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Clinical Case Studies
Published: 2018-12-25

The case of atypical anorexia nervosa

Zaporizhzhia State Medical University
atypical anorexia nervosa Pediatrics psychotherapy teenagers

Abstract

Background. Anorexia nervosa is a syndrome characterized by a deliberate and extremely persistent restriction in food, which often leads to cachexia. The leading symptom is the idea fixe about conviction in overweight, distorted perception of the one’s body in which the “fear of obesity” and the attitude to weight loss are formed. Anorexia nervosa, according to ICD-10, relates to eating disorders, which are behavioral syndromes associated with physiological disorders. The complexity of diagnosis and treatment is associated with the tendency of patients to dissimulation, late referral of parents and the low curability of psycho-pathological symptoms, the complexity of rehabilitation issues.

Objective. To demonstrate an atypical clinical picture of the anorexia nervosa case.

Materials. For the study purpose clinical history and anamnesis according to the mother were examined.

Results. A girl was administered medical treatment and out patiently visited psychologist. During the treatment of side effects, there were no complications. After discharge the girl continues to study at school, has good marks and friendly relations with peers. She became calmer in the family. She has been on maintenance therapy for six months. Later medication was discontinued. According to the two-year-old medical history mother does not notice any problems in food behavior.

Conclusions. The atypicalness of the clinical picture of anorexia nervosa in this case was manifested in the expressions of the personality accentuation. They manifested themselves in early childhood in heightened suspiciousness, vulnerability, and sensitivity, and were accompanied by various obsessions. In the future, these traits were expressed in psychopathization with a tendency to self-harm and aggressiveness to relatives, and they determined the peculiarities of the clinical picture of anorexia, which led to using an atypical antipsychotic in complex therapy. We mainly associate a good therapeutic effect when staying in the hospital and in the subsequent out-patient treatment with the fact that psychotherapy was conducted almost daily by both a doctor and a clinical psychologist.

Background

Anorexia nervosa is a syndrome characterized by a deliberate and extremely persistent restriction in food, which often leads to cachexia. It is more often in adolescent girls who are correcting an imaginary or sharply overestimated excess body weight. Anorexia nervosa, according to ICD-10, relates to eating disorders, which are behavioral syndromes associated with physiological disorders. The significance of studying this disorder for medical practice is determined by its considerable prevalence and life-threatening nature. The complexity of diagnosis and treatment is associated with the tendency of patients to dissimulation, late referral of parents and the low curability of psycho-pathological symptoms, the complexity of rehabilitation issues.

The leading symptom is idee fixe (in some cases, delusion) about conviction in overweight, distorted perception of the one’s body (dysmorfomania), in which the “fear of obesity” and the attitude to weight loss are formed. For a reliable diagnosis, in addition to a sharp decrease in body weight, the presence of secondary conditioned somatic and endocrine disorders, in particular amenorrhea, should be considered.

In numerous publications, when describing typical clinical symptoms, a wide variety of interpretations of the etiology and pathogenesis of this disease are given. Different authors attribute it to the field of border psychiatry, to the pathological course of the age crisis in adolescence, to the pathological development of the personality, to protracted reactive states, others do not exclude incipient schizophrenia. In most of foreign publications, anorexia nervosa and anorexia nervosa syndrome in schizophrenia are considered as completely different mental illnesses, wherein anorexia nervosa is one of the typical variants of psychosomatic pathology.

Despite the long history of studying this disease (the first medical report about anorexia nervosa belongs to Richard Morton, who described two cases of "nervous consumption" in 1689), the clinical assessment of each case does not lose its meaning, considering the characteristics of symptoms, often atypical, must be a basis of building therapeutic tactics.

Clinical examination

Patient Eve G, 2003 year of birth, student of 8th grade. She was admitted to the children's department 10/21/2016 for the first time. Complaints of the mother were about the daughter’s lack of appetite, weakness, a sharp restriction in food for the purpose of losing weight. After examining by the on-call doctor and the decision to hospitalize the patient, she left the office and hit her mother on the cheek, crossed herself with the words "I swear I will commit suicide." In the department, the behavior was calm, but when it was mentioned that she refuses to eat, patient claimed that this is not a complaint at all, she just does not want to eat.

Medical history according to the mother

No one in the family suffered from mental illness. Parents divorced when the girl was very young. The reason for divorce was frequent alcoholism of a man. Now he is supposedly coded, has another family, lives in the next house, takes care of his daughter, helps financially. The mother's pregnancy proceeded with toxicosis. There was even a question about the termination of pregnancy, since the mother suffered from urolithiasis and was preparing for the operation, but "the stone came out by itself". Childbirth was with squeezing, supposedly there was a hematoma on the head of the child, but the girl screamed right away, there was no asphyxiation. According to her mother, she was overly agile, whining, and "diagnosed hyperactivity" in early childhood. Henceforth, the mother observed various of daughter’s obsessions, she washed her hands frequently in fear of contamination, then there was a tendency to repeat the same words. Patient was raised by her mother and grandmother in hyper-care, any of her whims were immediately fulfilled. In her features, the mother notes increased suspiciousness, impressionability. There were whooping cough in early childhood, frequent tonsillitis. Stands registered with a rheumatologist, the girl has a mitral valve prolapse. Tuberculosis, TBI and viral hepatitis are denied. Menarche was at the age of 9, menstruation were regular, painless, but recently, due to the drastic weight loss, menstruation have lost its frequency and became scanty. Patient is a good student, she is considered one of the best in the class. She has many friends, she is friends with a boy, her mother complains that he is teasing her, saying that she is fat. Problems with food began in the end of summer. Patient spent a lot of time on the Internet, met a boy from Moscow, they’ve became a pen-pals and “she virtually fell in love with Danylo”. Common interests were in the artistic appreciation of Japanese girls with aspen waists and notches on their forearms. Following them, the patient also cut in the area of her left forearm. They constantly discussed the "charms" of thin people on the Internet with this boy. The girl’s weight fell from 52 kg to 43 kg since September, while her height is 167 cm, that is, in Quetelet index was 15.5, with a standard more than 17.5. Patient restricted herself in food, she is eating a small piece of meat, half a pear, a few spoons of soup. At the persuasion of the mother, grandmother and grandfather she "throws tantrums", threatens to commit suicide, in anger insults them, says that she hates them. When calms down, patient claims that remembers nothing. She was taken to the hospital by trick. Mother’s anxiety was caused by a sharp weakness in the daughter, her icteric sclera, cold hands, blue nails, the temperature drop below 36 degrees.

Mental state at admission

Consciousness is not changed, in a place, time, and herself is oriented correctly. Low mood; during the conversation, it has somewhat improved, she began to understand jokes and smile. But at the mere mention of food, tears appear in her eyes, she lowers her head, stops talking. Any violations of perception or delusions were not revealed, but overvalued ideas for weight loss clearly manifested. Patient denies the presence of suicidal thoughts. She agreed to the treatment, although she stipulates it with "no more than a week". On the first day in the department she completely refused to eat. While taking medication she constantly asks whether her weight will increase from them. She spends time in bed, sitting in one position. After persuasion, patient ate a few spoons of soup. She also refused to drink. During the prescribed treatment, and especially after small doses of insulin, followed by the doses of glucose, the condition improved. She began to take her food by herself. Her behavior had also improved. Patient became friendly with the medical staff, willingly answering questions. She began to communicate with children, drew for them. She read magazines, solved crossword puzzles. In a conversation with a doctor, she said that she had realized her wrong behavior. Before discharge, patient weight 50.5 kg. Insulin injections were canceled two days before discharge, the patient continued to eat food with appetite even after that. Burdened by staying in the hospital, missing family and school. Mother agreed to consult with the children's clinic, she understands the need to continue maintenance therapy. Patient was discharged November 4, 2016.

Examination

Complete blood count: hemoglobin – 179; erythrocytes – 5.35; color index – 1.0; leukocytes – 5.1; ESR – 2 mm/h.; basophils – 5; neutrophils – 55; eosinophils – 2; lymphocytes – 29; monocytes – 9.

Clinical urine test: specific gravity –1016; glucose, protein is absent; RBC – 0–1; WBC – 3–4.

Glucose test – 4.10 mmol/L, serum creatinine – 81.9 mcmol/L, urea – 2.25 mcmol/L. WR – negative.

Pediatric conclusion (10/21/16): Mild protein-calorie malnutrition.

Neurologist’s conclusion: there is no any focal neurologic signs.

ECG: sinus tachycardia.

Echoencephalography: displacement of the median structures, signs of hydrocephalus not found.

Rheoencephalography: without pathological features.

Electroencephalography: steady increase of the tonus of activating structures of the reticular formation.

Psychologist: examination reveals a neurotic variant of personality development with a fixation on weight loss.

Treatment

  • Sybazon 10 mg im first 72 hours;
  • Ryspetryl 0,5 mg twice a day;
  • Noobut 0,25 mg three times a day;
  • Insulin 12 units followed by glucose injection 0.5% 400.0 iv №10;
  • Eating in small portions 6 times a day;
  • Vitamin therapy;
  • Rational Psychotherapy, which took place every day.

On the background of the treatment of side effects, there were no complications. After being discharged, the girl continues to study at school, has good marks and friendly relations with peers. She became calmer in the family. She has been on maintenance therapy for six months:

  • Ryspetryl 0,5 mg in the evening;
  • Noobut 0,25 mg in the morning;
  • Trymetabol 5 ml half an hour before meals for lunch.

The girl out patiently visited a psychologist. Later the medication was discontinued. According to the two-year-old medical history mother does not notice any problems in food behavior.

Conclusion

The atypicalness of the clinical picture of anorexia nervosa in this case was manifested in the expressions of the personality accentuation. They manifested themselves in early childhood in heightened suspiciousness, vulnerability, and sensitivity, and were accompanied by various obsessions. In the future, these traits were expressed in psychopathization with a tendency to self-harm and aggressiveness to relatives, and they determined the peculiarities of the clinical picture of anorexia, which led to using an atypical antipsychotic in complex therapy. We mainly associate a good therapeutic effect when staying in the hospital and in the subsequent out-patient treatment with the fact that psychotherapy was conducted almost daily by both a doctor and a clinical psychologist.

How to Cite

1.
Ivanov M. The case of atypical anorexia nervosa. PMGP [Internet]. 2018 Dec. 25 [cited 2024 Mar. 28];3(4):e0304149. Available from: https://e-medjournal.com/index.php/psp/article/view/149