Presentation in adults and adolescents is similar.
An eating disorder could be comorbid with another psychiatric disorder, such as MDD, dysthymia, or panic disorder.5 Ms. A’s report of depression before she began restricting food favored a primary diagnosis of MDD. Her depressive symptoms of low appetite or low self-worth could have led to her preoccupation with body image.
There has been evidence that negative self-image and eating disorders are associated, but data are limited and the connection remains unclear.6 Ms. A’s self-esteem was very low. Her fixation on restricting food could have been perpetuated by her self-criticism and by being excluded from her peer group in school. Her weight loss could have brought anxiety symptoms to the forefront because of physiologic changes that accompany extreme weight loss.
The treatment team was concerned about her delayed responses, which could be explained by the catatonic features that reflected the severity of her depression. She had no obvious symptoms of psychosis, but her intrusive thoughts and obsessions with avoiding food did not completely rule out psychosis.
Childhood-onset schizophrenia, although rare, has been associated with catatonia; following up with a catatonia rating scale, such as the Catatonia Rating Scale or the Bush- Francis Catatonia Rating Scale (BFCRS), would be useful for tracking symptom progress. In Ms. A’s case, her mood disorder was primary, but did not rule out psychosis-like prodromal symptoms.7
Ms. A is diagnosed with MDD, single episode, severe, with catatonic features, and without psychosis, and eating disorder, NOS.
EVALUATION Mostly normal
Ms. A does not have a history of mental illness and was not seeing a psychiatrist or therapist, nor did she have any prior psychiatric admissions. She denies suicide attempts, but reports self-injurious behavior involving scratching her skin, which started during the current mood episode. She has never taken any psychotropic medications. Ms. A lives at home with her biological mother and father and 17-year-old brother. She attends middle school with average grades and has no history of disciplinary actions. She has no history of bullying or teasing, although she did report some previous difficulty with relational aggression toward her peers in the 5th grade. Her mother has a history of anorexia nervosa that began when she was a teenager, but these symptoms are stable and under control. There is additionally a family history of bipolar disorder.
Ms. A has a family history of coronary artery disease and diabetes in the mother and maternal relatives. Her grandfather died from liver cancer. She was allergic to sulfa drugs and was taking a multivitamin and minocycline for acne.
Physical examination reveals some superficial scratches but otherwise was within normal limits. Initial lab results reveal a normal complete blood count and differential. Thyroid-stimulating hormone is 1.29 mIU/L and free T4 is 0.96 mg/dL, both within normal limits. Urinalysis is within normal limits and urine pregnancy test is negative. A comprehensive metabolic panel shows mild elevation in aspartate aminotransferase (AST) at 60 U/L and alanine aminotransferase (ALT) at 92 U/L, respectively. Phosphorus level is within normal limits. Prealbumin level is slightly low at 15.1 mg/dL.
Which treatment plan would you recommend for Ms. A?
a) discharge with outpatient psychiatric treatment
b) recommend medical stabilization with follow-up from the psychosomatic team and then outpatient psychiatric follow-up
c) admit her to the psychiatric acute inpatient hospital with psychiatric outpatient discharge follow-up plan
d) discharge her home with follow-up with her primary care physician
e) recommend follow-up from the psychosomatic team while on medical floor with acute inpatient admission and psychiatric outpatient follow-up at discharge
The authors’ observations
Scarcity of data and reporting of cases of adolescent catatonia limits guidance for diagnosis and treatment.8 There are several rating scales with variability in definition, but that overall provide a guiding tool for detecting catatonia. The Brief Cognitive Rating Scale is considered the most versatile because it is more valid, reliable, and requires less time to complete than other rating scales.9
Ms. A’s symptoms were a combination of depressive symptoms with severity defined by catatonic features, eating disorder with worsening course, anxiety symptoms, and genetic loading of eating disorder in her mother. The challenge of this case was making an accurate diagnosis and treating Ms. A, which required continuous observation following an eating disorder protocol, resolution of her catatonia, resuming a normal diet, and decreasing her suicidality. Retrospectively, her scores on the BFCRS were high on screening items 1 to 14, which measure presence or absence and severity of symptoms.
The best option was to admit Ms. A to an inpatient psychiatric facility after she is cleared medically with outpatient services to follow up.