Although the symptoms of Anorexia Nervosa do present as mostly physical, it’s very much a condition of the mind and body. It also holds a unique position within the spectrum of mental health. It’s one of the few mental illnesses where the sufferer has little to no motivation to recover – unless there is a compelling intervention or their life is threatened. Even then, it’s not uncommon for cases to result in death. Sometimes the body has been denied nutrition for so long, the organs have atrophied so much, they’re beyond repair.
The reason why there is such difficulty in reversing Anorexia is it is often self-motivated. It is an ego-centric mental illness, rooted in the searching for an idealised version of the self through ‘enhanced’ body image. Of course, there are social and cultural influences at play that spiral out of control when taken to their nth degree. But once they take root, this searching for identity through the distorted perception of self-image creates the problem of finding true identity during the recovery phase.
Exmaning the case of Becky, an 18-year old, reveals the challenges with cognitive and behavioural aspects of recovery- even when there is a willingness to change. Her struggle with Anorexia began at age 16 while studying with stressors that included bullying and family difficulties as her sister was diagnosed with OCD.
She was treated by the Child and Adolescent Mental Health Service (CAMHS) for a 6-month course of therapy and was later referred to the adult eating disorder service at age 18. She continued to make good progress, raising her BMI from 15.5 in December to a BMI of 17 in July 2016. With support from her family, she stuck to a strict re-feeding plan was making steady improvement, taking on full responsibility for the planning and preparation of her meals.
However, there were still problems in her underlying thought processes. Becky was still experiencing a strong tendency towards perfectionist thinking that was affecting many areas of her life. There was a lot of rigidity around her eating habits that remained, and her social skills were also underdeveloped.
Throughout the study period, Becky was treated using the Maudsley Model of Anorexia Nervosa in Adults (MANTRA). The program places a strong focus on identity exploration and development as a means to alleviate the symptoms of Anorexia and increase focus around recovery.
During the latter stages, it was found that Becky’s eating difficulties were the result of pro-anorexia beliefs – the supposition that her condition made her a better person. There was also a correlation between being extremely detailed orientated, the presence of inflexible thinking, fear of making mistakes, self-criticism and unrelenting high standards. These findings were the result of the self-assessment Becky was asked to carry out in between her sessions. She later reported engaging in these reflective exercises gave her a clarity she might not otherwise have gained without them.
What this case demonstrated is when you place greater emphasis on identity instead of causative factors, the speed and quality of recovery improve, dramatically. The results of Becky’s cause show a marked improvement over the linear method of cause and effect. The strategy of creating a non-illness driven set of values were key in helping Becky with her recovery.
The issue with treating Anorexia Nervosa is the age at which it typically presents – between 15-25. These represent the peak years of young adulthood when we’re beginning to form our value systems. If the predominant mode of thinking during this time is rooted in poor self-image reinforced by restrictive behaviour patterns, it creates a problem of letting go. The overidentification with Anorexia occurs because there is no other reference point of character. That is what makes recovery so challenging. It is the absence of a personality that hasn’t been fully realised yet. There is nothing tangible that can be held onto because the identity of the sufferer has been co-opted before it has had a chance to truly flourish. Anorexia is the identity.