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.