Arlene is a 22-year-old woman who is coming for a first appointment with a psychiatrist, Dr. Bond, with a chief complaint of “anxiety.” Arlene graduated from small, elite college in the North East six months prior and has been living with her parents since then, interning in a law office, while studying for the Law School Admission Test (LSAT). Her father made the appointment to see the psychiatrist due to concerns that she seems more withdrawn than usual. He told Dr. Bond over the phone, while making the appointment, that he and his wife are worried that she seems sad and withdrawn, and that she has been losing weight. He asks to come in to talk with Dr. Bond before Arlene’s first appointment, but Dr. Bond suggests that he meet with Arlene on her own, to which her father reluctantly agrees.

Arlene presents as a thin young woman wearing a loose-fitting sweater, tailored slacks, and dress shoes. She has a large backpack and a yoga mat with her, with a large water bottle in the side pocket of her bag. She explains that her parents have asked her to come in because they think she is not the “superstar they think I’m supposed to be,” but that she is willing to be here as it might be helpful to talk. She reports that she has been working long hours in the law firm, returning home after 10 pm most nights, eating dinner on her own, and waking up early to go for a run “to relax” before going to work at 8:30 am. She has several friends from high school and college in the area, but she says that she has been tending to stay to herself, spending weekends studying in coffee shops in the neighborhood, taking walks, or going to yoga classes. She feels like she needs this “solitude” in order to get her LSAT preparation in and cope with the stress of her workplace. She describes feeling tired much of the time, attributing this to her work schedule and “having to wake up early” in order to run, though also describes having a lot of “nervous energy,” which is why she likes to walk home from the firm and stay active. She acknowledges that her concentration does not seem to be as good as it had been in high school and college, though believes that this is due to the under-stimulating content involved in studying for the LSAT compared to school coursework. She denies feeling depressed and denies suicidal ideation.

Elaborating on her earlier comment about her parents’ expectations, she explains that she was always an “overachiever,” at the top of her class in high school and for much of college; her extracurricular activities as a child included playing the viola, performing with an orchestra in numerous high-profile local concerts. She was otherwise a “quiet” child. She had a few good friends and was well liked by teachers and classmates. She describes always having felt “a little out of place” among her peers, with anxiety in some social contexts, feeling she was never sure what others’ “really thought” about her.

Regarding her eating and weight, she admits that she has been eating “less” since returning home and that she has lost “some weight” but denies knowing what her weight had been at the time of graduation. She reports that she is vegetarian but does not spontaneously give more information about her diet. She relates, with further questioning, that she was always “pretty slim,” though had gained some weight in late high school and the first year of college. She admits that in her junior year of college she lost “a lot” of weight in a fairly short period of time, explaining that she had been sick with a gastroenteritis and had lost 2 or 3 lb, and upon recovering, continued to make an effort to limit her food intake, finding it “interesting to experiment” with eating very little. She says that this went on for about one month, with her weight loss noticeable to others. Her grades dipped and she was feeling very tired all the time. She began eating more normally after that, though continued to avoid meat (which she had done for the first time during this period) and to eat less than she had been eating before the episode.

She denies wanting to lose weight or “be stick thin,” but is noticeably more clipped in her responses when Dr. Bond asks questions on this topic and about the specifics of what she eats. She agrees to return for another appointment the following week.

Preferred diagnosis: anorexia nervosa

Arlene most likely has a diagnosis of anorexia nervosa (AN) . Individuals with AN restrict food, maintaining a low weight, with a disturbed experience of body image or lack of insight into the seriousness of the low weight. Those who, in addition to restricting food, also compensate for food intake through vomiting or laxative use (whether or not they binge eat), fall under the Binge–eating/purging type; all others are classified as restricting type [see Text Box: Anorexia Nervosa: DSM-5 Diagnostic Criteria].