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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 19  |  Issue : 1  |  Page : 47-49

Anorexia nervosa in rural South India


1 Department of Psychiatry, Sagar Hospitals, Bengaluru, Karnataka, India
2 Department of Psychiatry, Mandya Institute of Medical Sciences, Mandya, Karnataka, India

Date of Web Publication26-Jun-2018

Correspondence Address:
Dr. Keya Das
G 02, Tuscan East Apartments, Lazar Road, Cox Town, Bengaluru - 560 042, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AMH.AMH_17_18

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  Abstract 


Anorexia Nervosa, an eating disorder having first been identified in the 17th Century Europe has been considered a western syndrome with emphasis on slimness as a measure of feminine beauty. Global development and rapid changes in South-East Asian countries in economy, mindsets, and Adoption of Western attitude has occurred there have been sporadic reports of Anorexia Nervosa in the past few years in India mostly in cities. Our case report digresses from the familiar theory of Anorexia Nervosa being a westernized concept in presenting a case from Rural South India. We report of a 12-year-old girl child from rural district, South India, belonging to a traditional South Indian family of middle class status, presented with somatic complaints of pain abdomen and vomiting with background of progressive weight loss over 3 months with amenorrhea of 3 months, precipitating factor of comments from relatives about weight gain and menarche. Diagnosis of Anorexia Nervosa was made, with Body Mass Index 14.9. A multidisciplinary approach to treatment was commenced. Authors aim to point out the need to screen for eating disorders irrespective of patients' geographic or cultural affiliations to ensure prompt intervention.

Keywords: Anorexia nervosa, culture, geography, rural, South India


How to cite this article:
Das K, Ashok K S. Anorexia nervosa in rural South India. Arch Ment Health 2018;19:47-9

How to cite this URL:
Das K, Ashok K S. Anorexia nervosa in rural South India. Arch Ment Health [serial online] 2018 [cited 2018 Dec 14];19:47-9. Available from: http://www.amhonline.org/text.asp?2018/19/1/47/235316




  Introduction Top


A postal survey of 30 cases of Anorexia Nervosa was reported from Malaysia (19 Chinese, 8 Indians, 2 Eurasians and 1 Malay).[1] A similar postal survey in Japan by Suematsu et al. found 1312 cases of Anorexia Nervosa, a doubling of prevalence in 10 years.[2] Ong et al. reported 7 cases of Anorexia Nervosa in Singapore.[3] AN is almost absent in the Chinese population with only a few cases being reported from Hong Kong.[4] Three cases of Anorexia Nervosa have been reported in Vietnamese refugees.[5] The exact prevalence of Anorexia Nervosa in the Indian subcontinent has not been explored. However, there have been sporadic case reports from the Indian subcontinent and Pakistan. Most of such findings are confined to the affluent strata and those with a cosmopolitan background.[6] We present a case of contrasts regarding cultural views and geographical influences as against the norm of anorexia nervosa theories thus far. As per our findings, this is the first presentation of anorexia nervosa among the rural Indian subcontinent.


  Case Report Top


Miss X, aged 12 years and 8 months, Grade 6 student, elder child of two siblings hailing from rural district and belonging to Hindu faith, of traditional family sensibilities was referred by the Pediatrician because of concerns about her insidious weight loss for which no organic cause was found. Thorough investigations with the suspicion of tuberculosis, abdominal malignancies, endocrine disorders were conducted and were found to be well within normal limits. In the months before the referral, the patient had lost weight significantly for the past 2½ months and reported to be eating sparingly at home. On a daily basis, the patient was reported to be eating only 1 meal per day, which consisted of a small bowl of rice with lentils. Weight loss over the past 2½ months was 13 kg. Parents reported that the child would at times claim she has eaten elsewhere to avoid eating with the family at mealtimes and when insisted on would get into frequent arguments with family members. The family also mentioned her concerns regarding a need to “remain slim unlike her mother” and her preoccupation with body image post her attaining puberty 10 months back.

There was a history of excessive exercise and overt indulging in sports activities for the past 2 months; often, the adolescent was found checking her weight in the weighing scale kept in the retail shop owned by her parents. There was no history of laxative abuse or self-induced vomiting. Menstruation which had commenced 10 months earlier, was initially regular but had become irregular for the past 4 months with amenorrhea of 3 months. Parents described her as a highly organized child, a good pupil and ambitious about school performance. During the past month, the parents had noticed her progressive weight loss and frequent days wherein she was easily fatigued. The reason for pediatric help being sought was that the child developed vomiting and pain abdomen lasting for 3 days, associated with exhaustion and was admitted for the same.

On examination, Miss X was stunted as per her age, asthenic and dehydrated. Her Body Mass Index was 14.9, with a body weight of 30.05 kg and height of 142 cm. She had cold extremities, tachycardia with poor peripheral pulses, and a low-blood pressure of 96/60. Secondary sexual characteristics were noted to be minimal. Blood investigations showed her to be anemic (Hb 8.2), with borderline calcium levels and hypokalemia.[7]

Detailed evaluation established a better rapport with the child. She admitted to “Dieting” and checking her weight more than before as “people” had warned her that she might become obese like her mother after puberty. Further explanations from the child revealed, by “people” she meant extended female family members, i.e., maternal aunts and cousins who discussed her possibility of gaining weight after menarche like her mother. Family psychodynamics revealed that the child was well adjusted at home, had a good rapport with parents and younger sibling. However, the mother did hint towards some amount of sibling rivalry regarding academic performance between both the children.

Clinical depression was ruled out, with no suicidal ideations or Deliberate Self-Harm Behaviour following which a diagnosis of Atypical Anorexia Nervosa was made (according to ICD-10). The general health questionnaire and the eating disorder examination questionnaire were administered. In addition to the pediatric management of maintaining her electrolyte levels, and treatment commencement of anemia with iron and folic acid tablets, psychiatric management was initiated with a focus on weight gain in a gradual manner. Psychoeducation about the disorder was given to the child and parents, myths and misconceptions about body image and menstruation were addressed. Nutritional rehabilitation was planned, where she was asked to maintain a dairy about her intake of food. Initiation of a low dose psychotropic was discussed with patient and family. However as they chose not to opt for medication, it was withheld. She was encouraged to eat food with high caloric value and introducing certain food items into her meal was planned with the patient. Parents were asked to keep a watch for possible purging behavior. Improvement in weight was noted by 1.5 kg at the end of 10 days of hospital stay. The patient was discharged with a diet chart, maintenance of meal diary, with subsequent follow-up at 2 weekly intervals with a plan to initiate cognitive-behavioral therapy for distortion in body image.


  Discussion Top


The past decades have seen a rise in the cases of anorexia nervosa in the Indian subcontinent. Early age of onset from 12 to 20 years is the most common presentation.[8] With this case report, we hope to bring to the notice that the earlier notion of Anorexia Nervosa being an urban concept is now changing and seeping into the rural areas as well or has gone undetected in the past.

Recent reports suggest a rise in the clinical cases of Anorexia Nervosa in India,[7] with the cases cropping up in urban population and more often only when the Somatic complaints are severe enough to warrant medical attention. Reports from Asian subcontinent and Pakistan found that there was evidence that most westernized girls were at great risk of developing an eating disorder. There was also support for the hypothesis that the effects of Westernization on eating attitudes were mediated through greater dissatisfaction with body shape.[6] They expected to find an increased incidence of eating disorders with the widespread acquisition of western manners, customs, styles, and perspectives.

Cultural factors in the etiology of Eating Disorders have been clearly operative. However, this case report along with others from Asian Subcontinent disputes the notion that Anorexia Nervosa is restricted only to the Caucasian individuals or just to the urban-westernized mindset.[6] In our case study, the child came from a traditional south Indian household of India and hailing from a rural district. Several factors could be considered in the etiology of pathogenesis, particularly the developmental theory which states the inability to cope with developmental demands of Adolescence in keeping with Crisp's view.[9]

Characteristically, the child had attained puberty only 10 months before the development of symptoms. This could be considered a significant life event, which is in keeping with theories of onset of psychiatric disorders, including Eating Disorders.[6] The emphasis on body image especially on the female gender is as prevalent in the Indian culture as it is in other ethnic/racial groups, and this case evidences the same with the child experiencing a need to “fit in” to extended family expectations.

The child presented with somatic complaints for which multiple specialist opinions were sought to discern the underlying reason for symptomatology. As no definitive organic condition was arrived at, the case was referred for psychiatric evaluation. Report of this specific case hopes to bring to the attention of pediatricians, general practitioners, and other medical practitioners to be aware of the symptomatology of eating disorders as most patients would manifest somatic conditions similar to the reported case. It also points to the need to keep an open mind as to the possibilities of an eating disorder in children and adolescents irrespective of geographical or racial distribution. A need for dispelling myths and misconceptions regarding healthy body proportions as per gender, age, race, and association with height is essential to combat the development of eating disorders. Further exploration of the prevalence of eating disorders in the Indian subcontinent may shed light as to the real extent of the disorder prevailing in the nation. Consent has been taken from Patient and Family, with care not to disclose the patients identity.

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

1.
Buhrich N. Frequency of presentation of anorexia nervosa in Malaysia. Aust N Z J Psychiatry 1981;15:153-5.  Back to cited text no. 1
[PUBMED]    
2.
Suematsu H, Ishikawa H, Inaba Y. Epidemiological studies of anorexia nervosa. Shinshin Igaku Psychosom Med 1986;26:53-8.  Back to cited text no. 2
    
3.
Ong YL, Tsoi WF, Cheah JS. A clinical and psychosocial study of seven cases of anorexia nervosa in Singapore. Singapore Med J 1982;23:255-61.  Back to cited text no. 3
[PUBMED]    
4.
Lee S, Chiu HF, Chen CN. Anorexia nervosa in Hong Kong. Why not more in Chinese? Br J Psychiatry 1989;154:683-8.  Back to cited text no. 4
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5.
Kope TM, Sack WH. Anorexia nervosa in Southeast Asian refugees: A report on three cases. J Am Acad Child Adolesc Psychiatry 1987;26:795-7.  Back to cited text no. 5
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6.
Imran A, Ashraf N. Anorexia nervosa in a Pakistani adolescent girl: A case report with literature review of anorexia nervosa in Asia. Annals 2008;14:156-8.  Back to cited text no. 6
    
7.
Srinivasa P, Chandrashekar M, Harish N, Gowda MR, Durgoji S. Case report on anorexia nervosa. Indian J Psychol Med 2015;37:236-8.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Mammen P, Russell S, Russell PS. Prevalence of eating disorders and psychiatric comorbidity among children and adolescents. Indian Pediatr 2007;44:357-9.  Back to cited text no. 8
[PUBMED]    
9.
Crisp AH. Anorexia Nervosa: Let Me Be. London: Academic Press; 1980.  Back to cited text no. 9
    




 

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