Warning: Some readers may find details in this report distressing

THE SABOTAGING BEHAVIOUR, including techniques to appear heavier than they are, exhibited by patients with anorexia nervosa has been detailed in a new report by healthcare professionals based in Sligo.

A so-called ‘pop-up eating disorder unit’ based at Sligo University Hospital and St Columbas Hospital, which specialises in mental health services, has treated 20 acutely ill patients since its inception in 2014.

The team – which consists of a psychiatrist, physician, dietician and nurse – meets twice a week and formulates a plan for the duration of a patient’s admission.

Anorexia affects 0.5% of the Irish population, with 90% of patients being female.

It has the highest mortality of any psychiatric illness. Many people die by suicide but there is a significant mortality rate among those admitted to a general hospital with deaths from both under-feeding (malnutrition) or over-feeding (refeeding syndrome).

The patients in Sligo are treated in a designated ward with continuous cardiac monitoring, one-to-one continuous supervision, complete bed rest, careful calorie intake (usually through  nose-feeding) with twice daily phosphate, magnesium, calcium and potassium concentrations measured and replaced.

The mean age of patients treated to date is 22 years, and all but two patients have been female.

New research published in the Irish Medical Journal details the “sabotaging behaviour” witnessed among patients.

This includes micro-exercising, requests for windows to be opened in order to shiver; food concealment; faecal or urinary loading on weighing days as well as wearing heavy hair accessories to appear heavier; vigorous page turning and toothbrushing; and animated conversations.

The report notes that “random unannounced weighing” takes place on the ward. Patients wear minimal clothing and are weighed while facing away from the digital dial on the scale.

“Results are not disclosed to the patient to avoid excessive focus on weight.

The team has experience of patients hiding batteries in sanitary towels on weighing days, weights embedded in hairstyles, and hems of clothing, and gripping of scales with toes.

The researchers state that patients engage in “inventive” harmful techniques such as “animated conversation” in an effort burn calories.

All the patients in question receive one-to-one supervision at all times, usually through a health care assistant (HCA).

“Changes of personnel and shifts pose challenges. Such personnel are instructed not to engage in conversation, as this is met with animated conversation in an effort to micro-exercise.

“Clear handover to incoming HCAs and on-call staff is paramount and flustered interns are often requested to chart laxatives, so clear instructions for out-of-hours staff is important,” the report states.

Full bed rest and no phones

Researchers note that full bed rest is enforced to minimise calorie expenditure. A commode is supplied by the bedside, but no bathroom trips are allowed “as it is a vulnerable point for sabotage”.

Bedding is examined daily in case food has been hidden in the pillows or if the mattress is wet because the feeding tube was disconnected.

The researchers note that the initial feeding of patients can involve “profound calorie restriction” at 5-10 cal/kg/day with slow augmentation to minimise electrolyte imbalances. Patients also receive vitamin replacement – which can be oral, via the nose or intravenous.

A “separation period” is enforced whereby phones, computers and all electronic equipment is removed from the patient.

We have experienced cases of bullying by peers on electronic devices, so removal of all such intrusive portals is important to allow this to be a “safe space” free from bullying, and also to permit “reflective time” and “recovery time” without electronic distractions. We have experienced one patient micro exercising by typing vigorously on the laptop.

The researchers add that they have experience of family members “colluding with the sabotaging behaviour, insisting that the problem is gastrointestinal disease, bringing in food, hiding food, and relatives sitting constantly by the bedside and interfering in neighbouring patient’s affairs”.

Family psychological counselling is an integral part of the longer term process but initially visiting may have to be restricted in the interest of rest, calorie preservation and mindful of other patients on the ward.

Some of the conditions experienced by patients who presented at the ward include emaciation, very slow heart rate, hypothermia and self-harm.

Discharge and follow-up

Day-leave is permitted before patients are discharged and a person’s coping mechanisms and family support system is assessed by the team.

Discharge is followed by twice weekly enhanced cognitive behavioural therapy (CBTE) and dietetic support.

Since the unit in Sligo began operating in 2014, there has been one voluntary readmission. The patient reported restricted eating and feeling weak but self-discharged within 24 hours.

None of the patients treated in the unit have died. Three people have disengaged with the CBTE prior to completion of the programme, and two of these people have had a fall in BMI (body mass index) post-discharge.

Other patients had an increased BMI at the last recorded weighing compared to that at discharge. Satisfaction ratings are high among service users upon formal evaluation, the report notes.

The researchers describe the patients in question as “very challenging … with a significant mortality [rate]” and that a multidisciplinary approach to care is needed. 

The nature of the illness crosses community/hospital and medical/nursing/psychiatric domains and with poor insight, family collusion and sabotage these patients can struggle with multiple disparate care-givers. Hence multidisciplinary cooperation and communication is essential for successful outcomes.

The report adds that “collaboration, appropriate clinical skills and patience are the keys to success with this cohort of patients”.

“Of paramount importance is physician awareness of the clinical issues that are presented by these patients and increasing awareness among health care professionals to allow early identification, appropriate management and prevention of morbidity in this patient group.”

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