Ms L came to see me reluctantly. Her parents had made an appointment with the Eating Disorders Clinic without her knowledge.
She discovered she would be seeing a psychiatrist only that morning and, naturally, she was very angry when she came into the consultation room.
She kept silent for quite a while. It was only with much persuasion that she relented to speak. But she soon broke into tears.
Ms L was 16 years old when, at a festive gathering, some of her relatives said she had put on weight. She became conscious of her appearance and tried to lose weight.
Over the next few months, she went on a strict regimen of eating less and exercising more. She felt good about herself only when she lost weight.
Her diet subsequently changed to one which comprised only vegetables and fruit. She refused to take any form of carbohydrates or meat.
She thought that eating meat and fried food would make her fat.
Ms L also became more active, running at least an hour a day, in addition to her physical education lessons in school.
Her parents noticed the drastic weight loss and her mood changes.
Their attempts at encouraging her to eat more and exercise less were often met with anger. She often left the dining table in tears whenever her parents encouraged her to eat more. She would sometimes keep to herself at home.
She could not stop the punishing exercise regimen and extreme dieting. She was afraid that if she stopped exercising and ate more, she would gain a lot of weight.
She also lost sleep over her O levels. She was tired on most days and lost interest in most things.
Once a syndrome that was associated with the affluent West - affecting women in particular - eating disorder is a growing phenomenon in Asia, such as in Malaysia, Hong Kong, India and Singapore.
A 2006 study showed that 7.4 per cent of young Singaporean women with a mean age of about 16 years were at risk of developing an eating disorder.
Another study in 2005 examining the clinical characteristics of patients with anorexia nervosa found that school and work stress were common factors that brought on the illness.
Most people with this condition also suffered from depression, the study found. In fact, it was reported that the symptoms of patients suffering from anorexia nervosa here were not very different from their Western counterparts'.
In a 2015 study here which compared the clinical profile of patients with those in the 2005 study, patients were found to be suffering from more severe forms of anorexia nervosa.
They tend to have a lower body weight and body mass index (BMI). Mood disorder was also a common psychiatric condition.
More than a quarter of the patients also had medical complications such as bradycardia or a weak heartbeat, low bone density and electrolyte abnormalities or an imbalance of minerals in the body.
This study showed that from 2003 to 2010, the number of new cases of anorexia nervosa increased by 115 per cent.
The reluctance to seek treatment is not uncommon.
We took several sessions to build a rapport with Ms L. She later revealed that she was worried that poor sleep and difficulty in concentration were affecting her studies.
She did not understand that her poor diet was taking a toll on her physical and mental health.
She was diagnosed with anorexia nervosa and major depressive disorder, and was admitted to hospital for a short period.
Her weight was dangerously low, her periods had stopped and she was suffering from low heart rate and low blood pressure.
Even when she was in hospital, she needed persuasion and encouragement to eat more.
The first few days in hospital were tough for her.
Fortunately, with reassurance from our multidisciplinary team, comprising a dietitian, nurses and therapist, as well as support from her parents and younger sister, Ms L was finally able to start eating normally again and her physical health soon improved.
Her state of mind also became better. As her self-esteem improved, she stopped feeling guilty about eating and she was no longer fixated about body-image issues such as size and shape.
Her body was able to start recovering after she stopped her punishing exercise regimen.
She began to sleep better and was able to concentrate on her revision for her O levels.
After she was discharged from hospital, she continued with family-based therapy and outpatient monitoring. (Family- based therapy is an intensive form of therapy which involves the family as a unit, with the aim of restoring weight and re-establishing normal eating for a young patient with anorexia nervosa).
Happily, she passed her examinations and was enrolled into the junior college of her choice.
Family-based therapy is the mainstay of outpatient treatment for younger patients with anorexia nervosa. Other forms of treatment include nutritional rehabilitation to normalise eating patterns by supporting patients with exposure to their feared foods, encouraging them to eat a greater variety of foods and using different methods of food preparation.
For some patients, individual psychotherapy and art therapy sessions may help.
We generally do not rely on medications to treat anorexia nervosa unless the patient is suffering from other psychiatric conditions such as depression or anxiety.
Anti-depressants can be considered, but underweight patients are more prone to side effects such as hyponatraemia (abnormally low levels of sodium in the blood) and gastrointestinal disturbances. Hence, such prescriptions are given with much caution.
Ms L recovered without the need for medication. As she sought help early, her symptoms were not so entrenched. Her family was supportive, providing her with comfort and reassurance.
Such support is important as it strengthened her determination to overcome her problems during the months of treatment.
She was discharged well from the clinic after a year of treatment.
•Dr Ng is director of the eating disorders programme and consultant at the department of psychiatry at the Singapore General Hospital.