In response to:
The Starved Self from the February 22, 1979 issue
To the Editors:
Rosemary Dinnage’s article “The Starved Self” sweepingly consigns all the possible pathophysiological etiologies of anorexia nervosa to a historical wastebasket. She says, “The authors under review, however, are representative of current thinking in treating the syndrome as entirely psychological.” The case is not so simple. Kelly M. Bemis after an exhaustive review of the literature in Psychological Bulletin (1978, Vol. 85, No. 3, p. 611) about possible primary organic etiologies of anorexia concludes, “At the present stage of understanding, it is impossible to classify anorexia nervosa definitively as a functional or organic disorder, and continued investigation in, both areas is clearly imperative.” Bemis, when pressed for an opinion about current thinking, tows a middle line, arguing that it is likely a constitutional vulnerability may predispose to development of anorexia when the individual becomes exposed to environmental stresses.
Ms. Dinnage accepts the notion of a current epidemic of anorexia, even though through her own admission there are no statistics to back up this “common observation.” Again I would refer the interested reader to Bemis’s excellent review article where he concludes that “clinical reports of rising incidence are particularly subject to the biasing effects of referral and exposure factors;…and it is possible that heightened awareness among physicians may account for some of the marked rise in diagnosed cases.” Ms. Dinnage also accepts that anorexia “is found more often in middle-class than in working-class families.” To this, Bemis would caution that “others have found a more normal distribution [of anorexia in the general population] and it has been suggested that the skewed findings may be more indicative of selection factors than actual prevalence.”
Psychodynamic formulations of the etiologies of mental illnesses have a disconcerting tendency towards reductionist viewpoints. They glibly ignore evidence which does not fit the formulation while readily accepting anecdotal clinical evidence that does. As behavioral scientists we must seek to understand the multiple factors which contribute to a disease state. Just as in anorexia it is inappropriate to ignore the possible biological etiologies, it would be similarly inappropriate to ignore the possible social factors contributing to a disease such as hypertension.
David L. Fogelson, M.D.
Rosemary Dinnage replies:
The psychoanalytical literature on early feeding experiences is very large; in particular the object-relations school of Klein claims that feeding, as the earliest encounter with the outside world and earliest source of gratification and frustration, radically affects character development. Dr. Bruch does, as she says, devote three pages to infantile experience in which she briefly makes the point, expanded in my review, that there may be a history of insensitivity to the baby’s real needs in anorexia nervosa, and a temperamental difficulty on the child’s side in signaling them. This is a most important point, but it hardly represents the literature on infantile antecedents of eating disorders, to which Dr. Selvini Palazzoli does at least devote a brief chapter.
To turn to her second point: writing of the problems of psychotherapy for anorexia nervosa, Dr. Bruch refers to “the maze of denial, contradiction, and determination not to change that characterizes the therapeutic involvement in anorexia nervosa” and states that “on principle, anorexic patients resist treatment,” that they “will agree with what has been said, quote it in a different context, but actually feel that it means nothing,” and that they resist change “like other patients only more so,” often by “pseudo-agreeing.” Doubt about the prognosis for severe, longstanding cases is implied when she writes that “eventually they have to face the basic issues. The earlier the deceitful maneuvers are interrupted, the greater the chance of effective resolution of the illness.” In her earlier book she quotes a discouraging follow-up study and comments that “my own observations are similar to this somewhat pessimistic assessment of the course of anorexia nervosa once a chronic picture has developed.” Nevertheless she is, I agree, much more optimistic about individual therapy than Selvini Palazzoli.
David Fogelson refers to a research review by Bemis. This states that “the reported incidence of anorexia nervosa has been increasing dramatically over the last twenty years,” argues against a bias in referrals by quoting hospital records, and concludes that “it is possible that heightened awareness among physicians may account for some of the marked rise in diagnosed cases” (my italics). Where the social background of patients is concerned, an English study quoted by Bruch found one case among 200 girls at private schools as compared to one among 3,000 in state schools; in any case, selective factors are unlikely to be relevant to reporting such a serious illness. Lastly, the question of anorexia as an illness of body rather than mind: Bemis’s review cites a number of hypotheses about physical factors that have been disproved, and physical treatments that have been discontinued. The remaining evidence for an organic cause is slender at the moment and open to several interpretations. Bemis’s conclusion, as paraphrased by Dr. Fogelson, is the same as my own—“constitutional fragility, or insensitive impingement from the environment, or both” (p. 8).
April 19, 1979