Audrey is a 26 year old single female who was referred for assessment by her primary care physician (PCP). Audrey is attempting to be approved for gastric bypass surgery, but her eating patterns have been a concern of her PCP for 4 years, and he has refused to refer her to a surgeon unless she is assessed and actively participates in any recommended treatment. Audrey is openly angry at her PCP "He has no business getting into my personal business. He has been telling me for years to lose weight. I have been on a 100 diets and have never been able to lose more than 40 pounds, so surgery is my only hope of a normal life." Audrey reported she is 5'6" tall and weighs 340 pounds. She reported her weight has been a struggle her entire life but has progressively gotten worse over the past 4 years, spinning out of control about 2 years ago. "I hate being this fat and want to be normal again. Just because my doctor thinks I have a problem with food... that means I have to stay huge forever?"

Audrey stated that at the age of 22 she began having periods of feeling a loss of control while eating. She struggled with her weight and food choices since early childhood, reporting most of the people in her nuclear family are obese and "eating junk was how I grew up". Even though weight has been a long term struggle, she clearly remembers the first time she felt out of control while eating. She stated that currently these "episodes" of being out of control and consuming "a large amount of food" occur 4-5 times per week. She noticed that for the first two years after her first episode she only lost control and "ate everything in the world" once per week, but over the past two years the episodes have increased to the current level. Audrey reported that an episode will last around 60-90 minutes and she will eat "everything I can get my hands on. It does not matter what it is, as long as it is food." She stated that during these times she will eat very quickly and will not stop, even after she feels full "to bursting". She stated that after an episode she cannot look in a mirror for days without having thoughts like "I am gross. I hate myself. If I keep this up I will die. Sometimes I feel like I cannot stand the guilt and self-hate after an episode." Audrey often feels depressed after an episode and will sometimes cry. She reported no suicidal ideations or history, but often feels overwhelmed and tries to think of a way to escape herself. Audrey reported that these episodes occur while she is alone "I never do this crazy stuff in front of people" and the episodes will often start when she is not hungry. Audrey denied any purging type behavior "At the beginning I made my self-throw up twice, but throwing up is too gross and using laxatives is disgusting." She reported no history of restricting her calorie intake or exercising to compensate for calories consumed. She reported no history of significant depression or anxiety outside of the eating episodes. She has never had a manic episode or any type of thought disorder/ loss of touch with reality. Audrey reported she drinks 2-4 beers a week and has not been drunk since graduating from college at 22 years old.

She works full time as a sales associate, which is getting difficult because of the amount of time she has to stand. "My doctor told me my weight is destroying my hips and knees, and I know standing 10 hours a day does not help, but I do not think I can get another job. Who would want to hire someone who looks like I do?" Audrey has begun calling in sick to work one day every other week and her supervisor has given her a written warning. She reported a high level of anxiety about possibly losing her job. "My supervisor really likes me because I am kind and do a good job, but she is getting tired of me calling in sick. She agreed to give me the time off work if I got the surgery. She is excited that I might get my weight under control. But if I keep calling in sick she will have no choice but to fire me. That is what my doctor does not understand, this surgery could make everything right again."

Audrey is the third of five children born to her mother, who has been married three times. Audrey has a different father than all her other siblings, being the only child born to that union. Her mother and step-father are currently married. She is close to her younger two sibling and her two older sibling went to live with their father when Audrey was 10 years old. "We are not close, but the rest of the family talks weekly. We all have weight trouble." Audrey has not dated since she began having the "eating episodes". She stated that she is afraid to let anyone close to her right now because she might have an episode in front of them and would "die of embarrassment". Audrey has two close female friends, one with whom she recently confided her eating struggles. "She was very understanding and said she would support me no matter what. She is the first person I have told besides my mom and my doctor." Audrey agreed that her "eating episodes" are not normal, have contributed to her obesity and is willing to do whatever it takes to get the referral for surgery.

Diagnoses