Clinical Analysis

Client: Gregory

DoB: Unknown

CA: 43 years old


Race unknown
Present at Intake: Gr
Presenting Problem
Gregory is a 6’1” 43-year-old male who currently weighs 192lbs. He was referred by his internist because of his significant weight loss and cannot stop dieting. He is now obsessed with food and has started to induce vomiting after eating.
Background Information
He was worried about his wife leaving him because of his weight.
• He has a history of being heavy and would often turn to food in times of stress.
• His weight was never a bother to him until his wife mentioned it.
• He lost 58 lbs in the last 5 months. He is still terrified of getting fat.
• When dieting didn’t result in sufficiently rapid loss of weight, he started sticking his finger down his throat to induce vomiting after meals.

• He is currently “obsessed” with food and being thin.
• He worries about what he will order when he goes to a restaurant because of what is easiest to purge.
• He knows where all of the bathrooms are when he goes out
• He worries that his stomach is fat
• He binges 3-4 times a week.
• He feels his eating is out of control.
• Gregory had an original goal of 190lbs and then changed it to 185lbs
• Gregory exercises by walking an hour a day
• Gregory more recently began working out with weights several times a week
• Gregory is on a strict dietary regimen
• Gregory has never used laxatives, diuretics, or diet pills to lose weight

Previous Treatment History
• Gregory recently saw an internist who saw no physical problems. No other information is available.

Family Information

Gregory is married.

Developmental and Social History

• Gregory has always been somewhat heavy turning to food in times of stress.
• No other information is available on his developmental and social history

Medical History
• He recently saw his internist who found no physical problems and
referred him for psychiatric evaluation
• Gregory has never used laxatives, diuretics, or diet pills to lose weight

Family Medical and Psychiatric History
• Unknown

Academic or Emplyoment Information

Gregory is a theatrical manger

Assessment of Present Functioning

• Gregory is worried about dieting even though his wife has told him that he is now too thin
• Gregory believes that women look at him differently now: when he was heavy, they glanced at him casually; now their response is “admiring.”
• Gregory can no longer enjoy any meals and feels he has lost control of this area of his life as he cannot stop dieting.
• Gregory has a strict dieting regime

Diagnostic Impression

Primary Diagnosis: Body dysmorphic disorder
Didn’t have time to complete

Secondary Diagnosis: Bulimia Nervosa
Greogory’s symptoms meet the following criteria of binging. A lack of control.

Rule out: Obsessive Compulsive Disorder

Treatment Recommendations

Individual Therapy 1X/2 weeks To address his anxiety and help with his obsessions.
Nutritionist 1X/2weeks To address his rigid dietary restrictions and help develop appropriate meal planning and an exercise regime.

Support Group/Therapy 1X/2weeks Attend a support group with others who suffer from body dysmorphic and bullemic disorders.

Other: Wife should consider attending therapy with Gregory 1x a month.

General Treatment Goals:

Gregory will learn self strategy models to help him work on his self-image.
Group counseling would help provide peer support.
Marriage counseling would help provide stability in his marital relationship. It will also foster communication.
A nutritionist will provide support for his overall health.

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