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Journal of Psychiatric & Mental Health Nursing

(C) 2002 Blackwell Science Ltd.

Volume 9(1), February 2002, p 65-71

Anorexia nervosa and culture
[Original Articles]

SIMPSON, K. J.
Student Nurse (BSc Nursing (Hons)) Department of Nursing Studies, Adam Ferguson
Building, University of Edinburgh, Edinburgh, UK
Correspondence: K. J. Simpson Department of Nursing Studies Adam Ferguson
Building 55/56 George Square Edinburgh EH8 9JU UK
Accepted for publication: 20 November 2000

--------------------------------------------

Abstract

Anorexia nervosa is currently considered a disorder confined to Western culture.
Its recent identification in non-Western societies and different subcultures
within the Western world has provoked a theory that Western cultural ideals of
slimness and beauty have infiltrated these societies. The biomedical definition
of anorexia nervosa emphasizes fat-phobia in the presentation of anorexia
nervosa. However, evidence exists that suggests anorexia nevosa can exist
without the Western fear of fatness and that this culturally biased view of
anorexia nervosa may obscure health care professionals' understanding of a
patient's own cultural reasons for self-starvation, and even hinder their
recovery.

----------------------------------------------

Introduction

Anorexia nervosa is a condition characterized by food denial, marked weight loss
and amenhorrea, and is most commonly found in young women (Lee 1996). Anorexia
nervosa has become of particular interest to health care professionals working
in psychiatry because of the role of culture in the disorder and because it
seems that psychiatric disorders may not present in the same form irrespective
of culture. The most popular, current hypothesis about the social causation of
anorexia nervosa involves the role of Western culture in the disorder. It is
customarily seen as a disorder caused and sustained by Western cultural values
of slimness and beauty, so much so that it has been coined a Western culture-bound
syndrome (Banks 1992). Anorexia nervosa is presumed to be rare both outside
North America, Europe and those places undergoing westernization (Japan), and in
those places where food is in shortage.

This hypothesis blames the changing cultural trends in female body shape for why
women strive to be thin. Thinness and fragility became feminine ideals in the
nineteenth century amongst middle class women. In the 1960s and 1970s, models
such as Twiggy were given a high profile and their svelte-like appearance became
a part of popular culture (Hepworth 1999). Not only has this ideal continued to
be very prominent in modern Western culture but it is now supported by a mass
media (Ponto 1995) and a multimillion dollar diet industry. 'Calorie-counting',
'dieting' and 'weight-watching' have become idioms of the language of an
industry that has encouraged a preoccupation with dieting and slimness amongst
Western women (Hepworth 1999).

As a corollary to these cultural values, the expected cultural reasons to be
given by an anorectic individual (for their deliberate food refusal) are based
on a fear of fatness and a wish to be thin in order to live up to these social
ideals. The thinness-as-beauty hypothesis is so popular that fat-phobia has been
included in diagnostic criteria used to diagnose anorectics. At the time of
writing, current formal diagnostic criteria are the fourth revision of the
Diagnostic and Statistical Manual of the American Psychiatric Association
(DSM-IV; American Psychiatric Association 1994) and the 10th edition of the
International Classification of Diseases (ICD-10; WHO 1992). The diagnostic
criteria for anorexia nervosa as outlined by the DSM-IV include:

* Refusal to maintain body weight at or above a minimally normal weight for age
and height (e.g. weight loss leading to maintenance of body weight less than 85%
of that expected; or failure to make expected weight gain during period of
growth, leading to body weight less than 85% of that expected).

* Intense fear of gaining weight or becoming fat, even though underweight.

* Disturbance in the way in which one's body weight or shape is experienced,
undue influence of body weight or shape on self-evaluation, or denial of the
seriousness of the current low body weight.

* In postmenarchal females, amenorrhea (American Psychiatric Association 1994).

In Western society, the increase in reported cases of anorexia nervosa can
perhaps be explained by the 'slackening' of the diagnostic criteria. The amount
of weight loss required for a diagnosis has decreased from 25% or more of
premorbid weight in the DSM-III to 15% in the DSM-IV. Similarly, the ICD-10
includes a 'dread of fatness' in the diagnostic criteria. The contemporary
diagnostic criteria therefore have de-emphasized emaciation and emphasized
fat-phobia (Lee 1996).

The view that anorexia nervosa is bound to Western places is no longer valid in
the light of its recent identification in a number of non-Western societies,
including Hong Kong, Taiwan, China, Malaysia, India and Singapore (Lee 1996).
More recently, a study conducted by Lee et al. (2001) into rationales for food
refusal in Chinese patients with anorexia nervosa, confirmed at least 48 cases
of diagnosed anorexia nervosa in China. Also, anorexia nervosa can no longer be
confined to white, middle class women as there are an increase of reported cases
amongst black women (Salt Lake Tribune 1999) and different socioeconomic levels
and ethnic groups in Western societies (Lee 1996).

Nasser (1994) attributed this transculturality of anorexia nervosa to a
globalization of 'fat-phobia' due to the emergence of a culturally shrunken
world by virtue of mass communication technology. Thus, Western researchers
presume that incidences of anorexia nervosa in non-Western societies are
replicas of the West. As a result, fat-phobia still remains the 'core'
psychopathology underlying anorexia nervosa despite its presence in non-Western
societies.

The argument put forward here is that anorexia nervosa can occur in the absence
of a cultural drive for thinness and that it may present differently in other
cultures, a phenomenon that nurses and other health care professionals working
with anorectics need to be aware of. The potency of Western diagnostic criteria
has created a cultural bias, compromising nurses' understanding and treatment of
the disorder. Indeed, the diagnostic criteria describe any diagnostic non-conformists
as 'eating disorder not otherwise specified' (EDNOS) or 'atypical' without
further explanation of other cultural influences behind the disorder.

Anorectics may explain their food denial consciously through various cultural
norms and belief systems, but there are unconscious elements to the disorder.
Psychologists and psychoanalysts have described various motives for anorexia
nervosa that the anoretic may themself be unaware of. For example, Banks (1992)
discusses issues of separation. However, although in no way are the unconscious
motives being dismissed, this paper focusses on the conscious reasons that
underpin diagnostic criteria, e.g. a fear of becoming obese and disturbance in
the experience of body weight, size and shape.

The case for fat-phobia

Although many influences have been noted as formative in the development of
fat-phobia and anorexia nervosa, it is perhaps the role of the media in
portraying Western ideals of slimness that has been given most attention in
recent years. Thompson & Heinberg (1999) discussed the role of the media as 'the
most potent and pervasive communicators of sociocultural standards' (p. 340).
Although it is recognized that this potency can be used to good effect by the
media, for example in health promotion, they argue that the role of the media in
communicating societal ideas about beauty and slimness has an important part to
play in the manifestation of anorexia nervosa. They also suggest that women
internalize or endorse these difficult-to-achieve standards of beauty (particularly
from television and women's magazines) and that this significantly influences
their body image, and they describe psychological mechanisms which might account
for how media imagery becomes internalized into fat-phobia.

Stice et al. (1998) put forward a dual-pathway model which asserts that
maladaptive messages in the mass media predispose individuals to eating
disorders when family and peers reinforce those messages and when it occurs
against a setting of low self-esteem, a poorly developed self-concept and
perceptions of being above an ideal weight. Haworth-Hoeppner (2000) also
indicates that, although all women are exposed to cultural standards of beauty
that might be linked to a 'normative discontent' such as fat-phobia, not all
women develop eating disorders. She suggests that, although culture does have a
role to play in the development of eating disorders, it is mediated through
groups such as the family and work peers. She also indicates that it is the
family in which the fundamental work of identity is carried out. The extent to
which the family transmits cultural messages about the ideal body shape and the
way in which these messages are conveyed by family members to others, is crucial
in understanding the development of body image dissatisfaction and eating
disorders (Haworth-Hoeppner 2000). These messages conveyed by social groups may
cause internalization of media imagery when it contains information on the means
of achieving this ideal body shape, e.g. fasting and over-exercising.

Other theories look at the potency of media images in the development of
anorexia nervosa. The developmental transitions model put forward by Levine &
Smolak (1998) suggests that childhood predisposition to beliefs about the
importance of thinness are developed and maintained by family and peer pressure
about weight concern. At adolescence these predispositions are stimulated into
actual body dissatisfaction by developmental changes, particularly weight
increase at puberty and a change of body shape. At the same time, media images
about thinness and societal support for weight control through dieting cause
disordered eating which can lead to an eating disorder (Levine & Smolak 1998).

Similarly, psychoanalytical models of anorexia view the anorectic's refusal of
food as an expression of a psychobiological state in which self-starvation
induces changes in physical appearance and reproductive drive. This sustains an
avoidance of maturation into womanhood and the development of sexuality (Banks
1992).

There is evidence to support the presence of fat-phobia in Western women.
According to Banks (1992), research on 'normal' non-anorectic subjects confirms
that the majority of women in North America think they are too fat and are
preoccupied with body weight and dieting. In a study on a group of 271
adolescents in North America, it was found that most of the girls thought they
were fatter than they really were. Almost half the girls in the study thought
they were too fat, even though 83% were a normal body weight. However, this
sample size may be too small to have significant value as research into the
level of fat-phobia experienced by American women and it should be noted that
these individuals were not anorexic. Many women diet in pursuit of thinness but
never develop an eating disorder. The question is whether these concerns with
dieting and slimness in our culture are related to the anorectic's own
subjective reasons for self-starvation, particularly in other cultures.

As has been mentioned, the globalization of these cultural attitudes is often
thought to be the reason behind the occurrence of anorexia nervosa in non-Western
cultures and Western subcultures. Different ethnic groups within Western culture
were previously thought to be immune from fat-phobia, due to the lack of
prevalence of eating disorders in these groups. However, Lee (1995) suggests
that fat-phobia and eating disorders are now to be found in virtually all
socioeconomic strata and ethnic groups within Western society. What is the
evidence for this? Ruth Streigel-Moore, who has done extensive research into
eating disorders in black women says, in the Salt Lake Tribune (1999), 'more and
more black women experience the same pressure to be thin, to prove they blend in
and participate in the white world'. This is despite the fact that black culture
traditionally offers a more favourable view of full-figured women. Bryant-Waugh
& Lask (1991) conducted case reports on four girls of Asian origin with anorexia
nervosa according to diagnostic criteria. All cases expressed a fear of becoming
fat.

Although not the most recent of studies, evidence for the transculturality of
fat-phobia anorexia nervosa has been put forward by researchers such as Goh et
al. (1993), who conducted a retrospective study on anorectics found in West
Malaysia. They examined the ward registers of admissions to male and female
psychiatric wards in the University of Malaysia between 1970 and 1988. Out of
9000 female admissions, 15 cases of anorexia nervosa (fulfilling at least two of
the DSM-IV criteria) were reported. Nine had body image disturbance similar to
that found in Western populations. Furthermore, in a two-stage survey in Hong
Kong Chinese, there was found to be a cognitive fear of fatness in female
undergraduates (Lee 1996). It must be acknowledged, however, that prior to 1997,
westernized Hong Kong culture was very different from mainland China.

More recently, Lee et al. (2001) conducted a study on rationales for food
refusal in Chinese patients with anorexia nervosa. Forty-eight consecutive
patients with broadly defined anorexia nervosa underwent evaluation with a
self-report rationale for food refusal questionnaire. The results showed that 32
of the patients expressed fat-phobia and, amongst this group, the most commonly
selected rationale for food refusal was fat-phobia. The study has the limitations
of small sample size and it must be noted that 16 of the patients did not
express any fat-phobia in the presentation of their illness.

This evidence, however, does suggest that Western images and ideals of beauty
and slimness have perhaps insidiously infiltrated a wide variety of cultural
groups, causing anorexia nervosa to be present in those cultures previously
thought to be immune from eating disorders. However, despite all the extensive
publicity given to fat-phobia and its link to anorexia nervosa, the evidence is
not sufficient to determine it as the sole cultural factor in anorexia nervosa
across the world.

Evidence for alternative cultural influences on the presentation of anorexia
nervosa

Several cases of anorexia nervosa without accompanying fat-phobia have been
reported in different societies and cultures. In China, where anorexia nervosa
was previously unheard of, two series of childhood and adult onset anorexia
nervosa patients were reported from the capital of Beijing in 1990, and at the
Shanghai Institute of Mental Health seven discharged patients were reported to
have anorexia nervosa. Among these Chinese anoretics, fat-phobia was noticeably
absent (Lee 1995).

Similarly, Lee (1995) carried out a psychiatric study of anorexia nervosa. In a
qualitative analysis of 70 Chinese anorexia nervosa patients (who had all been
examined by an experienced psychiatrist over a period of 12 years), 59% did not
express any fat-phobia throughout their illness. This shows that although
anorexia with fat-phobia does occur in non-Western societies (41% expressed fat
phobia), anorexia can also occur without accompanying fat-phobia. The non-fat-phobic
anorectics used epigastric bloating, no appetite or simply 'don't know' as their
reasons for food refusal. They differed from their fat-phobic counterparts only
in that they were premorbidly slimmer and demonstrated no signs of bulimia,
often considered a sign of fat-phobia (Lee 1995).

Lee et al. (2001) found 16 non-fat-phobic anorectics in a group of 48 Chinese
anorectics. It was noted that these anorectics were premorbidly slim; therefore,
the urge to shed fat was not an issue for them. Also, they gave rationales other
than fat-phobia for their refusal to eat, e.g. stomach bloating and no appetite
(Lee et al. 2001).

In Chinese culture and tradition, when compared to Western tradition, there is
less stigmatization of obesity and slimness is less inextricably bound up with a
woman's future. Plumpness symbolizes economic power and robust health for the
Chinese family. Traditional Chinese notions state that 'fat people have more
luck' and 'gaining weight means good fortune'. In fact, thinness is associated
with ill health and saying 'you've lost weight' may be less of a compliment than
it would be in Western culture (Lee 1996). With this in mind, what were the
possible cultural influences behind the meaning of these Chinese women's
self-starvation? Lee (1995) looked at the case studies of two Chinese anoretic
women and the possible cultural values that gave meaning to their food refusal.
One of the women (Miss Y) started refusal of food following her desertion by a
boyfriend who had departed for England. Greatly saddened by this she started to
complain of abdominal discomfort and reduced food intake. Her explanation of
food refusal stemmed around a lack of hunger and abdominal pain and she showed
no signs of fat-phobia or body image disturbance. Lee (1995) concluded that Miss
Y's complaints of abdominal bloating and her conviction that she could not eat
were psychosomatic symptoms which authenticated her chronic grief over the loss
of her boyfriend. In the rural society where she grew up, abdominal discomfort
was a more meaningful way of communicating her sadness than complaining of
fat-phobia.

The Chinese cosmological notion of humanity does not recognize the Cartesian
mind-body split of Western culture. Lee (1995) suggests that the Chinese amplify
the body as a complex symbol system 'and endorse somatization as a powerful
metaphor for orchestrating the social response to illness' (p. 27). Thus, this
Chinese anoretic gave meaning to her food refusal through cultural influences
other than fat-phobia. In Chinese society where there is not a shortage of food,
food refusal arouses concern. The anorectic's reasons for self-starvation may
carry symbolic meanings and connotations about such things as academic
pressures, parental conflicts, maternal infantilization, as well as physical
stigmata such as acne and deafness (Lee 1995).

Khandelwal & Saxena (1990), from the Department of Psychiatry in Delhi, asserted
that the presentation of eating disorders in India varied from the typical
description of anorexia nervosa. Their female anorexic patients were typically
showing decreased appetite, excessive weight loss and amenhorrea but no
fat-phobia or body image disturbance. Hyperactivity, abnormal food handling and
bulimia were also not seen. These patients did not satisfy the necessary
criteria of anorexia nervosa according to classification systems like the
DSM-IV. They suggested that this variation was due to sociocultural factors, as
Indian culture does not dictate slimness as a beauty ideal, and that there was
not as much concern with body image as in the West.

Despite the belief that anorexia nervosa is associated with fat-phobia, it is
becoming increasingly apparent that there are statistical exceptions in
non-Western and Western societies to this potential rule. These exceptions
cannot be ignored and Banks (1992) calls for more awareness of an anorectic's
own subjective reasons to explain their food refusal. She studied the case of
two anorectic women from the Minneapolis-St Paul area of Minnesota. Both women
were from conservative religious fundamentalist backgrounds and expressed their
desire to reduce food intake through religious understanding about food, the
body and sexuality, provided by their religious culture.

One of the women (Jane A) came from a family belonging to the Missouri Synod
Lutheran church. Jane went to church regularly throughout her childhood and
anorectic days. Banks collected information about Jane's religious beliefs and
anorexia through the detailed diary journals that she had kept from childhood.
The journals reveal the religious symbols and language that Jane used to give
meaning to her food refusal. The diaries expressed a wish for God to control her
body and her sexuality, and her food refusal is referred to as fasting. This
fasting often coincided with the church calendar and is coined as 'religious
fasting'. Nowhere is a fear of fatness expressed. However, when does fasting
become anorexia nervosa, as fasting is an acceptable part of religious practice
for many religious people? It is suggested that dieting is a precursor to
anorexia nervosa in fat-phobic anorectics; maybe fasting is a precursor to
anorexia nervosa in this instance. Where religious asceticism is the goal (not
the desire to be thin), fasting becomes obsessive and out of control. Jane often
expressed dual thinking about the body and the mind and saw the two as
conflicting. She believed the spirit or soul to be heavy when the body is fat.
Jane also saw her thinness as a way of deterring male sexual advances and thus
allowing her to remain virginal. Banks comments on the ascetic aspect to Jane's
anorexia and states that psychologists and psychoanalysts have often commented
on the asceticism of anoretics. Asceticism is characterized by self-denial,
asexuality and rejection of bodily death along with a heightened morality and
idealism. Banks claims, however, that these scholars do not consider how this
asceticism can have a particular cultural meaning, as in the case of Jane A,
where it was linked to religious values.

Mumford et al. (1991) studied the sociological correlates of eating disorders in
204 Asian girls and 355 Caucasian girls in a school in Bradford, in the UK. They
hypothesized that only the most westernized of the Asian schoolgirls would have
eating disorders and body image dissatisfaction. The EAT (Eating Attitudes
Test), BSQ (Body Shape Questionnaire) and EDE (Eating Disorders Examination)
were all used to assess the level of disordered eating, body image disturbance
and fat-phobia leading to anorexia nervosa amongst the Asian girls. According to
DSM-III-R criteria, one of the Asian girls and none of the Caucasian girls had
anorexia nervosa.

It is perhaps methodologically impaired to draw conclusions from a ratio of 1 :
0 (Asian : Caucasian) incidence in relation to an association between EAT
scores, BSQ scores and anorexia nervosa. However, there is still valuable
information to be found in the study, in that the researchers found that the
Asian girls had higher EAT scores than the Caucasian girls, suggesting a greater
concern with food intake and weight than the Caucasian girls. They suggested
that this could not be due to excessive concerns with body shape and the desire
to be thin because the scores on the BSQ were not significantly different
between the Asian and Caucasian girls. Amongst the Asian girls, those who made
the greatest use of Asian language and dress had the highest mean scores on the
EAT and BSQ, contradicting their hypothesis that only the most westernized of
the Asian girls would suffer from disordered eating and body image dissatisfaction.

The explanation Mumford et al. (1991) suggest for these results is that the most
traditional of the Asian girls may be experiencing cultural conflict, causing
problems with identity when they are growing up, and that the greater the
difference between the two cultures the more conflict arises. However, they do
not mention how such a cultural conflict could lead to disordered eating and
concern with food intake. Perhaps the cultural conflict arises from the Asian
girls' desire to fit in with the Western girls by endorsing Western ideals about
slimness and beauty (which may in itself conflict with Asian ideals about
beauty).

Mumford et al. (1991) questioned the cultural validity of these three instruments
(EAT, BSQ and EDE), indicating that they have been developed in the West for use
on Western subjects. They were doubtful of their validity when used on Asian
schoolgirls in Bradford, anticipating that Asian girls, for example, might place
different construction on certain items, e.g. few Asian girls might rate
strongly EAT item 8 ('cut my food into small pieces') since knives are not
commonly used when eating meals. In fact, Mumford et al. (1991) did establish
cross-cultural conceptual equivalence in the instruments, but the question of
the need for more culturally sensitive interviews and questionnaires, as well as
diagnostic criteria for anorexia nervosa, was raised.

Rieger et al. (2001) critically examine the assumptions that weight concerns are
specific to contemporary, Western manifestations of the disorder and that the
'spread' of Western values regarding slimness is primarily responsible for the
development of anorexia nervosa in non-Western societies. They state that
non-Western cultures may have other cultural beliefs that are pathogenic for
anorexia nervosa. Confucian familial practices do not encourage autonomy or
hostility to authority figures. Anorexia nervosa is frequently attributed to
deficits in the development of an autonomous self and therefore these practices
may make an individual more susceptible to the disorder (Rieger et al. 2001).

Rieger et al. (2001) also describe information obtained from the medical records
of 14 Asian patients with anorexia nervosa and bulimia (six from Hong Kong,
three from Japan, two from Singapore, two from Malaysia and one from Indonesia).
Of the 14 patients, eight had anorexia nervosa, and not all of them expressed
fat-phobia. One patient described an unhappy marriage in which her husband
expected obedience from her; she gained a sense of control in being thin (Rieger
et al. 2001). It is clear that, for this woman, the issue was one of loss of
control over her life and not one of fat-phobia.

Discussion

Although anorexia nervosa still occurs more commonly in Western societies and
fat-phobia is a significant factor in the disorder, the variations discussed in
this paper should not be ignored. The danger of the potency of the fat-phobia
theory is the hindrance of good practice. Health care professionals may not
recognize individual reasons for self-starvation if they presume fat-phobia to
be the psychopathology behind the disorder.

Recommendations for future practice with people with anorexia include the
development of more culturally sensitive tools and diagnostic criteria. It could
be argued that the current biomedical instruments, including the EAT, BSQ and
EDE, are contextually invalid and that they need to be reconstructed to be more
culturally sensitive (Lee 1995). This will aid the health care professional to
recognize cases of anorexia that may not conform to present criteria. Instead of
trying to place patients within these criteria, health care professionals should
recognize the individual cultural reasons for self-starvation and treat the
person accordingly. For example, when treating the woman with the dominant
husband mentioned earlier, the issue of loss of control needs to be dealt with
and trying to treat her according to the fat-phobia theory would not be helpful.

It seems that in the case of anorexia nervosa, therapy has been influenced by
its own cultural context and may be constrained by it. Lee (1995) suggested more
culturally sensitive diagnostic criteria, which could aid diagnosis across
cultural contexts and ultimately encourage individual and sensitive therapy for
people with anorexia. One of the diagnostic criterion suggested by Lee (1995)
states that, 'in response to others' attempts to make them increase food intake,
the patient uses complaints such as abdominal bloating or pain, loss of
appetite, no hunger, distaste for food, fear of fatness, and/or "don't know" to
resist such attempts' (p. 33). It is possible to see how this criterion is less
culturally limiting and thus may improve practice regarding anorexia nervosa.

Conclusion

Anorexia nervosa provokes much interest amongst health care professionals due to
the role of culture in the disorder. Anorexia nervosa is commonly thought to be
confined to Western culture or those places undergoing westernization. It is not
thought to be prevalent in ethnic cultures within Western society. The most
popular, current hypothesis blames Western ideals of slimness and beauty,
portrayed by the mass media and reinforced by the dieting industry, for the
prevalence of anorexia nervosa in Western society. This hypothesis is so potent
that Western diagnostic criteria for the disorder, namely the DSM-III-R, are
based on Western cultural ideas about body shape, and fat-phobia is presumed to
be the core principal in biomedically defined anorexia nervosa.

Anorexia nervosa can no longer be confined to Western culture because of its
identification in a number of non-Western societies and ethnic groups within
Western society. It has been suggested that this is due to the globalization of
fat-phobia through the insidious infiltration of Western images and ideals into
these cultures and subcultures. Thus the presentation of anorexia nervosa in
these cultures is presumed to be similar to that in Western culture and Western
diagnostic criteria are still used in these cultures.

The identification of anorexia nervosa in other cultures without accompanying
fat-phobia suggests that psychiatric disorders are not the same irrespective of
culture, because they are biologically and psychologically determined. There may
be other cultural reasons for food refusal and therefore health care professionals
working in this field may need more culturally sensitive diagnostic criteria to
diagnose and treat the disorder. Lee (1995) designed such diagnostic criteria,
the acceptance of which, along with an increased awareness for other cultural
causes of anorexia nervosa, could benefit diagnoses and treatment of the
disorder. It also challenges the assumptions of psychiatric diagnosis that we
are biologically and psychologically similar and therefore develop mental
illness in the same ways.

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Let me know if you want the reference list for this, or any other article, I can email it to you.




I've got 26 articles stored away, I was wondering which ones people might want to read?



1. Understanding Women's Journey of Recovering From Anorexia Nervosa, The American Journal of Maternal/Child Nursing

2. An innovative treatment programme for Anorexia Nervosa, Journal of Paediatrics and Child Health

3. Early experiences and their relationship to maternal eating disorder symptoms, both lifetime and during pregnancy, The British Journal of Psychiatry

4. Gender differences in brain activity generated by unpleasant word stimuli concerning body image: an fMRI study, The British Journal of Psychiatry

5. Bulimia nervosa: 25 years on, The British Journal of Psychiatry

6. The aetiology of eating disorders, The British Journal of Psychiatry

7. Bulimia Nervosa in Adolescents: A Disorder in Evolution? Archives of Pediatrics & Adolescent Medicine

8. Caloric Restriction and Incidence of Breast Cancer, The Journal of the American Medical Association

9. Association between childhood feeding problems and maternal eating disorder: role of the family environment, The British Journal of Psychiatry

10. The implications of starvation induced psychological changes for the ethical treatment of hunger strikers, Journal of Medical Ethics

11. Social and Cultural Considerations in Recovery From Anorexia Nervosa: A Critical Poststructuralist Analysis, Advances in Nursing Science

12. Self-help for bulimic disorders: a randomised controlled trial comparing minimal guidance with face-to-face or telephone guidance, The British Journal of Psychiatry

13. Eating Disorders and Childbearing: Concealment and Consequences, Birth

14. Eating behaviours and attitudes following prolonged exposure to television among ethnic Fijian adolescent girls, The British Journal of Psychiatry

15. Anorexia nervosa and culture, Journal of Psychiatric & Mental Health Nursing

16. Functional brain abnormalities in anorexia nervosa, The Journal of Pediatrics

17. Cognitive behaviour therapy was more effective than interpersonal psychotherapy for bulimia nervosa, Evidence-Based Mental Health

18. Caring for adolescent females with anorexia nervosa: registered nurses' perspective, Journal of Advanced Nursing

19. Osteopenia in young adolescents with anorexia nervose and related dieting disorder, Journal of Paediatrics & Child Health

20. Risk of several psychiatric disorders was increased in relatives of anorexics and bulimics, Evidence-Based Mental Health

21. Impact of pregnancy on bulimia nervosa, The British Journal of Psychiatry

22. Anorexia nervosa: a cognitive-behavioural approach, Nursing Standard

23. Difficulties in family functioning and adolescent anorexia nervosa, The British Journal of Psychiatry

24. Salinophagia in anorexia nervosa, The British Journal of Psychiatry

25. Disgust - the forgotten emotion of psychiatry, The British Journal of Psychiatry

26. Cerebral gray matter and white matter volume deficits in adolescent girls with anorexia nervosa, The Journal of Pediatrics

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Let me know if you're interested in any of them, and I'll post any requested, if the mods don't mind.


Apologies for the length of my first post!
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