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Fat phobic and non-fat phobic anorexia nervosa: a comparative study of 70 Chinese patients in Hong Kong

Published online by Cambridge University Press:  09 July 2009

S. Lee ,
T. P. Ho  and
L. K. G. Hsu
S. Lee*
Affiliation:
Department of Psychiatry, Chinese University of Hong Kong, Shatin, Department of Psychiatry, University of Hong Kong, Hong Kong; Western Psychiatric Institute and Clinic, University of Pittsburgh, USA
T. P. Ho
Affiliation:
Department of Psychiatry, Chinese University of Hong Kong, Shatin, Department of Psychiatry, University of Hong Kong, Hong Kong; Western Psychiatric Institute and Clinic, University of Pittsburgh, USA
L. K. G. Hsu
Affiliation:
Department of Psychiatry, Chinese University of Hong Kong, Shatin, Department of Psychiatry, University of Hong Kong, Hong Kong; Western Psychiatric Institute and Clinic, University of Pittsburgh, USA
*
1Address for correspondence: Dr Sing Lee, Department of Psychiatry, Prince of Wales Hospital, Shatin, Hong Kong.
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Synopsis

A mixed retrospective–prospective study of 70 Chinese anorexic patients in Hong Kong shows that although they were similar to Western anorexics in most other ways, 41 (58·6%) of them did not exhibit any fear of fatness throughout their course of illness. Instead, these non-fat phobic patients used epigastric bloating (31·4%), no appetite/hunger (15·7%) or simply eating less (12·9%) as legitimating rationales for food refusal and emaciation. Compared to fat phobic anorexics, they were significantly slimmer pre-morbidly (P < 0·0001) and were less likely to exhibit bulimia (P = 0·001). The possible explanations for the absence of fat phobia and the interpretive dilemma this provokes are discussed from historical, pathoplastic and cultural anthropological perspectives. It is argued that anorexia nervosa may display phenomenological plurality in a Westernizing society, and its identity may be conceptualized without invoking the explanatory construct of fat phobia exclusively. As non-fat phobic anorexia nervosa displays no culturally peculiar features, it is not strictly speaking a Western culture-bound syndrome, but may evolve into its contemporary fat phobic vogue under the permeative impact of Westernization. Its careful evaluation may help clarify the aetiology and historical transformation of eating disorder, foster the development of a cross-culturally valid taxonomy of morbid states of self-starvation, and exemplify some of the crucial issues that need to be tackled in the cross-cultural study of mental disorders.

Type
Original Articles
Information
Psychological Medicine , Volume 23 , Issue 4 , November 1993 , pp. 999 - 1017
Copyright
Copyright © Cambridge University Press 1993

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References

American Psychiatric Association (1987). Diagnostic and Statistical Manual of Mental Disorders (3rd edn, revised) (DSM-III-R). APA Washington: DC.Google Scholar
Arya, D. K. (1991). Anorexia nervosa across cultures. British Journal of Psychiatry 158, 285–286.CrossRefGoogle Scholar
Bernstein, R. L. & Gaw, A. C. (1990). Koro: proposed classification for DSM-IV. American Journal of Psychiatry 147, 1670–1674.Google ScholarPubMed
Berrios, G. E. & Morley, S. J. (1984). Koro-like symptom in a non-Chinese subject. British Journal of Psychiatry 145, 331–334.CrossRefGoogle Scholar
Bhadrinath, B. R. (1990). Anorexia nervosa in adolescents of Asian extraction. British Journal of Psychiatry 156, 565–568.CrossRefGoogle ScholarPubMed
Bruch, H. (1973). Eating Disorders: Obesity, Anorexia Nervosa, and the Person Within. Basic Books: New York.Google Scholar
Bruch, H. (1980). Preconditions for the development of anorexia nervosa. American Journal of Psychoanalysis 40, 169–172.CrossRefGoogle ScholarPubMed
Brumberg, J. J. (1988). Fasting Girls: The Emergence of Anorexia Nervosa as a Modern Disease. Harvard University Press: Cambridge, MA.Google Scholar
Buhrich, N. (1981). Frequency of presentation of anorexia nervosa in Malaysia. Australian and New Zealand Journal of Psychiatry 15, 153–155.CrossRefGoogle ScholarPubMed
Bynum, C. W. (1988). Holy anorexia in modern Portugal. Culture, Medicine and Psychiatry 12, 239–248.CrossRefGoogle Scholar
Cantwell, D. P., Sturzenberger, S., Burroughs, J., Salkin, B. & Green, J. K. (1977). Anorexia nervosa: an affective disorder? Archives of General Psychiatry 34, 1087–1093.CrossRefGoogle ScholarPubMed
Casper, R. C. (1983). On the emergence of bulimia nervosa as a syndrome: a historical view. International Journal of Eating Disorders 2, 3–16.3.0.CO;2-D>CrossRefGoogle Scholar
Chen, C. N., Wong, J., Lee, N., Chan-Ho, M. W., Lau, J. & Fung, M. (1993). The Shatin community mental health survey in Hong Kong. II. Major findings. Archives of General Psychiatry 50, 125–133.CrossRefGoogle Scholar
Chen, J. (1990). Behavioural therapy of seven cases of childhood anorexia nervosa. Chinese Mental Health Journal 4, 26.Google Scholar
Cheng, T. A. (1989). Symptomatology of minor psychiatric morbidity: a crosscultural comparison. Psychological Medicine 19, 697–708.CrossRefGoogle ScholarPubMed
Chiu, C. H. (1978). Standard weights for Chinese adults. Journal of the Chinese Nutrition Society (Taiwan) 3, 85–94.Google Scholar
Chiu, L. P. W. (1989). Anorexia nervosa in a young Chinese woman in Hong Kong. Canadian Journal of Psychiatry 34, 162–163.CrossRefGoogle Scholar
Cooper, P. J. & Fairburn, C. G. (1987). The eating disorder examination: a semi-structured interview for the assessment of the specific psychopathology of eating disorders. International Journal of Eating Disorders 6, 1–8.3.0.CO;2-9>CrossRefGoogle Scholar
Crisp, A. H. (1980). Anorexia Nervosa: Let Me Be. Plenum Press: London.Google Scholar
Crisp, A. H., Callender, J. S., Halek, C. & Hsu, L. K. G. (1992). Long-term mortality in anorexia nervosa: a 20-year follow-up of the St George's and Aberdeen cohorts. British Journal of Psychiatry 161, 104–107.CrossRefGoogle Scholar
Davis, C. & Yager, J. (1992). Transcultural aspects of eating disorders: a critical literature review. Culture, Medicine and Psychiatry 16, 377–394.CrossRefGoogle ScholarPubMed
DiNicola, V. F. (1990). Anorexia multiforme: self-starvation in historical and cultural context. Part II: anorexia nervosa as a culture-reactive syndrome. Transcultural Psychiatric Research Review 27, 245–286.CrossRefGoogle Scholar
Dolan, B. (1991). Cross-cultural aspects of anorexia nervosa and bulimia: a review. International Journal of Eating Disorders 10, 67–78.3.0.CO;2-N>CrossRefGoogle Scholar
Dolan, B. M., Birtchnell, S. A. & Lacey, J. H. (1987). Body image distortion in non-eating disordered women and men. Journal of Psychosomatic Research 31, 513–520.CrossRefGoogle ScholarPubMed
Erikson, E. H. (1955). The problem of ego identity. Journal of Psychoanalytic Association 4, 56–121.CrossRefGoogle Scholar
Fabrega, H. Jr. (1992). Diagnosis interminable: toward a culturally sensitive DSM-IV. Journal of Nervous and Mental Disease 180, 5–7.CrossRefGoogle Scholar
Fahy, T. A., Robinson, P. H., Russell, G. F. M. & Sheinman, B. (1988). Anorexia nervosa following torture in a young African woman. British Journal of Psychiatry 153, 385–387.CrossRefGoogle Scholar
Fairburn, C. G. & Hope, R. A. (1988). Disorders of eating and weight. In Comparison to Psychiatric Studies, 4th edn (ed. Kendell, R. E. and Zealley, A. K.), p. 589. Churchill Livingstone: Edinburgh.Google Scholar
Gandhi, D. H., Appaya, M. P. & Machado, T. (1991). Anorexia nervosa in Asian children. British Journal of Psychiatry 159, 591–592.CrossRefGoogle ScholarPubMed
Garfinkel, P. E. & Garner, D. M. (1982). Anorexia Nervosa: A Multidimensional Perspective. Basic Books: New York.Google Scholar
Garner, D. M. & Garfinkel, P. E. (1979). The Eating Attitudes Test: an index of the symptoms of anorexia nervosa. Psychological Medicine 9, 273–279.CrossRefGoogle ScholarPubMed
Garner, D. M. & Garfinkel, P. E. (1981). Body image in anorexia nervosa: measurement, theory and clinical implications. International Journal of Psychiatry in Medicine 11, 263–284.CrossRefGoogle ScholarPubMed
Goh, S. E., Ong, S. B. Y. & Subramaniam, M. (1993). Eating disorders in Hong Kong. British Journal of Psychiatry 162, 276–277.CrossRefGoogle ScholarPubMed
Gull, W. W. (1874). Anorexia nervosa (apepsia hysterica, anorexia hysterica). Transactions of the Clinical Society (London) 7, 22–28.Google Scholar
Habermas, T. H. (1989). The psychiatric history of anorexia nervosa and bulimia nervosa: weight concerns and bulimic symptoms in early case reports. International Journal of Eating Disorders 8, 259–273.3.0.CO;2-#>CrossRefGoogle Scholar
Hamilton, M. (1985). Fish's Clinical Psychopathology, 2nd edn.Wright: Bristol.Google Scholar
Hsu, F. L. K. (1971). Psychosocial homeostasis and Jen: concepts for advancing psychological anthropology. American Anthropologist 73, 23–44.CrossRefGoogle Scholar
Hsu, L. K. G. & Sobkiewicz, T. A. (1991). Body image disturbance: time to abandon the concept for eating disorders? International Journal of Eating Disorders 10, 15–30.3.0.CO;2-I>CrossRefGoogle Scholar
Jellinek, E. M. (1960). The Disease Concept of Alcoholism. Hill House Press: New Haven, Connecticut.CrossRefGoogle Scholar
Kaptchuk, T. K. (1983). Chinese Medicine – The Web that has no Weaver. Rider: London.Google Scholar
Kay, D. W. K. & Leigh, D. (1954). The natural history, treatment, and prognosis of anorexia nervosa based on a study of 38 patients. Journal of Mental Science 100, 411–431.CrossRefGoogle ScholarPubMed
Kendell, R. E. (1989). Clinical validity. Psychological Medicine 19, 45–55.CrossRefGoogle ScholarPubMed
Khandelwal, S. K. & Saxena, S. (1990). Anorexia nervosa in people of Asian extraction. British Journal of Psychiatry 157, 784.CrossRefGoogle Scholar
King, M. B. (1989). Eating disorders in a general practice population: prevalence, characteristics and follow-up at 12 to 18 months. Psychological Medicine, Supplement 14, 1–34.CrossRefGoogle Scholar
Kiriike, N., Nagata, T., Tanaka, M., Nishiwaki, S., Takeuchi, N. & Kawakita, Y. (1988). Prevalence of binge-eating and bulimia among adolescent women in Japan. Psychiatry Research 26, 163–169.CrossRefGoogle ScholarPubMed
Kirmayer, L. J. (1991). The place of culture in psychiatric nosology: Taijin Kyofusho and DSM-III-R. Journal of Nervous and Mental Disease 179, 19–28.CrossRefGoogle ScholarPubMed
Kirmayer, L. J. & Robbins, J. M. (1989). Three forms of somatization in primary care: prevalence, co-occurrence, and sociodemographic characteristics. Journal of Nervous and Mental Disease 179, 647–655.CrossRefGoogle Scholar
Kleinman, A. M. (1987). Anthropology and psychiatry: the role of culture in cross-cultural research on illness. British Journal of Psychiatry 151 447–454.CrossRefGoogle ScholarPubMed
Lee, S. (1991). Anorexia nervosa in Hong Kong – A Chinese perspective. Psychological Medicine 21, 703–711.CrossRefGoogle Scholar
Lee, S. (1993). How abnormal is the desire for slimness? A survey of eating attitudes and behaviour among Chinese undergraduates in Hong Kong. Psychological Medicine 23, 437–451.CrossRefGoogle ScholarPubMed
Lee, S., Chiu, H. F. K. & Chen, C. N. (1989). Anorexia nervosa in Hong Kong: why not more in Chinese? British Journal of Psychiatry 154, 683–688.CrossRefGoogle Scholar
Lee, S., Leung, C. M., Wing, Y. K., Chiu, H. F. K. & Chen, C. N. (1991). Acne as a risk factor for anorexia nervosa in Chinese. Australian and New Zealand Journal of Psychiatry 25, 134–137.CrossRefGoogle ScholarPubMed
Lee, S., Hsu, G. L. K. & Wing, Y. K. (1992). Bulimia nervosa in Hong Kong Chinese patients. British Journal of Psychiatry 161, 545–551.CrossRefGoogle ScholarPubMed
Littlewood, R. (1990). From categories to contexts: a decade of the ‘New Cross-Cultural Psychiatry’. British Journal of Psychiatry 156, 308–327.CrossRefGoogle ScholarPubMed
Lucas, A. (1981). Toward the understanding of anorexia nervosa as a disease entity. Mayo Clinic Proceedings 56, 254–264.Google ScholarPubMed
Mead, M. (1947). Concept of culture and psychosomatic approach. Psychiatry 10, 57–76.CrossRefGoogle ScholarPubMed
Mezzich, J. E., Fabrega, H. Jr. & Kleinman, K. (1992). Cultural validity and DSM-IV. Journal of Nervous and Mental Disease 180, 4.CrossRefGoogle ScholarPubMed
Millon, T. (1991). Classification in psychopathology: rationale, alternatives and standards. Journal of Abnormal Psychology 100, 145–261.CrossRefGoogle ScholarPubMed
Mizushima, N. & Ishii, Y. (1983). The epidemiology of anorexia nervosa in junior and senior high-school students in Ishikawa Prefecture. Japanese Journal of Psychosomatic Medicine 23, 311–319.Google Scholar
Mumford, D. B., Whitehouse, A. M. & Choudry, I. Y. (1991). Sociocultural correlates of eating disorders among Asian school-girls in Bradford. British Journal of Psychiatry 158, 222–228.CrossRefGoogle Scholar
Murphy, H. B. M. (1977). Transcultural psychiatry should begin at home. Psychological Medicine 7, 369–371.CrossRefGoogle ScholarPubMed
Nasser, M. (1986). Comparative study of the prevalence of abnormal eating attitudes among Arab female students of both London and Cairo Universities. Psychological Medicine 16, 621–625.CrossRefGoogle ScholarPubMed
Nicolle, G. (1939). Prepsychotic anorexia. Proceedings of the Royal Society of Medicine 32, 153–162.CrossRefGoogle ScholarPubMed
Ong, Y. L. & Tsoi, W. F. (1982). A clinical and psychosocial study of seven cases of anorexia nervosa in Singapore. Singapore Medical Journal 23, 255–261.Google ScholarPubMed
Palmer, R. L. & Jones, M. S. (1939). Anorexia nervosa as a manifestation of compulsion neurosis. Archives of Neurological Psychiatry 41, 856–861.Google Scholar
Parry-Jones, B. (1991). Historical terminology of eating disorders. Psychological Medicine 21, 21–28.CrossRefGoogle ScholarPubMed
Parry-Jones, W. L. (1985). Archival exploration of anorexia nervosa. Journal of Psychiatric Research 19, 95–100.CrossRefGoogle ScholarPubMed
Patton, G. C., Johnson-Sabine, E., Wood, K., Mann, A. H. & Wakeling, A. (1990). Abnormal eating attitudes in London schoolgirls – a prospective epidemiological study: outcome at twelve-month follow-up. Psychological Medicine 20, 383–394.CrossRefGoogle ScholarPubMed
Prince, R. (1992). A symposium on the vulnerable male: cultural variations on the castration theme. Transcultural Psychiatric Research Review 29, 87–90.CrossRefGoogle Scholar
Prince, R. & T., Cheng-Laroche, F. (1987). Culture-bound syndromes and international disease classifications. Culture, Medicine and Psychiatry 11, 3–19.CrossRefGoogle ScholarPubMed
Robinson, P. H. (1989). Perceptivity and paraceptivity during measurement of gastric emptying in anorexia and bulimia nervosa. British Journal of Psychiatry 154, 400–405.CrossRefGoogle ScholarPubMed
Rosen, J. C. (1990). Body image disturbances and the eating disorders. In Body Images: Development, Deviance and Change (ed. Lach, T. and Pruzinsky, T.), pp. 190–216. Guilford Press: New York.Google Scholar
Russell, G. F. M. (1970). Anorexia nervosa: its identity as an illness and its treatment. In Modern Trends in Psychological Medicine, vol. 2 (ed. Price, J. H.), pp. 131–164. Butterworths: London.Google Scholar
Russell, G. F. M. (1983). Anorexia nervosa and bulimia nervosa. In The Neuroses and Personality Disorders (ed. Russell, G. F. M. and Hersov, L.), pp. 285–298. Cambridge University Press: Cambridge.Google Scholar
Russell, G. F. M. (1985). The changing nature of anorexia nervosa: an introduction to the conference. Journal of Psychiatric Research 19, 101–109.CrossRefGoogle ScholarPubMed
Russell, G. F. M. & Treasure, J. (1989). The modern history of anorexia nervosa – an interpretation of why the illness has changed. In The Psychobiology of Human Eating Disorders: Preclinical and Clinical Perspectives (ed. Schneider, L. H., Cooper, S. J. and Halmi, K. A.), pp. 13–30. The New York Academy of Sciences: New York.Google Scholar
Shirai, K., Shinomiya, M., Saito, Y., Umenzono, T., Takahashi, K. & Yoshida, S. (1990). Incidence of childhood obesity over the last 10 years in Japan. Diabetes Research and Clinical Practice 10, Supplement 1, 65–70.CrossRefGoogle ScholarPubMed
Shorter, E. (1987). The first great increase in anorexia nervosa. Journal of Social History 21, 69–96.Google Scholar
Silverman, J. A. (1989). Louis-Victor Marcé, 1828–1864: anorexia nervosa's forgotten man. Psychological Medicine 19, 833–835.CrossRefGoogle ScholarPubMed
Skrabanek, P. (1983). Notes towards the history of anorexia nervosa. Janus 70, 109–128.Google ScholarPubMed
Society of Actuaries and Association of Life Insurance Medical Directors of America (1979). Build and Blood Pressure Study. Author: Chicago IL.Google Scholar
Song, Y. P. & Fang, Y. K. (1990). A clinical report of 9 cases of anorexia nervosa. Chinese Mental Health Journal 4, 24–25.Google Scholar
Spitzer, R. L., Williams, J. B. W., Gibbon, M. & First, M. B. (1988). The Structured Clinical Interview for DSM-III-R. Biometrics Research Department, New York State Psychiatric Institute: New York.Google Scholar
Spitzer, R. L., Delvin, M., Walsh, B. T., Hasin, D., Wing, R.Marcus, M., Stunkard, A., Wadden, T., Yanovski, S. & Agras, S. (1992). Binge eating disorder – a multisite field trial of the diagnostic criteria. International Journal of Eating Disorders 11, 191–203.3.0.CO;2-S>CrossRefGoogle Scholar
Stacher, G., Abatzi-Wenzel, T.-A., Weisnagrotzki, S., Bergmann, H., Schneider, C. & Gaupmann, G. (1993). Gastric emptying, body weight and symptoms in primary anorexia nervosa: long-term effects of cisapride. British Journal of Psychiatry 162, 398–402.CrossRefGoogle ScholarPubMed
Steinhausen, H.-C., Rauss-Mason, C. & Seidel, R. (1991). Follow-up studies of anorexia nervosa: a review of four decades of outcome research. Psychological Medicine 21, 447–454.CrossRefGoogle ScholarPubMed
Suematsu, H., Ishikawa, H., Kuboki, T. & Ito, T. (1985). Statistical studies on anorexia nervosa in Japan: detailed clinical data on 1.011 patients. Psychotherapy and Psychosomatics 43, 96–103.CrossRefGoogle Scholar
Swartz, L. (1985) Anorexia nervosa as a culture-bound syndrome. Social Science and Medicine 20, 725–730.CrossRefGoogle ScholarPubMed
Tseng, M. C., Lee, M. B. & Lee, Y. J. (1989). A clinical study of Chinese patients with eating disorders. Chinese Psychiatry 3, 17–28.Google Scholar
Tseng, W. S. (1975). The nature of somatic complaints among psychiatric patients: the Chinese case. Comprehensive Psychiatry 16, 237–245.CrossRefGoogle Scholar
Vandereycken, W. (1990). The relevance of body-image disturbances for the treatment of bulimia. In Bulimia Nervosa: Basic Research, Diagnosis and Therapy (ed. Fichter, M. M.), pp. 321–330. John Wiley & Sons: Chichester.Google Scholar
Vandereycken, W. & van Deth, R. (1990). A tribute to Lasègue's description of anorexia nervosa (1873), with completion of its English translation. British Journal of Psychiatry 157, 902–908.CrossRefGoogle ScholarPubMed
van Deth, R. & Vandereycken, W. (1991). Was nervous consumption a precursor of anorexia nervosa? Journal of the History of Medicine and Allied Sciences 46, 3–19.CrossRefGoogle ScholarPubMed
Weiss, M. G., Doongaji, D. R., Siddahartha, S., Wypij, D., Pathare, S., Bhatawdekar, M., Bhave, A., Sheth, A. & Fernandes, R. (1992). The explanatory model interview catalogue (EMIC) – contribution to cross-cultural research methods from a study of leprosy and mental health. British Journal of Psychiatry 160, 819–830.CrossRefGoogle ScholarPubMed
Whitaker, A., Davies, M., Shaffer, D., Johnson, J., Abrams, S., Walsh, B. T. & Kalikow, K. (1989). The struggle to be thin: a survey of anorexic and bulimic symptoms in a non-referred adolescent population. Psychological Medicine 19, 143–163.CrossRefGoogle Scholar
WHO (1992). The ICD-10 Classification of Mental and Behavioural Disorders – Clinical Descriptions and Diagnostic Guidelines. World Health Organization: Geneva.Google Scholar