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Understanding Eating Disorders: Anorexia, Bulimia and Obesity

Alexander-Mott & Lumsden (eds.) (1994) Taylor & Francis, London. £19.50 Hardback.

In the preface to this book, the editors state that 'this book will be of interest to hose working directly with people with eating disorders, including counsellors, psychologist, nurses, medical practitioners, psychiatrists, and individuals working in eating disorders' clinics and programs.' (p.xvi) There is certainly a wide variety of approaches adopted by the different contributors, for example Sansone and Sansone produce a comprehensive guide to the medical complications which can arise in bulimic patients, Rand critically assesses the various means available of measuring obesity, and Marx evaluates the causes for the onset and continuation of anorexia. Crow and Mitchell consider a number of evaluations of psychotherapeutic treatment, which indicates that despite the variety of treatments on offer, the results in terms of cessation of bulimic symptoms have been very disappointing.

The book is divided into four sections, the first of which is entitled 'General Issues', the other three sections each being devoted to one of the major eating disorders, including obesity, whose status as an eating disorder is often questioned. Indeed, despite the editors' efforts to achieve balance, the 'hierarchy' of the eating disorders is inescapable. For example, the otherwise excellent overview of the historical origins of eating disorder by Blinder and Chao devotes most attention to anorexia nervosa and fasting, somewhat less space to bulimia, and a mere cursory glance at obesity. It is also interesting to note that the section on obesity is the only one that contains a chapter on 'Sociocultural Perspectives' (Yuker and Allison), whereas this theme is (somewhat surprisingly) omitted in the sections on anorexia and bulimia. Likewise, whereas the chapters on the definition and diagnostic criteria for anorexia and bulimia also contain 'associated psychological problems', the equivalent 'definition and diagnostic criteria' chapter for obesity is lumped together with 'associated health problems'. This tends to convey the message that psychological or development issues are less relevant to obesity, except to the extent that negative attitudes from others may serve to lower self esteem. There is thus a real omission in the failure to adequately cover issues related too psychological, development and family traits which can be identified as precursors of obesity in early childhood and adolescence.

Apart from Blinder and Chao's chapter in 'General Issues', this section includes a chapter on family factors in eating disordered individuals, sexual abuse, and development psychopathology. The latter, by Linda Smolak and Michael P. Levine, is worthy of note because of the issues they raise in putting forward their model of development psychopathology in relation to eating disorders. These include the importance of poor interceptive awareness among eating disordered patients and the concurrence of stressor in early adolescence (threats to achievement, increased heterosocial demands and change in weight/body image), which, when accompanied by a severe 'thinness schema' can have disastrous effects. They operate with the notion of a limited continuum of eating disorders. On a more optimistic note, they call for more research to be done on factors which serve to mediate the effects of a disturbed separation-individuation process.

The rest of the book, especially the sections on anorexia and bulimia, are mainly concerned with diagnostic criteria, history of the disorders (especially history of diagnostic criteria!), and medical complications, but not much devoted to treatment and recovery. A notable exception is the chapter by Scott J. Crow and James E. Mitchell which assesses the outcome of psychotherapeutic and psychopharmacological trials in treatment of bulimia. They conclude that results were very mixed in both types of treatment, with post-treatment abstinence rates (of bulimic behaviour) reaching 50% or more in only about half of the psychotherapeutic trials. This surely calls for a through reassessment of current treatment strategies.

One issue which none of the contributors scarcely touch upon is that of media images and cultural stereotypes. While this might appear to be an over familiar theme, contributors nevertheless still point to Garner and Garfinkel's study of Miss American prizewinners and playboy centrefolds. While to some extent reflecting the cultural standards of the day, these are nevertheless images of women that most of the female population is least likely to be interested in, or even to be exposed to. And surely the issue of 'difference' needs to be explored with regard to the images of women (and men) that the eating disordered and non-eating disordered population aspire to. Marx begins this process with his reference to the work on body image among gay male patients, and this is an area which no doubt needs to be further explored.

As is often the case with edited volumes, the quality of each contribution is variable. In some respects the editors may have been advised to concentrate contributors' articles into more narrowly defined field - the strengths of this volume tend to lie in the fields of diagnostic criteria and history of eating disorders. However, each chapter is extremely well referenced and is followed by discussion questions and sometimes exercises, which can be used in a teaching situation. If using the volume as a teaching tool to provide an overview, then its shortcomings will be noticed in the fields of societal context of eating disorders, and perhaps more importantly, of treatment and recovery.

Dawn de Kock
Therapist, Warley, UK