Transcript Food planning vs Calorie counting

Treatment and Management of
Adults with Anorexia Nervosa
Dr Melanie Bash, Consultant Clinical Psychologist
Dr Sylvia Dahabra, Consultant Psychiatrist
Treatment and Management Tasks
1. Biological tasks: Weight, height,
physiological health, bone density
2. Psychological tasks: Co-morbidity, e.g.
depression, motivation for change,
individual and group therapy, family
therapy
3. Social tasks: Education, occupation,
relationships - friends and family
Biological tasks at transition
• Achieving best skeleton health
– Height
– Bone density
• Physiological health
– Puberty and endocrine aspects
Marsipan for adults (2014)
• Be aware of increased risk of deterioration
of physical health during transitions
Case discussion
• Details omitted re confidentiality
Management of physical
health
Psychological Tasks
Collaborative working
• Where is the patient in journey through
treatment?
• Young, not chronic, aim for weight recovery
• SEED (5-10 years), need to negotiate and
maybe compromise
• Goals may be revisited - without deceit
• Aims: Ownership and self-efficacy
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(Self-efficacy is the extent or strength of one's belief in one's own ability to
complete tasks and reach goals)
• Aim = get better not feel better
Negotiating an appropriate BMI
• Important to help patient work to a weight and
BMI that are developmentally appropriate.
• Ask any dressmaker, weight and shape change
with age (!)
• Patients often need persuading and reassuring
that: e.g. weight in late 20s will look and feel
very different from the same weight in early to
mid-teens.
Treatment does not end with
weight gain!
• Professionals and patients need to
recognise and embrace this.
• Weight gain without foundational change
is unlikely to be sustained and built upon.
• We might know this, important not to
overlook it….e.g. “she can have therapy
as an outpatient; or “the patient wants to
be discharged, they say they can do it”.
Our patient’s journey
Dietary Development
Important to remember that for most people, palate
changes with age (studied by psychologists).
Most children detest mushrooms and green
leafy vegetables. Dietary intake usually
improves with maturation.
Important to take into account what is normal
development, and how normal development
might be delayed in AN. Need to work with it,
whilst improving intake.
Dietary intake
• Specialist dietitian
Body composition
Body image
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Very poor initially
Didn’t feel fat at low weight
Weight gain provoked some concerns
Body image group
Explored BI in individual therapy
Menstruation
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Privacy – hypothetical group exercise
Exploring acceptability
How to support patient not to do a U-turn
First period just before 30 (more later)
Exercise and activity – our patient
• Wished to improve overall health
• Improved BMI (moderately adequate)
• Listened and adhered to advice (ED and
gym)
• Gym became social
• Made friends
• Had fun
• Learned to enjoy her body
General mental health
• Addressed in CAT therapy
• Poor self-esteem (incl. not feeling
accepted, and fear of change)
• Sense of hopelessness (“I’ll never catch
up”)
• Grief for lost years and milestones
• Tendency to please
• Overall tendency to snag progress (no
identity outside of AN)
What next?
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Anxiety about recovery
Little education
Never worked
No friends
No relationships
No sexual experiences
Feeling overwhelmed by the task ahead
Tasks to address in therapy
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Taking some calculated risks
Education
Work experience (DBS; Benefits trap)
Interests
Friendships
Relationships
Overcoming family set-backs
Professional – supporting, guiding, being a
‘dolphin’. Consistency and reliability.
General developmental milestones
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Late
Pace might be faster - or slower
Importance of patient’s own speed
Birthdays and cake
Important birthdays, and making up for loss
Sexual relationships
Holidays
Engagement and marriage
(Having children – subject of another talk)
Financial skills
• Overwhelming fear of adequate budgeting
• Ability to spend sufficient on self
• Ability to spend sufficient on food
• Controlling impulsivity
Our patient
• Ability to budget and spend £ on food therapy
Being realistic
• Some difficulties have to be worked around and
managed, collaboratively
• Bones
• Teeth
• Parental and some other significant relationships
• DBS
• Grief for lost time and milestones
• Sexual trauma and medium term residual
symptoms
Working towards a good ending
• Working with SEED takes a long time
• Patience!
• Helping others be patient (the patient,
family, commissioners, service managers,
colleagues)
• Good endings are discussed, agreed and
planned. Compromise sometimes
necessary.
Moving on
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For the patient
For the professional
Final session
Keeping in touch??? And boundaries
Our patient’s reflections – at
discharge
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“Not really sure “
Chance to give it another go
Professional consistency and reliability
Hopefulness from professionals – not
giving up
• Feeling better about her body (food,
activity, using a body with health, fun with
clothes and going out)
• Living independently and ‘normally’
Final comment
• Important to maintain hope
• Patients may be more resilient than we
give them credit for
• Never give up!