This case study reports the treatment of a young adult female in Sri Lanka who presented with atypical anorexia nervosa and moderate depressive disorder. She was successfully treated with nine sessions of enhanced cognitive-behavioural therapy (CBT-E).
Miss J is a 24-year-old single student from Anuradhapura which is a rural area situated 250 km away from the capital of Sri Lanka. She presented with a history of reduced oral intake for 3 years with malaise and fatigability. Her reduced food intake started while she was studying for the General Certificate of Education Advanced Level examination which is one of the most competitive examinations in Sri Lanka. Initially she thought that reduced food intake would help her to study well by reducing drowsiness in the night and increasing attention span in the day time. Miss J developed abdominal discomfort including fullness of stomach and belching after meals following reduced food intake for few months. Further, she lost 18 kg (36% of total body weight) over a period of three years since reduction of food intake. In the last 3 months, Miss J completely refused solid meals and consumed liquid meals only as she could not tolerate the appearance and smell of solid foods. She was preoccupied about food which led to negative emotions and distracted her from studies. Miss J developed depressive symptoms 1 year after she restricted food intake in the context of her inability to enter University. Miss J started to question her intellectual ability and had poor self-evaluation. She developed amenorrhea 2 years after her initial symptoms. As Miss J was concerned about her excessive weight loss and being very thin, she attempted to make changes in her dietary habits. However, anxiety and abdominal symptoms prevented her from eating when she tried doing so. There was no history of binge-eating, self-induced vomiting, abuse of slimming medications, excessive exercise, diarrhoea, constipation or vomiting. She had no significant developmental history or features suggestive autism such as restrictive repetitive interests, difficulties in social relationships, social conversation or interpretation of others emotions.
After excluding possible organic causes for her presentation, Miss J was referred to the psychiatric unit for further evaluation where she was diagnosed to have avoidant/restrictive food intake disorder or Atypical AN-non fat-phobic type with co morbid moderate depressive episode. On admission Miss J was started on mirtazapine 7.5 mg nocte. Following week enhanced CBT was commenced. Inputs from dietician and gastroenterologist were sought.