Anorexia nervosa, compulsive eating less than necessary and an intense focus on lowering one’s own body weight, is the deadliest of all psychiatric conditions. Dies every ten years one in twenty patients to malnutrition or suicide. About one in 25 women and one in 300 men will develop the disease at some point in their lives. It occurs in all population groups and at all ages, and is increasing more developed, healthier countries. In the Netherlands, anorexia increasingly affects young girls, sometimes younger than ten years old. But we don’t know what best helps to heal these young people.
The latter is evident from a systematic review that remedial educationalist Renée Broersma (36) recently conducted together with colleagues. published in it International Journal of Eating Disorders. Broersma is a practitioner at Levvel in Amsterdam, an organization for specialized youth and family care. Together with colleagues from Levvel, Leiden University of Applied Sciences, the University of Amsterdam and Stanford University, she searched and assessed existing research into the treatment of young people (8-18 years) with anorexia.
“I specifically focused on young people because that is when eating disorders often arise,” says Broersma during a lunch in an Amsterdam café. “And the sooner you treat, the less time it takes. Early recognition and treatment are therefore necessary. But as far as we know, our review is the first to focus exclusively on young people. Previous reviews combined young people and adults, while treatment in adolescence has a different dynamic. Adolescence is a complicated phase of life in which identity formation, physical development and the tension between dependence on parents and growing autonomy come together.”
Photos Jagoda Lasota
Broersma and colleagues looked at so-called randomized controlled trialsexperiments in which participants are randomly assigned to different treatment groups. In itself, this is the best way to measure the effectiveness of a treatment, but the 22 RCTs they found, published between 1987 and 2024, were often small and difficult to compare because the design and outcome measures differed. There is no consensus on how to measure recovery from anorexia, says Broersma.
It does seem clear, with all these blows, that family therapy works better than individual therapy for young people with anorexia. “With the important nuance,” says Broersma, “that it mainly concerns physical recovery, medical recovery.” For example, the BMI is measured and whether menstruation (which stops if you are seriously underweight) has started again. “Psychological recovery has not been studied enough to make any statements about it.”
In family therapy, parents usually temporarily take control of the child’s eating. Broersma suspects that it therefore works better for medical recovery than individual therapy. That control is gradually regained, even if the child still lies about food, is difficult, or becomes angry about it. “But that behavior is the eating disorder, that is not your child. The biggest challenge for parents is: being loving to your child, but being tough on the eating disorder.”
Patients in individual therapy must organize these boundaries for themselves, together with the practitioner. Like family therapy, individual therapy for anorexia comes in different types. Such as cognitive behavioral therapy, and there is also a form of therapy in which patients write letters to their eating disorder. “One letter to the eating disorder as a friend: you get me all this, you are my buddy when I feel lonely, whatever. And a letter to the eating disorder as an enemy, about everything that the eating disorder takes away from you.” In this way, patients can place the eating disorder more outside themselves, as an entity with its own will, and gain insight into its advantages and disadvantages.
“By the way, it might be good to mention,” says Broersma before the sandwiches with avocado and hummus are on the table, “that I am here from three perspectives. I am a practitioner of mainly young people with anorexia, currently only girls; I am a researcher; and I don’t want to be here. how can I make this about mestory, but I used to have anorexia myself.” Sometimes she tells that to her patients. “Of course I work according to guidelines, but if I think it can give someone the feeling of ‘okay, I know what a struggle it is’, then I will tell them. It can provide some kind of connection, although I certainly don’t say that I am a better therapist.”
How did she get rid of it? “That is very difficult to answer. There are so many things that influence it. We still know little about how recovery from anorexia actually works. For me, it was necessary for others to take over for me temporarily, and for them to quickly see in the clinic where I was admitted that I had to return to my own environment and parents.” Anorexia patients in a clinic were still very much separated from the outside world at the time, in 2003. “I was not allowed to speak to my parents for the first few weeks, later I was allowed to call them twice a week for fifteen minutes. And further contact with the outside world was only by post. I still remember video tapes full of film material from my classmates. Later there were visiting afternoons. It was quite drastic.” She later returned to the clinic, “to arrange the recording.”
Practitioners now find it very important to involve their own patient network in the treatment. “I think that is the big change compared to the past. And we have also increasingly realized that you can start psychological treatment if someone is not yet medically stable. Provided a doctor approves it.” The hospital is mainly for medical stabilization, as it is called, getting patients physically healthy again, and the eating disorders clinic is for intensive treatment.
However, there are also a few studies – more research needs to be done – that suggest that a shorter clinical admission can be just as effective as a longer one, says Broersma. This is therefore cheaper for society and less drastic for the young person. But I don’t think anyone is going to cheer about it. For some patients, the following applies: only once you have been to the clinic can you choose recovery and ask for help.” Then that is allowed, ‘because of the eating disorder’. “Sometimes a recording can cause such a breakthrough, but if it doesn’t have to, it’s better not to.”
Being admitted is not only scary for patients; Inside there is also the risk that competition will arise (who can eat the least) and that they will learn tricks from each other. “You have to consider for each case whether the advantages of admission outweigh the disadvantages. Contact with fellow sufferers can also be connecting and recovery-oriented. I have young people in treatment who have become friends. The families and practitioners find that quite exciting, but the patients can also pull each other out without pulling each other down again.”
An eating disorder is not just about food, that’s important to say
Broersma herself has also made friends from the clinic. “But a number of them have died. I attended quite a few funerals at the time. Why, that is a question that has been bothering me for a long time. I remember when I came back to school, after a year or so, and I had a really nice, loving class and teachers, but I felt little connection because I had been busy with other things than my peers. Little is thought about that. In any case, there is hardly any long-term research. If the studies we looked at did have a follow-up, it was for a year later. You would like to follow patients for longer: five years, or ten.” Recovery from anorexia takes several years and is not linear.
What Broersma would also like to do is provide tailor-made solutions and be able to tailor the treatment to the patient. “An eating disorder is not just about food, that is important to say. It is an ineffective way to deal with complicated things and to get the feeling of having a grip on something. And there are differences and similarities in what those complicated things are. If someone has experienced sexual abuse and has therefore developed self-hatred towards the body and does not want to feel anything, then that may require a different treatment than perfectionism. And for some people a negative self-image is central, or problems with emotion regulation. Then you have to focus the treatment on that. There are lots of treatment options and there is none one size fits all. But you do want it to be well researched.”
And relatively less research money goes to anorexia than to other mental disorders, says Broersma. “Maybe because anorexia is a difficult target group, with a high dropout rate, so it is uncertain whether you will get good data… Or perhaps because you are less clearly a victim than when you suffer a trauma.” Or because it is usually a women’s disease? “Yes, I sometimes think about that too. And perhaps also because there is still a persistent belief, even among some care providers, that recovery is not possible at all.”
But recovery is possible, Broersma emphasizes. So there is no consensus on how exactly to determine recovery. “The psychological questionnaires that are available are mainly about eating disorder symptoms: to what extent you still think about dieting, for example. Patients are asked less often: have you recovered now?” She herself thinks that healing is about, in addition to physical recovery, feeling the freedom to make your own choices again, that you are no longer held hostage by obsessive thoughts about food and weight. “But I also sometimes hear people say: ‘I no longer have an eating disorder, but I eat exactly three meals a day, nothing in between, and I’m doing well.’ And if that is enough for you, who am I to say that you have not recovered?”
