Chapter 30. CRITICAL REVIEW
Student Samples Page
The samples below are papers by students, unless specifically noted.
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part of this chapter says.
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Sample One: Critical Review of One Book
1114-91, Spring 2006
© 2006 by Laura Beres
Critical Review of Man’s Search for Meaning
In Man’s Search for Meaning,
Viktor E. Frankl tells the very personal story of his experience as a prisoner
in a concentration camp during the Holocaust.
He presents this story in the form of an essay in which he shares his
arguments and analysis as a doctor and psychologist as well as a former
prisoner. This paper will review
Frankl’s story as well as his main arguments, and will evaluate the quality of
Frankl’s writing and focus on any areas of weakness within the story.
This section contains a summary of Man's Search. Frankl begins his book
by stating that his purpose in writing the book is not to present facts and
details of the Holocaust, but to provide a personal account of the everyday life
of a prisoner living in a concentration camp.
He states, “This tale is not concerned with the great horrors, which
have already been described often enough (though less often believed), but…it
will try to answer this question: How
was everyday life in a concentration camp reflected in the mind of the average
prisoner?” (21). Frankl then goes
on to describe the three stages of a prisoner’s psychological reactions to
being held captive in a concentration camp.
The first phase, which occurs just after the prisoner is admitted to the
camp, is shock. The second phase,
occurring once the prisoner has fallen into a routine within the camp, is one of
apathy, or “the blunting of the emotions and the feeling that one could not
anymore” (42). The third phase,
which occurs after the prisoner has been liberated from the camp, is a period of
“depersonalization”, in which “everything appears unreal, unlikely, as in
a dream” (110). In this phase,
released prisoners also feel a sense of “bitterness and disillusionment”
when returning to their former lives (113).
Frankl describes each of these phases using psychological theory and
provides personal experiences to exemplify each of the stages.
As described above, Frankl’s main purpose for writing this book is to
present and analyze the average prisoner’s psychological reactions to the
everyday life of a concentration camp. His
three main arguments are his presentation and analysis of each of the
psychological stages that the average concentration camp prisoner experiences:
shock, apathy and depersonalization.
He bases his analyses of each of these stages on the actions of the
prisoners and his own personal thoughts and reactions as he experienced life in
a concentration camp.
example, Frankl argues that the second phase of apathy forces “the
prisoner’s life down to a primitive level” (47) in which “all efforts and
all emotions were centered on one task: preserving
one’s own life and that of the other fellow” (47).
He bases this theory on events he witnessed while living in the camp
himself, and states, “It was natural that the desire for food was the major
primitive instinct around which mental life centered.
Let us observe the majority of prisoners when they happened to work near
each other and were, for once, not closely watched.
They would immediately start discussing food” (48).
Frankl continuously uses examples from his experiences in the
concentration camp to illustrate and strengthen his psychological arguments
throughout the text.
This section contains an evaluation of Frankl’s book.
Firstly, the author is a survivor of the Holocaust and was a prisoner of
a concentration camp himself, which gives him the personal insight to be able to
comment on the psychological conditions of an average prisoner.
However, this also creates a bias and because of his personal experience,
he is unable to be entirely objective in writing his analysis.
Frankl acknowledges this bias in the beginning of his book, by stating,
“Only the man inside knows. His
judgments may not be objective, his evaluations may be out of proportion.
This is inevitable. An
attempt must be made to avoid any personal bias, and that is the real difficulty
of a book of this kind” (24-25). Although
he is aware of this bias, it creates a partiality that will sway the readers
throughout his story and it serves as a minor weakness in his writing style.
A second weakness in Frankl’s writing is in the assumptions he
sometimes makes to prove his point. He
makes overarching generalizations several times in his book, making statements
that, although may have been true for himself and those around him, might not
have been true for every prisoner in every concentration camp during the
Holocaust. For example, in one
instance, he says, “The prisoner of
, in the first phase of shock, did not
fear death” (37). It is very bold
to say that no prisoner of Auschwitz, one of the most well-known and deadly
concentration camps of the Holocaust, did not fear death, as death was all
around them and was a very real threat in their daily lives.
Although he might have not feared death during his phase of shock, it is
impossible for him to guarantee that no prisoner was at all fearful of death in
this first psychological phase, and for him to make overarching assumptions like
this is a weakness to the overall quality of his book.
Finally, Frankl sometimes becomes too technical and verbose in his
writing style, which makes it very hard for the average reader to understand.
One example of this is as follows. Frankl
states, “I remember an incident when there was an occasion for
psychotherapeutic work on the inmates of a whole hut, due to an intensification
of their receptiveness because of a certain external situation” (102).
This sentence, which is overly wordy and complicated, makes it difficult
for the average reader to understand exactly what he is saying.
A reader can easily get frustrated when trying to decipher the author’s
meaning due to overly complicated language, and this is a third weakness of
This critical review has evaluated the book Man’s Search for Meaning
by Viktor E. Frankl. The
psychological theories that Frankl presents are very interesting and he does a
good job of illustrating these theories with his own personal experiences.
However, his writing is weakened by the presence of bias, the overarching
assumptions he occasionally makes, and his sometimes overly technical and
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Sample Two: Critical Review of One Essay
SPECIAL NOTES: This short, rough-draft critical review examines only one
short, argumentative essay and has no other sources.
University of Minnesota
Eng 3027, Advanced Expository Writing
© 2001 by Petter Woll
Review of "Condom use will increase the spread of
The use of condoms to prevent unwanted pregnancies and,
even more important, the spread of sexual transmitted diseases (STDs) has been
controversial. This critical review examines an article that links condom usage to the
spread of AIDS. The article, "Condom use will increase the spread of AIDS," was
written by Anthony Zimmerman, a Catholic priest. As the title of the article indicates,
the author is against the use of condoms to prevent the spread of AIDS and other STDs. In
fact, he claims that teaching children how to use condoms will eventually increase the
spread of AIDS. Although the author has some good points, his article is biased and
contains some misinterpretation of data from others analysis of the effectiveness of
This sections contains a summary of the article
"Condom use will increase the spread of AIDS." In his introduction, Zimmerman
says that condom usage "may break its [AIDS] spread in the short run; but accelerates
its spread in the long run" (p. 111). He bases his conclusion on an analysis done for
the World Health Organization (WHO) published in Population Reports. The results
from this analysis indicated that condoms users have a one-third lower risk for acquiring
STDs compared to non-condom users. This, however, provides small comfort for the author.
He says that using a condom is like playing Russian roulette.
There are two reasons why condom usage will increase the
spread of AIDS. Firstly, the promotion of condoms by the authorities, like teachers and
health workers, increases sexual promiscuousity. This leads to miseducation of
adolescents, breaking down their natural and cultural barriers against sex before
marriage. Secondly, condom usage promotes a false sense of security and a
According to the author, the most prevalent HIV virus is
the one that spreads more easily through sodomitic (anal) intercourse among homosexual
men. However, if todays trend continues, the African type, which spreads through
heterosexual intercourse, "may strike our schools like the atom bombs which
devastated Nagasaki and Hiroshima" (p.113).
In his conclusion, the author draws parallels to the Black
Death that haunted Europe during the fourteenth century. This is the scenario he pictures
if schools promote sexual education. It is already happening in Uganda, he says, where
AIDS is endemic.
This section looks into the authors arguments and
what these arguments mean to the general population. In addition, counterarguments from
the public and professional spheres are contrasted with those of the author.
AUTHORS ARGUMENTS AND IMPLICATIONS
The main purpose for the article written by Zimmerman is
to abolish the promotion of condom use in the society. He argues for this by saying that
promotion of condom use will increase the spread of AIDS. According to the author, there
are two reasons for this. One is that the promotion of condom usage will increase sexual
immorality: that is, more sex before marriage. If people are more frequently exposed to
sex, they will have sex earlier in adolescence, compared to if they are exposed less
frequently. Exposure increases the risk of acquiring HIV and, thus, developing AIDS. The
other reason why condom usage will increase the spread of AIDS is that it leads to a false
sense of security and something the author calls pseudo-responsibility. People, he says,
who promote condom usage advertise condoms as reducing the risk of transmitting HIV. This,
according to the author, misleads ordinarily people to think that all sex is safe, and
therefore it increases their sexual behavior.
The implication of the authors arguments is that to
reduce the spread of AIDS and avoid a future catastrophe having the same devastating
effects as the black plague in Europe on the 14th century, promotion of condom
use must be stopped.
Zimmerman has a very moralistic view on sexuality that is
not compatible with the publics view. The trend today is that young people start
having sex earlier than before. Also, there are few people who wait to have sex until they
are married. This trend was illustrated by the controversial movie, "Kids," made
by a sixteen-year-old American boy, which has been highly debated by health workers.
The view on condoms in the sphere of public health is that
they are our best means of reducing the spread of sexual transmitted infections like HIV.
In one study that looked at the transmission rate among heterosexual partners with one
partner infected by HIV, among the 123 couples that consistently used condoms, none of the
partners became infected, whereas 12 of the 122 who didnt consistently use condoms
For optimum effect in using a condom, correct use and
storage is a necessity. Therefore, health workers travel around to schools to teach
adolescents to use condoms correctly. This method belongs to the principles of harm
reduction, which says: "You should not use, but if you do
studies have confirmed that up to the present time, this is the most effective method for
preventing the spread of STDs. Some people go as far as to say that condoms should be made
as common as toothpaste and toilet paper, in order to protect us against infections.
This section contains an evaluation of the article.
Firstly, the authors arguments appear to be biased towards his Christian beliefs. He
is a Catholic priest and has a very moralistic view of sex. In his opinion, sex before
marriage is immoral. A minority in the American population would support this kind of
view. His views on sexuality are, in short, not consistent with current views within the
population. Furthermore, he shows prejudice against homosexuals and Africans. He holds
these two groups as the source of the HIV virus. The fact that the virus is more prevalent
in these two groups does not mean that they are the source of the spread. In his article
he says that "the ghetto of sodomites is going into extinction, and that could lead
to the extinction of AIDS." This is an extremely prejudiced statement, and it has
parallels to Hitlers statements about Jews: if we eliminate all the homosexuals, we
can get rid of AIDS.
Another negative point about this article is that it is
very argumentative with little support. The author throws out statements, giving no
evidence or supporting details for them. This is bad writing, and the author loses his
Finally, he misinterprets information from other data and
gives the wrong information or only parts of the truth. The data from the analysis done
for the WHO indicate that condoms significantly decrease the risk of transmitting HIV.
However, Zimmerman overlooks this, and instead interprets it to show that condoms increase
the spread of HIV. Furthermore, he refers to the endemic situation in Uganda, and claims
that this is the situation we are going to experience in the future if the promotion of
condoms continues. What he fails to mention is that the situation in Uganda could have
been avoided with the promotion of condoms. The number one cause of the spread of HIV is
unprotected sex, and with the correct use of condoms, the spread can effectively be
This critical review has evaluated the article "Condom
use will increase the spread of AIDS" by Anthony Zimmerman. The arguments in the
article show the presence of bias, prejudice, argumentative writing without supporting
details, and misinformation. These points weaken the authors arguments and reduce
Return to top.
Sample Three: Researched Critical Review of Three
Essays Using MLA Style
NOTES: This critical review examines three essays and has additional sources.
University of Minnesota
Eng 3027, Advanced Expository Writing
© 2000 by Sarah Pearson
A Critical Review of Three Articles on
Music and Feminist Pedagogy
The importance of feminism in music has come to the forefront
in many colleges and universities. However, for several reasons, one of
which is that scholars hold differing views on the relevancy and
appropriateness of feminism in the musical realm, feminism has not been included as
quickly in music as in other fields. Neuls-Bates offers another reason for
this lack of speed: "The discipline of women's studies has been slower to
develop in the field of music . . . mainly because of the necessary, time-consuming tasks
involved in obtaining performances of composer's works" (265). In
other words, music is slow to
incorporate womens studies because of the intense effort required to change an
already well-respected, dependable curriculum. This critical review will examine three
different articles on this issue and evaluate their contents based on a set of criteria.
Each of the articles, published in College Music Symposium, is written from a
feminist viewpoint. The authors discuss the importance of including a feminist curriculum
within the college setting, noting the positive benefits of using it in the classroom.
Their main argument is that not enough of this type of teaching is being used in
conservatories. One article is well written with supporting details and potential
solutions, while the other two include only general observations and offer no solutions.
Some background about this issue is useful. Prior to the 1970s, white middle- and upper- class males
dominated colleges. Because of this, womens issues often were
ignored. In the early
1970's, joint efforts were made by women across the country to try to persuade
colleges and universities to incorporate womens issues into their curriculum. They
felt that this incorporation would fill a vacancy for women attempting to earn a degree. Many
people believed that
exploring the numerous ways women helped to shape society would result in higher
self-esteem among women and give them a better understanding of the world. Slowly the
schools began implementing programs for women and started using textbooks that focused
more attention on womens achievements in particular fields. Currently many
departments within colleges have at least a small part of their curriculum devoted to
women. Feminists spent countless hours convincing departments to add these issues. It has
particularly been a struggle for both feminists and music departments to agree on what
subjects should or should not be included in an already well-established field.
A summary of the articles shows that the first one, "Feminist Scholarship and the Field of Musicology:
I" by Jane M. Bowers, discusses the issues of feminism and its place in music.
Published in College Music Symposium, this article focuses on the subject of music
history. Bowers argues that the "great" male composers dominate music history,
and almost nothing is said about women composers. That music history lacks a feminist
viewpoint is not surprising, she argues, as nearly all the disciplines in the arts have
little emphasis on womens issues. One reason for the void is that many scholars have
felt that it was not suitable to incorporate womens issues into their particular
field. According to Bowers, "[T]he scope of musicology is . . . not defined by lived
social realities, and hence its purview, like those of philosophy and literature, is
similarly less suited to the incorporation of women . . ." (83). She believes this
presents a dilemma to feminists, who must now explain why womens studies are
relevant to music. Bowers goes on to discuss historical ideas about women and their
function in music. She cites recent discoveries about the influence of women musicians in
the nineteenth century. In her conclusion she restates the argument that there is a
lack of research and studies being done on women in music. She suggests searching for ways
to emphasize womens compositions by focusing on the differences between men and
womens compositional styles, and looking at the instrumental music of women.
The second article, "Women, Women's Studies, Music
and Musicology: Issues of Pedagogy and Scholarship" by Susan Cook, also focuses on
the importance of including women in research. Also published in College Music Symposium,
this article contends that women's studies need to be included in more music courses.
Because of a lack of research of women in music, teachers are unable to integrate
the subject into
their curriculum. Even with some research available, professors are unsure how to use
it. According to Woods, whom Cook quotes, "We continue to operate within a
conservative methodology, whether compensatory or contributory, that is not necessarily
feminist and not specifically female. Rather it tends to relate and relocate women to the
accepted canon of great artists and great works" (95). Instead of incorporating
women into the canon, Cook believes professors are pushing them to the fringes, including
them only when time will allow. Cook then mentions numerous studies done recently that
have helped advance feminist ideas in the classroom. She feels this is a start, but much
more research is needed in order to push professors into using the information in their
Cook also discusses ways in which feminism has changed
teaching styles. She believes the traditional lecture has begun to give way to an open
forum, with the teacher leading the discussion. There is also an emphasis on equality in
all classroom situations: for example, teachers offer students more freedom concerning
grades, class management, and lecture (98).
The third article, also published in College Music Symposium, is "Application of Feminist Pedagogy: An Introduction to the
Issues" by Barbara Coeyman. It looks at ways of incorporating feminism into the current curriculum.
Unlike in the first two articles, the author does not emphasize research
and its importance to changing the curriculum; rather, she focuses on possible outcomes if
feminism is applied in the classroom. Her main argument is that the current music
curriculum can be enhanced and can lead to an enlightened classroom if feminism is
Throughout the article, Coeyman attempts to justify
feminist pedagogy by contrasting it to traditional teaching. She argues
"[traditional teaching] emphasizes formal constructions, static content, and
context-free artistic creation" (77), whereas feminist pedagogy
emphasizes students' creativity and encourages professors to become more involved in the
actual learning process. Coeyman
further promotes feminist pedagogy by
discussing its four main principles, which, according to her, include diversity, a voice for everyone,
responsibility, and application to real life situations. She suggests several ways of
applying these ideas through personalizing classroom lectures, including women composers
in the canon, and allowing students to "learn by doing" ( 83).
Analysis of Arguments
All three of these articles contain similar
arguments about feminism and music education. First, the authors believe that more
feminist issues need to be incorporated into music classes. Second, they imply that a
music students education is not wholly complete without the feminist viewpoint.
Lastly, Cook and Coeyman argue that feminist pedagogy can unite students
and faculty inside and outside of the classroom.
More in Curriculum
First, each author states that music courses do not
emphasize womens issues enough and need to begin incorporating more into the
curriculum. Bowers states, "If more than scant attention were paid to the interaction
of music history with social history, as well as to the attempt to include music as an
aspect of and in relation to culture in the large-areas which are virtually neglected
within musicology-women would also become a more relevant subject for
study" (84). By this statement Bowers shows her belief that feminist
ideas could be incorporated into music curriculum if scholars would exert a little more
Both Cook and Coeyman agree with Bowers that most music courses do not place enough
emphasis on women. The main argument among instructors is that there is not enough research
available to be able to add it to the curriculum. However, according to others
such as Neuls-Bates, "[A]t the present time there are quite sufficient materials to implement courses about women
in music . . ." (Zaimont 265). Thus the authors' arguments in this
regard have some validity.
Second, the authors imply that a student's education is not complete without the
feminist viewpoint. While neither directly state this, both Cook and Coeyman allude to
this idea. Cook closes her article by stating that feminist pedagogy can add to the
overall musical experience (98). Coeyman follows the same lines by stating that including
feminism in the classroom can inspire both students and faculty and can benefit the
overall person (77, 85).
Bowers, unlike the first two, does not focus on the education aspect, yet she
promotes this idea through her constant emphasis on continued research of women.
Commenting on a survey of articles focusing on women, she states, "Their central
concern was the degree to which research on women had achieved a place in the
mainstream of the disciplines where it had previously been absent" (81). This
statement and numerous others throughout the article show her belief that
research is important and can improve the overall education of a person.
All of these authors argue fervently that
feminist ideas can enhance music students' education. However, none offer
any evidence that this is true.
Unity of Students and Faculty
Lastly, the articles by Cook and Coeyman offer the idea that feminist pedagogy can unite
students and faculty. They both propose this through discussion of alternative classroom
Cook suggests that a more nontraditional lecture format can provide an
encouraging atmosphere in which students can learn. She states that
nontraditional teachers can " help all students to find their own answers and give birth to their own
ideas" (97). Thus she is arguing that if teachers use feminist methods, they
will stimulate students to think for themselves and producing better communication in the
Coeyman also argues that letting students become more involved in the classroom
allows for better communication between the professor and student, creating a feeling of
shared power (83), again a feminist method. By emphasizing these and other
feminist methods, such as a relaxed, non-threatening classroom experience, these
authors promote the belief that feminist pedagogy can bring the professor and student
Although all of these articles offer well-supported
arguments, they also have weaknesses. At times some of them appear to lack solid solutions to the problem,
tend to show bias towards the feminist
viewpoint, and may exaggerate the oppression of women composers in music.
Lack of Solid Solutions
A lack of solid solutions appears to exist in Bowers' and Cook's articles. Bowers,
in particular, fails to offer a
solid solution as to how to incorporate more feminist issues into the music history
curriculum. While she suggests alternatives to research within music, she omits discussing
solutions to changes in the current curriculum.
Like Bowers, Cook also neglects to provide
any solutions to the problem. She focuses on the differences between traditional teaching
and feminist pedagogy, discussing possible types of alternative teaching methods. Though
she notes that change is necessary, she fails to offer suggestions as to how these changes
could be integrated into the classroom (98).
In contrast to the first two articles, Coeyman does focus on possible ways to begin
incorporating feminism into music courses. She suggests using women's compositions during
lessons, offering non-musical courses that can amplify students' music classes, and
giving students a larger voice in how a class is run (83-84). Combined with some aspects
of traditional teaching, these methods could help enhance music students' education.
All three articles are also infused with a bias towards feminism. In her article,
Bowers portrays this bias when she states, "However
inadvertent the neglect of women ensuing from these patterns of musicological research,
the result has perpetuated the myth of female insignificance" (83).
Her use of the words "neglect" and "female insignificance"
show her strong feelings about feminist issues.
Cook and Coeyman use this same type of wording in their articles, but also show their bias
through ignoring the positives of traditional teaching. They comment only on the negative
aspects, making their suggestions seem more valid. Coeyman especially uses this tactic when she
describes ways to change traditional lecturing. For instance, as quoted before, she labels
traditional studies as "static," "context-free," and
"dictatorial" (77). By using these terms she degrades standard teaching and
enhances her own ideas about alternative methods.
Each author also exaggerates the oppression of women musicians in the nineteenth
century. First, Bowers continually comments on her belief that women musicians
have not been treated fairly throughout history. She states, "Further, women's
compositions were frequently reviewed in gender-biased ways, and overt discrimination . .
. was used against women who tried to enter male domains" (87). This statement is
only partly true. Clara Schumann was one example of a woman who composed and performed
across Europe. According to Green, "Clara Schumann . . . was the acknowledged peer of
the top male performers of the day" (60). Many other women musicians were also
well-respected in the music field such as Fanny Mendelssohn, Cecile and Natalie Chaminade,
Amy Beach, and Sofia Gubaidulina. Bowers fails to acknowledge the impact these women had
on music and ignores the freedom they had in performing and composing.
Cook and Coeyman do not directly exaggerate the oppression. However, they often allude to it.
Cook comments on continued open hostility to women's studies programs in higher education,
while Coeyman describes the field of music as a white male- dominated scene (Cook 93;
Coeyman 75). While neither openly state it as Bowers does, they still assume that all
women were excluded from music and have just recently begun to be accepted. Contrary to
this, in recent years many universities have felt it imperative to include womens
studies in their curriculum. According to the College Music Society, for
example, "To combat the
trend toward tunnel vision [in music] and to ensue that students and faculty integrate
knowledge from various disciplines, educational requirements need to be expanded and
reinvigorated" (6). Contrary to Cook and Coeymans beliefs, many music departments
have realized their curricula need to include more than just one race or genders
point of view.
This critical review has considered three different
articles. Each article focuses
on the issue of feminism and its place in the college music setting. Bowers and Cook look
at the research aspects, observing that a lack of research inhibits inclusion of women in
the classroom. Coeyman concentrates on the importance of including women in history
lectures and offers suggestions for alternative teaching methods. While all three articles
are well written, they fail to discuss the benefits of traditional teaching, focusing only
on the positives of feminism. They believe feminism will foster growth in the education of
many students. According to Ropers-Huilman, "[F]eminist teaching provides options for
teachers and administrators as they seek to educate and encourage respectful communities
grounded in difference" (19). However true this may be, to say that this
will only happen by using a feminist pedagogy is one-sided, and this
evident in the arguments of all three authors articles. Their arguments insinuate that
feminist teaching is the only solution to improving a music schools curriculum. This
misleads the reader and focuses the attention on feminism while ignoring all other
Bowers, Jane M. "Feminist
Scholarship and the Field of Musicology: I." College Music Symposium
29 (1989): 81-92.
"Applications of Feminist Pedagogy to the College Music Major Curriculum:
An Introduction to the Issues." College Music Symposium 36
College Music Society. Music in
the Undergraduate Curriculum: A Reassessment.
: College Music Society: 1989.
Cook, Susan C. "Women,
Women’s Studies, Music and Musicology: Issues of Pedagogy and
Scholarship." College Music Symposium 29 (1989): 93-100.
Green, Lucy. Music, Gender,
Neuls-Bates, Carol. "Creating
a College Curriculum for the Study of Women in Music." The Musical
Woman: An International Perspective. Ed. Judith Lang Zaimont.
Press, 1983. 265-284.
Ropers-Huilman, Becky. Feminist
Teaching in Theory and Practice.
: Teachers College Press, 1998.
Women in Modern America: A Brief History.
2nd ed. Orlando: Harcourt Brace Jovanovich,
Tenured Radicals. New, York: Harper
& Row, 1998.
A Feminist Critique. New York:
Harper Collins, 1996.
The Opening of the American Mind.
Boston: Beacon Press, 1996.
Mark, Michael L.
Contemporary Music Education. 3rd
ed. New York: Simon & Schuster Macmillan, 1996.
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Sample Four: Critical Review of Four Essays Using APA
SPECIAL NOTES: This critical
review of four professional journal essays is in APA format. There is no
bibliography, as all sources are sufficiently referenced in this semi-formal
paper. Main subtitles are underlined; sub-subtitles have all letters
A Critical Review of Studies
Showing the Prevalence
of Disordered Eating and Insulin Misuse among IDDM Patients
review discusses four studies that examine the prevalence of eating disorders
and eating problems among insulin-dependent diabetes mellitus (IDDM) patients
and the misuse of insulin involved. In the British Medical Journal
article “Eating Disorders in Young Adults with Insulin-dependent Diabetes
Mellitus: A Controlled Study”, the findings of Christopher Fairburn, Robert
Peveler, Beverly Davies, J. I. Mann, and Richard Mayou suggest that eating
disorders are not more common among IDDM patients compared to non-diabetics. The
results presented by Anne Rydall, Gary Rodin, Marion Olmsted, Robert Denenyi,
and Denis Daneman (1997) in the New England Journal of Medicine article
“Disordered Eating Behavior and Microvascular Complications in Young Women with
Insulin-dependent Diabetes Mellitus”, imply that there is a common “coexistence
of eating disorders and IDDM among young females” (p. 1849). In the Journal
of the American Dietetic Association article “Insulin Misuse by Women
with Type 1 Diabetes Mellitus Complicated by Eating Disorders Does Not Favorably
Change Body Weight, Body Composition, of Body Fat Distribution”, Sandra Affenito,
Nancy Rodriquez, Jeffrey Backstrand, Garry Welch, and Cynthia Adams suggest that
there is a high prevalence of eating disorders among the IDDM population. In
the Journal of American Academy of Child and Adult Psychiatry article
“Eating Disorders and Maladaptive Dietary Insulin Management among Youths with
Childhood-onset Insulin-dependent Diabetes Mellitus” Myrna Pollock, Maria
Kovacs, and Denise Charron-Prochownik suggest that eating disorders and problems
are not as common among young adults as it is thought. All of the articles imply
that insulin misuse is a common method for controlling weight among IDDM
patients with eating disorders or problems. Two of the studies have strong
elements that are worth noting. Each study has at least one weakness. These
include bias, contradiction, and limits of the study.
According to the
World Book Encyclopedia (1995), people with insulin-dependent diabetes
mellitus (IDDM or type 1 diabetes) have insufficient amounts of insulin in their
bodies, and they are unable to use and store glucose quickly. This leads to
buildup of glucose in the blood. Injecting insulin allows the body to use
glucose normally. Despite a strict diet, the daily dose of insulin may cause
rapid weight gain in some IDDM patients, and this may trigger and eating
disorder. The combination of IDDM and eating disorders is quite common.
According to Bonnie Irvin (1997), “it is not known if eating disorders are more
common among diabetics, but it is highly probable” (p. 28). Eating disorders
pose a serious health risk to those with IDDM. Lowering or skipping insulin
doses gives these people a special method of losing weight. According to Cheryl
Rock and Kathryn Zerbe (1995), the dietary restrictions focus on food, and
increased body awareness of diabetics are risk factors for an eating disorder.
Insulin withholding can cause severe health complications, and diabetes
“heightens the risks of mortality associated with eating disorders” (Rock &
Zerbe, 1995, p. 81). According to Irvin (1997), “insulin purging”, (reducing or
withholding insulin to control one’s weight) is now “recognized in DSM IV’s
diagnostic criteria for bulimia” (p. 28).
provides a quick glance at each study. All of the studies varied in the
subjects and methods used. Some specifically studied eating disorders, while
others looked at eating problems or disordered eating. Some studied both. All of
the studies also examined other aspects associated with eating disorders or
diabetes. (Note: this critical review specifically focuses on eating problems
and/or disorders, diabetes, and insulin misuse because these are the common
elements in these studies.)
Disorders in Young Adults with Insulin-dependent Diabetes Mellitus: A Controlled
Study” compared the prevalence of eating disorders among a sample of IDDM
patients and a sample of non-diabetics. The diabetic group consisted of 46 men
and 54 women, and the control group consisted of 67 non-diabetic women only.
Each subject was given an eating disorder examination to measure clinical
features of eating disorders. Those with diabetes were given an interview
adapted to distinguish behavior simply motivated by diabetes. All subjects also
completed an eating attitudes test. Fairburn et al. found no significant
difference in the prevalence of eating disorders among diabetic women and
non-diabetic women. None of the men met criteria for an eating disorder. Many
of the diabetic women underused insulin to control their weight, and 4 out of
the 6 currently doing so had an eating disorder.
Eating Behavior and Microvascular Complications in Young Women with
Insulin-dependent Diabetes Mellitus”, young women with IDDM were studied at
baseline and four to five years later to find the “prevalence and persistence
of disordered eating behavior” (Rydall et al., 1997, p. 1849). The participants
were 121 girls, ranging in age from 12-18, with IDDM. Each completed a
self-report survey of eating attitudes and behavior at baseline. According to
Rydall et al. (1997), “behavior relating to eating and weight psychopathology”
was assessed at baseline and at follow-up with the Diagnostic Survey for Eating
Disorders (p. 1850). This questionnaire was adapted to include items
specifically relating to diabetes. According to Rydall et al. (1997), eating
behavior at baseline and follow-up was categorized into “three mutually
exclusive, hierarchical categories: highly disordered, moderately disordered,
and nondisordered eating” (p. 1850). Ninety-one women participated at follow-up.
Rydall et al. (1997) found
“intentional omission or underdosing of insulin and dieting for weight loss”
increased in prevalence from baseline to follow-up (p. 1852). At baseline, 26 of
the 91 young women had highly disordered eating behavior that persisted in 16
and improved in 10. Of the 65 with normal eating at baseline 14 had disordered
eating at follow-up. 12 subjects at baseline and 30 at follow-up reported
omission or underdosing of insulin to lose weight.
In the article, “Insulin
Misuse by Women with Type 1 Diabetes Mellitus Complicated by Eating Disorders
Does Not Favorably Change Body Weight, Body Composition, of Body Fat
Distribution”, the relationship between improper use of insulin among type 1
diabetics mellitus (IDDM) and eating disorders was investigated. Subjects were
90 women who had type 1 diabetes for at least one year. They were divided into
three groups: clinical (all DSM-III-R criteria met), subclinical (criteria
partially met), and control (free of eating disorders). Diagnoses of eating
disorders were based on DSM-III-R criteria and confirmed by clinical interview
using the validated Eating Disorder Examination. According to Affenito et al.
(1998), the Bulimia Test Revised was administered to each subject to “assess
severity and frequency of bulimic behavior” (p. 687). Attitudes and behaviors
regarding insulin misuse were determined by clinical interview. The results
showed the women with eating disorders (clinical and subclinical) misused
insulin to a greater extent to control weight than those without eating
disorders. Nearly half of the women with eating disorders reported misuse of
The objective of “Eating
Disorders and Maladaptive Dietary Insulin Management among Youths with
Childhood-onset Insulin-dependent Diabetes Mellitus” was to determine the
prevalence of eating disorders and insulin misuse among IDDM youths. Girls and
boys ranging in age from 8-13 were assessed on various measures two to three
weeks after IDDM onset and at various follow-ups over the next eight to fourteen
years. Eating disorders were diagnosed by using the Interview Schedule for
Children and Adolescents (ICS) which contains symptoms that are flags for
possible eating disorders. 3 of the 79 subjects had a DSM-III eating disorder.
Pollock et al. (1995) further reported that each of the 3 had “serious dietary
indiscretion and repeated insulin omission” (p. 294). Six others had symptoms
of problematic eating behavior. According to Pollock et al. (1995) every one of
the youths with eating problems had at least “one episode of pervasive
noncompliance with diabetes care” (p. 295).
POPULAR AND ACCEPTED
discusses the implications of these studies, showing how they vary in popularity
and rationale. Most of the articles had results that one might expect.
Fairburn et al., Rydall et al., and Affenito et al. all implied that eating
disorders and/or problems are fairly common among the IDDM population. This is
in accordance with the expectations formed from the empirical relationship
between IDDM and eating disorders. It seems logical that eating disorders would
be common among this population due to the special diet imposed on diabetics and
their elevated body awareness. Those with diabetes also have a method of
controlling weight by reducing insulin doses readily available to them.
implications of these articles are not accepted so easily. Pollock et al.
(1995) suggest that only a small percentage of young adults have a combination
of diabetes and eating disorders or eating problems. This idea is not only
unpopular because it goes against the common expectations mentioned above, but
also because eating disorders are thought to be the most common among the
subjects’ age range (16-26 years old when assessed for eating disorders) of this
implication that is unpopular is Fairburn et al.’s (1991) conclusion that eating
disorders are not more common among diabetic women than non-diabetic women. The
findings and implications of this study contrast those of many other studies on
this topic. It can be argued that these results are due to the efforts of the
experimenters to study a representative diabetic sample and a non-diabetic
control group. According to Fairburn et al. (1991), there are no satisfactory
data on the prevalence of eating disorders in the community and few other
studies have included control groups. It is possible that these methodological
differences account for the findings of this study and the implications drawn
implication among all of the studies is not well recognized by the public.
Although the misuse of insulin among IDDM subjects was common in all of these
studies, it is not seen as a common problem outside of the medical profession.
According to Fairburn et al. (1991), “insulin misuse is not generally thought to
be common, and omission or underuse of insulin specifically for weight control
has received little attention outside clinical reports of patients with eating
disorders” (p. 21). These studies suggest that the practice is widespread among
IDDM patients (mostly women), and according to Affenito et al. (1998), it is not
confined to those that have a clinical eating disorder. The misuse of insulin
may seem logical due to the increased risk of eating disorders among diabetics
and their access to insulin.
SIMILARITIES IN STUDIES,
Some of the
studies had similar methods and/or subjects, but different results and
implications. The subjects in “Eating Disorders in Young Adults with
Insulin-dependent Diabetes Mellitus: A Controlled Study” and the subjects at
follow-up in “Eating Disorders and Maladaptive Dietary Insulin Management among
Youths with Childhood-onset Insulin-dependent Diabetes Mellitus” were similar in
sex and age, but the findings were different. Fairburn et al. (1991) found that
many of the diabetic women had eating disorders and disturbed eating, while no
men did. Pollock et al. (1995) contrastly found only a small percentage of the
IDDM subjects had eating disorders or problems, and one-third of the subjects
with eating problems were male.
The difference in
prevalence of eating disorders and problems suggested in these studies may be
due to the criteria that Pollock et al. used to determine an eating disorder and
eating problem. For the purpose of their study Pollock et al. (1995) determined
that an eating problem “required the joint presence of maladaptive eating and
repeated insulin misuse” (p. 293). In the Fairburn et al. study, insulin misuse
was not required for an eating problem. One might argue that a diabetic may
have disordered eating without misusing insulin, and therefore it should not be
a requirement. Pollock et al. (1995) used “comprehensive psychiatric evaluations
and differential diagnosis” to determine eating disorders (p. 293). This method
of assessment is more extensive than what would be done in a clinical setting.
The criteria and methods used by Pollock et al. may have excluded subjects that
would otherwise be considered for an eating problem or disorder. Pollock et al.
(1995) also considered misuse of insulin as the total omission of insulin rather
than the omission or reduction of insulin like most other studies. Contrastly,
in the Fairburn et al. (1991) study misuse of insulin was defined as “underusing
or even omitting insulin specifically to control weight” (p. 18). The
difference in criteria used for insulin misuse may also explain the differences
found on this measure.
Fairburn et al.
(1991) and Affenito et al. (1995) both compared the misuse of insulin among IDDM
patients with eating disorders and IDDM patients without eating disorders.
According to Fairburn et al. (1991) there was no significant difference in the
misuse of insulin among the groups. Affenito et al.’s results suggest that the
misuse of insulin is more common among diabetics with eating disorders than
among those without them. One could argue that the difference found by Affenito
et al. is due to demographic differences between the groups. Affenito (1998) et
al. found the women without eating disorders were “more educated, had more
professional occupations, and were more likely to be married” compared to those
without eating disorders (p. 687). No significant differences existed between
the groups in the Fairburn et al. study. It can be argued that these
differences are due to differences in the comparison groups and that no real
evaluates the quality of each study. Some of the studies have strong elements
that are worth mentioning. Each of these studies have at least one weakness
that lowers the value of their findings.
In two of the
studies special concern was given to the instruments used to measure eating
disorders and problems among the diabetic subjects. Fairburn et al. (1991) made
intensive efforts to go beyond the shortcomings of similar studies. According
to Fairburn et al. (1991), the Eating Disorder Examination used was “adapted to
distinguish behavior motivated by having diabetes and the demands of treatment
from that attributable to an eating disorder” (p. 18). Rydall et al. (1997)
used the Diagnostic Survey for Eating Disorders that was “modified to include
diabetes-related items” (p. 1850). By taking these extra steps, the authors
avoid attributing eating problems and other behaviors to eating disorders when
they could simply be the result of the diabetes.
important part of the study conducted by Fairburn et al. (1991) is that they
strived to use a more representative sample of diabetics, and they also used a
control group of non-diabetics that few other studies have used. The use of a
control group is important because, according to Irvin (1997) the prevalence of
clinical eating disorders in non-diabetic people is uncertain” (p. 17).
Two of the
studies did not making the studies blind when it may have been more effective to
do so, and the result of this may have been bias. In “Insulin Misuse by Women
with Type 1 Diabetes Mellitus Complicated by Eating Disorders does not Favorably
Change Body Weight, Body Composition, or Body Fat Distribution” by Affenito et
al. (1998), the Bulimia Test Revised and a “determination of attitudes and
behavior regarding misuse of insulin” were conducted by clinical interview” (p.
687). The subjects were broken into three groups, and the interviewer knew if
each subject was part of the clinical, subclinical, or control group. According
to Fairburn et al. (1991), in “Eating Disorders in Young Adults with
Insulin-dependent Diabetes Mellitus: A Controlled Study” the eating examination
was conducted by investigators, and the investigators knew if the subjects were
diabetic or not. The interpreters and interviewers of both of these studies may
have had expectations and stereotypes concerning eating disorders and diabetes.
These may have influenced how they rated, scored, or interpreted the subjects on
the measures used.
Fairburn et al.
contradict the purpose of their study. According to Fairburn et al. (1991), the
purpose of their study was to estimate the prevalence of eating disorders in the
entire diabetic and non-diabetic population, but men were only included in the
diabetic sample. By only studying women in the non-diabetic sample, the
non-diabetic population is not fairly represented. The absence of males in the
control group may have influenced the results.
A few of the
studies were limited by problems with their samples. In “Eating Disorders and
Maladaptive Dietary Insulin Management among Youths with Childhood-onset
Insulin-dependent Diabetes Mellitus” the number of subjects found to have eating
problems was too small to detect differences on different variables between
those with and without eating problems. This limited the authors’ ability to
suggest what factors cause eating problems among IDDM patients. According to
Rydall et al. (1997), a drawback of their study was that they lost participants
that had highly or moderately disordered eating at baseline. The information
provided by these subjects could have contributed greatly to the results. The
loss of participants is a drawback in any study.
experimenters could have avoided other limits of these studies. In the Pollock
et al. (1995) study the authors did not focus on “all manifestations of
diabetes-specific eating problems”, and they may have underestimated the rate of
these difficulties (p. 297). Unlike Fairburn et al. and Rydall et al., they did
not acknowledge the eating problems that may be caused by the diabetes.
In the Rydall et
al. article the authors could have avoided some of the limits of the study.
First of all, according to Rydall et al. (1997), eating behavior was only
assessed twice over a four to five year period. This is a big gap of time to
allow when measuring eating disorders among young women. Many changes may have
occurred in these girls’ lives in between assessments that the authors’ did not
take into consideration. By the time of follow-up more of the subjects had
reached the age of higher risk for eating disturbances, and this alone may have
influenced the results. Another limit was that, according to Rydall et al.
(1997), the self-report measure (a questionnaire) had “limited established
reliability” (p. 1853). An important part of every study is to use an
instrument with high reliability and validity. If such instruments are not
used, little faith can be put in the results.
review examined four studies on IDDM patients and the prevalence of eating
disorders and insulin misuse among them. Special concern seems warranted among
diabetics, because, according to Irvin (1997), “ diabetes can be a natural
jumping off place for an eating disorder and a perfect mask for the disorder
once it starts” (p. 28). Fairburn et al., Rydall et al., and Affenito et al.
all agreed that eating disorders occur at a great rate among IDDM patients.
Pollock et al. concluded that eating problems and disorders were not very common
among IDDM patients. All of the studies found a high occurrence of insulin
misuse among diabetic subjects with eating problems. Arguments can be made
against and in defense of the findings of these studies. Despite a few strong
elements in a few of the studies, each study had at least one weakness of bias,
contradiction, or limits of the study.
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