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Anorexia nervosa: Towards an early identification
552
BOOK REVIEWS
on the legal aspects of consent to treatment is one of the best sections in this book. His discussion of these issues and their development is entirely relevant to the British situation and his presentation is exceptionally clear and informative. For a number of reasons therefore I consider that this book is a worthwhile purchase. It would be understandable to the beginner to psychopharmacology and would offer some interesting new slants on well worn issues to those all too familiar with this subject. EVE C. JOHNSTONE MRC Clinical Research Centre Harrow
Anorexia Nervosa: Towards an Early Identification. Netherlands, 1984. Price not known.
W. L. WEEDA-MANNAK. Benedictus
Press, Hilversum,
IN A NUMBER of Continental countries the candidates for Doctorate in Medicine have to present printed doctoral theses. The thesis has also to be defended publicly, as the author’s was on 14 September 1984 at the University of Maastricht, Limburg. The thesis holds that slimming in anorexia nervosa patients differs from slimming undertaken for aesthetic or professional reasons in that the anorexic has a ‘fear of failure’, i.e. a sense of incompetence. This predisposing factor is thought to be ‘not exclusively due to parents’ interaction’ but to educational and socio-cultural factors as well. The author was handicapped in substantiating this main conclusion adequately, because precisely those subjects identified by the relevant psychological test as fearful of failure dropped out of the study most often. The author’s research design was a comparison between three groups: 1. Anorexia nervosa patients (AN); 2. patients with secondary amennorhoea, a group of individuals showing mild anorectic and menstrual characteristics (AM); 3. Asymptomatic controls (AF). The intermediate group is further specified as individuals having secondary amenorrhoea but not satisfying the criteria for AN. A fourth group was constituted in addition, consisting of ballet dancers. The numbers in each category were: AN 86; AM 82; AF 316; BA 192. Those subjects in the three main groups were interviewed, physically examined, and the AN Inventory for Self-rating (ANIS) administered, a German inventory unfortunately not adequately described in the text. The Achievement Motivation Test was also administered. (It measures achievement, negative fear of failure, and positive fear of failure). Hormone levels (FSH, LH and 17-beta-oestradiol) were also measured. The findings were that AN and AM groups were similar in FSH, LH and oestradiol levels. The AN group had the highest ANIS scores, the median score of the AM group more elevated to a statistically significant degree than the AF group. On the psychological tests the AN and the AM subjects did not differ in their drive to achieve. The test for Negative Fear of Failure obtained significantly higher scores for the AN group than for both other groups. This review will not report the more sophisticated additional statistical treatment of differences between the three groups. It may be mentioned that the fourth sub-sample, the ballet dancers were like the AN group in their Drive to Achieve, but different in not showing Negative Fear of Failure. A follow-up assessment did not succeed because time intervals prior to the second contact varied for the different groups and the drop-out rates were large. On the basis of these findings, the author proposes that ‘an underlying fear of incompetence and ineffectiveness’ is to be considered as a basic aetiological feature of anorexia nervosa. The finding is held to demonstrate that psychological factors are implicated in the pathogenesis of the disorder. The author’s theoretical considerations which follow concern the development of a negative fear of failure, and the possible role of parent-child interaction and the role of society in producing this attitude. The reader will doubtless conclude that the concept of ‘negative fear of failure’ seems a rather meagre dynamic to explain (even partially) so protean and potentially disasterous an illness as anorexia nervosa. Moreover, it is a test selected by the author for investigative purposes, when obviously a variety of other latent motivations of those who starve themselves could have been explored instead or in parallel. In contrast to the very extensive reference to the vast literature on anorexia nervosa, the subjects who were investigated appear to have been given little opportunity for self-reporting, apart from the items of the tests they completed. Any relevant clinical data which may have been gained from the interview procedure remain unreported. The few illustrative case reports add to the impression of an imbalance between incomplete clinical awareness and extensive acquaintance with the literature, not unusual in a doctoral thesis. But to earn its title this book would need more clinical substance. H. J. WALTON Professor of Psychiatry University of Edinburgh
BOOK REVIEWS
on the legal aspects of consent to treatment is one of the best sections in this book. His discussion of these issues and their development is entirely relevant to the British situation and his presentation is exceptionally clear and informative. For a number of reasons therefore I consider that this book is a worthwhile purchase. It would be understandable to the beginner to psychopharmacology and would offer some interesting new slants on well worn issues to those all too familiar with this subject. EVE C. JOHNSTONE MRC Clinical Research Centre Harrow
Anorexia Nervosa: Towards an Early Identification. Netherlands, 1984. Price not known.
W. L. WEEDA-MANNAK. Benedictus
Press, Hilversum,
IN A NUMBER of Continental countries the candidates for Doctorate in Medicine have to present printed doctoral theses. The thesis has also to be defended publicly, as the author’s was on 14 September 1984 at the University of Maastricht, Limburg. The thesis holds that slimming in anorexia nervosa patients differs from slimming undertaken for aesthetic or professional reasons in that the anorexic has a ‘fear of failure’, i.e. a sense of incompetence. This predisposing factor is thought to be ‘not exclusively due to parents’ interaction’ but to educational and socio-cultural factors as well. The author was handicapped in substantiating this main conclusion adequately, because precisely those subjects identified by the relevant psychological test as fearful of failure dropped out of the study most often. The author’s research design was a comparison between three groups: 1. Anorexia nervosa patients (AN); 2. patients with secondary amennorhoea, a group of individuals showing mild anorectic and menstrual characteristics (AM); 3. Asymptomatic controls (AF). The intermediate group is further specified as individuals having secondary amenorrhoea but not satisfying the criteria for AN. A fourth group was constituted in addition, consisting of ballet dancers. The numbers in each category were: AN 86; AM 82; AF 316; BA 192. Those subjects in the three main groups were interviewed, physically examined, and the AN Inventory for Self-rating (ANIS) administered, a German inventory unfortunately not adequately described in the text. The Achievement Motivation Test was also administered. (It measures achievement, negative fear of failure, and positive fear of failure). Hormone levels (FSH, LH and 17-beta-oestradiol) were also measured. The findings were that AN and AM groups were similar in FSH, LH and oestradiol levels. The AN group had the highest ANIS scores, the median score of the AM group more elevated to a statistically significant degree than the AF group. On the psychological tests the AN and the AM subjects did not differ in their drive to achieve. The test for Negative Fear of Failure obtained significantly higher scores for the AN group than for both other groups. This review will not report the more sophisticated additional statistical treatment of differences between the three groups. It may be mentioned that the fourth sub-sample, the ballet dancers were like the AN group in their Drive to Achieve, but different in not showing Negative Fear of Failure. A follow-up assessment did not succeed because time intervals prior to the second contact varied for the different groups and the drop-out rates were large. On the basis of these findings, the author proposes that ‘an underlying fear of incompetence and ineffectiveness’ is to be considered as a basic aetiological feature of anorexia nervosa. The finding is held to demonstrate that psychological factors are implicated in the pathogenesis of the disorder. The author’s theoretical considerations which follow concern the development of a negative fear of failure, and the possible role of parent-child interaction and the role of society in producing this attitude. The reader will doubtless conclude that the concept of ‘negative fear of failure’ seems a rather meagre dynamic to explain (even partially) so protean and potentially disasterous an illness as anorexia nervosa. Moreover, it is a test selected by the author for investigative purposes, when obviously a variety of other latent motivations of those who starve themselves could have been explored instead or in parallel. In contrast to the very extensive reference to the vast literature on anorexia nervosa, the subjects who were investigated appear to have been given little opportunity for self-reporting, apart from the items of the tests they completed. Any relevant clinical data which may have been gained from the interview procedure remain unreported. The few illustrative case reports add to the impression of an imbalance between incomplete clinical awareness and extensive acquaintance with the literature, not unusual in a doctoral thesis. But to earn its title this book would need more clinical substance. H. J. WALTON Professor of Psychiatry University of Edinburgh