Post by Mel on Dec 30, 2005 17:47:22 GMT -5
Anorexia Nervosa In a 16 Year Old Girl
Dr Jacinta Powell, Consultant Psychiatrist and Director, Eating Disorder Service, Royal Brisbane Hospital
Kaylee was a 16 year old student in Year 11 at a private girl's school. She had begun losing weight for 9 months and after a number of phone calls and a visit to the GP, Kaylee's mother brought her for assessment to the eating disorders service of the public hospital. Kaylee was reluctant to attend and insisted that there was nothing wrong with her and that the problem lay with her mother, who was over reacting.
Current Wt: 38kg
Ht: 160 cm
Wt(1yr previous): 48kg
Ht: 158cm
History of illness
Kaylee is a good student who just missed out on being Dux of Year 10. The previous year was difficult for her as she suffered a bout of glandular fever and missed quite a bit of school over a one month period. In addition her older sister, whom Kaylee idolised, moved out of the family home and in with her boyfriend. This situation created much family conflict with disapproval from both parents. As a result Kaylee felt torn between loyalty to her sister and to her parents. The weight loss appears to have commenced with the onset of glandular fever as Kaylee lost her appetite. On return to school, her fellow students commented on how good she looked and Kaylee felt she was noticed for the first time for her appearance rather than just her "brains". She decided to keep restricting her food intake so she didn't regain the weight she had lost through illness.
Within 2-3 months, Kaylee's parents had noticed her weight loss and began to confront her with what was happening. Kaylee denied any problems, but to keep her parents happy began to eat meals with them, but took to vomiting afterwards whilst in the shower. For a couple of months everything remained calm in the household as Kaylee appeared to be eating. Kaylee's mother noticed that Kaylee seemed particularly ravenous after school when she would have some weetbix, biscuits and bread before settling down in her room to do homework.
The situation finally came to a head however, when Kaylee's mother accidentally walked in on her daughter in the bathroom and saw her unclothed. She was horrified to see Kaylee's ribs clearly outlined under the skin and how wasted she appeared. They had a huge row but Kaylee agreed to see the family doctor, who conducted blood tests and arranged a referral for further assessment.
Kaylee denied that she was thin, stating that she felt fat and thought she could stand to lose some more weight. She was particularly upset about her thighs and abdomen, and described exercising in her bedroom at night for up to an hour. In addition she was walking to and from school, 4 km away. She described marked lethargy but had difficulty sleeping at night. She felt driven to walk but in the last two months had not enjoyed this. She denied any mood changes. Her mother however said, "Kaylee is a different person. She used to be sweet and cheerful and would do anything to help anybody. Now she is sullen, she stays in her room all the time, doesn't go out with her friends anymore. I am frightened to say anything to her because she either snaps at me or bursts into tears". Kaylee's teachers had also expressed concerns about her lack of attention in class and her falling grades, a situation which had become more obvious throughout year 11.
Oral Intake
Breakfast: Toast x1 no butter or spread
Black coffee
Morning tea: Diet Coke
Lunch: Diet Coke
Afternoon Tea: Binge after school (pkt biscuits, ½ loaf bread, 6 weetbix)
Vomit x1
Dinner: Whatever mother prepared.
Vomit x1
No laxative abuse, no use of cigarettes, alcohol, or drugs.
Periods: Commenced when 13 years old
Ceased 6 months ago.
Other Symptoms: Cold all the time
hair falling out
skin dry and flaky
slow pulse, dizziness and lethargy.
Family History
Lives with parents and brother.
Mother: 38 years old, healthy, walks daily and plays tennis weekly, works part time as an accountant and has done since her youngest child was 5 years old. Normal weight.
Father: 41 years old, runs a small sheet metal business and works long hours. Had a health scare two years ago with an episode of chest pain. Since then has given up smoking and alcohol, attends a naturopath and prepares his own meals following a low fat, non wheat diet. Normal weight. Doesn't have time to exercise.
Sister: 20 years old, university student, popular, outgoing and good at whatever she does include study, sport and music. Living with boyfriend of 2 years. A little overweight since adolescence. Her mother had expressed some concern about this but sister would not discuss her weight and apparently did not see this as an issue.
Brother: 12 years old, in Year 7 at boys private school, average academically, plays multiple sports. Relaxed and more interested in hanging around with his friends than in the family. Normal weight.
No family history of eating problems, alcohol abuse or depression. Kaylee's mother has dieted in the past but now tried to eat sensibly and ensure she exercised. She is not happy with her body but is more relaxed about it than she had been in the past.
Development
Kaylee described a happy childhood with no history of abuse. She had always been a good student and able to make friends without any problems. She idolises her big sister but at the same time feels she will never match up to her in terms of personality or achievements. She wasn't prepared for her sister moving out of home and misses her every day. Her relationship with her mother has been close until the last few months when there has been frequent conflict about food, eating and Kaylee's moods. Kaylee is not as close to her father and he has tended to leave the parenting to his wife as he is rarely available. Kaylee fights with her little brother but doesn't see this as significant. They see each other much less since her brother has become so involved with his friends and sport.
Assessment
Kaylee was assessed to be suffering from anorexia nervosa - bulimic subtype. She was noted to be depressed, lethargic and lacking in concentration, and was socially isolated; features consistent with starvation. Her pulse rate was 44 beats per minute and her blood pressure was 75/40, her temperature was 35.6 degrees C. Blood tests showed Kaylee to be low in potassium, a common problem as a result of vomiting. Low potassium results in muscle weakness and lethargy, but more alarmingly can cause arrhythmia's of the heart which place the person at risk of death. Her heart was small due to muscle loss which was evident throughout her body.
Kaylee did not accept this diagnosis and denied the seriousness of her condition despite extensive explanations about the risks to her health and her life. She expressed a desire to keep exercising and denied that she was vomiting despite knowledge her mother had found evidence in the shower including the smell.
The effects of starvation both physiological and psychological were discussed with Kaylee and her mother. Kaylee was able to recognise that her moods were consistent with what was described, and also that her grades were falling. It was at this point that she agreed to hospitalisation particularly when she realised how distressed her mother was.
Management
Kaylee was admitted to a hospital psychiatric unit which deals with patients with eating disorders on a regular basis. In view of the potential seriousness of her physical condition, Kaylee was seen by a medical team. She was assessed by a dietician and the clinical nurse in charge of the eating disorders unit.
Phase 1 - day 1-2
Replacement of potassium and fluids via an intravenous drip with monitoring of vital signs and blood tests. Cessation of exercise and encouragement of regular small meals. Kaylee complied with this plan but her oral intake remained poor. She did however, stop exercising and vomiting and her potassium normalised over two days.
Phase 2 - after day 2
Kaylee was reviewed by the dietician, doctors and nursing staff. She was feeling better physically and able to attend the dining room with the rest of the patients with eating disorders. She continued to struggle with intense guilt whenever she ate and was terrified that any intake would cause her to lose control and become incredibly fat. She was weighed twice a week, in the morning after waking.
Kaylee was started on three small meals and midmeal snacks of a glass of sustagen 3 times per day. Over the course of the next two weeks, Kaylee increased her weight to 40 kg. She was very apprehensive about weight restoration and required considerable reassurance, education and training in anxiety management strategies. The process was assisted by a primary nurse who came to know Kaylee well and was able to develop a good therapeutic relationship with her. She spent time with other patients with eating disorders in the formal group program as well as informally in the ward setting. This was a source of extra support for Kaylee early in her admission. Kaylee also had individual therapy sessions with the psychologist commencing anxiety management with a view to later moving to cognitive behavioural techniques specifically for dealing with the eating disorder. She saw the registrar regularly for extra support and to fully discuss the rationale for the actions of the treating team and the basis for treatment decisions.
Unfortunately when Kaylee reached 40 kg, she panicked and became increasingly upset. She began to ring her mother and begged to be allowed home, promising to eat regularly and do whatever her mother wanted. Kaylee's parents were seen by the hospital team and as they felt they now wanted to try and manage Kaylee's problems at home, she was given leave to go home with her family. Within 2 days the situation had deteriorated significantly and Kaylee was refusing to eat or drink anything at all, she would not go to bed and stood up all night moving around.
Phase 3 - after 3 weeks
Kaylee was returned to hospital by her family and was rehydrated with intravenous fluids. Her weight was 37 kg. In view of her intense guilt about actually eating, she was offered the option of night time nasogastric feeding via a tube through her nose into her stomach. She had seen other patients have this treatment and had spoken to them about it. As a result, she commenced on feeds overnight, inserting her own tube at night and removing it in the morning. During the day she went to meals with other patients and attempted to continue with small meals. Over the course of the next eight weeks, Kaylee gradually increased her oral intake at meals and gained on average 1 kg a week. This period was not without difficulty for her. At times she became incredibly anxious and could not stop herself from vomiting after meals. At other times she would slow the night time feeds down or empty them out. Regular sessions with her nurse and doctor however meant Kaylee eventually was able to tell them what she had done. This was also often be reflected in her weight. These problems were dealt with in a supportive, exploratory way and she was helped to deal with her anxiety. Kaylee was encouraged to keep a journal of her feelings and experiences and to share this with staff she had developed a good relationship with. Kaylee also requested help after meals. During these times she was most at risk of vomiting and a system of 1:1 nursing after meals was arranged. At times she would become angry with everybody around her, expressing anger at her parents for putting her in hospital; anger at the staff for what she saw as their control over her and for "making me fat"; and also particularly angry at herself for a myriad of perceived shortcomings in herself. It was important that these feelings were dealt with in a sympathetic way and that Kaylee was able to ventilate her emotions without turning to starvation or exercise as a way of managing them.
During the course of Kaylee's admission, her parents, and at times her siblings as well, were seen regularly by the team consultant, registrar and psychologist. They attended a family education programme run by a local private hospital and were encouraged to seek assistance from the Eating Disorders Association Resource Centre. They were perplexed about what had happened to their daughter and spent much time ruminating over where they had gone wrong. They also experienced shifting emotions from fear to frustration and anger. They recognised that they did not know where to place their anger. They felt they could not get angry with Kaylee so directed their anger at themselves, at each other, and at times to the treatment team. The situation was complicated by Kaylee's need for privacy and some sense of control over her own treatment as she attempted to overcome an illness which she felt very ambivalent changing. These needs conflicted with her parents' needs who felt guilty and confused and thus wanted to be involved in all aspects of Kaylee's treatment and her communication with hospital staff. These issues were dealt with in joint meetings involving both Kaylee and her parents. Kaylee's parents remained less than satisfied with the amount of information they were given but tried very hard to respect their daughter's wishes.
School: In the initial phase of treatment Kaylee was too ill to attend school. Her concentration was very poor and she was preoccupied with food and weight issues. As her health improved, her school sent over work and Kaylee was able to keep her in touch her lessons. School work was completed with supervision from nursing staff on the ward. At first Kaylee tried very hard to keep up and would frequently end up in tears as she fought to concentrate on the work. After discussing the situation with her parents and the school, Kaylee decided she would focus on achieving what she could this year and if necessary she would repeat Year 11 next year. With such an approach she was able to reduce the pressure she was placing herself under and in fact her work then improved considerably. This was also aided by her improved nutrition and better state of health. Kaylee began attending the hospital school once she was fit enough to leave the ward.
Phase 4 - after 11 weeks
In the preceding weeks Kaylee had begun to go home for weekends with her family. She would take the nasogastric pump and feeds with her. When she reached 45 kg, Kaylee began working on changing gradually from nasogastric feeds to oral supplements and continuing with meals. The process was not straightforward as Kaylee would reduce her night time feeds but would then balk at taking the supplemental drinks. However, as she realised that the process of weight restoration was proceeding as planned she managed wean herself off the nasogastric feeds. At this point Kaylee began attending her school again, initially for half days and gradually working up to full days. This process was difficult as Kaylee had missed a lot of social interaction with her peers over the previous months, although her friends had visited her in hospital. She felt self conscious upon returning to school, as though everyone was looking at her and watching her eat, a situation which in fact had some basis in reality. She was however assisted by teachers who had talked with hospital staff prior to her return to school, and by friends who had made an effort to understand how best to help her deal with the situation.
Phase 5 - Discharge
Kaylee was discharged from hospital at 48 kg, a less than ideal weight, but as she was managing well and had increasing periods of leave to home and school it became necessary to balance keeping her progress on the track with the need for her to be with her peers. Kaylee attended the hospital outpatient service once a week and had regular phone calls with her primary nurse-therapist. She was encouraged to use alternative coping strategies such as keeping a journal, supportive telephone calls, discussions with her family and friends, and relaxation strategies. Kaylee had commenced regular gentle exercise under physiotherapy supervision whilst in hospital and had a program to follow at home which she found useful as an anxiety release strategy. She continued to experience ongoing body image disturbance, but was much less preoccupied with food and eating, and her mood and anxiety had improved considerably.
Phase 6 - Ongoing outpatient therapy
During the assessment phase and throughout the admission it was impressed upon Kaylee and her family that the treatment for anorexia nervosa was likely to take at least 1-2 years and that most of the treatment would occur on an outpatient basis, after she left hospital. Whilst hospital is often necessary for weight restoration, which allows the person to think more clearly and become less anxious and depressed, ongoing therapy is needed both psychologically and nutritionally after discharge. Upon leaving hospital, Kaylee felt quite stressed, she had been anxious to leave but when she did so found she missed the structure of the hospital program and the reassurance of the ward staff. Along with the stress of being back at school and feeling under scrutiny, Kaylee expressed her disappointment that discharge from hospital didn't feel as good as she had anticipated. Her parents also needed help to understand this but were very supportive of their daughters attempts to eat regularly and attend school, and tried not to be intrusive during meal times.
Each week Kaylee saw her nurse therapist, the dietician and the doctor from the treatment team. She was encouraged to continue with keeping her journal. A mixed therapeutic approach was taken incorporating expressive, supportive and cognitive-behavioural strategies. During this phase Kaylee discussed the events and factors leading to the development of her eating problem, and talked about how anorexia had seemed to offer a magic solution to the difficulties she was experiencing. She described her growing awareness of her body from Year 8 and the way her friends focused on weight and eating at school. Even before developing glandular fever, Kaylee had become somewhat dissatisfied with her body and compared herself unfavourably with other girls who were taller and had males interested in them. Whilst admiring her sister greatly, she found it hard to accept the feelings of envy she had towards someone she loved greatly and had worked hard to quell this conflict in herself. Weight loss allowed her to have something she felt good at and that her sister was not. She later came to realise that, unconsciously, she was perhaps competing with her sister for her mother's attention. She may also have been punishing herself for unacknowledged feelings of pleasure from her idealised sister's conflict with her parents. It became obvious that the reasons for Kaylee's anorexia were multiple, complex and related to her phase of development. Once she began to lose weight however she found she was trapped in a vicious cycle from which she could not escape despite her at best, albeit ambivalent, intentions.
Kaylee continued in therapy over the next two years until the mid part of her first year at university. She had an up and down course with many pitfalls. Her weight increased to 54 kg. However, for a long time she hovered at 49 kg unable to break the psychological barrier of being 50 kg. At one stage, she became involved in her father's diet and attended his naturopath. On such a vegan diet she was unable to maintain her body weight or iron stores, and her weight dropped back to 45 kg. She was also tired and lethargic and the features of starvation made another appearance. With much support and encouragement from the treatment team and her family, particularly her father, Kaylee managed to avoid returning to inpatient treatment and was able to resume a more normal pattern of eating. Her periods returned after she had reached 51 kg, an event she had mixed feelings about but coped reasonably well with. At other times during this phase of her recovery, Kaylee returned to vomiting, particularly when she was anxious. However, as she matured and gained a much better understanding of herself, and with a good alliance with her therapists, this became much less of a problem.
Phase 7 - Termination of treatment
Kaylee had commenced a science course at university and was also working casually at Myer to earn some money and support herself in her studies as she was not eligible for Austudy. She met a male university student and began going out with him which improved her confidence. She had intermittent periods of depression and moments of self doubt but she was much more able to manage these herself as time went on. During the course of this year Kaylee explored termination with her nurse therapist and doctor and this was achieved with increasing spacing of her appointments. Kaylee was reassured she could return at any time in the future and was encouraged to seek help earlier rather than later if she experienced any relapse in symptoms whether this be depression or eating disorder. She subsequently kept in touch with occasional phone calls and Christmas cards to the treatment team and at last contact was continuing to do well.
Dr Jacinta Powell, Consultant Psychiatrist and Director, Eating Disorder Service, Royal Brisbane Hospital
Kaylee was a 16 year old student in Year 11 at a private girl's school. She had begun losing weight for 9 months and after a number of phone calls and a visit to the GP, Kaylee's mother brought her for assessment to the eating disorders service of the public hospital. Kaylee was reluctant to attend and insisted that there was nothing wrong with her and that the problem lay with her mother, who was over reacting.
Current Wt: 38kg
Ht: 160 cm
Wt(1yr previous): 48kg
Ht: 158cm
History of illness
Kaylee is a good student who just missed out on being Dux of Year 10. The previous year was difficult for her as she suffered a bout of glandular fever and missed quite a bit of school over a one month period. In addition her older sister, whom Kaylee idolised, moved out of the family home and in with her boyfriend. This situation created much family conflict with disapproval from both parents. As a result Kaylee felt torn between loyalty to her sister and to her parents. The weight loss appears to have commenced with the onset of glandular fever as Kaylee lost her appetite. On return to school, her fellow students commented on how good she looked and Kaylee felt she was noticed for the first time for her appearance rather than just her "brains". She decided to keep restricting her food intake so she didn't regain the weight she had lost through illness.
Within 2-3 months, Kaylee's parents had noticed her weight loss and began to confront her with what was happening. Kaylee denied any problems, but to keep her parents happy began to eat meals with them, but took to vomiting afterwards whilst in the shower. For a couple of months everything remained calm in the household as Kaylee appeared to be eating. Kaylee's mother noticed that Kaylee seemed particularly ravenous after school when she would have some weetbix, biscuits and bread before settling down in her room to do homework.
The situation finally came to a head however, when Kaylee's mother accidentally walked in on her daughter in the bathroom and saw her unclothed. She was horrified to see Kaylee's ribs clearly outlined under the skin and how wasted she appeared. They had a huge row but Kaylee agreed to see the family doctor, who conducted blood tests and arranged a referral for further assessment.
Kaylee denied that she was thin, stating that she felt fat and thought she could stand to lose some more weight. She was particularly upset about her thighs and abdomen, and described exercising in her bedroom at night for up to an hour. In addition she was walking to and from school, 4 km away. She described marked lethargy but had difficulty sleeping at night. She felt driven to walk but in the last two months had not enjoyed this. She denied any mood changes. Her mother however said, "Kaylee is a different person. She used to be sweet and cheerful and would do anything to help anybody. Now she is sullen, she stays in her room all the time, doesn't go out with her friends anymore. I am frightened to say anything to her because she either snaps at me or bursts into tears". Kaylee's teachers had also expressed concerns about her lack of attention in class and her falling grades, a situation which had become more obvious throughout year 11.
Oral Intake
Breakfast: Toast x1 no butter or spread
Black coffee
Morning tea: Diet Coke
Lunch: Diet Coke
Afternoon Tea: Binge after school (pkt biscuits, ½ loaf bread, 6 weetbix)
Vomit x1
Dinner: Whatever mother prepared.
Vomit x1
No laxative abuse, no use of cigarettes, alcohol, or drugs.
Periods: Commenced when 13 years old
Ceased 6 months ago.
Other Symptoms: Cold all the time
hair falling out
skin dry and flaky
slow pulse, dizziness and lethargy.
Family History
Lives with parents and brother.
Mother: 38 years old, healthy, walks daily and plays tennis weekly, works part time as an accountant and has done since her youngest child was 5 years old. Normal weight.
Father: 41 years old, runs a small sheet metal business and works long hours. Had a health scare two years ago with an episode of chest pain. Since then has given up smoking and alcohol, attends a naturopath and prepares his own meals following a low fat, non wheat diet. Normal weight. Doesn't have time to exercise.
Sister: 20 years old, university student, popular, outgoing and good at whatever she does include study, sport and music. Living with boyfriend of 2 years. A little overweight since adolescence. Her mother had expressed some concern about this but sister would not discuss her weight and apparently did not see this as an issue.
Brother: 12 years old, in Year 7 at boys private school, average academically, plays multiple sports. Relaxed and more interested in hanging around with his friends than in the family. Normal weight.
No family history of eating problems, alcohol abuse or depression. Kaylee's mother has dieted in the past but now tried to eat sensibly and ensure she exercised. She is not happy with her body but is more relaxed about it than she had been in the past.
Development
Kaylee described a happy childhood with no history of abuse. She had always been a good student and able to make friends without any problems. She idolises her big sister but at the same time feels she will never match up to her in terms of personality or achievements. She wasn't prepared for her sister moving out of home and misses her every day. Her relationship with her mother has been close until the last few months when there has been frequent conflict about food, eating and Kaylee's moods. Kaylee is not as close to her father and he has tended to leave the parenting to his wife as he is rarely available. Kaylee fights with her little brother but doesn't see this as significant. They see each other much less since her brother has become so involved with his friends and sport.
Assessment
Kaylee was assessed to be suffering from anorexia nervosa - bulimic subtype. She was noted to be depressed, lethargic and lacking in concentration, and was socially isolated; features consistent with starvation. Her pulse rate was 44 beats per minute and her blood pressure was 75/40, her temperature was 35.6 degrees C. Blood tests showed Kaylee to be low in potassium, a common problem as a result of vomiting. Low potassium results in muscle weakness and lethargy, but more alarmingly can cause arrhythmia's of the heart which place the person at risk of death. Her heart was small due to muscle loss which was evident throughout her body.
Kaylee did not accept this diagnosis and denied the seriousness of her condition despite extensive explanations about the risks to her health and her life. She expressed a desire to keep exercising and denied that she was vomiting despite knowledge her mother had found evidence in the shower including the smell.
The effects of starvation both physiological and psychological were discussed with Kaylee and her mother. Kaylee was able to recognise that her moods were consistent with what was described, and also that her grades were falling. It was at this point that she agreed to hospitalisation particularly when she realised how distressed her mother was.
Management
Kaylee was admitted to a hospital psychiatric unit which deals with patients with eating disorders on a regular basis. In view of the potential seriousness of her physical condition, Kaylee was seen by a medical team. She was assessed by a dietician and the clinical nurse in charge of the eating disorders unit.
Phase 1 - day 1-2
Replacement of potassium and fluids via an intravenous drip with monitoring of vital signs and blood tests. Cessation of exercise and encouragement of regular small meals. Kaylee complied with this plan but her oral intake remained poor. She did however, stop exercising and vomiting and her potassium normalised over two days.
Phase 2 - after day 2
Kaylee was reviewed by the dietician, doctors and nursing staff. She was feeling better physically and able to attend the dining room with the rest of the patients with eating disorders. She continued to struggle with intense guilt whenever she ate and was terrified that any intake would cause her to lose control and become incredibly fat. She was weighed twice a week, in the morning after waking.
Kaylee was started on three small meals and midmeal snacks of a glass of sustagen 3 times per day. Over the course of the next two weeks, Kaylee increased her weight to 40 kg. She was very apprehensive about weight restoration and required considerable reassurance, education and training in anxiety management strategies. The process was assisted by a primary nurse who came to know Kaylee well and was able to develop a good therapeutic relationship with her. She spent time with other patients with eating disorders in the formal group program as well as informally in the ward setting. This was a source of extra support for Kaylee early in her admission. Kaylee also had individual therapy sessions with the psychologist commencing anxiety management with a view to later moving to cognitive behavioural techniques specifically for dealing with the eating disorder. She saw the registrar regularly for extra support and to fully discuss the rationale for the actions of the treating team and the basis for treatment decisions.
Unfortunately when Kaylee reached 40 kg, she panicked and became increasingly upset. She began to ring her mother and begged to be allowed home, promising to eat regularly and do whatever her mother wanted. Kaylee's parents were seen by the hospital team and as they felt they now wanted to try and manage Kaylee's problems at home, she was given leave to go home with her family. Within 2 days the situation had deteriorated significantly and Kaylee was refusing to eat or drink anything at all, she would not go to bed and stood up all night moving around.
Phase 3 - after 3 weeks
Kaylee was returned to hospital by her family and was rehydrated with intravenous fluids. Her weight was 37 kg. In view of her intense guilt about actually eating, she was offered the option of night time nasogastric feeding via a tube through her nose into her stomach. She had seen other patients have this treatment and had spoken to them about it. As a result, she commenced on feeds overnight, inserting her own tube at night and removing it in the morning. During the day she went to meals with other patients and attempted to continue with small meals. Over the course of the next eight weeks, Kaylee gradually increased her oral intake at meals and gained on average 1 kg a week. This period was not without difficulty for her. At times she became incredibly anxious and could not stop herself from vomiting after meals. At other times she would slow the night time feeds down or empty them out. Regular sessions with her nurse and doctor however meant Kaylee eventually was able to tell them what she had done. This was also often be reflected in her weight. These problems were dealt with in a supportive, exploratory way and she was helped to deal with her anxiety. Kaylee was encouraged to keep a journal of her feelings and experiences and to share this with staff she had developed a good relationship with. Kaylee also requested help after meals. During these times she was most at risk of vomiting and a system of 1:1 nursing after meals was arranged. At times she would become angry with everybody around her, expressing anger at her parents for putting her in hospital; anger at the staff for what she saw as their control over her and for "making me fat"; and also particularly angry at herself for a myriad of perceived shortcomings in herself. It was important that these feelings were dealt with in a sympathetic way and that Kaylee was able to ventilate her emotions without turning to starvation or exercise as a way of managing them.
During the course of Kaylee's admission, her parents, and at times her siblings as well, were seen regularly by the team consultant, registrar and psychologist. They attended a family education programme run by a local private hospital and were encouraged to seek assistance from the Eating Disorders Association Resource Centre. They were perplexed about what had happened to their daughter and spent much time ruminating over where they had gone wrong. They also experienced shifting emotions from fear to frustration and anger. They recognised that they did not know where to place their anger. They felt they could not get angry with Kaylee so directed their anger at themselves, at each other, and at times to the treatment team. The situation was complicated by Kaylee's need for privacy and some sense of control over her own treatment as she attempted to overcome an illness which she felt very ambivalent changing. These needs conflicted with her parents' needs who felt guilty and confused and thus wanted to be involved in all aspects of Kaylee's treatment and her communication with hospital staff. These issues were dealt with in joint meetings involving both Kaylee and her parents. Kaylee's parents remained less than satisfied with the amount of information they were given but tried very hard to respect their daughter's wishes.
School: In the initial phase of treatment Kaylee was too ill to attend school. Her concentration was very poor and she was preoccupied with food and weight issues. As her health improved, her school sent over work and Kaylee was able to keep her in touch her lessons. School work was completed with supervision from nursing staff on the ward. At first Kaylee tried very hard to keep up and would frequently end up in tears as she fought to concentrate on the work. After discussing the situation with her parents and the school, Kaylee decided she would focus on achieving what she could this year and if necessary she would repeat Year 11 next year. With such an approach she was able to reduce the pressure she was placing herself under and in fact her work then improved considerably. This was also aided by her improved nutrition and better state of health. Kaylee began attending the hospital school once she was fit enough to leave the ward.
Phase 4 - after 11 weeks
In the preceding weeks Kaylee had begun to go home for weekends with her family. She would take the nasogastric pump and feeds with her. When she reached 45 kg, Kaylee began working on changing gradually from nasogastric feeds to oral supplements and continuing with meals. The process was not straightforward as Kaylee would reduce her night time feeds but would then balk at taking the supplemental drinks. However, as she realised that the process of weight restoration was proceeding as planned she managed wean herself off the nasogastric feeds. At this point Kaylee began attending her school again, initially for half days and gradually working up to full days. This process was difficult as Kaylee had missed a lot of social interaction with her peers over the previous months, although her friends had visited her in hospital. She felt self conscious upon returning to school, as though everyone was looking at her and watching her eat, a situation which in fact had some basis in reality. She was however assisted by teachers who had talked with hospital staff prior to her return to school, and by friends who had made an effort to understand how best to help her deal with the situation.
Phase 5 - Discharge
Kaylee was discharged from hospital at 48 kg, a less than ideal weight, but as she was managing well and had increasing periods of leave to home and school it became necessary to balance keeping her progress on the track with the need for her to be with her peers. Kaylee attended the hospital outpatient service once a week and had regular phone calls with her primary nurse-therapist. She was encouraged to use alternative coping strategies such as keeping a journal, supportive telephone calls, discussions with her family and friends, and relaxation strategies. Kaylee had commenced regular gentle exercise under physiotherapy supervision whilst in hospital and had a program to follow at home which she found useful as an anxiety release strategy. She continued to experience ongoing body image disturbance, but was much less preoccupied with food and eating, and her mood and anxiety had improved considerably.
Phase 6 - Ongoing outpatient therapy
During the assessment phase and throughout the admission it was impressed upon Kaylee and her family that the treatment for anorexia nervosa was likely to take at least 1-2 years and that most of the treatment would occur on an outpatient basis, after she left hospital. Whilst hospital is often necessary for weight restoration, which allows the person to think more clearly and become less anxious and depressed, ongoing therapy is needed both psychologically and nutritionally after discharge. Upon leaving hospital, Kaylee felt quite stressed, she had been anxious to leave but when she did so found she missed the structure of the hospital program and the reassurance of the ward staff. Along with the stress of being back at school and feeling under scrutiny, Kaylee expressed her disappointment that discharge from hospital didn't feel as good as she had anticipated. Her parents also needed help to understand this but were very supportive of their daughters attempts to eat regularly and attend school, and tried not to be intrusive during meal times.
Each week Kaylee saw her nurse therapist, the dietician and the doctor from the treatment team. She was encouraged to continue with keeping her journal. A mixed therapeutic approach was taken incorporating expressive, supportive and cognitive-behavioural strategies. During this phase Kaylee discussed the events and factors leading to the development of her eating problem, and talked about how anorexia had seemed to offer a magic solution to the difficulties she was experiencing. She described her growing awareness of her body from Year 8 and the way her friends focused on weight and eating at school. Even before developing glandular fever, Kaylee had become somewhat dissatisfied with her body and compared herself unfavourably with other girls who were taller and had males interested in them. Whilst admiring her sister greatly, she found it hard to accept the feelings of envy she had towards someone she loved greatly and had worked hard to quell this conflict in herself. Weight loss allowed her to have something she felt good at and that her sister was not. She later came to realise that, unconsciously, she was perhaps competing with her sister for her mother's attention. She may also have been punishing herself for unacknowledged feelings of pleasure from her idealised sister's conflict with her parents. It became obvious that the reasons for Kaylee's anorexia were multiple, complex and related to her phase of development. Once she began to lose weight however she found she was trapped in a vicious cycle from which she could not escape despite her at best, albeit ambivalent, intentions.
Kaylee continued in therapy over the next two years until the mid part of her first year at university. She had an up and down course with many pitfalls. Her weight increased to 54 kg. However, for a long time she hovered at 49 kg unable to break the psychological barrier of being 50 kg. At one stage, she became involved in her father's diet and attended his naturopath. On such a vegan diet she was unable to maintain her body weight or iron stores, and her weight dropped back to 45 kg. She was also tired and lethargic and the features of starvation made another appearance. With much support and encouragement from the treatment team and her family, particularly her father, Kaylee managed to avoid returning to inpatient treatment and was able to resume a more normal pattern of eating. Her periods returned after she had reached 51 kg, an event she had mixed feelings about but coped reasonably well with. At other times during this phase of her recovery, Kaylee returned to vomiting, particularly when she was anxious. However, as she matured and gained a much better understanding of herself, and with a good alliance with her therapists, this became much less of a problem.
Phase 7 - Termination of treatment
Kaylee had commenced a science course at university and was also working casually at Myer to earn some money and support herself in her studies as she was not eligible for Austudy. She met a male university student and began going out with him which improved her confidence. She had intermittent periods of depression and moments of self doubt but she was much more able to manage these herself as time went on. During the course of this year Kaylee explored termination with her nurse therapist and doctor and this was achieved with increasing spacing of her appointments. Kaylee was reassured she could return at any time in the future and was encouraged to seek help earlier rather than later if she experienced any relapse in symptoms whether this be depression or eating disorder. She subsequently kept in touch with occasional phone calls and Christmas cards to the treatment team and at last contact was continuing to do well.