I thought I wasn’t thin enough to be anorexicBMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5378 (Published 06 December 2017) Cite this as: BMJ 2017;359:j5378
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As so often it is those brave sufferers and their carers willing to share their lived experience who provide the most valuable insights for health professionals to learn from. Caitlin was not only speaking for sufferers but also for those many health professionals (and lay public) who do not realise that it is perfectly possible to have an eating disorder without a depressed BMI. Anorexia Nervosa only makes up 10% of all eating disorders and yet when questioned about eating disorders is always the first to be mentioned. Bulimia Nervosa and Emotional Overeating are mostly not associated with a depressed BMI. Also the depressed percentage BMI centiles/BMI levels that must be achieved to earn a diagnosis of anorexia nervosa are counterproductive to effective management (as recognised by NICE guidelines 2017) and encourage gaming by service providers when denying a specialist referral on such grounds, and gaming by service users when trying to avoid referral!
Furthermore, I have observed men and women pumping iron in the gym who probably have as little body fat as sufferers with anorexia nervosa but clothed in (steroid induced) muscle maintain a normal BMI. Bigorexia comes with its own physical and psychological penalties.
Caitlin reflects that had the media not portrayed women in such unrealistic light, would her life have taken a different healthier course. In 1958 Mattel launched Barbie on an unsuspecting world and it is interesting that cases of anorexia nervosa increased in the succeeding 2 decades. Karen Carpenter, the first celebrity anorexic, would have been 8 at the time - food for thought. As Churchill said "If we do not learn from the mistakes of history we are doomed to repeat them".
Sally observed that treating Caitlin as an adult created trust between her and her service provider and helped Caitlin feel more in control. Trust is an essential prerequisite to engagement, and contrary to the commonly held belief that sufferers with anorexia nervosa seek to exert and maintain control in their eating disordered lives, by the time of presentation they have long since lost any control they initially enjoyed by virtue of their illness. By this time, it is the eating disordered entity in their mind that is, and seeks to maintain, full control of the sufferer, their carers and those service providers who seek to intervene and support recovery. The therapeutic challenge is to help and support the sufferer mount a successful rebellion and reclaim their lives.
Competing interests: No competing interests