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Eating disorders include anorexia nervosa, bulimia nervosa, and binge-eating disorder. Patients with anorexia or bulimia have a disturbed body image and use extreme measures to avoid gaining weight (vomiting, laxatives, diuretics, enemas, fasting, and excessive exercise). Patients with binge-eating disorder typically binge in response to negative emotions.
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Ms. Williams is a 17-year-old female without prior psychiatric history who is brought to the emergency room by ambulance after her parents called 911 when they found her having a seizure in their living room. She was admitted to the medical intensive care unit in status epilepticus and was quickly stabilized with intramuscular lorazepam and fosphenytoin loading. Her height is 5 feet 6 inches, she is of medium build, and her weight is 101 pounds (BMI 16.3 kg/m2). She has no significant medical history, and this is her first seizure. Laboratory workup shows an electrolyte imbalance as the most likely cause for her seizures. Although initially reluctant, she admits to self-induced vomiting several times this week. She reports that although she normally restricts her daily caloric intake to 500 calories, she regularly induces vomiting if her weight is above 100 pounds. Her last menstrual cycle was 1 year ago. Psychiatric consultation is requested in order to confirm her diagnosis.
As the psychiatrist on call, you evaluate Ms. Williams and find that she appears underweight and younger than her stated age. She is in mild distress, has a nasogastric tube in place, and exhibits poor eye contact. She reports feeling “sad” and admits to experiencing constant preoccupation about her physical appearance, stating “I’m fat. I hate my body.” She also reports insomnia, low energy levels, and a history of self-harm behavior by cutting her forearms. She reports that she is careful in hiding her symptoms from her parents, whom she describes as strict disciplinarians. She also expresses concerns that she will disappoint them.
Ms. Williams's parents describe her as a perfectionist. They say that she is involved in multiple school activities, takes advanced placement classes, and has been recently concerned about being accepted to her college of choice. They report that she has maintained a 4.0 grade point average in high school, and they expect her to become a doctor. Her parents have noticed that she is underweight and rarely see her eat, but have attributed this to stress from her many academic pursuits. Ms. Williams's mother receives treatment for obsessive-compulsive disorder.
What is Ms. Williams's most likely diagnosis?
The most likely diagnosis is anorexia nervosa—binge-eating/purging type. As described above, she refuses to weigh more than 100 pounds, which is significantly below the minimal normal weight for her height. Despite being underweight, she expresses intense fear of gaining weight and has a disturbed self-image. In addition, she has engaged in binge-eating/purging behavior regularly. You should also explore for comorbid depression, anxiety, and a personality disorder. Remember that malnutrition in itself can lead to some of the symptoms experienced in depression, ...