Browse extracts from the book
Anorexia Nervosa, Bulimia, Induced
"...According to Halliday's and our own definition Anorexia Nervosa is not psychosomatic.
That is because the mechanism through which the psyche affects the soma is
wholly conscious and external. However, we have included it here because it is
usually regarded as psychosomatic and because it is common, difficult to treat, may
break marriages and threaten other members of the family. Although the management
required is not easy to arrange in general practice, GPs by making an early diagnosis
and by knowing the most suitable form of treatment for a particular patient can make
an important contribution to the outcome..."
Browse through selected extracts from this chapter by choosing from
the chapter headings at left. Please follow this link for a full contents
list.
Psychopathogenesis
"...While genetic factors such as inherited timidity may play a part, a major factor
is a sense of insecurity acquired through experiences in childhood which prevent
them gaining a separate identity. For example, the child may be deterred by seeing
a sibling behaving outrageously and causing great parental distress, or if circumstances
during the mother's pregnancy or after the birth result in a tightly bonded
relationship with that child. The role of fathers in psychopathogenesis has been much
neglected. Fathers of anorexic children are often belittled by the mother and are, or
appear to be, inert emotionally..."
Psychological Management
"...Recognition that Anorexia Nervosa patients were ill and as phobic about putting on weight as
someone else might be for heights or enclosed spaces resulted in the empathetic yet
firm approach by doctors and nurses which remains the basis of the standard behavioural
approach..."
Behavioural Management
"...Many, but not all, anorexics initially require admission to hospital which temporarily
removes them from the cockpit of the family meal and enables their activity to be
restricted until they attain a mutually agreed weight. Essentially this is a behavioural
approach of reward and punishment. Privileges such as bathing, sitting out of bed,
and going for walks which are initially removed, are gradually restored as rewards
for gains in weight..."
Outpatient or Inpatient Management or Both
"...An example of a successful outpatient management alone was a girl who was at boarding school.
At the first interview with both her parents they were asked if they would agree that, as she was
nearly adult, she might be treated accordingly and come to subsequent interviews on her own.
She had three brothers and no sisters. Most of the family pursuits were masculine, and the mother
appeared to use her daughter as an ally in a long-running but tacit irritation with the males.
Psychotherapeutic sessions enabled the patient to talk about her feelings about family and friends
in a way she had not been able to do before. She said her AN started when a girlfriend at school
had suddenly become interested in boys and discarded her (almost as common a trigger as
competitive dieting with a friend or being teased for early signs of femininity).
After about six interviews she was still short of her contract weight, and it was re-affirmed
that if she had not reached this by Christmas, she would have to come into hospital until she
had reached it. At the same time she was asked if there was any carbohydrate she liked, and
surprisingly she answered: "chocolate!" She was told she could eat as much as she liked. Two
days later an irate mother telephoned.
M: My daughter has asked me to take 20 lbs (8 kilos) of chocolate to her at school - I have never
heard such nonsense.
D: Well, you must decide, but I would have thought that it was good news that she was prepared
to eat anything.
The receiver was slammed down, but the girl got her chocolate and recovered. She later
married and had children, and to date has not relapsed. The chocolate episode was the first time
she had won against her mother.
Sadly, most cases of AN are more difficult..."
Family Therapy - The Systems Model
"...The following case illustrates the value of this and may be considered an example of underfocusing.
She was 20 and had just married. Three years previously she had become anorexic
and had responded to the behavioural approach at another hospital. Even so, she still regarded
herself as fat, and a never relenting fear of putting on even a few grams of weight and of losing
control persisted. Two weeks after her wedding she took an overdose of anti-depressants, and
the ensuing admission enabled the diagnosis of unresolved AN to be made. She said she was
very close to her mother and expected the close bond to continue despite her marriage. In therapy
it was pointed out that even those who love us most can also hurt and frustrate us. She said her
mother was worried about her, and she feared that she would be visiting and telephoning even
more than ever when she left hospital. Asked what happened when she and her mother went out
shopping or visiting, she replied: "Mother says we'll go out this afternoon, visit Auntie Joan and
buy the Christmas things. She just says it - sometimes I think I would like her to ask me, but I
have never said anything because I like being with her so much." Her husband confirmed this.
It was suggested that her mother was probably unaware of this behaviour, and that both parents
and husband be invited to the next session. She gave her permission for her mother to be asked
tactfully whether she realised what she did.
D: (to mother) You have both liked doing things together for so long, I wonder if
you may not tend to take her for granted?
M: I don't think I do, do I dear?
P: Well, sometimes I feel I would like you so ask me whether I want to go out,
instead of assuming I do.
M: (taken aback) Do I do that?
Husband and father: Yes, I think you do.
From then on mother asked if she could visit, instead of just arriving, and she asked her
daughter's opinion about things in general. Having at last gained a separate identity and control
of the relationship with her mother, her obsessional need to control her weight was no longer
necessary, and she remitted...."
Prognosis
"...Key Words: Power and Control. Doctors and nurses, when first treating patients with
AN, are usually struck by their power and the unrelenting refusal to give it up.
Patients themselves do not see themselves as powerful but they will acknowledge
that control is of paramount importance. It is their overwhelming terror at losing
control that leads to their implacable refusal to give in to their hunger and put on
weight, which conveys the impression of power..."