Treatment of anorexia nervosa (III)

Treatment of anorexia nervosa

Treatment of anorexia nervosa.

The approach to these eating disorders must be multidisciplinary so as not to be doomed to failure. Treatment with psychotropic drugs, psychotherapy, nutritional recovery and adequate treatment of all metabolic complications of the disease will be necessary.

In recent years, the creation of specific centers to address these problems has represented a great advance, which has made the prognosis of anorexics improve substantially.

 Next, we will comment on some aspects that are of great importance in order to successfully complete the treatment of the anorexic patient. We are going to highlight some generalities about various aspects of the treatment of anorexia:

Pharmacotherapy.

In anorexia nervosa, psychotropic drugs do not work, but they do in bulimia where the fundamental thing is to control impulsivity (it occurs more in borderline patients).

The APA in its guidelines on systematic studies indicates that in four of seven studies in patients with anorexia nervosa, antidepressants did not show any evidence of benefit . However, in bulimia the antidepressants ISSR (selective serotonin reuptake inhibitors) and topiramate are effective in controlling binge eating .

Psychotherapy in anorexia nervosa.

In relation to psychotherapy, the American Psychiatric Association says in its guide to eating disorders:

“ The evidence for the efficacy of cognitive behavioral treatment is limited. A 20-week, randomized treatment in 56 women with anorexia nervosa, where they compared cognitive behavioral therapy, interpersonal and control through non-specific support measures, demonstrated that supportive therapy was superior to interpersonal and probably cognitive behavioral ” .

The link with the therapist.

The link that the anorexic patient establishes with the analyst has peculiar characteristics. It is a bond in which you need to be with the therapist, but at the same time, you need to be independent from him. There are two clearly differentiated transference patterns: One is open oppositionism, struggle, fights, demands. Another is passivity, dependence on an impenetrable silence.

Family therapy.

Regarding the dilemma of joint or individual family therapy, it must be said that joint family therapy is not so useful, as it quickly focuses attention on weight and makes weight the focus of treatment . If it is necessary to do family therapy, it is advisable to do it separately from the patient’s treatment. 

Hospitalization.

Hospital admission in patients with anorexia nervosa is sometimes unavoidable. The main reasons for hospitalization are usually weight loss and heart problems.

The American Psychiatric Association (APA) recommends admission when there is significant weight loss. It would be the case of losing 25% or more of body weight in less than three months or losing more than 1 kg a week in a sustained manner. Another criterion would be to have a BMI (Body Mass Index) lower than 17.5.

Hospitalization may be necessary in the treatment of anorexia.

Psychotherapy in a clinical case of anorexia nervosa.

We will now see the case of an anorexic patient treated by Professor Hugo Bleichmar. It is about a college girl who was carried by her parents weighing 45 kilos. Psychotherapy lasted three years. She arrived with amenorrhea, took laxatives, vomited, threw away food, and she passively accepted the treatment.

Force psychotherapy.

Anorexic patients do not come to treatment voluntarily: they are brought by force, which causes an added difficulty, since it raises what kind of bond the therapist should establish with a patient who does not want to come to therapy and is obliged, generally by the parents. In this case the therapist approached the situation by saying:

“Your parents brought you to treatment. They are concerned about your weight. I want to be frank with you, I am also worried about your weight. I see you on a dangerous path, but I will not be your weight watcher. What I want is to understand and try to help you understand why being thin is so important to you.

I want to know you as a person, not only how much you weigh, but what things interest you, which ones worry you, how you feel with your friends. For me you are much more than a body with a certain weight. What I want is for you to feel free here, so that you can freely decide your life.

My role is to help you so that you can get to know yourself better. Sometimes you live without knowing yourself well enough. With me you are not obliged to eat more. Tell me about yourself, what interests you, your relationships, memories you have from your childhood that you consider are important to you ”.

Get him to see himself as a person.

With this intervention, the therapist creates a framework that tries to set a goal: that she sees herself as a person. Everyone around her is watching the weight, her parents are watching the weight, the doctor is watching the weight, but no one is watching her as a person.

She considers herself in a very partial dimension as a person. She looks at herself to see if she is thin or not. His entire being is mutilated and restricted to a single dimension: his body weight.

 The idea of ​​this frame is that she feels that the therapist is not a mere transmission belt of the parents, but that he tries to see her in a different way, that I want to know and understand her and that she is not going to tell the parents anything that she has. is counted in therapy.

The weight problem.

It is very convenient in the psychotherapy of the anorexic that the therapist is freed from the mission of monitoring the weight. This mission should fall on the doctors or caregivers, but it should always remain outside the psychotherapist. When this does not happen, in the end psychotherapy ends up becoming a monothem: weight.

You have to be very clear when establishing the contract with the patient and with the parents. It is necessary to explain to the parents what one is going to develop in psychotherapy, without interfering in the issue of weight, but that as a consequence of that work there will be a benefit for the problem of anorexia.

The weight problem hampers the progress of psychotherapy.

Separation of therapeutic roles.

There must be a doctor who takes care of the weight, the diet, the clinical analyzes and who leaves the field free for the therapist so that he can focus on the characterological factors and specific motivations of that patient.

This characteristic of separating on the one hand the doctor in charge of monitoring weight and on the other the therapist, is not only something typical of psychodynamic currents, but the American Psychiatric Association (APA) in its guidelines for eating disorders, recommends this separation based on evidence. The APA in its detailed guide says:

“Much of the psychological work will not focus on eating behavior, but on the affective issues surrounding the eating disorder. The mental health worker can be helpful in guiding other team members on mental health issues. Putting a single focus just to address weight issues can leave many anorexia patients with persistent psychological problems . “

This fact was demonstrated in a study on 70 women with anorexia. Many of these women, after overcoming the problems of anorexia and failing to meet the DSM-V criteria, persisted with problems of depression, alcohol dependence and anxiety disorders.

That is, we can improve weight, but if the psychological aspects are not worked on, in the end a varied symptomatology such as depression, anxiety or alcoholism ends up persisting. We are not here before the famous controversy with which psychoanalysts attacked behaviorists by pointing out that they eliminated a symptom, but it later reappeared in another way.

In the case of anorexia, it is not that when the weight problem is solved, it reappears transformed into new symptoms, but rather that anorexia acts as a smokescreen that prevents a series of underlying disorders from being seen and that, once the anorexia has been eliminated If they are not treated properly, they become evident in a very obvious way.

Attitude towards the patient’s parents.

The therapist must reach an agreement with the parents of the patient , indicating that he will not take care of the weight, but that this task will fall on the doctor.

Faced with possible doubts from parents about whether this attitude is correct, it is convenient to read what the APA guidelines on eating disorders say, which advocate a medicine based on evidence and contrasted with multiple and rigorous medical studies.

With this we get parents to stand on our side and be our allies. If not, parents may boycott therapy, arguing that after a month of treatment their daughter does not gain weight.

The image of the anorexic.

Let’s look at other aspects of the relationship with the patient: The girl says that the university exams are approaching, she says that she does not have them well prepared, but that she is not afraid that they will fail her, but rather to do “a piece of paper” that is, not to get some notes outstanding.

In other words, the patient requires herself not only to approve, but to do so with a very good grade. Here we can observe the persecutory image of other people (parents?) Observing it and demanding high performance. Given this fact, it is convenient for the therapist to say:

“From the facts you are telling me, I realize that it is important for you, not only not to fail, but also to be someone excellent, and that by fear of being a fool it shows that you are a person who takes care of your good name and image ”.

 In this subtle way, the therapist can introduce the subject of the image . But here it is important to emphasize that these statements made by the therapist are supported by what she has said: “Because of the facts that you are telling me …” which reinforces the autonomy of the patient who does not see the observation, as something gratuitous or imposed by The therapist.

With anorexic patients it is important to promote, whenever possible, the issue of autonomy , to which they attach great value.

The anorexic values ​​and takes great care of her image in front of others.

The oppressive silence.

Faced with an observation of this type, it is not uncommon for the patient to remain silent, sometimes a tense and oppressive silence , since it is usually adolescent patients who feel very persecuted and have an extraordinary difficulty in opening up , so silence is usually your natural response.

The inexperienced psychoanalyst may feel uncomfortable with this patient’s silence, but must know how to channel it properly with observations similar to this:

“I need your silence, because that indicates that you want to be careful in your relationship with me. You still don’t know me and despite my initial words, you want to make sure that I am not an employee of your parents who is going to tell them what you tell me ”.

At this point the analyst cannot ask : “What are you thinking about?”

The analyst must respect her silence and legitimize it in some way , without her feeling questioned by his attitude. That is why the analyst points out:

“Silence is uncomfortable not only for you, but also for me, but I think we need time for you to feel more secure and to open up more, and without a doubt you will when it is your time.”

At this point, the analyst transmits something of his own to him (“he also feels discomfort in the face of silence”) and tries to make him begin to see the analyst as a person and not as an interpretive machine. It is about starting to make a bond with the analyst seen as a person .

In these situations in which the silence is overwhelming, the analyst can choose the option of asking about situations or memories of the past, the analyst being aware that it is an attitude of going defensively towards the past.

Faced with a tense situation in the present (prolonged silence) that the patient cannot cope with, we ask about memories of the past, not so much to know the patient’s history, but to get away from the immediate that does not have a persecutory character. It is easier to talk about the past than about a threatening present.

Idealized models.

Looking back on childhood memories, it is not uncommon for comparisons to a model of idealized beauty to appear. When questioning the patient, she relates that she keeps the memory of her cousins “ like movie stars. They were very beautiful. 

You look at another thin person and you want to be like them. This comparative aspect makes anorexia an epidemic phenomenon, since there is no shortage of actresses or models that become objects of comparison with adolescents.

There is a comparison with the idealized image of the body in anorexia.

It should be noted that the therapist in this situation uses the patient’s personal history as a way to get in touch with her and strengthen the therapeutic bond . This attitude is different from that of classical psychoanalysis, which searches personal history for the interpretive keys of the present . This historical reconstruction is an instrument to strengthen the nature of the bond.

It is not uncommon, at this point in therapy, calls from parents inquiring about the course of treatment. A good recommendation is to thank them for the call and their interest and tell them that they are working on increasing a climate of trust with the patient.

This attitude favors the “narcissization” of parents, praising their interest and involvement and thus avoiding a possible boycott of therapy if they feel marginalized and without information.

Sexuality in anorexia nervosa.

Within therapy it is important to talk about sexuality , being relatively frequent to observe rejection or disgust towards sex. In the case of the patient, she says that she is not interested in sexuality and that she remembers with disgust a scene in which she saw two dogs mating.

When delving into the subject it is frequently observed that anorexia is not an instrument to conquer man, but an attitude to achieve resemblance to their idealized models of beauty. It usually covers up conflicts about sexuality and fear of men.

Autonomy and oppositionism.

In anorexic patients, it is convenient to analyze the annoyance and anger that for patients involves paying attention to other people, especially in relation to diet.

These patients have a great need for autonomy and this causes them to confront their parents on issues related to weight and encourages a rebellious attitude.

It is not uncommon to observe in the families of anorexics the presence of fathers, especially mothers, who are very controlling, before whom the patient rebels. Any word from the therapist, which evokes the controlling family figure, unconsciously unleashes an oppositional attitude in the patient.

This oppositional attitude, in the absence of therapy, creates a vicious circle: the greater the malnutrition, the greater the concern and controlling attitude of the parents and consequently a greater oppositionism of the patient, which aggravates the state of health.

Avoid errors.

As the therapeutic alliance improves and the therapy advances, if it is accompanied by weight gain, the analyst must be very careful to comment on this issue, since this leads the patient to think that the analyst is only interested in her weight.

Bibliographic references.

  • American Psychiatric Association. Practice guidelines for the treatment of patients with eating disorders, third edition. Am J Psychiatry 2006; 163(Suppl): 1-50
  • American Psychiatric Association. (2014). Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th Ed. Arlington, VA, American Psychiatric Association: Pan American.
  • Barrera, A. (2016). Impulsivity and ADHD in adolescent patients with eating disorders. Doctoral thesis Link .
  • Bleichmar, H. (2014). The anorexia. In “Course of specialist in clinical and psychoanalytic psychotherapy”. Madrid.
  • Doyen, C. and Cook-Darzens, S. (2005). Anorexia, Bulimia: guidelines to prevent, face and act from childhood. 1st edition. Barcelona: Amat.
  • Madruga, AD, Leis, TR & Lambruschini, FN (2010). Eating behavior disorders: Anorexia nervosa and bulimia nervosa. In: Spanish Association of Pediatrics. Link .

This article is the third part of the summary of Gerardo Castaño Recuero’s Monograph “La Anorexia Nerviosa”, which is part of the TFM of the “University Specialist Course in Clinical and Psychoanalytic Psychotherapy”. You can download the complete work at the following link:

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Alexa Clark specializes in Cognitive Behavioral Therapy. She has experience in listening and welcoming in Individual Therapy and Couples Therapy. It meets demands such as generalized anxiety, professional, love and family conflicts, stress, depression, sexual dysfunction, grief, and adolescents from 15 years of age. Over the years, She felt the need to conduct the psychotherapy sessions with subtlety since She understands that the psychologist acts as a facilitator of self-understanding and self-acceptance, valuing each person's respect, uniqueness, and acceptance.

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