Anorexia Nervosa with Compulsive Exercising – A Case Report

Yamini Kannappan, Aishwariya Ramesh

Department of Psychiatry, Kauvery Hospital, Chennai

*Correspondence: [email protected]

Abstract

Background:

Anorexia Nervosa, a type of Eating Disorder previously uncommon in India is now on a steady rise due to globalization and increasing cultural westernization. The following case represents an unconventional presentation of symptoms to add to the scarce extant Indian literature.

Case presentation:

A 14-year-old girl with history of amenorrhea, compulsive exercising, and restricting food intake had come for treatment. With a significantly low BMI of 10.6 kg/m2, she was immediately admitted for refeeding, psychometric assessments were also conducted. She was diagnosed with Anorexia Nervosa, restricting type (F50.01) and initiated on Adolescent Focused Psychosocial Interventions. Family-focused Interventions were also provided with the involvement of the parents after careful assessment of family dynamics. Within a period of eight months amenorrhea abated, and her BMI reached 18 kg/m2.

Conclusion:

For Anorexia Nervosa with compulsive exercising, it is beneficial to provide Cognitive Behavior Therapy, Nutritional Rehabilitation, and Family-Focused Interventions parallelly as it would induce an expedites reduction of overall ED severity and improve treatment outcome.

Keywords:

Anorexia Nervosa, Eating Disorder, Cognitive Behavior Therapy, Refeeding, Family-Focused Interventions

Background

Anorexia Nervosa (AN) is an Eating Disorder (ED) indicated by intense fear of gaining weight, restriction of energy intake, and persistent behaviors that inhibit weight gain [1]. Anorexia in India has a prevalence rate of 0.063% in children and adolescents with a female-male ratio of 5:1 [2]. Since 1990, the occurrence of AN has seen a steady increase due to varied factors such as globalization and targeted advertisements, resulting in an estimated loss of 73782 disability-adjusted life years (DALYs) and 55 deaths [3]. Literature regarding EDs is limited in the Indian context. The following case highlights an unconventional presentation of the phenomenon with comorbid culture specific compulsions.

Case Presentation

A 14-year-old girl from Chennai, studying 10th grade, was brought for Psychiatric consultation with history of continuous and progressive weight loss of 19 kg in nine months, lanugo, amenorrhea, and compulsive exercising for eight months.

Patient was apparently functioning well until the start of 9th grade. Due to the increase in her schoolwork, she had stopped badminton classes and started working out at home using a fitness app. Around this time, due to a rift with her best friend who no longer spent lunch breaks with her, she started throwing away food. Her family noticed an onset of obsession with need for exactness and ordering/arranging compulsions. With the start of the pandemic lockdown, classes were shifted online. She insisted on taking up household chores and performing it in peculiar ways to maximize physical exertion. For instance, she would place a bucket of washed clothes at one end of the terrace, run up and down to pick up articles one by one and put it up to dry. The other overt behaviors that she developed for the purpose of weight reduction were secretive eating to throw away food, looking up quantity of calories in her food online, weight checking, drinking large amounts of water before and after food, and doing jumping jacks even while attending classes. She also engaged in covert methods such as standing majority of the day for better digestion. She used to play football in the evening with her friends but stopped when they started noticing and commenting on her weight loss. Movements and speech progressively slowed, and irritability increased with frequent outbursts directed towards her parents. Until relatives insisted on it, her parents had not realized the requirement for interventions. In the pretext of going elsewhere they took her to a psychiatrist who prescribed medication. Due to the high sedative effect, she discontinued it within three days. After being coerced by her parents to stop doing the jumping jacks she began doing high intensity yoga asanas which consisted of repeated cycles of Surya Namaskar. When the parents saw no improvement in her weight, they convinced her to again consult a psychiatrist. In the waiting room she was found performing Surya Namaskar. She weighed 26 kg, BMI of 10.6 kg/m2 and was admitted for nutritional rehabilitation (Fig. 1).

issue8_image25

Fig. 1. Day 3 of admission.

She was assessed using various psychometric scales such as Yale-Brown Obsessive- Compulsive Scale (Y-BOCS), Eating Attitudes Test (EAT-26), Compulsive Exercise Test (CET). Projective tests such as Draw a Person test, Draw Yourself test, and Draw Your Family test were also done to analyze self-perception and family dynamics. She was diagnosed with AN, restricting type (F50.01) and initiated on Psychotherapy (Table 1), Pharmacotherapy (Fluoxetine 2 mg and Olanzapine 5 mg), while family-based interventions were also provided.

Table 1: Psychosocial Interventions

Adolescent-Focused Interventions

(15 sessions with Psychiatrist and Psychologist)

(1).Building rapport through conversations on neutral topics and on patient’s likes (art).

(2).Psychoeducation

(3).Setting a target weight and inducing motivation to improve

(4).Cognitive Behavior Therapy: Acknowledging patient’s emotions, identifying irrational thoughts, addressing fear of weight gain, cognitive restructuring, and behavioral modifications.

(5).Exposure-Response Prevention- modifying asanas, reducing time spent in energy expending activities and covert behaviors.

Family-Focused Interventions

(15 sessions with Psychiatrist and Psychologist)

(1).Psychoeducation

(2).Monitoring overt and covert behaviors without interfering

(3).Supervised exercising

(4).Consistent, empathetic, and authoritative parenting

(5).Avoiding hypervigilance, and providing space to improve without excessively worrying about setbacks

(6).Supportive psychotherapy

Within a period of seven months, she had significantly reduced her exercising and increased food intake to reach her present 44 kg, BMI of 18 kg/ m2 that resulted in the abatement of amenorrhea.

Discussion

The typical profile of AN in India indicates a female with difficult temperament, neurotic traits, and possibly fat phobia [4], all of which were present in the patient. Supervised exercising is found to positively influence adolescent’s state of mind [5]. ED can be conceptualized as being precipitated by affective-motivation and cognitive factors [6]. She related her fear of gaining weight to an incident in the past where she was teased for being fat by her neighbor in front of many people which caused her significant distress. This enabled the formation of adverse cognitions regarding body-self, determined by body-perception and body concept. The obsessive-compulsive traits also played a part in the development of ED, both categorized by similar neurobiochemical and psychological etiology [7,8]. The ED severity, dietary restrictions and negative perfectionism is known to be greater for those with CE [9]. Thus, restricting CE is proposed to result in better treatment outcome for EDs. The simultaneous exposure to CBT/ERP, Nutritional Rehabilitation, and Family Interventions had caused a quick resolution of the ED symptoms in the patient.

Conclusion

The outlined case represents a distinctive configuration of AN unlike the usually documented types in India. In similar cases of ED with compulsive exercising, it is beneficial to provide CBT/ERP, Nutritional Rehabilitation, and Family-Focused Interventions parallelly as it would induce an expedites reduction of overall ED severity and improve treatment outcome. Parents of adolescent children are one of the most crucial members in therapy. Thus, the family dynamics must be analyzed prior to their involvement.

Acknowledgements

None.

Competing interests

The authors have no competing interest to declare.

Consent

Consent was obtained from the mother.

Reference

[1].American Psychiatric Association (Ed.). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed). 2013; APA.

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[3]. Mohandoss A. A study of burden of anorexia nervosa in India 2016. J Ment Health Hum Behav 2018;23(1):25.

[4]. Malhotra S, Malhotra N, Pradhan B. Anorexia nervosa in Indian adolescents: A report of two cases. J Indian Assoc Child Adolesc Ment Health. 2014;10:230–243.

[5]. Noetel M, Miskovic-Wheatley J, Costa D, et al. Exercise for the compulsive exercisers? An exploratory study in adolescent inpatients with anorexia nervosa. Adv Eating Disorders. 2016;4(3):264–276.

[6]. Grzelak T, Dutkiewicz A, Paszynska E, et al. Neurobiochemical and psychological factors influencing the eating behaviors and attitudes in anorexia nervosa. J Physiol Biochem 2017;73(2):297–305.

[7]. Monteleone P. Eating disorders and obsessive-compulsive disorder: Phenomenological and biological similarities. Curr Opin Psychiatry, 2000;13(6).

[8]. Steinglass JE. Identification and treatment of eating disorders in people with obsessive–compulsive disorder. Clin Pract. (2007);7.

[9]. Levallius J, Collin C, Birgegård A. Run for it: Compulsive exercise in adolescents with eating disorders – a nationwide longitudinal study. Eur Psychiatry. 2017;41(S1):S555–S556.

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