CASE REPORT

ANOREXIA NERVOSA

SUBMITTED BY:
LADY JOWAHER ALLAS RN

SUBMITTED TO:
ALFREDO Z. FELICIANO, RN, PhD
INTRODUCTION

People with eating disorders experience severe disruption in normal eating patterns and severe
disruptions in perception of body shape and weight. Unlike most psychiatric conditions, these disorders
can cause severe physiological damage.

The diagnosis of Anorexia Nervosa is based on the psychological and physical criteria. According to the
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Diagnostic and Statistical Manual of Mental Disorder 5 edition (DSM 5), Diagnostic Criteria include: (A)
restriction of energy intake relative to requirements, leading to a significantly low body weight in the
context of age, sex, developmental trajectory, and physical health. (B) Intense fear of gaining weight or
becoming fat, or persistent behavior that interferes with weigh gain. (C) Disturbance in the way in which
one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation,
or persistent lack of recognition of the seriousness of the current low body weight. Behaviors such as self-
induced vomiting and misuse of laxatives, diuretics and enemas may lead to abnormal laboratory finding;
limited social spontaneity, preoccupied with thoughts of food and suicidal tendencies. Persons may also
exhibit fluctuating factors of weight gain and relapses. Unresolved complications may even lead to death.

Types:

 Restricting Type: During the last 3 months, the individual has not engaged in recurrent episodes
of binge eating or purging behavior. Weight loss is primarily accomplished through dieting,
fasting, and/or excessive exercise.
 Binge-eating/purging type: During the last 3 months, the individual ha engaged in recurrent
episodes of binge eating or purging behavior

Associated features include:

 Emaciated

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Low body weight of equal or less than 17 kg/m for adults and less than 5 percentile for children
and adolescent
 Amenorrhea
 Hypotension, hypothermia, bradycardia
 Lanugo
 Petechia or ecchymosis
 Yellowish of the skin
 Dental enamel erosion
 Hypertrophy of salivary glands
 Peripheral edema upon weight restoration or laxative cessation

Risk Factors

 More common in female

 onset in adolescent and young adult
 Genetics (Family History of psychiatric disorder)
 Culture
 Psychiatric Co-morbidity

The management of the disorder calls for the involvement of a multidisciplinary approach. This case
report describes an adolescent patient presenting with anorexia nervosa.

CASE REPORT

This is a case of Ms. L, a 17 year old female, single, and a grade 12 student. She was brought by her
parents with complains of menstrual irregularities and amenorrhea since 6 months and gradual loss of
weight. With symptoms of weight loss and amenorrhea, she was evaluated by a physician. A series of
history taking and investigations were conducted. Laboratory results show anemia and electrolyte
imbalances.

She was further evaluated by a gastroenterologist; an intestinal biopsy was done to rule out
malabsorption syndrome. Gynecological opinion was taken in the background of amenorrhea and
investigations show low estrogen levels. Thus no clear cut cause could be established to the loss of
weight. The patient was referred to psychiatric consultation by her treating physician as she appeared dull
inactive and less cheerful.

During psychiatric interview she had easy fatigability, low mood, pessimistic, decreased attention and
concentration. Further information was elicited and she revealed dieting for 9 months and avoided foods
that are high in fat. She frequently missed breakfast and lunch. During dinner, she would secretly put the
food in plastic bag and threw it into the dustbin and at times hide and eat, and or would secretly go into
the bathroom and induce vomiting. She admits the use of laxatives. No suicidal ideas were reported. She
perceived herself as ‘fat’. Prior to this problem, her elder brother used to tease her that she was ‘fat’. She
also experienced low self-esteem as she believed that she was not pretty and was not happy with her
self-image.

Ms. L is the youngest of the two siblings. She described her father as a strict and over-protective parent.
She was not able to express herself well and often repressed her feelings. She had difficulty in
communicating with her father and her elder brother.

Her parents described her as someone who was rather perfectionist. She was above average student
academically but she aimed to achieve better results in the future. She denied any symptoms of
depression. There was no family history of eating disorder.

Further clinical examination revealed an emaciated girl with a body weight of 35.9 kg and height 1.52m
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and BMI of 15.5 kg/m . She had lanugo hair. Vitals were stable and further blood investigations shows
FSH and LH and oestradiol values were low, pelvic ultrasound and ECG showed no abnormality.
Diagnosis of Anorexia nervosa was made. She was admitted for inpatient care and started immediately
on IV fluids. Initially she developed facial edema that gradually reduced with fluid redistribution. A
multidisciplinary team approach was employed. Psychotherapy and cognitive behavioral therapy were
structured. Nutritional rehabilitation was planned, where she was asked to maintain a diary about her
intake of food. She was encouraged to eat food with high caloric value. Parents were involved in the
therapeutic process and was asked to keep a watch on her purging behavior. The patient was given a low
dose of Olanzapine. Her weight gain after 1 week was 1 kg. Ms. L gradually became cooperative for
treatment process. She was subsequently discharged and a follow up for every 2 weeks as outpatient.
She was referred to the dietician for dietary advice, psychologist for further counseling and child
psychiatrist for any problems and further management. During the follow-up, she progressed well and her
weight increased gradually. She achieved a BMI of 18 and began menstruating again after two years. Her
eating habits and negative thoughts also improved with the psychological intervention given.

DISCUSSION

Multiple specialist opinions were taken to ascertain the cause of symptomatology of Ms. L condition. With
no clear cut causal factor, the case was referred for psychiatric evaluation. Ms. L was diagnosed of
Anorexia Nervosa based on Diagnostics and Statistical Manual of Mental Disorder (DSM 5). She fulfilled
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all the criteria with associated signs and symptoms. A BMI of 15.5 kg/m indicates she is underweight,
avoidance of fatty foods, body image distortion, amenorrhea, anemia, electrolyte imbalances, abnormal
levels of FSH, LH, oestradiol, and estrogen levels, presence of lanugo, anxiety and depression as co-
morbidty is also present. Risk factors such as being female of 17 years of age (adolescent),
overprotective parents (culture). The affected adolescent were described as frustrated children who feel
unable to challenge their parents thus developing repressed feelings. Some described as perfectionist
have low self-esteem. Poor communication and dysfunctional interactions are also known to have a role
in etiology. Ms. L had all the features above except for family history of eating disorder.
Ms. L was managed with the help of other disciplines which included a dietician, psychologist and
psychiatrist. The principle of management with anorexia nervosa includes: i) weight restoration, ii)
psychological intervention, iii) medication if necessary and iv) long term follow-up to avoid
relapse. Teaching patients how to eat is the primary importance in the treatment, thus she was referred to
a dietician. had to fill in a weight diary which required the physician to weigh her twice weekly and monitor
her closely to ensure that she complies with the management.
Psychological intervention includes supportive therapy, behavioral intervention, initial assessment for
patient’s insight, motivation for recovery and resolving family conflicts. In addition, psychoeducation to
patient and family as well as family involvement and support are crucial to help the patient to progress.
Behavioral intervention is necessary to improve eating habits and negative thoughts towards her body
image. It also helps her to be more flexible in thinking. Medication was necessary as she have
depression.
The role of the primary care physician is to assess medical complications, monitor weight and nutritional
status, assist in the management strategies of other team members and serve as the care co-ordinator.
Long term follow-up is necessary to ensure the patient achieves the target weight which is 95-100% of
average body weight for height and age and to prevent relapse. During the follow-up the physician should
assess for complications such as hypotension, arrhythmia, electrolyte imbalance, kidney dysfunction,
constipation, elevated liver enzymes, haematological abnormalities, seizures, peripheral neuropathies
and endocrine abnormalities such as osteoporosis and amenorrhoea. If complications occur, appropriate
management should be given and referral to other specialists is indicated.
By reporting the particular case, it must be caught to attention of general practitioners and other medical
practitioners to be aware of the symptomatology of eating disorders as most patients would overtly
express somatic conditions similar to the reported case. Such awareness would have called for an earlier
psychiatric intervention and curbed other unnecessary investigations.

CONCLUSION

When an individual is diagnosed with eating disorder, numerous things must be taken into account and
intervention options can vary. Anorexia Nervosa is a known healthcare problem seen among young
people in the community. Anorexia Nervosa often requires long term treatment and follow-up; success in
treatment varies, but early recognition and treatment increase chances for recovery.

To reduce the magnitude of disturbances this disorder can have on the individual, the family and society,
it is critical that practitioners complete a thorough diagnostic assessment, treatment plan, and practice
strategy that can efficiently embrace, identify, and effectively treat individuals who suffer from anorexia
nervosa.

Nursing care is focused on keeping the client safe, facilitating or providing treatment for medical
problems, and providing adequate nutrition and hydration. Other therapeutic goals including decreasing
the clients’ depressive, manipulative, or regressive behavior and preventing secondary gain. It is
important to remain focused on the client’s eventual discharge. Family-related factors such as support
and willingness for treatment assistance are an important dynamic that should always take into account to
facilitate treatment success.
 REFERENCES

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American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. (5 ed.).
American psychiatric Association Publishing.

Srinivasa,P., Chandrashekar, M., Harish,N., Gowda,M., & Durgiji, S.(2015). Case Report on Anorexia
Nervosa. Indian Journal of Psychological Medicine, 37(2), 236-238.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4418263/

Khairani, O., Majmin, S.H., Saharuddin, A., Loh, S.F., Azimah, N.M., & Tohid, H. (2011). An Adolescent
with Anorexia Nervosa- A Case Report. Malaysian Family Physician ,6(2-3),79–81.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4170427/