Chapter 5. Jenny’s Case: "They’re Just Jealous"

5.1 Screen 1

Clinical Choices
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You must read each slide, and complete any questions on the slide, in sequence.
Anorexia Nervosa

Individual purposely takes in too little nourishment, resulting in body weight that is very low—and below that of other people of a similar age and the same gender.
Individual is very fearful of gaining weight, or repeatedly seeks to prevent weight gain despite low body weight.
Individual has a distorted body perception, places inappropriate emphasis on weight or shape in judgments of herself or himself, or fails to appreciate the serious implications of her or his low weight.
(Information from: APA, 2013)
Bulimia Nervosa

Repeated binge-eating episodes
Repeated performance of ill-advised compensatory behaviors (e.g., forced vomiting) to prevent weight gain
Symptoms taking place at least weekly for a period of 3 months
Inappropriate influence of weight and shape on appraisal of oneself
(Information from: APA, 2013)
Binge Eating Disorder

Recurrent binge-eating episodes
Binge eating episodes that include at least three of these features:
Unusually fast eating
Absence of hunger
Uncomfortable fullness
Secret eating due to sense of shame
Subsequent feelings of self-disgust, depression, or severe guilt
Significant distress
Binge eating episodes take place at least weekly over the course of 3 months
Absence of excessive compensatory behaviors
(Information from: APA, 2013)
Body Dysmorphic Disorder (BDD)

Individuals are preoccupied with having defect(s) or flaw(s) in their appearance that seem, at most, trivial to others.
In response to their concerns, the individuals repeatedly perform certain behaviors (e.g., checking their appearance in the mirror) or mental acts (e.g., comparing their appearance to that of others). The individuals experience significant distress or impairment.
(Information from: APA, 2013)
Obsessive-Compulsive Disorder (OCD)

Occurrence of repeated obsessions, compulsions, or both. The obsessions or compulsions take up considerable time. Significant distress or impairment. (Information from: APA, 2013)
Factitious Disorder Imposed on Self

False creation of physical or psychological symptoms, or deceptive production of injury or disease, even without external rewards for such ailments.
Presentation of oneself as ill, damaged, or hurt.
(Information from: APA, 2013)
Enmeshed Family Pattern

A family system in which family members are overly involved with each other’s affairs and are overconcerned about each other’s welfare
Psychoanalysis

Psychoanalysis would involve psychoanalytic treatment techniques such as free association, or letting the client talk about whatever comes to mind, and therapist interpretation, which involves giving insight and offering an opinion on patterns noticed in the client’s free association and other things such as dreams. A psychoanalyst would treat Jenny by seeing her 3–5 times per week for several years. Psychoanalysis is costly, and it requires a large time commitment.
Family Therapy

Family therapy focuses on the relationship among family members as the primary “patient” to be treated in therapy. It requires the active involvement of all family members in the treatment process to help the person with the diagnosed disorder, to overcome her or his symptoms. In Jenny’s case, treatment would first focus on the entire family supporting Jenny in her efforts to halt her unhealthy eating behaviors. Then treatment would address the enmeshed or too tightly knit relationship between Jenny and her family members as well as the pressures she received from her family to maintain a low weight.
Predominant pain pattern

A pattern of somatic symptom disorder in which the individual's primary bodily problem is the experience of pain, which causes disruptions and concerns that are disproportionate to the severity of the pain.
Cognitive Behavioral Therapy (CBT)

CBT involves challenging distorted thoughts and helping patients change maladaptive behaviors. A trained CBT therapist may require the completion of “homework” assignments between sessions. In Jenny’s case, treatment would involve monitoring her food intake before trying to change her maladaptive eating habits, then exploring the cognitions that are causing Jenny to engage in these behaviors and trying to find other, more adaptive, coping mechanisms.
Medication

Medication involves taking a chemical agent prescribed by a medical doctor to alter brain chemistry, which subsequently alleviates symptoms. A psychiatrist, who has a medical degree (MD), would be able to prescribe patients with eating disorders a medication such as Prozac. In Jenny’s case, this medication would address any mood-related symptoms that may be exacerbating her eating habits. As a therapist, you would continue to meet with Jenny regularly to monitor her symptoms and to refer her to a psychiatrist to adjust the dose of her medication as necessary.

Author: Taryn A. Myers, PhD, Virginia Wesleyan University

A young woman stands on a scale to measure her weight in a bedroom.

5.2 Screen 2

Begin

Please note: Clinical Choices allows you to enhance and test your understanding of the disorders and treatments covered in your textbook, in a simulated case study environment. It is not intended to replicate an actual intake interview or therapy session or provide training on therapeutic techniques. Clinical Choices is for educational purposes only and is not intended as a substitute for clinical training.

5.3 Screen 3

Get instructions for the interview
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The receptionist hands you the intake paperwork prior to your interview with your new client, Jenny, and mentions that she looks very pale and sickly. Select the button to review the paperwork before you begin the interview.

New Client
Jenny: Case #10111

Psychological Clinic

Intake Paperwork

Client Name: Jenny

Age: 20 years old

Gender: Female

Ethnicity: Asian-American and Caucasian

Occupation: Student

Current living situation: I live with my parents

Why are you seeking services at our clinic? My friends dragged me here. They said they are worried about my eating habits. I can’t help it if I’m healthier than they are. I think they’re just jealous.

5.4 Screen 4

Begin the interview

You will now ask Jenny a number of questions you would typically ask during the intake interview. As you conduct the interview with Jenny, begin to think about her symptoms, what her diagnosis might be, and later, what type of treatment might be most helpful to her. Select the “play” button to hear Jenny’s responses to your questions. To read the transcript for these answers, select the “transcript” button.

5.5 Screen 5

Ask Jenny the next question

“Hi, Jenny, it’s good to meet you. What we are doing today is called an intake interview. I’m going to have you tell me what brought you here today, and I’m going to ask you some questions that I ask everyone who comes to the clinic. This information will tell me how best to help you. This may mean having you continue to see me for therapy at this clinic, or it may involve referring you to another mental health professional or facility. I see from your paperwork that your friends encouraged you to come, but you are not sure you need to be here. Asking you these questions will help us determine if you need any kind of assistance, so bear with me as we go through them. Tell me about what brought you to the clinic today.”

A young woman, Jenny, attends an intake interview in a clinic.

Transcript

Jenny: Well, like you said, my friends kind of dragged me here. They say that I have an eating disorder. That’s ridiculous. I think they’re just jealous because I have more self-discipline than they do. If anything, I eat more healthily than they do! They just bugged me about it so much that I figured I’d come talk to you to get them off my back.

5.6 Screen 6

Ask Jenny the next question

“Hmm. That sounds like an awkward situation. Why do you think they are concerned?”

Jenny appears thin and expresses her concerns about looking fat.

Transcript

Jenny: They say they are worried about my weight. They think I’m losing too much weight. I think that’s crazy. [earnestly and emphatically] I have to be very careful about what I eat to make sure I don’t gain weight … I gain weight very easily. I don’t think I worry about my weight any more than I have to or any more than my friends do … Like, yesterday I really pigged out at dinner, so I was super anxious when I got on the scale this morning. Luckily, I weighed the same as yesterday. It’s such a battle to keep my weight where I want it to be. I’ll set a goal for myself … my current goal is to lose 5 more pounds … then I’ll be good. Of course, I thought that before, but when I reached my current weight … well, as you can see … I’m still fat. My friends still call me skinny – it’s crazy! Can’t they see this fat on my gut? Don’t even get me started on my thighs! I really want that “thigh gap,” but I just can’t seem to get it. Maybe you can answer this – is there a weird condition where my body can hold onto fat in some places – like my hips and thighs – but lose it in others?

Question 5.1

Which of the following disorders is a potential diagnosis for Jenny based on the symptoms she has just shared? Select ALL that apply. To review the diagnostic criteria for each disorder, select the disorder name.

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Anorexia Nervosa

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Bulimia Nervosa

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Binge Eating Disorder

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Body Dysmorphic Disorder (BDD)

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Obsessive-Compulsive Disorder (OCD)

Congratulations! Your assessment is correct. Jenny’s concerns could be due to anorexia nervosa, bulimia nervosa, or body dysmorphic disorder. However, the diagnostic criteria for BDD state that you must rule out weight or fat concerns that may be better explained by an eating disorder, so you should keep this idea in mind as you proceed with the interview. Jenny likely does not have OCD because of her specific focus on her weight, and individuals with binge eating disorder usually do not lose weight.
Think about Jenny’s loss of weight and her concern with her weight.
That’s not quite right. Jenny’s concerns could be due to anorexia nervosa, bulimia nervosa, or body dysmorphic disorder. However, the diagnostic criteria for BDD state that you must rule out weight or fat concerns that may be better explained by an eating disorder, so you should keep this idea in mind as you proceed with the interview. Jenny likely does not have OCD because of her specific focus on her weight, and individuals with binge eating disorder usually do not lose weight.

Hint

Think about Jenny’s loss of weight and her concern with her weight.

5.7 Screen 7

Ask Jenny the next question

“I’ve never heard of a physical disorder where that happens, but I’ve certainly heard of disorders where psychological symptoms can give people those perceptions. However, I need a lot more information from you before we can determine if there is anything we should work on together. Let’s start with some simple information: Can you share your height, your current weight, and your highest and lowest weights?”

Jenny explains changes in her weight.

Transcript

Jenny: [a little proudly] Okay, so I’m 5’5” and I just finally got down under 100 lb. As of this morning, I weigh 98 lb. I’m never going to let myself get above 100 lb. again! But it was so hard to get here. [pause] I was heaviest probably when I was 14 when I got my period. [disgusted] I think I hit [disgusted] 130 lb. then because my body changed so fast. I focused on controlling my weight after that. When I was 17, I finally got down to 105 lb. You know what? I just realized that before now, 105 was my lowest weight. [excited] I’m currently at my lowest weight ever! That was so hard. When I was 17 I broke my hip and I gained all this weight when I was recovering and couldn’t work out. I just started losing weight again this year. [quieter, sad] I was dating this guy Josh, and he broke up with me for a skinnier girl. So I decided to lose weight again, to show him. It was really easy – I just slipped back into my old routine.

Calculate Jenny’s current Body Mass Index, or BMI, a ratio of her weight to height, by plugging her height (65 inches) and weight into the BMI calculator. Then check her BMI Status using the table here.

Height in inches

Weight in pounds

BMI

BMI Status

Below 18.5

Underweight

18.5—24.9

Normal

25.0—29.9

Overweight

30.0 and Above

Obese

Source: Centers for Disease Control (CDC), 2015.

Question 5.2

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2
Correct.
Make sure that you are using Jenny’s weight from this morning and use the BMI calculator to calculate her BMI. Then use the BMI/Weight Status table to determine which BMI status that weight falls under.
Incorrect.

Hint

Make sure that you are using Jenny’s weight from this morning and use the BMI calculator to calculate her BMI. Then use the BMI/Weight Status table to determine which BMI status that weight falls under.

Question 5.3

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2
Correct.
Make sure that you are using Jenny’s 105 lb. and 130 lb. weights to calculate her BMIs with the BMI calculator. Then use the BMI/Weight Status table to determine the BMI status for both weights.
Incorrect.

Hint

Make sure that you are using Jenny’s 105 lb. and 130 lb. weights to calculate her BMIs with the BMI calculator. Then use the BMI/Weight Status table to determine the BMI status for both weights.

5.8 Screen 8

Ask Jenny the next question

“A broken hip at 17 — that sounds really painful! I’ve got to ask, how did you break your hip at such a young age?”

Jenny shares her experience about her hip injury that happened when she was a teenager.

Transcript

Jenny: It was painful! And it took so much physical therapy to rehab it! I used to be a competitive figure skater. My mom got me into it when I was real young, and she was so encouraging, taking me to early morning practices, enrolling me in competitions, and celebrating when I won. [sadly] then I had a bad fall… on the ice. The doctors told us that I was malnourished and had brittle bones. … I guess I was more vulnerable to fractures… [sadly] I never went back on the ice.

5.9 Screen 9

Ask Jenny more about her past

“You must miss figure skating. How long did you skate?”

Jenny explains her experience about skating, which she stopped after her hip injury.

Transcript

Jenny: Yeah … sometimes I do miss it. It was such a big part of my life. I started when I was only 3, and I skated competitively until I broke my hip. I don’t miss the practice, though! It was tough. I practiced for hours after school every day, and when I wasn’t practicing, I was in the gym cross-training or trying to fit in my schoolwork. Figure skating emphasizes having “the right kind of body” and looking good… long and lean — like a dancer. I figured this out pretty early on — in the third grade, when my mom caught me eating chips and told me I couldn’t eat like other people if I - was serious about skating. I mean, it was obvious to her I didn’t have a naturally thin body.

Question 5.4

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2
Correct.
Think about the messages Jenny got from her mother and others about the “look” for the sport.
Incorrect.

Hint

Think about the messages Jenny got from her mother and others about the “look” for the sport.

5.10 Screen 10

Ask Jenny the next question

“That’s a lot of pressure for a young girl. Tell me more about your family. What was it like growing up in your household?”

Jenny talks about her family.

Transcript

Jenny: I don’t want you to think my mom was mean – she was just being honest! She just always pushes me to be my best. I am who I am today because she has such high standards for me. I was an only child, but I wasn’t spoiled. My dad worked really long hours – he is a doctor in the E.R. – so sometimes it could be a little lonely. My mom was like my best friend. I told her everything, and she told me things, too. My parents set a very good example –they drilled it into me to always look and be my best. Mom wants to be perfect in everything she does, and she gets down when something goes wrong. She and I stay up and talk … sometimes my mom would cry and tell me how she felt like a failure. [quieter, smaller voice] That’s hard to hear. Those conversations felt really awkward, like I knew too much about her. [embarrassed] It’s also awkward when my mom comments on my clothes or how I look. Sometimes I feel like I don’t have any privacy.

Question 5.5

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2
Correct.
Think about how Jenny described her relationship with her family, particularly her mother.
Incorrect.

Hint

Think about how Jenny described her relationship with her family, particularly her mother.

5.11 Screen 11

Ask Jenny the next question

“I feel like we keep circling back to your appearance and your weight. You said you came in because your friends were concerned about your eating habits. Can you share with me what a typical day of eating and exercise is like for you?”

Jenny discusses her eating habits and her concerns about gaining weight.

Transcript

Jenny: That’s easy! I try to keep it the same every day! I weigh myself first thing in the morning. Then I write down everything I’ll eat for the day. I don’t eat breakfast because I go to the gym right away. I do at least 90 minutes of cardio and 30 minutes of weights. Sometimes the manager there is so annoying – he tried to send me home once because he said I looked like I was going to pass out. [annoyed] What does he know? … So, if my workout goes well, then I go home and let myself eat lunch. I always have a plain salad – no dressing – too much fat! – half a can of tuna, and a diet soda. Between classes I allow myself to have coffee with my friends. They always want me to snack, so I bring my own healthy food, but I try not to eat it, especially if I’ve had lunch. If they stare at me until I eat, I have a hard time paying attention in my next class because I can’t stop thinking about all those calories! I swear I can feel my fat cells ballooning. It’s so disgusting! At night, I eat a low-cal frozen meal or my new favorite, fat-free cottage cheese, corn, and hot sauce. If I eat too much during the day I won’t eat at night – I don’t eat more than 500 calories per day. [more quietly, ashamed to admit this] Sometimes I wish I could throw up if I eat too much. … I can’t make myself do it like so many other people can. So I just sit there feeling fat and gross.

Question 5.6

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
2
Correct.
Think about how much Jenny says she is eating relative to her other reported behaviors.
Incorrect.

Hint

Think about how much Jenny says she is eating relative to her other reported behaviors.

5.12 Screen 12

Ask the next question

“You’ve clearly thought through your daily activities very carefully. Jenny, this is going to sound like a strange question, but do you ever find yourself thinking about food all the time, or cooking for other people?”

Jenny says she loves cooking for her friends but hesitates to eat with them.

Transcript

Jenny: [surprised] How did you know? Actually, I love looking for new recipes and cooking for my friends and family. I don’t eat with them because I’m always prepping the next course, but I love to see people enjoying my cooking. … [pauses] Sometimes I do think a lot about food and calories. It’s worst when I’m hungry. I hate feeling hungry – it’s a sign of weakness. When I’m hungry, I drink water and diet soda to fill up… I love watching other people eat, because then I realize how much more control I have.

5.13 Screen 13

Ask Jenny the next question

“Do you remember when you first started thinking about food this much?”

Jenny shares her motivation about wanting to be slimmer and more beautiful.

Transcript

Jenny: Yeah … When I was 14 and my body changed. I had a really hard time skating with my new body … my coach told me I was getting chubby. He told my mom to take me to a dietitian, and they put me on a really strict diet. My mom monitored my diet and planned all my meals. I lost like 15 lb in 6 months, and everyone told me I looked great! That’s when I started focusing on what I ate and food even more. I even started dreaming about eating! I felt really strong when I controlled what I ate and lost weight. I was able to keep losing weight ... [an afterthought] I did get some weird side effects, like my hair being dry and breaking, and my fingernails cracking really easily. Oh! … and I was freezing all the time, not just when I was at the rink. Then when I broke my hip I couldn’t train or exercise. I gained all the weight back … and then some. Then I didn’t think about it for a while.

Question 5.7

Which of the following could be reasons Jenny started engaging in restrictive eating habits? More than one answer could be correct. Select ALL that apply.

bI0LPa9lfHQ+dYqk

Jenny’s coach’s comments about her being “chubby”

bI0LPa9lfHQ+dYqk

Jenny’s dietitian putting her on a strict diet

wCfH0QtRgXJ8o+c+

Jenny’s hair and nails being dry

bI0LPa9lfHQ+dYqk

The reinforcing compliments that Jenny received about her weight loss

wCfH0QtRgXJ8o+c+

Jenny being affected by images of thin celebrities she saw in the media

wCfH0QtRgXJ8o+c+

Jenny’s friends encouraging her to lose weight

Congratulations! Your assessment is correct. Negative comments about a young girl’s weight can certainly lead her to change her eating behaviors. A strict diet can lead to more restrictive eating behaviors in the future. Compliments about weight loss can reward the weight loss and encourage individuals to keep losing weight in order to get more compliments.
Think about the ways that the feedback of others might have influenced Jenny’s behaviors.
That’s not quite right. Negative comments about a young girl’s weight can certainly lead her to change her eating behaviors. A strict diet can lead to more restrictive eating behaviors in the future. Compliments about weight loss can reward the weight loss and encourage individuals to keep losing weight in order to get more compliments.

Hint

Think about the ways that the feedback of others might have influenced Jenny’s behaviors.

5.14 Screen 14

Ask Jenny about this issue

“I’d like to get to know you a bit more, Jenny. How is school going? What do you like to do in your spare time?“

Jenny shares her school history and childhood with the nurse.

Transcript

Jenny: I’ve always been good at school – I’ve always been a straight-A student. I graduated high school with a 3.96 GPA. I got accepted to all these highly competitive schools, but then [pause] I decided to go to community college with my friends. My dad was so embarrassed of me. He told people at church I was “taking a year off” to think over my academic goals and find the “right” school. [sadly] I was so sorry I let him down. I wish we were closer … and then broke my hip and had to go through all that rehab. When I was 19, I decided to transfer to the state college, where I am now. I’ve done really well, but lately I’ve been having a hard time concentrating and sleeping, so my grades are slipping a little. I really want to move out, but I don’t want to leave my mom alone, so I still live at home. That can make it hard to socialize. I volunteer at an animal shelter on the weekends ... [softly] I love animals. My friends don’t get my relationship with my mom or my focus on dieting … [softly] the animals don’t judge me.

Question 5.8

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
2
Correct.
Think about the reason why Jenny came to therapy.
Incorrect.

Hint

Think about the reason why Jenny came to therapy.

5.15 Screen 15

Review Jenny’s symptoms

“Jenny, you told me that other people have expressed concern about your eating habits. Have you ever been concerned about your focus on food and your weight?”

Jenny expresses her concerns about feeling weak.

Transcript

Jenny: [quietly] This morning, when I woke up, I thought to myself, “I can’t live like this anymore. I really think I might die.” [with determination, convincing herself] But then I snapped out of it and told myself not to overreact and that I was just shaky and weak because I had just woken up.

Question 5.9

9AeUs+eQKTF8H/VTIfOx3fDKc74n++j85gv+ZnRRxkmDpgAXc3CiOMXWx02vVWCFNmPlTZPzA6RhW8gfGlHQD9z7Ae/rC/oH4qtHqy+HJw8ItoQqNY+LX9ETop7FkHlgrTNwG+INKEA4XmuRaYbmdiIgEq7O79LqwLvyME8p2OnADajl0iiAGb3ZmhwAGjsMna+JXzoWFUFs7gnzTRoBAqDjA0x8I0+3N93GSz0t+U3dqjI6U/L9xW2pmsXx9Gjriuojpv2r4zbwtTqR6RQYJMaLK3va4yoUptf1LIyEAiOWXsQMiXEJe5RqE/FXaVBZblvva0LRJAJq0QdQhk1vUQlrJzuiLWH6sT/dayuBP6Ke/zZ2EIXkNs2Qw3yO+vp8vu5nmQ6KJhQbzth/5HbdqadM32EF8RevlgNoYlZGQJIgiNrm8Nk1EOVzPvHw23dwKfGQzi2anI1VVJej0TW8v6uoJWSS87ihpAq6AdEP1eBns/pB9AmCC7xx7n4Uf3V7n1m9JaK7TKu7rsGCTAdmp5nubrbXTCjb/JycPnuFJtmXGwbS85iVa9LzP1hepw0bm35g+hVIEKMg+KcH/emqFz+ALmS5GlbjWoJfAVgJ2QQbXGcOab/3XrM97Ga6+pVzM9DJN7WDJKIENuIuP9GRrG/MuXPsq2DzftLzs/7YWK90vgdhPoHvHJ7GbmSNsDkZ8qnWbLtwvIJwZNkF1Fzp2RSpF/FWkHkCn/luDVEXi0RZ8YFIthL4yhIfHhfgp44Ol+prcAQGa9XLAwd09tcgBzybPRSj2098ts2SWuSoVkW8lnY8OZarCpYAoMfK+sVC+WpazUSAYxeGJY0XHYrxbWub+pcUMyAEYCsfEZOS8+LIbzj60E2KYODJqvPjrlv35PMpYo1DiygCDwuaXqPGjwkJy9isCsUV0lL7uizAmaU4/WzWKgbOJXboBLgqtBF+YCzV0c5Ej086gWXkjYegV1fEehg3fiPX3A7WQBeSMTbcO1LMZH3ax4NmkgVzVX7n18BWVhw21uqb75nyRmTV3oW5YCcOXgu9rBDk8xvsnr2TkANGCKrBEHo74AYdtHNxiQrpwv13dI4+EHc6jEFBiC0KLtOoWM9JmWQWchC3bn27T0rEWpPK7xvR6HHiihqsVHr8nD1zK3BCslEdK6D0EFfLDhQ8Ng8tPGw7fDNBvUORWV6T0HHWsblCDYWkAGOJIM9rrzPoz4i57HOa+Z7lsspjSrOLrLzvgOphYjvIOmsEecClweKB52GSnpmTF0BEAxiv6kgem23otvR47TsChtfiHee3N9ZeIeCvXtDU8OHeuBaWuRXgsRZHAge8g/nolfWALu4mQ2ReH0fDtXgOaORX/tSNdDNUnEtJ+tknyIuCWTOMFanoPg7rmNq4rZJ6G6ajLQb1odNDD7hJ8sQKw/KDRweAf/U1FC1TXetnOQVBqVL07YiHUo8ToqGUoRzl
2
Correct.
Think about all of the symptoms Jenny described and her struggle with them.
Incorrect.

Hint

Think about all of the symptoms Jenny described and her struggle with them.

5.16 Screen 16

Review a similar case

Question 5.10

Which of the following symptoms is Jenny currently experiencing? Select all that apply.

bI0LPa9lfHQ+dYqk

Significantly low body weight

wCfH0QtRgXJ8o+c+

Eating a large amount of food in a short amount of time

bI0LPa9lfHQ+dYqk

Restriction of energy intake

wCfH0QtRgXJ8o+c+

Sense of lack of control over eating

wCfH0QtRgXJ8o+c+

Vomiting to prevent weight gain

bI0LPa9lfHQ+dYqk

Fear of gaining weight

wCfH0QtRgXJ8o+c+

Misuse of laxatives to prevent weight gain

bI0LPa9lfHQ+dYqk

Fear of becoming fat

bI0LPa9lfHQ+dYqk

Behavior that interferes with weight gain

bI0LPa9lfHQ+dYqk

Misconception about her weight and/or shape

wCfH0QtRgXJ8o+c+

Eating until feeling uncomfortably full

bI0LPa9lfHQ+dYqk

Lack of recognition of the risks of extremely low weight

wCfH0QtRgXJ8o+c+

Eating more rapidly than usual

Congratulations! Your assessment is correct. Jenny has a significantly low body weight and a fear of gaining weight and getting fat. In addition, she exhibits behavior—such as restricting her energy intake—that interferes with weight gain. She has a misconception about her weight and shape, and she seems unaware of the health risks of extremely low weight.
Think about both the physical symptoms and the psychological symptoms Jenny has told you about.
That is not quite right. Jenny has a significantly low body weight and a fear of gaining weight and getting fat, In addition, she exhibits behavior—such as restricting her energy intake—that interferes with weight gain. She has a misconception about her weight and shape, and she seems unaware of the health risks of extremely low weight.

Hint

Think about both the physical symptoms and the psychological symptoms Jenny has told you about.

5.17 Screen 17

Diagnose Jenny

From the File. You remember a former patient who exhibited symptoms similar to Jenny’s. You review this case to help you diagnose Jenny.

Transcript

NARRATOR: 12-year-old Natasha is the youngest girl in the clinic. She was admitted six weeks ago, at just over 4 stone.

NATASHA: You don't really mind if you die, to be honest, because you're not that happy anyway.

NURSE: Did you sleep well?

NATASHA: Yeah.

NURSE: That's really good.

NATASHA: When they were telling that I would die, I was thinking, well, you said that to me a week ago, and I'm not dead now. And I've lost more weight. And you never really-- you push it to the limit, really.

NURSE: You're 0.05 above your line.

NATASHA: Is that all?

Because people at school were saying that I was already skinny, but I didn't think so. I wanted to see it for myself. And so that's when you stop eating and you still don't see it.

Others say you're freakishly skeletal, but you don't see it.

When you step on the scales and see that you've gained weight, you just sort of think, you're a failure. You're a huge hunk and you've gained so much weight in such a short space of time.

When I get to my target weight, I know that I'm going to feel absolutely disgusting. I'm just going to feel horrible. And I'll want to lose more weight.

Question 5.11

ZN0DKCgofg+75Qt6BFDyp22EYJEOGZC0mEilqTbwrjw2u1bucy0OGOR5f8BY22JkSc0TWrrqly2c6GdGUIXZYJUZJjEWQUCjLf1r5qOQCbQbLhcrUSiU6RwWiy4bKrUKcr1wCiT97gGjG9MEavYQGfV0TpkQa5sFWrOosELbndc=
Both Natasha and Jenny discuss how their symptoms make them think about death. Both of these young women have had people they know express concern about their weight and eating habits, but they have difficulty understanding why others are expressing these concerns. Natasha and Jenny both talk about weighing themselves excessively, and they admit that their moods are determined by the number on the scale. Both talk about wanting to lose more weight whenever they gain any at all.

5.18 Screen 18

Next Question

Question 5.12

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
2
Correct.
Think about Jenny’s weight loss and excessive concern with her weight.
Incorrect.

Hint

Think about Jenny’s weight loss and excessive concern with her weight.

5.19 Screen 19

What happened to Jenny?

Question 5.13

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2
Correct.
Think about Jenny’s diet and how she monitors her food intake.
Incorrect.

Hint

Think about Jenny’s diet and how she monitors her food intake.

Question 5.14

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2
Correct.
In making your choice, think about research on the role of the enmeshed family pattern in anorexia nervosa and Jenny’s relationship with her mother.
Incorrect.

Hint

In making your choice, think about research on the role of the enmeshed family pattern in anorexia nervosa and Jenny’s relationship with her mother.

5.20 Screen 20

Real World Application

EPILOGUE

Jenny lives a happy life after treatment.

Jenny was shocked when you explained that she met criteria for a diagnosis of anorexia nervosa. She had difficulty believing that anything was wrong with her. However, she did acknowledge her nagging worry that she might die, so she agreed to therapy. You validated her concerns, explaining that anorexia nervosa has the highest mortality rate of any of the mental disorders and emphasizing that many individuals have to be hospitalized when their symptoms are severe. You reassured her that you believed she could address her symptoms on an outpatient basis for now, but you insisted that she also see a primary care doctor to monitor her physical health and a nutritionist with specialized training in working with patients with eating disorders. You explained that if she lost too much weight, there was a chance she would have to enter a residential treatment program.

Jenny was hesitant to involve her parents in her treatment, because she thought her diagnosis would disappoint them. However, when you explained the research showing the effectiveness of family therapy and the rationale for how the entire environment needs to change to support recovery, she reluctantly brought her parents to therapy. Her father was very resistant to the diagnosis at first, as he could not believe that, as a doctor, he had missed a problem this serious in his own daughter. Jenny’s mother was devastated and blamed herself for Jenny’s problem, which only made Jenny feel guiltier. However, with your psychoeducation about anorexia nervosa and how helpful family therapy would be, you were able to get everyone on board. You started Jenny’s treatment by enlisting her parents in helping her establish regular, healthy eating habits to help her gain weight to attain a healthy BMI.

Treatment was a long haul, as it is for any patient with anorexia nervosa. Jenny would be eating regularly with a plan, but then she would be scared by her weight gain and slide back to her old unhealthy eating habits. However, with your help she was able to maintain healthy eating. Having her parents on board to encourage her to eat regularly and healthfully was a vital part of keeping Jenny on track.

Once Jenny had maintained a healthy weight for some time, she was able to talk to her parents about her desire to move out and be independent. Her mother was resistant at first, but when Jenny reminded her parents that she was about to graduate from college and talked about how difficult it was for her to support her mother, her mother seemed to understand. About 6 months after graduation, Jenny got her first apartment. She began work at her first full-time job, which she enjoyed. She was considering graduate school, but she acknowledged that first she needed to give herself time outside an achievement-oriented environment to cement her recovery from anorexia nervosa.

5.21 Screen 21

Real World Application

Watch the following video about another woman with an eating disorder. Then answer the questions.

Transcript

STEVE HARTMAN: It's generally not polite to stare at people in a gym. But here at the YMCA in Nashville, Tennessee, there was one college girl named Lauryn Lax that some people couldn't help but look at. In their minds, Lauryn was clearly anorexic.

MAN 1: Her body was just deteriorating and you could see it.

MAN 2: Her eyes were getting kind of gray and sunk in, and it didn't look good.

STEVE HARTMAN: They say it was a pity to watch. And most people would have probably left it at that. Just watched. But not these Y members.

MAN 3: We knew what we had to do.

STEVE HARTMAN: First thing they did was secretly track down Lauryn's parents who lived in another state. Her folks confirmed that Lauryn was anorexic and had been since she was about 10. Over the years, she'd been in and out of treatment several times to no avail.

Again, hearing that, most people would have just let it be. But instead, this group began plotting their own intervention.

WOMAN 1: We can't sit back and one day she not be here because we didn't do something.

STEVE HARTMAN: It happened here in the parking lot. When Lauryn arrived for her workout, they surrounded her car and told her they were taking her to the hospital. Lauryn protested.

She cried. Said, leave me alone pretty forcefully. And yet, this random group of people who really barely knew her refused to give up on her

MAN 1: We said we're not taking no for an answer. Please, we're just going to take you to the hospital and have your vital signs checked.

MAN 3: We could not let her get away. If she left us, we'd never see her again.

STEVE HARTMAN: They all agree, especially Lauryn.

LAURYN: I don't think I would be here talking today.

STEVE HARTMAN: It was that desperate?

LAURYN: Yes At that point, yes.

STEVE HARTMAN: Lauryn says not long after they brought her here to the Vanderbilt Medical Center. Her heart came so close to failing doctors almost had to put in a pacemaker. But she survived that scare, went back into treatment, and now three years later and 36 pounds heavier she's a new person.

LAURYN: I cannot even express how my mind thinks so differently than I did.

STEVE HARTMAN: What a gift they gave you. They gave you your life.

LAURYN: Honestly, no way-- I don't think I can say thank you, though, for how much-- they were the instigators of starting my recovery. How are you?

MAN 1: Good to see you.

STEVE HARTMAN: In our not my problem, every man for himself society, there are still those who believe it takes a village. Who help people, not because they're friends or family, but because they're human.

WOMAN 2: You look so wonderful!

STEVE HARTMAN: Tomorrow, Lauryn is graduating with a doctorate in occupational therapy. She plans to devote her life to helping others with eating disorders, which I think makes for a pretty good thank you.

Steve Hartman, On the Road, in Nashville.

Question 5.15

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Answers to this question will vary, but what these individuals did is the model of bystander intervention. This follows the advice that if you see something wrong, you should say something. By saying something, even if Lauren did not want to hear it at the time, these strangers likely saved her life.

Question 5.16

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The most important thing is to say something, and to say it in a non-accusatory way. Here are some tips from the National Eating Disorders Association (NEDA; nationaleatingdisorders.org) for helping a friend with an eating disorder:
<ul> <li>Set a time to talk</li> <li>Communicate your concerns</li> <li>Ask your friend to explore these concerns</li> <li>Avoid conflicts or a battle of the wills</li> <li>Avoid placing shame, blame, or guilt</li> <li>Avoid giving simple solutions</li> <li>Express your continued support</li> </ul>