286 CORRESPONDENCE - Cambridge University Press...286 CORRESPONDENCE...
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286 CORRESPONDENCE view anorexia nervosa and atypical eating disorder as distinct disorders. The syndromeseenrarely in the Indian subconti nent is the one characterised by body image disturb ance and preoccupation with weight reduction. In that senseanorexia nervosa may be a culture-bound syndrome of the West, influenced by the western cultural norms and practices. Whereas traditionally in the Indian culture full nessof the body has been regarded as a sign of a well nourished,healthy, affluent and beautiful lady, west ern beliefs,values,perception and behaviour regard the pursuit of thinness as a perfectly logical concept of beauty.Thus it will not be wrong to suggestthat the westernsociocultureitself dictatesthis particular behaviour. Until there is significant weight loss and emaci ation, psychiatrists in the West fail to recognise this impairment injudgement and deficient insight about her condition in an anorexia nervosa patient. That is probably also the reasonwhy the classificatory sys tem, which is entirely ‘¿ western', placesmore empha sis on measuring physical parameters for making a diagnosis of anorexia nervosa,than on recognising the overvalued idea or even a delusion of being obese as primary psychopathology. Solitary casesof this disorder seen in the children of Asian migrants to the West only substantiates the fact that it isthewesternculture which influencesthis disorder. As the Indian subcontinent becomes more ‘¿ westernised' and adopts the value systems of the West, it will be surprising if this culture-bound syndrome of the West does not percolate to the East. DINESH K. ARYA Pastures Hospital Mickleover Derby DE3 5DQ References BRUSCH, H. (1975) Anorexia nervosa. In American Handbook of Psychiatry. VolIV(ed.S.Arieti), p.788. SIMM0ND5,M. (1914) Uberemlodische Prozesse in der Hypophysis. ArchivesofPathol.Anat.217,226. Anorexia nervosain theelderly SIR: We read with interest the report of Gowers & Crisp of an80-year-oldwomanwith anorexianervosa (Journal, November 1990, 157, 754—757). Although anorexianervosaisconsideredto berarein theelderly it is perhapsunsurprising that suchcasesexistgiven the significant incidence in young people and the high rateof chronicity associatedwith thedisorder. Among schoolgirls,Crisp haspreviouslyshownan incidence of one severe case in every 200 over the age of 11 years, rising to one in every 100over the age of 16 years (Crisp et a!, 1976). This may still be an underestimategiven the rate of body-shapedis satisfaction among British comprehensive schoolgirls found by Salmonset al (1988). In their survey some 25% to 30% ofgirls aged 16to 18years admitted to being only rarely satisfied with their bodyweight, and ‘¿ usually' or ‘¿ always' terrified of gaining weight. A multitude ofstudies on the outcomeof anorexia nervosahavedemonstrateda high rateof chronicity. Hsu (1980) and Schwartz & Thompson (1981), reviewing the more rigorous studies which had appeared over the preceding 15 years, found a generalrecognition that some50% of casesshowed continued abnormal eating behaviour at follow-up, which extendedin somesurveysup to 35 yearsafter the time of first diagnosis.Even if this is an overesti mate,the implication is that many peoplewho suffer from anorexia nervosain their youth maintain their abnormal eatingattitudes throughout their lives,and it is perhapssurprising that anorexia nervosais not describedmore frequently in theelderly. Wehaverecentlytreateda73-year-oldwomanwith featuressimilar to thewomandescribedbyGowers & Crisp (Cosford & Arnold, 1990).Shesufferedanepi sodeof anorexianervosafollowing abereavementat theageof 23years.This wascharacterisedbymarked weight loss, extreme behaviour to avoid food intake, an expressedfear of gaining weight, and secondary amenorrhoea.Sherecoveredafter ninemonthsof in patient treatment and subsequentlymaintained an adequateweight for some 50 years afterwards. She recently suffered a relapse, with severe weight loss, a distorted body imageand a fear of becomingfat. Her eating behaviour again became markedly abnormal, and multiple investigationsfailed to reveala physical causefor her weight loss. She respondedto a strict dietary regimeand wasdischargedfive months after admission having regained her former weight, which she has subsequently maintained during out-patient follow-up. We would suggestthat anorexia nervosais prob ably underdiagnosed in the elderly, and would support the assertionthat it should beincludedin the differential diagnosis of unexplained weight loss in this age group. St Mary's Hospital London W2 Central Middlesex Hospital London NWJO PAULC08F0RD ELAINE ARNOLD Downloaded from https://www.cambridge.org/core. 28 Jan 2021 at 05:50:14, subject to the Cambridge Core terms of use.
Transcript of 286 CORRESPONDENCE - Cambridge University Press...286 CORRESPONDENCE...
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
Downloaded from https://www.cambridge.org/core. 28 Jan 2021 at 05:50:14, subject to the Cambridge Core terms of use.
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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