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Week8Case.docx

CASE of GINA 

 

INTAKE DATE: July 2020 

 

PRESENTING PROBLEM:  

Patient was brought to counseling by her mother.  Following an argument with her parents, she threatened to cut her wrist.  Prior to cutting her wrist, Gina’s mother says she started screaming and became very angry with her after discussing her eating habits.   

PSYCHOLOGICAL DATA: 

Gina is a 14-year-old white female who resides in Pennsylvania with her parents and older sister.  She appears to be of average intelligence as she was able to respond to numerous questions in an articulate and intelligent manner.  She was well versed about world history and current affairs.  Her mother confirms that she has always done pretty well in school, maintaining a “B”, average, although IQ testing indicates she could do better.  She has always been somewhat of a perfectionist and likes to do well, and studies hard to get good results.  Gina participates in various school activities (i.e., chorus, school newspaper).  Gina is quite shy and reserved in character but is generally well-liked by people.  

Gina started dating a boy from her school year and felt very happy.  After a few weeks, her boyfriend dumped her and started going out with her best friend.  Gina feels an overwhelming sense of betrayal and hurt, and tries to talk to her family about it, who tell her ‘there are plenty more fish in the sea’, and not to worry about it.  Gina feels ashamed and embarrassed of her feelings and very alone.  Not only has she lost her boyfriend but also her best friend, and no one around her seems to understand the severity of what she is going through.  To Gina, whose life as a teenager revolves heavily around her friend and boyfriend, she feels she has lost everything. 

In order to cope and distract herself, she plunged herself into her studies, working until late at night and ensuring her grades are high.  She started to eat less thinking maybe she was overweight and that is why her boyfriend dumped her. Within a few weeks, people began commenting on how fantastic she looks with her weight loss.  Gina went to a party one night in a tight fitted dress and received a large amount of attention from the boys.  In a very difficult and painful time, Gina finally finds she has some praise for something, and begins to more consciously restrict her food intake to ensure that she continues to lose weight and feel good about herself.  At times, Gina finds herself eating more than she wants and goes into the bathroom and induces vomiting to rid herself of the extra calories.  She has done this about 6 times over the past several months. 

MEDICAL HISTORY: 

Gina had a complete physical by her doctor in May 2020.  The doctor identified that Gina was thin but remained in her weight range for her age.  He also confirmed that she continued to have her menses.  She denied any dieting or fasting to the doctor.   

 More recently Gina’s family began to worry about her, as she did not want to eat evening meals with them.  Gina’s friends also comment on how thin she is getting.  Gina only sees this as a positive thing, believing it is praise and attention from others, but she has become completely obsessed with food.  She goes to bed at night counting the calories she has had in the day, and rigidly planning what she will eat the next day.   

SUBSTANCE ABUSE HISTORY:  

Gina denies any drug or alcohol use.   She states “I could do drugs if I wanted to. I don’t want to because it’s dumb”. 

PSYCHIATRIC HISTORY: 

Gina had been evaluated at the community hospital ER a few weeks ago.  Gina believed the clinicians that are trying to diagnose her only have book skills, no people skills and have no idea what is going on. 

MENTAL STATUS: 

Gina presented casually dressed.  She was in a lively manner with good eye contact and the conversation flowed freely.  Thought and speech patterns were clear.  Affect was appropriate.  She was oriented in three spheres.  Gina denies feeling depressed, anxious, or suicidal.  When questioned about her family’s concern of her eating habits, she suddenly became quiet, teary eyed, lowered her head, and responded, “You don’t understand it, I don’t want to hurt myself, there is nothing wrong.”