Effective treatment for eating disorders in people with diabetes

Eating disorders may be responsive to psychotherapy. Once again, the number of published intervention studies is small, and several of the studies which have been published lack rigour, statistical power, control groups and follow-up measures. With these caveats in mind, one finds in the literature some evidence that psycho-education directed toward specific cognitive distortions may be effective for individuals with mild to moderate eating disorders in the early stages83. Psycho-educational therapy is a highly structured treatment programme in which therapeutic milieu and didactic instruction are used to help patients understand the nature, aetiology and complications of disordered eating behaviours. The purpose of this intervention is to foster attitudinal and behavioural change in the patient.84 Psychotherapeutic interventions should address the complex of underlying issues which often cause and sustain eating-disordered behaviour. These issues include depression, diminished self-esteem and excessive dependence. Risk-taking behaviour, such as substance abuse and sexual acting out, should also be addressed72. Boehnert and colleagues85 described strategies for the management of patients with diabetes and eating disorders who are severely non-compliant with the medical regimen. These strategies include: (a) The specific monitoring of provider countertransference; (b) the development of a careful working alliance with the patient and his/her family; (c) careful limit setting; and (d) dealing with the patient's frustrated dependency needs. These authors caution that patients must be dealt with honestly, directly and proactively. They suggest that therapy address denial, magical thinking and enhanced vulnerability secondary to diabetes, depression and demoralization.

Given the tremendous difficulties inherent in treating established eating disorders in people with diabetes, health care providers should be familiar with strategies for primary prevention for young female patients who have diabetes. These strategies, discussed fully elsewhere71 include: addressing the drive for thinness and associated body dissatisfaction; de-emphasizing dieting; counselling patients about the need to express negative feelings about diabetes management; helping the patient with conflict over normal developmental struggles; addressing metabolic reactivity during adolescence; and involving the family.

Pharmacotherapy may benefit some patients with eating disorders. Since many patients suffering from eating disorders are also depressed, treatment with any of the antidepressants discussed earlier in this chapter should be considered. Some antidepressants in the SSRI class may positively affect compulsive behaviour, including eating disordered behaviour, as well as depression. Prozac has been used successfully for this purpose, and other agents in the same class may provide similar benefits.

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