CASE STUDY THREE

Joan was a 38-year-old woman with a good job and family life. She lived with her second
husband, Mitch; her 16-year-old son, Charlie, from her first marriage; and her husband’s 18-year-
old daughter from a previous marriage. Joan was employed as a secretary at a university, and Mitch
was a temporary federal employee. Joan was 5'3" and weighed approximately 125 pounds.
Although she was concerned about her weight, her current attitudes and behaviors were much more
reasonable than they had been a few years earlier, when she had been diagnosed with anorexia
nervosa. Joan had struggled with a serious eating disorder from the ages of 29 to 34. She was
eventually hospitalized for 30 days. The treatment she received during that hospital stay had finally
helped her overcome her eating problems. Four years later, her condition continued to be much
improved.

Social History

Joan was born in a suburb on the outskirts of a large northeastern city. Her one brother was
2 years younger. Her father worked as a supervisor for an aircraft subcontractor. Joan’s mother
stayed at home while the children were young and then worked part time for a number of years as
a waitress and bookkeeper. Both parents were of average weight.

Joan’s early childhood was ordinary. She was an above-average student and enjoyed school.
She and her brother bickered, but their disagreements did not extend beyond the usual sibling
rivalry. Her family lived in a large neighborhood filled with lots of children. Joan was somewhat
overweight during elementary school. She had high personal standards and strove to be a perfect
child. She always did what was right and conformed completely to the wishes of her parents.

When Joan was 14 and entering the ninth grade, tragedy struck her family and forever
changed her home life. She and her 12-year-old brother were home while her parents were at work.
Although her brother was too old to require babysitting, she was supposed to keep an eye on him.
Joan had a friend over, and the two girls were upstairs in her room. Joan heard some loud noise
outside and looked out the window. She saw her brother lying dead in the road. He had been run
over by a car. Although the feeling became less intense as years passed, Joan continued to feel
guilty about her brother’s death well into adulthood.
 After the accident, Joan’s parents changed. They became extremely overprotective, and
Joan felt as if she “had a leash on all of the time.” From age 14 on, she no longer had a normal
childhood. She could not hang out with friends, be away from the house for long periods of time,
or go out in cars. Her parents wanted to know where she was and what she was doing, and they set
a strict curfew. Joan knew that if she were late, her parents would worry, so she always tried to be
home early. She made a special effort to do exactly as she was told. Joan did not go out much
because she felt the need to stay near her parents so that they would know that she was alive and
well.

The rest of high school was unremarkable. Joan earned reasonably good grades and got
along well with the other students. During the summer after her brother’s death, when Joan was
15, she met and began to date a boy who was 2 years older than she. Joan’s parents were initially
unhappy with this relationship, in part because Randy owned a car, and they didn’t want her to
ride around with him. Joan had to meet Randy secretly for the first few months. As her parents got
to know him better, they grew to like him, and the young couple no longer had to sneak around.
During this time, Joan continued to feel guilty when she was in cars because she was reminded of
her brother’s death. She frequently stayed home because she knew that her parents would suffer
horribly if anything happened to her.

After high school, Joan attended a two-year business school and became engaged to Randy.
The couple was married after Joan graduated. She was 19 years old as she began her marriage and
her first full-time job as a secretary in a medical office. Prior to this time, Joan’s father had never
allowed her to hold even a part-time job. He insisted on providing for all of her needs.

Although this marriage lasted legally for 6 years, it became clear within 9 months that the
relationship was in trouble. Joan cared for her husband, but she did not love him. She soon realized
that she had used Randy as an escape route from her parents’ home. She felt as if she had simply
jumped from one dependent relationship into another. When she had been at home, her parents
provided everything. Now Randy was taking care of her. Joan worried that she did not know how
to take care of herself. Despite these negative feelings, Joan and Randy tried to make the marriage
work. They bought a home 1 year after their wedding. Two years later, Joan accidentally became
pregnant.
 Joan gained 80 pounds during the course of her pregnancy. When Charlie was born, she
weighed 200 pounds. Over the next few months, Joan found it difficult to lose weight but
eventually got down to 140 pounds. Although it was hard for her to adjust to this weight gain, she
did not try to change her weight because it felt “safe” to her. Joan and Randy were legally separated
2 years after Charlie was born. They continued to see each other occasionally and sought marital
counseling at various times during the next couple of years. They could not reconcile their
differences, however, and Randy eventually moved to another state. The divorce was finalized
when Joan was 25 years old.

Shortly after she and Randy were separated, Joan stopped working and went on welfare.
With financial help from her father, she managed to keep up the mortgage payments on her house
for several months. She and Charlie continued to live on their own, but Joan fell further into debt
while she and Randy tried to work things out. She was forced to sell her home when the divorce
became final. Although she came to regret the decision, she moved back into her parents’ home.
Living there was stressful for Joan. Although she was 25 years old, she felt like a child. Her parents
once again took care of Joan, and now they also provided for her son. In this submissive role, Joan
started to feel more like Charlie’s older sister than his mother.

Joan lost some weight after she and Charlie were involved in a serious car accident, 6
months after moving back to live with her parents. Charlie was not hurt, but Joan’s left hip and leg
were broken. She spent a month in the hospital. She was immobile when she came home, and her
mother had to take even greater care of her and Charlie. Joan needed repeated surgery on her knee,
as well as extensive physical therapy, and she had to relearn how to walk. During her recovery,
she had little appetite, was nauseated, and did not eat much, but she was not consciously dieting.
Joan’s weight went down to about 110 pounds, which she considered to be a reasonable weight.

While she was recovering from her injuries, Joan became involved with a man named Jack,
whom she met in one of the hospital’s rehabilitation programs. She was now 27 years old. To
escape her parents’ overly protective home, she decided to take Charlie and move in with Jack.
This move actually created more problems than it solved, in large part because Jack had a serious
problem with alcohol. Joan had never been a heavy drinker. In the beginning of their relationship,
she drank only during the weekend. After she started living with Jack, drinking became a daily
activity. Much of their relationship and socializing revolved around alcohol. On the average
weekday, Joan consumed a couple of beers and some wine, or perhaps a glass or two of bourbon.
On weekends, she drank considerably more. Charlie was increasingly left at day-care centers and
with babysitters. Joan eventually recognized the destructive nature of this relationship and ended
it after a few months. She reluctantly moved back into her parents’ home. After leaving Jack, Joan
stopped drinking, except occasionally when she was out socializing.

Onset of the Disorder

After breaking up with Jack, Joan lived with her parents for 2 more years. When she was 29 years
old, almost 3 years after her accident, Joan returned to the hospital for more surgery on her leg.
After being discharged, she began the diet that set the stage for 5 years of serious eating problems
and nearly destroyed her life. Joan had gained a few pounds while she was drinking heavily and
now weighed 125 pounds. She was concerned that she would start to gain more weight while she
was inactive, recovering from surgery.

Joan’s diet was strict from the beginning: She measured and weighed all her food. Within a year,
she weighed less than 100 pounds. Her food intake was severely restricted. During the day, she
consumed only coffee with skim milk and an artificial sweetener. Occasionally, she ate a piece of
fruit or a bran muffin. When she and Charlie ate dinner with her parents, Joan took a normal
amount of food on her plate but played with it rather than eating it. After dinner, she usually
excused herself to go to the bathroom where she took laxatives in an effort to get rid of what little
food she had eaten. Joan hardly ate any meats, breads, or starches. She preferred fruits and
vegetables because they consist mainly of water and fiber. Although she did not allow herself to
eat, Joan still felt hungry; in fact, she was starving most of the time. She thought about food
constantly, spent all her time reading recipe and health books, and cooked elaborate meals for the
family.

Although she weighed less than 100 pounds, Joan still felt overweight and believed that
she would look better if she lost more weight. She had an overwhelming fear of getting fat because
she believed that gaining weight would mean that she was not perfect. She tried to be a model
young adult and struggled to be what she imagined everybody else wanted. She gave little thought
to what she would want for herself. She felt like everything in her life was out of her control except
for her weight and body. The demonstration of strict self-control over eating was a source of pride
and accomplishment to Joan.
 As she lost weight, Joan experienced several of the physical effects that accompany
starvation. Her periods stopped; she had problems with her liver; her skin became dry and lost its
elasticity; her hair was no longer healthy; and she would often get dizzy when she stood up. At
this time, Joan was working as a secretary in a university medical school. Some of her coworkers
noticed the drastic change in her appearance and became concerned. An internist in her department
recognized her symptoms as those of anorexia nervosa and tried to get Joan to seek help. Joan
agreed to attend an eating disorders support group and even went to some outpatient therapy
sessions, mostly in an attempt to appease her friends. She also consulted a dietician at the university
hospital and worked on an eating plan. There were moments when Joan considered the possibility
that her behavior was not normal, but most of the time, she viewed her ability to control her weight
and appetite as a sign of strength. When she was transferred to a different department within the
university, she left therapy and returned to her restrictive dieting.

Joan’s parents were also acutely aware of their daughter’s abnormal patterns of eating and
her excessive weight loss. They were extremely worried about her health. The more they tried to
talk to her about this issue, the more resistant she became to their pleadings. Arguments about
eating became frequent, and the level of tension in the home escalated dramatically.

A year and a half after the onset of her eating disorder, Joan moved with Charlie into her
own apartment. Her decision was prompted in large part by the aversive nature of her interactions
with her parents. She continued to diet and now weighed about 90 pounds. Charlie’s diet had also
become restricted, in part because there was very little food in the house. Joan could hardly bring
herself to go to the grocery store. Once there, she made an effort to behave normally and went
through the store putting food into her shopping cart. When it came time to pay, however, she
would not actually buy anything. She believed that food was bad and that it was a waste of money.
Instead of purchasing anything, she would wander up and down the aisles, eating much of what
was in her shopping cart. Her reasoning was that it made no sense to pay for food that could be
eaten while you were in the store.

This type of binge eating also happened whenever she did manage to buy something. In
one afternoon, she would occasionally eat two dozen donuts, a five-pound box of candy, and some
ice cream. After this, Joan took 20 to 30 laxatives to rid herself of the food. At times she made
herself vomit by sticking a toothbrush down her throat, but she preferred to take laxatives. Some
weeks she did not binge at all, others once or twice. On the days in between binges, she ate only a
little fruit and drank some liquids.

Joan’s eating problems persisted for the next 5 years. Her weight fluctuated between 90
and 105 pounds during this period. At times she ate more normally, but then she would eat
practically nothing for months. She tried therapy, though she was not seriously or consistently
committed to changing her behavior. Her life seemed like a roller coaster, as she cycled back and
forth between relatively healthy patterns of eating, severe restricting, and bingeing and purging.
Most of her diet consisted of liquids such as diet soda, water, and coffee. Occasionally she drank
beer, seeking the numbing effect it had on her appetite. She was pleased with her weight when it
was very low, but she felt horrible physically. She was weak most of the time, and other people
constantly told her that she was too thin. In Joan’s mind, however, she was still too heavy.

When she was 32 years old, almost 3 years after the onset of her eating problems, Joan met
Mitch at a church group she was attending. They began to date on a regular basis. Mitch was
different from all of the other men in Joan’s past. He genuinely cared about her, and he also liked
her son. Her weight was at one of its peaks when they met, somewhere between 100 and 105
pounds, so her eating problems were not immediately obvious to him.

Unfortunately, soon after they began dating, Joan once again began to restrict her eating,
and her weight quickly dropped to another low point. Mitch noticed the obvious change in her
behavior and appearance. His reaction was sympathetic. As their relationship grew stronger, Mitch
seemed to help Joan feel differently about herself. They talked frequently about her weight and
how little she ate. Mitch expressed great concern about her health, pleading gently with her to gain
weight, but her restrictive patterns of eating persisted despite the other psychological benefits that
accompanied the development of this relationship. One year after she started dating Mitch, Joan
needed major abdominal surgery to remove two cysts from her small intestine. During the
operation, the surgeon saw that she had other problems and reconstructed her entire bowel system.
When she left the hospital, Joan’s weight had fallen to 85 pounds. She ate reasonably well at first,
trying to regain her strength. After 2 months, she was feeling better, returned to work, and went
back on a restrictive diet. This time, however, Mitch and her friends would not let her continue
this prolonged pattern of self-imposed starvation.