PE6.5 | Adolescent Eating Disorders — Summary & Reflection

KEY TAKEAWAYS

Anorexia nervosa (AN) is characterised by three DSM-5 criteria: (A) restriction leading to significantly low body weight; (B) intense fear of weight gain; (C) body image distortion or lack of recognition of severity. Two subtypes: AN-R (restricting) and AN-BP (binge-purge). Severity by adult BMI: mild ≥17, moderate 16–16.99, severe 15–15.99, extreme <15. AN carries the highest mortality of any psychiatric disorder. Bulimia nervosa (BN) requires: (A) recurrent binge eating; (B) compensatory behaviours; (C) ≥1 episode/week for 3 months; (D) self-evaluation by body shape; (E) not exclusively during AN. Russell's sign (dorsal hand calluses) is pathognomonic of BN purging. Medical complications of AN are systemic (bradycardia, amenorrhoea, osteopenia, electrolyte disturbances). Refeeding syndrome (hypophosphataemia → arrhythmias) is prevented by slow calorie escalation, phosphate monitoring, and thiamine supplementation. Management: FBT (Maudsley) is first-line for adolescent AN outpatient care; inpatient admission for haemodynamic instability or BMI <15; CBT-E + fluoxetine 60 mg for BN.

REFLECT

Anorexia nervosa is ego-syntonic — the patient does not experience her food restriction as a problem; she experiences it as achievement, control, and identity. As a clinician, you will encounter a patient who vehemently resists your diagnosis and resists treatment. Reflect on how you would approach a 15-year-old who says: 'I am not sick. I eat enough. You're just trying to make me fat.' How would you engage with this statement therapeutically, without dismissing her perspective, while also clearly communicating the medical danger she is in? What does the Maudsley approach offer for this dilemma — and why does it take the responsibility for eating away from the patient initially, rather than trying to motivate her through insight?