To Improve the Initial Inpatient Management of Adolescents Admitted with Severe Anorexia Nervosa: A Narrative Review and a Convenient Protocol

Inadequate nutritional rehabilitation of severely malnourished adolescents with Anorexia Nervosa (AN) increases the risk of medical complications. There is no consensus on best practices for inpatient nutritional rehabilitation and medical stabilization for severe AN. This study aimed to elaborate an admission protocol for adolescents with severe AN based on a comprehensive narrative review of current evidence. A Pubmed search was conducted in July 2017 and updated in August 2020, using the keywords severe AN or eating disorders (ED), management guidelines and adolescent. Relevant references cited in these guidelines were retrieved. A secondary search was conducted using AN or ED and refeeding protocol, refeeding syndrome (RS), hypophosphatemia, hypoglycemia, cardiac monitoring or cardiac complications. Evidence obtained was used to develop the admission protocol. Selective blood tests were proposed during the first three days of nutritional rehabilitation. Higher initial caloric intake is supported by evidence. Continuous nasogastric tube feeding was proposed for patients with a BMI < 12 kg/m2. We monitor hypoglycemia for 72 h. Continuous cardiac monitoring for bradycardia <30 BPM and systematic phosphate supplementation should be considered. Developing protocols is necessary to improve standardization of care. We provide an example of an inpatient admission protocol for adolescents with severe AN.

Multidisciplinary healthcare teams' challenges and strategies in supporting people with type 1 diabetes to recover from disordered eating

AIM

To examine the challenges healthcare teams face when treating people with type 1 diabetes and disordered eating and the strategies these teams have developed to facilitate effective treatment.

METHODS

Four semi-structured focus groups were conducted including two tertiary diabetes specialist teams and three tertiary eating disorders specialist teams between July and December 2018. Thematic analysis of the transcripts followed a six-phase process.

RESULTS

Twenty-nine experienced healthcare professionals (16 diabetes and 13 eating disorder specialists, 16±12 years' professional experience) were interviewed. The challenges identified in treating people with type 1 diabetes and disordered eating included subthemes the 'challenges specific to the healthcare professional' (feeling not competent enough and perceived emotional burden), 'challenges pertaining to patient factors' (e.g. difficulties with engaging in therapy) and 'challenges created by the healthcare system' (time pressure and staff shortage). Healthcare professionals expressed the need for a consensus on diagnosis and the definition of disordered eating in type 1 diabetes, as well as the need for training and educational resources specific to type 1 diabetes and disordered eating. Healthcare professionals gave practical examples of strategies of communication for better patient engagement and felt that multidisciplinary working in joint clinics with the other specialty were facilitators for recovery from disordered eating.

CONCLUSIONS

Healthcare professionals require multidisciplinary team support when treating people with type 1 diabetes and to improve their own competencies. The development of effective screening and assessment tools, educational resources and training for healthcare professionals, and developing multidisciplinary treatment pathways will be key to improving outcomes for their service users with type 1 diabetes and disordered eating.

Internet Usage by Women with Eating Disorders during Illness and Recovery

Internet usage may have both positive and negative impacts on people with eating disorders. In research to date, most of the focus has been put on the harms connected with platforms that support people in continuing their disorder. Less studied have been the benefits of other technology platforms used by people with eating disorders. When these different platforms were investigated, users were rarely interviewed about their experience. To fill this gap, we conducted 30 interviews with participants aged 16 to 28, all female, living in the Czech Republic. The interviews focused on their experiences with the harmful and helpful impacts of the internet on the course of their eating disorders. The data were analyzed via thematic analysis. The results provided insight into the participants' experience with the following online environments: 1) nonprofessional pro-eating disorder platforms; 2) nonprofessional pro-recovery platforms; 3) social networking sites (SNS); 4) platforms for counting calories and setting weight goals; 5) platforms about food, exercise, and lifestyle; and 6) platforms providing professional help. The participants noted many benefits these platforms could provide; however, their ability to achieve the benefits was affected by their motivation for treatment. As a result, even platforms designed to support recovery could be used for illness maintenance. The results are discussed in the context of research on the changing motivations for recovery in people with eating disorders and the theory of different processes connected to the course of the eating disorders according to the differential interactivity of digital platforms.

Utilising cognitive bias modification to remedy appearance and self-worth biases in eating disorder psychopathology: A systematic review

BACKGROUND AND OBJECTIVES

This study systematically reviewed the impact of Cognitive Bias Modification (CBM) on biases related to attention (CBM-A) and interpretation (CBM-I) for appearance and self-worth stimuli and the subsequent impact on eating disorder (ED) psychopathology.

METHOD

The current review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), with 12 studies meeting inclusion criteria (CBM-A n = 5; CBM-I n = 7).

RESULTS

The literature provides preliminary support for CBM-A and CBM-I efficacy in eliciting bias change in varying degrees of psychopathology (Cohen's d ranging between -1.67 and 1.34; 9 studies reflected improved bias, and 3 reflected no change or did not assess), while highlighting the less robust effects associated with improving ED psychopathology (d ranging between -1.30 and 0.61; 5 studies reflected symptom improvement, and 7 reflected no change or did not assess).

LIMITATIONS

The review only considered peer reviewed research and did not report on the findings of unpublished data; thus, the current findings may not provide an accurate representation of CBM in EDs.

CONCLUSIONS

The current findings highlight the potential of CBM as an adjunct intervention for EDs; however the limited number of investigations and high degree of heterogeneity across the included studies impedes on the generalisability of the findings.

Therapeutic effect of a cleft lip teat on infants with respiratory and feeding disorders: Two case reports

RATIONALE

Existing research into the effects of teat application has mainly focused on its negative and positive influence on the development of the oral cavity. Our work demonstrates that apart from changing the setting of the articulatory organs, the teat can also affect the quality of breathing, eating and sleeping.

PATIENTS CONCERNS

We described the cases of 2 children: a 19-month-old girl and a 2.5-month-old boy, who had breathing disorders due to withdrawal of the tongue and impaired food intake.

INTERVENTION

The babies were bottled fed with a special teat for cleft lip patients to observe the influence of the teat on the setting of the articulatory organs and breathing.

DIAGNOSIS

We suspected that the specific construction of the teat-the wide outer part and the short internal part-would affect children's reflexes and articulatory organs so as to force the frontal position of the tongue, which was meant to facilitate breathing and eating.

OUTCOMES

It was found that feeding with the cleft lip teat stimulates the gyro-linguistic muscle, which results in the proper position of the tongue and consequently better breathing and improved quality of sleep.

LESSONS

A specialist bottle teat designed for babies with cleft lips can constitute an effective tool in the therapy of nonspecific respiratory disorders resulting from improper position of the tongue and other articulatory organs.

[Occupational therapy and eating disorders, a care case study]

Occupational therapy offers support through actuation via a suggested activity. It opens up a differentiated space, a space of experiences where patients can contemplate themselves through play. The therapeutic relationship, assured by the occupational therapist, offers flexibility and malleability to welcome, contain and support the person with an eating disorder. It aims to be compassionate without judgement to favour the experience of movement. 'Making do with oneself' to 'be with oneself' while respecting the temporality of the patient's possibilities.

Recovery from disordered eating: What life histories reveal

There are few studies seeking to understand the illness from the experiential perspective of a person who has recovered from an eating disorder. The clinical and research literature shows inconsistencies and varying degrees of support for the risk factors associated with eating disordered behaviour. It is important to note, however, that most contemporary research relies upon brief self-report questionnaires, which may be providing a fragmented picture of the behaviour. The focus of the current study is to gain a greater understanding of women's perceptions of developing, living with and recovering from an eating disorder. This study reports interviews with five former eating disorder sufferers who were recruited via an advertisement placed in an Eating Disorders Support Network newsletter. Life histories were gathered from each woman and the paper reports how these women perceive the origins of their illness and what event(s) lead to their recovery. Participants' narratives were analysed to elucidate themes pertaining to the lived experience of illness and recovery. The women talk about a lack of control of their lives and unrealistic family expectations as reasons for the development of their eating disordered behaviour. Recovery was very strongly related to self-determination and self-acceptance. Suggestions concerning new ways of conceptualising recovery from eating disordered behaviour are posited.

[The newest therapeutic directions in the rehabilitation of patients with mental disorders]

In this paper, the authors attempted to present the comprehensive literature review on the newest therapeutic interventions such as cognitive remediation therapy (CRT), mindfulness-based cognitive therapy (MBCT), social cognition and interaction training (SCIT), and acceptance and commitment therapy (ACT) which appeared promising whilst their implementing among schizophrenic patients, patients with anxiety disorders, eating disorders, and affective disorders. In the presented work particular attention was focused on two kinds of psychotherapeutic interventions: social cognitive trainings and cognitive remediation therapy (CRT) and their effectiveness in the rehabilitation process of schizophrenic patients. The growing body of research based on application of the above mentioned techniques in psychiatric population gives remarkable hope to improve quality of cognitive and psychosocial therapeutic interventions and to set up both complex and comprehensive therapeutic programme for patients with mental disorders.

[Child psychiatric viewpoint towards early childhood feading disorders]

Early childhood feading disorders are estimated to occur in 20% to 40% of normally developing young children. In most severe cases, troubles associated with feading interfere with the child's growth and development and may continue until adulthood. Early childhood feading disorders are discernible into different types of disorder, such as early childhood anorexia, sensory food aversion and posttraumatic feading disorder. Early childhood feading disorders are often associated with problems in parent-child interaction either primarily or secondarily as factors maintaining the disorder. Interactive therapy is often beneficial regardless of the etiology of the disorder.

Omega-3 essential fatty acid status is improved during nutritional rehabilitation of adolescent girls with eating disorders and weight loss

AIM

Essential fatty acid status is altered in eating disorders with weight loss, and deficiencies in polyunsaturated omega-3 essential fatty acids have been implicated in the development of depression and other psychopathologies. Presently, recovery of essential fatty status during the treatment of adolescent girls with eating disorders has been investigated.

METHODS

Fatty acids were analysed in erythrocyte membranes of 24 adolescents girls with eating disorders of short duration, and on the average >10 kg weight loss at presentation. Blood samples were obtained at presentation and following weight recovery on standard diet without supplementation with essential fatty acids.

RESULTS

Alterations of essential fatty status observed at presentation largely normalized during treatment. Omega-3 status improved following weight gain.

CONCLUSION

Adequate nutrition, normalization of eating behaviours, weight gain and the consequent return to normalization of metabolism and endocrine function are sufficient to ensure normalization of essential fatty acid status. Supplementation with omega-3 polyunsaturated fatty acids does not appear warranted.

The extent and nature of need for mealtime support among adults with intellectual disabilities

BACKGROUND

For many adults with an intellectual disability (ID), mealtimes carry significant health risks. While research and allied clinical guidance has focused mainly on dysphagia, adults with a range of physical and behavioural difficulties require mealtime support to ensure safety and adequate nutrition. The extent of need for and nature of such support within the wider ID population has yet to be reported.

METHODS

In this study, we have estimated the prevalence of need for mealtime support among people with ID in the UK, using a population of 2230 adults known to specialist ID services (in Cambridgeshire, UK, total population 586,900). In a sample (n = 69, aged 19 to 79 years, with mild to profound ID), we characterised the support provided, using a structured proforma to consult support workers and carers providing mealtime support, and health and social care records.

RESULTS

Mealtime support was found to be required by a significant minority of people with ID for complex and varied reasons. Prevalence of need for such support was estimated at 15% of adults known to specialist ID services or 56 per 100,000 total population. Within a sample, support required was found to vary widely in nature (from texture modification or environmental adaptation to enteral feeding) and in overall level (from minimal to full support, dependent on functional skills). Needs had increased over time in almost half (n = 34, 49.3%). Reasons for support included difficulties getting food into the body (n = 56, 82.2%), risky eating and drinking behaviours (n = 31, 44.9%) and slow eating or food refusal (n = 30, 43.5%). These proportions translate into crude estimates of the prevalence of these difficulties within the known ID population of 11.9%, 6.6% and 6.4% respectively. Within the sample of those requiring mealtime support, need for support was reported to be contributed to by the presence of additional disability or illness (e.g. visual impairment, poor dentition and dementia; n = 45, 65.2%) and by psychological or behavioural issues (e.g. challenging behaviour, emotional disturbance; n = 36, 52.2%).

CONCLUSIONS

These findings not only highlight the need for a multidisciplinary approach to mealtime interventions (paying particular attention to psychological and environmental as well as physical issues), but also signal the daily difficulties faced by carers and paid support workers providing such support and illustrate their potentially crucial role in managing the serious health risks associated with eating and drinking difficulties in this population.

Cognitions and emotions in eating disorders

The cognitive model of eating disorders (EDs) states that the processing of external and internal stimuli might be biased in mental disorders. These biases, or cognitive errors, systematically distort the individual's experiences and, in that way, maintains the eating disorder. This chapter presents an updated literature review of experimental studies investigating these cognitive biases. Results indicate that ED patients show biases in attention, interpretation, and memory when it comes to the processing of food-, weight-, and body shape-related cues. Some recent studies show that they also demonstrate errors in general cognitive abilities such as set shifting, central coherence, and decision making. A future challenge is whether cognitive biases and processes can be manipulated. Few preliminary studies suggest that an attention retraining and training in the cognitive modulation of food reward processing might be effective strategies to change body satisfaction, food cravings, and eating behavior.

Cognitive remediation therapy for eating disorders: development, refinement and future directions

In this chapter, we aim to address some basic conceptual and practical questions about cognitive remediation therapy (CRT) for eating disorders. We begin by providing an overall historical, conceptual, and theoretical framework for CRT. Next, we discuss the specific indications for how and why CRT might be useful for eating disorders based on existing neuropsychological research evidence. We also provide an overview of the types of tasks and stimuli used in CRT and a general protocol for a manualized version of CRT. In addition, modifications of the adult CRT manual for use with adolescents as well as preliminary acceptability of the approach with this younger age group are described. We also propose various ways to integrate CRT in a variety of inpatient and outpatient programmes. Finally, a discussion of potential future directions in research using the tools of neurocognitive assessment, imaging and treatment research is provided.

Predictors of recovery of ovarian function after weight gain in subjects with amenorrhea related to restrictive eating disorders

OBJECTIVE

The aim of the present study was to investigate the anthropometric and endocrine characteristics of subjects with amenorrhea related to eating disorders after weight recovery, in order to identify factors connected with the resumption of menses.

METHODS

Clinical data, body composition parameters and serum levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), thyroid-stimulating hormone (TSH), free triiodothyronine, free thyroxine, cortisol, leptin and insulin were assessed in two groups of young women classified according to menstrual status after weight rehabilitation: 43 subjects who displayed persistent amenorrhea and 34 who resumed menses. Univariate and multivariate logistic regression analyses were used to examine the relationships between the different parameters and menstrual recovery.

RESULTS

The patients who resumed menses had low initial weight and BMI, and a greater difference between current and initial BMI (DeltaBMI), than those with amenorrhea. No differences were observed in lean mass, body fat or bone density between the two groups. Moreover, the reduction in FSH and the increase in LH, insulin and leptin emerged as significant predictors of menstrual recovery. Increased DeltaBMI and insulin continued to be positive predictors in the multivariate analysis.

CONCLUSION

Following weight rehabilitation, the individual's metabolic set point before weight loss and the current insulin levels appear significant in predicting the reactivation of reproductive function.

Assessing readiness for change in adolescents with eating disorders

The Readiness and Motivation Interview (RMI) is a semistructured interview measure of readiness and motivation to change that can be used for all eating disorder diagnoses. The RMI has demonstrated excellent psychometric properties and has both clinical and predictive utility in adult samples. This study examined the psychometric properties of the RMI in a younger population, namely, 12- to 18-year-old girls with eating disorders. Study participants (N = 65) completed the RMI and measures of convergent, discriminant, and criterion validity. Adolescents with eating disorders were able to conceptualize and articulate their readiness for change and to report the extent to which change efforts were for themselves versus for others. RMI readiness profiles across eating disorder symptom domains in adolescents were comparable to those in adults, with higher reported readiness to change binge eating than to change dietary restriction or compensatory strategies. Differences in internal consistency between adult and adolescent samples are discussed. Interviewing adolescents early in treatment about readiness may assist clinicians in forming an alliance with this difficult-to-engage population, while also providing valuable information for treatment planning.

The course of illness following inpatient treatment of adults with longstanding eating disorders: a 5-year follow-up

OBJECTIVE

The objectives of this article were to study the course and outcome of longstanding eating disorders (ED) 5 years after completing treatment and to identify subgroups of patients with different course and outcome.

METHOD

A total of 77 patients with a mean age of 30 years were assessed at the beginning and end of in-patient therapy and at 1-, 2- and 5-year follow-up, respectively.

RESULTS

Of the 90% who participated in the 5-year follow-up, 46 patients (61%) had improved, and 30 (39%) did not meet diagnostic criteria for an ED. Cluster analysis identified a group of patient with no improvement over time.

CONCLUSION

Overall, the course is favourable, but a subgroup of patients with no improvement over time may need intensified treatment efforts.

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.

Collaborative care between professionals and non-professionals in the management of eating disorders: a description of workshops focussed on interpersonal maintaining factors

The aim of this paper is to describe the content and processes involved in a series of workshops for carers of people with an eating disorder. These workshops were designed to equip carers with the skills and knowledge needed to be a 'coach' and help the person with an eating disorder break free from the traps that block recovery. The first hurdle is to overcome the unhelpful patterns of interpersonal processes between the person with an eating disorder and their carers. In both naturalistic studies and randomised controlled trials (RCT), family factors have been implicated either as moderators or mediators of outcome. High levels of expressed emotion (EE), misattributions about the illness or unhelpful methods of engaging with the eating disorder symptoms contribute to this effect. These workshops aim to reduce EE such as over protection. Carers are introduced to the transtheoretical model of change and the principles of motivational interviewing so that they can help rather than hinder change. They learn how to use reflective listening to reduce confrontation and how to sidestep resistance. Carers learn what is needed to help their daughter change by reflecting on the processes involved in changing their own behaviours in relationship with the person with eating disorders. Once they recognise that they may need to change then they can use their skills, information and insight to help change eating disorder symptoms.

Remapping the body: learning to eat again after surgery for esophageal cancer

Surgery for esophageal cancer offers the hope of cure but might impair quality of life. The operation removes tumors obstructing the esophagus but frequently leaves patients with eating difficulties, leading to weight loss. Maintaining or increasing body weight is important to many patients, both as a means of returning to "normal" and as a means of rejecting the identity of the terminal cancer patient, but surgery radically alters embodied sensations of hunger, satiety, swallowing, taste, and smell, rendering the previously taken-for-granted experience of eating unfamiliar and alien. Successful recovery depends on patients' learning how to eat again. This entails familiarization with physiological changes but also coming to terms with the social consequences of spoiled identity. The authors report findings from in-depth interviews with 11 esophageal cancer patients, documenting their experiences as they struggle to achieve a process of adaptation that is at once physiological, psychological, and social.

Disordered Eating: Young Women's Search for Control and Connection

PROBLEM

Approximately 5% of American women suffer from eating disorders and scores more exhibit signs of disordered eating. The purpose of this study was to gain an understanding of disordered eating in adolescence.

METHODS

Grounded theory method was employed. In-depth interviews were conducted with 15 college women to explore their experiences with disordered eating.

FINDINGS

Choosing disordered eating behaviors as a method of control occurred when the young women lacked connected and close relationships with others. Conversely, when meaningful relationships were present in their lives, the dysfunction abated.

CONCLUSIONS

Psychosocial and dietary assessments are necessary to identify youngsters without connected relationships and/or predispositions to disordered eating.

Developing a parenting skills-and-support intervention for mothers with eating disorders and pre-school children part 1: qualitative investigation of issues to include

OBJECTIVE

This study aimed to (i) identify themes and issues that might usefully be addressed in a skills-and-support intervention for mothers with eating disorders who have children less than 5 years of age, and (ii) determine the most appropriate format for such an intervention.

METHOD

Focus groups and individual interviews were conducted with seven mothers with eating disorders and pre-school children, and four local health professionals working with mothers of pre-school children.

RESULTS

Thematic analysis of interview transcripts revealed 10 themes: 'Passing on Traits', 'Food Preparation and Provision', 'Interactions Around Food and Mealtimes', 'Mother's Intake', 'Self Care', 'Self Identity and Parental Expectations', 'Impact on General Parent-Child Relationship', 'Need for Control', 'The Group Experience' and 'Practicalities and Format'.

DISCUSSION

Findings highlight a number of difficulties and concerns experienced by mothers with eating disorders who have pre-school age children. An intervention incorporating the identified themes could provide important support to this patient group and potential benefit to their offspring.

Psychometric testing of the McGill Ingestive Skills Assessment

The goal of this study was to determine the psychometric properties of the McGill Ingestive Skills Assessment. Interrater and intrarater reliability and score stability were tested using repeated administration of this test. The Functional Independence Measure and Modified Mini-Mental State Examination, as well as patient characteristics, were used to determine the validity of the assessment. One hundred and two persons with ingestive skill loss of neurologic origin were evaluated. Intraclass correlations for interrater, intrarater reliability and stability reached or surpassed 0.80 for most subscales. In validity testing, significant relationships were found between McGill Ingestive scores and Functional Independence Measure and Mini-Mental scores, as well as with patient characteristics. It is concluded that the McGill Ingestive Skills Assessment approaches or meets levels of reliability necessary for assessing patients and is valid for adults with neurogenic feeding difficulties residing in tertiary care facilities.

Is an integral nutritional approach to eating disorders feasible in primary care?

Patients with eating disorders (ED) show alterations in both their behaviour and their intake of food, frequently presenting nutritional and somatic affectations. Besides the classical forms such as anorexia or bulimia nervosa, there has recently been an increase in atypical or incomplete forms of ED, such as binge eating. Primary care (PC) services form the central and closest nucleus of health care for the individual and the family, where ED occur and leave their mark. This allows PC to provide an integral response at all levels of care for ED. Primary prevention at school, in the family and community is fundamental to avoiding its inception. Secondary prevention is based on early diagnosis and treatment of ED and favours a better prognosis of the illness. Tertiary prevention tries to reduce the serious consequences with rehabilitation measures to alleviate complications and avoid risk to life. Due to its complexity, these patients are afforded the attention of multidisciplinary teams of specialists with experience in treating this condition. In consultation with the team, the general practitioner should adopt a leading role at all levels of attention, as he/she is the link between the team, the family and the patient. This requires both regulated, specific training in the disease and the allocation of resources to carry it through. Putting into practice all these plans would allow us to give a positive answer to the question posed in the title of the present article.

Ethical debating: therapy for adolescents with eating disorders

Groups are a common component of treatment programs for adolescents with eating disorders (EDs). This article discusses a weekly group run by nursing and psychology members of a multidisciplinary EDs team. The theme of this group was ethical debating, and it was designed for adolescent patients aged between 14 and 18 years. These ED patients were provided with basic information about five ethical principles, and they debated weekly ethical scenarios. Debate content and process, as well as its therapeutic benefits, will be discussed in this article.

Normalization of bone density in a previously amenorrheic runner with osteoporosis

PURPOSE

To examine changes in bone mineral density (BMD) and bone mineral content (BMC) in relation to pharmacological and nutritional interventions in a distance runner diagnosed with the female athlete triad of disordered eating, amenorrhea, and osteoporosis.

METHODS

BMD of the lumbar spine (L2-L4) and total proximal femur were measured from ages 22.9 to 30.8 yr using dual x-ray absorptiometry (DXA).

RESULTS

At age 22.9, the patient presented with primary amenorrhea, low body weight (BMI: 15.8 kg.m(-2)), and low BMD in the spine (74% of normal, T score: -2.50) and hip (80% of normal, T score: -1.54). For the next 2 yr, the patient took oral contraceptives to induce menses, but continued to maintain a low weight. Her BMD remained unchanged. At age 25.1 yr, she decided to gain weight and improve her nutrition, resulting in small increases in spinal BMD (+1.1%), hip BMD (+1.6%), and total body BMC (+7.6%) in 4 months. From ages 25.4 to 30.8 yr, the patient continued to gain weight, eventually reaching a healthy BMI of 21.3 kg.m(-2); correspondingly, since baseline, her BMD had increased 25.5% in the spine and 19.5% in the hip, bringing her BMD to within normal values (spine: 94% of normal, hip: 96% of normal).

CONCLUSION

This case illustrates that even if skeletal development is interrupted in adolescence, there is still the potential for "catch-up" in BMD well into the third decade of life. Reversal of large bone density deficits in this patient can be attributed to improved nutrition and weight gain but not to hormone replacement.

Quality of life: eating disorders

OBJECTIVE

There is a lack of measurements with predictive validity that are specific for quality of life (QOL) in patients with eating disorders.

METHOD

A total of 306 eating disorder patients treated as inpatients completed the Quality of Life for Eating Disorders (QOL ED): 109 at both admission and discharge from hospital, 65 at both admission and after 12 months. Patients also completed well-validated measures of eating disorders, psychological dysfunction and general physical and mental QOL. QOL ED consists of 20 self-report questions that provide scores for the domains of behaviour, eating disorder feelings, psychological feelings, effects on daily life, effects on acute medical status and body weight, and a global score.

RESULTS

QOL ED domain scores correlated appropriately with previously validated well-known measures of eating disorders, psychological dysfunction, general QOL and behaviour and body weight (p < 0.001). The QOL ED shows high reliability (Cronbach's alpha = 0.93). All scores changed significantly and appropriately during inpatient hospital treatment and between admission and 12 months after discharge from hospital (p < 0.001). The scores differed for anorexia nervosa, bulimia, eating disorder not specified (EDNOS) and no diagnosis. All no diagnosis (recovered) domain and global scores were significantly different from all diagnoses scores (p < 0.001).

CONCLUSION

This quick, simple instrument fulfils all potential uses for QOL assessments in the clinical and research settings associated with eating disorders, including outcome.

Disordered eating behaviors in youth with type 1 diabetes

Eating disorders are a significant health problem for many adolescents and are described as occurring along a spectrum of symptoms including disordered eating behaviors and clinical eating disorders. Poor self-esteem and body image, intense fear of gaining weight or refusal to maintain weight, and purging unwanted calories are clinical features of some eating disorders. Type 1 diabetes is a chronic illness with marked insulin deficiency. Chronic hyperglycemia creates a state of glucosuria with subsequent weight loss. Diabetes treatment focuses on intensive daily management of blood glucose by balancing insulin, food intake, and physical activity. Insulin omission offers an easy method for the purging of unwanted calories. The combination of these 2 illnesses is potentially deadly and also leads to an increased risk of poor diabetes outcomes. This includes poor metabolic control (measured by elevated hemoglobin A1C), increased risk of diabetic ketoacidosis, and microvascular complications such as retinopathy and nephropathy. Diabetes clinicians should be aware of the potential warning signs in an adolescent with diabetes as well as assessment and treatment options for eating disorders with concomitant type 1 diabetes. This article reviews the available data on the prevalence, screening tools, assessment guidelines, and treatment options for eating disorders in youth with type 1 diabetes.

Management and treatment of eating disorders in an Italian region

OBJECTIVE

Eating disorders (ED) are an outstanding health problem in western countries, and bear significant mortality, e.g. anorexia nervosa (AN), and morbidity. The Liguria Region Health Department set up a study with the support of a number of specialists to investigate the number and characteristics of patients referred to institutions, how patients were managed, and the healthcare facilities and personnel involved.

METHODS

The retrospective study required that all regional institutions, except two, involved in the treatment of ED during the year 2001 filled out a special questionnaire.

RESULTS

Twenty-one institutions (n=19 public, n=2 private) followed 1,220 patients with ED in the mentioned year. The prevalence of such disorders was 6 fold higher in females (1,054 F, 166 M; age range 12-32 years). Bulimia nervosa (BN) proved to be the disorder category most frequently observed (prevalence 59%) followed by AN (26%, p<0.0001) and ED not otherwise specified (EDNOS) (15%, p<0.0001). Most (approximately 90%) of these patients were managed in outpatient settings, and a multidisciplinary team approach was used in fewer than 20% of cases. Hospitalization (complete or partial) was required in 10.5% of patients: 7.1% for mental disturbances and 3.4% for severe malnutrition/electrolyte abnormalities. Fewer than one fourth of patients was admitted to two specialty units (one public and one private) for inpatients in our region with ED. Treatment provided in these centers included a specific nutritional rehabilitation program and psychologic/psychiatric care. Patients more severely underweight underwent nasogastric or parenteral feeding whenever deemed clinically appropriate. The grade of knowledge of ED by general practitioners/pediatricians and their links with trained centers were poor.

CONCLUSIONS

Although our data were obtained from a selected population, thus preventing epidemiological conclusions, they show that ED are a significant health concern in our region, with BN representing the most common disorder diagnosed in the different settings (general or specialized medical practices). Overall, the prevalence of such disorders was assessed as six fold higher in females than in males. The emerging issues to be improved are: i) poor level of communication among different specialists and subsequent scanty use of a multidisciplinary team approach in the management of ED ii) insufficient use of guidelines for the management of such disorders iii) paucity of specialty institutions for inpatients with ED iv) inadequate knowledge of the problem by primary care physicians and the community, and poor links with the healthcare institutions that might help.

Trastornos de la conducta alimentaria como factor de riesgo para osteoporosis

Eating disorders (TCA per its abbreviation in Spanish) are common in young women, with an estimated prevalence of 4-5%. One of the physical complications of eating disorders, especially anorexia nervosa (AN) and eating disorder not otherwise specified (TANE) is bone mass loss, which affects both cortical and trabecular bone. The synergistic effect of malnutrition and estrogen deficiency produces significant bone mass loss, resulting from the uncoupling of bone turnover characterized by a decrease in osteoblastic bone formation and an increase in osteclastic bone resorption. The mechanisms implied in the pathogenesis of bone loss are the hypoestrogenism, hypercortisolism, serum leptin levels and insulin-like growth factor decrease. Severity of bone loss in anorexia nervosa varies depending on duration of illness, the minimal weight ever and sedentarism or strenuous exercise. Long term consequences occur, such as a fracture risk increase in patients who have suffered anorexia nervosa, compared with the general population. The first treatment line to recover bone mass is nutritional rehabilitation together with weight gain. Hormonal replacement therapy may be effective if combined with an anabolic method. Osteopenia and osteoporosis are terms adopted to define the deficiency of bone mass in adults. Authors have used these terms to define densitometric data in young subjects who have not reached their peak bone mass. We suggest the term "hypo-osteogenesia" to define the deficiency in the development of bone mass in adolescents or children.

Personality subtypes in eating disorders: validation of a classification in a naturalistic sample

BACKGROUND

Research has identified three personality subtypes in patients with eating disorders: emotionally dysregulated, constricted and high-functioning/perfectionistic.

AIMS

To see whether the subtypes are distinguished in ways indicative of valid classification, notably in patterns of adaptive functioning, comorbidity, treatment response and therapeutic interventions.

METHOD

A random sample of experienced clinicians provided data on 145 patients with bulimic symptoms, including data on eating disorder symptoms, DSM-IV comorbidity, personality pathology, treatment response and treatment interventions.

RESULTS

Patients categorised as dysregulated had the poorest functioning, most comorbidity and worst outcome, followed by patients in the constricted and high-functioning groups. The three subtypes elicited different therapeutic interventions and accounted for substantial incremental variance in outcome, holding constant the severity of eating disorder symptoms and presence of other Axis I disorders.

CONCLUSIONS

The data provide accumulating evidence for the validity of three personality subtypes in patients with eating disorders.

Motivation to change in eating disorder patients: a conceptual clarification on the basis of self-determination theory

OBJECTIVE

The current study critically reviews the different motivational frameworks that are applied in the study of eating disorders and provides a more comprehensive conceptualization of motivation to change on the basis of self-determination theory.

METHOD

The most important conceptualizations of motivation to change among eating disorder patients are identified.

RESULTS

Eating disorder patients' motivation to change has been defined very differently, adding confusion to the field and preventing research from being cumulative. On the basis of self-determination theory we argue (a) that the quality of motivation to change is primarily reflected in the degree of internalization of change rather than by the intrinsic motivation to change; (b) that the internalization of change suggests more than only the change being initiated from within the person (internal motivation) for it requires an acceptance of the personal importance of change; and (c) that, in addition to its quality, the quantity of motivation to change should be considered too.

DISCUSSION

These three conceptual issues are applied to the study of motivational dynamics in eating-disordered patients.

Motivation zur psychosomatisch-psychotherapeutischen Bearbeitung von beruflichen Belastungen - Entwicklung und Validierung eines Fragebogens

BACKGROUND

There is a lack of questionnaires assessing the motivation of inpatients to scrutinize occupational stresses and deal with them as part of their psychotherapeutic treatment. Work-related stress contributes significantly to the development of mental disorders. Vocational reintegration is an outcome criterion for the success of vocational rehabilitation. Patients are often not motivated for dealing with occupational stresses during inpatient medical rehabilitation. Therefore it is necessary to assess patient motivation at the beginning of treatment, in order to assign them to specific interventions, e. g. promoting motivation.

METHOD

A questionnaire (Fragebogen zur berufsbezogenen Therapiemotivation -- FBTM) consisting of 84 items was developed, based on published questionnaires for psychotherapy motivation. 283 psychosomatic rehabilitation inpatients were administered the FBTM, subsequently analyzed by item and factor analyses. Based on a second sample (n = 282) confirmatory factor analyses and validation of the questionnaire were executed.

RESULTS

Item and factor analyses revealed a four factor structure. 24 items constituted the subscales that could be described as "intention to change", "wish for pension", "negative treatment expectations" and "active coping". Reliability (Cronbach's Alpha) was satisfactory with coefficients between 0.69 and 0.87, and only low correlations could be found between the four subscales. Correlations with other measures were most pronounced for the subscale "intention to change". Some significant but low correlations could be reported between the FBTM and a standardized questionnaire of psychotherapy motivation (FMP). Confirmatory factor analyses of a second sample (n = 282) confirmed the original four factors. First evidence of sensitivity could be observed in a sample of patients who took part in an intervention promoting work-related therapy motivation during psychosomatic inpatient rehabilitation.

CONCLUSIONS

The FBTM is a reliable and valid instrument assessing work-related therapy motivation of inpatients, as a relevant therapeutic measure in psychosomatic rehabilitation. Further validation, especially the analysis of predictive validity is desirable.

Struggling with recovery: participant perspectives on battling an eating disorder

Recovery from an eating disorder encompasses a complex matrix of mental, physical, and social factors. Although methodological differences affect rates of reported recovery (from 24 to 76%), many women are not experiencing full recoveries from eating disorders. This trend is apparent in persons who discontinue severely destructive behaviors but continue to exhibit psychiatric problems and impairment in social and occupational roles. The purpose of this grounded theory study was to provide an explanatory schema about recovery. Data collection included 17 interviews, a focus group, and participant observation. Findings included repeating wavelike patterns of disease and recovery that seldom returned to a state of normal eating but, instead, remained at a level of atypical eating.

Reliability of the Body Awareness Scale-Health

In physical therapy the clinical assessment Body Awareness Scale-Health (BAS-H) focusing on the quality of movements and movement behaviour has previously been studied for validity. The aim of this study was to address the inter-rater reliability and test-retest reliability in three groups. The groups assessed were: patients in psychiatric care with eating disorders (n = 26), patients in rehabilitation of prolonged musculoskeletal pain (n = 22) and healthy individuals (n = 22). Results revealed inter-rater reliability (n = 70) of the BAS-H total to be 79.9 % with acceptable agreement (accepting one scale-step of difference) and 48.7% with perfect agreement. Weighted Kappa ranged between 0.34 and 0.92. Test-retest reliability (n = 54) as a mean for both raters were found to be 90.5% for the BAS-H total with acceptable agreement and 60.4% with perfect agreement. Weighted Kappa ranged between 0.65 and 0.92. The BAS-H seems to be a reliable assessment in the rehabilitation of patient with prolonged pain, psychiatric disorders and healthy controls when used according to the manual. The authors, however, suggest some revisions.

Chewing and spitting in eating disorders and its relationship to binge eating

OBJECTIVE

This study examined (i) the frequency of chewing and spitting and (ii) its association with other pathological eating behaviors in eating-disordered inpatients. We hypothesized a positive association between chewing and spitting and binge eating given the phenomenological similarities between these disordered eating behaviors.

METHOD

Frequent chewers/spitters were compared with those who did not regularly engage in this behavior with regard to diagnosis, psychometric test results, and associated eating pathology.

RESULTS

Chewing and spitting was not associated with elevated bingeing. Rather, frequent chewers/spitters exhibited higher levels of restrictive eating behaviors and the behavior was more prevalent in younger patients.

DISCUSSION

Contrary to our predictions, chewing and spitting is more closely associated with restrictive than with binge behaviors. This suggests that most individuals chew and spit small portions of food. The behavior is frequent, occurs across diagnostic groups, and may be associated with greater psychopathology. Future studies should clarify the amount of food consumed during chew/spit episodes and the presence of a sense of loss of control.

Short-term follow-up of adults with long standing anorexia nervosa or non-specified eating disorder after inpatient treatment

OBJECTIVE

There are few follow-up studies on outcome for patients with long standing anorexia nervosa (AN) or non-specified eating disorder with several comorbid psychiatric disorders. Inpatient treatment is one option for these patients. The aim of this prospective study was to report one-year follow-up for a consecutive sample of these patients after an inpatient treatment program.

METHOD

All 24 patients with a mean age of 28 years and mean duration of an eating disorder of 11 years were treated in a 23-week inpatient group treatment program for AN. Patients were assessed using Eating Disorder Examination interview (EDE), Eating Disorder Inventory (EDI) and Symptom Check List (SCL-90-R) at pre-treatment, post-treatment and at one year after start of treatment. At the follow-up 24 patients were personally interviewed. On admission 12 (50%) had AN, 8 (33%) non-specified eating disorder (EDNOS) and 4 (17%) bulimia nervosa (BN). All had previously suffered from AN and were clinically evaluated to have mostly anorectic psychopathology.

RESULTS

Ten (42%) patients had improved at follow-up and 14 (58%) had a poor outcome. There was a moderate but significant improvement on the EDE, EDI and GSI from pre-treatment to follow-up. The improvement occurred during inpatient treatment, and no significant differences from post-treatment to follow-up were found. Patients with low weight on admission showed a significant mean weight increase of about 4 kg at the follow-up.

CONCLUSIONS

At one-year follow-up there was a moderate reduction of eating disorder symptoms and general psychiatric symptoms for patients with long standing anorexic symptoms. The improvement occurred during inpatient treatment. Inpatient treatment may be a treatment option in long-time rehabilitation for some of these patients.

[Different explanatory models for addictive behavior in Turkish and German youths in Germany: significance for prevention and treatment]

Due to cultural and social barriers, immigrants seldom frequent centers for information, counseling, and treatment of addictive disorders. We examine cultural differences in the explanatory models of addictive behavior among Turkish and German youths in Germany with statistical devices that map the concepts associated with problems of addiction. Relevant differences were found between the disorder concepts of Turkish and German youth. German but not Turkish youths classified eating disorders among severe addictive disorders and associated them with embarrassment and shame. Concerning substance abuse, German but not Turkish youths clearly differentiated between illegal drug abuse and the abuse of alcohol and nicotine. Nearly half of all Turkish youths rejected central medical concepts such as "physical dependence" or "reduced control of substance intake" as completely inadequate to characterize problems of addictive behavior. Preventive information programs must consider these differences and use concepts that are accepted and clearly associated with addictive behavior by immigrant populations.

Weight and eating concerns in outpatient men and women being treated for substance abuse

This study examined the specific features of weight and eating concerns, and explored gender differences, in a racially diverse group of outpatients (45 men and 39 women) currently being treated for substance abuse but abstinent from substance use. Overweight was prevalent and similarly distributed across gender: 60% of the men and 69% of the women were overweight. Most of the overweight participants did not identify themselves as such. No significant gender differences were observed in terms of the behavioural features of eating disorders: 8% of the men and 11% of the women reported binge eating on at least one day per week; inappropriate weight compensatory behaviours were reported by 8% of the men vs 16% of the women, but the women had significantly higher attitudinal scores than the men. Our findings suggest that, in patients recovering from substance abuse, overweight and features of eating disorders are common in both men and women, and occur in poor and minority groups.

Remission, recovery, relapse, and recurrence in eating disorders: conceptualization and illustration of a validation strategy

In a consensus-building process a group of experts from 19 European countries (COST Action B6) adapted the terms partial and full remission, relapse, recovery, and recurrence according to principles described by Frank et al. for depression. The empirical validity of the operationalizations was illustrated by longitudinal data on the post treatment course of 233 anorectic and 422 bulimic patients (diagnosed according to DSM-IIIR) from the German Project TR-EAT. These data were collected 2.5 years after admission using the Longitudinal Interval Follow-up Evaluation (LIFE) and statistically explored by survival-analysis. It was demonstrated that these consensus definitions measure what they intend to measure. They open a longitudinal perspective in that one can learn not only whether, but also when and with what probability patients change for the better or worse. Data suggest that persistence of symptom improvement has different implications for anorexia and bulimia nervosa. For example, relapse prevention would be most beneficial for bulimic patients for about 4 months after key symptoms remit, while this would be of less importance for anorexic patients. It is discussed whether and how this longitudinal approach can contribute to an empirically based rationale for targeted and individualized treatment.

Practitioner review: The effectiveness of systemic family therapy for children and adolescents

BACKGROUND

Systemic family therapy has become a widely used intervention in child and adolescent mental health services over the last twenty years.

METHODS

This paper reviews the development of systemic family therapy, briefly describes the theory and techniques associated with the most prominent contemporary strands of systemic practice, and examines the empirical justification for using systemic family therapies with children and adolescents.

RESULTS

There is a paucity of well-designed randomised controlled trials of systemic therapies with children and adolescents and those trials that do exist evaluate older structural and strategic therapies. Methodological limitations of existing research include the use of unrepresentative participants, small sample sizes and wide age ranges. There is a lack of credible no-treatment or alternative treatment controls, tests of clinical as opposed to statistical significance, and conceptually relevant outcome measures that examine underlying interactional mechanisms. The term 'family therapy' encompasses a wide range of interventions and it is not always clear what treatment intervention has been delivered. Nevertheless, there is good evidence for the effectiveness of systemic family therapies in the treatment of conduct disorders, substance misuse and eating disorders, and some support for their use as second-line treatments in depression and chronic illness.

CONCLUSIONS

Systemic family therapy is an effective intervention for children and adolescents but further well-designed outcome studies are needed using clearly specified, manualised forms of treatment and conceptually relevant outcome measures.

[Therapeutic programmes focusing on job related problems - which psychosomatic patients should participate?]

The necessity to offer special therapeutic programmes focusing on job related problems in psychosomatic rehabilitation has become increasingly evident. Which patients should participate in such programmes? This question has not yet been discussed with regard to its theoretical and methodological implications. In clinical practice the decision has been based on the therapists evaluation. 105 patients, consecutively admitted in a psychosomatic hospital were interviewed with a screening questionnaire about their job related strains and the perceived interaction between symptomatology and job. According to the literature guidelines for inclusion of psychosomatic patients to a special work hardening programme were used. Therapists were asked to independently assign their patients to the programme. The overlap between the two procedures was small. While the guidelines focussed on a high level of job strain and the patient's motivation for a job-related therapeutic approach, the therapists' decision was based on duration of inability to work, impairments at work due to the symptoms, conflicts with colleagues at work and the patient's ability to perceive problems in a differentiated manner. Considering the problem of inclusion-criteria for a work hardening programme, the highly complex constellations behind routine therapeutic decisions in psychosomatic rehabilitation became evident. To integrate medical diagnosis, symptomatology, psychological models, job strain, the patient's social situation and values, is a neglected but important goal of rehabilitation sciences and should be a base for a concept guiding the development, evaluation and establishment of work related therapeutic programmes.

Outcome of severe anorexia nervosa patients receiving inpatient treatment in Japan: an 8-year follow-up study

Sixty-one subjects with anorexia nervosa (AN) were followed for a minimum of 4 years after discharge (mean 8.3 years). They were evaluated using the Morgan-Russell Outcome Assessment Scale. Thirty-one (51%) were categorized as having good outcome, eight (13%) as intermediate, 15 (25%) as poor, and seven (11%) had died. As predictors of outcome, later onset (after 20 years of age) and low minimum body mass index were associated with poor prognosis. The outcome of AN in Japan is relatively similar to those in Western countries, irrespective of different sociocultural backgrounds and health systems.

Assessing readiness for change in the eating disorders: the psychometric properties of the readiness and motivation interview

This study examined the psychometric properties of the Readiness and Motivation Interview (RMI), a symptom-specific measure of readiness and motivation for change in the eating disorders. For 4 symptom domains, the RMI assesses the extent to which individuals are in precontemplation, contemplation, and action/maintenance, and the extent to which change is made for internal versus external reasons. Ninety-nine individuals with eating disorders completed the RMI and measures to assess convergent, divergent, and criterion validity. RMI profiles revealed differences in readiness and motivation across symptom domains. The RMI demonstrated good reliability and construct validity, and RMI scores predicted anticipated difficulty of recovery activities, completion of recovery activities, decision to enroll in an intensive symptom-reduction program, and treatment dropout. The RMI may have important clinical applications by providing much-needed information on client readiness for action-oriented treatment.

[Clinical mentorship as a bridge to life in the treatment of eating disorders]

The aim of this article is to describe a community-based multi-modality intensive treatment program, which demonstrates a significant reduction in symptoms of eating disorders while providing an opportunity to deal with the functional and social skills. Treatment is delivered through a multidisciplinary team. The uniqueness of the team is in the inclusion of clinical mentors. These are social workers, art therapists and graduate level psychology students who are trained to connect with clients in an informal, intensive manner (10-40 hours a week). The mentors focus on legitimizing healthy attitudes to food, eating and life, while highlighting the pain and loss associated with the disorder. The mentors serve as meal companion and calming figure, representing the healthy self-caring voice. The relationship established during the many hours spent together becomes a powerful experience, completely different from the isolation of the disorder. The treatment intervenes in most areas of life, focusing on an active search for possibilities, in contrast to the emptiness associated with the disorder. This article presents the results and principles of a 2.5-year practice. Seventeen patients, ill for 6 years and more, completed this program more than a year ago. An assessment of their BMI and their general outcome using Eckert scales was performed. One year after completing the program, 76% of the patients were defined as recovered and 12% were almost recovered with only a few remaining symptoms. All of these patients function satisfactorily in the community, both in social and occupational aspects. Six percent were partially recovered and 6% suffered from regression during the first year of follow-up. This treatment provides the intensity required in hospitalizations, while enabling patients to stay in the community and maintain those activities that survive the disorder. This program has proven to work well with chronic patients. Further data, not analyzed as yet, also indicates the efficacy of this treatment in acute cases.

A decision aid for long-term tube feeding in cognitively impaired older persons

OBJECTIVE

To describe the development and evaluation of a decision aid for long-term tube feeding in cognitively impaired older people.

DESIGN

Before-and-after study.

SETTING

Acute care hospitals in Ottawa, Canada.

PARTICIPANTS

Substitute decision makers for 15 cognitively impaired inpatients 65 years and older being considered for placement of a percutaneous endoscopic gastrostomy tube.

MEASUREMENTS

Questionnaires were used to compare the substitute decision makers' knowledge, decisional conflict, and predisposition regarding feeding tube placement before and after exposure to the decision aid. The acceptability of the decision aid was also assessed.

RESULTS

Substitute decision makers significantly increased their knowledge (P = .004) and decreased their decisional conflict (P = .004) regarding long-term tube feeding after using the decision aid. The impact of the decision aid on predisposition toward the intervention was greatest for those who were unsure of their preferences at baseline. All substitute decision makers found the decision aid helpful and acceptable despite very difficult and emotional circumstances.

CONCLUSIONS

A decision aid improves the decision-making process for long-term tube feeding in cognitively impaired older patients by decreasing decisional conflict and by promoting decisions that are informed and consistent with personal values. There are particular challenges for developing and evaluating these tools in the context of end-of-life decisions.