Monday, July 15, 2013

Anorexia Nervosa: The History.

© Am Ang Zhang 2012

Il faut manger pour vivre et non pas vivre pour manger.
(One should 
eat to live and not live to eat.)
Moliere (1622 – 1673): L'Avare (The Miser)
Some hae(have) meat and cannot eat,
Some cannot eat that want it:
But we hae meat
 and we can eat,
Sae let the Lord be thankit.
Robert Burns (1759 – 1796): The Kirkcudbright Grace


First introduction of the term Anorexia

Sir William Withey Gull (1816 – 1890) first used the term:
“In… 1868, I referred to a peculiar form of disease occurring mostly in young women, and characterized by extreme emaciation…. At present our diagnosis of this affection is negative, so far as determining any positive cause from which it springs…. The subjects…are…chiefly between the ages of sixteen and twenty-three…. My experience supplies at least one instance of a fatal termination…. Death apparently followed from the starvation alone…. The want of appetite is, I believe, due to a morbid mental state…. We might call the state hysterical.”

Source: Anorexia Nervosa (apepsia hysterica, anorexia hysterica).
Transactions of the Clinical Society of London, 1874, 7: 22-28.

Classic description of Anorexia Nervosa.

Earliest published accounts
Richard Morton (1637-98), a London physician: The Treaty in his book Phthisiologia, or a Treatise of Consumptions, first published in Latin in 1694.
Ernest-Charles Lasègue (1816 - 1883), a professor of clinical medicine in Paris: “De l’Anorexie Hysterique” containing descriptions of eight patients.
More recent views

Anna Freud’s psychoanalytic view (1958):

  • Adolescent emotional upheavals are inevitable
  • Anorexia Nervosa is the outward manifestation of the battle between the ego and eating, with the former struggling for it’s very survival
Crisp (1967 - 1980):
  • Anorexia nervosa serves to protect the individual from adolescent turmoil.
  • Anorexia nervosa reflects a phobic avoidance of sexual maturation.
  • Unsettling effects of sexual maturation at puberty may drive the female adolescent to a pursuit of thinness leading to greater acceptance, self-control and self-esteem.
  • Anorexia nervosa tends to appear in families with buried, but unresolved, parental conflicts.
Palazzoli (1978) on women’s role (not just Anorexia Nervosa)
  • Women are expected to be beautiful, smart and well-groomed.
  • They are expected to have a career and yet be romantic, tender and sweet.
  • They are expected to devote a great deal of time to their personal appearance even while competing in business and professions.
  • In marriage, they are expected to play the part of the ideal wife cum mistress cum mother.
  • They are expected to put away her hard-earned diplomas to wash nappies and perform other menial chores.
  • The modern woman is therefore exposed to a terrible social ordeal, and the conflicting demands and dual image of the female body as sex symbol and as commodity.
  • An adolescent girl may develop feelings of insecurity and alienation toward her changing body.
Minuchin:

Alert readers would have noted a number of Anorexia Nervosa cases on this blog and in my book, The Cockroach Catcher and that Minuchin’s name has indeed been mentioned.

Regardless of what present day psychiatrists (and that includes those dealing with Anorexia Nervosa, Minuchin have in one way or another inspired us in our dealings with Anorexia Nervosa and of course families in general.

He has inspired me the most in my work with families and with anorexia Nervosa in particular.

He was born in Argentina and soon served in the Israeli army before continuing his training including that of psychoanalysis in New York. It may be of interest to readers that the new generation of psychiatrists including those in the US were no longer brought up in psychoanalysis and with that they have little understanding of both the personal psyche and the family dynamics that we grew up in. Of course psychoanalysis has its many faults but to totally dismiss it is very sad for mankind.

Minuchin above all helped me in my understanding of family dynamics and in turn in my personal dealings with problem families and Anorexia Nervosa.

Minuchin has recognized a group of family system characteristics that reflect the family dynamics of patients with anorexia nervosa:

Enmeshment:
This is a transactional style where family members are highly involved with one another. There is excessive togetherness, intrusion on other's thoughts, feelings and actions, lack of privacy, and weak family boundaries. Members often speak for one another, and perception of the self and other family members is poorly differentiated. A child growing up in this type of family learns that family loyalty is of primary importance. This pattern of interaction hinders separation and individuation later in life.

Overprotectiveness:
This refers to the excessive nurturing and protective responses commonly observed. How can the psychiatrist begin to argue against such a good trait! Pacifying behaviors and somatization are prevalent.

Rigidity:
These families are heavily committed to maintaining the status quo. The need for change is denied, thereby preserving accustomed patterns of interaction and behavioral mechanisms. Rigidity is commonly observed in the family cycle during periods of natural change where accommodation is necessary for proper growth and development. You must have seen families where for every single day of the week they eat the same meal year in year out.

Avoidance of conflict/ conflict resolution:
Family members have a low tolerance for overt conflict, and discussions involving differences of opinion are avoided at all costs. Problems are often left unresolved and are prolonged by avoidance maneuvers. Everyone would come up with a highly believable excuse. After all everyone is very clever!


Apart from classical Autism, parents of many sufferers of Anorexia Nervosa are amongst the most successful in their own profession. Many are CEOs of major corporations including Hospital Trusts and PCTs. Minuchin’s powerful understanding of the family dynamics has allowed me to navigate the very difficult terrain. More so than trying to learn Tango!


Anorexia Nervosa: Complacency or Creativity!

As we move into the gaming era of the NHS, one diagnosis that will be on AQP's 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 Cameron. Don't say that nobody told you.
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.



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.

Anorexia Nervosa: All Posts.






One hath no better thing under the sun than to eat, and to drink, and to be merry ...
- Ecclesiastes 8.15



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