Flying under the radar: first hospitalisation with anorexia nervosa at age 54

“Is it better to walk 10 hours or cut myself … I found it reinforcing to feel a ‘lightness’ … I was surviving like a beast.. I would easily fall into a deep depression if I got better”, recounted a 54-year-old woman with a 40-year history of eating disorder, admitted to hospital for the first time with complications of her illness.

Anorexia nervosa is an often recalcitrant condition, remarkably immutable to change, due to the effect of behaviour reinforcement.1 There is also a growing literature about women with this disease presenting later in life. Body image dissatisfaction is an enduring issue for many women, with one study finding that 3.8% of women aged 60–70 years meet the criteria for having an eating disorder.2

The Diagnostic and statistical manual of mental disorders, fifth edition, has broadened the criteria for anorexia nervosa to allow for persistent behaviours that resist weight gain even in the absence of distorted body image. With this criterion, a recent study found that the prevalence of anorexia nervosa in the Australian population was about 0.46%.3 Earlier research had shown that more people with anorexia nervosa were surviving in the community than were being cared for in primary care or mental health facilities.4

At the time our middle-aged patient was referred to the consultation liaison psychiatry service, she had a body mass index (BMI) of 13.8 and was in life-threatening condition with acute kidney injury, significant anaemia, electrolyte disturbance, and delirium. Her history revealed 12 months of worsening symptoms after her mother died of cancer. This was on the background of chronic gastrointestinal disturbance, which her mother had had as well, and which was intimately linked with her disordered eating. In the acute stage, her course was complicated by severely delayed gastric emptying, necessitating a brief period of total parenteral nutrition to avoid bowel perforation.

This patient provided a convincing history of anorexia nervosa, restrictive type (in the extreme range of severity), marked by excessive walking. She did not seem to realise that the level of caloric restriction she had placed on herself was abnormal, but she did acknowledge that something was wrong because she could no longer “keep on walking” — she usually walked up to 50 kilometres each day. Her illness limited her ability to work and socialise. Her treatment was supported by a treatment order under the Mental Health Act 2000 (Qld) because of an initial brief episode of psychosis, and then maintained until after a period of stable nutritional rehabilitation.

While this patient did not conceptualise her condition as an eating disorder, she displayed impressive psychological mindedness and receptivity to considering the contribution of chronic pain, grief, and illness identity in perpetuating ill health and dysphoria. Despite her severe illness and some challenges related to eating-disordered behaviour, she had a generally cooperative attitude which further facilitated brief insight-focused supportive psychological therapy. Her BMI increased to within the normal range over several months as her care was continued under psychiatric inpatient, and then outpatient, services.

Managing mature patients with considerable life experience who have survived despite disordered eating provides unique perspectives on the balance between autonomy and control. Management of such patients requires greater flexibility.