Hilde Bruch had no doubt about the answer to this question: 'one might speak of an epidemic illness, only there is no contagious agent; the spread must be attributed to psycho-social factors'. This is an exaggeration as the increase in anorexia nervosa does not merit the term 'epidemic'. (25) Indeed, such a notion was dismissed in an article 'The epidemic of anorexia nervosa: another medical myth?'.(26) It was concluded that there had been an increase in first admissions of patients over 10 years (1972-1981) but that this was due to an increase in the number of young women in the population. This rejection of a true increase in the incidence of anorexia nervosa has in its turn been criticized.
The most reliable evidence for changes in the incidence of anorexia nervosa comes from repeated surveys of the same population. This has been achieved with the surveys conducted in southern Sweden/!7» northeast Scotland/1.^ Switzerland/20 Monroe County, New York,(l8) and Rochester, Minnesota/21» The researchers applied the same methodology to a similar population after an interval of several years, thus controlling for many of the variables that make it impossible to compare surveys conducted in different centres. There was a clear trend for an increase in incidence over time. The most thorough study was in Rochester, Minnesota. The researchers separated female patients aged 15 to 24 years (61 per cent) from the remainder and established an increase in these younger patients, but only in hem. They concluded that this increased incidence over time reflected a greater vulnerability of younger female subjects to adverse social factors.
There remains at least one sceptic who has argued that there is no evidence of an increase in anorexia nervosa. (28> He has found statistical imperfections in all epidemiological studies so far, and even questioned the possible significance of changes in diagnostic criteria from DSM-III to DSM-IIIR. He agreed that the Rochester survey had produced robust data, but thought that it still contained unresolved analytic problems.
This issue remains an important one because of its significance in the search for sociocultural factors causing anorexia nervosa. But it is better to pose a different question which renders this controversy unnecessary. We should ask instead whether there has been an increase in the incidence of eating disorders including anorexia nervosa. This is especially relevant in view of the fact that bulimia nervosa is a variant of anorexia nervosa, and in many patients follows an earlier episode of anorexia nervosa/29 There is strong evidence that bulimia nervosa is a new disorder and has not simply appeared because of improved medical recognition. (30) Moreover, the incidence of bulimia nervosa has risen sharply during the past 20 years, so that it is now about double that of anorexia nervosa (see also Chapter.. 4_.!0:2). In conclusion, it is clear that since the 1960s there has been a significant increase in eating disorders, of which the two clearest syndromes are anorexia nervosa and bulimia nervosa.
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