Health: How the NHS helps anorexics

THE image of NHS treatment for anorexics is of heartless nurses force-feeding heaps of stodge to a ward of emaciated women. But the reality is very different. Although Petra Taffoy was a patient at a private clinic, there are similar specialist units in NHS hospitals.

St George's Hospital, London, for instance, has acquired an international reputation for its approach, combining diet and weight control with psychological help involving both patient and family. (Its work is described in Anorexia and the Wish to Change: Self Help and Discovery by A H Crisp, Neil Joughin, Christine Halek and Carol Bowyer, available from the Department of Mental Health Sciences, St George's Hospital Medical School, London SW17 ORE, price pounds 5 inc p+p) Patients sign up for up to six years. That's how long Professor Crisp believes it takes for anorexics to 'catch up' on the failed adolescent development which gave rise to their symptoms.

Most anorexics are seen at out-patient clinics. Although doctors have the power under the 1983 Mental Health Act to tube-feed patients whose lives are in danger, this is rare. 'There is little point in dragging someone into hospital, sedating them and filling them full of calories. It's terrifying for the patient and it just confirms to them that they have no control over their body. It also increases the risk of suicide or starvation when they are discharged,' says Dr Diana Tamlyn, consultant psychiatrist at High Royds Hos

pital, Ilkley, Yorkshire.

Modern therapy has been devised to ensure that most patients co-operate with efforts to stabilise and gradually increase their weight. 'Gaining weight has to be at the cental plank of treatment. It is easy to talk around it, but we have to give patients targets. For the most seriously ill in-patients, that might be a couple of pounds a week; less for out-patients,' explains Dr Janet Treasure, who heads the Eating Disorders Unit at the Maudsley Hospital in London.

At the Maudsley, patients are seen weekly for the first four months, monthly for about a year and then followed up for at least a further 12 months. Out-patients are seen mainly on a one-to-one basis by their psychiatrist, though there is more group therapy for those being treated as in-patients. Families are given advice about anorexia but do not routinely take part in therapy sessions.

By contrast, at St George's, family therapy is an essential part of treatment. 'Our approach is based on the view that anorexia is a phobic avoidance response to the psychological strains of adulthood. Patients find the threat of puberty too frightening. We want to re-engage them in the maturation process at the point where they pulled out. That means involving the family to tease out the problems that precipitated the condition,' explains Professor Crisp.

Very depressed patients are likely to be treated with antidepressants although, in general, doctors try to avoid drugs. Research is looking for new approaches to treating what can be a lethal condition. At the Maudsley, for example, psychiatrists are developing a day centre for anorexic patients - something half way between out-patient and in-patient clinics. Patients would stay all day, and take part in a range of activities - group therapy as well as one-to-one.

Cost is now a factor, as Dr Treasure points out: 'In-patient treatment is so expensive that there is pressure for more out- patient care. But we need to show that the long-term effects of out-patient therapy are as good as those achieved with in-patient treatment. We can stop patients deteriorating but will they make a full recovery?'