Descriptive Psychopathology: The Signs and Symptoms of ...

302 Section 3: Examination domainsemaciation and apparent weakness, there was a peculiar restlessness, difficult, I was informed tocontrol. The mother added, “She is never tired”. Amenorrhoea since Christmas 1866.The prevalence of classic OCD in patients with anorexia is many fold higher thanpopulation estimates, and in the more severe forms of anorexia as many as 40% ofsufferers also have OCD. 61 About 25% of patients with bulimia have co-morbidOCD and many others have OCD features, but many have a picture of manicdepression.62 The presence of OCD traits in childhood is a risk factor for thedevelopment of anorexia nervosa in later life, 63 and the natural history of anorexiaoften begins with the emergence of features of body dysmorphic disorder. 64Patients with anorexia nervosa who have sustained substantial weight loss areunmistakable in appearance, evoking images of Nazi concentration camp survivors.They are skeletal. They move slowly, their fluidity of movement lost andenergy sapped. In light-skinned patients, the skin is gray and dry. Head hair isdry, broken and drained of color.Patients with anorexia nervosa have an intense fear of gaining weight orbecoming fat even though underweight. They deny the seriousness of their weightloss. Most anorexic patients have a disturbed body image. They perceive themselvesto be fat despite a cachetic appearance. For diagnosis, the DSM requires arefusal to maintain at least 85% body weight for age and height and absence ofthree menstrual cycles (a clear gender bias). About 10% of patients with anorexianervosa are male, and the incidence is estimated to be increasing, particularly inmale athletes, models, and actors. In adolescent male patients, stunted growth is apresenting symptom. 65 Males with anorexia nervosa have temperaments similarto those of women with anorexia nervosa. 66 Subtyping into restricting or bingeeating/purging groups is not meaningful.Patients with anorexia nervosa often have associated brain gray and whitematter volume loss during the ill state that partially normalizes with recovery. 67Some of these abnormalities and associated cognitive problems may, however,persist, eliciting concerns of an early-onset dementia. The observed parietal lobedysfunction may explain their altered body image. 68Bulimia nervosaWhile the evidence is strong that anorexia nervosa is a variant of OCD, 69 thenature of bulimia nervosa is less clear. 70 Although best fitting an association withmanic-depression, it is discussed here to minimize redundancy.Unlike the patient with anorexia, the patient with bulimia nervosa is notunderweight and rather than having personality traits associated with OCD(e.g. perfectionism, reduced expression of emotion), patients with bulimia exhibitchronic problems with regulation of emotion. 71