Anorexia nervosa: An Indian perspective

Abstract

Anorexia nervosa is a condition thought to be associated with the western culture. However, the recent publication of a case series from Asia suggests that it is a syndrome related to a changing culture. We present a detailed clinical form of this syndrome based on descriptive analysis of 2 cases of anorexia nervosa. Both these patients were adolescent, school-going girls from middle socioeconomic class of urban background. They were pre-morbidly non-obese and did not have any pressures to pursue slimness for beauty. However, there was an identifiable psychosocial stressor as a precipitant in both of them. Both the patients had symptoms of refusal to eat followed by weight loss. We could not identify any risk factor in our patients for anorexia nervosa. Our report illustrates the differences in developmental and psychodynamic issues related to the development of anorexia nervosa, though the clinical symptoms may be similar.

Full text

Clinical Case Report
Neuropsychiatry and Headache Clinic, Pratap Nagar, Metro Pillar 129,
Delhi 110007, India
D. N. MENDHEKAR
Children First, Vasant Vihar, New Delhi, India
K. ARORA
Long Island Jewish Medical Center, Glen Oaks, NY 11004, USA
D. LOHIA Department of Child and Adolescent Psychiatry
G.B. Pant Hospital, New Delhi 110002, India
A. AGGARWAL, R. C. JILOHA Department of Psychiatry
Correspondence to D. N. MENDHEKAR; dnmendhekar@vsnl.net
Anorexia nervosa: An Indian perspective
D. N. MENDHEKAR, K. ARORA, D. LOHIA,
A. AGGARWAL, R. C. JILOHA
ABSTRACT
Anorexia nervosa is a condition thought to be associated with
the western culture. However, the recent publication of a case
series from Asia suggests that it is a syndrome related to a
changing culture. We present a detailed clinical form of this
syndrome based on descriptive analysis of 2 cases of anorexia
nervosa. Both these patients were adolescent, school-going
girls from middle socioeconomic class of urban background.
They were pre-morbidly non-obese and did not have any
pressures to pursue slimness for beauty. However, there was
an identifiable psychosocial stressor as a precipitant in both of
them. Both the patients had symptoms of refusal to eat
followed by weight loss. We could not identify any risk factor
in our patients for anorexia nervosa. Our report illustrates the
differences in developmental and psychodynamic issues related
to the development of anorexia nervosa, though the clinical
symptoms may be similar.
Natl Med J India 2009;22:181–2
INTRODUCTION
There has been a recent spurt in the recognition of patients with
anorexia nervosa (AN) in non-western countries, with one study
reporting the prevalence of women at risk of developing eating
disorders to be 7.4%.1 This suggests that the western concept of
equating beauty with being slim is being accepted in some Asian
countries such as Thailand.2 Though there are few published
reports,3–7 a qualitative study probing the clinical form is lacking
in the Indian literature. We focus on the clinical pattern of AN in
India by providing a descriptive analysis of 2 cases.
THE CASES
Case 1
A 15-year-old girl, student of class X, living with her adoptive
parents but unaware of her adopted status, belonged to an urban
family of middle socioeconomic status. She presented with a 15-
© The National Medical Journal of India 2009
month history of a change in eating habits. Just before the onset
of her illness, her adoptive mother was diagnosed with
hypertension, which needed dietary restrictions. The mother
perceived a change in eating habits around this time as the patient
started asking for a piece of sweetmeat every day. After a few
weeks, she started demanding one or more ice-cream scoops/
sweetmeat everyday. A few weeks later, she started reporting
abdominal pain after ingestion of one of these items and therefore
stopped having them altogether. After about 6 months, she started
complaining of abdominal pain upon eating any kind of solid
food, subsequently decreasing her food intake. She started having
an essentially liquid diet and, as a result, her weight decreased. At
the same time, she started getting complimented by her friends
and neighbours for looking slim and attractive. Over a few
months, her ingestion of liquids, especially those with a high
calorie content such as cold drinks, also decreased, and by this
time (about 4 months before presentation), she weighed 30 kg.
The parents perceived her weight loss to be around 40% as
evidenced by marked loosening of her clothes and comparison
with her older photographs. She avoided all sweets, oily food,
fruits and even beverages. Over 6 months after the onset of her
symptoms, she also began taking immense pleasure in making
elaborate meals for her family, which was beyond her regular
fondness for cooking. There was no associated history of purging,
binge eating, or use of laxatives or emetics. There was no significant
personal or family history other than her adoptive status, of which
the patient was not aware. She was treated by the parents as their
own child.
A work-up for organic causes of weight loss was negative.
She weighed 26 kg (body mass index [BMI]=10.2), and had
amenorrhoea for the past 4 cycles. 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. She did not consider her weight abnormally
low or her appearance too thin. Her higher mental functions were
within normal limits.
The patient was started on supervised feeding of oral foods,
given frequently in small quantities. The need for continuous
vigilance was emphasized. A good therapeutic alliance was
established with the patient. The patient gradually started gaining
weight (3 kg over 4 weeks). Despite detailed evaluation, no
evidence of weight phobia or preoccupation with pursuit of
thinness was found. Gradually, she re-started monitoring her
weight as well as caloric count but again decreased her food intake
after reaching a weight of 31 kg. This time, she repeatedly
verbalized not wanting to gain more weight, as she perceived
herself to be well and healthy. Her weight stabilized for a while,
but again started decreasing. At this time the patient was lost to
follow up.
Case 2
A 15-year-old girl, student of class IX, resident of an urban area,
of middle socioeconomic status, presented with an 18-month
history of an eating disorder. The onset could be traced to a period
when the patient’s elder sister had a love marriage with a boy of
a different caste, going against the wishes of the family and
prevailing social norms. This marriage led to a social boycott of
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182 THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 22, NO. 4, 2009
the family. Since then, she gradually started decreasing cereals
from her diet as she did not feel like eating them.
In the initial 6 months, her weight decreased to 30 kg. She
increasingly began insisting on doing physically strenuous
household chores all by herself, and would exercise daily. The
patient gave no other reason for not eating other than ‘not feeling
like’ eating certain items. Subsequently, she developed
amenorrhoea and her weight decreased to 26 kg (BMI=11.1). She
began complaining of nausea and abdominal pain. However, she
did not acknowledge that she was underweight; in fact, she
insisted that she was not thin enough.
She was admitted to a psychiatric unit 6 months before being
seen by us, where she received parenteral nutrition, gaining 2 kg
over 4 weeks. She began accepting cereals, vegetables and fruits,
but still avoided oily preparations. Over the next 6 months, she
slowly gained weight (33 kg), but subsequently began reporting
‘feeling fat’, and expressed a desire to decrease her diet. Her
weight started decreasing again and she presented to us when her
weight was 28 kg with a refusal to acknowledge that she was
underweight or ‘thin enough’. Her personal history was non-
contributory.
On examination, she appeared cachectic, with facial lanugo
hair and poorly developed secondary sexual characteristics. The
patient was started on supervised feeding regimen consisting of
oral foods in small quantities. Initially the patient refused to
acknowledge having any problems, giving no reason for not
eating, except for vague abdominal pain as the reason. However,
after several sessions, a reasonable therapeutic alliance was
established, and the patient reported a dread of becoming fat as the
reason for refusal of food. She also appeared distressed because
of her sister marrying against the wishes of the family. She was
asked to self-monitor her food intake, and given appropriate
nutritional advice for calories needed. The interpersonal issues
were discussed during family meetings.
Over 6 weeks, the patient gained weight steadily, weighing
33 kg at the time of discharge. Her fear of becoming overweight
remained unchanged though her intake improved. At follow up
after 6 months, the patient had resumed menstruating and weighed
40 kg. She recently started reporting uneasiness at her ‘excessive’
weight while maintaining her earlier conviction that she was not
thin enough.
DISCUSSION
These 2 patients share some characteristics: both are adolescent,
school-going girls from middle socioeconomic urban background
without a family history of any psychiatric disorder. Both had
been interpersonally compliant, pre-morbidly non-obese without
apparent pressure to pursue slimness for beauty or any other
reason. Their families did not list any problem in psychosocial
development nor reported any ties with the fashion world or any
belief of being slim. Clinically, they had similarities in symptoms
of refusal to take normal food, weight loss and ritualistic dietary
habits. Both had a discernible psychosocial stressor evident as a
precipitant for refusing to eat with a hint of concern about body
image. However, the patients themselves did not acknowledge it
initially. This may partly be explained by the ambivalence and
denial frequently leading those with AN to minimize their
symptoms. At the same time, initial preoccupation with calorie
intake and later revelation of weight phobia could be due to
greater exploration over time on our part or improved rapport with
the patients. This suggests that clinical symptoms of AN in India
may not be different from AN in western countries and it may not
be a strictly western culture-bound syndrome.
Traditionally, cases of AN from India surmised lack of the
fundamental characteristic, that AN is not accompanied by a ‘fear
of fatness’ or desire to be thin,4 but rather by a desire to fast for
religious purposes or eccentric nutritional values.8 Fear of fat,
which is a feature of AN, occurs in the context of a culture that
values slimness. As India becomes more industrialized, weight
phobia may become increasingly common. Furthermore, Asian
women who have lived in the West and developed AN also show
weight phobia.9 A case of restrictor AN in a 13-year-old girl raised
in a traditional, sheltered Muslim home in Pakistan has been
reported.10 This disorder developed due to family concerns and
preoccupations about weight and appearance, and desire to be
attractive. The western media might have a profound negative
impact upon body image and attitude towards eating in traditional
societies in which eating disorders have been thought to be rare.11
In contrast, an Iranian survey reported that women in Tehran who
were more interested in the western culture were more likely to be
satisfied with their body shape, which suggests that the hypothesis
of cultural effects on eating disorders may be limited.12
The risk factors for AN include early feeding difficulties,
symptoms of anxiety, perfectionist traits, and parenting styles, but
none of these can be considered to have been conclusively
demonstrated in our patients.13,14
These cases illustrate that although symptomatology may be
similar to that of western AN, psychosocial developmental and
psychodynamic issues may not be similar to those in the western
culture as our patients developed AN as an unexpected crisis in
response to a psychosocial stressor without any risk factors for AN.
In India, due to economic reforms, increased societal pressure
and media bombardment that ‘slim is beautiful’, we are likely to
see an increase in the number of patients with AN in the future.
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