The Changing Profile of Eating Disorders at a Tertiary Psychiatric Clinic in Hong Kong (1987–2007)
Sing Lee, MBBS King Lam Ng, BSSc Kathleen Kwok, MSSc Corina Fung, PhD International Journal of Eating Disorders (2010)
Abstract:
Objective: To examine the clinical profile of Chinese eating disorder patients at a tertiary psychiatric clinic in Hong Kong from 1987 to 2007.
Discussion:
The clinical profile of eating disorders in Hong Kong has increasingly conformed to that of Western countries.
Overall, our findings strongly suggest that the clinical presentation of eating disorders in Hong Kong has transformed to an increasingly fat-phobic form. This is not unlike what has been documented in Western communities. Whether clinical under recognition, difference in treating-seeking pattern or historical change in phenomenology accounts for the lower proportion of nonfat phobic than fat phobic AN patients in this study remains to be clarified. Nonfat-phobic AN questions the ontological nature of AN, the validity of current classification, and treatment approaches based on fat concern.
A recent clinical study indicated that patients with EDNOS without over evaluation of shape and weight exhibited no clinical and treatment differences compared to those with AN. The authors recommended that these patients should be captured as AN in the DSM-V. Regarding community epidemiological research, nonfat-phobic AN suggests that our dominant assessment tools fail to capture the phenomenological diversity of AN and may contribute to the repeated finding of misleadingly low rates of the disorder. Published studies on clinical eating disorders in Asia have predominantly focused on AN. The transformation of eating disorders found in the present study suggests that higher prevalence of fat-phobic AN and of BN are likely to arise in Chinese and other Asian communities. This will constitute a challenge to their typically under resourced mental health services.
Case report
The variability of phenomenology in anorexia nervosa
Ngai ESW, Lee S, Lee AM.
Acta Psychiatr Scand 2000: 102: 314±317. Munksgaard 2000
Objective: To study the variability of phenomenology in Chinese patients
with anorexia nervosa in Hong Kong.
Anorexia nervosa (AN) has been considered to be a homogeneous `western' entity. This is evident in authoritative diagnostic systems, such as the DSMIV, which includes `intense fear of becoming obese, even when underweight' as an essential characteristic for diagnosing anorexia nervosa , irrespective of the race, nationality and the subculture to which the subject belongs.
Discussion
The above cases illustrate the variability of anorexic phenomenology and tentatively suggest a typology of AN as follows: 1) fat phobic type I (fat phobia consistently present), 2) fat phobic type II (fat phobia changing to non-fat phobic presentation), 3) non-fat phobic type I (consistently non-fat phobic), and 4) non-fat phobic type II (non-fat phobic initially, but fat phobic later). The first type represents `typical' fat phobic AN as defined in the DSM-IV (1), and is probably the most common form of the illness in the community nowadays. The second type is representative of patients that clinicians often encounter, namely, fat phobia is present initially, but diminishes or disappears as weight loss becomes advanced or chronic.
The sufferers then do not report any desire to be thinner and say that they want to gain weight (3, 6). The third type is `atypical' AN frequently found in older, male or premorbidly slim patients, especially in non-western societies (3). The fourth type adds to the diversity of anorexic phenomenology. As a formerly slim and non-fat phobic patient gains weight she may well develop a degree of fat concern which is now collectively present among young females in modern societies, be they western or nonwestern. Among sufferers of childhood onset AN, fat phobia is also not uncommonly absent but emerges as treatment progresses (7). Others may simply not be able to articulate the reasons why they have lost weight (6).
There are at least four explanations for the absence of fat phobia in AN patients. The first and conceptually the simplest is that these patients `deny' or conceal fat concern, thereby deceiving their doctors and/or family members. However, this simplistic speculation is not supported by our clinical and research experience, and certainly cannot be an adequate explanation for the majority of non-fat phobic patients in Hong Kong (3). The second explanation is that non-fat phobic AN is really a form of somatized or atypical depression associated with marked weight loss. However, this is contradicted by patients' relatively low ratings on depression, and the lack of efficacy of antidepressant drugs in AN. The third explanation is that since non-fat phobic patients are usually premorbidly slim, the urge to shed fat is not an issue for them.
This is supported by the fact that about 15% of constitutionally slim young women in Hong Kong desired to gain rather than lose weight, but it cannot account for the variability of fat experience within the same patient. The last explanation is that non-fat phobic patients come from subcultures in which fat phobia is not an effective idiom of distress. Rather, as in historical accounts of AN (3), non-fat phobic rationales for non-eating provide better excuses for food refusal in patients' local worlds. This explanation may be partly true, but is not entirely compatible with the ending that some 80% of young females in Hong Kong do feel distressed about being fat even though they are slim.
Clearly, anorexic patients' attributions for noneating are more complex than the DSM-IV would have us to believe. The second and fourth patients further indicate that the `typical' vs. `atypical' typology of AN is inadequate. In fact, fat phobia in AN is not an immutable core symptom, and that fat phobic and non-fat phobic anorexic experiences are not mutually exclusive.
Anorexic attributions can change with body weight, chronicity, age and, above all, many contextual factors (5). This is congruous with evidence in social psychology and anthropology that psychological attributions are generally mutable (8). Among anorectic patients, attributions for food refusal may represent a point of entry into the dynamic interpersonal processes and changing symbolic meanings of the illness.Thus, as a fat phobic anorexic subject's emaciation becomes irreconcilable with everyday aesthetic instincts, she may be blamed for risking her life and causing immense pain to family members. At that point, she may develop a different attribution about her food refusal and weight loss, such as stomach bloating, as in case 2.
All existing psychometric instruments for eating disorders rest on the central construct of fat
phiobia. If they are used in epidemiological studies, non-fat phobic AN may well be screened out (8). It is unclear if this accounts for the typically low rates of AN found in most community studies. Since the variability of AN phenomenology challenges the current fat phobia paradigm and has implications on the diagnosis, treatment, psychometric assessment and prognosis of eating disorders, more attention to non-fat phobic anorexic experience is warranted.
ANOREXIA NERVOSA IN ARAB CULTURE: A CASE STUDY
Journal of Law and Psychology, ISSN: 2078-1083, September, 2010. Abdalla A.R.M. Hamid Associate Professor, Department of Psychology, United Arab Emirates University (UAE)
Abstract
Incidence of anorexia nervosa is extremely rare in Arab culture. This case study is concerned with anorexia nervosa in a young woman who is 14-years old. The onset of the disorder was at a very young age (12.5 years). Attitudinal, behavioral and cognitive aspects that contribute to the occurrence of anorexia nervosa were identified. Cognitive behavioral techniques were employed to deal with negative attitudes, thoughts and maladaptive behavior. Difficulties encountered by therapists such as social stigma and negative cultural attitudes toward psychiatric illnesses and psyc hotherapy were addressed. The role of these cultural barriers in hindering the process of therapy was also discussed.
Eating Disorders in British Asians –John Wiley and Inc 1998 Dev Ratan, Devang Gandhi and Robert 13 March 1998
Abstract:
Objective: There has been a clinical impression that British Asians present with eating disorders less commonly than expected. The study examines the numbers and characteristics of Asians presenting to the Leicestershire Eating Disorders Service with a catchment area which includes a substantial proportion of people with a background in the Indian subcontinent. Method: Case note review and comparison of rates of presentation of people with and without such a background. Results: Twenty-one eating-disordered Asians were seen in 10 years. Their clinical characteristics resembled the rest of the referrals. However, the rate of presentation of people from the Asian population was about one fourth of that of the white population. Discussion: Asian women with eating disorders were referred less often. This might be because of a lower prevalence in this population. However, it seems likely there are variable and sometimes high threshold filters to secondary care for such women.
INTRODUCTION
Leicester is perhaps unique in the United Kingdom in having both a substantial population with a background in the Indian subcontinent an a specialized Eating Disorders Service (EDS). The EDS accepts referrals of people aged 16 or older. Most adults in Leicestershire with an eating disorder referred for psychiatric care are seen within the EDS. Our impression was that there were fewer Asians seen than expected from the ethnic composition of the local population. For this study, Asians are defined as persons with a personal or family background in the Indian subcontinent. The literature on eating disorders among Asian people in Britain is limited. Few cases actually presenting to psychiatric services have been reported.
DISCUSSION
The results suggest that anorexia nervosa and bulimia nervosa occur regularly in British Asians. Certainly, this would seem to be the case for the Asian population of Leicester which is largely of Gujarati background. The results may not apply to other Asian populations in the United Kingdom. The Asians who presented to the EDS resembled their non-Asian counterparts in age and clinical characteristics. A minority did meet entirely the ICD-10 diagnostic criteria because of the absence of evident weight concern and fear of fatness. This absence has been reported as a feature in some other series of eating-disordered subjects from Asiatic cultures (Lee et al., 1993).
Lacey and Dolan (1988) suggested that patients from ethnic minorities presenting with eating disorders were likely to have especially severe disorders associated with unusually severe personal and social disturbance. This did not seem to be so with the present series. The rate of presentation of people of Asian background to the EDS with markedly lower than that of the rest of the local population of Leicestershire. It is at present unclear whether this arises because of a relative rarity of eating disorders among Asians or because of some obstacle on the pathway to specialist care or both.
It may be that people of Asian background are even less likely to want or to be thought appropriate for referral to hospital-based specialist services. The role of cultural factors is difficult to formulate. In considering the life difficulties of young Asian women, there is a risk of taking an unduly ethnocentric view which construes their troubles as cultural and those of their indigenous counterparts as normal. Nevertheless, it may be useful to consider as special any difficulties that seem to arise from a conflict between two contrasting sets of cultural expectations. It may be that such conflicts of expectation are more common in young women of Asian background.
Are Eating Disorders a Significant Clinical Issue in Urban India? A Survey Among Psychiatrists in Bangalore- (Int J Eat Disord 2012; 45:443–446)
Abstract
Objective:
It is believed that cultural changes such as urbanization and westernization can lead to increasing rates of eating disorders (EDs). A survey was conducted among psychiatrists in Bangalore, India to assess whether they were seeing more cases of ED in the last year.
Results:
Sixty-six psychiatrists took part in the study. Thirty-eight (56%) were in private practice and 28 (42%) in teaching hospitals. 45 (67%), reported having seen patients with eating disorders in the last year. The total number of cases seen was 74. Of these, 32 were diagnosed as anorexia nervosa (AN), 12 as bulimia nervosa (BN), and 30 as eating disorders not otherwise specified (EDNOS). Sixteen (23.5%) respondents were of the opinion that EDs were increasing in Bangalore, 18 (26.5%) felt the rates were stable and 28 (42%) were not sure.
Two-thirds of psychiatrists reported seeing at least one case of ED indicating that EDs are not uncommon in urban India. Epidemiological studies of EDs in India are needed to provide better estimates of their prevalence.
Discussion
A survey of psychiatrists such as this cannot provide accurate or even approximate estimates of the prevalence of eating disorders. Nor can it answer questions about trends over time. However, it can confidently refute the idea that eating disorders are rare at least within the city of Bangalore. The finding that two-thirds of Bangalore psychiatrists had seen a case in the preceding year and that between them they had seen at least 74 cases in one year, indicates that eating disorders are not uncommon. With an estimated population of 5.8 million in 2001, Bangalore is the third most populous city in India.10 However, this cannot be considered as the complete denominator of the patient population served by the psychiatrists in Bangalore as ‘‘difficult to treat’’ patients from nearby towns and states also seek help from psychiatrists and institutions in the city.
The method of this study is simple. The strength is that the diagnoses were made by qualified psychiatrists. They are likely to be broadly valid even if not always conforming to the niceties of diagnostic criteria. A potential weakness is the possibility that a patient could have consulted more than one psychiatrist in the city. This could not be verified due to confidentiality issues and because patients seldom inform their psychiatrists if they are taking a second opinion, unless their case is referred.
Bangalore has well developed psychiatric services both in private and public health systems.Patients from rural areas and low-income settings tend to use the public health services more often. While psychiatrists in private practice tend to see the more well to do patients. Many patients who need tertiary care (of all socio economic and demographic strata) are referred to teaching hospitals. Also teaching hospitals offer specialized psychological and family therapy services which are not routinely available in private practice. This might account for the slightly higher number of patients seen in institutions.
Do physicians other than psychiatrists see patients with eating disorders? It is possible that patients with milder forms of eating disorders do not seek help from mental health services. Most physicians (generalists) who might see a person with an eating disorder would refer the patient to a psychiatrist because of their difficulty in managing the condition once they diagnose it correctly. However, there may be some who seek treatment from other systems of care such as Ayurveda or Homeopathy but these might be for the more milder forms of illness. It is hence possible that patients with milder forms of illness did not consult psychiatrists.
The finding of substantial numbers of people with eating disorders presenting to psychiatrists in Bangalore may not reflect the situation elsewhere in India. If the speculations about the effects of globalization are true, then the people of Bangalore are likely to be affected more than most. At present, the only other comparable data are from a hospital database in South India among children and adolescents (up to 18 years), in which only six cases of anorexia nervosa were reported over a 5 year period of 2000 to 2005. Other studies have focused on attitudes towards eating and body image in urban Indian students and report high levels of preoccupation with body image.8 The finding that thinness itself may not be the main motivating factor for eating disorders and certain changes in society through westernization may bring to the fore different methods of resolving conflicts and issues related to control have been considered as one of the reasons for a rise in eatingdisorder in any culture.
It is time that more systematic surveys related to eating disorders are conducted among adolescent girls and young women in India to know the real extent of the problem. Also important, is to study variations in clinical manifestations of eating disorders in different cultures such as in Hong Kong where fear of fatness is an uncommon finding.
Currently, the psychiatrist to population ratio in urban Bangalore with 92 psychiatrists for a million population is approximately 1:63,000, which are very inadequate. Specialized services for eating disorders are a distant dream, given that most mental health professionals in India have limited or no experience in dealing with eating disorders due to their infrequent occurrence. If current speculations are true, globalization and rapid westernization being seen in many cities in India may demand a response in the form of both preventive efforts and service delivery. The epidemiological study of eating disorders in India would need to be complex to be adequate.
The extraordinary heterogeneity of Indian society makes generalization between different populations inappropriate. However, because of this wide variety of populations and subcultures, such a study might not only produce information relevant to particular service planning but could also provide illumination upon the general role of social and other factors in the etiology of eating disorders.
Restricter Anorexia Nervosa in a Thirteen-Year-old Sheltered Muslim Girl Raised in Lahore, Pakistan: Developmental Similarities to Westernized Patients
Joel Yager Melanie Smith (Accepted 18 September 1992)
An academically perfectionistic and interpersonally compliant 13-year-old girl raised in a traditional, sheltering Muslim home in Lahore, Pakistan developed restricter anorexia nervosa in the context of being teased about her weight by her closest friend and younger brother, and in a context of family weight preoccupation. Similarities to current pathogenetic hypotheses among Western adolescents are discussed.
DISCUSSION
Reports of the onset of anorexia nervosa in non-Western countries and cultures are rare and usually lack the opportunity for an assessment of psychological and family features believed to be operating in the genesis of this disorder. This patient demonstrated clearly that weight preoccupation and appearance preoccupation may be major issues among contemporary early adolescents in Pakistan, and that Pakistani adolescents are no less susceptible than American and European ones to teasing by one's peer group and siblings, family concerns and preoccupations about weight and appearance, and the desire to be attractive. Similarly, the personality traits of this patient, academic perfectionism, interpersonal compliance, and a deep need to please her family, siblings and friends, are all consistent with Western formulations of the psychodynamics of this disorder.
The case illustrates that in spite of cultural differences, early adolescents growing up in non-Western countries may display psychodynamic and developmental issues similar to those in Western countries. They are also susceptible to peer pressures and family pressures regarding weight and appearance no less than those blessed with heavy doses of daily exposure to the media and culture of the Western world.
The articles below are free articles which can be downloaded from the websites in full for free.
Contrary to historic perceptions, eating disorders are not "culture-bound" phenomena predominantly confined to young White female populations in Western countries, but occur at similar rates in minority ethnic groups and in the general populations of non-Western countries. AN, BN and binge eating disorder have been documented in Asia, Africa, South America and the Middle East, as well as in individuals of Asian, African, Latin, Hispanic and Middle Eastern ethnicities in Europe, the US and Australia. Despite comparable point prevalence rates for eating disorders in Western and non-Western countries, and between White and non-White groups within Western societies, differences exist in cultural attitudes to food, body image perceptions and precipitating factors for eating disorders that may complicate diagnosis in minority ethnic groups and confound effective management.
Key points
Although research in this previously neglected area has increased markedly in recent decades, further studies are needed to better understand eating disorders across ethnicities, particularly regarding assessment, risk factors and potential adaptations to established interventions. For example, one of the authors (EC) is conducting work on symptom profiling of eating disorders within the Bangladeshi population. This research aims to inform the devel opment of a clinical tool to aid earlier identification of eating disorders in this group. Similar initiatives are needed to enhance clinicians' awareness of the varying presentations of eating disorders across diverse populations. Such awareness would improve the prospects for earlier recognition, diagnosis and treatment, ultimately leading to better outcomes.
You can download the article here-
https://kclpure.kcl.ac.uk/ws/portalfiles/portal/333960654/CEPiP6-Article-4_3.pdf
The rise of eating disorders in Asia: a review
https://jeatdisord.biomedcentral.com/counter/pdf/10.1186/s40337-015-0070-2.pdf