A Critical, Review of the Literature Dealing with Current

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Master's Theses Graduate College

12-1976

A Critical, Review of the Literature Dealing with Current A Critical, Review of the Literature Dealing with Current

Psychological Approaches to the Treatment of Anorexia Nervosa Psychological Approaches to the Treatment of Anorexia Nervosa

Pamela Jane Goy

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A CRITICAL, REVIEW OF THE LITERATURE DEALING WITH CURRENT PSYCHOLOGICAL APPROACHES

TO THE TREATM ENT OF ANOREXIA NERVOSA

by

P a m e la Jan e Goy

A T h esis Subm itted to th e

F a c u lty of T he G rad u a te C ollege in p a r t ia l fu lfillm en t

of th eD egree of M a ste r of A rts

W estern Michigan University Kalamazoo, Michigan

December 1976

Reproduced with permission o f the copyright owner. Further reproduction prohibited w ithout permission.

ACKNOWLEDGEMENTS

I would lik e to e x p re ss m y deepest g ra titu d e to P ro fe s s o r s

C h ris to p h e r K oronakos and F re d e r ic k G ault fo r th e i r adv ice,

encouragem en t, and a s s is ta n c e in p rep a rin g th is th e s is .

A lthough th e i r a id fa c ili ta te d the com pletion of m y th e s is ,

I am , n o n e th e le ss , so le ly re sp o n sib le fo r what is w ritte n h e re

P a m e la Jan e Goy

■; - '


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MASTERS THESIS 13-9434

I GOY, Pamela Jane \ A CRITICAL REVIEW OF THE LITERATUREf DEALING WITH CURRENT PSYCHOLOGICAL\ APPROACHES TO THE TREATMENT OF ANOREXIA\ NERVOSA.k

Western Michigan U niversity, M=A., 1976 [ Psychology, c lin ica l

; Xerox University Microfilms, Annats**,Michigan<sios


TABLE OF CONTENTS

PAGE

INTRODUCTION. ....................................................... 1

HISTORY OF THE CONCEPT OF ANOREXIANERVOSA . . . 3

THE PRE-M O RBID PERSONALITY &PRECIPITATING FA C T O R S............................ 9

DIFFEREN TIA L DIAGNOSIS ............................................... 16

THERAPEUTIC CO N SID ERA TIO N S......................................23

CURRENT MODES OF TREATM ENT * .............................27

P S Y C H O T H E R A P Y ...................................................................... 29

ATYPICAL PSYCHOTHERAPEUTICT E C H N IQ U E S ................................. 40

BEHAVIOR T H E R A PY ................................................................. 49

FAM ILY T H E R A P Y ......................................................................59

SU M M A R Y ........................................................................................ 67

iii


INTRODUCTION

T he p u rp o se of th is p a p e r is to rev iew the l i te ra tu re

dealing w ith c u r re n t p sycho log ical ap p ro ach es to the t r e a t

m en t of a n o re x ia n e rv o sa . Secondly, a c r i t ic a l evaluation

of e ac h th e ra p e u tic app roach is undertaken , w ith sp ec ia l

c o n s id e ra tio n given to the c lin ica l fa c to rs which m ay

fa c il i ta te o r im pede its e ffec tiveness in tre a tin g ano rex ia .

T he sy nd rom e of an o rex ia n e rv o sa has been the ob jec t

of m ed ica l and p sy c h ia tr ic investiga tion fo r the p a st two

hundred y e a r s . D esc rip tio n s of the d is o rd e r have rem a in ed

highly s te re o ty p e d throughout th is tim e p e rio d . Individuals

su ffe rin g fro m an o rex ia a re p redom inan tly fem a le , betw een

the a g e s of te n and tw enty y e a rs , who d isp lay an ex trem e

a v e rs io n to food. T he accom panying p h y sica l sym ptom s

a r e cachex ia , b rad y c a rd ia , a m e n o rrh ea , and low ered blood

p r e s s u r e . No physio log ica l pathology is p re se n t, the

sy n d ro m e i s p sycho log ica lly d e te rm in ed .

S ince a n o re x ia n e rv o sa is a f a i r ly r a r e d iso rd e r , m any

peop le do not have knowledge of i ts o c c u rre n c e , o r of th e

p h y sica l and psycho log ica l fa c to rs w hich i t involves. T h is

p a p e r i s w r it te n to g ive th e r e a d e r a b as ic understand ing of

1


th e phenom enon, and to fa m ilia r iz e h im w ith the d iv e rse

th e ra p e u tic ap p ro ach es w hich a r e c u rre n tly used in i ts

tre a tm e n t.

It shou ld be noted tha t no e ffo rt is m ade, w ithin the

sco p e of th is p a p e r , to d iffe ren tia lly evaluate the m ale

a n o re x ic . M ost of the rev iew ed stud ie? involved a

p red o m in an tly fem ale population. It is th is pa tien t population

to w hich th e focus of th is p a p e r is d irec ted .


HISTORY OF THE CONCEPT OF ANOREXIA NERVOSA

T he concept of an o rex ia n e rv o sa w as f i r s t d e sc r ib e d in

the m ed ica l l i te ra tu re in 1689, by R ich a rd M orton, He

re fe r r e d to a s ta te of nervous consum ption in which the

pa tien t underw ent p ro g re s s iv e w asting and lo s s of ap p etite

w ith no signs of cough, fe v e r , o r dyspepsia (Ushakov,

1971).

T he f i r s t sy s te m a tic study of the syndrom e w as

in itia ted a lm o st two cen tu rie s la te r , in 1873, by C h a rle s

L asegue (B ruch, 1973; Ushakov, 1971; G oodsitt, 1969;

T hom ae, 1975). He r e f e r r e d to eight p a tien ts su ffe rin g

fro m what he ca lled "an o rex ia h y s te r iq u e ." L a se g u e 's

c la s s ic a l d e sc rip tio n of th e d iso rd e r noted th e p re se n c e of

s e v e re weight lo s s , re je c tio n of food, am en o rrh ea , and

constipa tion in h is p a tien ts , a s w ell a s the absence of

so m atic pathology. He fu r th e r de lineated th re e s ta g e s in

the c o u rse of th e h y s te r ia . T he f i r s t , o r " g a s tr ic s ta g e

(Ushakov, 1971)" involves the p a tien t's in itia l re fu s a ls of

food, due to com plaints of s to m ach pain w hile ea ting . T h is

is follow ed by a "s tru g g lin g s ta g e (Ushakov, 1971)" a t w hich

tim e th e p a tie n t 's se n sa tio n s of pain d isappear. T he

3


individual th en equates h is s ta rv in g behav io r w ith health*

L a s tly , e x tre m e em acia tion o c c u rs du ring the "cach e tic s tag e"

and w eakness confines the individual to bed (Ushakov, 1971).

G ull, in 1874, re p o r te d s im ila r find ings, and a ttr ib u te d

h is p a tie n t 's lack of ap p e tite to a m o rb id m en ta l s ta te

(G oodsitt, 1969). He coined the te rm "an o re x ia n e rv o sa"

w hich w as then adopted, and is s t i l l in u se in E nglish ,

R ussian , and G erm an m ed ica l l i te r a tu r e (B ruch , 1973;

U shakov, 1971).

Since the in itia l re p o r ts of an o rex ia n e rv o sa , the

syndrom e has been the ob ject of innum erab le sy s te m a tic

stu d ies d esp ite i ts a p p aren t r a r i ty . It i s in te re s tin g to note

th a t in the p ast one hundred y e a rs , r e p o r ts of the

sym ptom atology re m a in highly co n sis ten t. M ost c lin ic ians

rep ea ted ly note the p re se n c e of th e sy nd rom e in a p r e

dom inantly fem ale population betw een th e ages of ten and

tw enty y e a r s . I t Is c h a ra c te r iz e d by a s tro n g a v e rs io n to

food, re su ltin g in s e v e re w eight lo s s , cachex ia , a m en o rrh ea ,

and co n stip a tio n (Rowland, 1970).

A lthough th e so m a tic p ic tu re of th e d is o rd e r has not

been su b jec t to change e v e r th e y e a rs , concep ts reg a rd in g

e tio lo g ica l fa c to rs have undergone m any changes (B ruch,


5

1970a). In the e a r l ie s t l i te ra tu re , an o re x ia n e rv o sa w as

v iew ed a s a b ra in d is tu rb an ce o r som e fo rm of m en ta l m a l

functioning. T he adven t of L aseg u e ’s concept of h y s te r ia

th en in troduced th e notion of an in h e rite d d eg en era tiv e d is

o rd e r (B ruch , 1970a). G u ll 's in te rp re ta tio n s of an o re x ia

n e rv o sa a s being cau sed by som e fo rm of m en ta l s t r e s s Is

co m p arab le to a num be^ of co n tem p o ra ry psychoanaly tica l

in te rp re ta tio n s .

U ntil the e a r ly 1900 's, i t w as g e n e ra lly a g re e d upon

th a t an o re x ia n e rv o sa w as a psychogenic d iso rd e r . H ow ever,

a s m o re s tu d ie s w ere com pleted , th e c lin ica l p ic tu re of th e

sy nd rom e becam e m o re confused. In 1914, Sim m ond, a

p a th o lo g ist, re p o r te d th e d isco v ery of d e s tru c tiv e le s io n s in

th e p itu ita ry g land of a wom an w ith m ark e d em acia tion , who

had d ied follow ing p regnancy and d e liv e ry (B ruch , 1970a).

T h is cau sed a to ta l change in th e ap p ro ach to any fo rm of

m a ln u tritio n , a ttr ib u tin g the cau se to d is tu rb an c es in th e

endocrine sy s te m . T hus, th e concept of an o re x ia n e rv o sa w as

fu r th e r confused , w ith no c le a r a g re e m e n t on w hat w as includ

ed w ithin th a t concept. T he th e o ry of endocrino log ica l o r ig in

of an o re x ia n e rv o sa p e rs is te d in th e U nited S ta te s in to th e

1930’s , an d lo n g e r in E u ro p e (B ruch , 1970a). E ventually ,


6

a ttem p ts w e re m ade to d iffe ren tia te S im m ond 's D ise ase fro m

psycho log ica l a n o re x ia n e rv o sa . T he ch ief d iagnostic

in d ic a to r of S im m ond’s D ise a se is th e a lm o st com plete

d e s tru c tio n of th e a n te r io r lobe of th e p itu ita ry gland

(Rowland, 1970). It w as fin a lly reco g n ized th a t th e d iso rd e r

can be d iffe re n tia te d both b io ch em ica lly and c lin ica lly . T hus,

th e p sycho log ica l o rig in of an o re x ia n e rv o sa w as once again

e s ta b lish e d and has p e rs is te d to the p re se n t.

T he d isp ro v ed th e o r ie s of endocrino log ica l im ba lances in

an o re x ia n e rv o sa w e re soon re p la c e d in the 1940 !s by

psy ch o an a ly tica l in te rp re ta tio n s . T he d is o rd e r w as th en

view ed a s th e r e s u l t of d is tu rb in g e x p e rien c es in the p a tie n t 's

life w hich le d to p sycho log ica l co n flic ts (B ruch , 1970a).

T h is schoo l of thought has p red o m in a ted fo r th e p a s t th ir ty

y e a r s and has had profound im p act on c u rre n t c lin ica l and

m ed ica l ap p ro ach es to an o rex ia .

An offshoot of th e p sy ch o an a ly tica l app roach , w hich has

gained a rep u ta tio n in the p a s t decade, is th a t of fam ily

th e ra p y . Its c e n tra l th eo ry em p h a size s the im p ac t th a t an

in d iv id u a l's so c ia l sy s te m h a s upon h im , sp e c if ica lly h is

immediate fam ily (M inuchin, 1969). T h e a n o re x ic 's sym ptom s

of food re fu s a l a r e 3a id to be su p p o rted by th e dysfunctional


s t ru c tu re of th e fam ily (Aponte, 1973). T he fam ily

in ad v e rten tly fo cu ses on the p a tie n t 's sym ptom s " a s a way of

avoiding o r d e tou ring . . . fam ily con flic ts (L eibm an,

M inuchin, & B a k er, 1974, p. 434 )."

T he m o st re c e n t ap p ro ach to a n o re x ia n e rv o sa is tha t

tak en by p roponen ts of le a rn in g th eo ry (B achrach , E rw in , &

M ohr, 1966; L ang , 1966). T he so c a lle d n eu ro tic behav io rs

of an o re x ic s a r e v iew ed a s "unw anted re sp o n se s of the

o rg an ism , e lic ited by a d e te rm in ab le c la s s of s tim u li (Lang,

1966, p. 217)." T he individual is sa id to have acq u ired o r

le a rn e d unwanted b eh av io rs , which m u st be rep la ce d w ith

m o re d e s ira b le b eh av io ra l re sp o n se s . T he app roach is

s t r ic t ly a b eh av io ra l one, focused on re s to r in g and m ain ta in

ing ea ting behav io r, w ith no a ttem p ts to a s s i s t th e p a tien t in

gain ing in sig h t o r d isco v erin g h is unconscious m otives (Lang,

1966). C onsequently p roponen ts of p sy cho therapy a re highly

c r i t ic a l of th e u se of behav io r m odifica tion in th e tre a tm e n t

of a n o re x ia n e rv o sa (B ruch , 1974), d e sp ite re p o r ts of i ts high

su c c e s s r a te s (B a c a ra c h , 1965; H alm i, 1975; S tunkard,

1975).

T he concept of a n o re x ia n e rv o sa continues to be the

ob jec t of c lin ica l c o n tro v e rsy , due to th e w idely d ivergen t

p sycho log ica l a p p ro a ch e s w hich have developed in the p a s t


cen tu ry . The s in g le point of ag reem en t fo r m o st c lin ic ians

is th e s te reo ty p ed sym ptom atology w hich p re se n ts itse lf in

each c a se study. T he c u rre n t c lin ica l p ic tu re of th is d is

o rd e r w ill not be m o re c le a r ly defined until m o re ex tensive

r e s e a r c h is com pleted w ith long te rm stud ies of anorex ic

p a tien ts . Hopefully, such s tu d ies w ill be undertaken by the

p roponen ts of a w ide v a rie ty of psycho log ical app roaches.

. . . '■ ■ / . . . , . . . . . . . . . ; A y K g


THE PRE-M O RBID PERSONALITY & PRECIPITATINGFACTORS

M uch sp ecu la tio n has been m ade a s to th e p o ss ib ility of

a typ ica l p re -m o rb id p e rso n a lity type in connection w ith

an o rex ia n e rv o sa . W hile som e a u th o rs m ain ta in tha t it

o c c u rs in any p e rso n a lity type {G oodsitt, 1969), c u rre n t

s tu d ies do indeed re p o r t findings of a n u m b er of common

c h a ra c te r is t ic s am ong an o rex ics . T he m a jo rity of the

p a tien ts a r e sa id to be highly in te llig en t and m o st su ccessfu l

in th e i r educa tional endeavors (Ushakov, 1971; Rowland,

1970; H alm i, 1974; Kolb, 1966). T hey a r e s e t a p a rt fro m

th e ir p e e rs by in te lle c tu a l ach iev em en ts , but ra re ly by th e ir

p e rs o n a litie s . M ost c lin ic ians d e sc r ib e th e se individuals a s

being qu ite sh y and re s e rv e d , and often o v e r-s e n s it iv e

(U shakov, 1971; Row land, 1970; K olb, 1973). They d isp lay

unusually h igh p r in c ip le s fo r th e i r a g es , and 3 tr iv e fo r a life

of p e rfe c tio n (B ruch , 1.973; G aldston , 1974; Kolb, 1973).

P a re n ts of a n o re x ic p a tien ts d e sc r ib e th e i r ch ild ren a s being

v e ry com plian t and obedient; m odel c h ild re n who alw ays

conform to t h e i r p a re n ta l w ish es (B ruch , 1970a & 1973;

G aldston , 1974; G oodsitt, 1969). P r i o r to th e onset of

9


a n o rex ia n e rv o sa , o b sess iv e -co m p u ls iv e t r a i t s a r e freq u en tly

noted by th e ind iv idua l’s fam ily and fr ie n d s (H alm i, 1974;

Rowland, 1970; Seligm ann, 1974). T he p a tien t a p p e a rs to be

o b se ssed w ith co n tro lling ev ery a sp ec t of h e r life (Seligm ann,

1974).

It is in te re s tin g to co n sid er su ch o b se rv a tio n s in ligh t of

the typ ica l fam ily background which has com e to be a sso c ia te d

w ith th is psychogenic d iso rd e r . T he an o rex ic in v ariab ly

com es fro m a h ighly p ro sp e ro u s fam ily w ith above a v e rag e

liv ing conditions (Ushakov, 1971). T he fa th e r , l ik e the

an o rex ic child , is often qu iet and re se rv e d ; a p a ss iv e m an who

rem a in s som ew hat detached fro m the pa tien t (Rowland, 1970;

S zy rynsk i, 1973; Selv in i, 1970). C o nverse ly , th e m o th e r is

sa id to be o v e rco n tro llin g and p o sse ss iv e , dom inating the

ch ild and e n tire fam ily to an ex cess iv e d eg ree (Rowland,

1970; G ifford , 1970; Selvini, 1970; Szyrynsk i, 1973). T he

fam ily m ay ou tw ard ly a p p ea r to be a s ta b le one. Y et, on

c lo s e r in spection , i t is often the c a se th a t the p a re n ts s h a re

a cold and lo v e le s s re la tio n sh ip (G roen & F e ld m an -T o led an o ,

1966). T hey a r e unable to d em o n s tra te th e i r fee lin g s of

a ffec tion fo r one an o th e r, and a lso , fo r th e i r c h ild ren

(G roen & F e ld m an -T o led an o , 1966).


11

C o n sid e ra tio n of th e s e fam ily in te ra c tio n a l p a tte rn s

n e c e s s a r ily b rin g s one to th e in v es tig a tio n of p o ss ib le

p re c ip ita tin g fa c to rs . A lthough a wide v a r ie ty of fac to rs

have been docum ented in th e l i te ra tu r e , th o se re la tin g to the

a n o re x ic 's fa m ilia l re la tio n sh ip s have re c e n tly gained the

m o st a tten tio n . C u rre n t c lin ica l in te rp re ta tio n s of an o rex ia

n e rv o sa view the pa tien t as a v ic tim of fam ily psycho

pathology (A ponte, 1973; C risp , 1974). Due to th e frequency

of over-controlling m a te rn a l re la tio n sh ip s , Rowland (1970) has

concluded th a t th e m o th e r is in s tru m e n ta l in con tribu ting to

the i lln e s s of an o rex ic p a tien ts . F o r exam ple, dysfunctional

fam ily re la tio n s m ay be m an ifes ted in a h o s tile s tru g g le fo r

co n tro l betw een m o th e r and daugh ter (Kolb, 1973; G ifford,

1970; S zy rynsk i, 1973). T he g ir l , respond ing to an o v e r

co n tro llin g m o th e r, disavow s h e r own fem in ity in an a t t e m p t

to deny any id en tifica tio n w ith h e r m a te rn a l m odel (Szyrynski,

1973). T h e re i s th e p o ss ib ility th a t th e an o re x ic th e reb y gains

a se n se of p e rs o n a l co n tro l by s e lf -s ta rv a tio n , w hich eventually

le a d s to th e d isa p p ea ran c e of seco n d a ry sexual c h a ra c te r is t ic s

(B ruch , 1973).

T he o n se t of p u b e rty and accom panying f e a r s of sex u a lity

have freq u e n tly been c re d ite d a s m a jo r p re c ip ita tin g even ts in


an o re x ia n e rv o sa (W all, 1959; M arg o lis & J e m b e rg , 1960,

Rowland, 1970; Szyrynsk i, 1973). T he young g ir l who has

not been ad eq u a te ly p re p a re d fo r physica l changes m ay fee l

th re a te n e d by th e p re se n c e of m en a rch e and in c re a se d

a tten tion fro m the opposite sex (W ieklund, 1973). T h e re is a

p o ss ib ility th a t " sexuality and ea ting becom e equated and

a sso c ia te d w ith grow ing up and w ith o ra l im pregnation

fa n ta s ie s (W all, 1959, p. 9 9 8 ).M T he p a tien t m ay re fu se food

in an a ttem p t to s ta le m a te sex u a l developm ent (G ardner, 195S).

She is then p le a se d w ith th e c e s sa tio n of m en s tru a tio n and h e r

d isap p ea rin g sex u a l c h a ra c te r is t ic s (K e ss le r , 1966). Self

s ta rv a tio n becom es re in fo rc in g , and te m p o ra r ily a ffo rds h e r

p ro tec tio n f ro m having to cope w ith a new sex u a l identity .

T h e re is l i t t le a g re em e n t am ong c lin ic ian s a s to w hether

p re -m o rb id d is o rd e rs of n u tr itio n a re cau sa l agen ts in

an o rex ia n e rv o sa . Som e s tu d ie s re p o r t th a t the m a jo rity of

a n o re x ic s have su ffe red fro m p r io r ea ting d is o rd e rs (Ushakov,

1971; C r is p , 1970fc; Kolb, 1973; K e s s le r , 1966). Many p a tien ts

w ere p rev io u s ly o b ese o r su b je c t to com pulsive eating. The

f a c to r s of h igh b ir th weight and h igh grow th r a te a re , a c c o rd

ing to C r is p (1970b), ” s ig n ifican tly p o sitiv e ly a sso c ia ted " w ith

a n o re x ic s , (p. 23), B ru ch (1973), on th e o th e r hand, m ain -


ta in s th a t only a sm a ll num ber of h e r p a tien ts w ere

p rev io u s ly obese.

R e g a rd le ss of p re -m o rb id w eight, m ost au tho rs do a g re e

th a t the m a jo r ity of an o rex ics have shown som e p r io r p re

occupation w ith eating {Bruch, 1973; K e s s le r , 1966). F u r th e r

m o re , food often has a sp ec ia l im portance fo r the p a ren ts

(G oodsitt, 1969; K e s s le r , 1966). W hen a g ir l com es from a

household, th a t is a lre ad y d ie t conscious, it is easy fo r h e r to

g rad u a lly d e c re a se h e r food in take w ithout gaining undue

a tten tio n (B ruch , 1973). Such d ieting m ay in itia lly be

undertaken fo r a v a rie ty of rea so n s . Some pa tien ts re p o rt

th a t they begin w ith the so le in ten tion of slim m ing down.

W hen p ra is e d fo r th e ir w eight lo s s , they then decide to lo se

m o re w eight (B ruch , 1973). O th e rs a re incensed by

d exogatc-y re m a rk s about th e ir fig u re (Rowland, 1970; B ruch ,

1973), w hile som e diet when confronted w ith new life

ex p e rie n c e s w hich cause se p a ra tio n fro m the fam ily (B ruch,

1973; A ponte, 1973; Selvini, 1970).

I t is obvious th a t th e p o ss ib le cau sa l ag en ts behind

a n o re x ia n e rv o sa a re both num erous and d iv e rse . C lin ic ians

a p p e a r to be in g re a te r ag re em e n t on the ex istence of a

ty p ic a l p re -m o rb id p e rso n a lity and fam ily background.


1 4

A lthough a la rg e num ber of an o rex ic p a tien ts do ap p ea r to

s h a re com m on c h a ra c te r is t ic s and backgrounds, th e re is a

su b s tan tia l num ber of indiv iduals who do not. T he ex is ten ce

of th is p e rcen tag e should s ig n a l c lin ic ian s to be highly

ob jec tive and cautious in the com pilation of th e i r p a tie n ts ’

c a se h is to r ie s . T h e re a p p e a rs to be an inheren t d anger in

dealing w ith an o re x ic s , in th a t a c lin ic ian m ay m ake p r io r

a ssu m p tio n s about the s te reo ty p y of the p a tie n t 's p e rso n a lity ,

background, and co n tribu ting -m o tives. By p re m a tu re ly

lab e lin g the s itua tion , the th e ra p is t then e n te rs the in itia l

in te rv iew w ith c e r ta in suppositions about h is pa tien t w hich m ay

be highly in accu ra te . F u r th e rm o re , he m ay in ad v erten tly

conduct the in terv iew in a lead ing m an n e r, ask ing questions in

su ch a way th a t the a n sw e rs can only con firm h is p r io r

assu m p tio n s about the individual.

I t would be d ifficu lt to d e te rm in e how m any anorex ic

c a se s tu d ies have been m isco n s tru e d by su ch fa c to rs of

su b jec tiv ity and m is in te rp re ta tio n . As m o re re p o r ts con firm

th e ex is ten ce of com m on p e rso n a lity t r a i t s , backgrounds, and

p rec ip ita tin g fa c to rs , it m ay be a n a tu ra l inc lina tion fo r a

c lin ic ian to evaluate h is p a tien t p r im a r ily in te rm s of su ch

p ro to ty p es. A se r io u s c lin ica l m is ta k e such a s th is can only

■ r'--


be avoided when ob jec tive in te rv iew ing techn iques a re

em ployed, avoiding any p r io r a ssu m p tio n s about th e pa tien t

fa lling into ty p ica l c a teg o rie s . E ac h pa tien t m u st be

evaluated on a s t r ic t ly individual b a s is . T h is is a c r i t ic a l

s te p in dealing w ith a ll an o rex ics ; by th is m eans alone can

the m o st a p p ro p ria te th e rap eu tic ap p ro ach be chosen. T he

c lin ic ian who a ssu m e s th a t a il an o rex ic p a tien ts a re psycho-

dynam ic a lly a lik e , w ill undoubtedly encoun ter th e rap eu tic

roadb locks.

■ ' • ••• ' ' • • • •• — ••• • • - ' • ' •; •••• • ■ . ' ••••.. •• - . . • • ■ ̂ . <■; ■ - . • • • . '


D IFFER EN TIA L DIAGNOSIS

A norex ia n e rv o sa has been re p o rte d in the p a s t decade,

a s in c re a s in g in freq u en cy (Rowland, 1970; Duddle, 1973;

S elv in i, 1970). Y et, th e re is the p o ss ib ili ty th a t the d is

o rd e r is s im p ly being recogn ized m o re frequen tly . T he

l i t e r a tu r e on a n o re x ia n e rv o sa is c h a ra c te r iz e d by a lac k of

d iffe ren tia tio n betw een m any types of p h y sica l em acia tion .

F o rtu n a te ly , in the p a s t few y e a r s , a nu m b er of c lin ic ian s

have em phasized th e need fo r d iffe ren tia l d iagnosis (B ruch ,

1965; T o ls tru p , 1975). F i r s t and fo re m o st, it m u st be

reco g n ized th a t not a l l ind iv iduals who have undergone an

e x tre m e lo s s in w eight, a r e n e c e s s a r i ly su ffe rin g fro m

an o re x ia n e rv o sa . T h e re a re any n u m b er of unspecific

p sycho log ica l d is o rd e rs involving w eight lo s s , th a t m ay

decep tive ly re s e m b le a n o re x ia , but w hich can u ltim ate ly be

iden tified a s a ty p ic a l (B ruch , 1965).V- -

A b r ie f rev iew of th e ou tstand ing c lin ic a l fe a tu re s of

an o rex ia n e rv o sa o ffe rs a s ta r t in g poin t fo r any d iffe re n tia l

d iag n o sis . T he a n o re x ic p a tien t is ty p ic a lly fem a le , betw een

th e ag es of te n and tw enty , and has undergone a s e v e re weight

lo s s , due to h e r d e lib e ra te re fu s a l of food. T h is r e s u l ts in

16

. . ■. ■ . . . „ . . . . . _ . . . . ■■■ ' . . . . .

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission

cachex ia , accom panied by a lo w ered b a sa l m etab o lism , reduced

blood p r e s s u r e and pu lse ra te , constipa tion , and a m e n o rrh ea

(T o ls tru p , 1975; T hom ae, 1963; B ruch , 1965; B ruch , 1973).

T he l a t t e r m ay be one of th e f i r s t sym ptom s to a p p e a r, o r it

m ay o c c u r a s em acia tion becom es m o re pronounced (Thom ae,

1963). No physio log ical c au ses such a s tu b e rc u lo s is o r

m alignancy a re p re se n t, the d is o rd e r is psycho log ically

d e te rm in e d (B ruch, 1973).

A lthough an o rex ia n e rv o sa and Simmond*s D isease

re s e m b le one a n o th e r in sym ptom atology, a d iffe ren tia l

d iagnosis is , in fac t, a s im p le ta sk . C achex ia and am en

o r rh e a a r e ty p ica l of both d is o rd e rs , but em acia tion is

m ark e d ly m o re s e v e re in an o re x ic s (U shakov, 1971; Szyrynsk i,

1973). T h e re is no endocrino log ical d is tu rb an ce in ano rex ia ,

a s ev idenced by the re te n tio n of pubic and a x illa ry h a ir

(S zy rynsk i, 1973; W illiam s, 1974). L a b o ra to ry te s ts can

fu r th e r d iffe ren tia te the two d is o rd e rs . T he p a tien t su ffe rin g

fro m Sim m ond’s D ise ase is u su a lly c h a ra c te r iz e d by apathy

and d u lln e ss (U shakov, 1971; W all, 1959). in c o n tra s t , the

a n o re x ic re m a in s highly a c tiv e an d r e s t le s s , d esp ite s e v e re

m a ln u tritio n (B ruch , 1973; S zy rynsk i, 1973; M argo lis &

Je rn b e rg , 1971; U shakov. 1971).


O ther conditions involving psycho log ically de te rm in ed

weight lo s s , w hich a re often confused w ith an o rex ia n e rv o sa ,*

can be d iffe ren tia ted in a num ber of w ays. F i r s t of a ll,

a m e n o rrh e a m ay be p re se n t in som e of th e s e c a se s , but not

w ith th e sa m e re g u la r ity a s in ano rex ia . T h ese p a tien ts a re

highly concerned w ith th e ir w eight lo s s , w hich is usually

re la te d to som e o th e r psychological p rob lem (B ruch, 1973).

If they value th e i r lo ss in weight a t a ll, i t is only fo r its

p o ten tia l in con tro lling o th e r people (B ruch , 1973). They do

not d isp lay a s tro n g d e s ire to rem a in th in . F u r th e rm o re , they

a re su b jec t to fatigue and a p p ea r to be l i s t l e s s (B ruch, 1973).

T he individual su ffe rin g fro m p r im a ry an o rex ia n e rv o sa typ ica lly

den ies any co n ce rn about h e r em acia ted s ta te (G ifford, M uraw ski,

& W hite, 1970; T hom ae, 1963). R a th e r, sh e is e a g e r to lo se

m o re w eight and w ill r e s i s t any encouragem ent to eat (B ruch,

1973; U shakov, 1971). A lso , a s p rev io u s ly m entioned, th e

an o rex ic con tinues to d isp lay an ex cess iv e d riv e fo r ac tiv ity ,

w hich s e e m s re m a rk a b le in ligh t of advanced s ta g es of em acia-

tio n (S zyrynsk i, 1973; U shakov, 1971; B ruch , 1973).

Bruch (1965) has delineated three areas of "disordered

psychological functions (p. 560)" which, she states, indicate

the true syndrome of anorexia nervosa. The first area


involves a "d is tu rb an c e of de lusional p ro p o rtio n s in the body

im age (p. 566)." O ther a u th o rs have a lso noted th e a n o re x ic 's

p e rs is te n t den ia l of th e i r em acia tio n a s being abnorm al

(T o ls tru p , 1970; T hom ae, 1963). T he p a tien t p e rc e iv e s h e r

a lre a d y th in body a s overw eight (G aldston, 1974; G ottheil,

Backup & C o m eliso n , 1969; B ruch , 1965).

T he second a re a of d is tru b an ce involves an in accu racy in

the "p e rc ep tio n of s tim u li a r is in g in the body (p. 566). " T he

pa tien t a p p e a rs to be unable to reco g n ized hunger. T h e re is a

p e rs is te n t "ab sen ce o r den ia l of d e s ire fo r food (p. 566)."

Som e ind iv iduals who do give in to the im pu lse to ea t, then

go rge th e m se lv e s . T h is m o m en tary lack of con tro l m ay th en

be follow ed by se lf-in d u ced vom iting (T hom ae, 1963).

T he th ird c h a ra c te r is t ic d is tu rb an c e is what B ru ch (1965)

c a lls a "p a ra ly z in g s e n s e of in effec tiv en ess (p. 561)." T he

pa tien t p e rc e iv e s h e rse lf a s respond ing only to the dem ands of

o th e rs , n e v e r ac tin g on h e r own in itia tiv e . It h as been noted

th a t an o rex ic ch ild ren a r e freq u en tly d e sc rib e d a s highly

com plian t and obedient. B ru ch (1965) concludes fro m h e r

s tu d ies th a t th e s e ch ild ren have not le a rn e d to be independent

and to re ly on th e i r own re s o u rc e s , When th e ir liv e s

eventually re q u ire m o re of them th an "conform ing o b e d ie n c e ,"


th ey a r e unable tc function in an autonom ous m anner. C onsid

e rin g the num erous re p o r ts of o v e rco n tro llin g m o th e rs of

a n o re x ic s (Rowland; 1970; Kolb, 1S73; G ifford et a l . , 1970),

it se e m s qu ite lik e ly th a t n o rm al a ttem p ts by a ch ild to becom e

independent, would be s tro n g iy d iscouraged .

W hether o r not th e se th re e a re a s of d is tu rb an ce a re

indeed c h a ra c te r is t ic of p r im a ry an o rex ia n e rv o sa , it is

im p o rtan t to note B ru c h 's ca re fu l a ttem p t a t d iffe ren tia l

d iagnosis . T h ese delineations w ere m ade in an a ttem p t to

d isc r im in a te an o rex ia n e rv o sa fro m num erous types of

"psycho log ica lly d e te rm in ed em ac ia tio n (B ruch , 1970b). "

M uch o f the p a s t confusion su rro u n d in g th e c la ss if ic a tio n of

an o rex ia n e rv o sa , faasn undoubtedly been due to a la c k of

p ro p e r d ifferen tia tion . Food re je c tio n is e x tre m e ly com m on,

and if one w ishes to d e sc r ib e a ll fo rm s a s an o rex ia n e rv o sa ,

th en th is d iso rd e r c e r ta in ly does not e x is t a s a se p a ra te

c lin ica l en tity . Y et, a s U shakov (1971) poin ts out, an o rex ia

is a sp e c ific fo rm of food re fu s a l found in ad o le scen ts , w hich

show s su ch "co n stan t and w ell-d efin ed s ta g e s of developm ent,

th a t i t can only be sa fe ly a ssu m e d th a t it is a d is tin c t c lin ica l

en tity . . . (1971, p. 274)."

A ssum ing th a t an o rex ia n e rv o sa is^ a s e p a ra te c lin ica l

en tity , som e au th o rs m ain ta in th a t th e d iso rd e r is e a s ily


recogn ized (T o ls tru p , 1975). T he sym ptom atology is rep ea ted ly

d e sc rib e d in s im ila r te r m s , and th e t ru e sy n d ro m e ap p ea rs to

be qu ite un ifo rm (B ruch , 1S65). H ow ever, one cannot ignore

th e v a rio u s fa c to rs w hich freq u e n tly im pede an a c c u ra te d iag

n o sis . A s p rev io u s ly noted, the c lin ic ian m u s t tak e c a re to

d iffe ren tia te a n o re x ia n e rv o sa f ro m o th e r psychological

conditions involving w eight lo s s . T he p r im a ry fo rm of the d is

o rd e r a p p e a rs to be c h a ra c te r iz e d by a " r e le n t le s s p u rsu it of

th in n ess a s the d riv ing m otiva tion . . . (B ruch , 1873}."

A dditional o b s ta c le s in th e d iagnostic p ro ce d u re a re

re la te d to th e a n o re x ic !s ty p ica l m en ta l a ttitu d e . Many

c lin ic ian s find th a t the an o rex ic pa tien t is shy and guarded , and

cannot be depended upon to be tru th fu l (Selvini, 1970; T hom ae,

1963; B ruch , 1973). F u r th e rm o re , th ey m ain ta in a d e te rm in ed ,

if not s tu b b o rn cam paign to e m a c ia te th e m se lv e s (Selvini, 1970).

Ideally , th e d iag n o stic ian should t r y to develop som e s o r t of

ra p p o rt w ith th e p a tien t, to b e t te r in su re th e v a lid ity of the

p a tien t’s d is c lo s u re s . In itia l a tte m p ts a t d iagnosis m ay be m et

w ith r e s wtouC e , m aking th e p ro c e d u re a long and ted ious one.

Yet, th e c lin ic ian m u st be p re p a re d to cope w ith such fa c to rs

if an a c c u ra te d iagnosis is to be m ade.

A lthough th e a c tu a l n u m b er of an o re x ic p a tien ts who die

is sm a ll , th e u ltim a te p o ss ib il i ty o f d ea th i s p re s e n t in a ll


c a se s (Donovan, 1975; B row ing & M ille r , 1968; S ^yrynsk i,

1973; B ruch , 1971). T h is s e r io u s a sp ec t o f-the d is o rd e r

fu r th e r in d ica tes the need fo r an exact d iffe ren tia l d iagnosis .

T he th e ra p is t should have ex ten siv e knowledge of the d is

o rd e r , a s w ell a s adequate ex p erien ce w ith ano rex ic p a tien ts .

M any d iagnoses of an o rex ia th a t a r e re p o rte d in th e l i te ra tu re ,

a r e m ade by indiv iduals who have had lim ite d exposure to

tru e a n o re x ic s . Som e p a tien ts a r e p rev io u s ly lab e led an o rex ic

in hosp ita l re c o rd s , and th e i r c u rre n t th e ra p is t then a ccep ts

su ch la b e ls w ithout a new evaluation . One can only question

the v a lid ity of such p ra c t ic e s . W hen if is not known who

m ade the o rig in a l d iag n o sis , o r what th e i r qua lifica tions a re ,

questions should be r a is e d concern ing the ac tua l ex is ten ce of

th e d iso rd e r .

P e rh a p s one of the m o st im p o rtan t re a so n s fo r com pleting

an in ten siv e and cau tious d iagnostic p ro ce d u re , is i ts d ire c t

im p a c t on th e p ro g n o sis of th e d iso rd e r . T h e rap eu tic e r r o r s

can b e s t be p rev en ted by com pleting a thorough in v es tig a tio n of

the m ed ica l, p sycho log ical, and so c ia l fa c to rs con tribu ting to

each ind iv id u a l's c a se h is to ry .


22

THERAPEUTIC CONSIDERATIONS

Any th e ra p is t who p lans to in itia te tre a tm e n t of an

a n o rex ic , should f i r s t be aw are of som e of the m a jo r fa c to rs

w hich w ill a ffec t h is e ffo r ts , re g a rd le s s of which psychological

ap p ro ach is chosen.

A norex ic p a tien ts a re m ost often desc:- ibed a s uncoopera

tiv e , and highly re s is ta n t to tre a tm e n t (Ushakov, 1971;

T hom ae, 1S63). F u r th e rm o re , th e i r p e rs is te n t denial of illn e ss

and ap p a ren t enjoym ent of weight lo se a r e lik e ly to be the

so u rc e of f ru s tra t io n and anx ie ty fo r the a ttending th e ra p is t

(T hom ae, 1963). As a re s u lt, th e re is th e n a tu ra l danger th a t

th e c lin ic ian w ill respond to h is pa tien t w ith the sam e an g er

and anx ie ty th a t c h a ra c te r iz e s m o st paren ts* reac tio n s

(Selvini, 1971; B row ning & M ille r , 1S68). Ju s t a s the pa tien t

m ay have used h is re fu sa l of food to unconsciously m an ipu late

h is fam ily , he m ay a ttem p t to do th e sa m e w ith h is th e ra p is t .

T h e pow er s tru g g le w hich m ay ensue can only in te r fe re w ith

th e ra p e u tic e ffec tiveness (B row ning & Miller-, 1968). G oodsltt

(1969) a d v ise s th a t the c lin ic ian n e v e r em ploy non-ea ting a s

" a barga in ing point (p. 118).”

A n o th er s e r io u s c o n sid e ra tio n in th e tr~ a tm en t of an o rex ia

23


n e rv o sa is th e constan t th re a t of death. How ever, B row ning

and M ille r (1968) re p o r t th a t m ost an o rex ic p a tien ts a re ab le

to m ain ta in ex tre m e ly low lev e ls of weight fo r pro longed

p e rio d s of tim e . T hey conclude tha t th is fac t should a ffo rd a

th e ra p is t som e re l ie f , allow ing him to fee l le s s co erced , and

f r e e r to deal w ith h is pa tien t effectively .

An in itia l decision to be m ade by the th e ra p is t, is

w hether o r not the patien t w ill be hosp ita lized . T he l i te r a tu r e

re v e a ls what a p p e a rs to be a un iv ersa l approach , th a t of

se p a ra tin g the pa tien t from h is fam ily , and p lacing him in a

h osp ita l o r in s titu tio n (Kolb, 1973; W all, 1959; G aldston , 1974).

It has been maintained that such a separation allows the

individual to m a tu re , and to becom e m o re independent, th e re b y

d im in ish ing th e p ro b ab ility of sym ptom re c u rre n c e (Szyrynsk i,

1973; G aldston , 1974). H ow ever, som e au th o rs have vo iced

their m isgivings about such practices, questioning its need

and advisability. Rowland (19?0> states that:

It seem s peculiar to take a patient's illn ess, treat it, and then to return the patient to the sam e constellation without any attempt to alter it.Anorexic patients do eventually return to their fam ilies and it would seem that som e attempt to understand and treat the family is necessary (Rowland, 1970, p. 124).

A follow-up study by Browning <1968) of th irty-six fem ale

patients who had been hospitalized with anorexia nervosa.


concludes th a t "h o sp ita liza tio n should not be co n sid ered a p r e

re q u is ite fo r su c c e ss fu l outcom e (p. 1128)." No s ta tis t ic a lly

sign ifican t re la tio n sh ip w as found betw een the two fa c to rs .

P e rh a p s th e w ise s t ap p ro ach in d e te rm in in g the need fo r

h o sp ita liza tion is th a t of m aking individual evaluations. E ach

p a tie n t 's m ed ica l, psycho log ical, and so c ia l s itu a tio n should be

exam ined in an e ffo rt to d e te rm in e the efficacy of v a rio u s

th e ra p eu tic se ttin g s .

A s p rev io u s ly noted, indiv iduals su ffe ring fro m an o rex ia

n e rv o sa a re highly re s is ta n t to tre a tm e n t. When an an o rex ic

p a tie n t 's w eight has in c re a s e d and a p p e a rs to be s ta b iliz e d , the

th e ra p is t is re liev e d , and often in te rp re ts su ch a developm ent

a s rec o v ery . Y et, a note of cau tion should be sounded. T his

d iso rd e r has com e to be known f o r its cyc les of re m iss io n s

and re c u r re n c e s (T o ls tru p , 1975; Rowland, 1970). M any

-patients w hose ph y sica l and psycho log ical d ifficu lties a p p e a r to

be re so lv ed , l a t e r r e tu rn fo r tre a tm e n t in a m a t te r of m onths

(B ruch, 1971). Any d iagnosis of re c o v e ry should be m ade

w ith th e g re a te s t of c a re . T he p re m a tu re w ithdraw al of

m ed ica l and psycho log ica l su p p o rt could con tribu te to un fo re

se e n re la p s e s , and in som e c a se s , the p o ss ib ility of death .

The therapist who is about to undertake an anorexic

case, should be aware of the clinical considerations noted


h e re . T h ese fa c to rs w ill undoubtedly have a m a jo r im pact on

th e ra p e u tic su c c e ss . By an tic ip a tin g re s is ta n c e , p o ss ib le

pow er s tru g g le s , and p e rso n a l f ru s tra t io n , the c lin ic ian w ill

be b e tte r p re p a re d to handle a d ifficu lt pa tien t.


CURRENT MODES O F TREATM ENT

C u rre n t p sycho log ical ap p ro ach es to an o rex ia n e rv o sa

a r e qu ite d iv e rse . T he tre a tm e n t of th is d is o rd e r h as under

gone ex ten siv e change throughout the p a s t fifty y e a rs .

C lin ic ian s in th e 1920!s re lie d on th e m anipulation of the

p a tie n t’s d ie t to a r r e s t the syndrom e. F r e s h c a lf ’s l iv e r ,

beefsteak , and lam b kidney w ere su g g ested a s appetite

s tim u la n ts (B a rtle tt , 1928). O ther p ra c tic e s included the

a d m in is tra tio n of cod l iv e r o il and iro n (Hobnouse, 1925).

Since th a t tim e , th e ra p eu tic ap p ro ach es to an o rex ia

n e rv o sa have been m ost highly influenced by psycho therapy .

T he l i te ra tu r e re v e a ls th a t th e m a jo r ity of an o rex ic pa tien ts

a r e t r e a te d w ith som e fo rm of psycho therapy . R ecen tly ,

how ever, behav io r th e ra p y has gained reco g n itio n fo r i ts

re p o r te d e ffic iency in r e s to r in g eating behav io r in th e an o rex ic .

Further developments in the treatment of the syndrome

have been stimulated by a new shift in attention to the contribu

tion of fam ily psychopathology to the anorexic's problem s.

Fam ily therapy often utilizes methods from both psychotherapy

arid operant conditioning.

Each erf these therapeutic approaches w ill be reviewed,

with special emphasis on both their positive and negative

27


a sp e c ts . A norex ia n e rv o sa is a s e r io u s d iso rd e r p lacing

unusual dem ands on th e th e ra p is t. T h e re fo re , the se lec tio n

of a p a r t ic u la r fo rm of th e ra p y f o r each pa tien t, should take

into co n sid e ra tio n not only the needs of the c lien t, but a lso

th o se of th e c lin ic ian . Ideally , the th e ra p is t should choose

an ap p ro ach w hich he expects to be highly effective, but

w hich he w ill a lso fe e l com fortab le em ploying.


PSYCHOTHERAPY

The l i te ra tu re dealing w ith th e use of psycho therapy in

re la tio n to an o rex ia nervosa is c h a ra c te r iz e d by inconclusive

findings. Many stu d ies do not c la r ify the exact fo rm of

th e rap y used, o r the type of an o rex ic p a tien ts involved.

Seldom is a c r i te r io n d esc rib ed fo r re c o v e ry o r im provem en t.

T h e re fo re , it is often im possib le to m ake any c o rre la tio n

betw een technique and re s u lts . R ep o rted su c ce ss ra te s should

be reg a rd e d w ith som e deg ree of sk e p tic ism , as long te rm

fo llow -ups a r e not alw ays com pleted.

The l i te ra tu r e d e sc rib e s the use of a wide v a r ie ty of

p sycho therapeu tic techniques in re la tio n to an o rex ia n e rv o sa .

M ost c lin ic ian s p re fe r to p e rso n a liz e th e i r techn iques, using

so m e basic psycho therapeu tic concep ts , but a lso innovating

new m ethods of th e ir own. T he m a jo rity of co n tem porary

th e ra p is ts s tan d in ag reem en t th a t th e use of trad itio n a l

p sychoana ly sis is ineffective in th e tre a tm e n t of an o rex ia

n e rv o sa (Selvini, 1970; G aldston, 1974; Rowland, 1970, B ruch ,

1973). H ow ever, a few c lin ic ian s still maintain that its

influence on an o rex ic p a tie n ts is m o re fav o rab le than any

o th e r approach . T hom ae (1963) re p o r ts that the u se of

29


in te rp re ta tiv e techniques can b rea k down re s is ta n c e , and

u ltim ate ly fa c ilita te p e rso n a lity change. He w arn s a g a in st the

so le use of sym pathe tic understanding . U nless th e p a tien t is

a c tiv e ly le d to d isc lo s in g h e r p rob lem s th rough in te rp re ta tio n ,

sh e is lik e ly to r e g r e s s m o re deeply in to s ic k n e ss . By

m eans of follow ing psychoanaly tical ru le s , e igh t of n ineteen

p a tien ts w ere supposedly im proved o r rec o v e re d . It is

in te re s tin g to note th a t an additional n ine p a tien ts w ere d iag

nosed a s experienc ing spontaneous reco v ery .

S zy rynsk i (1973) re p o r ts tha t two th ird s of h is pa tien t

population show ed im provem en t follow ing the a d m in is tra tio n

of dynam ic psycho therapy . T h is app roach involves ven tila tion ,

d e se n s itiz a tio n to food and eating , in tro jec tio n of the th e ra p is t ’s

a ttitu d e , and an ad just ir-cnt of th e p a tie n t 's env ironm ent. T he

p ro b lem s of food re fu sa l a r e not d irec tly dea lt w ith in the f i r s t

s ta g e s of th e rap y . R a th e r, an e ffo rt is m ade to s tren g th en

th e to ta l p e rso n a lity fu tu re change.

The patient is usually removed from his house and placed

in a hospital, or with another family. Furthermore, it is

considered w iser to alter the individual’s attitude toward his

parents, rather than attempting to overcome parental resistance.

Two underlying conflicts, sexual fears and hostility

toward the mother, are dealt with in the process of ventilation.


T he th e ra p is t and p a tien t engage in open d isc u ss io n , in te r

p re tin g th e in d iv id u a l's l e t t e r s , d ia ry , and d re a m s . The

c lin ic ian a tte m p ts to d isp e l any in a c c u ra te sex u a l ideas w hich

th e p a tien t m ay have, su ch a s a f e a r of o r a l im pregnation .

Secondly, the m o th e r is p re se n te d as "a m o re o rd in a ry hum an

being (S zy rynsk i, 1973, p. 501 )," who has p ro b lem s and

w eak n esses o f h e r own. T h is s ta g e of th e ra p y is sa id to

allow th e p a tie n t a m o re r e a l is t ic v: ew o f h e r c u rre n t

p ro b lem s.

A s th e ind iv idual spends m o re t im e in th e ra p y , she has

th e oppo rtun ity to o b se rv e the w ell a d ju s te d p e rso n a lity of h e r—

th e ra p is t . B oth th e v e rb a l and n o n -v e rb a l b eh av io r of the

c lin ic ian s e rv e a s an im p o rtan t m odel. T he p a tien t m ay now

unconsciously in c o rp o ra te som e of the d e s ira b le q u a litie s of

h e r th e ra p is t , th e re b y stren g th en in g h e r own w eakened ego.

The l a s t s te p in th e ra p y is th e d e se n s itiz a tio n of the

p a tien t to w a rd food and eating . T h is i s b rough t about by

m ean s of th e th e ra p is t d isc u ss in g th o se th re a te n in g to p ics in a

ca lm and o b jec tiv e m an n e r. O nce again , the p a tie n t is s a id

to o b se rv e th e th e r a p is t 's r e l a x e d b eh av io r, and then in tro je c ts

co m p arab le a tt i tu d e s . The open and f ra n k d isc u ss io n o f the

in d iv id u a l's a v e rs io n to food, en ab les h e r to face h e r p ro b lem

m o re e a s ily . A dditional d e se n s itiz a d o n p ro c e d u re s involve


co n v ersa tio n s p e rta in in g to n u tritio n and the counting of

c a lo r ie s .

T ra d itio n a l p sycho therapeu tic p ra c tic e s su ch as th o se

ju s t d e sc rib e d , have p roven to be not only u s e le s s , but

dam aging fo r som e an o rex ic p a tien ts (B ruch , 1973). By

confron ting th e pa tien t w ith in te rp re ta tio n s of h e r unconscious

m o tiv es , th e th e ra p is t m ay be rep ea tin g the p a tte rn of in te r

a c tio n betw een p a re n t and child . T he an o rex ic is faced w ith

add itional ev idence th a t she , h e rse lf , not know h e r own

fe e lin g s , though ts , and in ten tions (B ruch , 1970b). T h is m ay

r e s u l t in in c re a s e d re s is ta n c e to th e rap y and to in te rp e rso n a l

con tac t (Selvini, 1971).

B ru ch (1973) m ain ta in s th a t the c lin ic ian who re l ie s on

th e tra d itio n a l m odel "m ay be tem p ted to su p erim p o se p r e

conceived notions on th e pa tien t (p. 5 7 )." H e r p e rso n a l

ap p ro ach to an o rex ia n e rv o sa em phasizes th e need fo r lis te n in g

to th e p a tien t, and tak in g a te m p o ra r i ly le s s ac tiv e ro le in th e

p ro c e s s o f th e ra p y . T he indiv idual is given th e opportun ity to

f r e e ly e x p re s s h e rs e lf , w ithout im m ed ia te in te rp re ta tio n s and

la b e ls f ro m h e r th e ra p is t.

B oth B ru ch (1970b) and Selv in i (1971) re p o r t th a t th e

p a re n ts of a n o re x ic s have ty p ic a lly t i l e d to fo rc e on th e i r

ch ild ren , th e i r own in te rp re ta tio n s of th e c h ild 's needs. Any


33

a ttem p t by the ch ild tow ard se lf- in itia tiv e and autonom y a re

f irm ly d isco u rag ed by the p a re n ts . T h is r e s u l ts in fee lings

of h e lp le s sn e ss and in e ffec tiv en ess , a s w ell as an inab ility to

reco g n ize o n e 's own fee lin g s and im pu lses {Bruch, 1973).

B ru c h 's p e rso n a liz e d tre a tm e n t app roach c e n te rs around

th e se developm ental d e fic its . T he m ain goal in th e ra p y is

" to m ake it p o ss ib le fo r a pa tien t to uncover h e r own a b ilitie s ,

h e r r e s o u rc e s and in n e r cap ac itie s fo r thinking, judging and

fee lin g (B ruch , 1973, p. 339)." It is co n sid ered e sse n tia l

th a t th e p a tien t becom e an ac tiv e p a rtic ip a n t in therapy : when

th e re a r e fee lin g s and e x p e rien c es to be uncovered, the pa tien t

is g iven th e opportun ity to m ake such d isc o v erie s on h e r own.

A s th e th e ra p is t encourages se lf -a w a re n e ss , the individual

w ill hopefully becom e m o re confident in re ly in g on h e r own

im p u lse s , thoughts, and em otions (B ruch, 1973).

B ru c h (1973) has g rad u a lly developed th is n o n - in te rp re ta

tiv e a p p ro ach o v e r a p e rio d of th ir ty y e a rs , follow ing th e ra

p eu tic d ifficu ltie s and fa i lu re s w hile tre a tin g a n o rex ics w ith

p sy ch o an a ly sis . H er p e rso n a l experience w ith ano rex ic

p a tien ts in d ic a te s ; tha t a s th e individual le a rn s to re ly on h e r

own r e s o u rc e s , food re fu s a l w ill becom e le s s and le s s of a

p ro b lem .


S elv in i (1971) a lso con firm s th e efficacy of su ch an

app roach , adv ising th e ra p is ts to be s in c e re and unassum ing

w ith th e i r p a tien ts . C lin ic ians a re w arned ag a in st re in fo rc in g

th e p a tie n t’s fee lings of h e lp le ssn e ss ; o ffe rs of help and

affection a r e to be avoid^cU The ind iv idual gains a s s is ta n c e

in le a rn in g to r e ly on h is own p e rc ep tio n s . Conjoint th e rap y

se ss io n s involving the m o th e r and daugh ter, and m ale and

fem ale c o - th e ra p is ts a re a lso used, and a r e re p o rte d to be

highly effective.

W hereas som e c lin ic ian s such as B ru ch and Selv in i

delay any d ire c t th e rap y concern ing food re fu sa l, o th e rs

believe th a t th e in itia l concen tra tion should be on re in s ta tin g

eating behav io r (T o ls tru p , 1975; Kolb, 1973; G aldston , 1974).

The p o ss ib ility of long te rm harm fu l e ffec ts due to a m in im al

d iet should be kep t in m ind a t a ll t im e s . T o ls tru p (1975)

adv ises th a t each p a tien t’s physical condition be c a re fu lly

evaluated p r io r to tre a tm e n t, delaying psycho therapy until th e

individual has m ade a su b s tan tia l ga in in w eight. He d e lin ea tes

th re e g o a ls in tre a tin g th e ano rex ic p a tien t. The f i r s t is to

"e n su re su rv iv a l (p. 7 7 ),11 secondly to p rev en t any p h y sica l

re la p s e s , and la s tly to rem ove "o v e rt psychopathology (p. 7 7 )."

T o ls tru p ’s s tu d ie s ind ica te th a t the f i r s t tw o goals can be

ach ieved fo r app rox im ate ly one half to two th ird s of any


p a tien t population, but th a t the th ird goal is r a r e ly ach ieved

fo r m o re than a few ind iv iduals .

G aldston (1974) concludes fro m h is study of fifty

an o rex ic p a tien ts , th a t w eight ga in should take p r io r i ty o v e r

the "acq u is itio n of in sigh t (p. 255)." His tre a tm e n t technique

is based on th e concept th a t th e anorex ic re fu se s food due to

a "phobia of bodily p le a su re (p. 253). " T h erap y is a im ed a t

helping the p a tien t re g a in p e rso n a l contro l of su ch p le a su re .

T he an o rex ic is in fo rm ed by h e r th e ra p is t th a t she is evidently

not ab le to m ain ta in h e r own health , a s evidenced by h e r

e x tre m e lo s s in w eight. T he hosp ita l s ta ff s te p s in and

tak e s th e re sp o n s ib ility of se lf -p re se rv a tio n fro m th e p a tien t,

until sh e is ab le to d isp lay a c e r ta in deg ree of w eight gain.

At each meal a staff member sits with the patient,

occasionally feeding her, and frequently speaking of the

necessity of feeding one‘s self. Privileges are granted only

when weight is gained, while a further loss in weight results

in restriction to bed and suspension of activities.

Psychotherapy is also included in the total therapeutic

approach, with its form , intensity, and frequency varying from

one individual to the next. These sessions are carried on in a

non-threatening manner, consisting mainly of brief discussions.

The therapist does not pressure the patient for disclosure of


35

M s m otives o r fee lin g s .

T he c r i te r io n fo r d isc h a rg e r e s t s upon th e p a tie n t 's

"d e m o n s tra te d a b ility to enjoy h e rs e l f . . . in in te rp e rso n a l

a c tiv ity on th e w ard . T h is to g e th e r w ith w eigh t ga in su ffic ien t

to keep the p a tien t out of d an g er of m a ln u tritio n (G aldston,

1974, p . 256)," a r e a p re re q u is i te fo r leav in g th e hosp ita l.

G a ld ston re p o r ts th a t out of a ll th e p a tien ts m ee tin g th is

c r i te r io n , none w ere e v e r in need of re a d m is s io n fo r weight

lo s s . A lthough th e p ro b lem of food re fu s a l w as supposed ly

re so lv e d in a l l but th re e c a se s , m o s t p a tien ts continued to

ex p e rien ce a f e a r of ea ting and ge tting fa t , long a f te r th e ir

d isc h a rg e . I t w ould a p p e a r th a t su s ta in ed w eight ga in was

acM eved by m ean s of tM s th e ra p e u tic ap p ro ach , but th a t the

underly ing p e rso n a lity p ro b lem s accom panying th e o rig ina l

w eight lo s s , w e re s t i l l in ex is ten ce .

Rowland (1970) reports equally negative findings in a

long term follow-up study of tMrty anorexic cases. Most

patients upon discharge were considered to be fairly sick

despite the recurrence of eating. The follow - up contacts

revealed that few patients had undergone permanent personality

change; original maladaptive personality traits were still

evident. Most individuals were described as "evasive,

manipulative, coercive, immature, and dependent (Rowland,


37

1970, p. 130). ” T h e se p a tien ts had undergone som e fo rm of

p sycho therapy , rang ing fro m ligh t d iscu ss io n s to in sigh t

th e ra p y , fo r an a v e ra g e of ten m onths.

It is in te re s tin g to no te tha t th is study as w ell a s m any

o th e rs (Z ie g le r & S o u rs , 1968; B ruch , 1971; T o ls tru p , 1975)

re p o r t a h igh inc idence of sym ptom re c u r re n c e and continuing

psycho log ica l p ro b lem s. A s Rowland (1970) d e sc r ib e s

a n o re x ia n e rv o sa , th e "sy n d ro m e is one of re m iss io n s and

e x ac e rb a tio n s , and m ay re q u ire m u ltip le h o sp ita liza tio n s (p„ 130).

A bleak p ic tu re su c h a s th is should r a is e som e se r io u s questions

a s to th e c o rre la t io n betw een p sycho therapeu tic ap p ro ach es and

expected p ro g n o sis .

T he l i te r a tu r e r e p o r ts two se p a ra te s tu d ies w hich conclude

th a t th e re is no s ig n ifican t re la tio n sh ip betw een the type of

tre a tm e n t u sed in a s so c ia tio n w ith an o rex ia n e rv o sa , and the

fina l ou tcom e of th e d is o rd e r (S e id en steck er & T zag o u rn is ,

1968; Browning & M iller, 1968). Other factors such as age,

educational achievem ent, degree of weight lo ss , and duration of

symptoms were considered to be more important in determining

the likelinood of recovery (Seidenstecker & Tzagournis, 1968).

Yet, in direct contradiction, Browning (1968) found age, amount

of weight lo ss and duration of symptoms to be unimportant

with regard to final outcome.


C onflic ting re p o r ts su ch a s th ese c h a ra c te r iz e the

confusion a s s o c ia te d w ith the ro le of p sy ch o th erap y in

t r e a tin g a n o re x ia n e rv o sa . M any s tu d ie s re v e a l incom plete

d e sc r ip tio n s of th e i r tre a tm e n t tech n iq u es, o m iss io n of

c r i t e r i a used in the d iagnosis of rec o v e ry , and th e absence

o f lo n g - te rm fo llow -ups. T hus, tru e e fficacy of such

ap p ro ach es cannot be e a s ily de te rm ined .

A dditional d raw backs th a t appear to be re la te d to

p sy ch o th erap y a r e the te m p o ra l and financ ia l fa c to rs which

a r e involved. M any an o rex ic pa tien ts a r e re p o rte d to rem ain

in th e ra p y fo r a y e a r o r m o re , spending m ost of tha t tim e

h o sp ita liz e d and s e p a ra te d fro m th e ir fa m ilie s . C onsidering

th e r is in g costs erf medical and p sy c h ia tr ic c a re , such extended

p e rio d s of t r e a tm e n t can only becom e a financ ia l burden fo r

m o s t p a tien ts .

Furthermore, the longer the patient is separated from h e r

fam ily, the m ore distant her prohlem becomes to them. Her

eventual return to the home setting may constitute a cr isis for

the fam ily who has become accustomed to not coping with her

problem s.

Another danger is that prolonged treatment may encourage

the anorexic to develop a highly dependent relationship with

her therapist.


In ligh t of th ese co n sid era tio n s, it would ap p ea r th a t a

highly effective th e rap eu tic ap p ro ach to an o rex ia n e rv o sa would

be one which fa c ilita te s the e a r ly re tu rn of the patien t to h e r

fam ily and p e e r group. F r ic tio n a sso c ia ted w ith the re a d ju s t

m ent to fam ily liv ing can p robably b est be avoided by including

the p a tie n t 's fam ily in the tre a tm e n t p ro g ram .

P sycho therapeu tic app roaches often view the anorex ic in

iso la tion , not dealing w ith the im pact th a t h e r im m edia te

fam ily has upon h e r. M any re la p se s and conflic ts o ccu rrin g a

few m onths a f te r d isch arg e , m ay be re la te d to th is p ra c tic e .

By educating and p rep a rin g the fam ily fo r th e ir d au g h te r’s r e

tu rn , it is m o re lik e ly th a t sh e w ill p e rm an en tly m ain ta in h e r

weight gain and c u rre n t psycholog ical ad ju stm en t.


ATYPICAL PSYCHOTHERAPEUTIC TECHNIQUES

T he few th e rap eu tic techn iques tha t have been used w ith

an o rex ic p a tien ts a r e som ew hat d ifficu lt to ca teg o rize . They

have e ith e r been used in conjunction w ith psycho therapy (se lf-

im age ex perience), o r , th e ir m ethods (anac litic th e ra p y and

educative therapy) re se m b le psychotherapy m o re c lo se ly than

any o th e r psychological approach .

A n ac litic th e rap y (fro m the G reek w ord anak linein ,

m eaning to lea n upon) is a som ew hat unusual ap p ro ach which

has been used on a lim ite d b a s is w ith an o rex ic p a tien ts .

M argo lis and J e rn b e rg (1960) re p o r t a c a se involving a fo rty -

eight y e a r old, m a r r ie d w om an, w hose an o rex ia w as s u c c e s s

fu lly tr e a te d by th is p ro ce d u re . A lthough th is p a r t ic u la r

ind iv idual does not fit the conventional p a tte rn of m o st a n o rex ics ,

due to h e r age and m a r ita l s ta tu s , sh e did d isp lay a ll of the

s te re o ty p e d sym ptom s, w ith the exception of a m e n o rrh ea .

This disorder appeared to lave been triggered by her

husband's demands for fellatio. Despite continuing emaciation,

she resisted psychotherapy sessions involving history taking

and inquiries about her feelings. At this tim e, anaclitic

therapy was undertaken.

40


T he th e o re tic a l b a s is of an ac litic th e ra p y , r e s t s upon the

no tion th a t the c re a tio n of a dependency re la tio n sh ip between

p a tien t and th e ra p is t, w ill u ltim ate ly allow th e p a tien t to give

up h e r re s is ta n c e . She w ill no lo n g e r decline help, but

accep t i t w illing ly aft e r re liv in g the " in fan tile conflict

(M argoils & J e m b e rg , 1960, p. 281)."

T re a tm e n t involves responding to th e p a tien t a s if she

w ere an infant o r sm a ll child . She is a ttended to by the s ta ff

in a tend ing and loving m an n er. T he p a tie n t 's fo reh ead is

s tro k ed , h e r hand held fo r hours a t a tim e , and sh e is given

w a rm baths and alcohol ru b s . The th e rap is t'-s encoun ters with

the an o rex ic a re c h a ra c te r iz e d by "d e lib e ra te om n isc ien t

behav io r (M argo lis & J e m b e rg , 1960, p. 291)," continuing

k indness and indulgence, a ll in an e ffo rt to s tre n g th e n the

p a tie n t 's confidence in h im .

T h is p e rio d of tre a tm e n t is r e f e r r e d to a s th e "ca tabo lic

p ro c e s s ” w hereby the p a tie n t 's anx ie ty is a llev ia te d , and she

begins to t r u s t h e r th e ra p is t . T he l a t t e r p h ase , o r "anabolic

p ro c e ss " involves a change in p e rsp e c tiv e , a s th e ano rex lc

begins to view the th e ra p is t a s a d e s ira b le m odel, r a th e r than

a n u rtu rin g m o th e r. She can now f re e ly e x p re ss h e r em otions

without th e f e a r of being re je c te d o r pun ished . I t is sa id tha t


42

during th is fin a l s ta g e , th e ego is s tren g th en ed , allow ing the

p a tien t to becom e m o re independent.

T he th e ra p e u tic p ro ce d u re fo r th is p a r t ic u la r pa tien t

la s te d th ir te e n and a ha lf m onths. A follow -up re p o r t

in d ica ted th a t she w as ab le to m ain tain h e r w eight and good

health , d e sp ite s e p a ra tio n fro m h e r husband.

Since th is a p p ro a ch has not been used ex tensively in the

t re a tm e n t of an o rex ia n e rv o sa , it is d ifficu lt to m ake any

le g itim a te conclu sions about its e ffec tiv en ess . T he draw backs in

su ch a p ro c e d u re a re q u ite obvious. It p laces constan t dem ands

on both the th e ra p is t and hosp ita l s ta ff, req u ir in g un lim ited

t im e -a n d p a tien ce of them . F u r th e rm o re , se r io u s questions

should be ra is e d a s to th e ad v isab ility of d e lib e ra te ly c re a tin g

su c h a s tro n g dependent re la tio n sh ip . It is quite p o ss ib le tha t

som e a n o re x ic p a tie n ts would r e g r e s s to an in fan tile o r ch ild ish

s ta te a s p lanned , but would then continue to cling indefin ite ly

to both th e th e ra p is t and -• taff. M any ind iv iduals m ight not w ish

to g ive up th e sa fe ty of the ca tabo lic p ro c e s s , and would n ev er

p ro g re s s in to th e anabo lic p ro c e ss .

Further studies may determine the various personality

types with whom it would, and would not be advisable to use

anaclitic therapy. Until that tim e, clinicians should em ploy


su ch techn iques w ith e x tre m e caution, in the tre a tm e n t of

a n o re x ia n e rv o sa .

T he "ed u ca tiv e tre a tm e n t" of an o rex ia n e rv o sa (G roen &

F e ldm an-T cledano , 1966) is s lig h tly s im ila r to an ac litic

th e rap y , in th a t a m o thering ap p ro ach is taken by a fem ale

th e ra p is t , H ow ever, a m ale t a s ra p is t a lso in te ra c ts w ith the

p a tien t, and to g e th e r the c o - th e ra p is ts te m p o ra r ily a c t a s

loving p a re n ts fo r th e ano rex ic .

T he synd rom e is view ed as the r e s u l t of a lack of love

fro m th e n a tu ra l p a re n ts . T he an o rex ic is sa id to encounter

som e d ifficu lt s itu a tio n in h e r life , w hich sh e is unable to

handle w ithout em otional suppo rt fro m h e r p a re n ts . H er

em otional s e c u r i ty is s e v e re ly th rea te n ed , and she then r e

g re s s e s to a p a tte rn of food re fu s a l u sua lly se en in m uch

younger ch ild ren .

Traditional psychoanalytical procedures are considered

inappropriate, as the patient’s emotional status appears to be

that of a child. Groen & Feldman-Toledano's approach treats

the anorexic as a sm all child, despite age, offering her

affection and sm all gifts. During m eals she is told stories and

praised for. any eating behavior that occurs, no matter how

lim ited. Food is never forced on the child, neither is she

chastised for her refusal of it.


The m ost in te re s tin g a sp ec t of th is approach , how ever,

involves the inclusion of th e p a re n ts in educative s e s s io n s .

They a re not blam ed, o r m ade to fee l guilty fo r th e i r in ab ility

to e x p re ss love fo r th e ir child. R a th e r, they a re to ld that

th e ir daugh ter is su ffe ring fro m a d is o rd e r of the hypothalam ic

appetite c e n te r . T he p a re n ts a re encouraged to d em o n stra te

th e ir affection In sm a ll w ays, such as k iss in g the ch ild , and

paying h e r com plim ents. The c o -th e ra p is ts se rv e a s m odels

fo r the p a re n ts , a s w ell as offering them support and the

opportun ity to d iscu ss th e ir own m a r ita l p rob lem s. N e ith e r

child n o r p a re n ts a re engaged in "deep p sy c h ia tric tre a tm e n t

(G roen & F e ldm an-T o ledano , 1960, p. 6 8 0 )." The em phasis

is on behav io r, sp ec ifica lly the a ffectionate behavior d isp layed

tow ard the child . It is hoped tha t the p a re n ts w ill o b se rv e

th is m odeling behavior, and perm anen tly adopt It.

This approach was reportedly successful in dealing with

seven individuals suffering from anorexia nervosa. A ll of the

patients were able to gradually withdraw them selves from the

special care received in the hospital. It is suggested that

the patient does not go directly home, but first reside in a

home with a strong maternal figure. Outpatient v isits with the

therapists are continued on a weekly basis. The final return

to their own home is usually a period requiring patience and


understand ing on th e p a r t o f th e p a re n ts . The ch ild w ill no

lo n g er be a s com plian t and su b m iss iv e a s sh e w as p r io r to

h o sp ita liza tio n . The th e ra p is ts v is i t th e fam ily in th e hom e

o ffering continued encouragem en t and su p p o rt fo r th e p a re n ts .

A ll sev en p a tien ts w ere re p o r te d to be in good p hysica l

and m ental health , in a follow -up check rang ing fro m one to

s ix y e a rs .

The re c o v e ry of a ll th e p a tien ts , a s w ell a s th e sh o rt

du ra tion of th e ra p y (an av e rag e of th re e m onths) a r e im p re ss iv e

fa c to rs in th is study. L ikew ise , th e e lim ina tion of a pow er

s tru g g le o v e r food is a lw ays a p o sitiv e fa c to r . H ow ever, one

draw back to educative tre a tm e n t is th a t it re q u ire s a sp ec ia l

p e rso n a lity o f both th e ra p is ts . T he two c lin ic ian s m ust be

p re p a re d to w ork to g e th e r on a v e ry c lo se b a s is , coopera ting

in th e i r m utual m a te rn a l and p a tr ia rc h a l ro le s . T he num ber

of p a tien ts who have been t r e a te d by educative techn iques i s ,

of c o u rse , qu ite sm a ll, and fu r th e r s tu d ies u tiliz in g th is

ap p ro ach a r e needed to v a lid a te i ts e ffec tiv en ess .

The unusual technique of " s e lf - im a g e confrontation"

exposes th e an o rex ic to sound m otion p ic tu re s o f h e rs e lf

(G ottheil e t a l . , 1969). T he p ro ce d u re is designed to help th e

p a tien t becom e m o re re a l is t ic about h e r body im ag e . A s

p rev io u s ly no ted , an o rex ic p a tien ts ty p ica lly view th e i r


e m a c ia te d f ig u re s a s overw eight (B ruch , 1973). Seeing one’s

s e lf in th e m ir r o r , o r rev iew ing p a s t and p re s e n t photographs

have been re p o r te d a s ineffective in changing a p a tie n t 's in

a c c u ra te body im age (Rowland, 1970).

T h is ap p ro ach w as used in com bination w ith p sy ch o an a ly sis ,

a lthough handled by d iffe ren t p sy c h ia tr is ts , and a t d ifferen t

in s titu tio n s . O nce a week, th e pa tien t undergoes a se lf- im a g e

e x p erien ce se s s io n , and every o th e r w eek a b eh av io ra l re c o rd

ing s e s s io n is com pleted . T he la t t e r involves film ing the

p a tien t a s sh e a n sw e rs a s ta n d a rd s e t of q u estio n s concern ing

what tim e she got up, w hat food she la s t a te , and how it

tasted. Then, in self-im age session s she views th o se m otion

pictures, and answers another set of standardized questions.

This set asks who the person was in the film , what the patient

liked and disliked about the picture, and what changes she

would like to make in it„ Gradually, earlier film s are altered

with more recent ones. The psychiatrist makes an effort not

to develop a therapeutic relationship with the patient, although

he does respond to her in an accepting, positive manner.

Goitheil theorizes that upon viewing these film s, the

patient w ill have to do one of three things. She can either

deny her screen! image, change her self-im age, or "become

disorganized (Gottheil et a l . , 1969, p. 249). ”


T he in itia l r e s u l ts w ith a sev en teen y e a r old ano rex ic

w ere c h a ra c te r is e d by continued den ia l of h e r th in n e ss , as

ev idenced by h e r a n sw e rs to th e s ta n d a rd iz e d q u estio n s .

G radually , th e h o s tile d en ia ls d im in ished , and the p a tien t

becam e m o re o b jec tiv e , reco g n iz in g th e p o s itiv e and negative

a sp e c ts of h e r im age. She w as even tually ab le to adm it

th a t h e r a p p ea ra n c e w as both s ick ly and u n d esirab le .

T he p a tien t w as exposed to a to ta l of 54 confron ta tions,

and h o sp ita lize d fo r ap p ro x im ate ly 16 m onths. Upon d is

ch a rg e , sh e w as m ain ta in ing h e r body w eight, and d isp layed a

m o re realistic body image. A two y e a r follow-up re v e a le d

that she was s till in good health, and well adjusted. The

authors conclude:

Although recovery could possibly have been the result of psychotherapy alone, the changes which took place slowly against a great deal of resistance appeared to be associated with the continued and repeated self-im age confrontations (Gottheil et a l . ,19S9, p. 249),

This approach to anorexia nervosa is certainly an atypical

one, which appears to have potential in treating one aspect of

the syndrome. The alteration of the patient's self-im age may

facilitate the recurrence of eating, as well as an increase in

self-relian t behavior. It is possible that self-im age confronta

tion session s could be used effectively in conjunction with any

number of psychological approaches to anorexia nervosa. Its


value when unaccom panied by any o th e r th e ra p y a p p e a rs to

q uestionab le , but c e r ta in ly m e r i ts fu r th e r in v estig a tio n in

the fo rm of c o n tro lle d s tu d ie s .


BEHAVIOR THERAPY

One of th e m o st c o n tro v e rs ia l app roaches to ano rex ia

n e rv o sa is th a t of behavior th erap y . D esp ite i ts rep o rte d

effic iency in the rap id re s to ra tio n of eating behavior, few

c lin ic ian s a r e in ag reem en t on th e ad v isab ility of u tiliz ing its

techn iques. R ese rv a tio n s a re held not only by the proponents

of p sycho therapy , but by the th e ra p is ts , th em se lv es , who

have tre a te d a n o rex ics w ith behav io r th e rap y (B linder et a i . ,

1970; L e ite n b e rg e t a l . , 1968; H alm i, 1975). M ost c lin ic ians

recogn ize th is a p p ro ach as a re la tiv e ly new one, which h a s

not y e t been v a lid a ted by long te rm follow -up s tu d ies in

an o rex ia n e rv o sa (B ruch , 1974).

T he behav io ra l techniques em ployed in the tre a tm e n t of

an o rex ia n e rv o sa usua lly take the fo rm of indiv idualized r e

in fo rcem en t p ro g ra m s (H alm i, 1974: B a ch t'ich et a l . , 1965;

Sturikard, 1975; B lin d e r et a l . , 1970), o r th e u se ox sy s te m a tic

d e sen s itiz a tio n (Lang, 1965; H ailsten , 1965). T he la t te r

"a ttem p ts to Inhibit anx iety evoked by a g raded s e r ie s of

im ag ined sc e n e s w ith co n cu rren t deep m u sc le re lax a tio n

(L e iten b erg e t a l . , 1968, p. 211)."

H ails ten (1965) p ilo ted a study u tiliz ing sy s te m a tic de

se n s itiz a tio n to r e -e s ta b l is h ea ting behav io r in 4212 y e a r old

49


an o rex ic . T h is p a r t ic u la r pa tien t exhib ited two se p a ra te

phobias w hich w e re in te rfe r in g w ith h e r da ily living: a f e a r

of s to rm s , and a f e a r of becom ing obese. T he au th o r s ta te s

that:

A sso c ia tin g th e eating of fatten ing foods w ith a s i tu a tion incom patib le w ith f e a r o r anx ie ty would w eaken th e an x ie ty a sso c ia tio n su ffic ien tly (H ailsten , 1965, p . 3 9 ) .

T he a n o re x ic is tra in e d in re lax a tio n tech n iq u es, and

fa m ilia r iz e d w ith th e p roposed p lans fo r tre a tm e n t. H er

phobia of s to rm s w as dealt w ith f i r s t , s in ce it w as view ed a s

a lik e ly su c c e s s . A g raded h ie ra rc h y of m ost th rea ten in g ,

to le a s t th re a te n in g s itu a tio n s a sso c ia te d w ith s to rm s w as

developed. W ithin a week, the pa tien t w as ab le to v isu a lize

th e m o st th re a te n in g s itu a tio n s and re m a in re lax ed . No

change in ea ting h ab its o r weight o c c u rre d follow ing th is

p h ase of t re a tm e n t.

T he m a s te ry of th is h ie ra rc h y w as then follow ed by one

re le v a n t to th e g irl* s f e a r of becom ing o bese . Once again ,

th e p a tien t w as to ld to re la x a s p rev io u s ly tra in e d , and then

taken th ro u g h th e v isu a liza tio n of b eh av io rs a sso c ia te d w ith

th e ea ting of fa tten in g food. F o r exam ple , th is a e r ie s

included th e im ag in ing of s ittin g a t a ta b le , eating fa tten ing

foods, and se e in g h e r s e l f in a m ir r o r , show ing s ig n s of w eight


gain. T he p a tien t w as ab le to rem a in re la x ed throughout

th e in itia l se ss io n .

F u r th e rm o re , sh e w as ab le to ea t h e r e n tire evening

m ea l th a t day, and exh ib ited in c re a se d eating b ehav io r a t a ll

subsequent m e a ls . A to ta l of 12 se ss io n s w e re undertaken ,

and the s ta ff re p o rte d a g radual, p ositive change in the g i r l ;s

p e rso n a lity . H e r w eight in c re a sed fro m 57 pounds to slig h tly

above 80 pounds upon d isch arg e . No o th e r fo rm of th e rap y

w as ad m in is te re d , and no a ttem p t w as m ade to uncover

psycho log ical con flic ts . A five m onth fo llow -up rev ea led

th a t the individual w as eating no rm ally , and m ain tain ing h e r

w eight.

P o s itiv e re in fo rce m en t p ro c e d u re s used in the tre a tm e n t

of an o rex ia n e rv o sa a r e designed to d iffe ren tia lly re in fo rc e

eating behav io r. T he assum ption h e re is th a t a s th e ind iv idua l's

frequency of ea ting is in c re a sed , h e r anx ie ty w ill g rad u a lly be

a llev ia te d flLeitenberg e t a l . , 1968).

A study by L .eitenberg e t a l. (1968) exam ined th e e ffec ts

of re in fo rcem en t on w eight g a in , eating , and p h y sica l com plain ts

in itwrh s e p a ra te su b je c ts . A te n day b ase lin e p e rio d w as follow ed

by a n o n -re in fo rce m en t p e rio d , during w hich the p a tie n t 's

p h y sica l com plain ts w e re ignored , and no p le a su ra b le a c tiv itie s

w e re allow ed. N ext, a re in fo rcem en t p e rio d involved v e rb a l


p ra is e fo r ea tin g g rad u a lly in c re a s in g am ounts of foori- At

th is tim e , p r iv ile g e s w e re g ran te d contingent on w eight gain .

No ex ac t am ount of expected w eight ga in w as specified ,

r a th e r th e th e ra p is t was d e lib e ra te ly vague about how m uch

of a gain would d e te rm in e p r iv ile g e s . T he p a tien t counted and

g ra p h ic a lly re c o rd e d the num ber of m outhfu ls sh e a te a t each

m ea l, a s w ell a s h e r daily w eight. Any positive s ta te m e n ts

about ea tin g w e re v e rb a lly re in fo rc e d by s ta ff m em b ers .

T h is s u b je c t 's p h y sica l co m p la in ts , w hich had p e rs is te d

fo r two y e a r s , w e re com plete ly ex tingu ished . D uring the

re in fo rc e m e n t p h a se , both h e r c a lo r ic in take and weight

in c re a s e d , and continued to r i s e th roughou t tre a tm e n t and

follow ing d isc h a rg e . A nine m onth fo llow -up rev e a le d tha t

th e p a tien t w as continuing to gain w eight, and w as in good

health .

A second subject's treatment procedure omitted the

baseline period, and began with an immediate non-reinforce

ment period. An additional phase of extinction was included,

during which weight gain was no longer verbally reinforced,

and privileges were withheld.

This patient's weight gradually rose from 69 pounds to

95 pounds, during the reinforcem ent periods. The extinction

phase did not result in decreased eating and weight gain as


expected . H ow ever, th is w as a ttr ib u te d to a n u m b er of

p o ss ib le c au sa l fa c to rs , such a s the p h ase being in troduced

too la te in th e p ro c e d u re , and not being m ain ta ined fo r a long

enough tim e . A fo u r m onth follow -up con firm ed th e s ta b iliz a

tio n of the in d iv id u a l's w eight.

L e ite n b e rg et a l. (1968) conclude th a t s e le c tiv e re in fo rc e

m en t of ea ting b eh av io r is an effective app roach to the t r e a t

m ent of an o rex ia n e rv o sa , s in ce n e ith e r of h is su b je c ts gained

w eight until th is p ro ce d u re w as in stitu ted . T he au th o r m ain ta in s

th a t th is study is e sp ec ia lly im portan t in that th e in c re a se of

eating and c a lo r ic in take could not be a ttr ib u te d to the su p p o rt

ive env ironm ent of th e ho sp ita l, o r to th e expec ta tions fo r su e - ,

c e s s by the th e ra p is t . Both of th e se fa c to rs w e re p re se n t p r io r

to the in troduc tion of re in fo rcem en t, and did not, a t that tim e ,

le a d to any in c re a s e s .

A nother study undertaken by H alm i e t a l. (1975) iso la ted

th e an o rex ic in h e r room , w ith v is itin g p r iv ile g e s , so c ia l

a c tiv it ie s , and in c re a s e d physica l a c tiv ity contingent on w eight

gain. T he p a tien t w as re q u ire d to ga in 1.1 pounds fo r ev e ry

five day p e rio d , in o rd e r to m ake one phone c a ll, re c e iv e

m ail, have one v is i to r f o r one hour, and to be out of h e r

room fo r one h ou r each day. W eight lo s s w as cons equated by

continued iso la tio n and tube feeding un til the p a tien t once again


a tta in e d h e r p r io r weight a t th e beginning of the la s t five day

p e rio d . Only one of eight p a tien ts re q u ire d tube feeding.

A behav io r m odification p ro g ra m w as a lso in stitu ted fo r

each p a tien t upon d ischarge . T he sam e am ount of weight gain

w as re q u ire d fo r sp ec ia l a c tiv itie s a t hom e. Any lo s s in

w eight was to re s u lt in h o sp ita liza tio n fo r tube feeding. None

of the p a tien ts re q u ire d the la t te r , and w ere rep o rte d to be

m ain tain ing th e i r su b s tan tia l w eight gains.

B oth B lin d e r (1970) and S tunkard (1971) com pleted stu d ies

w hose re s u l ts a lso d e te rm ined th a t in c re a se d ac tiv ity m ay be

used a s an effective re in fo rc e r fo r w eight gain. F o r exam ple,

one p a tien t w as re q u ire d to gain a ha lf pound p e r day, to be

aw arded an u n re s tr ic te d s ix hour p e rio d ou tside th e hosp ital

each day. T he sub jec t show ed im m ed ia te and su s ta in ed w eight

gain , a v erag in g fou r pounds p e r w eek fo r h e r s ix weeks of

hospitalization (Blinder, 1970).

Stunkard (1971) points out that there is a wide variety of

reinforcers available to most therapists. Increased activity

need not be the sole reinforcer utilized, as each patient is

likely to have individual likes and d islikes. One seventeen

year old anorexic complained of the sedative effects of the

chlorpromazine (a drug used to control nausea and vomiting)

that she was receiving. She was then allowed decreased


dosages p ro p o rtio n a l to the am ount of weight gained p e r day.

T his pa tien t gained a n a v e rag e s ix pounds a w eek under th is

p e rso n a lize d re in fo rce m en t p ro g ra m (Stunkard, 1971).

B ach rach et a l. (1965) re p o r t a c ase involving a wom an

whose w eight had dropped o v e r a s ix y e a r p e rio d fro m 120 to

47 pounds. He m ain ta in s th a t behav io r th e rap y can p lay a

c r i t ic a l ro le in p rev en tin g death in se r io u s an o rex ic c a se s .

B ating behav io r can be rap id ly r e s to re d when tim e is of the

e sse n ce to a fa ilin g p a tien t.

The p a tien t w as p laced in iso la tio n , in a b a rre n room

containing only a bed, c h a ir , and nightstand . At each m eal,

a s ta ff m em b er v e rb a lly re in fo rce d any m ovem ent a sso c ia ted

w ith eating . T he c r i te r io n fo r re in fo rce m en t w as g radua lly

changed, so th a t sh e was re q u ire d to ea t in c re a s in g am ounts

of food. If the p a tien t a te no food, sh e was le f t in iso la tion

until h e r next m ea l. The w om an 's weight slow ly ro se to a

s a fe r lev e l, and sh e w as th en allow ed to have v is i to r s , and

tak e w alks, a ll contingent upon in c re a s in g w eight gain . Upon

d isch a rg e , the p a tie n t had gained a to ta l of 38 pounds.

A s p rev io u s ly m entioned , th e u se of behav io r th e ra p y

in the tre a tm e n t of an o rex ia n e rv o sa is a highly c o n tro v e rs ia l

p ra c tic e . B a ch ra ch (1970) w a rn s th a t " th e pow er of the

Reproduced w ith permission o f the copyright owner. Further reproduction prohibited w ithout permission.

o p e ran t tre a tm e n t m ethod re q u ire s cau tion in its app lica tion

(p. 1096)." W eight gain alone does not ind ica te re c o v e ry fro m

the d iso rd e r . One of B lin d e r’s (1970) p a tien ts , w hose w eight

had been re s to re d by behav io ra l techn iques, com m itted

su ic id e sh o rtly th e re a f te r .

B ru ch (1974) a lso re p o r ts th a t death in an o rex ia n e rv o sa

is not uncom m on in p a tien ts who have gained su b s ta n tia l am ounts

of w eight, but su ffe r a re la p se m onths la te r . She m ain tains

th a t behav io r m odification is a som ew hat " s im p lis itc app roach

(p. 1419)," w hich can be t ru ly dangerous fo r som e p a tien ts .

T h re e an o rex ic p a tien ts se en by B ru ch had a ll been

tr e a te d w ith behav io r th e rap y , and had gained w eight. However,

they soon lo s t it follow ing d isc h a rg e fro m th e ho sp ita l. A ll

th re e g ir ls w e re sa id to have ex p erien ced behav io ra l p ro g ram s

a s "b ru ta l coerc ion , by which they w ere reu d ced to utifcerr help

le s s n e s s (B ruch , 1974, p. 1421)."

B ru c h (1974) concludes tha t w eight ga in can be beneficial

only when it is p a r t of a b ro a d e r tre a tm e n t p ro g ra m which

re so lv e s th e underly ing p e rso n a lity co n flic ts . She po in ts out

the danger of behav io r m odifica tion p ro c e d u re s being im p le

m ented by n o n -p ro fe ss io n a ls who have no t ru e ex p erien ce w ith

th is d iso rd e r . T h e re is alw ays th e p o ss ib ility tha t d e te rio ra tio n


57

m ay not be c a re fu lly m on ito red , re su ltin g in g rav e p h y sica l

d an g er fo r th e p a tien t.

S e rio u s a lleg a tio n s su ch a s th e s e cannot be ig no red by

th e c lin ic ian who is co n sid e rin g the u se of behav io r th e ra p y

in th e tre a tm e n t of an a n o rex ic . H ow ever, to ta l re je c tio n of

i ts tech n iq u es does not se em w a rran ted . I ts lim ita tio n s

shou ld undoubtedly be reco g n ized , and its fu r th e r use adap ted

to such re s t r ic t io n s .

M ajo r d raw backs a p p e a r to be re la te d to behav io r th e ra p y 's

im m ed ia te but only te m p o ra ry e ffec ts on ea ting behav io r, its

la c k of long te r m fo llow -ups, and i ts a d v e rse effects on c e r ta in

p e rs o n a lity ty p es . It se e m s p ro b ab le th a t the pro longed m ain

ten an ce of ea ting m ay not be a tta in ed , due to the ab sen ce of

add itiona l th e ra p e u tic in te rv en tio n . W hen tre a tin g a n o re x ic s ,

th is ap p ro ach w ill p robab ly be m o st e ffec tive when u sed in

con junction w ith som e fo rm of ind iv idual o r fam ily th e ra p y .

Som e c lin ic ian s m ay choose to in itia lly in c re a s e the p a tie n t’s

w eight by b eh av io ra l m ean s. T hen, a s the ind iv idual’s g e n e ra l

h e a lth im p ro v e s> so m e o th e r fo rm o f th e ra p y m ay be u sed to

deal w ith underly ing co n flic ts and p e rso n a lity p ro b lem s.

L ong te rm fo llow -ups shou ld be ro u tin e in any study

dealing w ith th e t re a tm e n t of a n o re x ia n e rv o sa . M ost of th e

s tu d ie s w hich have u sed b e h av io r th e ra p y , rec h ec k on th e i r


p a tien ts in fou r o r five m onths. Ideally , th is tim e p e rio d

should be ex tended to a num ber of y e a rs a t the m inim um .

T he tru e e fficacy of behav io ra l techn iques in re la tio n to

an o rex ia , w ill not be d e te rm in ed until su c h rec h ec k s a re

ro u tin e ly p rac tic ed .

C lin ic ian s shou ld be aw are tha t som e an o re x ic p a tien ts

m ay respond to o p e ran t conditioning techn iques in an a v e rs iv e ,

r e s is ta n t m an n er. It would be fo o lish to a ssu m e th a t a ll

an o re x ic s can be e ffec tive ly t re a te d by any one psychological

app roach . C a re fu l c o n sid e ra tio n of the p a tie n t 's p e rso n a lity

and background should co n trib u te to th e fin a l se le c tio n of

a p p ro p ria te t re a tm e n t techn iques. T h e ra p is ts can b est p reven t

th e ra p eu tic roadb locks by m a in ta in in g a wide v a r ie ty of

techn iques in t h e i r p ro fe ss io n a l re p e r to ire .


FAMILY THERAPY

In v es tig a to rs of ano rex ia n e rv o sa frequen tly d esc rib e

th e ex is ten ce of fam ily psychopathology, to which the pa tien t

inev itab ly re tu rn s , follow ing h o sp ita liza tio n (Rowland, 1970;

B ruch , 1973; C risp , 1974). D esp ite th e recognition th a t such

pathology m ay con tribu te to sym ptom re c u rre n c e , few

clin ic ian s a ttem p t any re s tru c tu r in g of the fam ily sy stem .

T ra d itio n a l app roaches to an o rex ia d ire c t th e rap y to the patien t

only, dealing w ith him in iso la tio n fro m h is fam ily. T he

an o rex ic and h is th e ra p is t can only ta lk about fam ilia l conflicts

and p r e s s u re s , th e re is no d ire c t o b se rv a tio n of th e ir typ ica l

in te ra c tio n s (L andes & W in ter, 1966).

F a m ily th e ra p y is a f a i r ly new approach , whose u se in

th e tre a tm e n t of an o rex ia n e rv o sa has gained m uch recognition .

T he p a tie n t 's a n o re x ia is v iew ed a s se rv in g a specific function

in a dysfunctional fam ily (Crisp, 1974).

By ccncentratingonly on the symptoms of the patient, the parents wereaHbieto <*eny and avoid dealing with problems that eklis^^-tHstween them or with the siblings. The symptoms were therefore reinforced within the context of the family (Leibman et a l ., 1974, p. 435).

Subsequently, the reconditioning of eating behavior, and

signs of substantial weight gain, are not considered sufficient

59


fo r re c o v e ry (L eibm an e t a l . , 1974). It is lik e ly th a t when

th e indiv idual re tu rn s to da ily liv ing w ith h e r fam ily , a re la p se

w ill o ccu r.

T h is th e ra p eu tic ap p ro ach m ain ta in s th a t the s tru c tu re of

th e fam ily m ust be c o n s tru c tiv e ly changed, to f re e th e pa tien t

fro m h e r sym ptom s. T he focus of a tten tion is sh ifted fro m the

an o rex ic to th e typ ical p a tte rn s of fam ilia l in te rac tio n w hich

a re causing conflicts (L eibm an et a l . , 1974; B a rca i, 1971).

M ost often, the patien t is ho sp ita lized , and therapy is begun

w ith th e e n tire fam ily . T h is te m p o ra ry se p a ra tio n rem o v es

th e so u rc e of m uch anx ie ty and h o s tility from the hom e,

re liev in g th e p a re n ts , and enabling the pa tien t to becom e m o re

autonom ous in h e r eating beh av io r (B erlin , 1953). P la n s a re

m ade to g rad u a lly re in tro d u ce th e ch ild into the hom e situa tion ,

once h e r w eight has begun to in c re a s e (L andes & W in ter, 1966).

A ponte (1973) in itia te s tre a tm e n t by g a th erin g the fam ily

to g e th e r fo r lunch se s s io n s . A fte r becom ing fa m ilia r w ith

th e ir tra n sa c tio n a l p a tte rn s and sp ec ific p rob lem a re a s , th e

th e ra p is t ” s e t s the s tag e fo r d isa g ree m e n t (p. 10). " In th is

way in te ra c tio n a l con flic ts a r e rev e a le d , and th e c e n tra lity of

th e p a tie n t 's i lln e ss is d e c re a se d (B a rc a i, 1971).

Such p ra c tic e s a r e often r e f e r r e d to as " c r is is - in d u c e d

fam ily th e ra p y ." M inuehin (1971) a ss ig n s th e fam ily a ta sk


w hich w ill c re a te a conflict th a t cannot be e a s ily avoided.

M any an o rex ic fam ilie s a re d e sc rib e d a s r ig id and incapable

of re so lv in g p ro b lem s (L eibm an e t a l . , 1975), they w ill

ty p ica lly d e to u r conflicts (M inuehin, 1971). By in troducing

an unavoidable s ta te of c r i s is , th e fam ily w ill find it n e c e s

s a ry to respond in an a typ ica l m an n er, w hich is lik e ly to

r e s u l t in confusion and d isa g ree m e n t. T he th e ra p is t can

then redefine the ac tu a l fam ily p ro b le m s, designating spec ific

a re a s of th e i r m alfunctioning. L ik ew ise , th e fam ily is

d ire c te d in th e co n stru c tiv e re so lu tio n of the c r i s is situa tion .

G rin k e r (1968) po in ts out th a t using d e lib e ra te in terven tion

techn iques m akes it e s se n tia l fo r the c lin ic ian to be ava ilab le

a t a ll t im e s to reg u la te and suppo rt th e unstab le sy s tem he has

c re a te d .

D esp ite the unusual dem ands th is appx-uu.cn p laces on the

th e ra p is t , m any c lin ic ian s fee l th a t i ts po ten tia l is un lim ited

(Donovan, 1975; M inuehin e t a l . , 1969). T he exact influence

of fam ily m em b ers on a p a tien t is no lo n g er a guessing gam e

fo r th e th e ra p is t. T hey a r e a l l p re se n t, rev ea lin g th e ir

dynam ic p a tte rn s of in te rac tio n ,

R ecent co n sid era tio n has been given to in c re as in g the

e ffec tiv en ess of fam ily th e ra p y , by using it in conjunction w ith

o p e ran t conditioning techn iques (L eibm an et a l . , 1974 & 1975).


A tre a tm e n t p ro g ra m u tiliz e d by L eib m an e t a l. (IS74) involves

the fam ily of th e an o re x ic soon a f te r h e r ad m iss io n , and du ring

ou tpatien t c a re a s w ell.

In itia lly , th e th e ra p is t holds in fo rm a l luneh s e s s io n s w ith

th e p a tien t, speak ing of h is p h y sica l re sp o n se s to hunger, and

o ffering to s h a re h is m ea l. In th is way a pow er s tru g g le o v e r

food and eating is s a id to be avoided. T he p ro p o sed o p e ran t

re in fo rce m en t p ro g ra m is exp lained to th e p a tien t, and she is

in fo rm ed th a t h e r fam ily has no c o n tro l o v e r i t . F u r th e rm o re ,

th ey a r e a sk ed not to d isc u ss it w ith th e p a tien t. T h ese s te p s

a r e taken "to g ive th e p a tie n t an in c re a s e d se n se of autonom y

and re s p o n s ib ility fo r h e r p h y sica l s ta te (L eibm an e t a l . , 1974,

p. 434 )."

A s in m any b eh av io ra l p ro g ra m s fo r a n o re x ia , a c c e s s to

p h y sica l a c tiv ity is m ade contingent upon w eight gain . A da ily

gain of ha lf a pound o r m o re e n title s the p a tien t to te lev is io n ,

having v is i to r s , th e u se of the ba th room , and fo u r to s ix hours

of u n re s tr ic te d a c tiv ity on th e w ard . When le s s th an one half

of a pound is gained , th e ind iv idual is r e s t r ic te d to bed.

F a m ily th e ra p y lu n ch s e s s io n s a r e begun w ith tw o goa ls in

m ind. T he th e ra p is t hopes to re la b e l th e fam ily p ro m em ,

d iv ertin g th e focus o f a tten tio n aw ay f ro m th e p a tien t and h e r

sym ptom s. Secondly, he w ishes to n e u tra liz e ea ting , so th a t


63

th e indiv idual w ill be ab le to ea t in the p re se n c e of h e r

fam ily w ithout an ensuing pow er s tru g g le . A t th is tim e a

goal is a lso e s ta b lish e d fo r a fin a l d isc h a rg e w eight.

L e ibm an e t a l. (1974) r e p o r t th a t a ll of th e i r p a tien ts

rem a in e d in th e h o sp ita l fo r an a v e ra g e of one to two weeks

follow ing th e f i r s t lunch se ss io n .

T he ou tpatien t p h ase of tre a tm e n t revo lves a round th re e

goa ls . T he f i r s t is to e lim in a te food re fu sa l and its sym ptom s

so th a t th e fam ily can no lo n g er avoid i ts p ro b lem s by

focusing on th e an o rex ia . Secondly, the c lin ic ian a ttem p ts to

illu m in a te the fam ily p a tte rn s of in te ra c tio n w hich encourage

o r re in fo rc e the sym p tom s. L a s tly , p e rm an en t change in the

fam ily functioning is sought to p rev en t fu tu re re la p s e s .

An ou tpatien t re in fo rce m en t p ro g ra m , to be en fo rced by

th e p a re n ts , is in s titu ted . T h is is to m ain ta in th e p a tie n t 's

w eight gain , and to p ro v id e M. . . th e p a re n ts w ith som eth ing

c o n c re te to do a t hom e, w hich d e c re a s e s th e ir anx ie ty and

p rev io u s fee lin g s of h e lp le s sn e ss in d ea lin g w ith th e i r s ic k

ch ild (L eibm an e t a l . , 1974, p. 4 3 4 )." U nder th is p ro g ra m

th e p a tien t is re q u ire d to gain a m in im um o f two pounds w eekly

to m ain ta in n o rm al a c tiv it ie s on th e w eekends. If th e p a tien t

does not gain, sh e is r e s t r ic te d to th e house, and a fam ily

m em b er m u st re m a in a t hom e w ith h e r . T he l a t t e r condition


64

brings the fa m ily to g e th e r in a united e ffo rt to encourage the

p a tie n t’s eating .

The p a tien t continues to gain w eight, and the fam ily ’s

concern is sh ifted to th e in te rp e rso n a l conflic ts being dealt

w ith in the th e ra p y s e s s io n s . T he individual g rad u a lly lo s e s

h e r ro le a s th e fam ily scapegoat, and can becom e reinvo lved

in school and com m unity a c tiv itie s .

T h is p a r t ic u la r com bination of behav io r and fam ily

th e ra p y a p p e a rs to fo s te r few of th e negative a sp e c ts so

c h a ra c te r is t ic of o th e r app roaches to an o rex ia n erv o sa .

R apid and im m ed ia te w eight gain is achieved , but m ore

im p o rtan t, re la p s e s a re p reven ted by continuing in te rven tion

in an ou tpatien t phase of tre a tm e n t. Both th e pa tien t and h e r

fam ily a r e a s s is te d in dealing w ith th e an o rex ia in a m ore

c o n stru c tiv e m an n e r, and a r e m ade aw are of th e i r dysfunctional

p a tte rn s of in te ra c tio n w hich have suppo rted th e ano rex ic

sym p tom s.

P a tie n ts spend an a v e rag e of fo u rteen days in th e hosp ita l,

and an add itiona l a v e ra g e of seven m onths in fam ily th e rap y .

T he tim e fa c to r is not ex cess iv e , th e re b y reduc ing th e financ ia l

c o s ts fo r the fam ily . F u r th e rm o re , th e indiv idual is re tu rn e d

to h e r fam ily and p e e r g roup in a re la tiv e ly sh o r t am ount of


tim e , p rev en tin g th e estab lish m en t of a s tro n g dependency

re la tio n sh ip w ith th e th e ra p is t.

O bviously, th e re w ill be som e an o rex ic p a tien ts w hose

i lln e s s does not a p p ea r to be suppo rted by a dysfunctional

fam ily s tru c tu re . T h is app roach m ay not be a panacea fo r

e v e ry individual su ffe rin g fro m an o rex ia n e rv o sa . W hat is

im p o rtan t is th a t a th e ra p eu tic app roach has been devised ,

th a t w a rra n ts ag a in s t the u sua l c lin ica l roadb locks and unfore

seen re la p se s so c h a ra c te r is t ic of th e syndrom e. S ince m ost

an o rex ic p a tien ts a r e ad o lescen ts , i t is a ssu m e d th a t the

m a jo rity of them re tu rn to th e i r fam ilie s follow ing h o sp ita liz a

tion . T h e re fo re , i t is qu ite lik e ly th a t th e i r im m ed ia te fam ily

has a m ax im al effect on th e ir daily l iv e s . T he inc lusion of

fam ily m em b ers in the e n tire tre a tm e n t p ro g ra m w ill help to

d isc lo se th e ac tu a l p a tte rn s of fam ilia l in te rac tio n , and d e te r

m ine th e i r influence, if any, on the p a tie n t 's an o rex ic sym ptom s.

E ven if cau sa l agen ts a r e iden tified a s o rig in a tin g ou tside of the

fam ily s tru c tu re , fam ily m em b ers can be a s s is te d by the

th e ra p is t in p rov id ing su p p o rt and encou ragem en t fo r th e p a tien t.

One p o ss ib le lim ita tio n to th is p ro ce d u re , w hich is not

m entioned by its p roponen ts , is th e ra p eu tic d ifficulty due to the

l im ite d coopera tion of th e fam ily . I t would se e m th a t r e s is ta n c e

on the p a r t of any one fam ily m em b er could s e r io u s ly jeo p a rd ize


66

the efficacy of th is app roach . P o ss ib ly , su ch r e s is ta n c e is

not uncom m on, but even tually d is s ip a te s during re p e a te d and

in te n se fam ily se s s io n s . F u r th e r r e p o r ts , dealing w ith p o ss ib le

com plica tions involved in th is conjoint th e ra p eu tic app roach ,

would be a va luab le re s o u rc e fo r th e c lin ic ian who w ish es to

im plem ent a com parab le p ro g ram .


SUMMARY

A no rex ia n e rv o sa re m a in s a h ighly puzzling d iso rd e r fo r

c o n tem p o ra ry c lin ic ia n s , d e sp ite th e c u rre n t in c re a s e in

a s so c ia te d r e s e a r c h . T he relevant literature is c h a ra c te r iz e d

by confusion concern ing th e sy n d ro m e 's c la ss if ic a tio n , cause ,

and tre a tm e n t. M uch of th is confusion a p p e a rs to be due to a

la c k of p ro p e r d iffe ren tia tio n betw een psycho log ica lly de te rm ined

fo rm s of em ac ia tio n . F u r th e rm o re , m any a u th o rs re p o rt th e ir

find ings in vague and incom plete d e sc r ip tio n s , w hich com pli

ca te , r a th e r than c la r ify th e g e n e ra l p ic tu re of an o rex ia .

A w ide v a r ie ty of p sy ch o lo g ica l ap p ro ach es have been used

in the t re a tm e n t of a n o re x ia n e rv o sa . H ow ever, no sing le th e r a

peu tic m o d a lity has ye t p ro v en i ts e l f to be th e m o st effective.

W hat s e e m s un fo rtunate i s th a t th e p roponen ts of som e

ap p ro ach es m a in ta in th a t a ll a n o re x ic p a tien ts can, and should

be t r e a te d by any one m e th o d a lone . T h is r ig id a d h eren ce to

th e notion th a t a l l a n o re x ic s a r e p sychodynam ica lly a like , m ay

be p rev en tin g va lu ab le p ro g re s s In ex p e rim e n ta l s tu d ie s , w h ere in

conjunctive fo rm s of th e ra p y could be te s te d f o r th e i r e ffec tive

n e ss .

67


T he c lin ic ian who w ishes to in s titu te a tre a tm e n t p ro g ra m

f o r ind iv iduals su ffe rin g fro m an o rex ia n e rv o sa w ill p robab ly

en co u n te r few er com plica tions by m ain ta in ing a d iv e rs ity of

techn iques in h is p ro fe s s io n a l r e p e r to ire . In th is way, he w ill

be ab le to evaluate and t r e a t each pa tien t w ith the fo rm of

th e ra p y w hich is m o st idea l fo r tha t p e rso n .

T ra d itio n a l p ra c tic e s of excluding the fam ily of the

an o rex ic f ro m any p h ase of th e rap y , should be rev iew ed a t th is

tim e . T h e high incidence of sym ptom re c u r re n c e and re la p se

follow ing a r e tu rn to the fam ily , m ay be an ind ication that

th ey d ire c tly co n trib u te to th e p a tie n t 's i l ln e s s . The s tru c tu re

of th e fa m ily and i ts ty p ica l p a tte rn s of in te ra c tio n should be

in v es tig a ted fo r th e i r p o ss ib le influence on th e ex is ten ce of the

d iso rd e r .

T he p rev e n tio n of a n o re x ia n e rv o sa is not, a t th is tim e ,

a fe a s ib le c o n s id e ra tio n . P re v en tiv e m e a su re s w ill not be

a v a ila b le un til th e exac t n a tu re of th e d is o rd e r is m o re c le a r ly

defined. T h e p re s e n t em p h asis should be on th e e a r ly detection

and tre a tm e n t of th e i l ln e s s .

I t i s hoped th a t a n o re x ia n e rv o sa w ill continue to be the

ob jec t of e x ten siv e r e s e a r c h in the m ed ica l, p sycho log ical, and

so c io lo g ica l f ie ld s . F u tu re investiga tions w ill be c r i t ic a l in


developing effective th e rap eu tic techn iques fo r th o se ind

su ffe rin g fro m th is unusual d iso rd e r.


REFEREN CES

Aponte, H ., and Hoffman, L . T he open door: A s tru c tu ra l a p p ro ach to a fam ily w ith an an o re c tic child . F a m ily P ro c e s s , 1973, 12, 1-44.

B a rc a i, A. F a m ily th e rap y in the tre a tm e n t of an o rex iane rv o sa . A m erican Jo u rn a l of P sy c h ia try , 1971, 128, 286-290.

B achrach , A . J . , & E rw in , W. J . , & M ohr, J . P . The con tro l of eating behav io r in an anorex ic by operan t conditioning techn iques. In L . P . U llm an, & L . K ra s n e r (E d s .) , C ase s tu d ies in behav io r m odifica tion . New York: Holt, R in eh a rt and W inston, 1965.

B a r tle tt , W. M. An a n a ly sis of an o rex ia . A m erican Jo u rn a l of D iseases of C h ild ren , 1928, 35, 26-35.

B e rlin , I. N . , Boatm an, M. J . , Sheim o, S. L . , & S zurek , S. A. A dolescen t a lte rn a tio n of an o rex ia and obesity . In G eorge G a rd n e r (E d .) , C a se s tu d ies in childhood em otional d isa b ili tie s . New York: A m e ric an O rth o p sy ch ia tricA ssoc ia tion , 1953.

B lin d e r, B. J . , F re e m a n , D. M ., & Stunkard, A. J . B ehav io r th e ra p y of an o rex ia nervosa : E ffec tiv en ess of a c tiv ity a sa r e in fo rc e r of w eight gain . A m erican Jo u rn a l of P sy c h ia try , 1970, 26, 1093-1098.

B row ning, C . H*, & M ille r , S. J . A norex ia n erv o sa : A studyin p ro g n o sis and m anagem en t. A m erican Jo u rn a l of P sy c h ia try , 1968, 124, 1128-1132.

B ruch , H. A norex ia n e rv o sa and i t s d iffe ren tia l d iagnosis . T he Jo u rn a l o f N ervous and M ental D ise a se , 1965, 141, 555- 566.

B ruch , H. Changing ap p ro ach es to an o rex ia n e rv o sa . In C . Rowland (E d .) , A norex ia and obesity . Boston: L itt le ,Brow n, 1970a.

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