Mental health articles

Given the multiple routes to anorexia, the optimal emphasis of treatment may vary considerably across individuals. Potential interventions include cognitive behavioural therapy, family therapy, insight-oriented psychotherapy, with each being complementary rather than competitive interventions. Interventions can be considered in two stages: fi rst, initial treatment, usually in hospital, focusing on weight gain; and second, longer-term outpatient treatment focusing on sustained cognitive and behavioural change.

Promoting weight gain

In-patient care may be necessary where an individual’s weight is seriously compromised: that is, less than 75 per cent of ‘normal’ for an individual’s height and age. Interventions in hospital usually focus on providing extrinsic rewards for weight gain. This operant-based process involves gaining pre-specifi ed rewards for pre-specifi ed gains in weight, the most valued of which may be discharge from hospital on achieving a target weight. This avoids the danger of rewarding food intake, which may be subsequently vomited up and is therefore ineffective. Some years ago, the nature of these rewards included access to a telephone or television. These are now considered to be basic rights, and removal of them would infringe such rights. Accordingly, the ‘rewards’ for eating are now typically defi ned by the individual and are more than the basic elements available to all in-patients. They may include increased social privileges, access to visitors, and exercise privileges. Calorifi c intake is gradually increased over time: too high an initial calorie intake may result in refusal to consume the calories. Nurses may also educate the individual about anorexia and provide more informal support and encouragement. Critical here is the reassurance that weight gains made at this time will not be translated into becoming overweight in the longer term. In a recent study of this approach, from a research group in Milan, Gentile et al. reported that of 99 individuals, 18 prematurely interrupted their treatment and 75 continued intensive inpatient treatment until they achieved their required weight. Thirty-two people with severe malnutrition were fed through a nasogastric tube until their weight increased and ‘they started to cooperate with treatment’. The issue of whether people should in essence be ‘force fed’ is a very live issue in anorexia, and is particularly associated with the risk to health of continued non-eating as well as having other psychological co-morbidities.

 

This debate has focused, in particular, on the competence or otherwise of people with anorexia to make what are truly life and death decisions. Some clinicians have argued that the majority of people with anorexia are mentally competent to make decisions about whether or not to eat. As a result, they suggest that it is inappropriate to treat them against their wishes, even if this leads to their death. Others, while accepting that force-feeding is inhumane and unacceptable, have pointed out that both it and other active treatments can be legally used with people with anorexia in extremis, as they are not mentally competent to make decisions that may result in their death. Treasure  identifi ed four general principles that defi ne whether an individual is competent under the law to make therapeutic choices or to refuse treatment. They must be able to do the following:

take in and retain information relevant to their decision and understand the likely consequences of having or not having the treatment believe the information weigh the information in the balance as part of the process of arriving at a decision recognize they have a health problem and take action to remedy their condition.

According to Treasure, individuals with anorexia do not conform to these criteria and are there fore deemed, under law, incompetent to make medical decisions that may endanger their life. Accordingly, doctors have the right to treat the individual without their consent. This argument is in accord with legal precedents that have stated that compulsory treatment of people with anorexia, including force-feeding, is both legal and may be necessary on occasion.

Tags: anorexia, anorexia nervosa, interventions, nervosa, nursing