Anorexia Nervosa-restricted type with obsessive traits in a pre-pubertal female: A case report

Abstract

Sir, Anorexia nervosa is an eating disorder characterized by refusal to maintain a healthy body weight and an obsessive fear of gaining weight. Once a rare entity in non-western countries like India, it is now being reported more frequently here too. Westernization of our society and change in attitudes’ and beliefs’ may be the reasons for such a change. Earlier, the cases of Anorexia Nervosa from the Asian countries showed an atypical presentation, where there was significant weight loss, but no body image distortion;[1] however, now in the more recent times, the presentation has changed to the typical form, which includes significant concerns about the body image as well.[2 3] Obsessive traits in childhood are a known risk factor for future development of Anorexia Nervosa.[4 5] A 13 year old, pre-pubertal, Hindu female, was brought to our institute forcibly by her family. She belonged to a semi-urban family of middle socio-economic status, and the duration of her illness was for around 2 years. Her symptoms began in the year 2008 at the age of 11 years after some dietary restrictions by her physician during high grade fever of unspecified nature, which gradually changed into a disturbed eating behaviour pattern. She initially refused food with high calorie content like roti and dal, as she considered them “fattening”; and later on, started restricting herself to a liquid diet of low calorie to lose weight as she “felt fat”. She remained preoccupied with her weight which dropped down from 43 to 30 kg, and also her school performance deteriorated. Later, her diet was restricted to one or two bites of fruit like apple and a few sips of water. She was unable to walk, and could not attend school because of her weakness. Her premorbid personality was of a perfectionist type. Even as a child, she kept her things in precise order, and became uncomfortable if her things were disturbed. On physical examination, she had signs of emaciation, poor nutrition and poorly developed secondary sexual characteristics. Her height was 4 feet 10 inches, and weight was 30 kg. Her menstruation cycle had yet not started. Investigations carried out to rule out organic causes of weight loss showed normal results. On examination of the mental condition, findings included morbid fear of fatness, irritability and non acceptance of the fact that she was underweight. She showed obsessive traits about cleanliness and orderliness. She was hospitalized for treatment of disordered eating behaviour, and to ensure a proper nutritional restoration and weight gain. Cognitive behaviour techniques were employed to treat her fears about “fatness”, obsessive traits and ideas about distorted body image. Graded increase in her weight was targeted. Additional medical intervention was given for her obsessive symptoms in the form of 5 mg olanzapine and 100 mg/day fluvoxamine. On being discharged after 3 weeks, she showed signs of improvement and her weight had increased to 35 kg. She was motivated to maintain the normal body weight for her age and height. She was reviewed every week for the initial 2 months after discharge and monthly thereafter. On follow up visits, it was observed that she had maintained a normal body weight and dietary pattern. Her obsessive symptoms also showed improvement; with her ideas about body image and diet changing greatly for the better. After 6 months she had menarche, marking an important milestone. Earlier, the reporting of cases of Anorexia nervosa from non-western countries like India, was fewer, and this can be attributed to a number of protective biologic factors, as also the socio-cultural norms of the country, with a good family support system and emphasis on good nutrition and health.[1] In fact, a healthy body weight was considered as symbol of nurturance and good family life.[6] Our case further confirms the changing concept of Anorexia nervosa in India, and how imitation of western lifestyle is affecting our society. We have to be more vigilant about this new “culture change syndrome”, and educate individuals that “being slim” and the “size-zero fad” should not be blindly considered as a sign of attractiveness. In India, so far only 3 studies have been done on Anorexia nervosa,[2 3] and the need for more in-depth studies can be felt. The importance of good nutrition and maintaining a healthy body weight, while preventing eating disorders, should be stressed upon.