Psychiatry · Year 2 · from Psychiatry
Case 1: Anorexia Nervosa - Restricting Type
Patient Presentation
Demographics: 17-year-old female
Chief Complaint: "My parents are making me come. I'm fine, just trying to be healthy."
History of Present Illness: A 17-year-old high school junior is brought to the pediatrician by her concerned parents. They report she has lost 35 pounds over the past 6 months, dropping from 130 lbs to 95 lbs at 5'4" (BMI 16.3). She initially started "eating healthy" for cross-country season but progressively eliminated food groups. She now eats only vegetables, drinks large amounts of water, and exercises excessively (running 8-10 miles daily even on rest days). She counts every calorie (eating approximately 600-800 kcal/day) and weighs herself multiple times daily. She wears baggy clothes and complains of being "fat" despite visible bony prominences. She denies binging, purging, or laxative use. She has not menstruated in 4 months. She is an honors student and perfectionist who becomes extremely distressed if she gets anything less than an A. She sees nothing wrong with her eating and says she "feels the best she's ever felt."
Physical Examination:
- Vital signs: BP 88/52 (orthostatic changes present: BP drops to 70/45 standing), HR 48, T 35.8C
- Height: 5'4", Weight: 95 lbs, BMI: 16.3 kg/m2 (severely underweight)
- General: Cachectic-appearing adolescent female, lanugo hair on face and arms
- Cardiac: Bradycardic, no murmurs
- Extremities: Cold, acrocyanotic, no edema
- Skin: Dry, lanugo, hair thinning on scalp
Mental Status Examination:
- Appearance: Emaciated, wearing oversized clothing
- Behavior: Cooperative but defensive about eating
- Mood: "I'm fine"
- Affect: Restricted, anxious when discussing weight
- Thought content: Body image distortion (perceives self as overweight), minimizes seriousness of low weight, preoccupied with food and calories
- Insight: Absent - denies illness severity
- Judgment: Impaired regarding nutritional needs
Workup:
- CBC: Hgb 10.2 (low), WBC 3.2 (low), platelets normal
- CMP: K 3.2 (low), glucose 62 (low), BUN 22, albumin 3.0
- Magnesium: 1.5 (low)
- Phosphorus: 2.8 (low-normal - critical to monitor during refeeding)
- TSH: 1.2, free T4 normal, T3 low (euthyroid sick syndrome)
- ECG: Sinus bradycardia (HR 46), prolonged QTc (480 ms)
- EAT-26: Score 42 (clinical cutoff is 20)
Diagnosis: Anorexia Nervosa, restricting type, severe (BMI <16)
Treatment:
- Meets criteria for medical hospitalization:
- HR <50
- Hypotension with orthostatic changes
- Hypothermia
- QTc prolongation
- Weight <75% ideal body weight
- Admitted to adolescent medicine for medical stabilization
- Refeeding protocol initiated:
- Started at 1200-1400 kcal/day to avoid refeeding syndrome
- Advanced by 200-300 kcal every 2-3 days as tolerated
- Daily electrolytes, especially phosphorus (refeeding can cause dangerous drops)
- Phosphorus supplementation prophylactically
- Continuous cardiac monitoring initially
- Strict meal supervision with 1-hour post-meal observation
- Bed rest initially, activity restrictions
- Once medically stable, transferred to eating disorder program
- Family-Based Treatment (FBT/Maudsley approach) initiated:
- Parents empowered to take control of refeeding at home
- Gradual return of control to patient as weight restored
- Individual therapy addressing perfectionism and body image
- Nutritionist involvement for meal planning
- Target weight: BMI >19 (approximately 111 lbs)
- At 3-month follow-up: Weight 105 lbs, menses resumed, QTc normalized
Clinical Pearl: Anorexia nervosa has the highest mortality rate of any psychiatric disorder (5-10% in hospitalized patients). Medical instability criteria for hospitalization include HR <50, hypotension, hypothermia, electrolyte abnormalities, and QTc prolongation. Refeeding syndrome is a potentially fatal complication - hypophosphatemia can cause cardiac arrhythmias, respiratory failure, and death. Phosphorus, potassium, and magnesium must be monitored closely and repleted. Family-Based Treatment is first-line for adolescents. No medications are FDA-approved for anorexia nervosa.