Psychogenic Malnutrition and Atypical Anorexia Nervosa
In the previous chapter I have reviewed various efforts at defining anorexia nervosa in meaningful terms and have tried to come to an understanding of the underlying psychodynamic factors. There are many contributions which seem to aim at the exact opposite, applying the term to every case of malnutrition with psychological problems. Many authors have drawn attention to this as creating confusion and as interfering with the understanding of the condition. Clauser found it difficult to draw conclusions from the data compiled from the literature because the clinical material was so heterogeneous, ranging from mild uncomplicated cases of weight loss to severe psychiatric disorders associated with cachexia (4). He also commented on the fact that the patients often had not been observed by the authors themselves; instead, information had been culled from hospital records which had accumulated over an extended period of time, where somebody with unknown experience had diagnosed some weight loss as anorexia nervosa. From my own evaluation of certain longrange surveys, I have drawn the same conclusion. More often than not, the original diagnosis had been made by a house officer without him or his supervisor ever having seen a patient with true anorexia nervosa. Often it looks as if the experience of the authors of such reports, who draw their authority from the large number of patients or the renown of the medical center at which the observations were made, is also limited and not based on actual observations of their own. Notable exceptions are the recent surveys by Dally and Theander (5, 8).
The monograph by Bliss and Branch, which was published in 1960 with the title Anorexia Nervosa (2), is a prime example of considering any weight loss for psychological reasons as meriting the diagnosis anorexia nervosa. The authors give a stimulating review of the early cases, and they note that with increasing reports, the syndrome to which Gull had given the name "anorexia nervosa" had become blurred and poorly defined. They themselves, "having failed to find in the literature a neat solution for