Shirah Vollmer MD

The Musings of Dr. Vollmer

Re-Posting Since I Did A Repeat Performance: Teaching about Anorexia Nervosa

Posted by Dr. Vollmer on February 3, 2012

        “The young woman is looking for some sort of control over her life,” I say to fourth-year medical students, as a way to help explain the self-destructive behavior that might underlie Anorexia Nervosa. “What does she say when you ask her about how it feels to have control over her life by not eating,” an eager, soon to be primary care physician asks me. “Well, she would deny the experience. She would say that she does not have a problem; that her parents are overly concerned and they always have been. Her denial of her problem, stimulates a question about what is going on, on a deeper level of her brain. This leaves us, the clinician, to speculate that it is possible that on an unconscious level, there is a positive affirmation in her starvation, in her ability to control her bodily urges.” I say, wondering if these future physicians are looking at me glassy-eyed because they are tired or because I am not explaining the unconscious very well, or both. “So, what is a primary care physician supposed to do?” Another eager and enthusiastic fourth-year medical student, interested in Internal Medicine, asks me. “Well, as with so many complicated diseases, the primary care physician, needs to shepherd the patient through the health care system. The patient will need monitoring of her electrolytes, her weight, her blood pressure. She will also need to see a nutritionist, along with, a mental health provider. The primary care doctor needs to coördinate care; provide the patient with a “medical home,” the new buzz phrase. The student looks at me with recognition, maybe a little embarrassment that the answer was obvious, and yet because we are dealing with mental health issues, the clarity of the situation gets blurred.

      I am back to wondering my age-old question. Do medical students, our future physicians, need to understand human behavior? If so, what is the best way to teach them? If not, should their psychiatry curriculum be limited to psychopharmacology? My answer is clear. A major challenge in being a physician is to help people, help themselves. Understanding how patients get in their own way is critical to helping all patients stay on a good path. This seems both obvious and neglected.

8 Responses to “Re-Posting Since I Did A Repeat Performance: Teaching about Anorexia Nervosa”

  1. Kristin said

    It seems like a big part of the primary care physician’s job is to act as an advocate for the patient in dealing with insurance companies. Do patients generally get the referrals they need from their primary care physicians to mental health professionals, or do primary care doctors end up treating mental disorders themselves? I think I read somewhere that the majority of prescriptions for antidepressants are written by primary care doctors.

    • Yes, the majority of prescriptions written for antidepressants are written by primary care doctors-that is true. A physician needs to advocate for their patients in multiple ways, including the insurance company. How people come to mental health is a fascinating question. Primary care is one portal, but of course, word of mouth is another one. Now, the internet is another portal, so the world, as we know, is changing rapidly.

  2. Shelly said

    What your medical student interested in Internal Medicine said was of course the correct answer, but a woman suffering from anorexia will probably accept the shepherding through the health-care system, the appointments with the nutritionist, the monitoring, etc… Will she even admit that she has a problem? If the issue is about control, why is it such a huge, huge deal today where so many young (and not so young) men and women starve and purge themselves in order to look like the magazine models and meet the demands of society to be thin? It is not a matter of control; it is a matter of looking like society expects them to look like. Then why is considered a mental disorder?

    • Shelly said

      Sorry…I meant to say that a woman suffering from anorexia will probably NOT accept the shepherding through the health-care system.

      • Yes, you are right that there are a number of factors which lead to Anorexia Nervosa, and you are also right that some women are more reluctant to accept help than others. As with everything else, sometimes there is a window of opportunity where help is welcomed. A mental disorder, by our definition impairs social and occupational functioning, and if someone does not eat enough then they are unable to engage in their world. As with all of our diagnoses, the lines are blurry between normal and abnormal functioning. There is a great deal of subjectivity to these diagnoses and hence there is a lot of room for discussion. Maybe one day we will have objective tests, but we are not there yet.

  3. jo said

    I’m a type 1 diabetic and have struggled with aspects of the disease for most of my life. Doctors and nurses would repeatedly ask me how they could help, what was getting in my way of better results, etc. But never once did anyone ever mention that it might help to talk to a mental health professional. My friend recommended that I see a therapist to deal with some other issues, and I did. And it’s helped so much with my diabetic struggles as well. Not sure why the docs never thought to suggest it (although I might not have responded as favorably to their suggestion anyway).

    • Hi Jo,
      Thank you so much for sharing your experience. Your situation is an ideal example of what I am trying to illustrate. The goal of my work with primary care physicians is to help them understand this mind/body connection. With this understanding, physicians would then think about offering patients psychotherapy as one way to encourage the patient to improve his/her physical health. Your story supports this notion. The fact that you might have rejected their suggestion does not mean that they should not have mentioned it. It is their job to plant the seed so that you can think about it over time. Thanks Again!

      • Jo said

        You are more than welcome. I now believe in a fairly strong mind/body connection, even though I was pretty skeptical at first. Also, I wanted to comment that the health care professionals I mentioned were caring specialists (CDE, endocronologist, opthalmologist, etc) that had earned my trust and respect, not just random doctors who hardly ever saw me. They were willing to go the extra mile for me (and did), yet still never suggested that I consider some therapy or counseling.

        Thanks so much for blogging and sharing your experiences and expertise! I truly enjoy your blog.


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