NCMHCE Practice Test 11

Presenting Problem

You are a licensed mental health counselor working in a private practice. Simone, a 23-year-old staffing coordinator, schedules an intake after her boyfriend, Julian, walked in on her vomiting in their bathroom and told her he would not "pretend this isn't happening anymore." Simone says, "I've been hiding this for almost a year. I'm here because he made me promise, but I also know I can't keep doing it."

Simone reports that about 10 months ago, after she was passed over for a promotion, she started a strict diet: she skips breakfast and lunch and tries to eat only a small dinner. On about three evenings a week she eats far more than most people would in a similar time, such as a family-size box of cereal, a sleeve of cookies and leftover takeout within about an hour. "Once I start, I can't stop until I feel sick." After each binge she makes herself vomit, and she also vomits after some ordinary meals that include foods she considers "off limits." She estimates that she vomits about five times a week on average and has done so for at least the past six months. She denies laxative, diuretic or diet-pill use and says she exercises "normally."

Simone says her weight "has barely moved," and her primary care provider described her weight as in the healthy range at a physical about a year ago. Even so, "If I gain two pounds, the whole day is ruined. How I look decides whether I'm a good person or not." After a binge she tells herself, "I'm disgusting." Twice in the past month she has felt light-headed when standing up quickly, and once she noticed her heart "fluttering" at work; she has not told anyone. She spends about $60 a week on binge food, has been late to work several times after nights of bingeing, and now declines dinner invitations from friends because she "can't control what will be served."

When asked about safety, Simone denies suicidal ideation, intent or plan and denies any history of self-harm: "Sometimes I wish I could disappear for a week so nobody sees me like this, but I would never hurt myself." She denies homicidal ideation.

Mental Status Exam

Simone arrived on time, well groomed and casually dressed. She was oriented to person, place, time and situation. Her affect was anxious and constricted, congruent with her stated mood of "ashamed and worn out." Recent and remote memory were intact. Motor activity and gait were normal. You observed mild swelling along both sides of her jaw and small calluses on the knuckles of her right hand. Eye contact was good except when she described eating episodes, when she looked at the floor. Thought process was linear and goal directed; thought content was preoccupied with weight, shape and food rules. She denied perceptual disturbances, suicidal or homicidal ideation, and any history of mania or hypomania. She drinks two or three glasses of wine on weekends and denies drug use.

Psychosocial and Family History

Simone grew up with her mother and older brother after her parents divorced when she was 9. She describes her mother as loving but "always on a diet" and recalls her mother commenting on her body when she was a teenager. Simone competed in gymnastics through high school. She has lived with Julian for a year and describes the relationship as supportive but strained since he discovered the vomiting. She earned a business degree and has worked as a staffing coordinator for two years; her finances are stable, and she uses her employer's insurance for counseling. She was raised Catholic and does not currently practice. A trauma screen was negative. At the end of the intake she says, "Please don't call my doctor. She'll want to weigh me and run tests, and I'll freak out. Can this just stay between us?"