Clinical diagnostic criteria for primary anorexia nervosa: An analysis of 54 consecutive admissions

Clinical data on 54 consecutive patients presenting with primary anorexia nervosa were analysed under three main headings--demographic and family composition, patient personality and attitudes, and quality of family interaction. Eleven characteristic features were determined. It is suggested that a definitive diagnosis of anorexia nervosa can be made on purely clinical grounds, and without recourse to expensive and time-consuming investigations, if these features are considered. These features are also valuable in predicting whether a stringently dieting girl is in the early stages of anorexia nervosa or is merely conforming to the current adolescent fad for thinness.

Body image disturbance in anorexia nervosa during the acute and recuperative phase

Perception of body size, subjective experience of body image distortions and differentiation of body concept in the human figure drawing were assessed in adolescent anorexia nervosa patients and controls shortly after hospital admission, and again 6 months later during the recuperative phase. Size estimation was not found to be a distinguishing variable, as both groups exhibited overestimation tendencies of comparable magnitude at both time periods. By contrast, experiences denoting estrangement from the body, insensitivity to body sensations, and weakness of body boundaries were more prevalent in anorexics, and persisted at high levels after frank symptoms of weight and eating disorder had subsided. Anorexics were also shown to depict the human figure with less differentiation relative to controls. Within the anorexic sample the presence of vomiting was linked to greater subjective experience of body image distortion, and such phenomena appear to be a more enduring feature in this subgroup. Overall, the results were viewed as lending support to the argument that defects in body image formation render the anorexic vulnerable to their manifest pathology, which is itself activated by maturational conflicts unique to adolescence.

The stability of perceptual disturbances in anorexia nervosa

Patients with anorexia nervosa have previously been shown to display disturbances in visual self-perception and interoception. In the present investigation we wished to determine the stability of these disturbances and the effects of weight gain on them. We studied 29 females, 16 patients with primary anorexia nervosa and 13 controls, who had also been studied one year previously. Each subject took part in investigations of body image, using a distorting photograph technique, and interoception, using a satiety aversion to sucrose test. We found that some anorexic subjects tend to overestimate body size and have an absence of aversion to repeated sucrose tastes. Moreover, these disturbances were stable over the year and were not affected by weight change.

Anorexia nervosa and mental retardation: a case report

This is the first published report of a retarded individual developing anorexia nervosa. The authors discuss the interaction between subnormal intelligence and the presentation of anorexic symptomatology. They also discuss the relationship between this disorder and depression. Anorexia nervosa may not be uncommon in retarded adolescents but may go undiagnosed because of the belief that mentally retarded individuals do not develop this disorder.

Unique features associated with age of onset of anorexia nervosa

The relationship between age of onset of anorexia nervosa and a variety of personal characteristics was examined in 105 patients. Age of onset of anorexia nervosa had a bimodal distribution, with peaks at 14 1/2 and 18 years. The patients whose onset of illness occurred at the later age tended to have a greater weight loss during their illness, more "underweight problems" before the onset of illness, less of the typical anorectic behaviors and attitudes, greater body disparagement, more symptoms of depression, and a greater number of previous hospitalizations. These associations suggest that an older age of onset of anorexia nervosa might predict a poor outcome.

Anorexia nervosa in males

Five cases of anorexia nervosa in males aged 13--23 years are described. Four patients presented to a general medical outpatient clinic with emaciation, and the fifth was diagnosed retrospectively. Sinus bradycardia was a useful pointer to the diagnosis, which was confirmed by the finding of characteristic psychopathological features of a relentless "pursuit of thinness", along with a fear of becoming obese.

Bulimia nervosa: an ominous variant of anorexia nervosa

Thirty patients were selected for a prospective study according to two criteria: (i) an irresistible urge to overeat (bulimia nervosa), followed by self-induced vomiting or purging; (ii) a morbid fear of becoming fat. The majority of the patients had a previous history of true or cryptic anorexia nervosa. Self-induced vomiting and purging are secondary devices used by the patients to counteract the effects of overeating and prevent a gain in weight. These devices are dangerous for they are habit-forming and lead to potassium loss and other physical complications. In common with true anorexia nervosa, the patients were determined to keep their weight below a self-imposed threshold. Its level was set below the patient's healthy weight, defined as the weight reached before the onset of the eating disorder. In contrast with true anorexia nervosa, the patients tended to be heavier, more active sexually, and more likely to menstruate regularly and remain fertile. Depressive symptoms were often severe and distressing and led to a high risk of suicide. A theoretical model is described to emphasize the interdependence of the various symptoms and the role of self-perpetuating mechanisms in the maintenance of the disorder. The main aims of treatment are (i) to interrupt the vicious circle of overeating and self-induced vomiting (or purging), (ii) to persuade the patients to accept a higher weight. Prognosis appears less favourable than in uncomplicated anorexia nervosa.

Personality, body weight and ultimate outcome in anorexia nervosa

The Eysenck Personality Inventory, a highly standardized self-rating questionnaire, allows 2 measures of psychosocial functioning on independent scales entitled "emotionally" and "extroversion/introversion." A population of severely ill, low body weight anorectics revealed a high degree of "introversion" and variable amounts of "emotionality" on these measures. Low amounts of "emotionality" were associated with abnormally high "lie" scores. Following restoration of body weight to full matched population mean levels within an intensive treatment program, significant changes occurred on these measures--increased extroversion scores, decreased emotionality and lie scores. However, possibly qualitative changes had occurred in the state of emotionality since high levels were now related to good clinical outcome many years later. The nature of this phenomenon is discussed.

[Reciprocity of intrapsychic and interpersonal processes in anorexia nervosa: observations and interpretations from the therapy of the family]

This article uses sections of transcribed tape-recordings of family interviews to elucidate the pubescent anorexia nervosa of a 14 year-old girl within the context of her family interactions. The reciprocal action of intrapsychic disturbance and interpersonal processes within the family, as well as the feedback machanisms involved in both systems are discussed. Analogous to the neurotic aspect of the anorexia itself, the neurotic family dealings with the puberty crisis are shown, which are dedicated to the repression of drive-desires, turn against, a restructuring of family equilibrium necessitated by the life cycles of various family members, resulting in a power struggle for symmetrical positions within the family. Analogous to the internal ego disorder found in anorexia, the permanent struggle to differentiate ego functions and integrate bodily experience and thereby achieve indentity as a separate, autonomous subject is described. The struggle for autonomy is made more difficult by family norms which do not allow for the expression of personal desires, needs and interests. Thoughts on the development of anorexia nervosa relevant to the family situation described in our example follow the phenomenological presentation. The disturbance in self-object differentiation arises from the early mother-child relationship, and is viewed as the result of the mother's disturbed relationship to primary maternal preoccupation. A symbiotic-antagonistic relationship between mother and child is perpetuated by means of mystifying, binding strategies. The family keeps the traditional roles of victim an savior ready to overcome psychosocial crises. Finally, the casuitry explains anorexia as a form of confrontation within a family context, which is moulded by the norms of village social structure.

Body image and perfectionism of ballerinas: comparison and contrast with anorexia nervosa

The authors studied a group of young ballerinas through responses to a questionnaire and intensive interviews. The young women described a life characterized by complete dedication in which academics, social life, and pleasures were sacrificed and a program of intensive exercise and practice became their main activity. They tended to feel overweight in spite of being thin and continued to diet or to employ other means to become even thinner. Two heuristic conclusions were reached: (a) the goal of thinness was in part a flight from conflicts about adult sexuality that arose at puberty; and (b) repetitive practice was engaged in for its own sake, not for career advancement, in an attempt to lose themselves in a transcendental quest for perfection. A comparison was made between this group and girls of the same age with anorexia nervosa. Several similarities but many more differences were found. Findings are based on a very small sample and must be interpreted cautiously, but directions for further studies are implied.

[Anorexia nervosa - a familial socialization deficit]

This study is based on the hypothesis that there is a connexion between the condition of Anorexia nervosa and factors of family socialization. The empirical examination of this assumption was carried out using the hospital records of 51 female patients treated for Anorexia nervosa in the Psychiatric University Hospital Göttingen from the period of 1967 to 1973. The family structure was investigated under the following context: 1) family constellation, 2) socioeconomic factors, 3) interactional patterns. At first sight these families have a normally disturbuted family constellation, a stable and accepted social status together with traditional social values. However, disturbed parental and matrimonial relationships in fluence the family attitudes in such a way as to enhance these behavior patterns associated with high performance and pseudo-solidarity. This complex family structure effects the anorexic patients such that--in an interactional view--an inbalance of ego identity arises and a adolescence crisis occurs.

Psychosocial dynamics in anorexia nervosa

Anorexia nervosa represents a self-destructive struggle for separate identity, and cultural factors play a part in the present increasing incidence. This paper presents a broad view, which embraces family dynamics and the natural history of the disease, to clarify important issues in its management and prevention. Both family and individual psychotherapy may have a place in the patient's personal rehabilitation.

The dietary chaos syndrome: a useful new term?

Following typical primary anorexia nervosa some subjects enter a state characterized by disordered eating behaviour and emotional instability whilst remaining at or above a normal weight. Other subjects may reach a similar position without having been in a state of anorexia nervosa. Surprisingly the state seems to lack a satisfactory name. The term 'Dietary chaos syndrome' is proposed.

The Eating Attitudes Test: an index of the symptoms of anorexia nervosa

Data on the development of a 40-item measure of the symptoms in anorexia nervosa are reported. The scale (EAT) is presented in a 6-point, forced choice, self-report format which is easily administered and scored. The EAT was validated using 2 groups of female anorexia nervosa patients (N = 32 and 33) and female control subjects (N = 34 and 59). Total EAT score was significantly correlated with criterion group membership (r = 0.87, P less than 0.001), suggesting a high level of concurrent validity. There was very little overlap in the frequency distributions of the 2 groups and only 7% of the normal controls scored as high as the lowest anorexic patient. Female obese and male subjects also scored significantly lower on the EAT than anorexics. Recovered anorexic patients scored in the normal range on the test, suggesting that the EAT is sensitive to clinical remission.

Anorexia nervosa in a male: comment and illustration

Attention is drawn to the possible diagnosis of anorexia nervosa in young males with weight loss. The symptoms and signs are described, along with the setting in which the condition may develop. These points are illustrated by reference to a recently treated case. The poor prognosis of anorexia nervosa in males is emphasised.

Anorexia nervosa: death from complications of ruptured gastric ulcer

Death from the complications of a ruptured gastric ulcer in a 15 year old girl with anorexia nervosa is reported. A Medlars II search of the literature indicates no previously reported deaths from this cause in anorexia nervosa. This patient presented the classical clinical characteristics of the syndrome and the course of her illness serves to re-emphasize the seriousness of the disease and the importance of early management of anorexia nervosa.

Outcome of anorexia nervosa

100 females with anorexia nervosa were followed up 4-8 years after first presentation. All but 12 had had refeeding and/or psychotherapy. 48 had a good outcome (weight at least near normal, regular menstruation, largely satisfactory mental state and psychosexual and psychosocial adjustments) but outcome was intermediate in 30, and poor in 20 patients. 2 had died. Poor outcome could be positively associated with clinical data such as longer duration of illness, older age of onset and presentation, lower weight during illness and at presentation, presence of symptoms such as bulimia, vomiting, and anxiety when eating with others, poor childhood social adjustment, and poor parental relationships.

Psychotherapy of the medically ill

The author assesses the current status of psychotherapy with medically ill patients. He reviews the special problems of psychological treatment for this population; the respective rationales for the utilization of various psychotherapeutic approaches including psychoanalysis, dynamic psychotherapy, and family and group therapy; and the results of case reports and research studies. The author identifies specific areas of future investigation and research, elucidates some specific implications for clinical practice, and recommends more critical exploration of the role of psychotherapy in the treatment of the medically ill.