Case Reports
References I. Morselli E: Sulla dismorfofobia e tafefobia. Bollerrino Accademia Scien:e Mediche (Genoa) 6: 100-119.1886 2. McKenna PJ: Disorders with overvalued ideas. Br} Psychiatry 145:579-585. 1984 3. Binchnell SA: Dysmorphophobia: a centenary discussion. Br} Psychiatry 153(suppI2):41-43. 1988 4. Andreasen NC. Bardach J: Dysmorphophobia: symptom or disease'! Am} PsychiOlry 134:673-676. 1977 5. Hay GG: Dysmorphophobia. Br} Psychiatry 116:399406.1970 6. American Psychiatric Association: Diagnostic andStatis· tical Manual of Mental Disorders. Third Ed. Rel'ised. Washington. DC. American Psychiatric Association.
1987 7. Crisp AH: Dysmorphophobia and the search for cosmetic surgery. Br Med} 282: 1099-1100.1981 8. Riding J. Munro A: Pimozide in the treatment of monosymptomatic hypochondriacal psychosis. Acta Psychiatr Scand 52:23-30. 1975 9. Garety PA. Hemsley DR: Characteristics of delusional experience. Eur Arch Psychiatry Neurol Sci 236:294298.1987 10. Insel TR. Akiskal HS: Obsessive-compulsive disorder with psychotic features: a phenomenologic analysis. Am } Psychiatry 143:1527-1533.1986
Thyrotoxicosis and Bulimia Nervosa DEAN KRAHN.
hyroid disorders can cause abnonnalilies in patients' appetite and weight regulation. gastrointestinal function. and mood. These systems are also dysfunctional in patients with eating disorders. Hypothyroidism commonly results in mild weight gain with constipation. lethargy•and depression.1.2 In contrast. the classic description of symptoms of hyperthyroidism is weight loss despite an increased appetite. hyperactivity. irritability. and emotional lability.3.4 Given the great overlap ofthe symptoms of thyroid abnonnalities with the symptoms of eating disorders. it is surprising that more cases of coexistent thyroid and eating dysfunctions have not been reported. This case report describes a patient with bulimia nervosa and a history ofanorexia nervosa who also suffered from hyperthyroidism. The prodigious binge-eating behavior of this patient
T
Received January 16. 1989; revised May 31. 1989; accepted June 28. 1989. Address reprint requests to Dr. Krahn. Eating Disorders Program. Depanment of Psychiatry. University of Michigan. 1500 East Medical Center Drive. Ann Arbor. MI48109. Copyright © 1990 The Academy of Psychosomatic Medicine
222
M.D.
resulted in the unusual presentation of thyrotoxicosis with weight gain. Successful treatment of the thyrotoxicosis resolved not only her increased appetite and anxiety. which are characteristic of this endocrine dysfunction. but also her cognitive distortions about her body image. which are characteristic of eating disorders.
Case Report A 21-year-old female student presented to the University of Michigan Eating Disorders Program for help with prodigious episodic binge-eating that occurred two or more times per night. She fasted almost constantly between her nocturnal binges. The patient was upset because she had gained 25 pounds in the past six months. Her height was 61 inches. and her weight was 166 pounds. She had formerly used vomiting to control her weight. and she contemplated returning to this behavior. She reported heat intolerance. some diarrhea. rare heart palpitations. increased feelings of anxiety. and emotional lability during the rapid weight gain. She specifically denied dysphagia. neck pain. changes in her vision. or galactorrhea. PSYCHOSOMATICS
Case Reports
The patient's excessive concern with body weight was triggered by a weight increase from 130 to 180 pounds at menarche. She had fasted and exercised obsessively and lost 75 pounds. When family members confronted the patient about her fasting, she began to eat meals but also to vomit following them. The family later organized a system of aftermeal monitoring and the patient stopped all bingeeating and purging except for very rare, brief relapses. However, the patient remained markedly overconcerned about her weight; she dieted often and had frequent weight swings around a mean of 125 pounds. Her mother also had a history of vomiting to control her weight and ongoing obsessive fasting and exercising. A sister was known to binge and purge. No personal or family history of other psychiatric disorders was noted. Her mother had hypothyroidism, and another sister had undergone surgery for a benign thyroid nodule. The patient was noted to have very warm, moist hands. She spoke rapidly and seemed anxious. No delusions, hallucinations, obsessions (other than those related to weight), or cognitive defects were noted. On the Eating Disorders Inventory (EDl),5 the patient scored 16 on the Drive for Thinness Subscale; 9 on the Interoceptive Awareness Subscale; 10 on the Bulimia Subscale; 22 on the Body Dissatisfaction Subscale; I on the Ineffectiveness Subscale; I on the Maturity Fears Subscale; 2 on the Perfectionism Subscale; and 3 on the Interpersonal Distrust Subscale. The patient's scores on the first four subscales were typical of the scores of the bulimic patients we see in the clinic, but her scores on the last four subscales were relatively low compared to the scores of our other bulimic patients. Physical examination revealed a pulse of 108 at rest; warm, moist skin; a fine, bilateral tremor in the upper extremities; and a diffusely enlarged thyroid gland without nodules. Thyroid function tests confirmed the clinical suspicion of hyperthyroidism. Her T 4 level was 17.9 jlgldJ (normal range, 4.4jlg to 11.6jlgldl). She had a T J uptake of 106% (normal range, 86% to 114%). TSH levels were less than 0.2 jlU/ml (normal, O.3jlU/ml to 6.0 jlU/ml). She had a free thyroxine index of 18.97 (normal, 3.8 to 13.2). Treatment with 12 milliCuries of LJI I resulted in a marked decrease in anxiety and in her drive to eat. She began to eat three normal meals per day, and abnormal patterns of eating ceased. Neither the patient nor the therapist saw residual symptoms of an eating disorder that required therapy. She tolerated with equanimity a five-pound weight gain during a brief VOLUME 31· NUMBER 2· SPRING 1990
FIGURE I. Scores on subscales of the Eating Disorder Inventory (EOI) in a patient with concurrent bulimia and hyperthyroidism before and after treatment of thyrotoxicosis. The solid bar represents the mean±SD scores of 191 normal college-age women. Key: DT, Drive for Thinness; lA, Introspective Awareness; B, Bulimia; BD, Body Dissatisfaction; IE, Ineffectiveness; MF, Maturity Fears; P, Perfectionism; 10, Interpersonal Distrust 30
• • •
20
NORMN.. PlUREAT POSITREAT
10
o OT
IA
B
II)
E
tJF
P
10
period of iatrogenic hypothyroidism, and she did not resume dieting or other weight control behaviors. Her scores on the EDl showed an impressive resolution of cognitive distortions: scores on all subscales dropped to zero, with the exceptions of the Body Dissatisfaction Subscale, on which she scored 8, and the Perfectionism Subscale, on which she scored 2. These scores are lower than those seen in normal college-age women (Figure I). After six months, the patient remained binge-free, and her thyroid function tests were normal (TSH, 1.0 jlU/ml; free T4 , 1.7 ngldl).
Discussion Although the symptoms of thyroid and eating disorders overlap in the areas of mood disturbance, gastrointestinal symptoms, and appetite changes, only five cases of eating disorders coincident with hyperthyroidism have been reported.&-9 Only two cases describe concurrent bulimia and hyperthyroidism. b .x Neither report described the course of the patients' bulimic symptoms after the hyperthyroid state was treated. One anorexic patient refused to comply with treatment because she feared it might interfere with weight loss. In this patient, as in our patient, the onset of bulimia led to weight gain, despite the hyper223
Case Reports
metabolic state. 8 Wong et aI. 6 described a patient with severe bulimia nervosa and elevated thyroid function tests who showed mild improvement during 15 weeks of psychotherapy that coincided with a spontaneous improvement in thyroid indices. The authors stated that no treatment for the thyroid disorder was undertaken as the patient "was not clinically hyperthyroid" (p. 764).6 Added to those described in the literature, our case suggests that one possible symptom of hyperthyroidism is a bulimic eating pattern. The association of bulimic behavior, typical bulimic cognitive distortions, and the hyperthyroid state in our patient is interesting. While one could assume that thyroid abnormalities caused the entire seven-year illness, this is unlikely, as the patient denied previous episodes of anxiety or
heat intolerance. It seems more likely that the patient, in partial remission from her eating disorder, reacted to the increased appetite and anxiety secondary to hyperthyroidism with an intensification of her usual coping strategies of rigid dieting and disparagement of her body. Resolution ofthe hyperthyroid state relieved not only her generalized anxiety and her bulimic behavior, but also her cognitive symptoms of bulimia. This case report is important because it more clearly demonstrates a link between the hyperthyroid state and bulimic behavior than previous reports. Bulimic patients should be asked routinely about symptoms related to thyroid dysfunction. Thyroid function tests can be very useful when assessing bulimic behavior.
References I. DeGroot U. Larsen PRo Refeloff S. el al: Adult hypothyroidism. in The Thyroid and Its Diseases. Fifth Ed. New York. Wiley. 1984. pp 546--609 2. Whybrow P. Ferrill R: Thyroid state and human behavior~ontributions from a clinical perspective. in Prange AJ Jr (ed): The Thyroid Aris. DrllIlS. and Behal'ior. New York. Raven. 1974. pp 5-28 3. Palmer ED: Gastrointestinal repercussions of thyroid disease. Am Fam Physician 5: 131-132.1979 4. Morley JE. Krahn DO: Endocrinology forthe psychiatrist. in Nemeroff CB. Loosen CB (eds): Handbook ofClinical PsychoneuroendocrinolollY. New York. Guilford. 1986. pp 3-37 5. Gamer OM. Olmsted MP. Polivy J: Development and validation of a multidimensional eating disorder inven-
224
6.
7.
8.
9.
tory for anorexia nervosa and bulimia. InternationalJournal of Eating Disorders 2: 15-34. 1983 Wong C. Birmingham CL. Tildesley HO: Hypenhyroidism and bulimia: case repon. International Journal of Eating Disorders 6:763-765. 1987 Byerley B. Black OW. Grosser BI: Anorexia nervosa with hypenhyroidism: case repon. J Clin Psychiatry 44:308309.1983 Kuboki T. Suemalsu H. Ogata E. et al: Two cases of anorexia nervosa associated with Graves' disease. Endocrinol Jpn 34:9-12. 1987 Rolla AR. Ghada AE. Goldstein HH: Untreated thyrotoxicosis as a manifestation of anorexia nervosa. Am J Med 81:163-165.1986
PSYCHOSOMATICS
References I. Morselli E: Sulla dismorfofobia e tafefobia. Bollerrino Accademia Scien:e Mediche (Genoa) 6: 100-119.1886 2. McKenna PJ: Disorders with overvalued ideas. Br} Psychiatry 145:579-585. 1984 3. Binchnell SA: Dysmorphophobia: a centenary discussion. Br} Psychiatry 153(suppI2):41-43. 1988 4. Andreasen NC. Bardach J: Dysmorphophobia: symptom or disease'! Am} PsychiOlry 134:673-676. 1977 5. Hay GG: Dysmorphophobia. Br} Psychiatry 116:399406.1970 6. American Psychiatric Association: Diagnostic andStatis· tical Manual of Mental Disorders. Third Ed. Rel'ised. Washington. DC. American Psychiatric Association.
1987 7. Crisp AH: Dysmorphophobia and the search for cosmetic surgery. Br Med} 282: 1099-1100.1981 8. Riding J. Munro A: Pimozide in the treatment of monosymptomatic hypochondriacal psychosis. Acta Psychiatr Scand 52:23-30. 1975 9. Garety PA. Hemsley DR: Characteristics of delusional experience. Eur Arch Psychiatry Neurol Sci 236:294298.1987 10. Insel TR. Akiskal HS: Obsessive-compulsive disorder with psychotic features: a phenomenologic analysis. Am } Psychiatry 143:1527-1533.1986
Thyrotoxicosis and Bulimia Nervosa DEAN KRAHN.
hyroid disorders can cause abnonnalilies in patients' appetite and weight regulation. gastrointestinal function. and mood. These systems are also dysfunctional in patients with eating disorders. Hypothyroidism commonly results in mild weight gain with constipation. lethargy•and depression.1.2 In contrast. the classic description of symptoms of hyperthyroidism is weight loss despite an increased appetite. hyperactivity. irritability. and emotional lability.3.4 Given the great overlap ofthe symptoms of thyroid abnonnalities with the symptoms of eating disorders. it is surprising that more cases of coexistent thyroid and eating dysfunctions have not been reported. This case report describes a patient with bulimia nervosa and a history ofanorexia nervosa who also suffered from hyperthyroidism. The prodigious binge-eating behavior of this patient
T
Received January 16. 1989; revised May 31. 1989; accepted June 28. 1989. Address reprint requests to Dr. Krahn. Eating Disorders Program. Depanment of Psychiatry. University of Michigan. 1500 East Medical Center Drive. Ann Arbor. MI48109. Copyright © 1990 The Academy of Psychosomatic Medicine
222
M.D.
resulted in the unusual presentation of thyrotoxicosis with weight gain. Successful treatment of the thyrotoxicosis resolved not only her increased appetite and anxiety. which are characteristic of this endocrine dysfunction. but also her cognitive distortions about her body image. which are characteristic of eating disorders.
Case Report A 21-year-old female student presented to the University of Michigan Eating Disorders Program for help with prodigious episodic binge-eating that occurred two or more times per night. She fasted almost constantly between her nocturnal binges. The patient was upset because she had gained 25 pounds in the past six months. Her height was 61 inches. and her weight was 166 pounds. She had formerly used vomiting to control her weight. and she contemplated returning to this behavior. She reported heat intolerance. some diarrhea. rare heart palpitations. increased feelings of anxiety. and emotional lability during the rapid weight gain. She specifically denied dysphagia. neck pain. changes in her vision. or galactorrhea. PSYCHOSOMATICS
Case Reports
The patient's excessive concern with body weight was triggered by a weight increase from 130 to 180 pounds at menarche. She had fasted and exercised obsessively and lost 75 pounds. When family members confronted the patient about her fasting, she began to eat meals but also to vomit following them. The family later organized a system of aftermeal monitoring and the patient stopped all bingeeating and purging except for very rare, brief relapses. However, the patient remained markedly overconcerned about her weight; she dieted often and had frequent weight swings around a mean of 125 pounds. Her mother also had a history of vomiting to control her weight and ongoing obsessive fasting and exercising. A sister was known to binge and purge. No personal or family history of other psychiatric disorders was noted. Her mother had hypothyroidism, and another sister had undergone surgery for a benign thyroid nodule. The patient was noted to have very warm, moist hands. She spoke rapidly and seemed anxious. No delusions, hallucinations, obsessions (other than those related to weight), or cognitive defects were noted. On the Eating Disorders Inventory (EDl),5 the patient scored 16 on the Drive for Thinness Subscale; 9 on the Interoceptive Awareness Subscale; 10 on the Bulimia Subscale; 22 on the Body Dissatisfaction Subscale; I on the Ineffectiveness Subscale; I on the Maturity Fears Subscale; 2 on the Perfectionism Subscale; and 3 on the Interpersonal Distrust Subscale. The patient's scores on the first four subscales were typical of the scores of the bulimic patients we see in the clinic, but her scores on the last four subscales were relatively low compared to the scores of our other bulimic patients. Physical examination revealed a pulse of 108 at rest; warm, moist skin; a fine, bilateral tremor in the upper extremities; and a diffusely enlarged thyroid gland without nodules. Thyroid function tests confirmed the clinical suspicion of hyperthyroidism. Her T 4 level was 17.9 jlgldJ (normal range, 4.4jlg to 11.6jlgldl). She had a T J uptake of 106% (normal range, 86% to 114%). TSH levels were less than 0.2 jlU/ml (normal, O.3jlU/ml to 6.0 jlU/ml). She had a free thyroxine index of 18.97 (normal, 3.8 to 13.2). Treatment with 12 milliCuries of LJI I resulted in a marked decrease in anxiety and in her drive to eat. She began to eat three normal meals per day, and abnormal patterns of eating ceased. Neither the patient nor the therapist saw residual symptoms of an eating disorder that required therapy. She tolerated with equanimity a five-pound weight gain during a brief VOLUME 31· NUMBER 2· SPRING 1990
FIGURE I. Scores on subscales of the Eating Disorder Inventory (EOI) in a patient with concurrent bulimia and hyperthyroidism before and after treatment of thyrotoxicosis. The solid bar represents the mean±SD scores of 191 normal college-age women. Key: DT, Drive for Thinness; lA, Introspective Awareness; B, Bulimia; BD, Body Dissatisfaction; IE, Ineffectiveness; MF, Maturity Fears; P, Perfectionism; 10, Interpersonal Distrust 30
• • •
20
NORMN.. PlUREAT POSITREAT
10
o OT
IA
B
II)
E
tJF
P
10
period of iatrogenic hypothyroidism, and she did not resume dieting or other weight control behaviors. Her scores on the EDl showed an impressive resolution of cognitive distortions: scores on all subscales dropped to zero, with the exceptions of the Body Dissatisfaction Subscale, on which she scored 8, and the Perfectionism Subscale, on which she scored 2. These scores are lower than those seen in normal college-age women (Figure I). After six months, the patient remained binge-free, and her thyroid function tests were normal (TSH, 1.0 jlU/ml; free T4 , 1.7 ngldl).
Discussion Although the symptoms of thyroid and eating disorders overlap in the areas of mood disturbance, gastrointestinal symptoms, and appetite changes, only five cases of eating disorders coincident with hyperthyroidism have been reported.&-9 Only two cases describe concurrent bulimia and hyperthyroidism. b .x Neither report described the course of the patients' bulimic symptoms after the hyperthyroid state was treated. One anorexic patient refused to comply with treatment because she feared it might interfere with weight loss. In this patient, as in our patient, the onset of bulimia led to weight gain, despite the hyper223
Case Reports
metabolic state. 8 Wong et aI. 6 described a patient with severe bulimia nervosa and elevated thyroid function tests who showed mild improvement during 15 weeks of psychotherapy that coincided with a spontaneous improvement in thyroid indices. The authors stated that no treatment for the thyroid disorder was undertaken as the patient "was not clinically hyperthyroid" (p. 764).6 Added to those described in the literature, our case suggests that one possible symptom of hyperthyroidism is a bulimic eating pattern. The association of bulimic behavior, typical bulimic cognitive distortions, and the hyperthyroid state in our patient is interesting. While one could assume that thyroid abnormalities caused the entire seven-year illness, this is unlikely, as the patient denied previous episodes of anxiety or
heat intolerance. It seems more likely that the patient, in partial remission from her eating disorder, reacted to the increased appetite and anxiety secondary to hyperthyroidism with an intensification of her usual coping strategies of rigid dieting and disparagement of her body. Resolution ofthe hyperthyroid state relieved not only her generalized anxiety and her bulimic behavior, but also her cognitive symptoms of bulimia. This case report is important because it more clearly demonstrates a link between the hyperthyroid state and bulimic behavior than previous reports. Bulimic patients should be asked routinely about symptoms related to thyroid dysfunction. Thyroid function tests can be very useful when assessing bulimic behavior.
References I. DeGroot U. Larsen PRo Refeloff S. el al: Adult hypothyroidism. in The Thyroid and Its Diseases. Fifth Ed. New York. Wiley. 1984. pp 546--609 2. Whybrow P. Ferrill R: Thyroid state and human behavior~ontributions from a clinical perspective. in Prange AJ Jr (ed): The Thyroid Aris. DrllIlS. and Behal'ior. New York. Raven. 1974. pp 5-28 3. Palmer ED: Gastrointestinal repercussions of thyroid disease. Am Fam Physician 5: 131-132.1979 4. Morley JE. Krahn DO: Endocrinology forthe psychiatrist. in Nemeroff CB. Loosen CB (eds): Handbook ofClinical PsychoneuroendocrinolollY. New York. Guilford. 1986. pp 3-37 5. Gamer OM. Olmsted MP. Polivy J: Development and validation of a multidimensional eating disorder inven-
224
6.
7.
8.
9.
tory for anorexia nervosa and bulimia. InternationalJournal of Eating Disorders 2: 15-34. 1983 Wong C. Birmingham CL. Tildesley HO: Hypenhyroidism and bulimia: case repon. International Journal of Eating Disorders 6:763-765. 1987 Byerley B. Black OW. Grosser BI: Anorexia nervosa with hypenhyroidism: case repon. J Clin Psychiatry 44:308309.1983 Kuboki T. Suemalsu H. Ogata E. et al: Two cases of anorexia nervosa associated with Graves' disease. Endocrinol Jpn 34:9-12. 1987 Rolla AR. Ghada AE. Goldstein HH: Untreated thyrotoxicosis as a manifestation of anorexia nervosa. Am J Med 81:163-165.1986
PSYCHOSOMATICS
