Figure 1. Physical examination of patient’s scalp showed patches
of baldness over the head, mainly over the crown region.
She has also been having intermittent binge eating attacks with
excessive exercising for 4 months and currently has a BMI of 20.7
kg/m2. She binged mainly on junk food and each episode
lasted 45 minutes to an hour. She consumed around 7000-8000 kilocalories
per binge. She tends to exercise excessively in order to compensate for
the excessive eating. She has an intense fear of gaining weight and is
constantly preoccupied with thoughts of weight loss despite the binging.
She demonstrates no emesis, diuresis or diarrhea. She has no knuckle
calluses/ parotid swelling/dental erosion/pharyngeal tears. The patient
is amenorrhoeic and has not had her menstrual cycles for six months.
Prior to this, she had irregular cycles (40-45 days). Medical causes for
amenorrhea were ruled out and it was attributed to excessive exercise.
Results of the routine lab investigations performed are mentioned in
Table 1.
She was diagnosed with attention deficit hyperactivity disorder (ADHD)
at the age of fifteen and has been demonstrating symptoms congruent with
ADHD for approximately one and a half years. The patient had been
absent-minded and distracted during classes. Her academic performance
had been sub-optimal with especially poor results in mathematics. Her
teachers believed that her mediocre academic performance was not due to
inadequate effort or modest intellect but rather due to a lack of
concentration. She was often fidgety and found it hard to stay still.
Substance abuse was ruled out as a differential diagnosis considering
the age and symptom profile. The diagnosis of ADHD was made by a team
consisting of a pediatrician, a psychiatrist and a counselor. The
treatment plan was also devised by the aforementioned team. She was
prescribed methylphenidate 10 mg daily and was compliant with her
medication. She had periods of remission in between and had considerable
improvement in several symptoms. The patient was lost to follow-up after
about two years.
At the age of 22, she was diagnosed with major depressive disorder
(MDD). She had come in with symptoms of feelings of worthlessness,
insomnia and weight loss. The symptoms had been present for around four
months. She had multiple psychosocial stressors including academic
stress and personal relationship issues. Additionally, the patient also
had a worsening of her ADHD symptoms. She was put on bupropion
sustained-release tablets. A satisfactory response was not seen. She
seemed to have a slight improvement in depressive symptoms, however,
ADHD symptoms did not improve. She was hence taken off bupropion and
continued on methylphenidate. Additionally, escitalopram and clonazepam
were added. The dosage of escitalopram was increased slowly to 10 mg,
and thereby her symptoms slightly improved. The patient was on the same
medication for 8 months and was subsequently changed to Lisdexamfetamine
and escitalopram along with clonazepam which showed a better response
after 4 months. Clonazepam was stopped after that. The antidepressants
were gradually tapered after 7 months of treatment. However, for the
last 2 months, due to increased stress about her exams, symptoms of
involuntary hair pulling and bulimia worsened. So, she was restarted on
escitalopram, which showed a good response to bulimia but an
unsatisfactory response to impulsive hair-pulling. She is being followed
up for further dose adjustments in medications and cognitive behavioral
therapy (CBT) for habit reversal.