Problem
Clinical Case
Ann was a 26 year old white woman who presented with a chief complaint: "I have problems throwing up." These symptoms had their roots in early adolescence, when she began dieting despite a normal BMI. At age 18 when went away to college and began to overeat in the context of new academic and social demands. A 10-lb weight gain led her to routinely skip breakfast. She often skipped lunch as well, but then-famished-would overeat in the late afternoon and evening.
The overeating episodes intensified, in both frequency and volume of food, and Ann increasingly felt out of control. Worried that the binges would lead to weight gain, she started inducing vomiting, a practice she learned about in a magazine. She first thought this pattern of behavior to be quite acceptable and saw self-induced vomiting as a way of controlling her fears about weight gain. The pattern became entrenched: morning food restrictions followed by binge eating followed by self-induced vomiting.
Ann continued to function adequately in college and to maintain friendships, always keeping her behavior a secret from those around her. After college graduation, she returned to her hometown and took a job at a local bank. Despite renewing old friendships and dating and enjoying she often did not feel well. She described diminished energy and poor sleep, as well as various abdominal complaints, including, at different times, constipation and diarrhea. She frequently made excuses to avoid friends, and she became progressively more socially isolated. Her mood deteriorated, and she found herself feeling worthless. At times, she wished she were dead. She decided to break out of this downward spiral by getting a psychiatric referral from her internist.
On mental status examination, Ann was a well-developed, well-nourished female, in no apparent distress. Her BMI was normal at 23. She was coherent, cooperative, and goal directed. She often felt sad and worried but denied feeling depressed. She denied an intention to kill herself but did sometimes think life was not worth living. She denied confusion. Her cognition was intact, and her insight and judgment were considered fair.
Discuss your diagnosis and reasons on the discussion board.