Year : 2014 | Volume
: 2 | Issue : 1 | Page : 34--36
Atypical bulimia nervosa in a male patient of rural north-east India
Manabendra Makhal, Uttam Majumder
Department of Psychiatry, North Bengal Medical College, Sushrutanagar, Darjeeling, West Bengal, India
Dehimondal Ghat, Shyampur, Howrah - 711 301, West Bengal
Eating disorders such as bulimia nervosa rarely seem to manifest in males from non-Western cultures like India, but occur infrequently in milder forms with fewer symptoms as atypical bulimia nervosa. This report describes a male case of bulimia nervosa from rural area of India presenting with atypical features. He was treated successfully with fluoxetine and cognitive behavioural therapy.
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Makhal M, Majumder U. Atypical bulimia nervosa in a male patient of rural north-east India.J Health Spec 2014;2:34-36
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Makhal M, Majumder U. Atypical bulimia nervosa in a male patient of rural north-east India. J Health Spec [serial online] 2014 [cited 2020 Feb 24 ];2:34-36
Available from: http://www.thejhs.org/text.asp?2014/2/1/34/126068
Anorexia nervosa and bulimia nervosa are characterised by an abnormal eating behaviour deriving primarily from an overvaluation of the desirability to lose weight that result in functional, medical, psychological and social impairment.  Aetiological factors are a complex interplay of biological, psychological and social factors. 
Bulimia nervosa, a disorder characterised by recurrent episodes of binge eating in which large amounts of food are consumed in short periods and purging to counteract the "fattening" effects of food by self-induced vomiting and/or purging, alternating periods of starvation and use of drugs such as appetite suppressants. There is a persistent pre-occupation with eating, a strong compulsion to eat and an intrusive dread of fatness.  It begins during adolescence, with the peak period of onset around 18 years of age. 
Patients with atypical bulimia nervosa who deny distorted body-image and maintain normal or even excessive body weight are not uncommon among Asian patients. , Strober et al., reported these atypical features in one-fifth of their patients.  Herzog et al., noted an incidence in males of 4 - 5% of a total bulimic patients. 
The most commonly overlooked categories of patients with eating disorders are men, matrons and minors, largely because clinicians rarely think of an eating disorder in these populations.  So far, to our knowledge there has been only one female case of atypical bulimia reported from India. 
A 37-year-old male, Hindu, married, truck driver, illiterate and from the lower socioeconomic strata of rural north-east India was brought to the Psychiatry Department of a Medical College in West Bengal, India complaining of his irresistible urge to eat food constantly irrespective of time and place. In the past year he started to take excessive amounts of boiled rice throughout the day and night, most of the days in a week. He started this type of disproportionately excessive eating and frequency for beyond his previous normal habit. He almost lost control over his eating. He took a bowl of rice to the wash room and when he went out. He even kept a bowl of boiled rice by his bedside to eat immediately after awaking. He felt hungry all the time, even after eating. He had several episodes of self-induced vomiting to reduce discomfort of abdominal distension. The patient denied fear of weight gain as an explanation of his vomiting. There was no guilty feeling following each binge eating. He never used any other inappropriate compensatory behaviour to lose weight such as fasting or excessive exercise, misuse of laxatives, diuretics, or using enemas. The patient was normotensive, euthyroid, non-diabetic but obese with average build. He had no pre-occupation of distorted body image. There was no history suggestive of an impulse control disorder, obsessive compulsive disorder or attention deficit hyperactivity disorder. Over the course of time he had gained 19 kg of weight and on follow-up he was found to be diabetic. He had never developed anorexia nervosa, substance abuse, or other psychiatric illness. There was no family history of an eating disorder and clinically he had no neuro-deficit.
Laboratory findings of haemoglobin, peripheral blood smear, renal and liver function tests, thyroid and lipid profiles, as well as electrolytes were all normal. Blood sugar was normal initially but increased later above diabetic range. Computed Tomography scan of brain and ultrasonography of whole abdomen was normal.
He was given 10 mg/day of fluoxetine daily in the morning which was gradually increased up to 60 mg/day by the end of the fourth week. He had taken metformin 500 mg twice daily for diabetes and eventually became euglycaemic. Simultaneously, the patient was kept under dietary and healthy life style counselling and cognitive behavioural therapy (CBT) to maintain a normal diet and break the vicious cycle of binge eating. His symptoms started to improve from the seventh week. Later, we found remarkable improvement in his eating pattern but his weight did not reduce.
Atypical anorexic patients denying a dread of fatness and body-image distortion were reported from the Asian subcontinent in the past few years.  These atypical features were explained on the basis of cultural factors.  One female patient with atypical bulimia nervosa denying any dread of fatness and body-image distortion was reported from India.  So far, to our knowledge we are reporting this first male case of atypical bulimia nervosa from India. This patient had satisfied almost all ICD-10 criteria of bulimia nervosa except distorted body-image as discussed previously. Various recurrent inappropriate compensatory behaviours in order to prevent weight gain were reported in patients with bulimia nervosa; , but all were absent in our patient except for vomiting. The patient used to vomit to reduce physical discomfort of distended abdomen. Absence of fear of fatness and body-image disturbances in patients with eating disorders in Asian populations have been well-documented.  Male patients with eating disorders tend to have a higher pre-morbid weight and less concern with strict weight control.  Our patient had an excessive weight unlike the usual patients with bulimia nervosa. Bulimia nervosa is seen among young women in developed countries, as well as in urbanised regions of developing countries.  Male patients with bulimia nervosa appear to have a later age of onset when compared to females.  Our patient was from a rural area with the age of onset 36 years. Lee et al., supported the existence of non-fat phobic anorexic nervosa as a heterogeneous group with regard to reasons used for food refusal.  The presence of binge eating associated with self-induced vomiting but absence of the dread of fatness and body-image disturbances in our patient suggests that these atypical features observed in Asian anorexics may also be applicable to people with bulimic behaviour from Asia. Fluoxetine at doses higher (60 - 80 mg/day) than those used for depression has been found to be more effective for bulimic symptoms.  There is evidence that treatment programmes that include nutritional counselling as part of the management are more effective than those excluding counselling.  Our patient, when treated with combined nutritional counselling, CBT, metformin and high dose of Fluoxetine (60 mg/day) had a remarkable improvement in his eating pattern and blood sugar level.
Bulimia nervosa in males had received relatively little attention in the literature. Cultural perspectives should be considered to understand the pathogenesis of atypical bulimia in males. Future research should focus on more rigorous analytic studies.
We did not receive any grant or sponsorship from any agencies, the study was funded by us. We express our gratitude to Prof. Nirmal Kumar Bera, Head of the Department of Psychiatry, North Bengal Medical College and Prof. Gautam Kumar Bandyopadhyay for their guidance as well as motivation.
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