At one time inpatient programmes were run on behavioural principles, but in recent years 'lenient' programmes have found favour. (H8) The great advantage of treating a patient in a specialist eating disorders unit programme is the certainty that considerable benefit will accrue, including a substantial gain in weight, if the patient can be persuaded to remain in hospital/132)
Inpatient treatment will include a wide range of psychotherapeutic interventions (individual, group, and family) as well as occupational therapy and an educational programme. But the sheet anchor of successful treatment is a well-trained nursing staff working as a team. The role of the medical staff is subsidiary and consists of maintaining a high level of expectation that the patient's weight will be restored to a normal (or healthy) level. It is necessary to give the nursing staff moral support so that they can develop their confidence and skills.
There are two main components to the nurses' treatment: their psychotherapeutic input and their supervisory role. The latter is less important and should never be draconian. The nursing team establish a relationship of trust with the patient. They get to know each patient as an individual with her own personal needs and concerns. The nurses should also be acutely aware of the anorexic patient's tendency to avoid food and to exercise excessively. It is preferable for the treatment programme to stress the supportive aspects of the nurse's relationship with her patient rather than the undoubted need for careful supervision. The nurse will come to rely on the daily weight record to monitor the success of her treatment as the weight chart should show a smoothly rising curve. All meals are taken in the ward; thus the anorexic patients constitute a group in which peer interactions take place. The meal is taken in the presence of one or more nurses also seated at the table. From the beginning of the treatment the patient learns that she is expected to consume all the food placed before her.
It is not only the patient who tends to underestimate the food requirements to restore her weight to normal. Metabolic studies have demonstrated that for each kilogram of weight gain a surplus calorie balance of 7500 cal is needed. (133) It is prudent to begin with a modest calorie intake of 1200 to 1500 cal daily during the first 7 days in order to avoid the rare but dangerous complication of acute gastric dilatation. Thereafter the caloric intake is gradually increased and may rise to 4000 cal daily. The best diet is that consisting of a wide range of foods avoiding any preferences for 'safe' foods and including carbohydrate and fat-containing foods. Concentrated foods (e.g. Build-up, Complan, Carnation Breakfast Food) added to milk may be used to achieve a high caloric intake. The aim is to achieve a positive energy balance of 1500 to 2250 cal daily, leading to a daily weight gain of 200 to 300 g.
Weighing should be a standardized daily procedure before breakfast after the patient has emptied her bladder and while she wears light night clothes. A paradoxical psychological improvement, with a diminution in concern with body size and shape, occurs with weight gain. The improvement is partly through the correction of malnutrition and partly the result of the 'exposure treatment' whereby the patient gradually accepts a higher body weight.
Exceptionally the patient's tension and depression do not improve and there is a continued resistance to food. It may then be helpful to prescribe moderate doses of chlorpromazine (not more than 300 mg daily), carefully avoiding a fall in blood pressure which is a risk in the emaciated patient. In the case of persistent depression, treatment with an antidepressant may be indicated. However, antidepressants are often ineffective in the presence of malnutrition, and by themselves do not assist the patient to gain weight.
Inevitably the patient will find it irksome to forego home visits for the whole period of weight gain. Therefore interesting and therapeutic activities should be provided through group meetings, occupational therapy, and social interactions. Visiting is generally encouraged unless the patient's restlessness is such that visiting parents are subjected to emotional appeals to be taken home. They may then be asked to postpone their visits or reduce their duration.
The aim is to restore body weight to a healthy level within 8 to10 weeks; a further period (usually 2 weeks) in hospital is needed to allow the patient to test her ability to maintain her weight by eating in the general dining room or at home on leave days. It is important to effect a smooth transition to further treatment as a day patient or outpatient.
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