Girl in a Chemise circa 1905 Pablo Picasso (1881-1973)
Tate Collection
A Brief History
Il faut manger pour vivre et non pas vivre pour manger.
(One should eat to live and not live to eat.)
Moliere (1622 – 1673): L'Avare (The Miser)
First introduction of the term Anorexia
Sir William Withey Gull (1816 – 1890) first used the term :
“In… 1868, I referred to a peculiar form of disease occurring mostly in young women, and characterized by extreme emaciation…. At present our diagnosis of this affection is negative, so far s determining any positive cause from which it springs…. The subjects…are…chiefly between the ages of sixteen and twenty-three…. My experience supplies at least one instance of a fatal termination…. Death apparently followed from the starvation alone…. The want of appetite is, I believe, due to a morbid mental state…. We might call the state hysterical.”
Earliest published accounts
Richard Morton (1637-98), a
Ernest-Charles Lasègue (1816 - 1883), a professor of clinical medicine in
More recent views
Anna Freud (1958):
Adolescent emotional upheavals are inevitable
Anorexia Nervosa is the outward manifestation of the battle between the ego and eating, with the former struggling for it’s very survival
Bruch (1966): relentless pursuit of thinness
Crisp (1967): weight phobia
Russell (1970 ): a morbid fear of becoming
Crisp (1967 - 1980):
Anorexia nervosa serves to protect the individual from adolescent turmoil.
Anorexia nervosa reflects a phobic avoidance of sexual maturation.
Unsettling effects of sexual maturation at puberty may drive the female adolescent to a pursuit of thinness leading to greater acceptance, self-control and self-esteem.
Anorexia nervosa tends to appear in families with buried, but unresolved, parental conflicts.
Palazzoli (1978) on women’s role:
Women are expected to be beautiful, smart and well-groomed. They are expected to have a career and yet be romantic, tender and sweet. They are expected to devote a great deal of time to their personal appearance even while competing in business and professions. In marriage, they are expected to play the part of the ideal wife cum mistress cum mother.
They are expected to put away her hard-earned diplomas to wash nappies and perform other menial chores. The modern woman is therefore exposed to a terrible social ordeal, and the conflicting demands and dual image of the female body as sex symbol and as commodity. An adolescent girl may develop feelings of insecurity and alienation toward her changing body.
Some hae(have) meat and cannot eat,
Some cannot eat that want it:
But we hae meat and we can eat,
Sae let the Lord be thankit.
Robert Burns (1759 – 1796): The Kirkcudbright Grace
Collection Anorexia
Mass Failure
© Am Ang Zhang 2011
Collecton Anorexia
Let Her Die
©2016 Am Ang Zhang
Can a patient be allowed to die? Can a seventeen year old patient be allowed to die?Can a seventeen year old Anorexia Nervosa patient be allowed to die?
Are we not supposed to save lives?
Could doctors be held to ransom? By?
Here is a Play: Let Her Die!
The Players:
The parents:Father used to run a business security agency specialising in industrial counter espionage. Or was it espionage? I cannot be sure.
Too often there is this bizarre desire by some parents to make sure that if they cannot do it, no one else should either. We need to recognise it early enough. We are doomed otherwise, and so is the patient.
The patient: NicolaIt was really quite painful to sit there and talk to someone who looked worse than the worst they showed from Auswitz. Why could Nicola not realise that if she wanted any man to like her she would need to look a lot better, which involved doubling her weight for starters.
The Doctors:Dr Hillman:
This was a family given up even by Dr Hillman, my most fervent supporter of family therapy. Father used to run a business security agency specialising in industrial counter espionage. Or was it espionage? I cannot be sure.
The Consultant: I did not go round looking like a hippie or pretending that I liked the music the teenagers listened to. I told them to me it was trash. I did not pierce my ear or have a tattoo. I certainly did not wear trainers to work. In short, you do not have to gain respect by becoming like them or worse, by pretending that you are like them.
I spent one session with them and agreed with Dr Hillman. They were good. We looked like a bunch of amateurs dealing with professionals. None of the family therapy tricks work, Minuchin or Haley. Impenetrable!
The NHS Trust & GMC
To me, suspension on full pay is a risk every doctor takes nowadays, as the basis is no longer limited to bad practice. It is no longer a reflection on whether you are good or bad clinically. Many psychiatrists are no longer prepared to use techniques that might upset their patients or parents of their patients.
The Main Action:
A family meeting was called and it lasted only a few minutes. I was in top form.
“Nicola has been eating but after two months has not put on any weight. I cannot see any reason for her to continue to stay here. She might as well do the eating at home. She can then sort out for herself why she is not gaining weight without the pressure from us.” I tried to put it in the calmest way possible. “You mean you will let her die?” Father sounded a bit annoyed.
With that father got up and left the room without saying another word.
“What do I do now? You have upset him!” said mother. Good, something got to him at last, but I did not say it. Nicola gave a wry smile to me as if to say, “You found me out.” She turned to mum, “Let’s pack and leave this dump.” We all kept still. Six months later, one of the nurses bumped into Nicola in a nearby town. She was kicked out by father and moved in with another ex-anorectic. She was with a boy friend. More importantly she was wearing a very sexy dress to show off her then very good figure. She did not die.
Collection Anorexia
The Peril of Diagnosis
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.
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.
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
“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.
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.
Jane
Jane was never abused by anyone. Not as far as I know.
She was every bit a classical Anorexia Nervosa. Or that was what I thought.
She was a very attractive girl, more so when she was skinny. Her older sister was slightly overweight and looked unattractive. It is amazing how that Hepburn look is so attractive and was desired then and still is now.
She was very intelligent and studied the cello with a famous cellist.
I was never quite sure if she liked the cello or not. If truth be told, being that middle class in an adolescent unit does not bode well.
Most of the others knew nothing about classical music and preferred pop. Nobody read quality newspapers and that went for the staff as well. However, a number of the admitted anorectics came from the upper middle class background. Most if not all.
You guess right. There was an undercurrent of “dumbing” down. It was everywhere. It was in keeping with government policy.
With Jane I tried every ploy available to me.
Some thought it was hard work going to a private school. Not just going to one, but being at the top of your year with a scholarship.
One day mother confessed to me in private that she too went through a phase of Anorexia. Nobody knew. Not even her own doctor, and could I keep it a secret?
Jane got on well with me.
She had to, as nobody understood that to her achieving was not a hardship but something she secretly enjoyed. She was no longer allowed to pick up her books as she had not put on any weight since her admission.
She missed the cello too, the only thing she could use to shut out her worries.
Fourteen and carrying the burden of the world.
Cello would be banned too, if her nurse was to have her way. For the unit to function the nurse must have her way. After all I was not there all the time to watch her. To watch if she was eating, vomiting, exercising or whatever else they did to avoid gaining weight.
But I was determined that it would be the first privilege she would get if she put on half a gram. Or any excuse I could think of.
Brutal confrontation is often what happened in many adolescent units dealing with Anorexia Nervosa. The brutality is not physical.
But these patients are intelligent and have such strong will power that confrontation generally fails and the failure can be a miserable one. Yet it is the kind of condition that hurts. It hurts those trying to help. It hurts because these patients deserve better for themselves. It hurts because they are not drop-outs of society.
Was it too hard for Jane to keep at the top academically? Someone offered that as an explanation. Perhaps she should be moved to a state school.
The idea horrified me.
A fourteen year old non-smoking, non-drinking, non-drug taking, intelligent girl turning up at your local comprehensive. It sounded like a major disaster to me.
I had to take the matter into my own hands. She did put on some weight and at the earliest opportunity I decided she should get back to the cello which had always been by her bed at the unit.
“I cannot tune it.”
“What?”
But why should I be surprised? It was quite an expensive Cello, an heirloom from her grandmother on father’s side. She had been a good cellist in her time although she stopped playing when she married Jane’s grandfather and went to
Jane’s teacher had kept the cello in tune and although my children tuned their violins now, it was the teacher who did it for Jane.
Luckily it only needed minor adjustment but we had no modern day Cell Phone tuner.
But I was not to be defeated having come this far.
She was not going to play unless it got tuned. “Dad used to tune it, and he was very good.”
I phoned my daughter and she played an A on the piano at home, which I recorded on my cell phone. We got the cello to sound a little bit decent.
“I am not going to be as good as your teacher, but I hope this will do.”
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.
“My grandma gave me Casals.”
I knew Casals was even more emotional than Ma, but Ma is Chinese and he was less affecting, allowing the listener to tune in to his own mood.
She played from memory. What talent! What went wrong?
“I wish my dad could hear me.”
It was the first time she could talk about her father. They had a very comfortable life in
He died of lung cancer. That much we knew. The family came back to
We had for a while adopted a policy of no weight gain no talk. Looking back now, it was probably a rebound from previous experience with a girl who never really got any better from hours of psychotherapy. Rules can be dangerous in psychiatry as every individual is different, and the assumption that the patient wants to put on weight and talk may be wrong.
She gained enough weight to get home and soon I put her back on outpatient care. One of my juniors started to provide a weekly time. I did not use the term psychotherapy as it was more to see if she would click with someone other than me. I was too much of an authority figure for her.
We were only able to “hover” her. Her weight would go up for a couple of weeks and then down and then up again.
Then I retired and after a year or so my junior left too.
In one of the letters from my contacts at the clinic, I was told that Jane had to be admitted to a hospital in
News of a famous heiress just flashed through this morning’s news and the psychodynamics of Jane’s Anorexia Nervosa suddenly became clearer. The heiress witnessed her uncle’s murder and was anorectic ever since. Jane was home when her father died in mother’s arms with a massive haemoptysis (coughing up of blood, a rare but not unknown effect of lung cancer, generally a massive bleed). It must have been very traumatic.
How dim of me. That was bereavement, a slow suicide by someone who felt less worthy to survive.
Collection Anorexia
Seven Minute Cure
Those of you who managed to catch the first Chapter "The Seven Minute Cure" will be wondering: Is the Cockroach Catcher famous as Barbados 
Well, let the truth be told, Am Ang discovered Barbados long before the celebs. He is still very fond of it though he tends to visit when the celebs have left and he can have the beaches to himself. His favourite beach is Accra Beach
This is the Captain again. I hope you have enjoyed the view of
In seven minutes I would start my life of leisure in this
Seven minutes.
Seven minute cure. My famous seven minute cure. It was the making of me at the Adolescent Inpatient Unit. It was the pinnacle of my career. The most defining seven minutes in my career.
And Candy really helped me launch myself into it.
“It is our view that clinically it was wrong for Candy to be transferred at this stage. It was wrong for the NHS to accept her back and in our view Candy is in serious risk of – quite frankly – dying.”
Those were more or less the words said at the transfer meeting by the nurse from the private hospital where Candy had been for the past eighteen months. She had been compulsorily detained twice and she had been put on Olanzapine. Olanzapine is one of a new group of drugs licensed for Schizophrenia and has been found to induce a voracious appetite especially the bingeing of carbohydrates. Some psychiatrists have started using it for this specific effect. In Candy’s case she managed to fight the biochemical effect of Olanzapine.
Candy was just two days free of tube-feeding, which apparently was the only way to get her weight to a less frightening level.
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. Some would argue: since we as a state hospital would not be getting the money, why should we take the risk? After all, the consultant in charge would be in the dock if the patient did die. Nowadays, patients and their families are trigger happy and complain even if the patient becomes better. God help us if they die.
I argued the case in the opposite fashion. We shall help the authorities without precondition and who knows, I may be able to get them to give us something when the time is right.
Cynics at the unit looked at me as if I had just dropped off another planet. Get something out of the Health Authority? When were you born?
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 clinics 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 Clinics 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
The poor nurse did not realise what hit her. That was my first week. I am never threatened. I like the challenge of difficult cases and definitive statements like – the patient will die. I like to prove it otherwise.
The nurse concerned was not naïve either. Far from it. She based her judgement not on what she knew about me. It was only my first week after all.
No, she based her judgement on her knowledge of the unit, as she used to work here. She was once its lead nurse. Alas, poor pay and bad conditions coupled with the deteriorating consultant leadership prompted her to jump ship. I could not blame her for that.
The unit went through a difficult phase until the last consultant was finally suspended. Even before that, other consultants started refusing to refer patients here, and the two main Health Authorities that the clinic served had to fund ECRs (Extra Contractual Referrals in the then re-organised Health Service lingo) to mainly private hospitals.
Then the unit had a locum and the operation was scaled down drastically. Bed availability dropped to less than half the normal capacity and the waiting list for admission grew. Unlike elective surgery, some patients in psychiatry cannot wait. Beds had to be found and often they were placed with adult psychiatric patients. It was not ideal even for the psychotics and certainly inappropriate for Anorexia Nervosa. Private Hospitals had to be used.
My first task as the new consultant in charge was to ask the Charge Nurse what would limit our ability to admit to full capacity. “Your time,” was his reply.
So we aimed to move to full capacity, not overnight but within the following three months. The shock on the faces of the managers as this was announced at a meeting gave me such an adrenaline rush.
Or, did they think, “What a fool!”
Fool or no fool, one needs to enjoy one’s work, even in the NHS.
This perhaps is one thing that the government has conveniently forgotten. Many of us do what we do because we enjoy it. Otherwise why should anyone want to teach in universities when they can earn ten or twenty times more in industry? We may also decide to dedicate more time to work for personal pride and satisfaction. During the few years I worked at the inpatient units I spent in excess of a hundred hours a week there, one man doing the job of at least two. In addition to that, I was still looking after two outpatient clinics.
With increased capacity, we were ready to take on transfers. At that time the Health Authorities still had decent managers not yet blinded by directives and performance targets. For a start these managers did not interfere with clinical matters. For our part we were free to exercise our clinical judgment. Unfortunately many consultants abuse this privilege of clinical independence, often making excessive demands for treatments and investigations, and managers have learnt to ignore them. Worse the government set up this organisation called NICE (National Institute for Health and Clinical Excellence) to try to deal with such behaviour.
“It is our view that clinically it was wrong for Candy to be transferred at this stage. It was wrong for the NHS to accept her back and in our view Candy is in serious risk of – quite frankly – dying.”
The nurse was probably unwise to make such a declaration, as my mind was already made up to take on Candy regardless.
What if the private hospital did not exist? It would have been down to us then. So to me that was no big deal. After all, most private hospitals are notorious for transferring their dying patients to NHS hospitals so as not to mess up their pristine mortality figures. What was so different here?
“Shall we meet the family?” I said, trying to break the ice.
There had of course been a pre-visit by our Charge Nurse and his team.
“This one is difficult and I think you may have a problem with father.”
Candy led the three-some. She gave me such a look as if to say, “Wait till I give you all the trouble.” She looked out of the window for the rest of the time. Mother was warm but worn. Eighteen months had taken its toll and she was gracious enough to be pleased to meet me. Father on the other hand seemed to show some anxiety. In fact, he was a quite a powerful negotiator, and had managed to persuade the insurers to agree to extend the private medical care for another six weeks on a shared cost basis, either with the parents or with the Health Authority. He was still quite keen on the private treatment, and was half hoping that I would refuse to take Candy on clinical grounds and then the Health Authority would pick up the bill from then on.
To be fair, eighteen months was a long time even for Anorexia Nervosa. Perhaps someone else should have a go. NICE had not yet come up with a standard treatment and I certainly would challenge them to do so. Tube feed everybody? That would be the day.
Mother was more intuitive and I think she got the measure of me very quickly. “Darling, perhaps we should give Candy a new start. The new doctor might work in a different way.”
“It is the nurses that did most of the work.” A final and desperate attempt by the nurse from the private hospital to set the record straight was missed by the nervous family. The rest of the world still looked up to the consultant, perhaps not for much longer but until Armageddon, I was going to enjoy it.
“I will give it my best shot.”
So on a rather unusually beautiful sunny Tuesday morning, we received a soon to be dead Anorexia Nervosa patient who had been abandoned by her insurer to the unsafe NHS. What a challenge! Some of those at the meeting must have considered that I was delusional. I believed that money should not be part of the consideration for the best health care and I was determined to make sure that my delusions should remain true for me. I had to maintain a good service in my little corner of the NHS.
Perhaps I was able to capture mother’s heart and gain her confidence through mine. She decided that they should give us a try.
Do I tube feed her straightaway or do I wait?
I am no coward. So let us wait.
Adolescent units are notorious for making life difficult for authority figures. This is perhaps due to severe professional rivalry. To most of the nursing staff, the only difference between the psychiatrist and them is that the psychiatrist is licensed to prescribe. If a patient is not on medication a psychiatrist would barely be needed. Over time various mechanisms have been introduced to minimize the input of the psychiatrist even when he is supposed to be in charge. Many psychiatrists gave up the fight a long time ago just to survive. A patient’s stay in hospital involves a large number of multidisciplinary meetings that often lead to half-baked treatment plans that have little hope of success. Surprises are unwelcome and generally discouraged.
I have found this kind of “consensus” approach a serious problem. It is simply not my style. Perhaps one of the reasons I stayed as an outpatient consultant all these years was to continue to enjoy the independence from such approach.
Now all eyes were on me.
On that Tuesday I felt as though the whole unit was putting me through a trial. It was like living through a reality show. Everybody was watching me, and I would have to deliver or perish. My reputation, the reputation of an alien psychiatrist, was at stake. I needed to act fast and I did not have eighteen months. Otherwise I would be packing and leaving this jungle, house or whatever reality show I was in.
Apart from true madness, Anorexia is the only condition where one can use the Mental Health Act to detain and if necessary force feed against the patient’s wishes, although little is known about how effective this aspect of our law is. There is still a rather high mortality rate, even in acknowledged centres of excellence like the Maudsley . Tube feeding does not seem to be saving lives. It also hurts our pride if we have to succumb to tube-feeding. It means that we have failed as psychiatrists.
Then I remembered my own golden rule about parenting. When all else fails, try bribery. And that is what I did, but not with Candy.
Any nurse that could get Candy to start eating would get three bottles of nice wine or two cases of beer. It might not be strictly against the rule, but I am sure a few eyebrows were raised. Candy refused to eat or even drink.
I had to be in
“No tube feeding, just check her blood chemistry” was what I decided should be done. People do not die so easily even with committed fasting. We had got time, and nobody was going to get my wine or beer, I told myself.
By Sunday, there was a major concern that Candy, having not eaten for five days, might be at some risk. A quick electrolyte check showed normal sodium and potassium levels. I left instructions again not to jump up and down and worry too much. I was quite sure she must have been secretly drinking, perhaps not from her own jug. Often other patients would “help”, not quite comprehending how their “help” might indeed be a “hindrance”. I have even seen nurses “helping” to dispose of patient’s food or even eat it. Anorexia stirs up funny emotions.
By the time I got in on Monday, Sophie, Candy’s nurse said to me, “I think you had better see Candy. There has been no change at all.” This was in some ways quite unusual as most of the time the consultant in charge only gets involved in family meetings and reviews that are pre-planned. Junior doctors deal with the day to day checking on patients. Perhaps she was somehow hoping that I would give in and put Candy back on tube-feeding.
I think if there had been a NICE guideline , I might not have been given this chance. Instead some on-call doctor over the weekend would have put her on tube-feeding as per protocol. After all, that had been her mode of feeding for weeks.
We would use the law if and when it became necessary. However, that would have defeated the whole point, as she would have been stuck with the old ways forever.
Stubborn patients deserve stubborn doctors.
Candy came in.
“Aren’t you going to tube feed me?”
“No.”
“Then I will die.”
“So I will be very sad but we do not tube feed here.” At least I don’t.
“You can’t do that. I want to be discharged
These are more or less verbatim reports. My mind was racing fast trying to come up with an answer.
“I want to be discharged!”
“Candy, it is actually possible.”
I can still remember the look of horror on Sophie’s face: “Is this doctor for real?”
“You mean discharged today?”
“Yes. I mean today.”
I could see Sophie was in complete shock. “What planet did this consultant drop out of and how is he going to pull this one off?”
“Well. If you start off by drinking one carton of Ensure Plus and some squash, then eat your lunch and have another Ensure Plus in the afternoon, you will be discharged home and you can come back daily.”
When I used this case in my teaching sessions with junior doctors, they invariably showed incredulity that I offered this to Candy just like that, without consulting her parents or her nurse. I knew that if there had been any discussion it would never have happened. There would have been objections from somewhere. That is the trouble with consensus.
But you see, it was important for Candy to know that I had authority. Many adolescent units have gone too far the other way, and they really are a reflection of dysfunctional families where the adolescent rules the roost. A totally democratic approach will never produce the thunderbolt and deliver the sustainable therapeutic effect.
A strange bond was developing between me and Candy. I gave her a way out and she would oblige. I had no doubt at all she would be compliant.
Sophie then went to fetch exactly what I told Candy she needed to consume. When Sophie came back, the drinks went down in seconds. I could see the relief and disbelief in Sophie’s eyes.
That took seven minutes.
And now the real work began: the details. I told Candy she would be discharged as an inpatient and would need to come in every day as a day-patient. A trick you might say.
She did not object.
She never expected to be discharged in her state. The important thing was that I took control. For her it was a relief. She never protested that I perhaps tricked her. It too was a relief for her to have something in her stomach. What was more important was I saved her face and she, mine.
I was to stay on in the show.
How could I justify sending a fragile fasting patient home on the first day of resumption of eating?
For five days we achieved nothing when she was in hospital.
What about the parents?
In fact I phoned mother in front of Candy straight away. I played a trick on her. I just said, “Candy is coming home.” A long silence indicated how shocked she was. Then I told her of our seven minutes.
“I knew you could do something. That was what I told my husband, but I did not know it was going to be this quick. I did tell him you were OK.”
You can wait for years for a case like this. It is like a hole-in-one. You just know the moment the ball leaves the tee. With one such case, I could now put up with anything anyone cared to throw at me.
At least for a while.
To Candy, it was like a heart transplant. She had been stuck for too long and was probably pleased to get out. Hospital was not like home and she had not been home for a long long time.
So where is Candy now?
She was eventually discharged to attend a state school but that did not work. She eventually went to an agricultural college where she worked mainly with horses and did extremely well. Her weight was well maintained. That took another fourteen months. But she remained a day patient throughout except for a long weekend when her parents went away for their anniversary. At Candy’s request, she stayed in the hospital that weekend.
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