Eating disorders in adolescence

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ITAL J PEDIATR 2004; 30: 00-00

THE PEDIATRICIAN AND THE ADOLESCENT Section Editor: S. Bertelloni

H. CHABROL, R. RODGERS, A. ROUSSEAU Centre d’Etudes et de Recherche en Psychopathologie, Université de Toulouse-Le Mirail, France

Eating disorders in adolescence MANCA titolo italiano

SUMMARY Cases of anorexia nervosa and bulimia nervosa are rare, but partial anorexic and bulimic syndromes are frequent in adolescents. They are related to the frequency with which adolescents are dissatisfied with their bodies, a reflection of the restrictive social ideal of thinness. The risks of eating disorders and psychological and physical disorders persisting into adulthood are high. The few controlled studies carried out in university centres have shown some success but so far it is unknown if results would apply to ordinary treatment conditions. Studies in prevention have so far only met with a limited success.

RIASSUNTO Nell’adolescenza i casi di anoressia e bulimia nervosa sono rari, ma le sindromi anoressiche e bulimiche sono frequenti; la loro incidenza è in relazione alla frequenza con la quale gli adolescenti sono insoddisfatti del loro aspetto fisico – riflettendo l’ideale sociale della magrezza. Il rischio che tali disturbi del comportamento alimentare, nonché i distrurbi psicologici e fisici persistano fino all’età adulta è elevato. Resta da verificare se i risultati dei pochi studi controllati svolti in centri universitari siano ottenibili anche al di fuori dell’ambito della ricerca. Gli studi mirati alla prevenzione, invece, hanno dato scarso successo.

Key words Anorexia • Bulimia • Subclinical eating-disorders

Parole chiave Anoressia• Bulimia• Disturbi subclinici del comportamento alimentare

INTRODUCTION Adolescent eating disorders are a serious health problem in western societies. If cases of anorexia nervosa and bulimia nervosa are rare, partial syndromes of these disorders are frequent and frequently lead to psychological and physical problems in early adulthood. the available data on the effectiveness of treatments and prevention remains very insufficient.

SYMPTOMS AND CLASSIFICATION Anorexia and bulimia are both characterized by a common syndrome that includes a loathing of one’s physical appearance, an obsessive fear of losing control of one’s eating behaviour and fear of gaining weight. Anorexia nervosa is defined by an substantial loss of weight (body weight less than 85% of normal weight in relation to age and height) brought on by severe eating restrictions due to the belief of being overweight and that certain parts of the body are too fat. Two

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types are recognised: the restrictive type (with no binge-eating or vomiting, or use of laxatives or diuretics) and the binge-eating type (with bingeeating and/or vomiting, use of laxatives or diuretics). Nearly 50% of anorexics develop bulimic behaviour. In most cases weight loss only serves to increase the fear of gaining weight or becoming fat and reinforces restriction. Anorexics actively fight against the hunger pains they feel. The loss of hunger sensations can occur only belatedly. Anorexics usually deny being thin and many still believe themselves to be overweight although painfully thin. This denial can reach near delirious proportions and resist all attempts of rational explanation. Others admit being slim or even thin, but remain very worried about certain areas of the body (especially the stomach, bottom, and thighs) that they believe are still too fat, despite their denied thinness, and that they aim to reduce in size. Most of them refuse to admit that their thinness could have serious medical consequences and the denial of their illness seems complete. Bulimia is characterized by repeated episodes of uncontrollable binge-eating, followed by compensatory behaviour. Two types are recognised: the purging type defined by regular vomiting and use of laxatives, diuretics or enemas, and the nonpurging type that mainly involves excessive dieting and exercise. These various criteria have given rise to several minor types of anorexia and bulimia referred to as sub-clinical disorders. These are characterized by fewer and/or less intense and/or frequent symptoms. So far their definition has not been agreed upon.

H. CHABROL, R. RODGERS, A. ROUSSEAU

Table I shows the main signs that should be alarming for general pediatricians.

EPIDEMIOLOGY There are few disorders that fit the international classification diagnosis. Recent studies have reported that less than 1% of girls are affected by anorexia and bulimia 1-3. Sub-clinical disorders or partial anorexic or bulimic syndromes are more frequent. Depending on their definition, rates for girls very from between 1% 1 to 3% 3, 8% 2 or 20% 4. Male anorexia and bulimia are very rare, but subclinical disorders seem to be on the increase.

COMORBIDITY OF ANOREXIC AND BULIMIC DISORDERS In clinical or community population samples, there is a high proportion of comorbidity of anorexia nervosa and bulimia and their partial syndromes. The most frequent disorders are depressive disorders, anxiety disorders, particularly separation anxiety and generalised anxiety, personality disorders, use of psycho-active substances 1. Adolescent anorexia is often accompanied by obsessive, hysterical, narcissic, borderline or schizoid personality traits, bulimia by borderline or hysterical personality traits 5.

EVOLUTION Long term and short term risks are somatic complications linked to the lack of nutrition in anorexia. The main risk is osteoporosis. Cerebral atrophy is frequent, but reversible in recent anorexias; and cardiac rhythm disorders are a great threat. In cases of severe undernourishment the immune system is weakened. Bulimia carries the risk of tooth decay due to vomiting, impaired renal functions and car-

Tab. I. Signs and symptoms that must alarm the general pediatrician.

Quick weight loss or weight fluctuations. Menstrual irregularity or amenorrhoea occurring after regular menses have appeared. Parotid hypertrophy or erosion of the dental enamel which can reveal vomiting. Calluses over the knuckles of the dominant hand which are linked to self-induced vomiting. Excessive weight concerns. Dieting even though underweight. Fasting. Excessive exercice.

diac rhythm disorders. Eating disorders present the risk of evolving towards chronic conditions in the long term, and physical and mental problems in adulthood. Clinical studies of the evolution of anorexia Estimates of the frequency of recovery vary and are very much a function of the criteria chosen. Rates of complete recovery are estimated to lie between 30% and 75% in studies carried out in specialised university centres 6-8. If the return to normal weight is frequent, it would seem that psychiatric disorders (depressive disorders, anxiety disorders, substance abuse, personality disorders), psychological difficulties and scars (bodily dissatisfaction, minor eating disorders, self-esteem disorders, relational and sexual disorders) are also frequent. Other adolescents evolve towards bulimia. Yet others experience relapses and chronic conditions. Death due to somatic complications or suicide occurs in 5-10% of cases. Prognosis factors are still open to discussion. Two main criteria seem to be put forward: firstly, the lower the minimal weight reached by the adolescent, the worse the outcome; secondly, the shorter the duration of the illness, the better the prognosis. Clinical studies of the evolution of bulimia Bulimia can also evolve over a period of years with periods of partial remission and relapses. Even in cases of 2

prolonged remission, psychiatric disorders, difficulties and psychological scars frequently remain. Fichter and Quadflieg (1996) 6 followed 32 young bulimics aged from 16 to 20 during their treatment: 2 years later, 50% were still bulimic, 3% had become anorexic and only 47% were free from eating disorders. Herzog et al. (1999) 7 followed 110 bulimic adolescents and young adults for 7.5 years: 74% went into complete remission, the medium necessary time being 90 months; 1% of the cases of bulimia persisted throughout the period; the others showed partial remissions; 35% of the cases of bulimia that went into complete remission relapsed. No prognosis factor has been put forward. Community studies These have shown that adolescent anorexia and bulimia generally have a less severe evolution than in clinical studies whilst revealing that subclinical forms or certain isolated symptoms were associated with a high risk of mental health and physical disorders in early adulthood 9 10. Lewinshon et al. (2000) 1 and Striegel-Moore et al. (2003) 11 have studied the evolution of subjects having suffered in adolescence from a partial or complete anorexia or bulimia syndrome. These partial or complete syndromes all had a similar fate: they had all evolved towards remission during adolescence and few had relapsed in early adulthood. The adolescents having had an eating dis-

EATING DISORDERS IN ADOLESCENCE

order presented a higher risk of eating disorders, depressive disorders, anxiety disorders, substance abuse, disruptive behaviours, antisocial personalities and borderline personalities in early adulthood. Despite an apparent remission of eating disorders for most of them, the adolescents having suffered from an eating disorder experienced a more difficult psychosocial adaptation than the other groups. These disruptions were indicated by self-esteem disorders, depressive symptoms, poor physical health, lower academic achievement, fewer social connexions, less family support and a higher number of negative events endured throughout the year.

DETERMINISMS Anorexia nervosa and bulimia are related to multiple and heterogeneous factors: psychological, familial, social and biological factors that exert a mutual influence upon each other and contribute to trigger, maintain and aggravate eating disorders. Personal factors Bodily dissatisfaction is the main risk factor. A longitudinal study of 1,100 adolescents without eating disorders has evaluated the risks of appearance of one of these disorders over a period of 3 years 12. Preoccupation with physical thinness and social pressure towards thinness were the only significant predictors of the appearance of eating disorders. Bodily dissatisfaction is frequent in adolescents. A study gathering over 15,000 adolescents in the European Union found that 69% of this sample were dissatisfied with their weight 13. A longitudinal study in a community sample of adolescents showed that perfectionism associated to slimness was a risk factor for developing anorexia, whereas bulimia was predicted by negative emotions 14.

Familial factors Eating disorders have been linked to psychiatric disorders, in particular depression, or parental personality traits or types of familial relations. It is also difficult to differentiate between pre-existing disorders and those induced by eating disorders that submit parents to high levels of tension. Eating disorders can cause major dysfunctions within families. A longitudinal study of 800 children over a period of 17 years showed a link between the development of eating disorders in adolescence and early adulthood and, disorders of the fatherchild relationship, lack of affection shown to the child, lack of communication with the child, and weak identification of the child with the father 15 . Physical neglect and sexual abuse in childhood were also risk factors for the later development of eating disorders. Social and cultural factors The main factor is the social ideal of thinness. Adolescents today are intensively exposed from childhood to an extreme norm of thinness conveyed by tremendous media pressure. Women’s magazines in particular present anorexic young women put forward as the ideal feminine model. A longitudinal study examined 6,982 girls aged from 9 to 14 twice at a oneyear interval 16. Among the factors studied, worries about weight, the importance of thinness for friends, and the influence of the media (trying to look like women seen on television, on film or in magazines) predicted resorting to vomiting and the use of laxatives. The intense media pressure on dieting contributes to the setting off of eating disorders. Adolescents are exposed to an unprecedented emphasis on dieting to meet the social expectations for thinness. However, dieting is a relatively ineffective method of weight control and usually leads to a weight gain greater than the weigh loss when the diet is stopped. Dieting may trigger an eating disor3

der. A diet is usually found to have preceded the eating disorder in adolescents. Pediatricians must warn adolescents and their parents of the harmful effects of dieting. Biological factors Under-nourishment has a high psychological impact. It favours locking oneself into anorexic patterns of behaviour. Under-nourishment produces rigid ways of thinking and reactions that are fixed into inflexible stereotypes, almost out of reach of psychotherapy. Under-nourishment produces binge-eating as the compensatory behaviours encourage bulimic phases in both anorexics and bulimics.

TREATMENT Treatments associating different styles of interventions, psychotherapeutic and nutritional, aim to take into account the different aspects of eating disorders. In anorexia as in bulimia, the emphasis is on weight gain and nutritional re-education that may require hospitalisation. In the absence of an improvement in diet and sufficient weight gain, any psychotherapeutic attempt stands less chance of succeeding. There are very few existing controlled studies on adolescent anorexia and bulimia and no therapeutic controlled studies concerning sub-clinical disorders. There is very little scientific evidence as to the efficiency of these therapies. Hospitalisation In cases of anorexia, hospitalisation is often necessary when the weight is 25% or more under the ideal average weight for girls of the same age and height. In bulimia, the recurring episodes of binge-eating and vomiting several times a day can make hospitalisation necessary. Re-nourishment is an important part of treatment. In anorexia, the nearer

H. CHABROL, R. RODGERS, A. ROUSSEAU

to ideal weight the adolescent, the lower the risk of relapse. Weight gain must be cautious and progressive, never more than 1 kg to 1.5 kg a week. The weight contract usually defines that an adolescent will be discharged when he/she has obtained or stabilised around a weight that is 90% to 100% of the ideal average weight according to her age and height. It may mention the advantages to be obtained at each level of weight gain (contact with parents, recreational activities, trips in or out of the hospital). In bulimia it is also important for weight to approach the ideal weight and, to re-establish healthy eating habits. Guidance towards an appropriate physical activity, combining enjoyment and healthiness, is a useful therapeutic tool. Individual psychotherapies Cognitive-behavioural psychotherapies have been studied mostly in adults samples, and have not been the object of any controlled studies in adolescents. They are mainly put into practice in cases of bulimia, where they rely on several components: increasing self-esteem and body image; developing coping capacities when faced with interpersonal problems that contribute to triggering bulimic binge-eating – such as social skills training and problem solving; learning to recognise emotional states, thoughts and feelings that may trigger binge-eating, and developing alternative thoughts and behaviours; dietary re-education and physical activity. There are no controlled studies on the efficiency of psychodynamic psychotherapies. Family therapies Systemic therapies have had a relatively large impact on family thera-

pies for anorexia; Psychoanalytical family therapies are harder for parents to bear, as is the therapeutic approach suggested by Selvini-Palazzoli et al. (1990), which immediately confronts parents with their responsibilities by establishing a link between anorexia and marital disagreements 17. Evaluation studies Russell et al. (1987) have shown that a family therapy of systemic inspiration was more efficient than individual therapy for anorexics and bulimics aged below 19 years 18. Robin et al. (1999) have also compared family therapy and individual therapy for anorexic adolescents 19. Approximately half of the subjects were hospitalised at the start of treatment. The therapeutic sessions were initially held weekly, then twice monthly. On average, both therapies lasted 16 months. Their family therapy is an eclectic therapy that borrows from both systemic therapies and cognitive behavioural therapies. The individual therapies were based around the individualisation process, development problems and their relations to eating disorders and body image. Both treatments proved to be successful. The planned weight was achieved by two thirds of the adolescents at the end of treatment. The eating behaviours and affective disorders were improved. Both therapies obtained similar modifications of the ego functioning and family interactions. The results were consistent one year after the end of therapy. There are very few studies that examined the results of usual therapies. The monitoring of 216 adolescents suffering from anorexia, bulimia or a non-specified eating disorder over a 5-year period, showed that possible treatment had no influence on the course of the illness 20. The authors

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concluded that: “the efficacy of existing interventions is questionable” (p. 1254).

PREVENTION The frequency of eating disorders has led to prevention programmes in educational settings. The studies carried out have led to variable results: some claim a relative success, others have had no results. The most pertinent targets seem to be body dissatisfaction and the influence of the social ideal of thinness. An Italian study 21, representing the few European programs, evaluated the preventative effect of 4 weekly 2 hour sessions in schools. The subjects touched upon were weight changes in puberty, body dissatisfaction, the wish to lose weight in order to increase self-esteem and be attractive to others, difficulties linked to adolescence, interpersonal relations within the family and with friends, clashes induced by the search for autonomy, anorexia and bulimia, the frequency of diets and the problems caused by diets, social and cultural aspects such as attitudes towards food and meals and social pressure towards thinness. The program reduced body dissatisfaction in the adolescents defined as low-risk, but was unsuccessful for the adolescents in the high-risk group. This study shows the limitations of prevention campaigns. To start with, it would be difficult to extend this type of program to all adolescents. Despite satisfactory conditions – competent professionals, a duration of 8h, relatively small groups – the success was limited. Further work is needed in order to evaluate such programs that could be more easily distributed on a wider scale.

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Submitted: June 10, 2004 Correspondence: Dr. H. Chabrol Centre d’Etudes et de Recherche en Psychopathologie, Université de Toulouse-Le Mirail, France E-mail: [email protected]

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