Review article: recognition and treatment of eating disorders in primary and secondary care

Dietary management of irritable bowel syndrome: considerations, challenges, and solutions

Diet is a cornerstone in the management of irritable bowel syndrome (IBS). There is evidence of efficacy across the spectrum of dietary management strategies, including some supplements (eg, specific fibres), foods, and whole diets (eg, a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols [known as the low-FODMAP diet]). Whole-diet interventions, in particular those that restrict intake, can be challenging to deliver effectively and safely. Factors to consider include patient demographics, food cost and availability, and the acceptability of dietary management and its impact on food-related quality of life. There is concern regarding a potential role of restrictive whole-diet interventions in eating disorder risk. Optimal approaches to delivering dietary management in the health-care setting are unclear. The aim of this Review is to summarise the clinical evidence for the dietary management of IBS; to discuss the challenges, burdens, and risks of dietary management; and to propose how these challenges, burdens, and risks should be mitigated and minimised in clinical practice.

Baseline personality characteristics of responders to 6-month psychotherapy in eating disorders: preliminary data

OBJECTIVE

The Karolinska Psychodynamic Profile (KAPP) was used for the assessment of the six-month outcome of Brief Adlerian Psychodynamic Psychotherapy (B-APP).

METHOD

Fifty-seven eating disordered women (28 with anorexia nervosa, 29 with bulimia nervosa), were included in the study. The sample was evaluated at baseline (time 0) and after six months (T6) with a clinical assessment and with Temperament and Character Inventory (TCI), Eating Disorder Inventory (EDI-2), State-Trait Anger Expression Inventory (STAXI), and KAPP.

RESULTS

Based on symptomatologic improvement, two sub-groups were obtained: responders (66.6%) and non-responders (33.3%). Significantly higher baseline scores emerged in the responders group on Ineffectiveness and Impulsivity (EDI-2) and on Harm Avoidance (TCI). Several KAPP items and areas improved in both groups at T6.

CONCLUSION

Multimodal treatment centered on B-APP lead to both a global clinical improvement and an improvement in several psychological and psychopathological features as assessed by EDI-2, STAXI and KAPP. The results suggest interesting clinical implications, though outcome predictors are quite weak.

Gastric emptying in patients with restricting and binge/purging subtypes of anorexia nervosa

OBJECTIVES

Gastrointestinal symptoms are common in anorexia and in bulimia nervosa, but their relationship with gastric dysmotility and their possible improvement with refeeding are still debated.

METHODS

Twenty-three anorexic patients (12 with the binge/purging and 11 with the restricting subtypes) were studied using an ultrasonographic gastric-emptying test, psychopathological questionnaires, and bowel symptom questionnaires, before and after 4 and 22 wk rehabilitation.

RESULTS

Gastric symptom scores were markedly higher in patients than in controls and improved significantly with treatment. On entry, compared to controls, gastric emptying was significantly delayed in restricters and purgers (357 +/- 25.3 and 360 +/- 13.0 min, respectively, mean +/- SEM; controls 207 +/- 9.1). After 4 and 22 wk of treatment, it improved in restricters (315 +/- 20.1 and 296 +/- 17.2 min, respectively), but not in purgers (337 +/- 14.3 and 335 +/- 15.9 min). No relationship was found between entry values of symptoms of gastric emptying and of psychopathological tests or between their variations over time.

CONCLUSIONS

Gastric emptying derangement and dyspeptic symptoms are present in both subtypes of anorexia nervosa patients. Long-term rehabilitation improves gastrointestinal symptoms, gastric emptying, and psychopathological distress in an independent manner, whereas short-term refeeding does not.

Antidepressant use in psychiatry and medicine: importance for dental practice

BACKGROUND

Many dental patients receive antidepressant therapy. However, antidepressants taken with other drugs may increase the risk of complications that require special dental precautions and care.

METHODS

The authors conducted a retrospective study of 1,800 randomly selected patient records and evaluated the prevalence of using antidepressants and other medications concurrently. They analyzed antidepressant intake relative to drug classification and mechanism of action, age, sex and associated potential for clinical complications such as xerostomia, orthostatic hypotension and interaction with vasoconstrictors. The potential for additive adverse effects between antidepressants and other medications also was analyzed.

RESULTS

Three hundred eighty-one (21 percent) of the 1,800 patient records indicated that patients were being treated with 412 antidepressants. Female subjects out-numbered male subjects by an approximate 2.3:1 ratio. Selective serotonin reuptake inhibitors were most commonly prescribed, followed by tricyclic antidepressants, atypical and third-generation antidepressants, and monoamine oxidase inhibitors. Based on reported medication intake, almost 58 percent of subjects in the antidepressant group were receiving treatment with two or more medications that had the potential for producing xerostomia. Two hundred fifty-seven (67 percent) of the 381 records documented intake of an antidepressant or other medication with orthostatic hypotension potential.

CONCLUSIONS

Three hundred eighty-one patients reported that they were receiving antidepressant therapy for psychiatric and other medical reasons. Potential adverse effects and interactions with other medications have direct implications for dental treatment.

CLINICAL IMPLICATIONS

Patients receiving antidepressant therapy are at risk of developing xerostomia and orthostatic hypotension, as well as experiencing the adverse effects of interaction with vasoconstrictors. Dentists must take appropriate precautions in treating these patients.

Nutritional interventions for individuals with bulimia nervosa

Many physical and psychological effects of bulimia nervosa are caused by the patient's partial starvation and chaotic nutritional cycle. Attention should thus be initially directed to correcting nutritional deficiencies and abnormal eating patterns, and providing dietary counselling. Nevertheless, very little has been written about the nutritional management of this eating disorder. Nutritional counselling for bulimia patients is reviewed in this paper. Current knowledge about nutritional therapy and its efficacy, goals and objectives is presented, along with recommendations used in treatment programmes. Lastly, the key steps of nutritional management are summarised.

Evolution of symptom severity during residential treatment of females with eating disorders

OBJECTIVES

The overall objective of this study was to measure the evolution of symptom severity in a residential programme based on a multidimensional approach to treatment that includes cognitive-behavioural, interpersonal, experiential and family therapies. The specific aims of the study were: 1) to evaluate changes in symptom severity in bulimic and anorexic patients between admission and discharge; 2) to compare the severity of these symptoms with those of non-patient college females (control group); and 3) to monitor the progression of symptom changes six months after discharge.

METHODS

The evolution of symptom severity was measured by comparing the mean raw scores of the Eating Disorder Inventory (EDI original inventory, 1983 version), which was administered at the beginning and end of the residential treatment. A subgroup of patients was also administered the EDI six months after discharge. The study involved 99 females: 47 with bulimia and 52 with anorexia as diagnosed by means of a clinical interview using DSM-IV criteria. The mean raw EDI scores in the control group (FC1, female college students) were obtained from the EDI manual. The population means were compared using the t-test for paired data (Microsoft Excel, version 2000).

RESULTS

The overall results for the population as a whole show that the eight subscales of the EDI improved significantly with treatment (<0.001). The subscales with the largest numerical improvements were drive for thinness, ineffectiveness and interoceptive awareness. When divided on the basis of diagnosis, the mean feelings of perfectionism score of the bulimic patients was less than that of the control female college sample; the symptoms of bulimia in the anorexic patients were similar to those found in the control group. The fact that the mean follow-up scores for a number of the ED1 subscales remained similar to those recorded at the time of discharge suggests that some of the improvements in symptoms remained for at least six months.

CONCLUSIONS

The results of our study show that multidimensional residential treatment leads to statistically significant changes in the severity of the symptoms manifested by females with eating disorders.

Eating disorders: 1. anorexia nervosa

Although many of the factors that contribute to anorexia nervosa are not within the physician's control, early detection and prompt initiation of treatment may improve patient outcome. A high level of suspicion and a willingness to address the issue can serve our patients well.