Anorexia Nervosa: A Clinician's Guide to Treatment 9783110848229, 9783110095319

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Anorexia Nervosa

Walter Vandereycken Rolf Meermann

Anorexia Nervosa A Clinician's Guide to Treatment

W Walter de Gruyter G Berlin· New York 1984 DE

Walter Vandereycken, Μ. D. Psychiatrische Universiteitskliniek St. Jozef Universiteit Leuven Leuvensesteenweg 517 B-3070 Kortenberg Rolf Meermann, Μ. D. Psychiatrische und Nervenklinik der Westfälischen Wilhelms-Universität Klinik für Psychiatrie Albert-Schweitzer-Straße D-4400 Münster

CIP-Kurztitelaufnahme der Deutschen Bibliotek

Vandereycken, Walter: Anorexia nervosa : a clinician's guide to treatment / Walter Vandereycken ; Rolf Meermann. - Berlin ; New York : de Gruyter, 1984. ISBN 3-11-009531-9 NE: Meermann, Rolf:

Library of Congress Cataloging in Publication Data

Vandereycken, Walter, 1949 Anorexia nervosa. 1. Anorexia nervosa. I. Meermann, Rolf, 1949 II. Title. [DNLM: 1. Anorexia Nervosa-therapy. WM 175 V232a] RC552.A5V36 1984 616.85'2 84-72039

© Copyright 1984 by Walter de Gruyter & Co., Berlin 30. - All rights reserved, including those of translation into foreign languages. No part of this book may be reproduced in any form - by photoprint, microfilm, or any other means - nor transmitted nor translated into a machine language without written permission from the publisher. - Printed in Germany. The quotation of registered names, trade names, trade marks, etc. in this copy does not imply, even in the absence of a specific statement that such names are exempt from laws and regulations protecting trade marks, etc. and therefore free for general use. Printing: Druckerei Gerike GmbH, Berlin - Binding: Dieter Mikolai, Berlin. - Cover Design: Rudolf Hübler, Berlin.

Preface Mr. Duke's daughter in St. Mary Axe, in the year 1684, and the Eighteenth Year of her Age, in the month of July felt into a total suppression of her Monthly Courses from a multitude of Cares and Passions of her Mind, but without any Symptom of the Green-Sickness following upon it. Richard Morton, Phthisiologieζ (1689)

Although she was probably not the first person ever with anorexia nervosa, Mr. Duke's daughter is commonly considered the first well-documented case in medical history. For this reason, the present book is a tercentenary homage to Richard Morton who was as confounded by the disorder as we are, 300 years later (Silverman, 1983). Regardless of its long medical history which goes back to the Middle Ages, anorexia nervosa is often viewed as a 'modern' disease, "a glamorous cross between two Victorian favorites, consumption and hysteria, but updated for a modern audience" (Sandra Gilbert, cited by Chernin, 1981, p. 47). The voluminous literature illustrates how vividly the anorexic has caught the imagination and how strongly clinicians and researchers have been attached to her, perhaps even enamored (Spignesi, 1983). But the actual burgeoning interest in this 'illness' could be 'morbid' in itself or at least potentially 'pathogenic'. In the medical literature, no doubt, anorexia nervosa is 'in' and even to such an extent that it has already become the victim of the academic 'publish-or-perish' pressure ending up in plagiarism (Broad, 1980)! John Adams Atchley, the president of the American Anorexia Nervosa Association, said he really doubted that we need more books on anorexia nervosa : "It strikes me, in trying to keep in touch with the situation, that we are (...) just about 'booked out'; at least until there is something new to say" (Atchley, 1981 -82, p. 197). But this was not our motive in writing this book. The primary reason was the need which we felt for a practical guide, as suggested by Zavodnick (1983): "In stark contrast to the wasting of the patient, the literature on the anorexic condition is fairly bursting at the seams. The number of scholarly publications on the subject is legion. The clinician seeking the latest information in a concise form would welcome a comprehensive yet compact approach to the subject" (p. 140). So, our primary intention was to examine - from a clinician's point of view the complexity of anorexia nervosa in a comprehensive yet compact manner, relying on our own clinical experiences as well as on the most relevant and upto-date literature. We intend to offer the reader a practice-oriented 'guide' rather than a therapeutic 'cookbook'. From our anorectic patients we have learned that they may very often conceal their basic insecurity and helplessness behind a facade of preoccupations with cooking and pseudo-gastronomy. In a similar way, inexperienced clinicians may conceal their insecurity and helplessness by copying therapeutic recipes from a

V

'how-to-do-it' book. Although we will make some recommendations, suggestions and warnings, we have deliberately avoided reducing our writing to a few simple "do's" and "don'ts". The guidelines we offer must be assimilated and then supplemented by each clinician's own creativity. "Still, the psychodynamicists debate with the behaviorists, and both groups have little hope that the psychobiologists will discover anything of real significance" (Sweeney, 1981-82, p. 193). We have attempted not to stimulate irrelevant academic polemics and sterile competition between theoretical schools. This does not alter the fact, however, that we have our personal preferences. All in all, we feel bound to a scientist-practitioner perspective of human behavior. Though our approach may be characterized as an eclectic, multimodal or broadspectrum view, it is basicly behaviorally and interactionally orientated. It may be important for some readers to recognize that this book has been written by two Europeans for whom English is not their mother tongue. Though we had excellent correctors of our manuscript (Gene Lowenkopf in New York and Mike Talbot in Münster), we apologize for any unevenness in our English and any lack of clarity we might possibly be guilty of. Nevertheless, we hope that the reader will be inspired by the collaborative work between the two of us, across the frontiers of language and nationality. Neither geography nor defense of professional territory should be a hindrance to the sharing of our experiences as clinicians : let us replace competition by collaboration, that's our message.

A final remark regarding the formal aspect of this book. Because the vast majority of the patients we write about are females, we will only use the female gender of pronouns when speaking about the patient, instead of using 'he and/or she' or 's/he', etc. This is just aimed at avoiding awkward writing and is not meant to disparage either gender. Moreover, it does not imply that our approach, as described in this book, would be essentially different for male patients. The 'textbook case' is a rarity, and so is 'the' anorexia nervosa patient! We have learned so much from so many people - patients, colleagues, friends, relatives - that it would be impossible to mention them all. Although we as authors are entirely responsible for the end product you are reading, the present book has been 'shaped' by the stimulation, cooperation and discussion from Prof. Dr. R. Pierloot (Kortenberg), Prof. Dr. R. Tolle (Münster), Johan Vanderlinden (Kortenberg), Elly Kog (Leuven), M.E. Houben (Kortenberg), Christiana Napierski (Münster), Dr. A. Van Acker (Brussels), Dino Van Werde (Leuven), Dr. Arnold Andersen (Baltimore), Dr. Regina Casper (Chicago), Dr. Jeffrey Chang (Los Angeles), Dr. David Garner (Toronto), Dr. Robert Hendren (Washington), Dr. Craig Johnson (Chicago), Dr. Katherine Halmi (New York), Dr. Michael Strober (Los Angeles), Dr. Gerald Tarlow (Los Angeles), Dr. Joseph Silverman (New York), and in particular, Dr. Eugene Lowenkopf (New York) and Michael Talbot (Münster). Parts of this book have been made possible by a grant from the Deutsche Forschungsgemeinschaft (DFG Me 716/1-3) for the second author (R.M.).

VI

And lastly, to our beloveds our deep gratitude not only for their constant support, but also for tolerating the disruptive effect on normal living of sparetime writing.

References Atchley, J.A. (1981-82), Anorexia nervosa: Let's get going. International Journal of Psychiatry in Medicine, 11 : 195-197. Broad, W.J. (1980), Imbroglio at Yale. Science, 2310 : 38-41, 171-173. Chernin, K. (1981), The Obsession. Reflections on the Tyranny of Slenderness. New York : Harper & Row. Silverman, J.A. (1983), Richard Morton, 1637-1698. Limner of anorexia nervosa: His life and times. A tercentenary essay. JAMA, 250 : 2830-2832. Spignesi, A. (1983), Starving Women. A Psychology of Anorexia Nervosa. Dallas : Spring Publications. Sweeney, D.R. (1981-82) Anorexia nervosa: In quest of the lesions. International Journal of Psychiatry in Medicine, 11 : 193-194. Zavodnick, J.M. (1983), Anorexia revisited (book review). Contemporary Psychiatry, 2(2)·: 140-141.

VII

LIST OF TABLES 1 - 1. Comparison between anorexia nervosa and bulimia nervosa

3

1- 2. The Feighner criteria for anorexia nervosa

7

1- 3. DSM-III criteria for anorexia nervosa

9

1 - 4. General medical interview of the patient with a weight problem

10

1- 5. Possible findings during the physical examination

11

1- 6. Some endocrinological changes in anorexia nervosa

14

1- 7. DSM-III criteria for bulimia (nervosa)

16

1- 8. Features of psychogenic vomiting

16

1- 9. The anorectic behavior - Outline for clinical interview

19

1-10. An outline for the family diagnostic assessment

21

2- 1. Anorectic cognitions

55

2- 2. Levels of dysfunctions and therapeutic approaches

61

4- 1. Definition and use of the prognostic nutritional index (PNI)

84

4- 2. Complications associated with nutritional rehabilitation

89

6- 1. Weight gain program for inpatients anorectics

117

6- 2. Sample treatment plan

125

8- 1. Anorexia nervosa : contrasting approaches

152

9- 1. The physical complications of bulimia nervosa

174

9- 2. Topics covered in assessment of bulimia

175

9- 3. Antecedents and consequences of bulimia with suggested behavioral treatment approaches

177

10- 1. The'perfect'treatment study

197

11 - 1. Global clinical score - Criteria for assessing anorexia nervosa

241

VIII

LIST OF FIGURES 1-1. The dysorexia/dysponderosis continuum

4

1-2. Metabolic and morphological changes in anorexia nervosa

12

1-3. Endocrine changes in anorexia nervosa

13

2-1. Psychopathology and pathophysiology of anorexia/bulimia nervosa

44

2-2. Anorexia nervosa as a multidetermined disorder

45

2-3. Multidimensional schema of pathogenesis of anorexia nervosa.

52

2-4. Assumptions as determinants of anorectic behavior

54

2-5. Functional analysis of anorexia nervosa

60

6-1. Schematic view of the diagnostic therapeutic procedure in behavior therapy

114

9-1. Diagrammatic formulation of bulimia nervosa

172

9-2. The development and maintenance of bulimia nervosa A cognitive behavioral model

173

10-1. Interactions in the treatment process

203

IX

LIST OF APPENDICES

1-1. The analogue scale measurement

31

1-2. Eating attitudes test (EAT)

31

1-3. Eating disorder inventory (EDI)

34

1-4. Anorectic behavior observation scale (ABOS) for parents/spouse

39

5-1. Outpatient psychotherapy for anorexia/bulimia problems Treatment contract

111

6-1. Information for patients

133

6-2. Information for the family

137

10-1. Suggested background reading

224

10-2. A selected bibliography of treatment methods in anorexia nervosa.

225

10-3. Literature for counselors and social workers

229

10-4. Literature for nurses

230

10-5. Guidelines for anorexia nervosa patients in a psychotherapeutic community

231

10-6. An anorexia nervosa patient's counsel to therapists

232

10-7. Literature for 'laymen'

233

10-8. Addresses of self-help organizations

234

X

TABLE OF CONTENTS Preface

V

List of tables List o f figures List of appendices

VIII IX X

1. How can a reliable diagnosis be made ? 1.1. The spectrum of eating disorders 1.2. Diagnostic criteria 1.3. Differential diagnosis 1.4. Behavioral assessment 1.4.1. The clinical interview 1.4.2. Assessment instruments 1.5. Conclusion

1 5 9 17 17 22 24

2. What are the causes ? 2.1. 2.2. 2.3. 2.4. 2.5. 2.6.

Introduction The psychodynamic perspective The systems theory approach The sociocultural interpretation The biological point o f view The cognitive-behavioristic model 2.6.1. Cognitive deficits 2.6.2. Body image disorders 2.6.3. The false problem solving strategy 2.7. Conclusion

43 45 47 49 50 51 52 54 57 59

3. Is prevention possible ? 3.1. 3.2. 3.3. 3.4. 3.5. 3.6. 3.7.

Introduction Epidemiology The culture of slenderness The upper/middle-class family The adolescent-at-risk Towards early detection Conclusion

65 66 66 69 70 72 76

4. What should be done at the acute stage ? 4.1. Introduction 4.2. Emergency cases 4.3. Refeeding

83 84 87

XI

4.4. Feeding or treating 4.5. Conclusion

90 93

5. When is outpatient treatment possible ? 5.1. 5.2. 5.3. 5.4. 5.5.

Resistance and motivation Criteria for admission The step towards the hospital Outpatient approaches Conclusion

97 99 102 104 108

6. How should an inpatient treatment program be structured ? 6.1. 6.2. 6.3. 6.4.

Introduction Behavior analysis and treatment planning The short-term perspective The long-term perspective 6.4.1. Changing body image 6.4.2. The group approach 6.4.3. The aftercare program 6.5. Conclusion

113 114 116 120 120 123 128 130

7. Are drugs useful ? 7.1. 7.2. 7.3. 7.4. 7.5.

Introduction The patient's attitude Electroconvulsive therapy (ECT) Psychosurgery Pharmacotherapy 7.5.1. Neuroleptics 7.5.2. Antidepressants 7.5.3. Appetite regulators 7.5.4. Miscellaneous 7.6. Conclusion

139 139 140 140 141 141 142 143 145 145

8. Has the family to be treated ? 8.1. 8.2. 8.3. 8.4. 8.5. 8.6. 8.7.

Protection or confrontation ? The balance between authority and autonomy The family-oriented systems approach Working with instead of against the family The family of the hospitalized patient Parent groups Conclusion

151 153 155 158 159 162 165

9. How should specific problems be handled ? 9.1. Amenorrhea, infertility, and contraception

XII

169

9.2. Bulimia 9.3. Vomiting and abuse of laxatives/diuretics

172 181

10. W h o is the best therapist ? 10.1. To treat or not to treat 10.2. Competition and specialization 10.2.1. Therapy models 10.2.2. Treatment settings 10.2.3. Therapist factors 10.2.4. Self-help 10.3. Pitfalls during treatment 10.3.1. Detrimental therapist reactions 10.3.2. Therapeutic traps and team work in the hospital 10.4. Conclusion

191 194 195 198 202 206 209 209 213 219

11. When can the patient be said to have recovered ? 11.1. The significance of follow-up investigations 11.2. The long-term course of anorexia nervosa 11.3. Conclusion About the authors

237 242 246 251

XIII

Chapter 1

How can a reliable diagnosis be made ? 1.1. 1.2. 1.3. 1.4.

The spectrum of eating disorders. Diagnostic criteria. Differential diagnosis. Behavioral assessment. 1.4.1. The clinical interview. 1.4.2. Assessment instruments. 1.5. Conclusion. References. Appendix: 1.1. The Analogue Scale Measurement. 1.2. Eating Attitudes Test (EAT). 1.3. Eating Disorder Inventory (EDI). 1.4. Anorectic Behavior Observation Scale (ABOS).

1.1. The Spectrum of Eating Disorders Although anorexia nervosa and obesity have been regarded for a long time as being different and distinct psychosomatic entities, there is enough evidence from clinical practice and research to justify abandoning such a dichotomous view. Already in 1951, Berlin and co-workers remarked that the psychopathology, as enunciated by various authors, is almost identical in both conditions. And it is no mere coincidence that Hilde Bruch is recognized as a worldwide authority on both anorexia nervosa and obesity in which she presumed the same pathogenetic process : "In both conditions food intake and body size are manipulated in a futile effort to solve or camouflage inner stress or adjustment difficulties" (Bruch, 1976, p. 269). Speaking of anorexia nervosa and obesity as separate syndromes disregards, for instance, the fact that both conditions can alternate in the same person. Guiora (1967) was the first to suggest the name 'dysorexia' for a clinical picture comprising both anorectic and bulimic behavior as the extreme ends of the same disorder. Almost simultaneously but independently, Ziolko (1966, 1967) in Germany published a few papers on the same subject using the terms 'hyperorexia' versus 'anorexia'. Neither Guiora nor Ziolko, however, made further attempts to reformulate the nosology of eating disorders in a more dynamic and dimensional sense. One must wait another decade until the static way of defining eating disorders is critically questioned. In the case of anorexia nervosa each 'expert' used his own diagnostic criteria but seemed, nevertheless, to agree tacitly upon a supposedly universal definition of the syndrome. When Feighner and associates

1

ANOREXIA

NERVOSA

(1972) suggested their diagnostic criteria for research purposes, they created considerable discussion on this topic which has continued ever since the publication of the DSM-III criteria (American Psychiatric Association, 1980). For the first time it became overtly clear that a definition of anorexia nervosa according to a syndrome method of diagnosis leads to a number of difficulties, especially classification problems, in the large group of patients who quantitatively or qualitatively deviate form the so-called 'typical' picture (Andersen, 1977). Several signs indicate that there is an actual trend to regard anorexia nervosa as far more complex than the simple disease concept used since Gull, in the 19th century, wrote the first pages of its modern medical history. There have been several attempts to subdivide the syndrome with respect to specific behavioral characteristics. Even if one relies on strict diagnostic criteria, it seems increasingly likely that anorexia nervosa contains different subgroups. Beumont, George and Smart (1976) proposed that anorexia nervosa might be considered to consist of two different clinical forms according to whether the presenting symptom (the main way of inducing weight loss) is mere abstinence of food, or self-induced vomiting or purging; so they spoke about the 'dieters' or 'abstainers' on the one hand, and the 'vomiters and purgers' on the other. Actually, several research reports stress the significance of sub-classification in anorexia nervosa suggesting that patients with bulimia may constitute a distinct subgroup (Casper, Eckert, Halmi et al., 1980; Crisp, Hsu, Harding et al., 1980; Strober, Salkin, Burroughs et al., 1982; Vandereycken & Pierloot, 1983). Bulimia - like its synonyms: binge eating, hyperorexia or compulsive overeating - refers to a voracious appetite or the consumption of large amounts of food in a short period of time. Relying on this description, bulimia must be considered primarily as a symptom which may be associated with several forms of behavioral and organic pathology (Mitchell & Pyle, 1982). As such, it has already a long history in medical literature (Casper, 1983; Ziolko, 1981). But a 'new' syndrome has been 'discovered' in recent years. Surprisingly enough, in the second half of the 70s a number of different authors independently described a peculiar cluster of features centered around bulimia, the irresistible urge or compulsion to overeat (mostly in secret), followed by (self-induced) vomiting and/or purging, or alternating with episodes of self-starvation to keep the body weight under control within (sub)normal limits. Although there may be some disparity in the accentuation of some characteristic or another, the description of this 'new' bulimia syndrome by various authors is strikingly similar despite the different labels which have been suggested : bulimia nervosa, bulimarexia, compulsive eating, dietary chaos syndrome, gorging-purging syndrome, hyperorexia nervosa, kibarashi-gui, stuffing syndrome, TanthalPolyphem syndrome (see Vandereycken & Pierloot, 1981 b). Although it is now mostly referred to as simply bulimia (according to the DSM-III description), we prefer the term bulimia nervosa, suggested by Russell (1979), in order to avoid terminological confusion witn the tern: bulimia which in fact refers only to the symptom of voracious './petite an J which has been used in medicine for many centuries.

2

HOW CAN A RELIABLE

DIAGNOSIS

BE MADE ?

This distinction becomes particularly important when one distinguishes between bulimic anorexia nervosa patients and bulimia nervosa patients. According to DSM-III (see next paragraph) the distinction seems to be based primarily on the presence or absence of considerable weight loss. The similarities and differences between anorexia nervosa and bulimia nervosa are summarized in Table 1 -1.

Table 1-1. Comparison between Anorexia Nervosa and Bulimia Nervosa BULIMIA NERVOSA

ANOREXIA NERVOSA Epidemiology

Natural

increases with higher socioe c o n o m i c status

history

Weight

Menstrual

periods

90-95 % female

m o r e than 80 96 female

slightly y o u n g e r

slightly older

a b o u t 1-3 % of precollege girls s h o w (preclinical symptoms

5-13 % college w o m e n s h o w (preclinical symptoms

frequent conversion to bulimia with chronicity

occasional conversion to food-restricting anorexia nervosa with chronicity

below 80 % of ideal body weight

variable weight w i t h i n or close to n o r m a l r a n g e irregular or absent

absent preoccupation with food, weight a n d body size often dysphoric, guilty a n d self-blaming often socially isolated

Behavior

fear of fatness f r o m anticipated loss of control of eating

fear of fatness f r o m actual loss of control of eating

m o r e obsessional

m o r e histrionic

less a w a r e of psychological distress

m o r e a w a r e of psychological distress

Adapted from Andersen (1983) Though researchers mostly prefer a dichotomous viewpoint for sharply subdividing defined disease entities, clinicians are usually forced to abandon the static and categorical conceptualization of anorexia/bulimia nervosa being a unitary illness. Recently, several authors have defended the idea that eating disorders among adolescents and young adult women may be a continuum from problem-free to primary anorexia nervosa (Thompson & Schwartz, 1982). Hence, anorexia nervosa is considered to be a 'spectrum disorder' with presentations ranging from normative adolescent concern about weight, dieting, appearance etc., to severe psychopathology and classical anorectic symptomatology among those predisposed (Swift & Stern, 1982). It is clear that anorexia nervosa, like most disorders, occurs on a continuum with varying degrees of severity, i.e. with only quantitative distinction between milder and severe cases. There is, however, a qualitative (psychopathological) difference between anorectic patients and the growing number of weightpreoccupied women (Garner, Olmsted & Garfinkel, 1983). The same applies to

3

ANOREXIA

NERVOSA

anorectic patients and secondarily amenorrheic women : they may share certain psychological features, but the former show personality characteristics and especially a 'fear of failure' which are fundamentally different (Weeda-Mannak, Drop, Smits et al., 1983). These differences might be particularly important with respect to early recognition and prevention of anorexia nervosa (see 3.3. 'The culture of slenderness'). The clinical considerations discussed so far lead us to think that eating/weight disorders could be better approached and understood if we abandon a static system of diagnosis and use a more dynamic and dimensional model instead. By 'dynamic' we mean that we wish to include an important time factor in our descriptive approach, indicating that clinical situations change. Indeed, every classification is the product of a given assessment at a given moment, i.e. a static picture, a snapshot or cross-section of temporarily observed characteristics. A dynamic approach takes into account the fact that the clinical picture of a 'dysorectic' patient may alter in the course of time while the core problem remains unchanged. We, therefore, also advocate a dimensional model that takes into account that the heterogeneity of anorexia nervosa is a clinically relevant fact and that anorectic pathology may be closely related to other eating/weight disorders such as bulimia nervosa and psychosomatic obesity.

1, d i e t e r s / a b s t a i n e r s D, vorriiters p u r g e r s ID. bulimia n e r v o s a H , t h i n / f a t people V, s t a b l e e x t r e m e o b e s i t y

Figure 1-1. The Dysorexia/Dysponderosis Continuum (Reprinted from Vandereycken, 1982).

4

HOW CAN A RELIABLE

DIAGNOSIS BE MADE ?

The dysorexia/dysponderosis continuum shown in Figure 1-1 is an attempt to describe eating/weight disorders in a dynamic and dimensional way. If the core problem is labeled as disturbed eating behavior (disregulated appetite, hunger and/or satiety) the disorder can be put on the dimension dysorexia (anorexia or food abstinence versus hyperorexia or overeating). When the disorder is mainly conceptualized as disturbed or dysfunctional weight regulation or distorted weight control, it seems more appropriate to speak about the dimension dysponderosis (pursuit of thinness or 'Magersucht' versus obesity or 'Fettsucht'). This is, of course, only an artificial distinction since most cases in clinical practice display a cluster of combined or concomitant characteristics of both dimensions. At one end of the continuum we place the 'classical' picture of primary anorexia nervosa, namely the dieters or abstainers. The subgroup of 'vomiterspurgers' are also those anorexia nervosa patients who show bulimic tendencies or behavior. Bulimia nervosa occupies a somehow pivotal position between the bulimic anorexia nervosa patients on the one hand and those overweighed subjects who impulsively overeat on the other. The latter are (formerly) obese patients or 'thin-fat people' (Bruch, 1973) in whom Stunkard (1959) observed peculiar eating patterns such as 'binge-eating syndrome', 'night-eating syndrome' and 'eating-without-satiation'. If one disregards the overweight in these obese subjects, their eating behavior and their struggle to vainly control their body weight ('chronic dieters') are very similar to the bulimia nervosa patients'. Finally, at the other pole of the continuum we may place the more or less stable psychosomatic obesity in which the overweight is the result of different factors (not merely caused by overeating). These five identified clusters of symptoms have to be regarded as a kind of landmarks according to which we can subdivide a series of patients (e.g., for comparative studies) and trace out the individual history of one patient (see e.g. Holmgren, Humble, Norring et al., 1983). Some cases may develop just one of these clinical forms whereas others may move from one position to another. The interchangeability or alternation of symptoms is either a spontaneous phenomenon (e.g., in the course of time a chronic obese patient or an anorectic dieter may become a binge-eater) or it is induced in an iatrogenic way (e.g., the extremely obese patient put on a strict medical diet moves to the position of 'thinfat people'; forced feeding of the emaciated anorectic risks provoking vomiting or purging). Although some of our research findings (Vandereycken & Pierloot, 1983) support these assumptions, clinical reality may force us, in the future, to abandon classification systems based upon overt symptomatology. It could be, for instance, that the factor age or time is sometimes far more relevant in differentiating patients phenomenologically and also with regard to treatment (Dally & Gomez, 1979 ; Strober, 1980).

1.2. Diagnostic Criteria As already mentioned, up to the 1970s scientific literature lacked any reliable criteria for the diagnosis of anorexia nervosa. Either there was an absence of

5

ANOREXIA

NER VOSA

clearly defined diagnostic indications in spite of some of the 'experts' having their own criteria, or there seemed to be a silent agreement in the literature as to what was meant by the term anorexia nervosa without being explicit. In 1979 Bhanji collated the different attitudes of internists and psychiatrists to the diagnosis and treatment of anorexia nervosa. It was most surprising to find that 40 % of the internists and 25 % of the psychiatrists still believed that anorexia nervosa was only to be found in the female sex. They all agreed, however, on the diagnostic triad : weight loss, anorexia, and amenorrhea. Recently, Whyte and Kaczkowski (1983) have compared the opinions and practices of psychiatrists and psychologists when dealing with anorexia nervosa. The results of the survey indicate that both professional groups agreed on the many signs of anorexia nervosa, but differed in their views on the significance of physical overactivity, anxiety related to food intake, and presence of additional psychological illness. In addition, there were more similarities than differences between the two groups regarding precipitating events and treatment of anorexia nervosa. Kendell (1982) advises against relying solely on one system of categorization when diagnosing psychiatric disorders; at least two should be used. In the case of anorexia nervosa two systems are widely used : the Feighner-criteria and DSMIII. The former hd been formulated in particular for researchers, whereas nowadays the latter are preferred both in research and clinical practice. However, both sets are criticized with regard to their usefulness and adequacy (Askevold, 1983; Halmi, 1983; Rollins & Piazza, 1978; Vandereycken & Pierloot, 1981a). The criteria proposed by Feighner and associates (1972) are presented in Table 1-2.

A. Onset of illness before the age of 25 : It is no doubt true that the majority of anorexia nervosa patients come under this category, which is clearly stated in the German expression 'Pubertätsmagersucht' (pubertal pursuit of thinness). From clinical experience, however, we know that the onset of anorexia nervosa can also occur later on in life (Vandereycken, 1984). For this reason, few investigators are currently using age as an exclusion criterion. We would propose - at least for research purposes - that the patients be divided into groups according to their age at onset of illness, e.g. 11-14, 15-18, and 19 and over, as has been suggested by Dally and Gomez (1979). It is significant that there have been no recommendations in the literature on the subject which clearly set any limits for the earliest age of onset (Askevold, 1983). A further problem is caused by there being no clear definition of what is meant by 'onset' (Beumont, Abraham, Argall et al., 1978). Does this mean the behavior leading to the loss of weight, or is it the onset of weight loss itself ? This leads us to the as yet unanswered question of when does 'normal' fasting end and when do pathological anorectic symptoms begin ? The settlement of this last question as well as a precise definition of what is meant by the onset of the illness are of special importance for primary prevention of anorexia nervosa (see Chapter 3). B. Anorexia with accompanying weight loss of at least 25 % of the original body weight: This statement has been repeatedly criticized, first of all, for the use of 6

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Table 1-2. Feighner-Criteria for Anorexia Nervosa* A. Age of onset prior to 25. B. Anorexia with accompanying weight loss of at least 25 % of original body weight. C. A distorted, implacable attitude toward eating, food, or weight that overrides hunger, admonitions, reassurance, and threats : e.g. (1) denial of illness with a failure to recognize nutritional needs; (2) apparent enjoyment in losing weight with overt manifestation that food refusal is a pleasurable indulgence; (3) a desired body image of extreme thinness with overt evidence that it is rewarding to the patient to achieve and maintain this state; (4) unusual hoarding or handling of food. D. No known medical illness that could account for the anorexia and weight loss. E. No other known psychiatric disorder with particular reference to primary affective disorders, schizophrenia, obsessive-compulsive and phobic neurosis. (The assumption is made that even though it may appear phobic or obsessional, food refusal alone is not sufficient to qualify for obsessivecompulsive or phobic disease). F. At least two of the following manifestations : (1) amenorrhea, (2) lanugo, (3) bradycardia (persistent resting pulse of 60 or less), (4) periods of overactivity, (5) episodes of bulimia, (6) vomiting (may be self-induced). * For a diagnosis of anorexia nervosa, A through Ε are required (Feighner et al., 1972).

the misnomer 'anorexia', i.e. loss of appetite. We know from the patients themselves that feelings of hunger and appetite can be present not only at the onset of the illness but also during the chronic stages. Patients try to repress these feelings, and instead of an aversion to food they frequently show preoccupation with food, cooking, recipes, etc. So, rather than anorexia, one should use the term self-starvation (fasting, dieting, food abstinence) or self-induced weight loss. Furthermore, there is no logical reason for setting the limit at 25 % loss of the original body weight. This criterion disregards the fact that such a weight loss in an overweight subject only brings the person's weight within a more 'normal' range ! Both for clinical reasons and for research purposes, it is better to define the degree of emaciation with respect to the ideal body weight for height for age (referring to pediatric growth charts or to the statistics of the Metropolitan Life Insurance Company). The next and most important criterion makes even a numerical definition of a weight limit superfluous. Indeed, it is the patients' relentless desire to reduce their weight and body size, and not the actual weight loss itself, which is of pathognomonic significance.

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C. A distorted attitude toward eating, food or weight: This is certainly the crux of the diagnosis, consisting of various behavioral characteristics which express a tendency to be slim, a pursuit of thinness, or a weight phobia. The decision whether this central criterion has been achieved or not is made all the more difficult by the patients' tendency to deny their illness or by the fact that they very often show relatively little insight into it. It is most surprising that this aspect, namely the denial of illness or tendency to dissimulate one's own symptoms, has received so little attention in the literature on the subject (Vandereycken & Vanderlinden, 1983; see also 1.4.1.). As with other psychiatric disorders, it is possible in many cases to avoid this problem by carrying out an interview with a third party (e.g. a relative). For purposes of objectifying and quantifying the 'anorectic behavior', a number of self-rating questionnaires and assessment scales for clinicians have been developed which will be discussed later on (1.4.2.). DIE. No known medical or other psychiatric illness : The problems related to these exclusionary criteria will be discussed in the next paragraph on differential diagnosis (1.3.). F. Secondary criteria: Feighner's list with its three physical symptoms (amenorrhea, lanugo, bradycardia) and three further behavioral features (overactivity, vomiting, bulimic episodes) has often been the topic of scientific criticism. Amenorrhea : The arguments for and against this criterion usually depend on the theoretical position of the investigator with regard to the question of primary versus secondary hypothalamic dysfunction in anorexia nervosa (see 2.5. 'The biological point of view'). If one considers the amenorrhea as an essential symptom, the diagnosis is very difficult or even impossible in the following cases: (1) male subjects; (2) very young patients with so-called primary amenorrhea (what is an abnormal age of menarche ?); (3) pregnant women (see Vandereycken, 1982); (4) the very large group of females taking oral contraceptives which induce artificial menstrual bleedings (we have seen some patients who took the pill in secret and claimed that they were not anorectic since they still had their monthly periods !). Hence, for practical reasons we consider amenorrhea to be a second rate criterion and we propose the specification that a cessation of menses for at least three months should be required. Lanugo : A fine downy hair, indistinguishable from villous hair over the body, especially over the back and face. Although sometimes viewed as a cardinal sign of primary anorexia nervosa (King, 1963), this is an unnecessary criterion as only a minority of the patients clearly show lanugo (Askevold, 1983). Bradycardia (persistent resting pulse of 60 or less) develops as a secondary consequence of emaciation; so, it is in fact only a sign of severe inanition just as, for instance, low blood pressure or acrocyanosis. Hyperactivity: Physical (or intellectual) overactivity despite a state of emaciation is a conspicuous and paradoxical phenomenon that still remains an important criterion for differentiating between anorexia nervosa and medical illnesses (Krön, Katz, Gorzynski et al.. 1978). Attempts have been made by

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means of a pedometer (Stunkard, 1972) or telemetric monitoring (Foster & Kupfer, 1975) to assess this very hard to define feature more objectively. Vomiting.· this striking (but often concealed) form of behavior presents a further possibility for attaining the desired goal of skinniness and diminution of bodily dimensions. As such it should be listed in the cluster of behavior patterns under point C, together with the abuse of laxatives and diuretics. The presence of (at least once weekly) vomiting, purging or binge-eating distinguishes the patient from the pure dieting/fasting anorectics as discussed before. Bulimic episodes : The definition problem concerning bulimia has been mentioned in the first paragraph; this item presents diagnostic problems when trying to differentiate it from bulimia nervosa (Lowenkopf, 1982; Fairburn, 1982). These considerations concerning the many problems related to the use of the Feighner-criteria lead us to conclude that, both for practical and clinical reasons, the DSM-III description of anorexia nervosa is to be preferred (see Table 1-3). This does not alter the fact that these criteria still have to be improved (Halmi, 1983; Irwin, 1981), and that research investigators, in particular, must pay close attention to defining their cases (Kirstein, 1981-82).

Table 1-3. DSM-III Criteria for Anorexia Nervosa* A. Intense fear of becoming obese, which does not diminish as weight loss progresses. B. Disturbance of body image, e.g., claiming to 'feel fat' even when emaciated. C. Weight loss of at least 25 96 of original body weight; or, if under 18 years of age, weight loss from original body weight plus projected weight gain expected from growth charts may be combined to make the 25 %. D. Refusal to maintain body weight over a minimal normal weight for age and height. E. No known physical illness that would account for the weight loss. * American Psychiatric Association (1980).

1.3. Differential Diagnosis "When a young girl, wasting uncontrollably away, is brought to a doctor the situation will be riven by anxiety, and probably guilt, for the family will have exhausted their stock of exhortations, cajolings, bribery, and threats before turning for medical help. The best attitude for the doctor at this first consultation is of firm, yet sympathetic, authority and assurance; yet who can blame the physician who demonstrates uncertainty and doubt in the face of this puzzling, unexplained, and (most important) rare condition ? A stream of recondite

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differential diagnoses will run through his mind, pursued by, the nagging fear, drummed into him as a medical student, of missing something. All is not lost, provided any initial hesitation is overcome, for the early establishment of rapport with patient and family is the keystone of successful treatment. In fact the distinction from other somatic disease is rarely difficult, and a few estimations on a sample of blood, together with a chest X-ray examination, should suffice to reassure the clinician" (Editorial, The Lancet, 1971, p. 900). We believe that the diagnosis of anorexia nervosa is relatively easy to make if the clinician pays more attention to the patient's behavior than to her bodily functions (see also 1.4. 'Behavioral Assessment'). For this reason, the physician has to start with questions about the patient's own percpetion of the problem before proceeding to the more usual medical history taking (see Table 1 -4).

Table 1-4. General Medical Interview of the Patient with a Weight Problem 1. 2. 3. 4.

5. 6. 7. 8.

Client's perception of problem - Is there a disturbance in body weight ? Onset of problem. Course of problem. Aggravating or ameliorating circumstances. a. Nature of circumstance. b. Duration of exacerbation or remission. c. Diet and activity history. Medical history - including history of medications, drugs, alcohol (used or abused). Review of systems, looking particularly for precipitating or aggravating medical problems. Family history of weight disturbance, genetic abnormalities, illnesses associated with weight disturbance. Past psychiatric history.

Reprinted from Falk (1979).

The purpose of the medical examination (which is always necessary, even if the physician or the psychologist is sure about the diagnosis) and other technical diagnostic aids is to rule out any somatic cause for the emaciation and to document the already tangible physical consequences of the starvation which have to be monitored during the course of treatment. In the medical history (Table 1-4), special attention should be paid to the gynecological history (menarche, menstrual regularity, date of last period, use of contraceptives, pregnancy, date of last gynecological check-up etc.). The general physical examination includes the measurement of height and weight preferably naked (beware of possible attempts at deception by the patient such as hiding heavy objects in the clothes or drinking water before being weighed), general inspection and palpation, auscultation and percussion. In this way several physical characteristics may be found the most important of which are listed in Table 1 -5.

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Table 1-5. Possible Findings During the Physical Examination General:

underweight cachexia hypothermia bradypnea

Cardiovascular:

hypotension bradycardia arrhythmias peripheral edema acrocyanosis

Cutaneous:

atrophic dry skin yellowish skin hair loss lanugo hair

Oral:

dental abnormalities swollen salivary glands

This physical examination should not be viewed merely as a diagnostic observation procedure. It may be the first step towards treatment if used as a means of confronting the patient and the family with the seriousness of the condition, for instance by stressing the various physical consequences of the weight loss (the problems of denial, lack of motivation, and resistance are discussed in Chapter 5). The physician must also realize that practically all of the abnormalities found during the course of a physical examination of the patient with anorexia nervosa are caused by malnutrition (see Figure 1-2). One of the main implications of this starvation picture ought to be the limitation of further technical investigations. The inexperienced physician will otherwise be tempted to ask for more and more extended investigations which may only reveal more confusing abnormalities and make things worse. This is certainly true for endocrinological parameters which may be very misleading if not interpreted as signs of semistarvation (see Figure 1-3 and Table 1-6). The presentation of these data here should not be interpreted as suggesting that all of these abnormalities have to be looked for in every patient. On the contrary, we would like to illustrate how anorexia nervosa may be associated with numerous metabolic, physiological and endocrinological changes that are directly associated with the emaciated state and that usually return to the normal range with weight gain. It is very important for the clinician to recognize this, so that unnecessary further investigations are not pursued.

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Figure 1-2. Metabolie and Morphological Changes in Anorexia Nervosa (Reprinted from Barbosa-Saldivar and Van Itallie, 1979).

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Figure 1-3. Endocrine Changes in Anorexia Nervosa (Reprinted from Barbosa-Saldivar and Van Itallie, 1979). Taking the previous considerations into account, a routine laboratory checkup is usually performed to rule out other causes of inanition and to evaluate the degree of starvation : red and white blood count, electrolyte imbalance, liver parameters, total protein (to mention the most important). Some physiological changes such as increases in serum enzymes such as SGOT, LDH, and alkaline phosphatase can occur with refeeding and will return to within normal range after the patient has maintained a normal weight for a period of time (Halmi and Falk, 1981). In the case of extreme bradycardia, irregular pulse rate, systolic heart murmurs or electrolyte imbalance an ECG (electrocardiogram) is called for (see Moodie, 1982). In order to exclude a brain tumor we recommend a twodimensional X-ray of the skull, a special X-ray of the sella turcica, and an EEG (electroencephalogram). CAT-scans and other more sophisticated investigations should only rarely be necessary. The same applies to gastrointestinal X-rays which are only indicated in 'suspicious' cases (e.g., exclusion of regional enteritis or Crohn's disease). But the discovery of an organic problem does not necessarily exclude the diagnosis of anorexia nervosa since the latter may be associated with some somatic illnesses or syndromes such as diabetes mellitus, Crohn's disease and Turner syndrome (see 3.6 Towards early recognition'). For this reason, an

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Table 1-6. Some Endocrinological Changes in Anorexia Nervosa I.

Hypothaiamic-Pituitary-Gonadal Axis Α. LH and FSH levels Β. 24-hour LH and FSH patterns. Age-Inappropriate C. Serum estrogen levels Ο. Serum testosterone levels E. Ratio: Etiocholanolone F.

II.

III.

IV.

androsterone Responses of LH and FSH to LHRH

Hypo thalamic-Pituitary-Adrenal Axis A. Urinary 17-OH corticosteroid levels B.

Half-life plasma Cortisol

C. D. Ε. F. G. H.

Metabolic clearance rate of Cortisol Cortisol binding capacity Cortisol production rate/Kg. body weight Urinary free Cortisol Dexamethasone suppression Response to ACTH

Hypothaiamic-Pituitary-Thyroid Axis A. Free T 4 levels Β. Mean T 4 and T3 levels C. Serum reverse T3 and 3, 3' Τ2 D. T.R.H. effect on T 3 E. T.S.H. levels F. T.R.H. effect on T.S.H. Other Pituitary Hormones A. Human growth hormone (hGH) levels B. hGH response to hypo- or hyperglycemia C. D. Ε. F. G.

hGH response to apomorphine Prolactin levels Prolactin response to L-DOPA and chlorpromazine Antidiuretic hormone levels Ability to excrete water load

4· + -ΙI t 4· or Ν 4· t

t Ν t t 4Ν or t Ν 4· t t Ν or t t or Delayed Ν or t Ν or Paradoxical 4Ν Ν Ν 4

Reprinted from Weiner (1982). assessment of the patient's behavior (see 1.4) at the first consultation is as important as the routine physical examination. If careful attention is paid to the behavioral features and attitudes which constitute the essential psychological criteria for the diagnosis as described in DSM-III (Table 1-3), psychiatric differential diagnosis should not be difficult (Waller, 1979). Patients with schizophrenia who stop eating because of delusions relating to food (e.g., that it turns into worms in the stomach) do not have the weight phobia and pursuit of thinness characteristic of anorexia nervosa. Nevertheless, the near delusional ideas many patients hold about their body or about food may suggest that anorexia nervosa is a 'forme fruste' of

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schizophrenia. Although there have been reports of anorectic patients developing schizophrenia (Hsu, Meitzer & Crisp, 1981), familial studies lend no support to this association (Snaith, 1981). There is stronger support for the view that anorexia nervosa is a form of depressive illness. An association between eating disorders such as anorexia/ bulimia nervosa and affective disorder (major depressive disorder) has been increasingly reported in recent literature but it still remains a controversial issue. Studies of this association have arisen from the following five areas (Hendren, 1983; Hudson et al., 1983 a + b): (1) Phenomenology : Depressive symptoms are commonly described in patients with anorexia nervosa or bulimia. (2) Course of illness : Outcome studies have found that patients with anorexia nervosa often exhibit depressive symptoms at follow-up. (3) Biological tests : Cortisol abnormalities and a positive dexamethasone suppression test are frequently found in anorectic and bulimia patients. (4) Family history : A higher than expected prevalence of affective disorder is reported among relatives of patients with an eating disorder. (5) Treatment response: Beneficial effects of antidepressant medication have been reported in both anorexia nervosa and bulimia patients. Though an association between eating disorders and disturbances of mood is incontrovertible, the hypothesis that anorexia nervosa and bulimia are forms of affective disorder has yet to be proven (Cooper & Fairburn, 1983). The question whether anorexia nervosa really is a distinct syndrome is based upon the clinical experience that many patients may show symptoms of depression, psychosis or obsessional neurosis in their illness history or after 'recovery'. This question will remain unresolved until more careful surveys of large samples of patients over lang periods of time have been reported (Snaith, 1981). We emphasized at the beginning of this chapter that a static categorical nosology sharply distinguishing anorexia nervosa from other eating/weight disorders has to be abandoned. Without absolute criteria such as body weight, an attempt to define a clinical eating disorder at normal weight presents many difficulties in setting precise boundaries. Crisp (1981), for instance, mentioned the 'abnormal normal weight control syndrome !' The presence or absence of substantial weight loss appears to be the most important factor in distinguishing between bulimic anorexia nervosa and mere bulimia (nervosa) as defined in DSM-III (see Table 1-7). A rare variant of bulimia which we did not find described explicitly in the literature is the chewing-spitting syndrome as we call it. These are patients who have a strong urge to taste large or very concentrated amounts of food (mostly sweets) they do not really eat: they masticate the food without swallowing it and then spit it out. Most of them have had anorexia nervosa and/or bulimia but searched for a less painful way than vomiting or purging in order to fulfill their need to taste food without having its 'side-effects' on body weight. It is not really a 'new' syndrome, but in our dynamic and dimensional view just another step further in the dysorectic patient's career. Crisp (1980, p. 32) suggested a similar evolution : Patients in a state of constant bingeing and vomiting "often develop a sustained yearning to have things in their mouth and may become chain

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Table 1-7. DSM-III Criteria for Bulimia (Nervosa)* A. Recurrent episodes of binge-eating (rapid consumption of a large amount of food in a discrete period of time, usually less than two hours). B. At least three of the following : (1) consumption of high-caloric, easily ingested food during a binge, (2) inconspicuous eating during a binge, (3) termination of such eating episodes by abdominal pain, sleep, social interruption, or self-induced vomiting, (4) repeated attempts to lose weight by severely restrictive diets, self-induced vomiting, or use of cathartics and/or diuretics, (5) frequent weight fluctuations greater than 10 pounds due to alternating binges and fasts. C. Awareness that the eating pattern is abnormal and fear of not being able to stop eating voluntarily. D. Depressed mood and self-deprecating thoughts following eating binges. E. Bulimic episodes are not due to anorexia nervosa or any known physical disorder. * American Psychiatric Association (1980).

smokers, may turn to alcohol or other drugs". Whatever the presenting symptom, it has the characteristics of an addiction. Some patients are not primarily concerned with their weight but exhibit a longstanding pattern of episodic, stress-related, non-organic or functional vomiting : psychogenic vomiting (Rich, 1978; Rosenthal et al., 1980; Wruble et al., 1982).

Table 1-8. Features of Psychogenic Vomiting 1. Usually chronic and episodic. 2. Typically occurs soon after the meal has begun or just after it has been completed. Can be suppressed if necessary. 3. Commonly occurs in the absence of nausea - "The food just seems to come back up". 4. The vomiting act is often self-induced. 5. Rarely associated with retching. 6. Weight loss is not significant. 7. Vomiting is often of relatively little concern to the patient - more concern to the family. 8. No definite "personality type". Reprinted from Wruble, Rosenthal and Webb (1982).

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Vomiting and weight loss as symptoms of a conversion disorder may be easily differentiated from anorexia nervosa (Garfinkel et al., 1983). In the case of laxative or enema abuse (Barton et al., 1982; Cooke, 1977), a dysorectic disorder could be the underlying cause. The same applies to psychogenic nausea (Swanson et al., 1976), functional dysphagia (Fitzgerald & Walsh, 1977), and habitual rumination (Levine et al., 1983). The management of bulimia, vomiting and purging is discussed in Chapter 9.

1.4. Behavioral Assessment 1.4.1. The Clinical Interview In a third of the patients they investigated, Mattingly and Bhanji (1982) found that the diagnosis of anorexia nervosa had not been considered previously despite the typical histories and clinical findings. The general practitioner is often misled by : (1) A less marked weight loss (e.g., in those who binge, vomit or take purgatives), (2) the unnecessary and extensive investigations carried out to exclude other medical pathology, (3) the patients themselves who deny having eating/weight problems. Denial, i.e. the mere negation of a situation others are worried about (see also 2.6.1. 'Cognitive deficits'), might certainly be the first stumbling-block in the diagnostic process, but mostly for inexperienced clinicians. Indeed, the fact that an emaciated girl claims to be healthy and acts as such must be the first clue that should increase suspicion and prompt immediate concern and direct questioning of the patient and her family. "The anorectic often misleads people so completely that she can effectively manage to be under intense medical care and be painstakingly investigated into some facet of her disorder, (e.g. unexplained diarrhea and the question of whether or not this is due to excessive purgative ingestion) without the underlying diagnosis of 'weight phobia' or 'pursuit of thinness' being suspected" (Crisp, 1980, p. 17). Anorexia nervosa patients are known for being reluctant to reveal certain aspects of themselves and their denial of illness is even considered as a typical characteristic with diagnostic significance (Crisp, 1967). But the patients should not be blamed for this ! In her lucid and brilliant autobiography, 'The Art of Starvation', Sheila MacLeod (1981) wrote.· "I did the only thing I could: I became anorexic. There was nothing conscious or deliberate about my decision, if indeed it can be called a decision at all" (p. 82). On the other hand, Naish (1979) in his controversial article on deception in medical practise, suggests that some anorexia nervosa patients, especially the vomiters and purgers, might be included in the group of overprivileged manipulators, liars, and cheaters who are abusing medical attention. Indeed, anorexia nervosa patients often evoke frustration and outrage in doctors who regard them as impostors because they do not have a 'genuine illness', deliberately harm themselves, and refuse to cooperate in treatment, just as self-poisoners and addicts do. Here anorexia nervosa is challenging the medical profession in the same sense as are malingering, factitial or self-induced disease, self-injury, deliberate disability, simulated disease,

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mimicry of illness, or the Munchausen syndrome (Vandereycken & Vanderlinden, 1983). The simplest distinction between malingering and 'real' illness suggests that in the former the symptoms are developed as a conscious pretense, whereas in the latter they arise unconsciously (Merskey, 1979). The question as to what extent the anorectic symptoms are consciously or deliberately produced is closely linked to the issue of denial of illness or 'blissful indifference' in these patients. In other words, the crucial question in this discussion seems to be: Can we trust the anorexia nervosa patient ? We can answer this question from a therapist's point of view : We can trust the patient as far as she can trust us ! Bulimic patients, in particular, are so ashamed of their problem that spontaneous, clear, and direct communication with the physician is unlikely. When questioned about their previous contacts with physicians, several patients may reveal that they have repeatedly tried to tell their physicians about their problem. "Most patients said that they had frequently given numerous signals with the hope that their physicians would directly question them about their eating habits or their vomiting. Often, as time passed and they returned to see their physicians, they would be bolder in their attempts to seek help and might complain of being unable to control their diet or their vomiting. At other times patients had inquired about the short- and long-term effects of laxatives or diuretics, in hopes that the physicians would discover their 'secret' problem" (Winstead & Willard,1983, p. 314). So, the first step is to establish a good doctor-patient relationship avoiding negative counteraggressive reactions (see Chapter 10) and working with instead of against the family (Chapter 8). If both parties, patient and family, are approached in a sympathetic and understanding way, the clinical interview which focuses on the typical anorectic behavior (see Table 1-9) will not only reveal essential information but also gain the patient's and/or the family's confidence : The doctor is asking the right questions in the right way. In some cases the interview requires subtle clinical skills as demonstrated in the following excerpt from an interview by the well-known child psychiatrist E. James Anthony (1982, pp. 324-325). A 16-year-old girl, suffering from anorexia nervosa and manifesting elective mutism, was asked to cooperate in an information-processing strategy which she did most reluctantly. (The information-processing strategy consists in asking a series of increasingly constraining categorical, close-ended questions with each subsequent question carefully selected on the basis of the yes or no answer given to its predecessor). "I want you to answer, as best you can, by 'yes' or 'no' to the questions I am going to ask you" The patient nods her head silently and looks expressionless. "I believe you have a weight problem ?" She nods her head. "You want to lose weight ?" She nods her head. "You prefer that to any other wish you have ?" She looks exasperated, fleetingly, but nods her head.

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'

Table 1-9. The Anorectic Behavior - Outline for Clinical Interview 1. Weight What do you think about your present weight ? Have you recently lost weight ? How much in what period of time ? Did you want to lose weight ? How much and why ? What is your ideal weight ? Do you often 'feel fat' ? Do other people (e.g., at home) think you should lose or gain weight. Are you afraid of becoming overweight ? What do you consider to be overweight for you ? Do you ever use laxatives (diuretics) to lose weight ? Have you ever been treated for a weight disorder ? 2. Eating What do you eat ? How much ? How often ? When and where ? Do you prefer eating alone ? Do you avoid eating in front of other people ? Do you ever fast ? How often ? For how long ? Do you ever fear not being able to stop eating ? Do you ever eat large amounts of food in a short period of time ? Do you find yourself thinking about food and calories much of the time ? Does eating interfere with your life ? To what extent ? Do you ever induce vomiting after you have eaten ? Do you ever take pills to curb your appetite ? Do you think your eating pattern is normal ? Have you ever been treated for an eating disorder before ? 3. Activity Do you exercise ? What type of exercise ? Do you feel tired more quickly than before ? Do you have an active life-style (present and past athletic history, type of job : active, sedentary, involved with food) ? Adapted from Falk (1979), and Neuman & Halvorson (1983).

Note : In order to standardize intake information, Dr. Craig Johnson has developed an intake questionnaire for eating disorders, the Diagnostic Survey for Eating Disorders (D.S.E.D.)'. This rather comprehensive questionnaire can be used as either a self-report measure or as a structured interview guide. It is also computer coded for easy transcription. Requests for this questionnaire may be addressed t o : Craig Johnson, Ph. D., Institute of Psychiatry, Northwestern Memorial Hospital, 320 East Huron Street, Chicago, Illinois 60611, U.S.A. Topics which have to be covered in the assessment of bulimic patients are summarized in Table 9-2.

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"Although others consider you to be thin, you see yourself as fat ?" She nods vigorously. " Y o u r menstrual periods have stopped ?" She nods, warily. " Y o u feel pleased about this ?" She stares for a while in surprise and then slowly shakes her head. "Does that mean you do want to grow up ? " Again she stares, looks confused and then slowly nods her head. " Y o u want therefore to fall in love with a man, get married and have children ? " She tries to rise from her chair, but then turns sideways. "Does that mean 'yes' or 'no' ?" She snorts and shakes her head. " A r e your parents upset at your weight loss ?" There is no response for a while and then she nods. " D o they get angry with you about it ?" She looks sad, fleetingly, but nods her head. " A r e you rebelling against them by not eating enough ? " She shakes her head vigorously. " D o you get angry with them ?" She shakes her head. " A r e you afraid of them ?" She shakes her head. " D o you have strong feelings about them putting you in hospital ?" She remains quite still and then slowly shakes her head. " D o you feel that your mother loves you ?" Again she turns away from the interviewer. "Did you say 'no' to that ?" Shakes her head, still looking away. "Does your mother worry too much about your eating enough ? " She hesitates and then nods. "Does she nag you ?" She nods. " D o you think she expects too much from you ?" She again nods. "Is she disappointed in you ?" She nods. "Can you ever please her ?" She shakes her head. " D o you want to please her ? " She stares perplexedly and then shakes her head. " D o you then want to displease her ? " She hangs her head and turns to the side. "Perhaps your father is easier on you ?" Shrugs her shoulders. " A r e you saying he doesn't care for you ?" Again, shrugs her shoulders. "It seems you do not have anyone to love you ?" Her face looks pained. She rises slowly and walks out of the room.

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More and more clinicians are advocating a family approach to anorexia nervosa, especially in the case of younger patients (see Chapter 8). The clinician will prefer then to see all family members simultaneously for the assessment interview. "This enhances various family members' ownership of their perspectives on the problem and assures a relative degree of objectivity in the reporting of their own histories and their efforts to deal with the pathology. The conjoint family interview also sets up clear expectations for family involvement and offers the practitioner the initial opportunity to join with the family and begin to establish a therapeutic relationship. The gathering of data also provides a forum in which the therapist can engage the entire family and offers an opportunity to observe the family's interactions" (Giesey & Strieder, 1982, pp. 84-85). If, for one reason or another, it is impossible to have a meeting with the entire family, an interesting alternative (suggested by Bruch, 1978) is to ask all family members for a letter about what each feels has caused the illness. An outline for the family diagnostic assessment is presented in Table 1-10.

Table 1-10. An Outline for the Family Diagnostic Assessment I. Family demographic data : A. Names and ages of all family members. B. Employment or current educational level of family members. C. Activities in and outside the home. D. Social interaction. II. Presenting problem (as perceived by each member in turn): A. Presenting symptoms and their duration. B. Physical and biological contributors, factors, and predispositions noted in the patient and in the family in general. C. Current social, educational, and vocational functioning. D. Financial, sexual, and religious factors, if pertinent. E. Optimal premorbid functioning. F. Stressors (for example, significant losses - family death, injury to self or a friend, breakup of a relationship with a boyfriend). G. Prior professional help sought. III. Family relationships (often most easily sought by asking, "Who is closest to whom ?"): A. Relationships of parents to children. B. Relationships of children to parents. C. Relationships among siblings. D. Marital relationship. E. Extended-family relationships (should include both parents' families of origin). F. Extrafamilial significant others (should include parents', children's, or whole family's associations who are seen as having a significant impact on the family's functioning). Reprinted from Giesey and Strieder (1982).

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1.4.2. Assessment Instruments In general, the characteristic features of anorexia nervosa should be readily recognizable. Although a good clinical interview is a sine qua non for diagnosing the eating disorder, it can be helpful for practical purposes as well as for research purposes to use standardized, reliable and valid methods for determining individual aspects of the illness. In the last few years various more or less usable scales have been published. They consist of self-rating scales, assessment or observation scales, methods of ascertaining body-image disorders, and objective measurements. Some of these instruments may be important: (1) To help and simplify the gathering of information in clinical practice, e.g. self-rating scales to supplement the clinical interview, or assessment scales to record the course of illness during inpatient treatment. (2) For research purposes : — for a more objective, reliable and valid determination of individual symptoms and characteristics; — for examining (symptomatic) changes during the course of therapy (constant diagnostic re-appraisal) and follow-up (see Chapter 11); — for determining those at risk of developing an eating disorder by means of epidemiological surveys (see Chapter 3 about prevention). A growing number of self-rating scales have been developed for anorectic and bulimic patients. We will present only the most important and relevant to clinical practice. The phrasing of the individual items as well as the instructions for each scale can be found in the appendix of this chapter. Apart from the EAT and the EDI, these instruments often make no mention of their reliability and validity (according to current standards of test construction). Moreover, the major weakness of each of these scales is that none of them includes a so-called liescale. They seem to overlook the crucial problem of denial which is an important stumbling block in assessment procedures that rely upon self-reporting (Vandereycken & Vanderlinden, 1983). The A nalogue Scale Measurement (see Appendix 1 -1) as described by Folstein and associates (1977) is a good example of how the practitioner - who is not primarily interested scientifically - can quickly acquire information about the degree of severity of the patient's symptoms. The patient can mark on a 'barometer' the degree of severity for each symptom or characteristic as she or he experiences it. In fact each clinician can construct such scales with individual variations adapted to each patient. As shown in Appendix 1-1, each patient has to rate on a graphic scale - the ends of which are defined as 'extremely/not at all' - the extent to which a certain word (e.g., hunger, thirst, nausea, depressed mood) is applicable to them. This can be repeated after regular intervals during treatment and follow-up. As regards characteristic test theory values, Folstein et al. (1977) report that the reliability and validity of the scales "were acceptable as in previous studies". The Anorectic Attitude Scale (Goldberg et al., 1980; Halmi et al., 1979) is a scale consisting of 63 items which with the aid of factor analysis have been

22

HOW

CAN A RELIABLE

DIAGNOSIS

BE MADE ?

arranged in the following subscales : denial of illness, psycho-sexual immaturity, loss of appetite, interpersonal control, thin body ideal, hypothermia, compulsivity, hyperactivity, and use of purgatives. The scale has 4 intervals : not at all a little - quite a bit - extremely. Further information about the reliability and validity of the scale are not available at the moment. Up until now the studies cited have reported on pretreatment predictors of outcome in anorexia nervosa using this scale. The following were found to be good prognostic indicators which correlated positively with weight gain : a great amount of overactivity before treatment, less denial of illness, less psychosexual immaturity, and the admission of feeling hungry. No doubt, the Eating Attitudes Test or EAT (Appendix 1 -2) is the most widely used and the best documented test. Two forms exist: the original 40-item test (Garner & Garfinkel, 1979) and its abbreviated version EAT-26 (Garner, Olmsted, Bohn et al., 1982) which correlates highly with the original scale. Three factors were identified by factor analysis : dieting, bulimia and food preoccupation, and oral control. The answers are given on a 6-point scale : always - very often - often - sometimes - rarely - never. The authors have presented psychometric and clinical correlates for a large sample of female anorexia nervosa patients and controls. According to this the EAT is a reliable, valid and economical measure of objective determination of symptomatic behavior in anorexia nervosa, e.g. as an outcome measure in clinical groups or as a screening instrument in non-clinical settings. Unfortunately, the problem of denial has been overlooked in the test construction (Vandereycken & Vanderlinden, 1983). As shown in Appendix 1-3, the evaluation occurs as follows: the most 'anorectic' response ('always' or 'never' depending on the keyed direction) earns a score of 3; the immediately adjacent response 2, and the next response 1; the three choices furthest away from the 'anorectic' response are considered 'normal' (score of zero). The Eating Disorder Inventory or EDI (Garner, Olmsted & Polivy, 1983 a + b) is a quite new self-reporting questionnaire. It consists of eight subscales measuring psychological and behavioral traits common in anorexia/bulimia nervosa patients (see Appendix 1-3) : drive for thinness, bulimia, body dissatisfaction, ineffectiveness, perfectionism, interpersonal distrust, interoceptive awareness, maturity fears. The answers are given on a 6-point scale and evaluated in the same way as with the EAT. The reliability and validity scores given by the authors show the EDI to be, on the whole, a sufficiently reliable and valid self-rating instrument, differentiating between patients with anorexia/bulimia nervosa and those without such eating disorders (see Garner, Olmsted & Garfinkel, 1983). Besides the fact that once again denial has been overlooked in test construction, this instrument may prove to be the best of all questionnaires available because it assesses a broad range of behavioral and attitudinal features typical of the anorectic and bulimic stances. Ideally, self-reporting measures should be complemented by observation from an outsider. Slade's (1973) Anorexic Behaviour Scale has been designed for inpatient observation by nurses. Containing 22 items it gathers information on the following : resistance to eating, patient's relation to food, and activity. Although the patient's family (spouse) can deny the severity of the situation in

23

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the same way as the patient herself does, usually their information about eating behavior is more reliable and objective than the patient's. In the Collaborative Study on Anorexia Nervosa (Drs. Halmi, Eckert, Casper and co-workers) a 'Parent/Spouse Anorexic Behavior Scale was used. A modified version of this scale is presented in Appendix 1-4. In its present form the scale is not yet fully developed as studies on reliability and validity are currently being carried out by the senior author (W.V.). Body image disorders (distorted body perception) in patients with eating disorders have aroused the interest of a number of research teams lately (see 2.6.2.). Apart from projective methods such as the Body-Image Boundary Score in the Rorschach Test and Fisher's Body Distortion Questionnaire, there are a number of so-called 'experimental' methods now in use which compare subjective estimations of one's own body dimensions with objective measurements : distortion by means of video, mirror or a photographic technique; a visual size estimation task with a moveable caliper device; or paper and pencil methods (for a review see Garner and Garfinkel, 1981; Meermann and Fichter, 1982; McCrea, Summerfield and Rosen, 1982). These methods of examination have so far been reserved for centers with their own research departments. Up until now, they have little relevance to clinical practice. The same applies to the attempts to assess objectively the distortion of internal perception of bodily stimuli, e.g. disturbances of taste perception, sensation of hunger and satiety (see Garfinkel & Garner, 1982). An area which has almost completely been overlooked in research is the excessive physical activity or restlessness (hyperactivity) displayed by anorectic patients. Only very few researchers have attempted to record these symptoms, e.g. by means of pedometric (Stunkard, 1972), ergometric (Davies et al., 1980) or telemetric monitoring (Foster & Kupfer, 1975). All of these methods, however, suffer from a lack of practical implications for the treatment of anorexia nervosa patients.

1.5. Conclusion Some of the problems which are hindering a uniform diagnosis of the anorexia nervosa syndrome arise from the fact that we still have an incomplete and fragmentary knowledge of its causes and perpetuating conditions (see Chapter 2). The nosological classification is just as difficult as a clear delimitation of the clinical picture. The question is whether this clinical picture of 'pursuit of thinness" can be classified at all by our present nosological system or whether it takes up a unique diagnostic category of its own. With regard to the presumed etiology anorexia nervosa can best be described as a neurotic disorder; phenomenologically, its symptomatology easily fits the description of a psychophysiological disorder; and its course is unmistakeably similar to that of an addictive illness (sometimes even to that of a borderline state). In general, we believe that the disorder can better be approached and understood by referring to a dynamic and dimensional model of eating disorders, i.e. a continuum model including an important time factor - the clinical picture of a dysorectic patient may change in the course of time, either spontaneously or iatrogcnically.

24

HOW

CAN A RELIABLE

DIAGNOSIS

BE MADE ?

W e believe the DSM-III criteria to be the most useful for practical purposes the diagnosis is sustained by the behavioral and experiential peculiarities of the patient (fear of becoming obese, body image disturbance, refusal to eat normally) which are decisive for the diagnosis. The loss of weight - along with the consequences of emaciation - is the outward sign of warning, but not the crux of the problematic stance which can best be labeled as 'pursuit of thinness" or 'weight phobia'. Anorexia nervosa is a psychophysiological disorder which is relatively easy to diagnose not only by the psychiatrist or clinical psychologist, but also by the general practitioner, the pediatrician and other medical specialists if only they take into account the following guidelines. Necessary information for the diagnosis is provided by the medical and biographic history, by focusing on the patient's behavior instead of on bodily functioning, by questioning the relatives, spouse, friends etc., if possible. With some basic knowledge of the psychological peculiarities of this syndrome it should not be too difficult to reach a positive clinical diagnosis. For this reason, w e believe that it is a mistake to proceed merely in a 'negative' diagnostic process which is primarily aimed at excluding all kinds of somatic causes. This would mean that the patient has to undergo a series of unnecessary diagnostic steps and above all a delay before therapy can be begun. Only when there are wellfounded doubts about the positive diagnosis of anorexia/bulimia nervosa is it necessary to consider somatic possibilities for the differential diagnosis. Then, and only then, can a further more sophisticated instrumental form of additional diagnosis be applied. Even the laboratory parameters should be limited to a few characteristic values. W e believe that at present patients are being burdened by far too many examinations (e.g. endocrinologic) before a diagnosis is reached. Other psychiatric disorders can be ruled out by the examination of the actual psychopathological findings. The personal exploration by means of an interview with the patients and with members of the social environment they live in can be further supplementend by the use of self-rating scales and questionnaires. Careful history taking and the establishment of a good doctor-patient relationship (also with respect to the family) are the best ways of preventing diagnostic errors and of avoiding unnecessarily extended or repeated technical investigations. A further differential diagnostic indication which is very valuable is the course (success or failure) of treatment once started. Therapy is the best means of analyzing a problem and testing hypotheses with regard to its etiology (precipitating and maintaining factors). For this reason, w e would plead not to waste valuable time on complex diagnostic examinations, but rather to begin with the therapeutic intervention as soon as possible.

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Spectrum Publications, pp. 143-155. Whyte, B.L. & Kaczkowski, Η. (1983), Anorexia nervosa : A study of psychiatrists' and psychologists' opinions and practices. International Journal of Eating Disorders, 2(3): 87-92. Winstead, D.K. & Willard, S.G. (1983), Bulimia: Diagnostic clues. Southern Medical Journal, 76 : 313-315. Wruble, L.D., Rosenthal, R.H. & Webb, W.L. (1982), Psychogenic vomiting : A review. American Journal of Gastroenterology, 77 : 318-321. Ziolko, H.U. (1966), Hyperphagie und Anorexie (Hyperphagia and anorexia). Nervenarzt, 37 : 400-406. Ziolko, H.U. (1967), Hyperorexie-Anorexie (Hyperorexia-anorexia). Hippokrates, 13: 522-526. Ziolko, H.U. (1981), Hyperorexia nervosa. I n : Koptagel-Ilal, G. & Tunper, O. (Eds), Proceedings of the !3th European Conference on Psychosomatic Research (Istanbul, September 8-12, 1980). Istanbul : Society of Psychosomatics and Psychotherapy, pp. 40-45.

30

HOW CAN A RELIABLE

DIAGNOSIS BE MADE ?

Appendix 1-1 The Analogue Scale Measurement*

Name:

Date:

Time:

1. Please note the way you feel in terms of dimensions given below. 2. Note your feelings as they are at the moment. 3. Mark clearly perpendicularly across any part of each line toward the dimension which best describes how you feel at this moment. You may mark any part of the line. Extremely hungry

Not at all hungry

Not at all fat

Extremely fat

Extremely blown out

Not at all blown out

Not at all thirsty

Extremely thirsty

* Sample analogue scale reprinted from Folstein et al. (1977) Note : Patients are asked to report their inner state (thoughts, feelings, sensations) by making a 100-mm line bounded by 'not at all' or 'extremely' and a descriptive word or phrase. Items can be scored by measurement with a ruler. It is advisable to alternate the descriptions 'not at all' and 'extremely' from side to side on the page in order to minimize response set.

Appendix 1-2 Eating Attitudes Test - EAT (Garner & Garfinkel, 1979)

Instruction Please place an (X) under the column which applies best to each of the numbered statements. All of the results will be strictly confidential. Most of the questions directly relate to food or eating, although other types of questions have been included. Please answer each question carefully. Thank you.

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1. Like eating with other people.

(

2. Prepare foods for others but do not eat what I cook. ( 3. Become anxious prior to eating. ( 4. A m terrified about being overweight.

(

5. A v o i d eating when I am hungry.

(

6. Find myself preoccupied with food.

(

7. Have gone on eating binges where I feel that I may not be able to stop.

(

8. Cut my food into small pieces. 9. A ware of the calorie content o f foods that I eat.

( (

10. Particularly avoid foods with a high carbohydrate content (e.g. bread, potatoes, rice, etc). ( 11. Feel bloated after meals. 12. Feel that others would prefer if I ate more.

( (

13. Vomit after I have eaten.

(

14. Feel extremely guilty after eating.

(

15. A m preoccupied with a desire to be thinner.

(

16. Exercise strenuously to burn o f f calories. 17. Weigh myself several times a day.

( (

18. Like my clothes to fit tightly.

(

19. Enjoy eating meat.

(

20. W a k e up early in the morning. 21. Eat the same foods day after day.

( (

22. Think about burning up calories when I exercise.

(

23. Have regular menstrual periods. 24. Other people think that I am too thin. 25. A m preoccupied with the thought of having fat on my body. 26. Take longer than others to eat my meals. 27. Enjoy eating at restaurants.

( (

28. 29. 30. 31. 32.

( ( ( ( (

32

Take laxatives. A v o i d foods with sugar in them. Eat diet foods. Feel that food controls my life. Display self control around food.

( ( (

HOW CAN A RELIABLE DIAGNOSIS BE MADE ?

Μ α> Ε

>H >60 %

serum albumin, gm/100 ml triceps skin fold, mm serum transferin, mg/100 ml delayed hypersensitivity reactivity to Candida (0 = nonreactive, 1 = < 5 mm, 2 = > 5 mm reactivity) = low risk = intermediate risk = high risk

Reprinted from Drossman (198.Ό

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WH A Τ SHOULD BE DONE A Τ THE ACUTE STAGE ?

An analysis of a series of deceased anorexia nervosa patients established that the following elements are serious vital risk factors in the long run (Deter et al., 1983): - weight loss below 50 % of the ideal body weight; - disturbance of liver and/or renal function (increased serum creatinine); - drop in total protein to below 6 %; - increase or decrease of phosphorus and potassium in serum. As already explained in Chapter 1, a physical examination and laboratory testing will reveal several abnormalities caused by malnutrition (see Halmi & Falk, 1981; Silverman, 1983). The major complications of anorexia nervosa include cardiovascular and respiratory changes (e.g., bradycardia, hypotension), renal changes (e.g., reduced concentrating capacity), hematological changes (e.g., leukopenia), gastrointestinal complications (e.g., delayed gastric emptying), neurological complications (e.g., convulsions, cerebral atrophy), dental erosion and reduced skeletal maturation (see Garfinkel & Garner, 1982). Generally, the severity of the clinical and laboratory abnormalities and the prevalence of medical complications correlate with the degree of undernutrition, and revert to normal with weight restoration. Anorexia nervosa patients have a considerable ability in adapting to varying degrees of caloric restriction. However, a severe or long-standing malnutrition in (pre)puberty can seriously affect normal growth processes to such an extent that even nutritional rehabilitation will not bring about catch-up growth resulting in reduced final height (Fohlin, 1980; Root & Powers, 1983; Russell, 1983). A few changes, such as increases in serum enzymes (SGOT, LDH) and alkaline phosphatase, can occur with refeeding and will return to within normal range after the patient has maintained a normal weight over a period of time (Halmi & Falk, 1981). Other unwanted or unforeseen side effects of refeeding are discussed in the next paragraph. One would normally be afraid of infectious complications in severely emaciated anorexics. Indeed, these patients may show signs of considerable malnutrition and leukopenia which would usually contribute to a susceptibility to infection and to immunological deficiencies. However, contrary to this expectation, anorexia nervosa patients have been found to be exceptionally free from infection until very advanced stages of the illness. They rarely develop the common cold or influenza (an immunity they lose after refeeding) and seldom die from infectious illnesses. It appears that the maintenance of a relatively intact cell-mediated immune system may be an important factor which distinguishes the malnourished anorectic patient from other protein-calorie malnourished patients (Golla et al., 1981). Generally speaking, 60 % of the ideal body weight seems to be the critical level below which cellular immunity is impaired (Pertschuk et al., 1982). So, although a certain resistance to infection may be preserved in anorexia nervosa, a long-standing and/or severe malnutrition will at a certain moment contribute to an increased susceptibility to infection which might then become lifethreatening (George, 1981). Here it is important to note that evaluation of fever is somewhat different in

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anorexia nervosa patients since they normally show some degree of hypothermia. One should regard a sick anorexic with a temperature of 38°C or 101°F as having a high fever if her basal body reading is usually 35°C or 95°F (Silverman, 1983)! In hospitalized cachectic patients vital signs should be ascertained on a regular daily basis. These include measurements of temperature, pulse, respiration, and blood pressure. Fluid and electrolyte imbalance should be measured regularly and corrected, especially in the vomiters and abusers of laxatives/diuretics. Lifethreatening arrhythmias, extreme bradycardia and hypotension, tetany, and severe hypokalemia require emergency management preferably in an intensive care unit. Specific attention should be paid to the possibility of ileus and gastric distention, sepsis, coagulopathies, hypoproteinemia, and eventual complications of nutritional rehabilitation (see next paragraph). If a patient is confined to bed, one must be aware of the danger of venous thromboses or thrombophlebitis. Therefore, early ambulation and passive or active exercises in bed are important prophylactic measures. Malnourished bedridden patients may also develop decubitus ulcers caused by sustained pressure on the skin usually over bony prominences (e.g., sacrum, heels). Cachectic individuals are susceptible to pressure sores due to subcutaneous fat loss and muscle wasting. For this reason, bedridden anorexics should be inspected regularly for areas of skin damage. Again, early mobilization is the most important element in prevention Prolonged inactivity in emaciated patients - together with vitamin deficiencies and loss of subcutaneous tissue - may also cause peroneal nerve palsies presenting as foot drop which usually resolves with partial refeeding and resumption of activity (Schott, 1979; Sherman & Easton, 1977). Abnormal muscle function and fatigability are, usually, quickly restored to normal with refeeding (Russell et al., 1983). As already explained in the previous chapter (3.6), diabetic patients may face the clinician with puzzling diagnostic and therapeutic situations. A number of case reports have appeared on the association of diabetes mellitus and anorexia nervosa or bulimia (Hillard et al., 1983; Hudson, Hudson & Wentworth, 1983; Hudson, Wentworth & Hudson, 1983; Powers et al., 1983; Roland & Bhanji, 1982; Szmukler & Russell, 1983). These patients use their diabetes in different ways : both as a powerful trump card in the confrontation with the clinician, and as a means of regulating their weight (by manipulating their insulin dosage) when their ability to abstain from food falter. They appear to accept the (selfinduced) complications of their diabetes since the desire for thinness overrides their desire for physical well-being. Compared to other anorexics, these patients are more likely to disrupt treatment and seem to be, in general, less cooperative and more prone to somatic risks including life-threatening hypoglycemia. Hypoglycemic coma, however, may also occur in non-diabetic patients due to severe starvation (Zalin & Lant, 1984). Finally, although not really 'medical' reasons, emergency psychiatric intervention may be required for patients with severe depression and, in particular, suicidal tendencies (not uncommon in bulimics), and in the case of

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WH A Τ SHOULD BE DONE A Τ THE A CUTE STA GE '

acute psychosis. Transient psychotic episodes in anorexia nervosa may occur as a result of organic factors, particularly malnutrition (Dally & Gomez, 1979) or following considerable psychological stress (Grounds, 1982). Note here that suicidal as well as psychotic reactions may also occur during treatment, for instance induced by long/strict deprivation or isolation as it was sometimes applied in the early days of behavior modification.

4.3. Refeeding Nutrition rehabilitation occurs most efficiently and rapidly in a hospital milieu with a structured treatment program. Even in severely undernourished anorexics such a program, as described in Chapter 6, will suffice to bring about the necessary weight gain. As will be explained further on (6.3), we prefer to make an explicit contract with each patient concerning her minimal and maximal weight gain. For patients over 15 years old, goal weight is determined by the well-known statistics of the Metropolitain Life Insurance Company for ideal body weight according to height and age. For those under 15 years, pediatric growth charts are appropriate. Target weight must be at least 90 % of the ideal body weight. This threshold is inspired by Frisch's (1977) data - not generally accepted (see Chapter 9) - regarding the critical body weight necessary for the onset of menses. We expect the patient to maintain her weight within a 4kg-range the target weight being in the middle of this range (see Appendix 5-1). Anorexia nervosa patients appear to avoid or reject food with a high-energy density, i.e. foods rich in-fat, while they usually maintain a proportionately high intake of proteins and a normal to reduced intake of carbohydrates (Beumont et al., 1981). These patients need high-energy food in order to restore their body weight but there seems to be no advantage in giving a very-high-protein diet since protein is probably slightly more satiating than other energy sources (Garrow, 1980). Moreover, injudicious use of very-high-protein diets (such as Sustagen, Metrecal, Carnation Instant Breakfast, etc.) may contribute to an elevation of blood urea nitrogen or azotemia. We consider a weekly weight gain between 0.5 and 1.5 kg acceptable for anorexics. One may start refeeding with 1500 calories per day, increasing progressively to even 4000-5000 calories. It is difficult, however, to ascertain accurately the caloric requirements for weight gain, especially because of the changing basal metabolic rate : the closer a patient is to the standard weight, the higher the caloric requirement for weight gain (Olson et al., 1981; Walker et al., 1979). Moreover, it has been shown that previously obese anorexics gain weight more rapidly (due to a lower basal metabolic rate) on the same food intake than those who were of normal weight before their illness began (Stordy et al., 1977). It is generally assumed that, despite several sources of variability, weight gain is directly proportional to the caloric intake above energy requirement, at least

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over long periods. On the short term, however, there seems to exist a nonlinearity of weight gain and nutrition intake in anorexia nervosa. In other words, there is a very variable and unpredictable relationship between caloric consumption and daily weight gain. This poses a special problem for behavioral approaches based on daily weight changes : there is the risk of unjustified punishment or reinforcement (Pertschuk et al., 1983). This is one reason why our contract system (see 6.3) is on a weekly basis, although patients may gain weight more rapidly in a daily reinforcement schedule (Eckert, 1983). We generally advise against using special diets (except for some protein supplements at the beginning); instead we offer the patient the standard hospital menu. The rationale here is that anorexia nervosa patients have already been preoccupied with diets and calorie counting for such a long time or to such an extent that they have created a position of 'specialness' we don't want to reinforce any further. Patients not only have to learn to eat more and thus to restore their body weight, but also to eat normal food in order to re-establish the social significance of sharing a meal with others. Nevertheless, it may be useful in some cases to start with liquid diets which the patients find easier to tolerate both physiologically (because of delayed gastric emptying after long starvation) and psychologically (the sight of too much solid food, especially warm meals, may sometimes be frightening). When patients are fearful of various types of food, it might be easier and more efficient to give them all their nutrition in a formula such as Sustacal (a mixture of eight ounces or 225 grams of whole milk and one package of Sustacal contains about 240 calories) which contains adequate amounts of vitamins, minerals, proteins, fatty acids, and carbohydrates, conveniently blended so that the patient cannot selectively discard any item (Halmi, 1983): "If the formula is given in equal-sized feedings throughout the day, the patient will not have to ingest a large amount at any one time. The total amount of Sustacal intake can be increased by 50 % every 5-day period. Some patients who have been ill for a long time may need to take Sustacal until they reach their target weight. Other patients can be taken off Sustacal after about 2 weeks and returned to a weight-gaining diet. After the patient has reached her target weight, it is wise to give her the amount of food to maintain that weight so she can visually conceptualize the amount of food she should be eating each day to maintain the target weight. After a week or two of presenting the patient with the number of calories needed to maintain her target weight, it is important to begin to allow the patient to choose her own foods and to practice maintaining her target weight without aid from the staff. Giving the patient the autonomy to choose her own foods after she is medically normal rather than earlier usually results in a smoother transition to normal eating patterns" (Halmi, 1983, p. 48). There is much controversy about the use of nasogastric intubation or tube feeding in anorexia nervosa patients. For Sours (1980), tube feeding "which makes the anorectic feel she has been defeated, should be avoided if at all possible" (p. 363). Thomä (1972), on the contrary, strongly promotes the use of tube feeding as a standard procedure in emergency situations : "Self-starvation becomes a self-perpetuating mechanism, at the very end of which the primarily

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WH A Τ SHOULD BE DONE A Τ THE ACUTE STAGE ?

Table 4.2. Complications Associated with Nutritional Rehabilitation Problem

Recommendation

Comment

1. Abdominal discomfort and nausea

Explanation and reassurrance; initial limitation of fats and milk products.

May be a sign, together with vomiting and diarrhea, of 'refeeding disease' (due to intestinal hyperosmolality); delayed gastric emptying is common in starvation.

2. Edema

Slower calorie intake until resolved; avoid diuretics; no added salt at table.

Water retention may be due to rapid increase of calorie intake and/or excessive fluid intake.

3. Constipation

Adequate dietary bulk, fruits and vegetables; chronic constipation with fecal impaction may require occasional use of a purgative.

Resolves with nutrition rehabilitation; may be exaggerated by patient in order to obtain laxatives especially in the 'purgers'.

4. Diarrhea

Look for secret use of laxatives; slower calorie intake; monitor serum potassium; use mild antidiarrheic drugs.

May be a sign of 'refeeding disease' (see 1); in chronic cases intestinal infection must be ruled out.

5. Gastric dilatation

Discontinue feeding; prompt gastrointestinal examination, gastric aspiration and emergency management.

Potentially fatal; danger of vomiting aspiration and pneumonia; overeating and acute gastric distension may cause gastric rupture and infarction.

6. Hypophosphatemia

Intravenous phosphorus administration and monitoring in an intensive care unit.

Danger of cellular hypoxia in vital tissues; monitoring of serum phosphate is advisable in severe emaciation.

7. Congestive heart failure

Bed rest and sodium -restricted diet; digoxin if necessary; repeated surveillance.

Increased metabolic demands during (rapid) refeeding may lead to cardiac complications.

Items 1, 2, 3 and 5 have been adapted from Andersen (1984); item 6 has been documented by Sheridan and Collins (1983), and item 7 by Powers (1982)

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psychological abstinence has turned into physical, bodily 'negativism', as it were. Tube feeding, then, is the only 'psychosomatic' means of breaking through the vicious circle" (p. 305). The pros and cons of tube feeding, from a psychological point of view, are discussed in the next paragraph. In our opinion, it should be used only in exceptional cases. If for one reason or another oral feeding is insufficient or not feasible, tube feeding makes it possible to bring about the necessary nutritional rehabilitation (Richard et al., 1983). By using a thin, flexible naso-gastric tube and a continuous drip system (continuous enteral feeding with nutripump), and by regular determination of a number of clinical and biochemical parameters, the risk of complications is very low and certainly below that of intravenous feeding which is also more expensive and time-consuming. This does not alter the fact that tube feeding may have its specific complications such as injuries to the nose or throat, and aspiration with the risk of respiratory insufficiency and pneumonia. Other complications, listed in Table 4-2, apply to different forms of oral and enteral refeeding in malnourished patients. Intravenous feeding or parenteral alimentation is the subject of similar discussions as in the case of tube feeding (see also next paragraph). An intravenous infusion of nutrients has its own risks, especially infection, thrombosis, metabolic imbalance and biochemical disturbances. These physiological risks apply in particular to Total Parenteral Nutrition (TPN), i.e. parenteral hyperalimentation via subclavian vein catheterization. Since this method also requires specialized equipment and close patient monitoring, its cost is very high. Although its advocates do not consider it a panacea for anorexia nervosa, they stress that TPN can provide a rapid method of establishing nutritional balance in the case of severe weight loss (Chiulli et al., 1982; Maloney & Farrell, 1980; Maloney, Brunner et al., 1983). But the incidence of (sometimes life-threatening) complications is high (Pertschuk et al., 1981) and even severe psychiatric reactions may be induced, especially if TPN is used as the primary treatment for anorexia nervosa rather than as an adjunctive modality (Hall et al., 1981). Therefore, we conclude that TPN has very little place in the treatment of anorexia nervosa: "Its use should be restricted to those rare cases when a medical emergency, such as high fever or trauma, induces an obligatory hypermetabolic state or when the patient is assessed as at a high nutritional risk and such enteral forms of support as tube feeding are not tolerated" (Kovach, 1982, p. 71).

4.4. Feeding or Treating ? When faced with an emaciated anorexic showing signs of potentially fatal consequences of severe weight loss, both family and physician become very concerned about the patient, but all too easily they get involved in and confused by a great deal of pleading, cajoling, and reprimands revolving around such topics as the sanctity of life, the right of self-determination, and the responsibility to self and others. Ethical and psychological dilemmas inherent in the treatment

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WH A Τ SHOULD BE DONE A Τ THE ACUTE STAGE ?

of anorexia nervosa patients are extensively discussed in Chapter 10. Here, we wish to highlight some aspects which are inevitably linked to the emergency management of these patients. Our first responsibility is to save the patient's life. But, as Reinhart and coworkers (1972) have stressed, the therapist must not feel threatened by the possible death of the patient: "We have been most fortunate to have escaped this possible outcome, but the neurotic need to cure every patient must not be allowed to interfere with treatment. We hesitate to commit ourselves to heroic treatment of patients with tube feeding or intravenous methods and feel there is more to lose than to gain" (p. 119). Several years later, similar words of caution are repeated this time regarding the use of hyperalimentation. Reinhart and Goetz (1980) emphasize how easily a physician may feel the need to do something active when treating anorexics: "However, we believe that responsibility for eating belongs to the patient, and that even the most disturbed patients are able to assume that responsibility. When the physician assumes the responsibility, we feel it may be dynamically counterproductive. Nevertheless, the threat of a patient's death is anxietyprovoking and a strain on the omnipotent feelings of physicians. (...). Our anxiety has often been great, but we have taken comfort in the fact that physicians are not all-powerful, and in our belief that patients, supported by their physicians and families, do want to live" (p. 1473). The desire to treat anorexia nervosa patients rapidly may come from three principle sources : "(1) The concern that the patient may die if treatment is not begun immediately and pursued aggressively, (2) the implicit awareness of possible legal consequences if the patient were to die if a somatic treatment had not been initiated within a reasonable time after admission, and (3) the physician's need to see early tangible change" (Browning, 1977, p. 402). However, attempts at rapid weight gain may neither be necessary nor indicated because o f ( l ) the patients' capacity to tolerate a considerable degree of starvation and associated metabolic imbalances, (2) the significant risk of morbidity and even mortality associated with attempts to induce rapid weight gain, and (3) the importance for some patients of taking sufficient time to establish a therapeutic alliance in psychotherapy (Browning, 1977). Some clinicians defend a total care system in the initial management of anorexia nervosa patients : the patient is ill and cannot take care of herself and, until she regains this ability, the physician will make all decisions; this means that the physician "tries to create a temporary 'realistic regression' for the patient during which she can concentrate her efforts on getting better (Silverman, 1974). "The acutely starving anorectic is told that she is toxic and cannot do adequate psychological work until her nutrition is at least partly restored" (Sours, 1980, p. 363). Other authors even advice that psychological issues should not be discussed until the patient is well on the way to gaining weight; psychological exploration of conflict-laden topics early in the treatment process could produce an excessive amount of anxiety in the patient and might distract her from concentrating on the primary task of gaining weight (Maxmen et al., 1974).

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It was, however, in reaction to the latter opinion that Goodsitt (1974) expressed the following warning : "By coercing food intake, we duplicate the experience these children receive at home from over-controlling, foodpreoccupied parents, and we thus preclude individuation. When the patient compliantly gains weight under duress, she is saying : Ί give up. You can have my body. It is an extension of you'. This treatment promotes the patient's central pathology of a fragmented sense of self with poor boundaries" (p. 372). This topic will be repeated in Chapter 10. Therefore, we will end this paragraph with some short suggestions and warnings. When using coercive tube feeding and phenothiazines as a routine procedure in the treatment of anorexia nervosa patients, Meyer and Otte (1970) realised that their approach closely resembled 'brain washing'. They found that the patients tended to see a strict, dictatorial and virile figure - the conscious or unconscious image of a 'raping male' - in their principal therapist ! Andersen (1984) considers nasogastric feeding as a failure in adequate management: it is all too often used prematurely and punitively ("You better eat or we'll tube you") and provides an illusion of rapid improvement. It seems to us, however, that tube feeding, just like ECT, has become an emotionally controversial symbol of so-called repressive psychiatry. Though we are not defending either method, we feel that, very often, the possibly deleterious effect does not primarily depend on the method itself, but on its users (i.e. the therapeutic context). That's why we would prefer, in certain circumstances, tube feeding to, for instance, the more subtle manipulation of a nurse who keeps "adding that extra mouthful while coaxing the patient with 'Just eat it up as a favor for me, there's a good girl, etc.' " (Selvini-Palazzoli, 1974, p. 121). Even when rapid weight gain is the primary goal in emergency cases, patients need special support during this phase, for example specific attention to their increased social anxiety and to their lowered self-esteem (Pillay & Crisp, 1977; Robinson et al., 1983). Patients need reassurance and explanation about normal physiological changes which occur during refeeding and which may cause physical discomfort or psychological tension. We explain to them, for instance, that swelling of the face or protruding of the stomach are transient phenomena : redistribution will occur with time and exercise. The lowering of thresholds for thermoregulatory sweating and vasodilatation may be a contributory factor to the abnormally low core temperature and may explain some of the anorexics' common complaints relating to feelings of warmth in the hands and feet after meals (Luck & Wakeling, 1980; 1981). Both empathy and rational explanation can show the patient that the clinician cares about her total health and not just about her disturbed physiology, that he cares for her as a person and not just for her underweight.

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WHA Τ SHOULD BE DONE A Τ THE ACUTE STAGE ?

4.5 Conclusion The decision for active, emergency intervention in anorexia nervosa should be made by weighing the potential benefits of a particular treatment procedure against its possible risks. "Information about anorexia nervosa patients indicates these patients have a remarkable capacity to tolerate the somatic manifestations of their illness and that aggressive attempts to correct the obvious abnormalities are likely to be only temporarily effective, completely ineffective, or fatal" (Browning, 1977, p. 402). Somatic therapeutic activism is as deleterious as an attitude of therapeutic nihilism. Therefore, it is equally important that psychotherapists learn to recognize the medical complications of starvation and collaborate with medical personnel in the treatment of these challenging problems (Maloney, Pettigrew & Farrell, 1983). Adequate evaluation of the patient, physiologically as well as psychologically, and careful consideration of the risk/benefit ratio of available treatment modes are a conditio-sine-qua-non before beginning with any somatic treatment. In case of doubt, it would be wise to discuss the case with experienced colleagues, staff members, or at least someone else who has no direct responsibility for the care of the patient and is removed from the pressure of events or the pressures from either family, patient or staff (Browning, 1977). Finally, no important emergency intervention should take place without close liaison between medical and psychiatric (psychological) services. We are treating sensitive and fragile human beings instead of correcting laboratory abnormalities and restoring emaciated bodies. Our view is best expressed in the following poem by Ron Charach (The New England Journal of Medicine, 1979, Vol. 301, p. 335): She will no longer take her food She will no longer take her food, H o w impossible to predict - that she, the perfect eater in the family should suddenly turn this bad. Tomorrow they try to feed her through a tube, or so the doctor threatened; failing that: she'll just have to take her food by vein. Today is September 4; as I see it they have another month; because in mid-December w e g o to Nassau as a family - it's been that w a y for years - and so, if her weight doesn't climb by October w e whisk her straight to Mayo.

That she should end up like this - she, the dearest, most accommodating little girl on earth - but she must k n o w h o w she's hurting us ! Her mouth would not accommodate; the tube - though greased w o u l d g o d o w n no further. They reeled it out said they'd try again later and her blue eyes glared; as they left her mouth once rigid as a vise formed a perfect Ό'; a siren pulling at her hair, and then the overdetermined scream...

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References Andersen, Α.Ε. (1984), Treatment of anorexia nervosa and bulimia. In : Bayless, T.M. (Ed.), Current Therapy in Gastroenterology. B.C. Decker Publishers. Beumont, P.J.V., Chambers, T.L., Rouse, L. & Abraham, S.F. (1981), The diet composition and nutritional knowledge of patients with anorexia nervosa. Journal of Human Nutrition, 35 : 265-273. Browning, C.H. (1977), Anorexia nervosa: Complications of somatic therapy. Comprehensive Psychiatry, 18 : 399-403. Chiulli, R., Grover, M. & Steiger, Ε. (1982), Total parenteral nutrition in anorexia nervosa. In : Gross, M. (Ed.), Anorexia Nervosa. A Comprehensive Approach. Lexington (Mass.): Collamore Press, pp. 141-152. Dally, P. & Gomez, J. (1979), Anorexia Nervosa. London : William Heinemann. Deter, H.C., Petzold, E., Hengst-Theis, R., Breider, U. & Lanzinger-Rossnagel, G. (1983), Katamnestische Ergebnisse einer klinisch-psychosomatischen Behandlung von 103 Patienten mit Anorexia nervosa aus internistischer Sicht unter besonderer Berücksichtigung der Mortalität (Catamnestic results of a clinical-psychosomatic treatment of 103 anorexia nervosa patients from an internist's point of view with special reference to mortality). Innere Medizin, 10(1): 3-12. Drossman, D.A. (1983), Anorexia nervosa - A comprehensive approach. In : Stollerman, G.H. (Ed.), Advances in Internal Medicine. Volume 28. Chicago : Year Book Publ., pp. 339-361. Eckert, E.D. (1983), Anorexia nervosa - A comprehensive approach. In : Darby, P.L., Garfinkel, P.E., Garner, D.M. & Coscina, D.V. (Eds.), Anorexia Nervosa : Recent Developments in Research. New York : Alan R. Liss, pp. 377-385. Fohlin, L.P.M. (1980), The effects on growth, body composition, and circulatory function of anorexia nervosa in adolescent patients. In : Berg, K. & Eriksson, B.O. (Eds.), Children and Exercise. IX (International Series on Sport Sciences, Vol. 10). Baltimore : University Park Press, pp. 317-326. Frisch, R.E. (1977), Food intake, fatness, and reproductive ability. In : Vigersky, R. (Ed.), Anorexia Nervosa. New York : Raven Press, pp. 149-161. Garfinkel, P.E. & Garner, D.M. (1982), Anorexia Nervosa. A Multidimensional Perspective. New York : Brunner/Mazel. Garrow, J.S. (1980), Dietary management of obesity and anorexia nervosa. Journal of Human Nutrition, 34 : 131-138. George, G.C.W. (1981), Anorexia nervosa with herpes simplex encephalitis. Postgraduate Medical Journal, 57 : 366-367. Golla, J.Α., Larson, L.A., Anderson, C.F., Lucas, A.R., Wilson, W.R. & Tomasi, T.B. (1981), An immunological assessment of patients with anorexia nervosa. American Journal of Clinical Nutrition, 34 : 2756-2762. Goodsitt, A. (1974), Anorexia nervosa (letter to the editor). JAMA, 230 : 372. Grounds, A. (1982), Transient psychoses in anorexia nervosa: A report of 7 cases. Psychological Medicine, 12 : 107-113. Hall, R.C.W., Stickney, S.K., Gardner, E.R. & Popkin, M.K. (1981), Psychiatric reactions to long-term intravenous hyperalimentation. Psychosomatics, 22 : 428-443. Halmi, K.A. (1983), Treatment of anorexia nervosa : A discussion. Journal of Adolescent Health Care, 4(1) : 47-50 Halmi, K.A. & Falk J.R. (1981), Common physiologic changes in anorexia nervosa. International Journal of Eating Disorders, 1(1): 16-27. Hillard, J.R., Lobo, M.C. & Keeling, R.P. (1983), Bulimia and diabetes - A potentially life-threatening combination. Psychosomatics, 24(3) : 292-295

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Hudson, J.I., Hudson, M.S. & Wentworth, J.M. (1983), Self-induced glycosuria. A novel method of purging in bulimia. JAMA, 249 : 2501. Hudson, M.S., Wentworth, S.M. & Hudson, J.I. (1983), Bulimia and diabetes (letter). New England Journal of Medicine, 309 : 431-432. Kovach, K.M. (1982), The assessment of nutritional status in anorexia nervosa. In : Gross, M. (Ed.), Anorexia Nervosa. A Comprehensive Approach. Lexington (Mass.): Collamore Press, pp. 69-79. Lefebvre, J. (1980), Treatment of undernutrition and electrolyte disturbances in anorexia nervosa. Acta Psychiatrica Belgica, 80 : 551-556. Luck, P. & Wakeling, A. (1980), Altered thresholds for thermoregulatory sweating and vasodilatation in anorexia nervosa. British Medical Journal, 2 8 1 : 906-908. Luck, P. & Wakeling, A. (1981), Increased cutaneous vasoreactivity to cold in anorexia nervosa. Clinical Science, 61 : 559-567. Maloney, M.J., Brunner, R., Winget, C. & Farrell, M. (1983), Hyperalimentation as a research model for studying the cognitive, behavioral, and emotional effects of starvation and nutritional rehabilitation. In : Darby, P.L., Garfinkel, P.E., Garner, D.M. &Coscina, D.V. (Eds.), Anorexia Nervosa: Recent Developments in Research. New York : Alan R. Liss, pp. 311-321. Maloney, M.J. & Farrell, M.K. (1980), Treatment of severe weight loss in anorexia nervosa with hyperalimentation and psychotherapy. American Journal of Psychiatry, 137 : 310-314. Maloney, M.J., Pettigrew, H. & Farrell, M. (1983), Treatment sequence for severe weight loss in anorexia nervosa. International Journal of Eating Disorders, 2(2): 53-58. 53-58. Maxmen, J.S., Siberfarb, P.M. & Ferrell, R.B. (1974), Anorexia nervosa. Practical initial management in a general hospital. JAMA, 229 : 801-803. Meyer, A.E. & Otte, H. (1970), The semantic differential as a measure of the patients' image of their therapist. Psychotherapy and Psychosomatics, 18 : 56-60. Olson, D., Moxness, K. & Anderson, C.F. (1981), Self-inflicted weight loss and subsequent refeeding. Journal of the American Dietetic Association, 78 : 505-507. Pertschuk, M.J., Crosby, L.O., Barot, L. & Mullen, J.L. (1982), Immunocompetency in anorexia nervosa. American Journal of Clinical Nutrition, 35 : 968-972. Pertschuk, M.J., Crosby, L.O. & Mullen, J.L. (1983), Nonlinearity of weight gain and nutrition intake in anorexia nervosa. I n : Darby, P.L., Garfinkel, P.E., Garner, D.M. & Coscina, D.V. (Eds), Anorexia Nervosa : Recent Developments in Research. New York : Alan R. Liss, pp. 301-310. Pertschuk, M., Forster, J., Buzby, G. & Mullen, J.L. (1981), The treatment of anorexia nervosa with total parenteral nutrition. Biological Psychiatry, 16 : 539-550. Pillay, M. & Crisp, A.H. (1977), Some psychological characteristics of patients with anorexia nervosa whose weight has been newly restored. British Journal of Medical Psychology, 50 : 375-380. Powers, P.S. (1982), Heart failure during treatment of anorexia nervosa. American Journal of Psychiatry, 139 : 1167-1 170. Powers, P.S., Malone, J.I. & Duncan, J.A. (1983), Anorexia nervosa and diabetes mellitus. Journal of Clinical Psychiatry, 44 : 133-135. Reinhart, J.B. & Goetz, P.L. (1980), The danger of hyperalimentation (letter to the editor). American Journal of Psychiatry, 137 : 1473. Reinhart, J.Β., Kenna, M.D. & Succop, R.A. (1972), Anorexia nervosa in children. Outpatient management. Journal of the American Academy of Child Psychiatry, 11 : 114-131. Reynaert, J., Degroote, J. & Lisaerde, J. (1983), Anorexia nervosa: Somatische afwijkingen (Anorexia nervosa : Somatic disturbances). Tijdschrift voor Gastroenterologie , 7 : 23-50.

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Richard, J.L., Bringer, J., Mirouze, J., Monnier, L. & Bellet, M.H. (1983), Interet de l'alimentation enterale ä faible debit continu dans le traitement de l'anorexie mentale (Efficiency of low-flow enteral feeding used as a nutritional support in anorexia nervosa). Annals Nutrition Metabolism, 27 : 19-25. Rockwell, W.J.K., Ellinwood, E.H., Dougherty, G.G. & Brodie, H.K.H. (1982), Anorexia nervosa : Review of current treatment practices. Soulhern Medical Journal, 75 :1101-1107. Roland, J.M. & Bhanji, S. (1982), Anorexia nervosa occurring in patients with diabetes. Postgraduate Medical Journal, 58 : 354-356. Root, A . W . & Powers, P.S., Anorexia nervosa presenting as g r o w t h retardation in adolescents. Journal of Adolescent Health Care, 4 : 25-30. Rüssel, D.M., Prendergast, P.J., Darby, P.L., Garfinkel, P.E., Whitwell, J.L., Jeejeebhoy, K.M. (1983), A comparison between muscle function and body composition in anorexia nervosa : The effect of refeeding. American Journal of Clinical Nutrition, 38:229-237 Russell, G.F.M. (1983), Delayed puberty due to anorexia nervosa of early onset. In : Darby, P.L., Garfinkel, P.E., Garner, D.M. & Coscina, D.V. (Eds.) Anorexia Nervosa : Recent Developments in Research. N e w York : Alan R. Liss, pp. 331-342. Schott, G.D. (1979), Anorexia nervosa presenting as foot drop. Postgraduate Medical Journal, 55 : 58-60. Selvini-Palazzoli, M. (1974), Self-Starvation : From the Intrapsychic to the Transpersonal Approach to Anorexia Nervosa. London : Chaucer (American edition : N e w York, Jason Aronson, 1978). Sheridan, P.J. & Collins, M. (1983), Potentially life-threatening hypophosphatemia in anorexia nervosa. Journal of Adolescent Health Care, 4 : 44-46. Sherman, D.G. & Easton, J.D. (1977), Dieting and peroneal nerve palsy. JAMA, 238 : 230-231. Silverman, J.A. (1974), Anorexia n e r v o s a : Clinical observations in a successful treatment plan. Journal of Pediatrics, 84 : 68-73 Silverman, J. A. (1983), Medical consequences of starvation; the malnutrition of anorexia n e r v o s a : Caveat medicus. In : Darby, P.L., Garfinkel, P.E., Garner, D.M. & Coscina, D.V. (Eds.), Anorexia Nervosa : Recent Developments in Research. N e w York : Alan R. Liss, pp. 293-299. Sours, J. (1980), Starving to Death in a Sea of Objects. The Anorexia Nervosa Syndrome. N e w York : Jason Aronson. Stordy, B.J., Marks, V., Kalucy, R.S. &Crisp, A.H. (1977), Weight gain, thermic effect of glucose and resting metabolic rate during recovery f r o m anorexia nervosa. American Journal of Clinical Nutrition, 30 : 138-146. Szmukler, G.I. & Russell, G.F.M. (1983), Diabetes mellitus, anorexia nervosa and bulimia. British Journal of Psychiatry, 142 : 305-308. T h o m ä , H. (1972), Treatment. Advances in Psychosomatic Medicine, 7 : 300-315. V a n d e w o u d e , M., Vangaal, L. & Deleeuw, I. (1983), Anorexia n e r v o s a : A nutritional profile. Tijdschrift voor Gastroenterologie, 7 : 51-55. Walker, J., Roberts, S.L., Halmi, K.A. & Goldberg, S C. (1979), Caloric requirements for weight gain in anorexia nervosa. American Journal of Clinical Nutrition, 32 : 1396-1400.

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C h a p t e r 5.

When is outpatient treatment possible ? 5.1. Resistance and motivation 5.2. Criteria for admission 5.3. The step towards the hospital 5.4. Outpatient approaches 5.5. Conclusion References Appendix 5-1 : Outpatient psychotherapy for anorexia/bulimia problems Treatment contract

5.1. Resistance and Motivation Resistance -any attitude, behavior, feeling, pattern or style on the part of the therapist, patient, or system that opposes change- is part of every therapeutic relationship. While resistance is inevitable, especially in the beginning of therapy, it is almost always accompanied by some desire (perhaps not consciously admitted) for relief from the distress which brings the patient a n d / o r the family into contact with the therapist. The latter must always evaluate the context of resistance in order to determine its function in the family and the therapeutic system (Anderson & Stewart, 1983). Before any treatment can be initiated, attention must be paid to the fact that most anorexia nervosa patients are (overtly) disinterested or resistant to treatment since they claim to 'feel good' and they protest that nothing is wrong with them (denial of illness : cf. 2.6.1.). They are usually brought to a doctor's office unwillingly by agonized parents w h o are alarmed by the weight loss, food refusal or related signs of anorexia such as amenorrhea. W e should not lose sight of the fact, however, that there are also important resistances on the part of the patient's family. The first type of resistance is responsible for both the (long) delay in initiating treatment and the early drop-out during treatment. It has to do with a sometimes 'unbelievable tolerance' (Israel et al., 1971) not only by the patient's family (parents, spouse) but also by the general practitioner with regard to the severity of the anorectic symptomatology : by minimizing or even ignoring the emaciation and its consequences, they apparently utilize the same denial mechanisms as the patient herself. Branch and E u r m a n (1980) confirmed these observations: although friends and family members are often embarrassed by the patient's eating habits, they are often 'astonishingly tolerant'. Moreover, some attitudes of friends and relatives may reinforce the patient's appearance and behavior, by means of direct or indirect feedback that the patient is attractive, socially accepted and even admired.

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A second type of resistance has to do with the family's conceptualization of the 'illness'. Here the family seems to realize the gravity of the patient's physical situation (labeled as an 'illness' that requires treatment), but they still are reluctant to face up to the psychological meanings of anorexia nervosa. The family avoids consulting a psychiatrist or psychologist; they prefer a 'real' physician or medical specialist. Another sign of this type of resistance is the refusal of a psychotherapeutic approach (or drop-out during such an approach) once the patient's weight is improved or restored. Such resistances may result "from the family's wish to deal with food rather than with underlying dysfunctional family patterns that would shift the focus from the anorectic child and emphasize the marital discord [of the parents]" (Conrad, 1977). The change from the patient's resistance to treatment or 'imposed' change to her being prepared to contemplate real change in herself is a great one (Crisp, 1980). By talking the anorectic's language, the therapist may get in touch with the experiential world of the patient. "The aim is to convert the patient from someone exercising extreme resistance and denial to someone who can acknowledge 'the price she is paying' for her illness and move her from an egosyntonic position to that of a patient. This seems an obvious prerequisite to accepting treatment" (Kalucy, 1978, p. 200). The first thing the therapist must do is to convince the patient and her family that they should participate in a treatment program. In doing this it is important to emphasize the benefits of treatment first of all for the patient herself: "She can be told that with treatment she can expect a decrease in the obsessive thoughts she has about food and body weight that interfere with her ability to concentrate on other matters. She can expect a resumption of more normal eating patterns and hence will feel more comfortable with socializing with her peers. With treatment, the anorectic adolescent can expect to obtain relief from insomnia and depressive symptoms and feel less irritable. If the anorectic is extremely emaciated, she will be upset that she no longer has the energy to be active. Reassurance that her previous activity level could be restored with treatment may also be helpful in persuading the patient to enter a treatment program" (Halmi, 1983, p. 47). The parents' support for a treatment program is essential and considerable time should be spent explaining the rationale and purpose of the treatment program to help ensure continued cooperation. The therapist's decision to commence treatment and the possibility of doing constructive work with the patient's family depend, first and foremost, on the parents' ability to ally themselves with such work. Their attitudes towards treatment may vary considerably (Harper, 1983): (a) They spontaneously seek help and are cooperative in treatment. (b) They present passively upon referral but form an alliance following confrontation. (c) They resist confrontation, but ally themselves with the therapist following a mandated report. (d) They only ally at prospect of legal restraint. (e) They only ally when custody is legally transferred.

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(f) They never ally. The question of 'protection and confrontation' is discussed in Chapter 8. As emphasized there, the cooperation of the parents is a crucial issue both in the inpatient and outpatient treatment of adolescent anorexics. We consider it a major principle that patients are admitted to an inpatient treatment program only if the parents (or the spouse of married patients) make a commitment to support the described treatment program and not to allow the patient to terminate treatment against medical advice (see Vandereycken & Pierloot, 1983). "This avoids the frustrating situation of a family admitting their daughter for emergency correction of electrolyte imbalance but then refusing to cooperate with the weight gain program. Initially, patients tend to cooperate with the program because they want to get out of the hospital. Parents tend to cooperate because they fear their daughter may die and agree that adherence to the program is a more acceptable alternative" (Collins et al., 1983, pp. 5-6). This brings us to the following question : When is hospitalization necessary or unavoidable ?

5.2. Criteria for Admission In 1972, Thomä asserted : "Perhaps there is one aspect of treatment in regard to which most observers are in agreement: The very emaciated patients must be removed from their home environment and hospitalized. Every other facet of the therapy provides material for controversy and discussion" (p. 303). But how many clinicians would agree on emergency indications for hospitalization ? In many referrals for hospitalization we have the impression that the referring clinician's own helplessness or insecurity was the primary motive for thinking about admission. We start from the principle that, as far as possible, anorexia nervosa patients should be treated in their natural milieu. Removing an adolescent from her family and habitual milieu not only means a very frustrating experience (in spite of some relief) on the part of both patient and family, but in many cases the symptoms have a clearly interactional significance which has to be dealt with in treatment. The child psychiatric-pediatric team at the Philadelphia Child Guidance Clinic and the Children's Hospital of Philadelphia has promoted a family systems orientation to treatment (see Chapter 8). They prefer to work, as much as possible, on an outpatient basis. The percentage of patients referred to their treatment team who need hospitalization, has gradually diminished from 57 % (Minuchin, Rosman & Baker, 1978) to less than 25 % (Hodas, Liebman & Collins, 1982), and is currently averaging 10-15 % (Liebman, Sargent & Silver, 1983). This trend may reflect a change in the patient population referred (e.g. earlier referrals, younger or more 'benign' cases) as well as a change in the attitude of the treatment team based on growing clinical experience. They use a (preferably pediatric) inpatient unit as a therapeutic environment to implement interventions aimed at changing the structure and functioning of the more resistant families and patients "The indications for psychiatric hospitaliza-

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tion are the presence of suicidal or (nonorganic) severe psychotic symptoms in the patient, situations in which prior or current outpatient psychotherapy has been ineffective, and those patients who have repeatedly gained weight in the hospital only to relapse after discharge" (Liebman, Sargent & Silver, 1983, p. 130). Selvini-Palazzoli (1974) advises, for the sake of the patient's psychological health, against hospitalization if there is any alternative: "(...) experience has shown me time and again that if only one does not panic in the face of dramatic weight losses and runs the unquestionable risk of keeping the patient out of hospital even while the relatives clamour for it, one can often draw the patient into a positive psychotherapeutic relationship. Quite often the therapist will be tempted to agree to the patient's hospitalization which is always justifiable on purely organic grounds simply for his own peace of mind. But while hospitalization may benefit the patient physically, it can ruin an interhuman relationship that is likely to have a much more decisive and profound curative effect" (p. 117). But Selvini-Palazzoli has to admit that she has no personal experience with inpatient treatment and that her opinion may be influenced by the situation in Italy where "the hospital atmosphere is, with few exceptions, not conducive to psychotherapeutic treatment". Moreover, she has advocated a therapeutic flexibility refusing to immure herself in rigid rules ! A therapist's flexibility will depend, among other factors, on his clinical experience (capacities, limitations), the setting he is working in and the people (colleagues, patients) he is working with. But a serious error in treating anorexics is to confound flexibility with indulgence. At times patients may fleetingly recognise that they are grossly undernourished, but their anxiety about losing control over their eating prevents them from making a wholehearted effort to regain weight. A degree of judicious coercion to eat is necessary if the self-starving anorexic is going to start eating and reverse distorted metabolic and hormonal processes, and correct the psychological effects of starvation. Some proponents of outpatient treatment, however, seem to consider it a basic principle to avoid, at any cost, every coercive effort (including hospitalization) to get the patient to eat even for the most severely cachectic patients (see also Chapter 10). Such an attitude "can prolong the treatment and even endanger the patient's life by collaborating with her in her struggle with her family and her regressive wishes to maintain infantile dependency. (...) In this program, the therapist dissociates himself from the feeding problem and overall medical management, not simply working collaboratively with an internist or pediatrician in the medical management, but totally divorcing himself from medical knowledge of the physical status" (Sours, 1980, p. 364). Brüggen and O'Brian (1980) have convincingly pleaded that the patient and the family be assigned the active role of a participant-decision maker with regard to treatment in general and hospitalization in particular : "Decisions about discharge and admission are often made on the basis of symptomatology and the

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likelihood of anticipated relief from those symptoms. Such a basis is unclear if we define therapy as a means of enabling people to get back to living together. To achieve that aim we have to look at what is going on between the parties concerned - the stresses and strains of the relationships. Those caught up in these relationships should not be deflected from the responsibility of being decision makers. We can probably enjoy our work and do better at it if we release ourselves from the notion that we are responsible for making all decisions" (p. 47). Anyan and Schowalter (1983) propose an evaluation scheme for the decision between ambulatory care and hospitalization. The patient and the family are encouraged to take an active part in this decision and their requests are usually followed except in those instances where the staff does not consider outpatient treatment to be possible. A recommendation for inpatient versus outpatient care is based on consideration of the following six factors : (a) Patient assessment. 1. The patient's physical condition. 2. The patient's negativism with regard to having a problem and needing treatment for it. 3. The patient's opinion regarding the site in which she would be able to get better, home or hospital. (b) Family assessment. 1. The presence of marital discord and its severity. 2. The parents' realization that care is necessary and their ability to unite in support of this care. 3. The parents' degree of anger or anxiety about the patient's physical or emotional status. Actually, one may add to this list some factors relating to the therapist himself, especially if the clinician involved is working in a private practice or in a setting with limited therapeutic possibilities or resources. Then he has to question his own position and whether he is the right person to treat this patient, recognizing the limits of his treatment potential (see Chapter 10). The decision to hospitalize an anorexia nervosa patient can be based on several criteria of which we may distinguish three types (Hodas, Liebman & Collins, 1982; Pierloot, Vandereycken & Verhaest, 1982): (1) Medical criteria. A life-threatening situation or a serious deterioration of the patient's health makes hospitalization necessary or even unavoidable : - severe acute or unremitting extreme weight loss (e.g. 30 % or more below the statistically normal level); - alterations in vital signs (postural hypotension, bradycardia, hypothermia) and absence of urinary ketone bodies; - electrolyte abnormalities, especially hypokalemia (often resulting from laxative/diuretic abuse or recurrent vomiting); - intercurrent infection in a severly cachetic patient. A clear suicidal tendency or attempt (mostly in binge-eaters) and psychotic reactions may also be considered as medical emergency criteria.

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(2) Psychosocial criteria. Hospitalization seems the only way out from an increasingly deteriorating vicious circle in which the patient has become imprisoned, e.g. marked family disturbance (with massive denial or inability to engage in outpatient therapy) or a situation of abnormal social isolation (with inability to study or work). These situations may be, at the same time, cause and consequence of the anorectic behavior, and are major risks for chronicity. (3) Psychotherapeutic criteria. In its negative form, this concerns previous treatment failures (especially in those patients with a poorer prognosis, e.g. longer duration of illness, late onset of disease, occurrence of bingeing, vomiting or purging) and a lack of motivation or even complete refusal (on the part of the patient and/or family) to engage in outpatient treatment. But hospitalization in a specialized setting can also have positive indications for offering a particular psychotherapeutic climate which may induce a considerable change that otherwise would take a long time to achieve, i.e. admission as a catalyst of a change process. With the exception of medical emergency indications (see also Chapter 3), hospitalization of anorexia nervosa patients is usually based on several of the above mentioned criteria which should always be scrutinised carefully. No doubt, outpatient treatment is the first choice if intervention occurs at an early stage of the disorder (see 3.6. Towards early recognition'). It is likely that beginning with outpatient therapy may be successful in adolescents who (a) have had anorexia for less than 4 months, (b) are not bingeing and vomiting, and (c) have parents who are likely to cooperate and effectively participate in family therapy (Halmi, 1983). But since it may be successful in many other cases, it should always be tried out if possible.

5.3. The Step Towards the Hospital. If hospitalization is indicated, we have to pay attention to the way in which this decision will be executed. If a clinician wants to be convincing in this matter, he must be, first and foremost, convinced himself of the necessity of this step. "Anorexia nervosa patients who are dangerously ill, but deny it, should be treated in hospital even though they pull every string to stay outside" (Thomä, 1972, p. 308). Hence the clinician has to take a firm stand or follow a wellplanned strategy in order to carry out his plan. He usually has to deal with strong opposition from both patient and family, as Stern et al. (1981) have described so vividly : "At the time of initial referral the family is usually in a regressed, dysfunctional state, and the decision-making process has all but broken down. Often the patient has been allowed to tyrannize the family with her illness for months, sometimes years. The parents, in fearful compliance with her demands and protestations, have gone along with her refusal of treatment and allowed her to starve herself to the point of life-threatening malnutrition. Even after the pediatrician has explained the need for immediate hospitalization, the daughter may succeed in convincing one or the other parent that she does not need to come in or that, given 'one more week at home', she will start to eat. Frequently

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at this point a hysterical scene ensues between daughter and parents in which the daughter tearfully insists she will not be admitted and the parents try various strategies -arguing, pleading, insisting- to persuade her to comply. Finally, in frustration, the parents turn to the pediatrician and ask directly, or by their look of defeat, what they should do. At this juncture we have found that it is most efficacious for the pediatrician to intervene and, in effect, take over responsibility for the identified patient. The parents have admitted their impotence, and the pediatrician acts as a 'holding' parent to the family : she or he confronts the family with the medical dangers of the anorexic's condition, being as authoritative as necessary to ensure that she be admitted. Usually, both the patient and the parents welcome this injection of reality and authority and experience considerable relief after the admission decision is made" (Stern et al., 1981, pp. 400-401). The question of how to convince the parents to comply with the decision to hospitalize will depend, of course, on several factors but particularly on their type of resistance (see 5.1.), i.e. their conceptualization of the problem ('illness') and their attitude (fears, expectations) towards eventual treatment. The strategy of direct confrontation, as described above, is probably the most used. This confrontation with the severity of the condition may sometimes be deliberately exaggerated and dramatized as a kind of 'horror' technique in order to frighten the parents (e.g. by quoting statistics on the mortality of anorexia nervosa). Frequently, although they seek help, the anorexic's parents do not give up their own ineffective efforts to fatten the patient and they cannot admit having failed in this respect. Crisis induction is a strategy aimed at bringing the family to the point of admitting failure or impotence. We use this very often as follows : in a case where we feel that outpatient treatment is almost impossible for any chance of success, but the patient or parents wish one last chance, we go along with their wish and design a time-limited (3 to 4 weeks) contract, for instance on a minimal weight gain (see next paragraph). If they fail to reach the goal within the prearranged time-span, they are more likely to accept hospitalization or even ask for it themselves. Minuchin's lunch session (see Chapter 8) is partially directed toward the same purpose. The family is invited to have lunch with the therapist who allows them to repeat their usual unsuccessful attempts to get the patient to eat. The therapist underlines their failure as strongly as possible, and tries to get the parents to acknowledge that the patient has 'won' again. Sometimes we use a rather paradoxical strategy combining prestige and ordeal (Rabkin, 1977). We explain to the patient and the family that, since our center is so renowned for treating anorexia nervosa, we have a long waiting list. Furthermore, we stress that, since treatment is paid by the official health insurance services (i.e. by the entire community), we cannot tolerate unmotivated patients occupying a bed while so many others are asking for help. Then, we may even emphasize that the patient's psychological condition is 'far too bad' for the special treatment we have to offer. Needless to say that, at this point, patient and family are very curious about that 'special' treatment program in our hospital! Finally, when parents hesitate, mainly fearing a 'stigmatization', it may be helpful to put them in touch with other parents whose children have already

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been hospitalized and, in the meantime, demonstrate the benefits of this treatment by having improved or even recovered. Self-help organizations could play an important role in this motivation process (see 10.2.4.). Nevertheless, even if one can convince the patient and/or family of the necessity for hospitalization, this decision and its concrete execution must be placed in an appropriate therapeutic context. "Whilst admission to hospital might make the situation safe for a while, especially when weight is very low or there is suicide risk, it can also involve considerable disruption in the patient's management: it may represent counterproductive retreat from confrontation with certain life difficulties and signify confirmation of sick role in the eyes of relatives who then dissociate themselves from active participation in therapy" (Morgan et al., 1983, p. 286). The risk of regression in a hospital is dealt with in Chapter 10, and the importance of involving the patient's family in the treatment process from the very beginning, and through all of its stages, is clearly emphasized and extensively discussed in Chapter 8.

5.4. Outpatient Approaches. The general principles of a multidimensional treatment for anorexia nervosa based on a functional analysis of the actual problematic behavior are discussed in the next Chapter on inpatient treatment, whereas the question of competing treatment models is dealt with in Chapter 10. Therefore, we will confine ourselves here to some specific aspects of outpatient treatment. In order to decrease the target symptoms of anorexia and to simultaneously stimulate restructuring of the family system, Liebman and coworkers (1983) use an outpatient operant reinforcement paradigm by assigning anorexia-related but interaction-oriented tasks which establish generational boundaries and clarify differentiation of the roles of family members. "The parents are told that it is their responsibility as parents to enforce the paradigm, and that they will be successful if they work together in a mutually supportive way. If the patient refuses to eat and loses weight, this indicates that the parents are not working together. The patient is told that it is her responsibility to herself and to her parents to follow the paradigm. The authority for the paradigm rests with the child psychiatrist and the pediatrician; if there is a crisis, the parents can call the therapist, but they are not to acquiesce to the patient's refusal to eat. This formulation increases the effectiveness of the parents and also gives the patient increased responsibility and autonomy. As long as she follows the paradigm, she can control the entire area of eating. At times of crisis, family therapy lunch sessions may again be indicated. The patient is told that she has to gain a minimum of 2 lb [ ± 900 gr] a week in order to maintain normal weekend activities. If she gains less than 2 lb, from Friday to Friday, she is not allowed out of the house during the weekend and she cannot have friends come to the house. In addition, a member of the family has to stay home with her. This produces a great deal of stress in the family system, causing members of the family to join together to ensure that the patient eats. (...).

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WHEN IS OUTPA TIENT TREA TMENT POSSIBLE ? Frequently, the parents believe that they are helpless and incapable of cooperating with one another. Alternately, the family may superficially agree with the treatment plan without having developed new problem-solving skills, rendering them vulnerable to the stresses associated with initiating treatment. Occasionally, the progress of treatment may plateau after an initial weight gain with the patient still being grossly underweignt. Also, the patient may try to gain weight rapidly at the beginning of treatment in an attempt to decrease the need for continued family therapy which may be perceived as threatening. The therapist must develop an effective therapeutic relationship with the family members and establish goals for changing those behavior patterns which may reinforce the perpetuation of symptoms. Throughout treatment, the therapist must anticipate potential resistances to change and consistently support the family to remain engaged in the process of developing improved skills to cope with stress and resolve or prevent problems" (Liebman, Sargent & Silver, 1983, pp. 131-132). Once weight is increasing progressively, structural family therapy is organized shifting the focus from eating to interpersonal issues.The further steps are not specific anymore for anorexia nervosa patients, but are centered around the particular attachment-autonomy problems in families with adolescent children (see also Chapter 8). When used in a family context as described above, behavior modification programs for weight restoration are effective methods of avoiding self-defeating power struggles. They provide the parents with something concrete to do at home and decrease their anxiety and previous feelings of helplessness in dealing with an anorectic child. This type of intervention is aimed at neutralizing the problem of food refusal or threatening weight loss. It permits both the therapist and the parents -and after a while even the patient herself- more freedom of maneuver during the treatment process. As explained in the next chapter, we ourselves prefer the use of behaviorally oriented treatment contracts. Such a contract is part of a consistent and transparent approach that focuses on the anorectic symptoms as the main point of entry for changing the individual's overall functioning. Even when weight has been restored (outside or inside the hospital), maintenance of normal weight and eating has to be ensured not only to prevent relapses but also to avoid the situation of anorectic symptomatology hampering, once more, the individual's development during the further psychotherapeutic process. For the latter purpose, a contract system as presented in Appendix 5-1 may be helpful. When weight loss or abnormal eating is still the central issue, we try out the following outpatient strategy. No causal explanations are given with regard to the anorectic problems, following the axiom that we cannot change the past but can try to avoid repeating its unfruitful experiences. Two basic rules are explained : the family has to restore its normal living pattern and the patient has to restore her health. Weight restitution is the patient's own and primary responsibility. A contract is made regarding the minimal weight gain required (depending on the patient's physical condition but usually a minimum of 500 gr and a maximum of 3 kg a week, the latter limit in order to avoid overeating). If

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the patient does not meet this condition some consequences will follow with an increasing degree of severity (e.g. limitation of physical activity, interdiction of working or studying, hospitalization). The patient has to eat in a separate room at the usual dinner times and she is free to eat what and how much she likes herself with the exception that she has access only to the same food the other family members are eating at the same time. Moreover, she is not allowed to eat in other rooms or at other times, to buy or hoard food, to interfere with cooking or with her mother's choice of menu. No one family member is permitted to control her eating or to make comments about it; the same applies to her weight which is only controlled by the therapist. The rationale of this approach is twofold : (a) Anorexia nervosa patients have difficulty eating with others; therefore it is easier for them to start learning to eat normally again while being alone; the more they are controlled, the less they eat. (b) The family has to learn to resume normal mealtimes as a social event; this means that they have to return to their usual eating habits with no special menu (low calorie diet) for one member and without controlling each other's eating behavior. Moreover, instead of talking about food or body shape, they have to resume normal dinnertable talks so that dining may again become a pleasant family meeting. The patient may rejoin the family during mealtimes once she can eat properly for her age. It is the family's responsibility to see that these rules are respected and that eventual consequences of the contract will be carried out. We often explain here to the worried parents that, in order to prevent cardiovascular complications, it is far more important to be concerned about hyperactivity ('exhaustion of a weak body') than about the patient's eating behavior. In this way we are deflecting attention onto a symptom which is less disruptive for family interactions ("It is easier for you to achieve a decrease of her physical activity than an increase of her food intake"). On the other hand, we ask the anorexic to report to us immediately when some family member interfered with her eating. Such a restructuring of the interactional nature of eating within a family context may soon have a great impact if at least one of the parties involved (patient or family) is following the rules. If not, a failure can be used as a confrontation with the therapist's "growing evidence that there must be something wrong in this family". This might bring the family closer to compliance or closer to the decision to hospitalize. A vexing problem among some anorexia nervosa patients is their maintenance of idiosyncratic eating habits even after adequate weight gain has been achieved. These habits include the hoarding or hiding of food, eating when family members are out of sight, refusal of food at mealtimes only to be eaten later alone, refusal to eat with family or friends or the creation of a variety of explanations for being unavailable at mealtimes, the commandeering of parts of the refrigerator, freezer or cupboard for the patient's own 'special foods', and the refusal to sample or eat a sizeable variety of foods which are viewed as 'taboo'. For these types of abnormal, secretive or ritualized eating behavior Rosen (1980) utilized a contract procedure similar to ours but emphasizing in particular the tactic of symptom prescription : he prescribed the patients to practise only their

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WHEN IS OUTPA TIENT TREA TMENT POSSIBLE ? self-imposed maladaptive eating styles while excluding more acceptable eating behavior. Patients quickly recognized the impracticality of their behavior when it became the sole mode of operating, abandoned it and adopted acceptable patterns of eating. Other interesting tactics of outpatient treatment are described by McGlynn (1980) who showed that a treatment package involving self-monitoring and long distance praise can produce successful outcome with minimal therapist-patient contact. The treatment had the following features : (1) The patient was to ingest at least 2000 calories per day. (2) She was to self-monitor and chart her caloric intake and weight daily. (3) She was to prepare duplicates of the weight and caloric-intake graphs each week and mail them to the therapist. (4) She was to telephone the therapist once a week to get feedback on the charts, discuss her progress, and iron out any unforeseen problems with the plan. Such approach necessitates, of course, a reliable compliance on the part of the patient but in other cases similar procedures may be carried out with the help of family members. Another practical suggestion has been made by Poole and coworkers (1978). They frequently established, from reports of relatives, that the anorexic's eating behavior at home would vary considerably, declining shortly after a therapy or follow-up session only to pick-up immediately prior to the next appointment so that her weight was on target when she was next seen. "In order to reduce this fluctuation the current procedure is not to stipulate subsequent outpatient appointments, but rather to contact the patient the day prior to each appointment and advise them of its time. These appointments are scheduled by the therapist on a random basis so that the patient has no way of knowing whether her next appointment will be, for example, in 3 days or 3 weeks. In this way, the patient is obliged to maintain her weight within narrow limits since if she is below the specified lower limit she is aware that she has contracted to accept readmission" (Poole et al., 1978, p. 51). Finally, we wish to mention the possibility of outpatient group therapy for anorexia nervosa patients. This topic is extensively discussed in the next chapter : the basic ideas of what we say there with regard to group treatment for hospitalized patients, also apply to group therapy on an outpatient basis. While experimenting with such an outpatient group approach, Huerta (1982) found that, although the initial purpose of the group was to provide additional support for outpatients in order to avoid hospitalization whenever possible, additional uses had become apparent: 1. "The group is a diagnostic tool. Even after thorough evaluation, further and crucial information may be obtained in a single group session. As the patient is able to identify with other group members, she becomes less defensive and more willing to reveal information that she was embarrassed or afraid to admit to the physician. Some of this information may be critical in making an accurate diagnosis and, therefore, a reasonable treatment plan. 2. The group can be preparation for intensive treatment in the hospital. Outpatients who have previously denied the seriousness of their illness and actively resisted any treatment may acknowledge the need for treatment and

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switch from the position of having treatment forced on them to that of being receptive to the idea of treatment and actively participating in the tailoring and implementation of the treatment plan. 3. The group is extended support for patients recently discharged from the hospital. Group participation serves as a transitional stage in which the patient is able to maintain communication with the hospital while going through the difficult adjustment from life in the hospital to a return to the real world. 4. A large proportion of patients make excellent progress on an outpatient basis, with group psychotherapy as the main therapeutic modality, and individual and family sessions taking a secondary role. 5. The group is a refresher course for ex-patients who have been away from treatment. Some patients may return for a few sessions when, because of unexpected stressful situations, they become more aware of and concerned about early signs of relapse. Other patients return for one or two sessions whenever they have the opportunity (...). When these patients are doing well, they serve as healthy models for identification by other group members." (Huerta, 1982, p. 117).

5.5. Conclusion We might well answer the title question of this chapter - 'When is outpatient treatment possible ?'- with a simple 'always'. Indeed, in one way or another it is always possible, which does not mean that it is always potentially successful. It is a leading principle that outpatient therapy of anorexia nervosa patients should be tried unless emergency situations force us to hospitalize the patient or unless we have solid reasons for preferring inpatient management. In many cases, especially when the patient and/or the family are resistant towards (psychotherapy, for example because of denial of the problem situation, outpatient treatment is the only approach the family is willing to accept. Even when the experienced clinician fully recognizes the fact that outpatient therapy will almost unavoidably lead to failure, he may deliberately exploit this failure as a 'lever' in a motivation process which ends up in the family's acceptance of hospitalization. Whenever the clinician, after having realisticly assessed the situation he is faced with, feels he has little or nothing to lose with an outpatient treatment trial, he can justify such attempt on the condition that he regularly evaluates its costs and benefits both with respect to the patient and the family involved.

References Anderson, C.M. & Stewart, S. (1983), Mastering Resistance.

A Practical Guide to Family

Therapy. New York : Guilford Press. Anyan, W.R. & Schowalter, J.E. (1983), A comprehensive approach to anorexia nervosa. Journal of the American Academy

of Child Psychiatry,

22 ·. 122-127.

Branch, C.H.H. & Eurman, L.J. (1980), Social attitudes toward patients with anorexia nervosa. American Journal of Psychiatry,

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137 : 631-632.

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Brüggen, P. & O'Brian, C. (1982), An adolescent unit's focus on family admission decisions. In : Harbin H.T. (Ed.), The Psychiatric Hospital and the Family. Jamaica (N.Y.): Spectrum Publications, pp. 27-47. Collins, M., Hodas, G.R. & Liebman, R. (1983), Interdisciplinary model for the inpatient treatment of adolescents with anorexia nervosa. Journal of Adolescent Health Care, 4 : 3-8. Conrad, D.E. (1977), A starving family. An interactional view of anorexia nervosa. Bulletin of the Menninger Clinic, 41 : 487-495. Crisp, A.H. (1980), Anorexia Nervosa : Let Me Be. London/New York : Academic Press/ Grune & Stratton. Halmi, K.A. (1983), Treatment of anorexia nervosa : A discussion. Journal of Adolescent Health Care, 4 : 47-50. Harper, G. (1983), Varieties of parenting failure in anorexia nervosa: Protection and parentectomy, revisited. Journal of the American Academy of Child Psychiatry, 22 : 134-139. Hodas, G. Liebman, R. & Collins, M.J. (1982), Pediatric hospitalization in the treatment of anorexia nervosa. In : Harbin, H.T. (Ed.), The Psychiatric Hospital and the Family. Jamaica (N.Y.): Spectrum Publications, pp. 131-141. Huerta, E. (1982), Group therapy for anorexia nervosa patients. In : Gross, M. (Ed.), Anorexia Nervosa. A Comprehensive Approach. Lexington (Mass.): Collamore Press, pp. 111-118. Israel, L., Ebtinger, R., Bolzinger, Α., Renoux, Μ., Weil, J. & Wysoki, V. (1971), A propos des interventions inopportunes de l'entourage de l'anorexique (Inappropriate interventions on the part of the anorexic's family). Revue de Neuropsychiatrie Infantile, 19 : 639-643. Kalucy, R.S. (1978), An approach to the therapy of anorexia nervosa. Journal of Adolescence, 1 : 197-228. Liebman, R., Sargent, J. & Silver, M. (1983), A family systems orientation to the treatment of anorexia nervosa. Journal of the American Academy of Child Psychiatry, 22 : 128-133. McGlynn, F.D. (1980), Successful treatment of anorexia nervosa with self-monitoring and long distance praise. Journal of Behavior Therapy and Experimental Psychiatry, 11 : 283-286. Minuchin, S., Rosman, B. & Baker, L. (1978), Psychosomatic Families. Anorexia Nervosa in Context. Cambridge (Mass.): Harvard University Press. Morgan, H.G., Purgold, J. & Welbourne, J. (1983), Management and outcome in anorexia nervosa. A standardized prognostic study. British Journal of Psychiatry. 143 : 282-287. Pierloot, R., Vandereycken, W. & Verhaest, S. (1982), An inpatient treatment program for anorexia nervosa patients. Acta Psychiatrica Scandinavica, 66 : 1-8. Poole, A.D., Sanson-Fisher, R.W.& Young, P. (1978), A behavioural programme for the management of anorexia nervosa. Australian and New Zealand Journal of Psychiatry, 12 : 49-53. Rabkin, R. (1977), Strategic Psychotherapy. Brief and Symptomatic Treatment. New York : Basic Books. Rosen, L.W. (1980), Modification of secretive or ritualized eating behavior in anorexia nervosa. Journal of Behavior Therapy and Experimental Psychiatry, 11 : 101-104. Selvini-Palazzoli, M. (1974), Self-Starvation : From the Intrapsychic to the Transpersonal Approach to Anorexia Nervosa. London : Chaucer (American edition : New York, Jason Aronson, 1978). Sours, J. (1980), Starving to Death in a Sea of Objects. The Anorexia Nervosa Syndrome. New York : Jason Aronson. Stern, S., Whitaker, C.A., Hagemann, N.J., Anderson, R.B. & Bargman, G.J. (1981),

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Anorexia nervosa: The hospital's role in family treatment. Family Process, 20 : 395-408. Thomä, Η. (1972), Treatment. Advances in Psychosomatic Medicine, 7 : 300-315. Vandereycken, W. & Pierloot, R. (1983), Drop-out during in-patient treatment of anorexia nervosa: A clinical study of 133 patients. British Journal of Medical Psychology, 56 : 145-156.

WHEN IS OUTPATIENT

TREATMENT

POSSIBLE ?

Appendix 5-1 University Psychiatric Center St. Jozef, Kortenberg (Belgium)

Anorexia Nervosa Unit (Head : Dr. W. Vandereycken)

Outpatient psychotherapy for anorexia/bulimia problems Treatment contract Name:

Date:

Outpatient psychotherapy is only possible if my physical health is good and if I keep to some rules. For these reasons I agree to the following contract: - My minimum normal body weight is .... kg. - I will be weighed at the therapist's request. - If my weight drops 2.5 kg below the minimal limit mentioned above, exception program 1 will be enforced; if it drops 5 kg below that limit, exception program 2 will be enforced, and if it drops 7.5 kg below the limit, exception program 3 will be enforced. - If I again become bulimic or vomit or abuse laxatives, I will submit to monthly blood checkups and if the symptoms get out of hand, exception program 2 will be enforced. - I will attend therapy sessions regularly and warn the therapist of any unforeseen interferences. - If I can't keep any part of this agreement the treatment program can be altered and my family will be warned. Exception program 1 means : No more sports nor physical exertion and each week an extra weight control with the general practitioner. If, after one month, my weight is still 2.5 kg below the normal limit, the extra weight control will be carried out here at the hospital. More than 2 months at 2.5 kg or more below the limit will mean referral to exception program 2. Exception program 2 means : I will stop working or going to school and I will come three days a week to the day-hospital. If after one month I have shown insufficient improvement, I will attend the day-hospital five days a week. If I still fail to improve sufficiently after 2 months, exception program 3 will be enforced. Exception program 3 means : Full hospitalization for at least one month. I hereby agree to the above contract,

(signature)

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Chapter 6

How should an inpatient treatment program be structured ? 6.1. 6.2. 6.3. 6.4.

Introduction Behavior analysis and treatment planning The short-term perspective The long-term perspective 6.4.1. Changing body image 6.4.2. The group approach 6.4.3. The aftercare program 6.5. Conclusion References Appendix 6-1 : Information for patients 6-2 : Information for the family

6.1. Introduction In the present chapter we are going to try to point out some of the specific problems in the hospital management of anorexia nervosa patients. Our recommendations and suggestions are based on the current literature and our own clinical experiences. In our attempt to describe the principles of inpatient treatment we are well aware that we cannot completely do justice to the specific aspects of the individual case. On the other hand, we did not want to make our account disjointed by a multitude of case examples, which although illustrating diverse aspects of individual cases tend to be more of a hindrance to a compact and systematized account of the principles of treatment. Each therapist has to 'translate' them according to his own clinical experience and the treatment setting he is working in. Copying a successful or recommended treatment procedure is in fact impossible since one cannot copy a therapeutic attitude. Without an appropriate therapeutic attitude (basic knowledge and clinical skills) even the best technique will inevitably fail. Therefore, it is advisable to read first our thoughts in Chapter 10 on therapist variables. A good therapeutic relationship is a basic prerequisite but not a sufficient condition for successful treatment. A consistent, wellstructured therapeutic strategy is the second corner stone of an effective treatment. The present chapter will present some guidelines in this respect, especially for those clinicians who do not merely occasionally see anorexia nervosa patients, but who are responsible for treating in the normal course of their work a growing number of anorexics.

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6.2. Behavior Analysis and Treatment Planning During the course of the initial contact with a hospitalized patient, the aims of the therapy should be discussed at length, as well as the history taken and the physical and routine laboratory examinations carried out (see Chapter 1). In order to draw up a multidimensional therapeutic program, a detailed behavior analysis of the actual problematic behavior is necessary.

Figure 6-1. Schematic View of the Diagnostic Therapeutic Procedure in Behavior Therapy (Adapted from Schulte, 1974).

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In Figure 6-1 we have reproduced a flow diagram of diagnostic-therapeutic procedures in behavioral medicine. The important thing about this diagram is that the phase of information gathering is never finished during the whole course of the therapeutic process. Furthermore, at different stages during the course of treatment the aims are checked and controlled to see if the provisional hypotheses are adequate for the aims. Whenever this leads to a negative result, we have to start again with the information gathering phase. This diagnostictherapeutic procedure, which is clearly distinct from the classic and conventional separate steps of diagnosis and treatment, offers several advantages : first, during the course of treatment it allows the patient to keep a continual eye on the aims of the therapy; second, both therapist and patient have the opportunity to examine the progress in therapy whenever they want to; third, a therapyaccompanying behavior analysis permits one to repeatedly fit the therapeutic strategy to changing needs and new situations. In addition to this, the diagram clearly points out that a behavioral analysis is closely connected to the therapeutic objectives or definitions of the aims which have been decided upon with the patient and preferably also with the family. In this way the patient as well as her family take an active part in the treatment from an early stage which includes their taking responsibility for the process of change. A behavioral analysis of the actual eating disorder and related problems has to be carried out at different levels. Here Lazarus' (1981) BASIC-ID model offers an easy mnemonic aid. These letters stand f o r : Behavior, Effect, Sensation, /magery, Cognition, /nterpersonal relations, and Drugs. On the behavioral plane, information is sought, for instance, on the increase and decrease in certain problematic forms of behavior, on the frequency, intensity and duration of the problematic behavior, as well as - in the sense of classic functional analysis - on the question of preceding stimulus configurations and the consequences of the problematic behavior. On the emotional plane questions are asked about different types of emotions (anxiety, joy, anger, depression). One also tries to get a general view of pleasant/ unpleasant, hidden or distorted feelings, or rather to what extent feelings are perceived and can be expressed. In anorexics the sensory plane concerns, in particular, disorders of interoceptive perception and body image or bodily experiences (see 2.6.2.). One also tries to find out the extent to which these perceptions or sensations are regarded as being pleasant, unpleasant, conscious, hidden or overconscious. Regarding the imagery plane, the patient is asked to describe some fantasies or 'mental images' of important experiences in the past or special expectations in the future. A discussion of these images reveals important information about cognitive and emotional elements evoked by them. Problems on the cognitive level have already been dealt with in Chapter 2 (see 2.6.1). They concern, in particular, the patient's distorted self-concept, irrational ideas or errors in reasoning. Interpersonal modes can be ascertained, on the one hand, by the patient's own reports (or information from relatives, friends, etc.), and on the other by means of directly observing interpersonal behavior within the hospital, whereby not only the therapist-patient relationship should be considered but also the patient's

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interactional behavior on the ward (relations with other patients and staff). In Lazarus' model, the term drugs is used in a very comprehensive manner. Here it means the gathering of information about the patient's physical appearance, all forms of bodily complaints and disorders, as well as the question of physical training, fitness, diet, taking laxatives etc. So, as we already emphasized in Chapter 1, a behavioral assessment and analysis is far more complex than just weighing the patient or counting the number of calories she is eating. The working out of a multidimensional diagnostic approach is a necessary step before a provisional treatment plan can be outlined. Although such treatment planning is always individualized, certain general principles govern our approach of anorexia nervosa patients. The therapist should make it clear that the restitution of weight is only one and not the main aim of inpatient treatment. Anyhow, though the problems and conflicts responsible for the abnormal eating behavior should be dealt with, there is no point in trying to achieve this until the patient has reached a certain minimal weight. As a major implication of this approach, we believe that already during the first contact the therapist has the task of passing on some basic information about the underlying principles of the treatment to the patient as well as to her family. In Appendix 1 and 2, we have reproduced some information brochures intended to make the essential ideas of the treatment as transparent as possible. In the following, we consider the inpatient treatment process from a twophase perspective, as proposed by Van Buskirk (1977): (1) The short-term perspective, where the emphasis lies on a quick elimination of symptoms (i.e. weight restoration and normalization of eating habits); (2) the long-term perspective intent upon psychosocial adjustment and the maintenance of a normal body weight and eating behavior. The former aim is usually accomplished to a great extent within the hospital, whereas the latter necessitates further outpatient treatment after discharge from the hospital.

6.3. The Short-Term Perspective Restoring weight is an essential requirement for psychotherapeutic work with an anorexia nervosa patient. Though several methods have been described as successful, Agras and Kraemer (1984) conclude that the overall treatment outcome of anorexia nervosa has not improved over the last years. Most of the approaches may be categorized as standard therapy or medical treatment, i.e. a general category of procedures including hospitalization, often combined with confinement to bed, supervised eating, psychotherapy, family therapy, and occasionally tube feeding. There is little evidence that pharmacologic agents add to this standard treatment (see Chapter 7). Behavior therapy, on the other hand, appears to produce better results on the short-term (see Agras & Kraemer, 1984). Usually it consists of the structured use of reinforcement for weight gain in a hospital setting whereby activities in which

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''

the patient likes to engage are made contingent on a certain increase in daily weight. An example of such weight gain program is summarized in Table 6-1. Table 6-1, Weight Gain Program for Inpatient Anorectics 1. The patient, after discussion with the dietitian, is given a 2500-3000 calorie diet each day, and orders most of the items herself. The patient determines how much food she consumes; the staff makes no attempt to force or cajole the patient to eat. 2. The patient is weighed each morning at the same time dressed in nightgown only. A weight gain of 0.25 kg entitles the patient to full privileges on the unit. Weight gain of less than 0.25 kg or weight loss results in loss of privileges for that day. 3. If the patient fails to gain 0.25 kg on a given day, her activity is restricted in the following ways : - no visitors or phone calls, including parents, - confinement to bed with curtain drawn without access to television or reading material, - no bathroom privileges for that day. 4. When bedrest is enforced, the patient is told that this is medically necessary in order that she conserve her limited calories and concentrate more effectively on gaining weight. The purpose of the bedrest is medical, not punitive. 5. Once the patient has reached her previously set discharge weight, she is discharged into outpatient family therapy. Reprinted from Hodas, Liebman and Collins (1982).

Whatever the concrete procedure one prefers, it ought to be a carefully planned approach which will allow a patient to gain weight slowly enough to adapt to her new body image gradually, and which will protect her from the fear of gaining too fast, losing control, and becoming obese. In our experience, it is a substantial advantage to treat several anorexics at the same time within the same hospital sstting using a standardized contract system. By the latter we mean a written contract which stipulates in detail the basic principles and concrete guidelines of the therapeutic program. The contract used in the Anorexia Nervosa Unit of the University Psychiatric Center St. Jozef at Kortenberg (see Appendix 6-1) includes, for instance, the following rules : a minimal weekly weight gain of 700 gr is required with a maximum limit of 3 kg a week; patients receive the regular hospital menu and are not allowed to eat something else, nor to take snacks in between meals nor to hoard food. If these conditions Eire not met, the patient is placed in the 'exception program' which is, in fact, the more classical operant treatment with varying degrees of deprivation. So, the rather coercive contingency management program which we applicated before in every case (see Vandereycken & Pieters, 1978), is now used as a kind of negative reinforcer : the patient will have relative freedom as long as she can stay in the 'regular program' which consists of three stages. The

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patient moves to the following stage each time she has gained one third of the total weight she should gain. A patient who has been placed in the exception program may return to the regular program once she again meets the basic conditions of the contract. In the first stage of the regular program, the patient eats in her own room, is weighed daily, has to stay on the ward and may receive visitors one day of the weekend. In the second stage, the patient receives a set portion of food in the dining room where she eats together with the other patients and under the supervision of a nurse; she is now weighed only three times a week, is free to leave the ward but not the hospital except for a weekly outing with other patients and a nurse; visitors are allowed during the entire weekend. In the third stage (i.e. once two thirds of the required weight gain are reached), the patient eats freely in the dining room, is weighed just twice a week, may receive visitors every day or leave the hospital for an outing on her own and for a weekend at home. The use of such a standardized contract system not only has several practical advantages for the nursing staff (especially in a unit with a large number of anorectic patients), but it also appears to be of important psychological significance. The patient feels rather safe in a graduated, well-structured program of which each new stage is viewed as a challenge : it is desired and feared at the same time. Moreover, the evolution of each patient is easily comparable with others': they derive a certain identity from it (e.g. being in the first stage means to be ill whereas those in the third stage are considered almost recovered); patients compare and discuss each other's stage and so do the relatives. The important thing here is the high degree of transparence or openness for both patient, family, and staff. Another advantage is that the patient's autonomy is more or less guaranteed. This means, for instance, that too much external control is avoided since such control risks provoking deception, manipulative behavior or even more severe symptoms such as bulimia and vomiting (Cohen, 1978; Schlemmer & Barnett, 1977). In our view, treatment is aimed at enhancing the internal control of the patient. From the very beginning she ought to be fully informed about the program and see herself as an active participant. The aim here is also to minimize the feelings of ineffectiveness and to increase the patient's responsibility for her own health and thus for her own treatment. The patient's and parents' usual responses to inpatient treatment appear to change according to the following three phases (Anyan & Schowalter, 1983; see also Stern et al., 1981). During the first phase (the start of treatment) ambivalence is high and the extent of the problem is minimized. The patient may fear the separation from her family, may continue to postpone making real changes that would increase her weight, and, in particular, may test the integrity of the therapeutic team : - by attempting to set one staff member's comments against another's, - by splitting staff members into being 'good' or 'bad', - by checking whether rules can be broken or altered, - by sequestering food or other contraband in her room,

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by prevailing upon other patients and/or visitors to believe that she is being victimized and/or to carry out missions on her behalf. In this first phase the patient may also agonize over the menu and suggest that something must be wrong with the food because she eats so much and gains so little. She may protest that, since she has tried so hard and not succeeded in gaining weight, it is not worthwhile trying anymore and therefore insists upon going home. During this beginning phase of treatment, the parents may : - experience frustration over the lack of tangible progress in relation to the length of the hospital stay, - doubt whether they have made the right decision about treatment, - criticize treatment procedures or express anger at the staff, - disregard therapeutic rules, e.g. seeking contact with their daughter when not allowed or bringing in food (medication), - test the team to see if they are strong enough to maintain authority and control over the therapeutic situation. The second phase begins when the patient recognizes the need to solve the problem and takes action that is visible as weight gain. Once the patient gains considerable weight, her mood usually heightens, her affect and behavior change positively, her contacts on the ward and with the staff become more spontaneous, her attitudes and feelings can be discussed constructively and likewise her former and current interaction with her family. The parents now support the treatment and change their interactional patterns to accommodate the developmental needs of the patient and to regain their status as parents. Intrafamilial and marital relationships become more accessible to discussion. The third phase begins as the patient approaches her weight goal and discharge planning becomes a focus of attention. The patient now may : - slow down or even reverse her progress, - delay passes home or avoid home visits which otherwise pass off tensely and stormily, - resist the need to give attention to the ways in which she can resume contact with her peers and re-enter school (or work). The parents may be : - eager to terminate care without aftercare planning, - unduely optimistic about the patient's recovery, - ambivalent about the patient returning home. All these reactions require specific attention from the staff whose functioning may be challenged in several ways (see also 8.5 and 10.3). As in all forms of behavioral intervention, the consistency of the therapeutic team as a whole is of decisive importance when carrying out a structured inpatient treatment program as described above. Bargaining, persuasion, and the use of force are contraindicated. Countertransference reactions on the part of the staff have to be

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recognized in time and worked out in mutual teamwork or by supervision, in order to prevent splitting within the team. Here the therapeutic experience, the extent to which the staff is familiar with the anorectic patient and her reactions toward treatment, is probably the most crucial factor with regard to treatment success.

6.4. The Long-Term Perspective Restoring the nutritional state is a first and necessary step, but not the crux of the treatment. Even a strict behavior therapist will not confine his treatment to the restoration of a normal body weight. His final therapeutic goal will be the establishment of some major sources of positive satisfaction or reinforcement (other than dieting), i.e. the development of alternative interests and a new repertoire of behaviors to replace the single one of anorectic behavior (Slade, 1982). As emphasized in paragraph 6.2, treatment must be guided by a problem analysis at different levels. This will reveal several issues to be dealt with, in particular : a weight phobia or fear of losing control over eating; a distorted body image; an inability to recognize one's own body signals and needs; an overwhelming feeling of ineffectiveness and helplessnees; ambivalence and insecurity about sexuality and interpersonal relationships; problems caused by leaving home, becoming independent and adopting an adult role. These are the focal points of psychotherapy which is governed by the basic principle that "weight changes and resolution of psychological problems interact closely, and lasting recovery requires a change in the inner image of the patient herself' (Bruch, 1982, p. 1535). At the end of Chapter 2, we summarized the different levels of dysfunction in anorexia nervosa patients and the possibilities of therapeutic intervention (Table 2-2). We will not discuss all these approaches as it would be impossible and even needless since a huge amount of literature has been written about it. In Chapter 10, the clinician who is interested in a particular method will find references to the most important literature on the subject (Appendix 10-2). Here, we will confine ourselves to some topics of personal interest: (1) changing body image, (2) the group approach, and (3) the aftercare program. Another important issue, the family approach, is discussed in Chapter 8.

6.4.1. Changing Body Image The significance of a disturbed body image in anorexia nervosa as a psychopathological phenomenon is quite evident to us (see 2.6.2.). The relatively large number of experimental studies concerning the assessment of body image disorders stands in stark constrast to the few direct attempts to influence the actual body image of anorectic patients. Furthermore, for a long time, a variety of static visual techniques of body estimation have been used by several investigators. Only recently, the first reports appeared about the use of video

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techniques in the assessment of body image in anorectics (Freeman et al., 1983; Meermann, 1983). Although there are extensive reports on the therapeutic use of video selfconfrontation techniques in psychiatric literature (see Do wrick & Biggs, 1983; Fry rear & Fleshman, 1981), in the case of anorexia nervosa there are only a few reports on this subject. In a single case study, Gottheil et al. (1969) reported how they successfully treated an anorexia nervosa patient who denied her emaciation. They showed her films of her emaciated body during the course of her 16-month stay in hospital. The authors called it 'self-image confrontation'. Biggs et al. (1980) described a comparative study using video playback in anorectic patients. The patients could see themselves on videotape in a clothed state whereby they discussed their preference for certain pictures with the researcher. Whereas normal controls showed an increase in positive feelings towards their social and emotional behavior after having seen the video playback, the anorectic patients' reaction was completely different: their personal self-esteem decreased and they judged their own effectiveness as being more negative than the controls did. The authors conclude from these results that video self-confrontation may reinforce an anorectic's already low self-esteem. An important fact here seem to be that patients are possibly more interested in (and more anxious about) how others see them. Yager and coworkers at U.C.L. A. (Yager et al., 1981; Metzner & Yager, 1983) have done some experiments with videotape body image confrontation. Anorexia nervosa patients, dressed in a bikini bathing suit, are requested to pose in certain positions and to carry out certain simple exercises in front of the camera. A total body picture is recorded from a variety of angles and then the camera zooms in on particular parts of the body. The patients are asked then to verbalize their perceptions and feelings towards these body parts. The whole procedure lasts roughly 20 minutes. A week later the patients are shown a videotape playback of the initial session. The tape is shown without soundtrack and the patients are encouraged to verbalize their reactions to the film. The playback can be controlled by means of a remote control device which permits both patient and therapist to freeze the film when desired. These sessions last nearly 45 minutes and are also recorded on video. Yager et al. (1981) distinguish three types of reactions to video tape playback. 1. Concept-percept dissonance: in this situation patients report their selfconcepts as being completely different to what they were shown on the screen; this means that their internal conception of their body (usually that they are too heavy) is at striking variance with how they perceive it on television·, the response is astonishment, disgust, and emotionality; the therapeutic impact (especially breaking through denial of emaciation) may be powerful. 2. Concept-percept congruence : these patients report little difference between their original self-concept and the perception of their bodies in the video playback; they are very accurate when describing their overall view and are able to denote particular bodily characteristics as too thin or skinny; here, the playback causes no great surprise and the patient may have either the

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determination to remain thin (as she views herself both internally and on the screen) or she may voice the desire to gain weight, appreciating her actual situation yet unable to overcome the internal resistances. 3. Concept-percept confusion .· here the patient claims that she is unable to interpret or to judge either her internal body image or the one on the screen; that is, she lacks an adequate sense of what she should look like and what she wants for herself; this state of confusion may resolve and be replaced with a more realistic and definable body concept later in the patient's course. These first impressions, which have to be confirmed in further systematic studies, seem to suggest that video self-confrontation may be a powerful adjunctive treatment technique especially in patients with concept-percept dissonance. But apart from obvious advantages (e.g. inducing an internal change in motivation to gain weight, raising the patient's sensitivity for her own body) there are a number of dangers involved in the use of video self-confrontation. The most important disadvantages or dangers, as mentioned in the relevant literature (see Dowrick & Biggs, 1983; Fryrear & Fleshman, 1981) are : more negative self-descriptions, decreased level of self-esteem, excessive anxiety reactions, and symptom deterioration. These negative effects should be taken into account for each individual case before video confrontation can be applied. This method should only be carried out in the general context of further individual and/or group psychotherapeutic measures, after careful consideration and preparation. At the moment, we have not as yet substantial evidence on the effectiveness of video feedback and playback in the treatment of patients with eating disorders. Nevertheless, the experiences mentioned and similar experiments with obese patients (McCrea, 1983; Meermannn, 1984) appear to be in favor of the use of video as an important adjunct in the treatment of eating disorders. This means, however, that this technique must be integrated in a broader psychotherapeutic approach. As will be explained in the following paragraph, at the University Psychiatric Center in Kortenberg treatment of anorexia nervosa patients is essentially group oriented. An important part of this group approach are the 'body-work sessions' (three hours per week) of which video-confrontation is an essential therapeutic ingredient (Depreitere et al., 1983). In exceptional cases (e.g., very low body weight with great physical weakness), a preparatory individual psychomotor program is applied including special isometric exercises as proposed by Ziemer and Ross (1970). But usually, patients start from the first week on with the body oriented group sessions, i.e. a mixture of dance-movement therapy, progressive relaxation, sensory-awareness and bioenergetic exercises. Patients can observe themselves in large mirrors and the sessions are videotaped. Excerpts of the video-recordings are shown at the end of the session and commented upon by the group members and the therapist. Furthermore, of each newcomer an individual videotape of her total physical appearance is made at the very beginning and at the end of hospitalization. The 'admission' tape is 122

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used (several times, if necessary) for self-confrontation and will be compared with the 'departure' tape before the patient leaves the hospital. The group approach, then, has the great advantage of combining the benefits of both self-confrontation and heteroconfrontation. This combination: (1) accelerates the motivation process (breaking through the patient's denial of illness), (2) allows the patient to correct her body-perception - the discrepancy between her actual but distorted perception and her real physical appearance as perceived by others - by means of comparison to others' appearance, and (3) facilitates the development of a realistic and positive body image through a process of social learning within the group (Depreitere et al., 1983). Especially in case of strong denial, heteroconfrontation - either by direct contact with others or by means of videomaterial - might be more effective than self-confrontation in order to tackle the patient's negation of her own physical condition and appearance (Badura & Steinmeyer, 1984). It would be worthwhile to study these clinical impressions in a more systematic way those interested in this area are invited to contact us with a view to collaborative research. Finally, we have to stress that videoconfrontation is not the only method for altering body image in anorexics : Gross (1982) has used hypnotic suggestions for correcting body image and defect in interoceptive awareness, while McKee and Kiffer (1982) have done some experiments with biofeedback. The applicability and usefulness of both methods, however, seem restricted and require more appropriate investigations.

6.4.2. The Group Approach Like several other centers renowned for treating eating disorders, we are faced with an increasing number of dysorectic patients. Within less than five years, the Anorexia Nervosa Unit at the University Psychiatric Center in Kortenberg has expanded from 8 to 16 beds. Both for economic and psychological reasons, we had to shift our approach from an individual to a group treatment. Moreover, the growing popularity of self-help groups (see 10.2.4) showed us the possibilities (and pitfalls) of the group approach in these patients. It soon became clear that the large group of patients as well as the nursing staff needed a well-structured milieu to work in. As described in paragraph 6.3, the standardized contract system with regard to short-term weight restoration was the first important step in structuring the therapeutic setting. The 3-stages program serves as a point of reference for both patients and staff members. There are two groups of at least 8 patients each (their age ranging from 16 to 35 and older). Two nurses are in charge for each group : beside informal contacts daily, they meet twice a week (on Monday and Friday, i.e. just after and before a week-end) with their group in a structured way to discuss routine problems on the ward, to arrange and organize activities inside and outside the hospital, to prepare and evaluate week-ends at home or steps towards the social reintegration of those in the final stage of treatment. Each group has a representative chosen each month among the patients who are in the third stage. This group representative is the official group's

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spokeswoman or go-between who can transmit important messages between patients and staff. She also has to pay specific attention to newcomers and take care that every member attends the group therapies. Three times a week each group has a separate one-hour group psychotherapy session the principles and dynamics of which are described further on. Two weeks after admission, each patient must present her treatment plan she has prepared with the help of the nurses and the other group members. This written plan contains short-term and long-term goals with regard to anorectic problems as well as to general psychological and interpersonal issues. Since it takes some time for the patient to learn to think in psychological terms, it is helpful to assist her in the preparation of her treatment plan while using a list of problems that frequently occur in anorexics. Relying on the items of the Eating Disorder Inventory (EDI), described in Chapter 1 (see Appendix 1-4), we ask the patients to select at least two problematic items from each of the following categories : (1) drive for thinness and bulimia, (2) body dissatisfaction and interoceptive awareness, (3) ineffectiveness and perfectionism, (4) interpersonal distrust and maturity fears. Then they have to translate these items (and others that are not mentioned in the EDI) into concrete steps, the short-term goals, ending up in a treatment plan which is quite similar to the therapeutic contract described by Levendusky et al. (1983). Such a plan (an example of which is given in Table 6-2), may change, of course, during treatment and can also be used in outpatient treatment (aftercare). A rather well-known strategy by which problem behaviors and treatment goals are specified is Goal-Attainment Scaling (Kiresuk & Sherman, 1968). Individual goals for each patient are selected and for each goal a scale is created, composed of a series of likely treatment outcomes varying from 'least favorable' (-2), to 'most likely' (0), to 'most favorable' ( + 2). An objective event is tied to each scale point. In an example provided by Kiresuk and Sherman (1968) a goal was "dependency on mother". The least favorable outcome (-2) was "lives at home; does nothing without mother's approval". The most likely outcome (0) was "chooses own friends, activities, without checking with mother; returns to school". The most favorable outcome ( + 2) was "establishes own way of life; chooses when to consult mother". In our experience, it is advisable to evaluate treatment progress in a similar way while utilizing a visual analogue scale measurement as described in Chapter 1 (see Appendix 1 -1). Each patient's evolution is evaluated monthly in the group both by the patient and other group members, and by the treatment staff. Finally, patients attend daily creative therapy (art therapy, occupational therapy) sessions in group, and they have three times a week special group psychomotor therapy or so-called 'body-work sessions' wherein videotaped selfconfrontation plays an important role (see previous paragraph). From the second stage of the treatment on, patients are encouraged to leave once a week for an outing together (e.g. shopping, seeing a movie, going to a disco). In Chapter 8, we also show the potential of a group approach in the management of conflicts and needs in the patient's family (see 8.6).

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Table 6-2. Sample Treatment Plan I. Long-term goal: Normalize eating habits. Short-term goals : a. Eat three meals each day; keep records on other food eaten. b. Add flexibility to meals by choosing one new food each day; document. c. Stay in the living room with others after each meal for at least one hour; document vomiting. d. Go and talk with other group members or staff whenever bulimic tendencies occur. II. Long-term goal: Improve body image. Short-term goals : a. Do relaxation exercises once a day; keep records. b. Wear clothes that show my body shape. c. Discuss body sensations with other group members. d. Question my own ideas about what I mean by 'feeling fat'; document. III. Long-term goal: Improve self-esteem. Short-term goals : a. Document at least one positive experience per day. b. Reality test when I feel helpless or inferior to others; discuss with group members and staff. c. Ask others what they think about me; document. IV. Long-term goal: Improve relationship with parents. Short-term goals : a. Assert myself with my parents on each visit. b. Question feelings of guilt and responsibility towards parents. c. Explain my incertitude about leaving home in the future. Although we do not advocate special treatment units for anorexia nervosa patients only (see Chapter 10), clinical experience with different forms of group psychotherapy has taught us that homogeneous groups are to be preferred as long as the anorectic symptoms have a great impact on the patient's overall behavior. When conducting group psychotherapy with anorexics and other neurotics mixed together, considerable time might be lost in endless descriptions or complaints about eating patterns, weight problems and related anorectic preoccupations. Before the other group members begin to recognize the anorexic's smokescreen and games, and become able to tackle these, several therapy sessions can be wasted. Other group members often feel that they have been fooled and react in a counteraggressive way which repeats the way in which the anorexic has been treated at home and thus isolates her still more in her illness. Another important disadvantage of mixed groups is that they are not only accepting for a long time but even promote the patient's performance of a detached, 'pseudonormal' role (Sclare, 1977). Lafeber et al. (1967 a + b), in the Netherlands, were probably the first to start experimenting with an 'all anorexia'

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group : " [In a mixed group], the anorexic patient leaves all initiative to others. She elicits comments and action of others, but does not take part, personally, in what is taking place. She is in a more or less concealed way withdrawing from all activities and manages in sustaining this role for a very long time, limiting her action to a benevolent but obstinate silence, or echoing prevalent opinions. In this way, the social pseudo-adjustment of the anorexic patient is not influenced". One would fear that anorexia nervosa patients would protect, defend or even reinforce each other's maladaptive behavior, but this is usually not the case in well-structured group psychotherapy. We have, for instance, the same experience as Schmitt (1980) who stressed the corrective influence of mutual body perception in the group (e.g., patients may be shocked by the appearance of an emaciated newcomer). A positive group culture, with patients in different stages of evolution, is the best means to avoid regressive tendencies (Frisch, 1976) or negative competition. "Old members would encourage new members not to eat merely to get out of the hospital and then lose the weight again, but to eat to gain energy for the enjoyment of life; not to eat for others, but for oneself. Provocation and negativism were not reinforced by the group. They began to praise each other for progress made toward the weight goal, rather than, as before, competing to stay thin or negatively responding to efforts to help with 'tricks of the trade' " (Piazza et al., 1983, pp. 277-278). In our own groups, we are often astonished by the hard way in which patients may confront each other and tackle the 'anorectic games' they keep on playing. Apparently interaction in these groups is governed by the old saying : set a thief to catch a thief! The fact that all members of the group are anorexics seems to facilitate acceptance of direct feedback and sometimes sharp criticism (Polivy, 1981). The mutual support, both inside and outside the group, is aim directed and conditional, i.e. they all know what anorexia nervosa is about and do not let themselves be fooled as easily as relatives, friends or even therapists. They require each other to drop their masks and come to term with the real issues. Although there may sometimes be an escalation to a higher bidding in 'seriousness' of symptoms (especially between starvers on the one hand and binge-eaters or vomiters/purgers on the other), the atmosphere of acceptance, confidence and feeling of belonging will usually allow them very soon to leave descriptive talk and start looking behind the curtain to the psychological meanings of their symptoms. When a group member is close to her discharge from the hospital or when an outpatient returns to the group (see e.g. Piazza et al., 1983; Schmitt et al., 1981, 1982), the outside world will be the central theme of discussion. In any case, the therapist has to avoid a sometimes subtle but considerable danger - probably the biggest pitfall in self-help groups (see 10.2.4) - namely the potential for 'all anorexia' groups to increase the patient's identity as anorexic (Polivy, 1981). Other problems arising from group therapy with anorexia nervosa patients are 'flight into health' and overdependence on the group (see also Chapter 10). Whatever the theoretical or therapeutic technique, a group therapist should be familiar with those factors which seem to influence outcome, the so-called

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'therapeutic factors'. These refer to a process occurring in group therapy that contributes to the improvement of the patient's condition and is regarded as a function of the actions of the therapist, the other members of the group, and the patient herself. The following therapeutic factors, as described by Bloch et al. (1981), appear to be of great importance in group therapy with anorexia nervosa patients: (1) Self-disclosure, the revelation of important personal information which sometimes may have a cathartic effect, i.e. a relief following the release of intense feelings. Anorexia nervosa patients usually are reluctant to self-disclose because of their fear of losing control over their emotions. They prefer to rationalize their feelings and are inclined to use what we call 'book language' or 'therapy talk'. This means that they easily appropriate someone else's expressions (the therapist's or another group member's) to label their own thoughts and feelings. Nonverbal and action-oriented techniques may then be helpful to break through this defense mechanism of hiding oneself behind intellectualization and stereotyped verbalizations. The same difficulty applies to the following factor : (2) Insight, whereby two interrelated categories may be distinguished: (a) psychogenetic insight, i.e. the patient's understanding of her own psychological processes (feelings, thoughts, attitudes, fantasies); in other words, why she behaves the way She does; (b) the patient's understanding of the nature of her relationships with others; this category of insight is associated with interpersonal learning, i.e. the patient's learning how she comes across to others from the feedback she gets from the therapist and other group members (or from videotape playback). Once again there is the trap of intellecutualization, especially in those patients who have had psychotherapy before or have 'psychoanalyzed' themselves by means of lay literature (see also 10.2.4). From the very beginning on, the therapist has to unmask this impersonal insight as well as the patient's irrational ideas and interpretations (see Garner & Bemis, 1982). (3) Acceptance and cohesiveness, whereby a distinction can be made between total-group cohesiveness, i.e. the extent to which the group is attractive to its members, and individual-member cohesiveness (acceptance), i.e. the extent to which a member feels accepted and valued by the group. In 'all anorexia' groups this process is facilitated by the homogeneity of the group relying on the therapeutic factor of universality, the patient's realisation that her problems are not unique. Two major problems have to be recognized, however, namely negative competition and power struggles (similar to the interactions at home, e.g. sibling rivalry) on the one hand, and excessive altruism on the other. The latter factor refers to the benefit derived from the patient's recognition that she can be helpful to fellow group members. But anorexia nervosa patients are quickly inclined to play such a co-therapist role (sometimes indirectly encouraged by an admiring therapist) in order to obliterate themselves or to please the therapist (by assuming the role of a 'model' patient). For this reason, the group therapist must be aware, in particular, of the positive and negative aspects of vicarious learning. Such a process depends (a) on the observation of other group members (including the therapist) and their ways of dealing with shared problems, or (b) on the identification and imitation of particular characteristics in them that are found desirable (Bloch et al., 1981).

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The change process in group therapy will also depend on some formal characteristics, e.g. closed versus open-ended groups, inpatients versus outpatients (or both mixed). We found that the mixing of different ages stimulated the liveliness of the groups as different experiences and different identification possibilites give the patient a large scope for feeling, expressing and sharing oneself. Confronting, for instance, an adolescent with an adult who could be her mother activates powerful interpersonal dynamics or allows an intense and vivid role-playing with regard to parent-child attachment/autonomy conflicts. But whatever the theoretical framework, method or form of treatment, there is growing clinical evidence that anorexia nervosa patients may profit very much from group therapy. They usually show a considerable progress through a series of stages as described by Sclare (1977): 1. Resistance.· The patients confine their observations to matters of food, weight, and physical symptoms associated with eating. 2. Exploration : They begin to speak about a variety of emotional reactions, e.g., a sense of guilt after eating and their general oversensitivity. 3. Emotional confusion : They discuss their problems about decision making, the conflicts about leaving home, and their general suggestibility. 4. Cohesion : They become more autonomous, meet together socially, and may even conduct the group session when the therapist is absent. Most of what has been said about group therapy with inpatient anorexics also applies to outpatient groups. The latter can be helpful to avoid hospitalization, to prepare for intensive treatment in the hospital (when necessary), or to provide support for patients who have been discharged from the hospital (Huerta, 1982; see also 10.2.4).

6.4.3. The Aftercare Program The discharge phase in the treatment of the hospitalized anorexia nervosa patient may be felt as a threatening and stressful event. The challenge of returning to the natural environment ('where all began') as well as the separation from the inpatient treatment milieu ('where all changed') can provoke tension, insecurity and anxiety in the patient. Consequently regression can occur, e.g. emergence of (new or old) anorectic symptoms as a non-productive defensive response to separation-individuation conflicts (Shields & Choras, 1982). It is important to discuss and prepare, together with the patient and the family, this transition phase as a process that cannot be stopped, but rather anticipated and examined with regard to aftercare planning. This planning cannot be successful without the active involvement of the patient and the family. Both parties have usually learned so much during the hospitalization that they become the major consultants as to the appropriate discharge date and aftercare program. The therapist has to confront them with the adaptation problems they may expect, in order to protect them from overoptimism and 'flight into health'. As Crisp (1980, p. 110) emphasized, "it is important at this stage to share with the anorectic the expectation (so fearful for her) that, at a normal weight, she is likely to feel more distressed at times, chaotic not only in relation to management of her weight and shape but hopefully also her personal life. She will need skillful

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help to be sustained in this uncertainty, protected thereby from precipitately relapsing or else committing herself to some other structured lifestyle". Ideally, the primary therapist for the patient and/or the family in the hospital should be the outpatient therapist. When we, indeed, referred the patient for continuation of treatment elsewhere, we frequently had the experience that either the patient never engaged in such a pre-arranged therapy or experienced difficulties in establishing a good relationship with the new therapist. In both cases there is a relatively high risk of relapse. Therefore, we like to keep further treatment in our own hands, if possible, to make the most of the existing therapeutic relationship with the patient and the cooperation of the family, both of which have been enhanced during the inpatient treatment. If the patient/family has to be referred to another outpatient therapist, the latter must be involved in the final stage of the hospitalization. This means, at least, that he must have met his future clients before discharge from the hospital. Furthermore, this therapist has to agree on the general treatment approach used thus far by the hospital staff, and take an active part in the aftercare planning. Ideally, the decision-making process should be viewed then as a quadripartite one involving himself, the primary inpatient therapist, the patient, and the family. In any case, a clear contract must be made with regard to long-term maintenance of normal body weight and eating patterns (see Appendix 5-1). If emphasis lies on individual life adjustment, especially in the older patients, we prefer outpatient group therapy. Family therapy following discharge is an important method of tertiary prevention in patients who still maintain family ties. Further treatment is always needed to ensure that whatever progress had been achieved in the hospital will be continued, and rehospitalization be prevented. However, when an anorexia nervosa patient comes out of the hospital, the outpatient therapist is faced with a situation of incongruity in the family hierarchy (Madanes, 1982). The anorectic adolescent needs the care of the parents, but, at the same time, may maintain power over the parents by the threat of relapsing; this holds them together by providing them with crises that distract the parents from their own problems and from the need to resolve their difficulties. Here, strategic family therapy is needed to restore an adequate balance between parental authority and autonomy of the adolescent (see Chapter 8).

As discussed elsewhere (Chapter 5 and 8), Minuchin and coworkers advocate an outpatient family systems approach. If a patient has been hospitalized and regained sufficient weight, the family has to make a commitment to the obligatory 6 months of outpatient family therapy (Liebman, Sargent & Silver, 1983). We think this is too short: patients who have to be hospitalized are usually more difficult cases and in our opinion aftercare must be extended to at least one year after discharge from the hospital. Crisp (1980) even proposes that individual psychotherapy on a weekly or bi-weekly basis should continue for at least a year and more often for two or three years. During this period, Crisp advises the family to remain in regular contact with the social worker. Stern et al. (1981) emphasize the need of the hospital's continuing availability

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especially in the more difficult cases. Following discharge, the patient maintains contact with the hospital through weekly weigh-ins administered by a specially trained nurse: "The program consists of a weekly ritual in which the patient comes in to be weighed, have her blood drawn to check for electrolyte imbalance (if she is a vomiter) and talk to the nurse for 10 to 20 minutes. If her weight is the same or higher than her previous level, the nurse simply asks her how things are going. It it has dropped the nurse asks her why. (...). If a patient's weight begins to drop dramatically, the nurse will inform the relevant team members and the parents. When hospitalization becomes imminent, the nurse makes this clear to the patient and establishes a definite limit below which the team will insist on readmission. This gives the patient (and family) the choice of whether to reverse the process by themselves or return to the holding environment" (Stern et al., 1981, p. 406). The question of repeated hospital admissions and danger of dependency on the hospital staff is discussed in Chapter 10.

6.5. Conclusion As discussed in Chapter 5 ('criteria for admission'), hospitalization may have its own positive indications, especially when it offers a supporting and stimulating therapeutic milieu. In the previous pages we have advocated a well-structured, intensive and multimodal inpatient treatment program which does not make a sharp distinction between symptom (weight, eating) and problem-oriented (psychological, interactional) treatment. It is more useful to distinguish between short-term and long-term management instead. In our opinion, an inpatient treatment for anorexia nervosa patients should : - be as transparent as possible both for the patients and their families; - rely on general and clear principles or rules while remaining flexible enough to fit each individual's (changing) demands; - focus, in one way or another, on the patient's body image and self-concepts; - use group dynamics as a powerful therapeutic instrument; - involve the family as much as possible in the therapeutic process; - guarantee a continuity in treatment after discharge from the hospital; - be regularly evaluated on account of its immediate and remote, positive and negative effects. The latter condition, in particular, appears to be the best means for preventing the treatment approach and all parties involved (patient, family, staff) from becoming stiffened in preprogrammed routine. Therefore, we hope that the reader will follow us in a scientist-practitioner's spirit which stimulates and guides a continuing trial-and-error process oscillating between therapeutic realism and scientific skepticism.

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References Agras, W.S. & Kraemer, H.C. (1984), The treatment of anorexia nervosa: Do different treatments have different outcomes ? In : Stunkard, A.J. & Stellar, E. (Eds.), Eating and its Disorders. New York : Raven Press, pp. 193-207. Anyan, W.R. & Schowalter, J.E. (1983), A comprehensive approach to anorexia nervosa. Journal of the American Academy of Child Psychiatry, 22 : 122-127. Badura, H.O. & Steinmeyer, E.M. (1984), Psychotherapeutic effect by audiovisual heteroconfrontation in a case of anorexia nervosa. Psychotherapy and Psychosomatics, 41 : 1-6. Biggs, S., Rosen, B. & Summerfield, A. (1980), Video-feedback and personal attribution in anorexic, depressed and normal viewers. British Journal of Medical Psychology 53 : 249-254. Bloch, S., Crouch, E. & Reibstein, J. (1981), Therapeutic factors in group psychotherapy. A review. Archives of General Psychiatry, 38 : 519-526. Bruch, Η. (1982), Anorexia nervosa: Therapy and theory. American Journal of Psychiatry, 139 : 1531-1538. Cohen, S.I. (1978), Hostile interaction in a general hospital ward leading to disturbed behaviour and bulimia in anorexia nervosa: Its successful management. Postgraduate Medical Journal, 5 4 : 361-363. Crisp, A.H. (1980), Anorexia Nervosa : Let Me Be. London-New York : Academic PressGrune & Stratton. Depreitere, L., Van Wouwe, V. & Vandereycken, W. (1983), Lichaamsgeorienteerde therapie bij anorexia nervosa patienten (Body oriented therapy in anorexia nervosa patients). Tijdschrift voor Psychomotorische Therapie, 12 : 121-128. Dowrick, P.W. & Biggs, S.J. (1983), Using Video. Psychological and Social Applications. Chichester-New York : John Wiley. Freeman, R.J., Thomas, C.D., Solyom, L. & Miles, J.E. (1983), Body image disturbances in anorexia nervosa: A reexamination and a new technique. In : Darby, P.L., Garfinkel, P.E., Garner, D.M. & Coscina, D.V. (Eds.), Anorexia Nervosa. Recent Developments in Research. New York : Alan R. Liss, pp. 117-127. Frisch, F. (1976), Psychotherapie d'un groupe d'anorectiques mentales (Group psychotherapy in anorexia nervosa patients). Revue de Medecine Psychosomatique, 18 : 292-294. Fryrear, J. & Fleshman, B. (1981), Videotherapy in Mental Health. Springfield (111.): Charles C. Thomas. Garner, D.M. & Bemis, K.M. (1982), A cognitive-behavioral approach to anorexia nervosa. Cognitive Therapy and Research, 6 : 123-150. Gottheil, Ε., Backup, C.E. & Cornelison, F.S. (1969), Denial and self-image confrontation in a case of anorexia nervosa. Journal of Nervous and Mental Disease, 148 : 238-250. Gross, M. (1982), Hypnotherapy in anorexia nervosa. In : Gross, M. (Ed.), Anorexia Nervosa. A Comprehensive Approach. Lexington : Collamore Press, pp. 119-127. Hodas, G., Liebman, R. & Collins, M.J. (1982), Pediatric hospitalization in the treatment of anorexia nervosa. In : Harbin, H.T. (Ed.), The Psychiatric Hospital and the Family. Jamaica (N.Y.): Spectrum Publications, pp. 131-141. Huerta, E. (1982), Group therapy for anorexia nervosa patients. In : Gross, M. (Ed.), Anorexia Nervosa. A Comprehensive Approach. Lexington : Collamore Press, pp. 111-118.

Kiresuk, T.J. & Sherman, R.E. (1968), Goal attainment scaling : A general method for evaluating comprehensive mental health programs. Community Mental Health Journal, 4 : 443-453.

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Lafeber, C., Jongerius, P.J. & Lansen, J. (1967a), Groepstherapie voor anorexia nervosa patienten (Group therapy for anorexia nervosa patients). Voordrachtenreeks van de Nederlandse Vereniging van Psychiaters in Dienstverband, 9 : 65-80 (Reprinted in Tijdschrift voor Psychiatrie, Special 25th Anniversary Issue, 1983). Lafeber, C., Lansen, J. & Jongerius, P.J. (1967b), A group therapy with anorexia nervosa patients. Paper presented at the 7th International Congress of Psychotherapy (Wiesbaden, April 21-26, 1967). Lazarus, A.A. (1981), The Practice of Multimodal Therapy. New York : McGraw Hill. Levendusky, P.G., Berglas, S., Dooley, C.P. & Landau, R.J. (1983), Therapeutic contract program : Preliminary report on a behavioral alternative to the token economy. Behaviour Research and Therapy, 21 : 137-142. Liebman, R., Sargent, J. & Silver, M. (1983), A family systems orientation to the treatment of anorexia nervosa. Journal of the American Academy of Child Psychiatry, 22 : 128-133. Madanes, C. (1982), Strategic family therapy in the prevention of rehospitalization. In : Harbin, H.T. (Ed.), The Psychiatric Hospital and the Family. Jamaica (N.Y.): Spectrum Publications, pp. 49-77. McRea, C. (1983), Impact on body image. In : Dowrick, P.W. & Biggs, S.J. (Eds.), Using Video. Psychological and Social Applications. Chichester-New York : John Wiley, pp. 95-103. McKee, M.G. & Kiffer, J.F. (1982), Clinical biofeedback therapy in the treatment of anorexia nervosa. In : Gross, M. (Ed.), Anorexia Nervosa. A Comprehensive Approach. Lexington : Collamore Press, pp. 129-139. Meermann, R. (1983), Experimental investigations of disturbances in body image estimation in anorexia nervosa patients, ballet- and gymnastic pupils. International Journal of Eating Disorders, 24): 91-100. Meermann, R. (1984), Body image disturbances in psychiatric disorders. University of Münster Department of Psychiatry (unpublished report). Metzner, R.J. & Yager, J. (1983), Video tape body confrontation in anorexia nervosa. Los Angeles : Neuropsychiatric Institute UCLA (unpublished report). Piazza, E., Carni, J.D., Kelly, J. & Plante, S.F. (1983), Group psychotherapy for anorexia nervosa. Journal of the American Academy of Child Psychiatry, 22 : 276-278. Polivy, J. (1981), Group therapy as an adjunctive treatment for anorexia nervosa. Journal of Psychiatric Treatment and Evaluation, 3 : 279-283. Schlemmer, J.K. & Barnett, P.A. (1977), Management of manipulative behavior of anorexia nervosa patients. Journal of Psychiatric Nursing, 15(11): 35-41. Schmitt, G.M. (1980), Klientenzentrierte Gruppenpsychotherapie in der Behandlung der Pubertätsmagersucht (Client-centered group psychotherapy in the treatment of anorexia nervosa). Praxis der Kinderpsychologie und Kinderpsychiatrie, 29 : 247-251. Schmitt, G.M. & Wendt, R. (1982), Die stationäre Behandlung magersüchtiger Jugendlicher unter dem Gesichtspunkt der sozialen Reintegration (Inpatient treatment of anorexia nervosa in adolescents with special emphasis on social integration). Zeitschrift für Kinder- und Jugendpsychiatrie, 10 : 67-73. Schmitt, G M., Wendt R. & Jochmus, I. (1981), Stationäre Behandlung magersuchtiger Jugendlicher mit vorwiegend klientenzentrierter Einzel- und Gruppentherapie (Inpatient treatment of anorexic adolescents with predominantly client-centered individual and group therapy). In : Meermann, R. (Ed.), Anorexia Nervosa. Stuttgart: Ferdinand Enke, pp. 158-169. Schulte D. (1974), Diagnostik in der Verhaltenstherapie (The Diagnostic Process in Behavior Therapy). München : Urban & Schwarzenberg. Sclare, A.B. (1977), Group therapy for specific psychosomatic problems. In : Wittkower, E.D. & Warnes, H. (Eds.), Psychosomatic Medicine. Its Clinical Applications.

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Hagerstown ( N . Y . ) : Harper & R o w , pp. 107-115. Shields, J.D. & Choras, P.T. (1982), Treatment of the hospitalized adolescent: Management of regression during discharge. Adolescent Psychiatry, 10 : 407-424. Slade, P. (1982), Towards a functional analysis of anorexia nervosa and bulimia nervosa. British Journal of Clinical Psychology, 21 : 167-179. Stern, S., Whitaker, C.A., Hagemann, N.J., Anderson, R.B. & Bargman, G.J. (1981), Anorexia nervosa : The hospital's role in family treatment. Family Process, 20 : 395-408. Van Buskirk, S.S. (1977), A two-phase perspective on the treatment of anorexia nervosa. Psychological Bulletin, 84 : 529-538. Vandereycken, W. & Pieters, G. (1978), Short-term weight restoration in anorexia nervosa through operant conditioning. Scandinavian Journal of Behaviour Therapy, 7 : 221-236. Yager, J., Rudnick, F.D. & Metzner, R.J. (1981), Anorexia nervosa : A current perspective and s o m e n e w directions. In : Serafetinides, E.A. (Ed.), Psychiatric Research in Practice. Biobehavioral Themes. N e w York : Grune & Stratton, pp. 131-150. Ziemer, R. & Ross, J. (1970), Anorexia nervosa : A n e w approach. American Corrective Therapy Journal, 24 : 34-42.

APPENDIX 6-1 INFORMATION FOR PATIENTS

I. General principles We would like to inform you about the main principles of our treatment program and the rules we use to reach agreements and come to decisions during your stay here. Of course we take individual differences into account so that the specific treatment plan is suited to your personal situation and thus to your own therapeutic aims. The first aim of treatment is the restoration of normal body weight and normal eating patterns. To attain this we have devised a treatment plan which gives you relative freedom but which also includes some restraints. Only if you show yourself incapable of managing your freedom will we assume control temporarily. The aim is that you could take charge of yourself again, depending on your evolution and according to the following regulations.

II. Food and weight regulations First of all the concrete goals of the treatment plan will be discussed with you. This means for instance, that an "ideal" weight or target weight (between min. and max. boundaries) has to be agreed on. This will be based on scientific norms, according to your age and height.

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A. Basic principles Re-establishment of the normal body weight should take place gradually and regularly, neither too slow nor too fast. Conditions : 1. Body weight is not allowed to drop below the weight at admission. 2. Weight has to stay above a minimal level. This level is an ascending line: starting from the actual weight on the first Wednesday* of your stay and climbing with a fixed ratio of 700 grams a week. If you drop below this minimal level we allow you two weeks to catch up. Three consecutive weeks below this level are not allowed. 3. Weight increase should not be in excess of 700 grams a day (except for the first week of hospitalization). 4. The total weekly weight increase should not be more than 3 kg a week (except for the first week of hospitalization). 5. It is forbidden to eat or take snacks in between meals, and to hoard food in your room. * Note : All therapeutic decisions will be taken on Wednesdays during the meeting of the entire treatment team. As long as these conditions are met, the "regular program" will be followed. If these conditions are not met, we switch immediately to the "exception program" : if you failed condition 1 or 2, it will be enforced until your weight has reached the minimal level again; if you fail condition 3, 4 or 5, it will be enforced for at least 5 days. B. The regular program W e distinguish between three phases : First phase : until you have gained 1 / 3 of the weight to be gained. Second phase : until you have gained 2 / 3 of the weight to be gained. Third phase : until you reach the target weight. W e have as agreements : a) During the first phase - You eat in your room. You receive a set portion from which you eat whatever you want. You will also receive an extra protein drink at 10 a.m., 3 p.m. and 8 p.m. Besides this no food or meal will be taken. - You will be weighed daily before breakfast. - You may only leave the ward for medical investigations, psychological testing or therapeutic activities. - Visitors are only allowed on Saturday or Sunday. - You are not allowed to write or receive letters. - No telephone calls, except at the week-end. B) During the second phase - Meals will be taken in the dining room under the supervision of a nurse. There is a set portion but no extra protein drinks. No extra food or snacks are allowed.

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You will be weighed three times a week. You may leave the ward according to the general hospital rules and you will take part in the occupational therapy. Visitors are allowed both on Saturday and Sunday. Letters may be sent and received and telephone calls made. A weekly outing can be organised under the supervision of a nurse.

c) During the third phase - You may eat freely in the dining room. - You will be weighed twice a week. - You may leave the hospital for a walk, an evening out, or a week-end at home, according to the general rules. - Visitors are allowed every day according to general hospital rules. C. Exception-program The exception-program will be enforced when one or more of the above mentioned conditions are not met. Exception-program I (Below admission weight) - Meals to be taken in your room. - You will be given a protein drink three times a day. - Daily weight control. - You must wear your nightclothes and are confined to your room; the wardrobe will be kept locked. - Occupations : reading, radio, drawing, needle work, etc. - No visitors, telephone calls or letters. Exception-program II (First phase weight) - Meals to be taken in your room. - You will be given a protein drink three times a day. - Daily weight control. - You must wear your nightclothes and are confined to your room; the wardrobe will be kept locked. - You can only join the others in the living room from 10-11 a.m., 4-5 p.m. and 8-9 p.m. - Visiting time on Saturday and Sunday is limited to one hour. - You are not allowed to send or receive letters. - One telephone call a week. - The kitchen and the dining room are out of bounds. Exception-program III (Second phase weight) - Meals with set portions are to be taken in the dining room. - No protein drink. - Weight control three times a week. - You must stay in your room but can get dressed; the wardrobe will not be locked. - You can join the others in the living room from 10-11 a.m., 4-5 p.m. and 8-9 p.m.; also on Saturday and Sunday from 9-10 a.m. and 2-3 p.m.

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Two telephone calls a week are allowed. Visiting time is limited to two hours on Saturday and Sunday. The kitchen is out of bounds.

Exception-program IV (Third phase weight) - Meals to be taken in the dining room under supervision of a nurse, but you decide the size of your portion. - Twice weekly weight control. - You can walk freely around the ward. - You may make three telephone calls and write/receive two letters a week. - You will be assigned your share of the household duties. - You can take part in the occupational therapy. - Visiting time is limited to three hours on Saturday and Sunday. Special rules during the exception-programs - If on three consecutive periods you were in the exception-program (this means that you did not meet the normal program requirements), in the case of the first exception-program tube feeding will be given, and in the other cases (the second, third or fourth exception-program) you will be reprogrammed to the preceding exception-program for at least one week and/or until minimal weight level has been reached. - If you gain more than 3 kg a week, the exception-program will be extended by 5 days extra.

III. Further treatment Re-establishment of normal weight and eating habits is a necessary step, but only one, in the search for a permanent solution of the tensions, problems or conflicts which you have got into. Weight and eating are not the main points of the treatment. Far more important are your feelings, thoughts, fears and uncertainties about yourself, your future and your social relationships (with your family and/or partner). These aspects will be dealt with in various ways (and you will be further informed about each by the nursing staff or the therapist): 1. Occupational Therapy : you will join in with the other patients of the ward once you are in the 2nd or 3rd phase (and in exception-program III or IV). 2. Body Exploration Therapy : you will participate three times a week (except in exception-program I and II). 3. Group Therapy : three times a week (except in the case of tube feeding). 4. Family Approach : your parents (or spouse) are invited to attend the parent groups (every 2nd and 4th Thursday evening); separate meetings with your family (or partner) will be arranged by the therapist in due course.

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APPENDIX 6-2 INFORMATION FOR THE FAMILY A member of your family or your partner has been admitted here as a patient. We think it important that you know our treatment principles. We also hope to obtain your cooperation.

General treatment principles 1. Problems with weight or eating patterns, known as anorexia nervosa or bulimia are psychosomatic illnesses. Psychosomatic means there are concomitant physical and psychological features. The patient will be thoroughly screened for physical disturbances by the medical department. Psychological aspects are more difficult to assess. Experience has taught us that there is no clear, well defined reason, somewhere in the past, but rather a multitude of different concurrent factors which have led to the actual situation. More important than "Why ?" is the question: "How are we going to manage the problems with regard to the future ?". 2. Experience has also taught us that disturbed eating patterns and weight abnormalities (especially weight loss) influence the patient's overall behavior, their feelings and thoughts, and their relationships towards others. Thus working on the consequences of their illness can be more important than worrying about the original causes. Talking does not help much as long as the weight and eating patterns are too disturbed. For this reason priority is given to the normalisation of eating patterns and weight. We hereby stress that the patient has to relearn to feed herself properly. It is a kind of re-education program. 3. Restoring normal eating patterns and body weight is not sufficient. The patient also has to be able to fullfill a normal role in society ·. school, work, family, etc. Thus, the second aspect of treatment will be a training intent on reintegrating the patient into society. This means that problems centered around body image, sexuality, inferiority feelings, social inhibitions, etc. have to be treated. Different kinds of psychotherapy during and after the stay in the hospital will be used to this end. 4. All those therapy aims cannot be reached without the active help of the family (parents, partner, siblings). Usually in a longstanding illness like this the surrounding people have become overinvolved and nobody knows clearly what to do next. Many times well intended help becomes part of a vicious circle that ultimately only makes things worse. Many parents or partners develop guilt feelings and wonder what went wrong. Instead of blaming someone or something, we prefer to search together for new solutions as a new approach is needed so as not to fall into the old trap again. The way you treat the patient on a visit or at home, after her discharge, is very important and full of consequences.

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Concrete details 1. Normalisation of eating patterns and weight A written, detailed program has been given to the patient. You can of course read it. In it we subdivide treatment into three phases. We need your help in enforcing the rules: - At the beginning, visiting and other forms of contact (e.g. letters, telephone calls, are restricted. These restrictions are gradually lifted according to the patient's progress. If however the patient does not improve according to plan, further restrictions can be imposed. We need your help to hold the patient to those rules, so always contact the nursing staff before planning a visit. - Do not disrupt the normal eating pattern in the hospital by bringing extra snacks or sweets. Do not bring any medication, including laxatives. - Try avoiding topics such as food or weight. It is far more important to talk about other things. 2. Your active participation - In addition to the general information offered here, we are of course always ready to answer additional queries. You can always telephone the psychiatrist or psychologist in charge. For concrete questions, such as visiting times, it is more efficient to contact the nursing staff directly. - Twice monthly, on the second and fourth Thursday evening, we have a group for the parents (spouses) of our patients. There you can exchange feelings, past experiences, frustrations, doubts, management problems or ask us for further information. - It is also possible to have a personal meeting with the responsible psychiatrist or psychologist. You can ask for it or we will invite you and other members of the family for a separate family session. Possible problems Many problems will arise during treatment. The main ones however are: - Separation from the family. This is hard on the patient and on you. The patient receives help from the other patients and staff to deal with feelings of being away from home in alien surroundings. The family, on the contrary, has to adapt on its own to a new situation missing one of its members. Therefore, we are always available for help; please do not hesitate to call! - Later on new problems arise : tensions, difficulties or conflicts will arise when the patient starts changing and is searching for a new role in the family. Especially difficult moments come when the patient, too afraid of change, blocks or even tries to avoid further treatment. These are frequent occurrences, so do not let it sap your determination to go through with the treatment. Try to avoid on the spot decisions and get in touch with us first. This is of prime importance as the patient who gets stuck will try to manipulate you in any possible way. Your patience and cooperation is a cornerstone of therapy we cannot do without.

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Chapter 7

Are drugs useful ? 7.1. 7.2. 7.3. 7.4. 7.5.

Introduction. The patient's attitude. Electroconvulsive therapy (ECT). Psychosurgery. Pharmacotherapy. 7.5.1. Neuroleptics. 7.5.2. Antidepressants. 7.5.3. Appetite regulators. 7.5.4. Miscellaneous. 7.6. Conclusion. References.

7.1. Introduction Therapists who take a predominantly organic stance to the treatment of anorexia nervosa have tried out virtually every biological method available. Their experience, however, is mostly based upon case material or anecdotal impressions. All kinds of psychopharmacological agents have been used and advertised for the treatment of anorexia nervosa. In a survey, Bhanji (1979) found psychiatrists to be more likely to prescribe neuroleptics, antidepressants and even insulin, and internists to use minor tranquillizers for anorexia nervosa. But no one drug appears to hold the definitive answer. This is because the vast majority of reports concern uncontrolled studies. Furthermore, most investigations in this area have combined psychotropic drugs with other therapeutic measures. We will discuss here, beside ECT and psychosurgery, the use of (psychotropic) drugs. The management of other medication such as laxatives (constipation), diuretics (edema), hormones (amenorrhea), as well as other biological methods, e.g. forced feeding (hyperalimentation), are discussed elsewhere (cf. Chapter 4 and 9). Our main interest concerns the question whether there is a real, researchbased evidence for the usefulness of drugs in the treatment of anorexia nervosa and bulimia. But first and foremost, we must consider a crucial issue: the patient's attitude.

7.2. The Patient's Attitude In order to maintain their thinness anorexia nervosa patients may take all kinds of drugs, mostly in secret. Well known is the abuse of purgatives or diuretics,

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and of amphetamine-like anorexigenic compounds. Patients may occasionally use thyroid-like hormones (increasing metabolism), alcohol or sedatives. Since they often consider these products useful in the maintenance of a status quo, these patients could be very resistant to the idea of abandoning their consumption (Crisp, 1980). Moreover, we have often learned that physicians all too easily prescribe drugs aimed at reversing a particular symptom the patient is complaining of (constipation, amenorrhea, sleep disturbances, 'lack of appetite', a 'voracious' appetite, etc.). These physicians (especially general practitioners, internists and gynecologists) do not seem to realize that their prescriptions may not only induce new problems (e.g., abuse of laxatives), but also risk to reinforce the patient's strong desire to become slimmer. On the other hand, physicians often overlook another important problem, namely the patient's lack of compliance. We often saw patients who were referred because of their 'refractoriness' to several psychotropic drugs which they in fact had never taken or had used improperly. For some patients, taking pills means to be weak or helpless; others refuse to consume drugs because of their (presumed) side-effects especially increase of appetite or weight; still others feel threatened by altered bodily sensations due to psychotropics. Blinder, Freeman & Stunkard (1970) used this resistance or aversion toward the use of psychotropic drugs as a reinforcing agent ('aversion relief treatment'): they gave their patient less medication as body weight increased !

7.3. Electroconvulsive Therapy (ECT) Since he hypothesized a progressive depletion of subcortical brain norepinephrine and/or dopamine, Mawson (1974) suggested that ECT and chlorpromazine could be useful in anorexia nervosa for their effects on these amines. "However, neither ECT nor chlorpromazine has actually been demonstrated to be superior to non-pharmacological therapies such as bedrest and high caloric diet, and both agents possess many other effects besides these on catecholamines" (Garfinkel & Garner, 1982, p. 86). Although Laboucarie (1976) in France has for many years advocated the use of ECT in anorexia nervosa (without publishing reliable reports), this method has only occasionally been recommended in other countries (e.g., Bernstein, 1964). Moreover, as in psychosurgery, the 'unblocking' effect of ECT may provoke bulimic reactions. Hence, ECT seems to be of very limited value and should be used only for a severe and persisting depression that has proven refractory to other therapeutic measures and is considered a possible hazard with regard to suicide attempts. In our clinical practice, with large groups of severely disturbed anorexia nervosa patients, we have never been obliged to resort to this method.

7.4. Psychosurgery Psychosurgical procedures (leucotomy) have been used, especially in England, but are reserved mainly for very severe and persistent cases of anorexia nervosa

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in whom all other treatments have failed, and in whom there is a serious risk of death from inanition or suicide. In the postoperative phase the anorectic patient usually cannot resist bulimic impulses and may become a secretive vomiter, with an increased risk of suicide ! These patients therefore need considerable help in re-establishing themselves in new social situations after the operation and in throwing off previous life-patterns that may be of many years standing (see e.g., Crisp & Kalucy, 1973; Post & Schurr, 1977). Psychosurgery should not be used, except as a very last resort, and then with the full understanding and agreement of the patient who must be informed about the unpredictable results of the operation.

7.5. Pharmacotherapy We do not intend to discuss exhaustively all reports on this subject (see the reviews by Garfinkel and Garner, 1982; Halmi, 1983; Johnson, Stuckey & Mitchell, 1983; Meermann, 1981; Szmukler, 1982). Our main interest concerns the question whether there is some (research-based) evidence for the usefulness of drugs in the treatment of anorexia nervosa and bulimia. 7.5.1. Neuroleptics Phenothiazines, especially chlorpromazine, have been considered for a long time the drugs of choice in anorexia nervosa patients. Chlorpromazine appears to have several advantages : - its anxiety reducing effect may help the patient to overcome the fear of eating and weight gain (weight phobia); - its sedating effect may be beneficial in restless and unusually hyperactive patients, especially if they have to tolerate bedrest (and artifical feeding) because of vital risks; - its side-effect of increasing weight (appetite) is wanted here. But chlorpromazine has also many disadvantages : - it lowers the already low blood pressure and reduces the already low body temperature; - it may aggravate leukopenia and can induce agranulocytosis and hemolytic anemia; - it reduces the convulsive threshold (i.e. increased incidence of epileptic seizures) and may provoke bulimia (two interrelated phenomena ?); - it may induce hyperprolactinemia and thus delay the return of normal menstrual function; - it may lead to Parkinson-like dyskinetic reactions and fluid retention. Since the late 1950s chlorpromazine in high doses (to 1-1.5 g) has been recommended in the United Kingdom (Dally & Sargant, 1960) and became one of the central elements in a popular medical regimen combining its use with bedrest and high caloric (tube) feeding in hospitalized patients. In Germany, this approach is sometimes referred to as the Frahm (1966) method and it is still widely used (Engel & Meyer, 1982; Niederhoff, Wiesler & Künzler, 1975).

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In spite (or because ?) of its popularity, the efficacy of chlorpromazine in anorexia nervosa still lacks real research evidence. Barry and Klawans (1976) hypothesized that a hyperfunctioning of the cerebral dopaminergic system may account for the major symptoms in anorexia nervosa. Hence, they suggested treatment with a selective dopamine-blocking drug like pimozide. Encouraged by some promising case reports, Vandereycken and Pierloot (1982, 1983) carried out a double-blind placebo-controlled crossover study using 4 and 6 mg pimozide in 18 anorexia nervosa patients who were treated with a uniform contingency management program. Although pimozide appeared to affect beneficially the weight gain (especially in the beginning) and to improve some attitudinal dimensions (e.g. motivation), the results are not to be interpreted as clear-cut evidence for the efficacy of pimozide in these patients. Munford (1980) advocated the use of single subject methodology in describing the effects of pharmacotherapy (e.g. haloperidol) on anorectic patients who may be concurrently receiving other psychological therapies. This could be, indeed, an interesting approach in pilot studies, but we need further research on large groups. For this reason, Vandereycken (1984) conducted another investigation similar to the pimozide-study mentioned above. This time the substituted benzamide drug sulpiride was tested against placebo. It is also a selective dopamine antagonist with an anti-emetic effect and a beneficial action on mood and appetite in depressives. No direct effect of sulpiride, however, has been established in anorexia nervosa patients with regard to behavioral and attitudinal characteristics. With respect to daily weight gain, on the other hand, sulpiride was mostly superior to placebo, but this effect did not reach statistical significance. 7.5.2. Antidepressants Depressive symptoms are not uncommon in anorexia nervosa. Several vegetative as well as cognitive features of depression are part of the anorexic's symptomatology. No wonder anorexia nervosa is often considered to be a variant of affective illness (Hendren, 1983; Kaplan, et al., 1981; Sours, 1981; see also 1.3). It has therefore been suggested that antidepressant medication may have a role in the treatment of anorexia nervosa. Several case reports described favorable responses to tricyclic antidepressants, such as amitriptyline, Imipramine and clomipramine. The last has been investigated in a double-blind placebo-controlled way (Lacey & Crisp, 1980). Clomipramine, as an adjuvant to an inpatient treatment program, was significantly associated with increased hunger, appetite and energy intake, but also with a reduced rate of weight gain possibly because of increased physical activity. Patients receiving clomipramine were more stable in their eating habits and maintained body weight better than those on placebo after leaving the trial. But once again, the reader has to keep in mind that "tricyclics alone are not thought radically to alter the evolution of anorexia nervosa" (Lacey & Crisp, 1980, p. 84). This statement is, up to the present, equally valid for all other medications in these patients. Very few anorexics really require antidepressants,

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7

a clinical impression we share with Garfinkel and Garner (1982, p. 246): "Because of their unproven benefits and potential for untoward effects, we reserve the use of these medications for those with major depressive features which have persisted after weihgt restoration". It is well known that tricyclic antidepressants may induce carbohydrate cravings and thus risk precipitating bulimic reactions. But bulimia itself is frequently associated with depressive mood or dysphoria (Johnson & Larson, 1982) and could be related to affective disorder (Hudson, Laffer & Pope, 1982). Recent reports suggest that antidepressants may be of value in treating bulimia (Brotman et al., 1984; Hudson, Pope & Jonas, 1984; Pope & Hudson, 1982; Pope, Hudson & Jonas, 1983). Results of controlled studies, however, are equivocal. In a placebo-controlled study, Pope, Hudson, Jonas et al. (1983) found that Imipramine was associated with a significantly reduced frequency of binge eating. Sabine, Yonace, Farrington et al. (1983), on the other hand, could not reveal a difference between mianserin and placebo in bulimic patients. Monoamine oxidase inhibitors (MAOIs) have also been reported to improve both mood and eating behavior in bulimic patients (Walsh, Stewart, Wright et al., 1982). This proclaimed efficacy, however, has still to be demonstrated in controlled studies (Fairburn & Cooper, 1983). The fluctuations of some anorectic patients between fasting and elation on the one hand, and bulimia and depression on the other, are sometimes compared to the mood swings of manic-depressives. It therefore seems logical that lithium should also be tried out in these patients (Stein, Hartshorn, Jones et al., 1982). A double-blind controlled trial of lithium carbonate in primary anorexia nervosa has been reported by Gross, Ebert, Faden et al. (1981). In a 4-week, parallelgroup study, 8 patients were evaluated on lithium and 8 patients were treated with placebo. All patients participated in a behavior modification program. Although some group differences were difficult to interpret, repeated measures performed at each individual time point showed greater weight gain in the lithium group at weeks 3 and 4. However, we do not recommend, except in very restricted indications and with especially careful monitoring, the use of lithium because of the great risk of intoxication among patients who are prone to vomit, purge themselves, misuse diuretics, restrict sodium, drink excessive amounts of water, and be liable to hypokalemia.

7.5.3. Appetite Regulators The obstinate survival of the misnomer anorexia nervosa probably explains why it is so often misinterpreted as an appetite disturbance. Many clinicians seem to search primarily for a method to enhance the 'poor appetite' of these patients. Neuroleptics and antidepressants are then sometimes used with this intention. The same but wrong logic governs the prescription of so-called specific appetite stimulants (which many patients refuse to take as we already mentioned before). Insulin has been recommended, especially in the United Kingdom, either to

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stimulate appetite or to induce more rapid weight gain. Although it is still used,insulin certainly has no place in the treatment of anorexia nervosa, not only for the mistaken assumption of appetite disturbance, but also for the occasionally high insulin levels, insulin resistance, and hypoglycemia seen in these patients (Garfinkel & Garner, 1982). Cyproheptadine is a serotonin and histamine antagonist with anticholinergic and sedative effects. For many years it has been marketed in Europe because of its appetite-stimulating properties. Vigersky and Loriaux (1977) found that cyproheptadine did not promote weight gain in significantly more anorexia nervosa patients than did a placebo. In a multi-center study, including a large series of hospitalized anorectic patients, Goldberg, Halmi, Eckert et al. (1979, 1980) investigated four treatment combinations : cyproheptadine or placebo with or without behavior modification. No overall drug effect on body weight was shown (only in a subgroup of patients characterized by a history of delivery complications), nor was there a distinct beneficial effect (only a tendency) of cyproheptadine on some attitudinal variables such as 'fear of becoming fat'. More recently, Halmi, Eckert and Falk (1982, 1983) found that cyproheptadine was superior to placebo in inducing weight gain, but not to amitriptyline. After all, we still doubt the usefulness of cyproheptadine in anorexia nervosa. Crisp (1980) seriously questions the use of appetite stimulants in anorexia nervosa patients : "... the anorectic does not eat, although she is hungry, because she is terrified of gaining weight and of altogether losing control over food intake, thereby becoming grossly fat. A logical pharmacological approach to this - especially for those who overeat and vomit and who are most often acutely aware of such imminent disaster for themselves - might be to give them drugs that curb appetite, thereby making it safer for them to eat and retain a little more food" (p. 96-97). Amphetamines are well-known anorectic drugs (appetite inhibitors). In a recent double-blind study, intravenous methylamphetamine was found to be quite effective in suppressing bulimia, but the beneficial effect was very shortlived (Ong, Checkley & Russell, 1983). At present, we urge extreme caution in the use of anorectic drugs for the following reasons. First, patients themselves must gain adequate self-control without depending upon artificial means which directly influence their body already experienced as ego-dystonic, strange and threatening. Second, we know that many bulimic patients vainly attempt to block their appetites by means of anorectic drugs (prescribed all too often by general practitioners), and end up in amphetamine dependency and an even worse 'dietary chaos'! Let us emphasize it once more : anorexia nervosa patients in general do not show a lack or excess of appetite, but a strong urge or compulsion to control their hunger and to master their food intake in order to reach or maintain a low body weight. They have to learn that nobody can violate the laws of nature regarding bodily functioning without subsequent distress and deterioration of biological and psychological well-being.

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7.5.4. Miscellaneous Rau, Struve and Green (1979) hypothesized an underlying neurophysiologic basis in patients with eating disorders, and they recommended the use of an anticonvulsant, diphenylhydantoin, especially in episodic compulsive overeaters who also display an abnormal EEG. A placebo-controlled study of Phenytoin in binge-eaters showed some improvement in about 40 % of the subjects (Wermuth, Davis, Hollister et al., 1977). Carbamazepine is a tricyclic compound with chemical features in common with antiepileptics and with polycyclic psychoactive drugs. Beneficial effects have been reported on its use in manic depressives. A double-blind crossover trial with carbamazepine in bulimics showed that only one patient out of six responded dramatically with cessation of binge eating (Kaplan et al., 1983). In a 4-week, double-blind crossover study with 11 anorexia nervosa patients, Gross et al. (1983) have tested delta-9-tetrahydrocannabinol, a psychoactive cannabinoid which has properties of appetite stimulation, promotion of weight gain, and antiemetic efficacy. The authors conclude, however, that this cannabinoid is not efficacious in the treatment of anorexia nervosa, and, moreover, that it is associated with significant psychic disturbance in some patients. Except for some cases of persisting amenorrhea or infertility (see Chapter 9), there is no indication for the use of hormone preparations in anorexia nervosa, although many have been tried, including (in addition to insulin which we discussed before) anabolic steroids, cortisone, ACTH, TRH, thyroxine, and testosterone. The metabolic deficiencies for which they have been wrongly prescribed are just correlates of weight loss or conservation responses to the stravation state (Garfinkel & Garner, 1982). Metoclopramide may be useful in reducing the delayed gastric emptying and postprandial dyspepsia in anorectic patients (Moldofsky, Jeuniewic & Garfinkel, 1977; Saleh & Lebwohl, 1980). The usefulness of domperidone for the same indication (Russell et al., 1983) has to be confirmed in a placebo-controlled study. Recommendations to use L-dopa (Johanson & Knorr, 1977), phenoxybenzamine, an alpha-adrenergic blocking agent (Redmond, Swann & Heninger, 1976), coppersulphate (Hoes, 1980), or even homeopathic treatment with arsenicum album (Pandelon & Ruderman, 1981) appear to express the subjective trial-anderror experience by which every clinician hopes to find once the 'innovative' treatment of anorexia nervosa. The same applies, it would seem, to the use of glycerol (Caplin, Ginsburg & Beaconsfield, 1973) and naloxone (Moore, Mills & Forster, 1981) as therapeutic adjuncts in the weight restoration of anorectic patients. And every time one may conclude with the classic sentence : "Further properly controlled studies are required".

7.6. Conclusion Drugs appear to be of little benefit in the treatment of anorexia nervosa and have not thus far enhanced our understanding of the underlying pathogenesis or

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pathophysiology (Szmukler, 1982). Though we know from· research and clinical experience that inpatients with anorexia nervosa may achieve considerable weight gain when treated with some psychotropic drugs (e.g., phenothiazines, antidepressants, cyproheptadine), similar and even better results can be achieved by behavior therapy or a medical regimen including bedrest and skilled nursing without drug therapy. "Even if more rapid weight gain is obtained through drug therapy it is of no advantage if it is perceived by the patient as obscene flesh that has to be removed again as soon as possible" (Tyrer, 1982, p. 400). As Russell (1977) rightly remarked, investigators into the treatment of anorexia nervosa often forget the basic fact that the criteria for a fundamental improvement in the course of the illness require a much more radical change in the patient than some weight gain over the course of a few weeks ! Future research on the utility of drugs should not be aimed at enhancing weight gain in anorectic patients, but at reducing binge eating, and - an equally great challenge - at changing the dysorectic patients' weight phobia and their distorted attitudes towards their own body. Moreover, treatment in general should not be based upon clinical beliefs, but on facts deriving from careful and methodologically proper research. Otherwise, clinicians who devise drug treatment according to their own preferences and wishful thinking, are just repeting the nonsensical statement of our ancient predecessor Galen : "All who drink this remedy recover in a short time, except for those whom it does not help, who all die and have no relief from any other medicine. Therefore it is obvious it fails only in incurable cases".

References Barry, V.C. & Klawans, H.L. (1976), On the role of dopamine in the pathophysiology of anorexia nervosa. Journal of Neural Transmission, 38 : 107-122. Bernstein, I.C. (1964), Anorexia nervosa treated successfully with electroshock therapy and subsequently followed by pregnancy. American Journal of Psychiatry, 120 : 1023-1025. Bhanji, S. (1979), Anorexia nervosa : Physicians' and psychiatrists' opinion and practice. Journal of Psychosomatic Research, 23 : 7-11. Blinder, B.J., Freeman, D.M.A. & Stunkard, A.J. (1970), Behavior therapy of anorexia nervosa : Effectiveness of activity as a reinforcer of weight gain. American Journal of Psychiatry, 126: 1093-1098. Brotman, A.W., Herzog, D.B. & Woods, S.W. (1984), Antidepressant treatment of bulimia: The relationship between binging and depressive symptomatology. Journal of Clinical Psychiatry, 45 (1): 7-9. Caplin, H., Ginsburg, J. & Beaconsfield, P. (1973), Glycerol and treatment of anorexia (letter). Lancet, I : 319. Crisp, A.H. (1980), Anorexia Nervosa : Let Me Be. N e w York/London : Academic Press/ Grune & Stratton. Crisp, A.H. & Kalucy, R.S. (1973), The effect of leucotomy in intractable adolescent weight phobia (Primary anorexia nervosa). Postgraduate Medical Journal, 49 : 1770-1773.

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Dally, P.J. & Sargant, W . (1960), A n e w t r e a t m e n t of a n o r e x i a nervosa. British Medical Journal, 1 : 1770-1773. Engel, Κ. & M e y e r , Α . Ε . (1982), T h e o r i e u n d E m p i r i e einer m e h r f a k t o r i e l l e n stationären A n o r e x i e t h e r a p i e f ü r s c h w e r e r k r a n k t e Patienten ( T h e o r y a n d results of a multifactorial inpatient t r e a t m e n t of severely ill anorectic patients). Medizinische Weh. 33 : 1812-1816. F a i r b u r n , C.G. & C o o p e r , P.J. (1983), M A O I s in t r e a t m e n t of b u l i m i a (letter). American Journal of Psychiatry, 140 : 949-950. F r a h m , H. (1966), Beschreibung u n d Ergebnisse einer somatisch orientierten Behand l u n g v o n K r a n k e n mit A n o r e x i a n e r v o s a (Description a n d results of a somaticly oriented t r e a t m e n t of a n o r e x i a n e r v o s a patients). Medizinische Welt, 17 : 2004-2011, 2068-2074. G a r f i n k e l , P.E. & G a r n e r , D . M . (1982), Anorexia Perspective. N e w York : B r u n n e r / M a z e l .

Nervosa.

A

Multidimensional

G o l d b e r g , S.C., Halmi, K.A., Eckert, E D., Casper, R.C. & Davis, J . M . (1979), C y p r o h e p t a d i n e in a n o r e x i a nervosa. British Journal of Psychiatry, 134 : 67-70. G o l d b e r g , S.C., Halmi, K.A., Eckert, E.D., Casper, R.C., Davis, J . M . & Roper, M. (1979), Attitudinal d i m e n s i o n s in a n o r e x i a nervosa. Journal of Psychiatric Research, 15 : 239-251. G o l d b e r g , S.C., Halmi, K.A., Eckert, E.D., Casper, R.C., Davis, J.M. & Roper, M. (1980), Effects of c y p r o h e p t a d i n e o n s y m p t o m s a n d attitudes in a n o r e x i a n e r v o s a (letter). Archives of General Psychiatry, 37 : 1083. Gross, H „ Ebert, M . H . , Faden, V.B., G o l d b e r g , S.C., Kaye, W . H . , Caine, E.D., H a w k s , R. & Zinberg, N. (1983), A double-blind trial of d e l t a - 9 - t e t r a h y d r o c a n n a b i n o l in p r i m a r y a n o r e x i a nervosa. Journal of Clinical Psychopliarmacology, 3 : 165-171. Gross, H.A., Ebert, M . H . , Faden, V.B., G o l d b e r g , S.C., Nee, L.E. & Kaye, W . H . (1981), A double-blind controlled trial of lithium c a r b o n a t e in p r i m a r y a n o r e x i a nervosa. Journal of Clinical Psychopharmacology, 1 : 376-381. H a l m i , K.A. (1983), A n o r e x i a nervosa. I n : Hippius, H. & W i n o k u r , G.(Eds.), Psychopharmacology 1. Part 2 : Clinical Psychopharmacology. Amsterdam : E x c e r p t a Medica, 313-320. Halmi, K.A., Eckert, Ε. & Falk, J.R. (1982), C y p r o h e p t a d i n e for a n o r e x i a n e r v o s a (letter). Lancet, 1 : 1357-1358. H a l m i , K.A., Eckert, Ε. & Falk, J.R. (1983), C y p r o h e p t a d i n e , an antidepressant a n d w e i g h t - i n d u c i n g d r u g for a n o r e x i a nervosa. Psychopharmacological Bulletin, 19 : 103-105. H e n d r e n , R. (1983), Depression in a n o r e x i a nervosa. Journal of the American Academy of Child Psychiatry, 22 : 59-62. Hoes, M.J. A.J.M. (1980), C o p p e r sulphate a n d pimozide for a n o r e x i a nervosa. Journal of Orthomolecular Psychiatry, 9 : 48-51. H u d s o n , J.I., Laffer, P.S. & Pope, H.G. (1982), Bulimia related to affective disorder by family history a n d response to the d e x a m e t h a s o n e suppression test. American Journal of Psychiatry, 1 3 9 : 685-687. H u d s o n , J.I., Pope, H.G. & J o n a s , J.M. (1984), T r e a t m e n t of b u l i m i a w i t h antidepressants : Theoretical considerations a n d clinical findings. In : S t u n k a r d , A.J. & Stellar, E. (Eds ), Eating and Its Disorders. N e w York : Raven Press, pp. 259-273. J o h a n s o n , A.J. & K n o r r , N.J. (1977), L - D o p a as t r e a t m e n t of a n o r e x i a nervosa. In : Vigersky, R.A. (Ed ), Anorexia Nervosa. N e w York : R a v e n Press, pp. 363-372. J o h n s o n , C. & Larson, R. (1982), B u l i m i a : An analysis of m o o d s a n d behavior. Psychosomatic Medicine, 44 : 341-351. J o h n s o n , C., Stuckey, M. & Mitchell, J. (1983), P s y c h o p h a r m a c o l o g i c a l t r e a t m e n t of a n o r e x i a n e r v o s a a n d bulimia. Journal of Nervous and Mental Disease, 171 :

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524-534. Kaplan, A.S., Garfinkel, P.E., Darby, P.L. & Garner, D.M. (1983), Carbamazepine in the treatment of bulimia. American Journal of Psychiatry, 140 : 1225-1226. Kaplan, S.L., Shenker, I.R., G o r d o n , B. & Weinhold, C. (1981), Depression in anorexia nervosa and obesity. In : Wells, C.F. & Stuart, I.R. (Eds)., Self-Destructive Behavior in Children and Adolescents. N e w York : Van Nostrand Reinhold, pp. 164-178. Laboucarie, J. (1976), Aspects pathogeniques, cliniques et therapeutiques de l'anorexie mentale (Pathogenic, clinical and therapeutic aspects of anorexia nervosa). Actualites Psychiatriques, 6(4): 26-35. Lacey, J.H. & Crisp, A H . (1980), Hunger, food intake and w e i g h t : The impact of clomipramine on a refeeding anorexia nervosa population. Postgraduate Medical Journal, 56 (Suppl. 1): 79-85. M a w s o n , A.R. (1974), Anorexia nervosa and the regulation of i n t a k e : A review. Psychological Medicine, 4 : 289-308. M e e r m a n n , R. (1981), Z u r Psychopharmakotherapie der Magersucht. In : Meermann, R. (Ed.), Anorexia Nervosa. Ursachen und Behandlung. Stuttgart: Ferdinand Enke, pp. 170-178. Moldofsky, H., Jeuniewic, N. & Garfinkel, P.E. (1977), Preliminary report on metoclopramide in anorexia nervosa. In : Vigersky, R.A. (Ed.), Anorexia Nervosa. N e w York : Raven Press, pp. 373-375. Moore, R. Mills, I.H. & Forster, A. (1981), Naloxone in the treatment of anorexia nervosa : Effect on weight gain and lipolysis. Journal of the Royal Society of Medicine, 74 : 129-131. M u n f o r d , P R. (1980), Haloperidol and contingency m a n a g e m e n t in a case of anorexia nervosa. Journal of Behavior Therapy and Experimental Psychiatry, 11 : 67-72. Niederhoff, Η.,Wiesler, Β. & Künzer, W. (1975), Somatisch orientierte Behandlung der Anorexia nervosa (Somaticly oriented treatment of anorexia nervosa). MonatSchrift für Kinderheilkunde, 123 : 343-344. Ong, Y.L., Checkley, S.A. & Russell, G.F.M. (1983), Suppression of bulimic s y m p t o m s with methylamphetamine. British Journal of Psychiatry, 143 : 288-293. Pandelon, R. & R u d e r m a n , D. (1981), Anorexie mentale, prise en charge institutionelle et homeopathie (Anorexia nervosa, residential treatment and homeopathy). Actualites Psychiatriques, 11(1): 78-80. Pope, H.G. & Hudson, J.I. (1982), Treatment of bulimia with antidepressants. Psychopharmacology, 78 : 176-179. Pope, H.G., Hudson, J.I. & Jonas, J.M. (1983), Antidepressant treatment of b u l i m i a : Preliminary experience and practical recommendations. Journal of Clinical Psychopharmacology, 3(5): 274-281. Pope, H.G., Hudson, J.I., Jonas, J.M. & Yurgelun-Todd, D. (1983), Bulimia treated with Imipramine : A placebo-controlled double-blind study. American Journal of Psychiatry, 140:554-558. Post, F. & Schurr, P H. (1977), Changes in the pattern of diagnosis of patients subjected to psychosurgical procedures, with c o m m e n t s on their use in the treatment of selfmutilation and anorexia nervosa. In : Sweet, W.H., Obrador, S. & MartinRodriguez, J.G. (Eds ), Neurosurgical Treatment in Psychiatry, Pain and Epilepsy. Baltimore : University Park Press, pp. 261-266. Rau, J.Η., Struve, F.A. & Green, R.J. (1979), Electroencephalographic correlates of compulsive eating. Clinical Electroencoplialography, 1 0 : 180-189. Redmond, D.E., S w a n n , A. & Heninger, G.R. (1976), Phenoxybenzamine in anorexia nervosa (letter). Lancet, 2 : 307. Russell, D.M., Freedman, M.L., Feiglin, D.H.I., Jeejeebhoy, K.N., Swinson, R.P. & Garfinkel, P.E. (1983), Delayed gastric emptying and improvement with

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domperidone in a patient with anorexia nervosa. American Journal of Psychiatry, 140:1235-1236. Russell, G.F.M. (1977), General management of anorexia nervosa and difficulties in assessing the efficacy of treatment. In : Vigersky, R.A. (Ed.) Anorexia Nervosa. New York : Raven Press, pp. 277-290. Sabine, E.J., Yonace, Α., Farrington, A.J., Barratt, K.H. & Wakeling, A. (1983), Bulimia nervosa : A placebo-controlled double-blind therapeutic trial of mianserin. British Journal of Pharmacology, 5 (Suppl. 2): 195S-202S. Saleh, J.W. & Lebwohl, P. (1980), Metoclopramide-induced gastric emptying in patients with anorexia nervosa. American Journal of Gastroenterology, 74 : 127-132. Sours, J. A. (1981), Depression and the anorexia nervosa syndrome. Psychiatric Clinics of North America, 4 : 145-158. Stein, G.S., Hartshorn, S., Jones, J. & Steinberg, D. (1982), Lithium in a case of severe anorexia nervosa. British Journal of Psychiatry, 140 : 526-528. Szmukler, G.I. (1982), Drug treatment of anorexic states. In : Silverstone, T. (Ed.), Drugs and Appetite. London-New York : Academic Press, pp. 159-181. Tyrer, P.J. (1982), Drugs in Psychiatric Practice. London : Butterworths. Vandereycken, W. (1984), Neuroleptics in the short term treatment of anorexia nervosa. A double-blind placebo-controlled study with sulpiride. British Journal of Psychiatry, 144 : 288-292. Vandereycken, W. & Pierloot, R. (1982), Pimozide combined with behavior therapy in the short-term treatment of anorexia nervosa; A double-blind placebo-controlled cross-over study. Acta Psychiatrica Scandinavica, 66 : 445-450. Vandereycken, W. & Pierloot, R. (1983), Combining drugs and behavior therapy in anorexia nervosa: A double-blind placebo/pimozide study. In : Darby, P.L., Garfinkel, P.E., Garner, D.M. & Coscina, D.V. (Eds.), Anorexia Nervosa : Recent Developments in Research. New York : Alan R. Liss, pp. 365-375. Vigersky, R.A. & Loriaux, D.L. (1977), The effects of cyproheptadine in anorexia nervosa : A double-blind trial. In : Vigersky, R.A. (Ed.), Anorexia Nervosa. New York : Raven Press, pp. 349-356. Walsh, B.T., Stewart, J.W., Wright, L. Harrison, W. Roose, S.P. & Glassman, A.H. (1982), Treatment of bulimia with monoamine oxydase inhibitors. American Journal of Psychiatry, 139: 1629-1630. Wermuth, B.M., Davis, K.L., Hollister, L.E. & Stunkard, A.J. (1977), Phenytoin treatment of the binge-eating syndrome. American Journal of Psychiatry, 134 : 1249-1253.

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Chapter 8

Has the family to be treated ? 8.1. Protection or confrontation ? 8.2. The balance between authority and autonomy. 8.3. The family-oriented systems approach. 8.4. Working with instead of against the family. 8.5. The family of the hospitalized patient. 8.6. Parent groups. 8.7. Conclusion. References.

8.1. Protection or Confrontation ? The idea that the anorectic child mas made sick by the parents and that relief followed separation, governed the treatment rationale of many clinicians beginning with William Gull in the 19th century. Long-term hospitalization, strictly isolating the child from her family, was promoted for several years as the best management of anorexia nervosa patients. 'Parentectomy' was considered to be the essential and crucial therapeutic instrument. Nowadays, however, such an approach has fallen into disfavor due to several changes in the psychiatric field : hospitalization was sharply criticized by antipsychiatrists, systems theory replaced linear models of causation, child psychiatry turned away from parent-blaming and enthusiasticly joined the family therapy movement. But, at the same time, clinicians have become aware of the anorexic's psychological vulnerability to external influences, i.e. her special contextdependent behavior. In anorexia nervosa, such context-dependence is, according to Harper (1983, p. 139), "reflected in the contemporary consensus that individual therapy alone rarely suffices in this disorder, but that some form of sociotherapy, contingency manipulation, or family re-structuring is necessary as well". Therapists, therefore, may be faced with the dilemma of confronting the patient with the dysfunctional family system or protecting her against deleterious family influences (see Table 8.1.). Harper (1983) rightly stresses, that the protective point of view is implicit in much contemporary work with anorexia nervosa patients and their families. In a lucid and courageous article that we strongly recommend be read, Harper tries to make explicit the concepts of parenting failure, child vulnerability, protective treatment, and parenting-stabilizing interventions (from the more familiar educative to the less familiar legal and administrative). "The concepts of protection and of therapeutic separation, if not the term parentectomy itself, are still useful in the assessment and management of anorexia nervosa. The ideas are two. Descriptively, certain children are unable to maintain their weight in the

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Table 8-1. Anorexia Nervosa : Contrasting Approaches Protective-Clinical

Individual and Family Therapy

Focus of formulation

External, one-way actions, from parents to child

View of identified patient

Agent, but also victim; weak as well as strong Protective, including separation Definite

Intrapsychic, intrasystemic, and interactional processes Interacting agent with underrecognized power Therapy

Modal intervention Use of objective standards in evaluation of parents' functioning Assumptions about parents' ability to change Dangers

Possible

Perhaps

Yes

Child-saving, rescue fantasies, adoption process ignoring child's role in process

Ignoring of protective needs of the child

Reprinted from Harper (1983).

presence of their parents but do so apart from them. In many cases, such failure is associated with gross deficiencies in parenting. Prescriptively, for such children, when attempts to help the parents to be more protective fail, i.e. when parents fail to change with treatment, other approaches to parenting stabilization, including a change in the child's living place or legal action, may make the crucial difference in weight recovery" (Harper, 1983, p. 134). Serious parenting failure, according to Harper (1983), is not uncommon among anorexia nervosa patients w h o do not respond sufficiently well to treatment. He describes the following varieties of parenting failure he faced: provision of harmful unprescribed medication (e.g., laxatives), malignant denial of a patient's life-threatening condition, persistent triangulation (e.g., the patient being manipulated in divorce battles), severe subversion of treatment plans, parental desertion and depression, and severe breakdown of the household. In such cases protective clinical work and enhancement of parenting may be critical in achieving recovery. The techniques used to bring about parenting stabilization range from the more educational to the more legal-administrative (Harper, 1983):

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(a) Instruction and confrontation : - unambiguous and unambivalent provision of medical information (e.g. clarification of medical risks); - appeal to parental responsibility; - explicit demonstration of the relation between events in the family and the patient's eating problems. (b) Voluntary change of residence : - parents agree that the child would live with a relative, at a boarding school, in a group home, in a foster-family etc. (c) Legal and I or administrative interventions : - voluntary or involuntary transfer of custody; - compulsory detention of the child or involuntary commitment of a severely disturbed parent. The degree of clinical, educational or legal intervention which a given patient requires is established by empirical trial. Clinicians must be aware, however, that the anorexia nervosa patient is not just a pure victim of parenting failure, and they should beware of nonobjective sentimentalization of the 'poor' child and competitive criticism of the 'bad' parents. "The clinicians working with anorexia nervosa must be open both to the possibility that parents (and patients) have hitherto unappreciated capacities to change, if only one can find the way to ally with them, but also to the possibility that they may not be able to do so and that clinical responsibility includes the obligation to act accordingly" (Harper, 1983, p. 138). Whatever the concrete therapeutic approach, a congruence is needed between the therapist, the patient, and the family. It is this congruence that often determines whether the family will be an ally or an adversary.

8.2. The Balance between Authority and Autonomy Whatever characteristics one has ascribed to anorexia nervosa families or whatever family pattern one has presumed to be (causally) linked with some eating disorder, there is one feature we encountered in all these families : a lack of adequate joint authority of the parents. 'Adequate' refers here to the balance of control and autonomy proper for the age of the child. The parental authority needs to be rational in the sense that it should be flexible and in harmony with the child's level of development. 'Joint' authority means that there is a basic agreement between the parents about child-rearing issues, that they function in concert and reinforce each other's requests and actions so that the child clearly knows what the expectations are. Compernolle (1982) stresses that an adequate joint parental authority is necessary for the resolution of major emotional and behavioral problems in children. To reestablish parental authority one needs not only to change the pattern of family interaction, but also to undo diagnostic 'disease' labels such as anorexia nervosa since these labels set the problem out of the parent's reach and call for the authority of a 'specialist'. "To enable the family to take charge of the

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problems the therapist needs to create a workable view of the problem, preferably an interactional one. Families do not know how to deal with the 'mysterious disease of anorexia nervosa', but they know most often very well how to deal with 'a child who refuses to eat' or 'a girl who will not eat unless she develops proper autonomy' " (Compernolle, 1982, p. 252). In anorexia nervosa families parental authority or control is sometimes too strong or too rigid, resulting in a lack of autonomy of the child (especially the older adolescent) who may use the symptoms as a means to escape from this situation (the 'sick' child) or to protest against it (the 'rebellious' child). In most cases, however, parental authority is undermined by coalitions of parents with their children (cf. Minuchin's notions of enmeshment and overprotectiveness; see 2.3). Though it is often difficult to ascertain whether the anorexia nervosa is cause or consequence of a lack of coalition between the parents, reestablishment of parental authority is practically always a priority in treatment. The older the identified patient, the more the therapist is inclined to emphasize the development of autonomy and a concomitant decrease of parental control. But many parents could give the necessary autonomy and freedom to their children only after having (re)gained control (Compernolle, 1982). As long as the anorexic symptoms exist, the patient maintains an important power over her parents and too much control over family interaction. "The therapist's goal is to get the young person to abandon the disturbed behavior that is the basis of his power, which means the parents must be able to gain control over the youth. They must set expectations and rules and establish consequences if these are not followed. The therapist must influence the parents to establish rules and consequences that are stringent enough to build up their power. When the young person loses his power over the parents he will begin to behave normally. At this point, the therapist must help the parents to deal with their own difficulties without involving the youth. This task will be made easier because of the experience they acquired by expecting appropriate behavior and negotiating agreements with each other in the process of setting rules and enforcing consequences for the young person" (Madanes, 1982, p. 58). Therapists should always be aware of the great impact anorexia nervosa has on the patient's individual experience as well as on the family life. One may never overlook this when organizing treatment in order to either increase or deemphasize the focus on eating or weight. The strategy adopted - overfocusing or underfocusing of the eating problem - apparently depends on rather idiosyncratic characteristics of therapist, patient, and family. But, whatever strategy the family therapist may prefer, interventions are aimed at transforming the issue of an anorectic patient into the drama of a dysfunctional family (Minuchin, Rosman & Baker, 1978). The expectation should be that the individual can achieve the next developmental step and that the family should be involved to allow and achieve this step.

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8.3. The Family-Oriented Systems Approach

The structural family therapist (Minuchin, Rosman & Baker, 1978) bases his approach on the principle that an elimination of the anorectic symptoms is a first and necessary, but insufficient step, which must be followed by a restructuring of the family system. The family systems oriented treatment is aimed a t : - eliminating the symptom of food refusal and weight loss on which the family concentrates as a way of avoiding or detouring intrafamilial conflicts; - elucidating the dysfunctional patterns in the family that reinforce and maintain the patient's symptoms; - changing the structure and functioning of the family system in order to prevent relapses or the appearance of a new symptom or a new symptom-bearer (Liebman, Sargent & Silver, 1983). Although the 'Philadelphia Group' prefers to work, as much as possible, on an outpatient basis (see Chapter 5), they also use an inpatient treatment program which is congruent with a family-oriented systems approach to therapy while maintaining the flexibility required to meet the individual needs of the patient (Hodas, Liebman & Collins, 1982; Liebman, Sargent & Silver , 1983). The general goals of short-term pediatric or psychiatric hospitalization (3-4 weeks) are to transform dysfunctional family coalitions, to increase the disengagement process by decreasing symptom severity, and to increase the patient's and parents' sense of competence and effectiveness by the acquisition of new problem solving skills. Liebman, Sargent and Silver (1983) stress that it is necessary to prevent the family from using hospitalization to reinforce the patient's role as the symptom-bearer for the family, as well as to prevent the parents from perceiving the admission as further acknowledgement of their personal failure as parents. This would produce a countertherapeutic situation which might lead to the hospital staff being unwittingly manipulated to act as the parents' substitutes or representatives (see 5.3). During hospitalization, the process of weight gain is initiated using an operant reinforcement program with access to activity and visitors as positive reinforcements for weight gain (see Chapter 6). Family therapy lunch sessions are held in which the patient, the family and the therapists) eat together (Rosman, Minuchin & Liebman, 1975). These lunch sessions are aimed a t : - accelerating the process of weight gain; - enabling the patient to eat with her parents without the development of a power struggle; this provides an entirely new experience for the family with respect to eating; - redefining the anorexia by dismantling the family's myth that they are fine except for the presence of their 'medically sick' child; this formulation is transformed into a recognition of the intrafamilial conflicts which decreases the patient's centrality and the manipulative power of her symptoms. The possible outcomes of such lunch session are : " 1. The anorectic eats uneventfully, which enables the therapist to reframe the

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problem as not an eating problem but a problem of growing up, communication, or other interpersonal issues. 2. The anorectic refuses to eat and the parents are given the responsibility of getting their daughter to eat. If the parents do not succeed initially, they are told to continue working together until the patient begins to cooperate. ["On occasion this has even meant that a parent has physically forced food into a resistant patient's mouth" (Collins, Hodas & Liebman, 1983, p. 5).] 3. The anorectic refuses to eat and the parents fail in their attempts to get her to eat. With this outcome, the therapist points out the power that the patient has over the parents and how she has defeated them. The parents are told that they will continue to fail unless they are able to work more effectively together and stimulate greater cooperation from the patient" (Hodas, Liebman & Collins, 1982, p. 136). The lunch session may serve, then, as a bridge between the hospitalization phase and the outpatient phase: "Once the patient realizes that the parents, supported by the therapist, are unified and will not tolerate noneating, she starts to eat. This paves the way for the outpatient phase where the parents are again responsible for enforcing their child's eating" (Collins, Hodas & Liebman, 1983, p. 5). As mentioned before, elimination of the symptoms (i.e. weight gain) is given top priority but is never considered sufficient. Restructuring of the family system is the final and essential goal. "Once weight gain is progressing gradually, the outpatient family therapy is organized by assigning family tasks aimed at different sybsystems of the family. The tasks are developed from an understanding of the individual, interpersonal, and family systems dynamics. They are aimed at expediting changes in the structure, organization, and functioning of the family and at changing the quality of the interpersonal relationships in the family. The choice, assignment, and implementation of relevant tasks provides structure and timed agendas for the treatment plan. This decreases parental anxiety and resistance to change while increasing their effectiveness in coping with their daughter's symptoms (...). As weight gain continues, the focus shifts from eating and the behavior paradigm to concern about interpersonal issues. As intrafamilial issues begin to be resolved, the emphasis shifts to school and community activities and peer group relationships. Within the family, there is a gradual shifting of emphasis to the problems of the parental dyad. At this point, the parents are seen separately for marital therapy with periodic family sessions as needed. In addition, the patients are seen individually to discuss age-appropriate developmental issues. The individual sessions with the patient center on understanding the complexities of interpersonal relationships (family and peer groups), learning to tolerate frustration and develop more independent problem-solving behavior to cope with stress at home, school, and in the community. The general goals are (1) the gradual disengagement of the children from the conflicts between their parents and movement of the children into age-appropriate peer group activities, (2) the resolution of marital-parental conflicts, and (3) individual psychotherapy for the patient (after weight gain and eating patterns are stabilized) when indicated (...)" (Liebman, Sargent & Silver, 1983, p. 132).

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The duration of this outpatient family therapy ranges from 7 to 14 months, with an average of 10 months. The results of this approach (see Minuchin, Rosman & Baker, 1978) seem to be impressive : a success-rate of about 86 % has been reported (recovery from both the anorexia and its psychosocial components). Though we do not doubt the usefulness and effectiveness of family therapy in anorexia nervosa patients, Minuchin's outcome research is too weak to allow overenthusiastic conclusions because it may be criticized on the following issues : - anorexia nervosa is viewed as a unitary concept and the heterogeneity of the syndrome is ignored (Minuchin treated a relatively young and selected sample of 'dieters'); - the 'uniformity myth' is also applied to the treatment format and the different therapists involved; - follow-up evaluation did not include independent and direct assessment (by means of a face to face personal interview with patient and family), did not report the occurrence of menses and peculiar eating practices, and, finally, did not systematically assess psychosocial adjustment and family functioning. But, without question, the family-oriented approach is one of the most fruitful recent contributions to the treatment of anorexia nervosa. It is, however, no panacea and its application is not so simple as it often appears on video-tapes or in easy reading reports. Although not necessarily contraindications for family therapy, the following situations need specially careful treatment planning by an experienced therapist (Liebman, Sargent & Silver, 1983): - patients having symptoms of eating disorder for more than one year prior to referral; - patients with prior significant delays or problems in psychosocial development; - families in which the parents are separated or divorced, or where one parent is deceased; - families in which one or both parents display severe psychopathology. Although the structural family approach may be suitable in adult patients (Fishman, 1979), it is most successful in fairly young patients who are relatively healthy emotionally and are not yet entangled in a chronically disturbed family pattern. The same possibilities and limitations apply to other models of family therapy in anorexia nervosa which do not essentially differ from the structural model and/or attempt to integrate other concepts as to family interaction. These include, for instance, the psychodynamically oriented family developmental model: e.g. Buddeberg and Buddeberg (1979), Overbeck (1979), and Stern, Whitaker, Hagemann et al. (1981); or the communications theory-inspired systems approach ä la Selvini-Palazzoli (1974) including paradoxical interventions : e.g. Caille, Abrahamsen, Girolami et al. (1977), Elkaim (1982), and Pina Prata (1980).

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8.4. Working With Instead of Against the Family

In our experience, it is a mistake to start from the axiom that every anorexic's family is somehow 'disturbed' and must, therefore, be 'treated'. True, every family we saw was in one sense or another 'dysfunctional' at the moment of referral or admission to the hospital. But which family would not be in some kind of crisis when being faced with a severely starving family member ? Which parents would not be upset when they are searching for professional help fearing that their child is in a medically dangerous condition ? In other words, a family crisis is not necessarily a sign of family pathology. All too often we ascertained that a so-called symptom-oriented approach, without engaging the family in a treatment 'for their own and the patient's good', suffices to bring about all by itself a considerable re-establishment of a positive family atmosphere (see Chapter 5). Termination of treatment at this point may be misleading, of course, both to the family and the therapist (the 'flight into health'), and continued contact for at least one year is needed (Moultrup, 1981). The need for family therapy stricto sensu will depend upon the functional analysis of the anorectic symptoms against the background of the family system. We have to analyze if and in which way the individual's behavior is maintained by family interaction, and, conversely, if and how the symptomatology of the identified patient maintains a dysfunctioning family system. This means that we must ask ourselves, first and foremost, questions such as : What function does this symptom serve or what gain is achieved through this symptom, both on the part of the patient and the whole family ? And in most cases we are unable to answer these questions until some therapeutic intervention has occurred or even after symptom removal. Therefore, treatment is the best way to test and reformulate hypotheses about the nature and function of a particular eating disorder. Ultimately, functional analysis is completed only at the end of a successful therapy. However, even when there is an indication for starting family therapy, the clinician must take into account family resistance to treatment, i.e. to change : "Such resistance results from the family's wish to deal with food rather than with the underlying dysfunctional family patterns that would shift the focus from the anorectic child and emphasize the marital discord" (Conrad, 1977, p. 493). The level of resistance in any family is affected by such factors as the health care system's response to the family, the way in which the referral is made, the availability of therapy, past experience with other therapists, conflicting schedules of family members, differing levels of sophistication about psychotherapy, and class or cultural differences (Anderson & Stewart, 1983). The therapist should be particularly aware of a history of previous treatment and should try to gain more information about the nature, type, progress and results of that effort. "Such information may help the new therapist to prepare to cope with resistance patterns, to avoid pitfalls and therapeutic errors, to assess the family's prior capacity to cope with certain types of interventions or maneuvers, and perhaps

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7

to predict whether the current therapy has any chance of success" (Moore & Coulman, 1981, p. 12). In the early stage of treatment, the therapist has to build up a strong bond with the family and, therefore, usually avoids confronting resistance directly in order to get a foot in the door. Anderson and Stewart (1983) state that "it is extremely important to start where the family is, never moving too quickly to a view of the problem that they cannot accept. The therapist must engage the family around what they have defined as the issue(s) that really matter to them" (p. 80). Hence, in the case of anorexia nervosa the therapist cannot afford to neglect or minimize the presenting problem of weight loss or eating disturbance (see also Chapter 5 on outpatient treatment). If family therapy is needed or wanted, we prefer to start it without naming it so in order not to enhance the resistance of family members who otherwise would feel accused or blamed for being the cause of the problem situation. We therefore ask the family to help us in resolving the problem of their ill child, a help they practically always are eager to offer ! This is, in fact, what we intend to do in all cases : to work with the family. When family therapy, on the contrary, is recommended or commenced in a direct and confronting way, the following problems may arise: "(1) The family may be unable to sustain the anxiety induced by the crisis approach and might thus choose to discontinue therapy. (2) An inadvertent, dangerous, and alarming reaction might occur in other family members as a result of confrontation and release of affects that have been pent up for a long time" (Barcai, 1971, p. 289). Family therapy or not, we have to meet the family's needs to the extent they 'ask' for it and at the level they are ready to accept it.

8.5. The Family of the Hospitalized Patient The approach we advocate here is guided by the idea that "when the anorexic patient is hospitalized, her family is 'hospitalized' also; that is, the family as well as the patient have certain needs to which the entire treatment team must respond in order to have maximum therapeutic impact" (Stern, Whitaker, Hagemann et al., 1981, p. 396). Ideally, the hospital staff should offer the patient as well as the family a 'holding environment', i.e. a combination of protection, clear but firm structure, reliability, support of initiative, and some tolerance of regression. Hospitalization breaks through a vicious circle of power struggles within the anorexic's family. The responsibility for the weight gain is shifted from the parents to the therapeutic team and, finally, to the patient. "In this way, the hospitalization offers a temporary 'time-out' period for the family in which conflicts over food are suspended, and the patient is given an opportunity to exert control in a positive direction and begin reclaiming her own body" (Hodas, Liebman & Collins, 1982, p. 135). It must be remembered, however, that physical separation from the parents Oparentectomy') can assuage a crisis at

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home, and will not automatically change the family system nor alter the patient's relationships with psychic representations of the parents (Sours, 1980). When an anorexia nervosa patient is admitted to the hospital, family members may scapegoat her as the problem in the family and thereby deny all tension within the parents' marriage or in the family at large. Anorexia nervosa in an adolescent intensifies the family's anxiety over developmental issues and possible splitting, and fuels continuous struggles over issues of autonomy and dependence. Hospitalization of the anorectic child can be then either threatening or reassuring for the family. In the former case staff members are viewed (or present themselves) as 'superparents' who have to repair what the real parents have done wrong, whereas in the second case the family feels relieved of a distressing responsibility which is temporarily accepted by 'experts' working in a competent and protective hospital environment (see also Chapter 10). The development of a working alliance among staff, patient, and family through which decisions can be realistically shared is one of the major tasks of the early part of treatment. The treatment staff, through its exercise of authority, can increase the capacity of family members to take responsibility for intrafamilial dynamics which become externalized through the anorexia nervosa and/or the subsequent hospitalization. "By managing authority within a consistently structured program, the staff can provide a 'safe' setting within which disavowed aspects of intrafamilial conflict can be mobilized for examination and integration" (Kolb & Shapiro, 1982, pp. 343-344). The stability and integrity of the treatment program and its boundaries, and the staffs capacity competently to exercise authority, provide models for parental behavior as well as protect the entire family from disruption as they proceed with the task of separation and individuation. Hospitalization and/or clinical improvement of the patient may precipitate a crisis in the parents' marriage previously stabilized by a common concern : the anorexia nervosa of their daughter. We often ascertain in such cases that, when the patient had been sent home on weekends too early in the treatment process, it was likely that the pathological family equilibrium had been reestablished, with continued enmeshment of the anorectic child in the marital conflict of the parents. In cases where parents are reluctant to discuss intrafamilial tensions, we sometimes 'manipulate' them, for instance by insisting that weekends could not be granted without the parents' participation in family meetings. On the other hand, weekends can offer the best opportunity to provoke some interactional conflicts between the parents and the hospitalized anorexic, especially when everything seems 'suspiciously quiet' both at home and in the hospital. In such cases hospitalization helps to conceal conflicts. A symptom of this situation may arise when a patient (deliberately) avoids the privilege of receiving company from the family or does not request a pass home for a weekend. Unusual changes on the weight curve just before or after contacts with the family are often clues for exploring covert interactional problems. Harper (1983) studied weight fluctuation in 25 adolescent anorexics during their hospitalization : 10 patients showed no association of weight loss and contact with parents,

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2 lost weight on contact with parents but only during, the first month of hospitalization, 8 did so for more than 1 month but eventually stabilized, and 5 lost weight consistently on contact with parents even after discharge. In an ingenious experiment using telemetric mobility monitoring of nocturnal activity, Foster and Kupfer (1975) demonstrated the impact of daytime family visits on a hospitalized anorexic's psychomotor activity recorded 8-12 hours later. Intrafamilial struggles may also become externalized in the relationships between family members and treatment staff (see also next paragraph). These externalizations should not be viewed merely as a resistance to treatment, but as an opportunity for the team to help family members understand aspects of their family tension (Shapiro & Kolb, 1979). Family reactions to the patient and hospital staff can be subdivided into three groups (Krajewski & Harbin, 1982): the overinvolved, the uninvolved, and the pseudo-involved family. In each of these family reaction types a variety of strategies are used to control the treatment process. The overinvolved family is enmeshed with the patient as well as with the ward staff. They may try to get more involvement in the decision making of the treatment team in order to obtain more control over the patient and to bring about a closer relationship between themselves and the patient. The uninvolved family, on the contrary, tries to control the staff in order to increase the distance between themselves and their hospitalized family member (they may, for instance, oppose discharge). Finally, the pseudo-involved family seemingly wants to be closely involved with the patient and the team, but when pushed to change, their ambivalence and wish for increased separation emerge. In our experience with hospitalized anorexia nervosa patients, the first type of family reaction is the most common and the second rather scarce. We always try to observe, as soon as possible, or to predict ahead qf time the type of family we are working with - there are, of course, also normally involved families - and to understand the motivation and rationale of their attitude, in order to have a better sense of what therapeutic strategies should be used and why. Finally, we wish to emphasize once more that we do not start from a 'defensive' point of view, suspecting that the family will somehow inevitably play an anti-therapeutic role. We also try to avoid uncritically generalized assumptions as to the 'pathological' nature of the family system. As mentioned before (Chapter 2), causal hypotheses related to 'anorexogenic' families are still to be critically tested and, as yet, they must be considered unproven (Yager, 1982). But this does not alter the fact that treatment plans for hospitalized anorexia nervosa patients which include an attempt to work with family interactions inevitably involve the treatment staff in the dynamics of the family process. "To the extent that parental turmoil surfaces and provides validation for the parents' fantasy that they will be exposed and blamed, it represents a crisis in treatment. Such crises may end by premature withdrawal from the program and another treatment failure added to the family's list. On the other hand, to the extent that the overt expression of parental psychopathology can be met with sensitivity and made part of the ongoing treatment process, it can relieve the focus on the adolescent and allow all family members to recognize their contributions to family strife" (Kolb & Shapiro, 1982, pp. 355-356).

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Families have to be considered as treatment resources rather than adversaries. This ought to be the basic attitude of the entire team, otherwise family therapy, even when indicated, may risk becoming a too easy response to (c)overt family problems that hamper treatment and thus frustrate hospital staff. Hence, indication for family therapy might just express the team's negative attitude ('scapegoating') towards the parents. Therefore, family therapy must be incorporated in an overall treatment approach which witnesses the entire team's concern with the well-being of both patient and family.

8.6. Parent Groups We consider it an axiom that treatment of adolescent anorexia nervosa patients requires parental support and involvement. The importance of positive parental involvement is particularly evident in hospital and residential treatment. It is, therefore, one of our basic principles that we will not admit an adolescent anorexic without parental willingness to support, cooperate with, and participate in the treatment process. Parents of anorexic or bulimic patients in residential or hospital treatment must cope with both the stress of the resultant separation and the burden of parenting a child now identified as severely disturbed or labeled as psychiatrically ill. Moreover, any shift of treatment focus, away from the individual patient and toward examination of family interactions, may prove threatening or psychologically painful for parents. It is no wonder that the treatment staff is faced with several negative parental reactions : ambivalence about the treatment, self-doubt and guilt about parenting abilities, shame over perceived exposure of personal liabilities (Rossman & Freedman, 1982). To cope with this stress, conjoint family or marital interviews are frequent components of residential treatment programs. Starting at a 'supportive' level, these meetings may progressively move to an 'explorative' and, finally, 'therapeutic' level, if necessary. Real family therapy is only needed when problem analysis reveals that it is crucial to alter family structure or marital interaction, or to aid parents to exercise responsible executive leadership roles. But even if necessary, family therapy is sometimes refused by the parents, especially in the beginning of residential treatment. So, for several reasons, parent counseling groups constitute an interesting and flexible alternative. When the first author (W.V.) in 1977 started with parent groups for hospitalized anorexia nervosa patients, the following major motives had led to that decision. 1. The drop-out problem (Vandereycken & Pierloot, 1983). In the formerly applicated 'orthodox' contingency management program (see Chapter 6), a number of premature discharges resulted as patients ran away or parents removed their children from the hospital against medical advice. We interpreted this phenomenon as our failure in establishing a positive and collaborative treatment relationship with the parents, a failure which seemed to be linked with the next issue.

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2. The deficient communication between treatment staff and parents. Apparently staff disregarded or inadequately responded to the following recurrent themes: (a) The parents' ambivalence about the treatment program ; parents seemed often perplexed about the nature of the residential setting (a psychiatric hospital) as well as the treatment program; they questioned their decision, feared negative consequences of the hospitalization ('stigma'), were skeptical of the treatment rationale or confused about some rules and events they experienced as unpredictable, unfair or even potentially harmful. (b) The parents' distress during treatment; the hospitalization and resultant separation arised an atmosphere of intrafamilial tension or even crisis; some parents felt isolated or left alone, apparently convinced that problems encountered with their anorectic child reflected unique and shameful family circumstances; they were particularly sensitive about being rejected and blamed as a scapegoat (the 'bad' parents as cause of the illness). The parent group was primarily aimed at giving support and information to distressed and perplexed parents. The counseling group was structured to provide a supportive, nonjudgmental and educational setting which focused on the shared experience of parenting an anorectic adolescent now admitted to a hospital treatment program. After several years of experience with such groups, we are struck by the fact that the group process and dynamics do not essentially differ from other counseling groups for parents of hospitalized adolescents (see Rossman & Freedman, 1982). Concerning anorexia nervosa patients, such parent counseling groups have been described first in France by Jeammet and coworkers (1971). Although they used a psychoanalytic framework, their conclusions after 8 years of experience (see Jeammet & Gorge, 1980) almost completely correspond with ours and those reported by Rose and Garfinkel (1980) in Canada. The group structure may vary considerably. The French authors' group meets once in three weeks for one and a half hour; it is an open group of 8 to 15 parents, with mothers outnumbering fathers by two to one. In the Canadian group ten sets of parents met bi-weekly for 18 months and the sessions lasted for 90 minutes. In our own treatment setting at Kortenberg, usually 16 to 30 parents meet every two weeks for one hour. Occasionally other family members, relatives, spouses, friends or acquaintances may attend the meetings. The group is led by the senior author (W.V.) who coordinates and supervises the total inpatient treatment without being directly involved in contacts with either patients or families. One or more team members serve as co-therapists. Rose and Garfinkel (1980) also engaged a successfully treated anorexia nervosa patient as a volunteer cotherapist. We neither select the group members nor require participation in the parent groups as a prerequisite to treatment, but we are persistent in inviting and encouraging the parents to join the group while emphasizing its importance both for them and the hospitalized patient. Moreover, we reinforce participation in the

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parent group in a way which proved to be very efficient and rewarding especially in the beginning of treatment: immediately after each meeting the participants are allowed an extra hour for visiting their hospitalized relative, regardless of the latter's evolution and related privileges (even if no other visits are allowed). With regard to the group process similar dynamics and recurrent themes appeared in the three groups mentioned above. In the beginning of a closed group or with the addition of newcomers in an open group, parents seek information about the etiology, treatment and prognosis of anorexia nervosa. Experiences of living together with an anorectic family member are compared, similarities and differences of illness history, past and current behavior of the patient are discussed. Senior group members are encouraged by the therapists to take over the educative role of 'experts' in this matter. We repeatedly stress the fact that parents have much more to learn from each other than from us, because they are all emotionally involved whereas we observe things from a more neutral and distant point of view. But this does not alter the fact that the therapists now and then take a didactic stance especially emphasizing the importance of cooperation between the family and the therapeutic team. With regard to the ever-recurring question about the 'cause' of the eating disorder, we primarily attempt to relieve guilt feelings in the parents. They are encouraged to verbalize feelings of demoralization, guilt and ambivalence arising from both past and current problems in parenting a disturbed child. We stress that these feelings reflect their special concern, interest, and emotional involvement which we would like to use now as 'therapeutic instruments' for the future. In the same way, parental criticism about the therapeutic program is relabeled in a positive sense as their willingness to participate constructively in our attempts to help their child. Time and again we emphasize our need to be supported and trusted by the patient's family. Our central message is : "Our professional knowledge and your personal involvement should be blended into one powerful therapeutic fuel whose potential energy will be strong enough to induce the necessary change process if it is used in one and the same direction and for the same purpose". By such an approach we are in fact indirectly modelling the importance of cohesion in each parent couple. When a positive atmosphere based upon a collaborative working relationship is created within the group, parents appear to be more willing to discuss issues of marital and family interaction, i.e. to look behind the symptom and to search for its psychological meanings (e.g. attachment-autonomy conflicts). We generally avoid direct confrontation and prefer to introduce a psychological theme in a rather indirect and seemingly didactic way (e.g. "In some cases we discovered that anorexia nervosa means..."). In the discussion senior group members often act as co-therapists, and parents are more likely to accept direct confrontation and reinterpretation from each other than from the group leaders, the 'real' therapists. Similarly, senior members are more convincing when they speak in defense of the therapeutic program and its rules or consequences for the family. Hence, they usually have more success and influence than we in dissuading other parents (mostly newcomers) from taking their child home against medical

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advice (our drop-out rate significantly decreased since we structured a family oriented approach in this way). "Regardless of the particular family treatment approach, parent counseling groups seem especially helpful in providing isolated, demoralized parents with the opportunity to experience gradual increments in self-esteem within a supportive treatment setting. The group offers a network of helping relationships within which the parents unburden themselves, obtain guidance and advice from both other parents and the leaders, and in turn experience the gratification of having something to offer to others" (Rossman & Freedman, 1982, p. 404). The group appears to be a useful treatment modality to aid parents to cope with ambivalent feelings about hospital treatment, to gain insight into the psychological and interactional meanings of the eating disorder, to realize the need of the family's participation in the change process, to strengthen collaborative relationships between parents and professional staff, and to enhance motivation for engaging in family therapy if necessary. An alternative, integrating the dynamics of group therapy and family therapy, is multiple family therapy, i.e. the treatment of several families simultaneously through the vehicle of a group meeting led by therapists. Here, the often uncanny accuracy of group members' observations about other families' dysfunctional interactions and the willingness to accept and utilize these comments, constitute a unique and powerful therapeutic process which may help to solve problems that are inherent in the hospitalization of a family member: family alienation, fragmentation, isolation, non-compliance and exacerbation of enmeshment (McFarlane, 1982).

8.7. Conclusion The answer to this chapter's title question may be summarized as follows : unlike Casper (1982), we do not think that "family therapy is mandatory", but a family oriented approach is ! The difference lies, of course, in the word 'therapy' which somehow presupposes that something is wrong in the family and has to be changed then. We prefer to work with the family in a constructive and collaborative w a y : we need their cooperation and they need at least our support and understanding. Functional problem analysis during the treatment of the 'identified patient' will reveal in which way the eating disorder is interwoven with family (dys)functioning, and to what extent and at which level interventions in the family system are necessary and possible. Looney et al. (1980, p. 507) cautioned "that a myopic focus on any single model can lead to the unfortunate situation in which treatment unit becomes a self-contained microcosm". Therefore, we would not like to treat an anorexia or bulimia patient by having to choose only one theoretical approach or one therapeutic model. The multidimensional perspective we defend in this book calls for a multifaceted eclectic approach tailoring the treatment program to individual needs and incorporating aspects of intervention at all levels of

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d y s f u n c t i o n (biologic, p s y c h o l o g i c , a n d social). T h e n , f a m i l y therapy is but o n e o f the available therapeutic i n s t r u m e n t s (see also Garfinkel & Garner,

1982;

H e d b l o m , H u b b a r d & A n d e r s e n , 1982; Parker, Blazer & W y r i c k , 1977; P e a k e & Borduin, 1977; Petzold, 1979; Piazza, Piazza & Rollins, 1980; S w i f t , 1982). Generally speaking, f a m i l y t h e r a p y is certainly indicated for y o u n g e r patients w h o are s o i m m e r s e d in the f a m i l y s y s t e m that their age-appropriate adolescent d e v e l o p m e n t is seriously h a m p e r e d . If the patient is in her late a d o l e s c e n c e a n d / or is further a l o n g in her p s y c h o s e x u a l d e v e l o p m e n t , individual p s y c h o t h e r a p y or g r o u p s t h e r a p y m a y be t h e treatment o f c h o i c e . But there are, o f c o u r s e , a n u m b e r o f useful variations, s u c h a s o c c a s i o n a l m e e t i n g s o f the a d o l e s c e n t a n d o n e o f his parents (or siblings), or periodic m e e t i n g s w i t h parents w h i l e s e e i n g the a d o l e s c e n t individually or, last but n o t least, parent c o u n s e l i n g groups. T h e c h o i c e s h o u l d b e flexible a n d d e t e r m i n e d b y c i r c u m s t a n c e s w h i c h h a v e to be regularly re-evaluated during the treatment process.

References Anderson, C M. & Stewart, S. (1983), Mastering Resistance. A Practical Guide to Family Therapy. N e w York : Guilford Press. Barcai, A. (1971), Family therapy in the treatment of anorexia nervosa. American Journal of Psychiatry, 128 : 286-290. Buddeberg, B. & Buddeberg, C. (1979), Familientherapie bei Anorexia nervosa (Family therapy in anorexia nervosa). Praxis der Kinderpsychologie und Kinderpsychiatrie, 28 : 37-43. Caille, P., Abrahamsen, P., Girolami, C. & S0rbye, B. (1977), A systems theory approach to a case of anorexia nervosa. Family Process, 16 : 455-465. Casper, R.C. (1982), Treatment principles in anorexia nervosa. Adolescent Psychiatry, 10:431-454. Collins, M., Hodas, G.R. & Liebman, R. (1983), Interdisciplinary model for the inpatient treatment of adolescents with anorexia nervosa. Journal of Adolescent Health Care, 4 : 3-8. Compernolle, T. (1982), Adequate joint authority of p a r e n t s : A crucial issue for the o u t c o m e of family therapy. In : Kaslow, F.W. (Ed.), The International Book of Family Therapy. N e w York : Brunner/Mazel, pp. 245-256. Conrad, D.E. (1977), A starving family. An interactional view of anorexia nervosa. Bulletin of the Menninger Clinic, 41 : 487-495. Cremer, K.J. (1980), Zur psychiatrischen Betreuung von Kranken mit Anorexia-nervosaSyndrom unter Berücksichtigung der Kommunikationsunterbrechung (The psychiatric approach to anorexia nervosa patients in the view of the interruption of communication). Praxis der Psychotherapie und Psychosomatik, 25 : 259-267. Elkaim, Μ. (1982), U n e approche systemique de quelques cas d'anorexie mentale (A systems approach to some cases of anorexia nervosa). Feuillets Psychiatriques de Liege, 15 : 252-265. Fishman, H.C. (1979), Family considerations in liaison psychiatry. A structural family approach to anorexia nervosa in adults. Psychiatric Clinics of North America, 2 : 249-263. Foster, F.G. & Kupfer, D.J. (1975), Anorexia nervosa : Telemetrie assessment of family interaction and hospital events. Journal of Psychiatric Research, 12 : 19-35.

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TO BE TREATED ?

Garfinkel, P.E. & Garner, D.M. (1982), Anorexia Nervosa. A Multidimensional Perspective. New York : Brunner/Mazel. Harper, G. (1983), Varieties of parenting failure in anorexia nervosa: Protection and parentectomy, revisited. Journal of the American Academy of Child Psychiatry, 22 : 134-139. Hedblom, J.E., Hubbard, F.A. & Andersen, A.E. (1981), Anorexia nervosa: A multidisciplinary treatment program for patient and family. Social Work in Health Care, 7(1): 67-86. Hodas, G. Liebman, R. & Collins, M.J. (1982), Pediatric hospitalization in the treatment of anorexia nervosa. In : Harbin, H.T. (Ed.), The Psychiatric Hospital and the Family. Jamaica (NY): Spectrum Publications, pp. 131-141. Jeammet, P. & Gorge, A. (1980), Une forme de therapie familiale : Le groupe des parents. Bilan de huit annees de fonctionnement d'un groupe ouvert de parents d'anorexiques mentales adolescentes (A form of family therapy : The parent group. Eight years of experience with an open parent group of adolescent anorexia nervosa patients). Psychiatrie de I'Enfant, 23 : 587-636. Jeammet, P., Gorge, Α., Zweifel, F. & Flavigny, Η. (1971), Etude des interrelations familiales de l'anorexique mentale et d'un groupe de psychotherapie des parents (A study of family relationships in anorexia nervosa and of a psychotherapeutic parent group). Revue de Neuropsychiatrie Infantile, 19 : 691-708. Kolb, J.E. & Shapiro, E.R. (1982), Management of separation issues with the family of the hospitalized adolescent. Adolescent Psychiatry, 10 : 343-359. Krajewski, T. & Harbin, H.T. (1982), The family changes the hospital ? In : Harbin, H.T. (Ed.), The Psychiatric Hospital and the Family. Jamaica (NY): Spectrum Publications, pp. 143-154. Lagos, J.M. (1981), Family therapy in the treatment of anorexia nervosa : Theory and technique. International Journal of Psychiatry in Medicine, 1 1 : 291-302. Liebman, R., Sargent, J. & Silver, M. (1983), A family systems orientation to the treatment of anorexia nervosa. Journal of the American Academy of Child Psychiatry, 22 : 128-133. Looney, J.G., Blotcky, M.J., Carson, D.I. & Gossett, J.T. (1980), A family-systems model for inpatient treatment of adolescents. Adolescent Psychiatry, 8 : 499-51 1. Madanes, C. (1982), Strategic family therapy in the prevention of rehospitalization. In : Harbin, H.T. (Ed.), The Psychiatric Hospital and the Family. Jamaica (NY): Spectrum Publications, pp. 49-77. McFarlane, W.R. (1982), Multiple-family therapy in the psychiatric hospital. In : Harbin, H.T. (Ed.), The Psychiatric Hospital and the Family. Jamaica (NY): Spectrum Publications, pp. 103-129. Minuchin, S., Rosman, B. & Baker, L. (1978), Psychosomatic Families. Anorexia Nervosa in Context. Cambridge (Mass.): Harvard University Press. Moore, J.A. & Coulman, M.U. (1981), Anorexia nervosa : The patient, her family and key family therapy interventions. Journal of Psychiatric Nursing, 19(5): 9-14. Moultrup, D, (1981), Composition and length of treatment in anorexia nervosa. In : Gurman, A.S. (Ed.), Questions and Answers in the Practice of Family Therapy. New York : Brunner/Mazel, pp. 133-137. Overbeck, A. (1979), Zur Wechselwirkung intrapsychischer und interpersoneller Prozesse in der Anorexia nervosa: Beobachtungen und Interpretationen aus der Therapie einer Magersuchtfamilie (On the interaction of intrapsychic and interpersonal processes in anorexia nervosa: Observations and interpretations form the treatment of an anorexia nervosa family). Zeitschrift für Psychosomatische Medizin und Psychoanalyse, 25 : 216-239. Parker, J.B., Blazer, D. & Wyrick, L. (1977), Anorexia nervosa : A combined therapeutic approach. Southern Medical Journal, 70 : 448-452.

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Peake, T. & Borduin, C. (1977), Combining systems, behavioral and analytical approaches to the treatment of anorexia nervosa : A case study. Family Therapy, 4 : 49-56. Petzold, E. (1979), Familienkonfrontationstherapie bei Anorexia Nervosa (Family Confrontation Therapy in Anorexia Nervosa). G ö t t i n g e n : Vandenhoeck & Ruprecht. Piazza, E., Piazza, N. & Rollins, N. (1980), Anorexia n e r v o s a : Controversial aspects of therapy. Comprehensive Psychiatry, 21 : 177-189. Pina Prata, F.X. (1980), Analyse differentielle du systeme rigide de l'anorexie mentale dans l'optique systemique de la therapie familiale (Differential analysis of the rigid system of anorexia nervosa patients f r o m the family therapeutic systems viewpoint). Therapie Familiale, I : 145-164. Rose, J. & Garfinkel, P.E. (1980), A parents' g r o u p in the management of anorexia nervosa. Canadian Journal of Psychiatry, 25 : 228-233. R o s m a n , B.L., Minuchin, S. & Liebman, R. (1975), Family lunch session: An introduction to family therapy in anorexia nervosa. American Journal of Orthopsychiatry, 45 : 846-853. Rossman, P.G. & Freedman, J.A. (1982), Hospital treatment for disturbed adolescents : The role of parent counseling groups. Adolescent Psychiatry, 10 : 391-406. Selvini-Palazzoli, M.S. (1974), Self-Starvation. From the Intrapsychic to the Transpersonal Approach to Anorexia Nervosa. London : Chaucer ( N e w Y o r k : Jason Aronson, 1978). Shapiro, E.R. & Kolb, J.E. (1979), Engaging the family meeting. Adolescent Psychiatry, 1 : 322-342. Stern, S., Whitaker, C A., Hagemann, N.J., Anderson, R.B. & Bargman, G.J. (1981), Anorexia nervosa : The hospital's role in family treatment. Family Process, 20 : 395-408. Swift, W.J. (1982), Family therapy and anorexia n e r v o s a : The hospital phase. I n : G u r m a n , A.S.(Ed.), Questions and Answers in the Practice of Family Therapy. Volume 2. N e w York : Brunner/Mazel, pp. 187-191. Vandereycken, W . (1980), Tussen mythen en feiten. Diagnose en behandeling van het zogenaamde anorexia nervosa gezin (Between myths and facts. Diagnosis and treatment of the so-called anorexia nervosa family). Tijdschrift voor Relatieproblematiek, 3 : 223-256. Vandereycken, W. & Pierloot, R. (1983), Drop-out during in-patient treatment of anorexia n e r v o s a : A clinical study of 133 patients. British Journal of Medical Psychology, 56 : 145-156. Weber, G. & Stierlin, H. (1981), Familiendynamik und Familientherapie der Anorexia nervosa-Familie (Family dynamics and family therapy of the anorexia nervosa family). In : Meerman, R. (Ed.),Anorexia Nervosa. Ursachen und Behandlung. Stuttgart: Ferdinand Enke, pp. 108-122. Yager, J. (1981), Anorexia nervosa and the family. I n : Lansky, M.R. (Ed.), Family Therapy and Major Psychopathology. N e w York : G r u n e & Stratton, pp. 249-280. Yager, J. (1982), Family issues in the pathogenesis of anorexia nervosa. Psychosomatic Medicine, 44 : 43-60.

168

Chapter 9

How should specific problems be handled ? 9.1. Amenorrhea, infertility, and contraception 9.2. Bulimia 9.3. Vomiting and abuse of laxatives/diuretics References

9.1. Amenorrhea, Infertility, and Contraception Although amenorrhea - the cessation of menses or inhibition of menarche - is often viewed as a major clinical sign of anorexia nervosa, it is not an essential diagnostic criterion according to DSM-III (see 1.2). It still remains, however, a puzzling symptom that might relate to a primary hypothalamic dysfunction or a 'vulnerable' hypothalamus which, in response to environmental stress, develops an impairment in the regulation of the secretion of gonadotropin-releasing hormone (see 2.5.). The documented disturbances in the hypothalamic-pituitary-ovarian system in anorexia nervosa patients are : (I) a decrease in estrogen secretion, (2) a decrease in pituitary secretion of LH (luteinizing hormone), (3) an 'immature' (prepubertal) pattern of LH secretion, (4) a decrease in LH response to estrogen stimulation, and (5) a shift of estradiol metabolism towards a disproportionate increase in cathecholestrogens (Halmi, 1982). Frisch (1977) proposed the critical body -weight hypothesis which states that anorectic amenorrheic females have lost the body weight that may be necessary for maintenance of menses (secondary amenorrhea), or do not have sufficient body weight for initiation of menses (primary amenorrhea). According to Frisch, the weight threshold, both for onset and for restoration of menses, corresponds to the 10th percentile of weight for height (i.e., approximately 87 % of average weight for height for age, the so-called 'ideal body weight'). Several studies, however, found that body weight was not a significant causal factor for the occurrence of amenorrhea in anorexia nervosa patients (Falk & Halmi, 1982). Menstrual cycles may cease without (or before) weight loss in onefifth to one-third of anorexia nervosa patients, and may not resume even though the minimum required body weight is attained. Psychological factors appear to be at least equally important in affecting the maintenance and onset of menstrual cycles. So, we do not know yet what really causes amenorrhea in these patients. Although it is often correlated with weight loss, the presence of anorectic behaviors seems to emerge as a stronger correlative factor than body weight. Falk and Halmi (1982) found that the amenorrheic anorexia nervosa patients

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whose weight has been restored, continued to be preoccupied with food and did exhibit many of the symptoms normally associated with anorexia nervosa of their weight. The menstruating patients, on the contrary, appeared to represent a group of individuals really recovered from their illness. Recently, Miles and Wright (1984) reported data which indicate that the hormonal status in anorexics might be closely linked to conflicts regarding adjustment to the adult role. It has also been shown that psychological factors, especially situations of stress, are primary in the development of functional secondary amenorrhea in nonanorectic women, despite the high incidence of weight disturbances among them (Brown et al., 1983). And in the chapter on prevention, we have already mentioned the deterioration of menstrual status among ballet dancers and female athletes (see 3.6). A relatively late age of onset of menarche among ballet dancers has been reported, but it is not clear whether this delay is due to the dancer's obsession with her body and her need to be thin, so that her weight fails to reach a 'critical' level (Frisch, 1983), or if the high energy output or endocrine changes associated with strenuous exercise is the main factor. Abraham et al. (1982) established that physical exercise, rather than a critical lean/fat ratio, is the main factor influencing menstrual disorders among ballet dancers. Whatever the explanation for its occurrence, amenorrhea is very often one of the only symptoms that the patients perceive as needing treatment and the reason why they (or their worried mothers) consult a physician. In this way the gynecologist may well be the first and sometimes only professional to be consulted by anorexia nervosa patients. Whereas the psychiatrist is unlikely to request many diagnostic tests, his colleagues may pursue exhaustive investigations of endocrine function which are time-consuming and may delay the start of correct treatment (Editorial, 1979) Indeed, the best form of treatment for amenorrhea in anorexics is to get the patient back to a normal body weight, and to help her accept it together with a positive body image. The spontaneous resumption of menses is then not only an important sign in the recovery process, but also frequently a situation of increased psychological tension that may elicit the return of anorectic symptoms. Our philosophy regarding amenorrhea is ? wait and see, and do not interfere pharmacotherapeutically unless there are solid reasons for doing it. These reasons are : primary amenorrhea in an anorexic of 18 years or more, or persisting secondary amenorrhea in an otherwise recovered patient one year after treatment. In any case, as a general rule, one should wait at least 6 months after the attainment of a normal weight level before trying to treat the amenorrhea with pharmacotherapeutic aids. Hormone treatment should only be dealt with by a specialist because of the danger of potential side effects caused by the prescribed drugs. The form of treatment for amenorrhea in anorexia nervosa is fundamentally the same as for any hypothalamic amenorrheic disorder. First of all, endocrine assessment should be carried out (laboratory studies should be directed toward

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HOW SHOULD SPECIFIC PROBLEMS

BE HANDLED ?

eliminating the possibility of pathologic problems, i.e., pituitary adenoma, gonadal dysgenesis; dynamic testing using gonadotropin-releasing hormone is not useful except for experimental purposes). Although the use of contraceptive medication is not detrimental, one should keep in mind that resumption of menstrual cyclicity is often delayed after discontinuation of the oral contraceptive medication. Nevertheless, in those patients who are likely to have sexual contacts we prefer to 'play safe'. A good alternative to the contraceptive pill is an I.U.D. (intrauterine device). The ability to induce withdrawal bleeding by administration of a progestational agent, such as medroxyprogesterone acetate, at 2- to 3-months intervals, is a positive sign since it implies that some endogenous estrogen production, and therefore endogenous gonadotropin releasing hormone stimulation, is occurring (Eisenberg, 1981). The use of a progestational agent will also lessen the likelihood of the development of endometrial hyperplasia. The success of treatment with clomiphene citrate depends on the level of estrogen after weight restoration : the chances of restarting ovulation with a normal level of estrogen are 4 times as high as in the case of a persistent low estrogen level, in which case the chances are 1 in 2. Despite this, the clomiphene citrate treatment is usually favored as the initial form of treatment in both cases, i.e. whether the estrogen level is low or normal. It is important to be aware of the fact that treatment with clomiphene can lead to an overstimulation of the ovaries with cyst formation and possibly acute symptoms in the lower abdominal region caused by an excessive production of gonadotropin. For this reason, treatment with clomiphene citrate should only be carried out under the supervision of a specialist. In the event that the patient is infertile as a result of anovulation, she is a good candidate for induction of ovulation by clomiphene citrate if she is above 90 % of her ideal body weight and shows serum estradiol levels comparable to those of normally cycling women in the early follicular phase (Eisenberg, 1981). If this measure fails and if the woman wants to have children, it is advisable to wait several months before attempting further diagnostic and therapeutic measures. In the case of infertility, in addition to an examination of the patient's condition (after weight restoration, of course), a medical examination of the male partner should also be undertaken. If clomiphene fails to achieve ovulation, induction of ovulation may be successfully accomplished by the use of human menopausal gonadotropins and human chorionic gonadotropin (hMG-hCG). And if this form of treatment fails, the gynecologist can still use the LHRH-hCG pump, i.e. chronic intermittent administration of gonadotropin releasing hormone in conjunction with human chorionic gonadotropin, a procedure which has recently shown promise in the production of follicular maturation, ovulation, and pregnancy in women with very low serum estradiol levels (Eisenberg, 1981). Once pregnancy is achieved, the patient should be followed closely in order to ensure that the weight will remain within normal ranges. As mentioned before (see 3.6), pregnancy may trigger anorectic or bulimic symptoms, eventually associated with excessive vomiting. But if these problems can be avoided and properly handled, the antepartum, labor and delivery, and postpartum course are not usually adversely affected by the past history of anorexia nervosa (Eisenberg,

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1981). Nevertheless, Danish researchers have found a higher perinatal mortality in the offspring of (former) anorexia nervosa patients than in a control group (Brinch et al., 1982).

9.2. Bulimia Bulimia appears to represent the worst fears of an anorexic come true. The individual loses control of food intake and literally goes 'wild', eating huge amounts of rich food rapidly. In order to keep the body weight under control, these binge eating episodes result either in more severe dieting or in efforts to disgorge the ingested matter. In most cases, vomiting is initially forced either by a finger down the throat or by use of a foreign body, but later on this can accomplished reflexively. Approximately 45 % of diagnosed anorexics, at some time or another, engage in such bulimic practices (Lowenkopf, 1983). Figure 9-1 shows some major factors contributing to the development of bulimia in (former) anorexia nervosa patients (see also, Figure 2-5). Re-established control

Bulimia nervosa (7)

Avoidance of weight gain

(8)

Avoidance of other problems

(9)

1 Bingeing 2. Vomiting a n d / or purgation

Hospitalization 1. Refeeding 2. Medication

Loss of control over food intake

3. Imitation of others

(5)

Food craving/ preoccupation (3)

Low body weight Nutritional disorder Other physiological

Physiological deprivation

Other psychological ieasons

(2)

Amenorrhea Anorexia nervosa