Case Reports
10. Mullan F: The Cancer Conson-An action agenda for cancer patients. in Current Concepts in Psycho-Oncology and Aids: Syllabus of the Postgraduate Course. New York. Memorial Sloan-Kettering Cancer Center, 1987 191-194 11. Holland J: Fears and abnormal reactions to cancer in physically healthy individuals, in Handbook of Psyclwoncology. Psyclwlogical Care of the Patient with Cancer. Edited by Holland JC and Rowland JH. New York. Oxford University Press. 1989 12. Ford CV: The Munchausen syndrome: a repon of four new cases and a review of the literature. Int] Psychiatry Med4:31-45,1973
13. Geracioti TO, Van Dyke C. Mueller J. et al: The onset of Munchausen's syndrome. Gen Hasp Psychiatry 9:405409,1987 14. Henderson S: Care-eliciting behavior in man.] NervMent Dis 159:172-181, 1969 15. Nadelson T: False patients/real patients: a spectrum of disease presentation. Psychotherapy Psychosomatics 44:175-184,1985 16. Nadelson T: The Munchausen spectrum: borderline character features. Gen Hosp Psychiatry 1:11-17, 1979 17. Kass FC: Identification of persons with Munchausen syndrome: ethical problems. Gen Hosp Psychiatry 7:195200,1985
Eating Disorders and Connective Tissue Disease Etiologic and Treatment Considerations ALLAN
S.
KAPLAN, M.D., MARK
T
KATZ,
he presence of a chronic nonpsychiarric medical illness has been hypothesized to be a risk factor for the later development of anorexia nervosa or bulimia nervosa.' The underlying mechanism for this is complex and probably relates to biological, intrapsychic, and familial variables. Biologically, there may be a genetic link between a specific nonpsychiatric medical illness and an eating disorder. as has been hypothesized for alcoholism 2 and depression. 3 Psychologically, the experience of struggling with physical illness may leave a person with a sense of having been betrayed by the body, contributing to a sense of ineffectiveness and lack of control over one's life. Controlling food intake and body weight may be an attempt to deal with such feelings in a vulnerable individual. In addition, chronic physical illness may lead to failure to thrive in childhood,lack of appropriate growth and weight gain in adolescence, or loss of weight in adulthood. These experiences may lead to an undue focus on VOLUME 33· NUMBER I' WINTER 1992
F.R.C.P.(C)
M.D.
eating and weight in a vulnerable individual and to a pathologic preoccupation with the pursuit of thinness. The presence of a nonpsychiatric physical illness may lead to families overprotecting a child, interfering with this child's successfully separating and becoming autonomous and contributing to the development of an eating disorder. A concurrent nonpsychiatric medical illness, although not necessarily predisposing a patient, can significantly complicate the course of an eating disorder and interfere with recovery. An example of this is the occurrence of diabetes and Received September 18, 1990; accepted November 5, 1990. From the Depanment of Psychiatry, University of Toronto. and the Toronto General Hospital. Address reprint requests to Dr. Kaplan, Director, Eating Disorder Centre. Toronto General Hospital, CW 1-311. 200 Elizabeth Street. Toronto, Ontario M5G 2C4, Canada. Copyright © 1992 The Academy of Psychosomatic Medicine.
105
Case Reports
bulimia nervosa, where there have been reports of patients who manipulate their blood sugar in order to lose weight. 4 Such behavior leads to serious complications and difficult management problems. We descri be here two cases of patients with connective tissue disease and eating disorders, where the above issues are highlighted.
Case Reports Case l. Miss A was a 21-year-old, single, unemployed female who presented with a 3-year history of anorexia nervosa characterized by extreme food restriction, feelings of fatness, progressive weight loss, and an intense desire to lose more weight. During the first year of her illness, she occasionally binged and vomited, but had been binge-free since that time. She continued to vomit weekly. At the time of presentation, she weighed 90 pounds (at 5 feet, 5 inches tall), representing 69% of matched population mean weight (MPMW). Her daily intake consisted of no breakfast, a salad for lunch, and a bag of popcorn for dinner. She had been amenorrheic for 1.5 years. Significant in her history was the fact that she had osteogenesis imperfecta. She had sustained over 20 broken bones prior to age 10 and had missed considerable amounts of school because of this. She was restricted in her physical activity throughout childhood, having broken her tibia as an infant simply by putting her foot through her crib. The parents commented on seeing her as fragile and at times they were concerned that simply holding her would lead to fractures. At consultation, the most significant sequelae of her illness related to increasing deafness and extreme self-consciousness because of her blue sclera. Physical examination revealed an emaciated woman with blue sclera, generalized loose jointedness, and a triangular shaped head and face. Laboratory investigation revealed leukopenia, hypophosphatemia, and borderline hypocalcemia. EKG revealed a significant number of ventricular premature beats and an echocardiogram demonstrated evidence for mitral valve prolapse. Case 2. Miss B was a 27-year-old, separated female who presented with a 5-year history of bulimia nervosa with more than daily episodes of bingeing associated with purging. At the time of presentation, 106
her weight was 131 pounds (at 5 feet 3 inches tall), 106% of MPMW. Her lowest weight, at age 21, was 110 pounds and her highest weight was 142 pounds at age 17. She was menstruating regularly. Her daily caloric intake consisted of no food until the evening when she would binge and take 20 laxative tablets. Significant in her history was the fact that I year prior to consultation. she had presented to a rheumatologist with a 6-year history of rosacea, Raynaud's phenomenon. intermittent arthralgia. shortness of breath on exertion, and extreme postprandial fullness and heartburn. Physical examination revealed puffy edematous fingers, nail-fold capillary dilatation, tightness of the skin on the dorsum of both hands. an erythematous blanching rash on the cheeks and forehead, telangiectasia on the face and the palmar and dorsal surfaces of both hands, and atrophic fissured skin in the vulvar and perineal area. Laboratory investigations revealed abnormal esophageal motility with evidence of gastrointestinal reflux (see Figure I), a positive antinuclear factor. and high positive anti-centromere antibodies. In addition. she was found to have an abnormal pulmonary diffusing capacity of 72%. A tentative diagnosis of scleroderma was made based on the presence of four of the five components of the Crest syndrome (telangiectasia. Raynaud's phenomenon. sclerodactyly and esophageal motility disorder).
Discussion The current literature includes descriptions of eating disorders in a variety of chronic nonpsychiatric medical conditions, including cystic fibrosis,S diabetes,4 renal disease,6 pancreatitis,? and multiple sclerosis. 8 All these conditions have in common the need to be vigilant about caloric intake, body weight, and psychological control. In a review of the derrnatologic 9 and gastrointestinal lO complications of anorexia nervosa and bulimia nervosa, there is no mention of a possible interrelationship between eating disorders and connective tissue disease. There is one case report of anorexia nervosa and Gaucher's disease, I I but the authors conclude that the patient did not in fact have anorexia nervosa. The above cases extend the current literature on the etiologic and treatment implications of an association between chronic nonpsychiatric PSYCHOSOMATICS
Case Reports
medical illness and eating disorders. The presence of osteogenesis imperfecta in the first case certainly contributed to the patient's inability to develop a distinct and secure sense of body self and an accurate body image. As described by Bruch,12 the core psychopathology in patients with eating disorders relates to disturbances in body image, defects in the perception and interpretation of stimuli originating from within the body, and a pervasive sense of ineffectiveness related to a feeling of not being in control ofone's life. All of these symptoms share a common underlying disturbance related to lack of a cohesive and secure sense of the physical self. In this particular individual, the presence of osteogeneFIGURE I. Radioisotope esophageal transit time study, supine position revealing liquid bolus (Technetium 99m sulfur colloid in H20) pooling in the mid and lower esophagus (~) throughout the entire study. This is indicative of abnormal esophageal motility and consistent with clinical diagnosis of scleroderma.
Whole esophagus
-l /)
c:
:::l
o
-o -
Upper
o
o
c:
Mid
Lower
o
15 Time (5)
VOLUME 33· NUMBER I • WINTER 1992
30
sis imperfecta was a significant risk factor for an eating disorder because of its psychological effect on the patient's inability to trust her body and subsequent problems around autonomy and separation. The adult sequelae of her osteogenesis, blue sclera and increasing deafness, served to increase this patient's self-consciousness and awareness of her defective body and of her need to attempt to control it through weight loss and dieting. There are specific management issues that need to considered in such a patient. For example, the secondary effects of weight loss and resultant prolonged amenorrhea on bone physiology in anorexia nervosa have been well described. 13 For a patient whose bone is congenitally fragile, prolonged amenorrhea and further loss of bone mass could lead to serious and debilitating consequences such as pathologic fractures. Consideration needs to be given to possible estrogen replacement therapy in such a patient because of the significant risk of osteopenia and osteoporosis. This patient's cardiac complications, especially mitral valve prolapse, could be a manifestation of the underlying connective tissue abnormality. However, arrhythmias and mitral valve prolapse have also been described in patients who are emaciated for whatever reason and specifically in patients with anorexia nervosa.1 4 In this patient, these comorbid conditions significantly increase the risk for cardiac complications and sudden death. A Holter monitor showed that the patient had clinically significant runs of ventricular premature beats associated with shortness of breath and chest pain that were successfully treated with propranolol. The interphase between a disorder such as scleroderma and bulimia nervosa occurs at severallevels. Psychologically, the rash, telangiectasia, and disfiguring tightness of the skin in the second patient led to an exacerbation of shape and weight concerns which increased her body image disturbance, and resistance to eating, because of fears that her tigh.t skin could not tolerate weight gain. This patient sought to achieve a measure of control over what she perceived as a rebellious body via dietary restriction. She viewed her illness as punishment for her innate 107
Case Reports
worthlessness, a manifestation of an underlying depressive diathesis. There is a well-known association between depression and nonpsychiatric medical illness generally,lS and this patient's depression and bulimia were temporally related to an increased awareness of the symptoms of scleroderma. Physically, her gastrointestinal motility disturbance was associated with severe reflux, dysphagia, bloating, and postprandial discomfort and contributed to her feeling of fullness and avoidance of eating, complicating the management of her bulimia. It was difficult to attribute these complaints solely to her scleroderma, since motility disturbances have been described in patients with anorexia nervosa and bulimia nervosal 6 secondary to nutritional instability. The presence of chronic self-induced vomiting common in patients with bulimia, although not present in this patient, could seriously exacerbate the underlying eosphageal dysfunction present in
scleroderma, contributing to difficulties in the management of the connective tissue disorder. Finally, studies investigating the prevalence of anorexia and bulimia nervosa among a highrisk group of young adult women who suffer from connective tissue disease have not been reported. Such studies may be justified in order to alert clinicians to the possible coexistence of these disorders. Patients with eating disorders are often secretive about their problem and will not disclose that they suffer from an eating disorder unless specifically asked about weight concerns and disturbed eating behaviors. Failure to inquire about these areas could lead to unnecessary complications, mismanagement of both the eating disorder and connective tissue disease, and possible iatrogenesis.
We gratefully acknowledge the assistance of Dr. C. Yip, Department of Radiology, Toronto General Hospital.
References I. Garfinkel PE. Gamer OM. Goldbloom OS: Eating disorders: implications for the 1990s. Can J Psychiatry 32:624-631. 1987 2. Bulik C: Drug and alcohol abuse by bulimic women and their families. Am J Psychiatry 144:1604-1606. 1987 3. Strober M. Katz J: Depression in the eating disorders: a review and analysis of descriptive. family and biological faclors. in DiaKnostic Issues in Anorexia Nervosa and Bulimia Nerl'Osa. Edited by Gamer OM. Garfinkel PE. New York. Brunner/Mazel. 1988 4. Rodin GM. Oaneman LE. Johnson A. et al: Anorexia nervosa and bulimia in female adolescents with insulindependent diabetes mellitus: a systematic study. J PsychiatrRes 19:381-384. 1985 5. Pumariega AJ. Pursell J. Spock A. et al: Eating disorders in adolescents with cystic fibrosis. J Am Acad Child Psychiatry 25:269-275. 1986 6. Brotman AW. Stem TA. Brotman OL: Renal disease and dysfunction in two patients with anorexia nervosa. J Clin Psychiatry 47:433~34. 1986 7. Gavish 0, Eisenberg S. Berry EM. et al: Bulimia-an underlying behavioural disorder in hyperlipidemic pancreatitis: a prospective multidisciplinary approach. Arch Intern Med 147:705-708. 1987 8. Tovy SW. Gertler R. Brigham S. et al: Anorexia nervosa
108
in a patient with multiple sclerosis: a case report.lnternational Journal ofEatinK Disorders 8:231-234. 1989 9. Gupta MA. Gupta AK. Haberman HF: Dermatologic signs in anorexia nervosa and bulimia nervosa. Arch Derma101123: 1386-1390. 1987 10. Cuellar RE. Van Thiel DH: Gastrointenstinal consequences of the eating disorders: anorexia nervosa and bulimia. Am J Gastroenterol81: 1113-1124. 1986 II. Erman MK. Murray GB: A case report of anorexia nervosa and Gaucher's disease. Am J Psychiatry 137:858859. 1980 12. Bruch H: EatinK Disorders: Ohesity. Anorexia Nervosa. and the Person Within. New York: Basic Books. 1973 13. Rigoni NA. Nussbaum SR. Herzog OB. et al: Osteoporosis in women with anorexia nervosa. N EnKI J Med 311:1601-1606.1984 14. Johnson GL. Humphries L. Shirley P. et al: Mitral valve prolapse in patients with anorexia nervosa and bulimia. Arch Intern Med 105:384--386. 1986 15. Rodin G. Voshart K: Depression in the medically ill: an overview. Am J Psychiatry 143:696-705. 1986 16. Robinson PH. Clarke M. Barren J: Determinants of delayed gastric emptying in anorexia nervosa and bulimia nervosa. Gut 29:458~64. 1988
PSYCHOSOMATICS
10. Mullan F: The Cancer Conson-An action agenda for cancer patients. in Current Concepts in Psycho-Oncology and Aids: Syllabus of the Postgraduate Course. New York. Memorial Sloan-Kettering Cancer Center, 1987 191-194 11. Holland J: Fears and abnormal reactions to cancer in physically healthy individuals, in Handbook of Psyclwoncology. Psyclwlogical Care of the Patient with Cancer. Edited by Holland JC and Rowland JH. New York. Oxford University Press. 1989 12. Ford CV: The Munchausen syndrome: a repon of four new cases and a review of the literature. Int] Psychiatry Med4:31-45,1973
13. Geracioti TO, Van Dyke C. Mueller J. et al: The onset of Munchausen's syndrome. Gen Hasp Psychiatry 9:405409,1987 14. Henderson S: Care-eliciting behavior in man.] NervMent Dis 159:172-181, 1969 15. Nadelson T: False patients/real patients: a spectrum of disease presentation. Psychotherapy Psychosomatics 44:175-184,1985 16. Nadelson T: The Munchausen spectrum: borderline character features. Gen Hosp Psychiatry 1:11-17, 1979 17. Kass FC: Identification of persons with Munchausen syndrome: ethical problems. Gen Hosp Psychiatry 7:195200,1985
Eating Disorders and Connective Tissue Disease Etiologic and Treatment Considerations ALLAN
S.
KAPLAN, M.D., MARK
T
KATZ,
he presence of a chronic nonpsychiarric medical illness has been hypothesized to be a risk factor for the later development of anorexia nervosa or bulimia nervosa.' The underlying mechanism for this is complex and probably relates to biological, intrapsychic, and familial variables. Biologically, there may be a genetic link between a specific nonpsychiatric medical illness and an eating disorder. as has been hypothesized for alcoholism 2 and depression. 3 Psychologically, the experience of struggling with physical illness may leave a person with a sense of having been betrayed by the body, contributing to a sense of ineffectiveness and lack of control over one's life. Controlling food intake and body weight may be an attempt to deal with such feelings in a vulnerable individual. In addition, chronic physical illness may lead to failure to thrive in childhood,lack of appropriate growth and weight gain in adolescence, or loss of weight in adulthood. These experiences may lead to an undue focus on VOLUME 33· NUMBER I' WINTER 1992
F.R.C.P.(C)
M.D.
eating and weight in a vulnerable individual and to a pathologic preoccupation with the pursuit of thinness. The presence of a nonpsychiatric physical illness may lead to families overprotecting a child, interfering with this child's successfully separating and becoming autonomous and contributing to the development of an eating disorder. A concurrent nonpsychiatric medical illness, although not necessarily predisposing a patient, can significantly complicate the course of an eating disorder and interfere with recovery. An example of this is the occurrence of diabetes and Received September 18, 1990; accepted November 5, 1990. From the Depanment of Psychiatry, University of Toronto. and the Toronto General Hospital. Address reprint requests to Dr. Kaplan, Director, Eating Disorder Centre. Toronto General Hospital, CW 1-311. 200 Elizabeth Street. Toronto, Ontario M5G 2C4, Canada. Copyright © 1992 The Academy of Psychosomatic Medicine.
105
Case Reports
bulimia nervosa, where there have been reports of patients who manipulate their blood sugar in order to lose weight. 4 Such behavior leads to serious complications and difficult management problems. We descri be here two cases of patients with connective tissue disease and eating disorders, where the above issues are highlighted.
Case Reports Case l. Miss A was a 21-year-old, single, unemployed female who presented with a 3-year history of anorexia nervosa characterized by extreme food restriction, feelings of fatness, progressive weight loss, and an intense desire to lose more weight. During the first year of her illness, she occasionally binged and vomited, but had been binge-free since that time. She continued to vomit weekly. At the time of presentation, she weighed 90 pounds (at 5 feet, 5 inches tall), representing 69% of matched population mean weight (MPMW). Her daily intake consisted of no breakfast, a salad for lunch, and a bag of popcorn for dinner. She had been amenorrheic for 1.5 years. Significant in her history was the fact that she had osteogenesis imperfecta. She had sustained over 20 broken bones prior to age 10 and had missed considerable amounts of school because of this. She was restricted in her physical activity throughout childhood, having broken her tibia as an infant simply by putting her foot through her crib. The parents commented on seeing her as fragile and at times they were concerned that simply holding her would lead to fractures. At consultation, the most significant sequelae of her illness related to increasing deafness and extreme self-consciousness because of her blue sclera. Physical examination revealed an emaciated woman with blue sclera, generalized loose jointedness, and a triangular shaped head and face. Laboratory investigation revealed leukopenia, hypophosphatemia, and borderline hypocalcemia. EKG revealed a significant number of ventricular premature beats and an echocardiogram demonstrated evidence for mitral valve prolapse. Case 2. Miss B was a 27-year-old, separated female who presented with a 5-year history of bulimia nervosa with more than daily episodes of bingeing associated with purging. At the time of presentation, 106
her weight was 131 pounds (at 5 feet 3 inches tall), 106% of MPMW. Her lowest weight, at age 21, was 110 pounds and her highest weight was 142 pounds at age 17. She was menstruating regularly. Her daily caloric intake consisted of no food until the evening when she would binge and take 20 laxative tablets. Significant in her history was the fact that I year prior to consultation. she had presented to a rheumatologist with a 6-year history of rosacea, Raynaud's phenomenon. intermittent arthralgia. shortness of breath on exertion, and extreme postprandial fullness and heartburn. Physical examination revealed puffy edematous fingers, nail-fold capillary dilatation, tightness of the skin on the dorsum of both hands. an erythematous blanching rash on the cheeks and forehead, telangiectasia on the face and the palmar and dorsal surfaces of both hands, and atrophic fissured skin in the vulvar and perineal area. Laboratory investigations revealed abnormal esophageal motility with evidence of gastrointestinal reflux (see Figure I), a positive antinuclear factor. and high positive anti-centromere antibodies. In addition. she was found to have an abnormal pulmonary diffusing capacity of 72%. A tentative diagnosis of scleroderma was made based on the presence of four of the five components of the Crest syndrome (telangiectasia. Raynaud's phenomenon. sclerodactyly and esophageal motility disorder).
Discussion The current literature includes descriptions of eating disorders in a variety of chronic nonpsychiatric medical conditions, including cystic fibrosis,S diabetes,4 renal disease,6 pancreatitis,? and multiple sclerosis. 8 All these conditions have in common the need to be vigilant about caloric intake, body weight, and psychological control. In a review of the derrnatologic 9 and gastrointestinal lO complications of anorexia nervosa and bulimia nervosa, there is no mention of a possible interrelationship between eating disorders and connective tissue disease. There is one case report of anorexia nervosa and Gaucher's disease, I I but the authors conclude that the patient did not in fact have anorexia nervosa. The above cases extend the current literature on the etiologic and treatment implications of an association between chronic nonpsychiatric PSYCHOSOMATICS
Case Reports
medical illness and eating disorders. The presence of osteogenesis imperfecta in the first case certainly contributed to the patient's inability to develop a distinct and secure sense of body self and an accurate body image. As described by Bruch,12 the core psychopathology in patients with eating disorders relates to disturbances in body image, defects in the perception and interpretation of stimuli originating from within the body, and a pervasive sense of ineffectiveness related to a feeling of not being in control ofone's life. All of these symptoms share a common underlying disturbance related to lack of a cohesive and secure sense of the physical self. In this particular individual, the presence of osteogeneFIGURE I. Radioisotope esophageal transit time study, supine position revealing liquid bolus (Technetium 99m sulfur colloid in H20) pooling in the mid and lower esophagus (~) throughout the entire study. This is indicative of abnormal esophageal motility and consistent with clinical diagnosis of scleroderma.
Whole esophagus
-l /)
c:
:::l
o
-o -
Upper
o
o
c:
Mid
Lower
o
15 Time (5)
VOLUME 33· NUMBER I • WINTER 1992
30
sis imperfecta was a significant risk factor for an eating disorder because of its psychological effect on the patient's inability to trust her body and subsequent problems around autonomy and separation. The adult sequelae of her osteogenesis, blue sclera and increasing deafness, served to increase this patient's self-consciousness and awareness of her defective body and of her need to attempt to control it through weight loss and dieting. There are specific management issues that need to considered in such a patient. For example, the secondary effects of weight loss and resultant prolonged amenorrhea on bone physiology in anorexia nervosa have been well described. 13 For a patient whose bone is congenitally fragile, prolonged amenorrhea and further loss of bone mass could lead to serious and debilitating consequences such as pathologic fractures. Consideration needs to be given to possible estrogen replacement therapy in such a patient because of the significant risk of osteopenia and osteoporosis. This patient's cardiac complications, especially mitral valve prolapse, could be a manifestation of the underlying connective tissue abnormality. However, arrhythmias and mitral valve prolapse have also been described in patients who are emaciated for whatever reason and specifically in patients with anorexia nervosa.1 4 In this patient, these comorbid conditions significantly increase the risk for cardiac complications and sudden death. A Holter monitor showed that the patient had clinically significant runs of ventricular premature beats associated with shortness of breath and chest pain that were successfully treated with propranolol. The interphase between a disorder such as scleroderma and bulimia nervosa occurs at severallevels. Psychologically, the rash, telangiectasia, and disfiguring tightness of the skin in the second patient led to an exacerbation of shape and weight concerns which increased her body image disturbance, and resistance to eating, because of fears that her tigh.t skin could not tolerate weight gain. This patient sought to achieve a measure of control over what she perceived as a rebellious body via dietary restriction. She viewed her illness as punishment for her innate 107
Case Reports
worthlessness, a manifestation of an underlying depressive diathesis. There is a well-known association between depression and nonpsychiatric medical illness generally,lS and this patient's depression and bulimia were temporally related to an increased awareness of the symptoms of scleroderma. Physically, her gastrointestinal motility disturbance was associated with severe reflux, dysphagia, bloating, and postprandial discomfort and contributed to her feeling of fullness and avoidance of eating, complicating the management of her bulimia. It was difficult to attribute these complaints solely to her scleroderma, since motility disturbances have been described in patients with anorexia nervosa and bulimia nervosal 6 secondary to nutritional instability. The presence of chronic self-induced vomiting common in patients with bulimia, although not present in this patient, could seriously exacerbate the underlying eosphageal dysfunction present in
scleroderma, contributing to difficulties in the management of the connective tissue disorder. Finally, studies investigating the prevalence of anorexia and bulimia nervosa among a highrisk group of young adult women who suffer from connective tissue disease have not been reported. Such studies may be justified in order to alert clinicians to the possible coexistence of these disorders. Patients with eating disorders are often secretive about their problem and will not disclose that they suffer from an eating disorder unless specifically asked about weight concerns and disturbed eating behaviors. Failure to inquire about these areas could lead to unnecessary complications, mismanagement of both the eating disorder and connective tissue disease, and possible iatrogenesis.
We gratefully acknowledge the assistance of Dr. C. Yip, Department of Radiology, Toronto General Hospital.
References I. Garfinkel PE. Gamer OM. Goldbloom OS: Eating disorders: implications for the 1990s. Can J Psychiatry 32:624-631. 1987 2. Bulik C: Drug and alcohol abuse by bulimic women and their families. Am J Psychiatry 144:1604-1606. 1987 3. Strober M. Katz J: Depression in the eating disorders: a review and analysis of descriptive. family and biological faclors. in DiaKnostic Issues in Anorexia Nervosa and Bulimia Nerl'Osa. Edited by Gamer OM. Garfinkel PE. New York. Brunner/Mazel. 1988 4. Rodin GM. Oaneman LE. Johnson A. et al: Anorexia nervosa and bulimia in female adolescents with insulindependent diabetes mellitus: a systematic study. J PsychiatrRes 19:381-384. 1985 5. Pumariega AJ. Pursell J. Spock A. et al: Eating disorders in adolescents with cystic fibrosis. J Am Acad Child Psychiatry 25:269-275. 1986 6. Brotman AW. Stem TA. Brotman OL: Renal disease and dysfunction in two patients with anorexia nervosa. J Clin Psychiatry 47:433~34. 1986 7. Gavish 0, Eisenberg S. Berry EM. et al: Bulimia-an underlying behavioural disorder in hyperlipidemic pancreatitis: a prospective multidisciplinary approach. Arch Intern Med 147:705-708. 1987 8. Tovy SW. Gertler R. Brigham S. et al: Anorexia nervosa
108
in a patient with multiple sclerosis: a case report.lnternational Journal ofEatinK Disorders 8:231-234. 1989 9. Gupta MA. Gupta AK. Haberman HF: Dermatologic signs in anorexia nervosa and bulimia nervosa. Arch Derma101123: 1386-1390. 1987 10. Cuellar RE. Van Thiel DH: Gastrointenstinal consequences of the eating disorders: anorexia nervosa and bulimia. Am J Gastroenterol81: 1113-1124. 1986 II. Erman MK. Murray GB: A case report of anorexia nervosa and Gaucher's disease. Am J Psychiatry 137:858859. 1980 12. Bruch H: EatinK Disorders: Ohesity. Anorexia Nervosa. and the Person Within. New York: Basic Books. 1973 13. Rigoni NA. Nussbaum SR. Herzog OB. et al: Osteoporosis in women with anorexia nervosa. N EnKI J Med 311:1601-1606.1984 14. Johnson GL. Humphries L. Shirley P. et al: Mitral valve prolapse in patients with anorexia nervosa and bulimia. Arch Intern Med 105:384--386. 1986 15. Rodin G. Voshart K: Depression in the medically ill: an overview. Am J Psychiatry 143:696-705. 1986 16. Robinson PH. Clarke M. Barren J: Determinants of delayed gastric emptying in anorexia nervosa and bulimia nervosa. Gut 29:458~64. 1988
PSYCHOSOMATICS
