Anorexia Nervosa in Tourette’s Syndrome

Anorexia has been seen in association with Tourette’s Syndrome (TS) [57, 58, 59]. Blinder et al. [57] described a 14-year-old anorectic with Tourette’s Syndrome diagnosed at age nine. The development of anorexia was associated with a family move, a change of schools, and a demanding social environment. The use of haloperidol, with consequent weight gain, may have been an additional provocative factor in initiating a restrictive eating pattern. Larocca [59] reported a 12-year-old male with obsessive-compulsive symptomatology who developed TS near the time of weight gain one year previously. For unexplained reasons, the patient exercised excessively and severely restricted his dietary intake. In Tourette’s Syndrome, inadequate impulse inhibition places an overwhelming stress on the ego which is weakened by this neurophysiologic disorder. In adolescence, these patients may need to cope with both heightened sexual and aggressive conflicts, separation-individuation and identity issues. Anorexia nervosa may be a maladaptive attempt at homeostasis. In the 12-year-old male, and in the case of a 22-year-old female with both Tourette’s Syndrome and anorexia nervosa, described by Yayura-Tobias [58] severe depression with overdose or self-mutilation occurred. The coexistence of anorexia nervosa and Tourette’s created an overwhelming sense of ineffectiveness resulting in helplessness and depression.

A common central nervous system mechanism may underlie both Tourette’s and anorexia nervosa. In addition, Yayura-Tobias [58] hypothesizes that both entities share a common CNS (hypothalmic, caudate) locus, since TS and anorexia nervosa present with a high incidence of associated obsessive-compulsive symptoms. Although neurotransmitter levels have not been studied in patients with both Tourette’s Syndrome and anorexia nervosa, Cohen et al. [60] found increased 5-hydroxyindole acetic acid (5-HIAA) in the cerebral spinal fluid of TS patients, suggesting increased serotonin turnover. Serotonin has been implicated in eating inhibition and a shift away from carbohydrate consumption [61].

Neurotransmitter labeled positron emission tomography may be helpful in determining shared neurotransmitter dysfunction, and CNS localization in these coexisting disorders. Further research into common psychodynamic, cognitive, and neurotransmitter determinants, including cerebral mechanisms, are indicated.

Anorexia Nervosa in Schizophrenia

Anorexia nervosa has been reported in patients with schizophrenia [24, 62, 63, 64]. Hsu [62] described six patients who had paranoid delusions and auditory hallucinations in which several heard people stating, "You’re so fat and ugly." Prior to the onset of overt psychosis, depressive and suicidal symptoms were present. In addition, major depression but not schizophrenia, was found in the families. Hsu [62] concluded that these patients would be better diagnosed as schizoaffective disorder than schizophrenia. Treatment with phenothiazines was effective in diminishing psychosis, and one patient became psychotic again with refeeding. Another patient with schizoaffective disorder and borderline mental retardation (IQ) was reported [65]. Similar developmental conflicts concerning separation, individuation, autonomy, and control issues may occur in both disorders [66, 44].

Anorexia Nervosa in Post-traumatic Stress Disorder

Anorexia nervosa has been reported in patients with post-traumatic stress disorder. In three patients, an accident caused physical injury, disfigurement, and preoccupation with their bodies. Damlounji and Ferguson [67] posit that physical injury and placement in a stressful hospital environment resulted in body image distortion, which may have been etiologic in the development of anorexia nervosa. Similarly a patient developed anorexia after prolonged use of the Milwaukee Brace [68] which restricted physical activity and may have promoted undesired weight gain.

Anorexia Nervosa in Depression

Fichter et al [69] reported a 15-year-old male presenting with depression, hyperactivity and fasting who lost 35 percent of body weight, but did not have other criteria of anorexia nervosa.

Anorexia Nervosa in Obsessive-Compulsive Disorders

In some patients with severe obsessive-compulsive disorders, not fulfilling DSM-III criteria for anorexia nervosa, obsessive-compulsive traits such as spending hours cutting and eating small amounts of food in a ritualized manner are present [32].

Anorexia Nervosa in Mental Retardation

Anorexia nervosa has been described in patients with mental retardation [70, 71]. A 15-year-old patient with agitated, withdrawn behavior and an IQ of 62 had a distorted body image and anorexia. This patient was treated with behavior therapy. Anorexia nervosa in the retarded may go undiagnosed because of the misconception that mentally retarded individuals do not develop this disorder [70]. Anorexia nervosa has been reported in a 35-year-old female with Down’s Syndrome [71]. Due to the developmental and cognitive delays of retardation the patient only recently experienced adolescent issues (e.g., separation individuation) associated with the onset of anorexia nervosa. Treatment approach involved modification of environment combined with family therapy.