Patients with anorexia nervosa hid weights in their clothes and hair in order to appear heavier than they were, according to a new report by healthcare professionals based in Sligo.
A temporary unit for eating disorders 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.
New research published in the Irish Medical Journal details the “sabotaging behaviour” witnessed among its patients.
Some of the conditions experienced by patients who presented at the unit included emaciation, very slow heart rate, hypothermia and self-harm.
The report notes that “random unannounced weighing” takes place on the unit’s designated 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.
On weigh-in days, some patients were putting weights in their hair and hems of clothing and were gripping scales with their toes, according to the report.
Patients also engaged in “inventive” harmful techniques such as “animated conversation” in an effort to burn calories, the report notes.
Other harmful techniques included micro-exercising, requesting that windows be opened so patients could shiver; food concealment; faecal or urinary loading on weighing days, wearing heavy hair accessories to appear heavier, and vigorous page-turning and toothbrushing.
Anorexia has the highest mortality rate of any psychiatric illness and affects 0.5 per cent of the Irish population.
The patients in Sligo are treated in the designated ward with continuous cardiac monitoring and one-to-one supervision, as well as bed rest and careful calorie intake which usually takes place through nose-feeding.
The one-to-one supervision is usually carried out by a healthcare assistant.
“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,” the report notes.
“Clear handover to incoming healthcare assistants and on-call staff is paramount ... flustered interns are often requested to chart laxatives, so clear instructions for out-of-hours staff is important,” the report adds.
Enforced bed rest
The report notes that bed rest is enforced on patients “to minimise calorie expenditure”.
A commode toilet 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 the mattress is wet because the feeding tube was disconnected.
While being treated in the unit, a “separation period” is enforced whereby phones, computers and all electronic equipment are removed from the patient.
The report notes the removal of all technology is important to allow the unit to be a “safe space” free from bullying, and also to permit “reflective time” and “recovery time”.
It also says that the unit experienced one patient micro-exercising by typing vigorously on a laptop.
The report notes family members of patients were at times “colluding with the sabotaging behaviour, insisting that the problem is gastrointestinal disease, bringing in food, hiding food ... [with] relatives sitting constantly by the bedside and interfering in neighbouring patients’ affairs”.
The researchers describe the patients in the unit as “very challenging … with a significant mortality rate”, and say that a multidisciplinary approach to care is needed.
The report adds that “collaboration, appropriate clinical skills and patience are the keys to success with this cohort of patients”.