case study on anorexia nervosa

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Case Report on Anorexia Nervosa

Preeti srinivasa, m chandrashekar, nikitha harish, mahesh r gowda, sumit durgoji.

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Address for correspondence: Dr. Mahesh R. Gowda Spandana Health Care, No. 236/2, 29 th Main Road, 5 th Block, Nandini Layout (Coconut Garden), Near Ring Road, Bangalore - 560 096, Karnataka, India. E-mail: [email protected]

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Anorexia nervosa is an eating disorder characterized by excessive restriction on food intake and irrational fear of gaining weight, often accompanied by a distorted body self-perception. It is clinically diagnosed more frequently in females, with type and severity varying with each case. The current report is a case of a 25-year-old female, married for 5 years, educated up to 10 th standard, a homemaker, hailing from an upper social class Hindu (Marvadi) family, living with husband's family in Urban Bangalore; presented to our tertiary care centre with complaints of gradual loss of weight, recurrent episodes of vomiting, from a period of two years, menstrual irregularities from 1 year and amenorrhea since 6 months, with a probable precipitating factor being husband's critical comment on her weight. Diagnosis of atypical anorexia nervosa was made, with the body mass index (BMI) being 15.6. A multidisciplinary therapeutic approach was employed to facilitate remission. Through this case report the authors call for the attention of general practitioners and other medical practitioners to be aware of the symptomatology of eating disorders as most patients would overtly express somatic conditions similar to the reported case so as to facilitate early psychiatric intervention.

Keywords: Anorexia nervosa , BMI , eating disorder , somatic complaints multidisciplinary therapeutic approach

INTRODUCTION

Eating disorder is defined as a persistent disturbance of eating behavior or behavior intended to control weight, which significantly impairs physical health or psychosocial functioning, often turning out to be chronic psychiatric conditions.[ 1 ] Anorexia nervosa is an eating disorder as recognized by both ICD-10 and DSM-IV-TR. It is characterized by excessive restriction on food intake and irrational fear of gaining weight, often accompanied by a distorted body self-perception. It typically involves excessive weight loss and is usually found to occur more in females than in males.[ 2 ] An individual with anorexia nervosa may exhibit a number of signs and symptoms that may be present but not readily apparent. The type and severity may vary in each case.[ 3 , 4 , 5 ]

Clinically they may present with symptoms of

Distorted body mass index range; of less than 17.5.[ 6 ]

Amenorrhea.[ 6 ]

Fearful of even the slightest weight gain.[ 6 ]

Cooking elaborate dinners for others, but not eat the food themselves.[ 7 ]

Hypotension orthostatic hypotension, bradycardia, or tachycardia.

May frequently be in a sad, lethargic state.[ 8 ]

Swollen joints, hair loss or thinning.[ 9 ]

Constipation,[ 10 ] electrolyte imbalance.[ 11 ]

Lanugo.[ 12 ]

The causes for Anorexia nervosa have been attributed to risk factors such as, family history, obesity, weight concerns, psychiatric comorbidity, and substance abuse.[ 13 , 14 , 15 , 16 ] Although anorexia nervosa is widely described in the Western literature, it is rather rare in nonwestern cultures. In India, the information regarding these disorders is very limited.[ 17 ] In most Indian clinical settings, patients chiefly present with refusal to eat, persistent vomiting, marked weight loss, amenorrhea, and other somatic symptoms, but rarely show over activity or disturbances in body image.[ 18 ] However, the management of the disorder does not markedly vary irrespective of the cultural and ethnic variations in the clinical picture. It calls for the involvement of a multidisciplinary approach.[ 19 ]

In this article, the authors report a case of atypical anorexia nervosa in an attempt to contribute to the Indian literature of eating disorders that currently lacks clinical reports on the same.

CASE REPORT

Case of Mrs S, a 25-year-old female, married for 5 years, educated up to 10th standard, currently a homemaker, hailing from an upper social class Hindu (Marvadi) family, living with husband's family in Urban Bangalore; presented to our tertiary care center with complaints of gradual loss of weight, recurrent episodes of vomiting, from a period of 2 years, menstrual irregularities from 1 year and amenorrhea since 6 months, with a probable precipitating factor being husband's critical comment about her weight. Patient was reported to be dull and inactive most of the times since her marriage able to carry out her activities of daily living adequately. With symptoms of weight loss and amenorrhea, she was evaluated by a physician. A series of investigations were conducted in the background of suspected tuberculosis, anemia for evaluation and abdominal tumors. However, all the investigations were well within normal limits except low hemoglobin.

She was further evaluated by a gastroenterologist; an intestinal biopsy was done to rule out malabsorption syndrome. Gynecological opinion was taken in the background of amenorrhea and infertility, and was advised endometrial biopsy. Endocrinologist was seen and investigations conducted were normal. Thus, no clear cut cause could be established to the loss of weight. The patient was referred to psychiatric consultation by her treating physician as she appeared less cheerful, dull, and inactive and decreased interest in sex.

During psychiatric interview it was difficult to establish rapport and Mrs S was uncooperative. With persistent probing, she expressed low mood, easy fatigability, apathy, decreased attention and concentration, bleak, and pessimistic ideas about future. No suicidal ideas or unusual perceptual experiences were reported. Attempt to establish the cause of above symptoms were futile.

Information was elicited by Mrs S’ husband, revealed an incident during their early days of marriage when he had casually remarked of her being slightly heavy near her flanks and thighs and that she would look more beautiful if she reduced it. Since then her intake of food decreased. She followed a change in the diet pattern with complete avoidance of all foods with high caloric value. She gradually began to skip breakfast and would have minimal lunch. She began to avoid eating in front of other family members. At times hide and eat, and/or would secretly go into the bathroom and induce vomiting.

After repeated sessions, the patient opened up to the clinician. When questioned about her purging behavior, she reported of being unable to tolerate the guilt associated with eating excessively. Patient was re-evaluated and probed about her eating habits. Premorbid personality assessment revealed an over concern about physical appearance, inspired by skinny models. She reported of wanting to impress her husband with her beauty as he was fond of thin looking girls. She recalled that her husband would repeatedly compare her with thin looking girls on television and magazines. She eventually developed a morbid fear of looking fat and ugly, began eating a handful of fennel seeds to facilitate digestion. She would use soap water enema and would occasionally use laxatives. Her weight dropped from 59 to 30 kg.

During clinical examination, her weight was 30 kg in relation to her height being 5.4 ft and a BMI of 15.6. She had lanugo hair on her face and looked emaciated. Vitals were stable and systemic examination was normal. Her thyroid function was normal, serum electrolytes were normal, her hemoglobin was 8 gm/dl. Clinical depression was ruled out and a diagnosis of atypical anorexia nervosa was made (according to ICD-10). The general health questionnaire (GHQ) and the eating disorder examination questionnaire (EDE-Q) were administered. She was admitted for inpatient care and started immediately on IV fluids. Initially she developed facial edema that gradually reduced with fluid redistribution. A multidisciplinary team approach was employed. Psycho education with regard to the disorder was given. Nutritional rehabilitation was planned, where she was asked to maintain a dairy about her intake of food. She was encouraged to eat food with high caloric value.

Post sessions with the family, husband was involved in the therapeutic process and was asked to keep a watch on her purging behavior. The patient was simultaneously given Cyproheptadine and low dose Olanzapine. Her weight gain after 1 week was 2 kg. Mrs S gradually became cooperative for treatment process. Supportive psychotherapy was planned that provided a maximum understanding of the patient perspective. Techniques of insight-oriented psychotherapy and cognitive behavioral therapy were structured to address the cognitive distortions. She was subsequently discharged and a follow up for every 2 weeks was done. Her weight gain at the end of 1 month was 4 kg. At the end of 6 months, there was a weight gain of 15 kg. At the end of 1 year, there was a relapse in symptoms with patient reported of decreased intake of food and purging tendencies. The symptoms were addressed through Psychotherapy only. Mrs S’ symptoms remitted. At the end of 2 years, her weight was 55 kg with no fresh complaints.

Though the cases of anorexia nervosa are reported greatly in the grey literatures of the western countries, the number of clinical cases in India is on the rise. The age of onset for most cases ranges between 12 to 20 years.[ 20 ] Most cases are brought to clinical attention only when there are severe somatic complaints.[ 18 ] In this case, Mrs S was taken to the physician by her husband with symptoms of weight loss and amenorrhea. Multiple specialist opinions were taken to ascertain the cause of symptomatology. With no clear cut causal factor, the case as referred for psychiatric evaluation. The clinical picture led to the diagnosis of anorexia nervosa. There were no other potentially fatal medical consequences as the case was referred at the earliest by the physician. By reporting the particular case, the authors call for the attention of general practitioners and other medical practitioners to be aware of the symptomatology of eating disorders as most patients would overtly express somatic conditions similar to the reported case. Such awareness would have called for an earlier psychiatric intervention and curbed other unnecessary investigations.

Ethical considerations

The confidentiality of the identity of the patient has been ensured.

The patient has been informed of the publication of the case.

The case report is in the best interest of the community and to create awareness among mental and general health professionals.

A copy of the article has been submitted to the ethical committee for clearance.

ACKNOWLEDGMENT

The authors thank Dr. M. Srinivasa, Director Spandana Nursing Home for his valuable guidance. We thank Dr. S. Kanchana for her clinical guidance and Mr. H. D. Harish for his ardent support. We also thank the treating team and the nursing staff at the Spandana Health Care for their minute yet valuable support.

Source of Support: Nil

Conflict of Interest: None.

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• Published: 22 November 2023

Severe-Enduring Anorexia Nervosa (SE-AN): a case series

• Federica Marcolini 1 ,
• Alessandro Ravaglia 1 ,
• Silvia Tempia Valenta 1 ,
• Giovanna Bosco 2 ,
• Giorgia Marconi 3 ,
• Federica Sanna 1 ,
• Giulia Zilli 1 ,
• Enrico Magrini 1 ,
• Flavia Picone 1 ,
• Diana De Ronchi 1 &
• Anna Rita Atti 1  

Journal of Eating Disorders volume  11 , Article number:  208 ( 2023 ) Cite this article

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Anorexia Nervosa (AN) poses significant therapeutic challenges, especially in cases meeting the criteria for Severe and Enduring Anorexia Nervosa (SE-AN). This subset of AN is associated with severe medical complications, frequent use of services, and the highest mortality rate among psychiatric disorders.

Case presentation

In the present case series, 14 patients were selected from those currently or previously taken care of at the Eating Disorders Outpatients Unit of the Maggiore Hospital in Bologna between January 2012 and May 2023. This case series focuses on the effects of the disease, the treatment compliance, and the description of those variables that could help understand the great complexity of the disorder.

This case series highlights the relevant issue of resistance to treatment, as well as medical and psychological complications that mark the life course of SE-AN patients. The chronicity of these disorders is determined by the overlapping of the disorder's ego-syntonic nature, the health system's difficulty in recognizing the problem in its early stages, and the presence of occupational and social impairment.

Introduction

Anorexia Nervosa (AN) constitutes a complex eating disorder (ED) characterized by low caloric intake, fear of gaining weight, dysfunctional behavior impeding weight gain, and misperceptions about one’s own body shape and weight [ 1 ]. The intricate nature of AN can lead to severe difficulties in the treatment, and patients may not necessarily benefit from conventional approaches. Most AN patients reach partial or complete remission only after several years from the development of the first symptoms [ 2 ]. Despite substantial intervention efforts, an estimated 20% of AN patients show limited improvements and, over time, become chronic [ 3 , 4 ]. Despite that, there are very few studies on chronic AN, especially in older populations, probably due to the relatively high drop out rate after a few years of treatment [ 5 , 6 ].

To delineate the domain of chronic AN, the definition of Severe and Enduring Anorexia Nervosa (SE-AN) had been proposed [ 7 ] (Table 1 ), accompanied by suggested maintenance factors [ 8 ]. This definition is useful to describe and analyze the peculiarities of chronic patients, to improve the relatively broad criteria for SE-AN definition and to better understand the clinical development of this ED. The search for a precise terminological framework has shown that the quality of the words used in the definitions, in addition to carrying the risk of stigmatizing patients, can influence the way patients and their families experience ED. Moreover, it can have a significant impact on the perspectives that clinicians have on treatment. For instance, the labels 'chronic' and 'treatment resistant' can both affect clinicians' perspective on a patient's curability or their willingness to engage cooperatively during the treatment. Other terms, such as 'severe and enduring’, 'long-lasting' and similar expressions relating to the severity and duration variation of the disease, may favor a lesser focus on the curability of an individual.

In the present case series, we aim to provide an overview of the possible associations that exist among the multiple variables, causal or consequential, peculiar to SE-AN. The search for common causal factors, although within a small population of patients with SE-AN, may facilitate a better understanding of the disorder and its main determinants in order to intercept cases that are more likely to develop a long history of illness or severe forms that would necessitate intensive treatment. It could also help to improve and personalize the therapeutic approach towards this specific population, considering that even today the available treatments do not always guarantee a positive outcome. In addition, this case series directs its focus on the effects of the disease, treatment compliance, and the description of variables that could contribute to a comprehensive understanding of the complex nature of the disorder.

Materials and methods

In the present case series, 14 patients were selected from those currently or previously taken care of at the ED Outpatients Unit of the Maggiore Hospital in Bologna between January 2012 and May 2023. To make the sample more homogeneous, we selected only adult patients (age > 18 years, by Italian law) who fully fit the eligibility criteria for SE-AN, as proposed by Hay and Touyz in 2018 [ 7 ].

Information on individual patients was obtained through data collection from several available sources: Electronic Medical Records (EMR), paper records, and other documents available in the psychiatric department.

Demographic characteristics

A total of 14 patients were enrolled, all from Bologna and its province, and all with a history of admission to Public Psychiatric Services (100%). Five patients (35.7%) were still in psychiatric service care, while four patients dropped out of services (28.6%). One patient had died. At the time of data collection, four patients (8.6%) were no longer followed within a psychiatric pathway. A summary of the main clinical and social characteristics of the patients is presented in Tables 2 and 3 .

The patients were all female (100%). The sample had an average age of 42.2 years old (ranging from 24 to 63 years old). Only four out of 14 patients (28.6%) were married and none of them had gone through a divorce. Three patients (21.4%) had at least one child, and only one had more than one. Therefore, the majority of candidates with SE-AN were not married (71.4%) and had no children (78.6%). However, 86% of the patients lived with someone: six lived with their partner/husband, and six with the family of origin.

Almost all of the patients had a job during their lifetime (78.6%), including seven employees (who carried out office work, without any specific responsibility), two hairdressers, one bartender, and one lawyer. Among those who had never worked, two were University students. Therefore, only one out of 14 patients never worked or pursued a college career. Among the 11 individuals who had had a job, however, only three people were known to be employed at the time of the analysis (27.3%). For two people, no data regarding their working life were available on their medical records.

Among the 14 patients, seven (50%) had a cigarette smoking habit, while two (14.2%) had a history of alcohol abuse. Three (21.4%) had a history of self-injury.

Clinical characteristics

The average age of onset of ED symptoms in our sample was 22.7 years (range 11–47), while the average age at which a diagnosis of AN was made in public services (Psychiatry or Dietetics) was 31.5 years (range 16–51). The patients had a mean disease duration of 17 years (range 8–31) combined, in the vast majority of cases (85.7%), with a series of unsuccessful therapeutic attempts. The latency period between the onset of the disease and its recognition by public health services was 8.79 years (range 1–34 years); in nine out of 12 cases (64.3%) the diagnosis was made after at least three years of illness, while in 6 cases (42.9%) after at least seven years.

The most frequent AN subtype in the considered sample was AN-Restrictive (85.7%), while only two patients (14.3%) suffered from the AN-Binge/Purging subtype. The most frequently reported caloric restriction methods were reduced caloric intake and intense physical exercise; this was followed by laxative use, self-induced vomiting, and diuretic use.

The average patient’s Body Mass Index (BMI) reported was 13.43 kg/m 2 (range 7.53–16.94 kg/m 2 ), highlighting the extreme severity of the cases described (according to the DSM-5 [ 1 ], AN patients with BMI < 15 kg/m 2 are classified as showing “extreme severity”). The patient with the lowest BMI included in the case series reached a value of 7.15 kg/m 2 .

Eleven patients (78.6%) had been hospitalized at least once in an internal medicine department because of their ED, due to their severe malnutrition; in addition, among the three patients who had never faced hospitalization, two had previously refused it several times despite the need expressed by their caregivers. In contrast, at least two out of 14 (14.3%) had multiple accesses and one patient was hospitalized at the time of data collection. In parallel, seven of the patients (50%) were admitted at least once to a psychiatric department to manage their disorder. In the examined clinical context, six patients (42.9%) received enteral nutrition through nasogastric tube administration on at least one occasion, while an additional six patients (42.9%) required parenteral nutrition. The purpose of the parenteral nutrition intervention was to augment daily caloric intake and provide supplementary support to oral nutrition exclusively.

Common complications of AN, such as anemia and hypokalemia, and their treatment needs, were also investigated. In 50% of the patients, the occurrence of at least one episode of anemia during the natural history of the disease was reported. Anemia was most commonly macrocytic (57%). Regarding treatment, at least 42.9% of anemia cases were of such severity that they required blood transfusion, 28.6% required only iron and vitamin supplementation. 21.4% had no history of anemia. For the 28.6% no data about the occurrence of anemia as a complication of their disorder was found examining the available clinical records, while several patients refused to take blood tests. At least one episode of hypokalemia was reported in 50% of cases. Of the seven confirmed cases of hypokalemia, 100% required treatment, and at least three were of such severity as to require intravenous infusion therapy.

Other ED complications present within the considered sample, consequences of persistent malnutrition and secondary hormonal disorders typical of AN, included osteoporosis and secondary amenorrhea. In 57.1% of the cases frank osteoporosis was shown and in 28.6% osteopenia was demonstrated. In 93% of patients there was at least one period of secondary amenorrhea during the natural history of the disease (no data regarding one individual); these included two patients taking an Estrogen-Progestin (EP) pill and two who reached menopause before having the diagnosis of AN (one of whom was in early menopause).

The presence of psychiatric comorbidities in the history of these subjects was assessed (Table 4 ), founding that 100% had at least one other psychiatric diagnosis in comorbidity to the ED (not necessarily present to date); three out of 14 patients (21.4%) had only one psychiatric comorbidity, nine (64.3%) had two, and two patients (14.2%) had up to three psychiatric disorders in addition to AN.

It was reported that 50% of patients had a history of familial psychiatric illness, and 14.2% had a parent with severe obesity.

With respect to the therapeutic approaches used for these patients, previous drug therapy attempts employed in ED treatment (in part related to the management of the various psychiatric comorbidities present in the individual cases), and the execution of ED-specific therapeutic pathways (e.g., Dietary care), were evaluated as far as possible.

Nine patients had experienced at least one ED-specific pathway, while five had never been through one; among the latter, four out of five had rejected the proposed ED treatment course, while one was considering the proposal at the time of the data collection. The setting most frequently used by those who had embarked on an ED treatment course was outpatient (100%), followed by semi-residential and residential (44.4%). Among those who started an ED pathway: six completed it, two dropped out, and one moved away.

Regarding the pharmacological therapies taken by patients during their treatment course, the use of three pharmacological classes mainly used in AN treatment (antidepressants, antipsychotics, and benzodiazepines) was analyzed, also considering the possible combined therapeutic indication with respect to the individuals' psychiatric comorbidities.

Nine out of 14 (64.3%) patients used at least one antipsychotic drug, while 28.6% never used antipsychotics; of one out of 14 patients no data were found about antipsychotic administration from the examined clinical documentations. Among users, at least three used more than one antipsychotic in their history, and the most frequently prescribed drug was olanzapine (66.7%), followed by risperidone (22%) and aripiprazole (22%).

11 of 14 patients (78.6%) used at least one antidepressant drug to manage their psychiatric disorders; two patients never used it (n = 14.3%), and one rejected the suggested treatment. Among antidepressant users, 36.4% used more than one. The most commonly prescribed antidepressant was sertraline (77.8%), followed by venlafaxine (44.4%).

Nine out of 14 individuals (64.3%) used at least one benzodiazepine during their course of treatment in psychiatric services. Four patients (28.6%) never used benzodiazepines: three had not been prescribed and one refused to take them. There was one reported case of benzodiazepine abuse, while for one patient no data was found in the available clinical records regarding sedative medications. The most commonly used benzodiazepine appears to be alprazolam (40%).

Lastly, the information obtained showed that all patients (100%) undertook individual psychotherapy during their treatment process, even though duration, frequency, and type of psychotherapeutic courses were not reported in the records.

The present work gives an insight into SE-AN, analyzing clinical features, treatment approaches, and risk factors that might contribute to the persistence of this disorder. Our patients showed a long history of illness, with an average duration of 17 years, punctuated by therapeutic failures. The majority of patients were diagnosed with the restrictive subtype of AN, characterized by caloric restriction methods, including reduced intake and intense physical exercise. The BMI average was 13.43 kg/m 2 , data highlighting the extreme severity of this clinical sample, aligning with the DSM-5 classification of extreme severity for AN patients with BMI < 15 kg/m 2 [ 1 ]. We identified a high prevalence of hospitalizations due to severe malnutrition or the occurrence of medical complications (i.e., anemia, hypokalemia, osteoporosis, amenorrhea). Moreover, the majority of the sample also suffered from psychiatric comorbidities. The presence and severity of these aspects confirms the condition of intense medical and psychological burden faced by these patients [ 9 , 10 ].

The treatment history of these individuals has often proven to be complex and ineffective, despite the multitude of approaches used, including outpatient, semi-residential, or residential treatment. In addition, this work has highlighted a difficulty on the part of the health care system in identifying the disease at the time of its presentation, leading to diagnostic delays and higher therapeutic resistance. In fact, consolidation of the symptoms and psychopathological mechanisms over time in AN patients reduces the likelihood of positive outcomes following treatments, consequently limiting the chances of recovery for these individuals [ 11 ]. There is growing bio‐behavioral evidence in EDs that the disease changes over time, with maladaptive eating and weight control behaviors becoming more automatic and entrenched [ 12 , 13 , 14 , 15 , 16 , 17 ]. Consistent with these results, many clinical studies suggest that response to treatment is more positive in the early stages of the disease (i.e., within the first three years of ED onset), and decreases the longer the condition persists [ 18 , 19 ] .

Likewise, it has been reported that, during early-stage ED, longer disease duration is associated with higher psychological distress and occupational and social impairment [ 9 , 20 ] . Therefore, the lack of—or delay in access to—treatment during the early-stage ED may facilitate chronicity, negatively impact the chances of recovery, impair social and occupational accomplishment [ 21 ]. In fact, from an environmental point of view, our sample showed relatively poor social and occupational adjustment, most of the patients not being married (71.4%), without children (78.6%), and unemployed (72.7%) at the time of data collection. These findings are in line with recent studies in the field, which characterizes individuals with SE-AN as impoverished in terms of intimacy and relationships [ 3 , 22 ], and exhibiting a propensity for economic frugality, some living below the poverty line, without well-remunerated employment behind them [ 22 , 23 ].

The duration of untreated ED (DUED) is the period of time between disease onset and the start of evidence‐based treatment. In the existing literature, the average DUED is reported to be between two and three years for anorexia nervosa (AN) [ 24 ] . However, it is noteworthy that our study yielded different findings, as we observed an average DUED of 8.79 years in our sample, with a wide-ranging variation from as short as 1 year to as long as 39 years. This significant deviation from the established averages underscores the heterogeneity and complexity of DUED across different populations, warranting further exploration to elucidate the contributing factors.

DUED can be divided into two distinct stages [ 25 ] . The initial stage is characterized by delays mostly driven by patient‐related factors, wherein individuals may experience symptoms but fail to recognize the presence of a problem or may not be prepared to seek help. In the second stage, individuals seek treatment, but they encounter service‐level delays, further prolonging the untreated illness period.

Flynn et al. [ 21 ] evaluated the role of First Episode Rapid Early Intervention for ED (FREED), finding that FREED, significantly reducing the DUED, is associated with significantly shorter wait times for both assessment and treatment, higher patients compliance to treatment, and possible distress reduction and deterioration prevention. The same results are suggested by Andrés-Pepiñá et al. [ 26 ], reporting that a substantial percentage of patients with adolescence-onset AN achieve complete remission of the disorder when they undergo specialist treatment, and an early intervention in AN may help to improve the disorder course. Also, Austin et al. [ 24 ] suggested that DUED may be a modifiable factor influencing EDs outcomes and that a shorter DUED may be related to a higher probability of remission.

Diagnostic and treatment delays appear to be partly attributable to gaps in the health system and scarce economic resources, and partly attributable to the ego-syntonic nature of the disorder itself. The treatment refractoriness, pushing the patient away from the therapeutic paths taken, if not rejected out of hand, is usually a result of an incomplete understanding of their disease state [ 25 , 27 ]. People with AN tend to hide their state of emaciation, avoiding an established relationship with primary care and resorting to emergency departments only when medical problems arise [ 28 ], leading in some cases to hospitalization. The prevalence of untreated individuals with EDs is estimated to be as high as 75% [ 29 ]. This considerable percentage may be attributed, in part, to comorbid conditions that influence motivation, scheduling constraints, or the need for clinical prioritization within general mental health services. These factors can result in delayed or hindered access to specialized ED services, particularly in cases where individuals with EDs also present with concurrent issues such as self-harm or suicidal behaviors [ 30 ].

Diagnostic-therapeutic delays thus lead to high rate of medical comorbidities due to malnutrition, the need for internal medicine/psychiatric hospitalization, as well as the substantial burden of psychiatric comorbidities [ 9 , 10 , 20 , 31 ]. Medical comorbidities and complications associated with EDs can range from mild to severe and life-threatening, potentially involving all body systems and placing people at increased risk of medical instability and death [ 32 ]. Therefore, understanding how comorbidities and co-occurring medical complications impact EDs is fundamental to treatment and recovery. In addition to the ED-associated medical comorbidities, EDs often occur together with other psychiatric conditions. Psychiatric comorbidities in people with EDs are associated with higher emergency department presentations and hospitalizations and health system costs [ 33 ]. Comorbidities may result from symptoms and behaviors associated with the ED, be co-occurring, or precede the ED onset [ 34 , 35 ]. People with an ED, their caregivers and care providers often face a complex dilemma: the individual with ED needs treatment for not only for their ED but also for their psychiatric comorbidities, and it can be hard to determine which is the clinical priority. This is further complicated because EDs and comorbidities may have a reciprocal relationship of mutual worsening, exacerbating each other's symptoms and negatively impacting treatments and outcomes.

The case series also confirms what literature shows about how the severity of SE-AN cannot be defined solely by BMI value and resistance to treatment [ 36 , 37 , 38 ], but also by the multiplicity of possible negative consequences that mark the life course of these patients, and the increasing consolidation of ED related psychopathology [ 39 ]. Repeated hospitalizations, severe complications, frequent comorbidities, a variety of unproven drug treatments are all equally present variables that indelibly mark the very long history of the disease.

This case series presented 14 cases of adult patients affected by SE-AN. It highlighted the relevant issue of resistance to treatment that marks the life course of these subjects, as well as the prospect of a variety of complications, both medical, psychological as well as social. The chronicity of this disorder is determined by the overlapping of numerous elements. First of all, the very nature of the disorder, which often makes the patient less likely to seek treatment, the difficulty of the health system in recognizing the problem in its early stages, but also the presence of an occupational and social impairment. Further studies on the topic are needed to broaden the knowledge of this disorder and its pathogenesis. This will enable us to develop more precise and effective interventions.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author following a reasonable request.

Abbreviations

• Anorexia Nervosa

Body Mass Index

Diagnostic and statistical manual of mental disorders, 5th edition

duration of untreated eating disorder

Eating Disorder

Estrogen-progestin

First episode rapid early intervention for eating disorders

Obsessive compulsive disorder

Personality disorder

Severe and Enduring Anorexia Nervosa

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Federica Marcolini, Alessandro Ravaglia, Silvia Tempia Valenta, Federica Sanna, Giulia Zilli, Enrico Magrini, Flavia Picone, Diana De Ronchi & Anna Rita Atti

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Marcolini, F., Ravaglia, A., Tempia Valenta, S. et al. Severe-Enduring Anorexia Nervosa (SE-AN): a case series. J Eat Disord 11 , 208 (2023). https://doi.org/10.1186/s40337-023-00925-6

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The Treatment Experience of Anorexia Nervosa in Adolescents from Healthcare Professionals’ Perspective: A Qualitative Study

Yu-shan chang, fang-tzu liao, li-chi huang, shu-ling chen.

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Received 2022 Aug 31; Accepted 2022 Oct 3; Collection date 2023 Jan.

Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( https://creativecommons.org/licenses/by/4.0/ ).

Anorexia nervosa (AN) is a serious psychiatric illness with a high mortality rate and a poor outcome. AN in adolescents can be difficult to treat. The prognosis of patients with AN depends highly on how early specialized AN treatment starts. Therefore, the purpose of this study was to explore the experiences of healthcare professionals in treating adolescents with AN. A qualitative study approach was conducted. Through semi-structured interviews, 16 healthcare professionals, including 10 nurses, 3 dieticians and 3 physicians from the paediatric ward at a university-affiliated medical centre in central Taiwan, shared their experiences. Recorded interviews were transcribed and analyzed by content analysis. Five themes and ten subthemes were identified: 1. Building a trusting relationship first: (a) spending time to build trust with the client and (b) establishing a relationship with the client’s parents; 2. The key to treatment success: (a) Clients’ awareness of the illness and (b) parents’ support for clients; 3. Consistency of team treatment goals: (a) maintaining stable vital signs and (b) achieving caloric intake; 4. Empowerment with knowledge about anorexia: (a) continuing education for healthcare professionals and (b) interdisciplinary collaborative care; and 5. Using different interaction strategies: (a) the hard approach and (b) the soft approach. In conclusion, the findings will provide important information for healthcare professionals to apply in monitoring the psychological and emotional states of adolescents with AN. The findings indicate that healthcare professionals should invite parents to participate in the treatment, support and guide them in their adolescent care, develop scales of family stress and support for AN in adolescents, develop interventions, and establish an early therapeutic alliance.

Keywords: anorexia nervosa, adolescents, healthcare professionals, treatment experience, qualitative research

1. Introduction

Anorexia nervosa (AN) is a serious illness characterized by self-induced underweight, body image distortion and fear of weight gain [ 1 , 2 , 3 , 4 ]. AN is one of the most common chronic diseases in teenage girls, ranking third after obesity and asthma, and continues to rise in that population [ 5 ]. Its treatment is long and complex, involving a multidisciplinary team [ 6 , 7 ]. AN begins most often during adolescence and affects mainly adolescent girls and young women [ 8 , 9 ]. With scientific research, the disease of anorexia has gradually been understood, and there are many clinical records available [ 10 , 11 , 12 , 13 ]. It is also understood from a psychiatric perspective [ 8 , 14 ] and a body perspective (somatic perspective) [ 15 ]. Scientists have also identified biological correlates, multiple risk factors and patterns of aetiology, particularly sociocultural, developmental and pathophysiological [ 16 , 17 ], and genetic [ 18 , 19 ] types. Although the understanding of the causes of anorexia has increased, the psychopharmacological treatment of patients with anorexia is still ineffective [ 20 ]. The patients are difficult to treat, and the prognosis and outcomes are often disappointing. The problems include patient ambivalence towards change; resistance to treatment; comorbidities and personality traits; and cognitive impairment [ 21 ]. Studies have found that medical providers are dominated by biomedical theories and emphasize the visible signs of anorexia, namely, the patient’s physical condition, weight and behavior [ 3 , 22 , 23 ]. Psychological well-being appears to be a central criterion for eating disorder recovery, in addition to the remission of eating problems [ 24 ]. However, even though adolescents focus on their mental states and emotions, most professionals do not address their emotional issues and the adolescents’ wish to be seen as a whole person [ 22 , 23 ]. The patients often feel that the health care focuses too much on physical recovery and on the normalization of eating and weight. This approach can be perceived as unempathetic and give patients the impression that the therapists do not understand the patient’s real problems [ 23 ]. Trusting relationships with healthcare professionals are also considered important in developing the motivation to seek and stay in treatment [ 25 ]. Despite the well-known practical challenges in providing intensive treatments to individuals with AN, qualitative research into the perspectives of healthcare professionals and their treatment experiences is limited. Therefore, this study used qualitative research to explore the experiences of healthcare professionals in treating patients with anorexia, including understanding healthcare professionals’ therapeutic relationships with AN patients and parental involvement in the treatment process. These experiences can be used as a reference for healthcare professionals to care for patients with anorexia, and improve anorexia-related care.

2.1. Design

A qualitative study approach was used to describe and understand the in-depth complex phenomena associated with healthcare professionals, including nurses, dieticians, and physicians. Purposive sampling was used to recruit healthcare professionals who met the following criteria: (1) experience in caring for adolescents with anorexia nervosa; and (2) agreement to participate in this research.

2.2. Setting and Patients

This study was conducted in a general paediatric ward at a children’s hospital. Adolescents with AN who have life-threatening conditions are admitted to our hospital for medical stabilization. The length of hospital stay is about three to four weeks.

2.3. Participants

Healthcare professionals were invited to participate in this study through invitation letters. They were asked to complete a paper-based survey to indicate their willingness to participate in an interview. The inclusion criteria for healthcare professionals to participate in this study were at least one year of work experience in the hospital, and experience in taking care of at least one hospitalized adolescent with AN. The study included 16 healthcare professionals, including 10 nurses, 3 dieticians, and 3 paediatric gastroenterologists. The nurses were all female with a mean age of 30.2 years, ranging from 26 to 40 years; 3–11 years of clinical experience; and experience with caring for 1–8 adolescent patients with AN. The three dietitians were two females and one male with a mean age of 39 years, ranging from 38 to 41 years; 10–13 years of clinical experience; and experience with caring for 2–10 adolescent patients with AN. The three paediatric gastroenterologists were males with a mean age of 50 years, ranging from 33 to 59 years; 8–34 years of clinical experience; and experience with caring for 10–27 patients with AN.

2.4. Data Collection

Data collection consisted of semi-structured interviews, based on the following questions: (1) Can you tell me about your experience in the treatment and care of adolescents with AN? (2) Can you tell me how to develop a therapeutic relationship with an adolescent with AN? What was your approach? (3) Can you tell me how to guide parents in caring for their children? How can one support and incorporate parents’ ideas? (4) Can you tell me how the medical team can be trained or educated to improve the care of AN? Data collection was conducted from January to June 2019. Each interview was recorded, coded, and analyzed verbatim, and the experience was shared and discussed with experts trained in qualitative research. Data collection was completed using the data saturation criterion through the repetition of information in the statements from a total of 16 in-depth interviews. The interviews ranged in length from 45 to 60 min.

2.5. Data Analysis

Data were analyzed with the qualitative content analysis approach from Graneheim and Lundman [ 26 ] by determining meaning units, condensed meaning units, codes, subcategories, categories, and themes. The interviews were carefully transcribed, and each transcription was read several times to obtain a general understanding of the interview. Then each text was read line-by-line and meaning units were identified, after which each meaning unit was condensed and assigned a code. Next, codes were assigned to subcategories according to their similarities and differences. Similar subcategories together formed categories, and finally, themes emerged.

2.6. Trustworthiness

To ensure the trustworthiness of the study, our procedure followed the guidelines proposed by Lincoln and Guba [ 27 ]. The credibility of the data was enhanced by the authors’ expertise in nursing and qualitative research, which allowed us to fully understand the healthcare professionals’ experiences regarding the treatment and care of adolescents with AN. Transferability was facilitated through the use of purposive sampling, and the data sources were enriched by including participants of different professions, ages and care experiences. Dependability was promoted by the authors meeting frequently to discuss the data analysis and by checking and rechecking the labelling, sorting and naming of themes during data analysis for verification, as suggested. Confirmability was ensured by describing the entire research process and procedures in detail, keeping a reflexive journal, and maintaining an audit trail [ 27 ]. Healthcare professionals’ experiences were extracted as thick descriptions of the related phenomena.

2.7. Ethical Considerations

This study was performed in accordance with the principles of the Declaration of Helsinki. All the study procedures were approved by the Hospital Human Investigation Committee at each of the medical centres (IRB No. CMUH106-REC1-132(AR-1)). The participants’ rights of anonymity, confidentiality and withdrawal from the study were explained at the time of the interview.

3.1. Participants’ Characteristics and Identified Themes

The study included 16 healthcare professionals, including 10 nurses (all female, aged from 26 to 40 years), 3 dieticians (all female, aged from 38 to 41 years), and 3 physicians (all male, aged from 33 to 59 years), for a total of 16 participants.

The findings were categorized into five major themes and ten sub-themes: 1. Building a trusting relationship first, including the sub-themes: (a) spending time to build trust and (b) establishing a relationship with the client’s parents; 2. The key to treatment success, including the sub-themes: (a) awareness of the illness and (b) parents’ support; 3. Consistency of team treatment goals, including the sub-themes: (a) maintaining stable vital signs and (b) achieving caloric intake; 4. Empowerment with knowledge about anorexia, including the sub-themes: (a) continuing education and (b) interdisciplinary collaborative care; and 5. Using different interaction strategies: (a) the hard approach and (b) the soft approach. The main themes and sub-themes are presented in Table 1 .

Themes and Sub-themes.

3.2. Theme 1. Building a Trusting Relationship First

The need to build a trusting relationship is based on the fact that healthcare professionals (including nurses, dieticians, and paediatric gastroenterologists, referred to as physicians) cannot easily establish a therapeutic relationship with a client at the first encounter. In the beginning, the client is highly defensive and reluctant to express her thoughts and feelings. She engages in little social interaction and exhibits apathy and rigid behaviors. Thus, the establishment of the initial trusting relationship is very important. Once such a relationship is built, follow-up treatment can ensue. This theme included two subthemes: (a) spending time to build trust with the client and (b) establishing a relationship with the client’s parents. The first subtheme, “spending time to build trust,” shows that the establishment of trust requires spending time to gain her trust, understand her, make her dependent on us, and slowly persuade her to share her innermost thoughts. Three physicians identified the importance of a trusting relationship.

As one physician said, “ You must take the time to establish a relationship with her. She is willing to rely on you, and she is willing to tell you where the problem is. Slowly change her mind and see if she can recognize that food refusal is not good for her. ” (C2).

Physicians also believe that the characteristics of nurses are very important, and that they are willing to spend time talking to and understanding the client. As one physician said, “ The characteristics of nurses are very important. They may not be able to take care of them if they don’t have the right characteristics. You need to screen nurses. Like some discharged cases, nurses are also willing to contact them. Because my (the physician’s) time with her is limited, the nurse has more time with her, especially some night nurses .” (C1). However, for most nurses, the routine care to be performed every day is multifarious and complicated, and the work schedule is tight, with an average of 6–7 patients per day. It takes a lot of time to perform general care. When facing patients with anorexia, they need sufficient time to understand the mental illness. As one nurse said, " It often takes more time to establish a relationship with patients with anorexia, but the usual nursing work is already quite busy. So there is no way to deeply understand the case, and it is more difficult to build therapeutic relationships .” (C13).

The second subtheme, ‘establishing a relationship with the client’s parents’, refers to the fact that, since it is difficult to establish a relationship with the client at the beginning, healthcare professionals can first establish a relationship with the client’s parents to understand the client’s preferences. As one nurse said, “ Initially, anorexia patients are alienated from us; they don’t even want to talk to us. So I choose to establish a relationship with the parents of the case first. And then I learn about the reasons for the client’s anorexia, her thoughts, and her preferences from the parents. Knowing that the client likes the punch-in food on Instagram (IG), the Lala Bear, etc., I will go up to see what food is available near the hospital, and then recommend it to her during treatment ” (C13).

It is also important to let parents know that family relationships are very important. As one participant said, “ We still emphasize that parents should give children enough love and tolerance, and they will be easier to deal with and less likely to come to this point. ” (C2). Some doctors also hope that parents will realize that it is not appropriate to blame the child. They must understand that the child is ill, and her thoughts will be affected by the disease. For example, one participant said, “ In fact, the client is in a state of illness, her thoughts will be affected physiologically. If the parents are willing to accept it, it will be better, instead of blaming the child all the time. ” The participant also stated, “ We can imagine that their parents and families must be in conflict with anorexia, because the parents must have hurriedly forced her to eat and dragged her to see the doctor .” (C1).

3.3. Theme 2. The Key to Treatment Success

This theme includes two sub-themes: (a) Clients’ awareness of the illness and (b) parents’ support for clients. The first theme, “Clients’ awareness of the illness,” means that the most difficult aspect of the treatment and care of adolescents with anorexia is whether the patient understands that they have an illness. A patient who is aware of the illness understands that the disease causes physical problems and can generally gain weight through treatment. In contrast, adolescents who do not perceive an illness do not think they have a problem, but their parents take them to a doctor for treatment. In general cases of this lack of awareness of the illness, when the physician asks, “ Why did your parents take you to see a doctor? Why did you come to see a doctor? ”, the patients will often answer, “ I’m fine, it’s my parents who asked me to see a doctor .” (C1). One physician also said, “ In fact, these children don’t have enough awareness of the illness. I told (one girl) to go to the intensive care unit, but she would not agree … At this time, her heartbeat had dropped to 28, and she didn’t think anything was wrong with her. ” (C3).

Another dietician said, “ We compared children who lacked awareness of the disease, and they would say that they should not eat this and should not take this IV, because there are too many calories .” (C14).

The second subtheme, “parents’ support for clients”, is very important. Three physicians believe that parents should give their children enough love and tolerance, and they should not blame the child, because the child is currently in a state of illness. Therefore, her thoughts will be affected by the disease. One physician mentioned that “ the most difficult part of treating anorexic teenagers is not only that the patient has no awareness of the illness, but also, if the parents’ support is not enough, sometimes it is very difficult to treat anorexia. ” (C3). It is also very important to let parents know that family relationships have great significance. One physician said, “ We still emphasize that if parents give children enough love and tolerance, they will be easier to deal with and less likely to come to the end of the disease. Family relationships and support are still very important. ” (C2). Three physicians also hope that parents will not blame the child in an attempt to change the child’s behavior. One physician said, “ The child is sick now, not because she is unwilling to cooperate or skip meals, but because her mind is affected physically. If the parents are willing to accept it, they will not be blamed all the time .” (C1).

3.4. Theme 3. Consistency of Team Treatment Goals

This theme included two sub-themes: (a) maintaining stable vital signs and (b) achieving caloric intake. The first subtheme, “maintaining stable vital signs,” refers to the fact that healthcare professionals’ treatment goals must start with physiology, as it is believed that nutritional deficiencies can affect cognitive function. First, the client’s vital signs should be stable. As one physician said, “Anorexia nervosa is most commonly [associated with] a very low heartbeat (30 bpm), or low body temperature (35 °C), low blood pressure, electrolyte imbalances. These are life-threatening conditions, and sometimes they have to be admitted to the ICU, which may be mandatory.” (C1). The second subtheme, ‘achieving caloric intake’, is about focusing on the patient’s dietary intake and weight growth. One dietician said, “We will start by increasing the amount of food she eats at each meal, and try to add to it slowly, and maybe reach her caloric intake. We may use other intravenous methods, or even use nutritional supplements to intervene, and to pull her whole weight up!” (C14). The nurse and the client set a weight goal together, and upon achieving the goal, the client will be allowed outside or discharged from the hospital. One nurse said, “Give her a goal, how much I want you to eat every day, and if you gain this much weight, I can give you time off, and your mother can take you out for fun. And if you gain that much weight, we will let you out of the hospital.” (C4).

3.5. Theme 4. Empowerment with Knowledge about Anorexia

This theme refers to the ways medical team members can improve collaborative care and their related knowledge of anorexia, and then continuously improve their care. This theme includes two sub-themes: (a) continuing education for healthcare professionals and (b) interdisciplinary collaborative care. The first theme, “continuing education for healthcare professionals,” describes the lack of knowledge of healthcare professionals, especially nurses and dieticians, in the care of anorexia and the expectation of continuing education related to anorexia. One physician said, “ Our care for anorexia is taught by the attending physician one by one, from the intensive care unit to the ward care, and then to the outpatient care. In fact, education is carried out during the follow-up process and the ward rounds. This kind of education only means that the few people who are cared for know how to take care of them. Nurses still don’t know how to care of them. ” (C3). One dietician reflected on the need to improve her knowledge of psychology. As she said, “ We should study psychology. Anorexia is not only physical; the psychological part also plays a big role in the treatment. ” (C16). The second subtheme, ‘interdisciplinary collaborative care’, reflects the fact that most nurses feel that they lack experience in caring for patients with anorexia, and they look forward to continuing education in this area or sharing their caring experiences in the ward. For example, one nurse said, “ We can invite psychiatrists to do ward teaching activities to teach us how to face and how to care for people with anorexia, what conversations and behaviors are helpful to them, and what to avoid .” (C13) Another nurse said, “ Interdisciplinary discussions can be held, and paediatricians, psychiatrists, social workers, dieticians, and nurses can be invited to discussions, and individual discussions can be conducted on individual cases to provide patient-centred care. ” (C10). Physicians expect a dietician to function not only in nutritional assessments but also in psychological assessments. As he said, “ If a dietician falls into a machine and it looks like she’s taking care of a machine, she doesn’t take into account the whole body and mind of the patient. What the patient needs, such as providing what to eat, should not only focus on nutrition, but also on whether it tastes good or not! ” (C3).

3.6. Theme 5. Using Different Interaction Strategies

This theme includes two sub-themes: (a) the hard approach and (b) the soft approach. The first theme, “the hard approach,” refers to the fact that some participants would use coercive methods to require patients to increase their caloric intake and achieve body weight goals. Most children fear the insertion of the nasogastric tube the most, so one physician said, “If you stop eating again, I will put you on a nasogastric (NG) tube. I will force-feed you, I will transfer you to the intensive care unit, and then put the TPN, and I will force you to be given nutritional injections.” (C3). Even placing the NG tube where the child can see it can be effective; as the nurse stated, “put the nasogastric tube at the end of the bed.” (C5).

The second subtheme, ‘the soft approach’, describes the approach of some participants of using gentleness or physical comfort, combining euphemisms with a strict manner, creating an agreement with the patient, and expressing empathy. For gentleness or physical comfort, one physician said, “ I use chatting, and every time I go in, she will chat for more than 30 min. And when I go in, I will hug the child and touch her hand. Then I’ll tell her that she can tell me anything, and also allow her parents to be by her side. ” (C2). From the physician’s point of view, a massage strategy can be useful for building a trusting relationship. One physician stated, “ I also do a lot of things that general doctors can’t do. I sit down and talk to the children…I will give the children massage, and they have no flesh but bones, then the parents will be by their side, and gradually I will teach the parents. I’ll say, when you are in contact with the child, give her a massage and physical touch when you have time, because if you don’t develop a little relationship with her, she will never make progress. ” (C2) Regarding the use of euphemisms with a strict manner, as one physician said, “ I am more euphemistic. I don’t scold people, but at this time, it is necessary to make comparisons. If she does not cooperate, I may need to be stricter and tell her clearly that she can’t do this, and if she doesn’t cooperate, the less I will bargain with her. ” (C3). Regarding creating an agreement with patient, as one nurse said, “ The doctor made us draw up three rules with the child: not to self-harm, not to hurt the parents, and not to engage in violent behavior; otherwise, she would be transferred to the psychiatric ward. ” (C5). Regarding empathy, as one nurse said, “ At the beginning of taking care of such a case, when I spoke, she would just stare at me and her hostility was very strong. I would empathise in the here and now; if I were her, what would I want? ” (C4).

4. Discussion

The main objective of the present study was to explore the experiences of healthcare professionals in treating adolescents with AN by interviewing physicians, nurses, and dieticians. Our results showed that, beginning at the patient’s admission, it was crucial to build a trusting relationship in the treatment process by spending time to understand the patient and establish a relationship with their parents. This finding is similar to those of previous reports [ 28 , 29 ], which reported that nurses perceived trust as important in the care of people with AN, as it was essential for guiding changes in the patients’ behaviors. Trust was described as a component of the relationship that could be developed over time [ 30 , 31 ]. It was also consistent with Gulliksen et al. [ 30 ], who emphasized the importance of the therapeutic “relationship” in the treatment of chronic AN. That is, one therapeutic aspect of patient admission is establishing a ‘secure base’ in individuals where one is lacking. As Ross et al. [ 32 ] found, patients reported that positive encounters were ones that made them feel understood, safe, and valuable, while also putting them in a better mood. The phrase “like home” was used to express positive encounters with health professionals. Therefore, establishment of the therapeutic alliance is a fundamental activity in mental health nursing [ 33 ], and an important aspect of care when working with people who have AN, with implications for the outcomes [ 34 , 35 ].

Anorexia nervosa is a psychiatric disorder with a considerable risk of serious physical morbidity, and even death. Healthcare professionals must look at extremely thin, malnourished bodies [ 36 ], so the team treatment goal of healthcare professionals in this study consistently focused on (a) maintaining stable vital signs and (b) achieving caloric intake. This finding is similar to a previous report [ 37 ] that, when it is important to stick to a task (e.g., weight gain in anorexia nervosa), the clinician should be consistent in pushing the need to achieve that goal. As Sibeoni et al. [ 22 ] found, healthcare professionals can then have great difficulty focusing their attention on what the adolescent thinks and feels about it. This issue is undoubtedly more serious within inpatient units. Therefore, healthcare professionals tend to focus on the visible signs of anorexia nervosa, namely, the condition of the body and the patient’s weight, while adolescents focus on their psychological state and their emotions. The clinician and the patient focus on different points, which can easily lead to conflict. Bourion-Bedes et al. [ 35 ] suggest that, to establish an early therapeutic alliance, healthcare professionals need to pay attention to the psychological and emotional states of these adolescents and try to approach how the adolescents live the disease from the inside.

The healthcare professionals in this study perceived that the key to treatment success was the patient’s awareness of the illness and the parents’ support. Although it is difficult for a patient with AN to recognize her own disease, parental support is so important that treatment of anorexia nervosa in adolescence should always involve the parents [ 38 ]. They too must initially focus on issues important to the teen; that is, the individual psychological aspects of the disease. In fact, this is the most important aspect for the adolescent’s involvement in his or her treatment, and parents have an important role to play in this step of the treatment process.

Regarding the component of knowledge about anorexia, the nurses and dieticians in this study perceived that they lacked knowledge about caring for patients with anorexia. Therefore, they had an expectation of continuing education related to anorexia. This finding is similar to previous reports [ 39 , 40 ] that there is a need for adequate education, training, support and preparation for dealing with patients with AN with greater understanding. As Wu & Chen [ 41 ] found, nursing staff generally lack positive feelings about patient care for AN and even question their abilities to provide quality nursing care. Ramjan [ 40 ] also reported that, when nurses lacked knowledge about the illness, this mindset facilitated an overly narrowed focus on the patient’s behaviors, resulting in a power struggle in the relationship. Therefore, Ramjan [ 40 ] suggested that education for these ‘specialist’ nurses needs to include an understanding of the elements, stages and turning points in recovery from anorexia nervosa, and not only the understanding of its symptoms and aetiology.

Regarding the use of different interaction strategies, our study found that healthcare professionals will interact with patients with AN in different ways to build a trusting relationship and increase their caloric intake. The hard approach was mentioned in a previous study [ 41 ], indicating that, when a doctor discusses a patient’s condition in a threatening way, the patient will fear the consequences of punishment and passively accept treatment. As a result, patients cannot entirely trust the healthcare professionals, and the healthcare professionals and patients are suspicious of each other. Similarly, Geller & Srikameswaran [ 42 ] indicated that, although clinicians may at times have to implement interventions which are not wanted by the patient, having a predetermined contract of non-negotiables, reiterating the rationale for these non-negotiables, and attempting to offer as much choice as possible can help to maintain trust and the therapeutic alliance.

Moreover, our study also found that participants described interaction strategies with a soft approach (gentleness or physical comfort, combining euphemism with a strict manner, creating an agreement with the patient, and empathy). These findings are similar to those of Geller & Srikameswaran [ 42 ], who indicated that nursing approaches may vary between the unwavering strict and stern approach to the democratic, negotiation-based and non-pressurised approach. In addition, our study also found that a massage strategy could be used for building a trusting relationship. This finding has not been mentioned in previous studies. From this, it can be concluded that it is important to make the client feel as if she is cared for and regarded as an individual.

5. Study Limitations

First, this study recruited 16 experienced health professionals (3 paediatric gastroenterologists, 10 nurses, 3 dieticians) who had cared for patients with AN in central Taiwan. Therefore, the experiences presented here cannot be generalized to health professionals from other parts of Taiwan, or to health professionals in western countries. However, the experiences of the participants are powerful and add richness to the existing knowledge on health professionals’ experiences with patients with AN, and they provide motivation to rethink the design of in-service education for AN patient care. Second, the paediatric gastroenterologists were all male, while the nurses and dieticians were all female, and the dieticians were 2 females and one male. The sample of participants was very unequal, not only in gender but also in number (10, 3 and 3). It is recommended that the question of whether different genders have different care experiences be explored in the future. Finally, because patients under the age of 18 in Taiwan are admitted to paediatric wards, adolescents with AN will first be hospitalized in a paediatric ward for observation, and not in a psychiatric ward. In addition, paediatric nurses do not have experience in supporting each other across departments, so their care experiences may be limited.

6. Conclusions

Patients with anorexia have extremely fragile and malnourished bodies, and healthcare professionals can be shocked by the sight them—reduced to only skin and bones, these patients even face the risk of death. Healthcare professionals are therefore more focused on the visible signs of anorexia, namely, the physical condition and weight maintenance, and they find it more difficult to focus on the individual’s thoughts and feelings. All physicians will first spend time to build a trusting relationship with the patient, and they will address the patient’s emotional problems. If both are not simultaneously addressed, the risk of relapse and readmission after discharge is high. Thus, it is well established that both mental and physical recovery are very important in patients with AN. The results of this study should provide further understanding of the perspectives of medical professionals, ways to face the disease of anorexia, and ways to function as a team and to strengthen the team’s knowledge about anorexia.

Acknowledgments

We would like to thank the participants of this study.

Author Contributions

Conceptualization, Y.-S.C., F.-T.L., L.-C.H. and S.-L.C.; Formal analysis, F.-T.L. and S.-L.C.; Supervision, L.-C.H. and S.-L.C.; Writing—original draft, Y.-S.C. and S.-L.C.; Writing—review & editing, L.-C.H. and S.-L.C. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

This study was approved by the Institutional Review Board of China Medical University Hospital (CMUH106-REC1-132(AR-1)). All participants signed an informed consent form to participate in this study.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The data are not publicly available due to restrictions regarding privacy and ethical considerations of the study participants.

Conflicts of Interest

The authors declare no conflict of interest.

Funding Statement

This work was supported by the Ministry of Science and Technology, Taiwan, MOST 107-2314-B-241-001-. The MOST funding agencies had no role in the design of the study, the analysis and interpretation of the data, or the preparation, review, or approval of the manuscript.

Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

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Anorexia nervosa in children and adolescents: an early detection of risk factors

• Elena Bozzola   ORCID: orcid.org/0000-0003-2586-019X 1   na1 ,
• Sarah Barni 1 , 2   na1 ,
• Maria Rosaria Marchili 1 , 2 ,
• Romie Hellmann 3 ,
• Emanuela Del Giudice 2 ,
• Giampaolo De Luca 2 &
• Vita Cupertino 2

for the Italian Pediatric Society Adolescent Study Group

Italian Journal of Pediatrics volume  50 , Article number:  221 ( 2024 ) Cite this article

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The incidence of eating disorders in children, mainly of anorexia nervosa, is dramatically increased in the last years. A timely identification of the disease is associated with higher rates of recovery. Aim of the work is to underline signs and symptoms that can be used to an early detection of anorexia nervosa in the pediatric age.

A scoping review has been conducted by The Italian Pediatric Society Adolescent Study Group according to the PRISMA Extension guidelines for Scoping Reviews, using the search term “anorexia nervosa” and the following filters “review”, “systematic review”, “age 0–18”, “last 4 years”.

The strategy search produced 657 studies, of which 52 were included in this revision. Screening and red flags were discussed in 23 reports, genetics in 12, neurological pathways in 11, environmental factors in 10, and gut microbiota in 7. An accurate physiological and pathological anamnesis, physical and psychological examination, including the body perception, should be taken in account as well as the presence of co-morbidities, including chronic functional abdominal pain and autoimmune/autoinflammatory diseases. Evidence suggests the role of familiar predisposition as well as of neurological morphology and pathway in anorexia nervosa development. Gut microbiota has also been included among possible risk factor for developing anorexia nervosa due to a complex direct and indirect interactions between gut and brain.

The Italian Pediatric Society Adolescent Study Group suggests performing an accurate familial and personal anamnesis, including psychological evaluation as well as a physical exam including auxological parameters as a screening tool during pediatric checks to better explore the risk of developing anorexia nervosa. 

Eating disorders (ED) in children and adolescents encompass a range of behavioral conditions marked by profound and persistent disruptions in eating habits, along with distressing thoughts and emotions. After the COVID-19 pandemic, the number of minors affected by anorexia nervosa, who limit food intake and/or engage in excessive physical activity even when the individual is already underweight, is dramatically increased [ 1 , 2 , 3 ]. These are potentially life-threatening conditions that affect the quality of life of children and adolescents as well as their families. Most of the adolescents affected by ED usually present with body dissatisfaction and an obsessive focus on the food and the body weight. These are among the main reasons to follow unbalanced and dangerous diets which in turn negatively affect nutritional intake, growth and development of children and adolescents. Minors may also require a prolonged hospitalization and are at risk of mortality stemming from both the physical and psychiatric complications [ 2 , 4 ]. Eating disorders are underdiagnosed and undertreated, as most affected patients have poor insight and deny the severity of their illness. Early identification and diagnosis of eating disorders by physicians is critical, as timely intervention is associated with a higher likelihood of successful treatment and with higher rates of recovery [ 5 ].

This scoping review has been conducted by The Italian Pediatric Society Adolescent Study Group to optimize an early medical approach to anorexia nervosa (AN). Starting from a review of the international literature. The aim of the project was to develop a useful tool for general practitioners and pediatricians to an early detection of AN in the pediatric age.

This scoping review has been performed following PRISMA Extension guidelines for Scoping Reviews [ 6 ].

An electronic search was undertaken on PubMed database on 8th December 2023, using the search term “anorexia nervosa” and the following filters “review”, “systematic review”, “age 0–18”, “last 4 years”.

The research results were downloaded from PubMed and then uploaded on the web application “Rayyan”, a website used to screen and analyze articles, specific for writing reviews.

First, the duplicates, and articles written in other language rather than English, were identified by the web application, Rayyan [ 7 ]. Then, two authors checked the detected duplicates, eventually excluding the undue copies. To limit errors and bias, three authors independently screened titles and abstracts produced by the research and defined those articles distinctly irrelevant to the review.

Exclusion criteria were:

reports including adults, without age distinction.

reports dealing with other themes (e.g., medical complications, prognosis, therapy, other).

Afterward, full texts were examined and reviewed for eligibility by three authors. If full text articles could not be found, an attempt of contacting authors was performed, to obtain the full text.

Finally, according to PRISMA guidelines, the references not originally included but evaluated as relevant to the review were analyzed. Disagreements on articles’ inclusion or exclusion were settled between the researchers through a discussion.

The search of the selected electronic databases produced 657 studies. Figure 1 represents the flow chart according to PRISMA guidelines (Fig. 1 ).

Flow chart of the selection process, adapted from PRISMA guidelines

Out of them, 3 were duplicates and 13 were not written in English.

Of the remaining 641, all abstracts were analyzed, and 423 records were discharged because they dealt with different topics, or with adult population.

Afterwards, 218 records were analyzed by reading their full-length text; however, 2 articles could not be retrieved. Hence, 216 full-length reports were assessed for eligibility: 173 were excluded because they did not display any data (n. 20), or because no age subgroups could be identified (n. 114), or the topic was not pertinent to our research (n. 38), finally, 1 was written in a foreign language, not previously detected. Afterwards, 9 reports reported in the references were added to this research.

In conclusion, 52 records were included in this revision, and Table 1 below shows the main issues found in this scoping review. Screening and red flags was discussed in 23 reports, genetics in 12 reports, neurological pathways in 11 reports, environmental factors in 10 reports and gut microbiota in 7 reports.

Red flags/screening/risk factors

Twenty three articles deal with red flags to identify children and adolescents mainly at risk to develop AN [ 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 ]. Table 2 shows their main findings. 

Most of the articles highlight the importance of an accurate physiological and pathological anamnesis, focusing on weight loss, compensatory behaviors (fasting, self-induced vomiting, use of laxatives or diuretics), exercise, and cold intolerance, fatigue, dizziness, or fainting, unexplained growth/puberal delay and amenorrhea [ 8 , 9 ].

During medical check, questions should include the body perception, to investigate body image disturbance, including body estimation and attitudinal body image. Attitudinal body image can be divided into global subjective satisfaction, affect (feelings towards the body), cognitions (investment in the body), and behaviors [ 10 ]. Eating behaviors can include checking behavior or avoiding situations in which the body is exposed, and also slow eating, discarding food, undertaking new diets, spitting, secretive or excessive exercising, and frequent weighing [ 8 , 10 ].

Reviewing over 24 years of clinical samples, 75% of samples reported overall higher perceptive body image disturbance in AN patient, compared to healthy controls. In detail, 85.71% of the studies of female children and adolescents with AN or bulimia nervosa exhibited greater body dissatisfaction, higher affective or cognitive body image disturbance than controls. Approximately 80% of the clinical sample reported behavioral body image disturbance, especially in terms of body checking [ 10 ].

Analyzing AN patient behavior, a greater rate of increase in physical activity than in healthy controls had been observed, especially one year prior to the onset of AN [ 11 ]. Male adolescents with eating disorders were more involved in over-activity than females, reporting lower weight and higher shape apprehensions [ 12 ].

Casper et al., referred that nearly 90% of patients with acute AN restricting type feel compelled to move and physically restless at their greatest weight loss, despite experiencing fatigue and feeling tired, as if they neglect the life-threating consequences of the severe loss of body weight [ 13 ].

Therefore, practitioners need to know that AN patients can also appear active even if extremely underweight and in poor health condition.

Almost all (97%) people hospitalized for an ED have a concomitant health condition [ 14 ]. Mood disorders, including depression, anxiety, post-traumatic stress disorder, and substance abuse have been linked to AN [ 14 ]. Oppositional defiant disorder, attention deficit hyperactivity (ADHD), obsessive compulsiveness, and suicidal ideation have been associated with AN as well [ 15 ]. The drive for thinness in female adolescent patients with AN and in those with ADHD and one hypothesis indicates the role of genetic risk factors, namely a melanocortin-4- receptor deficiency as common base responsible of the compresence of both diseases [ 16 ].

Compared to controls, adolescents with an ED presented a greater tendency for personality traits related to Negative Affectivity (CI = 0.59–0.96; p  < .001), detachment-related traits (CI = 0.59–1.08; p  < .001), and conscientiousness (opposite pole of disinhibition) (CI = − 0.72 to − 0.34; p  < .001). Antagonism (CI = − 0.21 to 0.58; p  = .107) was the only domain of personality traits that did not appear to differ in ED and control adolescents. The disinhibition trait was lowest in samples with elevated percentage of AN patients, suggesting a greater tendency for impulse control among adolescents suffering from AN compared with other types of ED [ 17 ].

Therefore, patients with psychological or psychiatric conditions need to be screened for the increased risk to develop AN.

Self-esteem and socializing problems in adolescents are related to ED onset. An important role is played by social stressors, in particular by bullying regarding shape, weight, and appearance [ 18 ].

Social experiences of sexual minorities are a contributor to eating disorder behaviors and body dissatisfaction among this population, as reported by “the minority stress theory”. In details, sexual minorities (e.g., gay, lesbian, bisexual), and gender minorities (e.g., transgender, gender nonconforming) are at higher risk of developing eating disorder behaviors (fasting, diet pill use, purging via vomiting or laxative use, binge eating, and any restricting behavior) and body dissatisfaction compared to heterosexual individuals [ 19 ].

Adolescents affected by Chronic Functional Abdominal Pain (CFAP) may be at a higher risk of AN compared to controls [ 20 ]. In order to avoid discomfort, CFAP patients follow dietary restriction which may impact psychological and behavioral changes leading to restrictive eating disorders [ 20 ]. Quadflieg N reported that recurrent abdominal pain in childhood (age 7–9 years) represents a risk factor for weight control at age 16. Additionally, three abdominal pain episodes a year in childhood were predictive of future fasting [ 21 ].

A bidirectional correlation has been found between AN and autoimmune/autoinflammatory disease: patients with an autoimmune or autoinflammatory diseases are at greater risk (37%) of developing AN [ 22 , 23 ]. Likewise, individuals with a diagnosed ED are at higher risk of autoimmune or autoinflammatory diseases [ 23 ].

AN and autoimmune diseases share common immunopathological pathways [ 24 ]. In particular, AN and Systematic Lupus Erythematosus (SLE) seem to have specific brain-reactive autoantibodies [ 22 ]. The therapy with corticosteroids may also be responsible for body weight and shape alterations as well as adverse psychiatric effects, acting as a trigger for body image dissatisfaction and AN [ 25 ].

EDs, in particular AD, are increasing also in the youngest. Male children are found to have a younger age of presentation than females [ 12 ]. Screening should start from childhood, as reported by Salatto et al., identifying risk factors or behaviors suggestive of future development of eating disorders [ 26 ]. Selective meals, consumed slowly, with most calories ingested through liquid, and no interest in food are considered among the red flags in the young, together with excessive concern for one’s weight and body shape, restriction in food intake or verbalizations concerning the fear of gaining weight. Guilt at mealtimes, shame regarding eating in the presence of others as well as compulsive physical exercise are behaviors that may be considered as risk factors for developing AN.

Childhood traumatic factors, anxiety, obsessive compulsive disorders, depression, family conflict and parental mood disorders [ 27 ].

A physical exam, including measurement of weight, height, and body mass index (BMI) adjusted for sex and age is a required approach to AN [ 9 , 15 ]. Notably, more than one single measurement should be considered in the pediatric age. The child’s historical growth curve should be calculated, because starvation may arrest the growth in height [ 15 ]. In case of transgender youth with eating disorders, doctors may consider consulting growth curves for both the young person’s birth-assigned sex and gender identity to establish goal weights [ 9 ]. In Germany, a complete physical examination, including weight measurement, at 12–15-year-old early identified AN, leading to a significantly short illness duration [ 28 ].

An accurate physical examination may also underline other key signs suggestive for AN, including pallor, languo hair, acrocyanosis, dehydration as dry mucous membranes, poor skin turgor, poor dentition, parotid gland enlargement, thinning hair, easy bruising, and calluses on the knuckles due to purging [ 8 , 9 ].

The oral cavity is often one of the first sites involved by nutritional deficiency due to the rapid turnover of epithelial cells in the mucous membranes (3–7 days). Approximately 94% of patients have oral manifestations including dental erosion, carious disease, and periodontal diseases induced by vitamin C deficiency (spontaneous gingival bleeding, ulceration, dental mobility and increased periodontal infections) [ 29 ].

Pediatricians need to be aware of atypical AN patient, presenting with a normal weight. A previous personal anamnesis of obesity or overweight may led to an underestimation of AN by both the family and the clinicians, even if no difference in physical parameters on presentation have been found, except for the lower white blood cell count [ 26 , 30 ].

Electrocardiogram to assess bradycardia, prolonged QTc and other arrhythmias may be initially prescribed. Cardiovascular instability, including bradycardia, hypotension, postural hypotension and hypothermia, must be investigated in case of suspected AN to verify if hospitalization is required [ 9 , 15 ].

Blood investigations for alternative medical diagnoses as well as for testing blood parameters, including electrolytes, vitamins and hormones, may present as well red flags for hospitalization [ 8 , 15 ].

Evidence suggests that AN is a heritable genetic disorder in which many genes may play a role [ 22 , 31 , 32 , 33 ]. Studies on twins in particular suggest a genetic component for eating disorders ranging from 16 to 74% for AN [ 34 ]. Many genes have been reported to be likely associated as well as many genetic loci involved in molecular pathways that lead to AN, including serotonergic, dopaminergic, and opioid genes [ 23 , 31 , 32 , 34 ]. The 5-hydroxytryptamine system, involved in food intake, mood, and body weight regulation, as well as the dopaminergic system, modulating thinking processes, reward, emotional behavior, substance dependence, feeding and motor activity had been demonstrated involved in AN [ 32 ]. Opioid receptors polymorphism, involved in food intake, reward sensitivity, pain, and vulnerability to addictive disorders, are linked to AN as well [ 32 ]. Altered levels of adiponectin, a hormone that plays a key role in energy homeostasis and appetite regulation, have been observed in patients with AN [ 34 ]. Altered methylation of genes regulating expression of alpha-synuclein, dopamine, oxytocin, histone deacetylase and leptin may play a role as linked to nutritional status and the immune response [ 33 ]. Genes CPA3 and GATA2 expression were positively associated with levels of leptin, suggesting a genetic overlap between AN, autoimmune disease, and metabolic function [ 34 ]. AN and autoimmune diseases share a bidirectional relationship since they both rely on common immunopathological pathways [ 24 , 25 ].

AN demonstrates higher familial aggregation and higher heritability than other ED [ 15 , 33 , 34 , 35 , 36 ]. The influence of genetics may be variable depending on the sex, being higher in males prior to puberty and in females after puberty onset [ 15 ]. Sex-specific relationships between AN and anthropometric traits have been found as well: AN and body fat percentage more highly genetically correlates among females than males [ 36 ].

Genetic predisposition studies are useful and should be encouraged also for therapeutic aim. Study family-based treatment to prevent AN in adolescents exhibiting signs and symptoms of subclinical AN may contribute in reducing the burden of the disease [ 37 ]. Nevertheless, further studies are required to clarify the influence of genetic components on disease onset. To date, the available evidence does not allow to offer a unique molecular AN diagnosis, hence any reliable screening measures.

Table 3 below shows the main findings of the reported articles.

Environment

Environment and changing society may have an impact on the development and expression of AN [ 38 , 39 , 40 , 41 ]. For example, COVID-19 pandemic led to an increased incidence and severity of ED, linked to either loss of activities and social interaction as well as increased time on social media [ 18 , 38 , 39 , 40 , 41 ]. Diverse environmental influences have been postulated to have a role in AN, including obstetric insults, gestational stress, childhood trauma, familial conflict, anxiety or anger, bullying, abandonment, sexual or emotional abuse and bereavement [ 33 , 42 ]. Moreover, appearance-focused gaming may have its effect as well on body dissatisfaction and on nutrition [ 28 ]. A maternal history of eating disorders has an impact in adolescents aged less than 14 years as they were nearly 3 times more likely to purge than controls [ 43 ]. Virtual spaces as well, with problematic internet use, social media and pro-ana websites are environmental risk factors to consider as adolescents can exchange ideas about their body image and physical aspect [ 44 ].

Table 4 summarizes the main findings.

Neurological pathways

Understanding abnormalities in brain structure and activity may help clarify psychopathological mechanisms and plan prevention and treatment of AN. Recently, neuroimaging studies on the neural circuitry engaged when people process social information improved our knowledge on the correlation among social problems observed in AN and brain development. Abnormalities in the feeling of bodily sensations, namely interoception, may play a role in the pathogenesis of AN. An alteration of the neural interoceptive-processing regions, particularly between subcortical and anterior midline cortical regions, suggest how interoceptive deficits may play a role in altered emotional experience and body-objectification [ 45 ]. In adolescents with AN, almost total hypoconnectivity at resting state compared to controls was noted, as well as decreased activity between subcortical–cortical midline structure [ 45 ]. At rest, four subcortical regions (i.e., thalamus, caudate and cerebellum) show decreased “resting-state functional connectivity”) with cortical areas, whereas one region, the putamen, is observed to have increased connectivity with precuneus [ 45 ]. AN adolescents showed lower activation in the striatum, frontal and temporal areas for negative images and in precuneus and hippocampus for positive images [ 46 ]. Adolescent AN showed more activation in the medial prefrontal gyrus than controls when viewing neutral and positive images and in the cerebellum for negative images [ 46 ]. Also, patients’ gyrus rectus volume, in the frontal lobe, was negatively related to sweet pleasantness rating [ 47 ].

Focusing on the cognitive domains of memory, working memory and visuospatial abilities, AN adolescents have cognitive underperformance, compared to controls [ 48 ]. A significant effect of age also emerged, revealing that older participants had poorer neuropsychological test performance [ 48 ]. On this topic, studies on hippocampus, a structure associated with memory, learning, visuospatial processes, and food intake, highlighted that adolescents with AN have a reduction in hippocampal volume and in all hippocampal subfields apart from the fissure [ 49 ]. Compared to adults, greater atrophy in AN adolescent hippocampus and resting-state functional alterations were noted [ 50 ]. A prominence of limbic structures is considered indicative of emotional and reward processing deficits being at the root of the disease [ 50 ]. Specific brain regions such as the insula and parietal cortex appear to be consistently affected in young patients, suggesting their potential role in the disease pathophysiology [ 50 ].

As the insula helps to integrate and regulate autonomic, affective, and sensory systems, researchers proposed a theory of insular dysfunction playing an etiologic role in AN [ 15 ].

Tomography, magnetic resonance imaging, electroencephalography and more recently magnetoencephalography have been used as powerful tools to improve our knowledge [ 22 , 51 , 52 ]. Magnetoencephalography, providing noninvasive measurements of fluctuations in the excitability of neuronal populations, has a potential role in delineating normal and abnormal brain dynamics and in understanding the pathological oscillatory activity that underline disorders including AN in which alpha- and beta-band dysregulation was found [ 51 ].

Table 5 summarizes the main findings.

Gut microbiota

Table 6 shows the major findings of the articles dealing with gut microbiota as a possible risk factor for developing anorexia nervosa [ 53 , 54 , 55 , 56 , 57 , 58 , 59 ].

Several cases of AN have been reported after severe infections. Indeed, viral and bacterial infections, especially group A b-hemolytic streptococcal infection, or parasite infections, can induce reduction in food intake and changes in gut microbiota composition acting as potential triggers for AN [ 53 ].

Of note, up to 13.6% of patients with AN or BN have experienced a viral infection during puberty and immediately prior to the onset of their ED [ 54 ].

Pediatricians need to be aware that although the resulting secondary anorexia may be physiologically beneficial to fight infection, its persistence after the clearance of the pathogen may constitute a risk to develop typical AN [ 53 ].

Studies have found altered bacterial groups in patients with acute AN, which were not normalized with weight recovery in either adults or adolescents [ 55 , 56 ]. Observing taxonomic group analyses in adolescent patients Romboutsia and Enterobacteriaceae species decrease, whereas Lachnospiraceae and Anaerostipes species increase [ 56 , 57 ]. Interestingly, species belonging to the Lachnospiraceae family helped to predict short-term clinical outcome, independent of other predictors, such as low body weight at admission [ 55 , 56 , 57 ]. This predictive power of Lachnospiraceae can be useful for clinicians to help decisions upon interventions [ 56 ].

Moreover, microbiota in the “gut–brain axis” (the complex direct and indirect interactions between gut and brain), influences complex behaviors, such as learning, stress, anxiety, and gut dysbiosis may lead to an elevated risk of developing psychiatric disorders [ 55 , 57 ].

Similarly, the endocannabinoid system, or endocannabinoidome (eCBome), a lipid signaling system, plays a role in the regulation of food intake, body weight and energy homeostasis. Independently or affecting the gut microbiome, creating the eCBome-gut microbiome axis, it can take part in the mechanisms underlying the pathogenesis of eating disturbances [ 58 ].

Interestingly, anomalous gut peptide signaling has also been reported in ED [ 59 ]. Levels of ghrelin, an enteropeptide that stimulates appetite in the absence of nutrients, were found to be inversely associated with BMI and body fat. Hyperghrelinemia may serve as a compensatory mechanism to drive food intake and fat storage in AN. However, the psychological side of the disorder may prevail over these homeostatic signals to increase feeding, otherwise there may be a reduced ghrelin sensitivity in AN patient [ 59 ]. Adolescents and adults affected by AN share similar ghrelin expression, suggesting that the hormone response is likely independent upon age and age of onset [ 59 ]. Cholecystokinin (CCK) is produced in the small intestine and released in response to intraluminal nutrients, to facilitate the digestion of food and to develop satiety, through the stimulation of vagal afferents. In adolescents’ samples, significantly reduced CCK postprandial levels were found in response to different meal composition [ 59 ]. Also, peptide YY produced in the small intestine and colon in response to the intraluminal presence of food, in adolescents with AN, its basal active form (PYY3–36) levels were found to be elevated relative to healthy controls. This higher fasting peptide YY can contribute to the reduced hunger reported in AN [ 59 ].

AN is a complex multifactorial disease, based on genetics, familial predisposition, highly influenced by environmental-social-psychological aspects, but also determined by organic causes such as gut dysbiosis and alteration of neurological pathways. This is also the reason why a therapeutic approach is complicated. However, prompt diagnosis is fundamental to start an early intervention, to prevent medical complications due to prolonged AN, and to reintroduce the child/adolescent to social life.

For this reason, The Italian Pediatric Society Adolescent Study Group suggests:

an accurate familial and personal anamnesis, including psychological evaluation.

a physical exam including auxological parameters.

The key topics for an early detection of AN are summarized in Table 7 and may be investigated as a screening tool during pediatric checks to better explore the risk of developing AN.

Laboratory and radiological examinations, including blood exam alteration (i.e. anemia, dysvitaminosis, etc.) may be of help in the approach to AN at a very early stage. When performed, neuroradiological exam may highlight abnormalities in brain structure (i.e. alteration of the neural interoceptive-processing regions) that are suggestive for AN. New research strategies are developing studying on gut dysbiosis, endocannabinoidome, genetics, hormones, including ghrelin, CCK and PYY which may play a role in AN.

AN presentation may be sneaky and challenging but its timely and early identification is associated with higher rates of recovery. The Italian Pediatric Society Adolescent Study Group suggests to perform an accurate familial and personal anamnesis, including psychological evaluation as well as a physical exam including auxological parameters as a screening tool during pediatric checks to better explore the risk of developing AN.

Data availability

Not applicable.

Abbreviations

anorexia nervosa

eating disorders

attention deficit hyperactivity

Chronic Functional Abdominal Pain

body mass index

endocannabinoidome

Cholecystokinin

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Acknowledgements

This work was supported also by the Italian Ministry of Health with “current Research funds”.

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Elena Bozzola and Sarah Barni contributed equally.

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Pediatric Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy

Elena Bozzola, Sarah Barni & Maria Rosaria Marchili

The Italian Pediatric Society Adolescent Study Group, The Italian Pediatric Society, Rome, Italy

Sarah Barni, Maria Rosaria Marchili, Emanuela Del Giudice, Giampaolo De Luca & Vita Cupertino

Saint Camillus International University of Health Sciences, Rome, Italy

Romie Hellmann

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EB conceived the study; SB coordinated the study; MRM and GDL participated in its design; RH, EDG and VC carried out the literature research. All the authors read and approved the final manuscript.

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Bozzola, E., Barni, S., Marchili, M.R. et al. Anorexia nervosa in children and adolescents: an early detection of risk factors. Ital J Pediatr 50 , 221 (2024). https://doi.org/10.1186/s13052-024-01796-6

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Received : 16 June 2024

Accepted : 20 October 2024

Published : 26 October 2024

DOI : https://doi.org/10.1186/s13052-024-01796-6

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