A 24-year-old woman with anorexia nervosa

DR DALEY: Ms K is a 24-year-old, single graduate student with a 7-year history of anorexia nervosa. She attends a professional graduate program and lives in Boston with her boyfriend whom she describes as very supportive. Her medical insurance is through a commercial indemnity company. MsKdevelopedanorexianervosaabout7yearsagowhenshe matriculated college. She is 5 ft 5 in (162.5 cm) tall. Her highest body weight has been 115 lb (52 kg) and her lowest body weight has been 67 lb (30 kg). Her current weight is about 75 lb (34 kg) and she has recently determined not to let her weight drop below73 lb (33kg).Sheweighsherselfaboutevery2weeks.She does not use laxatives or induce vomiting. She has a history of exercising (biking) to reduce her weight, but has not done so recently. She has never been told she has any electrolyte disturbances. She has been amenorrheic for many years. Before arriving in Boston to attend graduate school in the fall of 1997, she was treated for her eating disorder with a multidisciplinary team approach including a primary care internist, a nutritionist, a psychotherapist, and family counseling with her parents. She had been diagnosed as having coexisting depression and treated with antidepressants, including fluoxetine hydrochloride and sertraline hydrochloride, without improvement. She had been hospitalized on numerous occasions for extended periods when her weight loss became life threatening.Shereports thathertreatment includedfrequent weigh-ins and the granting or loss of privileges, such as freedom or money for allowance, based on her weight. Upon arriving in Boston, Ms K established a multidisciplinary treatment team with a psychotherapist, a psychopharmacologist, a nutritionist, and a primary care internist. She stated that the previous therapeutic approach of tying reward and withdrawal of privileges to her weight “doesn’t work for me” and asked that a treatment plan be designed around her own motivation. A trial of oral contraceptive pills resulted in significant weight gain and edema that were intolerable to the patient and she discontinued taking the medication. Her medical history was significant for iron deficiency anemia (hematocrit, 0.17), with no bleeding source discovered after extensive testing including colonoscopy. The anemia resolved with iron therapy. She does not smoke or use alcohol or other drugs. Her only medication is nortriptyline hydrochloride, 50 mg at bedtime. Physicalexaminationrevealedanextremelythinwomanwith sunken cheeks and general inanition. She was 5 ft 5 in (162.5 cm) tall and weighed 75 lbs (34 kg). Blood pressure was 88/62 mm Hg with a heart rate of 78 beats/min. Her skin was dry with no lanugo hair. Teeth were normal without caries or erosions. Onlaboratoryexaminationherelectrocardiogram(ECG)was normal; her blood cell count and chemistries included a white blood cell count of 4.3 3 109/L (4.3 3 103/μL); hematocrit, 0.37; hemoglobin, 126 g/L (12.6 g/dL); calcium, 2.33 mmol/L (9.3 mg/ dL); phosphate, 3.3 mg/dL; glucose, 4.11 mmol/L (74 mg/dL); serum urea nitrogen, 4.28 mmol/L (12 mg/dL); and creatinine, 53 μmol/L (0.6 mg/dL). Albumin, total protein, bilirubin, liver function tests, serum iron, and serum electrolytes were normal. Ms K is currently seeing her psychotherapist weekly, her primary care physician weekly for a weight check, a nutritionist periodically, and a psychopharmacologist for adjustment of her psychotropic medications. She has begun a shiatsu therapeutic massage program, which she states has been helpful. The patient reports that her significant stressors are the demands of her graduate program (she is planning to become a part-time student in the upcoming semester), her relationship with her boyfriend, and ongoing issues related to her relationship with her parents, who live in another city.