Dathan Carmichael (he, him, his), a 33-year-old White man, presents to the clinic.

Vitals

• Name:Dathan Carmichael
• Sex assigned at birth:Male
• Gender:Man
• Height:6 ft 0 inHeight: 6 feet 0 inch
• Weight:274 pounds
• BMI:37.2
• Age:33
• Chief Complaint:"I've gained so much weight over the last year; I have no control over my eating."

HPI

Patient complains of "uncontrollable eating" leading to weight gain of more than 50 pounds over the past year. He describes progressively frequent episodes of overeating during which time he feels he has no control over the amount of food he consumes. He reports eating as much as 10 times a day and overeating to the point of physical discomfort during most meals. "For example, just yesterday for dinner I ate an entire large pizza, my left-over Chinese take-out from the night before, and my wife's leftovers that she'd brought over, 20 chicken wings, and half of a chocolate cake." He admits that on several occasions he has vomited after meals, "I just feel so bloated and filled to the brim that I can't help it. I don't want to throw up, and I've never made myself throw up after I eat like that." He denies restricting food intake, has never misused diet pills or laxatives, and denies engaging in excessive exercising. "I am just humiliated by how much weight I've put on this past year. My self-esteem is shot; I'm so embarrassed by how big I am that I've avoided hanging out with my buddies like I usually do on weekends. I'm tired all the time; I'm struggling to stay motivated; and it's been hard to concentrateI'm always thinking about food. It's starting to affect my marriage; I've been so short with my daughter, too." He reports episodic mood swings, "I snap at people easily; it's always when I'm feeling stressed or overwhelmed. I never get violent with anyone; I just have a short temper sometimes." No history of manic or hypomanic symptoms. He reluctantly admits that 3 years ago he had a less severe episode of uncontrollable eating and weight gain of 20 to 30 pounds. "I was able to get a handle on that by going on the Subway diet. Right now, I just can't control myself. I'm interested in bariatric surgery to see if that'll help me lose this weight."

History

• Medical history:Motor vehicle accident (MVA) 2 years ago; chronic pain secondary to MVA injuries; thyroid carcinomadiagnosed 2 years ago, treated with radiation and surgical resection
• Surgical history:Multiple arm and elbow fractures repaired post MVA 2 years ago; thyroid carcinoma resection 2 years ago
• Social history:Married, currently separated, 1 daughter, unemployed, receives disability benefits from injuries sustained in the MVA 2 years ago; distant history of "problems with alcohol" and had DWI in the past, denies alcohol use since the DWI; former 10 pack-year history of cigarette smoking; denies any illicit substance use
• Psych history:Was seeing an individual therapist weekly for CBT/psychodynamic therapywas inconsistent with attendance and stopped going; reportedly was prescribed fluoxetine (Prozac) by PCP but never started it, "I had an uncle who took that, and it made him crazy."
• Family history:Uncledepression, questionable bipolar disorder

Current Medications

Levothyroxine (Synthroid) 150mcgMicrogramdaily

Tests

• TSH:Normal for the past 2 years on current dose of levothyroxine
• Triglycerides:202mg/dLMilligrams per deciliter
• Total cholesterol:210mg/dLMilligrams per deciliter
• UA/UDS:Normal

Mental Status Exam

• Cooperation:Somewhat guarded
• Awake, alert, oriented 4, obese man
• Thoughts:Linear, goal-directed
• Thought content:Shame, embarrassment about weight gain, somewhat preoccupied with undergoing bariatric surgery, no suicidal/homicidal ideation, no hallucinations, delusions, or obsessions
• Mood:Mildly irritated
• Affect:Constricted

Feedback:Dathan meets the criteria to be diagnosed with binge eating disorder (BED). He's having recurrent episodes of binge eating: consuming an amount of food that is definitely larger than most people would eat in a similar discrete period of time and having a lack of control over eating during these episodes. Additionally, he's eating more rapidly than normal, eating until feeling uncomfortably full, eating large amounts of food when not feeling physically hungry, and experiencing marked distress regarding the binge eating episodes.

How do you proceed in Dathan's treatment? Include what medication(s) you prescribe and what type of psychotherapy you recommend for him.