An adolescent with anorexia nervosa presenting with catatonia.

Sir,

Anorexia nervosa is defined by a significantly low body weight in the context of age, sex, and physical health, intense fear of weight gain and disturbed body perception.[1] The prevalence of anorexia nervosa is 1%–4% among women, with a male:female ratio of approximately 1:10.[2] The peak age of incidence is 14–17 years.[3] Catatonia is a syndrome of severe motor and speech disturbances. It is most commonly associated with affective and psychotic disorder and is extremely rare with anorexia nervosa. Till now, only one case of anorexia nervosa with catatonia has been reported.[4]

A 16-year-old unmarried Hindu female of rural background belonging to middle socioeconomic status was referred from the medicine department, admitted for 3 days with complaint of mutism, not taking orally and sitting in one position for long hours for 2 months. After taking written informed consent, detailed history was taken by us; the total duration of illness was found to be 9 months with insidious onset and continuous and deteriorating course. Initially, she started skipping meals and sometimes missing school, saying that she does not like going there. Following 4 months, she started talking irrelevant things that she is hearing voices of people, standing outside to take her away. Sometimes, she kept her arms in air in an uncomfortable posture for hours. There was no history of head injury, seizures, fever, vomiting, headache, blurring of vision, bleeding from orifices, repetitive ideas, images, big talks, and excessive worrying and no surgical or medical history. She also had secondary amenorrhea for 5 months. On premorbid temperament, she was easy going child. On general physical examination, there was pedal edema, sunken eyes, blackening around the face, prominent cheek bones, clavicle and ribs, scaphoid abdomen, dry skin, and brittle nails. Blood pressure – 96/68, pulse – 80/min, and body mass index (BMI) – 14.26 kg/m2 noted. On mental status examination by Kirby's method, posturing, muscles tension, and negativism were observed. Higher mental function could not be assessed. The patient was screened and rated on severity using Bush–Francis Catatonia Rating Scale (BFCRS), yielded score 24. On investigations, there was decreased serum vitamin D and Luteinizing hormone, on urine examination, Ketones were present and urine pregnancy test was negative. On cerbrospinal fluid examination(CSF), viral markers and Cartidge based nucleic acid amplification test for tuberculosis(CBNAAT) were found negative. Ultrasonography revealed gallbladder sludge. Nutrition was mantained via ryles tube feeding, hydration via intravenous fluids along with mobilization, skin care, and safety of the patient. A trial of lorazepam was undertaken under close observation and vitals monitoring as an initial step. A significant improvement was seen (BFCRS = 7). The patient was assessed by neurology, endocrinology, gynecology, and gastroenterology to rule out organic cause, and no pathology was found. Subsequently, after 2 days, it was found that the patient was speaking few words now on asking questions. Serial Mental Status Examination, ward observation, and psychological tools for assessment showed the ideation of losing excessive weight and becoming thin since 9 months in the patient. She was preoccupied about weight gain. Presence of low BMI (14.26 kg/m2), self-induced weight loss by avoidance of food, preoccupation with fear of fatness, and amenorrhea along with catatonia favored diagnosis of anorexia nervosa with catatonia. Pharmacological and nonpharmacological intervention was done.

This shows that body and mind work together. It is widely accepted that physical causes can lead to mental symptoms and that mental illnesses could express as physical symptomatology.

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Conflicts of interest

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