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CASE REPORT

Anorexia Nervosa Features in : A Starving Mind within a Susceptible

Nik Ruzyanei NJ1, Wan Salwina WI1, Choo SP2, Rosdinom R1

1Department of , Faculty of Medicine, Universiti Kebangsaan Malaysia 1Jalan Yaakob Latiff, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia 2Hospital Bahagia Ulu Kinta, Tanjung Rambutan, Ipoh, Perak

Abstract

Schizophrenia poses challenges in diagnosis and treatment strategies when the predominant clinical features represent another spectrum of disorder like disorders. Nevertheless, symptoms of in schizophrenia are not entirely uncommon although never included in the diagnostic criteria. We reported a case of a woman who first presented at seventeen years old with food refusal and underlying resulting in severe , but defaulted treatment for almost a decade. In 2009, she presented again with sinus and secondary amenorrhoea. In this report, we discussed about the patient’s vulnerability for psychosis and its psychodynamic drive which led to a complex symptoms manifestation. Our aim is to highlight its diagnostic dilemma and suggestions to treatment strategies unique to this presentation.

Keywords: Nervosa, Schizophrenia

Introduction disorganized and abnormal food intake as Features of anorexia nervosa (AN) in being characteristic of schizophrenia. schizophrenia represent the complexity of schizophrenia. between Subsequent studies found 3 to 12 % of anorexia nervosa and schizophrenia has patients with AN may have a final diagnosis been reported1,2,3 and need to be considered. of Schizophrenia6,7. It was suggested that There is a need to differentiate symptoms of AN acts as a defence against psychotic AN as part of the spectrum of schizophrenia, breakdown whereby treating the abnormal those that co-occur as distinct clinical entity, eating may uncover the underlying and those that represent overlapping psychosis into full blown psychotic comorbidity. It is also of clinical interest as phenomenon6. However, abnormal eating in Kraepelin4 and Bleuler5 once described schizophrenia, as opposed to symptom of AN was descrinbed as delusional in nature8 MJP Online Early MJP-01-05-11 which corresponds to like once every two days. She chewed slowly a somatic passivity and made action. While normal amount of food consisting of there may be presence of distorted body elaborate meal of many types of dishes. She image and fear of being fat in schizophrenia, also exercised excessively for few hours the patients rarely have concerns of the food everyday but there was no use or caloric content and other eating induced . There was a brief use of preoccupations and obsessions typically over-the-counter supplements in the seen in AN8. While the course of the illness. Her reasoning for the distortion in AN may also amount to fixation on being petite was noted to be delusional proportion, the themes are usually superficial and concrete. For example, she restricted to the primary eating disorder9. explained ‘I eat little because I’m a girl.’ These characteristic differences and overlapping psychopathology of the two She liked to cook and serve food to others conditions would give good guidance for but did these oddly. For example, she served clinicians in tackling this complex inedible food to her parents and neighbours phenomenon. every hour. Other strange behavior include dressing inappropriately, e.g. wearing In this case report, we addressed the underpants in the living room) and soaking diagnostic dilemma and challenges in in inflated tub. Further assessment revealed treatment engagement and strategies. We underlying abnormal thoughts and auditory reported a woman in her late twenties who hallucinations (second and third person) in has schizophrenia since . One the themes of distorted body image and main feature throughout her illness was her eating. The voices derogatorily mocked her food refusal in order to maintain a petite small-framed body. She also had built. She stopped treatment after brief of reference, persecution and thought interventions in her teens but reappeared ten broadcasting in similar themes. There was years later when her dangerously low weight absence of affective symptoms. (32kg) came to an attention of a general practitioner (GP). In this report, we also Physically, she experienced intermittent discussed about the role of atypical generalized muscle and bone aches. There antipsychotics in AN by utilizing its weight- was no history of fracture, or gaining propensity. blackout. She had secondary since the illness onset but experienced few CASE REPORT breakthrough bleeding, the last of which was few months prior to the recent illness. History Over the years, she deteriorated in her A 28-year-old single woman first sought social, interpersonal and occupational psychiatric treatment at age seventeen for functioning although her personal care and severe weight loss and abnormal behavior. handling of simple household chores were She improved but unfortunately was lost to preserved. She was a graphic design student follow-up until a decade later. at the illness onset, but never completed her studies or had permanent employment ever In 2009, she presented with similar since. complaints of food refusal and abnormal eating habit as she fixated on maintaining She was never involved in meaningful low bodyweight. She ate only at midnight heterosexual relationship. In the early course MJP Online Early MJP-01-05-11 of her illness, she experienced life stressors This time (2009), admission was warranted when her mother became ill with systemic again due to severe weight loss. The lupus erythematosus (SLE) and later when immediate treatment goals were to restore she discovered that her father had a second weight and control the psychosis. She was marriage, which caused family disharmony. co-managed by multidisciplinary teams of psychiatry, dietetic, endocrine, orthopedic She is the youngest of three siblings from and gynecology. Re-feeding regime was upper-middle class family. Prominently, her started with close monitoring of weight and siblings were both high achievers and good vital signs. She was surprisingly cooperative looking while the patient was constantly to treatment and showed no resistance to teased due to her small-built and dark regulated eating. Olanzapine (titrated up to appearance. There was family history of 20mg daily) was restarted primarily to treat psychosis in the late paternal grand-uncle. psychosis. Upon discharge six weeks later, Premorbidly, she was an obedient child but her weight was restored to 35 kg rather withdrawn and emotionally aloof. (BMI=15.76kg/m2)) with stable vital signs (=90-100/60-70 mmHg, pulse Examinations and Investigations rate=70-80 bpm) and reduced psychotic Mental state examination on admission symptoms. Despite the improvement, she showed a small-built lady who was soft- never gained insight. Nevertheless, we spoken with superficial rapport. Her affect focused on engaging and educating her was restricted. She had of distorted family. Soon after discharge, monthly depot body image and overvalued ideas on food. intramuscular flupenthixol was added as she Her social judgment and insight were poor. took medications irregularly. She ate more Physical examination showed a thin lady regularly and less of abnormal behavior was (BMI of 14.4kg/m2) with observed. Later, she also managed to secure i.e. (50 beats per minute (bpm)) and fully a part-time job at a boutique. Her current developed secondary sexual characteristics. weight was 39.2 kg (BMI=17.7 kg/m2). Biological investigations showed reduced midcycle peak (LH) Discussion and follicular stimulating hormone (FSH) levels (2.0 IU/L and 6.3 IU/L respectively) Distortion of body image is recognized as and reduced bone mineral density (BMD) one of elementary features of consistent with . schizophrenia10. Such cognition may predispose patients with schizophrenia to an Diagnosis and Treatment course entire spectrum of eating disorders from She was diagnosed to have schizophrenia restrictive to disinhibition. A diagnostic with secondary anorexia nervosa-like dilemma arises from this phenomenology: is symptoms. During the early admissions, she schizophrenia and AN co-exist as co- was started on tablet olanzapine. She morbidity, or is the eating disorder a part of improved and regained weight but stopped Schizophrenia spectrum? While the patient medications after discharge. She relapsed fulfilled diagnostic criteria for both but her family became accustomed to her schizophrenia and AN11, the psychosis odd behavior and accepted it. She never predominated the full clinical picture. The behaved aggressively. However, they psychodynamic drive to starve oneself needs became concern of her physical health as her further exploration, but may be distorted by weight deteriorated. MJP Online Early MJP-01-05-11 the neurochemical imbalances producing In view of the patient’s history of poor psychotic processes in schizophrenia. compliance and insight, her family were engaged and given psychoeducation. She is the youngest in a family whose other was limited to supportive members constantly teased her physical despite few psychodynamic conflicts appearance which disrupted healthy self- identified as the patient was not image at adolescence phase. This might be psychologically-minded. the drive behind her eating disorder. Her mother’s illness and perceived father’s For pharmacotherapy, atypical betrayal of second marriage introduced antipsychotics like olanzapine can be a chaos in the patient’s life. The inferiority of “double-edged sword”. Its use has been having imperfect body image and lack of reported in AN to aid weight gain14 by control in life was compensated by gaining increasing and restricting energy control over own body by starving. Genetic use as sleep improves due to sedation15. vulnerability for psychosis and a fragile However, it might risk adherence as patients personality development with schizoid traits with AN commonly resist . In provided immature coping through this case, although the patient showed no regression and psychotic manifestation. overt resistance to treatment, she had problems with adherence and therefore Interestingly, eating-related cognitive depot antipsychotic was the choice long- dimensions were found to be correlated term therapy. strongly with patients' perceived distress of psychiatric symptoms rather than the References 12 severity of overt psychotic symptoms . This implies that cognitive distortions correspond 1. Ferguson JM, Damluji NF. Anorexia to the patients’ reported distress (caused by Nervosa and Schizophrenia. Int J the symptoms) rather than the degree of Eat Dis 1988; 7: 343-352 psychiatric manifestation. This finding is observed in this patient. She only revealed 2. Cheung P, Wilder-Smith E. Anorexia her experience of having abnormal thoughts nervosa and schizophrenia in a male and hallucinations to others (including the Chinese. Int J Eat Dis 1995; treating doctor and family members) much 18(1):103-106 later after establishment of some rapport. This however, was causing her great distress 3. Cinemre B, Kulaksizoglu B. Case to which she responded by the manifestation Report: Comorbid Anorexia Nervosa of abnormal eating behavior. and Schizophrenia in a Male Patient. Turkish Journal of Psychiatry 2007; In strategizing treatment for the patient, it is 18(1):87-91 important to resolve the diagnostic issue which helped clarifying the treatment 4. Kraepelin E. Praecox and pathway. In cases of severe weight loss, Paraphrenia. Edinburgh: Thoemmes medical stabilization and weight restoration Press; 2002:87 [original published 13 took priority . Once stabilized, we decided 1919] to primarily treat her psychotic symptoms.

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Corresponding Author: Associate Professor Dr. Nik Ruzyanei Nik Jaafar Department of Psychiatry, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaakob Latiff, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia Tel: +603-91456149 Fax: +603-91737841

Email: [email protected]