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Sweden: clinician describes treatment for eating disorders including anorexia nervosa.

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Swedish treatment for eating disorders


Wednesday, 28 March 2007



RICHARD AEDY: There's a lot of pressure on women—men too, as well—to be thin and it's common for young women to be on and off diets in that eternal quest for the ideal body type. In a small proportion of cases, however, it becomes much more than a diet. It turns into an eating disorder, either anorexia or bulimia.


Anorexia is a potentially fatal illness, difficult to treat and with high relapse rate. Conventional treatment views anorexia as a psychological disorder but Swedish doctors are taking a different approach, focussing on the physical effects of starvation which they believe drive and sustain the condition.


Forty Australians have been treated in Sweden and now Swedish clinician Dr Cecilia Bergh is in Australia to promote this approach for eating disorders.


Welcome to Life Matters.


Cecilia Bergh: Thank you, thank you for inviting me.


RICHARD AEDY: Can you begin by clarifying the different thinking about anorexia? That the process of starvation produces mental illness rather than the other way round.


Cecilia Bergh: When you lose a bit of weight and increase your physical activity, first you are rewarded, you like to lose weight and even more so when your friends are commenting on your body appearance, that you look great.


Very soon when the starvation continues, you will develop the negative symptoms of starvation. And that is psychiatric symptoms such as anxiety, depression, obsessional acts and thoughts.


And to be able to stand those systems you increase your activity—your physical activity—even more. And it is impossible for parents to interfere with their daughter—it’s mostly girls, young girls, five per cent are boys—it’s almost impossible for the parents to interfere in this process while the daughter is dieting and (inaudible) when she diets.


RICHARD AEDY: Giving the body less food produces, eventually, physical effects in the brain and those physical effects sustain anorexia?


Cecilia Bergh: Yes. All patients with an eating disorder present with psychiatric symptoms. And what we see is: when the eating behaviour normalises, the psychiatric symptoms gradually disappear and when patients are in remission the psychiatric symptoms are gone.


RICHARD AEDY: What’s actually happening in the brain if you starve yourself in this way?


Cecilia Bergh: When you starve yourselves you get an increase of stress hormones and you get rewarded, you feel very good about starvation and your dopamine system is activated and you want to starve even more because of this reward. And then when your body appearance is commented upon and your friends admire you for losing weight, you feel even better.


And then you learn certain behaviours in this starved condition. And those queues that maintain the starved condition—or illicit the distorted eating behaviour—as soon as you are in the same environment you will maintain the starvation.


And therefore, it’s so important that you are moved from the risk environment to extinguish the environmental queues. And that we do by moving the patient away from the risk environment—for example: to a patient apartment or a patient hotel—for a couple of months.


And then when we train the eating behaviour and we normalise the eating behaviour we restore their social life and the patients increase in weight. Then when they are in remission, of course they should be able to go back to their risk environment without relapsing. And this is also a remission criteria, that they can be back in the risk environment without a relapse.


RICHARD AEDY: When you say risk environment, do you mean where they normally live and work?


Cecilia Bergh: Yes, correct.


RICHARD AEDY: When these effects are going on in the brain do they actually stop someone who has anorexia from feeling hungry?


Cecilia Bergh: Where patients with anorexia nervosa are feeling hungry all the time the only thing that is on their mind is eating and dieting. And we see, for example, the anorexics hoarding food, they collect food but they do not eat of it. And they want to be in the kitchen, they want to be involved in preparing food, shopping for food etcetera. And they think about food and dieting all the time. And that is actually a sign of eventually they will put something in their mouth.


RICHARD AEDY: But the changes to the brain chemistry have set up a, kind of, vicious circle which, for the most part, is more strong than the urge to eat.


Cecilia Bergh: Yes and you could also say that we don’t know today who is actually going to develop anorexia nervosa. We know that of all dieting girls, about ten per cent will develop symptoms that reminds us of anorexia nervosa. And about one per cent of all dieting girls and women will eventually develop anorexia nervosa. But we can just speculate about what is the common denominators for those one per cent.


RICHARD AEDY: Can I get you to describe the treatment program in Sweden. What are the steps that patients go through?


Cecilia Bergh: First they are evaluated, their eating behaviour is measured, there is a sematic and psychiatric examination, we are taking a blood count.


And then the treatment starts. And when we start with an individual treatment program or a training program, the first thing that we have to do is to decide the goal weight because when a patient presents for treatment the only thought she has on her mind is: how much will this clinician make me increase in weight?


So therefore, this is the most important issue to take care of—the goal weight. And to be able to do that we need to build confidence with the patient. When you decide a goal weight you start by asking the patient: what was her weight when she lost her period; does she know of a friend that she thinks highly of and like her body appearance—how much does she weigh and what’s her height; does she know of a famous person that she would like to look like and what does she think her weight is. And then we ask her what is her desired weight. And this is a conversation with the patient and she and the clinician agrees upon a goal weight that is not frightening to her.


At the same time we decide her meal plan and that is done from the date that we collect, when we measure her eating behaviour with a medical device that we call a mandometer. And from this date we decide the first eating curb and her perception of society. And this device actually helps her eat and helps her to start to feel … to perceive fullness again. And it relearns how to eat.


And the first curb could, for example, be 50 grams in 18 minutes and then gradually we approach towards normal eating behaviour which is 350 grams in 12 to 15 minutes. And the patient is aware of and part of when we discuss what should be on her plate and it is her eating data—it’s not yours or my eating data—it’s her eating data that we modify towards normality.


Then we also structure her day as far as resting, as far as physical activities, social activities, etcetera. And she has a personal case manager or a clinician that works with her daily until she is in remission.


And, of course, during the treatment time we also measure her progress and then we renegotiate her weight goal because when she has gained a little bit of weight—let’s say two kilos—she is in a completely different state than when she was emaciated. And you can all of a sudden discuss with her, you can argue with her and you can make her understand why she doesn’t function when she is emaciated.


RICHARD AEDY: On Life Matters today our guest is Doctor Cecilia Bergh who’s a Swedish clinician specialising in eating disorders. She’s in Australia to talk about the Swedish approach to curing—or at least helping young women, in particular—who have anorexia, to get better. They have a very successful program at the Karolinska Institute in Stockholm.


Cecilia, it’s clear that this approach is very carefully measured and timed and you use this—I guess it’s a computer program—to reinforce things, but what is it actually that gets them to eat, to put on those first two kilos, where all of a sudden they’re in a different state?


Cecilia Bergh: You start by laying a table together with a patient and she knows that she doesn’t have to drink or to eat. You ask her to pour water a glass and she knows that she doesn’t have to drink. You ask her to bring the glass to her lips, she knows that she doesn’t have to drink. You ask her to put food on the plate and she knows she doesn’t have to eat. And eventually she will put something in her mouth.


And you will never fail with this procedure. And especially when they are part of the di scussion—how much they should eat and why they should eat. And they know that they will not lose control over eating and lose control over their body weight.


RICHARD AEDY: This sounds like an incredibly lengthy process. How long does it take on average to get them back to health—a normal appetite?


Cecilia Bergh: That takes about three to four months to normalise an eating behaviour. And that is from eating nothing or eating very little, to be able to eat the normal meal and that is 350grams in 12 to 15 minutes.


RICHARD AEDY: This is clearly a very expensive way of doing things. How is this funded in Sweden?


Cecilia Bergh: This is funded by the government since 1997 and we are defined as ‘A’ standard care for the treatment of eating disorders.


RICHARD AEDY: What is the plan in Australia? Are you planning to encourage more Australians to come to Sweden, or what?


Cecilia Bergh: The goal is, of course, to treat Australians in Australia. And therefore we started a clinic in Brighton in Melbourne and we already expanding this to a day-care clinic. And the next step is, of course, to include an in-patient unit and an R&D department, so we have a national site in Australia. And then we don’t have to send any patients to Sweden.


I think the Australian clinicians want to see a randomised controlled trial happening in Australia and we welcome that. We would like—and we are now in the position when we have started this clinic—to be able to participate in such a trial where we compare mandometer treatment to standard care. And it’s only by randomised controlled trials you can say if a new treatment is affective or how effective the treatment is.


And then, of course, the next step is to get this trial started and to get funding for this trial.


RICHARD AEDY: Well, Cecilia thanks very much for joining us today.


Cecilia Bergh: Thank you.


RICHARD AEDY: Doctor Cecelia Bergh from The Centre for Eating Disorders in Sweden, recently in Australia to talk about the mandometer treatment program.