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Book Review   |    
Lorie Gearhart
Psychiatric Services 2007; doi: 10.1176/appi.ps.58.2.273
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edited by Timothy D. Brewerton, M.D.; New York, Marcel Dekker, Inc., 577 pages, $175

Just a Little Too Thin: How to Pull Your Child Back From the Brink of an Eating Disorder

by Michael Strober, Ph.D. and Meg Schneider, M.A., L.M.S.W.; Cambridge, Massachusetts, DaCapo Press, 2005, 235 pages, $25

Dr. Gearhart is a psychiatry resident at the University of Maryland/Sheppard Pratt Psychiatry Residency Training Program, Baltimore.

Eating disorders have pervaded society for many centuries, even dating back to the ancient Greeks, who described "vomitoriums" and adhered to the philosophy of "eat, drink, and be merry." Voluntary self-starvation has also been long reported, including among nuns who restricted their caloric intake to avoid sinful gluttony and cachectic women who were once accused of being witches, because people believed that the women were losing weight in order to fly more easily. But only more recently have eating disorders been acknowledged as psychiatric illness and been given treatment and research consideration.

The Clinical Handbook of Eating Disorders strives to provide an integrated and current overview of the full spectrum of eating disorders: anorexia, bulimia, binge-eating disorder, as well as obesity—perhaps a contemporary validating nod to the nutritional impropriety and indiscretion of the multitudes. An international panel of authors, as well as writers from many disciplines, creates a convergence—and divergence—in the way one may approach patients with such afflictions.

The handbook ranges in complexity from the extremely technical to the simplistic. Although a wide array of interested readers will benefit from many aspects of the text, to say that one type of practitioner would appreciate the book in its entirety would be minimizing its heterogeneity. Physicians, psychologists, and other therapists would particularly benefit from such a reference, although students of medicine and nursing, dieticians, and researchers may also find it useful.

This source provides material outlined in four principal parts: diagnosis, epidemiology, and course; risk factors, etiology, and psychiatric and medical comorbidities; psychobiology, including a discussion of neurotransmitters, neuroendocrine and neuropeptide dysregulation, as well as neuroimaging and some molecular details of the illnesses; and treatment, which combines a consideration of psychotherapy, psychopharmacology, nutritional counseling, and a particularly insightful chapter on family assessment and therapy.

Common themes interwoven throughout the text, which may be found especially useful given the current financial climate of medicine, are the emerging role of cognitive-behavioral therapy in treatment as well as the increased use of partial hospitalization programs and intensive outpatient programs. Cultural aspects of eating disorders are emphasized in the first section and are incorporated at various points in other chapters, likely representing the diversity of contributors. Psychodynamic theory, as it pertains to the meaning of symptoms and their role in maintaining the psychic homeostasis of patients, is also addressed by several authors throughout multiple chapters.

The extensive referencing is suggestive of a comprehensive evaluation of the most up-to-date literature. Almost universally, the authors are not seduced by the temptation of subjectivity, nor do they minimize the complexity of these illnesses. This is also possibly a statement about the editor, Timothy Brewerton, who is affiliated with the Medical University of South Carolina. Although impressively evidence based, the text is coupled nicely with observed clinical material and relevant anecdotes. Overall, this is an impressive integration of ideas and information, which will be illuminating to anyone seeking to further understand these multifaceted diagnoses.

Clinicians aren't the only people who need information on eating disorders. For any parents who have ever wondered if their child is on the brink of an eating disorder, Just a Little Too Thin can assist in navigating through the confusion. This book is not only terrific for therapists taking care of adolescents who may be affected but also concrete reading for parents who are trying to figure out how to proceed with dealing with their child's problems.

Dr. Strober and Ms. Schneider have extensive experience in this area. Dr. Strober is on the faculty at the University of California, Los Angeles, Medical School and is editor-in-chief of the International Journal of Eating Disorders. Ms. Schneider, a private practitioner in New York, is coauthor of several books on parenting. They are aware that most parents experience fear and bewilderment and don't know how to begin to help their child. This book offers concrete advice on what to say, what to look for, and what to do.

The authors strive to accomplish multiple things: alert parents to changes that may signal conversion from a benign diet to one that is more disturbing, instruct parents how to back their child off the "slippery slope," help parents to understand where their child may rest on the continuum of eating disorders, and help parents understand the emotional components of the disorder.

This is primarily a book about restrictive eating. Other disorders are touched upon but not deeply explored. An account of the progression of dieting, in very simple terms, is easy to understand for the lay public and nonmedically trained professionals. Although physicians may find it useful to recommend to families, the text does not explain how these disorders affect the body medically or address pharmacologic treatment. Further, parts seem outdated, such as referring to "the four food groups" and implying that avoidance of dairy is unhealthy.

The book describes the barely visible stage of "The Innocent Dieter," in which the child is beginning to study food labels. Recommendations are made to ensure the child's diet is healthy and to communicate in such a way that innocent dieting remains exactly that. An examination of the subtle transition to "The Exhilarated Dieter" follows. This piece reveals signs that a child's symptoms have progressed—such as, she or he eats in a secretive manner or cannot identify how much weight she or he wants to lose. Suggestions include explaining the concept of maintenance and understanding the connection between pain and chaotic eating patterns.

The striking progression to the next stage, "The Obsessed and Preoccupied Dieter," seems easier to notice. The authors discuss disturbing, unpleasant, and dangerous dilemmas that evolve with this type of dieting. The physical effects of food deprivation are outlined, and a connection is made with binge eating and purging behavior. Warning signs are identified, including avoiding certain social gatherings and forsaking interests unrelated to food.

The authors deserve ample praise in producing such an easy-to-understand account. The tangible and explicit suggestions they offer make this book perfect for perplexed parents or therapists seeking to help them and their child.




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