Assessing and Diagnosing Patients with Anorexia Nervosa

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation

Assessing and Diagnosing Patients with Anorexia Nervosa 

Name: S.H.

DOB: November 29th, 2011

Minor: Yes

Accompanied by: Mother

Age: 11 Years

Gender: Female 

(Assessing and Diagnosing Patients with Anorexia Nervosa)

SUBJECTIVE:

CC: “S.H. has is experiencing difficulties in school, has problems paying attention, forgets easily, and cannot stay still.” (Assessing and Diagnosing Patients with Anorexia Nervosa)

HPI: The patient is an 11-year-old female presenting at the clinic with her mother who claims she is experiencing difficulties in school, problems paying attention, and remembering things. The mother states S.H. cannot stay as she jumps from one activity to another. She cannot remembers her assignments very well, and needs an assignment list, which she also fails to keep track of and losing it, necessitating the teacher to also giver her mother another list. She cannot stay still while reading, unless she really likes it, then she can stay still for about five minutes. S.H. has difficulties remembering what she read or what her teacher read her, and she loses her things easily. She loses her temper when her teachers ask her something she did not hear. S.H. states that she daydreams about different things, including good and bad times. Mother states that the patient’s concentration is impaired, but she loves art, although she jumps from one painting to another at the museum. Mother reports that S.H. loves video games, and she can stay on them for long periods. Mother reports risky behavior when S.H. was young and lack of perception of danger. (Assessing and Diagnosing Patients with Anorexia Nervosa)

Social History: S.H. lives with her parents in Washington, D.C. She has a younger borther. m

Substance Current Use and History: Denied any substance use history.

Legal History: None reported. 

Family Psychiatric/Substance Use History: Denied family mental health or substance use issues.

Past Psychiatric History:

Hospitalization: Denied previous hospitalization

Medication trials: No previous medical trails

Psychotherapy or Previous Psychiatric Diagnosis: No previous psychiatric diagnosis

Medical History: Denies medical history.

• Current Medications:None reported.
• Allergies:
• Reproductive Hx:

Development Milestones:

Development milestones met on time

Health Promotion:

Vaccination up to date

Sleeps 9-10hrs/night

Has proper nutrition per PCP, although meals are difficult because she cannot stay still to eat.

ROS:   

General: Denies weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

Skin: No rash or itching.

Cardiovascular: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.

Respiratory: Denies wheezes, shortness of breath, consistent coughs, and breathing difficulties while resting.

Gastrointestinal: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

Genitourinary: Denies burning on urination, urgency, hesitancy, odor, odd color

Neurological: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. Reports difficulties concentrating and paying attention. Reports memory difficulties.

Musculoskeletal: Denies muscle, back pain, joint pain, or stiffness.

Hematologic: Denies anemia, bleeding, or bruising.

Lymphatics: Denies enlarged nodes. No history of splenectomy.

Endocrinologic: Sweating, No reports of cold or heat intolerance. No polyuria or polydipsia.

OBJECTIVE:

Vital signs: Unstable

Temp: 98.8F

B.P.: 100/55

P: 60

R.R.: 15

O2: Room air

Pain: 4/10

Ht: 5’5 feet

Wt: 95 lbs

BMI: 15.8

BMI Range: Underweight

LABS:

Lab findings WNL

Tox screen: Negative

Alcohol: Negative

Physical Exam:

General appearance: The patient appears lean, malnourished, and dehydrated, with the BMI indicating she is underweight. The patient converses appropriately and regularly with the interviewer, but appeared irritated with some questions. The patient has impaired concentration and did not answer some questions appropriately.

HEENT: Normocephalic and atraumatic. Sclera anicteric, No conjunctival erythema, PERRLA, oropharynx red, moist mucous membranes.

Neck: Supple. No JVD. Trachea midline. No pain, swelling, or palpable nodules.

Heart/Peripheral Vascular: Regular rate and rhythm noted. No murmurs. No palpitation. No peripheral edema to palpation bilaterally.

Cardiovascular: The patient’s heartbeat and rhythm are slow. The patient’s heart rate is slow, and capillaries refill in more than two seconds. The patient shows signs of hypotension.

Musculoskeletal: Normal range of motion. Low muscle mass for age. No signs of swelling or joint deformities. Patient indicates muscle wasting. Muscle and back pain are rated 4/10 on the pain scale.

Respiratory: No wheezes, and respirations are easy and regular.

Neurological: Balance is stable, gait is normal, posture is erect, the tone is good, and speech is clear. Patient has frequent headaches. Patient shows signs of mineral and vitamin deficiencies.

Psychiatric: The patient has a depressed mood, irritability, insomnia, impaired concentration.

Neuropsychological testing: Social-emotional functioning is impaired.

Behavior/motor activity: Patient behavior was appropriate and constant throughout the assessment

Gait/station: Stable.

Mood: Depressed mood.

Affect: The patient’s mood was depressed.

Thought process/associations: comparatively linear and goal-directed.

Thought content: Thought content was appropriate.

Attitude: patient was uncooperative at times

Orientation: Oriented to self, place, situation, and general timeframe.

Attention/concentration: Impaired

Insight: Good

Judgment: Good.

Remote memory: considered good

Short-term memory: considered good

Intellectual /cognitive function: considered good

Language: clear speech, with a tone, assessed to be normal

Fund of knowledge: Good.

Suicidal ideation: The patient reports suicidal ideation, but negative for active plans.

Homicide ideation: Negative.

ASSESSMENT:

Mental Status Examination:

The patient is a 25-year old female presenting with gradual weight loss, loss of appetite, feeling fatigued, and depressed mood. Patient reports easy irritability. During psychiatric interview, the patient was uncooperative at times and her concentration was impaired, making it difficult to establish a rapport. She expressed a low mood, persistent probing, decreased attention and concentration, apathy, and easy fatigability. The patient appeared bleak and expressed pessimistic ideas about her life, marriage, and future, fearing her husband would leave her. She reports suicidal ideation, but negative of active plans. She denies homicidal ideation. (Assessing and Diagnosing Patients with Anorexia Nervosa)

Differential Diagnosis:

1. 0 Anorexia Nervosa:

Anorexia nervosa is characterized by a restriction of nutrient intake comparable to requirements, resulting in substantially low body weight. Patients suffering from this eating disorder will experience a fear of weight gain, as well as a distorted perception of themselves and difficulty comprehending the gravity of their condition. Menstrual irregularities, cold intolerance, bowel problems, extremity edema, exhaustion, and irritability are among the symptoms reported by patients. Patients describe food-related restrictive behaviors such as calorie restriction or portion control, and purging methods, including self-induced vomiting or the using diuretics or laxatives (Moore & Bokor, 2022). Many people exercise obsessively for long periods. Numerous complications result from anorexia nervosa patients’ extended fasting and purgation. DMS-5 criteria for Anorexia Nervosa requires a patient to indicate energy intake restriction relative to requirements, causing significant weight loss relative to age, sex, developmental trajectory, and physical health, less than minimally expected. To establish the diagnosis, the patient should report excessive fear to gaining weight or fattening or persistent behavior interfering with weight gain (Moore & Bokor, 2022). N.D. indicates nutritional restriction, weight gain fear and anxiety, persistent behaviors and activities to prevent weight gain, including exercising for extended period of time and using medication to help with weight loss. For this reason, the diagnosis was established. (Assessing and Diagnosing Patients with Anorexia Nervosa)

2. 9 Major Depressive Disorder

Depression can co-occur with eating disorders, such as anorexia nervosa. Depression is a mood disorder leading to constant sorrow and disinterest. Between 50-70% of individuals experiencing eating disorders show signs of depression. The close relationship between these disorders makes it vital to consider when diagnosing and treating the eating disorder. All depressive disorders share the symptoms of melancholy, emptiness, or irritation, along with physical and mental changes that significantly impair the patient’s capacity to operate (Chand et al., 2021). Patients who are depressed have a noticeably lower interest in or enthusiasm for nearly all activities for the majority of the day, practically every day. According to the DMS-5 criteria, a diagnosis must include 5 of the following symptoms: trouble sleeping, decreased interest or enjoyment, feelings of guilt and worthlessness, fatigue and energy swings, difficulty focusing or paying attention, changes in appetite and weight, psychomotor problems, suicidal thoughts, and depressed mood. Because the patient does not exhibit 5 of the 9 symptoms mentioned above, this diagnosis cannot be made. (Assessing and Diagnosing Patients with Anorexia Nervosa)

3. 10 Social Anxiety Disorder

Individuals with eating disorders such as anorexia nervosa commonly experience anxiety in social situations and are often concerned about how people perceive their body. Anorexia nervosa patients develop fear and anxiety eating in front of other people, including their spouses and children. Therefore, during the assessment, patients tend to indicate symptoms of social anxiety. Also, anorexia nervosa can indicate another underlying mental health disorder, such as social anxiety (Rose & Tadi, 2021). Per the DSM-5 criteria, a person must exhibit pronounced fear or anxiety in one or more social situations where they may come under others’ potential scrutiny. The individual worries that they will behave in a way that might be perceived adversely. Most of the time, social situations cause anxiety or fear, which is excessive compared to the threat they truly present. As a result, people either avoid them entirely or tolerate them with worry or fear. Usually lasting at least six months, the avoidance, fear, or worry significantly impairs or distresses one of the fundamental areas of functioning. The symptoms of another mental disorder or the consequences of a substance should not be linked to this fear. If a different medical issue is present, the anxiety, avoidance, or fear is also excessive or unconnected (Rose & Tadi, 2021). This diagnosis was refuted because, although the patient admits to anxiety and fear of weight gain, she does not indicate intense fear and anxiety relative to requirements. (Assessing and Diagnosing Patients with Anorexia Nervosa)

  PLAN:

The patient would benefit from a combination of nutritional rehabilitation and psychotherapy.

Safety Risk/Plan:

The patient indicates minimal intent to cause self-harm and is negative of active plans. The patient shows no intent to harm others. Patient has minimal suicidal and negative homicidal ideation. Initial admission is required to stabilize vitals.

Pharmacological Interventions:

Medications are not used initially. However, the patient can be prescribed olanzapine as first-line medication to help with weight gain (Moore & Bokor, 2022). Combination therapy with selective reuptake inhibitors (SSRIs) will help reduce symptoms such as fear and anxiety and the increased urge for nutritional restriction.

Psychotherapy:

The patient will undergo intensive therapy, 2-3 hours every weekday and partial hospitalization for about 6 hours a day to help stabilize vitals in the first one week. Family-based psychotherapy will help investigate and understand the underlying nature of the home environment and restructure it (Moore & Bokor, 2022). Cognitive behavioral therapy will help address behavioral changes to control eating and body perception. Self-control is required for successful behavioral changes, making CBT a fundamental intervention. (Assessing and Diagnosing Patients with Anorexia Nervosa)

Education:

1. Educate the patient about side effects, potential complications, and need for medication adherence.
2. Educate patient on the need to follow-up with therapy to manage complications and address body image.
3. Monitor vital signs.
4. Monitor withdrawal symptoms to determine risk of relapse.
5. Educate the patient regarding making healthy lifestyle choices.
6. Encourage the patient to work with the healthcare team and seek help anytime.
7. Advise the patient to join a support group or group therapy to help enhance social skills.

Consultation/follow-up: Follow-up is in one week for further assessment.

Referral: The patient needs to see a gynecologist to address menstruation irregularities.

Reflection

The primary challenge in addressing anorexia nervosa is that patients do not realize the severity of their situations or the risk associated with nutritional restriction. Patients also experience fear and anxiety of weight gain, which increases non-adherence behavior and the probability of relapse mid-course treatment. Additionally, ordinary people, including patients and their families, do not consider anorexia nervosa a mental health disorder that significantly impacts an individual’s mental health. Treating this disorder requires commitment from the patient and a reliable support system because the risk of relapse is high. Ethical treatment of eating disorders is complicated because most patients lack insight into the severity of their situation and the need for treatment. Treating eating disorders has distinct ethical principles, including respect for persons, autonomy, veracity, nonmaleficence, privacy, duty to protect, and beneficence. However, these principles are weighed and applied differently depending on the situation and severity of anorexia nervosa. For instance, in severe anorexia, the need to protect the patient from harm might override the need to promote patient autonomy. Treatment refusal is an issue in treating eating disorders that conflicts with the principle of autonomy. This case offers insights into the categorization of eating disorders as mental health illnesses and the challenges associated with treating these disorders. Given another chance with the patient, I would inquire about their attitudes towards their eating habits and ask for the husband to be present to explore his attitude towards her wife’s lean body and eating habits and how the home environment contributes to the situation.   (Assessing and Diagnosing Patients with Anorexia Nervosa)

References

Chand, S. P., Arif, H., & Kutlenios, R. M. (2021). Depression (Nursing). In: StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK568733/

Moore C.A., & Bokor, B.R. (2022). Anorexia Nervosa. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459148/

Rose, G. M., & Tadi, P. (2021). Social anxiety disorder. In StatPearls [Internet]. StatPearls Publishing.https://www.ncbi.nlm.nih.gov/books/NBK555890/

 

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