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Anorexia nervosa in Indian adolescents: a report of two cases

Article in Journal of Indian Association for Child and Adolescent Mental Health · July 2014
DOI: 10.1177/0973134220140305

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J. Indian Assoc. Child Adolesc. Ment. Health 2014; 10(3):230-243

Case Report

Anorexia nervosa in Indian adolescents: a report of two cases

Dr. Savita Malhotra, Dr. Nidhi Malhotra, Dr. Basant Pradhan

Address for correspondence: Dr. Savita Malhotra, Prof. and Head, Department of
Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh 160012,
India. Email: [email protected]
ABSTRACT

Recent times have seen rise in reporting of Anorexia nervosa (AN) cases from non-

western societies. Classically it has been thought that the cases from traditional societies

are atypical and are not associated with weight phobia. We present case descriptions of

two adolescent girls with AN presenting to our centre with restriction of food intake and

fear of fatness. Difficult temperament, predominant neurotic traits and marked family

pathology was prominent in both the cases. They initially showed resistance to treatment,

however later responded to combination of behavioural and psychological measures.

These case descriptions suggest that the clinical picture and risk factors associated with

AN as well as the response to treatment in India may be similar to that reported from the

West.

Key words: Anorexia, India, Adolescents

Introduction

The   term   anorexia   nervosa   is   derived   from   the   Greek   term   for   “loss   of   appetite”   and   a  

Latin word implying nervous origin. The term anorexia is a misnomer because loss of

appetite is not always present in this disorder. It is a disorder of characteristic eating

behaviours, associated thoughts, attitudes and emotions, and their resulting physiological
 231

impairments. The behavioural component includes a self-induced starvation to a

significant degree resulting in significant weight loss. The psychological component

includes a relentless drive for thinness and/or a morbid fear of fatness. The essential

psychopathology seems tightly linked to overvalued beliefs, primarily the overvaluation

of thinness. Anorexia nervosa is often, but not always, associated with disturbances of

body image, the perception that one is distressingly large despite obvious medical

starvation. The distortion of body image is disturbing when present, but not pathognomic.

The physiological component is the presence of medical signs and symptoms resulting

from starvation. AN can be sub typed as restricting and binge/ purging type. Two

subtypes of anorexia nervosa exist with much overlap and frequent transitions between

them, especially from the restricting subtype to the binge or purge subtype. In the classic

historical form of anorexia nervosa, food intake is highly restricted, and the patient may

be relentlessly and compulsively overactive, with overuse athletic injuries such as stress

fractures and soft tissue tears. In the second subtype, patients alternate attempts at

rigorous dieting with intermittent binge or purge episodes. Purging represents a

secondary compensation for the unwanted calories, most often accomplished by self-

induced vomiting, frequently by laxative abuse, less frequently by diuretics, and

occasionally with emetics.A central theme in all anorexia nervosa subtypes is the highly

disproportionate emphasis placed on thinness as a vital source, sometimes the only

source, of self-esteem, with weight becoming the overriding and consuming day-long

preoccupation of thoughts, mood, and behaviours.Though not much is known about

various factors involved in the pathogenesis of this disorder, a number of risk factors
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have been proposed which include female gender, living in western societies, adverse

parenting, obesity, occupational pressure. Amongst these the role of cultural influence

has been most widely studied. It has been proposed that exposure to western culture in

which more importance is laid on slimness is most important risk factor for AN. Owing

to the same, AN has classically been considered a culture bound syndrome. Earlier notion

was that this entity does not exist in non-western population. However in recent times

many cases of anorexia nervosa have been reported from Asian countries including India

[1-8]. Despite increasing number of reports, the information regarding clinical picture

and the risk factors present in patients presenting with AN in India as well as about the

response to various forms of treatment remains unclear. We hereby focus on these aspects

in two cases of AN presenting to our centre.

Case 1

A 14-year-old girl, student of class 9, from a Sikh extended family of urban background

presented with 2 years history of decreased food intake. Patient was initially a thin built

girl, but as per family members, she started to gain weight when she turned 12. Though

she did not appear very fat, but was criticized by family members and peers for the

weight gain which prompted her to join a gymnasium. In addition, in the quest to lose

weight she started imposing dietary restrictions on herself. Gradually food intake

decreased from 3 proper meals and frequent snacking in between to mere 2-3 bowls of

vegetables per day. Repeated efforts by parents to make her eat failed miserably and were

attended by crying spells and anger outbursts. She started to lose weight and developed

amenorrhoea within a year but continued with the dietary restrictions. A month before
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presentation she also started to remain sad throughout the day, lost interest in previously

enjoyable activities and started to have poor sleep along with decreased attention and

concentration. At the time of presentation her food intake consisted of a few biscuits per

day only. Anthropometric measures revealed weight=39.5kg, height=162 cm and BMI=

15.05 Kg/m2. She appeared cachectic, pale, with lanugo hair over her face. She had

prominent bones with a maxillary prominence. Her secondary sexual characteristics were

poorly developed. Patientwas hospitalized and relevant investigations were carried out to

rule out any endocrine, metabolic or any other medical disorder which could explain the

weight loss and amenorrhoea. In addition, careful psychiatric evaluation was done to rule

out any co-morbid psychiatric disorders. Patient initially reported decreased appetite and

food sticking in her throat as the reason for not eating. However, once rapport was

established she gradually revealed fear of becoming fat as the reason for her dietary

restrictions. Interestingly, patient equated being thin with being successful.Further

assessment revealed that since her early child hood her paternal grandmother had been

the dominating figure in their family to the extent that parents could not make any

independent decisions for themselves or for the patient.Due to the same patient’s  

grandmother took the role of the head of the household which   patient’s   father should

have ideally taken. In addition,patterns of communication in the family had been faulty

with no direct communication between patient and her mother; and between the parents.

These indirect communication patterns led to marked inconsistencies in parental

handling, accentuated by patient’s  grandfather’s liberal  attitude  and  grandmother’s  strict  

notions which conflicted with each other. Over time patient gradually learned whom to
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approach in order to fulfil her demands. Patient also revealed the presence of bias on the

basis of gender in the family. She reported that extra care, attention and praise given to

her brother by the grandmother was a source of continuous stress for the patient, and she

wanted to become successful in order to earn the same. This attitude was further

reinforced by the over expecting attitude of family members. Sessions with the family

revealed that patient had always had a difficult temperament and she would throw temper

tantrums when her demands were not met. She in addition was egoist, was very sensitive,

had a perfectionist attitude and was highly ambitious. Psychometry revealed disturbed

relations with prominent conflicts with mother and brother, poor self esteem and affective

instability.

Initial attempts at increasing her food intake in graded manner were met with resistance.

She would repeatedly indulge in anger outbursts and self harming behaviour.

Behavioural measures like contingency management, token economy, positive

reinforcement, activity scheduling, and externalization of interests were used to decrease

the maladaptive behaviours and eventually it was possible to engage her in a meaningful

conversation. She was educated about balanced diet, anthropometry, ideal body weight

and symptoms of malnutrition. Gradually eating specific amount foods, increasing food

items in diet was made contingent with the activities she liked. Psychotherapeutic

measures were instituted in the form of supportive sessions and family therapy. During

supportive psychotherapy sessions with the patient her fears, apprehensions, day to day

problems were addressed. Emphasis was laid on building up her skills, equating success

with leading a good personal and academic life. During family therapy sessions, which
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involved   patient’sparents   and   grandparents,   aforementioned issues like abnormal

communication patterns amongst family members, inconsistencies in parenting, critical

and over expecting attitudewere addressed and they were asked to be patient. Patient was

also started on T. Mirtazapine 30mg for depressive symptoms and continued for 6

months. Patient gradually increased daily food intake, initially added few sweets to her

diet and over one year started to take fruits, rice and curd. She started to gain weight and

her menstrual cycle resumed after a year or so. Gradually her diet intake further improved

and she eventually included breads and vegetables in the diet after one and a half year.

Her interpersonal relationships improved and she started to perform better at school. She

was maintaining improvement at the time of last follow-up, 2 years after discharge.

Case 2

An 11-year-old girl, student of class 6, from a Sikh nuclear family of urban background

was referred to our clinic from Gastroenterology department. She presented with12

months history of restriction in food intake. The onset of illness temporally correlated

with her failure in class 5 exams, preceded by inability on the part of her mother to give

her enough time, as she had started giving tuitionsaround the same time in order to

combat ongoing financial crisis. Around this time the patient started to skip her lunch,

would avoid calorie dense food and reduced the portion of meals. Over a period of 6

months she would have vomiting after eating any solid food item and her daily diet

consisted of fruit juices and semi-solid foods like khichadi only which lead to weight

loss. Eventually she started to vomit out even liquids and therefore had to be hospitalised.

Her weight was 24.6 kg, height 144.6 cm and BMI 11.7 Kg/m2. Workup for any
 236

endocrine, metabolic, or any other medical disorder which could explain the weight loss

came out to be negative. On examination, she appeared pale and cachectic, and had facial

lanugo hair. Initially, patient gave food sticking in her throat leading to vomiting as the

reason for not eating, however later on she was repeatedly seen to weigh herself and

gradually revealed that she feared gaining weight. She did not consider herself fat but,

dreaded becoming so.Detailed evaluation revealed that patient had a difficult

temperament from early childhood with poor adaptability, high intensity of reaction, lack

of persistence. She would often indulge in temper tantrums,her mood would belabile and

family members would find it difficult to predict her reactions.However she was not

defiant, did not indulge in problem behaviours like stealing or lying and there was no

evidence of sadness or anhedonia. She was highly ambitious, sensitive and remained

apprehensive most of the times. Parental handling had been poor with gross

inconsistencies. Father was in a touring job, would mostly remain outside, visited only

during weekends, and pampered the patient with gifts and special foods. Mother followed

a strict schedule, did not give easily to her demand, but at the same time would spend a

lot of time playing with the child and assisting her with all her activities. Father left the

job when patient was 10, started a spare part shop, started gambling and suffered from

heavy losses. This led to severe interpersonal relationship problems between the parents

with almost daily altercations. It was during this time that the mother started taking

tuitions, and patient was left on her own for daily chores and studies. Psychometry

revealed prominent conflict with mother, poor self esteem, marked aggression towards

authority, tendency to manipulate and affective instability.

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She was initially  fed  with  Ryle’s  tubebut  gradually  shifted  to  oral  intake.  Along  with  that  

psychotherapeutic and behavioural measures were instituted. Behavioural measures

included contingency contract, negative reinforcement, activity scheduling,

externalization of interests and rectifying patterns of parental handling.Psychotherapeutic

measures included play therapy, family therapy and supportive measures. During play

therapy sessions patient was encouraged to pick up and play with her favourite toys in

play room, and mutual story telling with the therapist was also encouraged. These

sessions were directed at building rapport with the patient and to encourage her to express

her feelings without fear. During supportive sessions with the patient her problems in

dealing with day to day problems and apprehensions regarding going to school with

Ryle’s  tube  were  addressed. She was encouraged to build up her skills and healthy ways

of eating were promoted.Sessions with family aimed at reducing inconsistencies. Family

members were asked to remain patient. They were explained that this may lead to an

initial increase in her temper tantrums, but eventually would help the patient in long run.

Patient was also started on Tab. Olanzapine 5mg mainly to decrease her aggression and

promoting the appetite and the same was continued for around 6 months. During the

initial few weeks she resisted treatment, indulged in aggressive behaviour and simulated

other patient’s problems. Parental discord also interfered with treatment and hampered

the progress. However, gradually with combination of behavioural and psychotherapeutic

techniques patient benefited from the treatment, she started taking orally, gained weight

and was able to engage herself in the therapeutic and parental relationship more
 238

meaningfully. She maintained the improvement for about 1 and a half years following

which she was lost on follow-up.

Discussion

Both patients presenting to us had similar profile. They were adolescent school going

girls coming from urban background with symptoms of restriction of food intake, refusal

to eat normal meals and weight loss. Both held on to the fact that they were not eating

due to food sticking in the throat initially, only to reveal fear of fatness at a later stage.

Difficult temperament, predominant neurotic traits and abnormal behaviour was

prominent in both the cases. Family pathology was present with marked abnormalities in

parental handling. Both the patients responded to a combination of behaviour therapy and

psychological interventions.

Literature suggests that AN can have onset during childhood, adolescence or in adulthood

[9]. Adolescent onset AN has good prognosis when treated aggressively in the initial

presentation [1]. In the present series both the patients were adolescents females, similar

to what has been reported previously [9].With regards to gender,Western literature quotes

a higher prevalence of AN among females as compared to males. Barry et al, 1990

reported that 90% of patients with AN were girls and 5–10 % boys [10]. In National Co-

morbidity Survey the prevalence rate was 3 times in females as compared to males[11].

In previous descriptions of anorexia nervosa from India, it was evident that the

presentation is atypical and AN is not accompanied by weight phobia [5,6].Cultural

factors were thought to be accounting for the difference as traditionally, eating well is

considered a sign of nurturance and prosperity in India [5]. Whereas owing to wide
 239

availability of cheap, high-fat foods obesity has become much more prominent among all

social classes, particularly poorer populations. Concurrently, pressures to be thin, weight

control efforts and eating disorders with fear of fatness as clinical problems have become

increasingly associated with affluent societies. However this case series and other cases

described by Mandhekar et al, 2009 suggestthat the presentation of AN in developing

countries may not be different from the West [2]. Exposure to western culture, in which

being slim is considered as a sign of attractiveness, may be responsible for dilutingthe

protective effect of our culture. Previously also, it hasbeen demonstrated that the Western

media isassociated with a negative impact on body image in non western societies [12].

Another striking commonality between the two patients was presence of neurotic traits

and difficult temperament with problem behaviour in form of temper tantrums and anger

outbursts. These factors though not previously reported from India, have been

consistently reported as risk factors for AN in the West [13,14].Marked family pathology

with poor parenting was evident in both the cases.Pathological familial interaction had

been earlier reported in a 13 year old from India by Chadda et al, 1987 and similarly by

Chandra et al, 1995 [5,8]. No single specific family functioning style appears to be either

a necessary or sufficient requirement for developing an eating disorder. However families

with high expectations, low contact and parental discord seem to enhance the risk.

Criticism, teasing, and bullying focused on food, weight, and shape issues are important

risk factors for developing an eating disorder [15].Negative comparisons between an

individual’s body shape and that of the ideal contributes to poor self-esteem [16].The

confusion that arises in the midst of idealisation of thinness, stigmatisation of fatness, and
 240

easy access to highly palatable food, can lead to weight control behaviours that can have

a destabilising eff ect on the biology of appetite control[17]. Many other risk factors

implicated include adverse premorbid experiences like childhood sexual abuse, family

history of depression, substance use, obesity, early menarche. Most prominent risk

factors include low self esteem and perfectionism, the latter being a particularly common

antecedent of anorexia nervosa [9]. Both the patients received treatment in inpatient

setting. Indications for admission to hospital include risk of suicide, severe interpersonal

problems at home, and failure of less intensive methods. Physical indications include a

very low weight, rapid weight loss, and the presence of medical complications, such as

pronounced oedema, severe electrolyte disturbance, hypoglycaemia, or great intercurrent

infection [9].In treatment of both the patients, initial emphasis was laid on improving the

nutritional status. It is of utmost importance so as to prevent the long term complications

and also as improving nutrition itself usually leads to substantial improvement in the

patient’s  overall state [9]. Both our patients, initially showed resistance to treatment, but

eventually were amenable to combination of behavioural and psychotherapeutic

measures. Different forms of psychotherapies including cognitive, psychodynamic,

supportive and family based psychotherapies have been used in treatment of AN. In the

western literature family based therapies have shown to have best outcome in adolescent

onset AN [18,19] and same appears to stand true for our population as well. Little

importance has been laid down on use of pharmacological management in AN. Though

there is some inconsistent evidence for the use of antidepressants and low dose

antipsychotics [20]. However, whenever possible a multi disciplinary approach including

 241

medical, nutritional, social, and psychological components is recommended [17].To

conclude, these case descriptions suggest that AN exists in its typical form in non-

western societies as well. The disorder though poses a difficult challenge to the clinicians

but is amenable to intensive treatment. Further descriptive studies are warranted for better

understanding of this disorder.

References

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Adolescents in a Tertiary Care Centre in India. Indian J Paediatrics 2012. Epub ahead

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Dr. Savita Malhotra, Professor and Head, Dr. Nidhi Malhotra, Senior Resident, Dr.
Basant Pradhan, Former Senior Resident, Department of Psychiatry, Postgraduate
Institute of Medical Education & Research, Chandigarh 160012, India.

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