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• Anne is a 14-yo who lives with her two professional parents, and who enjoys doing ballet
• She is brought to see you due to their concerns about weight loss.
• She has always been a perfectionist, and teachers have always praised her for getting good marks as well as her perfectionism.
• Stressors this year include academics, conflicts with parents and peer issues
• Due to teasing by peers about being fat, she started skipping meals, and began losing weight
• Now parents are concerned about her weight loss, but she can’t seem to stop losing weight…

• Brianna is a 14-yo teenager who lives with her single mother
• She is brought to see you for a yearly physical exam.
• However, you notice that her breath is extremely bad, and that her teeth appear to be eroded
• Stressors include ongoing conflict between parents (despite their being separated) as well as peer and school stresses
• She finds that binging helps her cope with her moods, and thus she binges on chips, ice cream and other junk foods. She learned from a classmate that by making herself vomit, she can avoid gaining weight

• Up to 90% of teenage girls and many teenage boys will try to diet, however, only a small number develop an eating disorder
• Predisposing factors include:
  • Biological
    • Family history of an eating disorder or mood disorder
  • Psychological
    • Underlying comorbidity such as anxiety or depression
    • Fears of maturity
    • Personality traits such as perfectionism and low self-esteem,
  • Social
    • Reduced emotional expression within family - absence of family meals
    • Being sensitive to peer pressure to look and act a certain way,
    • Being sensitive to cultural influences and societal pressure focused on having a thin body ideal. 
    • Participation in sports or activities that put a preference on certain body weight and shape (e.g. models, gymnasts, ballet dancers, etc.)

Take parental concerns seriously. Children/youth tend to underreport their issues, so be respectful of parent intuition or concern regarding their child’s nutrition.

Possible screening questions include…

If these questions screen positive, then consider further assessment:

Questions for comorbid mood/anxiety problems

• How is your mood? Any problems with your mood? Any problems with anxiety?
• Any problems with sleep? Energy? Concentration? Appetite? Loss of interests?

Anorexia nervosa

• Preoccupation with food or weight
  • Change of eating pattern to “healthy eating” e.g. Vegetarian, vegan, cutting out “fast food”, etc.
  • Focus on food labeling
  • Increased interest in food items/cooking
  • Frequent weighing / mirror gazing / body checking (suggesting increased preoccupation with weight)
• Restrictive behaviours
  • Patient not having meals with the family
  • In the morning, patient may say: “I ate before you got up”, when in reality, the patient did not eat at all
  • Baggy clothes (to hide loss of weight)
• Thoughts
  • Body image distortion
  • Dissatisfaction with body
  • Obsessive-compulsive thoughts around food
• Behaviours
  • Food rituals – moving food round on plate, cutting into small pieces, small bites, excessive chewing, spitting
  • Problems eating in public

Note: Symptoms of binging/purging can also be seen in anorexia nervosa

Bulimia nervosa

• Binging and purging behaviours
  • Family’s food disappearing more quickly than usual
  • Food wrappers, plates and other food items in room
  • Using bathroom immediately after eating (in order to induce vomiting
  • Toilet bowl stained with emesis (i.e. vomit)
  • Compulsive exercising (in order to burn off calories)
  • Self-induced vomiting
    • Dental erosion
    • Parotid hypertrophy
• Impulsivity symptoms seen in patients with BN such as:
  • Legal problems
  • Drug/alcohol abuse
  • Mood disturbances
  • Sexual hyperactivity
  • Higher rate of suicide attempts (risk augmented by impulsivity and substance use)

DSM-5 Criteria for Anorexia nervosa

• Persistent restriction of energy intake leading to significantly low body weight (in context of what is minimally expected for age, sex, developmental trajectory, and physical health
• Intense fear of gaining weight / becoming fat, or persistent behaviour that interferes with weight gain (even though significantly low weight).
• Disturbance in the way one's body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight
• Subtypes:
  • Restricting type
  • Binge-eating/purging type

DSM-5 Criteria for Bulimia nervosa

• Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
• Eating, in a discrete period of time (e.g. within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.
• A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating).
• Recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.
• The binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for three months.
• Self-evaluation is unduly influenced by body shape and weight.
• The disturbance does not occur exclusively during episodes of Anorexia Nervosa.

• Eating disorders are not diagnoses of exclusion.
• Symptoms and cognitions are not always apparent in the beginning, but may become more overt over time.
• If the patient does not fulfill DSM-5 criteria, be aware of potential alternative diagnoses such as the following (non-exhaustive) differential diagnoses

Findings on physical exam may include, but are not limited to the following:

• Most patients with an eating disorder in primary care will have normal laboratory results (i.e. lab results may not accurately indicate how severe the illness is), and this is especially true for anorexia nervosa
• Normal lab results should not be interpreted as reassuring in the context of severe ED symptoms and weight loss
• Rather, normal lab results are assessed primarily to determine the need for hospitalization.
• In summary, do not be less vigilant in the face of normal vital signs and lab investigations!

Baseline laboratory may include:

• Referral to your local eating disorder program if criteria are met.
  • Eating Disorders Programs generally consist of a team approach with:
  • Physician(s) (such as family doctors, paediatricians or psychiatrists)
  • Therapist(s) (such as psychologists, or social workers)   
  • Dietitian(s)
  • The family, which is the primary resource in the child’s recovery process
• Typical treatments for eating disorders include:
  • Family based treatment (FBT)
    • Empirically validated treatment with manualized approach performed by an FBT trained therapist.
    • Focus is on weight restoration.
    • It is less studied in bulimia nervosa wherein DBT (dialectic based therapy) is thought to be effective
  • Emotion focused family therapy (EFFT)
    • Also has been used with success
  • Individual counseling/therapy
    • Helps a person to learn more about eating disorders, and examine some of the difficult feelings that lie underneath
    • Useful with comorbid mood/anxiety issues as well
    • They will work on improving their self-esteem and developing new coping strategies.
  • Motivational enhancement approaches also help the patient to become motivated to recover from an eating disorder.
  • Family therapy:
    • Education about eating disorders, and helping parents develop the tools and strategies needed to support their child’s recovery. Once the eating disorder behaviours have improved, family work may also focus on reducing any other stress in the family, and on adolescent issues in general.
• Referrals to other specialists may be subsequently indicated for treatment of comorbid psychiatric disorders.

Medication

Anorexia nervosa

• There are no medications proven to treat anorexia nervosa per se
• Atypical antipsychotics may be useful for symptoms such as overwhelming anxiety that can cause patients to become ‘stuck’ and ‘rigid’ in their disease process.
• Examples
  • Olanzapine
• Once weight has been restored, if there are comorbid mood/anxiety disorders, then SSRI's may be helpful
• Until weight is restored “food is the best medication”.

Bulimia nervosa

• SSRI’s, at relatively higher doses, have shown some efficacy in binge reduction

• Patient is not getting better outside of the hospital despite support from their family and professionals
• Patient has severe psychiatric comorbidity, and/or inadequate family support.

• Criteria will be tightened in the face of:
  • Younger children (<12)
  • Families unable to provide strong containment
  • Youth who are ‘unmotivated’ or psychiatrically unstable
  • Youth who experience severe dysfunction in other domains

Note that these criteria are guidelines only and must be considered within the overall context.
 

• When to refer to a specialized treatment program:
  • Lack of progress despite attempted intervention
  • Chronicity of > 6-12 months
  • Significant comorbidity
  • Medical instability (may need to send patient to the ER)
• With many programs, it may be possible to ask for a telephone consultation if the provider is uncertain how to proceed

• Primary care providers play a key role in early identification of eating disorders
• Early identification and prompt effective response is essential in mitigating the risk of chronicity, biopsychosocial morbidity and mortality
• Primary care providers can refer patients to resources for their eating disorders, and play an ongoing role with monitoring, support and case management

Crow, S.J., Peterson, C.B., Swanson, S.A., Raymond, N.C., Specker, S., Eckert, E.D., Mitchell, J.E. (2009) Increased mortality in bulimia nervosa and other eating disorders. American Journal of Psychiatry 166, 1342-1346.
 

Hudson, J. I., Hiripi, E., Pope, H. G. & Kessler, R. C. (2007). The Prevalence and Correlates of Eating Disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3), 348-358.

Khalifa I, Goldman R. Anorexia nervosa requiring admission in adolescents. Canadian Family Physician, Feb 2019, 65(2): 107-108. 
http://www.cfp.ca/content/65/2/107

Sullivan, P. (2002). Course and outcome of anorexia nervosa and bulimia nervosa. In Fairburn, C. G. & Brownell, K. D. (Eds.). Eating Disorders and Obesity (pp. 226-232). New York, New York: Guilford.

Written by Dr. Stephen Feder MDCM, MPH, CCFP, Chief, Division of Adolescent Medicine, Medical Director, Regional Eating Disorders Program for children and Youth, CHEO and members of the eMentalHealth.ca Primary Care Team, which includes Dr’s M. St-Jean (family physician), E. Wooltorton (family physician), F. Motamedi (family physician), M. Cheng (psychiatrist).

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