BMI 17.8, restricting intake to ~800 cal/day with compulsive exercise. GPA 3.9. Reports feeling 'in control' when restricting but terrified of losing control around food. Fainting episodes. Amenorrhea for 6 months. Roommate called campus counseling center. Ava says: 'I don't have an eating disorder. I'm just disciplined. Everyone in my family is heavy and I refuse to end up like them.'
History
Parents divorced at 10. Mother is obese and emotionally volatile — 'food was love, food was comfort, food was everything.' Father critical, appearance-focused, praised Ava for being 'the thin one.' Restriction began at 15 after a comment from a ballet teacher. Hospitalized briefly at 17 but left AMA. Currently in a highly competitive pre-med program. Identifies as queer. No current relationship.
Clinical note: Eating disorders have the highest mortality rate of any mental illness — medical monitoring (weight, vitals, labs) is non-negotiable regardless of modality. At Ava's BMI, medical stabilization must precede any psychotherapeutic work. The evidence hierarchy is clear at one end: FBT/Maudsley for adolescent AN achieves ~50% full remission (Lock & Le Grange, 2013; NICE NG69: recommended). For adults, CBT-E (Fairburn et al., 2009) is first-line with strong transdiagnostic evidence; DBT shows moderate-to-large effects for binge-purge presentations (Safer et al., 2001). RO-DBT targets the overcontrol profile (rigid, perfectionistic restricting) that standard DBT was not designed for (Lynch et al., 2020). But the deepest tension in ED treatment is epistemological: CBT-E asks what maintains the disorder (dietary restriction, overvaluation of shape/weight) and targets those mechanisms directly — it doesn't ask why. Psychodynamic approaches see restriction as meaningful — a compromise formation, a defense against engulfment, an embodied negotiation of autonomy. Feminist approaches see it as a rational response to a culture that rewards women for disappearing. IFS depathologizes the restricting part while still working toward change. None of these frameworks is wrong, but they are operating at different levels of analysis, and the treatment implications diverge sharply. Ava's queer identity adds a critical dimension: LGBTQ+ individuals have significantly elevated ED rates (Parker & Harriger, 2020), body image distress intersects with gender identity in ways most ED manuals don't address, and the ballet history layers a third body-surveillance system on top of family and culture. The clinician must decide: stabilize first (behavioral), then explore meaning (depth work) — or risk losing the client by starting with meaning while her body is in medical danger?
Where Approaches Genuinely Disagree
Behavioral control first or understand the function?
CBT
Normalize eating behavior first. The starved brain cannot do therapy.
vs.
Psychoanalysis
The eating disorder serves a function — control, self-punishment, expression. Treating behavior without meaning risks symptom substitution.