Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Getting Cinderella to the Ball
- Rebecca F Slack (29 April 2007)
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Exercise in Anorexia Nervosa
- Cathy L Zanker (4 May 2007)
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Is Anorexia Nervosa a Psychotic Illness?
- Joss A Bray (7 May 2007)
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Anorexia nervosa: A radical family intervention deserves repetition
- John S. Price (8 May 2007)
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If Anorexia Nervosa is a Delusional Disorder
- René Sieders (8 May 2007)
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Re: If Anorexia Nervosa is a Delusional Disorder
- Jane Morris, Edinburgh EH10 5HF (11 May 2007)
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Undetected anorexia nervosa
- Janice W Allister (20 May 2007)
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Rebecca F Slack, Medical Student John Radcliffe Hospital, Oxford, OX3 9DU
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Morris and Twaddle have clearly set out a major problem facing clinicians in dealing with anorexia nervosa: the paucity of reliable evidence regarding effective treatment (1). The provision of suitable treatment is undoubtedly essential, but so is adequate access to those facilities, and acceptable follow-up afterwards. Despite NICE guidance suggesting specialist services should be available nationwide (2), most patients still have to reach a severely low bodyweight before they receive specialist input, and even this is highly dependant upon location. Given that there is ample evidence showing a positive correlation between BMI at the start of treatment and successful recovery (3), it is surprising that we have yet to practically incorporate this into standard care. Similarly, the unfortunate pressure to discharge patients at the magic “BMI 19” - which is frequently the most stressful adjustment period - can lead to relapse due to poor support networks. It is of course a question of rationing, but should we not be focusing on assisting all patients with anorexia throughout their illness, no matter their BMI or postcode, as well as evaluating what the best treatment might be? 1.) Morris J, Twaddle S. Anorexia Nervosa. BMJ 2007;334:894-898 2.) National Collaborating Centre for Mental Health Eating disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. National Clinical Practice Guideline CG9. British Psychological Society. 3.) Berkman N, Lohr K, Bulik C. Outcomes of eating disorders: A systemic review of the literature. Int J Eat Disord 2007; 40(4)293-309. Competing interests: None declared |
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Cathy L Zanker, Reader in Exercise Physiology Leeds Metropolitan University
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I enjoyed reading Morris’ and Twaddle’s comprehensive clinical review on anorexia nervosa. I would like to suggest that over-exercise and/or ritualistic exercising in anorexia are practiced for reasons other than ‘burning calories’. Such exercise behaviours can also instil an anorexic individual with low self worth and a fragile physique with a sense of achievement and perception of potency (akin perhaps to being ‘superhuman’). And there can be an ascetic component (‘I am self- disciplined and in control of my body’). I would also suggest that anorexic individuals may be attracted to certain sports not only because they provide a culture in which they can practice their anorexic behaviours. Some individuals start to exercise at a healthy weight, but the act of regular training and aiming for perfection in a sport triggers the weight loss and rigid exercising and diet behaviours that are eventually diagnosed as anorexia nervosa. Given that the endocrine response to prolonged and vigorous exercise is comparable to that of sustained fasting, then undertaking such exercise in a semi-starved state may augment or prolong the sense of ‘numbness’ experienced in anorexia nervosa. Competing interests: None declared |
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Joss A Bray, GP Birtley Medical Centre, Durham Road, Birtley, DH3 1AD
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Dear Editor, When I read the article on anorexia nervosa (Morris and Twaddle BMJ 28 April 2007), I was reminded of something which has bothered me for a long time. Namely, why is anorexia nervosa not classified as a psychotic illness and treated as such? After all, there seems to be a primary somatic delusion - a fixed unshakeable belief that the person is overweight. It might be said that a delusion needs to be out of keeping with the local culture - but this does not really apply - even though we all recognise the media and peer pressure that people are under to be thin. The fact is, the belief that the person is overweight is not shared by the vast majority of our culture when we see the emaciatation that the illness causes. I don't understand what is essentially different from, for example, nihilistic somatic delusions when the person believes they are empty inside or even dead. If anorexia nervosa was seen as a psychotic illness, then antipsychotics would be worth using in their own right - not just for their weight gain side effects. I would be very interested to see a debate about this - perhaps through the pages of the British Medical Journal. Yours sincerely Dr Joss Bray
Competing interests: None declared |
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John S. Price, Retired Odintune Place, Plumpton, BN7 3AN
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Your review of the treatment of anorexia nervosa (1) does not mention the work of De Giacomo and his colleagues in Bari, Italy, who reported a good outcome in 20 out of 21 girls and young women (2-4). Put very simply, their method was to send the girl on holiday with her father for a month, but the theory behind it and the actual technique are quite complex. This prescription is so out of line with current treatment that it would be difficult for any individual practitioner in this country to justify it, but I would think it could be subjected to a randomised controlled trial with proper ethical backing. 1 Jane Morris J, Twaddle S. Anorexia nervosa: clinical review. Br Med J 2007; 334: 894 – 898. 2 De Giacomo, P. Finite Systems and Infinite Interactions: The Logic of Human Interaction and its Application to Psychotherapy. Norfolk CT: Bramble Books, 1993 (pp. 170-181). 3 De Giacomo P, Margari F, Santoni Rugiu A. Short term Interactional Therapy of Anorexia Nervosa. International Journal of Family Psychiatry 1989; 10:111-122. 4 De Giacomo P, Margari F, Santoni Rugiu, A. Successful one session treatments of Anorexia Nervosa: a report on fifteen cases. International Journal of Family Psychiatry 1989;10:123-132. John S. Price, retired psychiatrist, Odintune Place, Plumpton, BN7 3AN Competing interests: none Competing interests: None declared |
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René Sieders, Founder of patients organisation Stichting Anorexia en Boulimia Nervosa. Amorijstraat 10; 6815 GJ Arnhem, The Netherlands
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In his rapid response dated 4 May Dr. Joss A. Bray suggests that if Anorexia Nervosa (AN) is a delusional disorder antipsychotics should be tried in their own right, not just for their weight gain side effects. In their article "Is Anorexia Nervosa a Delusional Disorder?", J.Psychiatric Practice 2007, 13(2): 65-71, Joanna E. Steinglass et al mention that in recent years the utility of antipsychotics in AN has received attention. As early as in 1980 Dr. Christine Lafeber in the Dutch journal Soma & Psyche Wereldwijd No. 6 described that the refusal of food in some AN patients immediately stopped after flufenazine decanoate treatment. In the USA about 5% of the AN patients receive olanzapine which stops the anorectic thinking. I consider the weight gain side effects as undesirable. If the anorectic delusion disappears the weight problems will follow. Perhaps it is good practice to add topiramate to the medicine. Topiramate eliminates this weigh gain side effect and is known to be effective against bulimia nervosa that often accompanies AN. Also in a non psychotherapeutic treatment stepped care should be applied and the approach described by Dr. Agnes Ayton at al in e.g. European Psychiatry 19 (2004): 317-319 should be given a chance before an antipsychotic is given. More literature references on request: r.sieders@chello.nl . Competing interests: None declared |
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Jane Morris, Child & Adolescent Psychiatrist Royal Edinburgh Hospital, Edinburgh EH10 5HF
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The recent rapid responses of Joss A Bray and René Sieders dated 7th and 8th May raise the question of whether Anorexia Nervosa (AN) is a delusional disorder and if so whether antipsychotics should be tried in their own right, not just for their weight gain side effects. In my own practice I have encountered few patients whose drive to be exceedingly thin has been based on any delusional belief that they were fat - although repeated 'body checking' can certainly cause disrupted perception. I would formulate their attitude as closer to an obsessional fear of fatness, resulting in compulsive 'undoing' and 'checking' rituals and leading to a fear of weight gain that grows with avoidance. In this it is like the OCD fear of contamination, where the patient 'feels' dirty unless they have washed far more than the average person, and engages in 'undoing', checking and avoidance. It is interesting to note that OCD patients too can often obtain relief from antipsychotic medications such as risperidone and olanzapine. This may be because of the anxiety relief which they bring, allowing people to tolerate the levels of anxiety which would otherwise result in rituals. I certainly do not prescribe antipsychotics directly for their weight -gaining results, but sometimes offer them for the anxiolytic properties. I am always open about the effects of increased appetite, but would be concerned about the potential dangers of adding topiramate in physically compromised low weight patients. I suggest instead that they are used for a limited period only, until the person has developed the capacity to engage in psychotherapeutic techniques for dealing with their terror - or perhaps until they can book a holday with their father! Seriously, though, we are grateful to Dr Price for drawing our attention to this fascinating research, which deserves fresh attention. Competing interests: I am the lead author of the Review Article |
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Janice W Allister, GP Brinnington SK5 8BS
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How much anorexia nervosa is undetected? Jane Morris refers to the obsessional fears from which people with anorexia suffer which extend to fears of being detected. It is vehemently denied, so the presentation may be through other medical routes(1). Is it also any wonder that those who were subject to the behavioural modification programmes previously favoured are often deeply suspicious and afraid of “psychiatric” intervention? 1. Hediger C, Rost B, Itin P, Cutaneous manifestations in anorexia nervosa. Schwerz Med Wochenschr. 2000 Apr 22; 130 (16): 565-75 (PubMed) Competing interests: None declared |
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