The Cockroach Catcher: Anorexia Nervosa: It may not need to be so!

Wednesday, September 14, 2011

Anorexia Nervosa: It may not need to be so!

As we move into the gaming era of the NHS, one diagnosis that will be on AQP list will be Anorexia Nervosa. Unlike hip replacement, the variation of the condition is such that it is ripe for Private Providers to make a case for a fairly long drawn out treatment. AQP will not worry as "the longer, the better".

That is why I have argued that where there is such an incentive, "gaming" will happen. So, Mr Lansley and Mr Cameron. Don't say that nobody told you.

Girl in a Chemise circa 1905 Pablo Picasso (1881-1973)
Tate Collection

It may not need to be so:

There is a misguided belief that Psychiatry is like other branches of medicine, that we make diagnosis as if we know the definitive cause, course of treatment and prognosis.

I accept that even in other branches of medicine, what we used to know sometimes can be turned upside down overnight. We only need to look at the evolution of the understanding and treatment of Leprosy and Tuberculosis over time, and in the modern era, that of HIV/AIDS.

I was brought up to understand that “scientific truth is nothing more than what the top scientists believe in at the time.” In this modern era of “biotech” approach to medicine, new understanding is yet to be found for many conditions. In these cases, are we content to continue with empirical and symptomatic approaches?

Anorexia Nervosa comes to mind and this is one of the conditions that have for want of a better word captured the imagination of sufferers and public alike. I have already posted an earlier blog on its brief history.

Sometimes a diagnosis as powerful as Anorexia Nervosa can be a hindrance to the improvement of “sufferers”. Over my years of practice, I found that those who did well were cases where we indeed moved away from the medical/conventional psychiatric model to a somewhat paradoxical approach.

Let us consider a couple of “WHAT IF” scenarios.

What if in DSM V (the next edition of DSM), Anorexia Nervosa was voted out by the psychiatrists as a mental condition? (As they did with Homosexuality in 1973.) What if the European Court of Human Rights deemed it against human rights to forcibly treat Anorexia Nervosa? (Remember Ghandi?)

My speculations are that under these circumstances:

1:A third of the parents would take over and make sure that their bright young offsprings eat properly and stop blaming adolescent units for failing them.

2:A third would have rich enough parents who would pay for their expensive treatment in health farms.

3:Some would be snapped up by modelling agencies as the world is hungry for skinny models.

That is not 100%, you may observe.

Ah, what about mortality rate? That would be same as now or lower.

This is only one child psychiatrist’s conjecture.

The reality is that the availability of force feeding as a last resort often leads to complacency in the Psychiatric Team. Creativity is key to the resolution of many Child Psychiatric problems and the fact that Anorexia Nervosa patients can change dramatically in a split second is testament to the need for such an approach. (The Chapter “Seven Minute Cure” in The Cockroach Catcher describes such a case.) I am not advocating the declassification of Anorexia Nervosa, but would just like to encourage those of us dealing with these cases to try to understand the underlying dynamics and be innovative in their management. It could be a worthwhile experience.