I’m writing on behalf of my family concerning my sister’s eating disorder situation, as she is refusing to seek treatment and we are struggling with what course of action to take and was hoping you would be able to shed some light to help us out. Any kind of help would be greatly appreciated as my parents are at a loss as to what to do.

My sister was first diagnosed with anorexia in 2012 at age 13, when she was so severely underweight that she was hospitalised for a week, then put under an eating plan and had regular checkups at KKH with a doctor and psychologist. However, she refused to communicate and talk to the psychologist and did not follow up with her psychologist appointments frequently and so never received proper psychological treatment/psychotherapy. Her weight stabilised and she was discharged from medical care by 2016.

However, in 2017 and 2018, she continued to be very restrictive in her eating habits, and her mental health worsened as she suffered the trauma of a close friend’s suicide and stress from her A levels. In September 2018, she flew to the UK to pursue university studies but the experience of living with an unpleasant roommate and the stress of studying worsened her mental state. When she returned in December 2018 she had lost significant weight but refused to be weighed. From January 2019 onward she has been living on her own in the UK with no family or friends to monitor her condition, and in April began experiencing severe depressive episodes and heightened anxiety.

She has just returned in July, now aged 20, and my family has again noticed further weight loss. Other symptoms include her lying about eating food when she goes out with friends—she tells us she is eating out but does not eat with her friends, leading us to worry she is skipping meals. When living overseas, she would follow an incredibly strict routine with walking to and fro to class and back to make her own lunch and then back for classes, as well as walking to do groceries, walking at least 5 miles everyday.

My parents do not know what to do as she refuses to discuss the issue of her weight or her eating habits, telling my mother that she is trying very hard on her own and my mother’s nagging only makes her more stressed and unhappy. She also refuses to see a doctor, and has made excuses to avoid seeing a psychiatrist. We are worried that she has relapsed but she refuses to acknowledge it as her past experience of treatment was highly traumatising and she does not want to admit that she has relapsed; it would be crushing for her morale.

My family is desperate because she will have to fly back to the UK in around one and a half months and if her weight loss continues her health might be endangered. We have received conflicting advice online about whether it is wise to use ultimatums and threaten to stop her from flying back to force her to see a psychiatrist, but am unsure if it is wise as it might worsen her mental state and close her off from the family.

I know this is an irregular request but if you could spare some time to advise us on what to do we would be immensely grateful as we are at a loss to what to do and how to proceed to get her help.

RESPONSE FROM DR. KIM LIAN ROLLES-ABRAHAM:

It is definitely not easy to deal with a family member who has an eating disorder and little insight or motivation to get well – especially as she is on the cusp of adulthood.

What I would say is, continue to engage with her when it comes to treatment – perhaps if her previous experience was traumatic, suggest another place/hospital/clinic/therapist/doctor.

She is still a minor (in Singapore) as she is under 21, however, she is likely at the stage where she is independent and individuating from the family, so do get her involvement in making plans as far possible.

However, if you do feel that she is at a stage where she is severely medically compromised, do not hesitate to take firm action like getting her hospitalised – she may or may not thank you later, but at least she will still be alive!

If her insight is so poor, she may spiral downwards and not realise how physically ill she is until it is too late.