Clinical Case study
What is the DSM-5 diagnosis for Uma?
Uma, an 11-year-old girl in a gifted and talented school, was referred to an eating disorder specialist by a child psychiatrist who was concerned that Uma had drifted below the 10th percentile for weight. The psychiatrist had been treating Uma for perfectionistic traits that caused her significant anxiety. Their sessions focused on anxiety, not on eating behavior.
Uma's eating difficulties started at age 9, when she began refusing to eat and reporting a fear that she would vomit. At that time, her parents sought treatment from a pediatrician, who continued to evaluate her yearly, explaining that it was normal for children to go through phases. At age 9, Uma was above the 25th percentile for both height and weight (52 inches, 58 pounds), but by age 11, she had essentially stopped growing and had dropped to the 5th percentile on her growth curves (52.5 inches, 55 pounds).
The only child of two professional parents who had divorced 5 years earlier, Uma lived with her mother on weekdays and with her nearby father on weekends. Her medical history was significant for her premature birth at 34 weeks' gestation. She was slow to achieve her initial milestones but by age 2 was developmentally normal. Yearly physical examinations had been unremarkable with the exception of the recent decline of her growth trajectory. Uma had always been petite, but her height and weight had never fallen below the 25th percentile for stature and weight for age on the growth chart. Uma was a talented student who was well liked by her teachers. She had never had more than a few friends, but recently she had stopped socializing entirely and had been coming directly home after school, reporting that her stomach felt calmer when she was in her own home.
For the prior 2 years, Uma had eaten only very small amounts of food over very long durations of time. Her parents had tried to pique her interest by experimenting with foods from different cultures and of different colors and textures. None of this seemed effective in improving her appetite. They also tried to let her pick restaurants to try, but Uma had gradually refused to eat outside of either parent's home. Both parents reported a similar mealtime pattern: Uma would agree to sit at the table but then spent her time rearranging food on her plate, cutting food items into small pieces, and crying if urged to eat another bite.
When asked more about her fear of vomiting, Uma remembered one incident, at age 4, when she ate soup and her stomach became upset and then she subsequently vomited. More recently, Uma had developed fear of eating in public and ate no food during the school day. She denied any concerns about her appearance and only became aware of her low weight after her most recent visit to the pediatrician. When educated about the dangers of low body weight, Uma became tearful and expressed a clear desire to gain weight.