Copyright is owned by the Author of the thesis. Permission is given for a copy to be downloaded by an individual for the purpose of research and private study only. The thesis may not be reproduced elsewhere without the permission of the Author. ANOREXIA NERVOSA - ITS NATURE AND TREATMENT: A PHENOMENOLOGICAL INVESTIGATI ON A dissertation presented in partial fulfilment of the requirements for the degree of Master of Philosophy Susan Bridget Webb 1982 in Education at Massey University A B S T .R A C T This study e xamined the psychosomatic syndrome of anorexia nervosa , its characteristics , etiology and effects. In addition the t r eatmen t of the disorderwas considered from the perspective of the three psy~hotherapeutic approaches most commonly appl ied to it ; psychodynamic , behavioural and family therapy . The historical emergence and identification of ano r exia nervosa was briefly described and the emergence and develop­ ment of the three treatment approaches were outlined . The diagnosis, characteristics , incidence and factors concerning outcome in the disorder were examined . Each treatment perspective was considered in turn by outlining its under ­ st~ndings of human functioning and approach to abnormal functioning in general. Its theoretical stance towards anorexia ne rvosa was elaborated and the treatment p r ocedures based upon this described . Finally the outcome of t reatment within each approach was considered . ii A case study method employing a phenomenological approach was used to explore the perceptions and experiences of seven subjects who were o r who had been anorexic. In addition the perspective and experience of some of those closely associated with them at the time of thei r anorexia was also examined . Issues concerning the research method and the selection of the subjects were d iscussed and the na t ure of the contact wi th them and the manner in which the data was collected described . Data collected from the subjects, their associates , documentation provided by the ~ubjects and observations were analysed into themes which emerged during the process of the data collection . These were grouped into four theme categories comprising : The Self- Physical , the Self­ Psychological, the Self and Others and Interverrtion . The findings in each theme category are discussed in relation to existing literature. Major findings included an emphasis on issues concerning control and self ~oncept in the disorder , a reluctance to iii develop sexual r~lationships and a continued concern about food. exercise and interpersonal relationships. Vocational chcice indicated a preference for welfare-type work. Close family relationships were evident with some confusion apparent about female roles. Treatment experiences in the main tended to be perceived negatively in that they appeared largely controlling and insensitive. No one theoretical approach to the disorder could be identified as providing a completely comprehensive perspective with each having distinct advantages and disadvantages. Control and self-concept issues were identified as needing to be central to any consideration of anorexia nervosa treatment and it was reiterated that psychotherapeutic treatment needs as much as possible to recognize the unique nature of each case and not be too constrained by prescribed theoretical frameworks. iv A C K N 0 W L E D G E M E N T S I would like to acknowledge the assistance and support of a large number of people in the undertaking of this thesis. It would be impossible to name all of those to whom I am indebted but this in no way diminishes my gratitude to them. The following, however, I would like to make special mention of: Professor Ray Adams, for the provision of a stimulating and helpfulsetting in which to pursue my studies and especially for his very able and penetrating assistance in the early stages of this work when he helped me to clarify the topic and formulate the structure of the thesis. I am also indebted to his tolerance of any delays. Dr. James Chapman, whose understanding, good nature, refusal to panic and unshakeable faith in my abilities were of even more importance to me than his discernment and penetration with regard to the supervision of my work. I am deeply grateful for the meticulous and conscientious way in which he exercised his supervisory duties. Dr. David Battersby, for his wide-ranging interest in research and his enthusiasm for a topic outside of his normal sphere, for his guidance with regard to the methodology of this study and for the generous way in which the contents of his book­ shelves gradually found their way into my office to stimulate and clarify my thinking. Dr. Gary Hermansson, whose contribution to the completion of the thesis has been major. His dedication both on the personal and professional fronts has made it possible to complete the research and his stalwart determination has manifested itself not only in the meticulous way in which he has supervised the final stages of the study but also in the extra burdens he has assumed at home and at work in order to allow me the time needed. Jeanette Cooke and Asma Ibrahim, for their work in typing earlier drafts and their good-natured tolerance of the disorganization I brought into their lives through my involvement in this study. Jeanette Jones, who stepped ably into the breach to type the final draft at a time when it was invaluable to know that the security of a reliable, intellig~nt and efficient typist was at hand . Students at Massey and at Exeter Universities, who have been assailed by my ideas at various stages and whose apparent interest in the topic has helped to keep alive my own enthusiasm. Their understanding of the nature of my commitments other than to them has greatly eased the process of this research. Casie, Rhys and Leon, for whom theses appear to be becoming a way of life and who have be.en required to fend for and entertain themselves at times when I would dearly have lpveu- · to be involved too. Their support for my work and their preparedness to assist at home has been ~uch appreciated. Lastly, and most important, the subjects, their families and associates, who participated in this research and whose willingness to revive memorjes that were often painful and disclose aspects of themselves with which they were not comfortable have made this work possible. The time which they gave to me, the hospitality they offered and their desire to contribute to an area of knowledge about which they were concerned have been much appreciated. v TABLE OF CONTENTS Abstract ii Acknowledgements iv Table of Contents vi List of Tables and Figures viii Chapter One Introduction 1 Anoreiia Nervosa 1 The Treatment of Anorexia Nervosa 5 Psychotherapeutic Treatment Approaches 8 The Purpose of This Study 11 Chapter Two Review of the Literature 14 Anorexia Nervosa 14 Characteristics 14 Incidence 20 Treatment Outcomes 2i Prognostic Factors 22 Anorexia Nervosa and Psychodynamic Therapy 24 A Brief Outline of the Theory 24 Anorexia Nervosa as Personality Dys- function 27 The Psychodynamic Approach to Treat- ment of Anorexia 32 Psychodynamic Treatment Outcomes 37 Anorexia Nervosa and Behaviour Therapy 40 A Brief Outline of The Theory 40 Anorexia Nervosa as Maladaptive Behaviour 42 The Behavioural Approach to Treatment 44 Treatment Outcomes with Behaviour Therapy 56 Anorexia Nervosa and Family Therapy 60 A Brief Outline of the Theory 60 Anorexia Nervosa as Family Dysfunction 63 The Family Therapy Approach to Treatment 68 Treatment Outcomes in Family Therapy 78 Summary and Foundations for the Empirical Study 80 Chapter Three. Methodo1..2..g_z 84 The Research Approach 84 The Subjects 'and Their Selection 86 Data Collection 90 Data Analysis 92 Chapter Four Results and Discussion 96 The Subjects 96 Theme Category One - The Self-Physical 98 Food 98 Shape 102 Menstruation 105 Exercise and Activity 10 6 Summary and Discussion 10 7 Chapte~ Four (Codtinued) Theme Category Two - The Self-Psychological Willpower and Control Self-Concept Sexuality Work Summary and Discussion Theme Category Three-Self and Others Interaction Nuclear Family Extended Family Outside the Family Summary and Discussion Theme Category Four - Intervention The Early Stages Treatment Outcome Summary and Discussion Chapter Five Summary and Conclusions Appendix Bibliography Summary of Findings Limitations of the Study Suggestions for Furthsr Research Conclusions / 110 110 114 116 118 120 122 122 124 129 130 132 134 134 135 138 140 143 143 147 _- 148 149 151 154 Table I II 1 LIST OF TABLES AND FIGURE~ TABLES Details of the Anorexic Subjects Sources of Data FIGURES Dat3 Analysis Processes Page 88 89 95 1. CHAPTER ONE IN T R 0 D u.c T I 0 N This Introductory Chapter provides an overview of the major components of the study: anorexi~ nervosa and the three major psychotherapeutic approaches most commonly applied to it, and develops the research questions. Initially the concept of anorexia nervosa is described, its diagnosis, characteristics and incidence are considered and issues relating to these are identified. Confirming the relevance of historical and cultural contexts for treatment methods, attention is given to early descriptions of the disorder and its treatment. The development and features of the three psychotherapeutic approaches that most frequently are utilized in relation to anorexia nervosa: psychodynamic, behavioural and family therapy, are then briefly described and related to the disorder. / Questions arising from a consideration of anorexia nervosa and the treatment approaches applied to it are formulated and the rationale for employing a case study research method which emphasises phenomenological perspectives, in order to address these; is outlined. Anorexia Nervosa Anorexia nervosa is a serious disorder with a number of quite distinctive characteristics. According to Bruch (1973) the literal meaning of the concept is the loss of appetite due to 'nervous' problems. Regarded in most of the literature as being difficult to treat, it has been seen as one of the more dangerous problems occurring during adolescence, with mortality rates for cases ranging from 10% to 23% (Van Buskirk, 1977.) Because it is characterized by a number of symptoms the disorder is generally classed as a syndrome (Brady & Rieger, 1975). It affects mainly adolescent girls and young adult women (Bruch, 1973; Van Buskirk, 1977), the majority of anorexics falling into an age range of 10 to 25 years (Minuchin, Rosman & Baker, 1978). The syndrome is regarded as a psychosomatic disorder (Kaufman & Heiman, 1964) in as much as it includes physio­ logical and psychological symptoms. Physiologically, severe weight loss is the most notable symptom and this is usually 2. defined as a loss of 25% or more of body weight, (Minuchin et al, 1978). · Amenorrhea (i.e. the cessation of menstruation) is also seen as a symptom in post-pubertal girls (Stunkard & Mahoney, 1976). An excess of physical activity is generally evident, ann this differentiates anorexia nervosa from malnutrition caused by physical illness or circumstances external to the individual, where severe weight loss leads rather to lethargy (Bruch, 1973). Hypothermia, or the loss of body heat, especially in those in whom weight loss is great, is often a secondary symptom (Minuchin et al, 1978). In some cases sudden episodes of bulimia (i.e. voracious eating) occur, often followed by self-induced or involuntary vomiting and the misuse of laxatives and purgatives (Brady & Rieger, 1975). Various other physical symptoms ~re frequently evident, with examples of these being an increase in body hair and constipa­ tion (Palmer, 1980). In addition to the physical symptoms, the most notable psychological symptoms are an active pursuit of 'thinness' by controlling food intake (Minuchin et al, 1978) and a dread of , gaining weight (Stunkard & Mahoney, 1976). Some (e.g. Bruch, 1973) have considered a distortion of body image to be a symptom central to diagnosis, with the anorexic denying that her emaciated body is in any way abnormal. A sense of ineffectiveness and a struggl e for control are also identified as symptomatic by numerous researchers (Boskind-Lodahl, 1976 ) . The family characteristics of anorexics appear to have some consistency. Anorexia nervosa seems to occur mainly in middle-class and upper-class families where shortage of food is unlikely to have been an issue, at least during the anorexic's lifetime (Bruch, 1973; Minuchin et al, 1978). These same writers do suggest, however, ~hat food and its I ' preparation are likely to . be a central concern within the family. Families ten~ to see themselves as loving and usually problem-free until the emergence of the anorexia (Minuchin et al, 1978). The prpblem usually begins with an initially reasonable desire to lose weight, with anorexics having often been slightly overweight in childhood, but continues beyond what is seen as reasonable (Brady & Rieger, 1975; Boskind­ Lodahl, 1976). The family's picture of the anorexic is usually one of a model child; obedient, quiet, eager to please and hard-working, until the emergence of the disorder (Brady & Rieger, 1975). Despite the apparent distinctiveness and clarity of the various physiological and psychological symptoms in anorexia nervosa, diagnosis, for several reasons, has been and still 3. is problematic. One major reason is related to variations in cultural norms. Weizsack~r (1937), for example, noted that the religious ascetic tradition of self-denial, especially denial of bodily needs, has existed in many cultures for centuries and in this way self-starvation has been seen as a virtue. In addition, the post-war affluent world and in particular its media have emphasised the desirability of slim­ ness. Describing self-starvation as a 'problem' therefore becomes relative t0 the meaning ascribed to it by its culture. Another reason relates to difficulties in differentiating- / between anorexia nervosa and other disorders, heightened by the range of physical and psychological characteristics involved. There is a tendency to perceive it in relation to such other disorders. Historically, it was linked to tuber­ culosis by Sir Richard Morton in 1684, although he termed it 'Nervous Consumption' in order to differentiate it (Bruch, 1973). Later, both Gull (1873) and Lasegue (1873) provided a diagnostic description and between them established its modern name which stressed the psychosomatic nature of the disorder. With the discoYery in 1914, however, of Simmonds disease, a diso~der of the pituitary gland which causes severe weight loss, anorexia nervosa too was presumed to result from hormonal dysfunctioning and attempts were made to discover its endocrinic origins (Bruch, 1973). More recently there has been difficulty in differentiating anorexia nervosa from schizophrenia and depressi.on., both of which can involve considerable weight loss (Brady & Rieger, 1975). Van Buskirk (1977) in criticising some studies of anorexia nervosa stated that a number had included cases which could be diagnosed in terms of those disorders. Another difficulty relates to problems in establishing which symptoms are primary and which are secondary. For example some writers see amenorrhea as being a separate 4. symptom (e.g. Crisp & Fransella, 1972) whilst others see it as secondary and resulting from the malnutrition (e.g. Brady & Rieger, 1975). Similarly, constipation,increase in body hair, loss of interest in sexual activity and peculiar food preferences, all relatively minor identifying symptoms, may also be secondary to the malnutrition (Bruch, 1973). An additional reason for difficulties in diagnosis lies in the fact that one of the most distinctive symptoms, weight loss, is a relative phenomenon. It is established in relation to previous weight, yet sufferers may have been overweight before the onset of the anorexia or it may be difficult to decide at what point the problem began in order to calculate weight loss. Moreover, as Van Buskirk (1977) pointed out, weight loss or gain needs to be seen in the context of age; if at 16 years a girl has lost 25% of her body weight over four years this is more serious than for a 22 year old over the same period who is unlikely to have grown much in tha~ time. Even an apparently straightforward characteristic like age is likely to be confused, with some cases manifesting appropriate symptomatology being identified outside the most likely age range of 10 to 25 years. (Hall, 1975). It is not surprising then that Bruch (1973) has stated that the concept of anorexia nervosa has become quite blurred. Minuchin et al (1978) highlighted this too when pointing out that not only had many cases in the past been diagnosed as anorexic that were not, but also that many cases had been excluded because they did not fit the definitions accepted at the time. Taking into account these various diagnostic problems, general indications do seem to be that anorexia nervosa is becoming more prevalent. Although widely described as 'rare' (Stunkard & Mahoney, 1976) ', claims are being made that it is becoming quite a common condition. Kalucy and Crisp (1977) see it in this way, claiming that it affects one in every 100 women aged 16 to 18 years in the London area. The' fact of an actual increase,and if so whether it is due to changes in diagnosis, social conditions., public awareness, fashions in body shape, child-rearing practice, or other causes1 is open to co~iderable debate. What can be stated with some 5. certainty, howevei; is that anorexia nervosa has become more widely recognized and discussed; for example, recently a self­ help guide for anorexics was published by Pelican (Palmer,l980), a widely publicized play about the syndrome appeared on New Zealand television in 1980, several articles appeared in 'Broadsheet' a New Zealand feminist magazine (Matthew, 1980; Coney, 1980, Calvert, 1980), an autobiographical account by a novelist was published (MacLeod, 1981), and several letters have appeared in the problem pages of young people's magazines (e.g. 'Photo-Love' 1982). Anorexia nervosi then appears to be becoming a rather ubiquitous concept. It is defined by a number of character­ istics yet there are major difficulties concerning diagnosis, largely because of the number and variety of symptoms involved and the uncertainty of their interrelationships. The compexity of the disorder has lent itself to the emergence of a variet~ _ of causative explanations, none of which has proved conclti~ive. These explanations have mainly emerged from within the perspectives of the different treatment approaches that have been applied to it rather than developing from a independent consideration of the disorder itself. This circumstance is not peculiar to anorexia nervosa, it is the same with various specific disorders (e.g. depression). However, anorexia nervosa represents a striking example of the different under­ standings which may be developed with regard to a disorder and the different emphases applied in treatment. The Treatment of Anorexia Nervosa In considering the treatment of anorexia nervosa it is important to recognize that treatment procedures arise out of concepts of functioning which have social and historical roots. These determine the direction and limits of treatment develop­ ment (Minuchin et al, 1978). Consideration of past and present treatments of anorexia nervosa therefore must bear in mind the belief systems implicit in them. In relation to mental disorders in general, it seems that medieval European thought perceived psychologic~l problems as resulting from the commission of sins or possession by evil spirits. Punishment and torture provided penance for the sins and attempted to cast out the spirits (Stafford-Clark, 1963). 6. Body and soul were·seen as separate in Christian thought and the flesh needed to be controlled so that its weaknesses did not permanently tarnish the soul. In the late 18th Century and early 19th Century, in line with other humanitarian developments, a moral therapy involving a process of education and example rather than punishment for-psychological problems emerged (Belkin, 1980). Expansion in the understanding, diagnosis and treatment of organic illnesses, heralded by the discovery of the syphilis bacteria in the early 19th Century, . then led to an attempt to identify physiological causes for . emotional problems too (Stafford-Clark, 1963). When organic causes could not be identified, the disease model was trans­ ferred to a framework of psychical illness (O'Leary & Wilson, 1975). Elements of these varying stances are evident in the early reports of treatment of anorexia nervosa, and these reports also introduce issues relevant to more contemporary treatment methods. / It has been suggested that the earliest known report of a case of anorexia nervosa appeared in the writings of a Persian physician and poet, Nizami-i Arudi in about 1155 A.D. (Shafii, 1972). The rather humanitarian approach adopted to treatment seems to be in contrast to the European thinking of the times described above. The case involved a young prince who was refusing . to eat and was under the delusion that he was a cow that should be killed. The treating physician, Avicenna, chose not to con.front the delusion but rather addressed the young man as a cow stating that he needed fattening before he could be killed. As well, after the first consultation, Avicenna treated the prince indirectly by dealing with his friends and family, thus altering the social context in which the disturbed behaviour occurred. The young man recovered and the delusion apparently d~sappeared. Shafii (1972) considered that, given the prince's youth, social situation and refusal to eat, he had suffered from anorexia nervosa. However,. the existence of the delusion might suggest another d~agnosis. A 17th Century account of a case seems recognizable as anorexia nervosa. The treatment prescribed, however, indicates that it was perceived predominantly as a physical ailment. In 1648 Sir Richard Morton described the case of a girl who died 7. of a 'fainting fit 1 (Bruch, 1973). Morton was aware of the emotional content of the problem which he called 'Nervous Consumption', but had treated it by adopting a physical illness model in which herbal preparations and tonics were prescribed to encourage appetite. Other likely cases prior to the end of the 18th Century may not have been recorded for a variety of reasons. It may be that few were affluent enough to be vulnerable to anorexia nervosa, that since malnutrition was relatively common, self­ induced starvation passed. unnoticed, or that it was seen as a relatively normal expression of youthful religious fervour. Progress in the field of medicine in general in the 19th Century was echoed with regard to anorexia nervosa. A number of cases were reported which seem recognizable as anorexia nervosa, and in this period the disorder was identified, named and delineated as a syndrome. Aspects of treatment then appear -- . to have similarities with more contemporary approaches,as / will be evident in later material. For instance, in 1873 Gull recommended with regard to what a person would eat that 11 the inclination of the patient must in no way be consulted" (in Kaufman & Heiman, 1964, p.l35). He also stated that 11 the patients should be fed at regular intervals and surrounded by persons who would have moral control over them, relations and friends being generally the worst attendants" (ibid.~p.l30). Gull appears to have adopted a 'moral therapy' approach, and highlighted the influence of existing social contexts. Also in 1873, Lasegue noted the significance of social contexts indicating the frequency of family entreaties and the equal failure of these. He saw the presence of these to the extent that they might well even be a diagnostic factor (in Kaufman & Heiman, 1964). Las~gue found patients to be "docile for the least attractive remedies'', although "invincible in regard to food" (ibid.,J l964, p.l49). He also recorded that he knew of patients who 10 years after the origin of the problem were still unable to eat normally. One patient who had recovered, when asked ~hy she could not eat during the period of her illness, replied 11 I could not, it ~vas too strong for me and moreover I was very well" (ibid.,l964, p.155). In 1899, Charcot contributed interesting new perspectives, 8. of relevance to contemporary treatment approaches. The overt treatment model was again physical and the girl was referred to a 'watering place', but Charcot made the firm recommendation that her family not accompany her. This was initially ignored and only after the reluctant parents had withdrawn did she start to recover. Charcot suggested that such patients should always be separated from their families and rare contact with them should be used as a reward after some initial improvement (in Kaufman & Heiman, 1964). These methods not only recognized the importance of family functioning but also were a forerunner of behavioural methods that have been elaborated in more recent times. These early descriptions of the disorder and its treatment provide a picture of the thinking prevalent at the time. They also reveal many similarities with contemporary perceptions. In the 20th Century, whilst the search for medical solutions has continued, there has been considerable development in/ treatment approaches to anorexia nervosa, as with other dis­ orders, that concentrate on psychological dynamics. For anorexia nervosa, three psychotherapeutic approaches in particular have been applied in regard to both causative explanations and treatment methods. These psychotherapeutic approaches are psychodynamic, behavioural and family therapies. Psychotherapeutic Treatment Approaches The emergence and development of these specific treatment approaches are important to consider in themselves, as each builds its own perspective from which the explanation of causes and the treatment of anorexia nervosa are undertaken. With the failure of attempts during the 19th Century to find physical causes for the majority of mental disorders, as previously mentioned, the . disease model was not discarded but transferred to a psychological framework. Abnormal behaviour was regarded as a symptom of an underlying psychological illness and theoretical explanations were elaborated. Treat­ ment aimed to search for the illness and identify its causes rather than merely treating the apparent symptoms. At this stage Freud and various colleagues began to develop the concepts of personality and treatment which came 9. to be known as Psychoanalysis. This approach perceived abnormal behaviour as symptomatic of underlying problems, which related to early experiences (Hall, 1953). It challenged the separation of body and mind implicit in earlier thinking (Alexander, 1939), seeing the mind as possessing power over the body, the function­ ing of which it might alter to meet needs relating to early experiences. Hysterical paralysis is a clear example of this (Stafford-Clark, 1963). The influence of Darwinian thought led Freud and others to consider reorganization between psyche and soma as being caused by the organism 1 s need to adapt in order to survive (Mt. Sinai Group, 1964), so abnormal behaviour· was seen then as a coping mechanism. Modern psychodynamic thinking, which has developed from classical psychoanalysis, although disputing and to some extent rejecting much of what Freud and his contemporaries postulated, still searches for the underlying dynamics of disorders, concentrates on individual functioning, looks to past experiences for the/ cause of problems, and tends to adopt an illness model with the therapist as 'expert'. Anorexia nervosa in broad terms, is perceived within this framework as an illness based on dysfunctional adjustments between psyche and soma which have their roots in childhood experiences. Treatment focusses on exploring the underlying and historical meanings of the refusal to eat in order to resolve the conflicts associated with these (Bruch, 1973). Behaviour therapy was developed after the Second World War period from the belief that emotional problems were essentially learned responses and that more adaptive responses to situations could be substituted by new learnings (Wolpe, 1969). Abnormal behaviour was not seen as a symptom of under­ lying illness, but as a consequence of inappropriate environ­ mental reinforcements. Moreover, the perception of a behaviour as abnormal or maladaptive was dependent on its social context (Kazdin, 1980). Whereas the medical model presumed an expert working directly with a patient, the behavioural model, in line with a more egalitarian philosophy evident in society as a whole, recognized the influence on behaviour of those in everyday contact with the client and attempted to use them to alter behaviour by training them and the clients appropriately (Kazdin, 1980). In this approach anorexia nervosa is seen as a learned set of inappropriate behaviours that have been reinforced and treatment focuses mainly on shaping more appropriate eating behaviour ·(stunkard & Mahoney, 1976). 10. Family therapy also developed after the Second World War period. In line with sociological thinking, it has directed attention to the social context of problems and underlined the limits of individual power within a system (Belkin, 1980). Behaviour is perceived as a function of the psychosocial context (Walrond-Skinner, 1977) and since the individual is both dependent on and affects the family system as a whole, it is this whole system. that must be treated (Boszormenyi­ Nagy & Spark, 1973; Minuchin et al, 1978). Family therapy regards balance within the system (homeostasis) as a major focus, as balance is regarded as the family's intention (Walrond-Skinner, 1977). If the system's balance is upset by an alteration in one individual's behaviour, either the family will exert pressure for the re-instatement of that behaviour or the whole system must adjust to establish a new balance. Treatment is not geared directly to the alteration of the identified patient's behaviour but to establishing a more satisfactory, constructive balance within the family. From the perspective of General Systems Theory, most commonly used in family therapy work, family problems are s.een in relation to breakdowns in communi­ cation within the system which lead to inappropriate means of maintaining balance. In the disturbed system, communication may be blocked, displaced or damaged (Walrond-Skinner, 1977), so the family is unable to adjust to changing circumstances by establishing a new form of balance. In treating family systems, therapists must be aware of their own social role in relation to the system and also be able to recognise and work with relationships between. systems (Haley, 1976). Anorexia nervosa viewed from the family therapy perspective is regarded as an indication of family dysfunction and a breakdown in communica.ti.on, . and treatment focuses- on creating a more functional mlance within the family system (Minuchin et al, 1978). Treatment outcomes in psychotherapy can be difficult to determine and many elements impinge on whether it is possible 11. to provide accura~e results regarding success or failure. This difficulty seems particularly relevant to a disorder as complex as anorexia nervosa. Studies relating to the effects of treatment have mainly taken place within separate theoretical frameworks (e.g. Bruch, 1973; Bhanji & Thompson, 1974; Minuchin et al, 1978). Although some studies, ·such as those by Eckert, Goldberg, Halmi, Casper and Davis (1979) and Garfinkel, Moldofsky and Garner (1977) have attempted to compare treatments based on different theoretical approaches, the results have proved inconclusive. Hsu (1980) in a comprehensive review of treatment outcomes, stated that differences between treatment studies from a variety of approaches seemed to depend on the selection of cases and the assessment criteria employed. No treatment approach emerged as the preferred method. At this stage then it appears that no one treatment approach can be claimed to be the most effective with regard to anorexia nervosa. In addition, success rates for treatment overall cannot be regarded as satisfactory (Bemis, 1978). Whatever the reasons claimed for this in the individual studies, there is obviously a general need to obtain a clearer understanding of the nature of anorexia nervosa which is complicated by the number of factors involved in the disorder and the uncertainty of the underlying dynamics. Until a greater understanding has been achieved, the most effective treatment methods cannot be identified and utilized in therapy. Indeed, it may be that it is unidentified features of the syndrome which render successful treatment so elusive. The Purpose of This Study Although anorexia nervosa has been extensively studied then, there would appear to be a great deal yet to be discovered. It has proved difficult to treat, the success rate has not been good and the mortality rate is high relative to other mental disorders in this age group. There is confusion with regard to diagnostic criteria since the relationships between symptoms of the syndrome are not fully known. Moreover, the incidence would appear to be increasing. Whilst there are some common elements to the under­ standings and treatment procedures employed with regard to anorexia nervosa, there remain considerable differences of 12. opinion as to the· appropriate method or methods of treatment, since these are linked to general beliefs held about human functioning by the different approaches. The causes of anorexia nervosa remain unclear and the subject continues to elicit extensive debate in therapeutic circles. This is because the disorder provides a fertile battleground, not only for discussion about the relationship between mind and body, but also for the contrasting beliefs of the different theoret­ ical perspectives into which the disorder has been fitted. It is possibly for these kinds of reasons that previously so rare a complaint has been the subject of so much attention of late in the literature of therapy. Despite the extensive literature, a need still exists for a more direct consideration of the dynamics and causative factors in anorexia nervosa. These may then be translated into appropriate treatment methods rather than methods being_ applied which have emerged from more general theoretical / perspectives. It seems inevitable in the latter situation that perceptions of the disoTder will be moulded to fit the particular theoretical perspective involved. This study attempts furth~r to explore questions of the likely nature and causes of anorexia nervosa in girls and young women by approaching it largely from a phenomenological perspective employing a case study method. This allows the experience of the anorexics themselves and those closely associated with them to emerge without the constraints of a particular explanatory framework forced upon the disorder by any treatment approach or treatment setting. The overall aim in this study is to explore the perceptions and experiences of a small. number of anorexic subjects with a view to gaining increased understandings of the disorder and to establishing where these link with those of the major treatment models. In this way selected practices within existing approaches may emerge as being especially relevant for effective treatment. In addition t~e purpose is to seek to uncover aspects of the disorder in these subjects which are not necessarily accounted for at present in the theoretical explanations and to begin to postulate some ~ossible new theoretical understandings of the syndrome. The case study method has been recognized by 13. Neale and Liebert (1973) as a useful tool both for questioning previously established beliefs and for exploring the existence of possible new elements; and the phenomenological perspective allows a more intensive individual consideration of unique experiences and perceptions in doing this (Bullivant, 1978). Initially the extensive literature on anorexia nervosa itself and as it is considered within the major psychothera­ peutic approaches will be reviewed in order to determine various themes and viewpoints which emerge from those doing research and therapy on the disorder. Their perceptions of the nature and dynamics of the disorder will be examined, their treatment methods described and reviewed in relation to anorexia and the results of their treatment considered. Then the perspectives which arise from a consideration of a small number of past and present cases of anorexia nervosa will be analyzed through an exploration of their own experience and that of some of those directly concerned in their anorexia. Their perceptions will be outlined and their meanings for their actions and the actions of those around t h em, both past and present will be examined. This will be done by the identification of themes which emerge from their accounts supported by examples of their own statements, written documents and the observations of the researcher. It is proposed to link these themes with the understandings offered by the three treatment approaches described. In this way it should be possible to identify any other elements of the syndrome present in these cases which are not adequately addressed by any of the approaches but which may be influential in treatment. New elements which might emerge from this consideration of a small number of cases could then perhaps be pursued in a more general research context in order to establish their more general applicability. 14. CHAPTER TWO R E V I E W 0 F T H ·E 1 I T E R A T U R E Having developed the various research questions to be examined in this study: what are the likely causative dynamics of anorexia nervosa and to what extent do the three psychotherapeutic treatment approaches most frequently utilized in relation to it seem appropriate with regard to explanation and treatment, this Chapter considers them in greater detail through an examination of the literature . This material both elaborates the major questions of the study and highlights some of the essential themes to be pursued in the context of the more empirical analysis . Firstly, there is consideration of the literature on anorexia nervosa itself in relation to its physical, psychological and social characteristics, its incidence, general treatment outcomes and prognostic features. Then consideration is given to the three psychotherapeutic approaches most commonly applied to the disorder . The psychodynamic approach is briefly descri bed from major literature resources, looking at its perspective on human functioning and on psychological problems, then material is • reviewed on the approach in regard to an explanation of anorexia nervosa, the treatment procedures adopted and their reported outcomes. Behaviour therapy literature is considered within the same broad fo rma t and then family the rapy is similarly examined. Finally, there is a summary of what this literature seems to be claiming about anorexia nervosa and its treatment. From this the development of the foundations for the empirical study are elaborated. Anorexia Nervosa Characteristics Anorexia nervosa is characterized by a variety of relatively distinctive symptoms . These symptoms are utilized for diagnosis and an exact determination of the nature of anorexia nervosa is likely to remain problematic while there are conflicting theories as to its origins . It is regarded as a syndrome requiring multi - factorial diagnosis in both the physical and psychological areas (Szyrynski, 1973). Andersen 15. (1977) has suggested that most diseases are initially regarded as syndromes, or collections of empirically derived symptoms, until their causes are found with the majority of psychiatric disorders in particular being in this situation. The problem that goes with using symptoms as evidence of a disorder is that some features will be more important "than others in diagnosis, with some even being dependent on others. Moreover, emphasis given to and understandings of various symptoms will depend on the orientation of the examiner or therapist (P erk in & Surtees, 1976). The boundaries of the syndrome become difficult to identify since writers do not all apply the same diagnostic criteria . The lack of a rigorous and uniform definition of anorexia nervosa in the literature has been pointed out by among others, Hsu (1980), Van Buskirk ( 1977), and Vigersky and Andersen (1977) . Tolstrup (1975) considers that the widely differing views o~ - . the nature and management of anorexia nervosa arose mainly because of the different descriptive criteria used in diagnosis. It may also be postulated however, that different understandings of its nature and managemen.t have influenced the diagnostic criteria selected. The criteria for defining anorexia nervosa have been separated in the literature into physical and psychological symptoms. The central physical symptom is severe weight loss (Bruch, 1973), usually defined as mor e than 25% of original body weight (Bemis , 1978). Other symptoms may include amenorrhea in post - pubertal girls, growth of downy hair upon the face and body, a low pulse rate and body temperature, hyperactivity (us ed in the anorexia literature to mean constant, restless activity), bulimia, and vomiting which may be self­ induced or involuntary ( Feigner, Robins, Gaze, Woodruff, Winokur & Munoz, 1972; Halmi, Goldberg, Casper, Eckert & Davis, 1977). The likelihood of constipation is also noted by, for example, Szyrynski (1973) and a loss of interest in sex, ~oskind-Lodahl, 1976) which may perhaps be ~ore accurately described as a psychological characteristic. There are some difficulties involved in applying these physical criteria to diagnosis . The exact definition of severe weight loss is problematic. As Bruch ( 1978) pointed 16. out, many anorexics are somewhat overweight before they begin dieting, the exact point of the onset of weight loss is usually difficult to determine (Brady & Rieger, 1975; Bruch, 1'73), and developmental changes in adolescence may obscure the full extent of the weight loss. The existence of downy hair, slow pulse rate, low body temperature, constipation and loss of sexual interest may be a direct consequence of a state of starvation, as these characteristics also occur in people suffering from externally induced malnutrition (Bruch, 1973; Palmer , 1980; Silverman, 1977). There is argument too as to whether amenorrhea and hyperactivity should also be presumed to result from malnutrition. Some writers reported that amenorrhea mainly occurs early in the disturbance and before the re is any appreciable weight loss (e .g. Halmi et al, 1977; Silverman, 1977; Thoma, 1977) while others claimed that it resulted directly from the weight loss ( e.g. Boskind-Lodahl, 1976). Bruch (1977) ment~oned the particular sensitivity of­ menstrual functioning to emotional stress , while Vigersky and Andersen (1977) stated that menses resumed at an appreciably . higher weight than did menarche, suggesting that the relation- ship between weight and menstruation was not clear-cut. Hyperactivity, another physical symptom , has also been widely accepted as a diagnostic factor (Feigner et al, 1972; Halmi et al,· 1977 ; Minuchin et al, 1978), yet Crisp and Stonehill (1976) suggested that this too could be related to the nutritional state. They stated that restlessness and difficulties in sleeping, both usually perceived as aspects of hyperactivity, were common when a subject was experiencing hunger. Together these concerns about the relationships among the physical symptoms raise serious questions about their utility in diagnosis. A wide range of psychological criteria, of some uniformity yet of equal uncertainty, have also been identified. These include a firm determination to eat as little as possible, a fear of being fat, a denial both of hunger and of the existence of any eating problem, a distorted body image and unusual food hoarding and food handling behaviours (Feigner et al, 1972). The distorted body image notion has been found by Casper, Halmi , Goldberg, Eckert and Davis (1979), Crisp, 17. Kalucy, Lacey an~ Harding (1977) and Garfinkel et al (1977) to involve an overestimation of body width. Bruch (1973) and Minuchin et al (1978) also included in the psychological symptoms a sense of ineffectiveness and a struggle for control. In challenging some of these symptoms in diagnosis, Bruch (1978) suggested that anorexics' unusu~food handling behaviours, such as cutting food into very small pieces, were also typical of those suffering from externally induced starvation. She also stated that individually-specific critical weight loss in itself can lead to increased bodily toxicity and associated psychological dysfunction. Although Casper, Halmi et al (1979) found the extent of body image distortion to be greater among anorexic patients, an age-matched female control group also overestimated their body widths, suggesting that this also is not an accurate diagnostic criterion. In addition to establishing which symptoms may indicate - ' the presence of the syndrome, diagnosis must also exclude any involvement of other major complaints, either physical or psychological, which involye weight loss. Thus, as Ross (1977) pointed out, tuberculosis, malignancy, hormonal disturbances and diseases of the digestive system must be excluded as must psychiatric illnesses where weight loss may occur, such as schizophrenia, depression and obsessive-compulsive neurosis (Brady & Rieger, 1975). Yet, Silverman (1977) included 19 diagnosed schizophrenic subjects in a study of 65 anorexics and Halmi et al (1977) included subjects who were considered depressed or obsessive-compul_sive at the time of the anorexia but who had not been formally diagnosed as such previously. Age is also regarded as ~broad criterion for diagnosis. Feigner et al's (1972) criteria stated that 25 years was the maximum age of onset. Halmi et al (1977) restricted patients to those between 10 and 40 years but for them the onset of illness needed to be between 10 and 30 years as was the case with, for example, Bru~h 1 s (1973) 60 patients. All of Minuchin et al 1 s (1978) subjects were under 20 years at the time of onset. Lucas, Duncan and Piens (1976) suggested that the later the age of onset the more likely that the disturbance was not anorexia. Not all studies, however, have confined themselves to these age groupings (e.g. Bliss &· Branch, 1960) 18. and this has added to the confusions about accurate diagnosis. The lack of well-defined, uniform and unique character­ istics which indicate anorexia nervosa is clearly a confusing feature of the disorder. Andersen (1977), however, while recognizing the desirability of clea~ diagnostic criteria such as those presented by Feigner et al (1972), noted the problems that a strict adherence to them could cause in diagnosis, understanding and treatment. He suggested that there were three types of atypical anorexia nervosa (i) where the syndrome is typical but the presentation is atypical, when for instance the age of the patient is more than 25 years at onset (ii) where the presentation is typical but the syndrome is atypical, either quantitively, the subject not having enough symptoms to qualify, or qualitatively, where the symptoms exist but are not severe enough to qualify, and (iii) where neither presentation nor syndrome are typical but no other cause for the weight loss- ~ can be found. Andersen felt that diagnosis should be sufficiently flexible to accommodate these variations. / As well as various physical and psychological symptoms, anorexia is broadly identifiable in relation to various social characteristics. It appears to be a predominantly female . disorder. The ratio of males to females suffering from anorexia nervosa seems relatively uniform in various studies on incidence. Brady and Rieger (1975) quoted one male to 10 females as did Szyrynski (1973). Six of 53 subjects studied by Minuchin et al (1978) were male, as were 10 of Bruch's (1973) 60, and 27 of Crisp et al's (1977) 350 anorexics. Anorexics have seemed to come from mainly middle and upper socio-economic class . groups and to be high achievers academically. Crisp, Palmer and Kalucy (1976) from a sample from the London area noted that one girl in 200 at private and boarding schools sufiered from anorexia whilst in state schools the incidence was less than one per 3,000. Hall (1978), in New Zealand, stated that most families came from what she identified as the middle and upper classes. Halmi et al (1977), in the USA, claimed that there was not one well-documented case in the literature of this d~sorder occurring in a black 19. American, and Hall (1978) stated that she had only seen one case of a half-Maori girl in New Zealand and that she came from a socially upward-mobile family. Minuchin et al (1978) also noted the middle class origins of their patients in the USA, but Lawrence (1981), in Britain, made the claim that not all anorexics came from middle-class families. She considered that many were working class by father's occupation, but out of 60 clients seen by her, only one did not achieve at least 1 0 1 level standard at school. Conscientiousness and a high level of intelligence have been found to be common in anorexic patients (Hall, 1978; Boskind-Lodahl, 1976; Bruch, 1973). Silverman (1977) noted that nearly all of his sample were of average intelligence but that most of them were 'overachievers'. Family characteristics appear to be important in the development of anorexia nervosa, although genetic inheritance did not seem to be a factor as it appears to be, for example_,_ . with some obesity problems (Stunkard & Mahoney, 1976). Hall's (1978) study of the family structure and relationships of 50 anorexic patients provided information in the New Zealand context. Parent's ages tended to be higher than in the general population, with this being supported by Bruch (1973) in the American context. Hall found the incidence both of psychiatric illness and physical illness to be more common in parents of anorexics than in the population as a whole, although these problems tended to be under-emphasized by them. Th is ma y link in with the denial or minimization of the anorexic problems by the cases themselves, as noted. by Feigner et al (1972). Hall (1978) also found that marital unhappiness was common, a finding shared. by Minuchin et a.l (1978) in the USA, and Kalucy, Crisp, Lacey and Harding (1977) in Britain, and that a uniform picture of social conformity was evident. Bruch (1978) also noted ~ family emphasis on polite behaviour. This supports the description by Minuchin et al (1978) of rigid, conflict-avoiding families. Some reports mention the particular role of the mother in the family. Szyrynski (1975) mentioned the frequent dominance of the mother, Boskind-Lodahl (1976) and Bruch (1978) commented that. many mothers seemed to have been career women who had sacrificed their ambitions for the good of their families. When considering siblings, Hall (1978) found that the families of her 50 cases contained more daughters than sons. 20. The family size did not differ from that of the New Zealand population in general and contained 112 female children to 48 males. Bruch (1978) found that two thirds of her families contained daughters only. Stunkard and Mahoney (1976) stated that there was a high incidence of anorexia among sisters, but in only two of Hall's families was this evident, when older siblings had developed and recovered from mild anorexia nervosa. In the light of the apparent increase in the disorder, this does not suggest a high concordance. Incidence Recent evidence suggests that the incidence of anorexia nervosa is increasing, although it was formerly believed to be a relatively rare disorder (Brady & Rieger, 1975; Stunkard & Mahoney, 1976). Szyrynski (1973) for example, estimated th~~ ­ one in 300 cases referred to psychiatric hospitals and c~inics were anorexic. Kalucy et al (1977) described the disorder as affecting one in every 100 sixteen to eighteen year old school girls in and around London. Bruch (1978) stated that over the last 15-20 years the incidence of anorexia nervosa had increased at a rapid rate. She found that whereas her patients in former years had no knowledge of the existence of anorexia nervosa as a diagnosed disturbance, very few young women she now saw were unaware of its existence. She also suggested that the increase in the problem might be partially associated with an increased emphasis on slimness, especially for adolescents. Palmer (1980)noted a considerable increase in the professional literature on anorexia nervosa, which was proportiona~ely greater than the increase of such publications in general. However, he pointed out ~he difficulty in distinguishing a real increase in the inci.dence of the disorder from an increase in referrals for treatment arising from a greater consciousness. Kalucy and Crisp (1977) pointed out that the typical avoid~nce of medical attention and denial of illness characteristic of those suffering from anorexia nervosa made it difficult to estimate the incidence and both Lawrence (1981) and Palmer (1980) suspected that for these reasons those identifiec represented but a small proportion of the problem. 21. Treatment Outcomes In the literature, a great deal of uncertainty surrounds questions of treatment outcom~s and prognosis . Considerable variation occurs among the different treatment approaches and where it is possible to identify the approach being used then attention will be given to these findings under the categories of the treatment methods themselves. However, a number of general confusions surround these questions. As Van Buskirk (1977) pointed out , criteria for outcome vary a great deal according to the stance being taken to the problem and the treatment approach utilized . The extent of this led Hsu (1980) and Thoma (1977) to claim that it was impossible adequately to compare studies of outcome. The difficulty is accentuated by the fact that there are wide variations in the different patient populations studied, as pointed out by Crisp et al (1977) and Vigersky and Andersen (1977), with Russell (1977) seeing this as a function of the treatment settings and referral agencies as much as of the therapis~sand any diagnostic confusions. Variations in follow - up time periods were also pointed out by Crisp et al (197 7) and Vigersky and Andersen (1977), with the former stressing the fact that the problem of anorexia may fluctuate over a considerable time span and being supported in this by Russell (1977) and Theander (19 70) . Hsu (1980) also raised questions about follow-up studies indicating that information for these was often incomplete and Ross (19 77) saw them as often being more impressionistic than factual . The various procedures .utilized in outcome studies also raise important questions . Given the tendency for subjects and their families to deny the existence of problems, the con­ tacts made by letter or telephone and information provided by relatives in Russell's (1977) and Brady and Rieger's (1977) studies, for example, make the results questionable . Similarly, Bhanji and Thompson's (197() postal questionnaire to the Gener~l Practitioners of anorexic patients leaves considetable room for doubt about the results. Other instruments such as the Middlesex Hospital Questionnair.e as used by Crisp et al (1977) or the Anorexic Attitude Scale &s used by Halmi et al (1979) · have limitations in the extent to which they impose general 22. cultural values Ofr the concept of normality. Acknowledging these limitations both in general and as they apply to studies undertaken within specific treatment frameworks, it seems to be widely regarded that anorexia nervosa is difficult to treat and that a high relapse rate is likely (Brady & Rieger, 1975; Bruch, 1973). There is also a relatively high mortality rate for cases· - claimed by Brady and Rieger (1975) to range between three and 20 %, Minuchin et al (1978) 10-15 %, and Van Buskirk (1977) 10-23 %. Russell (1981) makes the statement that there is no solid evidence to suggest that any treatment alters long-term the natural course of anorexia nervosa. A reasonably extensive study undertaken by Theander (1970), making no distinction among various treatment approaches, considering 94 patients treated between 1931-61 in a variety of settings, and incorporating a relatively long-term follow:- / up in that data were obtained a minimum of six years after treatment, arrived a t the following results. It was found that 44 % could be regarded. as recovered although onl y 17% could be regarded as being mentally heal t hy; 39 % suffered from mild anorexia and/or considerable symptoms of other mental distress; and 17% had either died or were still suffering from severe anorexia nervosa. Prognostic Factors Keeping in mind the major limitations of outcome studies, the work involving the determination of prognostic factors can be considered. A study by Russell (1977) provides a useful starting point since subjects were only given general nursing care and supportive psychotherapy of a non-specific kind. It was therefore suggested that outcome could be seen to reflect the natural course of the illness influenced only by the general care received. Russell found that a later age of onset, lengthy duration of the illness and disturbed family relationships all indicated a po·or outcome. Behaviour in the hospital setting and changes occurring during hospitalization. did'not seem to predict long-term outcome, and nor did intelligence, feeding difficulties in childhood or obesity prior to the anorexia. In contrast to other studies, such as Theander's (1970), self­ induced vomiting did not seem to influence outcome. 23 . Late ag~ of ~nset was identified by Crisp et al (1977) as indicati ve of poor outcom~ . · Minu chin et al ' s (1978) highly succes s ful results with a younger sampl e group than most might be seen to support thi s , as might the finding that being married is indicative of a less positive outcome (Crisp et al , 1977) . The prognosis has been consi dered to be worse amon g mal es by Crisp et al (1977) and by Bruch (1973) , and a mong those f r om lower socio - econ omi.c groups . This latter feature seemed to be related to difficulties in establishing what were regarded as appropriate therapeutic relationships with these patients and their families . It may also partially explain the finding of Garfinkel et al (1977) that inadequate educational and vocational adjustment , which included poor or non - attendance at school or work , was linked to less positive outcomes . Contrary to Russell (1977) , Crisp et al (1977) found pre~ ? morbid obesity to be indicative of a poor outcome, possibly because it indicated an inability to accurately gauge nutritional needs . Bulimia and vomiting also for them suggested a poor outcome and this was supported by Garfinkel et al (1977) and Bruch (1973) . This may be associated with previous hospital ­ izations which also predicted a less successful outcome (Garfinkel et al, 1977 ; Halmi et al, 1977) since Bruch (1974) suggested that bulimia and vomiting behaviour often began after treatment which emphasised rapid weight gain . Not surprisingly , Crisp et al (1977) found that motivation for treatment indicated a good prognosis . This factor may also be linked to the number of previous hospitalizations since patients would be less likely to be a s optimistic of receiving help after first or subsequent courses of treatment . Motivation for treatment also presupposes acceptance that a problem exists and therefore is likely to involve less denial of the problem which was found by Halmi et al , (1979) to indicate a good outcome . Denial may also be linked to a failure to recognize hunger , which for Halmi et al (1979) was found to be indicative of a poo r progn osis . Garfinkel et al (1977) considered body size perception to be indicative of outcome, as assessed two to eight years after cessation of treatment . They argued that distortion 24. of body image is ~lso linked to a denial of thinness. Casper et al (1979) also found that the greater the overestimation of body size the lower the weight gain over a five week period. Halmi et al (1979) found that a great amount of hyperactivity was predictive of a good outcome, but since the study measured weight gmn only over a short period, this might be related to enforced restriction of exercise during hospitalization. Goldberg et al (1977) found less sleep disturbance, also linked to hyperactivity, to contribute to a positive outcome. Halmi et al (1977) found, contrary to expectation, that greater weight gain was associated with a smaller weight loss in the disorder. This finding might suggest that the smaller weight loss was related to the less serious nature of the problem or to its more recent development. Finally, along with. these many and varied prognostic indices, family factors have also been seen to play a part~ - ­ Crisp et al (1977) noted the frequency with which anorexics came from families where other members suffer from weight disorders or who control normal weight by excessive exercise. They suggested that this might indicate a poor prognosis. They also suggested that excessive rigidity in the family and anorexic alike predicted a less positive outcome. This finding is similar to that of Minuchin et al (1978) who found that famiies of anorexics seemed to be resistant to change. A consideration of the characteristics, incidence, out­ comes and prognostic factors in anorexia nervosa leads naturally to an examination of treatment. An examination of the ~order in the context of the three major psychothera­ peutic approaches follows. In each case a brief introductory section describes the theoretica~ framework in order to proYide a context for the review of the particular approach as it is applied to anorexia nervosa. Anorexia Ne,rvosa and Psychodynamic Therapy A Brief Outline of the Theory Contemporary psychodynami.c approaches to the explanation of personal functioning and treatment have their roots in Freudian thought. The Freudian concept of personality perceived the individual as having a finite amount of energy which must be expressed (Brown, 1961). This propositio-n is 25. drawn from discoveries in Physics which were especially influential during Freud's pro~essional formative stages in the late 19th Century. It is held by Freudian dynamicists that energy forces known as instinctual drives must emerge through various channels (Hall, 1954). The personality is seen as being comprised of three components, the super-ego, ego and id. Where energy forces arise out of the id, or unconscious mind, the direct expression of which is unaccept­ able to the ego, or conscious mind, the force is channelled by the use of defence mechanisms into a mo re acceptable field. The individual is seen as a complex whole in which the various parts work to balance each other. Changes to one part of the system will bring about changes elsewhere and the unconscious mind can alter physical as well as psychological functioning to meet its needs (Alexander , 1939). The ways in which an individual establishes balance are - - . seen as being developed early in life (Wolman , 1972). Dtiring the first years of life the individual must pass through stages of development each of which focuses energy into a different body location and has accompanying psychological features (Freud, 1905). In the first stage, termed the oral stage, attention is focused on the mouth and feeding activity and thebS:byexperiences itself and its environment through its mouth. The concept of infantile sexuality holds that sexual energy is already present at this stage and is linked to the mouth and feeding . One of the tasks of this stage is to begin to differentiate between the self and others , at first perceived as one, and by so doing to begin to recognize the limits of individual power (Klein, 1936). The baby is believed initially to phantasize its power as being unlimited. During the anal stage, which follows the child begins to learn bodily control and. to develop a more realistic picture of its own capabilities. In the third stage, referred to as the phallic stage, the child learns to identify with the parent of the opposite sex and to fix the locus pf sexual interest and activity in the genital area. This task , which begins at about age four and lapses during the period of latency, is resumed with the advent of puberty and what is referred to as the genital stage . 26. Psychodynamicists see problems in human functioning as arising from inappropriate channelling of energy into areas which ultimately prove detrimental or destructive to the individual (Alexander, 1963). Therapy involves locating the suppressed direction for the energy force, exploring it so that its functioning is raised from the unconscious to the conscious mind and finding a more appropriate means of expressing it. They believe that dealing only with the symptoms of the dysfunction will ultimately lead to another inappropriate expression of the energy elsewhere, referred to as symptom substitution. They argue that the underlying cause must be treated in order for this not to occur (Brown, 1961). Problems with regard to the expression of energy arise when the tasks to be completed in each stage of development are not successfully achieved. This results in fixations / which then interfere with functioning at later stages. Difficulties to do with feeding,for example, are usually presumed to stem from the o ral stage and fixation at this point may involve a failure to differentiate between feeding, sexual activity, andaggression. Inappropriate patterns of balance are laid down in early life, such that "later traumatic experience will only result in pathological symptomatology if during psychic development a scar remained which sensitized the patient to the later emotional shock. Therefore all pathological manifestations of a psychosomatic nature have their roots in the past" (Deutsch, 1927/1964, p.51). In psychosomatic illnesses, the ego is seen as having adapted normal functioning in order to spare and protect the total organism from some stressful situation,the chief function of the ego being to maintain "physiopsychosociol­ ogical balance" (Mt. Sinai Group, 1964, p.97) and to achieve optimum constructive tension through an arrangement of least expensive compromises. More recent advances in psychoanalytic thinking with regard to personality development, dysfuncti.oning and treat­ ment have concentrated on exploring the individual's relationships with others. (Sullivan, 1953). Emphasis 27. continues to be .on early life and, in particular, relation­ ships and their impact on lat_er functioning. Therapists are more likely to use their own relationships with their clients to explore past relationships and to 'repair' failures which appear to emerge (Brown , 1961 ) . Anorexia nervosa , for example, is seen in some of its elements as resulting from a failu re to establish adequate boundaries between the self and others through inappropriate communi­ cation in the early part of life (B ruch , 1973) , and this difficulty with self-other boundaries will inevitably be manifested within the patient-therapist relationship. Any examina tioo of the literature on the psychodynamic approach as it is related to anorexia nervosa , its nature and t rea tment , poses particular problems for a reader. A vast amount of material which covers a considerable time­ span offers a variety of perspectives which can be difficul~ to compare or relate to each other . At times the compYexity of concepts presented dominates the writing so that cases are used largely as illustrative material of c oncepts and it is frequently difficult to determine a writer's overall perspective on anorexia nervosa or the extent of and nature of contacts with actual cases. Anorexi~ Nervosa as Personality Dysfunction Anorexia nervosa is seen as a dysfunctional organization of the personality in this framework and attempts have been made to categorize it as such. However , there is disagree­ ment among psychodynamicists as to t·~type of personality dysfunction it is. For example, Tol strup (19 79) suggested that anorexic cases could be divided into four groups : obsessive-compulsive neurosis (which he regarded as the core group); hysterical neurosis; psychotic borderline states; and endogenous depression. The symptoms are likely to be similar but the underlying personality for.ma tion is seen as different. Chediak (1977) used three groupings : obsessive-compulsive; hysterical; and schizoid ,· but also recognized that 'borderline personali ty organization ' had begun to be used as a category. Bruch (1973) used this latter category to distinguish anorexia nervosa from schizoid difficulties,seeing it as involving personality 28. disorganization of a milder nature . Sugarman, Quinlan and Devenis (1981) also supported ~his distinction,recognizing the existence of tenuous boundaries to the personality in anorexia nervosa whereas in schi.zophrenic conditions they saw the boundaries as not existing. Several writers have discounted these kinds of divisions. For example, Stonehill and Crisp (1977) stated that since anorexia nervosa should be recognised as an attempt to avoid the turmoil of adolescence, emphasis on any p re-existing personality structure was often inappropriate . Bruch (1978) supported this more functional emphasis, suggesting that the apparent severe ego defects (splitting of the ego ) and depersonalization were related more to the starved state than to any pre-existing personality structure. For her, the sense of being divided related to the hidden and denied self's existence which the anorexic disapproved of , the struggle being enacted by the mind's attemp t s to control ' the despised body . Lawrence (1981 ) also noted the ongoing struggle between the divided personality which she perceived as being divided into the sensible side and 'the other' side . She stated that treatment needed to recognize both and work towards their integration. It can be seen that there is no clear agreement on the type of personality formation invo lved in anorexia nervosa nor on the value in attempting to categorize it . There appears to be, however, a shared emphasis on the importance of and difficulties in establishing appropriate boundaries of the self. The psychodynamic approach to anorexia appears to fall mainly into two schools of thought . The first of these can be termed the psychosexual stance and the second the ego psychological stance. The psychosexual stance. The basis for the psychosexual approach to anorexia nervosa lies in Freud's assumption that impairment in. the nutritional instinct is related to the organism's failure to master sexual excitement (Ross, 1977). Rampling (1978) suggested that food and eating assume a significance they held early in life when orality· and sexuality were linked, with Chediak (1977) believing that the eroticiz­ ation of the eating function indicated massive regression. 29. Fears of oral impregnation are apparently common in otherwise well-informed anorexic girls (Qrote & Meng, 1934; Syrynski, 1973), and not eating was also seen by Ceaser (1977) as a defence against oral sadistic and libidinal impulses, that is an unconscious desire to destroy by biting and swallowing. The refusal to eat is also seen as the denial of a wish to incorporate (Ceaser, 1977), incorporating being the process by which 'objects' (e.g. food, emotions) outside the self are taken in and made part of the self. Learning to achieve this appropriately, without either being overwhelmed by the environment or overwhelming it, is .Perceived as a task of the oral stage. Ceaser stated that anorexics have failed to internalize (incorporate) the loved maternal object, and Sugarman et al (1981) suggested that alternate bingeing and vomiting behaviour was a concrete representation of a need to incorporate the mother (food) and then express oral rage towards her by rejecting her (vomiting). Chediak (1977) / saw the anorexic as struggling to gain a sense of omnipotence, seen by Thoma (1977) as being sustained by the hyperactivity, which serves to avoid a pervading sense of helplessness and the anorexic's fear of being overwhelmed by her own needs (Chediak, 1977). Some writers have believed that the constipation frequently associated with anorexia is part of a desire to maintain a sense of self by the retention of body products (Rampling, 1978; Sugarman et al, 1981). In addition to assertions concerning regression to the oral stage, some writers have commented on anorexics' relation­ ships with their mothers which, within the psychosexual stance, would be seen as involving fears related to the phallic stage. Hostile, ambivalent impulses towards the mother were noted by Szyrynski (1973) and linked with sexual anxiety, the mother being perceived as agg~essive and castrating. Grote and Meng (1934) also commented on oedipal and castration fears as playing a major part in the development of the di.sorder. Crisp and his co-workers (e.g. Crisp & Fransella; 1972; Stonehill & Crisp, 1977) also highlighted the issue of sexuality,however they have preferred to identify the roots of anorexia less early in the individual.' s life. They have perceived it as an attempt to avoid puberty and adult sexual 30. functioning and & return to the safety of pre-pubertal function­ ing. The cessation of menstruation which both Szyrynski (1973) and Thoma (1977). claimed occ~rred early in the illness is seen as indicating regression through abandonment of the genital stage (Thoma , 1977). The four cases reported by Ceaser (1977) all had unpleasant sexual experiences immediately prior to the onset of the anorexia . Bruch (1978) would seem to agree that the illness is an attempt to return to childhood size and functioning, but she found a fear of pregnancy as a sexuality component not to be an issue in her cases, concluding that fears of adult sexuality were not paramount . Selvini Palazzoli (1978) stated that in her view sexual fears in anorexics were almost invariably an expression of their fear of p sychologieal invasion • . The aim of treatment in the psychosexual model focuses on conscious understanding of the psychosexual conflict, allowing a more constructive energy balance and a movemifnt through to genitality and continued psychophysiological development, (Thoma, 19 77) . The ego psychological stance. The ego psychological approach to anorexia appears to stem largely from a view­ point o.:fl in terpers:onal dynamics and con tends that inappropriate learning in the earliest stage of life leads to an inadequate awareness of self and the self's needs. Bruch (1970) stated that awareness of hunger is learned and that this is achieved through early ~reciprocal transactional feedback" between mother and child. Both obese and anorexic clients do not easily recognize sensations of hunger , she claimed. She saw this failure as being related to the mother ' s not allowing a transaction to take place because she anticipated every need and totaJly controlled the interaction so that the child did not learn to identify sensations or initiate actions with regard to theae (Bruch, 1978). The refusal to eat thus becomes both a failure to recognize own needs and an attempt to reject external control. The rigid self-discipline and denial of hunger are seen as an indication of the fear of a lack of inner control (Bruch, 1977.). Selvini Palazzoli (1978) stated that the anorexic shows a keen desire, however distorted, to become autonomous by rejecting the self as a passive 31 . vessel , but is unable to rely on her own sen~ions to decide when to e;~;~. t. Lawrence ( 19 81) .Perceived the emphasis on control of the body as an avoidance of dealing wi~h other control issues in the anorexic's life . Within this ego psychological framework, amenorrhea and constipation and even hyperactivity serve to illustrate issues to do with control over the self (Bruch , 1973). Anger and hatred towards the self are also seen as significant by several writerswithin this s tance . Selvini Palazzoli (1978) saw the 'I am too fat' message as a concrete expression of dislike for the self and Lawrence (1981 ) also commented on the anorexic's poor self- image . Geller (1975) made reference to a client who stated that her refusal to eat was connected with anger at herself , and Chediak (1977) mentioned cases in which there were signs of minor mutilation . Thoma (1977) commented that some anorexics would refuse go~d . food but eat scraps from dustbins or even shoe polish, / suggesting that they did not think that they deserved better . Boskind- Lodahl (1976) felt that a poor self- image , involving a fear of rejection in intimate relati onship s, resulted in anger towards the self which was expressed in terms of bingeing and vomiting . She aiso noted a lack of a sense of identity . A distorted body image , as noted by,among othersJ Feigner et al (1972), can also be seen to demonstrate self-hatred and a lack of a clear sense of self. The aim of treatment within the ego psychological stance focuses on the encouragement of autonomy (Crisp, 1980; Lawrence 1981 ; Palmer , 1980), the development of self- awareness, competence and effectiveness (Bruch , 1970 , 1979 ) and the improvement of self- image (Boskind-Lodahl, 1976) . The fami lies of anorexics within the psychodynamic frame­ ~· Recognition of the importance of family functioning in anorexia nervosa is evident in the earliest general literature on the disorder and was clearly stressed by both Lasegue (1873/ 19 64) and Charcot ( 1889/19 64) . The d:iJ,emma of how to handle fami ly involvement remains. Various writers in th~ psycho ­ dynamic framework whe n considering the anorexic patient have attempted to char acterize family members. Szyrynski (1973 ) saw the mothers of anorexics as dominating the family, while 32 . the fathers tended to be passive and ineffectual. He also noted frequent conflicts between the grandmother and the mother . Bruch (1978) considered the mothers to be w0men who had sacrificed their careers for their family . She also stated that mothers, and sometimes fathers, were weight or diet _conscious and that many anorexics felt that they had a special responsibility for their mothers. Chediak (1977) noted a shared belief in mothers and their anorexic daughters that the daughter is part of, or is 'owned' by, the mother . Both Selvini Palazzoli (1978) and Bruch (1977) have commented on the power of the family to disrupt treatment and both have themselves moved over the years to having a greater involvement with the whole family in treatment. Their approach broadly maintains a psychodynamic base, but it has moved from a concentration on intrapersonal dynamics alone . / The Psychodynamic ~pproach to Treatment of Anorexia Nervosa In considering treatment studies within this approach, it is at times difficult to be clear on many important factors~ for example, what criteria were used to diagnose the case or cases of anorexi (e . g. Sugarman et al , 1981), what the treatment actually involved (e . g. Chediak, 1977), or the extent to which the cases were representative of that writer's experience of anorexia nervosa (e.g. Ceaser, 1977). Bemis (1978) stated that many accounts presented information on a very small number of cases and that aspects of treatment were often unclear. However , some researchers such as Bruch (1973) and Selvini Palazzoli (1978) in their studies provi.de a much sharper picture of the processes involved and their likely efficacy. Certain dilemmas are seen to face psychodynamic therapists as they engage in work with anorexic clients. The first of these is the type of therapeutic relationship to be developed and maintained, since this is central to treatment. To what extent should, for instance, classical, analytical interpretive techniques be applied? The second dilemma is the manner in which weight gain is to be achieved - the therapeutic norm in this approach is that treatment is likely to be long and p ainful, but the therapist cannot allow the patient ' s weight to hover at a dangerously low level for much of that time. Thirdly, therapists must determ~ne the involvement, if any, they wish to have with the family of an anorexic . Running through all of these dilemmas is a question relating to the interest in and necessity for combining psychodynamic psychotherapy with other forms of treatment. 33. The psychodynami-c therapeutic relationship. Differences of opinion among psychodynamicists are evident as to the type of therapeutic relationship seen as most appropriate in the treatment of anorexia nervosa. The position adopted by individual researchers and therapists depends to a large extent on the stance, psychosexual or ego psychological, to which they ascribe . Much of the argument here centres on how interpretive the treatment should be . Bruch (1970 , 1977) suggested that the clinical analytical approach involving interpretation provided a painful repetition / of previous experiences of being told what to feel or think. Perls (1969) pointed out that in any therapy there is a natural and healthy resistance by the client to "swallowing whole" the therapist's ideas . Selvini Palazzoli (1978) stated that a resistance to interpretation may be expressed through absence from sessions or a refusal to communicate and Thoma (1977) also noted the anorexic ' s tendency to reject the therapist's prescriptions and recommendations . Rampling (1978) thought this rejection, often seen even in compliance to avoid related to a fear of losing control to the therapist . (1977) recommended that patients be allowed to express conflict , Bruch their own experiences without these immediately being labelled or explained. Conceptual defects and distortions were regarded as needing to be repaired through the relationship but not by interpretation . She also recommended (197~ the use of a humourous , do~~- to - earth approach to deal with the often stilted and serious anorexic . Chediak (1977) postulated tha~ Bruch's disenchantment with interpretati on might be related to a reliance on verbal communication and suggested that interpret­ ive therapy needs to be complemented by non-verbal or pre­ verbal interaction . He did not , however , elabor ate on the meaning of this . Cr isp (1980) suggested that psychoanalysis has failed to 34. recognize the regressive nature of anorexia nervosa and instead, through its traditional treat~ent approach, had worked to increase it, thus assisting puberty avoidance. Ross (1977) noted that the decision as to how analytic, and therefore regressive in orientation, treatment should become was important ; experience seeming to suggest that an ego supportive or expressive mode was more successf~l than a classical, interpretive analysis. Some of what has been written illustrates the difficulty therapists have experienced in relating to anorexic patients. Rampling (1978) suggested that a psychodynamic understanding would enable the therapist to avoid sharing the patient's belief in her own 'sinfulness '. He also noted the difficulties involved in transferring such a patient to another therapist should the therapeutic relationship fail. Lucas et al (1976) stressed the importance of remaining optimistic and convinced of the patient's desire to recover. Thoma (1977 ) , commenting on ? the decepti0n and manipulation common in anorexia, stressed the value for the therapist of relying on their own counter ­ transference feelings as a cue to recognizing the hidden and indirectly expressed feelings of the patient towards them . He underlined the need for a working alliance . Both he and Rampling (1978) emphasised the difficulty in treating a person against their will. The issue of whether a male or a female therapist was more appropriate in anorexia nervosa has als o been discussed in the psychodynamic literature . While Szyrynski (19 73) stated that a male therapist could be more effective because he could replace the inadequate father figure and avoid identification with the hostile mother , and Thoma (1977) noted a tendency in female colleagues to mother anorexics inappropriately, Selvini Palazzoli (1978) suggested a female therapist was more appropriate . She considered it would be more difficult for a patient to be open with a mal~ therapist who also risked becoming identified with the weak and neglectful father . Boskind- Lodahl (1976) also suggested that a female therapist could provide an appropriate role model. An important aspect of the therapeutic relationship in this framework would seem to be related to issues of power . Some therapists such as Lucaa et al (1976), Thoma (1977) and Rampling (1978), seem to argue for a powerful role for 35. themselves. Lucas et al, for instance, suggested the therapist should be involved in establishing the feeding routine and should use information confront the patient. Bruch (1977) , Lawrence acquired from the nursing staff to Others, such as Boskind-Lodahl (1976) , (1981) and Selvini Palazzoli (1978) , have recommended that patients be given more sense of their own power. It is perhaps significant to note that these last four writers are all women. Achieving weight gain . There is a generally held belief in the more recent psychodynamic literature on anorexia nervosa that psychotherapy cannot be effective if the anorexic is still at starvation point (e.g . Bruch , 1977) . It is also recognized that the benefits of psychotherapy are generally not sufficiently immediate to remove the client quickly from danger . Bruch (1978) considered severe starvat i on to have a considerably disorganizing effect, as it makes it difficult for sufferers to concentrate -- . on anything other than food and renders them apparently / inaccessible for treatment because of the semi-toxic state which it induces. In addition therapists cannot work as successfully if they are anxious for the lives of their clients ( Thoma, 1977). The question then becomes what means should be used in refeeding and to what extent should the therapis t be involved? Tolstrup (1975) and Thoma (1977) both recommended tube feeding i n severe cases . Bruch (1977) suggested intravenous hyperalimentation , the use of a high calorie intravenous drip , since it avoided therapist -pa tient conflict. Geller (1975) combined behaviour modification and psychodynamically- based psychotherapy, using the latter to explore issues aroused by the more active former. In Russell's (1981) account nurses assumed control of the feeding initially. In the Lucas et al (1976) study, food was also rigorously supe~vised by nursing staff and was organized initially to maintain admission weight, and later to increase weight with periodic increments. Their suggestions echo Gull's (1873/1964) thoughts tha~ firmness and 'moral control' are needed in those who supervise the eating. Bruch (1978) believed that patients need reassurance that their eating will not be allowed to go out of control and that a nutritionally sound diet will be provided. She criticized schemes which conce~trate on weight gain without reference to the foods involved, since these might encourage the anorexics to eat 'junk' fooda · which they associate with bingeing. This, she felt, would lead to considerable guilt and self-loathing and accentuate the-problem. Throughout the literature there is fear expressed that therapists might become inappropriately involved in the struggle over food and lose their effectiveness (e.g. Thoma 1977), Lucas et al (1976) involved the psychiatrist in the administration of the refeeding regime and Geller (1975) supervised both psychotherapy and behaviour modification procedures. Szyrynski (1973) however, recommended that the psychotherapist not only be uninvolved in the refeeding but also should avoid mentioning food at all in the initial stages of treatment. Lawrence (1981) avoided involvement in the process of weight gain by using an agreement in which counselling was provided on the condition that the anorexic take responsibility for her own adequate nutrition. Since her clients were all self-referrals, such an arrangement was possible. 36. Several writers in this framework have perceived a place in treatment for weight gain combined only with supportive psychotherapy (i.e. psychological support without attempts at exploring and dealing with any underlying dynamics). Chediak (1977) considered this to be sufficient in mild cases. Dally and Sargant (1966) used supportive psychotherapy in conjunction with chlorpromazine and insulin. Lucas et al (1976) employed supportive psychotherapy initially but aimed to aid the expression of negative feelings and to consider dependency issues later. Psychodynamic treatment and the family. As a result of increasing awareness of the family's role in anorexia nervosa, there has been · concern as to how best to counteract the effects of this as part of the treatment plan. Szyrynski (1973) suggested that either the family environment should be changed or the patient moved to another environment, stressing the difficulty likely in achieving the former. For this reason hospitalization is often seen as an appropriate tempoTary solution (e.g. Lucas et al 1976; Ross, 1977). Selvini Palazzoli (1978), however, cautioned against hospitalization, stating how terrifying and destructive an experience it could be. Lawrence (1981) likened the medical system to the family system itself and suggested that the anorexic's symptoms encourage others-to take control of her, either at home or in hospital, when this is really what she is struggling against. 37. It has appeared to be difficult for some psychodynamic therapists to contemplate treating the whole family as a unit. It is clear that in many cases other family members go on to receive individual psychotherapy themselves (e.g. Bruch, 1978; Lucas et al, 1976) and that some therapists have begun to include family therapy of a kind (e.g. Bruch, 1978; Chediak, 1977; Lucas et al, 1976; Sugarman et al, 1981; Szyrynski, 1973). This family work would appear however, to be suppor~~ve in nature and to treat the family as a collection of individuals. The difficulty of changing family behaviour is noted (Szyrynski, 1973). The move from treating an individual to treating the family as a whole has been claimed by Minuchin et al (1978) to necessitate a paradigm shift which naturally is difficult to make. Selvini Palazzoli (1978) however, for one, has documented this shift in her own thinking and therapeutic behaviour. The use of family therapy, pharmacotherapy and supportive psychotherapy within the psychodynamic framework highlights the issue of the combination of treatment approaches. There is in fact little description of combining treatment approaches in the literature and where they are mentioned there is little explanation of what was involved. Crisp (1981), however, described a combination of behavioural procedures to induce weight gain, occupational therapy, social skills training and small group therapy. Family therapy, where appropriate was also provided. Again however, the family treatment briefly described indicates that families were perceived as a collection of people with individual problems. Psychodynamic Treatment Outcomes Many of the general issues previously mentioned about the limitations of outcome studies within the field of 38. anorexia nervosa relate to the psychodynamic approach, in as much as goals, manners of assessment and follow-up details are usually not clearly stiptilated. As well, several writers provide no indication of what were . the actual outcomes of their treatment. For example, Chediak (1977) discussed only one case which by implication was su~cessful .whereas Sugarman et al's (1981) individual case seemed to be unsuccessful. It is unclear from Ceasar's (1977) study whether the four cases considered were successful in outcome or not. In considering treatment goals, Crisp et al (1977) under­ lined the importance of achieving not only biological maturity but also suitable psychological and social adjustment. Sixty percent of the 340 patients they studied up to 17 years after treatment had achieved biological maturity, while approximately 40% had alBa . made a _good recovery in psychological and social terms. Lucas et al (1976) reporting on 32 patients stated that although three patients left the programme against advice, the 'great majority' were improved up to three years after discharge. They do not give figures to elaborate on what constitutes the great majority. They did state that three years was too early to draw any long-term conclusions. Szyrynski (1973) reported on 16 cases treated but did not state how long after treatment they were assessed. Three over 30 years old were considered to be schizophrenic and/or hysteric and improved slightly for a while, one case died, eight recovered and two made partial recoveries. Of Bruch's (1973) 60 patients, she identified 45 as being clear cases •Of anorexia nerve sa (primary). Of these 25 were followed-up one-to-five years after onset and the remainder six-to-19 years after· onset. She was unable to obtain information on six patients and two patients· were still in treatment. Four had died (one by accident), four had become schizophrenic and five. were chronic anorexics. Twenty-four had established a normal weight but only 13 of these were said to have recovered. Eight of those recovered had developed anorexia before the age of 14 and had received treatment wi thi.n the fi.r.s t . year. Selvini Palazzoli (1978) divided her patients into two 39. groups. The eight patients she saw in her early years whilst working at a Medical Clinic were described as serious cases; two of those had died, two were chronically ill, three had stabilized their weight but suffered from neurotic disturbances. One had married and moved away from home . Of the 22 patients seen at her Private Clinic, 13 had been seen at an early stage in the illness. Nine of these she assessed as cured, two suffered from marked mental disturbances , and for two she felt that her own treatment had brought about failure . The remain­ ing nine patients were seen after the anorexia had become chronic, three of these recovered, three had improved some­ what, one had become schizophrenic and two had died . Both she and Bruch (1973) stressed the importance of the therapist's understanding of each individual case in obtaining a successful outcome . In concluding this discussion of the literature on the psychodynamic approach to anorexia nervosa, it may be said that the wide range of material produced over a considerable period of time offers a variety of perspectives on the disorder. In addition, psychoanalytic / psychodynamic thinking has had considerable impact during that time on the treatment of psychological problems in general and it is at times difficult to determine if a particular treat ment should be included in a consideration of the psychodynamic approach or if it may merely be thinking . Dally and said to owe a considerable debt to psychodynamic This is the problem when examining the work of Sargant (1966) for example, where the main part of treatment involved pharmacotherapy but supportive psycho ­ therapy, which is not described but which in a medical setting is likely to be psychodynamic in nature, was also included. The style of reporting is also problematic in the psychodynamic approach . · Writers are concerned mainly with intricately exploring the specific concepts involved and often the number of cases treated, the interaction between therapist and patient, the outcome of treatment and other important issues are blurred . The explanation of an