Prevalence of obesity and comorbid eating disorder behaviors in South Australia from 1995 to 2015.

BACKGROUND: Obesity and eating disorders are often studied and treated separately. While the increases in obesity prevalence are well known, examination of its co-occurrence with eating disorders, a problem also of public health concern, is important because eating disorder behaviors are known to contribute to obesity onset and maintenance, and vice versa. METHODS: Data from large cross-sectional representative statewide community samples of people in the years of 1995 (n=3001), 2005 (n=3047) and 2015 (n=3005) were analyzed. Data were collected using a structured, self-report interview that included demographic, health-related, weight, height and eating disorder behavior questions. Eating behavior questions assessed binge eating, very strict dieting/fasting and purging, and were derived from the Eating Disorder Examination. Logistic regression analyses were conducted comparing prevalence of obesity, eating disorder behaviors and their co-occurrence. RESULTS: The prevalence of obesity or binge eating, or obesity with comorbid binge eating, each increased significantly from 1995 to 2005 (P<0.001 for each comparison) and continued to increase significantly from 2005 to 2015 (P<0.001 for each comparison). The highest increases from 1995 to 2015 were in the prevalence of obesity with comorbid binge eating (7.3-fold), or obesity with comorbid very strict dieting/fasting (11.5-fold). The prevalence of very strict dieting/fasting also increased significantly from 1995 to 2015 (3.8-fold). The prevalence of purging, or obesity with comorbid purging, did not change significantly from 1995 to 2015. CONCLUSION: There were statewide increases during the 20 years from 1995 to 2015 in the independent prevalence of obesity, binge eating and very strict dieting/fasting, and even higher increases in the prevalence of obesity with comorbid binge eating, and obesity with comorbid very strict dieting/fasting. These findings support the need for more integrated approaches to both the prevention and treatment of obesity and eating disorder behaviors, namely binge eating and very strict dieting/fasting.

A randomised controlled trial of three psychological treatments for anorexia nervosa.

BACKGROUND: There is a lack of evidence pointing to the efficacy of any specific psychotherapy for adults with anorexia nervosa (AN). The aim of this study was to compare three psychological treatments for AN: Specialist Supportive Clinical Management, Maudsley Model Anorexia Nervosa Treatment for Adults and Enhanced Cognitive Behavioural Therapy. METHOD: A multi-centre randomised controlled trial was conducted with outcomes assessed at pre-, mid- and post-treatment, and 6- and 12-month follow-up by researchers blind to treatment allocation. All analyses were intention-to-treat. One hundred and twenty individuals meeting diagnostic criteria for AN were recruited from outpatient treatment settings in three Australian cities and offered 25-40 sessions over a 10-month period. Primary outcomes were body mass index (BMI) and eating disorder psychopathology. Secondary outcomes included depression, anxiety, stress and psychosocial impairment. RESULTS: Treatment was completed by 60% of participants and 52.5% of the total sample completed 12-month follow-up. Completion rates did not differ between treatments. There were no significant differences between treatments on continuous outcomes; all resulted in clinically significant improvements in BMI, eating disorder psychopathology, general psychopathology and psychosocial impairment that were maintained over follow-up. There were no significant differences between treatments with regard to the achievement of a healthy weight (mean = 50%) or remission (mean = 28.3%) at 12-month follow-up. CONCLUSION: The findings add to the evidence base for these three psychological treatments for adults with AN, but the results underscore the need for continued efforts to improve outpatient treatments for this disorder. Trial Registration Australian New Zealand Clinical Trials Registry (ACTRN 12611000725965) http://www.anzctr.org.au/.

How abnormal is binge eating? 18-Year time trends in population prevalence and burden.

OBJECTIVE: Although findings suggest that binge eating is becoming increasingly normative, the 'clinical significance' of this behaviour at a population level remains uncertain. We aimed to assess the time trends in binge-eating prevalence and burden over 18 years. METHOD: Six cross-sectional face-to-face surveys of the Australian adult population were conducted in 1998, 2005, 2008, 2009, 2014, and 2015 (Ntotal = 15 126). Data were collected on demographics, 3-month prevalence of objective binge eating (OBE), health-related quality of life, days out of role, and distress related to OBE. RESULTS: The prevalence of OBE increased six-fold from 1998 (2.7%) to 2015 (13.0%). Health-related quality of life associated with OBE improved from 1998 to 2015, where it more closely approximated population norms. Days out of role remained higher among participants who reported OBE, although decreased over time. Half of participants who reported weekly (56.6%) and twice-weekly (47.1%) OBE reported that they were not distressed by this behaviour. However, the presence of distress related to OBE in 2015 was associated with greater health-related quality-of-life impairment. CONCLUSION: As the prevalence of binge eating increases over time, associated disability has been decreasing. Implications for the diagnosis of disorders associated with binge eating are discussed.

A randomized controlled trial of in-patient treatment for anorexia nervosa in medically unstable adolescents.

BACKGROUND: Anorexia nervosa (AN) is a serious disorder incurring high costs due to hospitalization. International treatments vary, with prolonged hospitalizations in Europe and shorter hospitalizations in the USA. Uncontrolled studies suggest that longer initial hospitalizations that normalize weight produce better outcomes and fewer admissions than shorter hospitalizations with lower discharge weights. This study aimed to compare the effectiveness of hospitalization for weight restoration (WR) to medical stabilization (MS) in adolescent AN. METHOD: We performed a randomized controlled trial (RCT) with 82 adolescents, aged 12-18 years, with a DSM-IV diagnosis of AN and medical instability, admitted to two pediatric units in Australia. Participants were randomized to shorter hospitalization for MS or longer hospitalization for WR to 90% expected body weight (EBW) for gender, age and height, both followed by 20 sessions of out-patient, manualized family-based treatment (FBT). RESULTS: The primary outcome was the number of hospital days, following initial admission, at the 12-month follow-up. Secondary outcomes were the total number of hospital days used up to 12 months and full remission, defined as healthy weight (>95% EBW) and a global Eating Disorder Examination (EDE) score within 1 standard deviation (s.d.) of published means. There was no significant difference between groups in hospital days following initial admission. There were significantly more total hospital days used and post-protocol FBT sessions in the WR group. There were no moderators of primary outcome but participants with higher eating psychopathology and compulsive features reported better clinical outcomes in the MS group. CONCLUSIONS: Outcomes are similar with hospitalizations for MS or WR when combined with FBT. Cost savings would result from combining shorter hospitalization with FBT.

Treating severe and enduring anorexia nervosa: a randomized controlled trial.

BACKGROUND: There are no evidence-based treatments for severe and enduring anorexia nervosa (SE-AN). This study evaluated the relative efficacy of cognitive behavioral therapy (CBT-AN) and specialist supportive clinical management (SSCM) for adults with SE-AN. METHOD: Sixty-three participants with a diagnosis of AN, who had at least a 7-year illness history, were treated in a multi-site randomized controlled trial (RCT). During 30 out-patient visits spread over 8 months, they received either CBT-AN or SSCM, both modified for SE-AN. Participants were assessed at baseline, end of treatment (EOT), and at 6- and 12-month post-treatment follow-ups. The main outcome measures were quality of life, mood disorder symptoms and social adjustment. Weight, eating disorder (ED) psychopathology, motivation for change and health-care burden were secondary outcomes. RESULTS: Thirty-one participants were randomized to CBT-AN and 32 to SSCM with a retention rate of 85% achieved at the end of the study. At EOT and follow-up, both groups showed significant improvement. There were no differences between treatment groups at EOT. At the 6-month follow-up, CBT-AN participants had higher scores on the Weissman Social Adjustment Scale (WSAS; p = 0.038) and at 12 months they had lower Eating Disorder Examination (EDE) global scores (p = 0.004) and higher readiness for recovery (p = 0.013) compared to SSCM. CONCLUSIONS: Patients with SE-AN can make meaningful improvements with both therapies. Both treatments were acceptable and high retention rates at follow-up were achieved. Between-group differences at follow-up were consistent with the nature of the treatments given.

Public perceptions of people with eating disorders: Commentary on results from the 2022 Australian national survey of mental health-related stigma and discrimination.

Mental illness is highly prevalent in the community. As such, significant attention has been paid in recent years to raising awareness of the mental health disorders (including eating disorders). This includes efforts to normalise help-seeking, campaigns to reduce stigma and discrimination, targeted research funding and advocacy for improved and accessible mental health service provision. But have these initiatives changed public attitude? The 2022 National Survey of Mental Health-Related Stigma and Discrimination is the first of four national surveys canvassing the general public's perceptions of people with mental health disorders (including stigmatising and discriminatory beliefs) conducted since 1995 to include eating disorders. It finds significant prejudice against those with mental health disorders still exists within the community, particularly among younger Australians. For eating disorders, this is primarily related to attributions of blame and personal weakness. Findings from the survey are discussed in this commentary.

What kind of illness is anorexia nervosa? Revisited: some preliminary thoughts to finding a cure.

Two decades have elapsed since our publication of 'What kind of illness is anorexia nervosa?'. The question remains whether our understanding of anorexia nervosa and its treatment thereof has evolved over this time. The verdict is disappointing at best. Our current gold standard treatments remain over-valued and clinical outcomes are modest at best. Those in our field are haunted by the constant reminder that anorexia nervosa carries the highest mortality rate of any psychiatric disorder. This cannot continue and demands immediate action. In this essay, we tackle the myths that bedevil our field and explore a deeper phenotyping of anorexia nervosa. We argue that we can no longer declare agnostic views of the disorder or conceive treatments that are "brainless": it is incumbent upon us to challenge the prevailing zeitgeist and reconceptualise anorexia nervosa. Here we provide a roadmap for the future.

Population-based analysis of sociodemographic predictors, health-related quality of life and health service use associated with obstructive sleep apnoea and insomnia in Australia.

Although there is growing recognition of the effects of living with sleep disorders and the important role of primary care in their identification and management, studies indicate that the detection of sleep apnoea (OSA) and insomnia may still be low. This large representative community-based study (n=2977 adults) used logistic regression models to examine predictors of self-reported OSA and current insomnia and linear regression models to examine the association of these sleep conditions with both mental and physical components of health-related quality of life (HRQoL) and health service use. Overall, 5.6% (95% confidence interval (CI) 4.6-6.7) and 6.8% (95% CI 5.7-7.9) of subjects self-reported OSA (using a single-item question) and current insomnia (using two single-item questions) respectively. Many sociodemographic and lifestyle predictors for OSA and insomnia acted in different directions or showed different magnitudes of association. Both disorders had a similar adverse relationship with physical HRQoL, whereas mental HRQoL was more impaired among those with insomnia. Frequent consultations with a doctor were associated with a lower physical HRQoL across these sleep conditions; however, lower mental HRQoL among those frequently visiting a doctor was observed only among individuals with insomnia. The adverse relationship between sleep disorders and physical and mental HRQoL was substantial and should not be underestimated.

An evaluation of the effectiveness and short-term stability of an innovative Australian day patient programme for eating disorders.

There is a dearth of literature evaluating day patient treatment for eating disorders based upon the targeted goals of treatment, to conclude that day patient programmes are effective. This study aimed to explore the effectiveness of an innovative day patient programme by examining whether the seven key treatment goals improved across treatment and were maintained 3 months after discharge. Of the 58 participants who completed measures assessing BMI, eating disorder cognitions, behaviours, core beliefs, readiness to change, quality of life and perpetuating factors at admission, discharge and follow-up, 44 completed the day programme with 14 non-completers. The results demonstrated that all seven treatment goals improved across treatment and the improvements were maintained or further improved at 3 month follow-up. The results are discussed in context of the published day patient programme literature with implications for future research to maximise optimal treatment outcomes from day patient treatment.

Anorexia nervosa: towards an integrative neuroscience model.

We reviewed the evidence for emotion-related disturbances in anorexia nervosa (AN) from behavioural, cognitive, biological and genetic domains of study. These domains were brought together within the framework of an integrative neuroscience model that emphasizes the role of emotion and feeling and their regulation, in brain organization. PsychInfo and Medline searches were performed to identify published peer-reviewed papers on AN within each domain. This review revealed evidence for 'Emotion', 'Thinking and Feeling' and 'Self-regulation' disturbances in AN that span non-conscious to conscious processes. An integrative neuroscience framework was then applied to develop a model of AN, from which hypotheses for empirical investigation are generated. We propose that AN reflects a core disturbance in emotion at the earliest time stage of information processing with subsequent effects on the later stages of thinking, feeling and self-regulation.

Translating evidence-based treatment for digital health delivery: a protocol for family-based treatment for anorexia nervosa using telemedicine.

BACKGROUND: Family-based treatment (FBT) is an efficacious outpatient intervention for young people diagnosed with Anorexia Nervosa (AN). To date, treatment to protocol has relied on standard face-to-face delivery. Face-to-face therapy is subject to geographic, temporal and human factors, rendering it particularly susceptible to inequities and disruption. This has resulted in poorer service provision for rural and regional families, and recently a significant challenge to providing face-to-face services during the COVID-19 global pandemic. The present study examines whether FBT for AN can be successfully translated to a digital delivery platform to address these access issues. METHOD: Forty young people aged 12 to 18 years who meet DSM-5 diagnostic criteria for AN, and live in a rural or regional setting, will along with their family be recruited to the study. Trained therapists will provide 18 sessions of FBT over 9 months via telemedicine to the home of the young person and their family. The analysis will examine treatment effectiveness, feasibility, acceptability, and cost-effectiveness. DISCUSSION: The study addresses the treatment needs of families not able to attend face-to-face clinical services for evidence-based treatment for eating disorders. This might be due to several barriers, including a lack of local services or long travel distances to services. There has been a recent and unprecedented demand for telemedicine to facilitate the continuity of care during COVID-19 despite geographical circumstances. If delivering treatment in this modality is clinically and economically effective and feasible, it will facilitate access to potentially lifesaving, evidence-based treatments for families formerly unable to access such care and provide evidence for the continuity of services when and where face-to-face treatment is not feasible.

Coercion in the treatment of anorexia nervosa: clinical, ethical and legal implications.

Because of its high mortality and treatment resistence, clinicians sometimes invoke the law in aid of retaining their most acutely ill-patients in treatment or re-feeding programs. Depending on the jurisdiction, various laws, including mental health and adult guardianship laws, have been invoked to achieve this objective (Carney, Tait, Saunders, Touyz & Beumont, 2003). Until recently, little was known about the therapeutic impact of coercion on patients (Saunders, 2001, Carney & Saunders 2003), or the relative advantages of different avenues of coercion (Carney, Saunders, Tait, Touyz & Ingvarson 2004). Most obscure of all, however, has been our understanding of the factors influencing clinical decisions within specialist anorexia treatment units regarding which in-patients will be selected for coerced treatment. This paper reports legal and ethical implications of findings from analysis of data gathered from a major Australian specialist anorexia treatment facility over nearly 5 years.

Does severe dietary energy restriction increase binge eating in overweight or obese individuals? A systematic review.

Severe dietary energy restriction is often used for overweight or obese individuals to achieve rapid weight loss and related health improvements. However, the extent of putative adverse effects on eating behaviour is unknown. We thus systematically searched seven databases for studies that assessed binge eating before and after severe dietary energy restriction (low or very low energy diets) in overweight or obese individuals. Fifteen clinically supervised interventions from 10 publications (nine of which involved only women) were included. Among individuals with clinically relevant pre-treatment binge eating disorder, severe dietary energy restriction significantly decreased binge eating in all four interventions involving this population, at least during the weight loss programme. In contrast, no consistent association between severe dietary energy restriction and the onset of bingeing was found in 11 interventions involving individuals without pre-treatment binge eating disorder, with four such interventions showing significant increases, two showing no change, and five showing significant decreases in binge eating. We conclude that clinically supervised severe dietary energy restriction appears safe and beneficial for overweight or obese individuals with pre-treatment binge eating disorder, and does not necessarily trigger binge eating in those without binge eating disorder.

A psychophysiological investigation of the short-term effects of clozapine upon sleep parameters of normal young adults.

A nine consecutive night, double-blind design was used to assess the effects of a psychotropic agent (clozapine) upon sleep parameters as well as measures of mood and performance in a group of seven normal, young adults. Placebo was administered to a control group of seven subjects. EEGs and EOGs were monitored throughout the night in a laboratory environment and were scored according to standardized criteria. The administration of 25 mg clozapine/night for three consecutive nights significantly reduced stage 4 sleep on the second and third nights. Whereas stage REM sleep was not affected, a variety of REM indices were significantly increased on the third night of clozapine administration and/or on the first night of clozapine withdrawal. The number of body movements and the number of body movements/minute of sleep were significantly reduced on the three nights of clozapine administration. Numerous psychophysiological side effects were reported. These results indicate that clozapine may be a useful medication in the treatment of sleep disorders. However, the incidence of adverse side effects of represents a major limitation in the use of clozapine as an hypnotic agent at the dose-rate employed.

Altered energy metabolism in anorexia nervosa.

Optimal nutritional rehabilitation of anorexia nervosa requires more information concerning actual energy and substrate requirements. To this end, indirect calorimetry was performed in female patients (n=34, age 20.9+/-1.2 yr, body mass index [BMI] 15.6+/-0.2 kg/m(2); mean+/-SEM) soon after commencement of refeeding and at the time of discharge from hospital (n=18, BMI 19.0+/-0.3 kg/m(2)). Healthy female controls (n=18, age 24.6+/-1.3 yr, BMI 21.6+/-0.6 kg/m(2)) were also tested. Resting energy expenditure (REE) and respiratory quotient (RQ) were measured in the fasting state, followed by diet-induced thermogenesis (DIT) and RQ over a 4 h period following a 100 g oral glucose load. Compared with post-refeeding patients and controls, pre-refeeding patients had a high basal RQ and a low REE, with a paradoxically higher DIT (13.2+/-0.9% of REE vs. 8.3+/-1.2% and 8.6+/-0.9% in post-refeeding patients and controls, respectively). RQ values in pre-refeeding patients exceeded unity following the glucose load, probably reflecting net lipogenesis, whereas in the post-refeeding patients, post-glucose RQ was similar to that of controls, suggesting premature curtailment of lipogenesis. These data demonstrate energy wasting in emaciated patients with anorexia nervosa. Biological repair processes could account for disproportionate energy loss early in refeeding and there may be some later impediment to full restoration of fat stores.

A psychophysiological investigation of the long-term effects of clozapine upon sleep patterns of normal young adults.

A 25-night single-blind cross over design was employed to determine the long-term effects of clozapine on the sleep patterns of six normal young adults. Subjects received 12.50 mg placebo on the first and last five nights, whereas on the intermediate 15 nights 12.5 mg clozapine was administered. The subjects slept in the laboratory on the third and fourth nights to obtain baseline recordings, and on the eight, twelfth, sixteenth, and twentieth nights to determine the effects of clozapine on sleep variables. Recordings on nights 21 and 25 were used to assess withdrawal effects. Percentage stage 1 sleep and indices of body movements during sleep were significantly reduced, suggesting that clozapine may have sleep-inducing properties. There were no significant rebound of stage REM sleep during drug withdrawal despite a small but significant reduction in stage REM during drug administration. Numerous side effects, indicative of sleepiness, were reported on the mornings following drug administration, and there was evidence of a rapid tolerance to clozapine. These findings may limit the efficacy of clozapine as an hypnotic agent over an extended period of time. Further research on insomniac subjects is therefore indicated.

Correcting the eating disorder in anorexia nervosa.

The aim of the present study was to assess whether direct informational feedback using videotape recordings would improve abnormal eating behaviour in patients with anorexia nervosa. Eight inpatients participated in the study. A statistically significant improvement was noted in the occurrence of obsessional eating behaviour and in table manners. However, there was no change in the speed of eating, disposal of food or behaviours which reduce caloric intake. The implications of these findings for the treatment and prognosis of anorexia nervosa are discussed.

The role of the clinical psychologist in gynecological cancer.

Gynecological cancers, which account for a substantial proportion of cancer cases in women, can precipitate a wide range of psychological difficulties including affective disturbances, sexual problems, certain somatic symptoms, and family issues. The clinical psychologist has a unique contribution to make in the assessment and treatment of the psychological needs of gynecological cancer patients, while also conducting research and providing training for health professionals regarding the psychological issues associated with gynecological cancer. Although the gynecological cancer setting affords the clinical psychologist multiple personal benefits, strategies must usually be implemented to minimize any negative impact arising from working in an area of considerable psychological stress.

Consistency of the first fixation when viewing a standard geometric stimulus.

Eye movements in response to presentation of a standard geometric figure (Rey Complex Geometric Figure) were investigated in 33 normal subjects. The figure was presented to each subject for 20 s, with instructions to remember as much detail as possible. Stimulus display was managed by special software that ensured all subjects were focused on the centre of the monitor before presentation, thus controlling for the initial point of gaze. Subjects were instructed, after viewing the stimulus, to reproduce the figure to scale on a blank sheet of paper. Location of the first voluntary fixation during the viewing period was consistently near the same feature in 80% of subjects (cohort I, n = 20). Patterns of eye movement during the remainder of the period, however, were found to vary widely among individuals. A complementary experiment using a second group of subjects (cohort II, n = 13) was undertaken to examine possible effects of brain function lateralisation on processing a feature in the left hemi-field. No lateralisation effect was evident and consistent identification of the same feature in the first voluntary fixation was confirmed for all subjects. No systematic relationships were found between eye movement indices obtained from real-time viewing of the Rey Figure and subsequent recall by drawing.

Forensic neuropsychology: a selective introduction.

During the last decade, neuropsychology has emerged as one of the fastest growing disciplines within clinical psychology. One of the most important roles for neuropsychologists is their contribution to the forensic sciences. The present paper reviews how lawyers may best utilize the services of clinical neuropsychologists. Suggestions are also offered to neuropsychologists on how better to meet the needs of lawyers. The following forensic science issues are discussed: the legal framework in which neuropsychologists function; contributions psychologists may make towards answering basic medicolegal questions such as the elucidation of the nature, extent, and duration of head injury sequelae; criteria for acceptable neuropsychological reports; medicolegal aspects of severe head injury, minor head injury (posttraumatic syndrome), and pseudo-head injury (malingering). There are many causes of damage to the nervous system (for example, industrial toxins and medical malpractice) that are eligible for compensation. Examples will be confined to head injury since the basic forensic science principles remain the same, whatever the etiology of such brain damage.