A first study on the usability and feasibility of four subtypes of suicidality in emergency mental health care.

BACKGROUND: Based on clinical experience, a (hypothetical) four-type model of suicidality that differentiates between subtypes with a unique pathway to entrapment ((h)4ME)was developed. The subtypes are: 1) perceptual disintegration (PD), 2) primary depressive cognition (PDC), 3) psychosocial turmoil (PT) and 4) inadequate communication/coping (IC). This study was carried out to examine the usability and feasibility of the subtypes in an absolute and dimensional way with the SUICIDI-2 instrument. OBJECTIVE: A first step was to examine the model and the SUICIDI-2 instrument for usability and feasibility in clinical practice. We aim to investigate the'real life' practical application of the model and hope the feedback we get after practical use of the model will help us with improvements for the model and the SUICIDI-2 instrument. METHODS: Discharge letters to general practitioners of 25 cases of anonymized suicidal emergency patients were independently reviewed by three psychiatrists and three nurses. Using the SUICIDI-2 instrument, describing the proposed subtypes, cases were classified by the psychiatrists and nurses. Intraclass Correlation Coefficients (ICC) for absolute/discrete and dimensional ratings were calculated to examine the model's usability and the instrument's feasibility. The study was approved by the ethical board. RESULTS: All raters were able to recognize and classify the cases in subtypes. We found an average measure of good reliability for absolute/(discrete) subtypes. For dimensional scores, we found excellent average measures for the subtype PDC, and good average measures for the subtypes PD, PT and IC. The reliability of dimensional score for the SUICIDI-2 was relatively lower than an alternative dimensional rating, but had good ICC values for all subtypes. After reviewing the results though, we found some inconsistently assessment between raters. This was ground to narrow down the criteria per subtype to describe the subtypes more precisely. This resulted in adjusted formulations for subtypes PD and IC and agreement was achieved about formulations in the revised SUICIDI-3. CONCLUSIONS: The hypothetical model of entrapment leading to suicidality shows promising results for both the usability and feasibility of the SUICIDI instrument. Follow up studies with participants with a more diverse background may show consistency and validity for the model.

A Clinical Model for the Differentiation of Suicidality: Protocol for a Usability Study of the Proposed Model.

BACKGROUND: Even though various types of suicidality are observed in clinical practice, suicidality is still considered a uniform concept. To distinguish different types of suicidality and consequently improve detection and management of suicidality, we developed a clinical differentiation model for suicidality. We believe that the model allows for a more targeted assessment of suicidal conditions and improves the use of evidence-based treatment strategies. The differentiation model is based on the experience with suicidality that we have encountered in clinical practice. This model distinguishes 4 subtypes of entrapment leading to suicidality. The earliest description of this model and a proposal for usability research has been previously presented in a book chapter. OBJECTIVE: In this study, we present the most recent version of the 4-type differentiation model of suicidality and a protocol for a study into the usability of the proposed model. METHODS: The 4-type differentiation model of suicidality distinguishes the following subtypes: (1) perceptual disintegration, (2) primary depressive cognition, (3) psychosocial turmoil, and (4) inadequate coping or communication. We plan to test the usability of the 4 subtypes in a pilot study of 25 cases, and subsequently, we will include 75 cases in a follow-up study. We looked at the case notes of 100 anonymized patients with suicidality who presented to mental health care emergency service in The Hague International Center. The summary and conclusions of the letters sent to the patients' general practitioners after suicide risk assessment will be independently rated by 3 psychiatrists and 3 nurse-scientists for absolute and dimensional scores. The Suicidality Differentiation version 2 (SUICIDI-II) instrument, developed for this study, is used for rating all the cases. Intraclass correlation coefficients for absolute and dimensional scores will be calculated to examine type agreement between raters to examine the usability of the model and the feasibility of the SUICIDI-II instrument. RESULTS: We consider the model tentatively valid if the intraclass correlation coefficients are ≥0.70. Subsequently, if the model turns out to be valid, we plan to rate 75 other cases in a follow-up study, according to a similar or adjusted procedure. Study results are expected to be published by the end of 2023. CONCLUSIONS: The theoretical roots of the differentiation model stem from classic and contemporary theoretical models of suicidality and from our clinical practice experiences with suicidal behaviors. We believe that this model can be used to adjust the diagnosis, management, treatment, and research of suicidality, in addition to distinguishing different dynamics between practitioners and patients with suicidality and their families. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/45438.

The effect of parental emotional abuse on the severity and treatment of PTSD symptoms in children and adolescents.

BACKGROUND: Maltreatment by a primary caregiver is an important risk factor for the development of PTSD symptoms. Whereas meta-analyses indicate that parental emotional abuse is one of the most common forms of maltreatment, the impact of emotional abuse on PTSD symptoms and treatment effectiveness is still unclear, especially in children. OBJECTIVE: We aimed to investigate the impact of parental emotional abuse on PTSD symptom severity and effectiveness of trauma treatment in children and adolescents. METHOD: In an outpatient sample (N = 287, mean age = 15.5 years), emotional abuse, index traumatic event, and PTSD symptoms were assessed at baseline. Thereafter, patients received evidence-based treatment for trauma-related symptoms embedded in a broader (systemic) treatment package. In a subsample (n = 130, mean age = 15.3 years) PTSD symptoms were assessed again 6 and 12 months after baseline. RESULTS: Emotional abuse (rather than any other type of maltreatment) was associated with more severe PTSD symptoms in all symptom clusters. This was independent of whether emotional abuse was reported as index traumatic event or not. Moreover, PTSD symptoms were significantly reduced 6 months after the start of trauma-focused treatment, and emotional abuse was associated with more severe PTSD symptoms over the course of treatment. CONCLUSIONS: These findings underline the detrimental nature of emotional maltreatment in the context of PTSD symptomatology and treatment effectiveness. This calls for routine assessment of parental emotional abuse in the diagnostic phase, even when this is not the reason of referral.

Depressive symptoms rather than executive functioning predict group cognitive behavioural therapy outcome in binge eating disorder.

Executive functions play an important role in mediating self-control and self-regulation. It has been suggested that the inability to control eating in Binge Eating Disorder (BED) may indicate inefficiencies in executive functioning. This study investigated whether executive functioning predicted cognitive behavioural therapy outcome in BED while accounting for other possible predictors: depressive symptoms, interpersonal factors, eating disorder psychopathology, and self-esteem. Executive functioning and other predictors were assessed in 91 patients with BED by means of neuropsychological tests and questionnaires at baseline. Eating disorder (ED) symptoms were assessed during treatment at variable time points. Potential predictor variables were investigated using multivariate Cox regression models. Recovery was defined by means of two different indicators based on the Eating Disorder Examination-Questionnaire: (a) showing a 50% reduction in baseline symptom ED severity and/or reaching the clinical significance cut-off; and (b) achieving abstinence of objective binge eating. Severity of depressive symptoms was a significant predictor for outcome on both indicators. Patients with no or mild depressive symptoms recovered faster (i.e., 50% reduction in ED symptoms and abstinence of objective binge eating) than those with severe depressive symptoms, which is in line with previous studies. Executive functioning was not related to treatment outcome in this study.

Predictors of psychological outcome in patients with eating disorders: A routine outcome monitoring study.

BACKGROUND: Identifying predictors of psychological outcome for patients with eating disorders may improve the effectiveness of treatment. Patients with different pre-treatment characteristics and symptoms may benefit from different therapies. This study aimed to identify potential predictors of treatment outcome in a large naturalistic cohort of patients with an eating disorder. METHOD: The study sample included patients (N = 1153) with all types of eating disorders who were receiving residential, day, or outpatient treatment. Remission was defined by means of four different indicators based on the Eating Disorder Examination-Questionnaire global score: 1. achieving reliable change; 2. showing a 50% reduction in baseline symptom severity; 3. reaching the clinical significance cut-off point; and 4. a combination of indicators 2 and 3. Potential predictor variables were investigated in univariate and multivariate Cox regression models. RESULTS: Different predictors were found for the four outcome criteria. Patients with high levels of interpersonal distrust at baseline were less likely to have achieved reliable change in eating disorder psychopathology. Higher self-esteem and less body dissatisfaction at baseline was independently associated with a symptom reduction of more than 50% and/or reaching the clinical significance cut-off point. Contrary to our expectations, no differences in outcome were found between the eating disorder subtypes. DISCUSSION: Clinically, it is important to reduce the risk of poor outcome and to achieve a rapid response in treatment using an intervention designed for this purpose, such as shared decision making or an intervention directed at self-esteem or body image, which may act as a catalyst for change. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:863-873).

A common mineralocorticoid receptor polymorphism (I180V) interacts with life events in relation to perfectionism in eating disorders: a pilot study.

The stress response is regulated by the mineralocorticoid receptor (MR) and the glucocorticoid receptor (GR). When the balance between GR and MR signalling is disturbed, one's capacity to cope with a stressful event is diminished. In this pilot study, we tested the hypothesis that an interaction between common variants in the MR (rs5522) or GR gene (rs41423247) and stressful life events influences perfectionism levels in a group of patients with an eating disorder (ED; n = 113). Patients carrying the minor G allele of rs5522 had a higher perfectionism score if more stressful life events were experienced [ß = 0.95, t(109) = 3.75, p < 0.01]. This effect was not found for patients carrying the AA genotype. These results suggest that rs5522 G allele carriers might be vulnerable to stressful life events. When patients with an ED are carriers and experience multiple life events, this might fuel their insecurity, which in turn may engender higher levels of perfectionism. Further studies are necessary to replicate and expand our findings.

Correlates and associations between weight suppression and binge eating symptomatology in a population-based sample.

Weight suppression (WS), the discrepancy between a person's highest ever and current body weight, has been found in a number of studies to be associated with the onset and maintenance of bulimia nervosa (BN). The current theories on the working mechanism hypothesize that individuals with BN might be caught in a (psycho)biobehavioral bind and suggest a circle of weight loss, weight suppression, weight gain, and binge eating that in theory should also apply to a broad spectrum of binge eating symptomatology. This study was intended to test the hypothesis that WS predicts current binge eating with a loss of control (BE+LOC) in a population-based sample. We used a population-sample of participants (N=3,512) who responded to a survey in a women's magazine. In a logistic regression analysis, WS did not predict current BE+LOC, in contrast to high diet activity in the past year. Possible explanations for the lack of association are discussed. Future studies are needed to specify the specific active ingredients in the relation between WS and BN.

Eating disorders in the general practice: a case-control study on the utilization of primary care.

OBJECTIVE: To investigate primary care utilization between patients with an eating disorder (ED) and other patient groups, and between the ED subgroups anorexia nervosa (AN) and bulimia nervosa (BN). METHOD: The present study was an observational case-control study. In total, 167 patients with ED were matched with two control groups (with and without mental disorders). General practitioners (GPs) kept electronic records and provided all patient contacts, prescriptions and referrals with a diagnostic code. RESULTS: Although patients with BN have the highest number of face-to-face contacts compared with all other groups, these patients less often seek help for eating problems compared with patients with AN, even when the ED diagnosis is known to the GP. Overall, patients with mental disorders showed a comparable rate of GP care, which was elevated compared with patients without mental disorders. DISCUSSION: Patients with BN might need more active encouragement by the GP to talk about their eating problems because there are indications that point at an unmet need for GP care.

Course and outcome of eating disorders in a primary care-based cohort.

OBJECTIVE: To study the course and outcome of patients with eating disorder detected in primary care. METHOD: General practitioners (GP's) provided information on the course and outcome of eating disorders in patients (n = 147) diagnosed with anorexia nervosa (AN) or bulimia nervosa (BN) identified during a Dutch nationwide primary care-based incidence study. The research team determined the outcome based on the data provided by the GP's. The mean duration of the follow-up was 4.8 years. RESULTS: About 57% of the patients initially diagnosed with AN and 61% of those diagnosed with BN were fully recovered. AN binge/purge subtype (ANBP) demonstrated the most extended median survival time of all diagnostic subgroups (the point at which half of the group has reached full recovery). Diagnostic crossover was low. A younger age at detection predicted recovery at outcome for AN and BN. One patient (AN) died. DISCUSSION: The results of this study on differences in outcome and low crossover support the diagnostic distinction between AN and BN in the DSM-IV. Early detection is of major importance for a favorable outcome.

Urbanisation and the incidence of eating disorders.

The link between degree of urbanisation and a number of mental disorders is well established. Schizophrenia, psychosis and depression are known to occur more frequently in urban areas. In our primary care-based study of eating disorders, the incidence of bulimia nervosa showed a dose-response relation with degree of urbanisation and was five times higher in cities than in rural areas. Remarkably, anorexia nervosa showed no association with urbanisation. We conclude that urban life is a potential environmental risk factor for bulimia nervosa but not for anorexia nervosa. These findings provide a promising avenue for further research into the aetiology of eating disorders.

Time trends in the incidence of eating disorders: a primary care study in the Netherlands.

OBJECTIVE: This Dutch epidemiological study used primary care-based data to examine changes in the incidence of eating disorders in the 1990s compared to the 1980s. METHOD: A nationwide network of general practitioners, serving a representative sample of the total Dutch population, recorded newly diagnosed patients with anorexia nervosa (AN) and bulimia nervosa (BN) in their practices during 1985-1989 and 1995-1999. RESULTS: The overall incidence of AN was stable (from 7.4 to 7.7 per 100,000). However, the incidence among 15-19-year-old females increased significantly (from 56.4 to 109.2 per 100,000). The incidence rate of BN decreased nonsignificantly from 8.6 to 6.1 per 100,000. CONCLUSION: The time trend of an increasing AN incidence among the high risk group continued to the end of the past century. The BN incidence did not rise as was expected.