To help Antoaneta understand emotions about sexual abuse in her childhood, I began by asking her to imagine how she would feel watching a child she cares about growing up exactly as she did.  Most of my childhood stress survivors spent years learning to suppress feelings connected to their abuse.  As a result, they find it difficult to consciously connect with those emotions.  But if they imagine the same experience being inflicted on an innocent child, usually they begin to experience those long-buried emotions.  Once they have this connection, the next step, when they feel ready, is to write about what they are feeling.  Writing has an almost magical ability to pull out emotions of which people are only slightly aware.

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The second part of Antoaneta’s treatment for anorexia focused on unexpressed outrage about her sexual abuse in childhood.  To survive the abuse, many children find a place to lock emotions away.  By the time they become adults, their ability to experience those feelings is limited.  As their self-esteem recovers during the adult years, recognition of how wrongly they were treated grows and pressure to express the associated emotions becomes compelling.  Lacking facility in verbalizing those feelings, many of my patients (including Antoaneta a few years earlier) express them somatically (which means via the body) which results in physical symptoms.  In others, such as Antoaneta during the time of her anorexia, the emotional pressure causes a sense of chaos for which tight control over eating and weight provides some relief.  The common source of both the physical symptoms and the anorexia lies in the unexpressed outrage at maltreatment in childhood.  This is why treatment methods developed to relieve physical symptoms also succeeded in relieving Antoaneta’s anorexia.  The key is to help the patient learn to express the emotions verbally.  More in the next post.

The first part of treating Antoaneta’s anorexia focused on her low self-esteem.  I deliberately avoided discussion of eating habits, body image or weight.

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Antoaneta’s refusal to accept counseling for her anorexia nervosa from anyone but me created the most challenging ethical dilemma I ever faced involving one of my own patients.  Fortunately I served for many years as Ethics Director for my hospital and for my medical group and I had learned when faced with two bad options, to try to find a third way.

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When Antoaneta insisted she would allow no one but me to counsel her about her anorexia nervosa, my first reaction was that this was analogous to asking a dermatologist to treat your heart attack or a plumber to fix your computer.  Even among therapists experienced in treating anorexia, success rates are not ideal.  As the NIMH Eating Disorders site puts it, “no specific psychotherapy appears to be consistently effective for treating adults with anorexia.”

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Continuing the story of Antoaneta, I was glad to find that her nutritional status was still within normal values despite her profound weight loss to 110 lb (50 kg) and body mass index of  just under 18 (normal 20 – 25).  However, a review of her chart revealed steady loss of 7-8 lbs (3.5 kg) every month for over a year and it was clear she would soon be in serious, potentially life-threatening trouble.

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Caring for the patient I am about describe was so challenging it could have cost me my job.

Antoaneta was a middle-aged native of an eastern European country who came to the U.S. at age 10.  She spoke perfect English with a charming accent and I recalled treating her for irritable bowel syndrome a few years earlier.  Now she was referred for a nutritional evaluation.  (In addition to my work as a gastroenterologist, I also directed the nutrition support team at the hospital.)  The reason for this was that she had steadily lost a total of 113 lbs (51 kg) over the preceding 15 months due to anorexia nervosa.  Her primary clinician had already checked for other conditions that might have caused her weight to fall from 223 lbs (101 kg) to 110 lbs (50 kg)  on a 5′ 6″ (1.68m) frame but found no other problems.

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