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Psychological correlates of weight gain in patients with anorexia nervosa
J. psychrar. Res.. Vol. 19, No. 213. PP. 267-271, Printed in Great Britam
0022-3956/U 53.W+ 40 Pcrgamon Press Ltd.
1985
PSYCHOLOGICAL CORRELATES OF WEIGHT GAIN IN PATIENTS WITH ANOREXIA NERVOSA S. CHANNON and W. P. DESILVA Departmentof Psychology,Institute of Psychiatry, London Summary-Self-report measures of desiredweight, eating attitudes, depressive mood and obsessional symptoms were obtained for anorexicpatientsupon admission to hospital, discharge and 1 yr follow-up. Eating attitudes and depressed mood were significantly improved at discharge and follow-up, but still remained within the clinical rather than the normal range. Severity of abnormal eating attitudes upon discharge was the main psychological factor significantly correlated with degree of weight maintenance at follow-up.
INTRODUCTION A NUMBERof studies (e.g. GARNER and GARFINKEL, 1979; ECKERTet al., 1982; SOLYOM et al., 1982) have investigated psychological factors associated with anorexia nervosa such as disturbed attitudes to eating and body size, depressive and obsessional symptoms, and there is some evidence that these disturbances are less common at follow-up in patients who are weight recovered. Weight restoration in hospital has been successfully achieved by a variety of methods. However, RUSSELL(1981) pointed out that short-term weight restoration alone is essential but insufficient to ensure long-term improvement. The present study aimed to investigate the relationship between psychological factors and weight restoration, since these factors might play an important part in recovery from anorexia nervosa. The study focused on a hospital weight restoration programme known to be effective in producing short-term weight gain with anorexic patients (RUSSELL, 1981). Three main questions were addressed: (1) Does hospitalization bring about changes in selected psychological variables in addition to weight gain? (2) Are the psychological changes achieved in hospital maintained at follow-up? (3) Do these psychological factors relate to weight maintenance at follow-up? In addition, we examined whether basic patient characteristics were related to weight maintenance at follow-up. METHOD Subjects
A series of 45 patients (42 female, 3 male) formed the basis of the study. The mean age was 21 yr (SD = 6, range 14-45 yr). The mean duration of illness was 3.6 yr (SD = 6.9, range O-l 1 yr). These comprised all those who entered the standard ward treatment programme for anorexia nervosa at the Maudsley Hospital during the 2.5 yr period of data collection. They all had: (a) diagnosis of anorexia nervosa or anorexia nervosa with bulimia nervosa; and (b) a hospital stay of at least one month’s duration. 267
268
S.
CHANNON
-\ND
W. P.
DESILV-\
Measures
(1) Body weight; (2) Patients’ desired weight, i.e. the weight subjects personally wanted to be, rather than medically desirable weights; (3) Eating Attitudes Test, EAT-40 (GARNER and GARFINKEL, 1979); a self-report questionnaire to measure attitudes to food and eating habits, dieting and body size. (4) Wakefield Depression Inventory (SNAITH ef al., 1971). This self-report questionnaire was designed to measure depressive mood. It has a maximum score of 36, and depressed patients were reported to score 14 or above on this scale; (5) Maudsley Obsessional-Compulsive Inventory, MOCI (HODGSON and RACHMAN, 1977). This is a self-report questionnaire designed to measure obsessional symptoms. The maximum score on the MOCI is 30. The mean for obsessional patients was reported to be 18.9 (SD 4.92), whilst the mean for neurotic non-obsessional patients was 9.3 (SD 5.43). Procedure
A repeated measures design was used where each subject filled out the standard set of self-report questionnaires upon admission, then every lo-12 days throughout hospitalization, at discharge, and again at one year follow-up. Height and weight data were collected from the nursing charts. Patient characteristics such as age and previous psychiatric history were collected from the case-notes. All patients were being treated by the ward programme described in detail by RUSSELL (1977). Patients were normally hospitalized for a period of 6-12 weeks, and were then usually seen as outpatients for a year after discharge. RESULTS Upon admission and discharge a full set of data was obtained for each of the 45 patients. Weight data at follow-up have so far been collected for 34 of the 45 patients. Ten patients have not yet been discharged for a full year, and consequently it is not possible to present full data for the group at this time, and one patient totally refused to co-operate at followup. Of the 34 patients for whom weight data were obtained, four did not wish to fill out a further set of questionnaires, so that data are missing in a few cases. The follow-up occasion was taken to be one year after discharge except in cases where patients lost so much weight that they had to be readmitted to hospital before the end of a year. There were 8 (23.5%) such cases. In these cases data were collected at the time of readmission. (Maintaining the “one-year” criteria for these cases would have been misleading since follow-up weight would have appeared artificially high after further periods of weight restoration in hospital.) The present analysis covers only the data obtained at admission, discharge and followup. The measures taken every lo-12 days are not reported here. In order to standardize weight data for subjects of different heights, all raw weight data were calculated as percentages of average weight using the Metropolitan Life Insurance (1959) weight-forheight tables. Means and standard deviations for weight and the other variables are given in Table 1.
CORRELATES OF
WEIGHT GAIN
269
TABLE 1. MEANS ANDS~ANDARDDEV~AT~ONSUPONADMISSION.D~SCHARGEANDFOLLOW-UP FOREACHOFTHEVARIABLES
Admission (n = 45) Mean SD Average weight (%I) Raw weight (kg) Desired weight (kg) EAT-40 Wakefield MOCI
67.1 38.2 46.8 60.8 22.5 9.9
(8.09) (5.34) (7.25) (24.34) (6.06) (7.08)
Discharge (n = 45) Mean SD 91.9 52.4 49.9 39.2 14.7 7.7
(7.09) (6.32) (6.77) (29.85) (8.45) (7.22)
Follow-up (n = 30y Mean SD 80.3 45.5 47.9 39.7 16.1 7.9
(17.31) (9.97) (8.48) (30.98) (11.75) (7.47)
* For weight, n = 34.
In order to compare findings at admission, discharge and follow-up, a series of multivariate F tests were performed on the data. Paired comparisons of each two occasions for each variable showed highly significant differences between occasions for percentage average weight, patients’ desired weight, EAT-40 and Wakefield scores. For the MOCI there was no significant difference between occasions (Table 2).
TABLE~.SIGNIFICANCELEVELSOFSINGLEDEGREEOFFREEM)MFTESTSFORDIFFERENCESINEACH PAIROFMEANSATADMISSION (ADM) DlSCHARGE(DIS)ANDFOLLOW-UP (FU) FOREACHOFTHE VARIABLES*
Average weight (‘J7o) Desired weight EAT-40 Wakefield MOCl
ADM vs DIS
DIS vs FU
ADM vs FU
p = 0.0001 p = o.ooo3 p = 0.0011 p = 0.0001 NS
p = 0.0001
p = O.oool
*Since 15 tests were performed,
NS NS NS NS
NS
p = 0.0029 NS NS
0.05 a significance level of x (0.003), was used as the
criterion, rather than 0.05)
Weight was found to change significantly over the three occasions. Separate tests on each pair of occasions showed that mean weight was significantly higher at discharge from hospital than at admission. At follow-up it had decreased significantly again, but still remained significantly higher than upon admission to hospital. Patients’ desired weight also changed significantly over the three occasions. Mean desired weight was significantly higher at discharge than admission, but dropped significantly again at follow-up and did not differ significantly from admission desired weight. The mean eating attitude (EAT-40) and Wakefield depression scores changed significantly over the three occasions. For both variables, discharge and follow-up scores were significantly improved when compared to the admission scores. Scores on the obsessional scale (MOCI) did not change significantly from admission to follow-up.
270
S. CHANNON
AND W. P. DESILVA
Variables predicting follow-up weight In order to do a regression analysis to predict percentage of average weight at follow-up, the variables which might be related to this were examined. These included both psychological variables and patient characteristic. If a large number of variables were used simultaneously in the regression analysis, the results would be unreliable with a small sample size. The method used to reduce the number was simply to select those with significant univariate correlations with the dependent variable, weight. The only psychological variables which correlated significantly with follow-up weight were EAT-40 (r - 0.409, p < O.Ol), and patients’ desired weight on discharge (r + 0.373, p < 0.05). Several demographic variables also correlated significantly with follow-up weight: discharge weight (r + 0.558, p < O.OOl), severity of weight loss upon admission (r + 0.328,~ c 0.05) number of months of previous hospitalization (r - 0.407, p < 0.01) and duration of illness (r - 0.298, p < 0.05). The other psychological variables (patients’ desired weight on admission, EAT-40 on admission, Wakefield on admission or discharge, and MOCI on admission or discharge) did not correlate significantly with follow-up weight. Neither did age at onset nor presence of bulimic features. A stepwise multiple regression analysis was then performed using follow-up weight as the dependent variable, and the six variables which correlated significantly with this as the independent variables. The results are given in Table 3. As can be seen, a combination of three variables, EAT-4Oscores on discharge, admission weight, and duration of illness gave the best prediction of follow-up weight. The remaining three variables did not contribute significantly to the equation.
TABLE
3. REGRESSION COEFFICIENTS WHICH GAVE THE BEST PREDICTION OF FOLLOW-UP WEIGHT
Variable
Regression coefficients
EAT-40 on discharge
- 0.29435
Duration of illness (Constant) weight Admission
- I .56924 21.65840 1.14425
Multiple R 0.674
1
DISCUSSION
The findings show that hospitalization was successful in producing short-term weight restoration to near-average weights. In the sample followed up so far, 23% relapsed and had to be readmitted to hospital, whilst the remainder had maintained their weight at least to some extent at one year follow-up. Upon admission to hospital the patients scored in the anorexic range on the EAT-40, and in the depressive range on the Wakefield scale. Unlike those in the study by SOLYOM et al. (1982) where anorexic patients could not be distinguished from obsessional patients on the Leyton scale, patients in the current study had scores similar to neurotic non-obsessional patients on the MOCI scale.
CORRELATES OF WEIGHT GAIN
271
Other authors (GARNER and GARFINKEL, 1979; ECKERT ef ul., 1982) found significant improvements for anorexic patients in eating attitudes and depressive symptoms after treatment, and this also held true for the present study. However, although these improvements were statistically significant, mean scores at follow-up were still within the clinical range rather than the normal range. Patients’ desired weights were still lower than average weights at follow-up. Previous studies (e.g. HSU, 1980) have shown that short-term weight restoration is insufficient to ensure later adjustment and long-term maintenance of weight, and the present finding of a 23% relapse rate within one year was in line with this conclusion. Patient characteristics such as older age at onset, previous admission to psychiatric hospitals, longer duration of illness and severity of weight loss have been suggested by other authors (e.g. Hsu, 1980; GARNER and GARFINKEL, 1982) to be related to unfavourable outcome. At least two of these variables, duration of illness and severity of emaciation, appeared to be related to follow-up weight maintenance in the present study. Whilst findings from a small sample using self-report measures of psychological variables with relatively short follow-up can only be stated tentatively, this study suggests that improvement in eating attitudes may also be an important factor in determining outcome. Discharge decisions tend to be based on adequate weight restoration and maintenance whilst in hospital. Since in this study there was no significant correlation between changes in psychological factors and changes in weight, perhaps we should look at both of these areas in our assessment of progress. It is possible that if greater psychological change could be effected during treatment, this would increase the chances of long-term weight maintenance. Acknowledgement-The
authors are grateful to the Bethlem-Maudsley
Research Fund for supporting
this
research. REFERENCES ECKERT,E. D., GOLDBERG,S. C., HALMI, K. A., CASPER,R. C. and DAVIS,J. M. (1982) Depression in anorexia nervosa. Psycho/. Med. 12, 115-127. GARFINKEL,P. E. and GARNER,D. M. (1982) Anorexia Nervosa: A Multi-dimensional Perspective. Brurmer/ Mazel, New York. GARNER,D. M. and GARFINKEL,P. E. (1979) The Eating Attitudes Test: an index of the symptoms of anorexia nervosa. Psychol. Med. 9, 273-279. HODGSON,R. J. and RACHMAN,S. (1977) Obsessional compulsive complaints. Behav. Res. Ther. 15,389-395. Hsu, L. K. G. (1980) Outcome of anorexia nervosa. A review of the literature (1954-1978). Archsgen. Psychiat. 37, 1041-1046. RUSSELL,G. F. M. (1977) General management of anorexia nervosa and difficulties in assessing the efficacy of treatment. In Anorexia Nervosa (Edited by VIGERSKY,R. ), pp. 277-289. Raven Press, New York. RUSSELL,G. F. M. (1981) The current treatment of anorexia nervosa. Br. J. Psychiat. 138, 164-166. SNAITH, R. P., AHMED, S. N., MEHTA, S. and HAMILTON,M. (1971) Assessment of the severity of primary depressive illness. The Wakefield self-assessment depression inventory. Psycho/. Med. 1, 143-149. SOLYOM, L., FREEMAN,R. J. and MILES, J. E. (1982) A comparative psychometric study of anorexia nervosa and obsessive neurosis. Can. J. Psychiat. 27, 282-286.
0022-3956/U 53.W+ 40 Pcrgamon Press Ltd.
1985
PSYCHOLOGICAL CORRELATES OF WEIGHT GAIN IN PATIENTS WITH ANOREXIA NERVOSA S. CHANNON and W. P. DESILVA Departmentof Psychology,Institute of Psychiatry, London Summary-Self-report measures of desiredweight, eating attitudes, depressive mood and obsessional symptoms were obtained for anorexicpatientsupon admission to hospital, discharge and 1 yr follow-up. Eating attitudes and depressed mood were significantly improved at discharge and follow-up, but still remained within the clinical rather than the normal range. Severity of abnormal eating attitudes upon discharge was the main psychological factor significantly correlated with degree of weight maintenance at follow-up.
INTRODUCTION A NUMBERof studies (e.g. GARNER and GARFINKEL, 1979; ECKERTet al., 1982; SOLYOM et al., 1982) have investigated psychological factors associated with anorexia nervosa such as disturbed attitudes to eating and body size, depressive and obsessional symptoms, and there is some evidence that these disturbances are less common at follow-up in patients who are weight recovered. Weight restoration in hospital has been successfully achieved by a variety of methods. However, RUSSELL(1981) pointed out that short-term weight restoration alone is essential but insufficient to ensure long-term improvement. The present study aimed to investigate the relationship between psychological factors and weight restoration, since these factors might play an important part in recovery from anorexia nervosa. The study focused on a hospital weight restoration programme known to be effective in producing short-term weight gain with anorexic patients (RUSSELL, 1981). Three main questions were addressed: (1) Does hospitalization bring about changes in selected psychological variables in addition to weight gain? (2) Are the psychological changes achieved in hospital maintained at follow-up? (3) Do these psychological factors relate to weight maintenance at follow-up? In addition, we examined whether basic patient characteristics were related to weight maintenance at follow-up. METHOD Subjects
A series of 45 patients (42 female, 3 male) formed the basis of the study. The mean age was 21 yr (SD = 6, range 14-45 yr). The mean duration of illness was 3.6 yr (SD = 6.9, range O-l 1 yr). These comprised all those who entered the standard ward treatment programme for anorexia nervosa at the Maudsley Hospital during the 2.5 yr period of data collection. They all had: (a) diagnosis of anorexia nervosa or anorexia nervosa with bulimia nervosa; and (b) a hospital stay of at least one month’s duration. 267
268
S.
CHANNON
-\ND
W. P.
DESILV-\
Measures
(1) Body weight; (2) Patients’ desired weight, i.e. the weight subjects personally wanted to be, rather than medically desirable weights; (3) Eating Attitudes Test, EAT-40 (GARNER and GARFINKEL, 1979); a self-report questionnaire to measure attitudes to food and eating habits, dieting and body size. (4) Wakefield Depression Inventory (SNAITH ef al., 1971). This self-report questionnaire was designed to measure depressive mood. It has a maximum score of 36, and depressed patients were reported to score 14 or above on this scale; (5) Maudsley Obsessional-Compulsive Inventory, MOCI (HODGSON and RACHMAN, 1977). This is a self-report questionnaire designed to measure obsessional symptoms. The maximum score on the MOCI is 30. The mean for obsessional patients was reported to be 18.9 (SD 4.92), whilst the mean for neurotic non-obsessional patients was 9.3 (SD 5.43). Procedure
A repeated measures design was used where each subject filled out the standard set of self-report questionnaires upon admission, then every lo-12 days throughout hospitalization, at discharge, and again at one year follow-up. Height and weight data were collected from the nursing charts. Patient characteristics such as age and previous psychiatric history were collected from the case-notes. All patients were being treated by the ward programme described in detail by RUSSELL (1977). Patients were normally hospitalized for a period of 6-12 weeks, and were then usually seen as outpatients for a year after discharge. RESULTS Upon admission and discharge a full set of data was obtained for each of the 45 patients. Weight data at follow-up have so far been collected for 34 of the 45 patients. Ten patients have not yet been discharged for a full year, and consequently it is not possible to present full data for the group at this time, and one patient totally refused to co-operate at followup. Of the 34 patients for whom weight data were obtained, four did not wish to fill out a further set of questionnaires, so that data are missing in a few cases. The follow-up occasion was taken to be one year after discharge except in cases where patients lost so much weight that they had to be readmitted to hospital before the end of a year. There were 8 (23.5%) such cases. In these cases data were collected at the time of readmission. (Maintaining the “one-year” criteria for these cases would have been misleading since follow-up weight would have appeared artificially high after further periods of weight restoration in hospital.) The present analysis covers only the data obtained at admission, discharge and followup. The measures taken every lo-12 days are not reported here. In order to standardize weight data for subjects of different heights, all raw weight data were calculated as percentages of average weight using the Metropolitan Life Insurance (1959) weight-forheight tables. Means and standard deviations for weight and the other variables are given in Table 1.
CORRELATES OF
WEIGHT GAIN
269
TABLE 1. MEANS ANDS~ANDARDDEV~AT~ONSUPONADMISSION.D~SCHARGEANDFOLLOW-UP FOREACHOFTHEVARIABLES
Admission (n = 45) Mean SD Average weight (%I) Raw weight (kg) Desired weight (kg) EAT-40 Wakefield MOCI
67.1 38.2 46.8 60.8 22.5 9.9
(8.09) (5.34) (7.25) (24.34) (6.06) (7.08)
Discharge (n = 45) Mean SD 91.9 52.4 49.9 39.2 14.7 7.7
(7.09) (6.32) (6.77) (29.85) (8.45) (7.22)
Follow-up (n = 30y Mean SD 80.3 45.5 47.9 39.7 16.1 7.9
(17.31) (9.97) (8.48) (30.98) (11.75) (7.47)
* For weight, n = 34.
In order to compare findings at admission, discharge and follow-up, a series of multivariate F tests were performed on the data. Paired comparisons of each two occasions for each variable showed highly significant differences between occasions for percentage average weight, patients’ desired weight, EAT-40 and Wakefield scores. For the MOCI there was no significant difference between occasions (Table 2).
TABLE~.SIGNIFICANCELEVELSOFSINGLEDEGREEOFFREEM)MFTESTSFORDIFFERENCESINEACH PAIROFMEANSATADMISSION (ADM) DlSCHARGE(DIS)ANDFOLLOW-UP (FU) FOREACHOFTHE VARIABLES*
Average weight (‘J7o) Desired weight EAT-40 Wakefield MOCl
ADM vs DIS
DIS vs FU
ADM vs FU
p = 0.0001 p = o.ooo3 p = 0.0011 p = 0.0001 NS
p = 0.0001
p = O.oool
*Since 15 tests were performed,
NS NS NS NS
NS
p = 0.0029 NS NS
0.05 a significance level of x (0.003), was used as the
criterion, rather than 0.05)
Weight was found to change significantly over the three occasions. Separate tests on each pair of occasions showed that mean weight was significantly higher at discharge from hospital than at admission. At follow-up it had decreased significantly again, but still remained significantly higher than upon admission to hospital. Patients’ desired weight also changed significantly over the three occasions. Mean desired weight was significantly higher at discharge than admission, but dropped significantly again at follow-up and did not differ significantly from admission desired weight. The mean eating attitude (EAT-40) and Wakefield depression scores changed significantly over the three occasions. For both variables, discharge and follow-up scores were significantly improved when compared to the admission scores. Scores on the obsessional scale (MOCI) did not change significantly from admission to follow-up.
270
S. CHANNON
AND W. P. DESILVA
Variables predicting follow-up weight In order to do a regression analysis to predict percentage of average weight at follow-up, the variables which might be related to this were examined. These included both psychological variables and patient characteristic. If a large number of variables were used simultaneously in the regression analysis, the results would be unreliable with a small sample size. The method used to reduce the number was simply to select those with significant univariate correlations with the dependent variable, weight. The only psychological variables which correlated significantly with follow-up weight were EAT-40 (r - 0.409, p < O.Ol), and patients’ desired weight on discharge (r + 0.373, p < 0.05). Several demographic variables also correlated significantly with follow-up weight: discharge weight (r + 0.558, p < O.OOl), severity of weight loss upon admission (r + 0.328,~ c 0.05) number of months of previous hospitalization (r - 0.407, p < 0.01) and duration of illness (r - 0.298, p < 0.05). The other psychological variables (patients’ desired weight on admission, EAT-40 on admission, Wakefield on admission or discharge, and MOCI on admission or discharge) did not correlate significantly with follow-up weight. Neither did age at onset nor presence of bulimic features. A stepwise multiple regression analysis was then performed using follow-up weight as the dependent variable, and the six variables which correlated significantly with this as the independent variables. The results are given in Table 3. As can be seen, a combination of three variables, EAT-4Oscores on discharge, admission weight, and duration of illness gave the best prediction of follow-up weight. The remaining three variables did not contribute significantly to the equation.
TABLE
3. REGRESSION COEFFICIENTS WHICH GAVE THE BEST PREDICTION OF FOLLOW-UP WEIGHT
Variable
Regression coefficients
EAT-40 on discharge
- 0.29435
Duration of illness (Constant) weight Admission
- I .56924 21.65840 1.14425
Multiple R 0.674
1
DISCUSSION
The findings show that hospitalization was successful in producing short-term weight restoration to near-average weights. In the sample followed up so far, 23% relapsed and had to be readmitted to hospital, whilst the remainder had maintained their weight at least to some extent at one year follow-up. Upon admission to hospital the patients scored in the anorexic range on the EAT-40, and in the depressive range on the Wakefield scale. Unlike those in the study by SOLYOM et al. (1982) where anorexic patients could not be distinguished from obsessional patients on the Leyton scale, patients in the current study had scores similar to neurotic non-obsessional patients on the MOCI scale.
CORRELATES OF WEIGHT GAIN
271
Other authors (GARNER and GARFINKEL, 1979; ECKERT ef ul., 1982) found significant improvements for anorexic patients in eating attitudes and depressive symptoms after treatment, and this also held true for the present study. However, although these improvements were statistically significant, mean scores at follow-up were still within the clinical range rather than the normal range. Patients’ desired weights were still lower than average weights at follow-up. Previous studies (e.g. HSU, 1980) have shown that short-term weight restoration is insufficient to ensure later adjustment and long-term maintenance of weight, and the present finding of a 23% relapse rate within one year was in line with this conclusion. Patient characteristics such as older age at onset, previous admission to psychiatric hospitals, longer duration of illness and severity of weight loss have been suggested by other authors (e.g. Hsu, 1980; GARNER and GARFINKEL, 1982) to be related to unfavourable outcome. At least two of these variables, duration of illness and severity of emaciation, appeared to be related to follow-up weight maintenance in the present study. Whilst findings from a small sample using self-report measures of psychological variables with relatively short follow-up can only be stated tentatively, this study suggests that improvement in eating attitudes may also be an important factor in determining outcome. Discharge decisions tend to be based on adequate weight restoration and maintenance whilst in hospital. Since in this study there was no significant correlation between changes in psychological factors and changes in weight, perhaps we should look at both of these areas in our assessment of progress. It is possible that if greater psychological change could be effected during treatment, this would increase the chances of long-term weight maintenance. Acknowledgement-The
authors are grateful to the Bethlem-Maudsley
Research Fund for supporting
this
research. REFERENCES ECKERT,E. D., GOLDBERG,S. C., HALMI, K. A., CASPER,R. C. and DAVIS,J. M. (1982) Depression in anorexia nervosa. Psycho/. Med. 12, 115-127. GARFINKEL,P. E. and GARNER,D. M. (1982) Anorexia Nervosa: A Multi-dimensional Perspective. Brurmer/ Mazel, New York. GARNER,D. M. and GARFINKEL,P. E. (1979) The Eating Attitudes Test: an index of the symptoms of anorexia nervosa. Psychol. Med. 9, 273-279. HODGSON,R. J. and RACHMAN,S. (1977) Obsessional compulsive complaints. Behav. Res. Ther. 15,389-395. Hsu, L. K. G. (1980) Outcome of anorexia nervosa. A review of the literature (1954-1978). Archsgen. Psychiat. 37, 1041-1046. RUSSELL,G. F. M. (1977) General management of anorexia nervosa and difficulties in assessing the efficacy of treatment. In Anorexia Nervosa (Edited by VIGERSKY,R. ), pp. 277-289. Raven Press, New York. RUSSELL,G. F. M. (1981) The current treatment of anorexia nervosa. Br. J. Psychiat. 138, 164-166. SNAITH, R. P., AHMED, S. N., MEHTA, S. and HAMILTON,M. (1971) Assessment of the severity of primary depressive illness. The Wakefield self-assessment depression inventory. Psycho/. Med. 1, 143-149. SOLYOM, L., FREEMAN,R. J. and MILES, J. E. (1982) A comparative psychometric study of anorexia nervosa and obsessive neurosis. Can. J. Psychiat. 27, 282-286.