Psychiatria Danubina, 2014; Vol. 26, Suppl.

1, pp 250–255 Conference paper

© Medicinska naklada - Zagreb, Croatia

THE MULTIFACTORIAL ETIOLOGY OF EATING DISORDERS

OUTLINED IN A CASE OF ANOREXIA NERVOSA AND
COMPLICATED BY PSYCHIATRIC CO-MORBIDITIES
Francesca Falzon Aquilina1,2,3,4, Mark Agius5,6,7 & Kriti Sharma1,2
1
Foundation Year 2 Doctor, UK
2
Mater Dei Hospital, Msida, Malta
3
Mount Carmel Hospitals, Attard, Malta
4
Dar Kenn Ghal Sahhtek (Obesity & Eating Disorders Services), Malta
5
Clare College Cambridge, The University of Cambridge, Cambridge, UK
6
South Essex Partnership University Foundation Trust, UK
7
Department of Psychiatry, University of Cambridge, Cambridge, UK

SUMMARY
This article outlines a case of anorexia nervosa within the context of its multifactorial etiology and complex neurobiology.
Additionally, it also highlights that in this case there were several co-morbid personality traits and other psychiatric co-morbidites
such as OCD and bipolar disorder.
Key words: eating disorder - anorexia nervosa - multifactorial etiology - co-morbidities - personality traits - OCD - bipolar
disorder

Abbreviations: AN - Anorexia Nervosa; BN - Bulimia Nervosa; BED - Binge eating disorder; OCD - Obsessive
compulsive disorder

* * * * *
INTRODUCTION on the intrauterine contraceptive device. Moreover, the
role of the amygdala could also be described in this
A 23 year old female of Romanian origin was case. The amygadala is responsible for the control of
interviewed in order to assess the multifactorial etiology emotions, anxiety, depression, affection and aggression.
of eating disorders, particularly anorexia nervosa. At the The patient did prove to have emotional instability
time of the interview the patient was stable and attended accompanied by a labile mood and also tends to be
solely the outpatient psychiatric clinic at Mater Dei verbally aggressive towards her mother while being
Hospital for follow up visits. The patient had had a interviewed. This is also reflected in her regular panic
psychiatric history of several admissions to both medi- attacks and the affection she shows towards her pets and
cal and psychiatric wards due to general deterioration in current boyfriend.
physical and mental health following a 7 year history of Secondly, cultural issues involved in the etiology of
anorexia nervosa. The aim of the interview was to eating disorders could also be highlighted. Media played
outline the multifactorial etiology as well as the a very important role in the development or perpetuation
complex neurobiology of eating disorders, particulary of this condition. The patient passed through two major
AN, using the case chosen. phases in her history of AN. Initially, she would
admired models and wanted to look like one. She not
ETIOLOGY OF THE CASE STUDIED only took classes in modeling and perceived it as a
hobby but would also read magazines and follow this
This case demonstrated very well the etiology of AN. industry online. Due to the financial burden of keeping
Firstly, biological factors were indeed present. The up with such a hobby she has to focus her attention onto
patient’s sister, back in Romania, had also suffered from another and more feasible lifestyle. Therefore, she
an eating disorder, thus proving that such conditions can started doing athletics since it is cheaper to keep up with
be influenced by genetics. Other features also shed light and also involved less expenses. As a result, her
on the importance of the hypothalamus on human conception of an ideal body image changed from that of
homeostasis. It is known that the hypothalamus is a frail model to a muscular athlete. Irrespective of this
involved in the control of eating, sleep, sexual behavior, change in mind frame, media still continued to play an
body temperature, hunger and thirst. The patient did essential role in her daily life. She then converted her
have erratic sexual behavior as she was noted to have focus onto a world class athlete and would devotedly
been promiscuous before she entered a current stable follow her life methodically on the internet while
relationship. In fact, she had been encouraged to be put aspiring to be like her idol.

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IN A CASE OF ANOREXIA NERVOSA AND COMPLICATED BY PSYCHIATRIC CO-MORBIDITIES
Psychiatria Danubina, 2014; Vol. 26, Suppl. 1, pp 250–255

Moreover, risk factors for development of AN were fitted into the criteria for either BN or AN in reality may
also present. The patient was a young 23 years old and have had a binge eating problem (APA 2013).
also belonged to the female gender, which is a highly For the purpose of the case report, we focus on the
susceptible group for such conditions. She also belon- criteria for AN. In the DSM V, AN is described as
ged to a below average social class, thus increasing the affecting primarily adolescent girls and young women
risk of developing such a condition. Race and ethnicity accompanied by distorted body image and excessive
is also known to play an important role in eating dieting that eventually leads to severe weight loss. A
disorders. In fact the patient was adopted from Romania pathological fear of becoming fat also co-exists.
and brought up in Malta. We below list the criteria for AN as listed in DSM
Personality disorder traits may also contribute to the IV, and then indicate the changes made in DSM V.
multifactorial etiology of AN. The patient demonstrated
traits belonging to the unstable personality disorder DSM IV criteria
class. These included; low self esteem, dependency on A. „A refusal to maintain body weight at or above a
those around her and problems with self direction. The minimally normal weight for age and height (e.g.
latter was demonstrated in many instances, notably in weight loss leading to a maintenance of body
the change in ideal body image as described above. weight less than 85% of that expected, or failure to
The patient also demonstrated avoidant personality make expected weight gain during period of
disorder traits as she proved to be a perfectionist in body growth, leading to body weight less than 85% of
image and fitness regimen with the constant goal of that expected).
wanting a ‘good image’. She also passed through phases B. Intense fear of gaining weight or becoming fat,
of being emotionally and sexual disinhibited when not even though underweight.
in a stable relationship and is also terrified of failure, C. Disturbance in the way in which one’s body weight
criticism and humiliation by others. On the other hand, or shape is experienced, undue influence of body
she also exhibited narcissistic personality disorder traits weight or shape on self-evaluation, or denial of the
as she obviously gives her image extreme importance seriousness of the current low body weight.
while being unable to soothe herself, lacks empathy D. In post menarchal females, amenorrhea, i.e. the
towards others, feels the constant need for admiration absence of at least three or more consecutive
from those around her and is hypersensitive to criticism. menstrual cycles. (A woman is considered to have
Finally, she also demonstrated obsessive compulsive amenorrhea if her periods occur only following
personality disorder traits as she would obsess about hormone, e.g. oestrogen, administration).
exercising and restricting food intake. In return, her
ruminations would persist unless she carries out her Specify type
compulsions to over exercise and starvation. Both Restricting Type: during the current episode of
compulsions have proved to be distressing to her life as Anorexia Nervosa, the person has not regularly
she was admitted to medical wards multiple times. engaged in binge-eating or purging behaviour (i.e.
Psychiatric co-morbidities were also present. These self-induced vomiting or the misuse of laxatives,
included panic attacks at night, phobias related to the diuretics or enemas)
death of those around her and bipolar mood disorder. Binge-Eating/Purging Type: during the current
The patient had suffered unipolar depression throughout episode of Anorexia Nervosa, the person has
her 7 year history of AN but towards the end was regularly engaged in binge-eating or purging
admitted to the psychiatric unit in Mater Dei due to an behaviour (i.e. self induced vomiting or the misuse
episode of hypomania. As a result her treatment needed of laxatives, diuretics or enemas)” (APA 1994).
alteration. She also suffered body dysmorphic disorder Differences in DSM V criteria
as she would see her thighs as being too big in the
Several minor but important changes were made.
mirror irrespective of how much weight she lost.
1. Criterion A focuses on behaviors eg: restricting
caloric intake and no longer uses the word ‘refusal’
DISCUSSION in terms of weight maintenance since that implies
intention from the part of the patient which may
DSM V in relation to eating disorders prove difficult to assess.
DSM V included various changes in its diagnosis of 2. Criterion D was deleted as this does not cover pre-
eating & feeding disorders with the aim to outline better menarchal females, males, females on the OCP and
the symptoms and behavior of patients struggling with post menopausal females. In other individuals, all
these conditions. The fundamental changes included the symptoms of AN maybe seen but some menstrual
revised diagnostic criteria for anorexia and bulimia activity still present (APA 2013).
nervosa and also greater recognition of binge eating In this case study, the patient fitted the diagnosis of
disorders. Patients who across the years could not have anorexia nervosa (restrictive type).

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IN A CASE OF ANOREXIA NERVOSA AND COMPLICATED BY PSYCHIATRIC CO-MORBIDITIES
Psychiatria Danubina, 2014; Vol. 26, Suppl. 1, pp 250–255

Causality of Anorexia Nervosa found that food restriction and intense activity causes
symptoms similar to anorexia in female rats (Bergh
Hypotheses have been made linking the continuance
1996), though it is still unclear why it affects only
of disordered eating to the epiphenomenon of starvation.
females.
The Minnesota Starvation Experiment has shown that
The patient studied reported feeling satisfied and
when normal controls are subjected to starvation, beha-
happy about herself when undergoing starvation. As a
vioral patterns similar to AN maybe exhibited. The
latter maybe due to numerous changes in the neuroendo- result, she would feel a tremendous sense of guilt after
crine system which ultimately results in a self-per- eating, especially if she went beyond her normal food
petuating cycle (Zandian 2007, Thambirajah 2007, Kaye limit.
2008, Støving 1997). Serotonin dysregulation. This has also been inves-
Studies have suggested that dieting may be a trigger tigated using brain imaging. Imaging has implicated
for developing AN in some cases with a possible back- alterations in 5-HT1A and 5-HT2A receptors and also
ground of inherent predisposition towards AN (Nygaard the 5-HT transporter. Alterations of such circuits may
1990). On the other hand, even though females do in turn also affect mood and impulse control in
outnumber males in AN, studies show that males with a addition to the motivating and hedonic aspects of
female twin have a higher chance of developing AN. feeding behaviour (Kaye 2005). Interestingly enough,
Thus, anorexia maybe linked to intrauterine exposure to evidence has been found that personality traits
female hormones (Schacter 2011). associated with AN and disturbances to the serotonin
In our case report, the patient was in fact a female. system persist, even when having recovered from AN
(Kaye 2005).
Biological
Even though brain imaging or receptor testing was
Obstetric complications. These have been a factor not available for this case report, the patient studied did
predisposing to AN and may include anemia, diabetes suffer from labile moods. In fact, she developed a
mellitus and preeclampsia (Favaro 2006). It was hypomanic episode a few months before the interview,
impossible to obtain such information from the patient requiring admission to a psychiatric ward in Mater Dei
in studied as she was adopted from Romania at very Hospital. Before this, she had always suffered from co-
young age and her adoptive parents did not have such morbid unipolar depression. Additionally, the mental
information. Also, no medical records were available in state examination carried out by various psychiatrists
our hospital in Malta. following her case described her as being impulsive
Genetics. AN is believed to be highly heritable with while in the social history, a degree of promiscuity was
a rate ranging from 56%-84% (Klump 2002). Studies documented.
have been done in which polymorphisms were found to BDNF. Brain derived neurotrophic factor is found to
occur in 43 different genes, the latter being related to be implicated in subjects suffering from AN. BDNF is a
motivation, reward mechanisms, personality traits and
protein that regulates neuronal development and neuro-
emotions. Moreover, consistent associations have been
plasticity, while also playing a role in the pathway of
found for polymorphisms of genes (Rask-Andersen). In
eating and energy homeostasis. BDNF is said to amplify
one particular study, variations in the norepinephrine
responses and promotes synaptic communication in the
transporter gene promoter were associated with restric-
enteric nervous system (Monteleone 2005). Exercises
tive anorexia nervosa, but not the bing-purging type
also increases levels of BDNF (Ferris 2007).
(Urwin 2002) .
BDNF testing was not available for this case study.
Epigenetic mechanisms have also been implicated in
various eating disorders; “We conclude that epigenetic Ghrelin. A study carried out in 2013 showed that
mechanisms may contribute to the known alternation of anorexic subjects may have diminishes ghrelin bio-
atrial natruretic peptide homeostasis in women with activity due to an alteration in carrier-antibody affinity,
eating disorders” (Epigenetic Downregulation of Atrial thus causing a decrease in efficiency in its transportation
Natriuretic Peptide but not Vasopressin mRNA Ex- to the brain and therefore reduced hunger sensation
pression in Females with Eating Disorders is Related to (Takagi 2013). Ghrelin is a hormone which reduces
Impulsivity). appetite (anorexigenic) by causing a feeling of satiety. It
Genetic testing was not available for use in this case is produced by the stomach and the upper part of the
study. However, the patient had a sister back in Roma- small intestine.
nia who also suffered a form of eating disorder. Due to Ghrelin testing was not available for this case study.
lack of communication it could not be further specified Cerebral blood flow. By means of neuroimaging, it
what type of eating disorder this was. was found that there is reduced blood flow to the
Addiction. Addiction to chemicals released by the temporal lobes of anorectic patients. The latter may well
brain during the starvation period have also been be a predisposing factor in the onset of AN (Lask 2005).
reported in subjects suffering from AN. They are Neuroimaging testing was not carried out in this
believed to get some sort of high from not eating. It was case study.

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IN A CASE OF ANOREXIA NERVOSA AND COMPLICATED BY PSYCHIATRIC CO-MORBIDITIES
Psychiatria Danubina, 2014; Vol. 26, Suppl. 1, pp 250–255

Infections. PANS (paediatric acute-onset neuro- Obesity. It has been noted that AN is more likely to
psychiatric syndrome) is a hypothesis that describes occur in populations in which obesity is prevalent
children who have an abrupt and dramatic onset of OCD (Lozano 2008). Interestingly enough, Eurostat has
or AN coincident with the presence of two or more documented that among the 19 EU Member States for
neuropsychiatric symptoms. It is hypothesized that which data is available, the adult population varied in
some subjects have developed AN abruptly as a result 2008/9 between 8.0% (Romania) and 23.9% (UK) for
of having a streptococcal or mycoplasmic infection women and 7.6% (Romania) and 24.7% (Malta) for
(Swedo 2012). men. This is remarkably highlighted in our case study as
the patient was not only subjected to a cultural change
Sociological
as described above, but in addition adopted from the
Cultural change. AN has been the subject of many country with the lowest prevalence of obesity and lived
sociocultural studies which have described the pro- for the majority of her life in the EU country with one of
motion of thinness as the ideal female form in Western the highest prevalences of obesity (Eurostat 2011).
industrialized nations. Culture maybe a cause, trigger or
Media effects. Advances in neuroscience have shed
simply a kind of marker which determines in which
light on the complex combination of genetic and envi-
sector of society or cultures AN is more likely to
ronmental influences leading to AN. Media intervention
develop. The thesis of this connection is that culture acts
may be the source of distorted ideas of ideal body
as a cause by providing a blueprint for AN to develop.
image. Field, Cheung, et al’s survey carried out on 548
Thus, this connection shows that culture may trigger the
preadolescents and adolescent girls found that 69%
illness which in turn is determined by multiple factors
acknowleged that images in magazines had influenced
such as; family interactions, individual psychology or
their conception of what an ideal body should look like,
biological predisposition. Culture change can trigger the
while 47% reported that they felt the need to lose weight
development of AN in adolescent girls from immigrant
after seeing such images (López-Guimerà 2010).
families living in highly industrialized Western Socie-
The patient in this case report was influenced greatly
ties (Dinicola 1990). The latter is perfectly represented
by the media as she would watch TV shows, review
by this case study as the patient was adopted from
magazines and search on the website in relation to
Romania at a young age after living in sub-optimal
modelling. In fact, research has shown that pro-anorexia
socioeconomic family status. She was thus subjected to
websites stress thinness as the ideal choice for women
a culture change when she started living in Malta. Malta
and in some websites ideal images of muscularity for
has been greatly influence by Westernized practices,
men. These sources may reinforce restrictive eating and
particularly when it comes to gastronomy. Maltese,
exercise behaviours and are of great concern (Juarez L
have shifted towards a more Westernized diet as the
2012).
years have gone by. Moreover, due to this culture
change the patient admitted to have suffered long years Half way through her history of AN, it was reported
that the patient had changed the idea of an ideal body
of low self esteem as she never felt equal to her peers
image from a thin individual to a very athletic and
since she was Romanian.
muscular body. The latter was partly due to her inability
Modeling. On the other hand, a study published in to finance her modeling career as this proved more
1980 has shown that people in professions such as expensive than following a sport such as athletics.
dancers and models are put under greater social pressure Irrespective of this change in body image, she would
to be thin during their career (Garner 1980). Research obsessively follow the life of a world famous athlete on
has shown that such subjects have greater contact with the internet. In return, she would over exercise in order
cultural sources that encourage weight loss (Toro 1994). to look like a professional athlete.
Our patient had taken up modeling as a hobby in the
past. She was subjected to pressure from the modeling Co morbid Disorders
management to be strict about her diet and exercise Body dysmorphic disorder (BDD). This is a soma-
regime, causing the patient to suffer a considerable toform disorder and involves the excessive rumination
amount of psychological stress. over a perceived physical flaw. It is found to occur in
Puberty. Also, AN is more likely to occur in puber- 2% of the population and while it occurs equally amongst
tal years, especially for girls (Schmidt 2006). In this men and women, BDD may either be misdiagnosed for
case study the patient is a girl and developed AN at the AN or exists co-morbidly in 25-39% of AN patients
age of 16. Female students are also 10 times more likely (Grant JE 2002). The subject in this case report did have
to develop AN compared to male subjects. In a survey co-existing BDD with constant rumination that her
carried out in Japan in 1799, female high school tights looked big when seeing herself in the mirror even
students showed that “85% who were a normal weight though they were not from an objective point of view.
wanted to be thinner and 45% who were 10-20% Axis I. The subject of this case report also had co-
underweight wanted to be thinner” (Mukai 1994). Our morbid unipolar depression for approximately 6 years
subject in question suffered a continuous urge to lose and a recent episode of hypomania. Depression is
weight when in secondary school ie: ages 11-16 years. known to be greatly associated with eating disorders

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IN A CASE OF ANOREXIA NERVOSA AND COMPLICATED BY PSYCHIATRIC CO-MORBIDITIES
Psychiatria Danubina, 2014; Vol. 26, Suppl. 1, pp 250–255

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Correspondence:
Dr. Francesca Falzon Aquilina M.D
Mater Dei Hospital
Msida, Malta
E-mail: [email protected]

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