CORRESPON DENCE
Prognosis in anorexia nervosa To the editor: I found the article by Drs. Garfinkel, Moldofsky and Gamer (Can Med Assoc J 117: 1041, 1977) to be most interesting because anorexia nervosa, although fortunately rare, is seen by pediatricians, psychiatrists, internists, family physicians and others. It is unfortunate, therefore, that some of the conclusions reached by the authors cannot be made properly on the basis of the data they present. The most important methodologic defect in the study is that the group given operant conditioning was different in a number of very important ways from the group given other forms of therapy. In particular, they were younger at the time of onset of their disease and at the time therapy was begun. More important, the patients in the study group, on average, weighed 6 kg less than the patients given other therapies, which suggests that the disease of the former was more severe. The authors state that none of the treatment groups were "pure.. because patients received various types of psychotherapy after leaving the hospital. Although they acknowledge these two major defects in their discussion, Garfinkel and colleagues still believe that they could conclude that "treatment in hospital with an operant conditioning technique does not improve the long-term results". In fact no conclusions regarding therapy can be made from a study in which the two different treatment groups were so different at the outset. I hope the authors continue their important work in the study of anorexia nervosa by designing and executing a properly controlled, prospective, randomized study, whose goal is to answer the important and vexing question, Contributions to the Correspondence section are welcomed and if considered suitable will be published as space permits. They should be typewritten double-spaced and, except for case reports, should be no longer than 1½ manuscript pages.
How should one best treat the patient with anorexia nervosa? W. FELDMAN, MD, CM, FRCP[CI Professor of pediatrics McMaster University Hamilton, Ont.
To the editor: Dr. Feldman raises a number of methodologic problems that were discussed in our paper. We compared treatment modalities specifically to determine whether operant condi. tioning techniques were harmful to patients with anorexia nervosa, as had been suggested by Bruch.1 We found that these behavioural techniques were not harmful to our patients, but Feldman is correct in saying that because of the design of our study we were unable to determine if they were beneficial beyond initial weight restoration. Feldman assumes that greater weight loss is the index of severity of anorexia nervosa. From our data there is no relation between degree of weight loss and course of illness, irrespective of therapeutic modality. In fact, some patients whose condition progresses to bulimia, vomiting and purging might be able to sustain an adequate weight, yet be severely disabled by their symptoms and be clinically difficult to manage. It was for this reason that we developed a global clinical scale. Patients treated with operant conditioning were not more severely ill by this scale. Until recently it has been widely accepted, as indicated by Feldman, that anorexia nervosa is rare. Crisp, Palmer and Kalucy2 recently found in London, England 1 case in every 200 highschool girls and 1 case in every 100 girls over 16 years of age. Ikemi and colleagues3 noted 13 cases of anorexia nervosa in 230 (5.6%) Japanese adolescents with school maladjustment.Furthermore, at least 15% of women presenting with secondary amenorrhea have anorexia nervosa.4 Physicians should recognize that the disorder is clearly much more common that is generally believed. Feldman recommends a controlled
230 CMA JOURNAL/FEBRUARY 4, 1978/VOL. 118
prospective study of modes of therapy for anorexia nervosa. Such a study currently is being carried out by our group. PAUL E. GARFINKEL, MD, FRCP[C] HARVEY MOLDOFSKY, MD, FRCP(C] DAVID M. GARNER, PH 1) Clarke Institute of Psychiatry Toronto, Ont.
References 1. BRUCH H: Perils of behavior modification in treatment of anorexia nervosa. JAMA 236: 1419, 1974 2. Cuss' AR, PALMER RL, KALUCY RS: How common is anorexia nervosa? A prevalence study. Br J Psychiatry 128: 549, 1976 3. IKEMI Y, AGO Y, NAKAGAWA S, et al: Psychosomatic mechanism under social changes in Japan. J Psychosom Res 18: 15, 1974 4. JACOB H5, K.Num VA, HULL MGR, et al: Post-"pill" amenorrhea - cause or coincidence? Br Med 1 2: 940, 1977
Living with the dying To the editor: I apologize for returning to the topic of the now notorious study by R.W. Buckingham and colleagues (Can Med Assc'c J 115: 1211, 1976) as I have no wish, with or without flamboyance, to prolong unnecessarily the correspondence, but B.M. Mount's letter (Can Med Assoc J 117: 14, 1977), in which he defends the study, has reached me only recently and it raises too many important points to be ignored. I believe the study breached generally accepted principles of medical and psychologic research ethics, but Mount professes not to understand what I mean. I know of no code of research ethics the study does not breach, including the principles established at Nuremberg. I have been able to find no text of medical ethics by whose terms the experiment is not at fault. Mount's "relevant ethical issue" concerning the neglect of dying patients is a non sequitur. Of course we need good studies of terminal care (Mount's group has produced some excellent examples), but that is no defence for a bad study. I cannot pretend to understand Mount's explanation of how one may deny the
Prognosis in anorexia nervosa To the editor: I found the article by Drs. Garfinkel, Moldofsky and Gamer (Can Med Assoc J 117: 1041, 1977) to be most interesting because anorexia nervosa, although fortunately rare, is seen by pediatricians, psychiatrists, internists, family physicians and others. It is unfortunate, therefore, that some of the conclusions reached by the authors cannot be made properly on the basis of the data they present. The most important methodologic defect in the study is that the group given operant conditioning was different in a number of very important ways from the group given other forms of therapy. In particular, they were younger at the time of onset of their disease and at the time therapy was begun. More important, the patients in the study group, on average, weighed 6 kg less than the patients given other therapies, which suggests that the disease of the former was more severe. The authors state that none of the treatment groups were "pure.. because patients received various types of psychotherapy after leaving the hospital. Although they acknowledge these two major defects in their discussion, Garfinkel and colleagues still believe that they could conclude that "treatment in hospital with an operant conditioning technique does not improve the long-term results". In fact no conclusions regarding therapy can be made from a study in which the two different treatment groups were so different at the outset. I hope the authors continue their important work in the study of anorexia nervosa by designing and executing a properly controlled, prospective, randomized study, whose goal is to answer the important and vexing question, Contributions to the Correspondence section are welcomed and if considered suitable will be published as space permits. They should be typewritten double-spaced and, except for case reports, should be no longer than 1½ manuscript pages.
How should one best treat the patient with anorexia nervosa? W. FELDMAN, MD, CM, FRCP[CI Professor of pediatrics McMaster University Hamilton, Ont.
To the editor: Dr. Feldman raises a number of methodologic problems that were discussed in our paper. We compared treatment modalities specifically to determine whether operant condi. tioning techniques were harmful to patients with anorexia nervosa, as had been suggested by Bruch.1 We found that these behavioural techniques were not harmful to our patients, but Feldman is correct in saying that because of the design of our study we were unable to determine if they were beneficial beyond initial weight restoration. Feldman assumes that greater weight loss is the index of severity of anorexia nervosa. From our data there is no relation between degree of weight loss and course of illness, irrespective of therapeutic modality. In fact, some patients whose condition progresses to bulimia, vomiting and purging might be able to sustain an adequate weight, yet be severely disabled by their symptoms and be clinically difficult to manage. It was for this reason that we developed a global clinical scale. Patients treated with operant conditioning were not more severely ill by this scale. Until recently it has been widely accepted, as indicated by Feldman, that anorexia nervosa is rare. Crisp, Palmer and Kalucy2 recently found in London, England 1 case in every 200 highschool girls and 1 case in every 100 girls over 16 years of age. Ikemi and colleagues3 noted 13 cases of anorexia nervosa in 230 (5.6%) Japanese adolescents with school maladjustment.Furthermore, at least 15% of women presenting with secondary amenorrhea have anorexia nervosa.4 Physicians should recognize that the disorder is clearly much more common that is generally believed. Feldman recommends a controlled
230 CMA JOURNAL/FEBRUARY 4, 1978/VOL. 118
prospective study of modes of therapy for anorexia nervosa. Such a study currently is being carried out by our group. PAUL E. GARFINKEL, MD, FRCP[C] HARVEY MOLDOFSKY, MD, FRCP(C] DAVID M. GARNER, PH 1) Clarke Institute of Psychiatry Toronto, Ont.
References 1. BRUCH H: Perils of behavior modification in treatment of anorexia nervosa. JAMA 236: 1419, 1974 2. Cuss' AR, PALMER RL, KALUCY RS: How common is anorexia nervosa? A prevalence study. Br J Psychiatry 128: 549, 1976 3. IKEMI Y, AGO Y, NAKAGAWA S, et al: Psychosomatic mechanism under social changes in Japan. J Psychosom Res 18: 15, 1974 4. JACOB H5, K.Num VA, HULL MGR, et al: Post-"pill" amenorrhea - cause or coincidence? Br Med 1 2: 940, 1977
Living with the dying To the editor: I apologize for returning to the topic of the now notorious study by R.W. Buckingham and colleagues (Can Med Assc'c J 115: 1211, 1976) as I have no wish, with or without flamboyance, to prolong unnecessarily the correspondence, but B.M. Mount's letter (Can Med Assoc J 117: 14, 1977), in which he defends the study, has reached me only recently and it raises too many important points to be ignored. I believe the study breached generally accepted principles of medical and psychologic research ethics, but Mount professes not to understand what I mean. I know of no code of research ethics the study does not breach, including the principles established at Nuremberg. I have been able to find no text of medical ethics by whose terms the experiment is not at fault. Mount's "relevant ethical issue" concerning the neglect of dying patients is a non sequitur. Of course we need good studies of terminal care (Mount's group has produced some excellent examples), but that is no defence for a bad study. I cannot pretend to understand Mount's explanation of how one may deny the
