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Objective and Method The prior occurrence of regular extreme weight-control behaviors was examined in a community sample of women (n = 27) with binge eating disorder (BED) or subthreshold BED. Results Approximately two thirds of participants (65.4%) reported the prior use of either purging at least weekly or nonpurging behaviors three or more times per week, for a period of 3 months or more, whereas 38.5% of participants reported either purging at least twice weekly or nonpurging behaviors five or more times per week. Comparatively few participants (11.1%) had ever met formal diagnostic criteria for BN. Discussion Considerable overlap be-tween disorders characterized by binge eating in the absence of extreme weight-control behaviors and those characterized by extreme weight-control behaviors in the absence of binge eating may be apparent when a longitudinal perspective is taken. Caution needs to be exercised in drawing conclusions concerning the extent of this overlap based on any one operational definition of the term “regular extreme weight-control behaviors”. © 2009 by Wiley Periodicals, Inc. Int J Eat Disord 2010

Background and Methods: In a community sample of women who reported the use of extreme weight-control behaviors in the absence of binge eating, subgroups of participants who reported (n = 23) and who did not report (n = 42) recurrent subjective bulimic episodes (SBEs) were compared on a range of outcomes, including current levels of eating disorder and comorbid psychopathology. Results: Participants who reported SBEs had higher levels of eating disorder psychopathology, impairment in role functioning, and general psychological distress, than those who did not. Scores on these measures among participants who reported SBEs were similar to those of eating disorder patients receiving specialist treatment, whereas those of participants who did not have recurrent SBEs tended to be intermediate between eating disorder patients and healthy women. Discussion: The findings are consistent with the hypothesis that it is the combination of SBEs and extreme weight-control behaviors, rather than extreme weight-control behaviors per se, that indicates clinical significance. © 2009 by Wiley Periodicals, Inc. Int J Eat Disord 2010

Background Psychotic illness following childbirth is a relatively rare but severe condition with unexplained etiology. The aim of this study was to investigate the impact of maternal background characteristics and obstetric factors on the risk of postpartum psychosis, specifically among mothers with no previous psychiatric hospitalizations. Methods and Findings We investigated incidence rates and potential maternal and obstetric risk factors of psychoses after childbirth in a national cohort of women who were first-time mothers from 1983 through 2000 (n = 745,596). Proportional hazard regression models were used to estimate relative risks of psychoses during and after the first 90 d postpartum, among mothers without any previous psychiatric hospitalization and among all mothers. Within 90 d after delivery, 892 women (1.2 per 1,000 births; 4.84 per 1,000 person-years) were hospitalized due to psychoses and 436 of these (0.6 per 1,000 births; 2.38 per 1,000 person-years) had not previously been hospitalized for any psychiatric disorder. During follow-up after the 90 d postpartum period, the corresponding incidence rates per 1,000 person-years were reduced to 0.65 for all women and 0.49 for women not previously hospitalized. During (but not after) the first 90 d postpartum the risk of psychoses among women without any previous psychiatric hospitalization was independently affected by: maternal age (35 y or older versus 19 y or younger; hazard ratio 2.4, 95% confidence interval [CI] 1.2 to 4.7); high birth weight (≥ 4,500 g; hazard ratio 0.3, 95% CI 0.1 to 1.0); and diabetes (hazard ratio 0). Conclusions The incidence of psychotic illness peaks immediately following a first childbirth, and almost 50% of the cases are women without any previous psychiatric hospitalization. High maternal age increases the risk while diabetes and high birth weight are associated with reduced risk of first-onset psychoses, distinctly during the postpartum period., Unnur Valdimarsdóttir and colleagues studied the risk factors for psychiatric illness following childbirth and found that, for women who had never previously been hospitalized for a psychiatric illness, the risk of mental illness was greatly increased following childbirth., Editors' Summary Background. The first cries of a new life echo around the delivery suite: this is a time of great joy for most women. Yet, in the following days and weeks (the postpartum period), up to 80% of new mothers experience some sort of mental disturbance. Usually, this is the “baby blues,” a normal reaction to childbirth that is characterized by short-lived mood swings or postnatal depression. However, about one in 1,000 women develop postpartum psychosis, a serious mental disorder that needs immediate medical attention. Postpartum psychosis usually develops suddenly in the first 2–3 weeks after delivery and, like other forms of psychosis, is characterized by a loss of contact with reality. Women with postpartum psychosis may have false ideas about current events and about themselves (delusions) and see and hear things that are not there (hallucinations). They sometimes stop eating or sleeping and may become anxious and agitated. In the worst cases, they can have suicidal thoughts or even threaten their baby's life. Treatment for postpartum psychosis includes antipsychotic drugs, counseling, and hospital admission if the woman is a danger to herself or others. Why Was This Study Done? Women with a personal or family history of psychosis have an increased risk of developing postpartum psychosis, but what causes this disorder is unknown. The rapid changes in hormone levels that occur after delivery are likely to be involved—but might social circumstances, stress, other illnesses, or the birth itself also affect whether a woman develops postpartum psychosis? If additional risk factors for postpartum psychosis could be identified, it might be possible to prevent some cases of this serious mental disorder. In this study, the researchers investigate the incidence rate (the rate at which new cases occur in a population) and risk factors for psychotic illnesses diagnosed among first-time mothers registered in the Swedish Medical Birth Registry between 1983 and 2000. What Did the Researchers Do and Find? The researchers identified three-quarters of a million first-time mothers and, from the Swedish Hospital Discharge Registry, found that 892 of these women (1.2 per 1,000 births) had been admitted to hospital because of psychosis within 90 days of giving birth. Put another way, the incidence rate of psychosis over the first 90 days postpartum in this population was 4.84 per 1,000 person-years. Almost half of the women who developed postpartum psychosis had not been previously admitted to hospital for any psychiatric disorder. Among this subset of women, the incidence rate of postpartum psychosis was highest during the first month after delivery but dropped to less than a tenth of this initial rate after 90 days postpartum. Furthermore, the risk of developing psychosis during the first 90 days postpartum (but not after) increased with age—women older than 35 years were more than twice as likely to develop psychosis than those aged 19 years or less—but was reduced in women who had large babies or who had diabetes. Many other factors (including smoking and not living with the infant's father) did not affect the risk of psychosis during the first 90 days postpartum in these women. What Do These Findings Mean? These findings indicate that the occurrence of psychotic illness severe enough to require hospitalization peaks shortly after giving birth for the first time, even in women with no previous psychiatric illness. Indeed, women with no history of mental disorders account for almost half the women admitted to hospital for postpartum psychosis, at least in Sweden. The timing of the peak of postpartum psychosis supports the idea that either giving birth or the hormonal changes that occur shortly after may trigger the development of psychosis, and the findings that maternal diabetes and high infant birth weight reduce the risk of postpartum psychosis whereas increasing maternal age increases the risk provide new clues about the causes of postpartum psychosis. Most importantly, however, these findings highlight the importance of carefully monitoring women for psychosis during the first month after delivery. Additional Information. Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000013. This paper is further discussed in a PLoS Medicine Perspective by Phillipa Hay The MedlinePlus Encyclopedia contains a page on MedlinePlus encyclopedia psychosis (in English and Spanish); MedlinePlus also provides links to information on psychotic disorders The UK National Health Service Direct Health encyclopedia has information on psychosis and on postnatal depression Mental Health America has a fact sheet on postpartum disorders

Of 107 recently admitted psychiatric patients screened for eating-disorder symptoms by questionnaire, 17% met DSM–III–R criteria for eating disorders. Eight patients (one male) had bulimia nervosa. Ten patients had eating disorder not otherwise specified: seven (three male) bulimic type, and three (one male) anorexia nervosa type. The most common concurrent diagnoses were mood and personality disorders. As eating-disorder symptoms are relevant to the diagnosis and management of other psychiatric disorders they should be assessed routinely in all psychiatric patients.

Objective: To measure the cooccurrence of obesity and eating disorder (ED)behaviors in the South Australian population and assess the change in level from 1995 to 2005. Method: Two independent cross-sectional single stage interview based population surveys were conducted a decade apart. Self-reported height, weight, ED behaviors, and sociodemographics were assessed. Changes between the two time points were analyzed. Results: From 1995 to 2005 the population prevalence of comorbid obesity and ED behaviors increased from 1 to 3.5%. Comorbid obesity and ED behaviors increased more (prevalence odds ratio (POR) 5 4.5; 95% confidence interval (CI) 5 95% CI 5 [2.8, 7.4]; p\.001) than either obesity (POR 5 1.6; 95% CI 5 [1.3, 2.0]; p \ .001) or ED behaviors (POR 5 3.1; 95% CI 5 [2.3, 4.1]; p\.001) alone. Discussion: Comorbid obesity and ED behaviors are an increasing problem in our society. Prevention and treatments efforts for obesity and EDs must consider and address this increasing comorbidity.

BackgroundEvidence for an increase in the prevalence of eating disorders is inconsistent. Our aim was to determine change in the population point prevalence of eating disorder behaviors over a 10-year period.Methodology/principal findingsEating disorder behaviors were assessed in consecutive general population surveys of men and women conducted in 1995 (n = 3001, 72% respondents) and 2005 (n = 3047, 63.1% respondents). Participants were randomly sampled from households in rural and metropolitan South Australia. There was a significant (all pConclusions/significanceIn this population sample the point prevalence of eating disorder behaviors increased over the past decade. Cases of anorexia nervosa and bulimia nervosa, as currently defined, remain uncommon.

Objective and Methods: Agreement between self-report and interview assessment of purging behaviours was examined in a community sample of women with a high level of eating disorder symptoms (n = 324) who completed both the Eating Disorder Examination (EDE) and Eating Disorder Examination Questionnaire (EDE-Q). Results: Of 46 individuals who reported any use of self-induced vomiting or laxative misuse on the questionnaire, 19 (41.7%) denied these behaviours when subsequently questioned in a face-to-face interview. These individuals had lower levels of eating disorder psychopathology, functional impairment and general psychological distress, than participants who reported purging on both the questionnaire and at interview (n = 27). Conclusions: The assumption of interview superiority in the assessment of specific aspects of eating disorder psychopathology should not be uncritically accepted. Caution should be exercised in drawing conclusions concerning the level of agreement between self-report and interview assessment of purging based on research in clinical samples.

There is a dearth of qualitative research exploring eating disordered individuals' emotional responses to the sight of different types of food. In this study we asked 10 adult women diagnosed with bulimia nervosa, anorexia nervosa or an eating disorder not otherwise specified (EDNOS) to articulate their thoughts whilst viewing slides of a range of different foodstuffs, during an in-depth interview session. The data were transcribed and subjected to qualitative analysis. A core theme of 'Control' was identified. Whilst control has been previously acknowledged in the literature as an important aspect of eating disordered behaviour, this is the first report to link control with negative emotional responses to the sight of food. Clinically, an exploration of the notion of control and how it relates to particular foods may be beneficial in therapy.

Objective and Methods The comparative validity of the Eating Disorder Examination Questionnaire (EDE-Q) (22 items) and SCOFF (five items) in screening for cases of the more commonly occurring eating disorders was examined in a primary care sample of young adult women (n=257). Diagnoses were confirmed in a sub-group of interviewed participants (n=147). Results Twenty-five cases, primarily variants of bulimia nervosa (BN) not meeting formal diagnostic criteria, were identified in the interviewed sample. An EDE-Q global score of ⩾2.80 yielded the optimal trade-off between sensitivity (Se) (0.80) and specificity (Sp) (0.80) (positive predictive value (PPV)=0.44), whereas a score of two or more positive responses on the SCOFF was optimal (Se=0.72, Sp=0.73, PPV=0.35). Validity coefficients for both measures varied as a function of participants’ age and body weight, although these effects were more pronounced for the SCOFF. Conclusions Both measures performed well in terms of their ability to detect cases and to exclude non-cases of the more commonly occurring eating disorders in a primary care setting. The EDE-Q performed somewhat better than the SCOFF and was more robust to effects on validity of age and weight. These findings need to be weighed against the advantage of the SCOFF in terms of its brevity.

Background: Prior use of health services was examined in a community sample of women with bulimic-type eating disorders. Method: Participants (n = 159) completed a structured interview for the assessment of eating disorder psychopathology as well as questions concerning treatment-seeking and type of treatment received. Results: Whereas a minority (40.3%) of participants had received treatment for an eating problem, most had received treatment for a general mental health problem (74.2%) and/or weight loss (72.8%), and all had used one or more self-help treatments. Where treatment was received for an eating or general mental health problem, this was from a primary care practitioner in the vast majority of cases. Only half of those participants who reported marked impairment associated with an eating problem had ever received treatment for such a problem and less than one in five had received such treatment from a mental health professional. Conclusion: Women with bulimic-type eating disorders rarely receive treatment for an eating problem, but frequently receive treatment for a general mental health problem and/or for weight loss. The findings underscore the importance of programs designed to improve the detection and management of eating disorders in primary care. © 2007 by Wiley Periodicals, Inc. Int J Eat Disord 2007

Objective: To examine functional impairment associated with bulimic behaviors in a community sample of men and women. Method: Binge eating, purging, fasting, extreme weight and shape concerns, and "days-out-of-role" were assessed in a community sample of men (n = 1,290) and women (n = 1,757) aged 15–94 years. Results: Participants who reported regular eating disorder behaviors had higher levels of functional impairment than those who did not. This was the case for both men and women and for each of the behaviors assessed, although differences between purgers and nonpurgers were not statistically significant. Also in both men and women, participants who reported eating disorder behaviors and weight or shape concerns had higher levels of impairment than those who reported these behaviors in the absence of weight or shape concerns. In multivariate analysis, binge eating, fasting and weight or shape concerns all contributed to the likelihood of impairment in men, whereas only the presence of weight or shape concerns was significantly associated with impairment in women. Conclusion: Whereas bulimic behaviors are associated with elevated levels of functional impairment in both men and women, weight or shape concerns may be more central to the experience of this impairment in women.

Objective: To examine associations between obesity and impairment in developmental functioning in a general population sample of pre-school children. Method: Standardized medical examinations were conducted in nine consecutive cohorts of male and female children (n=9415) aged between 4.4 and 8.6 years (mean=6.0, s.d.=0.37) residing in the Lower Bavaria region of Germany. Tests designed to assess performance in subdivisions representing four broad developmental domains, namely, motor development, speech development, cognitive development and psycho-social development, were completed by all participants. Results: Boys had significantly higher rates of impairment than girls. The prevalence of obesity in boys was 2.4%, whereas in girls it was 4.3% (χ2=21.51, P < 0.01). After controlling for age, gender, year of recruitment and other potential covariates, the prevalence of impairment in gross motor skills was higher among obese male children than normal-weight male children (adjusted odds ratio=1.76, 95% confidence interval (CI)=1.02, 3.01, P < 0.05), whereas the prevalence of impairment in the ability to focus attention was higher in obese female children than normal-weight female children (adjusted odds ratio=1.86, 95% CI=1.00, 3.44, P < 0.05). Conclusions: The findings suggest that gender-specific associations between obesity and impairment in specific aspects of developmental functioning may be evident in younger children.

Compulsive exercise is known to be a problematic feature of adult eating disorders (ED), however, there is little research investigating compulsive exercise in adolescents with EDs. In particular, the acute anxiolytic and anti-depressant properties of exercise are yet to be determined in adolescent ED inpatients. Thus, the current study examined the prevalence and psychopathological correlates of compulsive exercise in a sample of 60 female adolescent ED inpatients. The study also aimed to identify the psychological benefits of a supervised inpatient physiotherapy-lead exercise program, and if these benefits were greater in participants reporting higher levels of compulsive exercise. At the commencement of their inpatient treatment participants completed a series of standardised self-report questionnaires, assessing eating and psychiatric pathology as well as compulsive exercise features. Participants' mood state was then repeatedly assessed immediately before and after participating in physiotherapy sessions (exercise condition) and school classes (control condition) using visual analogue scales for an admission period of up to three weeks. Results indicated that higher levels of ED symptomology and anxiety were significantly associated with compulsive exercise. Significant acute mood benefits in response to the exercise intervention were also identified in preliminary analyses. The findings support the relevance of assessing compulsive exercise in adolescents with EDs and provide an understanding of the positive and negative reinforcement functions of exercise, which may guide future treatment efforts within ED inpatient settings.

The Eating Beliefs Questionnaire (EBQ; Groves, Abbott & Baillie, 2015) is a 32-item self-report questionnaire assessing positive and negative beliefs about binge-eating, which are implicated in the maintenance of binge-eating in keeping with Cooper et al.'s (2004) cognitive model. The EBQ was shown to be a valid and reliable measure of eating-related beliefs with excellent psychometric properties. The EBQ has yet to be cross-validated with a clinical sample, and clinical cut-off scores have not been determined. In order to address these issues, a sample of 739 participants was recruited (544 community, 195 clinical: 95 with a diagnosed eating disorder and 100 obese Ps). Participants completed the test-battery, of which 54 clinical participants completed the test-battery before and after receiving psychological treatment for binge-eating, and 38 community participants completed the test-battery again after a lapse of two-weeks. The results of a Confirmatory Factor Analysis will be presented, including evaluation of the EBQ's psychometric properties (internal consistency, criterion validity, construct validity, agreement, reliability, responsiveness, and interpretability). Results will be interpreted with regard to current cognitive models and the EBQ's utility for use in clinical and research settings will also be discussed.

Compulsive exercise in anorexia nervosa (AN) has been associated with adverse effects in treatment, and is a major risk factor for relapse. However, exercise is often surreptitious and measurement problematic. For example, females in community samples have been found to over-report physical activity when compared to objective assessment. The current study aimed to explore the relationships between objectively recorded and subjectively reported physical activity (PA) in AN outpatients. Participants were 34 females with AN enrolled in a randomised-controlled trial of outpatient treatment of anorexia nervosa (Hay et al., in progress). They completed the Eating Disorder Examination (EDE) interview; self-report questionnaires assessing eating disorder and exercise cognitions and behaviours; and wore an accelerometer for 4 days as an objective PA measure. Participants also self-reported their average daily PA. Results demonstrated significant under-reporting (objective PA greater than self-report PA) on light and total PA, but not vigorous or moderate PA. Discrepancy scores between moderate PA (accelerometer – self-report) were also negatively correlated with motivation to change in AN (p

There are no evidence-based treatments for severe and enduring anorexia nervosa. Objective To evaluate the relative efficacy of Cognitive Behavioral Therapy (CBT) and Specialist Supportive Clinical Management (SSCM) for adults with severe and enduring anorexia nervosa. Design Randomised controlled trial. Participants Sixty-three participants aged 18 and over (range 20-62) with a DSM-IV diagnosis of anorexia nervosa with at least a seven year illness history. Interventions Thirty outpatient visits over 8 months. Participants were assessed at baseline, end of treatment (EOT), and 6-month and 12-month post-treatment follow-up. At EOP and follow-up, both groups improved significantly on the majority of outcome measures. However, there were no differences between treatment groups at EOT. At 6- and 12-month follow-up, analyses indicate greater improvement for those in CBT compared to SSCM. At 6-month follow-up, CBT participants had higher scores on the social adjustment scale (p = .038), and at 12-month they reported lower eating disorder examination global score (p = .004), and higher readiness for recovery (p = .013) compared to SSCM. Conclusions Patients with severe and enduring anorexia nervosa can make significant and meaningful improvements with therapy. CBT shows significant advantage over SSCM in terms of social adjustment, core eating pathology, and readiness for change over time.

AIM: To compare outcomes in anorexia nervosa (AN) in different treatment settings: inpatient, partial hospitalization and outpatient. METHODS: Completed and published in the English language, randomized controlled trials comparing treatment in two or more settings or comparing different lengths of inpatient stay, were identified by database searches using terms “anorexia nervosa” and “treatment” dated to July 2014. Trials were assessed for risk of bias and quality according to the Cochrane handbook by two authors (Madden S and Hay P) Data were extracted on trial quality, participant features and setting, main outcomes and attrition. RESULTS: Five studies were identified, two comparing inpatient treatment to outpatient treatment, one study comparing different lengths of inpatient treatment, one comparing inpatient treatment to day patient treatment and one comparing day patient treatment with outpatient treatment. There was no difference in treatment outcomes between the different treatment settings and different lengths of inpatient treatment. Both outpatient treatment and day patient treatment were significantly cheaper than inpatient treatment. Brief inpatient treatment followed by evidence based outpatient care was also cheaper than prolonged inpatient care for weight normalization also followed by evidence based outpatient care. CONCLUSION: There is preliminary support for AN treatment in less restrictive settings but more research is needed to identify the optimum treatment setting for anorexia nervosa.

Objective: Self-recognition of eating-disordered behavior was examined in a community sample of young adult women (n = 158) with bulimic eating disorders. Method: A vignette was presented describing a fictional person meeting diagnostic criteria for bulimia nervosa. Participants were asked whether they might currently have a problem such as the one described. Scores on measures of eating disorder psychopathology, functional impairment and general psychological distress were compared between participants who recognized a problem with their eating and those who did not. Results: Participants who recognized a problem with their eating (n = 86, 51.9%) had higher levels of eating disorder psychopathology and general psychological distress, were more likely to engage in self-induced vomiting, and tended to be heavier, than those who did not (n = 72, 48.1%). In addition, participants who recognized a problem were more likely to have received treatment for an eating or weight problem. In multivariate analysis, the occurrence of self-induced vomiting and higher body weight were the only variables significantly associated with recognition. Conclusion: Poor recognition of eating-disordered behavior may be conducive to low or inappropriate treatment seeking among individuals with bulimic- type eating disorders. The perception that only disorders involving self-induced vomiting are pathological may need to be addressed in prevention programs.

In an ecological study in this issue of PLoS Medicine, Milane and colleagues found a temporal association between prescription of specific serotonin reuptake inhibitor (SSRI) antidepressants and suicide rates in the United States [ 1]. Their study addresses a subject of great public health importance and clinical interest. The researchers asked the question: was the use of antidepressants associated with a change in suicide rates in the general population of the United States between 1988 and 2002? There were two underlying hypotheses: (1) antidepressants can trigger suicide and subsequently increase suicide rates, and (2) through the treatment of depression with antidepressants, suicide rates decline over time.

Levels of eating disorder psychopathology, impairment in psycho-social functioning and use of health services were compared among probable cases of binge eating disorder (BED) with and without extreme weight or shape concerns ("undue influence of weight or shape on self-evaluation") recruited from a large community sample of women. Data for obese non-binge eaters (n=457), also recruited from the community sample, and for a clinical sample of eating disorder patients (n=128), recruited separately, were included for comparative purposes. BED cases who reported extreme weight or shape concerns (n=51, 46.4%) had significantly higher levels of eating disorder psychopathology and functional impairment than those who did not report such concerns (n=59), after controlling for between-group differences in age and body weight. In addition, BED cases who reported extreme weight or shape concerns were more likely to have sought treatment for an eating or weight problem than those who did not. Whereas levels of eating disorder psychopathology and functional impairment were markedly elevated among BED cases with extreme weight or shape concerns, BED cases who did not report extreme weight or shape concerns resembled obese non-binge eaters in most respects. The findings support the inclusion of an undue influence of weight or shape on self-evaluation as a diagnostic criterion for BED. In the absence of this influence, eating disorders that otherwise resemble BED do not appear to be "clinically significant".

The correlates of self-induced vomiting and laxative misuse were examined in a large community sample of young adult women (N = 5255). Scores on measures of eating disorder psychopathology, general psychological distress, functional impairment, as well as the use of health services for an eating or weight problem were compared among participants who reported regular self-induced vomiting, but not laxative misuse (N = 59), and those who reported regular misuse of laxatives, but not vomiting (N = 39). Individuals who misused laxatives were older, perceived poorer physical health, and were less likely to have sought treatment specifically for a problem with eating than those who engaged in self-induced vomiting. In all other respects, the groups were similar. However, individuals who regularly engaged in both forms of purging (N = 8) had particularly high levels of eating disorder and comorbid psychopathology. The perception among women of normal weight that only syndromes involving the use of self-induced vomiting constitute an eating disorder may need to be addressed in prevention programs. The combination of self-induced vomiting and laxative misuse may indicate a particularly severe psychiatric disturbance.

Objective The current study informed the definition of excessive exercise by examining relations between exercise behavior, eating-disordered behavior, and quality of life (QOL) in a community sample of women. Method Self-report measures of frequency of exercise, obligatory exercise and motivation for exercise, and of eating disorder psychopathology and QOL, were completed by 3,472 women aged 18-42 years who engaged in regular exercise. Results The extent to which exercise is intended to influence weight or shape and the degree to which guilt is experienced when exercise is postphoned were the exercise variables most strongly associated with elevated levels of eating disorder psychopathology and reduced QOL. Subgroups of participants who reported exercising solely for weight and shape reasons (n = 322 [9.3%]), intense guilt after postponement of exercise (n = 136 [3.9%]), or both (n = 116 [3.3%]), had markedly elevated levels of eating disorder psychopathology. There was no association between excessive exercise and reduced QOL after the effects of eating disorder psychopathology were statistically controlled. Conclusion The findings suggest that exercise is excessive when its postponement is accompanied by intense guilt or when it is undertaken solely to influence weight or shape. Operational definitions of excessive exercise might usefully include reference to these terms. The findings may also be of benefit in informing the content of prevention programs, which address dysfunctional exercise behavior. Excessive exercise is unlikely to be associated with impairment in psychosocial functioning in the absence of eating disorder psychopathology. It may, however, be a useful indicator of such psychopathology.

Background. To increase access to cognitive behavioural therapy for bulimia nervosa new delivery modes are being examined. Guided Self-Help (GSH) in primary care is potentially valuable in this respect. This research aimed to compare outcomes following GSH delivered by general practitioners (GPs) in the normal course of their practice to a delayed treatment control (DTC) condition, and to examine the maintenance of treatment gains at 3 and 6 months following completion of GSH.Method. Participants were 109 women with full syndrome or sub-threshold bulimia nervosa, randomly allocated to GSH (n=54) and DTC (n=55). The GSH group received direction and support from a GP over a 17-week period while working through the manual in Bulimia Nervosa and Binge-Eating: A Guide to Recovery by P. J. Cooper (1995). GSH and DTC groups were assessed pre-treatment and 1 week following the 17-week intervention or waiting interval. The GSH group was reassessed at 3- and 6-month follow-up.Results. Intention-to-treat analyses at end of treatment revealed significant improvements in bulimic and psychological symptoms in GSH compared with DTC, reduction in mean frequency of binge-eating episodes by 60% in GSH and 6% in DTC, and remission from all binge-eating and compensatory behaviours in 28% of the GSH and 11% of the DTC sample. Treatment gains were maintained at 3- and 6-month follow-up.Conclusion. Outcomes in GSH compare favourably with those of specialist-delivered psychological treatments. These findings are considered in light of the nature of the therapy offered and the primary care context.

Objective: To examine quality of life among subgroups of eating disorder patients. Method: Self-report questionnaires which included two quality of life measures were completed by 87 individuals referred for treatment to the Australian Capital Territory Eating Disorders Day Program. Health-related quality of life, as measured by the Medical Outcomes Study 12-item Short Form Mental Component Summary scale, and subjective quality of life, as measured by subscales of the World Health Organization Brief Quality of Life Assessment Scale (WHOQOL-BREF), were compared among individuals who received the diagnosis of anorexia nervosa purging subtype (n=15), anorexia nervosa restricting subtype (n=19), bulimia nervosa (n=40) and binge eating disorder (n=10), and among a general population sample of young adult women employed as a control group (n=495). Results: Eating disorder patients, when considered together, showed marked impairment in both health-related and subjective quality of life relative to normal control subjects. However, in both domains, restricting anorexia nervosa patients reported significantly better quality of life than other patient groups, after controlling for levels of general psychological distress. Scores on the Social Relationships subscale of the WHOQOL-BREF among individuals in this subgroup were similar to those of normal control subjects. Conclusions: Reliance on any one instrument is likely to be misleading in assessing the quality of life of eating disorder patients. Careful consideration needs to be given to the assessment of restricting anorexia nervosa patients in particular.

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.

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.

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. © 2004 by Wiley Periodicals, Inc. Int J Eat Disord 36: 62–68, 2004.

Few studies have examined attitudes towards eating-disordered behaviour among women in the general population. A vignette describing a fictional person meeting diagnostic criteria for bulimia nervosa (BN) was presented to a community sample of women aged 18–45. Respondents (n = 208) were asked a series of questions concerning the severity and prevalence of the problem described. Most respondents viewed BN as a distressing condition whose sufferers are deserving of sympathy. However, more than one-third of respondents had at some stage believed that it ‘might not be too bad’ to be like the person described in the vignette. Most respondents believed that the prevalence of the problem described among women in the community was likely to be between 10 % and 30 % (48.6%) or between 30% and 50 % (23.1 %). Individuals with a clinically significant eating disorder (n = 13, 6.3%) were more likely to perceive the symptoms of BN as being acceptable, and its prevalence higher, than individuals with no eating disorder diagnosis. Information concerning the medical and psychological sequelae of BN and other eating disorders might usefully be incorporated in prevention programmes. Prospective community-based research is required to elucidate the nature of the relationship between perceived acceptability of eating disorder symptoms and actual eating disorder psychopathology. Extension of the present research to examine the views of women in other cultures would also be of interest.

Bulimia nervosa occurs in about 1% of young women in Western countries. It is often chronic and adversely affects quality of life.1 The rate of diagnosis is very low, and community and primary care studies have shown that treatment is often delayed.2 3 An important contributing factor to this delay is the secrecy and shame around binge eating, self induced vomiting, and laxative misuse.4 Bulimia nervosa should be suspected in young and middle aged women who present with weight and shape concerns (whether they are normal or overweight)3 or with common comorbid conditions such as depression, anxiety, or substance …

We (Raman et al., 2013) have developed a conceptual and theoretical framework of obesity maintenance termed the Clinical Obesity Maintenance Model (COMM). We argue that psychological variables, that of executive function, habit clusters, emotional dysregulation, level of depressed mood, and health literacy (eating beliefs and attitudes about obesity) interact and impact on the overeating/binge eating and sedentary obesity maintaining behaviours of individuals who are obese. The main aim of the present study was to test how well the COMM predicts obesity maintaining behaviours in an adult community sample. Specific aims were: (a) to test the strength and direction of associations between the individual constructs of the model, and (b) the independent effects of individual model constructs on obesity maintaining behaviours. Study participants (n = 100) were community volunteers who completed the following assessments and instruments: a demographic and anthropometric profile, a neuropsychological battery that included tests of executive function (e.g., Wisconsin Card Sort Test, Rey Complex Figure Test, Brief A, Trail Making Task and Digit Span), the Self Report Habit Index, the Depression Anxiety and Stress Scale, Difficulties in Emotion Regulation Scale, Modified Health Literacy Questionnaire and the Eating Beliefs, Grazing and the Eating Disorder Examination Questionnaires. Data were analysed with univariate correlational statistics followed by multivariate statistical modelling using multiple regression.

Competing interests: PJH has received reimbursement for attending symposiums from Solvay Pharmaceuticals, Bristol-Myers Squibb, and Pfizer Pharmaceuticals and for educational training of family doctors from Bristol-Myers Squibb. JB has received fees from Janssen-Cilag Farmaceutica. If you are interested in being a contributor or peer reviewer for Clinical Evidence please visit the Clinical Evidence website (www.clinicalevidence.org) Clinical Evidence is published by BMJ Publishing Group. The fifth issue is available now, and Clinical Evidence will be updated and expanded every six months. Individual subscription rate, issues 5 and 6 £75/$110; institutional rate £160/$240; student rate £55/$80. For more information including how to subscribe, please visit the Clinical Evidence website at www.clinicalevidence.org

Background Problem-based learning (PBL) and other small-group teaching methods which incorporate principles of adult learning, are exciting innovations in medical education. In the application of these methods to medical curricula many schools have introduced non-expert tutors. However, research evaluating the effectiveness of non-expert lead teaching has been inconclusive. Aim The present study aim was to compare the outcome of teaching in small groups facilitated by either an ‘expert’ or a ‘non-expert’ tutor, in a single topic area. Method Fourth-year medical students were allocated randomly to teaching of eating disorders either by a non-expert or an expert tutor. Outcomes were evaluated by (i) a knowledge test, and (ii) self-report ratings by tutors and students of their learning methods and other qualities. Results The study found that while the non-expert tutor was rated more highly for her group management skills, and she also rated her students more highly in the area of oral communication, students who were taught by the expert scored higher in the end-of-course test in the topic area. Conclusion The findings suggest that caution should be exercised, and the need for more research before widespread adoption of teaching by non-expert tutors.

Objective: The objective of this study was to valuate the effectiveness, tolerability and acceptability of various classes of antidepressants compared with placebo in the treatment of bulimia nervosa.Method: A meta-analysis including 16 randomised controlled trials and 1300 bulimic patients was performed. Dichotomous outcomes were analysed by calculating relative risks, and continuous outcomes by calculating effect sizes. Methodological quality, heterogeneity in the results and selective publication were assessed.Results: Short-term remission in bulimic symptoms was statistically more likely on antidepressants than placebo (Relative Risk = 0.88, 95%% Cl = 0.83–0.94, p < 0.0001). Drop-out rates were high but no statistical difference was found between treatment groups (34.6%% and 31.4%% for drug and placebo; RR = 1.03, 95%% CI = 0.80–1.32, p = 0.8). No difference in efficacy could be demonstrated among different classes of antidepressants.Conclusions: The use of a single antidepressant agent was clinically effective for the treatment of bulimia nervosa when compared with placebo, with an overall greater remission rate and a higher rate of drop-outs. No differential effect regarding efficacy and tolerability among the various classes of antidepressants could be demonstrated.

[Figure][1] This is a short and initially engaging book written in an informal style. Its purpose is to help non-specialists \`gain confidence and competence in assessing and treating weight and eating issues' (p. 7). Cognisant of the growing number of those with \`overweight and obesity

Results Men represented 23 - 41% of participants who reported ED features. Objective binge eating was associated with greater reductions in mental HRQoL in men compared to women (p 0.05). Mental HRQoL impairment associated with binge eating had increased over time for men but not for women (p < 0.05). Conclusions

Objective Obsessive-compulsive personality disorder (OCPD) traits and obsessive-compulsive disorder (OCD) are commonly associated with patients with Anorexia Nervosa (AN). The aim of this review was to systematically search the literature to examine whether OCPD and OCD are positively associated with excessive exercise in patients with AN. Method A systematic electronic search of the literature (using PsycInfo, Medline and Web of Knowledge) was undertaken to identify relevant publications until May 2012. Results A total of ten studies met criteria for inclusion in the review. The design of the studies varied from cross-sectional to retrospective and quasi-experimental. Seven out of the ten studies reviewed demonstrated a positive relationship between OCPD and/or OCD in AN patients who exercise excessively, whilst three studies found a lack of relationship, or a negative relationship, between these constructs. Conclusion There is evidence from the literature to suggest that there is a positive relationship between OCPD and excessive exercise in patients with AN. However, the relationship between OCD and excessive exercise is less clear and further research is required to qualify the strength of such relationships. Future research should utilise the most comprehensive and reliable clinical assessment tools, and address prognostic factors, treatment factors and specific interventions for patients with OCPD and/or OCD and excessive exercise.

SynopsisThere is controversy over how best to classify eating disorders in which there is recurrent binge eating. Many patients with recurrent binge eating do not meet diagnostic criteria for either of the two established eating disorders, anorexia nervosa or bulimia nervosa. The present study was designed to derive an empirically based, and clinically meaningful, diagnostic scheme by identifying subgroups from among those with recurrent binge eating, testing the validity of these subgroups and comparing their predictive validity with that of the DSM-IV scheme.A general population sample of 250 young women with recurrent binge eating was recruited using a two-stage design. Four subgroups among the sample were identified using a Ward's cluster analysis. The first subgroup had either objective or subjective bulimic episodes and vomiting or laxative misuse; the second had objective bulimic episodes and low levels of vomiting or laxative misuse; the third had subjective bulimic episodes and low levels of vomiting or laxative misuse; and the fourth was heterogeneous in character. This cluster solution was robust to replication. It had good descriptive and predictive validity and partial construct validity.The results support the concept of bulimia nervosa and its division into purging and non-purging subtypes. They also suggest a possible new binge eating syndrome. Binge eating disorder, listed as an example of Eating Disorder Not Otherwise Specified within DSM-IV, did not emerge from the cluster analysis.

Bulimia nervosa is a significant source of morbidity amongst young women. There has been a considerable body of work on its treatment since it was first described in 1979. Three treatments have shown particular promise: antidepressant drug treatment, cognitive behaviour therapy and exposure with response prevention. The research findings indicate that the approach of choice is cognitive behaviour therapy, with most patients benefiting significantly and the changes being well maintained. However, cognitive behaviour therapy is neither necessary nor sufficient for all patients with bulimia nervosa: some benefit from simpler interventions whilst others fail to respond. At present, too little is known about the factors that predict response to particular forms of treatment to allow the matching of patients with treatments.

The study retrospectively evaluated risk factors for osteopenia in anorexia nervosa (AN) patients. Sixty-nine outpatient, female anorexia nervosa patients (age range 20-40 years, mean 27.5) at varying stages of recovery, and 31 controls had lumbar spine trabecular bone density assessed with single energy computed tomography (CT) scans. An investigator-based, semistructured interview assessed weight and menstrual histories from age 10. Current exercise and dietary calcium levels were categorized and lifetime durations in categories were estimated for each subject. Bone density was significantly lower in the patient group (mean 120 mg/cm3) than in the controls (mean 148 mg/cm3, P less than 0.001). Bone density correlated significantly with duration of illness, amenorrhea, and weight histories but not with measures of dietary calcium or exercise histories. The most important predictor of bone loss on stepwise multiple regression analysis was duration of AN (23% of variance, P less than 0.001), and duration of an inadequate calcium intake in adolescence explained a further 5% of the variance (P = 0.052). There was no evidence that regular exercise and adequate dietary calcium prevented bone loss related to prolonged periods of low weight and amenorrhea in these subjects.

Walter Vandereycken and Pierre J.V. Beumont (eds) London: Athlone, 1998 ISBN 0 48524 101 3 pp.286 $16.95Treating Eating Disorders: Ethical, Legal and Personal Issues is the first in a series of stu...