Saturday 24 March 2018

Anorexia nervosa and its treatment back in the media spotlight

High Court President Peter Kelly. Photo: Shane O'Neill Photography
High Court President Peter Kelly. Photo: Shane O'Neill Photography

Patricia Casey

'Without that [treatment] she will die. It is not a question that she might, she will". These were the stark predictions of Mr Justice Peter Kelly, President of the High Court, earlier this year when he renewed an emergency order made by Mr Justice Abbott. The young woman is now "stable but critical", the judge was told in a recent hearing in which he continued orders for her treatment. This will allow the 40kg woman to be given food either intravenously and by nasogastric tube. She has the eating disorder, anorexia nervosa, and like many if not most with this condition, she saw no problem with severely restricting her intake of food and fluids even though her life is at risk. She lacks the capacity to make decisions about her treatment even though she is an adult.

According to media reports, she had been living on tea and cigarettes for months and she is being treated physically in intensive care.

Psychological treatment will follow but she may need to receive this in the UK, as did a young man sent there in January of this year, the first male case to come before the courts.

In the summer of 2016, a 15-year-old female was also sent there for treatment by Mr Justice Kelly and has since returned. According to newspaper reports, the girl had made "remarkable and commendable" progress and this contrasted with the other cases Mr Justice Kelly had dealt with where "very little" progress was made.

Anorexia nervosa is the most life-endangering of psychiatric disorders from suicide as well as the physical complications. As a cause of death, suicide is identified in about 20pc of cases, according to the National Association of Eating Disorders (NAED) in the US.

The physical treatment of starvation is infinitely less demanding than the psychological interventions. There are undoubtedly challenges with refeeding since heart muscle bulk and strength are reduced with weight loss. When refeeding is resumed it can put a strain on heart muscle and potentially cause cardiac failure.

However, such demands arise every day in intensive care units when dealing with a variety of common physical conditions like bowel disease and cancer and the metabolic problems associated with vomiting that lower potassium and which in the long- term cause osteoporosis.

Interestingly, anorexia nervosa is uncommon in non-Western countries, even those that are well developed like Japan, with a prevalence of less than 0.05pc whereas in Western countries the prevalence in females varies from 0.1pc to 5.7pc and about 10pc of cases are in men.

The underlying problem in many with the condition is not achieving thinness per se, but fear of adulthood and all that goes with it, manifesting itself by seeking a child-like shape. So the loss of weight and the absence of menstruation are a symptom of something more profound.

While anorexia nervosa is underpinned by fears of maturation, women in certain sports are at higher risk, especially athletes, suggesting that preoccupation with leanness puts at least some young women at risk of developing anorexia nervosa.

So the ideal of attaining size 0 or a pre-occupation with fitness is for some a danger. Anorexia nervosa was first named in 1868, but it may have existed long before that - the "holy" anorectics such as St Theresa of Lisieux were clearly identified in Church history and these predate any size 0 models.

So if anorexia nervosa is largely a socially determined disorder, why did it exist all those centuries ago when the desirable shape for women was rotund and well-padded? Why women should be more vulnerable than men is possibly due to the differences in body image between men and women with the latter viewing their shape more negatively than men.

Childhood trauma is also recognised as a risk factor. Aside from deeply rooted personal uncertainties and socially driven images regarding shape, there is a recognition that genetic factors may play a part in determining who is at risk. The largest genetic study of anorexia is currently under way at the University of North Carolina and has recently suggested that a genetic abnormality on chromosome 12 may cause metabolic underpinnings for the disorder.

It is tempting to argue that we should be able to treat anorexia nervosa in this country rather than imposing the burden of going away for treatment on the young person and his/her family. While the psychological strain is an issue, the costs of treatment and travel are met by the State. The psychological treatment of anorexia nervosa is complex and demanding and we are unlikely to have the critical mass of patients to sustain the cost and level of expertise for such a specialist facility.

Neither do we have the first-hand knowledge and research experience in anorexia nervosa that combine to create a centre of excellence. For the foreseeable future, we are likely to need to seek treatment for these ill young people outside this country.

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