Anorexia Multiforme: Self-starvation in Historical and Cultural Context Part I: Self-starvation as a Historical Chameleon1
Identifieur interne : 000784 ( Istex/Corpus ); précédent : 000783; suivant : 000785Anorexia Multiforme: Self-starvation in Historical and Cultural Context Part I: Self-starvation as a Historical Chameleon1
Auteurs : Vincenzo F. DinicolaSource :
- Transcultural Psychiatry [ 1363-4615 ] ; 1990-09.
Url:
DOI: 10.1177/136346159002700301
Links to Exploration step
ISTEX:55E14A21E465E7FA9755A3C5E6A141D50EAC31D3Le document en format XML
<record><TEI wicri:istexFullTextTei="biblStruct"><teiHeader><fileDesc><titleStmt><title xml:lang="en">Anorexia Multiforme: Self-starvation in Historical and Cultural Context Part I: Self-starvation as a Historical Chameleon1</title><author wicri:is="90%"><name sortKey="Dinicola, Vincenzo F" sort="Dinicola, Vincenzo F" uniqKey="Dinicola V" first="Vincenzo F." last="Dinicola">Vincenzo F. Dinicola</name></author></titleStmt><publicationStmt><idno type="wicri:source">ISTEX</idno><idno type="RBID">ISTEX:55E14A21E465E7FA9755A3C5E6A141D50EAC31D3</idno><date when="1990" year="1990">1990</date><idno type="doi">10.1177/136346159002700301</idno><idno type="url">https://api.istex.fr/document/55E14A21E465E7FA9755A3C5E6A141D50EAC31D3/fulltext/pdf</idno><idno type="wicri:Area/Istex/Corpus">000784</idno><idno type="wicri:explorRef" wicri:stream="Istex" wicri:step="Corpus" wicri:corpus="ISTEX">000784</idno></publicationStmt><sourceDesc><biblStruct><analytic><title level="a" type="main" xml:lang="en">Anorexia Multiforme: Self-starvation in Historical and Cultural Context Part I: Self-starvation as a Historical Chameleon1</title><author wicri:is="90%"><name sortKey="Dinicola, Vincenzo F" sort="Dinicola, Vincenzo F" uniqKey="Dinicola V" first="Vincenzo F." last="Dinicola">Vincenzo F. Dinicola</name></author></analytic><monogr></monogr><series><title level="j">Transcultural Psychiatry</title><idno type="ISSN">1363-4615</idno><idno type="eISSN">1461-7471</idno><imprint><publisher>Sage Publications</publisher><pubPlace>Sage CA: Thousand Oaks, CA</pubPlace><date type="published" when="1990-09">1990-09</date><biblScope unit="volume">27</biblScope><biblScope unit="issue">3</biblScope><biblScope unit="page" from="165">165</biblScope><biblScope unit="page" to="196">196</biblScope></imprint><idno type="ISSN">1363-4615</idno></series><idno type="istex">55E14A21E465E7FA9755A3C5E6A141D50EAC31D3</idno><idno type="DOI">10.1177/136346159002700301</idno><idno type="ArticleID">10.1177_136346159002700301</idno></biblStruct></sourceDesc><seriesStmt><idno type="ISSN">1363-4615</idno></seriesStmt></fileDesc><profileDesc><textClass></textClass><langUsage><language ident="en">en</language></langUsage></profileDesc></teiHeader></TEI><istex><corpusName>sage</corpusName><author><json:item><name>Vincenzo F. Dinicola</name></json:item></author><articleId><json:string>10.1177_136346159002700301</json:string></articleId><language><json:string>eng</json:string></language><originalGenre><json:string>other</json:string></originalGenre><qualityIndicators><score>5.512</score><pdfVersion>1.4</pdfVersion><pdfPageSize>614 x 792 pts</pdfPageSize><refBibsNative>true</refBibsNative><abstractCharCount>0</abstractCharCount><pdfWordCount>10903</pdfWordCount><pdfCharCount>71286</pdfCharCount><pdfPageCount>32</pdfPageCount><abstractWordCount>1</abstractWordCount></qualityIndicators><title>Anorexia Multiforme: Self-starvation in Historical and Cultural Context Part I: Self-starvation as a Historical Chameleon1</title><genre><json:string>other</json:string></genre><host><volume>27</volume><publisherId><json:string>TPS</json:string></publisherId><pages><last>196</last><first>165</first></pages><issn><json:string>1363-4615</json:string></issn><issue>3</issue><genre><json:string>journal</json:string></genre><language><json:string>unknown</json:string></language><eissn><json:string>1461-7471</json:string></eissn><title>Transcultural Psychiatry</title></host><categories><wos><json:string>social science</json:string><json:string>psychiatry</json:string><json:string>anthropology</json:string></wos><scienceMetrix><json:string>health sciences</json:string><json:string>clinical medicine</json:string><json:string>psychiatry</json:string></scienceMetrix></categories><publicationDate>1990</publicationDate><copyrightDate>1990</copyrightDate><doi><json:string>10.1177/136346159002700301</json:string></doi><id>55E14A21E465E7FA9755A3C5E6A141D50EAC31D3</id><score>1</score><fulltext><json:item><extension>pdf</extension><original>true</original><mimetype>application/pdf</mimetype><uri>https://api.istex.fr/document/55E14A21E465E7FA9755A3C5E6A141D50EAC31D3/fulltext/pdf</uri></json:item><json:item><extension>zip</extension><original>false</original><mimetype>application/zip</mimetype><uri>https://api.istex.fr/document/55E14A21E465E7FA9755A3C5E6A141D50EAC31D3/fulltext/zip</uri></json:item><istex:fulltextTEI uri="https://api.istex.fr/document/55E14A21E465E7FA9755A3C5E6A141D50EAC31D3/fulltext/tei"><teiHeader><fileDesc><titleStmt><title level="a" type="main" xml:lang="en">Anorexia Multiforme: Self-starvation in Historical and Cultural Context Part I: Self-starvation as a Historical Chameleon1</title></titleStmt><publicationStmt><authority>ISTEX</authority><publisher>Sage Publications</publisher><pubPlace>Sage CA: Thousand Oaks, CA</pubPlace><availability><p>SAGE</p></availability><date>1990</date></publicationStmt><sourceDesc><biblStruct type="inbook"><analytic><title level="a" type="main" xml:lang="en">Anorexia Multiforme: Self-starvation in Historical and Cultural Context Part I: Self-starvation as a Historical Chameleon1</title><author xml:id="author-1"><persName><forename type="first">Vincenzo F.</forename><surname>Dinicola</surname></persName></author></analytic><monogr><title level="j">Transcultural Psychiatry</title><idno type="pISSN">1363-4615</idno><idno type="eISSN">1461-7471</idno><imprint><publisher>Sage Publications</publisher><pubPlace>Sage CA: Thousand Oaks, CA</pubPlace><date type="published" when="1990-09"></date><biblScope unit="volume">27</biblScope><biblScope unit="issue">3</biblScope><biblScope unit="page" from="165">165</biblScope><biblScope unit="page" to="196">196</biblScope></imprint></monogr><idno type="istex">55E14A21E465E7FA9755A3C5E6A141D50EAC31D3</idno><idno type="DOI">10.1177/136346159002700301</idno><idno type="ArticleID">10.1177_136346159002700301</idno></biblStruct></sourceDesc></fileDesc><profileDesc><creation><date>1990</date></creation><langUsage><language ident="en">en</language></langUsage></profileDesc><revisionDesc><change when="1990-09">Published</change></revisionDesc></teiHeader></istex:fulltextTEI><json:item><extension>txt</extension><original>false</original><mimetype>text/plain</mimetype><uri>https://api.istex.fr/document/55E14A21E465E7FA9755A3C5E6A141D50EAC31D3/fulltext/txt</uri></json:item></fulltext><metadata><istex:metadataXml wicri:clean="corpus sage not found" wicri:toSee="no header"><istex:xmlDeclaration>version="1.0" encoding="UTF-8"</istex:xmlDeclaration><istex:docType PUBLIC="-//NLM//DTD Journal Publishing DTD v2.3 20070202//EN" URI="journalpublishing.dtd" name="istex:docType"></istex:docType><istex:document><article article-type="other" dtd-version="2.3" xml:lang="EN"><front><journal-meta><journal-id journal-id-type="hwp">sptps</journal-id><journal-id journal-id-type="publisher-id">TPS</journal-id><journal-title>Transcultural Psychiatry</journal-title><issn pub-type="ppub">1363-4615</issn><publisher><publisher-name>Sage Publications</publisher-name><publisher-loc>Sage CA: Thousand Oaks, CA</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="doi">10.1177/136346159002700301</article-id><article-id pub-id-type="publisher-id">10.1177_136346159002700301</article-id><article-categories><subj-group subj-group-type="heading"><subject>Articles</subject></subj-group></article-categories><title-group><article-title>Anorexia Multiforme: Self-starvation in Historical and Cultural Context Part I: Self-starvation as a Historical Chameleon1</article-title></title-group><contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Dinicola</surname><given-names>Vincenzo F.</given-names></name></contrib></contrib-group><pub-date pub-type="ppub"><month>9</month><year>1990</year></pub-date><volume>27</volume><issue>3</issue><fpage>165</fpage><lpage>196</lpage><custom-meta-wrap><custom-meta xlink:type="simple"><meta-name>sagemeta-type</meta-name><meta-value>Other</meta-value></custom-meta><custom-meta xlink:type="simple"><meta-name>search-text</meta-name><meta-value>165 OverviewAnorexia Multiforme: Self-starvation in Historical and Cultural Context Part I: Self-starvation as a Historical Chameleon1 SAGE Publications, Inc.1990DOI: 10.1177/136346159002700301 Vincenzo F.Dinicola Only in an enlarged research context that considers meaning as well as behavior will we be able to understand how anorexia nervosa is experi- ' enced and why it has become the characteristic disorder of the female adolescent in .our day. Joan Jacobs Brumberg (1985, p. 104) In an earlier medical era, Sir William Osler dubbed syphilis "the great mimic" because of the random unpredictable localization of spirochaetes throughout the body, leading to a multiplicity of clinical symptom complexes (Robbins, 1974, p. 378). Hence, one of Osler's (1932) teaching aphorisms was, "Know syphilis in all its manifestations and relations, and all things clinical will be added unto you." This is an instructive analogy for the illness we construe today as anorexia nervosa because of its impact on growth and development and its medical consequences on many organ systems. There are other parallels: if historical accounts are to be believed, like syphilis anorexia nervosa also takes on many forms; and like syphilis which accrued special meanings (overtones of shame and punishment for sexual misdemeanors) that mirrored Victorian social and historical conditions, anorexia nervosa too has taken on special meaning in modern Western cultures. Anorexia nervosa, however, has no proven cause: its diversity is due perhaps to a more protean nature, leading to questions about caseness (species) versus continuum (genus) and 1. Part II: Anorexia Nervosa as a Culture-Reactive Syndrome will appear in the next issue (October, 1990). 166 whether it is best understood as an entity (disease) or an attribution (explanatory model). The psychiatric study of anorexia nervosa' reveals it to be a modern clinical entity commonly occurring within a narrow range of circumstances: among pubertal girls and young women, living in stereotyped family conditions; in the privileged classes of Western or westernizing affluent societies; and among racial groups of European descent. In this view, anorexia nervosa is a cuLture-bound syndrome of technologically-developed affluent Western societies - what Brumberg (1988) has characterized as an illness with "a highly specific social address" (p. 13). However, each of these terms can be challenged: historical accounts of fasting women have suggested various analogues of anorexia nervosa throughout history; child psychiatry has shown both anorexia nervosa and its clinical analogues to occur in significant numbers in prepubertal children and among boys; clinical impressions of family interaction patterns remain to be validated; clinical and community surveys reveal that it now has a broader social class distribution; reports of its occurrence outside the Western world and among many races are beginning to appear; and lastly, there is a strong challenge to anorexia nervosa as a clinical entity, arguing for a more complex, contextual and connotative view. In this view, self-starvation emerges in different times and places as instances of anorexia multiforme, cx scultural chameleon with protean manifestation, sometimes shaped by the prevailing social and cultural conditions into the "inedia prodigiosa" of "miraculous maidens", and at other times constructed as medical illnesses such as "chlorosis", "sitomania" and "anorexia nervosa". Which view is correct? Each view takes us significantly beyond the medical model; each deals with significant aspects of self-starvation. In this overview I wish to place self-starvation in cultural and historical perspective. My task in Part I is to question the caseness or entity-centred views and examine historical accounts of fasting, self-starvation, and anorexia nervosa and their clinical and historical analogues from a more meaning-centred view. , CHOOSING CONTEXTS Is anorexia nervosa best understood as an illness experience, a metaphor for women's distress in Western societies, a human predicament, a psychiatric disease entity, a medical chameleon that changes with the times, or a culture-bound syndrome? Each of these 167 approaches has some value in describing a part of the whole; most of them fall far short of being comprehensive in accounting for what is known about anorexia nervosa. Be reviewing the literature on anorexia nervosa, I will outline the requirements for a comprehensive model of the illness. Different approaches set different tasks or goals for themselves, working within a chosen context. The choice of the context reflects the worker's specific clinical and research competence, discipline boundaries, and dominant ideology. As an interpretive social science, medical anthropology may explore the social and cultural meanings of anorexia nervosa as an illness experience. Feminists see in anorexia nervosa a metaphor for women's struggle, all the more ironic and puzzling in my view, since this illness has emerged in the relatively more open and liberal societies of the developed West. Contextually-oriented child psychiatrists and family therapists may focus on anorexia nervosa as a human predicament (Tay- lor, 1985), charged with psychological and moral dilemmas for the individual sufferer and her family and friends. Psychiatric researchers tend to ask questions about anorexia nervosa as a disease entity, looking for biological causes and medical consequences while evaluating treatment options. Using a diachronic approach, some scholars (including academic historians) look for evidence of the illness in other times; self-starvation emerges from this view as anorexia multiforme - a medical chameleon that changes with the times. Transcultural psychiatry's synchronic approach compares the prevalence and features of anorexia nervosa around the world. In this view, anorexia nervosa is a socio-culturally mediated illness exquisitely responsive to context, to the degree that (as I argue in Part II), to find anorexia nervosa in a culturally unusual context is to encounter an "orphan case" (Simons, in press) - a different illness experience, an altogether diverse human predicament, another kind of metaphor, and evidence that makes us review the claims for anorexia nervosa as a disease entity. Transcultural psychiatry gives us the tools to "deconstruct" anorexia nervosa as a disease, allowing us to "unpack the meta- phors" within the symptoms, and to read the cultural connection. DECONSTRUCTING ANOREXIA NERVOSA In October 1873, Sir William Withey Gull (1816-1890) gave a presentation to the Clinical Society of London (Anonymous, 1873) on the illness he had first called apepsia hysterica or anorexia hysterica 168 in his Address in Medicine at the meeting of the British Medical Association at Oxford in August 1868 (Gull, 1868): Anorexia hysterica is "a form of disease occurring mostly in young women between the ages of fifteen and twenty-three, and characterized by extreme emaciation" in which "the want of appetite was due to a morbid mental state" and "the origin was central not peripheral". "In the starvation stage, when the patients were for the most part brought for advice, all the functions were found to be below the normal standard, but otherwise normal." On examination, "the clinical characteristics were those of starvation only, without any signs of visceral disease.... Such patients, though extremely wasted, complained of no pain, nor indeed, of any malaise, but often were singularly restless and wayward, if the prostration had not reached its -extremist point." " "In one case only had fatal issue occurred, though sometimes the exhaustion was so great as to make possible recovery seem very doubtful." . "In reference to treatment," Gull "contended that the patients require moral control; and that, if possible, a change in domestic relations should be made; that, from the beginning, food should be given at short intervals; and that patients should not be left to their own inclinations in the matter." The discussion noted that "moral management of these cases is to be insisted upon; medical treatment is of little use" and that "the malady was more mental than physical." The report concludes, "The cases which Sir William Gull had described were not strictly insane; there was, however, something wrong in the nervous equilibrium, and usually something queer in the family history" (Anonymous, 1873, p. 527-528). These are the essential features of the illness which Gull called Anorexia nervosa in his publication of the full paper a few months later (Gull, 1874) and in his Clinical Note in The Lancet (Gull, 1888). It should be noted that a French neuropsychiatrist, Ernest Charles Lasegue (1816-1883), independently described the same illness, calling it anorexia hysterica (Las6gue, 1873a, b): and that controversy exists as to who was the first to describe this illness (see Vandereycken and Van Deth, 1989).2 Gull's account of anorexia nervosa highlights: its occurrence in adolescent girls and young women (15 to 23 years), the absence of any primary medical lesion, its central (brain) rather than peripheral (stomach) origin, lack of appetite being 169 due to a morbid mental state, the patient's uncomplaining attitude, restlessness and constant motion, associated psychological disturbance, and family dysfunction. Gull's management was psychological ("moral") rather than only medical and included changing family relationships. He was also the first to champion careful feeding with supervision, as it could not be entrusted to patients. Gull's general description holds up remarkably well in its clinical details, accompanying psychological profile, family context, and recommendations for treatment. A hundred years later all we can add to his description is a differentiation of subtypes (in 1979, Gerald Russell, another London physician, established the distinction between anorexia nervosa and bulimia nervosa), and more details, largely confirmatory, about the associated personality and family features. A great deal more is also known about the medical consequences of the illness yet no causative agent has been discovered or even suggested. It remains a specifically psychiatric disorder. The current clinical and research criteria for anorexia nervosa define an eating disorder characterized by "refusal to maintain body weight over a minimal normal weight for age and height; intense fear of gaining weight or becoming fat, even though underweight; a distorted body image; and amenorrhoea (in females)", as outlined in DSM-III-R (APA, 1987, p. fi5)3 Some observations about this definition are cogent here. First, the name for this illness has created controversy since the beginning, reflecting different view of its origin and phenomenology. Hence, Gull's (1868) first term "apepsia hysterica" suggests a peripheral (stomach) manifestation and hysterical origin. Gull's correct observation that food is well digested suggested the appellation "anorexia . hysterica" (Anonymous, 1873). Eventually, Gull coined the term anorexia nervosa: "We might call the state hysterical without committing ourselves to the etymological value of the word, or maintaining that the subjects of it have the common symptoms of hysteria. I prefer, however, the more general term 'nervosa', since the disease occurs in males as well as females, and is probably rather central than peripheral" (Gull, 1874, pp. 25-26). In English usage, the term anorexy or anorexia indicating lack of appetite, dates from the sixteenth century according to the Oxford English Dictionary. In this context, however, "anorexia" is a misnomer since it is known that in the early stages at least patients do suffer from hunger although they try to suppress and deny it. Later, 10170 as a biological starvation state sets in, hunger does indeed diminish. The disorder is called "mental anorexia" in the modern French (anorexie mental, coined by Huchard; Axenfeld and Huchard, 1883, p. 1018) and Italian (anoressia mentale) medical literature. A translation of the Chinese term is "disease of being fed up with eating" (Lee, et al, 1989), another misnomer. The German term Pubertaets Magersucht or "pubertal addiction to thinness" is more consistent with current theories (Bruch, 1985; Fichter, 1985). Perhaps self-starvation (Selvini Palazzoli, 1963/1974) is the simplest, most descriptive and accurate term. Second, "refusal" in the DSM-III-R definition, chosen to imply a psychological rather than an organic medical condition, suggests more conscious control on the part of the patient than is warranted. In the light of socio-cultural data, anorexia nervosa does not represent an individual or conscious choice. The impact is on the individual, but the vector is the group. In following "the instructed taste of the time" (Veblen, 1899/1953), women contract a socio-cultural illness, spread by social contagion (Nasser, 1986) and dubbed as "me-too" anorexics (Bruch, 1985). Third, the diagnostic criteria were significantly modified in the revision to DSM-III, including the more liberal 15 percent rather than 25 percent weight loss and the inclusion of a biological sign (amenorrhoea) in females. Insofar as DSM-III-R is a research tool; this will change the epidemiological data collected. In general, clinicians have not followed the previous 25 percent weight loss criterion, as the new weight loss criterion will better reflect clinical practice. The change will no doubt also shape clinical perceptions of the illness toward a more liberal, inclusive view. The new weight loss criterion is more medically appropriate for children (DiNicola, et al, 1989) for two reasons. Since children have a different proportion of fat stores to body fluids, a smaller amount of weight loss is more dangerous; furthermore, children are more likely to generalize intake restrictions to fluids along with solids and more rapidly approach a life-threatening illness. , HISTORICAL VIEWS: ANOREXIA MULTIFORME The past is ct foreign country: they do things differently there. L. P. Hartley (1953, p. 1) In the search for earlier cases, historical analogues and the evolution of clinical analogues, historical research constructs self-starvation 11171 as a medical chameleon - what I call anorexia muLtifarme. Several kinds of historical enquiries have been reported. 1. MEDICAL HISTORY. Selvini Palazzoli's (1963/1974) historical survey outlines four periods in the medical history of anorexia nervosa. The first period may be called the prehistory of anorexia nervosa: "It is quite possible that cases of anorexia nervosa have been known since time immemorial....It also seems likely that inanition due to voluntary starvation was observed by ancient physicians, though Hippocrates, Galen and Celsius do not mention it explicitly in their writings. Two Italian writers, Accornero (1943) and Baraldi (1952), have claimed that the earliest account of anorexia nervosa was given by Simone Porta, a sixteenth century Genovese" (Selvini Palazzoli, 1963/1974, pp. 3-4). Skrabanek (1983) qualified that Porta's account (Portius, 1551) was a second-hand report about a fasting girl, possibly the German Mar- garetha Weiss. In the English-language literature, the more common view is that Richard Morton (1694), a seventeenth century English physician, provided the first detailed description (Silverman, 1983). Morton used the term "nervous atrophy" to describe a form of consumption without fever or dyspnoea accompanied by loss of appetite, amenorrhoea, constipation, extreme emaciation ("like a skeleton only clad with skin"), overactivity, and characteristic indifference to their condition or cure. Guilhelm Fabricius Hildanus, a German physician, observed cases of fasting he called inedia pro- digiosa in 1646 (see Brumberg, 1988, p. 294). The term Anorexia mirctbilis coined by Franqois Boisser de Sauvages de la Croix in 1772, was apparently more extensive than inedia prodigiosa, covering diseases in which individuals fasted long (see Brumberg, 1988, p. 194). While these are part of the history of medical attempts to understand fasting, they cannot be considered anorexia nervosa with any certainty. Accounts were also published in 1764 by Robert Whytt, an eighteenth-century English physician who made the term "nerves" fashionable (Silverman, 1987b); in 1789 by a French physician, Nau- deau (Selvini Palazzoli, 1963/1974; Vandereycken; 1988); and in 1790 by London physician Robert Willan (Silverman, 1987a). Vandereycken (1988) is critical of historical descriptions of anorexia nervosa, reading one of Lasegue's cases as hysterical food refusal and Naudeau's report as a food aversion conditioned by association with attacks of pain. 12172 In a fascinating instance of how clinical syndromes are described without widespread recognition, William Stout Chipley (1859) published the first United States description of sitomania, an "intense dread of food". Chipley did not classify sitomania as a "distinct form" but a phase of insanity; nonetheless, he identified some aspects of the modern syndrome of anorexia nervosa: emaciated adolescent girls in "high-born families", sent to the asylum after failed outpatient treatment, with doting family and friends, discovering the power of self-starvation. Brumberg (1988), who appears to be the first to rediscover Chipley's contribution, offered cogent reasons why his description of sitomania attracted little attention. These include a reluctance to admit youths to asylums and the stigma of institutionalization among well-to-do families who could choose such options as private "nervous" homes and spas, travel and visits with relatives (cf. Binswanger's case of Ellen West, 1944, 1958). The second period, which started with Gull (1874) and Las6gue (1873a, b), established anorexia nervosa as a modern clinical entity and with names like anorexia nervosa (Gull in 1874) and anorexie mentale (Huchard in 1883), it became widely regarded as a mental illness. The third period began in 1914 with Morris Simmonds' description of a fatal case of cachexia due to atrophy of the anterior pituitary lobe. Cases of anorexia nervosa were mistakenly taken for Simmonds' Disease, an endocrinological disease: , "The confusion reached its climax in 1937 when E. Kylin described what he called 'emaciation of girls during late puberty' and attributed it to a dysfunction of the anterior pituitary lobe. Most of the fifty cases he observed were clearly cases of anorexia nervosa. The same is true for many other conditions mentioned at the time, for example of Bickel's simple pituitary emaciation, of von Bergmann's hypophysical emaciation, of Whal- burg's grave hypophysial asthenia, of Dogliotti's juvenile hypo- phisal asthenia and of May's and Lavani's cachexia of adoles- cence" (Selvini Palazzoli, 1963/1974, p. 8) As a result, such cases were not diagnosed as anorexia nervosa and pituitary grafts and injections of extracts were prescribed as cures. Ironically, it was another endocrinologist, H. L. Sheehan, recognizing in 1937 that postpartum pituitary necrosis or Sheehan's Syndrome was not accompanied by weight loss, who dispelled the mistaken belief that pituitary destruction must lead to cachexia. 13173 This rediscovery of anorexia nervosa as a mental disorder, allowed the fourth period of investigations into its psychological and socio-cultural determinants to take place. This period includes the pioneering work of Selvini Palazzoli (1963/1974, 1985; psychological and family approach) in Italy; Hilde Bruch (1973, 1985; psychodynamic approach) and Salvador Minuchin (1984; family therapy) in the United States; Paul Garfinkel and David Garner (1982; Garner and Garfinkel, 1985; clinical and social research using their multidimensional model) in Canada; and Gerald Russell (1979, 1985; delineation of bulimia nervosa; medical consequences of anorexia nervosa) and Arthur Crisp (1977; anorexia nervosa as adolescence avoided) in London. ° 2. HISTORICAL CASES. This is the search for "cases" of anorexia nervosa in other times, a task that requires the use of clear, consistent and reliable criteria to assign cases. Historical cases, however, rarely have adequate data to apply our current diagnostic criteria. Recent psychobiographical studies have examined such historical figures as Mary, Queen of Scots (McSherry, 1985), nineteenth century English poets Lord Byron (Paterson, 1982) and Elizabeth Barrett Browning (Dally, 1989) and playwright James M. Barrie who created Peter Pan (Fried and Vandereycken, 1989) as anorexics; and twentieth century figures such as the Prague Jewish writer Franz Kafka (Fichter, 1987) and the Jewish-Christian mystic Simone Weil (VanHerik, 1984) as anorexics. Binswanger's (1944/1958) case off "Ellen West" has been re-evaluated as anorexia nervosa from a psychodynamic perspective by Hilde Bruch (1973), from a family therapy perspective by Salvador Minuchin (1984), and from a feminist perspective by Kim Chernin (1981). 3. HISTORICAL ANALOGUES. The examination of people in other times for predicaments that somehow resemble anorexia nervosa in the twentieth century is the search for what I call "historical analogues". Rather than fitting these historical figures into current diagnostic criteria, these studies challenge the validity of current psychiatric notions of anorexia nervosa. Some putative historical analogues are: "holy anorexics" such as the medieval Catherine of Siena (Bell, 1985) with a modern-day counterpart in Portuguese Catholic "non-eaters" (Pina-Cabral, 1986; Bynum, 1988); the thousand-year legend of St. Wilgefortis, a bearded female saint (Lacey, 1982); a ninth century Arabian prince (Hajal, 1982); seventeenth century New England witches (Demos, 1982); and the nineteenth century "Welsh fasting 14174 girl" (Brumberg, 1988; Fowler, 1871) and other "miraculous fasting women" such as the German Friderada (Habermas, 1986). These predicaments surely represent vastly different socio-cultural and historical contexts from the young women with anorexia nervosa in twentieth century Western societies. The more seriously we take a contextual view of human experience, the more context is taken as fundamental in constructing the illness, rather than mere "cultural dressing" . Here historians get entangled in a paradox. Historian would seem to be allied with the hermeneutic approach of the social sciences, yet by arguing for some overarching disorder bridging these manifestations of fasting and emaciation in different eras with vastly different contexts (what historian Brumberg, 1985, calls "sympto- matic continuities"), they sound more like those psychiatrists who see it as a disease entity. Any physician knows that symptoms are ' sign-posts to disease. Collecting examples of women who fasted and had other food preoccupations - Brumberg's "symptomatic contin- uities" - can be misleading. Brumberg (1985) is aware of this pitfall and cautions that "to call Catherine of Siena an anorectic - that is, to use a contemporary psychosomatic model to explain her behavior - is to distort her psychological orientation, misread her actions as she understood them, and misrepresent the context in which she lived" (p. 97). Indeed, few authors (e.g., Bell, 1985; Morgan, 1977; . Shorter, 1987; Silverman, 1986; Skrabanek, 1983) have been willing to equate historical cases of fasting women with modern anorexia nervosa (Habermas, 1989). Brumberg makes us question the validity of anorexia nervosa as a diagnostic entity, reminding us that masturbation was once treated as a disease and, more importantly, that chlorosis (an iron-deficiency anaemia that resembled anorexia nervosa, discussed below) is now an anachronistic diagnostic entity. Furthermore, she argues that social changes and not medical advances account for these transformations. Brumberg (1985) pleads for "a more complex historical view of the meaning of diseases and disorders, how these conditions are perceived..." and for "an enlarged research context that considers meaning as well as behavior... to understand how anorexia nervosa is experienced" (p. 104). Brumberg (1985) exhorts us to examine both culture and history in the study of anorexia nervosa, although these two approaches sometimes collide (cf. Levi-Strauss, 1966, p. 256). Caroline Walker Bynum's (1987) informative study, Holy Feast and Holy Fast, provides just the kind of larger context 15175 Brumberg suggests. Both Brumberg (1982, 1985, 1988) and Bynum (1987, 1988) have offered astute and informed reflections on these historical accounts. Some historical writing, however, displays an uncertain grasp of basic medical definitions and the critical review of medical data.4 4 4. HISTORICAL EVOLUTION. Another type of historical study examines how the presentation of the illness changes over time. This includes the study of illnesses that share important features with anorexia nervosa as possible "clinical analogues". One possible clinical analogue in the evolution of anorexia nervosa was chlorosis (Brumberg, 1982; Loudon, 1980; Theriot, 1988). Chlorosis was commonly recognized as a disease from the sixteenth to the nineteenth centuries (Loudon, 1980) without any adequate causal explanation. With the development of haematology in the nineteenth century, it was shown to be a form of iron-deficiency hypochromic anaemia; from epidemic proportions in earlier times, it disappeared as a medical diagnosis in .the 1920s. The features of chlorosis were: its predominance among young women; the cardinal feature of amenorrhoea, a disturbed mental state including depression, hypochondria, weakness, and social isolation ; disturbed appetite including anorexia, reduced food intake, nausea and vomiting, bizarre food selection and pica, severe weight loss sometimes resulting in death, fear of obesity, bulimia alternating with anorexia; and the supposedly characteristic (but controversial) green colour (Loudon, 1980). Before the mid-nineteenth century chlorosis was thought to be a disorder of the affluent, due to sexual frustration and cured by sexual activity and pregnancy (in 1554 Lange called it mobus virgineus - the "virgin's disease"); after that it was believed to be a disease of the lower class in unhealthy tenements and factories caused by poor nutrition and absence of fresh air and sunlight. Loudon (1980) notes that the anaemia theory, widely accepted by 1890, was eagerly received because it fitted well with the dominant model of laboratory medicine and relieved physicians from making personal enquiries into the menstrual state and sexual activities of young women. Furthermore, the traditional cure by "the exercise of venery" was impractical as affected girls had neither the inclination nor energy for such exercise and this advice was unlikely in an age that regarded "erotomania", "nymphomania" and "onanism" as possible causes of insanity or death. 16176 "The 'orbus virgineus' of Lange, the green sickness and chlorosis", Loudon (1980) suggests, may be "disorders lying on the same evolutionary line of psychopathology as anorexia nervosa" and offers the hypothesis that anorexia nervosa and chlorosis are "two closely related conditions, each a manifestation of the same type of psychological reaction to the turbulence of puberty and adolescence" (p. 1675). While the similarity of features is striking, anorexics do not commonly have anaemia. It is possible that in the absence of a clear set of clinical criteria and laboratory studies in earlier times, the multifaceted descriptions of chlorosis included among them some cases compatible with contemporary anorexia nervosa. Retrospective studies employing rigorous clinical criteria would therefore be useful. Parry-Jones (1985) did just that by studying hospital archives to establish a wider view of anorexia nervosa and similar presentations in the nineteenth and early twentieth centuries. Examining admission registers and case records relating to over 36,000 admissions to two general infirmaries and four asylums in England, Parry-Jones found only 40 cases suggesting anorexia nervosa. These cases were carefully distinguished from numerous cases of food refusal and emaciation associated with melancholia, mania and dementia treated at the asylums. Records from the two general hospitals sampled "indi- cate the regular diagnosis of chlorosis throughout the nineteenth century, in keeping with Loudon's findings (1980)" (p. 100). Parry-Jones suggested "that choloris... and anorexia nervosa are analogous conditions, on the same psychopathological continuum" pointing to the key sign of amenorrhoea in both conditions and concluded, "It seems likely that present day anorexia nervosa has had varying counterparts during the last two centuries" (p. 100). In his historical review, Russell (1985) argued that anorexia nervosa "has undergone major transformation over the course of recent decades" (p. 101). Russell cited three lines of evidence: (1) increased incidence of anorexia nervosa, (2) alterations in the core psychopathology of anorexia nervosa, and (3) changes in form with the emergence of bulimia nervosa. A parallel with the major psychoses was suggested by Russell who cited research showing how their incidence and course had changed during the nineteenth and twentieth centuries. From the data of the WHO International Pilot Study ~ .of Schizophrenia and follow-up studies (Sartorius, et al, 1986), we can also add that the major psychoses have a marked cultural variation. Russell (1985) concluded, "mental illness may 'evolve' over 17177 the course of time, and an analogy has been drawn with the progress of Darwinian evolution (Hare, 1981), though the differences in time scale are such that this analogy should not be pressed too far" (p. 101).5 Let us see how far we can take it. The problem of "gaps" in the fossil record has been a major difficulty for evolutionary theory. In their critique of "phyletic grad- ualism" in evolution which holds that new species arise from slow, steady population transformations, Eldredge and Gould (1972) proposed an explanation for fossil record gaps. According to them, the theory of "geographic speciation" leads to a new view of the history of life: homeostatic equilibria (periods of great stability) disturbed ("punctuated") only rarely by sudden saltatory (L. sadtus, jump) bursts of speciation. With their theory of "punctuated equilibria", one of the most exciting new ideas in biology, Gould and Eldredge (1977) have proposed that "a general theory of punctuational change is broadly... valid throughout biology" (p. 145). A major problem in the history of self-starvation has been that we either take a continuum view where we look for historical and clinical analogues of anorexia nervosa that were missed or misunderstood in context (despite gaps in medical perception, this conforms to a gradualism view of self-starvation) or a caseness view which argues that anorexia nervosa is a modern disease which suddenly appeared under the requisite socio-cultural conditions. I propose that what is definitive about self-starvation is the changing socio-cultural blueprint: it determines whether fasting will be construed in religious terms as "holy anorexia", in medical terms as "chlorosis", in psychiatric terms as "anorexia nervosa", or in political terms such as "hunger strike". In this view, anorexia nervosa is a chameleon with protean clinical manifestations changing with the times, what we might call anorexia multiforme. What we consider core in a hermeneutic, biological, psychological or political sense may change because holy anorexia had a core religious meaning that was married to the context of medieval Italy; a new and possibly related predicament arose under the vastly different biological and environmental conditions of industrial England, leading to the anaemia and anorexia of chlorosis; the last great jump was anorexia nervosa, a paradoxical psychological response to the conflictural demands of Western affluence, the watchful gaze of the middle-class family and changing sex roles. In late twentieth century Western societies, there are signs that we have made a new saltus: the epidemic of "me too anorexics", "hunger strike" as a moral crusade against mas- 18178 culinism, anorexia nervosa as a cultural icon and as a socio-cultural explanatory model. Eisenberg (1986) reminds us that the "caseness" and the "contin- uum" approaches are not mutually exclusive. He reviews several medical diseases to demonstrate that disease definitions change historically : "what was originally thought to be a `species'- (a clinical syndrome sui generis) has been shown to be more in the nature of a genus comprised of many species" (p. 471). However, the view of "anorexia multiforme", a genus of many species of anorexia nervosa variants, may be incorrect. What appear to be clinical and historical analogues on a continuum or spectrum may well be distinct cases or entities (if one.takes the syndrome-centred approach) or diverse illness experiences (if one takes a contextual or meaning-centred approach). One of medicine's most powerful conceptual tools is differential diagnosis. An example of the importance of differential diagnosis was demonstrated in Isolde Prince's recent overview on pica and geophagia (1989). Paradoxically, both benign and malignant forms of geophagia occur: why can some people eat significant quantities of dirt with impunity, yet others contract a life-threatening disease? Malignant forms of geophagia include cachexia african and pobough lang, which have an accompanying anaemia. The paradox may be resolved by the differential diagnosis of the anaemia associated with malignant geophagia: the anaemia may be due to another illness, sickle-cell anaemia. Prince suggested that sickle-cell anaemia and malignant geophagia may co-exist and that this might resolve the paradox. ANOREXIA NERVOSA AS A METAPHOR As I have argued (DiNicola, 1988c) confusing an illness, its explanation and its use as a metaphor blurs important distinctions, leading to muddled thinking such as "emic-etic confusions" (cf. Marano, 1982): "The essential problem in blurring the illness-metaphor distinction is that the metaphor loses its 'bite' as polemic (to which it is best suited) and mistakenly leads the reader to make causal connections between illness and metaphor" (p. 52). For example, there is a current trend to make vivid metaphors from anorexia nervosa ("hunger strike", Orbach, 1986) or to apply the abel anorexia metaphorically to another human predicament ("holy ' anorexia", Bell, 1985: Bynum, 1988) and then to proffer it as an explanation of the disease. 19179 Anorexia nervosa has become a major preoccupation and a cultural icon in the West.' Brumberg (1985) argues that "we use 'anorectic' much as we have used 'syphilitic', 'epileptic', or 'diabetic' to mark an individual in a particular way" (p. 94). The New York Times' "Architecture View" has referred to "anorexic skyscrapers" and "bulimic buildings". Comedians have satirized the "anorexic cook- book" and declared a new disease, "anorexia ponderosa" (Brumberg, 1988). A recent "lifestyle" newspaper article referred to "overload bulimia" (Snead, 1989, p. Al) in a discussion of a book on information anxiety. This is doubly interesting: as an example of a general preoccupation with eating disorders and because it is an inaccurate quote. In fact, Wurman (1989) discusses "overload amnesia", not bulimia (p. 127). Even a prosaic, disciplined thinker like B. F. Skinner, not given to metaphoric extensions of meanings, coined the terms "lib- ertas nervosa" and "aritas nervosa" (Skinner, 1987). Each era has a set of dominant medical models which shape the perceptions of illness. A generation ago the schizophrenias held this role in Western psychiatry as evidenced by both the medical literature and popular accounts such as the widely read I Never Promised You a Rose Garden (Greenberg, 1965) by a patient of Frieda Fromm-Reichmann. In Western medical cultures today, anorexia nervosa has become and explanatory model in its own right. Schwartz and associates (1985) have suggested that eating disorders have become "pet" mental disorders. Well-known figures and famous cases are now being viewed and reinterpreted as "anorexic" by well respected mainstream medical researchers. The argument for Franz Kafka as an anorexic is especially fascinating in light of his haunting story, "The Hunger Artist" (Fichter, 1987). James M. Barrie, the creator of Peter Pan or "the boy who would not grow up", has been presented as an anorexic (Fried and Vandereycken, 1989). A book- length biography of Elizabeth Barrett Browning now interprets her illness as anorexia nervosa (Dally, 1989). First-person accounts such as Sheila Macleod's The Art of Starvaction (1981) in Britain and Valerie Valere's Le Pavillon des Enfants Fous (1978) in France, and the disclosure of celebrities with eating disorders (e.g., Jane Fonda's bulimia and Karen Carpenter's anorexia nervosa) reflect what Har- per (1984) has called the "'anorectic' as cultural hero". The case of "Ellen West" is now vying with Freud's case of "Dora" as the most famous woman in psychiatric literature. She was first presented by Ludwig Binswanger (1944/1958) in an example of existential analysis. She had been diagnosed as schizophrenic by Eugen 20180 Bleuler himself (who coined the term); and for all of R. D. Laing's critical stance towards schizophrenia as a disease, he confirmed the diagnosis ("Her existential Gestalt... shows the unfolding of a schizophrenic illness that was predestined to destroy her", 1982, p. 62), rather than opening up new interpretations. Binswanger and Laing are examples of psychiatrists whose perceptions were shaped by the model of schizophrenia that Bleuler constructed. Selvini Palazzoli (1963/1974) and Hilde Bruch (1973), both pioneers in the study of anorexia nervosa, read Ellen West as anorexic. Salvador Minuchin, who became renowned for his family treatment of anorexia nervosa, also reads it as a case of anorexia nervosa and made it into a short play: "The Triumph of Ellen West" (Minuchin, 1984). Kim Chernin (1981), in a sensitive feminist portrayal of Ellen West, reads her illness as anorexia nervosa. The issue that arises from these interpretations is not whether they are diagnostically correct. What these accounts articulate is of a different order than what medicine and psychiatry understand as diagnostics and therapeutics. They articulate something about the social order and about the cultural meaning of illness, which is why historian Brumberg (1985) calls for.enlarging the context for observing the illness. Taylor's (1985) notion of roredicaments is a richly nuanced attempt to grasp this larger envelope within which both disease (objective signs and symptoms) and illness (subjective experience of distress and disease) are situated: "predicaments are painful social situations or circumstances, complex, unstable, morally charged and varying in their import in time and place" (p. 130). The notion of predicament is to the social psychiatrist what the unconscious is to the psychoanalyst and family process is to the family therapist (DiNicola, 1989). However much we endorse this larger project (which is more satisfying on the level of meaning), we must not confuse its aims. Anorexia nervosa does not pose the problem of being only a metaphor. Those like Orbach (1986), who insist it is, have the burden of explaining for what it stands. Orbach says it is a metaphor for women's struggle. Yet the power of the metaphor is derived from the clinical reality of self-starvation and not vice-versa. Anorexia nervosa is not solely a "metaphor that is meant" (to use Bateson's apt phrase) by the patient or an "interpretation of experience" by the physician that emerges under specific socio-cultural conditions. It can also be constructed as a medical syndrome (defined as an 21181 "aggregate of signs and symptoms associated with any morbid process, and constituting together the picture of a disease", Stedman's Medical Dictionary, 1972, p. 1233) and arguably as a disease entity (characterized usually by at least two of these criteria: a recognized etiologic agent (or agents); an identifiable group of signs and symptoms ; consistent anatomical alterations", Stedman's 1972, p. 358). However, it cannot be classified as an organic medical syndrome since no primary or essential pathophysiology or anatomical lesion has been discovered. HYPOTHESES OF ANOREXIA NERVOSA In our evolving understanding of anorexia nervosa, many causal hypotheses have been formulated, ranging across a variety of individual, family and socio-cultural explanations. One way to organize these wide-ranging causal hypotheses is in order of their increasing level of breadth and complexity (see Table 1). INDIVIDUAL HYPOTHESES. The individual hypotheses construe anorexia nervosa as a personal dysfunction, varying from Russell's (1977) biomedical hypothesis of hypothalamic dysfunction to Bruch's (1973) psychodynamic hypothesis. 22182 1. BIOMEDICAL HYPOTHESIS. Gerald Russell (1977), a London psychiatrist, proposed a theory of primary hypothalamic dysfunction of unknown aetiology underlying anorexia nervosa. While there are some findings that support this hypothesis (see Hsu, 1988), it cannot account for all the clinical and epidemiological features of anorexia nervosa. Specifically, this hypothesis cannot explain why the disorder affects selected groups (Western women) and why its incidence is increasing. Furthermore, biomedical explanations have tended to interfere with a clear understanding of the illness. As noted above, Simmons' discovery in 1914 of a pituitary disorder which presents with symptoms similar to anorexia nervosa (amenorrhoea, cachexia) delayed the recognition of, and research into, anorexia nervosa as a psychiatric disturbance for several decades. It took another endocrinologist working in the 1930s and 1940s, H. L. Sheehan (1937), to dispel the mistaken belief that the destruction of the pituitary must lead to cachexia (Selvini Palazzoli, 1963/1974). 2. MOOD DISORDER HYPOTHESIS. In 1977, Cantwell and associates asked if anorexia nervosa is an affective disorder (see review by DiNicola, et ccl, 1989). Since then a minor industry has arisen to study the relationship between eating and mood disorders. Anorexia nervosa is part of a long list of disorders that are supposedly a mask for mood disorders; oddly, a view that is shared by both biologically- and psychotherapeutically-oriented psychiatrists. The symptom of depression is commonly associated with many medical illnesses, including starvation, and does not in itself comprise the psychiatric diagnosis of a mood disorder. For this and other reasons (see critical review by Katz, 1987; DiNicola, et al, 1989), therefore, despite the fact that from 25 to 75 percent of patients may show signs and symptoms of both types of disorders, anorexia nervosa is not primarily a mood disorder and a coherent model for the relationship remains to be found. 3. DEVELOPMENTAL PSYCHOBIOLOGICAL HYPOTHESIS. Arthur Crisp's (1977) widely-known hypothesis constructs anorexia nervosa as "adolescence avoided": a fear of gaining weight and of growing up. The psychobiological changes of puberty are thus considered pivotal triggering events. Added to this are insights about the family environment of the anorexic including the illness as a way to detour family conflicts. Because the onset of anorexia nervosa is often during puberty and is associated with well-recognized family reaction 23183 patterns, Crisp's (1977) hypothesis has intuitive appeal and clinical explanatory value. It has however, two major faults: (1) it does not articulate any specific testable causal mechanisms operating during puberty; (2) the emergence of anorexia nervosa well before and after the onset of puberty challenges the explanatory power of Crisp's hypothesis. A developmental hypothesis that takes early-onset cases into account and posits different life stress events at different stages of development as mechanisms for triggering anorexia nervosa expands Crisp's hypothesis (DiNicola, et al, 1989). 4. PSYCHODYNAMIC HYPOTHESIS. Psychoanalytic views of anorexia nervosa have centred around the presumed psychodynamics of feeding and eating. Key ideas have included oral impregnation fantasies, rejection of female genital sexuality and oral cannibalistic fantasies. These ideas are speculative (and perhaps untestable) and attempt reconstructions of the mental state of the developing infant and child that assume adult cognitive structures. Furthermore, the notion of self-starvation to avoid growing up (fear of adult sexuality) is a teleological argument which tries to explain events by reference to final causes or end goals. Teleology is a form of reasoning long refuted in biology. Does the average teenager realize that dropping below a critical weight will terminate her menstrual flow, retard puberty, put off the adult female distribution of body fat, and affect her breast development and fertility? In fact, the realization of many of these relationships has yet to reach the medical mainstream (DiNicola, 1988c). Other ideas have received more widespread acceptance as they have at least some face validity: self-starvation expresses hostility, control and aggression toward the family. Bruch (1973) portrayed anorexia nervosa as a struggle for differentiation, identity and self- respect and pointed to defective parenting. Such ideas are now generally accepted as plausible, yet remain unproven. Rampling (1980) has provided one of the few detailed case studies documenting "abnormal mothering". FAMILY HYPOTHESIS Some of the individual hypotheses acknowledge the dyadic nature of the early feeding situation in the developing child and the interactional nature of family problems observed in anorexia nervosa. However, the focus on the individual does not lead to a model of what sorts of family conflicts trigger anorexia nervosa and relate 24184 them to observed interactional patterns. Individual psychotherapy, furthermore, was unfruitful (see Selvini Palazzoli, 1963/1974; 1985). A broader view of anorexia nervosa places the illness in a family context (Selvini Palazzoli, 1963/1974; Minuchin, et ccl, 1978). 5. FAMILY SYSTEMS HYPOTHESIS. Interestingly, the two most outstanding family therapists are psychiatrists who made anorexia nervosa central to their work and developed specific models for its treatment. Mara Selvini Palazzoli employed three different models for treating anorexia nervosa. Self Starvation chronicles Selvini Pal- azzoli's (1963/1974) conversion from individual psychoanalytic therapy to the systemic family therapy she developed at the Centre for Family Studies in Milan. Later, she developed a new model, using "the invariant prescription" which was used to investigate the different types of family games among anorexic patients (Selvini Palazzoli and Viaro, 1988). Invited to comment on the cultural aspects of anorexia nervosa, Selvini Palazzoli (1985) called it "a syndrome of the affluent society". Selvini Palazzoli's hypothesis is that cultures have inherent contradictions: "The culture of the affluent society presents... such contradiction which... is related to anorexia nervosa: in proportion as food becomes abundant and available to everyone, so each person is obliged to be thin. The demand for self-discipline in the consumer society...prescribes an inverse relationship between abundance of food and body weight" (p. 201). She hypothesizes that the fashion for thinness acts as a trigger for anorexia nervosa in dysfunctional families: "the thin look reigning in Western culture has supplied anorexics the instrument to express covertly their relational distress" (p. 202). _ In Psychosomatic Families, Salvador Minuchin (Minuchin, et al, 1978) developed a systems model of anorexia nervosa, a profile of the characteristics of the psychosomatic family (enmeshment, over- protectiveness, rigidity, and lack of conflict resolution), and family treatment (the "family lunch session" and structural family therapy); outcome research showed 86 percent recovery rate for "both anorexia and its psychosocial components" (p. 133). In Family Kaleidoscope, Minuchin (1984) presented his interpretation of the case of Ellen West as anorexia nervosa in a dramatic format and re-exam- ined the Menotti family from Psychosomatic Families. SOCIO-CULTURAL HYPOTHESES . Anorexia nervosa has some compelling features which demand an even larger context to explain them: the fact that females predominate by at least ten to one has engendered a feminist social hypoth- 25185 esis (Orbach, 1986); its much greater prevalence in industrialized nations and among immigrants has fostered cultural hypotheses (Prince, 1985; DiNicola, 1985b). To paraphrase Brumberg (1988), anorexia nervosa has a highly specific socio-cultural address. 6. FEMINIST (SOCIAL) HYPOTHESIS (Orbach, 1986; Swartz, 1985b; DiNicola, 1988c). A fundamental fact to be explained by any theory is the female predominance of eating disorders (see Hsu, 1989). This issue has been taken up by many feminist social critiques (see Cas- key, 1986). However, few feminist studies have studied anorexia nervosa seriously as more than an emblem or example of a general argument. This approach is revealed in titles such as Fed Up and Hungry: Women, Oppression and Food (Lawrence, 1987). Some feminist accounts are more genuinely concerned with the illness experience of anorexia nervosa (Chernin, 1981); others are more scholarly reviews (Dyrenforth, et al, 1980; Swartz, 1985b). In my reading, the strongest version of the feminist position has been articulated by Susie Orbach who works with anorexics (1985, 1986) and has addressed the larger socio-cultural issues (1986). Orbach (1986) presents anorexia nervosa as a hunger strike to protest against the social definition of femininity. In rejecting their social roles, some women also reject their own bodies: Orbach argues that this struggle makes the anorexic sick. If this is so, why does it appear in higher social classes and in more technologically-developed and female-liberated Western societies where women have greater opportunities? And why in men at all? The strength of Orbach's feminist hypothesis is that it addresses its female predominance, the most striking fact about anorexia nervosa, and makes culture a causal factor in its occurrence. Its weaknesses are that "hunger strike" is a powerful metaphor that only restates the social problems of women. It neither explains them nor points to solutions either for women generally or for anorexics. Bruch (1973) called the case of a prisoner's hunger strike psychogenic malnutrition (pp. 232- 233). Orbach does not explain how hunger strikes such as Bruch's case, and the more political cases of Gandhi (India) and Bobby Sands (Northern Ireland) differ from anorexia nervosa. Another limitation is that Orbach does not address the ironic interrelationships among anorexia nervosa, women and feminism across cultures. 7. CULTURE-BOUND SYNDROME (cultural) hypothesis (Prince, 1985; Swartz, 1985a). 26186 8. CULTURE-CHANGE SYNDROME (transcultural) hypothesis (DiNicola, 1985b) . In Part II, these two cultural hypotheses are discussed in detail. From the literature on anorexia nervosa, seven basic features of anorexia nervosa are extracted and reviewed: sex, occupation, social class, culture, period prevalence, and predisposing and precipitating events. These seven basic- features outline the requirements for a comprehensive model of the illness. Part n will demonstrate that an enlarged socio-cultural context is necessary for a comprehensive explanation. A comprehensive model of anorexia nervosa, accounting for the basic features of the illness, must also be able to integrate or refute each of the eight causal hypotheses presented here. My contention in Part II is that to understand the modern illness anorexia nervosa, we need the methods of transcultural psychiatry. In this view, anorexia nervosa emerges as a culture-reactive syndrome. The cultural hypothesis is of Anorexia nervosa as cm culture-bound syndrome of Western societies (Prince, 1985; Swartz, 1985a). The cultural hypothesis identifies the typical conditions that produce anorexia nervosa. However, anorexia nervosa is also beginning to appear under conditions that fall outside those defined by the cultural hypothesis. I have called these atypical presentations "orphan cases" (adapted from Simons, in press), occurring during rapid culture change (among migrants and in societies undergoing rapid economic and socio-cultural change). Therefore, a transcultural hypothesis of anorexia nervosa as a cuLture-change syndromes (DiNicola, 1985b) is posited as an adjunct or corollary of the culture-bound syndrome hypothesis. ACKNOWLEDGEMENTS This overview is based in part on presentations at the Canadian Psychiatric Association's Annual Meeting, Quebec City, Canada, October 1985 (DiNicola, 1985a) and at symposia on culture bound syndromes at the American Psychiatric Association's Annual Meeting, Montreal, May 1988 (DiNicola, 1988a) and at the VIII World Congress of Psychiatry, Athens, October 1989 (DiNicola, in press). I am grateful to the symposia panelists for their stimulating discussions, particularly Raymond Prince (Prince, 1985; Prince and Tcheng-Laroche, 1987) and Ronald Simons (Simons, in press; Simons and Hughes, 1985). , 27187 A version of Part II was presented at the BASH Treatment and Research Center for Eating and Mood Disorders, Deaconess Hospital, St. Louis, Missouri (DiNicola, 1988b). I benefitted from discussions with Brian Lask and Rachel Bryant-Waugh at the Sick Children's Hospital, London, and with the staff of Gerald Russell's Eating Disorders Unit at the Maudsley Hospital. For some time, I had been using Ethiopia as an example of an unimaginable context for anorexia nervosa until Tom Fahy (Fahy, et ccl, 1988) brought just such a case to my attention. Christopher Dare pointedly brought out the tension in my argument between "entity" and "meaning- centred" views of anorexia nervosa; I have tried to articulate and resolve that tension here. I wish to thank Louise Oke, Evelyn Chow and Janet Joyce, Royal Ottawa Hospital's Rhodes Chalke Library for their help in tracking down the far-flung sources of this overview. This work was supported in part by research grants from the University of Ottawa School of Medicine and the Royal Ottawa Hospital Foundation. NOTES 1 This overview concerns anorexia nervosa and not the eating disorders generally for several reasons: anorexia nervosa has been recognized as a medical illness since 1873 (Anonymous, 1873; Gull, 1874) and is more easily recognized by all medical practitioners because of self-starvation leading to life-threatening weight loss. Bulimia nervosa was only recently (Rus sell, 1979; APA, 1987) differentiated as a separate disorder, it is less well- established as a medical diagnosis (rather than as a variant of anorexia nervosa, or eating anomaly), and the medical complications are less often life-threatening and less certainly related to intentional nutritional defi ciencies. Furthermore, owing to its weight fluctuations within broadly normal limits and the often secretive habits of bingeing and purging, buli mia nervosa can be kept hidden from a medical examiner who is not alerted to the possibility (such physical evidence as the "Russell sign" of skin ulceration over the hand and the erosion of tooth enamel from chronic self-induced vomiting must be carefully observed). Lastly, my impression that anorexia nervosa has a much greater public profile than bulimia ner vosa is supported by a recent community study (Murray, et al, 1990). The other two eating disorders recognized by DSM-III-R (APA, 1987) are special cases of interest to paediatrics and child psychiatry: pica (Blinder, et al, 1988b; for a cultural perspective, see I. Prince, 1989) and rumination (Blinder, et al, 1988a). Obesity is considered a medical rather than a spe cifically psychiatric disorder (see APA, 1987). For anthropological reviews of obesity see Powdermaker (1960) and Brown and Konner (1987). 2 Documentary sources. This overview contains a fairly exhaustive refer ence list of the English-language reports of the occurrence of anorexia nervosa around the world. A sourcebook on some key historical documents 28188on anorexia nervosa can be found in Kaufman and Heiman (1964), includ ing the first papers by Gull (1868, 1874, 1888; Anonymous, 1873) and Lasègue (1873a, b). Historical reviews of Gull's work (Silverman, 1988) and his claim for priority in describing the illness (Vandereycken and Van Deth, 1989) are of interest. One of Gull's epigrams is of interest here: "Savages explain; science investigates" (quoted in Lyons and Petrucelli, 1978, p. 516). Other historical surveys include: Brumberg, 1988; Haber mas, 1989; Russell, 1985; Selvini Palazzoli, 1963/1974; Shorter, 1987; Sil verman, 1983, 1986, 1987a, b; and Skrabanek, 1983. Brumberg's Fasting Girls (1988) is a lucid and informed history of anorexia nervosa, which marshals the medical data very well and draws many important distinc tions. For a historical overview of bulimia, see Blinder and Cadenhead (1986). 3 DSM-III-R diagnostic criteria for anorexia nervosa (APA, 1987, p. 67): A. Refusal to maintain body weight over a minimal normal weight for age and height, e.g., weight loss leading to maintenance of body weight 15 percent below that expected; or failure to make expected weight gain during period of growth, leading to body weight 15 percent below that expected. B. Intense fear of gaining weight or becoming fat, even though under weight. C. Disturbance in the way in which one's body weight, size, or shape is experienced, e.g., the person claims to "feel fat" even when emaciated, believes that one area of the body is "too fat" even when obviously underweight. D. In females, absence of at least three consecutive menstrual cycles when otherwise expected to occur (primary or secondary amenor rhoea). (A woman is considered to have amenorrhoea if her periods occur only following hormone, e.g., oestrogen, administration.) 4 If psychiatrists want to investigate socio-cultural aspects of mental dis orders, they must undertake the necessary training. If social scientists want to study the people and predicaments that come to medical attention, they must do the same. I share Bynum's (1988) concern over the exces sively narrow attempts at providing cultural context made by present- day psychiatrists" (p. 244) and am informed by her own work in this regard, but I am also chagrined by careless or systematic distortions of medical literature by social scientists. In a weakly-argued article on chlo rosis, for example, Theriot (1988) states that nineteenth century physi cians employed the term "anorexia" to mean "loss of appetite" and not as a disease in and of itself. She offers this as "indication that chlorosis was what today would be diagnosed as anorexia" (p. 464). This reveals two mistakes: a misunderstanding of basic medical terms and faulty deductive reasoning. First, these axiomatic definitions still hold: anorexia means loss of appetite and is a symptom not a disease. It is a misnomer in anorexia nervosa and more importantly, "anorexia" should never be stated to imply the illness "anorexia nervosa", as Theriot employs it throughout her arti cle. Second, disease diagnosis is based on a complex reading of sign and symptom patterns, aetiology and course. Theriot's symptomatic equiva lence of loss of appetite with anorexia nervosa reveals a misunderstanding 29189of clinical medicine. The differential diagnosis of the symptom of anorexia includes organic gastric disease (ulcers, biliary disease leading to sito phobia), any chronic disease process (cancer, alcoholism), and psycholog ical conditions (depression, delusions, anorexia nervosa) (see Hart, 1979). At one point, Bynum (1988) states that psychologists disputed over causal explanations, opposing biochemical theories to psychodynamic and cultural ones (p. 241), but then makes a similar opposition of physiological and cultural causes (p. 243). Bynum argues cogently that "the appearance of similar behavior in different cultural contexts does not prove that the behavior has a physiological cause" (p. 243), but then asserts that "the incidence of non-eating behavior... clearly varies enormously over time.... If the cause were physiological, the incidence would vary little if at all" (p. 243). There are some problems here. "Non-eating behavior" is much too broad a category, as my example of the differential diagnosis of "anorexia" shows. More importantly, medicine does not present diseases as either "phys iological or cultural". Two issues can be highlighted: "caseness" vs. "con tinuum" (Eisenberg, 1986) and the interaction of factors. Medical models for most diseases are strongly interactive. Infectious diseases have to be understood in terms of infectious agents, host vulnerability, and vectors of transmission. Allergic diseases such as asthma have to be understood as an interaction between genes, phenotype and environment. Even genetic diseases are interactive. For example, G-6-PD deficiency is a sex-linked glycolytic enzyme defect affecting millions of people around the world whose chief clinical feature is haemolytic anaemia, precipitated by drugs or toxins. Some individuals with the Mediterranean type G-6-PD are exquis itely sensitive to fava beans (Vicia fava, hence the clinical name favus) and will develop a fulminant haemolytic crisis following exposure. Is this a genetic or an environmental disease? Neither. Genes interact with the environment. Furthermore, favism is one "case" on a wide "continuum" of glycolytic enzyme defects. Without our knowledge of haematology and genetics, favism would be a separate disease from the other 100 or so variants. 5 Cultural and historical perspectives of medical illnesses naturally lead to analogies with biological evolution, as suggested by several historical accounts (Loudon, 1980; Parry-Jones, 1985; Russell, 1985). Gerald Russell (1985) has begun the groundwork for a more detailed study: "diseases, like species, represent the balance of a process by which living organisms struggle to adjust to a continually changing envi ronment. The main difference is that diseases change much more quickly than species do. And perhaps psychiatric diseases change much more quickly than others because their expression is largely psycho logical and follows changing fashions" (Hare, 1981; cited by Russell, 1985, p. 101). "From (a history of illness) we can learn how the picture of illness shifts though scientifically the illness may be identical; the neuroses in particular have a contemporary style - they flourish in certain sit uations and are almost invisible in others." (Jaspers, 1963; cited by Russell, 1985, p. 101. 30190 6 Another metaphor for anorexia nervosa comes from the study of addic tions (see Vandereycken, 1990). This metaphor is rather empty in calories (to use another metaphor), with little explanatory power. Among other problems, the addiction metaphor confuses addiction with compulsion and habituation and tolerance with purposive drive. The term addiction is widely but loosely used to label such behaviour as food cravings ("cho coholic"), promiscuity ("sexual addiction"), information anxiety ("neo holic") and excessive work ("workaholic"). These phenomena are complex and interesting but labelling them as addictions muddles rather than clar ifies our understanding. REFERENCES Accorneq, F. 1943. L'anoressia mentale. Una priorità italiana e l'osservazione di 4 casi. Rivista Sperimentale di Freniatria e Medicina Legale delle Alienazioni Mentale 67:447-489. American Psychiatric Association. 1987. Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev). Washington, DC: APA . ANONYMOUS. 1873. Clinical Society of London, Friday, 24 October, 1873 ... Anorexia hysterica (apepsia hysterica). British Medical Journal (Nov. 1) 2:527-528. Axenfeld, A. and Huchard, H. 1883. Traité des Névroses. Paris: Baillière et cie. Baraldi, M. 1952. Contributo allo studio della anoressia mentale . Rivista Sperimentale di Freniatria e Medicina Legale delle Alienazioni Mentale 76:381-395. Bell, R.M. 1985. Holy Anorexia. Chicago: The University of Chicago Press. Binswanger, L. 1944. Der Fall Ellen West. Schweizer Archiv fuer Neurologie , Neurochirurgie und Psychiatrie 53:155-282. ___ 1958. The Case of Ellen West: An Anthropological-Clinical Study . In (R. May, E. Angel and H. F. Ellenberger, eds.): Existence: A New Dimension in Psychiatry and Psychology. New York: Basic Books, pp. 237-364. Original published in 1944. Blinder, B.J. and Cadenhead, K. 1986. Bulimia: A Historical Overview. In: S. C. Feinstein (ed.), Adolescent Psychiatry: Developmental and Clinical Studies, Vol. 13. Chicago: University of Chicago Press, pp. 231-240. Blinder, B.J., Goodman, S.L. and Goldstein, R. 1988a. Rumination: A Critical Review of Diagnosis and Treatment . In: B. J. Blinder, B. F. Chaitin and R. S. Goldstein (eds.), The Eating Disorders: Medical and Psychological Bases of Diagnosis and Treatment. New York: PMA, pp. 315-329. Blinder, B.J., Goodman, S.L. and Henderson, P. 1988b. Pica: A Critical Review of Diagnosis and Treatment . In: B. J. Blinder, B. F. Chaitin and R. S. Goldstein (eds.), The Eating Disorders: Medical and Psychological Bases of Diagnosis and Treatment. New York: PMA, pp. 331-344. 31191 Brown, P.J. and Konner, M. 1987. An Anthropological Perspective on Obesity. In: R. J. Wurtman and J. L. Wurtman (eds.), Human Obesity. New York: New York Academy of Sciences, pp. 29-56. Bruch, H. 1973. Eating Disorders: Obesity, Anorexia and the Person Within . New York: Basic Books. ___ 1985. Four Decades of Eating Disorders. In: D. M. Garner and P. E. Garfinkel (eds.), Handbook of Psychotherapy for Anorexia Nervosa and Bulimia. New York: Guilford , pp. 7-18. Brumberg, J.J. 1982. Chlorotic girls, 1870-1920: A historical perspective on female adolescence. Child Development 53:1468-1477. ___ 1985. "Fasting girls": Reflections on writing the history of anorexia nervosa. Monographs of the Society for Research in Child Development 50:(4-5, Serial No. 211):93-104. ___ 1988. Fasting Girls: A Social and Cultural History of Anorexia Nervosa. Cambridge, MA: Harvard University Press. Bynum, C.W. 1987. Holy Feast and Holy Fast: The Religious Significance of Food to Medieval Women. Berkeley: University of California Press. ___ 1988. Review article: Holy anorexia in modern Portugal. Culture, Medicine and Psychiatry 12:239-248. Cantwell, D.P., Sturzenberger, S., Burroughs, J. et al. 1977. Anorexia nervosa: An affective disorder? Archives of General Psychiatry 34:1087-1093. Caskey, N. 1986. Interpreting Anorexia Nervosa. In: S. R. Suleiman (ed.), The Female Body in Western Culture . Cambridge: Harvard University Press, pp. 175-189. Chernin, K. 1981. The Mysterious Case of Ellen West. In: The Obsession: Reflections on the Tyranny of Slenderness. New York: Harper & Row, pp. 162-179. Chipley, W.S. 1859. Sitomania: Its causes and treatment. American Journal of Insanity 16:4, 41. Crisp, A.H. 1977. Diagnosis and outcome of anorexia nervosa: The St. George's view. Proceedings of the Royal Society of Medicine 70:464-470. Dally, P. 1989. Elizabeth Barrett Browning: A Psychological Portrait . London: Macmillan. Demos, J. 1982. Entertaining Satan: Witchcraft and the Culture of Early England. London: Oxford University Press. Dinicola, V.F. 1985a. Anorexia nervosa as a culture-bound syndrome. Symposium on "Eating Disorders", Canadian Psychiatric Association 35th Annual Meeting Abstracts, Quebec, Quebec, October 1985, pp. 134-135. ___ 1985b. Family therapy and transcultural psychiatry: An emerging synthesis. Part II: Portability and culture change. Transcultural Psychiatric Research Review 22:151-180. ___ 1988a. Anorexia nervosa: A culture-bound syndrome. Symposium on "Culture-Bound Syndromes and DMS-II-R", American Psychiatric Association 141st Annual Meeting Abstracts, Montreal, May 1988, p. 228. ___ 1988b. Anorexia nervosa from a transcultural perspective: The requirements for a comprehensive model. The BASH Magazine 7:210-215. 32192 ___ 1988c. Essay-review of Susie Orbach's Hunger Strike: The Anorectic's Struggles as a Metaphor for Our Age. Transcultural Psychiatric Research Review 25:47-54. ___ 1989. The child's predicament in families with a mood disorder . Psychiatric Clinics of North America 12:933-949. ___ In press. Anorexia Nervosa: A Culture-bound Syndrome. In: C. Stefanis (ed.), VIII World Congress of Psychiatry. Amsterdam: Elsevier Science Publishers. Dinicola, V.F., Roberts, N. and Oke, L. 1989. Eating and mood disorders in young children. Psychiatric Clinics of North America 12:873-893. Dyrenforth, S.R., Wooley, O.W. and Wooley, S.C. 1980. A Woman's Body in a Man's World: A Review of Findings on Body Image and Weight Control. In: J. R. Kaplan (ed.), A Woman's Conflict: The Special Relationship Between Women and Food. Englewood Cliffs (NJ): Prentice-Hall , pp. 30-57. Eisenberg, L. 1986. When is a Case a Case? In: M. Rutter, et al (eds.), Depression in Young People: Developmental and Clinical Perspectives. New York: Guilford Press, pp. 469-478. Eldredge, N. and Gould, S.J. 1972. Punctuated Equilibria: An Alternative to Phyletic Gradualism . In: T. J. M. Schopf (ed.), Models in Paleobiology. San Francisco: Freeman, Cooper & Co., pp. 82-115. Fahy, T., Robinson, P.H., Russell, G.F.M., et al. 1988. Anorexia nervosa following torture in a young African woman. British Journal of Psychiatry 153:385-387. Fichter, M.M. 1985. Magersucht und Bulimia: Empirische Untersuchungen zur Epidemiologie, Symptomatologie, Nosologie und zum Verlauf. Berlin: Springer-Verlag. ___ 1987. The anorexia nervosa of Franz Kafka. International Journal of Eating Disorders 6:367-377. Fowler, R. 1871. A Complete History of the Case of the Welsh Fasting Girl (Sarah Jacob) with Comments Thereon, and Observations on Death from Starvation London: Henry Renshaw. Fried, R. and Vandereycken, W. 1989. The Peter Pan syndrome: Was James M. Barrie anorexic? International Journal of Eating Disorders 8:369-376. Garfinkel, P.E. and Garner, D.M. 1982. Anorexia Nervosa: A Multidimensional Perspective . New York: Brunner/Mazel. Garner, D. M. and Garfinkel, P. E. (eds.) 1985. Handbook of Psychotherapy for Anorexia Nervosa and Bulimia. New York: Guilford Press. Gould, S.J. and Eldredge, N. 1977. Punctuated equilibria: The tempo and mode of evolution reconsidered. Paleobiology 3:115-151. Greenberg, J. 1965. I Never Promised You a Rose Garden. New York: New American Library. Gull, W. 1868. The address in medicine delivered before the annual meeting of the British Medical Association, at Oxford. Lancet 2 (8 August):171-176. ____ 1874. Anorexia nervosa (apepsia hysterica, anorexia hysterica) . Transactions of the Clinical Society of London 7:22-28. ___ 1888. Anorexia nervosa. Lancet 1 (17 March):516-517. 33193 Habermas, T. 1986. Friderada. A case of miraculous fasting. International Journal of Eating Disorders 5:555-562. - 1989. The psychiatric history of anorexia nervosa and bulimia nervosa: Weight concerns and bulimic symptoms in early case reports. International Journal of Eating Disorders 8:259-273. Hajal, F. 1982. Psychological treatment of anorexia: A case from the ninth century. Journal of the History of Medicine and Allied Sciences 37:325-328. Hare, E. 1981. The two manias: A study of the evolution of the modern concept of mania. British Journal of Psychiatry 138:89-99. Harper, G. 1984. Anorexia nervosa: What kind of disorder? The "consensus" model, myth, and clinical implications. Pediatric Annals 13:812-828. Hart, F.D. 1979. French's Index of Differential Diagnosis (11th ed.). Chicago: John Wright. Hartley, L.P. 1953. The Go-Between. London: Hamish Hamilton. Hsu, L.K.G. 1988. The Etiology of Anorexia Nervosa. In: B. J. Blinder, B. F. Chaitin and R. S. Goldstein (eds.) The Eating Disorders: Medical and Psychological Bases of Diagnosis and Treatment . New York: PMA, pp. 239-246. ____ 1989. The gender gap in eating disorders: Why are the eating disorders more common among women? Clinical Psychology Review 9:393-407. Jaspers, K. 1963. General Psychopathology (Trans. from the 7th German ed. by J. Hoenig and M. W. Hamilton). London: Manchester University Press. Originally published in 1959 . Katz, J.L. 1987. Eating and affective disorder: Relatives or merely chance acquaintances? Comprehensive Psychiatry 28:220-228. Kaufman, M.R. and Heiman, M. 1964. Evolution of Psychosomatic Concepts. Anorexia Nervosa: A Paradigm. New York: International Universities Press. Kylin, E. 1937. Magersucht in der weiblichen Spaetpubertaet. Ein eigentümliches Krankheitsbild sui generis. Deutsches Archiv fuer Klinische Medizin 180:115-180. Lacey, J.H. 1982. Anorexia nervosa and a bearded female saint. British Medical Journal 285:1816-1817. Laing, R.D. 1982. The Voice of Experience: Experience, Science and Psychiatry . Markham, Ont: Penguin . Laspgue, C. 1873a. De l'anorexie hystérique. Archives Générale de Médecine 1 (avril):385-403. ___ 1873b. On hysterical anorexia. Medical Times and Gazette 2 (6 Sept.):265-266; (27 Sept. ):367-369. Lawrence, M. (ed.) 1987. Fed Up and Hungry: Women, Oppression and Food. London: The Women's Press Ltd. Lee, S., Chiu, H.F. and Chen, C-N. 1989. Anorexia nervosa and Hong Kong: Why not more in Chinese ? British Journal of Psychiatry 154:683-688. Levi-Strauss, C. 1966. The Savage Mind. Chicago: University of Chicago Press. 34194 Loudon, I.S.L. 1980. Chlorosis, anaemia, and anorexia nervosa. British Medical Journal 281:1669-1675. Lyons, A.S. and Petrucelli, R.J. 1978. Medicine: An Illustrated History. New York: Abrams. Macleod, S. 1981. The Art of Starvation: An Adolescence Observed . London: Virago. Marano, L. 1982. Windigo Psychosis: The Anatomy of an Emic-Etic Confusion . In: R. C. Simons and C. C. Hughes (eds.), The Culture-Bound Syndromes: Folk Illnesses of Psychiatric and Anthropological Interest. Boston: D. Reidel, pp. 411-448. McSherry, J.A. 1985. Was Mary, Queen of Scots, anorexic? Scottish Medical Journal 30:243-245. Minuchin, S. 1984. The Triumph of Ellen West: An Ecological Perspective . In: S. Minuchin, Family Kaleidoscope: Images of Violence and Healing . Cambridge: Harvard University Press. Minuchin, S., Rosman, B.L. and Baker, L. 1978. Psychosomatic Families: Anorexia Nervosa in Context . Cambridge: Harvard University Press. Morgan, H.G. 1977. Fasting girls and our attitudes to them. British Medical Journal 2:1652-1655. Morton, R. 1694. Phthisiologia - Or a Treatise of Consumptions. London: Smith & Walford. Murray, S., Touyz, S. and Beumont, P. 1990. Knowledge about eating disorders in the community . International Journal of Eating Disorders 9:87-93. Nasser, M. 1986. Comparative study of the prevalence of abnormal eating attitudes among Arab female students of both London and Cairo Universities. Psychological Medicine 16:621-624. Naudeau, J. 1789. Observation sur une maladie nerveuse accompagnée d'un dégoût extraordinaire pour les aliments. Journal de Médecine, Chirurgie et Pharmacologie 80:197-200. Orbach, S. 1985. Accepting the Symptom: A Feminist Psychoanalytic Treatment of Anorexia Nervosa. In: D. M. Garner and P. E. Garfinkel (eds.), Handbook of Psychotherapy for Anorexia Nervosa and Bulimia. New York: Guilford Press, pp. 83-104. ___ 1986. Hunger Strike: The Anorectic's Struggle as a Metaphor for Our Age. New York: Norton. Osler, W. 1932. Aequanimitas: With Other Addresses to Medical Students, Nurses & Practitioners of Medicine, 3rd ed. New York: McGraw-Hill. Parry-Jones, W.L. 1985. Archival exploration of anorexia nervosa. Journal of Psychiatric Research 19:95-100. Paterson, W. 1982. Was Byron anorexic? World Medicine May 15:35-38. Pina-Cabral, J. De. 1986 Sons of Adam, Daughters of Eve: The Peasant Worldview of the Alto Minho. Oxford: Oxford University Press. Portius, S. 1551. De Puella Germanica, Quae Fere Biennium Vixerat Sine Cibo, Potuque. Florence. Powdermaker, H. 1960. An anthropological approach to the problem of obesity . Bulletin of the New York Academy of Medicine 36:286-295. Prince, I. 1989. Pica, geophagia and culture. Transcultural Psychiatric Research Review 26:167-197. 35195 Prince, R. 1985. The concept of culture-bound syndromes: Anorexia nervosa and brain-fag. Social Science and Medicine 21:197-203. Prince, R. and Tcheng-Laroche, F. 1987. Culture-bound syndromes and international disease classifications. Culture, Medicine and Psychiatry 11:3-19. Rampling, D. 1980. Abnormal mothering in the genesis of anorexia nervosa . Journal of Nervous and Mental Diseases 168:501-504. Robbins, S.L. 1974. Pathologic Basis of Disease. Toronto : W. B. Saunders. Russell, G. 1977. The present status of anorexia nervosa. Psychological Medicine 7:353-367. ___ 1979. Bulimia nervosa: An ominous variant of anorexia nervosa . Psychological Medicine 9:429-448. Russell, G.F.M. 1985. The changing nature of anorexia nervosa. Journal of Psychiatric Research 19:101-109. Sartorius, N., Jablensky, A., Korten, G., et al. 1986. Early manifestations and first-contact incidence of schizophrenia in different cultures. Psychological Medicine 16:909-928. Schwartz, D.M., Thomson, M.G. and Johnson, C.L. 1985. Anorexia Nervosa and Bulimia: The Sociocultural Context . In: S. W. Emmett (ed.), Theory and Treatment of Anorexia Nervosa: Biomedical, Sociocultural and Psychological Perspectives. New York: Brunner/Mazel , pp. 95-112. Selvini Palazzoli, M. 1963. L'Anoressia Mentale: Dalla Terapia Individuale alla Terapia Familiare. Milano: Feltrinelli. ___ 1974. Self-Starvation. From Individual to Family Therapy in the Treatment of Anorexia Nervosa (Trans. by A. Pomerans) New York: Jason Aronson. ___ 1985. Anorexia nervosa: A syndrome of the affluent society (Trans. by V. F. DiNicola). Transcultural Psychiatric Research Review 22:199-205. Selvini Palazzoli, M. and Viaro, M. 1988. The anorectic process in the family: A six-stage model as a guide for individual therapy. Family Process 27:129-148. Sheehan, H.L. 1937. Post-partum necrosis of the anterior pituitary . Journal of Pathology and Bacteriology 45:189. Shorter, E. 1987. The first great increase in anorexia nervosa. Journal of Social History 21:69-96. Silverman, J.A. 1983. Richard Morton, 1637-1698, Limner of anorexia nervosa: His life and times. A tercentenary essay. Journal of the American Medical Association 250:2830-2832. ____ 1986. Anorexia nervosa in seventeenth century England as viewed by physician, philosopher, and pedagogue. International Journal of Eating Disorders 5:847-853. ___ 1987a. An eighteenth century account of self-starvation in a male. International Journal of Eating Disorders 6:431-433. ___ 1987b. Robert Whytt, 1714-1766, eighteenth century limner of anorexia nervosa and bulimia, an essay. International Journal of Eating Disorders 6:143-146. ___ 1988. Anorexia nervosa in 1888. Lancet 1 (April 23):928-930. 36196 Simmonds, M. 1914. Ueber embolische Prozesse in der Hypophysis. Virchows Archiv (Pathologische Anatomie) 217:226-239. Simons, R.C. In press. Sorting the Culture-bound Syndromes into Descriptively Similar Taxa. In: C. Stefanis (ed.), VIII World Congress of Psychiatry. Amsterdam : Elsevier Science Publishers. Simons, R. C. and Hughes, C. C. (eds.) 1985. The Culture-Bound Syndromes: Folk Illnesses of Psychiatric and Anthropological Interest. Boston: D. Reidel. Skinner, B.F. 1987. What is Wrong With Daily Life in the Western World? In: Upon Further Reflection. Englewood Cliffs (NJ): Prentice Hall, pp. 15-31. Skrabanek, P. 1983. Notes towards the history of anorexia nervosa. Janus —Revue Internationale de l'Histoire des Sciences de la Médecine , Pharmacologie et Technologie 70:109-128. Snead, E. 1989. Information overload. Ottawa Citizen , November 21, A1. STEDMAN'S MEDICAL DICTIONARY (22nd ed.) 1972. Baltimore: Williams & Wilkins . Swartz, L. 1985a. Anorexia nervosa as a culture-bound syndrome. Social Science and Medicine 20:725-730. ___ 1985b. Is thin a feminist issue? Women's Studies International Forum 8:429-437. Taylor, D.C. 1985. The sick child's predicament. Australian and New Zealand Journal of Psychiatry 19:130-137. Theriot, N.M. 1988. Psychosomatic illness in history: The "green sickness" among nineteenth-century adolescent girls. The Journal of Psychohistory 15:481-480. Valere, V., 1978. Le Pavillon des Enfants Fous. Paris : Editions Stock. Vandereycken, W. 1988. Anorexia Nervosa in Adults. In: B. J. Blinder, B. F. Chaitin and R. S. Goldstein (eds.), The Eating Disorders: Medical and Psychological Bases of Diagnosis and Treatment . New York: PMA, pp. 295-304 ___ 1990. The addiction model in eating disorders: Some critical remarks and a selected bibliography. International Journal of Eating Disorders 9:95-101. Vandereycken, W. and Van Deth, R. 1989. Who was the first to describe anorexia nervosa: Gull or Lasègue? Psychological Medicine 19:837-845. Van Herik, J. 1984. Looking, Eating and Waiting in Simone Weil. In: T. A. Idinopulos and J. Z. Kopp (eds.), Mysticism, Nihilism, Feminism: New Critical Essays on the Anti-Theology of Simone Weil. Johnson City (TN): Institute of Social Sciences and the Arts , pp. 57-90. Veblen, T. 1953. The Theory. of the Leisure Class. New York: American Library. Originally published in 1899. Whytt, R. 1764. Observations on the Nature, Causes, and Cure of Those Disorders Which are Commonly Called Nervous, Hypochondriac or Hysteric to Which are Prefixed some Remarks on the Sympathy of the Nerves Edinburgh: Becket, DeHondt, and Balfour Willan, R. 1790. A remarkable case of abstinence. Medical Communications 2:113-122. Wurman, R.S. 1989. Information Anxiety. Toronto : Doubleday.</meta-value></custom-meta></custom-meta-wrap></article-meta></front><back><notes><p>1. Part II: Anorexia Nervosa as a Culture-Reactive Syndrome will appear in the next issue (October, 1990).</p><p>1 This overview concerns anorexia nervosa and not the eating disorders generally for several reasons: anorexia nervosa has been recognized as a medical illness since 1873 (Anonymous, 1873; Gull, 1874) and is more easily recognized by all medical practitioners because of self-starvation leading to life-threatening weight loss. Bulimia nervosa was only recently (Rus sell, 1979; APA, 1987) differentiated as a separate disorder, it is less well- established as a medical diagnosis (rather than as a variant of anorexia nervosa, or eating anomaly), and the medical complications are less often life-threatening and less certainly related to intentional nutritional defi ciencies. Furthermore, owing to its weight fluctuations within broadly normal limits and the often secretive habits of bingeing and purging, buli mia nervosa can be kept hidden from a medical examiner who is not alerted to the possibility (such physical evidence as the "Russell sign" of skin ulceration over the hand and the erosion of tooth enamel from chronic self-induced vomiting must be carefully observed). Lastly, my impression that anorexia nervosa has a much greater public profile than bulimia ner vosa is supported by a recent community study (Murray, <italic> et al,</italic> 1990). The other two eating disorders recognized by DSM-III-R (APA, 1987) are special cases of interest to paediatrics and child psychiatry: pica (Blinder, <italic>et al,</italic> 1988b; for a cultural perspective, see I. Prince, 1989) and rumination (Blinder, <italic>et al,</italic> 1988a). Obesity is considered a medical rather than a spe cifically psychiatric disorder (see APA, 1987). For anthropological reviews of obesity see Powdermaker (1960) and Brown and Konner (1987).</p><p>2 Documentary sources. This overview contains a fairly exhaustive refer ence list of the English-language reports of the occurrence of anorexia nervosa around the world. A sourcebook on some key historical documents on anorexia nervosa can be found in Kaufman and Heiman (1964), includ ing the first papers by Gull (1868, 1874, 1888; Anonymous, 1873) and Lasègue (1873a, b). Historical reviews of Gull's work (Silverman, 1988) and his claim for priority in describing the illness (Vandereycken and Van Deth, 1989) are of interest. One of Gull's epigrams is of interest here: "Savages explain; science investigates" (quoted in Lyons and Petrucelli, 1978, p. 516). Other historical surveys include: Brumberg, 1988; Haber mas, 1989; Russell, 1985; Selvini Palazzoli, 1963/1974; Shorter, 1987; Sil verman, 1983, 1986, 1987a, b; and Skrabanek, 1983. Brumberg's <italic>Fasting Girls</italic> (1988) is a lucid and informed history of anorexia nervosa, which marshals the medical data very well and draws many important distinc tions. For a historical overview of bulimia, see Blinder and Cadenhead (1986).</p><p>3 DSM-III-R diagnostic criteria for anorexia nervosa (APA, 1987, p. 67):</p><p>A. Refusal to maintain body weight over a minimal normal weight for age and height, e.g., weight loss leading to maintenance of body weight 15 percent below that expected; or failure to make expected weight gain during period of growth, leading to body weight 15 percent below that expected.</p><p>B. Intense fear of gaining weight or becoming fat, even though under weight.</p><p>C. Disturbance in the way in which one's body weight, size, or shape is experienced, e.g., the person claims to "feel fat" even when emaciated, believes that one area of the body is "too fat" even when obviously underweight.</p><p>D. In females, absence of at least three consecutive menstrual cycles when otherwise expected to occur (primary or secondary amenor rhoea). (A woman is considered to have amenorrhoea if her periods occur only following hormone, e.g., oestrogen, administration.)</p><p>4 If psychiatrists want to investigate socio-cultural aspects of mental dis orders, they must undertake the necessary training. If social scientists want to study the people and predicaments that come to medical attention, they must do the same. I share Bynum's (1988) concern over the exces sively narrow attempts at providing cultural context made by present- day psychiatrists" (p. 244) and am informed by her own work in this regard, but I am also chagrined by careless or systematic distortions of medical literature by social scientists. In a weakly-argued article on chlo rosis, for example, Theriot (1988) states that nineteenth century physi cians employed the term "anorexia" to mean "loss of appetite" and not as a disease in and of itself. She offers this as "indication that chlorosis was what today would be diagnosed as anorexia" (p. 464). This reveals two mistakes: a misunderstanding of basic medical terms and faulty deductive reasoning. First, these axiomatic definitions still hold: anorexia means loss of appetite and is a symptom not a disease. It is a misnomer in anorexia nervosa and more importantly, "anorexia" should never be stated to imply the illness "anorexia nervosa", as Theriot employs it throughout her arti cle. Second, disease diagnosis is based on a complex reading of sign and symptom patterns, aetiology and course. Theriot's symptomatic equiva lence of loss of appetite with anorexia nervosa reveals a misunderstanding of clinical medicine. The differential diagnosis of the symptom of anorexia includes organic gastric disease (ulcers, biliary disease leading to sito phobia), any chronic disease process (cancer, alcoholism), and psycholog ical conditions (depression, delusions, anorexia nervosa) (see Hart, 1979).</p><p>At one point, Bynum (1988) states that psychologists disputed over causal explanations, opposing biochemical theories to psychodynamic and cultural ones (p. 241), but then makes a similar opposition of physiological and cultural causes (p. 243). Bynum argues cogently that "the appearance of similar behavior in different cultural contexts does not prove that the behavior has a physiological cause" (p. 243), but then asserts that "the incidence of non-eating behavior... clearly varies enormously over time.... If the cause were physiological, the incidence would vary little if at all" (p. 243). There are some problems here. "Non-eating behavior" is much too broad a category, as my example of the differential diagnosis of "anorexia" shows.</p><p>More importantly, medicine does not present diseases as either "phys iological or cultural". Two issues can be highlighted: "caseness" vs. "con tinuum" (Eisenberg, 1986) and the interaction of factors. Medical models for most diseases are strongly interactive. Infectious diseases have to be understood in terms of infectious agents, host vulnerability, and vectors of transmission. Allergic diseases such as asthma have to be understood as an interaction between genes, phenotype and environment. Even genetic diseases are interactive. For example, G-6-PD deficiency is a sex-linked glycolytic enzyme defect affecting millions of people around the world whose chief clinical feature is haemolytic anaemia, precipitated by drugs or toxins. Some individuals with the Mediterranean type G-6-PD are exquis itely sensitive to fava beans <italic>(Vicia fava,</italic> hence the clinical name <italic>favus)</italic> and will develop a fulminant haemolytic crisis following exposure. Is this a genetic or an environmental disease? Neither. Genes interact with the environment. Furthermore, favism is one "case" on a wide "continuum" of glycolytic enzyme defects. Without our knowledge of haematology and genetics, favism would be a separate disease from the other 100 or so variants.</p><p>5 Cultural and historical perspectives of medical illnesses naturally lead to analogies with biological evolution, as suggested by several historical accounts (Loudon, 1980; Parry-Jones, 1985; Russell, 1985). Gerald Russell (1985) has begun the groundwork for a more detailed study:</p><p>"diseases, like species, represent the balance of a process by which living organisms struggle to adjust to a continually changing envi ronment. The main difference is that diseases change much more quickly than species do. And perhaps psychiatric diseases change much more quickly than others because their expression is largely psycho logical and follows changing fashions" (Hare, 1981; cited by Russell, 1985, p. 101).</p><p>"From (a history of illness) we can learn how the picture of illness shifts though scientifically the illness may be identical; the neuroses in particular have a contemporary style - they flourish in certain sit uations and are almost invisible in others." (Jaspers, 1963; cited by Russell, 1985, p. 101.</p><p>6 Another metaphor for anorexia nervosa comes from the study of addic tions (see Vandereycken, 1990). This metaphor is rather empty in calories (to use another metaphor), with little explanatory power. Among other problems, the addiction metaphor confuses addiction with compulsion and habituation and tolerance with purposive drive. The term addiction is widely but loosely used to label such behaviour as food cravings ("cho coholic"), promiscuity ("sexual addiction"), information anxiety ("neo holic") and excessive work ("workaholic"). These phenomena are complex and interesting but labelling them as addictions muddles rather than clar ifies our understanding.</p></notes><ref-list><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Accorneq, F.</surname></name><year>1943</year>. <article-title>L'anoressia mentale. Una priorità italiana e l'osservazione di 4 casi</article-title>. <source>Rivista Sperimentale di Freniatria e Medicina Legale delle Alienazioni Mentale</source><volume>67</volume>:<fpage>447</fpage>-<lpage>489</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>American Psychiatric Association.</surname></name><year>1987</year>. <source>Diagnostic and Statistical Manual of Mental Disorders</source> (<edition>3</edition>rd ed., rev). <publisher-loc>Washington, DC</publisher-loc>: <publisher-name>APA</publisher-name> .</citation></ref><ref><citation citation-type="other" xlink:type="simple">ANONYMOUS. 1873. Clinical Society of London, Friday, 24 October, 1873 ... Anorexia hysterica (apepsia hysterica). British Medical Journal (Nov. 1) 2:527-528.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Axenfeld, A.</surname></name> and <name name-style="western"><surname>Huchard, H.</surname></name><year>1883</year>. <source>Traité des Névroses</source>. <publisher-loc>Paris</publisher-loc>: <publisher-name>Baillière et cie</publisher-name>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Baraldi, M.</surname></name><year>1952</year>. <article-title>Contributo allo studio della anoressia mentale</article-title> . <source>Rivista Sperimentale di Freniatria e Medicina Legale delle Alienazioni Mentale</source><volume>76</volume>:<fpage>381</fpage>-<lpage>395</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Bell, R.M.</surname></name><year>1985</year>. <source>Holy Anorexia</source>. <publisher-loc>Chicago</publisher-loc>: <publisher-name>The University of Chicago Press</publisher-name>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Binswanger, L.</surname></name><year>1944</year>. <article-title>Der Fall Ellen West. Schweizer Archiv fuer Neurologie</article-title> , <source>Neurochirurgie und Psychiatrie</source><volume>53</volume>:<fpage>155</fpage>-<lpage>282</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple">___ <year>1958</year>. <source>The Case of Ellen West: An Anthropological-Clinical Study</source> . In (<name name-style="western"><surname>R. May</surname></name>, <name name-style="western"><surname>E. Angel</surname></name> and <name name-style="western"><surname>H. F. Ellenberger</surname></name>, eds.): <source>Existence: A New Dimension in Psychiatry and Psychology</source>. <publisher-loc>New York</publisher-loc>: <publisher-name>Basic Books</publisher-name>, pp. <fpage>237</fpage>-<lpage>364</lpage>. Original published in <year>1944</year>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Blinder, B.J.</surname></name> and <name name-style="western"><surname>Cadenhead, K.</surname></name><year>1986</year>. <source>Bulimia: A Historical Overview</source>. In: <name name-style="western"><surname>S. C. Feinstein</surname></name> (ed.), <source>Adolescent Psychiatry: Developmental and Clinical Studies</source>, Vol. 13. <publisher-loc>Chicago</publisher-loc>: <publisher-name>University of Chicago Press</publisher-name>, pp. <fpage>231</fpage>-<lpage>240</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Blinder, B.J.</surname></name>, <name name-style="western"><surname>Goodman, S.L.</surname></name> and <name name-style="western"><surname>Goldstein, R.</surname></name><year>1988</year>a. <source>Rumination: A Critical Review of Diagnosis and Treatment</source> . In: <name name-style="western"><surname>B. J. Blinder</surname></name>, <name name-style="western"><surname>B. F. Chaitin</surname></name> and <name name-style="western"><surname>R. S. Goldstein</surname></name> (eds.), <source>The Eating Disorders: Medical and Psychological Bases of Diagnosis and Treatment</source>. <publisher-loc>New York</publisher-loc>: <publisher-name>PMA</publisher-name>, pp. <fpage>315</fpage>-<lpage>329</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Blinder, B.J.</surname></name>, <name name-style="western"><surname>Goodman, S.L.</surname></name> and <name name-style="western"><surname>Henderson, P.</surname></name><year>1988</year>b. <source>Pica: A Critical Review of Diagnosis and Treatment</source> . In: <name name-style="western"><surname>B. J. Blinder</surname></name>, <name name-style="western"><surname>B. F. Chaitin</surname></name> and <name name-style="western"><surname>R. S. Goldstein</surname></name> (eds.), <source>The Eating Disorders: Medical and Psychological Bases of Diagnosis and Treatment</source>. <publisher-loc>New York</publisher-loc>: <publisher-name>PMA</publisher-name>, pp. <fpage>331</fpage>-<lpage>344</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Brown, P.J.</surname></name> and <name name-style="western"><surname>Konner, M.</surname></name><year>1987</year>. <article-title>An Anthropological Perspective on Obesity</article-title>. In: R. J. Wurtman and J. L. Wurtman (eds.), <article-title>Human Obesity</article-title>. <publisher-loc>New York</publisher-loc>: <source>New York Academy of Sciences</source>, pp. <fpage>29</fpage>-<lpage>56</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Bruch, H.</surname></name><year>1973</year>. <source>Eating Disorders: Obesity, Anorexia and the Person Within</source> . <publisher-loc>New York</publisher-loc>: <publisher-name>Basic Books</publisher-name>.</citation></ref><ref><citation citation-type="book" xlink:type="simple">___ <year>1985</year>. <source>Four Decades of Eating Disorders</source>. In: <name name-style="western"><surname>D. M. Garner</surname></name> and <name name-style="western"><surname>P. E. Garfinkel</surname></name> (eds.), <source>Handbook of Psychotherapy for Anorexia Nervosa and Bulimia</source>. <publisher-loc>New York</publisher-loc>: <publisher-name>Guilford</publisher-name> , pp. <fpage>7</fpage>-<lpage>18</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Brumberg, J.J.</surname></name><year>1982</year>. <article-title>Chlorotic girls, 1870-1920: A historical perspective on female adolescence</article-title>. <source>Child Development</source><volume>53</volume>:<fpage>1468</fpage>-<lpage>1477</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple">___ <year>1985</year>. "<article-title>Fasting girls</article-title>": <article-title>Reflections on writing the history of anorexia nervosa</article-title>. <source>Monographs of the Society for Research in Child Development</source><volume>50</volume>:(<issue>4-5</issue>, Serial No. 211):<fpage>93</fpage>-<lpage>104</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple">___ <year>1988</year>. <source>Fasting Girls: A Social and Cultural History of Anorexia Nervosa</source>. <publisher-loc>Cambridge, MA</publisher-loc>: <publisher-name>Harvard University Press</publisher-name>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Bynum, C.W.</surname></name><year>1987</year>. <source>Holy Feast and Holy Fast: The Religious Significance of Food to Medieval Women</source>. <publisher-loc>Berkeley</publisher-loc>: <publisher-name>University of California Press</publisher-name>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple">___ <year>1988</year>. <article-title>Review article: Holy anorexia in modern Portugal</article-title>. <source>Culture, Medicine and Psychiatry</source><volume>12</volume>:<fpage>239</fpage>-<lpage>248</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Cantwell, D.P.</surname></name>, <name name-style="western"><surname>Sturzenberger, S.</surname></name>, <name name-style="western"><surname>Burroughs, J.</surname></name> et al. <year>1977</year>. <article-title>Anorexia nervosa: An affective disorder?</article-title><source>Archives of General Psychiatry</source><volume>34</volume>:<fpage>1087</fpage>-<lpage>1093</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Caskey, N.</surname></name><year>1986</year>. <source>Interpreting Anorexia Nervosa</source>. In: <name name-style="western"><surname>S. R. Suleiman</surname></name> (ed.), <source>The Female Body in Western Culture</source> . <publisher-loc>Cambridge</publisher-loc>: <publisher-name>Harvard University Press</publisher-name>, pp. <fpage>175</fpage>-<lpage>189</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Chernin, K.</surname></name><year>1981</year>. <source>The Mysterious Case of Ellen West</source>. In: <source>The Obsession: Reflections on the Tyranny of Slenderness</source>. <publisher-loc>New York</publisher-loc>: <publisher-name>Harper & Row</publisher-name>, pp. <fpage>162</fpage>-<lpage>179</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Chipley, W.S.</surname></name><year>1859</year>. <article-title>Sitomania: Its causes and treatment</article-title>. <source>American Journal of Insanity</source><volume>16</volume>:<issue>4</issue>, <fpage>41</fpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Crisp, A.H.</surname></name><year>1977</year>. <article-title>Diagnosis and outcome of anorexia nervosa: The St. George's view</article-title>. <source>Proceedings of the Royal Society of Medicine</source><volume>70</volume>:<fpage>464</fpage>-<lpage>470</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Dally, P.</surname></name><year>1989</year>. <source>Elizabeth Barrett Browning: A Psychological Portrait</source> . <publisher-loc>London</publisher-loc>: <publisher-name>Macmillan</publisher-name>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Demos, J.</surname></name><year>1982</year>. <source>Entertaining Satan: Witchcraft and the Culture of Early England</source>. <publisher-loc>London</publisher-loc>: <publisher-name>Oxford University Press</publisher-name>.</citation></ref><ref><citation citation-type="confproc" xlink:type="simple"><name name-style="western"><surname>Dinicola, V.F.</surname></name><conf-date>1985</conf-date>a. <article-title>Anorexia nervosa as a culture-bound syndrome</article-title>. <conf-name>Symposium on "Eating Disorders", Canadian Psychiatric Association 35th Annual Meeting Abstracts</conf-name>, <conf-loc>Quebec</conf-loc>, <conf-loc>Quebec</conf-loc>, October <conf-date>1985</conf-date>, pp. 134-135.</citation></ref><ref><citation citation-type="journal" xlink:type="simple">___ <year>1985</year>b. <article-title>Family therapy and transcultural psychiatry: An emerging synthesis. Part II: Portability and culture change</article-title>. <source>Transcultural Psychiatric Research Review</source><volume>22</volume>:<fpage>151</fpage>-<lpage>180</lpage>.</citation></ref><ref><citation citation-type="confproc" xlink:type="simple">___ <conf-date>1988</conf-date>a. <article-title>Anorexia nervosa: A culture-bound syndrome. Symposium on "Culture-Bound Syndromes and DMS-II-R"</article-title>, <conf-name>American Psychiatric Association 141st Annual Meeting Abstracts</conf-name>, <conf-loc>Montreal</conf-loc>, May <conf-date>1988</conf-date>, p. 228.</citation></ref><ref><citation citation-type="journal" xlink:type="simple">___ <year>1988</year>b. <article-title>Anorexia nervosa from a transcultural perspective: The requirements for a comprehensive model</article-title>. <source>The BASH Magazine</source><volume>7</volume>:<fpage>210</fpage>-<lpage>215</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple">___ <year>1988</year>c. <article-title>Essay-review of Susie Orbach's Hunger Strike: The Anorectic's Struggles as a Metaphor for Our Age</article-title>. <source>Transcultural Psychiatric Research Review</source><volume>25</volume>:<fpage>47</fpage>-<lpage>54</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple">___ <year>1989</year>. <article-title>The child's predicament in families with a mood disorder</article-title> . <source>Psychiatric Clinics of North America</source><volume>12</volume>:<fpage>933</fpage>-<lpage>949</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple">___ In press. <source>Anorexia Nervosa: A Culture-bound Syndrome</source>. In: <name name-style="western"><surname>C. Stefanis</surname></name> (ed.), <source>VIII World Congress of Psychiatry</source>. <publisher-loc>Amsterdam</publisher-loc>: <publisher-name>Elsevier Science Publishers</publisher-name>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Dinicola, V.F.</surname></name>, <name name-style="western"><surname>Roberts, N.</surname></name> and <name name-style="western"><surname>Oke, L.</surname></name><year>1989</year>. <article-title>Eating and mood disorders in young children</article-title>. <source>Psychiatric Clinics of North America</source><volume>12</volume>:<fpage>873</fpage>-<lpage>893</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Dyrenforth, S.R.</surname></name>, <name name-style="western"><surname>Wooley, O.W.</surname></name> and <name name-style="western"><surname>Wooley, S.C.</surname></name><year>1980</year>. <source>A Woman's Body in a Man's World: A Review of Findings on Body Image and Weight Control</source>. In: <name name-style="western"><surname>J. R. Kaplan</surname></name> (ed.), <source>A Woman's Conflict: The Special Relationship Between Women and Food. Englewood Cliffs (NJ)</source>: <publisher-name>Prentice-Hall</publisher-name> , pp. <fpage>30</fpage>-<lpage>57</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Eisenberg, L.</surname></name><year>1986</year>. <source>When is a Case a Case?</source> In: <name name-style="western"><surname>M. Rutter</surname></name>, et al (eds.), <source>Depression in Young People: Developmental and Clinical Perspectives</source>. <publisher-loc>New York</publisher-loc>: <publisher-name>Guilford Press</publisher-name>, pp. <fpage>469</fpage>-<lpage>478</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Eldredge, N.</surname></name> and <name name-style="western"><surname>Gould, S.J.</surname></name><year>1972</year>. <source>Punctuated Equilibria: An Alternative to Phyletic Gradualism</source> . In: <name name-style="western"><surname>T. J. M. Schopf</surname></name> (ed.), <source>Models in Paleobiology</source>. <publisher-loc>San Francisco</publisher-loc>: <publisher-name>Freeman, Cooper & Co.</publisher-name>, pp. <fpage>82</fpage>-<lpage>115</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Fahy, T.</surname></name>, <name name-style="western"><surname>Robinson, P.H.</surname></name>, <name name-style="western"><surname>Russell, G.F.M.</surname></name>, et al. <year>1988</year>. <article-title>Anorexia nervosa following torture in a young African woman</article-title>. <source>British Journal of Psychiatry</source><volume>153</volume>:<fpage>385</fpage>-<lpage>387</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Fichter, M.M.</surname></name><year>1985</year>. <source>Magersucht und Bulimia: Empirische Untersuchungen zur Epidemiologie, Symptomatologie, Nosologie und zum Verlauf</source>. <publisher-loc>Berlin</publisher-loc>: <publisher-name>Springer-Verlag</publisher-name>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple">___ <year>1987</year>. <article-title>The anorexia nervosa of Franz Kafka</article-title>. <source>International Journal of Eating Disorders</source><volume>6</volume>:<fpage>367</fpage>-<lpage>377</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Fowler, R.</surname></name><year>1871</year>. <source>A Complete History of the Case of the Welsh Fasting Girl (Sarah Jacob) with Comments Thereon, and Observations on Death from Starvation</source><publisher-loc>London</publisher-loc>: <publisher-name>Henry Renshaw</publisher-name>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Fried, R.</surname></name> and <name name-style="western"><surname>Vandereycken, W.</surname></name><year>1989</year>. <article-title>The Peter Pan syndrome: Was James M. Barrie anorexic?</article-title><source>International Journal of Eating Disorders</source><volume>8</volume>:<fpage>369</fpage>-<lpage>376</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Garfinkel, P.E.</surname></name> and <name name-style="western"><surname>Garner, D.M.</surname></name><year>1982</year>. <source>Anorexia Nervosa: A Multidimensional Perspective</source> . <publisher-loc>New York</publisher-loc>: <publisher-name>Brunner/Mazel</publisher-name>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Garner, D. M.</surname></name> and <name name-style="western"><surname>Garfinkel, P. E.</surname></name> (eds.) <year>1985</year>. <source>Handbook of Psychotherapy for Anorexia Nervosa and Bulimia</source>. <publisher-loc>New York</publisher-loc>: <publisher-name>Guilford Press</publisher-name>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Gould, S.J.</surname></name> and <name name-style="western"><surname>Eldredge, N.</surname></name><year>1977</year>. <article-title>Punctuated equilibria: The tempo and mode of evolution reconsidered</article-title>. <source>Paleobiology</source><volume>3</volume>:<fpage>115</fpage>-<lpage>151</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Greenberg, J.</surname></name><year>1965</year>. <source>I Never Promised You a Rose Garden</source>. <publisher-loc>New York</publisher-loc>: <publisher-name>New American Library</publisher-name>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Gull, W.</surname></name><year>1868</year>. <article-title>The address in medicine delivered before the annual meeting of the British Medical Association, at Oxford</article-title>. <source>Lancet</source><volume>2</volume> (8 August):<fpage>171</fpage>-<lpage>176</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple">____ <year>1874</year>. <article-title>Anorexia nervosa (apepsia hysterica, anorexia hysterica)</article-title> . <source>Transactions of the Clinical Society of London</source><volume>7</volume>:<fpage>22</fpage>-<lpage>28</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple">___ <year>1888</year>. <article-title>Anorexia nervosa</article-title>. <source>Lancet</source><volume>1</volume> (17 March):<fpage>516</fpage>-<lpage>517</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Habermas, T.</surname></name><year>1986</year>. <article-title>Friderada. A case of miraculous fasting</article-title>. <source>International Journal of Eating Disorders</source><volume>5</volume>:<fpage>555</fpage>-<lpage>562</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple">- <year>1989</year>. <article-title>The psychiatric history of anorexia nervosa and bulimia nervosa: Weight concerns and bulimic symptoms in early case reports</article-title>. <source>International Journal of Eating Disorders</source><volume>8</volume>:<fpage>259</fpage>-<lpage>273</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Hajal, F.</surname></name><year>1982</year>. <article-title>Psychological treatment of anorexia: A case from the ninth century</article-title>. <source>Journal of the History of Medicine and Allied Sciences</source><volume>37</volume>:<fpage>325</fpage>-<lpage>328</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Hare, E.</surname></name><year>1981</year>. <article-title>The two manias: A study of the evolution of the modern concept of mania</article-title>. <source>British Journal of Psychiatry</source><volume>138</volume>:<fpage>89</fpage>-<lpage>99</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Harper, G.</surname></name><year>1984</year>. <article-title>Anorexia nervosa: What kind of disorder? The "consensus" model, myth, and clinical implications</article-title>. <source>Pediatric Annals</source><volume>13</volume>:<fpage>812</fpage>-<lpage>828</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Hart, F.D.</surname></name><year>1979</year>. <source>French's Index of Differential Diagnosis</source> (<edition>11</edition>th ed.). <publisher-loc>Chicago</publisher-loc>: <publisher-name>John Wright</publisher-name>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Hartley, L.P.</surname></name><year>1953</year>. <source>The Go-Between</source>. <publisher-loc>London</publisher-loc>: <publisher-name>Hamish Hamilton</publisher-name>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Hsu, L.K.G.</surname></name><year>1988</year>. <source>The Etiology of Anorexia Nervosa</source>. In: <name name-style="western"><surname>B. J. Blinder</surname></name>, <name name-style="western"><surname>B. F. Chaitin</surname></name> and <name name-style="western"><surname>R. S. Goldstein</surname></name> (eds.) <source>The Eating Disorders: Medical and Psychological Bases of Diagnosis and Treatment</source> . <publisher-loc>New York</publisher-loc>: <publisher-name>PMA</publisher-name>, pp. <fpage>239</fpage>-<lpage>246</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple">____ <year>1989</year>. <article-title>The gender gap in eating disorders: Why are the eating disorders more common among women</article-title>? <source>Clinical Psychology Review</source><volume>9</volume>:<fpage>393</fpage>-<lpage>407</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Jaspers, K.</surname></name><year>1963</year>. <source>General Psychopathology</source> (Trans. from the 7th German ed. by J. Hoenig and M. W. Hamilton). <publisher-loc>London</publisher-loc>: <publisher-name>Manchester University Press</publisher-name>. Originally published in <year>1959</year> .</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Katz, J.L.</surname></name><year>1987</year>. <article-title>Eating and affective disorder: Relatives or merely chance acquaintances?</article-title><source>Comprehensive Psychiatry</source><volume>28</volume>:<fpage>220</fpage>-<lpage>228</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Kaufman, M.R.</surname></name> and <name name-style="western"><surname>Heiman, M.</surname></name><year>1964</year>. <source>Evolution of Psychosomatic Concepts. Anorexia Nervosa: A Paradigm</source>. <publisher-loc>New York</publisher-loc>: <publisher-name>International Universities Press</publisher-name>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Kylin, E.</surname></name><year>1937</year>. <article-title>Magersucht in der weiblichen Spaetpubertaet. Ein eigentümliches Krankheitsbild sui generis</article-title>. <source>Deutsches Archiv fuer Klinische Medizin</source><volume>180</volume>:<fpage>115</fpage>-<lpage>180</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Lacey, J.H.</surname></name><year>1982</year>. <article-title>Anorexia nervosa and a bearded female saint</article-title>. <source>British Medical Journal</source><volume>285</volume>:<fpage>1816</fpage>-<lpage>1817</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Laing, R.D.</surname></name><year>1982</year>. <source>The Voice of Experience: Experience, Science and Psychiatry</source> . <publisher-loc>Markham, Ont</publisher-loc>: <publisher-name>Penguin</publisher-name> .</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Laspgue, C.</surname></name><year>1873</year>a. <article-title>De l'anorexie hystérique</article-title>. <source>Archives Générale de Médecine</source><volume>1</volume> (avril):<fpage>385</fpage>-<lpage>403</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple">___ <year>1873</year>b. <article-title>On hysterical anorexia</article-title>. <source>Medical Times and Gazette</source><volume>2</volume> (6 Sept.):<fpage>265</fpage>-<lpage>266</lpage>; (27 Sept. ):<fpage>367</fpage>-<lpage>369</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Lawrence, M.</surname></name> (ed.) <year>1987</year>. <source>Fed Up and Hungry: Women, Oppression and Food</source>. <publisher-loc>London</publisher-loc>: <publisher-name>The Women's Press</publisher-name> Ltd.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Lee, S.</surname></name>, <name name-style="western"><surname>Chiu, H.F.</surname></name> and <name name-style="western"><surname>Chen, C-N.</surname></name><year>1989</year>. <article-title>Anorexia nervosa and Hong Kong: Why not more in Chinese</article-title> ? <source>British Journal of Psychiatry</source><volume>154</volume>:<fpage>683</fpage>-<lpage>688</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Levi-Strauss, C.</surname></name><year>1966</year>. <source>The Savage Mind</source>. <publisher-loc>Chicago</publisher-loc>: <publisher-name>University of Chicago Press</publisher-name>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Loudon, I.S.L.</surname></name><year>1980</year>. <article-title>Chlorosis, anaemia, and anorexia nervosa</article-title>. <source>British Medical Journal</source><volume>281</volume>:<fpage>1669</fpage>-<lpage>1675</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Lyons, A.S.</surname></name> and <name name-style="western"><surname>Petrucelli, R.J.</surname></name><year>1978</year>. <source>Medicine: An Illustrated History</source>. <publisher-loc>New York</publisher-loc>: <publisher-name>Abrams</publisher-name>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Macleod, S.</surname></name><year>1981</year>. <source>The Art of Starvation: An Adolescence Observed</source> . <publisher-loc>London</publisher-loc>: <publisher-name>Virago</publisher-name>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Marano, L.</surname></name><year>1982</year>. <source>Windigo Psychosis: The Anatomy of an Emic-Etic Confusion</source> . In: <name name-style="western"><surname>R. C. Simons</surname></name> and <name name-style="western"><surname>C. C. Hughes</surname></name> (eds.), <source>The Culture-Bound Syndromes: Folk Illnesses of Psychiatric and Anthropological Interest</source>. <publisher-loc>Boston</publisher-loc>: <publisher-name>D. Reidel</publisher-name>, pp. <fpage>411</fpage>-<lpage>448</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>McSherry, J.A.</surname></name><year>1985</year>. <article-title>Was Mary, Queen of Scots, anorexic?</article-title><source>Scottish Medical Journal</source><volume>30</volume>:<fpage>243</fpage>-<lpage>245</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Minuchin, S.</surname></name><year>1984</year>. <source>The Triumph of Ellen West: An Ecological Perspective</source> . In: <source>S. Minuchin, Family Kaleidoscope: Images of Violence and Healing</source> . <publisher-loc>Cambridge</publisher-loc>: <publisher-name>Harvard University Press</publisher-name>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Minuchin, S.</surname></name>, <name name-style="western"><surname>Rosman, B.L.</surname></name> and <name name-style="western"><surname>Baker, L.</surname></name><year>1978</year>. <source>Psychosomatic Families: Anorexia Nervosa in Context</source> . <publisher-loc>Cambridge</publisher-loc>: <publisher-name>Harvard University Press</publisher-name>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Morgan, H.G.</surname></name><year>1977</year>. <article-title>Fasting girls and our attitudes to them</article-title>. <source>British Medical Journal</source><volume>2</volume>:<fpage>1652</fpage>-<lpage>1655</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Morton, R.</surname></name><year>1694</year>. <source>Phthisiologia - Or a Treatise of Consumptions</source>. <publisher-loc>London</publisher-loc>: <publisher-name>Smith & Walford</publisher-name>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Murray, S.</surname></name>, <name name-style="western"><surname>Touyz, S.</surname></name> and <name name-style="western"><surname>Beumont, P.</surname></name><year>1990</year>. <article-title>Knowledge about eating disorders in the community</article-title> . <source>International Journal of Eating Disorders</source><volume>9</volume>:<fpage>87</fpage>-<lpage>93</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Nasser, M.</surname></name><year>1986</year>. <article-title>Comparative study of the prevalence of abnormal eating attitudes among Arab female students of both</article-title><publisher-loc>London</publisher-loc> and <publisher-loc>Cairo</publisher-loc> Universities. <source>Psychological Medicine</source><volume>16</volume>:<fpage>621</fpage>-<lpage>624</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Naudeau, J.</surname></name><year>1789</year>. <article-title>Observation sur une maladie nerveuse accompagnée d'un dégoût extraordinaire pour les aliments</article-title>. <source>Journal de Médecine, Chirurgie et Pharmacologie</source><volume>80</volume>:<fpage>197</fpage>-<lpage>200</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Orbach, S.</surname></name><year>1985</year>. <source>Accepting the Symptom: A Feminist Psychoanalytic Treatment of Anorexia Nervosa</source>. In: <name name-style="western"><surname>D. M. Garner</surname></name> and <name name-style="western"><surname>P. E. Garfinkel</surname></name> (eds.), <source>Handbook of Psychotherapy for Anorexia Nervosa and Bulimia</source>. <publisher-loc>New York</publisher-loc>: <publisher-name>Guilford Press</publisher-name>, pp. <fpage>83</fpage>-<lpage>104</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple">___ <year>1986</year>. <source>Hunger Strike: The Anorectic's Struggle as a Metaphor for Our Age</source>. <publisher-loc>New York</publisher-loc>: <publisher-name>Norton</publisher-name>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Osler, W.</surname></name><year>1932</year>. <source>Aequanimitas: With Other Addresses to Medical Students, Nurses & Practitioners of Medicine</source>, <edition>3</edition>rd ed. <publisher-loc>New York</publisher-loc>: <publisher-name>McGraw-Hill</publisher-name>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Parry-Jones, W.L.</surname></name><year>1985</year>. <article-title>Archival exploration of anorexia nervosa</article-title>. <source>Journal of Psychiatric Research</source><volume>19</volume>:<fpage>95</fpage>-<lpage>100</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Paterson, W.</surname></name><year>1982</year>. <article-title>Was Byron anorexic?</article-title><source>World Medicine</source> May 15:<volume>35</volume>-<volume>38</volume>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Pina-Cabral, J. De.</surname></name><year>1986</year><source>Sons of Adam, Daughters of Eve: The Peasant Worldview of the Alto Minho</source>. <publisher-loc>Oxford</publisher-loc>: <publisher-name>Oxford University Press</publisher-name>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Portius, S.</surname></name><year>1551</year>. <source>De Puella Germanica, Quae Fere Biennium Vixerat Sine Cibo, Potuque</source>. <publisher-loc>Florence</publisher-loc>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Powdermaker, H.</surname></name><year>1960</year>. <article-title>An anthropological approach to the problem of obesity</article-title> . <source>Bulletin of the New York Academy of Medicine</source><volume>36</volume>:<fpage>286</fpage>-<lpage>295</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Prince, I.</surname></name><year>1989</year>. <article-title>Pica, geophagia and culture</article-title>. <source>Transcultural Psychiatric Research Review</source><volume>26</volume>:<fpage>167</fpage>-<lpage>197</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Prince, R.</surname></name><year>1985</year>. <article-title>The concept of culture-bound syndromes: Anorexia nervosa and brain-fag</article-title>. <source>Social Science and Medicine</source><volume>21</volume>:<fpage>197</fpage>-<lpage>203</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Prince, R.</surname></name> and <name name-style="western"><surname>Tcheng-Laroche, F.</surname></name><year>1987</year>. <article-title>Culture-bound syndromes and international disease classifications</article-title>. <source>Culture, Medicine and Psychiatry</source><volume>11</volume>:<fpage>3</fpage>-<lpage>19</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Rampling, D.</surname></name><year>1980</year>. <article-title>Abnormal mothering in the genesis of anorexia nervosa</article-title> . <source>Journal of Nervous and Mental Diseases</source><volume>168</volume>:<fpage>501</fpage>-<lpage>504</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Robbins, S.L.</surname></name><year>1974</year>. <source>Pathologic Basis of Disease</source>. <publisher-loc>Toronto</publisher-loc> : <publisher-name>W. B. Saunders</publisher-name>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Russell, G.</surname></name><year>1977</year>. <article-title>The present status of anorexia nervosa</article-title>. <source>Psychological Medicine</source><volume>7</volume>:<fpage>353</fpage>-<lpage>367</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple">___ <year>1979</year>. <article-title>Bulimia nervosa: An ominous variant of anorexia nervosa</article-title> . <source>Psychological Medicine</source><volume>9</volume>:<fpage>429</fpage>-<lpage>448</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Russell, G.F.M.</surname></name><year>1985</year>. <article-title>The changing nature of anorexia nervosa</article-title>. <source>Journal of Psychiatric Research</source><volume>19</volume>:<fpage>101</fpage>-<lpage>109</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Sartorius, N.</surname></name>, <name name-style="western"><surname>Jablensky, A.</surname></name>, <name name-style="western"><surname>Korten, G.</surname></name>, et al. <year>1986</year>. <article-title>Early manifestations and first-contact incidence of schizophrenia in different cultures</article-title>. <source>Psychological Medicine</source><volume>16</volume>:<fpage>909</fpage>-<lpage>928</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Schwartz, D.M.</surname></name>, <name name-style="western"><surname>Thomson, M.G.</surname></name> and <name name-style="western"><surname>Johnson, C.L.</surname></name><year>1985</year>. <source>Anorexia Nervosa and Bulimia: The Sociocultural Context</source> . In: <name name-style="western"><surname>S. W. Emmett</surname></name> (ed.), <source>Theory and Treatment of Anorexia Nervosa: Biomedical, Sociocultural and Psychological Perspectives</source>. <publisher-loc>New York</publisher-loc>: <publisher-name>Brunner/Mazel</publisher-name> , pp. <fpage>95</fpage>-<lpage>112</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Selvini Palazzoli, M.</surname></name><year>1963</year>. <source>L'Anoressia Mentale: Dalla Terapia Individuale alla Terapia Familiare</source>. <publisher-loc>Milano</publisher-loc>: <publisher-name>Feltrinelli</publisher-name>.</citation></ref><ref><citation citation-type="book" xlink:type="simple">___ <year>1974</year>. <source>Self-Starvation. From Individual to Family Therapy in the Treatment of Anorexia Nervosa (Trans. by A. Pomerans)</source><publisher-loc>New York</publisher-loc>: <publisher-name>Jason Aronson</publisher-name>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple">___ <year>1985</year>. <article-title>Anorexia nervosa: A syndrome of the affluent society (Trans. by V. F. DiNicola)</article-title>. <source>Transcultural Psychiatric Research Review</source><volume>22</volume>:<fpage>199</fpage>-<lpage>205</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Selvini Palazzoli, M.</surname></name> and <name name-style="western"><surname>Viaro, M.</surname></name><year>1988</year>. <article-title>The anorectic process in the family: A six-stage model as a guide for individual therapy</article-title>. <source>Family Process</source><volume>27</volume>:<fpage>129</fpage>-<lpage>148</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Sheehan, H.L.</surname></name><year>1937</year>. <article-title>Post-partum necrosis of the anterior pituitary</article-title> . <source>Journal of Pathology and Bacteriology</source><volume>45</volume>:<fpage>189</fpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Shorter, E.</surname></name><year>1987</year>. <article-title>The first great increase in anorexia nervosa</article-title>. <source>Journal of Social History</source><volume>21</volume>:<fpage>69</fpage>-<lpage>96</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Silverman, J.A.</surname></name><year>1983</year>. <article-title>Richard Morton, 1637-1698, Limner of anorexia nervosa: His life and times. A tercentenary essay</article-title>. <source>Journal of the American Medical Association</source><volume>250</volume>:<fpage>2830</fpage>-<lpage>2832</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple">____ <year>1986</year>. <article-title>Anorexia nervosa in seventeenth century England as viewed by physician, philosopher, and pedagogue</article-title>. <source>International Journal of Eating Disorders</source><volume>5</volume>:<fpage>847</fpage>-<lpage>853</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple">___ <year>1987</year>a. <article-title>An eighteenth century account of self-starvation in a male</article-title>. <source>International Journal of Eating Disorders</source><volume>6</volume>:<fpage>431</fpage>-<lpage>433</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple">___ <year>1987</year>b. <article-title>Robert Whytt, 1714-1766, eighteenth century limner of anorexia nervosa and bulimia, an essay</article-title>. <source>International Journal of Eating Disorders</source><volume>6</volume>:<fpage>143</fpage>-<lpage>146</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple">___ <year>1988</year>. <article-title>Anorexia nervosa in 1888</article-title>. <source>Lancet</source><volume>1</volume> (April 23):<fpage>928</fpage>-<lpage>930</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Simmonds, M.</surname></name><year>1914</year>. <article-title>Ueber embolische Prozesse in der Hypophysis</article-title>. <source>Virchows Archiv (Pathologische Anatomie)</source><volume>217</volume>:<fpage>226</fpage>-<lpage>239</lpage>.</citation></ref><ref><citation citation-type="confproc" xlink:type="simple"><name name-style="western"><surname>Simons, R.C.</surname></name> In press. <article-title>Sorting the Culture-bound Syndromes into Descriptively Similar Taxa</article-title>. In: C. Stefanis (ed.), <conf-name>VIII World Congress of Psychiatry</conf-name>. <conf-loc>Amsterdam : Elsevier Science Publishers</conf-loc>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Simons, R. C.</surname></name> and <name name-style="western"><surname>Hughes, C. C.</surname></name> (eds.) <year>1985</year>. <source>The Culture-Bound Syndromes: Folk Illnesses of Psychiatric and Anthropological Interest</source>. <publisher-loc>Boston</publisher-loc>: <publisher-name>D. Reidel.</publisher-name></citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Skinner, B.F.</surname></name><year>1987</year>. <source>What is Wrong With Daily Life in the Western World?</source> In: <source>Upon Further Reflection. Englewood Cliffs (NJ)</source>: <publisher-name>Prentice Hall</publisher-name>, pp. <fpage>15</fpage>-<lpage>31</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Skrabanek, P.</surname></name><year>1983</year>. <article-title>Notes towards the history of anorexia nervosa. Janus —Revue Internationale de l'Histoire des Sciences de la Médecine</article-title> , <source>Pharmacologie et Technologie</source><volume>70</volume>:<fpage>109</fpage>-<lpage>128</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Snead, E.</surname></name><year>1989</year>. <article-title>Information overload</article-title>. <source>Ottawa Citizen</source> , November 21, <fpage>A1</fpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><source>STEDMAN'S MEDICAL DICTIONARY</source> (<edition>22</edition>nd ed.) <year>1972</year>. <publisher-loc>Baltimore</publisher-loc>: <publisher-name>Williams & Wilkins</publisher-name> .</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Swartz, L.</surname></name><year>1985</year>a. <article-title>Anorexia nervosa as a culture-bound syndrome</article-title>. <source>Social Science and Medicine</source><volume>20</volume>:<fpage>725</fpage>-<lpage>730</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple">___ <year>1985</year>b. <article-title>Is thin a feminist issue</article-title>? <source>Women's Studies International Forum</source><volume>8</volume>:<fpage>429</fpage>-<lpage>437</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Taylor, D.C.</surname></name><year>1985</year>. <article-title>The sick child's predicament</article-title>. <source>Australian and New Zealand Journal of Psychiatry</source><volume>19</volume>:<fpage>130</fpage>-<lpage>137</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Theriot, N.M.</surname></name><year>1988</year>. <article-title>Psychosomatic illness in history: The "green sickness" among nineteenth-century adolescent girls. The</article-title><source>Journal of Psychohistory</source><volume>15</volume>:<fpage>481</fpage>-<lpage>480</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Valere, V.</surname></name>, <year>1978</year>. <source>Le Pavillon des Enfants Fous</source>. <publisher-loc>Paris</publisher-loc> : Editions <publisher-name>Stock</publisher-name>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Vandereycken, W.</surname></name><year>1988</year>. <source>Anorexia Nervosa in Adults</source>. In: <name name-style="western"><surname>B. J. Blinder</surname></name>, <name name-style="western"><surname>B. F. Chaitin</surname></name> and <name name-style="western"><surname>R. S. Goldstein</surname></name> (eds.), <source>The Eating Disorders: Medical and Psychological Bases of Diagnosis and Treatment</source> . <publisher-loc>New York</publisher-loc>: <publisher-name>PMA</publisher-name>, pp. <fpage>295</fpage>-<lpage>304</lpage></citation></ref><ref><citation citation-type="journal" xlink:type="simple">___ <year>1990</year>. <article-title>The addiction model in eating disorders: Some critical remarks and a selected bibliography</article-title>. <source>International Journal of Eating Disorders</source><volume>9</volume>:<fpage>95</fpage>-<lpage>101</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Vandereycken, W.</surname></name> and <name name-style="western"><surname>Van Deth, R.</surname></name><year>1989</year>. <article-title>Who was the first to describe anorexia nervosa: Gull or Lasègue?</article-title><source>Psychological Medicine</source><volume>19</volume>:<fpage>837</fpage>-<lpage>845</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Van Herik, J.</surname></name><year>1984</year>. <source>Looking, Eating and Waiting in Simone Weil</source>. In: <name name-style="western"><surname>T. A. Idinopulos</surname></name> and <name name-style="western"><surname>J. Z. Kopp</surname></name> (eds.), <source>Mysticism, Nihilism, Feminism: New Critical Essays on the Anti-Theology of Simone Weil</source>. <publisher-loc>Johnson City</publisher-loc> (TN): <publisher-name>Institute of Social Sciences and the Arts</publisher-name> , pp. <fpage>57</fpage>-<lpage>90</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Veblen, T.</surname></name><year>1953</year>. <source>The Theory. of the Leisure Class</source>. <publisher-loc>New York</publisher-loc>: <publisher-name>American Library</publisher-name>. Originally published in <year>1899</year>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Whytt, R.</surname></name><year>1764</year>. <source>Observations on the Nature, Causes, and Cure of Those Disorders Which are Commonly Called Nervous, Hypochondriac or Hysteric to Which are Prefixed some Remarks on the Sympathy of the Nerves</source><publisher-loc>Edinburgh</publisher-loc>: <publisher-name>Becket</publisher-name>, DeHondt, and Balfour</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Willan, R.</surname></name><year>1790</year>. <article-title>A remarkable case of abstinence</article-title>. <source>Medical Communications</source><volume>2</volume>:<fpage>113</fpage>-<lpage>122</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Wurman, R.S.</surname></name><year>1989</year>. <source>Information Anxiety</source>. <publisher-loc>Toronto</publisher-loc> : <publisher-name>Doubleday</publisher-name>.</citation></ref></ref-list></back></article></istex:document></istex:metadataXml><mods version="3.6"><titleInfo lang="en"><title>Anorexia Multiforme: Self-starvation in Historical and Cultural Context Part I: Self-starvation as a Historical Chameleon1</title></titleInfo><titleInfo type="alternative" lang="en" contentType="CDATA"><title>Anorexia Multiforme: Self-starvation in Historical and Cultural Context Part I: Self-starvation as a Historical Chameleon1</title></titleInfo><name type="personal"><namePart type="given">Vincenzo F.</namePart><namePart type="family">Dinicola</namePart></name><typeOfResource>text</typeOfResource><genre type="other" displayLabel="other"></genre><originInfo><publisher>Sage Publications</publisher><place><placeTerm type="text">Sage CA: Thousand Oaks, CA</placeTerm></place><dateIssued encoding="w3cdtf">1990-09</dateIssued><copyrightDate encoding="w3cdtf">1990</copyrightDate></originInfo><language><languageTerm type="code" authority="iso639-2b">eng</languageTerm><languageTerm type="code" authority="rfc3066">en</languageTerm></language><physicalDescription><internetMediaType>text/html</internetMediaType></physicalDescription><relatedItem type="host"><titleInfo><title>Transcultural Psychiatry</title></titleInfo><genre type="journal">journal</genre><identifier type="ISSN">1363-4615</identifier><identifier type="eISSN">1461-7471</identifier><identifier type="PublisherID">TPS</identifier><identifier type="PublisherID-hwp">sptps</identifier><part><date>1990</date><detail type="volume"><caption>vol.</caption><number>27</number></detail><detail type="issue"><caption>no.</caption><number>3</number></detail><extent unit="pages"><start>165</start><end>196</end></extent></part></relatedItem><identifier type="istex">55E14A21E465E7FA9755A3C5E6A141D50EAC31D3</identifier><identifier type="DOI">10.1177/136346159002700301</identifier><identifier type="ArticleID">10.1177_136346159002700301</identifier><recordInfo><recordContentSource>SAGE</recordContentSource></recordInfo></mods></metadata><serie></serie></istex></record>Pour manipuler ce document sous Unix (Dilib)
EXPLOR_STEP=$WICRI_ROOT/Wicri/Psychologie/explor/TherFamFrancoV1/Data/Istex/Corpus
HfdSelect -h $EXPLOR_STEP/biblio.hfd -nk 000784 | SxmlIndent | more
Ou
HfdSelect -h $EXPLOR_AREA/Data/Istex/Corpus/biblio.hfd -nk 000784 | SxmlIndent | more
Pour mettre un lien sur cette page dans le réseau Wicri
{{Explor lien
|wiki= Wicri/Psychologie
|area= TherFamFrancoV1
|flux= Istex
|étape= Corpus
|type= RBID
|clé= ISTEX:55E14A21E465E7FA9755A3C5E6A141D50EAC31D3
|texte= Anorexia Multiforme: Self-starvation in Historical and Cultural Context Part I: Self-starvation as a Historical Chameleon1
}}
| This area was generated with Dilib version V0.6.29. |  |