Journal of Religion and Health, Vol. 20, No. 3, Fall 1981
Anorexia Nervosa: A Pastoral Update RICHARD DAYRINGER ABSTRACt. Anorexia nervosa is a disorder of unknown etiology that is a complex of physical, emotional, and behavioral changes occurring in individuals who starve themselves. The incidence of this disease has increased dramatically in the last twenty years. Most patients seem to be unaware of or unconcerned about their emaciation. After presenting a case, this study reviews the most recent findings about this disease, including the symptoms, social characteristics of its victims, increaed incidence, history, and prognosis. Suggestions are offered for pastoral care and counseling.
An eighteen-year-old patient, who was single and a member of a Christian church, was diagnosed as having anorexia nervosa by her physician and was admitted to the hospital. This patient was five feet, five inches tall and of light frame or bone structure. She was bright-eyed and smiled almost constantly. I saw her more in the hallways than any place else. She usually was dressed in a pink housecoat; her hair was always nicely combed; she wore a minimum of make-up and was attractive except for her emaciated appearance. She gave some indication through her smile of belle indifference. I was consulted about this patient by her physician. He asked me if we needed anyone to play the piano for our chapel services. I told him to encourage her to play the piano at her convenience during the week and that we would keep her in mind for our chapel services as well. My purpose in visiting the patient was to follow through on the doctor's consultation. I also hoped that I might convey to her a deepening awareness of God's acceptance of her, which might help her to be more accepting of herself and less punishing.
Visits 1-6 I made a "get-acquainted" visit. The patient was cheerful. We discussed her room mostly. It was still decorated for Christmas with cards pasted on the window in the shape of a Christmas tree and gifts on display. Balloons were hanging from the ceiling as a representation of the New Year. I began structuring a relationship by telling her that I would like to visit her again. 1-8 The patient attended the chapel service I conducted. With the patient were her father, mother, and sister. In a discussion after chapel with the family, the patient, and her physician, I noticed that her mother was opinionated and loquacious. The father was rather quiet. Her sister was attractive.
The Reverend Richard Dayringer, Th.D., is Associate Professor in the Departments of Medical Humanities and Family Practice at Southern Illinois University School of Medicine, Springfield, Illinois. 218 0022-4197/81/1500-021850.95
9 1981 Institutes of Religion and Health
RichardDayringer
219
I-9 I talked to the patient in the hall by the auditorium where she had just come from playing the piano. At this time she gave m e some personal history, which will appear below. 1-10 Again I saw the patient in the hall,this time just outside her room. Her room was stillgaily decorated, and she was stillflashing her ready smile. At this time I sensed either her resistance or m y frustration that we had not established a closer personal relationship.
Family constellation The family consisted of mother, father, and two daughters. The patient's sister appeared to be older than the patient but was actually about a year younger. The mother seemed to be the dominant member of the family. T h e patient's relationship with her family supported the diagnosis of a rather classic psychiatric picture of anorexia nervosa which often involved sibling rivalry with an attractive sister.
School adjustment The patient had graduated from high school the previous spring and was taking two music courses in a local college. Because of her illness, she would get credit for only one of these courses. She seemed somewhat disappointed that she had not been able to go away to school. The patient's sister was a senior in high school.
Social adjustment The patient apparently met people readily and normally won them to herself easily with her smile. However, I had some questions as to the depth of her friendships and relationships with others.
Religious adjustment The patient was a member of a nearby Christian church. She and her family attended the chapel service in the hospital and chose to sit near the front, where they readily participated in all of the worship service. As a matter of fact, the patient functioned as the leader for the congregation in the responsive readings. Her faith was obviously meaningful to her.
Marital adjustment The patient was single at the time.
Vocational adjustment We did not discuss this at all. However, the patient was interested in music.
Summary The patient's physician first consulted me thinking that she might benefit from "music therapy" while in the hospital. He also asked that the chaplain see her while she was
220
Journal of Religion and Health
hospitalized. He indicated to me that the patient would probably be hospitalized for a fairly long period, as she had come into the hospital weighing 59 pounds and needed to gain considerable weight before leaving. I observed a discussion between the doctor and the family following the chapel service. The doctor seemed to relate easily and informally to the family. The chaplain-patient relationship was still in the beginning stages. I hoped that its dimensions might be greatly deepened in the days to come. We had not yet had the opportunity to sit down and have a long discussion. We needed this. There were a good many things that we had not yet discussed that we might possibly talk over. Her intense involvement in the chapel service indicated to me that Christianity had played a fairly prominent role in her life. She seemed to feel comfortable in talking to me as a minister, which was indicative of her past experiences with clergy. I thought that, if I could be accepting of her, this would help her to understand that God also accepted her and that there was no reason for her to inflict the punishment of starvation upon herself. I wrote the above notes for a medical-religious case conference twelve years ago. The conference was presented in collaboration with the patient's physician to a group of medical students at the University of Kansas School of Medicine as a part of their elective course entitled "Medicine and Religion." Much new information has been gained about anorexia nervosa since then. The symptoms of anorexia nervosa have been variously described. Nevertheless, there appears to be consensus on the following features: 1) onset by the age of twenty-five; 2) much more common in females than in males; 3) emaciation and weight loss of twenty-five percent of total body weight because of food refusal; 4) a disturbance of delusional proportions concerning body image; 5) a disturbance in accuracy of perception or interpretation of bodily stimuli; 6) hyperactivity; 7) a sense of ineffectiveness; 8) endocrine dysfunction, always including amenorrhea; 9) frequent retarded psychosocial development; 10) vomiting, sometimes self-induced; 11) family pathology; a n d 12) bradycardia. ~ All these symptoms were present in the patient I have described. There are also certain social characteristics typical of anorexia nervosa patients. They tend to come from intact, middle-class, religious families and to be the youngest children in small families. 2 This disease befalls the young, rich, and beautiful daughters of educated and successful families in the United States and other affluent countries2 Although it was once considered extremely rare, the incidence of anorexia nervosa has been increasing dramatically over the last t w e n t y years. 4 The incidence of anorexia nervosa has been estimated at between .245 and 1.62 A survey in London found one case in every 200 high school girls and one case in every 100 girls over sixteen years of age. 7 A similar survey in J a p a n notes thirteen cases of anorexia nervosa in 230 (5.6 percent) adolescents with school maladjustments, s Furthermore, at least fifteen percent of women with secondary amenorrhea have anorexia nervosa2 It is possible t h a t increased awareness among physicians m a y account for some of the rise in diagnosed cases of this disorder. The literature reveals t h a t mortality from anorexia nervosa ranges from ten to twenty-three percent, with the most frequently
Richard Dayringer
221
cited figure being fifteen percent. Browning said that the few cases reported in the literature of death from anorexia nervosa during treatment do not specify whether death was from the illness itself or from "overly vigorous somatic treatment."~~ He suspects the latter and has reported two such cases himself. L This disease has a 300-year history. Richard Morton, an English physician, first reported two cases of anorexia nervosa in 1689 in which he described the appearance of his patients as being "like a skeleton only clad with skin. ''12 The ailment was named anorexia nervosa by Sir William Gull. Actually, anorexia nervosa is a misnomer; it means lack of appetite, not the relentless pursuit of excessive thinness. Nevertheless, the term is widely accepted and will probably continue to be used. 18 Several studies have determined various demographic and behavioral predictors of successful outcome with anorexia nervosa patients independent of the method of treatment 14These include the following: 1) early age of onset, 2) no previous hospitalization for anorexia nervosa, 3) no extensive vomiting, 4) no laxative use, 5) no bulimia, 6) no severe depression or obsessive-compulsive traits, 7) little history of poor adjustment at school, 8) {for adult patients) higher educational achievement and employment in professional and skilled occupations, and 9) no over-estimation of body size. This list is extremely important to the pastoral counselor concerned about how to deal with a person (and her family) who has the symptoms of anorexia nervosa yet has not been hospitalized. The treatment that even the best practitioners have reported in the literature obtained a cure rate of no better than seventy percent and seemed to average a cure rate of forty to fifty percent, is Minuchin reported fifty-three cases treated for an average of six months with a recovery of eighty-five percent after a two-year follow-uple This was the highest success rate reported in the literature. Hospitalization was used infrequently with these patients. Individual psychotherapy, family therapy, behavior modification, and medication are the treatment modalities most commonly reported. The cadaverous appearance of the anorexia nervosa patient arouses strong reactions and interferes with all human relationships. Wulliemier thinks there are two reasons why anorexia patients frighten physicians: their wasted skeleton-like bodies evoke the physician's fear of death and these patients often defy doctors with their disobedience or noncompliance with treatment as outpatients.17 Of course, anorexia nervosa patients who are dangerously ill, even though they may deny it, should be treated in a hospital, no matter how hard they strive to stay outside. Under no circumstances should clergy join such a patient or her family in "glossing things over." However, Browning and Miller concluded that their data did not demonstrate any tangible benefits from hospitalization, is Another study found that the only deaths reported in its sample occurred when outpatient therapy was not used. 19 Thus, the pastor need not always insist on hospitalization but should always work with anoretic patients in consultation with their physicians. If I were to have the opportunity to work now with the patient and her family described at the beginning of this paper, I would include some
222
Journal of Religion and Health
additional activities in my ministry to her. My visits to her would be planned to occur at the times that her meals were served. I would volunteer to "return thanks" before her meals, andmy petitions would include asking God to "give her an appetite and help her to enjoy her food," etc. I would also select, read, and discuss with her scripture passages concerning food, eating, or fasting. Her understanding of these passages would be noteworthy and would probably provide fruitful material for therapeutic interactions. I would try to arrange to eat lunch with her and her family in the hospital cafeteria after chapel on Sunday. This would give me an opportunity to observe what happened between family members at mealtimes and perhaps an opportunity to intervene;. I would recommend that her pastor or her designate serve her the Lord's Supper each Sunday. I would be present if possible and stay afterward to discuss communion with her. Thus, I would focus my ministry toward her problem in such a way that more discussion of her sickness would naturally occur. In attempting to relate therapeutically to anoretic patients without a Christian background, clergy would still do well to focus their relationship on food. Being present with the patient and the family in the patient's room during mealtime would enable the minister to see the dynamics that occur between patient and family. The two most helpful books that will bring clergy up to date on this disease are by Bruch and Minuchin. 2~Both are interesting reading and provide useful information for understanding and helping persons with anorexia nervosa.
References 1. Bruch, H., Eating Disorders. New York, Basic Books, 1973, passim. 2. Bruch, H.; Sturzenberger, S.; Cantwell, D.P.; Burroughs, J.; Salkin, B; and Green, J.K., "A Follow-up Study of Adolescent Psychiatric Inpatients with Anorexia Nervosa," J. Am. Acad. Child Psychiatry, 1977, 16, 703-715. 3. Bruch, H., The Golden Cage: The Enigma of Anorexia Nervosa. Cambridge, Mass., Harvard University Press, 1978, p. vii. 4. Bemis, K.M., "Current Approaches to the Etiology and Treatment of Anorexia Nervosa," PsychoL Bulletin, 1978, 85, 593-617. 5. Theander, S., "Anorexia Nervosa," Acta Psychiatry Scand., 1970, 214, Suppl. 6. Kendell, R.E.; Hall, D.J.; Hailey, A.; and Babigan, H.M., "The Epidemiology of Anorexia Nervosa," Psychol. Med., 1973, 3, 200-203. 7. Crisp, A.H.; Palmer, R.L.; and Kalucy, R.S., "How Common Is Anorexia Nervosa?" British J. Psychiatry, 1976, 12~ 5459. 8. Ikemi, Y.; Ago, Y.; Nakagawa, S.; "Psychosomatic Medicine under Social Changes in Japan," J. Psychosom. Res. 1974, 18, 15. 9. Jacob, H.S.; Knuth, V.A.; Hull, M.; "Post-'pill' Amenorrea--Cause or Coincidence," British Med. J. 1977, 2, 940. 10. Browning, C.H., "Anorexia Nervosa: Complications of Somatic Therapy," Comprehensive Psychiatry, 1977, 18, 399-403. 11. Browning, C.H., and Miller, S.I., "Anorexia Nervosa: A Study in Prognosis and Management," Am. J. Psychiatry, 1968, 124, 1128-1135. 12. Morton, R., Phthisiologia--or Treatment of Consumption. London, Smith, 1720. 13. Bruch, The Golden Cage, op. cir. 14. Garfinkel, P.E.; Moldofsky, H.; and Garner, D.M., "Prognosis in Anorexia Nervosa as Influenced by Clinical Features, Treatment and Self-Perception," Canadian Medical Assoc. J., 1977, 117, 1041-1045; Halmi, K.A.;' Brodland, G.; and Loney, J., "Prognosis in Anorexia
Richard Dayringer
15. 16. 17. 18. 19. 20.
223
Nervosa," Am. Intern. Med., 1973, 78, 907-909; Kay, D.W.D., and Leigh, D., "The Natural History of Treatment and Prognosis of Anorexia Nervosa Based on a Study of 38 Patients," J. Med. Sci., 1954, 100, 411-430; Morgan, H.G., and Russell, G.F.M., "Value of Family Background and Clinical Features as Predictors of Long-Term Outcome in Anorexia Nervosa: Four Year Follow-up on 41 Patients," Psychol. Med., 1975, 5, Seidensticker, J.F., and Tzagournis, M., "Anorexia Nervosa--Clinical Features and Long-Term Follow-up," J. Chron. Dis., 1968, 21, 361-367; Theander, op. cir. Minuchin, S.; Rosman, B.L.; and Baker, L., Psychosomatic Families: Anorexia Nervosa in Context. Cambridge, Mass., Harvard University Press, 1978, pp. 126-138. Ibid. Wulliemier, F., "Anorexia Nervosa: Gauging Treatment Effectiveness," Psychosomatics, 1978, 19, 497-499. Browning and Miller, op. cir. Flinder, B.J.; Freeman, D.; and Stunkard, A.J., "Behavior Therapy of Anorexia Nervosa: Effectiveness of Activity as a Reinforcer of Weight Gain," Am. J. Psychiatry, 1970, 126, 1089-1093. Bruch, The Golden Cage, op. cir., and Minuchin, Psychosomatic Families, op. cir.
Anorexia Nervosa: A Pastoral Update RICHARD DAYRINGER ABSTRACt. Anorexia nervosa is a disorder of unknown etiology that is a complex of physical, emotional, and behavioral changes occurring in individuals who starve themselves. The incidence of this disease has increased dramatically in the last twenty years. Most patients seem to be unaware of or unconcerned about their emaciation. After presenting a case, this study reviews the most recent findings about this disease, including the symptoms, social characteristics of its victims, increaed incidence, history, and prognosis. Suggestions are offered for pastoral care and counseling.
An eighteen-year-old patient, who was single and a member of a Christian church, was diagnosed as having anorexia nervosa by her physician and was admitted to the hospital. This patient was five feet, five inches tall and of light frame or bone structure. She was bright-eyed and smiled almost constantly. I saw her more in the hallways than any place else. She usually was dressed in a pink housecoat; her hair was always nicely combed; she wore a minimum of make-up and was attractive except for her emaciated appearance. She gave some indication through her smile of belle indifference. I was consulted about this patient by her physician. He asked me if we needed anyone to play the piano for our chapel services. I told him to encourage her to play the piano at her convenience during the week and that we would keep her in mind for our chapel services as well. My purpose in visiting the patient was to follow through on the doctor's consultation. I also hoped that I might convey to her a deepening awareness of God's acceptance of her, which might help her to be more accepting of herself and less punishing.
Visits 1-6 I made a "get-acquainted" visit. The patient was cheerful. We discussed her room mostly. It was still decorated for Christmas with cards pasted on the window in the shape of a Christmas tree and gifts on display. Balloons were hanging from the ceiling as a representation of the New Year. I began structuring a relationship by telling her that I would like to visit her again. 1-8 The patient attended the chapel service I conducted. With the patient were her father, mother, and sister. In a discussion after chapel with the family, the patient, and her physician, I noticed that her mother was opinionated and loquacious. The father was rather quiet. Her sister was attractive.
The Reverend Richard Dayringer, Th.D., is Associate Professor in the Departments of Medical Humanities and Family Practice at Southern Illinois University School of Medicine, Springfield, Illinois. 218 0022-4197/81/1500-021850.95
9 1981 Institutes of Religion and Health
RichardDayringer
219
I-9 I talked to the patient in the hall by the auditorium where she had just come from playing the piano. At this time she gave m e some personal history, which will appear below. 1-10 Again I saw the patient in the hall,this time just outside her room. Her room was stillgaily decorated, and she was stillflashing her ready smile. At this time I sensed either her resistance or m y frustration that we had not established a closer personal relationship.
Family constellation The family consisted of mother, father, and two daughters. The patient's sister appeared to be older than the patient but was actually about a year younger. The mother seemed to be the dominant member of the family. T h e patient's relationship with her family supported the diagnosis of a rather classic psychiatric picture of anorexia nervosa which often involved sibling rivalry with an attractive sister.
School adjustment The patient had graduated from high school the previous spring and was taking two music courses in a local college. Because of her illness, she would get credit for only one of these courses. She seemed somewhat disappointed that she had not been able to go away to school. The patient's sister was a senior in high school.
Social adjustment The patient apparently met people readily and normally won them to herself easily with her smile. However, I had some questions as to the depth of her friendships and relationships with others.
Religious adjustment The patient was a member of a nearby Christian church. She and her family attended the chapel service in the hospital and chose to sit near the front, where they readily participated in all of the worship service. As a matter of fact, the patient functioned as the leader for the congregation in the responsive readings. Her faith was obviously meaningful to her.
Marital adjustment The patient was single at the time.
Vocational adjustment We did not discuss this at all. However, the patient was interested in music.
Summary The patient's physician first consulted me thinking that she might benefit from "music therapy" while in the hospital. He also asked that the chaplain see her while she was
220
Journal of Religion and Health
hospitalized. He indicated to me that the patient would probably be hospitalized for a fairly long period, as she had come into the hospital weighing 59 pounds and needed to gain considerable weight before leaving. I observed a discussion between the doctor and the family following the chapel service. The doctor seemed to relate easily and informally to the family. The chaplain-patient relationship was still in the beginning stages. I hoped that its dimensions might be greatly deepened in the days to come. We had not yet had the opportunity to sit down and have a long discussion. We needed this. There were a good many things that we had not yet discussed that we might possibly talk over. Her intense involvement in the chapel service indicated to me that Christianity had played a fairly prominent role in her life. She seemed to feel comfortable in talking to me as a minister, which was indicative of her past experiences with clergy. I thought that, if I could be accepting of her, this would help her to understand that God also accepted her and that there was no reason for her to inflict the punishment of starvation upon herself. I wrote the above notes for a medical-religious case conference twelve years ago. The conference was presented in collaboration with the patient's physician to a group of medical students at the University of Kansas School of Medicine as a part of their elective course entitled "Medicine and Religion." Much new information has been gained about anorexia nervosa since then. The symptoms of anorexia nervosa have been variously described. Nevertheless, there appears to be consensus on the following features: 1) onset by the age of twenty-five; 2) much more common in females than in males; 3) emaciation and weight loss of twenty-five percent of total body weight because of food refusal; 4) a disturbance of delusional proportions concerning body image; 5) a disturbance in accuracy of perception or interpretation of bodily stimuli; 6) hyperactivity; 7) a sense of ineffectiveness; 8) endocrine dysfunction, always including amenorrhea; 9) frequent retarded psychosocial development; 10) vomiting, sometimes self-induced; 11) family pathology; a n d 12) bradycardia. ~ All these symptoms were present in the patient I have described. There are also certain social characteristics typical of anorexia nervosa patients. They tend to come from intact, middle-class, religious families and to be the youngest children in small families. 2 This disease befalls the young, rich, and beautiful daughters of educated and successful families in the United States and other affluent countries2 Although it was once considered extremely rare, the incidence of anorexia nervosa has been increasing dramatically over the last t w e n t y years. 4 The incidence of anorexia nervosa has been estimated at between .245 and 1.62 A survey in London found one case in every 200 high school girls and one case in every 100 girls over sixteen years of age. 7 A similar survey in J a p a n notes thirteen cases of anorexia nervosa in 230 (5.6 percent) adolescents with school maladjustments, s Furthermore, at least fifteen percent of women with secondary amenorrhea have anorexia nervosa2 It is possible t h a t increased awareness among physicians m a y account for some of the rise in diagnosed cases of this disorder. The literature reveals t h a t mortality from anorexia nervosa ranges from ten to twenty-three percent, with the most frequently
Richard Dayringer
221
cited figure being fifteen percent. Browning said that the few cases reported in the literature of death from anorexia nervosa during treatment do not specify whether death was from the illness itself or from "overly vigorous somatic treatment."~~ He suspects the latter and has reported two such cases himself. L This disease has a 300-year history. Richard Morton, an English physician, first reported two cases of anorexia nervosa in 1689 in which he described the appearance of his patients as being "like a skeleton only clad with skin. ''12 The ailment was named anorexia nervosa by Sir William Gull. Actually, anorexia nervosa is a misnomer; it means lack of appetite, not the relentless pursuit of excessive thinness. Nevertheless, the term is widely accepted and will probably continue to be used. 18 Several studies have determined various demographic and behavioral predictors of successful outcome with anorexia nervosa patients independent of the method of treatment 14These include the following: 1) early age of onset, 2) no previous hospitalization for anorexia nervosa, 3) no extensive vomiting, 4) no laxative use, 5) no bulimia, 6) no severe depression or obsessive-compulsive traits, 7) little history of poor adjustment at school, 8) {for adult patients) higher educational achievement and employment in professional and skilled occupations, and 9) no over-estimation of body size. This list is extremely important to the pastoral counselor concerned about how to deal with a person (and her family) who has the symptoms of anorexia nervosa yet has not been hospitalized. The treatment that even the best practitioners have reported in the literature obtained a cure rate of no better than seventy percent and seemed to average a cure rate of forty to fifty percent, is Minuchin reported fifty-three cases treated for an average of six months with a recovery of eighty-five percent after a two-year follow-uple This was the highest success rate reported in the literature. Hospitalization was used infrequently with these patients. Individual psychotherapy, family therapy, behavior modification, and medication are the treatment modalities most commonly reported. The cadaverous appearance of the anorexia nervosa patient arouses strong reactions and interferes with all human relationships. Wulliemier thinks there are two reasons why anorexia patients frighten physicians: their wasted skeleton-like bodies evoke the physician's fear of death and these patients often defy doctors with their disobedience or noncompliance with treatment as outpatients.17 Of course, anorexia nervosa patients who are dangerously ill, even though they may deny it, should be treated in a hospital, no matter how hard they strive to stay outside. Under no circumstances should clergy join such a patient or her family in "glossing things over." However, Browning and Miller concluded that their data did not demonstrate any tangible benefits from hospitalization, is Another study found that the only deaths reported in its sample occurred when outpatient therapy was not used. 19 Thus, the pastor need not always insist on hospitalization but should always work with anoretic patients in consultation with their physicians. If I were to have the opportunity to work now with the patient and her family described at the beginning of this paper, I would include some
222
Journal of Religion and Health
additional activities in my ministry to her. My visits to her would be planned to occur at the times that her meals were served. I would volunteer to "return thanks" before her meals, andmy petitions would include asking God to "give her an appetite and help her to enjoy her food," etc. I would also select, read, and discuss with her scripture passages concerning food, eating, or fasting. Her understanding of these passages would be noteworthy and would probably provide fruitful material for therapeutic interactions. I would try to arrange to eat lunch with her and her family in the hospital cafeteria after chapel on Sunday. This would give me an opportunity to observe what happened between family members at mealtimes and perhaps an opportunity to intervene;. I would recommend that her pastor or her designate serve her the Lord's Supper each Sunday. I would be present if possible and stay afterward to discuss communion with her. Thus, I would focus my ministry toward her problem in such a way that more discussion of her sickness would naturally occur. In attempting to relate therapeutically to anoretic patients without a Christian background, clergy would still do well to focus their relationship on food. Being present with the patient and the family in the patient's room during mealtime would enable the minister to see the dynamics that occur between patient and family. The two most helpful books that will bring clergy up to date on this disease are by Bruch and Minuchin. 2~Both are interesting reading and provide useful information for understanding and helping persons with anorexia nervosa.
References 1. Bruch, H., Eating Disorders. New York, Basic Books, 1973, passim. 2. Bruch, H.; Sturzenberger, S.; Cantwell, D.P.; Burroughs, J.; Salkin, B; and Green, J.K., "A Follow-up Study of Adolescent Psychiatric Inpatients with Anorexia Nervosa," J. Am. Acad. Child Psychiatry, 1977, 16, 703-715. 3. Bruch, H., The Golden Cage: The Enigma of Anorexia Nervosa. Cambridge, Mass., Harvard University Press, 1978, p. vii. 4. Bemis, K.M., "Current Approaches to the Etiology and Treatment of Anorexia Nervosa," PsychoL Bulletin, 1978, 85, 593-617. 5. Theander, S., "Anorexia Nervosa," Acta Psychiatry Scand., 1970, 214, Suppl. 6. Kendell, R.E.; Hall, D.J.; Hailey, A.; and Babigan, H.M., "The Epidemiology of Anorexia Nervosa," Psychol. Med., 1973, 3, 200-203. 7. Crisp, A.H.; Palmer, R.L.; and Kalucy, R.S., "How Common Is Anorexia Nervosa?" British J. Psychiatry, 1976, 12~ 5459. 8. Ikemi, Y.; Ago, Y.; Nakagawa, S.; "Psychosomatic Medicine under Social Changes in Japan," J. Psychosom. Res. 1974, 18, 15. 9. Jacob, H.S.; Knuth, V.A.; Hull, M.; "Post-'pill' Amenorrea--Cause or Coincidence," British Med. J. 1977, 2, 940. 10. Browning, C.H., "Anorexia Nervosa: Complications of Somatic Therapy," Comprehensive Psychiatry, 1977, 18, 399-403. 11. Browning, C.H., and Miller, S.I., "Anorexia Nervosa: A Study in Prognosis and Management," Am. J. Psychiatry, 1968, 124, 1128-1135. 12. Morton, R., Phthisiologia--or Treatment of Consumption. London, Smith, 1720. 13. Bruch, The Golden Cage, op. cir. 14. Garfinkel, P.E.; Moldofsky, H.; and Garner, D.M., "Prognosis in Anorexia Nervosa as Influenced by Clinical Features, Treatment and Self-Perception," Canadian Medical Assoc. J., 1977, 117, 1041-1045; Halmi, K.A.;' Brodland, G.; and Loney, J., "Prognosis in Anorexia
Richard Dayringer
15. 16. 17. 18. 19. 20.
223
Nervosa," Am. Intern. Med., 1973, 78, 907-909; Kay, D.W.D., and Leigh, D., "The Natural History of Treatment and Prognosis of Anorexia Nervosa Based on a Study of 38 Patients," J. Med. Sci., 1954, 100, 411-430; Morgan, H.G., and Russell, G.F.M., "Value of Family Background and Clinical Features as Predictors of Long-Term Outcome in Anorexia Nervosa: Four Year Follow-up on 41 Patients," Psychol. Med., 1975, 5, Seidensticker, J.F., and Tzagournis, M., "Anorexia Nervosa--Clinical Features and Long-Term Follow-up," J. Chron. Dis., 1968, 21, 361-367; Theander, op. cir. Minuchin, S.; Rosman, B.L.; and Baker, L., Psychosomatic Families: Anorexia Nervosa in Context. Cambridge, Mass., Harvard University Press, 1978, pp. 126-138. Ibid. Wulliemier, F., "Anorexia Nervosa: Gauging Treatment Effectiveness," Psychosomatics, 1978, 19, 497-499. Browning and Miller, op. cir. Flinder, B.J.; Freeman, D.; and Stunkard, A.J., "Behavior Therapy of Anorexia Nervosa: Effectiveness of Activity as a Reinforcer of Weight Gain," Am. J. Psychiatry, 1970, 126, 1089-1093. Bruch, The Golden Cage, op. cir., and Minuchin, Psychosomatic Families, op. cir.
