# Clinical Cases: Somatic Symptom and Eating Disorders

## 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.

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## Case 2: Bulimia Nervosa

### Patient Presentation
**Demographics:** 22-year-old female

**Chief Complaint:** "I can't stop binging and purging. It's ruining my teeth and my life."

**History of Present Illness:** A 22-year-old college senior presents requesting help for her eating disorder. She has been binging and purging for 4 years, beginning during her freshman year. She describes a typical pattern: restricts food during the day, then in the evening experiences an "uncontrollable urge" to eat, consuming large quantities of food (entire pizza, pint of ice cream, bags of chips) within 1-2 hours while feeling completely out of control. Afterward, she feels disgusted and ashamed and induces vomiting "until I see blood sometimes." She binges and purges 5-7 times per week. She has tried to stop many times but cannot control the urges. She exercises excessively and occasionally uses laxatives. Her self-worth is entirely based on her weight and shape; she weighs herself daily and her mood depends on the number. Her weight has fluctuated between 120-140 lbs at 5'5" (BMI 20-23, normal range). She reports that her dentist is concerned about her tooth enamel. She has noticed swelling in her cheeks and sometimes has blood in her vomit. She is embarrassed and has hidden this from family and friends.

**Physical Examination:**
- Vital signs: BP 108/68, HR 78
- Height: 5'5", Weight: 128 lbs, BMI: 21.3 (normal)
- General: Normal weight female
- Oral: Dental enamel erosion, especially on posterior surfaces (from stomach acid)
- Face: Bilateral parotid gland enlargement ("chipmunk cheeks")
- Hands: Calluses on dorsum of right hand (Russell's sign from inducing vomiting)
- Cardiac: Regular rhythm

**Mental Status Examination:**
- Appearance: Normal weight, well-groomed
- Behavior: Embarrassed but engaged
- Mood: "Ashamed, out of control"
- Affect: Anxious, dysphoric
- Thought content: Preoccupied with weight/shape, recognizes binge-purge cycle is harmful
- Insight: Good - motivated for treatment
- Judgment: Impaired around food/eating

**Workup:**
- **CBC:** Normal
- **CMP:** Potassium 2.9 (low from vomiting), chloride 92 (low), bicarbonate 32 (elevated - metabolic alkalosis from vomiting)
- **Amylase:** 180 (elevated - from salivary glands)
- **Magnesium:** 1.6 (low)
- **ECG:** Normal sinus rhythm, no arrhythmia despite low K
- **EDE-Q (Eating Disorder Examination Questionnaire):** Elevated scores across all subscales

**Diagnosis:** Bulimia Nervosa, purging type, moderate (4-7 episodes/week)

**Treatment:**
- Potassium and magnesium repletion
- Started fluoxetine 60 mg daily (FDA-approved for bulimia at this dose)
- Psychoeducation about medical complications and the binge-purge cycle
- Referral for CBT-E (enhanced cognitive behavioral therapy for eating disorders):
  - Self-monitoring of eating, binging, and purging
  - Regular eating pattern (3 meals, 2-3 snacks) to reduce dietary restriction
  - Identifying triggers and developing alternative coping strategies
  - Addressing over-evaluation of shape and weight
- Nutritionist for meal planning support
- Dental referral for enamel evaluation and protection
- At 12-week follow-up:
  - Binge-purge episodes reduced to 1-2/week
  - Electrolytes normalized
  - Mood improved significantly
  - Continuing CBT-E with goal of full remission

**Clinical Pearl:** Bulimia nervosa is characterized by binge eating with compensatory behaviors (purging, laxatives, fasting, excessive exercise) at normal or above-normal weight. The electrolyte pattern of hypokalemic, hypochloremic metabolic alkalosis is classic for purging via vomiting. Fluoxetine 60 mg daily is FDA-approved and effective - notably higher than the typical depression dose. CBT-E is the first-line psychotherapy. Russell's sign (calluses from teeth on knuckles) and parotid enlargement are physical exam clues. Unlike anorexia, patients with bulimia often have good insight and motivation for treatment.

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## Case 3: Somatic Symptom Disorder

### Patient Presentation
**Demographics:** 48-year-old female

**Chief Complaint:** "My stomach has been hurting for 3 years and no one can figure out why. I know something is seriously wrong."

**History of Present Illness:** A 48-year-old woman presents with chronic abdominal pain that has persisted for 3 years. She describes the pain as constant, aching, and located throughout her abdomen. The pain "consumes her life" - she thinks about it constantly, spends hours daily researching possible causes online, and has seen over 15 specialists seeking an explanation. She has undergone extensive workup including 3 CT scans, 2 MRIs, 2 upper and lower endoscopies, multiple labs, and an exploratory laparoscopy - all essentially normal with only minor, non-specific findings. Despite reassurance from every physician that there is no serious disease, she remains convinced something is being missed. She checks her abdomen for lumps multiple times daily and keeps detailed symptom diaries. She has missed significant work and stopped socializing due to her symptoms and the time spent on medical appointments. She experiences significant anxiety about her health and fears she has undiagnosed cancer. She has comorbid depression. Her husband is frustrated with her constant focus on symptoms.

**Physical Examination:**
- Vital signs: Normal
- Abdomen: Soft, diffuse mild tenderness without localization, no masses, no organomegaly, normal bowel sounds
- All prior imaging and endoscopy reviewed - essentially normal

**Mental Status Examination:**
- Appearance: Well-groomed, anxious
- Behavior: Focused on physical symptoms, brought extensive medical records
- Mood: "Worried, frustrated"
- Affect: Anxious
- Thought content: Preoccupied with health concerns, fears of undiagnosed illness, no SI
- Insight: Limited - believes all prior doctors "missed something"

**Workup:**
- **PHQ-15 (somatic symptom severity):** Score 18 (high)
- **PHQ-9:** Score 14 (moderate depression)
- **GAD-7:** Score 12 (moderate anxiety)
- Review of extensive prior workup: No organic cause identified

**Diagnosis:** Somatic Symptom Disorder with predominant pain, severe, persistent

**Treatment:**
- Validated patient's suffering - "Your pain is real and significantly impacting your life"
- Explained diagnosis: The problem is not that nothing is wrong, but that the pain has become the center of her life with thoughts, feelings, and behaviors that have become excessive
- Treatment approach:
  - Regular scheduled visits (every 2-4 weeks) rather than symptom-triggered visits
  - Brief physical exam at each visit for reassurance
  - Limit further diagnostic testing unless new objective findings
  - Focus on function rather than symptom elimination
- Started duloxetine 30 mg, titrated to 60 mg (for pain, depression, and anxiety)
- Referral for CBT focused on:
  - Reducing health-related anxiety
  - Decreasing checking and reassurance-seeking behaviors
  - Gradually increasing activities despite symptoms
  - Cognitive restructuring of catastrophic health beliefs
- Physical therapy for deconditioning
- At 3-month follow-up: Pain unchanged but functional improvement
- No longer researching symptoms online; returned to part-time work
- Accepted that pain may persist but is not life-threatening

**Clinical Pearl:** Somatic symptom disorder emphasizes the excessive thoughts, feelings, and behaviors related to symptoms rather than the symptoms being "unexplained." Patients genuinely suffer and should be validated, not dismissed. Treatment involves regular scheduled visits (not just when symptomatic), limited testing, focus on function over symptom cure, and treating comorbid depression and anxiety. CBT addresses the cognitive and behavioral factors maintaining disability. The therapeutic relationship is essential - patients often feel invalidated by prior providers.

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## Clinical Image

![Medical complications of anorexia nervosa](case_01_image.jpg)

**Image Description:** Diagram illustrating the multisystem medical complications of anorexia nervosa including: cardiac (bradycardia, hypotension, arrhythmias, QT prolongation), endocrine (amenorrhea, hypothermia, low T3), hematologic (leukopenia, anemia), musculoskeletal (osteoporosis), gastrointestinal (delayed gastric emptying, constipation), dermatologic (lanugo, hair loss, dry skin), and electrolyte abnormalities. Refeeding syndrome risk highlighted.

**Attribution:** Educational diagram of anorexia nervosa medical complications. For clinical teaching purposes.

**Image Source:** Create educational diagram or source from medical education resources on eating disorder complications