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Psychiatric Consultation 55 Obsessive-compulsive disorder is another anxiety disorder that may accompany an eating disorder. Indeed, perhaps one-fifth of anorexic patients have some significant obsessional symptoms. Obsessions are recurrent and persistent thoughts or impulses that are experienced as unpleasant, intrusive, and inappropriate (not ordinary worries about real problems). Compulsions are repetitive behaviors, such as hand washing, checking, counting, or praying, in order to reduce distress or to prevent some imagined dreaded event. Since eating disordered patients are often preoccupied with food and exhibit eating behaviors that appear obsessive, the clinician may wonder whether obsessive-compulsive disorder may be an important aspect of the problem. In fact, among anorexic patients, the one-fifth who have clinically significant obsessive symptoms, have behaviors that go well beyond the usual eating disorder food and weight preoccupations. These obsessive/compulsive symptoms vary greatly but are typically rigidly ritualized behaviors such as counting bites or counting the number of times food is chewed. Other rituals might be cutting food into particular shapes, spitting out food according to some ritualized schedule, or a compulsion to tap fingers or feet a particular number of times before each bite or after each swallow. Medication may help to relieve these symptoms, though generally the medications, even when they reduce obsessive/compulsive symptoms, usually have little or no effect on the patient’s nonobsessive anorexic attitudes and behaviors. These are not the only comorbid symptoms and illnesses for which psychiatric consultation may be useful, but they are the most common. Some patients present more unusual or complex symptom pictures, but the general principles elaborated above still apply. It is important to keep in mind what the psychiatrist can and cannot do. The consulting psychiatrist can provide an expert opinion about the patient’s condition from a specialized perspective. The psychiatrist’s role does not involve oversight of the therapy as a whole, nor can the psychiatrist offer opinions about the specifics of the therapy itself. When patients have concerns about the effectiveness of the therapy, a second opinion should be sought to evaluate the course of treatment and make recommendations. While this second opinion can be rendered by a psychiatrist experienced in the treatment of eating disorders, other senior professionals can also provide this service.
56 Psychiatric Consultation When meeting with the psychiatrist, the patient should understand that, for the most part, the therapist and psychiatrist will communicate freely, exchanging whatever information is required to make the consultation effective and precise. However, both parties are bound by the same obligation to respect the patient’s privacy and to observe confidentiality.
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editor BARBARA P. KINOY EATING DISO
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Eating Disorders New Directions in
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To our patients’ children and gra
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viii Contents 3. Psychiatric Consul
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x Foreword Although serious deficie
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preface In 1994, in the first editi
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Preface xv psychological hazards to
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Preface xvii partial, complete, or
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acknowledgments We wish to acknowle
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contributors Debra Bader, CSW, BCD:
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Eating Disorders
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Introduction diane w. mickley I am
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Introduction 3 needs of patients wh
Page 30 and 31: Introduction 5 therapy or on medica
Page 32 and 33: 1 Medical Aspects of Anorexia and B
Page 34 and 35: Medical Aspects of Anorexia and Bul
Page 42 and 43: 2 Recovery Through Nutritional Coun
Page 44 and 45: Recovery Through Nutritional Counse
Page 46 and 47: Lesson 1: Daily Caloric Need and Me
Page 54 and 55: ical activity to a normal level. If
Page 56 and 57: patient who binges, it may be helpf
Page 58 and 59: and allowing herself to consume a l
Page 60 and 61: Figure 2.3 Typical Hunger and Food
Page 62 and 63: herself. She frequently feels hopel
Page 74 and 75: 3 Psychiatric Consultation with Eat
Page 76 and 77: Psychiatric Consultation 51 standab
Page 78 and 79: Psychiatric Consultation 53 difficu
Page 82 and 83: 4 A Family Systems Perspective on R
Page 84 and 85: A Family Systems Perspective on Rec
Page 90 and 91: she calls her mother and tells her
Page 102 and 103: 5 Relationship to Food as to the Wo
Page 104 and 105: iors—somehow to integrate the fra
Page 106 and 107: treatment, Theresa wanted to see an
Page 108 and 109: Relationship to Food as to the Worl
Page 114 and 115: 6 The Therapeutic Use of Humor in t
Page 116 and 117: The Therapeutic Use of Humor 91 Amy
Page 118 and 119: The Therapeutic Use of Humor 93 was
Page 120 and 121: The Therapeutic Use of Humor 95 ass
Page 122 and 123: The Therapeutic Use of Humor 97 Ron
Page 124 and 125: Jodie’s Story 99 capacity to make
Page 126 and 127: Jodie’s Story 101 house and a ter
Page 128 and 129: Jodie’s Story 103 She did not do
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adness. The dream also revealed tha
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8 Eating Disorders and Managed Care
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Eating Disorders and Managed Care 1
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Eating Disorders and Managed Care 1
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Cognitive-Behavioral Therapy and Ot
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10 The Nurse’s Role in a Pilot Pr
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The Nurse’s Role in a Pilot Progr
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The Nurse’s Role in a Pilot Progr
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11 Individual Psychotherapy: A Long
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Individual Psychotherapy 135 Such p
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Individual Psychotherapy 137 empath
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weight and shape, as well as change
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Individual Psychotherapy 141 vomiti
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Individual Psychotherapy 143 During
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Individual Psychotherapy 145 and re
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Individual Psychotherapy 147 Mitche
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Young Adult Women 149 to surface an
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Young Adult Women 151 with their at
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Young Adult Women 153 ing; in fact,
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Young Adult Women 155 doomed, and a
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part of a treatment team where the
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13 Recovery margaret goldkopf-woodt
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Recovery 161 I can appreciate both
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Recovery 163 meant. I certainly cou
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Recovery 165 ate other uncomfortabl
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Recovery 167 connection between my
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Recovery 169 safe place, and our ow
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Recovery 171 My pregnancies and mot
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Recovery 173 They seem to be living
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Recovery 175 Self-disclosure remain
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nel. All that I feared, the hurts I
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Afterword 179 surprisingly rapidly
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Afterword 181 With eating disorders
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Treatment helped me to face life, i
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AA/BA. See American Anorexia/Bulimi
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37; prevention of, 29-31; rigid die
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problems and, 19; events triggering
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Keel, P. K., 180 Keller, H., 133 Ke
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Psychoeducational group therapy, 12
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112-20; IPT, 121-22; psychoeducatio
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