(108) Identify Quickly, Intervene Effectively- Medically, Psychiatrically, and Ethically Complex Care of Anorexia Nervosa in an Early Adult Female

Abstract:

Background: Anorexia nervosa is the most life-threatening psychiatric disorder and can present with a combination of medical and psychiatric symptoms (Westmoreland, 2016). We present a case of severe anorexia nervosa in an adult at a pediatric hospital who exhibited signs of psychosis, catatonia, and delirium, in the context of severe premorbid anxiety. There are few published case reports on presentations of anorexia with catatonia and psychosis, and no randomized control trials discussing effective treatment.



Case: A 19-year-old college female with anorexia nervosa, anxiety, obsessive compulsive tendencies, was admitted for severe malnutrition with a BMI of 13, bradycardia, and low motivation for treatment. Parents obtained temporary guardianship to permit lifesaving treatment. A nasogastric tube was placed for nutritional rehabilitation. Early in the hospitalization she began independently consuming adequate meals. Concurrently, she began exhibiting paranoia, incontinence, verbigeration, schizophasia, echolalia, stereotypies and appeared to respond to internal stimuli. She was hyper-religious, physically aggressive towards her father, and sexually preoccupied with both him and physicians. Intensity and frequency of inappropriate and childlike behavior escalated for discrete periods surrounding examinations by clinicians. The Cornell Assessment of Pediatric Delirium screen was negative. The Busch Francis Catatonia Rating Scale was positive with a partial response to lorazepam challenge. Olanzapine was started to address sleep disturbances concerning for acute mania with potential auxiliary benefit of weight gain. She benefited from a multidisciplinary approach to safe refeeding management and supportive and cognitive behavioral therapy by psychiatry and ancillary services. While resistant to long-term eating disorder treatment at the time of discharge, her insight had improved. She was medically stable, and despite some residual impairments in attention, mentation was largely restored.



Discussion: In such a psychiatrically complex case, accurate diagnosis was essential for identification of appropriate intervention as the respective treatments could exacerbate the symptoms of the alternative etiologies. Literature postulates that compulsory treatment of anorexia can worsen the patient’s disease by creating a fixation on perceived loss of control (Sawhill, 2020). This was demonstrated by our patient’s behavioral and psychological regression. Her lack of capacity was ostensibly attributable to the cognitive rigidity and para-delusional nature of distorted beliefs that is characteristic of anorexia and compounded by the neurocognitive vulnerabilities inherent in severe malnutrition and re-feeding (Westmoreland, 2016).



Conclusion: Acute management of severe anorexia nervosa requires a multidisciplinary and systematic evaluation of both medical and psychiatric factors affecting the patient’s presentation to arrive at the most effective treatment.



References:

Sawhill, C., Fipps, D. C., Palomo, J. V., & Miller, M. (2020). End-stage anorexia nervosa: When to say “when”—a literature review of an ethically complicated case. Psychosomatics, 61(6), 779–786

Westmoreland, P., Krantz, M. J., & Mehler, P. S. (2016). Medical Complications of Anorexia Nervosa and Bulimia. Am J Med, 129(1):30-7