Childhood onset exercise addiction or atypical anorexia nervosa during Covid-19: case report

Abstract

Background Childhood-onset Anorexia Nervosa (AN) 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, 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 AN 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 AN 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.

The Long-Term Impact of Covid-19 On Presentations To A Specialist Child & Adolescent Eating Disorder Program

“…The majority were attending secondary school (88%). Nearly all youth (93%) referred had a diagnosis of Anorexia Nervosa (AN) made post ED specialist team assessment, with non -AN cases (7) all being referred post pandemic. The majority (N=101, 78.9%) had at least one co-morbidity, most often a mood disorder (N=76, 59%).…”

“…[15] It is possible, and reported, that initial adaptive coping strategies may become excessive over time, and lead to engagement in excessive exercise regimes, calorie counting, or restrictive eating. [7] Deschasaux-Tanguy and colleagues also reported on mixed changes in diet and physical activity with half (52.8%) of their sample reporting a decrease in physical activity, early weight gain reported by a third (35%) while weight loss was reported by almost a quarter (23%). [16] The extent and nature of psychological di culties in youth during Covid-19 is complex, mixed and unequal [17] In the current study, many youth (80%) self-declared Covid-19 as having had an adverse effect on their overall wellbeing and this was viewed as contributory to their ED pathology.…”

“…This offers some support to this study, and that of others, suggesting atypicality in clinical presentation. [7] Fear was expressed early on about the impact of 'stay at home' orders and lockdowns on help-seeking hesitancy and lack of access to services. Although there was a successful compensatory move to telepsychiatry, limited access of face to face services for youth where medical reviews constitute an important part of treatment monitoring was a concern, [13] and might have contributed to delayed help seeking, lower IBW% and account in part for the increased emergency department attendances [6] The increased number of referrals, and shorter time to refer to the FBT team might re ect a true increase of more clinically sinister eating pathology, during Covid-19, or might re ect an increased onward referral from generic CAMHS exposed to unmanageable demand.…”

“…Some suggested presentations in youth were with higher medical risk and more atypical symptoms. [6,7] Although the causes of EDs remain complex, with biological, cultural and psychological components, personal control is proposed to play a central role in both etiology and maintenance. The pandemic, a period of tremendous uncertainty and self-perceived lack of control, could be particularly intolerable for a group of vulnerable youth and might account for the rise in ED referrals reported.…”

HSE National Clinical Programme for Eating Disorders in Ireland: COVID‐19 pandemic and eating disorder care in a new national eating disorder service

“…Similar internationally, we report that there has been a trend in anorexia nervosa and OSFED diagnosis in children and adults (Hansen et al, 2021; Kurisu et al, 2022). There is a growing literature that children presented with a myriad of ED symptoms that did not fit Anorexia Nervosa diagnosis clearly and were best categorized as OSFED by clinicians (Agostino et al, 2021; Matthews et al, 2021; McNicholas, 2021). The authors surmise that certain disorders (e.g., Bulimia Nervosa) may be under‐represented in the data and may not reflect the true trend during the COVID‐19 pandemic.…”