You are considering treating a 21-year-old female with a history of anorexia nervosa and depression with an antidepressant.
Which one of the following should you avoid?
Correct Answer D:
Phenelzine is a monoamine oxidase inhibitor (MAOI). It can interact with certain foods that have a high tyramine content (such as wine, cheese) and cause severe side effects such as a hypertensive crisis.
Therefore, dietary restrictions must be made for a patient placed on an MAOI. This would not be appropriate in a patient already suffering from anorexia nervosa.
Once the diagnosis of anorexia nervosa is established, the most important initial goal of treatment is:
Correct Answer A:
Once the diagnosis of anorexia nervosa is confirmed, the initial goal of treatment is to prevent death by starvation. Depression, a common finding in anorexia nervosa, is usually alleviated with nourishment. In cases that are refractory to proper nutrition, an antidepressant may be helpful. Psychotherapy, using a combination of behavioral and cognitive techniques, is an important adjunctive therapy. It begins when the diagnosis is established and continues after the patient has returned to normal weight. Family therapy is also recommended in younger patients. It facilitates recovery in the individual by addressing problems in the family environment and also often continues for years after the patient’s return to normal weight.
Each of the following statements about anorexia nervosa is true, except:
Anorexia nervosa (AN) has been observed in both the very young and very old, but the disorder is primarily a phenomenon of puberty and early adulthood. 85% of patients have onset of the disorder between the ages of 13 and 18 years. Patients who are older at the time of onset of the disorder have a worse prognosis.
→ AN is much more common in women, especially in social and vocational environments demanding thinness, such as dancing, modeling, and athletics.
→ Typically reluctant or secretive about their illness, the presence of amenorrhea may be a suspicious clue for the primary care physician to pursue other associated symptoms and behaviors.
→ Obsessive-compulsive traits and depression are common comorbid conditions.
→ It is not unusual for family or friends to bring the anorectic for evaluation due to family concerns rather than the patient’s concern.
An 18-year-old female is brought to your department by her worried parents, because of her missed menstrual periods for the last 4 months and a very low weight. On questioning, the patient says that she has no appetite, denies any vomiting, and says that she is more interested in exercise to stay fit because she thinks she is “still super fat.” She denies laxative use. She reports having a boyfriend but she is not sexually active. Physical examination reveals a BMI of 15 kg/m2, dry skin, and cold hands.
Which of the following is most likely to be present in this patient?
This patient’s diagnosis is most likely anorexia nervosa. The DSM-V criteria for diagnosing anorexia nervosa include refusal to maintain appropriate body weight, intense fear of becoming fat, undue influence of body weight or shape on self-evaluation, and amenorrhea.
Anorexia nervosa can have serious implications if its duration and severity are significant. Medical complications resulting from semi-starvation and overexercising affect virtually every organ system. Common signs and symptoms include loss of subcutaneous fat tissue, orthostatic hypotension, bradycardia (choice A), impaired menstrual function, hair loss, and hypothermia.
→ Elevated serum FSH (choice B) is incorrect. Amenorrhea in anorexia nervosa is caused by the hypothalamic pituitary axis failure and is characterized by low levels of FSH.
→ Elevated serum beta hCG (choice C) would be seen in amenorrhea due to pregnancy or trophoblastic neoplasias.
→ Hypoalbuminemia (choice D) is incorrect. Albumin and protein levels are usually normal.
→ Shortened QT interval on ECG (choice E) is incorrect. Anorexia nervosa is associated with hypocalcemia and prolonged QT interval on ECG.
Key point:
The diagnosis of anorexia nervosa includes refusal to maintain appropriate body weight, intense fear of becoming fat, undue influence of body weight or shape on self-evaluation, and amenorrhea. Anorexia nervosa is associated with bradycardia and orthostatic hypotension.
What is the definition of a delusion?
The Diagnostic and Statistical Manual of Mental Disorders (DS) defines a delusion as:
A false belief based on incorrect inference about external reality that is firmly sustained despite what almost everybody else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary.
A visual hallucination involves sight, which may consist of formed images, such as of people, or of unformed images, such as flashes of light.
An aura is a premonitory, subjective brief sensation (e.g., a flash of light) that warns of an impending headache or convulsion.
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