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CASE REPORT
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A case of anorexia nervosa in a preadolescent male


 Department of Psychiatry, Dr. D Y Patil Medical College, Hospital and Research Centre, Dr. D Y Patil Vidyapeeth, Pune, Maharashtra, India

Date of Submission25-Sep-2020
Date of Decision30-Apr-2021
Date of Acceptance28-May-2021

Correspondence Address:
Suprakash Chaudhury,
Department of Psychiatry, Dr. D Y Patil Medical College, Hospital and Research Centre, Pimpri, Pune - 411 018, Maharashtra
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_539_20

  Abstract 


Anorexia nervosa (AN) is one among the severe psychiatric disorders of adolescence. AN in boys is often overlooked by both physicians and psychiatrists since it is predominantly seen in females. Teenagers usually get over the disorder, but in some cases, AN can cause serious complications, including chronicity and death. AN is often encountered among females and more so in the affluent class. Here, we present an 11-year-old boy belonging to a middle-class Indian family, referred for psychiatric evaluation from the pediatrics department after ruling out all medical causes for the weight loss. The patient complained of loss of appetite along with weight loss of 14 kg in the last 3 months. In-depth psychiatric evaluation revealed significant distress of gaining weight as well as an intense disgust related to his body shape. A cluster of determined food refusal and weight loss triggered the exploration of other symptoms of AN. The patient responded to antidepressants and well-planned cognitive behavioral therapy. Results were seen in the form of return to the normal range of body weight, shape, and size along with its confident acceptance.

Keywords: Anorexia nervosa, body image, cognitive behavioral therapy, eating disorders, preadolescent male



How to cite this URL:
Patkar P, Singh I, Chaudhury S, Saldanha D. A case of anorexia nervosa in a preadolescent male. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2022 Dec 6]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=336738




  Introduction Top


The term anorexia nervosa (AN) was coined in 1873 by Sir William Gull in London and Dr. Charles Laségue in France who referred to it as “anorexia hysterique.” Both physicians described cases of individuals presenting at markedly low body weights and engaging in self-starvation behaviors. However, the initial medical description of the condition was by Richard Morton in 1689.[1] AN is a serious physical and psychiatric disorder that carries a crude mortality rate of 5%.[2] AN is most commonly seen in the Western world and has a significantly lower incidence in developing countries like India. The prevalence in India was reported as 0.18%, which is much lower than in Western countries.[3] This disorder is predominantly seen in adolescent females of the age group of 15–19 years of age. The clinical presentation of AN among males is rare.[4],[5] Males and females tend to share similar clinical presentation and psychopathology except for amenorrhea. In addition, males are disposed to vigorous exercise, have sexual concerns, and suffer comorbid psychiatric disorders more often than females. However, owing to later onset of puberty and distinctly different social images, males often tend to present at a later age than females.[5] Men are seen to be reluctant to seek treatment out of shame, and clinicians too are less likely to recognize the syndrome in male versus female patients. Moreover, while AN has been thought of historically as a disease of white, wealthy women, it impacts individuals of all racial and socioeconomic backgrounds.[6],[7] Hence, the prevalence of this disorder in the Indian setting is very less and more so in preadolescent males. Considering this, we present this case to discuss a slightly uncommon form of presentation and moreover in an unusual profile.


  Case Report Top


Our patient was an 11-year-old boy, studying in the 6th grade, referred to the psychiatry department for unexplained weight loss. The pediatrics department had ruled out all the causes for the unexplained weight loss. The patient's parents gave a history of refusal of food and weight loss for the last 2–3 months. It initially started off as decreased food intake owing to a feeling of being bloated, which made the child reduce his meals as he did not feel hungry very often. At first, the boy would only avoid the amount of food he would take and then the number of meals. He gradually started avoiding sweet foods and even fried or oily foods. His parents said that he would often read up on the internet about the caloric content of various food items and keep sharing this information with everyone at home. Later, he stopped eating any kind of bread and rice to avoid any carbohydrates. The child would often taunt the other family members about their food habits and even asked them to eat less on multiple occasions. A lot of times, he would stand next to his mother in the kitchen and supervise her cooking to make sure that she did not use any unhealthy ingredient. On further questioning, his parents revealed that they had observed him deliberately inducing vomiting on a few occasions and even asking them for laxatives saying he was experiencing some stomach discomfort. When advised by the family or friends to have a proper meal or questioned about his sudden weight loss, the parents complained of irritability and anger outbursts.

Due to all this, he rapidly started losing weight. His weight drastically dropped from 34 kg to 20 kg, a 14 kg or a 40% weight loss in a mere 2 ½–3 months. His BMI came down to 10.36 kg/m2, making him severely underweight. The ideal weight for his 140 cm height should have been 38 kg. Due to sudden weight loss, he became weak, complained of intolerance to cold, fatigue, and constipation at times. Off late, this boy became so weak that someone had to assist him in doing his day-to-day activities such as bathing, dressing, or toilet activities. The child was unable to attend school in the last 10–12 days before admission. There was no history suggestive of binge eating or excessive exercising to lose weight. There were no symptoms suggestive of depression or psychosis.

This child belonged to a joint family and was the second son to his parents. They lived in a small apartment located in the outskirts of a tier two city. His family included grandparents, parents, a widowed aunt, and an elder brother. Both the parents had formal education up to the 8th grade. His father worked as a clerk in an office, mother being a homemaker. His brother was a below average class 10 student, who was not interested in studying and would always be spending his time with his friends in spite of being scolded by his parents. The patient had always been a bright child who would be among the class toppers and, hence, disagreed with the rebellious and careless attitude of his brother and was never very close to him emotionally. Automatically, this made him the favorite and pampered child in the household as he always was an obedient and bright child. He had a very demanding nature and used to get extremely upset if things did not go according to him. His parents described him as a perfectionist especially when it came to things related to school. He had a few friends in school and around home and would get along fine with them, although he had not gone out to play much in the last few months. The boy thought that his parents had a lot of expectations from him, especially because his brother would not entertain their concerns about his callous attitude. Apart from this, his developmental history was normal with no significant medical or psychiatric history. There was no history of any psychiatric illness in the family.

On examination, he was averagely built boy with a cachexic body [Figure 1]. Blood pressure was 90/70 mmHg and pulse 70/min. He had dry skin and cold extremities. Some proximal muscle wasting was seen and he was too weak to sit upright in the chair for long. Apart from this, the systemic examination was normal. On mental status examination, he was very guarded in the beginning and it was very difficult to establish a rapport with him. In subsequent interviews, he confided that he was teased by a few kids in school about his weight and they called him names saying he was fat or plump. Having felt very hurt by this, he started dieting to lose weight. He revealed that he used to be preoccupied with his weight and admitted that he checked it after every meal. The patient had significant distress related to his body image and believed that he was “fatter and chubbier” than his friends at school. When questioned about his ideal weight, he agreed that he had lost weight because of his food restriction and said it is very good that he weighed less now even though it was below the ideal weight for kids his age as he would not be teased now at least. The child very rigidly said multiple times that he should always weigh <25 kg and it would be a disaster if at all his weight would be more than 30 kg. When asked as to why he would not attend school, said he felt weak and had difficulties being attentive and concentrating. Routine investigations such as hemogram and liver and renal function tests were normal. Hormonal levels such as growth hormone, cortisol levels, thyroid function tests, and sex hormones such as follicle-stimulating hormone, LH, and testosterone were normal. Magnetic resonance imaging brain and abdomen revealed no abnormalities. Hence, all other causes of weight loss were meticulously ruled out.

After establishing a diagnosis of AN according to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), treatment was initiated with an SSRI, namely, tablet sertraline. It was started at a low dose of 12.5 mg in the beginning and slowly uptitrated to 50 mg. Multivitamin and other nutritional supplements were also added to ensure replenishment of the body stores. The main focus of the treatment was cognitive behavioral therapy (CBT). Detailed structured sessions of CBT by a trained psychotherapist were planned for the child. It first focused at understanding the child's cognitive distortions about his weight and body image. There were also sessions planned to get a better understanding of his dynamics with family and friends, who would later be involved in the therapy. After getting a better understanding of all this, the child was slowly made aware of the faults in his way of thinking and the problematic effects it was having on his mental and physical health. After developing an insight into his illness, he was convinced to work on his attitudes toward his body image and subsequently gradually alter his food habits. Along with this, his family had to be educated in detail about his disorder. Family counseling sessions were carried out to explain how they could support us in treating him and how reinforcement could help achieve better results. A well-balanced diet was chalked down with the help of a dietician with inputs from the patient as well. Slowly and steadily the boy started gaining weight. He gained 6 kg by the end of 1½ months and 14 kg by the end of 3 months [Figure 2]. Since this all started with the child being affected by the school bullies and the name calling, he was also counseled on how to better deal with similar incidents in future. Even after 6 months, the patient and parents have maintained a regular follow-up to the hospital. He now realizes his misconceptions about his weight and body image and how harmful they were to him. The child weighs around 36 kg over the last 3–4 months and has been well maintained on treatment.
Figure 1: Anorexia nervosa patient before treatment

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Figure 2: Anorexia nervosa patient after treatment

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  Discussion Top


In today's world, size and appearance is unfortunately one of the biggest parameters to assess beauty. Societal and peer pressure to be and to look the best creates undue stress in children and adults alike. Beauty lying in the eyes of the beholder is a concept that has acquired an almost antagonistic effect on the minds of the people. Other's opinion of our body image has become of greater value than one's own comfort and health as was seen in our patient. AN is invariably linked with a fear of fatness and issues with one's own body shape. The current guidelines of psychiatric disorders, namely, ICD-10 and DSM-5, also corroborate with it. It is defined as a disorder characterized essentially by a restriction of energy intake, intense fear of fatness or gaining weight, and misconceptions or preoccupations with one's body shape and image. Invariably assumed to be a disorder affecting the adolescent females of the affluent class, it is most commonly seen in the Western world. Eating disorders in males are often overlooked and diagnosed late as physicians often keep it as a diagnosis of exclusion as was clearly highlighted in our patient. Studies now reveal that male-to-female prevalence ratio of AN is about 1:10.[8] In addition, physicians may have a lower index of suspicion for eating disorders in boys compared with girls. It is postulated that eating disorders are only diagnosed in males when significant psychiatric comorbidity is present.[9]

There are differences in predictors of eating disorders in studies. One study observed that eating disorder cognitions in girls were predicted by childhood body dissatisfaction in girls but only in interaction with BMI in boys.[10] Another study reported that symptoms at 12 years of age were greater body dissatisfaction for both sexes but higher depressive symptoms only for girls. Other studies have identified early feeding difficulties, parenting styles, anxiety symptoms, and perfectionist traits as risk factors for AN.[11],[12] Out of the above, our patient definitely had perfectionist traits and was concerned with body weight, but there were no signs of depression.

Our case highlighted a preadolescent boy who belonged to a very conservative Indian family in a patriarchal setting with a lot of academic expectations from the index case. The onset of his symptoms was essentially very early, being in the preadolescent period. Being initially diagnosed as a case of severe weight loss, a lot of time and money was spent in ruling out any cause for the same before being referred to psychiatry. Thus, a vigilant physician is of utmost importance in such cases. Our patient was of the purging subtype with intermittent episodes of purging and laxative use. Furthermore, since family belonged to an average middle-class Indian society with parents not as well educated, it was a challenge to make them appreciate and identify the symptoms and acknowledge them as problematic and contributing to the food refusal, weight loss, and body image issues as these concepts were extremely foreign to them. Along with psychotherapy to the patient, family counseling was equally important in this case.

This case not only highlights the rare presentation but also emphasizes the importance of a strong interdepartmental liaison when it comes to dealing with unusual presentations in children.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Crisp A. Collaborators: Anorexia nervosa in males: Similarities and differences to anorexia nervosa in females. Eur Eat Disord Rev 2006;14:163-7.  Back to cited text no. 4
    
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Erriu M, Cimino S, Cerniglia L. The role of family relationships in eating disorders in adolescents: A narrative review. Behav Sci (Basel) 2020;10:71.  Back to cited text no. 8
    
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Bramon-Bosch E, Troop NA, Treasure JL. Eating disorders in males: A comparison with female patients. Eur Eat Disord 2000;8:321-8.  Back to cited text no. 9
    
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Micali N, De Stavola B, Ploubidis G, Simonoff E, Treasure J, Field AE. Adolescent eating disorder behaviours and cognitions: Gender-specific effects of child, maternal and family risk factors. Br J Psychiatry 2015;207:320-7.  Back to cited text no. 10
    
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Jacobi C, Hayward C, de Zwaan M, Kraemer HC, Agras WS. Coming to terms with risk factors for eating disorders: Application of risk terminology and suggestions for a general taxonomy. Psychol Bull 2004;130:19-65.  Back to cited text no. 11
    
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