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 Table of Contents    
Year : 2021  |  Volume : 63  |  Issue : 4  |  Page : 403-404
Early-onset anorexia nervosa with psychotic symptoms: A case report

Department of Psychiatry, Gandhi Medical College, Secunderabad, Telanagana, India

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Date of Submission14-May-2020
Date of Decision12-Jun-2020
Date of Acceptance01-Jul-2021
Date of Web Publication07-Aug-2021

How to cite this article:
Bheemireddy R, Kethawath SM, Pingali S, Molanguri U. Early-onset anorexia nervosa with psychotic symptoms: A case report. Indian J Psychiatry 2021;63:403-4

How to cite this URL:
Bheemireddy R, Kethawath SM, Pingali S, Molanguri U. Early-onset anorexia nervosa with psychotic symptoms: A case report. Indian J Psychiatry [serial online] 2021 [cited 2022 Oct 1];63:403-4. Available from:


Anorexia nervosa (AN) is an eating disorder (ED) with an intense fear of gaining weight or becoming fat, with a disturbed body image.[1] EDs have high rates of psychiatric and medical comorbidity[2] with depression being the most common.[3] Psychotic experiences are estimated to occur in none to 13 percent of patients with primary ED.[4] In AN, these experiences have received little attention in the epidemiological literature.[4] We present a case of AN with psychotic-like experiences.

Miss N, an adolescent female of 10 years old, from low socioeconomic status, hailing from rural background, with no family history of psychiatric illness was brought to outpatient clinic with complaints of avoidance of food and weight loss for 7 months. History revealed that she skipped meals, and reduced the amount of food in each meal. At times, she gave away her food to other siblings or threw it away stating that she was not hungry. She often divided her food into smaller pieces and ate at a slower pace than usual. After 3 months, she complained of difficulty in passing stool for which she was prescribed laxatives. However, her mother noticed that Miss N was wrapping her feces and throwing it away secretly. When confronted, she denied such behavior and continued using laxatives. Her picky eating was noticed at school, but she was made to finish her meals. She then started avoiding going to school. She frequently asked her mother if she was becoming thinner and would be reassured with difficulty. Her interaction with family members gradually decreased and she was irritable when anyone confronted about her eating habits. She continued in a similar pattern for the next 4 months. Subsequently, she reduced drinking water and food intake further decreased. She was taken to a pediatrician where she was hospitalized and investigated thoroughly to rule out organic causes for her decreased food intake. However, as all investigations came out normal, she was referred to our psychiatric outpatient clinic. She weighed 20 kg in contrast to her ideal weight of 31.5 kg and lost 9 kg in the past 7 months. She was admitted for inpatient management.

On physical examination, she was pale, thin built with normal vital signs. Mental state examination showed irritable affect and was guarded initially. On subsequent examination, there was a body image distortion, an overvalued idea of being overweight despite being thin. She had no insight into her illness. Neurocognitive functions were intact. A diagnosis of AN was established as per ICD-10. Dietary supplementation was started with the help of dietician. She was started on tablet fluoxetine 10 mg and increased to 30 mg as there was a minimal improvement over the next 2 weeks. After which patient started accepting meals on own and was cooperative for interviews. Cognitive behavior therapy sessions were started to target her core beliefs. Over the next 3 weeks, there was a significant improvement and she gained 4 kg. Her faulty eating behaviors improved. The overvalued idea of being fat reduced. She was discharged and regular to follow-ups for the next 3 months. She maintained well and started going to school. Subsequently, she did not follow-up and discontinued medications. Her previous symptoms reappeared within 3 weeks. Moreover, muttering and smiling to herself was noted. She frequently inserted her fingers through the anal opening and remained in the same position for 30–40 minutes. Her mother noticed blood staining of her clothes. She did this even when her family was around. When asked to stop, she would either remain calm or sometimes used abusive language but did not give any explanation for her behavior. She would keep sharp objects with her, and in one occasion, she cut her hair without giving any explanation. She was re-admitted and was given intravenous fluids as she was refusing oral feeds. On mental state examination, she was unkempt, rapport not established, hallucinatory behavior noted, and was mostly irritable. The overvalued idea of being overweight despite being overtly thin was noted. Odd behavior such as inserting her fingers through the anal opening was observed in ward course. On Brief Psychiatric Rating Scale (BPRS) scale,[5] she scored 52/126. She was started on tablet fluoxetine 20 mg and increased to 30 mg. Tablet risperidone 1 mg was started in view of overt psychotic symptoms and increased to 2 mg over 1 week. The patient started taking oral feeds, but hallucinatory behavior and odd behaviors continued. Risperidone was further increased to 4 mg. Over the next 2 weeks, there was a significant improvement in both psychotic symptoms and eating habits. On the BPRS scale, there was >50% reduction in symptom severity (22/126) and was discharged. She has been regular to follow-ups and maintaining well for the past 9 months.

Clinical presentation of psychotic symptoms in AN in early-onset adolescents is rare. In the current case, psychotic symptoms occurred following recovery from AN. Among ED, restring type of AN is three times more associated with schizophrenia/psychosis compared to Bulimia nervosa.[6] The current case also points toward an association between restricting variants of AN and psychosis. Further, the onset of AN developing at early onset is rare. Currently, evidence linking psychotic symptoms in ED is scarce and many hypotheses have been postulated.[7] One hypothesis is that ED patients may suffer from starvation, electrolyte, and metabolic imbalance, conditions that can provoke transient psychotic symptoms.[7] However, in the current case, all the biochemical parameters were normal. Some proposed a role for disordered eating as a defense against psychosis and that ED exist in a continuum ranging from neurosis to character disorder to psychosis.[8] Similarly, some of the case reports have been reported with schizophrenia-like psychosis with their onset after recovery from AN, further pointing toward some continuity between the two disorders.[8] Preliminary evidence indicates a role of dopaminergic pathway abnormalities in ED[9] similar to that found in patients with schizophrenia.[10] However, no conclusive evidence could be drawn from the existing literature. Thus, the current case report highlights the need for further research into the causality of psychotic symptoms in AN.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Andersen AE, Yager J. Eating disorders. In: Sadock BJ, editor. Kaplan and Sadocks Synopsis of Psychiatry. 10th ed. Baltimore: Lippincott Williams and Wilkins; 2007. p. 727-9.  Back to cited text no. 1
Lee S, Chiu HF, Chen CN. Anorexia nervosa in Hong Kong. Br J Psychiatry 1989;154:683-8.  Back to cited text no. 2
Becker CB, Plasencia M, Kilpela LS, Briggs M, Stewart T. Changing the course of comorbid eating disorders and depression: What is the role of public health interventions in targeting shared risk factors? J Eat Disord 2014;2:15.  Back to cited text no. 3
Koyanagi A, Stickley A, Haro JM. Psychotic-like experiences and disordered eating in the English general population. Psychiatry Res 2016;241:26-34.  Back to cited text no. 4
Overall JE, Gorham DR. The brief rating psychiatric scale. Psychol Rep 1962;10:799-812.  Back to cited text no. 5
Blinder BJ, Cumella EJ, Sanathara VA. Psychiatric comorbidities of female inpatients with eating disorders. Psychosom Med 2006;68:454-62.  Back to cited text no. 6
Seeman MV. Eating disorders and psychosis: Seven hypotheses. World J Psychiatry 2014;4:112-9.  Back to cited text no. 7
Hugo PJ, Lacey JH. Disordered eating: A defense against psychosis? Int J Eat Disord 1998;24:329-33.  Back to cited text no. 8
Barbato G, Fichele M, Senatore I, Casiello M, Muscettola G. Increased dopaminergic activity in restricting-type anorexia nervosa. Psychiatry Res 2006;142:253-5.  Back to cited text no. 9
Van Os J, Kapur S. Schizophrenia. Lancet 2009;374:635-45.  Back to cited text no. 10

Correspondence Address:
Shanti Mohan Kethawath
Department of Psychiatry, Gandhi Medical College, Secunderabad, Telanagana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/psychiatry.IndianJPsychiatry_446_20

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