CASE REPORT:

ANOREXIA NERVOSA
PRESENTED BY:
LADY JOWAHER P. ALLAS RN
 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 Diagnostic and Statistical Manual of Mental Disorder, 5 th
edition (DSM 5), Diagnostic Criteria include: (A) restriction of energy intake relative
CASE REPORT to requirements, leading to a significantly low body weight in the context of age,

INTRODUCTION
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CONCLUSION

sex, developmental trajectory, and physical health. (B) Intense fear of gaining
DISCUSSION

weight or becoming fat, or persistent behavior that interferes with weight 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; 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 has engaged in
CASE REPORT recurrent episodes of binge eating or purging behavior

INTRODUCTION
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CONCLUSION

DISCUSSION

Associated features include:

• Emaciated
• Low body weight of equal or less than 17 kg/m2 for adults and less than 5th
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

CASE REPORT
multidisciplinary approach. This case report describes an adolescent patient
REFERENCES

INTRODUCTION
CONCLUSION

DISCUSSON

presenting with anorexia nervosa.

 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

CASE REPORT

INTRODUCTION
CONCLUSION
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DISCUSSION

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.
There was no family history of eating disorder.

CASE REPORT
Further clinical examination revealed an emaciated girl with a body weight of 35.9 kg

INTRODUCTION
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CONCLUSION

DISCUSSION

and height 1.52m and BMI of 15.5 kg/m2. 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 2 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

CASE REPORT

INTRODUCTION
intervention given.
CONCLUSION
REFERENCES

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 all the criteria with
associated signs and symptoms. A BMI of 15.5 kg/m 2 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-morbidity is also present. Risk factors were

CASE REPORT

INTRODUCTION
being female of 17 years of age (adolescent), and with overprotective parents
REFERENCES

CONCLUSION

DISCUSSION
(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.

CASE REPORT

INTRODUCTION
REFERENCES

CONCLUSION

DISCUSSION
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

CASE REPORT

INTRODUCTION
abnormalities such as osteoporosis and amenorrhoea. If complications occur,
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CONCLUSION

DISCUSSION
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.
 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

CASE REPORT
diagnostic assessment, treatment plan, and practice strategy that can efficiently

INTRODUCTION
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CONCLUSION

DISCUSSION
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.
   

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of

Mental Disorders. (5th 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.

CASE REPORT

INTRODUCTION
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4418263/

REFERENCES

CONCLUSION

DISCUSSION
 
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/
 
 

 
 
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