Healthcare Training Institute - Quality Education since 1979
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To correct the sufferer's views about food. We have mentioned that patients who have anorexia nervosa read a great deal about food from diet books and magazines, and in consequence tend to have more knowledge about food than the average person. However many of their opinions of food and eating are erroneous and, unless corrected, will perpetuate their eating disorder. They are also often rigid and opinionated in their beliefs. For these reasons, an important part of treatment is for the sufferer to receive educational sessions (preferably in a group setting) from a dietitian so that their distorted opinions about food, dieting, and eating behavior are corrected. To help the sufferer feel that she has control over her abnormal eating behavior, so that she no longer persists with her ‘relentless pursuit of excessive thinness’, to quote Hilda Bruch, who was a pioneer in treating anorexia nervosa. Correcting the disordered thoughts, attitudes and feelings about body image that are thought to be central to the development and maintenance of anorexia nervosa is essential. To persuade the patient to adopt normal eating behavior, and to avoid starving herself, if she has restrictive anorexia nervosa. If she is a binger and purger the objective is to help her to stop using these potentially dangerous behaviors. If she is a compulsive exerciser, this behavior also needs to be tackled. To explain to the sufferer why she has developed the physical changes, that they are a consequence of starvation and weight-losing behaviors, and to help her correct them. To help the sufferer deal with any associated problems which may be present or may arise during treatment. These problems, if not addressed, may prevent recovery.
Refeeding: As mentioned earlier, refeeding is the main way in which the sufferer is helped to gain weight. During the refeeding program, she has regular sessions with her therapist, is provided with nutritional information by her dietitian, learns to eat normally, and is helped to cope with her everyday problems, particularly if she has had anorexia nervosa for some time. Whether she is treated as an out-patient or is admitted to hospital, she is first given the opportunity to be responsible for her own weight gain with the help of the supporting health professionals. During this time she may be ambulant, doing supervised, very low intensity exercise and attending discussion and educational sessions with other sufferers to help her gain insight into her eating disorder and any other problems. She is encouraged to pursue interests such as relaxation techniques, craft, and painting. If she is of school age, she can continue with her school curriculum with home or hospital-based programs developed with the help of her teachers. During refeeding she is alerted to the possibility of a rapid weight gain which occurs when refeeding begins. It results from the expansion of fluid in the tissues between the body cells (the extracellular compartment) and an increase in the body's glycogen-water pool. This may cause great anxiety and the woman needs to be assured that the weight gain, which is due to rehydration, will resolve spontaneously if she continues to adhere to the refeeding program.
Some women may be encouraged to recover more quickly if the woman and her therapist or dietitian agree that she may remain at the same increased weight for a week or two before another increase is expected. Most anorexia nervosa sufferers respond to the lenient approach to treatment. If the patient refuses to be refed, an ethical problem arises about whether she should be forcibly refed against her wishes, or no refeeding undertaken, in which case she may die. This issue is under debate but no resolutions have been reached. If the woman does not respond, a more structured program should be implemented. In extreme cases the woman may have to be observed continually or kept in somewhat extreme isolation in a single-bedded room and have to stay in bed until the ‘target weight’ is reached by refeeding. This strategy is necessary because many patients try to find methods to avoid eating or to get rid of food by inducing vomiting or abusing laxatives. If she eats the amount of food expected and conforms to treatment by avoiding weight-losing strategies, and starts gaining weight, she is offered a ‘reward’ or a ‘privilege’. For example, she may be allowed to get up and have a shower, or to watch television. On the other hand, if she fails to put on weight she knows that privileges may be taken away and she may be ordered to go back to bed and stay there. Although this appears to be a very strict program, women who are at very low body-weight frequently are unable to think clearly and the fear of gaining weight is overpowering. Some women who have experienced refeeding will ask to go on a bed-rest program, as will some women who are finding eating and weight gain difficult to achieve. These women see this strict program as helpful and supportive, rather than punitive. The negative aspects reported by patients are boredom and isolation.
Helping the patient gain confidence: This part of the treatment is designed to help the women gain confidence. With her therapist's support and encouragement she learns how much she needs to eat to control her weight at an appropriate level. She has to be made aware that she will not be rewarded for gaining weight rapidly, as this may merely indicate that she is binge-eating. The therapist also has the responsibility of helping the patient to adjust to the other problems (such as relationship problems) which may have arisen because of the patient's fear of losing control. The therapist's function is to explore these problems with the patient, so that he or she gains the patient's trust, and to encourage her motivation to return to ‘normal’ eating. She must also give the patient the confidence to continue with treatment and must help her to maintain her body weight within the normal range.
As the therapist becomes aware of the patient's fear of losing control and her resistance to changing her eating behavior, it may become apparent that treatment will have to be delayed until the patient is ‘ready to get better’, even though this means that a few patients will become severely ill and have to be rescued from impending death by urgent admission to hospital. Other patients who require admission include those who are severely ill when first seen, those who fail to make progress as an out-patient, those who persist in continuing with their weight-losing behavior, and those who are incapable of responding to treatment as a result of the physical and mental consequences of the very low body weight. In other cases the patient's doctor may feel she should be admitted to hospital, or she herself may prefer to be treated in hospital.
During the time that she gains weight, the patient often feels ‘full’ and her stomach may bulge. She needs to be told that this will happen, and needs to be reassured that the abdominal swelling will not remain. Unless this is done, she may feel that she is losing control. These are temporary symptoms which the patient has to suffer to achieve her goal. The abdominal swelling is due to distension of the intestines, and, once intestinal function becomes normal, the abdomen becomes flat, whilst fat is deposited on her limbs and body. During refeeding the patient should avoid buying tight-fitting clothes, such as jeans, because within two or three weeks after her desirable weight has been achieved and the distension has subsided they will be too big. The appearance of a ‘bulging stomach’ is usually more marked among patients who are refed in hospital and who are not permitted to exercise, than among patients who are allowed to undertake supervised low intensity exercise.
When a reasonable amount of weight gain each week has been obtained, it will be found that the amount tapers off as the ‘target’ body weight range is approached. At this stage women who are patients in hospital should remain in hospital for two or three weeks after their weight is in the desirable weight range to make sure that the weight is maintained, and that they gain confidence that they can maintain their weight in the desired weight range, and can learn how much to eat. The patient needs reassurance that her weight gain is not predominantly due to an increase in body fat. In fact during this period the body selectively gains protein, increasing the woman's lean body mass rather than her adiposity. After achieving a body weight in the middle or upper part of her target range, the woman's diet is modified to contain slightly more energy than would be considered necessary to maintain a weight in the normal weight range, for about a month. This strategy prevents a sudden drop in body weight to below the desired weight range when refeeding stops. Some women require higher than expected energy intakes for some weeks, or even months, if they are to maintain the desired body weight. The reason for this energy wasting in women during and after refeeding is not known.
Establishing normal eating behavior: As most anorexia nervosa patients restrict the number of different foods they eat, the second aim of treatment is for the patient to learn to choose from a wide range of foods. This wide choice provides her body with the many nutrients it needs. She is helped to stop seeing foods as ‘good’ (that is, with a low energy content and low or no fat) or ‘bad’ (with a high energy and fat content), and learns to eat a wide variety of foods in sensible amounts. Eating sensibly includes learning to eat in front of people, at different venues and in social situations, and to be comfortable about this. For example, if someone who has had anorexia nervosa goes to a social function, such as a wedding or a Chinese banquet, she may eat far more than her body requires that day and has to learn to accept that this is normal. She also has to conquer her preoccupation with food and her urge to weigh every item of food she eats and to calculate its kilojoule (calorie) content. Many patients have no idea of how much they can eat without weight gain and have trouble recognizing cues for hunger and satiation. During treatment they learn to recognize these cues and are taught the elements of dietetics. Many patients who have an eating disorder do not know what ‘normal’ eating is.
These matters are explored and discussed during the educational sessions which take place concurrently with the refeeding program. They may be discussed when the woman and her therapist meet or in group sessions led by the dietitian or one of the skilled members of the nursing staff. Many eating disorder experts believe that this ‘psycho-education’ is most effective if conducted with a group of patients.
Ceasing weight-losing behaviors: A major concern is to change the potentially dangerous weight-losing behaviors resorted to by many women who have anorexia nervosa. Many patients respond to information about the short- and long-term effects of vomiting and abuse of purgatives, diuretics, and slimming tablets, and are willing, at least initially, to reduce the frequency of these behaviors. They find reassurance on learning what effects to expect when they stop vomiting and using laxatives, for example, that they may undergo a temporary weight gain as they become rehydrated, and that constipation may persist for some time, as well as abdominal fullness and cramps. As the patients are preoccupied with their body weight and abdominal fullness, these are the very symptoms which make them anxious and may make them return to vomiting and laxatives unless they know that these symptoms are to be expected.
Women who have anorexia nervosa may be manipulative and untruthful when they are questioned about their food intake and their methods of losing weight. The therapist may have to confront the patient before treatment is started, to establish, as far as possible, whether she is prepared to agree to try and eat more food. Truthful common-sense confrontation is also required during treatment if the patient is discovered cheating. For example, she may appear to take all the food offered and then dispose of most of it surreptitiously down the sink, or place weights in the pockets of her clothing when she knows that she is to be weighed. She may exercise frenetically in her room or in the shower or bathroom, where she knows that she can do it secretly. She may also secretly resort to self-induced vomiting or abuse laxatives when she decides that she has reached a certain weight and does not want to gain more, as she is fearful that she is losing control of her eating.
Reflection Exercise #7