Oliver is a 12 year old boy admitted to the paediatric hospital, following precipitous weight loss, as a result of increase exercise in an otherwise very active and sporty boy. According to his mother, this commences the ‘day after lockdown’ and was not linked with any intentional reduction in food intake or body image dissatisfaction. In fact Oliver maintained the position that he was too thin. In the days after lockdown, to replace his previous structured day, he started running 10-11k a day, initially alongside his mother’s daily walk, and later independently and much faster. He later joined his brother in cycling 10-20k daily and spent evening hours on the trampoline, unrelated to weather. He joined the family for meals as per norm with no reduction in usual amounts or variety consumed, and there was no obvious change in his mood state.
During Covid-19 restrictions, Oliver missed his social contact and school routine and recreated this himself with his own personally driven and initiated exercise schedule. At the time of lockdown, Oliver’s father had been abroad and his absence from the family home further prolonged by a two-week enforced post-holiday quarantine. Mother was balancing a heavy work-at-home schedule with providing for her other children, and the extent of Oliver’s exercise and associated weight loss, in the presence of usual eating and general demeanour had gone unnoticed until father’s return. It was at that point that mother attended her family physician, and based on the extent of weight lost, presented to the Emergency department.
Degree of weight loss: Pre-morbidly Oliver’s weight was estimated at 33.1kg, corresponding to a Body Mass Index (BMI) of 15.6 (15th %) or 90% Ideal Body Weight (IBW). He lost almost 5 kilos in 2 month and was medically very comprised on admission. His admission weight was 27.5Kg, BMI 12.9 (0.03%) or IBW 70.35%.
Oliver’s developmental milestones are within normal boundaries. He was always somewhat of a faddy eater, eating much less than even his younger siblings, but never suffered any ill consequences. Mother estimated typical daily intake at 1300- 1500 calories daily. He is talented athletically, plays soccer and football competitively, with a heavy but structured training timetable schedule of daily soccer training, and weekend competitive games with two different clubs. He is popular at school with many friends and academically very able. He engaged well with his family, was generally very active but not perceived to have difficulties with attention or impulsivity. There was no suggestion of any pre-morbid anxiety, obsessional features or low mood. Although he generally liked routines, and well planned activities, mum was adamant that there were no social communication difficulties. He was self-sufficient, empathetic and not overly emotional, tending to deal with difficulties or upsets himself. Given mother’s work with children with special needs, she felt that this was a precise and accurate reflection of his presentation. There was no prior contact with mental health services.
Oliver is the middle of 5 healthy and well-adjusted children aged from 17 to 10. His parents describe a happy marriage and no difficulty with co-parenting. Mother describes some personal difficulties with weight maintenance and past dieting behaviour, with weight fluctuation of 2 stone. At the time of presentation, she was happy with her weight, and had an exercise routine built into her day to ensure stability. Father is tall and thin, as are all his siblings. All the family are sporty, of slim physique and Oliver’s older brother was a national athlete for many years. The family follow a very healthy diet of home based and natural ingredients and limit social media use. Parents described and displayed a good and nurturing home environment with low levels of expressed emotions.
MSE: Oliver was extremely thin, gaunt, with a very visible skeletal frame. He found it hard to engage and eye contact was generally poor. Speech was low in volume and conversation restricted. He denied any evidence of eating psychopathology and endorsed an obsession with a need to exercise, and its mood elevating component. He denied any attempt to limit his calorie intake, sated he enjoyed his meals, but denied any feelings of hunger, ‘it had never occurred to me to eat more, and no one told me’. He described his mood good until he was prevented from exercising, and denied any ideas or behaviours linked to self-harm. There was no evidence of any abnormal thought form or perceptual abnormalities. His thought content was very much focussed on his desire to return to his usual sports, go home and play with his friends. He was eager to follow the treatment plan and be discharged.
Medical examination revealed a catechetic boy, with cardiac insufficiency with low heart rate (30s at night time), low blood pressure and abnormalities in his biochemistry and haematology results. Electro-cardiograph revealed sinus bradycardia with normal QTc.
Impression: At the time of admission Oliver was severely undernourished, having lost an excessive amount of body weight in a short time, secondary to significant imbalance between energy expenditure and intake, but with no eating disordered psychopathology. He was not felt to meet criteria for anorexia nervosa, and a working diagnosis of exercise addition was considered (Table 1). Child Behaviour Check List completed by parents suggested no area of clinical concern. Oliver completed the Rosenberg Self-Esteem scale, scoring 40/40. He scored very highly on the exercise addiction scale, scoring 29/30, indicating significant difficulties. By contrast his global score on the Eating Disorder Examination Questionnaire (EDE-Q) was 0.39, suggesting no pathology, reflected by very low scores on each of the subscales: Restrain: 0; Shape: 0.75 and Weight 0.8.
Table 1
Diagnostic Criteria for Anorexia Nervosa: DSM-5, as pertains to Oliver
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Diagnostic Feature
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Oliver
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Significant food restriction leading to failure to continue along developmentally appropriate weight trajectory
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No food restriction, calories consumed as before, but inadequate to energy expended
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Fear of becoming fat or gaining weight
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No fear weight gain
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Over valuation or distorted view of body weight and shape (or parts of body)
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Perceives self as underweight, eager to return to pre-morbid state
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Behaviour motivated by desire to avoid weight gain, maintain low body weight,
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No, exercise was part of a desire for structure and became mood boosting
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Progress on admission:
Oliver commenced a refeeding program, with a gradual increase from 1400 calories/day to a meal plan of 2000-2400 with phosphate and thiamine supplements. He found it very difficult to eat all the food offered, eating as little as 4-500 calories per day initially. This low intake was driven by severe abdominal discomfort upon refeeding, reflux, and severe constipation. Oliver had no bowel movement over a 4 week period, despite heavy doses of laxatives. Clinical examinations and plain film of abdomen did not reveal any evidence of impaction. His mood dropped significantly as he struggled to adhere to the meal plans, tolerate painful abdominal peristaltic movements, leading to poor weight gain. His parents also struggled with what they perceived to be the multi-disciplinary team’s over focus on weight restoration and a fear that Oliver’s complaints were misinterpreted as wilful refusal, rather than an inability to eat. They considered discharge against medical advice. An early intensive transitional out-patient plan was progressed to facilitate family engagement and assist with careful weight restoration. Oliver was allowed trials home for family meals and over-nights, despite being medically compromised, with careful monitoring by his mother. Initial progress was met with a significant drop in weight and low sodium which precipitated a medical re-admission and a need for cardiac monitoring. Oliver admitted he had been spitting out half of the food plated by his mother, for fear of a return of his abdominal pain. After one week of medical stabilization, transitional care continued with twice weekly psychiatry/medical review, allowing discharge to community child and adolescent mental health service (CAMHS) after 2 weeks. His weight was 30.4kg, BMI 14.5, IBW 82.6%, still below pre-morbid levels.
Zoom out-patient sessions were planned with his CAMHS, given reduced face-to-face contact during Covid-19. Oliver found these sessions very difficult, finding it hard to engage and missing out on no-verbal cues. Subsequent Zoom calls were with his mother who reported on adherence to the meal plan, (he was eating 1800-2000 without resistance), weekly weights, any physical symptoms, and general re-engagement with family and social life. Casual sporting activities were gradually re-introduced. With time, and restoration of initial weight lost, additional snacks were dictated by preference rather than imposed. He was discharged from CAMHS 8 weeks post hospital discharge and correspondence 2 months later, 6 moonths post initial presentation, with an enclosed photo of Oliver enjoying a ‘McDonalds’ equivalent, reported he was ‘back to his normal self’ with pre-morbid eating habits and reaching his pre-morbid weight. Oliver did not receive any neuroleptic medication during admission.
Covid-19 impact: Oliver created his own daily routine following the imposed lock down and loss of his previously busy schedule of football training and competitive matches. Initially this followed the family’s engagement in health optimisation during Covid-19, and pursued as a shared activity, but quickly surpassed it, and seemed to take primacy over other activities. Oliver seemed increasing driven and addicted to the mood boosting effects of his exercise, and being unaware of any hunger sensations, continued with his previous scheduled meal and snack routines. He maintained contact with some friends through social media, and the family coped well with any additional stressors from both parents and all children working and studying from home. The inability of face-to-face clinical session made ongoing CAMHS difficult for Oliver, due to his difficulty picking up subtle non-verbal cues and his difficulty with emotional intelligence but flexibility of CAMHS approach allowed safe medical monitoring by empowering and informing his mother.