Advice on management

It is not possible for the clinician to confine his treatment of anorexia nervosa to those methods which have been proved to be effective. Main obstacle to treatment: the patient's avoidance of treatment

The avoidance of treatment by the patient is part and parcel of anorexia nervosa. There have been attempts to predict the likely level of the patient's compliance with treatment. For example, a 'transtheoretical model of change' is aimed at improving the patient's motivation by overcoming ambivalence while at the same time avoiding confrontation/124) Different stages in the patient's approach to treatment have been recognized: precontemplation, contemplation, preparation, action, maintenance, and relapse. Motivational enhancement therapy is at an early stage of development but a practical guide is available. (125)

At our present level of knowledge it is simplest to ascertain the patient's attitude to treatment through the mental state examination. A revealing question is to ask her at the initial interview what weight she would be willing to reach. At this stage it is best to refrain from challenging the patient's weight threshold, even though it will be well below a reasonable therapeutic goal. Having ascertained the limited degree of compliance on the patient's part, the clinician needs to develop a strategy to improve it gradually as treatment proceeds. It is poor clinical practice to place all the onus on the patient herself for accepting or rejecting a package of treatment at the first interview, or even at a later stage. 'Engaging' the patient in treatment is an essential part of most psychotherapeutic methods including cognitive-behavioural therapy/!26) Another tactic for improving the patient's co-operation is to enlist the help of close members of the family. In the case of young patients it is essential to form a therapeutic alliance with the parents. Young patients are likely in any case to require a form of family treatment.

Breaking Bulimia

Breaking Bulimia

We have all been there: turning to the refrigerator if feeling lonely or bored or indulging in seconds or thirds if strained. But if you suffer from bulimia, the from time to time urge to overeat is more like an obsession.

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