|
|
Features Departments Information |
 Tami Benton, MD
If you have questions about the diagnosis and treatment of a disorder or are interested in case consultation, please contact us. No physician or patient names will be used in the articles. Responses will be written by selected members of the Department of Child and Adolescent Psychiatry. |
The Doctor is in— Questions and answers about behavioral and TAMI BENTON, MD aSpring 1997 When does regular dieting become an eating disorder? I have been caring for a 13-year-old girl for many years who has always been healthy, bright and well-adjusted. I have noticed, however, over the last 12 months that she has not grown or developed menses and that she has, in fact, lost seven pounds. She is involved in competitive gymnastics and has recently asked for advice about losing approximately five pounds. She has always been small for her age; her parents report that she seems to eat well except for a recent decision to stop eating meat and to remove all fat from her diet. Her parents are a little concerned about her height, but they believe that she is well. I have completed a thorough medical evaluation and nutritional assessment with all results being negative I am concerned, though, that she may be developing an eating disorder. How can I assess this given her young age, athletic activities and the family’s lack of concern about the issue? Dr. Tami Benton responds: You are absolutely correct to question the possibility of an eating disorder. The presence of eating disorders is frequently overlooked in this age group due in part to the incorrect belief that athletic girls, particularly gymnasts, are somehow given a “reprieve” from puberty. Delayed growth and amenorrhea are accepted as normal in this population. At the same time, the absence of these symptoms (i.e., loss of menses) can make the diagnosis easy to miss. The current criteria for anorexia nervosa in the Diagnostic and Statistical Manual (DSM-IV) require that an individual refuse to maintain weight at or above a minimally normal weight for age (85% of that expected, or failure to gain during a period of normal growth), intense fear of becoming fat even though underweight, body image distortion, and amenorrhea (missed three cycles). The disorder may be classified either as restricting type or binge-purging type. For bulimia nervosa, there must be recurrent episodes of binge eating or recurrent inappropriate compensatory behaviors to prevent weight gain, such as exercise, laxatives, etc. These behaviors must occur at least twice a week for three months. Body image distortion can be difficult to assess if the norm for a particular athletic event, such as gymnastics, happens to be thinness. Unfortunately, societal support for being extremely thin can reinforce striving to lose weight. Recent studies in the US, the UK and Canada confirm that dieting behavior and dissatisfaction with body shape is common. In Canada, increasing numbers of girls see themselves as overweight as age increases. By 18 years of age, more than 50% see themselves as too fat even though 80% of them are of normal weight. A recent US study found that nearly half of underweight girls wished to lose weight and that 80% of this underweight sample were unhappy with their weight. In general, studies consistently show that between 50% to 70% of normal-weight girls consider themselves to be overweight. Although epidemiologic data is limited, the onset of eating disorders is occurring in younger age groups. Interviews with 6- to 12-year-old girls about dieting, weight and body-shape revealed that 60% of them believed they were overweight, and 35% reported being on at least one diet. As pediatric health care providers, we need to be aware that dieting is ubiquitous among teens and common among preteens. The issue for the clinician is deciding what signs suggest that dieting is outside of the norm, while not losing sight of the fact that dieting of any sort carries with it significant risks. Here are some of the warning signs:
The presence of any of these symptoms should prompt a thorough assessment, particularly because of the direct correlation between longer duration of illness and reduced response to treatment. The key factors to be evaluated in order to establish the diagnosis include weight history, eating behavior, history of binge eating or purging, diet history, use of diet aids, overexercise patterns, body image, and in girls, menstrual history. The following are good screening questions:
If you suspect an eating disorder, the type of disorder and severity will need to be assessed. Multiple studies have shown that female athletes in sports that emphasize a thin body or appearance are more at risk for eating disorders than participants in other sports. Female gymnasts, figure skaters, distance runners and swimmers are particularly vulnerable. Among boys, wrestlers are at greater risk. Fortunately, there are some screening assessment tools that can be included as part of your evaluation of youngsters in high-risk sports. Your assessment may find children who do not meet the diagnostic criteria for anorexia nervosa or bulimia but who may indicate symptoms of atypical eating disorders or subsyndromal eating disorders. These patients may, for example, experience weight loss without body distortion or without the preoccupation with weight. Patients who occasionally binge and purge but who do not meet frequency criteria also fit in this category. Although these patients may appear to be less pathologic, they are at risk for the same long-term complications as those who meet the full diagnostic criteria. How can you help your patient? The first step, and often the most difficult given the high rates of denial of illness in patients and families with these disorders, is to engage the family in a collaborative treatment plan. A detailed, thorough, empathic assessment that emphasizes the relationship between behavior, symptoms and signs may facilitate the patient and family’s participation and the transition to a mental health provider. The decision on the need for inpatient or outpatient treatment should be made early. Youngsters with medical complications, those whose weights are more than 25% below their ideal body weight, those who binge-eat and exhibit purging anorexia nervosa, or those who have been ill for more than two years will likely need hospitalization. Day therapy may also be an option to meet intensive treatment needs. More stable children can be treated as outpatients. Most patients with bulimia do not require hospitalization and can benefit from some of the briefer therapies, including time-limited group therapies, cognitive behavioral therapies or interpersonal therapy techniques. Medications have been shown to have limited utility in anorexia nervosa unless the patient suffers from concomitant psychiatric disorder. Thirty to fifty percent of patients with anorexia nervosa later develop symptoms of depression; antidepressants are appropriate when the patient is no longer in the semistarved state. Prozac has been shown to be effective in reducing the episodes of binge eating and purging in bulimia. The drug of choice, however, remains food. In general, a team approach that includes a mental health expert, a physician, a nutritionist and the family yields the optimal outcome. FOR FURTHER READING 1. American Psychiatric Association: DSM-IV: Diagnostic and Statistical Manual of Mental Disorders, Washington DC, 1994. 2. Powers P: Initial assessment and early treatment options for anorexia nervosa and bulimia nervosa. Psychiatric Clin North Am 1996;19:639–655. 3. Van De Loo DA, Johnson M: The young female athlete. Clin Sports Med 1995; 687–707. 4. Woodside, DB: A review of anorexia nervosa and bulimia nervosa. Curr Probl Pediatr 1995;25:67–89. |