Treatment of Anorexia Nervosa - Coursework Example

Important Aspects of Assessment and Treatment in Anorexia Nervosa Introduction to Anorexia Nervosa Anorexia Nervosa is a type of psychological disorder associated with eating habits. People with this disorder refuse to eat food that is normally required for maintaining a healthy body. They suffer an intense fear of gaining weight or becoming fat. This disorder is found to be extremely rare in occurrence, and is found mostly in specific groups such as the American and English Whites. It is more common in women than in men. This occurrence and frequency can be related to the nature of this disorder. Research and evidences indicate a variety of manifestations of this disorder, however not all signs can be found in all patients. For this reasons, its assessment and prognosis becomes a challenge to the physicians. Its physical manifestations or complications are numerous; also affects the entire endocrine system, which further contributes to weight loss, mood changes, inappropriate growth arrest etc. These hormonal changes also affect central nervous system, cardiovascular functioning and other vital functions of the body. Research indicates that anorexia nervosa is associated with psychological aspects related to sociocultural beliefs, professional pressures, and other personal issues, rather than medico-pathological reasons. It has multiple effects on the patient’s health. These outcomes can be individually treated, but such treatment cannot guarantee complete cure from the disorder. Foremost, it requires appropriate assessment and subsequent treatment in clinical and psychological aspects. The Diagnostic and Statistic Manual of Mental Disorders, DSM-IV, (1994) defines anorexia nervosa as ‘characterized by a relentless pursuit of thinness and a refusal to maintain body weight at a minimally acceptable standard for age and height combined with an intense fear of gaining weight or becoming fat’ (Kuyck et al, 2006; p.55). Anorexia nervosa could be of two types: restricting type in which the patient had not adopted self-induced vomiting, misused laxatives, diuretics and enemas to get rid of food, which the patient believes to be excessive; second is the binge eating/purging type in which the patient had opted for self-induced vomiting and misused laxatives, diuretics etc. Findings from research The term ‘anorexia nervosa’ was first coined by Sir William Withey Gull who has worked extensively on studying this disorder. The turning point in his research included the instance when Gull discovered consistent absence of gastric dysfunction and related loss of appetite along with a morbid mental state. His discovery could eminently differentiate other states of starvation, and was classified as one of the psychomedical conditions (Hepworth, 1999). Following this, much research has been conducted, and numerous cases studied with respect to medicine and developing field of psychiatry; consequently, anorexia nervosa was grouped under the phenomenon of psychopathology. Hepworth’s (1999) work has challenged this conceptualization arguing its association with various social and cultural aspects of western societies and that its construction is associated with different social discourses that were evidenced with each case that anorexia nervosa presented in the field of medicine and psychiatry. In her work, Hepworth (1999) has referred to the role spirituality and religion played in self starvation, specifically of women, and also to emergence of madness and starvation meant for enlightenment; further, she highlights the emergence of medicine, clinic and health-consciousness. This entire study indicates the transformation of beliefs based on religion to authority, guided by social regulations from time to time. Through this, the author intends to draw a relation between the custom self-starvation and ideology of woman based on the changing knowledge. In turn, Hepworth (1999) draws our attention to this disorder’s medical as well as moral discourses. Likewise, researches conducted on anorexic patients have revealed a myriad of factors associated with medical, psychological, sociocultural, genetic and even prenatal conditions. For instance, somewhat supporting Hepworth’s (1999) thesis, Garner and Garfinkel’s (1980) research conducted on professional dance and modeling students revealed a relation between individuals’ sociocultural background and chances for development of anorexia nervosa. In this research, the chosen students were expected to focus on maintaining slim figure. Based on results obtained from questionnaire to assess symptoms of anorexia nervosa, significant number of girls were found to be at risk of developing anorexia nervosa and were also under high pressure of competition in their professions. Two researches were studied that dealt with patient attitudes towards treatment. In research conducted by Tan et al (2006), female participants in the age group of 13-21 and also their parents were interviewed to understand the ethical and conceptual implications of findings related to decision-making capacity with respect to acceptability of treatment. This study emerged with two broad issues: difficulties in thinking and changes in values. Difficulties in thinking included issues such as muddled thinking and difficulties in concentration during the entire treatment regimen; ambiguity of belief related to severity of the disorder, physical risks and possibility of death; and external influences on thinking. Secondly, changes in values included values and beliefs attached to fatness/obesity; depressive values caused by their morbid physical condition; giving utmost importance to losing weight than any other thing in life; patients’ positive beliefs of being thin and ability to lose weight quickly; patients regarded being anorexic as characteristic of their personal identity and style as some regarded that state as rigid, controlled, high achieving and perfectionist life style (p.279). Another recent research conducted by Tan et al. (2010) on assessing attitudes of anorexic patients towards treatment, 29 women were interviewed to know their opinion regarding compulsion and coercion in treatment of anorexia nervosa. Very similar results were obtained, which indicated that patients supported compulsion and coercion in treatment only in life-threatening situations. In this research, the perception of coercion was justified by relationships with parents, other family members and even mental health professionals. Characteristics and challenges involved Most of the studies indicated that the potential risk factors for anorexia nervosa include negative self-evaluation and perfectionism. Although the actual cause for anorexia nervosa cannot be ascertained in all cases, all these researches indicate that its treatment cannot be completed with just clinical interventions, but also requires psychotherapy; the treatment should be focused on changing patients’ attitude and belief towards their physical appearance and should be made to realize the importance of maintaining weight in the right proportions to lead healthy life. Most important characteristic of patients with anorexia nervosa is their constant denial of presence of the problem, itself, and are said to be non-cooperative in terms of assessment and treatment. For this reason, it becomes necessary to involve parents or other people associated with the patient to evaluate the degree of weight loss and other features of the illness. Hence, most of the time treatment is compulsory and forceful. Tan et al.’s (2006) study found that anorexia nervosa impacts patients’ thinking process, affects concentration, causes confusion and varied beliefs. This state of mind also affects patients’ responses to treatment and its regimen. Other risk factors include genetic/hereditary presence, developmental factors related to puberty and life transitions, psychological factors such as chronic stress and anxiety besides sociocultural factors such as profession, competition, peer influence, family situations etc (Shepphird, 2009). One of the critical considerations that psychologists and physicians include in treatment of anorexia nervosa is the competence of the patient in understanding the need for treatment. Tan et al.’s (2006) study clearly explains legal implications associated with patient’s consent to treatment, and his/her competence in understanding the need for treatment. Treatment can be forced upon the patient only if proven incompetent to ascertain the need for treatment, which includes criteria such as ability to understand facts relevant to treatment decision, retention of these facts in order to use them in coming to a decision; the ability to believe the facts; and the ability to weigh facts and coming to decision. Although these criteria are used for assessing the patient’s competence to take decision related to treatment, they do not determine the treatment regimen by any means. Age of the patient should also be considered while assessing for competence. Research indicates that anorexia nervosa has one of the highest mortality rates among psychiatric disorders (Evans, 2005). Treatment of anorexic patients without their consent is guarded by statutes related to health care in most of the nations (Tan et al, 2006). Physicians and psychiatrists face significant dilemma in treating anorexic patients without obtaining their consent, either because the binding laws or because of emotional involvement of family members and others with the patient. Beumont and Vandereycken (1998) have asserted that the treatment of anorexia nervosa often involves implementing a re-feeding programmeme that may require the use of strict supervision, enforcement of prescribed dietary plans, prevention of exercising or purging, and naso-gastric or gastrostomy tube feeding. All these measures restrict freedom and can be experienced as intrusive and coercive by the patients, their families, and the clinical staff. Those involved can, for these reasons, feel concern about imposing treatment irrespective of whether they believe them to be effective (cited by Tan et al., 2006; p.269). In addition to eating disorder, anorexic patients also exhibit symptoms associated with depression, anxiety, substance use, and also personality disorders. Hence, assessment and treatment need to consider these aspects also. Assessment and Treatment In all types of eating disorders, people tend to suffer from recognizing and expressing their emotions, which further hampers their ability to differentiate between psychological and somatic needs like frustration and hunger. Fassino et al. (2007) assert that psychosomatic perspective of eating disorders like anorexia nervosa indicates the role of psychosocial factors as a cause of vulnerability; the interaction of psychosocial and biologic factors on the course of the disorder; and the use of psychological therapies in prevention and treatment of these disorders. As seen in most of the researches, assessment of anorexia nervosa based on behaviour or clinical symptoms is extremely difficult in early stages. Usually, patients suspected to have this eating disorder is usually interviewed and questioned systematically. Initially these patients are assessed for speech, emotion, appearance, alertness, and activity. While speech is usually clear, it may not provide sufficient evidence. Anorectic patients carry varied emotions like anger, depression, anxiety etc. Physically, they are lean and look malnourished. In cases other than severe, these patients are usually alert; however, they may be evaluated for shortness of breath, chest pain, and changes in heart rate. In addition to these findings, patients tend to follow a rigorous exercise regimen besides starving (Polk & Mitchell, 2008). Hence, indexes of physical activity levels need to be assessed, considering all possible intensive, self-initiated exercises such as jogging, walking, or aerobic exercises meant to drastically cut down calories. In many cases, an eating attitude test (EAT) is also preferred. EAT is a 40-item index developed by Garner and Garfinkel (1979) for assessing attitudes associated with anorexia nervosa (Donovan & Marlatt, 1988). However, it becomes very important for the clinicians to first rule out presence of other eating disorders or misinterpretation of anorexia nervosa with other disorders such as bulimia nervosa. For this, Eating Disorder Inventory (EDI) is used to assess psychological and behavioural components common in anorexia and bulimia (Donovan & Marlatt, 1988). Clinical tests for leucopoenia, hypoglycemia, anaemia and thyroid functioning are also considered. However, these tests need to be combined with behavioural observations and interviews for appropriate assessment. Considering the limitations of self-reported information on these tests, collateral reports obtained from parents, friends or roommates can be helpful to validate patients’ self-reported information. Treatment of anorexia nervosa depends upon its severity, i.e. whether mild, moderate or severe. Indications for hospitalization of patients also depend upon the severity; however, the trend of weight loss is also a significant indicator of method of treatment. Rapid weight loss warrants hospitalization; mild to moderate cases with slow weight loss might require an outpatient treatment regimen. Nevertheless, mild to moderate cases that show slow rate of weight gain can potentially progress to chronic anorexia nervosa and eventually terminal illness. After clinical decision of assessment and treatment is made, patient’s psychological treatment plan becomes necessary. In fact, both the treatments should be simultaneous so that patient’s thought process during treatment is gradually changed. Mehler (2001) asserts, ‘cognitive psychotherapy, which attempts to help patients recognize the connection between their dysfunctional thoughts and maladaptive behaviours, is frequently used’ (p.1051). Subsequent to clinical and behavioural assessment for anorexia nervosa, its treatment includes a multidisciplinary regimen consisting of clinical and dietary interventions along with behavioural monitoring and counseling sessions, if required. While the physical status and body weight is constantly monitored by the physician, psychotherapy should aim at regular intervention, patient adherence, integration and prioritization of treatments, and effective treatment of comorbid psychiatric illness. Through the treatment period, patient must be given reassurance of his/her physical appearance, positive side of gaining weight in right proportions (Mehler, 2001). In addition, taking help from family members in the treatment process post hospitalization has been proved to be more effective than individual therapy; this can also check symptoms of disorder relapse. However, the results are not clearly established (Evans, 2005). Critical evaluation of research on anorexia nervosa Although assessment of anorexia nervosa requires interviewing and questioning of patients, most of the researches cannot guarantee accurate answers for the questions by the patients. If sample is directly taken from a group or community, it is difficult to find sufficient sample size because this disorder is relatively rare. Hence, if the sample is collected from referrals by hospitals, then the sample size could be prone to selection bias. Tan et al.’s (2006) study also experienced similar limitation in that they could not include men in their study, and the entire sample population consisted of patients belonging to one ethnic group. From research perspective, according to Agras and Robinson (2010), some of the challenges to researchers in anorexia nervosa include insufficient sample size, higher dropout rates, recruitment difficulties, and placebo controls. As seen in many cases, occurrence of anorexia nervosa is related to sociocultural values and beliefs; hence consideration of ethnicity becomes important in assessing its prevalence and treatment. However, due to the limited number of cases, gathering large sample data consisting of mixed population becomes highly impossible unless an attempt to conduct postal/telephonic interviews of sample patients from all over the world is made. This attempt seems far from feasible. Tan et al’s (2006, 2010) researches indicate that patients’ experiences with lack of choice in treatment regimen and use of leverage were ethically problematic. However, involving the patient in treatment planning and obtaining consent can be good way to gain commitment from the patient. This will also help in proactively removing the stigma associated with weight gain. In spite of this, treatment regimen, whether coercive or otherwise, is difficult to be implemented mainly because of patients’ inability to interpret and appreciate the need and change their pre-existing notion of physical appearance. It has been seen that even after obtaining patients’ consent to treatment; they still feel the process is traumatic and pressurizing. This could be due to ineffective engagement of treating professionals in the process and/or inability to establish strong relationship with the psychotherapists. Thus, clinical as well as psychotherapeutic interventions remain ethically debatable. Conclusions and Recommendations: In conclusion, anorexia nervosa is a complicated eating disorder that presents with other disorders related to anxiety, depression, personality etc. Although its occurrence is rare, this disorder severe and presents with acute co-morbidity and chances of mortality. As the disorder manifests in various clinical and psychological ways, its assessment could be very confusing and misleading if not approached in an appropriate manner. Moreover, the developmental sequence of this disorder and its associated conditions significantly vary among patients. Treatment of anorexia nervosa requires multiple interventions at physical, clinical and mental levels simultaneously. The most challenging part of its treatment is the patients’ cooperation for clinical, dietary, and psychotherapeutic treatments. Considering the high rate of mortality, patients with this disorder require paramount care and attention by family, friends, partners as well as healthcare professionals. Timely treatment and care should be provided to the patients so that their health is restored to normal. This care should include medical as well as psychological treatments. Clinical treatments should include restoration of electrolyte balances; replenishing all required nutrients to the body through food or medicines; reversal of haemotologic abnormalities like leucopoenia, anaemia, platelet counts; reversal of hormonal imbalance; treatment of other medical complications, if present; weight restoration; reducing acute depression and anxiety through antidepressants. Most importantly, psychotherapy of these patients plays a major role in helping the patient recover physically as well as mentally. Considering the reluctance of patients to treatment, involvement of family and other members associated with the patient becomes necessary for providing effective and complete treatment, and also in preventing relapse. Hence, psychotherapy involving all family members may be recommended. References Agras, W.S and Robinson A.H. (2010). What Treatment Research is Needed for Anorexia Nervosa? In The Treatment of Eating Disorders: A Clinical Handbook. NY: Guilford Press. David M. Garner and Paul E. Garfinkel (1980). Socio-cultural factors in the development of anorexia nervosa. Psychological Medicine, 10 , pp 647-656 Donovan, D.M and Marlatt, G.A. 1988. Assessment of addictive behaviours. London: Taylor & Francis. Evans, D.L. (2005). Treating and preventing adolescent mental health disorders: what we know and what we don't know : a research agenda for improving the mental health of our youth. U.S.A: Oxford University Press US. Fassino, S, Daga, G.A, Piero, A and Delsedime, N. (2007). Psychologic Factors Affecting Eating Disorders. In Porcelli, P and Somino, N’s (eds.) Psychological factors affecting medical conditions: a new classification for DSM-V. Adv Psychosom Med. NY: Karger Publishers. Vol:28, pp: 141-168. Hepworth, J. (1999). The social construction of anorexia nervosa. London: SAGE. Kyuck et al. (2006). Functional Neuroimaging in Anorexia Nervosa. In Kyuck, K.V’s (ed.) Electrical Brain Stimulation in Psychiatric Disorders: Contributions from Research in Animal Models. Leuven, Belgium: Leuven University Press. (Ch: 4, pp:55-82). Mehler, P.S. (2001). Diagnosis and Care of Patients with Anorexia Nervosa in Primary Care Settings. Ann Intern Med. Vol. 134, pp: 1048-1059 Polk, D.A and Mitchell, J.T. (2008). Prehospital Behavioural Emergencies and Crisis Response. London: Jones & Bartlett Learning. Shepphird, S.F. (2009). 100 Questions & Answers About Anorexia Nervosa. MA: Jones & Bartlett Learning. Tan et al. 2006. Competence to make treatment decisions in anorexia nervosa: thinking processes and values. Philos Psychiatr Psycho. 13(4): 267–282. Tan et al. 2010. Attitudes of patients with anorexia nervosa to compulsory treatment and coercion. International Journal of Law and Psychiatry. 33(1): 13–19. Read More