My last blog was about eating issues and included some general information about the different types of Eating Disorders (EDs). This blog provides some information about treatment of EDs. In general, treatment involves:
• A multidisciplinary approach, including restoring nutrition.
• The reversal of starvation symptoms, and correction of any malnutrition.
• Care in hospital if the person is medically unwell, or if there are severe psychiatric symptoms, then inpatient treatment for specific ED treatment programs may be indicated.
• Restoration of weight and normal eating patterns.
• A range of psycho-social treatments.
• Addressing anxiety and depression, or other symptoms.
• Restoration of healthy body image and self-esteem.
• Addressing interpersonal issues and social functioning.
• Medication may or may not be helpful.
It is also important to note that:
• Many individuals with EDs will be treated in primary care, and managed with nutritional education, diary keeping and frequent follow up.
• Nutritional counselling includes providing explanation of the consequences of restricting food intake or bingeing, and providing guidance around eating.
• Because of the enduring nature of many EDs, ongoing treatment with a range of psychotherapeutic interventions is frequently required for at least a year and may take a number of years.
• A ‘stepped care’ approach is advocated. This involves individuals with EDs moving from;
o a minimal approach such as psycho-education and supervised self-help and support (e.g. from GP, non-government organisations),
o to community treatment with nutritional rehab, medication or various psychological therapies,
o to specialized and intensive inpatient therapies.
• The person can progress by stepping up or down these levels depending on their individual needs and progress (Yeo, 2011, p110).
The use of medication will depend on the individual patient’s age and presentation, including severity of the ED and any other issues, such as anxiety and depression. Medication should not be used as the sole or primary treatment for AN (NICE, 2004). The foundation of most psycho-social approaches is psycho-education, that is, providing information about EDs. Individuals with EDs and their families / carers will have many questions, and it is important to address any myths held about EDs, for example, “spoilt rich girls get ED” or “AN is a lifestyle choice.”
A range of psychological approaches are utilised in managing EDs, and a summary follows:
1. Motivational interviewing (MI) is a directive, client-centred counselling style that has been shown to be effective in its aim to bring about behaviour changes, may assist in the early stages. Sometimes we feel ambivalent about change or resist change. We might have a degree of comfort in how things are, but there might be discomfort about changing too. MI helps individuals to explore and resolve this ambivalence (Noonan, 1997; Rollnick, 2002).
2. Cognitive behavioural therapy (CBT) can assist with psycho-education; goal-setting; behaviour change; reducing binge-eating and purging behaviours in Bulimia Nervosa (BN); reducing food restriction in Anorexia Nervosa (AN); increasing the variety of foods eaten; encouraging healthy but not excessive exercise patterns; addressing unhelpful thinking patterns / beliefs which may be involved in high expectations of self and perfectionism; addressing body image concerns, self-esteem; affect regulation and problem solving.
3. Schema-Focused Cognitive Therapy proposes an integrative systematic model of treatment for a wide spectrum of chronic and difficult problems. It addresses lifelong, self-defeating patterns called early maladaptive schemas which makes the individual more vulnerable to emotional disorders. Origins of the schemas are early childhood experiences, the young person’s temperament and cultural influences (Schema Therapy, 2015).
4. Family therapy such as the Maudsley approach. Family Therapy focusses on teaching families how to ventilate emotion, set limits, resolve arguments and solve problems more effectively; increase the parents’ understanding of the difficulties of the affected child; challenge any views of success or failure being measured in terms of weight, food and self-control.The Maudsley approach assists the family to play an active and positive role to help restore the patient’s weight and empower the family to assist recovery from the ED. It is mostly an outpatient based treatment, and is supported by good scientific evidence (50-75% weight restored by end of treatment, and 60-90% recovered by 4-5years)(Yeo, 2011, p 110).
5. Psychotherapy aims to address a range of issues such as identity confusion, becoming independent or past abuse.
6. Interpersonal psychotherapy (IPT) looks at the issues from biological, psychological and social perspectives, and in particular assists in identifying and modifying current interpersonal difficulties and adjustment to adolescent role transitions.
7. Mindfulness-based therapies (e.g. MBCT) aims to teach individuals to become more aware of thoughts and feelings and to relate them as “mental events” rather than aspects of the self.
8. Acceptance and Commitment Therapy (ACT) is a behavioural therapy and it incorporates ideas from Eastern philosophies, as well as elements of a number of Western therapies such as CBT, Narrative Therapy, NLP and Hypnotherapy. ACT receives its name from one of its central principles, namely taking action. This relates to accepting what is out of our control, and taking action that helps create a rich and meaningful life (Harris, 2009, p 2).
9. Dialectical Behaviour Therapy (DBT) helps individuals who use problematic and sometimes life threatening behaviours (e.g. self-harming, bulimia) as a way of coping with intense and extreme emotions. DBT is a skill based therapy teaching coping skills, and including a strong emphasis on acceptance of the person as they are, combined with the expectation that current behaviours need to change.
10. Narrative Therapy is derived from Family Therapy, and aims to render visible, “taken for granted beliefs and assumptions,” with regards to life and relationships. The individual is seen as having expertise, and deriving meaning from the stories about themselves or their lives. The patient is assisted to re-story some aspects of their life, in part by externalising the ED and exploring ways to manage it (White, 1998).
11. Group therapy can provide information, support and help for individuals to more effectively deal with their problems, as well as providing additional peer-based feedback and support.
12. Self-help and guided self-help: there are self-help books available for AN, BN and Binge Eating Disorder. Online resources are also available (refer to Frequently Asked Questions section).
13. Expressive therapies: a range of expressive therapies, such as art therapy, may be utilised to encourage expression of affect and positive body image. Journalling can also be very useful.
Referral to a range of doctors or therapists may be helpful or necessary to ensure appropriate treatment of the ED. In Adelaide, South Australia (SA), we can refer to:
• Private dieticians (some have more experience with ED).
• Private psychologists, psychiatrists (same applies).
• The Statewide ED Service (phone: 08 81980800 and fax: 08 81980899).
For all people affected by EDs referral to a self-help consumer-based organisation can be helpful and a source of ongoing information, support and assistance. It is also important for the patient to have a list of people or services to contact in times of crisis, and these may include:
1. Family or friends.
2. The GP or health professionals involved.
3. Community supports such as Lifeline and Beyondblue.
4. Mental health triage.
5. Other e.g. going to the local hospital ED.
The GP plays a central role in assisting the patient in times of crisis in terms of carrying out a medical and risk assessment. The GP may speak with a specialist for advice, or refer the patient to a hospital Emergency Department or the Mental Health Triage service.
Emergency Numbers in SA:
Police: 000 (emergency) or 131 444 (nonemergency assistance)
Lifeline: 13 11 14
Crisis Care Unit SA: 13 16 11
Mental Health Triage SA: 13 14 65
Alcohol and Drug Information Service (ADIS): 1300 13 13 40
CAMHS After Hours Emergency Referrals Service: (08) 8161 7000 (WCH switchboard: ask the switchboard operator to page the after-hours mental health nurse)
Please refer to the ‘Frequently Asked Questions’ tab for information about books or websites which may be useful.
• Eating Disorders Association. (2013). An Information Pack for General Practitioners, retrieved 3rd Feb 2015 www.eda.org.au/wp-content/uploads/Complete-GP-Information-Kit-2013.pdf
• Harris, R. (2007). The Happiness Trap: Stop struggling, start living, Exisle Publishing, Wollombi, NSW.
• Harris, R. (2009). ACT made simple: An easy-to-read primer on acceptance and commitment therapy, New Harbinger Publications, United States of America.
• National Institute for Health and Clinical Excellence. (2004). Eating Disorder Core interventions in the treatment and management of Anorexia Nervosa, Bulimia Nervosa and related Eating Disorders. NICE guideline 9, retrieved 4th Feb 2015, www.nice.org.uk
• Noonan, W.C., & Moyers, T.B. Motivational interviewing. Journal of Substance Use, 1997; 2(1).
• Rollnick, S., Miller, W. What is Motivational Interviewing? Behavioural and cognitive Psychotherapy, 1995; 23: 325-334.
• Schema Therapy, retrieved 14th Jan, 2015, http://www.cognitivetherapy.me.uk/schema_therapy.htm
• White, M. (2007). Maps of narrative practice. W.W Norton & Company, Inc, New York.
• White, C & Denborough, D. (1998). Introducing Narrative Therapy: A collection of practice-based writings, Dulwich Centre Publications, Adelaide.
• Yeo, M., Hughes, E. Eating disorders Early identification in general practice. Australian Family Physician, 2011; 40(3): p 108-111.