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Rebekah Lieberman (she, her, hers), a 75-year-old Jewish woman, presented to the emergency room at the insistence of her daughter. Later, Rebekah was involuntarily admitted to an inpatient psychiatric unit where you provide services for people with feeding and eating disorders. You go to the unit before the day ends. Vitals Name: Rebekah Lieberman Preferred name: Bekah Sex assigned at birth: Female Gender: Woman Height: 5 ft, 7 inHeight: 5 feet 7 inches Weight: 86 pounds BMI: 13.5 Age: 75 Chief Complaint: “I’m only here because my daughter says I’ve lost too much weight and I’m not taking care of myself. I think she’s overreacting; I’ve had so much reflux lately.” HPI A 75-year-old Jewish woman presents to the ER for self-neglect and severe weight loss of about 20 pounds over the last few months. When asked why she is in the hospital, she says, “I really don’t know; I’ve lost some weight recently but that’s because of my gastric reflux-it’s just tearing up my esophagus.” While she acknowledges her weight loss, she minimizes the severity of her illness and indicates she would like to gain weight, “but only with healthy foods; I must follow a special diet that only includes whole foods like kale, quinoa, and fresh, organic vegetables. I love sugar, but sugar fuels cancer.” She perseverates on this belief that “sugar causes cancer” throughout her interview. She also mentions that she stopped eating flour, sugar, fried foods, and oils: “Those make my stomach acid worse, and my skin breaks out in pimples. That’s why I’ve lost weight recently.” She’s insistent that she must follow a special diet and insists on knowing the origin of the foods served in the hospital and a list of ingredients from the dietary department. She’s preoccupied with her prior diagnosis of esophageal cancer and dysphagia and worries that certain foods cause cancer, which is why she insists on following her specialized diet. She denies any intense fears of gaining weight or feeling fat. She denies any depressive symptoms, denies suicidal or homicidal ideation, denies having auditory or visual hallucinations, denies any manic symptoms. Per collateral from her daughter: “Mother has always been very particular about what she eats; she’s had various fears about certain foods for as long as I can remember. She has phases where she’ll only eat some things and won’t eat other things—one time she only ate sugar free frozen yogurt for about 2 months straight. Over the last 2 years, I think she’s seen at least 15 doctors and GI specialists for her stomach acid. She took medications after she was hospitalized in 2006, but I’m pretty sure she stopped taking everything on her own when she was discharged home. She’s always researching “natural remedies” and vitamins and herbs. I think at one point we counted, and she was taking more than 80 supplements per day. Mother loves spending time with my kids, going to museums and parks, and listening to classical music. I knew something was wrong when she wasn’t leaving her apartment over the past several months. I came over to visit her, and she just looked so frail and terrible. She’s so stubborn and was adamant that she’s eating healthily, but I told her I was going to call the police if she didn’t go to the hospital, so she reluctantly agreed to go.” History Medical history: GERD, squamous cell esophageal cancer treated with radiation, esophageal dysphagia secondary to stenosis from radiation treatment Surgical history: Hysterectomy Psych history: Saw psychologist in her 40s and was diagnosed with OCD, later diagnosed with ADHD in her 40s. History of major depressive episodes after divorce, history of suicide attempt with pills and alcohol and hospitalized for 5 days shortly after the divorce. Previous medications—aripiprazole (Abilify)—unsure of response; trazodone—ineffective; lamotrigine (Lamictal)—unsure of response Social history: Divorced 13 years ago, lives alone, has 1 daughter and 4 grandchildren; no alcohol use, illicit substance use, or tobacco use Family history: Mother—hoarder, Sister—body dysmorphic disorder, Brother—kleptomania Current Medications Famotidine (Pepcid) 20 mgMilligram daily Tests LFT, CMP, CBC, Vitamin B12: All within normal limits BUN/Cr: Mildly elevated GFR: Normal Mental Status Exam Appearance: Cachectic and frail Cooperation: Guarded, dismissive, gives vague responses Motor: Steady gait, ambulatory without assistive devices, normal muscle strength Mood: Anxious, dysphoric Affect: Heavily constricted Speech: Clear, regular rate Thought process: Linear and goal directed Thought content: Somatically preoccupied, dietary obsessions, denies suicidal ideation or homicidal ideation No evidence of internal preoccupation or auditory/visual hallucinations Awake, alert, oriented to person, place, time Montreal Cognitive Assessment (MOCA): 27/30 Insight: Poor Judgement: Poor What differential diagnoses do you consider for Bekah?
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