IACAPAP Textbook of Child and Adolescent Mental Health

Chapter

H.1

OTHER DISORDERS

EATING DISORDERS
2016 Edition

Phillipa Hay & Jane Morris

Phillipa Hay DPhil, MD,
FRANZCP
Chair of Mental Health andConsultant Psychiatrist,
Western Sydney University,
Campbelltown, NSW, Australia
Conflict of interest: none
declaredJane Morris MA, MB, BChir(Cantab), MRCPsych
Consultant Psychiatrist, Eden
Unit, Royal Cornhill Hospital,
Aberdeen, Scotland, UK
Conflict of interest: none
declaredThis is the updated version
by Phillipa Hay of the chapter
written in 2012 by Jane Morris
Acknowledgement: art work
was provided by patients in the
EDGE Young People’s group.

Glutony - The Seven Deadly Sins and the Four Last Things. Hieronymus Bosch.
Prado Museum, Madrid
This publication is intended for professionals training or practising in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2016. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial.
Suggested citation: Hay P, Morris J. Eating disorders. In Rey JM (ed), IACAPAP e-Textbook of Child and Adolescent Mental Health.
Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions 2016.

Eating disorders

H.1

1

IACAPAP Textbook of Child and Adolescent Mental HealthT

his chapter will focus on the three main feeding and eating disorders,anorexia nervosa, bulimia nervosa and to a lesser extent binge eating
disorder. Anorexia and bulimia nervosa are two of the most commonand severe psychiatric disorders of adolescence, characterized by the obsessive
drive to lose weight. Other disorders – often described as “feeding disorders”
and seen more often in younger children – are considered here largely in terms ofdifferential diagnosis. Some of these disorders, such as avoidant restrictive foodintake disorder or ARFID, share the psychological sequelae of weight loss and may
evolve into secondary anorexia or bulimia if the obsession with thin body image
develops. This is particularly likely in westernized cultures. Childhood obesity is
not specifically addressed here, although a variety of psychological difficulties may
be associated with its origins and consequences.
In what follows, the term “parent” is used to mean parents, guardiansand careers, while “child” is used to mean both children and adolescents unlessotherwise specified. Sometimes the child is referred to as “she” since the majorityof sufferers are female, but both genders are included. We speak deliberatelyof “parents” rather than just “mothers”, since family carers of both genders canprovide important contributions to recovery. Sometimes the term “adults” is used,indicating that professionals – doctors, nurses and other therapists – are includedin the comment.

The English physician
William Gull (1816-1890) andthe French Ernest-Charles
Lasègue (1816-1883) (below)
are considered to have been
the first to describe almost
simultaneously (in 1873) andindependently what we now
call anorexia nervosa

HISTORICAL BACKGROUND
Anorexia nervosa is a syndrome of obsessional fear of weight gain, manifest
in a range of compulsive weight-losing behaviours. It has been recognised formany centuries, in all societies, even where cultural preference is for a well-fed
appearance. It is believed that some of the medieval christian female saints, suchas St Catherine of Sienna, suffered from anorexia nervosa, whilst Richard Morton
famously described two cases in a paper of 1689. By the late 19th century there
was competition between the English physician William Gull (1874) and theFrench Lasègue, both claiming to have been the first to describe the condition.
While experts still disagree, it would appear that it was Lasègue (1873) who gave
the condition its enduring name “anorexia” in his paper De L’Anorexie Hystèrique.
Feeding/eating problems in children and their key characteristics
•
•
•
•
•
•
•
•
•
•
•
•

Failure to thrive: physical or social causes
Selective eating: extreme faddinessRestrictive eating: child has small appetite and eats a normal range of food but in small
amounts
Functional dysphagia: fear of choking or vomiting—certain foods avoided
Food refusal: refusal to eat rather than searching for thinness
Pervasive refusal syndrome: not only food is refused but also refusal to drink, talk, walkand engage in any form of self-care. May be a consequence of severe trauma
Food avoidance emotional disorder: mood disturbance with weight loss
Obsessive compulsive disorder: eating rituals and other rituals
Weight loss associated with psychostimulants (e.g., for ADHD)
Weight gain associated with antipsychotic medication, which increases appetite
Anorexia and bulimia nervosa
Avoidant/restrictive food intake disorder: lack of interest in eating or food, avoidance
because of the color, smell, texture etc of food.

Eating disorders

H.1

2

IACAPAP Textbook of Child and Adolescent Mental Health

Awareness of the condition was largely limited to the medical profession
until the latter part of the 20th century, when German-American psychoanalyst
Hilde Bruch published her popular work The Golden Cage: the Enigma of Anorexia
Nervosa in 1978. At the same time, clinicians were also becoming aware of a new“ominous variant of anorexia nervosa”, or “bulimia nervosa” as Russell (1979)
described the condition. The name bulimia nervosa was applied to the newly
observed epidemic characterized by dysregulated eating in which binge eating
undermines the sufferer’s attempts to lose weight.

••

DEFINITIONS
Disordered eating is only one of the symptoms of anorexia nervosa andbulimia nervosa. It may be more helpful to consider them as disorders of obsessive
fear of weight gain, involving a range of different compulsions designed to avoid the
dreaded consequence. The term anorexia which literally means “lack of hunger” isparticularly unsuitable for an illness in which the sufferers are constantly obsessedby thoughts – and even dreams – of food, and tormented by calculating how toresist their extreme hunger in order to avoid weight gain.
Restriction of eating is obviously a prominent feature, but there are manyother compensatory behaviors, such as over-exercising, various forms of purging
and repeated checking and reassurance-seeking by weighing, measuring or mirror
gazing, for instance. The precise definition is a matter of some controversy, since
psychiatric diagnosis is evolving. The DSM (American Psychiatric Association,2013) and ICD (World Health Organization, 1992) are gradually moving
closer to describing syndromes that embody statistically valid symptom clusters,
reflect growing genetic and neurological understanding, and predict responses
to treatment. These considerations make it worthwhile, even in children andadolescents, to divide the disorders into anorexia nervosa and bulimia nervosa,Table H.1.1

Body Masss Index
(BMI)

•

•

Body mass index(BMI, Quatelet’s
index) is a commonlyused index of
adiposity that controls
for the effectsof height whenassessing weight
BMI = weight in kg
divided by height (inmeters) squared
BMI is used in
actuarial tables, sincea BMI of 20 to 25
is associated withlower morbidity andmortality
Children andadolescents are ina state of perpetualand irregular growth,
so that BMI may beblind to a fall-off in
expected height aswell as weight.

Symptoms used for the diagnosis of anorexia and bulimia nervosa
Anorexia nervosa

Bulimia nervosa
Abnormal eating•

Restricting food intake and weight loss to less than thatminimally expected for age, sex and developmental
stage*••

Recurrent episodes of binge eating that areassociated with as sense of loss of control and theepisode is an unusually large amount of foodFear of gaining weight•

Persistent behaviour to avoid weight gain (e.g., dieting,exercising—restricting type—vomiting, purging, using
laxatives—binge eating/purging type)••

Compensatory behaviour in order to prevent weightgain after binging (e.g., vomiting after binging,
purging—purging type—alternating periods of fasting,excessive exercise—nonpurging type)
Weight is usually average or above average

Body shape distortion••

Undue influence of one’s body weight or shape on self-evaluation
Lack of recognition of the seriousness of the problem*DSM-5 has no upper limit for underweight status. Binge-eating disorder solely requires recurrent binge eating with marked
distress and specifiers of features of the binge eating suh as disgust.

Eating disorders

H.1

3

IACAPAP Textbook of Child and Adolescent Mental Healthacknowledging some overlap and acknowledging also that using weight or bodymass index (BMI) to distinguish between the two may not be an accurate proxy forthe nature of the core psychological disorder. Young people with bulimia nervosa,who by definition have a normal weight, share the drive for thinness. However,people who maintain low weight for long periods by restriction alone or with
exercise may be genetically different from those who end up bingeing and purging(Kiezebrink at al, 2009).
Table H.1.2

Comparative symptoms in the eating and feeding disorders

DisorderWeightBody image
concerns

Presence of
bingeing

Famineinducedstarvation

Low

No

When foodavailable

Weight lossof physicalillness

Low

No

Not usually

Low, andusually
stableYes, marked,
althoughoccasionallythinness andstarvation
are valued
for religious
reasons

Anorexia
nervosa,
restrictive type
(AN-R)

Purging

Comments

No

Starvation
brings its own
psychologicalconsequencesNo, though vomiting anddiarrhea may occur aspart of the illnessNoNo, by definition.
However, compulsive
exercise is often part ofthe picture

Deliberate
self-harm may
be used toself-punish
or if obligatory
refeeding is
imposedYes, by self-induced
vomiting, use oflaxatives, compulsive
exercising or overactivity

See above

Anorexia
nervosa, binge
purge subtype(AN- BN)Low andfluctuating

Yes, as for AN-R

Yes, but usuallysmaller binges
than in normal
weight AN-BN

Bulimia
nervosa

NormalYes

Yes, often
massive

Yes

Eatingdisorder in
Psychosis

Low ornormalSometimes.
Explanations
may be bizarre
or delusional

Occasionally

RarelyAutistic
spectrum
disordersLow,normal or
overweight

Sometimes
and may be
eccentric

OccasionallyOccasionally

Avoidant/
restrictive foodintake disorder

May be low
or fallingNo

Not usually

Not usuallyObsessive
compulsive
disorderLow,normal or
overweight

Often (bodydysmorphia)

Variable

Variable

Exercise
may becomecompulsive also

All habits may
become subject
to obsessionality

AN-R: anorexia nervosa, restrictive type; AN-BN: anorexia nervosa, binge purge type.

Eating disorders

H.1

4

IACAPAP Textbook of Child and Adolescent Mental Health

Disorders of concern about body image are increasingly seen in pre-pubertal
children of both genders. Nomenclature is misleading to non-specialists. On
one hand there are so-called “feeding” disorders, such as avoidant restrictive foodintake disorder, where food is shunned for reasons other than its fattening capacity,
occurring in the context of other physical and psychological disorders. On theother hand anorexia nervosa is characterized by a deliberate drive for thinness.
Avoidant restrictive food intake disorder, characterised by an obsessive foodavoidance without body image concern, can closely resembles anorexia nervosa.

EPIDEMIOLOGY, GENDER AND CULTURE
Anorexia nervosa
The average age of onset for anorexia nervosa is around 15 to19 years. It
is the commonest cause of weight loss in teenage girls and the commonest cause
of inpatient admission to child and adolescent services. Eric Stice and colleagues(2013) found that around 1% of 20 year old women had a life history of anorexia
nervosa or atypical anorexia. This is close to the incidence reported in a rangeof epidemiological studies. Similar outcomes have been reported in Australianadolescents. However, having a full or subthreshold eating disorder in adolescencehas been found to be associated with increased risk of other mental health problems
in adulthood (Patton et al, 2003).
Whilst more than 90% of anorexia sufferers are female when prevalence ismeasured across the life span, in young children the sex difference in prevalencenarrows (Madden et al, 2009). There is also growing awareness that body image
concerns may take a different form in adolescent boys. Some male sufferers
describe striving for a muscular body rather than merely a thin one. Compulsive
exercise rather than food restriction may be the earliest sign of the disorder in thesecases. Some boys become addicted to exercise without body image concerns at
first, although these often develop later.
Rationale for food avoidance varies across cultures, with religious
explanations for fasting and self-denial prevalent in some, whilst Blake Woodside(2003) has described Indian patients who endorse gastro-intestinal symptoms as
their reason for not eating. Interestingly, if these individuals are treated in groups
with sufferers from Western anorexia, they often develop fear of becoming fat andbody image concerns that replace their earlier somatic concerns. Even in Westernsettings, some patients start out with somatic or ascetic preoccupations but go on to
re-ascribe their behavior to the media-endorsed value of thinness.
The epidemiology of avoidant restrictive food intake disorder is unknown.
However in very young children it may be a sizable minority of presentations toclinics and is more common than anorexia nervosa in boys (Nicely et al, 2014).

Bulimia nervosa and binge eating disorder
The emergence of bulimia nervosa in the late 20th century correspondswith both media glorification of a thin body image, for both bulimia nervosa andbinge eating disorder, with increasing availability of palatable high calorie snack
food, and the loss of ceremonious communal mealtimes. The peak age of onset
is similar to anorexia nervosa – 15-20 years (Kessler et al, 2013). Symptoms are

Eating disorders

H.1

Are eating disorders
becoming morecommon?
Anorexia nervosa is foundin all historical periods andgeographical areas. Clinicalincidence studies indicate
there has most likely beena small increase in thetwentieth century in young
women.
Bulimia nervosa and binge
eating disorder emerged
in increasing numbers indeveloped countries in thetwentieth century, reflecting
both the increased
availability of food andvalue of slimness.
The Island of Fiji is typicalof the global spread ofeating disorders (Pike andDunne, 2015). Fiji did nothave television for many
years. It experienced anincrease in eating disorders
after the introduction of TV,
but largely of the bulimia
nervosa and binge eating
disorder type. Despite theincreased prevalence ofdieting, the average BMI of
the population increased.
The most rapidly growing
problem worldwide in thecommunity is recurrent
binge eating

5

IACAPAP Textbook of Child and Adolescent Mental Healtheasier to conceal than in anorexia nervosa, however,and the average medical presentation does not occur
until the sufferer has been aware of the disorder for up
to 10 years.
Up to 12% of adolescent girls may experiencebulimia nervosa, binge eating disorder or a specified(OSFED) or uspecified feeding and eating disorder(UFED) form of bulimic or binge eating disorders(Stice et al, 2013). It is not yet know how many boys
are affected, but an increasing emphasis on boys’
appearance may be contributing to an increase, and it
is believed that boys in the gay community are more
vulnerable to develop bulimia nervosa. In studies ofpeople over the age of 15 there is an increasing andlarge minority of men with eating disorders and binge
eating disorder in particular (Mitchison et al, 2014).

AETIOLOGY AND RISK FACTORS
Genetics and neurobiology
There is substantial evidence that complex genetic factors predispose to
the development of the various eating disorders – not necessarily corresponding
to accepted diagnostic categories (Mitchison et al, 2014). Family studies havedemonstrated the aggregation of cases within families, whilst twin studies of bothanorexia and bulimia indicate greater concordance for monozygotic than dizygotic
twins. Scandinavian studies (Gillberg & Råstam, 1992) suggest an association
between anorexia and autistic spectrum conditions such as Asperger’s syndrome,particularly in male sufferers.
Where there is anorexia in a family member, it is often found that otherrelatives frequently show high perfectionistic and obsessive personality traits.
Rather than inheriting an eating disorder per se, individuals appear to inherit
personality traits of perfectionism and high anxiety, and reduced central coherence(the cognitive tendency to perceive fine detail rather than the “bigger picture”).
Where there is bulimia nervosa or binge eating disorder, other relatives seem
more likely to be vulnerable to obesity, depression and substance misuse. It has
also been observed that eating disorders often complicate or are comorbid withborderline personality disorder.
Looking to the future, research is increasingly investigating the relationships
between disturbed gut homones and appetite regulation in eating disorders.
Potentially, the impact of starvation on gut microbiota may help explain changes
in satiety and taste perception of people binge with anorexia nervosa.

Environmental factors
Families where at least one person has an eating disorder may contributeboth genetically and environmentally. Since eating disorders occur in a familial
environment of increased genetic risk, it becomes difficult to dissect the genetic
and environmental contribution to the illness.

Eating disorders

H.1

6

IACAPAP Textbook of Child and Adolescent Mental HealthWork showing a high incidence of perinatal loss in families of teenagers withanorexia (Shoebridge & Gowers, 2000) suggests a causative role for pathologicalgrief, but the study did not take into account the possibility that the mothers
concerned were themselves of low weight and so more likely to miscarry. The
same study found that girls with anorexia nervosa were less likely than controls tohave spent a night away from home before age 12. This may reflect an empathic
response to the personalities of the children concerned rather than be a cause of
the disorder.

Triggers
Puberty and adolescence are undoubtedly major triggers (Mitchison etal, 2014). Young people simultaneously experience the challenge of living witha changing and growing body, new hormone-driven urges, the new cultural
expectations, sexual, intellectual and social demands, and the need to process allthese with a brain that is itself anatomically and chemically in a state of flux.
However, it may be observed that these are non-specific triggers. In young people
with different pre-disposing vulnerabilities, such triggers may precipitate different
disorders, such as a depressive illness, obsessive compulsive disorder or substancemisuse. In particular, people with binge eating disorder and bulimia nervosa may
develop a problem when binge eating is used to alleviate low mood.
In particular, the onset of both anorexia and bulimia nervosa may betriggered by identical precipitants and may even appear similar for some time.
Teenagers with bulimia nervosa may initially lose some weight before binges undo
this, and some sufferers follow a fluctuating course, moving between different
diagnoses. This unsatisfactory state of affairs makes it difficult to use current
definitions and classifications to distinguish between disorders which may wellhave different genetic roots and perhaps respond to different treatments.

Figure H.1.1

Eating disorders

A model of the development of anorexia nervosa

H.1

7

IACAPAP Textbook of Child and Adolescent Mental Health

CLINICAL FEATURES AND DIAGNOSISAnorexia nervosa
Psychiatric classifications such as ICD-10 and DSM-5 define anorexia
nervosa as:•••

Restricted eating leading to deliberate weight loss, or failure to growand increase in weight and height as expected according to age andgender with
Fear of weight gain and/or persistent failure to maintain a normal
weight for age and height, andDisturbance of body image, which translates any distress into aperception that their body is too fat.

For patients to meet the diagnostic criteria, there should be at least a loss of
15% of minimum normal weight or, according to ICD-10, a BMI below 17.5 infully grown adults. Menstruation is typically absent (though women who take thecontraceptive pill may have withdrawal bleeds). In males, low testosterone causes
atrophied genitalia and absence of morning erections. In the restrictive subtype, lowweight is achieved by starvation alone or with over-activity. The binge-purge subtype
involves purging by means of vomiting, use of laxatives, diuretics or slimming pills
to get rid of calories. It is widely agreed that these criteria exclude many who
may fit into the spirit of the diagnosis and DSM-5 has introduced a new category
under the other specified feeding or eating disorder (OSFED): atypical anorexia
nervosa where the person may have lost a substantive amount of weight but is nottechnically underweight.
In children and teenagers it is even more important not to adhere to strict
definitions of normal weight and DSM-5 does not specify an upper limit ofunderweight criteria. This recognises that weight and height are moving targets
in a growing body. A healthy 12 year old boy on the 50th centile for both weightand height will have a BMI of around 17.5 – which would be underweight formost adult women. On the other hand the teenage daughter of tall parents may
have a BMI within the normal range but have severely restricted her intake so that
her metabolic rate slows down; she fails to grow and experiences severe obsessive
symptoms. She would now be diagnosed with atypical anorexia nervosa.
It is best practice to plot the weight and height of young patients onstandard growth charts to compare progression and trends with what is expected.
Information about parental height improves the perspective in which growth isassessed. The outward weight and height trajectory of a child is our best proxy forthe healthy nutrition of the developing brain within. As already discussed, current
definitions and classifications fail to discriminate between probable differencesin genetic susceptibility, but adolescents whose eating disorder causes starvationmust be re-fed to prevent physical and neurological stunting, regardless of precise
aetiology.
Anorexia nervosa patients are usually protective of their habits, or so
focused on losing weight they no longer notice or admit the physical and social
consequences of starvation, so it is important to also hear from parents, siblings orother informants. It is recommended to document the timeline of weight loss, theEating disorders

H.1

What is a binge?
The definition of a binge is:•
A quantity of foodconsumed at a single
sitting, which is•Considerably larger
in amount than what
would be reasonably
consumed at the timeAND•
There is a sense ofloss of control overthe consumption of
the food.
Sufferers may eventually
give up trying to control
binges and may evenplan them. Some patientswith anorexia describe
any unplanned foodconsumption a as binge.
In bulimia nervosa there is
generally purging behavior
after a binge and sufferers
may use the term bingeto refer to the purging
behavior itself. In ICD-11
the requirement for the
binge to be objectively
large may be removed.

8

IACAPAP Textbook of Child and Adolescent Mental HealthSita
14 year old Sita presented to the adolescent mental health clinic after multiple gastrointestinal investigations had failed to explain her weight loss, constipation and abdominal pain.
She was assessed by a psychologist who raised the possibility of sexual abuse—this caused
massive offence to Sita’s parents. She had gradually stopped eating every food type that she
associated with stomach pain and now existed on a very restricted range of bland foods, indiminishing quantities.
She was hospitalized in a pediatric ward where she declined almost everything on themenu and was eventually naso-gastrically fed (with her and her parents’ consent) as apragmatic measure to re-nourish her. However, as her weight increased Sita became very
distressed and asked to go home as she could not tolerate “getting fat”. She was reviewed bya child psychologist who made the diagnosis of anorexia nervosa.

patient’s highest and lowest weight, preferred weight, and menstruation. Cliniciansneed to know about current daily food intake, liquids consumed, including low
calorie and caffeine-containing drinks, alcohol, drugs and medications. Is there
self-induced vomiting, compulsive activity and exercise, use of laxatives, diet pills,
herbal medicines, and deliberate exposure to the cold? These behaviors interferewith health and social functioning as well as prevent weight gain. Sufferers
typically engage in a mixture of both body-checking behaviors (repeated weighing,measuring, mirror gazing, touching, prodding, pinching, trying on particulargarments and comparison with others) and avoidance (such as not appearing in

Example of weight graphAt the end of primary school, this girl wasamongst the tallest of her peers, though inhealthy proportion in terms of weight for height.
However, she developed anorexia nervosa andlost weight over a matter of months. From theonset of the illness she also stopped gaining
height and was overtaken by her classmates.

Eating disorders

H.1

9

IACAPAP Textbook of Child and Adolescent Mental Health

SCOFF questionnaire (Morgan et al,1999)
•
•
•
•
•

Do you make yourself Sick because you feel uncomfortably full?
Do you worry you have lost Control over how much you eat?
Have you recently lost more than One stone (6kg) in weight over a 3 month period?
Do you believe yourself to be Fat when others say you are thin?
Would you say that Food dominates your life?

swimming costumes or without makeup, or being unable to take a bath because oflooking down on their body). Social withdrawal and conflict are both common,and shy, obedient girls may become verbally or physically violent, or self-harming
if their eating disordered rules are challenged. Those with bulimic difficulties may
become so desperately hungry that they steal or hoard food.
Surprisingly, even very low weight can be missed when young patients dress
and make up smartly. Family members who see the person daily may not noticeinsidious changes. It is helpful if there is a climate of awareness in schools andamong primary care clinicians. We can make it a habit to routinely ask young
patients about their eating habits. The SCOFF questionnaire (Morgan et al, 1999)
is a validated, brief instrument to screen for eating disorders, similar in concept
to the CAGE questionnaire for alcohol problems (see Box). It is important toactively seek the psychological symptoms of eating disorders rather than proceed
simply by excluding physical diseases. In our concern not to overlook diabetes,
thyrotoxicosis, cystic fibrosis, bowel diseases, malignancies or other causes ofweight loss, young people are often over-investigated while the possibility ofanorexia nervosa is neglected.

Bulimia nervosa
This diagnosis is usually made from the binge-purge behavior of a normal
weight sufferer – the BITE questionnaire (see Appendix) is a useful way toassess the range and severity of symptoms. Menstrual irregularities, fertility
problems, unexplained seizures, “funny turns”, and chronic fatigue should alert
us to a possible eating disorder. Gastro-intestinal complaints can be both theconsequence of and the excuse for an eating disorder (as in the case vignette ofSita). More psychological presentations include depression, anxiety, obsessional
symptoms and relationship problems. Girls are of course at higher risk, but boys
with unexplained weight loss should be also asked about diet, exercise and attitudes
to their physique. Observation in a hospital or day clinic may reveal symptoms apatient does not tell clinicians.

Binge-eating disorderThis diagnosis is made where there is recurrent regular binge eating in theabsence of purging, vomiting, fasting or compulsive exercise as compensatory
behaviour. These weight control behaviors may occur but do not meet thresholdfrequency for a diagnosis of bulimia nervosa. Unlike anorexia and bulimia nervosa,body image concern is not a requirement. However, marked distress and at least
three other symptoms consequent to the binge eating (such as guilt and disgust)are required.

Eating disorders

H.1

Usefulquestionnaires andrating scales•
The Eating Disorders
Examination, selfreport version(EDE-Q; Fairburn &Beglin, 1994). This
instrument is freely
available and oneof the most widelyused self-reportquestionnaires;
suitable foradolescents but notfor younger children.
•
Eating Disorders
Inventory-3 (Garner,
2004). Self-rated
questionnaire
covering 12 domainsof eating cognitions,behaviours and social
function; validated foryounger patients andsensitive to change.
•
The Children’s Eating
Attitudes Test (ChEAT;
Maloney et al, 1988).
Version of the adult
EAT, also self-reportquestionnaire•
Morgan-Russell
Average Outcome
Scale (MRAOS;
Morgan & Hayward,1988). Interviewerbased measure of
global outcome inanorexia nervosa (notcopyright).
•
Bulimic Investigatory
Test (BITE; Freeman& Henderson,1997). Self-reportquestionnairevalidated for
adult patients but
also suitable foradolescents; highly
sensitive to change
in bulimic symptoms,
thus useful to trackprogress in treatment(not copyright).

10IACAPAP Textbook of Child and Adolescent Mental Health

Other disorders
DSM-5 specifies five other specified feeding or eating disorder (OSFED)
categories:
•
•
•
•
•

Atypical anorexia nervosa
Subthreshold bulimia nervosa
Binge-eating disorder (of low frequency or limited duration)
Purging disorder, andNight eating syndrome.

People who do not meet criteria for OSFED or avoidant/restrictive foodintake disorder (ARFID) (food avoidance/restriction with physical or psychologicalconsequence in absence of body image concern) may be diagnosed with unspecifed
feeding or eating disorder (UFED). The revision of the ICD (ICD-11) is likely toalso introduce ARFID and subthreshold categories.

INVESTIGATION OF PHYSICAL CONDITIONS ANDPSYCHOLOGICAL SYMPTOMS
Eating and feeding disorders need a multi-disciplinary evaluation involving
physical investigations, food diaries, growth charts, and psychiatric assessment.
Family history and involvement are crucial; it is illuminating to observe a family
meal, preferably in the home. Alternatively, the family can be asked to bring apicnic meal to be eaten in the clinic.
It’s essential to measure and weigh patients – extreme reluctance to beweighed is likely to be a symptom of excessive body image concern. This can help
to explain that patients who co-operate with physical monitoring can be moresafely managed as outpatients that those who are uncooperative, where the severityof starvation can only be estimated. Physicians sometimes decline to admit
patients whose diagnosis is a psychiatric one, and may need to be supported by
specialist consultation liaison services, so that treatment for the physical sequelae
of starvation are not undermined by the patient’s psychopathological concerns.
Routine blood tests are helpful in excluding most of the common differential
diagnoses of weight loss. Glucose is low in anorexia (except with comorbid, poorly
controlled diabetes). The thyroid is often protectively and reversibly underactive
in anorexia nervosa, with normal or slightly low TSH, whereas T4 will be highwith suppressed TSH if weight loss is caused by thyrotoxicosis. Electrolytes may
show low (reflecting protein intake) or high urea (reflecting dehydration) and low
potassium (vomiting). Liver function tests may suggest comorbid drug or alcohol
problems, though extreme starvation alone can cause liver damage. Anorexia
often causes anemia, and if white cell count is not low, this may reflect infection.
Neutropenia is usual in starved patients – if significantly below one, the patientneeds to be protected from exposure to infection. ECGs are helpful to monitor
electrolyte and cardiac status. Annual bone density scans, if available, allow
monitoring the risk of osteoporosis but at this stage may not change management.
Young women may become pregnant at an unhealthy low weight andvomiting makes oral contraception unreliable. It is wise always to consider
pregnancy as a possibility in young women with weight change, vomiting andEating disorders

H.1

11

IACAPAP Textbook of Child and Adolescent Mental Health

No to anorexia“I thought this could be a chance to use my suffering
to get a message across, and finally put an image
on what thinness represents and the danger it leads
to — which is death”, said Isabelle Caro, a French
actress and model who died of complications ofanorexia nervosa on 17 November 2010 in Tokyo,
Japan. She was 28 years old.
Caro had received a variety of unsuccessfultreatments. She had suffered from anorexia since she
was 13, and was hospitalized for the first time when
she was 20. At her worst, in 2006, she went into acoma weighing just 25 kg (BMI = 9.2).
Caro used the last years of her life to campaign
against the fashion industry using skinny models. The climax of this campaign was when she posed nude to be photographed
for an anti-anorexia campaign for a clothing company. Images in newspapers and billboards under the headline "No Anorexia”
were released during Milan’s 2007 fashion week. At the time she had a BMI under 12. The fashion industry was under
the spotlight about anorexia after a 21-year-old Brazilian model had died from the disorder. Caro’s pictures caused a stir,sparking much debate. The campaign was initially approved by Italy’s health department, but was subsequently banned by
the advertising watchdog while France's authority told French companies not to use it. Some groups working with anorexia
patients also believed that this campaign was not helpful.
Caro spoke often about anorexia, her efforts to overcome it, and the menace of eating disorders in the fashion industry. She
was working to pass a law in the French parliament that would prohibit models from working if they were too thin.
“No to anorexia” campaigner dies. IACAPAP Bulletin, February 2011, p28.

amenorrhea. If there is both an eating disorder and pregnancy, the patient needs
to be monitored physically, nutritionally and psychologically with great carethroughout the pregnancy and beyond, so that the mother-baby pair can build ahealthy relationship and survive the eating disorder together. Eating disorders, evenif sub-clinical, can impair fertility and increase the risk of damage to an unborn
child. Both pregnancy and labor may be more difficult. Up-to-date information
should be sought about the relative risks of medication versus untreated disorders
during pregnancy and lactation. Mothers who have suffered from an eating
disorder themselves may need support to learn the skills of healthy playful toddler
feeding. It follows that it is always advisable to discuss issues related to conception
in a sensitive and supportive manner.
Always assess mood and anxiety symptoms – this is a helpful way to findcommon ground with patients who reject physical concerns. Moreover the risk of
self-harm and suicide is raised in all eating disorders (Arcelus et al, 2011).

COMORBIDITY
In addition to considering the following conditions as differential diagnoses,
it is important to recognize their co-existence with eating disorders.
Psychological co-morbidity:••

Depression. Low mood and dysphoria secondary to starvation needs tobe distinguished from a co-morbid major depressive episodeAnxiety and obsessionality. In some cases the eating disorder is one

Eating disorders

H.1

Click on the picture to accessa summarry of the the NICE
guideline

12

IACAPAP Textbook of Child and Adolescent Mental Health

•
•

•

•

of a range of symptoms of extreme anxiety. Social anxiety is the mostcommon comorbidity (Swinbourne et al, 2012). Starvation also causes
obsessive symptoms around food and body image (Keys, 1950).
Autistic spectrum disorders
Emerging borderline personality disorder. Binge eating is a common
emotion regulating behavior seen in borderline personality disorderbut in this context occurs without weight or shape overvaluation
Substance abuse. Steroids may be used to increase body musculatureand stimulants to reduce weight. Opiates cause nausea and reduced
appetite, young people may use all available money for drugs rather
than food
Chronic fatigue syndrome. It may be associated with eating disorders
and is unlikely to respond to treatment unless all symptoms are tackled
simultaneously.

Physical comorbidity:
•

•

•

•

Diabetes. Insulin omission is a common practice in people withinsulin-dependent diabetes, particularly girls, who use it as a way tolose weight. The result is that even if weight remains in the normal
range and no other purging behaviors are present, lasting damage canbe done to the body because of poor glycemic control. Mortality inpeople with comorbid diabetes and an eating disorder is many times
the mortality for either condition separately
Cystic fibrosis is another condition where under-treatment of thedisease results in weight loss, which may be welcomed by the young
person, but at the unrealized expense to overall health
Gastrointestinal conditions, epilepsy and even cancer may predispose
body-image conscious youth to neglect any treatment which increases
body weight
Obesity. Increasingly people with bulimia nervosa and binge eating
disorder are overweight/obese.

COURSE AND BURDEN
Anorexia nervosa is one of the most lethal of psychiatric conditions andwhilst around 40% may achieve a full recovery, a small percentage have a severe
and enduring course; the average time to recovery (where it occurs) is six to sevenyears (Strober et al, 1997; Steinhausen, 2002; Steinhausen et al, 2003). As a result,patients with anorexia are a substantial burden on psychiatric services and on theirfamilies, with morbidity in carers on a par with that experienced by those caring
for patients with schizophrenia (Whitney, 2007). Whilst symptoms of bulimia
nervosa may remit spontaneously in the young, there is still disagreement as towhether early diagnosis and intervention bring about better outcomes or whether
they merely reflect the natural course of the disorder in teenagers. Over fifty
percent of individuals with bulimia nervosa or binge eating disorder will achieveremission at five years of follow-up (Steinhausen & Weber, 2009) but untreated
symptoms are likely to persist with significant impact on health related quality oflife (Hay et al, 2012).

Eating disorders

H.1

Refeeding syndrome
The The refeeding
syndrome is a potentiallyfatal shift in fluids andelectrolytes that canoccur in malnourishedpatients receiving too
fast, imperfectly balanced,
artificial or even oral
feeding. It may encompass
a mixture of biochemical,
electrolyte, fluid balance
and metabolic changes
that may include—or lead
to—hypophosphatemia,
hypomagnesaemia,
hypokalemia, gastricdilation, congestive cardiac
failure, severe edema,
confusion, coma, anddeath.
The refeeding syndrome
was a common causeof death in the early
management of anorexia
as well as other starved
patients. However, there
has been criticism thatcurrent guidelines onrefeeding are over-cautious
and lead to initial further
weight loss with increased
risk and longer stays in
hospital. With adequate
medical monitoring andreplacement, especiallyof phosphate, refeeding
syndrome should not occur.
Refeeding at home can beundertaken more safely by
avoiding sudden changes
to the diet and using
high phosphate products
such as milk as a major
constituent of the diet.

13

IACAPAP Textbook of Child and Adolescent Mental Health

MANAGEMENT
Anorexia nervosa
In anorexia nervosa, clinicians are faced with the challenge of managing
the acute physical risk, being aware of how psychopathology increases that risk
beyond that of the physical condition alone. Precipitous weight loss (>1kg/week,less in small children) is dangerous. Mortality is further increased by purging
or substance abuse. Such patients should be urgently discussed with specialists.
Some need hospital admission – and involuntary treatment if necessary to save life.
Particular danger signs in emaciated patients are weakness (climbing stairs, risingfrom a squat), chest pain, and cognitive slowing.
Physical indices of risk such as blood tests or weight measurements fail totake account of the behavioral risk, which would be absent in patients with similar
results from other illness, as the latter can be expected to co-operate with advice andtreatment rather than opposing and undermining it. Thus general medical wards
need extra support in nursing children and young people with eating disorders inorder to compassionately but firmly deal with their damaging behaviors.
There is particular urgency about refeeding underweight children; thesmaller the child, the faster the dehydration and deterioration. Children’s
metabolism is faster than adults’. Physical growth and exposure to infections add
further demands. Starvation at times of crucial physiological growth may cause
long-term damage. For example, starvation in 10-14 year olds during the siegeof Leningrad was associated with higher blood pressure, cholesterol levels, andoverall mortality in long term survivors. The Dutch famine of 1944 (Stein et al,1975), showed similar consequences including second generation consequencesof starvation, such as obesity in the offspring of starved pregnant women. Theremay be permanent stunting of height in those starved during puberty and effects
on a still developing brain. The brain, particularly the frontal lobes, continues
developing during adolescence, with both myelination and pruning of neuralconnections (Giedd, 2008), reflected in growing social skills and capacity for
abstract thought, but many patients with severe anorexia nervosa can continue tofunction showing academic success and superficial maturity.
Cognitive function is impaired by short-term starvation and by vomiting– with enormous individual variation. Considerable recovery occurs with renutrition, allowing better engagement in psychological therapies. Social andpsychological development can be compromised by illness and by hospitalization.
Happily, there is evidence that a well-supported family engaged in family-based
treatment can provide an alternative to inpatient care, can maintain progress andallow earlier discharged from hospital (Madden et al, 2014).
Families become understandably frightened, helpless and angry whenchildren starve themselves, and high levels of arousal make eating even harder.
Family education needs to avoid blame but welcome responsibility, acknowledge
the seriousness and difficulty of the situation, and teach firmness with calm. It’s
helpful if carers can understand the child’s fears but not let go of the convictionthat the symptoms are unacceptable and damaging. Neither collusion nor bullying
is as effective in facilitating healthy change as concerned firmness.

Extract from a letterto anorexia
Dear Mr
Anorexia,
I am writing thisletter to dump you.
Yes really! I havefallen out of lovewith you. It ’s notyou, it ’s me .
I will never forgetyou. I did truly
love you once andwe had a goodtime for a bit, but
you are just toohigh maintenanceand it is wrecking
my life .
My family never
liked you butthat made you
just seem morecool . But then I
found I was losing
friends over you
and they said myparents were rightand you were
wrong for me . You
don’t really carefor me , I see that
now - you wantme to think about
you all the time
instead of looking
after myself
properly …

It is helpful to communicate with schools and other agencies involved.

Eating disorders

H.1

14

IACAPAP Textbook of Child and Adolescent Mental HealthPrinciples of the Mausdsley model offamily therapy in anorexia nervosa
•
•
•
•

•

•

The family is encouraged to take the illness very
seriously
Anorexia is externalized; that is, it is spoken of as
an entity in itself (“the anorexia”) and treated as alife-threatening illness rather than the child’s choice
Therapy is not focused on the causes of the illness
and avoids blaming the family for their child’s illness
On the other hand responsibility for recovery is
explicitly placed with the family in partnership withprofessionals. It is assumed families “know best”
how to feed their children.
The adults re-take control until the child can feed
herself autonomously again. They are urged to use
all their existing skills and to learn new ones where
necessary to bring this about
Only when adequate nutrition is successfully
achieved and maintained there is an examinationof developmental issues and age-appropriate
autonomy facilitated..

Teachers and youth leaders may not want to supervise meals, but they can set
appropriate boundaries on exercise and activity and arrange privacy at mealtimes.
School activity trips may not be safe for low weight children or ritualistic eaters.
Dietetic expertise is essential on inpatient wards and it is important for
outpatients to have specialist dietetic input. However, the problem lies far lessin terms of knowing what to eat – learning how to tolerate the absorption of
sufficient calories is the struggle. Re-nutrition is central to treatment and recovery
cannot occur without this. Restoration of weight against the patient’s will canonly lead to recovery if therapy – or life itself – can persuade the patient tovoluntarily maintain a healthy weight. Therapy, preferably family based, is needed
to support non-negotiable benefit from therapy not only to prevent burnout anddepression, but because family based treatment has been demonstrated to be thus
far the most effective long term treatment for the disorder and is recommended byinternational guidelines (NICE, 2004; Hay et al, 2014). Well-meaning efforts totreat depression in an extremely low weight patient are likely to meet with limited
success unless re-nutrition is in progress.
Motivational approaches
Sadly, it is not common for an intelligent child who is shown the physicaldangers of starvation to be frightened into eating normally again. Indeed thechild’s indifference, in contrast with adults’ increasingly fearful concern, may
widen the gulf between them. The best approach is to gradually and repeatedly
help children see the links between the symptoms they dislike – weariness,agitation, obsessionality, being preoccupied with food and its avoidance, sleep
problems, feeling the cold, loss of friendships, inability to join in socially, falling
sport or academic performance, “fussing” by parents – and the anorexic illness.
It is useful as children progresses to help them notice how weight gain brings thecorresponding benefits: more energy, clear headedness, resistance to cold, growing

Eating disorders

H.1

Motivational talk
•
•
•
•
•

Anticipate
ambivalence
Express empathy
Roll with resistance
Support self-efficacy
Conduct a decisional
analysis: what are
the positives andthe negatives of theeating disorder?

The non-negotiables•••

Patients move
– however slowly –towards the healthy
weight range, notaway from it
Everyone has to learn
to accept and cooperate with medical
monitoring to staysafe and to develop
trust and respect
Doctors and parents
have a legal andmoral duty to savelife and prevent
irreversible damage.

15

IACAPAP Textbook of Child and Adolescent Mental Healthin height (it’s generally “cool” to be tall), capacity to have fun with friends, andbeing well enough to join in games again.
We should acknowledge sympathetically, not angrily, the benefits which
undoubtedly come with a serious eating disorder: its power to oblige people tocare and placate, the relief from social and sexual demands, the sense that one’s
body is now controlled rather than terrifyingly unpredictable. Young patientsneed new techniques for coping with these aspects of life without having to starve
themselves.
The principles of motivational interviewing have been adapted for use in
the management of eating disorders from the Miller and Rollnick (2008) approachto substance misuse disorders. They are not intended to constitute a stand-alone
treatment but to enable the development of a therapeutic relationship in otherwise
unpromising circumstances (Geller, 2005). The clinician encourages the patientsto explore the consequences of anorexic behavior as openly and scientifically as
possible, so that patients are the ones to articulate the disadvantages as much as
possible. When a therapist tells patients what to do, they resort automatically to an
oppositional stance (even the best clinicians find this but can recover by realizingthat the pattern is happening.) There are a number of workbooks available tofoster playful motivation techniques, such as writing “love letters” and “rejection
letters” to anorexia.
Clinicians who explore ambivalence sensitively, seeking to understand bothpros and cons of the eating disorder, are more likely to find themselves on the sideof the patient against the disorder. Patients find it less daunting to give up theireating disorder if they can learn alternative coping skills.
Medication
One useful metaphor in work with anorexia nervosa is that food is the
medicine. This means that food has to be prescribed and taken at the times
specified and in the amounts prescribed. It is the task of the nurses or parents
to dispense the medicine in the right dose and ensure that the child takes it. It
is the child’s job to take the medicine and not get rid of it, even though they
may not enjoy the taste or may be upset by the side-effects (weight gain). This is
non-negotiable ; the choice for the young person is limited to how they take their
medicine – orally as food, orally as commercially available supplement drinks (ifavailable) or by a naso-gastric tube.
There is little evidence to support prescribing of psychoactive medicationin the treatment of eating disorders, and in fact it is important to avoid drugs
which may prolong the QTc interval and thus threaten the weakened heart (e.g.,
first generation antipsychotics, tricyclic antidepressants, some antihistamines
and macrolide antibiotics). Initial reports that fluoxetine might reduce relapse
in weight-recovered anorexic patients failed to be replicated in later studies,
unfortunately.
A growing body of evidence supports the prescription of relatively low doses(2.5-10mg) of olanzapine or other antipsychotic to reduce rumination and improve
tolerance of weight gain in both adults and young people with anorexia nervosaand it is safe (Couturier & Lock, 2007). It may be preferred to benzodiazepines inpromoting relief from anxiety and, if necessary, tranquillization to allow insertionof nasogastric tubes.
Eating disorders

H.1

Admit to hospital ormanage at home?
Gowers et al (2007)
found that, when it wassafe to manage anorexic
patients on an outpatientbasis, the outcome wassignificantly better if
treatment was deliveredby an outpatient clinicwith specialist expertisein eating disorders. Even
general outpatient child andadolescent psychiatrists
brought about greater
physical and psychosocial
improvement than did
inpatient treatment.
Guidelines now
recommend outpatientcare for medically stableadolescents with anorexia
nervosa. Where there
is no outpatient clinic
available, outreach services
and telemedicine are
increasingly able to deliver
home-based care.

16

IACAPAP Textbook of Child and Adolescent Mental Health

Is it “just a phase”?
Experts disagree and there are mixed research findings about the benefits of early intervention. Perhaps there are somespontaneous early recoveries, regardless of treatment. However, chronicity is associated with poor prognosis.
•

Stice et al (2009) reported an eight-year prospective study of 495 female adolescents from age 12 to 20. There was a
12% prevalence of some form of eating disorder by age 20, but most resolved within months and more than 90% resolved
within one year.

On the other hand:•

Patton et al. (2013) found whilst disordered eating in adolescent may resolve with maturity, there is an increased risk ofmood disorder and substance use in older years.

•

Hay et al. (2012) found strong persistence of symptoms such as binge eating over time Iin a cohort of young women withdisordered eating behaviours.

•

Mitchison et al. (2013) found a self-reported life time history of anorexia nervosa was associated with poor health related
quality of life in a large community sample of men and women.

•

Steinhausen et al (1991) found that the longer the duration of an eating disorder the harder it is to recover•

Treasure and Russell (2011) argued that early treatment is essential, pointing retrospectively to improved outcomes inyounger patients with a relatively brief history of anorexia nervosa•

Meta-analytic studies (Schoemaker, 1997; Raes et al, 2001) have found that early recognition and diagnosis did notguarantee earlier recovery.

Bulimia nervosa and binge-eating disorder
Bulima nervosa in young people appears to benefit from antidepressants as
in adults – typically fluoxetine 60mg daily (Couturier & Lock, 2007) and these
are also reported effective in binge eating disorder. However, cognitive behavioral
therapy (CBT), targeting bulimic symptoms, is the gold standard treatment for
both disorders in adolescents as in adults (Pretorius et al, 2009).
Where notrained therapists are available there are good results reported using self-help
books, CDs, or web-based programs, guided or directed by a professional if
possible. The interpersonal therapy (IPT) model of Kerman and Weissman has
also been successfully used in the treatment of bulimia nervosa in young adults,
and is potentially a reasonable alternative to CBT for adolescents (Fairburn et al,1995).
It would appear reasonable to employ CBT for low weight as well as
normal weight eating disorders, and indeed Fairburn’s CBT-E – an enhanced
version of CBT – has been recommended by the originator as suitable for all eating
disorders in patients down to age 15 and down to a BMI of 15 (Fairburn, 2009);
unfortunately, many young patients will not fall into this category.

MODELS OF SERVICE DELIVERY FOR EATING DISORDERS
The key to safe and effective treatment of anorexia nervosa is the orchestrationof a coordinated systemic response. This is harder than it sounds when the patients
instinctively behave in a way which protects anorexic behavior and brings aboutmaximum confusion and disruption to the therapeutic process. School can be aparticularly difficult place for teenagers who need to be monitored – their return toschool may not turn out to be a journey towards health and progress but a retreat
from adult supervision, allowing anorexic behaviors to flourish. The competitive

Eating disorders

H.1

17

IACAPAP Textbook of Child and Adolescent Mental Healthenvironment of school examinations often further drives anorexic and obsessive
responses to stress, and adults often hesitate to interrupt public examinations toprioritize treatment.
Group therapy may appear on the face of it to be a more economical way
to deliver treatment. However, anorexia nervosa patients tend to avoid groups
or use them to compete with other sufferers. Group therapy has however beenused successfully with patients who have bulimia nervosa or binge-eating disorder.
Families also benefit considerably from the support offered by other struggling
parents and there is growing evidence for the value of multi-family groups (Eisler,
2005).
When a bulimia nervosa patient is maintaining a normal weight and is able
to access minimal medical monitoring, web-based and CD-ROM manualized
treatments can provide a useful initial treatment (Hay & Claudino, 2015).
Schmidt’s team (Pretorius et al, 2009) have modified these materials specificallyfor adolescents from the authors’ own self-help book Getting Better Bit(e) by Bit(e)(Schmidt & Treasure, 1993).

COURSE AND PROGNOSISSten Theander’s (1985) early follow up studies found that a shocking 20%
of anorexic patients died of causes related to the disorder. Even now, mortality inanorexia is ten times that in the general population and is among the top threeor four causes of death in teenagers in Western countries. Today’s lower mortality
figures partly reflect changes in diagnostic criteria – since the publication of DSM
III-R in 1987 we require only 15% body weight to be lost (or a BMI below 17.5)
before making the diagnosis, compared with 25% (BMI below 15) previously. As
a result, the population of people diagnosed with anorexia nervosa has expanded,
whilst the number of people so starved by the disorder that they die remains fairly
constant, so that when expressed as a percentage, it would appear superficially thatthe death rate is decreasing.
Treatment for fully established anorexia nervosa is slow and difficult: theaverage time to recovery is six to seven years though treatment is likely to be
episodic rather than continuous over this period. Younger, intensively-treatedpatients often show a more rapid improvement, and it is likely that some cases will
have resolved even without treatment.
Improved management may also contribute to longer survival – it is now
acknowledged that a tolerant, respectful relationship allows long-term physicalmonitoring and support to be offered. Early treatments for anorexia nervosa
tended to involve strict behavioural regimes whereby patients started hospital
admission on bed-rest and were allowed privileges such as using a toilet rather thana bed-pan, or being allowed to receive visitors only in return for weight gain. Suchregimes are no longer seen as either useful or acceptable, although sadly, the spiritof “rewarding” or “punishing” patients based on their weight, seems to persist
in some centres. This may be an instinctive response to the nature of anorexia
nervosa itself, which is to offer a sense of reward for weight lost or punishment forweight gained.

Eating disorders

H.1

Websites
Most of the websites oflarger professional or
major charitable bodies
are reliable and up to date.
There are many excellent
lay-run sites and also many
dangerously misinformed
and even “pro-anorexia”
sites, often short-lived or
outdated.
•
The Centre for Eatingand Dieting Disorders(Australia)•
The American-based
but internationally
represented Academyof Eating Disorders
offers useful
information, including
guidelines for medical
management.
•
The site of the Royal
College of Paediatrics
and Child Healthhas a section whichmakes WHO GrowthCharts available (click
Child Heath/Research
Projects/GrowthCharts)•The Royal College of
Psychiatrists’ website
has useful information
both for professionals,
carers and sufferersof all ages.
•“BEAT”, formerly the
UK Eating Disorders
Association, offers
information and help
for lay people on all
aspects of eating
disorders.
•“Diabetics With Eating
Disorders” (DWED)a website by and fordiabetics with eating
disorders.
•“Men get eating
disorders too” by andfor men and boys.
•“Something Fishy” isan English language
website that provides
links to sites in otherlanguages.
•
The Butterfly
Foundation (Australia)

18

IACAPAP Textbook of Child and Adolescent Mental HealthA significant minority of patients with anorexia nervosa fail to fully recover
but these patients may at least be enabled to live valuable and tolerable lives. It is
not possible to identify which patients will fall into this category whilst they arestill in their teens, and young people should not be regarded as chronic sufferers
until many years of treatment have passed.
Starvation and malnutrition from all causes reduce fertility. The minimum
weight needed for menstruation and fertility varies between individuals. Youngpeople with anorexia and their families often fear that fertility is irredeemably
damaged by the disorder, when in fact with restoration of adequate weight andhealthy eating patterns, fertility returns given time. Patients in their thirties andforties, with longstanding primary amenorrhoea have been shown to be ovulating
normally after weight recovery.
Sadly, though, the death rate from anorexia nervosa is still high (Arcelus
et al, 2011). The excess mortality is partly as a result of the physical damage
associated with the illness and partly because of suicide. Some deaths may result
from ambivalently-taken overdoses that would not have killed individuals with ahealthy weight. Likewise, the effects of substance abuse are greatly amplified at
low weight. In cold countries, the majority of deaths occur in the winter months
when hypothermia and infections (including tuberculosis) account for manyfatalities. The starved heart is especially vulnerable when over-exercised in cold
temperatures. In hot countries dehydration and enteric infections are importantrisks. Patients who have induced vomiting can harm the gastrointestinal system,
predisposing them to fatal perforation.

Follow up
In childhood and adolescence and when anorexia acutely threatens life weare obliged to take action, but if patients do not recover despite intensive efforts
and are not at significant risk of death, the priority becomes to maintain usefulcontact and keep the door open for them to accept as much help as possible:
medical monitoring, a listening ear, and keeping hope – and patients – alive (Hayet al, 2014). Recent studies show that recovery is still possible even twenty years
after the onset of anorexia. Because of the age group affected and the time span
involved, patients’ care often involves many transitions, for instance, moving fromchildren’s services to adult clinics, leaving the relatively protected environment ofschool, leaving home, perhaps to take on challenging university courses or to work
away from home, and thus further changes in health service care.
Transitions are peak times for relapse and decompensating. People withanorexia tend to see their illness as a coping strategy and even as a cherishedidentity so that professional energy is needed to either entice or, when necessary,
coerce them into treatment. Unsurprisingly, many professionals experience anger
and frustration at one time or another. However, there is much satisfaction
when a young person with anorexia nervosa recovers and regains a positive senseof purpose and satisfaction in their lives. It should be emphasised that anorexia
nervosa and other eating disorders are psychiatric disorders where complete andlasting recovery does occur.

Eating disorders

H.1

19

IACAPAP Textbook of Child and Adolescent Mental Health

PREVENTION
Prevention programs are typically conducted with groups of children oradolescents in school or clinic settings or with youth groups such as athletics clubs.
Overall, the outcome of prevention programs has been mixed. Targeted programs
show small to moderate effect sizes, whereas universal ones have been found to
be largely ineffective. The most efficacious interventions focus on improving selfesteem, media literacy training and a specific approach, cognitive dissonancetraining individually or in groups (Stice et al, 2007). Some countries haveintroduced legislation to require a minimum BMI for fashion models and alreadysome schools of dance require minimum as well as maximum BMI bands. It is
too soon as yet to evaluate the preventative effects of such policies, but they give asound message to the public.
Concern has been raised that anti-obesity campaigns may have theundesirable side-effect of promoting eating disorders in the vulnerable. It has
been demonstrated, however, that thoughtfully delivered health promotion thatexamines healthy nutrition and exercise (rather than focussing on weight reduction)
can actually protect against both obesity and body-image related eating disorders(Schwarz & Henderson, 2009).

BARRIERS TO THE IMPLEMENTATION OF CARE IN
DEVELOPING COUNTRIES
Until recently, traditional and ceremonial eating practices and family
influences offered developing countries relative protection against the developmentof eating disorders, together with an ideal setting in which to treat those who havesuccumbed to the illness. The structured regular eating patterns of specialist units
and the ethos that patients eat what is put in front of them without quibbling
and with respect to people eating alongside them is very close to the traditional
attitudes to eating that can keep humans healthy physically, psychologically andsocially. The thin body image ideal has not been endorsed by non-Western cultures
until lately and, even now, countries where AIDS is feared tend not to admire an
emaciated body.
It is a sad irony that whilst disordered and obsessive body image values havebeen widely transmitted by TV, the Internet and other media, it is more difficultfor health services to keep up with the harm. Although the treatment of eating
disorders in young people does not need to rely on sophisticated or expensive
medications, education and training in structured psychotherapies is equally – if
not more – expensive. Bulimia nervosa and other eating disorders respond wellto CBT delivered in self-help or guided self-help form, but there is evidence thatin anorexia nervosa outcome relates more closely to the level of experience ofthe clinician than to any specific model of therapy (Hay et al, 2014). Anorexia
nervosa, though devastating, is often hidden not only by sufferers but also byashamed families, so that general clinicians are unlikely to build up expertise,whilst specialist centres are too expensive and too far geographically to serve muchof the world’s population.
In the final analysis it is the family – or surrogate family – which will needto come to the rescue of the child with anorexia nervosa. The style of parenting

Eating disorders

H.1

•
•

Do you havequestions?
Comments?

Click here to go to the
Textbook’s Facebook
page to share yourviews about thechapter with otherreaders, question theauthors or editor andmake comments.

20

IACAPAP Textbook of Child and Adolescent Mental Healthrequired can seem counter-intuitive to western middle-class families and may also
be counter-intuitive to families afflicted by the same obsessionality as the affectedchild. However, family based treatment is both manualized and described in a lay
paperback so that it is accessible to all English speaking literate families (Lock et al,
2001; Lock & Le Grange, 2005). Rather than the cause of eating disorders modern
research has demonstrated that families are the most likely source of recovery.

REFERENCES
American Psychiatric Association (2013) Diagnostic andStatistical Manual of Mental Disorders, 5th edition.
Washington, DC: American Psychiatric Association.
Arcelus J, Mitchell AJ, Wales J, et al (2011) Mortality rates
in patients with anorexia nervosa and other eating
disorders: A meta-analysis of 36 studies. Archives ofGeneral Psychiatry 68:724–731.
Blake Woodside D (2003) Culture as a defining aspect of theepidemiology and aetiology of eating disorders. In
Maj M, Halmi K, Lopez-Ibor JJ et al (eds) Eating
Disorders. Chichester: Wiley, pp114-116.
Bruch H (1978) The Golden Cage: the Enigma of Anorexia
Nervosa. Cambridge: Harvard University Press.

Gowers SG, Clark A, Roberts C et al (2007). Clinicaleffectiveness of treatments for anorexia nervosa inadolescents. Randomised controlled trial. British
Journal of Psychiatry, 191:427-435.
Gull WW (1874) Apepsia hysterica, anorexia hysterical. ClinicalSociety’s Transactions, vii:22.
Hay PJ, Claudino AM (2015) Bulimia nervosa: online
interventions. BMJ Clinical Evidence. Mar 4. pii:1009.
Hay PJ, Buttner P, Mond JM et al (2012) A community-based
study of enduring eating features in young women.
Nutrients May 2012, 4(5).

Couturier J, Lock J (2007) A review of medication use forchildren and adolescents with eating disorders.
Journal of the Canadian Academy of Child & Adolescent
Psychiatry, 16:173-176.

Hay P, Chinn D, Forbes D et al (2014) Royal Australian and
New Zealand College of Psychiatrists clinical practiceguidelines for the treatment of eating disorders.
Australian and New Zealand Journal of Psychiatry.
48:977-1008.

Eisler I (2005) The empirical and theoretical base of family
therapy and multiple family day therapy for adolescentanorexia nervosa. Journal of Family Therapy, 27:104131.

Kessler RC, Berglund PA, Chiu WTet al(2013) The prevalence
and correlates of binge eating disorder in the World
Health Organization World Mental Health Surveys.
Biological Psychiatry. 73:904-914.

Fairburn CG (2009) Cognitive Behavior Therapy and Eating
Disorders. New York: Guilford Press.

Keys A, Brozek J, Henschel A et al (1950) The Biology of Human
Starvation. Minneapolis: University of Minnesota
Press.

Fairburn CG, Beglin SJ (1994) Assessment of eating disorders:interview or self-report questionnaire? International
Journal of Eating Disorders, 16:363-370.
Fairburn CG, Norman PA, Welch SL et al (1995) A prospective
study of outcome in bulimia nervosa and the longterm effects of three psychological treatments. Archivesof General Psychiatry, 52:304-312.
Freeman C, Henderson M (1987) A self-rating scale for bulimia.
The ‘BITE’. British Journal of Psychiatry, 150:18-24.
Garner DM (2004) Eating Disorders Inventory-3. Odessa, FL:
Psychological Assessment Resources.
Geller J (2005) What a motivational approach is and what a
motivational approach isn’t: reflections and responses.
European Eating Disorders Review, 10:155-160.
Giedd JN (2008) The teen brain: insights from neuroimaging.
Journal of Adolescent Health, 42:335-343.
Gillberg C, Råstam M (1992) Do some cases of anorexia nervosareflect underlying autistic-like conditions? Behavioural
Neurology, 5:27-32.

Eating disorders

H.1

Kiezebrink K, Campbell D, Mann E et al (2009) Similarities
and differences between excessive exercising anorexia
nervosa patients compared with DSM-IV definedanorexia nervosa subtypes. Eating and Weight
Disorders, 14:e199-e204.
Lasègue E-C (1873). On hysterical anorexia, Medical Times andGazette (September 6, 1873), pp265-266 [originalFrench report in Archives Générales de Médicine(April 1873), quoted in Brumberg JJ, Fasting Girls,
Cambridge, Mas: Harward Univrsity Press, p129].
Lock J, Le Grange D, Agras WS et al (2001). A Treatment
Manual for Anorexia Nervosa: A Family-BasedApproach. New York: Guilford.
Lock J, Le Grange D (2005). Help Your Teenager Beat an Eating
Disorder. New York: Guilford.
Madden S, Morris A, Zurynski YA et al. (2009) Burden of eating
disorders in 5–13-year-old children in Australia. The
Medical Journal of Australia 190: 410–414.

21

IACAPAP Textbook of Child and Adolescent Mental Health

Madden S, Miskovic-Wheatley J, Wallis Aet al (2014) A
randomized controlled trial of in-patient treatment
for anorexia nervosa in medically unstable adolescents.
Psychological Medicine, 14:1-13.
Maloney MJ, McGuire JB, Daniels SR (1988) The Children’s
Eating Attitudes Test (ChEAT). Journal of theAmerican Academy of Child and Adolescent Psychiatry,
44:632-639
Miller WR, Rollnick S (2008). Motivational Interviewing:
Preparing People for Change, 2nd edition. New York:
Guilford.
Mitchison D, Hay P, Mond J et al (2013) Self-reported historyof anorexia nervosa and current quality of life:
Findings from a community based study. Quality ofLife Research, 22:273–281.

Shoebridge P, Gowers S (2000) Parental high concern andadolescent onset anorexia nervosa, British Journal of
Psychiatry, 176:132-137.
Stein Z, Susser M, Saengler G et al (1975). Famine and Human
Development. The Dutch Hunger Winter of 1944-1945.
London: Oxford University Press.
Steinhausen H-C (2002) The outcome of anorexia nervosa inthe twentieth century. American Journal of Psychiatry,
159:1284-1293.
Steinhausen H-C, Weber S (2009) The outcome of bulimia
nervosa: Findings from one-quarter century of
research. American Journal of Psychiatry 166:1331–
1341.

Mitchison D, Hay PJ (2014) The epidemiology of eating
disorders: Genetic, environmental, and societal factors.
Clinical Epidemiology 6: 89–97.

Steinhausen HC, Boyadjieva S, Griogoroiu-Serbanescu M, et al.
(2003) The outcome of adolescent eating disorders:
Findings from an international collaborative study.
European Child & Adolescent Psychiatry 12 Sup 1:191–
198.

Morgan HG, Hayward AE (1988). Clinical assessment ofanorexia nervosa. The Morgan-Russell outcome
assessment schedule. British Journal of Psychiatry,
152:367-372.

Stice E, Shaw H, Marti CN (2007). A meta-analytic review of
eating disorder prevention programs: Encouraging
findings. Annual Review of Clinical Psychology, 3: 233257.

Morgan JF, Reid F, Lacey JH (1999). The SCOFF questionnaire:assessment of a new screening tool for eating disorders.
British Medical Journal, 319: 1467-1468. doi:10.1136/
bmj.319.7223.1467.

Stice E, Marti CN and Rohde P (2013) Prevalence, incidence,
impairment, and course of the proposed DSM-5
eating disorder diagnoses in an 8-year prospective
community study of young women. Journal of
Abnormal Psychology 122: 445–457.

NICE (National Institute for Clinical Excellence) (2004) Eating
Disorders in Over 8s: Management. Available at:https://www.nice.org.uk/guidance/cg9
Nicely TA, Lane-Loney S, Masciulli Eet al (2014) Prevalence
and characteristics of avoidant/restrictive food intake
disorder in a cohort of young patients in day treatment
for eating disorders. Journal of Eating Disorders. 2;21.
Patton G, Coffey C, Sawyer S (2013) The outcome of adolescenteating disorders: Findings from the Victorian
Adolescent Health Cohort Study. European Child &Adolescent Psychiatry [Suppl 1] 12:25–29.
Pike KM and Dunne PE, 2015. The rise of eating disorders in
Asia: a review. Journal of Eating Disorders, 3:33.
Pretorius N, Arcelus J, Beecham J et al (2009) Cognitivebehavioural therapy for adolescents with bulimic
symptomatology: The acceptability and effectivenessof internet-based delivery. Behaviour Research andTherapy, 47:729-736.
Raes DL, Schoemaker C, Zipfel S et al (2001). Prognostic
value of duration of illness and early intervention inanorexia nervosa: A systematic review of the outcome
literature. International Journal of Eating Disorders,
30:1-10.
Schmidt U, Treasure J (1993). Getting Better Bit(e) by Bit(e). A
Survival Kit for Sufferers of Bulimia Nervosa and Binge
Eating Disorders. Hove: Psychology Press.
Schoemaker C (1997). Does early intervention improve theprognosis in anorexia nervosa? A systematic reviewof the treatment outcome literature. International
Journal of Eating Disorders, 21:1-15.

Strober M, Freeman R, Morrell W (1997). The long term courseof severe anorexia nervosa in adolescents: Survival
analysis of recovery, relapse and outcome predictors
over 10-15 years in a prospective study. International
Journal of Eating Disorders, 22:339-360.
Swinbourne J, Hunt C, Abbott M, et al. (2012) The comorbidity
between eating disorders and anxiety disorders:Prevalence in an eating disorder sample and anxiety
disorder sample. Australian and New Zealand Journalof Psychiatry 46:118–131.
Theander S (1985). Outcome and prognosis in anorexia nervosaand bulimia: Some results of previous investigations,compared with those of a Swedish long-term study.
Journal of Psychiatric Research, 19:493-508.
Treasure J, Russell G (2011). The case for early intervention
in anorexia nervosa: theoretical exploration ofmaintaining factors. British Journal of Psychiatry,
199:5-7.
Whitney J, Haigh R,Weinman J et al (2007). Caring forpeople with eating disorders: Factors associatedwith psychological distress and negative caregiving
appraisals in carers of people with eating disorders.
British Journal of Clinical Psychology, 46:413-428.
World Health Organisation (1992). The ICD-10 Classification of
Mental & Behavioural Disorders: Clinical Descriptions
and Diagnostic Guidelines. Geneva: World HealthOrganization.

Schwartz MB, Henderson KE (2009). Does obesity prevention
cause eating disorders? Journal of the American
Academy of Child & Adolescent Psychiatry, 48:784-786.

Eating disorders

H.1

22