eMJA: Gilchrist et al, Eating disorders revisited I: anorexia nervosa

Eating disorders revisited. I: anorexia nervosa

Peter N Gilchrist, David I Ben-Tovim, Phillipa J Hay, Ross S Kalucy and M Kay Walker

MJA 1998; 169: 438-441

Synopsis - Introduction - Risk factors - Psychopathology - The role of the GP - Diagnosis - Treatment - References - Authors' details
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Synopsis

Anorexia nervosa is a serious psychiatric illness with a high morbidity and a significant lifetime mortality.

Recurring themes in such patients centre on issues of self-worth and control.

Treatment is difficult and prolonged, and may require hospitalisation.

Therapy focuses on altering the misperceptions that patients have of themselves, both psychologically and physically.

A multi-disciplinary team based in a specialised unit provides the treatment of choice, but if this is not available, a consistent, supportive relationship with an individual therapist familiar with the condition will be beneficial.

Successful outcome should be based not simply on body weight but also on the resolution of anorexic thinking.

Introduction
Eating disorders have captured the public imagination. Images of severely emaciated young women suffering from anorexia nervosa appear often in glossy women's magazines and current affairs programs, while public disclosure of bulimia nervosa has become commonplace. This publicity tends to obscure the continuing puzzle created by these enduring, hard-to-treat, and sometimes fatal conditions. It is therefore timely to review the clinical dilemmas provided by eating disorders.
Anorexia nervosa is not new,¹ having first been described in the 17th century. The clinical presentation appears essentially unchanged since the first comprehensive accounts were produced in the late 19th century. Patients with anorexia nervosa are characterised by a relentless pursuit of thinness, resulting in weight loss and a refusal to maintain a normal body weight. This refusal has been described as a "normal weight phobia".
Anorexia nervosa is not common. Worldwide, the true point prevalence is certainly no more than 0.5% of the female population over 15 years of age, and may be considerably less. Two studies of prevalence have been conducted in Australia: one reported a prevalence of 0.1% among a large group of schoolgirls,² and the other reported a lifetime prevalence of 0.4% among a large group of twins.³
Evidence for changes in the incidence of anorexia nervosa is controversial. Reports of recent increased incidence in specific populations have been criticised on methodological grounds.⁴ Increased use of hospital services may reflect a change in the threshold for admission, as much as changing incidences.⁵ In our experience, demand for hospital services for these patients has not changed substantially.
Anorexia nervosa can be fatal. Although death rates vary between studies and may be falling, a rule of thumb is that one patient per two hundred treated will die as a result of starvation or suicide during each treatment year. For patients who do survive, the burden of disability and distress remains considerable. Overall outcome varies between studies, but about 40% of patients make a good five-year recovery, 40% remain symptomatic but function reasonably well, and 20% remain severely symptomatic and are chronically disabled.⁶
Risk factors

Sex: Anorexia nervosa occurs mainly, but not exclusively, among women; the female to male ratio is at least 10 to one. The origins of this sex difference remain unclear. However, as a society we are continually bombarded with images of impossibly slender young women. This, in part, explains the development of a "normative discontent" about physiologically unremarkable variations in body weight and shape.⁷
Dieting: Dieting is common in women in Australia and the first world, but only a small proportion of dieters develop anorexia nervosa. Why this proportion is so small remains unclear. However, normal dieting is almost certainly a trigger for the condition, and participation in occupations or sporting activities that require adherence to a strict diet is likely to place individuals at some risk.^8,9
Other influences: Factors ranging from family communication characteristics such as blurring of boundaries and over identification, to personality styles such as perfectionism and obsessionality have been implicated as being of aetiological importance, but none have been validated with any scientific rigour.¹⁰
Psychopathology and clinical features
The clinical features are deeply distressing for the observer; for the patient, the anorexic condition is a solution, but to what problem?
The anorexic attitude is more understandable if being fat is seen as not being good enough, and being thinner is being better. In our view, the anorexic belief is: if my weight is right, then I am all right and if I am thinner then I must be a better person.
Although the exact origins of such a state are unclear, patients commonly describe a pre-morbid sense of hopelessness, self-hatred and profound unworthiness. As weight loss occurs, individuals feel more disciplined and special. They can do something that their peers often talk about, but rarely succeed at: they can lose weight. In so doing they feel the ultimate triumph of control over their own bodies. Unfortunately, as self-control fails to influence the sense of self, and distress continues, the person displays a rigidity of outlook, and continues to pursue dietary perfection.¹¹
The clinical picture that results is quite typical (Box 1). A change in eating patterns is one of the earliest signs of the disorder. Commonly, patients develop eating routines that have the effect of spreading out whatever enjoyment is to be had from eating, without losing control. Often these give the family and the patient the impression of an adequate dietary intake. Patients may dirty plates and eating utensils to maintain the facade of eating.
Although the term "anorexia" implies loss of appetite, this is not correct. Anorexic patients are terrified of losing control of their appetite. Patients regularly describe a fear that meals will immediately be deposited as fat, so they must maintain control over food intake despite continuing hunger. Many abstain from food; others have eating binges followed by self-induced vomiting or purging. Vomiting and purging can also be seen in individuals whose food consumption is minimal.
At one time, it was believed that anorexic patients had a distorted perception of themselves, as though they saw an expanded representation of themselves when they looked in the mirror. That view has not held up to scientific examination, but most people with anorexia nervosa do hold deeply negative attitudes towards their own bodies.¹² They commonly feel that their hips and thighs are too large, and that their abdomen is too rounded and protuberant. The tenacity with which those feelings persist even in the face of profound emaciation is one of the most disconcerting and puzzling features of the condition. The clinical presentation and underlying problems are similar in men, although there may be a greater concern about health and fitness, rather than appearances.¹³
Patients with well-established anorexia nervosa are starving, and demonstrate various associated physiological changes (Box 2). These changes are non-specific consequences of the particular form of starvation seen in anorexia nervosa, and reverse with recovery. Anorexic patients may have changes in their menstrual patterns (oligo- or amenorrhoea) that may be concealed by the use of the contraceptive pill. Menses may cease before any substantial weight loss has occurred.
Patients with anorexia nervosa are often depressed. There is debate whether the depression is solely related to the weight loss; more often a depressed mood or self-loathing precedes the decision to lose weight. Patients commonly describe a sense of hopelessness and acknowledge suicidal ideation. There may be a decrease in the level of enjoyment of life, although as they begin to lose weight, there may be increased physical activity. Whether this is a reflection of internal agitation or yet another way to burn off calories is not always clear.
Patients often give a history of hyperventilation. Alcohol is used at times to decrease anxiety, and food intake is further reduced to compensate for the caloric intake.
The role of the general practitioner
General practitioners have an essential role in the early recognition and ongoing management of anorexia nervosa. Patients can present with anorexia nervosa at any age, but the onset of the disorder is most often in the mid-teenage years. Patients rarely present themselves for treatment; usually they are brought by family members who do not know what else to do. The family's concerns should be acknowledged, and the severity and potential chronicity of the illness be discussed even if there has not yet been a dramatic weight loss. For younger patients, the effects of starvation on physical development should be conveyed.
Initial assessment is often difficult as patients may endeavour to conceal a degree of weight loss, be reluctant to be weighed, and try to minimise their difficulties. Information from other sources, such as family or school authorities, is usually necessary to complete the clinical picture. General practitioners are familiar with the dilemmas of caring for young people who seek to conceal information regarding their reasons for consulting from their families; when these issues relate to weight or diet, they are best seen as part of the illness.
Families are commonly disrupted by the behaviour of the anorexic patient, and need support and advice. General practitioners can play a useful role in providing ongoing information and ensuring that families continue to maintain patients' safety despite entreaties by the patients that they will best recover by being left alone. Formal family therapy improves the outcome of adolescent patients still residing with their families, but does not change the outcome of older patients.¹⁴ In our experience, relationships that patients began when severely underweight often involve an element of rescue on behalf of the partner, who will then find actual recovery problematic.
Anorexia nervosa is a serious condition and in our view specialised assessment, if only for diagnostic purposes, is indicated wherever possible. Further management can then be discussed with the specialist concerned. The therapeutic challenge presented by anorexic patients should never be underestimated.
Diagnosis and investigations

The diagnosis remains a clinical one. There are no specific investigations diagnostic of the disorder. The most widely used diagnostic criteria for defining anorexia nervosa are those in Box 3. With careful history-taking clinicians can elicit the degree of weight loss, which should be related to the pre-morbid weight. They should ask about the patient's heaviest, lightest and current weight, and the patient's own perceived ideal weight. Weight loss of more than 15% of average body weight is of considerable concern. Younger patients may show a failure to gain weight with developmental maturation, rather than loss of weight. Further enquiry should be made to determine if the weight loss has been voluntary, and to elicit any accompanying disturbances in body and self-related attitudes.
While the diagnosis of anorexia nervosa is dependent on accurate history-taking, supporting observations may be made during physical examination and routine investigations (Boxes 2 and 4). The physical findings associated with starvation are quite variable, but the emergence of the biochemical indicators of starvation (Box 4) indicates a serious deterioration in the patient's health.¹⁶
Hormonal investigations are not warranted unless pituitary or ovarian dysfunction is seriously considered.
Abnormal results such as hypokalaemia, a metabolic acidosis or alkalosis may suggest an eating disorder if the diagnosis was not previously considered. If the anorexic condition has been longstanding, bone densitometry may be useful to define the degree of bone loss and abnormalities.
Treatment
Treatment must be tailored to the needs of the patient and the severity of the illness. Denial of the severity or even the existence of a problem is extremely common, and the early phases of treatment are often difficult. Anorexia nervosa is a solution and an escape for the patient, so patients must have confidence that support will be available if they are to confront the varied internal and external conflicts that have precipitated the condition. These underlying problems are hard to deal with while patients have access to anorexia nervosa as a means of avoiding or resolving difficulties, so weight restoration and dietary normalisation remain the fundamental touchstones of treatment. However, they should only be one part of a comprehensive program of care, not a substitute for a long term approach.
Referral to a specialised eating disorders service should always be contemplated, even for individuals whose weight loss is not yet marked. Referral is more urgent if amenorrhoea or weight loss of more than 10% has already occurred. If the general practitioner is experienced in the treatment of anorexia nervosa, this should continue, if possible, in conjunction with a specialised unit. Provision of such services varies between centres, however, and access may be particularly difficult for patients in country areas.
Patients may become acutely medically unwell as a result of severe weight loss and dehydration, and may require resuscitation before any further treatment can be considered. Our unit has a close working relationship with our intensive care physicians, and severely unwell patients are admitted to the Intensive Care Unit for resuscitation before being transferred to our specialised eating disorders unit. The treatment of anorexia nervosa in our unit has evolved from long term inpatient programs with outpatient follow-up, to a predominantly outpatient strategy with hospital backup.¹⁷ Treatment begins on an outpatient basis, with inpatient care reserved for those individuals who fail to progress.
The guiding principles of treatment are restoration of a normal weight range for height and age and the identification, and resolution, of the contributing family and personal problems. The hospital and staff should be portrayed as a resource that is available to the patient rather than as being able to provide a magical solution to the individual's problems. An eclectic approach is necessary, including individual and family therapy when warranted, dietary advice and, if considered appropriate, pharmacotherapy.
A depressed mood may reflect an associated depressive illness and antidepressant medication can be of use. However, antidepressant medication is not recommended as a routine treatment. If a patient is highly agitated, especially when attempting to eat, then a major tranquilliser that does not have the disinhibiting effects of an anxiolytic agent may be useful, but should be instituted as part of the formal treatment program.
Supervised weight gain, often involving bed rest, is still used for those who are unable to gain weight outside hospital. Prolonged hospitalisation is now limited to those who have failed in outpatient treatment or who have not benefited from brief admissions, except in young patients, where it is essential to gain weight to allow normal physical development.
For patients who refuse active treatment, are treatment-resistant or live in isolated areas, general practitioners can provide an ongoing monitoring of patients' physical health. Insisting on admission to hospital is occasionally required if the patient is at physical risk, but should be avoided if possible. Such admissions should be in consultation with members of the ongoing treatment team. As a long term strategy, treatment orders have not proved helpful. Forced feeding, either naso-gastrically or intravenously, should only be used in life threatening medical situations, again, in conjunction with the treating team.
References

Kaufman MR, Heiman H. Evolution of psychosomatic concepts: anorexia nervosa. A paradigm. London: Hogarth Press, 1965.
Ben-Tovim DI, Morton J. The epidemiology of anorexia nervosa in South Australia. Aust N Z J Psychiatry 1990; 24: 182-186.
Wade T, Heath AC, Abraham S, et al. Assessing the prevalence of eating disorders in an Australian twin population. Aust N Z J Psychiatry 1996; 30: 845-851.
Frombonne E. Anorexia nervosa. No evidence of an increase. Br J Psychiatry 1995; 166: 462-471.
Halmi K. Changing rates of eating disorders: what does it mean? Am J Psychiat 1997; 152: 1256-1257.
Herzog DB, Keller MB, Lavori PW. Outcome in anorexia nervosa and bulimia nervosa. A review of the literature. J Nerv Ment Dis 1988; 176: 131-143.
Rodin J, Silberstein L, Striegel-Moore R. Women and weight: a normative discontent. Nebr Symp Motiv 1984; 31: 267-307.
Richert AJ, Hummers JA. Patterns of physical activity in college students at possible risk for eating disorders. Int J Eating Disorders 1986; 5: 757-763.
Gilchrist PN, Burke L. Eating disorders. In: Bloomfield J, Fricker PA, Fitch KD, editors. Textbook of science and medicine in sport. 2nd ed. London: Blackwell Science, 1995; 665-672.
Strober M, Morrell W, Burroughs J, et al. A controlled family study of anorexia nervosa. J Psychiatr Res 1985; 19: 239-246.
Vitousek KB, Daly J, Heiser C. Reconstructing the internal world of the eating- disordered individual: overcoming denial and distortion in self-report. Int J Eating Disorders 1991; 10: 647-666.
Ben-Tovim DI, Walker MK. A quantitative study of body-related attitudes in patients with anorexia and bulimia nervosa. Psychol Med 1992; 22: 961-969.
Carlat DJ, Camargo CA, Herzog DB. Eating disorders in males: a report of 135 patients. Am J Psychiat 1997; 154: 1127-1132.
Russell GF, Szmukler GI, Dare C, Eisler I. An evaluation of family therapy in anorexia nervosa and bulimia nervosa. Arch Gen Psychiatry 1987; 44: 1047-1056.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994.
Sharp CW, Freeman CPL. The medical complications of anorexia nervosa. Br J Psychiatry 1993; 162: 452-462.
Kalucy RS, Gilchrist PN, McFarlane CM, McFarlane AC. The evolution of a multi therapy orientation. In: Garner DM, Garfinkel PE, editors. Handbook of psychotherapy for anorexia nervosa and bulimia. New York: Guildford Press, 1984; 458-487.

Authors' details

Weight Disorder Unit, Flinders Medical Centre, Bedford Park, SA.
Peter N Gilchrist, MB BS, FRANZCP, Clinical Director;
David I Ben-Tovim, PhD, FRANZCP, Director of Research, and Associate Professor, Department of Psychiatry, Flinders University;
M Kay Walker, BA(Hons), Research Officer.

Department of Psychiatry, The University of Adelaide, Adelaide, SA.
Phillipa J Hay, DPhil, FRANZCP, Senior Lecturer.

Department of Psychiatry, Flinders University, Adelaide, SA.
Ross S Kalucy, FRACP, FRANZCP, Professor.

Reprints: Dr P N Gilchrist, Clinical Director, Weight Disorder Unit, Flinders Medical Centre, Bedford Park, SA 5042.

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Synopsis	Anorexia nervosa is a serious psychiatric illness with a high morbidity and a significant lifetime mortality. Recurring themes in such patients centre on issues of self-worth and control. Treatment is difficult and prolonged, and may require hospitalisation. Therapy focuses on altering the misperceptions that patients have of themselves, both psychologically and physically. A multi-disciplinary team based in a specialised unit provides the treatment of choice, but if this is not available, a consistent, supportive relationship with an individual therapist familiar with the condition will be beneficial. Successful outcome should be based not simply on body weight but also on the resolution of anorexic thinking.
Introduction	Eating disorders have captured the public imagination. Images of severely emaciated young women suffering from anorexia nervosa appear often in glossy women's magazines and current affairs programs, while public disclosure of bulimia nervosa has become commonplace. This publicity tends to obscure the continuing puzzle created by these enduring, hard-to-treat, and sometimes fatal conditions. It is therefore timely to review the clinical dilemmas provided by eating disorders. *Anorexia nervosa is not new,¹ having first been described in the 17th century. The clinical presentation appears essentially unchanged since the first comprehensive accounts were produced in the late 19th century. Patients with anorexia nervosa are characterised by a relentless pursuit of thinness, resulting in weight loss and a refusal to maintain a normal body weight. This refusal has been described as a "normal weight phobia". Anorexia nervosa is not common.* Worldwide, the true point prevalence is certainly no more than 0.5% of the female population over 15 years of age, and may be considerably less. Two studies of prevalence have been conducted in Australia: one reported a prevalence of 0.1% among a large group of schoolgirls,² and the other reported a lifetime prevalence of 0.4% among a large group of twins.³ Evidence for changes in the incidence of anorexia nervosa is controversial. Reports of recent increased incidence in specific populations have been criticised on methodological grounds.⁴ Increased use of hospital services may reflect a change in the threshold for admission, as much as changing incidences.⁵ In our experience, demand for hospital services for these patients has not changed substantially. *Anorexia nervosa can be fatal.* Although death rates vary between studies and may be falling, a rule of thumb is that one patient per two hundred treated will die as a result of starvation or suicide during each treatment year. For patients who do survive, the burden of disability and distress remains considerable. Overall outcome varies between studies, but about 40% of patients make a good five-year recovery, 40% remain symptomatic but function reasonably well, and 20% remain severely symptomatic and are chronically disabled.⁶
Risk factors	*Sex:* Anorexia nervosa occurs mainly, but not exclusively, among women; the female to male ratio is at least 10 to one. The origins of this sex difference remain unclear. However, as a society we are continually bombarded with images of impossibly slender young women. This, in part, explains the development of a "normative discontent" about physiologically unremarkable variations in body weight and shape.⁷ *Dieting:* Dieting is common in women in Australia and the first world, but only a small proportion of dieters develop anorexia nervosa. Why this proportion is so small remains unclear. However, normal dieting is almost certainly a trigger for the condition, and participation in occupations or sporting activities that require adherence to a strict diet is likely to place individuals at some risk.^8,9 *Other influences:* Factors ranging from family communication characteristics such as blurring of boundaries and over identification, to personality styles such as perfectionism and obsessionality have been implicated as being of aetiological importance, but none have been validated with any scientific rigour.¹⁰
Psychopathology and clinical features	The clinical features are deeply distressing for the observer; for the patient, the anorexic condition is a solution, but to what problem? The anorexic attitude is more understandable if being fat is seen as not being good enough, and being thinner is being better. In our view, the anorexic belief is: if my weight is right, then I am all right and if I am thinner then I must be a better person. Although the exact origins of such a state are unclear, patients commonly describe a pre-morbid sense of hopelessness, self-hatred and profound unworthiness. As weight loss occurs, individuals feel more disciplined and special. They can do something that their peers often talk about, but rarely succeed at: they can lose weight. In so doing they feel the ultimate triumph of control over their own bodies. Unfortunately, as self-control fails to influence the sense of self, and distress continues, the person displays a rigidity of outlook, and continues to pursue dietary perfection.¹¹ The clinical picture that results is quite typical (Box 1). A change in eating patterns is one of the earliest signs of the disorder. Commonly, patients develop eating routines that have the effect of spreading out whatever enjoyment is to be had from eating, without losing control. Often these give the family and the patient the impression of an adequate dietary intake. Patients may dirty plates and eating utensils to maintain the facade of eating. Although the term "anorexia" implies loss of appetite, this is not correct. Anorexic patients are terrified of losing control of their appetite. Patients regularly describe a fear that meals will immediately be deposited as fat, so they must maintain control over food intake despite continuing hunger. Many abstain from food; others have eating binges followed by self-induced vomiting or purging. Vomiting and purging can also be seen in individuals whose food consumption is minimal. At one time, it was believed that anorexic patients had a distorted perception of themselves, as though they saw an expanded representation of themselves when they looked in the mirror. That view has not held up to scientific examination, but most people with anorexia nervosa do hold deeply negative attitudes towards their own bodies.¹² They commonly feel that their hips and thighs are too large, and that their abdomen is too rounded and protuberant. The tenacity with which those feelings persist even in the face of profound emaciation is one of the most disconcerting and puzzling features of the condition. The clinical presentation and underlying problems are similar in men, although there may be a greater concern about health and fitness, rather than appearances.¹³ Patients with well-established anorexia nervosa are starving, and demonstrate various associated physiological changes (Box 2). These changes are non-specific consequences of the particular form of starvation seen in anorexia nervosa, and reverse with recovery. Anorexic patients may have changes in their menstrual patterns (oligo- or amenorrhoea) that may be concealed by the use of the contraceptive pill. Menses may cease before any substantial weight loss has occurred. *Patients with anorexia nervosa are often depressed.* There is debate whether the depression is solely related to the weight loss; more often a depressed mood or self-loathing precedes the decision to lose weight. Patients commonly describe a sense of hopelessness and acknowledge suicidal ideation. There may be a decrease in the level of enjoyment of life, although as they begin to lose weight, there may be increased physical activity. Whether this is a reflection of internal agitation or yet another way to burn off calories is not always clear. Patients often give a history of hyperventilation. Alcohol is used at times to decrease anxiety, and food intake is further reduced to compensate for the caloric intake.
The role of the general practitioner	*General practitioners have an essential role* in the early recognition and ongoing management of anorexia nervosa. Patients can present with anorexia nervosa at any age, but the onset of the disorder is most often in the mid-teenage years. Patients rarely present themselves for treatment; usually they are brought by family members who do not know what else to do. The family's concerns should be acknowledged, and the severity and potential chronicity of the illness be discussed even if there has not yet been a dramatic weight loss. For younger patients, the effects of starvation on physical development should be conveyed. Initial assessment is often difficult as patients may endeavour to conceal a degree of weight loss, be reluctant to be weighed, and try to minimise their difficulties. Information from other sources, such as family or school authorities, is usually necessary to complete the clinical picture. General practitioners are familiar with the dilemmas of caring for young people who seek to conceal information regarding their reasons for consulting from their families; when these issues relate to weight or diet, they are best seen as part of the illness. Families are commonly disrupted by the behaviour of the anorexic patient, and need support and advice. General practitioners can play a useful role in providing ongoing information and ensuring that families continue to maintain patients' safety despite entreaties by the patients that they will best recover by being left alone. Formal family therapy improves the outcome of adolescent patients still residing with their families, but does not change the outcome of older patients.¹⁴ In our experience, relationships that patients began when severely underweight often involve an element of rescue on behalf of the partner, who will then find actual recovery problematic. Anorexia nervosa is a serious condition and in our view specialised assessment, if only for diagnostic purposes, is indicated wherever possible. Further management can then be discussed with the specialist concerned. The therapeutic challenge presented by anorexic patients should never be underestimated.
Diagnosis and investigations	*The diagnosis remains a clinical one.* There are no specific investigations diagnostic of the disorder. The most widely used diagnostic criteria for defining anorexia nervosa are those in Box 3. With careful history-taking clinicians can elicit the degree of weight loss, which should be related to the pre-morbid weight. They should ask about the patient's heaviest, lightest and current weight, and the patient's own perceived ideal weight. Weight loss of more than 15% of average body weight is of considerable concern. Younger patients may show a failure to gain weight with developmental maturation, rather than loss of weight. Further enquiry should be made to determine if the weight loss has been voluntary, and to elicit any accompanying disturbances in body and self-related attitudes. While the diagnosis of anorexia nervosa is dependent on accurate history-taking, supporting observations may be made during physical examination and routine investigations (Boxes 2 and 4). The physical findings associated with starvation are quite variable, but the emergence of the biochemical indicators of starvation (Box 4) indicates a serious deterioration in the patient's health.¹⁶ Hormonal investigations are not warranted unless pituitary or ovarian dysfunction is seriously considered. Abnormal results such as hypokalaemia, a metabolic acidosis or alkalosis may suggest an eating disorder if the diagnosis was not previously considered. If the anorexic condition has been longstanding, bone densitometry may be useful to define the degree of bone loss and abnormalities.
Treatment	*Treatment must be tailored to the needs of the patient* and the severity of the illness. Denial of the severity or even the existence of a problem is extremely common, and the early phases of treatment are often difficult. Anorexia nervosa is a solution and an escape for the patient, so patients must have confidence that support will be available if they are to confront the varied internal and external conflicts that have precipitated the condition. These underlying problems are hard to deal with while patients have access to anorexia nervosa as a means of avoiding or resolving difficulties, so weight restoration and dietary normalisation remain the fundamental touchstones of treatment. However, they should only be one part of a comprehensive program of care, not a substitute for a long term approach. Referral to a specialised eating disorders service should always be contemplated, even for individuals whose weight loss is not yet marked. Referral is more urgent if amenorrhoea or weight loss of more than 10% has already occurred. If the general practitioner is experienced in the treatment of anorexia nervosa, this should continue, if possible, in conjunction with a specialised unit. Provision of such services varies between centres, however, and access may be particularly difficult for patients in country areas. Patients may become acutely medically unwell as a result of severe weight loss and dehydration, and may require resuscitation before any further treatment can be considered. Our unit has a close working relationship with our intensive care physicians, and severely unwell patients are admitted to the Intensive Care Unit for resuscitation before being transferred to our specialised eating disorders unit. The treatment of anorexia nervosa in our unit has evolved from long term inpatient programs with outpatient follow-up, to a predominantly outpatient strategy with hospital backup.¹⁷ Treatment begins on an outpatient basis, with inpatient care reserved for those individuals who fail to progress. The guiding principles of treatment are restoration of a normal weight range for height and age and the identification, and resolution, of the contributing family and personal problems. The hospital and staff should be portrayed as a resource that is available to the patient rather than as being able to provide a magical solution to the individual's problems. An eclectic approach is necessary, including individual and family therapy when warranted, dietary advice and, if considered appropriate, pharmacotherapy. A depressed mood may reflect an associated depressive illness and antidepressant medication can be of use. However, antidepressant medication is not recommended as a routine treatment. If a patient is highly agitated, especially when attempting to eat, then a major tranquilliser that does not have the disinhibiting effects of an anxiolytic agent may be useful, but should be instituted as part of the formal treatment program. Supervised weight gain, often involving bed rest, is still used for those who are unable to gain weight outside hospital. Prolonged hospitalisation is now limited to those who have failed in outpatient treatment or who have not benefited from brief admissions, except in young patients, where it is essential to gain weight to allow normal physical development. For patients who refuse active treatment, are treatment-resistant or live in isolated areas, general practitioners can provide an ongoing monitoring of patients' physical health. Insisting on admission to hospital is occasionally required if the patient is at physical risk, but should be avoided if possible. Such admissions should be in consultation with members of the ongoing treatment team. As a long term strategy, treatment orders have not proved helpful. Forced feeding, either naso-gastrically or intravenously, should only be used in life threatening medical situations, again, in conjunction with the treating team.
References	Kaufman MR, Heiman H. Evolution of psychosomatic concepts: anorexia nervosa. A paradigm. London: Hogarth Press, 1965. Ben-Tovim DI, Morton J. The epidemiology of anorexia nervosa in South Australia. Aust N Z J Psychiatry 1990; 24: 182-186. Wade T, Heath AC, Abraham S, et al. Assessing the prevalence of eating disorders in an Australian twin population. Aust N Z J Psychiatry 1996; 30: 845-851. Frombonne E. Anorexia nervosa. No evidence of an increase. Br J Psychiatry 1995; 166: 462-471. Halmi K. Changing rates of eating disorders: what does it mean? Am J Psychiat 1997; 152: 1256-1257. Herzog DB, Keller MB, Lavori PW. Outcome in anorexia nervosa and bulimia nervosa. A review of the literature. J Nerv Ment Dis 1988; 176: 131-143. Rodin J, Silberstein L, Striegel-Moore R. Women and weight: a normative discontent. Nebr Symp Motiv 1984; 31: 267-307. Richert AJ, Hummers JA. Patterns of physical activity in college students at possible risk for eating disorders. Int J Eating Disorders 1986; 5: 757-763. Gilchrist PN, Burke L. Eating disorders. In: Bloomfield J, Fricker PA, Fitch KD, editors. Textbook of science and medicine in sport. 2nd ed. London: Blackwell Science, 1995; 665-672. Strober M, Morrell W, Burroughs J, et al. A controlled family study of anorexia nervosa. J Psychiatr Res 1985; 19: 239-246. Vitousek KB, Daly J, Heiser C. Reconstructing the internal world of the eating- disordered individual: overcoming denial and distortion in self-report. Int J Eating Disorders 1991; 10: 647-666. Ben-Tovim DI, Walker MK. A quantitative study of body-related attitudes in patients with anorexia and bulimia nervosa. Psychol Med 1992; 22: 961-969. Carlat DJ, Camargo CA, Herzog DB. Eating disorders in males: a report of 135 patients. Am J Psychiat 1997; 154: 1127-1132. Russell GF, Szmukler GI, Dare C, Eisler I. An evaluation of family therapy in anorexia nervosa and bulimia nervosa. Arch Gen Psychiatry 1987; 44: 1047-1056. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994. Sharp CW, Freeman CPL. The medical complications of anorexia nervosa. Br J Psychiatry 1993; 162: 452-462. Kalucy RS, Gilchrist PN, McFarlane CM, McFarlane AC. The evolution of a multi therapy orientation. In: Garner DM, Garfinkel PE, editors. Handbook of psychotherapy for anorexia nervosa and bulimia. New York: Guildford Press, 1984; 458-487.