Anorexia nervosa: an overview1
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Anorexia nervosa: an overview 1
Meir Gross, M.D. This brief overview of anorexia nervosa, which includes a
description of the history, behavioral and medical symptoms, med-
ical complications, and treatment, emphasizes the importance of
obtaining a thorough history to establish an early diagnosis in
patients who do not have the usual physical appearance of emacia-
tion characteristic of this disorder.
Index terms: Anorexia nervosa
Cleve Clin Q 50:371-376, Fall 1983
T h e first detailed report on anorexia nervosa was pub-
lished by Richard Morton in 1689, in which he described
two patients whom he defined as suffering from "nervous
atrophy." He described the symptoms of lack of menstrual
periods, reduction in eating, followed by constipation lead-
ing to severe thinness and overactive behavior. About two
centuries later, in 1874, William Gull in England 1 de-
scribed the same syndrome coining the name "anorexia
nervosa" since he believed it was due to a nervous morbid
mental state of the patient. At about the same time in 1873,
E. Charles Laseque in France 2 published a description of
the same condition referring to it as "anorexia hysterique,"
based on emotional disturbances and changes in thinking
defined by him as intellectual perversion.
Anorexia means lack of appetite. However, the appetite
1
in anorexia nervosa is usually normal, but the patient tries
Department of Psychiatry, T h e Cleveland Clinic
F o u n d a t i o n . S u b m i t t e d f o r publication M a y 1983;
to block or deny hunger to avoid eating. In this regard the
accepted J u n e 1 9 8 3 . term anorexia is a misnomer. T h e word nervosa suggests
371
Downloaded from www.ccjm.org on October 10, 2021. For personal use only. All other uses require permission.'372 Cleveland Clinic Quarterly Vol. 50, No. 2
a nervous condition, which categorizes anorexia to lose weight, they continue relentlessly to the
nervosa as an emotional disorder. point of severe emaciation. When a substantial
Anorexia nervosa is a somewhat baffling dis- amount of weight is lost, they become fearful of
ease with an elusive cure in many cases. 3 It seems regaining it and will resist any pressure by parents
to have increased in frequency during the past or others to eat more. Fear of gaining weight can
few years, 4 possibly because dieting is so popular reach phobic proportions.
or anorexia nervosa is recognized more fre-
quently. Recently, anorexia nervosa has become Medical complications
a popular subject in the mass media, and it is As the disease progresses there is significant
possible that some girls may choose it as a pre- weight loss to the point of severe emaciation.
senting symptom to other unconscious underly- Adult patients who had been overweight may
ing conflicts. 5 T h e disorder occurs predomi- develop wrinkled skin, but this is seen only rarely
nantly in girls at a ratio of 9:1 usually during in adolescent anorexic patients due to greater
adolescence. It affects about one in 2 5 0 girls skin turgor. Newbornlike hair, called lanugo may
between the ages of 12 to 18 years. Regardless appear on the body and alopecia of the scalp may
of its recent popularity, there are still cases that occur.
are not diagnosed in time. T h e results of several When weight loss is profound, hypothermia
studies show that the mortality rate for anorexia may develop, along with bradycardia and hypo-
nervosa is between 14% and 21%. 6 ' 7 Death may tension. Leukopenia and hypogammaglobuline-
result from progressive starvation, electrolyte im- mia lessen resistance to infection. If there is lax-
balance, or overwhelming infection. If weight ative abuse or induced vomiting, hypokalemia
loss becomes severe, hospitalization is required may occur, causing cardiac arrhythmias, lethargy
to prevent death. Despite these impressive mor- or even cardiac arrest. Initially, weight loss con-
tality figures, there are cases of spontaneous re- sists mainly of adipose tissue. This is followed by
covery even without treatment. Conversely, depletion of muscle tissues and hypoproteinemia.
other patients, even with intensive treatment, Short stature may result especially when the ill-
have episodic relapses regardless of the type of ness starts before puberty. If the illness becomes
therapy. In males, anorexia nervosa usually oc- chronic and continues beyond age 17 or 18 when
curs as a single episode with full recovery there- there is closure of the epiphyses, the patient will
after, especially if treatment is begun early. probably not attain full growth.
T h e typical anorexic girl usually has a body Amenorrhea is a common feature and usually
image distortion. She feels fat or overweight even occurs before substantial weight loss. 9 Patients
though she is emaciated. She is preoccupied with may ask about the possibility of having irreversi-
her size and appearance and frequently looks in ble effects from the illness, especially of the re-
the mirror. At times there is preoccupation with productive organs. There is no known perma-
only part of the body such as thighs, breasts, or nent damage. When the patient regains normal
hips, with the patient claiming they look too big. 8 weight, she usually commences menstruation al-
Patients lose weight by reducing food intake though there may be a few months delay after
or by eating only food low in carbohydrates or return to normal weight. In most cases patients
fat. They may induce vomiting to get rid of food should be able to conceive and deliver children.
immediately after meals or may take laxatives,
diuretics, or enemas. Most tend to overexercise Changes in personality
in an obsessive-compulsive manner for many Changes in personality and behavior are ap-
hours every day. parent throughout the course of the illness. T h e
At the onset of the disease there may be evi- patient may succumb to feelings of hunger and
dence of a stressful life situation, e.g., conflict in overeat, usually large amounts of carbohydrates.
the family, environment, school, or peer group. After these binging episodes, because of severe
These patients tend to be perfectionistic and guilt and fear of gaining weight, the patient may
usually were model children. Surprisingly, only induce vomiting (bulimia). Usually, the patients
one third of these patients were overweight be- are preoccupied with thoughts of food most of
fore anorexia developed. T h e y may begin dieting the day. Many of them undertake elaborate prep-
because of being mildly overweight and adapt arations of foods and cook for others, but rarely
obsessive-compulsive eating habits to lose weight eat and avoid the dinner itself with the family.
as the primary goal. However, after they begin Often, anorexic patients eat alone. They usually
Downloaded from www.ccjm.org on October 10, 2021. For personal use only. All other uses require permission.Fall 1 9 8 3 Anorexia nervosa 373
eat slowly, cut their food into many small pieces, Table 1. Differential diagnosis of anorexia nervosa
and do not finish the meal. Some hoard food but Malignancy
never eat it. T u b e r c u l o s i s o f the gastrointestinal tract
T o suppress hunger, the patient involves her- M a l a b s o r p t i o n s y n d r o m e such as s p r u e
self in many activities. Many fear growing up and R e g i o n a l e n t e r i t i s ( C r o h n ' s disease)
Hypothalamic disorder
facing adult responsibilities and use anorexia to
Pituitary tumor
stop the growth process. Many have delayed psy- S h e e h a n ' s s y n d r o m e ( p o s t p a r t u m p i t u i t a r y necrosis)
chosexual development to avoid coping with the S i m m o n d ' s disease ( p a n h y p o p i t u i t a r i s m )
transition of adolescence. Interest in sex is de- Depressive illness
creased, and few anorexic patients are interested Schizophrenia
Bulimia
in dating or getting married during the illness.
It has been speculated that the anorexic patient
fears sexuality and oral impregnation, and that
this is why she avoids eating, believing she might life. Refusal to eat conveys the message to the
become pregnant by eating. I have seen hundreds parents that there is one area in which they will
of anorexic patients, but have rarely seen a pa- not be controlled. Food and eating become the
tient who expressed any conscious or unconscious means of a desperate striving for independence
fear of oral sexuality, or who associated any sym- and control. T h e dinner table becomes the bat-
bolic sexual feelings with food. It seems that this tleground for trials of assertion against the au-
notion has been transferred from one book to thoritarian family and establishment. T h e self-
another without any attempt to substantiate it. denial of food becomes a symbolic weapon
Fear of sexuality could be seen as part of the against the controlling parents, a weapon to win
fear of growing up. A task of normal adolescence trials of gaining separation and individualization.
is achieving independence and separation from However, these situations also are the source
parents. T h e separation is achieved by develop- of anxieties and frustrations that lead to convic-
ing relationships with other people, especially the tion of inadequacy, ineffectiveness, and guilt.
opposite sex. T h e anorexic patient may fear sep- Self-denial of food and other pleasures such as
aration, not being able to achieve it and thus not rest and sexual satisfaction become the sacrifice
being able to shift her interpersonal relationship of a rigid control over the body and what are
from parents to a boyfriend. perceived as evil natural impulses or drives.
Obsessive-compulsive behavior is characteristic
Diagnosis
of anorexia nervosa. Some patients may engage
in elaborate ritualistic behavior with a rigid daily Although the disease can be easily diagnosed
routine. T h e y are concerned with orderliness, in the late stages (Table I), there may be errors
and become upset if there are changes in the or delays in the diagnosis. T h e following case is
order of things that involve them. Many anorexic a classic example of the failure to recognize the
patients are perfectionistic. They tend to dress symptoms of anorexia nervosa with resulting de-
meticulously although they are never satisfied lay in diagnosis.
with their appearance.
Case report
Because anorexics are competitive, many are
excellent students. They try for perfection in A 22-year-old white woman was mildly overweight during
adolescence. After her marriage at age 18, she started a
everything they do. They are usually preoccupied crash diet at about age 19. Six months later her menstrual
with cleanliness. Some of my patients cleaned periods stopped, and for about two and a half years she did
house repeatedly daily, whether it was necessary not menstruate. She consulted a gynecologist who did an
or not. Patients may spend hours in the kitchen, elaborate medical work-up and gave her an injection of
not only cooking for the family, but also cleaning progesterone hoping to trigger menstruation. Another
gynecologist was consulted and again an elaborate endocrin-
excessively. Such activity serves to keep the pa- ological evaluation of hypothalamic function was done; the
tient busy and also consumes calories. results were negative. Another attempt by him to induce
T h e inability to be assertive is typical of many menstrual periods with hormonal therapy was unsuccessful.
anorexic patients. As children they were almost Therefore, his opinion was that the patient had premature
menopause. After two years of amenorrhea an endocrinol-
always the best-behaved girls, complying with
ogist was consulted who again evaluated the endocrine
parents' demands. T h e eventual refusal to eat is system. He noted that she was depressed and suggested she
a rather pathetic attempt to become assertive. see a psychiatrist. She had been under pressure by her
They feel that somebody has always run their husband and his family to become pregnant and finally came
Downloaded from www.ccjm.org on October 10, 2021. For personal use only. All other uses require permission.'374 Cleveland Clinic Quarterly Vol. 50, N o . 2
to the psychiatric clinic. This decision was precipitated by of the American Psychiatric Association lists five
family members who realized that she had already lost too
much weight. When seen, her weight loss was not apparent;
important criteria. T h e most important of these
she looked well and attractively thin, like a model. T h e r e is the intense fear of becoming obese, which does
was no severe cachexia such as one might expect in anorexia. not diminish even with weight loss. T h e second
Her appearance was not suggestive of anorexia nervosa. is the distortion of body image. Patients feel fat
Only close family members realized how much weight she even when severely emaciated. A weight loss of
had lost. It was evident that her menstrual periods stopped
because of loss of weight. History revealed all the obsessive-
at least 25% of original body weight is diagnostic
compulsive characteristics of anorexia nervosa. She usually of anorexia. If the patient is under 18 years,
avoided eating dinner with her husband; she liked to cook weight loss from original body weight plus pro-
but never ate with him or other family members. She jected weight gain expected from growth charts
became very tense, emotionally labile, and depressed. should be added to calculate the 25% or more.
Her consultations with the two gynecologists and endo- Patients show persistent refusal to maintain body
crinologists had been part of the denial process. Uncon-
sciously she probably knew that absence of menstruation
weight over a minimal normal weight. It is im-
could be due to her successful loss of weight. When anorexia portant to rule out any known physical illness
nervosa was diagnosed, she was able to give up the denial that could account for the weight loss, such as
and admit to the anorexic habits she had never before malignancy or gastrointestinal tract disorder
mentioned to a physician. She was willing and motivated to (Crohn's disease). Loss of appetite due to severe
receive psychotherapy to help gain the necessary weight,
have menstrual periods, and become pregnant. T h e moti-
depressive illness should also be considered. In
vation to become pregnant had been due to the pressure of depression there is loss of appetite primarily,
her husband and his family to have a child. T h e marital whereas in anorexia nervosa the appetite is good.
relationship had already been deteriorating because of her Loss of weight in anorexia occurs regardless of
inability to conceive. the good appetite of the patient, because of the
attempt of the patient to block or deny it. In
This case demonstates the importance of care- schizophrenic anorexic disorders there is often a
ful history-taking. Because the patient did not bizarre eating pattern. For example, the schizo-
look too thin and in fact was attractive, anorexia phrenic patient may stop eating to, "starve a
nervosa was never suspected. A good history, delusional creature in the stomach." Some pa-
including initial weight, could have obviated elab- tients may binge eat and then vomit but not have
orate endocrinological and gynecological studies, severe weight Toss. In these cases the diagnosis of
and helped the physicians correctly diagnose the bulimia may be justified. Only if weight loss in
condition earlier, without hormonal therapy, the patient with bulimia surpasses 25% of the
which proved to be unsuccessful. original body weight is the diagnosis of anorexia
It is essential that the clinician know the diag- nervosa justified. In these cases the diagnosis is
nostic criteria of anorexia nervosa. T h e Diagnos- both bulimia and anorexia nervosa; about half of
tic and Statistical Manual of Mental Disorders # 3 all anorexic patients engage in occasional binging
and vomiting. 1 1 1 2
Table 2. Tests for evaluation of anorexia nervosa
Medical work-up
G e n e r a l physical e x a m i n a t i o n
H e m a t o l o g i c values i n c l u d i n g h e m o g l o b i n , w h i t e b l o o d cell c o u n t Since the diagnosis of anorexia nervosa can be
a n d d i f f e r e n t i a l w h i t e b l o o d cell c o u n t made from observing symptoms and signs pre-
H e m a t o l o g i c values ( c h e m i s t r y ) as S M A - 1 8
sented by the patient, it is possible to confirm the
S e d i m e n t a t i o n rate
Q u a n t i t a t i v e stool fat
diagnosis only by taking a good history without
Urinalysis any laboratory tests. However, it is necessary at
P u r i f i e d p r o t e i n d e r i v a t i v e test times to do some essential tests to rule out other
T h y r o i d f u n c t i o n tests s u c h as T 3 a n d T 4 pathology or physical complications due to the
C o r t i s o l , AM. a n d PM. anorexia itself, so that the patient may be treated
H e a d C T scan w i t h c o n t r a s t m e d i u m
appropriately (Table 2.)
Chest roentgenogram
C o m p l e t e r o e n t g e n o g r a m o f the gastrointestinal tract i n c l u d i n g t h e T h e hypothalamic-pituitary-ovarian system is
small b o w e l usually affected in anorexia nervosa patients.
Electrocardiogram There is a decreased secretion of estrogen and a
Pelvic examination
defective positive feedback release of luteinizing
N u t r i t i o n a l assessment
hormone (LH) for estrogen stimulus, both at the
Downloaded from www.ccjm.org on October 10, 2021. For personal use only. All other uses require permission.Fall 1983 Anorexia nervosa 375
emaciated and weight-recovered states. 13 ' 14 In 10 Table 3. Treatment modalities for anorexia
anorexic patients seen at the Cleveland Clinic nervosa
with a weight loss of 25% to 50% of the original 1. M e d i c a l t r e a t m e n t : c o r r e c t i n g d e h y d r a t i o n a n d e l e c t r o l y t e im-
body weight, the levels of FSH and LH were low balance
in the severe state of the illness. Also, the vaginal S u p p l y o f necessary n u t r i e n t s by e a t i n g , nasogastric t u b i n g o r
i n t r a v e n o u s r o u t e i n c l u d i n g total p a r e n t e r a l n u t r i t i o n ( T P N )
mucous membrane of the vagina and cervix was
2. P s y c h o t h e r a p y : I n d i v i d u a l insight o r i e n t e d (psychoanalytic)
hypoestrogenic, and galactorrhea was absent. 15 Individual supportive
These levels of LH are more typical in prepuber- G r o u p ( g e n e r a l i n c l u d i n g patients w i t h o t h e r
tal and early pubertal patients. Frisch et al 16 has problems)
estimated that a body fat content of at least 17% S p e c i a l g r o u p f o r a n o r e x i a n e r v o s a patients
is required for menarche to occur. In our expe- Assertiveness training group
Family therapy
rience, even when body fat returned to 17% or Biofeedback
more, resumption of normal menstrual periods Hypnosis
occurred from one to six months later and in a Creative or art therapy
few cases, even longer. Recreational therapy
Behavior therapy (behavioral weight contract)
Cranial computed tomography (CT) with con- Vocational rehabilitation
trast medium is recommended to rule out the Psychopharmacotherapy (medication)
possibility of brain tumor, especially in the hy-
pothalamic area. Occasionally, a brain scan may
show mild brain atrophy in severe anorexia,
which becomes normal as the patient regains a ment estrogen therapy in order to prevent osteo-
normal weight level. T h e significance of this find- penia.
ing is not clear. In a series of 27 anorectic patients
at the Cleveland Clinic who had C T scans, 6
showed mild atrophy of the brain. Treatment
Roentgenographic examination of the whole T h e treatment of anorexia nervosa is compli-
gastrointestinal tract is recommended including cated because most of the patients are resistant
upper gastrointestinal series, small bowel series, to treatment and refuse to give up their denial.
and barium enema examination to rule out any They may also be resistant to any change in their
defect in the swallowing mechanism, ulcer, tu- obsessive-compulsive habits; therefore, it is im-
mor, tuberculosis of the gastrointestinal tract, portant that the therapist be sensitive to the needs
Crohn's disease, or malabsorption syndrome. of the patients, but resist the typical manipulative
Negative findings may reassure the patient that behavior of the patient. It is unlikely that one
his or her bowel is normal, and reduce preoccu- mode of treatment will be completely successful
pation with possible "obscure illness in the gut." in the treatment of this disorder. It is important
An electrocardiogram is obtained to evaluate to tailor the treatment to the specific problem
the heart rhythm, which may be affected by the from a variety of modalities (Table 3). T h e best
low potassium blood level. Cardiac function tests results are being achieved in a milieu setting of a
done on 12 anorexic patients at the Cleveland large medical center in which a special remedial
Clinic showed normal results. T h e evaluations program for eating disorders is established. T h e
included electrocardiograms, 24-hour Holter therapist in charge of the treatment should work
monitor recordings, systolic pressure response with a team in which there is complete collabo-
during exercise, heart rate during exercise, and ration among all team members to prevent the
echocardiograms. This study showed that the patient from manipulating one therapist against
major cardiogenic risk in anorexia nervosa is loss the other. Frequent meetings of team members
of potassium due to vomiting or abuse of laxa- are important to assess progress in therapy. 19
tives, causing severe arrhythmias, particularly Behavioral therapy is used only if the patient -
ventricular fibrillation leading to cardiac arrest is motivated to accept the responsibilities of a
and death. 17 Ayers et al, 18 at T h e Cleveland behavior contract. T h e patient is thus able to
Clinic Foundation, recommended skeletal evalu- control his or her own eating and face the contin-
ation in anorexic females because of the finding gency of the contract whenever unsuccessful.
of significant osteopenia in 6 of 14 such patients. T h e contract enables the patient, with the help
This raises the question of the need for replace- of a dietitian, to learn how much food is required
Downloaded from www.ccjm.org on October 10, 2021. For personal use only. All other uses require permission.'376 Cleveland Clinic Quarterly Vol. 50, N o . 2
to attain and to maintain a certain weight accept- 3. B r u c h H . T h e Golden Cage: T h e E n i g m a of A n o r e x i a Ner-
vosa. C a m b r i d g e , Mass: H a r v a r d U n i v e r s i t y Press, 1 9 7 8 .
able to the patient.
4. B r u c h H . Eating Disorders: Obesity, A n o r e x i a Nervosa and
Assertiveness training is part of therapy for the P e r s o n W i t h i n . N e w Y o r k : N Y Basic B o o k s , 1 9 7 3 .
many anorexic patients, which helps the patient 5. M i n u c h i n S. P s y c h o s o m a t i c F a m i l i e s ( A n o r e x i a N e r v o s a i n
with the process of separation from parents in C o n t e x t ) C a m b r i d g e , Mass: H a r v a r d U n i v e r s i t y Press, 1 9 7 8 .
becoming more independent. 6. H s u L K G , C r i s p A H , H a r d i n g B . O u t c o m e o f a n o r e x i a ner-
vosa. L a n c e t 1 9 7 9 ; 1 : 6 1 - 6 5 .
Art or creative therapy is used to assess the
7. H s u L K G . O u t c o m e o f a n o r e x i a n e r v o s a . A r e v i e w o f the
progress of the patient during therapy and also literature ( 1 9 5 4 - 1 9 7 8 ) . A r c h G e n Psychiatry 1980; 3 7 : 1 0 4 1 -
to help the patient verbalize underlying conflicts 1046.
by drawing and painting or working on craft 8. B r u c h H . P e r c e p t u a l a n d c o n c e p t u a l d i s t u r b a n c e s in a n o r e x i a
projects. Since patients may deny feelings of hun- nervosa. P s y c h o s o m M e d 1 9 6 2 ; 24: 1 8 7 - 1 9 4 .
9. Fries H . A n o r e x i a Nervosa. New Y o r k , N Y : Raven Press,
ger, satiety, and any other sensations of their
1977.
bodies, either internal or external, biofeedback 10. A m e r i c a n P s y c h i a t r i c Association. Diagnostic a n d Statistical
or hypnosis may help them gain awareness of Manual o f Mental Disorders. 3d ed, Washington, D . C . , 1980.
their bodies and also learn to rest and take better 11. Casper R C , Eckert E D , H a l m i K A , Goldberg S C , Davis J M .
care of their bodies, improving the distorted B u l i m i a . Its i n c i d e n c e a n d clinical i m p o r t a n c e i n patients w i t h
anorexia nervosa. A r c h G e n Psychiatry 1980; 3 7 : 1 0 3 0 - 1 0 3 5 .
body image. Family therapy is an integral part of
12. Garfinkel P E , Moldofsky H , G a r n e r D M . T h e heterogeneity
any treatment program, if the underlying con-
o f a n o r e x i a n e r v o s a . B u l i m i a as a distinct s u b g r o u p . A r c h G e n
flicts are the result of faulty family relations. Psychiatry 1980; 3 7 : 1 0 3 6 - 1 0 4 0 .
Recently, self-help organizations have begun to 13. S h e r m a n B M , H a l m i K A , Z a m u d i o R . L H a n d F S H response
operate in several cities around the country. Pa- to g o n a d o t r o p i n - r e l e a s i n g h o r m o n e in a n o r e x i a n e r v o s a : E f -
tients are involved in activities of helping other fect o f n u t r i t i o n a l r e h a b i l i t a t i o n . J C l i n E n d o c r i n o l Metab
1975;41:135-142.
patients through their local Anorexic Aid Soci-
14. W a k e l i n g A , D e S o u z a V A , B e a r d w o o d C J . Assessment o f the
ety. This type of help is similar to that given in negative a n d positive feedback effects o f a d m i n i s t e r e d oestro-
other self-help groups such as Alcoholics Anon- gen o n g o n a d o t r o p h i n release in patients w i t h a n o r e x i a ner-
ymous. T h e growth of the Anorexic Aid Society vosa. P s y c h o l M e d 1 9 7 7 : 7 : 3 9 7 - 4 0 5 .
as a self-help group is encouraging since part of 15. G i d w a n i G P . G y n e c o l o g i c a l signs a n d s y m p t o m s in a n o r e x i a
n e r v o s a . G r o s s M , ed. A n o r e x i a N e r v o s a — A C o m p r e h e n s i v e
their goal is to enhance the recognition of the
A p p r o a c h . L e x i n g t o n , Mass: T h e C o l l a m o r e Press, 1 9 8 2 , pp
problem by professionals and lay people so that 41-44.
the diagnosis can be made earlier. Usually, the 16. Frisch R E , McArthur JW. M e n s t r u a l cycles: Fatness as a
sooner the diagnosis is confirmed, the better the d e t e r m i n a n t o f m i n i m u m w e i g h t f o r height necessary f o r t h e i r
prognosis is. Denial mechanism and obsessive- m a i n t e n a n c e a n d / o r onset. S c i e n c e 1 9 7 4 ; 1 8 5 : 9 4 9 .
compulsive habits are not yet deeply imbedded 17. M o o d i e D S . C a r d i a c f u n c t i o n in a n o r e x i a n e r v o s a . G r o s s M ,
ed: A n o r e x i a N e r v o s a — A Comprehensive A p p r o a c h . L e x i n g -
and the patient can more easily give up the path- ton, Mass: T h e C o l l a m o r e Press, 1 9 8 2 , pp 4 5 - 5 8 .
ological eating habits if treatment is started early. 18. A y e r s J W T , Gidwani G P , Schmidt I M V , Gross M. Osteopenia
i n hypoestrogenic y o u n g w o m e n w i t h a n o r e x i a n e r v o s a . F e r t i l
References S t e r i l ( I n press.)
1. G u l l W . A n o r e x i a n e r v o s a (apepsia h y s t e r i c a , a n o r e x i a hyster- 19. Reece B A , Gross M. A comprehensive milieu program for
ica). T r a n s C l i n S o c L o n d o n 1 8 7 4 ; 7 : 2 2 - 3 1 . t r e a t m e n t o f a n o r e x i a nervosa. A n o r e x i a N e r v o s a — A C o m -
2. Laseque C . D e I'anorexie hysterique. A r c h G e n M e d 1873; p r e h e n s i v e a p p r o a c h . G r o s s M , ed. L e x i n g t o n , Mass: The
1:385. C o l l a m o r e Press, 1 9 8 2 , pp 1 0 3 - 1 0 9 .
Downloaded from www.ccjm.org on October 10, 2021. For personal use only. All other uses require permission.You can also read
