European                        Eating

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Clinical Handbook of Eating Disorders: An Integrated Approach (2004) Timothy D. Brewerton (Editor) Marcell Dekker, inc. New York.

 Review by: Tímea Kovács - kovacstimea@yahoo.com

Romania as a post- communist country has gone through enormous changes, that allowed the appearance of the process called “westernization” in our society, this being one of the factors that influences the development of eating disorders.  During my student years and now as a PhD. student, my interest has been focused on the problem of eating disorders; a field neglected in our country by most of the researchers.

This handbook achieves what it sets out to do. That is, it provides an integrated overview giving full attention to the very well known eating disorders – anorexia nervosa, bulimia nervosa and binge eating disorder.           

Initially, the book presents a modern overview of the diagnosis and assessment of the eating disorders (Chapter 1), then in chapter 2 presents the most common and reliable psychometric instruments used in the assessment of eating disorder patients. It then analyses feeding disorders in infancy, which are increasingly recognized in the pediatric population. In chapter 4, by highlighting the gender, age and cultural differences, the book analyses the epidemiology of eating disorders and later points out the long term out-comes and mortality of the life-threatening illness. Risk Factors, Etiology and Co-morbidity are discussed in detail in chapters 6 to 10.

An exploration of recent research regarding neurotransmitter deregulation in eating disorders, and some of the very exciting findings regarding neuroendocrine and neuropeptide deregulations is followed by reviews of the data which underlay the brain mechanisms involved in the development of these disorders and covers clearly the role of molecular biology in elucidating the role of genes in the etiology of eating disorders.

Eight chapters of the handbook (15-23) are dedicated to the treatment of eating disorders presenting a detailed overview of the models of cognitive behavioral therapy, family therapy, interpersonal psychotherapy and dialectical behavioral therapy.

Chapter 21 discuss the role of psychopharmacology in the treatment of AN, BN and BED which is not sufficient or optimal for the treatment of any of the eating disorders. The final chapter it is about future directions in the field exploring several areas where there is need for new data.            

I found this book to be different and unique by pointing out the insufficiencies in the field. For example it conceded that only slender research findings are available in the case of binge eating.  A strong preference for prospective longitudinal studies is expressed and the book proposes new diagnostic criteria for anorexia nervosa, dividing them between culture- independent criteria and criteria which are culture specific.

Since my own research is focused on the effect of westernization upon the cultures coexisting in Romania, namely the Hungarian, Gipsy and Saxon minorities and the Romanian majority and upon the analyses of socio-cultural factors regarding eating disorders in these three cultural groups, this new diagnostic approach offered me a new and helpful point of view.

In summary, the Clinical Handbook of Eating Disorders is a well-structured, complex work and I am glad to recommend it to a large group of scientists, researchers, therapists and clinicians and also for students and scholars who are searching for a better understanding of the nature of eating disorders or treatment of patients.  This book has helped me to fulfill many of the insufficiencies I had in this field and offered me information on which to ground my future research.

Timea Kovács,

Sapientia-Transilvanian Hungarian University of Science, Romania.

This revised edition of the first and foremost manual dealing with eating disturbances in children and adolescents, provides accessible and sensible information combined with straightforward and practical advice on how to detect and approach such problems, taking into account all the distinctive features of this age group. This is achieved in a compelling way portraying nuances that can only be provided by an experienced clinician comfortably immersed in the world of children, adolescents and their parents. Case vignettes are interspersed throughout, and reading is both fascinating and compassionate.

The strength of this book is on many levels, but especially in the care with which parents are addressed, both in guiding them through a cautious assessment of the problem at hand, and in emphasizing a non blaming stance. Throughout the text the authors keep an exceptionally empathic and respectful attitude towards the plight of all those involved in dealing with the problem. In their careful description of the different manifestations of eating disturbances, the facts are separated from the popular myths and the authors answer practically all the possible questions a worried parent can come up with, hence enabled to emerge with a probable diagnosis and a clear path to follow in the search for solutions.

In clear language and with a most readable style the chapters are organized to cover all the areas related to eating disturbances for this age group. The usual listing of eating disorders is expanded to cover selective eating, restrictive eating, food phobia, and food avoidance emotional disorder. Each of these is described in such a way that the difference between difficult eating and eating disorder becomes apparent and the parent unmistakably knows what constitutes a reason for concern. The authors list and depict the physical changes and those related to food and to general mood and behavior that point to the presence of an eating disorder. A salient asset of this book are the author’s guidelines for parents in how to face an eating problem. These are condensed in sections called “Crucial Principles” and in “Fundamental Points of Management” in which each of the critical items is priceless.

The authors are very clear regarding when professional help should be sought, and equally emphatic about the irreplaceable position parents are in terms of taking responsibility for the child’s health, safety, and recovery.  The description they make of the decisions parents need to make at different stages of the disorder are not only fundamental, but clinically savvy. Parents are warned against getting caught in unnecessary confrontations and guided in the utilization of productive interactions.

Of particular value is the authors’ description of what they call stage two of the anorexia nervosa, which starts when the patient begins to eat again. In this especially difficult phase things seem to have gotten worse; eating remains problematic and at the same time the patient is extremely angry. In current literature, not only had this trying segment in the course of the anorexia nervosa received insufficient attention; but parents were never as persuasively told why and how to deal with it. Overall, the chapter on “What can I do with specific problems” is fathomless. Additionally, the chapter on Who should I consult and what will they do? is seamless in steering the parents in the direction of treatment options and in how to assess help providers.  

In sum, this book is invaluably empowering both for parents and for clinicians working with those suffering from eating disturbance. Moreover, it has the remarkable merit of pleasurable reading, precise wording, and clinical wisdom.

Cecile Rausch Herscovici, Ph.D., Universidad del Salvador, Buenos Aires, Argentina

This book provides an overview of the epidemiology, sociocultural risk factors and treatment facilities in Turkey, Egypt, Spain, Portugal, Croatia, Italy, Greece and Israel. It is a welcome contribution to the literature that is often dominated by the English speaking cultural perspective. The book is divided into two sections. Section one explores cultural and social issues in relation to eating disorders, focusing particularly on the role of “body ideals promoted by the media” and “psychological confusion due to partial modernization”.  Section two provides chapters about each of the above mentioned countries.

Chapter one examines culture and its relationship with key cognitive concepts in eating disorders such as negative self-evaluation and sense of control. Chapter two discusses aspects of “Mediterranean culture” such as the “honour and shame” construct and traditional versus modern values. Chapter three is a contribution from that well known Mediterranean country, the UK, which explores shame, social stress and eating disorders using social ranking theory as the method of investigation.

An author native to the country being discussed writes each chapter in section two. A review of the local epidemiological and socio-cultural risk factor literature is presented, and an overview of treatment services given. The editor acknowledges that research in these areas is somewhat limited and comparisons between countries are difficult. I found the chapter on Egypt by Mervat Nasser particularly interesting as it corrected several inaccurate stereotypes I held about modern Egyptian culture. There was also a thought provoking analysis of the role of “veiling” and its relationship with eating disorders in Egyptian society.

The description of treatment services in each country shows the wide variation in facilities within and between countries, reflecting the development of services in English speaking countries by being led by academic centres and large hospitals in urban areas. This book will be of interest to European Council members who already enjoy the possibilities of cultural exchange provided by the Council’s bi-annual conferences.

Sam Clark-Stone, Eating Disorders Team, Gloucestershire, UK

Shortly after Susan Albers became a therapist, she discovered that there are many people who are suffering from hunger, weight issues and eating problems. Not because they have a full-blown eating disorder, but maybe because eating in a mindless manner is very common in our society. Therefore, Albers has written this self-help-book to prevent further suffering and, for those already affected by it, become a mindful eater.

Mindless eating, according to Albers, is not a cause of eating disorders, but it is the result of complex body and mind issues.  Many factors play their own part: low-self esteem, body image problems, the absence of control, social and cultural values, emotional problems, etc. Although these problems can exist for a very long time, it might sometimes lead to a more severe eating disorder, like anorexia or bulimia nervosa. Mindfulness is the key and it has four foundations, all based on Buddha’s teachings. They are: mindfulness of mind; mindfulness of body; mindfulness of thoughts and mindfulness of feelings. Practising mindful eating means, that you become more aware of your thoughts and feelings. Eventually, it might lead to mindfulness in everyday life.

Albers describes four broad categories of mindless eaters: the chronic mindless dieter, the mindless under eater, the mindless overeater and the mindless chaotic eater.  Their specific characteristics are all described within the context of the four foundations. For example: a mindless under eater has a strong desire for perfection (mind) and is preoccupied with appearance (thoughts); a mindless chaotic eater experiences extreme fluctuations in weight (body) and fears being or becoming fat (feelings).

This book is filled with self-help advice with lots of exercises to learn how to eat mindfully. All these exercises are based on the four foundations. Although it is possible to become a mindful eater on your own, Albers recommends professional help for those who are more trapped inside a negative mindset. Help from family and/or friends may be tricky; they may have the same weight and eating issues as you have. But, whatever you do, give it a try. Mindful eating is not about developing discipline over your fork, but  mastering control of your mind.

Liesbeth Libbers, Librarian ´Kenniscentrum Eetstoornissen Nederland,  Informatiecentrum, locatie Hoge Roest, Postbus 422, 2260 AK Leidschendam, The Netherlands

This book is part of a series of self-help titles, which cover subjects as diverse as oppositional children, sexuality and PTSD. The authors are a psychiatrist and a psychologist specialising in eating disorders and cognitive behavioural therapy. It is addressed principally to sufferers of anorexia nervosa, both adolescent and adult, and also to families and spouses. Much of it could also be relevant to normal weight bulimics.

The layout is clear and reader-friendly with each chapter divided into short, clear sections with use of tables, questionnaires, lists and case vignettes. The tone is informative and optimistic. 

The introduction and first chapter are concerned with the place of food in our society, the split between the real and the ideal body and the quest for the latter through diet, purging and exercise. The next provides information for sufferer and family about how to recognise when things are becoming pathological. Then come chapters describing the different types of anorexia nervosa, the bio psychosocial model and diagnostic criteria with emphasis on the importance of recognising the function of the illness for each individual. Then a discussion with useful flow charts about how the illness arises with predisposing, precipitating and maintaining factors considered in an open and un-dogmatic way. Following this, a description of consequences of the illness; physical, psychological and social.

The second part of the book addresses the "comment sortir” promised in the title and in my opinion makes about as good a job of it as can be made.  It begins with some motivational exercises around the benefits or otherwise of recovery and recognising the stages of motivation. Then there is practical information about the kinds of help that might be available. Then a series of exercises which address recognising pathological behaviours and cognitive distortions and observing interpersonal relations, then overcoming the behaviours one by one and challenging the distortions, also accepting a normal body shape and weight.  It is emphasised that the book is not intended to be used alone but as part of a therapeutic structure. This is important as I can imagine that all but the most motivated anorexic might find herself flagging before the comprehensiveness of the cognitive behavioural and motivational exercises offered if she did not have someone to help pace things. Also, she might well feel rather lost in the face of the ten rules for recovery which include restoring confidence in yourself and improving your relationship with (or experience of) your body. Easier said than done without outside help.  Used as suggested, however, the book could provide invaluable backup. The exercises are clearly explained and are likely to be found interesting, motivating and very helpful.

The book ends with further advice for relatives and then a brief discourse on prevention of anorexia; primary, secondary and tertiary. Finally there is a list of useful contacts in French speaking countries.In conclusion, I found this is a very good, comprehensive, self-help book, which fulfils the remit of the title. I am glad to have it to recommend to patients.

I received this book with high hopes of it being of great relevance to eating disorder professionals. Given the subject matter, emotional and behavioural difficulties in young people, I expected at least a chapter devoted to one of the commonest emotional problems affecting adolescent girls in Western cultures. However, I was most surprised to find that anorexia nervosa appears only once in the index, referring to a single sentence on cultural differences in presentation of different psychological difficulties and bulimia nervosa is not mentioned at all!

The book is written from the point of view of educators, and the majority of chapters are written by UK based Educational Psychologists, hence there is an understandable bias towards the British education system. But why the lack of mention of eating disorders? Reading further I came to understand a little more about the perspective of teachers on children with emotional and behavioural difficulties (EBDs), which is mainly focused around the impact of the child's difficulties on their own learning, but also, more importantly, on other children in the class. This focus leads to those identified with EBDs most commonly being males with 'acting out' or 'externalising' type problems such as Oppositional Defiant Disorder, ADHD and Conduct Disorder, rather than the quiet and non-disruptive girl who sits and the back of the class and never eats her lunch.

Having said all this I did find the book useful in understanding the increasingly complex processes to be followed in the UK education system for identifying and helping children with EBDs. I would suggest that any mental health professional who works with school-age children needs to be well aware of this area in order to communicate effectively with educators. This is crucial for them to be able to as smooth the path for their younger patients to get the most out of the education system. However, I was concerned by what I read that children with eating disorders may be being missed by the education system and hence not receiving the extra help they need.

 This book deals with anorexia nervosa in children (girls and boys) of the age of 8 to 12 years. It is in the main written as a guide for parents who are confronting this illness. In the first part, the author illustrates the problems associated with the illness using accounts of patients and mothers and fathers of the patients. Next, the eating disorder problem, the dangers and the consequences of dieting and changing eating behaviours are explained in a comprehensive way.

In the second part a variety of frequently asked questions are discussed: why is anorexia nervosa dangerous?, where does the disease come from?, how to avoid anorexia nervosa? and, how to care for a child with anorexia nervosa? This book is a guide for parents who are for the first time confronted with an eating disorder and who have a lot of elementary questions. The author tries in her book to reassure the parents that each phase of change of eating behaviour is not a synonym of   anorexia nervosa. This informative book is easy to read even for non-native French speakers.

 This is a book about men’s issues with their bodies, the authors clearly stating at the outset that fat is a men’s issue, it is no longer just a feminist issue. It is suggested that this book is for men who cannot stand the way they look in the mirror and for the ones who are so driven for perfection that they neglect the deeper areas of life. The well-respected authors all have wide experience in working with men who have concerns with their shape and weight.  Arnold Anderson has previously written about men with eating disorders, Lee Cohn has co-authored many books on eating disorders and self-esteem, whilst Thomas Holbrook has been treating men for 20 years in Psychiatric practice and is recovered from both compulsive exercising and an eating disorder.

‘Making Weight’ is primarily a book for sufferers: for men who are overeaters or anorexic, bulimic or excessive exercisers.  However, the book is also extremely useful for families and friends who want to help and for professionals who treat these disorders.  The book begins by describing the problems that plague today’s men.  It is uncompromisingly an American viewpoint although the book no doubt reflects the concerns that western man is facing in other countries.  In a very engaging, reader friendly way the book examines the ‘over weight’ epidemic, men’s drive for thinness, body shape concerns, eating disorders, appearance obsession, and the effects of an extremely sedentary lifestyle or one characterised by compulsive exercising.

An explanation of the differences between the sexes helps to focus the attention on purely male issues with particular emphasis on how men develop both body and self-esteem.  The authors manage extremely well to combine facts and accepted theory with thought provoking ideas that keep the reader engrossed. A chapter on ‘why today’s men are having problems’ is fascinating for its study of differing cultural norms through the ages whether it be clothing, body hair or even body piercing.  The chapter helps us to understand the particular distress that men may feel in today’s culture.  Men having to come to terms with the fact that our culture continues to change in the direction of sexualisation, externalisation of values, materialism and worship of youth. Thomas Holbrook writes about his own anorexia nervosa and how it has affected his life and work with refreshing honesty.  It leaves hope for recovery, and a path that could be taken for those struggling with the illness.

Much of the rest of the book attempts to deliver a program that can help lead to healthy living.  This is a comprehensive attempt to allow men to feel better about themselves and looks much further than simply telling us what we should be eating.  Most of the advice is common sense and little of it is new to those versed in self-help books.  However, it is well presented and I suspect that it is likely to leave many readers motivated to try at least some of the suggested steps to healthy living.

The book is excellent in presenting men’s conflict with food, weight, shape and appearance as a continuum.  The conflict affects all men to varying degrees and as a man I found the book stimulating and relevant to my own life and the conflicts within it.  However, the book also clearly identifies eating disorders as complex illnesses with genetic, cultural and psychological determinants.  It takes the reader through the different types of treatments available for eating disorders and includes a very helpful chapter specifically directed to the family and friends of men who have struggled with food, weight, shape, height and appearance. This book is very accessible, providing an exceptional resource not only for men who are caught in conflict with their bodies but also for health professionals looking for well written, well balanced books on men and eating disorders.