CASE A fainting spell
Ms. A, age 13, is admitted to a pediatric unit after fainting and losing consciousness for 5 minutes in the shower, during which time she was non-responsive. She reports feeling nauseated and having blurry vision before dropping to the floor.
Ms. A reports intentional self-restriction of calories, self-induced vomiting, and other purging behaviors, such as laxative abuse and excessive exercising.
During the mental status examination, Ms. A is lying in bed wearing hospital clothes, legs flexed at the knee, hands on her side, and a fixed gaze at the ceiling with poor eye contact. She is of slender stature and tall, seems slightly older than her stated age, and is poorly groomed.
Throughout the interview, Ms. A has significant psychomotor retardation, reports her mood as tired, and has a blunted affect. She speaks at a low volume and has poverty of speech; she takes deep sighs before answering questions. Her thought process is linear and she cooperates with the interview. She has poor recall, including delayed 3-minute recall and poor sustained attention. Her abstraction capacity is fair and her intellect is average and comparable with her age group. Ms. A is preoccupied that eating will cause weight gain. She denies hallucinations but reports passive death wishes with self-harm by scratching.
What is the differential diagnosis to explain Ms. A’s presentation?
HISTORY Preoccupied with weight
Ms. A reports vomiting twice a day, while showering and at night when no one is around, every day for 2 months. She stopped eating and taking in fluids 3 days before admission to the medical unit. Also, she reports restricting her diet to 700 to 1,000 calories a day, skipping lunch at school, and eating minimally at night. Ms. A uses raspberry ketones and green coffee beans, which are advertised to aid weight loss, and laxative pills from her mother’s medicine cabinet once or twice a week when her throat is sore from vomiting. She reports exercising excessively, which includes running, crunches, and lifting weights. She has lost approximately 30 lb in the last 2 months.
Ms. A says she fears gaining weight and feels increased guilt after eating a meal. She said that looking at food induced “anxiety attack” symptoms of increased heart rate, sweaty palms, feeling of choking, nervousness, and shakiness. She adds that she does not want to be “bigger” than her classmates. Her understanding of the consequences of not eating is, “It will get worse, I will shut down and die. I do not fear death, I only fear getting bigger than others.”
She reports that her fixation on avoiding food started when she realized that she was the tallest girl in her class and the only girl in her class running on the track team, after which she quit athletics. She reports that depression symptoms pre-dated her eating disorder symptoms; onset of significant depression likely was precipitated by her grandfather’s death a year earlier, and then exacerbated by the recent death of a family pet.
Ms. A’s depressive symptoms are described as anhedonia (avoiding being outside and not enjoying drawing anymore), decreased energy, tearfulness, sadness, decreased concentration, and passive suicidal thoughts. Her mother is supportive and motivates her daughter to “get better.” Ms. A denies any symptoms of psychosis, other anxiety symptoms, other mood disorder symptoms, substance abuse, or homicidality.
Ms. A’s mother says she felt that, recently, her daughter has been having some difficulty with confused thoughts and significantly delayed responses. However, the mother reports that her daughter always had somewhat delayed responses from what she felt is typical. Her mother adds that Ms. A’s suicidal thoughts have worsened since her daughter started restricting her diet.
Which diagnosis likely accounts for Ms. A’s presentation?
a) major depressive disorder (MDD)
b) eating disorder, not otherwise specified (NOS)
c) anorexia nervosa, purging type
d) catatonia, unspecified
e) anxiety disorder NOS
f) cognitive disorder
g) psychosis NOS
The authors’ observations
There are many reported causes of catatonia in children and adolescents, including those that are psychiatric, medical, or neurological, as well as drugs (Table 1).1,2 Affective disorders have been associated with catatonia in adults, but has not been widely reported in children and adolescents.1,3 Organic and neurologic causes, such as neurological tumors and cerebral hemorrhage, should be ruled out first because, although rare, they can be fatal (Table 2).2 If the cause of catatonia is not recognized quickly (Figure,1,2) effective treatment could be delayed.4
Catatonia involves psychomotor abnormalities, which are listed in Table 3.1,4