What other symptoms does Nikki display outside her eating symptoms? What diagnosis encapsulates these symptoms?

Question

DSM Diagnosis
307.1 Anorexia Nervosa, Restricting Type, Extreme
296.21 Major Depressive Disorder, Single Episode, Mild, Chronic
Amenorrhea, hair loss, irregular heartbeat, as reported by client
V62.89 Phase of life problem
V60.89 Discord with roommate

Rationale
Nikki meets criteria for Anorexia Nervosa as follows:
A. Refusal to maintain body weight at a minimally normal weight (at five foot four inches, Nikki is 85 pounds).
B. She describes an intense fear of gaining weight and becoming fat, even though she is underweight.
C. Nikki presents with disturbance in the way her body weight or shape is experienced (feeling fat even though she is seriously underweight), undue influence of body weight or shape on self-evaluation (if she were heavier, she would feel “totally worthless,” and a lack of recognition of the seriousness of her current low body weight (although she has some insight, her ambivalence is such that she denies at times that there is any problem).
She qualifies for “restricting type” since she mainly restricts her food intake. Although she binges occasionally, she denies purging. The specifier “extreme” is added as her BMI percentile for her weight and height is currently less than 15 (14.6).
Nikki further meets criteria for Major Depressive Disorder. She displays the following five symptoms for more than a two-week period:
1) depressed mood as indicated by subjective report
2) diminished interest or pleasure in almost all activities as indicated by subjective report
3) insomnia
4) feelings of worthlessness
5) suicidal ideation without a plan
The severity “mild” has been delineated because Nikki meets the minimal number of symptoms. She seems to have sustained this level of depression for the past four years. Hence, the qualifiers, “single episode” and “chronic.”
V codes were also added to flesh out the diagnostic picture. V62.89 Phase of life problem describes her difficulties with the adjustment to college, leaving home, and contemplating an adult future. V60.89 Discord with roommate captures the problems with a roommate who disrupts the living arrangement and is oblivious to any attempts to communicate about the problems with her carelessness and lack of consideration.

Additional Information Required
A medical examination is critical so that any health risks for Nikki can be known and addressed. Additional information about the client’s family background and dynamics will help to better understand some of the psychological and social influences on her development of the eating disorder. It appears that she had conflicted relationships with both her mother and father, and they in turn had a conflicted relationship. Learning more about Nikki’s patterns of interaction with others, acquired in her family of origin, will help to clarify her sense of identity in relation to others. Finally, it will be helpful to know more about Nikki’s dating history. It seems paradoxical that she likes boys when at the same time she wants to be a little girl (presumably, without sexual interests).

Risk and Resilience Assessment
Onset
Nikki might have been at risk biologically because there may be some mental illness in the family. Nikki’s mother might have depression and possibly borderline features (fluctuating between “all good” and “all bad” appraisals of people, dissociation, paranoia, low sense of self, impulsive eating, mood disturbance); there were also alcohol problems on the paternal side. Nikki was at further risk because of her adolescent developmental stage. She had first started thinking she was fat when she physically developed at thirteen. Nikki reported being depressed since age 14, which may have put her at risk for an eating disorder. She has body dissatisfaction and body distortion since she feels fat, even though at times she is aware that she is actually emaciated. Nikki has perfectionist standards for herself, such that she should receive all A’s in school. Nikki further demonstrates impulsivity (eating binges, alcohol use in high school), another risk influence.
At the environmental level, the family is at least middle class and upwardly striving. There seems to be a strong emphasis on achievement and individualism. Nikki’s father seems distant from her and the rest of the family, and the marital relationship is discordant. Nikki’s mother focuses negatively on her own weight and shape, which models for Nikki an emphasis on these aspects of herself. Nikki seems to have some friends but is not interested in developing other relationships.

Course
Features of the disorder that put Nikki at risk include the fact that her weight is very low at 85 pounds. However, she has only shown clinically significant symptoms for the last six months before she saw a counselor. One could argue that she has shown eating disordered behaviors since age 14 (low weight, body distortion, fear of becoming fat). The fact that she is an adolescent is a protective influence in that hopefully some of her patterns can be changed before they become entrenched in adulthood. Nikki demonstrates some resistance and denial in that she gets panicky if anyone talks about her gaining weight, and she was very guarded with the counselor until she realized that she wasn’t going to be pressured. Nikki can sometimes be impulsive, which is another risk influence for recovery. Her family relationships were a problem before Nikki developed an eating disorder, although she does have some friends and the residential advisor offered her support. Nikki presented as intelligent, articulate, and with some insight into her problems; therefore, it seems she would make a good candidate for psychotherapy.

Treatment
The treatment plan must start with a medical examination. The fact that Nikki is having medical complications – hair falling out, loss of menses, and irregular heartbeat – as a result of her weight loss is a major concern. Coupled with her low weight, the recommendation might be that she should be hospitalized. A psychiatric evaluation would be important to ascertain the need for medication; a course of antidepressant medication would most likely be initiated.
Interpersonal therapy given Nikki’s family dynamics, frequent disruptions of relationships because of moving around, and her co-morbid depression, might be the treatment of choice. An essential element of treatment would be feeling identification and management, as Nikki seems disconnected from her feelings. At the end of a course in interpersonal therapy, Nikki’s progress would be evaluated, and cognitive-behavioral therapy might be implemented at that point.
Structuring Nikki’s days might help her find more balance in her activities. The schedule would include meals, study time, bedtime, and finding (or discovering) some leisure activities she could enjoy through the many courses and clubs the University offered. Volunteering for course credit might be another option so that Nikki could begin to explore career options. A visit to the career counseling office might also help her consider different career paths
Family involvement would be an important part of the treatment plan since family dynamics might have contributed to the development of the depression and the eating disorder. In addition, her parents would have to be included on any plans to hospitalize Nikki.

Critical Perspective
Anorexia nervosa, as well as the other eating disorders, may have some biological risk mechanisms, but the social influences of American culture, particularly pertaining to women (“thin” bodies as ideal, and the importance of physical attractiveness) appear to be more influential to their development. Nikki’s case further demonstrates how family stresses and depression may contribute to the eating disorders. While the seriousness of Anorexia, and the reluctance (or inability) of such persons to admit to having a disorder, lend credence to its conceptualization as a “disorder”, it seems that so many factors go into its development that it could represent one possible “outcome” for a young man or woman who is dealing with many types of family and social pressure. Thus, social workers need to understand that these clients may need assistance with a broad range of life concerns.

Answer 1

Nikki complains of feeling depressed. She describes loss of interest in activities and meeting new people. The only exception is meeting young men and dating. She sleeps only five to six hours a night. Her lack of appetite could be ascribed to the eating disorder, but it could also be a symptom of depression. She feels hopeless about the future and describes wishing that she was dead though with no suicidal plan. She describes feelings of worthlessness unless she is thin and gets all A’s. Therefore she meets six of the symptoms for major depression when only five are required.