Emergency department lengths of stay: characteristics favouring a delay to the admission decision as distinct from a delay while awaiting an inpatient bed

BACKGROUND

A prolonged stay for a patient within the emergency department (ED) can adversely affect the outcome of their ensuing hospital admission.

AIMS

To investigate the characteristics of those eventual general medical hospital inpatients who stay in the ED awaiting a decision to be admitted and then await a bed.

METHODS

Data from Flinders Medical Centre's patient journey database were analysed. The analysis was carried out on 19 476 patients admitted as an emergency under the General Medicine units.

RESULTS

A less urgent Australian Triage Scale category significantly prolonged triage-to-admit time but did not affect boarding time. The decision to admit a patient took 29% longer for patients who presented to the ED outside of working hours. However, a decision to admit taken outside working hours meant the boarding time was over 3 h shorter than if the decision had been taken inside working hours. For every additional patient in the ED at the time of presentation, the admission decision was delayed by about half a minute. Every additional patient in the ED at the time of an admission decision increased boarding time by almost 10 min.

CONCLUSION

Outside of working hours, patients presenting to ED have longer triage-to-admit times while patients for admission have shorter boarding times. ED congestion delays admission decisions only slightly and prolongs patients' boarding times to a greater extent. Strategies to reduce the time patients spend in ED should differ depending on whether a decision to admit the patient has been reached.

Relationship between in-hospital location and outcomes of care in patients of a large general medical service

BACKGROUND

The discrepancy between the number of admissions and the allocation of hospital beds means that many patients admitted under the care of a general medical service can be placed in other departments' wards. These patients are called 'outliers', and their outcomes are unknown.

AIMS

To examine the relation between the proportion of time each patient spent in their 'home ward' during an index admission and the outcomes of that hospital stay.

METHODS

Data from Flinders Medical Centre's patient journey database were extracted and analysed. The analysis was carried out on the patient journeys of patients admitted under the general medicine units.

RESULTS

Outlier patients' length of stay was significantly shorter than that of the inlier patients (110.7 h cf 141.9 h; P < 0.001).They had a reduced risk of readmission within 28 days of discharge from hospital. Outlier patients' discharge summaries were less likely to be completed within a week (64.3% cf 78.0%; P < 0.001). Being an outlier patient increased the risk-adjusted risk of in-hospital mortality by over 40%. Fifty per cent of deaths in the outlier group occurred within 48 h of admission. Outlier patients had spent longer in the emergency department waiting for a bed (6.3 h cf 5.3 h; P < 0.001) but duration of emergency department stay was not an independent predictor of mortality risk.

CONCLUSION

Outlier patients had significantly shorter length of stay in hospital but significantly greater in-patient death rates. Surviving outlier patients had lower rates of readmission but lower rates of discharge summary completion.

The significance of reduced kidney function among hospitalized acute general medical patients

BACKGROUND

Inpatient general medical units often look after older patients who have more complex co-morbidity including renal insufficiency. The consequences of renal insufficiency with respect to length of hospital stay (LOS) and mortality have not been well described in hospitalized general medical patients.

AIM

To use a general medical inpatient population to evaluate the impact of reduced kidney function.

DESIGN

Retrospective cross-sectional study.

METHODS

We studied 504 acute medical admissions through an Acute Assessment Unit between February and November 2007. Patients were classified as having chronic kidney disease (CKD), acute kidney injury (AKI), neither (control) or both. LOS, in-hospital mortality and post-discharge survival were evaluated.

RESULTS

Renal impairment was present in 151 patients. Ninety patients had CKD only and 61 had AKI with or without CKD. In-hospital mortality was increased in those with renal impairment compared with controls (9.3 vs. 3.4%; P = 0.006). Within 4 years of admission, 187 (39%) patients had died. Post-discharge mortality was significantly higher in all renal failure populations (hazard ratio: 2.57-4.38; P < 0.01). Adjustment for patient age, gender and Charlson index explained the increased mortality during and after hospital admission but did not explain increased LOS. Only a small proportion (13%) of admitted patients with renal insufficiency had renal disease documented in their discharge summaries.

CONCLUSION

Many general medical inpatients (30%) have reduced kidney function at the time of admission. This study provides validation of the Modification of Diet in Renal Disease equation as a predictor of poor outcomes. Reduced renal function was associated with increased hospital LOS and mortality. Mortality rose with AKI and was explicable on the basis of the patients' age and co-morbidities. Renal insufficiency is documented infrequently in discharge summaries.

Quality of resuscitation orders in general medical patients

BACKGROUND

Documentation of resuscitation status in hospitalized patients has relevance in the management of cardiopulmonary arrest. Its association with mortality, Length Of hospital Stay (LOS) and the patients' primary diagnosis has not been established in general medical inpatients in hospitals in Australia and New Zealand.

AIM

To investigate the association of resuscitation orders with in-hospital mortality and LOS in a range of diagnoses, adjusting for severity of illness and other covariates.

DESIGN

Retrospective study.

METHODS

The admission notes of 1681 medical admissions to four tertiary care teaching hospitals across Australia and New Zealand were reviewed retrospectively for frequency and nature of resuscitation documentation and its association with mortality, LOS and primary diagnosis.

RESULTS

Resuscitation orders were documented in 741 patients (44.7%). For the 232 patients with a Not For Resuscitation (NFR) order, the in-hospital mortality rate was higher than in control patients (14% vs. 1.2%, P<0.005). The mortality rate remained significantly higher in the NFR group after propensity matching of the controls for age and co-morbidity (14% vs. 5%, P<0.005). The death-adjusted LOS for the NFR group was also significantly higher compared to the control patients (9.7 days vs. 4.7 days, P<0.005) and this difference remained after propensity matching (9.7 days vs. 7.7 days, P<0.05). Those patients with a primary diagnosis of respiratory tract infection or cardiac failure were more likely to be documented NFR compared to those with cellulitis or urinary tract infection.

CONCLUSIONS

The documentation of NFR in a patient's admission notes is associated with increased in-hospital mortality and LOS. This is only partly explicable in terms of these patients' greater age and co-morbidity.

Resuscitation orders and their relevance to patients' clinical status and outcomes

BACKGROUND

Documented resuscitation orders have relevance in the management of a pulseless, unresponsive patient. Although useful, the frequency of their documentation in the case notes of newly admitted medical patients is not well established.

AIM

To investigate the frequency of early clear documentation of resuscitation orders in patients' admission notes.

DESIGN

Retrospective audit.

METHODS

The admission notes of 618 medical admissions to an Australian tertiary referral teaching hospital between January and December 2007 were reviewed to calculate the frequency of clear resuscitation documentation. Certain outcomes of each admission, such as in-hospital death, were obtained via hospital-based computerized records.

RESULTS

Within the first 24 h of admission, discussions regarding resuscitation were not documented for 78% of patients. Of the 482 patients with no documented resuscitation orders, 5 patients died during their index admission. Of the 136 patients with documented resuscitation orders, 24 patients died during their index admission. As age or a measure of clinical debility increased, the absolute number and relative proportion of resuscitation discussions increased significantly (P<0.0001) and the number and proportion of patients deemed not for resuscitation also increased (P<0.0001).

CONCLUSION

Those patients apparently targeted for discussion were older, more frail and acutely unwell. We propose widespread use of a clinical scoring system to identify those patients who need their resuscitation status clarified early in their admission prior to clinical deterioration.

Outcome in patients with eating disorders: a 5-year study

BACKGROUND

Eating disorders are disabling, unpredictable, and difficult to treat. We did a prospective 5-year investigation of a representative sample of patients with eating disorders. Our aim was to identify predictors of outcome and to assess effects of available treatments.

METHODS

We prospectively investigated 95 patients with anorexia nervosa, 88 with bulimia nervosa, and 37 with eating disorders not otherwise specified (EDNOS), who sought treatment in Adelaide, South Australia. We divided patients into those who had, and had not, received treatment in specialist units and reached a safe body weight. Individuals were then further classified dependent on intensity of any treatment received. We assessed clinical symptoms, body-related attitudes, and psychosocial function.

FINDINGS

216 (98%) patients were available for follow-up after 5 years. Three patients with anorexia nervosa and two with EDNOS died. 65 (74%) bulimic, 29 (78%) EDNOS, and 53 (56%) anorexic patients had no diagnosable eating disorder. A small proportion of patients in every group had poor Morgan-Russell-Hayward scores at outcome. Final outcome was predicted by extent and intensity, but not duration, of initial symptoms in patients with anorexia nervosa, and by initial body-related attitudes and impaired psychosocial functioning in bulimia patients. We were unable to predict EDNOS outcome. Treatment did not affect outcome for any group.

INTERPRETATION

Deaths in the study confirm the serious nature of eating disorders. However, our results suggest that the efficacy of existing interventions is questionable.

Does the body image exist in three dimensions? The study of visual mental representation of a body and a nonbody object

Do the mental images of 3-dimensional objects recreate the depth characteristics of the original objects? This investigation of the characteristics of mental images utilized a novel boundary-detection task that required participants to relate a pair of crosses to the boundary of an image mentally projected onto a computer screen. 48 female participants with body attitudes within expected normal range were asked to image their own body and a familiar object from the front and the side. When the visual mental image was derived purely from long-term memory, accuracy was better than chance for the front (64%) and side (63%) of the body and also for the front (55%) and side (68%) of the familiar nonbody object. This suggests that mental images containing depth and spatial information may be generated from information held in long-term memory. Pictorial exposure to views of the front or side of the objects was used to investigate the representations from which this 3-dimensional shape and size information is derived. The results are discussed in terms of three possible representational formats and argue that a front-view 2 1/2-dimensional representation mediates the transfer of information from long-term memory when depth information about the body is required.

[Personal behavior and mental state in anorexia nervosa]

Personality of the patients with anorexia nervosa is characterised by high neurotization and anxiety that resulted in diffuse anxiety in stress situation. Personal peculiarities included also high total hostility and intrapunitivity, inclination to obsessive-phobic and dysthymic reactions and tendency to somatization of anxiety. Such peculiarities promoted the choice of intrapunitivity type of reaction in situation of frustration. Its manifestation increases with an increase in the disease duration. The range of psychotic disorders in anorexia nervosa is restricted to anxious-depressive, obsessive and asthenic sphere.

Eating disorders revisited. II: Bulimia nervosa and related syndromes

Bulimia nervosa and related syndromes are common, and occur in up to 5% of women who attend general practitioners. Young women in First World countries, particularly those who "diet", are at increased risk. Behaviours, such as binge eating and induced vomiting, are typically kept well hidden. Only a minority of those with these disorders present for treatment. General practitioners play a key role in primary and secondary prevention. Effective treatments include psychotherapies that focus on the patient's attitudes and relationships, not just the binge eating behaviour. About 50% of patients make a complete recovery, but the long term outcome is unknown.

Eating disorders revisited. I: Anorexia nervosa

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.

Recall of the visual body image using a novel boundary detection task

A new task for eliciting a pictorial mental image of the body or other objects is described. The task involved relating a pair of crosses to the boundary of a mental image 'projected' onto a computer screen. Responses were assessed for accuracy defined as identifying a relationship between a cross and an image that would hold when a photograph (of the same object) was substituted for the mental image. A group of 30 female students achieved between 70 to 80% accuracy when using this task to assess mental images of their own faces, torsos, or a familiar nonbody object. Accuracy was similar for body and nonbody objects. The presence of some kind of quasipictorial representation of the body is confirmed. Its characteristics await further elucidation.

Telepsychiatry: 'tele' yes, but what about the 'psychiatry'?

To investigate what is lost or gained in a psychiatric evaluation when it takes place via telepsychiatry we compared the interrater reliability between two psychiatrists interviewing 63 subjects in an observer/interviewer split configuration in telepsychiatry and same-room settings. The measures used were the BPRS and interviewer ratings from a semi-structured interview. Patients also rated their experience. There were some clear differences between the telepsychiatry and same-room evaluations. Despite these variations, diagnoses were as reliably made by telepsychiatry. Patient acceptance of telepsychiatry was high.

Effects of serotonin reuptake inhibitors on hemostasis

OBJECTIVE

To examine the hematologic safety profile of the selective serotonin reuptake inhibitors (SSRIs), with particular emphasis on the effects of these drugs on platelet aggregation.

METHODS

Platelet aggregation studies were undertaken at baseline, and repeated 2 and 4 weeks after the initiation of treatment with an SSRI. Other investigations undertaken included analysis of serum electrolyte and liver enzyme concentrations, complete blood count, and coagulation studies. Patients were also assessed for clinical signs of bleeding. Eight patients (7 treated with fluoxetine, 1 with paroxetine) completed the study protocol.

RESULTS

Repeated ANOVA revealed no abnormalities in platelet aggregation, hematopoiesis, or coagulation profile. No patient developed clinical signs of abnormal hemostasis during the study period. A statistically significant elevation in the mean serum bilirubin concentration was detected, but this was not of clinical significance.

CONCLUSIONS

Although the SSRIs may cause abnormal hemostasis, this effect is probably rare. Another possibility is that abnormal hemostasis is more likely to occur when high doses of SSRIs are administered.

Low levels of interrater reliability in a standard measure of outcome in eating disorders (the modified Morgan-Russell Assessment Schedule)

OBJECTIVE

The interrater reliability of the modified version of the widely used Morgan-Russell Assessment Schedule was assessed.

METHOD

Sixty-six female patients presenting for treatment for the first time in a general hospital and a community health center were assessed by a treating clinician and a researcher during sequential interviews. Two extra items were added to the Schedule to allow for the assessment of bulimic behaviors. Ratings were analyzed using the Cohen's weighted kappa.

RESULTS

Poor to very poor levels of agreement were found between rater pairs assessing the 66 separate patients.

DISCUSSION

The necessity for a specific, standardized format in using the Morgan-Russell Schedule is discussed. In its current, unstandardized format the Schedule may not be suitable for comparing outcome in eating disorders across different centers.

Psychiatric and substance abuse disorder diagnoses as predictors of length of hospital stay

The mental health and substance abuse components of AN-DRG 3 were examined using data from all inpatient separations in two Australian States over a two-year period. Assignment to a mental health or a substance abuse diagnosis related group (DRG) predicted about 20 per cent of the variability in average length of stay of patients treated for such conditions. Assignment to a substance abuse DRG was a much less robust predictor of length of hospital stay than assignment to a mental health DRG. There was little variation between years or States. Day-only intent patients were excluded, as were long-stay outliers identified using an inter-quartile range trimming process. Psychiatric DRGs are similar to a number of other non-surgically focused diagnosis related groups in their capacity to predict length of hospital stay. They are likely to remain an important component of casemix classification systems.

Body image, disfigurement and disability

The body-related attitudes of groups of women suffering from physical conditions that are commonly regarded as being disfiguring and/or disabling were studied by means of the Body Attitudes Questionnaire. Despite their conditions, the women did not necessarily disparage their bodies. They also seemed to worry less about small changes in weight and shape than did comparable women without physical difficulties, and to have an enhanced sense of their own robustness. There was an indication that development of negative body attitudes might be linked to emergence of a chronic physical condition during adolescence, rather than from birth or during adulthood. If our results are confirmed, they point to the need to pay special attention to the psychological needs of women whose bodies become dysfunctional at this sensitive time.

Pictorial adaptation of Stroop measures of body-related concerns in eating disorders

Patients with eating disorders were asked to color-name pictures of a variety of body shapes. The time taken to color-name these stimuli was compared with the time taken to color-name a series of neutral visual stimuli. There was a significant delay in naming body shapes in comparison to neutral stimuli, and this delay was greater in anorexic and bulimic patients than in controls. Previous Stroop adaptations have used verbal stimuli to assess the intensity of weight and shape-related concerns. The possible advantages of pictorial stimuli are discussed.

Making casemix work for psychiatry

Providers of mental health and substance abuse care cannot afford to ignore the existence of casemix descriptions of their services. As casemix comes to be the predominant language used to describe the products of hospital care, its use will inevitably impinge upon psychiatric services. The psychiatric components of the Australian national diagnosis-related groups classification 1 and 2 (AN-DRG 1 and 2) do not describe the relevant products with great accuracy. We review some possible reasons for this and the effects on the homogeneity of resource consumption of technical procedures, such as trimming of data sets, in the context of the current casemix system and that proposed for AN-DRG-3. The evolution of a casemix system which does justice to current and future psychiatric services will be a complex process. Some of the crucial areas are discussed. Clinicians involved in mental health and substance abuse care must continue to advocate for the resources and effort needed to improve casemix information in their area.

An insight into the personal and cultural significance of weight and shape in large Samoan women

The aim of this work was to investigate the personal and cultural significance of body weight and shape for women in Western Samoan culture. A cross cultural study was carried out of Western Samoan and Australian women comparing responses to the Body Attitude Questionnaire (BAQ). The work was carried out in a tertiary education institution and an occupational setting in Apia, Western Samoa, and on community residents in Adelaide, South Australia. The subjects were 70 volunteer female respondents from Western Samoan educational and occupational settings, individually matched for weight and height with 70 respondents from a South Australian random community setting. The psychometric properties of the BAQ, as completed by the Western Samoan respondents, were found to be similar to those for Australian women. Samoan women who were biologically overweight, felt as fat and had similar feelings about lower body fatness as their identical weight Australian counterparts. They, however, showed highly significantly less salience of fatness than the Australian sample, indicating that fatness is not a pre-occupying in Samoans as it is in Australian women. Despite this apparent non-concern over their fatness, Samoan women were significantly more disparaging about their bodies than their Australian counterparts. The other significant finding from this cross-comparative study, was that large Samoan women felt more attractive and much stronger and fitter than their Australian counterparts. It was concluded that Samoan women's body-related attitudes can be studied using techniques and concepts originating in the west, but the specific concerns of Samoan women need to be explored in further detail.

The influence of age and weight on women's body attitudes as measured by the Body Attitudes Questionnaire (BAQ)

The influence of age and weight on the body-related attitudes of a large sample of South Australian women were measured by the Ben-Tovim-Walker Body Attitudes Questionnaire (BAQ). Attitudes were found not to vary substantially with age, and only the Feeling Fat, Body Disparagement and Lower Body Fatness sub-scales of the BAQ were correlated with BMI. The effect of BMI on attitudes was independent of age. Obese subjects felt significantly less attractive than those with BMIs only slightly above average. However, they did not disparage their bodies more than did less overweight women. Body attitudes appear to be substantially independent of the current physical body.

Failure to demonstrate gender differences in interference to information-processing of body-shape stimuli

The Stroop test was adapted to assess disruption to processing of body-shape stimuli. Women are usually considered to be more concerned with personal body-shape and weight issues than men. This analysis yielded no differences between men and women when processing body-shapes and weight stimuli.

Abnormal platelet aggregation associated with fluoxetine therapy

OBJECTIVE

To document the development of abnormal hemostasis in a patient treated with fluoxetine.

CASE SUMMARY

A 49-year-old man developed a release-type defect in platelet aggregation during treatment with fluoxetine. Abnormal platelet aggregation was observed during platelet viability testing, in which adenosine diphosphate, epinephrine, ristocetin, arachidonic acid, and collagen were used as agonists. Two days after the withdrawal of fluoxetine, platelet function returned to normal.

DISCUSSION

Fluoxetine is an antidepressant that is thought to act through inhibition of serotonin reuptake in the central nervous system. Fluoxetine also inhibits the reuptake of serotonin in platelets, significantly decreasing granular storage and potentially influencing platelet aggregation characteristics. Clinical manifestations of abnormal platelet function have been reported in association with fluoxetine therapy.

CONCLUSIONS

The rapid normalization of platelet aggregation after the withdrawal of fluoxetine in this patient does not conform to the known clinical pharmacokinetics of norfluoxetine. The half-life of fluoxetine is shorter, suggesting that the parent drug (rather than norfluoxetine) was the causative agent. Serum fluoxetine and norfluoxetine concentrations were not measured in this patient.

A quantitative study of body-related attitudes in patients with anorexia and bulimia nervosa

The Ben-Tovim Walker Body Attitudes Questionnaire (BAQ) is a psychometrically sound self-report instrument for assessing women's attitudes towards their own bodies. The BAQ responses of a large sample of patients with eating disorders (ED) diagnosed in accordance with DSM-III-R criteria were compared with those from a normative population and from diverse groups of psychiatrically and physically ill patients. The ED group was distinct, and showed extreme responses in the area of weight and shape concerns. But a better discrimination between the ED and other populations was achieved using subscales that related to 'body disparagement' (an intense loathing of the body) and 'attractiveness', rather than to weight and shape concerns. ED patients may have a more pervasive disturbance in body-related attitudes than is currently widely accepted. Patients with anorexia and bulimia nervosa showed very similar attitudes despite the symptomatic differences between the groups.

Some body-related attitudes in women smokers and non-smokers

The body-related attitudes of female current, ex, and never-smokers were compared using a new questionnaire that assesses a wide range of attitudes towards the body. In a population survey, current smokers felt less attractive than those women who had never smoked, but they did not experience themselves as being less strong and fit than the non-smokers. There were no significant inter-relationships of smoking status, attitudes and body weight. The implications of these observations for anti-smoking campaigns are briefly discussed.

The development of the Ben-Tovim Walker Body Attitudes Questionnaire (BAQ), a new measure of women's attitudes towards their own bodies

A measure has been developed which assesses a broad range of attitudes which women hold towards their bodies. The Ben-Tovim Walker Body Attitudes Questionnaire (BAQ) is a 44-item self-report questionnaire whose subscales encompass six distinct aspects of body experience (feelings of overall fatness, self-disparagement, strength, salience of weight, feelings of attractiveness and consciousness of lower body fat). The development of the BAQ involved administering increasingly refined versions to a wide range of female respondents. The final version appears to have satisfactory psychometric properties. When the BAQ scores of 29 patients with anorexia nervosa were compared with those of a large community sample, a more complex pattern of deviant attitudes appeared than would previously have been suspected. The BAQ appears to have potential as a research instrument in this and other fields in which the measurement of attitudes towards the body is important.

Effect of a mirror on body-size estimation

This study investigated the effect of mirror feedback on body-width estimation in 66 normal adolescent girls. The presence of the mirror had no substantive effect on their estimating behaviour. The authors argue that the result cast further doubt on width estimation as a valid method for accessing the internalized image of the self.

The epidemiology of anorexia nervosa in South Australia

A survey of 5,705 pupils in girls' schools in South Australia revealed that the one year prevalence of cases of anorexia nervosa, diagnosed according to DSM-III criteria, was 1.05 cases per thousand of the population studied. This study has a number of advantages in comparison to the majority of other school-based surveys, and confirms that descriptions of anorexia nervosa as a disorder of epidemic proportions may be premature.

Cutaneous abnormalities in anorexia nervosa

Anorexia Nervosa (A.N.) is a relatively common eating disorder with well recognised psychological and physiological features. A study of 14 female patients with A.N. revealed a number of dermatological disorders, including lanugo hair, xeroderma and hyperpigmentation. Laboratory investigations revealed various abnormalities including elevated Beta-carotene levels, abnormal sex hormone and thyroid function. An unusual finding was the development of acne in a small subset of patients at the time of weight gain, during recovery from A.N. Anorexia Nervosa represents a useful model for the interaction between eating disorders, endocrine function and the skin.

Bulimia: symptoms and syndromes in an urban population

The widely used DSM-III criteria for the diagnosis of bulimia essentially define bulimia as a syndrome of guilty, secretive and subjectively hard to control binge over-eating. A self-report questionnaire for bulimic behavior was administered to three community and two hospital populations in South Australia. 13% of females in the community samples could be categorized as bulimic according to the DSM-III criteria. Those criteria did not adequately define the behaviour of patients in treatment for bulimia in a Weight Disorders Unit, 85% of whom not only binged, but induced vomiting afterwards. When diagnostic criteria were more closely aligned to clinical experience, the prevalence of bulimia in the community appeared closer to 1-2%. New DSM criteria (DSM-III-R) have been proposed and prevalence rates using them fell within the 1-2% range.

A comparison between patients admitted to psychiatric hospitals in Botswana and South Australia

Cohorts of patients admitted to psychiatric hospitals in Botswana and South Australia were compared. The psychiatric hospital in Botswana was used almost entirely for the care of patients with psychotic disorders, whilst one third of the patients in South Australia had either a neurotic or personality disorder diagnosis. A higher proportion of patients in Botswana than South Australia had had only a brief period of illness prior to admission. Violence was equally common amongst Tswana and Australian patients, but was directed outwards towards property and other people in Botswana and inwards towards the self in Australia. It was tentatively concluded that in both countries there was a group of severely ill patients who could not be handled without containment.

DSM-III, draft DSM-III-R, and the diagnosis and prevalence of bulimia in Australia

A self-report questionnaire for bulimic symptoms was administered to three different groups of community residents and to patients in a hospital's weight disorders unit and its dietetics department. The prevalence of DSM-III bulimia was 12.7% among female community residents, while the prevalence of draft DSM-III-R bulimia was 1.7%. The questionnaire, scored to reflect DSM-III, categorized as bulimic large numbers of patients who were not given that diagnosis by clinicians. The draft DSM-III-R criteria seemed more closely aligned to clinical experience.

Abnormal perception of food size in anorexia nervosa

The hypothesis that patients with anorexia nervosa exaggerate the perceived size of food was tested. Video recordings of five items of food and four neutral objects of a similar size were made such that the size of each object increased steadily from half to twice its normal size. Each of the nine objects was placed on a ledge inside a dummy television screen next to the video screen, the food items alternating with the neutral objects, and 20 female patients with anorexia nervosa and 20 female controls matched for age were asked to adjust the size of the video recording to that of the real object. Although there was no overall difference in perceptual accuracy between patients and controls, both groups perceived the food items as being bigger than the neutral objects, the patients exaggerating the size of the food significantly more than the controls. These results imply that patients with anorexia might start eating more easily when admitted if their food were presented as small portions on large plates.

A group method for learning about psychiatric research

Psychiatric trainees in their final year of training met fortnightly with an experienced psychiatric researcher. A group format was used to facilitate the development of skills employed in psychiatric research. Various exercises, including conducting a research project during the group sessions, were undertaken. This report highlights certain issues that may inhibit clinicians from undertaking research projects. It is presented from both the group leader's and the participants' perspectives.

The prevalence of schizophrenia in a remote area of Botswana

We ascertained the one-year prevalence of schizophrenia amongst individuals aged 15 years or older living in six villages in a remote area of Botswana. All cases were diagnosed independently by two experienced psychiatrists, following ICD9 rubrics. DSM-III criteria were also applied, separately. Accurate contemporary population estimates of the villages were available. The age-adjusted prevalence of schizophrenia was 5.3 per 1000 in terms of ICD9, or 4.3 per 1000 by DSM-III, which has an upper age limit for onset of 45 years. These figures are well within the range generally reported for industrial communities. Remote village life in Botswana appears to offer no protection against the development of schizophrenia.

Therapy managing in Botswana

Varied and apparently ideologically incompatible systems of health care are available in many developing countries. Patients move freely between them, receiving care serially or simultaneously from different types of healers. Therapy managing is an anthropological term used to describe how choice of health care is made by an informal group that forms around the patient. The author's experiences while running a community-based psychiatric treatment program in Botswana are discussed in terms of his interaction with patients' managing groups.

DSM-III in Botswana: a field trial in a developing country

The author found that DSM-III criteria were generally applicable to the diagnoses of a series of new and repeat outpatients studied under field conditions in Botswana, a developing African country. Some problems were encountered, however, with axis II, which was not commonly used. Other clinical aspects of the patients are commented on, including the rarity of acute psychoses and culture-bound syndromes.

The reliability of estimates of body width and their relationship to current measured body size among anorexic and normal subjects

Normal and anorexic subjects' estimates of their own body width were obtained. The estimates were reliable measures, but they did not correlate with the subjects' actual body widths. The implications of this finding especially when relating anorexic patients' self-perceptions to their clinical outcome, are discussed. It seems preferable to use such estimates untransformed by division with the subjects' actual body widths.

Modern or traditional? A study of treatment preference for neuropsychiatric disorders in Botswana

Subjects in Botswana were asked to state their preference between modern (doctor or nurse) or indigenous (traditional or religious healer) care for three case vignettes of epilepsy, psychosis, and tuberculosis. Nurses, medical patients, and a general village population were studied. Many subjects preferred modern care for all disorders, whilst a small number favoured indigenous treatment only. A significant percentage discriminated between disorders, choosing indigenous care for some and modern for others. Indigenous care was most favoured for epilepsy, and least for tuberculosis. Psychosis took an intermediate position. The size of the discriminating group varied between populations, but the overall pattern of attitudes remained the same. Neither demographic factors nor aetiological beliefs consistently identified those who choose indigenous care.

The representation of transference through serial grids: a methodological study

During a patient's psychotherapy serial grids were collected so that aspects of 'transference' defined as the interrelationships of dyadic elements such as 'me now with the therapist', 'me with father when I was a child' could be measured. By forming composite grids of the same two elements from each testing occasion, changes could be traced over time. Content analysis of tape-recordings of the sessions showed that changes on the grid measures could be related to the therapist's interventions. The correlations obtained suggest a process of delayed reconceptualization by the subject.

A psychiatric service to the remote areas of Botswana

A psychiatric service was provided to the remote areas of Botswana by means of regular visits from psychiatrists and psychiatric nurses to the primary care facilities in those areas. The service was well used by the local health workers and general populations and encountered a substantial psychiatric morbidity. Studies in one region indicated that by using the primary care staff as case finders a substantial proportion of a total likely population of schizophrenic and epileptic patients could be bought into treatment. The specific conditions that enabled this service to become established are discussed.

Hypoalgesia in depressive illness

Neurophysiological studies of experimental pain were carried out on two severely depressed patients who complained of an inability to experience emotion. They had normal thresholds for stimulus appreciation but markedly increased thresholds for pain. These abnormal pain thresholds normalized with clinical recovery.

The assessment of the ego states

The hypothesis that ego states, as defined in Transactional Analysis, are distinct and identifiable phenomena was tested. Ten TA therapists were asked to assess which of the three ego states, Parent, Adult or Child, were present in forty statements extracted from the tape of a family therapy session. The level of agreement reached was statistically highly significant. There was a certain amount of interrater variability, and potential sources of disagreement are discussed.