Dosed people with anorexia have binging moments

Therapies for anorexia (anorexia)

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Treatment starting points: body weight - eating behavior - conflicts

Because both the psyche and the body of those affected are changed in anorexia, it is very difficult to break this vicious circle with insight or willpower alone. Even the attempt to resolve the background conflicts alone cannot lead to success. It is therefore imperative to correct the physical deficiency first.
Only when this step has been initiated (i.e. weight gain starts again) does it make sense to change the psychological factors that are at work within the vicious circle. And only when these factors gradually improve (i.e. the fear of weight gain becomes smaller, the body perception becomes more realistic, the feeling of hunger satiety returns), then the "external" background conflicts and stresses can also be effectively resolved (i.e. all factors that are important for the Eating disorders of the individual affected are important, e.g. the family situation, the fear of one's own femininity / masculinity or growing up, dealing with conflicts and performance, etc.).

The central starting points for treatment result from the risk factors ... [read more]

The central starting points for treatment result from the risk factors:

1. Underweight
The central factor is being underweight, because the associated deficiency symptoms further intensify the other factors (no more feelings of hunger and satiety, cravings, distorted perception, fear of being fat, restrictive eating, psychological impairments). It is therefore imperative to gain weight quickly and safely at the beginning of treatment. Only when the normal weight has been reached can the other factors return to normal. Continuous weight gain up to a healthy target weight is therefore the absolutely primary goal of any anorexia treatment.

2. Sustaining factors
By normalizing eating behavior, the body's metabolism is restored, and with increasing body weight, the deficiency symptoms and their consequences are also eliminated. For some sufferers, this alone reduces the fear of being fat. In most cases, however, it still has to be treated separately psychotherapeutically, since the fear of being fat is also fed from other sources, such as B. the ideal of slimness. The tendency to cravings also decreases with the normalization of eating behavior, but additional measures are required to be completely overcome. The same applies to the body schema disorders, which decrease with increasing body weight, but also require targeted therapy. And the disturbed eating behavior itself must be systematically improved and normalized with special therapeutic exercises in order to achieve stable, balanced eating behavior in the long term without restriction, without vomiting or other countermeasures.

3. Background conflicts
Finally - this is only possible with gradual weight gain - the "external" factors of the vicious circle are also changed: The "rewards" that have been achieved by the eating disorder so far should also be able to be achieved through other behaviors; the ideal of slimness should no longer be so powerful; and all the personal background factors such as B. Conflicts in the family, problems at school, stressful relationships, fear of growing up or of being a woman or a man are dealt with in the therapy in order to find solutions that ensure the long-term success of the treatment.

Duration of treatment

A very important point in the therapy of anorexia nervosa must be clearly mentioned: The treatment of anorexia takes a long time. This depends on the body weight that must be achieved in the therapy in order to be sure that the anorexia has also been overcome. The minimum weight is calculated using the Body Mass Index (BMI). We create an individual minimum weight based on gender and age for each person affected. For an 18-year-old woman, for example, this is a BMI of 19, for a 17-year-old boy a BMI of 18.

For severely emaciated sufferers who only have a body weight of 35 kg ... [read more]

For severely emaciated sufferers who only have a body weight of 35 kg and a height of 1.61 m (that would be a BMI of 13.5 kg / m2), it can take a long time to reach a BMI of 19 kg / m2 . Those affected by this underweight have to gain more than 14 kg to reach their target weight of 49.2 kg. Although it is possible to gain 2 kg and more in a week, continuous weight gain of 0.5 to 1.0 kg per week is more realistic and better tolerated by those affected. It can take more than a few weeks to reach your target weight.

In the German word “anorexia” the aspect of “addiction” is emphasized. We therefore assume during treatment that there is always a proportion of the person affected who does not want to change, who would rather lose weight again, etc. This can also be the case after inpatient treatment. According to more recent scientific findings, however, the relapse rate can be reduced considerably if those affected can maintain their final weight for a few weeks during their inpatient stay. This knowledge is also reflected in our treatment concept.

We have had very good experiences with what is known as "interval therapy". This means that before the first treatment in our house is completed, it can be decided together with the patient whether, after several weeks of testing the strategies learned here in everyday life, while maintaining the minimum weight, depending on the treatment needs, they can go to the Christoph- Dornier Clinic come. During this second inpatient stay, the focus is on the one hand on strengthening personal responsibility and on the other hand on the evaluation of everyday trials and the corresponding consolidation of strategies for combating the eating disorder. We consider it necessary that those affected continue or begin their outpatient psychotherapy between the two treatment periods. In order to better consolidate the success of inpatient treatment, we are in regular contact with the outpatient follow-up treatment (subject to the consent of the person concerned).

This interval therapy not only helps to save costs, but also offers a unique combination of intensive inpatient therapy with the everyday advantages of outpatient treatment, so that experiences and successes from inpatient treatment can always be tested and consolidated under realistic conditions in the home environment. These everyday experiences can then be evaluated again and further stabilized in the following short stationary interval.

Methods of treatment

1st phase: Dosed weight gain
The first goal in treating anorexia is to gain weight as quickly as possible. However, for almost every anorexic adolescent or adult, the fear of weight gain is far too great to make such a change lightheartedly. And to keep doing this for a long time, sometimes months - this is hardly possible without outside help. Even during treatment, conversations, good words, or particularly “delicious” food will not be enough.

The solution to the problem is therefore at the beginning: Food is viewed as a "drug" ... [read more]

The solution to the problem is therefore at the beginning: Food is viewed as a "drug". Precisely because weight gain is so important and at the same time so heavy at the beginning, we take responsibility for it: Every day, based on the increase in the weighing appointments, patients are given the amount of calories they need to achieve the agreed upon create weekly weight gain. Eating together under therapeutic guidance also ensures that this amount of calories is supplied to the body in the correct “dosage”.

The dosed food intake is the focus of the first treatment phase. And this lasts until the BMI has the agreed minimum level (for a 19-year-old this is a BMI of 19 kg / m2, for a 15-year-old this is a BMI of 18 kg / m2; for a male affected person who are 19 years old, the minimum BMI is 18.5 kg / m2 and for a 23-year-old man it is 20 kg / m2). A weight gain of 500 to 1000 grams per week is aimed for. The weight changes are measured on three weighing appointments a week. Afterwards, the meal plans of those affected are adjusted so that the weight can increase in a controlled manner.

During this time, the therapy mainly takes place in small groups, in which those affected are intensively cared for by specially trained therapists and nurses. In small groups, all meals are taken under therapeutic guidance. In group therapy sessions, the anorexics deal with the individual factors and risks of their personal eating behavior (psychoeducational group) and learn to deal with current problems and stress (“topic of the week”). They also learn to deal with states of tension that can occur during the process of weight gain (“skill training”). In addition, regular one-on-one discussions take place, the intensity and frequency of which are adapted to the BMI. In these individual therapies, the first phase of treatment is primarily about weight gain and the possibilities of supporting this process.

2nd phase: increasing personal responsibility
As soon as the healthy BMI is reached, the treatment is individualized and left more to the personal responsibility of those affected. In other words, there is now much more control, e.g. B. in the choice and amount of food, in the individual. This is a very important phase of therapy, because the better the affected person is able to take the necessary changes into their own hands, ie to become an “expert” on their own disease and its treatment, the more successful the therapy will be also remain stable over the long term.

In order to support those affected, this therapy phase takes place ... [read more]

In order to support those affected, this therapy phase takes place primarily as an intensive individual therapy with an average of 10 individual therapy hours (50 minutes each) per week. The individual therapeutic sessions and, above all, practical exercises, in which, in addition to further weight gain, the psychological factors and backgrounds of the vicious circle are now increasingly dealt with, are still supplemented by group therapies.

The daily calorie intake is no longer guaranteed by the group therapist, because those affected can now determine for themselves (and also try out) how much and what they have to eat in order to stabilize a healthy body weight. We also no longer weigh every other day, but only once or twice a week to determine whether the weight has been maintained.

What if the weekly weight gain is not achieved?

There are different consequences for the dosed and self-controlled food intake in the event that the weekly target weight is not reached:

If 500 to 1000 grams are not achieved with the dosed food intake despite the increased and controlled calorie intake, measures are discussed in the rounds and in one-to-one meetings to improve the therapy (e.g. more breaks in between, more calories, more control etc.).

If, however, the minimum weight has fallen below the minimum weight by more than 500 grams during the self-check, those affected will again take part in the meals of the dining group until the minimum weight is reached again.]

Involvement of the family

Especially with young anorexic sufferers, family members, especially the parents, have a great influence on the development of the eating disorder. This is especially true for the course of therapy.

Often parents and siblings are quite helpless and do not know how to ... [read more]

Often parents and siblings are quite helpless and do not know how to behave “correctly”; and it is not uncommon for the family to be considerably burdened by the problems of the adolescent with eating disorders. We want to help reduce this burden by including the family of the person affected in the treatment from the start. Because it is extremely important that all family members are precisely informed about the background of the disease, but above all about the specific procedure in the treatment.

The trial periods between inpatient stays take place in the home environment, i. H. mostly at home in the family of the person concerned. The family can also actively support the person affected during any future inpatient intervals. We help with joint discussions right from the start. We therefore advise that the family should accompany the adolescent or young adult to the initial diagnosis, if possible before the treatment, so that we as the practitioner get the most comprehensive possible impression of the situation at home and the entire family from the beginning Background and procedure in the therapy is informed. This means that everyone knows what to expect in the next few months and what to expect.

During the treatment and beyond, joint conversations take place again and again (regular phone calls with the family, but also personal conversations). In some cases, the family members are also involved in individual therapeutic exercises.

Normalization of eating behavior

Normal eating behavior means:

  1. Sufficient calories to maintain the weight.
  2. Balanced composition of fat, protein, carbohydrates and fiber.
  3. Varied selection of foods.
  4. Distribution over five meals a day.
The normalization happens gradually. First of all, more calories per day are ... [read more]

The normalization happens gradually. First of all, more calories per day are necessary because the weight should not only be maintained, but increased. Right from the start, the focus is on a balanced diet so that the metabolism can normalize quickly and the physical deficiencies are corrected as soon as possible. We also pay attention to the varied selection right from the start, even if there will be some foods that are particularly frightening to those affected. And right from the start, the meal is divided into five meals: breakfast, lunch and dinner, as well as at least two snacks.

Exposure therapy

Some foods will be scary during weight gain, especially those high in fat and carbohydrates. The fear of being fat is also triggered by one's own figure, v. a. if you have already gained some body weight. Then it is usually the particularly "critical" parts of the body such as the stomach, buttocks or thighs that cause this fear. The scales or the moment when the usual clothing becomes too tight also trigger anxiety in some sufferers. This fear can be so bad that it turns out to be panic.

For those affected, for whom this fear is very pronounced, ... [read more]

For those affected, for whom this fear is very pronounced, special therapeutic exercises are carried out at the start of self-controlled weight gain, i.e. only after the minimum BMI, which specifically combat this fear. These exercises are called exposure exercises or exposure therapy. In doing so, those affected are instructed to confront precisely those situations that arouse the fear. So with certain “threatening” dishes, or the sight of your own figure in front of the mirror or in the video. If you then really confront yourself with the fear in these situations, it initially becomes even stronger, but then gradually subsides and disappears more and more with repeated confrontation.

Such exercises are very intense; H. very stressful, but also highly effective. However, they only work from a certain body weight when the improved physical situation means that the brain is able to process such new learning experiences again.

Group therapies

At the beginning of anorexia treatment, i.e. during the dosed weight gain, many therapy elements are carried out in the form of group therapies. These are z. B. the groups in which one eats together under therapeutic guidance. At the beginning of this treatment phase, all meals are consumed in the group.

Another group therapy ("psychoeducational group") is about a better ... [read more]

Another group therapy ("psychoeducational group") is about a better understanding of the connections between eating behavior and metabolism as well as the consequences of disturbed eating behavior: What actually happens in the body when eating behavior is changed? How does this affect the psyche? And what happens if the body gains weight again during the treatment?

Other group therapies (“Topic of the Week”) deal with the sustaining conditions of the vicious cycle of anorexia: What role do conflicts play? How does the body react to stress? What options are there to better deal with stress? What is the importance of the family for the development of anorexia and for the success of the therapy? The “cooking group” is also about relearning how to handle food and cooking independently and in a balanced way.

In the second phase, we also work with those affected to select those group therapies that could be helpful in overcoming individual problems. This can be “social skills training”, the group for “increasing self-esteem”, “body therapy” and “training for emotional regulation”.

Individual therapies

During the first phase of therapy, in addition to group treatments, there are regular individual therapies in which those affected are supported in their efforts to gain weight. The individual therapy is also the place to better understand the background of the disorder as well as the treatment, to solve problems that arise when changing eating behavior, to find ways out of conflicts and stress.

When a healthy BMI is reached, the individual orientation ... [read more]

When a healthy BMI is reached, the individual orientation of the treatment is greatly increased:
The therapy now takes place predominantly as an intensive individual therapy (a total of 10 sessions per week). The exercises, e.g. B. in the context of exposure treatment, become much more intensive and time-consuming, and those affected learn not only through conversations but through new experiences to improve and stabilize their eating behavior. The background conflicts and current problems of those affected are increasingly becoming the focus of treatment.

Medication

Drug therapies have not proven very effective in treating anorexia. There is no drug that can help against anorexia. The only effective means is to change the eating behavior in order to gain sufficient weight steadily and to be able to benefit as optimally as possible from psychotherapy. So: balanced food as medicine, in sufficient dosage.

Only in very rare cases, namely when there are additional psychological or physical disorders, it may be useful or necessary to treat medication, e.g. B. in severe depressive crises, or if the metabolism, circulation or organ functions are so impaired that serious physical damage can only be absorbed by medication. The preparation of a medication as well as possible effects and side effects are of course always discussed in advance with those affected and do not happen without consent.

Rounds

In the phase of controlled weight gain, there are two visits per week. On Mondays, the patients have a conversation with the head psychotherapist. This is about the current issues and conflicts that preoccupy those affected and how the treatment team can provide support. Medical rounds with a senior doctor take place on Wednesdays. The focus here is on the physical problems associated with anorexia (the treatment also interferes with physical processes!).

The visits generally take place as individual visits. The possible use of medication is also decided during the rounds.

Examination by a doctor

Due to the considerable physical damage caused by anorexia, those affected are regularly examined by a doctor right from the start. In particular, blood counts, cardiovascular functions, metabolism and general physical condition must be carefully monitored to ensure that treatment is also achieving its goals on a somatic level.