Problems in the treatment of premenstrual syndrome

Three categories of treatments for premenstrual syndrome (PMS) have been proposed: those designed to correct the cause of the disorder; those designed for symptom relief; and those aimed at eliminating the menstrual cycle. Many of these recommendations are based on poor research with loose definitions of the disorder and uncontrolled open trials. This paper reviews the literature on treatment methods with emphasis on recent random, placebo controlled, double-blind studies. The most effective current management of PMS is a conservative one including accurate diagnosis, stress control, sensible levels of diet and exercise and perhaps the use of alprazolam in the premenstrual period. Other approaches such as the use of mefenamic acid and evening oil of primrose remain unproven. Progesterone has been proven uneffective. Further research is required into the value of antidepressant medication.

Psychological factors in irritable bowel syndrome

This paper describes the prevalence and incidence of psychiatric disorders in IBS patients using a standardized psychiatric interview, and proposes a psychological model for investigating one aspect of IBS. Forty-four IBS patients and 28 nonclinical participants received a psychiatric interview (Diagnostic Interview Schedule) and completed the Lie Scale of the Eysenck Personality Inventory (L-EPI). Results indicated that a significant percentage (59%) of the IBS group met DSM-III criteria for a psychiatric disorder within the last year, far more than occurred in the matched nonclinical comparison group. Relative to the comparison group, the IBS group also had significantly higher lie scores on the EPI indicating a response style of social desirability. On the basis of these findings, together with earlier work by Latimer's group, a conceptual model was formulated on the notion that some IBS patients may have a self-schema (i.e. knowledge of self, stored in memory) characterized by social desirability. We suggest that the construct of self-schema may be helpful in differentiating IBS from psychiatric groups both conceptually and therapeutically.

Self-schema in irritable bowel syndrome and depression

Some investigators have suggested that irritable bowel syndrome (IBS) represents a physiologic expression of an affective disorder. This study investigated whether IBS patients differed in their self-schema from depressed patients. Self-schema refers to a cognitive framework of the individual's beliefs, attitudes, and self-perceptions which is stored in memory and which influences incoming information. The sample consisted of 21 IBS patients, 21 psychiatric outpatients with major depression (MD), and 19 normal controls. All groups were age matched. Subjects completed a structured psychiatric interview (Diagnostic Interview Schedule (DIS) and a Beck Depression Inventory (BDI), in addition to a test of self-schema, which involved rating and recall of a variety of "depressed" and "nondepressed" content adjectives. Consistent with previous work on self-schema, the MD group recalled significantly more depressed adjectives rated under the self-referent task than the Control group (p less than 0.05) and, also, the IBS group (p less than 0.05). Most striking was the finding that a subgroup of IBS patients who met criteria for MD (43% of the sample) recalled significantly more self-referent nondepressed words (and less self-referent depressed words) than the MD group (p less than 0.05). In other words, IBS patients with MD do not view themselves as depressed. These findings suggest that while some IBS and depressed psychiatric outpatients may share depressive symptoms, these groups can be differentiated by their self-schema.

Self-report symptoms that predict major depression in patients with prominent physical symptoms

The diagnosis of depression in patients presenting with both depressive and physical symptoms is potentially confounded and problematic. The present study of 271 patients with four types of illness all with prominent physical symptoms--end-stage renal disease (n = 99), irritable bowel syndrome (n = 21), post-infectious neuromyasthenia (n = 25) and eating disorders (n = 126)--investigates if there are a group of symptoms on the Beck Depression Inventory (BDI) which predict the diagnosis of major depressive episode (MDE) made using the Diagnostic Interview Schedule (DIS). Discriminant function analysis of BDI responses yielded a four item function--self-hate, indecisiveness, loss of appetite and suicidal thoughts--which maximally discriminated between patients with and without a current MDE and correctly classified 75 percent of subjects.

The neuropsychological dimensions of postinfectious neuromyasthenia (chronic fatigue syndrome): a preliminary report

Postinfectious neuromyasthenia (PIN) is a clinical syndrome of protracted and incomplete recovery after an apparent viral-like illness. Medical investigation yields few abnormalities which might account for the symptomatology. A substantial number of PIN patients complain of cognitive changes. Specific complaints include impaired attention, concentration and abstraction skills. This study was designed to systematically investigate whether the aforementioned subjective complaints could be quantified objectively using standard neuropsychological instruments. Results indicated that on all tests but one, the subjects' performances were significantly higher than those of their age matched groups in the normative data. Specifically, PIN patients scored significantly better than their age matched norms on tests of concentration, attention and abstraction. What is most striking is the discrepancy between the subjective complaints of cognitive impairment and the objective results of the subjects' performances on all tests. These findings suggest that psychological factors may play an important role in the cognitive functioning of individuals diagnosed with postinfectious neuromyasthenia.

Measured weight loss and the dexamethasone suppression test

In a prospective study of 28 subjects with major depression, weight was significantly related to nonsuppression in the dexamethasone suppression test (DST) on admission and seven days later. However, changes in weight between these two times did not alter the DST status.

The clinician-investigator interface in psychiatry I--Values and problems

The two following papers describe some of the benefits and problems involved in integrating clinical and investigative work. It is stressed that there are a number of advantages to such integration. Researchers especially benefit from the proximity to patients and clinicians. Education can be significantly enhanced when researchers and clinicians are in one setting and this can benefit residents, medical students and non-medical health personnel. There are a number of problems to such clinical research in psychiatry. These are discussed especially as they relate to senior faculty and their resistances to research. The shortage of clinician scientists in teaching positions means that most residents are not involved with such people as mentors early in their training and do not consider this as a career option after their residency training. Reductionistic thinking on the part of some researchers and when researchers are not first-rate clinicians both contribute to residents not becoming involved in clinical investigation. Funding policies as well as chairmen's hiring policies also play a role here.

The clinician-investigator interface in psychiatry: II--The role of the Clinical Investigation Unit

The Clinical Investigation Unit has served as a natural focus for clinical research; as such it has a number of advantages and specific problems. On such units a variety of themes may occur. Some of these have the potential to interfere with the integration of clinical and research work. These include the theme that the research itself is therapy, or that research will find all the answers. Both may result in problems for the functioning of the ward. Most problematic of all is the theme that research is harmful and exploitative. Optimally, the unit develops an attitude that the research is compatible with excellent patient care. Problems of patients, staff, ethical issues, admissions policies and problems of the clinician-scientists are reviewed with recommendations on how to minimize difficulties.

Changes in melatonin levels but not cortisol levels are associated with depression in patients with eating disorders

Disturbances were studied in the nocturnal circadian pattern of serum melatonin and plasma cortisol levels in 33 female patients with an eating disorder (anorexia nervosa, n = 11; bulimia nervosa, n = 12; or both, n = 10) and in ten female control subjects of comparable age. Blood samples were obtained hourly from 8 PM to 6 AM under controlled darkness. Serum melatonin levels in all patient groups were initially similar to those of control subjects. When patients were divided according to depression status, those with concurrent major depression had significantly lower nocturnal melatonin values than the nondepressed group. Weight did not appear to influence melatonin levels. In contrast, all patient groups had significantly higher nocturnal levels of plasma cortisol than control subjects, and neither weight nor depression separated patient groups on profiles of plasma cortisol.

The DST and TRH test in bulimia nervosa

Abnormal neuroendocrine responses have been found in depression and eating disorders. It remains unclear whether these reflect an underlying shared biology or epiphenomena. To evaluate this further, we conducted the 1 mg DST and the TSH response to 500 micrograms i.v. TRH in normal-weight bulimics and controls. Bulimics (n = 18) demonstrated significantly more DST non-suppression (45%) than controls (18%; n = 20). In the bulimic group, non-suppressors were significantly thinner than suppressors, but did not differ from them on any measure of depression. Bulimics (n = 19) and controls (n = 12) responded similarly without blunting on the TSH response to TRH. These data suggest that DST non-suppression may be related to non-specific variables such as weight. Bulimics do not demonstrate TSH blunting as found in some depressed patients. These tests do not support evidence for a biological link between these disorders.

A trial of isocarboxazid in the treatment of bulimia nervosa

Eighteen women completed a double-blind, placebo-controlled crossover study designed to investigate the effects of isocarboxazid in the treatment of bulimia nervosa. There was a significant reduction in binge eating and vomiting during isocarboxazid treatment. Response was not influenced by either the presence or absence of current major depression or personality disorder. There were no serious adverse effects from this monoamine oxidase inhibitor therapy, although over 50% of patients elected to discontinue isocarboxazid 1 year after the study.

Affective and anxiety disorders in the long-term follow-up of anorexia nervosa

This study investigated the incidence and onset of affective and anxiety disorders in women who were diagnosed with anorexia nervosa five to fourteen years earlier. Based on the clinical outcome of anorexia nervosa, patients were classified as asymptomatic, improved or symptomatic. Affective and anxiety disorders were assessed by a structured psychiatric interview (Diagnostic Interview Schedule). Results indicated that affective and anxiety disorders developed frequently, regardless of outcome of anorexia nervosa. Major depression and anxiety disorders developed before the eating disorder in one-half and three-quarters of these cases respectively. The symptomatic group had a significantly higher incidence of anxiety disorders prior to the development of their eating disorder compared with the asymptomatic group.

Anorexia nervosa, bulimia, and pregnancy

Of 74 women previously treated for anorexia nervosa or bulimia, 15 had conceived 23 pregnancies when assessed at follow-up. The status of the eating disorder, course of pregnancy and delivery, infant health, and postpartum adjustment are described. Women in whom eating disorders were in remission at conception had greater maternal weight gain and babies with higher birth weights and 5-minute Apgar scores than women who conceived while they still had symptoms of restricting anorexia nervosa or bulimia. Women who had symptoms of eating disorders at conception also had continuance or worsening of these symptoms during pregnancy and the postpartum year. We recommend delay of pregnancy until the eating disorder is truly in remission.

Eating disorders: implications for the 1990's

In the past decade much has been learned about the clinical features, diagnosis and understanding of people with anorexia nervosa and bulimia nervosa. In order to provide the next level of improvement in our care for these patients, our understanding of certain problems must be addressed by empirical research. Areas which require further study include the definition of high risk groups, the refinement of diagnoses, understanding factors which result in chronicity, determining the complications of chronicity and comparative evaluations of different treatments. These five areas are outlined in this article. Populations at risk for anorexia nervosa and bulimia nervosa may be those who must be thin and achieve according to career choice, those with a particular family and personal psychiatric history; obesity and chronic medical illnesses may be further risks. Improved diagnostic understanding has occurred by the differentiation of bulimic from restricting subtypes of anorexia nervosa. Further work must determine the relationship between the bulimic subtype of anorexia nervosa and bulimia in normal weight women and to further clarify the relationship between eating disorders and affective disorders. A number of factors may result in a chronic illness. These have been described on a variety of levels. The consequences of starvation in altering an individual's thinking, feeling and behaviour do play a role. It is not clear what factors at a neurochemical level contribute to this. Elevated endogenous opiates decreased noradrenergic function and decreased serotonin may be important. Information about the chronic complications is required for clinicians to understand the broad range of difficulties that may develop over time so that clinicians may use this information in planning treatment strategies.(ABSTRACT TRUNCATED AT 250 WORDS)

Stress, immunity and illness--a review

Psychological factors have long been thought to play a contributing role in either the predisposition, onset or course of various physical illnesses. Recently, rapid advances in immunology have created interest in the interaction between psychosocial factors, behaviour and the immune system. This paper reviews some of the models proposed to explain the relationship between psychological variables and physical illness and presents evidence for a contribution of psychological factors to certain illnesses in which abnormalities in immunologic state are thought to be important. From a somewhat different perspective, animal studies have demonstrated complex effects of stress, on disease susceptibility. Recent human studies have demonstrated consistent immunologic changes in people undergoing acute naturally occurring psychological stress such as bereavement or an important examination. In humans, the effects of chronic stress may be different from acute stress, corresponding to the findings in animals. Abnormalities in immunologic functioning and physical illness are reviewed for different psychiatric disorders--depression, anorexia nervosa and schizophrenia; depression is the only disorder which consistently demonstrated immunologic changes. Possible mechanisms for the stress/immune-change relationship are suggested.

Cognitive style of patients with bulimic and diet-restricting anorexia nervosa

Recent studies have reported that subjects with bulimic anorexia nervosa are more behaviorally impulsive than those with diet-restricting anorexia nervosa. This study found that bulimic anorexic patients made significantly more errors on the Matching Familiar Figures Test than restricting anorexic and comparison groups. This preliminary finding leads to the speculation that bulimic patients are more cognitively impulsive than restricting anorexic patients.

Depression in patients with neuromyasthenia (benign myalgic encephalomyelitis)

Neuromyasthenia (benign myalgic encephalomyelitis) is a term used to describe a protracted and incomplete recovery phase following viral-like illnesses. There are few significant physical findings or abnormal laboratory determinations. Although depressive symptoms have been observed in individuals with neuromyasthenia, systematic psychological investigations based on a standardized interview technique have not been reported. This study was designed to investigate the prevalence of psychiatric disorders and psychiatric symptoms in a group of patients presenting with neuromyasthenia. The study consisted of three parts: a structured psychiatric interview (The National Institute of Mental Health Diagnostic Interview Schedule), a self-report measure (The Beck Depression Inventory) and Dexamethasone Suppression Test. Results indicated that relative to a matched comparison group of non-clinical volunteers, a significant percentage (67%) of neuromyasthenic patients met criteria for major depression. Even more striking was the observation that 50 percent of the sample had a major depressive episode prior to the development of neuromyasthenia. These findings suggest that sporadic neuromyasthenia may be the result of an organic illness in psychologically susceptible individuals.

A prospective study of eating disturbances in the ballet

A group of 35 ballet students was assessed and then retested between 2 and 4 years later to determine the persistence of eating symptoms and to identify factors which predict eating disorders. Of those interviewed at follow-up, 25.7% had anorexia nervosa and 14.2% had either bulimia nervosa or a 'partial syndrome'. 'Drive for thinness' and 'body dissatisfaction' scales of the Eating Disorder Inventory were the only measures which predicted development of eating disorders at follow-up. The finding that most cases of anorexia nervosa gained weight at follow-up was similar to an earlier report; however, the view that these disorders were benign adaptations to the ballet subculture was challenged by the observation that many continued to experience significant eating disorder symptoms at follow-up. Findings indicate that vulnerable adolescents may be identified early using economical self-report measures as the initial step in a two-stage screening process.

Changes in insulin sensitivity and clearance in anorexia nervosa

Anorexia nervosa (AN) is a state of self-induced malnutrition characterized by a marked pursuit of thinness and the fear of obesity. Although low fasting blood glucose and insulin have been demonstrated, there is contradictory data on insulin sensitivity and a lack of information about insulin metabolism and its metabolic effects in AN. Insulin sensitivity, kinetics, and metabolic effects were measured using the euglycemic clamp in nine females with AN (age 25.2 +/- 1.9 years and 70.6 +/- 2.2% ideal body weight), and the results compared with seven female normal controls (NC) (age 23.6 +/- 1.0 years and 92.7 +/- 2.5% ideal body weight). Fasting plasma glucose (FPG), immunoreactive insulin (IRI), and C-peptide were significantly lower in AN as compared to NC (84.3 +/- 1.5 v 91.5 +/- 1.7 mg dL-1, 9.3 +/- 1.0 v 13.5 +/- 1.4 microU mL-1, and 0.26 +/- 0.03 v 0.41 +/- 0.02 pmol mL-1) (P less than 0.05). During the glucose clamp, the glucose metabolized (M), the metabolic clearance rate of glucose (MCRg), and the glucose metabolized per unit of insulin (M/I ratio) were all higher in AN as compared to NC (M, 8.7 +/- 1.2 v 6.9 +/- 0.6 mg min-1 kg-1; MCRg, 9.9 +/- 1.5 v 7.4 +/- 0.6 mL min-1 kg-1; M/I ratio, 8.6 +/- 1.6 v 5.0 +/- 0.3 mg min-1 kg-1/microU mL-1 X 100), but only the M/I ratio attained statistical significance (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term follow-up of anorexia nervosa

This study compared the long-term outcome of restricting and bulimic anorexic women using standardized psychometric instruments in addition to global clinical ratings. Results indicated that, in general, restricting and bulimic anorexic subtypes did not differ in their long-term outcome according to clinical ratings and standardized assessments of anorexic symptoms, psychiatric diagnoses, and psychosocial functioning. The only exception to this pattern was that the bulimic group had a higher incidence of substance use disorders during the last year compared with the restricting group. Findings also indicated that relative to a matched comparison group of women of average weight, a significant percentage of anorexics from both subtypes met DSM-III criteria for an affective or anxiety disorder at some point in their lives as well as at long-term follow-up. Results are discussed in terms of theoretical and methodologic issues involved in the long-term follow-up of anorexia nervosa.

Integration and sequencing of treatment approaches for eating disorders

General principles for the management of eating disorders are viewed with particular emphasis on correcting disturbed eating and weight within the current cultural context. A range of different therapeutic options are outlined with indications for the integration and sequencing of these as part of a multidimensional model of treatment.

Eating disorders in female adolescents with insulin dependent diabetes mellitus

Recent case reports have suggested an association between anorexia nervosa and/or bulimia with insulin-dependent diabetes mellitus (IDDM). Fifty-eight females aged fifteen to twenty-two with IDDM for more than one year were assessed for the presence of eating disorders. Patients were screened for eating and weight pathology using the Eating Disorder Inventory (EDI) and Eating Attitudes Test-26 (EAT-26). Glycosylated hemoglobin (HbA1) was measured to assess metabolic control. Subjects who scored above the cut-off points associated with eating and weight pathology were interviewed. Clinically significant eating and weight pathology was found in 20.7 percent of the population. Of these subjects, anorexia nervosa was found in 6.9 percent and the syndrome of bulimia, based on DSM-III criteria, was found in 6.9 percent. In patients with bulimia, there was a strong inverse correlation between bulimic symptoms and metabolic control. These findings suggest that anorexia nervosa may be more common in female adolescents with IDDM than in nondiabetic populations and that bulimic symptoms may be a risk factor for poor metabolic control.