One assignment, a psychiatric evaluation, is worth 10% of this course grade. Students will be expected to select one of the patients in the clinical site without using any identifiable demographics and write a psychiatric evaluation of the client and case formulation.
1
Psychiatric Evaluation
Chief of Complaint
“I am not bulging any more but still feel the pressure.”
History of Present Illness
Patient began with concerns about weight since the high school when tried to be accepted
into a new group of peers. She graduated with honors from the college, for which she earned a
scholarship for bachelor in accounting. During the time she was an accounting student, she
increased the purging behavior and obsession with body´s features. She met her current partner
who never has complained about her physical and body´s features, but she feels compelled to be
desirable. Her family who never directly discovering her behavior. Eating from her generated
guilt because she does not want to look like the typical Latin which led her to start vomiting
without receiving information. On other occasions, she managed to regulate her food intake for
short periods, but physically she looked overweight. She affirms that binge eating has been
almost daily for months, and she rests for a couple of weeks, repeating her patterns due to a lack
of control over her thoughts and behaviors.
Past Psychiatric History
The patient states that she has no physical or mental diagnosis of any pathology or
disease. She claims to understand that her lifestyle is unhealthy, as she has seen her health
deteriorate due to binge eating and vomiting episodes. Since childhood, she has felt devalued,
guilty, and frustrated by other´s actions and words. She denies mental or genetic illnesses in her
family, but she believes this is due to the family’s poverty in accessing medical or mental
services. She does not know more information about the extended family of her mother or father.
2
Psychiatric Review of System (Psych ROS)
a) Anxiety: anxiety, guilt, frustration and bodily reactive.
b) Mania: abnormal charges of energy while eating and drops of energy after vomiting with
feelings of gratification.
c) Depression: episodes of sadness associated with binge eating that worsen after vomiting.
Feelings of shame, guilt, and hopelessness over your loss of control. She continues with her
personal, work, family, and social projects. There is no loss of interest in contact with others and
in receiving and giving affection.
d) Schizophrenia: denies hallucinations and irreal auditory, olfactory, and tactile experiences.
Denies feelings of persecution or delusions.
e) Panic Attack: denies night terrors, gasping, choking, drowsiness, or hypervigilance.
f) PTSD: denies changes in the personality or perception of reality in challenging events. Denies
feeling stress or anxiety when remembering events in the life.
g) OCD: denies fixation for order or perfectionism. Reports having a list, schedules, and
methods for eating and vomiting, but is not limited to complying with them.
h) ADHD: denies having deficiencies in social interaction and recognizes the affective and
bodily limitations of others. Maintains concentration and attention to different activities.
i) Eating disorders: reports having events of loss of control with thoughts of overeating. Has a
list, schedule, and programming to eat and vomit without others noticing. Reports guilt, shame,
sadness, and frustration when eating that are worse when vomiting. She sets aside money from
her income to buy food even if she must stop paying other bills. Binges almost daily or between
one or more events per day. Has constant thoughts about greasy, sweet, salty, and spicy food.
Avoid gatherings that include eating.
3
j) Personality Disorders: denies disorganization or alteration of the personality. Denies
suffering from self-harm, violent behavior, or aggressiveness. Reports to have routine behaviors
in which loses control overeating.
Mental Status Examination
a) Appearance: alert and oriented x 4-oriented in place, date, time, and space. Patient with good
posture, clean without visible neglect of hygiene. Evidence of oral deterioration, pain when
speaking, and red, swollen, and scarred fingers of the right hand.
b) Behavior and Psychomotor Activity: anxious patient with self-consolation and gratification
behaviors with upper extremities. Patient willing to answer the questions attentively and with the
congruence of her verbal expression with her body expression.
c) Consciousness: fully alert with proper manner. Understand commands and questions.
d) Orientation: LOCx4, to a person, place, time, and date.
e) Memory: evidence of ability to recall consistent information in the short, medium, and long
term. Remember details about home, clothing, and feelings at events.
f) Concentration and Attention: patient maintains concentration and attention during the
consultation, following instructions, responding to the response and receiving feedback in the
process.
g) Intellectual Functioning: appears to be average or above average.
h) Speech and Language: evidence of difficulty coming out after speaking if the subject of food
behavior is elicited. Coherence and congruence with the story referring to shared events with
fluency, ownership and mastery of words and ideas.
4
i) Perceptions: recognizes verbal, physical, and social stimuli during interview without
reactively responding to unreal events. Understands and distinguishes internal and external
stimuli. Evidence of altered self-perception of body composition.
j) Thought Processes: sadness, guilt, shame, frustration, avoidance with food fixation.
k) Thought Content: Easily understandable with coherent speech. No overvalued ideas,
preoccupations, or concerns.
l) Suicidality or Homicidal: No evidence of thoughts, planning and execution of suicide
attempts or harm to others.
m) Mood: sadness, guilt, shame, frustration, avoidance with food fixation.
n) Affect: sadness, emotional frustration, interest in receiving and giving compensatory affection
for attention and care.
o) Judgment: positively understands the consequences of actions. Ability to fulfill social, work,
academic and personal duties, and obligations.
p) Insight: Fair, understands the present mental state. Recognize the need of mental guidance
and assistance.
q) Reliability: ability to recognize feelings, emotions thoughts in general and evoked to specific
events.
The availability of psychometrically sound assessment instruments for assessing eating
disorder symptomatology is crucial for the clinical practice. Eating disorder screening tools and
questionnaires can help identify signs and symptoms that indicate a person has an eating
disorder. Tools that screen for eating disorders can help identify a person who is struggling and
allow them to get appropriate treatment. The accurate diagnosis of eating disorders serve for
tailoring treatment to the individual and monitoring patient progress during treatment.
5
Screening Tools for Eating Disorders
The SCOFF Questionnaire is a five-question screening tool designed to clarify suspicion that
an eating disorder might exist rather than to make a diagnosis. The questions can be delivered
either verbally or in written form.
S – Do you make yourself Sick because you feel uncomfortably full?
C – Do you worry you have lost Control over how much you eat?
O – Have you recently lost more than One stone (6.35 kg) in a three-month period?
F – Do you believe yourself to be Fat when others say you are too thin?
F – Would you say Food dominates your life?
Scores of 2 or greater were originally set a cut-off point for maximum sensitivity to
detect anorexia and Bulimia nervosa. A cut-off points of 3 has been suggested as the best
compromise between sensitivity and specificity. Patient has scored 4 which indicates a need for
further questioning and discussion.
The Eating Disorder Examination (EDE) is a diagnostic interview that reflects the current
DSM-5 diagnostic criteria for eating disorders. It is also available in The Eating Disorder
Examination Questionnaire (EDE-QS). Both are considered gold-standard screening tools.
The EDE-QS can be completed by a patient on their own, but the interview and
questionnaire include four subscales related to symptoms of eating disorders (restraint, eating
concern, shape concern and weight concerns). The screening tool also asks questions about
eating disorder behaviors, like using laxatives, how often binge eating occurs or whether a
patient exercises excessively. This information can help clinicians provide a more specific and
accurate diagnosis. The high score of 0.58 indicates more frequent and severe eating disorder
symptoms, and thus a higher risk of eating disorder.
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EATING DISORDER EXAMINATION QUESTIONNAIRE SHORT (EDE-QS)
Name: ______O.P.____
Date: ____03/07/2023__ Weight: _162__
ON HOW MANY OF
THE PAST 7 DAYS….
0
days
Height: __5´4”__ BMI: 27.8 kg/m2
1-2
days
3-5
days
6-7
days
1. Have you been deliberately trying to limit the
amount of food you eat to influence your weight or
shape (whether or not you have succeeded)?
3
2. Have you gone for long periods of time
(e.g., 8 or more waking hours) without eating anything
at all in order to influence your weight or shape?
3
3. Has thinking about food, eating or calories
made it very difficult to concentrate on things you
are interested in (such as working, following
a conversation or reading)?
3
4. Has thinking about your weight or shape made
it very difficult to concentrate on things you are
interested in (such as working, following a
conversation or reading)?
2
5. Have you had a definite fear that you might
gain weight?
2
6.
2
Have you had a strong desire to lose weight?
7. Have you tried to control your weight or shape
by making yourself sick (vomit) or taking laxatives?
0
8. Have you exercised in a driven or compulsive
way as a means of controlling your weight, shape
or body fat, or to burn off calories?
1
9. Have you had a sense of having lost control
over your eating (at the time that you were eating)?
0
10. On how many of these days ( i.e. days on which
you had a sense of having lost control over your
eating) did you eat what other people would
regard as an unusually large amount of food in one go?
OVER THE PAST 7 DAYS …
11. Has your weight or shape influenced how you
think about (judge) yourself as a person?
12. How dissatisfied have you been with your weight
or shape?
0
Not at all
Slightly
Moderately
Markedly
2
3
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Blood Laboratory Examination and Results
Clinical Impression
The patient developed a food aversion and inappropriate behavior which led to the
development of Bulimia nervosa. Since childhood, the relationship with food surrounded the
context of benefit and privilege. Diet is fixed on guilt for others, duty for others, and the need to
maintain the same lifestyle. Pre-binge guilt often worsens after vomiting to relieve the feeling of
satisfaction and fullness from overeating. The feeling of “empty” generates momentary wellbeing that is replaced by the guilt of losing control over thoughts about food. Shame hides eating
habits to avoid social judgment and deteriorating thoughts. Constant thoughts about food take
over most of life, progressively eliminating the ability to control or identify binge eating and
vomiting as self-punishing behaviors due to the feeling of satiety. Laboratory findings might be
completely normal, but targeted laboratory testing can be helpful to rule out medical illness.
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Clinical Diagnosis
F50.2 Bulimia nervosa: according to the DSM5 (APA, 2022), patient presents with three of the
following symptoms:
a)
Recurrent episodes of binge eating; eating, in a discrete period of time (e.g., within any 2-
hour period); a sense of lack of control overeating during the episode.
b)
Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as
self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive
exercise.
c)
The binge eating and inappropriate compensatory behaviors both occur, on average, at
least once a week for 3 months.
d)
Self-evaluation is unduly influenced by body shape and weight.
e)
The disturbance does not occur exclusively during episodes of anorexia nervosa.
An average of 1-3 episodes of inappropriate compensatory behaviors per week. The
period of moderate takes an average of 4-7 episodes of inappropriate compensatory behaviors
per week. In the case of severe the average of 8-13 episodes of inappropriate compensatory
behaviors per week. The extreme cases take an average of 14 or more episodes of inappropriate
compensatory behaviors per week.
The criteria described and the evidence agree with the diagnosis due to the feelings
surrounding eating. The binges with vomiting, and the use of laxatives agree with the recurrent
behaviors in the patient. Maintaining behaviors with a schedule and food list is consistent with
the intention to overeat in a short period. Avoidance of gatherings that include food shows the
patient’s inability to complete her thought of overeating and vomiting.
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Differential Diagnosis
F50.01 Anorexia nervosa, binge-eating/purging type: individuals whose binge-eating behavior
occurs only during episodes of anorexia nervosa are given the diagnosis anorexia nervosa, bingeeating/purging type, and should not be given the additional diagnosis of bulimia nervosa.
F50.8 Binge-eating disorder: Some individual binges foods but do not engage in regular
inappropriate compensatory behaviors.
F45.22 Body dysmorphic disorder: is a mental health condition where a person spends a lot of
time worrying about flaws in their appearance. These flaws are often unnoticeable to others.
Clinical and Treatment Plan
Program´s features involve type of meal planning, nutrition education, and medication
management options in outpatient setting. Most patients seeking treatment for bulimia nervosa
will undergo CBT. Most programs also require at least one day a week of individual, group, or
family therapy.
Pharmacological Treatment
Fluoxetine 40 mg PO bid x 4 weeks and Lisdexamfetamine (Vyvanse) 30 mg PO qd x 4 weeks.
Psychosocial and Environmental Factors
About body weight and image is a major contributing factor for bulimia nervosa. In
particular, difficulty managing emotions and pressures from the surrounding environment is a
common link between many individuals that suffer from the condition. Allowing inner-thoughts
to occur without actively trying to change or ignore them. Seeing oneself and one’s innerthoughts as separate entities. Staying mindful of external surroundings and conditions.
Dedication to changed and healthy behaviors.
10
Plan of Care (Standardized Format)
Diagnostic Level
Diagnosis
Bulimia nervosa, bingeeating/purging type.
Medications
Fluoxetine
Related to
Planning
Motivation
Nutrition Formulation
Relapse Prevention
Cognitive Restructuring
Mood Regulation
Body Image
Self Esteem and
Resources
Contribution Factors
Implementation
Establishing and
maintaining a regular
healthy eating pattern.
Maintaining positive
behavioral changes learnt
throughout the course of
therapy and preparing to
cope with setbacks.
Recognizing and coping
with negative emotions.
Addressing the negative
attitudes towards own
bodies, and influence
of perceived weight on selfworth.
Class/Rational Dose/Route/Time
SSRI
40mg PO bid 4 w
Lisdexamfetamine d-amphetamine
30mg PO qd 4 w
As Evidenced by
Rationales
The use of cognitive
behavior therapy is
associated with
remission rates
approaching 50% at the
end of treatment, and
this level of
improvement is
generally well
maintained.
Signs and Symptoms
Evaluation
Increasing self-worth:
Identifying strengths,
establishing new hobbies
and interests,
reflecting on what brings a
healthy eating pattern,
weight regulation, and
psychosocial functioning.
Range
25-50 mg
Mechanism of Action
Block the reuptake of
serotonin into presynaptic
serotonin neurons by
blocking the reuptake
transporter protein located
in the presynaptic terminal.
Common SE
difficulty asleep
or staying asleep,
nausea, diarrhea,
dry mouth,
heartburn, sexual
dysfunction.
10-70 mg
Increase catecholamine
availability in the
extracellular space
Dizziness, dry
mouth, headache,
constipation,
diarrhea.
Psych Cons
Reduction of
frequency of
objective
binge-eating
episodes,
frequency of
purging.
Regulating
eating behavior
and reward.
11
Case Formulation
Case
Presenting
Predisposing
Biological
Psychosocial
Social
Bulimia nervosa with
Acceptance for
Refusal to acceptance
binge-eating/purging
medical therapy due
in social groups due
type
to uncontrol of
to obesity/body
behavior
identification.
Family body
Eating habits with
Inadaptation to be
tendency to obesity.
heavy composition of
correlated with Latin
carbohydrates/fats.
culture (assimilation
and acculturation).
Precipitating
Tendency to gain
Ineffective denial
Disturbed body
weight if not self-
related to delayed ego image/low self-
restrictive measures.
development and fear
Taking laxatives
of losing weight and
daily, a self-induces
control.
esteem.
vomiting after eating.
Perpetuating
BMI is overweight.
Imbalanced nutrition
Unresolved
dependency needs
Protective (+/-)
Maintained 85% of
Verbalizes plans for
expected body
future maintenance of supporting circle.
weight. V/S, BP, and
weight control.
lab serum studies
within normal limits.
Family and social
12
Writing Case Formulation
The presenting case is related to a patient who has been diagnosed with Bulimia nervosa
with binge-eating/purging type. She is presented in the clinic after accepting the needs for
medical therapy due to uncontrol of behavior related to feeding and purging and the self-refusal
to acceptance in social groups due to obesity/body distortion self-identification. The
predisposing factors include a family history of obesity and eating habits with heavy
composition of carbohydrates/fats. The situation seems to be correlated with the inadaptation
under the assimilation and acculturation processes of the Latin body image and the American.
The invalidation of mental status as well as the inadaptation affect the social relationships with
other settings.
The precipitating factors reveals a tendency to gain weight if not self-restrictive
measures. Such precipitating psychological factors has resulted in the reactivation of a crisis of
invalidation due to the peers’ pressure since the adolescence. The perpetuating factors include
the genetic and familiar tendency to obesity, the long-term imbalance nutrition, and the
ineffective coping strategies which lead to unresolved dependency needs. The positive
protective factors involve the maintenance of 85% of expected body weight as well stable vital
signs within normal values (BP and lab serum studies). In addition, the patient verbalizes plans
for future and healthy maintenance of weight control with the support of family members and her
social circle.
13
References
American Psychiatric Association. (2017). Diagnostic and statistical manual of mental disorders.
(5th ed.). Washington, DC.
Brown, M. L., & Levinson, C. A. (2022). Core eating disorder fears: Prevalence and differences
in eating disorder fears across eating disorder diagnoses. International Journal of Eating
Disorders, 55(7), 956–965. https://doi.org/10.1002/eat.23728
Fairburn, C. G., & Beglin, S. J. (2019). Assessment of eating disorders: Interview or self-report
questionnaire? International Journal of Eating Disorders, 16(4), 363–370.
https://doi.org/10.1002/1098-108X
Lunn, S., & Poulsen, S. (2022). Psychoanalytic psychotherapy for bulimia nervosa: A
manualized approach. Psychoanalytic Psychotherapy. 26(1), 48–64.
https://doi.org/10.1080/02668734.2011.652977
Monsen, K. (2018). Evidence-based standardized care plans for psychiatric Interventions. Appl
Clin Inform. 2(3):373-83. doi: 10.4338/ACI-2018-03-RA-0023.
Morgan, J F; et al. (2019). The SCOFF questionnaire: A new screening[…]or eating disorders.”
The Western Journal of Medicine. Retrieved from
https://www.therecoveryvillage.com/mental-health/eating-disorders/screeningtools/#:~:text=The%20SCOFF%20questionnaire
Schaefer, L.M., Crosby, R.D., & Machado, P. (2021). A systematic review of instruments for the
assessment of eating disorders among adults. Curr Opin Psychiatry. 34(6):543-562. doi:
10.1097/YCO.0000000000000746
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