Treatment of anorexia nervosa in children

The term ” anorexia ” has a Greek origin, meaning “no desire for food.” Anorexia nervosa is formed on the basis of mental deviations, refusal to eat is the result of distorted attitudes and values, combined with uncertainty, suggestibility, and dependence on the opinions of others.

The prevalence of the disease among boys and boys is 0.2-0.3%, among girls and girls 0.9-4.3%, which is 90-95% of the total number of patients. 

The peak of the incidence is 12-15 years – the age of active physiological maturation, changes in the body. About 20% of cases are fatal, half of them – as a result of suicide .

Causes of anorexia nervosa in children

Psychogenic changes in eating habits occur in preschool, primary school and adolescence. The puberty period, which coincides with the adolescent developmental crisis, becomes the most dangerous in terms of the debut of the disease – a critical perception and self-assessment is formed, emotional instability increases, appearance changes.

Among the risk factors for the disease are:

• Genetic. There is a genetic predisposition to the disease. At risk are children whose close relatives have mental disorders : bulimia , psychogenic anorexia, schizophrenia and other endogenous psychosis.
• Biological. The development of pathology contributes to the earlier puberty, accompanied by hormonal changes, affective instability. In girls, the mammary glands and fat layer increase, which becomes an additional provocative factor.
• Family. The disorder may be a form of child protest against educational measures. With hyper-care and parental authoritarianism, food intake becomes one of the few areas for self-reliance.
• Personal. Anorexia is more susceptible to children with an inferiority complex, uncertainty, perfectionism, pedantry. Weight reduction becomes proof of dedication, a condition of visual appeal.
• Cultural. In modern society, thinness is often presented as a symbol of beauty, sexual attractiveness. Girls tend to conform to the generally accepted “ideal of beauty”, limiting themselves in food

The basis of anorexia nervosa is dysmorphophobia – a psychopathological syndrome characterized by the presence of obsessive delusional thoughts about deformity, the imperfection of one’s own body. The patient’s perception of bodily deficiencies does not correspond to reality, but changes the emotional state and behavior. The experience of imaginary defects, excessive completeness, begins to determine the content of all spheres of life.

The overvalued idea of ​​losing weight and severe nutritional restrictions lead to a distortion of the food instinct and the instinct of self-preservation. At the physiological level, defense mechanisms are activated: metabolic processes slow down, insulin levels, bile acids, and digestive enzymes decrease. The body adapts to the minimum amount and rare food intake. The digestion process causes nausea, a feeling of heaviness in the stomach, dizziness,fainting . In a difficult stage, the ability to process food is lost. Cachexia (a state of extreme exhaustion) with a risk of death is developing.

Classification of anorexia nervosa in children

Anorexia nervosa in children and adolescents is classified according to the clinical course and the stages of the pathological process. Depending on the main symptoms, the syndrome is isolated with monothematic dysmorphophobia (the idea of ​​excess weight dominates), with bulimia (periodic disinhibition of inclinations, gluttony), with a predominance of bulimia and vomitmania (with occasional overeating, followed by provocation of vomiting).

According to the stages of development, there are three types of anorexia:

• Initial It lasts for 3-4 years, debuts with preschoolers, younger students. It is characterized by a gradual change in the interests of the child, a shift in ideas about a beautiful body, attractiveness, and health.
• Active It develops more often in adolescents. Differs in a pronounced desire to reduce weight (food restriction, exhausting exercise, taking diuretics, laxatives, causing vomiting). Body weight is reduced by 30-50%.
• Kahekticheskaya. There is a depletion of the body, pronounced asthenic syndrome , a violation of critical thinking. In the absence of medical care, the stage ends in death.

Symptoms of anorexia nervosa in children

The first signs of the disease – dissatisfaction with his own body, increased interest in methods of losing weight. Changing ideas about beauty, health, attractiveness. The child begins to admire the famous personalities, film characters who have a thin, frail physique. The idea of ​​excess weight, ugliness is only being formed. Thoughts are carefully hidden from others. With the development of the patient’s body changes, in adolescence, physiological transformations occur, often accompanied by an increase in fat layer. This becomes a starting factor for the beginning of active actions.

The teenager is trying to quietly skip the meal, fanatically involved in sports that promote weight loss. At the initial stage, there is a desire to hide the desire for weight loss from adults, gradually the behavior becomes oppositional and negativistic: refusals from food are becoming more frequent, when persuasion and reproaches of parents arise outbreaks of irritability, conflicts are provoked. The child shows more and more selectivity in food, often creates its own “diet”. First of all, it excludes products with a high content of fats and carbohydrates from the diet. The menu is dominated by vegetables, fruits, low-fat dairy products. To reduce the feeling of hunger, the patient begins to smoke, drink a lot of fluids (drink water, coffee, teas), take medicines that reduce appetite.

There is a constant emotional tension, depression, dysphoricity (anger), dissatisfaction with yourself, fears are formed. In some adolescents, periods of depressive states are replaced by hypomania – the general activity and mood increase, and with emotional uplift, behavioral control decreases. Disinhibition of inclinations is manifested by bouts of gluttony, after which self-incrimination, self-deprecation develops, and vomiting is sometimes provoked. In the somatic sphere, symptoms of asthenia (weakness, dizziness) and disorders of the gastrointestinal tract (heartburn, nausea, pain in the stomach) predominate.

After reducing the weight by a third or more, the process of losing weight slows down. The body is depleted, which is manifested by hypo- or adynamia (decreased motor activity), high fatigue, feeling of fatigue, dizziness, fainting, decreased critical function of thinking. The teenager continues to refuse to eat food, is unable to assess thinness, the state of their own health. The overvalued / delusional thought about the imperfection of the body is preserved. Dehydration of the body develops, the skin becomes pale, dry, epigastric pains increase, girls break or stop menstruation. The function of digesting food is gradually lost, each intake causes a feeling of heaviness, nausea, heartburn, pain,  prolonged constipation .

Complications

Due to the tendency of adolescents to hide the manifestations of the disease, seeking medical help is out of time, at the stage of development of complications. Lack of nutrients leads to disruption of all functional systems. Pubertal development stops, turns back. Develops B12-deficiency anemia, bradycardia, heart attacks, amenorrhoea, osteopenia and osteoporosis (loss of calcium), hypothyroidism, dental caries. Against the background of a decrease in immune protection, various infections arise. Depressive, dysphoric, anxiety disorders, the tendency to self-incrimination and the reduction of critical abilities increase the risk of suicide – up to 50% of deaths due to suicide.

Diagnostics of anorexia nervosa in children

Children and adolescents tend to hide the true goals of starvation, to deny the presence of the disease. This position complicates timely diagnosis, contributes to the errors of differentiation of anorexia nervosa with somatic diseases. Appeal to specialized specialists – a psychiatrist, a psychologist – usually occurs 2-3 years after the debut of the first symptoms.

Specific examination methods are:

• Interview. The conversation can be conducted according to the scheme or in free form. The doctor determines the patient’s attitude to his body, weight, adherence to diets or food systems. Additionally parents are interviewed, the specialist clarifies the time of onset of symptoms, weight loss for the last month, especially behavioral, emotional disorders.
• Questionnaires. Specific diagnostic tools are used to identify eating disorders – Eating behavior rating scale, Cognitive-behavioral patterns for anorexia nervosa. Also used questionnaires study of the emotional sphere, personal characteristics, self-assessment – the method of Dembo-Rubinstein, SMIL (MMIL), PDO (Pathocharacterological diagnostic questionnaire).
• Projective tests. These methods allow you to identify trends that are hidden, denied by a teenager during a conversation and filling out questionnaires – self-acceptance, the dominant ideas of weight loss, depressive and impulsive features. Patients are offered a test of color choices (Lüscher test), the “Self-portrait” drawing, a drawing apperception test (PAT).

Specific diagnostics are supplemented by laboratory tests (general, biochemical analysis of blood and urine, liver, kidney, hormonal tests), instrumental studies of the gastrointestinal tract. Anorexia nervosa can occur against the background of schizophrenia, if you suspect a psychotic disorder, a study of the cognitive sphere, in particular – the functions of thinking, is conducted.

Treatment of anorexia nervosa in children

Disease therapy has two directions: the restoration of the digestive system with a gradual increase in weight and a return to healthy eating habits. At the first stage, fractional nutrition, bed rest, medication elimination of vomiting, dehydration, and constipation are applied. On the second – psychotherapy, symptomatic treatment of psychopathological manifestations. In the third – the transition to normal life, control relapse, the completion of psychotherapy.

Specific treatment includes:

• Cognitive behavioral therapy . Working with a psychotherapist takes 4-6 months. Correction of negative, distorted ideas, pathological emotions – fear, anger, anxiety. Produces a positive attitude towards yourself, the adoption of the body. At the stage of behavior change, the patient independently creates a menu that includes a variety of products, including those previously avoided (carbohydrate, high-calorie). In the personal diary, the patient notes the arising destructive thoughts and the success of their replacement with positive ones, describes well-being.
• Family psychotherapy . The sessions discuss the complexities of intrafamily relations provoked by the disease – conflicts, lies, emotional estrangement. The psychotherapist helps parents understand the mechanisms of anorexia, the experience of the child. Practical classes are used to work out ways of productive interaction – discussion of problems, cooperation. Mother and father are connected to individual behavioral psychotherapy – they are learning to gradually transfer responsibility for regular eating of food to a teenager.
• Pharmacotherapy . Special drugs to eliminate psychogenic anorexia are absent, but the relief of emotional and behavioral abnormalities can improve the effectiveness of psychotherapy and rehabilitation. The treatment regimen is determined by the clinical picture of the disease, antidepressants, tranquilizers, neuroleptics, appetite stimulants (for example, antihistamines) are prescribed.
• Lifestyle correction. Patients attend nutritional counseling , group meetings of supporters of proper nutrition. Adolescents talk about the importance of a balanced diet, complete fractional nutrition for the preservation of health, beauty. In practice, they learn how to make a menu, share successes in the fight against the disease. Parents help replace exhausting exercise with exciting, interesting sports.

Prognosis and prevention

The prospect of recovery depends on the timeliness of diagnosis and treatment – the earlier professional assistance is provided, the shorter the recovery phase and the less likely a relapse. According to statistics, 50-70% of patients with regular preventive visits to the doctor recover, the treatment process takes 5-7 years. An effective way to prevent anorexia – the formation of healthy eating habits, a positive attitude to the body from an early age. In the upbringing of the child, it is important to instill values ​​that promote health, physical strength, dexterity, and endurance.

Anorexia nervosa in children and adolescents is a eating disorder characterized by complete or partial refusal to eat in order to reduce body weight. With the development of the disease, the food instinct is disturbed, supervaluable ideas about losing weight dominate in thinking. Patients skip meals, adhere to strict diets, engage in intense exercise, provoke vomiting. Diagnosis includes counseling a psychiatrist and a gastroenterologist, psychodiagnostics. The treatment is based on cognitive behavioral psychotherapy, supplemented by drug correction of nutritional, emotional and behavioral disorders.