Eating Disorder

Ava, 22, college senior

Presentation

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.

Philosophical Lenses

These are not treatment plans. They are ways of seeing — philosophical perspectives that illuminate aspects of this case that clinical modalities may not address directly.

Simone de Beauvoir

Ava's restriction is not simply a pathology of body image. It is a response to the situation of being a woman in a culture that simultaneously demands women's bodily compliance and denies women's subjectivity. The 'control' she feels is the only form of freedom available within a system that controls her — an attempt at transcendence through the body that collapses into immanence. Her 3.9 GPA and her 800 calories are the same gesture: proving she can exceed the demands placed on her. De Beauvoir would say that individual therapy without addressing the structures that produce this situation is inadequate — Ava is not merely sick, she is enacting the impossible contradictions of femininity.

Julia Kristeva

Ava's relationship to food is a relationship to the maternal body — to incorporation, boundary, and abjection. Restriction is a refusal of the abject: the formless, the messy, the out-of-control. By controlling what enters her body, she maintains the boundary between self and not-self that the maternal relationship first established and first threatened. Her terror of 'losing control around food' is a terror of dissolution — of the body's porousness, its refusal to stay contained. Kristeva would see the eating disorder as a crisis of subjectivity that plays out at the border of the body, where meaning and matter, self and other, are never fully separable.

Michel Foucault

The clinical gaze that diagnoses Ava — BMI calculations, calorie counts, amenorrhea as symptom — reproduces the same disciplinary logic that produced the disorder. Her body is measured, weighed, monitored, and found deficient. The eating disorder and its treatment are both technologies of the self in a biopolitical regime that governs through the body. Ava has simply taken the culture's techniques of bodily management — dieting, exercise, self-surveillance — to their logical conclusion. The question is not how to correct her deviance but how to recognize that her 'disorder' and the culture's 'health' are on the same continuum.

8 Formulations

Select 2–3 modalities to compare side by side:

Sources & Method

This is a composite fictional case — no real client is depicted. Formulations represent how each modality would typically conceptualize and approach a case with this presentation, based on published clinical literature and training materials. Each formulation draws on the modality's own theoretical framework, key texts, and clinical principles as documented on its modality page. Full source citations for every modality are available on the Sources page.