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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor=Gonzalo Romero
|QuestionAuthor=[[User:Serge korjian|Serge Korjian, M.D.]], [[User:Gonzalo Romero|Gonzalo A. Romero, M.D.]] [mailto:gromero@wikidoc.org] (Reviewed by Will Gibson and Serge Korjian)
|ExamType=USMLE Step 1
|ExamType=USMLE Step 1
|MainCategory=Behavioral Science/Psychiatry
|MainCategory=Behavioral Science/Psychiatry
|SubCategory=General Principles
|SubCategory=General Principles
|MainCategory=Behavioral Science/Psychiatry
|Prompt=A 17-year-old woman is brought to the outpatient clinic by her mother because she is refusing to eat and is exercising more than usual. She has earned several awards because of her athletic skills in the past, and is extremely competitive in school. Five months ago her parents divorced.  Shortly thereafter, the patient started a special diet and she has lost approximately 25 pounds. Her mom has tried to enforce a regular diet with sufficient calories,  but the patient is reluctant to increase her caloric intake.  She reports a strong fear of gaining weight and feels fat in front of the mirror. The patient reports that she stopped having a menstrual cycle 6 weeks ago. Her heart rate is 78/min, blood pressure is 123/80 mm Hg, temperature is 37°C (98.6 °F), and BMI is 16.5 kg/m<sup>2</sup>. Examination reveals hair thinning, dry skin with fine hair over the body, and mild parotid swelling. What is the most likely diagnosis?
|SubCategory=General Principles
|Explanation=Most of this patient's symptoms are consistent with a diagnosis of [[anorexia nervosa]], including the constant fear of gaining weight, body image disturbance, restriction in caloric intake, and excessive exercise. Approximately half of anorexia nervosa patients develop bulimia-like binging and purging behaviors. Depression is also common among anorexia patients. On physical exam, patients may have lanugo or baby-like hair, dental cavities due to vomiting, and possibly could have a lower Tanner stage if the disease starts in adolescence. Treatment usually consists of psychotherapy and counseling to stabilize body weight and improve body image.  [[Mirtazapine]] is an antidepressant commonly suggested for [[anorexia]] treatment on the USMLE, as it increases appetite as a side effect.  
|MainCategory=Behavioral Science/Psychiatry
 
|SubCategory=General Principles
Several important characteristics help distinguish [[anorexia]] from [[bulimia]]. Anorexia nervosa causes low [[BMI]] and [[amenorrhea]] due to the strict caloric intake. Patients with anorexia most often lack insight and are not perturbed by their symptoms making treatment more challenging. Conversely, [[bulimia nervosa]] is a syndrome that is characterized by episodes of binging and purging, often by induced vomiting or laxative abuse. These patients tend to have a normal or high BMI and often view their symptoms as excessive and abnormal.  They may display signs of vomiting induction such as callous on fingers, [[halitosis]], enlarged [[parotid gland|parotids]], and dental cavities. While this patient has signs of frequent vomiting, her low BMI, caloric restriction and excessive exercise make [[anorexia]] the more likely option.
|MainCategory=Behavioral Science/Psychiatry
|MainCategory=Behavioral Science/Psychiatry
|SubCategory=General Principles
|MainCategory=Behavioral Science/Psychiatry
|SubCategory=General Principles
|MainCategory=Behavioral Science/Psychiatry
|SubCategory=General Principles
|MainCategory=Behavioral Science/Psychiatry
|SubCategory=General Principles
|MainCategory=Behavioral Science/Psychiatry
|MainCategory=Behavioral Science/Psychiatry
|SubCategory=General Principles
|Prompt=A 17 year old female is brought to the Outpatient Clinic by her mother because she is refusing to eat and is exercising a lot more than usual. She has gotten several awards because of her athletic skills in the past, is extremely competitive in school, is one of the best students in the class. She started a special diet 4 months ago which has made her loose weight over this period of time after her parents divorce. Her mom has tried to make her eat a regular diet in calories,  but she is reluctant to increase her body caloric intake due to a strong fear of gaining weight and feels fat in front of the mirror as described. Her mother states that she stopped having a menstrual cycle 5 weeks ago and that she has been drinking more water than usual and exercising more than before. On physical exam her vitals HR: 78, BP: 123/80, Temp: 37 C, BMI: 16.5. She has fine hair over her entire body, multiple dental cavities, her breasts look atrophied, extremities are atrophied. What is the most likely diagnosis?
|Explanation=This is an interesting case as it involves a teenager dealing with a strong stressful event, such a recent divorce. Most of her symptoms and signs fall into the category of Anorexia Nervosa due to the constant fear of gaining weight, the body image disturbance, the restriction in caloric intake, exercising more than usual. Important characteristics help distinguish Anorexia from Bulimia; Anorexia causes low BMI due to the strict caloric intake and also Amenorrhea. She is drinking more water than usual to fulfill herself and inhibit the hunger.
Bulimic patients often have a normal or higher BMI or weight, may have signs of vomiting induction such as callous on fingers and hands, halitosis, enlarged parotids, dental cavities due to the vomiting and could have cardiac abnormalities. Both of them could cause electrolyte imbalances which could lead to Arrhythmia and also Binge and purge could be present in Anorexic patients as well.


|AnswerA=[[Post traumatic stress disorder]]
In both anorexic and bulimic patients, cardiac complications may arise due [[electrolyte disturbances]] and consequent conduction defects.  A small percentage of these patients can die from fatal [[arrhythmias]].
|AnswerAExp=It is defined as the flashbacks which are the re-experience of the stressful events or recollections, nightmares and the avoidance of the associated stimuli. It also has sleep disturbances, irritability, compulsive behaviors avoiding the stimuli, inability to concentrate. Symptoms last more than a month, if less than a month it is considered Acute Stress Disorder. It usually presents after a stressful event severe enough to disrupt the person's coping mechanisms which commonly is presented as a life threat to self, or surroundings. It is commonly presented in women. An example of this is a woman being raped.
|AnswerA=Post-traumatic stress disorder (PTSD)
|AnswerB=[[Obsessive compulsive personality disorder]]
|AnswerAExp=[[Post traumatic stress disorder]] (PTSD) is characterized by the re-experiencing of a stressful event (flashbacks) and the avoidance of associated stimuli. Patients with PTSD often experience sleep disturbances, nightmares, irritability, and inability to concentrate. A diagnosis of PTSD requires that symptoms last more than one month, if symptoms last less than one month the diagnosis of "[[acute stress disorder]]" is made. PTSD usually presents after a stressful event severe enough to disrupt one's normal coping mechanisms. Common causes of PTSD include witnessing or being subject to extreme violence or rape.
|AnswerBExp=It is lifelong pattern of perfectionism that extends to all areas  of life (pervasive). Persons with this type of personality often are extremely organized, use lists and order as a must in their lives. It is more common in males. This patient might present traits, but not as intense or chronically present to be considered an Obsessive Personality Disorder.
|AnswerB=Obsessive compulsive personality disorder (OCPD)
|AnswerC=[[Anorexia nervosa]]
|AnswerBExp=[[Obsessive compulsive personality disorder]] (OCPD) is a cluster B personality disorder characterized by a lifelong pattern of perfectionism that extends to all areas  of life (pervasive). This patient might present traits of OCPD, but her presentation is not as intense or chronically present to be considered diagnostic of OCPD.  Furthermore, excessive calorie restriction and weight loss constitute the prevailing medical theme in this patient, and these behaviors are not generally characteristics of OCPD patients.
|AnswerCExp=It is an eating disorder frequently in female teenagers and young female adults. It is defined as a self restriction in caloric intake which causes significant weight loss 15 to 20% below ideal weight and the BMI <17.5. Characteristically they have a fear of gaining weight. Half percent of patients may develop binge and purge behaviors and could be depressed. They typically are resistant to accept the condition or deny the illness. On physical exam her BMI is less than 17.5, have lanugo or baby-like hair, could have dental cavities due to vomiting, and could have a lower stage of Tanner if presented in adolescence. Treatment usually is supportive to stabilize body weight and pharmacotherapy could be used like Mirtazapine which treats depression and also increases appetite as a side effect.
|AnswerC=Anorexia nervosa
|AnswerD=[[Bulimia]] nervosa
|AnswerCExp=[[Anorexia nervosa]] is an eating disorder frequently seen in female teenagers and young female adults. It is characterized by a restriction in caloric intake that causes significant weight loss 15 to 20% below ideal weight with a BMI <17.5 kg/m<sup>2</sup>.
|AnswerDExp=It is an eating disorder that involves binging and purging behaviors defined as voluminous ingestion of food followed by vomiting, laxative use, dieting pills or exercise. On physical exam they could have signs of vomiting such as callous on hands, enlarged parotids and other glands, dental cavities, esophageal tears or esophagitis, and her BMI usually stays normal or above normal. The treatment involves SSRIs, Imipramine, and support therapy.
|AnswerD=Bulimia nervosa
|AnswerE=[[Obsessive compulsive disorder]]
|AnswerDExp=[[Bulimia]] is an eating disorder that involves binging and purging behaviors defined as voluminous ingestion of food followed by vomiting, [[laxative]] use, dieting pills or exercise. On physical exam these patients often have signs of vomiting such as callous on hands, enlarged [[parotids]] and other glands, dental cavities, [[esophageal tear]]s or [[esophagitis]].  BMI usually stays normal or above normal. Treatment usually includes counseling, but may involve [[SSRIs]], [[imipramine]], or more structured rehabilitation.
|AnswerEExp=It is a subtype of Anxiety disorder which involves obsessions  defined as the focus in one thought; and compulsions which are repetitive actions to avoid the thoughts.
|AnswerE=Obsessive compulsive disorder (OCD)
The patient usually recognizes the problem and tries to resist the obsessions. It is focal and acquired which help distinguishing from Obsessive Personality disorder which is lifelong and pervasive.
|AnswerEExp=[[Obsessive compulsive disorder]] (OCD) is a sub-type of anxiety disorder characterized by intrusive thoughts that produce uneasiness and repetitive behaviors aimed at reducing the associated anxiety. [[OCD]] patients classically have focal obsessions and are aware that their behavior is not normal. Both these traits help distinguishing it from obsessive personality disorder which is lifelong and pervasive.
|EducationalObjectives=[[Anorexia]] nervosa is an eating disorder characterized by low [[BMI]], [[amenorrhea]], dry skin, hair loss, and lanugo.
|References=First Aid 2014 page. 512
|RightAnswer=C
|RightAnswer=C
|WBRKeyword=Eating, Eating disorder, Anorexia, Bulimia, Psychiatry, Behavioral Science
|Approved=Yes
|Approved=Yes
}}
}}

Latest revision as of 23:07, 27 October 2020

 
Author [[PageAuthor::Serge Korjian, M.D., Gonzalo A. Romero, M.D. [1] (Reviewed by Will Gibson and Serge Korjian)]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Behavioral Science/Psychiatry
Sub Category SubCategory::General Principles
Prompt [[Prompt::A 17-year-old woman is brought to the outpatient clinic by her mother because she is refusing to eat and is exercising more than usual. She has earned several awards because of her athletic skills in the past, and is extremely competitive in school. Five months ago her parents divorced. Shortly thereafter, the patient started a special diet and she has lost approximately 25 pounds. Her mom has tried to enforce a regular diet with sufficient calories, but the patient is reluctant to increase her caloric intake. She reports a strong fear of gaining weight and feels fat in front of the mirror. The patient reports that she stopped having a menstrual cycle 6 weeks ago. Her heart rate is 78/min, blood pressure is 123/80 mm Hg, temperature is 37°C (98.6 °F), and BMI is 16.5 kg/m2. Examination reveals hair thinning, dry skin with fine hair over the body, and mild parotid swelling. What is the most likely diagnosis?]]
Answer A AnswerA::Post-traumatic stress disorder (PTSD)
Answer A Explanation [[AnswerAExp::Post traumatic stress disorder (PTSD) is characterized by the re-experiencing of a stressful event (flashbacks) and the avoidance of associated stimuli. Patients with PTSD often experience sleep disturbances, nightmares, irritability, and inability to concentrate. A diagnosis of PTSD requires that symptoms last more than one month, if symptoms last less than one month the diagnosis of "acute stress disorder" is made. PTSD usually presents after a stressful event severe enough to disrupt one's normal coping mechanisms. Common causes of PTSD include witnessing or being subject to extreme violence or rape.]]
Answer B AnswerB::Obsessive compulsive personality disorder (OCPD)
Answer B Explanation [[AnswerBExp::Obsessive compulsive personality disorder (OCPD) is a cluster B personality disorder characterized by a lifelong pattern of perfectionism that extends to all areas of life (pervasive). This patient might present traits of OCPD, but her presentation is not as intense or chronically present to be considered diagnostic of OCPD. Furthermore, excessive calorie restriction and weight loss constitute the prevailing medical theme in this patient, and these behaviors are not generally characteristics of OCPD patients.]]
Answer C AnswerC::Anorexia nervosa
Answer C Explanation [[AnswerCExp::Anorexia nervosa is an eating disorder frequently seen in female teenagers and young female adults. It is characterized by a restriction in caloric intake that causes significant weight loss 15 to 20% below ideal weight with a BMI <17.5 kg/m2.]]
Answer D AnswerD::Bulimia nervosa
Answer D Explanation [[AnswerDExp::Bulimia is an eating disorder that involves binging and purging behaviors defined as voluminous ingestion of food followed by vomiting, laxative use, dieting pills or exercise. On physical exam these patients often have signs of vomiting such as callous on hands, enlarged parotids and other glands, dental cavities, esophageal tears or esophagitis. BMI usually stays normal or above normal. Treatment usually includes counseling, but may involve SSRIs, imipramine, or more structured rehabilitation.]]
Answer E AnswerE::Obsessive compulsive disorder (OCD)
Answer E Explanation [[AnswerEExp::Obsessive compulsive disorder (OCD) is a sub-type of anxiety disorder characterized by intrusive thoughts that produce uneasiness and repetitive behaviors aimed at reducing the associated anxiety. OCD patients classically have focal obsessions and are aware that their behavior is not normal. Both these traits help distinguishing it from obsessive personality disorder which is lifelong and pervasive.]]
Right Answer RightAnswer::C
Explanation [[Explanation::Most of this patient's symptoms are consistent with a diagnosis of anorexia nervosa, including the constant fear of gaining weight, body image disturbance, restriction in caloric intake, and excessive exercise. Approximately half of anorexia nervosa patients develop bulimia-like binging and purging behaviors. Depression is also common among anorexia patients. On physical exam, patients may have lanugo or baby-like hair, dental cavities due to vomiting, and possibly could have a lower Tanner stage if the disease starts in adolescence. Treatment usually consists of psychotherapy and counseling to stabilize body weight and improve body image. Mirtazapine is an antidepressant commonly suggested for anorexia treatment on the USMLE, as it increases appetite as a side effect.

Several important characteristics help distinguish anorexia from bulimia. Anorexia nervosa causes low BMI and amenorrhea due to the strict caloric intake. Patients with anorexia most often lack insight and are not perturbed by their symptoms making treatment more challenging. Conversely, bulimia nervosa is a syndrome that is characterized by episodes of binging and purging, often by induced vomiting or laxative abuse. These patients tend to have a normal or high BMI and often view their symptoms as excessive and abnormal. They may display signs of vomiting induction such as callous on fingers, halitosis, enlarged parotids, and dental cavities. While this patient has signs of frequent vomiting, her low BMI, caloric restriction and excessive exercise make anorexia the more likely option.

In both anorexic and bulimic patients, cardiac complications may arise due electrolyte disturbances and consequent conduction defects. A small percentage of these patients can die from fatal arrhythmias.
Educational Objective: Anorexia nervosa is an eating disorder characterized by low BMI, amenorrhea, dry skin, hair loss, and lanugo.
References: First Aid 2014 page. 512]]

Approved Approved::Yes
Keyword WBRKeyword::Eating, WBRKeyword::Eating disorder, WBRKeyword::Anorexia, WBRKeyword::Bulimia, WBRKeyword::Psychiatry, WBRKeyword::Behavioral Science
Linked Question Linked::
Order in Linked Questions LinkedOrder::