Weight loss: differential diagnosis for splitting hairs

WEIGHT LOSS: DIFFERENTIAL DIAGNOSIS FOR SPLITTING HAIRS

Of course, features of any one particular illness often occur in other conditions as well. Colds cause runny noses and watery eyes, but so do allergies.
The same principle-the crossover of symptoms-applies to eating disorders. In fact, one expert referred to anorexia nervosa as one of the "great pretenders."
An endocrinologist might conclude that weight loss results from hyperthyroidism or Addison's disease (a malfunction of the adrenal glands that results in inadequate supplies of hormones). A gastroenterologist might suspect a disease of the bowels that prevents adequate absorption of nutrients, a neurologist might wonder about a defect in the hypothalamus or the possibility of epilepsy, and so on.
As a biopsychiatrist, I look for signs that some organic illness or abnormality is causing the patient's eating problem. A physical examination and lab tests will usually reveal whether some underlying illness, perhaps a tumor or some other condition, is causing the weight loss, the swelling of the ankles, the low blood pressure, and the extreme sensitivity to cold.
Many psychiatric and physical illnesses cause weight loss. With other illnesses, however, the patient usually complains about the problem, or is at least indifferent to it. In contrast, the anorexic takes inordinate pride in her thinness.
Depression-a symptom of anorexia in a certain number of patients-is also widespread. Depression can exist as a disorder of its own, with its own defined set of features, or it can arise from many organic illnesses. Sometimes feelings of depression are a natural, even healthy response to a troubling situation, such as the loss of a loved one.
Prolonged depression can lead to weight loss. But depressed individuals do not usually experience disturbance of body image or fear of fatness. Such attitudes signal the presence of anorexia.
People with schizophrenia often experience warped beliefs and behaviors related to food and eating. Typically, schizophrenics might maintain that their meal has been poisoned, or that "Martians have put aphrodisiacs in the water supply." They might also eat in weird ways that resemble the bizarre habits of an anorexic. But a schizophrenic usually will not meet the full set of criteria for anorexia. In rare cases, however, both disorders can be found in the same individual.
The behavior of the anorexic often suggests the presence of an obsessive-compulsive disorder. To illustrate, let me tell you about an anorexic patient named Sonya.
The day Sonya arrived at the hospital, I stopped by her room and saw her unpacking her suitcase. I saw that she had wrapped everything she had brought-toothbrush, underwear, books, a favorite cuddly toy-in aluminum foil. She had then placed each foil ball in a separate plastic bag.
Sonya noticed the somewhat startled look on my face. "Germs," she said tersely.
In my years of experience with eating disorders, I had never seen anything like it. She seemed to be laying in a year's supply of foil-wrapped baked potatoes. It's possible that even before her anorexia struck, Sonya, like some other eating disorder patients, may have had an obsessive-compulsive disorder. This is a very hot area of current research, and there seems to be more of an overlap than was previously thought between anorexia nervosa and an obsessive-compulsive disorder (OCD). Medications that are useful in OCD, such as Prozac (fluoxetine), may prove quite helpful in treating anorexia nervosa. It is important to remember, however, that starvation itself will increase obsessional thinking.

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WEIGHT LOSS

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