A young person who stops eating after a bullying episode
A 14-year-old boy is brought by his mother to a community clinic. Over 3 months he has dropped from 52 kg to 43 kg (BMI 16.1), eats only 'safe' foods, exercises at 5 am, and has stopped attending school. He says classmates posted humiliating images of him online and that he is 'disgusting'. He denies vomiting or laxative use. He is irritable, sleeps poorly, and has told a friend he 'wouldn't mind not waking up'. He has no prior psychiatric history. His parents are separated and disagree about whether this is 'just a phase'. Physical examination: pulse 58, BP 98/60, temperature 36.2 C, no lanugo, mild acrocyanosis.
1. What is your differential and what would you assess first?
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The leading differential is an eating disorder - likely anorexia nervosa, restrictive type - with a prominent psychosocial precipitant (bullying and online humiliation), social withdrawal and possible comorbid depression. Alternatives to keep in mind: avoidant/restrictive food intake disorder (ARFID) if the restriction is driven by sensory or fear-of-consequence issues rather than weight/shape concerns; major depressive disorder with appetite loss; an anxiety disorder with avoidance; a medical cause (thyroid disease, inflammatory bowel disease, coeliac disease, diabetes) requiring baseline bloods; and, less likely, substance use or early psychosis.
First assessments: risk - explore the suicidal statement directly, assess intent, plan and means, and involve parents as part of safety planning; medical stability - heart rate, postural BP, temperature, hydration, ECG if bradycardic, and bloods including electrolytes, phosphate, magnesium, renal and liver function, full blood count, and coeliac/thyroid screen if indicated; growth chart and weight trajectory; and mental state, including body image, fear of weight gain, and mood. Ask about vomiting, laxatives, and exercise. Given his age, take a developmental and family history, and clarify consent and confidentiality with him and his parents. Screen for bullying and online harm, and consider safeguarding referral if the images constitute abuse or if home circumstances are unsafe.
2. How would you structure the treatment plan and who needs to be involved?
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Use a multidisciplinary, family-inclusive approach appropriate to an adolescent. Medical monitoring by a paediatrician or GP with experience in eating disorders, dietetic input for a structured meal plan and weight restoration targets, and psychological therapy - family-based treatment (Maudsley-style) is the best-supported first-line for adolescent anorexia nervosa, with individual CBT-E as an alternative depending on formulation and engagement. Address the bullying and online images: involve the school, request removal of material, and consider a safeguarding referral. Treat comorbid depression with psychological input first; if medication is considered, an SSRI may be used but only with close monitoring for activation and suicidality in a young person, and never as a substitute for nutritional rehabilitation.
Set a clear risk and safety plan with the family, agreed review intervals, and thresholds for escalation (for example rapid weight loss, bradycardia, syncope, worsening suicidal ideation, or inability to maintain intake at home). Explain to the parents that this is a recognised illness, not a phase, and that their disagreement undermines treatment; offer them psychoeducation and family sessions. Document the young person's own views, capacity to consent to treatment in line with his developmental stage, and the confidentiality arrangements. Arrange a review within a week given the suicidal statement and weight trajectory.