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Friday 3 February 2012

Still struggling on

The Need for Complex Ideas in Anorexia Nervosa:
Why Biology, Environment, and Psyche All Matter, Why
Therapists Make Mistakes, and Why Clinical Benchmarks
Are Needed for Managing Weight Correction

Michael Strober, PhD, ABPP
Craig Johnson, PhD

I still have not finished reading this paper.  I admit I am finding it difficult reading on a number of levels and not just because of the content.  Maybe it is because I am not a scientist but I do find that descriptive passages do not sit well in clinical papers and that clinicians tend to lack the necessary to be great writers.  (Having said that, David Wood writes exceptionally well.)  Therefore, I expect clinical papers to be clinical.  Call me old fashioned, even narrow minded, but science has its own language for a purpose.

The language and presentation in this paper is almost....well....Gothic.  The opening two paragraphs read like a bad Gothic novel or a bad teenage vampire book (a genre with which I have had to become familiar since the Twilight craze began)

"It dates back to a July morning in 1974, when the lead author walked through the doors of the UCLA Neuropsychiatric Hospital and was welcomed almost immediately by a 13-year old patient whose ghoulish appearance was so horrifying I could do little more than stare incredulously. My greeter was unfazed by the reaction—as though she had seen it so many times it no longer touched her own sensibilities; if it ever did.
After the introductions, she said—a bit over-proudly I thought—that she had anorexia nervosa (AN) and weighed 52 pounds. I distinctly remember thinking I had seen something like this before; then I remembered. It was 1960. I was 11 years old and had come to my grandmother’s hospital bed to say goodbye for the very last time; she died the following day from colon cancer. When I asked my mother what made her so thin, she said it was the cancer; on the day my grandmother died she weighed only 69 pounds. I remember thinking this had to be a mistake—a grown person couldn’t be that thin.

As for my new acquaintance, she was only a fraction as old as my grandmother, but ‘‘thin’’ didn’t even come close to describing the skeleton that stood before me. Her skin had all but melted into the bones beneath and her head—it appeared so shrunken that her eyes dangled perilously from their orbits, seemingly held in place only by a single remaining sliver of muscle; I was certain they were going to drop at any moment."

If this was a book, not an article in the International Journal of Eating Disorders, it would be a faded green leather book, unloved and unread, lingering on the shelves of a charity shop for decades.  Perhaps Messrs Strober and Johnson are fans of the genre but it seems to me ghoulish and lacking in any kind of compassion or empathy.  A freak show moment, or a Sunday afternoon in Bedlam, not Eating Disorders experts, with lists of letters after their names and endless qualifications and articles to cite.  Perhaps after 12,000 cases, they suffer from compassion fatigue?


  1. I am halfway through the paper...

    I agree that it is somewhat rambling - and I don't like the opening paragraphs either. They're far too reminiscent of a 'tragic life story'/'misery lit' - and I don't like the fictional/creative writing style. Nevertheless, some parts of the paper are better written and I have to admit that I agree with a few things Strober and Johnson are suggesting. Yet there are parts that leave me, as a former sufferer of AN, feeling thoroughly annoyed and misunderstood.

    The problem (as I see it) is that there is a tendency for many professionals to project their own ideas onto the psyche of a person with AN. It is increasingly understood that people who are starved and very underweight with AN have a cognitive profile that is similar to that of a person with autism. One such aspect is poor theory of mind (ToM). The consequence of this is that the person thinks and feels differently to people with good ToM, is not good at understanding their own or others' thoughts, ideas and emotions - and is rather stuck in their own little world - of AN. Therefore, one cannot transpose typical thoughts and feelings (from a person with intact ToM) onto a person with poor ToM. One cannot say that their behaviours 'mean' this/that/the other.

    So, for example, the phrase: "After the introductions, she said—a bit over-proudly I thought—that she had anorexia nervosa (AN) and weighed 52 pounds." My response to that is that it appeared, to him, that the girl with AN was a little 'proud' of her condition.

    But that doesn't mean that the girl actually was 'proud' of her condition...

    I certainly wasn't proud of having AN in my teens, but like most young people with AN, I lacked insight and thought I was OK. The behaviours initially made me feel better about myself and better in control of my anxiety - and so I defended my behaviours and told doctors I felt fine and 'liked' being that way. I just wanted them to leave me alone.

  2. Sadly there is no like button for your reply, Extralongtail! There are a few nuggets in there but you have to spend a long time and a lot of energy looking......