Psychosomatics 43:506-507, December 2002
© 2002 The Academy of Psychosomatic Medicine
Xerophthalmia and Undiagnosed Eating Disorder
Sol Jaworowski, M.B.B.S., D.P.M., F.R.A.N.Z.C.P.,
Elena Drabkin, M.D., and
Yaacov Rozenman, M.D., Jerusalem, Israel
TO THE EDITOR: We describe a patient with xerophthalmia (ocular signs of vitamin A deficiency) and an undiagnosed comorbid eating disorder. To our knowledge, this is the first reported comorbidity of these conditions.
Case Report
Ms. A was a 24-year-old married Arab woman living in an affluent suburb who came in for treatment of a 3-week history of decreased vision and impaired night vision associated with ocular discomfort and the sensation of having an ocular foreign body. Her visual acuity was found to be 6/9 minus in each eye. Upon a slit-lamp examination, she was found to have typical ocular signs of vitamin A deficiency: conjunctival xerosis with dermalization and keratinization. The cornea showed severe dryness and coarse punctate epithelial keratitis with a very irregular surface. This was apparent more so in the left than in the right eye.
Upon examination of her skin, Ms. A was found to have superficial excoriation as a result of pruritis. She described a 13-year history of progressive dietary restrictions triggered by an older sister telling her that she should lose some weight because she was becoming fat. This occurred during the Gulf War, when Ms. A was feeling very anxious about dying in a missile attack. Over the last 2 years, she had stopped eating solids, and her diet consisted of crushed almond drinks. Her weight had decreased from 65 to 50 kg over the last 2 years. She said that her menses were regular. Ms. A reported no self-induced vomiting, use of purgatives, or increased exercise. She had married her first cousin 4 years earlier, and the couple had been unable to conceive. Her past psychiatric history was otherwise unremarkable.
A psychiatric examination revealed an anxious and depressed young woman who appeared adequately nourished. She demonstrated a good command of English. Her height was 164 cm, and she weighed 50 kg. Her body mass index was 21.8. She reported no body image disturbances at her current weight but acknowledged long-standing concerns with eating associated with fear of becoming fat, which she had not been able to disclose to friends or family members until now. There was no evidence of psychosis (hallucinations, delusions, or thought disorder) or active suicidal ideation. However, when Ms. A was informed that if she refused to treat her vitamin A deficiency she would risk suffering future blindness, she indicated that she would rather commit suicide than become blind. She described frustration that her husband had forbidden her from pursuing tertiary studies early in their courtship, and she currently felt unfulfilled from not being able to conceive. The couple had undergone investigation for infertility in the past without any organic cause having been found. Her husband appeared supportive of her.
Ms. A's serum level of vitamin A was low (2 µg %, normal range=25–200), as was her serum level of vitamin E (0.3 mg %, normal range=0.5–2.0). The results of other investigations were normal. Ms. A began supplementation with vitamin A (100,000 units twice daily for 2 days and subsequently 200,000 units per week) and vitamin E (200 mg three times a day). After 5 days of treatment, both serum levels had returned to normal: vitamin A (34 µg %) and vitamin E (0.8 mg %).
After 10 days of treatment, Ms. A's conjunctival dermalization had disappeared, and the appearance of her conjunctiva had returned to normal. The tear film was observed and significant improvement in the coarse punctate keratitis was noted. There was residual staining of the cornea.
After the initial psychiatric assessment, Ms. A began taking fluvoxamine, 25 mg at night, increasing to 50 mg after 3 days. She was seen daily for psychotherapeutic support while she was an inpatient. Her husband was also seen as part of marital assessment during ongoing marital therapy. Ms. A was discharged from the hospital after 5 days of inpatient treatment with psychiatric and ophthalmological review. When she was examined 10 days after her initial presentation, there was significant improvement in her mood. She was attempting to eat light solids and was more positive and optimistic concerning her future. This improvement was maintained at the 3-month follow up. Ms. A was referred for ongoing psychotherapeutic support with a psychiatrist.
Discussion
Vitamin A deficiency is the leading cause of childhood blindness worldwide and is most prevalent in developing countries in the context of malnutrition.1 In Western countries, the deficiency has also occurred because of poor dietary intake, liver disease, and malabsorption syndromes.2,3 Night blindness is the earliest and most common symptom of vitamin A deficiency.4 Treatment with vitamin A supplementation results in a rapid resolution of ocular signs and normalization of vitamin A level, as occurred in this instance.
Since the patient's current weight was within normal limits, her eating disorder was classified as "not otherwise specified" rather than as "anorexia nervosa" (DSM-IV), despite the described significant loss of weight. The impact of Western body shape ideals and simultaneous role conflict between traditional and modern images of the female role have been highlighted by several authors in relation to eating disorders in the traditional Arab population.5,6
The case underscores the need to take an adequate psychosocial history of eating disorders in patients who are seen with vitamin deficiencies. The diagnosis of xerophthalmia should also be considered in persons not suffering from malnutrition. This report highlights the importance of early detection and treatment of eating disorders in the community, some of which may go untreated for long periods as a result of normal weight.
REFERENCES
- Prevention of Childhood Blindness. Geneva, World Health Organization, 1994
- Bishara S, Merin S, Cooper M, Azizi E, Delpre G, Deckelbaum RJ: Combined vitamin A and E therapy prevents retinal electrophysiological deterioration in abetalipoproteinemia. Br J Opthalmol 1982; 66:767-770[Abstract/Free Full Text]
- Wright JM, Wright JS: Vitamin A for night blindness in prolonged jaundice. Br Med J 1971; 3:92-93
- Smith J, Steinemann TL: Vitamin A deficiency and the eye. Int Ophthalmol Clin 2000; 40:83-91[CrossRef][Medline]
- Apter A, Abu Shah M, Iancu I, Abramovitch H, Weizman A, Tyano S: Cultural effects on eating attitudes in Israeli subpopulations and hospitalized anorectics. Genet Soc Gen Psychol Monogr 1994; 120:83-99[Medline]
- Nasser M: Comparative study of the prevalence of abnormal eating attitudes among Arab female students of both London and Cairo universities. Psychol Med 1986; 16:621-625[Medline]
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