Age May Affect Clinical Presentation of an Eating Disorder

The unique physiologic, psychological, and developmental differences between adolescents and adults with eating disorders should be considered during diagnosis and treatment, according to the results of a recent study (J Adolesc Health 2001;28:222). For some teens, early, aggressive treatment may produce a better outcome.

Martin Fisher, MD, and researchers at North Shore University Hospital, Manhasset, NY, studied charts of women presenting with eating disorders to identify age-rated differences on clinical presentation. The data came from 622 female patients treated for an eating disorder between 1980 and 1994. The cases were divided into 2 groups by age: 438 women younger than 20 years (9-19 years of age) and 184 women older than 20 (20-46 years of age). The researchers looked at demographic and family factors, weight loss and changes, eating-related behaviors, the diagnosis and severity of the disorder, and issues that arose during treatment.

Diagnosis, severity, and levels of denial

Thirty-five percent of the 622 women met DSM III-R criteria for anorexia nervosa, 20% met DSM III-R criteria for bulimia nervosa, and 4% had symptoms of both. The remaining women (41%) met the diagnosis for eating disorders not otherwise specified (EDNOS). Teens were more likely than adults to have a diagnosis of EDNOS, a lower global severity score, greater denial, and more reluctance to seek help. Teens also were more likely to have a history of fasting and elimination of junk food from their diets. More than 40% of the teens did not meet official DSM-III-R criteria for either anorexia or bulimia nervosa, compared with 34% of the adults.

The adults were significantly more likely than the teens to have been losing weight for more than 1 year, to have greater total weight loss, a history of binge eating and laxative abuse, a history of use of diuretics and ipecac, a diagnosis of bulimia nervosa, and prior treatment with psychiatric medications. Adolescents 15-19 years of age reported significantly more of these behaviors than did younger teens.

The teens and adults did share some characteristics: parents’ occupational level, height, weight, and percent ideal body weight at presentation, original ideal body weight, use of diet pills, elimination a of meat and use of a low-fat diet, daily calorie intake, prior hospitalization for treatment of an eating disorder, and hospitalization during treatment.

Treating along a spectrum of disease

The authors suggest that teens present earlier in the course of their illness than do adults. In this study, some teens had less than 3 months of amenorrhea or had not lost enough weight to meet the DSM III-R criteria for anorexia nervosa. According to Dr. Fisher, this pattern is especially true of those in early adolescence, where failure to gain appropriate weight, as opposed to weight loss per se, may be the indicator for the eating disorder, and normal menstrual periods may not have been established. Vomiting and binge eating are also less common in teens, and thus they may not meet the DSM-III-R criteria for bulimia nervosa.

Weight loss patterns are also different for teens and young adults. In this study, teens generally presented with a shorter period of, but more rapid, weight loss—indicating an illness of shorter duration that presumably would be more amenable to treatment than that seen in adults. They also had a smaller total weight loss than did adults.

According to the authors, adolescents and young adults are often evaluated and treated at a different point on the spectrum of disease. This suggests that teens will have a better outcome if they are treated with aggressive attempts to reverse weight loss and use of hospitalization. The researchers, who treat both teens and adults regularly, have found that teens usually have a more acute illness that requires a more aggressive approach, whereas adult patients generally have a more longstanding illness that calls for a less-aggressive, longer-term approach.