A 15-Year-Old Girl With Severe Weight Loss and Fear of Weight Gain

Case Scenario

A 15-Year-Old Girl With Severe Weight Loss and Fear of Weight Gain

Patient Profile

· Name: Ava Thompson

· Age: 15 years

· Grade: 10th grade

· Sex: Female

· Height: 165 cm (5’5”)

· Weight:5 kg (74 lbs)

· BMI: Significantly below the 5th percentile for age

Chief Complaint: “My stomach sticks out, and I look huge. I just need to lose a few more pounds.”

History of Present Illness

Ava is a 15-year-old student admitted for severe weight loss, fatigue, and absence of menstrual periods for the past eight months. She reports eating less than 400 calories a day and exercising excessively, including running in the morning, dance practice, and nightly abdominal workouts.

She frequently restricts food intake, eats alone, avoids family meals, and expresses profound guilt after eating. She reports intense fear of gaining weight, despite severely low body weight. She purges after eating by inducing vomiting and occasionally uses laxatives or her mother’s diuretics to “reduce bloating.”

She reports feeling cold frequently, experiencing dizziness, headaches, thinning hair, and muscle cramps. She denies suicidal thoughts, hallucinations, or drug/alcohol use.

Psychosocial and Family History

Ava lives with her parents and younger brother. Her father has a history of alcohol misuse. Her mother struggles with obesity and frequently diets without success, often commenting negatively about her own weight.

Ava began calorie-counting at age 12, tracking everything she ate. She became increasingly concerned about her appearance, especially after exposure to fitness influencers and peer comparison at school. She lost over 25 pounds over a year and began purging whenever she felt she had eaten “too much.”

Over the past six months, she has withdrawn from friends, stopped attending social events, and spends hours researching “clean eating” and watching cooking shows while restricting her own intake.

Menstrual and Physical Health History

· Menarche at age 12

· Last menstrual period: 8 months ago

· Not sexually active

· Reports dizziness, cold intolerance, hair loss, and constant fatigue

Mental Status Examination

Component Observation

Component

Observation

Appearance

Very thin, pale, lanugo present, dressed in athletic wear

Behavior

Restless, repeatedly stretching and exercising during interview

Mood

“Fine, but I feel guilty after eating”

Affect

Constricted but cooperative

Thought Process

Logical and coherent

Thought Content

Preoccupied with calories, body image, exercise, fear of weight gain

Insight/Judgment

Poor insight about severity of condition

Cognition

Intact attention and memory; perfectionistic tendencies

Physical Signs

· Bradycardia

· Hypotension

· Dry skin with lanugo

· Brittle nails

· Thinning scalp hair

Questions

1. Which DSM-5-TR criteria are met in this case? Provide a detailed explanation supporting your diagnostic impression.

2. Identify three potential differential diagnoses relevant to Ava’s presentation. For each, provide a brief clinical rationale explaining its applicability and how it can be distinguished from the primary diagnosis.

3. How does family influence and social media contribute to the onset in adolescents?

4. Compare and contrast Anorexia Nervosa and Bulimia Nervosa with regard to diagnostic features, behavioral patterns, psychological characteristics, and associated complications.

5. What medical complications should be monitored in severe anorexia nervosa? Provide rationale.

6. Discuss evidence-based treatment modalities for adolescents with eating disorders, including both pharmacological and non-pharmacological interventions.

7. What are the key safety priorities during the initial phase of treatment for adolescents with severe eating disorders? Discuss risks related to medical instability and psychological safety.

8. What aspects of her thinking reflect distorted body image and body dysmorphia?

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