Eating disorders: Psychosocial treatment
Although people with eating disorders may seem at first to have an encyclopedic knowledge of nutrition, it is frequently infused with mythology and morality. And despite an intellectual awareness of eating disorders, patients may feel terribly alone and unique in their problems.
There are many accounts of eating disorders and strategies for coping with them that patients and families can access and identify with. These experiences can help people see the connections between the symptoms that bother them (trouble sleeping or concentrating, mood instability) and their eating disorder, which may increase motivation to get better.
Evidence shows that patient self-help books and guided self-help (regular meetings with the primary care provider) can make a difference, primarily with binge eating disorder and, to a lesser extent, bulimia nervosa. The best of these books are:
- McCabe. R.I., McFarlane, T.L. & Olmsted, M.P. (2004). The Overcoming Bulimia Workbook. Oakland, CA: New Harbinger. (all authors Canadian!)
- Cooper, P. (2009). Overcoming Bulimia Nervosa and Binge Eating: A Self-Help Guide Using Cognitive-Behavioural Techniques (2nd ed.). New York: Basic Books.
- Fairburn, C.G. (1995). Overcoming Binge Eating. New York: Guilford Press.
In addition, books exist for families of adolescents with eating disorders, such as:
- Katzman, D.K. & Pinhas, L. (2005). Help for Eating Disorders: A Parent's Guide to Symptoms, Causes and Treatments. Toronto: Robert Rose. (from the Hospital for Sick Children)
- Lock, J. & Le Grange, D. (2005). Help Your Teenager Beat an Eating Disorder. New York: Guilford Press.
Monitoring and nutrition
You can play a key role not only in monitoring progress and complications but also in liberating people from the tyranny of bathroom scales. You should assume responsibility for regular weight monitoring and have the patient (and often reluctant family) throw out the home's scale. This makes weighing less frequent and patients less able to regulate their self-esteem and self-appraisal by minor weight fluctuations.
For the underweight patient, you need to establish a healthy weight range (not a single number because weight naturally fluctuates) that can be maintained without undue dieting and that will allow a return of regular menses.
Simply asking patients to keep a regular diary of their eating and associated behaviour can be informative and transformative. It tells you what actually goes on, and the patients begin to see the connections between food, weight, emotions, thoughts and behaviours. Many self-help books provide templates for this kind of self-monitoring.
Restoring regular eating is an important therapeutic goal. Patients who feel that a good day is one where they have not "given in" to hunger during the day are far more likely to binge eat at night, perpetuating the cycle of restriction and loss of control. Realizing that their fear of gaining significant weight from a single meal is not realistic will help to reduce anxiety about eating and the fear that it will become a runaway train.
A rate of weight gain of 0.5–1.0 kg per week is appropriate in anorexia nervosa when moving toward a target weight range.
Cognitive-behavioural therapy (CBT) and interpersonal therapy (IPT) are the most validated treatments for bulimia nervosa and binge eating disorder. Many primary care providers, and even some psychiatrists, feel insufficiently skilled in these modalities, but training in these approaches is becoming more popular as continuing education.
CBT is particularly appealing because it takes a common-sense, here-and-now approach, requires patients to do homework and challenge their assumptions, and focuses on behavioural change. It can also be effective in the primary care management of depression, anxiety, irritable bowel syndrome and insomnia. Community-based social workers, psychologists, occupational therapists and counsellors skilled in CBT could be enlisted to the treatment team.
For anorexia nervosa, the evidence base for psychotherapy or other treatments is much weaker. There is a role for family therapy after weight restoration in adolescents.