Editorial

DSM 5 has justifiably celebrated its first birthday – an extraordinary and admirable amount of time and energy was expended in its conception and delivery – the time has now come to consider how it helps us to help our patients. Whatever its conceptual basis and its empirical validity in categorising specific types and sub-types of eating disorders, the time has come to consider whether it truly goes to the heart of these conditions and, for the purposes of this Editorial, anorexia nervosa (AN) in particular. While a considerable improvement on DSM IV, the focus of each of the main diagnostic criteria, behaviour, emotions and cognitions, remains food, weight and shape, exactly as it is for our patients. Yet, there is so much more to AN. The relative inadequacy of our treatments, and of our knowledge of who responds better to which treatments, under what circumstances (Gowers, 2013; Steinhaussen, 2002), even the highly specialised ones, surely demands a broader consideration of psychopathology than the perennial and pervasive food, weight and shape focus.

Here is a brief mention of other common underlying psychological features. It is surprising how relatively little attention they get in standard practice, compared with weight restoration:

• Low self-esteem / high self-disgust

• Intense sense of shame and guilt

• Intense anxiety and sensitivity

• Excessive movements – e.g. jiggling

• Compulsive exercising

• Withdrawal and irritability

• Depression and self-harm

• Impaired sense of taste

• Raised pain threshold

• Difficulty in integrating thoughts with feelings

• Lack of awareness of illness (anosagnosia)

• Cognitive weaknesses – rigidity, poor visuo-spatial skills, weak central coherence

Additionally, AN is full of contradictions. For example, our patients feel fat when they are thin and full when they are empty; starve then binge; are obsessed with food but avoid it as much as they can; have low self-esteem despite being popular and successful; feel they have no control but behave in a ‘controlling’ way; have previously been conscientious, compliant and caring of others, but in the illness are the opposite; perceive the illness as more of a friend and a comfort than a torment and an enemy, with more advantages than disadvantages; look fragile but behave with great strength; fluctuate between having insight and no insight, between motivation and lack of it; and experience what we perceive as our help and support as coercion and torment (Lask & Frampton, 2009).

Thus, there are many other ways of conceptualising AN beside it being an eating disorder. It could equally be categorised as

• anxiety disorder – intense, persistent anxiety;

• phobic disorder – persistent fear of an object or situation which the sufferer commits to great lengths in avoiding, typically disproportional to the actual danger posed;

• obsessive compulsive disorder – intrusive thoughts that produce uneasiness, apprehension, fear or worry; repetitive behaviours aimed at reducing the associated anxiety or by a combination of such obsessions and compulsions;

• mood disorder – intense sadness, guilt and self-doubt;

• affect regulation disorder – difficulty in modulating affect, especially of a negative nature;

• self-esteem disorder – persistent and pervasive low self-esteem and intense shame;

• delusional disorder – fixed false belief;

• body dysmorphic disorder – excessive concern about and preoccupation with a perceived defect in physical appearance;

• cognitive disorder – impairment of cognitive processing, such as executive functioning, perception and visuo-spatial skills;

• contradiction disorder – as described above.

While there is much overlap between some of these, for example anxiety, phobias, obsessive compulsive disorder and affect regulation, each highlights a particular aspect of our whole being. It is intriguing therefore that so much focus is placed on food, weight and shape, and so much less on such fundamental components of what makes each of us a unique individual.

What follows emanates from some inspiring meanderings along the beaches of Bunker Bay in Western Australia a few months ago, in the company of this co-editor's friend, mentor and oracle, Prof Ken Nunn. Notwithstanding the glorious sea, sand and scenery and passing whales, our thoughts turned to the enigma that is indeed AN. Perhaps the very name, Bunker Bay, had a subconscious influence on our contemplations, in that bunkers tend to be hidden and containing much that cannot be seen. Perhaps we should have been shamed by our academic ramblings while gazing upon what must be among the World's most beautiful scenery. But what transpired was yet a new conceptualisation and, of course, a new acronym, for what currently we call AN. As we drank excellent local wines watching the sunset over the meeting points of the Indian and Southern Oceans, we were inspired, or fooled, or seduced into thinking of AN as a Body Related Anxiety and Shame Disorder (BRASH-D).

Under the influence of such natural delights who could not be seduced? But even in the cold light of dawn, BRASH-D did seem to capture a little more of what lies beneath the sand, a little more of what is hidden in the bunker, than ‘eating disorder’. I am hesitant to say this but – ‘food for thought’.

On the flight back to the Northern Hemisphere, I was gazing with childish delight at the in-seat moving map of the World when I spotted Stockholm and was reminded of a number of conversations I had been having with one of my very bright undergraduate students, Rhian Davies. Much of what follows emanates from these conversations and Rhian's reading of the literature.

We had been considering the similarities between AN and Stockholm Syndrome, a situation first described in 1973 after a Stockholm bank-robbery in which four people were held hostage for several days. After the incident, the hostages displayed positive feelings towards the captors, defending their captor's actions as well as denouncing the police efforts (Cantor & Price, 2007). Since this first incident, numerous cases of the syndrome have been portrayed in the media, for example that of Patty Hearst who was abducted by the Symbionese Liberation Army and subsequently took part in their illegal activities. Ms Hearst was tried for robbery and convicted, however this conviction was later repealed after it was concluded that she participated due to her development of Stockholm syndrome (Namnyak et al., 2008).

Although not officially a disorder according to the various diagnostic schema, Stockholm syndrome has been defined as the development by hostages of positive feelings, such as sympathy and understanding, for their captor. These are accompanied by negative feelings, such as anger and frustration, towards family, friends or authorities. When kidnapped, the hostage becomes like an infant; all of their needs are controlled by the kidnapper. Victims may regress and view the kidnapper in the same way as a child views their care giver (Favaro, Degortes, Colombo, & Santonastaso, 2000; Speckhard, Tarabrina, Krasnov, & Mufel, 2005).

Stockholm syndrome has also been suggested in cases of domestic abuse (Cantor & Price, 2007). In the same way that hostages must rely on their captors to care for their needs and accept a subordinate position in the relationship, victims of domestic abuse do not act without their partner's permission.

Might there be any parallels between AN and Stockholm Syndrome? Although we could find no reference in the academic literature to this concept, there are a few such references on various online forums, subscribed to by patients. For example, one forum member commented ‘Anorexia is like Stockholm syndrome. It completely f***s up your perspective’ (www.olivebranchoutreach.com/parents.html).

Another website has a page dedicated to treating AN akin to Stockholm syndrome (http://www.crazyboards.org/forums/index.php/topic/44593-am-i-on-my-way-to-anorexia/page-3. The author equates the eating disorder to the abductor and acknowledges the positive feelings some patients feel towards the disorder. While obviously there are significant differences between Stockholm Syndrome and AN, it is an analogy that seems to have meaning to patients and parents and worthy of further exploration (work in progress – Davies R and Lask B).

We must continue to try and unravel the mystery that is AN, a condition that is far more complex and profound than a pervasive preoccupation with food, weight and shape. Undoubtedly, these are important components, but by far from the only ones. Perhaps it is not surprising that our treatments remain as inadequate as they are, when the focus is so much on ‘weight restoration’ and ‘parental empowerment’, however unquestionably relevant these are. But they are merely the start, just as an anaesthetic and a sterile area are necessary for a surgical procedure to commence. What lies beneath needs attention too, be that anxiety in any of its manifestations, mood disturbance, low self-esteem, shame, self-disgust, delusional beliefs, cognitive impairments or the torment of living in a world of self-doubt and shame, a dilemma of contradictions or a bunker of captivity.

Acknowledgements

With deep gratitude to Ken Nunn and Rhian Davies.