A case report on Anorexia Nervosa in a
Pre-adolescent female from rural
background & lower socioeconomic
class
Dr. Anamika Jain, Dr. Hiral Kotadia, Dr Jitendra keshwani,
Dr. Srikanth Reddy, Dr. Pawan Rathi
Sri Aurobindo Medical College & PG Institute, Indore
INTRODUCTION
• Anorexia nervosa (AN) has been predominantly reported from western
countries and females from affluent societies.
• Recently a rising trend of AN having onset in preadolescent and in individuals
from lower socio-economic status and rural background have been reported.
• Here we present a case of AN in a preadolescent belonging to lower socio-
economic strata and rural background.
CASE SUMMARY
• Miss K, 10 ½ year old female, currently in 4th std, living in a nuclear family, belonging to
LSES and rural background, was referred from pediatrics department for unexplained
abdominal pain and weight loss since 1-1.5 years.
• Hemogram, LFT, RFT, ESR, S. protein, ECG, S. Electrolytes, Mantoux, CXR, USG W/A,
CECT abdomen were done by Paediatrics department for evaluating weight loss and
abdominal pain. As all investigations were within normal limits except low haemoglobin.
Patient was admitted in psychiatry ward for further evaluation.
• There was history of restricted oral intake, regular monitoring of weight and taking
measures to reduce weight since 1-1.5 years.
• Multiple detailed MSEs revealed
- Significant body image concern, apprehension regarding gaining weight
- Idealization of the actresses for body shape/weight and waist size
- Wishing for loss of fat & having slim body shape
- Criticism by peers upon body shape/weight
- Reported of restricting oral intake, Denied of any purging behaviour or use of laxative
• On examination –
- Cachectic, pale, with lanugo hair over her face and back, PR – 80/min, BP – 110/70 mmHg
- Loss of buccal pad of fat
- Wt-26.5 kg (-2.7 SD) (Between 10th and 25th centile), Ht=152.5 cm (90th centile) (-1.0 SD) ,
BMI= 11.5 kg/m2 (1.8 SD) (<3rd centile) waist circumference- 56cm (5th centile)
- Eating disorder examination questionnaire-adolescent (EDE-A) = 2.26
• Treatment - managed in liaison with paediatrics department and dietician.
- Tablet Olanzapine 5 mg was started & increased to 7.5 mg.
- Rapport was established with adolescent and trust was gained with difficulty.
- Adolescent was also involved in decision making about dietary intake.
- Oral refeeding was initiated at calorie intake of approx. 800 kcal/day
(25 - 30kcal/kg/day) and was increased by 200 kcal every 2-3 days.
- In frequently divided meals
-oral iron supplements and antacid were also added .
• A gradual increase of 0.5-1.0 kg/week of weight was targeted.
• Regular serum electrolytes measurements were done.
• Adequate precautions were taken to avoid the possibility of refeeding syndrome.
• CBT was done to address her concerns regarding body image. She was also explained
the need of adequate nutrition for healthy life while not commenting/criticizing about her
body shape/weight.
• Adolescents’ coping skills to tackle the criticism regarding her body weight by her peers
were enhanced.
• Family intervention - family psychoeducation, appropriate reinforcement techniques.
• She was admitted for 12 weeks and was discharged with stable vitals, weight of 34.5 kg
(50th centile) and BMI of 14.4 kg/m2 (between 10th and 25th centile) , EDE-A = 1.7 .
Olanzapine was tapered off in the next 6 weeks.
• Adolescent is on regular follow up for last 3 months. Her current weight and BMI are
41.5 kg (between 75th and 90th centile) and 17.2 kg/m2 (50th centile) respectively. EDE-A
= 1.2 CBT sessions are being continued.
DISCUSSION
• AN is a critical clinical condition leading to significant medical and psychiatric morbidity.
• Prevalence in India ranges from 4% to 45.4%. However most of the studies included late
adolescents and young females as sample and most of them belonged to higher SES and
urban background.
• The clinical diagnosis of AN is often missed even in adolescents and young females
presenting to clinic.
• The possibility of missing diagnosis of AN is even higher in preadolescents especially
individuals who belong to LSES and rural background.
DISCUSSION
• Eating disorders including AN are significantly underdiagnosed in preadolescent individuals
from rural background due to :-
- clinician’s unawareness about the clinical presentation and prevalence of ED in this age group
- belief that AN is predominantly a disorder of individuals belonging to urban background & HSES
- belief that children from this age group are not cognitively mature enough to be aware about
concepts of body image of self.
• Our case highlights the fact that the diagnosis of AN is often undermined in this population
• The clinical pattern in this child :
- being obsessed with having a lean and thin body
- predominant restrictive eating behaviour (less of purging/use of laxatives)
coincides with the scant current existing literature about patterns of behaviours in ED in children.
CONCLUSION
• The patients of Anorexia Nervosa require specialized care and treatment, which can be
difficult to access and are costly.
• There is a large deficit in literature regarding ED (including AN) in this particular
demographic (children from LSES & rural background).
• Clinicians should be made aware about considering a differential diagnosis of AN (ED) in a
pre-adolescent female (belonging to any background) presenting with unexplained weight
loss.
• Regular screening for eating disorders and body image concerns should be carried out in
children belonging to any background & presenting with weight loss.
• There is also dire need to conduct prevalence and longitudinal studies about ED in this
particular demographic.
REFERENCES
1. Regier DA, Kuhl EA, Kupfer DJ. The DSM‐5: Classification and criteria
changes. World psychiatry. 2013 Jun;12(2):92-8.
2. Bargiacchi A, Clarke J, Paulsen A, Leger J. Refeeding in anorexia
nervosa. European journal of pediatrics. 2019 Mar;178(3):413-22.
3. Resmark G, Herpertz S, Herpertz-Dahlmann B, Zeeck A. Treatment of
anorexia nervosa—new evidence-based guidelines. Journal of clinical
medicine. 2019 Feb;8(2):153.
4. Fairburn, C. G., & Beglin, S. J. (2008). Eating Disorder Examination
Questionnaire (EDE-Q 6.0). In C. G. Fairburn (Ed.), Cognitive behavior
therapy and eating disorders (pp. 309–313). New York: Guilford Press
