Problem
Scenario:
Matteo is an 18-year-old bisexual adolescent of Latino decent, who has been on and off diets for the past five years. They are in their sophomore year of an accelerated bachelor's degree program and have been binge eating takeout meals from fast food restaurants on campus late at night. The binge eating episodes have become so expensive that Matteo's parents have addressed this overspending, which has led Matteo to begin shoplifting and stealing money to support the bingeing.
Currently, Matteo has been binge eating at least three times a week over several months. This episode followed the breakup of a stormy relationship with their high school boyfriend. They are beginning to gain weight even though they restrict food between bingeing episodes and induce vomiting afterward to control weight. In the past, they have used laxatives and diuretics to rid themselves of calories but did not like the side effects of constipation. Matteo's eating problems became severe when they started college and was living in a dormitory with a self-serve cafeteria.
As a child, Matteo had difficulty controlling snacks between meals and would get into arguments with their parents, who threatened to put a lock on the refrigerator. Matteo's weight has fluctuated by 10 to 20 pounds within several months. They is secretive about the binge eating, which is difficult to manage because they live in a quad with other students. They plan the late-night episodes and then often walks downtown through unsafe neighborhoods to consume food and vomit. Recently, they have been approached by older men who are soliciting them. Parents found out from one of Matteo's friends who was concerned about their judgment.
Matteo fears gaining weight because they are on scholarship with the dance department. Matteo often goes days without eating. They have begun using methamphetamine with a new acquaintance for the euphoric and appetite suppressing effects. Matteo has had problems with insomnia for many years but recently reports decreased need for sleep.
Matteo has been having headaches, muscle cramps, and fatigue for several days and has not been going to dance practice. They are being seen by the nurse practitioner in the health clinic with whom Matteo confides that they "feel horrible and need some help." Physical exam and labs show serum potassium at 3.2 mEq/L, BUN:creatinine ratio >58, volume depletion, scarring on the dorsum of the right hand, dental caries, and enamel erosion.
A. What important information is missing from the case study?
B. Discuss normal developmental achievements and potential vulnerabilities.
C. What precipitating factors could be contributing to the current symptoms?
D. What is the differential diagnosis?
E. Describe the etiology of the primary diagnosis.
F. How should physiologic complications be monitored and assessed?
G. What are the usual nonpharmacologic therapies that would help?
H. What medications could help and why?
I. Identify safety risks and how they should be dealt with in the treatment plan.