Table 6.

Patient perspectives

Ms A

“Ms A.” was a 21-year-old college student seeking treatment for AN and OCD. Ms A. arrived for treatment weighing 111 pounds with a height of 5 feet 6 inches (BMI = 17.9). Upon admission, Ms A. had an EDE-Q score of 4.2, a Y-BOCS-SR score of 28, and a BDI-II score of 29. She reported restricted intake in both overall calories and types of foods eaten. Ms A. endorsed overexercising, continuously adding and being preoccupied with the number of calories consumed throughout every day, weighing herself multiple times per day, spending 90 minutes per day examining her appearance in mirrors to make sure her stomach appears flat, and comparing her body to others in response to anxiety regarding eating and her appearance. Ms A. also endorsed OCD symptoms including concern with order with excessive time spent perfectly making her bed, folding clothes, and arranging items and obsessions regarding perfection with school work including rereading material, and rewriting notes or papers. She spent significant amounts of time checking her work for mistakes and frequently sought reassurance from others.

Upon admission, Ms A. met with her cognitive-behavioral therapist to create an exposure hierarchy for both OCD symptoms and her eating disorder. Ms A. was expected to complete numerous hours of exposure work per day and to track any OCD or eating-related rituals she performed. Her exposure work was expected to include a combination of OCD-specific exposures and eating disorder-specific exposures. At the beginning of treatment, she started with mid-level exposures including eating wheat bread or string cheese, writing a sentence with a spelling error, leaving her pillow crooked on her bed, and reading one sentence without rereading it. Later in treatment she moved up her hierarchy to do exposures such as being served and eating a dessert after dinner that she did not choose herself, going to a fast food restaurant for lunch and ordering and eating a high calorie cheeseburger, reading a chapter from a text book and writing a summary paper without rereading or rewriting, completely disorganizing her closet (i.e., shoes in a pile on the floor, hangers facing multiple directions, clothing not organized by type, or color) and leaving it this way for weeks, and leaving dirty clothes on the bedroom floor for days. Her therapist helped her to challenge fear-related thoughts (e.g., “If I don’t reread this information, I may fail at school”), and thoughts regarding her body image (e.g., “unless I am thin, no one will like me”).

After 10 weeks of treatment, Ms A. gained 19 lbs to achieve weight restoration, and also experienced a significant reduction in time spent engaging in rituals. Ms A. was able to eat a wider variety of foods. By discharge, she had completed 70% of her exposure hierarchy and was able to successfully resist engaging in her ordering rituals and checking behaviors related to her AN and to her OCD symptoms the majority of the time. She continued to experience some anxiety around eating dessert items. She also reported significantly improved mood. At the time of discharge, she had BMI of 21.0, an EDE-Q score of 2.7, a Y-BOCS-SR score of 15, and a BDI-II score of 12.

Ms B.

“Ms B.” was a 20-year-old college student seeking treatment for BN and OCD. She reported a history of restrictive eating followed by binge eating and purging that began during her senior year of high school. On days where she was restricting, Ms B. reported that she closely checked food labels for caloric and fat content and added up her caloric intake as she ate (i.e., “counted calories”). Several days of restricting were typically followed by several days of binge eating and purging, during which she typically had several instances per day of eating large quantities (approximately 1000 calories) in one sitting, accompanied by a sense of loss of control. After each binge episode, she induced vomiting. Her symptoms had been worsening: her restricting days included fewer calories and her binge eating days included greater quantities of food and more episodes of purging. Uponadmission, she weighed 140 pounds and stood at 5 feet 7 inches (BMI = 21.9 kg/m2). Ms B. denied overexercising or use of laxatives, diuretics, enemas, or appetite suppressants. She weighed herself several times per day and checked her appearance in the mirror multiple times per day to evaluate what she viewed as trouble areas, wore excessively loose clothing, and often covered her stomach with her arms or other objects such as a blanket or pillow. In addition to her eating disorder symptoms, Ms B. also endorsed intrusive thoughts about harming others and frequent checking and reassurance seeking to make sure she had not caused someone harm. She reported religious obsessions and prayed hundreds of times per day to attempt to “cancel out” sinful or blasphemous thoughts or actions. She sought reassurance multiple times per day from her pastor and others regarding her religious obsessions and confessed on a regular basis for what she considered to be sinful thoughts. Her reassurance seeking and confessing often involved her mother, creating considerable stress in their relationship. Ms B. also endorsed depressive symptoms (e.g., depressed mood, loss of interest in previously enjoyed activities, feelings of guilt, feelings of hopelessness, and fatigue) that started approximately six months ago. Upon admission, Ms B. had an EDE-Q score of 3.9, a Y-BOCS-SR score of 27, and a BDI-II score of 23.

Ms B. and her cognitive-behavioral therapist developed an exposure hierarchy. She was assigned to track the number of times per day she submitted to or resisted engaging in rituals or maladaptive behaviors, including calorie counting, weighing herself, checking food labels, checking that she has not caused harm, praying, reassurance seeking, and confessing. Exposures assigned early in her treatment included sleeping with scissors next to her bed, driving over a speed bump without checking to make sure she did not run anyone over, eating chicken breasts, sitting without covering her stomach, and purposefully dropping a Bible on the floor without praying, seeking reassurance, or confessing. Later in treatment, Ms B. worked on exposures such as holding a butcher knife to her therapist’s back, writing a swear word in a Bible in pen, eating a single serving of potato chips without purging, wearing appropriately sized clothing, trying on a swimsuit, eating red meat, and purposefully thinking a “bad” thought in church. Ms B. was also taught to challenge her fear-related thoughts, depressive thoughts, and maladaptive thoughts about her body image and eating. At discharge, Ms B. had an EDE-Q score of 1.5, a Y-BOCS-SR score of 16, and a BDI-II score of 10.