1.6. Death, survival and recovery in anorexia nervosa: a thirty five year study

\udAn excess of premature deaths at long-term followup,\udin people who have presented to secondary/tertiary\udreferral centres over the last sixty years or so\udwith diagnoses of anorexia nervosa, is well documented.\udAt 20þyears of follow-up, it often stands\udat around 10–20% of those first presenting with a\udmean age of around 20 years (Kay 1953; Ratnasuriya,\udEisler, Szmuckler, & Russell, 1991; Seidensticker &\udTzagournis 1968; Theander, 1985). In two other such\udseries (Crisp, Callender, Halek, & Hsu, 1992), clinically\udcomparable to the others at presentation, death\udat 20-year follow-up had arisen in only 4% of the\udanorectic population, no more than expected within\udthe general population over the same time span.\udNielsen et al. (1998) suggested that this might be\uddue to the treatment package delivered to the majority\udof that population.\udSubsequent deaths of patients presenting in this\udway and within this time scale are predominantly\udreported as being due to malnutrition or frank suicide.\udNearly seventy years ago Crichton-Miller\ud(1938) construed anorexia nervosa itself as ‘a compromise\udwith suicide’ and, to some other clinicians,\udthe disorder appears to be ‘a form of psychic suicide’\ud(Brill, 1939) and primarily self-destructive (e.g.\udStrauss 1956). Simply searching national registers\udfor deaths recorded as due to or contributed to by\udanorexia nervosa, is a seriously faulty procedure.\udIn the United Kingdom, nearly 30 years ago, two of\udus pressed Government to increase service provision\udfor people with anorexia nervosa. Government\udresponded by claiming that the national register of\uddeaths revealed between only 21 and 26 such deaths\udper year over the previous five years. Government\udconcluded that it was not a seriously crippling or\udfatal condition. But it is. Anorexia nervosa, egosyntonic\udand often marked by secrecy, like alcoholism\ud(Bell & Cremona, 1989; Maxwell & Knapman,\ud1985), was almost certainly frequently overlooked\udas a background cause to death during the period\udin question (Crisp, 1978). In the case of anorexia nervosa\udsuch deaths are often due to malnutrition or\udsuicide. Meanwhile, mislabelling of malnutrition in\udterminal illness in the elderly as anorexia nervosa,\udoccasionally introduces false positives