Anorexia, Murder, and Suicide What can be Learned from the Stories of Three Remarkable Patients

by Malan, David H.

• ISBN13: 9780750630030
• ISBN10: 0750630035
• Format: Paperback
• Copyright: 1997-10-15
• Publisher: Hodder Education Publishers

Summary

The implications for the management of these patients are discussed in detail and some surprising findings are presented. Included is a comprehensive review of the literature on anorexia and sexual murder, and a discussion with many clinical examples of the author's extensive experience of the handling of suicidal patients.

Table of Contents

ACKNOWLEDGEMENTS	xiv
1 INTRODUCTION: COMMON THEMES	1	(2)
PART I ANOREXIA	3	(94)
THE SUN WORSHIPPER AND THE HEALING OF SELFDESTRUCTIVENESS	3	(2)
2 INITIAL ASSESSMENT	5	(3)
Introduction	5	(1)
Initial interview	5	(3)
History of Anya's anorexic condition	6	(1)
Interpretation of one of her major conflicts	7	(1)
Her background	7	(1)
3 OVERVIEW OF ANYA'S INDIVIDUAL PSYCHOTHERAPY	8	(2)
The question of family therapy	8	(1)
Dynamic psychotherapy plus behaviour therapy	8	(1)
The course of dynamic psychotherapy	8	(1)
The position at termination	9	(1)
4 LETTERS WRITTEN DURING THERAPY	10	(4)
The first signs of improvement: a visit to Greece	10	(1)
Major improvement: the relation with Shaun	11	(2)
Disillusion still gives evidence of improvement	13	(1)
5 THE REST OF THERAPY, TERMINATION	14	(2)
6 FOLLOW-UP	16	(5)
Anya's experience of therapy	16	(1)
Two major events	17	(1)
Transactional analysis	17	(1)
Primal Therapy	17	(1)
A medical emergency	18	(1)
Her daughter, Crystal	18	(1)
`Rebirthing' sessions lead to crucial insight	18	(1)
The Indian Commune	19	(1)
The Danish Commune	19	(1)
Return to India. A long-term relationship with a man	20	(1)
The birth of another child	20	(1)
Symptoms	20	(1)
7 ANYA'S BACKGROUND AND THE ORIGIN OF HER PROBLEMS	21	(5)
Anger and her relationship with her mother	21	(1)
Her relationship with her father	22	(1)
Her sister	23	(1)
Guilt about sex	23	(1)
Guilt and sadistic feelings	24	(1)
`Some thoughts on anorexia'	24	(2)
8 PSYCHIATRIC ASPECTS OF ANOREXIA NERVOSA	26	(4)
Definition	26	(1)
The distinction from other conditions	27	(1)
Epidemiology	27	(1)
Genetic factors	27	(1)
Gender ratio and age of onset	28	(1)
Can the gender ratio be explained?	28	(1)
The influence of culture	29	(1)
`Sub-clinical' AN	29	(1)
9 A MYSTERY: THE POWER OF THE ANOREXIC STATE	30	(3)
The vicious circle of under-eating in AN	30	(2)
Anorexia as addiction	32	(1)
10 THE DEVELOPMENT OF VIEWS ON THE PSYCHOPATHOLOGY OF ANOREXIA NERVOSA	33	(2)
Traditional psychoanalytic views	33	(1)
Thoma	33	(1)
Bruch and Palazzoli	34	(1)
11 VIEWS ON THE INFLUENCE OF UPBRINGING `DEVELOPMENTAL' ISSUES	35	(5)
Feeding	36	(1)
The conflict over autonomy	37	(1)
The conversion of an interpersonal into an intrapersonal conflict	38	(2)
12 HOW WELL DOES ANYA FIT INTO THE DESCRIPTION OF ANOREXIA NERVOSA IN THE LITERATURE?	40	(2)
Anya's attitude to weight and thinness	40	(1)
The twin questions of compliance and being aware of her needs	40	(1)
The issue of control	41	(1)
13 THE PSYCHIATRIC TREATMENT OF ANOREXIA NERVOSA	42	(3)
Drug treatment	42	(1)
In-patient treatment	42	(1)
Modern in-patient treatment	42	(3)
14 PSYCHOTHERAPY OF THE INDIVIDUAL	45	(4)
Psychoanalysis: Thoma	45	(1)
Bruch (1973)	45	(2)
Bruch (1988): `Conversations with anorexics'	47	(1)
Behaviour therapy	47	(1)
Cognitive-behavioural therapy	48	(1)
15 FAMILY PATTERNS IN ANOREXIA NERVOSA	49	(4)
Crisp's case histories	49	(1)
Minuchin	50	(1)
Palazzoli	50	(1)
Research results	51	(2)
16 INVOLVING THE FAMILY IN TREATMENT	53	(5)
Bruch's views on family therapy	53	(1)
Crisp	53	(1)
Minuchin	54	(1)
Palazzoli	55	(1)
Controlled studies of family therapy	56	(2)
17 THE PROGNOSIS IN ANOREXIA NERVOSA WITH AND WITHOUT TREATMENT	58	(5)
The prognosis without treatment, or with non-specific treatment	58	(2)
Outcome with specific treatment	60	(1)
Mortality	60	(1)
Prognostic factors	61	(1)
Summary	61	(1)
The problem of the depth of changes	62	(1)
18 PATHOLOGICAL MECHANISMS IN ANYA AND COMPARISON WITH THE LITERATURE	63	(5)
The difficulty of treating anorexics	63	(1)
AN as a defence against a possible constitutional factor	64	(1)
Intensity of emotion in other anorexics	64	(1)
Hunger as a means of withdrawing from feelings, relationships, life	65	(2)
Conclusion	67	(1)
19 COMPLIANCE, AUTONOMY, CONTROL	68	(2)
20 GUILT AND OBSESSIONAL PHENOMENA	70	(4)
Guilt about anger and hostility	72	(2)
21 SELF-DESTRUCTIVENESS AND ITS ORIGINS	74	(5)
Anorexia and suicide	74	(1)
Self-destructiveness in general	75	(1)
Self-destructiveness in Anya, guilt and self-punishment, sexuality and sadism	75	(1)
Two mechanisms that give further clues to the difficulty of treating anorexics	76	(2)
Destructive rage at disappointment and a clue to resistance	77	(1)
A destructive defence against disappointment and a clue to the terror of being made to eat	77	(1)
Conclusion	78	(1)
22 THE IDENTIFICATION OF `DEEP' CHANGES	79	(3)
Withdrawal from feelings XXX normal sadness	80	(1)
Withdrawal from feelings, withdrawal from people, compulsiveness, loss of identity XXX spontaneous enjoyment, genuine identity	80	(1)
Withdrawal from life XXX spontaneous enjoyment	80	(1)
Conformity and loss of autonomy XXX genuinely owning her quite normal feelings	80	(1)
Compulsiveness XXX spontaneity	81	(1)
Compulsiveness, fear of loss of control XXX spontaneity	81	(1)
Perfectionism XXX relaxation	81	(1)
Loss of identity, inability to face aggression XXX owning her own feelings	81	(1)
23 DEEP CHANGES IN ANYA	82	(3)
Enjoyment of food	82	(1)
The re-discovery of Shaun	82	(1)
The healing of self-destructiveness	82	(3)
24 ANYA'S SYMPTOMS	85	(2)
The Sun	85	(1)
Food, weight, and the issue of hunger	85	(1)
Menstruation	86	(1)
25 ANYA'S RELATION TO MEN AND SOME RESIDUAL PROBLEMS	87	(3)
The relation to men	87	(1)
Other residual problems	88	(2)
The `anorexic potential'	88	(1)
Self, identity, adequacy	88	(2)
26 OVERVIEW OF THE ORIGIN OF ANYA'S PROBLEMS	90	(2)
Background problems before she reached puberty	90	(1)
Puberty and beyond	91	(1)
27 THE PROCESS OF THERAPY	92	(3)
Dynamic psychotherapy	92	(1)
Transference and `transference cure'	93	(1)
Anya's subsequent therapy	93	(2)
28 CONCLUSION	95	(2)
PART II `A BLUEPRINT FOR MURDER'	97	(52)
29 HUGH: INITIAL ASSESSMENT	99	(2)
Introduction	99	(1)
Initial interview	99	(1)
Projective testing	100	(1)
30 THERAPY I	101	(3)
Failure of work on the transference and the past	101	(1)
Trance-like states in the sessions	101	(3)
31 THERAPY II. INCREASED DISTURBANCE AND THE CORD OF LIFE	104	(8)
An ever-recurring emergency	104	(1)
A second opinion	105	(1)
A change in therapeutic arrangements	105	(1)
A series of crises	105	(1)
A desperate crisis	106	(1)
A visit to America and its dangers	107	(1)
A further attempt at the link with the mother	108	(1)
Further emergency arrangements	108	(1)
The `Moors Murders'	109	(1)
An act of great courage and the first sign of therapeutic effects	109	(1)
Preliminary follow-up	110	(2)
32 PRELIMINARY DISCUSSION OF THE EVIDENCE PROVIDED BY HUGH'S THERAPY	112	(3)
Expected features that were absent	112	(1)
Evidence from moments of clear insight and temporary therapeutic effects	113	(1)
Discussion of Hugh's psychopathology	113	(1)
Lasting therapeutic effects	114	(1)
33 FINAL FOLLOW-UP	115	(5)
Sexual problems	115	(1)
Further psychotheraphy	116	(1)
Drug treatment	116	(1)
Discussion of the term `compulsive'	117	(1)
Relations with adult women	118	(1)
Social life	118	(1)
Work history	118	(1)
His own children	118	(1)
His relation with his parents	118	(1)
Self-assertion	119	(1)
34 DYNAMIC MATERIAL FROM THE FOLLOW-UP	120	(7)
Therapeutic effects	120	(1)
Therapeutic factors: the `Moors' trial	120	(1)
Therapeutic factors: his colleague's 12-year-old daughter	121	(1)
Violent feelings	121	(1)
Violent feelings in the follow-up period	122	(1)
His relation with his mother and the link with adult women	123	(2)
The essence of his sexual desires and impulses	125	(1)
The meaning of some of Hugh's sexual impulses	125	(1)
Discussion	126	(1)
35 THE ROOTS OF HUGH'S DISTURBANCE	127	(4)
The early relation with his mother	127	(1)
A constitutional factor	127	(1)
Punishment by his mother	127	(1)
Arrested emotional development	128	(1)
The meaning of one aspect of his sexual needs: acceptance of his sexuality	128	(1)
The problem of aggression	128	(1)
Low self-esteem and rejection by the girls at school	128	(1)
The problem of rivalry	129	(1)
Inhibited rivalry and further arrested development	129	(1)
The problem of violence	129	(1)
The other side of the coin	129	(1)
An omission	130	(1)
36 THE EFFECTS OF THERAPY	131	(3)
Factors external to therapy	131	(1)
The relation with his wife	131	(1)
The `Moors' trial	131	(1)
The relation with Hilary	131	(1)
Factors within therapy	132	(1)
The role of trust	132	(1)
The role of fantasy	132	(1)
Factors in Hugh's personality	132	(1)
The therapeutic alliance	133	(1)
Sertraline	133	(1)
37 OVERVIEW OF THE LITERATURE ON SEXUAL MURDER	134	(3)
Classification of sexual murder	134	(1)
The importance of comparative studies	135	(2)
38 CHARACTERISTICS FOUND IN SEXUAL MURDERERS BUT MOSTLY IRRELEVANT TO HUGH	137	(2)
Alienation and isolation	137	(1)
Background	137	(2)
39 CHARACTERISTICS OF SEXUAL MURDERERS THAT ARE RELEVANT TO HUGH	139	(8)
A constitutional factor - exceptionally intense sexuality	139	(1)
The relation with the mother	139	(1)
The relation with the father	140	(1)
Punishment, often severe	141	(1)
Open masturbation and punishment for it	141	(1)
Separation as a punishment	141	(1)
Threats of castration as a punishment	141	(1)
Shyness	142	(1)
Aggression, first inhibited and then explosive	142	(1)
Problems of self-esteem and feelings of humiliation	143	(4)
40 HUGH'S STORY: CONCLUSION	147	(2)
Factors leading towards murder	147	(1)
The relevance for psychotherapists	147	(1)
Hugh's comments	148	(1)
PART III SUICIDE	149	(30)
41 MANAGEMENT OF THE SUICIDAL PATIENT IN PSYCHOTHERAPY	151	(4)
Introduction	151	(1)
The therapist's attitude to suicide	151	(1)
A sequence of interventions	152	(1)
The question of promises	153	(1)
A reaction to being rescued: the Refugee Musician	154	(1)
Another kind of promise: the Lecturer in Psychology	154	(1)
42 PATIENTS WHO DO COMMIT SUICIDE	155	(7)
Loss of hope in a `normal' person: the Woman in the Hungarian Uprising	155	(2)
Loss of hope in seriously disturbed people	157	(1)
The Man who Grew Tired of Women	157	(1)
Loss of hope in a semi-psychotic patient: the Refugee Musician (contd)	158	(1)
A patient who became manic-depressive: the Lecturer in Psychology (contd)	158	(1)
The Suicidal Receptionist	159	(3)
43 MOTIVES AND MECHANISMS IN SUICIDE	162	(8)
`External gain' or `avoidance'	162	(1)
Manipulation and revenge: the Angry Fiancee	163	(1)
Internal psychodynamics	163	(5)
Anger	163	(1)
Unexpressed anger combined with cry for help: the Woman with Summer Depression	164	(1)
Self-directed aggression when anger conflicts with love: the Man with School Phobia	165	(2)
Anger conflicting with guilt: the Daughter with a Stroke	167	(1)
Murderous feelings, self-destruction, guilt, and grief: the Woman with a Machine Gun	167	(1)
Suicide and the breakdown of ways of coping with loss: `Mrs M.'	168	(2)
44 THE FAILED STUDENT: A STUDY IN THE CONVERGENCE OF TRAUMATIC EVENTS	170	(9)
The story	170	(1)
The beginning of elucidation: the first strand, the first repetition	171	(1)
The second strand, a second repetition	172	(1)
The third strand, a third repetition	173	(1)
The fourth and fifth strands: the consequences of the breakdown of defences	173	(1)
The issue of anger	174	(1)
Discussion	174	(1)
The role of the confidant	175	(1)
The `cathartic effect' of a suicidal attempt	175	(1)
Subsequent events	176	(3)
EPILOGUE	179	(4)
45 TO OTHER PSYCHOTHERAPISTS	181	(2)
REFERENCES	183	(4)
INDEX	187