COVID-19 pandemic-onset anorexia nervosa: Three adolescent cases.

The world has faced a growing global health crisis caused by the COVID‐19 outbreak. All nations have implemented measures to control the spread of COVID‐19, including curfews, lockdowns, and restrictions on persons’ movements with social distancing. The first case diagnosed with COVID‐19 in Turkey was reported on 11 March 2020. As the world focused on measures to mitigate transmission of COVID‐19, the Turkish government ordered a nationwide school closure by 13 March and, by 1 April, a lockdown for people younger than 20 years. This quick action was taken to slow and prevent the infection's spread; however, school closure and home confinement might have adverse effects on children's physical health and psychological well‐being. When children are at home and reduce their outdoor activity, they may become less physically active; become socially withdrawn from their usual environment and devoid of peer relations; spend much more time viewing screens; have irregular sleep patterns; and have less favorable diets.

Additionally, in all age groups, reactive psychiatric symptoms have been described as secondary effects of social isolation and quarantine. Some of these symptoms are associated with changes in eating and exercise behavior. A study conducted in the general population reported both increased restricting and binge eating behaviors during the COVID‐19 pandemic; however, respondents also reported less exercise relative to before the pandemic. Another study that evaluated the early impact of COVID‐19 on people with eating disorders showed that participants with anorexia nervosa reported increased restriction, fears about being able to find foods consistent with their meal plan, and concerns about relapse related to COVID‐19 circumstances. These two studies included adult participants and there have been no reports on pandemic‐onset eating disorders or anorexia nervosa in adolescents.

In this case series, we present three adolescent girls of similar ages and similar psychiatric symptoms. The onset of their anorexia nervosa symptoms occurred suddenly in April 2020 when curfews were imposed because of the COVID‐19 pandemic. The three girls had initially fasted during Ramadan, the holy month of fasting, from 23 April to 24 May 2020. For healthy adolescent and adult Muslims, Ramadan fasting and prolonged hunger have a spiritual factor. All patients fasted during Ramadan by eating a single meal per day; however, after the month of Ramadan, they each continued to eat just one meal per day and excessive sports behavior began due to the excessive fear of gaining weight. One‐meal eating turned into restricted eating, fast weight loss, thoughts about being overweight, and refusal of eating. There was no binge eating, purging, or laxative misuse. Social isolation was a common feature in all three patients. Each girl withdrew from her family and peers, failed to attend online education, weighed herself every day, checked her body image in mirrors, engaged in discourse about weight gain, calculated calories, spent a lot of time on social media and the Internet (especially videos showing food recipes and people eating), and prepared food at home for family members. None of the patients had a premorbid psychiatric history, and their levels of academic success and peer relationships were described as good. Summaries of each case's background characteristics and clinical findings are given in Table 1.

Table 1

Summary of each case's background characteristics and clinical findings

	Case 1	Case 2	Case 3
Age (years)/sex/diagnosis	13/female/anorexia nervosa	16/female/anorexia nervosa	16/female/anorexia nervosa
Bodyweight (kg)	40	37	40
Body mass index (kg/m2)	14.3	14.1	15.2
Disease duration	8 weeks	6 weeks	8 weeks
Weight loss	20 kg in 4 weeks	10 kg in 4 weeks	15 kg in 8 weeks
Premorbid psychiatric history	None	None	None
Follow‐up in inpatient unit	1 day in pediatric emergency unit	10 days in pediatric inpatient unit	2 days in pediatric emergency unit
Comorbid psychiatric disease	Major depressive disorder	Major depressive disorder	Anxiety disorder
Amenorrhea	+	+	+
Psychiatric medication	Olanzapine 10 mg/day + fluoxetine 20 mg/day	Olanzapine 5 mg/day + fluoxetine 20 mg/day	Olanzapine 5 mg/day + sertraline 50 mg/day
Laboratory values on admission
Fasting blood glucose (mg/dL)	62	65	53
Na/K (mEq/L)	138/4.4	135/4.0	135/4.4
AST/ALT (U/L)	24/18	32/20	41/21
BUN/Cr (mg/dL)	6/0.76	8/0.80	14/0.84
WBC (×103/μL)	3.6	5.0	4.6
Hgb (g/dL)	13.9	12.5	15.1
Plt (×103/μL)	214	270	224
Heart rate (b.p.m.)	60	62	45

Laboratory reference values: fasting blood glucose, 65–110 mg/dL; ALT, 10–40 U/L; AST, 10–37 U/L; BUN, 5–18 mg/dL; Cr, 0–1.2 mg/dL; Hgb, 12.0–17.0 g/dL; K, 3.5–5.3 mEq/L; Na, 136–146 mEq/L; Plt, 150.0–440.0 ×103/μL; WBC, 4.0–10.0 ×103/μL; heart rate, 60–100 b.p.m.

ALT, alanine aminotransferase; AST, aspartate aminotransferase; BUN, blood urea nitrogen; Cr, creatinine; Hgb, hemoglobin; K, potassium; Na, sodium; Plt, platelets; WBC, white blood cells.

The insight about their symptoms and clinical courses of all patients was partial. They did not want to apply to the child and adolescent psychiatric outpatient unit due to worry about being infected with COVID‐19 at the hospital. One of the cases was monitored in the pediatric inpatient unit and the other two were monitored in the pediatric emergency unit. Tube feeding was not needed as they each agreed to adapt to an oral diet with the help of a nutritionist. They were each diagnosed with anorexia nervosa according to the DSM‐5 and were followed at Marmara University Pendik Research and Training Hospital Child and Adolescent Psychiatry Clinic. One of the patients had anxiety symptoms in addition to anorexia nervosa and the other two had major depression. Patients were followed up with olanzapine and fluoxetine/sertraline combination medication, individual cognitive behavioral therapy, and family interviews weekly. There was no history of contact with COVID‐19 or having COVID‐19 in patients or their family members. Follow‐up of patients continues at the same child and adolescent psychiatry clinic.

Chia et al. showed that dietary restriction for religious purposes, such as that observed during the practice of Ramadan, may not confer increased risk of eating disorder symptoms. Also, there were no patients with these symptoms presenting to the Marmara University Pendik Research and Training Hospital Child and Adolescent Psychiatry Clinic during the 2019 Ramadan period. In another study, social isolation was associated with binge eating, not dietary restraint. However, no study investigating the relation between social isolation and the onset of eating disorders has been observed in literature. Social isolation and quarantine may have important adverse psychological effects on the most vulnerable groups, such as adolescents, but it is not possible to say with three cases that social isolation and quarantine may cause eating disorders.

Written consent was taken from the participants. This study fulfills the ethical provisions of the Declaration of Helsinki.

Disclosure statement

The authors declare no conflicts of interest.