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Anorexia Nervosa: Who Are You? Where Are You?
Editorial Anorexia Nervosa: Who Are You? Where Are You?
were published. Before that, the disorder of AN was often not recognized by internists and psychiatrists, even after years of treatment of an afflicted patient. The third edition of the DiagIn an epidemiologic study of anorexia nervosa nostic and Statistical Manual of Mental Dis(AN) during a 45-year period in Rochester, Minorders (DSM-III), published by the American Psynesota, published in this issue of the Proceedings chiatric Association, provided widely accepted (pages 433 to 442), Lucas and associates provide criteria for AN in 1980,3 followed by a revised important data for the continuing debate about version (DSM-III-R) in 1987. Before the revised whether the incidence of AN has actually incriteria were available last year, patients had to creased. Media reports and several scientific lose 25% of their body weight as a necessary (but articles support the idea that new cases of AN not sufficient) requirement for the diagnosis of have increased dramatically. The study by Lucas AN. Since 1987, patients have had to lose only and colleagues defies current trends by concludenough weight to result in being less than 85% ing that, when all the various medical forms in of "minimal normal weight" for age and height which AN can manifest—especially endocrinopto qualify for the diagnosis of AN. Even though athy (amenorrhea, oligomenorrhea, and ovarian weight requirements were eased for the diagnosis, dysfunction) or starvation, weight loss, underwomen now must have three or more consecutive weight, and malnutrition—are carefully exammonths of amenorrhea, a previously unspecified ined, the rate of occurrence of anorexia nervosa requirement. has not increased during the past 45 years. They Although seeming to be a stable entity, the base their conclusions on a carefully planned study of Olmsted County medical records from term "anorexia nervosa" has undergone, and probably will continue to undergo, additional 1935 through 1979. changes—some minor, some of major conceptual In general, critical analysis of the design of a significance. If sacred things may be questioned, scientific study leads to either support for or let it be said that uncertainty exists about whether dissension from the conclusions of the study. In the first generally accepted cases of AN, those an academic tennis match, the first request is reported by Morton 4 in the late 17th century, usually "Show me your data." Questions about actually were AN. Those two cases are comthe empirical aspects of a research effort actually patible with, but not definitely equivalent to, must be preceded by even more basic linguistic modern cases of AN. Such has been the variconsiderations. The two fundamental questions ability and vagueness of the diagnostic criteria of science, in order or priority, are (1) "How are of AN. you using your terms?" and, only after this quesChanges in the definition of AN illustrate the tion has been answered, (2) "Where are your intrinsic difficulties that even extremely expedata?" During studies of the endocrine and hyporienced clinicians and researchers such as Lucas thalamic alterations associated with AN, con1 and colleagues face when studying disorders that ducted by Mecklenburg and associates at the involve primary abnormalities of behavior. DiagNational Institutes of Health in the early 1970s, nostic criteria for disorders of behavior remain it became clear that the biochemical data were syndromic in nature, rather than reflecting funan order of magnitude more precise than the damentally understood causes and mechanisms. psychiatric and behavioral data. During those This statement holds true not only for anorexia years, the first clear and specific diagnostic crite2 nervosa but also for bulimia nervosa, obesity, ria for AN, proposed by Feighner and co-workers, alcoholism, sexual disorders, and disorders of aggression. In the case of AN, Professor Gerald Russell 5 has taught consistently that three criteria are essential for the diagnosis: self-induced Address reprint requests to Dr. A. E. Andersen, Department of Psychiatry, Johns Hopkins University School of Medicine, starvation (a behavior), morbid fear of fatness (a Meyer 3-181, 600 North Wolfe Street, Baltimore, MD 21205. psychopathologic feature), and an abnormality of Mayo Clin Proc 63:511-513, 1988
511
512
EDITORIAL
function of reproductive hormones (a physiologic change). Until the recent DSM-III-R, the British and American criteria differed on even the central psychopathologic feature. Brash heretics have suggested that perhaps AN does not exist at all— it may be a forme fruste of affective disorder. The study by Lucas and associates attempts to answer and is partially successful in answering the question of whether an actual increase in the incidence of AN has occurred during the past 45 years in Rochester, Minnesota. No matter how good the study design is, investigators of change in incidence of AN must grapple with the fact that the quarry they are pursuing has been varying all the time the hunt has been in progress. The designation of "definite" cases of AN in the study by Lucas and co-workers had to meet four criteria, including the characteristic psychopathologic motif of AN, "fear of fatness or loss of control of eating, expressed or implied" (italics added). Thus, even the definite cases may have had only an implied rather than an expressed form of the central feature of AN. For "probable" and "possible" cases, this central defining feature was not essential. On the basis of their study, if only definite cases of AN are included, the change from 4 cases during the 1930s (derived by multiplying the 1935 through 1939 finding by 2), to 7 cases during the 1940s, 4 cases during the 1950s (thank you, Mamie Eisenhower), 15 cases in 1960 through 1969, and finally 18 cases between 1970 and 1979 suggests a trend, which may preclude statistical significance because of the small numbers involved but which nevertheless seems to support a conclusion directly opposed to theirs. Considerable uncertainty still exists about what constitutes anorexia nervosa. No place is more suited to asking the question and finding the answer to the incidence of AN than the Mayo Clinic. It provides or meticulously records virtually all the health care in the city and the surrounding county and has done so since the beginning of the century. Furthermore, its investigators are experienced and respected. The problems, however, are not at the level of facilities and expertise but at the level of definition. If the thesis is correct in Holy Anorexia? a recent provocative book in which the lives of fasting medieval Italian saints are examined, these persons may have suffered from a condition indistinguishable from modern AN. In the case of
Mayo Clin Proc, May 1988, Vol 63
these fasting saints, fatness was morbidly feared as a threat to the soul rather than as a threat to the first appearance in a bikini during spring break. Psychopathologically and pathophysiologically, these cases are indistinguishable from modern cases of AN, even to the extent of having a complete equation of their existential sense of self with their starved physical state. Other studies suggest that cases of AN have actually increased, even when the considerations of earlier and better diagnosis are factored out. The occasionally parodied and often envied investigators of AN who studied changes in the measurements of Playboy centerfolds and Miss America contestants during a period of 2 decades found that these numbers steadily decreased between 1959 and 1979. They substantiated what common observation suggests: our role models have become thinner. A current preference is for a lean, muscular, "tube" look for female role models—at best only a slight improvement over the starved look that high-volume periodicals have cultivated. Virtually no words in the English language have positive connotations for women whose weight is healthy but in the upper half of the normal range. "Thin," "svelte," "sleek," "modellike," and "lean" all have positive connotations and promote thinness-producing behavior. Pity the young woman from an upper-middle-class family who is perfectly healthy but happens to be in the upper part of the normal range of weight for her height, despite being normal by such physiologic standards as regular menses and appropriate percentage of body fat. No good, my dear, you must reduce. The message to reduce comes from parents, from educators, and from physicians; it virtually screams from advertisements and articles in popular magazines. Scientific reports of increased incidence of AN need to be given due respect. The increasing number of cases of AN in clinics and hospitals needs to be explained, rather than explained away. Science occasionally produces the unexpected and even defies conventional wisdom. Perhaps Lucas and associates are leading the way in their studies of the incidence of AN and showing us that no actual change has occurred in this pleomorphic and enigmatic entity. Still, the tennis match is far from over. Clinicians, researchers, and students of the eating disorders are watching from the stands to see from which court the next
Mayo Clin Proc, May 1988, Vol 63
serve will come—from the "AN is going up" court or the "AN remains stable" court. In the meantime, "play" must proceed. Medicine can only be advanced by such thorough studies as that of Lucas and colleagues. Arnold E. Andersen, M.D. Department of Psychiatry Johns Hopkins University School of Medicine Baltimore, Maryland
EDITORIAL
REFERENCES
513
1. Mecklenburg RS, Loriaux DL, Thompson RH, Andersen AE, Lipsett MB: Hypothalamic dysfunction in patients with anorexia nervosa. Medicine (Baltimore) 53:147-159, 1974 2. Feighner JP, Robins E, Guze SB, Woodruff RA Jr, Winokur G, Munoz R: Diagnostic criteria for use in psychiatric research. Arch Gen Psychiatry 26:57-63,1972 American Psychiatric Association Task Force on Nomenclature and Statistics: Diagnostic and Statistical Manual of Mental Disorders. Third edition. Washington, DC, American Psychiatric Association, 1980 Morton R: Phthisiologia: Or, a Treatise of Consumptions. London, S Smith and B Walford, 1694 Russell GFM: Anorexia nervosa. In Textbook of Medicine. Fourteenth edition. Edited by PB Beeson, W McDermott. Philadelphia, WB Saunders Company, 1975, pp 1386-1389 Bell RM: Holy Anorexia. Chicago, University of Chicago Press, 1985
were published. Before that, the disorder of AN was often not recognized by internists and psychiatrists, even after years of treatment of an afflicted patient. The third edition of the DiagIn an epidemiologic study of anorexia nervosa nostic and Statistical Manual of Mental Dis(AN) during a 45-year period in Rochester, Minorders (DSM-III), published by the American Psynesota, published in this issue of the Proceedings chiatric Association, provided widely accepted (pages 433 to 442), Lucas and associates provide criteria for AN in 1980,3 followed by a revised important data for the continuing debate about version (DSM-III-R) in 1987. Before the revised whether the incidence of AN has actually incriteria were available last year, patients had to creased. Media reports and several scientific lose 25% of their body weight as a necessary (but articles support the idea that new cases of AN not sufficient) requirement for the diagnosis of have increased dramatically. The study by Lucas AN. Since 1987, patients have had to lose only and colleagues defies current trends by concludenough weight to result in being less than 85% ing that, when all the various medical forms in of "minimal normal weight" for age and height which AN can manifest—especially endocrinopto qualify for the diagnosis of AN. Even though athy (amenorrhea, oligomenorrhea, and ovarian weight requirements were eased for the diagnosis, dysfunction) or starvation, weight loss, underwomen now must have three or more consecutive weight, and malnutrition—are carefully exammonths of amenorrhea, a previously unspecified ined, the rate of occurrence of anorexia nervosa requirement. has not increased during the past 45 years. They Although seeming to be a stable entity, the base their conclusions on a carefully planned study of Olmsted County medical records from term "anorexia nervosa" has undergone, and probably will continue to undergo, additional 1935 through 1979. changes—some minor, some of major conceptual In general, critical analysis of the design of a significance. If sacred things may be questioned, scientific study leads to either support for or let it be said that uncertainty exists about whether dissension from the conclusions of the study. In the first generally accepted cases of AN, those an academic tennis match, the first request is reported by Morton 4 in the late 17th century, usually "Show me your data." Questions about actually were AN. Those two cases are comthe empirical aspects of a research effort actually patible with, but not definitely equivalent to, must be preceded by even more basic linguistic modern cases of AN. Such has been the variconsiderations. The two fundamental questions ability and vagueness of the diagnostic criteria of science, in order or priority, are (1) "How are of AN. you using your terms?" and, only after this quesChanges in the definition of AN illustrate the tion has been answered, (2) "Where are your intrinsic difficulties that even extremely expedata?" During studies of the endocrine and hyporienced clinicians and researchers such as Lucas thalamic alterations associated with AN, con1 and colleagues face when studying disorders that ducted by Mecklenburg and associates at the involve primary abnormalities of behavior. DiagNational Institutes of Health in the early 1970s, nostic criteria for disorders of behavior remain it became clear that the biochemical data were syndromic in nature, rather than reflecting funan order of magnitude more precise than the damentally understood causes and mechanisms. psychiatric and behavioral data. During those This statement holds true not only for anorexia years, the first clear and specific diagnostic crite2 nervosa but also for bulimia nervosa, obesity, ria for AN, proposed by Feighner and co-workers, alcoholism, sexual disorders, and disorders of aggression. In the case of AN, Professor Gerald Russell 5 has taught consistently that three criteria are essential for the diagnosis: self-induced Address reprint requests to Dr. A. E. Andersen, Department of Psychiatry, Johns Hopkins University School of Medicine, starvation (a behavior), morbid fear of fatness (a Meyer 3-181, 600 North Wolfe Street, Baltimore, MD 21205. psychopathologic feature), and an abnormality of Mayo Clin Proc 63:511-513, 1988
511
512
EDITORIAL
function of reproductive hormones (a physiologic change). Until the recent DSM-III-R, the British and American criteria differed on even the central psychopathologic feature. Brash heretics have suggested that perhaps AN does not exist at all— it may be a forme fruste of affective disorder. The study by Lucas and associates attempts to answer and is partially successful in answering the question of whether an actual increase in the incidence of AN has occurred during the past 45 years in Rochester, Minnesota. No matter how good the study design is, investigators of change in incidence of AN must grapple with the fact that the quarry they are pursuing has been varying all the time the hunt has been in progress. The designation of "definite" cases of AN in the study by Lucas and co-workers had to meet four criteria, including the characteristic psychopathologic motif of AN, "fear of fatness or loss of control of eating, expressed or implied" (italics added). Thus, even the definite cases may have had only an implied rather than an expressed form of the central feature of AN. For "probable" and "possible" cases, this central defining feature was not essential. On the basis of their study, if only definite cases of AN are included, the change from 4 cases during the 1930s (derived by multiplying the 1935 through 1939 finding by 2), to 7 cases during the 1940s, 4 cases during the 1950s (thank you, Mamie Eisenhower), 15 cases in 1960 through 1969, and finally 18 cases between 1970 and 1979 suggests a trend, which may preclude statistical significance because of the small numbers involved but which nevertheless seems to support a conclusion directly opposed to theirs. Considerable uncertainty still exists about what constitutes anorexia nervosa. No place is more suited to asking the question and finding the answer to the incidence of AN than the Mayo Clinic. It provides or meticulously records virtually all the health care in the city and the surrounding county and has done so since the beginning of the century. Furthermore, its investigators are experienced and respected. The problems, however, are not at the level of facilities and expertise but at the level of definition. If the thesis is correct in Holy Anorexia? a recent provocative book in which the lives of fasting medieval Italian saints are examined, these persons may have suffered from a condition indistinguishable from modern AN. In the case of
Mayo Clin Proc, May 1988, Vol 63
these fasting saints, fatness was morbidly feared as a threat to the soul rather than as a threat to the first appearance in a bikini during spring break. Psychopathologically and pathophysiologically, these cases are indistinguishable from modern cases of AN, even to the extent of having a complete equation of their existential sense of self with their starved physical state. Other studies suggest that cases of AN have actually increased, even when the considerations of earlier and better diagnosis are factored out. The occasionally parodied and often envied investigators of AN who studied changes in the measurements of Playboy centerfolds and Miss America contestants during a period of 2 decades found that these numbers steadily decreased between 1959 and 1979. They substantiated what common observation suggests: our role models have become thinner. A current preference is for a lean, muscular, "tube" look for female role models—at best only a slight improvement over the starved look that high-volume periodicals have cultivated. Virtually no words in the English language have positive connotations for women whose weight is healthy but in the upper half of the normal range. "Thin," "svelte," "sleek," "modellike," and "lean" all have positive connotations and promote thinness-producing behavior. Pity the young woman from an upper-middle-class family who is perfectly healthy but happens to be in the upper part of the normal range of weight for her height, despite being normal by such physiologic standards as regular menses and appropriate percentage of body fat. No good, my dear, you must reduce. The message to reduce comes from parents, from educators, and from physicians; it virtually screams from advertisements and articles in popular magazines. Scientific reports of increased incidence of AN need to be given due respect. The increasing number of cases of AN in clinics and hospitals needs to be explained, rather than explained away. Science occasionally produces the unexpected and even defies conventional wisdom. Perhaps Lucas and associates are leading the way in their studies of the incidence of AN and showing us that no actual change has occurred in this pleomorphic and enigmatic entity. Still, the tennis match is far from over. Clinicians, researchers, and students of the eating disorders are watching from the stands to see from which court the next
Mayo Clin Proc, May 1988, Vol 63
serve will come—from the "AN is going up" court or the "AN remains stable" court. In the meantime, "play" must proceed. Medicine can only be advanced by such thorough studies as that of Lucas and colleagues. Arnold E. Andersen, M.D. Department of Psychiatry Johns Hopkins University School of Medicine Baltimore, Maryland
EDITORIAL
REFERENCES
513
1. Mecklenburg RS, Loriaux DL, Thompson RH, Andersen AE, Lipsett MB: Hypothalamic dysfunction in patients with anorexia nervosa. Medicine (Baltimore) 53:147-159, 1974 2. Feighner JP, Robins E, Guze SB, Woodruff RA Jr, Winokur G, Munoz R: Diagnostic criteria for use in psychiatric research. Arch Gen Psychiatry 26:57-63,1972 American Psychiatric Association Task Force on Nomenclature and Statistics: Diagnostic and Statistical Manual of Mental Disorders. Third edition. Washington, DC, American Psychiatric Association, 1980 Morton R: Phthisiologia: Or, a Treatise of Consumptions. London, S Smith and B Walford, 1694 Russell GFM: Anorexia nervosa. In Textbook of Medicine. Fourteenth edition. Edited by PB Beeson, W McDermott. Philadelphia, WB Saunders Company, 1975, pp 1386-1389 Bell RM: Holy Anorexia. Chicago, University of Chicago Press, 1985