A Classical Case of Bulimia Nervosa from India
A 22-year-old, unmarried female medical undergraduate, belonging to an urban Hindu extended nuclear family of the upper socio-economic status from a metropolitan city, with predominantly narcissistic and a histrionic traits and family history of recurrent depressive disorder in paternal grandmother, presented with the poor eating habits of insidious onset for 9 years. During her 8th class, she developed liking for a boy in her class who rejected her calling fat. Though, she managed to move on; however, developed dissatisfaction for her body image, and would consider herself fat on the mirror and started looking for means to reduce weight. With gradually increasing concern over growing fat, she started skipping two meals and would take only one meal and salads in class 10th. Over next 6-7 month period, she lost up to 12 kg and looked thin, although she would consider it inadequate and would find herself flabby, in front of the mirror, although at other times, she could appreciate that her clothes had become loose. However, she never had symptoms of micronutrient deficiency or menstrual irregularity. At the same time, she also developed intense liking for the high calorie foods. She would binge on them 5-6 times a month and would regret afterwards. She tried to induce vomiting also once or twice. She started exercising for 1-1½ h in order to compensate weight gain out of binging. This pattern continued for next 1-1΍ when she gave up working out unwillingly, to focus more on studies, and she gained about 4-5 kg. She would be distressed with it. She passed class 12th with expected marks and qualified for MBBS course. She restarted dieting; however, within few months she again started having increased craving for the high calorie foods and binging, which would be more when she would deny food in parties. Though she knew that her Body Mass Index (BMI) was well within normal range, she started taking one tablet of Orlistat daily secretly along with skipping meals and rejoining gymnasium in order to reduce her weight to below 50 kg, which was below normal for her height. She would often consume isaphgul husk for purging after binging. She sold her gold necklace without informing the family members to undergo liposuction. She could undergo a single session after which it came to the knowledge of a family member, who refrained her. During last 5 year, she would compare herself with every female she met or read about in novels, would feel better on seeing obese females, and feel let down if they were slim. She could not spend an hour without fear of becoming obese. In recent times, she would avoid parties, going out with friends, standing for photos, and would spend hours in the gymnasium.\nAt the time of consultation in the Psychiatry out-patient department, her BMI was 23, which is within normal range. Her laboratory investigations including, complete hemogram, liver, and renal function tests, serum electrolytes, plasma blood glucose levels were normal. She was put on Fluoxetine 40 mg, and Cognitive Behavior Therapy was started. She is under regular OPD follow-up with sustained improvement since last 18 weeks.