Depression can be the cause or effect of anorexia nervosa

SUMMARY This article presents the example of a clinical case that we face more and more often in the clinic, namely the associated pathology between depressive disorder and anorexia nervosa. It is necessary to focus our attention on the importance of mental health and how it influences our personal, family and social life, to notify early when an illness occurs and to intervene early in therapy, until it is not too late. These two disorders may have its base on a multifactorial etiology (genetic, biological, socio-cultural, psychological, etc.), which can evolve into different mental disorders, but when we are dealing with patients with these 2 associated disorders, we ask the first question that arose as a drug therapy. and especially the psychotherapy we use to have the desired effect in the shortest possible time, to identify what is the cause and what is the effect. Keywords: mental health, illness, disorder, depression, anorexia, therapy, effect
INTRODUCTION Depression may be a risk factor for the development of anorexia, but the inverse relationship may also be true. Depressive disorder is becoming more and more common at an early age, mainly due to the disruptive environment in which children live and at the same time people who have an eating disorder can develop depression over time. In the latter case, the physiological changes of the body involved in anorexia, such as low body weight, may trigger depressive symptoms, and we need to investigate more closely [1].
Depression can be both the cause and the effect of poor nutrition. It has been shown that people with anorexia nervosa are often prone to developing secondary depression. Depression is most often the result of physical and biological changes that anorexia produces in the body, including brain and body changes. People with anorexia evaluate themselves person in terms of their conformity, body weight and their ability to control them, so dissatisfaction with their physical appearance and lack of control leads to negative emotions with a major impact on social and professional functioning. Pragmatically when they fail to adhere to the rigid rules they set, they end up having low self-esteem. At the same time, negative events with negative emotional experiences lead to eating disorders to compensate for the negative mood and to divert attention from the negative events that create distress. There are patients who are sensitive to emotions, tolerate them with difficulty, or experience strong emotions, which predispose them to eating disorders. In addition, feelings of loss of control, powerlessness, low self-esteem and intolerance to strong emotions, associated with cognitive distortions, poor coping and problem-solving mechanisms increase suicide risk. Depressive features are less common than anxiety disorders in patients with restricted food intake. The eating habits of patients with eating disorders are receptive to external events and disposition changes, this connection may be prominent in mild cases while in serious cases eating disorders may seem autonomous, and as the treatment progresses and the mechanisms underlying the disorder are cleared this process is highlighted [2]. The internalizations of the negative affective states can influence the health state by diminishing the capacity of adaptation, this determining the persistence of the eating disorders [3]. In depression, low appetite is present, but there is no concern for caloric content, there is no fear of fattening and disturbing body image [4]. Some studies show that 33-50% of people with anorexia, and almost half of people with bulimia and eating disorders, have depression. Also, 32-39% of people with anorexia nervosa, 36-50% of people with bulimia nervosa and 33% of people with eating disorders are diagnosed with major depressive disorder. Depression is, perhaps, the most common psychiatric disorder in all types of medical services, but at least it is diagnosed. According to WHO estimates, this year (2020) will be the second leading cause of morbidity in the world. The prevalence is higher for women 25% vs. 12% for men, regardless of geographical area or culture. After the age of 50 this ratio is equalized. The incidence of the disease is increasing during the under-20s [1]. Suicide is a worldwide problem, 50-75% of patients with anorexia nervosa have associated major depressive disorder, which explains the increased risk of suicide in these patients [5]. It is also associated with the restrictive disorder in particular [6].
For this reason it must be treated with seriousness from the first symptoms that can be noticed by a doctor of any specialty, a family member, a friend, etc. Depressive disorders are part of a group comprising disruptive affective disorder, major depressive disorder, persistent depressive disorder (dysthymia), premenstrual dysphoric disorder, depressive disorder induced by drugs or substances, depressive disorder secondary to a medical condition, other depressive disorder or unspecified. Affecting 7% of the population [7], all these conditions share the following symptoms that significantly affect the individual’s ability to function: the presence of a sad mood, inner emptiness or irritability, somatic or cognitive changes. What distinguishes them are: the duration, the time of appearance and the supposed etiology. Major depressive disorder consists of one or more recurrent depressive episodes lasting at least 2 weeks, which may have different intensities [1].
The major depressive episode is characterized by:
– depressive mood, loss of motivation, interest and affective resonance in pleasant or unpleasant events, void of soul, absence of emotions, apathy or vice versa, there may be frustration, anger, anxiety, tension, irritability; – cognitive symptoms that decrease concentration, loss of self-esteem, avoidant decisions, lack of hope, devaluation, self-reproaches, unjustified self-accusations, suicidal ideation, recurrent thoughts of death; – psycho-motor symptoms, motor retardation (stupor, hypomimia, amimia, slowing of the movements) or agitation (motor restlessness, uncontrolled and meaningless hyperactivity);
– somatic signs, insomnia or hypersomnia, loss of vitality or vigor, fatigue, lack of appetite or appetite with the change of weight, fatigue [1]. Anxiety is associated with depression in 90% of cases, and 50% of patients do not express depressive experiences, requiring careful investigation. The etiology of depression comprises 6 hypotheses: monoamine, neuroendocrine, cognitive depression, neurotrophic factors, genetics, psycho-social factors and cognitive hypothesis [1]. The changes in the cerebral nervous system are at the level of the limbic system, the prefrontal cortex, the basal ganglia and the hypothalamus. Depression is generally recurrent, and in 25% of cases even chronic, the risk of recurrence after 3 or more episodes is 90% . Most patients have relapse before one year of discontinuation of antidepressant treatment. The treatment of depression is made according to severity, age, particular aspects of the disease, somatic, neurological and psychic examination, treatment delay, associated somatic diseases, side effects of the medication and as far as possible polypragmacy is avoided. Psychological therapies: cognitive-behavioral therapy, family therapy, relational-emotional therapy, interpersonal therapy. Electroconvulsive therapy. Light therapy [8]. Anorexia nervosa (mental) is defined as deliberate weight loss, induced and / or sustained by the patient. It affects especially adolescents and young women, less men. Body weight kept below 15% below the normal age and height limit, the loss being self-induced by starvation, vomiting, bleeding, excessive exercise, diuretic or anorexigen, the patient imposes a low weight threshold, plus the global endocrine disorder on the hipotalamo-pituitary-gonadal axis [9]. The average age at which he debuts is 15-17 years [8]. There are 2 types of AN, namely: – the restrictive type, in which the patient’s clinical chart describes the weight loss achieved mainly through diet, fasting and / or over-exercising during the last 3 months; – the type with compulsive feeding / evacuation in which the patient self-induced vomiting or abusively used laxatives, diuretics or enema, during the last 3 months [7]. The patient is deliberately maintained at 85% of normal weight with a BMI <17.0 kg / m² is considered to be moderate or severe subweight [7]. Anorexia nervosa can lead to different medical complications: Laboratory tests show changes such as frequent haematological anemia, increased urea level which means dehydration, frequently hypercholesterolemia. Metabolic alkalosis due to selfinduced vomiting, hypochloremia, hypopotassemia, mild metabolic acidosis due to laxative abuse. Sinus bradycardia is common. Bone density is low, the risk of fractures being high. The most remarkable aspect of the physical examination is emaciation [7]. Global endocrine disorder involving the hypothalamopituitary-gonadal axis, in women manifested through amenorrhea, and in men through loss of potency and sexual interest [8]. Serum estrogen levels are low in women, and testosterone levels in men [7]. Adolescents have a morbid concern about body weight and shape, having an intense fear of gaining weight. The etiology of this is multifactorial, comprising genetic, socio-cultural and psychological factors. Effective studies in patients with AN have found that neurotransmitters and the hypothalamus may have changes of the type of serotoninergic hyperactivity apparently involved in maintaining the restrictive diet and personality traits such as perfectionism, obsessionality or negative dispositional status. Norepinephrine plays a role in stimulating appetite, while serotonin stimulates satiety, and is also involved in modulating impulsivity and obsessive behavior [8]. This explains the frequent association between eating disorders and mood disorders, anxiety or obsessive-compulsive behavior. At the biological level, malnutrition affects the brain's ability to produce neurotransmitters responsible for positive emotions (serotonin and norepinephrine). Some research has shown that people with anorexia nervosa suffer from loss of ash matter in the brain (which is the active part of the cortex). Because anorexia nervosa has effects on brain tissue, attention, memory, decision making and problem solving are affected. The results of other studies suggest that genetic factors significantly influence the predisposition to anorexia nervosa and contribute substantially to the comorbidity observed between anorexia nervosa and major depression [8]. There is growing evidence that the interaction between socio-cultural and biological factors contributes to its generation. It has been found that people with anorexia nervosa had anxiety disorder or obsessive-compulsive behavior in childhood, or even a significant prevalence of first-degree relatives with regard to bipolar disorder and depressive disorder. It has a higher incidence in industrialized countries with a developed financial situation [7]. In one study (Abou-Saleh et al., 1986) shows that in anorexia cortozol secretion normalizes rapidly after consistent feeding, whereas in major depression, it normalizes only at the disappearance of symptoms [1]. There is growing evidence that the interaction between socio-cultural and biological factors contributes to its generation. The studies show on the computed tomography of the people with anorexia, a cerebral suffering (cortical pseudoatrophy) and a ventricular dilation due to the alimentary restriction, but that they return to normal after the correction of the weight deficit [7]. Research from a study of 432 patients with AN (22 men and 410 women) showed that 16.9% of patients with AN had attempted suicide, especially those with restrictive type. Suicide attempts are frequently encountered in AN [6]. Research from a study of 432 patients with AN (22 men and 410 women) showed that 16.9% of patients with AN had attempted suicide, especially those with restrictive type. Suicide attempts are frequently encountered in AN [6]. It is necessary to observe the conditions under which the child or adolescent is fed, the number of meals, the quantity, the restoration of an adequate eating behavior and the improvement of the motherchild relationship. A rigorous eating plan will be developed with the patient. Psychopharmacological treatment is done with SSRIs (selective serotonin reuptake inhibitors), tricyclic antidepressants, low dose chlorpromazine which has a very good effect if it is associated with depressive pathology. Cognitive-behavioral (CBT) and family therapy are very important, as well as supportive, establishing a strong relationship between doctor and patient, which is very important for patient compliance [8]. Cognitive-behavioral therapy was found to have very good results in treating AN [5]. CASE PRESENTATION Patient T.A aged 17, female, from urban area. He is admitted on 25.05.2019 for the following psychopathological picture dominated by: weight loss, innapetence, with volitional restrictive diet (he refuses to eat, and at the insistence of the parents he eats 1 or 2 spoons of food, which he chews for a long time), disorders body layout (considered fat enough, with broad hips and fat around the abdomen), depressive mood (refuses any activity that was pleasing to her in the past: going out with colleagues / friends, listening to music, reading novels, etc. says that these activities seem to her useless and meaningless), anhedonia, hypobulence, psychomotor anxiety, irritability, marked intrapsychic tension (she feels restless and often overcome by the situation, not understood by the family who presses her to do what she does not want) and mixed insomnia. Heredocolateral background Mom - high blood pressure Pathological personal history – Mitral insufficiency gr. 1 – Anxiety-depressive disorder (2017) – Juvenile Acne (2017) – Chronic constipation Psychomotor development: appropriate for age stages Living and environmental conditions: She is a student in grade X, comes from a legally constituted family, being the only child, in which the emphasis is not placed on the inter-family relationship, being described by the patient as a cold, formal family, with strict rules, in which her opinion doesn't count. The mother was a 42-year-old ballerina, an engineer by profession, with an excessive concern for the physical aspect, a concern she also directed at the patient when she was a child (she had to keep her clothes as clean as possible and make an impression good in society). Dad is 45 years old, as a manager, he is described by the patient as harsh and perfectionist, without any emotional involvement in the family relationship. The school precipitated the onset of the disease through the high expectations of colleagues and bullying especially related to acne and body weight. The patient smokes about 10 cigarettes / day for 2 years, in order to „relax for a short period". Condition on admission – Relatively good overall condition, skin and pale mucous membranes – Afebrile, low food appetite; G = 35 kg; cardiorespiratory balance; poorly represented adipose tissue, muscle atrophy, hypotonia. – Abdomen soft, supple, mobile with breathing, painless spontaneously and on palpation – TA = 110/60 mm Hg, FR = 15 breaths / min, FC = 64 bpm History of the disease The patient is in the record of the PNCA Clinic from 2002, with Dg: Fetal Suffering and AnxiousDepressive Disorder from 2017, for which she followed anxiolytic, timostabilizing treatment and made several individual psychotherapy sessions, which she interrupted because the father did not he understood their meaning. It presents with about 3 months before admission the following symptoms: food refusal, disorders of the body, anhedonia, easy crying, anxiety-depressive mood, marked intrapsychic tension, tendency to social withdrawal. If so, a restrictive diet followed by losing 6 kg in one month. Clinical exam – Somatic examination: T = 167 cm, G = 35 kg, BMI = 12.5 kg / cm2, t = 36 ° C, – Pale skin and mucous membranes, dehydrated, friable hair, prickly eyes. – Poorly represented connective tissue, muscular atrophy, hypotonia – Abdomen soft, supple, mobile with breathing, TI absent for 6 days, amenorrhea from April 2018. Neurological examination: no signs of acute outbreak. Psychiatric examination Patient with well-kept attire and maintained body hygiene. Temporarily-space oriented and allopsychic and situational oriented. Clear field of consciousness today. Psychic contact is relatively easy. Eye contact is maintained intermittently during the interview. Mimicry and gesture in accordance with emotional experiences. Coherent ideo-verbal flow. Abstract thinking. Hypnosis of fixation and evocation. Concentrated and persistent hypoprotosis. Distorted perception of body image with denial of weight loss, denial of menstrual cycle disorders, denies that nutrition is voluntarily restricted, denies excessive preoccupation with body weight. Disorders of body schema, tendency to conceal psychopathological experiences. Low self-esteem, ideas of worthlessness and incapacity, ruminations on the subject of the disease. Anxiety-depressive disposition, anhedonia, intrapsychic tension, psycho-motor restlessness, easy crying, tendency to social withdrawal. Irritability, dysphoric experiences, food refusal, opposition, perfectionist tendencies. Mixed insomnia. Insight absent. Psychological examination: QI = 110 MPS RAVEN. The patient has low vitality, relationalconventional complexity. The subjective tests highlight self-insecurity, sometimes combativity in the face of physical and social reality, censorship effort against the background of affective conflicts. Ambivalent attachment. Paraclinical examinations 1. Abdominal ultrasound: mesenteric lymphadenitis 2. Neurological examination: no signs of acute outbreak 3. EEG: path with teta-alpha background rhythm, half-vaulted, symmetrical, without pathological graphs 4. Cardiological consultation: Mitral insufficiency gr. 1 5. Endocrinological consultation: FT3, FT4 at the lower limit of normal; subclinical hypothyroidism is due to malnutrition and does not require treatment. 6. MRI - Cerebral Spectroscopy – Neuroimaging aspect suggestive for frontalbilateral cerebral suffering, predominantly left, neuronal population decrease and left frontal hypoperfusion. – Bilateral frontal glucose focus 7. Functional MRI – Inability to slow, deficient and inefficient mobilization of brain areas involved in sustained working memory / attention, symptoms characteristic of concentration disorders, but also problems of recall and rapid fatigue on mental effort. – Inability to block negative emotions coupled with experiencing intense emotional states, especially sadness and anxiety. – Inability to relax, to detach – A cognitive profile similar to that of people with inclinations towards perfectionism and compulsive behavior. 8. Gynecological consultation: Secondary amenorrhea due to the basic pathology 9. Laboratory examinations: Lymphocytosis with neutropenia; low insulinemia, hypocalcemia, hyperchloremia, low ferritin 10. Urinalysis: Low albumin, negative leukocytes, red blood cells 10 / UL Based on the anamnesis, the clinical and paraclinical examination support the following diagnoses according to DSM 5: Recurrent depressive disorder, severe current episode with no psychotic symptoms, Mean intelligence (QI-110 MPS RAVEN), Weight deficit; Secondary amenorrhea; Subclinical hypothyroidism, Gr 1 mitral insufficiency, Chronic constipation, Juvenile acne, Support group problems, Educational problems. DIFFERENTIAL DIAGNOSIS 1. The first stage of differential diagnosis - with all the organic disorders that are accompanied by weight loss: gastrointestinal diseases (excluded by gastroenterological consultation), occult tumors, hyperthyroidism 2. The second stage of differential diagnosis - with psychiatric disorders that may have an onset accompanied by symptoms characteristic of anorexia nervosa: depression, anxiety, social phobia, obsessive-compulsive disorder, body dysmorphic disorder, bulimia nervosa, consumption of psycho-psychoactive substances, schizophrenia. TREATMENT 1. Drug treatment with: – SSRI antidepressant - Sertraline anxiolytic - Alprazolam – gastric protector - Controloc i.v; Bifido plus p.o, P.E.V with electrolytes, As gluconic i.v and enema with electrolytes; 2. Individual, cognitive-behavioral psychotherapy; 3. Group therapy; 4. Family therapy. EVOLUTION z Slow favorable with partial food appetite present with slight rise of the weight curve z The evolution may be unfavorable and comorbidities may occur: generalized anxiety disorder, OCD, anakast personality disorder, bipolar disorder, alcohol consumption and / or psychoactive substances, or may develop into bulimia nervosa THE PARTICULARITIES OF THE CASE – The "perfect" family, dysfunctional with: high expectations, unrealistic, from parents. – Premorbid personality with anankaste notes: with strong personality, leader, performance, competitive. – Comorbidity between anorexia and depression – The socio-cultural factors (the ideal of intensely publicized beauty), supplemented by the negative influence of the family that led to learned weight loss. CONCLUSIONS In conclusion, it is the depression that preceded the development of anorexia nervosa in this case, this being the cause and not the effect of anorexia nervosa. The rigorous differential diagnosis between anorexia as a disorder or anorexia as a symptom of depression, the evaluation of the cause-effect relationship are important for a correct therapeutic approach and a good evolution in the short and long term. Identification of adaptive or non-adaptive functioning mechanisms, a correct understanding of the depression-anorexia relationship, achieved through a multidisciplinary approach are important for personalized therapy, reduction of physical and mental comorbidities, rapid remission and prevention of relapses. BIBLIOGRAPHY 1. Prelipceanu Dan, Clinical Psychiatry, Bucharest, Medical Publishing House, 2018. 2. Christopher G. Fairburn, Cognitive-Behavioral Therapy and Eating Disorders, ASCR Ed., 2014 3. Tiberiu Mircea, Psychopathology treatise on child and adolescent development, Semiology. Psychopathological processes, Vol. II, Artpress Publishing House, Timișoara, 2006. 4. Benjamin J. Sadock, M.D., Virginia A. Sadock, M.D., Kaplan & Sadock Pocket Manual of Clinical Psychiatry, Medical Publishing, 2001. 5. Calugi S, El Ghoch M, Conti M, Dalle Grave R Psychiatry Res. 2014 Aug 15; 218 (1-2): 195-200. 6. Bulik CM, Thornton L, Pinheiro AP, Plotnicov K, Klump KL, Brandt H, et al. Suicide attempts in anorexia nervosa. Psychosomatic Medicine. 2008; 70: 378-383 7. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: DSM-5, Callisto Medical Publishing, 2016 8. Iuliana Dobrescu, Handbook of child and adolescent psychiatry, Total Publishing, 2016 9. ICD-10 Classification of mental and co-morbid disorders. Clinical descriptions and diagnostic guidance, Trei Publishing House, 2016 10. Dehelean Liana, The biological basis of psychiatry, University Horizons Publishing House, 2010