Anorexia Nervosa: Beyond Boundaries

Laila Qadan, MD* ABSTRACT

Objective: To describe Anorexia Nerv-

osa in a patient from the Middle-East

where this condition is believed to be

rare.

Method: The diagnosis of Anorexia

Nervosa was based on detailed history

and physical examination, and was in ac-

cordance with DSM-IV diagnostic criteria.

Discussion: Anorexia Nervosa should

not be overlooked in Middle-Eastern cul-

tures. Local values may play an impor-

tant role in the management of the dis-

ease. VVC 2008 by Wiley Periodicals, Inc.

Keywords: anorexia nervosa; middle-

east; cholesterol

(Int J Eat Disord 2009; 42:479–481)

For a long time Anorexia Nervosa was thought tobe bound to Western countries. However, withinthe last decade some cases have been identified innon-Western societies.1–7 Among Middle-Easterncountries, very few cases have been reported in thepast.1,3 Here, we describe a Kuwaiti teenage girlwith classical features of Anorexia Nervosa. Thecase highlights the fact that this disorder crossescultural boundaries.

Case Report

A 14-year-old Kuwaiti female was referred to ourendocrine clinic for secondary amenorrhea. Shehad menarche at the age of 11, followed by regularmenstruation till 5 months prior to referral. Shehad lost 15 kg over 6 months. There was no historyof fever or other constitutional symptoms. She didnot report abdominal pain, vomiting, diarrhea,body aches, or loss of energy. On the contrary, shecould exercise continuously for a whole hour with-out difficulty. She had no relevant past medical his-tory and was not receiving any medications. Herfamily history was significant for one younger sisterwith obesity. Social history disclosed an excellentschool achievement which had been recently com-promised by a change of school. The mother wasdescribed as passive; the father was seen as over-protective and strict, whose anger and disapprovalof a child’s behavior could result in scalding or evenphysical punishment.

On Further one to one questioning, the patientadmitted the unavoidable urge to refrain from eat-ing because of an obsessive fear of gaining weight.She had distorted perception of body image, andconsidered her existing weight and look as desira-ble. She could not help that fear despite a counter-balancing concern of her father’s reaction and dis-approval. She and her family dated the onset of hersymptoms to their summer vacation in Lebanon.

On examination, the girl was grossly emaciated,wearing the traditional Islamic costume in a fash-ionable way. She seemed depressed and doubtful.Her body mass index (BMI) was 15. She was afe-brile; her blood pressure was 95/65 mm Hg, with-out orthostatic hypotension, and her pulse was 78beats/min. She had excessive lanugo hair all overher body. The rest of the physical exam was unre-markable. Chest radiograph and EKG were normal.Serum Glucose, Electrolytes, Urea, Creatinine,and liver Transaminases were within normallimits. Other laboratory tests showed: Estradiol:\50 pmol/L, Sex Hormone Binding Globulin(SHBG):189 nmol/L (normal range: 20–118), Fol-licle- Stimulating Hormone (FSH): 3.2 mIU/ml(normal range: 3.3–8.8), Luteinizing Hormone (LH):0.4 mIU/mL (normal range: 0.6–6.2), and normalProlactin level. Total and LDL Cholesterol were:10.34 mmol/L (normal range: 3.0–5.2) and 7.39mmol/L (normal \3.36), respectively. The patientwas diagnosed with Anorexia Nervosa according toDSM-IV diagnostic criteria.8

Management

In Kuwait, the lack of eating disorders centers orfacilities where patients could be easily directed

Accepted 20 October 2008

Department of Medicine-Endocrinology, Kuwait University,

Jabriya, Kuwait

*Correspondence to: Laila Qadan, P.O. Box: 39168, Nuzha 73052,

Kuwait. E-mail: lailaqadan@hotmail.com

Published online 29 December 2008 in Wiley InterScience

(www.interscience.wiley.com). DOI: 10.1002/eat.20641

VVC 2008 Wiley Periodicals, Inc.

International Journal of Eating Disorders 42:5 479–481 2009 479

CASE REPORT

makes the Psychiatric hospital the only resort.Additionally, the social stigma associated with see-ing a psychiatrist is difficult to handle, especially ina vulnerable family. Therefore, the parents chose tosee a private psychiatrist, in a discrete way, whoconcurred with the diagnosis. They were very dis-appointed with his counseling. He prescribed anti-depressants which made their daughter sleepy, soshe and her family decided to stop the medicationat their own discretion. She also tried thrice weeklyvisits to a psychotherapist who was recommendedby the psychiatrist. Although that seemed to bemore satisfactory to the family, it was not veryeffective in the patient’s opinion. After a few visits,they decided to quit due to unaffordable fees. Thus,despite a sincere trial to have a team approach intreating this patient, the lack of a specialized cen-ter, which accommodates that team, announcedthe failure of this approach. Consequently, theauthor became the only medical figure she wouldtrust.

Intensive outpatient counseling was carried out.Agreement on a mutually acceptable diet wasreached to provide around 1,500–1,800 Kcal/day. Itincluded low fat dairy products, cereal bars, fruits,vegetables, nuts, high grain carbohydrates, andbroiled chicken or fish. She continued to refuse anyfood cooked with fat and refused juices. Interest-ingly, she rejected adding salt to food, since shebelieved that it would cause water retention andprobably increase her body weight unnecessarily.Family counseling played a major role in under-standing the daughter’s disease and dealing withher obsessions in a supportive manner.

Six months after a slowly progressive improve-ment, the patient resumed menstruation, and after14 months she reached a BMI of 18.5. The mainsign of improvement during the earlier phases wasa gradual decrease in total and LDL Cholesterol lev-els. She continued going to school and maintainedexcellent levels of achievement.

Discussion

Until recently, Anorexia Nervosa has been consid-ered a disease of Western societies.1–2 The rarity ofthis disorder among Arabs and Muslims could beattributed to traditional Islamic loose clothingwhich obscures body details. Also, in many Araband Muslim communities girls marry at a youngage and most marriages are arranged by families,putting less pressure on girls to have a more com-

petitive slender figure. Nonetheless, our patient isevidence that Anorexia Nervosa is probably underdiagnosed in Third World countries. Although shelost 15 kg, the family did not seek medical attentionbecause of unawareness of the condition. Onlyamenorrhea prompted the request for medicaladvice. Lately, screening studies carried out in Iranand Egypt reported that the prevalence of eatingdisorders among Arab-Islamic communities wassimilar to the West.9,10

Anorexia Nervosa may arise in response to newexperiences with inadequate coping skills. Exam-ples include assimilation into a thinness-consciousculture or a response to new experiences.11 Ourpatient had both of these as precipitating factors.Her visit to Lebanon, which is, traditionally morewesternized compared to other Arab countries witha more figure and fashion conscious society, wascoupled with a change of school. She had an indi-vidual predisposition evident in a disturbed per-ception of body image, accompanied by a possiblegenetic component, and a familial factor markedby a domineering father and a passive mother.

The connection between Anorexia Nervosa andCentral Hypogonadism is well known amongphysicians. Other associations like anemia andmicrocytosis, hypercortisolism, and Euthyroid SickSyndrome are probably widely recognized too.5,12

Here, we would like to point out some valuable lab-oratory screening tests that would be extremelyhelpful in the outpatient setting when suspectingthe diagnosis; namely, elevated Sex Hormone Bind-ing Globulin (SHBG), LDL and total Cholesterol.These are reported to decline in individuals withanorexia nervosa with improving nutritional sta-tus.13,14 Our patient exhibited an elevation of bothCholesterol and SHBG. Regular monitoring of LDLand total Cholesterol during follow-up documentedthe behavioral changes in eating habits reported bythe patient and her family even before significantweight gain was achieved.

I believe that the issue of Anorexia Nervosa in anArab country is beyond the prevalence of the dis-ease but its management; facing a cruel societywhere sarcasm, verbal and physical abuse could beways of dealing with it. A society where empathyand care about others’ feelings is an exceptionrather than a rule. The shame associated with psy-chotherapy makes people refrain from acceptingcounseling. With our patient, this challenge waseven harder because she could access knowledgeabout diet and calories via the internet. That madenutritional therapy a difficult task too, probablyexplaining the very slow increase in her bodyweight.

QADAN

480 International Journal of Eating Disorders 42:5 479–481 2009

Healthcare systems in many developing coun-tries still do not cater for eating disorders especiallyAnorexia Nervosa; a disease where conventionalmedical therapy seems to be useless, while psycho-therapy and patience appears beneficial.12 Global-ization through travel and media is likely to causean increase in the magnitude of this illness. Thestigma associated with psychiatric illness in theThird World countries hampers its diagnosis andtreatment. Specialized units on the other hand maybe more acceptable and offer a multidisciplinaryapproach to the management of Anorexia Nervosa.Such units have been shown to reduce the mortal-ity compared to treating the condition in generalpsychiatric facilities.15

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