A Case Study of Anorexia

Nervosa
Lucy Howarth

Anne-Marie is a 15-year-old girl who was admitted to a General Teaching

Hospital because of prolonged weight loss and refusal to eat. On admission she
weighed 35 kg (5.5 st), which at a height of 1.55 m meant that she was well
below the third centile on Height and Weight standard charts. When I asked
Anne-Marie whether she had noticed any symptoms in association with her
weight loss she said that her skin had become dry and flaky, her hair was falling
out in clumps, she felt that her stomach was swollen and bloated, and she felt
very depressed.
Anne-Marie began dieting 8 months previously because she felt ‘fat
compared to “thin, cliquey bitches” at school’. She began a period of
bingeing on chocolate and large amounts of food, and then vomited and took
laxatives to purge herself. During a holiday taken with her ‘skinny’ cousin she
began to exercise heavily and stopped feeling hungry despite being on a strict
diet. At this point she weighed 51 kg (8 st) and set a target weight of 45 kg
(7 st), not an unreasonable weight for someone of her height. She said that her
mother thought that 45 kg was too little and wanted to ‘fatten her up’ to 48 kg
(7.5 st). At this point it became a battle of wits with her mother and Anne-
Marie became increasingly obsessed with not putting any weight on. She said
that perhaps she was using her weight to rebel against her mother for the first
time. Her mother could not cope with the situation and Anne-Marie moved in
with her father. She had to be collected from school because she was too weak
to walk home. Her periods, which had started 1 year previously, stopped 5
months before admission. Her breasts disappeared and her skin became bad. At
the point of admission Anne-Marie was consuming one weetabix per day, cups
of tea with 1/2 teaspoon of sugar and cans of diet coke. She was diagnosed as
having anorexia nervosa.
When I asked her why she had stopped eating, she said that the only time
she has had any say in her life has been recently. For example for the first time
she can decide where she wants to live. When I went to see her she had already

CCC 1072-+133/96/01005548 European Eating Disorders Review

8 1996 by John Wiley & Sons, Ltd. and Eating Disorders Association 4(1). 55-52 (1996)
L. Howarth

been an inpatient for 4 weeks, had lost half a stone and felt very depressed
claiming she had ‘nothing to live for’.
In order fully to understand why Anne-Marie was particularly susceptible to
developing anorexia nervosa, it is necessary to move away from her current
eating behaviour and focus on her life history.
Her mother and father separated when Anne-Marie was four. Her mother,
who is a health professional remarried a man whom Anne-Marie finds difficult
to relate to. Her father retired from dentistry following a nervous breakdown:
he is an alcoholic and when Anne-Marie was a child an injunction was taken
out to prevent her father from seeing her. She has two older sisters, aged 26 and
23, who live together in London.
Her earliest memory is of her father being too drunk to pick her up from an
ice-skating rink and making a scene about her mother going out dancing
without him. At the age of four Anne-Marie was sent to boarding school. She
had not realized it was a boarding school until the matron told her that her
mother was not coming to pick her up. Anne-Marie was the smallest girl at the
school, was ‘cute’ and was the matron’s favourite. She was bullied by the other
girls who teased her about being unwanted. She said that she did not want to
fight back because she ‘never had the guts’. She was often taken into the woods
by the other girls and left there.
She had very little contact with her parents and was sent away to camps
during the holidays. When her mother visited her at school she always seemed
to be in a rush, brought her presents and then disappeared again.
By the age of six she was achieving high academic standards and was
accelerated a year at school. When she was eight her mother moved to Spain
and came back at weekends to see her step-dad (not her). She felt as though at
this time she had to live according to her mother’s convenience and felt as
though ‘she pulled the strings’.
Because of her academic achievements Anne-Marie’s mother moved her to a
different school which was run in a very military style. She hated the school,
did not have any friends and felt very unhappy there. She said that her mother
used to make her father, who had reappeared on the scene, take her to the bus
stop so that she would blame him and not her mother for sending her to that
school. At the age of nine she began to cry every day ‘for no reason’ and felt
continuously lonely. She felt as though people were ignoring her all the time.
She began to suffer from splitting headaches associated with worry and was
labelled a ‘whinger’. She gradually made friends but felt very unsure whether
they liked her or not.
Aged 11 Anne-Marie moved to an independent day school for girls, and her
mother moved nearby. During this period of her life she was chopping and
changing between living with her mother and her father. She began crying less
at the new school and only did when she was on her own or felt that she was
being ignored. At 14 she spent a term at the local state school where she was

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~~~ ~~

beaten up and bullied for having a posh voice. She was so unhappy that her
mother moved her back to the girls’ school. However her old friends had
changed and her two best friends had become ‘giggly tarts’ and were sleeping
with boys. People at school told her that she was fat and she felt fat when she
could not get into her size 8 jeans anymore.
At this point in time multiple and combined stressors had left Anne-Marie
unable to cope, yet with what seemed to her a perfect solution to all her
problems. She felt in huge conflict over what she wanted with respect to her
parents: during her childhood she had not had any parental input on a day-to-
day basis but now all of a sudden she had become an adolescent and was also
having to establish a relationship with both her parents. She said that she felt
less in control of her own life than she ever had been previously. However
Anne-Marie said she felt that she had not finished being a child yet. She felt
that her mother used to be proud of her when she was a child because of her
intelligence, but that she ‘couldn’t do it any more’. She was also in conflict over
her own sexuality: she did not feel ready to enter into sexual relations in the
same way as her friends, yet she felt herself a failure if the boys at school did not
fancy her and felt that unless she was thin she would never have a boyfriend.
It seems that taking complete control over what she eats has been her way of
coping with her unhappiness. When I asked her what made her feel happy she
said, ‘losing weight’. She still did not feel happy with her body and felt that her
arms were too fat and her stomach bloated, she wanted to be taller and to have
hair that was not straight. It was as if she had turned all her unhappiness in on
herself and set about improving her life by changing her body. I wonder if
perhaps the initial diet would have progressed to such extreme lengths if weight
loss had not had such a desirable effect: her mother paid her lots of attention
and stopped ‘ignoring’ her, people at school stopped calling her fat and she
became emotionally more powerful than she had ever been.
Anne-Marie was in isolation when I saw her and all her privileges had been
taken away including social contact, she was on bed rest and ate meals
(hospital food) under supervision, she was not allowed to go to the toilet and
instead had to use a bed pan within her cubicle. All of these provisions were in
an attempt to prevent further weight loss. During Anne-Marie’s stay in hospital
she did not receive counselling or treatment, apparently because she was to be
transferred to another treatment centre for this. A cognitive-behavioural
model of treatment that was tried on Anne-Marie was unsuccessful, that is she
continued to lose weight.

POSSIBLE ALTERNATIVE TO THE BEHAVIOURAL MODEL

In 1955 George Kelly developed the theory of personal constructs as a reaction

to more traditional psychological approaches. In 1950s U.S.A., behaviourism

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L. Howarth

Table 1. Personal Construct Chart

Ratine
Not at all Totally Positive or
Construct* 0 1 2 3 4 5 6 7 negative construct
-
Worries about being t Negative
liked
Expressing thoughts t Negative
Planning future i t Negative
Self doubt t t Negative
Take criticism t t Negative
Perseverance t t Negative
Endurance t t Negative
Powehl $ t Negative
Comfortable with $ t Negative
emotions
Speak your mind t t Negative
Bottle up anger t Negative
Calm j: t Positive
Confident t t Positive
Care about hurting t t Positive
other’s feelings
Afraid of rejection t t Negative
Feminine $ t Positive
Ambitions t t Negative
Sociable t$ Positive

*These ConstructS were taken from Button, 1993.

$Indicate ratings for ‘Myself-Now’.
tIndicate ratings for ‘My aspirations for the future’.

was the predominant psychological model, with people viewed as adopting

certain behaviours in response to stimuli, that is as passive victims of
reinforcement and conditioning. Behavioural therapy emerged as a technique
for influencing a person’s learning experience. Eric Button (1993) points out
that both the behavioural approach, and the more fashionable and co-existing
psychoanalytic approach, view the individual as a victim in need of expert
help. Kelly’s work instead encapsulates the views and aspirations of the
individual: ‘We assume that all present interpretations of the universe are
subject to revision or replacement’. T h e idea behind this kind of therapeutic
approach is that people, such as Anne-Marie, who have anorexia nervosa
become so introspective and trapped by tunnel vision, focused on themselves as
fat, that they lose sight of their own ability to change what it is about
themselves that is making them unhappy. Button suggests that perhaps it is the
role of the therapist to challenge a person’s self-construction and guide them in
identifying and overcoming characteristics which they would like to change.

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While I was permitted to spend time with Anne-Marie I used the approach
suggested by personal construct theory, and asked her to compile a personal
characteristics chart of aspects of her personality that she felt were important.
She evaluated what she was like now by rating her characteristics between 0
and 7 with 0 being ‘not at all’ and 7 being ‘totally’,and then considered in what
ways she would like to change. This exercise showed her to have a very low
self-esteem and to be highly critical of herself, although some of her opinions
were slightly contradictory, for example she felt fairly confident while at the
same time often doubts herself. Somewhat revealingly one of the categories in
which she was closest to her ideal was femininity4espite the fact that she had
stopped menstruating and had lost her previously developed bust. The only
category where she felt that she was ideal was how sociable she is-a facet that
has run through her life is her desire to please everyone around her and get on
well with everyone. When I asked her whether she got on well with her parents
she said that she did and would usually smile and do anything they told her.
It is possible that by becoming anorexic Anne-Marie had subconsciously
addressed her construction of her self and through her illness had already
become (for example) more powerful, and more able to speak her own mind,
and certainly had proved her ability to persevere as well as her powers of
endurance. Perhaps by looking at a person’s evaluation of themself it may be
possible to understand better what a person is trying to achieve by starving
themself. By offering alternative methods of self improvement, it may be that
the deep-rooted desire of anorexic people to remain anorexic could be
removed.
Perhaps in order to develop more successful treatment methods we need to
consider what processes are responsible for the development of anorexia
nervosa. One of the most controversial issues is whether anorexia nervosa is in
fact a psychiatric illness with an organic cause.

IS ANOREXIA A SUBGROUP OF ONE

OF THE OTHER PSYCHIATRIC CONDITIONS?

Morton (cited in Palazzoli, 1974) first described a woman suffering from

anorexia nervosa towards the end of the 17th century. Subsequently many
people have tried to class it as a subgroup of a variety of other psychiatric
conditions. In the 19th century Gull and Lasegue maintained that it was a form
of hysteria (cited in Button, 1993).In 1938 Nicolle put forward the notion that
it was simply a manifestation of schizophrenia (Nicolle, 1938). Research
continues to attempt to prove that anorexia nervosa is an obsessivexompulsive
disorder (Mills and Medlicott, 1992;Holden, 1990; Hsu etal. 1990).Compulsive
rituals such as hoarding food and obsessive ruminations such as preoccupation
with thinness do seem to be related to eating disorders. Anne-Marie talked about

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a project she was doing at school about food and showed me several books on food
that she had in her room. From reading her medical notes I learned that her
mother had reported her to have been stealing food and hiding it in her bedroom.
Neurobiological findings do suggest that anorexia nervosa and obsessive-
compulsive disorder may share an underlying disturbance in serotonergic
functioning. Holden points out however that obessional personality traits are
brought out by starvation. Perhaps then, classing anorexia nervosa as an
obsessive-compulsive condition is an apt description of the way a woman might
behave after she has developed anorexic tendencies, but to suggest that there is a
premormid personality type that makes individuals likely to develop anorexia
nervosa somewhat simplifies the situation. It may be helpful to class anorexia
nervosa as a variant of obsessive-compulsive disorder in terms of drug therapy.
Serotonergic agents can be as effective in the treatment of anorexia nervosa as
they are in obsessive-compulsive disorder. While there are similarities with
various psychiatric disorders, anorexia nervosa remains a bizarre psychological
process with multiple causative factors. Almost without exception the
psychological theories so far developed to account for anorexia nervosa have
failed to explain the population which the disease affects, that is largely female,
teenage to mid-20s, high achieving, attractive persons. Anne-Marie clearly had
suffered from a very troubled family background and had had an unhappy life, but
the question is, why should her psychological instability manifest itself in this
way?Why was it that her friends teasing her about being fat was the final straw in
producing a psychological illness which for 5 per cent of sufferers ends in death
and for 50 per cent is never fully cured? (Treasure and Thompson, 1988).

ARE THE CULTURAL DEMANDS THAT ARE

PLACED ON WOMEN RELATED TO THE
DEVELOPMENT OF ANOREXIA NERVOSA?

Feminist historian Elaine Showalter describes madness as, ‘one of the wrongs of
women, madness as the essential feminine nature unveiling itself before
scientific male rationality’ and ‘a desperate communication of the powerless’
(Showalter, 1987). Showalter points to the decades 1870 to 1910, when
middle-class women were beginning to break through into higher education
and gain access to professional careers, as a time when female disorders of
anorexia nervosa, hysteria and neurasthenia became epidemic. Darwinian and
eugenic influences encouraged ‘suitable’ feminine behaviour and raised
opposition to women’s efforts to change the constraints of their lives.
Doctors warned that changes in the female sphere may ‘lead to sickness,
sterility and race suicide’ (cited in Showalter, 1987). It has been suggested that
in contemporary society women may be perceived as a threat to the
traditionally male role as supremos of culture, politics and finance, and that

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in order to thwart this threat women are treated as sex objects and caused to
link self-worth with their body image. It is fashionable at the moment for
women to dress in short skirts and long white socks rather like school uniform.
Chernin (1983) suggests that, ‘In this age of feminist assertion men are drawn
to women of childish body and mind because there is something less disturbing
about the vulnerability and helplessness of a small child’.
Chris Shilling (1993) points out that in the affluent West there is a tendency
to view the body as a project that should be worked at and accomplished as part
of an individual’s self-identity. Corsets and flowing dresses have been replaced
by clothes that leave little to the imagination and consequently there is a great
deal of social pressure placed on individuals to be conscious and actively
concerned about the management of their bodies. It has been discovered that
normal and underweight women tend to overestimate their body size whereas
normal or underweight men are very accurate when it comes to assessing their
body size (Dolan, 1987). In contrast to a Western cultural view that women
should be thin to be desirable, in African countries such as the Gambia fat
women are more sought after because their size is seen as a reflection of their
good health and wealthy status (Furnham and Bagume, 1994).

THE ROLE OF THE MEDIA

Studies have shown there to be a direct link between the media portrayal of
idealized female bodies and an increase in the individual’s dissatisfaction with
body size that heralds the beginnings of an eating disorder (Hamilton and
Waller, 1993). What is more, analysis of a longitudinal sample indicates that
the crucial interaction between the developmental stressors of adolescence and
a slender body results in fairly immediate and significant increases in disturbed
eating. It is possible that an alternate use for cognitive-behavioural therapy
could be to target women’s responses to media images of excessively thin
women. We also can hope that society’s idea of what constitutes femininity will
move away from waif like figures with their almost boyish physiques, who
model for the prominent, gay, male fashion designers and instead celebrate
womanly curves. Perhaps images of successful powerful women will become less
synonymous with being a slender size 8 and the gap between fantasy and reality
will be bridged.

CONCLUSION
Perhaps, as in this case, the psychological processes that lead to the
development of anorexia nervosa are determined in part by the individuals’s
previous experiences and their accumulated self-esteem, and in parz by external

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pressures from society. There is a need for more research to be done in the
psychology of anorexia nervosa because currently there are no theories that
account for its aetiology. In order to offer any sort of treatment it is vital that
there is a greater understanding amongst the medical profession and that we
move away from trying to tag anorexia nervosa onto other psychiatric illnesses
that can be treated by drugs or the crude use of behaviour therapy. It may be
beneficial for the doctor’s role to become more focused on helping patients to
develop an increase in their self-esteem by methods such as the personal
construct approach used above. Treatment for people with anorexia nervosa
desperately needs evaluating so that girls like Anne-Marie do not spend 1
month as a hospital inpatient and end their stay 1/2 st lighter and much more
depressed.

REFERENCES
BUTTON, E. (1993). Eating Disurders-Personal Construct Therapy and Change. Chichester:
Wiley.
CHERNIN, K. (1983). Woman Sire-The Tyrany of Sknckmess. London: The Women’s Press.
DOLAN, B. M. (1987). Body image distortion in non-eating disordered women and men. Journal
of Pyschosomatic Research, 31, 513-520.
FURNHAM, A and Bagume, (1994). Cross cultural differences in the evaluation of male and
female body shapes. InternationalJournal of Eating Disorders. 15, 81-89.
HAMILTON, K. and Waller, G. (1993). Media influences on body size estimation in anorexia
and bulimia. British Journal of Psychiatry, 162, 837-840.
HOLDEN, N. (1990). Is anorexia nervosa an obessive-compulsive disorder? British Journal of
P~ychia~ry,157, 1-5.
HSU, L. K. G., Kaye, W. and Weltzin, T. (1993). Are the eating disorders related to obsessive.
compulsive disorder. International Journal of Psychiatry, 157, 1-5.
MILLS, I. H. and Medlicott, L. (1992). Anorexia nervosa as a compulsive behaviour disease.
Quarterly Journal of Medicine, 83, 507-522.
NICOLLE, G. (1938). A prepsychotic anorexia. Lancet, ii, 1173.
PALAZZOLI, M. (1974). Self Starvanbn: F r m the Intmpsychic to the Transpersod Approach to
Anorexia Neruosa. New York: Jason Aronson.
SHILLING, C. (1993). The Body and Social Theory. London: Sage.
SHOWALTER, E. (1987). The F m k Malady: Women, Madness and English Culture 1830-1980.
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TREASURE, J. and Thompson, P. (1988). Anorexia nervosa in childhood. British Journal of
Hospital Medicine, 40,362-369.

Lucy Howarth
Medical Student
Southampton University Medical School
Southampton General Hospital, Tremona Road
Southampton, U.K.

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