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The study aimed to compare differences in physical activity, the relationship between physical activity and body composition, and seasonal variation in physical activity in outpatients with anorexia nervosa (AN) and healthy controls. Physical activity (CM-AMT) and time spent in different intensities of 10 female individuals with AN and 15 female controls was assessed across three seasons along with the percentage body fat. The two groups did not differ in their physical activity and both demonstrated seasonal variation. The percentage body fat of individuals with AN, but not that of the controls, was negatively related to CM-AMT and time spent in low-moderate intensity activity (LMI). Seasonal variation in physical activity emerged with increases in engagement in LMI during the summer period for both groups. Possible interpretations of the finding that decreased physical activity was related to a normalization of percentage body fat in the individuals with AN are discussed and implications for treatment are highlighted.

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OBJECTIVE: We compared the natural history of bacterial infection in patients with anorexia nervosa (AN) with controls, and assessed which of a range of patient characteristics were associated with infection, fever response, and the rate of infectious complications in AN patients. METHOD: The charts of 311 consecutive hospital admissions of AN patients were reviewed. Patients who had a bacterial infection while in the hospital were compared with the AN patients who did not have an infection, with respect to a range of demographic and disease variables. Fever response and infection complication rate also were evaluated in AN patients with a bacterial infection and in nonanorectic control subjects admitted with a bacterial infection. RESULTS: AN patients with a bacterial infection showed a reduced fever response, were often difficult to diagnose because of fewer signs and symptoms, and infection became more frequent with increasing patient age. DISCUSSION: A reduction in fever response and the signs and symptoms of infection significantly delayed diagnosis in AN patients and increased the complication rate from bacterial infection. We recommend that an increased index of suspicion and an early complete blood count and bacteriologic cultures be adopted for the investigation of bacterial infection in AN patients.

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OBJECTIVE: Recovery from anorexia nervosa is confounded by intrusive anorectic cognitions and rituals. It has been observed that olanzapine, an atypical antipsychotic, can reduce this anorexic rumination. A pilot study was designed to test the effectiveness of olanzapine in this role. METHODS: A randomized trial of olanzapine versus chlorpromazine, with anorexic rumination as the primary outcome, was conducted. Of the 26 patients who presented, 15 were randomized in a balanced block design, eight to olanzapine and seven to chlorpromazine. RESULTS: Only the olanzapine group had a significant reduction in the degree of rumination. CONCLUSION: Olanzapine may be of benefit in anorexia nervosa by causing a reduction in anorexic rumination.

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OBJECTIVE: To explore the tension between the definition of mental illness in clinical psychiatry and its embodiment in legislation applied by tribunals reviewing decisions to treat. METHOD: Severe anorexia nervosa is used as a case exemplar of the tension between the appropriate narrative to express the clinical imperative to treat and the law's focus on finer technical language which secures individual civil rights and liberties. Australian and international experience is reviewed. RESULTS: The paper finds that the clinical and the legal narratives about how to 'define' mental illness do differ at the formal level of expression where they necessarily intersect in the setting of tribunal review of involuntary treatment decisions. However, in practice mental health admissions and tribunal reviews generally endorse the clinical applications of that more capacious and fluid terminology of clinical psychiatry. CONCLUSIONS: While tribunal reviews of clinical decisions may occasionally require clinicians to participate in an unfamiliar legal dialogue about narrowly construed definitions of mental illness, tribunals apply more complex tests which are sensitive to clinical practice and good therapeutic objectives.

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BACKGROUND: The Royal Australian and New Zealand College of Psychiatrists is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Ministry of Health. This CPG covers anorexia nervosa (AN). METHOD: The CGP team consulted with scientists, clinicians, carers and consumer groups in meetings of over 200 participants and conducted a systematic review of meta-analyses, randomized controlled trials and other studies. TREATMENT RECOMMENDATIONS: It is extremely difficult to draw general conclusions about the efficacy of specific treatment options for AN. There are few controlled clinical trials and their quality is generally poor. These guidelines necessarily rely largely upon expert opinion and uncontrolled trials. A multidimensional approach is recommended. Medical manifestations of the illness need to be addressed and any physical harm halted and reversed. Weight restoration is essential in treatment, but insufficient evidence is available for any single approach. A lenient approach is likely to be more acceptable to patients than a punitive one and less likely to impair self-esteem. Dealing with the psychiatric problems is not simple and much controversy remains. For patients with less severe AN who do not require in-patient treatment, out-patient or day-patient treatment may be suitable, but this decision will depend on availability of such services. Family therapy is a valuable part of treatment, particularly for children and adolescents, but no particular approach emerges as superior to any other. Dietary advice should be included in all treatment programs. Cognitive behaviour therapy or other psychotherapies are likely to be helpful. Antidepressants have a role in patients with depressive symptoms and olanzapine may be useful in attenuating hyperactivity.

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OBJECTIVES: The current study examined the stability and internal consistency of the Eating Disorder Examination Questionnaire (EDE-Q) in a general population sample. METHODS: The EDE-Q was administered to a community sample of women aged 18-45 on two occasions, with a median test-retest interval of 315.0 days. RESULTS: Pearson correlations between items of the EDE-Q assessing attitudinal features of eating disorder psychopathology ranged from 0.57 for the Restraint subscale to 0.77 for the Eating Concern subscale. The stability of items addressing eating disorder behaviors was much lower, with phi coefficients for the occurrence of objective bulimic episodes, subjective bulimic episodes, and use of exercise as a compensatory behavior of 0.44, 0.24, and 0.31, respectively, and Kendall's tau b correlations of 0.44, 0.28, and 0.31, respectively, for the frequency of these behaviors, across occasions. The internal consistency of the EDE-Q was high, with a Cronbach alpha coefficient for the global scale of 0.93, compared with a value of 0.90 for the Eating Disorder Examination interview. DISCUSSION: Items of the EDE-Q assessing attitudinal features of eating disorder psychopathology demonstrate a high degree of temporal stability, whereas the stability of items addressing eating disorder behaviors is much lower. In the case of compensatory eating disorder behaviors, low stability is likely to reflect actual trait variation, whereas the low stability of binge eating behaviors, in particular subjective bulimic episodes, is likely to reflect both trait variation and measurement error. The high internal consistency of EDE-Q items supports its use as a screening instrument in two-phase epidemiologic studies.

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OBJECTIVE: To examine the beliefs of women concerning the helpfulness of various possible interventions for bulimia nervosa. METHOD: Face-to-face interviews were conducted with a community sample of 208 women aged 18-45 years. Respondents were presented with a vignette describing a fictional person meeting diagnostic criteria for bulimia nervosa and were asked to indicate whether various persons, treatments, medications, and self-help activities would be helpful, harmful, or neither helpful nor harmful for the person described. RESULTS: Respondents indicated that seeing a general practitioner (GP), counselor, or dietitian was more likely to be helpful than seeing either a psychologist or a psychiatrist. GPs were perceived as the individuals likely to be most helpful for the problem described, and most likely to be approached first, whereas counseling was regarded as the most helpful treatment. Self-help interventions, including the use of vitamins and minerals, were also highly regarded, while a minority of participants believed that anti-depressant medication would be helpful. CONCLUSIONS: Information concerning treatments that are effective for eating disorders should be included in prevention programs. Collaborations between mental health specialists and primary health providers are vital to ensure the optimal treatment of eating-disordered behavior.

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OBJECTIVE: To investigate nonresponse bias in a two-phase epidemiologic study of eating-disordered behavior. METHOD: Self-report questionnaires were delivered to a community sample of women aged 18-45 drawn from the electoral roll. Follow-up interviews were completed with a subgroup of respondents. Eating disorder psychopathology, general physical and mental health, and sociodemographic characteristics were compared among early (n = 259) and late (n = 71) respondents at the first phase of the study and among individuals with whom interviews were completed (n = 208) and individuals declining to be interviewed (n = 63) at the second phase. RESULTS: With respect to levels of eating disorder psychopathology, and on all other measures, individuals who responded at the first phase of the study only after repeated reminders did not differ from those who responded to the initial mailout, and individuals who declined to be interviewed did not differ from individuals with whom interviews were completed. CONCLUSIONS: Nonresponse bias among individuals declining to be interviewed is unlikely to pose a problem in two-phase epidemiologic studies of eating disorders. Further research is needed to examine the characteristics of nonrespondents at the first phase of such studies.

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OBJECTIVE: To examine the beliefs of women concerning causes and risk factors for eating-disordered behaviour. METHOD: Face-to-face interviews were conducted with a community sample of 208 women aged 18-45 years. Respondents were presented with a vignette describing a fictional person meeting diagnostic criteria for bulimia nervosa (BN) and were asked to indicate whether each of several factors was 'very likely', 'likely' or 'not likely' to be a cause of the problem described, which factor was most likely to be a cause, and whether particular subgroups of people would be 'more likely', 'less likely' or 'equally likely' to have or develop the problem described. RESULTS: 'Having low self-esteem' was considered very likely to be a cause of BN by 75.0% of respondents, and the most likely cause by 40.5% of respondents. Other factors perceived as significant were 'problems from childhood', 'portrayal of women in the media', 'being overweight as a child or adolescent' and 'day-to-day problems', while genetic factors and pre-existing psychological problems were perceived to be of minor significance. Most respondents believed that women aged under 25 years were at greatest risk of having or developing BN. CONCLUSIONS: Women's beliefs concerning causes and risk factors for BN are generally consistent with empirical evidence. However, information concerning the increased risk associated with pre-existing anxiety and affective disorders might usefully be included in prevention programs. Systematic investigation of the benefits of addressing individuals' beliefs concerning risk factors for eating disorders - as opposed to risk factors per se - would be of interest.

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OBJECTIVE: To examine disability associated with community cases of the more commonly occurring eating disorders and with particular eating disorder behaviours. METHOD: Self-report questionnaires, which included measures of eating disorder symptoms and impairment in everyday functioning, were completed by 495 female residents of the Australian Capital Territory region aged between 18 and 45 years. A structured interview for the assessment of eating disorders was completed by a subgroup (n = 208) of participants. Discriminant function analysis was used to identify cases of eating disorders in the total sample (n = 495) based on the characteristics of individuals interviewed. Impairment in functioning, as measured by the Medical Outcomes Study Short Form, was compared among eating disorder cases and non-cases, among subgroups of participants engaging in particular eating disorder behaviours, and among community cases of anxiety and affective disorders identified from the Australian National Survey of Mental Health and Well-Being. RESULTS: Community cases of eating disorders (n = 31; 6.3%) were associated with substantial impairment in functioning, comparable with that of community cases of anxiety and affective disorders. Among eating disorder behaviours, the use of extreme weight-control behaviours, in particular self-induced vomiting, was associated with the highest levels of impairment, although the occurrence of regular episodes of overeating was also associated with considerable impairment. CONCLUSIONS: The burden on the community of the more commonly occurring eating disorders may be substantial. Improving women's recognition of the adverse effects of eating disordered-behaviour on functioning, as well as their knowledge of effective treatments, will be important in reducing this burden.

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OBJECTIVE: To report a reduced febrile response to bacterial infections in anorexia nervosa (AN) patients. METHOD: Four cases were obtained from a retrospective review of charts from the St. Paul's Hospital Eating Disorders Program (Vancouver, Canada). The patients had died or had been admitted to the hospital for treatment of a bacterial infection. In addition, one case was obtained from the Royal Prince Alfred Hospital (Sydney, Australia). RESULTS: All patients suffered a bacterial infection during the course of AN. None of the patients had a temperature higher than 37 degrees C during the infectious illness. DISCUSSION: The absence of fever in AN may delay the diagnosis of bacterial infection and may be a marker of an impaired immune response. Therefore, alternative methods of investigation are necessary in patients with AN suspected of having a bacterial infection.

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BACKGROUND: General practitioners take on varying levels of responsibility for patients who have eating disorders. Roles appear to be tiered, from simply identifying illness and referring the patient on, to acting as care coordinator, providing medical and psychological treatment and/or continuing care. OBJECTIVE: Every GP has some level of responsibility toward this patient group. This article aims to identify the various levels of intervention and roles GPs may take and to provide practitioners with options regarding their level of clinical involvement. DISCUSSION: Just what role GPs choose to take in the management of patients with eating disorders depends on many factors including the stage of the patient's illness, and the doctor's interest, knowledge and clinical skills in this area of practice.

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Weight-restored patients with anorexia nervosa (AN) respond favorably to the selective serotonin reuptake inhibitor fluoxetine, which justifies association studies of the serotonin transporter gene (SLC6A4, alias SERT) and AN. Case-control studies suggest that the least transcriptionally active allele of the SERT gene promoter polymorphism (5-HTTLPR) has an increased frequency in AN patients. However, this finding was not replicated with 55 trios (AN child+parents) and the transmission disequilibrium test (TDT). To clarify the role of the 5-HTTLPR in susceptibility to AN, we used the TDT and 106 Australian trios to provide 93% power to detect a genotypic relative risk (GRR) of 2.0. Our results were negative for this GRR (McNemar's chi(2)=0.01, df=1, p=0.921, odds ratio 1.0, 95% CI 0.7-1.5). Additionally, we found no association with AN females, AN subtype, age at onset, or minimum BMI. We then performed the first reported investigation of epistasis between the SERT gene and norepinephrine transporter gene (SLC6A2, alias NET) in AN, as an earlier study suggested that atypical AN responds to the dual serotonin-norepinephrine reuptake inhibitor venlafaxine. We observed no epistasis between the 5-HTTLPR and a polymorphism within the NET gene promoter polymorphic region (NETpPR) (chi(2)=0.48, df=1, p=0.490). Although 5-HTTLPR modulates serotonin reuptake by the serotonin transporter, our analyses provide no evidence that susceptibility to AN is modified by 5-HTTLPR alone, nor in concert with as yet undetermined functional effects of the NETpPR polymorphism.

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OBJECTIVE: The clinical effectiveness of group and individual cognitive-behavioral therapy (CBT) for bulimia nervosa (BN) was compared. METHOD: Sixty BN patients from hospitals and general practitioners in Sydney, Australia, were allocated randomly to group or individual CBT. Forty-four completed treatment (n = 22 in group CBT and n = 22 in individual CBT). Patients were assessed at pretreatment, posttreatment, and at 3 and 6 months follow-up with the Eating Disorder Examination-12 and self-report questionnaires examining weight and shape attitudes (Eating Disorder Inventory-2), social adjustment (Social Adjustment Scale-Modified), self-esteem (Rosenberg Self-Esteem Scale), and general psychopathology (Symptom Checklist 90R). RESULTS: The effects of group and individual CBT were equivalent on most measures. However, a significantly greater proportion of individual CBT patients than group CBT patients were abstinent from bulimic behaviors at posttreatment, but not at follow-up. DISCUSSION: This has implications for the delivery of cost-effective and clinically effective treatment for BN.

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With the best will in the world, it is difficult not to become disillusioned with the diagnostic system for eating disorders. Although repeatedly revised, diagnostic criteria such as those of DSM-IV or ICD10 are inadequate to describe the patient's condition. This essay critically appraises the historical development of eating disorders and challenges the widely held notion that bulimia nervosa and anorexia nervosa share a common psychopathology. It further argues that the time has arrived to think about anorexia nervosa and the eating disorders in a way different to the current stereotyping. It suggests that anorexia nervosa like neoplasia is a disease that requires staging and a model for such staging is presented.

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OBJECTIVE: In the northern hemisphere, people with anorexia nervosa are more likely to be born in the spring and early summer, particularly when environmental temperature at assumed time of conception is warmer. This study investigates whether there is a comparable effect in the southern hemisphere (Australia), where seasonal and temperature patterns are reversed. METHOD: Date of birth and temperature at assumed time of conception were collected for 199 Australian and 259 UK patients with early-onset anorexia nervosa. Analyses determined patterns of birth and links to temperature at conception. RESULTS: There was little change across the year in the birth patterns of young people with anorexia nervosa in the southern hemisphere. However, there was a significant link between temperature at assumed time of conception and diagnostic subtype. Compared with anorexics of the binge/purge subtype, restrictive anorexics from the southern hemisphere were less likely to be conceived in relatively cool weather. CONCLUSIONS: The findings support a temperature at conception hypothesis (modified for local temperature ranges), rather than suggesting a simple seasonal pattern of birth.

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