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Jane Morris - Multidisciplinary Management of Eating Disorders

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Jane Morris Multidisciplinary Management of Eating Disorders

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This Handbook is an indispensable guide for the multidisciplinary management of eating disorders. It discusses a broad range of issues: managing high-risk patients, the challenges of inserting feeding tubes, addressing nutritional aspects and dealing with additional disorders which might complicate matters, such as diabetes, coeliac disease and cystic fibrosis. It discusses fertility, pregnancy, and eating disorders in children and adolescents, as well as addressing the needs of families.

Chapters contain key checklists and flow diagrams. Abundant pictures and conversations, coloured diagrams, charts, maps and boxes, support readers varying learning styles and assist retention of key points. Vignettes taken from real (but strenuously anonymised) cases appeal to clinicians preference for case-based learning. The book also functions as a practical manual of What to do and what NOT to do with practical scenarios.

In the acute situation, clinicians will be able to go directly to the relevant chapter to guide the team through the when, where, how, why and with whom of assessing and managing patients with eating disorders. The book is primarily aimed at postgraduate physicians managing patients with Eating disorders on Gastrointestinal, Endocrine or general medical wards, and those who seek to deepen their expertise as they sit higher professional examinations. It is of interest to both medical and psychiatric clinicians, as well as useful to nursing and multidisciplinary staff who want to develop a compassionate understanding of the true pain driving their patients behaviours.

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Springer International Publishing AG, part of Springer Nature 2018
Jane Morris and Alastair McKinlay (eds.) Multidisciplinary Management of Eating Disorders
1. Understanding Anorexic Behaviour
Jane Morris 1
(1)
Eden Unit, Royal Cornhill Hospital, Aberdeen, UK
Jane Morris
Email:
Further reading and related links, illustrative video clips and interactive learning resources are available on the ANOREXIABYTES website corresponding to topics in this handbook on a chapter by chapter basis.
Understanding Eating Disorders Leads to Better Management Key Chapter - photo 1
Understanding Eating Disorders Leads to Better Management
Key Chapter Questions
  • What can go wrong in the management of acute and severe cases of anorexia nervosa?
  • How can we improve the quality of acute medical care for such patients? Why are patients not always managed in psychiatric settings?
  • How can we diagnose and understand the so-called eating disorderswhat are the physical and psychological conditions which may mimic them? Are they diagnoses of exclusion?
  • What are the causes of eating disorders and how can they be distinguished from lifestyle choices or bad behaviour?
  • How common are anorexia and bulimia nervosa, and is there any increase in recent years?
  • What is the prognosis, and what should be our expectations for patients with severe anorexia nervosa?
This first chapter dramatises our experience in the form of a clinical vignette that amalgamates several episodes of care. It seeks to provide vivid and memorable snapshots to show why we prefer to work in the way we now do. We hope that readers will devour this broad overview and then, having digested it will refer ahead to other chapters which describe the issues that are raised in greater detail.
What Can Go Wrong in the Management of Acute and Severe Cases of Anorexia Nervosa?
It can be a nasty shock for experienced and usually confident clinicians to be confronted by a situation for which many years of training and clinical experience have not prepared us. Managing the case of a patient with severe anorexia nervosa can feel like a humiliation or an outrage, or perhaps a pernicious blend of both.
One winters day, Perdita, a 23 year old student, who had first been diagnosed with anorexia in her mid teens, was admitted to an acute medical ward by her worried psychiatrist. Despite previous inpatient treatment in adolescent units, and weekly psychology appointments for the past year, she had continued to lose weight, even when she returned home to her parents. Her BMI was now only 12.5kg/m2. She looked small, pale and fragile but was also remarkably angry and stubborn.
The ward team was initially reluctant to care for someone who behaved as if she was healthier than their other patients, and who had a condition they regarded as self-inflicted. Some staff even joked that they would like just a touch of her anorexia to help get back into shape. At first, though, they were pleasantly surprised by how little trouble she gave. In fact she spent most of her time on her mobile phone or visiting the hospital concourse or local shops. She was always very helpful, running errands and fetching things for the older ladies in the ward.
As a general principle, people with anorexia nervosa will become extremely anxious if their weight-controlling behaviour is threatened. This means that if Perdita appears relaxed and cheerful it is likely that her weight losing behaviour is not in fact being addressed. It is not usually healthy for an anorexic patient to be too helpful. From a physiological point of view, it represents a way to be physically active to burn off calories, whilst from a psychosocial perspective it denies a proper acknowledgement in the eyes of patient and staff that this is a severe and potentially life-threatening illness. Anorexia nervosa has the highest mortality of any psychiatric illness and should not be underestimated [].
The dietitian was the first to raise alarms when after 2 days Perditas weight had deteriorated further. Her sodium and potassium levels and all her haematological values were also lower than before. The worried lady in in the next bed told staff that Perdita was disposing of her meals in bins and corners and was walking long distances in the cold.
Whilst she was at the shops a nurse found laxatives in Perditas bag, but felt she could not act on this since she had not elicited permission to search her belongings. She said the patient spent a lot of time in the toilet. Sometimes her breath smelled as if she had been sick, although most of the time she chewed gum.
Sometimes anorexic behaviours are so skilfully concealed that staff do not discover them, and parents may vehemently deny that their child could be capable of such deception. Matters dont always improve even when such behaviours are discovered, though.
When confronted, Perdita admitted she had been disposing of food and explained that she could only tolerate eating food if she had prepared it herself. In the interests of the least restrictive practice, staff researched the hospitals Health & Safety Policies, and were eventually able to make an OT kitchen available to Perdita. The dietitian found she was unable to offer a service to any of the other patients on the ward as Perditas concerns occupied her entire working day.
After 48 hours, the dietitian went off sick.
Once the dynamic of confrontation begins, there is automatically a feeling of attack and defence, and a sense of there being two (or more) sides which are in opposition to each other. This is not a good recipe for patient care.
Meanwhile, medical staff argued as to whether Perditas antidepressants should be increased or else stopped altogether.
One young nurse broke down in tears when the patient told her mother that she was being abused by being watched in the bathroom.
There is now very little unified agreement about the care plan, and one of the most powerful forces in supporting treatmentthe patients motherhas potentially been alienated.
Perditas weight continued to fall, and she fainted on several occasions. As nurses helped her into a hospital nightdress and encouraged her to rest in bed they noticed weights and also further supplies of laxatives in her jeans pockets.
She was subsequently weighed and found to be 2 kg lighter than originally documented.
However, now that she was unable to go out walking or to use laxatives she was unable to tolerate eating even the food she prepared herself.
She was offered nasogastric tube feeding which she accepted in a docile manner. Remarkably, she still failed to gain weighther BMI had now dropped to 10.4kg/m2.
It was then discovered that she was running the tube into the bed linen.
Late in the day the team is finally getting on top of the situation and taking stock of the true nature of anorexia, but these discoveries are humiliating and damage the morale of the team. They feel that the disorder is always one step ahead of them and they fear they may be losing the battle.
At this point a bed became available in a specialist eating disorders centre. Perditas mother was by now vociferous in her criticism of the team and insisted that her daughter be transferred that same evening rather than waiting for ambulance transport to be available the following morning.
Perdita persuaded her mother to take her home first, to collect some belongings. She then refused to leave. Her mother told staff she could not justify forcing her daughter to be in a hospital far from home when so far she had been safer under her own care.
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