Pharmacotherapeutic Considerations in the Treatment of an Adolescent with Anorexia Nervosa and Obsessive Compulsive Disorder

[Author Affiliation]Timothy Rice. Icahn School of Medicine at Mount Sinai, Department of Psychiatry, New York, New York.Barbara J. Coffey. Icahn School of Medicine at Mount Sinai, Department of Psychiatry, New York, New York.Address correspondence to: Barbara J. Coffey, MD, MS, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1230, New York, New York 10029, E-mail: Barbara.coffey@mssm.eduChief Complaint and Presenting ProblemV. was a 17-year-old girl, the third of six children, referred following an inpatient hospitalization for medication management of anorexia nervosa (AN) and obsessive compulsive disorder (OCD).History of Present IllnessV. reported onset of anxiety at age 5 or 6 years, characterized by worries about her weight and appearance, school performance and peer interactions, and perfectionistic tendencies. By age 12 V. began to restrict eating. This significantly worsened around age 15, when V. reported eating one or fewer meals a day and engaging in occasional binge eating and purging. Her periods became irregular and she began experiencing significant palpitations when anxious. At age 16, V. was referred to an eating disorder specialty clinic where a trial of cognitive behavioral therapy (CBT) and family-based therapy (FBT) was initiated. This eight-session treatment failed to improve her disordered eating or weight loss. She notably went from 125.8 pounds to 113 pounds during the eight weeks she was in treatment; her periods completely ceased. By the eighth session, at the age of 16, V. was 5[variant prime]9'' and weighed only 108 pounds, with a body mass index (BMI) of 15.9; V. was subsequently admitted to an inpatient unit specialized in eating disorders and weight restitution. She was hospitalized for 16 weeks. On the 13th week of her hospitalization, following significant weight reconstitution, fluoxetine was initiated, which was titrated each week to a discharge dose of 30 mg daily. On discharge her weight was 149 pounds and BMI 22.0. She was discharged to follow-up in a community clinic associated with an academic medical center to manage treatment adherence and anger difficulties. Anger problems included screaming at her mother during family sessions and having a dismissive attitude towards therapists, which made treatment difficult.Four days after discharge from the inpatient service V. initiated treatment at the community clinic, and reported stuttering and an inability to speak coherently with friends or at school due to her anxiety. She experienced frequent intrusive thoughts, such as "I'm not smart," and "I'm not pretty." Additionally, V. was excessively concerned about contamination and cleaned compulsively, washing her hands over 30 times a day. She reported that cleaning, organizing, and her academic work significantly reduced her anxiety. She reported fears of saying the wrong things and losing things, and repeating and checking compulsions.V. reported that her fluoxetine had significantly improved her mood. She felt that the medication helped her to "look people more in the eye," a level of assertiveness that previously made her uncomfortable. However, V. questioned the medication, and reported that she did not feel she deserved to be happy. She reported a "hyper" mood, stating "I get up in the morning and dance around," and "I feel more alive." She reported that she was nervous about becoming "manic."On review of other symptoms, V. denied significant sadness, irritability, loss of interest, suicidal ideation, homicidal ideation, or self-injury; she denied auditory or visual hallucinations. She denied history of alcohol or illicit drug use. She denied purging with diet pills or laxatives. She reported adhering to a 3,000 kCal diet, but admitted to having concerns that she would "slip back into my disordered ways."Past Psychiatric HistoryV. had had no formal previous psychiatric treatment. …