August 2006, Vol. XXIII, No. 9
First described by Richard Morton, MD, in 1689,1 the incidence of anorexia nervosa (AN) has been increasing in the past century in Europe and North America. Lifetime prevalence rates in recent years have been reported at 0.3% to 3.7%.2-4 The illness is viewed as a phenomenon of western industrialized countries, although with increasing globalization and the spread of western culture, incidence rates in non–western countries are climbing.5
Affective disorders, anxiety disorders, and obsessive-compulsive disorder are often comorbid with AN restricting type.3 Braun and colleagues6 reported a 41.2% lifetime prevalence of affective disorders in patients with AN restricting type, making affective disorders the most common set of diagnoses comorbid with AN restricting type. Although the current literature describing AN restricting type with comorbid psychosis is limited, this combination was first described in 1939 by Nicolle,7 who noted that an anorexic patient's mental state had a distinct schizoid tendency.
Comorbid AN restricting type and pyromania is a particularly unexpected combination, given that the 2 illnesses involve very different types of patients: AN restricting type typically occurs in females with internalizing behaviors (eg, constraint, conforming, and perfectionism),8,9 while pyromania typically occurs in male patients with externalizing behaviors (eg, impulsivity, aggression, and delinquency).10-12 Patients with these disorders share some common risk factors, including poor family dynamics, lack of social skills, and decreased appropriate expression of anger and tension.11-13
A girl aged 14 years was referred to a university child and adolescent psychiatry eating-disorders unit from an outlier hospital. The patient had a 6-month history of eating disorder, with symptoms worsening 2 months before admission. The patient had begun exercising 20 minutes a day and gradually increased this to 90 minutes a day. When she became too weak to exercise the full 90 minutes, she initiated food intake restriction to continue her weight reduction.
On admission, the patient was interviewed and examined. Staff (attending and fellow physicians, registered nurse, and medical students) also interviewed her family and reviewed her medical records. The patient had lost a total of 15 lb, with a 10-lb loss in the 2 months before admission. At admission, the patient was only 68% of her ideal body weight. She denied episodes of binging, purging, or laxative use. She experienced menarche at age 12, but her menses had ceased 4 months before admission.
The patient presented with passive suicidal ideation, expressing that she would be better off dead. Two weeks before admission, the patient thought about jumping in front of traffic. She denied having previous suicide attempts, and her family concurred. The patient said she had been miserable for 4 to 5 years but noted more intense daily sadness in the 2 weeks before hospital admission.
The patient's parents described obsessive compulsive symptoms that had been present for 4 years. She was very preoccupied with being on time and said she felt like a failure if she arrived late for anything. She stated that arriving on time would prevent catastrophic things from happening to herself or her family. Her parents did not believe the symptoms were a problem, since they did not conflict with her schoolwork or personal life. They further thought this behavior was actually a positive thing—a sign of responsibility—and had not seen a need to address it.
In her initial evaluation, there were no obvious symptoms of psychosis, posttraumatic stress disorder, panic disorder, or bipolar disorder. She appeared to be a typical patient with an eating disorder.
Further inquiry was completed about 10 days after initiation of full nutritional support. Her cognitive blunting had reduced enough that she could give an accurate psychiatric history. During this interview, the patient described symptoms consistent with pyromania. The patient described burning paper in her room on multiple occasions over a 2-year period. She felt very tense and excited before burning the paper and intense relief and pleasure afterward. She had an intense curiosity and attraction to how the fire burned paper.
This fascination became more complicated 12 months before her admission when she expressed pleasure in burning paper with the names and telephone numbers of girls who had upset her at school. She described fantasizing that the burning paper relieved desires to kill girls at school who made my life miserable. She was not concerned with the fact that her home could burn down or that she and her family could be seriously injured. Further exploration of this unusual comorbidity over the next 28 days led to the penultimate discovery of delusional and disordered thoughts with eventual diagnosis of psychosis not otherwise specified. Initially it was thought that the patient's thought disorder could have been a product of her malnourished state, as seen in patients with AN. However, the patient's psychosis became more apparent only as her constitutional state improved.
As the therapeutic alliance improved, the patient was more comfortable discussing her thoughts. She revealed her chronic belief that people were out to get her, which had started as early as kindergarten. This belief included her teachers because they allowed the kids to pick on me. The patient fantasized a giant knife crashing down and cutting her kindergarten teacher in half. She became seclusive in elementary school and, eventually, the object of her classmates' ridicule. Her poor peer relations escalated to a classmate poking her in the head with a pencil.
At age 12, the patient started to focus on a group of beautiful girls at school that she believed were her enemies. She planned to become their friend so she would fit in and improve her social problems. Their focus on being thin and emulating teen idols was the basis of her eating disorder. Unfortunately, no matter how much weight she lost or how much she dressed up like teen idols, this group would not accept her. Her social skills were too immature and inhibited for this group of girls.
Her anger, frustration, sadness, and low self-esteem reached its peak. At this point, the patient started to have bizarre suicidal thoughts. She planned to raise money to pay the beautiful girls at school to kill her. She also wanted to make sure that the police found out about her murder. The beautiful girls would have to go to jail, and their lives would be ruined. The patient believed that the same thing could and would happen with the staff in the psychiatric unit.
The patient was also very upset by the length of time that it took to get to school. She believed the bus driver purposefully prolonged the bus ride to school in an effort to allow the other students more time to torment her. She expressed hatred for this man and had thoughts of killing him by ripping out his throat. The patient also had a plan for revenge on the girl who taunted and poked her in the head with a pencil during the bus ride to school: this girl had diabetes mellitus, and the patient planned to feed her chocolate candy to placate her aggression. She expressed ambivalence about this girl possibly dying from the chocolate candy and stated, I just want to help her calm down.
As a result, the treatment team decided to start an antipsychotic medication. After obtaining consent from her parents and with a baseline ECG revealing no abnormality, the patient was given 2.5 mg/d of olanzapine, a secondgeneration antipsychotic. (This is off-label use, since the antipsychotic olanzapine is not FDA-approved in children/adolescents. However, its use to treat psychosis is supported by the American Academy of Child and Adolescent Psychiatrists.14) This dosage was eventually increased to 10 mg/d. On a daily basis, the patient received cognitive-behavioral therapy, supportive therapy, medication evaluation, nutritional support with medication, and psychiatric evaluation by the treatment team. Her AN, depressive, obsessive-compulsive, and pyromania symptoms remitted by about the 34th day of hospitalization. After 41 days, the patient's psychosis had improved enough for her to begin outpatient care at a university eating-disorders program with a new adolescent psychiatrist.