Tuesday, May 31, 2016

Anorexia Nervosa & Argentina: Enmeshment & Failure!


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!



 Minuchin



 ©2013Am Ang Zhang  
From The Cockroach Catcher
Chapter 34  Failure?



I
t is not easy to admit to failures and harder still for doctors to do so especially if they did everything right and according to protocol. 


         Doing the “right” thing is not an indication of success.  

         Hardly.
         Yes. I am coming back to Anorexia Nervosa again and I do not apologise for it. I am apologising for our failures though.

         The British Daily Mail reported in March 2007[1]:
         “It is thought there are between 60,000 and 90,000 adults being treated for eating disorders at any one time in the UK. The average age of diagnosis is between 16 and 18between 60,000 and 90,000 adults are estimated to be treated for eating disorders at any one time in the UK.
         Over a 13-month period from March 2005, 206 preteenage children across Britain and Ireland were newly diagnosed with serious disorders ranging from bulimia and anorexia to binge eating.
         Half were admitted to hospitals for in-patient treatment. Some were showing symptoms of starvation such as a low temperature and a slow heart rate, while 10 per cent had to be fed by tube.”
        
         In the same month, the British Independent[2] reported:
         “Anorexia Nervosa has the highest death rate of any psychiatric condition. In ten years 3% of these patients died, and although half were by suicide, the rest were related to the starvation process.
         Just this week in Rome a 27-year-old model identified only as Ilaria died of Anorexia after an illness lasting ten years. She weighed 35kg at her death. Luisel Ramos, 22-year-old Uruguayan model died at a fashion show in August, 2006 after suffering a fatal heart attack that was thought to be the result of Anorexia. Ana Carolina Reston Marcan, the Brazilian catwalk queen died only three months later in a Sao Paulo hospital.”
        
         When I took over the adolescent unit as its consultant in charge there were six Anorexia Nervosa patients in varying stages of emaciation or weight gain depending on from which side you want to look at it.  It is not always wise to have so many anorectic patients together as they do share tricks with each other and it is often more difficult to customise treatment.

         What needed my urgent attention was of course Sammy. Sammy had a very feminine name but preferred the nickname Sammy. Sammy’s Section was due to expire in less than 14 days and I had to compile a report for the Tribunal which would be sitting to decide on her fate.

         It was perhaps a sign of our failure as psychiatrists to effectively treat Anorexia Nervosa that eventually case law was established to regard food in Anorexia Nervosa as medicine.  Therefore food may be used forcibly to treat Anorexia Nervosa when the condition becomes life threatening. 

         The usual test of mental capacity no longer applies. Instead the law is used forcibly to feed a generally bright and intelligent person “over-doing” what most consider to be “good”.  They try to eat less and eat healthily by avoiding fat and the like and wham we have the law on them.

         I have to admit that I have not liked this aspect of Sectioning. Unfortunately it is used often, judging by the high numbers of tube fed patients.

         On the other hand not everybody is able to treat Anorexia Nervosa patients or, in reality, do battle with them. It requires experience, energy, time, wit, charisma and often impeccable timing. However, sometimes I do wonder if we are indeed doing a disservice when we take things out of parents’ hands by agreeing to take over.

         With hindsight and upon reflecting on a number of cases I have dealt with, I often wonder: if hospitalisation had not been an option at all, would improvement rate and, more importantly, mortality rate have been any different.

         We do not section people for smoking, drinking, or doing drugs, which all endanger life. Nor do we stop people running the Marathon or eating raw oysters when these activities regularly lead to mortalities.

         Society is coming round to do something about over-eating in children but it will take some time before they apply the Mental Health Acts. 

         To me, the moment a psychiatrist turns to the law he is admitting that he has failed. 

         At least that is my view and if I perpetuated the Compulsory Order with Sammy, I too would be part of that failure.

         There had been no weight gain in Sammy despite the tube feeding and the debate was: shall we increase the feed or shall we wait? Everybody just assumed that she would stay on as a compulsory patient.

         Despite bed rests and even more embarrassingly the use of bedpans, many Anorexia Nervosa patients managed not to gain weight whatever we pumped into them. The balanced feeds were in fact quite expensive. There was no secret that they were aware of the exercises they could perform even on bed rest and the determination not to put on weight had to be seen to be believed. If such determination was applied elsewhere I was sure these young girls could be very successful.

         I had to find an answer, an answer for Sammy and an answer for myself.

         Being forced to eat by the State remained the treatment of choice for everybody except for one stubborn consultant.

         “At least we did all we could,” my staff constantly reminded me.
         “And she is the most determined of all the Anorectics we have right now.”
         More reason to show the others that this new psychiatrist had some other means than brute force, I thought to myself. 

         Yes, I could be as determined as they were.

         The hours of family therapy only brought about accusations and counter accusations with hardly any resolution. Middle class families have certain ways of dealing with things where some branches of family therapy are not particularly good at all.

         The modern trend is certainly moving away from blaming families.  Or that is the rhetoric of most who write publicly about it.

         Whatever the official line, families cannot help feeling blamed.

         “If we are not to blame, why do we need family therapy?”

         “There are so many other families like ours.  Why do they not have the same problem?”

         We may reassure them that there are and that is the truth, but the truth is that there are also Anorexia-free families.

         Yes, it might help if they do find a gene like they did with obesity.  Yet that cannot explain why there are more extremely obese people in say the U.S. which collects gene pools from across the globe.

         So Sammy’s family had the full benefit of eight sessions of family therapy by two very experienced therapists. In the end, there was just a lot of recrimination between all parties including the therapists and all agreed it would not be the way forward. That was when tube-feeding started.

         Minuchin[3] dealt with over-involvement, over-protectiveness and conflict avoidance in these families with no special apology on whether he blamed the family or not. He used to start with a meal session with the family. His success, like many such methods, probably had more to do with his charisma than his method and is thus difficult to replicate.

         For Sammy and her family the message was simple and clear enough, no matter how hard we lied.

         The family had failed and the hospital had to take over.

         That was the blunt truth. 

         But the hospital had failed too and we had to resort to the Mental Health Act on one of society’s most sensible and decent and safest citizens. 

         I decided enough was enough. I could no longer perpetuate the no-blame approach. I could no longer continue to hide behind the power conferred onto me by the law. 

         In short, I had to reverse just about everything that had gone on before, and more.

         Just two weeks before the tribunal sat we had the big review meeting. To most at the unit, the review was fairly routine as there was hardly any choice – a full Section for Hospital Treatment primarily intended for difficult to treat Schizophrenics and difficult to control Bipolars in the acute manic phase. Sammy would be “detained at Her Majesty’s pleasure”, and classed with the likes of the few psychotics who had committed the most heinous murders. To save Sammy’s life, it would be natural to continue with the Mental Health Act.

         Yes there would be weeks of tube feeding and bed rest, but the State had to take over the complete care of this bright young thing for her own sake.

         I could not see any other way either.

         Unless …….I could reverse everything that had gone on before.  

         If our work is to be therapeutic then a sort of therapeutic alliance is important, even if tentative.  Some people do not realise that you can fight with your patient and still have a sort of therapeutic alliance.

         I had a plan.

         These meetings were attended by just about everybody who had anything to do with the patient.  They were held at school times so that most of the teaching staff could be present as well. These meetings also had a tendency to drag on as everybody seemed to have a lot to say about very little, a trait not just limited to psychiatrists but also seen in social workers, therapists, nurses, junior grade doctors, teachers and visiting professionals. People always seemed to have a lot to say on cases where there was the least progress. 

         My personal view is that this was a sure sign of anarchy which had unfortunately drifted into our Health Service, encouraged in part by the numerous re-organisations that had gradually eroded the authority of the doctor. 

         Saul Wurman[4], an architect by training but also an author of business and tour books, famously wrote that meetings really do not always need to be an hour long. Why can it not be ten or twenty minutes?

         Could I achieve that?

         After briefly explaining to all the purpose of the meeting, I turned to Sammy, who still had the nasal feeding tube “Micropore’d[5]” securely and said, “What do you think?”

         “It is so unfair.  Now I shall not be able to go to Harvard.”

         It is generally perceived as a given that a U.K. citizen who has been Sectioned will not be able to use the Visa Waiver to visit the U.S. If that person then has to apply for a Visa, having been detained under the Mental Health Act must be a major hindrance, although I have never seen this applied in practice. One of my patients did have to cancel a horse trial trip to Kentucky because she was sectioned at the height of a manic episode.

         I did not know she had aspirations to get to Harvard but I was not surprised given what I already knew about mother.

         “Before I say anything else, can I ask you a few things?”
         “What? Sure!”
         “Do you smoke, drink, take Ecstasy or go out clubbing?”
         “No.  Why?”
         “Do you have piercings and tattoos on you?”
         “Tattoos—yuk!  Yes, I having my ears pierced. That is all.”
         “Do you like Pop music?”
         “No way. I play the violin and I like Bach and Bartok!”
         Everybody was attentive now.
         “Do you shoot heroin or smoke Cannabis?”
         “No way!”
         She was getting annoyed.
         “What about boys and sex?” I felt bad even to ask especially in front of her mother, who I thought would faint if we knew something she did not.
         “How can you even ask and in front of my parents? You know I don’t do things like that!”

         I can remember my own adolescence. I did not do any of those things either and I did not even have pierced ears.

         I then turned to the parents.  Mother was a history teacher at a famous private school in one of England’s most middle class town. She also spent a year at Harvard, hence Sammy’s ambition to follow her. Father was a prominent city lawyer.

         “You have always provided well for her, a good education, European and U.S. holidays, a comfortable home and expensive music lessons.”

         “We are fortunate enough to be able to do that. She is our only child.” Mother replied in a tone implying, “what’s wrong with that?”

         “And she has always been a bright child, strong willed and single minded. She passed her Grade 8 violin with distinction at 14 and could have become a musician. But she wanted to do International Studies.” Mother added.

         “So she always had her way.”
         “She has always got on with everything, studying and practising the violin. And she keeps a tidy bedroom!”
         A tidy bedroom! My goodness, everything was falling into place.
         “Sammy……”
         “Yes……”

         “You know what? You are the first adolescent I know that keeps a tidy bedroom, do not do drugs, do not drink, do not smoke and you do not do a load of other things I asked you about. You are by modern standards a FAILED adolescent!”
         Then I turned to the parents.
         “And you, FAILED parents!”
         “And we FAILED you. We failed you because we had to hide behind the law and force feed you.”
         Sammy said, “I can’t do all those things even if you make me.”
         Ah, the turning point.
         “No, don’t get me wrong. I don’t want you to either.”
         I then told her that I would like to take the tube off her despite lack of progress, or because of it.
         It simply had not worked.
         I wanted her to take over, do what she needed to do and I would decide in about ten days if I had to extend the Treatment Order.
         Forty five minutes. The meeting took forty five minutes as people had to present summaries of different reports, the details of which were irrelevant here.
         The battle was over. Sammy looked relaxed. Nobody was fighting her now. She was back in control.
         I took her off the Section as she started to put on weight and before long she was discharged. 

         We forget how easy it is to entrench. To entrench is a sure way to perpetuate a problem.






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


[1] Daily Mail report on 26th March 2007 – Children as young as six suffering from aneroxia.
http://www.dailymail.co.uk/pages/live/articles/health/healthmain.html?in_article_id=444646&in_page_id=1774
[2] Independent report on 29th March 2007:  The Versace family: Allegra and the curse of anorexia
http://www.independent.co.uk/news/europe/the-versace-family-allegra-and-the-curse-of-anorexia-442347.html
[3] Salvador Minuchin:  (born 1921 in Argentina), in 1965 became the director of the Philadelphia Child Guidance Clinic, which eventually became the world's leading center for family therapy and training. He is author of a number of books including Families and Family Therapy and Family Kaleidoscope and coauthor of Psychosomatic Families: Anorexia Nervosa in Context and Mastering Family Therapy.
[4] Richard Saul Wurman: (born 1936) an architect by training, published over 81 books including his best-selling book Information Anxiety and his award winning ACCESS Travel Guides. His latest books are UNDERSTANDING Children and UNDERSTANDING Healthcare (January 2004). http://www.wurman.com/rsw/

[5] Micropore™:  Micropore consists of a conformable, non-extensible non-woven fabric manufactured by 3M from 100% viscose, coated with a layer of an acrylic adhesive.

Monday, May 30, 2016

Tioman Island: Un-bleached & Outside the Box!


Ideas without precedent are generally looked upon with disfavour
and men are shocked if their conceptions of an orderly world are challenged.
Bretz, J Harlen 1928.

We have always been led to believe that bleaching of the world's coral reefs is final proof of global warming. Not quite according to the NOAA:
When corals are stressed by changes in conditions such as temperature, light, or nutrients, they expel the symbiotic algae living in their tissues, causing them to turn completely white.

Warmer water temperatures can result in coral bleaching. When water is too warm, corals will expel the algae (zooxanthellae) living in their tissues causing the coral to turn completely white. This is called coral bleaching. When a coral bleaches, it is not dead. Corals can survive a bleaching event, but they are under more stress and are subject to mortality.

In 2005, the U.S. lost half of its coral reefs in the Caribbean in one year due to a massive bleaching event. The warm waters centered around the northern Antilles near the Virgin Islands and Puerto Rico expanded southward. Comparison of satellite data from the previous 20 years confirmed that thermal stress from the 2005 event was greater than the previous 20 years combined.

Not all bleaching events are due to warm water.

In January 2010, cold water temperatures in the Florida Keys caused a coral bleaching event that resulted in some coral death. Water temperatures dropped 12.06 degrees Fahrenheit lower than the typical temperatures observed at this time of year. Researchers will evaluate if this cold-stress event will make corals more susceptible to disease in the same way that warmer waters impact corals.


These are doing fine at Tioman Island,  2.8167°N











All photos©2014 Am Ang Zhang

Medicine and Snorkelling: Think outside the box!

The first modern snorkel was invented by none other than Leonardo da Vinci, apparently at the request of the Venetian senate. It consisted of a hollow breathing tube attached to a diver's helmet of leather.

You may wonder why I wrote about snorkels in my book The Cockroach Catcher. The evolution of the snorkel tube makes me think about progress in medicine.

“... In those days we had snorkels that had a Ping Pong ball at the top end – a sort of umbrella handle at the top with the Ping PongBall inside a little cage so that it floated up to stop water coming in. ….

Imagine the shock when we went to the Great Barrier Reef and were given snorkels that bore no resemblance to the ones I used in my childhood. There was no Ping Pong ball in a cage and there was a drain at the bottom. The top was slightly curved with a clever design so that water from waves could not get in. Any water that managed to get in was drained away at the bottom. I looked at it and smiled. One must always question traditional beliefs. We can be blinded by what looks like a most sensible and reasonable approach – Ping Pong ball in a cage. ...

Medical Schools should remember to teach future doctors that without breaking rules and old dogma, no progress would ever be made in medicine....”
                                                                         
My Point is that doctors sometimes need to “think outside the box”.


Snorkelling is one of my favourite hobbies. I find it so relaxing and therapeutic. Slow breathing, say for 15 minutes a day, is now proven to help reduce blood pressure by a clinically significant amount. What better way to do it than in the sea, surrounded by fish and corals?                                                                                                                                                                       





The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US        

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.



Minuchin’s concept of the psychosomatic family (enmeshment, rigidity, over-protectiveness, and lack of conflict resolution) was both insightful and ground breaking at the time. However, it seems to be no longer fashionable or politically correct in the modern day no-blame culture. I do not have any argument with the no-blame approach, but it would not hurt psychiatrists to understand cases from Minuchin’s point of view without making a song and dance about it.
Sometimes modern parents give their children too much right and freedom for self determination.
In the chapter “SARS and Knowledge” of my book, I compared the freedom to starve oneself to that of not wearing a mask during the SARS outbreak in the endemic zones:
“…… If a child can be made to wear an uncomfortable mask, why can parents not make a child eat?...”
In matters concerning life or death, shouldn’t zero tolerance really be a no-brainer?

No doubt the promotion of zero size models by the fashion industry has managed to exert undue influence on some gullible teenagers and created a “cult” following. Have you not noticed how frightened some of the anorectics are of even the slightest touch of fat? How they panic when banned from exercising! There always seems to be a little voice in their head asking them to disobey their parents, nurses, psychiatrists and anyone who tells them that their belief is wrong. Like any cult rescue, someone needs to take over and the one taking over will take over the wrath of the new Anorexia god.
“It is not me who wants to eat, it is them.”
All those trying to help are on the “other side”
Yet, given time, there will be recovery for cult victims, at least for some.

Anorexia Nervosa: What If!

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 offspring 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.
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.

Anorexia Nervosa: Bach

In The Cockroach Catcher Dr Zhang got his Anorectic patient to play the cello that was banned by the “weight gain contract”:

“She missed the cello too, the only thing she could use to shut out her worries.

Fourteen and carrying the burden of the world. 

She played a couple of scales and we made some fine tuning. It was not quite the same as the violin, but at least I knew not to overdo the pegs. Then she started playing.

“Ah. The Bach G-major”

“So you know it”

Of course I do. The hours I spent listening to Yo Yo Ma and it was such amazing music, melancholic and uplifting at the same time. For a moment I forgot that I was her psychiatrist and she forgot she was my patient.

 

Anorexia Nervosa: Olanzapine (Zyprexa)-Veganism

The trick with Anorexia Nervosa is you need to be inventive and inventive every single day. Think Jay Haley, think Hobson’s choice. The patient can still be a vegan. She does not need any drugs. She does not need any ECT or neurosurgical procedure.

In the end, Anorexia Nervosa could be a rewarding condition to deal with:
 

“If our work is to be therapeutic then a sort of therapeutic alliance is important, even if tentative. Some people do not realise that you can fight with your patient and still have a sort of therapeutic alliance.” The Cockroach Catcher


The Times:  The internal market has been a costly disaster