Anorexias and bulimias (A clinical contribution)

Photo above: Mar del Plata, Argentina

Anorexias and bulimias (A clinical contribution) [1] 

How should we understand the so-called “Eating Disorders”? Are they “new” pathologies, a cultural phenomenon of a certain era, or a different capsule of an “old” symptom? Following longstanding debate and evidence, it is certain that post-Freudianism was rarely, if at all, called upon by such “disorders” [2].  A new field of clinical endeavour demonstrates the ineluctable division of the subject.  Is it also able to articulate any new questions? Can it respond to these by discovering hitherto unknown answers?


I. Eating disorders – or institutional disorders?

The increasing appearance of Anorexia and Bulimia Teams in hospitals, through the alibi of “good intentions”, provides a new identity, a false signifier that is in keeping with the times, to cover up and hide the in-existence of The Woman. The fact that these Teams are now commonplace makes this no less true. Thus, Karl Kraus’s razor-sharp sentence becomes true once again.[3]

In the Hospital I work in there are (at least) two or three of these Teams (!). Two of them belong to the Psychopathology Department (isolated one from another, like the whole Department). Quite independently there exists another Team that relates to the inpatient wards.

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The three focus on the symptom. The first intervention, immediately upon beginning an interview with the family of a supposed anorexic, is to enquire, to suggest and to bear upon the tracked “eating disorders” – after all, pursuit goes after these.  A dietician from the Team is immediately ready to indicate all the guidelines for appropriate ingestion, for adequate, suitable and desired – ideal – habits.

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The members of the Team start to feel anxiety and become restless if the patient does not eat. One of them asks me whether or not a medication can be administered so that she eats. If the negative response does not satisfy her, I may be branded as ignorant: she is positively certain that something like that must exist.

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They withdraw as soon as they have recommended a referral to a psychiatric Institution –indeed, there is nothing better than a referral to appease stirred consciences. Alone in an interview with me, the patient is able to say that, naturally, she likes to eat, especially pasta, which she longs for, more than anything else… if it weren’t for the vomiting that grips her whenever she attempts to do so. Her childish appearance belies her forty-one years of age. The mother speaks continuously (whilst the father remains silent, unnoticed, or whispers to me, sotto voce, trying to involve me in the complicity of an aside). She knows the most insignificant minutiae of everything that enters or leaves her daughter’s body. The exhibition of her knowledge, the details regarding her daughter’s diet or her menstruation, never cease. The anecdotes go up to the point of manipulation, in so far as they include the account of the extraction of faeces from the rectum of her constipated daughter: there is no intimacy. And the realisation of her child as an appendage of her own body impresses by its perfection without the slightest trace of anguish. If it weren’t for that vomiting!

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Of the many doctors and specialists who were brought to her, one made the mistake of prescribing her corticosteroids. In the midst of a serene and mechanical regularity of clockwork, these pills had the undesirable effect of setting off the eating and menstrual disaster. Years later, a reputed acupuncturist whom they consulted, had reversed the unfavourable situation and effected the opposite miracle: making her vomiting stop for two years. When they met him the mother had suggested that the cause was to be found in her daughter’s neck, and she was pleasantly surprised when the needles were placed in that very site. An indescribable relief overcame her when the professional explained to her that it was all nerves.

Her daughter is a spinster? Luckily, the mother quickly replied, because many marriages use to be so wretched… Besides (she whispers in my ear) she is frigid, no doubt: nothing whatsoever on the sexual side! – she quickly adds.

She didn’t want to have her until she was able to give up her work (each member of the couple is at least seventy-seven years old) since she knows parents who haven’t fully dedicated themselves to their children, something she loathes. Her daughter does nothing but read the newspapers that she accumulates (from time to time, her mother throws some out in order to avoid an excess) or magazines that she asks to borrow from the corner kiosk, the only place in the world to which she manages to go alone. Primary school was difficult, and she gave up during first grade.

Here I made an intervention that, in the moment of articulating it, seemed something savage, even brutal. I asked if they had thought of what would happen with her when they were no longer there.

The place that the institution lends me in this moment transforms this otherwise obvious enunciation into an act of immediate effects. Now the father is able to show something of his anguish: he admits having no answer to my question – he doesn’t know.[4] His discomfort is quickly quashed by the mother, the certainty of whose perennial and immortal well being never shows any weaknesses. In any case, she has put everything in place so that her daughter shall never lack anything.

But in this moment the daughter appears – however fleetingly and in a limited way –  disposed to argue back. When her mother reproaches her for not even being capable of making herself a cup of tea, she points out to her mother: what happens is that you do everything first. The patient’s mention of her dog phobia, so marked that at times she has run the risk of not crossing the street (after seeing an animal in front of her), allows us to suppose that something of the interval between the signifiers has been preserved, notwithstanding the ubiquitous atmosphere of holophrases.

Based on the hypothesis that the acupuncturist’s action had been efficacious since he was able to act from a “third place”, I suggest that they return to consult with him. In any case I propose that they may return to see me following discharge from hospital. Otherwise – adds the mother, with an uncanny smile –  she will have to be admitted to a neuropsychiatry unit, won’t she?

Once the discharge had been noted in the Clinical History, I tell them that they may now leave. The mother immediately requests that her daughter should be able to stay for another twenty minutes (it was midday) so she can eat

II. Intermezzo

One of the psychologists of the Anorexia and Bulimia Team recounts the success of the Course run by this group in one of the Hospital’s auditoriums. A great number of people attend the classes: the place is filled up, she says.

Similarly  – she continues – her private practice is going along splendidly, as it her consulting room is full.

This abundant insistence of the signifier draws our attention.

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III.

A thirty-five year old woman is admitted, weighing 35 kilograms. The clinicians decide to insert a naso-gastric tube (besides the drip). She has not eaten for two days.

When she turned eighteen the mother celebrated her birthday by cooking meat with oil. Her food problem started at that time. She is dying of hunger but there is always one of her internal organs (either the stomach, the liver, or the intestine) that rejects whatever she ingests. The members of the Eating Disorder Team mention that she personifies her organs (“he”). They suspect a psychotic structure.

She is moved to tears when she mentions her father who was so good. Of this inexpressible goodness she only mentions that he never stopped giving little gifts to the three women of the house (the mother, her older sister, herself) on special days – birthdays, wedding anniversary – every month (and not just once a year). The treatment with the Eating Disorders Team had been a success that vanished following the death of the father, one year ago, of lung cancer. It was a miracle: he was never seen never feeling the least bit of pain.

The mother exhibits an eternal smile and her few comments tend to become lost.

Upon entering her room, the patient is not visible. She is hidden behind a dreadful, ominous folding screen. She requested this in order to be able to eat in peace (it is reminiscent of the dinner scene in Buñuel’s The Phantom of Liberty [5]).

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Buñuel: Le Fantôme de la Liberté

At home, for the same reason, she has to have the food brought to her by her mother at the time of the family meal. In hospital, the kitchen staff brings the usual trays for the patients, taking them away after a predetermined amount of time. Nevertheless, this woman – always smiling despite her skeletal appearance –  is surrounded by food all day long. She explains that in this way she can study what – and how much – she eats, or not.

She begs them not to give her iron injections. She was given an injection, which had catastrophic effects on her. She checked what it contained: needless to say, it was iron.

Her relation with the Eating Disorders Team, and with the ward, has become prickly.

Members of the Team demand antipsychotic medication, whilst they also require her transfer to a psychiatric institution. The clinicians, on their side, request her discharge, since they see no reason for her to remain in bed. They say that the dietician has given a strange order: to keep the nasogastric tube in place but to put nothing through it [6]. But it’s not just a question of someone with clinical parameters only: there’s something more, something else.

A truce is declared.

She got out of the bath complaining insistently that her hair had been washed with cold water. A doctor helped her to get back to her bed. She remained standing in front of the bed, complaining that she was made to lie down all day long, when what she wanted to do was to walk around.

At home, at night, she was frightened by pains in her feet. She walked around all night, and at times, she added, all morning, wearing herself out (thus losing weight). The pains – she says – are beyond tears. She recounts that her father used to walk all day in his job of checking water mains in the street. He had bunions.

He had a parallel activity, which he carried out in brief spurts as a distraction from his public service job (he always fought hard, right up until the end). For her he is far from being dead; rather, he is always by her side. For this reason she has no interest in visiting his grave at the cemetery.

Of the many dreams she had of him, only one was unpleasant, terrible even. He appeared to her and she grabbed his index finger. But there is a price to be paid for holding onto a phallic appendix: he immediately declared that she, now, would have to purge herself. It made her cry.

Before recounting another dream she hesitated, asking me about my religion. As it was a Christian dream, she had confessed it to a priest. An angel appeared in the dream and declared to her: now you will have to suffer.

To what extremes does she have to go in this effort to give consistency to the Father?

Once again the Eating Disorders Team meets with the ward staff for a diagnostic and therapeutic-planning discussion.  They insist on the diagnosis of psychosis, which would require a referral elsewhere, since they did not have the necessary facilities for her to be contained. They demand from the psychiatrist – once again – an antipsychotic medication: they have reached their limit. Beyond this, there should and must be a medication that can help them in this predicament. As there are no positive or negative symptoms, they request a therapeutic trial with neuroleptics. If she returned home, she could die, or need to be readmitted…

They do not want – they finally say – to expose themselves to a failure.

What else does the anorexic do, if not to attempt to go beyond the limit? What else does the hysteric do, if not to make the Master fail?

The nurse recounts that it is quite something – impressive, as it is – to see the patient when she makes her have a bath that she usually refuses, because of her emaciated appearance. She caught her with her nasogastric tube turned off: she is certainly doing that on purpose. She can’t put up with her on the ward and is impatiently waiting for her to be discharged, since the ward is not a charity institution and the bed turnover has to be quick: besides – she pronounces – not to eat is a stupid weakness.

The nurse is obese.

The patient tells me a dream that – she says –  is extraordinary. The family has a female friend whom they call auntie, whose mother is about to turn 100 (another cinematographic association…[7]).  In the dream auntie tells her that her mother is sick. Upon waking she suspects that the quasi-centenarian has died, but this is not the case.

Travelling in a bus that passes nearby a cemetery, she smells the odour of a wreath of flowers, but she cannot see any funeral procession.

A few days later she has another dream: she finds herself with her own mother and with her sister in a particular place in the cemetery. The auntie appears.

Eleven days prior to the hundredth birthday, the nonagenarian dies. The patient attends the burial, which takes place in precisely the same spot as in the dream. She is stupefied.

During the funeral, a priest that her father admired – Father Saul, from the parish that she attends – recognises her and takes her arm.

A few days later the priest dies, two days prior to turning seventy. She is dumbfounded.

   This absence of symbolisation of death involves the necessity of the representation of the dead person… The essential thing for them is not to live. Dead at the same time as their parents, the order for them is: “- Enjoy not enjoying. Under no circumstances reach out to life”… They request one crumb less in exchange for a little more desire … thus getting closer and closer to death (Raimbault, 1982).

IV. Autophagia

An obese and diabetic patient (who is 53 years old) emphatically affirms that she is dying for a sandwich. She must be taken literally: she is on the verge of losing a foot.

The day of a party she had to tolerate seeing nougat and cakes pass in front of her, and into the hands of her family members, without even tasting them. But you ate everything the day before and the day after, her sister accuses. Certain that she was not being paid attention on the ward, she asserted to her voluminous son that the staff had abandoned her. He then hit the head nurse. She now maintains that she had not wanted to provoke any aggressive behaviour.

From the place of her imaginary, she extols the transgression and safeguards it: You – she says to me -, who are thin, will never understand fat people.

She alternates her feeding orgies with periods of forced anorexia in which, for several days, she eats no food at all. She scratches herself to the extent that she produces deep grazes on her abdomen, and then eats the material resulting from these. She whimpers as she recalls the amputations that were needed on both of her, now deceased, father’s gangrenous legs: uras [8] were swarming in them. Now it’s her turn and she already imagines them advancing on her foot. No therapeutic group, psychiatrist, no psychotherapy, has made the slightest dent in her.

At the risk of reducing a singular historical recourse to a technical procedure, I put into practice the “manoeuvre of Margaret Little” [9]: I told her I could do little for someone who, in her unshakeable well-being, wants no help of any kind, in so far as her lamentations are a mere and inconsistent façade.

To my surprise, such brutality only serves to produce greater euphoria in her. Two days later the clinical doctor told me that she had thanked her for putting her in contact with me, whilst asking her why she wasn’t being administered insulin anymore. You don’t need it – the doctor explained to her – your blood glucose is 1.2, a sign that for the moment she is not effecting any more transgressions.

In a previous essay [10] we attempted to situate the deterioration of the Symbolic reference in the marks that are printed in a singular history, as well as that of the times in which this history is immersed. In a book on such manifestations, there is a notice that this “forgotten aspect”, lies hidden as a consequence of putting forward and condemning, in an incarnated and hackneyed way, the supposedly enjoying-mother-who-leaves-no-place-for-desire. Indeed, such a figure is perhaps an effect, rather than cause, of such a deficiency (Fendrik, 1997). This, of course, does not prevent an identification with such an Imaginary “mother-figure”, another manifestation of the Superego correlative to jouissance [11].

A question remains as to whether the interventions I have described in these brief clinical sketches – whose objective might retrospectively take shape from their apparently abrupt nature – are capable of establishing possible, and more fluid, dialectics of subjectivity.

Translated by the author and Michael Plastow

___________

Notes

 

[1] These clinical images illustrate Liaison-psychoanalysis at a PublicHospital, a practice of “psychoanalysis in extension”, which usually has strict space and time limits. Case histories occupy the foreground, while theoretical considerations are kept to a minimum (as the supporting background can be found in the References).

2 There is, for example, a brief mention of this in Soifer, R. (1983). The Kleinian clinical observations are not devoid of interest, but the designation “constitutional” together with the hypostasis of the concept of the death drive, block the access to the signifying structure that determines them. Nearer to us, the impact of novelty and the pressing concern regarding technical matters are clearly perceptible in the tone of the reunion that Maud Mannoni had with Oscar Masotta’s initial Lacanian study group (Masotta, 1973) in so far as the latter proposes, as theme for discussion, the prototypical case of “anorexia” of Sidonie  – see Mannoni, M. (1970)

N. B. : Italics always indicate citations (patients’ verbatim statements, or lines taken from articles, books, etc.)

3 “Psychoanalysis is the disease it endeavours to cure”.

4 Once again, as an aside, he tells me that he was so worried about his daughter that he could not sleep. He asked me for my opinion “as a professional”.

5 Buñuel, L. Le Fantôme dela Liberté, script by Buñuel and Jean-Claude Carrière, 1974, with Michel Piccoli, Monica Vitti, François Maistre, Adriana Asti, Paul Frankeur. The alluded scene presents a table apparently set for dinner, but the seats are toilets and the guests lower their clothes to sit down. A boy tells her mother Mom, I’m hungry to which she hastily replies You’re not supposed to say those words at the table. A guest stands up, whispers a question to the waiter and receives his indications pointing at the end of the corridor: once there, he attempts to open a door, but a voice protests: Occupied. He waits until the person inside opens the door and leaves, and locks himself up to eat his dinner unseen.

6 There was a kernel of truth to the myth. A radiological test has to show that the nasogastric tube is located in the indicated site before any food can be passed through it.

7 Saura, C., Mamá cumple 100 años (Mother has her 100-anniversary birthday party), 1979.

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8 (an unusual word in Spanish)Wormsthat grow in wounds.

9 See Little, M. (1987). Lacan comments the case of Margaret Little’s patient “Frieda” in his Seminar on Anxiety (1962-3). A very brief summary might show that the patient had undergone analysis during 6 years with no positive results, whilst the analyst, following the book rather than the analysand’s discourse, interpreted  the “paranoid transference” first, then the “depressive transference” – until her resources were exhausted; thus, no choice was left for her but to tell “Frieda” how sorry she felt about her. The patient began to progress unrelentingly. Lacan places the beginning of transference at that point, rather than in the previous, imaginary sequences.

10 (Self-reference – deleted for submission)

11 See Ménard, A. (1985). Such an identification can be clearly noted in the agents of the institution as representatives of a hegemony, as will have been seen in the first of our clinical examples.

 

References

Fendrik, S. (1997), Santa Anorexia (Holy Anorexia), Corregidor,Buenos Aires, pp. 129-130.

Lacan, J. (2004), Le Séminaire, Livre VII, L’angoisse (1962-3), Seuil, Paris

Little, M. (1987), ” ‘R’ – la réponse totale de l’analyste aux besoins de son patient ” (1956), Le Contre-transfert, Navarin, Paris, pp. 48-76.

Mannoni, M. (1970), Le psychiatre, son “fou” et la psychanalyse (The psychiatrist, his “insane” and psychoanalysis), Seuil, Paris, pp. 130-161.

Masotta, O. (1973), “Reunión con Maud y Octave Mannoni del 4 de abril de 1972”(Reunion of April 4th, 1972 with Maud and Octave Mannoni), Cuadernos Sigmund Freud, No. 2/3, Buenos Aires, pp. 97-103.

Ménard, A. (1985), “L’anorexique entre désir et jouissance”(The Anorexic between desire and jouissance), Ornicar? No. 32, Navarin, Paris, pp. 152-158.

Raimbault, G. (1982), Clinique du Réel (Clinics of the Real), Seuil, Paris, pp. 138-139.

Soifer, R. (1983), Psiquiatría infantil operativa (Operative Child Psychiatry), Volume II, Psicopatología (Psychopathology), Kargieman, Buenos Aires, pp. 141-143.


[1] These clinical images illustrate Liaison-psychoanalysis at aPublicHospital, a practice of “psychoanalysis in extension”, which usually has strict space and time limits. Case histories occupy the foreground, while theoretical considerations are kept to a minimum (as the supporting background can be found in the References).

[2] There is, for example, a brief mention of this in Soifer, R. (1983). The Kleinian clinical observations are not devoid of interest, but the designation “constitutional” together with the hypostasis of the concept of the death drive, block the access to the signifying structure that determines them. Nearer to us, the impact of novelty and the pressing concern regarding technical matters are clearly perceptible in the tone of the reunion that Maud Mannoni had with Oscar Masotta’s initial Lacanian study group (Masotta, 1973) in so far as the latter proposes, as theme for discussion, the prototypical case of “anorexia” of Sidonie  – see Mannoni, M. (1970)

N. B. : Italics always indicate citations (patients’ verbatim statements, or lines taken from articles, books, etc.)

[3] “Psychoanalysis is the same disease that it endeavours to cure”.

[4] Once again, as an aside, he tells me that he was so worried about his daughter that he could not sleep. He asked me for my opinion “as a professional”.

[5] Buñuel, L. Le Fantôme dela Liberté, script by Buñuel and Jean-Claude Carrière, 1974, with Michel Piccoli, Monica Vitti, François Maistre, Adriana Asti, Paul Frankeur. The alluded scene presents a table apparently set for dinner, but the seats are toilets and the guests lower their clothes to sit down. A boy tells her mother Mom, I’m hungry to which she hastily replies You’re not supposed to say those words at the table. A guest stands up, whispers a question to the waiter and receives his indications pointing at the end of the corridor: once there, he attempts to open a door, but a voice protests: Occupied. He waits until the person inside opens the door and leaves, and locks himself up to eat his dinner unseen.

[6] There was a kernel of truth to the myth. A radiological test has to show that the nasogastric tube is located in the indicated site before any food can be passed through it.

[7] Saura, C., Mamá cumple 100 años (Mother has her 100-anniversary birthday party), 1979.

[8]Worms that grow in wounds.

[9] See Little, M. (1987). Lacan comments the case of Margaret Little’s patient “Frieda” in his Seminar on Anxiety (1962-3). A very brief summary might show that the patient had undergone analysis during 6 years with no positive results, whilst the analyst, following the book rather than the analysand’s discourse, interpreted  the “paranoid transference” first, then the “depressive transference” – until her resources were exhausted; thus, no choice was left for her but to tell “Frieda” how sorry she felt about her. The patient began to progress unrelentingly. Lacan places the beginning of transference at that point, rather than in the previous, imaginary sequences.

[10] Neuburger, R. P., Contra la disolución. In Psicoanálisis y el Hospital, No. 23, Buenos Aires, June 2003, pp. 85-88

[11] See Ménard, A. (1985). Such an identification can be clearly noted in the agents of the institution as representatives of a hegemony, as will have been seen in the first of our clinical examples.

Spanish version: (versión en castellano)

Anorexias y bulimias (y feudos institucionales)

Nuevas” patologías, fenómeno de cultura de una época, diferente cápsula del síntoma: tras la discusión y la evidencia de una respetable antigüedad, cierto es que el post-freudismo no fue convocado, casi, por estos “desórdenes1. Si era necesario un enfoque que pusiera en evidencia la ineludible división del sujeto frente a la necesidad; una nueva clínica ¿descubre otros elementos de articulación, y respuestas inéditas para hacerles frente?

I. ¿Trastornos de la alimentación, o de la institución?

No por haberse vuelto un lugar común es menos cierto: la aparición de los Equipos de Anorexia y Bulimia en los hospitales, a través de la coartada de las “buenas intenciones“, proporciona una nueva identidad, un significante postizo y acorde con los tiempos, a la in-existencia de La Mujer. Se realiza así la sentencia de Karl Kraus. 2

En algún Hospital de la Villa – multiplicación de los feudos – hay (por lo menos) dos. Uno dentro del Servicio de Psicopatología (aislado, como todo el Servicio) y otro independiente, con relación con las Salas de Internación. Se centra en el síntoma. La primera intervención, inmediatamente luego de empezar una entrevista familiar de una supuesta anoréxica, inquiere, sugiere o pretende incidir sobre los acechados “trastornos de la alimentación“. Una nutricionista del Equipo se halla pronta para indicar líneas directrices de la ingesta apropiada, de los hábitos adecuados, convenientes.

Los miembros del Equipo se angustian si la paciente “no come”. Una de ellas pregunta – oh, pesado fardo del certificado de Especialista en Psiquiatría – si no puede administrársele una medicación “para que coma”. Si la respuesta no la satisface, el renuente es tildado de ignorante: ella está segura (de que sí), y los psiquiatras que habitualmente trabajan con ella en el medio privado no la defraudan.

Se retiran luego de indicar la derivación a una Institución Especializada – como se habrá apreciado varias veces hasta ahora, y podrá comprobarse otras tantas más adelante, nada hay que tranquilice más a las conciencias. Luego, la paciente puede decir que, desde luego, le gustaría comer, “especialmente pastas”, que le apetecen sobre todo, si no fuera por los vómitos que se apoderan de ella si lo intenta. Su aspecto aniñado desmiente sus cuarenta y un años. La madre habla de continuo (en tanto el padre se mantiene en silencio, inadvertido, o habla al costado, “sotto voce”, cuando tiene alguien cerca, involucrándolo en la complicidad de un aparte). Ella conoce hasta la minucia insignificante todo lo que ingresa o sale del cuerpo de su hija. La exhibición de su saber, los detalles concernientes a la alimentación o la menstruación, no cesan jamás. Lo anecdótico no se detiene ante la manipulación, por lo que incluye el relato de la extracción de escíbalos del recto de su hija constipada. No hay intimidad, y la realización de su criatura en tanto apéndice corporal propio impresiona por su perfección sin angustia. “¡Si no fuera por esos vómitos!”

De tantos médicos y especialistas a los que la llevaron, uno tuvo la torpeza de indicarle “corticoides” (¿habían sido corticoides?), que trajeron consigo, en medio de su tranquila y  maquinal regularidad de relojería, el desastre alimenticio y menstrual. Años después, un acupunturista de buena fama – a quien consultaban, no sin éxito, distintos desahuciados – había conseguido el milagro inverso: hacer cesar los vómitos por dos años. Al encontrarlo, la madre le había sugerido que la causa se hallaba “en la nuca” de su hija, y se sorprendió gratamente cuando las agujas fueron colocadas en ese mismo sitio. Un alivio indescriptible la recorrió cuando el profesional le explicó que “todo era nervioso”.

¿Su hija es soltera? “Por suerte, porque hay cada matrimonio desgraciado...” replica velozmente la madre. “Además (me cuchichea al oído) seguramente es frígida”. De “lo sexual”, nada.

No la quiso tener hasta el momento en que pudo renunciar a su trabajo (cada miembro de esta pareja ha superado los setenta y siete), pues conoce padres que “no se han dedicado de lleno a sus hijos”, cosa que aborrece. Su hija no hace otra cosa que leer los diarios que acumula (de tanto en tanto, su madre elimina algunos para evitar el exceso) o revistas que pide en préstamo al quiosquero de la esquina, único lugar del mundo al que llega sola. La primaria fue “difícil”, y abandonó primer año.

Aquí llevo a cabo una intervención que, al momento de pronunciar, me parece algo salvaje, hasta brutal. Pregunto si han pensado qué sucederá con ella cuando ellos no estén. El lugar que la institución me presta en ese momento transforma lo obvio del enunciado en un acto de efectos inmediatos.

El padre es capaz, ahora, de mostrar algo de su angustia, como incógnita: no tiene respuesta a mi pregunta, no sabe. 3  Rápidamente su incomodidad es aplastada por la madre, a quien no abandona la certeza de su perenne e inmortal bienestar. Ha dispuesto todo para que jamás le falte nada a su hija, en cualquier caso.

Pero su hija aparece en este momento con la fugaz, aunque limitada, disposición a retrucarle. Cuando su madre le reprocha que no sabe “ni hacerse un té”, ella le señala: “lo que pasa es que vos hacés todo antes”. La mención, por parte de la paciente, de su fobia a los perros, tan desarrollada que a veces ha corrido peligro en la calle por no cruzarla (al ver un animal enfrente), permite suponer que algo del intervalo significante se ha conservado dentro de una ubicua atmósfera holofrásica.

Suponiendo (tal vez equivocadamente) que el acupunturista pudo tener una acción eficaz operando desde un lugar tercero, les indico volver a consultarlo. De todos modos, les propongo volver a verme tras el egreso. “Y si no – agrega la madre, con una sonrisa que no permite decidir si se trata de una “broma” – habrá que internarla en un neuropsiquiátrico, ¿verdad?”

Luego de asentar el alta en la Historia Clínica les digo que pueden retirarse. La madre solicita de inmediato que su hija pueda permanecer veinte minutos más (era el mediodía) “para que pueda comer…”

II. Intermezzo

Una de las psicólogas del Equipo de Anorexia y Bulimia relata el éxito del Curso que da dicha agrupación, en un Hospital. Acude una gran cantidad de gente: el aula – afirma – “se llena”.

Asimismo – continúa – le va de maravillas en su consultorio, que está “lleno”.

Llama la atención, desde luego, la pletórica insistencia significante.

III.

Se interna una mujer de 35 años, pesando 35 Kg. Los clínicos deciden ponerle una sonda naso-gástrica (además de la venoclisis). Hace dos días que “no come”.

A los 18 años la madre festejó su cumpleaños cocinando “carne con aceite”. Desde allí comenzó su problema con la comida. Se muere de hambre pero alguno de sus órganos internos (el estómago, el hígado, el intestino) rechazan lo que ingiere. Los miembros del equipo de Trastornos de Alimentación mencionan que personifica sus órganos (“él”). Sospechan una “estructura psicótica”.

Ella se enternece al mencionar a su padre, “tan bueno”. De dicha inenarrable bondad sólo menciona que no dejaba de hacer pequeños regalos a las tres mujeres de la casa (la madre, su hermana mayor, ella) en las fechas significativas (cumpleaños, aniversario de casamiento) todos los meses (y no solamente una vez por año). El tratamiento con el Equipo de TA había sido un éxito que se desvaneció tras el fallecimiento del padre, hace un año, de cáncer de pulmón. Fue un milagro divino: jamás sintió el menor dolor.

La madre exhibe una eterna sonrisa y sus pocos comentarios se pierden.

Al entrar en la habitación de la paciente, no es posible verla. Se halla oculta tras un ominoso biombo. Lo ha pedido “para poder comer tranquila” (hace recordar la escena de los comensales en “El Fantasma de la Libertad”, de Buñuel). En su casa, por la misma razón, la madre debe llevarle la comida luego del almuerzo común. En el hospital, empleados de cocina distribuyen las bandejas habituales para los pacientes, retirándolas luego de un lapso establecido. En cambio, esta mujer que sonríe pese a su aspecto esquelético, se halla rodeada de comida a toda hora. Explica que de ese modo pueden “estudiar qué – y cuánto – come y qué no”.

Rogó que no le inyectaran hierro. Le dieron una inyección que le trajo efectos catastróficos. Averiguó qué contenía: era hierro.

La relación con el Equipo de TA, y con la sala, se vuelve espinosa.

Miembros del primero reclaman una “medicación antipsicótica” transformadora, a la vez que exigen su traslado a una institución psiquiátrica. El personal de la sala, el egreso, al hallarse compensada en lo clínico. Se dice que la nutricionista ha dado una indicación extraña: mantener la sonda NG, pero no hacer pasar nada a través de ella 4.

Una médica clínica del Equipo TA explica a algunos médicos de la sala que no se trata de un organismo con parámetros clínicos solamente. Hay algo más, “otra cosa”.

Se obtiene una tregua.

Salió del baño quejándose con insistencia que le habían lavado el pelo con agua fría. Una médica la ayudó a trasladarse hasta su cama. Permaneció de pie frente a la misma, quejándose de que la obligaran a estar acostada todo el día, cuando ella quería caminar.

De noche, en su casa, la sobresaltaban los dolores en los pies. Caminaba toda la noche, y a veces agregaba toda la mañana, extenuándose (y bajando de peso). Los dolores -dice – se hallan “más allá de las lágrimas”.

Relató que su padre caminaba todo el día, revisando bocas de distribuidores en la vereda. Tenía “juanetes”.

Como tenía una actividad paralela, distraía momentos de su función pública para insertar breves incursiones en aquélla. Siempre luchaba, hasta el final.

Asegura que para ella no murió, sino que se halla siempre presente a su lado. Por eso no le interesa visitar su tumba.

De los numerosos sueños que tuvo con él, sólo uno fue desagradable, hasta terrible. Se le aparecía y ella se aferraba a su dedo índice. Pero apoderarse de un apéndice fálico tiene su precio: él sentenciaba de inmediato que ella, ahora, tenía que purgar. La hizo llorar.

Antes de contar otro sueño titubeó, interrogando acerca de mi religión. Como se trataba de un sueño cristiano, se lo había confesado a un sacerdote. En el sueño había aparecido un ángel que le decretaba: “ahora vas a tener que sufrir”.

¿A qué extremos puede llegar el esfuerzo de dar consistencia al Padre?

Nuevamente se reúne al Equipo de TA con el personal de la sala para una discusión diagnóstica y propedéutica. Insisten en el diagnóstico de “psicosis”, que exigiría su derivación, al no contar con la estructura necesaria para “su contención”. Exigen del psiquiatra – nuevamente – una medicación antipsicótica: han llegado “al límite”. Más allá de éste, debe haber un medicamento que los ayude. Si no hay síntomas positivos ni negativos, solicitan una “prueba terapéutica” con neurolépticos. De volver a su casa, podría morir, o requerir una nueva internación.

No están dispuestos – dicen finalmente – a exponerse a un fracaso.

¿Qué otra cosa hace la anoréxica, sino intentar ir más allá del límite? ¿Qué otra cosa la histérica, sino llevar al Amo al fracaso?

La enfermera relata que es impresionante ver a la paciente cuando la obliga a ser bañada – habitualmente se niega a hacerlo – por su aspecto emaciado. La ha sorprendido con la SNG cerrada: seguramente lo ha hecho adrede. No la tolera en la sala y aguarda con impaciencia su egreso, ya que la sala “no es lugar de beneficencia”, y el giro/cama debe ser rápido: además – sentencia – no comer es “una debilidad estúpida”.

La enfermera es obesa.

Me cuenta un sueño que califica de “extraordinario”. La familia tiene una amiga a la que llama “tía”, cuya madre se halla próxima a cumplir los cien años (otra asociación fílmica…). En el sueño la “tía” le comunica que su madre está enferma. Al despertar supone que la casi centenaria ha muerto, pero no es así.

Viajando en un colectivo que pasa cerca de un cementerio siente aroma a corona de flores, pero no distingue ningún cortejo.

Días después tiene otro sueño: se halla con su propia madre y con su hermana en un lugar determinado del cementerio. Aparece la “tía“.

Once días antes del centésimo cumpleaños, la nonagenaria muere. La paciente concurre al entierro, que tiene lugar en el preciso sitio en que se desarrollaba el sueño. Queda estupefacta.

Durante la ceremonia fúnebre, un sacerdote a quien su padre admiraba – el “cura Saulo”, de la parroquia a la que concurría – la reconoce, y la toma del brazo.

A los pocos días el cura muere, dos días antes de cumplir setenta años. Queda pasmada.

Esa ausencia de simbolización de la muerte implica la necesidad de la representación del muerto… Lo esencial para ellos es no vivir. Muertos al mismo tiempo que sus padres, el mandato para ellos es: “Goza de no gozar. No toques para nada la vida”… Piden una migaja menos por un poco de deseo más… acercándose cada vez más a la muerte”  5

IV. Autofagia

Una paciente obesa y diabética (de 53 años) asegura con énfasis que se “muere por un sándwich de miga”. Hay que tomarlo a la letra: se halla a punto de perder un pie.

Un día de fiesta tuvo que soportar ver pasar frente a sí, hacia las manos (y bocas) de sus familiares, turrones y masas, sin probarlos. “Pero te comiste de todo el día antes y después”, denuncia su hermana. Segura de que no le prestaban atención en la sala, aseguró a su voluminoso hijo que el personal de la misma la había abandonado. Éste golpeó a la enfermera jefe. Ella sostiene, ahora, que no había querido provocar ninguna conducta agresiva.

Desde su imaginario enaltece, resguarda la trasgresión: “Ud., que es flaco, jamás comprenderá a los gordos”.

Alterna sus orgías alimentarias con períodos de forzada anorexia en los que, por varios días, no ingiere alimento alguno, en tanto se provoca en su abdomen excoriaciones profundas por rascado, comiéndose el material resultante de las mismas. Lloriquea al recordar la necesaria amputación de las dos piernas gangrenosas de su padre, ya muerto: pululaban en ellas “las uras”. 6 Ahora es su turno, y las anticipa avanzando sobre su pie. Grupos, psiquiatras, psicoterapias, no le han hecho mella alguna.

A riesgo de rebajar en procedimiento técnico un recurso histórico singular, pongo en práctica la “maniobra de Margaret Little”: le digo que poco puedo hacer por alguien que no desea ayuda de ninguna especie en su bienestar inconmovible, en tanto su llanto es mera fachada inconsistente.

Para mi sorpresa, es sólo mayor euforia la que tal brutalidad le provoca.

Dos días después la médica clínica me cuenta que le ha agradecido haberla puesto en contacto conmigo, a la par que le ha preguntado por qué no se le administra más insulina. “No la necesita – le explicó la médica – su glucemia es 120″, señal de que por el momento no está haciendo trasgresiones.

En un ensayo anterior 7 intentábamos situar el deterioro de la referencia simbólica, en las huellas que imprime en la historia singular, así como la de la época en la que ésta se halla inmersa. Algún escrito acerca de estas manifestaciones ha señalado dicho “olvido”, tras la encarnizada y ya  rutinaria promoción condenatoria de una madre-gozante-que-no-da-lugar-al-deseo, acaso efecto, antes que causa, de tal carencia. 8 Lo que, por cierto, no impide la identificación con la misma, manifestación del superyó correlativa al goce 9.

Resta, como interrogante si las intervenciones – de cuyo carácter aparentemente abrupto puede perfilarse el objetivo en retrospectiva – son capaces de establecer una posible dialéctica de la subjetividad.

__________

* Psicoanalista, Hospital General de Agudos “Dr. I. Pirovano”

1 Por ejemplo, hay una mención somera en Soifer, Raquel, Psiquiatría infantil operativa, Tomo II, Psicopatología, Kargieman, Buenos Aires, 1983, pp.141-143. Las observaciones clínicas no carecen de interés, pero la asignación “constitucionalista”, de la mano de la hipostasis del concepto de pulsión de muerte, bloquean el acceso a la estructura significante que las determina.

En efecto, el impacto de la novedad y la inquietud acuciante acerca del recurso técnico son claramente perceptibles en el registro de la reunión que tuvo Maud Mannoni con el grupo de Oscar Massotta el 4 de abril de 1972 (Cuadernos Sigmund Freud No. 2/3, Buenos Aires, 1973, pp. 97-103) en la que éste propone, como eje de la discusión, el prototípico caso de “anorexia” de Sidonie (Mannoni, M, Le psychiatre, son “fou” et la psychanalyse, Seuil, Paris, 1970, pp. 130-161)

 2El psicoanálisis es la misma enfermedad que pretende curar”

3 Nuevamente en un aparte, me dijo que se hallaba tan preocupado por su hija, que no podía dormir. Me pedía mi opinión “como profesional”.

4 Había un núcleo efectivo en el mito. Un control radiológico debe probar que la SNG se encuentra en el sitio indicado antes de pasar el alimento por ella.

5 Raimbault, Ginette, Clinique du Réel, Seuil, Paris, 1982 (“El psicoanálisis y  las fronteras de la medicina”, Ariel, Barcelona, 1985, pp. 138-9)

6 Gusano que se cría en las heridas.

7 Contra la disolución. En Psicoanálisis y el Hospital, No. 23, Buenos Aires, Junio 2003, pp. 85-88

8 Fendrik, Silvia, Santa anorexia, Corregidor, Buenos Aires, 1997, pp. 129-130

9 Ménard, Agustín, L’ anorexique entre désir et jouissance, Ornicar ?, No. 32, Navarin, Paris, 1985, pp. 152-158. Dicha identificación es claramente notable en los agentes de la institución como representantes de una hegemonía, como se habrá visto en el primero de nuestros ejemplos clínicos.


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