Pennsylvania State University
Case Study: April - Anorexia Nervosa
April was a 17-year-old high school freshman who presented with severe emaciation due to self-starvation and excessive exercise. Despite being severely underweight, April indicated an intense fear of gaining weight. She bragged about how much weight she had recently lost, though she indicated that her "butt was still too fat." She also reported that she was constantly fatigued, had become socially withdrawn and depressed, and that her menstrual period had become highly irregular. The clinician noted a provisional diagnosis of 307.1 Anorexia Nervosa (American Psychiatric Association [DSM-IV-TR], 2000), as she was fairly certain that April would meet the full diagnostic criteria for the disorder but currently lacked adequate information to support a firm diagnosis. Diagnosis and Differential Diagnosis
Initially, April was subjected to both a physical and a neurological examination in order to rule out a primary medical condition as the reason for her weight loss and other reported symptoms. During the medical exam, April elaborated that she had not had her menstrual period for six months, thus indicating amenorrhea. She also informed the doctor that she had been having abdominal pains, was often very cold, and had developed a light, fluffy hair on her torso, which the doctor informed her was called lanugo. Most notably, April’s body weight was only 65% of what it should have been for a young woman of her age, height and build. It was determined that these issues were unrelated to a general medical condition and thus, the Axis III diagnosis was listed as “None.”
Based upon April’s symptoms and the absence of a general medical condition to explain her symptoms, it was believed that she had an Axis I clinical disorder. She refused to maintain a minimally normal body weight, indicated an intense fear of gaining weight, and despite her emaciated condition, continued to believe that certain parts of her body were still “fat.” She had been eating only 200 calories per day and would spend 4-5 hours on the treadmill each day. Although severe weight loss can occur with Major Depressive Disorder (MDD), April’s conscious desire to engage in extreme dieting and inordinate fear of weight gain were inconsistent with MDD (DSM-IV-TR, 2000). Individuals with schizophrenia also occasionally experience massive weight loss, but April’s distorted self body image and fear of weight are rarely seen in schizophrenia (DSM-IV-TR, 2000). Social phobia was ruled out as April failed to demonstrate any social fears that were unrelated to eating behavior (DSM-IV-TR, 2000). She did not exhibit any obsessive-compulsive tendencies unrelated to food, such as an excessive fear of germs, and thus a potential diagnosis of Obsessive-Compulsive Disorder was dismissed as well. She did not impart any distorted views of other parts of her body, such as the size of her head, so a diagnosis of Body Dysmorphic Disorder was not considered (DSM-IV-TR, 2000). Finally, a potential diagnosis of Bulimia Nervosa was disregarded as April had only maintained a body weight of 65% of what would be considered normal for a woman of her age, height, and build. These factors, along with the presence of amenorrhea, confirmed that April did indeed meet the full diagnostic criteria for the Axis I clinical disorder, 307.1 Anorexia Nervosa, Restricting Type (DSM-IV-TR, 2000).
As the multiaxial evaluation progressed, it was determined that April did not meet the criteria for an Axis II diagnosis, which is concerned with personality disorders and mental retardation (DSM-IV-TR, 2000), and thus her Axis II diagnosis was recorded as “V71.09 No diagnosis.” However, her clinician did note problems with her primary support group, as indicated along Axis IV, which is concerned with psychosocial and environmental problems (DSM-IV-TR, 2000)....