False Abuse Allegation Resulting from Therapy in a Case of Anorexia Nervosa
|The case description shown below is from a letter sent to a father of four, the sole breadwinner in a family, whose wife is suffering from anorexia nervosa and had to be repeatedly hospitalized. The father used to work about 100 miles or more away from home and could come home only during the weekend, but he has recently found work closer to home.|
That didn't help to alleviate his wife's obsession with dieting. Actually, it got worse, because she can now indulge in her passion with less fear of the consequences to her children whenever she feels that she should be hospitalized.
The average cost of treating an anorexic is in the order of $30 thousand or more per year. "There is gold in them thar anorexia-nervosa-hills." However, that is not all. These cases involve a lot of worry and suffering for all who are connected with the victim of her own destruction.
In this particular case, the mother, upon coming home on a day-pass — earned on account of having followed the regimen established in the hospital — woke up her infant son (he has a severe heart defect) and started carrying him around, ignoring the older children who had shoveled snow for the neighbours so that they could buy their mother a get-well card and flowers.
The seven-year-old daughter offered the following comment when she was told of the possibility that her mother could possibly die on account of her affliction: "I have got her picture...I'll get Mom's jewelry."
N.B.: The names and localities mentioned in the appended notes are fictitious, however, the situation involves a real case.
From THE MERCK MANUAL, TWELFTH EDITION
Ch. 9 Anorexia Nervosa 1423
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.
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 , 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. Under observation, they may resort to various subterfuges to dispose of food. This reflects a common rationalization: that their emaciation is not really a matter for serious concern.
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. Often, however, the family physician can reverse the process unassisted. The physician's appraisal is explained frankly to the patient.
A concrete demonstration of weight gain is good psychotherapy. 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. For 2 or 3 days after each increase, the patient will experience gastric distress which gradually subsides. 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.
Medication to increase the appetite is generally inadvisable for psychologic reasons.
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.
My Notes [by the husband's stepfather]:
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.
Next Page: five years later
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See also the story of "Soupy Kaspar" from the German children's book Der Struwwelpeter (Slovenly Pete) by Dr. Heinrich Hoffmann, published in 1844 (translated by Mark Twain).
Posted 1999 01 24
2001 01 25 (format changes)
2001 08 28 (format changes and to reflect addition of new pages)
2002 02 26 (corrected typos)
2003 05 10 (added follow-up: Four years later)
2003 12 03 (added another follow-up)