A 30-year-old woman was admitted to a psychiatric unit weighing 30 kg. Her body mass index (weight in kilogrammes divided by height in metres, squared) was, at 13, near the lower limit considered to be compatible with life. She was brought in by her husband, who had been increasingly worried about her but up to this point had been unable to persuade her to accept help. She had had eating disorder symptoms since at least the age of 15, when she had left home to live with her boyfriend, who eventually become her husband. She was terrified of excess weight and weighed herself several times a day. She ate little more than a crispbread and a slice of cucumber daily. She had never had regular periods, although, unusually for someone with anorexia nervosa, had managed to get pregnant with the help of ovulationassisted fertility treatment. She was closely involved with her mother, to whom she presented an 'everything is normal' front, while seeing her almost every day. She was very worried about her parents' marriage, which she saw as in great jeopardy. She was treated with a refeeding schedule, with which she was surprisingly compliant, until she weighted 45 kg, and then was discharged from hospital. Her outpatient care consisted of a combination of individual psychotherapy and family therapy.

Her individual therapy concentrated on looking at all the ways in which she pretended to herself and others that she was eating when in fact she was avoiding food. It used an 'addiction' model and suggested that she was addicted to not eating in the way that an alcoholic is addicted to alcohol - using it as a refuge whenever she felt stressed or confused. Therapy also looked at her image of herself as a woman, and at how frightened she was about becoming 'like' her mother, whom she saw as being trapped in a loveless marriage, constantly at her father's beck and call. The family therapy sessions tried to help extricate her from the parent-child relationship she had established with her husband and to foster a more equal partnership, in which she took charge of her own eating, rather than either deceiving him or relying on him to prompt her to eat. There were no further admissions, but her weight hovered just under 7 stone for many years, and she said that the idea of being 7 stone terrified her. Over the years she made many life changes. She left her husband and formed a new partnership, which was more emotionally open and caring, although not without its problems. Her new partner was more able to help her to eat at times when she was in the grip of her anorexic symptoms. Her parents' marriage also broke up, and she become much less involved with her mother.

Questions

1. Could intervention have started earlier?

2. What is the long-term  prognosis of anorexia nervosa?

Discussion

It is notoriously difficult to engage people suffering from anorexia nervosa in treatment. Teenage sufferers are often taken unwillingly to the doctor by worried parents. It is always important for the doctor - usually a family doctor in the first instance - to interview the patient on her own and to make determined attempts to establish rapport, a process which may take several interviews. There is a danger that the doctor will be pulled into identification either with the worried and exasperated parents, in which case he may become heavy handed and insensitive, or with the patient, when he may minimize the seriousness of the situation and fail to be appropriately firm and challenging. Anorexia is 'delusional' in the sense that such patients are convinced that they are fat, despite every rational argument to the contrary. There has been much debate about the ethics of admitting people with anorexia compulsorily to hospital. The current consensus is that the thinner the patient the less rational they are, and that in lifethreatening situations the use of the Mental Health Act is justified. On the other hand, it is essential to help the patient move towards taking responsibility for her own illness, and a Section may militate against that. Many patients put on weight while in hospital but immediately revert to dangerous weight loss once they are back home. Anorexia nervosa is a very varied illness, with many different trajectories, making it difficult to generalize about prognosis. In general, the shorter the interval between onset of illness and treatment, the better the prognosis. Most studies suggest a 60-70% recovery rate within 5 years. The longer the period of illness the greater the mortality. Different studies have shown lifetime mortality of between 5 and 10%. Partial recovery is probably the best that can be hoped for in a chronic form of the illness such as that suffered by the patient described, whose symptoms had lasted for more than 15 years.