Abstract
Anorexia nervosa (AN) is a severe eating disorder that commonly has its onset during puberty or adolescence. Late onset anorexia is commonly defined as AN occurring in patients older than 25 years [1]. We report the case of a first onset AN in an older woman with no previous history of psychiatric disorder.
Mrs A, a 56-year-old woman with a body height of 160 cm, was admitted to the Intensive Care Unit weighing 28 kg (BMI of 10.9 kg/m2). During her stay in the Intensive Care Unit and subsequent first weeks on the psychiatric ward where she was transferred after stabilization of her body weight at 29.4 kg, she showed all symptoms of AN according to the ICD-10 criteria. These included obsessive thoughts regarding food and body weight, drive for thinness, restlessness, restrictive eating and a profound disturbance of her body image. She had no history of eating disorder or of any other mental illness. However, 6 years prior to hospitalization, she began reducing her food consumption after her general practitioner had diagnosed hyperlipidemia and therefore had advised her to cut down on the intake of fat. During the 6 years prior to her admission to the Intensive Care Unit, severe AN had evolved and Mrs A had lost a total body weight of 52 kg. She had not received any inpatient or outpatient treatment for this disorder.
After her admission to the psychiatric ward, feeding was enforced after placing of a percutaneous endoscopic gastrostomy. Further treatment included contingency management and oral olanzapine (up to 7.5 mg daily). She regained 14 kg during her 15-week hospitalization period. After having gained that weight, Mrs A, who still showed all cognitive symptoms of AN, was transferred to a hospital specialized in treating elderly patients with eating disorders.
Discussion
AN occurring in older women has only rarely been reported [2–4]. Some authors have argued that in these cases patients are more likely to suffer from depressive disorders with appetite loss than from true AN [5]. Others have described late onset AN as a phenomenon distinct from depression, which can therefore not necessarily be successfully treated with antidepressants [3]. Obsessive thoughts regarding food and body shape are typical features of AN. In our case, the patient also had obsessive thoughts with regard to losing weight in order to stay healthy, which was threatened to the diagnosed condition of hyperlipidemia. In this sense, the case described here can be considered as a form of orthorexia nervosa (fixation on healthy food [6]), whereby the point is not ‘healthy’ eating but a reduced food intake in order to stay or become healthy, finally leading to a fully developed anorexia nervosa. It may also be of interest that these obsessions are thought to be a response to social pressure with regard to, for example, having to be thin and attractive in young women or healthy (and attractive) in older women. Fears pertaining to physical damage due to hyperlipidemia (such as myocardial infarction, stroke, etc.) may be a strong motivation for reducing food intake and have previously been described as causative in leading to AN[4]. The patient of Hatcher et al., however, was urged to keep to a restrictive diet and to increase her fitness training. In our case, the only advice given to the patient by the general practitioner concerned the treatment for her high cholesterol. Thus, the mere possibility of a potential threat to health seems to have been sufficient to trigger AN.