Abstract
The association between eating disorders and psychopathologies of both Axes I and II has been extensively described. In particular, eating disorders have significant comorbidity with affective, anxiety, and substance-related disorders [1], and emotional processing compromise may be linked to obsessionality [2]. However, the relationship between eating disorders and psychosis has been less closely scrutinized, and some earlier reports of psychotic symptoms occurring in the context of eating disorders have been attributed to mood disorders with psychotic features rather than discrete comorbid psychotic disorders [3]. Although there is a higher frequency of psychotic symptoms in general amongst eating-disordered patients, compared to age- and region-matched controls, there is no increase in frequency of symptoms specifically related to schizophrenia [4]. Furthermore, the prevalence of schizophrenia amongst patients with anorexia nervosa appears similar to that of the general population [5].
We describe here a 19 year old man who had developed symptoms of anorexia over the previous year. Initially weighing around 130 kg and being bullied at school, he began restricting his diet, counting calories and exercising vigorously. He increasingly relied upon caffeinated diet soft drinks and sugar-free chewing gum for appetite control. His weight gradually dropped to 60 kg (BMI 17.8 kg/m2) before he was referred to a psychiatrist. After outpatient attempts to alter his intake were unsuccessful, a hospital admission was planned. At that time he had intensely held beliefs about his weight and body image typical of anorexia nervosa but no psychotic symptoms.
Immediately prior to the first hospital admission he developed paranoid delusions and in the emergency department was found to be perplexed and thought-disordered. He believed that he had killed his mother when he ‘lost control’ and had delusions of reference that this had been reported on television. The patient had command hallucinations that he believed would be relieved by binge eating. These symptoms gradually remitted on risperidone, 3 mg daily.
It was initially hypothesized that the psychosis was a brief psychotic episode in reaction to being asked to challenge his anorexic behaviour, but three months later, after stopping his antipsychotic medications, the patient again became psychotic with marked disorganization, thought disorder and distress that he could not articulate, requiring four weeks in a psychiatric intensive care unit. He again had hallucinations and delusions that were distortions of his previous anorexic symptoms. The patient ate to excess because he believed himself to be dying of ‘ketosis’ and on one occasion broke into a locked kitchen area to obtain more food.
This report highlights and contrasts the pathological control of anorexia nervosa and the reduced control of disorganized schizophreniform psychosis. Psychoses have previously been reported which clearly predate the onset of the eating disorder, or which have developed some time after treatment [5,6]. The absence of a consistent symptom chronology makes determining the underlying aetiology of the psychotic symptoms challenging, and it remains unclear whether they reflect distinct psychotic disorders or are merely present within the psychopathological continuum of the eating disorder itself. In this case, the eating disorder reflected the patient's low self-esteem and search for control. It may also have represented an attempt to defend against the impending disorganization of his psychosis, and it is notable that some delusions related to losing self-control. As demonstrated in this case and previously [5], amelioration of the eating disorder may provoke development of psychotic symptoms and may warrant less stringent eating disorder treatment goals to improve overall quality of life.