5.2.6 Eating Disorders

Anorexia Nervosa and Bulimia Nervosa

Eating disorders are a group of mental health conditions characterized by disturbances in eating behaviours and attitudes, often leading to significant impairments in physical and psychological health. In children and adolescents, eating disorders are a serious concern, with potential impacts on growth and development, academic performance, and social relationships.

Prevalence and incidence rates of eating disorders in children and adolescents vary across different countries, cultures, and populations. According to a recent meta-analysis, the estimated prevalence of eating disorders among children and adolescents is 0.3% for anorexia nervosa, 2.6% for bulimia nervosa, and 1.7% for binge eating disorder (Smink et al., 2014). These rates are likely to be underestimated due to underreporting and diagnostic challenges.

The aetiology of eating disorders in children and adolescents is complex and multifactorial. Biological, environmental, and psychosocial factors have been implicated in the development of eating disorders. Genetic factors may play a role, with studies showing that individuals with a family history of eating disorders are at increased risk of developing these conditions (Treasure et al., 2020). Environmental factors, such as societal pressures to conform to idealized body images, may also contribute to the development of eating disorders.

Psychosocial factors, such as low self-esteem and negative body image, may also contribute to the development of these disorders.

The presentation of eating disorders in children and adolescents can vary widely but may include symptoms such as restrictive eating, binge eating, purging behaviours, and excessive exercise (American Psychiatric Association, 2013). Eating disorders can lead to physical complications such as malnutrition, dehydration, and electrolyte imbalances, as well as psychological complications such as anxiety, depression, and social withdrawal.

The treatment of eating disorders in children and adolescents typically involves a multidisciplinary approach, with medical, nutritional, and psychological interventions. Nutritional rehabilitation and weight restoration are often necessary in cases of severe malnutrition, while psychological interventions such as cognitive behavioural therapy (CBT) and family-based therapy are effective in addressing the underlying psychosocial factors that contribute to eating disorders (Lock et al., 2020).

The outcome of eating disorders in children and adolescents can vary widely, with some individuals experiencing full recovery while others may require long-term treatment and support. Early recognition and intervention are crucial in improving outcomes, particularly in terms of reducing the severity and impact of physical and psychological complications.

	Anorexia Nervosa	Bulimia Nervosa
Description	Weight loss is associated with abnormal beliefs and preoccupation regarding weight and/or shape.	A disorder characterized by recurrent binges and purges, a sense of lack of control, and morbid preoccupation with weight and shape.
Epidemiology	Prevalence 0.3% in adolescent girls. Lower rates in boys and pre-pubertally.	Rarely occurs pre-pubertally, is much more common in girls, often comorbid with depression. Many people with bulimia are of normal weight.
Assessment	Family and individual, eating, factors contributing to and maintaining the disorder, comorbidity, detailed risk assessment, full physical assessment and investigations, and motivation to change.	Similar to anorexia nervosa, with a focus on a binge and purge behaviours.
Management	A multidisciplinary approach, early intervention, family involvement, restoration of healthy weight, meal planning, education on nutrition, family and individual therapy, treatment comorbidity, inpatient or day patient care if needed, school liaison, relapse prevention.	Establish clear structures and boundaries, CBT adapted for adolescents, address physical health concerns, and fluoxetine as an adjunct in older adolescents if necessary.

Other Eating Disorders

Avoidant/Restrictive Food Intake Disorder (ARFID) is a DSM-5 and ICD-11 diagnosis characterized by persistent failure to meet appropriate nutritional and/or energy needs. This may lead to significant weight loss or failure to achieve expected weight gain, nutritional deficiency, dependence on enteral feeding or oral nutritional supplements, and marked interference with psychosocial functioning. ARFID is not characterized by disturbances in thoughts regarding weight and shape or by weight loss behaviours, and it cannot be attributed to a medical condition or better explained by another mental health disorder.

Pica is a condition in both ICD-10/11 and DSM-5 where an individual persistently eats non-nutritive substances for more than one month, at a developmentally inappropriate age. Common substances ingested include dirt, stones, hair, faeces, plastic, paper, wood, and string. Pica is particularly common in individuals with developmental disabilities and may be dangerous or life-threatening, depending on the substance ingested. Consequences may include toxicity, infection, or gastrointestinal tract ulceration/obstruction. Hypothesized causes of pica include nutritional deficiencies, cultural factors, psychosocial stress, malnutrition and hunger, and brain disorders.

Rumination Disorder, also known as Rumination-Regurgitation Disorder in ICD-11, is characterized by voluntary or involuntary regurgitation and re-chewing of partially digested food. This occurs within a few minutes after eating and may last for 1-2 hours. Regurgitation appears effortless and is preceded by belching. Typical onset is between 3-6 months of age and may persist for several months before spontaneously remitting. Rumination Disorder also occurs in older individuals with intellectual disabilities. The condition may result in weight loss, halitosis, dental decay, aspiration, recurrent respiratory tract infections, and sometimes asphyxiation and death in 5-10% of cases. Causes include intellectual disabilities, gastrointestinal tract pathology, psychiatric disorders, and psychosocial stress. Treatment involves a physical examination and investigations, behavioural methods, and nutritional advice.

An Understanding of How Eating Disorders Relate to Behaviours (e.g. Self-harm, Refusal to Attend School etc.) and Contexts (e.g. Pre-school Behaviours)

Eating disorders are complex mental health conditions that can affect individuals of all ages and backgrounds. They are characterized by abnormal eating habits and distorted attitudes towards food and body weight, often resulting in significant physical and psychological consequences.

Some common behaviours associated with eating disorders include:

• Self-harm: Individuals with eating disorders may engage in self-harm behaviours such as cutting, burning, or scratching as a way to cope with emotional distress or to feel a sense of control.

• Refusal to attend school: Eating disorders can significantly impact an individual’s ability to participate in daily activities, including attending school. Fear of being judged or criticized, low self-esteem, and physical symptoms such as fatigue and weakness can all contribute to school refusal.

• Obsessive-compulsive behaviours: Some individuals with eating disorders may exhibit obsessive-compulsive behaviours such as constant weighing, counting calories, or excessive exercising as a way to control their weight or shape.

In the context of preschool-aged children, eating disorders are less common but can still occur. Some signs that a child may be struggling with disordered eating behaviours include refusing to eat certain foods, becoming excessively upset or anxious around mealtimes, or expressing negative feelings about their body.

It’s important to note that eating disorders can have serious physical and psychological consequences if left untreated. Early intervention is crucial in order to help individuals recover and develop healthy coping mechanisms. Treatment typically involves a combination of therapy, nutrition counselling, and medical management, and can be tailored to meet the unique needs of each individual.

In summary, eating disorders in children and adolescents are a serious mental health concern, with potential impacts on physical and psychological health, growth and development, and social functioning. Early recognition and intervention are crucial in improving outcomes, with a multidisciplinary approach including medical, nutritional, and psychological interventions being the primary treatment approach.

References:

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
2. Lock, J., Le Grange, D., Agras, W. S., Fitzpatrick, K. K., Jo, B., Accurso, E. C., Forsberg, S., Anderson, K., Arnow, K. D., Stainer, M., Hill, L., & Stone, W. L. (2020). Can adaptive treatment improve outcomes in family-based therapy for adolescents with anorexia nervosa? Feasibility and treatment effects of a multi-site treatment study. Behaviour Research and Therapy, 126, 103547. https://doi.org/10.1016/j.brat.2019.103547
3. Smink, F. R. E., van Hoeken, D., & Hoek, H. W. (2014). Epidemiology of eating disorders: Incidence, prevalence and mortality rates. Current Psychiatry Reports, 16(5), 1–8. https://doi.org/10.1007/s11920-014-0481-8

Treasure, J., Nazar, B. P., Intemann, T., & Lopez-Polycarpou, J. (2020). Families in society: Eating disorders. Current Opinion in Psychiatry, 33(6), 524–529. https://doi.org/10.1097/YCO.0000000000000643