Practical Comprehensive Treatment of Anorexia Nervosa and Bulimia

This is a refreshingly concise, refreshingly practical book by a man who has had extensive experience in the treatment of anorexia and buhimic patients over a span of many years. It is of particular value for those who are actually engaged in treating such individuals. It is not intended to be an exhaustive review of all of the available studies, but relevant studies are cited throughout the many chapters of the book when appropriate. An example of the book’s practical approach is chapter 5, which describes inpatient treatment of anorexia nervosa. This chapter quickly gets down to specific recommendations, based on the author’s actual experience with anorexic inpatients. The chapter begins with a list of five indications for hospitalization, a sample contract for the patient to sign, a step-by-step discussion of the initial evaluation and the selection of the treatment team, and even a trouble-shooting guide for such problems as “patient will not eat,” “patient takes too long to eat,” “patient hides food,” and “use of laxatives or diuretics.” In each case, the author provides concrete suggestions as to how to deal with these specific issues. Similarly, in its discussion of psychotherapy, chapter S provides many specific suggestions and verbatim examples of possible responses to various patient issues. The chapter also provides useful tables, including one showing how to calculate whether an individual has a small, medium, or large frame. (I have always been baffled as to how to judge whether someone has a small, medium, or large frame when using the Metropolitan Life tables; now I know how to do it.) Finally, the chapter has several appendixes, including checklists for admission and discharge evaluations and a sample semistructured interview. This is an example of only one of the chapters. Others, describing outpatient treatment of anorexia nervosa and inpatient and outpatient treatment of bulimia, are similar in style. There is even a step-by-step guide on how to organize an eating disorders clinic. Also included are a few “nonpractical” chapters of interest. One presents three classical papers on anorexia nervosa from earlier centuries: Morton’s paper on “nervous consumption,” Gull’s classical description of anorexia nervosa, and Las#{232}gue’s paper on “hysterical anorexia.” Another chapter presents data from the author’s own experience with anorexia nenvosa in males. Two of the last chapters present data from the author’s center regarding the characteristics and outcome of anorexic patients treated there. In summary, although some data are presented, the book is primarily pragmatic, designed for clinicians actually engaged in treating patients. In keeping with this approach, the author refrains from elaborate theoretical discussions-an admirable approach in a field with few hard data and a great deal of theory. If one were to try to find a flaw in the book, it might be argued that it places a bit too much emphasis on psychotherapy-panticularhy in view of the fact that there are as yet no controlled studies (to my knowledge) showing any form of psychotherapy to be effective in anorexia nervosa. Indeed, in perhaps the only controlled study of psychotherapy in anorexia nervosa available-a preliminary report from Crisp and colleagues (1)-the patients who did not receive psychotherapy actually gained slightly more weight, both in the short term and on long-term follow-up, than those who did receive it. On the other hand, no other form of therapy for anorexia nenvosa-behavioral, sociocultural, or biologicalhas fared much better in controlled trials, so the author can hardly be faulted for presenting his practical observations of whatever modalities have seemed to work in his own hands through the years. As with all other books in rapidly evolving fields, there is always the problem that what was accurate at press time may already be slightly out of date on publication. For example, the author suggests that antidepressants may be useful for buhimia-citing a 1983 placebo-controlled double-blind study with imipramine-but suggests reserving antidepressants for bulimic patients who are behaviorally improved and who display evidence of persistent major depression. In the last year, three more placebo-controlled double-blind studies of antidepressants in bulimia have appeared (2-4), all with positive results and all suggesting that antidepressants are at least as effective in bulimic patients who are not depressed as in those who are. In fact, in one placebocontrolled study with desipramine at the Mayo Clinic (4), bulimic patients with major depression were specifically excluded from the sample, yet 68% of nondepressed bulimic patients experienced a remission of their bulimia with desipramine without any other ancillary treatment. Thus, it appears that antidepressants probably should not be reserved for bulimic patients who are depressed or who behaviorally improve. Again, however, the author can hardly be faulted for this omission, since these studies were unavailable at press time. In most respects, this book will not get out of date at any time in the near future, since its extensive practical advice is likely to remain useful for a long time to come. Therefore, I would strongly recommend it to anyone who is involved in the treatment of anorexic or bulimic patients.