Case Study #7
Miranda Richeson, a 16-year-old girl, was referred to our eating disorders clinic for assessment and inpatient treatment. Two days ago, Miranda had passed out during physical education class, apparently from dehydration. The hospital report indicated that Miranda was significantly underweight compared to girls her height and age, lacked sufficient hydration, and had an electrolyte imbalance. After she was medically stable, they released Miranda to her mother’s supervision and set up an intake appointment at our clinic.
Miranda presented as an extremely attractive, well-kempt girl. Perhaps her most striking features were her height (5’ 8’’) and stylish clothes that hung on her frame. Although Miranda reported her mood as “fine,” her general disposition seemed to be one of irritability. She resented being questioned by the psychologist. Miranda tended to answer questions using curt, one- or two-word utterances with her eyes fixated on some unseen object on the floor. Occasionally, she glanced at the psychologist, narrowing her eyes with a mixture of scorn and contempt. Her speech suggested above-average intelligence and ample vocabulary, supporting her mother’s report that she was an honors student. Thought contact focused largely on her desire to leave the treatment facility and return home, feelings of anger toward her mother who insisted that she receive treatment, and preoccupation with friends “back home.” When asked specifically about her weight, Miranda reported a preoccupation with her appearance and a desire for perfection. Her insight was poor; although Miranda recognized the need for medical treatment after she passed out during school, she said inpatient treatment was “a big waste of time and money.” Nevertheless, Miranda agreed to a “trial run” at the facility for 2 weeks.
Miranda eventually admitted to a history or bingeing and purging beginning approximately two years ago, when she was 13. At that time, she had moved from her local public junior high school to a new, private college preparatory school near her mother’s workplace in the city. Although Miranda was an excellent student and had many friends at her old school, she initially had difficulty performing well academically and fitting in socially.
Miranda began dieting in order to lose weight. Although she was never overweight, she often felt guilty when she would indulge in forbidden foods such as pizza, ice cream, and chocolate. Unfortunately, Miranda lacked the willpower to sustain her diets for long. After breaking a diet, she would give in to despair, indulge, and regret her weakness later. Several of her new friends introduced her to purging as a mean to avoid weight gain. Miranda soon learned that purging not only allowed her to avoid gaining weight, it also allowed her to reduce feelings of guilt for occasionally indulging in her favorite foods. Eventually, she developed a pattern of bingeing and purging that occurred several times per week. She felt out of control, emotionally vulnerable, and guilty for hiding her bingeing and purging from her family.
Miranda’s parents knew Miranda had an eating problem, but they never raised their concerns with her. Mrs. Richeson had a history of bulimia beginning in college. “I could see myself in Miranda,” she said. “All of the insecurity, the need for perfection, the lack of control. I felt that way for years. Some of her eating habits are probably my fault. Before I got help, I used to always diet and was obsessed with calories. It probably rubbed off on Miranda.”
Please answer the following questions:
1. What DSM-5 disorder best describes her behavior?
2. How might a clinician differentiate between the various eating disorders?
3. Identify at least two other health-related problems and two other psychological disorders that Miranda is at higher risk for experiencing because of her maladaptive eating behavior.
4. Take one theory of the eating disorder that you believe Miranda has and explain how she might have developed this disorder from that viewpoint.
5. There seems to be a growing consensus that ultra-thin media images are not healthy for young viewers. If this is true, why is it so difficult to change what is presented in the media?
