Japanese Journal of General Hospital Psychiatry Vol. 26(2014) No. 2

Treatments for eating disorders are accompanied by various difficulties. First of all, because it is necessary to manage physical conditions of eating-disorder patients because of their malnutrition, general psychiatrists tend to avoid their treatment. However, the burden which psychiatrists should shoulder when they treat eating-disorder patients will be much smaller if they entrust physical management of patients to the physicians whom patients can visit easily. There are several treatments for eating disorders and it is difficult to select one of them for one particular patient. By means of the classification of personality, namely, "reactive/conflictful type", "persistent type", "impulsive type", and that of stage of psychopathology, namely, "acute stage", "subacute stage", "chronic stage", psychiatrists can select one appropriate treatment for the patient. Moreover, eating-disorder patients appear to lack insight to their disease and motivation to be treated and psychiatrists have an impression that it is difficult to treat them, but these appearances come from the fact that their narcissism and addictive trait make them cling to the symptoms of eating disorders. It is necessary to understand their narcissism and lead them to abandon abnormalities of eating as addiction without anxiety. For the treatment for eating disorders, it is important to construct a good therapeutic relationship with patients, considering their actual situations, including physical conditions.

In japan, there are a few hospitals where patients with eating disorder can have inpatient treatment. In our hospital, we started the inpatient treatment for eating disorders in May 2012, and we were confronted with difficult problems. In this paper, we discuss two problems usually happened during inpatient treatment for eating disorders at general hospitals. At first, there is a huge number of urgent hospital admission. Secondly, there are the difficulties to cooperate with medical staffs. There are essential for medical staffs, patients and their families to recognize the unexpected admission is meaningful only for physical treatment, but the effect is limited for psychiatric treatment. Repeated psychological educations for medical staffs should be needed because of the influence of eating disorder psychopathology.

The Kitasato University East Hospital is responsible for community psychiatric medical care as a general hospital with beds for the treatment of psychiatric disorders. We often provide medical care to patients with anorexia nervosa, particularly those with refractory anorexia nervosa accompanied by markedly low weight or resistance to treatment. Treatment programs with behavioral therapy are provided on an outpatient basis, and a strong framework for treatment, with behavioral restrictions, is used on an inpatient basis mainly in severe cases. We are able to counter patients' resistance to treatment with a creative framework for their treatment, and active intervention in the lives of the patients and their families. With such a strong framework, we can also start patients’ oral food intake at an early stage of treatment, and minimize the development of refeeding syndrome. For a wide range of approaches to the treatment of eating disorders, community medical cooperation is required. Therefore, our future goals are to further community network building, and to train as many healthcare providers for treatment as possible.

Many patients suffering from eating disorders (ED) develop an recurrent and debilitating illness course. They have the highest mortality rate of any mental illness, severe and enduring anorexia nervosa (AN) imposes a heavy burden on health and public services, poses a significant burden to carers. Recently, there has been an increase in studies of the neural correlates to pathophysiology of EDs. Drawing from such findings, advances in the brain-directed treatment of AN, such as repetitive transcranial stimulation (rTMS) attract attention. In this manuscript, we described findings from outpatient with treatment-resistant AN, binge-purging type who have received single session of rTMS to the dorsolateral prefrontal cortex (DLPFC). These findings suggest that rTMS has potential as an adjunct to the treatment-resistant AN and requires further study.

Treatment of anorexia nervosa is often accompanied by difficulties. Although psychological and physical approaches are necessary, the patients are not always cooperative to the treatment team that provides such interventions. Case A was a 40-year-old female with a body mass index (BMI) of 9.04kg/m². She did not observe the rules of the psychiatric ward and exerted coercive pressure on inexperienced staff. She seemed to reject every offer of help and we found it difficult to set goals for her. In such a situation, our team gradually became exhausted and felt isolated from other staff. In the treatment of refractory cases, the therapists are likely to find it difficult to seek help from other staff, resulting in feeling of isolation. Opportunities for consulting others regularly, such as multi-disciplinary meetings, would be helpful to guard against such isolation. It is also important to openly discuss limitations of our intervention with patients. This is the effort to partner with a healthy part of her mind. Consequently, case A was transferred to another hospital, but treatment was continued. In the treatment of refractory cases, flexible thinking that enables us to consider various alternatives other than discharge is needed.

Among the patients with anorexia nervosa, some can have insight into their illness and accept treatment without much conflict; others have little insight into their illness and strongly resist treatment with severe behavioral problems. The severity of the pathology of the patients varies. Difficult-to-treat cases are assumed as follows; ① treatment does not progress due to strong treatment resistance, ② response to treatment is good, but relapse and hospitalization are repeated, ③ patients with physical complications, ④ patients with comorbidity of other mental disorders. The therapeutic options for the difficult-to-treat cases are as follows. First, it is important to establish the treatment structure. The severer the pathology of the patient is, the stronger the treatment structure is required to be. Second, it is important to improve the patient's motivation. It is necessary to help the patient to be able to realize a conflict in his/her recovery. Third, it is important to maintain the function of the therapist. It is necessary for the patient and the therapist to avoid falling into a conflictive relationship, and it is necessary to promote treatment in cooperation with multidisciplinary action. It is also necessary to prevent burnout of the therapists and to deal with the countertransference of the therapists.

Stimulus parameters in electroconvulsive therapy are believed to have unique neurobiological effects. Previous studies have demonstrated that briefer pulses, longer duration and lower frequency stimulation require less total charge to induce seizures. The authors argue the potential benefit of lengthening pulse width in situations where adequate seizures cannot be induced at the maximum stimulus charge and duration.

There have been few reports about the changes of autonomic nervous activity during ECT (electroconvulsive therapy). We evaluated heart rate and analysis of heart rate variability (HRV) sequentially using Memcalc Bonarylight software to study these autonomic nervous changes. Heart rate and HRV assessments were performed in three patients (two depression patients, and one schizophrenia patient), suggesting the triphasic stages of cardiac autonomic activity following a seizure. Just after ECT stimulus onset, bradycardia or sinus arrest was observed (the first stage) followed by increase of LF/HF (the second stage). Continuously, HF was increased while LF/HF was decreased (the third stage). Although the first stage and the second stage have been well investigated, this is the first description that elucidated parasympathetic nervous dominance separately from the reduction of sympathetic nervous activity in the third stage using HRV. Future study is needed to determine whether these triphasic stages of cardiac autonomic nervous activity are related to prognosis of ECT treatment and whether they predict an appropriate number of ECT session.

In December 2012, the Japanese General Hospital Psychiatry Survey 2012 sent questionnaires to 909 hospitals considered to provide general hospital psychiatric services, and 581 returned the questionnaires (response rate 63.9 %). The current report demonstrated an overall picture of services provided by general hospital psychiatry (GHP), in terms of structure and function of the institution, staff organization, service profiles, reimbursement of care, and financial situation. The survey demonstrated findings as follows: GHP provided valuable contributions to psychiatric care in emergency medicine, and to treatment of psychiatric disorders with comorbid physical illness, to name a few; the emergency services and treatment of patients with both psychiatric and physical illness were provided mainly in the facilities with psychiatric inpatient wards; the mean number of psychiatric inpatient beds in a hospital as below 50; the mean number of psychiatrists employed in a hospital was about 4; GHP had important therapeutic functions, including modified ECT, psychiatric emergency, and liaison-consultation psychiatry; high reimbursement for the inpatient charge for psychiatric emergency admission was not available to the most facilities; for a psychiatric inpatient ward, average hospitalization income per patient per day was less than half of that for a medical inpatient ward. Financial vulnerabilities observed in the previous surveys remained. Most institutions have not obtained merit from the current payment systems because of an excessively high requirement for the qualification of reimbursement. It is necessary to observe the impact of the revision of medical service fees this year on the financial situation of GHP.