eating disorders
Eating disorders: case study This case study is based on my experiences with several patients, although there was one who features more strongly. Details have been altered to preserve the confidentiality of the patients concerned, as well as giving an authentic overview of the challenges of in-patient treatment for people who are seriously ill with restrictive eating disorders.
Sheila Turner Sheila retired from her post as Community Dietetic Lead a year ago and continues to provide and develop a private dietetic service within a residential clinic for women and adolescents.
Patient: Female, aged 23. Median weight: 63.3 kg with fat 21 per cent or more. Diagnosis: Restricting type of anorexia nervosa of seven years duration. Medication: Mirtazapine, Forceval Liquid, Movicol, ADCal, initially thiamine and strong B for 10 days.
Treatments: • Initial 17-day assessment with refeeding, treatment for physical health and key worker sessions. • At day 17 review, decision to add CBT and Body Image Therapy at BMI 15. • Weekly review in multidisciplinary meeting. Family therapy added after four months.
Extracts from Dietetic Reports BMI 13.8 (kg/m2) Weight 35kg (Ht =1.59m) Fat 3%
March
Admission to specialised residential clinic for treatment of eating disorders. Admission was from a community service where there was a diet plan, but she had been able to follow that and most of her admitted intake was salad and some starch. Weight had been managed by restriction of food, physical activity and some purging, although purging was limited by her financial position where she would be unable to afford to waste the food. Laxatives x 2 a week claimed to be for constipation. Some superficial cutting, but not contemplating self-harm at admission. Blood sugars low normal and urea high normal, other electrolytes within normal range. Big fear food was cheese and “anything greasy”. Vegetarian. Although the refeeding risk was limited by her previous intake, it was planned that she would start on quarter portions and no snacks, milk at bedtime. If the refeeding risk had been higher, she would have started on 20 percent of 1,400 kcals, including milk, so would have been offered about the amount she was prepared to eat.
16.3.
One meal increased to half, but very little being eaten.
17.3.
Breakfast and tea now half. Eating a bit better, but refusing anything sweet including jam on toast.
18.3.
All meals to half. Accepting all eight drinks.
Wt 34.5kg Urea now normal
20.3.
Beginning sequential increase to full portions under guidance of key nurse. Refusing yoghurt.
No signs of refeeding syndrome
1.5.
Spends all her time thinking about food and much of contact time arguing against increase or even current amount. Keeps talking about her fear of grease and noncompliance about cheese. Monosyllabic and easily offended. Finds it difficult to socialise with other patients
Wt 36.5kg BMI 14.4 (kg/m2) Fat 3%
5.6.
Managing full diet apart from problems with cheese and compound dishes like lasagne. Still focusing on fat especially in cooked meals. Introduced savoury snacks of 250 to 300 kcals – rather limited without cheese. Still determined to avoid sweet foods because she “does not deserve nice things”. Will sometimes eat yoghurt and banana. To try dried fruits.
Wt 38.3kg, BMI 15.1 (kg/m2),Fat 3.5% Allowed to use stairs and offered five minutes activity a day
15.7.
Patient agreed to try mindfulness with a sweet food of her choice along with myself and her support key worker.
July
Continuing to gain weight on full portions with two savoury snacks. Very slow with some non-compliance and some inadequate snacks. As planned, reluctantly tried mindfulness using yoghurt raisins. Achieved four raisins and felt she may have enjoyed them a bit.
Wt 40.3kg BMI 15.9 (kg/m2)
NHDmag.com December 2014 / January 2015 - Issue 100
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