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Case Report

A Case of Anorexia Nervosa in a Preadolescent Male

Prajakta Patkar, Ichpreet Singh, Suprakash Chaudhury, Daniel Saldanha

Department of Psychiatry, Anorexia nervosa (AN) is one among the severe psychiatric disorders of

Abstract
Dr. D Y Patil Medical
College, Hospital and
adolescence. AN in boys is often overlooked by both physicians and psychiatrists
Research Centre, Dr. D since it is predominantly seen in females. Teenagers usually get over the disorder,
Y Patil Vidyapeeth, Pune, but in some cases, AN can cause serious complications, including chronicity and
Maharashtra, India death. AN is often encountered among females and more so in the affluent class.
Here, we present an 11‑year‑old boy belonging to a middle‑class Indian family,
referred for psychiatric evaluation from the pediatrics department after ruling
out all medical causes for the weight loss. The patient complained of loss of
appetite along with weight loss of 14 kg in the last 3 months. In‑depth psychiatric
evaluation revealed significant distress of gaining weight as well as an intense
disgust related to his body shape. A cluster of determined food refusal and weight
loss triggered the exploration of other symptoms of AN. The patient responded to
antidepressants and well‑planned cognitive behavioral therapy. Results were seen
in the form of return to the normal range of body weight, shape, and size along
with its confident acceptance.
Submission: 25‑09‑2020,
Decision: 30‑04‑2021, Keywords: Anorexia nervosa, body image, cognitive behavioral therapy, eating
Acceptance: 28‑05‑2021,
Web Publication: 28-01-2022 disorders, preadolescent male

Introduction However, owing to later onset of puberty and distinctly

T he term anorexia nervosa (AN) was coined
in 1873 by Sir William Gull in London and
Dr. Charles Laségue in France who referred to it as
“anorexia hysterique.” Both physicians described
cases of individuals presenting at markedly low body
weights and engaging in self‑starvation behaviors.
However, the initial medical description of the condition
was by Richard Morton in 1689.[1] AN is a serious
physical and psychiatric disorder that carries a crude
mortality rate of 5%.[2] AN is most commonly seen
in the Western world and has a significantly lower
incidence in developing countries like India. The
prevalence in India was reported as 0.18%, which is
much lower than in Western countries.[3] This disorder
is predominantly seen in adolescent females of the age
group of 15–19 years of age. The clinical presentation of
AN among males is rare.[4,5] Males and females tend to
share similar clinical presentation and psychopathology
except for amenorrhea. In addition, males are disposed
to vigorous exercise, have sexual concerns, and suffer
comorbid psychiatric disorders more often than females.
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different social images, males often tend to present at a
later age than females.[5] Men are seen to be reluctant
to seek treatment out of shame, and clinicians too are
less likely to recognize the syndrome in male versus
female patients. Moreover, while AN has been thought
of historically as a disease of white, wealthy women,
it impacts individuals of all racial and socioeconomic
backgrounds.[6,7] Hence, the prevalence of this disorder
in the Indian setting is very less and more so in
preadolescent males. Considering this, we present this
case to discuss a slightly uncommon form of presentation
and moreover in an unusual profile.
Case Report
Our patient was an 11‑year‑old boy, studying in the
6th grade, referred to the psychiatry department for
Address for correspondence: Dr. Suprakash Chaudhury,
Department of Psychiatry, Dr. D Y Patil Medical College, Hospital
and Research Centre, Pimpri, Pune ‑ 411 018, Maharashtra, India.
E‑mail: suprakashch@gmail.com
This is an open access journal, and articles are distributed under the terms of the Creative
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remix, tweak, and build upon the work non‑commercially, as long as appropriate credit is
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DOI: How to cite this article: Patkar P, Singh I, Chaudhury S, Saldanha D. A case
10.4103/mjdrdypu.mjdrdypu_539_20 of anorexia nervosa in a preadolescent male. Med J DY Patil Vidyapeeth
2022;XX:XX-XX.

© 2022 Medical Journal of Dr. D.Y. Patil Vidyapeeth | Published by Wolters Kluwer - Medknow 1
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Patkar, et al.: Anorexia nervosa in a preadolescent male
unexplained weight loss. The pediatrics department
had ruled out all the causes for the unexplained weight
loss. The patient’s parents gave a history of refusal of
food and weight loss for the last 2–3 months. It initially
started off as decreased food intake owing to a feeling
of being bloated, which made the child reduce his meals
as he did not feel hungry very often. At first, the boy
would only avoid the amount of food he would take
and then the number of meals. He gradually started
avoiding sweet foods and even fried or oily foods. His
parents said that he would often read up on the internet
about the caloric content of various food items and keep
sharing this information with everyone at home. Later,
he stopped eating any kind of bread and rice to avoid
any carbohydrates. The child would often taunt the other
family members about their food habits and even asked
them to eat less on multiple occasions. A lot of times,
he would stand next to his mother in the kitchen and
supervise her cooking to make sure that she did not use
any unhealthy ingredient. On further questioning, his
parents revealed that they had observed him deliberately
inducing vomiting on a few occasions and even asking
them for laxatives saying he was experiencing some
stomach discomfort. When advised by the family or
friends to have a proper meal or questioned about his
sudden weight loss, the parents complained of irritability
and anger outbursts.
Due to all this, he rapidly started losing weight. His
weight drastically dropped from 34 kg to 20 kg, a 14 kg
or a 40% weight loss in a mere 2 ½–3 months. His
BMI came down to 10.36 kg/m2, making him severely
underweight. The ideal weight for his 140 cm height
should have been 38 kg. Due to sudden weight loss, he
became weak, complained of intolerance to cold, fatigue,
and constipation at times. Off late, this boy became
so weak that someone had to assist him in doing his
day‑to‑day activities such as bathing, dressing, or toilet
activities. The child was unable to attend school in the
last 10–12 days before admission. There was no history
suggestive of binge eating or excessive exercising to
lose weight. There were no symptoms suggestive of
depression or psychosis.
This child belonged to a joint family and was the second
son to his parents. They lived in a small apartment
located in the outskirts of a tier two city. His family
included grandparents, parents, a widowed aunt, and
an elder brother. Both the parents had formal education
up to the 8th grade. His father worked as a clerk in an
office, mother being a homemaker. His brother was a
below average class 10 student, who was not interested
in studying and would always be spending his time with
his friends in spite of being scolded by his parents. The
2 Medical Journal of Dr. D.Y. Patil Vidyapeeth ¦ Volume XX ¦ Issue XX ¦ Month 2022
patient had always been a bright child who would be
among the class toppers and, hence, disagreed with the
rebellious and careless attitude of his brother and was
never very close to him emotionally. Automatically,
this made him the favorite and pampered child in the
household as he always was an obedient and bright
child. He had a very demanding nature and used to get
extremely upset if things did not go according to him.
His parents described him as a perfectionist especially
when it came to things related to school. He had a
few friends in school and around home and would get
along fine with them, although he had not gone out to
play much in the last few months. The boy thought
that his parents had a lot of expectations from him,
especially because his brother would not entertain their
concerns about his callous attitude. Apart from this, his
developmental history was normal with no significant
medical or psychiatric history. There was no history of
any psychiatric illness in the family.
On examination, he was averagely built boy with
a cachexic body [Figure 1]. Blood pressure was
90/70 mmHg and pulse 70/min. He had dry skin and
cold extremities. Some proximal muscle wasting was
seen and he was too weak to sit upright in the chair
for long. Apart from this, the systemic examination
was normal. On mental status examination, he
was very guarded in the beginning and it was very
difficult to establish a rapport with him. In subsequent
interviews, he confided that he was teased by a few
kids in school about his weight and they called
him names saying he was fat or plump. Having felt
very hurt by this, he started dieting to lose weight.
He revealed that he used to be preoccupied with his
weight and admitted that he checked it after every
meal. The patient had significant distress related to
his body image and believed that he was “fatter and
chubbier” than his friends at school. When questioned
about his ideal weight, he agreed that he had lost
weight because of his food restriction and said it is
Figure 1: Anorexia nervosa patient before treatment
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Patkar, et al.: Anorexia nervosa in a preadolescent male
very good that he weighed less now even though it
was below the ideal weight for kids his age as he
would not be teased now at least. The child very
rigidly said multiple times that he should always
weigh <25 kg and it would be a disaster if at all his
weight would be more than 30 kg. When asked as to
why he would not attend school, said he felt weak
and had difficulties being attentive and concentrating.
Routine investigations such as hemogram and liver
and renal function tests were normal. Hormonal
levels such as growth hormone, cortisol levels,
thyroid function tests, and sex hormones such as
follicle‑stimulating hormone, LH, and testosterone
were normal. Magnetic resonance imaging brain and
abdomen revealed no abnormalities. Hence, all other
causes of weight loss were meticulously ruled out.
After establishing a diagnosis of AN according to
the Diagnostic and Statistical Manual of Mental
Disorders, 5th Edition (DSM‑5), treatment was
initiated with an SSRI, namely, tablet sertraline. It
was started at a low dose of 12.5 mg in the beginning
and slowly uptitrated to 50 mg. Multivitamin and
other nutritional supplements were also added to
ensure replenishment of the body stores. The main
focus of the treatment was cognitive behavioral
therapy (CBT). Detailed structured sessions of CBT
by a trained psychotherapist were planned for the
child. It first focused at understanding the child’s
cognitive distortions about his weight and body
image. There were also sessions planned to get a
better understanding of his dynamics with family and
friends, who would later be involved in the therapy.
After getting a better understanding of all this, the
child was slowly made aware of the faults in his way
of thinking and the problematic effects it was having
on his mental and physical health. After developing an
insight into his illness, he was convinced to work on
his attitudes toward his body image and subsequently
gradually alter his food habits. Along with this, his
family had to be educated in detail about his disorder.
Family counseling sessions were carried out to
explain how they could support us in treating him and
how reinforcement could help achieve better results.
A well‑balanced diet was chalked down with the help
of a dietician with inputs from the patient as well.
Slowly and steadily the boy started gaining weight.
He gained 6 kg by the end of 1½ months and 14 kg by
the end of 3 months [Figure 2]. Since this all started
with the child being affected by the school bullies and
the name calling, he was also counseled on how to
better deal with similar incidents in future. Even after
6 months, the patient and parents have maintained
a regular follow‑up to the hospital. He now realizes
Medical Journal of Dr. D.Y. Patil Vidyapeeth ¦ Volume XX ¦ Issue XX ¦ Month 2022
Figure 2: Anorexia nervosa patient after treatment
his misconceptions about his weight and body image
and how harmful they were to him. The child weighs
around 36 kg over the last 3–4 months and has been
well maintained on treatment.
Discussion
In today’s world, size and appearance is unfortunately
one of the biggest parameters to assess beauty.
Societal and peer pressure to be and to look the best
creates undue stress in children and adults alike.
Beauty lying in the eyes of the beholder is a concept
that has acquired an almost antagonistic effect on the
minds of the people. Other’s opinion of our body
image has become of greater value than one’s own
comfort and health as was seen in our patient. AN
is invariably linked with a fear of fatness and issues
with one’s own body shape. The current guidelines
of psychiatric disorders, namely, ICD‑10 and DSM‑5,
also corroborate with it. It is defined as a disorder
characterized essentially by a restriction of energy
intake, intense fear of fatness or gaining weight, and
misconceptions or preoccupations with one’s body
shape and image. Invariably assumed to be a disorder
affecting the adolescent females of the affluent class,
it is most commonly seen in the Western world.
Eating disorders in males are often overlooked
and diagnosed late as physicians often keep it as a
diagnosis of exclusion as was clearly highlighted in
our patient. Studies now reveal that male‑to‑female
prevalence ratio of AN is about 1:10.[8] In addition,
physicians may have a lower index of suspicion for
eating disorders in boys compared with girls. It is
postulated that eating disorders are only diagnosed
in males when significant psychiatric comorbidity is
present.[9]
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Patkar, et al.: Anorexia nervosa in a preadolescent male
There are differences in predictors of eating disorders
in studies. One study observed that eating disorder
cognitions in girls were predicted by childhood body
dissatisfaction in girls but only in interaction with BMI in
boys.[10] Another study reported that symptoms at 12 years
of age were greater body dissatisfaction for both sexes but
higher depressive symptoms only for girls. Other studies
have identified early feeding difficulties, parenting styles,
anxiety symptoms, and perfectionist traits as risk factors
for AN.[11,12] Out of the above, our patient definitely had
perfectionist traits and was concerned with body weight,
but there were no signs of depression.
Our case highlighted a preadolescent boy who belonged
to a very conservative Indian family in a patriarchal
setting with a lot of academic expectations from the
index case. The onset of his symptoms was essentially
very early, being in the preadolescent period. Being
initially diagnosed as a case of severe weight loss, a lot
of time and money was spent in ruling out any cause
for the same before being referred to psychiatry. Thus, a
vigilant physician is of utmost importance in such cases.
Our patient was of the purging subtype with intermittent
episodes of purging and laxative use. Furthermore,
since family belonged to an average middle‑class Indian
society with parents not as well educated, it was a
challenge to make them appreciate and identify the
symptoms and acknowledge them as problematic and
contributing to the food refusal, weight loss, and body
image issues as these concepts were extremely foreign
to them. Along with psychotherapy to the patient, family
counseling was equally important in this case.
This case not only highlights the rare presentation
but also emphasizes the importance of a strong
interdepartmental liaison when it comes to dealing with
unusual presentations in children.
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
4 Medical Journal of Dr. D.Y. Patil Vidyapeeth ¦ Volume XX ¦ Issue XX ¦ Month 2022
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.
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