Psychology

Introduction: Karen Carpenter was one of the all time great musical sensations of the 1970’s. On the stage she was glamorous and loved by thousands of people. She guest starred on multiple television shows, was on the front cover of many national magazines, and even toured the world 9Schmidt & Warrick, 2010). But amidst all this fame and fortune, she was dying. One could say that she led her life in the spotlight, and many young girls looked up to her. She was a role-model and a symbol of American culture. At least, this is what she was trying to be. As it turns out, it was these social pressures that ultimately lead to her downfall. Karen Carpenter was suffering from an eating disorder not uncommon among the American population (Schmidt & Warrick, 2010). Although this disorder was not rare, it was rarely spoken about during the 1970’s (Schmidt & Warrick, 2010). Most people at that time had never heard of Anorexia Nervosa. Moreover, sad but true, the death of Karen Carpenter in 1983 opened the eyes of the world to this life threatening disease (Schmidt & Warrick, 2010). Comprehension Problem List: High Risk Factors: Females are ten times more likely to develop Anorexia Nervosa than males, and eating disorders most commonly arise during adolescence and early adulthood (Jacobi et al, 2004). Moreover, parental psychopathology, parenting problems, and physical and sexual abuse are general retrospective correlates common to AN (Pike et al, 2006), even though not fully proven there were rumors of this within the Carpenter household (Schmidt & Warrick, 2010). Additionally, family and personal histories of weight, shape and eating concerns, and personal vulnerability factors of perfectionism and negative affectivity are significant retrospective correlates that are more severe for AN than for other psychiatric disorders (Pike et al, 2006). Specifically, critical comments about weight, shape and eating represent specific onset of AN and these factors, coupled with more general interpersonal events, increase in the year immediately preceding the onset of AD (Jacobi et al, 2004). The impact of these stressors is also cumulative, an increased number of stressors being associated with an increased risk for onset of AN (Pike et al, 2006). Physical/Biological Complaints: Anorexia Nervosa is a serious illness with biological, emotional, and behavioral components (Davis, 2000). The hallmarks of this disorder are excessive weight loss, intense fear of gaining weight, amenorrhea, and cognitive and emotional disturbances in the way body weight and shape are experienced (Davis, 2000). AN is a disorder of the brain, and it is widely accepted that alterations in neuronal pathways play a role in the etiology of many eating disorders (Kaye, 2007). Individuals with anorexia have disturbances in brain serotonin, a neurotransmitter that helps regulate mood, appetite and behavior (Kaye, 2007). Moreover, serotonin disturbances are believed to contribute to the long term anxiety, obsessionality, and perfectionism that Karen Carpenter exhibited (Kaye, 2007). Anorexia is also polygenic, meaning that its development is influenced not by a single gene but by the combined effects of many (Kaye, 2007). Individuals like Karen Carpenter experience problems with attention, concentration, memory, and visospatial ability; with weight gain, some of these cognitive impairments resolve while others do not (Kaye, 2007). Psychiatric/Psychological Complaints: Karen Carpenter had many psychiatric and psychological issues; in 1967 her doctor put her on a water diet, bringing her weight down from 140 pounds to 120 pounds (Schmidt & Warrick, 2010). By the fall of 1975, Karen was down to 80 pounds, taking dozens of thyroid pills a day, and throwing up the little food that she ate (Schmidt & Warrick, 2010). She also overdosed on laxatives, could not sleep, and had many anxiety related issues especially when touring, and kept her emotions inside (Schmidt & Warrick, 2010). She was also psychotic about her weight and self conscious about her natural pear-shaped chubbiness (Schmidt & Warrick, 2010). According to Schmidt & Warrick (2010) Karen Carpenter was the kind of person who would take care of other people, but was unable to care for herself. Social/Cultural Symptoms: The apparent increase in anorexia over the last twenty years has been paralleled by our cultures aesthetic preference for thinness in women, something Karen Carpenter experienced (Pike et al, 2006). If social variables are of significance, the increased emphasis for women to appear slim, to diet and to exercise may be linked to the expression of Anorexia Nervosa (Pike et al, 2006). This raises fundamental questions about etiology and diagnosis; in particular, is Anorexia Nervosa a distinct entity or is it simply an extreme form of a relatively common dieting disorder' (Pike et al, 2006). One factor which may play a role in the increasing incidence of anorexia relates to the cultural pressure for women to diet and to assume a thin body shape (Pike et al, 2006). It may be viewed as one of several predisposing factors leading to the expression of Anorexia Nervosa (Pike et al, 2006). Functioning Levels: Functioning levels in Karen Carpenter fluctuated, but became worse as her increased weight loss became apparent (Schmidt & Warrick, 2010). For example, her body was so weak that she was forced to lie down between shows, and on many occasions the audience would “gasp” at her body as she walked out on stage (Schmidt & Warrick, 2010). During one show in Las Vegas, while signing, she collapsed on stage and had to be rushed to the hospital, her weight was reported to be 35 pounds underweight (Schmidt & Warrick, 2010). According to friend and family members, Karen Carpenter never acted like she was sick, she was bubbly, energetic and kept going right up until the end of her life, never identifying or coming to terms with her disorder (Schmidt & Warrick, 2010). Five Axis DSM Diagnosis: Axis I: 307.10 Anorexia Nervosa, Binge Eating/Purging Type 300.02 General Anxiety Disorder Axis II: V71.09 No diagnosis Axis III: None Axis IV: Problems with primary support group Problems related to the social environment Axis V: GAF=55 (Current) Based on this assessment and according to the DSM-IV (2000) the patient would meet the criteria for Anorexia Nervosa and Generalized Anxiety Disorder. The patient’s refusal to maintain body weight at or above minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected). The patient has intense fear of gaining weight or becoming fat, even though the patient is severely underweight. Additionally, the patient has extreme anxiety and worry about weight, occurring more days than not, for a period of six months or more. The patient finds it difficult to control the worry and the anxiety is associated with restlessness; feeling keyed up or on edge, becoming easily fatigued, has difficulty concentrating, finds her mind going blank, becomes irritable, has muscle tension and sleep disturbance. The anxiety and worry about weight have caused distress, and impairment in social, occupational and other important areas of functioning (DSM-IV, 2000). Therapy: Biological/Social Factors: Research suggests that a genetic predisposition to anorexia may run in families (Jacobi et al, 2004). Brain chemistry also plays a significant role, because individuals with anorexia tend to have high levels of cortisol, the brain hormone most related to stress, and decreased levels of serotonin and norepinephrine, which are associated with feelings of well-being (Jacobi et al, 2004). In addition to cultural factors to consider in therapy, other than the societal pressures to be thin, there are family and social pressures that can contribute to anorexia (Jacobi et al, 2004). This includes having parents who are over controlling, put a lot of emphasis on looks, diet themselves, or criticize their children’s bodies and appearance (Jacobi et al, 2004). Behavioral Factors: The messages individuals get from society about how one should look are greatly concerning and important when considering therapy for those with anorexia (Davis, 2000). Western culture (particularly the media) promotes extreme thinness as the epitome of body perfection, success and happiness (Davis, 2000). This leads many individuals to become dissatisfied with their own bodies, their self esteem suffers and they turn to dieting as they feel the pressure to be thin (Davis, 2000). Moreover, anorexia can develop from the desperation to live up to unrealistic cultural expectations, strained relationships within the family, and occupational pressures (Davis, 2000). Cognitive Factors: Cognitive factors that accompany anorexia that is vital to understand in therapy: Anorexia can have detrimental effects of cognition and can decrease learning abilities, it has a negative impact on behavior and performance, it decreases the ability to focus and concentrate, it also decreases the ability to listen and process information, can cause headaches, nausea, and an overall lack of energy which can lead to cognitive decline, individuals can become less active and more apathetic, withdrawn, and engage in fewer social interactions (Jacobi et al, 2004). Moreover, it creates a perfectionist attitude that may compel individuals to become obsessive and suffer from extreme bouts of anxiety (Jacobi et al, 2004). Functional Hypothesis: Anorexia Nervosa manifests a wide range of features which cannot fully be explained on the basis to be thin, or by starvation, or dehydration (Kaye, 2007). Evidence is emerging of a significant neurobiological condition to its etiology (Kaye, 2007). However, there has to date been no explanation for its pathogenesis that integrates the previously thought neurobiological and socio-cultural contributing factors (Kaye, 2007). It has been proposed that genetically determined noradrenergic deregulation, interacting with epigenetic factors, leads to high levels of anxiety, impaired neuroplasticity and regional cerebral hypoperfusion (Kaye, 2007). These in combination, lead to insula dysfunction which might explain the body image distortion (Kaye, 2007). This distortion, combined with high levels of body-focused anxiety, gives rise to intense dieting, noradrenergic precursor depletion, and initial reduction in anxiety (Kaye, 2007). Therefore, this leads to the subsequent rebound exacerbation of anxiety and to a vicious cycle of maintenance in the anorexic. Percipients of Anorexia Nervosa: In anorexia there is a deep fear of being overweight that leads to an obsession about restricting the number of calories that the individual is taking in. This can lead to extreme stages of starvation, which in turn has a number of effects on the way the body functions and how hormones are produced (Jacobi et al, 2004). Anorexics often have trouble mentally keeping a balance between calories taken in and calories used up. Moreover there can be deep-seated feelings of anxiety if the individual consumes a few calories too many. This can lead to self-loathing, depression or panic if the individual has not lost any weight or even worse, put a little on, despite their best efforts (Jacobi et al, 2004). Other current issues with anorexia are the extreme weight loss, excessive dieting and other extreme ways of controlling weight gain (Jacobi et al, 2004). Additionally, individuals with anorexia think about food, weight, and body image constantly. The main issue with this disorder as evidenced in the case of Karen Carpenter is excessive weight loss or maintaining an abnormally low weight for one’s age and height (Schmidt & Warrick, 2010). It is also accompanied by a variety of changes in behavior, emotions, thinking, perceptions, and social interactions (Jacobi et al, 2004). Problems with family system are also another current issue at hand when considering anorexia. The evidence suggests that family functioning is not enough on its own to deal with this type of disorder (Jacobi et al, 2004) Maintaining Factors of Anorexia Nervosa: While there are a variety of factors that can trigger anorexia, additional factors often help to maintain disordered behavior once it begins (Pike et al, 2006). Dysfunctional thinking and negative mindsets are apparent, for example, because of the dread of becoming fat or being disgusted with how one’s body looks, eating at meal times can be very stressful. However, what the anorexic can and cannot eat is practically all they think about. Usually thoughts about food, dieting and body image dominate the anorexics mindset, leaving little time for family, friends, and other activities that the anorexic used to enjoy (Pike et al, 2006). Life starts to become a relentless pursuit of thinness and going to extremes to lose weight. Other maintaining factors of this illness are: dieting despite being thin and eating only certain low-calorie foods and banning “bad” foods such as carbohydrates and fats (Pike et al, 2006). Obsession with calories, fat grams and nutrition, pretending to eat or lying about one’s eating, and strange or secretive food rituals which include refusing to eat around others or in public places, and eating in rigid, ritualistic ways (Pike et al, 2006). Additionally, anorexics use diet pills, laxatives, or diuretics, abusing water pills, herbal appetite suppressants, prescription stimulants, ipecac syrup, and other drugs for weight loss (Pike et al, 2006). Treatment Plan: 1. Karen Carpenter never asked for help (Smith & Warrick, 2010), gaining support from a trusted friend, family member, religious leader, counselor, or work colleague is for many the first step to recovery (Jacobi et al, 2004). Alternatively some individuals find it less threatening to confide in a treatment specialist, such as an eating disorder counselor or nutritionist. According to Jacobi et al, (2004), certain specific questions are important to tackle such as: When did the individual begin having different thoughts regarding food, weight, or exercise and what were the thoughts' When did the different behaviors start' What was the behavior and what did the individual hope to accomplish (lose weight, gain control of something, and get someone’s attention)' Has the individual noticed any physical health effects (fatigue, loss of hair, digestive problems, loss of menstrual cycle, heart palpitations, etc.)' How is the individual currently feeling physically and emotionally' 2. Once the individual has identified their health problems a long term treatment plan and eating disorder treatment team will be necessary. The team could include a family doctor, psychologist, nutritionist, social worker, or psychiatrist (Jacobi et al, 2004). The long term plan should include certain parameters such as: inpatient treatment, individual or group therapy, family therapy, eating disorder education, nutritional counseling and medical monitoring. The long term plan should also address the root causes of the problem, the emotional triggers that led to disordered eating, the stress, anxiety, fear, sadness and other uncomfortable emotions that accompany anorexia (Jacobi et al, 2004). 3. The most common therapy for anorexia is cognitive-behavioral therapy, which targets the unhealthy eating behaviors, and the unrealistic, negative thoughts that fuel them (Jacobi et al, 2004). One of the main goals for the individual is to become more self- aware of how they use food to deal with emotions. Other aspects of CBT involve education about nutrition, healthy weight management, and relaxation techniques (Jacobi et al, 2004). 4. Certain antidepressant medications are also useful to consider such as selective serotonin reuptake inhibitors (SSRIs) to help control the anxiety and depression associated with anorexia (Kaye, 2007). Moreover nutrition counseling is also important to consider, teaching the patient a healthy approach to food and weight and restoring normal eating patterns, while educating the patient on the importance of nutrition and a balanced diet (Kaye, 2007). 5. Another aspect to consider is group or family therapy. Family support is very important to treatment success (Jacobi et al, 2004). It is important that family members understand the eating disorder and recognize its signs and symptoms. Moreover, many individuals with anorexia benefit from group therapy, where they can find support, and openly discuss their feelings and concerns with others who share common experiences and problems. 6. Hospitalization is another important factor to consider as in the case of Karen Carpenter (Schmidt & Warrick, 2010). Severe weight loss that has resulted in malnutrition and other serious mental or physical health complications, such as heart disorders, serious depression, and risk of suicide (Jacobi et al, 2004). Intravenous (in the vein) fluids, nasogastric tube feedings or total parenteral nutrition (TPN) might be needed in cases of severe malnutrition (Kaye, 2007). References Davis, C.G. (2000). Not just a pretty face: Physical attractiveness and perfectionism in the risk for eating disorders. International Journal of Eating Disorders, 27(1), 67-93. Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV). (2000). American Psychiatric Association: Washington D.C. Jacobi, C., Hayward, C., DeZwaan, M., Kramer, H.D., & Agras, W.S. (2004). Coming to terms with risk factors for eating disorders: Application of risk terminology. Psychological Bulletin, 130: 19-65. Kaye, W.H. (2007). Alterations in serotonin activity and psychiatric symptoms. Archives of General Psychiatry, 55(10), 927-945. Pike, K.M., Wilfley, D., Hilbert, A., & Fairbain, G.C. (2006). Antecedent life events of anorexia and other eating disorders. Psychiatry Research, 142:19-29. Schmidt, R.L., & Warrick, D. (2010). Little Blue Girl: The Life of Karen Carpenter. Chicago Review Press: Chicago IL.