Abnormal Psychology Case Formulation Report Jung-yeon: A Case of Hikikomori

March 21, 2014

I. Identifying Information and Referral Problem Demographic Data Kim Jung-yeon is a female South Korean, unemployed and living with her father and mother in a condominium, though she reported never coming out of her room for three years. Her room is always locked from the inside, which is also full of trash of instant food, bubble wraps, and boxes and cans of corn, while her windows are covered with assortments of old clothes. She admitted being addicted to the Korean social media site Cyworld, wherein she uses an avatar of a pretty woman and uses the username Blue Bear. In there, she pretends to have bought and done things, assuming a totally different persona. Jung-yeon believes that she never has to come out of her room because with a few clicks, everything can be hers. She stated that for her, it doesnt matter whether what she posts are real or not, since what matters are the replies she gets on her site. Age, looks, jobs, anythings possible, she stated. When communicating with her mother, she just uses her cellphone to reply instead of answering verbally. Her mother actually provides her with all her needs, such as leaving a tray of food in front of her room before going off to work. Demeanor and Appearance Jung-yeon has a big scar on her upper right eyebrow, wears the same white long big shirt every day and has a disheveled hair. She looks thin for her height and age and always looks pale. Although she just stays inside her room, she seems to be agitated when doing and while waiting for things. She has the tendency to get lost in the virtual world, imagining things as if theyre real and as if shes part of it. Current Lifestyle Even though she just stays inside her room, and specifically sleeps inside her closet, Jung-yeon follows a strict set of rules and schedule wherein she wakes up at 8 in the morning after her father leaves, eats a can of corn with 172 calories for breakfast, then exercise using the pedometer by putting on 3000 steps before 9am. What she considers as work at 9am is her updating of posts in her Cyworld account. And what her cleaning of room is basically just vacuuming her keyboard. The only instance of her going out of her room is just when using the bathroom and this is when her mother leaves at 12. For lunch, she eats 525 calories, then doubles her pedometer exercise to 6000. Her version of having a breath of fresh of air is being in front of the fan. Jung-yeon actually has a concept of planning for a new life and self-improvement, though this is through the Cyworld again.

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After doing the above things which she considers as her work, she then pursues her hobby of photography taking pictures of the moon. She stated, I take pictures of the moon because no ones there. When theres no one, you cant feel lonely. Before going back inside her closet and sleep, she puts another 1000 steps in her pedometer. According to Jung-yeon, she doesnt exercise for health reasons, its more like she had a good, busy day after doing those. She knows that this is escapism, though she considers this as an all-too healthy one. When her Dad gets home by 9pm, Jung-yeon puts herself to sleep, which she believes as more of hypnotism and not sleeping, through watching a video tape. Overall, Jung-yeon is a social recluse and unemployed whose life revolves inside her room. This situation has a social context which is not yet included in the DSM V, called hikikomori. This will be explained later on.

II. Psychosocial History The scar on Jung-yeons face has unknown reason yet and this may imply things as to why and what but any speculations is not recommended to make, not unless she herself opens up. She also never shared anything yet about her past. Both of her parents are working and are supportive of her in a way, a proof of this is that they continued to allow her not to go out from her room instead of forcing her. An Event Every year, once in the spring and once in the fall, Jung-yeon really anticipates the Air-Attack Drills implemented in their country, a drill to prepare the citizens of South Korea from North Koreas possible sudden attacks. When this happened, Jung-yeon really became restless. She had worn her snickers though shes just inside her room, she kept fidgeting her foot, and she had a helmet with her, while sitting in her desk, staring at her clock, counting down the start of the drill. And when the siren rang, she had already worn her helmet, with the eye cover closed, but this time, she opened the curtains of her windows at broad daylight. As to why this event seemed very important to her, she stated that For just 20 minutes a year... the world seems like the empty moon. It feels lighter with 1/6th the gravity like on the moon. I wish the world would freeze like this. So life could be 1/6th lighter. Unexpected Event During the drill, Jung-yeon took pictures of the deserted city, and while shes looking through her camera lens, she spotted a sign from the nearby deserted islet in the middle of the Han River. The sign was written on the sand, saying HELP. She immediately exclaimed that its a sign from an alien and roamed her camera around the island to find the so-called alien. What she had found instead was a man wearing a business suit, on the verge of hanging himself from a rope tied into a tree. Jung-yeon suddenly emerged from her feelings of elation for being momentarily alone, and since she got really scared of what 2|simplyhue

she saw, she went inside her sleeping room her closet, even though its not yet her sleeping time in abidance to her strict schedule of doing things. Inside her closet, shes clutching bubble wraps in her hand. She said that she had tried doing hypnosis thirteen times, by watching the same video clips she used to be able to sleep, but it was no use. While panicking, she kept telling herself that it was not her fault, she must forget, she can forget, and that shes sleepy. By nighttime, even though shes very nervous, she went looking for the man she spotted earlier. When she saw him, she was glad that hes still alive. And while shes zooming the camera lens, still looking at the man shouting, she thought to herself that the alien was a freak, still referring to the man as an alien. She was in a daze later on, just staring into her computer, unable to do her usual routine of posting in her Cyworld account. A Series of Change in Jung-yeons Daily Activities From then on, through the lens of her camera, Jung-yeon watched as the man struggled to survive on the deserted island. She eventually took pictures of him, printed them on her printer, and posted them on top of the wall where she originally posted her pictures of the moon, which she later on called as her mini homepage of the alien. She also took notice of the change with the written message of the man on the sand, from previously saying HELP, into HELLO. The man continued to struggle, and so does Jung-yeon in her watching over the man, though every time she does this, she puts a cover on her left eye. Two months went by, her observations of the man are the following: He is shy. Likes dirty things. Enjoys adventures. Hes a total freak. And hes very curious about Earths black bean noodles. At the end of her description, she added, Will I be invited to join this lonely aliens world? Another noticeable change in Jung-yeon is that she has posted her picture of the HELLO message in front of her TV inside her closet, and she stared at it while her hypnosis video clip was playing. Covered with blankets, she told herself, I must go out into the earth. Can I do it without NASAs help? Just once. Only one time. Representing the 6 billion people on Earth, Ill reply to an aliens message. With that belief in mind, she went on to a series of preparation. She ordered online a bottle of wine, a toy robot, printed a message on a paper, printed a map and marked her way on it. Wearing a suit and a helmet, with a backpack, a timer and an umbrella, she waited until midnight, during the time when her parents are asleep. And for the first time in three years, she went out of her room. Breathing heavily and having a great deal of nervousness, she stated that, Since Armstrong, this is another giant step for mankind. Counting five to one, she stealthily went out of the condominium so that no one would see her. She did this through using the robot as the initial passenger of the elevator going down, basically distracting the security guard from monitoring the security cameras. Then she used 3|Case Formulation Report

the stairways in going down, fast enough to pass by behind the back of the guard while hes picking up the robot bait. Outside, Jung-yeon made sure that no one spots her. And when she arrived at her destination the bridge above the island, over there, she threw away her bottle of wine containing the piece of paper she printed out. Immediately the next morning, as soon as she woke up, she went on to look at the message written on the island, trying to see if anything has changed. Over knowing that theres still no reply, Jungyeon got disappointed, slumped on her chair, zipped the hoody of her jacket covering all over her face and turned the chair around and around. Three months later, her letter, which had the HELLO message printed, was finally found by the man and so when he replied HOW ARE YOU by changing his written words on the sand, Jung-yeon actually noted it as after three months and seventeen days and she took a picture of it, then printed it while smiling happily. For the second time, Jung-yeon went out again of her room, doing it in the same manner as the first time, to deliver another message in a bottle. This time, while on her way home, she spotted two butterflies on a tree under a street light, and here she admitted, The images and sound are slowly getting clearer. Jung-yeons second message to the man was FINE, THANK YOU AND YOU?, which the man replied to as FINE, THANK YOU, realizing that someone must be intentionally communicating with him. Throughout the five months of Jung-yeons observation of the man, hes been actually growing his own corn field, being obsessed to eat a black bean noodle. Jung-yeon actually saw all through this, and having seen all the hard work the man had done, again, for the first time in three years, she used her phone to talk to someone. And that call was to order from a delivery restaurant, though when giving the payment to the delivery boy, she did this through slipping the bill under her houses door. Unfortunately for her, the man refused the black bean noodles. She was actually watching the mans interaction with the delivery boy and so she got disappointed when the man did so. When the delivery boy returned the food in front of her apartment, another change happened. For the first time in three years, she opened her door, albeit only slightly, and personally talked to the delivery boy, asking him if the man did say something. Relaying what the man said that a bowl of black noodle was hope for him, Jung-yeon stated, Hope. I havent heard that in 100 years. And while eating the noodles, she thought, Im eating the giant hope the man sent me. It is truly the taste of hope. Later on, when her mother was about to go to work and asked her if she asked anything, again, for the first time, instead of her usual replying through messaging in her cellphone, she finally opened the door of her room and talked to her mother. She stated to her mother that she would like to grow some

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corn and if she could get the needed materials like the seeds and pots. Her mother was really shocked and got teary-eyed. Jung-yeon went out of her room for the third time, doing it in the same manner as the past two, delivering her message saying, I AM SORRY. The man replied to her through making funny gestures at the sand, with a sea-like background. During that time, Jung-yeon was actually crying, a happy one, since the man seemed to have forgiven her. When finally the man had made his own black bean noodles, with all the ingredients coming from his labored-field, hes crying while eating it and Jung-yeon took a picture of that moment, congratulating him through the picture. That night, Jung-yeon did not watch her video clips for hypnosis before sleeping. And while shes inside her closet, she wasnt able to fall asleep and again, for the first time, she slept outside of her closet, laid down in front of her window, now opened, and in front of her own plants of corn she had asked earlier from her mother. Jung-yeon sent another message to the man saying, CONGRATULATIONS, and this time it has an added emoticon to it, a winking one. The next day, Jung-yeon saw the mans reply asking, WHO ARE YOU? Jung-yeon can be seen being agitated again, a sign of her panicking. Because of that, she went back to her virtual world, printed out her online image, the image of a beautiful girl, went out again to deliver the bottle containing the picture, but at the last moment, she decided against it, and did not throw it instead. When the man looked for her message in a bottle and realized she did not reply, he added to his message on the sand saying, WHY? With this, Jung-yeon went back to her old self. She turned off her camera, closed her window, covered it with her curtain clothes, and went back to her Cyworld again. And when she checked her account, she saw a reply to one of her post whos a friend of the girl she posed as herself. She was accused that her homepage was a fake one, that shes a crazy bitch. Seeing all through this, added with her inability to answer the mans question, she underwent an emotional crying. Then, a storm hit the city. Jung-yeon was back in her closet, shivering and was unable to sleep. Her room window got opened due to the strong wind, but Jung-yeon just stared passively at it, so the rain got inside, making the room dripping from water, destroying her wall of pictures and her plants of corn. The next morning, thinking that the storm might have affected the island too, she quickly looked for the man through her camera, and was glad that hes fine. But suddenly there were two men behind the mans back. They were actually about to clean the islands mess brought about by the storm. Upon seeing this, the man fled and struggled not to be taken away from the island but he was brought back to the city in the end. Jung-yeon witnessed all of that happened. That scene made Jung-yeon to go out of her room, in broad daylight, without a suit and a helmet on. Just wearing her unchanging big long shirt and a pair of sneakers, overcoming her fear of going out of 5|Case Formulation Report

her room, she went on looking for the man. Running at her full speed, crying desperately, without a care to the people around her, she ran after the bus the man boarded at, but it went speeding away and so she thought shell never catch up. But when she was just about to give up, the siren signaling the Air-Attack Drill rang. So as the bus stopped, she was on her way to it, running but now while also smiling. Once inside the bus, she went straight to the man and told the man her name, saying, My name is Kim Jungyeon. Who are you?

III. Medical and Psychiatric History There is no current information regarding Jung-yeons medical and psychiatric history or any information that may relate to this. Further series of tests and questioning must be given to Jung-yeon to be able to give any conclusion.

IV. DSM-IV-TR Multiaxial Axis and DSM-V Diagnostic Criteria and Codes Axis I 300.23 (F40.10) Social Anxiety Disorder (Social Phobia) 307.1 (F50.01) Anorexia Nervosa, Restricting type 300.4 (F34.1) Persistent Depressive Disorder (Dysthymia), Late Onset, with MoodIncongruent Psychotic Features, Severe

Axis II

301.82 (F60.6) Avoidant Personality Disorder

Axis III

No general medical condition

Axis IV

Everything stated in Part I and II of this report is relevant

Axis V

15

Axis VI

Taein Kong Po/Taijin Kyofusho/Hikikomori

V. Rationale of Diagnosis For Axis I, Jung-yeon meets all the following criteria under the Social Anxiety Disorder (Social Phobia): She shows fear or anxiety about social interactions meeting Criterion A, as shown during her going out of her room to deliver the message in a bottle, wherein she tried hard not to be seen by the guard or anyone, to the point of even wearing a suit and a helmet. For Criterion B, it requires her to have 6|simplyhue

fears of negative evaluation and this is shown in her anxiety when the man asked her who she was, there she tried to use her virtual image, which was a fake one. In line with Criterion A, she meets Criterion C since when she went out for the first three times, she did it in the same manner as explained above, because social situations provoke anxiety or fear in her. An additional proof of her anxiety for this is the reason for Criterion B. Jung-yeon hasnt actually come out of her room for three years, making her meet Criterion D, proving that shes been avoiding social situations. She even mentioned that she didnt have to go out of her room because everything that she needs is on the internet. Her social anxiety is out of proportion since theres no threat to her posed by the social situation so there should be no logical reason for her to have fears, and for the sociocultural context, she is actually considered as a social recluse, or more culturally referred to as a hikikomori, which will be explained later on. Also Criterion F requires the disorder to be persistent, lasting more than 6 months and she clearly meets this. Jung-yeon has no actual job, even though she considers her posting on the Cyworld as her work, she is still unemployed, added with her relational impairment with her parents, she meets Criterion G. Her fear or anxiety is not attributable to the physiological effects of a substance (Criterion H) and it is not better explained by the symptoms of another mental disorder (Criterion I). Lastly, there is no other medical condition reported, making her meet the last criterion, Criterion J. Jung-yeons strict schedule and way of doing things, specially her everyday food intake followed by an exercise makes her meet the following criteria for Anorexia Nervosa: Her specific calorie intake per meal of the day, for instance, her eating only a can of corn with 172 calories for breakfast, then immediately exercising using the pedometer by putting on 3000 steps and with the same pattern until evening, is a proof for Criterion A, her restriction of energy intake leading her to a significantly low body weight. This is evident by her thin body structure, even without the available data on her body weight. She has been doing that same pattern of eating then exercising for three years, making her meet Criterion B which requires the behavior to be persistent. And lastly, for Criterion C, Jung-yeon has no recognition of the seriousness of her current low body weight brought about by her behavior, which she even denied as something she does not do for health reasons but since it brought a feeling of accomplishment to her when she does those exercise. With that, she is given the specifier restricting type since her weight loss is accomplished primarily through dieting (limited and counted calorie intake) and excessive exercising. While the specifier whether shes in partial or full remission and the severity of her disorder cannot be determined yet with the available information. A diagnosis of Persistent Depressive Disorder (Dysthymia) was also given to Jung-yeon for she meets the following criteria under it: 7|Case Formulation Report

For three years now, she hasnt come out of her room and though she does not report it herself, it can be observed through her daily activities (Criterion A). Criterion B requires the presences of at least two, and she meets the following: (B1) she has poor appetite, as explained earlier; and, (B4) she has low self-esteem since she even used an image of another woman in her Cyworld account than her own. During the duration of her disorder, she has never been without the symptoms in Criterion A and B for more than two months even though gradually shes been positively changed by the man throughout her observation of him through her camera lens. The criteria for major depressive disorder have been continuously present during her three years reclusion inside her room (Criterion D). Criterion E requires the absence of manic or hypomanic episode and the criteria for cyclothymic disorder has never been met, and Jung-yeon meets all of this. Jung-yeon meets Criteria F, G and H which require the disorder to be not better explained by other disorder under the Schizophrenia Spectrum, for it not to be attributable to the physiological effects of a substance and the symptoms cause significant distress or impairment on Jung-yeons areas of functioning. The specifier late onset was given since she is older than 21 years old. Plus, she exhibits moodincongruent psychotic features since her delusions happened when shes using the internet, imagining things on the virtual worlds as if it were real, assuming a different persona image and personality. This feature can also be seen during her reference to the man on the island as an alien rather than acknowledging him as a stranded person, added by her reference of going out of her room for the first time in three years as something like the achievement of Neil Armstrong, considering her action as a giant step to save mankind. Also, Jung-yeons depression is severe since it has markedly interfere with her social and occupational functioning as shown by her inability to go out of her room for three years and in her anxiety when going out. For Axis II, Jung-yeon was given the diagnosis of Avoidant Personality Disorder in connection to her Social Anxiety Disorder. She may have not admitted her reasons for not going out of her room yet, but with her behavioral patterns and cognitive reasoning presented in her psychosocial history, she meets the following criteria under Avoidant Personality Disorder, which requires at least four symptoms to be met: Criterion 1, Jung-yeon has clearly avoidance of occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval or rejection. This was shown when the man asked her identity and she was unable to do so, got anxious and went back to her Cyworld, was about to pose as her virtual image, then changed her mind in the end. Also, shes seen crying when she was busted by a friend of the woman she used to pose as her identity. For Criterion 3, she had showed restraint with her developing friendship with the man because of the said fear. Her being agitated and inability to sleep the following night shows her preoccupation with her fears (Criterion 4), these fears are clearly 8|simplyhue

because of her uncertainty and feelings of inadequacy (Criterion 5), and she was really reluctant to take personal risks or to engage in developing her friendship with the man (Criterion 7), wherein the threat of being not able to see the man again was the only thing that prompted her to finally introduce herself to the man. Jung-yeon has no reported general medical condition for Axis III. And the information stated in the first and second part of this report is considered important for her psychosocial development for Axis IV. Her Global Assessment of Functioning for Axis V is 15, since her disorders have caused her significant impairment in her social and occupational functioning, her being confined in her room for three years, unemployed, drowned in her virtual world, unable to properly communicate to her parents. It shall be noted that Jung-yeons case has a sociocultural context referred to in the DSM-V as Taijin Kyofusho which means interpersonal fear in Japanese. The Korean counterpart of this is called Taein Kong Po, although the more common term of this disorder is hikikomori. Basically, this is much related to the Social Anxiety Disorder, but has a broader context because this cultural syndrome is characterized by anxiety about and avoidance of interpersonal situations due to the thought, feeling, or conviction that one's appearance and actions in social interactions are inadequate or offensive to others. The society Jung-yeon lives in has a strong emphasis on the self-conscious maintenance of appropriate social behavior in hierarchical interpersonal relationships, which may be a great factor to her cognitive thinking, resulting to her disorder.

VI. Case Formulation Jung-yeons case conceptualization is written from the perspective of cognitive therapy in which the clients maladaptive or otherwise erroneous thought processes represent particularly fruitful points of assessment and intervention. Cognitive theories argue that our cognitions thoughts or beliefsshape our behaviors and the emotions we experience. The casual attributions we make for events, the answers to our questions of why something happens, can influence our behavior because they influence the meaning we give to events and our expectations for similar events in the future. These attributions can affect our emotions and self-concept. Aside from the attributions we make for specific events, we have also global assumptions broad beliefs about ourselves, our relationships, and the world, which can either positive and helpful to us or negative and destructive. These theories argue that most negative emotions or maladaptive behaviors are the result of one or more of the dysfunctional global assumptions that guide a persons life. This perspective will be further discussed into the following areas of Jung-yeons case:

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On Jung-yeons Social Phobia According to cognitive theories, people with social phobia have excessively high standards for their social performancefor example, they believe they should be liked by everyone. This can be seen on Jung-yeons use of a fake image of herself on her virtual account, using an image of a beautiful girl. When she read the comments on her posts, which were also made-up ones, she was glad by the praises she received. This act of online treachery brought her a false sense of being liked by other people, something she cannot achieve in real life, for she cannot even go out of her room, and thats for three years now. In addition, her beliefs that she never has to come out of her room since everything can be hers with just a few clicks, that it doesnt matter for her whether her posts are real or not, that anythings possible on the internet age, looks, jobs, and that what matters are the replies she gets on her site, make her social disorder worse since it provides her another false sense of completeness, which empower her social reclusion inside her room, and which can be attributed as to why she survived her reclusion that long. Even her concept of self-improvement is through the internet social media too. In connection to this, culturally, her being a hikikomori may be due to her appearance, specifically the scar on her face, which she may believe as unpleasant or offensive to others. This may be attributed to her online treachery too. And when someone busted her upon finding out that her accounts a fake one, she went into an emotional state and cried, since this pointed out the reality she was trying not to face, and since her virtual fantasy was crumbled, her only sense of being physically pleasant, as someone whos being appreciated by others. The kind of support she gets from her parents also affect the kind of cognition she has since as long as she has the resources, without even having to work or go out, she wont be left with no choice. In a way, instead of helping her to gradually go out and change for the better, though shes being supported silently, its not helping her at all, it pushes her even more to become more reclusive , perpetuating her symptoms. On Jung-yeons Eating Disorder The cognitive thinking of Jung-yeon regarding her daily schedule of activities is an erroneous one for as she stated, its as if she had a good, busy day after doing those, and while she knows that what she does is escapism, she still considers it as an all too healthy one. Her very calculated intake of calories followed immediately by an exercise shows that shes indeed concern with the kind of image she has, trying to achieve what a socially acceptable concept of beauty and thinness is. On Jung-yeons Depression According to cognitive theories, people with depression look at the world through a negative cognitive triad, they have negative views of themselves, the world, and the future. In Jung-yeons case, 10 | s i m p l y h u e

her depression may be an offset of her social phobia. This can be seen in her reasoning as to why she loves taking pictures of the moon as her hobby since she argues that the absence of people there make her not feel lonely. Another instance of her flawed reasoning is in her anticipation of the bi-annual drill done in her country, since again, the place would be deserted. These instances show her avoidant personality too, for she has developed a sense of likeness of being literally and emotionally alone. Jung-yeons depression even caused her to have psychotic tendencies, as seen in her delusions while in her virtual world, in her belief of the man as an alien, and in her delusion of going out as to something as grandiose as the achievement of being the first man on the moon.

VII. Recommendation Jung-yeon is advised to see a psychologist or a psychiatrist to help her cope up even better than the way she is gradually coping up now with her recent positive changes in connection to her budding friendship with the man. The recommended therapy approach to Jung-yeons case is cognitive-behavioral therapy (CBT) wherein the cognitive part will help her change the thinking patterns that support her fears, and help her identify and challenge these negative thoughts and dysfunctional belief systems. It also aims to help her learn more effective problem-solving techniques for dealing with concrete problems in her life. While the behavioral part will help her change the way she reacts to anxiety-provoking situations. The following are the main goals in her therapy: 1. Jung-yeon will be assisted in identifying her irrational and maladaptive thoughts. She might be asked to keep a diary of thoughts she has whenever she feels anxious, but this time this diary should be hand-written to lessen her time on the internet. 2. Then, Jung-yeon will be taught on how to challenge her irrational or maladaptive thoughts and to consider alternative ways of thinking. She might be asked to evaluate the evidence for a belief or to consider how other people might think about a difficult situation. 3. She will also be encouraged to face her worst fears about a situation and recognize ways she could cope. She would be asked to analyze her developing friendship with the man, the thought and emotional processes she underwent, and the things that helped her decide to go out of her room. The whole process must be through systematic desensitization. Deep breathing, meditation, stress management techniques and other types of exercises to relieve anxiety and encourage relaxation will also be taught to Jung-yeon since it is observed that she easily gets agitated or nervous during these situations. Jung-yeons therapy may be conducted individually or with a group of people who have similar problems since research has shown that group therapy is particularly effective for social phobia. Another reason why a group therapy might be effective for her is that during the onset of her observation of the 11 | C a s e F o r m u l a t i o n R e p o r t

man, whom she has somehow identified herself with as someone who was stuck to his own world, just like her, is that she has shown good development or changes in her daily activities her being able to go out is just one proof of it. Ways to Make the Treatment More Effective Talking with a trusted friend or a member of the family can also provide support, but it is not a substitute for care from a mental health professional. Jung-yeon must maintain her friendship with the man, making sure to have constant contact with him, or do activities together such as simply talking, exercising, and the like. In connection to exercise, since it is observed that Jung-yeon has a knack for it, this time however, the exercise should be done outside the house. This may be at the nearby park or recreational area. She could either be accompanied by her parents or by the man as her new friend. Furthermore, her hobbies of taking pictures of the moon could be used as a way to mingle more with other people. Thats why it is recommended that she photographs nature, then slowly include people too. She may enhance her hobby as a profession since she also seemed very skilled at it. For her eating disorder, her family should make sure to eat together and monitor her food intake to be at a normal level or more. Cooking together with her family or her new friend, who seemed to be good at it, is highly recommended too.

Citations American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

American Psychological Association. (2010). Anxiety disorders and effective treatment. Retrieved from https://www.apa.org/helpcenter/anxiety-treatment.aspx.

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Nolen-Hoeksema, S. (2011). Abnormal Psychology (5th ed.). New York, NY: McGraw-Hill.

Sturmy, P. (2009). Clinical Case Formulation: Varieties of Approaches. Singapore: Fabulous Printers Pte, Ltd. 12 | s i m p l y h u e