|Year : 2015 | Volume
| Issue : 1 | Page : 72-74
Diagnosis and treatment of a teenager with comorbid depression and anorexia nervosa
AO Coker1, OO Coker2
1 Department of Behavioural Medicine, Lagos State University College of Medicine, Lagos, Nigeria
2 Department of Medical, University of Lagos Medical Centre, University of Lagos, Akoka, Lagos, Nigeria
|Date of Web Publication||5-Jun-2015|
Dr. A O Coker
Department of Behavioural Medicine, Lagos State University College of Medicine, Lagos
Source of Support: None, Conflict of Interest: None
This is a case of an 18-year-old female Nigerian student who presented to the emergency department with symptoms of depression that was subsequently diagnosed with anorexia nervosa (AN). The clinical features, diagnosis, and complications of AN were also discussed. This case report supports the suggestions that anorexia previously unreported in Nigeria and other sub-Saharan countries may be underreported. Therefore, general practitioners and family physicians should be aware of the emergence of this illness in Nigeria in order to identify and treat adolescents with this illness.
Keywords: Adolescent, anorexia nervosa, Lagos, Nigeria
|How to cite this article:|
Coker A O, Coker O O. Diagnosis and treatment of a teenager with comorbid depression and anorexia nervosa. Indian J Health Sci Biomed Res 2015;8:72-4
|How to cite this URL:|
Coker A O, Coker O O. Diagnosis and treatment of a teenager with comorbid depression and anorexia nervosa. Indian J Health Sci Biomed Res [serial online] 2015 [cited 2019 Sep 16];8:72-4. Available from: http://www.ijournalhs.org/text.asp?2015/8/1/72/158251
| Introduction|| |
Anorexia nervosa (AN) has been described as a disease with high prevalence in adolescents and has been reported to carry the highest mortality of any psychiatric disorder.  AN is a form of eating disorder characterized by self-induced weight loss, intense fear of gaining weight or becoming fat even though underweight, avoidance of food, amenorrhea and feelings of distortion of body image.  In its etiology, biological vulnerability, psychological predispositions, family disturbances and environmental-societal influences have been implicated.  The psychological risk factors associated with AN include low self-esteem, lack of confidence, feelings of inadequacy, negative self-evaluation and poor self-perception.  Activities and behaviors that encourage dieting such as ballet, acting, modeling and gymnastics are reported to be additional risk factors. Socio-cultural risk factors in societies that emphasize thinness as being beautiful can also be risk factors for the development of AN. ,, AN has been observed to be rare in nonwestern countries.  However, the rapid urbanization and civilization of developing countries and the emphasis that female adolescents should maintain perfect body structure may probably be influencing the eating culture of adolescents from developing countries. , Previous studies have also indicated that psychiatric comorbidity in eating disorders is high most frequently with affective disorders. , However, AN was once observed to be rare in developing countries may be nonetheless under-investigated and underreported in countries such as Nigerian and other sub-Saharan states. This case report thereby highlights that AN may be underreported in Nigeria.
| Case Report|| |
Miss B is 18-year-old female, Nigerian student of a tertiary institution in Istanbul, Turkey whose mother sought psychiatric evaluation for refusal to eat food, loss of appetite, drastic weight loss, low moods, loss of interest in pleasurable events, decrease in daily activities, withdrawing to self and refusal to attend lectures. She was said to have been coping well academically and socially as an economic student in a Turkish university until 3 months prior to the presentation when her parents were contacted by her school authorities for the above-mentioned reasons. Her mother travelled to Istanbul, Turkey to bring her back to Lagos for psychiatric evaluation. On presentation and evaluation, she claimed to have lost approximately 20 kg within 3 months prior to presentation (her weight dropped from 62 kg to 42 kg), which was mainly due to loss of appetite and whenever she ate any food, she vomited the food. She mentioned that she experienced amenorrhea in the 3 previous months before presentation. She also claimed that she was too weak to attend lectures, and that was the reason she stopped attending lectures and also kept to herself. She does not have any past psychiatric history. She was born by normal vaginal delivery at term. The mother claimed that she had normal developmental milestones at the appropriate ages. She had good educational results both in primary and secondary schools. She finished her secondary education with good grades at the age of 17 years. She got an admission in a Turkish university to study economics. She was in her 1 st year when she was observed to be having the symptoms above. She comes from a monogamous family. She is the second of four children. The father is a business man while the mother is a civil servant. There is a cordial relationship between her and her parents. There is no family history of psychiatric illness in the family. The mental state examination revealed a young emaciated and cachectic girl, appropriately-dressed, calm but looking worried. The mood was depressed with a congruent affect. Her speech was coherent and relevant. There were no indications of perceptual disturbances, worthlessness or suicidal thoughts. She was alert and well-oriented to time, place and person. Her cognitive functions were intact. The muscle tone and strength were within normal limits. She had no insight into her condition. The electroencephalography, electrocardiography and other laboratory investigations were within normal laboratory limits.
A diagnosis of AN, restrictive type and a second diagnosis was moderate depressive episode without somatic features according to the criteria of International Classification of Disease-10. She was placed on initially on 10 mg of fluoxetine, which was later increased to 40 mg in divided doses. She was also started on o 5 mg olanzapine, which was also increased to 20 mg/day. She also had weekly sessions of cognitive behavior therapy (CBT). Four weeks after commencing psychotropic medications and CBT, her mood got better, other symptoms of depression subsided, her appetite for food improved and she started to gain weight. Within 8 weeks, her weight increased to 42 kg to 55 kg. She was monitored for another monthly for 6 months at the outpatient clinic. He weight increased gradually to 60 kg before she was certified fit to continue with her studies in Turkey.
| Discussion|| |
Anorexia nervosa has been reported to be an illness with an unknown etiology. It has been reported to affect all age groups and also found in all cultures. ,, This case report showed that AN can also be found in Nigerian adolescent. AN has been found to frequently comorbid with mood disorders.  This case also revealed that the patient manifested with symptoms of both illnesses. Due to its coexistence with depression, thus, the use of anti-depressant was indicated. However, the role of antidepressants in the management of anorexia has been reported not to be clear yet.  AN has been reported to occur during severe stressful periods. , The adolescent in this reported case left the shores of Nigeria to study in a foreign country at a tender age of 16 years. The probable risk factors in the etiology of her disorder could be due to the stress of settling down and her inadequate coping skills in a foreign country where English language is not their lingua franca. Separation from the family and living alone in a foreign country could also contribute to her being lonely. However, in the management of AN, behavior therapy, cognitive therapy and family therapy were found to be useful, while pharmacotherapy is at best an adjunct of these therapies.  Fluoxetine, a new generation selective serotonin reuptake inhibitor antidepressant has been reported to prevent relapse of AN. , Atypical antipsychotics such as olanzapine and quetiapine were also noted to be effective in weigh restoration of patients with AN. , Apart from the cognitive behavioral sessions, the reported patient's mental state also improved with the combination of fluoxetine and olanzapine. This observation was also in agreement with previous studies that reported that combination of fluoxetine and olanzapine as being effective in the management of symptoms of depression with AN in adolescent women. ,, Nonetheless, a multi-dimensional approach is suggested for patients suffering from AN to consist of cognitive therapy, family therapy, behavior therapy and pharmacotherapy. ,
| Conclusion|| |
This case report has shown that AN that is reported to be rare in nonwestern countries may be unrecognized and under-reported in developing countries such as Nigeria due to rapid urbanization and civilization. This case report also supports the suggestions that a combination of psychotherapy and pharmacotherapy are effective in the treatment of AN. Clinicians must also be aware of eating disorders in adolescents especially in those with depression.
| References|| |
Grover CA, Robin JK, Gharahbaghian L. Anorexia nervosa: A case report of a teenager presenting with bradycardia, general fatigue, and weakness. Pediatr Emerg Care 2012;28:174-7.
Olesti Baiges M, Piñol Moreso JL, Martín Vergara N, de la Fuente García M, Riera Solé A, Bofarull Bosch JM, et al.
Prevalence of anorexia nervosa, bulimia nervosa and other eating disorders in adolescent girls in Reus (Spain). An Pediatr (Barc) 2008;68:18-23.
Kaye WH, Fudge JL, Paulus M. New insights into symptoms and neurocircuit function of anorexia nervosa. Nat Rev Neurosci 2009;10:573-84.
Kaye WH, Bulik CM, Thornton L, Barbarich N, Masters K. Comorbidity of anxiety disorders with anorexia and bulimia nervosa. Am J Psychiatry 2004;161:2215-21.
Ali A, Maharajh HD. Anorexia nervosa and religious ambivalence in a developing country. Internet J Ment Health 2004;2:1-8.
Poutanen O, Huuhka K, Perko K. Severe anorexia nervosa, co-occurring major depressive disorder and electroconvulsive therapy as maintenance treatment: A case report. Cases J 2009;2:9362.
Blinder BJ, Cumella EJ, Sanathara VA. Psychiatric comorbidities of female inpatients with eating disorders. Psychosom Med 2006;68:454-62.
Lucas AR, Beard CM, O'Fallon WM, Kurland LT. 50-year trends in the incidence of anorexia nervosa in Rochester, Minn.: A population-based study. Am J Psychiatry 1991;148:917-22.
Hsu LK. Epidemiology of the eating disorders. Psychiatr Clin North Am 1996;19:681-700.
Abbate-Daga G, Delsedime N, Nicotra B, Giovannone C, Marzola E, Amianto F, et al
. Psychosomatic syndromes and anorexia nervosa. BMC Psychiatry 2013;13:14.
Halmi KA. The multimodal treatment of eating disorders. World Psychiatry 2005;4:69-73.
Gowers SG. Management of eating disorders in children and adolescents. Arch Dis Child 2008;93:331-4.
Parling T, Mortazavi M, Ghaderi A. Alexithymia and emotional awareness in anorexia nervosa: Time for a shift in the measurement of the concept? Eat Behav 2010;11:205-10.
Paul P, Mehta S, Coffey BJ. Anorexia nervosa in a 14-year-old second-generation Hispanic adolescent boy. J Child Adolesc Psychopharmacol 2013;23:295-9.