Br. J . med. Psychol. (1977). 50. 375-380
Printed in Great Britain
375
Some psychological characteristics of patients with anorexia nervosa whose weight has been newly restored M. Pillay and A. H.Crisp A preliminary study has served to demonstrate that patients with primary anorexia nervosa whose weight has been newly restored to normal, and who are currently involved in individual and family psychotherapy, are significantly characterized by having very low self-esteem, by being highly sensitive to social interactions and by being ‘obsessoid’. It is suggested that, in therapy, specific behavioural approaches to these problems may usefully complement other psychotherapeutic endeavours.
Clinically anorexia nervosa is a well-documented condition. Crisp (1%7, 1977) has claimed that there are three levels of diagnosis: (1) the commonly manifest behaviour stemming from (a) the individual’s need to maintain low body weight, and ( b ) the consequences of carbohydrate or more generalized starvation; (2) underlying and often denied terror generating the avoidance of normal adolescent weight and shape, which he regards as pathognomonic of the condition and has termed ‘weight phobia ’; (3) the maturational conflict previously present within the adolescent and the family and which was construed by the adolescent in terms of body weight and shape. He claims that the immediate psychopathological significance of the physical disorder is the avoidancelregression mechanism it provides, by virtue of the threshold role of increasing body weight during growth for the activation (or in the case of anorexia nervosa inactivation, through weight loss) of pubertal and hence adolescent processes. It has been claimed that the problems concerning adolescent maturation, which are basic but not specific to the disorder, are rooted in such matters as gender identity, individuation, separation, adolescent challenges to parental and marital adjustments, and threatened family break-ups (Crisp, 1970; Bruch, 1974; Kalucy, Crisp & Harding, 1977). It has been shown that restoration of the patient’s weight to normal, combined with individual and family psychotherapy, immediately promotes increased anxiety and depression in the parents despite their initial desperation when their child is ill (Crisp, Harding & McGuinness, 1974). Some authorities attempt to divide anorectics into those who display predominantly obsessional characteristics and those who display hysterical patterns in their premorbid ‘personalities’(Dally, 1%9). Others state that anorectics show a spectrum of such behaviour within their illness, all concerned with their central psychopathological needs, and that premorbidly they may or may not have shown similar traits. Moreover, the more striking aspect of their premorbid state has been their post-pubertal psychosocial inadequacy. Various workers have systematically studied ‘personality’ characteristics of groups of patients with anorexia nervosa. Using the EPI and MHQ, Crisp, Stonehill & Fenton (1971) and Crisp & Stonehill (1972) found a group of ten, and later 40 anorectics to be introverted and neurotic and to show relatively high levels of anxiety and depression as well as somatic complaint when compared with normal subjects. Nevertheless they found that, within their anorectic state, the patients were not socially phobic. Restoration of body weight combined with psychotherapy led, whilst the subject was still in the protective hospital milieu, to a significant reduction in neuroticism and an increase in extraversion. When this same population was followed up four to seven years later (Stonehill & Crisp, 1977) those that were recovered from their anorexia nervosa were characterized by having been found at the time of their illness to be less obsessional than the others, and now to display high levels of social anxiety (phobic scale of the MHQ). It was as if, having abandoned their primitive posture of total psychobiological
376
M.?Way and A. H . Crisp
avoidance of adolescence, they were now experiencing excessive anxiety in relation to its social demands. More recently, too, Smart, Beaumont & George (1976) have reported finding high levels of anxiety, neuroticism, introversion and obsessoid characteristics in a population of anorectics, whilst Pierloot, Wellens & Houben (1975) report a high score on the schizophrenic scale of the MMPI as heralding a poor prognosis. Finally, anorectics have been shown to report grossly increased self-estimates of their body widths (Slade & Russell, 1973; Crisp & Kalucy, 1974). This property is shared with the massively obese and probably also to a lesser extent with many adolescent females (Kalucy et af. 1975; Pollack et al. 1975), and some of these workers have shown that the distortion in anorectics can be considerably modified by supportive counselling prior to measurement. In 1%7 Crisp advocated a combined behavioural and psychotherapeutic approach to treatment, wherein the individual experienced gradual re-exposure to a strictly normal body weight within the context of a specific dietary and behavioural bedbound control regime, whilst at the same time psychotherapy was directed at the consequential maturational problems being rekindled for both the patient and her family (Crisp, 1967a, b). Such a combined approach leads to the patient staying in treatment. Other workers have also reported operant behavioural treatment programmes (Bhanji & Thompson, 1974; Halmi, Powers & Cunningham, 1975), whilst Bruch (1974) has also claimed that severe psychopathological reactions can arise if weight alone is restored without due attention to the psychological implications of this for the individual. Reports from this Unit over the years (Crisp & Fransella, 1972; Crisp, 1974) have emphasized that, as weight is restored, especially to around the 45 kg level, thereby rekindling aspects of the pubertal process, patients and sometimes their families often need intensive psychological help. As target weight (i.e. matched population mean weight) is approached, increased sensitivity about shape usually arises. Panic, shame and low self-esteem may be prominent features, all attributed by the patient to her appearance and body weight. The policy regarding psychotherapy is to attempt to help her and her family disengage such feelings from this issue, and to examine them instead in relation to the overall life situation. At any one time eight such patients are in various stages of the initial in-patient treatment programme. As the time comes for each patient to get up out of bed and also to leave the cubicle and move into the general ward, she is likely to display new anxieties, feeling socially inept although often wanting desperately to be socially acceptable as she now is (i.e. normal in shape). The present study is aimed at a preliminary investigation of some aspects of this experience of the patient. Social anxiety in this context is used in the sense described by Nichols (1974) and includes an inner lack of self-esteem which may or may not be accompanied by the physical phenomena of social phobias elucidated by Kraupl Taylor (1966) and Marks (1%9). Method The clinical sample in this report comprises consecutive patients who, having attained their target weight, were referred for investigation. It comprises 11 females with a mean age of 20.5 years (nine of the 11 patients being within the age range 16-23 years). Scholastically, in terms of number of ‘0’levels and ‘ A ’ levels, the majority were potential candidates for higher education. Four questionnaires were administered at this point, when the patients had attained and stabilized their target weight. The responses were compared with those of the total population of 60 normal female students enrolled in a human biology course. The questionnaires were given in random order to both groups. The students used code names ensuring that strict anonymity was retained.
Questionnaires 1. The Edwards Personal Preference Schedule (Edwards, 1959) and Hysteroid Obsessoid Questionnaire (Caine & Hope, 1%7) were used to obtain descriptive personality data. 2. The Fear Survey Schedule (Tasto & Hickson, 1970) and Social Questionnaire (Watson & Friend, 1%9) were used to obtain more detailed information on general sensitivity to stimulate and to clarify the observed social anxiety.
Characteristics of patients with anorexia nervosa 377 Apart from the total scores, the questionnaire responses were broken up into categories based on the clinical signs for hysteroidabsessoid characteristics(HOQ) (Caine & Hope, 1%7), and also into factorially derived categories (Rubin, Lawlis, Tasto & Namenek, 1%9) of anxiety precipitants for the FSS (Tasto & Hickson, 1970). The raw score for each subject on the EPPS (Edwards, 1959) was transposed to a percentile score with reference to the relevant female student or adult female norms. The percentile scores were then coded into five categories on the criteria suggested by Edwards (1959). The consistency score (1 1 +) in this forced choice test is a check against random responses and this provided an indication that neither of the two samples responded randomly (see Table 1). All completed protocols were used - only one student did not complete the questionnaire. The 30 items that load on ‘fear of negative evaluation ’ (FNE)and the 28 items that made up the ‘social avoidance distance’ (SAD) in Watson & Friend’s factor analysis (1%9) of various social questionnaires were randomized to create a single questionnaire and then scored for each of the two variables separately. Table 1.
EPPS. Anorexia nervosa group vs. student group
Variable
XZ
d.f.
P
Printed in Great Britain
375
Some psychological characteristics of patients with anorexia nervosa whose weight has been newly restored M. Pillay and A. H.Crisp A preliminary study has served to demonstrate that patients with primary anorexia nervosa whose weight has been newly restored to normal, and who are currently involved in individual and family psychotherapy, are significantly characterized by having very low self-esteem, by being highly sensitive to social interactions and by being ‘obsessoid’. It is suggested that, in therapy, specific behavioural approaches to these problems may usefully complement other psychotherapeutic endeavours.
Clinically anorexia nervosa is a well-documented condition. Crisp (1%7, 1977) has claimed that there are three levels of diagnosis: (1) the commonly manifest behaviour stemming from (a) the individual’s need to maintain low body weight, and ( b ) the consequences of carbohydrate or more generalized starvation; (2) underlying and often denied terror generating the avoidance of normal adolescent weight and shape, which he regards as pathognomonic of the condition and has termed ‘weight phobia ’; (3) the maturational conflict previously present within the adolescent and the family and which was construed by the adolescent in terms of body weight and shape. He claims that the immediate psychopathological significance of the physical disorder is the avoidancelregression mechanism it provides, by virtue of the threshold role of increasing body weight during growth for the activation (or in the case of anorexia nervosa inactivation, through weight loss) of pubertal and hence adolescent processes. It has been claimed that the problems concerning adolescent maturation, which are basic but not specific to the disorder, are rooted in such matters as gender identity, individuation, separation, adolescent challenges to parental and marital adjustments, and threatened family break-ups (Crisp, 1970; Bruch, 1974; Kalucy, Crisp & Harding, 1977). It has been shown that restoration of the patient’s weight to normal, combined with individual and family psychotherapy, immediately promotes increased anxiety and depression in the parents despite their initial desperation when their child is ill (Crisp, Harding & McGuinness, 1974). Some authorities attempt to divide anorectics into those who display predominantly obsessional characteristics and those who display hysterical patterns in their premorbid ‘personalities’(Dally, 1%9). Others state that anorectics show a spectrum of such behaviour within their illness, all concerned with their central psychopathological needs, and that premorbidly they may or may not have shown similar traits. Moreover, the more striking aspect of their premorbid state has been their post-pubertal psychosocial inadequacy. Various workers have systematically studied ‘personality’ characteristics of groups of patients with anorexia nervosa. Using the EPI and MHQ, Crisp, Stonehill & Fenton (1971) and Crisp & Stonehill (1972) found a group of ten, and later 40 anorectics to be introverted and neurotic and to show relatively high levels of anxiety and depression as well as somatic complaint when compared with normal subjects. Nevertheless they found that, within their anorectic state, the patients were not socially phobic. Restoration of body weight combined with psychotherapy led, whilst the subject was still in the protective hospital milieu, to a significant reduction in neuroticism and an increase in extraversion. When this same population was followed up four to seven years later (Stonehill & Crisp, 1977) those that were recovered from their anorexia nervosa were characterized by having been found at the time of their illness to be less obsessional than the others, and now to display high levels of social anxiety (phobic scale of the MHQ). It was as if, having abandoned their primitive posture of total psychobiological
376
M.?Way and A. H . Crisp
avoidance of adolescence, they were now experiencing excessive anxiety in relation to its social demands. More recently, too, Smart, Beaumont & George (1976) have reported finding high levels of anxiety, neuroticism, introversion and obsessoid characteristics in a population of anorectics, whilst Pierloot, Wellens & Houben (1975) report a high score on the schizophrenic scale of the MMPI as heralding a poor prognosis. Finally, anorectics have been shown to report grossly increased self-estimates of their body widths (Slade & Russell, 1973; Crisp & Kalucy, 1974). This property is shared with the massively obese and probably also to a lesser extent with many adolescent females (Kalucy et af. 1975; Pollack et al. 1975), and some of these workers have shown that the distortion in anorectics can be considerably modified by supportive counselling prior to measurement. In 1%7 Crisp advocated a combined behavioural and psychotherapeutic approach to treatment, wherein the individual experienced gradual re-exposure to a strictly normal body weight within the context of a specific dietary and behavioural bedbound control regime, whilst at the same time psychotherapy was directed at the consequential maturational problems being rekindled for both the patient and her family (Crisp, 1967a, b). Such a combined approach leads to the patient staying in treatment. Other workers have also reported operant behavioural treatment programmes (Bhanji & Thompson, 1974; Halmi, Powers & Cunningham, 1975), whilst Bruch (1974) has also claimed that severe psychopathological reactions can arise if weight alone is restored without due attention to the psychological implications of this for the individual. Reports from this Unit over the years (Crisp & Fransella, 1972; Crisp, 1974) have emphasized that, as weight is restored, especially to around the 45 kg level, thereby rekindling aspects of the pubertal process, patients and sometimes their families often need intensive psychological help. As target weight (i.e. matched population mean weight) is approached, increased sensitivity about shape usually arises. Panic, shame and low self-esteem may be prominent features, all attributed by the patient to her appearance and body weight. The policy regarding psychotherapy is to attempt to help her and her family disengage such feelings from this issue, and to examine them instead in relation to the overall life situation. At any one time eight such patients are in various stages of the initial in-patient treatment programme. As the time comes for each patient to get up out of bed and also to leave the cubicle and move into the general ward, she is likely to display new anxieties, feeling socially inept although often wanting desperately to be socially acceptable as she now is (i.e. normal in shape). The present study is aimed at a preliminary investigation of some aspects of this experience of the patient. Social anxiety in this context is used in the sense described by Nichols (1974) and includes an inner lack of self-esteem which may or may not be accompanied by the physical phenomena of social phobias elucidated by Kraupl Taylor (1966) and Marks (1%9). Method The clinical sample in this report comprises consecutive patients who, having attained their target weight, were referred for investigation. It comprises 11 females with a mean age of 20.5 years (nine of the 11 patients being within the age range 16-23 years). Scholastically, in terms of number of ‘0’levels and ‘ A ’ levels, the majority were potential candidates for higher education. Four questionnaires were administered at this point, when the patients had attained and stabilized their target weight. The responses were compared with those of the total population of 60 normal female students enrolled in a human biology course. The questionnaires were given in random order to both groups. The students used code names ensuring that strict anonymity was retained.
Questionnaires 1. The Edwards Personal Preference Schedule (Edwards, 1959) and Hysteroid Obsessoid Questionnaire (Caine & Hope, 1%7) were used to obtain descriptive personality data. 2. The Fear Survey Schedule (Tasto & Hickson, 1970) and Social Questionnaire (Watson & Friend, 1%9) were used to obtain more detailed information on general sensitivity to stimulate and to clarify the observed social anxiety.
Characteristics of patients with anorexia nervosa 377 Apart from the total scores, the questionnaire responses were broken up into categories based on the clinical signs for hysteroidabsessoid characteristics(HOQ) (Caine & Hope, 1%7), and also into factorially derived categories (Rubin, Lawlis, Tasto & Namenek, 1%9) of anxiety precipitants for the FSS (Tasto & Hickson, 1970). The raw score for each subject on the EPPS (Edwards, 1959) was transposed to a percentile score with reference to the relevant female student or adult female norms. The percentile scores were then coded into five categories on the criteria suggested by Edwards (1959). The consistency score (1 1 +) in this forced choice test is a check against random responses and this provided an indication that neither of the two samples responded randomly (see Table 1). All completed protocols were used - only one student did not complete the questionnaire. The 30 items that load on ‘fear of negative evaluation ’ (FNE)and the 28 items that made up the ‘social avoidance distance’ (SAD) in Watson & Friend’s factor analysis (1%9) of various social questionnaires were randomized to create a single questionnaire and then scored for each of the two variables separately. Table 1.
EPPS. Anorexia nervosa group vs. student group
Variable
XZ
d.f.
P
