# Clinical Cases: Eating Disorders

## 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

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## Case 2: Bulimia Nervosa

### Patient Demographics
- **Age:** 22 years old
- **Sex:** Female
- **Occupation:** College senior, pre-law

### Chief Complaint
"I can't stop the binge-purge cycle and I'm scared I'm going to hurt myself."

### History of Present Illness
The patient is a 22-year-old female self-presenting to outpatient psychiatry with a 5-year history of binge eating and purging behaviors. She describes episodes occurring 2-3 times daily where she consumes large amounts of food (2,000-4,000 calories in one sitting), typically in secret, followed by self-induced vomiting. Binge foods include "forbidden" items like pizza, ice cream, and chips. Episodes are triggered by stress (upcoming finals, relationship conflicts) and by periods of dietary restriction. She feels a loss of control during binges, describing it as "like I'm watching myself from outside." After purging, she feels temporary relief but then intense shame and disgust. She has tried to stop multiple times but relapses within days. She is at normal weight (BMI 22), which has allowed her to hide her disorder from others. She reports using multiple methods to compensate for binges including vomiting, laxatives (10-15 daily), and excessive exercise. She has noticed her teeth are "falling apart" and has frequent sore throats. She reports low mood, anxiety about her eating, and social isolation due to shame, but denies suicidal ideation.

### Mental Status Examination

**Appearance:** Well-groomed young woman of normal weight, calluses on dorsum of right hand (Russell's sign), slightly swollen parotid glands, wearing long sleeves

**Behavior:** Cooperative, tearful at times, appears ashamed, maintains eye contact

**Speech:** Normal rate, volume, rhythm

**Mood:** "Disgusted with myself"

**Affect:** Dysphoric, anxious, shame-laden, congruent

**Thought Process:** Linear, goal-directed, some rumination about food and weight

**Thought Content:**
- Preoccupation with shape and weight
- Overconcern about body shape influencing self-esteem
- Shame and self-criticism about eating behaviors
- Desire to stop but feels unable
- No suicidal ideation
- No psychotic symptoms

**Perceptions:** No hallucinations; normal body perception (unlike AN)

**Cognition:** Alert and oriented x4; intact attention and memory

**Insight:** Good - recognizes behaviors are harmful and wants help

**Judgment:** Fair - seeking treatment, continues behaviors despite wanting to stop

### Physical Examination

**Vital Signs:**
- Blood pressure: 108/68 mmHg
- Heart rate: 72 bpm
- BMI: 22 kg/m²

**Pertinent Findings:**
- Russell's sign (calluses on knuckles from inducing vomiting)
- Bilateral parotid hypertrophy ("chipmunk cheeks")
- Dental enamel erosion, multiple cavities
- Pharyngeal erythema
- Petechiae on soft palate

### Medical Workup

**Laboratory Studies:**
- CMP: K+ 2.8 mEq/L (hypokalemia from purging), Cl- 92 (hypochloremia), HCO3- 32 (metabolic alkalosis)
- CBC: Within normal limits
- Amylase: 168 U/L (elevated from parotid hypertrophy)
- BUN: 24 (elevated - dehydration)

**ECG:**
- Sinus rhythm at 74 bpm
- U waves present (sign of hypokalemia)
- QTc: 450 ms (slightly prolonged)

### Diagnosis

**Bulimia Nervosa, Moderate (F50.2)**

**DSM-5 Criteria Met:**
A. Recurrent episodes of binge eating characterized by:
   - Eating large amounts of food in discrete time period (>2000 kcal)
   - Sense of lack of control during episodes
B. Recurrent inappropriate compensatory behaviors to prevent weight gain:
   - Self-induced vomiting (2-3x daily)
   - Laxative abuse (10-15 daily)
   - Excessive exercise
C. Binge eating and compensatory behaviors occur at least once weekly for 3 months (currently 2-3x daily x 5 years)
D. Self-evaluation unduly influenced by body shape and weight
E. Disturbance does not occur exclusively during episodes of anorexia nervosa

**Severity:** Moderate (8-13 episodes of compensatory behaviors per week)

**Medical Complications Present:**
- Hypokalemia with metabolic alkalosis (purging)
- Dental erosion
- Parotid hypertrophy
- Dehydration

### Treatment Plan

**Pharmacotherapy:**
- Fluoxetine 60 mg daily (FDA-approved for bulimia nervosa, higher dose than depression)
- Start at 20 mg, titrate over 2 weeks
- Reduces binge-purge frequency and improves mood

**Psychotherapy - Cognitive Behavioral Therapy for Eating Disorders (CBT-E):**
- First-line psychological treatment for bulimia nervosa
- 20 sessions over 20 weeks
- Focus on:
  - Self-monitoring of eating behaviors
  - Establishing regular eating patterns
  - Addressing dietary restraint
  - Cognitive restructuring of shape/weight concerns
  - Relapse prevention

**Alternative Psychotherapy Options:**
- Interpersonal Therapy (IPT) if CBT-E not effective
- DBT for patients with significant emotional dysregulation

**Nutritional Counseling:**
- Work with registered dietitian experienced in eating disorders
- Establish regular meal pattern (3 meals, 2-3 snacks)
- Challenge food rules and forbidden foods
- Address restriction that drives binge-purge cycle

**Medical Management:**
- Potassium supplementation until normalized
- Dental referral for enamel erosion
- Monitor electrolytes weekly initially

**Safety:**
- Laxative taper (sudden cessation can cause rebound edema)
- Education about medical risks of purging
- Harm reduction if unable to fully stop (safer alternatives)

**Follow-up:**
- Psychiatry in 2 weeks for medication adjustment
- Weekly CBT-E sessions
- Dietitian weekly initially
- Labs in 1 week

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## Image Attribution

![Eating Disorders Illustration](case_01_image.jpg)

*Image: Medical illustration showing physical manifestations of eating disorders. Source: Wikimedia Commons. Used for educational purposes under Creative Commons license.*