Factorial Validity of the Toronto Alexithymia Scale (TAS-20) in Clinical Samples: A Critical Examination of the Literature and a Psychometric Study in Anorexia Nervosa.

There is extensive use of the 20-item Toronto Alexithymia Scale (TAS-20) in research and clinical practice in anorexia nervosa (AN), though it is not empirically established in this population. This study aims to examine the factorial validity of the TAS-20 in a Portuguese AN sample (N = 125), testing four different models (ranging from 1 to 4 factors) that were identified in critical examination of existing factor analytic studies. Results of confirmatory factor analysis (CFA) suggested that the three-factor solution, measuring difficulty identifying (DIF) and describing feelings (DDF), and externally oriented thinking (EOT), was the best fitting model. The quality of measurement improves if two EOT items (16 and 18) are eliminated. Internal consistency of EOT was low and decreased with age. The results provide support for the factorial validity of the TAS-20 in AN. Nevertheless, the measurement of EOT requires some caution and may be problematic in AN adolescents.

Eating disorders and non-suicidal self-injury: Structural equation modelling of a conceptual model.

Evidence suggests several risk factors for both eating disorders (ED) and nonsuicidal self-injury (NSSI), but the relationships between these factors are not well understood. Considering our previous work and a conceptual model, this cross-sectional study aimed to assess the relationships among distal and proximal factors for the presence of NSSI in ED. We assessed 245 ED patients with the Oxford Risk Factor Interview for ED. Structural equation modelling revealed that both distal and proximal factors were related to the presence of NSSI in ED, disclosing a mediating role of the proximal factors. Stressful life events mediated the relationship between childhood sexual abuse, peer aggression, and both ED and NSSI. Childhood physical abuse was related to ED and NSSI via substance use, negative self-evaluation, and suicide attempts. Findings provided support for the conceptual model and highlight the possible mechanisms by which psychosocial factors may lead to ED and NSSI.

Putative Risk Factors for Non-Suicidal Self-Injury in Eating Disorders.

Evidence suggests a common association between eating disorders (EDs) and non-suicidal self-injury (NSSI). The present study aimed to investigate the potential risk factors for NSSI among ED patients. We assessed 245 ED patients with the Oxford Risk Factor Interview for ED. The results showed that 33% of ED patients reported NSSI in their lifetime. NSSI appeared to occur more frequently among binge eating/purging type ED patients than among patients with other ED and to be related to a more severe eating pathology. A younger age at the onset of eating problems, more negative self-evaluation, suicide attempts, substance abuse, parents' low weight, family tension at mealtime, parental alcohol problems, childhood abuse, peer aggression, and negative antecedent life events were more common among patients with co-occurring EDs and NSSI than among patients without NSSI. The results may inform the risk assessment and treatment of NSSI in EDs in the early detection period. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Anorexia nervosa versus bulimia nervosa: differences based on retrospective correlates in a case-control study.

OBJECTIVE: This study is the result of two Portuguese case-control studies that examined the replication of retrospective correlates and preceding life events in anorexia nervosa (AN) and bulimia nervosa (BN) development. This study aims to identify retrospective correlates that distinguish AN and BN METHOD: A case-control design was used to compare a group of women who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for AN (N = 98) and BN (N = 79) with healthy controls (N = 86) and with other psychiatric disorders (N = 68). Each control group was matched with AN patients regarding age and parental social categories. Risk factors were assessed by interviewing each person with the Oxford Risk Factor Interview. RESULTS: Compared to AN, women with BN reported significantly higher rates of paternal high expectations, excessive family importance placed on fitness/keeping in shape, and negative consequences due to adolescent overweight and adolescent objective overweight. DISCUSSION: Overweight during adolescence emerged as the most relevant retrospective correlate in the distinction between BN and AN participants. Family expectations and the importance placed on keeping in shape were also significant retrospective correlates in the BN group.

A case of choking phobia: towards a conceptual approach.

Choking phobia, also known as phagophobia or swallowing phobia is an uncommon clinical entity that has been underappreciated and is included in the new DSM-5 and upcoming ICD-11 diagnostic category of avoidant/restrictive food intake disorder. Phenomenologically distinct from other eating disorders, it is characterized by the phobic stimulus of swallowing that results in the avoidance of food or drinks, and ultimately to low weight, social withdrawal, anxiety and depression states. Its prevalence and long-term course on the general population still needs to be determined, probably reflecting years of indefiniteness regarding its nosology and by the absence of a clear set of diagnostic criteria. We present a clinical case of choking phobia in a 32-year-old male patient after an episode of choke when eating chicken. An early diagnosis and distinction from other eating disorders is important for proper treatment and fundamental for prognosis. We also make a thorough revision on literature in clinical features, differential diagnosis and treatment approaches, suggesting a conceptual approach for choking phobia as a clinical spectrum settled by different degrees of phobic subtypes, which may depend on a varied number of clinical variables.

Individual lithium disilicate crowns in a full-arch, implant-supported rehabilitation: a clinical report.

This clinical report presents the clinical outcome of a maxillary full-arch implant-supported fixed rehabilitation with lithium disilicate reinforced glass ceramic monolithic crowns opposing a mandibular metal-acrylic implant-supported fixed rehabilitation in a 62-year-old woman. Eight implants were successfully placed (four maxillary, four mandibular), and no complications occurred in the postoperative or maintenance periods. Six months after delivery, the maxillary and mandibular prostheses were found to be clinically, biologically, and mechanically stable, and the patient was satisfied with the esthetics and her ability to function. Although the present indications for the use of lithium disilicate are still restricted to tooth-borne restorations, it is possible to successfully rehabilitate edentulous patients through implant-supported fixed prostheses using lithium disilicate reinforced glass ceramic monolithic crowns.

Cognitive processing of emotions in anorexia nervosa.

OBJECTIVE: This study attempts to explore the cognitive processing of emotions in anorexia nervosa (AN), based on the study of emotions felt and the assessment of meta-emotional abilities. METHOD: Eighty patients with AN and a control group of 80 healthy female participants were screened for anxiety, depression and alexithymia and completed an experimental task designed to analyse the emotional experience and meta-emotional abilities. RESULTS: Despite presenting higher levels of alexithymia, participants with AN demonstrated they were able to imagine emotions in hypothetical situations and to identify and label them. The group of patients with AN revealed feeling more intense and internally based negative emotions in comparison with the control group, but this emotional pattern tends to occur in situations associated with food and weight. CONCLUSIONS: Findings on meta-emotional abilities suggested no global deficit in emotional processing, but rather, specific sensitivities pertaining to situations relevant to AN.

Registration-based methods applied to serial high-resolution T1-weighted magnetic resonance imaging for the assessment of brain volume changes in anorexia nervosa of the restricting type.

We aimed to determine whether variation in the body mass index (BMI)­a marker of anorexia nervosa (AN) severity­is associated with brain volume changes longitudinally estimated using registration-based methods on serial high-resolution T1-weighted magnetic resonance images (MRI). Fifteen female patients (mean age = 21 years; standard deviation [SD] = 5.7; range: 15­33 years) with the diagnosis of AN of the restricting type (AN-r)­according to the Diagnostic and Statistic Manual of Mental Disorders, 5th edition criteria­underwent T1-weighted MRI at baseline and after a mean follow-up period of 11 months (SD = 6.4). We used the brain boundary shift integral (BSI) and the ventricular BSI (VBSI) to estimate volume changes after registering voxels of follow-up onto baseline MRI. Very significant and strong correlations were found between BMI variation and the brain BSI, as well as between BMI variation and the VBSI. After adjustment for age at onset, duration of illness, and the BMI rate of change before baseline MRI, the statistical significance of both associations persisted. Registration-based methods on serial MRI represent an additional tool to estimate AN severity, because they provide measures of brain volume change strongly associated with BMI variation.

Treatment of Anorexia Nervosa: The Importance of Disease Progression in the Prognosis.

INTRODUCTION: Anorexia nervosa is a severe, usually chronic, life-threatening disease of complex etiology characterized by food restriction, overestimation of the importance of body weight and image, intense fear of weight gain and distortion of body image. Anorexia nervosa is associated with high rates of mortality, suicide and decreased quality of life. Our aim is to present an anorexia nervosa treatment program offered in a major university hospital in Portugal, and to determine the impact of illness duration before admission on the outcome. Our hypothesis is that patients with greater disease longevity may have worse prognosis and poorer outcome. MATERIAL AND METHODS: The sample included data from case records of 169 patients seen consecutively and for the first time at Centro Hospitalar São João, between 2010 and 2015. We performed a retrospective observational study which included data collected at admission and from later follow-up years. RESULTS: From the initially selected patients, 14.8% reached total remission, 16% accomplished partial remission and 14.2% ended up with exacerbation/stagnation of the disease. The dropout rate was of 55% throughout our study period. We found significant differences on outcome rates between distinct illness duration groups (p = 0.007). DISCUSSION: There are several factors frequently associated with poor outcome for anorexia nervosa. The interpretation of outcome findings was limited by the high rate of dropout and lack of consistent definition criteria. CONCLUSION: Our results support the idea that illness duration has an important role on the outcome and prognostic features of these patients.

Introdução: A anorexia nervosa é uma doença severa, geralmente crónica e potencialmente fatal, de etiologia complexa e caraterizada por restrição alimentar, sobrevalorização da importância do peso corporal e da imagem, medo intenso de ganho ponderal e distorção da imagem corporal. A anorexia nervosa está associada a altas taxas de mortalidade, suicídio e diminuição da qualidade de vida. O nosso objetivo é apresentar um programa de tratamento da anorexia nervosa de um hospital universitário português e determinar o impacto da duração da doença, antes da admissão, no outcome. A nossa hipótese é que pacientes com maior longevidade da doença apresentam piores prognóstico e outcome. Material e Métodos: A amostra incluiu dados de 169 pacientes vistos consecutivamente e pela primeira vez no Centro Hospitalar de São João, entre 2010 e 2015. Realizámos um estudo observacional retrospetivo, que incluiu os dados colhidos na admissão e durante o seguimento. Resultados: Dos doentes inicialmente selecionados, 14,8% alcançaram remissão total, 16% remissão parcial e 14,2% terminaram com exacerbação/estagnação da doença. A taxa de dropout foi 55% durante o nosso período de estudo. Encontrámos diferenças estatisticamente significativas relativamente ao outcome para diferentes tempos de duração da doença (p = 0,007). Discussão: Existem vários fatores frequentemente associados com mau outcome na anorexia nervosa. A interpretação dos resultados foi limitada pela alta taxa de dropouts e falta de critérios de definição consistentes. Conclusão: Os nossos resultados apoiam a ideia de que a duração da doença tem um papel preponderante no outcome e prognóstico da doença.

Prevalence and Determinants of Bullying Among Health Care Workers in Portugal.

Bullying is defined as systematic exposure to humiliation as well as hostile and violent behaviors against one or more individuals. These behaviors are a serious, growing problem, which affects a significant proportion of health care professionals. To support the hospital's risk management policy, a cross-sectional study was undertaken to determine the prevalence of bullying in this institution and identify the determinants of bullying. Bullying was measured using the Negative Acts Questionnaire-Revised, Portuguese version (NAQ-R), a self-administered tool. The questionnaire was made available in digital format on the hospital's internal network (Intranet) and in hard copy; questionnaires were returned via nonidentified internal mail addressed to the occupational health unit or deposited in suggestion boxes located throughout the hospital. Multiple questionnaire delivery methods guaranteed data anonymity and confidentiality. The prevalence of bullying in this hospital was 8% (95% confidence interval [CI] = [6.2, 10.2]). Reported bullying was predominantly vertical and more frequently occurring among nurses, clerical staff, and health care assistants (12.5%, 7.6%, 6.4%, respectively; p = .005). After adjusting for gender, age, occupation, type of contract, and work schedule, only type of contract was significantly associated with bullying in the workplace; the risk of bullying was twice as high among government employees compared to workers with indefinite duration employment contracts ( p = .038). This study identified a high prevalence of bullying among health professionals; hence a program to prevent and control this phenomenon was implemented in this institution.

Alexithymia in anorexia nervosa: the mediating role of depression.

The role of depression in the expression of alexithymia in anorexia nervosa (AN) has been controversially explained and several variables that may mask or increase the presence of emotional difficulties have scant examination in previous studies. This study aims to analyze the associations between alexithymia and state variables, such as age, BMI, illness duration, treatment duration, and medication status in AN participants, and to test the mediating role of depression in emotional difficulties. The Toronto Alexithymia Scale (TAS-20) and the Zung Self-Rating Depression Scale were administrated to 160 females: 80 participants with AN and 80 healthy controls. High levels of alexithymia were not a function of state variables. The mediating role of depression differed by the alexithymia dimension, with total mediation found for the TAS-DDF and partial mediation found for the TAS-DIF. Alexithymia is a relevant feature throughout the spectrum of AN and does not seem to be related to developmental maturation and some clinical features. Depression is probably the variable that best accounts for the variance in alexithymia, but is not a complete explanation for the known cognitive-affective disturbances in AN. Specific emotional competencies require scrutiny during psychiatric treatment.

Forty years of a psychiatric day hospital.

INTRODUCTION: Day hospitals in psychiatry are a major alternative to inpatient care today, acting as key components of community and social psychiatry. OBJECTIVE: To study trends in the use of psychiatric day hospitals over the last decades of the 20th century and the first decade of the 21st century, focusing on patient age, sex, and diagnostic group, using data from Centro Hospitalar São João, Porto, Portugal. METHODS: Data corresponding to years 1970 to 2009 were collected from patient files. Patients were classified into seven diagnostic groups considering their primary diagnoses only. RESULTS: Mean age upon admission rose from 32.7±12.1 years in the second half of the 1970s to 43.5±12.2 years in 2005-2009 (p for trend < 0.001). Most patients were female (63.2%), however their proportion decreased from nearly 70% in the 1970s to 60% in the first decade of the 21st century. In males, until the late 1980s, neurotic disorders (E) were the most common diagnosis, accounting for more than one third of admissions. In the subsequent years, this proportion decreased, and the number of admissions for schizophrenia (C) exceeded 50% in 2004- 2009. In females, until the late 1980s, affective disorders (D) and neurotic disorders (E), similarly distributed, accounted for most admissions. From the 1990s on, the proportion of neurotic disorders (E) substantially decreased, and affective disorders (D) came to represent more than 50% of all admissions. CONCLUSIONS: Mean age upon admission rose with time, as did the percentage of female admissions, even though the latter tendency weakened in the last 10 years assessed. There was also an increase in the proportion of patients with schizophrenia.

Anorexia nervosa and dialysis: we have no time when the body is so damaged!

Anorexia nervosa remains challenging to treat and difficult to prevent. Nearly 5% of affected individuals die of this disease and 20% develop a chronic eating disorder. Anorexia nervosa may be associated with several medical complications of varying severity, including dysfunction of the renal system. Though there are some reports of renal failure in patients with anorexia nervosa, few reports are available concerning patients who required maintenance dialysis. We report a case of a patient with long-term untreated anorexia nervosa-binge eating/purging type who started psychiatric treatment when in a life-threatening situation (renal failure requiring dialysis), with unsuccessful weight recovery while on dialysis and died of septicaemia. The mechanisms that seem to be involved in the development of end-stage renal disease in this patient and the challenges associated with her treatment are reviewed. Patients with anorexia nervosa should be carefully monitored to discover the subtle manifestations of early renal failure.

Clozapine-induced palilalia?.

INTRODUCTION: Palilalia is an acquired speech disorder characterised by involuntary and spontaneous repetition of words or phrases two or more times in a row. It can occur in a variety of disorders including postencephalic parkinsonism, pseudobulbar palsy, schizophrenia, Gilles de la Tourette syndrome and others. CLINICAL CASE: We describe a case of a 28-year-old man with refractory schizophrenia that developed palilalia with 300 mg of clozapine. In the patient evaluation we found unspecific alterations in the electroencephalogram, with normal blood tests and cerebral magnetic resonance imaging. Palilalia disappeared with lowering doses of clozapine. DISCUSSION: The appearance of palilalia induced by clozapine is a rare pharmacologic side-effect which physicians should be familiarised with when evaluating this symptom presentation.

[Mental health of college students: experience of the university psychiatric outpatient clinic of Hospital de São João]. / Saúde mental em estudantes do ensino superior: experiência da consulta de psiquiatria do centro Hospitalar São João.

The mental health of college students has been raising major awareness, due to the increased prevalence and severity of psychiatric disorders in this population. Higher education is associated with significant stressors that contribute to the development of mental health disturbances, and most college students are in the high-risk age group for the emergence of symptoms of major psychiatric disorders. Early diagnosis and treatment of these disorders in college students are important areas of effort, since they pose a high impact at the educational, economic, and social levels. Thus, specifically planned mental health services play a major role in the management of this population, should be specialized and have easy accessibility. The purpose of this study is to describe and characterize the College Students' psychiatric outpatient clinic of the Department of Psychiatry, Hospital de São João.

[Antibiomania: a case of a manic episode induced by clarithromycin]. / Antibiomania: um episódio de mania induzido por claritromicina.

Antibiomania, or mania induced by antibiotics, is a rare, but important side effect of clarithromycin and others antibiotics. Although underestimated due to low clinical incidence, this phenomenon is being reported in a growing number of cases of mania associated with administration of antibiotics, in patients without a previous diagnosis of Bipolar Affective Disorder. The importance of Antibiomania in current clinical practice is associated with the increasing introduction and prescription of new antibiotics, and to the need for awareness of the phenomenon as a possible differential diagnosis of secondary mania. There are several theories that may explain Antibiomania, one of the most studied is related to the interaction of antibiotics with neurotransmitters, including the gamma butyric acid (GABA). However, the mechanism is still unknown. The authors present a case of a manic episode triggered by clarithromycin in a patient with no clinical history of disturbance of mood, followed by a brief literature review of the subject, including treatment strategies.

Forty years of a psychiatric day hospital / Quarenta anos de um hospital de dia de psiquiatria

INTRODUCTION: Day hospitals in psychiatry are a major alternative to inpatient care today, acting as key components of community and social psychiatry. Objective: To study trends in the use of psychiatric day hospitals over the last decades of the 20th century and the first decade of the 21st century, focusing on patient age, sex, and diagnostic group, using data from Centro Hospitalar São João, Porto, Portugal. METHODS: Data corresponding to years 1970 to 2009 were collected from patient files. Patients were classified into seven diagnostic groups considering their primary diagnoses only. RESULTS: Mean age upon admission rose from 32.7±12.1 years in the second half of the 1970s to 43.5±12.2 years in 2005-2009 (p for trend < 0.001). Most patients were female (63.2%), however their proportion decreased from nearly 70% in the 1970s to 60% in the first decade of the 21st century. In males, until the late 1980s, neurotic disorders (E) were the most common diagnosis, accounting for more than one third of admissions. In the subsequent years, this proportion decreased, and the number of admissions for schizophrenia (C) exceeded 50% in 2004- 2009. In females, until the late 1980s, affective disorders (D) and neurotic disorders (E), similarly distributed, accounted for most admissions. From the 1990s on, the proportion of neurotic disorders (E) substantially decreased, and affective disorders (D) came to represent more than 50% of all admissions. CONCLUSIONS: Mean age upon admission rose with time, as did the percentage of female admissions, even though the latter tendency weakened in the last 10 years assessed. There was also an increase in the proportion of patients with schizophrenia. .

INTRODUÇÃO: Os hospitais de dia em psiquiatria representam atualmente uma das principais alternativas ao internamento, atuando como componentes chave na psiquiatria comunitária e social. OBJETIVO: Avaliar tendências na utilização de um hospital de dia no período compreendido entre as últimas décadas do século 20 e a primeira década do século 21, com foco em idade, sexo e grupo diagnóstico, usando dados do Centro Hospitalar São João, Porto, Portugal. MÉTODOS: Dados correspondentes aos anos 1970 a 2009 foram coletados dos prontuários clínicos. Os pacientes foram classificados em sete grupos diagnósticos, tendo em conta o diagnóstico principal. Resultados: A idade média na admissão aumentou de 32.7±12.1 anos na segunda metade da década de 1970 para 43.5±12.2 anos em 2005-2009 (p < 0.001). A maioria dos pacientes era do sexo feminino (63.2%), no entanto sua proporção diminuiu de cerca de 70% na década de 1970 para 60% na primeira década do século 21. Nos homens, até o final dos anos 1980, o grupo das perturbações neuróticas (E) era o diagnóstico mais comum, representando mais de um terço das admissões. Durante os anos seguintes, essa proporção diminuiu, e o número de admissões por esquizofrenia (C) alcançou mais de 50% no período de 2004-2009. Nas mulheres, até o final dos anos 1980, as perturbações afetivas (D) e as perturbações neuróticas (E), distribuídas similarmente, respondiam pela maioria das admissões. A partir dos anos 1990, a proporção das perturbações neuróticas (E) diminuiu substancialmente, e as perturbações afetivas (D) passaram a corresponder a mais de 50% do total das admissões. Conclusões: A idade média na admissão ...

Prevalência da alexitimia na anorexia nervosa e sua associação com variáveis clínicas e sociodemográficas / Prevalence of alexithymia in anorexia nervosa and its association with clinical and sociodemographic variables

OBJETIVO: Analisar a prevalência da alexitimia numa amostra de pacientes com anorexia nervosa e sua relação com variáveis do foro clínico e sociodemográfico, em concreto, índice de massa corporal, duração da doença, idade, escolaridade e nível socioeconômico. MÉTODOS: Foram avaliados 2 grupos de participantes do sexo feminino, com idades compreendidas entre os 13 e os 34 anos. Um grupo foi composto por 80 participantes com anorexia nervosa (Grupo AN) e o outro por 80 participantes saudáveis (Grupo Controle). A versão portuguesa da Toronto Alexithymia Scale - 20 items - foi aplicada a ambos os grupos. RESULTADOS: A prevalência da alexitimia no Grupo AN foi 62,5 por cento e no Grupo Controle, 12,5 por cento. Os valores médios de alexitimia não diferiram significativamente entre os dois subtipos de AN, e ambos apresentaram valores estatisticamente superiores aos do Grupo Controle. A alexitimia não se correlacionou às variáveis clínicas e sociodemográficas consideradas, à exceção da escolaridade, cuja associação com a alexitimia foi positiva e baixa. CONCLUSÃO: Os pacientes com anorexia nervosa apresentaram, com elevada frequência, dificuldades na regulação dos afetos, independentemente de seu peso, tempo de evolução da doença, idade e nível socioeconômico. O tratamento deve privilegiar uma intervenção sistematizada no domínio das emoções.

OBJECTIVE: To analyze the prevalence of alexithymia in anorexia nervosa and its relationship with clinical and sociodemographic variables, such as, body mass index, anorexia nervosa duration, age, years of education and socioeconomic status. METHODS: Two groups of female participants, between the ages of 13 and 34 years, were recruited. One group was composed of 80 participants with anorexia nervosa (AN Group) and the other consisted of 80 healthy participants (Control Group). The Portuguese version of the Toronto Alexithymia Scale - 20 items - was applied to both groups. RESULTS: The prevalence of alexithymia in the AN Group was 62.5 percent and 12.5 percent in the Control Group. The mean values of alexithymia (total score and factors) did not significantly differ between the two AN subtypes, and both subtypes presented higher statistical values when compared to the Control Group. Alexithymia did not correlate with clinical and sociodemographic variables, with the exception of years of education, which had a positive and low association with alexithymia. CONCLUSION: Patients with anorexia nervosa revealed a high prevalence of affect regulation deficits regardless of their weight, duration of the disease, age and socioeconomic status. Therapy should focus on a systematic intervention in the domain of emotional regulation.