Case Scenario
Jane, a 19-year-old woman, presents to the emergency department as underweight and agitated, accompanied by her concerned parents. At age two, she was sexually abused by an older cousin with autism, a family secret that was never legally addressed. Her parents believe this trauma has impacted her development and are seeking counseling and possible hospitalization following their family doctor’s advice. Throughout her life, Jane has displayed impulsive and self-destructive behaviors, including mood swings, anger outbursts, social withdrawal, self-harm, and suicidal ideation, such as cutting her wrists. Jane denies doing this at present.
Differential Diagnosis for Jane
A differential diagnosis for Jane will include major depressive disorder, anxiety disorder, and bipolar disorder. It is crucial to explore Jane’s biographical details regarding her traumas and negative experiences. Particular attention will be paid to Jane’s age, which is 19 years old, and the underweight problem.
It is essential to note that unusual behavior can directly affect other vital aspects of human life, such as eating habits. According to Koning et al. (2022), “one intriguing aspect of the presentation of mood disorders is related to changes in metabolism and eating” (p. 2). Consequently, it is necessary to emphasize that Jane’s mood characteristics can reveal much about her problems with food intake. Additionally, factors such as cultural aspects, ethical and legal issues, and human diversity will be examined.
Before considering Jane’s current behavior, mood, and eating disorders, it is necessary to state detailed information about her. Jane’s parents reported that she experienced sexual abuse at two years old. However, they did not tell her, and it remains their family’s secret.
From this point, it is essential to recognize that early childhood traumas and negative experiences have a profound impact on a person’s entire life (Ray, 2019). There are many abnormalities in Jane’s behavior, such as mood swings, anger, and a lack of mutual understanding with her peers and others. Notably, Jane does not recognize the causes of her behavior and does not pay sufficient attention to it as something that needs to be changed. Therefore, the proper analysis of Jane’s health state is needed not only to understand the connection between sexual abuse and her current behavior but also to implement appropriate treatment to improve her condition.
One should explore peculiarities regarding eating disorders, which may help to understand the causes and specifics of Jane’s problems. Mainly, eating pathologies should be considered, and the results should be applied during the treatment. For example, Rai et al. (2019) state that such factors as child abuse or neglect can significantly change a person’s behavior externally and internally (Rai et al., 2019).
In other words, not only the person’s actions but also their thinking processes will change. These issues will lead to adverse outcomes such as personality and anxiety disorders, and, regarding adults, alcohol and drug use disorders (Rai et al., 2019). This factor underscores the importance of prompt action in treating Jane.
Another important aspect concerning eating disorders is phenotypes. As Koning et al. (2022) state, “phenotypes include maladaptive eating behaviors related to appetite, emotion, reward, impulsivity, diet style, and circadian rhythm disruption” (p. 1). It is essential to note the direct connection between the person’s appetite and their emotions.
Consequently, this correlation between eating disorders and mood disorders is a significant factor in various diseases. Among them are anorexia nervosa and bulimia nervosa. These factors are vital for the case of Jane because they highlight how her underweight condition can be caused by her emotional state and, in particular, by the adverse childhood experience of sexual abuse. It is necessary to underline that such eating abnormalities could act as a reaction to emotional stressors.
Cultural Aspect
The DSM-5 Online Assessment Measures document “Early Development and Home Background” (EDHB) considers critical factors across different cultural contexts. For example, the critical points relate not only to the problematic adult but also to their parents and caregivers (DSM-5 Online Assessment Measures, n.d.). The questions consider if the parent or caregiver has depression or anxiety, if they receive treatment, and other aspects (DSM-5 Online Assessment Measures, n. d.). These questions emphasize the importance of considering the patient’s surroundings, including family and caregivers, to account for cultural aspects that may contribute to the development of disorders.
Additionally, other aspects of the patient’s background and culture, such as social relationships, neglect, and damaging nurturing, are also relevant (Rai et al., 2019). Additionally, it is worth noting that Jane’s parents are from different cultures and countries: her mother is Japanese, and her father is Latino. Therefore, the factors above highlight the significant impact of various cultural and social aspects on a person’s development in relation to specific disorders.
Human Diversity Aspect
The first issue regarding human diversity in Jane’s case is gender. It is more difficult for girls to combat various social and cultural injustices regarding human diversity. Moreover, one should state that the primary disorder of Jane, major depressive disorder, occurs more often in females (Rai et al., 2019).
The second aspect is Jane’s age: 19. At this age, people tend to start thinking critically about their lives and are prone to depression and other factors connected with the question of who they are. In addition, as mentioned above, Jane’s parents are from different cultures and therefore hold different values and approaches to life. Consequently, children of these types of parents may experience some misunderstandings and misconceptions, leading to problems, for example, when communicating with peers, as Jane does.
Legal and Ethical Issues
Among the legal and ethical issues surrounding the case of Jane, it is crucial to consider the necessity of informing her about potential treatments and the specific characteristics of her disorders. It is essential to state that due to the sexual abuse in early childhood, Jane has specific issues in her behavior and thinking. Therefore, creating a friendly, sincere atmosphere is necessary when communicating with her (Ray, 2019). Another aspect that should be taken into account is the family’s secret regarding her child abuse. The consultation with parents should be conducted before communicating with Jane to determine whether it is possible to reveal the truth about her, if necessary, and to ensure that the parents do not object.
Notably, the situation can be difficult because, on the one hand, Jane is 19 and an adult. On the other hand, their parents are concerned about her state and want her to undergo medication, including hospitalization. In this regard, one should consider the situation in which Jane does not understand the necessity of the treatment and begins to refuse help. Nevertheless, the psychologist and other specialists have to gently explain to Jane the importance of taking specific measures regarding her health state because of particular abnormalities, which should also be explained to her carefully.
Provisional Diagnosis for Jane
The provisional diagnosis for Jane will be major depressive disorder (68.3 T-score) following DSM-5 (DSM-5 Online Assessment Measures).
Diagnosis Criteria
- Significant weight changes. It is the most observable disorder in Jane, which resulted in her parents’ willingness to seek help from specialists. Notably, Jane is underweight, which might be considered anorexia nervosa.
- Feelings of worthlessness or excessive guilt. There is no specific evidence to suggest that these factors influenced Jane’s thinking and behavior.
- Depressed mood. Jane’s state can be partially considered a depressed mood. On the one hand, she states that she stops cutting her wrists and does not realize the need to seek help. On the other hand, specific actions such as anger and mood changes can be considered depression symptoms.
- Psychomotor agitation. Jane does not have particular symptoms of psychomotor agitation.
- Sleep disturbance. Jane does not exhibit any particular symptoms related to sleep disturbance.
- Recurrent thoughts of death or suicidal ideation. This is one of the most observable of Jane’s actions. Remarkably, her parents saw how she was trying to cut her wrists. Notably, there were no specific direct suicidal intentions. In addition, Jane has a history of self-abuse.
- Anhedonia. Regarding anhedonia, Jane’s behavior can be considered in terms of how it affects her communication with friends. In other words, this factor can highlight the fact that he loses interest in communication.
- Diminished concentration. There is no specific evidence regarding Jane’s loss of concentration.
- Fatigue or loss of energy. There is no specific evidence of Jane’s energy loss or fatigue.
Treatment
Two theoretical models that may conceptualize Jane’s clinical presentation were selected: psychodynamic and cognitive-behavioral.
Psychodynamic Model
The psychodynamic model will be essential to combat such disorders as major depressive disorder and bipolar disorder. This model considers various traumas and adverse experiences of the person concerning particular side effects, including eating disorders (Rai et al., 2019). The importance of this model for Jane’s case is that it may help understand the reasons for her behavior in terms of whether it is caused by her emotions and mood disorder or another reason. In particular, it will allow specialists to research the connection between Jane’s current mood and the sexual abuse in her childhood.
In the psychodynamic model, it is essential to focus on Jane’s eating habits. The specific diet will be required to restore her eating balance and define why she refuses to eat normally. However, it is remarkable that during this diet, attention should be paid to Jane’s psychological reactions.
The circadian clock system is one approach that can be applied to create a specific diet for nutritional intervention. According to Koning et al. (2022), “this system optimizes the timing in which energetic processes occur to fulfill an organism’s energy needs, which oscillate across the day-night cycle” (p. 5). For example, as Jane can be partially considered a teenager, it might be helpful to implement smart trackers or mobile apps in the diet to constantly monitor not only Jane’s nutritional data but also specific medical points.
Cognitive-Behavioral Model
The cognitive-behavioral model will be crucial to deal with Jane’s anxiety symptoms. This model assumes the development of a mutual, trusting relationship between the patient and the psychologist. Consequently, as the treatment for Jane, it is crucial to create psychoeducation and psychotherapeutic methods regarding her communication with the specialist.
First, it will help to educate Jane about the specifications and the potential dangers of her state. Second, in communication, it will be easier for her to express what is bothering her and for specialists to determine the influence of her childhood sexual abuse experience on her present behavior. Notably, as Jane’s parents want, placing her in the hospital for a thorough examination will be essential. Regarding the results obtained after the examination, the psychotherapist should construct a step-by-step action plan to address Jane’s peculiarities without harming her and taking into account age and various aspects such as ethical, legal, cultural, and others.
References
DSM-5 Online Assessment Measures. (n. d.). American Psychiatric Association.
Koning, E., Vorstman, J., McIntyre, R., & Brietzke, E. (2022). Characterizing eating behavioral phenotypes in mood disorders: A narrative review. Psychological Medicine, 52(14), 2885-2898.
Rai, T., Mainali, P., Raza, A., Rashid, J., & Rutkofsky, I. (2019). Exploring the link between emotional child abuse and anorexia nervosa: A psychopathological correlation. Cureus 11(8).
Ray, W. J. (2019). Abnormal psychology. SAGE Publications.