Eating disorder patients are among the most difficult patients for a doctor. While the majority of people with pathologic symptoms go to the doctor with the aim of freeing themselves from their symptoms, and with strong motivation for therapeutic change, eating disorder patients go to the doctor with dubious intentions.

When eating disorder patients visit the doctor they do not usually do so primarily to ask the doctor to free them from the obsession due to weight and body image control that are their true pathological symptoms, but more often to be helped to regain the control that they think they have lost.

In fact, when these people ask for a medical consultation they do not have any real intention of giving up their weight control. They are in a blind alley and are very distressed by the idea of giving up the defence that for years has protected them from a world which makes them feel weak and inadequate.

According to a number of doctors it is difficult to grant this type of request and tolerate the low treatment motivation that these people show towards therapeutic proposals.

When the majority of these patients decide to see a doctor, after many years of illness, they would like to be helped to change, but, at the same time, they have a terrible fear of change. They fear that if they leave their symptoms, that have become a life style, they will be more vulnerable and unable to face others and will become overwhelmed.

So treatment is possible and, in the majority of cases, will be successful, but only on condition that they understand how much anxiety is hidden behind the appearance of efficiency, obsessiveness and perfectionism that leads to the challenge that these patients usually feign.

Eating disorder patients are like the survivors of a shipwreck who stay alive on a floating piece of wreckage and who, in the end are reached by helicopters who throw them a line and a life buoy. They ask themselves if it is advisable to leave the wood that until now has saved them, to hang onto something more uncertain.

What will happen if they let go of the piece of wood? Will they drown while trying to hold on to the life buoy? And then what if the life buoy is not enough to keep them afloat? And what if the line on the life buoy breaks while the crew are trying to hoist them aboard? And what if the helicopter breaks down and causes further wreckage?

Every time we want to persuade a patient to follow treatment, we try to bear in mind these difficulties. Only in this way can we understand their wishes, and their fear.