Running head: TO THE BONE 1

Case Assessment Paper:

To the Bone

Emily Milord

SWK 6500-02

Catherine Obordo

November 26, 2018

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Case Assessment Paper:

To the Bone

The presenting problem in the movie “To the Bone” is that the client Ellen, the main

character, presents with a severe case of anorexia nervosa. The client is a 20-year-old female,

who has an intense fear of gaining weight, restricts calories to an extreme, and engages in

excessive exercise. Ellen is visibly underweight. At the beginning of the film, she is “kicked out”

of an inpatient treatment program due to failure to comply with rules, and for being a bad

influence on the other patients. She briefly then goes to stay with her stepmother, father, and

stepsister. Her stepmother gets her into see a specialist, who runs a residential treatment group

home for adolescents with eating disorders. The client stays at the residential group home with

six other young adult patients. One of the patients, a male ballerina, becomes her love interest.

During the client’s time at the group home, her condition begins to worsen as her romantic

relationship becomes stressed. At this point in the film, the client’s condition is very unstable,

and she is just one day away from receiving a feeding tube, because of continued weight loss and

not eating.

After a fight with her therapist, who in harsh words tells her to deal with her problems

rather than feeling sorry for herself, she abruptly leaves the residential group home. She faints in

the bus station, then awakens and travels by bus to Phoenix, where her mother lives. At points in

the movie the client is so weak and frustrated from her seemingly endless battle with anorexia

that she contemplates being okay with the reality that she could die from her illness. After

leaving the group home, she walks through the desert and comes to the realization that she does

want to live, and keep trying. The movie ends with her returning to the group home to resume

treatment.
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Mental Status Examination

Appearance

The client is a 20-year-old Caucasian female who appears emaciated and very

underweight. Her rib cage is protruding, and there is excess hair growing on her arms and back,

which appears to be lanugo. She has very fair skin, brown hair, and brown eyes. The client wears

heavy eye makeup. Her clothes are very baggy, possibly to conceal how thin she is; she also

wears a hat, possibly to maintain warmth. She has dark circles under her eyes that look like

bruises.

Behavior

She is somewhat cooperative during assessment, but not with other girls at the treatment

center, as she is rude to them. Her manner of relating to others is defiant and sarcastic. She

exhibits strong eye contact. There is evidence of psychomotor retardation, as she walks very

slowly.

Speech

The rhythm of the client’s speech is sometimes monotone. The volume is moderate, not

too loud, but not quiet either.

Mood

The client has a depressed mood, but also seems irritable. The client’s mood varied

throughout the evaluation; she appeared more relaxed when her vitals were being taken, but

became very angry when she had to get weighed and kicked the scale in frustration.
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Affect

The client’s affect appears to be dysphoric. The range of affect appears restricted, and the

client seems vacant; therefore, it seems she has a somewhat flat affect. There is some expression

in her eyes when she is spoken to.

Thought Process

Client’s thought process appears to be normal; thoughts appear to be connected, and flow

linearly and coherently. There is no evidence of any abnormal associations, such as word salad

or flight of ideas. Thoughts do not appear to be circumstantial, tangential, and there is no

illogical shifting between topics.

Thought Content

The client has preoccupations about food and thinness. There is evidence of distorted

thinking about her weight, and what will happen if she stops restricting calories and were to gain

weight. The client seems to believe she has everything under control, despite evidence of the

health effects from her calorie restriction.

Cognition

The client’s cognition does not seem to be impaired; she is oriented to person, place, and

time. She can follow conversation, and understand others’ complex thinking. There are no

marked signs of impaired focus, except for when she is being distracted by preoccupations.

Insight/Judgment

The client’s insight into having anorexia nervosa is very good. She is very aware of the

fact that she has these struggles. Her judgment is impaired. She is aware that her behavior is very

risky and has the potential to lead to her own death. However, there is no evidence that she is
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making choices to safeguard her own well-being, and reports doing the opposite, avoiding

behaviors that would keep her healthy such as eating.

DSM-5 Diagnosis

Based on the diagnostic criteria provided by the Diagnostic and Statistical Manual of

Mental Disorders, (5th ed.; DSM-5; American Psychiatric Association [APA], 2013), the

diagnosis I would give this client would be 307.1 (F50.01) Anorexia Nervosa, Restricting type,

Extreme. The movie never gave a number for her weight, but I chose Extreme specifier for her

diagnosis, because her therapist said that there is a good chance she will die from her condition

given the direction she is headed, and because the DSM-5 allows the severity specifier for

anorexia nervosa, to reflect the degree of functional disability, in addition to the BMI (APA,

2013). I would diagnose the client with the with the restricting type of anorexia nervosa, because

she does not engage in purging behavior, but does restricts her calories. The diagnosis is

appropriate because the client meets the DSM-5 diagnostic criteria for Anorexia Nervosa (APA,

2013):

Criterion A: The client has a significantly low body weight, indicated by the evaluation; a

number was not given, but visually her body appears emaciated. Criterion B: She has an intense

fear of gaining weight, and this is evident through her behavior. She refuses to eat most of the

time, and at the restaurant she was chewing the food but spitting it out into napkins. The client

has persistent behavior that interferes with weight gain, such as engaging in excessive exercise;

for example, she does sit-ups whenever she can, has anemic bruising on her back from the sit-

ups, and will only go places if it involves walking or running there.

The client also meets Criterion C: The client has a disturbance in how she experiences

her weight and shape. The client does not believe she is thin enough, when to the outside
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observer’s eye she is clearly observably emaciated. Criterion C states that there could be a

persistent lack of recognition of the seriousness of the current low body weight, and this is

evident in her continuing her behavior despite being told of severe consequences such as death.

The client also has characteristics associated with the disorder, such as engaging in body

checking behavior, such as trying to fit her fingers around her whole upper arm to make them

touch. The client also has amenorrhea, which is not required for diagnosis in the DSM-5, but it is

often experienced by those with anorexia nervosa.

One diagnosis to rule out would be bulimia nervosa, because there could be some

crossover in symptoms, such as engaging in behaviors to avoid weight gain. Bulimia nervosa can

be ruled out here because individuals with bulimia nervosa maintain their body weight, and the

client has a significantly low body weight. The client does not engage in purging either, but if

she did she would receive the DSM-5 diagnosis of 307.1 (F50.02) Anorexia Nervosa, Binge-

eating/purging type (APA, 2013).

Biopsychosocial Assessment

Biological Factors

The client’s mother has bipolar disorder. The DSM-5 states that there is an increased risk

of bipolar and depressive disorders among first-degree relatives of individuals with anorexia

nervosa (APA, 2013). This indicates that there is a relationship and a higher risk for developing a

mood disorder for the client. However, the DSM-5 does not state that having a first-degree

relative with bipolar disorder would put the client at a higher risk for anorexia nervosa.

Nonetheless, I think it could be possible that the genetic factor of the client’s mother having

bipolar disorder could put the client at risk for developing anorexia nervosa.
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One biological contributor to the client’s development and maintenance of symptoms is

that she flushed her antidepressants down the drain because she did not want them to make her

gain weight. She likely has a neurotransmitter imbalance, that would have been treated by the

antidepressant. This is a biological factor which would contribute to her symptoms.

Psychological Factors

The client has distorted thinking about her body image, and is critical of how she looks.

At the same time, the client convinces herself that she has her behavior under control. The client

feels that everything else is her fault, such as her family fighting. The client feels that the world

will fall apart if she gives in to eating. The client is aware of the dangers of her behaviors,

including that they could result in death, but cannot find a way to stop. In her therapy session, the

client says: “I just do not see the point,” indicating that she may be feeling hopeless about the

future. It did not appear to be suicidal ideation in this case, however; it more seemed to be that

she was expressing that she does not know how to go on living the way she is but does not see

recovery as a possible alternative. The client expressed that she knows she is “messed up,” which

could indicate self-awareness that she has a serious illness.

Social Environment

Some of the social factors that may have played a role in the development and

maintenance of the client’s disorder include family dynamics, including the upheaval in her early

adolescence. During that period, her parents got a divorce and her dad remarried. She found out

her mother was a lesbian. The divorce and her mother’s sexuality were two things that she had to

adjust to in childhood. Another social factor related to family would be her father, more

specifically, a lack of relationship with him. Even when she comes home to stay with her

stepmom and stepsister, her father will not have dinner with them, and finds excuses not to see
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her. The client has not had much stability in her life the past couple years, going in and out of

treatment six different times. The client’s mother claimed to have kicked her out because she

could not handle the severity of her daughter’s anorexia, and the inability to help her symptoms,

and said she could not watch her daughter slowly dying.

As evidenced by the family therapy and other scenes of the movie, the client’s

relationship with her stepsister is a strong protective factor in her life, it is clear that her stepsister

cares very much about her; sister tells her, “If you die, I will kill you.” The stepsister is very

frustrated with the client, and worries a great deal about her prognosis. The client’s family seems

at a loss for ways to help the client and burnt out. The stepmother, while she appears to be

overbearing at times, worked very hard to get the client into see the specialist, and refused to

give up on the client. The client’s relationship with her biological mother seems to be a strength

too. Seeing her mother after leaving the group home was one of the only times the client

appeared to be filled with joy during the movie. However, all family members have said ignorant

comments to the client, such as “just eat” or “you look horrible.” These comments appear to

distress the client.

At the residential group home, the client developed a love interest, a male ballet dancer,

who also has an eating disorder. They bonded through their mutual struggles, and their

relationship seemed to be a positive influence on her outlook on life, although when they were

fighting it seemed as though the client’s condition worsened. The other patients at the group

home seem to be struggling greatly, and the client did not develop any close bonds with them

other than her love interest.

A traumatic time in the client’s life, happened when she had a Tumblr blog at one point a

year or two before her stay at the residential group home. At the time, the client’s drawings she
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posted to her blog were focused all on eating disorder-related subjects. A girl who was a stranger

to the client, followed the client’s Tumblr. The Tumblr follower committed suicide, leaving

behind a note that said she was inspired to kill herself because of the client’s Tumblr blog. The

family then sent pictures to the client of the girl’s dead body to the client after the suicide, and

the client was blamed for the suicide. This factor may contribute to the client’s symptoms of

anxiety and thinking things are her fault, which may have hindered her progress towards

recovery.

Cultural Considerations

One cultural factor that may have affected the development and maintenance of her

disorder is the cultural value and emphasis on thinness, and how being thin is promoted as the

ideal throughout the media, including in magazines and on television. This factor could have

caused the client to feel dissatisfied by her weight, and played a role in the development of

anorexia nervosa.

Strengths

The client has a strong will and she likes to make people laugh, even though it is

sometimes dark humor. Her caring nature is evident, despite lashing out at others them when she

is upset. One of the girls at the group home was pregnant, and the client drew her a picture of a

unicorn as a gift, which was a sentimental thing for the expecting mother. The client’s drawings

have become a strength for her, and a means to express herself, and she also learned to use them

as a way to lift others up. The client holds on to relationships with family despite how tough they

are, and she is willing to forgive others who have hurt her. The client also appears empathetic to

others’ suffering.
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In sum, Ellen, who is the client and main character in “To the Bone,” has been suffering

from a very chronic case of anorexia nervosa and has been hospitalized six times. Her intense

fear of gaining weight, and extreme measures of calorie restriction, have interfered with her

functioning, health, and life greatly. Although the client suffers from a very difficult and chronic

condition, she has many strengths that will guide her, and based on this assessment has the tools

she needs to overcome her challenges with time, and adequate support.
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References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders

(5th ed.). Arlington, VA: Author.