II CASE REPORT

ANNE E. BERNSTEIN, M.D.

GLORIA M. WARNER, M.D.

Onset of anorexia nervosaafter prolonged useof the Milwaukee braceThe authors treated three patients for whom artificialdistortion of body image was the trigger ' ! in the devel­opment of anorexia nervosa. All three had had theexperience of having to wear a bulky Milwaukee bracefor an extended period of time, one because of a brokenback and the other two for the correction of scoliosis.The brace, worn underneath the clothes, altered bodyimage and deprived the patients of the feeling ofcontrol over their activities and appearance.

Case 1A 15-year-old girl, 64 in tall and weighing 85 lb, felt de­pressed and hopeless about her perceived obesity, haddifficulty in sleeping, was failing academically after previ­ously receiving academic honors, and was becoming so­cially isolated. She had been amenorrheic for four months.

Eleven months prior to psychiatric evaluation, a Milwau­kee brace, extending from chin to hip, had been prescribedfor scoliosis. While it was being made, the patient wore aBoston brace beneath her clothing. She felt fat and gro­tesque and began a stringent diet. When the Milwaukeebrace arrived several weeks later, it was too large, and forthe first time her family noticed a significant weight loss.

She initially picked at her food, then refused to eat withher family, and was referred by the family pediatricianbecause of weight loss and severe anemia. After the diag-

Dr. Bernstein is associate clinical prOfessor ofpsychiatry andDr. Warner is assistant clinical prOfessor ofpsychiatry. both atthe Columhia University College of Physicians and Surgeons.Reprint requests to Dr. Bernstein. 1160 Greacen Pt. Rd.,Mamaroneck. NY 10543.

NOVEMBER 1983 • VOL 24 • NO t I

nostic interview, during which she expressed depressedfeelings about her "overweight," loss of friends, and aca­demic failure, she refused further therapy. Under the pros­pect of hospitalization, she agreed to bring her weight up to90 Ib, as advised by the pediatrician. She also agreed to takeamitriptyline, 50 mg at bedtime, for the sleep disorder andthen an additional dose of amitriptyline, 25 mg bid. Thesleep disturbance improved.

The mother was a small, trim gymnast. Caught in a powerstruggle with the daughter, she agreed to be seen concern­ing the problems of the illness. The mother was educated toignore the daughter'S diet, social isolation, and academicprogress as long as the girl took medication and attained aminimal medically safe weight.

After six weeks, the patient began to seek her mother'shelp. She asked if she might temporarily give up the Mil­waukee brace, to which the orthopedist agreed. She alsoasked her mother's help in establishing a normal diet. Withinanother three months, the girl's weight had risen to 112 lb.She was improving in school work, eating with her family,and resuming relationships with friends The amitriptylinewas tapered and discontinued over the next four weeks.

At the five-month follow-up, menses had returned. Thepatient was functioning, cheerful, and optimistic. Herparents considered that she had returned to her normalstate of health. The scoliosis was stable and required nofurther treatment.

She now understood that her friends had been frightenedby the extreme weight loss, even while her perception wasthat she had been grossly obese. She had confused herstate of "fatness" with her image of herself in a brace. Shehad felt unable to control the use of the brace, regarded asforced on her against her will. Her concerns about controlturned to food intake, her mother, and treatment.

1033

Case report

c... 2A 23-year-old woman reported herself as "vegetating" ather mother's summer home. She was 62 in tall and weighed80 lb. She was amenorrheic, and described herself aslethargic, unable to work, no longer attracted to men, andwith undesired early awakening.

The first attempt at stringent dieting was at age 15 whenshe was discovered to have scoliosis and had to wear aMilwaukee brace. She felt grotesque and obese. The pres­ent severe anorectic episode was precipitated in conjunc­tion with her father's having to undergo spinal surgery for atumor. His first surgery occurred after she no longer re­quired the Milwaukee brace, but she identified with a parentwho she anticipated would become paraplegic and ca­chectic, and die.

She felt it her duty to return home from a distant statewhere she had been working to participate in caring for herfather. Her mother, who also worked to support the family,was impatient with the father's complaints, and had longsince absented herself as much as possible from the home.

At a psychiatric evaluation, the patient was clinicallydepressed but refused medication. She agreed with therecommendation of an internist to whom she was referred tobring her weight to 90 lb. She was treated in psychoanalyt­ically oriented therapy for almost a year. Psychotherapywas directed toward helping her to resume her own life,which she felt too gUilty to do. During that time she ventedher rage at the scoliosis and the "grotesque brace," andalso at her father's illness. She gradually began to feel lessdisturbed about the father's illness, continuing as a func­tional problem, and more understanding of her mother'sfrustration.

After several months of treatment, she began to feelstronger, found a job and her own apartment, and began toplan for the future. She remained amenorrheic.

Case 3A 21-year-old married graduate student had been placed onhigh doses of antidepressants by a previous therapist be­cause of complaints of depression. She was then and still isboyish, yet wore loose clothing to hide what she perceivedwas her fat body. She was amenorrheic and avoided sexualrelations.

Her first psychiatric diHiculty occurred in the form ofdepression at age 14 when she had to wear a Milwaukeebrace for one year following a swimming pool accident. Shefelt fat and "disgusting" and began to diet stringently. Shethought herself unable to buy attractive clothing. At herparents' insistence, she married someone who had pursued

1034

her and whom they perceived to be a good caretaker.The patient was gradually withdrawn from medication and

began a classic psychoanalysis. Her mother, who alwaysinfantilized her, had doted on her even more after theaccident. During the analysis the daughter lost her anorexiaand. concern about body image until she injured her backagain. She then became obsessed anew about her "fat"body, believed that she had no control over her life, andonce more became depressed. Subsequent to further anal­ysis, she was able to join an exercise program and becamesuccessful at work. Eventually she was able to leave herunhappy marriage.

DiscussionThe three patients presented are similar in that theirsymptoms followed required wearing of the bulky Mil­waukee brace under their clothing. An ego deficit inself-representation was a feature common to all. Thisdeficit allowed the brace to be incorporated as part ofthe patient's own body image. They each failed toappreciate that weight loss would not change the bulkyshape of the brace.

Since these three women in various ways were subjectto concerns about control, they each attempted tocontrol their own bodies by decreasing their intake offood.

All three had problems with their mothers, problemsfrom which they might have broken free had it not beenfor the regressive dependence necessitated by wearingthe brace. This is clear in Case 1, in which the girl was sofearful of control and of separation from her motherthat she refused to see the therapist. In Case 2, anoverwhelming identification with the sick father wasmade worse by the mother's absence from the family. InCase 3, the anorexia was less severe and did notrepresent a medical emergency. This patient was able tobenefit from psychoanalytic treatment that changed herdefenses regarding control and separation and individ­uation from her mother. In times of stress she stillregressed to fears about her body image.

These three cases illustrate that the road to develop­ment of anorexia nervosa may start with distortion ofbody image as a primary etiologic factor. 0

REFERENCES1. Bruch H: The Golden Cage. London. Open Books. 1978.2 Sours J: Slarvmg 10 Dealh in a Sea of Objects. The Anorexia Nervosa

Syndrome. New York. Aronson, 1980.

PSYCHOSOMATICS