Fifty years of anorexia nervosa and other eating disorders in the Australian & New Zealand Journal of Psychiatry

The area of eating disorders has come a huge distance in the past 50 years. In addition to anorexia nervosa, three new disorders – bulimia nervosa, binge eating disorder, and Avoidant/Restrictive Food Intake Disorder (ARFID) – have been delineated. The former Eating Disorder not Otherwise Specified has become Other Specified or Unspecified Feeding or Eating Disorder (OSFED/UFED). Evidence-based treatments have been developed for all disorders and including people with severe and enduring anorexia nervosa (Hay et al., 2014). How much of this advance is found in the Australian & New Zealand Journal of Psychiatry? (termed the ‘Journal’ in this article). To answer this question, as an empirical researcher, I started (as one does) with a PubMed search of ‘eating disorder(s) and Australian and New Zealand Journal of Psychiatry’. This provided 75 articles dating to 1984, with the first about the new syndrome of bulimia (nervosa). However, before such online databases, there was a paper copy of this Journal, so I went to the College website and found articles that dated to 1975. The first is probably forgettable, but many stand out that are from seminal and leading Antipodean researchers in the area, including Peter Beumont, David Ben-Tovim and Ross Kalucy, and ‘second-generation’ researchers; Janice Russell, noted for work on psychological therapies and with Brown on sexual and physical abuse; and Tracey Wade, noted for her epidemiological studies with twins. It is rather reassuring to learn that an academic career can encompass more than 50 years of a journal’s publication as papers from Touyz are found in 1975 and in 2016, the latest on the nosology of another new syndrome, muscle dysmorphia (Santos Filho et al., 2016). Reflecting the diversity within the field, publications on eating disorders have covered a wide variety of topics including phenomenology, psychopharmacology, psychotherapies, treatment models, medico legal/ethical and service issues.

Deserving special mention is an early paper on obesity and anorexia nervosa by Bruch (1975). Bruch is the doyenne of eating disorder treatment and research in the 20th century and her 1975 paper was ahead of its time in proposing that obesity and anorexia nervosa share common psychological and societal determinants. She composed a humanistic and thoughtful integration of the understanding of the development of over eating (binge eating) and undereating and related these to inadequacies in early learning of appetite regulation and the awareness of hunger in childhood. She correctly pointed out that the desire for thinness is not an overriding concern in anorexia nervosa, but rather a sense of need for control. Similarly, she discussed the poor self-concept of people who become overweight or obese and pleaded for an empathetic approach to ‘their inner psychological plight’. She reported both anorexia nervosa and obesity to be driven by similar psychological vulnerabilities such as poor self-concept, with subsequent misuse of ‘eating function [in the] service ... of non-nutritional needs’ in the context of societal idealization of thinness (Bruch, 1975: 160). Before binge eating disorder was fully conceptualized, she described the phenomena of compulsive overeating in direct conflict with fear of fatness. While some of the analytic views discussed by Bruch (1975) may not have stood the test of time, she was ahead of her time in pointing to the inadequate development of internal satiety and hunger awareness, management of which is now being incorporated into new approaches in the treatment of people with dual problems of obesity and bulimia nervosa or binge eating disorder (Hay et al., 2014). I was also struck by how far the two fields of eating disorders and obesity have drifted apart over the past 50 years. This is in spite of rising prevalence of both problems. Certainly, it would be very rare to find now a paper similarly entitled ‘Obesity and Anorexia Nervosa’.

In contrast, Bruch’s views on the role of the family in the aetiology of anorexia nervosa, via inadequacies in ‘positive parental reinforcement’ and abnormal patterns of family interactions, have not persisted. Family dysfunction, if present, is now regarded as more likely a consequence than cause of the illness, and engaging families in treatment is associated with good outcomes (Hay et al., 2014). Papers by Hall and others in this era highlight this shift with regard to the family. Thus, in the 1980s, an early paper on the place of family therapy and the treatment of anorexia nervosa is found (Hall, 1987). Hall reports on the outcomes of family therapy with 23 consecutive presentations to an area-based service. Families of younger people were successfully empowered to aid the child with anorexia nervosa to improve nutrition, weight and psychological status, without a need for hospital admission. However, this was successful in only half of the cohort, a result consistent with more recent outcomes studies highlighting the need for refinement of therapies to improve overall remission rates following family therapy. Two decades on the development of manualized therapy by Lock and Le Grange and several randomized controlled trials later, a like approach is the leading treatment for children and adolescents with anorexia nervosa (Hay et al., 2014). Research is needed now to better inform what treatments work best for whom in adults, and particularly for younger people where engagement in such family therapy is impracticable or otherwise not possible.

Top cited articles in the Journal are most often epidemiologic or systematic reviews and practice guidelines, such as papers of the New Zealand Mental Health Survey (e.g. Oakley Browne et al., 2006) and the most recent clinical practice guidelines (Hay et al., 2014). From the perspective of the area of eating disorders, the New Zealand national survey is exemplary, estimating lifetime and point prevalence of the first two main disorders (anorexia nervosa and bulimia nervosa). To date, no epidemiology in Australia compares in comprehensively assessing distribution and functional impairment of bulimia nervosa and anorexia nervosa, but the burden of binge eating disorder and ARFID remains to be delineated.

In closing this retrospective, I think this Journal has clearly kept pace with the area of eating disorders and attracts submissions from leading as well as emerging researchers. Over the next 50 years, I anticipate increasing numbers of papers of the ‘new’ eating disorders and empirical trials of their treatment appearing. This will be alongside improved understanding of eating and weight disorders to attenuate the global burden of both. If so, this Journal’s stature should continue grow with publications that continue to push the boundaries of knowledge in the area of anorexia nervosa and beyond.