Anorexia Nervosa Case Study: Julie ( The thinner, The Better)

The overwhelming majority of individuals with bulimia are within 10% of their normal weight (Fairburn & Cooper, in press; Hsu, 1990). In contrast, individuals with anorexia nervosa (which literally means a “nervous loss of appetite”— an incorrect definition because appetite often remains healthy) differ in one important way from individuals with bulimia. They are so successful at losing weight that they put their lives in considerable danger. Both anorexia and bulimia are characterized by a morbid fear of gaining weight and losing control overeating. The major difference seems to be whether the individual is successful at losing weight. People with anorexia are proud of both their diets and their extraordinary control. People with bulimia are ashamed of both their eating issues and their lack of control (Brownell & Fairburn, 1995). Consider the case of Julie.

Julie was 17 years old when she first came for help. She looked emaciated and unwell. Eighteen months earlier she had been overweight, weighing 140 pounds at 5 feet 1 inch. Her mother, a well-meaning but over-bearing and demanding woman, nagged Julie incessantly about her appearance. Her friends were kinder but no less relentless. Julie, who had never had a date, was told by a friend she was cute and would have no trouble getting dates if she lost some weight. So she did! After many previous unsuccessful attempts, she was determined to succeed this time.

After several weeks on a strict diet, Julie noticed she was losing weight. She felt a control and mastery that she had never known before. It wasn’t long before she received positive comments, not only from her friends but also from her mother. Julie began to feel good about herself. The difficulty was that she was losing weight too fast. She stopped menstruating. But now nothing could stop her from dieting. By the time she reached our clinic, she weighed 75 pounds. Still, Julie did not initially seek treatment for her eating behavior. Rather, she had developed numbness in her left lower leg and a left foot drop—an inability to lift up the front part of the foot—that a neurologist determined was caused by peritoneal nerve paralysis believed to be related to inadequate nutrition. The neurologist referred her to our clinic.

Like most people with anorexia, Julie said she probably should put on a little weight, but she didn’t mean it. She thought she looked fine, but she had “lost all taste for food,” a report that may not have been true because most people with anorexia crave food at least some of the time but control their cravings. Nevertheless, she was participating in most of her usual activities and continued to do extremely well in school and in her extracurricular pursuits. Her parents were happy to buy her most of the workout videotapes available, and she began doing one every day, and then two. When her parents suggested she was exercising enough, perhaps too much, she worked out when no one was around. After every meal, she exercised with a workout tape until, in her mind, she burned up all the calories she had just taken in.

Clinical Description

Anorexia nervosa is less common than bulimia, but there is a great deal of overlap. For example, many individuals with bulimia have a history of anorexia; that is, they once used fasting to reduce their body weight below desirable levels (Fairburn & Cooper, in press; Fairburn, Welch, et al., 1997). Although decreased body weight is the most notable fea- ture of anorexia nervosa, it is not the core of the disorder. Many people lose weight because of a medical condition, but people with anorexia have an intense fear of obesity and relentlessly pursue thinness (Fairburn & Cooper, in press; Russell, 2009). As with Julie, the disorder most com- monly begins in an adolescent who is overweight or who perceives herself to be. She then starts a diet that escalates into an obsessive preoccupation with being thin. As we noted, severe, almost punishing exercise is common (Davis et al., 1997; Russell, 2009). Dramatic weight loss is achieved through severe caloric restriction or by combining caloric restriction and purging.

DSM-5 specifies two subtypes of anorexia nervosa. In the restricting type, individuals diet to limit calorie intake; in the binge-eating–purging type, they rely on purging. Unlike indi- viduals with bulimia, binge-eating–purging anorexics binge on relatively small amounts of food and purge more consis- tently, in some cases each time they eat. Approximately half the individuals who meet criteria for anorexia engage in binge eating and purging (Fairburn & Cooper, in press). Prospective data collected over 8 years on 136 individuals with anorexia reveal few differences between these two subtypes on severity of symptoms or personality (Eddy et al., 2002). At that time, fully 62% of the restricting subtype had begun bingeing or purging. Thus, subtyping may not be useful in predicting the future course of the disorder but rather may reflect a certain phase or stage of anorexia, a finding confirmed in a more recent study (Eddy et al., 2008). For this reason, DSM-5 criteria specify that subtyp- ing refer only to the last 3 months (Peat, Mitchell, Hoek, & Wonderlich, 2009).

Individuals with anorexia are never satisfied with their weight loss. Staying the same weight from one day to the next or gaining any weight is likely to cause intense panic, anxiety, and depression. Only continued weight loss every day for weeks on end is satisfactory. Although DSM-5 crite- ria specify only “significantly low” body weight 15% below that expected, the average is approximately 25% to 30% below normal by the time treatment is sought (Hsu, 1990). Another key criterion of anorexia is a marked disturbance in body image. When Julie looked at herself in the mirror, she saw something different from what others saw. They saw an emaciated, sickly, frail girl in the throes of semistar- vation. Julie saw a girl who still needed to lose at least a few pounds from some parts of her body. After seeing numerous doctors, people like Julie become good at mouthing what others expect to hear. They may agree they are underweight and need to gain a few pounds— but they do not really believe it themselves. Question fur- ther and they will tell you the girl in the mirror is fat. There- fore, individuals with anorexia seldom seek treatment on their own. Usually pressure from somebody in the family leads to the initial visit (Agras, 1987; Fairburn & Cooper, in press), as in Julie’s case. Perhaps as a demonstration of ab- solute control over their eating, some individuals with an- orexia show increased interest in cooking and food. Some have become expert chefs, preparing all food for the family. Others hoard food in their rooms, looking at it occasionally.

Medical Consequence

One common medical complication of anorexia nervosa is cessation of menstruation (amenorrhea), which also occurs relatively often in bulimia (Crow, Thuras, Keel, & Mitchell, 2002). This feature can be an objective physical index of the degree of food restriction but is inconsistent because it does not occur in all cases (Franko et al., 2004). Because of this inconsistency, amenorrhea was dropped as a diagnostic criterion in DSM-5 (Attia & Roberto, 2009; Fairburn & Cooper, in press). Other medical signs and symptoms of anorexia include dry skin, brittle hair or nails, and sensitivity to or intolerance of cold temperatures. Also, it is relatively common to see lanugo, downy hair on the limbs and cheeks. Cardiovascular problems, such as chronically low blood pressure and heart rate, can also result. If vomiting is part of the anorexia, electrolyte imbalance and resulting cardiac and kidney problems can result, as in bulimia (Mehler et al., 2010).

DSM disorder Criteria summary

Features of anorexia nervosa include the following: 

1. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health  
2. Intense fear of gaining weight, or persistent behavior that interferes with weight gain, even though at a significantly low weight  
3. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight