Brit. 3. Psychiat. (1976), 128, 555—8
Anorexia Nervosa After the Menopause By J. KELLETT, Summary.
M. TRIMBLE
and A. THORLEY
A patient is described who developed the classical syndrome of
anorexia nervosa at the age of 52. Her illness occurred in relation to the marriages of her daughters a determination
and showed an extreme to slim by diet, purging
preoccupation and vomiting,
with her body shape and and the hiding of food to
the extent of rendering herself too weak to cope with the demands of her life. It is suggested that anorexia nervosa, though predominantly a disease of onset in adolescence, may present at any age and should be considered in the differential diagnosis of anorexia in patients over the age of 50.
Anorexia nervosa is generally considered as an illness affecting young people. While debate still continues about its aetiology, it is charac teristically reported in young females who have weight loss and amenorrhoea without signs of any somatic causal factor. Some authors make a diagnosis primarily on psychological grounds. Thus, Bruch (1965) refers to a'. . . relentless pursuit
of thinness
. . .‘and
Crisp
Indeed, most published series suggest a mean age of onset for the disorder of about 17 years. However, the possibility of diagnosis of the condition
in
are
used.
While
(1972)
of pleasure
anorexic
may represent secondary as defined by King (1963).
CASE REPORT
November 1972 with a three-year history of in creasing loss of weight totalling 17 kg., the avoidance of carbohydrate foods (sugar, bread and potatoes) and
[email protected] with
slimming
tablets
and
purgatives. She had been seen by her daughters to make herself vomit, and she constantly
complained
of getting too fat. She was treated with imipramine without response, and was admitted to Bethlem Hospital on I7January
in for its own sake'.
this syndrome were many history, including an onset of
illness within
have
The patient, a 54-year-old widow, was referred by her G.P. to the Maudsley Hospital out-patients in
signs and symptoms. down five necessary
indulged
nervosa
published description of unequivocal anorexia nervosa with onset after the menopause.
conditions for the diagnosis, including onset before the age of 25. King (1963) separated a group with primary anorexia nervosa according to the criterion that ‘¿food refusal was in itself a Clustering with aspects of natural
of anorexia
The following case report represents the first
pathology characterized by a morbid fear of fatness'. Others, seeking less equivocal grounds for diagnosis, limit the conclusion to a certain
source
cases
explicit, and they forms of the disorder
condition by ‘¿. . . behaviour leading to a considerable weight loss . . . and a psycho
of clinical (1972) lays
post-menopausal
been recorded in the literature in females up to the age of 94, the criteria for diagnosis are not
associates the disorder with'.. . a resistance to eating fattening foods, often arising from an established fear of fatness, but always linked with a progressively single-minded pursuit of thinness. . .‘.Russell (i97o) also identifies the
clustering Feighner
middle-aged,
females need not be ruled out if psychopatho logical rather than strict ‘¿operational'criteria
1973.
At
that
stage
she
had
been
noted
to
be
failing
about at home and sitting so close to an electric fire that it was burning her dothes. She weighed 32.5 kg (ideal weight 48.5 kg), her height was 555 cm, and
the first seven years after
puberty. Others also limit the criteria to involve an age factor. For example, Dally (1969) limits his series to patients under the age of 35.
she was generally thin and weak. She had mild oedema of her ankles,severemyopia and bilateral 353
ANOREXIA
556 detached since
retinae,
childhood.
the latter
Physical
having
examination
NERVOSA
been
AFTER
present
was in other
res
THE
MENOPAUSE
Personalandfamilj history The patient was born at home prematurely (at 33
pects normal. Serum gonadotrophins were reduced (F.S.H. o.8 m.I.U./ml) (normal range 43—180); L.H. 0.4 m.I.U./ml (normal range 57.5—45.0); and there was a loss of diurnal drop in cortisol secre tion (plasma cortisol 9.00 a.m. 550 rig/mI, 530
weeks, weight I ,88o grams) and was not expected to
ng/mJ at 11.00p.m.).
shemarried. She was the eldest of five siblings. Her mother was
Her mental State hardly changed throughout her stay in hospital. She was constantly evasive in attitude, with a marked suspicion that doctors and relatives
survive.
She was breast
and bottle
fed and eventually
became a fat baby, later developing into a normally proportioned
child. She was an average pupil and
left school at 54, doing unskilled factory work until
a warm but nervous woman in whom it was difficult to confide. Her father, a bus driver, was a solid, were onlyconcernedtomake her fat.Her conversa dependable man who disappointed her by favouring @
tionwas entirely takenup with the theme oflosing her younger sister. She reacted to this by forming a her femininity through obesity and her dislike of warm and close relationship with her mother's carbohydrate foods. A counter-theme, to which she stepfather, a baker. There were no other notable always returned, was the loss of her husband in rivalries with her younger brother and three younger 1964. She experienced her body as being fat, and sisters. All have married and have been free stubbornly
disregarded
any
suggestions
to
the
of psychiatric illness except the youngest sister who
contrary. Soon afteradmissionher physicalconditionim proved, and the oedema disappeared. Other physical and laboratoryinvestigations revealedno abnor malities. A cautiousdiagnosis of anorexianervosa was made, and she was encouragedto eat appro
hasremainedsingle and in 1954briefly received out patient treatment at the Maudsley Hospital for
priately and achieve a mutually agreed target weight of 47.5 kg. No one on the staff was able to get dose
at home, and the patient reflects this in having felt a
room,
intercourse
personality
difficulties.
Her
parents
appear
to have
had a stable relationship, and there is no evidence of any abnormalattitudes tofoodor weight. Reference to sexual matters was strictly outlawed
disgust of physical sexual relations throughout her toher asa person,and itwas several weeksbeforeit life. This strict attitude did not prevent her from was discovered thatshe was secretly controlling her having boyfriends in her teenage years, but she weightby throwingfood out of the window of her remained totally unaware of the nature of sexual taking proprietary purgatives
(Senokot)
and
until
her
marriage.
Overt
sexuality
was
inducing vomiting with a finger. She gained weight
always a threat to her and intercourse with her with greatreluctance only when closely supervised husband a revolting duty. She appears to have had a on a highcalorie diet. When shespentweekendswith normal adolescence without any alteration in men her marrieddaughtersshewould gorgeherself with struation, fluctuation in weight or abnormal attitudes cakesand fattening foods, thussatisfying their concern to food. Her menarche was at 15, and until her and would then vomit and purge herself before menopause at 4.8, apart from the exception referred returning to the ward, invariably losing weight after to below, her periods were always present and a weekend with her elder daughter. She refused all regular. During the war she met and married her forms of medication, and when her weight reached husband who, like her father, became a bus driver, 43.6 kg at theend of May, shesuddenlydischarged and had a similar personality. In the post-war years
herself.
the patient was to become very dose to and de
For threemonths she attendedout-patients but continued to lose weight, and when she reached 38.1 kg she was readmitted. This time she agreed
pendent
to take part in an operant behavioural programme which rewarded weight gain with social contact and weekends at home. She responded slowly to this, and eventually by January 1974 she had reached
was always steady at about 54 kg but on both
44.4 kg. She then failed to maintain any further increase in weight, ceased co-operating in the pro. gramme and was subsequently discharged. Since then she has continued gradually to lose weight in out-patients. There has been no emergence of a
between
depressive illness, and no change in her fundamental
depressed,
attitudes and psychopathology.
however, when she briefly attended the Maudsley for
on both of them. Photographs
taken when
she was in her twenties show her to be have been a feminine and attractive occasions daughters
young woman. Her weight
when she was pregnant with her two (born 1946 and 1948), she displayed
bulimia, and her weight rose in excess of 86 kg. In these episodes
her attitude
to food was
completely normal, and by the time her younger daughter was three years old she had stabilized at 57kg. In 1953, after the death of her father she became hypochondriacal
and lost weight.
By 1958,
BY J. KELLETT,
M. TRIMBLE
reactive depression, she showed no signs of morbid
AND
A. THORLEY
557 Four years later, in 1972, her younger daughter
left home, and for the fIrst time in her life she was
attitudes to food and had regained her weight. Following this, she entered into what she describes as the best years of her married life. As her daughters
pressed she began to lose weight rapidly
entered adolescence she became uncomfortably
tinued
completely alone. Without appearing to deteriorate
physically
to be de
until
and con
her
hospital
aware oftheway inwhich theyincreasingly diverted admission in 1973. and absorbed her husband's sexual interest. In 1961,
at the time of her younger daughter's menarche, she herself had three months' amenorrhoea, but after wards resumed regular menstruation. At about the same time she openly
began
to encourage
her husband
to put on weight and at meals to eat up everyone else's leftovers, especially her own. He rapidly became overweight
but her own weight remained
steady and
her attitude to her body image remained normal. In 1964 the patient's husband died suddenly from a myocardial
infarction whilst on a summer
holiday, at a time when she felt particularly irritated by his attentions to her elder daughter. At the funeral, and for some time afterwards,
she was unable
to
register the loss emotionally and went on to develop an abnormal grief reaction—for instance, at home
she continued
to put out four place settings at meals
for many months. She began having regular dreams, which
continue
to the present
day, in which her
husband is in some way sexually involved with another woman. For the first time in her life her periods became irregular, and with a small weight gain she fancied she was pregnant and developed a pseudocyesis. A few months' later she developed pains in the back ‘¿like a heart attack' and a convic
DiscussioN To establish the diagnosis of anorexia nervosa
in this patient,
we need to examine
in the light
of her history the psychopathological criteria which have been attached to the diagnosis. Bruch (1962) distinguishes three criteria, the first
being
a distortion
of body
image
Slade
and Russell (1973) were able to confirm such distortion
of perception
in anorexia
nervosa,
and regard it as possibly a fundamental part of the psychopathology of the disorder. The patient frequently complained of being fat, as when at 36 kg. she complained of excessive fat around her shoulders, hips and abdomen, and would also complain of muscular arms which were in reality wasted and bony. Bruch's second criterion was the distortion of diet to slim, with the
addition of purging, vomiting, the hiding of food, etc. The patient showed all these features, and it was also clear
that
her refusal
of food did not
reflect a loss of appetite, but simply a desire to lose weight, a feature which Bruch considers essential in distinguishing true anorexia ncr
tion that her prolapsed haemorrhoids were deve loping into male genitalia, a distortion of her body
vosa. Crisp
image
central feature of this condition is a phobia of
through
which
she
identified
with
her
lost
husband. In the next two years she was to experience
further personal losses. She had two operations for a detached retina which left her partially sighted, and in early ig66 her older daughter married and left home. In late 1966 the patient ceased menstruating.
In November 1966 she was again referred to psychiatric out-patients by her general practitioner. She complained that her muscles were getting bigger and that she was frightened of becoming fat and
losing her femininity. There was no evidence of significant
though
weight
loss, and
her
selective. The impression
appetite
was
good
was that she had
an agitated depression with somatic and hypo
normal
(1967)
weight,
has also emphasized
and Crisp (1973) agreed
that the that the
patient showed many of the characteristics of classical anorexia nervosa when he interviewed her in October 1973. The third criterion is a sense of personal ineffectiveness, with the forma tion of a dependent, but negativistic, relation ship. Whilst the patient certainly showed herself to be dependent on her husband and daughters, at other times she would refuse help and insist that she was well, despite fainting on exertion. She was thus able, like so many patients with anorexia nervosa, to maintain her
dependence while protesting the .thondriacal symptoms. She respondedto tricydlic Symptom rating scales also suppport antidepressants, but a year later her somatic sensations
opposite. the diag
nosis of anorexia nervosa. She never scored thr.@ughout thetreatmentshe remainedpreoccupied above ii on the Hamilton Scale (196o) for and scored 22 on the anorexic with the loss of her husband. Her weight remained depression, weic unchanged. In 1967 she weighed 48 kg, and steady
and
she was discharged
practitioner in 1968.
back
to her general
behaviour scale (Slade, 1973) in which a score above i 2 is considered diagnostic The physical
ANOREXIA NERVOSA AFTER THE MENOPAUSE
558 features
of anorexia
nervosa
are
largely
normally
increased
in
the
post-menopausal
period, were markedly reduced. Alternative diagnoses include a depressive or a schizophrenic illness with delusions related to food. Neither of these diagnoses seems likely in this patient. While she is described as having had an agitated depression in the past, she has constantly denied depression during the current illness, especially when her weight was at its lowest. She showed no diurnal variation of mood, and her avoidance of food was always motivated by fear of gaining weight rather than by loss of appetite. Indeed, before her ad mission
she was
taking
tablets
to reduce
for depression.
There
REFERENCES BzlussmIN,
pression, but is typical of anorexia nervosa of late onset (Theander, 1970). Whilst patients who develop anorexia nervosa
at puberty may retain the trait and present in a similar condition later in life, few patients are the anorexia Ryle (1936)
has begun mentions i@
out of his series of 51 who presented over the age of 30, including one at the age of 59. He considered their outcome very similar to that of the younger age groups, but unfortunately gives little information to establish the diagnosis. Bernstein (1972) records a lady of 94 who stopped eating, but her prompt recovery with ECT throws doubt on the diagnosis. It is, of course, possible that the preconception of anorexia nervosa as a diseaseof adolescence
has led to an under-reporting of subjects of a later age of onset, and if so the publication of this case may help to redress the balance.
I. C.
(1972)
Anorexia
nervosa:
@.year-old
woman treated with electric shock. Minnesota Mcdi czne, 55, 552—3. BRUCH, H. (1962) Perceptual and conceptual disturbances in anorexia nervosa.Psychosomatic Medicine,24, 187-94. —¿
(1965)
Anorexia
nervosa
nosis. Journal
and
its
differential
of Xervous and Mental
diag
Disorders,
141,
555—60. Ciusp, A. H. (1965) Clinical and therapeutic aspects of anorexia
nervosa:
a study
of 30
cases.
Journal
of
Psychosomatic Research, 9, 67—78. —¿
(1967)
The
correlates
possible
significance
of weight
and
of
some
carbohydrate
behavioural
intake.
Journal
of Psychosomatic Research, 2, 117—31. —¿
was no evidence
of schizophrenia or dementia. Since her first presentation in 1972 up to the time of writing in March 1975, she has remained underweight and her attitude to her weight has not changed. Such a prolonged course is unusual in de
described in whom after the menopause.
Our thanks are due to Dr. Hare, the consultant in charge of the case; and to Dr. Buckle for the estimation of plasma cortisol.
her
appetite. Furthermore, she failed to respond to treatment
[email protected]
the
result of the weight loss. It is interesting to note that her gonadotrophin levels, which are
&
Toass,
D.
A.
(1972)
Primary
anorexia
or
weight
phobiainthemale:report onl3 cases. British Medical Journal, i, 334—8. —¿
(i@7@)
DALLY,
Personal
P. J.
communication.
(i@6@) Anorexia Nervosa.
Heinemann Medical Books. FalolniElt, J. P., ROBINS, Eu, Guza,
London:
William
SAMUEL B., Wooo
RUFF, R. A., WINOKUR, GEORGE & Mu9oz, (1972)
Diagnostic
criteria
for
use
in
RODRI0O psychiatric
research. Archivesof GeneralP@iat,y, a6, 27-63. HAMILTON,
M.
Journal
(i96o)
A
rating
scale
for
depression.
of Xeurology, Neurosurgery and Piat,y,
23,
56—62. KING, A. (1963)
syndromes.
Primary
and
secondary
anorexia
nervosa
British Journal of Psychi€thy,109, 470-9.
MetropolitanLife AssuranceCompanyStatistical Bulletin (1959) 40,
I.
RussEu., G. F. M. (1970) Anorexia nervosa: its identity as an illness and its treatment. In Modern Trends in Psychological Medicine (Vol. 2) (ed. J. H. Price).
London: Butterworths. Rvts@J. A. (1936) Anorexia nervosa. Lancet, ii, 893-9. [email protected],P. D. (z973) A short anorexia behaviour scale. British Journal of Psychiatry, 122, 83-5. —¿
&
RUSSELL,
G.
F.
M.
(,@73)
Awareness
of
body
dimensions inanorexia nervosa: cross-sectional and longitudinal studies. Journal of PsychosomaticResearch, 3, 188—99. THEANDER,
S.
investigation
(1970)
Anorexia
of 94 female
nervosa:
patients.
a
Ada
psychiatric
Psychiatrists
Scandinavica,Supplementwn,214.
John Kellett, M.R.C.P.,M.R.C.PIYCh., SeniorLecturer,St. George'sHospital, Blacks/zawRoad, Tooling, S. W.17 Michael Trimble, M.R.C.P., Registrar, Bet/ilem Royal and Maudsley Hospital, Denmark Hill, S.E.5 Anthony Thorley, M.B., B.Chir.,M.R.C.PSyCh., Registrar, Bethiem Royal and Mauddey Hospital, Denmark Hill, S.E.5 (Received 29 November 1974;
revised 8 May
1975)
Anorexia nervosa after the menopause. J Kellett, M Trimble and A Thorley BJP 1976, 128:555-558. Access the most recent version at DOI: 10.1192/bjp.128.6.555
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Anorexia Nervosa After the Menopause By J. KELLETT, Summary.
M. TRIMBLE
and A. THORLEY
A patient is described who developed the classical syndrome of
anorexia nervosa at the age of 52. Her illness occurred in relation to the marriages of her daughters a determination
and showed an extreme to slim by diet, purging
preoccupation and vomiting,
with her body shape and and the hiding of food to
the extent of rendering herself too weak to cope with the demands of her life. It is suggested that anorexia nervosa, though predominantly a disease of onset in adolescence, may present at any age and should be considered in the differential diagnosis of anorexia in patients over the age of 50.
Anorexia nervosa is generally considered as an illness affecting young people. While debate still continues about its aetiology, it is charac teristically reported in young females who have weight loss and amenorrhoea without signs of any somatic causal factor. Some authors make a diagnosis primarily on psychological grounds. Thus, Bruch (1965) refers to a'. . . relentless pursuit
of thinness
. . .‘and
Crisp
Indeed, most published series suggest a mean age of onset for the disorder of about 17 years. However, the possibility of diagnosis of the condition
in
are
used.
While
(1972)
of pleasure
anorexic
may represent secondary as defined by King (1963).
CASE REPORT
November 1972 with a three-year history of in creasing loss of weight totalling 17 kg., the avoidance of carbohydrate foods (sugar, bread and potatoes) and
[email protected] with
slimming
tablets
and
purgatives. She had been seen by her daughters to make herself vomit, and she constantly
complained
of getting too fat. She was treated with imipramine without response, and was admitted to Bethlem Hospital on I7January
in for its own sake'.
this syndrome were many history, including an onset of
illness within
have
The patient, a 54-year-old widow, was referred by her G.P. to the Maudsley Hospital out-patients in
signs and symptoms. down five necessary
indulged
nervosa
published description of unequivocal anorexia nervosa with onset after the menopause.
conditions for the diagnosis, including onset before the age of 25. King (1963) separated a group with primary anorexia nervosa according to the criterion that ‘¿food refusal was in itself a Clustering with aspects of natural
of anorexia
The following case report represents the first
pathology characterized by a morbid fear of fatness'. Others, seeking less equivocal grounds for diagnosis, limit the conclusion to a certain
source
cases
explicit, and they forms of the disorder
condition by ‘¿. . . behaviour leading to a considerable weight loss . . . and a psycho
of clinical (1972) lays
post-menopausal
been recorded in the literature in females up to the age of 94, the criteria for diagnosis are not
associates the disorder with'.. . a resistance to eating fattening foods, often arising from an established fear of fatness, but always linked with a progressively single-minded pursuit of thinness. . .‘.Russell (i97o) also identifies the
clustering Feighner
middle-aged,
females need not be ruled out if psychopatho logical rather than strict ‘¿operational'criteria
1973.
At
that
stage
she
had
been
noted
to
be
failing
about at home and sitting so close to an electric fire that it was burning her dothes. She weighed 32.5 kg (ideal weight 48.5 kg), her height was 555 cm, and
the first seven years after
puberty. Others also limit the criteria to involve an age factor. For example, Dally (1969) limits his series to patients under the age of 35.
she was generally thin and weak. She had mild oedema of her ankles,severemyopia and bilateral 353
ANOREXIA
556 detached since
retinae,
childhood.
the latter
Physical
having
examination
NERVOSA
been
AFTER
present
was in other
res
THE
MENOPAUSE
Personalandfamilj history The patient was born at home prematurely (at 33
pects normal. Serum gonadotrophins were reduced (F.S.H. o.8 m.I.U./ml) (normal range 43—180); L.H. 0.4 m.I.U./ml (normal range 57.5—45.0); and there was a loss of diurnal drop in cortisol secre tion (plasma cortisol 9.00 a.m. 550 rig/mI, 530
weeks, weight I ,88o grams) and was not expected to
ng/mJ at 11.00p.m.).
shemarried. She was the eldest of five siblings. Her mother was
Her mental State hardly changed throughout her stay in hospital. She was constantly evasive in attitude, with a marked suspicion that doctors and relatives
survive.
She was breast
and bottle
fed and eventually
became a fat baby, later developing into a normally proportioned
child. She was an average pupil and
left school at 54, doing unskilled factory work until
a warm but nervous woman in whom it was difficult to confide. Her father, a bus driver, was a solid, were onlyconcernedtomake her fat.Her conversa dependable man who disappointed her by favouring @
tionwas entirely takenup with the theme oflosing her younger sister. She reacted to this by forming a her femininity through obesity and her dislike of warm and close relationship with her mother's carbohydrate foods. A counter-theme, to which she stepfather, a baker. There were no other notable always returned, was the loss of her husband in rivalries with her younger brother and three younger 1964. She experienced her body as being fat, and sisters. All have married and have been free stubbornly
disregarded
any
suggestions
to
the
of psychiatric illness except the youngest sister who
contrary. Soon afteradmissionher physicalconditionim proved, and the oedema disappeared. Other physical and laboratoryinvestigations revealedno abnor malities. A cautiousdiagnosis of anorexianervosa was made, and she was encouragedto eat appro
hasremainedsingle and in 1954briefly received out patient treatment at the Maudsley Hospital for
priately and achieve a mutually agreed target weight of 47.5 kg. No one on the staff was able to get dose
at home, and the patient reflects this in having felt a
room,
intercourse
personality
difficulties.
Her
parents
appear
to have
had a stable relationship, and there is no evidence of any abnormalattitudes tofoodor weight. Reference to sexual matters was strictly outlawed
disgust of physical sexual relations throughout her toher asa person,and itwas several weeksbeforeit life. This strict attitude did not prevent her from was discovered thatshe was secretly controlling her having boyfriends in her teenage years, but she weightby throwingfood out of the window of her remained totally unaware of the nature of sexual taking proprietary purgatives
(Senokot)
and
until
her
marriage.
Overt
sexuality
was
inducing vomiting with a finger. She gained weight
always a threat to her and intercourse with her with greatreluctance only when closely supervised husband a revolting duty. She appears to have had a on a highcalorie diet. When shespentweekendswith normal adolescence without any alteration in men her marrieddaughtersshewould gorgeherself with struation, fluctuation in weight or abnormal attitudes cakesand fattening foods, thussatisfying their concern to food. Her menarche was at 15, and until her and would then vomit and purge herself before menopause at 4.8, apart from the exception referred returning to the ward, invariably losing weight after to below, her periods were always present and a weekend with her elder daughter. She refused all regular. During the war she met and married her forms of medication, and when her weight reached husband who, like her father, became a bus driver, 43.6 kg at theend of May, shesuddenlydischarged and had a similar personality. In the post-war years
herself.
the patient was to become very dose to and de
For threemonths she attendedout-patients but continued to lose weight, and when she reached 38.1 kg she was readmitted. This time she agreed
pendent
to take part in an operant behavioural programme which rewarded weight gain with social contact and weekends at home. She responded slowly to this, and eventually by January 1974 she had reached
was always steady at about 54 kg but on both
44.4 kg. She then failed to maintain any further increase in weight, ceased co-operating in the pro. gramme and was subsequently discharged. Since then she has continued gradually to lose weight in out-patients. There has been no emergence of a
between
depressive illness, and no change in her fundamental
depressed,
attitudes and psychopathology.
however, when she briefly attended the Maudsley for
on both of them. Photographs
taken when
she was in her twenties show her to be have been a feminine and attractive occasions daughters
young woman. Her weight
when she was pregnant with her two (born 1946 and 1948), she displayed
bulimia, and her weight rose in excess of 86 kg. In these episodes
her attitude
to food was
completely normal, and by the time her younger daughter was three years old she had stabilized at 57kg. In 1953, after the death of her father she became hypochondriacal
and lost weight.
By 1958,
BY J. KELLETT,
M. TRIMBLE
reactive depression, she showed no signs of morbid
AND
A. THORLEY
557 Four years later, in 1972, her younger daughter
left home, and for the fIrst time in her life she was
attitudes to food and had regained her weight. Following this, she entered into what she describes as the best years of her married life. As her daughters
pressed she began to lose weight rapidly
entered adolescence she became uncomfortably
tinued
completely alone. Without appearing to deteriorate
physically
to be de
until
and con
her
hospital
aware oftheway inwhich theyincreasingly diverted admission in 1973. and absorbed her husband's sexual interest. In 1961,
at the time of her younger daughter's menarche, she herself had three months' amenorrhoea, but after wards resumed regular menstruation. At about the same time she openly
began
to encourage
her husband
to put on weight and at meals to eat up everyone else's leftovers, especially her own. He rapidly became overweight
but her own weight remained
steady and
her attitude to her body image remained normal. In 1964 the patient's husband died suddenly from a myocardial
infarction whilst on a summer
holiday, at a time when she felt particularly irritated by his attentions to her elder daughter. At the funeral, and for some time afterwards,
she was unable
to
register the loss emotionally and went on to develop an abnormal grief reaction—for instance, at home
she continued
to put out four place settings at meals
for many months. She began having regular dreams, which
continue
to the present
day, in which her
husband is in some way sexually involved with another woman. For the first time in her life her periods became irregular, and with a small weight gain she fancied she was pregnant and developed a pseudocyesis. A few months' later she developed pains in the back ‘¿like a heart attack' and a convic
DiscussioN To establish the diagnosis of anorexia nervosa
in this patient,
we need to examine
in the light
of her history the psychopathological criteria which have been attached to the diagnosis. Bruch (1962) distinguishes three criteria, the first
being
a distortion
of body
image
Slade
and Russell (1973) were able to confirm such distortion
of perception
in anorexia
nervosa,
and regard it as possibly a fundamental part of the psychopathology of the disorder. The patient frequently complained of being fat, as when at 36 kg. she complained of excessive fat around her shoulders, hips and abdomen, and would also complain of muscular arms which were in reality wasted and bony. Bruch's second criterion was the distortion of diet to slim, with the
addition of purging, vomiting, the hiding of food, etc. The patient showed all these features, and it was also clear
that
her refusal
of food did not
reflect a loss of appetite, but simply a desire to lose weight, a feature which Bruch considers essential in distinguishing true anorexia ncr
tion that her prolapsed haemorrhoids were deve loping into male genitalia, a distortion of her body
vosa. Crisp
image
central feature of this condition is a phobia of
through
which
she
identified
with
her
lost
husband. In the next two years she was to experience
further personal losses. She had two operations for a detached retina which left her partially sighted, and in early ig66 her older daughter married and left home. In late 1966 the patient ceased menstruating.
In November 1966 she was again referred to psychiatric out-patients by her general practitioner. She complained that her muscles were getting bigger and that she was frightened of becoming fat and
losing her femininity. There was no evidence of significant
though
weight
loss, and
her
selective. The impression
appetite
was
good
was that she had
an agitated depression with somatic and hypo
normal
(1967)
weight,
has also emphasized
and Crisp (1973) agreed
that the that the
patient showed many of the characteristics of classical anorexia nervosa when he interviewed her in October 1973. The third criterion is a sense of personal ineffectiveness, with the forma tion of a dependent, but negativistic, relation ship. Whilst the patient certainly showed herself to be dependent on her husband and daughters, at other times she would refuse help and insist that she was well, despite fainting on exertion. She was thus able, like so many patients with anorexia nervosa, to maintain her
dependence while protesting the .thondriacal symptoms. She respondedto tricydlic Symptom rating scales also suppport antidepressants, but a year later her somatic sensations
opposite. the diag
nosis of anorexia nervosa. She never scored thr.@ughout thetreatmentshe remainedpreoccupied above ii on the Hamilton Scale (196o) for and scored 22 on the anorexic with the loss of her husband. Her weight remained depression, weic unchanged. In 1967 she weighed 48 kg, and steady
and
she was discharged
practitioner in 1968.
back
to her general
behaviour scale (Slade, 1973) in which a score above i 2 is considered diagnostic The physical
ANOREXIA NERVOSA AFTER THE MENOPAUSE
558 features
of anorexia
nervosa
are
largely
normally
increased
in
the
post-menopausal
period, were markedly reduced. Alternative diagnoses include a depressive or a schizophrenic illness with delusions related to food. Neither of these diagnoses seems likely in this patient. While she is described as having had an agitated depression in the past, she has constantly denied depression during the current illness, especially when her weight was at its lowest. She showed no diurnal variation of mood, and her avoidance of food was always motivated by fear of gaining weight rather than by loss of appetite. Indeed, before her ad mission
she was
taking
tablets
to reduce
for depression.
There
REFERENCES BzlussmIN,
pression, but is typical of anorexia nervosa of late onset (Theander, 1970). Whilst patients who develop anorexia nervosa
at puberty may retain the trait and present in a similar condition later in life, few patients are the anorexia Ryle (1936)
has begun mentions i@
out of his series of 51 who presented over the age of 30, including one at the age of 59. He considered their outcome very similar to that of the younger age groups, but unfortunately gives little information to establish the diagnosis. Bernstein (1972) records a lady of 94 who stopped eating, but her prompt recovery with ECT throws doubt on the diagnosis. It is, of course, possible that the preconception of anorexia nervosa as a diseaseof adolescence
has led to an under-reporting of subjects of a later age of onset, and if so the publication of this case may help to redress the balance.
I. C.
(1972)
Anorexia
nervosa:
@.year-old
woman treated with electric shock. Minnesota Mcdi czne, 55, 552—3. BRUCH, H. (1962) Perceptual and conceptual disturbances in anorexia nervosa.Psychosomatic Medicine,24, 187-94. —¿
(1965)
Anorexia
nervosa
nosis. Journal
and
its
differential
of Xervous and Mental
diag
Disorders,
141,
555—60. Ciusp, A. H. (1965) Clinical and therapeutic aspects of anorexia
nervosa:
a study
of 30
cases.
Journal
of
Psychosomatic Research, 9, 67—78. —¿
(1967)
The
correlates
possible
significance
of weight
and
of
some
carbohydrate
behavioural
intake.
Journal
of Psychosomatic Research, 2, 117—31. —¿
was no evidence
of schizophrenia or dementia. Since her first presentation in 1972 up to the time of writing in March 1975, she has remained underweight and her attitude to her weight has not changed. Such a prolonged course is unusual in de
described in whom after the menopause.
Our thanks are due to Dr. Hare, the consultant in charge of the case; and to Dr. Buckle for the estimation of plasma cortisol.
her
appetite. Furthermore, she failed to respond to treatment
[email protected]
the
result of the weight loss. It is interesting to note that her gonadotrophin levels, which are
&
Toass,
D.
A.
(1972)
Primary
anorexia
or
weight
phobiainthemale:report onl3 cases. British Medical Journal, i, 334—8. —¿
(i@7@)
DALLY,
Personal
P. J.
communication.
(i@6@) Anorexia Nervosa.
Heinemann Medical Books. FalolniElt, J. P., ROBINS, Eu, Guza,
London:
William
SAMUEL B., Wooo
RUFF, R. A., WINOKUR, GEORGE & Mu9oz, (1972)
Diagnostic
criteria
for
use
in
RODRI0O psychiatric
research. Archivesof GeneralP@iat,y, a6, 27-63. HAMILTON,
M.
Journal
(i96o)
A
rating
scale
for
depression.
of Xeurology, Neurosurgery and Piat,y,
23,
56—62. KING, A. (1963)
syndromes.
Primary
and
secondary
anorexia
nervosa
British Journal of Psychi€thy,109, 470-9.
MetropolitanLife AssuranceCompanyStatistical Bulletin (1959) 40,
I.
RussEu., G. F. M. (1970) Anorexia nervosa: its identity as an illness and its treatment. In Modern Trends in Psychological Medicine (Vol. 2) (ed. J. H. Price).
London: Butterworths. Rvts@J. A. (1936) Anorexia nervosa. Lancet, ii, 893-9. [email protected],P. D. (z973) A short anorexia behaviour scale. British Journal of Psychiatry, 122, 83-5. —¿
&
RUSSELL,
G.
F.
M.
(,@73)
Awareness
of
body
dimensions inanorexia nervosa: cross-sectional and longitudinal studies. Journal of PsychosomaticResearch, 3, 188—99. THEANDER,
S.
investigation
(1970)
Anorexia
of 94 female
nervosa:
patients.
a
Ada
psychiatric
Psychiatrists
Scandinavica,Supplementwn,214.
John Kellett, M.R.C.P.,M.R.C.PIYCh., SeniorLecturer,St. George'sHospital, Blacks/zawRoad, Tooling, S. W.17 Michael Trimble, M.R.C.P., Registrar, Bet/ilem Royal and Maudsley Hospital, Denmark Hill, S.E.5 Anthony Thorley, M.B., B.Chir.,M.R.C.PSyCh., Registrar, Bethiem Royal and Mauddey Hospital, Denmark Hill, S.E.5 (Received 29 November 1974;
revised 8 May
1975)
Anorexia nervosa after the menopause. J Kellett, M Trimble and A Thorley BJP 1976, 128:555-558. Access the most recent version at DOI: 10.1192/bjp.128.6.555
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