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Anorexia nervosa by proxy
CLINICAL A N D LABORATORY OBSERVATIONS
Anorexia nervosa by proxy Rebecca L. Katz, M.D., Cliff Mazer, M.S.W., and Iris F. Litt, M.D. Palo Alto, California
THE ROLE O F T H E F A MI L Y i n the pathogenesis of anorexia nervosa has been extensively studied? Kaiucy et al? suggested several ways in which excessive concerns about eating, body shape, and weight can become m a j o r vehicles for family interaction and communication. In weightpreoccupied families with narrow, limited coping mechanisms, food and dieting concerns m a y provide some of the few channels for communication. W e describe a 17-year-old adolescent girl with excessive weight loss and overactivity. A detailed psychosocial and family assessment revealed t h a t the patient's weight loss probably resulted from parental preference for extreme thinness. W e suggest t h a t the t e r m "anorexia nervosa by proxy" m a y be used to describe this clinical entity.
Table. Results of psychometric tests
Eating Attitudes Test (EAT) Eating Disorder Inventory (EDI) Drive for thinness Bulimia Body dissatisfaction Ineffectiveness Perfectionism Interpersonal distrust Interoceptive awareness Maturity fears
Pa,tient score
Anorexia nervosa sample
Control group
16
58.9
15.6
1 0 5 7 5 1 5 4
15.4 2.7 14.2 14.4 10,0 ;/.7 12,5 6,0
5)) 2.0 10.2 2.0 5.2 2.2 2.9 2.5
CASE REPORT This 17-year-old gir! was brought to our Eating Disorders Clinic with a history of self-induced weight loss of 2 months duration. The patient gave a history of restricting her calorie intake to 300 to 400 calories a day, resulting in a 12.3 kg weight 10ss, to a weight of 39.6 kg. She denied the use of laxatives, diuretics, or diet pills, nor had she engaged in bingeing or purging. She stated that she did participate in vigorous aerobic exercise for approximately 2 hours a day and was involved in various team sports at school. Her menses, which had been irregular since menarche at age i2 years, ceased during this period of rapid weight loss. There were no apparent precipitants for the marked reduction in weight. The patient stated that she thought she looked "stocky" at 52.3 kg (height 160 cm) and needed to lose about 2.5 kg. She thought that her ideal weight would be about 50 kg. When questioned about her perception of her appearance at 40 kg, she stated that she felt too thin but was having difficulty increasing her intake at mealtime because of her mother's close observation. Family history was remarkable for anorexia nervosa in the patient's older sister, which had been diagnosed several years prior to the patient's presentation. Although the patient's mother had not been formally diagnosed as having an eating disorder, it was From the Division of Adolescent Medicine, stanford University Medical Center, and the Eating Disorders Clinic, Children's Hospital at Stanford. Submitted for publication Oct. 24, ]984; accepted Jan. 7, 1985. Reprint requests: Iris F. Litt, M.D., Division o f Adolescent Medicine, StanJord University Medical Center, Children's Hospital at Stanford, 520 Willow Road, Palo Alto, CA 94304.
apparent that she was excessively thin and preoccupied with food and dieting. The mother frequently complained during the patient's weight rehabilitation that she was gaining weight along With her daughter, which she attributed to the presence of high-calorie foods in the kitchen. At initial evaluation, the patient's weight was 40 kg. Her pulse was 52, blood pressure 110/76 without orthostatic changes} and temperature 35.7 ~ C. Hemogram, sedimentation rate, serum electrolytes, blood urea nitrogen, and serum creatinine were within normal limits. The patient's test scores on the Eating Attitudes Test (EAT) and the Eating Disorders Inventory (ED1), tests designed to measure eating behavior and attitudes toward food and body weight] '4 were within the normal range and were remarkable for the absence of the psychologic and behavioral traits typical Of anorexia nervosa (Table). The Beck Depression Scale and the Spieiberger Anxiety Inventory (STAI-2) suggested that the patient was mildly anxious and depressed. She appeared to have difficulty identifying her own feelings, and often perceived herself as ineffective in influencing others' decisions and in Presenting herself in an assertive fashion with family members and friends (Table). The patient was observed weekly on an outpatient basis with the recommendation that she gain 1 pound (0.46 kg) per week. An agreement was made that if she were unable to meet this target weight, she would be hospitalized to facilitate weight gain. Specific dietary recommendations were made in consultation with a nutritionist. Individual psychotherapy was begun on a weekly basis. During the first 2 weeks, the patient gained 3 kg. The The Journal o f P E D I A T Rl CS Vot. t07, No. 2, August 1985
247
248
Clinical and laboratory observations
subsequent 2 weeks were notable for a 1.5 kg weight loss. at which time hospitalization was recommended. The family refused to comply with this recommendation. Her subsequent course was characterized by a weight gain of approximately 0.5 kg/wk, and she reached her target weight Of 48 kg 3 months after her initial presentation. As this target weight was approached, the mother expressed concern that perhaps this goal had been set too high. She felt that her daughter "looked fine" al 46 kg and would "probably look too heavy" at 48 kg. The patient's reaction to her mother's objection was. "Morn. 1 think we should listen to the doctor's recommendation." The mother raised the same issue on two other occasions, which elicited a similar response from the patient, who was very satisfied and comfortable with her appearance. Despite her mother's continued anxiety, the patient has successfully maintained her weight at 48 kg without any further difficulty. DISCUSSION The incidence of anorexia nervosa among family members of affected individuals is much higher than in the general population. The estimated prevalence of anorexia nervosa among sisters of patients is between 3% and 10%. 5 Crisp et al. 6 have reported "'probable" anorexia nervosa to have been present in a first-degree relative in 29% of 102 consecutive cases. Although there is considerable evidence that a familial predisposition exists, anorexia nervosa occurring as a result of parental preference for extreme thinness in a child has not been previously reported. On initial evaluation, our patient appeared to have "classic" anorexia nervosa. She had lost more than 25~ of her original body weight, engaged in vigorous physical activity, and had amenorrhea. However, closer examination revealed the absence of several features characteristic of true anorexia nervosa and led us to question this diagnosis. For example, there was no evidence of severe body image distortion or preoccupation with body size. When questioned regarding her perception of her appearance, the patient was acutely aware of the fact that she was too thin, but felt unable to deal effectively with the problem. The intense fear of becoming obese and the "relentless pursuit of thinness" that Bruch 7 described were not present. The patient's rapid weight rehabilitation and her ability to maintain her weight at an acceptable level were very unusual. Her psychotherapy course was atypical for a patient with anorexia nervosa in several regards: her acceptance of the process, ease in forming positive transference with a male therapist, and linear improvement in establishing psychosocial goals for herself and meeting these objectives within a brief period. Several aspects of the mother's behavior raised our suspicions that she might be playing more than just a passive role in the development of her daughter's eating
The Journal of Pediatrics August 1985
disorder. She was distressed that she was also gaining weight during the patient's weight rehabilitation and complained about the recent presence of high-calorie foods in the kitchen. Despite her initial Pleasure over her daughter's rapi d recovery, as the patient's weight approached 46 kg the mother became concerned that the goal weight of 48 kg was too high and that her daughter might look too heavy at this weight. The patient, however, was very comfortable with her appearance at 48 kg and exhibited no further interest in losing weight. She aligned herself with the physicians in the need for complying with our recommendations. These interactions provided convincing evidence of the mother's preoccupation with her daughter's body size and desire for her daughter's extreme thinness. Further psychiatric evaluation indicated that eating and food issues represented a central symbolic role in this family and served as a means of communication between family members. We propose that the development of anorexia nervosa in a teenager as a result of parental preference for extreme thinness, as in our patient, be called "anorexia nervosa by proxy." In view of the increasing incidence of anorexia nervosa, physicians caring for adolescents should be aware that not all cases of severe, self-induced weight loss represent true anorexia nervosa but may, in fact, represent a response to parental wishes for a thin body. It is essential to obtain a thorough medical, social, and family history when evaluating a teenager with severe self-starvation. Absence of the psychologic and behavioral traits characteristic of anorexia nervosa and excessive parental anxiety during weight restoration should raise the physician's suspicion that anorexia nervosa by proxy may be the correct diagnosis.
REFERENCES
1. Yager J: Family issues in the pathogenesis of anorexia nervosa. Psyehosom Med 44:43, 1982. 2. Kalucy RS, Crisp AH, Harding B: A study of 56 families with anorexia nervosa. Br J Med Psychol 50:381, 1977. 3. Garner DM, Garfinkel PE: The eating attitudes test: An index of the symptoms of anorexia nervosa. Psychol Med 9:273, 1979. 4. Garner DM, Olmsted MP, Polivy J: Development and validation of a multidimensional eating disorder inventory for anorexia nervosa and bulimia. Int J Eating Disorders 2:15, 1983. 5. Morgan HG, Russell GFM: Value of family background and clinical features as predictors of long term outcome in anorexia nervosa: Four year follow-up study of 41 patients. Psychot Med 5:355, 1975. 6. Crisp AH, Hsu LKG, Harding B, et al: Clinical features of anorexia nervosa. J Psychosom Res 24:179, 1980. 7. Bruch H: The golden cage: The enigma of anorexia nervosa. Cambridge, Mass., 1978, Harvard University Press.
Anorexia nervosa by proxy Rebecca L. Katz, M.D., Cliff Mazer, M.S.W., and Iris F. Litt, M.D. Palo Alto, California
THE ROLE O F T H E F A MI L Y i n the pathogenesis of anorexia nervosa has been extensively studied? Kaiucy et al? suggested several ways in which excessive concerns about eating, body shape, and weight can become m a j o r vehicles for family interaction and communication. In weightpreoccupied families with narrow, limited coping mechanisms, food and dieting concerns m a y provide some of the few channels for communication. W e describe a 17-year-old adolescent girl with excessive weight loss and overactivity. A detailed psychosocial and family assessment revealed t h a t the patient's weight loss probably resulted from parental preference for extreme thinness. W e suggest t h a t the t e r m "anorexia nervosa by proxy" m a y be used to describe this clinical entity.
Table. Results of psychometric tests
Eating Attitudes Test (EAT) Eating Disorder Inventory (EDI) Drive for thinness Bulimia Body dissatisfaction Ineffectiveness Perfectionism Interpersonal distrust Interoceptive awareness Maturity fears
Pa,tient score
Anorexia nervosa sample
Control group
16
58.9
15.6
1 0 5 7 5 1 5 4
15.4 2.7 14.2 14.4 10,0 ;/.7 12,5 6,0
5)) 2.0 10.2 2.0 5.2 2.2 2.9 2.5
CASE REPORT This 17-year-old gir! was brought to our Eating Disorders Clinic with a history of self-induced weight loss of 2 months duration. The patient gave a history of restricting her calorie intake to 300 to 400 calories a day, resulting in a 12.3 kg weight 10ss, to a weight of 39.6 kg. She denied the use of laxatives, diuretics, or diet pills, nor had she engaged in bingeing or purging. She stated that she did participate in vigorous aerobic exercise for approximately 2 hours a day and was involved in various team sports at school. Her menses, which had been irregular since menarche at age i2 years, ceased during this period of rapid weight loss. There were no apparent precipitants for the marked reduction in weight. The patient stated that she thought she looked "stocky" at 52.3 kg (height 160 cm) and needed to lose about 2.5 kg. She thought that her ideal weight would be about 50 kg. When questioned about her perception of her appearance at 40 kg, she stated that she felt too thin but was having difficulty increasing her intake at mealtime because of her mother's close observation. Family history was remarkable for anorexia nervosa in the patient's older sister, which had been diagnosed several years prior to the patient's presentation. Although the patient's mother had not been formally diagnosed as having an eating disorder, it was From the Division of Adolescent Medicine, stanford University Medical Center, and the Eating Disorders Clinic, Children's Hospital at Stanford. Submitted for publication Oct. 24, ]984; accepted Jan. 7, 1985. Reprint requests: Iris F. Litt, M.D., Division o f Adolescent Medicine, StanJord University Medical Center, Children's Hospital at Stanford, 520 Willow Road, Palo Alto, CA 94304.
apparent that she was excessively thin and preoccupied with food and dieting. The mother frequently complained during the patient's weight rehabilitation that she was gaining weight along With her daughter, which she attributed to the presence of high-calorie foods in the kitchen. At initial evaluation, the patient's weight was 40 kg. Her pulse was 52, blood pressure 110/76 without orthostatic changes} and temperature 35.7 ~ C. Hemogram, sedimentation rate, serum electrolytes, blood urea nitrogen, and serum creatinine were within normal limits. The patient's test scores on the Eating Attitudes Test (EAT) and the Eating Disorders Inventory (ED1), tests designed to measure eating behavior and attitudes toward food and body weight] '4 were within the normal range and were remarkable for the absence of the psychologic and behavioral traits typical Of anorexia nervosa (Table). The Beck Depression Scale and the Spieiberger Anxiety Inventory (STAI-2) suggested that the patient was mildly anxious and depressed. She appeared to have difficulty identifying her own feelings, and often perceived herself as ineffective in influencing others' decisions and in Presenting herself in an assertive fashion with family members and friends (Table). The patient was observed weekly on an outpatient basis with the recommendation that she gain 1 pound (0.46 kg) per week. An agreement was made that if she were unable to meet this target weight, she would be hospitalized to facilitate weight gain. Specific dietary recommendations were made in consultation with a nutritionist. Individual psychotherapy was begun on a weekly basis. During the first 2 weeks, the patient gained 3 kg. The The Journal o f P E D I A T Rl CS Vot. t07, No. 2, August 1985
247
248
Clinical and laboratory observations
subsequent 2 weeks were notable for a 1.5 kg weight loss. at which time hospitalization was recommended. The family refused to comply with this recommendation. Her subsequent course was characterized by a weight gain of approximately 0.5 kg/wk, and she reached her target weight Of 48 kg 3 months after her initial presentation. As this target weight was approached, the mother expressed concern that perhaps this goal had been set too high. She felt that her daughter "looked fine" al 46 kg and would "probably look too heavy" at 48 kg. The patient's reaction to her mother's objection was. "Morn. 1 think we should listen to the doctor's recommendation." The mother raised the same issue on two other occasions, which elicited a similar response from the patient, who was very satisfied and comfortable with her appearance. Despite her mother's continued anxiety, the patient has successfully maintained her weight at 48 kg without any further difficulty. DISCUSSION The incidence of anorexia nervosa among family members of affected individuals is much higher than in the general population. The estimated prevalence of anorexia nervosa among sisters of patients is between 3% and 10%. 5 Crisp et al. 6 have reported "'probable" anorexia nervosa to have been present in a first-degree relative in 29% of 102 consecutive cases. Although there is considerable evidence that a familial predisposition exists, anorexia nervosa occurring as a result of parental preference for extreme thinness in a child has not been previously reported. On initial evaluation, our patient appeared to have "classic" anorexia nervosa. She had lost more than 25~ of her original body weight, engaged in vigorous physical activity, and had amenorrhea. However, closer examination revealed the absence of several features characteristic of true anorexia nervosa and led us to question this diagnosis. For example, there was no evidence of severe body image distortion or preoccupation with body size. When questioned regarding her perception of her appearance, the patient was acutely aware of the fact that she was too thin, but felt unable to deal effectively with the problem. The intense fear of becoming obese and the "relentless pursuit of thinness" that Bruch 7 described were not present. The patient's rapid weight rehabilitation and her ability to maintain her weight at an acceptable level were very unusual. Her psychotherapy course was atypical for a patient with anorexia nervosa in several regards: her acceptance of the process, ease in forming positive transference with a male therapist, and linear improvement in establishing psychosocial goals for herself and meeting these objectives within a brief period. Several aspects of the mother's behavior raised our suspicions that she might be playing more than just a passive role in the development of her daughter's eating
The Journal of Pediatrics August 1985
disorder. She was distressed that she was also gaining weight during the patient's weight rehabilitation and complained about the recent presence of high-calorie foods in the kitchen. Despite her initial Pleasure over her daughter's rapi d recovery, as the patient's weight approached 46 kg the mother became concerned that the goal weight of 48 kg was too high and that her daughter might look too heavy at this weight. The patient, however, was very comfortable with her appearance at 48 kg and exhibited no further interest in losing weight. She aligned herself with the physicians in the need for complying with our recommendations. These interactions provided convincing evidence of the mother's preoccupation with her daughter's body size and desire for her daughter's extreme thinness. Further psychiatric evaluation indicated that eating and food issues represented a central symbolic role in this family and served as a means of communication between family members. We propose that the development of anorexia nervosa in a teenager as a result of parental preference for extreme thinness, as in our patient, be called "anorexia nervosa by proxy." In view of the increasing incidence of anorexia nervosa, physicians caring for adolescents should be aware that not all cases of severe, self-induced weight loss represent true anorexia nervosa but may, in fact, represent a response to parental wishes for a thin body. It is essential to obtain a thorough medical, social, and family history when evaluating a teenager with severe self-starvation. Absence of the psychologic and behavioral traits characteristic of anorexia nervosa and excessive parental anxiety during weight restoration should raise the physician's suspicion that anorexia nervosa by proxy may be the correct diagnosis.
REFERENCES
1. Yager J: Family issues in the pathogenesis of anorexia nervosa. Psyehosom Med 44:43, 1982. 2. Kalucy RS, Crisp AH, Harding B: A study of 56 families with anorexia nervosa. Br J Med Psychol 50:381, 1977. 3. Garner DM, Garfinkel PE: The eating attitudes test: An index of the symptoms of anorexia nervosa. Psychol Med 9:273, 1979. 4. Garner DM, Olmsted MP, Polivy J: Development and validation of a multidimensional eating disorder inventory for anorexia nervosa and bulimia. Int J Eating Disorders 2:15, 1983. 5. Morgan HG, Russell GFM: Value of family background and clinical features as predictors of long term outcome in anorexia nervosa: Four year follow-up study of 41 patients. Psychot Med 5:355, 1975. 6. Crisp AH, Hsu LKG, Harding B, et al: Clinical features of anorexia nervosa. J Psychosom Res 24:179, 1980. 7. Bruch H: The golden cage: The enigma of anorexia nervosa. Cambridge, Mass., 1978, Harvard University Press.