"Louisa" - A Case Study by Steve Clifford, Psychotherapist

A distorted body image, with fear and avoidance of food dominating every thought, Louisa became so obsessed with controlling food intake that when she came to the Eastbourne Clinic, it was in her words "the last resort". Looking shockingly thin, with a face once lively and expressive, she now looked gaunt and sad.

She told me that she was only here for her family and with tear filled eyes, stared forlornly at her children's photographs. Louisa suffers with Anorexia Nervosa, and like many with this potentially life-threatening condition, she hated herself for becoming so obsessed with food that it completely dominated her life. Upset and overwhelmed with guilt and shame, she was absolutely terrified that she might lose control and give in to the temptation of eating. Anorexia Nervosa in particular, has been on the increase over the past two decades and research has indicated that girls as young as nine years suffer from this condition.

Now in her mid-thirties Louisa is typical of a large number of sufferers who have been in treatment before and switch from one compulsive behaviour to another. Her first episode of Anorexia was as a teenager aged 15. Several hospital admissions followed, an overdose attempt aged 17 and then weight increase and difficulty with bingeing and vomiting. In her twenties, while still obsessed with the desire for thinness, she started consuming high quantities of alcohol such as vodka, cider and wine (up to 1-½ litres of wine by day and also drinking in the evening with her husband). During the day she would walk miles and her food intake would be the barest minimum, just enough to overcome her unwell feelings.

Treatment for Anorexia varies with most sufferers consulting their G.P in the first instance. They may be referred to specialist practitioners such as dietician or local mental health services. Depending on severity, in-patient treatment may be an option. Outpatient treatment may not always be successful, particularly with practitioners working alone tending to address one area in isolation, e.g. dietary regime or psychological conflict. Unfortunately specialist units are scarce and many sufferers end up in general psychiatric units where professionals have limited understanding of eating disorders. Likewise, traditional approaches to treatment often leave much to be desired, with draconian measures leaving sufferers feeling demoralised. Louisa recalls previous hospital admissions and rigid behaviour regimes where she says she felt as it she were being "punished" and were a "bad person", having to earn such things as wearing day clothes and visits according to weight gain.

A successful treatment plan will embrace the following areas:

1. Correction of malnutrition (including physical complications), re-establishing healthy body weight and restoration of normal (adequate) eating patterns.
2. Re-structuring distorted thinking, values and beliefs that contribute to weight phobia.
3. Addressing underlying psychological disturbance and emotional issues.
4. Family support
5. Relapse prevention strategies

At the Eastbourne Clinic we believe that a team approach is the best way to help sufferers such as Louisa, where pooling resources and continually reviewing treatment meets changing needs and offers a more flexible approach. One of the key elements of our success is the dedication and commitment of the whole team who go to great lengths to ensure our patients are really looked after. We are told that our family friendly ethos, the warmth and homely atmosphere we aim to create is very welcome and sets us apart from other mental health establishments.

Led by our Consultant Psychiatrists, our team of experts include two nurse specialists (RMN) who work with sufferers in promoting healthy eating with emphasis on "healing foods" and optimum nutrition rather than "fattening up". We have found that too much focus on maximising food and weight gain can intensify the sufferer's obsession with food and the scales. It can also cause great distress.

Physical aspects of treatment are undertaken by a Registered General Nurse, who ensures careful monitoring of individual's health throughout their stay to prevent and identify potential problems such as marked orthostatic hypertension, metabolic abnormalities, hematemesis, vital sign changes or the appearance of uncontrolled vomiting.

On assessment Louisa's presentation bears many of the hallmark characteristics of this condition. For example, Amenorrhoea, usually one of the first features to manifest, which arises as a result of low levels of pituitary gonadotrophins (luteinising and follicle stimulating hormones), and is associated with low body weight. Also, with her body attempting to overcome starvation and to preserve energy, the basal metabolic rate will be seen to diminish, resulting in lowered temperature, drop in blood pressure and reduced pulse. While Louisa certainly felt cold, advance acrocyanosis was not apparent. This is easily spotted with poor circulation to the extremities, highlighted by blueness of the hands and feet with a mottled appearance and extreme coldness to touch. In advanced cases whole limbs can be affected. Sufferers usually feel discomfort even in warm conditions and when the weather is cold it can become excruciatingly painful.

Ironically, Louisa had concerns about her body image, and in particular the roundness (fatness) of her face. Due to insufficient protein intake, osmotic pressure lowers and this results in tissue fluid formation thus oedema occurs and this leads to a puffy face (and swollen ankles). Other symptoms that can be found are dryness of head hair with a corresponding appearance of fine downy body hair known as lanugo.

When she first joined us Louisa was both physically and mentally restless and overactive. This is a common reaction to physiological changes associated with starvation. Sleep disturbance also occurs with reduction in total sleep time due to early morning wakening. Patients often report poor quality sleep and this arises through diminished deep sleep. While Louisa was sad and withdrawn on admission, at a pharmacological level it was decided to stop the antidepressant medication she had been taking and substitute Olanzapine, a neuroleptic medication with a tranquillising effect to quell her restlessness and induce calm. It also has the bonus of low indication of extra pyramidal side effects and is implicated in weight gain (though not specifically promoted thus). To date no specific pharmacological treatment for Anorexia has been established. In Bulimia Nervosa, antidepressants (e.g. Fluoxetine at 60 mg) are effective in reducing bingeing in a proportion of cases.

With the ultimate duration of treatment undetermined and an estimate at roughly 12 weeks, all therapeutic interventions had to be focused and managed within this "glass ceiling". We had to be prepared in the event we were called upon to stop at short notice thus our treatment took on a modular stance where past, present and future has to be worked on simultaneously, e.g. beginning work on relapse prevention from the outset, looking for primary triggers and patterning (where historic events reoccur in a cyclic pattern), and dealing with the trials of everyday life and management with a "solution focused" perspective, building on what is working well rather that what is not.

My role as a Psychotherapist was to provide Louisa with space to talk and reflect on her torturous journey and the course of her illness. In therapy the emphasis is taken off food and weight gain and is centred on awareness of the interconnectedness of underlying psychological conflict. While food is important it is viewed as a facet of a far larger whole. The essence is to look to see what the obsession with food and its component aspects are about, or, in other words, to discover the underlying meaning for Louisa. From a psychological perspective it could be said that Anorexia is an addiction and all addictions are displacement activities. Whether the addiction is drugs, alcohol, work or exercise, the condition is a distraction from the realities of life. It is inevitable that while exploring the beliefs and values that are perpetuating the eating problem patients will struggle with the emotional content, which can be very painful. It may be that denial and reluctance to acknowledge the intensity of internalised hurt has been carried for many, many years. I have found that there is always a reluctance to discuss feelings associated with their shape and weight, usually because such feelings consist of shame and self-condemnation. Indeed, many patients will not have discussed these matters in depth before. Thus considerable sensitivity on the part of the therapist is required.

From the outset Louisa was gradually introduced to group activities in the Clinic's therapy centre. These included anxiety management, anger management, relaxation and Cognitive Behavioural Therapy (CBT), all of which Louisa reported useful to her. Alongside psycho-educational groups Louisa also found benefit from Aromatherapy, Tai Chi and Meditation. The benefits derived as a result of touch cannot be under-estimated. The self-loathing aspect so prevalent with Anorexia often serves to keep others at a distance and the inclusion of beauty therapy ("pampering") alongside aromatherapy meant that Louisa was able to re-experience human contact at a physical level and nurturance through touch. This emphasis on re-connecting with the body is pivotal in learning to overcome poor self-image and work towards greater "self"-acceptance.

For some clients, however, just being in a group with others might be all they can tolerate. It is important to listen to the client. As a rule, having the opportunity to work with others in a group setting is helpful in enabling clients to see that others experience similar problems and have dealt with them effectively thus inspiring hope of recovery. Learning to help each other within the security of a therapeutic group often helps to boost low self-esteem and this certainly helped Louisa towards rebuilding her confidence. Another advantage is that clients are helped through feedback from others to identify and change distorted self-perception. Louisa found that she could be very articulate in group discussions and the feedback enabled her to express strong (often negative, often positive) feelings like anger and resentment.

It was several weeks before Louisa's weight and physical state began to improve noticeably. With her mood and thinking taking on a more balanced perspective, there was a corresponding rise in anxiety associated with the weight increase. This was a crucial phase and one that had to be managed very carefully. Previous treatment had failed when too rapid a weight gain led to Louisa absconding, as she felt overwhelmed and could not cope with the change. Much time was spent exploring and talking through her feelings of anxiety. It was important to help Louisa as she worked on re-defining her self-image and re-structuring the distorted thoughts, beliefs and values she held about herself and relation to weight increase. The resulting cognitive shift enabled other changes to occur relating to environment whereby Louisa was able to begin to accept her worth and re-appraise her role as a mother, wife and daughter.

In her individual psychotherapy Louisa worked on identifying pivotal life events, using a time line to record and analyse historic data, e.g. significant memories and emotional responses. We were then able to identify certain early childhood experiences, which may have led to Louisa making the decision (sub-consciously) to retard her physical development via her eating habits in order to combat the fear of sexual identity and development.

The correlation between thoughts and feelings/behaviours was explored through the medium of individual and group work. Food diaries and thought records were used to gauge progress as well as to provide a platform for discussion and therapeutic intervention. Much work was done with the whole nursing team supporting her and nutritional coaching being provided by the key specialists. The promotion of positive body image, a healthy, realistic body appraisal went hand in hand with establishing realistic cognitive messages regarding food intake and body size.

As well as her individual work with colleagues and me, we invited her husband to join her and engaged in couple counselling. It must be emphasised that this approach was decided upon as various complicating factors prohibited wider family work. Two therapists saw the couple, one with an integrative background and the other CBT trained. Louisa and her husband were seen in a weekly "stand alone" session. The focus was primarily on home concerns (pre and post-discharge) and communication, which was identified as a major factor in difficulties, which had precipitated clinic admission.

With Louisa making progress with regard to weight and physical health and a corresponding improved mental state, home leave was negotiated. Initially these were for short periods and valuable in assessing the impact of increased activity on weight maintenance, decreased supervision and self-monitoring. We were also concerned to see how she would cope without the intensive team support.

With minimal difficulties leave progressed satisfactorily and ultimately Louisa was successful in getting the balance right and managing to keep to her treatment plan and targets. Relapse prevention was addressed throughout Louisa's stay. It took on a realistic perspective with trial periods of home leave. Louisa was told to expect occasional setbacks and to view them as learning opportunities, and not to be disheartened. She was primed to anticipate times when slip-ups may occur, e.g. when tired, unhappy or under extreme stress.

Discussion on life management included such areas as planning days ahead, avoiding long periods of unstructured time or overbooking. Central to any successful transition is the ability to confide in others and seek help rather than resort to old and familiar dysfunctional coping strategies. Louisa is very aware that the real work of maintaining adequate weight gain and accepting personal responsibility for adequate nutrition really begins on discharge. Whilst pleased with her achievement during her stay at the Clinic, she still has concerns about her ability to maintain progress and also is still coming to terms with the "new" her in relation to body image and self-perception.

Liaising with her local health providers, plans were made for Louisa to receive ongoing support and counselling from specialists in her own locality on an outpatient basis, including continued couple work to support her and her partner. She remained on our day programme for a further two weeks post-discharge to increase self-reliance and assist with the transition.

We were pleased with the successful outcome of Louisa's treatment. At the end of the day there is no magic formula for people with Anorexia. Like Louisa, they must first admit the problem and be willing to ask for help from others. Sufferers need a great deal of love and support to recover. They need help to accept themselves and to feel worthwhile as they are, and for whom they are.