Getting Help for Anorexia and Bulimia

Recognizing the problem in anorexia nervosa

In anorexia nervosa, family members are often the first to notice that something is wrong. They notice that you are thin and continuing to lose weight. They become worried, and may be alarmed by your weight loss. You will probably continue to think that you are over-weight and will want to lose more weight. You may find yourself lying to other people about the amount you are eating, and the weight you are losing. If you have bulimia nervosa, you will probably feel guilty and ashamed of your behavior. You will try to hide it, even if it affects your work and makes it difficult to lead an active social life. People with bulimia often find that they finally admit to the problem when their life changes, perhaps a new relationship, or starting to live with other people. It can be a huge relief when this happens.

Getting the right help for anorexia

Your general practitioner can refer you to a counsellor, psychiatrist or psychologist who has experience with these problems. Some people choose private therapists, self-help groups or clinics, but it is still safest to let your GP know what is happening. You will need to have a regular physical health check.

Assessment

The psychiatrist or psychologist will first want to talk with you to find out when the problem started and how it developed. You will need to talk frankly about your life and feelings. You will be weighed and, depending on how much weight you've lost, you may need a physical examination and blood tests. With your permission, the psychiatrist will probably want to talk with your family, (and perhaps a friend), to see what light they can shed on the problem. However.. if you do not want other members of the family involved, even very young patients have a right to confidentiality. This may sometimes be appropriate because of abuse or stress in the family.

Self-help for anorexia and bulimia

• Bulimia can sometimes be tackled using a self-help manual with occasional guidance from a therapist.
• Anorexia usually needs more organized help from a clinic or therapist. It is still worth getting as much anorexia information as you can about the options so that you can make the best choices for yourself.

Things to do

Stick to regular mealtimes - breakfast, lunch and dinner. If your weight is too low, have morning, afternoon and night-time snacks.

• If you can't manage this, try to think of one small step you could take towards a more healthy way of eating. For instance, you may be unable to eat breakfast. To start with, get into the routine of sitting at the table for a few minutes at breakfast time, and perhaps drink a glass of water. When you have got used to doing this, try having just a little to eat, even half a slice of toast - but do it every day.
• Keep a diary of what you eat, when you eat it, and what your thoughts and feelings have been every day. You can use your diary to see if there seems to be any connection between how you feel, what you are thinking about, and how you eat
• Try to be honest about what you are or are not eating, both with yourself and with other people.
• Remind yourself that you don't have to be achieving things all the time- let yourself off the hook sometimes. Remind yourself that, if you lose more weight, you will feel more anxious and depressed.
• Make two lists - one of what your eating disorder has given you, one of what you have lost by it. A self-help book can help you to do this.
• Try to be kind to your body, don't punish it.
• Make sure you know what a reasonable weight is for you, and that you understand why.
• Read about stories of other people's experiences of recovery. You can find these in self-help books or on the internet.
• Think about joining a self-help group. Your GP may be able to recommend one or you can contact the Eating Disorders Association (see overleaf).

Things NOT to do

• Don't weigh yourself more than once a week.
• Don't spend time checking your body and looking at yourself in the mirror. Nobody is perfect. The longer you look at yourself, the more likely you are to find something you don't like. Constant checking can make the most attractive person unhappy with the way they look.

• Don't cut yourself off from family and friends. You may want to because they think you are too thin, but they can be a lifeline.

• Avoid websites that encourage you to lose weight and stay at a very low body weight. They encourage you to damage your health, but won't do anything to help when you fall ill.

What if I don't have any help or don't change my eating habits?

Most people with a serious eating disorder will end up having some sort of eating disorder treatment, so it is not clear what will happen if nothing is done. However, it looks as though most people with an established eating disorder will continue with it. Some sufferers will die, but this is less likely if you do not vomit, use laxatives or drink alcohol.

Professional help Anorexia

You need to get back to somewhere near a normal weight. To help with this, you and your family will first need information. What is a 'normal' weight for you? How many calories are needed each day to get there? You may ask, "How can I make sure that I don't become fat again ?" and "How can I be sure that I will be able to control my eating?" At first, you probably won't want to think about getting back to a normal weight, but you will want to feel better.

• If you are still living at home, your parents may get the job of checking what food you are eating, at least at first. This involves making sure that you have regular meals with the rest of the family, and that you get enough calories. Mounds of lettuce can be very deceptive! You will see a therapist regularly, both to check your weight and for support.
• Dealing with this problem can be stressful for everyone concerned and your family may need support to cope with an eating disorder. This doesn't necessarily mean that the whole family has to come to therapy sessions together (although this can be very helpful for younger patients). It does mean that your family may need help to understand and cope with the anorexia.

• It will be important to discuss anything that may be upsetting you, such as how to get on with the opposite sex, school, self-consciousness, or any family problems. Although it is important to be able to talk things over confidentially, sometimes a therapist may need to discuss things with you and your family together.

Psychotherapy or counseling

• This involves spending time regularly, probably about one hour every week, with a therapist to talk about your thoughts and feelings. It can help you to understand how your problem started, and then how you can change some of the ways you think about things. You can talk about the present, the past, and your hopes for the future. It can be upsetting to talk about some things, but a good therapist will help you to do this in a way which helps you to feel better about yourself.
• Sometimes it can be done in a small group of people with similar problems, in sessions lasting around 90 minutes.
• Other members of your family can be included, with your permission. They may also be seen separately for sessions to help them understand what has happened to you, how they can work together with you, and how they can cope with the situation.
• Treatment of this sort can last for months or years.
• Only if these simple steps do not work, or if you are dangerously underweight, will the doctor suggest admission to hospital.

Hospital treatment

This consists of much the same combination of controlling eating and talking about problems, only in a more supervised and concentrated way.

Physical health

• Blood tests will be done to check whether you have become so under-nourished that you are anaemic or at risk of infection.
• Your weight will be regularly checked to make sure that you are slowly getting back to a healthy weight.

Advice and help with eating

• A dietician may meet with you to discuss healthy eating - about how much you eat and whether you are getting all the nutrients you need to stay healthy.
• You can only get back to a healthy weight by eating more, and this may be very difficult at first. You will be encouraged to eat regularly, but also helped to deal with the anxiety this causes you. Staff will help you to set targets and to deal with the fear of losing control of your eating.
• Gaining weight is not the same thing as recovery - but you can't recover without first gaining weight. If you are starved, you won't be able to think clearly or concentrate properly.

Compulsory treatment

This is unusual. It is only done if someone has become so unwell that he or she:

• cannot make proper decisions for themselves
• needs to be protected from serious harm. In anorexia, this can happen if your weight is so low that your health (or life) is in danger and your thinking has been severely affected by the weight loss.

How effective is the treatment?

More than half of sufferers make a recovery, although they will on average be ill for five to six years. Full recovery can happen even after 20 years of severe anorexia nervosa. .Past studies of the most severe cases admitted to hospital have suggested that one in five of these may die. With up-to-date care, the death rate is much lower if the person stays in touch with medical care. .As long as the heart and other vital organs have not been damaged, most of the complications of starvation (even bone and fertility problems) seem to recover slowly, once a person is eating enough.

Bulimia:

Psychotherapy

Two kinds of psychotherapy have been shown to be effective in bulimia nervosa. They are both given in weekly sessions over about 20 weeks.

Cognitive Behavioural Therapy (CBT)

This is usually done with an individual therapist, but can be done with a self-help book, group sessions or even self-help CD-ROMs.CBT helps you to look at your thoughts and feelings in detail. You may need to keep a diary of your eating habits to help find out what triggers your binges. You can then work out better ways of thinking about, and dealing with these situations or feelings.

Interpersonal Therapy (IPT)

This is also usually done with an individual therapist, but concentrates more on your relationships with other people. You may have lost a friend, a loved one may have died, or you may have been through a big change in your life. It will help you to rebuild supportive relationships that can meet your emotional needs better than eating.

Eating advice

The aim is for you to get back to eating regularly, so you can maintain a steady weight without starving or vomiting. You may need to see a dietician for advice about a healthy, balanced diet. A guide such as "Getting Better BITE by BITE" (see references) can be helpful.

Medication

Even if you are not depressed, SSRI antidepressants can reduce the urge to binge eat. This can reduce your symptoms in 2-3 weeks, and provide a "kick start" to psychotherapy. Unfortunately, without the other forms of help, the benefits wear off after a while. Medication is useful, but not a complete or lasting answer.

How effective is the treatment?

• About half of sufferers recover, cutting their binge eating and purging by half. This is not a complete cure, but can enable someone to get back some control of their life, with less interference from their eating problem.
• The outcome is worse if you also have problems with drugs, alcohol or harming yourself.
• CBT and IPT work just as effectively over a year, although CBT seems to start to work a bit sooner.
• There is some evidence that a combination of medication and psychotherapy is more effective than either treatment on its own. .Recovery usually takes place slowly over a few months, or even years.
• Long-term complications include damaged teeth, heart burn, and indigestion. A small number of people will have epileptic fits.

The Royal College of Psychiatrists also produces mental health information for patients, carers and professionals including: Alcohol and Depression, Anxiety and Phobias, Bereavement, Depression, Depression in Older Adults, Manic Depression, Memory and Dementia, Men Behaving Sadly, Physical Illness and Mental Health, Postnatal Depression, Schizophrenia, Social Phobias, Surviving Adolescence and Tiredness.

The College also produces factsheets on treatments in psychiatry such as Antidepressants, and Cognitive Behavioural Therapy. All these can be downloaded from this website. For a catalogue of our materials for the general public, contact the Leaflets Department, Royal College of Psychiatrists, 17 Belgrave Square, London SW1X 8PG. Tel: 020 7235 2351 ext.259; Fax: 020 7235 1935; E-mail: leaflets@rcpsych.ac.uk.

Organisations that can help

Eating Disorders Association, 103 Prince of Wales Road, Norwich NR1 1DW Helpline: 01603-621-414; Monday to Friday, 9.00 am to 6.30 pm Youth Helpline: 01603-765-050; Monday to Friday, 4.00 pm to 6.00 pm www.edauk.com. Provides information and help on all aspects of eating disorders, including anorexia nervosa, bulimia nervosa, binge eating and related eating disorders.

NHS Direct 0845 4647 www.nhsdirect.nhs.uk. Provides information and advice on all health topics.

Patient UK. www.patient.co.uk. Provides information on leaflets, support groups, and a directory of UK websites on all aspects of health and disease.

Young Minds, 102 - 108 Clerkenwell Rd, London EC1M 5SA; Parents Information Line: 0800 018 2138; www.youngminds.org.uk. Provides information and advice on child mental health issues.

Anorexia Nervosa and Related Eating Disorders, inc www.anred.com/slf_hlp.html. Website with information on eating disorders. 17

Books

Breaking free from Anorexia Nervosa: A Survival Guide for Families, Friends and Sufferers, Janet Treasure (Psychology Press)

Overcoming Anorexia Nervosa: A self-help guide using Cognitive Behavioural Techniques, Christopher Freeman and Peter Cooper (Constable & Robinson)

Bulimia Nervosa and Binge-eating: A guide to recovery, Peter Cooper and Christopher Fairburn (Constable & Robinson)

Overcoming Binge Eating, Christopher G Fairburn (Guildford Press)

Getting Better BITE by BITE: A Survival Kit for Sufferers of Bulimia Nervosa and Binge Eating Disorders, Ulrike Schmidt and Janet Treasure (Psychology Press)

References

Agras, W. S., Walsh, B.T., Fairburn, C. G., et al (2000) A multicentre comparison of cognitive-behavioural therapy and interpersonal psychotherapy for bulimia nervosa. Archives of General Psychiatry, 57, 459-466.

Bacaltchuk J., Hay P., Trefiglio R. Antidepressants versus psychological treatments and their combination for bulimia nervosa (Cochrane Review). In: The Cochrane Library, Issue 2 2003.

Eisler, I., Dare, C., Russell, G. F. M., et al (1997) Family and individual therapy in anorexia nervosa. Archives of General Psychiatry, 54, 1025-1030.

Eisler, I., Dare, C., Hodes, M., et al (2000) Family therapy for anorexia nervosa in adolescents: the results of a controlled comparison of two family interventions. Journal of Child Psychology and Psychiatry, 41,727-736.

Fairburn, C. G., Norman, P.A., Welch, S. L., et al (1995) A prospective study of outcome in bulimia nervosa and the long-term effects of three psychological treatments. Archives of General Psychiatry, 52, 304-312.

Hay, P. J., & Bacaltchuk, J. (2001) Psychotherapy for bulimia nervosa and bingeing (Cochrane Review) In The Cochrane Library Issue 1.

Lowe, B., Zipfel, S., Buchholz, C., Dupont, Y., Reas D.L. & Herzog W. (2001). Long-term outcome of anorexia nervosa in a prospective 21-year follow-up study. Psychological Medicine, 31, 881-890.

Theander, S. (1985) Outcome and prognosis in anorexia nervosa and bulimia. Some results of previous investigations compared with those of a Swedish long-term study. Journal of Psychiatric Research 19, 493-508.

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