A 25-year-old woman was brought to a private hospital in Bengaluru with recurrent episodes of vomiting and complaints of gradual weight loss over a period of two years. After a thorough examination, psychiatrists at Spandana Health Care diagnosed her as suffering from anorexia nervosa.
Five years on, the woman is still being treated.
“Anorexia nervosa is an eating disorder as well as a serious mental health condition characterized by excessive restriction on food intake and irrational fear towards gaining weight,” says Dr Mahesh Gowda, psychiatrist and director of Spandana Healthcare. “The affected individuals also suffer from distorted self-image, lack of self-confidence and self-esteem.”
Experts say though cases of anorexia are reported more among women, men are not exempt. The common feature: the affected are largely young adults.
Largely seen among teenagers, cases of anorexia can also be found at the age of 30 to 40, says Dr Gowda. “Body-image disturbances leading to anorexia are seen more among teens as their sense of self keeps changing and the secondary sexual characters too.”
What causes anorexia- Case studies
The Bengaluru woman’s case study was published by the Indian Journal of Psychological Medicine in 2015. According to Dr Gowda, one of the authors, one probable factor for the woman to have had restrictive food intake was her husband’s critical comments on her weight gain. Being sensitive to criticism, looking for perfection and having an emotionally unstable personality predisposes a person to the illness, according to Dr Gowda.
Psychiatrists say the typical anorexia nervosa symptoms include a distorted body mass index range (less than 17.5), amenorrhea or absence of menstruation, being fearful of even the slightest weight gain, orthostatic hypotension (suffering low blood pressure while sitting, standing or lying down), feeling sad and lethargic frequently, swollen joints, hair loss or thinning, constipation and electrolyte imbalance. The symptoms also include having an irregular heart rate.
Dr Samir Parikh, director and head of department of mental health and behavioural sciences, Fortis Healthcare, New Delhi, says those suffering from anorexia are underweight but even then are worried about weight gain.
He recalls the case of a 17-year-old girl who weighed less than 35 kg when brought in for treatment. The girl was preoccupied about her weight, not willing to eat, not doing well medically or physically, and lacked energy.
“She was below 80 per cent of the basic requirement, weight-wise,” Dr Parikh tells Happiest Health. “Those suffering from anorexia nervosa constantly try to lose weight, even when their weight is lesser than the requirement. Scared about putting on weight, they compromise on health and well-being — because putting on weight is their ultimate fear, which they are not able to fight. If they eat, they try to purge or over-exercise.”
He says the telltale signs of those suffering from anorexia are eating alone, taking a longer time to eat, taking very small bites and being preoccupied.
“The affected individuals constantly struggle about how people perceive them, feel bad about themselves, are never happy with themselves, struggle with depression, anxiety and sleep disorders,” Dr Parikh says. “In addition, they also suffer from malnutrition and vitamin deficiency.”
Dr Sanjay Chugh, senior consultant psychiatrist from New Delhi, mentions the case of a 20-year-old anorexic girl whom he treated. “She would survive on roughly 700 to 800 calories every day [along] with intense exercise,” he says. “She would not be able to go out with her family or friends for fear of looking fat and ugly, and being forced by everyone to eat. There was an additional history of alcohol abuse and low mood with high levels of anxiety.”
Dr Chugh — who has been working on creating awareness about eating disorders, their treatment, information and resources in India for many years — says the line of treatment in this particular case involved intense psychotherapy which focused on addressing her negative beliefs about self, her unhealthy relationship with food along with medication to manage her mood-related problems. “Treatment helped her in learning how to regulate emotions and improved her self-image,” he says.
People who become targets of body shaming are vulnerable to anorexia. However, there are many who fight it out with required guidance and adherence to treatment. “They need stringent, regular monitoring for one to two years,” says Dr Gowda.
Celebrities who have had anorexia include American actress Mary Kate Olsen and Australian actress Portia De Rossi.
What causes anorexia nervosa
According to Dr Chugh, anorexia is an eating disorder that mostly has its origins in psychological distress. “Often, body size and appearance become an unhealthy way of measuring one’s self-worth,” he says. “The disorder is typically seen amongst young girls. Teenage is the time when one tends to give excessive importance to body size and shape. Physical beauty and appearance become crucial factors in shaping one’s self-image, and that puts enormous pressure on youngsters to look a certain way. Unfortunately, social media doesn’t make it any easier for them, creating a vicious loop of seeking external validation as a means to feel good about themselves.”
Moreover, owing to the stigma attached to anorexia, not everyone suffering from the disorder seeks treatment. “They are hesitant to take help or talk to anyone about their problem, and convincing people for anorexia nervosa treatment is not easy,” says Dr Parikh. “It requires tremendous family support for a person with anorexia to come forward to get treated. Worldwide, the reported cases are only the tip of the iceberg.”
Dr Chugh says studies regarding eating disorders in India are still rare and the data is inadequate. “However, one does see an increase in the number of cases in our country,” he says. “Growing awareness has made people seek help, although the numbers are still few compared to the number of people who might be suffering from this condition.”
Researchers say eating disorders are caused by a complex interaction of genetic, biological, behavioural, psychological and social factors. “Brain imaging studies are also providing a better understanding of eating disorders,” the National Institute of Mental Health, US, says about anorexia. “For example, researchers have found differences in patterns of brain activity in women with eating disorders in comparison with healthy women.”
Have six small meals a day
“The tummy size shrinks in those affected with anorexia. If the normal capacity of the human stomach is 1.5 litre, in anorexic persons it reduces to just 500 ml or one-third of the normal capacity. The stomach size shrinks, and they can’t each much,” said Dr Gowda. “Hence as a part of the treatment plan, we suggest that they eat small multiple meals at fixed times till they regain their appetite. Instead of eating thrice a day, they can have six small meals.”
Dr Gowda says the preoccupation of such people is only with gaining weight and they are neglectful about other matters, don’t eat well and feel overweight. “Their hair and face texture change and they become very lean. These are the visible physical signs, apart from psychological morbidities like depression, psychological distress and body-image disturbance,” he says.
Need for family support
Family support and understanding go a long way in patients’ recovery and sustained progress, says Dr Chugh. He says when a family understands the nature of the illness and the possible underlying causes, it is better equipped to deal with the patient’s emotional fluctuations, their thoughts and behaviour.
“This can help them in keeping their emotions in check and not transfer their stress and anxiety on to the patient,” he says. “This understanding makes the patient feel less judged and ashamed about their struggle, and hence more willing to seek help and support.”
Bengaluru-based dietitian Priyamvada Chandramouli says those affected by anorexia could have been normal healthy individuals at some point of time but might have got bogged down by peer pressure and comments about their appearance, and become too fearful about eating.
“The immense emphasis on being thin leaves them deprived of important nutrients such as iron, calcium and protein, leading to malnourishment, anemia and hormonal imbalance,” says Chandramouli. “Since parents are also not aware of such a condition, physicians in a hospital set-up evaluate the degree of patient anorexic condition and treat it with a holistic approach. Due to stigma attached over the issue, they prefer to keep the details under wraps.”
So, what’s the best first step? “For family members to support anyone affected to get professional help,” she says.
