A 17-year-old high school senior began dieting to improve her appearance. Although her family initially encouraged her, the parents became alarmed as her weight dropped precipitously and she became cachectic. She was obsessed with food and exercise and avoided friends, and for the first time her school grades dropped from straight As to Cs and Ds. Her parents reported a change in personality from sweet and compliant to argumentative and stubborn. Although everyone told her she was too thin, she saw herself as grotesquely obese. She resented her family’s pressure to gain weight and perceived them as being controlling and manipulative. She wanted to continue dieting and reported that her only concerns were that she was cold all the time, had trouble sleeping, could not concentrate well (“I feel in a fog”), and could not keep still.
The patient was hospitalized on a psychiatric unit when persistent bradycardia and hypotension resulted in episodes of fainting. Despite her verbal protests, she appeared relieved by the decision to be admitted. A behavior modification protocol was implemented, and she began to eat normally again. Her baseline personality returned as her weight goal was achieved.
In individual psychotherapy, she revealed that she was terrified about graduating from high school and leaving home to go to college. She felt she lacked the ability to take care of herself and did not have confidence that she could make friends or succeed aca-demically away from home. She also worried that her parents, who seemed to fight all the time, would break up when she left home. She felt powerless and her life seemed out of control; dieting had become the only thing she felt competent to do.
Although apprehensive at first, the patient seemed most responsive to family therapy. She was pleased by her parents’ resolve to work out their marital problems and reported that for the first time in years she could imagine liking herself.
Individual and family therapy continued for 1 year after discharge, during which time the patient was able to maintain a normal weight. She elected to remain in therapy during her freshman year of college and continued to thrive.
Revision date: July 9, 2011
Last revised: by Jorge P. Ribeiro, MD