby” and asked her mother to take her to a dietitian. Her mother complied, and Carrie was placed on a strict diet. All of her meals and snacks were planned by her mother and Carrie’s meals were monitored closely.

Over the next six months, she lost approximately 15 pounds and received numerous compliments on her looks from coaches, teachers, and friends. Before long, she became obsessed with food. She felt hungry all the time and would find ways to sneak food. She began to dream about eating. Yet, at the same time, she felt very strong and in control when she was able to continue losing weight. By the time she was 17 years old, she weighed only 105 pounds, but she realized that she had become terrified of eating and that her habits had taken a toll on her body. Her hair was dry and her fingernails were brittle. She was freezing all the time and was becoming very weak. One day in practice, she took a bad fall and broke her left hip. The doctors told her parents that she was malnourished, which had left her with brittle bones and susceptible to fractures. Carrie had to endure months of physical therapy, and has never been back on the ice.

Throughout her rehabilitation, Carrie regained some weight and muscle mass, worked a part-time job, and volunteered at an animal shelter. At the age of 20, while still living at home with her parents, Carrie decided to attend the local state college. She really wanted to move out and get an apartment, but she felt guilty about leaving her mother alone so she continued to stay at home.

Now in her senior year, Carrie was feeling the pressure. The year had started off well. She met Josh in one of her classes and they started dating. She cared about him deeply and after three months of dating, he informed her that he was interested in someone else. Carrie had seen this other girl and came to the conclusion that Josh liked her better because she was skinnier than Carrie. At that point Carrie vowed to lose weight once again. She knew it wouldn’t be that difficult since she had done it before. She was surprised however, at how quickly she lost weight and returned to the same obsessive thinking about food as she had experienced when she was an adolescent.

As she sat alone in her room, planning out her food for the day, Carrie wondered if she really would be satisfied with just 5 more pounds. She wondered if her friends were right; that maybe she really did have a problem. “No,” she thought, “they’re just jealous.”

1.3 Multiple-Choice Questions