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Personality and addictiveness in anorexic and bulimic patients
Person. individ. D@ Vol. 8, No. 5, pp. 749-751,
0191-8869/87 $3.00 + 0.00 Copyright 0 1987 Pergamon Journals Ltd
1987
Printed in Great Britain, All rights reserved
Personality
and addictiveness
in anorexic
PADMAL DE SILVA
and bulimic patients
and SYBIL EYSENCK
Department of Psychology, Instirute of Psychiatry, De Crespigny Park, London SE.5 8AF, England (Received 25 September 1986) Abstract-Fifty-nine female patients with anorexia nervosa were compared with 122 bulimics on their EPQ scores and an addiction score derived from the EPQ. The bulimics scored significantly higher than the anorexics on Psychoticism and Neuroticism, and lower on Social Desirability. They also scored considerably higher on addiction, and tended to be more like drug addicts.
INTRODUCTION The existence of different
sub-groups
of patients with eating disorder has been fully recognized in recent years (e.g. Garfinkel (1979) described a group of patients with ‘bulimia nervosa’, it has been widely acknowledged that this is an important and not uncommon variant of anorexia nervosa. While the diagnostic criteria for anorexia nervosa are generally agreed to be (i) self-induced weight loss, (ii) persistent amenorrhoea and (iii) a psychopathology characterized by a dread of losing control of eating and thus becoming fat (Russell, 1970), bulimia nervosa has been defined as marked by an irresistable urge to overeat, followed by self-induced vomiting or purging, along with a morbid fear of becoming fat (Russell, 1979). Despite these criteria, however, the literature is not consistent in the way these groups of patients are differentiated from each other, leading to difficulty in drawing general conclusions about the differences that may exist between them in terms of psychological factors (e.g. Beaumont, 1977; Beaumont, George and Smart, 1976; Garfinkel, Moldofsky and Garner, 1980). Robinson (1986) has recently produced a review of the various ways in which the ‘bulimic disorders’ have been described and of the ways in which the term ‘bulimia’, and related terms, have been used. One hypothesis about bulimics, as against anorexics, that has aroused interest is that they may show personality features similar to those of addicts. This is based on the fact that they have a craving to eat large quantities of food, which they find hard to control despite not wanting to gain weight (Garrow, Crisp, Jordan, Meyer, Russell, Silverstone, Stunkard and Van Itallie, 1975). In a study of 44 bulimic patients at the Maudsley Hospital, London, Feldman and Eysenck (1986) investigated this hypothesis, and found data that on the whole supported it. The bulimics were found to score much more highly on addictiveness than normals, and tended to be similar to drug addicts. The aim of the present study was to further extend this investigation. More specifically, the hypothesis to be tested was that while bulimic patients show addictive features, their anorexic counterparts do not. For this purpose, a comparison of bulimics with anorexics was undertaken. A secondary aim of the study was to explore overall personality differences between the two groups.
and Garner, 1982). Since Russell
METHOD Anorexic and bulimic patients who were referred for treatment to the Maudsley Hospital were asked to complete the Eysenck Personality Questionnaire (EPQ; Eysenck and Eysenck, 1975). This instrument measures four major personality dimensions: Psychoticism (P), Extraversion (E), Neuroticism (N) and Social Desirability (or lie score-L). In addition, the EPQ also yields a measure of addiction; an Addiction Scale, comprising thirty-two of its items, has been described by Gossop and Eysenck (1980) and Feldman and Eysenck (1986). Each of these items differentiated normal males and male drug addicts at or beyond the 0.001 level of significance. The majority of items on the Addiction Scale also differentiated between normal females and female drug addicts. Of all the anorexic patients seen, a group of 59 females (age 24.05 f 8.82) were used for this study. They all had anorexia nervosa as defined by Russell (1970). No patient with any bulimic features (binge eating, self-induced vomiting, laxative abuse) was included. This ‘pure’ anorexic group was compared with a group of 122 female bulimic patients (age 25.84 k 7.17), consisting of three sub-groups: (i) 60 bulimics (age 25.45 + 7.20) with major weight loss; (ii) 18 bulimics (age 28.50 & 8.10) with no such weight loss; and, (iii) the series of 44 bulimics (age 25.27 + 6.60) used previously in the study of Feldman and Eysenck (1986). The three sub-groups did not differ significantly in any of the measures under investigation and were therefore pooled together into one group. All the patients in this group satisfied the diagnostic criteria given by Russell (1979). Table
I.
Addiction scale means and standard anorexics. bulimics and other arows
Anorexics Bulmics Female drug addicts” Female normal control@
deviations
M
SD
n
l4.39.t 17.887 20.25 II.81
5.03 4.69 5.73 4.74
59 122 66 1546
tf-test difference between anorexics and bulimics significant level. ‘Gossop and Eysenck (1980). %ata collected by second author. 749
of
at 0.001
750
NOTES AND SHORTER COMMUNlCATlONS
Table 2. Means and standard
Anorexics Bulimic5 I-test Normals”
deviations of EPQ scores of anorexics, bulimlcs and normals
P
E
N
2.71 (2.26) 3.60 (2.76) P < 0.05 2.79C2.41)
9.71 (5.95) 10.13 (5.43) NS 12.89 (4.70)
16.63 (4.84) 19.01 (3.33) P < 0.001 12.87 14.99)
“Norms for 2&30-y%
I
~
9.29 6.40 P < 7.17
I
L
n
(4.64) (3.79) 0.001 13.85)
59 122 I366
old females, Eysenck and Eysenck (1975). RESULTS
The mean Addiction Scale scores for the two groups are presented in Table 1, together with figures for female drug addicts reported by Gossop and Eysenck (1980) and for normal controls. The mean P, E, N and L scores are given in Table 2, along with means of normal controls. The distribution of the Addiction Scale scores of the bulimic group is presented in Fig. 1, and that of normal females in Fig. 2.
15 14 13 12 11 10
1 -
:: i
89-
Lf ?6-
5432
L
1 0
2
4
6
10
B
12
14
Addiction
Fig. I. Percentage
of bulimic
patients
16 scale
18
20
22
24
26
28
30
scare
at each point
of the Addiction
Scale (N = 122).
9-
8-
7-
6-
6
8
10
12
Addiction
Fig. 2. Percentage
of normal
females
14
16
scale
at each point
18
20
22
24
26
28
30
score
of the Addiction
Scale (N = 1546)
NOTES
AND
SHORTER
COMMUNICATIONS
751
DISCUSSION The results show clear differences
between the anorexic and bulimic sub-groups of eating disorder patients. The Addiction Scale scores of the two groups were quite significantly different, with the bulimics showing higher scores as predicted. As can be seen from Table 1, their scores were almost as high as those of the drug addicts of the Gossop and Eysenck (1980) study. The distribution of their Addiction Scale scores is very different from that of normals (Figs 1 and 2). Thus the present data lend weight to the view that bulimia may best be seen as a form of addiction. That the overall personality profiles of the bulimic group (low E, high N and elevated P) tend to be similar to those of drug addicts (cf. Gossop and Eysenck, 1980) is a further pointer in this direction. The anorexics, on the other hand, showed relatively low scores on the Addiction Scale. Their mean score on this was within one standard deviation of the mean for normal females, and more than one standard deviation below the mean for female drug addicts. Thus it is clear that high Addiction Scale scores are not a feature of eating disorder per se, but peculiar to the bulimics. It is, however, interesting that the Addiction Scale scores of the anorexic group were somewhat elevated when compared to normals (see Table 1). A possible explanation of this is that this group of patients, although they are ‘pure’ anorexics in terms of current symptomatology, includes within it a certain proportion of patients who are potentially bulimic, and that it is the scores of these patients that have contributed to the higher-than-normal group means on the Addiction Scale. Many authors, including Russell (1979). have pointed out that some anorexics do end up as bulimics; in fact out of the thirty cases of bulimic patients described by Russell, seventeen had previously had anorexia nervosa. If our present explanation is correct, then those anorexics with a relatively high Addiction Scale score should be the ones most likely to become bulimics. Longitudinal and follow-up studies of anorexic patients would help to resolve this issue. It is hoped that we will be able to follow-up our present anorexic sample to see whether this prediction is supported. As for the other personality features, the elevated P of the bulimics, which fits with a typical ‘addictive’ personality cluster (see Feldman and Eysenck. 1986) is absent in the anorexic group. This is as predicted. They score significantly lower in this as well as in Neutroticism, but their Social Desirability (L) scores are higher. It has to be admitted that the higher L scores of the Anorexic group might in part be responsible for their lower N and P scores. but had dissimulation occurred to any great extent, one would have expected their group L mean to be considerably higher (see Table 2). Moreover, part of the addictive personality pattern is an ewcessivel,r low Social Desirability score and this is reflected in the Addiction Scale which includes L items. The existing literature does not offer a consistent picture with regard to general personality differences between sub-groups of eating disorder patients. For example, Beaumont (1977) compared ‘Dieters’ with ‘Vomiters and Purgers’ and found that, on the Eysenck Personality Inventory (Eysenck and Eysenck, 1964) the former but not the latter were significantly lower on extraversion than normal controls, while the L scores of both groups were similar to the controls. In our data, in addition to the finding that anorexics had high L scores, there was no significant difference between the two groups in extraversion. This is in contrast not only to Beaumont’s (1977) finding, but also to the observation of Garfinkel rr crl. (I 980). The latter authors, however, did not employ a psychometric instrument and based their conclusions on the patients’ histories. They concluded that their bulimic group were ‘more outgoing’ and ‘less isolated’ than their ‘restricting’ group (Garfinkel et al., 1980. p. 1039). Clearly, more studies with carefully differentiated patient groups are needed before a coherent picture of broad personality differences can begin to emerge. It is our belief that, since the subjects in the present study were allocated to the two groups according to very strict criteria, and since the numbers involved here were relatively large, the pattern of differences that has been found here may well form the basis of the identifying features of the two groups of patients, In conclusion, the clearest result from the present investigation is that bulimic patients tend to be similar to drug addicts in terms of their personality features whereas anorexics are, on the whole, not. The Addiction Scale particularly has shown the two groups to be different. These results further underline the need for more research using the Addiction Scale with anorexics, bulimics. drug addicts. gamblers and other clinical and non-clinical groups. If it is contirmed by further research that bulimics as a group have very different personality profiles from anorexics and that they are more like drug addicts, then there will be important implications for their management. Another promising possibility is that the EPQ in general. and the Addiction Scale in particular, may help in the early identification of those anorexics who are likely to develop bulimia. Such a development will be of considerable significance for clinical practice. AcknoM,ledRmlents-The authors wish to thank the patients for completing the questionnaires. and Professor G. F. M. Russell for encouraging the psychological investigation of patients under his care. Thanks are also due to Dr Joan Feldman for kindly agreeing to the use of some of the data collected by her in this report. and for many stimulating discussions. REFERENCES
Beaumont P. J. V. (1977) Further categorization of patients with anorexia nervosa. Ausr. N.Z. J. Psychiaf. 11, 223-226. Beaumont P. J. V., George G. C. W. and Smart D. E. (1976) “Dieters” and “Vomiters and Purgers” in anorexia nervosa. Psychoi. Med. 6, 617-627. Eysenck H. J. and Eysenck S. B. G. (1964) Manurrl qf the Eysenck Personality Imenrory. University of London Press, London. Eysenck H. J. and Eysenck S. B. G. (1975) Manual qf the E.vsenck Personuliry Quesrionnuire. Hodder and Stoughton. London. Feldman J. and Eysenck S. B. G. (1986) Addictive personality traits in bulimic patients. Person indioid. D$f 7, 923-926. Garfinkel P. E. and Garner D. M. (1982) Anorexia Neroosa: A Multidimensional Perspective. Brunner/Mazel. New York. Garfinkel P. E., Moldofsky H. and Garner D. (1980) The heterogeneity of anorexia nervosa: bulimia as a distinct sub-group. Archs Gen. Psych&. 37, 103GlO40. Garrow J. S., Crisp A. H., Jordan H. A., Meyer J. E., Russel G. F. M., Silverstone T., Stunkard A. J. and Van Itallie T. B. (1975) Pathology of eating: Group report. In Dahlem Kotzferenzen (Edited by Silverstone T.), Life Sciences Research Report, 2, Berlin. Gossop M. R. and Eysenck S. B. G. (1980) A further investigation into the personality of drug addicts in treatment. Br. J. Addict. 75, 305-31 I. Robinson P. H. (1986) The bulimic disorders. Clin. Neuropharmac. 9, 14 36. Russell G. F. M. (1970) Anorexia nervosa: its identity as an illness and its treatment. In Modern Trends in Psychological Medicine, Vol. 2. (Edited by Price J. H.). Butterworths, London. Russell G. F. M. (1979) Bulimia nervosa: an ominent variant of anorexia nervosa. P.yychol. Med. 9, 429 448.
0191-8869/87 $3.00 + 0.00 Copyright 0 1987 Pergamon Journals Ltd
1987
Printed in Great Britain, All rights reserved
Personality
and addictiveness
in anorexic
PADMAL DE SILVA
and bulimic patients
and SYBIL EYSENCK
Department of Psychology, Instirute of Psychiatry, De Crespigny Park, London SE.5 8AF, England (Received 25 September 1986) Abstract-Fifty-nine female patients with anorexia nervosa were compared with 122 bulimics on their EPQ scores and an addiction score derived from the EPQ. The bulimics scored significantly higher than the anorexics on Psychoticism and Neuroticism, and lower on Social Desirability. They also scored considerably higher on addiction, and tended to be more like drug addicts.
INTRODUCTION The existence of different
sub-groups
of patients with eating disorder has been fully recognized in recent years (e.g. Garfinkel (1979) described a group of patients with ‘bulimia nervosa’, it has been widely acknowledged that this is an important and not uncommon variant of anorexia nervosa. While the diagnostic criteria for anorexia nervosa are generally agreed to be (i) self-induced weight loss, (ii) persistent amenorrhoea and (iii) a psychopathology characterized by a dread of losing control of eating and thus becoming fat (Russell, 1970), bulimia nervosa has been defined as marked by an irresistable urge to overeat, followed by self-induced vomiting or purging, along with a morbid fear of becoming fat (Russell, 1979). Despite these criteria, however, the literature is not consistent in the way these groups of patients are differentiated from each other, leading to difficulty in drawing general conclusions about the differences that may exist between them in terms of psychological factors (e.g. Beaumont, 1977; Beaumont, George and Smart, 1976; Garfinkel, Moldofsky and Garner, 1980). Robinson (1986) has recently produced a review of the various ways in which the ‘bulimic disorders’ have been described and of the ways in which the term ‘bulimia’, and related terms, have been used. One hypothesis about bulimics, as against anorexics, that has aroused interest is that they may show personality features similar to those of addicts. This is based on the fact that they have a craving to eat large quantities of food, which they find hard to control despite not wanting to gain weight (Garrow, Crisp, Jordan, Meyer, Russell, Silverstone, Stunkard and Van Itallie, 1975). In a study of 44 bulimic patients at the Maudsley Hospital, London, Feldman and Eysenck (1986) investigated this hypothesis, and found data that on the whole supported it. The bulimics were found to score much more highly on addictiveness than normals, and tended to be similar to drug addicts. The aim of the present study was to further extend this investigation. More specifically, the hypothesis to be tested was that while bulimic patients show addictive features, their anorexic counterparts do not. For this purpose, a comparison of bulimics with anorexics was undertaken. A secondary aim of the study was to explore overall personality differences between the two groups.
and Garner, 1982). Since Russell
METHOD Anorexic and bulimic patients who were referred for treatment to the Maudsley Hospital were asked to complete the Eysenck Personality Questionnaire (EPQ; Eysenck and Eysenck, 1975). This instrument measures four major personality dimensions: Psychoticism (P), Extraversion (E), Neuroticism (N) and Social Desirability (or lie score-L). In addition, the EPQ also yields a measure of addiction; an Addiction Scale, comprising thirty-two of its items, has been described by Gossop and Eysenck (1980) and Feldman and Eysenck (1986). Each of these items differentiated normal males and male drug addicts at or beyond the 0.001 level of significance. The majority of items on the Addiction Scale also differentiated between normal females and female drug addicts. Of all the anorexic patients seen, a group of 59 females (age 24.05 f 8.82) were used for this study. They all had anorexia nervosa as defined by Russell (1970). No patient with any bulimic features (binge eating, self-induced vomiting, laxative abuse) was included. This ‘pure’ anorexic group was compared with a group of 122 female bulimic patients (age 25.84 k 7.17), consisting of three sub-groups: (i) 60 bulimics (age 25.45 + 7.20) with major weight loss; (ii) 18 bulimics (age 28.50 & 8.10) with no such weight loss; and, (iii) the series of 44 bulimics (age 25.27 + 6.60) used previously in the study of Feldman and Eysenck (1986). The three sub-groups did not differ significantly in any of the measures under investigation and were therefore pooled together into one group. All the patients in this group satisfied the diagnostic criteria given by Russell (1979). Table
I.
Addiction scale means and standard anorexics. bulimics and other arows
Anorexics Bulmics Female drug addicts” Female normal control@
deviations
M
SD
n
l4.39.t 17.887 20.25 II.81
5.03 4.69 5.73 4.74
59 122 66 1546
tf-test difference between anorexics and bulimics significant level. ‘Gossop and Eysenck (1980). %ata collected by second author. 749
of
at 0.001
750
NOTES AND SHORTER COMMUNlCATlONS
Table 2. Means and standard
Anorexics Bulimic5 I-test Normals”
deviations of EPQ scores of anorexics, bulimlcs and normals
P
E
N
2.71 (2.26) 3.60 (2.76) P < 0.05 2.79C2.41)
9.71 (5.95) 10.13 (5.43) NS 12.89 (4.70)
16.63 (4.84) 19.01 (3.33) P < 0.001 12.87 14.99)
“Norms for 2&30-y%
I
~
9.29 6.40 P < 7.17
I
L
n
(4.64) (3.79) 0.001 13.85)
59 122 I366
old females, Eysenck and Eysenck (1975). RESULTS
The mean Addiction Scale scores for the two groups are presented in Table 1, together with figures for female drug addicts reported by Gossop and Eysenck (1980) and for normal controls. The mean P, E, N and L scores are given in Table 2, along with means of normal controls. The distribution of the Addiction Scale scores of the bulimic group is presented in Fig. 1, and that of normal females in Fig. 2.
15 14 13 12 11 10
1 -
:: i
89-
Lf ?6-
5432
L
1 0
2
4
6
10
B
12
14
Addiction
Fig. I. Percentage
of bulimic
patients
16 scale
18
20
22
24
26
28
30
scare
at each point
of the Addiction
Scale (N = 122).
9-
8-
7-
6-
6
8
10
12
Addiction
Fig. 2. Percentage
of normal
females
14
16
scale
at each point
18
20
22
24
26
28
30
score
of the Addiction
Scale (N = 1546)
NOTES
AND
SHORTER
COMMUNICATIONS
751
DISCUSSION The results show clear differences
between the anorexic and bulimic sub-groups of eating disorder patients. The Addiction Scale scores of the two groups were quite significantly different, with the bulimics showing higher scores as predicted. As can be seen from Table 1, their scores were almost as high as those of the drug addicts of the Gossop and Eysenck (1980) study. The distribution of their Addiction Scale scores is very different from that of normals (Figs 1 and 2). Thus the present data lend weight to the view that bulimia may best be seen as a form of addiction. That the overall personality profiles of the bulimic group (low E, high N and elevated P) tend to be similar to those of drug addicts (cf. Gossop and Eysenck, 1980) is a further pointer in this direction. The anorexics, on the other hand, showed relatively low scores on the Addiction Scale. Their mean score on this was within one standard deviation of the mean for normal females, and more than one standard deviation below the mean for female drug addicts. Thus it is clear that high Addiction Scale scores are not a feature of eating disorder per se, but peculiar to the bulimics. It is, however, interesting that the Addiction Scale scores of the anorexic group were somewhat elevated when compared to normals (see Table 1). A possible explanation of this is that this group of patients, although they are ‘pure’ anorexics in terms of current symptomatology, includes within it a certain proportion of patients who are potentially bulimic, and that it is the scores of these patients that have contributed to the higher-than-normal group means on the Addiction Scale. Many authors, including Russell (1979). have pointed out that some anorexics do end up as bulimics; in fact out of the thirty cases of bulimic patients described by Russell, seventeen had previously had anorexia nervosa. If our present explanation is correct, then those anorexics with a relatively high Addiction Scale score should be the ones most likely to become bulimics. Longitudinal and follow-up studies of anorexic patients would help to resolve this issue. It is hoped that we will be able to follow-up our present anorexic sample to see whether this prediction is supported. As for the other personality features, the elevated P of the bulimics, which fits with a typical ‘addictive’ personality cluster (see Feldman and Eysenck. 1986) is absent in the anorexic group. This is as predicted. They score significantly lower in this as well as in Neutroticism, but their Social Desirability (L) scores are higher. It has to be admitted that the higher L scores of the Anorexic group might in part be responsible for their lower N and P scores. but had dissimulation occurred to any great extent, one would have expected their group L mean to be considerably higher (see Table 2). Moreover, part of the addictive personality pattern is an ewcessivel,r low Social Desirability score and this is reflected in the Addiction Scale which includes L items. The existing literature does not offer a consistent picture with regard to general personality differences between sub-groups of eating disorder patients. For example, Beaumont (1977) compared ‘Dieters’ with ‘Vomiters and Purgers’ and found that, on the Eysenck Personality Inventory (Eysenck and Eysenck, 1964) the former but not the latter were significantly lower on extraversion than normal controls, while the L scores of both groups were similar to the controls. In our data, in addition to the finding that anorexics had high L scores, there was no significant difference between the two groups in extraversion. This is in contrast not only to Beaumont’s (1977) finding, but also to the observation of Garfinkel rr crl. (I 980). The latter authors, however, did not employ a psychometric instrument and based their conclusions on the patients’ histories. They concluded that their bulimic group were ‘more outgoing’ and ‘less isolated’ than their ‘restricting’ group (Garfinkel et al., 1980. p. 1039). Clearly, more studies with carefully differentiated patient groups are needed before a coherent picture of broad personality differences can begin to emerge. It is our belief that, since the subjects in the present study were allocated to the two groups according to very strict criteria, and since the numbers involved here were relatively large, the pattern of differences that has been found here may well form the basis of the identifying features of the two groups of patients, In conclusion, the clearest result from the present investigation is that bulimic patients tend to be similar to drug addicts in terms of their personality features whereas anorexics are, on the whole, not. The Addiction Scale particularly has shown the two groups to be different. These results further underline the need for more research using the Addiction Scale with anorexics, bulimics. drug addicts. gamblers and other clinical and non-clinical groups. If it is contirmed by further research that bulimics as a group have very different personality profiles from anorexics and that they are more like drug addicts, then there will be important implications for their management. Another promising possibility is that the EPQ in general. and the Addiction Scale in particular, may help in the early identification of those anorexics who are likely to develop bulimia. Such a development will be of considerable significance for clinical practice. AcknoM,ledRmlents-The authors wish to thank the patients for completing the questionnaires. and Professor G. F. M. Russell for encouraging the psychological investigation of patients under his care. Thanks are also due to Dr Joan Feldman for kindly agreeing to the use of some of the data collected by her in this report. and for many stimulating discussions. REFERENCES
Beaumont P. J. V. (1977) Further categorization of patients with anorexia nervosa. Ausr. N.Z. J. Psychiaf. 11, 223-226. Beaumont P. J. V., George G. C. W. and Smart D. E. (1976) “Dieters” and “Vomiters and Purgers” in anorexia nervosa. Psychoi. Med. 6, 617-627. Eysenck H. J. and Eysenck S. B. G. (1964) Manurrl qf the Eysenck Personality Imenrory. University of London Press, London. Eysenck H. J. and Eysenck S. B. G. (1975) Manual qf the E.vsenck Personuliry Quesrionnuire. Hodder and Stoughton. London. Feldman J. and Eysenck S. B. G. (1986) Addictive personality traits in bulimic patients. Person indioid. D$f 7, 923-926. Garfinkel P. E. and Garner D. M. (1982) Anorexia Neroosa: A Multidimensional Perspective. Brunner/Mazel. New York. Garfinkel P. E., Moldofsky H. and Garner D. (1980) The heterogeneity of anorexia nervosa: bulimia as a distinct sub-group. Archs Gen. Psych&. 37, 103GlO40. Garrow J. S., Crisp A. H., Jordan H. A., Meyer J. E., Russel G. F. M., Silverstone T., Stunkard A. J. and Van Itallie T. B. (1975) Pathology of eating: Group report. In Dahlem Kotzferenzen (Edited by Silverstone T.), Life Sciences Research Report, 2, Berlin. Gossop M. R. and Eysenck S. B. G. (1980) A further investigation into the personality of drug addicts in treatment. Br. J. Addict. 75, 305-31 I. Robinson P. H. (1986) The bulimic disorders. Clin. Neuropharmac. 9, 14 36. Russell G. F. M. (1970) Anorexia nervosa: its identity as an illness and its treatment. In Modern Trends in Psychological Medicine, Vol. 2. (Edited by Price J. H.). Butterworths, London. Russell G. F. M. (1979) Bulimia nervosa: an ominent variant of anorexia nervosa. P.yychol. Med. 9, 429 448.