Nutritional Diseases

CASE 9: Anorexia Nervosa

Clinical History:

A 15-year-old girl is brought in to you by her mother, who is concerned about her daughter's health, after several recent episodes of fainting. The mother states that the girl has become a very picky eater over the past two years and rarely wants to sit with the family at mealtimes, but rather remain in her room reading fashion magazines or exercising. She describes most of the foods her mother prepares as bad or dangerous. She will often prepare elaborate meals for the rest of the family which she does not eat herself. When asked about her eating habits, the girl states that she gets plenty to eat and is concerned about not becoming too fat. She began menstruation at age 13 with irregular periods, but menstruation stopped 8 months ago. Her body mass index is 16.5. Physical examination reveals decreased muscle mass of extremities and decreased strength. Neurologic examination reveals no deficits.

Laboratory findings include:

WBC Count9070/microliter
Hgb11.9 g/dL
MCV77 fL
Platelet count307,000/microliter
Cr0.6 mg/dL
BUN12 mg/dL
Glucose58 mg/dL
Total protein6.0 g/dL
Albumin3.2 g/dL
Bilirubin, total0.4 mg/dL
Alk Phos109 U/L
  1. What do you suspect in this case?

  2. The findings represent the result of multiple nutritional deficiencies, not just one. The very low BMI is the most worrisome finding. In this setting, the disorder known as anorexia nervosa should be suspected. Similar findings can be seen with child abuse, but investigation of the home situation and interviews with the parents will help sort out the possibilities.

    This child has willfully diminished food intake to the point of near starvation. There is microcytic anemia, probably from iron deficiency. There is hypoalbuminemia suggesting protein-calorie deprivation (seen as kwashiorkor in children). Her intake is not enough to even keep a normal blood glucose level. The creatinine and BUN levels are those of someone with minimal muscle mass.

    Anorexia nervosa is a condition in which there is a distorted perception of one's body. Persons weigh less than 85% of what is expected for age and height. The disorder is most often seen in adolescents, with a female:male ratio of 9:1. The prevalence for females is higher for Caucasian, middle class, and college-educated populations. (The disorder in males may be more subtle, and masked by a vernier of athleticism, with considerable concern for one's "lean body mass" or anorexia athletica, forgetting that physical activity can be fun. Males who are anorexics tend to have more psychopathology.)

    The sufferer perceives that she/he is too fat, regardless of what others see. Persons with anorexia nervosa may have low tolerance for change and new situations, they may fear growing up and prefer to remain dependent on parents or family. Dieting may be a form of manipulative behavior, although not necessarily at a conscious level. The self-imposed dieting may represent avoidance of, or ineffective attempts to cope with, the demands of adolescence.

  3. What are organ-related consequences of this condition?

  4. The depletion of adipose tissue leads to cold intolerance. There is striated muscle wasting leading to weakness, and involving cardiac muscle if severe, with dysrhythmias. There can be features resembling irritable bowel syndrome (bloating, constipation, pain). Amenorrhea occurs in women. Osteoporosis can occur.

  5. What can be done for this condition?

  6. Behavioral therapy is directed towards achieving normal weight gain with dietary management. Individual and family therapy can help to deal with the underlying issues. There are no specific medications for this disorder, though mood disturbances may be treated with pharmacotherapy. Medical management may be needed for the disease conditions resulting from anorexia.

  7. The girl's 16-year-old friend advises that she has her own solution, "I eat everything I want, and then force myself to vomit all of it up, or I just stop eating for a couple of days. It works for me." What is the problem here?

  8. The condition characterized by binge and purge eating is known as bulimia. There may also be a history of laxative and diuretic use. Such persons often have a history of substance abuse. This disorder is also dangerous, because the sufferer is typically concerned about body image and tends to be underweight and malnourished. Anxiety and depression often underlie bulimia, and these persons can be impulisve, with little concern for the consequences of their actions. There is another consequence of bulimia accompanied by vomiting-accelerated tooth decay from the stomach acid. Bulimic persons may have sialadenosis, or painless salivary gland enlargement. Purging increases the risk for Mallory-Weiss tears in esophagus.

  9. What ethical issues are raised by this case?

  10. This is one of the most difficult conditions to treat. Treatment has the problems common to much of psychiatry where there is a denial of a problem by the patient, and treatment requires paternalism, overriding the patient's decisions. If the patient is an adult, the ethical problem is more obvious, but the same issues are present in adolescent patients. Given that the 'disease' tends to last for years or decades, such involuntary treatment is rarely successful. Patients tend to be admitted for a few weeks of observed feeding and calorie counts, and tube feeding if all else fails, often with a specific goal to gain 10 or 20 pounds, or a certain percentage of normal BMI. But the patient can lose that much weight within a week or two of discharge. Interestingly, while it is fashionable and believable to claim that it is caused by our sexist culture and the emphasis on a thin models as the paradigm of beauty, it is a very old disease, with documented cases in the Middle Ages.