Eating Disorder Teenager

Eating Disorder In Teenager’s
dr. Afriyan Wahyudhi, SpA, MKes

PREFACE
Dieting/Body Image Variation
• Dieting may occur if the child is overweight
but it should be a realistic program.
• The child does not completely eliminate any
food group, but generally decreases intake of
food, especially of sweets and fats or is on an
appropriate diet.
• The child favors a thin appearance but has a
realistic image.
• The individual can stop dieting voluntarily.
DSM-PC, Child and Adolescent Version, AAP,

1996
Dieting/Body Image Problem
• More intense dieting/food restrictions
resulting in weight loss or failure to gain
weight as expected, but not enough to
qualify for A.N. or E.D. NOS
• Obsessed with the pursuit of thinness
and develops systematic fears of gaining
weight
• Consistent disturbance in body
perception and starts to deny that weight
loss or dieting is a problem.
DSM-PC, Child and Adolescent Version, AAP,
1996
ANOREXIA NERVOSA
(pursuit of thinness)
WHAT A.N.?
• common psychiatric disorders in adolescents and
young adults
• the highest rates of morbidity and mortality of any
psychologic condition
• central feature of both disorders is an intense fear of
becoming overweight
• condition of self-produced weight loss, usually seen in
adolescent girls
• involves an intense preoccupation with weight and
shape, behaviors aimed at a relentless pursuit of
thinness
• resulting physical consequences of these behaviors
12 year old self-portrait
1) Library: 5 Minute Exercises,
Recipes for Health,
Calories Do Count,
Secrets of Staying Thin
2) Exercise rope
3) Clock always at mealtime
4) Plate with vegetables, fruit, no meat
or fat. Most food uneaten
5) Forbidden foods beyond arm’s
reach
6) Externally: Superwoman
7) Internally: An empty skeleton
HOW?
• Insufficient energy intake
• Wasting of the body
• Delusion of being fat
• Obsession to be thinner
• Does not diminish with weight loss
• Denial
CLINICAL MANIFESTATION
• severe electrolyte disturbance
• cardiac arrhythmia  congestive heart
failure in the recovery phase
• Physical complications  organ systems
disturbances
• Individuals: palpitations, weakness,
dizziness, shortness of breath, and chest
pains
• Physical signs
– irregular, weak pulse and peripheral
vasoconstriction
– bradycardia, postural hypotension
– other electrocardiographic arrhythmias,
supraventricular and ventricular dysrhythmias
– Pulse rates can be as low as 20 beats/minutes
– variety of electrocardiographic abnormalities 
low voltage, T-wave inversion and flattening, ST
depression, prolonged QTc interval
– Decreased cardiac output and mitral valve
prolapse may result from myofibrillar atrophy
• Disorders of the hypothalamic-pituitary-ovarian axis
– arrested psychosexual maturation, loss of libido, and amenorrhea
– fatigue, lassitude, and cold intolerance
Laboratory findings 
– increased secretion of cortisol, loss of diurnal variation
– Growth hormone secretion is abnormally high and the level of
somatomedin C is low.
– Thyroid-stimulating hormone levels are normal, thyroxine and
triiodothyronine levels are low
– Pseudoproteinuria is often found  the alkalinity of the urine gives a
false-positive reaction to albumin on the dipstick
– Mild proteinuria, hematuria, and pyuria, with negative findings on urine
culture
– Elevations of the blood urea nitrogen level may occur, reflecting
dehydration and a decreased glomerular filtration rate, but normal levels
may be found under these same conditions because of low protein
intake
Malnutrition and Hypometabolism
Muscle
wasting
Lanugo
•  Energy intake results in wasting of lean (muscle) > fat

• Metabolism occurs in the lean body mass>>>>>fat
• Energy conservation:  BMR;  Temp.;  HR; 
Peripheral blood flow;  Physical activity
• ~70% of regained weight is lean body mass
Week 1:
•Wt 91#;
•S.G. 1.018;
•HR: 62 70;
•36.9°C
Weekly visits
Week 5:
•Wt 91#;
Recheck Wt.
•S.G. 1.020;
(observed) and
•HR: 4482
physical exam
•35.3°Cl
Cardiovascular: Physiologic v
Pathologic
• Physiologic
– Bradycardia (low energy intake)
– Cold hands/feet (energy conservation)
– Slow capillary refill (low cardiac output)
– Acrocyanosis (deoxygenated hgb)
– Orthostatic pulse ∆ >25 BPM:
(compensatory)
• Pathologic
– ECG: Non-specific changes (voltage ↓, R
QRS axis, ST ↓, T flat or inverted, U waves)
– Echo: Normal contractility; C.O. ↓;
effusion?
– Dysrhythmia: Ventricular tachyarrhythmia
Edema
Livedo Reticularis
• Bluish discoloration of
skin
• Reticular (“lacy”)
pattern
• Asymptomatic, but
often associated with
low core temperature
and metabolism
www.pediatrics.wisc.edu/educati
on/derm/tutc/69.html
Cardiovascular Changes
• Symptoms respond to adequate nutrition
• Adequate energy intake needed to gain
weight
• Moderate exercise, after intake exceeds
output
• Limiting exercise is possible, but difficult
Gynecologic Status
• Amenorrhea and infertility are
related to weight and exercise
• Menstrual weight: 90% ABW for
height
• Prolonged amenorrhea does not
preclude childbearing
• With adequate weight gain, fertility
should return to normal, but
ovulation weight may exceed
Gynecologic Changes
• Birth control pills preclude using
menses as sign of physical health
recovery
• Birth control pills and other
hormonal therapy results in
withdrawal bleeding, NOT menses
• Progesterone challenge does NOT
“kick start” normal menstrual
periods
• Return of menses related to gain of
lean, as well as fat, body mass
Musculoskeletal Status
• Reduced skeletal muscle mass
• Causes of
osteopenia/osteoporosis
– Low weight
– Ineffective load-bearing
exercise
– Low estrogen
– High cortisol
PSYCHOLOGYCAL
SYMPTOMPS
• social isolation, depression, anxiety, and
obsessional symptoms, perfectionistic
traits, and rigid cognitive styles
• loss of sexual libido, reduced alertness
and concentration, and dysphoria,
introversion, poor peer relations, and low
self-esteem
BULIMIA NERVOSA
(avoidance of obesity)
WHAT?
• BN >> AN
• marked by long-term dietary restraint
interrupted by episodes of reactive
hyperphagia and compensatory behaviors,
such as vomiting and laxative abuse
• Body weight fluctuated in normal range
HOW?
• recurrent episodes of binge eating (rapid
consumption of a large amount of food in a
discrete period, usually <2 hr)
• during the eating binges, a fear of not being able
to stop eating
• regularly engaging in self-induced vomiting, use of
laxatives, or rigorous dieting or fasting to
counteract the effects of binge eating
• a minimum average of 2 binge eating
episodes/week for at least 3 mo
• self-evaluation is unduly influenced by body weight
and shape
• weakness and irritability as a side effect of
dehydration
• gastrointestinal distress and dysmotility as
a result of vomiting and laxative abuse
• irregular menses and fertility problems
• dental decay and parotid gland swelling
• and cardiac problems as the result of
ipecac abuse
Salivary gland enlargement
Parotid
Submandibular
Dental Enamel
Erosion
www.maxillofacialcenter.com/bulimia. www.thejcdp.com/issue001/gand
html ara/introgan.htm
- Dentin (yellow) visible beneath A: Less enamel loss on buccal
eroded enamel (white) surfaces
- Worse on lingual than buccal B: Enamel sparing in gingival
surfaces crevices
Erosion of enamel (white) and dentin
(yellow) from persistent vomiting,
resulting in tooth decay, fracture, and loss
PSYCHOLOGYCAL
•
SYMPTOMPS
depressive, anxious, and obsessional symptoms
• a sense of shame associated with the behavior that
prevents early treatment-seeking
• variety of deficits in impulse regulation, including self-
injury, substance abuse, suicidality, and sexual
promiscuity
• poor social adjustment and peer relationships,
sensitivity to criticism, excessive social dependence,
inadequate social support, and an intense desire to
please others
BINGE EATING DISORDER
WHAT?
• Binge eating disorder (BED) involves
episodes of severe overeating without the
compensatory behaviors of BN
• Childhood obesity and parental obesity are
specific risk factors
• Recurrent, secretive binge-eating
• Fear of not being able to stop eating
• Awareness that eating pattern is abnormal
• Depressed moods and self-deprecating
thoughts
• Temporary relief via avoidance of weight
gain by
– Fasting
– Self-induced vomiting
– Catharsis or diuresis
– Exercise
• Physical complications of BED include
weight gain and, rarely, gastric rupture
PSYCHOLOGYCAL
SYMPTOMPS
• traits of negative self-esteem, impaired
social functioning, and distress
• alcohol abuse and anxiety disorders
EATING DISORDER
Eating Disorders: Caveats in Primary
Care
Negativ
•e “Classic” presentation less likely in younger
patients and/or shorter duration of illness
• No single “cause” to this final common
pathway
• No diagnostic lab (blood, urine, ECG,
imaging, etc) studies
• Opinions are less important than facts
• Initial goal is not to diagnose an eating
disorder, but to determine the cause of
weight loss
Eating Disorders: Caveats in Primary
Care
Positive
• Physical findings are the result of weight
control habits
• Mental status is part of the physical
examination
• Laboratory studies for baseline, or to
reinforce physical examination finding
• Motivational interviewing avoids many
pitfalls in management
• Parents are part of the solution to, not
the cause of, the eating disorder
Diagnostic Algorithm for Weight Loss
• Is weight loss intentional and/or desired?
– Unrecognized illness
– Increased energy needs due to exercise or
growth
– Efforts to “get in shape”
– Energy restriction (intake) or output (exercise)
• Excessive dieting or exercise
– Symptoms, signs, body image distortion
• Pursuit of thinness/avoidance of obesity major
issue
– “Healthy” habits directed toward sport, dance,
etc
– Unhealthy habits
• Determine level of care needed
– Outpatient / Intensive Outpatient
Principles of Motivational
Interviewing (Miller & Rollnick)
1. Express empathy with patient’s

perceptions
2. Develop discrepancy between present
behavior & personal goals
3. Avoid argumentation and defensiveness
4. Redefine, rather than confront,
resistance
5. Support self-efficacy through autonomy
Treatment Of Osteopenia /
porosis
• Prevention is the only cure!
• Weight gain and resuming menses is the
MOST effective method of increasing
BMD
• Calcium and vitamin D supplementation
(if low dairy intake)
• Hormone therapy: NO evidence of
effectiveness in improving BMD
• Bisphosphonates, DHEA, IGF-I?
What Do I Do Until “Treatment
Begins”?
• Don’t waste time on “why”
• Focus on symptoms, signs and health
• Use motivational interviewing techniques
• Plan to gradually improve weight control
habits
• Enlist support from family
• Regular health check visits
• Plan follow-up visit(s) after treatment
begins to reinforce importance and
acknowledge challenge
Stages of Change
 Precontemplation
 Contemplation
 Preparing for Action
 Action
 Maintenance
 Termination
(Prochaska, Norcross, & Diclemente, 1994)
Support for Change in Primary
Care
• Provide information about
• Illness
• Recovery process
• How we get in our own way
• Therapeutic relationship (alliance)
• Awareness of influence of language,
environment and social norms
(Prochaska, Norcross, & DiClemente, 1994)

Principles of Motivational
Interviewing (Miller & Rollnick)
1. Express empathy with adolescent’s

perceptions
2. Develop discrepancy between present
behavior & personal goals
3. Avoid argumentation and defensiveness
4. Redefine, rather than confront, resistance
5. Support self-efficacy through autonomy
support
Engaging Parents in
Treatment
• Developmental framework (child  adult)
• Discuss blame, fault, guilt openly
• Realignment of roles in family
• Positive framing of family attributes
• Future orientation
• Authority to treat, and empowerment of,
professionals comes from parents
Problems Addressed In
Mental Health Treatment
• Low Self-esteem
• Distorted body-image
• Dysfunctional coping behaviors and
habits
• Depression
– SSRIs only for BN or weight recovered
AN
• Ineffective communication
• Conflict resolution
• Lack of assertiveness
Approach for Patients with Eating
Disorders
• Validation
• Direct/specific questions
• Don’t assume, clarify
• Anticipate cognitive distortions and reasoning
errors
• Be genuine/real (not opaque/distant)
• Use warmth, humor, consistency and
persuasiveness
• Educate
• Team approach and good communication
decreases

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Eating Disorder In Teenager’s

dr. Afriyan Wahyudhi, SpA, MKes

DSM-PC, Child and Adolescent Version, AAP,

•  Energy intake results in wasting of lean (muscle) > fat

1. Express empathy with patient’s

(Prochaska, Norcross, & DiClemente, 1994)

1. Express empathy with adolescent’s

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