Stella is a 29-year-old, cisgender, female of primarily European-American ethnic and cultural heritage, identifying with mainstream US culture. She is not married and has no children. She describes her religious orientation as “sorta Christian”, but not actively involved. Her grandmother, who she reports a close connection to, is “very Christian” but that this seemed to be more a point of contention for her parents than an asset. Stella enrolled in therapy to address relationship issues, stating that she was “always getting dumped” and wanted to figure out what was “wrong with me”.
Upon entering treatment, the provider observed that Stella was around 5’8”, pretty, and with very slender build, and appeared to have impeccable hygiene. She had a slight “yellowish” cast to her skin, however. What struck the therapist was the immediate sense of being in the presence of a teenager or even someone at the cusp of puberty rather than a mature woman. Stella’s immediate concerns were that she was interested in being in a relationship, had been involved in several relationships, in the last few years, and felt like she always “went the extra mile” to make the partner feel special and wanted, only to be dropped after a few months…sometimes after only a couple of weeks. Some romantic interests were found on dating websites as well. Boyfriends complained to her that she was too needy and that she could never make decisions, but would say things like, “whatever you want”. “I just wanted to make them happy! I would do whatever it took to keep them around,” she stated, with some tearfulness, noting that she would do this even if she didn’t really like them all that much. “I was just afraid they would leave me alone again”.
Rather quickly in the first session, Stella stated to the therapist that her goal for therapy was to find out what the therapist could tell her to do so that she could find a lasting relationship because she is feeling very lonely.
Upon request, Stella provided her developmental history and recent relationship history, as well as medical history – including obtaining a current full medical examination.
Stella was born in Colorado to parents who were successful in their careers. She is the youngest of three, with two brothers that are 3 and 5 years older. She was always the baby in the family and as the only girl, was doted on heavily. Her mother is a psychologist and her father is a cardiologist. She was healthy throughout development, with no medical issues or problems; and her family heavily emphasized health, wellness, and being physically active. This was part of the reason for their residence in Colorado, as it is an area highly focused on health and physical activity.
Stella’s family had a nice home outside of Denver that was always immaculately kept by a housekeeper and her paternal grandmother who lived in the house with them. Stella’s grandmother was an indulgent woman whose permissiveness was frequently frowned upon by her parents, but whom they cared for after her husband had died of heart failure. Stella’s grandfather was an undisciplined man with many vices and their son, Stella’s father, felt considerable shame at his father’s profligate and disreputable nature. He could not understand how his mother had remained so dedicated to her husband despite his many faults, although he notably displayed many of the same tendencies to be so dedicated to his mother despite her many perceived faults, primarily out of pity for the difficult life that she had lived. Stella’s maternal grandparents lived in New Jersey and had struggled with alcohol, physical infirmities and financial mismanagement. Her mother rarely visited or contacted her parents and Stella did not know them well.
Stella idealized her grandmother but also felt considerable guilt in the secret indulgences that her grandmother made on her behalf and felt tremendous tension in wanting to please her parents while also delighting in the seductive lure of violating her parents fairly restrictive parenting.
As stated, Stella was heavily “cared for” by the family who tended to baby her and make decisions for her or make statements like, “you don’t really feel that way” or “you don’t really want that”. As a child she began feeling considerable anxiety about what it was that she did feel and finding it harder and harder to recognize her own wants and interests. Making decisions became a considerably difficult exercise and she would frequently ruminate over things, often asking her parents or peers what they thought and what she should do. Although her parents and brothers initially thought this was cute and liked the sense of feeling that their views and opinions were valued by her, eventually her insistence on having their perspectives and making choices for her became obnoxious and frustrating.
Academically, Stella excelled when she had circumscribed tasks and knew exactly what the expectations were. However, as she grew older, her teachers recognized that she struggled to think creatively and when provided with options or the chance to think independently, she would get bogged down and be unable to work effectively, repeatedly seeking guidance and directives from her teachers on what to do and how to do it. Although tolerant, this became a point of frustration and challenge for teachers wanting to assist her in being more self-determined and having greater agency. She graduated high school with a strong GPA and excellent SAT scores and then attended college.
Relationally, Stella had several friends growing up, but rarely felt close to other girls. Although asserting she was “popular enough” and was invited to birthdays and events, she generally felt more on the periphery of social circles and did not feel she had any “best friends”. She dated a few boys in high school who eventually left her, finding her “too needy”. Stella found herself being sexually active with her boyfriends in late adolescence despite considerable anxiety about sex and her sexuality. She stated she found very little pleasure in her sexuality but desperately wanting to keep the relationships and typically felt very guilty after having sex, knowing that her parents would not want her to be sexually active, especially given fears she could get pregnant or mess up future college plans, etc. And yet, she also had intense curiosity about her sexuality and had engaged in masturbation on occasion, but with considerable sense of guilt and shame that seemed to negatively affect any pleasure she tried to experience. Eventually, she stopped this and even stopped being sexual with her boyfriends altogether.
While in college, Stella experienced what she termed “a breakdown”. She was overwhelmed by the stress of school, feeling incompetent, lonely, and emotionally “frazzled”. After a week in which she barely slept, was not eating much, had very irritable and intense mood, was talking in a pressured manner, and seemed somewhat disorganized and chaotic, she went to see her medical doctor. Her parents had also been upset with her for running up her credit card, which was atypical of her. Stella’s doctor thought that she appeared to be stressed and overwhelmed and recommended trying to drop one class and see a counselor at the school. Her doctor also prescribed Trazodone to improve sleep and recommended that Stella begin eating more regularly. The Trazodone was effective, she began sleeping better, dropped one class and felt like her mood and thinking became clearer. In working with her teachers, she was able to get extensions and make up the work. However, her perception of this “failure” gnawed at her and she struggled with increased guilt. This led to periods of time over the next few years in which she had to take sick time due to feeling too overwhelmed to get out of bed. In talking about these “episodes”, Stella notes that she generally would feel a lot of self-loathing, tearfulness, and just wanting to sleep all the time. Her guilt would generally force her to get active and often after a few weeks she could seem to get out of that “funk”, but during those times she was not interested in anything and on a couple of occasions felt suicidal before quickly “rejecting” those thoughts.
Stella also did not demonstrably improve in her nutritional intake after that medical appointment, tending toward a fairly ascetic diet. She recalls that health and attention to diet and wellness were heavily stressed in her family. In the course of telling her family story, she recounts one instance in which she had compared her lunch—filled with fresh vegetables, whole grains, and low-fat items—and some of her peers, who appeared to be indulging in meals with pizza, cupcakes and other goodies and noted that they seemed to be enjoying their food so much more than she was. On the way home she stopped at a convenience store and purchased several “forbidden” snacks and devoured them before she got home. However, she felt a tremendous sense of guilt and confessed to her mother. Stella remembers that her mother was shocked and reinforced how terrible these foods were for her and that she appreciated Stella telling her about this. Stella particularly recalls the disappointment that she felt in her mother’s response, hoping that she would relieve her of her guilt; but instead Stella felt even greater guilt and made herself “barf” up the food in the bathroom. Although Stella has not engaged in vomiting to address overconsumption or for eating the “wrong” things, she has fairly strictly avoided unhealthy foods or indulging in sweets or fatty meals. Friends in college frequently remarked about how impressed that they were that she could “keep off the Freshman 15” and were impressed with her discipline. While this made Stella feel good, she frequently had dreams in which she was devouring incredible amounts of unhealthy but delicious food. One dream in particular she recalls eating and eating and eating and then looking down and seeing all of the food passing out of a massive hole in her abdomen, undigested. Although not knowing what it meant, she remembers feeling very sad after that dream.
Stella’s medical results yielded low sodium and low gonadotropins. She had not had her period in about a year and was underweight. She also had hypercarotenemia, a condition associated with a primarily vegetable diet causing elevated carotene, typically resulting in giving the skin a slight yellowish cast. The doctor contacted Stella’s therapist to suggest that she be evaluated for an eating disorder.
