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Keywords:

  • anorexia nervosa;
  • antipsychotics;
  • schizotypal personality disorder

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. CASE REPORT
  5. DISCUSSION
  6. REFERENCES

Abstract  Schizotypal personality disorder (SPD) has rarely been reported as an eating disorder-related personality trait. A 23-year-old woman was diagnosed as having anorexia nervosa binge eating/purging type. At the age of 53 years, she was admitted to Jikei University Hospital because of excessive bodyweight loss. She was diagnosed as having SPD based on bizarre behavior, ideation and a tendency to seek isolation. She was treated with low-dose antipsychotics, and her impulsive behavior improved. The patient's SPD was considered to have had a psychopathological contribution to her chronic episodes of anorexia nervosa.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. CASE REPORT
  5. DISCUSSION
  6. REFERENCES

The personality traits associated with anorexia nervosa (AN) are perfectionism, obsessive–compulsiveness, neuroticism, negative emotionality, harm avoidance, low self-directedness, low cooperativeness, and traits associated with avoidant personality disorder (PD).1,2 However, only a few reports on the comorbidity of AN and cluster A personality disorders (PD), such as SPD, have been published.

In the present case, the authors describe a patient with chronic anorexia nervosa and comorbid SPD who exhibited a mild neurocognitive disorder supervened by secondary organic changes during the chronic course of anorexia nervosa. Such comorbidity has not been previously described in medical literature. To preserve patient privacy, all personal information has been altered. Written informed consent was obtained from the patient.

CASE REPORT

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. CASE REPORT
  5. DISCUSSION
  6. REFERENCES

The patient had not experienced any specific problems in growth, development, or with her school grades but had difficulty forming friendships and tended to seek isolation. She was interested in psychic phenomena and had been superstitious since her early childhood. Her father's sister had been diagnosed as having schizophrenia. The patient's parents and sister did not have any mental illnesses or eating disorders, but her parents often argued. When she was 17 years old, she began to worry about her bodyweight of approximately 60 kg (height, 160 cm); she started dieting because her peers had remarked about her bodyweight. At first, she restricted her intake of food, but then she began to overeat and purge repeatedly after gradually beginning to feel an unusual feeling of bodily discomfort whenever she ate food.

At the age of 23 years, she quit her job because she could not stop purging during the daytime. At that time, her bodyweight had decreased to 35 kg and she had also begun using purgatives. She was admitted to a hospital and was diagnosed as having AN. Despite being hospitalized for about 1 year, she could not maintain her bodyweight or stop overeating and purging.

At the age of 32 years, her bodyweight had decreased to 28 kg. She requested to be readmitted to ahospital and received behavior therapy focusing on appropriate weight gain and the observation of her caloric intake in addition to treatment with antidepressant or anxiolytics. Although she had repeated remissions and relapses, her bodyweight had increased to 50 kg at the age of 34 years. After that period of hospitalization, she began to live in a public dormitory as a live-in caregiver and was able to maintain her bodyweight at approximately 50 kg for approximately 15 years, with no overeating or purging impulses.

At the age of 50 years, the dormitory was closed and she began to live by herself. Her impulse to overeat and purge with the use of purgatives reappeared, and her bodyweight destabilized. She was consecutively admitted and discharged from several different hospitals.

At the age of 53 years the patient, who had an introduction letter from a psychiatry clinic, was admitted to Jikei University Hospital for the first time. She presented with excessive bodyweight loss, dehydration, and renal failure. Her bodyweight was 35.9 kg (height, 159 cm; body mass index, 14.2), and her emaciation and odd appearance were noticeable. For example, her hair reached her hip and she wore ragged clothes. She always complained of discomfort whenever she ate or drank, and she could not suppress her impulses and secretly defecated at her bedside or in other inappropriate locations. However, she strongly hoped that her bodyweight would reach an appropriate value. She was also overly suspicious of other people and tended to withdraw into herself. However, she did not have any noticeable delusions or hallucinations. She complained about subjective forgetfulness, and she scored slightly low on neuropsychological tests, digit span, trail making tests A and B, and seven serial tests. Her Mini-Mental State Examination score was 26 points (attention, delayed memory, design copying); no signs of dementia were observed. Laboratory findings showed severe dehydration: BUN, 6.1 mg/dL; Cr, 2.7 mg/dL; Na, 124 mEq/L; and K, 2.8 mEq/dL. Magnetic resonance imaging scans of her brain revealed a slight atropy in the temporal lobe cortex and myelinolytic changes: low intensities on T1-weighted images and high intensities on T2-weighted images of the central pontine and bilateral anterior nuclei of the thalamus (AN) were observed. 99mTc-ECD single-photon emission computed tomography showed hypoperfusions of relative cerebral blood flow in the pons and bilateral anterior cingulate gyri. Her dehydration and general condition gradually improved with fluid hydration, and the oral intake of foods was begun.

Although her bodyweight increased to 37 kg, she developed obsessive ideation regarding her bodyweight and her impulsive behavior reappeared. Over the course of other hospitalizations, she had been treated with the antidepressant mianserin and the selective serotonin reuptake inhibitors paroxetine and olanzpine. The authors began her treatment with a low dose of risperidone (2 mg per day), but this dosage was insufficient. She was then given a typical antipsychotic, haloperidol (3 mg per day), instead of the risperidone. After approximately 2 weeks of treatment, her impulsive behavior improved and her activity level increased; she began to want to be discharged and to go shopping. At 8 weeks later, her bodyweight finally reached 40 kg, but she continued to purge occasionally.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. CASE REPORT
  5. DISCUSSION
  6. REFERENCES

The authors retrospectively assumed that the patient's superstitious and suspicious personality traits and her unusual body perceptions and tendency to withdraw had been present since her youth and that the comments of her peers regarding her bodyweight had acted as a trigger for her overeating and purging impulses to reduce her bodyweight by more than 15%. Consequently, the authors established a 4th edition Diagnostic and Statistical Manual diagnosis of AN-binge eating/purging type and SPD. She persistently hoped to recover and was repeatedly hospitalized in many different hospitals, but her schizotypal personality traits made it difficult for her to recover and her AN-binge eating/purging type became chronic. Moreover, she had a mild neurocognitive disorder; a slightly low neuropsychological test score was observed, but no signs of dementia were observed; secondary organic changes during the chronic course of anorexia nervosa gradually supervened.

A previous case report described an improvement in the symptoms of a patient with AN and SPD who exhibited obsessive–compulsive disorder behavior after the patient began treatment with a combination of paroxetine and haloperidol.3 Low-dose risperidone has also been shown to be effective for the treatment of SPD, possibly because of the extensive similarities between SPD and schizophrenia.4 An open trial for the treatment of AN with haloperidol suggested that low-dose haloperidol may be effective for treatment-resistant AN-restricting subtype patients with severe body image disturbances.5 An intense fear of bodyweight and body image distortion can reach delusional proportions, possibly because of the hyperactivity of the dopaminergic system.6–8 In the present case, the patient's inappropriate and unusual body perceptions were close to delusional interoceptive perceptions or cenestopathy, therefore, the authors suspected that haloperidol might be effective for impulse control.

Some studies have reported that acutely underweight AN subjects have mild neurocognitive disorders in skills like short-term verbal and visual memory and visual construction problem solving.9 A recent study reported that a mild volume decrease in the hippocampus was found in subjects with AN.9 In the present case, evidence of external and central pontine myelinolysis was found on a brain magnetic resonance imaging; these findings were probably caused by repeated acute osmotic pressure changes inside and outside of the cells as a result of purging. However, correlating structural changes with neurologic impairment can be difficult.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. CASE REPORT
  5. DISCUSSION
  6. REFERENCES
  • 1
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    Heiden A, De Zwaan M, Frey R et al. Paroxetine in a patient with obsessive-compulsive disorder, anorexia nervosa and schizotypal personality disorder. J. Clin. Neurosci. 1998; 23: 179180.
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    Koenigsberg HW, Reynolds D, Goodman M et al. Risperidon in the treatment of Schizotypal personality disorder. J. Clin. Psychiatry 2003; 64: 628634.
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    Cassano BC, Mario MS, Alessandoro R et al. Six-month open trial of haroperidol as an adjuctive treatment for anorexia nervosa: a preliminary report. Int. J. Eat. Disord. 2003; 33: 172177.
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    Brunch H. Transformation of oral impulses in eating disorder. Psychiat. Quart 1962; 35: 459479.
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    Strinivasagam NM, Kaye WH, Plotnichov KH et al. Persistent perfectionism, symmetry, and exactness in anorexia nervosa after long-term recovery in anorexia nervosa. Am. J. Psychiatery 1995; 152: 16301634.
  • 8
    Kaye WH, Frank GK, McConaha C. Altered dopamine activity after recovery from restricting-type anorexia nervosa. Neuropsychopharmacology 1999; 21: 503506.
  • 9
    Tchanturia K, Campbell IC, Morris R et al. Neuropsychological studies in anorexia nervosa. Int. J. Eat. Disord. 2005; 37: 572576.