This paper considers the possible longer-term consultant manpower requirements in England and Wales for general or ‘mainstream’ psychiatry, its special interests, the psychiatry of old age and the dependencies, as well as for the specialties of psychotherapy and forensic psychiatry. It is based on papers prepared by the College (see References) and discussions with the Department of Health and Social Security. Consideration is also given to the training implications of these consultant manpower requirements. It discusses the possibility for growth in the special interests and specialties in the context of the number of consultants in adult psychiatry likely to be available. The psychiatric specialties of child psychiatry and mental handicap are not considered.

The findings in this paper are based on 13 patients (12 female and 1 male) under my personal care who all satisfied the criteria for the diagnosis of anorexia nervosa (Russell, 1970). In addition, they had persistently made themselves vomit after most meals, over the course of several years (mean of 5.4 years). There were also episodes of over-eating that culminated in vomiting. The vomiting was done in private and achieved by stimulating the throat with fingers or a toothbrush, drinking large amounts of fluids or bending over, or a combination of these devices.

When confronted with patients who indulge in frequent self-induced vomiting one has to ask oneself the question ‘why do they do it?’ At the simplest level the answer to this question is that there are clear advantages to the patient from this behaviour. Patients can indulge their cravings for food to excess while at the same time avoiding the consequences in terms of weight gain. They can literally ‘have their cake and eat it’. The first therapeutic requirement is therefore to convince the patient that the disadvantages of self-induced vomiting, in terms of effects on physical health, far outweigh these benefits. Let us assume that we have been successful in this respect; the next step is to undertake a behavioural analysis.