POSTGRAD. MED. J. (1966), 42, 443

SOME OBSERVATIONS ON ANOREXIA NERVOSACECIL B. KIDD, M.D., Ph.D., D.P.M.

Senior LecturerJ. F.- WOOD, MB., D.P.M.

Clinical Tutor

Department of Mental Health, University of Aberdeen

DISTURBANCES of gastro-intestinal function andof nutrition are to be found as a cause of, acorrelate with or a consequence to almost everyform of psychiatric illness (Millar, 1953).A'mong these, the distinct entity of anorexianervosa has attracted much attention from psy-chiatrists, general physicians, endocrinologistsand (biochemists. Although anorexia nervosa isa rare condition, the clinical interest accordedto it reflects both the severity of its impact onthe patient and the major therapoutic challengeit presents to the clihnician. The disease processcomprises a complex interplay of physical, psy-chological, endocrinological, metabolic and elec-trolytic dysfunction; treatment is very lengthy,relapse is frequent and a fatal outcome is notunknown.The diagnosis of anorexia nervosa rests on

the recognition of a triad of symptoms whichare unihersally accepted as pathognomomc ofthis condition; a gross loss of weight leadingto emaciation, a failure to eat, and disturbanceof menstrual function leading to oligomenorr-hoea and amenorrhoea. The psychological con-comitants of this state also have been describedas a triad; denial of hunger despite prolongedinanition, denial of thinness despite extremeemaciation, and denial of fatigue despite exces-sive and frantic activity done in a state ofchronic underfeeding (Mayer, 1963). A com-prehensive clinical description of this disorderwas provided by Sir William Gull who coinedthe term "anorexia nervosa" in 1874. He ob-served its occurrence in young women who pre-sented with "great emaciation, amenorrhoea,constipation, anorexia alternating occasionallywith a voracious appetite, restlessness, activity,peevishness of temper and a feeling of jealousy,together with an absence of any organic cause".He ascriibed this to a moebid mental process,he commented that the patients' activity andsense of well-being were-grossly out of propor-tion to their inanition, and observed shrewdlythat the family were generally the worst attend-ants (Gull, 1874). The early detection- ofanorexia nervosa is -vital to offsetting the hazard

it presents to the health and life of thesepatients and, as Stafford-Clark (1958) hasrightly pointed out, the management requiredboth uniquely illustrates and emphasizes thenecessity to resolve any dichotomy betweenphysiological and psychological approaches intreatment.

Prevalence and SurveysAnorexia nervosa is a rare condition, yet not

so rare that several new cases will present toclinicians each year at every major centre ofpopulation. Study of patient records at Aber-deen covering two selected periods 1949-1956and 1960-1965 inclusive revealed a firm diag-nosis of anorexia nervosa in 18 and 12 patientsrespectively who had been treated in the Pro-fessorial Psychiatric Unit. In a study in theNorth-east region of Scotland of all personsover the age of 15 years newly referred to apsychiatrist during one year, three of the 1,240new wom.n patients thus identified had a diag-nosis of anorexia nervosa (Innes and Sharp,1962). Despite the paucity of cases, meaningfulnumbers for study and follow-up have beenaccumulated in several on-going and retrospec-tive enquiries. Among these, Bruch (1962) stu-died in detail the psychological characteristicsof conceptual disturbances and disorders ofperception in nine women admitted for treat-ment of anorexia nervosa. Crisp (1965a) studiedthe clinical patterns and outcome of treatmentin 27 women with anorexia nervosa and inanother enquiry (Crisp, 1965b) presented dataon the evolution of this condition and thepatient charac-teristics of a series of 42 affectedwomen. Dally and Sargant (1960) carried outa treatment study comparing results from thethen new and now widely used regime of chlar-promazine combined with modified insulintherapy in 20 patients with other treatment re-gimes previously employed in a series of 24patients. Hawkings, Jones, Sim and Tibbetts(1956) reported a number of patients with "de-liberate disability" and drew interegting com-parisons between this group and five patients

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who were treated in the same unit for anorexianervosa. In the same paper the authors des-cribed the results of a postal follow-up enquiryon 23 patients treated for anorexia nervosaduring the ten year period 1938 to 1948. Kayand Leigh i(1954) reported on a definitive seriesof 34 women who were treated at the MaudsleyHospital for anorexia nervosa between 1932and 1952 and descriibed in detail their clinicalfeatures and outcome. King (1963) studied aseries of 21 anorexic patients to delineate fromanorexia nervosa those whose anorexia wassecondary to other psychiatric illness, and toidentify the signiificant background factors andclinical characteristics of the former. Anothermajor survey was reported by Nemiah (1950)who selected 14 patients on the basis of theclassical symptom triad and in whom no evi-dence of gross disease had been found in aprimarily aetiological role: as well as report-ing clinical observations this study detailed find-ings from enquiry into and measurement of thepatients' personality piofiles, attitudes and inter-personal relationships. Patient groups wereaccumulated for research on the metabolic andendocrinological aspects of anorexia nervosaand results have been reported recently: deltaglucose values before and after a high caloriehigh carbohydrate dietary regime were studiedin nine patients, the regulation of water balancewas studied in 12 patients (Russell, 1965), andgonadotrophin and oestrogen excretion wasstudied in seven severely emaciated women(Russell, Loraine, Bell and Harkness, 1965).Seventeen patients with anorexia nervosa andwho showed hypokalaemia on laboratory in-vestigation were studied by Wigley (1960) whoidentified and commented on the high occur-rence of renal disorder among this group. Theclinical state, management and 'progress of 53patients with anorexia nervosa who were treatedat the London Hospital between 1897 and 1957,the largest series to have been published, wasreported by Williams (1958); this paper empha-sizes especially the relationships between treat-ment procedures and outcome.

In addition to these major surveys of patientswith anorexia nervosa considerable clinical, psy-chological and biochemical data have accruedfrom smaller series and individual case reportswhich further advance medical understandingof this condition.Patient Characteristics

All patients who have anorexia nervosa arefemales since amenorrhoea is widely regardedas essential to the accurate diagnosis of this

condition. Some autthors have included males inthis diagnostic category (Bruch, 1962; Dallyand Sargant, 1960; K'ay and Leigh, 1954; Rus-sell and others, 1965) but, as Dally and Sar-gant (1960) have pointed out, the occurrenceof convincing anorexia nervosa-like states in menis most uncommon. Anorexia nervosa charac-teristically occurs among adolescent or youngwomen (Williams, 1958). In Crisp's (1965b)series of 27 women, all but two were adoles-cents with a mean age of 17 years. In his studyof 40 patients, it was found that all but sevenhad an onset of illness before age 21 (Crisp,1965a). Similarly Nemiah (1950) found the ageat onset of illness to be between 14 and 24years '(mean age 18 years) in his series and Kayand Leigh (1954) showed that 70 per cent oftheir patients had their first symptoms beforereaching the age of 26 years. The age patternson admission to the Professorial PsychiatricUnit in Aiberdeen of 12 patients studied from1960 to 1965 showed that half were below 25years, a proportion identical to the similardalta from the Guy's Hospital series (Stafford-Clark, 1958), but as Loeb (1964) has clbserved,many post-adolescent patients will have hadepisodes of anorexia in adolescence, althoughperhaps not maniifesting them to such a degreeas to have called for medical intervention atthe time. Crisp (1965a) showed that the typicalpatienft had a higher birth-weight than hersisters, was much more likely to have beenbottle-fed in infancy, or if ibreast4fed to havehad prolonged breast feeding, to have beenwell-nourished or over-nourished in childhoodand to have had an early menarche. Thesecharacteristics were found not to have beeninfluenced iby the factors of race, social class,maternial age and parity, 'length of gestation orgenetic inheritance. Most patients are describedas lbeing "plump" before the onset of illness.Often they are awkward, reserved, and physic-ally unattractive (Wall, 1964). The associationbetween the onset of illness and a crash dietprogramme to reduce weight occurs too fre-quently to be a fortuitous occurrence (Crisp,1965a; Mayer, 1963; Nemiah, 1950). In con-trast to the insightless extremes of self-depriva-tion to which these patients subject themselves,it is a characteristic common to the majoritythat they are talented and of high intelligence(King, 1963; Wall, 1964).

Physical FeaturesThe physical appearance of the patient is

marked 'by oibvious emaciation. The faciessuggest that the patient is older than her stated

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age, skeletal structure is clearly defined andpallor is invariably present. The patient has anintolerance to cold. Fatigue and apathy whileobvious are forcefully denied. Atrophy of thebreasts and of buttock fat are common. Wherethe latter is marked the sagging folds of skintake on the classical appearance of "elephantskin". In early phases of weight reduction lossof fatty tissue predominiates. Extreme weightloss in later emaciated patients indicates rapidkatabolism of non-fatty tissue reserves. Hairdistriibution is normal, but may be augmentedby facial and limb hirsuties and a ifine lanugo-like downy growth of hair on the body.Amenorrhoea is invariably present. In similarproportions of patients, menstrual disturbanceand anorexia appear together as the first fea-tures of the condition, menstrual disturbanceprecedes all other physical features, or followsduring the course of established weight reduc-tion (King, 1963). On examination, bradycardia,hypotension, diminished sweating and oedemaare commonly found. Constipation is alwayspresent. Abdominal tenderness may ibe elicited.Gynaecological examination normally revealsan infantile uterus and atrophic changes inthe vaginal mucosa due to depressed oestro-gen function. Restlessness and excessive activityare normally observed, always to a degree outof proportion to the clinician's assessment ofthe emaciated patient's physical reserves.

Metabolic FeaturesThe basal metabolic rate is low. The excre-

tion of 17-ketosteroids and oestrogenic su-b-stances is also markedly reduced. The Keplertest for hypoadrenal-cortical function is fre-quently positive (Wall, 1964). Crisp (1965a)has demonstrated recently that while patientswith anorexia nervosa have a flat glucose-tolerance curve due to sustained high bloodglucose levels which is reversible with weightgain, high plasma insulin levels persist. Para-doxically, this pattern is usual in obese subjects.It is not known whether this is present beforethe onset of illness. A further metabolic like-ness of the anorex'ic to the obese patient wasdemonstrated by analysis of the content inweight gain among patients with anorexia ner-vosa under treatment: disproportionately highfat deposits were found, a similar pattern tothat expected among over-feeding normal per-sons (Russell and Mezey, 1962). Russell (1965)and iRussell and others (1965) carried out threestudies aimed at testing the hypothesis thatanorexia nervosa is associated with hypothala-

mic dysfunction. In the 'first, delta glucosevalues shown 'by glucose tolerance tests werefound to be high but reversible when thepatients were fed on a high-carbohydrate high-calorie dietary intake. Russell has concludedfrom th'is that the metabolic change is secondaryto chronic carbohydrate deprivation and can (becorrected by adjusting the diet. The secondstudy, of regulation of water balance in thesepatients, sought to explain the findings thatmany patients with anorexia nervosa are oede-matous and ihave a reduced capaci-ty to excretea water load, yet urinary concentration remainsnormal. It was found that ability to excrete awater load depended not on weight loss buton duration of illness. Antidiuretic hormoneassay revealed normal levels, glomerular filtra-tion rate showed some reduction and it wasagain concluded that this metabolic disturbanceis the result of malnutrition, is correctalbleover time, and it is not due to a primary hypo-thalamic dysifunction. The third study soughtto gain data on hormone levels and on theeffect of malnutrition on endocrine function inanorexia nervosa patients by examinring theexcretion of human pituitary gonadotrophinsand oestrogens before and after treatment. Itwas found that 'before treatment the outputof these hormones 'was reduced. There wasalso disproportionate decrease in oestriol com-pared with decreases in oestradiol and oestrone.After feeding the oestrogen excretion returnedto a normal pattern and quantity, indicatinga secondiary process (the disproportionate re-duction in oestriol could be due to the way inwhich oestrogens are metabolised in malnutri-tion), 'but the gonadotrophin levels did not riseto the extent that normal cyclical activitv wasresumed. It was concluded that While manymetalbolic effects of anorexia nervosa aresecondary to malnutrition, the existence of aprimary hypothalamic defect might conceivablyaccount for some of the endocrine changes metin this condition.

Electrolyte deficiency may occur in anorexianervosa. Sunderman and Rose (1948) first des-cribed the occurrence of hypokalaemic alkalosisand Wigley (1960) reported and reviewed 17cases of anorexia nervosa all of whom had hypo.kalaemia, some of whom had hyponatraemiaand eight of whom showed evidence of renaldysfunction. This study underlines the import-ance of recognising potass'iu,m depletion inanorexiia nervosa which may lead to renal com-plications such as tubular vacuoliation. As wellas this, the patient with anorexia nervosa takes

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very little fluids, urinary output is low, manyhave a negative nitrogen balance and a ten-dency to osteoporosis, and the combination ofoliguria with hypercalcaemia may further im-pair renal efficiency iby calculus formation (Wall,1964).

Psychological FeaturesAnorexia nervosa is priimarily a psychogenic

disorder which leads to and is complicated byphysiological and pathological events. Theprime mover in this debilitating condition is,however, the psychogenic factor (Wall, 1964).Consistent patterns of pre-morbid personalityattributes, social attitudes 'and maladjustments,and behavioural anomalies during the courseof the illness all testify to the presence inanorexia nervosa of a gross psychiatric disorder.Normally it is found that the patient beforebecoming ill is descrilbed as stubborn, strong-minded, determined, of high ideals, not amen-able to reason, self-willed and overly sensitive(Palmer and Jones, 1939). Wall (1964) hasstressed the distinctly introverted personalityof the patient, her meticulousness and obses-sionality and an intellectual superiority whichis at variance with an attitude of unmitigatedstubborness. Lack of humour and irritabilitywhich were shown by Kinig (1963) ito be per-sonality facets of the pre-anorexic patient con-cord well with Gull's original observation of"peevishness" (Gull, 1874). An abnormal degreeof dependency by the patient on a parent,usually a characteristically dominant and res-trictive mother, is very commonly seen (King,1963). Many patients feel isolated and at bestattain only a poor social adjustment (Nemiah,1950). The quality of the patient's dependencyon her mother has been studied by Crisp(1965a) who postulates a relationship betweenthe typical patienit's pre-anorexic plumpnessand the mother's neurotic need to over-feedher. However, by no means all patients havebeen fat during adolescence and childhood.The onset of anorexia nervosa following avoluntary dieting regime occurs only in one-third to one-half of patients (Kay and Leigh,1954; Nemiah, 1950) and Loeb (1964) hasstressed the frequency of occurrence of otherprecipitating conflicts in anorexic patients whichare unrelated to the drive to diet. All patientswith anorexia nervosa do have, however, apathological distortion of t'heir own body image.While emaciation is not only obvious but ex-treme, the patient denies being thin land defendsher appearance as being normal and right. This

distortion is not amenable to reason (Bruch,1962; Mayer, 1963).A dominant psychological feature common

to all patients is (their preoccupation with anddisgust for sexual thought and development.Attitudes of revulsion and frigidity are eiltherexpressed or thinly veiled by protestations ofalleged ignorance of sexual matters. The sym-bolic relationship between feeding and sexualpleasure is well known in psychological theoryand many authors have illustrated from detailedpsycholo-gical investigation of anorexic patientsthat unconscious fantasies of oral impregnation,repressed in early life, can be revived in thestress of pu'berty and may play a contributoryrole in the genesis of anorexia nervosa (Grim-shaw, 1959; McCullagh and Tupper, 1940;Waller, Kaufman and Deutsch, 1940). Certainlythe sexual histories of many patients containan account of some sexual incident, often trivialbut frightening to the patient, around the timeof onset of anorexia nervosa (Crisp, 1965'b),but although attitudes of conflict and hostilityto sexuality, fears of pregnancy and poor hetero-sexual adaptation are invariable concomitantsof the condition, factors other than purely adisorder in psychosexual adjustment are heldgenerally to be essential to its development.

Denial of hunger is as striking a clinicalfeature in these patients as is a denial of thin-ness. Encouragement to eat is met with hostilityand complaints of unbearable abdominal full-ness follow the ingestion of even small amountsof food. The patient frequently complains ofconstipation, seeks for purgatives, or may in-duce vomiting to evacuate the stomach con-tents. She will go to enormous lengths to avoidtakinog food and will hide it or dispose of itunless arrangements are made to prevent this.

Denial of fatigue has also been emphasizedby Mayer (1963) as a significant feature in thepatient. Overactivity and restlessness are ob-served and the patient expresses a subjectivefeeling of alertness and a distaste for idleness.Despite her often intelligent awareness of thecaloric cost of exercise, the patient will nor-mally make every contrary effort to furtherjeopardise her limited energy reserves unlessshe is induced to do otherwise. The clinicianis often struck by the patient's determinedefforts to follow the path towards, seemingly,her self-destruction.

Understandably patients with anorexia ner-vosa are by itheir psychological characteristicsat least ambivalent or at most hostile to thera-neutic efforts which are aimed at their resusci-

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tation and recovery. Some patients revoke fromtreatment to the grave injury of their alreadyprecarious clinical state. Many develop emo-tional reactiions of withdrawal, depression andanxiety in the iace of the treatment regimeand these secondary psychiatric manifestationsrequiire recognition and management in theirown right.

Treatment and OutcomeWall (1964) commented that the most im-

portant element in treatment of anorexia ner-vosa is the actual recognition of the illness asa psychiatric disorder, one which demands fromthe clinician all the sustained effort and enthu-siasm required for the management of a patientwith interacting physical and psychological dys-function. Medical, endocrine, metabolic andpsychiatric aspects of treatment cannot be con-sidered separately. Mayer's examination of theliterature revealed a variety of reportedly effi-caceous but diverse treatment approaches. Hor-monal methods have been employed (oestro-gens, thyroid, piltuitary extracts, ACTH andcortisone); forced feeding, intubation or intra-venous fluid therapy have been reported tohave'brought about remission; and psychothera-peutic methods without physical treatments havebeen found lbeneficial in some cases (Mayer,1964). Williams (1958) stressed the primary im-portance of the nutritional aspects of treatment,basing this conclusion from his uniformly suc-cessful results in patients fed by intubation, andsuggested that specialised psychotherapy wasnot indicated in treatment. In general, polemicviewpoints about approach to the treatment ofanorexia nervosa are modified by the clinician'sawareness of the indivisible interplay of organicand psychological factors which present in thiscondition. A critical formulation of the thera-peutic priorities in each anorexic patient'sclinical presentation is required.The most successful treatment regime appears

to be the joint use of insulin and chlorpromazineor reserpine, given in combination with detailedattention to the patient'is nutritional require-ments and psychological needs. This regimewas described by Dally, Oppenheim and Sargant(1958) and by Davidson and Nabney (1959) andits superiority over other forms of treatmentwas evidenced first by Dally and Sargant in1960. This treatment programme is followedat Aberdeen, as in many other centres inBritain and abroad, with encouraging results.Each patient is confined to bed so that energyis conserved, observation is possible and foodintake can be supervised. Chlorpromazine is

prescribed in increasing dosage according totolerance. Soluble insulin is given by intra-muscular injection in increasing dosage andthe resultant hypoglycaermia is terminated whensigns of sweating and drowsiness appear. Ana-bolics, vitamins and high calorie food supple-ments are also given. Intulbation is avoidedas it is psychologically undesiTrable and rarelyrequired. Throughout the early stages of treat-ment supportive psychotherapy is employed toprovide encouragement, an atmosphere ofunderstanding and to mold the 'basis of thedoctor/patient therapeutic relationship. As thepatient improves the drugs are reduced, gradua-ted exercise is allowed and psychotherapy isemployed to aid the patient in making thenecessary readjustments in her psychologicalfunctioning that will both militate against re-lapse and favouir better personality and socialintegration. Mayer (1963) has emphasizedrightly th'at psychotherapy should be directedtowards specific aspects of the patient's ab-normal emotional characteristics. He has des-cribed this as a re-educative procedure wherebythe patient must gain'the insight to learn, first,"to see herself as others see her, as an abnor-mally and unaesthetically thin individual";second, to feel hungry and to want to reactto hunger by desiring food; and th(ird, to feelfatigue as others do. In short, psychotherapyhere aims to reverse the characteristic triad ofdenifals. In most cases, psychotherapeutic sup-port or management is required for some timeafter the patient has fully regained normal nutri-tional and menstrual functioning.

Follow-up for at least one year is essential(Dally and Sargant, 1960). Studies oif outcomereveal much about the natural history ofanorexia nervosa and the efficacy of treatment.Relapse may occur and a fatal outcomealthough now rare is still occasionally seen.Of 30 patients treated in Aiberdeen between1949 and 1965 only one is known to have died,by suicide. Foillow-up of William's (1958) seriesof 53 patients admitted to the London Hospitalduring a 60 year period showed that 10 haddied, 3 had not improved, 33 had improved orrecovered and 7 couild not be traced. Hawkingsand others (1956) traced 15 of their series of23 patients, all of whom had recovered. Dallyand Sargant (1960) found that of 20 patientstreated wi'th insulin and chlorpromazine, nonedied, only 3 relapsed and most made a goodrecovery to normal weight and normal men-struation. Stafford-Clark (1958) found on oneyear follow-up of 13 patients that 9 were either

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completely well or had some residual symptomsyet none sufficient to interfere with daily life,only one patient was still disabled by symptomsand three could not be traced. Kay and Leigh(1954) found on follow-up after periods from2 to 19 years that about half of the Maudsleyseries of patients still had some menstrual ab-normality, disturbance of appetite or fluctuat-ing weight and eight patients had died, 3 fromthe effects of anorexia nervosa, the remainderfrom other causes. Crisp (1965a) studied theoutcome of treatment in 21 patients two-and-a-half years after discharge; 2 had died, 17had regained normal weight of whom 12 ex-hibited normal eating behaviour, and 11 hadestablished menstrual cycles. Crisp drew themeaningful conclusion that treatment based onrefeeding alone is not enough and is as un-likely to be successful as unsupported attemptsat superficial manipulation of the patient's lifesituation. Physical and psychological treatmentsboth are required. In anorexia nervosa, wherepsychological and physiopathological factorscombine in producing a severe and debilitatingdisorder, a successful outcome depends on anawareness of these two components and on aprogramme of patient management based onthis recognition.

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CRISP, A. H. (1965b): Clinical and TherapeuticAspects of Anorexia Nervosa: a Study of 30Cases, J. psychosom. Res., 9, 67.

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PALMER, H. D., and JONES, M. S. (1939): AnorexiaNervosa as a Manifestation of Compulsion Neu-rosis, Arch. Neurol. Psychiat. (Chic.), 41, 856.

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RkUSSELL, G. F. M., LORAINE, J. A., BELL, E. T.,,and HARKNESS, R. A. (1965): Gonadotrophin andOestrogen Excretion in Patients with AnorexiaNervosa, J. Psychosom. Res., 9, 79.

RUSSELL, G. F. M., and MEZEY, A. G. (1962): AnAnalysis of Weight Gain in Patients with AnorexiaNervosa Treated with High Calorie Diets, Clin.Sci., 23, 449.

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SUNDERMAN, F. W., and ROSE, E. (1948): Studies inSerum Electrolytes: Changes in the Serum and(Body Fluids in Anorexia Nervosa, J. clin. Endocr.,8, 209.

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AVIGLEY, R. D. (1960): Potassium Deficiency inAnorexia Nervosa, with Reference to Renal Tubu-lar Vacuolation, Brit. med. J., ii, 110.

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