Body image involves how a person feels about their body, how they believe others feel about their body, and how this perception influences their confidence about their body and themselves more generally. We know that body image can have a significant impact on a person's psychological wellbeing and resilience, and that body image perceptions may change with mood or environment. People with eating disorders have a body image that is out of alignment with how others see them. It is important to acknowledge that this is a very real feeling, part of the eating disorder and something that can create a great deal of distress for clients. Concerns about body, weight and shape are central to our current weight-focused culture. Body dissatisfaction amongst women is seen as ‘normal'. There is an abundance of unhelpful messages relating to body, size, shape and diet regimens, which often conflate worth, or personal qualities, to enhance adherence to these ideals. However, these ideals do not take into account the diversity of people's bodies. Most individuals with eating disorders experience a significant disturbance in their concerns around body, weight and shape. For individuals with an eating disorder, intrusive thoughts about body, weight and shape can dominate the individual's life and inform their sense of self-worth. Many individuals feel significant disgust and shame about their bodies, which drives the eating disorder behaviours in an attempt to improve their body, weight and shape through weight loss or weight management. However, no change, no matter how significant, to weight or shape ever improves the individual's sense of body image and self-worth. The feelings about one's body can have a significant impact on the individuals' life – hiding their bodies from themselves and others, impacting their willingness to engage in social or outdoor activities and impacting their ability to form intimate relationships. As a health professional working in this space it is important to take a counter-cultural stance, by supporting the diversity of people's bodies, shapes and individual needs. We live in a culture that places a lot of emphasis on body image, weight and shape, and even as health professionals we are not immune to these influences. Sometimes, our own beliefs and attitudes about body, weight and shape are known to us, at other times, learning more about them can raise issues we were not expecting. It is important to have an awareness of our own body image concerns, as well as the concerns of the individuals we are treating, to ensure that these do not get in the way of treatment. This is a really helpful topic to raise with your clinical supervisor. Like other mental health problems, prevention is ideal. Whilst there is still much research to be done in the prevention space, we do have much clearer guidelines around what works and, more importantly, what does not. For consumers and carers, the issues of stigma and the stereotypes that surround eating disorders are fundamentally important. They can be barriers to accessing the type of treatment and support that is required. Clinicians, through a positive recovery-focused attitude and by adopting a non-judgemental, supportive approach, can help people with eating problems to access and fully participate in treatment. Unfortunately, preventative measures that have been directly aimed at decreasing inappropriate eating disordered behaviour have proved to be ineffectual, and sometimes even harmful. Prevention programs aimed at enhancing resilience, media literacy and self-esteem, especially in school children and adolescents is far more beneficial. This has the added advantage that it is probably also of value in preventing the development of other mental health problems, as well as obesity which is more common among young people than eating disorders. A preventive approach should focus not only on individuals who may be at risk, but on those sections of the community which contribute to and exacerbate unhealthy attitudes about body image and food (eg. fashion industry, media, cosmetic surgery). Dianne Neumark Sztainer (2009) has made key recommendations specifically related to eating, weight and body image that may be helpful for the prevention of both eating disorders and obesity, these are: 1 1 Discourage unhealthy dieting; instead encourage and support the use of positive eating and physical activity behaviours that can be maintained on an ongoing basis 2 2 Promote a positive body image among all adolescents 3 3 Encourage more frequent and more enjoyable family meals 4 4 Encourage families to talk less about weight and do more at home to facilitate healthy eating and physical activity 5 5 Assume that overweight teens have experienced weight mistreatment and address this issue with the individual and their families Prevention Strategies Parents need to be supported to prevent a child or adolescent moving from “at risk” to developing an eating disorder that meets diagnostic criteria. Strategies to do this include: bullet Enlist support of parents against eating disorder behaviours bullet Provide psychoeducation around the dangers of dieting bullet Dairy products and some meat should be emphasised as the normative diet bullet Eating a wide variety of different foods should be encouraged bullet Encourage parents with mental illness to obtain treatment, if not for themselves, then for their children bullet Young people need to know very clearly that they are loved and accepted without being “perfect”. In particular, parents need to be less intolerant of their own imperfections - children imitate actions, attitudes and behaviours. bullet Multiple after school activities and relentless pursuit of academic excellence are cumulatively stressful. Children should engage with things they are good at, and/or find rewarding, and there should be time for doing nothing. bullet Expressing emotions rather than swallowing feelings or attempting to ignore them, needs to be encouraged. bullet Parents should be positive, nurturing and encourage children to individuate in a healthy way and to accept responsibilities appropriate to their age. Stigma around mental health problems is one of the biggest barriers that people who experience eating disorders face on a day-to-day basis. Stereotypes, particularly when they are negative, reinforce the stigma that people can experience. Experiencing stigma may lead to a decrease in self-esteem and induce feelings of shame, both of which act as a barrier to accessing treatment, which may ultimately prolong recovery and increase the potential for relapse. It is important for clinicians to: bullet Recognise the stigma associated with eating disorders and potential impacts on individuals with an eating disorder. bullet Be aware of our own feelings and attitudes towards people with an eating disorder. bullet Model understanding and supportive attitudes towards people with an eating disorder. bullet Take an assertive role in challenging false assumptions and changing perception and attitudes towards people with an eating disorder. It is common for health professionals to have varied thoughts, opinions and ideas about what constitutes an eating disorder and what the causal and influencing factors in their development may be. In fact, health professionals can be just as misinformed about these disorders as the general public. Myth: Once you have an eating disorder you will never get better. Fact: It is definitely possible to recover from an eating disorder. Even people who have been living with an eating disorder for many years can get better. The path to recovery can be long and challenging, but with support from the right team of professionals and with a high level of commitment, recovery is certainly possible. Myth: Eating disorders are a lifestyle choice. Eating disorders are caused by vanity and body ideals Fact: An eating disorder is a serious mental illness that can potentially lead to death. Eating disorders involve considerable psychological distress and multiple medical complications. They are not a lifestyle choice or a diet gone too far. The link between eating disorders and vanity is mistaken. Eating disorders often co-occur with other mental illnesses, such as depression and anxiety. A person may experience severe disturbances in their behaviour around food, body and exercise because of difficulties managing their thoughts and emotions. Furthermore, there is a growing body of evidence that eating disorders have a genetic component. Myth: Eating disorders only affect women and girls, usually teenage girls. Fact: It is true that the peak period for the onset of eating disorders is between the ages of 12 and 25. It is also true that women are at high risk, particularly those going through key transition periods (e.g. from school to adult life). However, this high risk has led to the widespread misconception that eating disorders only affect females. In reality, eating disorders can affect anyone. They occur in both men and women of all ages and affect people from all cultural and socio-economic backgrounds. It is estimated that a third of people with an eating disorder are male. Recent studies have found that Anorexia Nervosa is more common among males than previously thought. Myth: Eating disorders are a cry for attention or a person going through a phase. Fact: People with eating disorders are not seeking attention. In fact, due to the nature of eating disorders a person may go to great lengths to hide their behaviour, or may not recognise there is anything wrong. An eating disorder is not a phase, it is a serious mental illness that requires treatment and support. The belief that someone with an eating disorder will ‘snap out of it' can be very harmful because it can delay access to treatment. Myth: Dieting is a normal part of life. Fact: Eating disorders almost always occur in people who have engaged in dieting or disordered eating. Persistent and unhealthy dieting can lead to significant mental and physical consequences. This is particularly true if the dieting behaviours start in childhood or adolescence. Dieting is linked with depression, anxiety, nutritional and metabolic problems, and contrary to expectation, an increase in weight. Myth: Families, particularly parents, are to blame for eating disorders. Fact: There is no evidence that eating disorders are caused by particular parenting styles. In fact, family and friends can play a crucial role in the care, support and recovery of people with eating disorders. There is, however, evidence that eating disorders have a genetic basis and people who have family members with an eating disorder may be at higher risk. Genetics play a role in many illnesses, so while a person's genetics may predispose them to developing an eating disorder, this is certainly not the fault of the family. Myth: People who are of average weight or overweight cannot have an eating disorder. Fact: An eating disorder cannot be detected based on weight, nor can its severity and impact. While some eating disorders (Anorexia Nervosa) are characterised by severe weight loss, other eating disorders (Bulimia Nervosa and Binge Eating Disorder) are not. In fact, people with Bulimia Nervosa tend to be at an average or above average weight. In the same way, achieving a normal weight does not mean recovery is complete, as eating disorders have a range of complex medical and psychological impacts. Myth: If I binge eat it means I am a weak person. Fact: Bingeing is not the result of being weak. Treatment can help you uncover and to control the factors that influence eating behaviours, but weakness is not one of them. Eating disorders are serious mental illnesses and they vary for everyone. It is important to seek help so you can work on identifying what your individual triggers might be. Recovery is never a straight trajectory forward, but instead involves many ups and downs, lapses and even relapses. As a health professional working with individuals with eating disorders, it is important to be realistic about lapses and relapses, and to frame them as essential learning opportunities to support long-term recovery. Asset 4@6x-8.png A lapse is a temporary return to an eating disorder behaviour, while a relapse is a full-blown return to the eating disorder behaviours and thoughts. Neither signifies a failure to recover. Lapses and relapses can provide the individual with the opportunity to consolidate the strategies that work, to identify triggers and to learn new strategies. The key here, is that individuals feel supported (and not judged) to be open about their lapses/relapse and engage with their treatment team and support network. There is no set definition for recovery, but it is generally considered to involve understanding and overcoming the beliefs and behaviours associated with the illness, and developing healthier ways of eating, thinking, feeling and behaving. "Being recovered is when the person can accept his or her natural body size and shape and no longer has a self destructive or unnatural relationship with food or exercise. When you are recovered, food and weight take a proper perspective in your life and what you weigh is not more important than who you are, in fact, actual numbers are of little or no importance at all. When recovered, you will not compromise your health or betray your soul to look a certain way, wear a certain size or reach a certain number on a scale. When you are recovered, you do not use eating disorder behaviours to deal with, distract from, or cope with other problems." Carolyn Costin in her book '8 Keys to Recovery from an Eating Disorder'. There is no set time for how long recovery will take, as this will depend on a number of factors including the treatment and support received. Evidence shows that the sooner you start treatment for an eating disorder, the shorter the recovery process will be. It is important that all health professionals working with eating disorder sufferers maintain hope for each individual's recovery, even though the treatment journey may be long. People who have recovered from an eating disorder often speak about how much stronger their relationships with their friends, family and carers became after working through the treatment together. Often people feel that they have a much better understanding of themselves and have grown as a person throughout the recovery journey. Eating disorders are a common group of psychiatric disorders with significant morbidity and mortality. 2 2 Anorexia Nervosa has the highest mortality and suicide rate of any mental illness. 3 3 Eating disorders are functional, ego-syntonic disorders. This means that the eating disorder can serve important functions in a person's life. 4 4 The development of an eating disorder is multifactorial with numerous factors appearing to contribute to susceptibility including familial and biological factors, psychological factors and socialcultural factors. 5 5 Dieting is the primary risk factor for developing an eating disorder. 6 6 Co-occuring psychiatric diagnoses are extremely common in individuals with an eating disorder. In fact, co-occuring disorders are the norm, not the exception. 7 7 Eating disorders in boys and men have traditionally been under recognised and under diagnosed. 8 8 Identifying people at risk of developing an eating disorder, or exhibiting symptoms suggestive of an emerging eating disorder are the responsibilities of all health professionals. 9 9 Screening is appropriate in those who are at risk or presenting with signs and symptoms of an eating disorder. 10 10 Early intervention is critical and affects prognosis and outcome. 11 11 Individuals with any eating disorder can become critically unwell. 12 12 Stigma and stereotypes are critical barriers for individuals with eating disorders seeking and accessing treatment. 13 13 It is important to have an awareness of our own body image concerns, as well as the concerns of the individuals we are treating, to ensure that these do not get in the way of treatment. 14 14 With the right treatment and support, a full recovery from an eating disorder is possible. We live in a culture that places great emphasis on physical appearance - especially body image, weight and shape, and even as health professionals, we are not immune to these influences. Sometimes we are aware of our own beliefs and attitudes about these issues, and at other times they may raise thoughts, feelings, and reactions in us that we were not expecting If you find any of the content of this eLearning course confronting, or if it raises any issues or concerns for you about your own well-being, we encourage you to seek support from your General Practitioner, friends, family or someone from your Employees Assistance Program. Remember, that as a caring professional, it is important we take of ourselves too. If you believe that your clinical practice may be affected, please discuss your concerns with your clinical supervisor. The initial assessment is one of the most critical points in the treatment process – it is an opportunity to connect with the person, establishing the therapeutic relationship and provide them with hope for the future. The therapeutic relationship is the cornerstone to recovery - many studies have shown that the therapeutic relationship itself, over and above sophisticated psychological strategies, is the most active ingredient in bringing about change. The clinician's attitude and approach will be the difference between a successful initial assessment, where the person feels that they have been heard, and one where the person feels defensive and is hostile or non-communicative. Aim to be ‘client centred'. That means employing three key values - demonstrating unconditional positive regard, congruence and empathy. 1 1 Unconditional positive regard is simply showing respect and acceptance of the person as a worthwhile human being. This establishes the basis for trust – a foundational element in the therapeutic relationship. Use the person's name, let them talk, be open and respectful in all interactions. 2 2 Congruence is about being in the same ‘place' as the person, communicating without jargon or professional language. Being genuine and honest will assists with this process. 3 3 Empathy is seeing beyond outward behaviour and sensing accurately the client's inner experience. This is different to sympathy, where objectivity is lost and the health professional feels what the person is feeling. Even if you have an established relationship with someone, it will be important to build rapport specifically around the eating disorder issues. Remember that the eating disorder may well have affected all areas of their life and that they may not have sought help for this ‘problem' voluntarily. They may appear defensive, deceitful, evasive, resistant or even hostile. It is probable that the disorder serves some very important functions in their life and they may not want to give it up or may be unable to do so at this point in time. Being able to understand and validate the person's position will be pivotal. Hold hope for the client even when they have lost hope for themselves. While respecting their wishes and acknowledging their level of motivation, let the person know that recovery is a potential even in the most severe cases and that when they are ready to engage, a collaborative therapeutic relationship is possible. A non-judgmental approach is best achieved by understanding eating behaviours as the person's way of trying to cope with life. Remember many symptoms are due to starvation/extreme dietary restriction, and therefore beyond their control. Express this non-judgemental stance via: Active listening when the person is talking about their behaviours Matter-of-fact questioning to elicit details Active nodding as they are talking to encourage them on and show you understand See the behaviours as a coping mechanism, which we all use to get through life. Validation involves working to understand the person's perspective and expressing that you understand. Validation does not mean that you agree with what the person says, but that you can understand why they feel or think or act the way they do. Validate feelings more than behaviours or thoughts – this makes it easier to engage the person in challenging the resulting behaviours, which they might not have been willing to do. Express validation through nods, facial gestures and words. Tip: If the therapeutic alliance is compromised it is often because validation is low – increase active validation. Working collaboratively helps build rapport and lets the person know that you are not going to dominate or impose your views on them. This may mean taking questioning slowly, allowing the person to ‘tell their story' at their own pace, or asking what they feel able to work on (rather than what you think should be the focus of attention). Providing it doesn't sabotage treatment, assist them with this first. As the relationship builds in strength, it can be used as a basis from which other more challenging goals may be tackled safely. This important counselling skill often gets lost in the treatment of eating disorders. Between the myriad of medical parameters that need to be monitored and the application of a successful treatment program (usually involving a lot of practical instruction and challenging tasks) it can be easily overlooked. Externalising the Eating Disorder Eating disorders often become internalised, as if they are a part of the person. Problems come to be seen as part of a person's nature, or a personality flaw. Such beliefs are reflected in speech such as “I am bulimic” and in the way people refer to ‘Anorexics' and ‘Bulimics' rather than as people who are experiencing one of these disorders. Externalisation separates the person from the problem. Ask questions in a way that externalises the problem and align yourself with the person against the disorder e.g. ‘together we will find a way to…' so the person is aware that you want to understand and are willing to try and help them collaboratively. Common features experienced by individuals who have suffered from an eating disorder: 1 Fear and Terror Many individuals are terrified that any sense of 'progress' in treatment will result in them becoming extremely 'fat'. 2 Embarrassment and Humiliation Individuals with eating disorders are fearful that health professionals won't believe them, won't understand their fears, won't think they're sick enough and that they are wasting your time. 3 Denial and Minimisation Denying that there is a problem and minimising behaviours and symptoms all work to protect the eating disorder. 4 Hypersensitivity Many individuals with an eating disorder have experienced stigma and shame around their behaviours, symptoms or the eating disorder diagnosis. Building the therapeutic alliance with a non-judgemental approach and being informed about eating disorders is essential. 5 Anger Individual with eating disorders can experience a great sense of anger. This may be amplified if the health professional is very directive at the expense of building a therapeutic relationship, is not actively listening or displaying empathy and understanding the individual's experience. 6 Grandiosity and Infatuation with the disorder Many individuals with Anorexia Nervosa feel that they are 'noticed' with their eating disorder. They report feeling that they now receive respect, attention and envy. They don't notice the pity and the horror that their physical appearance can elicit. Additionally the eating disorder provides them with a great sense of personal achievement. 7 Seeking Secondary Gain Individuals with eating disorders are not always keen to recover because there are many indirect benefits that having an eating disorder provides. People express concern for them, they are noticed and they get special provisions such as not having to do a school assignment, not having to do as many household tasks or being sent to hospital and escaping the stressors in their lives. 8 Bargaining Individuals with eating disorders become adept at negotiating. They may negotiate around food intake, weight goals and behavioural changes to appear to be making change and 'progress' whilst still ensuring that the eating disorder remains in charge. 9 Manipulation Sometimes individuals with eating disorders will deceive their parents and carers or health professional team. Deceptions or manipulations should be seen as an effort to protect the eating disorder, and indicate that the individual requires more support. 10 Splits and power struggles Some individuals with an eating disorder may engage in 'splitting', playing one team member off against the other all in an attempt to protect the eating disorder. Open communication with family and team members is essential. communication with family and team members is essential. 11 A deep sense of unworthiness Individuals with eating disorders are trying to survive in a world they find confusing and complex, using the only resources they have. They may experience a deep sense of unworthiness and require caring health professionals to help them recover. 12 Relief Individuals with eating disorders may eventually recognise that they are no longer in control of their lives; they want a way out of the obsession and misery of the eating disorder. It can be a tremendous relief when the eating disorder is recognised. Tips to Engaging Eliza bullet Encourage her to tell her story, in her own words bullet Listen without interrupting for at least a minute or two bullet Try to balance the use of open and closed questions bullet Clarify information by checking, summarising and reflecting bullet Talk in plain language bullet Being aware of your non-verbal as well as verbal communication - show that you are interested– nod, maintain a non-threatening level of eye contact, put down your pen, turn to face her bullet Be cautious in deciding what the main issues are - don't rush into drawing conclusions without ample information or time for reflection bullet Use probes to help gauge her understanding of their situation e.g. ‘Why do you think this is happening now?'; ‘How did it make you feel when it happened?' Most carers bolster treatment and contribute positively towards recovery. Treasure and Schmidt (2001) found that carers of people with AN can have an important role to play in aiding the person's recovery, and are often highly motivated to assist in the treatment process. They need education and support - good quality reading materials, support group contacts, and the opportunity to review their knowledge base directly with a health professional. The following factors will influence family involvement: Likelihood that they will be able to support treatment efforts Age of the person and willingness to accept family support Severity of the eating disorder People with eating disorders (at any age) often resist family or partner support - due to embarrassment, secrecy, or as an attempt to maintain disordered behaviours. Persist with encouraging the person to accept their support and involvement in treatment planning; reinforce confidentiality and the right to maintain privacy around some issues. The involvement of carers and family in the treatment of children and adolescents with eating disorders is absolutely essential. With adults it is also useful and wise to involve the family and carers in the therapeutic process, regardless of their anxiety, enmeshment or other psychopathology - these features are better ameliorated by inclusiveness and usually only exacerbated by exclusion. How to involve family, carers and significant others bullet Talk to family members as regularly as possible, particularly at critical times – first assessment and diagnosis, development of serious health complications, if hospitalisation is necessary etc. bullet Where possible and appropriate, involve the family in treatment planning – this is imperative with children and adolescents. bullet Share information without breaching confidentiality. bullet Take on a supportive and educative role. bullet Be aware that all family relationships will probably be suffering. bullet Encourage families to normalise family life as much as possible. bullet Remind parents that they have parenting skills they can draw from. bullet Keep an eye on the social impact on families of the eating disorder. When family members should not be involved: Sometime family members can be obstructive to treatment efforts, even following repeated efforts to provide education and support. In some circumstances, family members will be facing other problems or disorders that interfere with their capacity to provide support to the person with the eating disorder. In such instances it will be important to assess the family's capacity to provide useful support. Evidence of emotional, physical, or sexual abuse in the family, ongoing substance use disorders, or untreated major mental disorders, are contraindications to family members' direct involvement as treatment supports. The Medical Assessment The medical assessment provides information on the presence and severity of the physical effects associated with the eating disorder and may exclude the presence of other medical conditions. Eating disorders of all types and at almost all stage of illness have some impact on the person's physiological parameters and as the disorders become more entrenched, medical complications can become life threatening. The potential for these complications to become chronic, or to perpetuate other problems, is also high. The GP will usually be the first medical contact for the person and their family. If other health care professionals have the initial contact, referral to a GP for a medical assessment is a priority. The initial interview should be concerned primarily with engaging the individual, unless of course medical compromise becomes immediately apparent. Proceeding in a cautious open-ended way and making arrangements for the person to be seen again is the aim. Of course, the person's clinical state, during a limited assessment (and a rudimentary physical examination), will be the real determinant of the direction of the consultation. Recognition of medical compromise especially in children and adolescents is essential - kids get sicker, quicker because of their physical vulnerability and because they tend to cease fluids completely. A comprehensive mental health assessment, including a risk assessment, addresses the important psychological issues associated with eating disorders. It will also identify the stage of change and level of motivation of the person. Some of the key features addressed by the mental health assessment include assessment of co-morbid conditions such as depression, anxiety, obsessive compulsive symptoms, and substance abuse or drug use, an understanding of personality traits, mental health history, social history, level of functioning and impact of the illness on daily life and relationships and family history of eating disorders and mental illness. The purpose of the nutritional assessment is to gather sufficient information to inform treatment planning, practical goal setting, priorities for education and strategies for behavioural change. The aim is to obtain an in-depth understanding of the person and their relationship with food, eating and body weight, and also to begin the process of developing a therapeutic alliance. For some practitioners this will require a step out of their traditional role and the assumption of a more counselling type of role. Developing a therapeutic relationship is essential to successfully addressing nutritional issues – people with eating disorders are particularly uncomfortable talking about food, eating and body weight and/or shape - and a certain amount of trust is required. The nutritional assessment will provide more detail than the medical assessment around BMI, weight history, abnormal eating behaviours, attitude to weight loss (or gain) and exercise pathology. It will also include a detailed assessment of dietary intake, compensatory behaviours, biochemistry, anthropometry, family food/exercise beliefs and will provide information about nutritional status and identify associations between emotional issues and eating. Assessment Tools 6 of 21 There are a variety of eating disorders assessment methods available including structured, semi-structured and free form interviews, as well as standardised self-administered questionnaires. The method selected will depend upon the purpose of assessment (for clinical or research purposes). Structured and semi-structured interviews may provide a lot of information regarding the major symptoms of eating disorders, although they can be time consuming and may not be practical for clinical settings. For routine clinical assessment, a clinical interview is usually all that is conducted and may be more conducive to developing therapeutic alliance than a standardised tool. However, collecting information from standardised tools on admission and discharge from an episode of therapeutic treatment is always good clinical practice. The Eating Disorders Examination - Questionnaire is the most widespread validated self report measure for this population. EDE-Q The Eating Disorders Examination - Questionnaire (Fairburn & Beglin, 1994) is a widely used self report measure of eating disorder symptomatology. It was based on the Eating Disorders Examination (Cooper & Fairburn, 1987), a semi structured, clinician led interview to assess psychopathology associated with eating disorders. The EDE-Q is rated through the use of four sub-scales and a global score. The sub-scales are: 1. Restraint 2. Eating concern 3. Shape concern 4. Weight concern The questions concern the frequency to which the person engaged in eating disordered behaviours over the previous 28 day period. An assessment should be conducted by each member of the multidisciplinary team. Whilst each discipline will have a specific focus, there are many areas of the assessment that are common. Overall the components of the assessment include: 1 1 Medical and Psychiatric History 2 2 Social and Family History 3 3 Assessment of the Eating Disorder Behaviours 4 4 Assessment of Weight 5 5 Clinical Assessment 6 6 Medical Investigations 7 7 Psychological Assessment Gathering information on the individuals past medical and psychiatric history will provide you with valuable information about: bullet Past medical history, including major illnesses, operations, problems in perinatal period and infancy, recent health problems preceding the dieting behaviour and/or weight loss (such as infectious mononucleosis, chronic fatigue syndrome, food allergies and intolerances, sporting injuries and less commonly but importantly diabetes mellitus, thyroid disease and neoplastic conditions requiring chemotherapy) bullet Whether they screen for risk factors (including predisposing factors) - such as previous obesity, polycystic ovarian syndrome bullet How informed the individual is regarding their current experience bullet Whether the individual has previously sought treatment for the eating disorder – who, what worked, what didn't work, why was treatment discontinued bullet Whether the individual has experienced any co-morbidities The individual's social and family history provides important information that will inform treatment planning. It will provide you with background information about the individual's life and living situation, their daily activities, their support network and who may be involved in supporting them through treatment. In assessing social history you may gather information regarding: bullet The living situation of the individual – who they are living with, spend time with, who does the grocery shopping and cooking bullet Their day to day activities and routine – school, university, work bullet The individuals support network – who will be included in treatment and support their recovery, who knows about the eating disorder In assessing family history you may gather information regarding: bullet Eating disorder or other mental health history within the family bullet The family's perception of the individuals experiences bullet The family's relationship with food and body, weight and shape and any dieting history bullet The general body weight and shape of family members bullet Illnesses in the family such as hypercholesterolemia, cardiovascular disease diabetes mellitus and polycystic ovarian syndrome might also be relevant to the client's wish to weigh or eat differently. bullet History of other mental illness, drug or alcohol abuse should also be established. SNAPSHOT EXAMPLE - HANNAH Hannah, a 16 year old, was brought to her GP by her mother, concerned at Hannah's weight loss and lack of interest in food for some months. Hannah had always been thin, but her current BMI was 18. Weight loss had begun when life stresses had made her feel fairly sad some months before and she had lost her appetite. She had since found that she felt better if she didn't eat and had avoided doing so even when she felt hungry. There were no underlying medical problems. Hannah is an intelligent teenager who lives with mother, younger brother and stepfather and sees her father every second weekend as she has done since she was 3. She has a close relationship with all 3 caregivers and her parents divorce was fairly amicable with all the adults on friendly terms. Talking to Hannah revealed that recently her father, who remains single, had begun to drink heavily on access visits which made her quite sad and she felt a great sense of loss. Dealing with Hannah's issues involved a two pronged approach. Psycho-education about the evolution of eating disorders helped her understand the importance of getting her eating habits back to normal. Some simple structured problem solving and discussion of the issues with her father helped her find a way to address the problem. She decided to talk to him and explain that visits were wasted for her if he drank too much. She enlisted the help of her paternal grandmother and they agreed with her father to arrange for Hannah and her brother to spend time with her father at grandma's house so that it would be easier for him not to drink. Hannah's depression resolved and with some effort on her part her eating returned to normal. GRACE We consider ourselves to be a pretty normal Australian family. My husband and I are happy together and we have two rather wonderful daughters. Our elder daughter Grace, who developed Anorexia when she was 13-14, was a happy, clever, enthusiastic child who had shown no sign of emotional/psychological illness before the onset of anorexia. When Grace was 13 she started cross-country running and showed considerable talent for the sport. She was already playing representative netball. She started eating ‘more healthily' for her sport and began an adolescent growth spurt. By the time she was nearly 14 we were beginning to feel Grace was a bit skinny and were concerned that she was not eating enough to meet the energy demands of her sport and training. We also noticed at about this time that she was becoming a bit withdrawn, short tempered and uncharacteristically preoccupied with her weight and looks. We felt a niggling concern but basically dismissed these changes as normal adolescent behaviour. Anorexia never even entered our heads. However, after spending time together on a family holiday overseas we really became aware of how little Grace was eating. The first doctor and dietician we consulted failed to diagnose an eating disorder, but a sports specialist who we saw in June 2004 did and we commenced treatment with him, a paediatrician, a counsellor and a dietician immediately. These were the really hard things about the illness: Seeing our daughter transformed from a bright, joyous, out going child to a pale, emaciated, haunted being living in terrible fear, pain and misery, convinced that she was a truly hateful and vile person who didn't deserve food or joy in her life. While she was ill Grace eliminated all pleasurable activities – she wouldn't let herself read, play games, do crafts, sing, play music, choose a program on television, see friends or anything else she used to enjoy. Knowing that to help Grace recover we had to make her do the two things she feared most – eat and gain weight – again and again and again. Trying to keep sight of our real daughter while coping with the anorexia induced physical and verbal aggression towards us, and her self-harming and dangerous behaviour. Maintaining our faith that this would work – that with love, nutritious food and weight gain our Grace would return. And finally, as she recovered, handing back control of her eating to Grace. Learning to trust in her judgment again and coping with our own fears of a relapse. Assessing the effects of the eating disorder is an important part of the assessment as it will inform which treatment setting is most appropriate for the individual and what level of care is required. All eating disorder behaviours carry with them significant risks that can have impacts both physically and psychologically on the individual. As a result, many individuals with an eating disorder require medical monitoring. The physiological assessment should include: bullet Skin examination bullet Assessment for dehydration bullet Oral examination bullet Assessment for signs of vomiting bullet Assessment of cardiovascular / respiratory systems bullet Assessment of gastrointestinal and renal systems bullet Assessment of musculoskeletal systems bullet Assessment of menstrual disturbances Skin Examination When conducting a skin examination, important things to look for include acrocyanosis (blue discolouration), jaundice, carotenaemia (orange skin), dry skin, hair loss/thinning, lanugo hair (soft downy hair on back, arms), callused knuckles (repeated induced vomiting), skin infections and lesions from self-harm Assessment for dehydration When conducting an assessment for dehydration, important things to look for include sunken eyes, dry lips and tongue, poor skin turgor and slow capillary return Oral Examination When conducting an oral examination, it is important to look for signs that may occur with recurrent vomiting. These include dental erosions, pharyngeal redness and parotid enlargement Assessment for signs of vomiting Signs of vomiting to look out for include swollen parotid glands, recurrent sore throat, bouts of tonsillitis, halitosis, callused knuckles (repeated induced vomiting), bloodshot eyes and broken capillaries in the cheeks and eyelids Assessment of cardiovascular / respiratory systems It is important to asses blood pressure (seated and standing). A fall or rise of 10-20 mmHg on standing indicates cardiac compromise. Heart rate (seated and standing), bradycardia/tachycardia on minimal exertion indicates deconditioning. Core temperature, shortness of breath (orthopnoea, paroxysmal nocturnal dyspnoea, exercise tolerance), palpitations (sudden onset, frequency, duration), chest pain (onset, frequency, duration, associated symptoms, precipitating factors), examination of peripheries (circulation, coldness in hands and feet, oedema) and fainting, collapse, light-headedness, dizziness Assessment of gastrointestinal and renal systems It is important to assess for delayed gastric emptying (causes prolonged fullness), post prandial symptoms (distension, abdominal pain, bloating and early satiety), reflux, diarrhoea, constipation and urinalysis Assessment of musculoskeletal system Assess for stress fractures, overuse injuries and bone mineral density if indicated. Assessment of menstrual disturbances Although primarily considered a manifestation of low weight or malnutrition, amenorrhea can be associated with many factors including prolonged weight loss, erratic eating behaviours, poor nutrition, excessive exercise and stress, and can occur irrespective of the individuals weight. The persistence of amenorrhea for longer than 6 months can be associated with lowered bone mineral density, and therefore needs to be addressed as a priority. SNAPSHOT EXAMPLE - MANDY Mandy was a young girl who presented for a laxative prescription as her usual doctor was unavailable. She reported having problems with abdominal pain and constipation and requested a stronger laxative. She had tried most over-the-counter laxatives but they were not effective. On physical examination, Mandy looked thin and pale. Her height and weight were found to be within the normal range. She was not clinically constipated on physical examination. After telling Mandy that her constipation was probably due to a poor diet, she admitted to me that she had a problem with stress, controlling her weight and had difficulties managing her diet. She had just started a new job, was not eating regularly and was skipping meals. On further questioning, Mandy admitted she had lost a bit of weight since starting her new job. Apart from skipping meals, she had begun to restrict her calorie intake by becoming a vegan. She thought she had been suffering from food allergies. Other problems Mandy experienced were tiredness, moodiness and erratic menstrual periods. She agreed to return to her usual GP with a letter outlining what we had discussed and for blood tests. She also agreed to see a dietitian skilled in eating disorder management. Mandy did not leave my practice with a laxative prescription, but instead left with a structured treatment plan. Children and adolescents are particularly vulnerable to health problems as a result of disordered eating behaviours, and are prone to numerous long-term complications. These can include: Significant deficits in bone mass leading osteopenia and osteoporosis Growth faltering Amenorrhoea or irregular menstrual periods leading to an increased risk of infertility and low bone mineral density Delayed or incomplete pubertal development Increased risk of mortality, suicidal behaviours, clinical depression, obsessive compulsive disorder, anxiety, substance abuse and other psychiatric illnesses The following medical investigations may be conducted as indicated: ECG Useful in all individuals as it provides a more accurate resting pulse and assesses for arrhythmia's (especially prolonged QTc which is common with severe weight loss) Blood Tests This may include: full blood count, electrolytes, liver function tests, glucose, calcium, magnesium, phosphate, thyroid stimulating hormone, tri-iodothyronine, serum thyroxine, follicle stimulating hormone, luteinising hormone and oestradiol. Bone Densitometry Indicated in individuals that are restricting their energy intake for >6 months, if underweight, with or without amenorrhoea. Other investigations Erythrocyte sedimentation rate, ferritin, B12, folate, anti-transglutaminase antibodies and stool microscopy. Whilst many clinicians in the multidisciplinary team may carry out a basic psychological assessment, the mental health practitioner (such as a psychologist, psychiatrist) will carry out a much more extensive and detailed mental health assessment. THE PSYCHOLOGICAL ASSESSMENT The client's description of presenting problem/s History of the development of the problem/s Co-occurring psychiatric or psychological problems, previous treatments Personal, social and family history Mental State Examination Effect of the eating disorder on quality of life Provisional diagnosis and formulation A mental health assessment (MHA) begins at the initial contact and is ongoing. The person being ‘assessed' is central to the process and should be part of it, not a passive recipient. Consider what the assessment means to the person and whether their story has been faithfully represented. Consider too why we might have interpreted things in a certain way and how our own context and experiences impact on what has been shared. The MHA is a multi-dimensional evaluation including: Observation of a person's behaviours bullet Evaluation of developmental status bullet Listening to thoughts and feelings bullet Understanding psychological impact of physical illness/medication bullet Obtaining feedback from friends and family bullet Relating these to their social and cultural context. Context when conducting a MHA (e.g. location, who else is present, physical/medical problems, cultural/religious issues, legal status etc.) is important and can affect outcome so should be considered. The mental state examination (MSE) covers the following topics: bullet General Appearance and Behaviour Does the person appear physically unwell, anxious, or depressed? Is he or she emaciated, or are they wearing clothes that obscure their figure? Is the client restless? Many clients with anorexia nervosa are unable to sit still, or even sit, even when asked to do so, and continually jiggle their feet (This can be a result of ‘biological restlessness' rather than purposeful activity). bullet Speech Is the client communicative, or do they answer only briefly and reluctantly? Does the client set out to justify their reasons for dieting? Do they avoid eye contact when asked potentially confrontational questions about eating, exercise, vomiting, or laxative abuse? bullet Affect and Mood Affect refers to the immediate emotional response in the interview situation. Mood refers to the underlying emotional theme. Depression and elation Mild to moderate depression is so common in eating disorders as to be considered intrinsic to the diagnosis. Elation is usually simulated if present – the idea being that liveliness may protect against enforced treatment. bullet Anxiety and Phobias A high level of generalised anxiety is often obvious from the client's avoidant behaviour, restlessness and discomfort in the interview. Clients often admit to a fear of eating, food, or gaining weight, but these fears do not constitute phobias in the full psychiatric sense of the word. bullet Obsessions and Compulsions Obsessive ruminations about the need to lose weight, dieting, food, and particularly exercise are common and distressing. These are repetitive and troubling thoughts that the client tries but is unable to suppress. Compulsions or rituals are complicated patterns of behaviour designed to reduce anxiety e.g. cutting food into minute fragments and shuffling it around the plate. Most rituals of an eating disorder client are related directly to eating e.g. avoiding “contamination” by touching food. Sometimes, rituals of purification are also found. Thought The excessive salience that clients give to ideas of weight, shape and eating, the need for strenuous exercise, and the importance of abstinence are best considered as overvalued ideas (short of delusions). Eventually, these ideas become so entrenched and resistant to change, despite evidence of serious deterioration of health, and so egocentric that they resemble delusional thinking. bullet Perception A distorted image of self by which clients see themselves as obese when emaciated is often cited but is relatively rare in practice. More commonly, clients deny the severity of their weight loss, or say they “feel fat” even though they know that they are not. bullet Cognition With increasing debilitation cognitive function is increasingly impaired. This can progress to confusion and even coma. bullet Judgement and insight Judgement and insight of the client into their illness are characteristically poor, with little appreciation of the seriousness. Rapport Clients are often resentful when asked about their symptoms. This is because they often see the condition as being acceptable or even beneficial (we call this an “egosyntonic” illness). Denial of the presence or severity of the condition is common. Previous conflicts with parents or other relatives may lead clients to become especially sensitive about all matters concerning their illness. To establish rapport, it is necessary to show an interest in the client as a person, and their own perception of the situation, rather than to imply that they are being considered merely as a case of an eating disorder. Assessing co-morbid Depression & Anxiety Depression & anxiety are common in people with eating disorders. In some cases mood will improve with nutritional stabilisation. Depression can vary from mild unhappiness or dysthymia to severe suicidal ideation with social withdrawal. Anxiety can be mild or disabling. Assess mood using a mental state exam (MSE) and the person's description of their mood. Suicidal thoughts/actions must be assessed (asking does not increase the likelihood that they will occur). Use a series of questions that form a natural hierarchy - go along this hierarchy as far as necessary. Have you thought about taking your own life/harming yourself in any way? Have you made any plans to take your own life? Do you have the means at your disposal? Have you made an attempt? Occasional thoughts of suicide are fairly common but plans to act on these thoughts will require liaison with the local crisis team or community mental health team, with a possible view to hospital admission for safety. Assessing co-occurring Obsessive Compulsive Disorder Seen to a mild degree in many people who have eating disorders (and to an extremely pathological degree in some) OCD may manifest itself in the form of counting calories, repetitious weighing or obsessional thinking about body shape, weight and/or food. Upon initial assessment, a general question like, ‘Are you a person who likes things done in a certain order or in a certain way?' and 'What concerns you if you do not do things that way or in that order?' can help determine degree of obsessionality. Ask for descriptions of behaviours, frequency, duration, beliefs about and history of these symptoms. Target the compulsions like hand-washing, ordering and checking, that make up the symptoms of OCD and ask about the obsessions (repetitive thoughts, images or impulses) that lead to them. Assessing co-occurring Substance Abuse People with eating disorders, particularly Bulimia Nervosa, frequently abuse alcohol or drugs. Alcohol abuse may be binge-like as the eating disorder itself may be, or be used to control appetite and weight as in the case of amphetamine abuse. Certain appetite suppressant tablets have a mechanism of action similar to amphetamines and can cause a sensation similar in quality though less euphoriant. Abuse of those drugs can be associated with fluctuating mood states from mild elation to depression. All clients should be asked about their alcohol consumption, their use of recreational or illegal drugs, and particularly cigarette smoking as this is commonly used to suppress appetite, assist dieting and prevent weight gain. If the substance abuse is prominent it may need to be managed in its own right and would ideally be brought under control concurrently with attempts made to control the eating disorder. It is best to make a referral to a specific drug and alcohol clinic, or drug and alcohol counsellor and to stay in close communication with that counsellor. Assessing co-occurring Personality Disorders Some people suffering from an eating disorder, particularly those with Bulimia Nervosa, can exhibit characteristics of a borderline personality disorder. Their history may include past sexual abuse, either during childhood or later, substance abuse, deliberate self-harm, generalised impulsivity and considerable difficulties managing interpersonal relationships. The eating disorder behaviours may be better conceptualised in these cases as part of the impulsive behavioural repertoire of the personality disorder. However, the eating disorder behaviours will often need management in their own right, a person suffering from borderline personality disorder requires specialised psychotherapy as well. This can usually happen in tandem with treatment of the eating disorder. Assessing co-occurring Autism Spectrum Disorder (ASD) Autism spectrum disorders may be present for some individuals with eating disorders, particularly Anorexia Nervosa and ARFID. Diagnostic guidelines for ASD recommend using both developmental and observational assessment tools, and hence assessing suspected ASD may require referral to a specialist doctor or psychologist. It is important to get a sound diagnostic picture as treating co-occurring eating disorders and ASD may require more intensive therapy or specifically tailored interventions. Individuals with social and non-social difficulties characteristic of ASD may require treatment adaptations for instance, the use of distraction techniques in inpatient settings, e.g. encouraging social interaction and playing the radio during meals, may be too stimulating and overwhelming for someone with an ASD. Effect of the eating disorder on Quality of Life bullet Effects of the eating disorders - physically, emotionally, occupationally, socially and cognitively bullet Impact of the eating disorder on family or significant others bullet Amount of time spent thinking about eating, weight and shape bullet Effect of the eating disorder on sleep patterns bullet The individual's insight into what maintains the eating disorder bullet The individual's beliefs about what needs to change in order to get better bullet Denial or acknowledgement of illness severity Insight into the illness bullet Motivation to change - stage of change and confidence to execute change Using this and other assessment information one can create a formulation i.e. a model of the causative and maintaining factors that may be involved in an individual's eating disorder. A formulation can guide treatment and give clients an understanding of how their eating disorder works. At the end of the initial interview process, it can be helpful to present a formulation to the client. This can then inform the establishment of a joint management plan and assist with early goal setting for treatment. Naturally, formulations differ from client to client. Using a basic model of how Anorexia Nervosa or Bulimia Nervosa is understood can be a useful starting point for creating a formulation. A comprehensive assessment of nutrition intake will provide you with insight into the intensity and severity of the eating disorder, can help to inform the treatment plan, and informs medical monitoring and management. It is essential that you maintain a non-judgemental and client-centred approach, supporting and providing empathy to the individual as they reveal their experiences. It can be informative to collect the following information: Diet history and time course of beliefs around food bullet Current nutrition intake (including food and fluid) bullet Food and taste preferences such as vegetarianism bullet Food allergies and intolerances - self diagnosed or medically diagnosed bullet Food rules and feared foods bullet Food rituals - measuring, weighing, calorie counting bullet Hunger, fullness and satiety cues bullet Meal time environment - who prepares and cooks, eating environment and behaviours When assessing eating disorder behaviours, it is important to assess the type, method and frequency of engagement in these behaviours. This provides insight into the intensity and severity of the eating disorder, can help to inform the treatment plan, and informs medical monitoring and management. Most eating disorder behaviours carry with them significant shame and guilt for the individual. Often the individual has not ever revealed details about these behaviours to another person before, so you may be the first person that they have ever spoken to about them. Reflect the individuals experience so that they know that they have been heard and understood. It is essential that you maintain a non-judgemental and client-centred approach, supporting and providing empathy to the individual as they reveal their experiences. Assess the following eating disorder behaviours: 1 1 Restricting 2 2 Binge Eating 3 3 Purging Self-induced vomiting Laxatives Diuretics Diet pills Chewing and spitting 4 4 Exercise 5 5 Rumination 6 6 Night eating It is important to remember during assessment that the primary purpose is to get an understanding of the eating disorder behaviours, not necessarily provide psycho education at this stage. Restricting Assess the type, amount, frequency and duration of restrictive eating behaviours. Restricting food intake, commonly known as dieting, has become a culturally accepted behaviour to control or mitigate weight gain. Types of restricting: 1. Avoiding eating – Fasting or restricting intake which involves large time periods with little to no food. 2. Restricting total intake – Eating throughout the day but limiting the amount of total energy intake. 3. Avoiding types of food – Avoiding food that the individual deems to be ‘fattening', ‘bad', ‘unhealthy'. It is important to note that any type of intake manipulation that is intended to influence body, weight or shape is regarded as restricting. This includes eating ‘healthily', being ‘vegetarian', avoiding ‘lactose' or having a self-diagnosed ‘allergy' for the purpose of influencing body, weight or shape. Some individuals report that restricting their intake leaves them feeling deprived, hungry and grumpy, whilst others report that restricting gives them a sense of being in control and empowerment. Restricting food intake can result in significant physiological and psychological symptoms, known as the starvation syndrome. Binge Eating As a health professional working with people experiencing binge eating, it is important to try and understand what they are going through and to appreciate the emotional and psychological impact it has. Try and get a sense from the individual how the experience of binging feels to them. Assess the type, amount, frequency and duration of binge eating episodes. How often – per day, per week What types of food are consumed Objective/subjective binges – estimate of quantities Time of day Location and environment Feelings before, during and after a binge Triggers or cues to start binging There is great variation in the types of food and quantities eaten during a binge episode. Most commonly people will binge on foods that they are trying to avoid i.e. ‘unhealthy foods', or foods that the person deems as leading to weight gain. The average size of a binge episode can range from 1000 calories to 3500 calories, with some binge episodes accounting for 10 000 calories. Subjective binges are binge episodes that do not meet the DSM-5 criteria as they do not constitute abnormally large quantities of food, however they still cause considerable distress in the individual and involve a sense of loss of control. Because of the distress felt by the person, subjective binges should be addressed similarly to an objective binge eating episode. The experience of binge eating varies from person to person, however some of the following are common experiences felt by people who binge eat: Binge eating can start off as pleasurable, enjoyable and with a sense of freedom from breaking dietary rules. These feeling are often short lived, and replaced by feelings of guilt, disgust and shame. bullet During a binge, food is eaten rapidly, mouthful after mouthful, quickly swallowing and often without proper chewing. bullet Often bingeing occurs in secret and people go to great lengths to hide their binges. Sometimes it occurs in the car, bedroom or kitchen, or sometimes even at work or in public. bullet Sometimes bingeing is a planned event and sometimes it occurs unplanned. Some unplanned binges can result in a desperate need for food that becomes all consuming, and people can binge of food belonging to others. bullet There is a loss of control during the binge, and inability to stop. Binging often ends when the person is so incredibly full that they physically cannot eat anymore. People often feel disconnected during a binge, or as if they are in a trance during the episode. Binge Eating Triggers Under eating, restricting food intake or dieting Feeling hungry or being unsatisfied Feeling deprived from eating the foods that the person enjoys Breaking a dietary rule by eating a ‘forbidden food' or a food that isn't 'healthy' or ‘weight loss friendly' or eating too much of a particular food Feeling full, resulting in feeling like ‘I've already blown it, so may as well keep going' Intrusive thoughts about food Availability of food, especially foods which the person is trying to avoid Feeling upset or distressed about body, weight or shape and deciding to abandon all efforts to control eating, resulting in binging Weight increasing or decreasing Feeling fat Feeling uncomfortable in clothes because of perceived weight changes Feeling tired or exhausted Feeling low, depressed or upset Feeling lonely or isolated Feeling bored or irritable Feeling anxious Some people report binge eating when they feel happy, excited and feeling great Restricting nutrition intake and binge eating Restricting nutrition intake (commonly referred to as ‘dieting') and binge eating go hand in hand. Restricting nutrition intake creates physiological and psychological pressures to eat, which can trigger a binge-eating episode. 1 1 When we restrict what we eat, our bodies respond both physically and psychologically. Our metabolism begins to slow to conserve energy, hunger and appetite increases and our mind becomes obsessed with thoughts about food and eating. As food is restricted we often feel tired, low, depressed or anxious. Our bodies are working hard to push us towards eating more food to meet our body's requirements. This can result in binge eating. 2 2 The creation of rigid dietary rules about when, where or how much one should/shouldn't eat, facilitates a ‘deprivation mindset'. As our bodies are deprived from the food we need and want, breaking the dietary rules becomes inevitable. As a dietary rule is broken, many individuals feel such guilt and disappointment in themselves that they begin to break all the diet rules and abandon the diet. This can result in binge eating. Once an individual engages in a binge eating episode they may either unintentionally restrict nutrition intake, as they are genuinely full and do not feel the need to eat, or deliberately restrict nutrition intake to mitigate weight gain. Both of which can trigger another binge eating episode. Restricting nutrition intake can therefore both cause binge eating and maintain binge eating. This becomes a vicious cycle that can entrap people in binge eating patterns for years. As restricting intake is one of the main causes and maintaining factors for binge eating, ceasing restrictive eating patterns forms a fundamental goal of treatment. Purging Purging behaviours are compensatory behaviours that are primarily used to mitigate weight gain. These include behaviours that involve ridding the body of ingested food; self-induced vomiting, laxative, diuretic and diet pill misuse. Individuals report that purging provides a great sense of relief, alleviating any anxiety or fear of weight gain. It can also provide a sense of emotional release (especially with self-induced vomiting), alleviating anxiety, frustration and anger. For some individuals, purging is used as a form of self-punishment7. Whilst purging allows the individual to feel in control of their eating, it can also quite quickly become a compulsion that the individual feels that they are unable to control. Purging is associated with severe medical complications across all body systems8. Any individual engaging in purging behaviours should be assessed and monitored by a medical practitioner. Most individuals who engage in self-induced vomiting experience significant levels of shame and embarrassment regarding the behaviour. Be sensitive and acknowledge the courage it takes to talk about self-induced vomiting. Assess the method, frequency and effects of self-induced vomiting How is vomiting induced How many times per vomiting occasion Occasions of vomiting per day and per week Feelings before and after Triggers or cues to self-induce vomiting Physical and psychological effects from self-induced vomiting How? – Self-induced vomiting involves stimulating the pharynx to induce the gag reflex. For some, it can become an automatic or conditioned behaviour after eating. Some individuals are able to vomit by pressing on their stomach or leaning forward. Some people will only consume foods that they know are easier to vomit, and others will use a ‘flushing' technique, whereby they will drink fluid, vomit, drink fluid again, vomit again and repeat this cycle until they are sure that their stomach is empty ('flushing' is medically very dangerous). Where? – Self-induced vomiting typically occurs in private and in secret. People can mask self-induced vomiting from loved ones for years and some report ‘silently' vomiting, making it difficult to detect. When? – The frequency of vomiting can vary significantly. An individual may vomit: After binge eating episodes Multiple times throughout a binge eating episode After normal sized meals After very small amounts of food or fluids Whenever they feel like they have food in their stomach Why? – Self-induced vomiting is used primarily to mitigate weight gain. It can also be triggered by the need to manage uncomfortable emotions and many people report feeling a significant sense of tension release and emotional relief after vomiting. Whilst self-induced vomiting allows the individual to feel in control of their eating, it can also quite quickly become a compulsion that the individual feels that they are unable to control. Vomiting does not rid the body of all the food ingested, in fact there is evidence to suggest that a significant portion of the calories ingested are still absorbed. Additionally vomiting can result in serious physical complications including dehydration, dental erosion, electrolyte disturbances (low potassium), subconjunctival hemorrhages (small bleeds in the eyes), cardiac complications and oesophageal rupture. Laxatives are used as a method of compensation to mitigate weight gain. Other people may use laxatives to manage the idea of and discomfort of having food in their body - “I just need to feel empty”. Research indicates that up to 60% of individuals with Anorexia Nervosa and Bulimia Nervosa engage in laxative misuse. However, laxatives act on the lower part of the gut and food absorption occurs much higher up in the digestive system, making them an ineffective method of compensation. Laxatives can cause dehydration, electrolyte disturbances, loss of muscle tone in the bowel and kidney damage. There are several types of laxatives including, stimulant agents, saline and osmotic products, bulking agents and surfactants. Stimulant agents carry with them significant medical problems. These include dehydration and electrolyte disturbances that can affect the renal and cardiovascular systems and become life threatening, as well as long-term kidney and colonic damage. Diuretics Assess type, frequency and effects of diuretic misuse. nmnAsset 4@6x-8.png Diuretics are used with the aim of reducing body weight and bloating. Some people notice a loss of weight (water weight) if weighing themselves regularly, however this is reversed when fluids are consumed. Diuretics are ineffective at controlling body weight, as they have no effect on energy absorption. Diuretics can cause dehydration and electrolyte disturbances, and kidney damage. Diet Pills Assess type, frequency and effects of diet pill misuse. Diet pills are used with the aim of losing weight through suppressing hunger, increasing metabolism and thermogenesis, and reducing the absorption of energy. There is little evidence of the efficacy of diet pills, however there is evidence around their potentially harmful effects. Some ingredients common to diet pills can cause headaches, anxiety, chest pains, difficulty sleeping, increased blood pressure, tachycardia, gastrointestinal disturbances, nausea and vomiting and liver damage. Chewing and spitting Assess the frequency, environment and types of foods that are chewed and spat out. Chewing and spitting, involves eating a particular meal, snack or food item, with no intention to swallow and digest it. It involves chewing the food, tasting it, and then spitting it out. Chewing and spitting primarily occurs in secret. Chewing and spitting is used to allow the individual to ‘taste' the meal, snack or food item, without experiencing the effects that this may have on body, weight and shape. Many individuals that chew and spit will be guarded about revealing this behaviour, partly due to shame and embarrassment associated with the behaviour, but also because it is not widely understood by health professionals. Always remain client-centred, non-judgemental and curiously explore the individuals' experiences. Exercise Exercise is a common eating disorder behaviour, with 30-80% of eating disorder presentations featuring excessive exercise. Exercise is primarily used to influence weight and shape, alleviate negative emotions and manage anxiety. Assess type, frequenicy, intensity, duration and intention of physical activity. Type and intensity of physical activity (including incidental activity) bullet Duration of exercise bullet Frequency – per day, per week bullet Location and environment bullet Past physical activity patterns bullet Concerns about physical activity bullet Rest days Whether physical activities interferes with other life engagements bullet Feelings when unable to be active bullet Reasons, intentions and motivations for physical activity HEALTHY MOTIVATIONS For general health and wellbeing For enjoyment For mindful space, relaxation, connection with body Fuelled by adequate nutrition UNHEALTHY MOTIVATIONS Purge calories Influence weight or shape Reduce or manage general anxiety Manage an obsessive preoccupation with weight gain Alleviate negative emotions Minimise fear and anxiety about eating EXPLORE THE FOLLOWING: “Can you run me through what your exercise routine looks like?” “Does it change from day to day, or is your exercise session exactly the same each day – same place, same number or duration of exercise?” “Why do you exercise?” “Do you prioritise exercise over social engagements? What about occupational engagements?” “Will you exercise even when you don't feel like it? “What happens if its raining or miserable weather?” “What happens if for some reason you are unable to exercise?” “How do you feel at the thought or mention of taking a break from exercising?” “Do you have rest days? What are these like for you?” “Does your food intake change according to your exercise patterns?” “Have you ever sustained an injury from exercising? Did you stop exercising whilst you recovered or did you continue to exercise despite the injury?” Excessive exercise is exercise that: bullet Increases the risk of injury bullet Increases the risk of short and long term medical complications bullet Interferes with medically necessary weight gain bullet Occurs at inappropriate times or in inappropriate settings such as exercising very late at night or in secret in the bedroom bullet Is accompanied by feelings of anxiety, depression, intense guilt and extreme feelings of failure if the exercise is postponed or there is deviation from the routine bullet Is obsessive and cannot be controlled bullet Requires a rigid exercise schedule Requires detailed record keeping bullet Interferes with social relationships or educational and work activities bullet Is a self-punishment bullet Occurs despite injury, illness or medical complications bullet Is not fuelled with adequate nutrition bullet Is used to allow or to give ‘permission' to the individual to eat – known as ‘debting' Rumination Ruminating involves repeatedly and voluntarily regurgitating food. The food is then re-chewed, re-swallowed or spat out. Rumination can be an eating disorder behaviour within the context of any eating disorder, or can occur as a separate diagnosis; Rumination Disorder. Many individuals who ruminate describe being ‘in control' of some of their ruminating behaviours, but once this behaviour has become entrenched, it becomes habitual and somewhat unconscious. Many individuals that ruminate will be guarded about revealing this behaviour, partly due to shame and embarrassment associated with the behaviour, but also because it is not widely understood by health professionals. Always remain client-centred, non-judgemental and curiously explore the individuals' experiences. Night eating 4Asset 26@6x-8.png Night eating involves eating excessive food at night time, usually after the evening meal. This may be an eating disorder behavior within the context of any eating disorder, or can occur as a separate diagnosis; Night Eating Syndrome. The individual may be very conscious and aware of their night eating behaviours, or they may be in a ‘trance' like state and quite unaware of the eating behaviours. Additionally, some individuals report that their night eating resembles binge eating episodes. Assessing the effects of the eating disorder is an important part of the assessment as it will inform which treatment setting is most appropriate for the individual and what level of care is required. All eating disorder behaviours carry with them significant risks that can have impacts both physically and psychologically on the individual. As a result, many individuals with an eating disorder require medical monitoring. CHILDREN AND ADOLESCENTS Children and adolescents are particularly vulnerable to health problems as a result of disordered eating behaviours, and are prone to numerous long-term complications. These can include: Significant deficits in bone mass leading osteopenia and osteoporosis Growth faltering Amenorrhoea or irregular menstrual periods leading to an increased risk of infertility and low bone mineral density Delayed or incomplete pubertal development Increased risk of mortality, suicidal behaviours, clinical depression, obsessive compulsive disorder, anxiety, substance abuse and other psychiatric illnesses Explore with the individual what physical and psychological effects they have experienced since engaging in the eating disorder behaviours. Ensure that any concerning symptoms have been assessed and are managed by their general practitioner. The individual may not be aware that some of the physical and psychological symptoms they are experiencing may be a result of the eating disorder. This process can aid in raising awareness and can be used to build motivation. You may gather various symptoms throughout the assessment, or can screen for symptoms using a symptom checklist. Physical Symptoms Fainting, collapse, light headedness, dizziness Delayed gastric emptying causing prolonged fullness Diarrhoea, constipation Lack of concentration Feeling tired but not sleeping well Lethargy and low energy Amenorrhoea Increased sensitivity to coldness Weak nails, thin hair, dry skin Decreased libido, fertility issues Dehydration Growth faltering Decreased bone strength Weight fluctuations Calluses on hands Chronic sore throat, heart burn, reflux Dental erosion and decay, swollen salivary glands Irregular or slow heart beat Blood pressure changes on standing Psychological Symptoms Changes in mood Personality change Preoccupation with food Impaired concentration and alertness Agitation Impaired ability to make decisions, rigid and inflexible thinking Depression, anxiety Sleep disturbance Social withdrawal Low self esteem, poor body image The Starvation Syndrome Many of the changes (physical, psychological, social and behavioural) that people with eating disorders experience are the direct result of starvation. The starvation syndrome, or features of it, can be triggered by any significant energy deficit brought about by restriction, purging or excessive exercise. This means that even if a person appears to have an adequate caloric intake, or appears to be within or above a healthy weight range, they can still experience the symptoms of starvation. These symptoms are often attributed to other causes, rather than being correctly attributed to the result of a significant energy deficit and starvation. Attitudes to Food Preoccupation with food Obsession with food and food preparation Behaviours around food Unusual food rituals (e.g. hoarding food, long meal times) Binge eating (triggered by restricting food intake) Cognitive changes Impaired concentration, problem solving and comprehension. To compensate for this the person may become more obsessive in their intellectual work. Increased rigidity and inflexibility. Emotional changes Depression, mood swings, irritability, anger, anxiety Low libido Physical changes Sleep disturbance, dizziness, tiredness, fatigue, headaches, hypersensitivity to noise/light, cold hands/feet, hair loss, lanugo, visual/auditory disturbances, hypoglycaemia, decrease in heart rate and weight loss. Effects on Quality of Life Explore how the eating disorder has affected the individual's life in other ways, such as the emotional, occupational and social effects. This includes the impact that the behaviours associated with having an eating disorder have had on their lives such as their ability to eat food with others, eating out, eating food cooked by others. “Has the eating disorder affected your work?” “In what ways has the eating disorder affected your relationships?” The Refeeding Syndrome is the term used to describe severe fluid and electrolyte shifts that can occur when a starved and severely malnourished person commences nutrition support1,2. If untreated, refeeding syndrome can result in congestive heart failure, respiratory failure, pulmonary oedema, cardiac dysrhythmia, seizure, altered mental state such as delirium or agitation, and even sudden death2,3. Providing nutritional support is essential for immediate stabilisation of the acute complications of malnutrition, especially hypoglycaemia and cardiovascular complications that occur in eating disorder patients2-4. However, it is necessary to achieve a balance between providing enough nutrition to prevent weight loss and underfeeding syndrome, yet not provoking the re-feeding syndrome5. The re-feeding syndrome can occur regardless of whether patients are fed by oral, enteral, or parenteral routes6. Signs of The Refeeding Syndrome Clinical signs of the refeeding syndrome include: Hypophosphatemia1-3 Other significant electrolyte abnormalities such as hypokalaemia, hypomagnesaemia1-3 Peripheral oedema1-3 Disturbance to organ function (e.g. respiratory failure, cardiac failure, pulmonary oedema)8 Risk Factors for The Refeeding Syndrome Risk factors identified for the refeeding syndrome in eating disorder patients include: Degree of malnutrition and adaptation to this state9 Very low initial weight5 Weight suppression, defined as the difference between highest and current weight, may increase risk of the refeeding syndrome, even in normal weight individuals10 Low serum prealbumin11 Higher Hemoglobin12 Pre-existing or other electrolyte abnormalities before and during refeeding9,12 Rate of provision of carbohydrate in relation to other nutrients9 Infections and other medical complications5 Assessing an individual's weight needs to be done sensitively, with consideration, and within a ‘weight neutral' and non-judgemental approach. For many individuals, their self-esteem is based on their ability to control their body, weight and shape – and therefore talking about it and monitoring it can raise considerable distress and anxiety. Even if the individual appears to be happy to get on the scales, the impact of seeing their weight (as well as your reaction) will have lasting effects on their thoughts, feelings and behaviours. Consider the following when determining whether to include ‘weighing' in treatment: siora-photography-cixohzDpNIo-unsplash.jpg What is the rationale for weighing? Is knowing the individual's weight helpful in the process of recovery or colluding with the eating disorder? For individuals who require medical monitoring or where weight restoration is a treatment goal, thoroughly assessing the individual's weight history and regularly weighing the individual to track progress is necessary, as this is a marker of treatment progress. Without prompt and adequate weight restoration, medical risk reduction, reversal of psycho-endocrinological disturbances and improvement of mental state does not occur. For individuals whose weight does not pose imminent medical risk, or where weight restoration is not a goal of treatment, focusing on weight and weighing may have significant impacts on the individual. It may increase the individual's weight focus and may exacerbate any disordered behaviours. For others managing the anxiety of seeing ‘the number in the scale' may be an important component of recovery. Collect the following: bullet Current Weight bullet Current Height bullet Calculate BMI/BMI-for-age bullet Highest weight (and height at that time) bullet Lowest weight (and height at that time – check this is not a prepubertal weight) bullet Recent weight loss and over what time frame Body Mass Index (BMI), although still regularly used by health professionals, underestimates the health consequences associated with eating disorder behaviours. Instead of focusing on the individual's BMI as a marker or reflection of health status, rather assess their weight history, trend and eating disorder behaviours. Many terms are used to describe an individual's ‘healthy weight' such as ‘usual weight', ‘normal weight', ‘ideal body weight' and ‘expected body weight'. Encourage the individual to attain and maintain a weight that is healthy for their individual body. The individuals ‘healthy weight' will be a weight that: Supports normal physical and physiological functions bullet Enables normal growth and development in children & adolescents bullet Supports normal hormonal functions bullet Support resumption of menses in females bullet Improved bone mineral density bullet Enables maintenance of weight when responding to hunger and fullness cues bullet Enables maintenance of weight in the absence of disordered eating behaviours bullet Consistent with pre morbid weight, gender, ethnicity and family history bullet Supports cognitive, psychological and social functioning Setting a treatment goal weight range for individuals who need to gain weight, can help to inform the treatment plan. Determining a treatment goal weight range is complex, and requires acknowledgement of the multitude of factors that influence an individuals weight such as; age, weight history, height, genetic predisposition for body weight, shape and size, ethnicity, age at menarche and the weight at which periods ceased (menstrual threshold weight), chronic disease, food intake and habits, history of dieting, activity levels and psychosocial environment. A treatment goal weight should always be a ‘range' to allow for normal bodily fluctuations, and importantly it is a ‘flexible' construct, whereby the treatment goal weight is iterative and may be readjusted once reached if markers of physical and psychological health are not present. For children and adolescents the treatment goal weight provides an initial target, but more importantly the goal is to return to a growth trajectory that is in line with their normal growth and development. As the individual moves through treatment and is no longer engaging in disordered eating behaviours, is listening and responding to their hunger and fullness cues and is taking care of their body, they will begin to attain their body's healthiest weight. As you gently encourage the individual to trust their body to manage this process, you will need to remain weight neutral and encourage the acceptance of a wide variety of different body shapes and sizes. Treatment goal weight in adults 1 1 Determine treatment goal weight based on the individual's premorbid stable weight, with consideration of the multitude of factors that influence weight. 2 2 If the individual did not have a premorbid stable weight (i.e. they gained significant weight prior to the development of the eating disorder or always engaged in dieting behaviours) then, for women with amenorrhea, 2kg greater than the weight where menses was lost can be used. 3 3 If there is insufficient historical weight information or BMI data are unavailable, then weight consistent with the median BMI for adults can be used (22-22.5kg/m2). Treatment goal weight in children and adolescents There are a few methods to determine the treatment goal weight for children and adolescents. Whilst the treatment goal weight provides an initial goal for treatment, the ultimate aim is not to return to a specific weight, but rather a growth trajectory. Determine treatment goal weight based on the individual's premorbid growth trajectory. To determine a treatment goal weight range using growth charts: Accurately collect past and current anthropometric measurements - weight, height and BMI Plot these on growth charts to obtain a pattern of growth trajectory over time Given the individuals growth trajectory, estimate where their current weight should be If there is insufficient historical weight and height information or BMI data are unavailable, then weight consistent with the median BMI for age and sex can be used. To determine a treatment goal weight range using median BMI: Accurately collect current anthropometric measurements – weight, height and BMI Determine the median BMI (50th percentile BMI) for age and sex Using the individuals height and median BMI, calculate the individuals treatment goal weight However, this has numerous limitations, as it assumes that the treatment goal weight for all individuals is the median BMI from normative population data and does not consider those individuals who are on the extreme ends of the BMI spectrum or those individuals whose weights meet or are above the normal range. Pitfalls of Setting a Treatment Goal Weight Although setting a treatment goal weight range is common practice, there are some pitfalls to be aware of: bullet Weight can be difficult to measure accurately – it is easy to manipulate and falsify bullet There is a wide variation of normal weights within the population bullet Other health indicators may not have normalised once the individual reaches the treatment goal weight bullet The individual may be very resistant to increasing weight above the initial treatment goal weight For some, a treatment goal weight range can create an over-focus on numbers and may trigger guilt if this number is exceeded. Continued Height measurement bullet Measure height with the patient standing, using a stadiometer or portable anthropometer bullet No shoes or socks bullet Back and head should be straight and eyes looking forward bullet Feet, knees, buttocks, and shoulder blades should be in contact with the vertical surface of the stadiometer, anthropometer, or wall bullet Arms should be hanging loosely at the sides, palms facing thighs bullet Person takes a deep breath and stands tall to help straighten the spine bullet Headpiece should be lowered until it just touches the crown of the head Motivation to Change 17 of 21 Assessing motivation and stage of change are important not only during the initial assessment, but on an ongoing basis. These are important in planning future interventions and will influence the approach to treatment that you take. There is little point developing a treatment plan requiring the individual to be in full action, when they are still denying that there is a problem. Motivation to change is quite clearly related to the stage of change that the person is at. While there will be some instances where treatment needs to be implemented regardless of stage of change, for example, where the person is in a medical crisis and yet denying that there is a problem and still pre-contemplative in their approach to change, for the most part, treatment planning will need to be tailored to the stage of change and the level of motivation that the person is exhibiting. SNAPSHOT EXAMPLE - LIZ Liz is a 22 year old university student. She lives in Sydney and her family are in the country. She is referred by her GP who is concerned about weight loss, amenorrhea and increased anxiety. Whilst not currently in a dangerously low weight category, she has lost 5kg over the past 2-3 months. Liz describes how she had an eating disorder at high school. She was a high achieving, attractive, popular girl and, from her perspective, losing some weight heightened all of those things. She has never had treatment, other than speaking to the school counsellor a couple of times about stress management during the HSC. Liz tells you that she is managing well. She lives on campus and has lots of friends. She goes to 21st birthday parties most weekends. She thinks maybe she has lost a bit of weight, but doesn't really think it is concerning, and hasn't mentioned anything to her parents. “It is too stressful to eat more, and I am just too busy with uni and friends”. She thinks that the referral to you was an over-reaction and that she is happy to carry on as usual. What do you do? Since you have Liz in the room, use the opportunity to try to get her to consider the pros and cons of continuing as things are. Ask her about what the doctor said about her health. Ask her how she thinks her parents would react if they knew about the doctor's concerns. Talk about the impact of her increased anxiety and what she thinks may be causing this. Take a non-confrontational, non-judgemental stance. Just gathering the facts, rather than interpreting them. Consider drawing up the Pros and Cons on a sheet in collaboration with Liz. If the Cons are low, then it is understandable that Liz doesn't see the need for treatment. Ask her what she thinks it would take for her to accept treatment. How bad would the Cons need to be? How would life be if it got to that point? Is this something she would prefer to avoid if possible? Let Liz know that she doesn't need to commit to seeing you at this point. It is entirely voluntary, but check in with what her concerns are regarding treatment, to see if there are misperceptions that you can correct. If Liz is open to it, consider booking in a next appointment so as to leave the door open if Liz changes her mind regarding treatment after she leaves your appointment. Assure her she can cancel if she chooses, but that she is welcome to come back at any point. Assessment Considerations in C&A 18 of 21 Key differences to consider for assessment of children and adolescents with an eating disorder: bullet Assess for medical stability against age-appropriate reference ranges bullet Assess expected growth trajectory based on past height and weight data and parental height. Compare to current growth assessment. Determine evidence of delayed growth and if present, dietitians should determine appropriate nutrition intervention for catch-up growth. Determine presence or extent of bone mineral density changes, such as osetoporosis and osteopaenia. If present determine urgent appropriate nutrition intervention. Research shows that adolescent girls presenting for an eating disorder before menarche will have lost weight and stunted their growth – because poor nutrition is likely to be longstanding. bullet Involve families or carers in assessment process bullet Use communication styles and plan treatment options appropriate for age and developmental stage Communicating with children and adolescents 77Asset 6@6x-8.png Consideration of the child's developmental stage is important, particularly in terms of assessment and implementing treatment. This includes consideration of cognitive development (and the impact of starvation on cognitive processes) in relation to the child's capacity for understanding and communication. Always use age-appropriate language and communication styles and consider the complex interactions and influences that the young person will be exposed to – they may have received information from a variety of reliable and unreliable sources. Be mindful too, of not giving away too much information or over-emphasising specific behaviours to children and adolescents during your assessment. For example, some young people may not have considered the use of specific behaviours such as self-induced vomiting or laxative use, and may be suggestive to such ideas. Key Messages 19 of 21 1 1 Assessment of people with eating disorders requires a multi-faceted approach and ideally, a range of multidisciplinary health care professionals should be involved. 2 2 A medical, psychological and nutrition assessment should ideally be conducted by each respective member of the multidisciplinary team. 3 3 The therapeutic relationship is the cornerstone to recovery. The clinician's attitude and approach will be the difference between a successful initial assessment, where the person feels that they have been heard, and one where the person feels defensive and is hostile or non-communicative. 4 4 Every health professional should endeavour to involve family, carers and significant others in treatment where appropriate as Most carers bolster treatment and contribute positively towards recovery. 5 5 The individual's stage of change, along with their medical status, should be considered in the development of the treatment plan. Treatment Overview 3 of 25 77Asset 6@6x-8.png Carefully planning treatment is an important part of the recovery process. Engaging with the person, undertaking some basic psychoeducation and working on increasing motivation to change are fundamental concepts. Collaborating with the client and, where possible, carers or family members in establishing the treatment plan will be vital. Where management is shared between primary and secondary care, there should be clear agreement among individual healthcare professionals on the responsibility for monitoring patients with eating disorders. This agreement should be in writing and should be shared with the patient and, where appropriate, his or her family and carers. Ideally, treatment will be coordinated by a GP and include a multidisciplinary team consisting of a mental health professional and a dietitian with eating disorders experience, with access to specialist services for advice, support and referral as needed/required. General Management Principles bullet Plan treatment after assessing relevant problems bullet Ensure client preferences are considered bullet Target symptoms (e.g. weight loss, purging) and psychosocial problems (i.e. those underlying the eating disorder, those that are a consequence of it, contribute to it or are comorbid) bullet Be structured but sufficiently flexible to suit individual needs bullet Include family/ carers/ support persons in treatment planning as relevant bullet Guarantee continuity of care over an extended period of time bullet Evaluate the treatment plan regularly for positive and negative outcomes Treatment Non-Negotiables 4 of 25 A central tool in assisting individuals engaged in recovering from an eating disorder is to employ ‘non-negotiables' or clear boundaries around the clinician's role in treatment, team communication and individual safety. Typically, the more at risk an individual is in terms of health the stricter the treatment boundaries. However level of risk can change quickly, so all work in this area requires clear boundary setting from the beginning. Whatever the health status of the individual, there are foundational treatment frameworks that most health professionals recognise as mandatory components of treatment. Foundational Treatment Frameworks Non-negotiables are employed at the beginning of treatment (irrespective of whether treatment is in an inpatient or outpatient setting) and are set and implemented collaboratively, consistently and in a client-centred way. These non-negotiables are relevant to all treatment contexts. The key outcomes of non-negotiables Ensure safety by protecting both the health professional and the individual with the eating disorder Improve therapeutic alliance by having a clear understanding from the outset about expectations and agreements Prevent splitting of team members Create an environment that is conducive to change by ideally limiting the individuals engagement in particular unhelpful behaviours Clearly understood consequences or outcomes that are agreed determined and agreed upon by all involved Common non-negotiables in a community and hospital setting include the following: Non-negotiables in a community setting Non-negotiables in a hospital setting Medical monitoring with a GP Regular medical monitoring If medically unstable refer to hospital (emergency department) or have a plan to admit to hospital Weight gain of x kg/week Multidisciplinary team input Cessation/reduction of eating disorder behaviours Involvement of parents, family or carers if under 14 years of age Completion of x % of meals and snacks Research suggests that individuals with eating disorders clearly understand the reason and function of non-negotiables. However, what can be a significantly helpful framework for treatment can also be detrimental for the treatment process and outcomes. Some of these impacts are described below. Non-negotiables do not work well when: Non-negotiables are arbitrary (with no clear or reasonable rationale) bullet Non-negotiables are inconsistently implemented bullet Non-negotiables are brought up by surprise for the individual (i.e. not at the beginning of treatment or without inclusive conversation when required during a period of treatment) bullet Non-negotiables are not set collaboratively and do not provide the individual with choice4 bullet They are used to evaluate an individual's progress as being ‘good' or bad' which may subsequently lead to 'blaming' of the individual or treatment provider for lack of progress. The key to non-negotiables is setting them collaboratively with the individual at the beginning of treatment. This ensures that the individual is part of the process, empowers them to be responsible in their treatment process and ensures that when a non-negotiable is not met, that the consequences are already known to both the health professional and the individual. This is very important as it ensures that the health professional does not need to be punitive or authoritarian in their approach, maintaining the therapeutic alliance, and puts the responsibility and control in the individual's hands to manage the consequences. SNAPSHOT EXAMPLE - JENNY Jenny, a 22-year-old patient with Anorexia Nervosa is attending a day program and on the second day of her attendance at day program Jenny refuses to eat her lunch. As a non-negotiable to consume 100% of her meal plan was collaboratively set at the beginning of treatment, Jenny is already aware that the consequence of not eating the lunchtime meal is replacing it with fluid supplements. The nurse is able to support Jenny with the decision of consuming the meal or the supplement. It is Jenny's choice as to which she consumes, and she also knows that this is a non-negotiable to receiving treatment at the day program. The nurse does not need to argue with Jenny or cajole her into eating, but rather in a client-centred approach, help her to make a decision that is in her best interest. This may involve a separate discussion (outside of the distress and anxiety of meal times) to review whether Jenny is ready to attend Day Program or whether she requires a higher level of care. SNAPSHOT EXAMPLE - SARAH Sarah, a 21-year-old individual with Bulimia Nervosa has been seeing you in private practice over the past 4 months, and in today's session reveals that she has fainted at the gym three times this week and skipped her appointment with her general practitioner because she wasn't feeling well. A non-negotiable specified at the beginning of treatment was that Sarah would be reviewed by her general practitioner each week, and that if she was deemed to be medically unstable, that she would be required to go to the emergency department at the local hospital. In your session, you are able to refer back to the treatment non-negotiables established at the beginning of treatment and either ensure that Sarah is reviewed by her general practitioner the same day, or goes straight to the emergency department from your office. The key here is to follow through with the non-negotiable consequence. If you do not ensure that Sarah is medically reviewed, then this sends a message to her that fainting is not a matter to be concerned about. Stages of Treatment 5 of 25 Our Brand Elements for Icons.png There are 4 main stages of treatment: case identification, early intervention, treatment and maintenance. Of course the severity of the illness and the client's specific symptom profile (medical and psychiatric) will largely influence which management strategies will be appropriate and whether immediate multidisciplinary or specialist intervention is warranted. The clinician's specific health discipline will play a part in how these processes will occur, and what their individual role will be e.g. the GP is most likely to do the thorough medical assessment. Stage 1 Case Identification Establish a therapeutic relationship Acknowledge and empathise with client's distress Provide basic education in a collaborative way Conduct a thorough assessment Medical, psychological (including risk assessment), nutritional, activity Assist with developing insight and prompting the development of motivation for change Stage 2 Early Intervention 1. Initiate appropriate treatment – usually including specialists from many disciplines. For clients with Bulimia Nervosa, a medical practitioner, dietitian and psychologist experienced in eating disorders are appropriate. A psychiatrist may be involved particularly for any psychiatric comorbidities. Clients with Anorexia Nervosa will also require medical, dietetic and psychological intervention. In addition, family therapy or specialist paediatric medical treatment may be required for those under 18 years. It may be necessary to involve a psychiatrist, particularly in cases where consideration needs to be given to the diagnosis and medical management of comorbid conditions. For clients with other eating disorders, a medical practitioner is necessary and the involvement of other practitioners will depend on the specific presentation. 2. Help client plan appropriate and desirable goals – including life-goals as well as eating/weight related goals. Use motivational strategies Use positive reinforcement and behavioural experimentation Stage 3 Treatment 1. Restore weight (in AN) and normalise eating patterns (in all disorders). Developing a well-balanced, nutritious and regular eating plan Providing education about nutrition Rewarding and encouraging adaptive behaviours 2. Modify eating disorder behaviours. Using a food diary Providing education about binge-eating and compensatory weight loss behaviours Encouraging the use of alternative coping strategies Reinforcing and encouraging adaptive behaviours 3. Enhancing the client's psychological and physical well-being through: Fostering interests and achievements in other domains of the client's life (goal planning) Establishing effective stress management strategies Enhancing family support and communication Referring for psychological therapies as appropriate Stage 4 Maintenance 1. Fostering the development of healthy thinking and lifestyle by: Challenging unrealistic beliefs Providing psychoeducation as appropriate Providing or referring for further psychotherapy as needed 2. Preventing or effectively managing relapse with the aid of: Education about and planning for relapse episodes (whether they occur or not) Conducting follow-up assessments, evaluation and monitoring Treatment Settings 6 of 25 The treatment model and setting, will depend on many factors including severity and/or length of illness, previous treatment, presence of co-morbidities, age of the client, functioning of the family, health insurance status and where the person lives. Specialist consultation should be sought for most cases of Anorexia Nervosa. For patients with Bulimia Nervosa, Binge Eating Disorder and the other eating and feeding disorders, care is generally best provided in the community with a GP, dietitian and mental health professional. However, in situations where the illness is very severe or unremitting, or where the situation is complicated by a comorbid physical or mental health problem, specialist consultation may be required. Treatment settings include: 1 1 Community Care 2 2 Inpatient Care 3 3 Day Programs 4 4 Self-Help Community Care This is the preferred option for treatment which should involve establishing a multidisciplinary approach. Community-based care is usually required over the longer term and treatment may be required for up to several years. Lack of progress with community-based care can be an indicator for admission or referral to specialist services. Inpatient Care bret-kavanaugh-MIfUp3FA5ek-unsplash.jpg Inpatient admissions are used when a person is physically or psychologically unable to manage in the community, or when intensive community-based care has proven ineffective and may be essential in ensuring the individuals safety. Hospital admissions in Australia generally occur in medical settings and may include medical stabilisation (usually around 24-48 hours duration) or more intensive interventions such as specialised weight restoration programs (which may be for around 4-10 weeks duration). The purpose of admission is generally not to achieve full recovery, but to commence nutritional rehabilitation to assist the client to stabilise medically, then reach a level of health that will enable continued treatment within the community. Day Programs Day programs offer a step between community-based and inpatient care and may be used as a transition between the two. A client may benefit from a day program when they require more intensive intervention than community-based care, though do not require a hospital admission. Similarly, a client may be doing well enough to be discharged from hospital, though not ready for community-based care. Not all areas have access to day programs for people with an eating disorder. Self-Help dorothee-kraemer-26839y0vZME-unsplash.jpg A variety of self-help options are available and may be in the form of on-line programs, books or manuals. Self-help is a useful, effective and cost-effective treatment for people with Bulimia Nervosa or Binge Eating Disorder or subclinical versions of these, which can be offered in primary care. Outcome is improved when the self-help is guided, that is accompanied by professional treatment support (either face-to-face or by telephone). Self-help, however, is not recommended for Anorexia Nervosa given the special medical needs of patients with this disorder. CONSUMER SUPPORT SERVICES Consumer support services are an invaluable resource for people with an eating disorder, their families or carers and for health professionals. Telephone and on-line support, support groups and educational activities and resources may be provided by consumer organisations across Australia. Clients may also be directed to appropriate care or supported to stay in treatment by consumer agencies. A Team Approach 7 of 25 Ideally, treatment will be provided by a multidisciplinary team. Eating disorders are multi-faceted illnesses, impacting thoughts, behaviours, and physical health and emotional wellbeing. In order to most successfully combat these illnesses the treatment must be multi-faceted, as well. A 2015 study (Mitchell et al), found that “an interdisciplinary team has more therapeutic utility than counselling alone”, citing that these clients engaged with treatment longer than those not referred to a multidisciplinary team. Waiting until a critical point to involve other practitioners, usually when community treatment is not working and referral is necessary, can damage the relationship between primary clinician and the client – ‘are you giving up on me?', ‘treatment has failed'. Therefore, involving other practitioners from the outset is a non-negotiable aspect of treatment. Exactly what role each clinician takes varies and depends on interest, experience and availability of specialist services. It may also vary from client to client. Always discuss your role with the client and where appropriate, the family and/or carers. Whenever your role changes, be clear about how it has changed – with the client, carers and other professionals involved. ROLE OF THE GP The GP is often the first line of treatment and is thus instrumental in the detection and diagnosis of an eating disorder. In all cases, as with any other illness, the GP takes on medical management and the role of care coordinator. The GP is the crucial link between clinicians - a stable point of reference to which the client can return during and/or after treatment. The role of the GP includes: Listening effectively & building rapport Diagnosing the problem Assessing the severity of the illness by performing physical examinations and mental state assessments Conducting the necessary investigations Monitoring medical stability on an ongoing basis (no other health professional will likely do this), and Coordinating appropriate referrals and care plans and communicating with the treatment team The GP may also undertake to engage the person and assist them in accessing treatment, with the view of enabling motivation to change. Some GPs may provide treatment – family counselling, supportive psychotherapy, cognitive behavioural therapy or using guided self-help with clients who have Bulimia Nervosa. Over the course of treatment the GP's role may change, e.g. while a client is waiting to see a specialist it will be necessary to begin behavioural and nutritional strategies, however, once a client sees a dietitian, this may become less important and focus will return to monitoring the physical and psychological health of the person. Where the GP is the admitting officer for a rural/regional hospital, the role will be more complex, including directing other staff. Support from a specialist service should ideally be sought. ROLE OF THE PSYCHIATRIST Psychiatrists assess and diagnose the eating disorder, other comorbid psychiatric and/or medical problems. They may refer to a GP, paediatrician or physician to exclude physical differential diagnoses and to diagnose and manage physical complications. Using a biopsychosocial approach to treatment, they may provide individual psychotherapy, family therapy, and recommend and oversee psychopharmacological treatments. The psychiatrist also has a particular role in management of risk, including use of the Mental Health Act. In coordinating the care of clients with eating disorders, the psychiatrist may be required to provide supervision to staff regarding issues that may arise in the context of managing clients with complex problems. ROLE OF THE PAEDIATRICIAN Involving a paediatrician is vital for children and adolescents, as there is a serious risk of growth stunting as an effect of malnutrition. The paediatrician oversees the normal growth and development that occurs during puberty. ROLE OF THE PSYCHOLOGIST A psychologist or clinical psychologist can provide assessment and diagnosis of eating disorders, and evidenced-based individual and group psychological therapy and family therapy. A psychologist's role typically involves developing a collaborative understanding of the function of an individual's eating disorder and supporting the development of alternative coping methods. They assist a client to think about issues relating to food and eating, and broader areas such as identity, trust, control, and conflict resolution. Depending on their training and experience, psychologists may provide a range of evidenced based psychological therapies, including Cognitive Behavioural Therapy (CBT), Maudsley Family Based Treatment (FBT), Motivational Enhancement Therapy (MET). ROLE OF THE DIETITIAN The dietitian's role will vary depending upon the treatment setting, age of the person, severity of the illness, the overall treatment plan, therapies being used and the expertise and interest of the dietitian and other members of the team. With all clients with eating disorders, the dietitian must use a therapeutic approach that is mindful of the psychological issues and does not collude with the eating disorder. The dietitian's role in initiating refeeding, managing the risk of refeeding syndrome, restoring nutritional status, restoring weight and normalising eating are fundamental components of inpatient treatment, and are essential for recovery. The role of the dietitian is to: Conduct a nutritional assessment and assess malnutrition severity and risk of the refeeding syndrome. Evaluate the individual's eating patterns. Work collaboratively with the multidisciplinary team to develop and implement a treatment plan. Develop an individualised nutrition management plan to correct nutritional deficiencies, meet the individuals nutrition and hydration needs, promote optimal nutrition status and manage refeeding risk. Identify dysfunctional thoughts and feelings about food, eating and body weight. Identify knowledge and skill deficits that prevent the inpatient from achieving and maintaining optimal nutrition status. Explain the role of eating and adequate nutrition in physical and mental well-being. Provide nutrition education to challenge inaccurate beliefs about food. Offer active learning opportunities to help teach new behaviours and acceptance of food related tasks. This might include activities such as cooking, shopping, or modelling normal eating behaviour in a meal supervision format or as part of practical eating activities. Communicate findings effectively with other members of the multidisciplinary team, as well as the family, carers and significant others. ROLE OF THE NURSE Nurses work with patients who have eating disorders in a range of settings including inpatient and outpatient, medical and mental health services – these may be specialist settings but patients are more likely to receive medical treatment (i.e. the first stage of treatment ) in non-specialist settings, so all nurses need core skills and knowledge in caring for individuals with an eating disorder. Some aspects of the role of the nurse caring for eating disorder patients across the settings include: Monitor medical and mental health Contribute to developing treatment plan and implementation of the treatment plan Supportive counselling / emotional support Observe and document eating disorder behaviours Provide meal support Handovers (to multidisciplinary team and nursing) Individual and/or group therapy Carer support and psycho-education Holistic assessment Case management Creating a Team Where There Isn't One 8 of 25 If you are a solo practitioner or working in an area where direct access to specialist providers is limited or non-existent, it will be necessary to develop your own ‘team'. Essentially, the most important ingredient for all clinicians is a willingness to be involved, a genuine interest or investment in people who experience eating disorders and a preparedness to increase knowledge and skills in the area. It is always possible to access specialist support through a tertiary referral service via telephone or video conferencing and this is a recommended course of action, particularly where a diagnosis of Anorexia Nervosa has been made. It is always preferable to treat someone in their own local community and where a group of committed professionals is involved. The Medicare Benefits Schedule 9 of 25 Clients with an eating disorder are able to access a range of services under the Australian Medicare Benefits Scheme (MBS), including the following: 1 1 Eating Disorder Plan: From November 2019 a new MBS Item pathway for eating disorders became available. Patients who meet the eligibility criteria can access up to 20 sessions with a dietitian and up to 40 psychological sessions with a mental health provider within a twelve month period. The referral for the complete 20 dietetic sessions and initial 10 psychological sessions can be made by a GP. A GP needs to review the patient after each course of 10 psychological sessions. In addition, a specialist review with a Psychiatrist or Paediatrician must occur for patients to access more than 20 psychological sessions. 2 2 Better Access to Mental Health Care: GP, Psychiatrist or Paediatrician can refer clients with an eating disorder who do not meet the criteria for the Eating Disorders Plan to Psychologists, Social Workers or Occupational Therapists who are registered with Medicare Australia. This entitles them to up to 10 sessions of therapy within a calendar year. 3 3 Enhanced Primary Care Plan: A GP can set up an Enhanced Primary Care Plan for an individual with an eating disorder to receive Dietetic input. 4 4 The Mental Health Nurse Incentive Program: A time unlimited program offered by Credentialed Mental Health Nurses, according to program guidelines, in collaboration with a GP or a private practice Psychiatrist. Overarching Goals of Treatment 10 of 25 1 1 Restore normal eating patterns and behaviours to correct biological and/or psychological consequences of malnutrition that may perpetuate disordered eating behaviour. 2 2 Address any physical consequences associated with the disordered eating behaviours such as restoring weight. 3 3 Address associated psychological, social, family and behavioural problems that may underlie and/or contribute to the disorder (or contribute to relapse if left unattended) SNAPSHOT EXAMPLE - ANNE Anne, a 38-year-old mother of 2 has come to see you because she suspects that she has binge eating disorder. Anne explains that she has gained weight as a result of her 2 pregnancies and disordered eating patterns. She wants to learn how to eat well and get back to her ‘pre-baby weight' from 8 years ago, which is 11kg lower than her current weight. Unfortunately, Anne is basing her ‘healthy weight' on a weight from 8 years ago, prior to having children and prior to gaining weight as a result of binge eating. We do not know whether it is possible for Anne to get back to her ‘pre-baby weight' without engaging in unhealthy dieting practices. It would be helpful to encourage Anne to take the focus off her weight, and off the numbers, and instead focus on her eating behaviours. Types of Goals 11 of 25 plush-design-studio-94Ld_MtIUf0-unsplash.jpg Restore Weight Normalise Eating Behaviours Cease Eating Disorder Behaviours Restore Weight bullet Setting a treatment goal weight range and/or a number of incremental weight goals may be useful, however clients should understand that full weight recovery and normalisation of eating is the ultimate long term goal. bullet Some clients will attempt to negotiate the value of the treatment goal weight range. All clinicians must be consistent about the minimum acceptable weight, and work with the person to feel more comfortable about being at this weight. bullet Forewarn the person that early rapid weight gain of 1-2kg over a few days is due to rehydration, increased glycogen storage or fluid & electrolyte shifts (rather than fat tissue). For some people with long standing Anorexia Nervosa, a BMI within the 'normal' range may be unrealistic. As such, a lower target weight may need to be negotiated, provided it ensures medical stability. bullet Clients and health professionals should agree on frequency of weighing and which clinician will be responsible for weighing (ideally the Dietitian or GP). Clients and parents should be discouraged from weighing at home. Normalise Eating Behaviour bullet For clients with minimal food intake, negotiate a pattern of small regular meals and snacks. This helps to minimise gastrointestinal discomfort and psychological distress. bullet Some people restrict fluid intake whilst others may drink excessively. Both of these behaviours may result in serious medical complications. bullet Encourage a wide variety of foods – with the client, work out a hierarchy of feared foods and plan together to incrementally incorporate these into their normal eating pattern. Diet foods should be discouraged wherever possible. Further increases to food intake will be required as weight gain slows. As the clients reaches their minimum weight range, some will have been eating a larger than normal amount of food and will require some guidance and support in adjusting their food intake for weight maintenance. Cease Eating Disorder Behaviours bullet To encourage regular intake - ideally eating every 3-4 hours bullet To encourage adequate intake - eating enough food to meet energy requirements and distribution of food from all 5 food groups bullet To include a variety of foods with foods - including feared foods, or trigger foods This will help to set the foundation for weight gain in those individuals that are underweight, and will help to minimise engagement in binge eating behaviours. Goal Planning 12 of 25 CVCAsset 7@6x-8.png Goal planning is an extremely important and useful tool for determining a treatment plan and is an important point of collaboration. Goals are essentially about exposing the person to the things they fear, in a planned and structured way, in order to overcome the fear. This is also known as ‘exposure'. The premise is that to overcome fears one has to face them, tolerate the distress (fear) associated with facing them and learn that there is, in fact, nothing to fear. Eating disorders, to a certain point, are very useful coping tools that the individual may have found helpful during a difficult period in their life. As such, it will be particularly hard to change a behaviour that seems to be achieving its desired effect. It will be necessary to discuss, with the client, the reasons for making changes. For example – not having to count calories or think about food and weight may increase enjoyment of life, or improve relationships with the family members, or give the person more time to do things they enjoy etc. However, it is best if these observations come from the person, not from the clinician, so the aim is to encourage discussion about the pros and cons of behaviour change and to guide them towards making a decision in favour of change. Let the client talk about their thoughts, fears, and hopes so that you know what they want. During the conversation provide reassurance, correct any misconceptions, and do your best to understand the function the eating disorder has for the client. During the engagement phase developing a shared understanding of areas of need will assist in the development of broad treatment goals to be achieved. Maintaining hope for recovery is of paramount importance when goal setting. Recovery can be achieved! More detailed goal planning can occur after the client has decided to participate in treatment and has had the opportunity (through education and discussion) to understand more fully his or her most important strengths, problems and needs. Goal Setting Goals should be: Realistic Achievable Specific Broken into small steps Set by the client Identify Problem Areas and Needs Help the client to identify problem areas, for example: bullet Low self esteem bullet Vomiting bullet Can't eat in public bullet Avoiding some foods all the time bullet Thinking about food all the time bullet Depression Boredom bullet Perfectionism bullet Fear of failure bullet Loneliness Once the main problem areas are defined, rephrase the problems in positive terms and determine the need: Defining problems and needs in this way is the first step towards taking positive action to improve the situation. Identifying Strengths and Resources Ask the client to identify things that will help achieve their goals, such as any particular abilities, resources they may be able to access (e.g. people to help them), or interests they may use to distract with or occupy their time. Include activities and skills they enjoyed or did well before the onset of the illness, providing they will not compromise their health (e.g. played netball with friends or painted watercolour pictures). Problems Low self esteem Don't have many friends Think about food all the time Binge-eating Vomiting Chaotic eating Fear of becoming fat Depression Strengths / Resources Watercolour painting Netball with friends I get on well with my sister Still friends with Jacqui and Pat Enjoy my Uni course Good cook I recognise that I have an eating problem \ Most important needs To eat healthy and regular meals To learn to control my binge-eating To find better ways than binge-eating to cope with my problems To learn to like myself To increase my social circle To stop vomiting Common Challenges in Goal Setting Some people struggle to set realistic goals. This may be due to personal or familial pressure to excel, or perhaps due to the fact that the client denies that there is a problem. In these situations remember: bullet Recovery is a slow process that should not be rushed bullet Excessive pressure to ‘perform' will increase stress and lead to frustration and lack of co-operation bullet Goals will need to be flexible bullet More difficult goals can be set once previous goals have been achieved It may be necessary to discuss again the rationale for setting goals or to provide education about the process involved. SNAPSHOT EXAMPLE - DAVID David comes into your session looking down and disheartened. He says that therapy isn't working and that he should just quit. You ask him what has happened to bring on this feeling, as, to date, he has been quite positive and motivated. David says he tried to follow what you said about challenging 'feared foods', to help him overcome binge eating disorder. Last session you worked together to generate a list of 'feared foods' that he usually tries to avoid, as they are often associated with a binge. David understood the rationale for challenging 'feared foods' so he decided that he should go “all in” and really attack the list so that he could overcome the binge eating asap. He went to the supermarket and purchased 8 different fears foods. He planned to have at least 3 of them a day over the week. On Saturday morning, David made himself a large bowl of Coco Pops (a feared food) for breakfast. After breakfast, he was hanging around the house with nothing to do, waiting for the next challenge he had set for himself – cake at lunch time. He tells you that he couldn't stop thinking about the Coco pops in the cupboard. After about half an hour, David went and ate the rest of the coco pops and proceeded to eat the other 'feared foods' in the house, including the cake. How do you respond to David? Firstly, reassure David that he isn't the problem here – the goal is. It was great that he was enthusiastic, but by being so gung-ho, he created goals that were too large and uncontained. Remind him that it may be best to set up more contained situations e.g. attempt the Coco pops when there are other people around home and then leave the house straight afterwards. Also, planning on challenging two 'feared foods' on the one day was probably ambitious. If we can pull the goals back, and set them up with parameters, then he is likely to be able to progress through his 'feared foods' at steady, but sustainable pace, which will help reduce his binge eating. Treatment Considerations for Children & Adolescents Age Appropriate Treatment Consider age and developmental state-appropriate interventions and services for treatment of children and adolescents with an eating disorder. Communication strategies and styles should also consider developmental stage. Involve the Family The family should be integrally involved in the assessment, treatment planning and provision. For children and adolescents with Anorexia Nervosa under 18 years of age, Family Based Treatment is the first line treatment recommendation. In FBT the parents are charged with the responsibility to re-feed the young person back to health. The family will require specialist support during treatment. Specialist Involvement Where possible, children and adolescents with an eating disorder should be treated by a health professional who has expertise in eating disorder treatment. There are growing numbers of health professionals trained in Family Based Treatment. Bone Health The bone health of children and adolescents should be regularly monitored, and the treatment plan should aim to correct any delayed growth and protect against further bone mineral loss. Transitioning between Services Transition between services; discharge from hospital to a community team, or between child and adolescent services to adult services, can be high risk periods for lapses. Ensure adequate support is provided. Education The education process is a two-way experience. The client is receiving education about the disorder and is also educating the clinician about his or her unique experience of the disorder. Throughout treatment it is important to aim to learn as much as possible about how the client perceives his or her disorder and life situation. Such information provides an understanding of the client's attitudes, beliefs, and perceptions about the disorder and life in general, and of his or her motivation for change. Understanding the individual's perceptions Throughout the treatment journey you will get to know the individual and develop an evolving understanding of them and their eating disorder. Educational information or psycho-education can be provided throughout treatment as it becomes relevant. This provides an opportunity to correct unrealistic beliefs or enhance the client's knowledge base. At all stages the client should be encouraged to ask questions and to express his or her thoughts and feelings. Examples of questions that will help you understand the individual's perceptions: bullet “You say that you are experiencing symptoms such as... (abdominal pain, absence of menstruation, loss of energy, difficulty concentrating, etc.). What do you think might be causing these symptoms?" bullet “Do you feel that you could control your eating disorder behaviours if you wanted to? For example, could you stop restricting your food intake today and go back to eating normal, regular meals from now on?" bullet "You mentioned that you have unpleasant and distressing symptoms such as... In what way do you think these symptoms will change if you continue your present diet and behaviours?" bullet "What is the worst thing that can happen to you if you were to stop engaging in the eating disorder behaviours?” bullet "What is the worst thing that can happen to you if you keep engaging in the eating disorder behaviours?" (Possible outcomes: increasing deterioration of health or even death) bullet "Why is it so important to you to lose weight/diet?" "Are you happier and has your life improved since losing so much weight? For example, you said that thin people are more popular. Have you gained more friends or been to more parties since losing weight/dieting?...Do other people think you're more attractive now that you've lost so much weight?" Examples of questions to understand the individual's weight perceptions: bullet It may also be helpful to highlight the distinction between the client's actual weight and his/her worries about the perceived weight. “Do you think you're fat at the moment? How can you tell that you're fat? How do you think you look to me - do you think I see you as being very fat?” bullet “One of the characteristics of Anorexia Nervosa is that people who are actually extremely thin think of themselves as being fat, or having particularly fat body parts. I accept that you think of yourself as fat and that you feel fat, but in actual fact, to everybody else you look very thin. What do you think about that idea?” bullet “I'd like to suggest that part of the problem is that you've been dieting and thinking about your weight so intensely and for so long now that you can no longer be objective or impartial about your weight. You seem to view yourself as being fatter than you really are. How do you feel about this suggestion?” “Another common characteristic of serious eating problems is that people tend to think that everything will be ok once they've lost weight. However, when they get to their ideal weight they still feel fat and are unhappy with their life, and so feel compelled to lose even more weight. How does this fit in with your experiences?” bullet “What do you see as being the ideal solution to the problem?” Psychoeducation 16 of 25 nbAsset 13@6x-8.png Without attitudinal change, relapse is almost certainly guaranteed. Provide accurate information about the causes/effects of disturbed dieting/eating behaviour, about nutritional issues, social and cultural factors; help the person identify unrealistic thoughts, beliefs and values and to modify these where appropriate and possible. Psychoeducation is one area where taking the ‘expert stance' is fully appropriate, although the tone of delivery should always be respectful of the clients position. Psychoeducation will help clients gain understanding and insight into their disorder, can enhance motivation, and will reassure clients that they are not alone in their suffering or in the recovery process. It is important to provide psychoeducation as the information becomes relevant, and tailor it to the clients specific needs, rather than providing generalised 'hand out sheets' and overloading the client with a lot of information. Benefits of Psychoeducation during the Engagement Phase: 1 1 If a client drops out of treatment you will have offered them some concrete and factual information to consider over time. 2 2 It is less threatening to discuss impersonal facts (though they may have personal relevance) than it is to broach personal issues. 3 3 It may be a good icebreaker and assist in developing a trusting rapport. 4 4 It encourages clients to consider their ideas, beliefs and behaviours from a different perspective - that their physical and psychological experiences are not unique, but are common to others who have experienced eating disorders, starvation and semi-starvation. 5 5 Sometimes minimal intervention is the best approach; some may receive sufficient benefit from psychoeducation and access to self-help materials, such as reading appropriate books and/or attending self-help discussion groups. CONSIDER THE FOLLOWING What is Anorexia Nervosa, Bulimia Nervosa or an eating disorder? What factors may contribute to the onset or maintenance of the problem? What is involved in treatment? How to improve symptoms - how to reduce urges to binge, how to decrease obsessive preoccupation with food etc. The binge - purge cycle What constitutes a balanced diet Normal weight fluctuations, set point weight theory Legal and Ethical Issues Legal and ethical issues are important in mental health problems in general and in eating disorders in particular. Legal issues concern compulsory treatment, including the use of guardianship legislation and the Mental Health Act in Australia. Ethical issues include confidentiality, the concept of autonomy and its importance to recovery, and the distinction between coercive/compulsory treatment and social influence/strong persuasion – i.e. does the person accept treatment because they believe that refusal will result in treatment being enforced? Limited research in this area has found that predisposing factors to a person being admitted for compulsory treatment included a longer duration of illness, a history of childhood sexual or physical abuse, previous self-harm, psychiatric comorbidity, current health risk and a greater number of previous admissions. Compulsory Treatment Compulsory treatment is undesirable and should be avoided whenever possible. However, situations arise in which compulsory treatment may be necessary – where someone refuses life saving medical or psychological treatment or where there is an immediate risk of suicide or self harm. Over the age of consent, carers may obtain a legal order under guardianship legislation permitting them to take temporary control over the person's care and make decisions on their behalf to authorise medical or psychiatric treatments. Alternatively, the Guardianship Tribunal may appoint a public guardian. Irrespective of the treatment setting (i.e. primary practice, paediatric unit, gazetted mental health service), when life-saving treatment is refused, enforced treatment may be considered and the Mental Health Act invoked. GPs should seek assistance and advice from specialist eating disorder clinicians where compulsory admission is being considered. Confidentiality 19 of 25 Confidentiality is an important concept for all clients, but for young people it is a major factor associated with seeking out and engaging in treatment. The behaviours associated with eating disorders can raise intense feelings of shame and guilt and it can inhibit a young person's capacity to speak about their experiences, for fear of the issues being discussed with others. Raise the issue of confidentiality in the first meeting. The client (and their parent/carer) must understand that, for the most part, discussions between you will be confidential. However, they should also understand that if you are concerned for their safety or the safety of others, confidentiality rules do not apply and you may need to inform the client's parent, partner or other members of the treating team. Reassure the person that you will discuss these circumstances with them if and when they arise. Confidentiality is more complex at some times than others. While the right to confidentiality of clients must be respected, there is a balance between that and providing sufficient information to a parent/carer to allay their fears and provide them with information that will be beneficial to the client. Enlist the help of the client in deciding what to tell their parents/carers. In most cases, they will agree to the provision of broad information e.g. ‘Jane and I have been discussing the things that make it difficult for her to eat – we have a plan to continue this next week.' They may prefer to be present when the information is shared. Even where the client refuses to share any information with carers (which is rare), reporting around issues of safety still applies. Education and making general observations are still possible. For example, ‘Can I get you to ask Cathy to give you the specifics about her progress this week. In general, we often find that it takes a few weeks for people to be able to turn their eating around and these early days are difficult for everyone'. SNAPSHOT EXAMPLE - MELANIE Melanie, an 18 year old woman, goes to her local GP because she has been feeling tired and exhausted. The GP determines that Melanie's weight has dropped by 5kg, she is underweight and engaging in severe dietary restriction. Melanie explains to the GP that she does not want her parents to know how much weight she has lost, because they have already been expressing their concerns about her weight and it will only make them more worried. The GP communicates her concerns to Melanie about her health. She respectfully explains that Melanie will need the support of her parents. Melanie agrees for her parents to be contacted by the GP and told that her condition is serious but not life threatening, and that Melanie will continue to be monitored by the GP each week. The GP agrees to not disclose Melanie's current weight. At the next session the GP plans to talk to Melanie about her likely diagnosis of an eating disorder, the treatment options and engaging with a multidisciplinary team. The GP also intends on getting consent from Melanie to include her parents in the conversation, or at the very least updating them at the end of the session. The Internet & Social Media The internet and social media are increasingly a source of information about eating disorders, both positive and negative. One particularly damaging area is online communities that promote eating disorders, commonly known as “pro-ana” for pro-anorexia, “pro-mia” for pro-bulimia, “fitspiration”, “thinspiration”, or “thintention”. These sites are often image or blog-based and promote disordered eating patterns as a lifestyle choice. On a more positive note, there are support communities and online support groups, where those affected can ‘talk' with others who experience similar problems. Rules of these sites include avoiding ‘trigger-talk' such as detailed information about weight and restrictive weight loss practices. Interest is also expanding in providing treatment and therapy online and a number of trials are currently underway to utilise this mode of treatment delivery. Kids Help Line state that much of their online support is related to body image issues. This is a medium that young people feel comfortable with – it is easier to ‘type' about thoughts and feelings than to ‘talk'. Challenges for Health Professionals There are enormous rewards associated with assisting someone with an eating disorder in working towards recovery and watching them regain their health. However, this can be very challenging work, particularly for solo practitioners and those in rural or remote settings. Sometimes the struggle to assist someone to overcome an eating disorder can leave clinicians feeling disheartened, sad, unskilled, angry and exhausted. A variety of strategies assist clinicians to avoid the effects of stress and burnout. This will involve taking a proactive approach to developing your knowledge, skills and support networks and will include: bullet Regular debriefing and clinical supervision bullet Accessing telephone support and advice from specialists bullet Undertaking professional development including mentoring or working one-on-one with experienced staff bullet Contributing to development of the treatment plan bullet Avoiding destructive traps such as splitting, rescuing, distancing or overlooking your own needs bullet Increasing skills in handling the emotional aspects of the work bullet Looking after your own emotional needs Transference & Countertransference Because developing a rapport with someone who has an eating disorder can be so hard won, once trust is established, clinicians may feel deeply committed to the relationship. If one considers all the facets of the relationship – warmth, trust, familiarity, empathy, responsiveness, caring, positive regard – it is easy to see why one or other of the parties may become confused about the purpose of the relationship. Neither the clinician nor the client is immune to boundary confusion. ‘Transference' is the process by which emotions and desires originally associated with one person, such as a parent or sibling, are unconsciously shifted to another person, especially to the clinician (from the client). ‘Countertransference' is the surfacing of a clinician's own feelings through identification with the emotions, experiences, or problems of a person undergoing treatment. Countertransference can manifest in a variety of ways, including over- or under-involvement, taking personal affront at perceived failures or flouting of limits by the client. The relationship is then no-longer therapeutic – the client may become dependent on the clinician, or feel burdened by the confusing messages received from the relationship. Power and Control All health professionals working with this group of clients must also acknowledge issues of power and control. Developing a ‘cooperative working alliance' establishes the relationship as being one in which power struggles do not occur. Remember that resistance to change is, in part, owing to the client's perception that s/he must be in control and that relinquishing eating disorder behaviours equates to being out of control. It is damaging and professionally unacceptable to attempt to ‘control' the client rather than help him/her control their own eating behaviours. Clinical Supervision Clinical supervision is an essential component of a practitioner's continuing professional development and is a necessary component of work in the context of a “helping relationship”. It has been variously defined as: “A formal process of professional support and learning which enables individual practitioners to develop knowledge and competence... This involves reflective thinking, discussion regarding professional development issues, case- load, clinical issues, and staff interpersonal issues” (Martin, 2014) An opportunity for “the supervisee to reflect on their clinical practice in order to more fully appreciate the meaning of their experience, to develop their abilities, to maintain standards of practice and to provide a more therapeutic service to their patient” (Consedine, 1995). Clinical supervision provides a safe supportive environment, to explore and reflect on practice; opportunity to develop clinical and professional skills and boundaries to enhance care; assistance in containing stress and protecting against burnout; a setting in which to explore professional conduct, ethics and personal issues. Clinical supervision is not performance appraisal, nor is it ‘therapy' for health professionals. It is consultative, incorporates teaching and education aspects and concentrates on the supervisee's strengths. Key Messages 23 of 25 1 1 Collaborating with the client and, where possible, carers or family members in establishing the treatment plan will be vital. 2 2 Ideally, treatment will be coordinated by a GP and include a multidisciplinary team consisting of a mental health professional and a dietitian with eating disorders experience, with access to specialist services for advice, support and referral as needed/required. 3 3 Non-negotiables should be set at the beginning of treatment (irrespective of whether treatment is in an inpatient or outpatient setting) and should be agreed upon and implemented collaboratively, consistently and in a client-centred way. 4 4 Overarching goals of treatment are generally set around restoring normal eating patterns and behaviours, address any physical consequences associated with the eating disorder behaviours, and addressing any associated psychological, social, family & behavioural problems that may underlie and/or contribute to the disorder. 5 5 Collaborative goal setting is essential. 6 6 Treatment for children and adolescents should be age appropriate, involve the family and carers, and where possible should involve specialists in the field of eating disorders. 7 7 There are numerous ethical and legal issues involved in eating disorder treatment that should be considered by all health professionals. 8 8 Transference and countertransference are common issues that must be addressed. 9 9 Clinical supervision is an essential component of a practitioner's continuing professional development and is a necessary component of work in the context eating disorders Best Practice Treatment There are significant limitations in the evidence base to support effective treatment of people with an eating disorder. The majority of treatment recommendations are based on low-level evidence or expert consensus. Evidence generally exists for the use of: A multidisciplinary team Psychological therapies, and in some instances medications Education, support and rapport building at all stages and type of illness Anorexia Nervosa Evidence for particular psychological treatments in Anorexia Nervosa is limited by small trials with small numbers of participants however the following are supported by evidence: Maudsley Family Based Treatment (FBT) is recommended in the treatment of children and adolescents with Anorexia Nervosa. The findings for FBT with adults are mixed. Individual therapies can be problematic in Anorexia Nervosa when people may have cognitive impairment from starvation, but there is some initial evidence for the use of eating disorders specific Cognitive Behavioural Therapy1, Specialist Supportive Clinical Management2, and the Maudsley Model of Anorexia Nervosa Treatment for Adults3. Motivational Interviewing or Motivational Enhancement Therapy may be useful adjuncts to other therapeutic approaches Bulimia Nervosa & Binge Eating Disorder Then evidence base for Bulimia Nervosa and Binge Eating Disorder suggests: CBT-Enhanced1 or the broader form4 as the first line of psychological treatment Maudsley Family Based Treatment for children and adolescents with Bulimia Nervosa Interpersonal Therapy and Dialectical Behaviour Therapy may be of merit Evidence Based Therapies There are numerous psychological treatments for eating disorders, with differing levels of empirical evidence. Choosing the best approach depends on a variety of issues including the client's presenting features, client's cognitive capacity and ability to undertake the therapy, therapist's experience and expertise, treatment setting, client preference etc. Hackney (2000) identified that ‘technical eclectism' is often required - the idea that multiple techniques and different therapeutic approaches should be used to best respond to a client's mental health problems. Zarbo (2016) refers to “integrative psychotherapy”, which acknowledges that no single psychotherapeutic approach can be effective and appropriate for all patients, problems, and contexts. Keep in mind that even though some of the techniques and questions may appear straightforward or simple, they are specialist therapies that can be very difficult to administer artfully and bring about effective outcomes for the client- particularly in complex cases or where comorbid conditions are present. Clinicians planning to practice in these ‘models' should seek specific training and preferably arrange for supervision by a therapist experienced in the approach as they learn to deliver the treatment. The evidence based therapies for the treatment of eating disorders include: 1 1 Self Help 2 2 Motivational Interviewing (MI) 3 3 Cognitive Behavioural Therapy Enhanced for Eating Disorders (CBT-E) 4 4 The Maudsley Model of Family Based Treatment (FBT) for Children & Adolescents 5 5 The Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA) 6 6 Specialist Supportive Clinical Management (SSCM) for Eating Disorders 7 7 Mindfulness Based Therapies: Acceptance and Commitment Therapy (ACT) Dialectical Behaviour Therapy (DBT) Mindfulness Based Cognitive Therapy (MBCT) Mindfulness Based Eating Awareness Training (MB-EAT) 8 8 Psychotherapy: Interpersonal Psychotherapy (IPT) Psychodynamic Psychotherapy 9 9 Trauma Informed Care & Practice Family Based Treatment for Children & Adolescents Modern family therapy clinicians co-opt the family as the primary source of treatment and, in eating disorders, charge them with the task of re-feeding their child. The assumption is they have a well-developed series of skills and abilities but that as the illness progresses, they have become less able to use them. Family therapy is about making available and making use of those existing (but hidden or forgotten) adaptive mechanisms. The Maudsley Model of Family Based Treatment (FBT) The majority of children and adolescents (under 18) with Anorexia Nervosa or Bulimia Nervosa, as well as some young adults (with a different spectrum of involvement by parents) can be treated in an outpatient family therapy setting with good effect. As such, this is currently the gold standard, first line treatment, for these client groups. It has also been adapted for use for children with ARFID. Most families who have a child with an eating disorder will narrow the range of their adaptive behaviours and unhelpful family dynamics will be magnified by the intensity of the stressful situation. Of course, there are situations where family interactions are harmful and in these instances child protection issues take priority. Eating issues are formulated as creating anxiety and concern within the family and affecting every family relationship and routine, rather than the reverse. The eating disorder becomes the ‘central organising principle' for the family narrowing their capacity to focus on the here-and-now and restricting or ‘freezing' the repertoire of interactional processes they use, diminishing their ability to meet their life-cycle needs and creating a sense of helplessness. How families respond to this level of intrusion of the illness depends on their life-cycle stage and the nature of the family's organisation. What is Family Based Treatment? Lock and Le Grange's (2001) Maudsley model of Family Based Treatment (FBT)1 (based on the program developed by Dare in 1986) is a 12-month program for the treatment of Anorexia Nervosa conducted over approximately 20 treatment sessions over three distinct but overlapping phases. More recently, an abbreviated version of the program, delivered over six months, has been shown to be successful. It has also been shown to be adaptable to Bulimia Nervosa2. A major difference between FBT for adolescent Bulimia Nervosa versus Anorexia Nervosa is the fact that the adolescent with Bulimia Nervosa is encouraged to collaborate with their parents. FBT for Bulimia Nervosa involves 20 sessions over 6 months. Recently FBT has been adapted successfully for use in children with ARFID, although to date there are only case studies in the literature3,4. The 3 Phases of FBT 1 1 Phase 1: This involves the externalisation of the illness and mobilisation of the parents to get them working together to normalise their child's eating by refeeding their child and/or eradicating bingeing and compensatory behaviours. 2 2 Phase 2: This occurs at 90% ideal body weight or when their eating has been normalised and involves a 3 month time period where the adolescent gradually takes control of his/her eating. 3 3 Phase 3: This occurs at full weight restoration and resumption (or commencement) of menstruation (if relevant) and when the child is eating normally without much parental input. This phase aims to redress issues of normal adolescent development. Phase 1 PHASE 1 Weight Restoration and Normalising eating This phase involves several important areas of focus: Explaining the danger of severe malnutrition/ compensatory behaviours Assessing the family's way of interacting and their eating habits Assisting parents to re-feed their child Realigning the child with his/her siblings to form stronger and more age appropriate relationships Most of this phase involves coaching the parents toward success in the weight restoration and reducing bingeing and compensatory behaviours, expressing support and empathy toward the child given her predicament of entanglement with the illness, and realigning her with her siblings and peers. The therapist models an uncritical stance toward the child and will work hard to address any parental criticism or hostility toward the adolescent. THE FAMILY MEAL The therapist holds a family meal to: Observe the family's typical patterns of interaction around eating Assist the parents to encourage the child to eat a little more than s/he was prepared to, through expressing sympathy and understanding of their child's predicament (his/her ambivalence), at the same time being verbally persistent in their expectation that starvation is not an option. In this video, there is a demonstration of the FBT family meal. Phase 2 PHASE 2 Returning control over eating to the adolescent Phase two begins when the child accepts parent's demands to increase nutritional intake, there is obvious steady weight gain or cessation of bingeing and compensatory behaviours and the family mood is more positive and relieved that they have taken charge of the eating disorder. This phase focuses on encouraging the parents to help their child take back control over eating the return of the child to physical health in a way that is in keeping with the child's age and their parenting style Symptoms remain the focus of discussions between clinician and family, but minimising tension, particularly over weight gain if relevant , is encouraged. All other relationship issues or difficulties (day-to-day adolescent or parenting concerns) are now brought to the fore, but only in relation to the effect these issues have on the parents in their task of ensuring steady weight gain and reduced compensatory behaviours. For example, the child might want to go out for dinner and a movie with friends, but parents may insist she have dinner with them and then meet for the movie. Phase 3 PHASE 3 Establishing healthy adolescent identity Phase three begins when the child maintains his/her weight above 95% of ideal and/or when they are eating normally without eating disorder behaviours. Treatment focus starts to shift to the impact the eating disorders has had on the child in terms of his/her capacity to establish a healthy adolescent identity. The therapist reviews the key developmental aspects of adolescents and supports increasing levels of autonomy for the young person. This involves parental boundaries being re-organised to accommodate peers and identifies that they will need to re-organise their life together in preparation for when their child(ren) leave. Externalising the Problem As it is in motivational interviewing and narrative therapy, externalisation is a basic tenet of family therapy. Giving information about the illness and how it commonly appears is helpful in 'labelling the eating problem as a quasi external force taking over their daughter's life which she is unable to resist on her own'. The therapist uses techniques such as speaking about the illness as a separate entity e.g. “So how long have the eating problems been harassing your family?” or gets the family to position themselves around his/her (or an inanimate object e.g. chair) pretending s/he is anorexia; or the family members arrange themselves in the direction that the eating problem wants them to face and look only at the people that the eating problem wants them to look at. Discussing ‘tricks anorexia/bulimia plays' and what ‘place' and ‘role' it has created within the family, helps to re-focus on the disorder as apart from both patient and family. The FBT Team The FBT Therapist: The FBT Therapist has specialised training in the Maudsley model of Family Based Treatment. There are a growing number of trained practitioners around Australia who have skills and knowledge in FBT. bullet The medical practitioner: It is important that there is a medical practitioner involved in the FBT team to ensure that the individual is medically managed. The medical practitioner should have an understanding of the FBT model and work in line with its principles. Support for Families Guide for Parents The book, "Help Your Teenager Beat an Eating Disorder" is useful in helping parents navigate family based treatment. Maudsley Parents Direct your clients' families to Maudsley parents for more information and support for Family Based Treatment SNAPSHOT EXAMPLE - ANDREW You have been seeing Andrew, a 14-year-old boy with anorexia nervosa and his family, 10 year old, Ben, mother, Michelle and father, John, for six weeks. You have undertaken an assessment with the whole family and completed the family meal. The family got on board with the rationale for treatment, and Andrew gained 2 kg in the first three weeks. After weighing Andrew today, you realise that his weight hasn't really changed over the last three weeks. Andrew says that he is eating the same amount. When you meet with the family, you find that only Michelle has attended – Ben and John are absent. Michelle says that Andrew returned to school two weeks ago. Initially Michelle was going in to supervise his meals, but, after a few days it became too tricky to get away from work, so she stopped. Michelle says Andrew seems a lot happier than he was when he started treatment and he is spending a lot of time in his room doing school work. Michelle is still supervising all meals at home and reports that Andrew is finishing “most” of them, although sometimes he doesn't feel like supper, so they skip it. Remind Michelle that the family were able to do such a fantastic job fighting the eating disorder initially, and that it can be hard to maintain the momentum – other parts of life get in the way and it feels so restrictive to be constantly doing meal supervision. However, express your concern about the stalled weight gain and the imperative need for it to get back on track. Ask Michelle what she thinks might be happening, and what the family needs to do to turn things around again. Michelle decides that she should organise supervision of lunch again and may be able to speak to the school to see what supports they may have. She also thinks that Andrew might be exercising in his room and says she is angry at Andrew about this. Reframe this as “Perhaps the eating disorder is getting sneaky and has found ways to reduce Andrew's food intake and increase his exercise”. Remind Michelle that it is currently so, so hard for Andrew to fight back against the eating disorder's urges on his own, and that the family really needs to take over that, by making less room for the eating disorder to act out. Warn Michelle that this could mean that Andrew gets more upset and angry again, but that fighting an eating disorder is hard, and people are not usually happy when they are doing so. Encourage Michelle to ask John and Ben to come to sessions again so that the whole family can be on the same page about fighting the eating disorder, as otherwise it may try to play one parent off against the other in order to break the treatment apart. Cognitive Behavioural Therapy Cognitive Behavioural Therapy (CBT) is effective in the treatment of a wide range of psychological problems, including depression, anxiety, psychosis and eating disorders. Whilst there is less empirical evidence suggesting its effectiveness in Anorexia Nervosa, in the case of Bulimia Nervosa, CBT-E (a specific form of CBT for eating disorders) has been demonstrated to be superior to no treatment, waitlist control, other psychological treatments and medications alone. There is also some evidence for the use of CBT-E in Binge Eating Disorder, What is Cognitive Behavioural Therapy? CBT makes several assumptions about the causes and maintaining factors in psychological disturbance, particularly that thoughts (cognitions) affect how we feel (emotions) and how we act (behaviours). In turn, our behaviours can either reinforce or challenge our thoughts. Unhelpful thinking patterns can cause someone to engage in behaviours that bring relief in the short term, but over the long term are destructive. By intervening and challenging unhelpful thoughts one can alter behaviour, and vice versa, by altering behaviour one can challenge the thoughts an individual has about themselves and the world. So, CBT has two points of intervention - the client's thoughts and the client's behaviours - both are utilised to replace harmful behaviours with new behavioural patterns that are more adaptive, and in the process reduce negative thoughts and the resulting negatively experienced emotions. Cognitive Behavioural Therapy for Bulimia & Binge Eating CBT for Bulimia Nervosa was initially adapted from work in the fields of anxiety and depression and several manuals of CBT-BN were published (e.g. Fairburn et al, 1993). It was shown to significantly reduce bingeing and purging behaviours when delivered in both individual and group format. The cognitive-behavioural model of binge eating in Bulimia Nervosa postulates that binge eating occurs in response to dietary restriction, occurring in the context of negative emotions. The treatment therefore starts with normalising eating behaviours, then addresses unhelpful thoughts and beliefs associated with eating, body weight and shape. CBT-BN was further adapted for use with people with Binge Eating Disorder. It has been shown to be helpful in reducing bingeing, but not necessarily significantly reducing weight, so addressing unhelpful cognitions about acceptable body shapes and sizes, and appropriate weight loss, is important. Research suggests that combining medication and CBT may improve both binge eating and weight loss outcomes for people with BED4. CBT-Enhanced for Eating Disorders “Enhanced” Cognitive Behavioural Therapy for eating disorders, or CBT-E1, is a well-known and empirically-supported treatment, that developed on from CBT-BN. This manualised treatment is "transdiagnostic". That is, it addresses the underlying mechanisms that maintain all eating disorders, although the evidence base suggests it is best for non-underweight individuals. As a treatment, CBT-E is a structured, fixed-length intervention (usually 20 sessions) that begins with an evaluation and general clinical assessment. A case formulation is created and revised based on the individual's progress throughout treatment. Treatment targets the processes that maintain the person's eating problem. Usually this involves addressing concerns about shape and eating; enhancing the ability to deal with day-to-day events and moods; and the addressing of extreme dietary restraint. Multiple research studies have demonstrated the effectiveness of CBT-E with eating disorders both in individual and group format and online programs are being developed. CBT-E Formulation Using the assessment information one can create a formulation i.e. a model of the causative and maintaining factors that may be involved in an individual's eating disorder. A formulation can guide treatment and give clients an understanding of how their eating disorder works. At the end of the initial interview process, it can be helpful to present a formulation to the client. This can then inform the establishment of a joint management plan and assist with early goal setting for treatment. Naturally, formulations differ from client to client. CBT for Avoidant Restrictive Food Intake Disorder Since ARFID is a relatively new diagnosis, there is currently no evidence-based treatment for the disorder, but a specific CBT program, Cognitive Behavioural Therapy for ARFID (CBT-AR) is currently being studied and a manual has been published5. CBT-AR can be offered in an individual or family-supported format and comprises four stages: 1 1 Psycho-education and early change 2 2 Treatment planning 3 3 Addressing maintaining mechanisms (including sensory sensitivity, fear of aversive consequences, and/or apparent lack of interest in eating or food) 4 4 Relapse prevention over 20-30 sessions Core Components of CBT for Eating Disorders 1 1 Self monitoring 2 2 Collaborative weighing 3 3 Establishing a pattern of regular eating 4 4 Establishing alternatives to compensatory behaviours 5 5 Problem solving 6 6 Eliminating avoidance 7 7 Cognitive restructuring 8 8 Relapse prevention Self Monitoring Self-monitoring, in the form of food diaries, a once weekly weigh-in for the duration of therapy and thought monitoring forms, form the foundation of the therapy. It is the means by which the individual brings awareness of the eating patterns, compensatory behaviours and associated unhelpful thoughts, and can bring insight to the vicious cycle of thoughts, feeling and behaviours that are maintaining their eating disorder. Self-monitoring diary cards tailored to the person's presenting problems are the first principle of treatment and some clients show a reduction in target behaviours as a result of self-monitoring alone. These sheets should be the first thing discussed and reviewed at every session – looking in particular for patterns, triggers, effective use of skills to prevent a behaviour and ‘news of difference'. Clients should purchase a folder as their first homework task before beginning CBT, then bring this folder to each therapy session. This is where they will store all of their self-monitoring and therapy worksheets. Clients who are particularly chaotic may take several weeks to get the folder – in which case, the session should still follow the pattern of therapy – i.e. focus on what stopped the person from getting the folder, how they might plan to get a folder, what if the same distraction occurred again etc. This folder can also act as a relapse-prevention resource accessible anytime after treatment if they feel themselves slipping. Collaborative Weighing Why is in-session weighing important? 1. To provide objective evidence to challenge eating disorder thoughts/beliefs Clients will usually believe and have significant anxiety that any changes in eating patterns (i.e. regular eating) will result in excessive/out-of-control weight gain. Collecting regular weight records provides concrete facts to counter these uncomfortable fears and feelings and allows for the testing of predictions about the impact of behaviour change (particularly stopping dieting and engaging in regular eating) on weight 2. People with bulimia and binge eating problems tend to either weigh themselves excessively (sometimes multiple times per day) or avoid weighing all together but still remain highly concerned about weight. Some people oscillate between the two extremes depending on what their eating patterns are like at the time. Both extremes work to maintain the eating disorder. Excessive weighing, measuring and looking in the mirror, tends to increase the persons concern and preoccupation with their weight and shape as the person finds being privy to the normal fluctuations of weight very distressing and by sheer frequency of checking weight, this reinforces an over-valuing of weight and shape Avoiding weighing tends to increase the persons concern and anxiety about what their weight might actually be. Although they are not checking their weight, they may still be spending a great deal of time thinking about their weight, seeing it as a defining part of who they are, or worrying about what the number on the scale might be, and what that would mean for them . Regular weighing aims to create containment around frequent weight checking or fear/avoidance of body weight, in order to reduce the persons focus on weight as an important aspect of their identity . It allows for a reduction in avoidance/increased exposure to the person's feared stimuli (i.e. the number on the scales) . It also helps the person desensitise to, and begin to question the importance of, the number on the scale. Weighing also serves a function for you as part of reviewing your client's physical health status Session Tip: People with eating disorders tend to think their whole value as a person equates with a number they see on the scale. This is why separating the person from that number and the process of weighing can be a valuable part of treatment. Establishing a pattern of regular eating Dietary restraint or restriction, and associated compensatory behaviours are core target behaviours in CBT for eating disorders. It is hypothesised that in Bulimia Nervosa the strict dietary rules and restrictions lead the person to engage in episodes of overeating (bingeing) and in turn to purge after these episodes. Not until the person has accepted that the dieting itself, instead of being a solution to the problem, is in fact part of the cycle, and a pattern of regular eating has been established (e.g. 3 meals and 2-3 snacks a day), can s/he successfully start to reduce episodes of bingeing and vomiting, and begin to normalise their thoughts about what regular eating does to weight and shape etc. After a lengthy period of stable regular eating, the person will learn to tolerate and interpret and appropriately respond to hunger signals. In the early stages of treatment, when the person is engaging in bingeing, look for dietary restriction as a precursor or trigger to bingeing. Often a simple re-establishment of the 3 hour rule – where the person must eat every 3 hours whilst awake - will reduce binges and help commence nutritional rehabilitation in underweight people. It can be a difficult task to convince a person with an eating disorder that the activity that she has engaged in for many years (dieting), which she believes is the only thing saving her from ballooning outward, or losing control, is actually the problem! Good psycho-education is an integral part of treatment, as is repetition of the key facts, and often it will be necessary to ask the client to engage in a short-term experiment with you (i.e. behavioural experiment) and see what happens when she begins to eat regularly. In bulimia and binge eating, normalising eating usually reduces the frequency of binge episodes which a client will usually be happy about. Be aware though that in anorexia, effective treatment leads to the very thing the individual is afraid of, weight gain, which is a complicating factor. Establishing alternatives to compensatory behaviours Often food serves a number of functions for the person. Emotions that frequently come up in therapy as having preceded a binge are ‘loneliness' or ‘boredom' or ‘rejection'. Some binges seem more biological in nature (e.g. in response to restriction) while others appear to serve an emotion regulation function. Broadening the person's behavioural repertoire, giving them other things to engage in other than bingeing, and developing other ways to deal with their emotions, forms an integral part of treatment. In non-bingeing people, it is important to help develop alternatives to meet the needs that the eating disorder behaviours like restriction or excessive exercise might currently be meeting for them e.g. a need for a sense of control might be met through restrictive eating. In CBT the therapist would work on questioning the validity of the control that the eating disorder apparently serves, and examine why the individual was seeking that feeling and look for alternate ways of meeting that need. Problem Solving Eating disorder behaviours tend to increase during periods of stress and one of the recurrent prompting events for behaviours is interpersonal conflict. Problem solving strategies are designed to assist the person to develop methods for solving interpersonal and other difficulties in their life without resorting to bingeing and/or restriction as a way of managing these stressful times. When teaching this part of the program it is useful to use problems that have actually been leading to binges or other eating disordered behaviours in the early part of therapy – workshop them, discussing them in detail. This is when detailed self-monitoring sheets become useful, and is why all self-monitoring sheets should be kept and be producible at every treatment session. Eliminating avoidance People with eating disorders by definition: Avoid eating particular foods - feared foods, often those with high energy content like chocolate, plus protein and carbohydrates Avoid their bodies - specifically allowing others to see their bodies, participating in activities involving exposure e.g. going to the beach, and at times, even looking at or touching their own body Avoid social eating occasions Avoid eating new foods Using the principles of exposure people are encouraged to reduce avoidance, and by doing so challenge their underlying beliefs about what will happen if they eat a certain food, or show their body in public. Cognitive Restructuring Relapse is associated with persistent unhelpful thoughts about body, weight and shape, hence the importance of cognitive restructuring even in the absence of bingeing or vomiting (which can sometimes occur early in therapy) is paramount to a successful and sustainable outcome. Self-monitoring and thought monitoring sheets will help the client (and therapist) identify recurrent unhelpful thinking patterns and these should be actively challenged in session, for homework and during review. This skill combined with cleverly designed behavioural experiments is vital in challenging the person's body, weight, shape and food beliefs. Many texts talk about ‘faulty' or ‘maladaptive' thinking but it is preferable to stay away from these terms in clinical practice - they can reinforce a person's negative beliefs about themselves, which is the exact opposite of what restructuring is designed to achieve. Unhelpful thinking or eating disorder thoughts are preferred terms i.e. the goal is only to challenge the unhelpful thoughts, not to change who s/he is, or to alter thinking patterns that have obviously helped him/her survive and cope for all these years. This skill comes naturally to some and is a real battle for others – some clients have no access to their thoughts at all. Younger clients can find this particularly difficult (note: Maudsley family therapy, not CBT, is the treatment of choice for adolescents). If your client has identified a specific time that they binged/restricted but cannot access the thoughts that went through their mind at the time, ask them to jump directly to the challenge i.e. get them to write down the prompting event in detail, leave the thought column blank and then write down something they know they could have said to themselves or something they wish their best friend had come up and said to them at the time that would have made them feel better, and perhaps prevented the binge. From identifying what would have made them feel better you can usually work backwards to work out what the unhelpful thought must have been. Essentially, you have to be creative and persistent when teaching cognitive challenging. RELAPSE PREVENTION Relapse generally occurs during the first 4 months after CBT, affecting about 30-40% of patients – with a greater risk of relapse in those whose motivation during treatment was low, vomiting frequency was high and eating was extremely ritualized. Planning for relapse must occur before the end of therapy – contingency plans for difficult times should be developed and methods for preventing relapse must be discussed. The relapse prevention plan should consider in detail: Times of high risk Early warning signs that old behaviours or thoughts are creeping back Plans to combat warning signs Discuss the difference between a lapse and a relapse – how would the person deal with a setback? How would they take the necessary steps to get back on track. View lapses as an opportunity to learn. Looking back over treatment and reviewing thought diaries and behavioural experiments, problem solving and so on, can be useful way to analyse what has been helpful and what has been difficult. It can also help to highlight favourite tools and techniques. A maintenance plan will identify the behaviours that have been helpful in making changes and how disturbed eating and weight control behaviours were minimised. The addition of fluoxetine (a SSRI antidepressant) has been shown to reduce relapse rates and improve outcome. Mindfulness Based Therapies There are numerous 'third-wave behaviour therapies' which are mindfulness-based strategies, using a range of techniques to regulate emotions and behaviours which are used in the treatment of eating disorders. Mindfulness based therapies include: 1 1 Acceptance Commitment Therapy (ACT) 2 2 Dialectical Behaviour Therapy (DBT) 3 3 Mindfulness Based Cognitive Therapy (MBCT) 4 4 Mindfulness-Based Eating Awareness Training (MB-EAT) Acceptance Commitment Therapy (ACT) From an ACT theoretical perspective, disordered behaviour is understood as an attempt by the person to avoid or escape internal experiences, cognitions, emotions, urges and sensations which are aversive. The goal of ACT is to treat emotional avoidance, reactivity to cognitive content and the inability to make and keep commitments to behaviour change through acceptance of unwanted thoughts and feelings and increasing psychological flexibility. ACT uses CBT techniques (exposure, guided questioning) but focuses on different aspects of the story and pursues a different treatment goal. The skill is in the person's ability to observe cognitions without judgement and with acceptance, rather than engaging with disordered behaviours in reaction to them. In order to move in the direction of one's values, good nutrition is generally required. However, the focus of the intervention is not the behaviour changes required for good nutrition, it is in clarifying the person's most valued goals and directions. The vision is then how to move towards making choices based on values rather than an attempt to control one's emotions. There are six key elements to Acceptance and Commitment Therapy: 1 1 Defining values – how the person wants to live in the world. 2 2 Present moment – living in the here and now (i.e. mindfulness). 3 3 Cognitive Diffusion – seeing thoughts as thoughts (as opposed to seeing them as unavoidable truths). 4 4 Self as context – developing a sense of spiritual self. 5 5 Acceptance – embrace unwanted thoughts and feelings as an alternative to experiential avoidance. 6 6 Committed action. Dialectical Behavioural Therapy (DBT) Experiencing overwhelming emotions that are difficult to deal with are frequently the catalyst for the introduction of dieting practices, binge eating and/or purging behaviours. As a process, starvation has a very simplifying function i.e. the person concentrates on restriction and compensatory behaviours, rather than on the emotions or situations they find difficult to manage. Binge eating and purging can be a way of ‘numbing' out emotions, of swallowing anger or coping with boredom or loneliness. DBT aims to help people to manage overwhelming emotions through techniques addressing mindfulness, interpersonal effectiveness, emotional regulation and distress tolerance. The therapy is conducted over 20 weeks in individual or group settings and focuses on helping the person develop skills that help them to remain in control of their body and mind, to cope with interpersonal difficulties, tolerate stressful situations and regulate their emotions. The main goals of treatment are: 1 1 Gaining control over emotions and behaviour 2 2 Experiencing emotions fully (rather than emotionally shutting down) 3 3 Improving the quality of relationships 4 4 Working with feelings of emptiness, targeting self-destructive behaviours Mindfulness-Based Cognitive Therapy (MBCT) MBCT is a manualised therapy, originally developed to prevent relapse from depression. It has been adapted for use in people with Binge Eating Disorder (BED). Held over ten sessions, MBCT utilises a number of mindfulness practices that cultivate non-judgemental and non-reactive observation and acceptance of perceptions, cognitions, emotions and bodily sensations. The objective of therapy is for participants to increase their ability to: bullet Observe internal hunger and satiety cues bullet Increase their willingness to experience negative emotions (which might have previously triggered binge eating episodes) bullet Decrease the believability of negative thoughts bullet Increase the person's capacity to choose adaptive behaviours under stressful circumstances Mindfulness-Based Eating Awareness Training (MB-EAT) Mindfulness-based eating awareness training (MB-EAT) integrates elements of Mindfulness-Based Stress Reduction (MBSR) and CBT with guided eating meditations. Traditional mindfulness meditation techniques and guided meditation address issues surrounding body shape, weight, appetite, cravings, hunger and satiety as well as overeating and binge eating. The aim is to raise awareness of physiologically-based hunger and satiety cues, as well as the automatic patterns and undesirable reactive behaviours that are occurring. Each session includes meditation practice (and mini-meditations to be practiced at meal/snack times) and several eating-related guided meditations. Therapy includes: bullet Mindful body work: body scan, self-soothing touch, mindful walking bullet Making mindful food choices bullet Non-judgemental attention on sensations, thoughts, emotions as they relate to hunger, satiety and binge triggers bullet Forgiveness meditation – focus on body and self bullet Wisdom meditation – emphasising capacity for wiser choices. Components of Mindfulness Based Therapies 1 1 Mindfulness 2 2 Emotion Regulation 3 3 Distress Tolerance MINDFULNESS Mindfulness is a form of self-awareness training adapted from Buddhist mindfulness meditation. It is a state of being in the present, accepting things (thoughts, emotions, behaviours) for what they are without judgement. This is not the same as ‘relaxation' or ‘positive thinking'. In an eating disorders context, when people are mindful and aware, they are more likely to make adaptive choices and regulate their emotions using distress tolerance skills rather than engaging in disordered eating behaviours. The nice part about mindfulness is that because it finds its roots in spirituality, this can be an enriching focus for people who are recovering from an eating disorder. EMOTION REGULATION Emotion regulation is a term used to describe a person's ability to effectively manage and respond to an emotional experience. It is a key component of DBT. Skills training in emotion regulation is particularly useful for people who find their emotional experiences to be overwhelming and who engage in unhealthy behaviours to regulate their emotions. Skills training can help people understand the function of emotions, the behavioural urges that stem from emotions, and whether to heed or oppose these urges. It is common for one or more strong emotions to emerge when an individual engages in eating disorder behaviours. These include guilt, sadness, feeling overwhelmed or frustrated, anger, self-blame, and low self-worth. Eating disorder behaviours can serve as unhealthy attempts to cope with overwhelming negative emotions. These strategies, however, are ineffective over the long term in that they only provide short term relief, and are often followed by negative outcomes. Skills training in emotion regulation includes: learning to accurately label and acknowledge emotions, working on strategies to reduce emotional vulnerability, building in opportunities for positive experience, and working to decrease emotional suffering by letting go of emotions and acting in opposite ways to lessen the intensity and duration of the emotion. DISTRESS TOLERANCE Distress tolerance is a skill which can be particularly useful for people who use food to punish or control themselves by eating too much, not eating at all, or by throwing up what they do eat. Distress tolerance includes techniques such as: distraction (as opposed to avoidance) which allows time for the emotional intensity to subside and provides the person with an opportunity to find alternative coping strategies; and self-soothing strategies which help the person to treat themselves with compassion and to bring peace or relief from psychological or physical pain Once distraction is being used, self-soothing or relaxing strategies help the client to manage overwhelming emotions. Different things will work for different people and experimentation with these techniques is to be encouraged. Simple self-soothing can be approached across all five senses listed below. Supportive Specialist Clinical Management (SSCM) SSCM is described as an active non-specialised treatment for Anorexia Nervosa. It was designed as a comparative treatment in a clinical trial of outpatient therapy for adults with Anorexia Nervosa. Surprisingly to the authors, SSCM was superior to Cognitive Behavioural Therapy (CBT) and Interpersonal Therapy (IPT) at the end of treatment, although in the longer term the results were equivalent . SSCM has two distinct components: Clinical management: includes a persistent focus on giving information, advice and encouragement, to help restore weight, normalise eating and reduce symptoms Supportive psychotherapy: involves addressing general life issues which the client identifies as important. Unlike CBT, this treatment model is not based on a psychological formulation or theory, rather it uses a very practical and supportive approach. Phases of SSCM treatment SSCM is divided into three phases. Sessions are held weekly for 20 sessions, but flexibility in the frequency and duration of treatment is permitted. Phase 1: orientation to SSCM, collaborative identification of target symptoms and agreed goals for weight gain and normalising eating. Phase 2: the ongoing monitoring of target symptoms and support/encouragement. Phase 3: discussion of issues related to termination and planning for the future. There is a requirement that the client must stay medically stable throughout treatment. Medical status is evaluated throughout via weigh-in's and blood test monitoring in addition to the delivery of nutritional education and advice. Generally however, the clinician responds to the client's presentation and concerns flexibly and without specific agenda. The main focus and goal of treatment is on improving quality of life. Better physical health generally helps improve overall quality of life, thus, weight restoration, eating, food and overall health are addressed in a way that may be experienced as far less threatening for the client. Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA) The Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA)1 is a manualised treatment aimed at addressing the obsessional and anxious traits central to the illness. It draws on a range of therapeutic approaches including motivational interviewing, cognitive remediation and carer involvement1. Psychotherapeutic interventions are the treatment of choice for AN, but the results from studies examining CBT, which is useful in BN, are not very impressive. Hence, researchers and clinicians are developing and testing novel approaches specifically for Anorexia Nervosa in adults. MANTRA was specifically developed based on a maintenance model of Anorexia Nervosa. It is a cognitive-interpersonal treatment for adults with Anorexia Nervosa that considers both the biology and psychology of the disorder and how these factors interact to maintain the illness. MANTRA is a stand-alone treatment for Anorexia Nervosa that when delivered weekly can take between 20 to 30 one-hour sessions, depending on illness severity. The treatment model draws on recent neuropsychological, social cognitive and personality trait research in AN. It is modularised with a clear hierarchy of procedures and is tailored to the needs of the individual. A large randomised controlled trial showed MANTRA and Specialist Support Clinical Management to have equivalent results2. The model proposes that AN commonly arises in people with the following psychological temperaments: bullet Anxiety bullet Sensitivity bullet Perfectionism bullet Obsessionality AN in then maintained by four factors, which are all intensified by starvation: 1 1 Thinking style that is inflexible, detail focused, and perfectionist 2 2 Altered emotions and relationships: impairments in the socio-emotional domain (e.g altered regulation of emotions, particularly with regard to close relationships) 3 3 Valued nature of the Anorexia: beliefs about the positive function of AN in their lives e.g providing structure, control, safety, expressing distress 4 4 The role of carers: family members and partners may maintain AN by accommodating to the illness, enabling behaviours and/or having high levels of expressed emotional distress Motivational Interviewing Ambivalence is a core feature of the expression of eating disorders, particularly because the illness serves a function which is useful to a point – protecting the person from difficult personal, interpersonal and/or social situations. Motivation to change can be lacking and an important role of all clinicians is to assist clients to move towards increasing their motivation to change, so that treatment is more likely to be effective. Motivation based therapies have been adapted to eating disorders and appear best used as an adjunct to other psychotherapies. Motivational based therapies can also help develop the therapeutic relationship. Motivational Interviewing (MI) or Motivational Enhancement Therapy (MET), originally developed by Miller and Rollnick (1991) aims to help clients recognise their problems and to resolve ambivalence regarding change so that they can move towards recovery. Lack of readiness to change and poor or greatly fluctuating motivation is a symptom of eating disorders, not a deliberate ploy to make clinician's lives difficult - hence engaging and maintaining clients in treatment requires skill. Motivation is an important predictor of change in eating disorders and baseline motivation at the start of specialist treatment is a powerful and consistent predictor of outcome. If change is to occur, clinicians must work towards improving motivation in this client group. This is particularly important for clinicians working in primary care or private practice who are likely to see people in the early stages of illness although motivational levels fluctuate throughout the course of the illness. The aim is to work with the person, to encourage an increase in motivation to change, in order that the person will step off the downward trajectory before the disorder becomes entrenched and difficult to address. Not surprisingly, higher levels of readiness to change have been positively correlated with positive behaviour change across a range of problems and in eating disorders, reduce the likelihood of treatment drop out. Treatment is less likely to succeed where the treatment approach differs from the persons' stage of change. Seeking specific specialist training in Motivational Interviewing or Motivational Enhancement Therapy is highly recommended for those interested in using this approach. Principles of Motivational Interviewing 1 1 Express empathy 2 2 Develop discrepancy 3 3 Avoid argumentation 4 4 Roll with resistance 5 5 Support self-efficacy 6 6 Elicit self motivational statements 7 7 Use basic counselling skills: Open ended questions, reflective listening, affirming and summarising Express Empathy Empathy entails seeking to understand the client's feelings and perspectives without judging, criticising or blaming. Importantly, accept the client's ambivalence regarding change (or reluctance to change) as a normal part of human experience and that reluctance to give up problem behaviours is to be expected. Empathy can be difficult to sustain, so it is important to engage in procedures that will enhance empathy - specifically: Appreciate the high degree to which the person values the symptoms and how much their identities are linked to nurturing thinness. bullet Fully appreciate the desperation that drives behaviour – profound inadequacy, fear, hurt, extraordinarily unhappiness with them-self and their situation. bullet View resistance as an understandable response to the threat posed by treatment, rather than viewing clients as manipulative, deceitful or hostile. bullet Acknowledge the difficulty of change – we are asking someone to change something they may not fully want to change, when they are terrified of losing control and when they don't yet trust you. Develop Discrepancy There is a need to develop a discrepancy between the client's current symptomatic behaviour and their goals - a discrepancy between where one is and where one wants to be. Discrepancy can be triggered by an awareness of the disadvantages of current behaviour. However, clinicians must begin by asking about the advantages of current symptoms - showing interested in all of the consequences of living with the eating problems engenders trust and clients tend to be more candid in divulging drawbacks. Tipping the balance, so that the person comes to see the disadvantages outweighing advantages, requires that the client (not the clinician) present the reasons for change. They will be more persuaded by what they hear themselves say than by what other people tell them. However, if the eating disordered client concludes that, after considering all of the perceived advantages and disadvantages of the disorder, that the status quo (i.e., the maintenance of the disorder) truly is in his/her best interests, then you may need to enhance motivation to change. Avoid Argumentation Direct argumentation and head-to-head confrontations tend to evoke resistance from people. That is, arguing results in clients asserting their freedom to do as they please. “The more you tell someone ‘You can't', the more likely she or he is to respond ‘I will'” (Miller & Rollnick, 1991, p. 58) Roll with Resistance As an alternative to arguing, use ‘rolling with resistance' whereby statements made by the client are not rejected (as in argument), but are reframed slightly to create a new momentum towards change. New perspectives are invited but are not imposed. Rolling with resistance includes involving the client actively in the process of problem solving by frequently turning questions or problems back onto him/her. The clinician who attempts to generate all of the solutions allows the client to dismiss each idea with ‘Yes, but ...'. There are several strategies for rolling with resistance including double-sided reflection, emphasising personal choice and reframing information. Support Self-Efficacy Self-efficacy refers to the client's “belief in his or her ability to carry out and succeed with a specific task” (Miller & Rollnick, 1991, p. 61). If the client perceives no hope for change then no effort in the direction of change will be made. To enhance self-efficacy: Highlight past experiences of success to increase confidence in ability to change. bullet Discuss life before the onset of illness - proof that survival without the eating problem is possible. bullet Developing an internal locus of control i.e. assuming personal responsibility for change - is essential. bullet Setting small steps instils confidence in the possibility of change. bullet Talk about or with people who have overcome similar problems. Enhancing self-efficacy is particularly important for clients with chronic illness where treatment failures may have diminished hopefulness regarding the chances of treatment being effective. To enhance commitment to treatment, encourage clients to note any differences they have experienced which may increase the likelihood of the current treatment being effective. Eliciting Self-Motivational Statements One of the main skills utilised in motivational interviewing (and one which distinguishes it from many other approaches) is to elicit self-motivational statements from the client. Here, it is the client (rather than the clinician) who presents the arguments for change. The practice of clinicians stating the reasons for change tends to encourage clients to express the other side of their ambivalence (i.e., reasons for not changing). There are several categories of self-motivational statements: Problem recognition: “I guess my focus on weight might be interfering with my relationships more than I thought” bullet Expression of concern: “I'm really worried that my eating could be affecting my health” bullet Intention to change: “I've got to get on top of the eating problem before it permanently ruins my life” bullet Optimism about change: “I really think I can put on the weight this time” Basic Counselling Skills Basic counselling skills should be employed throughout treatment including the use of open-ended questions, reflective listening, affirming and summarising. OPEN ENDED QUESTIONS Asking open-ended questions results in the client doing most of the talking, which provides the client with an opportunity to explore the problem more fully, including both sides of their ambivalence. For example: “Tell me about your current weight." "What do you like about it?" "What are your concerns?” REFLECTIVE LISTENING Reflective listening focuses on the way in which the clinician responds to the client's statements. In reflective listening, the clinician feeds back to the client what he/she has just communicated. In deciding what to reflect back and what to ignore, particular emphasis is placed on any self-motivational statements made by the client. Clinician responses, which prevent the client from continued exploration, are to be minimised e.g. giving advice, agreeing or disagreeing, interpreting, or changing the subject. AFFIRMING AND SUMMARISING Statements of affirmation help to create an environment in which the client's attempts at exploration are encouraged. Affirming the difficulty of change is particularly important. Repeatedly summarising the client's self-motivational statements is helpful, as this provides clients with the opportunity to hear their own self-motivational statements several times. For example: “So far you've said that you're worried that your dieting may be affecting your health, that it makes you feel tired and that it makes it hard to have a good time when you go out. Is there anything else?” Traps to Avoid in MET/MI Confrontation-Denial – The most important interview trap to be avoided in MET/MI is that of confrontation-denial. In this trap, the clinician discusses the negative aspects of the problem, which is then met with resistance by the client. Clinician confrontation being met with client denial is predictable given the state of ambivalence experienced by most clients with eating disorders - if the clinician argues for one side of the ambivalence the client will voice the other side. Question-Answer Trap – In the question-answer trap, the clinician asks questions requiring simple yes/no responses which discourage open exploration by the client of both sides of his/her ambivalence while also encouraging the clinician to take an active role and the client to take a passive role. Expert Trap – The expert trap (in which the clinician conveys the impression of having all the answers) similarly places the client in a passive role, inconsistent with the basic tenets of motivational interviewing (i.e. giving people the opportunity to explore and resolve ambivalence for themselves). Labelling – The practice of labelling may also need to be avoided since the negative connotations associated with any diagnostic label may evoke resistance from the client. Discussing ‘eating problems' or ‘troubles with dieting' is preferable to most people than asking about ‘the anorexia' or ‘the bulimia'. Premature Focus Trap – Finally, the premature focus trap should be avoided. This trap involves the clinician focusing on the core eating disordered symptomatology prematurely, while the client is more interested in discussing wider concerns (e.g., depressed mood, family conflicts). Resistance may result if the clinician and client wish to focus on different topics. SNAPSHOT EXAMPLE - AMARA You are finding treatment with Amara so frustrating. You have been trying to undertake CBT for bulimia nervosa, but Amara just isn't doing the homework. How can you figure out the patterns that need breaking down if she isn't monitoring her food intake? Despite all your discussions with her about how dangerous bingeing and purging is, she just doesn't seem to be getting on board. CBT is an active treatment and requires the client to be somewhat motivated to do the work. Consider pivoting from CBT for a while to engage her in a motivational approach. A way of introducing this might be to ask: "Amara, you keep coming here every week, but you don't seem too keen to do the homework or the tasks of therapy. Perhaps you are unsure or scared about whether you can or want to make changes to your eating right now?" This gives Amara permission to discuss her concerns and ambivalence. If she says that she is not at all motivated, you could respond with: "And yet, for some reason you come here each week…. I'm wondering whether there is a part of you, even if it is only 1% that wants to be rid of this eating disorder?" This line of discussion will help open up the dialogue and give you a shared understanding of Amara's position. This will help you collaborate to set more realistic goals around treatment progression. Psychotherapy Psychotherapy, undertaken with a psychotherapist, is a long-term therapy which works with the personality structure and the underlying causes of behaviours. Psychotherapy is a dialogue-based therapy or a ‘talking' therapy, based on concepts such as ‘the unconscious', ‘splitting', ‘projection' and ‘transference'. It aims to increase the individual's sense of their own inner wellbeing. Psychotherapy is the development of a therapeutic relationship within which clients can profitably explore difficult, often painful, emotions and experiences such as anxiety, depression, trauma, or perhaps the loss of meaning of one's life. It is a process that seeks to help the person gain an increased capacity for choice, through which they become more autonomous and self-determined. Psychotherapy may be provided for adults, children, couples, families and in groups. A Psychotherapist works with people who have emotional, behavioural, psychological or mental health difficulties. The primary aim is to encourage the client to talk and explore their feelings, beliefs and thoughts, and, sometimes, relevant aspects of and events in their childhood and personal history. Some psychotherapists work to help the person understand more about their problems and then make appropriate changes in their thinking and behaviour. As a result, therapy can continue over quite a long term. There are a great number of different psychotherapeutic approaches, including: 1 1 Interpersonal Psychotherapy (IPT) 2 2 Psychodynamic Psychotherapy Interpersonal Psychotherapy (IPT) While recognising biological and psychological issues associated with aetiology and vulnerability to the mental health problem, IPT considers mental illness occurs in a social context, which has interpersonal antecedents and consequences, and as such, focuses on interpersonal problems (rather than cognitive aspects) and social factors. IPT is a time limited, manualised psychotherapy. Interpersonal relationships are the intervention point and symptom alleviation is the goal. IPT has been shown to be successful in the treatment of people with Bulimia Nervosa, over the long term. Interpersonal Psychotherapy has been shown to be effective in Binge Eating Disorder. There is evidence supporting the use of IPT in Bulimia Nervosa1,2, Binge Eating Disorder3-5 and, to a lesser extent, Anorexia Nervosa6,7. THE FOCUS OF IPT The focus of treatment is on here and now functioning with regard to interpersonal problems in one of four areas: Grief - facilitating mourning & moving on Role disputes - clarifying the situation, modifying expectations & repairing faulty communications leading to adaptive resolution Role transitions - mourning the loss of the old role, restoring self esteem & moving on to new role Interpersonal deficits - reduce loneliness and social isolation encouraging formulation of new relationships Interpersonal Psychotherapy involves: bullet Directive and non-directive exploration bullet Clarification bullet Encouraging the expression of affect (e.g. guilt, shame, anger, sadness) bullet Communication analysis: identify & modify unhelpful communication styles (e.g. sulking, being silent, self-harming, assuming people know how you feel) bullet Reflection on the therapeutic relationship, perhaps as an indicator of the way the person communicates in their lives more generally bullet Behaviour change techniques (e.g. structured problem solving) Dealing with resistance (e.g. arriving late, missing appointments, being silent, discussing irrelevant material) Psychodynamic Psychotherapy From the psychodynamic psychotherapy perspective, eating disorders are symptomatic expressions of unresolved psychological conflicts8. Early experiences impact on: bullet Development of the self bullet Emotion regulation bullet Coping skills Our understanding of ourselves, others, the world bullet How we get our physical needs met bullet How we get our relationship needs met Conflicted early relationships can cause people to have distorted views of themselves or others, or to find it difficult to regulate their moods or emotions. In eating disorders, early relational conflicts leads to self-reliance for reward, security, comfort and pleasure. The disordered eating behaviours enable avoidance of interpersonal needs and conflicts and self-regulation of distressing emotions. Psychodynamic psychotherapy treats the underlying condition, conflict or cause, not the symptoms of the illness. It is through the resolution of what underlies the symptoms, that true change becomes possible. The Key Concepts of Psychotherapy The following key concepts are used in psychotherapy: 1 1 The unconscious 2 2 Transference 3 3 Countertransference 4 4 Projection 5 5 Splitting 6 6 The "Frame" THE UNCONSCIOUS The metaphor of the iceberg is useful in understanding the conscious and unconscious mind. Just like the iceberg, that which is visible above the surface (the conscious) is relatively small when compared with the huge and powerful part, unseen below the surface (the unconscious). Sigmund Freud's theory purports that the unconscious mind is a reservoir of feelings (usually unacceptable or unpleasant), thoughts, urges, memories and dreams, which are outside of our conscious awareness and which influence our actions and thus, our experiences. Freud believed that the instinctual, unconscious forces of the ‘id' (which is pleasure seeking and destructive) and the ‘ego' (the executive function providing sense of self, dealing with the outside world and internal conflicts) are present from birth and that they contribute to the shaping of the personality. The ‘superego' or conscious is developed through socialisation by family and society and includes values, prohibitions and ideals. The purpose of psychoanalysis is to make the unconscious conscious, so that the individual can gain better control over their thoughts, feelings, behaviours and experience of life. TRANSFERENCE Transference occurs when someone transfers feelings, beliefs, behaviours or thoughts that occurred in the past to a situation that is happening in the here and now. In psychotherapy, the client transfers their unconscious thoughts, feelings or beliefs about someone in their past, to the therapist; conflicts or unresolved difficult emotions around that relationship will also be transferred. Some of the issues associated with transference may include sibling rivalry, issues with authority, anxiety or dependence. The client brings these unresolved issues into the relationship with the therapist and this might be displayed by lack of cooperation, contempt or hostility, deference or submissiveness. Transference can be triggered for a number of reasons, including how the clinician looks, their manner, age, the way they speak, their attitude or approach. A client's self-awareness is reduced as a result of transference, so helping them to identify the issues, determining how to manage the thoughts, emotions and feelings and working out how they impact on what is happening in the present is all part of therapy. COUNTERTRANSFERENCE Countertransference is very similar to transference, but refers to the therapist projecting his or her feelings, beliefs, or thoughts from the past onto the client. It can be helpful in therapy as acknowledging one's own response to the client can provide important information for the therapist about the client's interpersonal interactions outside of the therapy room. It can also be useful to help us think about what the illness may be communicating for the individual and to help hone therapist empathy. However, if not acknowledged or recognised, countertransference can get in the way of therapy e.g. a therapist who feels kindly and protective towards a client because they remind them of their loved aunt, may avoid challenging them, due to their own need to be liked by the client. PROJECTION Projection (like denial, repression, regression, sublimation, rationalisation and intellectualisation) is a ‘defence mechanism' – the purpose of which is to assist the ‘ego' to mediate anxiety. Unacknowledged feelings, thoughts and qualities (like shame, fear, disgust) are avoided by projecting them onto other people. Usually, the tendency is to see one's own distress through others. For example, a woman with a lump in her breast might exclaim ‘I don't like the look on your face, you look very concerned' when the fact is that she suspects she may have a cancer and is very concerned for her own wellbeing. Or, where a man feels that a colleague doesn't like them, when in fact, he is the ones who does not like the colleague. It is far more acceptable to witness these negative emotions in others than to admit to them ourselves. Projection protects us from confronting difficult feelings and helps us to reduce anxiety. The purpose of therapy is to understand what is being projected and why, to acknowledge and take ownership for one's own ‘stuff'. SPLITTING ‘Splitting' is a complex psychological phenomenon, whereby the internal conflict of someone who has experienced a trauma renders them unable to hold opposing concepts. This presents the survivor of an abuse or trauma as experiencing difficulties with forming or maintaining relationships of any kind, but particular therapeutic relationships. ‘Splitting' may show itself in how the person idealises or devalues individual team members – they will be considered all good, or all bad e.g. ‘you are the best nurse I've ever met…nobody else here understands me the way you do', and ‘she is the worst doctor I've ever had, she is so rude and uncaring'. Ultimately, a client cannot ‘split' a team – but a team can allow itself to be split. Communication between clinicians, working consistently and non-judgementally with the client, ensuring a plan is developed and that all members of the team stick with it – all help to maintain a structured and contained environment where the client feels safe and the team remains cohesive. THE FRAME The “frame” is the environment of therapy. It includes the physical situation, the emotional interaction, the therapeutic structure, and the therapeutic relationship. A secure frame is a safe space for the therapy to occur, in which the emotional and physical environment is structured, contained, safe and supportive. Psychodynamic therapists believe that the secure frame is a vital element of the therapy. Self-Help & Guided Self-Help Self-help is an accessible and affordable type of treatment. As a first step in a stepped-care approach, self-help, in the form of written materials, manuals or an online program, can be helpful and are useful for some people in the early stages of developing eating disorders and for those with Bulimia Nervosa and Binge Eating Disorder. There is currently no evidence that self-help is useful for Anorexia Nervosa. Self-help interventions entail the independent use of a treatment manual or protocol following step-by-step instructions contained in a book or via a web-based system. There are two crucial components of self-help: 1 1 The materials must be structured and described in sufficient detail that the person can work through the treatment method independently. 2 2 The aims of the program should be to increase the person's knowledge about the issues and equip them with the skills they will require to self-manage the problems.Self-help interventions can range from purely self-directed strategies (pure self-help) to treatments involving varying degrees of professional contact. It can be provided in addition to sessions with a health professional (supported self-help) or it can be worked through together with a health professional (guided self-help). Formats include written materials (work books, manuals, handouts), video tapes, audio tapes, or now more commonly computer-based materials (online programs) and the provider support can be given face-to-face or via telephone or the internet. There is mounting evidence that self help can be useful in treating people with Bulimia Nervosa, Binge Eating Disorder and subclinical presentations of these. It is not recommended for Anorexia Nervosa given the complex clinical and medical needs. Among the pop-psychology books and websites addressing self-esteem, relationship issues, physical and mental health, there are a range of self-help materials, addressing body image, weight loss, healthy eating, dieting, eating behaviours in children, eating for pregnancy and addressing overeating, binge eating and eating disorders. These types of publications and websites are highly acceptable to the general public and surveys have shown that, in general, self-help approaches are more positively endorsed than treatment with a health care practitioner, medication use or psychotherapy. Guided Self-Help Guided self-help, based on the principles of Cognitive Behavioural Therapy (CBT), provides some benefit for people with Bulimia Nervosa or Binge Eating Disorder. It has been proven to be more effective than no treatment at all and is beneficial in terms of availability and cost. An Australian study showed that guided self-help delivered by non-specialist GPs in primary care provided similar outcomes to major studies of CBT delivered in specialist settings. Clinicians in primary practice who have psychological training may wish to offer guided self-help as the first ‘step' of a stepped treatment response to people with Bulimia Nervosa or Binge Eating Disorder. Or, it could be offered while the person is waiting to access more specialised services. The client is ‘guided' by the clinician who helps with the implementation of the program, provides feedback on progress and supports the person to stay engaged in treatment. The programs are typically limited to a number of sessions e.g. 10, and contact need only be brief, usually 20-30 minute sessions. It is beneficial for the health professional involved to have received training in CBT approaches, or, at least, to have knowledge of self-help approaches. However, there is emerging evidence that mental health providers with minimal credentials can be as effective as specialised clinicians at providing guidance. As a guide to determining who you might suggest a self-help program to, consider that effective engagement in self-help can be affected by: engagement in self-help can be affected by: bullet Low motivation bullet Poor concentration bullet Reduced capacity for memory bullet Blurred vision resulting from medication bullet Severe illness bullet Capacity for internal locus of control bullet Levels of self-efficacy Self-Help Groups ‘Self-help' is also the term used to describe the support groups that are run by consumer organisations. These can be delivered to ‘sufferers', or ‘family/carers', or both. They can be specifically focused around Anorexia Nervosa, Bulimia Nervosa or Binge Eating Disorder, or they might address all types of eating disorders and disordered eating. In Australia, most states have a consumer organisation that either provides a support/self-help program or can identify where consumers might access one. Recommended Self-Help Materials Self-help materials should be evidence based, accessible and appropriate for the specific target audience. There are several key self-help books: Advantages of self-help materials Are accessible, brief and easily affordable Provide flexibility and ready access to treatment to suit the person (time, pace, place) Enable access to ‘treatment' with minimum delay Can be adapted for different cultural groups Avoid stigma associated with psychotherapy or psychiatric referral Suits people who prefer to work through their problems privately Encourage the growth of self-care and self-responsibility May enhance a person's sense of control over the eating problem Guided interventions can be implemented by non-specialist health care providers so are more easily disseminable Can be supplemented with individual or group therapy Can be accessed again and again at no further cost Disadvantages of self-help materials Individual choice of self-help materials may not be based on research evidence as consumers will often just google for recommendations Not all self-help materials have been proven to be effective There is often a presumed level of education and literacy required Currently there are few materials designed to meet needs of children & adolescents, people from ethnic or religious minorities or people with learning disabilities The offer of guided or supported self-help might be seen as a personal rejection Clinical deterioration is not monitored Drop-out, related to poor motivation and feelings of hopelessness, particularly in unsupported self-help, is high May use jargon which consumers do not understand Severe and Enduring Anorexia Nervosa Individuals with severe and enduring Anorexia Nervosa (SE-AN) have one of the most challenging disorders in mental health care . SE-AN has the highest mortality rate of any mental illness with a marked reduction in life expectancy. There are a variety of consequences resulting from the severity and chronicity of SE-AN. This includes impaired physical and psychiatric health, as well as implications on the individual's families, occupation and social life. Individuals with SE-AN are often under or unemployed, supported by government benefits, have high levels of disability and pose a significant burden both financially and emotionally on their family and carers. Individuals with SE-AN have often experienced multiple treatment failures with numerous admissions to both general and specialist medical facilities. They often require frequent hospitalisation due to medical instability and imminent health consequences (including death). Providing treatment in line with best practice guidelines for AN, which aims for ‘full recovery' can be traumatic for individuals with SE-AN as this is often not in line with their level of motivation and goals. This misalignment between the treating team's treatment plan and the individual's goals, further entrenches the individuals lack of hope for recovery and exacerbates their lack of trust in the health care system. A specific treatment paradigm that takes a global approach to treatment and where goals of therapy are re-conceptualised is required for individuals with SE-AN. What is SE-AN? There is currently no consensus on the definition and criteria for SE-AN. There are 3 domains, which are important to consider in defining an individual with SE-AN, however specific details of these domains are unclear. These include: 1 1 Clinical severity 2 2 Treatment failure or resistance 3 3 Chronicity The average illness duration for AN is 2-5 years, therefore SE-AN extends beyond this in terms of duration of illness. Treatment Principles for individuals with SE-AN Individuals with SE-AN require a specific treatment paradigm that takes a global approach to treatment and that is matched to the individuals needs and level of motivation. The foundation of standard treatment for AN (i.e. an outcome of making a ‘full recovery') may be more flexible when setting treatment goals for individuals with SE-AN. However, keep in mind that recovery is still possible at any point! To increase the individual's level of motivation and increase the possibility for further improvements in symptom and functioning, treatment for individuals with SE-AN should be centred on: 1 1 Crisis intervention 2 2 Harm minimisation 3 3 Improving engagement with an overall focus on improving quality of life SNAPSHOT EXAMPLE - JAN Background Jan is a 40-year-old woman who you have been seeing in your GP practice for about 6 months. When she first came in you were extremely worried as she looked very thin. Her BMI was 15 at the time. Jan has a 24-year history of anorexia nervosa with numerous long-term inpatient and day patient admissions, and numerous courses of CBT. You carried out extensive medical tests when you first saw her and considered looking into a hospital admission. Jan was adamant that she would not go to hospital, but agreed to start with a therapist. You referred her to a psychology practice that you know works with people with eating disorders. Current Issues Today Jan comes in and says that she has stopped seeing the therapist. When you ask about that, she says it is because the therapist kept asking about food and pushed her to regain weight. It has been a month since you have seen her so you start to worry that she may have deteriorated with no clinical care. Considerations and direction forward The GP could consider any of the following options: The GP could encourage Jan to reconnect with the therapist. The GP could discuss the possibility of therapy that does not focus solely on symptom reduction, but takes a more holistic view, by working with her to improve quality of life and overall general functioning. The GP could take on the role of “case manager” with a focus on improving quality of life, enhancing social functioning, and promoting independence by reducing the frequency and duration of hospitalisations. What about medical management? Since Jan has disconnected from her therapist, you make the assumption that outpatient treatment isn't working, so start to think about the need for hospitalisation again. Her BMI is 15, her blood work is slightly problematic, but stable, and she has low blood pressure. But perhaps the parameters for medical management and guidelines for admission may need to shift, as Jan has maintained a BMI of about 15 for many years, and has not benefited from lengthy inpatient specialist eating disorder admissions. So an admission solely based on BMI, and into an eating disorder long term service, is unlikely to be suitable. Perhaps you need to set new parameters regarding the need for short term acute admissions for medical stabilisation if/ when she deteriorates, or the need otherwise arises. It is important to maintain hope that things can improve for Jan both holistically and also with regard to the eating disorder, whilst not pushing too aggressively for symptom reduction. Working with SE-AN clients from a Psychodynamic perspective Trauma Informed Care and Practice Trauma-informed care and practice recognises the prevalence of trauma and its impact on the emotional, psychological and social wellbeing of people and communities. A key feature of trauma-informed care and practice is an understanding of the broader context of how services are delivered, not just what they may entail. Trauma Informed Care and Practice requires that service systems and interventions be designed and offered to individuals in a way that does no harm and promotes physical and emotional safety. Why is it important to be Trauma Informed and skilled when working with people with eating disorders? Eating disorders treatments, particularly inpatient admissions, can be highly stressful and sometimes traumatic for the patient, families and carers. There are a number of factors that may contribute to this: People with eating disorders are petrified of accessing treatments as it means being confronted with their worst fear, that is, weight gain. bullet Treatments (such as naso-gastric tube feeding) may be administered involuntarily via the Mental Health Act or Guardianship Act as necessary life-saving interventions bullet Inpatient admissions for refeeding can be lengthy bullet Restrictions may be placed on a patient's physical mobility such as being confined to bed bullet Most inpatient treatments for refeeding occur in general medical wards that are not purpose built, nor have the resourcing for activities or opportunities for distraction bullet Often health professionals and family/carers views regarding the eating disorder and treatment are at odds with the individual's views and wishes, which may lead to feelings of isolation Inpatients admissions may involve being placed under 1:1 observation, with little privacy As much as possible due care should be taken by health professionals to deliver interventions within a Trauma-Informed Framework in order to negate distress associated with treatments wherever possible. Concerted efforts should be made to engage individuals, families and carers as collaborators in care, empowering them and promoting their sense of safety and self-agency in all instances of care and contact. Key Messages 1 1 Maudsley Family Based Treatment (FBT) is recommended in the treatment of children and adolescents with Anorexia Nervosa and Bulimia Nervosa. 2 2 There is initial evidence for the use of eating disorders specific Cognitive Behavioural Therapy, Specialist Supportive Clinical Management, and the Maudsley Model of Anorexia Nervosa Treatment for Adults. 3 3 CBT-Enhanced or the broader form can be used as the first line of psychological treatment for Bulimia Nervosa and Binge Eating Disorder. 4 4 People with binge eating disorder may successfully reduce binge eating through the use of self help materials, or through guided self-help. 5 5 Interpersonal Therapy and Dialectical Behaviour Therapy may be of merit in the treatment of Bulimia Nervosa and Binge Eating Disorder. 6 6 Motivational Interviewing or Motivational Enhancement Therapy may be useful adjuncts to other therapeutic approaches. Inpatient Management By the time someone is admitted, the eating disorder has progressed to the point where the person is medically and/or psychologically at risk. It is important that nursing, medical and dietetic management is coherent, cohesive and recovery-focused. All clinicians involved must understand the best approach to take and how to support the patient through this terrifying ordeal. The experience for the individual ben-white-e92L8PwcHD4-unsplash.jpg Admission to an inpatient unit is often a stressful and frightening experience for any patient. This is particularly true where the length of admission may be unknown, and the patient may not be keen on the admission because of the prospect of having to normalise eating, gain weight and reduce eating disordered behaviours. People with eating disorders will frequently plead for more time, and tearful promises will be made to try harder, or to ‘do it' at home. However, once hospitalisation is necessary, it is important to be consistent in the decision to seek admission. It will also be important to ensure that the person's family are supportive and that there are no secret ‘deals' struck between family members and their loved one, about the conditions of his/her discharge (e.g. at a certain weight). Indicators for Admission Factors to consider when making a referral: Nature of the problem – Is the presentation predominantly an eating disorder or another mental health issue? What are the main aims of treatment? Is this something that can be managed within your current team? What type of health service or professional would best meet the needs of this individual? Severity of the Illness – Is the person at risk of medical instability? Is the person psychologically unsafe (risk of suicide or significant self-harm)? Is the severity of the eating disorder increasing over time rather than improving? Is the illness progressing despite intensive community-based care? Geographical Location – What community-based treatment services are available locally (e.g. local mental health team, dietitian, therapist, paediatrician, child & adolescent psychiatrist)? Remember local treatment services can be supported in their role by specialist services through video-conferencing, telephone support. Age of the person – Some services may only accept referral for adolescents of a specific age group. In some areas, children will be admitted to a paediatric unit, in others it may be to a mental health service. Health Insurance Status – If the person has private health insurance, this may increase the number of services they are able to access. Goals of the admission 5 of 28 1 1 Medical stabilisation 2 2 Nutritional rehabilitation 3 3 Interrupt disordered eating behaviours 4 4 Resume normal eating patterns and behaviours 5 5 Ensure that there is community based management and treatment available on discharge Considerations for Children and Adolescents Minimum levels of intervention: If the following minimum levels of intervention cannot be met, then the individual should be admitted to a hospital that can provide the following: bullet Paediatric input: Regular paediatrician consultation should be provided. It is preferred that the individual is admitted under a paediatrician, but if this isn't possible, a minimum weekly consultation is required for patients who are admitted for management of Anorexia Nervosa or who are medically compromised. bullet Psychiatric input: Psychiatric consultation should be provided, with ongoing management as determined by the psychiatrist. This may be provided via telepsychiatry or consultation with a psychiatrist from a specialist service. bullet Dietetic input: At least weekly Dietetic consultation, especially for individuals who are being re-fed. Ideally, adolescent patients with eating disorders should be admitted to a paediatric adolescent medical ward or a specialist child and adolescent mental health unit wherever possible. There should be a team meeting reviewing the individual's progress and management each week, and ongoing contact between the community team and the inpatient team. The family should be involved throughout the treatment process, and the plan for discharge should be an ongoing discussion throughout the admission. Nursing staff play a significant role in the support and management of the individual, and should have an understanding of eating disorders and best practice management. The Collaborative Treatment Plan 7 of 28 Developing a collaborative treatment plan that is clear and addresses the key issues of treatment and management will be helpful. The collaborative treatment plan should be developed by all members of the multidisciplinary team, including the patient and their family (where appropriate). The treatment plan should be a document that is regularly updated as treatment progresses, and should be easily accessible to all team members to ensure consistency in treatment. It is essentially a quick reference and guide about the patient's treatment plan. In eating disorder specialist settings, this treatment plan may include specific details pertaining to: bullet The treating team members bullet Medical management: regularity of blood tests and physical observations bullet Medications: type and when they will be administered bullet The patient's goals for the admission bullet The nutrition management plan: feeding regimen & supplementation or exchange regimen bullet Weighing practices: frequency of weighing and method (open/blind weighing) bullet The specific eating disorder behaviours that the patient struggles with Useful distraction techniques specific to the patient bullet Patient risks such as absconding risk, self-harm/suicide risk bullet Ward or unit restrictions bullet Family meetings, involvement and when/if leave has been permitted The treatment plan will include a range of treatment 'non-negotiables' - components of treatment that are necessary. It is important to discuss the treatment non-negotiables collaboratively with the inpatient at the beginning of treatment. This ensures that the inpatient is part of the process, manages expectations, empowers them to be responsible in their treatment process and ensures that if a non-negotiable is not met, that the consequences are already known to both the treating team and the inpatient. This is very important as it ensures that the treating team do not need to be punitive or authoritarian in their approach, maintaining the therapeutic alliance, and puts the responsibility and control in the inpatient's hands to manage their treatment goals. Non-negotiables of treatment must be reasonable, they must be clear, consistent and their rationale must be explained to patients. If limits are unreasonable, unclear or delivered in an authoritarian or parentified manner, then do not be surprised if the individual express irritation, feel patronised, act rebelliously or withdraw. Common inpatient non-negotiables include: bullet Regular medical monitoring bullet Regular weight monitoring bullet Meal supervision bullet Nutrition management plan determined by the Dietitian SNAPSHOT EXAMPLE - JENNY Jenny, an 18 year old with Anorexia Nervosa was admitted to a private eating disorders centre following a lengthy admission to a public hospital. She had previously had multiple admissions to The Children's Hospitals. Jenny's presentation was complicated by significant personality vulnerabilities. Previous discharge summaries indicated that she had been diagnosed with Oppositional Defiant Disorder as an adolescent as well as Narcissistic and Anti-Social Personality Disorder. Given the potential for difficulties that Jenny's treatment might have posed, Jenny's admission was conditional on her agreeing to be managed under a collaborative treatment plan. She was informed that she would meet with the Nurse Unit Manager and her consultant psychiatrist weekly to review her progress. Within a few days of her admission several other patients complained of her exercising in her bedroom, and it became apparent that Jenny was falsifying her weight. Initial weight recordings for Jenny were considerably higher than would have been expected for someone eating her meal plan. Jenny had random spot weights and these consistently indicated that Jenny had been falsifying her weight. When asked, she admitted to putting weights in her bra and exercising in her room in the afternoons. The Nursing Unit Manager and the Consultant Psychiatrist met with Jenny to discuss her struggles and to reinforce the non-negotiables and required behaviour for treatment as set out in the collaborative treatment plan. Together they came up with strategies that would help Jenny to stay on track, and clearly laid out the consequences of engaging in disordered behaviours. The collaborative treatment plan was updated to reflect these so that the entire team was clearly able to see the plan moving forward. The nursing staff felt able to contain Jenny's behaviour to within acceptable limits as the collaborative treatment plan indicated behavioural guidelines and strategies to help support Jenny. These included suggested activities that Jenny found helpful, as well as the consequences of engaging in an eating disorder behaviour (e.g. exercise) such as increased supervision and monitoring. Medical Management The management plan for the first 24 hours of admission should include: bullet Baseline and daily blood tests (E/LFTs and FBC) bullet ECG bullet Physical observations including blood pressure and heart rate (4 hourly in the first 24 hours) bullet Blood sugar level tests (4 hourly) bullet Treatment and management of any abnormalities bullet Risk assessment Meal Support Meal support and supervision is intended to prevent further deterioration of the inpatient's health, and to ensure adherence to the treatment plan. For individuals with eating disorders, food is medicine. Before, during and after meal times can be an overwhelming time for an individual with an eating disorder, as it challenges the individual's eating disorder, and the behaviours that help them to feel safe. Meal support and supervision aim to: 1 1 Facilitate the completion of all food, fluid and supplements prescribed as part of the nutrition management plan 2 2 Facilitate a reduction or cessation of eating disorder behaviours 3 3 Provide support and encouragement to the individual Meal supervision is usually undertaken by the nursing staff. However in some inpatient settings, for children and adolescents, their family and carers may be involved in meal supervision as well. The level of supervision provided depends largely on the individual's needs and the available resources. The greater the level of meal supervision provided, the more likely the individual will adhere to the nutritional treatment plan and meet treatment goals. If possible, meal supervision should be provided throughout the duration of the admission. General Meal Support Principles BEFORE MEALS Meal trays should be delivered directly to the nursing staff rather than to the patient if possible. Check all meals and snacks against the nutrition management plan from the Dietitian Ask the patient to use the bathroom, as they will to be unable to use it during meal times DURING MEALS Aim to support the individual to consume 100% of the meals, snacks and fluids as per the nutrition management plan If they are unable to complete the meal or snack provide appropriate supplement exchange as per the nutrition management plan Main meals should be completed within 30 minutes and snacks within 15 minutes. Provide a reminder for the individual when they have 10 minutes remaining. Where possible, reduce interruptions and distractions such as phone, visitors, appointments, procedures, or blood tests. Meal times should be outside appointments, groups, and visiting hours. Do not leave the patient unsupervised with food at any time. Engage in some conversation during the meal to provide distraction and lessen the anxiety and punitive experience of being observed while eating. Redirect and/or discourage conversation that focus on weight, diet and food during and after meals. Do not discuss your own food choices, calories, diets, weight and exercise patterns. AFTER MEALS At the end of the meal check all plates, containers and empty cartons to assess what food and fluid has been consumed. Accurately document all food and fluids that have been consumed. Only record what you have observed to be eaten. Do not take the patient's reports of what was eaten. Remove the meal tray and all food items from the patients room Document anything else you observed, such as unusual behaviours (even if you think it is not very important) as this may assist the team in effectively treating the individual. If possible, supervise or ensure that the individual is visible to staff for up to 60 minutes after main meals and 30 minutes after snacks Encourage the patient to engage in activities that they find distracting such as listening to music, watching television, reading, journaling or writing in a diary, playing board games or cards. If food is refused: bullet If the patient is distressed, upset or angry, validate their distress and experience – “I can see that this is really difficult for you right now” bullet Explain to the patient that you are going to help them get through their meal or snack – “I'm going to stay right here and help you get through this. Can you pick up your fork and have another bite?” bullet Coach and encourage the patient to have another bite, and keep going until the meal is complete – “That was great, well done. Now, can you have another bite?” bullet Validate the progress that the patient is making. bullet If the patient is unable to eat more, help them to refocus on their goals of treatment – “Can we take a step back from this meal right here and think about your goals. Is completing this meal going to help you to achieve your goals / treatment plan?” … “Can I help you to get through this meal? Let's start by taking another bite – you can do it.” bullet Coach the patient through the meal for 10 minutes. If the patient is doing well and it seems that they will complete the meal, then continue. However, if they are not making any progress, then explain to the patient that you understand that they are making a decision to not complete the meal and offer them the required supplement exchange. bullet Maintain an empathetic and non-judgemental approach. Common eating disorder behaviours at meal times: REGARDING FOOD Hiding food in pockets and sleeves. Emptying y drinks into plant pots. Disposing of food (e.g. in the toilet, in bed clothes, serviettes). Scraping margarine off toast onto clothing or napkins, under fingernails or into hair; Pooling foods such as raisins in the side of the mouth then spitting them out when they are not observed. Replacing unused cartons with empty ones prior to mealtime Cutting food into tiny pieces, pulling or picking food apart. Reading nutrition labels and ingredient lists on pre-packed food. Eating very slowly. Diluting milk, juice or supplements with water. ‘Messy eating' i.e. cutting food up carelessly with pieces falling off the plate, or crumbs falling onto the table or floor. Using excessive quantities of sauces, spices, salt and pepper. Leaving food on the sides of bowls and containers e.g. yoghurt. REGARDING ACTIVITY Standing, Jiggling, shaking, pacing. Exercising In the bed, bedroom, stairwell, bathroom. REGARDING VOMITING Hiding vomit in a vessel – pocket, bags, vases, jars, cups, pot plants, gloves. Vomiting in the bathroom, shower, sink, stairwell. REGARDING ENTERAL FEEDS Removing the tube. Emptying feed (in the toilet, sink, shower, in cups). Diluting the feed. Changing feed rate or turning the feed off. Using sharps to puncture tube. Using a syringe to draw back on tube. Using chewing gum to block tube. Running feed into bedclothes. Managing Challenging Behaviours People with eating disorders can engage in challenging and risky behaviours that are designed to protect the illness when they feel that their illness is under threat. Hospitalisation and treatment threatens the illness, making treatment exceptionally challenging for individuals with an eating disorder. To manage challenging behaviours effectively, it is important to have a good understanding of the function of the eating disorder for that individual and the fear that drives these behaviours. Eating disorders provide individuals with a sense of control and safety. They can help the person to manage or avoid difficult emotions, provide a sense of identity and are often experienced by the individual as providing them with support like that of a friend. When you have a good understanding of the individuals experience and understand the function of their illness, then you are more able to act from a place of empathy and work therapeutically with the individual. The behavioural manifestations of the eating disorder can be difficult to manage and the approach of health practitioners is very important. Health practitioners need to be mindful to not take a paternalistic, punitive or judgmental approach, as this will only result in a break down in the therapeutic relationship and ongoing engagement in the behaviours. The most important thing to understand is how difficult the person will find it to change their behaviour as the disorder compels them to behave in certain ways. As a result, asking the individual to promise not to engage in the behaviours or expecting that they will automatically ‘comply' with program rules will set the person up for failure. Becoming exasperated or angry when they do fail contributes to the negative feelings the person may have about themselves, and enhances the isolation that they feel as a result of the eating disorder. What are challenging behaviours? Challenging behaviours include any behaviour that interferes with treatment. The following list, while not comprehensive, includes particular areas to be aware of. 1 1 Food & eating: hoarding food, disposing of food (e.g. in pockets, in the toilet, in bed clothes, serviettes, pot plants), choosing low calorie or diet foods, chewing gum, picking at food, cutting food up into small pieces, eating at a very slow pace or very quickly, chewing & spitting food out, bingeing, regurgitating food & then re-swallowing. 2 2 Fluid: excessive or inadequate fluid intake, consuming diet soft drinks, consuming significant quantities of artificial sugars in drinks as well as drinks that have a laxative/diuretic effect. 3 3 Activity: excessive movement (shaking/jiggling legs), pacing around bedroom or ward, secretive exercise (in bathroom, sit ups in bed or leaving the ward to go for walks/runs). 4 4 Nasogastric feeds: compromising nasogastric feeds by removing tube, emptying feed (in the toilet, sink, shower, in cups), diluting the feed, changing feed rate or turning the feed off, using sharps to puncture tube, or a syringe to draw back on tube. 5 5 Vomiting: the eating disorder will force the person to look for opportunities to purge (e.g. in pockets, the bathroom, cups or bags, pot plants or vases). 6 6 Medications: self-medication of laxatives, diuretics and diet pills. 7 7 Weight: methods of weight falsification include fluid loading (increasing fluid intake the day prior to & the day of weighing), increasing salt intake prior to weigh days, hiding heavy objects on body (putting batteries in underpants/bra), gripping the scales. Addressing Challenging Eating Disorder Behaviours To effectively manage challenging behaviours, the team needs to be working cohesively and collaboratively. A collaborative treatment plan will help to establish and maintain consistency in managing the challenging behaviours. It is important that everyone involved is fully aware of the treatment plan, including the person and their family. The consistent implementation of the treatment plan is key, otherwise it implies to the individual that the treatment plan isn't really important, and that the eating disorder behaviours can continue. People with an eating disorder will require additional support to reduce engagement in their behaviours and to commence treatment. At the start of an individual's admission it is important to assess for challenging behaviours and identify risk factors for engaging in behaviours. This will assist the team in looking out for behaviours, monitoring and preventing behaviours from occurring. These may include: 1 1 Restrictive Eating 2 2 Purging 3 3 Binge Eating 4 4 Physical Activity MANAGING RESTRICTIVE EATING Validate the individuals struggle and distress in being required to eat the quantity/types of foods that are necessary for health. Work collaboratively with the individual to explore how to best support them in getting through the required amount of food. Do not enter into negotiations around the type and quantity of the food, but rather explore whether more support, distraction or eating with others may be more helpful. Ensure that the individual is aware of the program protocol from the outset, that they are required to complete 100% of their meals/snacks, and that a supplement will be offered on failure to complete their meal or snack. If the individual is struggling to complete their meal/snack, offer them support and coaching to take another bite – “I can see how difficult this is for you, so I'm going to help you if that's ok? Try to take another bite. If the individual continues to refuse meals and snacks, then the team need to have a discussion with the individual (outside of meal times) about the individual's goals of treatment. MANAGING PURGING Ensure that the process of stopping laxative and diuretics are conducted carefully and under the direction of a qualified medical practitioner. Validate the individuals struggle and distress around purging. Provide education to the individual around the medical implications of purging. Explain to the individual that purging is ineffective in aiding weight loss. Work collaboratively with the individual to explore how to best support them in ceasing purging. Some suggestions include: Ceasing stimulant laxatives. Lactulose can be prescribed if there are concerns about faecal impaction. Supervise bathroom use. No bathroom access 1 hour after meals and limit time off the ward after meal times. Do not leave tissues, bins, buckets, syringes or jugs near the individual as they may be used to purge feeds orally or via their nasogastric tube. With permission conduct regular searches of the individuals belongings to ensure that they do not have access to laxatives and diuretics. Encourage regular meals and snacks, adequate fibre and fluid intake. Monitor bowel movements, fluid balance, electrolytes and cardiac function. Encourage the individual to approach a staff member for assistance and support if feelings associated with purging arise. MANAGING BINGE EATING Validate the individuals struggle and distress around bingeing. Work collaboratively to identify any potential triggers for bingeing and any high-risk times e.g. mid- afternoon or evening. Explore with the individual what might be helpful in preventing binge episodes and how staff may assist e.g. supervised meal/snack, change in meal plan, engaging in a distracting activities, breathing exercises, being with a staff member. Explore with the individual what has been working to reduce binge episodes and document this in the medical records and management plan. Encourage the individual to approach a staff member for assistance and support if feelings associated with bingeing arise. Assist the individual in making their environment less prone to bingeing i.e. ensuring that the individual does not have access to additional food and that meal trays and snacks are removed after meal times. MANAGING PHYSICAL ACTIVITY Physical activity may be helpful or harmful depending on the medical and physical condition of the individual. Physical activity recommendations should be given by the medical team. Identify the individual's exercise behaviours (it may also be helpful to consult with the family) Address any false beliefs that the individual has around exercise. Work collaboratively with the individual to Identify triggers that lead to these behaviours (e.g. before or after meal times, when alone in the bathroom) Explore with the individual what could help to manage these triggers (e.g. distraction strategies, supervised bathroom access) Explore with the individual to explore how to best support them in reducing or ceasing their exercise in line with the teams recommendations. A graded approach is often required. Weight Monitoring Being weighed is a distressing and anxiety-provoking event for any individual with an eating disorder. The impact of seeing their weight (as well as your reaction) will affect their thoughts, feelings and behaviours. Approach weighing with empathy, sensitivity, a deep respect for the individual and an unbiased, non-judgmental attitude. Who? bullet In an inpatient setting it is most likely the nurses who will be weighing the inpatient. Where? bullet Weighing should occur on the same scales each occasion. These scales should be calibrated regularly. When? bullet Weighing should occur in the mornings, before breakfast and after going to the bathroom. bullet Weighing should occur approximately two to three times a week and the days spread apart, such as; Mondays, Wednesdays and Fridays. How? bullet Individuals should wear minimal clothing, empty their pockets and remove their shoes. Ideally, they should wear a hospital gown. bullet Always respect the individual's privacy during the weighing process. bullet If there is uncertainty around the accuracy of the inpatient's weight, or it is suspected that the individual is falsifying their weight, then consider doing a ‘random' spot weigh-in (weighing the individual at a random time when they are not expecting to be weighed). bullet The individual may prefer to be blind weighed (back to the scale and not knowing their exact weight) or open weighed (seeing their weight result each time). Then what? bullet Always refrain from making any comments or remarks about the weight result such as “well done”, “that's good” or “that's disappointing”, as this will straight away influence what the individual chooses to share with you when you enquire how they feel about their weight result. bullet Decide if the person weighing the individual or the Dietitian/ Doctor will discuss the weight outcome with the inpatient. Always reflect back to the individual what has occurred, be transparent and honest, and never try to conceal the outcome. bullet Clearly document the weight in the medical file and include the time and date of weighing. Transitioning to Adult Services Services in Australia are usually configured based on specialisation and the age of the client. Quite often services for children, adolescents and adults will be different and offer age-appropriate therapeutic styles of treatment. Child and adolescent services are usually family-based in their treatment approach, while those for adults are usually individually based but offering family support. For older adolescents who may transition to adults services, it is essential to consider the length of treatment that could be offered by the adolescent service and how the client (and the family) will manage the change from family-based to individually-based treatments. Preparation for such a move needs to be considered some time in advance, particularly because in the ‘adult system' it is easier to refuse treatment or to fall through the gaps. Outpatient Treatment Most people with eating disorders are successfully treated in outpatient settings – either in primary practice, by clinicians working in private practice, in outpatient clinics or eating disorder day programs. bvAsset 12@6x-8.png The majority of people with eating disorders will receive outpatient treatment. This is appropriate providing they are medically and psychologically stable. While it is still necessary to provide multidisciplinary treatment, treatment aims and goals will need to be modified to reflect the treatment setting. Specialist outpatient treatment includes Day Programs, Outpatient Clinics and practitioners in public or private practice. In local and regional areas, outpatient treatment might include attendance at an outpatient dietetic clinic, community health or community mental health setting. Specialist and non-specialist outpatient treatment is also provided by dietitians, GPs, mental health nurses, paediatricians, psychiatrists, psychologists and others in private practice settings. Eating disorder specialist outpatient clinics might provide: bullet Assessment by a multidisciplinary team bullet Time-limited 1:1 treatment (psychological and dietetic ideally) or, referral elsewhere for ongoing psychological, medical and dietetic management bullet Family therapy interventions or family support bullet Monitoring of the eating disorder (e.g. by Paediatrician and Psychiatrist, or GP) Support and advice to non-specialist providers (by telephone or video-conference) Outpatient Guidelines The NICE guidelines recommend the following: Outpatient treatment for Anorexia Nervosa Most people with Anorexia Nervosa should be managed on an outpatient basis, with psychological treatment (with physical monitoring) provided by a healthcare professional competent to give it and to assess the physical risk of people with eating disorders. Outpatient psychological treatment for Anorexia Nervosa should normally be of at least 6 months' duration and at least 20 treatment sessions. For patients with Anorexia Nervosa, if during outpatient psychological treatment there is significant deterioration, or the completion of an adequate course of outpatient psychological treatment does not lead to any significant improvement, more intensive forms of treatment (for example, a move from individual therapy to combined individual and family work; or day-care or inpatient care) should be considered. Dietary counselling or medication should not be provided as a sole treatment for Anorexia Nervosa. Outpatient treatment for Bulimia Nervosa Most people with Bulimia Nervosa should be managed as an outpatient. The primary treatment is psychological (with medical monitoring) and CBT based self help programs can be an appropriate initial treatment for adults with Bulimia Nervosa If self help is ineffective or contraindicated after 4 weeks, consider individual CBT based therapy Treatment duration should be around 6 months minimum In children and adolescent, a family based approach should be offered Medication should not be the sole treatment Outpatient treatment for Binge Eating Disorder Outpatient treatment is the primary setting for people with Binge Eating Disorder A CBT based self help program can be an appropriate treatment for adults with BED Othewise consider group or individual CBT based therapy Treatment duration is usually around 4 months Medication should not be the sole treatment Outpatient treatment for OSFED Use the psychological outpatient treatment approach best suited to the eating disorder it best resembles Day Programs Day programs provide diagnostic and treatment services as an alternative to inpatient care, or a transition stage (or stepping stone) between outpatient and inpatient care (or vice versa). The goals of inpatient and day patient services are generally the same, but structured time in treatment is significantly less. 30-50% of patients who have had an admission into an eating disorders unit relapse and are re-admitted. Therefore, an intermediary step, where clients are supported to recover whilst maintaining some social and vocational roles and learning skills that will benefit them in their natural environment, can be an effective treatment option for some. Day programs allow skills to be practiced immediately in ‘real life' and greater family contact and support is largely advantageous. There are also some limitations to day programs: bullet Participation in a day program requires motivation, medical and psychological stability. bullet Many day programs have minimum weight requirements. bullet Some patients require more structure e.g. where there is family crisis. bullet Attending day programs may be impossible for those who live in regional/rural/remote areas, as additional accommodation and/or travel arrangements may be prohibitive. Goals of Treatment The first goals of treatment will still be to develop a therapeutic relationship with the person and establish a multi-disciplinary or multi-skilled team of health professionals. ANOREXIA NERVOSA For adults with Anorexia Nervosa, providing the person has stabilised weight loss or is not in danger medically or psychologically, increasing motivation to change may be the primary focus of treatment in the early stages, and then focusing on weight restoration. BULIMIA NERVOSA & BED For a person with Bulimia Nervosa and Binge Eating Disorder cessation of binging and purging behaviours will be the primary goal, providing that any medical instability due to purging behaviours is resolved and stable. Normalising Eating The overarching goal of treatment is to support the individual to work towards ‘natural' eating, where eating patterns and food choices are no longer influenced by the eating disorder. Normal eating, looks, feels and is different for everyone. Everyone is born with their own intuitive sense of the unique combination of eating behaviours and food preferences that feels best for us. These can be influenced by many factors such as culture, family and religious beliefs. Normal, healthy eating is: bullet Maintaining health and wellbeing by eating in a relaxed/flexible way bullet Nutrition to support physical/mental/social/emotional wellbeing and development bullet Adequate nutritional intake from a wide variety of foods bullet Regular meals and snacks - “normal” in type/amount bullet Responding to hunger/satiety cues bullet Eating liked/desired foods and “junk” food occasionally without guilt bullet Eating socially with minimal anxiety Avoiding compensatory behaviours bullet Eating culturally appropriate meals for particular occasions Normal, healthy eating is not: bullet Preoccupation with food, eating or body weight bullet Where eating has much more significance than other activities bullet Measuring, counting or weighing what is eaten bullet Counting calories or fats bullet Continually following a rigid eating plan or having rigid rules around eating bullet Using supplements in place of whole foods Key principles that support normal, healthy eating: Being responsive to one's own body signals Being non-judgemental about foods (good vs. bad foods, healthy vs. unhealthy foods) and being inclusive of all foods Being non-judgemental about the foods that are desired, or preferred Eating foods in response to taste and preference Developing trust with ones body Becoming aware of any messages (internal, external) which may influence our food choices Respecting one's feelings, body and health It is vital that in supporting an individual in getting back to their own ‘natural' eating style, that they feel supported to experiment with different ways of eating and to explore what feels right and intuitive to them. However, there will be times when an individual's eating patterns are so disordered that prescribing to them what to eat (with the use of a meal plan) will be required. However, keep in mind that this is only an interim step towards reducing eating disorder behaviours; improving overall food intake and variety, with the ultimate goal being supporting that individual to figure out their own style of ‘natural eating'. Regular and adequate nutrition can be supported through the provision of a meal plan or the provision of guidelines. Whilst both meal plans and guidelines have value for different individuals depending on their circumstances, they can also hinder progress if they are not appropriate and relevant for that specific individual. In working from a client centred approach, collaboratively explore whether a meal plan or meal guidelines are going to be most helpful. This may take some experimenting with. An eating disorder causes mass disruption to our body systems that govern the intuitive eating process, and as such, a structured and somewhat mechanical process is often required to re-establish stable eating patterns and then work towards natural eating. Meal Plans and Guidelines 16 of 28 Regular and adequate nutrition can be supported through the provision of a meal plan or the provision of guidelines. Whilst both meal plans and guidelines have value for different individuals depending on their circumstances, they can also hinder progress if they are not appropriate and relevant for that specific individual. In working from a client centred approach, collaboratively explore whether a meal plan or meal guidelines are going to be most helpful. This may take some experimenting with. A meal plan is most suitable for individuals who are very restrictive, rigid and inflexible in their eating style, who are highly anxious regarding making choices, who require containment and require specific guidance to improve their nutritional intake. An individually tailored meal plan can provide a clear direction for nutritional intake for some individuals, reducing their anxiety and aiding treatment progress. It is important that the meal plan is created collaboratively with the individual, to ensure that the individual takes responsibility for their plan. This means that initially only the foods, meals and snacks that the individual feels reasonably comfortable to eat are included in the meal plan. For individuals who are restrictive with their intake (across any diagnosis), this may mean that their initial meal plan is rather scarce, but will develop over time. As such, a meal plan is an ever-evolving document as the individual progresses through treatment. SNAPSHOT EXAMPLE - MANDY Mandy is a 34-year-old with Anorexia Nervosa who has been losing weight and desperately wants to remain out of hospital. As she becomes more medically vulnerable, Mandy presents requesting a meal plan, as she wants some direction about what she needs to eat to stay out of hospital. Begin by exploring if Mandy has been in this situation before and if so, whether a meal plan was effective. Invite Mandy to contribute to the development of the meal plan and throughout the process seek clarification from Mandy as to whether she would like it to be generic or more detailed. Invite Mandy to write up the meal plan. Encourage Mandy only to include foods, meals and snacks that she knows she is likely to eat, to increase the chances of her following the meal plan. This can be expanded on as treatment proceeds. Meal guidelines are most suited to individuals who are generally eating regularly and adequately but require some guidance or direction. They can be useful for individuals who are wanting more flexibility than what a meal plan offers, who have a sense of trust in their decision making abilities, and may be experimenting with eating intuitively. The provision of guidelines around food intake can provide direction around how the individual should be eating, without being prescriptive and without the individual feeling limited by what may be written on a meal plan. Meal guidelines can be general or specific, depending on the individuals specific needs. For example: Eat 3 main meals a day, and 2-3 snacks bullet Include a source of carbohydrates, protein and fat at all main meals bullet Include a dairy food 3-4x/day SNAPSHOT EXAMPLE - ANDREA Andrea is a 38-year-old with Binge Eating Disorder and a long history of yo-yo dieting. Andrea reveals that she has tried every fad diet and that nothing has helped her lose weight and stop binging. Andrea presents wanting a meal plan, as she believes that if she knew what to eat and has something to follow, then she would be able stop binge eating. She trusts your expertise and can't wait to get started. As you collaboratively navigate how Andrea is going to eat regularly and adequately throughout the day as the key strategy to prevent binge eating episodes, it become apparent that Andrea knows exactly what and when she'd like to eat. Your validation and assurance that she is on track in her thinking gives her the confidence in her own knowledge of how to eat well. Upon discussing whether a meal plan or meal guidelines are going to be most helpful, Andrea recognises that meal guidelines will be the most helpful and that through your discussions she is already equipped with some guidelines, including to eat: every 2-3 hours, 3 main meals, and 2-3 snacks, adequate meals (including carbohydrates, proteins and fats) and to include all food groups. Self Monitoring Self-monitoring, otherwise known as ‘food monitoring' or keeping a ‘food diary', or 'food and thought diary' is an effective way to understand the eating disorder patterns and to monitor treatment progress. Self-monitoring in real time allows the health professional and the individual to develop awareness of their eating patterns and eating disorder thoughts and behaviours. Self-monitoring records can be useful for all members of the multidisciplinary team. A basic self-monitoring document can include: 1 1 The meal or snack type 2 2 The time the meal or snack was consumed 3 3 The foods and drinks consumed 4 4 The presence of eating disorder behaviours 5 5 Events, thoughts and feelings at the time Self monitoring records can highlight problems around: bullet Nutrition intake - regularity, adequacy and variety bullet Belief systems around food bullet Food rituals, timings of meals and eating patterns bullet Capacity for spontaneity and flexibility bullet Ability to use hunger and satiety bullet Engagement in eating disorder behaviours The self-monitoring records should be reviewed in session collaboratively, from a place of curiosity and exploration. Ask the individual to give you a summary of their week. This allows the individual to highlight anything that stood out for them. “How do you feel you managed with your eating this week?” “What do you see from your self-monitoring records this week?” “What do you think you did well with?” “Where do you see that you need some assistance?” Weight Monitoring 18 of 28 Being weighed is a distressing and anxiety-provoking event for any individual with an eating disorder. The impact of seeing their weight (as well as your reaction) will affect their thoughts, feelings and behaviours. Approach weighing with empathy, sensitivity, a deep respect for the individual and an unbiased, non-judgmental attitude. Most importantly, weighing should occur by only one health professional in the multidisciplinary team. Usually the Dietitian or GP will weigh the individual and communicate this to the other team members. Who? bullet In the community setting, it is most likely the GP or Dietitian will weigh the individual. bullet It is most helpful if only one member of the multidisciplinary team is weighing the individual, as this ensures the process for weighing is consistent and predictable, the same scales are used and the individual is supported and provided with a space to debrief about their weight result. bullet Discuss who will be weighing the individual with the multidisciplinary team, and provide regular updates on weight progress to other team members as required. What if the individual is also weighing himself or herself at home? Many individuals will also weigh themselves at home, sometimes very frequently. It is important to discuss the role that weighing at home plays and how it fuels the eating disorder. Work together with the individual to cease weighing at home. Where? bullet Weighing should occur in session, on the same scales each occasion. These scales should be calibrated regularly. n? bullet Weighing should occur at a similar time of day each week. In a community setting this may be difficult, and therefore it is important to account for greater fluctuations in the individual's weight. bullet Weighing should occur approximately once a week, however severely low weight individuals may need to be weighed twice a week. bullet Try to keep weighing to the first half of the session. This ensures the weight result can be used to inform treatment progress and goal setting. It also provides the individual with adequate time to explore their thoughts, feelings and fears about their weight and means that the individual isn't sitting through the session nervously anticipating the weigh-in. How? bullet Individuals should wear minimal clothing, empty their pockets and remove their shoes. bullet The individual may prefer to be blind weighed (back to the scale and not knowing their exact weight) or open weighed (seeing their weight result each time). Explore which method of weighing is most helpful for the individual. Then what? bullet Always refrain from making any comments or remarks about the weight result such as “well done”, “that's good” or “that's disappointing”, as this will straight away influence what the individual chooses to share with you when you enquire how they feel about their weight result. bullet Always reflect back to the individual what has occurred, be transparent and honest, and never try to conceal the outcome. bullet Explore with the individual how they feel about their weight outcome. “Anne, this week your weight has increased 700g. How do you feel about this?” – Simply provide support, empathy, reflect and affirm the individual. Blind vs. Open Weighing Work collaboratively with the individual to decide whether open weighing or blind weighing will be most helpful. Each individual is different, and what works for one individual may not work for another – some people like to know every movement and detail about their weight progress, and others don't want to know much at all. Collaboratively deciding what is the most helpful approach and what is going to support their treatment goals is useful, keeping in mind that this may take some time to explore and experiment with. OPEN WEIGHING When an individual is ‘open weighed' they see the number on the scale, drawn on a graph or are told their weight at each occasion of being weighed. Some individuals find open weighing most helpful, as it means they are aware of what is happening and can work on managing their anxiety around weight gain. It can be useful in helping the individual to: Challenge assumptions around the impact of food on weight Expose the individual to normal weight fluctuations Expose the individual to their weight and work on their anxiety around this. However, open weighing can also make the individual fixated on the numbers and can get in the way of them making changes to their food intake or behaviours. BLIND WEIGHING When an individual is ‘blind weighed' they will not know exactly what their weight is. Some individuals find this helps them to focus on improving their eating and disordered behaviors without directly linking each behavioural change to a change in weight. When an individual is ‘blind weighed' they can still receive feedback on how their weight is trending, for example: Talk about the amount it has changed by, but not the actual weight result i.e. “this week your weight has come up 200g” Talk about whether it is ‘increasing', ‘decreasing' or ‘stable' Talk about whether it is ‘on track' or ‘not on track' with the individual's goals “Your weight is looking just fine” “Everything is on track” “It looks like we'll need to add some more food to your meal plan” Psychological Treatment 19 of 28 Psychological therapy is essential in the outpatient treatment of eating disorders. Because in addition to improving nutrition and normalising eating, and medical management, to recover and maintain wellness, clients need to make changes in their thinking, emotional regulation, and behaviours. The specific types of psychological therapies that are useful for treatment in eating disorders include the following (and were outlined in Module 4): Cognitive Behavioural Therapy bullet Self-Help and Guided-Self Help bullet Maudsley Model of Family Based Treatment bullet Supportive Specialist Clinical Management bullet Mindfulness Based Therapies such as Acceptance and Commitment Therapy (ACT) and Dialectical Behaviour Therapy (DBT) bullet Psychotherapy SNAPSHOT EXAMPLE - MEL You have been seeing, Mel, aged 24 for some time for outpatient psychological treatment for an eating disorder. Progress in terms of overcoming the eating disorder has been slow, and Mel has been reluctant to engage in many of the strategies of CBT e.g. keeping a food log. She is engaged in the process of treatment, however, and always arrives at her appointment. She is pleasant and open and likes to debrief about her week with you and get support and understanding. However, you notice that when you try to direct the discussion towards challenging the eating disorder, she changes the topic. It is frustrating for you and sometimes you feel like dismissing Mel as “just unmotivated” and “wasting your time”. However, consider why these deflections occur. What is Mel scared about? You have this in the back of your mind as Mel discloses to you one day about her family history. You knew she wasn't in contact with her parents, but she hasn't really told you much about them before. Today though, she describes a family environment in which her emotions were not attended to or acknowledged as her parents were struggling with their own mental health issues. Mel learnt that it was not okay to have negative or intense emotions. She was able to see the binge purging behaviour helped keep her from those overwhelming and scary emotions. In this case, there is very little chance that Mel will give up her best coping mechanism, binging and purging, without developing other coping mechanisms, but more importantly, without addressing the lack of emotional support and attunement via therapy. If Mel is medically stable, then it may be useful to shift the goals of treatment to expectations for slower, more minor eating disorder change, to allow you to help address her other concerns. SNAPSHOT EXAMPLE - JO Jo presents with recent weight loss which has led to her losing her period. She is 20 years old and a second-year law student. Jo was school captain at her rural school and has moved to the city for university. She lives with flat mates whom she did not know before. Jo reports that she has to work very hard to keep up with uni work. She says she is very stressed and just “forgets to eat” because she isn't hungry or doesn't have the time to prepare her food. She reports that she has always been a bit particular about her eating so doesn't like just grabbing anything at a café. Jo also said that she has always been pretty anxious and a worrier, but that that is why she managed to do well academically because it kept her focussed. Jo is aware that she is underweight and seems motivated to work on normalising her eating and is happy to work with you on a meal plan. A couple of weeks go by and despite working really hard, Jo has not managed to increase her intake enough to lead to any real weight gain. You reinforce the need to add more food to her day. Jo reports that she feels her anxiety levels are “through the roof”. Even the thought of increasing her food further is unbearable. Given Jo has little support in the city and has to plan, shop for and prepare her food alone, she may really struggle being able to do this given the paralysing levels of anxiety. Furthermore, Jo has a long-term history of high anxiety. Perhaps pharmacological treatment for the anxiety might be of benefit to help Jo's anxiety levels become more manageable in the short term so that she can work on increasing her intake and improving her health? This medication won't treat the eating disorder, but can assist with the comorbid anxiety. Working with People in a Larger Body 20 of 28 Individuals living in a larger body can experience high levels of weight stigmatisation and discrimination, negatively impacting upon their treatment outcomes. There is a growing body of evidence that healthcare professionals hold strong negative opinions about people living in larger bodies, and that this impacts treatment. Health professionals may engage in less patient centered communication, provide less psycho-educational information and have shorter sessions with individuals living in larger bodies1. Additionally it is not uncommon for health professionals to over-attribute presenting symptoms or problems to obesity and fail to consider treatment options beyond treatment for weight management1. It is important that eating disorder treatments aimed at individuals living in larger bodies do not perpetuate the eating disorder behaviours. There is evidence to suggest that when weight is the focus of treatment, there are negative impacts upon both psychological and physiological determinants. There is a growing body of evidence to support taking a weight neutral approach to treatment2. Managing Exercise 21 of 28 Exercise has a really important function during recovery. It can reinforce weight gain, increase motivation and mood. It can increase compliance and decrease relapse among individuals with Anorexia Nervosa. However, it can also increase health risks and can derail treatment progress. It is therefore essential that exercise is well managed throughout treatment. What is excessive exercise? Excessive exercise, is exercise that: bullet Increases the risk of injury bullet Increases the risk of short and long term medical complications bullet Interferes with medically necessary weight gain bullet Occurs at inappropriate times or in inappropriate settings such as exercising very late at night or in secret in the bedroom bullet Is accompanied by feelings of anxiety, depression, intense guilt and extreme feelings of failure if the exercise is postponed or there is deviation from the routine bullet Is obsessive Cannot be controlled bullet Requires a rigid exercise schedule bullet Required detailed record keeping bullet Interferes with social relationships or educational and work activities bullet Is a self-punishment bullet Occurs despite injury, illness or medical complications bullet Is not fuelled with adequate nutrition bullet Is used to allow or to give ‘permission' to the individual to eat – known as ‘debting' The individual engages in exercise to: Purge calories Influence weight or shape Reduce or manage general anxiety Manage an obsessive preoccupation with weight gain Alleviate negative emotions Minimise fear and anxiety about eating Unhealthy exercise may include both intense and excessive levels of exercise, compulsive exercise, or excessive levels of activity or incidental exercise. These may include excessive levels of walking, standing, fidgeting, toe tapping or pacing. Healthy activity, is activity that is: bullet For general health and wellbeing bullet For enjoyment bullet For mindful space, relaxation, connection with body bullet Fuelled by adequate nutrition THE DANGERS OF EXERCISE Many individuals who exercise excessively are unaware of what constitutes a healthy level of activity, and are unaware that exercise may or is jeopardising their health. Educate the individual on the dangers of exercise and excessive exercise when in treatment. The type of information provided should be tailored to the individual's particular eating disorder diagnosis, physical and medical status and symptomology. Who engages in excessive exercise? Exercise is a common eating disorder behaviour, with 30-80% of eating disorder presentations featuring excessive exercise. Exercise is primarily used to influence weight and shape, alleviate negative emotions and manage anxiety. Managing excessive exercise in treatment With exercise being so embedded in eating disorder presentations, it is useful to have a process to help guide the management of exercise in treatment. General principles on managing exercise 1 1 Exercise guidelines should be set collaboratively and individualised. 2 2 Exercise is not recommended if the individual is not medically safe to participate, is underweight or undernourished. 3 3 Exercise should be limited if the individual is unable to eat adequately, is losing weight or below a weight deemed appropriate to exercise at, or is unable to comply with exercise guidelines. The Australian Fitness Guidelines Fitness guidelines have been developed by InsideOut and Fitness Australia which also help to provide guidance around the introduction and management of exercise in individuals with eating disorders. SNAPSHOT EXAMPLE - JANE Jane is a 24 year old University student who has attended her usual GP clinic complaining of ‘weird eating, exhaustion and depression'. During an initial brief assessment, the GP notes that Jane is within the healthy weight range, she has been experiencing oligomenorrhoea (ie. infrequent menstrual periods) and altered bowel habits, at times experiencing constipation and at others quite loose bowel motions. When the GP enquires about ‘weird eating' Jane says that she has ‘pretty erratic' eating behaviours - which she relates to ‘the typical student lifestyle'. Upon further investigation, the GP discovers that Jane is in fact engaging in binge eating episodes on most days (6/7). These usually occur in the afternoon or early evening when she is home alone. A typical binge might include 2 meat pies, 2 vanilla slices, 4 small quiches, 1 big box of cereal and 1 litre of milk. Compensatory behaviours include erratic exercise patterns and restricting eating to one small meal per day (usually 2 vitawheats with low fat cottage cheese and a carrot). Fluid intake includes approx 3L water per day, 1L diet coke, 1L low fat milk and 5-8 coffees (low fat milk, no sugar). Jane reveals that she has been bingeing since she was 16 years old. Jane is tired of the emotional roller coaster she feels she has been on, and is tired of the weight fluctuations associated with her eating behaviour. She weighs herself every day and reports fluctuations up to 2kg over a few days. Her current height is 166cm and weight is 65kg. Jane has never been underweight and has been up to 85kg on several occasions. Approximately 2 years ago, Jane reached 95kg (her highest past weight). Jane reportedly feels overweight and that her body is “gross”, although she doesn't have a particular goal weight in mind. The GP is the first person that Jane has admitted this “shameful secret” to, and is reluctant to consider being referred her elsewhere for treatment. THE GP You know Jane has a long history of anxiety and depression which she has had some counselling for and you have prescribed her with Fluoxetine (80mg per day) which she has been taking for 2 years. You undertake a series of blood tests which reveal hypokalaemia and low chloride levels (which you have noted on a previous blood test but not the last one), so you have also prescribed potassium supplements. All other screened bloods (including iron, vitamin B12 and folate) are normal. Jane doesn't want to talk to her existing therapist about the eating problems as she feels that he won't understand about ‘that sort of thing'. It emerges that Jane would rather see a female counsellor about this issue, so you contact the local eating disorder organisation and refer her to someone local who they identify as having an interest in working with clients who have eating disorders. Jane is able to get an appointment in 2 weeks time. THE DIETITIAN When you see her Jane reports vomiting episodes after binge eating, and also after eating anything at all “but only when I'm stressed”. Current “safe” foods and fluids include vitaweets, cottage cheese, all vegetables and salads (raw/steamed, no sauce) except avocado, all fruit, water, diet coke and coffee. Bread, pasta and rice (along with meats and higher fat foods) are “unsafe” foods for Jane as they tend to trigger binge episodes. Nil diuretics, laxatives or diet pills have been reported. Nil cigarettes. Binge drinking reported 1-2/7, and no alcohol in between times. 2-3/7 Jane runs for 60 minutes, then completes 2 aerobics classes at the gym (usually to relieve feelings of guilt associated with binge eating and potential weight changes). On other days, Jane might walk for 20 minutes or does not participate in physical activity. THE PSYCHOLOGIST Jane has been referred to you for counselling associated with the eating disorder. Jane tells you she had a very difficult childhood of abuse and neglect (often going for extended periods of time without food) and was removed from her parents at the age of 5 years. Jane consequently lived in two separate foster homes, until living independently at the age of 16 years. Jane cannot remember a period of time in her life where eating behaviours were not unstructured and erratic. Jane was able to successfully complete high school and enrolled in a teaching degree at University 18 months ago. Jane is finding the demands of juggling University and part-time employment at a patisserie increasingly difficult, and is concerned about her grades. Jane is currently living in shared accommodation with one other girl and a boy, who both have full time employment. All occupants of the house live fairly independent lives. Jane reported that she would like to be able to eat without all of this worry and emotion, and would like to stop binge eating and vomiting though does not know how to start. Medical Considerations 23 of 28 There are numerous medical considerations when working with individuals with an eating disorders. These span across all treatment settings, and should be considered by all medical practitioners: 1 1 Refeeding and Underfeeding Syndrome 2 2 Hypokalemia 3 3 Medications 4 4 Bone Health 5 5 Gastrointestinal disturabances 6 6 Diabetes 7 7 Pregnancy Refeeding Syndrome Studies demonstrate that rapid refeeding with higher calorie approaches is feasible1, with close electrolyte monitoring and correction and ensuring medical monitoring and management2-4. The first two weeks of refeeding pose the greatest risk to the inpatient with an eating disorder, with most cases of refeeding syndrome reported within the first 3 days of starting nutritional support5. However, it can develop after 3 weeks of re-feeding in severely unwell inpatients6. Management should involve6-9: 1 1 Prophylactic supplementation prior to any oral and/or enteral nutrition being provided. This include phosphate, thiamine and a multivitamin. 2 2 Gradually increase oral and/or enteral nutrition and ensure that it is nutritionally balanced with adequate protein and fat 3 3 Ensure close medical monitoring as feeding is initiated (at least 12 hourly in adults and 4hrly in children and adolescents and daily biochemical review until the target energy level has been achieved. If serum levels fall substantially (but are still within the reference range): bullet Do not increase feeds bullet Maintain feeds at the current rate bullet Correct electrolyte levels with supplementation bullet Recheck electrolytes every 24 hours bullet Gradually increase feeds when electrolytes are stable bullet Weigh the patient daily If serum levels fall below the normal range: bullet Reduce Feeds bullet Commence daily ECG monitoring bullet Correct electrolyte levels with supplementation bullet Recheck electrolytes every 24 hours bullet Increase feeds gradually when electrolytes are stable THE UNDERFEEDING SYNDROME Underfeeding syndrome refers to the weight loss and physical deterioration occurring in an inpatient because of failure to provide adequate nutrition support. Over-cautious refeeding protocols or “start low and go slow” approaches2, 8, 10 designed to prevent the refeeding syndrome, may put the severely malnourished person at risk of underfeeding syndrome. This can result in further medical deterioration and even death10. Once a medically unstable inpatient has been admitted it is essential to start refeeding as soon as possible, in order to prevent further deterioration. In inpatient settings that are not used to managing individual's with an eating disorder there can be delays in initiating nutrition support. Hypokalemia Hypokalemia (low potassium) causes muscle weakness, muscle aches and muscle cramps. ECG changes, palpitations and arrhythmias are also potential effects. Hypokalemia is more likely in people who vomit. Medications bullet There is some evidence to support use of medications in the treatment of specific subgroups of eating disorders. bullet Selective serotonin re-uptake inhibitors (SSRIs) in combination with psychotherapy (such as CBT) has been shown to have the best outcome in the management of bulimia nervosa and BED11. SSRIs may also be useful for treating co-morbid depression or anxiety. bullet Tricyclic antidepressants or antiepileptic medication e.g. topiramate may also be useful in Bulimia nervosa, but significant adverse effects limit their use. bullet Vyvanse (a type of dexamphetamine usually used in the treatment of ADHD) has been shown to help reduce bingeing in moderate to severe BED12. In acute anorexia nervosa, comorbid conditions such as depressive or obsessive-compulsive features may resolve with weight gain alone without the need for medication bullet SSRIs may be beneficial in the treatment of comorbid depression and obsessive-compulsive disorder in the non-acute stages of Anorexia Nervosa. bullet Low doses of antipsychotics such as olanzapine may help severely anxious or obsessive patients with Anorexia Nervosa13. Bone Health Decreased bone density and strength is a common consequence seen in individuals with restrictive eating disorders. The following factors increase the risk of decreased bone density: bullet Inadequate food intake bullet Low weight bullet Amenorrhoea bullet Pubertal delay or arrest bullet Family history of osteoporosis Additionally for adolescents, failure to achieve normal peak bone mass or early loss of bone mass, may lead to premature development of osteoporosis in adulthood. Pubertal arrest, regression or slowed growth should prompt assessment of hormonal status, and if persistent, consideration should be given to seek the opinion of an endocrinologist. Investigation of osteoporosis and osteopaenia with a whole body DEXA (Dual Energy X-Ray Absorptiometry) scan should be considered for all individuals who have been amenorrhoeic for more than six months and annually thereafter9. The key to prevention or minimizing osteoporosis is nutritional rehabilitation and the resumption of normal sex hormone metabolism (usually indicated by resumption of menses in females). Management: bullet Restoration of adequate nutritional status, including an increased energy intake to support adequate hormone production, menses and normal growth. bullet Restoration of healthy weight and increased muscle mass. bullet Ensure adequate intake of calcium and vitamin D containing foods. bullet Supplement intake of vitamin D and calcium if required. However calcium from food is always preferable. bullet Adequate sun exposure for vitamin D bullet Referral to an endocrinologist and physiotherapist for individuals with osteopenia or osteoporosis Weight bearing and resistance program developed by a physiotherapist, if the individual is medically stable and nutritional intake allows for increased energy expenditure. Gastrointestinal Disturbances Many individuals with an eating disorder experience a range of gastro-intestinal symptoms throughout treatment, especially in the early stages of re-establishing regular and adequate intake, such as bloating, cramps, constipation and diarrhoea. In fact, research indicates that 98% of individuals with an eating disorder also have a functional gastro-intestinal disorder14,15, due to the changes in gastro-intestinal sensitivity and function associated with disordered behaviours and changes in weight. Weight restoration has been shown to improve both gastric emptying and associated gastro-intestinal symptoms16. Although many of these symptoms improve through the course of treatment, there are some individuals who will experience persistent gastro-intestinal symptoms and this should not be ignored or overlooked. Persistent gastro-intestinal symptoms can compromise treatment and recovery from the eating disorder. It can make it difficult for the individual to incorporate a broad variety of foods if they are fearful of the impact that certain foods will have on their gastro-intestinal symptoms. The presence of significant gastro-intestinal symptoms can also interfere with eating intuitively if it compromises the individual's ability to sense their appetite, hunger and fullness cues. It is therefore crucial that we work in a client-centred approach listening to each individual about their symptoms and work with the individual to alleviate these where possible, ensuring that it aligns with treatment goals. Some tips include: bullet Ensure there is no organic cause to the symptoms (e.g. Coeliac Disease) bullet Eating and drinking regularly and sufficiently bullet Eating a broad variety of foods, across all food groups bullet Ceasing disordered behaviours (restricting, purging, binging, laxative abuse) bullet Encouraging stress reduction through meditation, deep breathing, yoga, guided relaxation Diabetes Young people with Type 1 Diabetes Mellitus have an increased risk of developing eating disorders. Intentional reduction or omission of insulin to achieve weight loss is a common strategy. Signs include poor glycaemic control including hyperglycaemia and hypoglycaemia, and an increased risk of diabetic complications. Management includes: bullet Education: At a diabetic clinic bullet Diet: adaptation of the diabetic diet to manage the eating disorder bullet Exercise: regular exercise must be maintained during regulation of the diabetes. Diabetic control depends on the effects of diet, exercise, and insulin together. Stress also changes diabetic control. bullet Insulin: the insulin regimen managed between the patient and a diabetologist – with diabetologist providing long-term follow-up bullet Monitoring: monitor blood sugar level four times a day during early treatment. Nurses should encourage testing to be done by the patient, but monitor that it is done correctly. Pregnancy and Eating Disorders Females with Anorexia Nervosa usually present with amenorrhoea of variable duration, which can persist for six months or longer after weight recovery. Because ovulation can occur without menstruation, women can be fertile without being aware. Most pregnancies occur during recovery – warn clients to use contraception! Women often worry about the effects of the eating disorder on their child. Children of mothers with Anorexia Nervosa are often aware and take on a caregiver's role to the mother within the first few years of life. The children often develop disordered eating and body image. Therefore, psychological support for the mother, and later the child or family, is imperative Identification – Consider the possibility of an eating disorder in a pregnant woman/adolescent who: Are anxious about weight or shape e.g. refuses to be weighed Has an inappropriate view of a healthy weight for her height or weight gain in pregnancy Has a low BMI or BMI centile for adolescents Fails to gain weight at two consecutive prenatal visits Has a history of periods of amenorrhoea, infertility, previous still birth, premature delivery or past infant feeding problems Has poor circulation; cold or purple fingers Has a history of dental caries (due to frequent vomiting) Management – Assess the depression and suicidality Reassess all medications and stop all those that should be stopped A thorough history, physical examination, and laboratory tests must be performed Obstetrician or family doctor should manage this as a high risk pregnancy Eating disorder follow-up should be weekly for a few weeks and then reduced to monthly A dietitian should assess the diet and nutrient supplements during pregnancy A psychiatric or psychological reassessment should be performed with follow-up visits Potential Perinatal Problems – Higher rate of miscarriage and caesarean section (in AN) and miscarriage, hypertension during pregnancy and caesarian section (in BN) Low pre-pregnancy weight and low weight gain in pregnancy is associated with low infant birth weight and a higher incidence of malformations such as cleft lip and palate. These can be prevented by adequate weight gain during pregnancy. Excessive concern about weight gain and body shape changes during pregnancy; Focus on “eating for the baby” or “gaining weight for the baby so that the baby can grow normally”. Increased risk and incidence of post partum depression. Breastfeeding – The effects of an eating disorder on infant feeding will vary with the type of eating disorder and whether the mother is currently symptomatic. Research on lactation and breast-feeding by women with eating disorders is scant and anecdotal. It is reported that they are less likely to breast feed, more likely to be concerned about their milk supply, to believe that their infant has an adverse reaction to their milk and to introduce bottle-feeding. Families & Carers Spencer et al. (2019) reported that: 1 1 Carers of people with Anorexia Nervosa have high levels of distress, loneliness and isolation, self-blame regarding the illness and insufficient knowledge to support their loved ones. 2 2 The caregiver burden associated with Anorexia Nervosa is similar or greater than that seen with schizophrenia. These carer needs merit help in their own right, but they may also be important maintaining factors and contribute to unhelpful carer behaviours that play a role in perpetuating the eating disorder. Thus, interventions aimed to target unmet carer needs may improve carer burden and positive impact the outcomes for the individual with the eating disorder. These might include carer support groups, self-help books targeted to helping carers manage the eating disorder (e.g. Skills-Based Caring for a Loved One with an Eating Disorder (2016) by Treasure) and specific face to face skills-based training programs. Early trials provide initial support for the use of targeted online interventions for carers of individuals with AN (Grover et al., 2011). Key Messages 1 1 Community treatment is preferable and most people with eating disorders receive treatment as outpatients, however, inpatient treatment is sometimes necessary. 2 2 Admission to an inpatient unit is often a very stressful and frightening experience for any patient. An empathetic and non-judgemental approach is required from all team members. 3 3 Children and adolescents with eating disorders get sicker, quicker and require more intensive re-nutrition to medically stabilise. 4 4 Developing a collaborative treatment plan that is clear and addresses the key issues of treatment and management will be helpful for all team members. 5 5 Parents and families are the best resource to engage with to support a young person through the illness towards recovery, but they themselves need support and skill development to remain calm, consistent and compassionate. 6 6 The key to management of all clients with eating disorders, of all ages, in all settings is the therapeutic relationship and the right approach. Resisting power struggles, externalising the illness, maintaining firm limits, boundaries and clear non-negotiables, using empathy and a warm, caring, non-judgemental approach help to diffuse the power of the eating disorder over the person and assists them towards recovery.