Chapter 8 Eating disorders, substance abuse and behavioural disturbances in adolescence

Case 8.1

1. What do you think Ellie actually means when she uses the term ‘anorexic’?

Like many non-health professionals, Ellie is possibly under the common misconception that ‘anorexic’ refers to a condition where an individual has lost a large amount of weight, or even has the disorder of anorexia nervosa. Anorexia, of course, simply refers to a symptom in which there is a decrease or a loss of appetite.

2. List some of the more important questions that you need to ask.

• Describe her diet.

• Do you actually see her eating?

• Does she frequently go to the bathroom following a meal?

• How much exercise does she do?

• What is her weight? Have you noticed a loss in her weight? Over what period of time?

• Does she make negative comments about her appearance?

• Does she believe that she is overweight?

• Is she excessively concerned about her weight?

• At what age did she commence menstruation? Does she still have her periods?

• Do you think she takes any laxatives?

3a In which of the eating disorders is purging a feature?

• Bulimia nervosa.

• Binge disorder.

• Occasionally in anorexia nervosa.

b What are some of the medical consequences of purging?

• Spontaneous regurgitation (may occur after about 5 years of persistent vomiting).

• Dental erosion on the palatal surface of the teeth.

• Erosion may lead to cavities, tooth loss, faulty bite, and gum disease.

• Constipation and/or diarrhoea in laxative users.

• Digestive mucosal irritation if using irritants (eg: castor oil).

• Mouth lesions (eg: abscesses).

• Bleeding and/or tearing of the oesophagus.

• Hiatus hernia.

• Salivary gland infection and swelling.

• Hypokalaemia (muscle fatigue, numbness, arrhythmias, kidney damage, and paralysis).

• Sodium deficiency (loss of skin elasticity, dry tongue, and low blood pressure).

• Substance abuse of laxatives and diuretics.

4. Ellie wishes you to explain to her the differences between anorexia nervosa, bulimia nervosa and binge disorder. Create a table which clearly differentiates between these disorders.

Anorexia nervosa	Bulimia nervosa	Eating disorder not otherwise specified
Loss of at least 15% of body weight	Repeated (usually secretive) episodes of binging and vomiting	Variable presentation — patients may have: • most (but not all) of the criteria required for a diagnosis of anorexia nervosa or bulimia nervosa • binge eating only, without the compensatory purging
Intense fear of weight gain	Feeling out of control during a binge	There may or may not be binge eating
Distorted body image (feeling fat even when too thin)	Extreme concern with body weight and shape Frequent dieting	There may or may not be weight loss
Absence of three consecutive menstrual periods (amenorrhea)	Purging after a binge (vomiting, laxatives or diuretics, excessive exercise)	There may or may not be amenorrhoea

5. What are the medical complications of anorexia nervosa?

These include:

• lethargy

• constipation

• abdominal pain

• amenorrhoea

• dehydration

• reduced body fat resulting in low body temperature and the inability to tolerate cold

• loss of muscle mass

• loss of essential minerals

• hypotension

• postural hypotension

• bradycardia

• hypogylycaemia

• low white blood cell count

• low parathyroid hormone levels

• mild anaemia

• organ damage and failure.

6. What recommendations will you make to Ellie?

Ellie and her daughter need to consult a mental health specialist immediately, to assess the possibility of an eating disorder.

Case 8.2

1. List the possible causes of Tom’s altered behaviour. Explain your choices.

Possible cause	Justification for choice
Drug abuse	• Experimentation with drugs is common at this age • Some drugs can cause hallucinations • His behaviour is characteristic of drug abuse
Exaggeration of typical adolescent behaviour	• Adolescent behaviour varies considerably
Schizophrenia	• Late teens is a typical age of onset • Hallucinations are typical of the disorder • His behaviour is commensurate with schizophrenia, although the information provided is not complete enough in order to determine if all diagnostic criteria are met
Depression	• Depression is not uncommon in males of this age • His behaviour is commensurate with a depressive illness, although the information provided is not complete enough in order to determine if all diagnostic criteria are met • However, hallucinations are uncommon in depression
Other form of psychosis	• Presence of hallucinations
Brain tumour	• Personality changes are common in frontal lobe tumours. However, this is probably an unlikely scenario. This type of tumour is more likely to occur in older adults

2. What will you suggest to his mother regarding the best plan of action?

To consult her general medical practitioner to obtain a referral to a mental health specialist. A clinical psychologist may be the most appropriate first contact, as Tom’s behaviour may be one requiring psychotherapy rather than medication. ‘Hearing voices’ may be his attempt at seeking attention, rather than an actual hallucinatory event.

3. If Tom is truly hearing voices, what information does that give you?

Auditory hallucinations are always of great concern, suggesting the possibility of drug abuse, schizophrenia or another form of psychosis. It will always necessitate referral to a mental health specialist.

Case 8.3

1. What are the most important questions to ask Jon, in order to obtain a complete description of his insomnia?

• How long has this been a problem?

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