Childhood Onset Exercise Addiction or Atypical Anorexia Nervosa during Covid-19: Case Report

DOI: https://doi.org/10.21203/rs.3.rs-121005/v2

Abstract

Background:

Childhood-onset Anorexia Nervosa is recognised to be atypical in presentation, both in terms of extent and nature of eating pathology, exercise and compensatory behaviours with many falling short of full diagnostic criteria. Failure to consider an eating disorder diagnosis in youth who present with extreme weight loss may have serious immediate and long term implications. However, failure to consider other non-organic causes of weight loss may be equally detrimental to the child’s health.

Case Presentation:

This case reports on the acute presentation of a 12-year old boy with no prior eating concerns, who presented to hospital in a severely malnourished state eight weeks into lockdown. To compensate for Covid-19 induced restrictions on sporting activity, this boy had followed a self-imposed daily schedule of arduous exercise, without increasing his nutritional intake. This report examines the clinical features suggestive of Anorexia Nervosa and other differential diagnosis. A discussion on the specific diagnostic differential of exercise addiction and challenges faced by youth during Covid-19 restrictions are presented.  

Conclusion:

Accepting that Anorexia Nervosa may present atypically in pre-pubertal youth, it is important that clinicians maintain an open mind in youth presenting without goal directed weight loss. Although weight loss was significant in this case, it was due to an excessive exercise regime. This may have commenced as a coping strategy in response to Covid-19 restrictions but subsequently became excessive and impairing in nature. The collateral damage of Covid-19 mandated restrictions, aimed at containing the spread of the virus, are evident in this case. Clinicians need to be alert to potentially maladaptive coping strategies and unusual or altered pathways of presentation, especially in younger children during these challenging times. 

Background

Anorexia Nervosa (AN) is a disorder characterised by self-imposed food restriction resulting in weight loss coupled with an intense fear of weight gain, or of being fat, and an over-evaluation of body weight and shape (DSM5, 2013). Associated behaviours may include over-exercising, binge eating, purging and use of diet pills or laxatives. In children failure to progress along expected weight trajectories occurs with detrimental effects on physical health. Although anorexia nervosa typically has its age of onset in adolescence, it may present both in pre-pubertal children and older adults. Of particular concern is that prevalence rates of AN have more than doubled in recent years (Steinhausen & Jensen (2015) increasing both in adolescents and younger aged children (Nicholls et al 2011).  Rates of hospital admissions have also increased (Holland et al 2016). The most recent community‐based studies using DSM-5 criteria reported estimated lifetime prevalence of AN of 6.2% for females and 0.3% for males (Silen et al, 2020). Poorer prognostic outcomes are a concern in pre-pubertal youth. AN is recognized to have high morbidity and mortality rates (Smink et al, 2013).  In a large study (n=68) of hospital treated youth under 14 diagnosed with AN, followed up for a mean of 7.5years, only 41% were reported as having a good outcome (Herpertz-Dahlmann et al, 2018). Given low body fat stores in children, weight loss rapidly leads to medical compromise and early onset AN more often presents to the paediatrician and results in hospital admission (Herpertz-Dahlmann et al, 2018). Presentation in younger children may be atypical with proportionally more boys presenting; ratio of girls: boys 4:1 as opposed to the adult ratio of 10:1 (Madden et al, 2009). Early recognition and appropriate treatment is essential to optimise treatment outcomes.

The aetiology of AN is not fully understood and treatment often assumes an agnostic approach.  Its origins are considered to be multifactorial with contributions from cultural, familial, individual, genetic and biochemical domains.  Adverse childhood events, stressors, bully-victim status and personality traits of perfectionism have also been suggested (Copeland et al, 2015). 

Following the declaration of the Corona Virus infection as a pandemic by the WHO in March 2020, governments around the world instigated various measures to contain the virus. In Ireland, as with many countries, these included closure of all non-essential businesses, schools and universities, restriction were imposed on gyms, sporting and training events and limits were placed on social gatherings. Many of these have had a direct impact on the lives of children. Family life has also been disrupted for many, with temporary and permanent job losses, working from home orders, and for some, combining work with home schooling. Prior experience with pandemics has alerted us to the risk of negative effects on mental health and wellbeing, with increases in anxiety, depression and stress (Maunder et al, 2006, Kumar &  Nayar 2020) Data is emerging of adverse effects in adults (Ettman et al, 2020) and in children resulting from Covid-19 pandemic (Racine et al, 2020). Given the salience of social contact and peer relationships during childhood, it is understandable how school closures and reduced social contact have been associated with increased loneliness, anxiety and low mood in youth during the pandemic (Loaded et al, 2020). Specifically, limitations on social gatherings and movement have been found to be associated with reduced levels of physical activity, higher sedentary behaviours and more screen time among Canadian youth aged 5-17 surveyed (Moore at al, 2020). Large scale population surveys have also shown significant effects on eating and exercise behaviours, with deterioration in eating symptomatology in those with pre-existing eating disorders (Phillipou et al 2020). In a national survey relating to post-pandemic changes in eating and exercise behaviours in Australia (N= 180 participants, with self‐reported prior eating disorder), 64.5% of the sample reported increased food restriction, with one quarter to one third showing increased frequency of binge eating and purging (Phillipou et al 2020). Interestingly, self-reported exercise levels increased for some (47.3%) and decreased for others (36%). Other population studies have highlighted the fear among those with AN of sourcing foods consistent with their meal plan (Termorshuizen et al 2020). Increased weight-control behaviours seen have been attributed by some authors to reflect a defence against Covid-19 enforced loss of control (Graell et al 2020). Reports have also described increased care-giver burden experienced by carers during lockdown, along with the urgent need to maintain but modify access to care (Walsh & McNicholas 2020).  Qualitative reports have offered insights into the difficulties brought about by these restrictions, but such reports have been restricted to adult cohorts (Clarke et al, 2020, McCombie et al, 2020).

This paper reports on the acute presentation of a young boy, with no prior eating concerns, who presented to hospital in a severely malnourished state eight weeks into lockdown.  It examines clinical features suggestive of Anorexia Nervosa and other eating disorders, it considers other differential diagnoses, and explores treatment implications. It examines the impact of Covid-19 linked restrictions on social gatherings and physical activity on his presentation. Ethical exemption was granted and written consent provided by the family. Names and minor details have been changed to protect subject anonymity.    

Case Presentation

Oliver is a 12 year old boy admitted to the paediatric hospital following precipitous weight loss as a result of increased exercise, in an otherwise very active and sporty boy. According to his mother, this commenced 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 previously 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 family trampoline, irrespective of weather. Oliver 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 attending school, socialising with peers and his training routine. He recreated this with a self-initiated exercise schedule. At the time of lockdown, Oliver’s father had been abroad and his absence from the family home was further prolonged by a two-week enforced post-holiday quarantine. Oliver’s 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 Oliver’s mother attended her family physician, and was advised to seek hospital admission due to significant weight loss. 

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 had lost almost 5 kilos in 2 months and was medically comprised on admission. His admission weight was 27.5Kg, BMI 12.9 (0.03%) corresponding IBW 70.35%. 

Oliver’s developmental milestones are within normal boundaries. He was described by his mother as a ‘faddy eater’, showing little interest in food and eating much less than his younger siblings, but without adverse effects. Although Oliver ate fast food when out with friends, at home he preferred simple, minimally flavoured, bland foods and rarely ate treats. Mother estimated typical daily intake at 1300- 1500 calories. He was talented athletically, played soccer and football competitively, with a heavy but structured schedule of daily soccer training and weekend competitive games with two different clubs. He was perceived to be popular at school with many friends and academically very able. He engaged well with his family, was generally very active but not considered 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, schedules and well planned activities, his mother 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 his mother’s work with children with special needs, she felt that this was a precise and accurate reflection of his development. Teacher reports described a biddable boy, who excelled in school and sports, with a close circle of friends. He was described as helpful and considerate. There were no concerns expressed by teachers regarding mood, social communication difficulties, or ADHD. There was no prior contact with mental health services and no history of substance misuse. There was no medical history of note, he was up to date with all his vaccinations, had no allergies and was not on any medication.

Oliver is the middle of 5 healthy children aged from 17 to 10. 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 a structured exercise routine built into her day to facilitate weight maintenance. Father, like his siblings, is tall and thin. . All Oliver’s family are sporty, of slim physique and his older brother was a national athlete for many years. The family follow a healthy diet of home based and natural ingredients and limit social media use. His parents describe a happy marriage and no difficulties with co-parenting. Parents described an authoritative parenting style, with low levels of expressed emotions and a preference for advanced planning, routine and structure. By way of example, holidays aboard were planned well ahead of time including scheduling and booking activities on various days. There were no other family stressors reported. There was a history of bipolar disorder on the paternal side, and depression in maternal first degree relative. 

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. Oliver described his mood as mostly ‘sad’ and ‘bored’, he reported difficulty adjusting to lockdown, he missed his friends and soccer training and found the days at home long and uneventful. He reported a preference to have ‘things planned’ and felt better when he joined his mother or brother on their activities. He denied his pursuit of exercise was driven by any wish to alter his body shape or to lose weight. He perceived that his engagement in exercise was ‘80% to stop being bored and 20% to keep fit’ and felt it aligned with the behaviour of his other family members. He recognised that he had become ‘obsessed’ with a desire to exercise and its mood elevating component. If he did not exercise for any reason, which he reported was very seldom, he reported feeling ‘sad’. He volunteered that immediately pre- admission he exercised less because he was too tired. Oliver denied any fear of an untoward outcome if he did not exercise as planned and allowed his brother to choose their cycle route, distance and timing. Although he chose his exact running route, his start time was linked to that of his mother’s walk. During this time, he denied any attempt to limit his calorie intake and stated he enjoyed his meals. He denied any feelings of hunger; ‘it had never occurred to me to eat more, and no one told me’. He described his mood as good unless he was unable to exercise for any reason 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 routine of school, sports and time with friends. He was eager to follow the hospital treatment plan and be discharged. 

Medical examination revealed a cachectic boy, with low body temperature (35.8-36, Normal 37.) There was evidence of cardiac insufficiency;  low heart rate (30s at night time) and orthostatic changes of 22bpm (lying 38/ standing 60). His blood pressure was variable; systolic ranging from 81-105mmHg, diastolic from 52-76mmHg, but with minimum orthostatic changes (< 10 mmHg). His electro-cardiograph revealed sinus bradycardia with normal QTc. There were some initial abnormalities in his biochemistry and haematology results (Table 1). 

Psychometric scales used:

Child Behaviour Check List (CBCL) completed by parents suggested no areas of clinical concern. Oliver completed the Rosenberg Self-Esteem scale, a self-esteem measure widely used in social-science research and helpful to examine self-esteem. Scores below 15 indicate problematic low self-esteem (Rosenberg, 1965). Oliver scored 40/40. The exercise addiction scale was also completed. This is a short screening tool used clinically to examine the possibility of exercise addiction, with scores above 24 being considered clinically relevant. Oliver scored 29/30, indicating significant difficulties. By contrast his global score on the Eating Disorder Examination Questionnaire (EDE-Q) was 0.39, with very low scores on each of the subscales: Restrain: 0; Shape: 0.75 and Weight 0.8, suggesting no eating disordered pathology.

Impression: At the time of admission Oliver was severely undernourished, having lost an excessive amount of body weight in a short time. This was due to a significant imbalance between energy expenditure and intake but without any evidence of eating disordered psychopathology. Specifically, Oliver did not endorse a fear of fatness or weight gain, body image dissatisfaction, or a distorted view of body shape. His excessive engagement in exercise was driven by a desire to impose structure on his day and fight boredom. It was subsequently reinforced by an improvement in his mood.  He did not meet criteria for anorexia nervosa or Atypical Anorexia Nervosa, included in Other Specified Feeding or Eating Disorders (OSFED). A working diagnosis of exercise addition was made (Table 2).

Progress on admission:

Oliver commenced a refeeding program, with a gradual increase from 1400 calories/day to 2000-2400 / day with phosphate and thiamine supplements. He found it very difficult to eat all the food offered, initially eating as little as 400-500 calories/ day. This low intake was driven by severe abdominal discomfort, reflux and severe constipation upon refeeding. Replacement with a nutritional supplement, Fortisip, was given. Oliver had no bowel movements 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 his meal plan, tolerate painful abdominal peristaltic movements and gain the necessary weight needed for discharge. One-one nursing was provided at meal times to support Oliver with oral intake, ensure postprandial bed rest and observe if any desire to exercise. 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, and these were carefully monitoring by his mother and clinical team. Initial progress was followed by 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 as an in-patient, transitional care continued with twice weekly psychiatry/medical review and heightened maternal supervision.  Oliver was discharged to community child and adolescent mental health services (CAMHS) after 2 weeks. His weight at discharge was 30.4kg, BMI 14.5, IBW 82.6%, still below his pre-morbid levels. Zoom out-patient sessions were planned with CAMHS given the reduced face-to-face contact during Covid-19. Oliver found these sessions very difficult, finding it hard to engage and missing out on non-verbal cues. Subsequent Zoom calls continued with his mother who reported on weekly weights and the degree of adherence to the meal plan; he was eating 1800-2000 calories per day without resistance. Oliver’s mother also reported on the return of any physical symptoms and the degree of Oliver’s 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. Oliver was discharged from CAMHS eight weeks post-hospital discharge. Two months post-discharge and 6 months post- initial presentation, Oliver’s mother wrote a letter updating the clinical team as to Oliver’s ongoing progress.  She enclosed a photo of Oliver enjoying a ‘McDonalds’ equivalent. She reported he was ‘back to his normal self’ with resumption of pre-morbid eating habits and reaching his pre-morbid weight. Oliver did not receive any neuroleptic medication during admission, and prescription of thiamine and laxatives had been discontinued. 

Covid-19 impact: Oliver had created a daily routine immediately following the imposed lock down and loss of his previously busy schedule of football training and competitive matches. Initially his pursuit of physical activity followed the family’s engagement in health optimisation during Covid-19 and was pursued as a shared activity. Within a few weeks it surpassed it and seemed to take primacy over other activities. Oliver reported being increasing driven to, and rewarded by, 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, but had not socialised with any face to face. The family coped as best they could with the additional stressors of parents and children working and studying from home. The delay in Oliver’s presentation was most likely due to mother having to manage on her own while her husband was in quarantine. The reduced ability of face-to-face clinical sessions made engagement with ongoing mental health services difficult for Oliver, due to his difficulty picking up subtle non-verbal cues and his difficulty with emotional intelligence. A decision to work  flexibly and independently with his mother, supporting and empowering her to monitor Oliver’s nutritional intake and physical state, allowed safe medical monitoring. 

Discussion And Conclusions

Childhood-onset Eating Disorders (ED) describes the onset of eating psychopathology in children under the age of 13 years. Although the DSM-5 does not have any specifiers for childhood onset Anorexia Nervosa, it is recognised in the literature to present in an atypical fashion, both in terms of degree and type of eating pathology, exercise and compensatory behaviours, with many falling short of the diagnostic criteria for AN (Madden et al, 2009; Nicholls et al, 2011)

Although early onset cases present with lower self-reported eating psychopathology, lower rates of binging, purging and less engagement in excessive exercise as a means of weight and shape control, early onset cases have been reported to lose weight faster, presenting with lower percentage of ideal body weight on admission (Peebles et al. 2006). Rapid weight loss in children places them at high risk of medical destabilisation given they have less adipose tissue than older aged youth (Madden et al, 2009). Many studies suggest earlier onset to be associated with relatively more boys presenting. Whilst adolescent or adult onset ED are viewed to be ten times more common in females than males, ratios of 4:1 have been reported by a national study in Australia (Madden et al, 2009) and 5:1 in United Kingdom and Ireland (Nicholls et al, 2011). Studies that have examined outcomes have also highlighted family and healthcare burden, with two-thirds of cases still in active treatment one year later. 

Given the atypical presentation described in the literature, especially the varied endorsement of typical eating psychopathology, and proportionally higher rates of presentation in boys, such youth may be at risk of delayed diagnosis and treatment. They may also be at risk of iatrogenic harm by nature of inappropriate investigations for weight loss. The alternative is also true; an assumption that all weight loss, or a high drive to exercise, relates to an undisclosed eating disorder might also lead to inappropriate treatment, therapeutic fatigue and family disengagement. Although Oliver never endorsed any eating psychopathology during his stay and he showed a willingness to eat high calorie foods to speed up his recovery, his parents felt that some of the clinicians were working on the assumption of an undisclosed, or yet to emerge, eating disorder.  This led to difficult family-clinician engagement at times, including a discharge against medical advice event. The steady, if slow, progress, the remittance of Oliver’s gastric symptoms and the ongoing commitment by his parents to adhere to a mutually agreed safety plan all allowed an opportunity to continue working therapeutically with the family and consider alternative diagnosis.

At the time of admission Oliver was severely undernourished having lost an excessive amount of body weight in a short time. This was secondary to a significant imbalance between energy expenditure and food intake. Oliver’s increase in physical activity post lockdown was motivated by a desire to impose a routine and re-enforced by mood enhancement. It exceeded his premorbid activity levels, whilst his food intake and eating schedule remained at pre-pandemic levels. His failure to increase his nutritional intake commensurate with energy expenditure was due to a lack of hunger and general disinterest in food, rather than intentional food restriction. Oliver did not endorse a fear of fatness or weight gain, body image dissatisfaction or a distorted view of body shape. He did not meet criteria for anorexia nervosa. Equally Oliver’s presentation was not consistent with Atypical Anorexia Nervosa, included under Other Specified Feeding or Eating Disorders (OSFED) in DSM V, and previously known as Eating Disorder Not Otherwise Specified (EDNOS). Such a diagnosis is considered when prominent eating disorder symptoms are present, including a restricted eating pattern, but the person’s weight remains within normal range. Oliver was underweight and without specific eating psychopathology.

Avoidant/restrictive food intake disorder (ARFID) describes a condition where there is a persistent failure to meet appropriate nutritional or energy requirements such that intervention is required. The food avoidance or refusal may result from a feared aversive consequence from eating, food avoidance based on sensory characteristics of food such as taste, smell or consistency, or a lack of interest in eating.  Typical eating psychopathology as seen in Anorexia Nervosa, such as body dissatisfaction, fear of weight gain or drive for thinness, are lacking.  For a diagnosis of ARFID to be made, the consequences of food restriction must be associated with one of the following; significant weight loss, faltering growth or nutritional deficiency, dependence on nasogastric feeding or nutritional supplements, or a significant impact on psychosocial functioning. A diagnosis of ARFID was considered, in that Oliver presented with low weight, was in need of medical management and nutritional supplements, and there was evidence of adverse medical and psychosocial functioning. However, the salient feature of food restriction causing the weight loss was not present. Although Oliver had shown a lower level of interest in foods than his siblings, this pre-dated his weight loss, and had not changed over this period.  Oliver’s weight loss was as a result of increased energy expenditure and failure to increase his food intake to negate this nutritional deficit. 

The clinical presentation also did not support a diagnosis of Obsessive Compulsive disorder (OCD), characterised by intrusive and unwanted obsessional thoughts, images or urges. Oliver’s engagement in exercise was deliberate, self-driven and enjoyable. In OCD, the associated repetitive behaviours or compulsions are often aimed at reducing the associated anxiety. Whilst Oliver was regretful when unable to carry out his exercise routines as planned, there were no feared consequences or escalation of anxiety. In fact, Oliver did not present with any anxiety symptoms, the only negative mood state being one of sadness due to Covid-19 related restrictions, and subsequent hospital admission. 

A diagnosis of autism spectrum disorder was also considered, but not substantiated. The developmental history offered by his mother did not suggest difficulties with reciprocal friendships, empathy, or social-emotional reciprocity. There was no report of restrictive or repetitive behaviours or interests. Whilst there may have been reduced expression of nonverbal communication, evidenced at time of assessment, it was present at home and more likely to have been influenced by his negative mood state commensurate with admission. Both at home and in the hospital, Oliver used language to communicate feelings (albeit with some reluctance) and engaged in reciprocal conversation. Furthermore, there were no concerns expressed by teachers in this regard. He was perceived to be pro-social and popular. 

 Exercise addiction 

A working diagnosis of exercise addition was considered most appropriate (Table 2).

Exercise is generally considered as healthy and mood enhancing and was recommended as a way to stay healthy during the pandemic. However, unrelenting pursuit and obsessional engagement in exercise, to the point of injury, over-use or disengagement from other activities, is problematic. Prevalence studies range from 0.5% to 52%, depending on whether studies are conducted in the general population (0.5%) or higher risk groups, such as competing triathletes (Blaydon et al, 2002). There are no available studies on prevalence rates in children. Exercise addiction shares many of the constructs more typically associated with addictive behaviours, such as the salience or importance of the activity, sense of loss of control, need to engage in increasing amounts and the experience of withdrawal symptoms when thwarted. The mood enhancing effect may also drive behaviour. Many of these features applied to Oliver; his exercise regime increased over the weeks and he opted to pursue them ahead of social engagement with family or alternative activities. He was also able to acknowledge the mood boosting components, pre-exercise anticipation and enhanced mood following his daily schedule. When disallowed following hospital admission, he felt irritated by his immobility but was also somewhat fatigued by his weakened medical state. 

The Exercise Addiction Inventory (EAI) offers a structured and reliable method of self-report (Terry et al. 2004). It is a short screening tool with good psychometric properties. Using six general components of addiction, responses are given along a 5-point Likert scale with a range of 6–30 points; scores greater than 24 reflective of exercise addiction. Whilst pursuit of exercise is often part of an eating disorder presentation, excessive exercise may occur in the absence of any eating psychopathology and in the absence of any reduced health-related quality of life (Lichtenstein et al. 2013). Personality traits such as perfectionism and narcissism, often associated with ED, have been described. These traits are considered to contribute to athletic excellence and an ability to withstand high degrees of bodily distress in terms of pain and exercise related injuries (Lichtenstein et al. 2013). However excessive exercise, not met with adequate nutrition, can lead to serious weight loss, body disfigurement and illness, along with loss of insight. Treatment is directed towards re-establishing health and moderating the level of activity, through cognitive behavioural approaches. Medication may be helpful for any associated depression, anxiety or medical compromise. Following adequate weight restoration Oliver’s treatment plan as an OPD included psycho-education regarding the role of nutrition and exercise in health and variations in energy requirements for males during puberty and at different levels of activity.   Identification of excessive or disordered exercise schedules were discussed along with examining the benefits of alternative and less intense exercise, such as mindfulness, yoga and walking. The prosocial aspect of exercise was also emphasised. 

Conclusion

Accepting that the clinical features of early onset Anorexia Nervosa may be atypical, it is important to maintain an open mind in cases presenting without goal directed weight loss. Although weight loss was significant in this case, its occurrence was due to an excessive drive to exercise without increasing calorific intake. In Oliver’s case, his exercise schedule might be seen as a coping mechanism to the ongoing stress and loss of structure brought about by Covid-19 restrictions. His failure to recognise bodily hunger signs and his general disinterest in food contributed to his weight loss Maternal delayed awareness was associated with additional roles and stressors brought about by Covid-19, such as working from home, temporarily single-handedly parenting 5 children, concern for her husband quarantined abroad. The relatively short resolution of Oliver’s difficulties lay in the absence of pre-morbid psycho-pathology, the family’s structured yet nurturing style and the flexibility offered by the hospital and community services to adapt during a time of Covid-19 induced unprecedented challenges.

Abbreviations

AN: Anorexia Nervosa; BMI: Body mass Index; IBW: Ideal Body Weight; EDE-Q: Eating Disorder Examination Questionnaire; CAMHS: Child and adolescent mental health services; ED: Eating Disorder; EAI: Exercise Addiction Inventory.

Declarations

Ethical Approval and Consent to participate:

Ethics exemption was received.

Consent for publication:

Informed assent and consent have been received from the family for publication.

Availability of supporting data: 

Additional information available from the author upon request Competing interests:

The author, Fiona McNicholas has no competing interests.

Funding:

No funding has been received.

Authors' contributions:

The paper was written in full by Prof Fiona McNicholas

Acknowledgements:

To Oliver and his family (not his real name) and all the multi-disciplinary team in the hospital for the care provided in this young boy’s case.

References

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013
  2. Blaydon MJ, Lindner KJ, Kerr JH. Metamotivational characteristics of eating-disordered and exercise-dependent triathletes: An application of reversal theory. Psychology of Sport and Exercise. 2002 Jul 1;3(3):223-36.
  3. Clark Bryan D, Macdonald P, Ambwani S, Cardi V, Rowlands K, Willmott D, Treasure J. Exploring the ways in which COVID‐19 and lockdown has affected the lives of adult patients with anorexia nervosa and their carers. European Eating Disorders Review. 2020.
  4. Copeland WE, Bulik CM, Zucker N, Wolke D, Lereya ST, Costello EJ. Does childhood bullying predict eating disorder symptoms? A prospective, longitudinal analysis. International journal of eating disorders. 2015 Dec;48(8):1141-9.
  5. Duan L, Shao X, Wang Y, Huang Y, Miao J, Yang X, Zhu G. An investigation of mental health status of children and adolescents in china during the outbreak of COVID-19. Journal of affective disorders. 2020 Oct 1;275:112-8.
  6. Ettman CK, Abdalla SM, Cohen GH, Sampson L, Vivier PM, Galea S. Prevalence of depression symptoms in US adults before and during the COVID-19 pandemic. JAMA network open. 2020 Sep 1;3(9):e2019686-.
  7. Graell M, Morón‐Nozaleda MG, Camarneiro R, Villaseñor Á, Yáñez S, Muñoz R, Martínez‐Núñez B, Miguélez‐Fernández C, Muñoz M, Faya M. Children and adolescents with eating disorders during COVID‐19 confinement: Difficulties and future challenges. European Eating Disorders Review. 2020 Nov;28(6):864-70.
  8. Herpertz‐Dahlmann B, Dempfle A, Egberts KM, Kappel V, Konrad K, Vloet JA, Bühren K. Outcome of childhood anorexia nervosa—The results of a five‐to ten‐year follow‐up study. International Journal of Eating Disorders. 2018 Apr;51(4):295-304.
  9. Holland J, Hall N, Yeates DG, Goldacre M. Trends in hospital admission rates for anorexia nervosa in Oxford (1968–2011) and England (1990–2011): Database studies. Journal of the Royal Society of Medicine. 2016 Feb;109(2):59-66.
  10. Kumar A, Nayar KR. COVID 19 and its mental health consequences. Journal of Mental Health. 2020 Apr 25:1-2.
  11. Lichtenstein MB, Hinze CJ. Exercise addiction. InAdolescent Addiction 2020 Jan 1 (pp. 265-288). Academic Press.
  12. Loades ME, Chatburn E, Higson-Sweeney N, Reynolds S, Shafran R, Brigden A, Linney C, McManus MN, Borwick C, Crawley E. Rapid systematic review: the impact of social isolation and loneliness on the mental health of children and adolescents in the context of COVID-19. Journal of the American Academy of Child & Adolescent Psychiatry. 2020 Jun 3.
  13. Madden S, Morris A, Zurynski YA, Kohn M, Elliot EJ. Burden of eating disorders in 5–13‐year‐old children in Australia. Medical Journal of Australia. 2009 Apr;190(8):410-4.
  14. Maunder RG, Lancee WJ, Balderson KE, Bennett JP, Borgundvaag B, Evans S, et al. Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak. Emerging infectious diseases. 2006 Dec;12(12):1924.
  15. McCombie C, Austin A, Dalton B, Lawrence V, Schmidt U. “Now It's Just Old Habits and Misery”–Understanding the Impact of the Covid-19 Pandemic on People With Current or Life-Time Eating Disorders: A Qualitative Study. Frontiers in Psychiatry. 2020 Oct 27;11:1140.
  16. Moore SA, Faulkner G, Rhodes RE, Brussoni M, Chulak-Bozzer T, Ferguson LJ, Mitra R, O’Reilly N, Spence JC, Vanderloo LM, Tremblay MS. Impact of the COVID-19 virus outbreak on movement and play behaviours of Canadian children and youth: a national survey. International Journal of Behavioral Nutrition and Physical Activity. 2020 Dec;17(1):1-1.
  17. Nicholls DE, Lynn R, Viner RM. Childhood eating disorders: British national surveillance study. The British Journal of Psychiatry. 2011 Apr;198(4):295-301.
  18. Peebles R, Wilson JL, Lock JD. How do children with eating disorders differ from adolescents with eating disorders at initial evaluation?. Journal of Adolescent Health. 2006 Dec 1;39(6):800-5.
  19. Phillipou A, Meyer D, Neill E, Tan EJ, Toh WL, Van Rheenen TE, Rossell SL. Eating and exercise behaviors in eating disorders and the general population during the COVID‐19 pandemic in Australia: Initial results from the COLLATE project. International Journal of Eating Disorders. 2020 Jun 1.
  20. Racine N, Cooke JL, Eirich R, Korczak DJ, McArthur B, Madigan S. Child and adolescent mental illness during COVID-19: A rapid review. Psychiatry research. 2020 Oct 1.
  21. Rosenberg M. Rosenberg self-esteem scale (RSE). Acceptance and commitment therapy. Measures package. 1965;61(52):18.
  22. Silén Y, Sipilä PN, Raevuori A, Mustelin L, Marttunen M, Kaprio J, Keski‐Rahkonen A. DSM‐5 eating disorders among adolescents and young adults in Finland: A public health concern. International Journal of Eating Disorders. 2020 May;53(5):520-31.
  23. Smink FR, van Hoeken D, Hoek HW. Epidemiology, course, and outcome of eating disorders. Current opinion in psychiatry. 2013 Nov 1;26(6):543-8.
  24. Termorshuizen JD, Watson HJ, Thornton LM, Borg S, Flatt RE, MacDermod CM, Harper LE, van Furth EF, Peat CM, Bulik CM. Early Impact of COVID-19 on Individuals with Eating Disorders: A survey of~ 1000 Individuals in the United States and the Netherlands. medRxiv. 2020 Jan 1.
  25. Terry A, Szabo A, Griffiths M. " The Exercise Addiction Inventory: A new brief screening tool": Erratum.
  26. Steinhausen HC, Jensen CM. Time trends in lifetime incidence rates of first‐time diagnosed anorexia nervosa and bulimia nervosa across 16 years in a Danish nationwide psychiatric registry study. International Journal of Eating Disorders. 2015 Nov;48(7):845-50.
  27. Walsh O, McNicholas F. Assessment and management of anorexia nervosa during COVID-19. Irish Journal of Psychological Medicine. 2020 Sep;37(3):187-91.

Tables

Table 1

Blood tests

WCC

RBC

U&Es

Liver Function

2.8 (4.5–13.5)

Plat 140 (150–450)

RBC 3.72 ( 4.2–5.2)

Hg 107 (115–155)

Na130 ( 135–145)

K 2.9 ( 3.6-5)

Protein 59 (60–80)

AST 42 (< 40)

ALT 53 (< 35)

LDH 788 ( 233–600)

Urea 7.3–8.3 (2–6)

Phosphate 47 50–350)

Inorganic Phos .61

(1.2-2)

Mg 0.68 (0.7–1.1)

Ca 2.38 (2.4–4.33)

TFT Normal

Parathyroid Normal.

   
Normal laboratory reference ranges are in parentheses

Table 2

Diagnostic Criteria for Anorexia Nervosa: DSM-5 compared with Oliver’s presentation

Diagnostic Features of AN

Oliver

Significant food restriction leading to failure to continue along developmentally appropriate weight trajectory

No food restriction; calories consumed were as before but inadequate for energy expended

Fear of becoming fat or gaining weight

No fear of weight gain, rather a recognition of being ‘too thin’ and a willingness to regain weight lost

Over valuation or distorted view of body weight and shape (or parts of body)

Perceives self as underweight, eager to return to pre-morbid state

No desire to alter body shape by exercise

Behaviour motivated by desire to avoid weight gain, maintain low body weight

Exercise was driven by a desire for structure and became positively re-enforced by mood boosting effect