*** this is a psychology question but that was not an option to choose *** I hav
ID: 64872 • Letter: #
Question
*** this is a psychology question but that was not an option to choose ***
I have to diagnose Tracy with 2 disorders. I know 1 is bulimia, but I'm not sure if the other is some sort of depression or body dysmorphic disorder?
Tracy was a 22-year-old in college when she was referred to the group therapy program. She had entered individual psychotherapy at the student health center three months earlier, hoping that her therapist could help her deal more successfully with the stress of university life. Their sessions had focused on the development of better study skills and on issues surrounding Tracy’s low self-esteem. Although she was very bright and had managed to earn a 3.2 GPA, Tracy’s academic performance was slipping. Planning and organization were not among her strengths. She attended classes only sporadically and regularly found herself staying up all night to finish writing papers or to prepare for tests. Her depressed mood and pattern of increasing social isolation were also a source of some concern, perhaps more to her therapist than to Tracy. She lived by herself in an apartment near the campus. Relatively few activities gave her any pleasure. She had developed a small circle of both male and female friends during her two years at the university. She had gone out with several different men but had not been involved in a serious romantic relationship for almost three years. Her feelings about these dating experiences were largely ambivalent. Occasional casual sexual encounters were more a source of puzzlement than pleasure for her. She couldn’t understand why these men found her attractive. Further discussion of this issue revealed Tracy’s pervasive concern about her appearance and her strong, negative feelings about her body. She told the therapist that she had tried to lose weight for several years. It eventually became apparent that Tracy had a serious disorder. After several extended conversations with her therapist, she finally agreed to join a group while she continued her individual psychotherapy sessions. During her first meeting with the woman who ran the therapy group, Tracy was obviously selfconscious and embarrassed while describing the nature of her eating problem. She was a reserved, attractive young woman, dressed neatly in casual clothes. Her graceful, athletic build (5’6” tall and 135 lbs.) gave the impression of a person who might be more comfortable with her body than she actually was. Her muscular hips and thighs were especially upsetting to her. She thought they were ugly and said that she very much wanted to lose 15 pounds. Tracy reluctantly provided more complete descriptions of her problems with food as the conversation continued. For the past two years, she had been going on private eating binges in which she consumed very large quantities of food and then forced herself to throw up. These episodes currently happened three to four times per week. At its worst, this binge/purge cycle had occurred 8 – 10 times per week. Tracy took 4 – 6 diet pills each day in a largely unsuccessful effort to control her appetite. She hoped that the pills would prevent her binge eating, but they did not. She also took laxatives on a regular basis, usually once a day. This practice was based on her erroneous assumption that the laxatives would decrease her body’s absorption of food. Taking laxatives made Tracy feel that she was somehow losing most of the food that she consumed. Tracy’s notion of an appropriate diet bordered on the concept of starvation. She tried not to eat all day long. After skipping breakfast and lunch, she would invariably experience intense hunger pains during the afternoon. Not trusting these signals from her body, she would manage to fight them throughout the rest of the day. Tracy usually returned to her apartment around 7 or 8 o’clock at night after a hectic day of classes, meetings, and work. By that point, she would be starving. That was the point at which her binges were most likely to occur. PSY240 Case Study 3 A typical binge would begin with a trip to the nearby grocery store. Tracy would buy a whole chicken and take it home to prepare it. The process usually began with a glass of wine, which made her feel more relaxed (particularly on an empty stomach), as she sipped her wine, Tracy would bake the chicken and prepare a large batch of stuffing and mashed potatoes – almost like a Thanksgiving dinner. Then she would order two large sausage pizzas to be delivered from a local restaurant. While she was waiting for the chicken to bake and the pizzas to be delivered, she would eating cookies and potato chips while finishing her bottle of wine. Whenever she started to feel full, she would go in the bathroom and make herself throw up. This lengthy process of eating and regurgitation would continue until all the food was consumed. Tracy felt helpless and out of control during these binges, which often lasted two and sometimes as much a three hours. After the process started, it seemed to demand completion. Tracy seldom ate sitting at a table. She ate quickly, pacing about her apartment. At times she felt as if she were outside her body, watching the process unfold. She usually took the phone off the hook so that she wouldn’t be interrupted by calls from any of the few friends she still had. After purging, her mood would go from bad to worse. Tracy felt awful about herself, particularly at these moments. Her stomach hurt, but physical pain was not as debilitating as the psychological consequences of the episode. She invariably felt disgusted by her own behavior and deep ashamed of her complete inability to control her binge eating. She felt guilty both because she had eaten so much and also because she didn’t have the control that others had. Tracy had read extensively about anorexia nervosa and now told her therapist that she envied the control that these women had over their appetites. If only she could do that! She began to experience several harmful physical effects from the repeated vomiting. Her dentist noticed that the enamel began to erode on the inner surface of her front teeth. He had asked Tracy about the pattern at her last checkup. She denied any eating problems, but the concern that she detected in his voice left her feeling even more unsettled about her problem. The skin over the knuckles on her right hand was now scarred; she had put those fingers down her throat to stimulate the gag reflex when she wanted to throw up. She knew that her throat was beginning to suffer, as indicated by recurrent hoarseness and sore throats. Perhaps most alarming was the fact that she began throwing up blood on occasion, a sign that the walls of her esophagus were tearing. The wine that Tracy consumed at the outset of her binges was also a source of considerable concern and reflected a drinking problem that intensified and complicated her disorder. Tracy found it annoying that some of her friends began to criticize her drinking, but she privately shared the feeling that she ought to cut back. She often drank heavily when she went out socially with other people, and sometimes engaged in casual sexual relations that contributed to her already ample feelings of guilt, confusion and lack of control. This aspect of her interpersonal relationships seemed particularly selfdestructive. Social History: Tracy’s parents were divorced when she was two years old. Their separation was messy and painful for everyone. Her father had been awarded custody of Tracy because of her mother’s substanceuse problems and because she had abandoned the family to live with her boyfriend. The relationship PSY240 Case Study 3 didn’t last much longer than the divorce proceedings, but her mother did eventually remarry and had two additional children, a boy and a girl. Tracy grew up living with her father, who provided her with a comfortable home. Unfortunately, he was so preoccupied with his job that he spent little time with her. While she was in elementary school she was supervised by a house keeper who lived with Tracy and her father. This woman was fond of Tracy but was also rather rigid and aloof. Tracy spent most of her time alone when she returned home after school. She watched T.V. and played games until her father got home from work at 8 or 9 o’clock. She looked forward to his arrival because that was when he would spend time with her. Unfortunately, he didn’t show much interest in her life. They would fix a meal of frozen dinners, snacks, and desserts, and then sit down and watch T.V. together. When Tracy was 13 years old, her mother – who was now 36 – suddenly reappeared. She and her second family had moved back to the city in which Tracy lived. She wanted to spend time with Tracy and become friends with her. Tracy’s father was understandably opposed to this idea, but the original divorce agreements had stipulated that Tracy could see her mother on weekends. That agreement was still in effect, even though her mother had never before followed through on the plan. In fact, Tracy had always been curious about her mom and was now anxious to meet her. They agreed to meet for lunch on a couple of occasions. Tracy was initially struck by her mother’s stunning appearance. She was beautiful – still very thin and exquisitely dressed. Tracy was charmed by her mother’s warm and friendly manner as well as her physical appearance. Her mother was intrigued by Tracy’s interests, her accomplishments, and her friends. This concern was a welcome change from the indifference that her father had always shown her. Tracy and her mother began to spend more time together on weekends and holidays. She admired her mother. It was fun to have a mom who would take her out to lunch and dote on her. As they got to know each other better, however, Tracy’s mother became more intrusive and critical of Tracy’s behavior and appearance. She began to tell Tracy that it wouldn’t hurt for her to lose a few pounds. Tracy’s younger half-sister was also very thin, like her mother. She and Tracy soon found themselves competing for her mother’s attention. Like most other teenagers, Tracy was self-conscious about her body and the changes that she was going through at this time. Whatever doubts she already had about her own figure and appearance were seriously exacerbated by these competitive interactions with her mother and half-sister. Tracy was built more like her father – muscular and stocky. At her mother’s suggestion, Tracy started to experiment with various kinds of diets. Her mother recommended a sequence of diets that had worked for her. Unfortunately, nothing worked for very long when Tracy tried it. If she did manage to lose 10 lbs., she would gain it back within 3 months. Her weight fluctuated for the next few years between 120 and 145 lbs. Tracy eventually found herself spending more time moving back and forth between her mother’s and father’s home. Her patterns of eating became even more inconsistent, perhaps largely because there were different ways to eat in these different places. Her dad lived on packaged cereal, snack food, and late, precooked dinners. Her mom’s family ate carefully prepared nutritious meals that emphasized low fat foods including lots of fruits and vegetables. The latter pattern was obviously healthier, but the atmosphere at these meals frequently made Tracy uncomfortable. Her half-sister seemed to be able to eat more than Tracy without gaining weight. Her half-sister and stepfather were PSY240 Case Study 3 always given bigger servings than Tracy as her mother reminded her to watch what she ate. Whenever Tracy expressed an interest in having a light dessert, her mother would smile at her and ask, “Do you really think you should do that?” For obvious reasons, Tracy experienced a lot of negative emotional responses – guilt, shame, and anger – when she ate with her mother’s family. Like many of her peers, Tracy was rebellious as a teenager. Her father was lenient with her as she entered adolescence, allowing her to run with a crowd of wild boys and girls. Her friends were unconventional and viewed themselves as outsiders in their high school. Their group drank alcohol and smoked marijuana regularly, beginning in their early teens. Her father’s house was occasionally the site for these gatherings because he was seldom around to supervise. After smoking marijuana, Tracy and her friends would get “the munchies” and consume large quantities of snacks and desserts (such as chips and cookies, which were abundant at her father’s house). This pattern of sporadic binge eating subverted more than one of her diet plans. Her weight increased noticeably. Although some of her friends skipped classes and used drugs at school, Tracy did not. She didn’t study very much but she was smart enough to be a good student. She did feel that she was subjected to unfair criticism and scrutiny from teachers and administrators because of her friends. Her academic talents were underdeveloped as she became more alienated from the school. Tracy found her first serious boyfriend at age 16. She fell head-over-heels in love with Jerome, who was 21 years old and working as a clerk at the video store where Tracy and her friends rented movies and games. Their relationship quickly became sexual which was both exciting and anxietyprovoking for Tracy, who had not had any previous sexual experience. When Tracy’s father found out that she was dating Jerome, he became angry. He told her mother, and soon everyone was embroiled in the conflict over this new romance. Tracy felt increasingly alienated from both of her parents and from her friends, who somewhat paradoxically shared her parents’ concern about her choice of boyfriends. When Tracy was 17 years old, she dropped out of high school in her senior year and moved to southern California to be with Jerome. He had moved there three months before she decided to go. Their romance had actually faded in recent months. Her decision to leave was perhaps more motivated by the desire to avoid high school and her family than by her feelings for Jerome. After she arrived in California, Tracy realized that he no longer cared for her. She started to feel depressed when it became apparent that Jerome did not want to spend much time with her. She realized that she now had no family, no friends, and no job. One night, after she had spent an entire day sitting alone in their small apartment, Tracy told Jerome that she felt like she might be better off dead. His only response was to say, “If that’s how you feel, go ahead and kill yourself.” Tracy’s binge eating and purging evolved gradually while she was living with Jerome in California. She became more seriously depressed. She often ate snack foods to make herself feel better. Within two months, she had gained 8 more pounds. Renewed concern about her appearance and guilt about her inability to control her snacking caused a further decline in her mood. In an attempt to lose the new weight, Tracy went back to some of her earlier diets. Nothing seemed to work. Increased efforts to control what she ate seemed to produce paradoxical increases in consumption of food. One day, after eating two large bags of pretzels, Tracy began to feel nauseated. Rather than waiting to find out if she would vomit spontaneously, she decided to go to the bathroom and stick her fingers down her throat. The process itself was upsetting, but she felt much better after it was over. Then it dawned on her: maybe self-induced vomiting was a way to avoid gaining weight. It was easy to do. Because she didn’t PSY240 Case Study 3 have a job, she was usually alone with plenty of time and privacy. She couldn’t control what she ate but she could be sure that it didn’t sit on her stomach. At first, she only threw up once or twice a week. The frequency progressed slowly over the next year. Three months after she had moved to California, Tracy returned to live with her father. It was difficult to admit that she had made a mistake, but she was shocked by Jerome’s lack of concern for her feelings and disgusted by the dismal quality of their relationship. She returned in a better mood than when she left. Her decision to leave Jerome had given her new energy and confidence. She got a parttime job and went back to high school classes at night. She was able to earn her high school equivalency degree and went on to school at a local community college. From there, she transferred to the university. Unfortunately, Tracy also returned home in the early stages of an expanding disorder. She was already starting to experience some physical consequences from throwing up repeatedly. She had severe stomach pains. One of her friends commented on the fact that she frequently had bad breath. As her secret problem escalated, she became more embarrassed and ashamed. Although she had managed to pass all her classes since entering at the university, Tracy knew that she was falling behind. She was taking courses in the School of Commerce, which was a very demanding curriculum. Pressure from assignments was becoming overwhelming. Her feelings of depression were beginning to return. Tracy’s father suggested to her that she might find it useful to see a psychologist at the student health center, in the hope that psychotherapy would help her cope with stress. She was not enthusiastic about going to see a psychologist, and wasn’t willing to acknowledge the severity of her eating problems. When Tracy did finally make an appointment with a psychologist, she said that she wanted to develop her study skills. Her goals was presumably to become a more effective student. She spent several weeks in treatment before she and her therapist eventually recognized that nature of her disorder.
Explanation / Answer
I hope she as already undergone through many unwanted parent issues that grew worse with due time, followed with that because of lots of family issue since childhood and loneliness, and already suffering with depression with the feeling of no family, no friends etc.
She has been going through heavy depression which in the extreme state got her into finally get her into so called "Body dysmorphic disorder" suggested as per her day to day weird activities.
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