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Case Report

Anorexia nervosa in the male with co-morbid

adjustment disorder and body dysmorphic disorder
A.K. Koushik, P.V. Bhaskar Reddy, N. Senthil
Department of General Medicine, Sri Ramachandra University, Porur, Chennai, Tamil Nadu, India

ABSTRACT
Anorexia nervosa is a rare psychological disorder. Epidemiological studies have shown a female to male ratio of 10:1, suggesting,
it is predominately seen among females. Anorexia nervosa and related eating disorders are rare in non-Western countries. The
association of anorexia nervosa with body dysmorphic disorder and Adjustment disorder indicate a more severe form of illness.
This case is rare because here in we present a male anorexic with adjustment disorder and body dysmorphic disorder. To the best
of our knowledge, there is no case report in the literature describing a male anorexic patient with co-morbid adjustment disorder
and body dysmorphic disorder.

Key words: Adjustment disorder, anorexia nervosa, body dysmorphic disorder, male

INTRODUCTION Statistical Manual-IV and International Classification

Anorexia nervosa is a rare psychological disorder.
Epidemiological studies have shown a female to
male ratio of 10:1, suggesting it is predominately
seen among females. [1] Anorexia nervosa and
related eating disorders are rare in non-Western
countries. [2] It is a life-threatening psychological
illness characterized by self-starvation and excess
weight loss. The association of anorexia nervosa
with body dysmorphic disorder and adjustment
disorder indicate a more severe form of illness. [3]
Among women the lifetime prevalence of Anorexia
nervosa is approximately 1%, it is much less in
males.[4] Diagnosis of anorexia nervosa is based on
history of weight loss accomplished by restrictive
dieting and excessive exercise accompanied by a
marked reluctance to gain weight. In Diagnostic and
Address for correspondence
Dr. A.K. Koushik,
7/23, Karunanidhi 3rd Street, Kotturpuram,
Chennai - 600 085, Tamil Nadu, India.
E-mail: drakkoushik@gmail.com
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of Diseases-10 classification systems (WHO, 1992 and
American psychiatric association, 1994) core feature
are intense fear of gaining weight.[5] Anorexia nervosa
can be associated with other psychiatric disorder but
with multiple disorders is rare.
CASE REPORT
A 20-year-old male was referred for hematemesis
and vomiting. He initially complained of vomiting
for 1 week (3-4 episodes per day after every meal,
not induced) and 1 episode of hematemesis (<50 ml)
3 days back. He gave a history of induced vomiting
after food for the past 1 year in an attempt to reduce
weight. He also gave history of weight loss around
50 kg in 1 year, self-imposed calorie restriction since
1 year (3 chapatti and few raw vegetables per day),
excessive exercise (3 h of walking per day), increased
fear of weight gain, repeated mirror and weight
checking, social phobia, prefers wearing baggy clothes
to hide his figure and decreased sleep. He skips
college and finds it difficult to concentrate in studies.
There was no history of binge eating, followed by
vomiting, fever, chest pain, diarrhea, headache. There
were no co-morbidities, or addictive habits.

DOI:
On examination vitals were normal, systemic
10.4103/2277-8632.153320
examination was normal. Speech was relevant and
coherent. Psychomotor activities were normal. Mood
Journal of Dr. NTR University of Health Sciences 2015;4(1) 39-41 39
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Koushik, et al.: Male anorexia nervosa
Figure 1: Six months before hospitalization, patient weight: 120 kg
was euthymic. Insight intact. He frequently thinks
about his weight and his abstract thinking was within
normal limits [Figures 1 and 2]. All routine blood
investigations, urine examination, FT3, T4, thyroid
stimulating hormone, electrocardiogram, serum
amylase, serum lipase, HIV 1 and 2, chest X-ray
and upper gastrointestinal endoscopy were normal.
Anorexia nervosa was diagnosed. Psychiatric opinion
was obtained, and patient was also diagnosed with
adjustment disorder and body dysmorphic disorder.
A treatment plan was designed by the attending
physician, psychiatrist and dietitian. It included
behavior therapy, family therapy and a watch on the
patient’s dietary intake. Patient was discharged and
was on regular out-patient follow-up. After 6 months
patient gradually improved, having normal meals, and
his body weight increased.
DISCUSSION
Anorexia nervosa is a severe life-threatening disorder
in which the individual refuses to maintain a minimal
normal body weight, is intensely afraid of gaining
weight, and exhibits a significant distortion in the
perception of the shape or size of his body, as well as
dissatisfaction with his body shape and size.
One of the most prevalent myths regarding eating
disorders is that it’s only seen in women, in fact, it
is also diagnosed in men. The symptoms of anorexia
nervosa in males are similar to females although the
criteria of amenorrhea will not apply.[6] The rate of
Anorexia nervosa in men seems to be increasing
along with increased messages in media about the
40
Figure 2: Three months before hospitalization, patient weight:
90 kg. Patient was not willing for photo during hospitalization but
at admission patient weighed 70 kg
ideal male figure and advertisements regarding weight
reduction in men. Men are under increasing pressure
to conform to an ideal physique.[7] Anorexia nervosa
with body dysmorphic disorder is more ill, the rate of
attempting suicide is significantly greater.[3]
Recent literature continues to reflect that multi-organ
systems are frequently affected by Anorexia nervosa.
Early treatment is vital, as once the disorder becomes
more entrenched, its damage becomes less reversible,
hence eating disorders should be diagnosed early.
Screening for such disorders should be done by
primary care physicians.[8]
Physicians play an integral role in educating and
assisting the individual who may be struggling. Many
people with Anorexia nervosa respond to outpatient
therapy support groups, nutritional counseling and
psychiatric medications under careful supervision
was also proven helpful. In-patient care is required
if associated with severe psychological or behavioral
problems. The exact treatment needs of each
individual will vary.
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2. Makino M, Tsuboi K, Dennerstein L. Prevalence of eating disorders:
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3. Grant JE, Phillips KA. Is anorexia nervosa a subtype of body
dysmorphic disorder? Probably not, but read on. Harv Rev Psychiatry
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4. Hudson JI, Hiripi E, Pope HG Jr, Kessler RC. The prevalence and
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Koushik, et al.: Male anorexia nervosa

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National Collaborating Centre for Mental Health (UK). Editors
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Management of Anorexia Nervosa, Bulimia Nervosa and Related
How to cite this article: Koushik AK, Bhaskar Reddy PV, Senthil N.
Eating Disorders.
6. Hoffman ER, Zerwas SC, Bulik CM. Reproductive issues in anorexia Anorexia nervosa in the male with co-morbid adjustment disorder and
nervosa. Expert Rev Obstet Gynecol 2011;6:403-14. body dysmorphic disorder. J NTR Univ Health Sci 2015;4:39-41.
7. Morris AM, Ka man DK. The impact of the media on eating disorders
in children and adolescents. Paediatr Child Health 2003;8:287-9. Source of Support: Nil. Conflict of Interest: None declared.

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