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From the Files of Ron Farmer  
CASE OF SEVERE ANOREXIA NERVOSA IN A BOY

Anorexia nervosa is a psychiatric condition – sometimes fatal - usually afflicting only teenage girls; rarely is it seen in boys. Its main feature is that the person has an extreme fear of being ‘fat’ which translates into a belief that they are indeed obese even when grossly underweight. The distortion of body image is so complete that the actual weight and mirror-reflection of the body does not register logically in the mind, being always superseded by their perceived reality of feeling and looking fat. Appetite is suppressed totally by the high anxiety surrounding eating and the thought of gaining weight. In many ‘anorexics’, the declared aim is to lose still more weight, even when their life is at risk.

When I first heard of James, I was a PhD student in psychology of the University of Queensland. The advent of what is still known as behaviour therapy had just begun and I was one of its early advocates. A child psychiatrist, Dr Barry Nurcombe, who knew of my explorative work in this new field, asked me if I would be willing to look at treatment options for James. I enthusiastically consented.

Meeting James at the children’s hospital where he’d been living for several months was a real shock. Nine years of age, his growth had been stunted by the severity of his illness as well as the absence of half of his pancreas, surgically removed to see if this could help him. He was severely emancipated, hiccupped every few seconds, vomited frequently and could barely walk. Because he was unable to eat or drink, feeding was via a tube directly into his stomach while he slept. He looked sad and deeply troubled, yet his eyes were bright with interest in this new person introduced into his life.

Being inexperienced and naïve I tried a range of simple behaviour therapy techniques, seeking to desensitise him to his fear of fatness and reward him for weight-gain. Nothing worked; in fact over the next ten months he continued to deteriorate and the hospital doctors were considering removing the remainder of his pancreas. I became quite depressed at my inability to assist James, particularly so because my intuition still insisted that there was a cure.

I decided to re-read Dr Nurcombe’s notes based on his first interview with James two years earlier. And it was then that the words stood out like a light on a hill. To paraphrase from memory:

James was happy at home in the care of his loving and protective parents prior to reaching school age. Being somewhat chubby and shy, on his first day at school he was targeted by older bullies who said, “You’re a fat little round ball. We’re going to roll you down the hill”, which they did. The next morning prior to leaving for school he vomited up his breakfast. He was five years old.

School refusal followed within days as did an increasing reluctance to eat or drink over the next few weeks, until within six months he was hospitalised for the first of many times.

I kept re-reading the notes until the realisation dawned that fear of fatness was not James’ primary fear – his real fear was that bullies would tease and harass him. So we can imagine his subconscious mind saying, “There’s no way I’m going to put on weight as that will attract the bullies again.” It was now obvious that what was required was to teach him how to deal with the bullies of this world. For that we needed what is called assertive training.

The principle behind assertive training is the building of verbal interactive skills and its corollary, self-confidence. The naturally self-confident person sees no need to assert themselves – they speak their own truth anyway. To train someone to be assertive is very simple: The therapist and client (patient) engage in a series of structured role-plays, first with the client acting the role of the protagonist and the therapist demonstrating how the client can respond, followed up with a reversal of roles which now gives the client an opportunity to put into practice what he observed the therapist doing before. The main skills required to be an effective assertion therapist are good acting skills and the ability to structure the interaction so that the client always ends up ‘winning’.

James guided me in creating a hierarchy of verbal harassment situations relevant for him, beginning with the least anxiety-provoking one, “You’ve got big feet” (his feet were small, along with his height), increasing through to, “You’re a new boy in school; where’ve you come from?”, up to the nightmarish one of, “You’re too little and you’re fat!”. Each of the twenty situations was printed on its own card to allow young James to re-order the hierarchy at any time or to insert an in-between scenario if the step up to the next one was proving too difficult.

Next we worked together to come up with about ten assertive responses, each one printed on its own card, a pack of which we both carried during the role play for easy reference. These included some nine year-old boy retorts such as, “Ah, run home to your mother,” or “Get lost!”, or “None of your business!”, and, “Look who’s talking!”, as well as more sociable replies such as, “I was in hospital for a while. Something to do with my pancreas”, or whatever was appropriate if the comment directed at him was not a verbal attack.

And so we began what turned out to be an intensive learning experience both for James and myself – training in assertive behaviour for six days every week for the next three months, beginning with only 15 minutes because of his limited strength and building up to one hour for each daily session as he grew more robust. The first few sessions were tiring for James and were often cancelled or cut short because he lacked both strength and motivation.

Consultation with his parents and Dr. Nurcombe gained their support for a reward system whereby every 15 minutes of engaging in the assertive training earned James a precious one hour of visiting time with his parents. Having only 30 minutes with them on the first weekend spurred James on to greater efforts, so that he pushed himself to engage in the training even while struggling with his feelings of nausea and weakness.

All of the assertive training was carried out while standing up facing each other. We stayed with the least disturbing scene on the hierarchy (‘You’ve got big feet’) for nearly two weeks while we had practice with each of the ten different vocal responses (e.g. ‘Get lost!’), referring for our choice of reply to the hand-held cards, each one expressed along with suitable voice intonations. During these initial sessions we also began experimenting with a range of hand gestures and body movements appropriate for supporting the verbal reply.

During the second week of assertive training James experienced his first signs of hunger and thirst in perhaps three years – he began to eat one or two small mouthfuls of soft food and take a sip of water. There was no sign of any weight-gain until about the sixth week of training. This slight increase precipitated some anxiety so, with James’ agreement, the reward system was modified so that units of weight-gain earned him the visiting hours with his parents.

By now James was an almost enthusiastic participant in his daily trainings in assertive behaviour. I had my research and tutorial work to attend to so I enlisted the help of a talented psychology Honours-year student to share the training sessions with me. She proved to be quite adept after just a little practice and was soon doing the bulk of the training with James. Progress was steady and strong.

After ten weeks of the training James was becoming really fluent and spontaneous in his assertive responses, at least within the relative safety of practising with an adult who was careful not to precipitate any more anxiety than was necessary for James to build up his emotional resilience and detachment. Naturally we were hoping that the gains being demonstrated in the training sessions would carry over to everyday life. Fate arranged such reassurance to be given in quite a delightful way: I was walking through the hospital grounds one day with James and he was telling me how much he enjoyed attending the small school provided for children receiving long-term in-patient care. As if to add to his story, there was a cheeky call from a ward balcony overlooking our lane, something to the effect of, “Are they taking you off to the funny farm, James?” Quickly, without any break in his stride, James looked up and laughed, letting off a stream of friendly insults to this boy of about the same age. Instantly I thought, “He is OK! He’ll be alright!” And he was.

Four years later I received a letter from a now 14 years-old James expressing gratitude and enclosing two photographs with his writing on the back. One said, “This is me on my push-bike”, and the other, “This is me in my football clothes.” He was now fully recovered, happy and bouncing with energy. Through a simple procedure of pretending to be confident he had journeyed towards a more innate form of believing in oneself.