This is final of three articles in the Westmeath Topic on anorexia nervosa, better known simply as anorexia. Last week’s article discussed psychotherapies used for anorexia. It discussed individual therapies and group therapies. The third type is family involvement.
The term “family work” covers any intervention that utilises the strengths and support of the family to tackle the patient’s disorder. “Family work” also tries to deal with the family’s stress due to the disorder. It includes family therapies, support groups and psychoeducational input.
The Maudsley model of family therapy and similar interventions have been found to be effective therapies. Whole families (or at least the parents and the patient) attend counselling sessions together.
Separated family therapy
The patient and the parents attend separate meetings, sometimes with two different therapists. This form of therapy seems to be as effective as conjoint therapy, particularly for older patients, and involves lower levels of expressed emotion.
Such groups provide a unique way of empowering parents by means of peer support and help from a therapist. Several families, including the patients, meet together for intensive sessions that often last the whole day and include eating together.
Relatives’ and carers’ support groups
These groups range from self-help groups to highly structured sessions led by a therapist that aim to teach psychosocial and practical skills to help patients with anorexia to recover while avoiding unnecessary conflict. Most aim to provide information and advice about the nature of anorexia.
How effective is psychotherapy
Short term structured treatments such as cognitive behaviour therapy and interpersonal psychotherapy are effective in other eating disorders but are not nearly as effective with anorexia. Studies have found no difference in outcome when behaviour therapy and cognitive therapy is provided. Some studies have shown some benefits with these therapies.
Expert consensus favours long term, wide ranging, complex treatments using psychodynamic understanding, systemic principles, and techniques borrowed from motivational enhancement therapy and dialectical behavioural therapy (explained above). The guiding principle of motivational enhancement is to acknowledge and explore rather than fight the patient’s ambivalence about recovery. Treatment is more effective when the therapist and the patient work together to tackle anorexia.
Family work is the only well researched intervention for anorexia that has a proven beneficial impact. Family work teaches the family and patient to be aware of the perpetuating features of the disorder. Anger and fighting lead to entrenched symptoms but too much tolerance and lenience towards the condition can encourage the condition by allowing it to become accepted. A balance needs to be found which is why families need professional guidance. Studies indicate that therapies involving the family and the patient tend to provide better results in terms of psychological improvement but weight gain was greater when families were seen by the therapist separately from the patient.
Accepted best management
Coercive approaches may result in impressive short term weight gain but make patients more likely to identify with and cling on to the behaviour associated with anorexia. Overall prognosis for patients with eating disorders is not actually dependent whether treatment is received or not. Traditional regimens for anorexia have been proven to be counterproductive. This includes incarceration in hospital, with removal of all “privileges” (such as visitors, television, independent use of bathroom), which were given back as a reward for weight gain.
This method of approach rarely provided sustainable improvement and often exacerbated the issue as the patient resented the cruel conditions and rebelled against general consensus once independence was regained. Hospital admission has been shown to have poor outcomes. Long term prognosis is worse for patients compulsorily detained in an inpatient facility than for those treated voluntarily in the same unit, with more deaths in the first group.
Is drug treatment effective?
Drug therapy tends not to be an effective treatment option for anorexia. Antidepressants are frequently used to treat depressive symptoms but have limited success. Evidence shows that antidepressants can be very effective in the treatment of bulimia; however for reasons that are not fully understood, they tend not to be nearly as effective for anorexia nervosa. There are some reports of the benefit of antipsychotic medication such as olanzapine to provide weight gain. This is likely to be due to the relief of anxiety and increased appetite. Increased appetite is a recognised “negative” effect of antipsychotics, especially olanzapine, but this actually becomes a “positive” effect in the case of anorexic patients. Harmful cardiovascular side effects of antipsychotic medication tend to be more pronounced for malnourished patients due to electrolyte imbalances; therefore more careful monitoring is advised than normal.
Full recovery has been demonstrated even after 21 years of chronic severe anorexia nervosa. However, there is approximately a 20% mortality rate. Bone recovery takes years rather than months, so patients should protect the spine and pelvis in particular against activities such as gymnastics too early after weight gain. Psychological recovery can in many situations be more challenging than physical recovery. Short term therapy is less effective; longer term therapy is generally required.
Bodywhys is a national voluntary organisation supporting people affected by eating disorders in Ireland. They provide support and education through volunteers as well as providing support and advice through their helpline as well as online support through their website (www.bodywhys.ie). For more help and information, you can lo-call Bodywhys at 1890 200 444 or e-mail firstname.lastname@example.org.
References for this article are available on request. More comprehensive and detailed advice and information on anorexia and bulimia is available in Whelehans pharmacy; ask our staff for details. Also detailed information on anorexia and bulimia is available at www.whelehans.ie.
Disclaimer: Information given is general; please ensure you consult with your healthcare professional before making any changes recommended