Slim but not Anorexia Nervosa!
© 2012 Am Ang Zhang
It is probably too late as so many doctors and psychiatrists are brought up on empirical diagnosis that sheds little light on the sufferings of the individual. The more powerful the diagnosis is, the easier it is to ignore the person as an individual and not to take into account his life history that may have a strong bearing on his treatment.
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In physical medicine we all understand that pain is a symptom and not in itself a diagnosis. When we move on to stroke or heart attack, it may be more problematic. Even in these cases, most clinicians will still be looking at or for the underlying cause or causes and will not rest until that is identified. Hopefully it may have important bearing on the treatment. Underlying hypertension or diabetes, for example, will have to be treated.
In psychiatry, attempted suicide is not in itself a diagnosis and that is simple enough.
When we come to Anorexia Nervosa, psychiatrists are suddenly blinded. It is what I call a powerful diagnosis because it overshadows everything else.
I am not arguing against the “pure” form of Anorexia Nervosa and I am sure it exists.
Why?
Because I have seen these cases myself.
What I really want to alert readers to is the inherent danger in following blindly DSM (Diagnostic and Statistical Manual of Mental Disorders) or ICD (International Classification of Diseases) classifications. The danger is in seeing an Anorexia Nervosa patient as someone who has caught the “virus” that causes it.
A great disservice will be done to the patient if this distinction between what is the manifestation and what is the underlying pathology is not recognised.
The same is of course true of Drug and Alcohol Abuse. It is however a lot easier for most people to understand that there is an underlying cause for these. Pearl Harbour star Kate Beckensale was recently reported to have the view that Anorexia Nervosa sufferers were not different to Cocaine junkies – an observation that stirred much controversy but was probably closer to the truth than most would care to admit.
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 was arrested and it helped me at least to understand the unfathomable.
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 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.
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Miss Beckinsale, whose weight once plummeted to five stones, said: "I believe anorexia, alcoholism and drug abuse in teens are more about what is happening in the home than a problem with images in the media.
"It is the nice girl's way of becoming a crack whore."
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