This document outlines an Oxford Advanced Studies Seminar on revisiting anorexia multiforme. The seminar will include presentations on the culturally and historically variable presentations of eating disorders, cases that illustrate how values and culture shape illness experiences, and discussions on transforming the meaning of anorexic behaviors. The seminar aims to show how notions of health and illness are socially and culturally determined rather than biological facts. It will also address critiques of globalizing Western psychiatric concepts and the need for decolonizing global mental health. The seminar presents anorexia as a "chameleon" that takes different forms based on changing sociocultural contexts.

1. Oxford Advanced Studies Seminar
ANOREXIA MULTIFORME
REVISITED

2. Oxford Advanced Studies Seminar
ANOREXIA MULTIFORME
REVISITED
Vincenzo Di Nicola
Collaborating Centre for Values-based
Practice in Health and Social Care
St Catherine’s College, Oxford
Wednesday, 30 October 2019
10 am – 4 pm

3. Vincenzo Di Nicola, MPhil, MD, PhD
vincenzodinicola@gmail.com
Professor of Psychiatry, University of Montreal &
The George Washington University
Chief, Child & Adolescent Psychiatry,
Montreal University Institute of Mental Health
President, Canadian Association of Social
Psychiatry (CASP)
President-Elect, World Association for Social
Psychiatry (WASP)

4. Exhibition at the Ashmolean

5. Conflicts of Interest
The seminar presenter has no financial
conflicts of interest to declare.

6. Seminar Outline
Bill Fulford, Hasanen Al Taiar
Introduction to the Centre & Welcome – 10:00-10:15
Vincenzo Di Nicola
Anorexia Multiforme Revisited I – 10:15-10:45
Hasanen Al Taiar
Eating Disorders in the Middle East – 11:15-11:45
Oxford Eating Disorders Team (Moderator)
Discussion – 11:45-12:30
VDN – Anorexia Multiforme II – 13:30-15:30
Bill Fulford, Hasanen Al Taiar (Chairs)
Concluding Panel – 15:30-16:00

7. Anorexia Multiforme Revisited
What it is and why cultural values are
important in the aetiology, presentation and
management of eating disorders

8. Anorexia Multiforme I
Readings:
Anorexia Multiforme – TPPR (1990a, b)
Theme: the socially, culturally and historically
variable presentations of a protean illness
Case of Antonella: “A Stranger in the Family”
Theme: estrangement – cultural, familial,
existential
Vignette: “A Private Language”
Theme: generation gap among immigrants

9. Anorexia Multiforme II
Readings:
Changing Bodies, Changing Cultures (2001)
Theme: culture change, body history
Hannah: “From the Cradle”
Theme: how a values-context based on religion
shapes the expression of suffering
Gloria Perez: “The Many Face of Self-
Starvation”
Theme: “predicament” is multiply determined

10. In the case of the affluent society,
Western and westernized, the anorexic
skeleton is the living imageof an
unfortunate encounter between
economic well-being and relational
malaise.
– Mara Selvini Palazzoli (1985)
Ref: M Selvini Palazzoli (1985). Anorexia nervosa: a
syndrome of the affluent society. Transcultural
Psychiatry, 23(1): 83-85.

11. As periods of cultural change inevitably carry
with them a greater degress of heterogeneity,
in the history of any culture or sub-culture,
periods will be found in which adequate social
forms for the expression of points of strain and
tension in the personality will be forced back
upon his own body for symbolic expression.
– Margaret Mead (1947)
Ref: M Mead (1947). The concept of culture and the
psychosomatic approach. Psychiatry, 10: 57-76.

12. Anorexia Multiforme I
Readings:
Anorexia Multiforme – TPPR (1990a, b)
Theme: the socially, culturally and historically
variable presentations of a protean illness
Case of Antonella: “A Stranger in the Family”
Theme: estrangement – cultural, familial,
existential
Vignette: “A Private Language”
Theme: generation gap among immigrants

13. Historical views:
Anorexia multiforme
Self-starvation as a medical chameleon:
Anorexia multiforme
Medical history
Historical cases
Historical analogues
Historical evolution

14. Antonella:
“A Stranger in the Family”
Antonella presented a fluctuating tableau of
anxiety and mood symptoms along with disturbed
eating against a background of her adoption as a
foundling child in Italy and her attachment
problems with her adoptive family

15. Antonella:
“A Stranger in the Family”
Generating chronically unfixed and unstable
identities, her eventual cross-cultural marriage as
both flight and refuge followed by conflicts so
intense that I characterized them as “marital
malocclusion” like teeth grinding in the night

16. Antonella:
“A Stranger in the Family”
Palliated by her passion for Canada’s landscape
and fauna, and her ultimate cross-species
identification as a dog-breeder.
Theme: estrangement –
cultural, familial, existential

17. Antonella:
“A Stranger in the Family”
Palliated by her passion for Canada’s landscape
and fauna, and her ultimate cross-species
identification as a dog-breeder.
Theme: estrangement –
cultural, familial, existential

18. Antonella:
“A Stranger in the Family”
Archaeology of the case of Antonella
Four constructions of her illness and suffering
Medical
Psychological
Relational
Existential

19. Antonella:
“A Stranger in the Family”
Philosophical archaeology (Agamben)
Social-psychiatric archaeology

20. Only in an enlarged research context that
considers meaning as well as behavior will we
be able to understand how anorexia nervosa is
experienced and why it has become the
characteristic disorder of the female
adolescent in our day.
–Joan Jacobs Brumberg (1985).
Ref: J Jacobs Brumberg (1985). Fasting girls: Reflections
on writing the history of anorexia nervosa. Monographs
of the Soc Research Child Dev, 50(4-5): 93-104.

21. Historical views:
Anorexia multiforme
Major problem
Continuum view
Historical and clinical analogues
Gradualism view
Caseness view
A modern disease that appeared under
requisite socio-cultural conditions

22. Historical views:
Anorexia multiforme
Proposal: What defines self-starvation is
the changing socio-cultural blueprint
“Holy anorexia” (religious view)
“Chlorosis” (medical view)
“Anorexia nervosa” (psychiatric view)
“Hunger strike” (political view)

23. At this cultural stage women take
thought to alter their persons, so as to
conform more nearly to the requirements
of the instructed tastes of the time
– Thorstein Veblen (1899/1953)
Ref: T Veblen (1953). The Theory of the Leisure Class.
New York: New American Library. (Original published
1899)

24. Historical views:
Anorexia multiforme
In this view, anorexia nervosa is a
chameleon with protean clinical
manifestations changing over time and
across culture

26. Anorexia Nervosa as a Metaphor
Confusing an illness, its explanations and
its use as a metaphor leads to muddled
thinking
Leads to causal connections between illness
and metaphor
“Hunger strike” and “holy anorexia” are vivid
metaphors that slide into explanatory models

27. Anorexia Nervosa as a Metaphor
Remember Hume’s Fork
Fact-value distinction
(Is-ought distinction)
In self-starvation:
From perception (construction) to reality
Observation – metaphoric description –
prescriptive imposition (looping effect)

28. Summary – Historical Views
and Metaphorical Constructions
Confusion, conflation, reduction

29. Questions
&
Comments

30. Anorexia Multiforme II
Readings:
Changing Bodies, Changing Cultures (2001)
Theme: culture change, body history
Hannah: “From the Cradle”
Theme: how a values-context based on religion
shapes the expression of suffering
Gloria Perez: “The Many Face of Self-
Starvation”
Theme: “predicament” is multiply determined

31. Changing Bodies, Changing Culture
Theme: Culture change, body history
The experience of the body is historically,
socially and culturally situated

32. In every epoch, bodies only exist in
context. The form the felt equivalent of
any age, insofar as that age can be
experienced by a specific group.
– Ivan Illich (1992)
Ref: I Illich (1992). Twelve years after Medical Nemesis:
a plea for body history. In: In the Mirror of the Past.
London: Marion Boyars, pp. 211-17.

33. Hannah:
“From the Cradle”
Expanding the family system to include God (the
religious community)
Theme: how a values-context based on religion
shapes the expression of suffering

34. Gloria Perez:
“The Many Faces of Self-Starvation”
Negotiating facts AND values
Cultural translation vs. therapeutic translation
Theme: Predicament is multiply determined

35. Transforming the meaning of anorexic
behavior through an emphasis on
personal values
– Kelly Vitousek (2000)
Ref: K Vitousek (2000). Workshop, 9th International
Conference on Eating Disorders, New York.

36. Values-based Practice

37. Questions
&
Comments

38. Final Comments –
Deathly Consequences
Self-starvation and suicide
Who killed Ellen West?
Suicide? Assisted Suicide?
Gaslighting? Psychic murder?
Binswanger’s foundational case of existential
analysis also announces its death

39. Emblema (mosaic panel)
“Death at the feast”
Last Supper in Pompeii Exhibition
Ashmolean Musaeum

41. Crazy Like Us
American journalist Ethan Watters’ Crazy Like Us: The
Globalization of the American Psyche (2010) criticizes
the notion of exporting US notions of health and
illness around the world, posing a key critique with
his his provocative and polemical title.
I agree that all notions of health and wellbeing,
illness and disease have a distinct human history and
cultural geography. By this I mean that these notions
are not merely biological givens, evolving over time
and taking different shapes under the influence of
social and cultural determinants.

43. Decolonizing Global Mental Health
China Mills’ (2013) more scholarly critique, Decolonizing
Global Mental Health: The Psychiatrization of the Majority
World, raises similar problems by placing GMH itself in a
global perspective, including the perspectives of critical
political theory and post-colonialism.
There are many mentions of radical critical thinkers in the
social sciences, politics, and colonialism, e.g., the Caribbean
psychiatrist and revolutionary Frantz Fanon is amply
discussed.
Mills is especially critical of a key GMH notion of “health
gaps.”

44. Questions
&
Comments

45. Acknowledgements
Advanced Studies Seminar
Dr. Bill Fulford
VBP Collaborating
Centre
St. Catherine’s College
Oxford Eating Disorders
Team
Dr. Hasanen Al Taier
Turku, Finland