Psychological management: Anorexia nervosa is a psychosomatic disorder, during which psychological and physical symptoms develop because of the self-induced starvation and other methods of inducing weight loss. The main treatment is psychological, involving cognitive behavior therapy, supportive psychotherapy, nutritional information, and counseling about eating and potentially dangerous methods of losing weight. When appropriate, other psychological techniques, such as relaxation, interpersonal therapy, family therapy, or marital therapy may be needed. Psychological changes may be slow and early in treatment sufferers and their families may wonder if psychological treatment is effective. Over a longer time, sometimes 2 to 5 years, unhelpful and sometimes destructive attitudes about eating and body image are slowly replaced by constructive and positive thoughts and behaviors. It is the therapist, in discussion with the patient, who suggests and decides upon the appropriate types of management at different stages of treatment.
The following was written by a patient in response to a task set by Elle's dietitian/psychologist. Elle was asked if she would like to compare the promises her illness had made to her with what in reality had occurred:
Promise: Order and satisfaction in your life. Reality: Disappointment and depression
Promise: Discipline and control. Reality: Confusion and uncertainty
Promise: Popularity and sociability. Reality: Isolation and loneliness
Promise: Respect and admiration. Reality: Pity
Promise: Perfection in all areas of life. Reality: Physical and mental self-destruction
Anorexia is a labyrinth of lies and destruction. No matter what options or solutions it may offer to you every choice will ultimately end in sadness and solitude. It works in the utmost deceiving and almost undetectable ways burying your true personality nearly to the point that even you may find it hard to recognize that once happy, vibrant person you were and still can be. The truth and reality I have learned, is that its power is merely an illusion. I simply had to believe I was stronger and gradually dig up those characteristics that represent me as a confident and content individual, buried beneath the lies of anorexia.
Often it's hard to believe I have it in me to fight because again and again anorexia tells me I have nothing to fight for that is worthy enough to save from destruction. But this is where I have to pay careful attention to the people around me, making a conscious effort to listen, believe and most importantly ‘remember’ (not dismiss) compliments and virtues they claim they saw and still see in me (despite anorexia's efforts to bury them!).
Anorexia creates its rituals through obsession and fear. The trick is to untrain these as rapidly as it trains. In the beginning it was an effort to force myself to ignore anorexia and create new habits—but if I listened to my heart, friends, and family—they always guided me whenever I questioned my actions.
You are able to train yourself back into reality and normality no matter how unattainable it may seem at the time.
Whenever I feel myself weakening in the fight and hear anorexia's criticisms polluting my mind, I hold onto memories of the past—how I was liked, happy, relaxed, and content, and I work on regaining these attributes. No one and certainly no disease of any kind has the power to change or destroy your memories of the past—so this is my power that anorexia cannot touch.
Rather than fighting the thoughts in my mind which tends to be confusing and a no win situation I have learned to fight ‘Anorexia’. I question its answers, disobey its orders knowing its evil.
Destroy it before it can destroy you and win the fight—I think this is truly an opportunity to achieve something many will never even begin to understand.
In the past many treatments for anorexia nervosa have been suggested and used, such as insulin shock therapy, force-feeding, ‘sleep therapy’, and using medications to stimulate appetite. These should not be used. Treatment should allow patients to learn or relearn normal eating behavior in a way that causes minimal feelings of loss of control, and panic. Drugs are seldom necessary but they may be needed in certain cases; for example, if a patient is clinically depressed she may need anti-depressants or if she has an infection she may need antibiotics. The mood of many patients improves when they are eating an adequate amount of food to ensure their bodies are no longer nutritionally deprived.
Anorexia nervosa patients are individuals. They have different problems, different needs, and are at different stages of their illness when they come for treatment—they need treatment by a person who can offer sympathetic understanding and individual treatment. This can be done by a multidisciplinary team as long as there is one consistent person in the team to whom the patient can relate and who can coordinate treatment.
Multidisciplinary teams: The varied needs of a woman suffering from anorexia nervosa frequently call for a multidisciplinary approach. The team is usually led by a psychiatrist or a clinical psychologist, but the team's dietitian has a vitally important role, as have the specialist nursing staff. The time being spent with an individual health professional depends on the patient's current needs and the relationships formed—for example, the dietitian may be the main therapist in certain cases.
The principal problem in treatment is that the patient wants to eat but is terrified that if she does so she will lose control of her eating and be unable to limit her weight gain. For this reason the hope expressed by parents, partner, or friends of an anorexia nervosa victim that ‘All she has to do to get better is to eat’ is unrealistic and counter-productive. The fear of losing control often extends to other aspects of the patient's life, but is particularly relevant to body weight and to food intake. For example, the fear of losing control over body weight prevents the patient from eating more than the amount she has set herself as she believes that if she eats what ‘other people eat’ she will put on weight rapidly. Because of this fear, patients weigh themselves daily or more often, and if they find that they have gained 1 kg (2 lbs) for no apparent reason immediately restrict the amount of food they eat or use some other method of losing weight. Even when they are emaciated they often find it safer to underestimate the amount of food they eat, rather than risk losing control over eating. As anorexia nervosa patients love food, this need to control their food intake may cause psychological turbulence. They are fearful that if they permit themselves to eat, they may be unable to stop, and that they will go on an eating binge. As many have experienced binge-eating before and after developing anorexia nervosa, the fear is real to them and it requires considerable patience by the therapist to dispel it.
Exercise disorder: A sensible exercise program which the woman does during refeeding and during the maintenance of her body weight in the target weight range may prevent her from replacing the eating disorder with an exercise disorder. In this, the pursuit of thinness and a preoccupation with body weight, shape, and food intake is replaced by a preoccupation with exercise, body building, and body shape, which can be just as disabling as the previous eating disorder.
- Abraham, Suzanne; Llewellyn-Jones, Derek; Anorexia nervosa; Eating Disorders (Oxford), 2001
Reflection Exercise #6
The preceding section contained information
about strategies in treating Anorexia Nervosa. Write
three case study examples regarding how you might use the content of this section
in your practice.
Why does Abraham suggest incorporating a sensible exercise program into the refeeding and maintenance stages? Record the letter of the correct answer