Austė Janušauskaitė
Faculty of Medicine, Lithuanian University of Health Sciences, Lithuania
Tutor: Jūratė Baltrėnė, MD. Child and adolescent psychiatrist
at Hospital of Lithuanian University of Health Sciences Kaunas Clinics
(Department of Psychiatry), Kaunas, Lithuania. Assistant at Lithuanian
University of Health Sciences, Kaunas, Lithuania.
Introduction: In March 2020, the World Health Organization
(WHO) declared an outbreak of coronavirus (COVID-19) a pandemic that
affected the economy, health care, and mental well-being. „It appears
that the COVID-19 pandemic has unmasked a global eating disorder public
health crisis that was already building“ [1]. In a recent study of
adolescents with various mental disorders, not only did they report a
deterioration in their mental health during the COVID-19 pandemic, but a
quarter stopped using mental health care [2]. This finding is of
particular concern for adolescents who have developed eating disorders
because they require multidisciplinary interventions. Activities that
promote emotional regulation (extracurricular activities, meetings of
friends, live communication, visits to therapists) were inaccessible or
partially allowed during quarantine. Closure and limited communication
become one of the major causes of eating disorders [3].
Case report: We present a case of a 16-year-old female patient who has
recently been diagnosed with anorexia nervosa, who expressed a desire to
lose weight, was reluctant to eat, was afraid of gaining weight, and did
not like her appearance. These symptoms occurred and worsened against
the context of a COVID-19 pandemic. Written informed consent was
obtained from the patient to publish this report in accordance with the
journal’s patient consent policy.
The patient has a younger sister under the age of 14, her mother is a
medical worker, and her father is an agronomist, and holds a senior
position. The father is very restrained and categorical, not very
communicative, does not maintain a close relationship with his daughter.
The patient notices that the father pays more attention to her little
sister, being closer to her. Mom talks about herself as controlling,
anxious. The patient feels the importance of family and health to her
mother. The girl notices that her mother is in control but also very
caring. The patient’s relationship with her mother was strengthened when
she developed anorexia.
Early psychomotor development was timely. According to her mother,
before kindergarten, the patient was more of an observer and in no hurry
to make contact with others. She attended kindergarten from the age of
3, adapted well, was very friendly, a leader, and took care of other
children. She was very responsive and constantly cared for her little
sister, with whom she went to the same group in kindergarten. She
attended school from the age of 7. She was always successful in school;
she was active, a leader, and had good grades. In the 9th grade, she
changed schools, rejoicing at the new school, although she got along
well with her former classmates. As a child, she was afraid to be alone
and afraid of thieves. At the age of 10, she experienced a panic episode
on the plane, vomited, shook her hands, beat her heart, and was afraid
to die.
2 years ago, the COVID-19 pandemic began, in March 2020, due to
quarantine restrictions, distance learning was introduced in Lithuania.
Having more free time, the patient became interested in weight loss and
diets. She lost weight in a few months, but when she returned to class
in the fall of 2020, she no longer had time to exercise and plan her
diet, claiming to gain up to 57 kg again (in October 2020). She wanted
to slim down, so she started reducing her portion of food at the
beginning of 2021. The patient actively loses weight for about one year.
The patient distanced herself from family and friends, avoided
collective activities, became introverted, reduced social contacts,
changed her behavior, „from a leading child full of life, became sad,
unwilling, uninterested, closed, quiet and isolated”. In July 2021,
after a conflict with her mother, the patient intensified her efforts,
began counting calories carefully, and became more active. At that time,
she weighed 52 kg, later losing her period. The patient adhered to
dietary rituals, sports routines, her circle of interests narrowed, and
her entire daily routine became focused on diet, weight loss and
thinking about it. The patient ate very little, counted grams, avoided
fat, sugar, flour products, threw out egg yolks, and ate only beef or
chicken. The patient visited the Eating Disorders Center on an
outpatient basis for about 3 weeks. Despite the following, the patient
began to restrict not only food but also water and stopped taking food
supplements. As a result, she was admitted to a psychiatric hospital at
the time, weighing 42,7 kg and having a BMI of 14,20 kg/m2. After
starting treatment in the child and adolescent psychiatry department
(inpatient), non-drug treatment was given: adequate nutrition, art and
employment therapy, occupational therapy, individual and group
psychological counseling, family counseling, social worker counseling.
After a few days, she gained up to 43.5 kg, but the patient did not gain
weight for a month later. Although she ate full portions, took food
supplements, she was constantly negotiating food, hiding food, and
secretly exercising. After eating, she felt guilty and was afraid to
gain weight, and the anxiety intensified in the evenings. After ensuring
a complete diet, persistent mood and anxiety symptoms were observed, so
the diagnosis was supplemented: anorexia was accompanied by depression.
The situation began to change with the introduction of fluoxetine, which
reduced anxiety and stabilized mood. The next step occurred in family
therapy; The patient dared to tell her father that she was angry, felt
abandoned, and wanted more of his time ”only when I am very ill, then I
am important.” During treatment, the weight increased to 47.7 kg, and
the patient was prescribed to continue treatment at home.
Discussion: Preventive measures that helped control the
Covid-19 pandemic also led to social restrictions, changes in the daily
lives of adolescents. Various studies conducted during the pandemic
provide reports showing an increase in the number of patients seeking
care for eating disorders [4,5]. In Lithuania, while working in
clinical practice, we have also observed an increase in eating
disorders; unfortunately, we do not have statistics at the national
level.
Social constraints of the pandemic deprived adolescents of social
support and adaptive coping strategies - decreased protective factors,
elevated barriers to care increased eating disorder risk, and burdened
their management [3]. Social media also influenced, even the
publication of personal images on social networks worsened mood and body
image [6]. Although our findings reflect one clinical case, they are
consistent with new reports showing that restrictions during a pandemic
situation have long-term significant adverse effects on the mental and
physical health of adolescents. As in our case, eating disorders were
observed in some adolescents during quarantine because they simply had
no activity and had more time for diet and exercise [7]. In the case
we discussed, the patient began to recover when her needs in the
relationship were met. It is therefore important to note the positive
consequences of the COVID-19 period, which in some cases include
improved family relationships, being less stressed, and having more time
for self-care [8].
This clinical case contributes to the practical understanding of how a
pandemic affects adolescent mental health. The major findings of this
study suggest that the experience of a pandemic situation, isolation,
may provoke changes in daily life and interpersonal relationships that
form a pathway to anorexia nervosa manifestation. On the other hand, it
may complicate the diagnostics of comorbid pathologies.
This clinical case’s limitations were: no possibility to establish a
cause-effect relationship, emotional bias and, findings cannot be
representative of the entire population. Future research is needed to
better understand the impact of the pandemic on the clinical course and
outcomes of adolescent eating disorders.
Conclusion: It is likely that social isolation, in this case,
was the most important factor in reflecting and highlighting
relationship problems in the family and inducing the onset of anorexia.
Anorexia, on the other hand, was accompanied by depression, which was
not observed at the beginning of treatment because it hid under the
symptoms of anorexia and, in the context of social isolation, seemed to
be the norm. Against the background of a pandemic, it is important for
mental health professionals to remain vigilant and to be able to notice
any developing mental health disorder and their comorbidities.