Psychiatry · Year 3 · from Psychiatry
Case 1: Anorexia Nervosa, Restricting Type
Patient Demographics
- Age: 17 years old
- Sex: Female
- Occupation: High school junior, competitive dancer
Chief Complaint
"My parents made me come. I don't think anything is wrong."
History of Present Illness
The patient is a 17-year-old female brought by her parents for psychiatric evaluation after her dance instructor expressed concern about her weight loss. Over the past 8 months, she has lost 35 pounds, going from 125 lbs to 90 lbs at 5'5" (BMI 15.0). Her parents report she has become increasingly restrictive with eating, eliminating entire food groups (carbohydrates, fats), and obsessively counting calories (limiting to 400-600 calories daily). She exercises 3-4 hours daily, including before school and late at night. She wears baggy clothing to hide her body and becomes agitated when family members comment on her weight. She admits to intense fear of gaining weight, stating "I feel huge even though everyone says I'm thin." She denies purging behaviors but acknowledges using laxatives "occasionally" and excessive water intake before weigh-ins. She reports amenorrhea for the past 5 months. Despite her severe malnutrition, she believes she needs to lose more weight to "be a better dancer." She denies suicidal ideation but expresses passive thoughts that "it wouldn't matter if I disappeared."
Mental Status Examination
Appearance: Cachectic adolescent female, lanugo hair visible on face and arms, dry skin, brittle nails, wearing oversized sweater despite warm room temperature, prominent zygomas and clavicles
Behavior: Cooperative but guarded about eating behaviors, fidgeting, difficulty sitting still (may be related to hyperactivity associated with AN)
Speech: Normal rate, soft volume, becomes defensive when discussing weight
Mood: "Fine" (minimizing)
Affect: Anxious, constricted, becomes tearful when discussing possibility of gaining weight
Thought Process: Linear but rigid, obsessional quality around food and weight
Thought Content:
- Intense fear of weight gain (ego-syntonic - does not see as problematic)
- Body image disturbance (feels fat despite emaciation)
- Preoccupation with calories, food, exercise
- Passive suicidal ideation without plan
- No psychotic symptoms
Perceptions: Body dysmorphic perceptions (sees self as overweight in mirror); no hallucinations
Cognition: Alert and oriented; attention somewhat impaired (possibly related to malnutrition); memory intact
Insight: Poor - does not recognize illness severity
Judgment: Poor - continued restriction despite medical consequences
Physical Examination
Vital Signs:
- Blood pressure: 88/52 mmHg (orthostatic drop to 72/48 on standing)
- Heart rate: 48 bpm (bradycardia)
- Temperature: 96.2°F (hypothermia)
- BMI: 15.0 kg/m² (<75% ideal body weight)
Pertinent Findings:
- Lanugo hair on face, arms, back
- Dry, yellow-tinged skin (hypercarotenemia)
- Brittle hair with temporal hair loss
- Dental erosion (despite denial of purging)
- Muscle wasting
- Peripheral edema (mild)
- Cold, mottled extremities
Medical Workup
Laboratory Studies:
- CBC: WBC 3.2 (leukopenia), Hgb 10.8 (mild anemia)
- CMP: K+ 2.9 mEq/L (hypokalemia), glucose 58 mg/dL (hypoglycemia), BUN 28 (elevated)
- Phosphorus: 2.2 mg/dL (low - refeeding risk)
- Magnesium: 1.4 mg/dL (low)
- TSH: 0.8 mIU/L (low-normal, sick euthyroid)
- Free T4: Low-normal
- Estradiol: <20 pg/mL (low - amenorrhea)
- LH/FSH: Suppressed
- Albumin: 3.0 g/dL (low)
- Lipid panel: Total cholesterol 248 (paradoxically elevated in AN)
- Amylase: 142 (elevated - concerning for purging despite denial)
ECG:
- Sinus bradycardia at 46 bpm
- Prolonged QTc: 480 ms (risk for arrhythmia)
DEXA Scan:
- Lumbar spine T-score: -2.8 (osteoporosis)
Diagnosis
Anorexia Nervosa, Restricting Type, Severe (F50.01)
DSM-5 Criteria Met: A. Restriction of energy intake leading to significantly low body weight (BMI 15.0, <75% expected) B. Intense fear of gaining weight or becoming fat, despite being underweight C. Disturbance in the way body weight/shape is experienced (feels "huge"), undue influence of weight on self-evaluation, persistent lack of recognition of seriousness
Subtype: Restricting - no binge eating or purging in past 3 months (though laxative use and elevated amylase warrant monitoring)
Severity: Severe (BMI 15.0, <15 kg/m²)
Medical Complications Present:
- Severe malnutrition with electrolyte abnormalities
- Bradycardia with prolonged QTc
- Orthostatic hypotension
- Hypothermia
- Amenorrhea
- Osteoporosis
- Hypoglycemia
Treatment Plan
Acute Management - Inpatient Medical Stabilization:
- Criteria for medical hospitalization met (HR <50, orthostatic changes, QTc prolongation, electrolyte abnormalities)
- Admit to medical unit with psychiatric consultation
- Continuous cardiac monitoring
- Strict intake/output
- Supervised meals
Nutritional Rehabilitation:
- Start refeeding at 1200-1400 kcal/day (lower start due to refeeding syndrome risk)
- Increase by 200-300 kcal every 2-3 days as tolerated
- Monitor phosphorus, magnesium, potassium BID during refeeding
- Supplement electrolytes as needed
- Thiamine supplementation
- Target weight gain: 2-3 lbs/week inpatient
Pharmacotherapy:
- No medications proven to treat core AN symptoms
- Avoid medications that may prolong QTc until ECG normalizes
- Consider low-dose olanzapine after medical stabilization (may help with weight restoration and anxiety)
- Calcium and Vitamin D for bone health
Psychotherapy (After Medical Stabilization):
- Family-Based Treatment (FBT/Maudsley approach) - first-line for adolescents
- Parents empowered to take control of refeeding
- Three phases: weight restoration, return of control to adolescent, adolescent identity development
- Consider individual CBT-E (Enhanced CBT for Eating Disorders) as adjunct
Disposition:
- Medical hospitalization until vitals stable, electrolytes normal, tolerating oral intake
- Transition to residential eating disorder treatment program
- Minimum 3-month treatment expected