Case Study

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CAC – Child & Adolescent Counselling
Case Study

At a height of 5 feet 7 inches and a weight of 79 pounds, Sandy, a 17-year-old white female, had the look of an emaciated fashion model when she arrived for for the initial assessment. Unlike a model, she was dressed in secondhand clothes and worn-out flip-flops, which stood in stark contrast to her parent's more polished professional presentation. Sandy didn't really think there was anything wrong with her, but her parents knew that her current condition warranted immediate clinical attention. Sandy had been evaluated by her family physician earlier and he reported the following medical problems: irregular heartbeat, amenorrhea (loss of menstrual cycles due to malnutrition) for the past 7 months, and potassium deficiency. They medical evaluation also found no significant medical history and no physical illness to explain her weight loss. During the parental interview, Sandy's parents reported significant weight loss and hoarding behaviour from their daughter (eg., saving food from other students' lunches and bringing it home). They mentioned that she would always read food labels to count calories/fat grams and analyze other nutritional information, and that she read cookbooks voraciously and talked about food incessantly. According to her parents, Sandy was an athletic girl who in the past had been very involved in her high school's dance society and sports teams, including soccer and volleyball. However, she dropped out of these extracurricular activities a year ago; at about the same time, she began exercising beyond what her parents thought was 'normal' – for hours on end, Sandy would engage in endless repetitions of pushups and situps, and drove herself relentlessly on the stationary bicycle her parents had given her one Christmas. Often times, her parents could hear her exercising at 1 or 2 in the morning. Always a straight-A student, Sandy became obsessed with obtaining perfect marks in every one of her classes; anything less than a perfect mark would drive her to study even harder. Her parents were baffled. She was often moody, irritable, and defensive; once close to her parents, she had withdrawn into a cocoon and barely communicated; and her increasing drive for perfectionism in her schoolwork seemed overzealous to them. Out of sheer frustration, and not knowing what else to do, Sandy's parents grounded her for five months, hoping that she would 'snap out of it'. She did not appear to mind this punishment, and often locked herself up in her bedroom for 2-3 consecutive days. During the interview with Sandy, she vehemently denied the seriousness of her weight loss and prolonged loss of menstrual periods. She said that her involvement with sports was attributed to concerns about fitness and not about appearance. However, at one point she admitted to being afraid of becoming fat; she thought that 'her arms and thighs were monstrous and ugly compared to the women she saw on the streets and the cover models on Cosmopolitan.' She also reported restricted food intake but with no binging, purging, self-induced vomiting, laxative abuse, or diuretic use. She denied any depressed moods. In school, her relationships with her female peers were troublesome and appeared to revolve around disturbed eating attitudes. She reported that a majority of the girls compared their diets at lunch, and bragged about how little they ate, their weight loss practices (some binged and purged, some abused laxatives and diuretics). They often compared themselves to other girls in the cafeteria, and made cruel remarks about the ones they deemed 'overweight and gross'. Dieting with them was one way for her to enter their world and to gain acceptance or attention. Sandy's school counselor referred her for group psychotherapy at school with girls her age who also have eating problems. However, she discontinued after two sessions, dismissing them as a complete waste of...
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