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.