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1 Case # 8: Ina Ima Student Holy Family University COUN 540: Psychopathology and Diagnosis Using the DSM 5 Professor Wayne J. Popowski [Date Due]

2 Clinical Overview Ina is a 33-year-old Caucasian woman who arrived at the clinic after experiencing a series of physical complications due to disordered eating. Ina has been married to her husband, Bob, for 6 years, and they live together with Ina ’s 14-year-old son from her previous marriage, and Bob ’s 18 year -old daughter. Bob states that he noticed Ina ’s restrictive eating habits shortly after they started dating, which led to increasingly severe abdominal issues that required surgery. Due to her husband’s growing c oncern, Ina has agreed to get help. Ina reports a normal childhood, with good grades, neighborhood friends, and a younger brother. She states that she always tried to be the “perfect child” and obey her parent’s rules. Ina ’s younger brother was hit by a car and killed when she was 14 years old and asked to keep an eye on him. Ina struggled with immense guilt following this accident, which lessened over the years but continued to follow her. After the death of her brother, Ina ’s parents became increasingly overprotective (such as not being allowed to go out with friends and not allowed to be away from home), limiting her ability to experience a normal adolescence. Ina tried her best to respect her parents’ wishes by obeying their strict rules. Ina met her first husband, Randy, as a sophomore in high school and got married after completing two years of trade school. She states that she knew nine months into the six-year marriage that she did not truly love Randy but was using him as a means to break away from her controlling parents. Ina also states that she feels like she never truly learned to take care of herself but went from one dependent relationship to another. She became pregnant with her son two years into her marriage. Ina gained a significant amount of weight (80lbs) during her pregnancy and struggled with weight loss. She divorced Randy when she was 25, which forced her to go on welfare and

3 move back in with her parents in order to make ends meet for her son. Ina reflected on how stressful moving back in with her parents was, as they continued to treat her like a child. Shortly after, she was involved in a serious car accident, requiring numerous surgeries on her hips and legs. This accident exacerbated Ina ’s dependency on her parents to take care of her and her son. During her recovery, she unintentionally lost a significant amount of weight. She met her ex-boyfriend, Jack, at rehab and agreed to move in with hi m in order to escape her parent’s home once again. Jack had a serious alcohol problem which rubbed off on Ina, who began to drink heavily with him everyday, leaving her son with sitters or at day care. However, eight months into the relationship, Ina began to see the destructive patterns and returned to live with her parents for two more years. She now only drinks socially and infrequently. During this time, Ina began dieting before undergoing another knee surgery because she did not want to risk complications to her recovery due to weight gain. Ina began to severely restrict her food intake, as well as weighing and measuring all of her meals. If she was eating around her family, she would play with her food rather than eat it. Afterwards, she would excuse herself to the bathroom to take laxatives in order to purge what little she did eat. Within a year, Ina went from 125 to 98lbs. Ina became preoccupied with her weight and insisted that she would look better if she was thinner, in spite of her continued weight loss. She states that she has an overwhelming fear of getting fat and took pride in her ability to control her eating, as she felt that every other aspect of her life was out of control. Due to her restricted eating and weight loss, Ina stopped having her period and began to have liver problems. Her skin and hair were dry and brittle, and she experienced lightheadedness and vertigo. Ina went to therapy a couple of times after being medically advised but stopped going due to believing that therapy is a sign of failure.

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4 Ina and her son moved out of her parent’s home due to nagging about her eating habits. However, these behaviors continued as Ina lived on her own, and she fluctuated between 90-105lbs. She would have patterns of eating normally and then starving herself, as well as binging and either taking laxatives of starving. There was seldom enough food in the house for her son to eat, as Ina viewed food as bad and a waste of money. Ina met Bob when she was 32 and weighed 105lbs. Shortly into their relationship, Ina resumed her restrictive eating habits. Bob fears that Ina is unable to properly take care of herself, and may not survive unless she gets help. Diagnosis and Rationale Ina meets the criteria for F50.02, Anorexia Nervosa, Binge Eating/Purging Type. Ina restricts her food intake relative to her physical requirements for nutrition and is at a significantly low weight because of this (Criterion A). She has an intense fear of gaining weight and becoming fat, and engages in behaviors that interfere with weight gain, such as taking laxatives and starving herself (Criterion B). This fear of gaining weight has caused a disturbance in the way she perceives her body, evidenced by her desire to be thinner despite currently being at a very low weight (Criterion C). Ina also has a history of binge eating and purging with laxatives. She also meets the criteria for F60.7, Dependent Personality Disorder. Ina ’s history reveals a pervasive need to be taken care of and submissive, clinging behavior. This is evidenced by Ina ’s need for others to assume responsibility for major areas in her life, such as excessively relying on past partners and her parents to take care of her and provide for her physical needs. She also has difficulty making everyday decisions, doing things on her own, going to excessive lengths to receive nurturance and support (as evidenced by a period of problematic drinking in

5 order to stay connected with her ex-boyfriend), and the tendency to seek another relationship after one ends. It is also worth noting that Ina agreed to seek help for her eating disorder after being urged by her husband, rather than acknowledging her problematic patterns on her own. Treatment Plan Ina ’s optimal course of treatment would begin with inpatient hospitalization in order to ensure that she is medically stable and has begun the process of restoring her weight in a controlled, supervised environment. During her inpatient hospitalization, Ina will begin individual and group therapy in order to come to terms with the severity of her disorder. Following discharge, Ina would benefit from a multimodal therapeutic framework that includes individual CBT and focal psychoanalytic therapy, as well as family therapy. Research by Pike, Walsh, Vitousek, Wilson & Bauer (2003) highlights the effectiveness of CBT and nutritional counseling in relapse prevention and symptom management. Focal psychoanalytic therapy is a time-limited approach based on psychoanalysis in which the therapist supports the patient in exploring the conscious and unconscious meanings of their symptoms in relationship to the patient's history and of their experience with their family, as well as the effects of AN and its influence on the patient's interpersonal relationship. In a randomized controlled trial of outpatient treatments for adults with AN, Dare, Eisler, Russell, Treasure & Dodge (2001) concluded that patients engaged in focal psychoanalytic therapy and family therapy showed significant symptomatic improvement compared to the control group, who received low-contact, routine follow-up treatment. Long Term Goal: Restore normal eating patterns, healthy weight maintenance, and a realistic appraisal of body size.

6 Goal A: Ina will examine her relational patterns relating to the symptoms of her eating disorder and develop healthy interpersonal relationships that help prevent relapse of the eating disorder. Objective 1: Ina will work with an individual therapist in order to explore her family of origin, trauma history, and events in her life that are linked to the development of problematic eating patterns. Ina will also engage in family and marriage counseling in order to recruit the support of loved ones and practice open communication around how AN has affected her family. Goal B: Ina will develop healthy cognitive patterns and beliefs that increase positive self-concept and reduce symptoms associated with AN. Objective 1: With the support of her therapist, Ina will begin to identify beliefs and thought patterns that contribute to problematic eating. She will learn to challenge these negative cognitions and replace them with beliefs that are strengths-based. Goal C: Ina will develop coping strategies to address emotional issues that could lead to relapse of the eating disorder. Objective 1: Ina will learn and practice coping skills such as emotional identification, problem-solving, and assertiveness. This will help Ina build a positive self-concept as a protective barrier to relapse, as well as helping her individuate from dependent relational patterns. Summary Ina is a married, 38 year-old Caucasian woman presenting with Anorexia Nervosa, Binge/Purging Type and Dependent Personality Disorder. It can be hypothesized that her eating disorder manifested as a means of reclaiming a sense of control after years of being overly reliant

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7 on her parents and romantic partners to guide her through life and meet her needs. Ina ’s diagnosis of AN is evidenced by a low body weight, a preoccupation with feeling fat, and restricted food intake. There are periods of time when she binges, which are followed by purging with laxatives. The physiological effects of Ina ’s eating disorder are brittle hair and nails, abdominal pain, decreased liver function, and lightheadedness. Ina would benefit from initial inpatient hospitalization to ensure medical stability prior to beginning outpatient therapy. This therapy would include CBT, focal psychoanalytic therapy, and family therapy in order to provide a holistic, systems-focused approach to recovery.

8 References American Psychological Association. (2013). Diagnostic and Statistical Manual of Mental Health Disorders (5 th ed.). Arlington, VA: American Psychiatric Publishing. Dare, C., Eisler, I., Russell, G., Treasure, J., & Dodge, L. I. Z. (2001). Psychological therapies for adults with anorexia nervosa: randomised controlled trial of out-patient treatments. The British Journal of Psychiatry , 178 (3), 216-221. Pike, K. M., Walsh, B. T., Vitousek, K., Wilson, G. T., & Bauer, J. (2003). Cognitive behavior therapy in the posthospitalization treatment of anorexia nervosa. American Journal of Psychiatry , 160 (11), 2046-2049.

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