Dear Sir, 

The comorbidity of eating disorders with psychosis is investigated less than other comorbidities. However, it is possible to find out some psychotic symptoms in patients with eating disorders and vice versa (1). We present a patient, whose symptoms started as eating disorder and then who was diagnosed as schizophrenia. 

16-year-old female patient was brought to the emergency service with the complaints of social withdrawal, food refusal and aggression approximately for the last two years, but her symptoms had worsened for the last three months. At the beginning, she had been overweight, she had restricted her food intake and refused to eat, particularly bread. She lost weight remarkably and then started to get scared when her body had been touched and she tried to wipe out her body with her salivary. She believed people laughed and talked about her. Fluvoxamine, risperidone were initiated with the diagnoses of brief psychotic disorder and obsessive-compulsive disorder but she stopped the medication after three months. 

At the emergency service, she was angry and hostile and it was difficult to communicate with her. Her self care was diminished. According to her family, she hardly ate and did not want anybody to eat around her, as well. She was afraid of bread, which seemed like “blood or devil” to her. She was not getting out her room for the last several weeks, even for the defecation. Delusions of reference and persecution and visual hallucinations were determined. She had no substance abuse history, head trauma or family history for any psychiatric disorder. All routine laboratory tests and thiamine level were within normal range. Her body mass index (18.8 kg/m2) was near the lower bound.

She was diagnosed as schizophrenia and was put on olanzapine (up to 30 mg/day). Partial improvement in behavioural symptoms was achieved in first two weeks of the treatment. Her fear of weight gain and restriction of food were continued. She was additionally diagnosed with eating disorder not otherwise specified. After the improvement of the psychotic symptoms, it is planned to start a selective serotonin reuptake inhibitor (SSRI) for the disordered eating behaviors. 

In anorexia nervosa, psychotic disorders prevelance ranged from 0-12% (2). Disordered eating attitudes are generally associated with female sex and young age and Fawzi and Fawzi (3) have also found the same results in patients with schizophrenia. 

Sometimes it is difficult to distinct an anorexic patient’s preoccupations on food from the delusional thought of a patient with schizophrenia (2). After loosing weight, our patient started to avoid being touched and to wipe out herself with her salivary. The addition of the psychotic symptoms to the eating disorder symptoms may represent the changing course of the illnesses.

Miotto et al. (2010) suggested that observation of psychotic symptoms in patients with eating disorders could be better explained within the psychopathology of the disorders rather than by assuming a link with schizophrenia (1). For our patient, it may be assumed that weight loss facilitate the occurance of the psychotic symptoms through neuroendocrinological changes.

In general, there are three possible explanations: 1- In the prepsychotic period, eating disorder symptoms started and then transformed into psychotic disorder, 2- Disordered eating attitudes and loosing weight triggered the psychosis and, 3- Eating disorder and schizophrenia exist as different entities. As fear of weight gain and food restriction continued after the psychotic symptoms resolved, last two explanations seemed to be more possible. 

Atypical antipsychotic medications such as olanzapine have shown some promise as a possible adjunctive treatment option for patients with anorexia nervosa, as evidenced by improved weight restoration, decreased levels of anxiety, and ruminating thoughts involving food and body image (4). However, olanzapine may increase weight and patients’ compliance to the treatment would terminate (5). In such cases, with the careful monitoring of the psychotic symptoms, an SSRI may be considered.

1. Miotto P, Barbara P, Restaneo A, Favaretto G, Sisti D, Rocchi MB, Preti A. Symptoms of psychosis in anorexia and bulimia nervosa. Psychiatry Res 2010; 175:237-243. 

2. Cinemre B, Kulaksızoglu B. Case report: Comorbid anorexia nervosa and schizophrenia in a male patient. Turk Psikiyatri Derg 2007; 18:87-91. 

3. Fawzi MH, Fawzi MM. Disordered eating attitudes in Egyptian antipsychotic naive patients with schizophrenia. Compr Psychiatry 2012; 53:259-268.

4. Norris ML, Spettigue W, Buchholz A, Henderson KA, Gomez R, Maras D, Gaboury I, Ni A. Olanzapine treatment for the adjunctive treatment of adolescents with anorexia nervosa. J Child Adolesc Psychopharmacol 2011; 21:213-220.

5. McKnight RF, Park RJ. Atypical antipsychotics and anorexia nervosa: a review. Eur Eat Disord Rev 2010; 18:10-21.