Book Review

Medical Issues and the Eating Disorders: The Interface

N Engl J Med 1993; 329:1974-1975December 23, 1993

Article

Medical Issues and the Eating Disorders: The Interface
(Brunner/Mazel Eating Disorders Monograph Series.) Edited by Allan S. Kaplan and Paul E. Garfinkel. 256 pp. New York, Brunner/Mazel, 1993. $30.95. ISBN: 0-87630-681-4

Medical Issues and the Eating Disorders nicely fills a niche in the medical literature by lucidly and comprehensively presenting the most common medical problems associated with anorexia nervosa and bulimia nervosa. Anorexia nervosa, first described at least three centuries ago, was initially seen as a medical disorder and treated with potions, pills, and powders. Until fairly recently, it was sometimes discussed in medical textbooks in the section on endocrinology. Gradually, a more psychological approach to anorexia nervosa emerged. In addition, bulimia nervosa, a syndrome first described in the 1970s, has been effectively treated by well-documented empirical psychotherapeutic techniques. As a result, the eating disorders are now often regarded primarily as psychological entities, and much of their treatment, not inappropriately, is given by nonmedical personnel such as psychologists and social workers. This psychological focus sometimes leads to neglect of serious, at times life-threatening, medical complications of anorexia nervosa and bulimia nervosa.

This book was edited by two internationally respected experts, Allan Kaplan and Paul Garfinkel, who have extensive experience in the field. The topics include assessment, medical syndromes and complications of anorexia nervosa and bulimia nervosa, psychologic disturbances, and the care of the hospitalized patient. Although the book tends to be encyclopedic in its coverage of the medical literature, most chapters end with summaries of the implications for clinicians. One of the helpful themes threaded through the book is the differentiation between adaptive psychologic responses to anorexia and bulimia, which by themselves do not require intervention but will subside with the improvement of the illness, and medical complications that require immediate intervention and vigorous treatment. The chapters on binge eating in obese patients and dental complications are especially up to date. Some recent work on the gastrointestinal aspects of eating disorders is not included.

Family practitioners, internists, pediatricians, and other medical specialists will find this book helpful and, in many ways, necessary. A comprehensive but selective medical assessment of patients with eating disorders will avoid the two extremes of endless searches for medical causes of a disorder with psychiatric origins and an entirely psychosocial approach without recognition of medical complications. Psychiatrists, psychologists, social workers, nurse-clinicians, and many others will also find it useful.

The book is clear, avoids most jargon, and is well organized and well edited. Eating disorders remain culture-bound syndromes. They originate in the use of weight and shape change to deal with fundamental issues in development, mood, and relationships, but they often progress in a stepwise fashion to become biomedically entrained chronic states. In some ways, an eating disorder is like a canoe headed for Niagara Falls. The entry into the canoe may be voluntary, but after a while the river takes over. The medical complications and consequences of eating disorders are substantial, with a death rate of up to 19 percent (documented by Theander in Sweden) in long-term follow-up studies. There is growing evidence that, with expert medical intervention and collaboration, both the short-term and the long-term death rates may be substantially lowered.

This book will offer guidance in the shared care of eating-disorder patients by medical and psychological experts. It will help them avoid medical-legal complications caused by a lack of recognition of the associated medical syndromes, as well as inappropriate, endless, medical testing for less and less probable medical causes of a psychogenic disorder. The best treatment for eating disorders remains a collaborative effort among medical specialists, psychiatrists, and other psychologically trained health care professionals. Kaplan and Garfinkel's book is timely, reasonable in price, and published by a firm with a special interest in books on the understanding and treatment of patients with eating disorders.

Arnold E. Andersen, M.D.
University of Iowa, Iowa City, IA 52242