Author: Taryn A. Myers, Virginia Wesleyan College
Please note: Clinical Choices allows you to enhance and test your understanding of the disorders and treatments covered in your textbook, in a simulated case study environment. It is not intended to replicate an actual intake interview or therapy session or provide training on therapeutic techniques. Clinical Choices is for educational purposes only and is not intended as a substitute for clinical training.
The receptionist hands you the intake paperwork prior to your intake interview with your new client, Jenny, and mentions that she looks very pale and sickly. Click on the button below to review the paperwork before you begin the interview.
Jenny: Case #10111
Client Name: Jenny
Age: 20 years old
Ethnicity: Asian-American and Caucasian
Current living situation: I live with my parents
Why are you seeking services at our clinic?
My friends dragged me here. They said they are worried about my eating habits. I can’t help it if I’m healthier than they are. I think they’re just jealous.
You will now ask Jenny a number of questions you would typically ask during the intake interview. As you conduct the interview with Jenny, begin to think about her symptoms, what her diagnosis might be, and later, what type of treatment might be most helpful to her. Click the “play” button below the illustration to hear Jenny’s responses to your questions. To read the transcript for these answers, click on the “transcript” button. Take notes in the box provided as you listen to Jenny’s responses.
“Hi Jenny, it’s good to meet you. What we are doing today is called an intake interview. I’m going to have you tell me what brought you here today and ask you some questions that I ask everyone who comes to the clinic. This information will tell me how best to help you. This may mean continuing to see me for therapy at this clinic, or it may involve referring you to another mental health professional or facility. I see from your paperwork that your friends encouraged you to come, but you are not sure you need to be here. Asking you these questions will help us determine if you need any kind of assistance, so bear with me as we go through them. Let’s start. Tell me about what brought you to the clinic today.”
Jenny: Well, like you said, my friends kind of dragged me here. They say that I have an eating disorder. That’s ridiculous. I think they’re just jealous because I have more self-discipline than they do. If anything, I eat more healthily than they do! They just bugged me about it so much that I figured I’d come talk to you to get them off my back.
Check Your Notes
- Friends encouraged/dragged her to the clinic
- Friends concerned about her eating habits
- She thinks her friends are just jealous
“Hmm. That sounds like an awkward situation. Why do you think they are concerned?”
Jenny: They say they are worried about my weight. They think I’m losing too much weight. I think that’s crazy. [earnestly and emphatically] I have to be very careful about what I eat to make sure I don’t gain weight … I gain weight very easily. I don’t think I worry about my weight any more than I have to or any more than my friends do… Like yesterday I really pigged out at dinner, so I was super anxious when I got on the scale this morning. Luckily, I weighed the same as yesterday. It’s such a battle to keep my weight where I want it to be. I’ll set a goal for myself … my current goal is to lose 5 more pounds … then I’ll be good. Of course, I thought that before, but when I reached my current weight … well, as you can see … I’m still fat. My friends still call me skinny – it’s crazy! Can’t they see this fat on my gut? Don’t even get me started on my thighs! I really want that “thigh gap,” but I just can’t seem to get it. Maybe you can answer this – is there a weird condition where my body can hold onto fat in some places – like my hips and, thighs – but lose it in others?
Check Your Notes
Why are friends concerned?
- Jenny’s friends are worried about her weight
- They think she is losing too much
- She says she has to watch what she eats
- Mentions she wants to continue losing weight
- Current goal is to lose 5 more lbs.
-Has set and changed weight loss goals in past
- Friends say she is skinny
-She sees fat on her stomach & thighs
- Wonders if she can hold onto fat in some body areas but lose it in others
Which of the following disorders is a potential diagnosis for Jenny based on the symptoms she has just shared? Check ALL that apply. To review the diagnostic criteria for each disorder, click on the disorder name.
|wCfH0QtRgXJ8o+c+||Binge eating disorder|
|bI0LPa9lfHQ+dYqk||Body dysmorphic disorder|
Think about Jenny’s loss of weight and concern with her weight.
“I’ve never heard of a physical disorder where that happens, but I’ve certainly heard of disorders where psychological symptoms can give people those perceptions. However, I need a lot more information from you before we can determine if there is anything we should work on together. Let’s start with some simple information – can you share your height, your current weight, and your highest, and lowest weights?”
Jenny: [a little proudly] Okay, so I’m 5’5” and I just finally got down under 100 lbs. As of this morning, I weigh 98 lbs. I’m never going to let myself get above 100 lbs again! But it was so hard to get here. [pause] I was heaviest probably when I was 14 when I got my period. [disgusted] I think I hit [disgusted] 130 lbs then because my body changed so fast. I focused on controlling my weight after that. When I was 17, I finally got down to 105 lbs. You know what? I just realized that before now, 105 was my lowest weight! [excited] I’m currently at my lowest weight ever! That was so hard. When I was 17 I broke my hip and I gained all this weight when I was recovering and couldn’t work out. I just started losing weight again this year. [quieter, sad] I was dating this guy Josh, and he broke up with me for a skinnier girl. So I decided to lose weight again, to show him. It was really easy – I just slipped back into my old routine.
Check Your Notes
- 5’5’ & 98 lbs
- Obsessed with not getting over 100 lbs
- Highest weight 130 lbs at age 14 (after puberty)
- Lowest weight = current weight
- Age 17 → down to 105 lbs
- Just started losing weight again this year
30.0 and Above
Check the BMI Status Chart to see what category Jenny’s BMI falls under.
“A broken hip at 17 – that sounds really painful! I’ve got to ask, how did you break your hip at such a young age?”
Jenny: It was painful! And it took so much physical therapy to rehab it! I used to be a competitive figure skater. My mom got me into it when I was real young, and she was so encouraging, taking me to early morning practices, enrolling me in competitions and celebrating when I won. [sadly] then I had a bad fall… on the ice. The doctors told us that I was malnourished and had brittle bones. … I guess I was more vulnerable to fractures… [sadly] I never went back on the ice.
Check Your Notes
How did you break your hip?
- Competitive figure skater
- Broke hip falling on ice
- Doctors said she was malnourished → bones brittle
- Stopped skating
“You must miss figure skating. How long did you skate?”
Jenny: Yeah… sometimes I do miss it. It was such a big part of my life. I started when I was only 3, and I skated competitively until I broke my hip. I don’t miss the practice, though! It was tough. I practiced for hours after school every day, and when I wasn’t practicing, I was in the gym cross-training or trying to fit in my schoolwork. Figure skating emphasizes having “the right kind of body” and looking good… long and lean—… like a dancer. I figured this out pretty early on—in the third grade when my mom caught me eating chips and told me I couldn’t eat like other people if I - was serious about skating. I mean, it was obvious to her I didn’t have a naturally thin body.
Check Your Notes
- Misses figure skating
- Started when she was 3, skated till age 17
- Practiced and cross-trained for hours every day
- Sport emphasizes a long, lean body
“That’s a lot of pressure for a young girl. Tell me more about your family. What was it like growing up in your household?”
Jenny: I don’t want you to think my mom was mean – she was just being honest! She just always pushes me to be my best. I am who I am today because she has such high standards for me. I was an only child, but I wasn’t spoiled. My dad worked really long hours – he is a doctor in the E.R. – so sometimes it could be a little lonely. My mom was like my best friend. I told her everything, and she told me things, too. My parents set a very good example –they drilled it into me to always look and be my best. Mom wants to be perfect in everything she does, and she gets down when something goes wrong. She and I stay up and talk … sometimes my mom would cry and tell me how she felt like a failure. [quieter, smaller voice] That’s hard to hear. Those conversations felt really awkward, like I knew too much about her. [embarrassed] It’s also awkward when my mom comments on my clothes or how I look. Sometimes I feel like I don’t have any privacy.
Check Your Notes
Tell me about your family:
- Mom wasn’t mean, just honest
- Only child, not spoiled
- Dad worked long hours as ER doctor
- Mom was her “best friend”
- Parents emphasized looking and being your best in all situations.
“I feel like we keep circling back to your appearance and your weight. You said you came in because your friends were concerned about your eating habits. Can you share with me what a typical day of eating and exercise is like for you?”
Jenny: That’s easy! I try to keep it the same every day. I weigh myself first thing in the morning. Then I write down everything I’ll eat for the day. I don’t eat breakfast because I go to the gym right away. I do at least 90 minutes of cardio and 30 minutes of weights. Sometimes the manager there is so annoying – he tried to send me home once because he said I looked like I was going to pass out. [annoyed] What does he know? … So if my workout goes well, then I go home and let myself eat lunch. I always have a plain salad – no dressing, too much fat – half a can of tuna, and a diet soda. Between classes I allow myself to have coffee with my friends. They always want me to snack, so I bring my own healthy food, but I try not to eat it, especially if I’ve had lunch. If they stare at me until I eat it, I have a hard time paying attention in my next class because I can’t stop thinking about all those calories! I swear I can feel my fat cells ballooning. It’s so disgusting! At night, I eat a low-cal frozen meal or my new favorite, fat-free cottage cheese, corn, and hot sauce. If I eat too much during the day, I won’t eat at night. I don’t eat more than 500 calories per day. [more quietly, ashamed to admit this] Sometimes I wish I could throw up if I eat too much. … I can’t make myself do it like so many other people can. So I just sit there feeling fat and gross.
Check Your Notes
- Maintains an exercise and eating routine
- Checks her weight first thing in the morning
- Writes down what she will eat
- Doesn’t eat breakfast
- Goes to gym
- If workout goes well, she eats lunch
- Coffee with friends, sometimes a snack
- Hard to pay attention in class → thinks about calories she’s consumed
- Doesn’t eat more than 500 calories / day
- Has tried to vomit to purge → unsuccessfully
- Feels gross and fat if she eats too much
Think about how much Jenny says she is eating relative to her other reported behaviors.
“You’ve clearly thought through your daily activities very carefully. Jenny, this is going to sound like a strange question, but do you ever find yourself thinking about food all the time, or cooking for other people?”
Jenny: [Surprised] How did you know? Actually, I love looking for new recipes and cooking for my friends and family. I don’t eat with them because I’m always prepping the next course, but I love to see people enjoying my cooking. … [pauses] Sometimes I do think a lot about food and calories. It’s worst when I’m hungry. I hate feeling hungry – it’s a sign of weakness. When I’m hungry, I drink water and diet soda to fill up… I love watching other people eat, because then I realize how much more control I have.
Check Your Notes
Thinking about food/cooking for others:
- Loves to look for new recipes
- Loves to cook for others
- Thinks about food a lot, especially when hungry
- Hates feeling hungry → sign of weakness
- Likes watching others eat → feels in control
“Do you remember when you first started thinking about food this much?”
Jenny: Yeah… When I was 14 and my body changed. I had a really hard time skating with my new body… my coach told me I was getting chubby. He told my mom to take me to a dietitian, and they put me
on a really strict diet. My mom monitored my diet and planned all my meals. I lost like 15 lbs in 6 months, and everyone told me I looked great! That’s when I started focusing on what I ate and food even more. I even started dreaming
about eating! I felt really strong when I controlled what I ate and lost weight. I was able to keep losing weight ... [an afterthought] I did get some weird side effects, like my hair being dry and breaking, and my fingernails cracking
really easily. Oh! …and I was freezing all the time, not just when I was at the rink. Then when I broke my hip I couldn’t train or exercise. I gained all the weight back… – and then some. Then I didn’t think about it for a while.
Check Your Notes
When she started thinking about food:
- Age 14 → body changed
- Coach told her she was getting “chubby”
- Mom took her to dietitian
- She lost 15 lbs in 6 months
- Side effects
- Then she broke her hip → gained weight and stopped thinking about food all the time
Which of the following could be reasons why Jenny started engaging in restrictive eating habits? More than one answer could be correct. Select all that apply.
|bI0LPa9lfHQ+dYqk||Jenny’s coach’s comments about her being “chubby.”|
|bI0LPa9lfHQ+dYqk||Jenny’s dietitian putting her on a strict diet.|
|wCfH0QtRgXJ8o+c+||Jenny’s hair and nails being dry.|
|bI0LPa9lfHQ+dYqk||The compliments Jenny received about her weight loss were reinforcing.|
|wCfH0QtRgXJ8o+c+||Jenny was affected by thin images of celebrities she saw in the media.|
|wCfH0QtRgXJ8o+c+||Jenny’s friends encouraged her to lose weight.|
Think about the ways in which others’ feedback might have influenced Jenny’s behaviors.
“I’d like to get to know you a bit more, Jenny. How is school going? What do you like to do in your spare time? “
Jenny: I’ve always been good at school – I’ve always been a straight-A student. I graduated high school with a 3.96 GPA. I got accepted to all these highly competitive schools, but then [pause] I decided to go to community college with my friends. My dad was so embarrassed of me. He told people at church I was “taking a year off” to think over my academic goals and find the “right” school. [sadly] I was so sorry I let him down. I wish we were closer… and then broke my hip and had to go through all that rehab. When I was 19, I decided to transfer to the state college, where I am now. I’ve done really well, but lately I’ve been having a hard time concentrating and sleeping, so my grades are slipping a little. I really want to move out, but I don’t want to leave my mom alone, so I still live at home. That can make it hard to socialize. I volunteer at an animal shelter on the weekends ... [softly] I love animals. My friends don’t get my relationship with my mom or my focus on dieting … [softly] the animals don’t judge me.
Check Your Notes
School spare time activities
- Good at school → straight A’s
- Applied to and got into highly competitive colleges
- Chose to go to community college with friends
- Broke hip and postponed college
- Transferred to local state college at 19 → now a senior
- Having a hard time concentrating
- Wants to move out, but doesn’t want to leave mom alone
- Enjoys volunteering at an animal shelter
Think about the reason Jenny came to therapy.
“Jenny, you told me that other people have expressed concern about your eating habits. Have you ever been concerned about your focus on food and your weight?”
Jenny: [quietly] This morning, when I woke up, I thought to myself, “I can’t live like this anymore. I really
think I might die.” [with determination, convincing herself] But then I snapped out of it and told myself not to overreact and
that I was just shaky and weak because I had just woken up.
Check Your Notes
Concerned about focus on food and weight?
- This morning woke up thinking she might die
- Told herself not to overreact
- Told herself → weak because she had just woken up
Think about how Jenny described her symptoms and her struggle with them.
Which of the following symptoms is Jenny currently experiencing? Check all that apply. Use your interview notes to help you remember!
|bI0LPa9lfHQ+dYqk||Significantly low body weight|
|wCfH0QtRgXJ8o+c+||Eating a large amount of food in a short amount of time|
|bI0LPa9lfHQ+dYqk||Restriction of energy intake|
|wCfH0QtRgXJ8o+c+||Sense of lack of control over eating|
|wCfH0QtRgXJ8o+c+||Vomiting to prevent weight gain|
|bI0LPa9lfHQ+dYqk||Fear of gaining weight|
|wCfH0QtRgXJ8o+c+||Misuse of laxatives to prevent weight gain|
|bI0LPa9lfHQ+dYqk||Fear of becoming fat|
|bI0LPa9lfHQ+dYqk||Behavior that interferes with weight gain|
|bI0LPa9lfHQ+dYqk||Misconception about her weight and/or shape|
|wCfH0QtRgXJ8o+c+||Eating until feeling uncomfortably full|
|bI0LPa9lfHQ+dYqk||Lack of recognition of the risks of extremely low weight|
|wCfH0QtRgXJ8o+c+||Eating more rapidly than usual|
From the File. You remember a former patient who exhibited symptoms similar to Jenny’s. You review this case to help you diagnose Jenny.
Note: 4 stone = 56 pounds
Think about Jenny’s weight loss and excessive concern with her weight.
Think about Jenny’s diet and how she monitors her food intake.
Think about who might be putting pressure on the cheerleaders.
Think about how many perspectives are being considered.
In making your choice, think about research on the role of the enmeshed family pattern in anorexia nervosa and Jenny’s relationship with her mother.
When you explained to Jenny that she met criteria for a diagnosis of anorexia nervosa, she was shocked. She had difficulty believing that anything was wrong with her. However, she did acknowledge that she had expressed a nagging worry that she might die during her intake interview, so she agreed to therapy. You validated her concerns, explaining that anorexia nervosa has the highest mortality rate of any of the mental disorders and emphasizing that many individuals have to be hospitalized when their symptoms are severe. You reassured her that you believed she could address her symptoms on an outpatient basis for now, but insisted that she also see a primary care doctor to monitor her physical health and a nutritionist you often work with who has specialized training in working with patients with eating disorders. You explained to her that if she lost too much weight, there was a chance she would have to enter a residential treatment program.
Jenny was hesitant to involve her parents in her treatment because she thought her diagnosis would disappoint them. However, when you explained the research showing the effectiveness of family therapy and the rationale for how the entire environment needs to change to support recovery, she reluctantly brought her parents to therapy. Her father was very resistant to the diagnosis at first, as he could not believe that, as a doctor, he would have missed a problem this serious in his own daughter. Jenny’s mother was devastated and blamed herself for Jenny’s problem, which only made Jenny feel guiltier. However, with your psychoeducation about anorexia nervosa and how helpful family therapy would be, you were able to get everyone on board. You started her treatment by enlisting Jenny’s parents in helping her establish regular, healthy eating habits to help her gain weight to attain a healthy BMI.
Treatment, as with any patient with anorexia nervosa, was a long haul. Jenny would be eating regularly with a plan, but then she would be scared by her weight gain and slide back to her old unhealthy eating habits. However, with your help, she learned to see these as “lapses” not “relapses” and get back on track with eating healthfully. Having her parents on board to encourage Jenny to eat regularly and healthfully was a vital part of helping to keep her on track.
Once Jenny had maintained a healthy weight for some time, she was able to talk to her parents about her desire to move out and be independent. Her mother was resistant at first, but when Jenny reminded her parents that she was about to graduate from college and talked about how difficult it was for her to support her mother, her mother seemed to understand. About 6 months after she graduated from college, Jenny got her first apartment. She began work at her first full-time job, which she enjoyed. She was considering graduate school, but acknowledged that she needed to give herself time outside an achievement-oriented environment to cement her recovery from anorexia nervosa before entering graduate school.
Real World Application