Classical anorexia nervosa postpubertal

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The illness usually occurs in girls within a few years of the menarche so that the most common age of onset is between 14 and 18. Sometimes the onset is later in a woman who has married and had children.

By the time the patient has been referred for psychiatric treatment she is likely to have reduced her food intake and lost weight over the course of several months, and her menstrual periods will have ceased. A regular feature of the illness is its concealment and the avoidance of treatment. Most clinicians are reluctant to express themselves frankly on this subject in case their observations sound derogatory. It is to the credit of one French author, that he has said explicitly: (72> 'Denial of the illness, lies, cheating, manipulation, are characteristic of the behaviour of anorectics'. Even after having lost 5 to 10 kg in weight and missed several periods, the patient's opening remark is often 'there is nothing wrong with me, my parents are unduly worried'. It is only when the clinician asks direct questions that she will admit to insomnia, irritability, sensitivity to cold, and a withdrawal from contacts with her friends, including her boyfriend if she has one.

Because of this denial, it is important to enquire from a close relative, as well as the patient, about the most relevant behavioural changes.

1. A food intake history is obtained by asking the patient to recall what she has eaten on the previous day, commencing with breakfast which is often missed. An avoidance of carbohydrate and fat-containing foods is the rule. It is likely that pastry, puddings, biscuits, and confectionery are entirely omitted, as are fried foods, butter, and full-cream milk. When asked to explain her restricted choice of food, the patient is likely to defend it on the grounds that she wishes to follow a 'healthy' diet. What remains is an often stereotyped selection of vegetables and fruit. 'Diet' drinks and unsweetened fruit juice are preferred, although some patients are partial to black coffee. It is the mother who will indicate that her daughter finds ways of avoiding meals, preferring to prepare her own food and withdrawing into her bedroom to eat it.

2. The patient is usually willing to provide a weight history and has a clear memory of her weight at successive stages of the illness. She may try to conceal her optimum weight before her decision to 'diet', but she is likely to be objective about her current weight, if only to express pride in the degree of 'self-control' she has exerted. The clinician then has an opportunity to enquire into her 'desired' weight by simply asking what weight she would be willing to return to. Her answer will betray a determination to maintain a suboptimal weight.

3. A history of exercising should be taken. Again, the patient is likely to conceal the fact that she walks long distances to school or to work rather than use public transport. She may also cycle vigorously or attend aerobic classes. A parent may report that his or her daughter is running on the spot or performing press-ups in the privacy of her bedroom, judging from the noise that can be heard. The amount of exercising may be grossly excessive, with the patient indulging in brisk walks or jogging even in the presence of painful knees or ankles due to soft tissue injuries.

4. Additional harmful behaviours which should be enquired into include self-induced vomiting, purgative abuse, and self-injury. Vomiting and purgative abuse are similar to the behaviours that occur in bulimia nervosa (see C.haP.teL,4,1.0,2.). In anorexia nervosa they may occur without the prelude of overeating and the patient's motive is simply to accelerate weight loss. Even so, vomiting is most likely to occur after the patient's frugal meals, and the laxative abuse is often at the end of the day. The favourite laxatives in the United Kingdom are Nylax, Senokot, and Dulcolax, and the patient is likely to take them in increasing quantities to achieve the wanted effect as tolerance develops. Self-injury should also be enquired into, and the skin of the wrists and forearms inspected for scratches or cuts with sharp instruments.

5. Menstrual history: the patient may not volunteer the information that her periods ceased, which often occurs soon after commencing the weight-reducing diet. On the other hand she may admit that she is relieved that her periods have stopped as she found them to be a nuisance or unpleasant.

The patient's mental state Specific psychopathology

Several near-synonyms have been used to describe the specific attitude detectable in the patient who systematically avoids fatness: a 'disturbance of body image', (6) a 'weight phobia',(35) or a 'fear of fatness'/7 Magersucht, or seeking after thinness, was a term applied in the older German literature. The patient will express a sensitivity about certain parts of her body, especially her stomach, thighs, and hips. Not only is she likely to assert that fatness makes her unattractive, but she may add that it is a shameful condition betraying greed and social failure. These distorted attitudes generally amount to overvalued ideas rather than delusions. Occasionally, however, a patient may be frankly deluded, such as one young woman who believed that her low weight was due to thin bones and that fatness was still evident on the surface of her body.

Studies have demonstrated that wasted patients, when asked to estimate their body size, see themselves as wider and fatter than they actually are. (73) Since these early observations, numerous perceptual studies have been undertaken using a variety of methods which have been reviewed and the conclusion drawn that anorexic patients overestimate their body width more often than normal controls. These distorted attitudes are often associated with a negative affect, so that the disturbance might be viewed as one of 'body disparagement'.(74)

The patient's dread of fatness is so common that it is pathognomonic of anorexia nervosa. There are, however, exceptions. Sometimes a patient may simply deny these faulty attitudes. Another exception is the occurrence of anorexia nervosa in Eastern countries where thinness is not generally admired (e.g. Hong Kong and India). The imposition of fear of fatness as a diagnostic criterion on patients from a different culture, where slimness is not valued, may amount to a contextual fallacy, i.e. a failure to understand the illness in the context of its culture. (75)

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