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Tuesday, 28 August 2012

Precisely which bit of normalised nutrition are you finding it difficult to understand?

Normalising nutrition.  Restoring regular eating.

I am calling out one of our UK inpatient units and CAMHS teams today (and grumbling at another for excessive tubeage) and a Primary Care Trust.

Firstly, Huntercombe Maidenhead: Kudos on weight restoration but restoring someone's weight who has anorexia nervosa, purely through using a NG tube alone for 12 weeks - WTF? However, I do understand funding was withdrawn before you felt she was ready.

Croydon PCT - You withdrew the funding for the Huntercombe, despite her only getting nourishment through an NG tube.  Why?   At what point did you think that a 16 year old who "refused to commit" to her recovery was in any way fit to be moved? (See Point and from the NICE Guidelines for Eating Disorders below)  This child was so sick in June that you ended up having to pay to treat her for infections on her self-inflicted wounds and can we talk about the ligatures she had made and the multiple admission for attempted suicide and serious self harm in 2011?.  Did it not occur to you that she was at risk of severe self-harm and suicide and that moving her would be detrimental to her?  What exactly is the cut off point financially for the life of a 16 year old girl?

SLAM Camhs - why do you apply for and get a section for this seriously sick child the first week in August and then decide to plan for her discharge 3 weeks later?  Is she better?  Eating anything?  Drinking anything (including water) other than 1600 cals worth of Fortisip a day?  If so, please share.  How do you expect her parents to cope with her, if a specialist unit is making no headway?  Is she one of those cases that you do not want mucking up your "success" figures?  Is her recovery just not worth it?

Just for you SLAM CAMHS

"4.4.4 Physical management of anorexia nervosa

Anorexia nervosa carries considerable risk of serious physical morbidity. Awareness of the risk, careful monitoring and, where appropriate, close liaison with an experienced physician are important in the management of the physical complications of anorexia nervosa.

Managing weight gain In most patients with anorexia nervosa an average weekly weight gain of 0.5 to 1 kg in inpatient settings and 0.5 kg in outpatient settings should be an aim of treatment. This requires about 3500 to 7000 extra calories a week. (C)" (NICE Guidelines for Eating Disorders)

That is 500 to 1000 calories PER DAY in excess of the RDA for a 16 year old girl of 2,110.  This child should be having a MINIMUM of 2,610 calories per day - that would make your 1,600 calories of fortisip a SEVERE WEIGHT LOSS PROGRAMME.  Just in case you haven't noticed, she has anorexia nervosa......

Just a few quotes from the NICE Guidelines, in case you haven't read them for the PCT - they obviously don't have a legal obligation to follow them but it would be nice to know that someone had read them, understood them and taken a decision on this particular case from a point of knowledge, rather than just assuming that this child was wilfully starving to death as the result of some trauma and she should pull herself together and want to get better.......

Many people with anorexia nervosa find it hard to acknowledge that they have a problem and are ambivalent about change. This contributes to their reluctance to engage with treatment and services. A precondition for any successful psychological treatment is the effective engagement of the patient in the treatment plan. Health care professionals involved in the treatment of anorexia nervosa should take time to build an empathic, supportive and collaborative relationship with patients and, if applicable, their carers. This should be regarded as an essential element of the care offered. Motivation to change may go up and down over the course of treatment and the therapist needs to remain sensitive to this. Special challenges in the treatment of anorexia nervosa include the highly positive value placed by people with anorexia nervosa on some of their symptoms, and their denial of the potentially life-threatening nature of their disorder.

It is common that individuals remain ambivalent about treatment received, particularly those with anorexia nervosa (Brinch et al., 1988, Carnell, 1998). Those who have anorexia nervosa in adolescence appear most likely to recall their treatment (whether inpatient or outpatient) in negative terms. This attitude tends to persist and does not appear to be related to treatment duration or intensity (Brinch et al., 1988; Buston, 2002). The ambivalence characteristic of people with eating disorders in relation to treatment may be an important issue. This ambivalence stems in part from the functional aspects of the disorder itself, and must form part of the backdrop against which views about satisfaction are interpreted. In this respect it might be understandable that some suggest that unlike other psychiatric disorders, patient dissatisfaction will tend to be high in eating disorders (e.g. Swain Campbell et al., 2001).

Anorexia nervosa is associated with an increased mortality (Nielsen, 2001). People at risk of death because of their extreme physical state are likely to be considered – appropriately – for admission to hospital. However, there is unlikely to be systematic evidence to support such practice. Furthermore, people suffering from anorexia nervosa may be at increased risk of self-harm and suicide (Favaro & Santonastaso, 2000). Inpatient treatment or day patient treatment should be considered for people with anorexia nervosa whose disorder has not improved with appropriate outpatient treatment, or for whom there is a significant risk of suicide or severe self-harm. (C) Inpatient treatment should be considered for people with anorexia nervosa whose disorder is associated with high or moderate physical risk. (C) Where inpatient management is required, this should be provided within a reasonable travelling distance to enable the involvement of relatives and carers in treatment, to maintain social and occupational links and to avoid difficulty in transition between primary and secondary care services. This is
particularly important in the treatment of children and adolescents. (C) People with anorexia nervosa requiring inpatient treatment should normally be admitted to a setting that can provide the skilled implementation of refeeding with careful physical monitoring (particularly in the first few days of refeeding) and in combination with psychosocial interventions. (C)* Health care professionals without specialist experience in eating disorders,  or in situations of uncertainty, should consider seeking advice from an appropriate specialist when contemplating a compulsory admission for a patient with anorexia nervosa regardless of the age of the patient. (C) Health care professionals managing patients with anorexia nervosa, especially those with the binge-purging sub-type, should be aware of the increased risk of self-harm and suicide, particularly at times of transition between services or service settings.

I just find this kind of treatment woeful, damaging, life threatening, neglectful and I am thoroughly ASHAMED to be British today.


  1. These are young people's lives they are gambling with...

  2. I despair. Why can everyone just make it up as they go along?

    It's like anorexia writes policy and approves funding.

  3. The suffering that could be prevented that isn't. It hurts my soul.