The silent scream – Anorexia nervosa in childhood and adolescence and its complex family based treatment
Anorexia nervosa (AN) is a classic biopsychosocial disorder because the psychological and physiological manifestations are intertwined. Most eating disorders begin during adolescence and more than 90% of individuals with eating disorders are diagnosed before the age of 25 years. The peak age at onset is mid adolescence (13–15 years). The number of younger children and adolescents with AN is growing.
The diagnosis of AN is associated with the highest mortality rate of any psychiatric disorder, mainly caused by medical complications. Sudden cardiac death along with other medical complications and suicide account for about 60% of the deaths. Besides the acute conditions there are plenty of long term nonreversible consequences of early onset AN, such as compromised final height, bone mineral density loss, brain volume deficits.
Besides physical health impairments, almost 50% of adolescent patients with AN meet criteria for at least one comorbid psychiatric illness.
AN does not have a single cause, but is related to many different factors. Biological vulnerability (genetics, personality), psychological predisposition (eg. stress, trauma), and sociocultural influence (eg. life transitions, bullying, entering puberty, family problems) precipitate dieting and weight loss and make a person vulnerable to develop, and trigger the onset. Certain personality traits such as perfectionism, low self‐esteem, obsessionality, social isolation, and feelings of ineffectiveness often predate the onset of the illness.
There are perpetuating factors that maintain the eating disorder, such as ongoing stress, abuse, overprotection or family tension.
Anorexia nervosa is a very complex disorder that needs complex, comprehensive and personalized treatment. The most important step to start with is conceptualizing the individual case: identifying the predisposing, the precipitating and the perpetuating factors on the personal, on the family and on the peer/social interactions level.
The next step is motivation. Patients with AN are known to be ambivalent about their symptoms. On one hand, the AN is perceived as a burden, but on the other hand, it also provides reasons to hold on to it. Consequently, adolescents with AN often display a low motivation to change and this is the cause for the lack of engagement which is the major problem in the treatment.
Interventions aiming the enhancement of motivation to change, are the key elements of the treatment plan.
After conceptualizing the case and motivating the patient and family comes the the integrated, complex psychotherapy. For adolescents, family based treatment is the best evidenced‐based approach for anorexia nervosa. Besides family therapy we also provide our patients individual psychotherapy (CBT, cognitive remediation therapy, EMDR‐if trauma is in the background), group therapy (anorexia‐specific art therapy, dance and movement therapy, mentalisation based therapy, assertive communication skills training, a special “hero‐therapy” for smaller children) and nutrition therapy.
The treating of anorexia nervosa in childhood and adolescence, is a fun and challenge, where the therapeutic stance should contain warmth, respect, empathy, curiosity, acceptance, humility, honesty and flexibility.