Mental health articles

Arguably this is one of the most difficult phases to bridge in the management of anorexia nervosa. The first hurdle usually is for carers, friends, teachers and colleagues to express their concerns for the individual’s health and to suggest that it is important to seek help. The interpersonal process of the meeting is a critical factor, which can have a profound impact on the process of diagnosis and management. Diagnosis should not be too difficult a process especially if a corroborative history is taken from informants.

The differential diagnosis includes rarer conditions such as brain tumours in children, and thyroid disease and inflammatory bowel disease. Thus simple investigations such as the erythrocyte sedimentation rate and thyroid function test and a physical examination are sufficient. However, delivering the diagnosis to the individual and negotiating a plan of management is a delicate procedure. The therapeutic alliance is critical. First the individual needs to engage in the process of change. It is usual in the first medical encounter for the patient to have recognized a health problem and to come to the health professional for help. This rarely occurs in anorexia nervosa. Instead in the classical case there is a rejection of the sick role and denial of disease. Lasegue illustrated this by one of his patient’s remarks ‘I do not suffer therefore I am well’. Thus if we use the concepts of the transtheoretical model of change we f ind that people with anorexia nervosa coming to a health professional are usually in the precontemplation or contemplation stage of readiness to change. That is they do not want to change (precontemplation) or they are in two minds about the need to change (contemplation). Figure 16.1 illustrates the various stages of change that are common in anorexia nervosa and also indicates what type of therapeutic approach might be helpful. The exchange of information, the assessment of risk and the development of a management plan need to be mapped onto this template. People with anorexia nervosa present to a health professional to appease close others who are all too aware of the signs of overt signs of illness. It is the carers who are concerned. These divergent views between the person with anorexia nervosa and those of her family and professional helpers have to be negotiated in order to attain a satisfactory outcome of treatment rather than a protracted tug of war. The interpersonal process within the first encounter needs to take this ambivalence or indeed resistance into account. The skills of motivational interviewing are invaluable for such an exchange. The theoretical concepts included in models of health behaviour can inform the exchange. Two elements are common to most of these models. The first is the importance of change to the individual and the second is confidence that change is possible. The importance of change relates to the decisional balance of the pros and cons about change. People with anorexia nervosa usually have some form of positive reinforcement (extrinsic or intrinsic) or avoid aversive situations by maintaining their illness. They also have little confidence in their ability to find other solutions to their problems, other than restricting their life. It is useful to acknowledge and elicit these maintaining factors in the first phase of information exchange. The meta beliefs about anorexia nervosa include the reinforcing features described above.

However, starvation itself results in secondary consequences that can maintain the illness. Thus, starvation itself can lead to a loss of hunger and a drive for overactivity as exemplified by animal models. The negative mood state can start a vicious circle in which not eating is seen as a solution to this stress. The switch of thought content from problems to food can be reinforcing for those who use avoidance strategies as a coping reaction to stress. In some cases the social consequences can merely exaggerate the type of stress that triggered the onset of the illness.

Tags: anorexia nervosa, management, treatment