An Athlete with Anorexia: Case Study
Winter 2006, Vol 5, Issue 1
Rachel Daberkow, MS, RD, Department of Nutrition Services
Jennifer Hazel, MA, LPC, Patient Care Services Division
Remuda Ranch Programs for Eating Disorders
Paige is a 20 year-old, female, African American, college dancer, diagnosed with anorexia nervosa, binge-eating/purging type. At admission, she was 5' 7", weighed 90 lbs., and was eating only 800 calories a day. She was abusing laxatives and exercising up to five hours a day. She clearly exhibited the classic female athlete triad—disordered eating, amenorrhea, and osteopenia. In recent months, she had become depressed because stress fractures and chronic fatigue were preventing her from dancing competitively.
Psychological testing indicated low ego strength, feelings of worthlessness, perfectionism, shame, hatred of her body, spiritual distress, and trouble understanding and managing her emotions. As such, her chief coping mechanisms consisted of repressing emotions, denial, and minimization.
Paige often mentioned the high expectations she experienced within her family. Her parents were both collegiate athletes. Currently, her father coaches at the collegiate level and her mother manages her own business. Her older brother was an all-star basketball player during college and is now in medical school. She reflected that her family has always emphasized excelling in school and showered attention on her for her performance. She had a younger sister who died several years ago. She felt responsible for her sister’s death and was trying to be the perfect daughter to make up for her parents' loss. She was slightly overweight when younger but had received praise for subsequent weight loss and the thin appearance that she attained. Because of her current appearance, she was frequently awarded leading dance roles and often asked on dates by popular men on campus. These experiences further reinforced the value that Paige placed on being thin.
Due to Paige’s low body weight at admission, her treatment team recommended nocturnal nasogastric tube feeding. She accepted the recommendation. During the first weeks of treatment, she progressed to a weight gain meal plan. Her labs were stabilizing and her activity status was increased. She had gained five pounds in three weeks. Then a peer disclosed that Paige was secretly exercising in her room during the night. As such, therapeutic interventions were initiated to help Paige identify the pros and cons of her decision to exercise using a tool called Behavior Chain Analysis (BCA; Eberly, Wall, & Cabrera, 2003; Linehan, 1993). BCA assesses vulnerabilities and triggers to eating disorder (ED) behaviors and challenges patients to explore how they can use their newly learned cognitive-behavioral skills to reduce these vulnerabilities and make more effective choices.
The treatment team challenged Paige to be open and honest with peers and staff and established an accountability plan for Paige to follow. In group therapy and in the milieu, her peers helped her to confront her habitual defenses of denial, minimization, and repression. During group and individual therapy, Paige began to notice, identify, and talk about her difficult emotions, including guilt and shame, sadness and loss, and anger. These emotions and related themes such as control, performance, and perfectionism were explored in relation to her ED. On her diary cards, she began to connect these emotions and themes with her behavioral choices to restrict, exercise, and ruminate about her body.
Part of her treatment included body image sessions to explore body image distortion, body shame, and identity apart from her appearance and performance. During spiritual direction, Paige discussed the shame and judgment she felt from God and explored the concepts of grace and forgiveness. Experientials with equine and adventure programming also assisted with problem solving, risk taking, trust building, and assertion.
The week before Paige’s family was to arrive for weeklong intensive family sessions, Paige was highly anxious about what her family would think about her eight-pound weight gain. During this stressful week, she restricted by refusing some tube feedings. Her treatment team therefore asked her to develop a plan for maintaining her nutritional intake. On her plan, she emphasized communication, emotion regulation skills, and confronting her obsessive and irrational thoughts.
Family Week provided deeper understanding of her ED. Her family acknowledged their emphasis on performance. They finally began to grieve the loss of the patient’s sister. They explored how insufficient attention devoted to the grief process had left each of them less able to talk about feelings and more likely to deny and suppress emotional difficulties.
After Family Week, Paige worked with her treatment team to set goals for a return to dance. She developed the goals of: 1) challenging her fears, irrational thoughts, cognitive distortions, and comparisons, and 2) making the most of her remaining weeks in treatment. Although she had setbacks, including restricting caloric intake on three more occasions and another episode of exercising in her room, she gained an additional 12 pounds during treatment, for a total of 20 pounds. She was also accepting more food challenges. In accordance with her spiritual values, she worked on appreciating her body for what it does, rather than focusing only on what she would like to push it to do. She was learning to give herself permission to relax and to have times of struggle, as opposed to criticizing herself immediately for not being good enough. Her activity status continued to progress and many of her medical diagnoses were resolving. A final, significant piece of the puzzle was continued grief work regarding the loss of her sister.
Paige’s discharge psychological testing indicated that her depression, perfectionism, body dissatisfaction, drive for thinness, alexithymia, and spiritual distress were improving. Paige was verbalizing hope and coming to build her identity on her character as opposed to her appearance and performance. She was also working towards other goals outside of dance, such as relationships and career planning. Her family was supportive of her recovery and was engaging in family therapy back home to consolidate gains made during Remuda’s intensive Family Week, such as modulating their performance-based expectations. Fortunately, Paige’s dance instructor verbalized clear support of her recovery goals and recommendations, and had long embraced the person-centered approach to dance instruction.
The treatment team assessed Paige’s barriers to recovery to include the competitive atmosphere of dance, relationships with other dancers, peers who were struggling with EDs, and Paige’s continued body focus. Due to her relatively short five-year history of ED, her commitment to follow recommendations, and identified support factors in her environment, her prognosis appeared to be fair to good. Paige also appeared to be internalizing more motivation, developing non-dance-related short- and long-term goals, discovering the joy of relationships outside the dance world, and growing spiritually by truly applying her spiritual values to her experiences. By her discharge date, she had progressed to the action stage in the Stages of Change.
The Remuda treatment team scheduled a teleconference with Paige’s outpatient therapist, parents, and dance instructor, with Paige participating fully. Together, the inpatient and outpatient teams reviewed aftercare recommenda-tions, explored ways to assist Paige with continued skill building, and addressed vulnerabilities and environmental barriers to recovery. The teams agreed on the need to assist Paige in de-emphasizing body weight, rejecting pathological weight techniques practiced by other dances, choosing not to attend dance group weigh-ins, and recognizing and celebrating physical differences related to individual genetics. During the teleconference, Paige’s family and outpatient team were struck by what her peers at Remuda had already begun to see: Paige’s emerging personality with a gentle spirit and relaxed demeanor, coupled with spunkiness.
To structure preparation for discharge, her treatment teams used Remuda’s Sports Return Assessment to develop a Terms of Participation Contract. This contract delineates when it would be appropriate for Paige to return to competitive dance. The six factors considered in this process are medical status, nutritional status, ED behaviors, prognosis, environment, and internal milieu. For more details, see the companion article in the current issue of The Remuda Review, titled Athletes and Eating Disorders (Littlefield, Zuercher, Daberkow, Hazel, & Woods, 2006).
Paige’s Terms of Participation Contract is reproduced below as a detailed, case-specific example of using this technology effectively in planning sport return parameters for ED athletes. The Terms of Participation were written separately for each of the dance-related activities that Paige wanted to engage in following discharge, since the criteria for each varied somewhat.
1. Criteria to engage in stretching and leisure walking for a total of 2-3x/week, 20-30 minutes per episode:
Medical Status
• Agrees to weekly monitoring for stabilization of labs
• Cannot participate until malnutrition resolves
• Cannot participate until stress fractures are showing evidence of healing, by x-ray
Nutritional Status
• Weight restoration must continue at 1-2 lbs/week until weight range is reached
• No physical evidence/signs of malnutrition
• Agrees to meet with an RD 2x/week for meal plan accountability
Eating Disorder Behaviors
• Accountability plan for laxatives and exercise
• Must follow meal plan & experience weight restoration
Prognosis
• Positive Indicators:
Moderate duration of illness, 5 years
Relatively young age of illness onset
Admission EDI-2 scores resemble positive prognosis cluster
African American female athlete
Admission MMPI-2 elevated on scales K and 9
• Indicators of Concern:
Lean sport
Female sport with revealing clothing
Judged sport
Admission MMPI-2 elevated on scale 1: I will continue to work with my outpatient treatment team to accurately identify, label, and discuss emotions, learning to express myself assertively rather than through physical symptoms
History of perfectionism: I will continue to challenge my automatic, rigid, perfectionistic thoughts, replacing with healthier cognitions
• OVERALL PROGNOSIS: FAIR TO GOOD
Environment
• Positive Indicators:
Supportive family (following Family Week)
Person-oriented dance coach
Outpatient treatment team and coaches on board with recommendations
Accountability established for comparisons and triggers with competition
• Indicators of Concern:
Social milieu of dance and at-risk peers: Paige will make efforts to develop friendships with non-ED peers outside of the dance community
Challenging expectations of sport: Paige will continue to work with her outpatient therapist on developing balanced expectations in light of her long-term recovery and life goals
• OVERALL ENVIRONMENT:
LARGELY SUPPORTIVE
Internal Milieu
• Positive Indicators:
Appears motivated for recovery
Testing suggests in Action Stage
Internal motivation
Goals to finish college whether or not she dances
Cultivating spiritual values of unconditional, instead of performance-based, self-acceptance
• Indicators of Concern: None
• OVERALL MOTIVATION: VERY POSITIVE
The Terms of Participation appears again below for three additional dance-related activities in which Paige wanted to engage. The last three factors remain the same as above, such that only the first three are detailed below.
2. Criteria to engage in strength training and dance 2-3x/week, 20-30 min per episode
Medical Status
• Cannot participate until stress fractures are healed, by x-ray
• Must have completed DEXA Scan within past calendar year
• Cannot participate until anemia resolves
Nutritional Status
• Must maintain low end of IBW range for 1 month
• Must follow meal plan without restricting or ED behaviors
• Must replace calories burned with snacks to maintain weight
• Must consume 2 challenge foods/week
• Must be working toward body composition of appropriate body fat and BMI
Eating Disorder Behaviors
• Must abstain from restricting, laxatives, and over- exercise
• Must meet regularly with accountability partners
• Will replace ED urges with cognitive-behavioral skills
• Will cultivate identity outside of performance and appearance
3. Criteria to engage in dance practice with college 3-5x/week, 45-60 min per practice
Medical Status
• Cannot participate until stress fractures are healed, by x-ray
• Must obtain medical provider’s clearance that bone density is sufficiently stable for this level of activity
• Cannot participate until anemia resolves
• Cannot participate until menses have resumed
Nutritional Status
• Must maintain IBW
• Must follow meal plan without restricting or ED behaviors
• Must replace calories burned with snacks to maintain weight
• Must consume 2 challenge foods/week
• Will continue weekly sessions with RD
• Must maintain appropriate body fat and BMI
Eating Disorder Behaviors
• Same as for strength training and dance 2x/week
4. Criteria to return to competitive dance
Medical Status
• Cannot participate until stress fractures are healed, by x-ray
• Must obtain medical provider’s clearance that bone density is sufficiently stable for this level of activity
• Regular menstrual cycle, remaining consistent throughout training
Nutritional Status
• Weight maintenance @ IBW with body fat at least 18-19% for 6 months
• Must follow meal plan without restricting or ED behaviors
• Must replace calories burned with snacks to maintain weight
• Must consume 2 challenge foods/week
• Will continue weekly sessions with RD
Eating Disorder Behaviors
• Same as for strength training and dance 2x/week
Following discharge, Remuda’s aftercare coordinator has contacted Paige at pre-defined intervals. Paige appears to be doing well, and recently met full criteria for resumption of participation in competitive dance.
References
Linehan, M. (1993). Skills training manual for treating borderline personality disorder. New York: Guilford Press.
Eberly, M., Wall, A.D., & Cabrera, D. (2003). Cognitive-behavioral therapy: Applications and skills. The Remuda Review: The Christian Journal of Eating Disorders, 2, 1-8.
Littlefield, K., Zuercher, J., Daberkow, R., Hazel, J., & Woods, B.K. (2006). Athletes and eating disorders. The Remuda Review: The Christian Journal of Eating Disorders, 5, 2-8.
