The treatment of anorexia nervosa with total parenteral nutrition.

Treatment outcome of 11 anorectic patients receiving total parenteral nutrition (TPN) is compared with outcome of anorectic patients receiving standard behaviorally oriented inpatient therapy. TPN resulted in significantly more rapid weight gain. Most patients could be successfully weaned from TPN to enteral feeding with continued weight gain. Complications during TPN were common including transaminase elevations and electrolyte imbalance. There was one death in the series. The role of TPN in the management of anorexia nervosa is discussed.

Immunocompetency in anorexia nervosa.

Twenty-two consecutively admitted patients diagnosed for anorexia nervosa were evaluated for cellular immune functioning by means of an anergy panel to test delayed hypersensitivity. The panel included candida, streptokinase-streptodornase, and mumps antigen administered by a standard protocol. A standard nutritional profile including current weight, usual weight, total protein, albumin, total iron-binding capacity, white blood cell count, total lymphocyte count, triceps skinfold, and arm muscle circumference was concurrently compiled on these subjects. Six of 22 patients studied were anergic. Visceral protein measures were generally within normal limits even in the most depleted patients. Malnutrition as measured by severity of weight loss and triceps skinfolds was significantly related to anergy, whereas visceral protein indicators (serum albumin, total iron binding capacity, transferrin) were not correlated with anergy. Anergy appeared to be related more strongly to anthropometric indices of malnutrition than to visceral protein values. Cellular immunity was generally preserved until weight loss was far advanced.

Total body water and total body potassium in anorexia nervosa.

In the ill hospitalized patient with clinically relevant malnutrition, there is a measurable decrease in the ratio of the total body potassium to total body water (TBK/TBW) and a detectable increase in the ratio of total exchangeable sodium to total exchangeable potassium (Nae/Ke). To evaluate body composition analyses in anorexia nervosa patients with chronic uncomplicated semistarvation, TBK and TBW were measured by whole body K40 counting and deuterium oxide dilution in 10 females with stable anorexia nervosa and 10 age-matched female controls. The ratio of TBK/TBW was significantly (p less than 0.05) higher in anorexia nervosa patients than controls. The close inverse correlation found in published studies between TBK/TBW and Nae/Ke together with our results suggest that in anorexia nervosa, Nae/Ke may be low or normal. A decreased TBK/TBW is not a good indicator of malnutrition in the anorexia nervosa patient. The use of a decreased TBK/TBW ratio or an elevated Nae/Ke ratio as a definition of malnutrition may result in inappropriate nutritional management in the patient with severe nonstressed chronic semistarvation.

Weight gain and nutritional efficacy in anorexia nervosa.

To evaluate the usefulness of interval weight change in assessing nutritional support efficacy, we studied four anorexia nervosa patients (52% ideal body weight) requiring long-term total parenteral nutrition (TPN) for 63 +/- 18 days. Fluid and electrolyte deficits were corrected before the initiation of nutritional support. Resting energy expenditure was measured before the initiation of TPN and weekly thereafter, using indirect calorimetry. Daily caloric expenditure was estimated at 1.1 X resting energy expenditure, based on previous studies of continuous heart rate monitoring in this patient population. Daily excess calories were calculated as caloric intake minus caloric expenditure. Each patient was weighed daily and linear regression analysis (excess calories versus weight change) was performed for individual patients and the group over intervals of varying length. There was no individual or group correlation between excess calories and weight gain on a daily or weekly interval basis. Cumulative weight changes over the long-term course of TPN correlated significantly with cumulative excess calories for each patient and the whole group (r = +0.82, p less than 0.01). The excess calories required to gain a kilogram body weight ranged from 5569 to 15619 kcal/kg with a mean of 9768. Cumulative long-term weight changes during nutritional repletion in anorexia nervosa are meaningful indicators of caloric balance, but short interval weight changes (daily, weekly) are not. The caloric cost of weight gain is variable in this population.

The psychology of cosmetic surgery: a review and reconceptualization.

This article discusses the psychology of cosmetic surgery. A review of the research on the psychological characteristics of individuals who seek cosmetic surgery yielded contradictory findings. Interview-based investigations revealed high levels of psychopathology in cosmetic surgery patients, whereas studies that used standardized measurements reported far less disturbance. It is difficult to fully resolve the discrepancy between these two sets of findings. We believe that investigating the construct of body image in cosmetic surgery patients will yield more useful findings. Thus, we propose a model of the relationship between body image dissatisfaction and cosmetic surgery and outline a research agenda based upon the model. Such research will generate information that is useful to the medical and mental health communities and, ultimately, the patients themselves.

Social and psychological effects of craniofacial deformity and surgical reconstruction.

Psychosocial evaluations of patients undergoing surgery for congenital craniofacial anomalies are being conducted preoperatively and postoperatively to document functioning prior to and following surgery. Our findings to date indicate that presurgically younger patients, those between 6 and 13, fare better than those 14 years and over. The former, for the most part, appear to be functioning adequately and test within normal range on standardized psychometric measures. The latter are more prone to social isolation and problems in self-concept and mood state. Postoperative evaluations are reported only for the younger group because of the small sample size of the older. Overall postoperative adjustment appears improved on several psychometric tests. The majority of patients and families are pleased with outcome. Improvement in appearance postoperatively as rated by independent judges has not reached statistical significance; however, there are significant correlations between changes in appearance and changes on several measures including self-concept and trait anxiety. This finding would tend to support the contention that improvement in appearance brought about by craniofacial surgery is associated with improvement in psychosocial adjustment.

Psychosocial considerations in craniofacial deformity.

The authors evaluate the hypotheses that duration and severity of craniofacial malformations correlate with psychosocial adjustment. Reviewing data from congenital and traumatic craniofacial malformation patients of varying ages, they find partial support for the hypothesized associations; however, the relationship between psychosocial adjustment and craniofacial deformity is far from straightforward.

Psychosocial adjustment and craniofacial malformations in childhood.

Forty-three children between the ages of 6 and 13 years with congenital facial anomalies underwent psychosocial evaluation prior to surgery. Also evaluated were healthy children matched to the craniofacial subjects by sex, age, intelligence, and economic background. Relative to this comparison group, the craniofacial children were found to have poorer self-concept, greater anxiety at the time of evaluation, and more introversion. Parents of the craniofacial children noted more frequent negative social encounters for their children and more hyperactive behavior at home. Teachers reported more problematic classroom behavior. Examination of these results revealed craniofacial malformations to be associated with psychosocial limitations rather than marked deficits. These children tended to function less well than the comparison children, but with few exceptions, they were not functioning in a psychosocially deviant range. Explanations for the observed circumscribed impact of facial deformity include the use of denial as a coping mechanism, possible diminished significance of appearance for younger children, and the restricted environment experienced by most of the subjects. It can be predicted that time would render these protective influences ineffective, so that adolescent and young adult patients could be at far greater psychosocial risk.

Psychosocial outcome of craniofacial surgery in children.

Thirty-four children between the ages of 7 and 15 years with congenital craniofacial anomalies underwent psychosocial evaluation before and 12 to 18 months after surgery. Also evaluated were healthy children matched to the craniofacial subjects by sex, age, intelligence, and economic background. Preoperative assessment revealed the craniofacial group to have multiple but not severe psychosocial limitations. At follow-up, only a measure of social functioning still differentiated the groups, with the craniofacial subjects experiencing more negative social encounters. Comparison of initial and follow-up scores for the craniofacial group revealed a significant reduction in trait anxiety and trends toward reduction in parent-reported inhibited and hyperactive behavior. Scores on measures of extraversion and social functioning tended to be positively correlated with age for the comparison subjects only. Results suggest a modest improvement in psychological adjustment following surgery with a residual, possibly increasing, deficit in social functioning.

Body image dissatisfaction and body dysmorphic disorder in 100 cosmetic surgery patients.

This study was the first empirical investigation of body image dissatisfaction and body dysmorphic disorder in cosmetic surgery patients. Of 132 women, 100 women (response rate, 76 percent) completed two body image measures prior to surgery, the Multidimensional Body-Self Relations Questionnaire and the Body Dysmorphic Disorder Examination Self-Report. Cosmetic surgery patients did not demonstrate greater dissatisfaction with their overall appearance compared with the reported normal values of the measures. However, when asked about the specific bodily feature they were considering for cosmetic surgery, they reported significantly greater dissatisfaction than a normative sample. In addition, 7 percent of the sample met diagnostic criteria for body dysmorphic disorder, a potential psychiatric contraindication to cosmetic surgery. Implications of these findings are discussed with respect to the nature of body image dissatisfaction and the prevalence of body dysmorphic disorder in cosmetic surgery populations.

Psychological investigations in cosmetic surgery: a look back and a look ahead.

This article reviews the history of psychological investigations of cosmetic surgery patients. These studies have been designed to address two fundamental questions: (1) Are there "patient types" or forms of psychopathology that serve as contraindications to cosmetic surgery? and (2) What is the likelihood of psychological change following cosmetic surgery? This review suggests that the research has not fully answered these questions. In response, we propose a new direction for psychological investigation, focusing on issues of body image in cosmetic surgery patients. We discuss the relationship between body image and cosmetic surgery and pose several relevant questions for future research.

Adult psychological functioning of individuals born with craniofacial anomalies.

This study represents an initial investigation into the adult psychological functioning of individuals born with craniofacial disfigurement. A total of 24 men and women born with a craniofacial anomaly completed paper and pencil measures of body image dissatisfaction, self-esteem, quality of life, and experiences of discrimination. An age- and gender-matched control group of 24 non-facially disfigured adults also completed the measures. As expected, craniofacially disfigured adults reported greater dissatisfaction with their facial appearance than did the control group. Craniofacially disfigured adults also reported significantly lower levels of self-esteem and quality of life. Dissatisfaction with facial appearance, self-esteem, and quality of life were related to self-ratings of physical attractiveness. More than one-third of craniofacially disfigured adults (38 percent) reported experiences of discrimination in employment or social settings. Among disfigured adults, psychological functioning was not related to number of surgeries, although the degree of residual facial deformity was related to increased dissatisfaction with facial appearance and greater experiences of discrimination. Results suggest that adults who were born with craniofacial disfigurement, as compared with non-facially disfigured adults, experience greater dissatisfaction with facial appearance and lower self-esteem and quality of life; however, these experiences do not seem to be universal.

Bigger is not always better: body image dissatisfaction in breast reduction and breast augmentation patients.

This study investigated body image dissatisfaction in breast reduction and breast augmentation patients. Thirty breast reduction and 30 breast augmentation patients completed two body image measures preoperatively. Breast reduction patients reported greater dissatisfaction with their overall body image as compared with breast augmentation patients, part of which can be understood as a function of their increased body weight. When asked specifically about their breasts, reduction patients displayed increased body image dysphoria and maladaptive behavioral change, including embarrassment about their breasts in public areas and social settings and avoidance of physical activity. Results are discussed in the context of ideal body weight cutoffs by third-party payers for reimbursement for breast reduction. Recommendations for reimbursement criteria that de-emphasize the role of body weight are made.

The effect of anorexia nervosa on bone morphometry in young women.

Changes in bone morphometry during chronic undernutrition were evaluated in 14 young women with anorexia nervosa (mean age +/- SEM = 25.5 +/- 4.4 yrs). Bone morphometry studies using the second metacarpal of the left hand showed significant depression for percent cortical area (p less than 0.05); cortical area (p less than 0.001) and combined cortical thickness (p less than 0.01) as compared to age, sex and race matched controls. A trend (p less than 0.10) was observed in study subjects for reductions in bone width and total area. Using percent cortical area (PCA) as the standard, subjects had mean cortical bone morphometry equivalent to 60-year-old women. Appendicular bone mass is significantly decreased in adults with anorexia nervosa. Anorexia nervosa should be considered in the differential diagnosis of osteopenia in young women, and serves as a model for studying the effects of chronic calorie and mineral malnutrition on bone remodeling at the time of attainment of peak bone mass.

Body image dissatisfaction in male cosmetic surgery patients.

This study was the first empirical investigation of body image dissatisfaction in male cosmetic surgery patients. Thirty men completed two body image measures prior to their initial consultation. Results were compared to the norms for each of the measures and with a sample of 30 women seeking similar cosmetic procedures. Results indicated that patients did not demonstrate greater dissatisfaction with their overall appearance than men in a normative sample. However, when asked about the bodily feature they were considering for surgery, they reported significantly greater levels of dissatisfaction than the normative sample. As compared to male patients, female patients reported a greater investment in their physical appearance. Implications of these findings are discussed with respect to the nature of body image dissatisfaction and the relevance of body image in the psychology of male plastic surgery patients.

Body image concerns of reconstructive surgery patients: an underrecognized problem.

This study assessed the body image concerns of reconstructive plastic surgery patients. Forty-three reconstructive surgery patients completed two measures of body image. Responses were compared with a group of patients seeking cosmetic procedures. The two groups did not differ in the degree of dissatisfaction with their overall appearance or dissatisfaction with the specific feature for which they were seeking surgery. Reconstructive patients did consider themselves less healthy and less invested in their appearance than did cosmetic patients. Seven of the reconstructive surgery patients (all scar revision patients) reported a level of dissatisfaction and preoccupation consistent with the psychiatric diagnostic of body dysmorphic disorder. These results underscore the importance of screening for body image dissatisfaction in persons with an objective deformity. Plastic surgeons are in an optimal position to identify body image concerns in these patients and provide appropriate referrals for psychotherapy.

Body image dissatisfaction in women seeking rhytidectomy or blepharoplasty.

Ninety-seven women seeking rhytidectomy, blepharoplasty, or both completed two measurements of body image prior to their initial consultation. Results were compared with the normal scores for each of the measurements and with a sample of 32 women seeking rhinoplasty. Results indicated that women seeking rhytidectomy, blepharoplasty, or both to improve aging facial features reported a greater investment in and satisfaction with their overall appearance than women in a normattive sample. As was consistent with the findings of previous investigations, when asked about the specific body feature for which they were considering surgery, patients who wished to improve the appearance of aging facial features reported significantly greater dissatisfaction with their appearance feature than the normative sample but significantly less dissatisfaction than patients undergoing rhinoplasty. Patients wishing to improve the appearance of aging facial features seem to present for cosmetic surgery with different body image concerns than patients undergoing other types of cosmetic surgery.

A longitudinal study of metacarpal bone morphometry in anorexia nervosa.

Osteoporosis is a known complication of anorexia nervosa. Although calorie and mineral malnutrition may contribute to changes in bone mass and morphometry, hypoestrogenism is thought to be the most important etiologic factor. In a seven-year longitudinal study of six women aged 19 to 35 years with adolescent-onset anorexia nervosa, the objective was to correlate menstruation and bone morphometry. At the onset of the study, five women were amenorrheic and had abnormal metacarpal bone morphometry. After seven years, three women remained amenorrheic and below 85% of ideal body weight. Anteroposterior roentgenographs of the nondominant second metacarpal taken at the beginning and end of the study revealed an increase in medullary canal diameter (p less than 0.03) and medullary area (p less than 0.04) and a decrease in combined cortical thickness (p less than 0.04) and percent cortical area (p less than 0.02). These findings suggest progressive endosteal resorption in the absence of compensatory periosteal apposition. Such bone remodeling characteristics are distinctly abnormal in this age group. The three women who regained menses showed up to one third less endosteal resorption and less cortical thinning than did the three women who remained amenorrheic. Resumption of menses may be an important milestone in preventing further cortical bone loss in anorexia nervosa.