What is the DSM-5-TR Diagnosis for the Case Study Below;

Clinical Case #4:

Valerie Gaspard was a 20-year-old single black woman who had recently immigrated to the United States from West Africa with her family to do missionary work. She presented to her primary care physician complaining of frequent headaches and chronic fatigue. Her physical examination was unremarkable except that her weight was only 78 pounds and her height was 5 feet 1 inch, resulting in a body mass index (BMI) of 14.7 kg/m2, and she had missed her last menstrual period. Unable to find a medical explanation for Ms. Gaspard's symptoms, and feeling concerned about her extremely low weight, the physician referred Ms. Gaspard to the hospital eating disorders program.

Upon presentation for psychiatric evaluation, Ms. Gaspard was cooperative and pleasant. She expressed concern about her low weight and denied fear of weight gain or body image disturbance: "I know I need to gain weight. I'm too skinny," she said. Ms. Gaspard reported that she had weighed 97 pounds prior to moving to the United States and said she felt "embarrassed" when her family members and even strangers told her she had grown too thin. Notably, everyone else in her U.S.-dwelling extended family was either of normal weight or overweight.

Despite her apparent motivation to correct her malnutrition, Ms. Gaspard's dietary recall revealed that she was consuming only 600 calories per day. The day before the evaluation, for example, she had eaten only a small bowl of macaroni pasta, a plate of steamed broccoli, and a cup of black beans. Her fluid intake was also quite limited, typically consisting of only two or three glasses of water daily.

Ms. Gaspard provided multiple reasons for her poor intake. The first was lack of appetite: "My brain doesn't even signal that I'm hungry," she said. "I have no desire to eat throughout the whole day." The second was postprandial bloating and nausea: "I just feel so uncomfortable after eating." The third was the limited choice of foods permitted by her religion, which advocates a vegetarian diet. "My body is not really my own. It is a temple of God," she explained. The fourth reason was that her preferred sources of vegetarian protein (e.g., tofu, processed meat substitutes) were not affordable within her meager budget. Ms. Gaspard had not completed high school and made very little money working at a secretarial job at her church. Ms. Gaspard denied any other symptoms of disordered eating, including binge eating, purging, or other behaviors intended to promote weight loss. However, with regard to exercise, she reported that she walked for approximately 3-4 hours per day. She denied that her activity was motivated by a desire to burn calories. Instead, Ms. Gaspard stated that because she did not have a car and disliked waiting for the bus, she traveled on foot to all work and leisure activities.

Ms. Gaspard reported no other notable psychiatric symptoms apart from her inadequate food intake and excessive physical activity. She appeared euthymic and did not report any symptoms of depression. She denied using alcohol or illicit drugs. She noted that her concentration was poor but expressed hope that a herbal supplement she had just begun taking would improve her memory. When queried about past treatment history, she reported that she had briefly seen a dietitian about a year earlier when her family began "nagging" her about her low weight, but she had not viewed the meetings as helpful.

Jennifer J. Thomas, Ph.D. Anne E. Becker, M.D., Ph.D.