Quality of life for patients with body dysmorphic disorder

Body dysmorphic disorder (BDD) is a relatively common, distressing, and impairing disorder. Quality of life in BDD, however, has not been investigated. In this study, 62 consecutive outpatients with BDD were evaluated with the self-report Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and other scales. SF-36 scores were descriptively compared to published norms for several populations. Physical health-related quality of life scores were generally worse than general U.S. population norms and better than norms for outpatients with a medical illness or depression. However, in all mental health domains, BDD subjects' scores were notably worse than norms for the general U.S. population and for patients with depression, diabetes, or a recent myocardial infarction. More severe BDD symptoms and greater delusionality were associated with poorer mental health-related quality of life. These results indicate that patients with BDD have notably poor mental health status and mental health-related quality of life.

Use of preventive services by managed care enrollees: an updated perspective

We examined whether enrollees in managed care plans received more preventive services than enrollees in non-managed care plans did, by conducting an updated literature synthesis of studies published between 1990 and 1998. We found that 37 percent of comparisons indicated that managed care enrollees were significantly more likely to obtain preventive services; 3 percent indicated that they were significantly less likely to do so; and 60 percent found no difference. Enrollees in group/staff-model health maintenance organizations (HMOs) were more likely to receive preventive services, but there was little evidence, outside of Medicaid managed care, that managed care plans are worse at providing preventive services. However, most of the evidence is equivocal: Provision of preventive services was neither better nor worse in managed versus non-managed care plans. Because of the blurred distinctions among types of health plans, more research is needed to identify which plan characteristics are most likely to encourage appropriate utilization.

Warfarin use among ambulatory patients with nonvalvular atrial fibrillation: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study

BACKGROUND

Warfarin dramatically reduces the risk for ischemic stroke in nonvalvular atrial fibrillation, but its use among ambulatory patients with atrial fibrillation has not been widely studied.

OBJECTIVE

To assess the rates and predictors of warfarin use in ambulatory patients with nonvalvular atrial fibrillation.

DESIGN

Cross-sectional study.

SETTING

Large health maintenance organization.

PATIENTS

13428 patients with a confirmed ambulatory diagnosis of nonvalvular atrial fibrillation and known warfarin status between 1 July 1996 and 31 December 1997.

MEASUREMENTS

Data from automated pharmacy, laboratory, and clinical-administrative databases were used to determine the prevalence and determinants of warfarin use in the 3 months before or after the identified diagnosis of atrial fibrillation.

RESULTS

Of 11082 patients with nonvalvular atrial fibrillation and no known contraindications, 55% received warfarin. Warfarin use was substantially lower in patients who were younger than 55 years of age (44.3%) and those who were 85 years of age or older (35.4%). Only 59.3% of patients with one or more risk factors for stroke and no contraindications were receiving warfarin. Among a subset of "ideal" candidates to receive warfarin (persons 65 to 74 years of age who had no contraindications and had previous stroke, hypertension, or both), 62.1% had evidence of warfarin use. Among our entire cohort, the strongest predictors of receiving warfarin were previous stroke (adjusted odds ratio, 2.55 [95% CI, 2.23 to 2.92]), heart failure (odds ratio, 1.63 [CI, 1.51 to 1.77]), previous intracranial hemorrhage (odds ratio, 0.33 [CI, 0.21 to 0.52]), age 85 years or older (odds ratio, 0.35 [CI, 0.31 to 0.40]), and previous gastrointestinal hemorrhage (odds ratio, 0.47 [CI, 0.40 to 0.57]).

CONCLUSIONS

In a large, contemporary cohort of ambulatory patients with atrial fibrillation who received care within a health maintenance organization, warfarin use was considerably higher than in other reported studies. Although the reasons why physicians did not prescribe warfarin could not be elucidated, many apparently eligible patients with atrial fibrillation and at least one additional risk factor for stroke, especially hypertension, did not receive anticoagulation. Interventions are needed to increase the use of warfarin for stroke prevention among appropriate candidates.

Warfarin use among ambulatory patients with nonvalvular atrial fibrillation: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study

BACKGROUND

Warfarin dramatically reduces the risk for ischemic stroke in nonvalvular atrial fibrillation, but its use among ambulatory patients with atrial fibrillation has not been widely studied.

OBJECTIVE

To assess the rates and predictors of warfarin use in ambulatory patients with nonvalvular atrial fibrillation.

DESIGN

Cross-sectional study.

SETTING

Large health maintenance organization.

PATIENTS

13428 patients with a confirmed ambulatory diagnosis of nonvalvular atrial fibrillation and known warfarin status between 1 July 1996 and 31 December 1997.

MEASUREMENTS

Data from automated pharmacy, laboratory, and clinical-administrative databases were used to determine the prevalence and determinants of warfarin use in the 3 months before or after the identified diagnosis of atrial fibrillation.

RESULTS

Of 11082 patients with nonvalvular atrial fibrillation and no known contraindications, 55% received warfarin. Warfarin use was substantially lower in patients who were younger than 55 years of age (44.3%) and those who were 85 years of age or older (35.4%). Only 59.3% of patients with one or more risk factors for stroke and no contraindications were receiving warfarin. Among a subset of "ideal" candidates to receive warfarin (persons 65 to 74 years of age who had no contraindications and had previous stroke, hypertension, or both), 62.1% had evidence of warfarin use. Among our entire cohort, the strongest predictors of receiving warfarin were previous stroke (adjusted odds ratio, 2.55 [95% CI, 2.23 to 2.92]), heart failure (odds ratio, 1.63 [CI, 1.51 to 1.77]), previous intracranial hemorrhage (odds ratio, 0.33 [CI, 0.21 to 0.52]), age 85 years or older (odds ratio, 0.35 [CI, 0.31 to 0.40]), and previous gastrointestinal hemorrhage (odds ratio, 0.47 [CI, 0.40 to 0.57]).

CONCLUSIONS

In a large, contemporary cohort of ambulatory patients with atrial fibrillation who received care within a health maintenance organization, warfarin use was considerably higher than in other reported studies. Although the reasons why physicians did not prescribe warfarin could not be elucidated, many apparently eligible patients with atrial fibrillation and at least one additional risk factor for stroke, especially hypertension, did not receive anticoagulation. Interventions are needed to increase the use of warfarin for stroke prevention among appropriate candidates.

Continuing screening mammography in women aged 70 to 79 years: impact on life expectancy and cost-effectiveness

CONTEXT

Mammography is recommended and is cost-effective for women aged 50 to 69 years, but the value of continuing screening mammography after age 69 years is not known. In particular, older women with low bone mineral density (BMD) have a lower risk of breast cancer and may benefit less from continued screening.

OBJECTIVE

To compare life expectancy and cost-effectiveness of screening mammography in elderly women based on 3 screening strategies.

DESIGN

Decision analysis and cost-effectiveness analysis using a Markov model.

PATIENTS

General population of women aged 65 years or older.

INTERVENTIONS

The analysis compared 3 strategies: (1) Undergoing biennial mammography from age 65 to 69 years; (2) undergoing biennial mammography from age 65 to 69 years, measurement of distal radial BMD at age 65 years, discontinuing screening at age 69 years in women in the lowest BMD quartile for age, and continuing biennial mammography to age 79 years in those in the top 3 quartiles of distal radius BMD; and (3) undergoing biennial mammography from age 65 to 79 years.

MAIN OUTCOME MEASURES

Deaths due to breast cancer averted, life expectancy, and incremental cost-effectiveness ratios.

RESULTS

Compared with discontinuing mammography screening at age 69 years, measuring BMD at age 65 years in 10000 women and continuing mammography to age 79 years only in women with BMD in the top 3 quartiles would prevent 9.4 deaths and add, on average, 2.1 days to life expectancy at an incremental cost of $66773 per year of life saved. Continuing mammography to age 79 years in all 10000 elderly women would prevent 1.4 additional breast cancer deaths and add only 7.2 hours to life expectancy at an incremental cost of $117689 per year of life saved compared with only continuing mammography to age 79 years in women with BMD in the top 3 quartiles.

CONCLUSIONS

This analysis suggests that continuing mammography screening after age 69 years results in a small gain in life expectancy and is moderately cost-effective in those with high BMD and more costly in those with low BMD. Women's preferences for a small gain in life expectancy and the potential harms of screening mammography should play an important role when elderly women are deciding about screening.

Breast carcinomas arising in carriers of mutations in BRCA1 or BRCA2: are they prognostically different?

PURPOSE

To review the preclinical and clinical studies relevant to the prognosis and prognostic associations of BRCA1- and BRCA2-associated breast carcinomas, with an emphasis on research methodology.

METHODS

Reports of relevant studies obtained from a MEDLINE search, and references from these articles, were critically reviewed.

RESULTS

Consistent associations with both favorable (medullary or atypical medullary carcinoma) and unfavorable (high tumor grade, hormone receptor negativity, somatic p53 mutation) prognostic characteristics have been found for BRCA1-associated breast carcinomas. Inconsistent results have been demonstrated for prognostic associations of BRCA2-associated breast tumors. Clinical studies that have directly assessed the prognosis of these tumors have not shown a clear effect of BRCA1 or BRCA2 mutation, but no study has used optimal methodology. In vitro and animal model data suggest a possible influence of these mutations on response to agents that cause double-strand DNA breaks, but clinical data are limited.

CONCLUSION

The elucidation of an identifiable subgroup of breast carcinomas that result from germline mutations in BRCA1 or BRCA2 may be an important step toward genotype-based understanding of prognosis and choice of therapy in this disease. However, currently there are inadequate data to support use of BRCA1 or BRCA2 status to counsel individuals regarding their prognosis or to select treatment. Well-designed studies of population-based inception cohorts of breast cancer patients, which have adequate sample size and complete follow-up, and which use objective outcome criteria and blinding of outcome assessment, are required to optimally address this question.

Thirty-three cases of body dysmorphic disorder in children and adolescents

OBJECTIVE

Body dysmorphic disorder (BDD), a preoccupation with a nonexistent or slight defect in appearance, usually begins during adolescence. Because there have been no studies of the clinical features of BDD in children and adolescents, the authors assessed these features in the largest series to date.

METHOD

Thirty-three children and adolescents with DSM-IV BDD were assessed for demographic characteristics, phenomenology, associated psychopathology, and treatment history and response.

RESULTS

Bodily preoccupations most often focused on the skin (61%) and hair (55%). All subjects had associated compulsive behaviors, most often camouflaging (e.g., with clothing) in 94%, comparing with others (87%), and mirror checking (85%). Ninety-four percent reported impairment in social functioning and 85% in academic or job functioning due to BDD. Thirty-nine percent had had psychiatric hospitalizations, and 21% had made a suicide attempt. Ten (53%) of 19 subjects treated with a serotonin reuptake inhibitor had much or very much improvement in BDD symptoms; in contrast, 0 of 8 trials with other psychotropic medications, 0 of 1 trial of cognitive-behavioral therapy, and 1 of 20 psychotherapy trials resulted in improvement. Twelve (36%) subjects received surgical, dermatological, or dental treatment, with a poor outcome in all cases.

CONCLUSIONS

BDD can cause significant morbidity in children and adolescents. These preliminary data suggest that serotonin reuptake inhibitors may be an effective treatment in this age group.

Frequency of p53 mutations in breast carcinomas from Ashkenazi Jewish carriers of BRCA1 mutations

BACKGROUND

Breast carcinomas occurring in carriers of BRCA1 gene mutations may have a distinctly different pathway of molecular pathogenesis from those occurring in noncarriers. Data from murine models implicate loss of p53 (also known as TP53) gene function as a critical early event in the malignant transformation of cells with a BRCA1 mutation. Therefore, breast tumors from BRCA1 mutation carriers might be expected to exhibit a high frequency of p53 mutations. This study examined the frequency of p53 mutations in the breast tumors of Ashkenazi Jewish carriers and noncarriers of BRCA1 mutations.

METHODS

Tumor DNA from carriers and noncarriers of BRCA1 mutations was screened for mutations in exons 4 through 10 of the p53 gene by use of the polymerase chain reaction and single-strand conformation polymorphism (SSCP) analysis of the amplified DNA. Direct sequencing was performed on gene fragments that showed altered mobility in SSCP analysis.

RESULTS

Mutations in the p53 gene were detected in 10 of 13 tumors from BRCA1 mutation carriers versus 10 of 33 tumors from non-carriers (two-sided P = .007). The p53 mutations were distributed throughout exons 4 through 10 and included both protein-truncating and missense mutations in both groups.

CONCLUSIONS

A statistically significantly higher frequency of p53 mutations was found in breast tumors from carriers of BRCA1 mutations than from noncarriers, which adds to the accumulating evidence that loss of p53 function is an important step in the molecular pathogenesis of BRCA1 mutation-associated breast tumors. This finding may have implications for understanding phenotypic differences and potential prognostic differences between BRCA1 mutation-associated hereditary breast cancers and sporadic cancers.

Body dysmorphic disorder and depression: theoretical considerations and treatment strategies

Body dysmorphic disorder (BDD), also known as dysmorphophobia, consists of a distressing and impairing preoccupation with an imagined or slight defect in appearance. BDD is an underrecognized and relatively common disorder that is associated with high rates of occupational and social impairment, hospitalization, and suicide attempts. BDD is unlikely to simply be a symptom of depression, although it often coexists with depression and may be related to depression. It is important to recognize BDD in depressed patients, because missing the diagnosis can result in refractory BDD and depressive symptoms. Available data indicate that BDD may not respond to all treatments for depression and may instead respond preferentially to serotonin-reuptake inhibitors. In addition, lengthier treatment trials than those required for depression may be needed to successfully treat BDD and comorbid depression. It can be difficult and challenging to diagnose BDD in depressed patients because the symptoms are often concealed due to embarrassment and shame. This paper discusses the relationship between BDD and depression and discusses practical strategies for recognizing and treating BDD and depressive symptoms in patients with depression.

Body dysmorphic disorder: clinical aspects and treatment strategies

Body dysmorphic disorder (BDD), a distressing and impairing preoccupation with an imagined or slight defect in appearance, is an "OCD-spectrum disorder" that appears to be relatively common. BDD often goes unrecognized and undiagnosed, however, due to patients' reluctance to divulge their symptoms because of secrecy and shame. Any body part can be the focus of concern (most often, the skin, hair, and nose), and most patients engage in compulsive behaviors, such as mirror checking, camouflaging, excessive grooming, and skin picking. Approximately half are delusional, and a majority experience ideas or delusions of reference. Nearly all patients suffer some impairment in functioning as a result of their symptoms, some to a debilitating degree. Psychiatric hospitalization, suicidal ideation, and suicide attempts are relatively common. While treatment data are preliminary at this time, selective serotonin reuptake inhibitors (SSRIs) appear to often be effective for BDD, even if symptoms are delusional. Cognitive-behavioral therapy is another promising approach. While much remains to be learned about BDD, it is important that clinicians screen patients for this disorder and accurately diagnose it, as available treatments are very promising for those who suffer from this distressing and sometimes disabling disorder.

A comparison study of body dysmorphic disorder and obsessive-compulsive disorder

BACKGROUND

Body dysmorphic disorder, a preoccupation with an imagined or slight defect in appearance, is classified as a somatoform disorder, but has been hypothesized to be related to obsessive-compulsive disorder. A reflection of this hypothesis, body dysmorphic disorder is included in the Yale-Brown Obsessive Compulsive Scale symptom checklist, and its transfer to the anxiety disorders' section was considered for DSM-IV. However, the similarities and differences between body dysmorphic disorder and obsessive-compulsive disorder have received little investigation.

METHOD

We compared patients with DSM-IV body dysmorphic disorder (N = 53), obsessive-compulsive disorder (N = 53), or both disorders (N = 33) in terms of demographic features, clinical features, comorbidity, and family history. We also assessed the rate of body dysmorphic disorder among 62 of these subjects initially diagnosed with obsessive-compulsive disorder.

RESULTS

14.5% (9 of 62) of subjects initially diagnosed with obsessive-compulsive disorder had comorbid body dysmorphic disorder. The 2 disorders did not differ significantly in terms of sex ratio; most other demographic, course, and impairment variables; illness severity; or lifetime frequency of most associated disorders in probands or first-degree relatives. However, subjects with body dysmorphic disorder were less likely to be married and more likely to have had suicidal ideation or made a suicide attempt because of their disorder. They also had an earlier onset of major depression and higher lifetime rates of major depression, social phobia, and psychotic disorder diagnoses, as well as higher rates of substance use disorders in first-degree relatives.

CONCLUSION

Body dysmorphic disorder appears to be relatively common among patients with obsessive-compulsive disorder. While the 2 disorders have many similarities, they also have some differences and should be differentiated in clinical and research settings.

Design and interpretation of clinical trials that evaluate agents that may offer protection from the toxic effects of cancer chemotherapy

PURPOSE

To review the features of randomized clinical trials (RCTs) used in the development of agents that may protect against chemotherapy-induced toxicities, including trials of the cardioprotective agent dexrazoxane, hematologic growth factors, and amifostine; to suggest recommendations based on information gained from such trials and improvements in the design of ongoing and future trials.

METHODS

Critical review of reports of RCTs obtained from a Medline search, references from these articles, and review of trials listed in the physician data query (PDQ) clinical trials data base.

RESULTS

Several of the phase III trials did not use a format of comparing widely accepted strategies of chemotherapy with and without a protective agent. Instead, patients in the control arms of some of the trials have been exposed to more prolonged use or increased dosage of toxic chemotherapy that placed them at greater risk of the toxicity the protective agent was designed to prevent (eg, cardiotoxicity in trials of dexrazoxane, myelosuppression or thrombocytopenia in trials of growth factors).

CONCLUSION

RCTs have shown clear evidence of biologic activity for the protective agents, but this does not imply therapeutic benefit as compared with alternative strategies such as avoidance of prolonged use of cardiotoxic agents or use of standard doses of chemotherapy. Ongoing and future trials of protective agents should be modified to avoid undue risk to patients.

Reliability and validity of depressive personality disorder

OBJECTIVE

Depressive personality disorder was introduced into DSM-IV's appendix amid controversy. While that disorder appears to be a reliable and valid one, the authors offer new data about its relationship to major depression, dysthymic disorder, and other personality disorders.

METHOD

The authors assessed 54 subjects with early-onset, long-standing mild depressive features for depressive personality disorder, axis I and axis II disorders, family history, and treatment history; they conducted follow-up interviews 1 year after the baseline assessment. Subjects with (N=30) and without (N=24) depressive personality disorder were characterized and compared in terms of those variables.

RESULTS

Although depressive personality disorder and dysthymia co-occurred in some subjects, 63% of subjects with depressive personality disorder did not have dysthymia, and 60% did not have current major depression. Although subjects with depressive personality disorder were more likely than the mood disorder comparison group to have another personality disorder, 40% had no such disorder. Contrary to study hypotheses, mood disorder was not more common in first-degree relatives of subjects with depressive personality disorder than in relatives of the comparison group. Subjects with and without depressive personality disorder had similar rates of past treatment with medication and psychotherapy; however, the duration of psychotherapy was significantly longer for subjects with than for those without depressive personality. The depressive personality diagnosis was relatively stable over the 1-year follow-up period.

CONCLUSIONS

Depressive personality disorder appears to be a relatively stable condition with incomplete overlap with axis I mood disorders and personality disorders. Further studies are needed to better characterize its treatment response and relationship to axis I mood disorders.

Understanding the context of healthcare utilization: assessing environmental and provider-related variables in the behavioral model of utilization

OBJECTIVE

The behavioral model of utilization, developed by Andersen, Aday, and others, is one of the most frequently used frameworks for analyzing the factors that are associated with patient utilization of healthcare services. However, the use of the model for examining the context within which utilization occurs-the role of the environment and provider-related factors-has been largely neglected.

OBJECTIVE

To conduct a systematic review and analysis to determine if studies of medical care utilization that have used the behavioral model during the last 20 years have included environmental and provider-related variables and the methods used to analyze these variables. We discuss barriers to the use of these contextual variables and potential solutions.

DATA SOURCES

The Social Science Citation Index and Science Citation Index. We included all articles from 1975-1995 that cited any of three key articles on the behavioral model, that included all articles that were empirical analyses and studies of formal medical care utilization, and articles that specifically stated their use of the behavioral model (n = 139).

STUDY DESIGN

Design was a systematic literature review.

DATA ANALYSIS

We used a structured review process to code articles on whether they included contextual variables: (1) environmental variables (characteristics of the healthcare delivery system, external environment, and community-level enabling factors); and (2) provider-related variables (patient factors that may be influenced by providers and provider characteristics that interact with patient characteristics to influence utilization). We also examined the methods used in studies that included contextual variables.

PRINCIPAL FINDINGS

Forty-five percent of the studies included environmental variables and 51 percent included provider-related variables. Few studies examined specific measures of the healthcare system or provider characteristics or used methods other than simple regression analysis with hierarchical entry of variables. Only 14 percent of studies analyzed the context of healthcare by including both environmental and provider-related variables as well as using relevant methods.

CONCLUSIONS

By assessing whether and how contextual variables are used, we are able to highlight the contributions made by studies using these approaches, to identify variables and methods that have been relatively underused, and to suggest solutions to barriers in using contextual variables.

Personality dimensions associated with depressive personality disorder

Depressive personality disorder (DPD) is a historically important construct that requires empirical attention. This study compares 26 subjects with this disorder to 20 non-DPD subjects who have similar histories of longstanding early-onset depression on three personality measures, the Tridimensional Personality Questionnaire (TPQ), NEO-Five Factor Inventory, and Defense Style Questionnaire (DSQ). The samples were demographically similar and had similar rates of comorbid depression and dysthymia. They differed in that DPD subjects scored significantly higher on Harm Avoidance and Neuroticism, and significantly lower on Novelty Seeking, Extroversion, and Adaptive defense mechanisms. Implications for clinical care and nosology are discussed.

Factors associated with women's adherence to mammography screening guidelines

OBJECTIVE

To examine individual and environmental factors associated with adherence to mammography screening guidelines.

DATA SOURCES

A unique data set that combines a national probability sample (1992 National Health Interview Survey); a national probability sample of mammography facility characteristics (1992 National Survey of Mammography Facilities); county-level data on 1990 HMO market share; and county-level data on the supply of primary care providers (1991 Area Resource File).

STUDY DESIGN

The design was cross-sectional. DATA EXTRACTION/ANALYSIS: Data sets were linked to create an individual-level sample of women ages 50-74 (weighted n = 2,026). We used multipart, sequential logistic regression models to examine the predictors of having ever had mammography, having had recent mammography, and adherence to guidelines. We categorized women as adherent if they reported a lifetime number of exams appropriate for their age (based on screening every two years) and they reported having had an exam in the past two years.

PRINCIPAL FINDINGS

Only 27 percent of women had the age-appropriate number of screening exams (range 16 percent-37 percent), while 59 percent of women had been screened within two years. Women were significantly more likely to adhere to screening guidelines if they reported participating with their doctor in the decision to be screened; were younger; had smaller families, higher education and income, and a recent Pap smear; reported breast problems; and lived in an area with a higher percentage of mammography facilities with reminder systems, no shortage of primary care providers, higher HMO market share, and higher screening charges.

CONCLUSIONS

A small percentage of women adhere to screening guidelines, suggesting that adherence needs to become a focus of clinical, programmatic, and policy efforts.