[ Pobierz całość w formacie PDF ]
.The patient claims that her parents are worrying about nothing andthat she has come to the office just to appease them.She states that shefeels fine, although her mood is slightly depressed.She denies havingproblems with sleeping or appetite and with any kind of drug or alcoholabuse.She says that she thinks she looks fat, but that if she could loseanother couple of pounds, she would be just right. She notes that heronly problem is that she stopped having her period 3 months ago; she isnot sexually active and therefore cannot be pregnant.When questioned separately, the parents report that the patient hasbeen steadily losing weight over the past 8 months.They say that shestarted dieting after one of her friends commented that she looked alittle plump. At that point, they noted that their daughter weighedapproximately 120 lb.The patient lost 5 lb and, according to the par-ents, felt good about the comments made by her friends.Since thattime, she has eaten less and less.She now dresses in baggy clothes anddoes not discuss with her parents how much she weighs.Despite this,she helps her mother cook elaborate meals for party guests when thefamily entertains.She exercises throughout the day, and her parents saythey can often hear her doing jumping jacks and sit-ups in her room inthe evening.On physical examination, the patient is found to be 5 ft 2 intall; she weighs 70 lb and appears cachectic.¤' What is the most likely diagnosis?¤' What are the next therapeutic steps? 358 CASE FILES: PsychiatryANSWERS TO CASE 44:Anorexia NervosaSummary: A 17-year-old girl appears in a psychiatrist s office grossly under-weight.Despite this, she denies having any problems other than being mildlydepressed, and she has not come to the office willingly.She views herself asoverweight despite obvious appearances to the contrary.Her parents note thatshe has increasingly restricted her intake of calories and exercises excessively.She has been amenorrheic for the past several months.¤' Most likely diagnosis: Anorexia nervosa.¤' Next steps: The patient would benefit from hospitalization, but it isunlikely that she will agree.However, because she is 17 years old, her parentscan sign her into a hospital without her consent.Her initial treatmentshould be aimed at restoring her nutritional status, as she is grosslymalnourished.Dehydration, starvation, and electrolyte imbalances must becorrected.The patient should be weighed daily, and her daily fluid intakeand output should be monitored.Therapy (behavioral management,individual psychotherapy, family education, and group therapy) should alsobe started, but her unstable nutritional status needs to be addressed first.ANALYSISObjectives1.Recognize anorexia nervosa in a patient.2.Make recommendations about the hospitalization, initial and longer termtreatment of a patient with anorexia nervosa.ConsiderationsThis patient meets all four criteria for anorexia nervosa: First, she has a refusalto maintain her body weight above a minimally normal level for her age.Thisyoung woman is in need of immediate hospitalization, as her weight (70 lb) is64% of the normally expected weight for her height (110 lb).Second, she hasdisturbance in the way her shape and body weight is perceived and a denial ofthe seriousness of her current low body weight.Her dieting began after sheheard a derogatory comment about her weight, and it has accelerated over thepast 8 months.The patient, despite being quite cachectic, believes herself tobe fat and wants to lose still more weight.Third, her intense fear of gainingweight is consistent with anorexia nervosa.Finally, the weight loss hascaused amenorrhea.She is not interested in psychiatric treatment and deniesthat there is anything wrong with her other than a mildly depressed mood; CLINICAL CASES 359this is commonly seen in patients with anorexia.Despite severely restrictingher caloric intake, she seems very much interested in food and its preparation.She exercises excessively as well.Individuals with this disorder are often dif-ficult to treat; they deny their behavior and try to mislead their parents orphysicians.This patient has the restricting type of the disorder.Anorexianervosa can also present with a pattern in which the patient binge eats andthen uses vomiting, laxatives, diuretics, and enemas to lose weight.Although not part of the official Diagnostic and Statistical Manual of MentalDisorders, 4th edition (DSM-IV) criteria, these patients tend to be perfection-istic high achievers, who are socially withdrawn and have a poor self-concept.The anorexia is often an attempt to gain a sense of control over their lives asthey are going through the physical and emotional changes of adolescence.APPROACH TOAnorexia NervosaDEFINITIONSAMENORRHEA: Absence of at least three consecutive menstrual cycles.ANORECTIC ABNORMAL BODY WEIGHT: Body weight that is less than85% of normal for age and produced by conscious weight loss efforts.LANUGO: Fine body hair present on prepubertal children and commonlyseen in patients with anorexia.CLINICAL APPROACHThere is a strong female predominance of individuals with eating disorders.Anorexia nervosa is observed as either a food-restricting or a binge-eating/purgingsubtype.A strong distortion of body image is present, and even at an extremelylow weight, patients believe they are overweight.In addition, there is agreat deal of evidence that family functioning may play an important rolein the development of this disorder.A good family assessment is essentialto treatment.Table 44 1 lists the diagnostic criteria.Anorexia nervosa is rarein non-Western societies, and immigrants who move from these societies tothe Western cultures (and adopt Western concepts of female thinness as beingdesirable) have much higher incidences of anorexia.DIFFERENTIAL DIAGNOSISWeight loss caused by a general medical condition should be listed first on thedifferential diagnosis.Many medical conditions cause weight loss and must beruled out prior to the initiation of treatment for anorexia nervosa.Major 360 CASE FILES: PsychiatryTable 44 1 DIAGNOSTIC CRITERIA FOR ANOREXIA NERVOSARefusal to maintain weight at or above the normal weight for one s age and height(85% of expected weight caused either by weight loss or by lack of expectedweight gain).Intense fear of gaining weight or becoming fat despite being underweight.Disturbance in the way one s body weight or shape is experienced, undue influence ofbody weight or shape on self-evaluation, or denial of the severity of the current lowbody weight.In females who are beyond menarche, amenorrhea may be present.depressive disorder can be associated with weight loss caused by a decreasedappetite; however, patients with this disorder are not concerned about theirbody image and readily admit that they have not put any effort into achiev-ing the weight loss.If the decreased food intake is caused by odd or paranoidthoughts, then schizophrenia and obsessive-compulsive disorder must be con-sidered
[ Pobierz całość w formacie PDF ]