Emily* is a 24-year-old single female with anorexia nervosa and depression who was referred for an assessment due to restricting food intake, being underweight with some alcohol abuse. Emily had been living in a share house but has returned to living with her parents due to her worsening mental health.
Anorexia nervosa is a psychiatric disease in which patients restrict their food intake (by extreme diets, purging and excessive exercise). Patients become severely underweight and do not realise it and have a distorted perception of weight. But eating disorders are treatable and can lead to good outcomes.
Emily presents to my outpatient rooms with her father, Daniel. She tells me about increased food restricting and alcohol abuse since the breakdown of a long-term relationship. Previously weighing 60kg, she has lost 15kg over a space of a few months. This was achieved with a diet consisting mostly of coffee, vodka binges on weekends, light salads and smoothies.
In addition, Emily makes sure she takes 20,000 steps a day and religiously monitors this on her smartwatch. Emily’s symptoms include chronic lethargy, lack of a period, poor concentration, increasing depression and self-harming. Emily’s father voices his frustration with Emily and mental health services in general, citing the difficulty of finding eating disorder specialists and eating disorder clinics. He says: “All Emily needs to do is eat and we wouldn’t be here.”
This is a common, albeit unhelpful, statement many family members or partners make. Eating disorders are not a choice and are an actual disease. Daniel says he understands this but I give him space to vent his frustrations.
Examining Emily, I notice how underweight and gaunt she looks. Her hair is thinning and she wears oversized clothing to hide her figure and superficial cutting on her forearms. She comments that she is too fat and needs to lose more weight.
I recommend an admission to the eating disorders unit. Fortunately, both Emily and her father agree to this. The first week on the ward is a struggle for Emily as meals are monitored by nurses and dieticians. Emily must attend all group therapy to stay in the program and, though initially reluctant, she begins to eat regular meals three times a day.
She eventually settles on the ward and this is helped by meeting other patients similar to her – usually young females from ages 16 to 30. It helps that Emily can see other patients going through similar issues. Emily’s fluid intake is monitored and she is encouraged to drink more fluids during the day and we manage to avoid an intravenous drip. Her ECG shows a low but normal heart rate. I also discuss medications with Emily, often a point of contention with anorexic patients.
Another important part of treatment is psycho-education about anorexia nervosa. Emily learns to look at her anorexia as a treatable illness and develops healthy ways to think about eating food. This work often involves challenging cognitive distortions around eating food.
I note her mother never visits while she is in hospital. Daniel informs me that his wife has a history of anorexia and finds the eating disorder units triggering. Emily and her mother meet on weekends when limited leave off the hospital grounds is permitted. When we discuss Emily’s alcohol abuse it is revealed that Daniel may have a drinking problem which has been made worse by work-related stress. He admits to drinking most nights and buys all the alcohol in the house. This potentially has enabled Emily’s binge drinking patterns on weekends. I recommend having a “dry house” when Emily eventually returns home. Both parents and Emily agree to this. Substance use disorders are a common comorbidity of eating disorders.
During our reviews, Emily mentions being diagnosed with anorexia when she was 14 years old. Emily eventually recovered from her anorexic episode as a teenager with family-based therapy and Fluoxetine; she did not require a hospital admission.
Daniel and Emily tell me that the family-based therapy was effective but was emotionally exhausting for the family. They imply they do not want to do it again. As Emily is enjoying the daily group therapy on the ward, I recommend weekly group therapy when she is an outpatient to avoid a relapse of her anorexia.
While family dysfunction can increase the risk of developing an eating disorder, I often try to involve families in the treatment plan, especially if they live together and are supportive of recovery. Emily finds her parents supportive but feels that she was “the problem child”.
She has two older siblings who are considered mentally stable, successful and not living at home. This added to Emily’s feelings of regression in the home environment with parents who are hypercritical of her ability to manage her anorexia and live independently as an adult.
Emily’s admission lasts for six weeks but is effective. She weighs 52kg and has a healthy BMI. Her mood has improved and she has not been self-harming or purging on the ward. The discharge plan is to follow up with a weekly eating disorder group program, regular medications, and psychologist follow-up for cognitive behavioural therapy to assist with her body image issues and navigating recovery. We arrange for monthly follow-up with myself in the outpatient clinic.
On the day of discharge, I’m told her mother came on to the ward and helped Emily pack up her belongings before leaving. I take this as a good sign. I see Emily for a total of two years with only one other hospital admission. When she is discharged from my care, she has been able to move out of her parents’ home and is dating again. Her weight is stable and she rarely worries about weight. Emily eats slightly less than I am comfortable with but her meals are healthy and she avoids restricting habits.
Eating disorder recovery is often a lengthy process but I see more people get better when they engage with services than not. I wish more people were made aware of how treatable these conditions are.
*Patient examples are amalgamations of people often seen by psychiatrists
• Dr Xavier Mulenga is an addiction psychiatrist based in Sydney
• In Australia, the Butterfly Foundation is at 1800 33 4673, the National Alcohol and Other Drug Hotline is at 1800 250 015; families and friends can seek help at Family Drug Support Australia at 1300 368 186. In the UK, Beat can be contacted on 0808-801-0677 and Action on Addiction is available on 0300 330 0659. In the US, help is available at nationaleatingdisorders.org, by calling ANAD’s eating disorders hotline at 800-375-7767, and at SAMHSA’s National Helpline at 988. Other international helplines can be found at Eating Disorder Hope
