Designing a Viable Treatment program for Anorexia Nervosa - Coursework Example

Designing a Viable Treatment program for Anorexia Nervosa Designing a Viable Treatment program for Anorexia Nervosa Anorexia Nervosa: symptoms and prognosis Anorexia Nervosa is a serious mental illness which is prevalent globally; though the research and empirical studies done on the illness are mostly concentrated to the western world due to greater concerns by the public and medical bodies. This illness is characterized by the “maintenance of an inappropriately low body weight, a relentless pursuit of thinness, and distorted cognitions about body shape and weight” (Attia and Walsh, 2007). The sufferers go through certain life events or mental anxiety which leads to a contorted view of physical beauty and health, as well as personal esteem issues- in order to be fully satisfied and content in their own self the patients of anorexia nervosa follow obsessive compulsive behaviors in order to achieve and maintain their ‘ideal’ weight. Demographically speaking, according to DSM-IV definition of the illness anorexia nervosa women are at higher risk with a lifetime prevalence estimates of .9%, compared with .3% among men (hudson et al, 2006). This study which included a sample size of approximately a 1000 patients, gave evidence of the idea that socioeconomic and cultural factors are often such that they have a more pronounced negative impact on the females in a given population. Body image issues and still considered to be the sole propriety of this demographic by many amateur observers. Amongst the patients, the outcomes of the illness vary greatly. Individuals patients may reach a full recovery through appropriate treatment programs but there is also the chance of chronic and severe psychosocial disability accompanied by physical complications and death estimate of of 5% per decade of follow-up (Attia and Walsh, 2007). Patients also have a high rate of relapse (1–3) and excessive morbidity (Hudson et al, 2006). Lifetime Anorexia Nervosa is associated with a low current BMI and has a few symptoms that are observable and there is almost unanimous evidence available from a large number of studies for the prognosis. Among these, vomiting, bulimia and purgative abuse, chronicity, and features of obsessive-compulsive personality represent unfavorable prognostic factors and may have an effect on the success of treatment and long term improvement. The illness is also difficult to treat successfully as there are many different associated acute and chronic medical problems which may occur as a result of AN including bradycardia, orthostatic hypotension, growth retardation, osteoporosis, and infertility (Steinhausen, 2002). At times, these physical problems are overshadowed by the more persistent psychological distress patients go through, which manifests itself in the form of depression and anxiety ( Lock and Grange, 2001). For patients who are unable to get the medical support needed to navigate their problems the results can be disastrous ranging from frequent relapses to suicide. In a study of 119 series which looked at the information available for 5,590 patients of anorexia nervosa available in English and German literature it was concluded that even with the full range of treatments available for these patients only 46%, fully recovered from anorexia nervosa, with a third improving to a point where they only showed partial or residual features of anorexia nervosa, and 20% remained chronically ill over the long term (Steinhausen, 2002). Comparative studies have shown, anorexia nervosa has a shorter period of onset risk than for the other eating disorders and the lifetime duration of the illness is also smaller with The mean number of years with anorexia nervosa coming out at 1.7 years. With a persistence of 12-months chances of complete and timely recovery are greater than those for other eating disorders (hudson et al, 2006). However, this estimate does not negate the fact that anorexia nervosa as a chronic and malignant condition with the success of the treatments constantly in question. In the study performed by Keel (2003) and Korndörfer (2003) the researchers attempted to quantify the reasons that had the greatest effect on the chances of recovery of female patients of AN. It was found that one overlooked aspect of the illness is the difficulty in social adjustment after the AN has being diagnosed and preliminary treatment started. For the women who had been suffering from AN for a longer duration felt greatly insecure about their own selves and ostracized from the society in general and some of them resorted to alcoholism as a way of dealing. It was identified by both these studies that greater duration of illness at intake and severity of alcohol use disorder during follow-up increased risk of mortality (Keel et al, 2003).  Client condition and situation: In one of the few studies which look at the illness from the patient’s point of view, we get an insight into the perceived causes of both the onset of the illness and the recovery process as identified by the patients themselves. More than one-third of patients highlight family dysfunction as a causative factor that led to the development of their eating disorder, with a 20% citing some kind of stress trigger in their lives (Tozzi, 2002). Though such studies are subjective in nature, they show a high consistency with existing literatures and can help us analyze the situation of the patient ‘Florence’. As an educated and ambitious women of 30, Florence does not have the stereotype conditions that patients of anorexia nervosa are considered to have. By all accounts her life should have been going in a healthy direction, but through the interview it is clear that she has been suffering from the eating disorder since she was a teenager and Florence herself still does not view this as a problem. The problems with body image and the obsession with weight started in adolescence when during puberty she had to face some minor bullying in school. This led her into a spiral of dieting, exercise and finally starvation in order to reach her ‘ideal’ weight- just 90 pounds at a height of 5 feet 8 inches. Despite facing fainting spells, amennorhea (a discontinuation of menstruation periods) and a decreasing body temperature which made her feel ‘always cold’ Florence refused to think that her eating habits were having any adverse effect and in fact thought she looked attractive (Getofeld, 2004). The complication in Florence’ case is that though she was diagnosed with anorexia Nervosa at age 15 and received extensive inpatient and outpatient therapy to equip her with the tools necessary to to overcome her problem, 15 years later Florence has reverted back to obsessively monitoring and controlling her weight and is still in denial about the implications of her illness. This indicates that the therapy was ineffective in the primary goal of changing the mindset of the patient about the physical health and dangers of AN. The initial results were good as Florence managed to bring her eating habits under control, but the psychological distress she felt was not adequately handled through the treatments. Hence, once her life a stressful point Florence relapsed. There are indicators in the interview that Florence had a pressurized childhood with parents who were concerned about her but not able to provide her with the guidance she needed going through puberty. As an adult she still feels the need to compare herself with other family members and to pass evaluations on herself. In order to feel better about herself she concentrates on maintaining optimum physical attractiveness but unfortunately her measure have once again led to an onset of AN. Another thing to note is that the new bout of AN emerged gradually from a strict regime of exercises and calorie counting wand these led to starvation as a tool to lose weight. The patients of Anorexia have to be able to fully understand the nature of their illness and taught how to control the urges which may cause a relapse. Goals of Treatment: Florence has to be placed in a treatment program which allows her to regain her essential body mass under medical attention and gives her the psychological support to understand, accept and control her tendencies towards anorexic behavior: Attainment and maintenance of ideal BMI Learn to incorporate balanced nutrient diet in her daily life Acceptance of the physiological damages that AN can cause Patient should learn to identify the symptoms of AN Learn coping and stress management techniques to productively handle the problems in her life Recognize and ask for professional help if it is needed Address the underlying reasons behind the urge to control her ‘looks’ Identify and relate to the real version of physical attractiveness and beauty These goals will have to be achieved through a therapy program, though there is some empirical data in favor of the use of the compound ‘Flouxetine’ to reduce the rate of relapses the research does not provide conclusive support for the use of drugs to aid AN patients, and certainly not as a single method of treatment. The treatment setting will be short term inpatient term focused on weight regaining and healthy eating habits followed by a longer term duration of outpatient therapy. At this time the inpatient method has not been exclusively researched to prove the ratio of success using a any optimum set of variants (indications of hospitalization, goals, treatment)(Fairburn, 2005). However it is the best place to start with as the initial nutrient intake can be monitored (until a minimum weight threshold is reached and the patient is out of immediate danger); it will also convey to the patient the seriousness of the illness and the hospital setting would be initially conducive to the therapy session. Study and analysis of available outpatient treatment methods: Outpatient treatments form the bulk of treatment plans for Anorexia Nervosa patients, with many of them receiving only this sole treatment. Outpatient therapy also usually follows inpatient or daypatient treatment programs acting as the patient’s support as they re-enter their old lives. The use of and emphasis of individual psychotherapy in the treatment of AN began after the 1960’s. The medical approach in use before with a reliance on neuroleptics was mostly abandoned in favor of psychotherapy which can be defined as a more multifaceted approach that can cover the biological as well as a developmental framework as suited to the needs of the patient. (Steinhausen, 2002). The different approaches for the individual therapy have been researched to a greater extent for adult patients of anorexia Nervosa and it is possible to devise an evidences based approach for the treatment program for Florence. “Cognitive behavior therapy for anorexia nervosa focuses on cognitive and behavioral features associated with the maintenance of eating pathology and uses a schema based approach to address a range of issues” (Pike et al, 2003). Pike and colleague did a study comparing the effects of cognitive behavior therapy with effects of Nutritional counseling for adult patients of AN. Nutritional counseling provides psychoeducational support to the patients with a focus on “specific dietary analyses and balanced meal planning”. The study provided preliminary support for the use of cognitive behavior therapy in posthospitalization treatments as these patients had a lower rate of relapse (22% versus 73%) and the duration of recovery was longer as well. The reasons suggested for this difference in effect include the fact that while Nutritional counseling provides the basic information and guidelines the patients need to recover from the damage of AN, it does not attempt to correct their mind sets or to motivate them to maintain a healthy BMI. Cognitive behavior therapy on the other hand helped the patients form a connection between actions and their thought processes and provided them with the tools to change their life patterns if necessary (Pike et al, 2003). However, further research has indicated that this form of therapy also fails in one aspect that is it relies on the patient to proactively change their habits, but the cognitive rigidity of such patients combined with obsessional personality traits makes that difficult (McIntosh, et al, 2005) The study performed by McIntosh and colleagues (2005) was among the first one which compared cognitive behavior therapy and interpersonal psychotherapy with a control therapy for adults with anorexia nervosa i.e. Nonspecific supportive clinical management using a sample size of 56 female AN patients. Interpersonal psychotherapy makes use of assessment of symptoms of the patients to link interpersonal issues with depression and then attempt to correct these issues so that the patient may be able to recover from the illness. This approach has a moderate to low success rate because it is not directly focused on removing the physical and mental distress which comes with AN but is focused on providing therapy for past stressful experiences. Nonspecific supportive clinical management on the other hand is a combination of clinical management and supportive psychotherapy that provides education, care, and support and develops a therapeutic relationship for the patient that deal directly with the causes and symptoms of the illness. This program also places a great emphasis on resumption of normal eating and the restoration of weight, the dietary patterns and unbalanced nutritional status of the patient is a central part of the program and the patient is provided with information, strategies and the re-learning to help eat normally. The study showed this approach was clearly superior to the other two approaches studied as it provides specific support for all aspects of the problems(McIntosh et al, 2005). This program can also include group therapy for the patients to gain motivation and strength in a more accepting and comfortable environment which can help negate some of the stress and anxiety the patients face when trying to join the normal world. If Florence had still been an adolescent, the Family-based treatment model would have been suitable for her case. This method involves the family as a source of support and monitoring for young patients who greatly benefit from strong family relationships and can gain the motivation to control their urges. FBT has been used since the 1970’s and the Maudsley three phases approach his often used. (Lock and Grange, 2001). Adolescents have a higher chance of full recovery than adult patients and some researchers claim FBT is the better approach out of the others, however this is a debatable point (Fairburn, 2005). Development of a treatment plan Given the evidence in favor of the Nonspecific supportive clinical management, this the method that will be used to treat Florence through the inpatient and outpatient settings. The focus of the program will be to educate Florence about true body perceptions and health requirements in a state where she can get the support of people who have gone through the same experiences. The benefit of this method is that it allows the practitioner the flexibility to design the program as it best suits the patient. Florence needs intensive cognitive behavioral therapy to change her way of thinking about the illness and then accept the measures that will have to be taken in order to repair the damage that has been done to her body. The program will be in following steps: Stage 1: Inpatient treatment to implement a balanced nutritional diet regime and start extensive cognitive behavioral therapy; at least 3 sessions per day up to a two weeks. There will also be sessions with a nutritionist to impart knowledge about proper dietary requirements. Stage 2: Outpatient treatment starts. 4 one-to-one sessions per each week with a therapist where the focus will be on developing self esteem and responsibility towards self; the therapist may work to include family members or friends to increase motivation and sense of comfort as many patients claim that close relationships were a major factor in helping them recover (Tozzi, 2002). One session with a nutritionist will also be there to monitor diet intake. Stage may go on up to 2 months. Stage 3: Sessions will be reduced to 2 per week with the therapist and a bi-weekly session with nutritionist. A group therapy session will be included instead as it is expected the patient will now be returning to normal life and may be helped by forming relationships with relatable people. The focus of one-on-one therapy can now be shifted to discover the underlying causes which led to the onset of AN and takes step to help the patient correct these. Time duration of stage 3 will be 6 months to ensure patient has adequate support. Stage 4: Bi-monthly therapy sessions and a nutritionist session every 2 months will be continued on for at least a year to minimize chances of relapse. Also given Florence’s history, continued professional support may be the key in helping her gain a full recovery. References Pike, K. M., Walsh, B. T, Vitousek, K, Wilson, G. T and Bauer J (2003). Cognitive Behavior Therapy in the Post hospitalization Treatment of Anorexia Nervosa. The American Journal of Psychiatry 160:11, November 2003, 2046-2049. Steinhausen, H-C (2002). The Outcome of Anorexia Nervosa in the 20th Century. The American Journal of Psychiatry, VOL. 159, No. 8, 1284-1293. Keel, P K; Dorer, D J.; Eddy, K T; Franko, D;. Charatan, D L. and Herzog, D B. (2003). Predictors of Mortality in Eating Disorders. Arch Gen Psychiatry. 2003;60(2):179-183. doi:10.1001/archpsyc.60.2.179. McIntosh, V.W. Jordan,J.; Carter, FA., Suzanne E. Luty, Janice M. McKenzie, Cynthia M. Bulik, Christopher M.A. and Peter R. Joyce. (2005). Three Psychotherapies for Anorexia Nervosa: A Randomized, Controlled Trial. The American Journal of Psychiatry, VOL. 162, No. 4, 741-727 Attia, E. and Walsh, B. T (2007). Anorexia Nervosa. The American Journal of Psychiatry, VOL. 164, No. 12, 1805-1810 Fairburn, C G. (2005). Evidence-Based Treatment of Anorexia Nervosa. International Journal of Eating Disorders 2005; 37:526–530. Hudson,J.I,   Hiripi, E, Pope, H G.Jr., and Kessler R C.(2006). The Prevalence and Correlates of Eating Disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007 February 1; 61(3): 348–358. Tozzi, F, Sullivan, P F. Fear, J.L McKenzie, J and Bulik, C M. (2002). Causes and Recovery in Anorexia Nervosa: The Patient’s Perspective. Wiley Periodicals, Inc. DOI: 10.1002/eat.10120, 144-153 Lock, J and Grange, D. L. (2001).Can Family-Based Treatment of Anorexia Nervosa Be Manualized? 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