Handbook of Eating Disorders - part 1 pdf

Ulrike Schmidt, Maudsley Hospital, Denmark Hill, London, SE5 8AZ, United Kingdom Dr Ulrike Schmidt is a Consultant Psychiatrist in the Eating Disorders Unit at theMaudsley Hospital and S

Handbook of Eating Disorders

Second Edition

Handbook of Eating Disorders Edited by J Treasure, U Schmidt and E van Furth.

Handbook of Eating Disorders

Maudsley Hospital, London, UK

Eric van Furth

Robert-Fleury Stichting, Leidschendam, The Netherlands

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Library of Congress Cataloging-in-Publication Data

Handbook of eating disorders / edited by Janet Treasure, Ulrike Schmidt,

Eric van Furth.—2nd ed.

p cm.

Includes index.

ISBN 0-471-49768-1 (Paper : alk paper)

1 Eating disorders I Treasure, Janet II Schmidt, Ulrike III Furth, Eric van.

RC552.E18 H36 2003

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

ISBN 0-471-49768-1

Typeset in 10/12pt Times by TechBooks, New Delhi, India

Printed and bound in Great Britain by Antony Rowe Ltd, Chippenham, Wiltshire

This book is printed on acid-free paper responsibly manufactured from sustainable forestry

in which at least two trees are planted for each one used for paper production.

To Machteld, and our children, Annick, Wytze and Bram

E.v.F

Bob Palmer

Daphne van Hoeken, Jacob Seidell and Hans

Wijbrand Hoek

Chapter 3 Genetic Aetiology of Eating Disorders and Obesity 35

Elizabeth Winchester and David Collier

Frances Connan and Sarah Stanley

Martina de Zwaan

Anne Ward and Simon Gowers

Roz Shafran and Padmal de Silva

Chapter 8 Sociocultural Theories of Eating Disorders:

Mervat Nasser and Melanie Katzman

Lucy Serpell and Nicholas Troop

Stephen Zipfel, Bernd L¨owe and Wolfgang Herzog

Chapter 11 Family, Burden of Care and Social Consequences 191

Søren Nielsen and N´uria Bar´a-Carril

viii CONTENTS

Janet Treasure and Ulrike Schmidt

Janet Treasure and Beatrice Bauer

Glenn Waller and Helen Kennerley

Denise Wilfley, Rick Stein and Robinson Welch

Bob Palmer and Helen Birchall

Claire Tanner and Frances Connan

Ivan Eisler, Daniel le Grange and Eia Asen

Tijs Bruna and Jaap Fogteloo

Lorna Richards

Paul Robinson

Anthony Winston and Peter Webster

Manfred Fichter and Heidelinde Krenn

Jorunn Sundgot-Borgen, Finn Sk˚arderud and Sheelagh Rodgers

Stephen Herpertz and Søren Nielsen

Dasha Nicholls and Rachel Bryant-Waugh

Runi Børresen and Jan H Rosenvinge

Greta Noordenbos

About the Editors

Janet Treasure, Department of Psychiatry, 5th Floor, Thomas Guy House, Guys Hospital,

London, SEI 9RT, United Kingdom

Professor Treasure is a psychiatrist who has specialised in the treatment of eating disordersfor over 20 years She trained with Professor Gerald Russell at the Maudsley Hospital andthe Institute of Psychiatry The clinic provides treatment for a population of 2 million

in south-east London and is a national referral centre The unit is active in research anddevelopment

Ulrike Schmidt, Maudsley Hospital, Denmark Hill, London, SE5 8AZ, United Kingdom

Dr Ulrike Schmidt is a Consultant Psychiatrist in the Eating Disorders Unit at theMaudsley Hospital and Senior Lecturer at the Institute of Psychiatry Her research interestsinclude all aspects of eating disorders, but in particular brief psychological and self-helptreatments She has co-authored two self-help books and accompanying clinicians’ guides

Eric van Furth, Robert-Fleury Stichting, National Centre for Eating Disorders, PO Box

2260, AK Leidschendam, The Netherlands

Dr Eric van Furth is a psychologist-psychotherapist in the National Centre for EatingDisorders at the Robert-Fleury Stichting (Robert-Fleury Foundation), a general psychiatrichospital in Leidschendam, The Netherlands He is Honorary Lecturer at the Department ofPsychiatry of Leiden University and Honorary Senior Research Fellow at the Department

of Psychiatry at St George’s Hospital Medical School, London (UK)

Eia Asen, Marlborough Family Service, London, UK

N ´uria Bar´a-Carril, Eating Disorders Unit, Institute of Psychiatry, De Crespigny Park,

London SE5 8AF, UK

Beatrice Bauer, Universit`a Luigi Bocconi, Via Bocconi 8, 20135 Milan, Italy

Helen Birchall, University of Leicester, Brandon Mental Health Unit, Leicester General

Hospital, Gwendolen Road, Leicester LE5 4PW, UK

Runi Børresen, Department of Psychology, University of Tromsø, ˚Asg˚ardveien 9, N-9037

Tromsø, Norway

Tijs Bruna, National Centre for Eating Disorders, Robert-Fleury Stichting, PO Box 422,

2260 AK Leidschendam, The Netherlands

Rachel Bryant-Waugh, Department of Psychological Medicine, Great Ormond Street

Hospital, Great Ormond St, London WC1N 3JH, UK

David Collier, Eating Disorders Unit, Institute of Psychiatry, De Crespigny Park, London

SE5 8AF, UK

Frances Connan, Vincent Square Eating Disorders Clinic, Osbert Street, London SW1P

2QU, UK

Padmal de Silva, Eating Disorders Unit, Institute of Psychiatry, De Crespigny Park,

London SE5 8AF, UK

Martina de Zwaan, Department of General Psychiatry, Wahringer Gurtel 18–20, 1090

Wien, Austria

Ivan Eisler, Adolescent Eating Disorder Service, Maudsley Hospital and Psychotherapy

Section, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK

Manfred Fichter, Department of Psychiatry, University of Munich and Klinik Roseneck,

AM Roseneck 6, D-83209 Prien am Hiemsee, Germany

Jaap Fogteloo, Department of General Internal Medicine, Leiden University Medical

Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands

Simon Gowers, Professor of Adolescent Psychiatry, Pine Lodge Adolescent Unit, 79

Liverpool Road, Chester CH2 1AW, UK

CONTRIBUTORS xi

Stephen Herpertz, Clinic of Psychosomatic Medicine and Psychotherapy, University of

Essen, Virchowstraβe 174, D-45147 Essen, Germany

Wolfgang Herzog, Ruprecht Karls Universitat, Medizinische Klinkum, Bergheimer

Strasse 58, 69115 Heidelberg, Germany

Hans Wijbrand Hoek, Department of Psychiatric Residency and Research, Parnassia,

The Hague Psychiatric Institute, Albardastraat 100, 2555 VZ The Hague, The Netherlands

Melanie Katzman, 29 West, 88th Street, New York, NY 10024, USA

Helen Kennerley, Oxford Cognitive Therapy Centre, Department of Clinical Psychology,

Warneford Hospital, Oxford OX3 7JX, UK

Heidelinde Krenn, Department of Psychiatry, University of Munich and Klinik Roseneck,

AM Roseneck 6, D-83209 Prien am Hiemsee, Germany

Daniel le Grange, Eating Disorders Program, Assistant Professor of Psychiatry, The

University of Chicago, 5841 S Maryland Avenue, MC 3077, Chicago, IL 60637, USA

Bernd L¨owe, Ruprecht Karls Universitat, Medizinische Klinkum, Bergheimer Strasse 58,

69115 Heidelberg, Germany

Mervat Nasser, Department of Psychiatry, 5th Floor, Thomas Guy House, Guys Hospital,

London SE1 9RT, UK

Dasha Nicholls, Department of Child and Adolescent Mental Health, Great Ormond

Street Hospital, Great Ormond St, London WC1N 3JH, UK

Søren Nielsen, Psychiatric Youth Centre, Storstrøm County Psychiatric Services,

Ringstedgade 61, DK-4700 Næstved, Denmark

Greta Noordenbos, Department of Clinical Psychology, Leiden University,

Wassenaarseweg 52, 2333 AK Leiden, The Netherlands

Bob Palmer, University of Leicester, Brandon Mental Health Unit, Leicester General

Hospital, Gwendolen Road, Leicester LE5 4PW, UK

Lorna Richards, Eating Disorders Unit, Bethlem Royal Hospital, Monks Orchard Road,

Beckenham, Kent, BR3 3BX, UK

Paul Robinson, Royal Free Eating Disorders Service, Department of Psychiatry, Royal

Free Hospital, Pond Street, London NW3 2QG, UK

Sheelagh Rodgers, Adult Psychological Therapies, Pontefract General Infirmary,

Friarwood Lane, Pontefract, W Yorkshire, SF8 1PL, UK

Jan Rosenvinge, Department of Psychology, University of Tromsø, ˚Asg˚ardveien 9,

N-9037 Tromsø, Norway

Ulrike Schmidt, Eating Disorders Unit, Institute of Psychiatry, De Crespigny Park,

London SE5 8AF, UK

Jacob Seidell, Department for Chronic Diseases Epidemiology, National Institute of

Public Health and the Environment, PO Box 1, 3720 BA Bilthoven, The Netherlands

Finn Sk˚arderud, Regional Centre for Child and Adolescent Psychiatry, University of

Oslo and The Norwegian Olympic Training Centre, Oslo, Norway

Sarah Stanley, Clinical Lecturer, Department of Metabolic Medicine, Faculty of

Medicine, ICSMT, Hammersmith Campus, London W12 0NN, UK

Rick Stein, The State University of New York, Department of Paediatrics, Division of

Behavioural Medicine, Room G56, Farber Hall, 3435 Main Street, Building #26, Buffalo,

NY 14214-3000, USA

Jorunn Sundgot-Borgen, The Norwegian University of Sport and Physical Education

and The Norwegian Olympic Training Centre, Oslo, Norway

Claire Tanner, 26 Vancouver Road, Forest Hill, London SE23 2AF, UK

Janet Treasure, Department of Psychiatry, 5th Floor, Thomas Guy House, Guys Hospital,

London SE1 9RT, UK

Nicholas Troop, Department of Psychology, London Metropolitan University, Calcutta

House, Old Castle Street, London E1 7NT, UK

Daphne van Hoeken, Department of Research, Parnassia, The Hague Psychiatric

Institute, Albardastraat 100, 2555 VZ The Hague, The Netherlands

Glenn Waller, Department of Psychiatry, St George’s Hospital Medical School,

University of London SW17 0RE, UK

Anne Ward, Psychotherapy Department, Maudsley Hospital, Denmark Hill, London SE5

8AZ, UK

Peter Webster, Eating Disorders Unit, Institute of Psychiatry, De Crespigny Park,

London SE5 8AF, UK

Robinson Welch, Department of Psychiatry, Washington University School of Medicine,

Campus Box 8134, 660 South Euclid Avenue, St Louis, MO 63110-1093, USA

Denise Wilfley, Washington University School of Medicine, Department of Psychiatry

660 South Euclid, Campus Box 8134, St Louis, MO 63110, USA

Elizabeth Winchester, Eating Disorders Unit, Institute of Psychiatry, De Crespigny

Park, London SE5 8AF, UK

Anthony Winston, Eating Disorders Unit, Woodleigh Beeches Centre, Warwick Hospital,

Lakin Road, Warwick CV34 5BW, UK

Stephen Zipfel, Ruprecht Karls Universitat, Medizinische Klinkum, Bergheimer Strasse

58, 69115 Heidelberg, Germany

This is the second edition of this very popular book The drive behind the first edition was tohonour the retirement of Professor Gerald Russell and many of the chapters were written bythe diaspora of clinicians and scientists emanating from his academic and clinical leadership.Within the decade since that edition was conceived, developed and executed there havebeen changes in the balance of clinical and academic connections A European school hasstarted to emerge In part EEC funding has facilitated this but, in addition, curiosity into thecontrasts and similarities between countries and the willingness and ability to communicatehas cemented this approach Thus this second edition now represents a European perspective.There have been marked advances in knowledge and understanding of the eating disorderover this time Also the spectrum of what is called ‘eating disorders’ has gradually expandedinto obesity as new conditions such as binge eating disorder have been introduced into thediagnostic system The dialectical process of synthesis between the body of knowledgefrom the obese and the lean end of the spectrum can enrich our understanding Manychapters embody this structure We also used a rather unique method to foster a synthesisand consensus approach We tried whenever possible to pair authors on the chapters withcolleagues in other schools, countries or disciplines

This has meant that all of the chapters have been rewritten However, we did not want tolose sight of the original edition, which had provided a coherent, readable and authoritativeoverview of this rapidly developing field

There are inherent paradoxes in such a task How can you satisfy the quality demands

of evidence-based science with the need by clinicians, carers and users for clear, concise,coherent models? We hope that we have been able to fulfil this task Thus, for the clinician,there is a strong practical emphasis with a problem-based approach, which means that thisbook has a richness of detail and wisdom that will be valued by all of the professionaldisciplines involved in caring for people with an eating disorder

J.T U.S E.v.F.

Preface to the First Edition

This volume marks the occasion of the retirement of Professor Gerald Russell It is ourtribute to his seminal influence on our understanding of the eating disorders To do this wehave organised a scholarly volume charting the achievements in the field over the past threedecades, an epoch during which he was such an important leader We know that a series

of personal tributes along the lines of a traditional festschrift would be unwelcome to him:

indeed they are unnecessary since his research and that of those associated with him speakfor themselves

Our aim has been to provide an up-to-date review of the eating disorders, anorexia nervosaand bulimia nervosa Space does not permit a detailed account of these disorders Rather

we have asked the contributors to focus on the powerful ideas, hypotheses, or models whichhave dominated the field The extent to which these ideas have supporting evidence, whatthey do and do not explain, and how they might be developed further are highlighted.The evolution of principles governing the treatment of these disorders is similarly treated

We invited contributors to take a broad view of their areas of special interest, to presentarguments in favour of the best models, to challenge them with rigour, and to examine theirimplications for our patients

The style of this volume, we hope, mirrors the approach exemplified by Gerald Russell It

is that of the clinician scientist—forever alert and faithful to clinical observation, discerning

in its apparent mysteries explanations able to be fashioned into hypotheses for scientifictesting, and forever maintaining a keen but critical eye on the implications of the results forthe care of his or her patients All of the contributors have been closely associated with him.Nearly all have worked with him in one of his units at various times over the past 30 years Allhave imbibed his methods and strived to maintain his high standards They have participated

in a programme of research where findings have been shared by all, so that, for example, thefamily therapy has been informed by genetics and nutritional physiology, and investigations

of follicular growth in the ovary have been sensitive to issues in psychosocial developmentand cognitive theory Such interchange between disciplines has deterred any tendency tosectarian thinking or refuge in unchallenged ideas inhibiting further developments Many ofthe contributors continue to work in the Eating Disorders Unit at the Institute of Psychiatryand the Maudsley Hospital The current addresses of many of the others incidate that theywent on to establish units of their own in the United Kingdom (Royal Free Hospital, Bristol,Liverpool, Westminster Hospital), Australia (Sydney and Melbourne), and the United States(Johns Hopkins)

The organisation of the book is a little unusual We have tried to provide a frameworkwhich compelled the authors to clarify their ideas as far as possible and to see how far theymight be pushed We probably would all agree that the eating disorders are multifactorial

in origin, but by asking contributors to explore discrete models to see how much they might

xvi PREFACE TO THE FIRST EDITIONexplain, we hoped to arrive at a richer understanding of what ‘multifactorial’ actually means.

In the introductory section the editors prevailed upon Gerald Russell to allow us to include

a paper by him examining the history of anorexia nervosa and bulimia which he recentlypresented at a conference at the Royal College of Psychiatrists We invited comments on hisideas from two senior figures in the field, Sten Theander and Joseph Silverman KatherineHalmi examines current concepts and definitions The separation of causal influences interms of aetiological versus maintaining factors (which are consequences of the disorders)was also planned as a spur to contributors to ask how our current models, involving differentlevels of abstraction, really explicate the origins of the eating disorders Similar principlesinformed the section dealing with treatment, the editors hoping that the range and limitations

of our key interventions would emerge, together with an appreciation of what they might tell

us about the nature of the disorders Then the difficult question of prevention is addressed.Finally, we include an evaluation of Gerald Russell’s contribution by Walter Vandereycken,but wish to add that many colleagues offered to contribute personal tributes

We hope this volume pleases its dedicatee and its readers as much as its preparation haspleased its compilers In seeing the contributions as a whole, we have become even morekeenly aware of Gerald Russell’s influence, especially his ability to newly create what hesaw, thus opening fresh directions for others to follow

G.S C.D J.T.

CHAPTER 1

Concepts of Eating Disorders

Bob Palmer

University of Leicester, Brandon Mental Health Unit,

Leicester General Hospital, UK

The nosology of mental disorders inevitably dithers between the wish to delineate usefulcategories and the hope of discovering natural kinds It would be good to achieve both buteach aspiration alone is elusive enough Indeed, some would reckon the second hope to beforlorn and there has been a tendency to emphasise the pragmatic and the descriptive Thecurrent classifications—ICD-10 and DSM-IV—are the offspring of this tendency (WHO,1992; APA, 1994) Yet there is a nagging feeling that there are ‘real’ disorders out there to

be discovered rather than merely defined

Within the field of eating disorders, anorexia nervosa crystallised out as a separate anddistinct disorder over the course of the last century (Mount Sinai, 1965) It had the advantage

of one criterion that was both undisputed and easy to measure, namely low weight However,

it was the description of the characterising beliefs and behaviours that led to the disorderbeing separated off from other states with weight loss Furthermore, it was the description

of similar beliefs and behaviours in people of unremarkable weight that led to the definition

of bulimia nervosa and its relatives However, it is arguably when the definition of mentaldisorder relies upon the mental state—as it almost inevitably should—that classificationbecomes more difficult Can we really measure people’s thoughts and feelings reliably and is

it reasonable to expect that they should fit neatly into categories? Even classifying behaviour

is problematic enough However, if we do observe that people come to suffer in similar waysand with similar beliefs then this may give clues not only about sociological generalisationsbut also, perhaps especially, about innate and probably biological mechanisms which mayunderpin their disorder

People may come to be more similar when they are stuck within a morbid process thanwhen they are well because the range of their behaviour and experience is at least in partconstrained by potentially definable processes in which such biological mechanisms areplaying some limiting part Tolstoy wrote, ‘all happy families resemble one another, buteach unhappy family is unhappy in its own way’ This is questionable even with regard tofamilies and unhappiness, but with individuals and disorder it seems likely that the reverse

is true The range of what is morbid is narrower than the range of the non-morbid psychiatrists tend to emphasise the prescriptive nature of ‘normality’ and to portray theperson who is ‘labelled’ mentally disordered as something of a free spirit However, the

Anti-Handbook of Eating Disorders Edited by J Treasure, U Schmidt and E van Furth.

2 BOB PALMERpsychiatric perspective is different The patient suffering from a mental disorder is seen asconstrained and trapped by forces that are outwith his or her control It is the sufferer who

is the tram compared with the normal person who resembles the bus in having much morefreedom Both the bus and the tram are limited by their physical attributes but the tram isadditionally constrained by the rails Study of the patterns of disorder could give clues as

to the nature of these ‘rails’

So what is the status of our current attempts at classification? What patterns can we discern

in people with eating disorders? How well do our conventional diagnoses map these patterns?And do any of these patterns suggest the presence of plausible mechanisms of aetiologicalsignificance? Do our categories promise to be more than convenient pigeonholes? Are there

‘real’ disorders out there?

What follows is a clinician’s view of our present classifications and some speculationabout what mechanisms and natural kinds might lurk beneath the surface of their syndromesand diagnostic criteria

CURRENT CLASSIFICATION

An ideal classification should consist of categories that are mutually exclusive and tively exhaustive Its entities should be discreet and together they should cover the ground.The classification of eating disorders measures up to these standards rather poorly Thecanon contains only two major categories—anorexia nervosa (AN) and bulimia nervosa(BN) Anorexia nervosa has low weight as an essential criterion Bulimia nervosa has bingeeating as a necessary criterion The two disorders share the criterion of what in broad termsmight be described as an over-concern about body weight and size although some wouldsee a major difference in degree or emphasis in the typical ideas held by sufferers from ANand BN In DSM-IV, AN takes precedence over BN in the sense that the presence of theformer bars the diagnosis of the latter In contrast in the earlier version, DSM-III-R, it waspossible to make the dual diagnosis of both AN and Bulimia Nervosa (APA, 1987) There is

collec-in DSM-IV, however, a new subclassification of AN collec-into bcollec-inge–purgcollec-ing and pure restrictcollec-ingsubtypes The rules in both of these sets of criteria represent different responses to thefact that low weight and bingeing occur together commonly and that, hence, the cardinalfeatures of AN and BN are closely related even in cross-section When longitudinal courseover time is considered then the overlap becomes even more striking In many series, asubstantial minority of BN sufferers have a past history of AN The reverse transition from

BN to AN is less common, but does occur Thus, AN and BN are far from being entirelydiscreet disorders and can be made to seem so only by dint of a certain sophistry However,

if the classification of the eating disorders fails to meet fully the ideal of providing discreetentities, it fails even more in respect of the second criterion, that of covering the ground.Many people present with eating disorders that fulfil criteria for neither of the two maindisorders How are these to be classified?

DSM-IV does provide two additional diagnoses, namely binge eating disorder (BED)and eating disorder not otherwise specified (EDNOS) Binge eating disorder is includedonly as a provisional category ‘for further study’ It is strictly a variety of EDNOS withinDSM-IV although, in practice,it has come already to be accorded the status of a diagnosis

in its own right However in general, EDNOS is defined essentially by exclusion, that is asbeing any clinical eating disorder that does not fulfil criteria for AN or BN

CONCEPTS OF EATING DISORDERS 3

THE PROBLEM OF EDNOS

The classification of the eating disorders achieves the standard of being collectively haustive only through having the ‘rag bag’ or residual category of EDNOS The EDNOScategory has only one positive criterion and one negative criterion The positive criterion

ex-is that the individual being thus diagnosed should be deemed to have an eating dex-isorder ofclinical severity—a disorder that matters The negative criterion is that the disorder shouldnot fulfil criteria for AN or BN

The EDNOS category thus defined is common In many clinical series of people senting to eating disorders services it is the single most common diagnosis and in someforms the majority of cases Furthermore, as with AN and BN, the longitudinal perspec-tive is illuminating but complicating Many cases of the two main disorders change theircharacteristics over time so that those who have suffered from either at one time come later

pre-to suffer from neither but continue pre-to have a clinically significant eating disorder (Sullivan

et al., 1998; Fairburn et al., 2000) They can then be diagnosed only as being in a state ofEDNOS It is less clear whether people commonly move from a time of sustained EDNOSinto one of the classic disorders

A weakness of the EDNOS category resides in the limitations of its two criteria The

positive criterion is not defined Where is the line to be drawn that defines a state as an eating disorder and of clinical significance? This is a matter of judgement For instance, someone

who is eating little and has lost a great deal of weight through severe major depression orbecause of delusions of poisoning would clearly have a disorder of clinical significancebut would still not be diagnosed as EDNOS The diagnosis is not appropriate because thestate is not construed as an eating disorder There is an implicit further criterion operatinghere; that is, that EDNOS should be diagnosed only if no non-eating disorder diagnosis isadequate The positive criterion is further tested when there is uncertainty about whether

an individual with eating disorder symptoms, such as maladaptive weight concern or induced vomiting, is affected to an extent that constitutes a disorder of clinical significance.Interestingly the judgement may sometimes depend upon the degree not only of the eatingdisorder symptoms but also of the associated non-specific symptoms Thus, if the person hasimportant associated anxiety and depressive symptoms or major problems of self-esteem—albeit not amounting to diagnosable syndromes in their own right—this may contribute tothe decision that a diagnosis of EDNOS is appropriate However, DSM-IV does not set outhow these judgements should be made

self-The negative criterion is also questionable when an individual fails narrowly to fulfil justone criterion for one of the major disorders For instance, amenorrhoea is a difficult symptom

to evaluate and yet some criteria demand that it should be present for the diagnosis of AN

in females The use of an oral contraceptive pill can complicate the issue and, furthermore,there is evidence to suggest that the presence or absence of this symptom makes littledifference Should someone who shows an otherwise typical picture of AN really be deniedthe diagnosis because of continuing menstruation? The ICD-10 system makes the sensibleprovision for a diagnosis of so-called ‘Atypical AN’ (or indeed ‘Atypical BN’) in cases where

an individual narrowly misses fully meeting criteria but is clearly in a state very closelyakin to one of these main disorders However, once again these categories are not reallydefined and the atypical categories merely provide a buffer zone between the full disordersand others There is still disputed territory at the other margin In epidemiological work, theterm ‘partial syndrome’ is often used to describe these sorts of states The decision about

4 BOB PALMERwhether to count a subject as a ‘case’ in a survey may require a different kind of judgement

to that of the clinician who must decide whether a patient fits a diagnosis In the formercase, the decision may affect aetiological inference; in the latter, the decision may influencethe nature of the treatment offered Sometimes whether or not treatment will be offered atall may be at stake These things can be important

Thus the EDNOS category inevitably includes some less severe cases that neverthelesspass the test of being of clinical significance Many of these will be ‘partial syndromes’

of a kind that just miss out on fulfilling criteria for one of the main disorders They willoften do so in ways which may be quantitative—the bulimic who does not binge quite oftenenough—or qualitative, that is, their difference does not seem to threaten the essence ofthe disorder—e.g the previously cited case of the female ‘anorectic’ whose periods persistsurprisingly despite important weight loss However, there will also be people who havedisorders which are diagnosed as EDNOS but who seem to be caught up in patterns ofdifficulty that are qualitatively different in ways which do seem to be significant

ATYPICAL BEHAVIOURS

Some unusual cases differ in terms of the behaviour that they show A not uncommonclinical picture is that of the person who is at an unremarkable weight and does not binge.She is thereby barred by definition from being diagnosed as having either AN or BN Shenevertheless induces vomiting after almost every meal This pattern is one of the examples

of EDNOS cited in the DSM-IV manual A similar behavioural variant would be the personwho eats nothing at all because of fear of weight gain but sustains a fair body weight entirelythrough the consumption of calorific fluids Another important condition is eating disorderassociated with insulin-dependent diabetes mellitus which may sometimes be severe withoutinvolving either weight loss or bingeing Omitting or using insulin erratically in the service

of weight control may constitute a clear eating disorder and be life threatening without evenapproximating to either classic AN or BN (Peveler, 1995) All such states are truly atypicalbut nevertheless they seem to be sufficiently akin to the typical eating disorders that it doesnot offend our clinical sensibilities to include them as interesting variants We seem to feelthat in essence they are the same Is this because we feel that the essence of the eatingdisorders lies in the beliefs and ideas of the sufferer? But what of people who are atypical

in their ideas?

ATYPICAL IDEAS

Controversies about details notwithstanding, both AN and BN include among their sary criteria the issue of what, for the sake of brevity, might be called ‘weight concern’.The different systems use different words but they all clearly refer to ideas which are atleast similar Furthermore, these ideas are held to be the central psychopathology of thedisorders They are deemed to be of the essence and to provide the motivation for the eatingrestraint which seems to be a key to the pathogenesis of AN and probably of BN too Andyet, there seem to be eating disordered people who do not have them or at least do not talkabout them Every clinician has come across many sufferers who initially deny concern

neces-CONCEPTS OF EATING DISORDERS 5about body weight and shape Some later reveal that they had had such ideas but that theyhad been wary and kept quiet about them Others continue to deny having such weightconcerns Some convince some clinicians that this is truly the case But is it possible tohave, say, anorexia nervosa without weight concern? The diagnostic criteria would say not.However, the clinicians who first described anorexia nervosa in the nineteenth century didnot emphasise weight concern Indeed, the early accounts by Gull and Lasegue do not men-tion it even though their clinical descriptions are in other respects both vivid and thorough(Mount Sinai, 1965) Likewise, colleagues working in China describe many young womenwho otherwise seem to have anorexia nervosa but who lack evident weight concern (Lee,

Ho & Hsu, 1993) So sure are they that these are cases of ‘anorexia nervosa’ that they are

so designated in the papers which describe them So much for diagnostic criteria But then,surely, Lee and his colleagues are following what most would regard as clinical commonsense Perhaps, such common sense rests upon an as yet unmentioned third attribute of

a good classification—along with discreet entities and covering the ground—namely that

of utility in practice The Chinese patients without weight concern probably need to bemanaged in much the same way as their more typical equivalents But what does suchpragmatism do to ideas about the essence of eating disorders?

MOTIVATED EATING RESTRAINT

It is possible to make only a modest change to the diagnostic criteria for the eating disordersand thereby encompass some of the non-weight concerned sufferers If eating restraint

is promoted to be a central or even necessary component of the mechanism of the eatingdisorders, then weight concern may be seen as one motivation for such restraint among manythat are possible (Palmer, 1993) For, instance, restraint may be motivated by religious ideas,ideas of fitness, ideas of asceticism and so on Many clinicians will recognise some patientsfor whom such ideas seem to occupy the same position as ideas of weight concern in moretypical cases They reflect the same ‘entanglement’ between ideas of weight and eatingcontrol and wider personal issues such as self-esteem and emotional control Such atypicalideas may be more common in atypical sufferers such as males

It is not difficult to think that motivated eating restraint might occupy a central position

in the pathogenesis of the eating disorders Restraint in some sense is clearly involved in

AN Furthermore, it may be plausibly invoked in BN via the kind of rebound effect that hasbeen called ‘counterregulation’ (Herman & Polivy, 1984; Palmer, 1998) However, suchexplanations seem to require that the sufferer is fighting her natural urges to eat She is seen

as not having lost her appetite but rather as attempting not to give in to it—‘successfully’ inthe case of the AN sufferer; unsuccessfully in the case of the BN sufferer Indeed it may bethought an advantage of accounts of eating disorders which give a central place to eatingrestraint that they are parsimonious in having no need to postulate some primary disorder

of appetite or drive to eat The effects of eating restraint upon individuals with an intactappetite are well documented (Herman & Polivy, 1984; Polivy & Herman, 1995) Restraintleads to distortion Indeed, a story can be told about these effects that can be spun into aplausible account of the eating disorders However, although parsimony of explanation may

be a virtue, the simplest accounts are not always true There could be a place for some moreprimary abnormality of appetite Surprisingly there is a deal of uncertainty about appetite

in eating disorders

6 BOB PALMER

THE VEXED QUESTION OF APPETITE

Hunger or appetite in eating-disordered people have received rather little systematic study.There remains considerable uncertainty This seems to be for at least three reasons Firstly,there are inherent difficulties in measuring the subjective strength of hunger or appetite.Secondly, ratings of hunger are likely to be unreliable in people who have complex anddistorting ideas about what they should be eating The sufferer may mislead others, andperhaps even herself, when putting her subjective experiences into words or filling in a ratingscale On the other hand, for obvious reasons, what an eating-disordered individual actuallyeats cannot be taken as a simple behavioural indicator of the drive to eat Lastly, cliniciansand other experts may assume that they know about hunger and the like in eating-disorderedsubjects However, various experts have various views Especially with respect to AN, someclaim that they ‘know’ that sufferers characteristically experience an enhanced urge to eatwhich is kept under tight control (see many of the present author’s writings) Others say thatthe drive to eat must be less than normal if the subjects are to ‘successfully’ stop themselvesfrom eating in the face of gross self-deprivation (Pinel, Assanand & Lehman, 2000) Manyare impressed—or perhaps bewildered—by the variety of accounts which their patients give

to them

With regard to the problems of measurement or even description, there are conceptual

as well as technical difficulties about what hunger or appetite or drive to eat may be taken

to mean as definable terms These terms do not seem to be used consistently or reliablyand may need to be thought of as far from synonymous For instance, an eating-disorderedperson may say that she is never hungry but may nevertheless acknowledge a strong urge

to eat It is as if the term hunger had too positive a connotation for it to be used about such

a problematic experience

In principle, hunger or the drive to eat might be abnormal in being reduced or increased

In practice, in many cases in which hunger is reduced—i.e where there is true anorexia—a

diagnosis of an eating disorder is not seriously considered For instance, weight loss ciated with physical illness with loss of appetite or depressive illness with true anorexia is

asso-not appropriately described as anorexia nervosa The ‘nervosa’ implies that the relationship

between the person’s eating and their weight loss is more complex—more entangled withwider personal issues—than that of being simply ‘off their food’ Once again, there is somelack of clarity here Even those who would claim that AN sufferers do have a diminishedappetite would want to reserve the diagnosis for those people who seem to be not eatingfor broadly ‘psychological’ reasons and who have relevant and related ideas often aboutweight concern For instance, a sufferer may couch her immediate aversion to eating interms of bloating or discomfort, but also have wider ideas of guilt or whatever At the ex-treme, it is certainly conceivable that a person could present at low weight who was withoutboth ‘weight concern’ and motivated eating restraint and who seemed to have some trueanorexia Under what conditions, if any, should she (or he) be considered for a diagnosis ofAN? Strictly, such a patient should be diagnosed as EDNOS if no other diagnosis fits Suchpeople probably do exist although they seem to be scarce (perhaps they present to otherkinds of clinician) However, their apparent rarity in practice may suggest that their charac-teristics should not be considered as threatening refutation of hypotheses about the nature

of AN itself Perhaps they are truly different At the other end of the dimension of appetite

or urge to eat, it seems likely that those who suffer from Binge Eating Disorder (BED)

CONCEPTS OF EATING DISORDERS 7might also have an unusual—this time increased—appetite which is not based upon thedistortions of restraint.

A primary increase in appetite or drive to eat might possibly be present in AN where it

would trigger the restraint as a reaction However, there seems to be little evidence for this.Such a primary increase is more plausible as a component of the mechanisms of BN andeven more so for BED In BN, the model of restraint acting upon an intact but unremarkableappetite is plausible Most BN subjects report that the onset of attempted restraint precededthe onset of binge eating However, this is not the case for a small but interesting minority of

BN sufferers and for most of those who suffer with BED Characteristically BED subjectseither do not consistently restrain or the onset of their bingeing precedes that of restraint(Mussell et al., 1995, 1997) The different average outcome of BN and BED in terms ofweight change at follow-up provides further support for a possible primary problem ofincreased appetite in the latter group Fairburn et al (2000) have shown that a communitygroup of BED sufferers put on an average of 4.2 kg over the five-year follow-up periodand that the rate of obesity rose from 22% to 39% This weight gain occurred whether ornot they continued to have BED In contrast, BN sufferers gained on average only 3.3 kgfrom a lower base line and only 15% were obese at follow-up Thus, many sufferers fromBED are or become obese Perhaps most are grappling with a drive to eat which is trulyincreased and which destines them for obesity, all other things being equal Perhaps thosewho have a more ‘straightforward’ psychology become straightforwardly obese in the face

of this increased drive to eat rather than becoming caught up in BED

SET POINTS OR SETTLING POINTS?

Restraint-based models of eating disorder tend to go along with models of eating controlwhich emphasise regulation of body weight This may be seen as involving a regulation

of weight around a set point or at least a set range that is variable across individuals butrelatively constant for any one individual (Keesey, 1995) Some people regulate around alow weight, some around a high weight and most, by definition, around an average weight

Or so this story goes The chief drive to eat is thought of as resulting from a biology in whicheven minor deprivation triggers the urge to eat in order to restore the well-fed state Suchset point models have an intuitive appeal Furthermore, they can have an ideological utility

in simplified form as the basis of a way of talking about eating disorders (Palmer, 1989).However, they have been criticised as not adequately accounting for important phenomena(Pinel, Assanand & Lehman, 2000) Especially, such models seem to overestimate the degree

of the inherent stability of people’s body weight, especially with regard to the evidentlywidespread vulnerability to weight gain and obesity Although there are anecdotes aboutSumo wrestlers and evidence from studies that sometimes weight gain is difficult, for manypeople much of the time weight gain is all too easy (Sims & Horton, 1968) This seems toapply even to weight gain to levels that carry significant disadvantages for health (Pinel,Assanand & Lehman, 2000) The degree to which the bodies of many people ‘defend’ anupper limit around any set point seems to be less than the models would predict Thereseems to be at least an asymmetry between the lower and upper limits Any dieter knowsthis Set point ideas seem to have merit with regard to downward deviations in weight

8 BOB PALMERbut are rather less good in accounting for weight gain above ‘normal’ levels In as much

as an eating disorder involves low weight and restraint, set point models may be useful.However, this may not be the case with respect to eating disorders at normal or above normalweight

Set point ideas are often dressed up with evolutionary stories It is suggested that latory mechanisms would have evolved which tended to keep an individual within a rangewhich was optimal for survival and reproduction However, a criticism of set point theorysuggests that in the ancestral environment, where food would have been scarce, mechanismswould have been favoured that allowed an animal to eat more food when it was available thanwould be necessary for its immediate needs Storage of potential energy and substance—putting on weight—would be advantageous in circumstances of erratic food supply in away that would not be the case for strong satiety mechanisms which cut consumption whenimmediate needs were met Furthermore, it is plausible that such permissive mechanismsmight be more advantageous for younger females of reproductive age and, indeed, somesexual difference in satiety mechanisms can be observed (Goodwin, Fairburn & Cowen,1987) But if restraint models are not fully adequate, what other models are available?One is that of so-called positive-incentive theory This emphasises the rewards of eating,including its hedonic properties Feeding is intrinsically rewarding and this is especially thecase with respect of foods which might well have been valuable but scarce in the ancestralenvironment such as sweet foods, fatty foods and salty foods Eating such foods was—and

regu-of course still is—especially rewarding In the past this meant they were especially soughtout despite the difficulty in finding them Now that they are readily available, they are eaten

to excess Positive-incentive theory may hold more promise in explaining aspects of thoseeating disorders in which restraint seems to play little or no part and which occur at normal

or high body weight There may be complex entanglement between the hedonics of eatingand emotion in people with binge eating And less dramatically the positive incentives may

be relevant to obesity

Pinel, Assanand and Lehman (2000) have proposed a tentative theory of anorexia nervosa

in which they suggest that the under-eating characteristic of that disorder may reflect achange of the usually positive incentive of eating towards the negative However, it is notclear that such an interpretation fits the facts Thus, as mentioned above, there is controversyabout the nature of the subjective urge to eat in AN Furthermore, it seems highly plausiblethat deprivation might well be the key drive to eating in those who are at a low weightand hungry and that the positive incentive to eat might well take over when the animal

or human is well fed Sensory specific satiety is a real phenomenon and bread and buttermay well suffice when one is deprived, but it takes chocolate pudding to override thatfull feeling after two or three previous courses While it may seem more parsimonious toinvoke either a set point theory or a positive incentive theory, perhaps both kinds of ideasare required; the first in discussing states of deprivation and weight loss and the second

in discussing the regulation of eating in times of plenty and higher weight It is at least aseasy to tell evolutionary stories around such a dual mechanism as it is around a simplermodel

The notion that there is a mechanism that regulates body weight around a set pointmay be contrasted with the idea that any apparent stability of body weight reflects asettling point which is the net result of two or more mechanisms that may have quitedifferent functions The implication for intervention may well be different, perhaps es-pecially for the treatment of obesity where the idea of a set point that is defended even

CONCEPTS OF EATING DISORDERS 9when it is problematically high tends to promote therapeutic pessimism (Garner & Wooley,1991).

CONCLUSIONS

Our cherished diagnoses of AN and BN are here to stay They clearly describe many patients

in the clinic and are useful Furthermore, the use of definite diagnostic criteria has made animportant contribution to research However, an undue concentration upon individuals whofulfil diagnostic criteria may lead to a somewhat blinkered view The testing out of newformulations such as that of BED is useful although it would be a pity if such categoriesinvented ‘for further study’ were routinely and prematurely reified as diagnoses We needideas to inform our observations but to be sufficiently open-minded to be able to notice theunexpected

The view from the clinic can potentially provide suggestions about where it might beprofitable to look for more basic physiological and pathological mechanisms

Returning to the metaphor used above, it may be possible to guess at the location of some

of the ‘tramlines’ that constrain our patients The following are some summary commentsbased upon the view through this particular pair of eyes

1 In looking for mechanisms underlying the eating disorders, ideas which invoke tially normal regulatory mechanisms which have been pushed out of kilter are to bepreferred as more parsimonious if they are adequate

essen-2 Models based upon eating restraint seem to have merit and may even be adequate formost cases of AN and BN

3 ‘Motivated eating restraint’ is a more inclusive and arguably better formulationthan ‘weight concern’ as the criterion for the core psychopathology of most eatingdisorders

4 The ‘normal mechanisms’ invoked may need to include positive-incentive ideas as well

as or instead of ideas of restraint if eating disorders at normal or high weight are to beadequately explained

5 True abnormalities of appetite or drive to eat may play a part in some cases of BN, inBED and in obesity Likewise, some cases of restricting AN may have some primarychange in appetite although this is more speculative Such variation of appetite may begenetically determined

6 There should be more research into the difficult topic of the phenomenology of appetite

in the eating disorders

7 Such research should go hand in hand with biological research into the complex anisms that are doubtless involved in normal and pathological feeding in animalsand human beings

mech-8 Whenever practical, research should include atypical (EDNOS) cases as well as thetypical

9 A future classification may include a major divide between ‘disorders of restraint’ and

‘disorders of increased appetite’

10 All true eating disorders—disorders with ‘nervosa’—are characterised by an glement’ between the relevant basic weight and eating control mechanisms and thesufferer’s interpretation of the meaning of the effects of these within his or her own

‘entan-10 BOB PALMERindividual experience And, although some generalisations can be made, such interpre-tations are likely to be varied or even idiosyncratic and to defy neat classification.

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