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Home , Anorexia nervosa, Bulimia nervosa

DISORDERS EATING DISORDERS

ating problems and disorders fall along a continuum, ranging from unhealthy eat- KEY FACTS ing and concern with body size/shape to ■ Approximately 7.5–11.0 percent of life-threatening disorders such as Enervosa and . adolescent females and 2.0–4.5 per- cent of adolescent males report that in the previous year they used aids or or induced vomit- ing to lose weight or avoid gaining weight (Kann et al., 2000). ■ Thirty-seven percent of elementary school children have tried to lose weight (Steiner and Lock., 1998). ■ Eating disorders are more common- ly seen in females, although males are also affected. Estimates of the male-female prevalence ratio range from 1:6 to 1:10 (American Psychi- atric Association, 2000b). ■ Approximately 5 percent of individ- uals with die from the disorder, with half of the deaths occurring as a result of (American Psychiatric Association, 2000b; Steiner and Lock, 1998).

233 DESCRIPTION OF SYMPTOMS

EATING DISORDERS EATING Anorexia Nervosa (Diagnostic code: 307.1) ■ Distorted of own weight or , Adapted from DSM-PC and DSM-IV-TR. Selected additional undue influence of body weight/shape on self- information from DSM-IV-TR is available in the appendix. esteem, or denial of seriousness of ■ Refer to DSM-PC or DSM-IV/DSM-IV-TR for full psychiatric Absence of at least three consecutive menstrual criteria and further description. cycles (in postmenarcheal females) Infancy and Early Childhood There are two types of anorexia nervosa. Individu- als with the restricting type do not regularly engage in Usually not relevant during these developmental binge-eating or purging behaviors. (Binge-eating refers stages. to episodes of eating a larger-than-normal amount of Middle Childhood and food, and feeling a lack of control over eating.) Those with the binge-eating/purging type regularly engage in ■ Refusal to maintain body weight at or above 85 per- these behaviors. cent of that expected for age and height ■ Intense fear of gaining weight

Bulimia Nervosa (Diagnostic code: 307.51) ■ Compensatory behavior to prevent Adapted from DSM-PC and DSM-IV-TR. Selected additional (e.g., restricting, excessive exercising, , or information from DSM-IV-TR is available in the appendix. using laxatives, , diet pills, or enemas) ■ Refer to DSM-PC or DSM-IV/DSM-IV-TR for full psychiatric Occurrence of binge-eating and compensatory criteria and further description. behaviors at least two times per week for at least 3 months Infancy and Early Childhood ■ Undue influence of body shape and weight on self- Usually not relevant during these developmental evaluation stages. There are two types of bulimia nervosa. Individuals Middle Childhood and Adolescence with the purging type regularly engage in purging behav- ior (vomiting or use of laxatives, diuretics, or enemas). ■ Recurrent episodes of binge-eating (episodes of eat- Those with the nonpurging type use other compensato- ing a larger-than-normal amount of food, and feel- ry behaviors, such as or excessive exercising, ing a lack of control over eating) but have not regularly engaged in purging behaviors.

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Description of Symptoms (continued)

Eating Disorder Not Otherwise Specified (Diagnostic code: 307.50) ■ Criteria for anorexia nervosa are met except that Adapted from DSM-PC and DSM-IV-TR. Selected additional menstrual cycles are regular (for postmenarcheal information from DSM-PC is available in the appendix. Refer females), or weight is at or above 85 percent of that to DSM-PC or DSM-IV/DSM-IV-TR for full psychiatric criteria expected for age and height ■ and further description. Purging behaviors occur in the absence of binge- eating or anorexia nervosa not otherwise specified is applied ■ Binge-eating and purging occur fewer than two to disorders of eating that do not meet the full criteria times per week or for less than 3 months for a specific eating disorder. For example, eating disor- ■ Recurrent binge-eating occurs without regular use of der not otherwise specified might be diagnosed when compensatory mechanisms

COMMONLY ASSOCIATED DISORDERS According to Steiner and Lock (1998), Yager Obsessive Compulsive Disorder (1996), and American Psychiatric Association Up to 25 percent of patients with anorexia ner- (2000b), the following disorders or psychosocial vosa have obsessive compulsive disorder. problems are associated with eating disorders in children and adolescents: Sexual Abuse History Mood Disorders Twenty to 50 percent of patients with eating disorders have a history of sexual abuse. A history of Major sexual abuse is more common among those with Between 30 and 50 percent of patients with bulimia nervosa than among those with anorexia anorexia nervosa and between 50 and 70 percent of nervosa. patients with bulimia nervosa have major depression. Twelve percent of patients with bulimia nervosa Substance abuse is more prevalent among patients have bipolar disorder. with bulimia nervosa and purging type anorexia nervosa than among those with non-purging type Disorders anorexia nervosa and the general population. Up to 60 percent of patients with anorexia ner- vosa and 40–60 percent of those with bulimia nervosa have an .

235 INTERVENTIONS • Educate children, adolescents, and families about healthy eating behaviors throughout the Eating disorders are chronic illnesses that present child’s or adolescent’s development. Identify long-term challenges. Studies indicate that approxi- parents with excessive concern about or rigid mately 44 percent of patients with anorexia nervosa

EATING DISORDERS EATING control of their children’s or adolescent’s eat- and 60 percent of patients with bulimia nervosa will ing and physical activity behaviors. have good long-term outcomes; 28 percent and 29 • Be aware that early-maturing girls are likely to percent, respectively, will have intermediate long- diet earlier than their peers and may be more term outcomes; and 24 percent and 10 percent, dissatisfied with their appearance and have a respectively, will have poor long-term outcomes, with poorer . mortality rates of 5 percent and 1 percent, respective- • Discuss with children and adolescents safe ways ly (American Psychiatric Association, 2000b; Fichter to maintain a healthy body weight. and Quadflieg, 1997). A poorer is associated with late onset of the disorder, longer duration of • Educate and reassure girls and adolescent symptoms, premorbid , lower minimum females about the natural process of fat gain weight, family dysfunction, co-occurring psychiatric during . (Females’ body-fat percentage diagnoses, and vomiting and use. normally increases from approximately 8 per- Treatment of children and adolescents with cent before puberty to approximately 22 per- eating disorders optimally takes place with the cent by the end of puberty.) support of an interdisciplinary team, including a • Emphasize that a healthy body weight is based primary care health professional, a dietitian, a on genetically determined build and shape dentist, and professionals. Because of rather than on a culturally defined weight. the complexity and chronicity of eating disorders, • Assess girls’ self-image as they approach clear behavioral expectations and communication puberty. Girls who feel most negative about among members of the team are essential. (See their bodies at puberty may be at highest risk Bright Futures Case Studies for Primary Care for the development of eating-disordered Clinicians: Anorexia Nervosa: Stephanie’s Long Walk behaviors. [Grace, 2001] at www.pedicases.org.) • For children and adolescents, avoid critical statements, but offer support for gradual Child or Adolescent weight loss via healthy eating, physical activity, 1. Primary care health professionals can help pre- and social support. vent eating disorders in children and adolescents. 2. Because eating disorders are prevalent in middle The following are some suggestions for how childhood and adolescence, it is important to health professionals can do this: screen for them. For information on screening for • Promote self-esteem in children and adoles- eating disorders, see Table 13. Eating Disorders: cents throughout their development. Assessment, Warning Signs, and Screening Questions.

236 EATING DISORDERS

Table 13. Eating Disorders: Assessment, Warning Signs, and Screening Questions

Assessment Warning Signs Screening Questions

Body image and weight history Distorted body image ■ How do you feel about the way you look? Extreme dissatisfaction with body shape or size ■ Has there been any change in your weight? Profound fear of gaining weight or becoming fat ■ Are you trying to change your weight? Tell me about the ways Unexplained weight change or you try to control your weight. fluctuations greater than 10 pounds

Eating and related behaviors Very low caloric intake; avoidance of fatty foods Poor Difficulty eating in front of others ■ What did you eat yesterday?

Chronic despite not being ■ Do you ever binge? overweight Binge-eating episodes ■ Have you ever induced vomiting (e.g., by using )? Self-induced vomiting, use of syrup of ipecac; laxative or use ■ Have you ever used laxatives, diuretics, or diet pills to lose Meal pattern Fasting or frequent meal skipping weight? to lose weight Erratic meal pattern with wide variations in caloric intake

Physical activity Preoccupation with weight ■ How much do you participate in because of participation in physical activity in a typical physical activity with weight or week? size requirement (e.g., gymnastics, wrestling, ballet) Overtraining or compulsive attitude about physical activity

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237 EATING DISORDERS Screening questions adapted,withpermission,from Powers,1996. Sources: sesetWrigSgsScreening Questions Warning Signs Assessment Physical examination Psychosocial assessment Health history Adams andShafer,1988;American MedicalAssociation,1996,ascitedinStoryetal.,2000;Perkins etal.,1997;Powers,1996. T able 13.EatingDisorders:Assessment,Warning Signs,and Screening Questions Peripheral edema Peripheral neuropathy Tooth enameldemineralization Loss ofmusclemass orirregularheartrate, BMI <5thpercentile History ofphysicalorsexualabuse Pressure fromotherstobea Constant thoughtsaboutfoodor Anxiety/obsessive compulsivetraits Depression Feeling bloated//abdominal ordiarrhea Fainting episodesorfrequent Cold intolerance Secondary amenorrheaorirregular arising suddenly decreased bloodpressureafter or othertraumatizinglifeevent certain shapeorsize weight pain unexplained byothercauses lightheadedness menses 238 (continued) ■ ■ ■ ■ your periods? Has therebeenanychangein (For postmenarchealfemales) period? How oftendoyougetyour (For postmenarchealfemales) eating oryourweight? How muchdoyouworryabout your mood? about yourbodyareaffecting Do youthinkyourfeelings EATING DISORDERS

3. Assess the following areas in further detail for -- Musculoskeletal: bone pain with movement children and adolescents who present with con- ( fractures). cerning findings on initial screening: • Physical findings • Psychosocial history -Vital signs: hypothermia, bradycardia (slow - Screen for associated depression, anxiety dis- heart rate), orders, substance abuse, or history of abuse. -Head/neck: tender/swollen parotid glands, Ask about suicidal ideation (suicidal dental caries, tooth enamel erosion thoughts). -Musculoskeletal: muscle wasting -Interview the child or adolescent and the par- - Skin: lanugo hair, dry skin, on ents about circumstances surrounding the knuckles (Russell’s sign), acrocyanosis of onset of eating behaviors and weight digits (blue fingers and toes due to changes. Ask about any family stressors or constriction of blood vessels) conflicts. • Medical evaluation -Inquire about any school difficulties or legal -Evaluate medical causes of weight loss or problems. menstrual abnormalities as indicated (e.g., • Review of symptoms thyroid disease, malignancy, hypothalamic -Ask about symptoms associated with eating- lesions, inflammatory bowel disease, celiac disordered behavior. disease, mellitus, HIV, Addison’s dis- -- Cardiac: fainting, dizziness, . ease, other chronic illness). -- Gastrointestinal: sore throat, heartburn, -Perform initial screening tests as indicated regurgitation, (sensation of food (e.g., complete blood count [CBC] and differ- getting stuck while swallowing), abdominal ential, sedimentation rate, urinalysis with pain, bloating, constipation. specific gravity, , glucose, calcium, magnesium, phosphorus, blood urea nitrogen -- Genitourinary: polyuria (passage of large (BUN), creatinine, thyroid functions, electro- amounts of urine that may be manifested cardiogram (ECG). by frequent urination). 4. For children and adolescents for whom -- Endocrine: , cold intolerance, outpatient treatment is indicated, consider the , hair loss. Amenorrhea may occur following: before weight loss in up to one-fourth of postmenarcheal females with anorexia ner- • An interdisciplinary team approach is critical vosa. Amenorrhea for up to 1 year in an for treating children or adolescents who have adolescent is associated with been identified as having eating-disordered (decrease in bone mass). Menstrual func- behaviors. Goals for treatment include tion is also impaired in 20–40 percent of -Stabilizing and treating medical complica- female patients with bulimia. tions

239 -Restoring and maintaining a normal weight -- Educates the child or adolescent about the -Reducing co-occurring psychiatric symptoms effects of poor nutrition on well-being: low energy (usually seen with intake of less - Addressing irrational thoughts about food than 500 calories per day), irritability, sleep and body image

EATING DISORDERS EATING disturbances, and poor concentration. - Enlisting family support for treatment -A dietitian • The outpatient treatment team ideally has -- Develops an eating plan for safe weight expertise in treating children and adolescents restoration and/or changing eating with eating disorders and includes the behaviors. following members: -- Works with the child or adolescent and -A primary care health professional family to facilitate acceptance of the eating -- May serve as coordinator with dietitian and plan and prevention of dieting and food mental health professionals. restriction that may trigger binge-eating. -- May coordinate the team’s consultation -- Educates the child or adolescent and family with the child’s or adolescent’s dentist. about nutritional needs and consequences -- Monitors the child’s or adolescent’s weight, of , binge-eating, and purging. postural vital signs, and laboratory test -Mental health professionals (may include a results as indicated. child and adolescent , clinical -- Monitors the child’s or adolescent’s long- psychologist, social worker, and/or other term growth and development, and treats mental health professionals) medical complications of eating disorders. -- May serve as coordinators with dietitian -- Educates the child or adolescent about and primary care health professional. potential health consequences of eating -- May coordinate the team’s consultation disorders. (Potential consequences of with the child’s or adolescent’s dentist. anorexia nervosa include growth -- Perform complete mental health evalua- retardation, pubertal delay, , tion, including assessment for associated or endocrine dysfunction [pituitary, co-occurring disorders. hypothalamic, thyroid abnormalities], cardiac , and congestive heart -- Engage child or adolescent in appropriate failure. Potential consequences of bulimia therapy as indicated by the evaluation (e.g., nervosa include serious cognitive-behavioral therapy, insight- imbalances such as , cardiac oriented therapy, supportive therapy) to arrhythmias, dental erosion, esophageal address underlying problematic beliefs tears, and aspiration pneumonia.) about body image and food and to identify and address circumstances that provoke

240 EATING DISORDERS

cent’s weight despite intensive outpatient treatment, (3) the presence of stressors that may interfere with the child’s or adolescent’s ability to eat, (4) prior knowledge of the weight at which medical instability is likely to occur, and (5) any co-psychiatric problems (e.g., major depressive disorder, ) that merit hospitalization (American Psychiatric Association, 2000b). The prognosis for recovery is improved if an indicated hospi- talization occurs before the onset of medical instability as manifested by abnormal vital signs. • Immediate admission to a medical service or food restriction or binge-eating/purging. joint medical/psychiatric service specializing in Address associated or co-occurring disorders eating disorders is indicated for unstable med- as indicated. ical conditions such as -- Work with the family to enlist support for -Heart rate less than 50 treatment and to address any underlying - Postural hypotension family difficulties. (See Interventions, - Cardiac instability Family, p. 242.) - Loss of greater than 25 percent of ideal body -- May provide group treatment. weight --Assess for interventions as - less than 3 milliequivalents indicated for treatment of associated mood per liter with abnormal ECG and anxiety symptoms or for stabilization of binge-eating/purging behaviors. (For the - Metabolic alkalosis latter, selective -reuptake - Severe inhibitors [SSRIs] may be helpful and safe- - Uncontrollable binge-eating and purging ly tolerated.) - Acute food refusal 5. For children and adolescents for whom hospital- based treatment is indicated, consider the • Immediate admission to psychiatric service or following: joint psychiatric/medical service specializing in eating disorders is indicated for • The decision to hospitalize should include consideration of (1) any rapid or persistent - Suicidal ideation decline in the child’s or adolescent’s oral - Psychiatric symptoms resulting in inability to intake, (2) a decline in the child’s or adoles- eat

241 - Failure to adhere to outpatient treatment 2. For children and adolescents with eating disor- plan and predetermined goals ders, research has shown to be • Day hospitalization may be effective as an effective (Steiner and Lock, 1998; Wiseman et al., intermediate level of treatment and as a transi- 1998; Yager, 1996). Family therapy should focus

EATING DISORDERS EATING tion from hospital to home. on • Improving communication and decreasing crit- Family ical comments 1. Help families promote a positive body image and • Decreasing ongoing conflicts a healthy attitude toward eating for their child or • Supporting the child’s or adolescent’s eating adolescent. and treatment plans • Emphasize the importance of family meals. Encourage families to eat meals together as School often as reasonably possible. 1. With appropriate permission, collaborate with • Encourage parents to school personnel to support the child or adoles- - Avoid making critical comments about their cent and to monitor her academic and physical own or others’ bodies needs. - Ensure that their children have positive role models whose body types differ (i.e., who do not all conform to the media ideal of thinness) - Focus on traits that are not appearance related -Discuss the reality behind media images of thin, glamorous models and actors - Discuss the overempha- sis on thinness in our society and the impor- tance of accepting a wide range of body types

242 EATING DISORDERS

2. Discuss guidelines for managing physical symp- Resources for Families toms or behaviors with school health profession- Academy for Eating Disorders als and mental health professionals (e.g., when to 6728 Old McLean Village Drive contact you with concerns about vital signs; McLean, VA 22101 monitoring the child or adolescent after lunch to Phone: (703) 556-9222 prevent purging). Fax: (703) 556-8729 3. Monitor the child’s or adolescent’s school perfor- Web site: http://www.acadeatdis.org mance, as poor nutrition may impair learning and concentration. American Anorexia Bulimia Association 165 West 46th Street, Suite 1108 Resources for Health New York, NY 10036 Phone: (212) 575-6200 Professionals Fax: (212) 501-0342 Childress AC, Brewerton TD, Hodges EL, et al. 1993. Web site: http://www.aabainc.org/home.html The Kids’ Eating Disorder Survey (KEDS): A Anorexia Nervosa and Related Eating Disorders study of middle school students. Journal of the American Academy of Child and Adolescent Psychi- P.O. Box 5102 atry 32(4):843–850. Eugene, OR 97405 Phone: (541) 344-1144, (800) 931-2237 Kuczmarski RJ, Ogden CL, Grummer-Strawn LM, et Web site: http://www.anred.com al. 2000. CDC growth charts: United States. Advance Data 314:1–27. Hyattsville, MD: Nation- Eating Disorders Prevention and Awareness al Center for Health Statistics. Available at 603 Stewart Street, Suite 803 http://www.cdc.gov/growthcharts. Seattle, WA 98101 Maloney MJ, McGuire JB, Daniels SR. 1988. Reliabil- Phone: (206) 382-3587, (800) 931-2237 ity testing of a children’s version of the Eating Fax: (206) 829-8501 Attitude Test. Journal of the American Academy of Web site: http://www.edap.org Child and Adolescent 27(5):541–543. This version of the Eating Attitude Test is for National Association of Anorexia Nervosa and school-age children. Associated Disorders Shore RA, Porter JE. 1990. Normative and reliability P.O. Box 7 data for 11 to 18 year olds on the Eating Disor- Highland Park, IL 60035 der Inventory. The International Journal of Eating Phone: (847) 831-3438 Disorders 9(2):201–207. This article presents an Fax: (847) 433-4632 eating disorder inventory and supporting data. Web site: http://www.anad.org

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