A novel 'practical body image' therapy for adolescent inpatients with anorexia nervosa: a randomised controlled trial.

PURPOSE: To determine the potential effectiveness of a novel 10-week manualised Practical Body Image therapy (PBI) with mirror exposure (ME), when used as an adjuvant to an intensive treatment package (TAU) in adolescent inpatients with Anorexia Nervosa (AN). To evaluate the effectiveness of ME in an adolescent population. METHODS: Using a randomised control design, 40 girls aged 11-17 years with AN were assigned to PBI with TAU (n = 20) and TAU alone (n = 20). Both groups completed self-report measures of body image at week 1 and week 10 of the study to measure the potential effectiveness of PBI. The PBI group completed measures at week 7 to evaluate the ME component. RESULTS: 31 participants completed the study; 16 TAU, 15 PBI. PBI participants had greater improvement in all outcomes than TAU participants. Medium effect sizes were seen for self-reported weight concern, body image avoidance in terms of clothing and body image anxiety. ME produced effect sizes in self-reported body image avoidance in terms of clothing and grooming that were greater than 0.40, n = 14. CONCLUSION: The findings demonstrate that PBI supports an intensive inpatient treatment package and addresses elements of negative body image. PBI was beneficial for addressing body image dissatisfaction with improvements in weight concerns, body image avoidance and physical appearance trait anxiety following the ME component. The magnitude of the effect sizes is comparable to previous studies. Positive qualitative feedback indicated the intervention was acceptable to users. PBI is a promising new adjuvant treatment for AN. EMB RATING: Level I: randomized controlled trial.

BodyWise: evaluating a pilot body image group for patients with anorexia nervosa.

Body image disturbance can be enduring and distressing to individuals with eating disorders and effective treatments remain limited. This pilot study evaluated a group-based treatment-BodyWise-developed for use in full and partial hospitalization with patients with anorexia nervosa at low weight. A partial crossover waitlist design was used. BodyWise (N = 50) versus treatment as usual (N = 40) were compared on standardized measures of body image disturbance. Results demonstrated significant improvement in the group compared to treatment as usual for the primary outcome measure (Eating Disorder Examination-Questionnaire Shape Concern subscale) and other manifestations of body image disturbance including body checking and body image quality of life. BodyWise appeared acceptable to participants, and was easy to deliver within the pragmatics of a busy eating disorder service. There is potential for its wider dissemination as a precursor to more active body image interventions.

Premature termination of treatment for anorexia nervosa: differences between patient-initiated and staff-initiated discharge.

OBJECTIVES: To investigate treatment drop-out by comparing clinical indicators of patients whose discharge was initiated by staff with those who initiated discharge themselves. METHOD: Ninety participants with anorexia completed questionnaires at admission and four weeks into hospitalized treatment. Weight data was collected over this same period. At discharge, participants were categorized into completer (n = 38) or patient-initiated (n = 36) /staff-initiated (n = 16) premature termination groups. RESULTS: Significant differences between staff-initiated and patient-initiated discharge groups were found at admission. Staff initiated groups were on average older (p = .035), and more likely to have had prior compelled treatment (p = .039). At 4 weeks those in the patient-initiated group had put on weight at a faster rate (p = .032) and reported a decrease in alliance (p = .017). At discharge, staff initiated discharge demonstrated greater time in treatment (p = .001), greater weight gain (p = .027), and a higher discharge BMI (p = .013). At discharge, staff-initiated drop-outs had comparable end-of-treatment outcomes to those who completed treatment as planned. DISCUSSION: There are key differences between those who prematurely discharge themselves from treatment, compared to those who are prematurely discharged by clinical staff. Future research into drop-out needs to take into account and recognize these differences.

Ten session body image therapy: efficacy of a manualised body image therapy.

OBJECTIVE: To determine the efficacy of 10 session body image therapy (BAT-10) in the treatment of anorexia nervosa with adherence to the methodological guidance for complex interventions. METHOD: Fifty-five adult inpatients with anorexia nervosa at two national centres received the group-based manualised body-image therapy (BAT-10). BAT-10 was refined, developed and manualised over two decades, by using the mindfulness-based cognitive behavioural therapy, including mirror exposure. Outcomes were evaluated using Body Checking Questionnaire, Body Image Avoidance Questionnaire, Physical Appearance State and Trait Anxiety Scale, Eating Disorders Examination Questionnaire and Quality of Life in Eating Disorders. Participant experience was evaluated qualitatively by an interpretative phenomenological analysis. RESULTS: Ten session body image therapy achieved highly statistically significant changes in body checking, body avoidance and anxiety, as well as shape-concern and weight-concern, without the between-therapist effects. The quality of life improved globally but not in relation to the psychological subcategory. DISCUSSION: Ten session body image therapy delivers behavioural and cognitive improvements in body image in the short-term, suggesting an effective, feasible and acceptable manual-based therapy.

The clinical implications of high levels of autism spectrum disorder features in anorexia nervosa: a pilot study.

OBJECTIVE: This study examined autism spectrum disorder (ASD) features in relation to treatment completion and eating disorder psychopathology in anorexia nervosa (AN). METHOD: Thirty-two adult women were recruited from specialist eating disorder services. Features of ASD and disordered eating were measured. Premature termination of treatment was recorded to explore whether ASD traits had impact on early discharge. A healthy control group was also recruited to investigate ASD traits between clinical and nonclinical samples. RESULTS: Significant differences were found between the AN group and the healthy control group in obsessive-compulsive disorder traits, depression and anxiety and ASD traits, with significant differences between groups in Social Skill and Attention Switching. The AN group reported no significant relationship between disordered eating severity and ASD traits. No significant effect was found between ASD features and treatment completion. DISCUSSION: Raw data on premature termination of treatment, despite no statistic impact, showed that seven out of the eight participants with high features of ASD completed treatment as planned compared with 50% of those with low ASD traits. Unexpectedly, this suggests enhanced treatment adherence in ASD.

Rules of engagement: qualitative experiences of therapeutic alliance when receiving in-patient treatment for anorexia nervosa.

Recent research has emphasised the importance of therapeutic alliance to treatment outcomes for anorexia nervosa. This study aimed to examine the experiences of service users in developing therapeutic alliance whilst in treatment for their eating disorders. This qualitative study, using purposive sampling, recruited a sample of service users receiving treatment at a national eating disorders service. In-depth interviews were audiotaped and transcribed, with transcriptions being subject to interpretative phenomenological analysis. Participants were eight adult women receiving tertiary level eating disorder treatment in a specialist setting. The text analysis produced four dominant categories: alliance as a key experience; being active, not passive; taboo talking; and first impressions count. The development of therapeutic alliance is a core component of treatment. This study identifies important areas that contribute to the successful cultivation of positive therapeutic alliance.

Knowledge and attitudes of psychiatrists towards eating disorders.

OBJECTIVE: This study examined the eating disorder mental health literacy of psychiatrists. METHOD: A sample of psychiatrists completed a questionnaire measuring knowledge of and attitudes towards eating disorders. Knowledge questions were based on the academic literature, standard diagnostic criteria and national guidelines on the management of eating disorders. Attitude items covered beliefs about the aetiology and treatment of eating disorders, confidence levels in diagnosis and management and the use of compulsory measures in anorexia nervosa. RESULTS: Psychiatrists' knowledge of eating disorders was variable with specific gaps in both diagnosis and management. Psychiatrists felt more confident in diagnosing eating disorders than managing these conditions. Attitudes towards eating disorders were less stigmatizing than those seen in other health professionals. DISCUSSION: There is a clear need for greater education of psychiatrists regarding the diagnosis and management of eating disorders. Implementing training programmes and making information readily available could contribute to addressing these issues.

Autism spectrum disorders in eating disorder populations: a systematic review.

OBJECTIVE: Empirical research addressing cognitive processing deficits in eating disorders has noted an overlap with autism spectrum disorders. We conducted a systematic review investigating the prevalence of autism spectrum disorder in its entirety in eating disordered populations. METHODS: A comprehensive search for relevant studies was performed on five electronic databases. Studies were not included if solely focused on specific traits of autism spectrum disorders, for instance, theory of mind, set shifting or central coherence. Titles, abstracts and full texts were screened by two members of the research team independently. Quantitative studies published in English were included. RESULTS: A total of eight studies were found to fit the inclusion criteria. Results showed significantly raised prevalence rates of autism spectrum disorder in eating disorder populations compared with those in healthy control participants. DISCUSSION: This discovery has clinical implications and may assist in deciphering poor responses to conventional treatment, facilitating new psychological interventions for eating disorders.

Eructophilia in bulimia nervosa: a clinical feature.

This report offers the first detailed description of repetitive eructation (belching) in a patient with bulimia nervosa. The case was a man in his 30's with bulimia nervosa characterized by daily bingeing and purging behavior. Detailed assessment revealed repetitive eructation which was construed as a learned behavior precipitated and maintained by aerophagia (air swallowing) secondary to regular binge-eating. Eructation was associated with a strong sense of "relief" that shared a common phenomenology with other purging behaviors. Repetitive eructation was addressed as part of outpatient treatment using a cognitive-therapy approach. Eructation became less frequent during outpatient treatment but the patient disengaged after six sessions. We define a new term "eructophilia" where repetitive eructation takes on an ego-syntonic, self-contained, and autonomous quality which serves as a reinforcing stimulus in itself. Issues of phenomenology and motivating factors are further discussed.

Salinophagia in anorexia nervosa: case reports.

We report two cases of pathological ingestion of salt as a feature of anorexia nervosa, which we have previously termed "salinophagia." Both cases were young women with anorexia nervosa of the purging subtype and of sufficient severity to necessitate inpatient treatment. In both instances, excessive quantities of salt were ingested in the context of treatment programs requiring nutritional rehabilitation, and motivated by a wish to despoil the food and render it distasteful, to rob its ingestion of any hedonic qualities. In one instance, this behavior pattern was imitated by other patients on the unit. Having first briefly described salinophagia in 1999, the first author has received considerable correspondence from other specialists suggesting that this is not an isolated phenomenon. The issues of phenomenology and treatment are further discussed.

SCOFF, the development of an eating disorder screening questionnaire.

OBJECTIVE: This article describes the three-stage development of the SCOFF, a screening tool for eating disorders. METHOD: Study 1 details questionnaire development and testing on cases and controls. Study 2 examines reliability of verbal versus written administration in a student population. Study 3 validates the test as a screening tool in primary care. RESULTS: The SCOFF demonstrates good validity compared with DSM-IV diagnosis on clinical interview. In the primary care setting it had a sensitivity of 84.6% and a specificity of 89.6%, detecting all true cases of anorexia nervosa and bulimia nervosa and seven of nine cases of EDNOS. Reliability between written and verbal versions of the SCOFF was high, with a kappa statistic of 0.82. DISCUSSION: The SCOFF, which has been adapted for use in diverse languages, appears highly effective as a screening instrument and has been widely adopted to raise the index of suspicion of an eating disorder.

A brief scale to assess hospital doctors' attitudes toward collaborative care for mental health.

OBJECTIVE: Collaborative care may improve mental health management in hospital settings. However, no scales assess doctors' attitudes toward its 2 core components: mental health management by nonpsychiatric physicians and psychiatric consultation. Our objective was to develop and assess the reliability and validity of the Doctors' Attitudes Toward Collaborative Care for Mental Health (DACC-MH) Scale. METHOD: Fifteen items assessing doctors' attitudes toward management of mental health problems (10 items) and psychiatric consultation (5 items) were administered to 225 physicians and surgeons from a London hospital. Item responses were dichotomous (agree or disagree). Confirmatory factor analysis models were conducted using Mplus for dichotomous data to identify items for inclusion in the DACC-MH and to test the validity of the 2 hypothesized factors. Known-groups validity was tested by comparing scores of surgeons and physicians, as physicians have been shown to view mental health management and psychiatric consultation more favourably. RESULTS: The 8-item DACC-MH included a 4-item Attitudes Toward Management of Mental Health Problems factor (Cronbach's a = 0.65) and a 4-item Attitudes Toward Psychiatric Consultation factor (alpha = 0.67; overall scale alpha = 0.70). Model fit was good (chi2 = 12.7, df = 11, P = 0.31; Comparative Fit Index = 0.99; Tucker-Lewis Index = 0.99; root mean square error of approximation = 0.03) with all factor loadings of 0.46 or greater. As hypothesized, physician scores were significantly higher than surgeon scores on both subscales, indicating more positive attitudes toward management of mental health problems and psychiatric consultation. CONCLUSIONS: Preliminary evidence was found for the validity of the DACC-MH, which will facilitate efforts to evaluate readiness of doctors to engage in collaborative mental health care.

Body image in gay and straight men: a qualitative study.

OBJECTIVE: Recent research has emphasized vulnerability to eating disorders in gay men, with calls for research on causality, cultural factors and focus on a younger age cohort. This study aimed to examine body image and related eating behaviours in younger gay and straight men. METHOD: Qualitative study using a sample of gay and straight male university students, applying audiotaped and transcribed depth interview subjected to interpretative phenomenological analysis. RESULTS: Fifteen young men (18-24) with a spectrum of sexual orientation (gay, straight and bisexual) agreed to participate. Five dominant categories emerged: body image ideal, external influences, perception of body image, dieting, mechanisms for modification (diet, exercise, cosmetics) and sexual orientation. CONCLUSION: Health and aesthetic ideals appear less divorced for young men than women, offering some degree of protection from eating disorders. Nonetheless there is widespread body dissatisfaction. Media and social influences are powerful, particularly for single gay men, but the study suggests fewer differences than similarities between gay and straight men.

Psychiatric disorders in hypertrophic cardiomyopathy.

OBJECTIVE: Depression is undertreated in cardiac disease. Our aim was to evaluate frequency and risk factors of psychiatric disorders in hypertrophic cardiomyopathy. METHODS: This was a two-phase epidemiological approach, using screening questionnaire then gold standard structured clinical interview. A cohort of 148 patients aged > or =18 (78% response rate) attending a dedicated hypertrophic cardiomyopathy clinic (1996-1998) were screened for psychiatric morbidity using Hospital Anxiety and Depression Scale and Social Adjustment Scale. Likely cases and noncases were evaluated by Structured Clinical Interview for DSM-III-R. The main outcome measure was prevalence of psychiatric diagnoses, with descriptive comparison against population statistics. RESULTS: Thirty-seven percent of cardiomyopathy patients fulfilled criteria for anxiety disorder and 21% for mood disorder. Presence of mood disorder was associated with chest pain [relative risk (RR) 4.5, 95% CI 2.8-17.5], older age (2.8, 1.4-5.6), higher perceived risk of death (5.4, 2.3-13.0), poorer social adjustment (2.1, 1.1-4.2) and problems with sexual relations (1.5, 1.2-3.6). Presence of anxiety disorders was associated with chest pain (RR 3.5, 95% CI 2.1-26.0), higher perceived risk of death (2.0, 1.2-3.4), perception of physical symptoms as 'severe' (2.2, 1.2-4.2) and more recent diagnosis (1.7, 1.0-2.7). CONCLUSIONS: Patients with cardiomyopathy have an elevated risk of mood disorders and anxiety disorders. Several demographic and clinical factors were found to be associated with these psychiatric conditions. Proper treatment intervention is likely to improve quality of life.

The SCOFF-c: psychometric properties of the Catalan version in a Spanish adolescent sample.

OBJECTIVE: The objective of this study is to validate the Catalan version of the SCOFF questionnaire with a community sample of adolescents. METHOD: This study used a community sample of 954 participants (475 girls and 479 boys; aged between 10.9 and 17.3 years and from the city of Barcelona) and a risk group of 78 participants (35 men and 43 women; derived from the community sample) that have exceeded > or =95 percentile in at least two of the three scales of the Eating Disorders Inventory-2 (EDI-2): Drive for Thinness, Bulimia, and Body Dissatisfaction. RESULTS: There were significant differences in total SCOFF scores across gender and school grades. The SCOFF best cutoff point was 2 (sensitivity=73.08%; specificity=77.74%). Concurrent validity with the EDI-2 varied between low and moderate. The reliability of the SCOFF questionnaire was moderate. Exploratory factor analysis of the SCOFF questionnaire showed a two-factor structure for the total sample and for girls, and one factor for boys. CONCLUSION: The best cutoff point for this community sample is 2. The data suggest that the SCOFF questionnaire could be a useful screening questionnaire to enable the detection of groups possibly at risk for eating disorders among adolescent Spanish community samples.

Screening for eating disorders in primary care: EDE-Q versus SCOFF.

OBJECTIVE AND METHODS: The comparative validity of the Eating Disorder Examination Questionnaire (EDE-Q) (22 items) and SCOFF (five items) in screening for cases of the more commonly occurring eating disorders was examined in a primary care sample of young adult women (n=257). Diagnoses were confirmed in a sub-group of interviewed participants (n=147). RESULTS: Twenty-five cases, primarily variants of bulimia nervosa (BN) not meeting formal diagnostic criteria, were identified in the interviewed sample. An EDE-Q global score of >or= 2.80 yielded the optimal trade-off between sensitivity (Se) (0.80) and specificity (Sp) (0.80) (positive predictive value (PPV)=0.44), whereas a score of two or more positive responses on the SCOFF was optimal (Se=0.72, Sp=0.73, PPV=0.35). Validity coefficients for both measures varied as a function of participants' age and body weight, although these effects were more pronounced for the SCOFF. CONCLUSIONS: Both measures performed well in terms of their ability to detect cases and to exclude non-cases of the more commonly occurring eating disorders in a primary care setting. The EDE-Q performed somewhat better than the SCOFF and was more robust to effects on validity of age and weight. These findings need to be weighed against the advantage of the SCOFF in terms of its brevity.

Treating young people with eating disorders: transition from child mental health to specialist adult eating disorder services.

BACKGROUND: The transition from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS) of young people with eating disorders may pose a number of difficulties, including an inconsistent referral process and age boundaries. METHODS: We compared young adults referred to a specialist Adult Eating Disorders Service (AEDS) who had previous involvement with CAMHS for the treatment of their eating disorder with those who did not. Information regarding the socio-demographic characteristics and eating disorders symptomatology of patients assessed by an AEDS over a 4-year period was collected. RESULTS: Patients who had previous involvement with CAMHS (particularly the ones treated as in-patients) presented with a lower self-esteem and more maturity fears (MF) than those without previous involvement. CONCLUSIONS: This study discusses the implication of these results in transitional arrangements between CAMHS and Adult services. It also highlights the need for heightened awareness of particular issues of self-esteem and maturation in these patients moving between services.

Risk of postnatal depression, miscarriage, and preterm birth in bulimia nervosa: retrospective controlled study.

OBJECTIVE: Bulimia nervosa is common and treatable. An association between bulimia and obstetric complications has been suggested, but sample size and absence of control have limited previous studies. Our aim was to determine if active bulimia nervosa affects obstetric outcome. METHODS: This was a retrospective case-control comparison of obstetric complications in primigravidae previously treated for bulimia in a specialist eating disorder service. A cohort of 122 women with active bulimia during pregnancy was contrasted against 82 with quiescent bulimia, using structured interviews comprising the Eating Disorders Examination, Structured Clinical Interview for DSM-III-R, and systematic questions addressing obstetric complications. RESULTS: Odds ratios (ORs) for postnatal depression, miscarriage, and preterm delivery were 2.8 (95% confidence interval [CI], 1.2-6.2), 2.6 (95% CI, 1.2-5.6) and 3.3 (95% CI, 1.3-8.8) respectively. Risk of unplanned pregnancy was markedly elevated (OR, 30.0; 95% CI, 12.8-68.7). Risk estimates were not explained by differences in adiposity, demographics, alcohol/substance/laxative misuse, smoking, or year of birth, but relative contributions of bulimic behaviors were not discerned. CONCLUSIONS: Active bulimia during pregnancy is associated with postnatal depression, miscarriage, and preterm delivery. Bulimia may be a treatable cause of adverse obstetric outcome.

Validity and reliability of the Hospital Anxiety and Depression Scale in a hypertrophic cardiomyopathy clinic: the HADS in a cardiomyopathy population.

OBJECTIVE: The purpose of this study is the validation of the Hospital Anxiety and Depression Scale (HADS) in patients suffering from hypertrophic cardiomyopathy in an inner city teaching hospital. The secondary objective was to establish whether the use of the total HADS score to detect "caseness" is justified. METHODS: One hundred fifteen patients in a cardiac outpatient clinic completed the HADS, which was compared against the gold standard Structured Clinical Interview for DSM-III-R nonpatient version (SCID-np). Receiver operating characteristic (ROC) curves were created for the anxiety and depression subscales, as well as the total score, then sensitivity, specificity, likelihood ratios and positive and negative predictive values were calculated. Retest correlation was assessed at 2 weeks in 31 patients. RESULTS: The depression subscale was highly sensitive (100%) when the cutoff score 8 was used; however, the corresponding specificity was poor (79%). Raising the cutoff to 10 improved specificity but compromised sensitivity. The anxiety subscale was performed similarly though with less accuracy. The total HADS score produced a poor ROC curve and performed best when the cutoff was 14. CONCLUSIONS: The HADS performs well as a screening instrument for anxiety and depression in this population at the designed cutoff score 8. However, its use as a research instrument and the practice of using the total score to detect caseness are not supported by this study.

Compliance with surgical after-care following bariatric surgery for morbid obesity: a retrospective study.

BACKGROUND: Non-compliant patients fail to match their behavior to the clinical prescription. Laparoscopic adjustable gastric banding requires strict compliance with surgical and dietary advice. Failure to attend follow-up appointments and the persistent consumption of calorie-dense liquid foods are associated with poor weight loss and postoperative complications. Prediction of "poor compliers" would enhance candidate selection and enable specific interventions to be targeted. METHODS: 9 poor compliers were identified and compared with 9 fully compliant controls. Case-notes were analyzed retrospectively. RESULTS: Cases were found to graze on foods and eat more in response to negative affects. They were reluctant to undergo psychiatric assessment, viewed the band as responsible for weight loss, and aroused caution in the psychiatric evaluator. Poor compliance was not associated with binge eating, purging, impulsivity or psychiatric illness. CONCLUSIONS: Unrealistic expectations and anxiety are known to predict non-adherence. Constant negative affects may be self-modulated by grazing. The results are explored in the context of Self-efficacy Theory, a socio-cognitive account of illness behavior.