11 Feeding, Eating and Elimination DisordersThe diagnostic crite.docx

11 Feeding, Eating and Elimination Disorders
The diagnostic criteria for the Feeding and Eating Disorders in
this chapter are categorized by recurrent disordered eating
activities and attitudes that are mutually exclusive, with the
exception of pica, which results in significant physical and/or
psychosocial impairment (APA, 2013). Research demonstrates
that eating disorders often originate in childhood or adolescence
with the average age of onset between 8 and 21 years (Hudson,
Hiripi, Pope, & Kessler, 2007). Approximately 20 million
women and 10 million men in the United States suffer from a
clinically significant eating disorder during their lifetime
(Wade, Keski-Rahkonen, & Hudson, 2011). Despite this
prevalence, only one in ten individuals with an eating disorder
receives treatment (Noordenbox, 2002). It is estimated that over
90% of those diagnosed with an eating disorder are young
females between the ages of 12 and 25 (SAMHSA, 2003), but
adult males suffer significantly as well (EDC, 2007).
Data from the National Comorbidity Replication Survey
(NCS-R) and the Adolescent Supplement (NCS-A) show that
adults and children with eating disorders often have coexisting
mental disorders such as depression, anxiety, and substance use;
sadly, few seek treatment specific to their eating disorder. More
distressing, this data demonstrates that eating disorders are
often associated with functional impairment and suicidality
(Hudson et al., 2007; Swanson, Crow, Le Grange, Swendsen &
Merikangas, 2011).
The first three disorders were relocated to this category
“Feeding and Eating Disorders” to highlight that although they
are most often diagnosed in children, they can occur at any age,
including adulthood. These disorders are distinguished by
problems with the process of eating and retaining food, eating
inappropriate food, or lack of interest in or avoidance of food.
Among individuals with intellectual disabilities their presence
appears to increase with the severity of the condition. Pica

Disorder is the eating of nonfood items such as paint chips,
string, hair, or newspaper. Although it may occur with other
eating and mental disorders, symptoms must be severe enough
to warrant an independent diagnosis. Rumination Disorder
involves vomiting and re-eating food. Avoidant/Restrictive
Food Intake Disorder was formerly feeding disorder of infancy
or early childhood, but it has been expanded to capture a
broader range of symptoms and age levels. This disruption in
eating and feeding behavior is marked by continuous inability to
meet appropriate sustenance and dietary needs. It is associated
with a serious decrease in body weight, failure to grow,
nutritional deterioration, reliance on enteral feeding and
impairment in psychosocial functioning (APA, 2013). For any
of these diagnoses, all three eating disorders should not develop
solely during the course of another eating disorder and cannot
be a culturally sanctioned practice or attributable to a medical
condition or another mental disorder (See DSM-5 for full
description of these disorders.)
The following three eating disorders are considered very
serious due to their chronic nature and morbidity, especially
without treatment. The first, Anorexia Nervosa, has an annual
prevalence rate of “0.4% among young females, with a 10:1
female-to-male ratio” (APA, 2013, p. 341) and is characterized
by significant weight loss resulting from excessive dieting and a
distorted body image. “Significantly low weight is defined as a
weight that is less than minimally normal or, for children and
adolescents, less than minimally expected” (APA, 2013, p. 338).
Individuals affected by this disorder have an unreasonable fear
of becoming fat regardless of their low body weight, which
interferes with weight gain. This intense focus on being thin is
often accompanied by a distorted body image; that is, the
individuals experience their weight or shape as greater than
what it actually is and often lack insight into the gravity of their
low body composition (APA, 2013).
There are two subtypes of Anorexia Nervosa: Restricting
Type and Binge/ Purging Type. Subtypes are used to identify

current symptoms over the last 3 months and often alternate
between subtypes. Individuals with the Restricting Type
severely restrict their food intake without engaging in bingeing
or purging behaviors. Individuals with the Binge/Purging Type
of anorexia maintain their weight at an abnormally low level
through food restriction but also engage in binge eating and
purging behaviors, such as self-induced vomiting or laxative or
diuretic abuse. Clinicians need to specify if individuals are in
partial (some of the criteria are met) or full (no criteria are met)
remission if the client previously met the full criteria. Also, the
current severity level of clinical symptoms and functioning
needs to be indicated from mild to extreme based on body mass
index (BMI) for adults and percentiles for children and
adolescents (APA, 2013).
Another significant eating disorder, Bulimia Nervosa (BN) is
also more prevalent in young females, “estimated at 1% to
1.5%” with female-to-male ratios similar to anorexia (APA,
2013, p. 347). Individuals suffering from bulimia generally
maintain a normal weight for their age and height. The primary
issue for the individual diagnosed with bulimia is a pattern of
binge eating that occurs at least once per week for 3 months.
This is followed by contradictory actions to avoid weight gain,
such as vomiting; laxative, diuretic, or enema abuse; fasting; or
excessive exercise. Additionally, bulimia is accompanied by
both a loss of control and excessive concern related to body
shape/weight. A binge consists of eating a larger amount of
food than normal under similar circumstances in a relatively
short period of time (usually less than 2 hours). To meet
diagnostic criteria, the bulimic behavior must not occur entirely
during episodes of anorexia nervosa. Clinicians need to specify
whether in partial or full remission as well as severity level
based on frequency of episodes of inappropriate compensatory
behaviors, from mild to extreme (APA, 2013).
Binge Eating Disorder (BED) became a diagnostic category in
the DSM-5 and is defined as repeating episodes of excessive
eating accompanied by feeling a loss of restraint and marked

distress. To meet diagnostic criteria, 3 out of 5 of the following
features must be present: eating more quickly than is typical;
eating without the physical sensation of hunger; eating until
excruciatingly full; eating alone out of shame over amount
consumed; and, feeling hopeless, remorse, and depressed
afterward. For diagnosis, frequency of bingeing episodes must
be at least once per week for 3 months and cannot arise only
during the course of anorexia or bulimia. Diagnosis must
specify the current severity of binge episodes (from mild to
extreme) as well as remission status (partial/full) if applicable
(APA, 2013).
Although BED is the most common eating disorder there is
limited knowledge about its development. Annual prevalence
“among U.S. adult (age 18 or older) females and males is 1.6%
and .08%, respectively” (APA, 2013 p. 351) to lifetime
prevalence rates of 3.5% in women and 2.0% in men (Hudson et
al., 2007). Gender differences are closest in BED than in either
anorexia or bulimia, with development still more prevalent in
women. However, for subthreshold BED, this gender ratio
reverses with males 3 times higher than females (Hudson et al.,
2007). BED has been shown to occur across the developmental
lifespan with age of onset generally reported as adolescence but
occurrence in adulthood is not uncommon (APA, 2013).
Eating Disorders Not Otherwise Specified (EDNOS) has been
replaced with two categories. The first, Other Specified Feeding
or Eating Disorder, applies to demonstrations that do not meet
the full criteria for any of the eating disorders in this section. It
is used when the “clinician chooses to communicate the specific
reason that the presentation does not meet the criteria for any
specific feeding and eating disorder” (APA, 2013, p. 353),
which must be included in diagnosis (for examples see DSM-5).
The other category, Unspecified Feeding or Eating Disorder, is
used to signal that there is inadequate information available for
the clinician to make a more specific diagnosis, such as in an
emergency room setting (APA, 2013).
Assessment

In assessing a client with a potential eating disorder, it is
important to conduct a thorough psychosocial evaluation,
including demographic information, reason for visit (which may
be different from the principal diagnosis), support systems,
family information, medical history, and any other history of
mental health intervention (see Chapter 1).
Clients who present with eating-disordered symptomatology
may not initially feel comfortable discussing behaviors
associated with the disorder due to the stigma, shame, and fear
of being discovered. Often, the behaviors have been held secret
for a significant period of time. The clients may be afraid of
family and friends pressuring them to change the behavior
before they are ready to make any changes.
Even when the eating-disordered person appears confident,
accomplished, fearless, and intelligent, the internal experience
is painful (e.g., terror of “getting caught,” pervasive feelings of
confusion or turmoil, concern about “going crazy”). Although it
may be obvious that the client has an eating disorder, several
sessions may be required before the client is willing to
acknowledge the problem. Family members may even maintain
or support such denial because eating-disordered behaviors
(e.g., dieting, overeating, abstaining from eating,
overexercising) are learned from the previous generation.
Although a client may be able to talk about the eating
disorder, the client or his or her family may question the
validity of such a diagnosis. For example, the parents of an
anorectic girl might suggest that their daughter just wants to
look like all the models in the magazines. In order for the
practitioner to address this defensive stance, it is crucial to join
with the family and establish good rapport and communication;
a nonjudgmental and empathic attitude; and a calm, neutral,
matter-of-fact tone concerning the eating-disordered symptoms.
If the clinician infuses the assessment interview with too much
emotion, the client and family may intensify their guardedness
and withdraw from treatment.
Adolescents with eating disorders are often pressured into

therapy by their parents, school counselors, friends, or relatives.
Their resistance to therapy may require the practitioner to focus
on other nonfood- or weight-related issues for a considerable
length of time before the adolescents develop enough trust to
confide in the therapist. Adults with eating disorders may be
motivated to come into therapy for a variety of reasons other
than wanting to recover from the eating disorder. Such reasons
may include wanting to assuage the family's or friends' worries;
fear of a particular medical manifestation, such as bleeding,
tachycardia, or incontinence; or problems with interpersonal
relationships.
Assessment of an individual who the practitioner suspects
might have an eating disorder involves exploring several
specific areas that pertain to eating behaviors and attitudes.
First, the practitioner should obtain a history of dieting or
compulsive eating habits. Second, the client should be assessed
for present symptoms of specific eating-disordered patterns
(e.g., restricting food intake, vomiting, abusing laxatives,
hiding food, hoarding food, having strict lists of “safe” foods,
being obsessed with recipes and cooking, and engaging in
excessive exercise routines).
Often these behaviors are accompanied by symptoms of
depression, low self-esteem, distorted body image,
hopelessness, anxiety, and, in more severe cases, suicidal
tendencies. Due to the possibility of comorbidity, specific
assessments can be conducted to rule out concurrent mental
disorders such as substance abuse, major depression, body
dysmorphic disorder, and obsessive-compulsive disorder. In
addition, personality disorders such as borderline personality
disorder, dependent personality disorder, histrionic personality
disorder, and avoidant personality disorder should be
considered.
People with eating disorders tend to have very rigid, fixed
thought patterns. This may affect their social relationships,
interpersonal skills, and ability to maintain intimate connections
with other people (e.g., close friends, partners, close work

relationships, family ties). If the client is under 18 years old,
the family situation should be thoroughly assessed. Family
factors that have been found to contribute to anorectic behavior
in adolescence include enmeshed family systems, blurred
boundaries between parents and children, and lack of separation
and individuation. Family factors that may influence bulimic
and compulsive overeating behaviors include chaotic family
dynamics, power imbalances, lack of flexibility, and a lack of
clear family structure. In all types of eating disorders, factors
that characterize families could potentially include a history of
sexual abuse or traumatic events, squelching of emotional
expression, and power and control issues.
Finally, it is essential that the eating-disordered client's case
be followed by a medical doctor while the client is in therapy
for the eating disorder. Clients with anorexia who fall below a
minimum weight are often hospitalized because of the life-
threatening risks that emaciation poses. Bulimic clients can
develop electrolyte imbalances and other physical problems that
can lead to medical complications. It is often necessary to have
a written contract with eating-disordered clients stating that if
they fall below a certain minimum weight, they understand that
they will be hospitalized. In addition, the practitioner must
obtain written consent from clients to exchange information
with the physician.
Assessment Instruments
The Eating Disorder Examination (EDE; Cooper & Fairburn,
1987; Fairburn & Cooper, 1993) is a well-validated and widely
used instrument to diagnose eating disorders (Cooper, Cooper,
& Fairburn, 1989; Grilo et al., 2010; Rizvi, Peterson, Crow, &
Agras, 2000. Peterson, Crow, & Agras, 2000). This
semistructured interview in its 16th edition, takes
approximately 1 hour to administer and assesses anorexia
nervosa, bulimia nervosa and binge eating disorder based on
responses to 33 open-ended questions (both Likert and
dichotomous). Training in both the technique of the interview as
well as the instrument is required.

The EDE is composed of 4 subscales related to the cognitive
symptomatology of eating disorders that measure dietary
restraint as well as eating, weight, and shape concern. Also,
behavioral symptoms are assessed including frequency of binge
eating, self-induced vomiting, laxative/diuretic misuse, and
excessive exercise. Scoring for these subscales is on a 7-point
scale (0–6) with higher scores indicating greater frequency or
severity of symptoms. For most items a 28-day timeframe is
employed, except for diagnostic purposes when a longer time
period may be required. A symptom composite score can be
calculated by averaging the diagnostic items. Research indicates
good internal consistency (Cooper et al., 1989) and inter-rater
reliability and test–retest reliability (Reas, Grilo & Masheb,
2004) over 2 to 7days for all the EDE subscales and high inter-
rater reliability (Rizvi et al., 2000). Good inter-rater reliability
and test–retest reliability for the EDE (6 to 14 days) was shown
in adult patients with BED (Reas et al., 2004). Research by
Berg, Peterson, Frazier, and Crow (2012) demonstrates that the
EDE scores correlate with measures of similar constructs and
support the use of this instrument to distinguish between eating
disorder cases and controls; however, they point out that no
studies to date have assessed the inter-rater reliability of scores
on items that assess laxative/diuretic misuse or excessive
exercise. There is a child's version (ChEDE) of this scale
designed specifically for use with children ages 8 to 14 (Bryant-
Waugh, Cooper, Taylor, & Lask, 1996) as well as a self-report
questionnaire (EDE-Q) that have been shown to correlate with
the EDE.
The Eating Disorder Inventory-3 (EDI-3; Garner, 2004) is a
self-report questionnaire used to assess the symptoms and
presence of eating disorders in individuals aged 13 and above.
This is the third version of one of the most popular self-report
scales (EDI; Garner, Olmsted, & Polivy, 1983 & EDI-2, Garner,
1991), and it consists of 91 items (same as EDI-2) that are rated
on a 6-point scale from “always” to “never.” It is organized into
12 scales (e.g., drive for thinness, bulimia, body dissatisfaction)

and yields 6 composite scores, including eating disorder risk
and 5 common psychological constructs. Higher scores indicate
a greater likelihood of an eating disorder. Furthermore, this
version included individuals with an EDNOS diagnosis, which
covers binge eating. The EDI-3 demonstrates good
discriminative validity and good to adequate internal
consistency (Garner, 2004; Cumella, 2006) with recent studies
of women demonstrating results that were even better than the
original (Clausen, Rosenvinge, Friborg, & Rokkedal, 2011).
The Eating Disorder Diagnostic Scale (EDDS; Stice, Telch, &
Rizvi, 2000) is a brief, 22-item, self-report screening measure
of anorexia nervosa (AN), bulimia nervosa (BN), and binge
eating (BE) disorders. The items can be standardized for
consistency and averaged (with the exception of 2 items) to
provide a symptom composite score, and the scale can be
administered in less than 10 minutes. Psychometric studies
provided criterion, convergent, and predictive validity of the
EDDS with samples containing adolescents and adults, as well
as nonclinical and clinical populations. The eating disorder
symptom composite demonstrated internal consistency (.89) and
convergent validity with similar scales assessing eating
pathology (EDE and SCID-I). The 1-week test–retest
coefficients were .95 (AN), .71 (BN), and .75 (BED) (Stice et
al., 2000; Stice, Fisher, & Martinez, 2004). Krabbenborg et al.
(2011); established an overall symptom composite cutoff score
of 16.5, which accurately distinguished those with a disorder
from controls and may be useful in identifying subthreshold
patients as well as detecting possible protective intervention
effects. Later factor analysis found good internal consistency
related to four factors of the scale: body dissatisfaction,
bingeing behaviors, bingeing frequency, and compensatory
behaviors (Lee et al., 2007).
The Eating Attitudes Test (EAT-26; Garner, Olmsted, Bohr, &
Garfinkel, 1982) is a brief, self-report screening measure of
eating disorder symptoms and is not intended to make a
diagnosis. Many studies have been conducted using the EAT-26

as a screening tool, including the 1998 National Eating Disorder
Screening Program (NEDSP). This 26-item questionnaire
contains 3 subscales: dieting (13 items), bulimia and food
preoccupations (6 items), and oral control (7 items).
Respondents must rate whether each item applies on a 6-point
scale (e.g., “always,” “usually,” “often,” “sometimes,” “rarely,”
or “never”). Items are summed to produce a total score. Clients
who score above 20 are considered at risk for an eating disorder
and referred for a diagnostic interview. Additionally,
information is gathered on the individual's BMI, and five
behavioral questions ask about weight-control behaviors (e.g.,
binge, vomit, laxative/diuretic, exercise, and weight loss). The
EAT-26 is easy to administer and score and has good
psychometrics (Mintz & O'Halloran, 2000).
The EAT-26 does not yield a specific diagnosis of an eating
disorder. A disorder must have a prevalence approaching 20% in
order for the test to be efficient in detection. This instrument
was developed and validated on primarily female populations
and is most often used to assess female high school and college
students. The EAT-26 can be useful in measuring pathology in
underweight girls but also shows a high false-positive rate in
distinguishing eating disorders from disturbed eating behaviors
in college women.
The EAT-26 has a children's version (ChEAT-26; Maloney,
McGuire, & Daniels, 1988) for use with children aged 8–13
years with psychometric properties similar to the adult version
(alpha = .88 with low item 19 deleted) and a suggestion that this
measure be further modified if used with younger children since
alphas increased with each grade level. The standard cutoff
score of 20, which is used with adults, was recommended
(Smolak & Levine, 1994; Sancho, Asorey, Arija, & Canals,
2005). Lack of honesty or accuracy in self-reporting can limit
the usefulness of the EAT-26, particularly with anorexia.
However, the EAT-26 has been shown to be useful in detecting
cases of anorexia nervosa, and the assessor can then combine
information gained from this assessment and other assessment

procedures to make a diagnosis (Maloney et al., 1988).
Emergency Considerations
Eating disorders are among the most lethal psychiatric illnesses
in the DSM-5 (APA, 2013). Meta-analysis conducted by
Arcelus, Mitchell, Wales, and Nielsen (2011), found that
mortality rates are substantial among individuals with eating
disorders, especially in those with anorexia nervosa. The
weighted annual mortality rates were 5 per 1000 person-years
for anorexia nervosa (AN), 1.7 per 1000 person-years for
bulimia nervosa (BN), and 3 per 1000 person-years for EDNOS.
More striking, one in 5 individuals with AN who died had
committed suicide. Additionally, age at assessment was found to
be a significant predictor of mortality for individuals with
anorexia. Utilizing data from the National Comorbidity Survey
Replication Adolescent Supplement, Swanson et al. (2011)
found that most adolescents who had a diagnosis of AN, BN,
and BED in the past 12 months reported significant role
impairment (97%, 78%, and 63%, respectively) especially in
their social and family relationships. Moreover, suicide risk was
demonstrated for all eating disorders. Bulimia and subclinical
anorexia were correlated with suicide plans, and BN and BED
were linked with suicide attempts.
Due to the physical complications that can develop from
starvation, laxative abuse, diuretic abuse, and vomiting
behaviors, clients with eating disorders can develop life-
threatening medical conditions that require emergency medical
procedures. Therefore, the practitioner who is working with
eating-disordered clients must develop a “team” approach to
treatment and include a physician or nurse practitioner, a
dentist, a nutritionist, and other medical professionals on the
treatment team to effectively treat the client.
Clients with eating disorders also often suffer from severe
depressive episodes that may lead to feelings of hopelessness
and, ultimately, suicidal behaviors. If the practitioner assesses
the client to have depressive symptoms, the severity of the
depression along with suicidal ideation should be considered.

Crisis intervention strategies should be utilized and a
psychiatric evaluation conducted if necessary to stabilize the
client and keep him or her safe.
Cultural Considerations
Culture beliefs and attitudes are factors that influence the
development of eating disorders (Miller & Pumariega, 2001). It
is important to recognize that in the developed Western
European and North American countries, food is taken for
granted, and only in countries in which there is an abundance of
food do eating disorders flourish. Poor and underdeveloped
countries in which food is scarce have far fewer eating-
disordered individuals among their populations. Cultural values,
therefore, are an important aspect of this illness. Culture shapes
both attitudes and behaviors related to body image and eating,
especially when values about physical aesthetics are involved.
For example, some cultural risk factors for anorexia include
social pressure to be thin (e.g., media attention/peer pressure)
and the focus on body image (Polivy & Herman, 2002; Striegel-
Moore & Bulik, 2007). Western culture's emphasis on thin
idealization can contribute to eating disorders, but it is not
solely culpable. Although the underlying causes of eating
disorders are not entirely clear, a multifactorial relationship that
includes biological, psychological, and sociocultural factors is
most accepted.
There is a growing controversy over why the number of
minorities with eating disorders is relatively low. Many feel
that the research on eating disorders in women of color suffers
from both underreporting and researcher bias (NEDA, 2012),
both of which can result in minorities going undiagnosed. Some
studies show that the experiences of African-American and
Caucasian female adolescents are extremely different, with
African-American girls being proud of their bodies regardless
of the cultural pressure to be thin (Woodrow Wilson
International Center for Scholars, 2000). A cultural identity that
embraces larger body types than does the dominant culture may
account for why some African-American women are at a lower

risk than White American females for developing eating
disorders that focus on thinness. This suggests that a protective
effect may exist in terms of ethnicity and culture for black
American females against the development of some eating
related psychopathology. However, Asian women reported equal
to higher levels of eating dysfunction as white American women
(Wildes, Emery, & Simons, 2001). In contrast, research on
Latinas showed that they are more inclined to exhibit binge
eating rather than restricting behaviors (Smolak & Striegel-
Moore, 2001). Significant ethnic differences emerged for
bulimia, with Hispanic adolescents reporting the highest
prevalence; there was a trend toward ethnic minorities reporting
more binge eating, while non-Hispanic White adolescents
tended to report more anorexia (Swanson et al., 2011).
However, for binge eating, other studies showed that risk
factors did not include ethnicity but rather childhood obesity
and familial eating problems in studies comparing Black and
White women (Striegel-Moore et al., 2005). The variability that
exists across studies is noteworthy and warrants further study.
Contrary to earlier beliefs, a growing number of studies
suggest that U.S. ethnic minority groups are trending toward
higher levels of eating disorders and that the relationship
between ethnicity and disordered eating may vary by disorder
(Striegel-Moore, 2000; Striegel-Moore & Smolak,
2000; Cachelin, Striegel-Moore, & Regan, 2006). One study, for
example, conducted in Minnesota among over 81,000
adolescents, found that the highest prevalence for disordered
eating was among Hispanic and Native American teens of both
genders (Croll, Neumark-Sztainer, Story, & Ireland, 2002).
Quite often this trend is attributed to acculturation (i.e., how
much they have adopted the values and behaviors of the
prevailing culture). As minorities accept the dominant culture's
values, they are subjected to the same kinds of pressures to be
thin as their Caucasian counterparts. Findings by Davis and
Katzman (1999) showed that in Chinese university students
increased acculturation was associated with greater reports of

bulimia and drive for thinness in females and greater
perfectionism in males, both factors in distorted eating.
Measuring the prevalence of eating disorders in minority
populations is further complicated by the fact that they are
underrepresented in most studies, and the likelihood that they
will seek help/ treatment or be asked about eating disorder
symptoms is poor (Stein, 2000). The role that ethnicity plays in
the development of distorted eating needs to be further studied
(Boisvert & Harrell, 2012; White & Grilo, 2005; Striegel-Moore
et al., 2005).
Eating disorders (ED) occur more frequently in women;
however, men are less likely to be diagnosed as they are often
stereotyped as female disorders (SAMHSA, 2011). Adolescent
studies regarding lifetime prevalence estimates found no sex
differences in the prevalence of anorexia or subclinical binge
eating disorders, while for bulimia, binge eating disorder and
subclinical anorexia prevalence was higher in girls (Swanson et
al., 2011). Just as was observed in minorities, eating disorders
are increasing among males as they are finding themselves
subjected to the same cultural ideals in regards to body image
and social pressures that women face (Boisvert & Harrell,
2012). For example, 10% to 15% of individuals with anorexia
and bulimia are male, and among gay men, the numbers increase
to 14% for bulimia and over 20% for anorexia (Russell & Keel,
2002).
Many believe that part of the problem with identifying men
with eating disorders goes beyond stigma and underreporting to
the very instruments used to assess eating disorders. Most of the
commonly used measures of eating pathology (both self-report
and interview-based) were developed and validated using all-
female populations (Stice et al., 2004). And many focus on
restricting behaviors as they are observed in women, which may
or may not be similar in men (Boerner, Spillane, Anderson, &
Smith 2004). More research with male populations is needed as
well as a better understanding of male-specific expressions of
eating pathology. It is important to note that in some states

(e.g., NJ, IL), as late as 2007, eating disorders were excluded
from conditions considered to be serious mental illnesses
(Klump, Bulik, Kaye, Treasure, & Tyson, 2009).
Social Support Systems
Individuals with eating disorders often report an unusual
amount of disruption in their social and intimate relationships
due to their symptoms. Anorectic clients frequently report
avoiding social interactions with others where food is the focus
of attention, fearing that their abstention from food will be
noticed. Also, anorectic clients may spend a great amount of
time thinking about food, cooking for others, exercising, and
avoiding people who might sabotage their efforts to restrict
their food intake.
Bulimic individuals often hoard food, eat secretively, and
purge in private, and therefore, frequently search for times to be
alone. Bulimic clients also describe spending large amounts of
time buying food, hiding food, eating and purging, and
exercising.
Persons with compulsive eating problems also avoid social
activities and instead, purchase and consume large amounts of
food. In sum, persons with eating disorders are often left with
few friends. If the individual is involved in an intimate
relationship, the person can experience difficulty maintaining
the relationship while engaging in eating-disordered behavior.
On the other hand, eating-disordered individuals often
struggle to maintain social relationships in an effort to disguise
the fact that they have a problem. Anorectic individuals may
feel that friends are necessary ingredients to being “perfect.”
However, as the eating disorder becomes more noticeable and
severe, the person generally becomes more and more reclusive
in the pursuit of thinness.
Due to these pervasive feelings of isolation in individuals
with eating disorders, group therapy has become a common
treatment modality for such clients. Eating-disorder groups
facilitated by a therapist with expertise in this illness can
provide social support as well as other therapeutic benefits.

For adolescents with eating disorders, it is highly
recommended that families become involved in family therapy.
Families are often resistant to treatment and must be educated
about the nature of the illness and ways to cope with the
teenagers' symptoms.
For college-age students and adults, group therapy that
focuses on the underlying reasons for the eating problems rather
than issues about food can be very beneficial to clients. Group
therapy can be both supportive and confrontive, thereby
preventing the individuals from denying their symptoms.
At nearly every large university health services center, there
are resources available to men and women with eating disorders.
There are also a number of Internet resources that provide
information and referral sources for eating-disordered clients,
such as the following sites:
· www.aedweb.org: The Academy for Eating Disorders is a
global professional association committed to leadership in
eating disorders research, education, treatment, and prevention.
· www.anad.org: The National Association of Anorexia
Nervosa and Associated Disorders (ANAD) is a nonprofit
organization dedicated to helping individuals with eating
disorders and their families. It provides hotline counseling and
referrals to support groups and health care professionals. ANAD
publishes a quarterly newsletter as well as educational materials
and will provide educational speakers, programs, and
presentations for schools, colleges, public health agencies, and
community groups.
· www.eatright.org: The world's largest organization of food
and nutrition professionals that is committed to improving the
nation's health and advancing the profession of dietetics through
research, education, and advocacy including information on
eating disorders.
· www.mentalhealthscreening.org: Screening for Mental
Health, Inc. (SMH) is a nonprofit organization that coordinates
mental health screening programs nationwide, including the
National Eating Disorders Screening Program (NEDSP), a large-

scale screening for eating disorders, and Interactive Telephone
Screening Programs. NEDSP includes an educational
presentation on eating disorders, body image, and nutrition, a
written screening test, and the opportunity to meet one-on-one
with a health professional.
· www.namedinc.org: The National Association for Males with
Eating Disorders' (NAMED) mission is to provide support to
males with eating disorders, to educate the public on the issue,
and to be a resource of information on the subject.
· www.nationaleatingdisorders.org: The National Eating
Disorders Association (NEDA) is the largest nonprofit
organization in the United States dedicated to eliminating eating
disorders. NEDA advocates on behalf of individuals and
families affected by eating disorders and offers prevention
programs, educational materials, research, and a toll free
referral hotline.
· www.nimh.nih.gov: National Institute of Mental Health's
(NIMH) mission is to transform the understanding and treatment
of mental illnesses through clinical research. Information on
eating disorders can be found under the health and education
tab.
· www.overeatersanaonymous.org: Overeaters Anonymous
(OA) is an international, nonprofit organization that provides a
worldwide network of volunteer support groups. Modeled after
the 12-step Alcoholics Anonymous program, the OA recovery
program addresses physical, emotional, and spiritual recovery
aspects of compulsive overeating.
Elimination Disorders
In the DSM-5, Elimination Disorders form a separate cluster of
symptomatology that is most commonly first diagnosed in
children under the age of 18 years. However, the onset of
elimination disorders can occur during any developmental
period and is often accompanied by environmental or social
stressors. There are two types of elimination disorders: primary
and secondary. The primary type is designated when the child
has never accomplished a pattern of continence for a period of

time. The secondary type is diagnosed if the child had
accomplished a pattern of continence before developing urinary
or fecal incontinence. Enuresis occurs when the child, who must
be at least 5 years old, urinates in clothing or bedding
repeatedly and frequently (2 times per week) over the course of
at least a 3-month period (APA, 2013). In addition, the
diagnosis of enuresis can be accompanied by the following
specifiers: “nocturnal only, diurnal only, or nocturnal and
diurnal” (APA, 2013, p. 355).
Encopresis occurs when the child, who is at least 4 years old,
has frequent and repeated bowel movements over a period of 3
months. In both cases, the pattern of behavior may be voluntary
or involuntary (APA, 2013). Specifiers for this disorder include:
“with constipation and overflow incontinence” and “without
constipation and overflow incontinence” (APA, 2013, p. 358).
In both cases, it is important for the helping professional to
refer the child and family to a physician for consultation since
the problem may be medical in origin. Certain medications can
cause constipation in a child and bowel movements may have
become painful. On the other hand, environmental or social
stressors may also result in enuresis or encopresis in children.
Both types of elimination disorders more commonly occur in
males than females.
Differential Diagnosis
A diagnosis of an eating disorder should be weighed against the
possibility that a client has another medical condition that could
lead to severe weight loss such as Crohn's disease,
hyperthyroidism, or HIV/AIDS. A client with Major Depressive
Disorder may experience weight loss due to a lack of appetite
but does not have a fear of gaining weight or a body dysmorphic
condition. Schizophrenia can result in odd eating behaviors and
preferences, but the symptoms of an eating disorder are not
present. Likewise, clients with diagnoses of social anxiety
(particularly fear of eating in public), obsessivecompulsive
disorder, or body dysmorphic disorder may have symptoms that
are similar to eating disorders; however, they do not possess the

fear of gaining weight nor do they meet the full criteria for any
of the eating disorders (APA, 2013).
Case 11.1
Identifying Information
Name: Greg Deal
Age: 24 years old
Ethnicity: Caucasian
Educational Level: Graduate student in law school
Marital Status: Single
Background Information
As a counselor at the student health center at a large university,
you see many young men and women who have concerns about
their self-image, self-confidence, and problems related to
depression and anxiety. You work primarily with young adult
GLBTQ men and women who have come voluntarily to the Out
Youth center on campus. The center serves all students at the
university who are gay, lesbian, bisexual, transsexual, or who
are questioning their sexual orientation. The center provides
individual counseling, group therapy, crisis intervention
services, psychoeducational seminars, and resources and
referral information. Students can access services free of
charge. The center has an intake worker who gathers basic
information about the student and sets up appointments with the
therapists.
Intake Information
Greg Deal called the student mental health clinic and requested
an appointment with a therapist due to feelings of depression,
difficulty completing his schoolwork, and ongoing eating
problems. He told the intake worker that he has been
experiencing the current problems for approximately 1 month.
He stated that he has been having difficulty getting himself to
classes, can't concentrate on his homework, feels drained of
energy, and wants to do nothing but sleep all day.
Initial Interview
During the first appointment with Greg, you gather information
about the history of the presenting problem, a social history,

and a family history. The first session is 90 minutes in duration
in order to obtain enough information to make an initial
assessment.
Greg is a noticeably thin, tired-looking young adult male who
is curled up in a chair in the waiting room when you meet him.
He is wearing a pair of baggy blue jeans, a long-sleeved shirt
covered by a heavy sweatshirt, and heavy socks and sneakers,
despite the fact that it is July. His hair is tousled as though he
forgot to brush it after getting up in the morning. You notice
that he has very dark circles under his eyes, and his face,
including his forehead, appears bony.
Greg states that he developed an eating problem 7 years ago
at age 17 after graduating from high school as class
valedictorian and gaining admittance into a prestigious
university in Boston. Prior to the eating problem, he weighed
approximately 160 pounds and was 5'10” (an ideal weight for
his height and age). Greg moved away from home into the
dorms at school and began limiting his food intake to only
vegetables and exercising, sometimes 4 hours a day.
Initially, Greg lost about 20 pounds and found he couldn't
lose any more weight without further restricting his diet. He
started eating very small quantities of food, counting the
number of bites he could have each day. At one point, he
allowed himself only 4 bites of food per day. If he ate more
than that, he would make himself exercise an extra hour.
Greg reports that by spring break of his first year, he weighed
only 120 pounds. His BMI was less than 16.0 kg/m2. When he
went home to visit, his parents were shocked at his appearance
and took him to his old physician. He managed to convince the
doctor that he did not have anorexia and that he had simply lost
his appetite because of the pressures at school. The physician
recommended that he drink three cans of Ensure each day in
order to bolster his weight. Greg was unwilling to do this
because of the high calorie content of the drink. Assuring his
parents that he would eat, he returned to school. He refused to
think he had a problem; rather, he just wanted to lose weight

and be popular. He felt that he had always been characterized
by his peers as a bookworm, and he desperately wanted to “fit
in” at college.
He states that on one occasion he was rushed to the hospital
by ambulance after fainting in class. He stayed at the hospital
for a week due to dehydration and electrolyte imbalance. He
begged his parents to allow him to finish the semester since it
would “ruin my grade-point average” not to complete the
classes. At that time, he got his weight up to 125 pounds to
“prove” he didn't have an eating disorder.
Later, he lost weight again, and his weight has hovered
around 115 pounds since that incident. Greg states that he has
been hospitalized on five different occasions over the past 7
years for dehydration, exhaustion, electrolyte imbalance, and
starvation/emaciation. He has rarely seen a counselor for more
than a few sessions, stating, “They just thought I should start
eating and that would resolve the problem.”
Due to his eating problems, his heavy school schedule, and
his exercise regime, Greg reports that he has had little time for
“having fun.” He states that he had a boyfriend for about a year,
but he couldn't handle his problems with food.
Currently, Greg weighs 118 pounds and feels “heavy.” He
considers his ideal weight to be 113 pounds. He suggests that he
can “see fat” on his thighs and stomach when he weighs more
than 113 pounds. Due to the 5-pound increase in his weight,
Greg has recently begun to use laxatives and occasionally
induces vomiting, although he states that it hasn't helped him
lose weight. He feels very anxious because he thinks he has lost
control of his eating, at times bingeing on ice cream and
chocolate bars when he gets extremely hungry. Greg does admit
that he thinks he may have an eating problem.
Family Session
After you have met with Greg on three occasions, he tells you
that his parents are coming for a visit. You ask Greg if they
would be willing to come to a session with him and he agrees to
ask them. Greg appears to have developed a working

relationship with you. He has kept his scheduled appointments
and has been on time for them.
The session with Greg and his parents lasts approximately 1
hour. It is apparent from the beginning of the session that
certain dynamics prevail in this family. Greg, who has
previously been very articulate and insightful in individual
sessions with you, becomes quiet, unassertive, and passive
during the family interview.
His mother makes numerous attempts to speak for Greg and
appears aggressive and overbearing. She admits that she herself
has dieted most of her adult life in order to “stay fit,” but that
she thinks Greg is overdoing it a bit. His father, on the other
hand, appears passive and emotionally distant. He does not
speak unless he is asked a question or spoken to directly. He
often glances at his wife while offering his opinion about the
family situation. He does suggest he is very concerned about
Greg's problems.
Greg's mother states that Greg has always been the “perfect”
child—an overachiever, a straight-A student, president of the
student council, and an exceptionally well-behaved adolescent.
“We never had any problems like other parents have with their
teenage children,” she states proudly.
As his mother speaks, Greg becomes increasingly
uncomfortable, despondent, and withdrawn. He curls up in his
chair as a small child might. It is apparent that Greg disagrees
with his mother's description of his life at home. When you ask
him how he is feeling at the moment, Greg replies, “Oh, yeah,
everything was just great as long as we all agreed with Mother
and her opinions, never letting anyone else have a say-so in
anything. Then, Dad would get real quiet for a while until
everything just blew up and all hell would break loose. Yeah, it
was perfect all right.”
At this statement by Greg, his mother becomes extremely
angry, saying that he cannot continue the session. You calm the
situation by discussing the importance of not talking for other
family members and of using “I statements” when speaking

about feelings. Although you are able to establish some order, it
is obvious that the family will need additional counseling
related to communication and family functioning. The family is
clearly enmeshed and needs to see the value of Greg becoming
an independent adult in his own right.
· 11.1–1 What are some of Greg's strengths?
· 11.1–2 With whom would you want to consult in order to
ensure that Greg receives the best possible treatment?
· 11.1–3 What resources might be beneficial to Greg?
· 11.1–4 What issues would you want to include in a contract
with Greg?
· 11.1–5 What is your diagnosis for this case?
· 11.1–6 Are there any physical or general medical conditions
that may affect diagnosis?
· 11.1–7 What subtype, severity, and course specifiers would
you want to use?
· 11.1–8 What psychosocial (V codes/Z codes) and contextual
factors including cultural may affect diagnosis and treatment?
· 11.1–9 What characteristics make this individual more
vulnerable to suicide?
Case 11.2
Client Name: Maria Lopez
Age: 16 years old
Ethnicity: Hispanic
Educational Level: 11th grade
Intake Information

The intake worker received a phone call from the mother of
Maria Lopez, who had been referred by her physician, Dr.
Amanda Welby, for mental health therapy. Maria's mother
stated that Maria has been having problems with eating for the
past 9 months and seems depressed and withdrawn much of the
time. She has been seeing her physician every 3 months for
physicals and weight checks. She is 5 feet 7 inches tall, and her
current weight is 102 pounds. The problem has persisted despite
Maria mother's efforts to ameliorate the situation. Maria was
discharged 1 week ago from the hospital after being admitted
after a fainting spell. She was treated for dehydration.
Initial Interview
Your initial interview with Maria Lopez lasts 90 minutes.
During that time you obtain information concerning the
presenting problem, a social history, and a family history. You
establish rapport with the client, discuss issues of
confidentiality, and schedule another appointment with her. In
your files you have made the following reports.
Presenting Problem
Maria Lopez is a 16-year-old Hispanic female who came to the
Eating Disorders Clinic at her family's request after being
hospitalized for a fainting and dehydration episode. Dr. Amanda
Welby referred her to the clinic over concerns about the client's
weight loss over the past 9 months.
Maria stated that she doesn't think she has an eating problem,
although she admitted to wanting to lose weight to look more
like the other girls at school. She stated that she used to be
overweight at 130 pounds (although 130 pounds would be an
ideal weight for someone 5 feet 7 inches tall). She stated that
being overweight gave her low self-esteem and that she didn't
feel that she “fit in” with the other girls.
She reported that she has been trying to lose weight since she
was 13 years old and had tried several diets but never seemed to
lose much weight until recently. During the past school year,
Maria began skipping breakfast and lunch. For dinner, she
primarily ate broiled chicken and salad. She stated that

eventually she was able to eliminate the salad and eat only a
piece of boneless, broiled chicken each day. She has found that
she can lose weight rapidly on this sparse diet.
In response to a question about her exercise regime, Maria
stated that she started walking 30 minutes a day about a year
ago. After a month, she began running about 3 miles a day,
which quickly escalated to running approximately 10 miles a
day. She also begged her parents for a stationary bike that she
exercises on approximately 2 hours a day. “Sometimes, if I can't
fit all the exercise in during the day, I wait until my parents go
to sleep at night and get up and work out on the stationary bike
until 1 A.M.”
Maria admits to being very tired and having no energy. She
states that sometimes it is exhausting to exercise, but she feels
that she has to in order to lose more weight.
When asked what she thinks of her weight now, she replied
that she would like to lose a few more pounds because weighing
less than 100 pounds is her goal.
Maria stated that she is not having problems in school and
that she is a straight-A student. She hopes to get a scholarship
to Princeton, Yale, or Harvard University, and she has been
studying hard for the SAT exams.
Social History
Maria stated that she has always liked school and has done well
throughout her school experience. She also plays the violin in
the school orchestra, is in the choir at her church, belongs to a
chess club, takes art lessons, and dancing. She stated that her
parents never let her sit around and watch TV; she is always
busy doing something.
She has a few good friends but not a lot of friends. “I guess
I'm kind of shy, and people sometimes mistake that for being
snooty,” she told you.
Maria appeared embarrassed when you asked her if she's had
any boyfriends. She stated that because she was overweight,
none of the boys in her class really liked her. About a year ago,
she overheard a boy talking to her best friend in the cafeteria at

school say that if she just lost a little weight in her thighs, she'd
be quite pretty. Maria stated that she's always felt left out of a
really popular group of girls at school because she doesn't have
a boyfriend. “They get together and go out to a movie or for a
pizza and never invite me because I don't have a boyfriend to go
with.”
Although she is not in the most popular group, Maria stated
that she was always so busy with other activities that it didn't
really bother her until this past year. She said she has always
had one or two good friends with whom she engaged in
activities and who also took dancing and art or played the
violin. During the past year, however, her good friends have
become involved with boys, thus leaving Maria out of their
group.
Family History
Maria stated that her family is very close. Maria has a younger
brother, Juan, age 14, and an older sister, Carla, who is 20 and
away at college most of the time. Her father works at a factory
that makes electronic parts for computers and often works
double shifts. Her mother is a homemaker and does volunteer
work for the school and church.
She said that her mother is always bugging her about her
eating. Maria felt that her mother has an eating problem also,
but would never admit it. “My mother is a very controlling
person and has always watched over me like a hawk whenever I
put a bite of food in my mouth,” said Maria. “I'm either eating
too much or too little. I can never seem to please her.”
Maria said that her mother is a foodaholic and has always
been pushing food at Maria as long as she can remember. Maria
described her mother as being of average weight but a little on
the heavy side. “She is always cooking and expects everyone in
the family to eat more than one plate of food for every meal.”
Maria described her sister, Carla, as “nothing like me. She's
real social and has lots of friends and doesn't care what anyone
thinks about her.” She stated that her sister is also slightly
overweight but not obese. Maria described her brother as just a

normal boy. He plays soccer and doesn't really care much about
school but does okay, with about a B average.
Maria said that she doesn't feel very close to her father since
he is gone so much. Without prompting, she related an incident
in which her father stated that Maria is “his little princess” and
he wishes she would never grow up. It was apparent that Maria
was upset by that remark. When asked if the remark bothered
her, Maria replied that she doesn't know how she can stay little
all her life when she is growing up and it is out of her control.
During the past year, Maria's relationship with her parents has
grown tense due to her losing so much weight. “They are
constantly telling me how, when, and where to eat, and if I
don't, they get upset.” She also stated that “being the middle
child and always having to live up to their expectations is not
easy all the time.”
When asked about arguments at home, Maria said that
everyone argues at home but it doesn't mean anything. “My
family is just highly emotional and scream and yell at each
other but it doesn't mean they don't love you. I just don't like to
listen to it so I go to my room and study.” When asked if she
thought she was angry about anything, Maria replied that she
never really gets angry and that she doesn't like conflicts with
anyone.
· 11.2–1 Briefly describe what you think are Maria's strengths.
· 11.2–2 What are some of the contributing factors (V codes/Z
codes) that seem to be involved in Maria's problems with food?
· 11.2–3 Are there diagnoses that you would want to rule out? If
so, what are they?
· 11.2–4 What is your diagnosis for this case (any subtype,
severity, and course specifiers)?
· 11.2–5 What would be some resources that you could suggest
to Maria and her family that would assist them in Maria's

recovery?
· 11.2–6 What cross-cutting symptom measures would you use
from Section III of the DSM- 5?
Case 11.3
Name: Karen Black
Age: 17 years old
Educational Level: 12th grade
Background Information
Karen Black decided to enter counseling after an initial intake
session where you assessed her as having low self-esteem and a
possible Major Depressive Disorder. During the initial intake,
she told you that she is going off to college in the fall and that
she just doesn't feel good about herself anymore. She stated that
she has never felt she is very pretty; however, it didn't really
bother her that much until this year, her senior year at Golden
High School.
Karen appears to be an attractive girl of average weight and
height. She stated that her parents are divorced. She lives with
her mother and two younger brothers, Mike, age 15, and Scott,
age 13. Her parents divorced about 2 years ago, and her father
lives in an apartment on the opposite side of town. Karen gets
along well with both parents although she confessed that the
year her parents separated was chaotic. Her mother accused her
father of seeing another woman. Karen doesn't feel that
allegation was true although she thinks her father may be dating
someone else now.
First Session
After you discuss issues of confidentiality, Karen tells you that
her biggest problem is being worried about going to college and
nobody liking her there. She feels like the “ugly duckling” at
school and doesn't have a boyfriend. She has had boyfriends in
the past and just recently broke up with someone she says was

more of a “friend” than a “boyfriend.”
Nevertheless, it bothers her to have no one to call on the
phone or go out with, and the loss of the relationship with her
boyfriend makes her feel even worse about her already poor
self-image. With some pride, she tells you that she is a straight-
A student and has received a scholarship to Golden State
University for the first year of college. She indicates that she
doesn't like sports and isn't athletic, but she does ride bikes
with her brothers occasionally and enjoys walking her golden
retriever, Nugget.
Karen thinks that she and her mother have a good
relationship. However, Karen states that her mother is always
nagging her about what she wears, how she fixes her hair and
makeup, and what she eats. She likes to go shopping with her
mother, and sometimes they go to lunch and a movie when her
mother isn't working. Her mother is a buyer at a large
department store, Canary's, at one of the malls and often has to
work on the weekends or go on buying trips for 3 or 4 days
during the week. Karen is expected to stay home and take care
of her brothers when her mother is gone.
· 11.3–1 At this point, what are the issues that you consider
important in assessing Karen?
Second Session
Karen arrives on time for her second session with you after
school on Wednesday at 4 P.M. She appears happy to see you
when you go to the waiting room. She is wearing blue jeans and
a pink top. You notice she has dark circles under her eyes and
looks very tired. You mention that she looks fairly tired today,
and she shrugs her shoulders and says that she had a term paper
due that she worked on late the previous night.
She sighs and says, “Everyone has been telling me that I look
tired, and I don't really know why they keep saying that. It
makes me feel really selfconscious.” When you tell her that she
has dark circles under her eyes, she says, “Oh, that's nothing to
be worried about.”

You decide to summarize the first session with Karen and
continue your assessment of her situation. You discuss her
parents' divorce, her scholarship to college, her fears about
attending the university in the coming school year, and her
concerns about her self-image.
“Is there anything I left out from our discussion last week?”
you ask.
“That's probably all we talked about, since I'm scared to tell
you the rest of it,” Karen replies.
“What do you think is making you scared to tell me
something?” you respond.
Karen looks despondently out the window. “I'm just afraid
you'll think I'm dumb or weird or crazy or something if I tell
you. It's something that's really been bothering me lately, and I
just don't feel like I can talk to anyone about it.”
You remind Karen that anything she tells you will be kept
confidential, unless it's about harming herself or someone else,
and that you are there to help her work on issues that are
bothering her. She sits quietly for a few moments staring out the
window and then begins talking in a quiet, measured voice.
“Well, I told you I feel really bad about myself and how I
look, and I feel like everyone thinks I'm just an ugly,
overweight, boring person to be around. So, for about a year,
I've been trying to lose weight. At first, I went on all these
crash diets, and I'd lose a few pounds, but then I'd gain it right
back because I'd get so hungry I'd eat everything in sight. It was
really frustrating to me because I had this friend who lost about
20 pounds and everyone was saying how good she looked, and
she kept saying all I had to do was exercise more and I'd lose
weight, too. Well, I tried that for a little while, but I hate
running and quit after about a month. While I was in one of my
starvation phases, my former boyfriend asked me out for pizza
one night. I went and sat there with a glass of tea. He asked me
why I wasn't eating, and I lied and said I wasn't hungry. He told
me I'd look good the way I was if I'd just lose a little weight in
my thighs. That comment was mortifying to me. I don't know

what happened, but I sat there and ate almost a whole pizza and
when I got home, I just stuck my finger down my throat and
threw it all up. I was so angry with him for saying that to me.
The next day I got on the scale, and I had lost 2 pounds. I felt
so good about having lost 2 pounds that I decided maybe I could
eat and lose weight at the same time by, you know, throwing up.
It sort of got me on a cycle. For a while, I tried to eat one meal
a day like I'd been doing, but it got harder and harder not to
binge. So, I would binge in the afternoon when my mother was
at work, and then I'd vomit it all up. It's just gotten to be a
vicious cycle.”
“Karen, I don't think you're weird or crazy. A lot of girls your
age have problems feeling good about themselves and their
bodies. From what you're describing, it sounds as if you're
struggling with food and body image. I'd like to ask you some
specific questions about these issues if it's okay with you.”
Karen shrugs her shoulders and says, “Okay, I'm sort of glad
I've finally told someone.”
“What do you mean by binge? Tell me a little bit about what
you ate when you ‘binged,'” you ask.
“Huge amounts of food,” Karen responds. “I mean everything
I could get my hands on. It was like this uncontrollable urge
that I just couldn't stop. For example, a few weeks ago when I
broke up with my boyfriend, I went home after school and ate a
whole box of chocolate cookies, a carton of ice cream, three
Hostess Twinkies, two candy bars, and a peanut butter and jelly
sandwich. Then, I was thirsty so I made about a quart-sized
glass of frappuccino. After that, I felt so bad about myself, I
just went into the bathroom and threw it up. It sounds terrible, I
know, but I felt better afterward.”
“It doesn't sound terrible, but it does sound like a problem for
you. How often does this happen, Karen?” you ask.
“It started out just like once a week,” Karen replies. “But
now, I do it every day, sometimes two or three times a day.
Sometimes, I feel like I've vomited so much, I can't vomit
anymore. So then I take laxatives.”

At this point, you decide to ask about Karen's feelings before,
during, and after a bingeing and purging cycle. Karen tells you
that she usually gets an uncontrollable urge to eat a lot of food
and tries to distract herself with other things to do until it
becomes unavoidable. She then begins looking for ways to
obtain the food without her mother noticing. She sometimes
goes out to fast-food restaurants and buys food so her mother
won't wonder where all the food went. She then finds a secluded
place to eat it—either in her car or her bedroom— and then
finds a place to throw up.
“I'm so nervous someone's going to walk in on me when I'm
vomiting. It almost happened a couple of times when I got sick
at school. I went into a bathroom that no one ever uses, and a
teacher walked in right after I had thrown up. I told her I wasn't
feeling well and needed to go home. She sent me to the main
office to get a permission slip to leave. I was so embarrassed.”
“How long ago did this problem start?” you inquire.
“About 6 months ago, I guess,” Karen sighs. “It's been a
roller coaster ever since. The worst part about it is that I feel
better after I get rid of the food, so I can't seem to make myself
stop.”
You ask Karen if she thinks her mother is aware of the
problem with food that she has been having. Karen thinks her
mother has some idea but hasn't said anything to her. She has
asked Karen about missing food at times and wonders out loud
what happened to it. Karen feels extremely guilty when her
mother questions her but avoids telling her the truth about the
food.
“I just don't know what I'm going to do. I don't want to go to
college with this problem. Everyone will know something's
wrong with me. I just don't know what to do about it.”
· 11.3–2 How concerned are you about Karen's medical status?
Explain why you would or would not involve a physician.
· 11.3–3 What are some of Karen's strengths?

· 11.3–4 From this assessment, what would be your diagnosis
for Karen?
· 11.3–5 What severity and course specifiers would you want to
use?
· 11.3–6 What psychosocial (V codes/Z codes) and contextual
factors including cultural may affect diagnosis and treatment?
· 11.3–7 What characteristics make this individual more
vulnerable to suicide?
· 11.3–8 What are some resources that might help Karen cope
with these issues?
Case 11.4
Client Name: Laurel Jackson
Age: 48 years old
Marital Status: Married, no children
Occupation: Middle school math teacher
Intake Information
Laurel Jackson, a 48-year-old schoolteacher at a large
metropolitan public school, makes an appointment to see you
for counseling at Community Mental Health Center. The intake
form states that she has a college education, is married, and has
no children. Under the heading “Presenting Problem,” the intake
worker has written, “The client stated on the phone that she is
concerned about problems she has had with her recent eating
habits.”
Initial Interview
Upon meeting Laurel for the initial interview, you notice that
she appears to be older than her stated age of 48. She is a petite
woman, approximately 5 feet 3 inches tall. She has gray hair
that is pulled back in a bun, and she is dressed rather

conservatively in a black skirt, a pink blouse with lace around
the collar, and a black cardigan sweater. She appears to be of
average to slightly above average weight. She smiles cordially
and carries on small talk about the traffic getting to the agency
while she gets settled in your office.
You explain your position as a counselor at the agency and
issues of confidentiality. Then, you ask her what had brought
her to the agency. She states that she was referred to you by a
physician, Dr. Miller, at the hospital across the street from the
agency. She explains that she had been in a program called
“Mediquik” at the hospital for the past 3 months. The program
is designed for persons who are more than 30 pounds
overweight. It involves a liquid diet for optimal weight loss.
Participants are medically supervised during weekly group
sessions at the hospital.
She explains that over the past 3 months she has lost 85
pounds. “I weighed over 200 pounds when I started the
program, and you can imagine how awful I must have looked
since I'm such a short person. I felt really good about losing all
that weight.”
You ask her if she was allowed to eat any solid food on the
diet, and she states that it is a completely liquid diet that
involves three liquid supplements per day, water, and nothing
else.
You comment that a strict diet like that must have required a
great deal of willpower, and Laurel states that initially it was
very hard, but that after a couple of weeks, she got used to not
eating and it got easier. Laurel stuck to the diet religiously for
the 12-week period of time. After 12 weeks the hospital gave
her an eating plan that consisted of solid food for a week, and
then the program was over.
Laurel states that recently she finds herself getting up in the
middle of the night and eating huge quantities of food,
especially carbohydrates, and then feeling so sick the next
morning she has a hard time getting to school on time. She says
that no matter what she does, she can't seem to stop this

midnight bingeing, and she is beginning to panic because she
has begun gaining weight.
“I'm so scared I'll gain all the weight back that I lost that the
other night, after I went on a major binge and ate everything in
the house, I forced myself to throw up. It actually made me feel
better, so the next night, I binged and then vomited again.”
Laurel states that she knows this behavior isn't healthy and
that's why she decided she needs some help.
· 11.4–1 What other information would you want to obtain from
Laurel before you could make a comprehensive assessment and
diagnosis?
You decide that you need more information about Laurel's
personal and professional relationships. You ask her about her
family, especially history of binge eating and obesity.
Laurel states that she has been married for the past 8 years.
“I've known Darin since high school. He went into the Navy
after school and got married. He came back home after a
divorce about 12 years ago. I didn't think I'd ever get married,
but Darin and I just hit it off. He has two daughters who are
grown and on their own now. So it's just the two of us at home.”
Laurel states that her relationship with Darin is very good.
Darin works at a local grocery store chain as a manager and
sometimes works long hours, but they usually have time
together during evenings and weekends. She states that Darin is
very proud of her for losing so much weight but never pressured
her about being overweight.
Laurel states that her 80-year-old mother lives in the same
neighborhood as she does. She talks to her mother every day on
the phone and visits her after school three or four times a week.
She says her mother has lived in the same house for the last 50
years. Laurel states that her younger sister is married, has three
children, and lives in another state. Laurel's father died 10 years
ago, so she feels a need to take care of her mother now.
When you ask Laurel about the quality of her relationship
with her mother, she states, “Mom and I are a lot alike. She has

always had a weight problem, too, although since she's gotten
older she's slimmed down. To my mother, food was love. She
always cooked big meals for our family. We always had big
breakfasts and lots of desserts. I was overweight when I was 5
years old! My whole family was obsessed with food, and I'd get
stuck on one certain kind of food and eat it every day.”
Laurel's last statement strikes you as unique, and you decide
you want more information about her desire to eat the same
food every day. You say, “So, you wanted to eat the same thing
every day?”
“Oh, yes,” Laurel sighs. “Once I ate nothing but potatoes for
an entire year. Then, I switched and I ate nothing but spaghetti
for another year.”
“So, you got stuck on one kind of food and ate nothing but
that specific food every day?” you query.
“For lunch and dinner, every day, for an entire year, like I
was obsessed with it,” Laurel states while rubbing her forehead.
“I haven't gotten stuck like that on one kind of food since I got
married because Darin likes regular meals and can eat anything
without gaining weight,” Laurel states with a deep sigh.
You suggest to Laurel that food has been problematic for her
for a long time. She explains that she feels food has been “the
enemy” ever since she can remember.
· 11.4–2 What are some possible emotional problems you would
want to rule out in assessing Laurel's situation?
You ask Laurel if she has noticed any changes in her mood
recently. She tells you that she has been upset about gaining
back some of the weight she lost but that she is normally a
fairly happy person.
You ask her if there is anything going on in her life that has
been making her feel anxious lately. Laurel states that at the
end of the school year, she always has a lot of work to do at
school. You decide to get more information about Laurel's job.
“Do you teach specific classes or grades at school?” you
inquire.

Laurel replies that she teaches sixth-, seventh-and eighth-
grade math, including general math and Algebra I. “I have been
teaching math for 27 years now,” Laurel states proudly. “I
really love math, but at the end of the year, I am in charge of a
County Math Fair that I developed about 5 years ago. It
involves middle schools from all over the county. There are
over 1,500 students and parents involved in this week-long
event. I'm in charge of the whole thing, and it just stresses me
out. I tend to be a perfectionist about my work, and I worry all
the time about being prepared for classes and getting all the
homework assignments graded. I want my students to see how
fun math can be, so I work very hard at making my classes
interesting.”
Laurel states that she tends to work nights and weekends on
her classes. “I have a hard time relaxing. Darin and I play
bridge on Saturday nights with some friends, but we don't do
much else. Darin and his brother go fishing on the weekends,
and I usually stay home and work. Sometimes we go out to eat.”
· 11.4–3 What are some of the strengths that Laurel has
mentioned in the session?
· 11.4–4 What are some resources in your town that might be
beneficial to Laurel?
· 11.4–5 Laurel's husband, Darin, comes to a session with
Laurel. What are some questions you could ask Darin that might
benefit Laurel in therapy?
Case 11.5
Client Name: Miguel Hernandez
Age: 10 years old
Ethnicity: Hispanic
Educational Status: 5th grade at Jones Elementary School
Intake Information:
Miguel Hernandez is a 10-year-old Hispanic male in the 5th

grade at Jones Elementary School. He has a younger brother,
Joseph, age 8. His mother, Michaela Hernandez, and father,
Carlos Hernandez, are divorced and Miguel and his brother live
with their mother in Houston. Miguel has had a history of
anxiety and is currently on medication. His mother contacted
the school counselor who referred the family to Houston Mental
Health Center with concerns that Miguel may have an eating
disorder. The intake worker stated that Miguel has lost a
significant amount of weight during the past year. You are a
therapist at the mental health center and have been assigned this
case. You determine that it would be beneficial to meet with
Ms. Hernandez prior to your assessment of Miguel.
Initial Interview with Ms. Hernandez:
You meet Ms. Hernandez in the waiting room and you notice
that the child care intern is encouraging Miguel to play a board
game with her. Miguel is curled up in a chair looking unsure
about whether or not to play. You introduce yourself and
suggest that Miguel play with the child care intern while you
talk with his mother. He reticently goes to the table where the
game is being set up by the intern. You smile and tell Miguel
where his mother will be and that you will be back in half an
hour to talk to him. You notice that Miguel's sweatshirt and
pants look three sizes too big for his slight frame.
Ms. Hernandez follows you to your office and takes a seat
next to your desk.
“So, Ms. Hernandez, the intake worker told me that you have
been having some concerns about your son, Miguel. Can you
help me understand what you've been worried about lately?”
you suggest.
“Oh, please call me Michaela. I have been tearing my hair out
with worry about Miguel. He is getting so thin and I tell him he
needs to eat so he can be strong, but he just plays with his food
and doesn't eat enough. I don't know what to do. I have tried
making his favorite foods and giving him extra helpings but he
just doesn't seem interested. If I push too much, he cries and
runs out of the room. Last week, he told me he just doesn't like

to eat because he's afraid he'll get sick to his stomach, but when
I told him that wouldn't happen, he just said, “how do you
know?” I'm afraid he's got that anorexia.
“Okay, so can you give me an example of what he eats in a
given day?” you inquire.
Michaela thinks for a moment and then replies, “Well, last
Sunday, for breakfast he ate half a pancake and some juice
before we went to church. He came home and when I asked him
what he wanted for lunch he said, “nothing,” but I made him
and his brother a sandwich and he only ate two bites and then
said he couldn't eat anymore. For dinner, I made tacos because
we were going to a potluck supper at church and I don't think he
ate anything at all. He drank some lemonade but I didn't see him
eat.”
“How long has this been going on?” you ask.
“Oh, let me think, I guess about 6–7 months. He got sick last
winter with a bad case of the flu and was vomiting for a couple
of days. I was very concerned that he was getting dehydrated so
I made him drink a lot of fluids. I think it really upset him that
he couldn't eat and was throwing up so much. But when he got
better, he wasn't eating much. At first, I thought it was just
because he was getting over the flu, but when it kept going on
and on, I realized he just wasn't eating. He says he doesn't want
to eat and it seems like he only wants soft stuff like ice cream
or juice. Sometimes, he'll eat a little cereal or mashed potatoes
but he doesn't want to eat anything that he has to chew.”
“That must be very hard for you. Do you know how much
weight he has lost?” you inquire.
“Miguel wasn't a big boy before he got sick but now he's skin
and bones. I think he's lost 15 or 20 pounds,” Michaela replies.
“I bet you think I'm a bad mother but I've tried to get him to
eat. I said to him, Miguel, you're getting too skinny and he just
shrugs his shoulders and says I know I'm thin but I'm not
hungry.”
“Okay, so he doesn't seem to be worried about being
overweight or too heavy?” you query.

“Oh no, I think he knows he's really thin and I even think kids
at school have said things to him, like you're going to blow
away if you don't eat more,” Michaela says with a worried look
on her face. She wrings her purse straps in her lap and says, “I
just don't know what's wrong with him.”
“How does Miguel get along with other students at school?”
you ask.
“Oh, he has lots of friends that he has grown up with in our
neighborhood that he goes to school with,” Michaela responds.
“Maybe, Miguel is one of the leaders in his class. He's always
bringing friends over to the house after school because a lot of
mothers work and I take care of them. Everyone likes Miguel.”
“What has his mood been like during the past 6 months?” you
inquire.
“Miguel is a happy kid most of the time. But when it comes
time to eat, he gets real quiet and gets an unhappy look on his
face. Sometimes, he just blurts out that he wishes he never had
to eat again.”
“How does he get along with his dad?” you ask.
“Oh, I suppose he gets along okay but his dad doesn't come
around very often. You know, he's always working and has a
new wife. Sometimes, I wonder if Miguel's problem is because
he never gets to see his dad.”
“Does he frequently ask about his father?”
“Every once in a while,” Michaela says wistfully.
“How about his brother? How does he get along with Joseph?”
you ask.
“Miguel is a good older brother. Sometimes they fight but I
think that's normal, don't you?” Michaela states.
“Absolutely, it sounds like they get along most of the time,”
you respond. “Is there anything else you are concerned about?”
Michaela thinks for a minute and says, “No, I'm mostly
concerned about his eating and weight loss.”
“OK, why don't we go get Miguel and talk for a few minutes
with him.”
Interview with Miguel

Miguel comes into your office and sits down in the chair next to
his mother. You ask about the game he was playing and he
brightens up and says, “I won two times!”
“Fantastic,” you reply. “You must be an expert at Angry
Birds.”
Miguel smiles and looks at his mother.
You move your chair closer to Miguel and say, “Your mom
tells me you don't like to eat much. Can you help me understand
why you don't want to eat?”
Miguel looks down and swings his legs and replies, “I don't
like the way it feels.”
“Do you mean how it feels inside your tummy or how it feels
in your mouth?” you ask.
“I don't like the way it feels in my tummy or my mouth,”
Miguel states without hesitation.
“Is there any kind of food you like?” you inquire.
“Sometimes, I like ice cream,” Miguels suggests.
“What's your favorite flavor?” you ask.
Miguel puts his finger to his head and says, “Vanilla.”
“Is there anything else you like to eat?” you question.
“No, not really. I don't like to eat much,” says Miguel.
“OK, see that mirror over there in the corner? Why don't you
go stand in front of it and tell me what you see in the mirror.”
Miguel gets up and moves in front of the mirror. He turns
from side to side and then says, “I wish I could fit in my
clothes” as he pulls his pants out from his waist. “I think I'm as
thin as my brother.”
“How does that make you feel?” you ask.
“I don't really like it much because all my friends tease me.”
“What do you do when your friends tease you?” you ask.
“I just tell them that if they want to come to my house they'll
stop it,” replies Miguel.
“And if they don't stop teasing you?” you ask.
“One time, I pushed a girl away because she kept saying
“baggy pants” over and over again and she wouldn't be quiet.”
“How is school going this year?” you ask.

Miguel looks at his mother and says, “OK, I guess.”
Michaela tells you that Miguel's grades have fallen from “A's”
to “C's” this past quarter and she's worried that he can't think
very well.
“Maybe you'd like to come back another time and talk to me
about how we can put some weight back on you so that you feel
better about yourself and you're able to think better at school?”
you ask.
Michaela smiles encouragingly at her son and Miguel agrees
to come see you again.
· 11.5–1 Briefly state what strengths you observe in this family.
· 11.5–2 What are some questions that you'd like to explore
further with Michaela and Miguel?
· 11.5–3 Are there other individuals that you would like to
interview concerning this family?
· 11.5–4 What is your primary diagnosis for Miguel?
· 11.5–5 What psychosocial and cultural factors may be
impacting your diagnosis?
· 11.5–6 What differential diagnoses would you consider in this
case?
Case 11.6
Client name: Sissy Stone
Age: 6
Educational Level: Rising first grader
Intake Information
Mrs. Nash is a 45-year-old, Caucasian, single mother with a
high-school son, Grant, and a college- aged daughter, Natalie.
She works as a foster parent for New York Child Protective
Services and has three foster children currently living in her

home. About five weeks ago, during summer break, Sissy Stone
was placed with Mrs. Nash and her three other foster children
after Sissy's mother was checked into a drug rehabilitation
center. You have been monitoring Sissy's case since she was
placed in Mrs. Nash's home. You have worked with Mrs. Nash
before and had good experiences with the level of care she
provided your clients.
Mrs. Nash states that Sissy is avoiding all interaction with the
foster family, is crying most of the time, and is not eating well.
She reports that this has been going on for the past 2 weeks. She
is worried because she knows it takes foster children a while to
adjust, but it is only getting worse with time. You agree to visit
with Sissy at the foster home.
When you arrive at the Nash residence, Mrs. Nash greets you
at the door with a big smile. She seems relieved you have
arrived. As usual, her house is clean and there are lots of
children's toys and activities scattered about. You casually chat
about the other foster children as well as her older children.
Transitioning to Sissy's progress, Mrs. Nash comments that she
has never seen a child so despondent. You ask if anything
besides her mood seems out of the ordinary. Mrs. Nash
hesitates, but mentions that when she does the laundry, there are
excrement stains on Sissy's underwear. She says she has not
mentioned anything to Sissy because it does not seem like a
very big problem. “Nothing a little bleach can't fix!” she says
with a laugh. “Still, it is a little unusual for a child her age.”
Mrs. Nash wonders if maybe her mother just did not teach her
very good personal hygiene. After meeting with Mrs. Nash for
30 minutes, you ask to meet individually with Sissy.
Initial Interview with Sissy
Sissy is lying on the couch in the living room watching TV
when you go in to talk to her. She looks tired and her gaze
wanders from the TV screen. Sissy looks up at you as you enter
the room but does not speak. You remind Sissy of your name
and tell her that you are here to see how she is doing and she
passively nods. Pulling out some art supplies from your bag,

you invite Sissy to color with you. She agrees silently. She
picks out her crayons and starts to draw a picture.
“What is happening in your picture?” you ask.
“The little girl is playing outside.” Sissy responds quietly.
When you ask if she would like to play outside today, she says
she misses her swing and her yard. You talk about what things
Sissy likes to do where she lives right now, but she does not
come up with many ideas besides watching TV. Sissy seems to
have a hard time focusing on the conversation and she appears
tearful.
Looking back at her picture, you wonder aloud, “How is that
little girl feeling?”
“She is sad and her tummy hurts,” Sissy says, her voice barely
above a whisper.
After talking to Sissy a little more, you tell her that you are
so glad that you were able to color with her some today. She
smiles weakly and goes back to absently watching TV.
Stepping out of the room, you look up her scanned medical
records on your laptop. There is no mention of Sissy ever
having any kind of gastrointestinal medical problem. You ask
Mrs. Nash to take Sissy to the doctor, noting that she is not
eating and seems to be complaining of a stomachache.
Interview with Kindergarten Teacher
You call Sissy's previous teacher, Mrs. Lyons, who taught Sissy
before she moved in with Mrs. Nash during the summer.
Mrs. Lyons has great things to say about Sissy. She was
usually a very curious, compassionate child with a fairly
reserved demeanor. Music was Sissy's favorite subject, although
she was generally engaged and enjoyed school. You ask what
Sissy's moods were like throughout the last school year. She
reports that Sissy went through two sad spells during the year in
her classroom. In fact, the change was so dramatic that she
called Sissy's mother to check in and see what was going on.
Her mom said she thought it was just a phase and was seeing if
the moods would pass. Mrs. Lyons states that Sissy's mom
seemed like an overwhelmed single parent, but always came in

for parent–teacher conferences. After a few weeks, Sissy's mood
got better, but then a few months later it returned a second time.
When you ask for more details about Sissy's sad spells, Mrs.
Lyons says, “She always looked so tired to me, and her mom
said she was sleeping much more than usual during those spells.
She was less interested in activities that usually she loved, like
music time. Sissy also had a much harder time paying attention
to the activities. She just seemed very distant and distracted. It
was very odd to me because most of my students will have a bad
day, or even a bad week, but Sissy's spells went on every day
for weeks.” When you ask about stomachaches, Mrs. Lyons says
she does not remember that. In fact, she does not remember
Sissy's appetite decreasing at all, although she notes she was
not a big eater to begin with.
Phone Call with Mrs. Nash
About one week later, you get a phone call from Mrs. Nash.
What started as stains in Sissy's underwear has become worse
and so have Sissy's stomachaches. Sissy seemed very
embarrassed about her accidents and sometimes refuses to get
out of bed in the morning and made Mrs. Nash promise not to
tell the other foster children what happened.
Mrs. Nash was finally able to get Sissy into see a doctor who
accepts Medicaid. The doctor said that Sissy has constipation
but that she could not find any underlying medical cause. She
prescribed some medications to help with the constipation but
recommended that Mrs. Nash call you for further support.
Mrs. Nash also says that Sissy is still having a hard time. She
has not noticed that Sissy's mood has improved at all, and in
fact she thinks it may be getting worse. She is especially
worried because school will be starting in about a month and
she does not know how Sissy will be able to learn anything in
her current state.
You decide to go to Mrs. Nash's home and do some further
play therapy with Sissy if possible. On the day you arrive, once
again, Sissy is lying on pillows in front of the TV watching
cartoons.

“Hi, Sissy, remember me?” you ask.
Sissy nods her head, sits up and says, “You're the lady with
all the art stuff. Are we going to draw today?”
“How would you like to play with a family of dolls?” you ask.
Sissy looks curiously at your bag. “Do you have a family in
there?”
You respond by pulling the dolls out of your bag and showing
her the dolls that represent the mother, father, and two children.
“Oh, those look like real people,” Sissy remarks. “Can I see
them?”
“Of course you can. They are sort of like real people,” you
respond.
Sissy examines the anatomically correct dolls and says, “Oh,
they have all their private parts!”
“They sure do, just like real people,” you suggest.
Sissy gathers all the dolls around her and says, “Well, once
upon a time there was a family with a mommy and daddy and
brother and little girl. And the daddy goes away because he did
something bad.”
“What did he do?” you ask.
“Well, he took something that didn't belong to him and now
he's in jail,” Sissy states in a matter-of-fact tone. “And the
mommy is very sad because the daddy is gone.”
“How do you know the mommy is sad?” you interject.
“Cause she cries a lot and then she drinks a lot of beer,” Sissy
says. “The mommy says go up to your room and play!” Sissy
demonstrates with the dolls. She takes the girl doll and pretends
she's going to her room and slamming the door.
“Is the little girl mad at the mommy?” you ask.
“She doesn't like it when her mommy's boyfriends come over
and she has to go to her room,” Sissy tells you in a soft voice.
“Do the boyfriends bother the little girl?” you ask.
“No,” Sissy holds the girl doll. “They just drink beer with the
mommy.”
“Sounds like the little girl might be lonely all by herself in
her room,” you query.

Sissy plays with the girl doll and holding it in
“I wish the boyfriends would go away and daddy would come
home and everyone would be happy again,” Sissy whispers
behind the girl doll's head. “And I wish mommy wouldn't drink
beer because it makes her sad and then she cries.”
“How does the little girl feel when mommy is sad?” you ask.
“She gets sad, too.” Sissy muses. “I don't think she'll be
happy until the daddy comes home.”
“So, the little girl really misses the daddy,” you suggest.
“She really really misses him,” Sissy says longingly. “He was
the best daddy in the world.”
After playing for a few more minutes, Sally tires of the dolls
and asks you if you have coloring paper in your bag. You give
her some paper and crayons and she draws a picture of her
family and her father behind bars. The little girl in the picture
has a downturned mouth and looks very lonely in the picture.
You tell Sissy that you enjoyed playing with her and that you
would come back again sometime soon. Sissy gives you a hug
when you leave.
· 11.6–1 What are some of the strengths you observe in Mrs.
Nash?
· 11.6–2 What other information would be helpful to you in
better understanding Sissy?
· 11.6–3 What are some resources that might help this foster
family?
· 11.6–4 What is your primary diagnosis for Sissy?
· 11.6–5 What are some of the cultural and psychosocial factors
that impact your diagnosis?
· 11.6–6 What are the differential diagnoses you might consider
in this case?

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