Anorexia nervosa

The news

I was a typical victim of anorexia—a high achieving, perfectionist, middle class teenager to whom no one would have thought it would happen. But it did; a gradual two year descent into severe food restriction, overexercise, deviance, and my own little anorexic world. I was 15 years’ old and extremely weak by the time a diagnosis was made, and it was the first time I had heard of anorexia nervosa. When I received the news it had little effect on me—I was so entrenched in the desire to lose weight and stay inside the “safe” place that anorexia had provided that I couldn’t see beyond the next meal, let alone consider my prognosis. I was in complete denial, insisting that nothing was wrong. For my family it was an enormous shock, not just the diagnosis of a mental illness, but the feeling of helplessness at not being able to feed their own child.

An opportunity missed

I had first visited my general practitioner several months previously because I was concerned that my periods had stopped. He was very approachable and suggested I start the oral contraceptive. I left feeling confused, but dutifully redeemed the prescription and started the pill. I was extremely underweight, so it was unfortunate that the diagnosis was missed, because the anorexia was gradually getting worse. Anorexia commonly presents as amenorrhoea, constipation, or chronic fatigue. Because patients with eating disorders lack insight into their condition and early diagnosis is associated with a good prognosis, doctors should always keep these conditions in mind.

Later that year I was referred as an emergency to the adolescent mental health services. There my parents and I were seen by a psychologist, who made the diagnosis and offered us advice on home refeeding and family therapy sessions. This is standard management of an adolescent with anorexia, but my experience makes me feel that direct referral to a specialist eating disorders team would have been much more helpful. Because of the lack of inpatient facilities in my area, my family was left to manage the situation at home. My parents’ perseverance against the stubbornness and deviousness born of anorexia allowed me to reach a safe weight, but I received no help in tackling the causes behind my illness. My family had been assured that my recovery hinged on weight gain (true), with the suggestion that this would be sufficient for me to regain full health (false). When I left home for university I quickly relapsed, which was upsetting for my family. I think it is important to make it clear that recovering from an eating disorder is extremely difficult, and to warn the family of the risk of relapse.

The usual course of anorexia

My illness has followed a course typical of anorexia—a slow development into the full blown clinical syndrome, followed by several relapses despite extensive treatment. Prognosis is usually quoted as the “rule of thirds”—a third fully recover, a third partially recover, and another third have chronic problems. Recovery is slow—it usually takes three to six years. I have had multiple courses of cognitive behavioural therapy and received day patient and inpatient care. As an inpatient I was put on a specialist programme combining refeeding with intensive therapy designed to reduce eating disordered behaviours and improve self esteem. With each course of treatment I made steps towards recovery, but each time I quickly relapsed, because I refused to admit that to succeed I needed to leave the illness completely behind. I believed initially that weight gain would make the “voice” go away, and I know it can happen, but for me it hasn’t. I still have the disordered thoughts, but I try not to act on them, and they are gradually weakening. I always tell others that no hospital or specialist can cure them—they can help initiate changes, but the legwork is done at home, day after day, by resisting the anorexia until you gradually start to win the battle (box).

Making the journey alone

When I was deeply entrenched in anorexia, it was difficult to motivate myself to do anything. My concurrent depression heightened this problem, and I struggled to meet the commitments needed to progress through medical school. It has taken me eight years to complete my training, during which time my friends have qualified and left me behind. Dropping behind my peers has worsened my feeling of inferiority, and I found it difficult to fit into a new year group. This made me feel very alone, and the safety of anorexia beckoned strongly. I have found that most people ignore the anorexia completely, pretending it isn’t there—this is especially true of clinicians. Those friends that have stuck by me have provided invaluable support and helped me adapt to my changed circumstances. My relationship with my family has been very strained at times, because it is hard to cope with someone who seems to be making such self destructive choices.

The future

After 10 years, I have finally reached the stage where I can maintain a healthy weight, manage my clinical commitments, and engage in normal relationships. I am by no means completely cured of anorexia—I still fight it daily and feel enormously fat and inferior—but I have turned the corner. Recently, I fractured my patella from a fall, a painful reminder that I have been left with osteoporosis, a common consequence of malnutrition.

No one knows exactly why an eating disorder develops, but when you have endured one the answer becomes irrelevant. I have started putting large amounts of time into raising awareness of the dangers of anorexia—especially among other doctors—both as an aid to my recovery and to prevent others from having to face such an isolating experience.