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Department of Psychiatry, University of Leicester, Brandon Mental Health Unit, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW
EDITED BY SIDNEY CROWN and ALAN LEE
I have an infectious diseases model — not of eating disorders — but of interest in eating disorders. Such interest is widespread but patchy. It is often clear from whom an individual contracts an interest and some develop severe conditions. I caught my interest, a really chronic and unremitting case, from Arthur Crisp and colleagues at St George's Hospital, London, nearly 30 years ago. However, others who have been similarly exposed develop little interest and, indeed, some seem to acquire an aversion and never wish to be involved with eating disorders ever again. They have a kind of immunity. These days, few psychiatrists can entirely avoid any contact with people suffering from anorexia nervosa, bulimia nervosa and the like. The generalist and the psychiatrist whose interests are quite otherwise need to know something about the eating disorders and where relevant information may be found. The eating disorders buff, severe or mild, will want to read more widely. Thirty years ago, some textbooks of psychiatry did not even mention anorexia nervosa and, of course, bulimia nervosa had yet to be defined. Now, the disorders are covered, although the coverage is often limited and unexciting. But who expects excitement? The strange predilections of my condition are showing.
The background of the eating disorders is well known. We live in times when body weight and shape are important to us. In this country, we are well nourished in terms of quantity of food — if not perhaps in quality. We are bigger than we were, but aspire to be smaller. All sorts of stories are told about why this might be the case. The psychology and sociology of this is the stuff of fascinating speculation. Brumberg's Fasting Girls: The Emergence of Anorexia Nervosa as a Modern Disease (1988) is a good place to start. Mervat Nasser's Culture and Weight Consciousness (1997) paints a picture of the issue as it is now around the world. However, there is plenty of room in the aetiology for issues other than weight consciousness as the observations of Sing Lee et al in China (1993) and Hans Hoek et al in Curaçao suggest (1998a).
The reasons for undereating are many. However, when people do restrict what they eat in the presence of a broadly intact appetite, their experiences tend to be similar. These were well documented in the classic work of Ancel Keys et al's The Biology of Human Starvation (1950). This describes the famous Minnesota experiment in which male conscientious objectors were starved down to about 75% of their former body weight, kept there for several months and then re-fed. They developed many of the food preoccupations and quirks which have become familiar as ‘symptoms’ of the eating disorders. Even after 50 years this work is worth reading, although the two-volume report is difficult to get hold of. If you ask for it from the British Library, you will find yourself on a waiting list which lasts for months. However, a substantial summary may be found in a chapter on psychoeducational principles in Garner & Garfinkel (1997).
The clinical conditions which seem to be built upon the psychosocial elaboration of this biological base have been thought about variously over the years. Evolution of Psychosomatic Concepts: Anorexia Nervosa — A Paradigm is a volume published in 1965 which is itself now of historical interest (Mount Sinai Group, 1965). However, it contains many of the key early writings from Gull, Lasegue, Janet and so on. It documents from a psychodynamic perspective a view of eating disorder just before the start of what might be called the present era (I guess that one inevitably defines that era from one's own point of view; for some, the 1970s are doubtless pre-history). However, the past two or three decades have seen an increase in salience of the eating disorders, a probable increase in prevalence and the emergence of bulimia nervosa as a recognised disorder. Gerald Russell's seminal paper in Psychological Medicine must be included as a landmark. (Russell, 1979). His delineation of bulimia nervosa heralded a couple of decades in which the whole issue of binge eating has come to be thought of as increasingly important both as a characteristic of subtypes of eating disorder and as a phenomenon in its own right. There has been much definitional anguish among the aficionados about what should be meant by a binge or by bulimia or even by bulimia nervosa. However, in this last respect the terminology seems to be settling down to more or less what Russell said in the first place. For those seeking a wide-ranging discussion of the issues around binge eating, the multi-author edited book of that title remains a good source (Fairburn & Wilson, 1993).
The journal article, together with such edited volumes, has become the mainstay of the literature in this field as in many others. Much of that literature is spread around the general journals but the leading specialist journal is the International Journal of Eating Disorders, although I like to think that the European Eating Disorders Review has an increasingly important place (beware, the preceding sentence contains prejudice and special pleading — I edit the EEDR). As for multi-author books, there has been a good crop of late. Notable among these for the clinician wanting a fairly brief introduction to some aspect of the eating disorders is Brownell & Fairburn's Eating Disorders and Obesity: A Comprehensive Handbook (Brownell & Fairburn, 1995). This is a big book organised into about 100 little chapters. Each reviews a particular issue and outlines the relevant opinion and evidence, although there are no references in the body of the text. However, each chapter is followed by a brief list of annotated references as further reading. This is useful although the lack of any citations in the text can be irritating. For a quick, ‘genning up’ on a topic within eating disorders, this is certainly the book. The similarly named Handbook of Eating Disorders: Theory, Treatment and Research is essentially a Festschrift for Gerald Russell but it is wide-ranging and contains useful reviews (Szmukler et al, 1995). A similar book is the more specifically named Neurobiology in the Treatment of Eating Disorders which, in reality, is fairly catholic in its coverage and not confined to the narrowly biological (Hoek et al, 1998b). It is up to date and has useful summary panels setting out the authors' views about the clinical implications of the findings which they present in their review chapters. Childhood Onset Anorexia Nervosa and Related Eating Disorders (Lask & Bryant-Waugh, 1993) is the book for those wanting a briefing on the issues raised by the care of children and early adolescents with eating disorders. The Handbook of Treatment for Eating Disorders (Garner & Garfinkel, 1997) is the second edition of a book which was earlier called the Handbook of Psychotherapy for Anorexia Nervosa and Bulimia. The chapters are authoritative and readable. It is edited by David Garner and Paul Garfinkel, a psychologist and a psychiatrist, respectively. Their Anorexia Nervosa: A Multidimensional Perspective published in 1982 was notable in its time. Indeed, in the 1980s, it was the book for someone wanting a solid introduction to the subject but unfortunately it has never been revised. The multiple-author volumes have taken over.
There have been few monographs or distillations of the experience and work of one clinician. A notable exception is Arthur Crisp's Anorexia Nervosa: Let Me Be (Crisp, 1980). The significance of the strange title emerges only after studying the text. To a degree, such a book bridges the gap between an older tradition of clinical writing which allowed itself to be rich and discursive and the more modern tome bedecked with graphs and tables. Arguably, clinicians need both if they are to be able to appraise evidence and have a feel for the meaningful experience of their patients. The more clearly psychodynamic writings, such as those of Hilde Bruch, retain their value (Bruch, 1973, 1978, 1988). However, some seem at times to be cantering off into a world of their own without reference to other ways of thinking. It may be uncomfortable to ride the twin horses of rigour and richness, of general scepticism and particular enthusiasm, but the clinician has to try to do so.
Undoubtedly, both Bruch and Crisp are read by sufferers, their families and that fabled creature the ‘intelligent general reader’. Their needs have been addressed directly by many books over the past couple of decades. Like its author, my own little book on anorexia nervosa is now showing its age (Palmer, 1980). There are now many alternatives (Palmer, 1996; Treasure, 1997) including, for the parents of the youngest sufferers, Eating Disorders: A Parent's Guide by Rachel Bryant-Waugh and Bryan Lask (1999). These books give information and, perhaps through information, support and solace. Others aim also explicitly to help sufferers to move towards recovery. Such ‘bibliotherapy’ has burgeoned over the past few years and evidence is accruing that self-help books used alone or with some additional guidance can have measurable benefits particularly in bulimia nervosa that is not too severe (Fairburn & Carter, 1997). The following books have some claim to be useful in this way — Getting Better Bit(e) by Bit(e): A Survival Kit for Sufferers of Bulimia Nervosa and Binge Eating (Schmidt & Treasure, 1993), Bulimia Nervosa: A Guide to Recovery (Cooper, 1995) and Overcoming Binge Eating (Fairburn, 1995). The hard-pressed generalist without ready access to specialist services might to well to read and to use one of these books as a major part of his or her response to demand for treatment for bulimic disorders. Bit(e) by Bit(e) now comes with a clinicians' guide (Treasure & Schmidt, 1996).
Then there are the books written for sufferers by sufferers. These are a mixed bag. I possess, but cannot recommend, a volume written entirely in rhyming couplets which I found as indigestible as those papers with lots of multivariate analyses but no ‘stories’. The clinician can gain from reading one or two of these. A good example is Sheila Macleod's The Art of Starvation (1981) which is personal, thoughtful and scholarly. Macleod avoids the temptation to use a punning title but many other authors succumb. I once spent a happy hour or so when I should have been doing something else thinking up further titles for such books. There were lots but the only one that I can remember is ‘Thinly Disguised’. I think that it is quite good. But then I would, wouldn't I? I guess that the whole exercise was strange and symptomatic. However, it must be remembered that I am a rather sad and severe case. My interest in eating disorders is now chronic and almost certainly irrecoverable. It may also be infectious. I wonder if you can catch it through reading? Don't say I didn't warn you.
REFERENCES
Brownell, K. D. & Fairburn, C. G. (eds) (1995) Eating Disorders and Obesity: A Comprehensive Handbook. New York: Guilford Press.
Bruch, H. (1973) Eating Disorders: Obesity, Anorexia Nervosa and the Person Within. Basic Books: New York.
Bruch, H. (1978) The Golden Cage: The Enigma of Anorexia Nervosa. Cambridge, MA: Harvard University Press.
Bruch, H. (1988) Conversations with Anorexics. New York: Basic Books.
Brumberg, J. J. (1988) Fasting Girls: The Emergence of Anorexia Nervosa as a Modern Disease. Cambridge, MA: Harvard University Press.
Bryant-Waugh, R. & Lask, B. (1999) Eating Disorders: A Parent's Guide. Harmondsworth: Penguin Books.
Cooper, P. J. (1995) Bulimia Nervosa and Binge Eating, A Guide to Recovery (revised). London: Robinson.
Crisp, A. H. (1980) Anorexia Nervosa: Let Me Be. London: Academic Press.
Fairburn, C. G. (1995) Overcoming Binge Eating. New York: Guilford Press.
Fairburn, C. G. & Wilson, G. T. (eds) (1993) Binge Eating: Nature, Assessment and Treatment. New York: Guilford Press.
Fairburn, C. G. & Carter, J. C. (1997) Self-help and guided self-help for binge eating problems. In Handbook of Treatments for the Eating Disorders (2nd edn) (eds D. M. Garner & P. E. Garfinkel). New York: Guilford Press.
Garner, D. M. & Garfinkel, P. E. (1982) Anorexia Nervosa: A Multidimensional Perspective. New York: Brunner/Mazel.
Garner, D. M. & Garfinkel, P. E. (1997) Handbook of Treatments for the Eating Disorders (2nd edn). New York: Guilford Press.
Hoek, H. W., van Harten, P. N., van Hoeken, D., et al
(1998a) Lack of relation between culture and
anorexia nervosa — results of an incidence study on
Curaçao. New England Journal of
Medicine, 338,
1231-1232.
Hoek, H. W., Treasure, J. L. & Katzmann, M. A. (eds) (1998b) Neurobiology in the Treatment of Eating Disorders. Chichester: John Wiley & Sons.
Keys, A., Brozek, J., Henschel, A., et al (1950) The Biology of Human Starvation. Minneapolis, MN: University of Minnesota Press.
Lask, B. & Bryant-Waugh, R. (eds) (1993) Childhood Onset Anorexia Nervosa and Related Eating Disorders. Hove: Psychology Press.
Lee, S., Ho., T. P. & Hsu, L. K. G. (1993) Fat phobic and non-fat phobic anorexia nervosa — a comparative study of 70 Chinese patients in Hong Kong. Psychological Medicine, 23, 999-1017.[Medline]
Macleod, S. (1981) The Art of Starvation. London: Virago.
Mount Sinai Group (1965) Evolution of Psychosomatic Concepts — Anorexia Nervosa: A Paradigm. The International Psycho-Analytic Library No. 65. London: Hogarth Press.
Nasser, M. (1997) Culture and Weight Consciousness. New York: Routledge.
Palmer. R. L. (1980) Anorexia Nervosa: A Guide for Sufferers and their Families. Harmondsworth: Penguin.
Palmer. R. L. (1996) Understanding Eating Disorders. London: Family Doctor Publications.
Russell, G. F. M. (1979) Bulimia nervosa: an ominous variant of anorexia nervosa. Psychological Medicine, 9, 429-448.[Medline]
Schmidt, U. & Treasure, J. (1993) Getting Better Bit(e) by Bit(e): A Survival Kit for Sufferers of Bulimia Nervosa and Binge Eating. London: Lawrence Erlbaum.
Szmukler, G., Dare, C. & Treasure, J. (eds) (1995) Handbook of Eating Disorders: Theory, Treatment and Research. Chichester: John Wiley & Sons.
Treasure, J. (1997) Anorexia Nervosa: A Survival Guide for Families, Friends and Sufferers. Hove: Psychology Press.
Treasure, J. & Schmidt, U. (1996) Clinician's Guide to Getting Better Bit(e) by Bit(e). Hove: Psychology Press.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
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