Magersucht (Anorexie) und Bulimie
Die Therapie von Patienten mit den Essstörungen Magersucht (Anorexie) und Bulimie muß sich v.a. bei längergristigen Therapien sehr an individuellen und sozialen Ressourcen, Konflikten und Persönlichkeitseigenschaften der Betroffenen orientieren. Über diese individuellen Verläufe der oftmals schwierigen und langwierigen Therapien kann im vorliegenden Rahmen naturgemäß wenig ausgesagt werden. Es soll sich deshalb beschränkt werden auf die Vermittlung einiger grundsätzlicher therapeutischer Prinzipien und im übrigen auf weiterführende spezielle Literatur verwiesen werden.
In der Therapie von Essstörungen geht es allermeist inhaltlich um die Erarbeitung und Sichtbarmachung der Zusammenhänge zwischen der Symptomatik einerseits und abgespaltenen Konflikten und einer zugrundeliegenden Selbstwertproblematik andererseits. Im Therapie-Verlauf muß es gelingen, die „verschobene“ Kontrolle über das Essverhalten wieder an die Stelle zu verpflanzen, wo die Kontrolle früher verloren gegangen ist, nämlich im zwischenmenschlichen Bereich und bei der Vermittlung eigener Bedürfnisse. Es geht ganz wesentlich darum, die verzerrte Selbstwahrnehmung der PatientInnen für das eigene Körpergewicht und die Nahrungsaufnahme durch kognitive Strategien zu korrigieren und die bestehende Phobie gegenüber der Nahrungsaufnahme durch Training und Exposition zu überwinden. Die Symptomatik der Essstörung, die Fressattacken (4000 – 20000 Kalorien pro Essanfall!), die Nahrungsverweigerung, die Abführmaßnahmen etc.. müssen im ersten Therapieschritt ins Zentrum gerückt und überwunden werden. Wichtig ist die Einführung einer geregelten Nahrungsaufnahme mit mehreren über den Tag verteilten Mahlzeiten. Die dabei auftretenden und sich verschärfenden psychischen Störungen müssen davon getrennt behandelt, für sie müssen alternative Konfliktlösungsstrategien erarbeitet werden. Untersuchungen haben interessanter Weise gezeigt, daß Therapien, die im weiteren Verlauf stärker auf interaktionelle Schwierigkeiten und weniger direkt auf das Essverhalten fokussieren, langfristig stabilere Therapieergebnisse erzielen!
Wegen der größeren Bedrohlichkeit der Störung sind die notwendigen therapeutischen Maßnahmen bei der Magersucht (Anorexie) oftmals intensiver als bei der Bulimie, was andererseits häufig auch die inneren „Widerstände“ der PatientInnen gegen die Behandlung forciert. So erfordert die Behandlung der Magersucht in der Regel ein multidisziplinäres Behandlungsteam, dem neben dem Psychotherapeuten eine Diätassistentin und ein somatischer Kollege angehören sollte, damit bei einer Unterschreitung des Gewichtes in einen lebensgefährlichen Bereich schnell gehandelt und eine intensivmedizinische und/oder zumindest stationäre künstliche Ernährung erfolgen kann. Bereits ein Gewichtsverlust von 30% unter das Gewicht vor Krankheitsausbruch (prämorbides Gewicht) stellt eine Indikation für eine stationäre Psychotherapie dar, besonders in Verbindung mit hartnäckiger Verleugnung der Untergewichtigkeit und des Behandlungsbedarfs.
Liegt eine Sollwertabweichung von 50% vor, muß eine intensivmedizinische Überwachung und Therapie erfolgen, um den eingetretenen Elektrolytverlust und die möglichen Folgen zu überwachen und eine angemessen langsame (!) Korrektur vorzunehmen. Diese Korrektur muß notfalls auch gegen den Willen der oder des Betroffenen durchgesetzt werden, da es sich um eine akut lebensbedrohliche Situation handelt!
Bei der Bulimie treten in der Regel weniger bedrohliche Zustände ein, die Störung veräuft zwar oft chronisch, aber weniger dramatisch. Oft besteht äußerlich „Normalgewicht“, die Schwankungen betragen allerdings einen Rahmen von – 30% bis +10% des Normalgewichtes.Zur Anwendung kommen in der Regel kognitive und verhaltenstherapeutische Techniken, allerdings eingebettet in eine empathische therapeutsche Grundhaltung. Häufig wird ein Therapievertrag mit der Bestimmung eines Zielgewichts und einer definierten wöchentlichen Gewichtszunahme (z. B. 0,5 – 2 Kg/Woche) sowie der Festlegung von Sanktionen oder Konsequenzen bei Nichterreichen der Therapieziele aufgesetzt, wobei mit Sanktionen zurückhaltend umgegangen und die Schritte der Gewichtsreduktion klein gewählt werden sollten. Vor allem im ersten Schritt sollte Selbstkontrollprogrammen der Vorzug gegeben werden, um die therapeutische Beziehung nicht unnötig zu belasten (Es gilt: soviel Selbstkontrolle wie möglich!). Die Führung eines Ernährungstagebuches st oft hilfreich. Ganz wesentlich ist auch die sogenannte Psychoedukation, d.h. die Aufklärung über die Erkrankung, die pathophysiologischen Zusammenhänge und die möglichen gefährlichen Folgeschäden. Wichtig (v.a. bei jungen PatientInnen) ist der Einbezug der Familie bzw. die Förderung der emotionalen Loslösung und Übernahme der Eigenverantwortung. Dies bedeutet auch eine gezielte Förderung der sozialen Kompetenzen allgemein. Der Therapieerfolg sollte durch tägliches Wiegen kontrolliert werden.
Weitere hilfreiche Therapieverfahren können sein:
- Entspannungsmethoden (Autogenes Training, progressive Muskelrelaxation)
- Mal- und Gestaltungstherapie, Musiktherapie sowie (in späteren Stadien) Körper- und Bewegungstherapie als non-verbale Verfahren Gruppentherapie
- Medikamente (z. B. Fluctine zur begleitenden Therapie der Bulimie)
Achtung: Da für essgestörte PatientInnen die Auslieferung in eine therapeutische Situation sehr oft einen bedrohlichen „Kontrollverlust“ bedeutet, stellen sich nicht selten sehr frühzeitig „Widerstände“ gegen die Therapie ein, die zum vorzeitigen Abbruch führen können. Ein „Machtkampf“ zwischen Therapeut und PatientIn muß nach m. E. unbedingt vermieden werden. Dabei hängt das Gelingen dann sowohl von den Fähigkeiten des Therapeuten, verschiedene Beziehungen anzubieten, ab als auch von der Intensität der kontrollverlustangst und von der Festigkeit der Persönlichkeitsstruktur des oder der PatientIn.
Hinweise zur Therapie von Binge Eating Disorder und Orthorexie
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