Case Study

Case 3: Rita

Rita is a 19 year old finishing her first year of college. Throughout her adolescence, Rita was

always sensitive to people’s opinions about her appearance and weight, particularly the opinions

of other women. Social, she always seemed to fall in with a group of girls who were equally

preoccupied with dieting and weight control. To Rita, their preoccupation seemed to be based not

on vanity but on anxiety. They lived under a cloud of concern that their weight and eating might

somehow grow out of control. Typically, her friends did into have significant weight problems,

not were they unusually vain or intent on being popular. In fact most of them had serious

academic interests and career goals. Thus she found it almost ironic that they, in particular, were

so focused on their physical image. But focused, they were, and Rita was no exception. Her

mother was an attractive woman who was always impeccably groomed and always on a diet. She

and her father had always looked down upon people who were overweight and “would let

themselves go.” Her family was a middle class family. Her parents were both mid-level

managers, in a computer and car dealership businesses. Rita is the oldest of 3; her two brothers

are 17 and 15. Rita has always been a good, if not stellar, student and has always had a close knit

group of friends. She lives in a small city in the Northeast and is in college about 5 hours away

from home in a large state university.

Since age 14, she always tried to keep her weight between 114 and 116 pounds, a standard that

began in the ninth grade, after she experienced a slightly overweight period. She would rigidly

follow what she called her “weight watchers” plan, although she had never actually gone to the

program of the same name. The eating plan consisted, when she was being “good”, of a breakfast

of dry toast and juice, a lunch of turkey or dry tuna on diet bread, and a low-fat frozen meal at

dinnertime. On some days, it also included, when she was being “bad”, a couple of candy bars or

two large “gourmet” chocolate chip cookies. She tried to keep bad days to a minimum, but there

were probably three to four of them each week. Rita felt she could tolerate such days, however,

as she was a regular exerciser, attending an aerobics class three evenings a week. During a

particularly bad week, however, she might go to the gym a couple of extra times to exercise on

her own.

In addition, she developed the habit of weighing herself several times a day, to reassure herself

that the reading did not exceed 115 pounds. When the scale showed that her weight was at or

below 115, she felt enormous satisfaction, similar to what another person might feel if her or his

bank statement showed a comfortable balance. Rita saw her 115 pounds as the well-earned

reward for sustained and concentrated effort. And like a miser who counts her money over and

over, she would get on the scale frequently to recapture that feeling of satisfaction, especially

when other aspects of her life were less than satisfying. One evening at home, when she saw that

her weight was 113, she returned to the scale a dozen times to experience the pleasure at seeing

that number.

At the same time, the frequent weighting had its downside. Sometimes she would observe a

reading of 116 or 117 pounds and have a very negative reaction. She would feel fat and bloated

and would resolve to limit her eating to a much stricter version of her weight watchers plan. In

addition, she might throw in extra exercise sessions for good measure. In the meantime, to avoid

anyone seeing her “fat” body, she would hide it under bulky sweaters and other concealing

clothing. This way, other people would at least not gossip about her.

Shortly after arriving at college, Rita’s eating habits became much more troubled. First, she

began to have eating binges, perhaps two to three times per week. Typically, she would become

aware of the urge to binge sometime in the afternoon, while at her work-study job. As the

afternoon progressed, the urge would build into a sense of inevitability, and by the end of the

workday, she knew she would be spending her evening on a food binge. She would then start to

fantasize about the foods she would be buying when she stopped at the different dining halls on

campus, so that no one would notice she was eating so much at any one of them.

The foods that figured in Rita’s binges were items that she had labeled as “bad” foods that, in her

mind, should never be eaten if she had any hopes of maintaining proper weight. On one binge

day, for example, she made stops at 3 dining halls. At the fist one she ate 3 large slices of pizza.

At the next one she picked up 3 large “super chunk” chocolate chip cookies. And a t the third

one, she made herself a large ice cream sundae with all kinds of toppings. At each of these stops,

she would look around to make sure no one she knew was around and would find a table in an

isolated corner of the dining hall, where no one was likely to notice her. This secrecy made her

feel like she was committing a crime. Yet, once the eating began, she felt powerless to stop it.

After the first mouthful, the binge was destined to run its course. In this particular occasion she

had consumed more than 4,000 calories.

She often felt as though she were in a changed state of consciousness during such binges. She

would even avoid answering her cellphone when she was eating like this.

Although she viewed the binge overall with disgust, she couldn’t deny there was some pleasure

in it. It was the only situation in which she could eat food that appealed to her. Under normal

conditions, eating was not a source of pleasure because she would restrict herself to unappetizing

foods. For her “normal eating” meant dieting—avoiding all foods that she enjoyed. She was

convinced that if she regularly ate foods that she did like, she would set in motion a process than

she couldn’t stop. And, now indeed, her binges seemed to be bearing this theory out.

Once the binge was over, the next step, in Rita’s mind was to repair the damage. Be the time she

was through, she was left with feelings of both physical and psychological revulsion. Physically,

she would fell bloated. The blow to her self-esteem was even more pronounced. Binge eating

was so inconsistent with her usual style of behavior that she wondered if she was developing

some sort of split personality: the competent, striving Rita versus the irresponsible, out-of-

control Rita. She was becoming concerned about her mental health.

Most important, the binge posed a severe threat to the one area of like by which she measured

most of her success and worth as a human being: her weight. After a binge, she felt that if she

didn’t do something about it, she might see a 5-pound weight gain on the scale the next morning.

During her first 2 or 3 months of binge eating, she would attempt to avoid weight gains by trying

to fast for a day or two. Then she saw a television show featuring women with bulimia, a show

that examined purging behavior at length. The message of the show had been to avoid this fate at

all costs. However, with her binges becoming more extreme and her weight reaching an all-time

high of 122 pounds, Rita saw purging as the solution to her problem: a way of eating what she

wanted while avoiding undesirable consequences.

She started to purge several times a week. She would stand over the toiled, touch her finger to

the back of her throat, and throw up as much of the binge food as she could. The first time Rita

tried this, it was not so easy. Indeed, she was surprised at how hard it was to stimulate a gag

reflex strong enough to bring up the food. Eventually, however, she often didn’t have to use her

finger at all; the food would seem to come up almost automatically as she bent over the toilet.

In the early stages, Rita’s purging felt gratifying. It typically brought an immediate sense of

release, as though some terrible wrong had been set right. The bloated feeling would go away,

and Rita would avoid seeing a weight gain the next day. But over the next few months, the need

to purge grew and grew. Even after eating normal meals, Rita would feel fat and she couldn’t get

the thought of purging out of her mind. Beyond purging, she would try additional practices to

undo the effects of binge eating. For example, she would try to go to the gym every day. Before

going, however, she had to follow a particular ritual in front of the mirror. She had to convince

herself that she looked slim enough to appear in a gym environment. She put on her exercise

outfit and inspected herself from every angle. Rita’s weight was within the normal range: she

was 5 feet 5 inches tall and weighed 122 pounds. Anyone would have described her as “slim”

however there were aspects of her body that caused her repeated concern. She felt that her

“center of gravity was too low,” meaning she was heavy in her hips and thighs. If after surveying

herself in the mirror, she believed that she looked “dumpy”, she would abandon her plan to go to

the gym.

Usually, however, if she spent enough time in front of the mirror, she was able to convince

herself that her appearance was not entirely repulsive. Sometimes in order to do this she had to

change outfits. At the gym she would spend at least 2 hours, alternating between jogging on the

treadmill and an elliptical machine. Going to the gym achieved two things in her mind. It burned

calories and it kept her away from food for a period of time. When she returned to her dorm, she

drank a couple of cans of diet soda and tried going to bed. Unfortunately, the long workout often

left her ravenous and frequently she found herself going to the dining hall, binging and purging.

After 6 months of bingeing, Rita found that she was falling further and further behind. As the

binges and snacking had become more regular, she experienced a gradual 10-pound gain,

“ballooning” as she called it, from 115 pounds to 125 pounds. She had never been this heavy

before, and she felt desperate to lose the weight. All the purging, dieting and exercise was adding

up to naught.

Rita was also becoming increasingly worried that she might resort to more extreme measures,

such as purging in places where she would be “found out” in order to lose weight. Ironically, her

only temporary relief from these anxieties was achieved through bingeing. But afterwards she

would often find herself sobbing. Her preoccupation with her eating had become the center of

her life and her grades (usually very good) had begun to suffer and she had stopped being

socially engaged with the other students she had met during her first semester at school. She was

afraid of what would happen when she went back home for the summer. Overwhelmed, she

contacted the college counseling center.