Case study - A troubled student

Dr Tillmann Jacobi describes how a sympathetic approach helped a struggling university student.

It is important to be open and non-judgmental in order to establish understanding and trust (Photograph: SPL)

A 19-year-old female student presented during the Christmas holidays as a temporary resident after being prompted by her concerned mother. She grew up in the area but I had seen her only a couple of times with minor complaints and no ongoing problems.

I remembered her as a high achiever at school with a degree of anxiety and stress-related depression during her GCSEs.

Changed appearance
This was her first visit back to her parents since starting university and they were alarmed by her changed appearance and significant weight loss.

She admitted to them that she found the change of environment at university stressful and, although she had done well during her assessments, she was worried about fulfilling the academic expectations.

She had noticed that she was increasingly checking her work, her appearance and other areas in her daily life. It had started to become an interference and obstacle to her general performance and function. Although she was aware of the irrational element of this controlling behaviour she found it difficult to alter it.

I considered it to be a positive sign that she had responded promptly and agreeably to the suggestion of her parents to attend rather than becoming defensive and withdrawn.

Sympathetic listening
It was important to establish the degree of her insight into this situation and check if there were signs of potential severe mental illness, including significant depression with or without any suicidal tendency or psychosis.

As when discussing any sensitive issues, it is useful to start with open questions and sympathetic listening to get a genuine overall impression.

The girl admitted she realised that 'something was not right' with her eating and that she was very anxious about losing control but found some comfort by controlling her eating.

Although she had an understanding of the situation she felt trapped and unable to work her way out of it. She denied excessive exercising, any induced vomiting, abuse of laxatives or other medicines or drugs. She confirmed that she was still menstruating, although her periods had become irregular.

Examination of her mental state showed a quiet and troubled young woman with a good rapport and no apparent thought disorders or plans to self-harm.

Her patient health questionnaire-9 score was 13 points. Her BMI had dropped from 24 two years previously to 18. There were no signs of a dysfunctional thyroid gland or any intra-abdominal abnormalities. BP and pulse were normal.

Psychological disorders
Depression, eating disorders and obsessive compulsive disorder are more common in students than in the average population. The Royal College of Psychiatrists states that more than 8 per cent of students see their home GP or the health services on campus for mental health problems, with numbers rising and with increasingly serious diagnoses.

Patients with psychological anorexia, as in this case, often remain unknown to their GP as they are likely to hide their eating problems for as long as they can. This means that effort should be made to identify such a patient during a consultation for a possibly unrelated health problem. Although eating disorders may be only temporary and self-resolving, it is crucial to detect and manage them early as this improves the long-term outcome.

Arranging local follow up
Luckily the patient was otherwise stable, had good insight, was able to co-operate and was motivated. After we had established that she needed support for a longer period of time, the question was how to facilitate help locally at her university.

Issues including consent and autonomy had to be maintained and any delay of action could undermine the chance of an early resolution.

I solved this by asking her to call her university GP and ask them to call us. This would indicate her motivation as well as confirm her consent. If she failed, I would have taken steps to ensure follow-up. However, I received a call from her campus GP only two hours later.

My description of the situation was sufficient for him to organise an immediate referral to the multidisciplinary eating disorder service run by the in-house psychology services.

At her next visit home she returned to the surgery for a review appointment and could report that she was already much improved.

Non-judgmental approach
Being open and non-judgmental in the initial consultation established understanding and trust. Consultations regarding eating disorders are a delicate balancing act to ensure the trust of the patient is gained before starting to address the problems.

The patient mentioned at follow up that this approach had been essential to allow her insight without adding pressure, which could have been counter-productive.

Key points
  • Establish the degree of insight the patient has into the situation.
  • Use open questions first.
  • Be non-judgmental in order to build a rapport and gain the patient's trust.
  • Exclude severe mental illness, such as depression or psychosis.
  • Arrange ongoing support and follow up.
  • Dr Jacobi is a salaried GP in York

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