[How much do patients know about the possible physical consequences of their eating disorder?]. / Onderzoek naar de kennis van patiënten over de mogelijke lichamelijke gevolgen van hun eetstoornis.

BACKGROUND: A lack of knowledge about the physical consequences of an eating disorder can be a sign that the patient either denies that there is a problem or minimises the problem; this can result in the patient being reluctant or unwilling to be treated. AIM: To find out how much patients know about the possible physical consequences of (or the risks involved in) their eating disorder and to check whether they know considerably more after some psycho-education. METHOD: Sixty-six female patients completed a questionnaire shortly after being admitted to a specialised eating-disorder unit and 44 patients completed the same questionnaire after about a month. In the intervening period patients received some psycho-education about the possible physical consequences of eating disorders. The psycho-education took the form of an interactive group session and a brochure of information. RESULTS: In general, the patients' knowledge about possible consequences of their illness was reasonably satisfactory (on average, 14 out of 20 questions were correct), although a considerable number of patients answered 11 questions with 'I don't know'. In the second round there was a considerable decrease in the number of 'I don't know' answers, showing that after a month patients' knowledge had improved (17 out of 20 patients now gave positive answers); the answers were independent of the type of eating disorder. One question in particular elicited the largest number of uncertain or incorrect answers, even in the second round; the question was: Can a woman who has never menstruated become pregnant?' CONCLUSION: It is advisable to assess, in a systematic way, whether patients have adequate knowledge about the physical consequences of an eating disorder. Gaps in patients' knowledge or misunderstandings can then serve as a starting point for a specific type of psycho-education.

Eating-disordered patients' perception of pregnancy in important others and therapists.

Since eating-disordered patients can show some ambivalence towards pregnancy, we wondered how they would react when an important other (relative, friend, therapist) gets pregnant. A group of 69 eating disorder patients filled out a questionnaire about their perception of the possible impact of a pregnancy in an important other or a therapist. In general, the experience was perceived as having had a positive influence on their view of womanhood and their idea to get pregnant, with a greater impact of pregnancy in therapists.

[An analysis of advertisements for psychotropic drugs in the Dutch Journal of Psychiatry ('Tijdschrift voor Psychiatrie')]. / Een analyse van advertenties voor psychofarmaca in het Tijdschrift voor Psychiatrie.

BACKGROUND: Through the marketing of psychotropics the pharmaceutical industry is able to influence the way in which psychiatrists practise their profession. AIM: To look at the image of psychiatry as reflected in advertisements for psychotropics. method Quantitative and qualitative analysis of the advertisements for psychotropics in the Tijdschrift voor Psychiatrie between 1999 and 2006. RESULTS: On average 6 per cent of the total number of pages was given over annually to advertisements of psychotropics. The number of pages used for these advertisements changed over the years, with a sharp decline between 2002 and 2004. Before 2002 the majority of advertisements was for antidepressants, but later most of them were for antipsychotics. Three-quarters of the illustrations for antidepressants featured women whereas three-quarters of the illustrations for antipsychotics featured men. In general, the advertisements were of an 'emotional' nature and surprisingly few of them contained any scientific information. CONCLUSION: The advertisements for psychotropics portrayed a stereotyped image implying that it is mainly women who are depressed and mainly men who are psychotic. In its advertisements the pharmaceutical industry seeks primarily emotional reactions and uses hardly any scientific arguments. We wonder if the editorial boards of scientific journals should perhaps adopt a more critical attitude to these kinds of advertisements.

[Water intoxication in two girls with anorexia nervosa]. / Waterintoxicatie bij twee meisjes met anorexia nervosa.

Two girls, 16 and 18 years old, with anorexia nervosa developed generalized convulsion as a result of drinking excessive amounts of water. The neurological symptoms disappeared, but the girls held on to their excessive drinking habits, despite psychoeducation. Although fluid restriction is known to be a major problem for anorexia nervosa patients within the context of extreme fasting, one should realize that these patients can also run the risk of water intoxication following excessive water intake. Therefore all patients should be questioned explicitly about their daily fluid intake. In the case of polydipsia, the patient's blood should be tested and serum electrolytes should be measured. Patients should be given psychoeducation in order to make them more aware of the possible dangers of excessive water intake.

[Eating disorders; 25 years of research and treatment]. / Een kwarteeuw onderzoek en behandeling van eetstoornissen.

As a result of the publication of DSM-III(-R) bulimia nervosa was recognised as a separate eating disorder, distinct from anorexia nervosa. Eating disorders occur mainly in young females. The incidence of anorexia nervosa in Dutch females aged 15 to 19 doubled between the 1980s and the 1990s. Over the past 25 years there have been many improvements in the treatment of patients with eating disorders, but only a very few of them utilise the health care facilities that are now available.

[Psycho-education about osteoporosis in anorexia nervosa patients]. / Psycho-educatie over osteoporose bij patiënten met anorexia nervosa.

Osteoporosis is a frequent complication in patients with eating disorders, particularly with anorexia nervosa. Informing patients about the disorder can give them a better understanding of their illness and encourage them to comply with treatment. Guided by the literature, which is rather limited, and our own clinical experience we make specific suggestions with regard to psychoeducation (particularly concerning a patient's need to put on weight and avoid the risk of fractures). We give three examples which illustrate how differently patients may react to our suggestions.

[Development and treatment of anorexia nervosa in patients with Turner syndrome. A case study]. / Ontwikkeling en behandeling van anorexia nervosa bij patiënten met het turnersyndroom.

summary We describe the case of a girl with Turner syndrome who has also developed anorexia nervosa. According to the available literature, patients with Turner syndrome do not have an increased risk of developing anorexia nervosa. However, if such comorbidity should occur, as it did in our case, then some aspects of treatment will have to be adjusted.

[The significance of perfectionism in eating disorders: a comparative study]. / De betekenis van perfectionisme bij eetstoornissen. Een vergelijkend onderzoek.

BACKGROUND: Various studies have shown a consistent relationship between perfectionism and eating disorders or related symptoms. Perfectionism, however, is not a single, unified concept but it is a multidimensional one. AIM: To study the relevance of the difference between maladaptive and adaptive perfectionism in patients with eating disorders and to find out whether perfectionism persists after eating disorder has been treated. METHOD: A sample of patients with eating disorders (n=122) was compared with a normal control group (n=48) by means of questionnaires relating to clinical measures and designed to reveal the difference between adaptive and maladaptive perfectionism. In addition, some of the patients were assessed just after their treatment for an eating disorder had finished. RESULTS: The eating-disorder group and the control group differed primarily with regard to maladaptive perfectionism. In the eating-disorder group maladaptive perfectionism only predicted the severity of eating-disorder symptoms. Although the scores for both types of perfectionism decreased during the course of treatment, at the end of the treatment the perfectionism scores of the eating-disorder group remained higher than those of the control group. CONCLUSIONS: The findings emphasise that in research into eating disorders it is important to distinguish between maladaptive and adaptive perfectionism; in addition, the findings suggest that maladaptive perfectionism can be a risk factor for relapse after the eating disorder has been treated.

Psychomotor performance and sequence planning in anorexia nervosa before and after weight restoration.

BACKGROUND: In the study of psychomotor performance in anorexia nervosa (AN), motor control has not been studied extensively. The present study explores sequence planning in a sample of AN patients. METHOD: A group of 26 female restricting AN inpatients, aged 14 to 25, was compared with 24 healthy women matched for age and educational level. During the performance of a simple copying task, in which movement planning, but not working capacity, was challenged, the ease with which generally favored graphic production rules could be applied was manipulated. Computerized recordings of the drawing movements allowed detailed analyses of reaction and movement times and of drawing sequences. Fifteen patients were retested after weight restoration, as were 15 controls. RESULTS: Copying patterns that normally elicit a conflict between preferred graphic production rules induced significantly less slowing in the reaction times of the anorexia nervosa patients than in the controls, both before and after weight restoration. There were no group differences as regards the consistency with which the implicit production rules were applied. DISCUSSION: AN patients seem to show a fast response style combined with good sequence planning capacity.

[Bitter and gilded pills: psychiatry in the light (or shadow) of the pharmaceutical industry]. / Over bittere en vergulde pillen: psychiatrie in het licht (of de schaduw) van de farmaceutische industrie.

Psychotropic medication has brought about far-reaching changes in psychiatry: in its nature and practice, its image of man and its public image. Never before have so many psychotropic drugs been prescribed for young people. 'Difficult' children are now referred to as ADHD children and moody youngsters are given antidepressants. In adult psychiatry treatment is being dictated more and more by protocols and guidelines: very often medication is the treatment of choice. The reasons for this are largely economic. Increasingly 'research' is being sponsored by the pharmaceutical industry. Published research results are often skewed so as to favour the sponsor. Some scientific journals owe their survival to drug advertisements. Even some patient organisations are supported by the pharmaceutical industry. How will psychiatry and mental health care be able to escape from this 'straightjacket' in the future? The purpose of this polemical essay is to draw the attention of health care professionals and researchers to this rather worrying development.

Body composition of anorexia nervosa patients assessed by underwater weighing and skinfold-thickness measurements before and after weight gain.

BACKGROUND: Weight restoration is a crucial element in the treatment of patients with anorexia nervosa. Therefore, the validity of different methods for measuring body composition is important. OBJECTIVE: We tested the concurrent validity of hydrodensitometry (underwater weighing) and anthropometry (12 skinfold thicknesses) and assessed body composition and subcutaneous fat before and after a refeeding program and a multifaceted program of therapy in a specialized inpatient unit for eating disorders. DESIGN: The body composition of a large sample of anorexia nervosa patients (97 restricting type, 33 binging-purging type) was studied by using 2 methods both before and after weight gain. We applied a behavioral contract for weight restoration with a minimum weekly gain of 700 g and a maximum of 3 kg. Bland-Altman analysis of agreement, Pearson correlation analysis, t tests, and analysis of covariance were used. RESULTS: There was good agreement between the results obtained by underwater weighing and by skinfold-thickness measurement (r = 0.76, P < 0.001); the results produced by the 2 methods did not differ significantly. On average, a significant weight gain (11.9 kg) was observed, composed of 6.6 kg fat and 5.3 kg fat-free mass. CONCLUSIONS: Body fat estimation by skinfold-thickness equation appeared to be as accurate as underwater weighing. The refeeding program led to a significant increase in body weight, of which 55.5% was body fat. The mean ratio of fat-free mass to fat mass at the end of the treatment was 3.4:1.

Inpatient treatment of anorexia nervosa: some research-guided changes.

Over a period of more than 15 years, our approach to the inpatient treatment of anorexia nervosa has changed considerably. Three major steps may be distinguished in this evolution. Until 1974, weight restoration was induced by a medical regime, and most patients had to stay in a psychotherapeutic community for several months. Between 1974 and 1980, different types of behavior therapy have been tried and compared ending up in a standardized behavioral contract system that is still used now. However, a large follow-up study forced us to question the second psychotherapeutic phase of the program and the long stay in the hospital. Moreover, the increasing number of patients made it practically impossible to treat them all individually. For these reasons, from 1982, an intensive multifaceted group approach was developed, the major components of which are described. It is concluded that continuing research from a scientist-practitioner's viewpoint is the best guide for a fruitful trial-and-error process in the therapeutic approach to patients with eating disorders.

Body image assessment in anorexia nervosa patients and university students by means of video distortion: a reliability study.

It is well known that anorexia nervosa is characterized by a disturbed body image. The video distortion method is one of the many methods to systematically study the perceptual aspect of this body image. Using a distorted image of her own appearance, the subject is asked to reconstruct the 'exact' measures of her body and to indicate her ideal image. The reliability of this method has been assessed in a study involving 67 anorexic patients and 105 female university students. Test--retest results within the same session and over a one-week interval were sufficiently constant. Nonetheless, for both anorexics and controls, significant differences were found between estimates with a narrowed (thin) image initially and those with a widened (fat) image initially. Both groups underestimate their body measures and only significantly differ on estimates of their ideal image, with anorexics clearly less underestimating their ideal image than students.

Body size estimation in anorexia nervosa patients: the significance of overestimation.

Using the video distortion method on a life-size screen, we have studied body size estimation in 100 female restricting anorexia nervosa patients. About half of the patients were accurate in estimating their own body dimensions and only 20% clearly showed overestimation. We then tested whether differences in accuracy of estimation were related to scores on the following questionnaires: Eating Disorder Inventory; Body Attitude Test; and Symptom Checklist (SCL-90). Overestimators reported a more negative body attitude and a more "neurotic profile" on the SCL-90. These differences might have both prognostic and therapeutic implications.

Body size estimation in eating disorder patients: testing the video distortion method on a life-size screen.

The video distortion method on a life-size screen is a new method for studying eating disordered patients' estimations of their own body width. Testing this method in female patients (53 with anorexia nervosa, 38 with bulimia nervosa) and 36 normal females, yielded high to very high reliability scores (consistency and test-retest stability). A careful analysis of the 'just noticeable difference' showed that a 5% deviation from the undistorted image should be considered as within the range of accuracy. Taking this into account, anorectic patients appear to score below, above, as well as within the normal range. Bulimia nervosa patients are either accurate in their body estimations or overestimate their body width. All control Ss are correct in their estimations. With this method no significant differences were found between the anorectic patients and the controls. Bulimics differ significantly from anorectics and controls on their optative responses (i.e. what they wanted to look like) and their affective responses (i.e. what they felt they looked like).

The management of eating disorders in a fertility clinic: clinical guidelines.

Although the wish for a child may be ambivalent in women with anorexia or bulimia nervosa, the prevalence of eating disorders in fertility clinics is probably underestimated. Motivated by the wish for a child, these couples may be reluctant to reveal a history of an eating disorder and/or show resistance to some therapy for this disorder. Nevertheless, in our opinion, the eating disorder must be in full remission before any fertility treatment can start, if treatment is still necessary at that moment. Illustrated with some case examples, we will discuss the major problems and clinical strategies in the management of these complex cases, based upon the experience in our own fertility clinic.

Marital intimacy in patients with an eating disorder: a controlled self-report study.

The clinical literature on married patients with anorexia nervosa or bulimia nervosa suggests a lack of intimacy in these couples. This assumption was tested by comparing the scores on the Marital Intimacy Questionnaire of 21 eating-disordered (ED) couples with those of two matched control groups of 21 maritally distressed (MD) and 21 non-distressed (ND) couples. The overall level of intimacy attained by ED couples is lower than that of ND couples but higher than that of MD couples. Whereas this quantitative difference may reflect the couples' differences in marital satisfaction (as assessed by the Maudsley Marital Questionnaire), an additional qualitative discrimination can be made between ED couples and the two control groups on account of the former group's relatively low level of openness and high level of intimacy problems.

Body experience in eating disorders before and after treatment: a follow-up study.

Since body dissatisfaction is an essential part of anorexia/bulimia nervosa, we wanted to assess the patients' body experience before and after intensive treatment. Body experience was studied in 290 eating disorder patients, admitted to a specialised unit, after six months and again after one year using the Body Attitude Test (BAT), the Eating Disorder Inventory (EDI), and the Eating Disorder Evaluation Scale (EDES). The clearly negative body experience of eating disorder patients evolved in a positive way after therapy and this improvement lasted for up to one year after admission. EDI scores and Body Mass Index at the time of admission appeared to be the strongest predictors of the total BAT score at follow-up. Although body dissatisfaction can be quite persistent in eating disorders, intensive treatment can substantially improve the patients' body experience.

Self-injurious behaviors in eating-disordered patients.

High rates of self-injurious behaviors (SIBs) have been described in eating-disordered patients. The present study in 134 female inpatients suffering from an eating disorder (ED) confirmed this: 44% of the total group reported at least one form of SIB (mostly hair pulling, scratching, cutting, or bruising) with a mean age at onset of 17.5 years. No major differences have been found between the subgroups (anorexics, bulimics). The considerable number of patients who did not feel any pain during SIB showed more tendency towards dissociative experiences. Those who admitted SIB reported higher levels of psychological dysfunctioning, dissociative experiences, and impulsiveness.