SINGAPORE - Being comfortable in your own skin is much easier said than done. This was particularly the case for Jane (not her real name), who attended an elite girls' school and did exceptionally well in her studies.
Despite her academic success, Jane developed an unhealthy obsession with her weight. At the age of 16, she was diagnosed with anorexia nervosa and bulimia.
Also known as Golden Girl Syndrome, anorexia nervosa is an eating disorder that causes patients to lose more weight than what is considered healthy for their age and Body Mass Index (BMI). They are usually unnaturally thin and display an intense phobia towards gaining weight despite being severely underweight.
There is no single cause for anorexia nervosa - rather, it is the result of a combination of emotional, social and biological factors.
The disorder is alarmingly common amongst girls in Singapore, and the number of cases seems to be on the rise. Between 1994 and 2002, there were a total of 126 cases recorded by the Child Guidance Clinic and the Eating Disorder Clinic at the Institute of Mental Health. In recent years, the number of anorexia cases has increased, with Singapore General Hospital (SGH) seeing an average of 120 new cases a year.
For Jane, her obsession with weight loss was triggered by a casual remark from her boyfriend, who said that she had put on a little extra weight. That innocent comment quickly became the driving force behind Jane's spiral into anorexia.
'His remark really affected me. I felt uncomfortable with my weight and I wanted to get thinner in the shortest time possible. It didn't help that half the girls in my school were extremely slim too,' she said.
Jane purchased a weighing machine and weighed herself every day. If her weight wasn't satisfactory, she would cut down on her already-meagre diet.
'My life was ruled by that weighing machine,' she said. 'It was a slippery slope for me because once I started losing weight, I felt "empowered" to lose even more,' she added.
Jane's methods of starving herself became ritualistic.
'I would wake up every morning at six and have a bar of chocolate to last me the entire day.
'During school, I would focus all my energy into my studies and would stay in class during recess because I didn't want to be surrounded by people eating.
'I only allowed myself to drink plain water and that was it.
'It was pure torture.'
Consequences of self-starvation
Jane's obsession with thinness led to a deterioration of her immune system. She fell sick regularly and experienced severe hair loss, fainting spells and most worryingly, get her period months late.
'One of the first signs that starvation has reached serious proportions is the absence of menses as body fat declines,' said Dr Lee Huei Yen, director of the SGH eating disorders programme and consultant at the Department of Psychiatry.
'In addition, starvation also affects almost all bodily systems. Some complications from weight loss include hypothermia, hypotension, changes in hair and skin texture, permanent loss of bone mass, anemia, and in more severe cases, atrophy of the brain.'
Jane also became, in her words, a 'human time bomb'. If her daily rituals were unexpectedly disrupted, she would become extremely emotional and prone to fits of self-destructive rage. For example, whenever she broke her routine of eating just one bar of chocolate per day, she would put her fingers down her throat to force herself to regurgitate whatever she had eaten.
'I wanted to purge that disgusting feeling of eating. I did that to the point that my throat bled.'
Binge and purge
What Jane didn't realise was that she was displaying symptoms of both anorexia and bulimia - a volatile mix with potentially fatal consequences.
'Bingeing and purging can result in hypokalemia which can cause an abnormal electrical conduction of the heart that may lead to death. Adding to that, continuous irritation of the throat can lead to a torn esophagus and the result of vomiting could cause gastric ruptures which will result in death,' said Dr Lee.
Jane's self-destructive lifestyle was eventually picked up by her mother Mdm Tan (not her real name) when she discovered her daughter forcing herself to vomit in the middle of the night.
Having suffered anorexia herself when she was a teenager, Mdm Tan lost no time in admitting her daughter to SGH's eating disorders programme.
'Seeing my daughter bent over the toilet sink trying to puke her insides out was painful. I felt as if history was repeating itself,' said Mdm Tan, choking back tears. 'Admitting Jane into hospital for an eating disorder was difficult, but I did what any parent would have done.'
Recovery is a long road
The long road to recovery
Jane weighed just 30kg when she was admitted into SGH, which made her Body Mass Index (BMI) 13.3. A healthy teenage girl has a BMI of about 20.
Despite being treated by a medical team comprising a psychiatrist, psychologist, dietician and a family counselor, Jane was initially unreceptive to treatments. 'I didn't want to accept that I had a problem, so I just told the doctors what they wanted to hear,' she said.
'I felt that the treatments were impersonal because I had a different doctor for each respective session. They didn't know anything about my progress apart from notes and indicators.'
Despite Jane's resistance to the treatment, her hospital experience played an important role in her recovery. During one family counselling session, Mdm Tan broke down and started sobbing uncontrollably.
'Seeing my mother and best friend cry like that was my catalyst for change," said Jane, now 20 years old. 'I couldn't bear the guilt of causing her that much pain.'
Jane was discharged from SGH after a month but her road to recovery was anything but easy. She had to return for weekly checkups to ensure that she was eating normally and maintained a healthy weight.
'Recovery from anorexia is usually a long, drawn out process, although some recover quicker than others. Recovery will be quicker and easier for those who have not been ill for too long,' said Dr Lee.
'After five years, approximately 30 per cent of anorexics would have recovered and about 70 per cent of them recover after 10 years.'
'Patients need regular follow ups in order to prevent relapse. We also encourage them after recovery to continue eating regularly, avoid skipping meals and to eat a variety of food,' he added.
Jane, now a second year student in Nanyang Technological University, admitted that she hasn't fully recovered from anorexia nervosa, despite the progress that she has made in the past four years.
'I'm not completely over it but I definitely wouldn't go back to how I was last time,' she said.
'Besides, I love chocolate now,' she laughed.
Warning signs and where to get help
Warning signs to look out for
How do you tell if your friend or family member has an eating disorder? Look for these 20 behaviours, signs and symptoms:
- Extreme preoccupation with food
- Distorted perception of their body
- Emotional state tied to eating habits
- Self loathing comments
- Becoming very secretive about food
- Moodiness, shakiness, irritability
- Obsessive rituals (such as eating only certain food at certain foods)
- Social withdrawal
- Avoidance of social situations that include food
- Loss of menstrual period
- Development of fuzzy hair on the body
- Exercises in an extreme manner
- Excessive calorie counting
- Dramatic weight loss unrelated to illness
- Gets very cold easily
- Dry and brittle hair
- Hoarding and hiding food
- Blisters on knuckles and fingers from sticking fingers down their throats
- Frequent and secretive trips to the bathroom after meals
- Consumes large amounts of food when experiencing stressful or unhappy emotions
- Eats secretively or is ashamed of the amount consumed
Source: Association of Women for Action and Research (AWARE)
Where to get help
Singapore General Hospital Eating Disorders Programme (Tel: 6321 4377)
Association of Women for Action and Research (AWARE) Eating Disorders Helpline: 1800-774-5935
Singapore Association of Mental Health (Support for Eating Disorders Singapore SEDS) Helpline: 1800 283 7019
The writer, Afiq Fitri B Alias, is a student reporter from Republic Polytechnic.