- Provide a full DSM-5 diagnosis of the client. Remember, a full diagnosis should include the name of the disorder, ICD-10-CM code, specifiers, severity, and the Z codes (other conditions that may be a focus of clinical attention). Keep in mind a diagnosis covers the most recent 12 months:
F50.02 Anorexia Nervosa, Binge Eating/Purging Type, in partial remission
Z72.4 Inappropriate Diet and Eating Habits
Z60.0 Phase of Life Problem
Z62.820 Parent Child Relational Problem
- Explain the diagnosis by matching the symptoms identified in the case to the specific criteria for the diagnosis:
Gina matches criteria for Anorexia Nervosa based on the following qualifying symptoms:
A- Not Present, as in scenario Gina’s doctor stated she was in weight range for Gina’s age.
B- Intense fear of gaining weight or of becoming fat.
C- Influence of body weight or shape on self-evaluation
Bing-eating/purging type- within the last 3 months has engaged in self-induced vomiting.
In Partial Remission- Disturbances in self-perception of weight.
- Recommend a specific evidence-based measurement instrument to validate the diagnosis and assess outcomes of treatment.
Client self-report Patient Health Questionnaire that covers depression, anxiety, alcohol, somatoform and eating disorder. This assessment is high sensitivity and specificity and is a valid and reliable in assessing the severity of depressive symptoms. It requires the client to be able to read and understand the questions which Cornell displays capabilities of doing so. This scale can also quantitatively assess responses to treatment and can catch any reductions of symptoms.
- Explain why it is important to use an interprofessional approach in treatment. Identify specific professionals you would recommend for the team and describe how you might best utilize or focus their services.
Some people can benefit from a stand-alone service and others will need to be treated for their physical, psychological, nutritional and functional aspects of their eating disorder. All four of the mentioned components in treatment have to work together in order to show progress in one area which will enable and support progress in the other areas. Some like Gina who has an eating disorder might need a multidisciplinary response to her immediate presenting health problem being the eating disorder. Inviting Gina’s doctor (who can talk through the signs and symptoms of the eating disorder), a nutritionist (who can provide general support to people with eating disorders in relation to nutrition education) and a psychologist (who can conduct assessments and conduct counseling for other problems like social problems) can all work collaboratively in assessment, treatment planning and treatment review to ensure safe treatment options.
- Explain how you would use the client’s family to support recovery. Include specific behavioral examples.
I would assist the family by encouraging and creating exercises that would demonstrate drawing the family closer together and to re0affirm their love and support for Gina or anyone with an eating disorder. Since Gina mentioned that her parents only reactions to her situation with her boyfriend being “there’s plenty of fish in the sea”, involving them in treatment can help Gina overcome any other barriers and resentments in that relationship by letting them be involved in the treatment process.
- Select and explain an evidence-based, focused treatment approach that you might use in your part of the overall treatment plan.
I am going to jump from usually using CBT, to utilizing IPT (Interpersonal psychotherapy) as it contextualized eating disorder symptoms as occurring and being maintained within a social and interpersonal context. IPT is associated with specific tasks and strategies linked to the resolution of a specified interpersonal problem area. IPT can help Gina and even her family improve relationships and communications and resolve interpersonal issues in identified problem areas.
- Explain how culture and diversity influences these disorders. Consider how gender, age, socioeconomic status, sexual orientation, and/or ethnicity/race affect the experience of living with an eating disorder.
There are cultures where they emphasis on being thin, especially if it linked to success. Across cultures there are different variations on the ideals of beaty as in some culture’s plumpness is considered more attractive and desirable. Attitudes and dynamics can contribute to the risk of a teen developing an eating disorder where they are focusing on high achievement, emphasis on being perfect, concerned about appearance, difficulty talking about or coping with negative emotions, worry about being accepted socially and or concerned about physical appearance.
F43.20 Adjustment Disorder Unspecified
F50.8 Other Specified Eating Disorder, Atypical Anorexia Nervosa
Z60.4 Social Exclusion or Rejection
Z91.5 Personal History of Self Harm
Gina is a 14-year-old white female who has experienced a breakup with her boyfriend after he decided to date her best friend. She has been eating less which has caused weight loss and once Gina received compliments about her weight loss, she became focused on continuing to eat minimally. She counts her food intake and plans at night what she will eat the next day to assure herself she will continue to lose weight. Gina has topped eating family meals and also makes herself vomit if she believes she has eaten too much. Gina denies there is a problem, denies depression and is still doing well in school. Gina was seen by a doctor who stated she is thin but was not in abnormal range for weight. However, her eating habits have caused her to have arguments with her parents, one of which she became very angry, screaming, and then cut her wrists.
The first place I considered for Gina’s mental health condition was the Decision Tree for Appetite Changes or Unusual Eating Behavior. Following the boxes led me to consider Anorexia Nervosa as a diagnosis. However, Gina did not meet criteria “A” because she does not have a low body weight. She also does not meet criteria for Bulimia Nervosa, because she does not purposely eat larger than normal amounts of food. The case notes states that she only makes herself vomit if she believes she has eaten more than she wanted. Gina does not binge eat, only gets fearful she has eaten too much. I then considered Other Specified Feeding or Eating Disorder. It appeared to me that Gina met criteria for anorexia nervosa, except her weight is in normal limits. The other criteria for anorexia nervosa Gina meets are criteria “B”, she has a fear of gaining weight with a persistent behavior to interfere with weight gain, and “C” she experiences undue self-evaluation regarding her body weight. Therefore, her specifier is atypical anorexia nervosa.
Gina’s eating disorder did not appear out of the blue but was a reaction to a stressor in her life. Gina met criteria “A” in that she developed symptoms within three months of the break-up. She also met criteria “B” in that she has marked distress out of proportion to the severity of the stressor. She also met criteria “C” in that her symptoms are not present due to a preexisting mental disorder. Gina is not experiencing normal bereavement due to loss, so “D” is met. I then had to pick a specifier keeping in mind that Gina is not having depressed mood, nor anxiety, nor a disturbance in emotions or conduct. Therefore, I chose Unspecified because Gina’s reactions are not classifiable as one of the above subtypes.
I then considered the symptom of self-harm due to her cutting her wrists during an argument with her parents. After reviewing the self-harm tree, I came to no conclusion, but the impulsivity tree led me to adjustment disorder, which I had already pinpointed. I wanted to make sure the writs cutting was identified so I went to “Z” codes. I chose history of self-harm due to this incident, but also came across social exclusion or rejection. Gina’s whole experience started after her boyfriend broke up with her to be with her best friend, so she was rejected by both.
Importance of Using an Interprofessional Approach: Specific Professionals Recommended
The interprofessional approach is necessary when working with those who are experiencing symptoms of eating disorders.
It is important that the client and family is linking with a medical doctor to monitor physical health, a dietician to guide the client and family on nutrition, and the therapist/clinician to provide psychological interventions (Lewis & Nicholls, 2016). If I were the clinician for Gina, I would have a consent for release of information obtained so that I, her medical doctor, and a dietician could keep close contact and work together on her treatment. The doctor could possibly prescribe medication, the dietician would teach the importance of nutrients and a healthy diet, and I would provide appropriate psychological interventions.
Use the Client’s Family to Support Recovery: Specific Behavioral Examples
Gina should have individualized therapy to help her with coping skills, but it has also been proven important for a minors family to be involved in treatment in cases of Anorexia Nervosa (Lewis & Nicholls, 2016). I have found an article that details family-based treatment (FBT) through adolescent anorexia nervosa. The article recommends that families go through three stages. In the first stage the clinician helps the parents develop a plan for restoring the adolescents health by taking over food and activity as well as being taught techniques to encourage their child to eat more. This empowers the parents to take control and have family decision-making. In the second stage, when there is medical evidence of the child’s physical stabilization, the family gives appropriate control of food over to the adolescent and any other relationship issues are worked out in family therapy. During the third stage, focus is on the impact the eating disorder has had on the family and recovery as a family unity (Bhatnagar, 2014). I would choose to use this FBT as well as individualized therapy with Gina in addition to linkage with medical and dietician professionals.
Evidence-based, Focused Treatment Approach
As of 2015, the only evidence-based treatment proven to be effective for adolescents with anorexia nervosa was FBT (lock, 2015). As stated above, I would use this treatment along with the interdisciplinary team of medical and dietician professionals. However, I do believe it would be beneficial to have Gina participate in cognitive behavioral therapy (CBT). Through CBT, Gina would learn how her thoughts of being overweight are negatively affecting her feelings and her behavior. Aiding Gina in changing those thoughts would change the feelings and behavior once she learned appropriate tools (Turner, 2017).
How Culture and Diversity Influence Eating Disorders
It has been proven through past studies that culture and the associated beliefs and attitudes play a significant part in developing eating disorders (Miller & Pumariega, 2001). Although eating disorders have been present in many places around the world, anorexia nervosa was previously thought to be rooted in western culture and has even been referred to as “culture-bound syndrome”. As focus of a culture gears more towards physical appearance and fitting in with those in the environment increases in eating disorders are noticed. Eating disorders have been recognized to be more present in various cultures than previously thought, especially where western culture and values are adopted. Rates of eating disorders increase where focus on aesthetics become of value (Miller & Pumariega, 2001).
Bhatnagar, Ph.D., K. (2014). The Importance of Family Involvement in Adolescent Eating Disorder Treatment. Eating Disorder Hope. https://www.eatingdisorderhope.com/treatment-for-eating-disorders/types-of-treatments/family-therapy/a-family-force-field-the-importance-of-family-involvement-in-adolescent-eating-disorder-treatment
Lewis, B., & Nicholls, D. (2016). Behavioural eating disorders. Paediatrics and Child Health, 26(12), 519–526. https://doi.org/10.1016/j.paed.2016.08.005
Lock, J. (2015). An Update on Evidence-Based Psychosocial Treatments for Eating Disorders in Children and Adolescents. Journal of Clinical Child & Adolescent Psychology, 44(5), 707–721. https://doi.org/10.1080/15374416.2014.971458
Miller, M. N., & Pumariega, A. J. (2001). Culture and Eating Disorders: A Historical and Cross-Cultural Review. Psychiatry: Interpersonal and Biological Processes, 64(2), 93–110. https://doi.org/10.1521/psyc.184.108.40.20621
Turner, F. J. (2017). Social work treatment interlocking theoretical approaches. New York Oxford University Press.