Case Study Analysis: Victoria

Victoria is a 24-year-old recent graduate with the position of a cheerleader. She presented binge eating disorder and purging, was initially diagnosed with depression and anxiety, and came under significant body image pressure. From substantial amounts of food consumed, particularly during binges and the subsequent purging, she experiences shame and guilt. After analyzing her symptoms, three main diagnoses and differential diagnoses are considered: Case Study Analysis: Victoria.

Primary Diagnosis: Bulimia Nervosa ICD-10 Code: F50.2

Specifiers

According to the DSM IV diagnostic criteria, it becomes clear that Victoria has Bulimia Nervosa to a moderate degree, seeing that she binges and purges a few times a week. The non-purging subtype does not fit into it because she was able to induce vomiting on her own, thus not meeting the criteria of having it done by someone else (American Psychiatric Association, 2022).

Rationale

Victoria best fits the diagnosis of Bulimia Nervosa (F50.2) to a moderate degree because she purges several times a week or binges frequently. The non-purging subtype is, therefore, not possible since, besides self-induced vomiting, she has compensatory behavior. Her fear of weight gain and avoidance of antidepressant medication due to concerns about weight further support this diagnosis.

Differential Diagnoses

Major Depressive Disorder (MDD) – Recurrent, Moderate (ICD-10 Code: F33.1)

Rationale

Victoria has a history of depression and anxiety dating back to her parent’s divorce when she was young. Although she does not report suicidal intent, she has thoughts that people would be better off if she were no longer alive, which indicates low self-worth and persistent depressive symptoms. Her avoidance of medication due to weight concerns, social withdrawal, and using exercise to manage stress instead of treatment suggest untreated depression. The DSM-5-TR outlines that MDD commonly co-occurs with eating disorders, as depressive symptoms can exacerbate binge-purge cycles (Giel et al., 2022).

Avoidant Personality Disorder (ICD-10 Code: F60.6)

Rationale

Victoria isolates herself socially, does not date, and avoids forming friendships, behaviors consistent with Avoidant Personality Disorder (AVPD). AVPD is characterized by fear of rejection, doubt in oneself, and avoidance of social situations (Sohel et al., 2024). Based on Victoria’s occupation as a cheerleader and dance instructor, one would expect her to have a more socially active status, yet she prefers seclusion. She may have low self-esteem, a focus on perfectionism, and fear of being judged for all the issues related to her eating disorder and her unwillingness to turn to people for help.

Pharmacological Treatment Recommendation

Fluoxetine (Prozac) 60 mg/day

Fluoxetine (Prozac) is the recommended pharmacological treatment for Victoria’s bulimia nervosa. The initial dosage starts at 20 mg per day, with a gradual titration of 10-20 mg per week until reaching the therapeutic dose of 60 mg per day. This drug is approved for the treatment of bulimia nervosa and has been proven to decrease the rate of binging and purging, as well as depression. Besides, the US National Library of Medicine notes that it has relatively low tendencies toward weight change when compared to other SSRIs, a preferred choice for Victoria because of her concerns with body image and weight gain.

Rationale

Fluoxetine is the only medication that has been approved by the Food and Drug Administration for bulimia nervosa and has proven to be effective in managing those who binge and purge. The efficacy of fluoxetine at a high dosage (60 mg per day) has been established as effective in decreasing episodes of binge eating and purging (Sohel et al., 2024). Thirdly, fluoxetine is used to treat both depression and anxiety and has minimal weight gain effects; this will be suitable for Victoria since she does not like taking medication due to the side effects of weight issues (Sohel et al., 2024).

Conclusion

Victoria’s case presents with bulimia nervosa as the primary diagnosis, accompanied by symptoms of major depressive disorder and avoidant personality disorder. The fact that she has had previous diagnoses of depression as a child, a negative attitude toward body image as well as abandonment of social activities makes her a good candidate for an eating disorder. Fluoxetine is the best option, as it is effective in treating bulimia as well as depression and does not cause much weight gain. Victoria should also be recommended for CBT for body image issues, perfectionism, and mood regulation issues.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders: DSM-5-TR (5th ed., text rev.). American Psychiatric Publishing.

Giel, K. E., Bulik, C. M., Fernandez-Aranda, F., Hay, P., Keski-Rahkonen, A., Schag, K., Schmidt, U., & Zipfel, S. (2022). Binge eating disorder. Nature Reviews Disease Primers, 8(1). https://doi.org/10.1038/s41572-022-00344-y

Sohel, A. J., Shutter, M. C., Patel, P., & Molla, M. (2024, February 28). Fluoxetine. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK459223/

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Read the case study.

1. List the diagnoses/differential diagnoses (total up to three)
2. Include ICD-10 codes and any specifiers
3. Provide a rationale for your diagnoses
4. Include one pharmacological option for this patient.  Include only the medication and full dosing information

Case Study:

Victoria is a Dallas Cowboy’s Cheerleader.  She is 24 years old and lives in Arlington, Texas.

C.C.:  My eating is out of control

HPI:  Victoria has a history of depression but is not currently taking any medication due to the concern for weight gain. In the last couple of years, when her depression gets bad, she will binge eat and then purge.  In one episode, she will eat an entire large pizza followed by a quart of ice cream with hot fudge and whipped cream.

She feels so bad after the binging that she makes herself vomit everything up.  She feels shame and guilt. She doesn’t know how to make it stop.

Current medication:  Occasional Motrin for pain, MVT

NKDA

Past Medical Hx: negative

Past Surgical Hx: negative

1. Ht 70 inches.  Wt. 120 lbs.  BP 110/72 P83 R12

Past psych Hx:  Hx of anxiety and depression since her parent’s divorce.  Started on sertraline 50 mg when she was 16.  Did not take it longer than 3 months due to concern for side effect of weight gain.

Since that time she tries to work out when she feels stressed or low.  No hx of SI or HI but has had thoughts people would be better off if she was no longer here.  No hx of hospitalizations.

Social Hx:  She lives with her mother, who was a Dallas Cowboy Cheerleader when she was a young woman.  Victoria’s parents divorced when she was five years old.  She does not have much contact with her father.

When not practicing with the team, she teaches dance and yoga.  She does not date and does not have many friends with whom she socializes.

Denies hx of smoking, ETOH, or any illegal drug use.

Criteria

Diagnoses

All three diagnoses/differential diagnoses are included and are correct.

ICD-10 codes

All ICD-10 codes are listed and correct.

Rational

Complete rational for all diagnoses.

APA Format

No more than 2 APA errors

Grammar

No more than 2 grammar errors

Text:

• DSM-5-TR text