Practice What Your Patient is Thinking

I thought I wasn’t thin enough to be anorexic

BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5378 (Published 06 December 2017) Cite this as: BMJ 2017;359:j5378

Caitlin, 17, and her mother, Sally, talk about what helped, and what didn’t help, when Caitlin developed anorexia

On 15 December 2015, two weeks after I was referred to CAMHS (Child and Adolescent Mental Health Services) and six months after my periods had stopped, I messaged my mum a random question: “Am I anorexic?” I expected my mum to reply: “No, of course you’re not.” Two minutes later, however, the answer came back. “Yes, I’m sorry darling, it’s true.” That was the first time I realised that I was ill.

I was 15, and I’d started dieting in April. By June, I’d stopped having periods. By September, I felt cold all the time and my mum was worried enough to involve my general practitioner. She saw the doctor and then took me separately. By November, my weight had dropped and I was urgently referred to CAMHS.

Struggling to accept my condition

Why did I find it so hard to accept I had an eating disorder? Partly it was because even though anorexia was being discussed in my CAMHS sessions, I hadn’t understood that this was because I had it. The doctors weren’t trying to deceive me, but because I was ill, things were foggy and I was less able to understand what they were trying to tell me. I needed to be spoken to directly. It might have helped to say “Caitlin, you have anorexia. Do you understand what I mean by that?”

Perhaps the main reason I didn’t believe I was anorexic was because I didn’t look that unwell. The stereotypical person with anorexia is incredibly skinny—so skinny that you can see their bones. It’s the image that’s used in schools for education on eating disorders.

But I never looked like that. I’m just 5 foot tall. Despite losing 20% of my body weight, having a resting pulse of 40 beats/min, low blood pressure, and no periods for a year, my body mass index remained within the normal range at 19.

If I had known that people can have anorexia but do not look like they do, maybe I would not have been so reluctant to accept I had it.

Barriers to trusting my doctors

My first meeting at CAMHS was led by a male doctor. He was highly qualified, kind, and understanding. However, it was embarrassing and uncomfortable for me to talk about my body and self confidence to a male doctor. Also, various medical professionals I met during treatment used the phrase, “It’s okay, I know how you feel.” This frustrated and upset me. I wanted to scream: “No, you don’t.” When I first heard it, I shut down and did not engage for the rest of the session. They couldn’t know how I felt as they were not me, so how could I trust them?

Social media and eating disorders

The triggers for my eating disorder were a drop in self confidence and an ambition to get trim for the summer before my GCSEs. I wasn’t overweight, but I was obsessed with magazines and social media, where I first saw pictures of very slim women who did not look anything like me. They had no curves, no thighs, no fat, yet they were considered very beautiful. I was determined to change my shape to look like them. I thought that was a healthy thing to do.

Doctors need to ask about social media and explain that these images are often altered or unrealistic. I often wonder, if I had known about Photoshop, would I have become ill? If I knew these women were not real, would I have wanted to change so much? If the media did not portray women in this unrealistic light, would my life be different now? Would I have had anorexia?

Sally, Caitlin’s mother, gives her perspective on Caitlin’s illness and treatment

It was difficult to persuade Caitlin to see the GP. I saw the doctor (a woman) alone first and together we hatched a plan that in a second appointment, she would ask me to leave and speak to Caitlin alone about the risks of not eating and not having periods to her bones and fertility. This was helpful because treating Caitlin as an adult created trust between them and helped Caitlin feel more in control. We left it that should things not improve, I could go back at any time.

Determination to succeed

I believe the external triggers to Caitlin’s eating disorder were a combination of GCSE exam stress and social media influences. As she reduced her food intake, her meals became ritualistic. Her breakfast and lunch were the same every day. Everything she ate was a specific size, a specific way, a specific thing, even down to using the same table mat. Caitlin’s drive and determination to succeed is a strong quality, but it can also be her weakness because it helped her stick rigidly to her regime. I remember her saying, proudly: “I'm stronger than other people as I can say no to food and stick to it.”

I suspect Caitlin had some idea things were wrong, but she couldn’t admit it to herself. This would mean letting go of what she saw as her successful mission to change her body shape. She was putting images on Instagram and got a lot of endorsement from people who didn’t know she was ill. This made things more difficult for us, as parents, to deal with.

It was hard to get Caitlin onto the scales but she was becoming increasingly withdrawn socially and was calling me daily to ask if she could leave school. When she finally agreed to be weighed, I saw she’d lost almost 10 kg in six months. I rang the GP, who immediately referred her to CAMHS.

Attending CAMHS sessions

I attended all of Caitlin’s CAMHS sessions; her dad came to several of them too. We agreed this with CAMHS as the best approach to treating Caitlin, and she accepted this. The meetings were draining and emotional. I wasn’t always popular, and she felt embarrassed sometimes, but I believe my input was helpful and looking back, so does she now. We were able to offer insights into her behaviour that Caitlin wasn’t even aware of, such as her total withdrawal from social groups, and to correct matters when Caitlin bent the truth about what she was doing. Had she been 16 and aware that she could exclude us from the sessions if she chose to, that would have been much more difficult. I don’t know what we would have done.

Talking about the harm anorexia causes

When it came to talking about the harm anorexia was causing her, doctors had more credibility than me and her dad. She thought we were worrying unnecessarily as that’s what parents do.

Her male consultant was a good doctor, but Caitlin found it easier to relate to the female psychologist and dietitian, especially when talking about things like periods and body shape.

After a year in CAMHS, and after having written a detailed relapse prevention strategy that she and I signed copies of, Caitlin was discharged in November 2016. Longer term recovery has naturally taken a while, but she is now back to her previous healthy weight. We remain conscious of her tendency to put excessive pressure on herself and external triggers such as stress. Caitlin can't remember much about the time she was poorly—I’m told memory loss is common—but she knows she felt absolutely terrible and doesn’t want to go back there.

What you need to know

• Patients might need to hear that even with a normal body mass index they can still be very unwell: it is the difference between pre-illness weight and body mass index that is key

• Young people can feel sensitive about their bodies. It may be appropriate to offer them a choice of male or female doctor

• Consider the impact of social media on young people’s self image and mental health, and explicitly ask about the role of social media in the young person’s life

Education into practice

• Caitlin didn’t realise she could have a diagnosis of an eating disorder with a normal body mass index. How might you explain the diagnosis of an eating disorder to a young person who has a normal body mass index?

• How might you approach a parent who presents with concerns about their child’s eating and exercise patterns? How might you manage a situation where the child is unwilling to attend an appointment?

• How might you sensitively ask about social media use? What advice do you give to young people about social media use?

Footnotes

  • Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following: none.

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