From THE MERCK MANUAL, TWELFTH EDITION

Ch. 9                                                                             Anorexia Nervosa 1423
 

9. ANOREXIA NERVOSA

  Food aversion, self-induced, which is a manifestation of psychiatric illness.  Severe emaciation is usual.  Most common in young, single women, it is frequently accompanied by amenorrhea.^[1]
 

Etiology

  Most cases develop in the years from puberty through the 30's. A variety of psychiatric disorders are seen, ranging from a neurotic concern with obesity to frank schizophrenic delusions.
 

Symptoms and Signs

 The somatic symptoms, including a low BMR (-35 or -40), reflect the effects of starvation.  The daily food intake may have been 1,000 calories for many months.  Vomiting is common if food is forced and is often self-induced.  Constipation is usual, and other vague and indefinite GI complaints may occur.  Patients sometimes weigh as little as 65 or 70 lb, usually appear senescent, and have pallor without anemia, dry hair and skin, low BP ^[2], sub-normal temperature, and slow pulse rate.  Slight edema of the ankles may be present.  Despite dietary inadequacy, usually there is no recognizable avitaminosis.  Hairiness of the arms and legs may be seen.
  Frequently, these patients remain capable of occupations, interests, and physical exertions astonishing in those of such frailty. They may insist that they eat amply; or if not, that they can eat no more.  Oddly, they often assume that some other family member is not eating enough.^[3]  Under observation, they may resort to various subterfuges to dispose of food.^[4]  This reflects a common rationalization: that their emaciation is not really a matter for serious concern.
 

Diagnosis

  Laboratory tests give limited aid in diagnosis.  Besides the low BMR, there is a tendency toward depression of the gastric acid and blood sugar.  The glucose tolerance curve is usually flat.
  Tuberculosis and other wasting diseases must be excluded.  In some instances, uncharacteristic symptoms arising from regional or terminal jejunoileitis will closely simulate anorexia nervosa. In hypothyroidism, increased blood cholesterol is common.  Addison's disease is accompanied by darkening of the skin, hyponatremia, and hyperkalemia.  The diagnosis is confirmed by ACTH tests and urinary 17-ketosteroid determinations.
  Since Simmonds' disease (pituitary cachexia) may be mimicked, the following points are helpful in the differentiation:
(1) In young unmarried women, one should consider the disorder

1424 Anorexia Nervosa

as anorexia nervosa until proved otherwise. (2) Occurrence in males favors a diagnosis of pituitary cachexia. (3) Occurrence in women following parturition, particularly if delivery is associated with much hemorrhage, is strongly suggestive of a true pituitary lesion (Sheehan's syndrome). (4) Onset following an acute, severe infection suggests true pituitary disease. (5) Loss of axillary and pubic hair occurs much more frequently in Simmonds' disease. (6) Patients with Simmonds' disease are rarely energetic; apathy is characteristic. (7) Sensitivity to insulin (prolonged hypoglycemic shock) and to thyroid is common in Simmonds' disease. (8) Any remarkable improvement due to adequate food intake favors a diagnosis of anorexia nervosa.
[Note that all possible causes for the symptoms of starvation other than anorexia nervosa have already been ruled out. --William]
 

Prognosis and Treatment

  Treatment succeeds in many cases though some patients succumb to intercurrent infections or develop chronic mental illness. Since these patients may actually fear to gain weight, curbing their activities is often a serious problem.  Hospitalization in the early phases of therapy is usually imperative.  The physician must be given total authority by the family.  He must limit their visits to a minimum, particularly at mealtime, and assign duties to carefully selected nurses; without such authority the physician cannot carry out effective treatment.  Psychiatric consultation is advisable in all cases, absolutely necessary in some.^[5]  Often, however, the family physician can reverse the process unassisted.  The physician's appraisal is explained frankly to the patient.^[6]
  A concrete demonstration of weight gain is good psychotherapy.^[7] The patient's customary daily caloric intake is calculated.  To this amount, 300 calories are added of protein and supplementary vitamins.  At 5- or 6-day intervals, similar 300-calorie additions are made until the daily intake is 3,400 to 3,600 calories.^[8]  For 2 or 3 days after each increase, the patient will experience gastric distress which gradually subsides.^[9]  When leaving the hospital, the patient is instructed to record the body weight 2 or 3 times/wk.  If gain is not progressive, it may mean that without realizing it the patient has decreased food intake.^[10]
  Medication to increase the appetite is generally inadvisable for psychologic reasons.^[11]
  Psychiatric consultation is indicated when the dietary regimen is without benefit.  Depth therapy will be neither essential nor desirable with some patients, while others will need narcoanalysis or psychoanalysis.  To prevent recurrences, all patients should receive psychiatric help.^[12]

_______________

My Notes [by the husband's stepfather]:

1. Primary Amenorrhea: Delay of menarche beyond age 18.

2. Secondary Amenorrhea: Cessation of uterine bleeding in women who have previously menstruated.  Physiologic amenorrhea occurs before menarche and in pregnancy, the puerperium, and the immediate postmenarchal and premenopausal periods.  The menopause is an irreversible, normal state of ovarian inactivity and amenorrhea. [page 794 of the Merck Manual, Twelfth Edition]
       If nothing else, ask Jane whether she appreciates that she is exposing herself to the risk of becoming a matron (an old woman) at an early age.

3. BP, as far as I know, stands for blood protein.  I don't know what BMR and the indicated values for that stand for, nor how they would be measured.

4. That is really not all that odd.  It seems to me that the patient's thinness is perceived as being relative to the obesity of other people.  As this is a psychiatric disorder, the rationalization would be that by urging others to eat, they'll become obese or increase their obesity.  Thereby the patient becomes relatively thinner.

5. One of them is the use of diet-pills or -candies.  Those are addictive.  Another may involve the use of laxatives.  They are not addictive but will lead to the same result: starvation.

6. I totally agree.  This is a very serious psychiatric illness.

7. Exactly!  You can't cure an alcoholic by hiding the fact that he is one.  Neither can an anorexic be cured by hiding the fact from the patient that she is suffering from a psychiatric illness.  It doesn't do anybody any good to believe, or to indoctrinate the patient, that her disease is a "border-line case of anorexia."

8. Don't kid yourself that anything else works.  It doesn't!  It is extremely important that the patient recognizes her illness and its consequences.  Only if she does will she be willing to eat enough to maintain a course of weight gain.

9. That means about a week for every 300 cal. increase in food-intake.  As I'm sure that Jane's intake was down to zero, that means that she'll be in for ten weeks of treatment.  You better be ready to make arrangements and accommodations for that.  It is hardly possible for us to carry on with the present situation of Mom trying to cope with looking after all four children entirely on her own so far away from here.  Perhaps the children will have to be brought to our residence and the older children be enrolled in school here.

10. Consider that when Jane came back from the Pleasant View Hospital on her way to the hospital in Prairie Butte, she was experiencing gastric distress even when she drank just a sip of water!  That appears to have been on account of her not having eaten anything while in the Pleasant View Hospital.

11. She may also circumvent possible weight gain by purging herself through self-induced vomiting (either by willing herself, or by drinking something that'll make her vomit, or by simply sticking her finger down her throat) or by any of the methods outlined in Note 5.

12. Think about why that is so.  If she is supposed to take medication to increase her appetite, she'll think that she is being forced to increase her food intake.  If she can successfully avoid eating sufficient amounts, she'll also be able to avoid taking the medication.  If anyone ensures that she takes the medication, she'll have that much more reason to limit her weight gain through any or all of the methods indicated in Notes 5 and 10.

13. This paragraph worries me and your Mom the most of all.  What is being mentioned here is psychotherapy that most certainly will take the form of what is called today "Recovered Memory Therapy."  That type of therapy presents an enormous danger to your family.  It is simply nothing other than the brainwashing techniques that were used against the US pilots and soldier interned in Chinese prisoner of war camps.
        Don't kid yourself.  It is already being used in Jane's case.  I have no firm knowledge at all that Jane is actually receiving that therapy, but the evidence is there.  I must point out that I predicted to Mom last Monday that Jane would receive that therapy and what the results would be.  The obvious result to be expected is that her father will be accused of sexually and/or physically abusing her in her childhood.  That would probably expand to allege that her older brothers (if she had any) abused her as well.  It may even include allegations that her mother participated in such abuse.  Many more variations of the theme are possible.
        I didn't think that it would be certain that this would happen, only that it was very likely to happen.  The evidence of allegations that have surfaced during this week makes my fears a reality.  Unfortunately, I didn't even think of who would be the most natural target of such allegations: her ex-husband!
        She stated during the last few days that her ex-husband threatened to rape her and your stepdaughter Elsie!  That is absolute nonsense.  If he really were a possible threat to that extent, why would she permit him to take his two children to live with him on every weekend?
        Don't underestimate the dangers that this represents!  The allegations will most likely expand to include even you, perhaps even me and your Mom.  It is very likely that your family and hers will be ripped apart forever!  The normal course of events as a result of such therapy is that the patient will become alienated from all and every member of her immediate and extended family.  She'll be most likely to become unable to ever be productively employed and has an enormously increased risk of committing suicide, regardless of whether she comes to terms with her anorexia or not.  For more information on the "good" that such therapy will do read "Manufacturing Victims" by Dr. Tana Dineen.  I have a copy of the book and can lend it to you.
        That isn't all.  The allegations against Jane's ex-husband (and anybody else for that matter) will most likely expand from allegations of having been threatened to be raped to allegations of rape and/or sexual abuse having taken place.
        Depending on the tendencies of the therapists, Jane is quite likely to become a lesbian, either on account of bonding to a possibly lesbian therapist or on account of the anti-male hostility that will be instilled in her.
        The emotional consequences to all family members are enormous.  That is not the least of it.  It is likely that criminal prosecution of some family members or acquaintances follows.  In such cases, the accused is assumed guilty unless he can prove himself innocent!  That proof is exceedingly difficult to establish as the accused must defend himself against accusations that are accepted as being true, because "women never lie" and because the evidence provided by the therapist is being accepted by our courts as hard, solid, scientific evidence.
        Everyone involved will be emotionally and financially devastated.  To boot, even if anyone manages to have his name cleared in the courts, which isn't very likely to happen, he'll carry the reputation of being an abuser.  That reputation will follow him for a life-time, because it will be permanently and irrevocably recorded in Social Services' files.  Not only that, but that reputation will be common knowledge in the local community, where it will have a permanent impact on the employability and social standing of the individual.
    
    To guard yourself against the possibility of any of this happening, and to enable you to mount a defence if that should become necessary, you must determine who the therapist is and insist that you receive a copy of the therapy session notes and tapes.  If necessary, force compliance with that requirement by obtaining a court order to have the therapist give you a copy.
        Take notes of any statements made by individuals involved: what they told you, who they are, and when and where they said it.  If possible, have the record of each statement authenticated by an independent witness.

Follow-up

More than four years later, the patient is still in psychological therapy and attends at least one session per week, and as far as we know, she still receives psychosomatic medication.

For more than three years she was grossly underweight, although she gained weight during the last little while. However, the weight gain is due to her eating mainly sweets and absolutely no meat or animal fat.
   When she is hospitalized, she asks for and receives prune juice.  Who knows why the nurses give her that.
   She began to cut her arms superficially but seriously enough to require medical attention whenever she cuts herself.  At one of her last hospital stays she was given only plastic cutlery with which she could not cut herself, but she circumvented that.  She used a tab from a soft-drink can and proceeded to cut herself with that, right in the hospital.

She has been hospitalized numerous times (so many times that we lost track), lately twice because she began to experience seizures that look to us like drug-withdrawal symptoms.
   The doctors who treat her try to assess what kind of drug-regimen will be needed to cure her condition.  We pointed out to them that unless they not only take into account what medication she is under and supposed to be under but also which of the herbal remedies she is consuming when and to what extent, any attempt to cure her with drugs will most likely produce one of a range of possible outcomes, from total futility to being deadly.
   She has in her house a very large number of bottles and packages of various herbal remedies and vitamins that defy being listed.  Besides those that are in plain view whenever a given cupboard is opened, there could be many more that are being hidden in various places.  Those that are in view are in various stages of consumption.

Another follow-up

Next Page: five years later

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