Summary of "Anorexia Nervosa and Its Differential Diagnosis"

In the article, "Anorexia Nervosa and Its Differential Diagnosis", Hilde Bruch argues against the fact that the pursuit of thinness, the key issue of anorexia nervosa syndrome, should separate it from other psychiatric conditions associated with weight loss (Brunch). The core concept in the discussion is whether there is a clinical existence that deserves and needs to be separated from other psychiatric conditions, and, if yes, what would be its characteristic symptomatology, proper diagnostic classification, prognosis, and treatment (Brunch). To achieve this Bruch says that one must recognize and isolate the crucial problems of the disturbed pattern of living in each individual case, and to assess the patient's tools for dealing with them.

Bruch conducts a study from 1942 to the middle of 1964 of 43 patients who had been diagnosed with anorexia nervosa. These 43 patients were a mix of both males and females. They came from different levels of social classes, ranged from the age of adolescence to early adulthood, and came from many types of ethnic and religious backgrounds. Within the 43 patients, two distinct types appeared. The first type consisted of 30 patients who's main issue was the struggle for control for a sense of identity and effectiveness, with their final effort being their relentless pursuit to be thin. Bizarre food habits were seen in this group and many partook in enormous eating binges and then vomiting. The second type was a smaller group of 13 patients. Their primary concern was with the actual eating function which they used in many different symbolic ways, and their weight loss was incidental to some other problem. These patients varied in levels of illness and accessibility to treatment. Within the group there were conflicts of conversion hysteria, psychoneurosis, manifest symptoms of schizophrenic reactions, phobias, and the need for the attention that not eating gave.

With the first type of patients three areas of disordered psychological functioning were seen. The first symptom was a disturbance in the body image and body concept of delusional proportions. The second was a disturbance in the accuracy of perception or cognitive interpretation of stimuli arising within the body. With the most substantial being the failure to interpret signals that the body was hungry and needed nutritional supplies. Also the denial of fatigue, and a marked deficiency in identifying emotional states. The third function is a paralyzed sense of ineffectiveness. They only acted in response to what others say and tell them to do, and not doing anything as if because they want to.

Bruch also took into consideration of what type of family background the patients came from and how their life at home came into play with their condition. Bruch states that "for normal development it appears to be essential that appropriate responses to the clues originating in the child and stimulation coming from the outside are well balanced".

Overall it was recognized that with the 43 patients using motivational interpretations of "unconscious" ways was useless. An interpretation to a more fact finding approach worked best with these individuals. In conclusion, referring back to the original argument, Bruch says "the literature on anorexia nervosa is classified by confusion about its proper delineation and diagnostic classification. This appears to be related to failure to discriminate between different types of psychologically determined emaciation, and to the shortcomings of our current psychiatric classification".