The Eating Disorders

A. James Giannini Andrew E. Slaby Editors

The Eating Disorders

With 11 Illustrations

Springer-Verlag New York Berlin Heidelberg London Paris Tokyo Hong Kong Barcelona Budapest

A. James Giannini, M.D. Clinical Professor, Psychiatry Ohio State University Columbus, OH 43210, USA and

Andrew E. Slaby, M.D., Ph.D., M.P.H. Medical Director Regent Hospital 425 E. 61th Street New York, NY 10021, USA

P.O. Box 2169 Youngstown, OH 44504, USA

Library of Congress Cataloging-in-Publication Data

The eating disorders 1 [edited by] A. James Giannini, Andrew E. Slaby. p. cm.

Includes bibliographical references and index. ISBN -13: 978-1-4613-8302-4 e-ISBN -13: 978-1-4613-8300-0 DOI: 10.1007/978-1-4613-8300-0 1. Eating disorders. I. Giannini, A. James, 1947-

11. Slaby, Andrew Edmund. [DNLM: 1. Eating Disorders. WM 175 E14612 1993]

RC552.E18E282 1993 616.85'26-dc20 DNLM/DLC for Library of Congress

Printed on acid-free paper. © 1993 Springer-Verlag New York Inc. Softcover reprint of the hardcover 1st edition 1993

93-20481

All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer-Verlag New York, Inc., 175 Fifth Avenue, New York, NY 10010, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, e1ectronic adaptation, computer software, or by similar or dissimilar methodology now known or here-after developed is forbidden. The use of general descriptive names, trade names, trademarks, etc., in this publication, even if the former are not especially identified, is not to be taken as a sign that such names, as understood by the Trade Marks and Merchandise Marks Acts, may accordingly be used freely by anyone. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein.

Production coordinated by Chernow Editorial Services. Inc. and managed by Christin R. Ciresi; Manufacturing supervised by Jacqui Ashri. Typeset by Best-set Typesetter Ltd., Hong Kong

987654321

ISBN-13:978-1-4613-8302-4

Ta luliette Nicole Giannini and locelyn Danielle Giannini

Always there when needed most.

Preface

As fish must swim so must man drink and eat

Examine thy customs of diet

For John eat & drank to drive away Loves pain But all he could do he grew thinner & thinner Tho he eat & drank as much as Ten men for dinner

Some said he had a Wolf in his stomach day and night

Titus Petronius Arbiter

Francis Bacon

William Blake

To paraphrase and cast in contemporary speech observations of the Gothic-era monk Bernard of Clairvaux, the eating disorders may be viewed as a corruption of the social process, a distortion of the body image, and a perversion of bodily processes. It is this multifactorial etiology that makes the diagnosis and treatment of dietary -disorders so difficult and frustrating. Because of social demands and a distorted (body) image, men and women have perverted the simple act of eating into always painful, sometimes tragic, and occasionally deadly outcomes.

The eating disorders fall into three categories. There is obesity-the overconsumption of food, and its antithesis, anorexia-the act of vol­untary starvation. In true Hegelian fashion, there follows the synthesis, bulimia-the voluntary purging of overconsumed amounts of food to produce an anorectic-like countenance. As the contributing authors em­phasize in their chapters, these diseases are not unique to contemporary culture. Rather they are cultural artifacts, created by both men and women, since classical antiquity.

The recognition of these diseases is dependent upon recognizing a disease actually exists: that there is a distortion of the eating process. Both medical and psychiatric etiologies are explored. The use of the clinicallaboratory and neurological examination as an adjunct to medical

vii

viii Preface

and pediatric treatment is explored. Special groups such as the male, the addict, and the geriatrie patient receive attention. In addition to general medieal management, the authors have dealt with ancillary treatment approaches from a dietary and occupational therapeutic perspective. The internationally acclaimed BASH approach is also reviewed. For the physician-manager, there is a chapter describing the initiation and ad­ministration of an eating disorders unit.

This book is intended to be both an introductory clinieal text for the treatment of the eating disorders and a reference guide to clinical practiee. It is the editors' intention that the reader will extract as much from the chapters as did they.

Acknowledgments

The editors would like to thank all of those individuals who assisted in the production of The Eating Disorders. Our senior research assistant, Marian Flaviani and her staff members, Ann Nakoneczie RN and Ann Watkins, helped to coordinate the conte nt of the chapters and to conduct the library search. A special category of gratitude is due to Dr. Louis Zona, director of the Butler Institute of American Art, for permitting us to reproduce the paintings and sketches from the Institute's collection. Also acknowledged is the assistance of Philip Jose Farmer, master science­fiction writer who taught us something of the craft of writing, and the editorial and production staff at Springer-Verlag. Crisis intervention was given p.r.n. by Amy Dyer, Denise Stavana, and Angela DeCapua.

The understanding of different cultural approaches to food and eating was most useful in framing this book. The editors hereby acknowledge the advice and wisdom given in this area. These were given in generous measure by Dr. Ivan Tulevski of Skopje, Macedonia; Dr. Vassos Pyrghos of Nieosea, Cyprus; Prof. Enrico Tempesta of Rome, Italy; Mr. James Biwott of Nairobi, Kenya; Dr. Mohammed EI-Masry of Cairo, Egypt; and Dr. Jorg Beyer of Bonn, Germany. Gratitude is also expressed to editor, Dr. Carmelo Nicolosi, for continuously furnishing us with copies of Ricerca e Salute, a most invaluable resource.

Finally, the senior editor wishes to note his personal debts to Drs. Henry Nasrallah, A.L. Carter Pottash, Mark Gold, and Carlton Turner.

Contents

Preface ........................................ , . . . . . . . . . . . . . . . . . . . . . . . . . Vll

Contributors xv

1. History of Anorexia Nervosa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Andrew E. Slaby and Randall Dwenger

Early Observations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Chlorosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Early Treatment .............................................. 6 Anorexia in Victorian Times . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Gull and Laseque ............................................. 9 The Biological Era ............................................ 11 The Psychoanalytic Era ........................................ 13 Anorexia Today . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Summary..................................................... 15 References ................................................... 16

2. A History of Bulimia A. farnes Giannini

18

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

3. The History of Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Deirdre K. Kocjan and A. farnes Giannini

References .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

4. The Presentation of Obesity .................................... 29 farnes R. Hodge and Erwin A. Maseelall

What is Obesity? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

ix

x Contents

Summary: How the Patient Presents ............................. 40 References ............................................. . . . . . . 42

5. The Biological Basis of Bulimia Peter M. Bolo

44

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Brain Regulation of Appetite and Feeding . . . . . . . . . . . . . . . . . . . . . . . . 45 Bulimia and Affective Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Drug Trials I-Suggested by Theorized Relationship of Bulimia to

Affective Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Drug Trials II-Suggested by Theorized Relationship of Bulimia to

Seizure Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Drug Trials III-Suggested by Theorized Neurotransmitter

Control of Appetite. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

References ................................................... 59

6. Biological Factors in Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 William S. Rea and Irl L. Extein

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Genetics ........... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Perinatal Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Neuroanatomy and Neurochemistry of Eating . . . . . . . . . . . . . . . . . . . . . 67 Nutritional Factors ............................................ 70 Metabolie Factors ........ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Biological Models of Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 References ................................................... 71

7. Clinical Laboratory Aspects of Eating Disorders . . . . . . . . . . . . . . . . . . . 76 David M. Martin, Carlton E. Turner, and Brian K. Long

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 General Laboratory and Medical Considerations. . . . . . . . . . . . . . . . . . . 76 Basal Luteinizing, Follicle Stimulating Hormone, and Gonadotropin

Releasing Factor (GnRF) Challenge Studies .................... 77 Basal Thyroid, Prolactin, Growth Hormone, and TRH

Challenge Testing .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Dexamethasone Suppression Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Drugs of Abuse, Diuretics, and Laxative Testing .................. 83 Additional Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 References ........ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Contents Xl

8. Neuropsychiatrie Approach to the Eating Disorder Patient. . . . . . . . . . 93 David A. Grass

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Medical Mimics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Neuropsychiatrie Investigation .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Clinical Example . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 References ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

9. Anorexia in the Elderly A. farnes Giannini

104

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

10. Depression and Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Russell D. Marx

Frequency of Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Family Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Antidepressant Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Polysomnography ............................................. 118 Positron Emission Tomography ................................. 120 Neuroendocrinology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Neurochemistry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 References ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123

11. Sexual Abuse and Its Relationship to Eating Disorders . . . . . . . . . . . . . 128 Robert H. Laiselle

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132

12. Males with Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Barbara Eller

Anorexia Nervosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Bulimia Nervosa .............................................. 141 Conclusion 144 References ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145

13. The Medical Care of the Patient with an Eating Disorder . . . . . . . . . . . 147 foel R.L. Ehrenkranz

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Endocrine and Metabolie Complications . . . . . . . . . . . . . . . . . . . . . . . . . . 148

XII Contents

Cardiac Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Gastrointestinal Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 References .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155

14. Pediatric Management of Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . 158 Kurt f. Wegner and farnes A. Nard

Anorexia Nervosa and Bulimia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 Specific Organ System Involvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 References ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168

15. The B.A.S.H. Approach. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 Felix E.F. Larocca

Pro gram Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 The "Significant Other" . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 Religion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 Evaluation ................................................... 180 ConcIusion ................................................... 181 References .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183

16. The Hospital Treatment of Eating Disorders . . . . . . . . . . . . . . . . . . . . . . 185 Michael M. Newrnan

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 Indications for Hospitalization .................................. 185 Treatment Interventions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 Treatment Planning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 ConcIusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194 References ...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194

17. The Treatment of Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196 Phillip M. Sinaikin

Defining Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198 The Diet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198 Behavior Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206 Weight Loss Programs and Products ............................. 208 ConcIusion ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211

18. Eating Disorders and Drug and Alcohol Dependency Norrnan S. Miller

213

Contents xiii

Definitions and General Characteristics of the Disorders . . . . . . . . . . . . 214 Prevalence of the Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215 The Co-occurrence of Alcohol and Drug Dependence and Eating

Disorders .................................................. 216 Familial Rates in the Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218 Common Interactions Between the Disorders ..................... 219 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221 Future Research ............................................... 224 References .................................................. . 224

19. Occupational Therapy Treatment of Anorexia Nervosa . . . . . . . . . . . . . 227 David J. Folts, Kent Tigges, and Gary Jackson

Occupational Behavior: A Model of Practice . . . . . . . . . . . . . . . . . . . . . . 227 Treatment Strategies, Assessment, and Treatment

Intervention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231 Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240 References ................................................... 240

20. Occupational Therapy Treatment of Bulimia Nervosa .............. 243 David J. Folts and A. Jarnes Giannini

Bulimia Nervosa .............................................. 243 A Theoretical Model in Treatment of Bulimia Nervosa:

Occupational Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244 Summary.................................................. ... 251 References ................................................... 251

21. Dietary Management of Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . 255 June Ventirniglia

Nutrition Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255 Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258 Anorexia Nervosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258 Bulimia ...................................................... 260 Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261 Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262 References .............. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262

22. Administration and Management of Eating Disorders Units . . . . . . . . . 264 Dorninick L. Flarey

Admission Criteria and Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264 Nutritional Assessment and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 266 Patient Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267

xiv Contents

Quality Assuranee and Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269 Unit Standards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269 Conclusion ................................................... 274 Referenees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274

23. Literary Resourees A. farnes Giannini

276

Birth of the Modern (Paul Johnson). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277 Bonfire of the Vanities (Tom Wolfe) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277 Bread and Choeolate (Francis Brusati) ..................... . . . . . . 277 Deeameron (Giovanni Boeaccio) .......................... . . . . . . 277 Dinner at Eight (George S. Kaufman/Edna Ferber) . . . . . . . . . . . . . . . . 278 Dinner for Adele (Oldrieh Lipsky). . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . 278 English Wayfaring Life in the Middle Ages (1.J. Jessread) .......... 278 fatso (Anne Baneroft) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278 Georgy Girl (Silvio Narizzino) .................................. 278 Good Fellows (Martin Seoreese) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279 Le Morte D'Arthur (Sir Thomas Mallory) ........................ 279 Metamorphosis (Franz Kafka). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279 Nina's Book (Eugene Burdiek) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279 Pantagruel (Franeois Rabelais) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279 Satyrieon (Titus Petronius Arbiter) .............................. 279 Sermons (Bernard of Clairvaux) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280 The Physiology of Taste (Jean-Anthelme Brillat-Savarin) ........... 280 Voss (Theodore White) ........................................ 280

Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281

Contributors

Peter M. Bolo, MD, Director, Adult Treatment Unit, Fair Oaks Hospital, 19E. Prospect Street, Summit, NJ 07901, USA

Randall Dwenger, MD, Director, Adolescent Substance Abuse and Alcohol Ser­vices, The Regent Hospital, 425 E. 61th Street, New York, NY 10021, USA

foel R.L. Ehrenkranz, MD, Associate Professor, Department of Medicine, Col­umbia University, New York, NY 10025, USA

Barbara Eller, MD, Health Insurance Plan of Greater New York, Nassau-Suffolk Mental Health Center, 185 Froehlich Farm Blvd., Woodbury, NY 11797, USA

Ir! L. Extein, MD, Medical Director, Lake Hospital of the Palm Beaches, Lakeworth, FL 33460, USA

Dorninick L. Flarey, RNC, CNAA, MBA, PhD, Associate Administrator/Patient Ca re and ChiefN urse Executive, Youngstown Osteopathic Hospital, Youngstown, OH 44505, USA

David f. Folts, OTR/L, Private Consultant, Occupational Therapy, 3040. Belmont Avenue, Liberty, OH 44505, USA

A. fames Giannini, MD, FCP, FA PA, FRSM, Clinical Professor, Department of Psychiatry, Ohio State University, Columbus, OH 43210; P.O. Box 2169, Youngstown, OH 44504, USA

David A. Gross, MD, FAPA, Palm Beach Evaluation and Treatment Center, Palm Beach, FL 33484, USA

farnes R. Hodge, MD, MA, FAPA, Professor, Department of Psychiatry, North­eastern Ohio UniversitiesCollege of Medicine, Rootstown, OH 44272, USA

xv

xvi Contributors

Gary Jackson, MS, OTR, Director, Rehabilitation Services, Institute of Living, Hartford, er 06106, USA

Deirdre K. Kocjan, LSW, Clinical Director, Chemical Abuse Centers Inc., 5211 Mahoning Avenue, Suite 110, Austintown, OH 44515, USA

Felix E.F. Larocca, MD, Founder and Director, Bulimia and Anorexia Self-Help Center (BASH), St. Louis, MO 63139, USA

Robert H. Loiselle, PhD, FCP, Professor of Psychiatry in Psychology, Northeastern Ohio Universities College of Medicine, Rootstown, OH 44272; P.O. Box 2169, Youngstown, OH 44504, USA

Brian K. Long, MD, Medical Review Officer, Firstlab, Ambler, PA 19002, USA

Da1?id M. Martin, PhD, Vice President and Executive Director, Firstlab, Ambler, PA 19002, USA

Russell D. Marx, MD, Assistant Clinical Professor, Department of Psychiatry, University of California San Diego, La Jolla, CA 92093, USA

Erwin A. Maseelall, MD, Clinical Assistant Professor, Department of Medicine, Northeastern Ohio Universities College of Medicine, Rootstown, OH 44272, USA

Norman S. Miller, MD, Associate Professor, Department ofPsychiatry, University of Illinois at Chicago, 912 South Wood St. M/C 913, Chicago, IL 60612, USA

James A. Nard, MD, Assistant Professor, Department of Pediatrics, Northeastern Ohio Universities College of Medicine, Rootstown, OH 44272, USA

Michael M. Newman, MD, Medical Director, Glacier View Hospital, 200 Heritage way, Kalispell, MT 59901, USA

William S. Rea, MD, Medical Director, CPC Fort Lauderdale Hospital, 1601 E. Las Olas Blvd., Fort Lauderdale, FL 33301, USA

Phillip M. Sinaikin, MD, MA, Director, Addictive Behavior Program, West Lake Hospital, 440 Crown Oak Center Drive. Longwood, FL 32750, USA

Andrew E. Slaby, MD, PhD, MPH, FAPA, Medical Director, Regent Hospital, 425 E. 61th Street, New York, NY 10021, USA

Kent Tigges, MS, OTR, Associate Professor, Occupational Therapy, University of Buffalo, Buffalo, NY 14272, USA

Contributors XVll

Carlton E. Turner, PhD, ScD, President, Princeton Diagnostic Laboratories of America, 100 Corporate Court, South Plainfield, NJ 07080, USA

lune Ventimiglia, RD, Clinical Dietitian, Children's Hospital of Michigan, 3901 Beaubien Blvd., Detroit, MI 48201, USA

Kurt l. Wegner, MD, FAAP, Professor, Pediatrics, Northeastern Ohio Universities College of Medicine, Rootstown, OH 44272, USA