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.