Difficulties for the Gastroenterologist in Engaging and Maintaining Patients in Treatment

Because patients with AN and BN are strongly ambivalent about giving up dieting behavior, gastroenterologists may find themselves unwitting accomplices of patients looking to feel better rather than to get better. Complaints about bloating, early satiety, constipation, nausea, reflux, and abdominal pain may prompt expensive, often invasive diagnostic or therapeutic procedures, the vast majority of which are unnecessary distractions from the task of behavioral change and recovery, which usually results in the resolu tion of all GI complications. Because of their denial and ambivalence, some patients may not be able or willing to accept the gastroenterologist's diagnosis and recommendations. Indeed they may seek second and third opinions and, in extreme cases, may inappropriately seek surgical intervention including colectomy or gastric bypass surgery.

These patients are clearly suffering, and the compassionate physician is faced with the difficult task of setting limits on requests for tests and procedures without being overly paternalistic and persuading patients that they would benefit most from psychiatric behavioral treatment. Because of the morbidity and mortality associated with eating disorders, we feel it is justified to exert a certain amount of pressure on patients with eating disorders to accept appropriate (ie, psychiatric) treatment.

Persuasion should consist of supportive yet repeated reminders that the cause of the patient's GI complaints is the disordered eating behavior itself, that the recommended treatment is behavioral, and that GI interventions are not appropriate in the absence of psychiatric treatment. Involvement of close family in this process is highly recommended, because parents and significant others may help patients accept the need for psychiatric treatment.

If the patient persists in refusing to see an eating disorder specialist, the gastroenterologist may consider terminating treatment. Termination should be framed for the patient as a consequence of his or her decision not to engage in the recommended treatment. Thus, the gastroenterologist allies him or herself with the psychiatrist, rather than allowing the illness-driven manipulation to continue.

Although patients may resist referral to an eating disorders specialist, it is our experience that when engaged in treatment many change their mind, develop increased insight, and, once they recover, are grateful for treatment (Heinberg et al, 2002). Furthermore, motivation for treatment does not appear to significantly affect rates of inpatient weight gain, which are equivalent in voluntarily admitted as compared to involuntarily admitted patients with AN (Russell, 2001).

Breaking Bulimia

Breaking Bulimia

We have all been there: turning to the refrigerator if feeling lonely or bored or indulging in seconds or thirds if strained. But if you suffer from bulimia, the from time to time urge to overeat is more like an obsession.

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