286 CORRESPONDENCE

view anorexia nervosa and atypical eating disorder asdistinct disorders.

The syndromeseenrarely in the Indian subcontinent is the one characterised by body image disturbance and preoccupation with weight reduction. Inthat senseanorexia nervosa may be a culture-boundsyndrome of the West, influenced by the westerncultural norms and practices.

Whereas traditionally in the Indian culture fullnessof the body has been regarded as a sign of a wellnourished,healthy,affluentand beautiful lady, western beliefs,values,perceptionand behaviour regardthe pursuit of thinness as a perfectly logical conceptof beauty. Thus it will not be wrong to suggestthatthewesternsociocultureitself dictatesthis particularbehaviour.

Until there is significant weight loss and emaciation, psychiatrists in the West fail to recognise thisimpairment injudgement and deficient insight abouther condition in an anorexia nervosa patient. That isprobably also the reasonwhy the classificatorysystem, which is entirely ‘¿�western',placesmore emphasis on measuring physical parameters for making adiagnosisof anorexia nervosa,than on recognisingthe overvalued idea or even a delusion of being obeseas primary psychopathology.

Solitary casesof this disorder seen in the childrenof Asian migrants to the West only substantiates thefact that it is thewesternculture which influencesthisdisorder. As the Indian subcontinent becomes more‘¿�westernised'and adopts the value systems of theWest, it will be surprising if this culture-boundsyndrome of the West does not percolate to the East.

DINESH K. ARYAPastures HospitalMickleoverDerby DE3 5DQ

ReferencesBRUSCH, H. (1975) Anorexia nervosa. In American Handbook ofPsychiatry.VolIV(ed.S.Arieti),p.788.

SIMM0ND5,M. (1914) Uberemlodische Prozesse in der Hypophysis.Archivesof Pathol.Anat.217,226.

Anorexia nervosain theelderly

SIR: We read with interest the report of Gowers &Crispof an80-year-oldwomanwith anorexianervosa(Journal, November 1990, 157, 754—757).Althoughanorexianervosaisconsideredto berarein theelderlyit is perhapsunsurprising that suchcasesexist giventhe significant incidence in young people and the highrate of chronicity associatedwith the disorder.

Among schoolgirls,Crisp haspreviouslyshownanincidence of one severe case in every 200 over the ageof 11 years, rising to one in every 100over the ageof 16 years (Crisp et a!, 1976).This may still bean underestimategiven the rate of body-shapedissatisfaction among British comprehensiveschoolgirls found by Salmonset al (1988). In theirsurvey some 25% to 30% ofgirls aged 16to 18yearsadmitted to being only rarely satisfied with theirbodyweight, and ‘¿�usually'or ‘¿�always'terrified ofgainingweight.

A multitude ofstudies on the outcomeof anorexianervosahavedemonstrateda high rateof chronicity.Hsu (1980) and Schwartz & Thompson (1981),reviewing the more rigorous studies which hadappeared over the preceding 15 years, found ageneralrecognition that some50% of casesshowedcontinued abnormal eating behaviour at follow-up,which extendedin somesurveysup to 35yearsafterthe time of first diagnosis.Evenif this is an overestimate,the implication is that many peoplewho sufferfrom anorexianervosain their youth maintain theirabnormaleatingattitudesthroughout their lives,andit is perhapssurprising that anorexia nervosais notdescribedmore frequently in theelderly.

Wehaverecentlytreateda73-year-oldwomanwithfeaturessimilar to thewomandescribedbyGowers &Crisp (Cosford & Arnold, 1990).Shesufferedan episodeof anorexianervosafollowing a bereavementattheageof 23years.This wascharacterisedbymarkedweight loss, extreme behaviour to avoid food intake,an expressedfear of gaining weight, and secondaryamenorrhoea.Sherecoveredafter ninemonthsof inpatient treatment and subsequentlymaintained anadequateweight for some50 yearsafterwards. Sherecently suffered a relapse, with severeweight loss, adistorted body imageanda fearof becomingfat. Hereating behaviour again became markedly abnormal,andmultiple investigationsfailed to revealaphysicalcausefor her weight loss.Sherespondedto a strictdietary regimeand wasdischargedfive months afteradmission having regained her former weight, whichshe has subsequently maintained during out-patientfollow-up.

We would suggestthat anorexia nervosais probably underdiagnosed in the elderly, and wouldsupport theassertionthat it shouldbeincludedin thedifferential diagnosisof unexplained weight loss inthis age group.

St Mary's HospitalLondon W2

Central Middlesex HospitalLondon NWJO

PAULC08F0RD

ELAINE ARNOLD

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287CORRESPONDENCE

ReferencesCOSFORD,P. A. & ARNOLD, A. E. (1990) Anorexia nervosa in the

elderly. In preparation.Caisp,A. H., PALMER,R. L. & K@tLucy,R. S.(1976)How common

is anorexia nervosa?A prevalencestudy. BritishJournal ofPsychiatry.128,549-554.

Hsu,L. K. 6. (1980)Outcomeof anorexianervosa.ArchivesofGeneraiPsychiatry,37,1041-1046.

SALMONS, P. H., LewIs, V. J., Roaras, P. et a/(1988) Body-shapedissatisfactionin school-children.BritishJournalof Psychiatry.153(suppl.2),27—31.

SCHWARTZ, D. M. & TisoawsoN, M. U. (1981) Do anorectics getwell? Current researchand future needs.AmericanJournal ofPsychiatry.138,319-323.

Psychologicalsequelaeof torture

Sat: I was grateful to read your annotation onpsychological sequelae of torture by Turner& GorstUnsworth (Journal,October 1990,157,475-480).

Torture has been a widespread experience in the20th century. Most probably therehasneverbeenatimewhen institutionalised torture hasbeensowidelyinflicted on large massesof people in all continents.After themilitary coupof 1980in Turkey, I witnessedlargenumbersof victims of torture in Metris MilitaryPrison, Istanbul, whereI wasimprisonedfor oneyear(1982—1983).I would agreewith theauthors that torture hasawidevariety of psychologicaleffectson thevictims, their familiesand friends. But psychologicalsequelaeof torture cannot be limited to them, butshouldbeextendedtothelargegroupoftorturerswhohavebeenespeciallytrained to torture.

The situation where individuals first have beenforced, thenslowly taught, to obeyand then to enjoyhuman suffering, and to become professionallytrained systematic torturers must be considered.Having had theopportunity to observetorturers, onecannot help feeling for thosewho have most probably in their turn beenpsychologicallyandphysicallyabused.In Turkey, manyturturerswarrant diagnosesof psychiatric syndromes which have never beendiagnosedor treated. Suicide rate, deliberate selfharm, alcohol dependencyand possibly other drugmisuse appears to be much higher in those individualstrained to beinvolved in torture. Different formsof psychotic episodesare commonplaceand homicide ratesamong torturers are much higher than inthegeneralpopulation.

Torture has wide implications upon the wholesocietywhereits practicetakesplace.Thesocietyasawhole getsenmeshedinto the idea of its existence,and fearanddegradationisextendedto all aspectsoflife. Now in Turkey torture has become a majortheme in short stories, poetry, films, pictures andsongs.In the last ten yearstherehavebeenhundredsof poetry books,short stories,paintingsand films on

the tortured, the torturers and their circumstances. Ithas become part of the language and culture andalmost a way of communicating. Its existencetranscendsallboundaries and makes itselffelt in all aspectsof life.

In my out-patient clinic at the Charing CrossHospital, Turkish immigrants who have never cxperiencedtorture comewith storiesof ill-treatmentastheir psychologicalcomplaints.Both neurosesandpsychoses in these people are flavoured with storiesoftorture, sufferingsand horror. The ideaof torture,even if they know little about it, has become anexpression of their persecutions, anxieties, racist andsexist experiences. It is a component of their guilt,self-pity and hopelessness. The individual and thewhole societyhasbeenmarred by the psychologicaleffects of torture.

DORAKo@Charing Cross and Westminster Medical SchoolLondon W6 8RP

British andAustraliandepressionrevisited

SIR: Two recent long-term outcome studies ofdepression,from Sydney(Kiloh etal, 1988;Andrewset al, 1990) and London (Lee & Murray, 1988;Dugganet al, 1990),haveshownsimilar results.Theinitial diagnosisoftenheraldedaverypoor long-termoutcome,and personality disturbancewasone partof the explanation for this. However, there areimportant differences between the Sydney andLondon findings which wewish to highlight.

The first of theseconcerns the neuroticism (N)subscaleof theEysenckPersonalityInventory (EPI).The EPI N now hasanexcellentpedigreeasapredictor of outcomein depression,but ProfessorAndrewset a! found itspredictivepower to beconfinedto theirsubgroupof ‘¿�neurotic'depressives.This mayencouragereadersto re-identify raisedN with adiagnosisof‘¿�neurotic'depression,which would be unwise. Inboth series,N scoresdo not differ between‘¿�neurotic'and ‘¿�endogenous'subtypes,so that whateverseparatesthe ‘¿�neurotic'from the ‘¿�endogenous'depressive,it isnot thedegreeof neuroticism. In London, unlikeSydney,we found that EPI N predicted chronicityparticularly in the ‘¿�endogenous'(melancholic) subgroup. We therefore propose that the relationshipbetweenhighN scores,diagnosticsubgroup,andoutcomeshould remain open to further investigation.

A second difference concerns the influence ofdepressedmood on the assessmentof personality.Andrews et a! apologise that their patients wereassessedwhen they still had symptoms, and arguethat ‘¿�recovered'personality hasthe more significant

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