Monday, February 16, 2015

Anorexia Nervosa: Hobson's Choice & Don’t You Dare!

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Anorexia Nervosa: Hobson's Choice!

©2012 Am Ang Zhang

 am sure we all have been asked the great “what if…..” question. I was fortunate enough in my practice to have had some “lucky” breaks.
         Given my interest in the very young, now and again we had some strange cases that tested our ingenuity to the limit.  No amount of SSRI (Selective serotonin reuptake inhibitors) would be able to help.  Often it was a clear battle of wills, a battle between the consultant and someone barely one sixth his age.
         That this particular child had already beaten two adults with a combined age well over ten times hers should have been a clear warning to me on what I was to take on.
         The contestant was a little girl nearing five years of age who had developed an addiction to Huggies. Yes, Huggies.
         It could well be the success of advertising or it could be the future of the human race, I joked to the nursing staff as the desperate parents agreed that the girl should be admitted to the children’s ward for “nappy withdrawal”.
         The problem was simply this. She needed to put on a disposable nappy in order to pass urine, or do No. 1, as she put it.  At her age, she required the biggest size available.  The cost had been piling up.  As it seemed so trivial, the parents never sought help until now when school days were imminent. It would not be possible to contemplate her going to school with nappies.
         With our enlightened staff, admission to the paediatric ward was no longer the traumatic experience it used to be.  This little girl soon settled in and was promoted to be the No. 1 helper around the ward.
         However, whenever she needed to, she helped herself to a nappy, and after performing, took it off and put it in the appropriate bin. She worked that one out in no time at all.
         One nil.
         I needed to come up with a battle plan quickly.  The ward was fast running out of the giant nappies and I had no intention to make a special requisition.
         “That is it. I HAVE AN IDEA.”
         I found a large clean plastic bag and put all the nappies in it.  There were three.  I gave it to my opponent and said, “These are the last three and, when you have finished, there will be no more.
         Unperturbed she snatched the bag from me as if to say, “Not a problem, doc.”
         I went on with the rest of the morning round and went to the clinic.
         After the day’s main clinics, I decided to have a peep.
         “She used two of the nappies and is now down to the last. She carries it around with her. It is becoming quite a sight.”  Sister told me.
         Everybody knew I was not going to win this one, but were prepared to see it to the end.
         By now she was quite urgent and you could see she was struggling a bit. Her last performance was over three hours ago.
         She looked at her nappy, thought about it, and then something curious happened.
         She went to her favourite nurse and took her by the hand, “Will you take me?”
         She sat on the toilet and passed urine, still holding on to the nappy. There was a sudden cheer from all the mothers. My head was visibly doubling in size.
         “Well done!”
          Shortly after, Sister took me to the side and asked, “What if she did use the last nappy? What would you have done?”
         “Sometimes there just is no what if. You have to do certain thing as if it were the only way.”
         Her family went on their planned camping holiday in the South of France and from there they sent a post card.
         “Yes! It is still working. We have truly cracked it or you have. Thanks a million. We are all having a lovely time.”
         In early 2007, a female astronaut wore a nappy in order to drive non stop to threaten another woman, a rival in love.
         No, she was not my patient.

Anorexia Nervosa: Don’t You Dare!

I have often been asked the simple question: how is it that a lovely child could turn out to be so strong-willed about food and weight.

We may have to go back to the beginning and I am reprinting a Chapter from The Cockroach Catcher that may give you some clue. There is no reference at all to Anorexia Nervosa!

Chapter 20  Don’t You Dare

 © Am Ang Zhang 1998

ominic was a boy of nearly three from a rather well-off middle class family. He had an older brother of five and a much older sister of nine. His father worked in the City and earned good money to support their comfortable lifestyle. Mother was often the only one that  attended the clinic with Dominic. Sometimes the older ones attended as well if the appointment happened to be during school holidays.
         I used to see many similar ones in my sleep clinic and early handling problem clinic.  Wealth sometime detaches one from the extended family and with modern education and so on, mother’s advice becomes old wives’ tales.  These young mothers much prefer to see their friendly child psychiatrist who is believed to be armed with the latest medical knowledge.
         Dominic, like his siblings, was an angelic and smart child. There was one small problem. Since mother’s rather late failed attempt to train him, he had taken to tearing off his large nappy and poo’ing behind a sofa in one of their grandest rooms – the one with the grand piano. He had refused to perform in the Mickey Mouse pot and umpteen other Disney inspired ones. Nor would he use the special attachment on the toilet seat or seats as there were four toilets he could use.  No, he preferred the spot behind the sofa.
         Mother was soft spoken and like many of the mothers with sleep problem children too gentle – too gentle in my book. Often these mothers tried to explain things to their six-month olds.  They never shouted at their children. In fact they never shouted at anyone. Most were lucky to have a nice older daughter and in her case a nice older daughter and an older boy. 
         Knowing where the problem lies is often not the same as knowing what the solution is. It is virtually impossible to try and teach such parents to raise their voice.  That would be like teaching them to be violent to their own child. They have to work it out for themselves.
         You mean she became “violent”? My junior would ask me.
         Well, I told mother that it was really not a psychiatric problem which of course was vaguely unbelievable to her. I started telling her stories about other mothers with similar but not exactly the same problem and how they managed to resolve things simply by becoming very “firm”.
         Very firm indeed!
         “You mean you get them shouting?” My junior would ask.
         “I never had to.  But it worked.”
         “Invariably? So what happened?”
         One day she turned up still in her riding gear. She told me she was too excited to go home to change.
         “What happened?”
         “Well, as you know my cleaning lady had great difficulty cleaning the yellow off the carpet. The different cleaning fluids have not really done the carpet any good.  My husband is having his colleagues from his firm for a big Christmas do and so I have put in a new carpet. I have decided that all I needed to do is to keep an eye on the little devil and catch him before he could do any damage.” 
         “You know he was so crafty.  I had to pretend to be reading my magazine but at roughly the right time I noticed he was edging towards the back of the sofa. I waited a few seconds for him to get to his favourite spot. When he tried to pull down his nappy, I did not know what got to me, I just saw red and shouted: don’t you dare.  Go to the toilet and do the ‘poo’ like everybody else.”
         “As if by magic, he looked at me, pulled his nappy up, went upstairs to his own toilet, the one with Mickey, and did the job.” Mother was so proud. “He has been doing the same since.”
         We had one happy family again, with one happy grateful mother who had not got a psychiatric problem child.
         I often used her story to help other mums.

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Email: cockroachcatcher (at) gmail (dot) com.

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