death related themes in anorexia nervosa: a practical exploration

Journal of Adolescence 1990, 13, 31 l-326

Death related themes in anorexia nervosa: a practical exploration

JANICE RUSSELL”, GEORGE HALASZ AND PIERRE J. V. BEUMONT

On the basis of an extensive literature review, Jackson and Davidson (1986) suggested that the theme of death may constitute an integral part of the psychodynamic aetiology of anorexia nervosa. This paper describes an attempt to explore this contention using a structured questionnaire in a group of adolescent patients to examine experiences, concepts of and attitudes concerning death. Comparison of the responses of this group with those of age matched school student controls and recovered patients revealed qualitative and quantitative differences which lent some support to the hypothesis. It is concluded that death related themes are of significance in the understanding and management of this illness.

INTRODUCTION

The cadaveric appearance of emaciated patients with anorexia nervosa suggests a state of mind in which death figures prominently. This seem- ingly obvious association has received scant attention in recent literature, possibly as a result of increasingly efficacious refeeding programmes which detract attention from the sizeable rates of relapse, chronicity and mortality which still attend the condition. More appropriate psychotherapy might be expected to improve prognosis but the inner worlds of these patients are all too often seen as dauntingly inaccessible. Thus, any area of insight is of potential value in management.

Weight losing behaviour may be seen as a way of regaining some illusory sense of control (Galdston, 1974) over circumstances which are changing more rapidly during the patient’s adolescence than at any other time before. The concurrence of loss and change related to life events, both expected and unexpected, serves to increase the adolescent’s sense of ineffectiveness and insecurity. Jackson and Davidson (1986) described anorexia nervosa in terms of risk taking, game playing behaviour which involves a magical

“Reprint requests should be addressed to Dr J. Russell, Room 8, Clinical Science Building, Repatriation General Hospital, Hospital Road Concord NSW 2139, Australia.

014I&1971/90/040311 + 16 $03.00/O 01990 The Association for the Psychiatric Study of Adolescents

312 J. RUSSELL ET AL.

wish to gain control and thus to prevent unexpected loss or threat. The patients’ apparent denial of the seriousness of their physical condition can be related to universal themes of invulnerability and the denial of one’s human frailty and mortality, themes likely to be brought into focus in the context of loss, bereavement, normative crisis and major life events. Be- cause the sensitive and predisposed youngster interprets even positive life events in a negative way, her engagement in anorexic behaviour represents an attempt to gain control and return to the status quo. Anorexia nervosa may represent the paradoxical result of this struggle whereby death is simul- taneously defied and risked.

For some, the illness may be the attempted solution of a painful dilemma arising out of separation anxiety and conflict. In this context, patients with anorexia nervosa have been said to suffer “survivor guilt” (Friedman, 1985) related to an unconscious fear that to separate would deplete those from whom one had become autonomous. This often appears to be the case where a child has been sensitized through early separation experiences or by overprotective, depressed, phobic or otherwise dysfunctional parents who themselves may have suffered early separation trauma.

As a major adolescent task, identity formation requires an ability to separate. In anorexia nervosa, there is difficulty at this level which Goodsitt (1985) suggested is attended by intense hostility and frustration. The patient perceives her attempts at individuation and identity formation thwarted, then cruelly “taunts” her parents with her “concentration camp appearance”. However, the prevailing view has been that patients deny that they are risking death (Strober, 1988).

This study represents an attempt to examine the hypothesis that death related themes are salient to the psychodynamics of anorexia nervosa. Its aim was to elicit information concerning the experience of bereavement and certain life events along with attitudes towards and concepts of death in a group of adolescent inpatients being treated for this illness. Comparisons were made with the responses of a group of age-matched normal controls.

METHODS AND PATIENTS

A structured questionnaire, the “Young Persons’ Attitude to Death & Dying” (Halasz, 1986, see Appendix 1) was used. This instrument has been administered to students aged 13 to 18 from a comprehensive high school in Melbourne Australia (Halasz, 1986), providing control data for the age groups 12-13 (grade 7) and 16-17 (grade 11). The responses of 238 students were surveyed in these two groups. The questionnaire consists of two parts: the first contains identification data and includes questions con-

DEATH THEMES IN ANOREXIA NERVOSA 313

cerning deaths in the family and life events experienced by the respon- dent; the second part specifically examines death related attitudes and concepts of death. The last question is unstructured, allowing the respon- dent to add anything which he or she feels is important.

A further brief questionnaire (Appendix 2) was administered which surveyed aspects of the patient’s illness, e.g. current and minimum weight, times in hospital, duration etc. A question was included which asked the patients to add any other information considered relevant to their eating disorder.

All the patients who participated were judged by their treating clin- icians (the authors: J. R., G. H. and P. B.) to be sufficiently low in weight and/or disturbed in behaviour to warrant treatment in hospital, although one girl had refused hospitalization and was being treated as an outpatient. All had recently fulfilled DSM-III-R diagnostic criteria for anorexia nervosa. The majority completed the questionnaire soon after admission to hospital, a smaller number later during treatment. Completion of the questionnaire was voluntary and no patients refused. There were 26 girls (aged 12-19) and two boys (aged 16 and 18) in the group. Six patients (all female) were tested again after refeeding and weight gain to within a few kilo- grams of the target weight range. The normal identical twins of two patients were also asked to complete the questionnaire as a unique form of normal controls.

RESULTS

Compliance

Unlike the normals, some of whom declined to answer specific questions, the compliance rate in the anorexic patients was close to 100 per cent for all questions l-17, i.e. they wrote something in answer to every item. Compliance rate in normals ranged from 76 per cent (Question 13- “do the dead dream?“) to 100 per cent compliance (Question lO-“does everybody eventually die?” to which 96 per cent answered in the affirm- ative). However, in the open ended question (No. 18 which asked for “any other ideas you may have”), compliance was similar for patients (38.5 per cent) and the younger age controls (38.2 per cent), although the content and manner of response differed (See Table 1).

The answers of normals to the unstructured questions tended to be brief and practical, e.g. “hard to answer because I’m not dead and don’t intend to go until I’m about 80” or “I don’t like the sound of death”. Others made reference to religion, euthanasia and bereavement, e.g. “. . . the


Table 1. Compliance with question 18

Anorexia nervosa Grade 7 Grade 11 (N=34) (N=122) (N=116)

Patients responding Controls responding Controls responding (13/34) 38.2% (47/122) 38.5% (63/116) 54.3%

Acute Pts. (12/28) 42.9%

Retest (l/6) 16.6%

questions were good and made me realize how I felt when my nana died last year”, “I don’t really believe in religion, heaven etc . . . death is natural and without it life would be boring”. Some were flippant and/or critical of the questionnaire or its author but always in simple straightforward terms. In contrast, the anorexic patients wrote long complex answers revealing much about themselves and their illness or making novel suggestions e.g. one 17-year-old girl wrote “why can’t we all die at the same time? It would save a lot of pain, hurt and confusion”. A 19-year-old girl with a chronic low grade illness wrote a lengthy intellectualized account suggesting that death might be “a new dimension . . . a new form of energy . . . we have assumed our environment and ourselves and are free (after death?) to as- sume a completely different set of rules and games of existing” in keeping with her engagement in over-exercise and her need for obsessional control. A 14-year-old girl, partly weight recovered, asked “Why about death and not life? I mean why life? No one knows. It’s the concepts we’re taught and the methods of working through it until our time is over. A strange questionnaire-something I don’t think much of anymore. When I was sick I thought it wouldn’t matter much if I died as it would all go on any- way. But now I want to join in!“. A 16-year-old male patient wrote in response “I thought the questions were appropriate and interesting, it brought about some subjects I would not really have thought about . . . such as can the dead dream. But most were very good questions as it en- abled you to realize the emotions of yourself towards death”. The 17- year-old girl who angrily refused hospitalization described the questions as “pathetic . . . as it is asking us to generalize when people like myself have only witnessed the reactions of a few people . . . it is impossible to ever re- cover from death”. When she recovered, this girl wrote “it felt a lot different answering these questions, now it took me all of about five minutes, although most of the answers are relatively similar (if I remember rightly?)“.

DEATH THEMES IN ANOREXIA NERVOSA

Table 2. Family loss events in anorexic and control adolescents

Controls

315

Subjects A.N. patients Grade 7 Grade 11

(N=28) (N=122) (N=116)

a. Both parents alive and at home

b. Both parents alive; sep/divorced

c. One parent dead d. Both parents dead e. Brother/sister dead f. Close relative died g. A pet has died

22 (78.5)” 104 (88) 105 (91)

5 (17.9) 12 (10) 9 (8) 1 (3.6) 2 (2) 1 (1)

- - - - 4 (3) 4 (3)

13 (46.2) 74 (61) 64 (55) 19 (67.9) 86 (70) 86 (74)

“The figures in brackets represent percentages.

Life events

Overall, the life event, (or more properly, family loss event) data shown in Table 2 revealed little difference between anorexia nervosa patients and normal controls. Thus, bereavement was apparently no more frequent in the patient group. However, parental separation/divorce was acknowl- edged in 18 per cent of the anorexic patients compared with 10 per cent and 8 per cent for year 7 and year 11 controls, respectively. A small number of patients spoke of the death of close friends and another patient had experienced the death in a motor vehicle accident of her favourite nurse while she was in hospital.

Readministration of questionnaire after weight gain

Following weight recovery the patients were more like controls in their approach to the questionnaire, e.g. they made flippant comments and had clearly spent less time considering their responses.

A number of minor changes and inconsistencies were also noted on readministration of the questionnaire after weight gain. Some were surprising in view of the usual conforming perfectionism of these patients, but osten- sibly of little consequence, while others suggested a change in attitude or cognition with recovery. Examples of the first type of change included adding dates for losses of close relative and pet; addition, deletion or changing the age at which a life event was experienced; or a change in reported frequency of religious observances. One patient who initially described


“the process of feeling after the death of someone”, on readmission left this blank, whereas two girls who initially declined to answer the unstructured questions (question 18 in part 2 of the Attitude to Death questionnaire and question 17 of the Eating Disorder questionnaire), wrote at some length on the second occasion. One such response was “prevention or proper help is a desperate need for eating disorders, especially for G.P.s. Catch it and treat it before it gets out of control”. The differing responses to question 18 on readministration in one 17-year-old girl has already been quoted. The latter response suggested a change in attitude and interest. One patient included starvation in a list of seven causes of death (question 8) but later listed only four and omitted starvation. A female anorexic patient whose normal identical twin was also tested, originally reported having lost a relative without noting the year or her own age, which she added on readministration. Her normal twin did not record this life event at all.

Perceived causes of death

Responses to question 8 “what causes death?” are interesting. “Suicide” and “lack of food” were amongst the responses from nine of 34 patients (28 on the first administration and six on the second), i.e. more than 25 per cent of anorexic patients overall and 28.7 per cent of the acute cases. Normals commonly cited illness, accidents, old age and disease in diminishing order of frequency, and only 4 per cent mentioned suicide. In addition, one patient made a poignant self reference “referring to me . . . neglect to care” and two others cited “things brought on by oneself”. Thus, in 35.7 per cent of patients themes of self neglect/lack of care and suicide were apparent. Whilst the two normal twins gave conventional answers for the question pertain- ing to causes of death, one anorexic twin’s responses included “suicide, murder and assassination”, whilst the other anorexic twin answered “lack of food and water”.

Although as a group the anorexia nervosa patients were less likely to attempt the unstructured question than age matched controls, the answers provided suggested a greater tendency to speculate, hypothesize or fantasize about death and bereavement. In their responses otherwise uncommuni- cative patients shared something of themselves and their inner world. A sub- sequent clinical observation was that the completion of the questionnaire often provided the impetus for discussion concerning loss of family members or close friends, the patient’s reaction to this or his or her observations of the reactions of other family members. Sometimes the losses described later were of a more symbolic nature, e.g. moving house, having friends move away, changing schools, failing an examination, gaining weight at puberty or developing acne.


FIGURE 1. Drawings made by a I7-year-old anorexic girl (weight 35 kg) during a school retreat, one week before presentention.

The postulated preoccupation with death is evidenced by drawings made by the 17-year-old female who refused hospitalization (see Figure 1). She had made the drawings whilst on retreat with her school one week prior to presentation at a weight of 35kg, and a Body Mass Index of 13.5. [Body Mass Index (BMI) is calculated as weight in kg/height (m2). Normal range 20-25 for persons 18 and over, and somewhat lower for younger girls (Beumont et al., 1988).]


Following a precocious puberty at the age of 9, Nerida, the older child of mature age parents, had become moderately obese (as depicted in her drawings of herself looking like an elephant from the rear and her tran-

sition from normal baby to obese unhappy teenager). She had begun to diet 2-3 years earlier on the advice of a dancing teacher. One year prior to presentation, her maternal grandmother had become terminally ill with carcinoma of the ovary and had “wasted away” by the time of her death five months later. Nerida and her mother departed on an overseas trip soon after the funeral (the trip being depicted by buildings and food items and a forlorn (and thin) Paddington Bear). Weight loss due to restriction and vomiting was severe from this point on, and shown by the crying skeleton, the smiling face in the coffin and a “gift wrapped” coffin above. The patient complained of mood swings (note the smiling and crying faces) and declared a determination to starve even if it resulted in her death. Hospitalization was recommended but Nerida adamantly refused, supported by her father (who later said by way of explanation, that his daughter had threatened to “die” if she weYe admitted to hospital). Nevertheless, in response to the threat of hospitalization, and with supervision from a nutritionist, she gained weight as an outpatient, stabil- izing at a healthy weight nine months after presentation. At this stage Nerida looked well and cheerful, had begun menstruating again, was said to be coping with her final year of school, socially active and looking forward to making her debut. During her initial visits to her treating psychiatrist she spoke of her feelings concerning the death of her grandmother and her mother’s reactions to this. She also expressed angry feelings towards her parents and their tendency to infantilize and over protect her, along with a determination to “show them” that she could ye- covey without hospitalization. In her most recent interview she preferred to spend the time enthusiastically describing the young man who would be escorting her and the dress she would be wearing to the debut than to talk about how she felt but agreed to complete a retest questionnaire- which indicated her changed attitude. At the time of writing she remains well 25 months after presentation.

DISCUSSION

The questionnaire did not examine the question of bereavement outside the family. Furthermore, the reliability and validity of life-event checklists have been questioned (Monroe, 1982; Rabkin & Struening, 1976). Al- though Jackson and Davidson (1986) referred particularly to “secondary” anorexia nervosa in their historical literature review, distinction between


this and the “primary” condition is controversial. Consequently, an attempt was made here to assess the importance of death related themes in patients selected simply on the basis of the DSM-III-R diagnostic criteria for anorexia nervosa and in whom hospital treatment had been recommended. They were not divided into sub-groups.

The apparent willingness of the patients to answer the structured items so meticulously not only distinguished them from normals but suggested a particular interest or even a preoccupation with these themes. Alterna- tively, it may merely have reflected their compliance with adult requests, a need to please and/or an abundance of time due to being in hospital. Anorexia nervosa patients are known to be perfectionistic and show strong obsessional personality traits (Smart et al., 1976). However, their concern and concepts appeared to be no less realistic or mature than that of normal peers and they certainly did not avoid the issues raised.

Much has been written concerning the significance of life events as aeti- ological factors in psychiatric illness in adult patients (Brown and Harris 1978), in children (Coddington, 1972) and in anorexia nervosa (Ryle, 1936; Kay and Leigh, 1954; Russell et al., 1988). Similarly, Beumont et al. (1978) reported that a bereavement had preceded the onset of anorexia nervosa in 11 of their 34 patients, and a severe life-threatening illness in a relative in a further two. Coddington (1972) demonstrated that an age-related curve of social readjustment scores mirrors the growth curve with a similar velocity of change between 9-14 years. This is hardly surprising as adolescence is a time of major life change. Thus, the fact that many normals and anorexia nervosa patients reported death of close relatives probably merely reflects ageing of the older generation by the time the subjects reach adolescence. However, in some youngsters presenting with anorexia nervosa, accelerated weight losing behaviour seemed to have been initiated at the time of bereavement or soon after (although the patients often denied that this event had caused them undue distress). At times the teenager appeared to be expressing parental (usually maternal) grief, but at other times it was clearly the youngster’s own grief at the loss of someone close in his or her first experience of bereavement. In yet other instances, it was not the actual bereavement per se as much as its propensity to precipitate the youngster’s ambivalent engagement in anticipatory grief occasioned by the impending need to achieve the adolescent task of separation. This is likely to be rendered more difficult where the mother/child relationship is disturbed, which is in accordance with

theories suggesting that anorexia nervosa represents a recapitulation of earlier crises in this regard (Winnicott, 1974; Rampling, 1980; Bruch, 1982). It might also be related to Lifton’s notion (as quoted by Jackson and Davidson, 1986) of the anorexic as a “survivor” of a “damaging” (but in the authors’ experience a damaged and emotionally needy) mother.


Patients did not seem to have suffered more actual bereavements than normals, although the trend towards more frequent experience of parental marital disruption in this group might have concealed a larger number of other associated life events. This would support the contention that patients with anorexia nervosa are reacting in a particular way to life events rather than to bereavement per se. The overriding need would appear to be for control and a sense of effectiveness. Perhaps the underlying fear is of separation as exemplified in its extreme by death. Patients can often be made aware of the paradox inherent in their situation whilst being assisted in recognizing and talking about their anxieties.

Certainly anorexic patients frequently made frank reference to “starvation, self neglect and suicide” as causes of death. Patients do verbalize, directly and indirectly, wishes and fears of actually starving to death. Swift et al. (1986) surmised that patients with anorexia nervosa were self damaging, even suicidal, but paradoxically self loving -the therapeutic challenge being to ensure that the latter supervenes. Facilitation and acceptance of the patient’s emerging identity is of great importance here and a major tenet of “self psychology” (Meares, 1987; Goodsitt, 1985). This is a recent, and in the authors’ opinion, appropriate theoretical approach to the psychotherapy of these patients. The risk of suicide remains a major concern and something which the therapist may feel helpless to subvert, particularly in the chronic patient. Jackson and Davidson (1986) drew attention to the therapist’s denial of these issues.

The results of the readministration of the questionnaire after weight restoration suggests that death related preoccupation may be an unstable phenomenon and one which can be readily influenced by therapeutic inter- vention on a physical and/or psychological level. There appears to be a return to “healthy” denial which is said to operate in normal individuals and which is presumably suspended during the process of becoming ill through self starvation. Perhaps recovered patients have less time or interest in accurately completing the questionnaire because their thoughts are on other more age appropriate, life orientated concerns. Another response in recovery was to rationalize the illness and offer suggestions for treatment and prevention.

In conclusion, it is surmised that the theme of death is of practical importance in anorexia nervosa and one which should be addressed in all patients sufficiently ill to require hospitalization. Themes of death feature prominently in the writings of early theorists and the morbid imagery of recovered anorexic patients, as quoted by Jackson and Davidson (1986); they are further evidenced by the observations concerning precipitants and McAll and McAll’s (1980) view that anorexia nervosa may represent a form of ritual mourning. Here such themes were illustrated by adolescent patients’ responses to the Young People’s Attitude to Death Question-


naire (Halasz, 1986). Despite the limitations of data collected by this tech- nique, clinically relevant descriptive material was obtained. Moreover, the instrument proved to be a useful therapeutic tool whereby discussion of actual projected or symbolic losses (e.g. bereavement, developmental crises, major life events and the patient’s own mortality) could be facilitated in a relatively non-threatening and non-intrusive manner. As recovery occurs, following weight restitution, “healthy” denial reasserts itself and the importance of death related themes recedes, concomitant with the patient electing an orientation towards life and the resumption of normative adolescent tasks. With relapse, these morbid issues may reappear, death related preoccupations eventually becoming more firmly entrenched in the older chronic patient in whom the long term mortality rate remains a major concern.

ACKNOWLEDGEMENTS

The authors wish to thank Mr C. Jackson for his continued interest and Drs Marie Bashir and George S?mukler for their assistance in the preparation of this manuscript. We are indebted to “Nerida” for giving us permission to publish her drawings.

REFERENCES

Beumont, P. J. V., Abraham, S. F., Argall, W. J., George, G. C. W. and Glaun, D. E. (1978). The onset of anorexia nervosa Australia and New ZealandJournal of Psy- chiatry, 12, 145-149.

Beumont, P., Al-Alami, and Touyz, S. (1988). Relevance of a standard measurement of undernutrition to the diagnosis of anorexia nervosa: use of Quetelet’s Body Mass Index (BMI). The InternationalJournal of Eating Disorders, 7(3), 399-405.

Brown, G. W. and Harris, T. 0. (1978). Social Origins of Depression. London: Tavistock publications.

Bruch, H. (1982). Anorexia nervosa: therapy and theory. American Journal of Psychiatry, 139(12), 1531-1538.

Coddington, R. D. (1972). The significance of life events as etiological factors in the diseases of children. A study of a normal population. Journal of Psychosomatic Research, l&205-21 3.

Friedman, M. (1985). Survivor guilt in the pathogenesis of anorexia nervosa. Psychiatry, 48,25-39.

Galdston, R. (1974). Mind over matter: observations of 50 patients hospitalized with anorexia nervosa. American Academy of Child Psychiatry, 13,246-263.

Goodsitt, A. (1985). Self psychology and the treatment of anorexia nervosa. In Handbook of Psychotherapy for Anorexia Nervosa and Bulimia, Gamer, D. and Garfinkel, P. (Eds). New York: Guildford Press.


Halasz, G. (1986). Adolescents’ attitudes to death and dying and grief. Abstract of paper presented at RANZCP Section of Child Psychiatry, Annual Meeting, Sydney, September 1986.

Jackson, C. C. and Davidson, G. P. (1986). The anorexic patient as a survivor: the denial of death and death themes in the literature on anorexia nervosa. International Journal of Eating Disorders, S(S), 821-835.

Kay, D. W. K. and Leigh, D. (1954). Natural history, treatment and prognosis of anorexia nervosa based on a study of 38 patients. Journal of Mental Science, 100, 411-431.

Meares, R. (1987). The secret and the self: on a new direction of Psychotherapy. Aus- tralian and New ZealandJournal of Psychiatry, 21, 545-559.

McAIl, R. K. and McAll, F. M. (1980). Ritual mourning in anorexia nervosa. The Lancet, September 13, p.368.

Monroe, A. M. (1982). Assessment of life events: retrospective versus concurrent strategies. Archives General Psychiatry, $606-610.

Rabkin, J. and Struening, E. (1976). Life events stress and illness. Science, 194, 1013- 1020.

Rampling, D. (1980). Abnormal mothering in the genesis of anorexia nervosa. Journal Nervous CY Mental Disorders, 168, 501-504.

Russell, J. D. , Berg, J. and Lawrence, J. (1988). Anorexia tardive: a diagnosis of ex- clusion? Medical Jburnal of Australia, 148, 199-201.

Ryle, J. A. (1936). Anorexia nervosa. The Lancet, October 17, pp.893-899. Strober, M. (1988). Personal communication. Smart, D. E., Beumont, P. J. V. and George, G. C. W. (1976). Some personality char-

acteristics of patients with anorexia nervosa. British Journal of Psychiatry, 128, 57-60.

Swift, W. J., Bushnell, N. J., Hansen, P. and Logemann, T. (1986). Self-concept in adolescent anorexics. American Academy of Child Psychiatry, 25(6), 826-835.

Winnicott, G. (1974). Child Health and the Growth of Love. Middlesex: Penguin Books.

APPENDIX 1

Questionnaire

Young people’s attitude to dying and death

This questionnaire enquires about your attitudes and ideas about dying and death.

There are two sets of questions. PART 1 consists of general questions about your school, date of birth, county of birth etc. Please answer each question.

PART 2 has more specific questions about death. Please attempt to answer each question by writing your answer in the space provided.

When you have finished answering both PART 1 and PART 2. If you wish you may write any other ideas you have at the end of the questionnaire- for example what you thought of the questions, if you have other thoughts that would be important or any other thoughts.


This survey is CONFIDENTIAL as your name does not appear on the questionnaire.

Thank you for taking part in this important survey.

School

Date

PART 1

Please answer each question by filling in the spaces or ticking as appropriate.

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

NAME OF SCHOOL _____________________

SCHOOL GRADE __

DATE OF BIRTH DAY MONTH _ _ YEAR -___

MALE OR FEMALE -------

COUNTRY OF BIRTH ______________ IF NOT AUSTRALIA, YOUR AGE YEARS_ _ _ MONTHS ----

WHEN YOU ARRIVED IN AUSTRALIA

LANGUAGES SPOKEN AT HOME (IF NOT ENGLISH)

RELIGION _--___-------- HOW OFTEN DO YOU ATTEND DAILY___ WEEKLY___ RELIGIOUS EVENTS (e.g. Sunday MONTHLY_ _ _ YEARLY_ _ School, praying with your family) (please tick) NEVER___

FATHER’S OCCUPATION

MOTHER’S OCCUPATION

FAMILY STRUCTURE: (please tick) How old were you when it happened?

YEARS MONTHS

a. Both parents alive & living at home -----

b. Both parents alive but separated or

divorced

c. One parent has died

d. Both parents have died

e. A brother or sister has died

f. A close relative has died

g. If you’ve ever had a pet die

-----

--___

324 J. KUSSELL Ii:?‘ AL.

PART 2

Please attempt to answer each question by writing your answer in the space provided.

1. What does dying mean? ------------

2. What happens to a person ____________ who dies? ____________

3.. Where do the dead go? ------------ ------------ ____________

4. Do the dead have any movement?

5. Can the dead see, hear, feel or think?

6. Can the dead be brought back to life?

7. Can the dead return back to life?

8. What causes death?

9. What functions stop when you die?

_______-----

IO. Does everything eventually die?

11. Does every living thing eventually die?

12. Do the dead feel?

13.

14.

15.

16,

17.

18.


Do the dead dream? ___---__----

------------

Is everyone affected the same way when they die?

Do you think it would be different for you?

___---__----

How do people BEHAVE after the death of someone close:

(a) immediately afterwards ------_----- ------__----

(b) one week later -------_----

(c) one month later -__---__---- ------_-----

(d) one year later

How do people FEEL after the death of someone close:

(a) immediately afterwards --_---__----

(b) one week later

(c) one month later

--_---__---- --_---___---

--_---___--_

(d) one year later

Any other ideas you may have (e.g. what you thought of the questionnaire, other thoughts you may have).


APPENDIX 2

Questions concerning your eating disorder

1. 2.

3. 4.

5.

6. 7.

8. 9. 10.

11.

12.

13.

14.

15.

16.

17.

How long have you had an eating disorder? Is this anorexia nervosa, bulimia or something else? (please specify) How old were you when you began dieting? ________---- Do you? Diet, vomit, overexercise, use laxatives or other pills (circle where applicable) Do other things (please specify) __________-- How many times have you been in hospital before this? ______-__--- What weight are you now (approx.) What weight were you when you came to hospital? What weight do you think you should be? How tall are you? How long have you been in hospital this time? How long (approximately) have you spent in hospital altogether for your eating disorder? Have you had any operations or other serious illnesses and when did this occur? Has anyone else in the family had an operation or serious illness and when was this? Please specify Has anyone else in the family had an eating disorder? Please specify Are you religious? i.e. is your religion important to you Have you been seen by a medical doctor or been admitted to a general hospital because of your eating disorder? Please give details.

Any other information you may wish to provide about your eating disorder

death related themes in anorexia nervosa: a practical exploration

Documents