Psychopathology refers to maladaptive behavior/s that causes distress to an individual and is brought about by a psychological disorder (Nolen-Hoeksema, 2004). A number of factors contribute to the development of psychopathology: collectively referred to as the vulnerability-stress model (Nolen-Hoeksema, 2004). This model breaks the stressors down into three categories: biological causes, social causes and psychological causes (Nolen-Hoeksema, 2004). There are four dominant psychological theories of psychopathology that govern treatment: Psychodynamic Theories, Behavioral Theories, Cognitive Theories and Humanistic and Existential Theories (Nolen-Hoeksema, 2008).
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Eating disorders are classified as a form of psychopathology. Bulimia Nervosa, in particular, is an eating disorder characterized by bingeing episodes; followed by extreme actions that serve to induce immediate weight loss, such as purging (Nolen-Hoeksema, 2008). Chassler (1998) states that bulimic nervosa sufferers turn to food as a way of alleviating their negative emotions. Food provides a form of distraction from their problems and comfort; this leads to bingeing episodes (Chassler, 1998). The purging occurs as a way of ensuring that they do not gain weight after their bingeing episodes (Chassler, 1998).
Individuals that suffer from bulimia nervosa tend to have been highly preoccupied with their shape and weight prior to developing the disorder. (Benninghoven, Raykowski, Solzbacher, Kunzendorf & Jantschek, 2007). Individuals developing this disorder tend to be highly dissatisfied with their bodies and many adolescent girls with low self-esteem tend to believe that all of their failures stem from the way that they look (Benninghoven, Raykowski, Solzbacher, Kunzendorf & Jantschek, 2007). These bulimic individuals follow cultural and societal norms that promise greater self-esteem to those who are slimmer (Benninghoven, Raykowski, Solzbacher, Kunzendorf & Jantschek, 2007). Interestingly, Benninghoven, Raykowski, Solzbacher, Kunzendorf and Jantschek (2007) discovered that bulimic women evaluated their own bodies in a skewed manner; however, they found no such disturbances in their cognition related to other women’s bodies or to what they assumed men might find attractive. It is also believed that those suffering from bulimia nervosa are mainly motivated by the desire to fulfill the expectations that men have about women’s bodies (Benninghoven, Raykowski, Solzbacher, Kunzendorf & Jantschek, 2007).
Lacey and Evans (as cited in Anestis et al., 2009) were the first researchers to divide bulimic nervosa patients into two distinct subgroups: multi-impulsive versus uni-impulsive. The multi-impulsive subgroup exhibits impulsive behaviors that include not only binging and purging but also one of the following behaviors: substance abuse, stealing, sexual promiscuity or self-injury. However, Harnden-Fischer and Westen (2001) have found that separating bulimics into subgroups runs the risk of confining a range of complicated personality factors into a single category. These factors seem to be, ‘characterized by emotional dysregulation, intense and labile affect, interpersonal desperation and impulsive efforts to escape distress and seek gratification.’ (Harnden-Fischer & Westen, 2001, p. 558).
Herzog, Keller, Sacks, Yeh, and Lavoril (as cited in Blinder, Cumella & Sanathara, 2006) found that 60% of those individuals with bulimic nervosa, who participated in their study, also had a co morbid Axis I diagnosis. Blinder, Chaitin and Goldstein (as cited in Blinder, Cumella & Sanathara, 2006) discovered that co morbidity with other Axis I disorders generally resulted in a poorer prognosis for bulimic nervosa patients. Blinder, Cumella and Sanathara (2006) found that the disorders that are most co morbid with bulimia nervosa are mood disorders, substance abuse (mostly alcohol abuse) disorders and anxiety disorders. Bryant-Waugh and Lask (as cited in Blinder, Cumella & Sanathara, 2006) highlighted another factor that is thought to contribute to a poor prognosis: the development of bulimia nervosa at an early age.
Another factor that is believed to contribute to the possible development of bulimia nervosa is that of family dynamics. Humphrey and Strober (1987) found that those individuals with parents who have a history of alcohol abuse and obesity, which are ill disposed towards said individual, show them no affection and give them minimal attention, are more likely to develop bulimia nervosa. Humphrey and Strober (1987) suggest that bulimic individuals did not learn good coping mechanisms because of being overwhelmed by their family environment; coupled with the pressure to be slim, leads to bingeing and purging behavior. The bingeing episodes may also act as a substitute for the nurturance that they never had (Humphrey and Strober, 1987). Arikian et al. (2008) also found that a family history of the father abusing alcohol, and the mother suffering from severe depression, resulted in a poorer prognosis for the bulimic individual.
This essay will focus on a particular subject, namely, Molly. The article will investigate Molly’s case and proffer possible solutions.
THE CASE OF 5
Molly is nineteen years old and a second year tertiary student. She arrived to the session wearing ‘tight jeans’ and a ‘white sweater’ with coffee stains on one of her sleeves. Her scarf was ‘out of place’. Her hair was untidy and messy and her eyes were sunken with dark rings around them. There were no problems with her making eye contact although she displayed no emotions throughout the interview. She appeared to be very tired as evidenced by the repeated yawning and rubbing of her eyes. This led to the smudging of her mascara.
Molly’s aunt was worried about her and insisted that she see a psychologist at U.C.T.’s Psychology Clinic. She was not doing her university work and was also having trouble sleeping. She had been caught bingeing and purging, which was a long-term problem, and was currently in a considerable amount of mental pain. She was also extremely suicidal.
History of the Presenting Problem
Molly was first exposed to trauma at a young age. Her parents were arguing loudly every night and Molly took it upon herself to stop them by banging with a toy on her door. This strategy worked for many years and led to Molly believing that she was the one who was responsible for keeping the peace between her parents. Molly was embarrassed to bring her primary school friends home as her father had an obvious alcohol dependency issue and was obese. Humphrey and Strober (1987) state that family discord; parental obesity and substance abuse are often seen to be some of the contributing factors to bulimia nervosa. During her primary school years, her father’s extreme negative reaction to her bad report cards – flying into a rage and forbidding her to have supper -left Molly feeling unloved, unwanted and rejected. Both her parents would often drink heavily, until they passed out, and so were not there for Molly when she needed parental guidance and support. Added to this was the comparison that was always made between Molly and her younger brother, Luke. Luke was praised as much as Molly was berated; leading to a deep-seated pain and a sense of never being good enough. This level of family neglect all contributed to Molly’s eventual development of bulimia (Humphrey and Strober, 1987).
Molly attempted suicide in an effort to ‘punish’ her parents, and herself, for the way in which they treated her. This demonstrates a tendency to rush into behaviors that lessen the negative affect that Molly feels, and Anestis et al. (cited in Anestis et al., 2009) discovered this tendency to be a predictor of bulimia.
Molly went to live with her mother after her parents divorced. Her mother suffered from depression and this is seen to be a contributor to Molly’s bulimia as Arikian, Keel, Miller, Thuras, Mitchell and Crow (2008) state that severe maternal depression could lead to a poorer prognosis.
Molly gained weight once she entered puberty and this led to the other children taunting her, at school, about her weight. She blamed her weight as the main source of her torment: a strong predictor for bulimia (Benninghoven, Raykowski, Solzbacher, Kunzendorf & Jantschek, 2007). Her friends were the ones who first exposed her to bulimic behavior. Even though she claims that many people engage in bulimic behavior, she nevertheless states the need to purge in secret.
Molly lost weight due to the bingeing and purging and this behavior was reinforced by her friends telling her how good she looked and by boys starting to take an interest in her. Molly started having sex with multiple partners, beginning at age 13. This behavior has continued into her university years. This can be seen not only as an expression of impulsivity but also as a form of reassurance seeking, two behaviors often associated with bulimics (Anestis et al., 2009).
The DSM-IV can be used to assist in diagnosing Molly. Axis I refer to clinical disorders: Molly suffers from bulimia nervosa. This is her primary diagnosis. Co morbidly, she also suffers from substance abuse and depression. Axis II refers to either personality disorders or mental retardation. Molly does not appear to have any personality disorders, even though she does display some features of a borderline personality disorder. As it is stated in Nolen-Hoeksema (2004), her impulsive behaviors, like sexual promiscuity and alcohol abuse, are all symptoms of Borderline Personality Disorder. However, she is not subject to the continuous vacillation between the extremes of only idealizing or only despising individuals, as described by Nolen-Hoeksema (2004). Nolen-Hoeksema (2004) states that a Borderline Personality Disorder is characterized by angry outbursts, due to an unstable mood, and alternates between feelings of low self-worth and feelings of grandiosity. However, in Molly’s case, her angry outbursts are brought about due to a lack of sleep and not due to unstable mood, though she does suffer from that with respect to depression; it seems that she always feels herself to be of low self-worth. Axis III refers to general medical conditions. Molly does not have any general medical conditions.
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Axis IV refers to psychosocial and environmental problems. Molly comes from a broken home and has poor relationships with both her parents. They have neglected her, been hostile and highly critical of her, since her days in primary school. Therefore, Molly’s social support comes from, mainly, her aunt who suggested that she visit a psychologist. Molly had weight problems at school that led to her being taunted and extremely unhappy. Her friends at the time, in high school, introduced her to bingeing and purging behavior. Molly began to get attention from boys and reacted to this by being sexually active from a young age. This behavior continued into her university years. Molly is not doing her university work and says that she needed to ‘take some time off’ from university. She is under added pressure as her primary caregivers were arguing over how Molly’s third year at university was to be financed. Her bingeing and purging episodes escalated dramatically following her visit to her parents and stepparent. Axis V refers to the Global Assessment of Functioning. A score of 20 characterizes Molly. Her symptoms are very serious as they can lead to her death or, at the very least, multiple physical problems. She is high in suicidal ideation, and this should be taken seriously and not ignored, and cannot continue with her studies at the present time. Her interpersonal relationships with men are marked by risky sexual behavior and her relationship with her parents serves to exacerbate her bulimic symptoms. She also seems to have no friends.
The primary diagnosis is one of bulimia nervosa. There are many factors that point to this diagnosis and that fulfill the DSM-IV diagnostic criteria. Molly binges on junk food, such as chips and ice cream throughout the day, which is followed by purging. She was also eating in secret thus pointing to a lack of control over her behavior. This behavior started when Molly was thirteen so it has definitely been going on at least twice a week and for longer than three months. Molly was haunted by being overweight at school and attributed all of her problems to her weight, as evidenced by people’s praise of her thinness and by boys starting to take an interest in her. Thus, her preoccupation with her weight is significant.
Molly also has two co morbid diagnoses: depression and substance abuse. Her symptoms of depression include emotional symptoms such as ‘waves of mental anguishâ€¦ which occurred more often, lasted longer, and grew in intensity’ and flat affect. Her physiological and behavioral symptoms of depression include ‘serious sleep problems’ and feelings of fatigue as she ‘yawned frequently’ and ‘rubbed her eyes repeatedly’. Her cognitive symptoms of depression include suicidal thoughts and a sense of hopelessness and worthlessness: she says, ‘I thought to myself, nobody cares whether I live or die, so why bother with hospitals?’ She has major depression as her symptoms have lasted for around two weeks and they interfere with her functioning.
Molly’s second co morbid disorder is substance abuse. She drinks heavily on the weekends and often gets drunk. She continues to consume alcohol despite having periods where she blacks out and wakes up in bed with someone she has no recollection of even meeting. This is said to have happened frequently. These are hazardous behaviors, as Molly could be assaulted by or contract a sexual disease from any one of these men.
The differential diagnoses in this case are substance abuse and depression. Depression is a differential diagnosis as Molly meets the diagnostic criteria of depression but this was ruled out, as the primary diagnosis, despite Molly’s initial suicide attempt, as Molly’s depressive symptoms appeared after her bulimia nervosa developed and can be seen as one of the symptoms thereof. As Blinder, Cumella and Sanathara (2006) state, ‘Perhaps prolonged illness and chronicity in EDs initiate adverse relational experiences, nutritional causality, and affective blunting that predispose longer-term ED patients to depressive symptoms’. Molly also could have been given a primary diagnosis of substance abuse but, once again, this behavior occurred long after the bulimia nervosa began and could be seen to be another symptom thereof. As Hildebrandt and Sysko (2009) state, ‘A significant percentage of treatment-seeking individuals with BN are also diagnosed with a co-morbid disorder, with approximately 20 to 80% classified with a lifetime major depressive disorderâ€¦’ and ‘Among individuals with eating disorders, patients with BNâ€¦ report a higher prevalence of alcohol or drug problems’.
There are a number of psychological theories that underpin Molly’s case but, perhaps, the most fitting theory is that of the psychoanalytic theory, a subset of psychodynamic theory (Nolen-Hoeksema, 2008). Freud developed psychoanalysis and this theory is largely based on the idea that all behavior stems from unconscious processes. As stated in Nolen-Hoeksema (2004), Freud termed the phenomenon of when a person’s defense mechanisms are no longer useful as they are harmful to that individual, the neurotic paradox. One could say that Molly suffers from the neurotic paradox: she has unresolved, and angry, feelings towards her parents and sublimates these feelings by bingeing and purging. Nolen-Hoeksema (2004) mentions Freud’s notion of repression: memories or feelings that an individual cannot or does not want to face and so, these memories or feelings, are banished from said individual’s consciousness. One could also say that Molly’s bingeing and purging stem from her repressing her angry feelings towards her father, turning them inwards and making use of maladaptive strategies to cope. Many of Molly’s problems stem from her family upbringing and the relationship that she has with her primary caregivers, her parents; as will be demonstrated below.
Sugarman and Kurash (as cited in Chassler, 1998) state that the bingeing episodes are a way of reconnecting to the mother and the purging occurs out of a fear of being swallowed-up by the mother. This theory points to Molly expressing her anger and disappointment at her mother for not being there to show her the love and support that she needed and so, in this way, Molly is trying to fulfill her need for maternal love in other ways. As Woodall (as cited in Chassler, 1998, p. 403) has pointed out, the bulimic nervosa sufferer uses food as a, ‘reliable transitional object as a way to undo the mother’s frightening unreliability’.
Bowlby (as cited in Chassler, 1998) first established the concept of attachment: a theorizing of the way in which humans are driven to form attachments to certain others. A healthy and nurturing attachment to a primary caregiver leads to a well-adjusted child (Chassler, 1998). However, disturbances in this attachment lead to all kinds of psychological problems developing (Chassler, 1998). As a child, Molly was exposed to her parent’s hostile feelings towards one another: expressed in their fighting matches. This can be seen to be a disruption in the positive attachment that should have developed between Molly and her parents (Chassler, 1998). Twice in her life, she felt as though she were responsible for her parent’s behaviors: (1) as a child when she would knock on the door in an attempt to get her parents to stop fighting and (2) when living with her depressed mother, now divorced, and feeling ‘responsible for her mother’s emotional wellbeing’. As Humphrey (as cited in Chassler, 1998, p. 406) states families of bulimic nervosa sufferers tend to be, ‘higher in conflict, chaos, detachment, neglect, dependency and contradictory communications than normal families’. Igoin-Apfelbaum (as cited in Chassler, 1998) found that there are a higher percentage of broken homes among his bulimic nervosa participants than among his control participants.
This hostile environment became unbearable for Molly during her primary school years. Her father’s emotional abuse led to Molly feeling worthless and, perhaps, seeing as he attacked her intellectual ability, she felt that she could succeed in another way – by controlling her weight and being attractive.
Molly may have a genetic predisposition to developing depression as her mother suffers from depression (Blinder, Cumella & Sanathara, 2006). Molly’s parents both abused alcohol and her father is described as being obese; these are two factors that are linked to the development of bulimia (Humphrey & Strober, 1987). Being in direct contact with her father’s obesity may have contributed to Molly’s obsession with being thin. Lilenfeld et al. (as cited in Hildebrandt & Sysko, 2009) found that individuals with bulimia nervosa with a co morbid disorder of substance abuse mostly have relatives who themselves have a substance abuse problem.
Keel et al.(as cited in Hildebrandt & Sysko, 2009) posits that alcohol abuse and eating disorders stem from different etiologies that mutually bear influence upon one another. O’ Malley et al. (as cited in Hildebrandt & Sysko, 2009) found, in his study, that successfully treating the substance abuse disorder did not completely eradicate the bulimic syndrome Therefore, Molly, who has co morbid alcohol abuse and bulimia nervosa, may require an integrated cognitive behavioral therapy treatment that addresses both disorders (Hildebrandt & Sysko, 2009).
There are specific modules that Hildebrandt and Sysko (2009) highlight as being the most significant targets that their integrated cognitive behavioral therapy should attempt to heal. Addressing motivation to change is key as adherence to recovery is necessary, in order to prevent relapse (Hildebrandt & Sysko, 2009). Addressing interpersonal relationships, making use of techniques gleaned from psychotherapy, is crucial as interpersonal conflict often serves to exacerbate the bulimic and substance abuse behavior (Hildebrandt & Sysko, 2009). Addressing reward sensitivity can be done in the form of cue exposure, which has been shown to be successful for both substance abuse and bulimic behavior (Hildebrandt & Sysko, 2009). However, cue exposure may not be appropriate for outpatient therapy as it could lead to alcohol consumption after the session (Hildebrandt & Sysko, 2009). Addressing impulsive behaviors is a necessary part of the treatment and dialectical behavior therapy has been found to be effective in treating the bulimia nervosa sufferers’ impulsive behaviors (Hildebrandt & Sysko, 2009). For as Hildebrandt and Sysko (2009, p. 95) have stated, ‘The DBT model for BN conceptualizes binge eating and purging as a means of controlling emotions, and emotion dysregulation is therefore considered to be primary problem with ongoing bulimic behaviors’.
Conclusion: Gender Bias
Benninghoven, Raykowski, Solzbacher, Kunzendorf and Jantschek (2007) found bulimic women, whose perceptions of the body shape and size of women that men find attractive, did not differ significantly from that of men. However, they also state that cultural norms indicate that adolescent girls hope to attain self-confidence by achieving a level of thinness. Therefore, women feel that they have to attain a particular level of thinness in order to be desired by the opposite sex. This places women under tremendous pressure. The media contributes to this pressure by displaying images of women who have attained this ideal thereby intimating that it is within every woman’s power to achieve similar results. Men are under more pressure to be successful in monetary terms as this can snare a mate, whereas women are under more pressure to be physically appealing in order to attract men. This is evident in Molly’s case as she states that boys began being interested in her once she had lost her weight. Therefore, it is apparent that bulimia nervosa would have a greater propensity in women than it would in men.