Sunday, February 22, 2015

Anorexia Nervosa: Eating Disorder Awareness Week



Anorexia Nervosa & Tango: Minuchin & Argentina

First published Sept. 1 2012:


Argentina is famous for its Tango:
 
© Am Ang Zhang 2010


What about Anorexia Nervosa?

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!A Brief History of Time: Anorexia Nervosa

First published March 1, 2008

 

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
This is not about Stephen Hawking’s famous book that sold over 9m copies world-wide, but a collection of material that relates to Anorexia Nervosa in a chronological order. You see, I believe in free sharing of knowledge.
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
Girl in a Chemise circa 1905 Pablo Picasso (1881-1973)
Tate Collection

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
Bruch (1966): relentless pursuit of thinness
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.
Finally, it is appropriate to close with two quotes:
L'appetit vient en mangeant.
(The appetite grows by eating.)
- 
Rabelais (1494 - 1553): Gargantua

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

Friday, February 20, 2015

Anorexia Nervosa: From Magritte to Amanda!

Rene Magritte exhibition


Could the Cockroach Catcher have missed this exhibition?


Art Institute of Chicago’s new special exhibition, “Magritte: The Mystery of the Ordinary, 1926-1938.”

 “Magritte was an amazing artist who has much to offer us today,” said Stephanie D’Alessandro, the Gary C. and Frances Comer Curator of Modern Art at the Art Institute, who was instrumental in assembling this exhibition of nearly 80 paintings, plus collages, objects, photographs, periodicals and examples of the artist’s work in advertising.
“I think that living in an age of mobile phones, in which we are so used to acquiring all sorts of information with great speed — and assuming it is ‘correct’ — has resulted in a loss of the ability to let a picture really take us into its own world, with all its unique habits and customs. So working with installation designer, Robert Carson, I’ve tried to create a series of small, initially quite dark spaces that should help make the experience of each art work more intense and intimate, and will let your imagination tell you where you want to go.”
The Magritte show, awash in images at once grotesque and erotic, mundane and mysterious, unspools in more or less chronological order. It begins with the crucial body of work, both paintings and paper collages, that he created in 1926 and exhibited the following year in his first one-man show at the elegant Galerie Le Centaure in Brussels — a show greeted by mostly negative reviews. It moves on to his subsequent time in Paris, where he lived for three years, becoming part of the Surrealist circle led by the French poet and theorist, Andre Breton, and such artists as Salvador Dali and Joan Miro.

 Magritte reminds me of Amanda.

Amanda
         My old secretary Karen went to work for a plastic surgeon in the local hospital specializing in burns. Out of the blue she gave me a call. 

         “It is about Amanda. You should see her. She has all these scars on her.”

         It had been over two years since I last saw Amanda. It was rather sad as she had a real talent in art and I managed to secure the last ever support from the Education Authorities for accommodation for her at the Art College. But she dropped out after a year.  Nevertheless she still managed to make appointments to see me a couple of times before disappearing.  

         “Why don’t you ask her to arrange to see me next time she has a follow up at the clinic.”

         “That should not be a problem.”
         “But only if she wants to.”
         “I think you may still be of some help.”

         Well, Karen actually drove Amanda to my clinic late that afternoon and I stayed on to see her. Luckily Karen was still in the room with me when Amanda simply decided to lift her T-shirt. She was not wearing anything else underneath and what she revealed was a body covered in a number of three to four inches long keloidal scars. Some were actually over her breasts.

         Karen stayed as chaperone and Amanda did not seem to mind. In our work there are certain risks when you see young people on their own and more so when you see someone like Amanda. I sometimes felt rather unsafe with some of the mothers too.

         Amanda was first presented to me as a severe anorectic who more or less required immediate hospital admission. I put her in the paediatric ward rather than referred her to the hospital as at that time we were having some trouble with the quality of care there.

         At the time, her weight was dangerously low. She was the only patient that I had to keep in the hospital over Christmas. It was rather strange that she seemed quite happy to do so. There were no protests from the parents either.  It meant that I had to see her on Christmas day and I even bought her a nice soft toy for a present, something I had never done before or after.

         Her body weight gradually picked up and it was time for some trial home leave. She pleaded with me not to let her go home even for half a day.

         I did not want her to become dependent on us and there was every sign that she had now settled in on the ward.

         She came back from home leave and decided not to follow our agreed contract. It was popular in those days to have a weight gain contract and we had one too. Of course now I realise how rigidity with a contract can have drawbacks. In fact in child psychiatry too rigid an approach often causes problems one way or another and it is one of the few medical disciplines with which strict guidelines are not a good idea.

         At the time, another patient was on the ward after a serious suicide attempt. She had been abused by her step-father and step-brother over the years. She had had enough and decided to end it all.  I was trying to sort out where she could go as there were all the child protection issues.  She became very friendly with Amanda.

         One day when I arrived on the ward, the Sister-in-charge handed me an envelope and said that Amanda would like me to read it first.

         I have since used the same two pages she wrote as teaching material. Most female junior doctors could not go through with reading it aloud. It is nice to think that years of medical training do not really harden someone. Or was it something too horrible to be faced with?  It was particularly upsetting when the abuser was Amanda’s father.

         Amanda was by then fourteen but her father had been abusing her since she was about eleven. Her mother worked night shifts and father would come to her bed room to tuck her in. This had been going on for as long as she could remember. She started to have budding breasts and her father would at first accidentally brush them and Amanda would be quite annoyed with that. Then one night he started fondling with her breasts and also outside her pants. She was so scared she froze and did not say anything. He went further and further until he penetrated her. She was bleeding quite badly and told her mother, who told her that was what happened to girls when they grew up. She knew what menstrual period was but she said this was different; but mum did not want to know and gave her a box of sanitary pads. Then her period started and she started to worry about becoming pregnant. Her father said it was not a problem and asked her to suck him instead. She recorded that she was sick every time. Then one day her father decided to try her “back-side”. It caused so much bleeding it stained her school skirt and when she told her mother she was bleeding from her “back side” she just said, “Don’t be silly.  It is only a heavy period.”

         It is disturbing even for me to give you the details now. But this is what is happening to many children and is happening all around the world. If anything, I probably have toned down the content of that letter. What has gone wrong with mankind?  I cannot say I know any better since my early cockroach catching days. 

         Then on the day I “forced” her to go home he picked her up and made her go down on him in the car on the way home when he parked on a lay-by.

         In the end it was the other girl in the ward who encouraged her to write to me. She told her that she suffered the same for a long time and was stupid enough to try and hurt herself before she could tell anyone.

         There was no time to waste to report this to Social Services. However, Amanda’s father, who worked at the local mental hospital, had a “breakdown” and was admitted under the Mental Health Act the night before all of this came out. Amanda was not aware of this.  When I showed mother what Amanda wrote, she just said to me, “He is in a mental hospital,” and walked out.

         It has taken me years to grasp that maternal failure plays a major role in family sexual abuse. This mother’s action says it all. Can’t you see he is mad?

         It was a most peculiar case. His psychiatrist refused to even let me know of his problem, citing patient doctor confidentiality. He obviously had not worked with child abuse. Mother denied all knowledge of the bleeding incidents and claimed that it was all in Amanda’s imagination and it became very hard trying to place Amanda because her mother would not acknowledge that there was a problem. At this time West[2] was arrested and it helped me at least to understand the unfathomable.

Magritte:
         One of the nurses who got on well with Amanda told me that I should look at her examination portfolio for art. Every picture was morbid.  One struck me with the René Magritte[3] style of surrealism. A body of a girl with a penis floating over what looked like a classical stone grave. The head was covered in cloth and separated from the body. There were many daggers on the upper body of this half-man half-woman. There was a sort of school in the distance with small figures of school children. The sky was normal blue with white clouds which contrasted dramatically with the central theme. There was no question that the sky was a Magritte sky, and so was the cloth covered head. The rest was original Amanda.

         I knew then from what I remembered of Erickson that the picture was not just about the past with which one naturally associated but also about the future. Yet it took me a few years to realise that it was about the cutting.

         She said she was now working as a waitress. Her teacher at college did not want her to do all the morbid paintings, so she quit. She had been sleeping with virtually any man she came across and every time she would cut herself afterwards. She wanted to feel something, she told me. What was worst was that whenever she was with a man she saw her father.

         What an outcome. I had spent so much time with this girl and this was in the end what happened. She said one day she would be in a mental hospital like her father, but she hoped to kill herself before then.

         I no longer remember Amanda as a severe anorectic but rather a very talented artist who suffered serious abuse. Yet in a society which prides itself in social care, she did not become a famous artist with a high income, telling all about her history of abuse in front of a famous chat show host. Nor did she become a movie star telling all after drug and alcohol rehab.

         Instead she was on benefits and I am struggling hard to find something uplifting to end this story.

It has taught me one thing: Anorexia Nervosa may be just a manifestation.

The Cockroach Catcher Chapter 33  The Peril of Diagnosis 


Wednesday, February 18, 2015

Anorexia Nervosa: The NHS & Safety Net.

In The Cockroach Catcher, in the opening chapter I recalled an Anorexia Nervosa patient that has been “dumped” by her Private Health Insurer.

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

This patient’s father works for a medical supplies company that continued to insure the family. Even then the Health Insurer chose to limit her treatment to 18 months.

Why? Because there is a safety net: The NHS.

Health Insurers write their own rules.

Why? Because there is a safety net: The NHS

“….Ethics in medicine has of course changed because money is now involved and big money too. What was in dispute in this case was that the private health insurance that sustained Candy through the last eighteen months had dried out. The private hospital then tried to get the NHS to continue to pay for the service on the ground that Candy’s life would otherwise be in danger. The cost was around seven hundred pounds a night….’

Let us not forget that many private hospitals can make more money from the NHS because the NHS does not exclude. The NHS pay for everything including those Private Health Insurers chose to exclude.

“……A quick calculation gave me a figure of over a quarter of a million pounds per year at the private hospital.  No wonder they were not happy to have her transferred out.  Before my taking up the post, there were at one time seven patients placed by the Health Authorities at the same private hospital. Not all of them for Anorexia Nervosa, but Anorexia Nervosa required the longest stay and drained the most money from any Health Authority. I have seen private hospitals springing up for the sole purpose of admitting anorectic patients and nobody else. It is a multi-million pound business. Some of these clinics even managed to get into broadsheet Sunday supplements.  I think Anorexia Nervosa Hospitals are fast acquiring the status of private Rehab Centres. Until the government legislates to prevent health insurers from not funding long term psychiatric cases, Health Authorities all over the country will continue to pick up the tabs for such costly treatments……”

I did not agree to that patient staying on at the private hospital paid for by the NHS. That hospital did not like me!!!

The Obama Health reform is dealing a big blow to Health Insurers as by 2014 they will have to take all comers and cannot exclude pre-existing conditions not to say dumping someone like my Anorexia Nervosa patient. Until then, the State or the Federal Government steps in.

Gov. Arnold Schwarzenegger of California, a Republican gave a rousing endorsement of President Obama’s health plan.  New York Times reported today.

The new government in a week’s time should take the first step in legislating against Health Insurers “dumping” patients because of psychiatric diagnosis or so called chronic conditions. That way, private hospitals and insurers can fight it out amongst themselves. At least  the small pot of NHS cash would be safe. That would be a first step.

I doubt if any government would follow Obama’s extremely courageous move of legislating against excluding pre-existing conditions but we could watch what happens in a few year’s time. If we can at least secure the position of those already insured we could save the NHS a great deal of money.

Unlike the US we have a safety net: the NHS.

Let us protect it. 

How? 

Save the NHSControl Health Insurers

Summary of a popular post:


  • Ends discrimination against people with pre-existing conditions.
  • Limits premium spread to normal, high risk and healthy risk to say under 20% either way of normal.
  • Limits premium discrimination based on gender and age.
  • Prevents insurance companies from dropping coverage when people are sick and need it most.
  • Caps out-of-pocket expenses so people don’t go broke when they get sick.
  • Eliminates extra charges for preventive care.
  • Contribute to an ABTA style cover.

                     
We could legislate that Insurers will have to pay for any NHS treatment for those covered by them. It will stop Insurers “gaming” NHS hospitals. This will prevent them saving on costly dialysis and Intensive Care. Legislate for full disclosure of Insured status.

Insurers cannot drop coverage or treatment after a set period and even if they do they will still be charged if the patient is transferred to an NHS Hospital.

This will eliminate problems like PIP breast implants.

It will indeed encourage those that could afford it to buy insurance and in any case most firms offer insurance for their employees including the GMC.

To prevent gaming of Insurers by individual patients (I look after their interest too), the medical fee should be paid up front by the patient and then deduction taken from premiums. Corporate clients like those with the GMC should not be gaming Insurers.

Imagine the situation where those with “individual personalised budget” being able to “buy” their own insurance!

In fact, to save money, government can buy insurance for the mental patients and the chronically ill.

This way their will be real choice and insurers will be competing with each other to provide the worst deal.

Why?

What Health Insurer will want the business? 


Perhaps they will go back to the US and we will have our own NHS back.

The Times:  The internal market has been a costly disaster




Monday, February 16, 2015

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

2 Old Posts:


Anorexia Nervosa: Hobson's Choice!



©2012 Am Ang Zhang

I
 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


D
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.” 
         “And?”
         “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.


NHS: The Way We Were! Free!
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Email: cockroachcatcher (at) gmail (dot) com.