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Clinical Handbook of Eating Disorders
 Medical Psychiatry
Series Editor Emeritus
William A.Frosch, M.D.
Weill Medical College of Cornell University
New York, New York, U.S.A.

Advisory Board
Jonathan E.Alpert, M.D., Ph.D.
Massachusetts General Hospital and
Harvard University School of Medicine
Boston, Massachusetts, U.S.A.

Bennett Leventhal, M.D.

University of Chicago School of Medicine
Chicago, Illinois, U.S.A.

Siegfried Kasper, M.D.

University Hospitalfor Psychiatry
and University of Vienna
Vienna, Austria

Mark H.Rapaport, M.D.

Cedars-Sinai Medical Center
Los Angeles, California, U.S.A

1. Handbook of Depression and Anxiety: A Biological Approach, edited by Johan

A.den Boer and J.M.Ad Sitsen
2. Anticonvulsants in Mood Disorders, edited by Russell T.Joffe and Joseph
R.Calabrese
3. Serotonin in Antipsychotic Treatment: Mechanisms and Clinical Practice,
edited by John M.Kane, H.-J.Möller, and Frans Awouters
4. Handbook of Functional Gastrointestinal Disorders, edited by Kevin W.Olden
iv

24. Autism Spectrum Disorders, edited by Eric Hollander

25. Handbook of Chronic Depression: Diagnosis and Therapeutic Management,
edited by Jonathan E.Alpert and Maurizio Fava
26. Clinlcal Handbook of Eating Disorders: An Integrated Approach, edited by
Timothy D.Brewerton
27. Dual Diagnosis and Psychiatric Treatment: Substance Abuse and Comorbid
Disorders, Second Edition, edited by Henry R.Kranzler and Joyce Tinsley
28. Atypical Antipsychotics: From Bench to Bedside, edited by John G. Csernansky
and John Lauriello
29. Social Anxiety Disorder, edited by Borwin Bandelow and Dan J. Stein
ADDITIONAL VOLUMES IN PREPARATION
 iii

5. Clinical Management of Anxiety, edited by Johan A.den Boer

6. Obsessive-Compulsive Disorders: Diagnosis • Etiology • Treatment, edited by
Eric Hollander and Dan J.Stein
7. Bipolar Disorder: Biological Models and Their Clinical Application, edited by
L Trevor Young and Russell T.Joffe
8. Dual Diagnosis and Treatment: Substance Abuse and Comorbid Medical and
Psychiatric Disorders, edited by Henry R.Kranzlerand Bruce J.Rounsaville
9. Geriatric Psychopharmacology, edited by J.Craig Nelson
10. Panic Disorder and Its Treatment, edited by Jerrold F.Rosenbaum and Mark
H.Pollack
11. Comorbidity in Affective Disorders, edited by Mauricio Tohen
12. Practical Management of the Side Effects of Psychotropic Drugs, edited by
Richard Balon
13. Psychiatric Treatment of the Medically III, edited by Robert G. Robinson and
William R.Yates
14. Medical Management of the Violent Patient: Clinical Assessment and
Therapy, edited by Kenneth Tardiff
15. Bipolar Disorders: Basic Mechanisms and Therapeutic Implications, edited by
Jair C.Soares and Samuel Gershon
16. Schizophrenia: A New Guide for Clinicians, edited by John G. Csernansky
17. Polypharmacy in Psychiatry, edited by S.Nassir Ghaemi
18. Pharmacotherapy for Child and Adolescent Psychiatric Disorders: Second
Edition, Revised and Expanded, David R.Rosenberg, Pablo A.Davanzo, and Samuel
Gershon
19. Brain Imaging in Affective Disorders, edited by Jair C.Soares
20. Handbook of Medical Psychiatry, edited by Jair C.Soares and Samuel Gershon
21. Handbook of Depression and Anxiety: Second Edition, Revised and
Expanded, edited by Siegfried Kasper, Johan A.den Boer, and J.M.Ad Sitsen
22. Aggression: Psychiatric Assessment and Treatment, edited by Emil F.Coccaro
23. Depression in Later Life: A Multidisciplinary Psychiatric Approach, edited by
James M.Ellison and Sumer Verma
 Clinical Handbook of
Eating Disorders
An Integrated Approach
edited by

Timothy D.Brewerton
Medical University of South Carolina Charleston, South
Carolina, U.S.A.

MARCEL DEKKER, INC.

NEW YORK • BASEL
 This edition published in the Taylor & Francis e-Library, 2005.
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This book is inspired by and dedicated to all my most
important teachers—my patients.
 Foreword

It is surprising that the literature on eating disorders has taken a very long time
to blossom. The original descriptions of anorexia nervosa by Gull and Lasègue date
back to 1874 and 1873 respectively, but there were long delays before its
recognition as a diagnostic entity. In its early editions, DSM merely labelled
anorexia nervosa as a gastrointestinal reaction or a feeding disturbance. It was
only in 1980, in DSM-III, that the “eating disorders” category was created and
the diagnostic criteria originally formulated by clinicians in the early 1970s
given a seal of approval. Bulimia nervosa was first described in 1979 and correctly
accorded this term in DSM-IIIR in 1987. Proposals for the recognition of a new
disorder, binge eating disorder, were put forward in the early 1990s, and
accorded grudging recognition in an appendix of DSM-IV in 1994.
The expansion of our field of study owes a great deal to the assiduous
research carried out by clinicians and scientists during the past 40 years, but
there is an additional reason not sufficiently recognised. This is the fact that
anorexia nervosa is an illness which has undergone profound changes over time.
It is not clear when this transformation began but the key socio-cultural changes
made an impact during the 1960s or even earlier. The actual increase in the
incidence of anorexia nervosa may have been fairly modest, but there has been
an outburst of eating disorders as a whole. Since the first description of the
syndrome of bulimia nervosa in 1979, its incidence has reached twice that of
anorexia nervosa. There has been an even larger number of patients with less
specified eating disorders. This proliferation explains in part why our subject
matter has become more varied and complex, and has given rise to a growing
clinical and scientific literature.
An important causative factor for the transformation of anorexia nervosa into
related disorders, is the cult of thinness which has pervaded modern westernised
and industrial societies. The components of the cult of thinness and its impact
have aroused much interest. In 1988, the social historian Joan Jacobs Brumberg
expressed deep concern about the social pressures promoting anorexia
nervosa and other eating disorders. She listed among the culprits magazines
 FOREWORD ix

disseminating weight reducing diets, the fashion industry catering for the
slimmer figure, and television attributing sexual allure and professional success
to the possession of a svelte figure. These concerns seem at face value to be
entirely justified. She went further, however, in describing how Americans are
competitive even about a disease and regretted what she called “an army of
health professionals and a deluge of publications and conferences since the
1970s.” Presumably these observations were made tongue in cheek and have
fortunately not deterred Professor Brewerton and his team of contributors from
producing this new handbook much needed to do justice to the growth of our
subject.
The handbook aims at providing an integrated approach. The first feature of
integration that immediately strikes the reader is the full cover given to the well-
established disorders—not only anorexia and bulimia nervosa, but binge eating
disorder (BED) as well, and sometimes obesity is thrown in for good measure.
This has led the authors sometimes having to concede that there are only slender
research findings available, especially in BED. For example, there are no
randomised controlled trials for the evaluation of the psychological treatments
and very few on pharmacological agents in this disorder. Yet this negative
statement is useful because it demonstrates the gaps that remain to be filled.
Similarly, the chapter on Risk Factors in the various eating disorders frankly
admits that the number of studies into BED are very small, owing to the recency
of defining its research criteria.
Also important in the editor’s mission of integration is the convergence of the
main avenues of investigation—the psychosocial, the biomedical and the study of
personality. This handbook adheres therefore to the multidimensional
perspective first put forward in 1982 by Garfinkel and Garner. The significance
of this commitment should not be under-estimated. For example, Campbell in
1995 boldly asserted that the term “multifactorial,” although popular in
psychiatry, has little explanatory power and may simply serve as a cloak to
conceal our ignorance. His plea was to insist on research seeking a unitary and
necessary causal element as has been possible in many physical illnesses.
Unfortunately this worthwhile goal remains just as elusive now as it was in
1995. It remains important practically to examine risk factors in the various
fields of endeavour—sociocultural, psychological, and biomedical—because
this approach ensures that no field of study is neglected. What is particularly
striking in this handbook is the breadth and erudition of the chapters devoted to
the biomedical approach which range from genetics and molecular biology to
neuroendocrine, neuropeptide, and neurotransmitter disturbances, and finally
opens the hopeful prospects of brain imaging in patients with eating disorders.
A striking feature of the handbook is a strict objectivity in assessing the
relevant literature. In the overview of risk factors for each of the eating
x FOREWORD

disorders, the authors rightly confine their appraisal to combinations of

symptoms forming syndromes and not the symptoms themselves. Their method
of establishing causality is a demanding one. They require that the factors
suspected of causing an eating disorder are indeed precursors to the illness
itself. Consequently they largely reject the findings of mere correlations in
cross-sectional studies, and express a strong preference for prospective
longitudinal studies. These are rather rare, and thus they are obliged to use
“retrospective correlates,” meaning factors shown to predate the onset of the
disorder according to the subjects’ self-report. This stark self-discipline leads to
a drastic pruning of our previously cherished lists of causal factors, such as
family interaction and perfectionism. We are left with the following shortened
list: gender, ethnicity, higher BMI, childhood eating problems, sexual abuse,
psychiatric morbidity, low self-esteem, weight concerns and dieting.
It cannot be said that the handbook is unduly rigid in insisting on objectivity.
Fluidity has been maintained and one example will suffice. In recent years the
concept of co-morbidity has entered the domain of psychiatric disorders, and
particularly eating disorders. The term “co-morbidity” features in several
chapters ranging from the co-existence of different psychiatric symptoms, to the
secondary complications from nutritional disturbances in anorexia and bulimia
nervosa. In his chapter, Dr. Brewerton expresses the view that co-morbidity is
the rule rather than the exception, and he ingeniously finds aetiological links in
the way trauma and victimisation are apt to result in a post-traumatic stress
disorder, co-morbid with an eating disorder in some patients. In case this
fluidity is thought to be excessive, there is a suitable corrective in the chapter
dealing specifically with co-morbidity, where clear definitions and illustrations
of the multiple use of this term are provided. There is also a timely warning to
avoid co-morbidity that arises as an artefact from overlapping diagnostic
criteria.
In the field of treatment, flexibility of approach is usually an advantage, and
this is certainly illustrated in the chapter on family evaluation and therapy. The
role of the family in the genesis of eating disorders remains uncertain and
controversial. In this chapter the arguments are presented fairly and from a
historical prospective. Justice is done to the different schools of family therapy,
including the Maudsley model. Due credit is given to the systematic evaluation
of family therapy through randomised control trials undertaken by the Maudsley
school. The contributors believe the value of these trials, at least in anorexia
nervosa. On the other hand they also recognise that there may be a place for family
therapy in bulimia nervosa and binge eating disorder where such studies are
sparse or non-existent. Here is another example of integration, this time
between research-based and clinical approaches.
 FOREWORD xi

Finally, a neat example of integration is provided in the very first chapter,

“Diagnostic Issues in Eating Disorders.” Leaning on the work of Sing Lee in
Hong Kong, the contributors propose a new approach to the diagnostic criteria
for anorexia nervosa, dividing them between cultureindependent criteria (e.g.,
deliberate food avoidance), and criteria which are culture-specific. The latter
include a fear of fatness in western patients, and a different reason for food
avoidance in Chinese patients, namely a desire for an enhanced spiritual or
religious experience.
This Clinical Handbook can be warmly recommended to clinicians and clinical
scientists, whether their main interest is in understanding the nature of eating
disorders or treating the patients suffering from them. Dr. Brewerton is to be
congratulated on designing a handbook with a coherent structure and
assembling a team of authors who display both erudition and well-balanced
judgement.
Gerald Russell MD, FRCP, FRCPEd., FRCPsych. (Hon.)
Emeritus Professor of Psychiatry
Consultant Psychiatrist
The Priory Hospital Hayes Grove
Bromley, Kent, England

REFERENCES

Brumberg JJ. Fasting Girls: The Emergence of Anorexia Nervosa as a Modern Disease.
Cambridge, Mass: Harvard University Press, 1988.
Campbell PG. What would a causal explanation of the eating disorders look like? In:
Szmukler G, Dare C, Treasure J, eds. Handbook of Eating Disorder: Theory,
Treatment and Research. Chichester: Wiley, 1995:49–64.
Garfinkel PE, Garner DM. Anorexia Nervosa: A Multidimensional Perspective. New
York: Brunner Mazel, 1982.
Lee S, Ho TP, Hsu LKG. Fat-phobic and non-fat phobic anorexia nervosa: a comparative
study of 70 Chinese patients in Hong Kong. Psychological Medicine 1993; 23:
999–1017.
 Preface

Eating is a basic drive that is taken for granted by most people. However,
disorders of human eating behavior, including eating and feeding disorders, have
been of increasing interest and importance to clinicians over the last several
decades. This has been in part due to their increasing prevalence and the realization
that they are associated with marked degrees of an array of medical and
psychiatric comorbidities, as well as significant mortality. Parallel to other areas
in medicine, psychiatry, and psychology, progress has been swift (although
never fast enough), and this book attempts to present a concise, integrated and
up-to-date overview of the scientific advancement to date in this knowledge
base. This perspective is designed to be of particular interest and relevance to
the clinical practitioner, but it also has potential appeal for students, scholars
and researchers alike. Areas covered in this book include diagnosis and
assessment, developmental perspectives, epidemiology, course of illness,
etiology, specific and nonspecific risk factors, medical and psychiatric
comorbidity, and various treatment approaches and perspectives, including
speculations about future directions in the field. These topics are organized into
4 basic sections: (I) Diagnosis, Epidemiology, and Course (Chapters 1–5); (II)
Risk Factors, Etiology, and Comorbidity (Chapters 6–10); (III) Psychobiology
(Chapters11–14); and (IV) Treatment (Chapters 15–23).
In Chapter 1, Dr. Blake Woodside and Richelle Twose provide a modern
overview of the diagnosis and assessment of the eating disorders, not only from
the perspective of an evolving DSM, which has had its limitations, but also from
the perspective of selective populations, such as men, the very young, and the
very old, who have eating disorders. Furthermore, the authors propose and
explain the rationale for a new classification scheme for anorexia nervosa (AN)
that is “culture-independent.” In this chapter the authors underscore the fact
that accurate diagnosis is the foundation of effective treatment interventions. In
an Appendix to this chapter a very helpful outline of a sample clinical diagnostic
interview that is suitable for distinguishing between AN, bulimia nervosa (BN)
and binge eating disorder (BED) is provided.
 PREFACE xiii

In Chapter 2, Drs. Jacqueline Carter, Traci McFarlane, and Marion Olmsted

extend the discussion about diagnosis into the area of assessment and review the
latest information on the most common and reliable psychometric instruments
used in the assessment and screening of eating disorder patients. Structured
interviews, self-report instruments, and motivation to change assessment tools
used in the evaluation of patients with eating disorders are covered. In addition,
structured interviews and self-report instruments used in the measurement of
comorbid psychopathology are reviewed, as well as some family function
assessment tools.
In Chapter 3, Dr. Dasha Nichols examines feeding disorders in infancy and
early childhood, such as rumination, pica, post-traumatic feeding disorder,
selective or picky eating, and general food refusal, which are increasingly
recognized clinically in pediatric populations. The complex interplay between
genetic factors and psycho-social factors, such as problematic parent-child
interactions, are discussed. Furthermore, the potential links between feeding
disorders of infancy and early childhood and eating disorders that occur later in
life are discussed.
In Chapter 4, Drs. Maria Råstam, Christopher Gillberg, Daphne van Hoeken
and Hans Hoek review studies to date on the epidemiology of disordered eating
and the formal eating disorders from a developmental perspective. Although
concentrated in the second and third decades of life, disordered eating and
eating disorders occur across the lifespan. In addition to age factors, gender and
cultural differences are also highlighted, which shed further light on the nature-
nurture interaction.
In Chapter 5, Drs. Pamela Keel and David Herzog provide an appraisal on
the long-term outcome, course and mortality of these potentially lifethreatening
illnesses. Although much remains to be learned in this area, the known
prognostic indicators for recovery and/or relapse are reviewed, as are the
results on the impact of treatment on outcome.
In Chapter 6, Dr. Corinna Jacobi, Lisette Morris, and Dr. Martina de Zwaan
provide a highly integrated and critically comprehensive overview of known risk
factors, both specific and nonspecific, for the development of AN, BN and BED.
Of particular interest to the field is the issue of causation, which serves to guide
treatment. Historically, there has tended to be a polarization of thinking about
etiology into classical nature vs. nurture arenas, but each pole falls short when it
attempts to stand alone. Available data clearly point to an interplay of factors
that cut across these classical divisions and point to an interactive model across
the life span. There does not appear to be only one cause of eating disorders,
any more so than there is only one cause of mood or anxiety disorders. The
“action is in the interaction,” as the anonymous saying goes.
xiv PREFACE

In Chapter 7, using a wealth of twin and family studies, Dr. Cindy Bulik
explores an exploding area of research and its profound clinical ramifications in
a chapter on the role of genetics in the eating disorders. These data underscore
the importance of biological factors in the development of all types of eating
disorders. However, because genetic factors do not explain 100% of the
variance, they also point out the limitations of genetics as an explanatory
paradigm and lend credence to the impact of important psychosocial forces in
shaping these disorders, perhaps by triggering and interacting with underlying
genetic and biological mechanisms.
In Chapter 8, Dr. Lisa Lilenfeld provides a comprehensive overview of axis I
psychiatric comorbidity that can be associated with AN, BN and BED.
Relationships with mood, anxiety, substance use, impulse control, psychotic,
dissociative, somatoform, attention-deficit, and disruptive behavior disorders
are all described, although the emphasis is on the most common co-occurring
conditions—mood, anxiety, and substance use disorders.
In Chapter 9, Drs. Howard Steiger and Kenneth Bruce look at the
increasingly recognized role of premorbid personality traits in the development
and perpetuation of the eating disorders. In addition, comorbid axis II
personality disorders that are typically associated with the eating disorders are
examined in depth. The implications of these data for the etiology and
treatment of eating disorders is a major focus of discussion in this chapter.
In Chapter 10, Drs. Pauline Powers and Yvonne Bannon examine in detail
the spectrum of medical (axis III) comorbidities associated with the various
eating disorders. Eating disorders are known to adversely affect literally every
organ system in the body, and it behooves the clinician to be informed of these
potentially irreversible and life-threatening problems. The importance of
working with a team of specialists, including a primary care physician who
understands and can treat these associated medical conditions is emphasized.
In Chapter 11, Dr. Howard Steiger and myself discuss neurotransmitter
dysregulation in the eating disorders. Primary focus is on the monoamines
(serotonin, norepinephrine, and dopamine), with special reference to
serotonin, which has been repeatedly found to be intimately involved in the
pathophysiology as well as the neuropsychopharmacology of the eating
disorders. A table that links various phenomenological aspects associated with
the eating disorders to each of these three neurotransmitter systems provides a
helpful perspective. Just as there is no one cause of the eating disorders, there is
also not just one neurotransmitter or neurochemical system involved in these
complex conditions.
Likewise, in Chapter 12, Drs. Ursula Bailer and Walter Kaye review the
fundamental areas of neuroendocrine and neuropeptide dysregulation in the
 PREFACE xv

eating disorders, which underlie many of their clinical manifestations, including

core symptoms as well as their medical and psychiatric comorbidities.
In Chapter 13, Drs. Janet Treasure and Rudolph Uher review data from the
emerging area of brain imaging of the eating disorders, which provide further
insights into the causes and underlying brain mechanisms involved in these
tenacious conditions. Although functional brain imaging of individual eating
disorder cases has not reached the status of clinical application as of yet, the
potential for this approach in the future and the immediate clinical implications
of these group comparison studies will be expounded.
In Chapter 14, Dr. Dorothy Grice gives an overview of the role of molecular
biology in elucidating the role of genes in the etiology of the eating disorders.
Dr. Grice takes us beyond the traditional genetic methodology of twin, family,
and adoption studies into the modern realm of genetic association analyses used
to identify genes, and she provides an up-to-date appraisal of this rapidly
changing field as applied to the eating disorders.
In Chapter 15, Dr. Wayne Bowers, Dr. Arnold Andersen and Kaye Evans
explain the indications for and role of inpatient and partial hospitalization in the
treatment of patients with eating disorders. In certain clinical situations, such as
low-weight AN, or BN with severe medical and/or psychiatric comorbidity, a
structured setting is often required in order to provide the level of intensity of
care required to significantly impact these conditions. This chapter provides the
theoretical basis and specific guidelines for this often life-saving level of
treatment.
In Chapter 16, nutritionists Jillian Croll and Dr. Dianne NeumarkSztainer
expound on the basics of the practice of nutrition counseling for AN, BN, and
BED. This chapter underscores the need for a multidisciplinary approach toward
all of the eating disorders in which a knowledgeable nutritionist is involved. The
authors guide the reader through the components of a comprehensive nutritional
assessment and provide the fundamentals of nutritional rehabilitation and
weight restoration/maintenance as well as their scientific basis. The authors also
provide a daily food and feelings journal, as well as sample meal plans for
various daily caloric intake levels.
In Chapter 17, Drs. Stephen Wonderlich, Jim Mitchell, Lorraine
SwanKremier, Scott Crow, and Carol Peterson provide an overview of
cognitivebehavioral therapy (CBT) in the treatment of the eating disorders,
particularly in the outpatient setting. CBT is clearly the most extensively
studied and best empirically supported psychotherapeutic approach to the eating
disorders, especially for bulimic disorders, and its fundamental principles and
components are expounded. The authors also provide a food and liquid
monitoring form that can be used by patients to identify contextual cues
(thoughts, feelings, circumstances) associated with eating disordered behaviors.
xvi PREFACE

In Chapter 18, Dr. Deb Marcontell Michel and Susan Willard, M.S.W.
provide an overview of family evaluation and therapy for AN, BN and BED.
Basic concepts and principles of family therapy are described, as is the history of
its application in the management of eating disorders. The family characteristics
of individuals with eating disorders are appraised, and the components of a
family evaluation are illustrated. In addition, common approaches and issues
seen in the treatment of eating disorders are discussed.
In Chapter 19, Drs. Joy Jacobs, J.D., Robinson Welch, and Denise Wilfley
instruct us on the principles of Interpersonal Psychotherapy (IPT) for AN, BN
and BED. Originally developed for the treatment of depression, IPT has been
successfully adapted to the treatment of BN and BED and has been empirically
validated for these conditions. The authors review the theoretical foundations of
IPT and discuss the role of interpersonal functioning in the eating disorders. The
basic concepts of IPT in the treatment of eating disorders are explained, as well
as its treatment structure, therapeutic stance and typical phases of evolution.
Finally, the authors review data to date on outcome studies of the use of IPT in
the treatment of eating disorders.
In Chapter 20, Drs. Marsha Marcus and Michele Levine bring us up to speed
on the powerful principles and techniques of Dialectical Behavior Therapy
(DBT) as applied to the treatment of eating disorders. The authors review the
philosophy and assumptions underlying DBT and discuss the modes of
treatment used in this approach. The authors also provide a DBT diary card
adapted for use in patients with eating disorders.
In Chapter 21, Drs. Joanna Steinglass and Timothy Walsh update the reader
on the role of psychopharmacology in the treatment of AN, BN and BED. Unlike
some psychiatric disorders, psychopharmacologic treatment alone is neither
sufficient nor optimal for the treatment of any of the eating disorders, so it
should be ideally conceived as an adjunct to appropriate psychotherapeutic
approaches. This is especially true for AN for reasons that are elucidated. In this
chapter current and realistic guidelines and limitations for using
psychopharmacologic agents appropriate for these and related conditions are
provided.
In Chapter 22, I review the recent literature on the role of victimization in
eating disorders and related psychiatric comorbidity. A host of controlled studies
now clearly implicate victimization experiences, especially childhood sexual
abuse and subsequent post-traumatic stress disorder (PTSD) or symptoms, as
important risk factors in the development of BN, and perhaps AN, binge-purge
type, BED, and severe obesity (but not AN, restricting type). In addition,
victimization experiences are associated with a host of commonly seen
comorbid psychiatric disorders, including mood, anxiety, substance use,
dissociative, somatoform, impulse control, disruptive behavior, and personality
 PREFACE xvii

disorders. The implications of these data for the understanding of the etiology
of eating disorders and associated psychiatric comorbidity, as well as for their
treatment in clinical practice, are highlighted. Specific principles or guidelines
used to approach the comorbid eating disordered patient are provided.
In Chapter 23, Dr. Joel Yager relies on his extensive experience, knowledge
and creative vision to speculate about future directions in the management of
eating disorders. Dr. Yager explores several areas, including future directions in
diagnosis, epidemiology, molecular genetic research, other biological
investigations, biological interventions, psychosocial interventions, and systems
of care. In addition, the impact of computers and information technology on
eating disorders management is explored.
I would like to earnestly thank all of these outstanding contributors. It is my
sincerest wish that the knowledge imparted to the reader will ultimately lead to
more lives saved, enhanced recovery from these formidable conditions, and less
suffering by patients and their loved ones. In addition, may it inspire continued
research and further advances in this field, without which this book would not
have been feasible.
Timothy D.Brewerton, M.D., D.F.A.P.A., F.A.E.D.
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