The Japanese Journal of Psychiatry and Neurology, Vol. 46, No. 4, 1992
Eating Disorder and Schizophrenia Hiroyasu Shiraishi, M.D., Junzo Koizumi, M.D., Toshihito Suzuki, M.D., Naomi Yamaguchi, M.D., Katsuyoshi Mizukami, M.D., Masashi Hori, M.D. and Yoshiro Tanaka, M.D. Department of Psychiatry, Institute of Clinical Medicine, The University of Tsukuba, Tsukuba
Abstract: Five cases with eating disorders (one case with anorexia nervosa alone, 4 cases with anorexia nervosa and bulimia nervosa) complicated with schizophrenia and 3 cases of bulimia nervosa complicated with schizophrenia were reported. The eating disorders and schizophrenia were diagnosed according to the diagnostic criteria of DSM-111-R. As to the type of schizophrenia, 4 patients were of an undifferentiated type and 4 cases were of a disorganized type. Regarding the prepsychotic personality, 6 of the 8 cases showed schizothyme personality traits. All the patients showed depressive symptoms which are relatively common in eating disorders. In all the patients, significant social or school life difflculties persisted and a resumption of premorbid functioning was not seen. The possibility of an afflnity between anorexia nervosa and schizophrenia was discussed. Key Words: eating disorders, anorexia newosa, bulimia nervosa, schizophrenia, complication Jpn J Psychiatr Neurol46: 859-867, 1992
INTRODUCTION Since anorexia nervosa was named and described by Gull"'2, some authors have noted a coincident occurrence of anorexia nervosa and schizophrenia. Nicollez3reported that the affective state in early schizophrenia, the shallowness of affection and sympathy explained by Mayer-Gross2', corresponded closely with those of anorexia nervosa. B d 3 regarded anorexia nervosa as nearly schizophrenic. According to DSM-111-R', anorexia nervosa and bulimia nervosa are rarely complicated by psychotic features. In schizophrenia, anorexia nervosa is rarely present; howReceived for publication on March 27, 1992. Mailing address: Hiroyasu Shiraishi, M.D., Department of Psychiatry, Institute of Clinical Medicine, The University of Tsukuba, Tsukuba, Ibaraki 305, Japan.
ever, when it is, both diagnoses should be given. Also, schizophrenia is rarely complicated by bulimia nervosa. In 1954, Kay et aLt6 reported the clinical course of 38 cases of anorexia nervosa. In one case, the patient developed schizophrenia-like symptoms such as auditory hallucinations, a delusion of being controlled and so on. Since then some single complicated cases have been presented" 2o 2b29 31 34, but reports of multiple cases of coincident occurrence of anorexia nervosa and schizophrenia have been few" 14. Hsu et al.I4reported six out of 105 cases with anorexia nervosa complicated by schizophrenia or schizophreniform illness. Ferguson et aLt0reported 12 patients who met the DSMI11 diagnostic criteria for both anorexia nervosa and schizophrenia. The incidences of such a duality are low. Morgan et al.22found no complication of schizophrenia in their
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prognostic investigation of patients with anorexia nervosa. Other studies revealed the percentage of the complication from 1% to 7%.9 lo l 3 l4 30 On the other hand, we found only one case report concerning the complication of schizophrenia and bulimia nervosa.* In this report we report on 5 cases of patients with schizophrenia and anorexia nervosa and 3 cases of schizophrenia complicated by bulimia nervosa. SUBJECTS AND METHODS
The study was retrospective and made use of case records of 55 female patients admitted to the psychiatric division of the Tsukuba
University Hospital during the 14-year/9month time period between February, 1977, and November, 1991. The patients were diagnosed as suffering from eating disorder according to the diagnostic criteria of DSM111-R.’ In an item of Eating Disorders in DSM-111-R, anorexia nervosa, bulimia nervosa, pica, rumination disorders of infancy and eating disorder not otherwise specified are listed, but pica and rumination disorders of infancy are rarely seen. In this paper we use the term “eating disorder” for anorexia nervosa and bulimia nervosa. Twenty-one patients were diagnosed as anorexia nervosa, 28 cases as anorexia nervosa and bulimia nervosa, and 6 as bulimia nervosa. The
Table 1 : Summary of Mental Disorders in the Present Cases Case Age
20 Anorexia nervosa, schizophrenia
Anorexia nervosa, bulimia nervosa, schizophrenia
Anorexia nervosa, bulimia nervosa, schizophrenia 26 Anorexia nervosa, bulimia nervosa, schizophrenia 22 Anorexia nervosa, bulimia nervosa, schizophrenia Bulimia nervosa, schizophrenia
20 Bulimia nervosa, schizophrenia
Bulimia nervosa, schizophrenia
Type of Schizophrenia
Undifferentiated Auditory hallucination, delusion of being controlled, possession, reference and persecution, loss of volition Disorganized Auditory hallucination, visual hallucination, delusion of reference, persecution, observation and poisoning, lack of initiative Undifferentiated Auditory hallucination, visual hallucination, delusion of observation and control Undifferentiated Auditory hallucination, delusion of possession and control Auditory hallucination, deluDisorganized sion of reference, persecution, and observation, autism, lack of initiative Undifferentiated Auditory hallucination, visual hallucination, delusion of persecution, autism, lack of initiative Disorganized Delusion of reference, persecution, and observation, loosening of association, mannerism, lack of initiative Delusion of reference, perseDisorganized cution, and observation, autism, lack of initiative
Depressed mood, compulsive behavior Depressed mood, suicide attempt
depressed mood, suicide attempt Depressed mood
Depressed mood, suicide attempt
Eating Disorder and Schizophrenia patients’ ages ranged from 12 to 39 with a mean of 19.3. One case with anorexia nervosa and 4 patients with anorexia nervosa and bulimia nervosa coincidentally met the DSM111-R criteria for schizophrenia, and three cases of bulimia nervosa were also diagnosed as having schizophrenia. The clinical features of the 8 patients are summarized in Table 1. The course of the disorders is illustrated in Fig. 1. An outcome of the patients was judged in the following viewpoints: nutritional status, eating behavior, menstrual function, psychiatric status, and social adjustment.
the 8 cases showed schizothyme personality traits. The relationship a t the onset and the subsequent progress between the eating disor-
1 1 1
Six out of the 8 patients with schizophrenia developed a paranoid hallucinatory state and the other 2 cases showed a delusional state. Seven patients showed negative symptoms such as lack of initiative or autism. According to the predominant clinical picture, 4 patients were defined as the “undifferentiated” type, while the other 4 cases were judged as the “disorganized” type described in DSM-111-R. As for the prepsychotic personality, 6 out of
%1 S A B ED
Schizophrenu Anorexu nervom Bulnnia nervou Eating disorders (Anorexu n.rvosa+
Time scale is different in each case.
Fig. 1 : Chronology of symptom onsets in schizophrenia and eating disorders.
Table 2: Outcome Patient No.
Normal weight Normal eating Normal weight Normal eating Normal weight Bulimia Emaciated (78.8% of
SBW’) Normal weight Normal eating Normal weight Bulimia vomiting Normal weight Bulimia Normal weight Normal eating ‘SBW:standard body weight.
Menstruation Regular menses Regular menses Regular menses Amenorrhea
Regular menses Regular menses Regular menses No trouble throughout the course
Psychotic Symptoms Depressive symptoms, delusion of reference Depressive symptoms, suicide attempt, delusion of reference Depressive symptoms, auditory hallucination Depressive symptoms, suicide attempt, auditory hallucination, delusion of possession Lack of initiative
Social Adaptation Part-time job Absence from school Admitted in mental hospital Admitted in mental hospital Absence from school
Depressive symptoms, auditory Unemployed hallucination Depressive symptoms, delusion Unemployed of reference Absence from school Lack of initiative
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der and schizophrenia is illustrated in Fig. 1. The schizophrenic symptoms of the 4 patients occurred before the symptoms of the eating disorder appeared. In the other 4 patients, eating disorders preceded schizophrenia. As the outcome of the subjects is shown in Table 2, body weight recovery in schizophrenic patients with anorexia nervosa is good except in one case and all three schizophrenic subjects, with bulimia nervosa alone, showed no weight trouble. Two cases with anorexia nervosa had bulimic eating trouble at the follow-up but the other three cases with anorexia nervosa had a normal eating habit. Two patients with bulimia nervosa alone still had bulimic eating trouble. Four of the 5 schizophrenic subjects with anorexia nervosa recovered their menstruation at the followup. The psychotic symptoms at the follow-up revealed 7 cases showed depressive symptoms and also 7 cases still had schizophrenic symptoms like auditory hallucination, delusion or lack of initiative. In regard to the social or school life adaptation, all the cases were not well adapted. Case 1 had a part-time job but even this patient could not work a full-time job. Significant social or school life difficulties persisted and a resumption of premorbid functioning was not seen in all the patients. ILLUSTRATIVE CASE REPORT
Case No. 1: Anorexia Nervosa and Schizophrenia Miss H was 20 years old in 1982 and had an older sister who died in an accident 3 years before. Her father, 48 years old, was managing a supermarket and had a quick temper. Her mother, 53 years old, was a housewife and was meticulous and diligent. They were all healthy. Her uncle had been autistic and abulic and died in a mental hospital. The patient had been meticulous and nervous in premorbid time. At age 12 she weighed 33 kg and her height was 142.2 cm. She wanted to be like her female classmate who was shorter than the
patient and ate very little, but always received good grades and exercised actively. She then began on a reducing diet and had a desire “not to be taller.” At age 13 she entered a junior high school. She used to say “I want to be loved by everyone, so I like to be small like a little girl and do not want to grow taller or to be fat.” She continued to diet and her body weight decreased to 29 kg. At the age of 14 she was admitted to a hospital for a week and the physical examination and the laboratory data were within the normal limits. She kept loosing weight and she finally reached 26 kg. Once in her classroom, she suddenly became excited and shouted “A woman is ordering me within my head.” “My ancestor is in my body.” Since then she said that she was possessed by such animals as a rabbit, a cat, a raccoon dog, a fox, and a rat and she could hear their voices. Sometimes she ate a lot of food, saying “I hear a voice ordering me to eat this and that.” So she was admitted to a mental hospital. She showed a delusion of possession, auditory hallucination and a delusion of being controlled. Fortunately, these symptoms gradually improved. Her eating behavior was selfish and abnormal. She did not eat breakfast, ate lunch alone late after the hospital lunch time, and had supper at about eleven at night. She was diagnosed as having schizophrenia. At age 15 she came out of the hospital after a 10-month admission. She kept dieting, saying “I do not want to grow taller,” as she repeatedly said before. She began to complain of hypersalivation and spit frequently. She was admitted to the same hospital again. This time she showed obsessive compulsive symptoms, a lack of initiative, emaciation, loss of appetite and abnormal eating behavior. She could eat meals only after she counted from one to seven hundred with her eyes closed. She walked without stepping on the edge of the tiles of the floor. When she was 16 years old, she was discharged from the hospital and consulted the psychiatric division of the Tsukuba University Hospital. A general physical examination revealed she was extremely emaciated: her
Eating Disorder and Schizophrenia skin was dry, her finger tips looked purple, breasts were not developed. Laboratory tests including hormonal tests showed normal results except for slight normocytic anemia. She did not have menarche yet at that time. She did not admit that she was quite thin and did not want to grow taller than she was. She also showed a delusion of observation, a fear of contamination, compulsion (spitting on a sheet of paper), anxiety and a depressed mood. She obstinately refused to weigh herself on the scale or measure her height. She was diagnosed as having anorexia nervosa, schizophrenia and obsessive compulsive disorder according to the criteria of DSM-111-R. She was given bromazepam 15 mg and thioridazine 30mg per day. At age 16 she reentered a junior high school, weighing 30 kg and 147.5 cm tall. The above symptoms except the spitting behavior continued and she was sometimes absent from school, taking a walk for 4-5 hours with her mother which was thought to be hyperactive movement. At the age of 17 thioridazine 30 mg was changed to clocapramine 30mg and the volume of food she took gradually increased. She had a menarche. At age 18 she managed to graduate from a junior high school. She began to take meals regularly and her weight was 39 kg. She began to work, helping in her father’s supermarket sometimes, but she still had a delusion of reference, the wish of not getting taller and a depressed mood. These symptoms gradually disappeared and during this time she weighed 40kg and was 150cm. She worked regularly as a part-time worker 2 days a week. She had only one female friend who had been an inpatient when the patient was admitted to the hospital. Her menstruation has been regular since she was 18 years old. Her psychic condition is not strong enough to get full-time occupation and her social relationships are still impaired. Case No. 8: Bulimia Nervosa and Schizophrenia
Miss Y was 22 years old in 1990 and had a sister, aged 24, who worked for a company.
Her father was a research worker and her mother was a housewife. They were all healthy. There was no family history of psychiatric disorder. At age 17 Miss Y weighed 57 kg (height 163 cm, average weight for height: 56.7 kg). At that time she started dieting, lost 5 kg, but her periods continued. At age 18 she lost control of her eating habit and began to eat large quantities of food several times a day. In her own words, she said, “I cannot control my overeating and cannot help inducing vomiting after taking a large amount of food. I do not want to be fat.” At age 19 she entered a university and began her college life in a dormitory of the university which is almost 500 km away from her home. In the later stage of her freshman year, she told her parents, “I cannot endure such a hard life, because others watch me and say bad things about me behind my back. Human relations wear me out.” Her binge eating continued and she sometimes felt depressed and once cut her wrist. She was called back to her home where she took a rest for several months. She was taken to consult a psychiatric clinic and was given some medicine but she did not improve. She soon stopped going to the clinic. When she was 20 years old she went back to the university and moved up to the second-year class. She was autistic and had a delusion of persecution. She stayed away from class for almost an entire term. She still sometimes had bulimic eating periods and began to use purgatives. By chance, her father was transferred to the office in the same city where the university is in. Her parents moved to the city so she started to live with her parents. At about that same time she complained that others were singling out her for unwelcome attention and that others were speaking ill of her. At age 21 she returned to school, but a week after returning she attempted suicide in her room by taking 55 antiemetic tablets which she had bought at the drug store. She was admitted to the psychiatric clinic of the Tsukuba University Hospital. The patient
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showed a delusion of persecution, apathy, and loss of initiative. She was diagnosed as having schizophrenia with bulimia nervosa according to the diagnostic criteria of DSM-111-R. She was treated with haloperidol, bromperidol, chlorpromazine, sulpiride, and clocapramine but her symptoms did not improve except the bulimic eating behavior. Her parents discharged her from the hospital after 2 months’ care without remission. She was being absent from school and did nothing at home. DISCUSSION
We have reported 5 schizophrenic patients with anorexia nervosa or anorexia nervosa and bulimia nervosa out of 55 inpatients with eating disorders. The high incidence of the complication was unexpected. We have noticed that schizophrenia occurring within anorexia nervosa, both properly diagnosed, is not a rare phenomenon. In regard to the symptoms of schizophrenia, the main symptoms in 6 of 8 cases were auditory hallucination, delusions, and a lack of initiative. We diagnosed these cases as the “undifferentiated” type because these symptoms could not be classified as “catatonic,” “disorganized” or “paranoid” types according to the diagnostic criteria of DSM-111-R. Two cases showed delusions and blunted affect, autism and a lack of initiative which we diagnosed as the “disorganized” type. Ferguson and Damlujil’ presented 12 patients who met the DSM-111-R diagnostic criteria for both anorexia nervosa and schizophrenia and all of the cases were the “disorganized” type. In our patients, negative symptoms were not as prominent as those described by Ferguson and Damluji. Kretschmer” explained schizoid temperament and divided the most common schizoid peculiarities into three groups as follows; 1. unsociable, quiet, reserved, serious (humorless), eccentric. 2. timid, shy, with fine feelings, sensitive, nervous, excitable, fond of nature and books. 3. pliable, kindly, honest, indifferent, dull-witted, silent. The character-
istics in group 1 are without question the most common, in that they run like a scarlet thread through the whole schizoid characteology, as well as through groups 2 and 3. He most often called the members of the large constitution class from which the schizophrenics are recruited, “schizothymes,” which he explained as the transitional stages between illness and health. He called the abortive pathological forms, “schizoid.” As for the premorbid personality in our cases, 6 of 9 patients appeared introverted, unsociable, silent, pliable and nervous and we diagnosed them as having a “schizothyme” personality after Kretschmer. According to DSM-111-R’, the premorbid personalities of people who develop schizophrenia are often described as suspicious, introverted, withdrawn, eccentric, or impulsive; paranoid, schizoid, schizotypal, or borderline personality disorder may be present. Premorbid personality of our schizothyme cases resembles the schizoid personality disorder of DSM-111-R but are not so pathological as seen in a schizoid personality disorder. Premorbid schizothyme personality of the complicated patients may have an affinity for the onset of schizophrenia. The disturbance in body image is manifested in anorexia nervosa. I Bruch’ reported that a disturbance in body image and body concept of delusional proportions is the outstanding symptom. Bruch4 also described that the disturbances in body concept seem to represent the link between the severe eating disorders and schizophrenia; where conceptual disturbances are more conspicuous. In a usual examination, we often observe that an anorectic emaciates like a skeleton and yet he denies its abnormality, in contrast to ordinary non-eaters who grieve the weight loss. This property of the disturbance in body image is closely similar to a delusional concept in schizophrenia. The patient with anorexia nervosa has a tendency toward ambivalence. Wall3*reported that the patients with anorexia nervosa had a special dependency and an antipathy at the same time toward their mothers. King’* also reported 9 of 12 cases of
Eating Disorder and Schizophrenia primary anorexia nervosa were dependent and at the same time hostile to their mothers. Shimosaka2’ reported the anorectic complicated with schizophrenia had a dependence and a resistance at the same time to their parents. One of our anorectic patients said “I have a feeling that I want to eat and I do not want to eat at the same time, so I am at a loss what to do.” This patient had an ambivalence and an ambitendency. In these respects, anorexia nervosa has an affinity to schizophrenia and it seems likely that the symptoms of the former disorder accompany those of the latter. The outcome of anorexia nervosa is not simple and there are some aspects of measuring it. The course and prognosis of our 8 cases were judged from the following viewpoints: eating difficulties, nutritional status, menstrual function, psychiatric status, and psychosocial adjustment. In some studies13 22 30 33 , the body weight had become normal in 50% to 62% of the patients at the follow-up. But the body weight was still below 75% of average in 15% to 20% of the patient^.'^ 22 On the other hand, overweight subjects were seen between 2% and 7%. At least three-quarters of the patients had improved the body weight at the follow-up. In the present cases, 4 of 5 anorectic patients showed the normal weight at the follow-up. The return of menstrual function is preceded by a weight increase and improvement in mental attitude, and 40-66% of the patients had returned to menstruation at the followup.2 l 3 l6 30 33 Four of the 5 present cases had returned to menstruation which is a better prognosis than the previous reports. As to eating behavior, only one-third of the patients were eating normally as of the follow-up1322, while others still had eating difficultiessuch as bulimia, vomiting and laxative abuse6 I 3 22 30. Two of the 5 anorectic patients in this study still had bulimic eating trouble at the followup, which corresponds to a rather bad prognosis of the previous studies. Concerning the psychiatric outcome, affective disorders6 22 or depressive symptoms
are common among the patients a t the follow-up9 l 3 30. A prominence of depressive symptoms in 4 of the 5 cases and suicide attempts in 2 cases with anorexia nervosa and schizophrenia showed the same tendency as previously reported. In the complicated cases of anorexia nervosa and schizophrenia, Hsu et a1.14 reported depression in 5 of the 6 patients and suicide attempts in 2 cases. Our cases showed the same tendency in point of the depressive symptoms. Obsessive compulsive features were relatively commonly seen in 13% of 23%.6 13 22 30 Case 1 in this study exhibited prominent obsessive compulsive symptoms. In regard to the psychosocial outcome, Morgan and Russell2* and other authors6 l 3 l6 30 reported that a high proportion of the subjects was engaged in full-time employment in 67% to nearly all the patients. However, social relationship and relationship with family were much impaired in still anorectic patient^.'^ 22 Ferguson et a1.I’ presented 12 patients with anorexia nervosa and schizophrenia (all disorganized type) and all the cases had an unremitting and continual decline because of the prominent negative symptoms of schizophrenia. Social or school life difficulties persisted in all of our 5 patients with anorexia nervosa and schizophrenia but the types were all undifferentiated and the schizophrenic symptoms were not in remission at the follow-up. The worse prognosis compared with that of the patients with anorexia nervosa alone might depend upon the unremitting schizophrenic symptoms regardless of the type of schizophrenia. Bulimic symptoms had been reported mainly as partial symptoms of anorexia nervosa.1230 In 1979, Russell24first proposed a concept of bulimia nervosa as an ominous variant of anorexia nervosa. He described that in contrast with true anorexia nervosa, the patients tended to be heavier, more active sexually, and more likely to menstruate regularly and remain fertile. Depressive symptoms were often severe and distressing and led to a high risk of suicide. Concerning the psychosis
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in bulimia nervosa, Hudson et al.” reported 11 cases of bulimia were complicated with
major depression, bipolar disorder and schizoaffective disorder but not schizophrenia. There has been only one report of a case of schizophrenia with a history of bulimia.* We experienced three cases of schizophrenia with bulimia nervosa out of 6 patients with bulimia nervosa. We d o not know whether this incidence is high or low, because the studies on an incidence of the complication of these two disorders have not been undertaken.
The usual course of bulimia nervosa is chronic and intermittent over a period of many years.’ Hudson et a l l 5 described that the prognosis of bulimia nervosa is less favorable than in true anorexia nervosa. At this stage, our knowledge of the prognosis of bulimia nervosa is limited, for long-term followup studies have not been undertaken. As for the prognosis of the present 3 cases of schizophrenia with bulimia nervosa, the body weight and menstruation were normal but 2 cases still showed bulimic eating difficulties. All the 3 patients had schizophrenic symptoms at the follow-up and the social adaptation of them was poor, which was the same result as that observed in patients with anorexia nervosa and schizophrenia. In bulimia nervosa a depressed mood that may be part of a depressive disorder is commonly observed.’ A t this stage long-term follow-up studies on the prognosis of bulimia nervosa and the case studies of a complicated case of bulimia nervosa with schizophrenia are expected. REFERENCES
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