Comparisons of weight concepts in groups of neurotic, normal and anorexic females

A group of normal women and a group of women in hospital for treatment of a neurosis but without a disorder of eating were compared with a group of anorexic patients in terms of their attitudes to weight. All subjects completed a rank order form of repertory grid. Differences in construct patterning between the anorexic patients and the other female groups could not be accounted for by social class, age or neurotic disorder. The most psychologically significant finding was a positive correlation between the constructs self at normal weight and ideal weight instead of a negative correlation which clinical experience would lead one to expect. Four explanations are proposed to account for this finding.

Disturbances in body image estimation as related to other characteristics and outcome in anorexia nervosa

Body image distortion in 79 female anorexia nervosa patients were examined on a visual-size estimation apparatus during the emaciated stage of illness. Both they and an age-matched female control group overestimated their body widths, so this overestimation cannot be considered unique to anorexia nervosa. Among anorexia patients the degree of overestimation was associated with less weight gain during treatment, greater denial of illness, and several other pretreatment characteristics indicative of poor outcome.

Anorexia nervosa--two cases in discordant MZ twins

Two female monozygous twin pairs discordant for anorexia nervosa are reported, and literature reports on 18 other monozygous pairs are reviewed. Four of the reported pairs are inadequately described and there is doubt about the diagnosis. When the 2 pairs reported here are included, 16 pairs remain: l (38%) were concordant and 10 discordant. Only 3 pairs fulfilled rigorous criteria for anorexia nervosa and zygosity and one of the pairs was concordant. The population prevalence is probably about 2 promille for hospitalized cases, and there is a 6% risk for female sibs of anorectic probands. Hence, if about 1/3 of monozygotic pairs are in fact concordant, a role of genetic factors in the etiology may be suggested.

Family structure and relationships of 50 female anorexia nervosa patients

Family features of the first 50 anorexia nervosa patients referred to a psychiatrist from a defined geographic area are documented. Information about the families was obtained from personal interviews with the parents during the course of the patients' treatment. High socio-economic class, absence of non-white population, older age of parents, instability factors in the parents' backgrounds and high incidence of both physical and psychiatric illness in the parents suggest multiple factors may be aetiological. Possible pathogenic factors are equally distributed between mothers and fathers.

Body awareness in anorexia nervosa: disturbances in "body image" and "satiety"

Patients with anorexia nervosa have been shown previously to display distortions in body image perception. Bruch has postulated that these disturbances as well as disturbances in interoception are meaningfully related to the development of the syndrome. We hypothesized that disturbances in body image, as measured by a distorting photograph technique, and interoception, as measured by a satiety-aversion to sucrose test, should be demonstrable in anorexic patients vs. normal controls. Furthermore, these disturbances should be modifiable by external cues (looking at one's image in a mirror and ingesting isocaloric "high" and "low" calorie connotation meals). We also hypothesized that body image and interoceptive disturbances would be interrelated in the same individuals. Results indicated that patients with anorexia nervosa (N = 26) differed from normal controls (N = 16) in overestimating their body sizes (p = 0.06) and in failing to develop an aversion to the sucrose tastes (p less than 0.001). However, neither viewing one's image in a mirror nor ingesting both "high and "low" calorie connotation meals altered body size perception. Intrasubject body size estimates were very stable from week to week for the anorexic subjects (r = +0.75, p less than 0.001) but less for the controls (r = +0.45, p less than 0.05). The data revealed that overestimation of body size was closely related to the failure to develop an aversion to sucrose tastes in anorexic patients.

The Middlesex Hospital Questionnaire: a validity study

The MHQ is a brief self-rating inventory purporting to measure aspects of six distinct categories of psychoneurosis and affective status. It has been found to be a reliable instrument and also valid as a profile measure. Two individual scales have also previously been explored in respect of validity. The present report describes a further attempt to examine the validity of individual scales in relation to pertinent single clinical diagnostic entities in a study involving 800 patients. The phobic and obsessional scales are found to be particularly accurate and differentiating in this respect. Patients variously diagnosed as suffering from anxiety states, depressive states and personality disorder tend to score very highly on several scales. The instrument serves overall to distinguish satisfactorily between such populations and others suffering from schizophrenia and anorexia nervosa. It also markedly differentiates them from 'normal' populations.

The onset of anorexia nervosa

In a retrospective study of case notes a number of experiential and psychological factors were discerned of possible importance to the psychogenesis of anorexia nervosa. These factors included issues of dependence and independence, sexual challenge, concern about obesity, and a variety of other, less specific stresses. Attempts to confirm the findings by means of a prospective study were impeded by difficulties in defining the onset of the illness. While in some patients the occurrence of anorexic type behaviour led immediately to weight loss, in others there was a significant delay between the onset of behavioural change and consequent emaciation.

Anorexia nervosa: reflections on theory and practice

Psychodynamic theory provides a critical element in the conceptual framework necessary for a therapist's understanding of the abnormal behavior exhibited by patients with anorexia nervosa. A model of the syndrome is presented here which the author has found useful in the ongoing treatment of patients. The paper has arisen out of a desire to clarify thinking and practice in the course of treating patients manifesting the classic syndrome identified in those whose symptoms are not secondary to physical disease or psychosis.

Self-induced vomiting. Psychiatric considerations

Self-induced vomiting has been associated with the psychiatric diagnosis of anorexia nervosa and a newly proposed disorder named bulimia. Two patients with a self-induced vomiting compulsion did not fulfill criteria for either of these diagnoses. One patient had an affective disorder, and the other had no psychiatric illness, but the habit had developed as a weight control measure. Systematic studies of these symptoms are not available. Clinical diagnostic decisions should not be base on one outstanding sign or symptom, eg, self-induced vomiting, unless research clearly relates the sign or symptom to only one disorder.

Hostile interaction in a general hospital ward leading to disturbed behaviour and bulimia in anorexia nervosa: its successful management

A girl of 17 years with severe anorexia nervosa, treated on a medical ward in a teaching hospital, developed bulimia, stole food, was sometimes doubly incontinent, behaved angrily, and aroused the hostility of patients and staff. The growth of a vicious circle of hostility is described and it was hypothesized that the hostility had aggravated the bulimia. On the basis of this hypothesis the situation was clarified with the patient and staff, attitudes changed, the patient's appetite dropped within a day from about six times to one-and-a-half times the normal and her behaviour became normal. The significance of these events is briefly discussed.

Estimation of body dimensions in anorexia nervosa

The estimation of body dimensions in a group of 31 patients with anorexia nervosa and a control group of 20 psychoneurotic females has been studied with different techniques, including a visual size estimation apparatus and the marking of indicated body points on a paper attached to the wall. The results confirm the previously described tendency by patients with anorexia nervosa to overestimate body size in the stage before their treatment in hospital. Various differences between the two groups were found and the anorexic patients were more inconsistent in the estimation of the different body measures. On the basis of correlations with the results of an internal-external control questionnaire, it is suggested that overestimation and variability in visual size estimation could be promoted by an orientation towards external control.

[Dysperception of body image and dysmorphophobias in mental anorexia. Apropos of 115 cases involving both sexes. I. Altered mechanisms of perception in mental anorexia]

We noted frequency of body-image disturbance (BID) and dismorphophobias (DPP) in 97 girls and 8 boys among 107 girls and 8 boys with Anorexia Nervosa (AN), seen since 1973 and coming up semiologic criterions of Laboucarie and Dally & Sargant. 91,5% of the girls and 7 out of 8 boys presented a BID at one time of their evolution. The other ones did not form a characteristic group. BID prevailed in no-perception of emaciation. No-perception of overweight was exceptional. That of variations of weight was frequent, explaining to need objective elements to measure real volume. BID seems to result from an incapacity to integrate well individually perceived details into a coherent image. Its apparition signals starting of AN, and it is a fundamental criterion of evolutivity. It's not frequent it's extended to body-image disperception of the close people, but it is often associated to an increase of mental representation of ingested feed volume.

[Dysperception of body image and dysmorphophobias in mental anorexia. Apropos of 115 cases involving both sexes. II. Dysmorphophobias in mental anorexia]

Study of DPP extended over 2 groups selected as following: It was prospective in every patient seen between July 1976 and May 1977 (systematic study: SS: 35 girls and 2 boys). It was retrospective in another group before selected for importance of DPP (no systematic study: NSS: 34 girls and 6 boys). DPP were distributed into Dalpha (fear of any weight recovery), Dbeta (obsessing repercussion of a real defect, amplified in its perception) and Dgamma (delirious and obsessing conviction of a physical anomaly). We researched correlations with the type of AN (fixity or recession to childhood), premorbid weight-height ratio, overweight of the same-sex parent, important problems towards sexuality (ASC = Absolute sexual conflict = An entirely caused by a sexual difficulty, or PSC = Partial Sexual Conflict = difficulty towards sexuality when insuffisant to explain AN, or no sexual conflict), attitude towards pregnancy in cases of big-belly DPP. Every DPP were DPP of localized or generalized obesity. Dalpha is constant and pathognomonic. In females of SS, 37% presented Dbeta and 5% Dgamma before AN, 25% Dbeta and 11% Dgamma during AN. Among the 8 boys of the 2 studies, 3 presented Dgamma before AN, and everyone expressed their obsessing fear of "ugly grease". In 20% girls and 50% boys, explained aim of loss of weight was to "wipe out" the anomally DPP emphasized. We did not find any correlation between generalized DPP and studied elements, particularly with sexual conflicts (22% of our cases). The more frequent localized DPP was "big-belly"-DPP, always associated with overweight of the same sex parent, but as for other localized DPP, without any correlation with sexual conflicts, problems towards the father, neither reject of pregnancy.

[Dysperception of body image and dysmorphophobias in mental anorexia. Apropos of 115 cases involving both sexes. III. Physiopathogenic deductions and introduction of a novel definition of the disease]

Ignoring of emaciation (IE), fear of any weight recovery (Dalpha), and dismorphophobias (DPP) represent the central problem of AN, with different incidence. Fundamental need of being lean expresses, at lesss in girls, distress of personality insufficiently prepared to autonomous adult life, with its responsabilities. Obesity-DPP may correspond to projection upon the body of the obsessing conviction of being inferior, with regard to social and publicitary patterns, and get an active play in starting and management of weight loss. So AN is either an attempt to accomodate this critic situation, trying to incarnate actual female archetype, either, in the more severe cases, a renouncing with an obstinate physical and psychological recession to the state of a protected child. It seems to correspond to an attempt of negation of morbid character of this situation, so that it may be perpetuated and so that feeling of culpability can be decreased in front of familial recrimination. Constancy of these symptoms, and their relation with deep meaning of this illness, justify their introduction into a new definition of AN, diagnosed by association of at less 2 out of 3 major criterious (loss of weight superior to 10% premorbid weight, feed restrictions and Dalpha) and one out of 2 minor criterions (amenorrhea and IE).

Anorexia nervosa in boys

The literature on primary anorexia nervosa in the male is reviewed and the case histories of 3 new patients are reported. Most surveys comment on the rarity of the syndrome in the male, with the sex ratio in the range of 1 in 10 to 1 in 20. The patients reported here had certain features in common. All the mothers and fathers were overweight, but obesity was marked only in the fathers, who also showed moderate to severe degrees of alcoholism. The mothers were oversensitive, insecure individuals, and the marriages suffered in proportion to the severity of the husband's alcoholism. Preoccupation with food was observed on home visits. There was overt mutual hostility between each father and anorexic son; the boys showed pronounced obsessional traits in their personalities. Dieting in order to ameliorate real or feared obesity was a first step in the development of the syndrome in each boy. In the past 3 years an equal number of boys and girls (new patients) have been referred for treatment in the psychiatric unit. Speculative reasons for this are discussed.

Anorexia nervosa: recent investigations

In this paper, I have: 1. described the typological diagnosis of anorexia nervosa, 2. discussed recent hematological, lipid, electrolyte, gastrointestinal, and electrocardiographic studies in anorexia nervosa, and 3. reviewed recent endocrine investigations including thyroid, adrenal cortical, gonadotropin, growth hormone, and catecholamine studies in anorexia nervosa. Although all of the reviewed studies have contributed greatly to the formation of descriptive criteria for anorexia nervosa, they have not supported any single hypothesis concerning the etiology of anorexia nervosa. Further studies are needed to ascertain relationships between the typical anorectic behavior and the endocrine and catecholamine changes observed in this disorder.

Perceptual experiences in anorexia nervosa and obesity

There is increasing evidence suggesting that the perceptual-cognitive experiences of people with anorexia nervosa and juvenile onset obesity may differ from those of people without eating disorders. The research related to several perceptual-cognitive dimensions is critically examined. These include body image perceptions; perception of hunger and satiety cues; perception of external cues; and certain personality variables which may be related to self-perception. The implications of these perceptual-cognitive variables for the treatment of anorexia nervosa and obesity are discussed. The relative efficacy of some behavioural and medical therapies may be related, in part, to their effects on perceptual-cognitive parameters. Recommendations are also made for investigations to further delineate the role of perceptual-cognitive difficulties in people with eating problems.

Implications from an unusual case of multiple psychosomatic illness

A 40-year-old patient who developed over her lifetime an unusually large number of psychosomatic illnesses is presented. She manifested in succession, bronchial asthma, peptic ulcer, regional ileitis and anorexia nervosa. In addition to the factor of multiplicity of illnesses, this series of illnesses is of special interest because the association of a classical psychosomatic illness with anorexia nervosa has not been reported previously. In order to take advantage of the unusual series of illnesses in one patient, I utilized a novel investigative approach. Basing myself upon the supposition that the fundamental make-up of the personality remains fairly constant over time, I criss-crossed bits of established knowledge from one illness to another. In this way, I was able to derive various implications with respect to the psychodynamic, the cognitive-perceptual and the hypothalamic levels of functioning in all the illnesses.

Some aspects of the relationship between body weight and sexual behaviour with particular reference to massive obesity and anorexia nervosa

There is some evidence for the existence of a precise weight/fat threshold for puberty. Following puberty, body weight and shape take on important new psycho-social significances for both males and females. Adolescent females usually strive to reduce their 'fatness' even it is not excessive from a biological standpoint. Super-obesity and anorexia nervosa are two human disorders of weight and fatness, more common in women, and importantly related to disturbances of sexual behavior, metabolic, social and experiential. These latter aspects sometimes at least reflect the presence of several factors which have contributed to the development of the disorders. Anorexia nervosa in particular reflects the adaptive psychosocial needs of the person concerned. Attention to this aspect during treatment will often allow the patient to tolerate the major weight gain required for recovery, thereby at the same time providing a paradigm for aspects of the pubertal process which can then be studied. The results of some such investigations together with related studies of the super-obese are reported here.

Fasting girls and our attitudes to them

Images

Some psychological characteristics of patients with anorexia nervosa whose weight has been newly restored

A preliminary study has served to demonstrate that patients with primary anorexia nervosa whose weight has been newly restored to normal, and who are currently involved in individual and family psychotherapy, are significantly characterized by having very low self-esteem, by being highly sensitive to social interactions and by being 'obsessoid'. It is suggested that, in therapy, specific behavioural approaches to these problems may usefully complement other psychotherapeutic endeavours.

Prognosis in anorexia nervosa as influenced by clinical features, treatment and self-perception

The use of behaviour modification in the treatment of anorexia nervosa has been controversial and has not undergone controlled studies. An investigation of 42 patients with anorexia nervosa treated a mean of 31.7 months earlier was conducted to determine factors related to prognosis. The three areas studied were (a) clinical features, (b) treatment (behaviour modification versus medical and psychologic therapy) and (c) self-perception (with a distorting photographic technique). Clinical outcome was assessed as "excellent" in 7, "much improved" in 14, "symptomatic" in 13 and "poor" In 8. Analysis of variance showed that vomiting (P less than 0.01), bulimia (P less than 0.01), poor educational/vocational adjustment (P less than 0.01) and higher global clinical score (P less than 0.001) were associated with a poor prognosis. There were no differences at follow-up between patients treated by behaviour modification and those treated by other methods; the data suggest that behaviour modification, while not harmful, does not provide long-term benefits. Self-estimates of body size were highly predictive of outcome (P less than 0.002); all patients with a poor outcome overestimated their size. Patients with only marginal improvement might be helped by treatment directed to self-perceptual disturbances.