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firmly in the hands of the patient, whereas hospitalisation can be perceived as a handing over of responsibility to the caring team.

Despite these drawbacks, there are several situations where hospital care offers advantages over out-patient treatment. The first consideration must be the preservation of life in cases of extreme weight loss or medical complications. It may be required for the care of a patient who is felt to be a serious suicide risk. There is a case to be made for considering admission for patients who are not in acute physical danger, but who remain chronically underweight over an extended period of time and do not respond to out-patient treatment. Hospitalisation can also provide an opportunity for interrupting the vicious circle of binge eating and vomiting for severe bulimic patients who do not achieve control in an out-patient setting.

It is often necessary to set individual thresholds beyond which admission to hospital will be required, such as continued weight loss below a certain weight, or low potassium levels over a specified period of time. It is difficult to specify an exact weight criterion, since the degree of emaciation which will cause concern will vary individually, but once weight drops below about 70 per cent of average then close monitoring should be instigated. In any such negotiation, it is important that hospitalisation be presented not as a punishment, but rather as a means of regaining control over behaviour which the patient is currently unable to regulate. Discussion of the possible need for hospitalisation should be held at an early stage in the treatment if it seems likely that this may be necessary, with careful explanation of why admission will be considered. The therapist may then develop an alliance with the patient focused on avoiding the need for hospitalisation, and with clear goals for producing improvement in an out-patient setting. In Carol’s case it was agreed that if weight loss progressed, or if any new signs of illhealth developed, she would be seen more urgently by the physician and the need for hospitalisation would be reviewed.

Psychological assessment

The assessment of eating disturbance and body size concerns must address several different areas. A clinical history is useful in giving clues to broad problem areas and possible causal and maintaining factors. Standardised questionnaires, selfmonitoring methods, and experimental techniques may then be used to supplement information obtained from clinical interviews. Table 6.1 provides a guide to some important aspects of assessment which could be taken into consideration. A detailed knowledge of eating habits, weight fluctuation, and dysfunctional thoughts and attitudes to eating and body size should form the basis of the assessment. Selection amongst the different problem areas and assessment tools would depend upon the particular difficulties of each individual patient. For a more detailed discussion of the investigation of eating and weight disorders, see Wardle (1987b).

The first session with Carol included discussion of her dieting and binge

Table 6.1 The assessment of eating disorders

Bulimia or rapid refeeding

1.gastric dilatation and perforation

2.sodium overload with oedema and cardiac failure

Self-induced vomiting

1.dental erosion

2.parotid swelling

3.hypokalaemic alkalosis

4.renal disease

5.cardiac arrhythmias

6.tetany

7.muscle weakness

Laxative abuse

1.hypokalaemic alkalosis

2.colonic denervation and atony

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Figure 6.1 Recording form

herself vomit, and occasionally take two Senokot laxative tablets. She binged mainly when she was alone and was feeling bored and lonely, but also when very tempting food was readily available.

Carol was weighed, and her weight was calculated with reference to both ideal weight tables (Metropolitan Life Insurance 1983) and body mass index (Florey 1970). It emerged that she was currently 68 per cent of the ideal population weight-for- height, with a body mass index of 14.6. This represented a serious degree of emaciation, indicating that regular medical assessment would be important in ensuring that she could safely be treated as an out-patient. She reported that she would prefer to be about half a stone heavier, but was terrified of losing control over her weight and becoming fat.

EATING DISORDERS 77

She also filled in self-report questionnaires. The Eating Disorders Inventory (Garner et al. 1983) was used to measure attitudes to food and eating. This showed her to have high scores on the Drive for Thinness and Body Dissatisfaction scales, and a fairly high Bulimia score. The Dutch Eating Behaviour Questionnaire (DEBQ) (Van Strien et al. 1986) was used to measure the degree of control exercised over eating (‘restraint’) and responsiveness to external or emotional eating cues. She scored highly on restraint and emotional eating. She was also asked to complete the Beck Depression Inventory (Beck et al. 1961) and a self-esteem scale (Rosenberg 1965). These suggested that she was fairly depressed (BDI score=22), and her pattern of responding on the Rosenberg scale indicated her selfesteem to be low. Body image satisfaction was assessed by asking her to rate how satisfied she felt with a range of body parts, showing her to be particularly dissatisfied with her stomach and thighs.

Treatment plan

On the basis of this assessment, it was clear that the most urgent aims of treatment were to help Carol gain control over both her progressive weight loss and her bingeing and vomiting, since these behaviours presented a significant risk to her health. This would necessitate addressing the relationship between the cognitions and behaviours which were maintaining her current problems. A second aim of treatment would be to examine the factors relating to her low mood and self-esteem, to see how closely these were linked to her eating problems. Finally, treatment would aim to address wider aspects of functioning such as career, family, and social issues.

The results of the assessment so far were discussed with Carol at the second session. A formulation of her problems was presented to her using the cognitive-behavioural model put forward by Garner and Bemis (1982), and the outline of a treatment based on these principles was negotiated with her. The treatment plan can be seen in Table 6.2. It was agreed that sessions would take place on a weekly basis for the first 2 or 3 months, and that this would gradually be reduced depending upon her rate of progress.

Table 6.2 Treatment plan

1.Present cognitive-behavioural model of anorexia nervosa and rationale for treatment.

2.Provide information and education about:

(i)the dangers of weight loss, binge eating, and vomiting

(ii)cultural pressures on eating and body size

(iii)dietary restraint and binge eating

(iv)nutrition and normal eating patterns

(v)normal weight regulation and fluctuation

3.Increase amount and range of foods eaten to reduce dietary restraint and restore weight to a normal healthy level.

4.Identify dysfunctional cognitions associated with eating, weight, and body size.

5.Challenge dysfunctional thoughts through a collaborative, didactic approach.

6.Address other areas such as self-esteem, depression, career, family, and social issues.

Developing motivation for treatment

In the case of anorexia nervosa, the initial contact with a treatment centre is commonly made by people other than the patient herself (we will refer to the individual patient as ‘her’; the majority of anorexia nervosa and bulimia nervosa patients are female). Referrals by family and friends who are concerned about progressive weight loss are often valuable in identifying the existence of a problem, but reluctance or active hostility on the part of the patient who arrives for treatment in this manner is not unusual. Bulimic patients who do not lose a substantial amount of weight may find it easier to conceal their difficulties from relatives, and are more likely to pursue treatment in order to control their binge eating. The other central issue in accepting treatment may be focused on the concept of desirable weight, since a central feature in both anorexic and bulimic disorders may be the pursuit of thinness and a refusal to accept the necessity for a body weight within or even above the normal range. The first task in developing a therapeutic alliance is to anticipate ambivalence about reaching or maintaining a normal body weight. Typically patients are keen to get rid of preoccupation with eating and size, and to gain control of symptoms such as craving and binge eating, but not at the expense of weight gain.

It is important to understand the degree of fear which may be aroused by the prospect of change through accepting treatment, particularly when there is a long history to the problem. Rituals around eating or resisting food, calorie counting, getting on the scales to monitor weight, and so on, may occupy a substantial part of daily life and even be perceived as valuable in that they may serve to maintain food restriction and emphasise the value of thinness. The therapist’s ability to

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empathise with the conflicting emotions which are likely to be experienced is likely to be important in gaining the patient’s trust. It is also helpful to show tolerance and lack of surprise at symptoms which may be presented by the patient as shocking confessions, such as the amount of food consumed in a binge. The patient’s beliefs, such as perceiving herself to be extremely fat, should be accepted as currently genuine for her, even if she is severely emaciated. As with the example below, taken from the case study of Carol, the beliefs can be reinterpreted as a part of the overall problem.

T: Do you see body size and weight as a problem for you at the moment? P: I’m worried about getting fat.

T: Do you think you are fat right now?

P: I feel very fat at the moment, it’s all on my stomach and thighs. T: How can you tell that you are fat?

P:When I get on the scales I’m terrified in case my weight goes up a pound, and I can tell from my clothes if they get tighter at all.

T: How do you think you look to me—would I see you as very fat?

P: You’ll probably say that I’m too thin. I know I’ve lost a lot of weight, but I feel so fat.

T:So you realise that you are thinner than most people at the moment, but you feel so worried about your weight that it doesn’t seem that way to you. Is that right?

P: Yes—I know other people think I’m too thin but I want to lose some more weight.

T:I think that’s part of the illness you have—it doesn’t seem to matter how much weight people lose, they always feel that they’re too fat and want to lose more. I expect that when you started dieting, you thought that everything would be fine after you’d lost some weight, but after you got there it didn’t seem enough?

P: I suppose so—I don’t know if I’ll be satisfied even when I’ve lost some more weight.

T:So it’s important that we distinguish between your actual weight loss, which is very worrying because you are so underweight at the moment, and your worries about feeling fat, which you probably have even at a very low weight, and which are part of the illness you have.

There may be difficulties in persuading the patient to acknowledge that there are any real problems for her which need to be addressed in treatment. It can at times be useful to use strategies such as stressing the specific dangers of the conditions, and spelling out the consequences of continuing to lose weight or vomit/abuse laxatives in order to increase motivation for treatment.

P:I wouldn’t mind if I could just put on a little bit of weight gradually —but I know I wouldn’t be able to stay there, I’d just get fat like I used to be, and I couldn’t stand it.

T:That’s something we can work on together. You’re bound to be frightened of putting on weight, but you know that you can’t go on at this level—it’s too much of a strain on your body. Do you notice that you don’t feel as well as you used to?

P: I know I get very tired lately, more than I used to.

T:I expect you do—you probably notice it’s more effort to climb stairs, and harder to keep warm, and things like that. Do you know why that is?

P: Not really.

T: Well, as you get thinner you use up more energy than you take in, don’t you. Do you know where that energy comes from? P: I suppose it comes from fat on my body.

T:That’s right, it does come from body fat—but there’s not much fat left on your body now, is there? You can tell that if you just pinch the skin together on your arm, for instance, and you’ll see that there’s hardly any fat under the skin. So that means that when your body has used up most of the fatty tissue, it has to take energy from the muscles —and that includes

your heart muscle and diaphragm muscle, not just your arms and legs and so on. P: Is that why I get so tired?

T:I think it’s one of the reasons. And you can see why it makes it important for you to put on weight, to take the strain off your heart and the rest of your body. Vomiting puts a big strain on your body as well, you lose the essential minerals that you need like potassium, and that makes it harder for your kidneys to work properly.

P: It sounds a bit frightening—do you think I’ve already done much damage?

This can be particularly difficult in cases where people have been ill for a long time, and none of the supposed consequences of practising food restriction or compensatory techniques has actually happened to them. It may then be useful to point out not only the acute dangers of cardiac or respiratory failure, but the longer-term risks of kidney damage and osteoporosis, and growth retardation for younger patients.