Postgrad Med J: first published as 10.1136/pgmj.42.489.443 on 1 July 1966. Downloaded from POSTGRAD. MED. J. (1966), 42, 443 SOME OBSERVATIONS ON ANOREXIA NERVOSA CECIL B. KIDD, M.D., Ph.D., D.P.M. J. F.- WOOD, MB., D.P.M. Senior Lecturer Clinical Tutor Department of Mental Health, University of Aberdeen

DISTURBANCES of gastro-intestinal function and it presents to the health and life of these of nutrition are to be found as a cause of, a patients and, as Stafford-Clark (1958) has correlate with or a consequence to almost every rightly pointed out, the management required form of psychiatric illness (Millar, 1953). both uniquely illustrates and emphasizes the A'mong these, the distinct entity of anorexia necessity to resolve any dichotomy between nervosa has attracted much attention from psy- physiological and psychological approaches in chiatrists, general physicians, endocrinologists treatment. and (biochemists. Although anorexia nervosa is a rare condition, the clinical interest accorded Prevalence and Surveys to it reflects both the severity of its impact on the patient and the major therapoutic challenge Anorexia nervosa is a rare condition, yet not it presents to the clihnician. The disease process so rare that several new cases will present to comprises a complex interplay of physical, psy- clinicians each year at every major centre of chological, endocrinological, metabolic and elec- population. Study of patient records at Aber- trolytic dysfunction; treatment is very deen covering two selected periods 1949-1956 lengthy, by copyright. relapse is frequent and a fatal outcome is not and 1960-1965 inclusive revealed a firm diag- unknown. nosis of anorexia nervosa in 18 and 12 patients respectively who had been treated in the Pro- The diagnosis of anorexia nervosa rests on fessorial Psychiatric Unit. In a study in the the recognition of a triad of symptoms which North-east region of Scotland of all persons are unihersally accepted as pathognomomc of over the age of 15 years newly referred to a this condition; a gross loss of weight leading psychiatrist during one year, three of the 1,240 to emaciation, a failure to eat, and disturbance new wom.n patients thus identified had a diag- of menstrual function leading to oligomenorr- nosis of anorexia nervosa (Innes and Sharp, hoea and amenorrhoea. The psychological con- 1962). Despite the paucity of cases, meaningful http://pmj.bmj.com/ comitants of this state also have been described numbers for study and follow-up have been as a triad; denial of hunger despite prolonged accumulated in several on-going and retrospec- inanition, denial of thinness despite extreme tive enquiries. Among these, Bruch (1962) stu- emaciation, and denial of fatigue despite exces- died in detail the psychological characteristics sive and frantic activity done in a state of of conceptual disturbances and disorders of chronic underfeeding (Mayer, 1963). A com- perception in nine women admitted for treat-

prehensive clinical description of this disorder ment of anorexia nervosa. Crisp (1965a) studied on September 24, 2021 by guest. Protected was provided by Sir William Gull who coined the clinical patterns and outcome of treatment the term "anorexia nervosa" in 1874. He ob- in 27 women with anorexia nervosa and in served its occurrence in young women who pre- another enquiry (Crisp, 1965b) presented data sented with "great emaciation, amenorrhoea, on the evolution of this condition and the constipation, anorexia alternating occasionally patient charac-teristics of a series of 42 affected with a voracious appetite, restlessness, activity, women. Dally and Sargant (1960) carried out peevishness of temper and a feeling of jealousy, a treatment study comparing results from the together with an absence of any organic cause". then new and now widely used regime of chlar- He ascriibed this to a moebid mental process, promazine combined with modified insulin he commented that the patients' activity and therapy in 20 patients with other treatment re- sense of well-being were-grossly out of propor- gimes previously employed in a series of 24 tion to their inanition, and observed shrewdly patients. Hawkings, Jones, Sim and Tibbetts that the family were generally the worst attend- (1956) reported a number of patients with "de- ants (Gull, 1874). The early detection- of liberate disability" and drew interegting com- anorexia nervosa is-vital to offsetting the hazard parisons between this group and five patients Postgrad Med J: first published as 10.1136/pgmj.42.489.443 on 1 July 1966. Downloaded from 444 444 POSTGRADUATE MEDICAL JOURNAL July, 1966 who were treated in the same unit for anorexia condition. Some autthors have included males in nervosa. In the same paper the authors des- this diagnostic category (Bruch, 1962; Dally cribed the results of a postal follow-up enquiry and Sargant, 1960; K'ay and Leigh, 1954; Rus- on 23 patients treated for anorexia nervosa sell and others, 1965) but, as Dally and Sar- during the ten year period 1938 to 1948. Kay gant (1960) have pointed out, the occurrence and Leigh i(1954) reported on a definitive series of convincing anorexia nervosa-like states in men of 34 women who were treated at the Maudsley is most uncommon. Anorexia nervosa charac- Hospital for anorexia nervosa between 1932 teristically occurs among adolescent or young and 1952 and descriibed in detail their clinical women (Williams, 1958). In Crisp's (1965b) features and outcome. King (1963) studied a series of 27 women, all but two were adoles- series of 21 anorexic patients to delineate from cents with a mean age of 17 years. In his study anorexia nervosa those whose anorexia was of 40 patients, it was found that all but seven secondary to other psychiatric illness, and to had an onset of illness before age 21 (Crisp, identify the signiificant background factors and 1965a). Similarly Nemiah (1950) found the age clinical characteristics of the former. Another at onset of illness to be between 14 and 24 major survey was reported by Nemiah (1950) years '(mean age 18 years) in his series and Kay who selected 14 patients on the basis of the and Leigh (1954) showed that 70 per cent of classical symptom triad and in whom no evi- their patients had their first symptoms before dence of gross disease had been found in a reaching the age of 26 years. The age patterns primarily aetiological role: as well as report- on admission to the Professorial Psychiatric ing clinical observations this study detailed find- Unit in Aiberdeen of 12 patients studied from ings from enquiry into and measurement of the 1960 to 1965 showed that half were below 25 patients' personality piofiles, attitudes and inter- years, a proportion identical to the similar personal relationships. Patient groups were dalta from the Guy's Hospital series (Stafford- accumulated for research on the metabolic and Clark, 1958), but as Loeb (1964) has clbserved, endocrinological aspects of anorexia nervosa many post-adolescent patients will have hadby copyright. and results have been reported recently: delta episodes of anorexia in adolescence, although glucose values before and after a high calorie perhaps not maniifesting them to such a degree high carbohydrate dietary regime were studied as to have called for medical intervention at in nine patients, the regulation of water balance the time. Crisp (1965a) showed that the typical was studied in 12 patients (Russell, 1965), and patienft had a higher birth-weight than her gonadotrophin and oestrogen excretion was sisters, was much more likely to have been studied in seven severely emaciated women bottle-fed in infancy, or if ibreast4fed to have Bell and Harkness, 1965). had prolonged breast feeding, to have been

(Russell, Loraine, http://pmj.bmj.com/ Seventeen patients with anorexia nervosa and well-nourished or over-nourished in childhood who showed hypokalaemia on laboratory in- and to have had an early menarche. These vestigation were studied by Wigley (1960) who characteristics were found not to have been identified and commented on the high occur- influenced iby the factors of race, social class, rence of renal disorder among this group. The maternial age and parity, 'length of gestation or clinical state, management and 'progress of 53 genetic inheritance. Most patients are described patients with anorexia nervosa who were treated as lbeing "plump" before the onset of illness. at the London Hospital between 1897 and 1957, Often they are awkward, reserved, and physic- on September 24, 2021 by guest. Protected the largest series to have been published, was ally unattractive (Wall, 1964). The association reported by Williams (1958); this paper empha- between the onset of illness and a crash diet sizes especially the relationships between treat- programme to reduce weight occurs too fre- ment procedures and outcome. quently to be a fortuitous occurrence (Crisp, In addition to these major surveys of patients 1965a; Mayer, 1963; Nemiah, 1950). In con- with anorexia nervosa considerable clinical, psy- trast to the insightless extremes of self-depriva- chological and biochemical data have accrued tion to which these patients subject themselves, from smaller series and individual case reports it is a characteristic common to the majority which further advance medical understanding that they are talented and of high intelligence of this condition. (King, 1963; Wall, 1964). Patient Characteristics Physical Features All patients who have anorexia nervosa are The physical appearance of the patient is females since amenorrhoea is widely regarded marked 'by oibvious emaciation. The facies as essential to the accurate diagnosis of this suggest that the patient is older than her stated Postgrad Med J: first published as 10.1136/pgmj.42.489.443 on 1 July 1966. Downloaded from Jtily, 1966 KIDD and WOOD: Anorexia Nervosa 445 age, skeletal structure is clearly defined and mic dysfunction. In the 'first, delta glucose pallor is invariably present. The patient has an values shown 'by glucose tolerance tests were intolerance to cold. Fatigue and apathy while found to be high but reversible when the obvious are forcefully denied. Atrophy of the patients were fed on a high-carbohydrate high- breasts and of buttock fat are common. Where calorie dietary intake. Russell has concluded the latter is marked the sagging folds of skin from th'is that the metabolic change is secondary take on the classical appearance of "elephant to chronic carbohydrate deprivation and can (be skin". In early phases of weight reduction loss corrected by adjusting the diet. The second of fatty tissue predominiates. Extreme weight study, of regulation of water balance in these loss in later emaciated patients indicates rapid patients, sought to explain the findings that katabolism of non-fatty tissue reserves. Hair many patients with anorexia nervosa are oede- distriibution is normal, but may be augmented matous and ihave a reduced capaci-ty to excrete by facial and limb hirsuties and a ifine lanugo- a water load, yet urinary concentration remains like downy growth of hair on the body. normal. It was found that ability to excrete a Amenorrhoea is invariably present. In similar water load depended not on weight loss but proportions of patients, menstrual disturbance on duration of illness. Antidiuretic hormone and anorexia appear together as the first fea- assay revealed normal levels, glomerular filtra- tures of the condition, menstrual disturbance tion rate showed some reduction and it was precedes all other physical features, or follows again concluded that this metabolic disturbance during the course of established weight reduc- is the result of malnutrition, is correctalble tion (King, 1963). On examination, bradycardia, over time, and it is not due to a primary hypo- hypotension, diminished sweating and oedema thalamic dysifunction. The third study sought are commonly found. Constipation is always to gain data on hormone levels and on the present. Abdominal tenderness may ibe elicited. effect of malnutrition on endocrine function in Gynaecological examination normally reveals anorexia nervosa patients by examinring the an infantile uterus and atrophic changes in excretion of human pituitary gonadotrophins by copyright. the vaginal mucosa due to depressed oestro- and oestrogens before and after treatment. It gen function. Restlessness and excessive activity was found that 'before treatment the output are normally observed, always to a degree out of these hormones 'was reduced. There was of proportion to the clinician's assessment of also disproportionate decrease in oestriol com- the emaciated patient's physical reserves. pared with decreases in oestradiol and oestrone. After feeding the oestrogen excretion returned to a normal pattern and quantity, indicating Metabolic Features a secondiary process (the disproportionate re- The basal metabolic rate is low. The excre- duction in oestriol could be due to the way in http://pmj.bmj.com/ tion of 17-ketosteroids and oestrogenic su-b- which oestrogens are metabolised in malnutri- stances is also markedly reduced. The Kepler tion), 'but the gonadotrophin levels did not rise test for hypoadrenal-cortical function is fre- to the extent that normal cyclical activitv was quently positive (Wall, 1964). Crisp (1965a) resumed. It was concluded that While many has demonstrated recently that while patients metalbolic effects of anorexia nervosa are with anorexia nervosa have a flat glucose- secondary to malnutrition, the existence of a tolerance curve due to sustained high blood primary hypothalamic defect might conceivably on September 24, 2021 by guest. Protected glucose levels which is reversible with weight account for some of the endocrine changes met gain, high plasma insulin levels persist. Para- in this condition. doxically, this pattern is usual in obese subjects. It is not known whether this is present before Electrolyte deficiency may occur in anorexia the onset of illness. A further metabolic like- nervosa. Sunderman and Rose (1948) first des- ness of the anorex'ic to the obese patient was cribed the occurrence of hypokalaemic alkalosis demonstrated by analysis of the content in and Wigley (1960) reported and reviewed 17 weight gain among patients with anorexia ner- cases of anorexia nervosa all of whom had hypo. vosa under treatment: disproportionately high kalaemia, some of whom had hyponatraemia fat deposits were found, a similar pattern to and eight of whom showed evidence of renal that expected among over-feeding normal per- dysfunction. This study underlines the import- sons (Russell and Mezey, 1962). Russell (1965) ance of recognising potass'iu,m depletion in and iRussell and others (1965) carried out three anorexiia nervosa which may lead to renal com- studies aimed at testing the hypothesis that plications such as tubular vacuoliation. As well anorexia nervosa is associated with hypothala- as this, the patient with anorexia nervosa takes Postgrad Med J: first published as 10.1136/pgmj.42.489.443 on 1 July 1966. Downloaded from 446 POSTGRADUATE MEDICAL JOURNAL July, 1966 very little fluids, urinary output is low, many distortion is not amenable to reason (Bruch, have a negative nitrogen balance and a ten- 1962; Mayer, 1963). dency to osteoporosis, and the combination of A dominant psychological feature common oliguria with hypercalcaemia may further im- to all patients is (their preoccupation with and pair renal efficiency iby calculus formation (Wall, disgust for sexual thought and development. 1964). Attitudes of revulsion and frigidity are eilther expressed or thinly veiled by protestations of Psychological Features alleged ignorance of sexual matters. The sym- bolic relationship between feeding and sexual Anorexia nervosa is priimarily a psychogenic pleasure is well known in psychological theory disorder which leads to and is complicated by and many authors have illustrated from detailed physiological and pathological events. The psycholo-gical investigation of anorexic patients prime mover in this debilitating condition is, that unconscious fantasies of oral impregnation, however, the psychogenic factor (Wall, 1964). repressed in early life, can be revived in the Consistent patterns of pre-morbid personality stress of pu'berty and may play a contributory attributes, social attitudes 'and maladjustments, role in the genesis of anorexia nervosa (Grim- and behavioural anomalies during the course shaw, 1959; McCullagh and Tupper, 1940; of the illness all testify to the presence in Waller, Kaufman and Deutsch, 1940). Certainly anorexia nervosa of a gross psychiatric disorder. the sexual histories of many patients contain Normally it is found that the patient before an account of some sexual incident, often trivial becoming ill is descrilbed as stubborn, strong- but frightening to the patient, around the time minded, determined, of high ideals, not amen- of onset of anorexia nervosa (Crisp, 1965'b), able to reason, self-willed and overly sensitive but although attitudes of conflict and hostility (Palmer and Jones, 1939). Wall (1964) has to sexuality, fears of pregnancy and poor hetero- stressed the distinctly introverted personality sexual adaptation are invariable concomitants of the patient, her meticulousness and obses- of the condition, factors other than purely a by copyright. sionality and an intellectual superiority which disorder in psychosexual adjustment are held is at variance with an attitude of unmitigated generally to be essential to its development. stubborness. Lack of humour and irritability Denial of hunger is as striking a clinical which were shown by Kinig (1963) ito be per- feature in these patients as is a denial of thin- sonality facets of the pre-anorexic patient con- ness. Encouragement to eat is met with hostility cord well with Gull's original observation of and complaints of unbearable abdominal full- "peevishness" (Gull, 1874). An abnormal degree ness follow the ingestion of even small amounts of dependency by the patient on a parent, of food. The patient frequently complains of usually a characteristically dominant and res- constipation, seeks for purgatives, or may in- http://pmj.bmj.com/ trictive mother, is very commonly seen (King, duce vomiting to evacuate the stomach con- 1963). Many patients feel isolated and at best tents. She will go to enormous lengths to avoid attain only a poor social adjustment (Nemiah, takinog food and will hide it or dispose of it 1950). The quality of the patient's dependency unless arrangements are made to prevent this. on her mother has been studied by Crisp (1965a) who postulates a relationship between Denial of fatigue has also been emphasized by Mayer (1963) as a significant feature in the the typical patienit's pre-anorexic plumpness on September 24, 2021 by guest. Protected and the mother's neurotic need to over-feed patient. Overactivity and restlessness are ob- her. However, by no means all patients have served and the patient expresses a subjective been fat during adolescence and childhood. feeling of alertness and a distaste for idleness. The onset of anorexia nervosa following a Despite her often intelligent awareness of the voluntary dieting regime occurs only in one- caloric cost of exercise, the patient will nor- third to one-half of patients (Kay and Leigh, mally make every contrary effort to further 1954; Nemiah, 1950) and Loeb (1964) has jeopardise her limited energy reserves unless stressed the frequency of occurrence of other she is induced to do otherwise. The clinician precipitating conflicts in anorexic patients which is often struck by the patient's determined are unrelated to the drive to diet. All patients efforts to follow the path towards, seemingly, with anorexia nervosa do have, however, a her self-destruction. pathological distortion of t'heir own body image. Understandably patients with anorexia ner- While emaciation is not only obvious but ex- vosa are by itheir psychological characteristics treme, the patient denies being thin land defends at least ambivalent or at most hostile to thera- her appearance as being normal and right. This neutic efforts which are aimed at their resusci- Postgrad Med J: first published as 10.1136/pgmj.42.489.443 on 1 July 1966. Downloaded from July, 1966 KIDD and WOOD: Anorexia Nervosa 447 tation and recovery. Some patients revoke from prescribed in increasing dosage according to treatment to the grave injury of their already tolerance. Soluble insulin is given by intra- precarious clinical state. Many develop emo- muscular injection in increasing dosage and tional reactiions of withdrawal, depression and the resultant hypoglycaermia is terminated when anxiety in the iace of the treatment regime signs of sweating and drowsiness appear. Ana- and these secondary psychiatric manifestations bolics, vitamins and high calorie food supple- requiire recognition and management in their ments are also given. Intulbation is avoided own right. as it is psychologically undesiTrable and rarely required. Throughout the early stages of treat- Treatment and Outcome ment supportive psychotherapy is employed to Wall (1964) commented that the most im- provide encouragement, an atmosphere of portant element in treatment of anorexia ner- understanding and to mold the 'basis of the vosa is the actual recognition of the illness as doctor/patient therapeutic relationship. As the a psychiatric disorder, one which demands from patient improves the drugs are reduced, gradua- the clinician all the sustained effort and enthu- ted exercise is allowed and psychotherapy is siasm required for the management of a patient employed to aid the patient in making the with interacting physical and psychological dys- necessary readjustments in her psychological function. Medical, endocrine, metabolic and functioning that will both militate against re- psychiatric aspects of treatment cannot be con- lapse and favouir better personality and social sidered separately. Mayer's examination of the integration. Mayer (1963) has emphasized literature revealed a variety of reportedly effi- rightly th'at psychotherapy should be directed caceous but diverse treatment approaches. Hor- towards specific aspects of the patient's ab- monal methods have been employed (oestro- normal emotional characteristics. He has des- gens, thyroid, piltuitary extracts, ACTH and cribed this as a re-educative procedure whereby cortisone); forced feeding, intubation or intra- the patient must gain'the insight to learn, first, venous fluid therapy have been reported to "to see herself as others see her, as an abnor- by copyright. have'brought about remission; and psychothera- mally and unaesthetically thin individual"; peutic methods without physical treatments have second, to feel hungry and to want to react been found lbeneficial in some cases (Mayer, to hunger by desiring food; and th(ird, to feel 1964). Williams (1958) stressed the primary im- fatigue as others do. In short, psychotherapy portance of the nutritional aspects of treatment, here aims to reverse the characteristic triad of basing this conclusion from his uniformly suc- denifals. In most cases, psychotherapeutic sup- cessful results in patients fed by intubation, and port or management is required for some time suggested that specialised psychotherapy was after the patient has fully regained normal nutri- not indicated in treatment. In general, polemic tional and menstrual functioning. http://pmj.bmj.com/ viewpoints about approach to the treatment of anorexia nervosa are modified by the clinician's Follow-up for at least one year is essential awareness of the indivisible interplay of organic (Dally and Sargant, 1960). Studies oif outcome and psychological factors which present in this reveal much about the natural history of condition. A critical formulation of the thera- anorexia nervosa and the efficacy of treatment. peutic priorities in each anorexic patient's Relapse may occur and a fatal outcome clinical presentation is required. although now rare is still occasionally seen. The most successful treatment regime appears Of 30 patients treated in Aiberdeen between on September 24, 2021 by guest. Protected to be the joint use of insulin and chlorpromazine 1949 and 1965 only one is known to have died, or reserpine, given in combination with detailed by suicide. Foillow-up of William's (1958) series attention to the patient'is nutritional require- of 53 patients admitted to the London Hospital ments and psychological needs. This regime during a 60 year period showed that 10 had was described by Dally, Oppenheim and Sargant died, 3 had not improved, 33 had improved or (1958) and by Davidson and Nabney (1959) and recovered and 7 couild not be traced. Hawkings its superiority over other forms of treatment and others (1956) traced 15 of their series of was evidenced first by Dally and Sargant in 23 patients, all of whom had recovered. Dally 1960. This treatment programme is followed and Sargant (1960) found that of 20 patients at Aberdeen, as in many other centres in treated wi'th insulin and chlorpromazine, none Britain and abroad, with encouraging results. died, only 3 relapsed and most made a good Each patient is confined to bed so that energy recovery to normal weight and normal men- is conserved, observation is possible and food struation. Stafford-Clark (1958) found on one intake can be supervised. Chlorpromazine is year follow-up of 13 patients that 9 were either Postgrad Med J: first published as 10.1136/pgmj.42.489.443 on 1 July 1966. Downloaded from 448 POSTGRADUATE MEDICAL JOURNAL July, 1966 well or had some residual GRIMSHAW, L. (1959): Anorexia Nervosa: a Con- completely symptoms tribution to its Psychogenesis, Brit. J. med. Psy- yet none sufficient to interfere with daily life, chol., 32, 44. only one patient was still disabled by symptoms JGULL, W. W. (1874): Anorexia Nervosa, Trans. Clin. and three could not be traced. Kay and Leigh Soc. Lond., 7, 22. (1954) found on follow-up after periods from /HAWKINGS, J. R., JONES, K. S., SIM, M., and TIBBErrS, of R. W. (1956): Deliberate Disability, Brit. med. J., 2 to 19 years that about half the Maudsley i, 361. series of patients still had some menstrual ab- INNES, G., and SHARP, G. A. (1962): A Study of normality, disturbance of appetite or fluctuat- Psychiatric Patients in North-east Scotland, J. ing weight and eight patients had died, 3 from ment. Sci., 108, 447. the effects of anorexia nervosa, the remainder JKAY, D. W. K., and LEIGH, D. (1954): The Natural History, Treatment and Prognosis of Anorexia from other causes. Crisp (1965a) studied the Nervosa, J. ment. Sci., 100, 411. outcome of treatment in 21 patients two-and- ' KING, A. (1963): Primary and Secondary Anorexia a-half years after discharge; 2 had died, 17 Nervosa Syndromes, Brit. J. Psychiat., 109, 470. had regained normal weight of whom 12 ex- LOEB, L. (1964): The Clinical Course of Anorexia hibited normal eating behaviour, and 11 had Nervosa, Psychosomatics, 5, 345. established menstrual cycles. Crisp drew the J MAYER, J. (1963): Anorexia Nervosa, Postgrad. Med., treatment based on 34, 529. meaningful conclusion that iMILLAR, W. M. (1953): Psychiatric Implications of refeeding alone is not enough and is as un- Disturbances of Eating and Nutrition, Proc. Nutr. likely to be successful as unsupported attempts Soc., 12, 144. at superficial manipulation of the patient's life MOCULLAGH, E. P., and TUPPER, W. R. (1940): situation. and treatments Anorexia Nervosa, Ann. intern. Med., 14, 817. Physical psychological NEMIAH, J. C. '(1950): Anorexia Nervosa. A Clinical both are required. In anorexia nervosa, where Psychiatric Study, Medicine (Baltimore), 29 225. psychological and physiopathological factors PALMER, H. D., and JONES, M. S. (1939): Anorexia combine in producing a severe and debilitating Nervosa as a Manifestation of Compulsion Neu- disorder, a successful outcome depends on an rosis, Arch. Neurol. Psychiat. (Chic.), 41, 856. awareness of these two and on a /RUSSELL, G. F. M. (1965): Metabolic Aspects of by copyright. components Anorexia Nervosa, Proc. roy. Soc. Med., 58, 811. programme of patient management based on RkUSSELL, G. F. M., LORAINE, J. A., BELL, E. T., this recognition. ,and HARKNESS, R. A. (1965): Gonadotrophin and Oestrogen Excretion in Patients with Anorexia Nervosa, J. Psychosom. Res., 9, 79. RUSSELL, G. F. M., and MEZEY, A. G. (1962): An REFERENCES Analysis of Weight Gain in Patients with Anorexia Nervosa Treated with High Calorie Diets, Clin. BRUCH, H. (1962): Perceptual and Conceptual Dis- Sci., 23, 449. turbances in Anorexia Med., J STAFFORD-CLARK, D. (1958): Anorexia Nervosa, Brit. Nervosa, Psychosom. http://pmj.bmj.com/ 24, 187. med. J., ii, 446. CRISP, A. H. (1965a): Some Aspects of the Evolu- SUNDERMAN, F. W., and ROSE, E. (1948): Studies in tion, Presentation and Follow-Up of Anorexia Serum Electrolytes: Changes in the Serum and Nervosa, Proc. roy. Soc. Med., 58, 814. (Body Fluids in Anorexia Nervosa, J. clin. Endocr., CRISP, A. H. (1965b): Clinical and Therapeutic 8, 209. Aspects of Anorexia Nervosa: a Study of 30 WALL, N. M. (1964): Anorexia Nervosa, Psychoso- Cases, J. psychosom. Res., 9, 67. matics, 5, 157. DALLY, P. J., OPPENHEIM, G. B., and SARGANT, W. WALLER, J. V., KAUFMAN, M. R., and DEUTSCH, F. (1958): Anorexia Nervosia, Brit. med. J., ii, 6313. (1940): Anorexia Nervosa: a Psychosomatic En- /DALLY, P. J., and SARGANT, W. (1960): A New Treat- tity, Psychosom. Med., 2, 3. on September 24, 2021 by guest. Protected ment of Anorexia Nervosa, Brit. med. J., i, 1770. AVIGLEY, R. D. (1960): Potassium Deficiency in DAVIDSON, J. C., and NABNEY, J. B. (1959): A Case Anorexia Nervosa, with Reference to Renal Tubu- of Anorexia Nervosa Treated by a Oomrbination lar Vacuolation, Brit. med. J., ii, 110. of Psychotherapy, Insulin, and Reserpine, Ulster "WILLIAMS, E. (1958): Anorexia Nervosa: a Somatic med. J., 28, 205. Disorder, Brit. med. J., ii, 190.