Case Study: Severe Anorexia Nervosa with Anosognosia and Complicating Trauma History

Case at a Glance

A 34-year-old female with a long-standing diagnosis of anorexia nervosa presents for treatment with a dangerously low BMI of 15.4 kg/m². Her case is complicated by profound anosognosia (lack of insight into the severity of her illness), significant body dysmorphia, and an underlying history of sexual trauma, which acts as a major barrier to weight restoration.

Patient's Story

The patient is a 34-year-old female who has been in treatment for anorexia nervosa. She presented with a significant discrepancy between her clinical assessment and her self-perception. Despite her medical team classifying her condition as 'risky' due to her low body weight, the patient expressed disbelief and a feeling that they were 'overreacting.' She stated, 'I certainly don’t feel sick enough to be labelled risky,' and reported a persistent perception of being 'too fat.' The patient disclosed a history of weighing approximately 50kg prior to the full onset of her eating disorder, a weight she associates with negative body image. She further revealed that her resistance to returning to a healthy weight is linked to a past sexual assault, stating she is 'afraid of returning to a similar body as the one when I was sexually assaulted.' The eating disorder behaviors appear to have developed as a maladaptive coping mechanism to gain a sense of control following this trauma.

Initial Assessment

Upon presentation, the patient was found to be severely underweight.

• Age: 34
• Height: 158 cm (1.58 m)
• Weight: 38.5 kg
• BMI: 15.4 kg/m²

This BMI places her in the World Health Organization's classification of 'severe thinness' and the DSM-5's 'extreme' severity category for anorexia nervosa. Her physical condition puts her at high risk for severe medical complications, including cardiac arrhythmias, organ failure, and sudden death. Psychologically, she exhibited classic symptoms of anorexia nervosa, including an intense fear of gaining weight, a distorted body image, and significant anosognosia. Her avoidance of discussing her trauma in detail, coupled with physical manifestations of distress (uncontrollable shaking) during therapy sessions, suggested co-morbid post-traumatic stress.

The Diagnostic Journey

The diagnosis of anorexia nervosa was previously established, but the patient's current presentation prompted a re-evaluation of the severity and treatment approach. The primary diagnostic challenge was the patient's profound lack of insight. Despite being presented with objective data regarding her BMI and the associated mortality risk (an 11.5% five-year mortality rate for BMI of 15), she was unable to apply this information to her own situation. Her cognitive distortions ('I'm too fat,' 'gaining weight...is only going to make me considerably obese') were deeply entrenched. The diagnostic picture was further clarified by her disclosures in therapy, which linked the eating disorder's genesis to a need for control following trauma. This highlighted that the eating disorder was not simply about food or weight, but a symptom of deeper psychological distress. Her difficulty engaging in trauma-focused work and her concern that her current therapist was not 'trauma-informed' were identified as critical barriers to progress.

Final Diagnosis

Anorexia Nervosa, Restricting Type, Extreme Severity (DSM-5 307.1). Co-morbid Post-Traumatic Stress Disorder (PTSD) and Body Dysmorphic Disorder (BDD) are strongly indicated and are significant contributing factors to the maintenance of the eating disorder.

Treatment Plan

A multidisciplinary and intensive treatment plan was recommended to address the acute medical risk and underlying psychological factors.

1. Medical Stabilization: Urgent consideration for a higher level of care, such as an inpatient or residential treatment facility, to ensure medical safety, manage refeeding syndrome risk, and provide 24/7 support.
2. Nutritional Rehabilitation: Collaboration with a registered dietitian specializing in eating disorders to implement a structured meal plan for gradual and safe weight restoration. The goal would be to reach a medically stable weight (a minimum healthy BMI of 18.5, aiming for a range of 50-60kg as per her history).
3. Psychotherapy: A shift in therapeutic approach was deemed necessary.
   • Trauma-Informed Care: Referral to a therapist specializing in both eating disorders and trauma. Modalities such as Eye Movement Desensitization and Reprocessing (EMDR) or Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) would be appropriate to process the underlying trauma safely.
   • Cognitive and Behavioral Therapy: Continued use of therapies like CBT-E (Enhanced Cognitive Behaviour Therapy for Eating Disorders) to challenge cognitive distortions related to weight, shape, and eating, and to address the severe body dysmorphia.
   • Therapeutic Alliance: Prioritize building a strong, trusting relationship with the new therapist to overcome the patient's avoidance patterns.

Outcome and Follow-up

The patient was currently engaged in outpatient treatment but making minimal progress due to the previously identified barriers. The prognosis is guarded given the severity of her low weight, the profound anosognosia, and the complexity of the co-morbid trauma. Successful engagement in a more intensive and specialized treatment program is critical to mitigate the high risk of mortality and facilitate recovery. Long-term, consistent follow-up involving medical, nutritional, and psychological support will be essential to manage this chronic condition and work towards sustained recovery and relapse prevention.