case study for anorexia

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Eating Disorder Case Study

• Eating Disorders Case Study

Emma’s* parents, Mr and Mrs James*, were worried about their 16 year old; for over a year she had been on a diet that didn’t seem to stop. They didn’t understand why she was on a diet because she had never been overweight, and it didn't seem as though she had secured any happiness from her diet.

Emma's dieting behaviours made her more withdrawn, depressed and anxious. Every time her parents expressed their concerns, she burst into tears or shouted at them. She had stopped eating with the family and spent most of her time in her bedroom. She was still going to school and doing extremely well in her exams, but her friends were worried about her. Emma’s parents had repeatedly suggested that she went to see the doctor but she insisted that there was nothing wrong with her, asking them why they couldn't just leave her alone. Mr and Mrs James had started to disagree about how to handle Emma's behaviour and argued frequently. As a result of this, Emma's younger brother and sister were very angry with her and wouldn’t talk to her.

Finally, Mr and Mrs James received a phone call from school to say that Emma had fainted and was in hospital.

She was discharged a short while later but with the recommendation that they saw an eating disorders specialist. Emma’s parents took her to the GP who referred her to Priory’s eating disorder service . She was immediately admitted to a Priory hospital as an inpatient because her weight was dangerously low. Emma also had a very low heart rate (bradycardia) and a low temperature (hypothermia).

After a thorough assessment of not only her physical condition, but also her mental health, Emma had repeated blood tests and an electrocardiogram (ECG). Because of her bradycardia and hypothermia she was nursed on bed rest with 24-hour care. She was prescribed a gradually increasing diet by the dietitian, and was supported to increase her dietary intake to improve her physical health and weight.

As her weight went up, Emma's condition improved. She began participating in Priory’s intensive therapy programme and was allocated an individual therapist.

Once Emma’s physical health had improved, she began to participate in group therapy which involved anxiety treatment , body image, cognitive behavioural therapy (CBT) and psychoeducational nutrition groups. Emma and her family also received regular family therapy sessions. In her individual therapy, Emma was able to address a number of life events and issues which had caused her considerable distress prior to the onset of her eating disorder. Emma and her family were also supported to have meals together on the unit and the dietitian advised her family on how to manage her meal plan when she went home. Emma’s parents also attended the parents’ support group.

When Emma was ready for weekend leave, she related much better to her family. They all believed that the family therapy had helped, as well as the carer support group and education sessions.

Emma was pleased that she was supported by the unit and her school to continue studying for her AS levels during her stay at Priory, and held on to her dream of going to university.

16 weeks later, on discharge, Emma had gained control over her eating disorder, dealt with a number of significant life issues and was looking forward to relating more appropriately with her friends again. Her family were more relaxed as they knew how to help Emma, and no longer felt helpless or fearful for the future. *Names have been changed to protect patient identity.

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• v.6(2-3); 2011

An Adolescent with Anorexia Nervosa – A Case Report

MD(UKM), MMedFamMed(UKM)

1. Family Medicine Department, Universiti Kebangsaan Malaysia Medical Centre. (Khairani Omar, Majmin Sheikh Hamzah, Saharudin Ahmad, Noor Azimah Muhammad, Hizlinda Tohid)

A Saharuddin

B Econs(Kobe), MClinPsy(UKM)

2. Psychiatry Department, Universiti Kebangsaan Malaysia Medical Centre. (Loh Sit Fong)

MBBS(Queensland), MMedFamMed(UKM)

MBChB(Manchester), MMedFamMed(UKM)

This case report illustrates an adolescent with clinical presentation of moderate anorexia nervosa with no significant co-morbidities. It highlights the management of anorexia nervosa in the outpatient setting by a multi-disciplinary health care team which includes a family physician, a dietician, a psychologist and a child psychiatrist.

INTRODUCTION

Anorexia nervosa is a chronic eating disorder which primarily affects adolescent girls and young women. 1 The prevalence of anorexia nervosa varies between 0.1-1%. 1 Although the prevalence is low, the morbidity is high and the mortality varies between 0.1-25%. 2 Relapse is common and chances of recovery are less than 50% in 10 years while 25% of the patients remain ill throughout their life. 2

Anorexia nervosa is characterized by weight loss as a consequence of voluntary restricted caloric intake, intense fear for obesity, pre-occupied with body appearance and amenorrhoea. 3 If left untreated, it can lead to serious physical and psychological complications, including osteoporosis, cardiac problems, infertility, malnutrition, depression and death. 4

As the prevalence is expected to be increasing in our community, the primary care physicians ought to be able to identify patients with anorexia nervosa and perhaps co-ordinate the care if the cases are uncomplicated with no significant co-morbidities. This case report describes an adolescent patient presenting with anorexia nervosa and discusses its management using a multidisciplinary approach at an outpatient setting.

CASE ILLUSTRATION

YL, a 14-year-old girl, was brought by her parents to the clinic for amenorrhoea for three months. She attained menarche at 12 years old. Her menstruation cycle had been regular, 28-30 days cycle with five to seven days duration. She denied having any boyfriend or involvement in sexual activity.

The parents also complained that she had been dieting since seven months prior to the clinic visit which had caused her to lose weight. She frequently missed breakfast and lunch. During dinner, she would secretly put the food in a plastic bag and threw it into the dustbin. She avoided food that was high in fat. However, she denied inducing vomiting, purging or doing excessive exercise. She perceived herself as ‘fat’. Prior to this problem, her elder brother used to tease her that she was ‘fat’ and this had initiated her to diet. She also experienced low self-esteem as she believed that she was not pretty and was not happy with her self-image.

YL is the youngest of the two siblings. She described her father as a strict and over-protective parent. She felt that the father was over-controlling her life. She was not able to express herself well and often repressed her feelings, thus felt that she was not able to be her real self. She admitted that she had difficulty in communicating with her father and her elder brother. Her mother was more understanding towards her.

Her parents described her as someone who was rather perfectionist and obsessive in cleanliness and punctuality. She was an above average student academically but she aimed to achieve better results in future. She denied any symptoms of depression. There was no family history of eating disorder in the family.

Clinical examination revealed a thin girl with a body weight of 35.9 kg, height 1.52 m and body mass index (BMI) of 15.5 kg/ m 2 . During the clinic visits, her vital signs were normal and other systems were unremarkable.

Blood investigations which included full blood count, renal profile, liver function test, thyroid profile and serum calcium phosphate were within normal limits. Serum follicle stimulating hormone (FSH), luteinizing hormone (LH) and oestradiol values were low which were consistent with anorexia nervosa disorder. Urine pregnancy test was negative. Pelvic ultrasound and electrocardiogram (ECG) showed no abnormality.

YL was managed at the outpatient clinic. She was referred to the dietician for dietary advice and psychologist for further counselling. A child psychiatrist was also consulted regarding YL’s problems and management. During the follow-up, YL progressed well and her weight increased gradually. She achieved a BMI of 18 and began menstruating again after two years. Her eating habits and negative thoughts also improved with the psychological intervention given.

YL was diagnosed as having anorexia nervosa. Based on ICD-10, the diagnosis is made if: i) the BMI is less than 17.5 kg/m 2 or the body weight is maintained at least 15% below expected weight, ii) weight loss is self-induced by avoidance of fattening foods, exercise, vomiting or purgation, iii) body image distortion manifested as a dread of fatness and iv) amenorrhoea. 5 YL fulfilled the criteria above as she had significant weight loss (BMI of 15.5), avoided fattening food, had body image distortion and amenorrhoea.

The age of onset for anorexia nervosa is usually between 14-19 years old and the aetiology is multi-factorial. 1 There is a higher risk if eating disorder is present in the first degree relative. The affected adolescents are usually described as perfectionist, high achievers and often have low self-esteem. 3 Some are described as angry and disappointed frustrated children who feel unable to challenge the parents, thus developing a coping, obliging self with repressed feelings. 5 Over-protective parents, dysfunctional interactions and poor communication in the family are also known to have a role in the aetiology. 5 Besides that media influence, peer pressure and comments from others are known to be causal factors. 7 YL had all the features above except for family history of eating disorder.

YL was managed at the outpatient setting clinic with the help of other disciplines which included a dietician, a psychologist and a child psychiatrist. It is known that mild to moderate variants of anorexia nervosa with no significant co-morbidities can be treated as outpatient. 8 Indications for admission include hypotension, bradycardia, cardiac arrythmia, electrolyte imbalance, BMI <13, severe depression with suicidal ideation and poor family support. 8 As for YL, there was no indication for admission.

The principle of management for YL with anorexia nervosa includes: i) weight restoration, ii) psychological intervention, iii) medication if necessary and iv) long term follow-up to avoid relapse. 5 , 7 , 8 Teaching patients how to eat is the primary importance in the treatment, thus she was referred to a dietician. She was advised to gain 0.5 to 1 kg of weight per week. 9 She had to fill in a weight diary which required the physician to weigh her twice weekly and monitor her closely to ensure that she complies with the management.

Psychological intervention includes supportive therapy, behavioural intervention, initial assessment for patient’s insight, motivation for recovery and resolving family conflicts. 5 In addition, psychoeducation to patient and family as well as family involvement and support are crucial to help the patient to progress. 6 Behavioural intervention is necessary to improve eating habits and negative thoughts towards her body image. It also helps her to be more flexible in thinking. 8 Medication was not necessary for YL as she did not have depression or obsessive compulsive disorder. 8

The role of the primary care physician is to assess medical complications, monitor weight and nutritional status, assist in the management strategies of other team members and serve as the care co-ordinator. 8 Long term follow-up is necessary to ensure the patient achieves the target weight which is 95-100% of average body weight for height and age and to prevent relapse. 5 , 7 The follow-up schedule depends on the patient’s weight gain, initially weekly, then fortnightly, then monthly and finally three monthly for a year once the target weight is achieved. During the follow-up the physician should assess for complications such as hypotension, arrhythmia, electrolyte imbalance, kidney dysfunction, constipation, elevated liver enzymes, haematological abnormalities, seizures, peripheral neuropathies and endocrine abnormalities such as osteoporosis and amenorrhoea. 8 If complications occur, appropriate management should be given and referral to other specialists is indicated.

Anorexia nervosa is a known healthcare problem among young people in the community. It is important for primary care physicians to be able to identify this disorder and provide prompt management. In mild to moderate cases with no significant co-morbidities, they can be managed by a multi-disciplinary health care team at the outpatient setting. 8 , 10 However, if complications occur or there is continuing weight loss despite close monitoring of outpatient treatment, referral for inpatient care is indicated.

Contributor Information

O Khairani, MD(UKM), MMedFamMed(UKM)

SH Majmin, MD(UKM), MMedFamMed(UKM)

A Saharuddin, MD(UKM), MMedFamMed(UKM)

SF Loh, B Econs(Kobe), MClinPsy(UKM)

NM Azimah, MBBS(Queensland), MMedFamMed(UKM)

H Tohid, MBChB(Manchester), MMedFamMed(UKM)

• Case Report
• Open access
• Published: 26 January 2012

Adolescent male with anorexia nervosa: a case report from Iraq

• Maha S Younis 1 &
• Lava D Ali 2  

Child and Adolescent Psychiatry and Mental Health volume  6 , Article number:  5 ( 2012 ) Cite this article

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This is the first reported case of an adolescent male with anorexia nervosa in Iraq. This disorder is believed to be rare in males across cultures and uncommon for both genders in Arab countries. The patient met the DSM-IV diagnostic criteria for anorexia nervosa. He was hospitalized and received medical and psychiatric treatment at local facilities as discussed below and responded well to treatment.

Anorexia nervosa (AN) is a serious eating disorder with an incidence rate of 135.7 per 100,000 per year in Western countries [ 1 , 2 ] characterized by self-induced starvation in which the body mass index (BMI) is below 17.5. It is associated with an array of signs and symptoms leading to serious medical complications and sometimes death [ 1 – 3 ]. This disorder is characterized by intentionally starving oneself and failing to maintain a minimum body weight that is considered healthy for the person's age and height. The starvation is inflicted by severe calorie restriction and/or purging behavior (self-induced vomiting, use of laxatives, enemas and diuretics). It is believed to be caused by intense fear of gaining weight or becoming fat and is associated with a disturbed body image [ 1 – 3 ].

AN is common in adolescents, with variable data reported about its incidence, psychopathology and outcome. It is often under-diagnosed in males because of the atypical symptoms and rarity of the condition. However, recent studies have demonstrated an increased incidence with remarkable similarities of presentation and psychopathology to that of females, except for amenorrhea [ 4 – 6 ].

Many Arab societies do not consider being overweight a stigma, but instead a sign of good health [ 7 , 8 ]. Thus, anorexia nervosa is scantily documented in the Arab world [ 7 – 9 ] except for a study by Al-Awadi [ 10 ]. Findings revealed that 10.9% of Omani males had disturbed eating attitudes. However, there are no population-based prevalence surveys of AN in the Arab world, and all available published reports agree on its rare incidence [ 11 – 15 ]. The case reported here shows the awareness of being overweight that was sensed at the age of 14, prompted by the harsh comments of the patient's friends. This case reflects anorectic symptoms and signs at an early age, possible due to the athletic ambition of boys in their early teens who want to build a more muscular body [ 4 ].

Case presentation

MR was a 14-year-old Muslim Kurdish student living in Sulimania, northeast of Iraq. His parents were of an educated middle class family who enjoyed good health and stable relationships. He was brought by his mother to the hospital on 18th July 2010 for refusing to eat, which had led to severe weight loss and generalized weakness. His condition began seven months prior when his friends teased him about his plumpness and greedy appetite. Consequently, he started restricting his food intake, avoiding high-calorie foods and indulging routinely in extensive exercise. His parents tried to convince him to eat regular meals, but he refused. He was obsessed about his body shape and measured his waist and thigh circumferences regularly. His food intake decreased rapidly until his daily meal became no more than a cup of yogurt and pieces of cucumber. A few weeks before his visit to the hospital, he experienced severe fatigue, headaches, joints aches and attacks of epigastric pain followed by vomiting. He was treated by the local doctor with multivitamins, anti-emetics and anti-spasmodics, but without improvement.

The patient seemed to be overprotected by his mother. He was the youngest of seven siblings and a clever boy. She described him as being a graceful and obedient child, but somewhat of a perfectionist. There was neither a history of physical or mental illness nor sexual abuse during childhood.

On admission to the hospital, he appeared to be severely ill. He was pale, emaciated and dehydrated. He had lost about 20 kg during the past four months, according to his mother, who reported episodes of irritability and depressed mood with the decrease in weight. His body weight was 28 kg and height 147 cm, which is below the 2nd percentile for his age according to the growth chart. His BMI was 13.0, reflecting a 37% deficit in weight for his height [ 16 ].

Upon examination, he showed generalized muscle wasting, and his skin was dry and covered by lanugo hair. His chest was clear, and he had a scaphoid soft abdomen. His blood pressure was 90/60 mmHg, heart rate 55 bpm and body temperature 37.8°C. Laboratory tests were as follows: blood glucose: 60 mg/dl, blood urea: 18 mg/d, serum sodium: 136 mg/dl, serum creatinine: 0.6 mg/dl, serum cholesterol: 147 mg/dl, WBC: 2200, platelet count: 150000, ESR: 1, and HB: 12 mg/dl. Blood proteins were low with slightly elevated liver enzymes. The blood culture was negative. Thyroid functions tests and steroid hormones were normal. General urine examination and culture revealed an acute bacterial infection, which accounted for his fever. Skull, spine and chest x-ray, brain scan and abdominal ultrasound were all normal. A previous gastroscopy at another hospital showed mild mucosal atrophy. An ECG revealed sinus bradycardia. The patient was smaller and shorter than his matching peers. He looked attentive but indifferent to his serious condition. His speech was rational and did not reveal delusions or hallucinations. However, he expressed strong denial of his body appearance and insisted he had a normal body shape. His mood was depressed, but he denied suicidal ideation.

The patient was admitted on 18th July 2010 to Sulimania General Hospital and was referred later for psychiatric consultation. A liaison treatment plan was designed by the attending physician, psychiatrist and dietitian focusing on scheduled feeding under the dietitian's advice, which was to be achieved through a nasogastric tube. Caloric intake was measured to reach 2000 calories per day, and he was instructed to rest in bed under a nurse's supervision. This ameliorated his previous hypoglycemic attacks. He was prescribed oral cephalosporin 250 mg qds to treat his urinary infection. On the second day of his admission, the psychiatrist prescribed a 20 mg daily dose of fluoxetine to treat his depressed mood and food-related obsessions. A 5 mg nightly dose of olanzapine was prescribed to resolve the distorted thoughts about his body image and promote sedation. Nasogastric refeeding was continued for the first week in the hospital until oral feeding was established. The tube was removed on the 6th day. In addition, a few sessions of cognitive psychotherapy were conducted with the patient.

At the end of the third week, he became more realistic and rational about his body weight and was more compliant with eating normal meals. His mood and irritability improved. He was discharged after 24 days in the hospital, advised to abide by the regulations of the dietitian and continue his medication for three months. He was to report to the psychiatry clinic on alternate weeks. His body weight had increased to 30 kg.

He did not keep his appointments and appeared six months later at the clinic weighing 38 kg. He was enjoying better health, although he was still having eating peculiarities. He had maintained his daily exercise but was reluctant to gain more weight. After consultation, he was advised to continue on fluoxetine for another three months. The family was advised to escort him regularly for psychotherapy sessions and watch his dietary intake.

Conclusions

The clinical presentation of anorexia nervosa among males is rare [ 2 , 5 , 6 ], with many subclinical cases being overlooked. Males and females tend to share similar clinical presentation and psychopathology except for amenorrhea. In addition, males are inclined towards strenuous exercise, have sexual concerns and show psychiatric comorbidity more often than females. Reports about age of onset in males vary. However, it is agreed that males tend to present at a later age than females probably because of the later onset of puberty and different social roles [ 5 , 6 , 17 ].

The influence of culture on the development of AN has long been appreciated and is believed to be more prevalent in industrialized and Western cultures, being far more common among young females than males and reflecting cross-cultural differences in the importance of thinness for women [ 7 , 8 , 17 , 18 ]. Apart from a few studies showing a propensity for anorexic-like behavior, the available literature indicates that anorexia nervosa is rare among females in the Arab culture [ 8 – 10 , 13 , 19 ]. Traditional values and cultural norms regards thinness as socially undesirable, with plumpness considered a sign of wellbeing in both genders and viewed as a symbol of fertility and womanhood in females [ 8 , 10 , 19 , 20 ]. A positive relationship between increased body weight and higher social class has been observed in the Arab culture, contrary to Western ideals [ 8 , 10 , 13 , 19 , 20 ]. It has been suggested in the available literature that exposure to Western values regarding body shape and weight can be blamed for the occurrence of anorexia nervosa in the Arab region [ 1 , 9 , 10 , 14 , 20 ].

Iraq, like many other Arab countries, is known for using English as the teaching medium, thus facilitating access to Western culture through satellite television, the Internet and periodicals. It is believed that exposure to the differences between the two cultures contributes to the etiology of eating disorders [ 21 – 23 ]. Through recent globalization, Western cultural norms have infiltrated many Arab societies and changed local traditional values regarding ideal body shape and weight. MR was a boy from an educated middle class family residing in a suburban area north of Iraq where local values did not favor thinness. There was easy access to media, including the Internet, which might have contributed to an internal conflict regarding body image.

We believe that nutritional correction by oral and nasogastric feeding helped in weight restoration of this patient, which is a prerequisite for the effective use of psychotropic interventions [ 24 ]. Using an oral antidepressant (flouxetine, 20 mg) improved the patient's gloom and irritability. The oral antipsychotic (olanzaine, 5 mg) ameliorated his weight-related beliefs and probably helped him gain weight by the end of the second week with no serious side effects apart from daytime sleepiness. Medicating anorexic patients with a combination of an antidepressant and antipsychotic has previously been tried and shown to be successful [ 10 , 19 ].

The patient was diagnosed with anorexia nervosa, according to DSM-IV diagnostic criteria and the Eating Disorder Inventory (EDI). His history and personality profile together with the nurturing attitude of his mother were strikingly similar to many previous reports in Western and Arab societies [ 25 , 26 ]. Despite the short period of hospitalization, lack of a special unit for eating disorders and brief psychotherapy, our patient showed significant improvement as a result of the available medical and psychiatric care he received.

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Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

The patient at admission to the hospital medical ward in July 2010 .

The patient with a nasogastric tube 2 days after admission .

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Acknowledgements

We are grateful to Dr Rebwar Ghareeb, the attending consultant psychiatrist who referred the patient and agreed to publish this case report. We are also indebted to Dr Hazim Obaydi, consultant psychiatrist at Hertfordshire Partnership NHS Foundation Trust, for his valuable review of this paper.

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Maha S Younis

Suliamania University Hospital, Kurdistan region, Iraq

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Younis, M.S., Ali, L.D. Adolescent male with anorexia nervosa: a case report from Iraq. Child Adolesc Psychiatry Ment Health 6 , 5 (2012). https://doi.org/10.1186/1753-2000-6-5

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Received : 27 September 2011

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DOI : https://doi.org/10.1186/1753-2000-6-5

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“It’s Never About the Food” – an Anorexia Case Study

By: Debby ☂

In a 2015 report commissioned by the UK charity Beating Eating Disorders (B-EAT), it was estimated that over 725,000 Brits suffer from an eating disorder . Of that number, around 10% are thought to suffer from anorexia nervosa.

Laura* is one of the lucky ones who found support for her struggles with anorexia and recovered. Now happily married and a mother herself, she shares her story in hopes that parents and loved ones of anorexics can understand and help.

*name changed to protect privacy

Safety and control – an anorexia case study

It started when my grandma died when I was thirteen. We’d always been really close and I had spent many happy weekends and holidays with her. I couldn’t understand why she had to be taken from me, and in hindsight I think it sparked depression as from that moment things started to spiral out of control.

It’s funny I’d use the word control, as if there is one thing I understand now is that anorexia isn’t about food at all, but about control. Control and safety.

The world didn’t seem so safe without my Gran, and somehow I must have blamed myself, as what was growing was definitely self-hatred.

By: Steve Bozak

At the time I was a little chubby, and the kids at school would tease me for my chubby cheeks and clothes that were too tight. Even family members commented on the ‘puppy fat’ I was carrying and one well-meaning aunt suggested to my mum I was put on a diet, which didn’t help.

The reality was I had friends, puberty was creeping up, I was bright and liked school. Sure, I was carrying a little extra weight, but it wasn’t anything serious and would have gone in time.

But in my mind back then, I wasn’t pretty enough, I wasn’t tall enough, I was flat chested, I had spots, my hair was brown not blond, I didn’t fit in the popular clique.

And then I just summarised all that into being because I was fat. The only thing that could make me not a failure and geek was if I was thin. Really thin. I admired girls where I could see their bones. I wanted that, to see my hip bones jut out, my collarbone visible.

By: Gareth Williams

The changes were small – at first. We had a canteen that was packed with chips, beans and burgers but I started opting for the jacket potato, leaving half, and then just picking. Everyone was so busy talking about boys and pop groups they didn’t care what I was eating and no one ever commented.

Rather than hate cross-country I began to love it, as I knew that the pain in my chest equaled fat coming off my body.

By the time I turned 14 all I thought about was losing weight. I was young, there was no internet, no support forums or chat rooms, how was I to know there was anything wrong? I had never even heard the word anorexia.

But then a teacher at school took me aside to have a chat. She had seen me going from being a bubbly little thing with a smiley face and healthy appetite to a tiny, fragile girl who was always in cardigans and jumpers with blue fingers. I brushed it off out of utter embarrassment, said it was family genes and a fast metabolism, but headed straight to the library to look it up.

Anorexia was described in the encyclopaedia as a serious mental illness and sufferers would do anything to lose weight and maintain that loss. I didn’t think I was mental at all, I just wanted to be thin. I didn’t ever overeat , purge or vomit and I didn’t use laxatives.

So I put anorexia to the back of my mind and carried on with my quest.

Writing this I feel sad that only that teacher did anything. I can’t help but think, how did nobody else notice? Why did nobody else talk to me? The child inside of me doesn’t understand, even though as an adult and now mother myself I do see that my parents did know there was something wrong but just didn’t know what to do about it. It was the 1980s, people weren’t talking about eating disorders as much back then.

And like all good anorexics, I was secretive. I would lie that I had eaten and I was fine. Hide food and throw it in the bin on the way to school. I never went out with friends if food was involved – I pretended I was busy, or wasn’t allowed out.

Even at six-and-a-half stone I still thought I was fat and knew that if I wanted to hit the jackpot and see my bones sticking out then I would have to keep going.

My stomach hurt all the time, I was dizzy whenever I stood up, and my periods were nonexistent. Then there was the cold – I was always so chilly that sometimes my teeth chattered. And the fatigue. Nobody ever talks about how exhausting anorexia is. You just have no energy at all .

At fifteen I hit my goal and reached six stone. I wore tiny skirts. I felt so proud of my little legs sticking out. And it seemed to be working. Boys noticed me, and the cool girls did want to be my friend.

As a child I thought my newfound popularity was because I was thin, but now I can see that maybe it was because I sadly felt better about myself and thought I was more interesting thin. The other kids probably just bought into my confidence, not knowing that they were encouraging my illness.

Six stone must have looked very scary. My mother did, in the end, march me to the doctors. Did it matter by then? Not at all. I thought I looked great and they were jealous. I told them I would start to eat, and I’m afraid they believed me and that was that.

We sat in her room, wrapped in blankets and holding hot water bottles in the middle of a hot August, discussing how many apples and rice cakes we were keeping it to a day, and what size kids clothes we now fit into.

And then, at my summer job at a local cafe, I fainted. Right in front of customers and other staff. It was mortifying. And somehow, lying on the floor and looking up at their shocked and concerned faces, I woke up a little. I knew I’d taken it too far.

I started to notice the bad side of starving myself. The fur that had grown on my face, the way my hip bones dug into my mattress making it hard for me to sleep. I wasn’t proud of the problems it was causing at home and I hated having to lie all the time.

I went back to the GP, by myself this time, and we talked. He was kind, and he understood, but he showed me some tough love. These are the facts, he said. If you don’t stop you might never have kids, you could have a heart attack, your hair could fall out, your bones could crumble away and ultimately you might die.

I walked out of there shocked, a bit angry at him for laying in to me, but ultimately, with the decision taken that I wanted to get better. I was about to start sixth form. I knew that I needed to grow up and be responsible.

I won’t lie. Recovery was hard. Even eating a tuna sandwich was traumatic and it took over an hour the first time. I was convinced that everything I ate was going to make me fat.

More than anything, looking at food on my plate that I knew I had to eat, I felt vulnerable. Not eating had in a weird way been my way of feeling safe.

I started being open about my struggles, which meant my friends and family could finally support me and there was no more hiding.

I kept seeing the GP who then got me further help that I needed. I think what worked about eating disorder counselling was to have someone who wasn’t angry or scared that I was struggling, and didn’t force advice on me, but just listened.

When asked for advice for handling a loved one who is anorexic, that is the best tip I can offer – listen. Be there for them.

I think changing schools was lucky timing as my new friends were brilliant, and it let me create a new life for myself.

Because really, recovering from anorexia isn’t about the food, either. It’s about deciding to live, and for me that meant doing things that made me want to live. Laughing with my friends, for starters.

Being able to go out for dinner with my friends on my 17th birthday was a massive achievement and with thirty of us sat around the table it dawned on me that you didn’t need to be skeletal to be liked. You needed to be you. You needed to be comfortable in your own skin.

You needed to be happy. Not in a big, perfect, showy way. Just in a way that works for you.

Even now in my forties there are times when I think I am not attractive enough , not smart enough, not popular enough, not successful enough. But I catch the voice now, and rather than listen to it, I tell it, no. I am good enough. And now, when I see my sons smile at me and hear my husband tell me he loves me, I know it was all worth it and appreciate my healthy life so much.

Have you struggled with anorexia? Want to share your experience? Do so below.

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Anorexia nervosa: a Case Study

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Richard L. Steele; Anorexia nervosa: a Case Study. Psychother Psychosom 1 January 1976; 27 (1): 47–53. https://doi.org/10.1159/000286995

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D.R., a single 19-year-old female experiencing anorexia nervosa, was admitted to a mental health center inpatient unit weighing 64 lb, approximately 54 lb underweight, with liver, kidney, and pancreas damage. D.R. was hospitalized for 59 days. Treatment consisted of utilizing a hierarchy of reinforcements in the form of privileges mutually agreed upon between patient and therapist, psychodynamic and supportive psychotherapy, and involvement in the ward milieu therapeutic program. All privileges had to be earned. Access to food was controlled by the staff. For pounds gained privileges were granted, for pounds lost privileges were curtailed. Dynamically, D.R.’s eating behavior was viewed as an unconscious spite and revenge reaction toward her parents as well as an attempt to elicit attention. At the time of discharge D.R. weighed 104.5 lb. Prior to discharge D.R. agreed that if her weight dropped below 100 lb she would return for readmission. Five months later D.R/s weight stabilized between 102 and 104 lb. Two years later, D.R.’s weight remains at that level. The study cautions against using solely a behavior modification approach in the treatment of anorexia nervosa.

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