On Orthorexia Nervosa: A Systematic Review of Reviews

INTRODUCTION

Orthorexia nervosa (ON), characterized by a pathological preoccupation with "extreme dietary purity," is increasingly observed as a mental health condition among young adults and the general population. However, its diagnosis is not formally recognized and has remained contentious.

OBJECTIVE

In this systematic review, we attempt to overview previous reviews on ON, focusing on the methodological and conceptual issues with ON. This would serve both as a summary and a way to highlight gaps in earlier research.

METHODS

This systematic review took reference from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines, and using combinations of the search terms ("orthorexia" OR "orthorexia nervosa" OR "ON") AND ("review" OR "systematic review" OR "meta-analysis"), a literature search was performed on EMBASE, Medline and PsycINFO databases from inception up to October 31, 2023. Articles were included if (1) they were written or translated into English and (2) contained information pertaining to the diagnostic stability or validity of ON, or instruments used to measure ON symptoms and behaviors. Only review articles with a systematic literature search approach were included.

RESULTS

A total of 22 reviews were qualitatively reviewed. Several studies have reported variable prevalence of ON and highlighted the lack of thoroughly evaluated measures of ON with clear psychometric properties, with no reliable estimates. ORTO-15 and its variations such as ORTO-11, ORTO-12 are popularly used, although their use is discouraged. Existing instruments lack specificity for pathology and several disagreements on the conceptualization and hence diagnostic criteria of ON exist.

DISCUSSION

Previous reviews have consistently highlighted the highly variable (and contradictory) prevalence rates with different instruments to measure ON, lack of stable factor structure and psychometrics across ON measures, paucity of data on ON in clinical samples, and a need for a modern re-conceptualization of ON. The diagnosis of ON is challenging as it likely spans a spectrum from "normal" to "abnormal," and "functional" to "dysfunctional." "Non-pathological" orthorexia is not related to psychopathological constructs in the same way that ON is.

Females with Eating Disorders and Urinary Incontinence: A Psychoanalytic Perspective

Eating disorders (EDs) are complicated mental illnesses with significant treatment resistance and dropout rates. For successful treatment, it is important for clinicians to better understand the patients’ narrative and their lived experiences. A thorough psychodynamic understanding of patients’ childhood attachment and primary relationships, personality traits and mental processes is, therefore, crucial for managing patients with ED. Interestingly, several studies have observed an association between functional urinary symptoms and individuals with ED. EDs such as anorexia nervosa are associated with an increased risk of all urinary symptoms, and functional incontinence was also more common in extreme female athletes with low energy availability and with disordered eating. There is, however, a dearth of literature describing this relationship, and the underlying mechanisms remain remote. In this paper, we present a psychoanalytic approach to the presence of urinary symptoms in females with EDs. We hypothesize that these symptoms are tied to specific traits or characteristics of ED patients, namely the overarching need for control, a pathological strive for perfection and the self-denial of basic bodily urges. This is discussed in relation to psychopathological processes, development and personality factors commonly seen in patients with ED.

Making Sense of Kleptomania: Clinical Considerations

An understanding of the historical roots, clinical features and current diagnostic criteria of kleptomania would help in a better appreciation and assessment of this condition. One of the few psychiatric conditions that is defined by an illegal activity, kleptomania has been classified as one of the impulse control disorders under ICD-10 and DSM IV-TR. In terms of assessment, it is not sufficient merely to look at the operational criteria. One should take a complete history and probe for predisposing factors including childhood development and behaviour, previous relationships, losses, and habits. It is also necessary to detect current stressors and concomitant symptoms or disorders that may precipitate and perpetuate the condition. Some of the diagnostic criteria are based on subjective claim or report which may be unreliable. The use or value of the articles stolen is relative but may be easier to assess. As a guide, kleptomania should be a diagnosis by exclusion of other contributing disorders. When other contributing symptoms/disorders such as depression are present, care should be exercised before a diagnosis of kleptomania is made.

Depression in the planet's largest ethnic group: the Chinese

OBJECTIVE

The authors reviewed the evidence for the claim that the Chinese tend to deny depression or express it somatically, examined the possible determinants of those characteristics, and explored implications of the findings for the diagnosis and management of depression in China and for psychiatry in the WEST:

METHOD

This paper reviews and interprets original studies and literature reviews considering emotional distress, depression, neurasthenia, and somatization in Chinese subjects.

RESULTS

Interpretation of the literature is complicated by the considerable heterogeneity among people described as "the Chinese" and by numerous factors affecting collection of data, including issues of illness definition, sampling, and case finding; differences in help-seeking behavior; idiomatic expression of emotional distress; and the stigma of mental illness. Despite difficulties in interpreting the literature, the available data suggest that the Chinese do tend to deny depression or express it somatically.

CONCLUSIONS

The existing evidence supports the hypothesis that the Chinese tend to deny depression or express it somatically. However, Western influences on Chinese society and on the detection and identification of depression are likely to have modified the expression of depressive illness quite sharply since the early 1980s. Analyzing these changes may provide useful insight into the evolution of the diagnosis of depression in Western and other cultures.

Clinical evaluation of risperidone in Asian patients with schizophrenia in Singapore

OBJECTIVE

To evaluate the short-term efficacy and safety of risperidone in a group of Asian patients with schizophrenia in an 8-week open-label, prospective study.

METHODS

Patients with DSM-IV schizophrenia were recruited from Woodbridge Hospital. After a washout period, they were started on a 56-day trial of risperidone. Outcome was assessed with the positive and negative syndrome scale (PANSS), the clinical global impression scale (CGI) and the extrapyramidal symptom rating scale (ESRS).

RESULTS

The mean daily risperidone dose at end point was 5.6 mg (range, 3 to 8 md/day). Mean PANSS scores were reduced significantly from 78 +/- 15.1 at baseline to 56.6 +/- 10.9 at end point. Seventeen patients (85%) who were treatment responders, showed at least a 20% reduction in total PANSS scores at end point while nine patients (45%) had a greater than 50% reduction in the total PANSS scores. According to the CGI scale, 85% improved at end point. The severity of extrapyramidal symptoms (mean ESRS scores) were significantly lower at end point than at baseline.

CONCLUSIONS

Risperidone was effective in the treatment of positive and negative symptoms of schizophrenia.

Management of panic disorder

Symptoms of panic attack can be found in both medical disease and mental disorder. At least 4 of 13 diagnostic symptoms need to be present to constitute an attack which onset is sudden and unpredictable. The duration of attack usually lasts minutes but sometimes longer. In panic disorder there is recurrent attacks of severe anxiety which are unprovoked and unexpected. Dominant symptoms vary from person to person. The syndrome is likely to be heterogeneous as the biological aetiology may be related to abnormalities in the function of a number of neurotransmitters ie serotonin, noradrenaline, gamabutyric acid, dopamine and cholecystokinin. As such different benzodiazepines and anti-depressants are efficacious in the treatment of the disorder. Medications should be titrated to prevent attacks and restore confidence. Maintenance therapy needs to be balanced with premature termination of treatment. Reassurance is important and there is a place for cognitive behavioural therapy, relaxation exercise and breathing control technique.

De Clerambault syndrome and medical practitioners: medico legal implications

De Clerambault's syndrome or erotomania is a condition in which a patient, usually a woman, develops a delusional belief that a man, usually older and of higher social status, is in love with her. This paper describes such cases where medical practitioners were involved. In a case where a doctor was brought to court, the judge stressed that because of the nature of the allegation, it was vital that there be corroborative evidence. When faced with such patients, a prudent doctor would ensure that a nurse be in attendance at all times, that notes be carefully kept and phone calls recorded. Other measures might be necessary, depending on the situation.

Oculogyric spasm in Asian psychiatric in-patients on maintenance medication

BACKGROUND

The objective was to investigate the occurrence and characteristics of oculogyric spasm (OGS) in an Asian country.

METHOD

All 2035 Asian (88% Chinese, 7% Malays and 5% Indonesians) psychiatric in-patients in the state psychiatric hospital in Singapore were surveyed for occurrence of oculogyric spasm (OGS) over a two-month period.

RESULTS

Thirty-four patients (1.7%) developed OGS (53% male and 47% female). All the 34 patients had been on maintenance antipsychotic drugs for more than five months. Eighteen patients had recurrent attacks. The mean chlorpromazine equivalent daily dose for those patients with recurrent OGS was 511 mg. This was significantly higher (P < 0.05) than the 277 mg daily dose received by those without recurrent OGS. Most (68%) of the attacks occurred between 1400-2000 h suggesting that OGS may have a diurnal variation.

CONCLUSIONS

OGS presenting as tardive dystonia may be due to a relative increase in cholinergic activity.

A postmarketing surveillance study of zopiclone in insomnia

Zopiclone, a novel cyclopyrrolone compound has recently become available for the treatment of insomnia in Singapore. Pharmacodynamic and pharmacokinetic studies have shown it to be an effective hypnotic with a good safety profile and minimal side-effects. The efficacy of Zopiclone was studied in a group of patients with insomnia (n = 40). The study group comprised patients with and without a psychiatric diagnosis. About two-thirds (65%) of the patients had been on hypnotics previously without relief of the insomnia. There was improvement in the various sleep parameters studied: sleep latency, sleep duration, night awakening, sleep quality, dreams, "day-after" effects. The drug was well-tolerated and only four patients experienced minor side-effects.

Medico-legal implications of electro-convulsive therapy--a Singapore viewpoint

The clinical characteristics of 100 consecutive cases of ECT in a state mental hospital were surveyed. The medico-legal implications with regards to indications for and consent to ECT were looked into. The findings showed that ECT was given mostly for management reasons rather than based on diagnosis. Only 2 patients out of 100 gave their own consent. The discrepancy between teaching and practice was discussed.

Depersonalization syndrome--a report of 9 cases

Depersonalization is defined and the clinical characteristics of 9 patients presenting with Depersonalization Syndrome are discussed. The cases comprise 5 males and 4 females with an age range of 15-47 years, of which two-thirds presented with an acute onset of symptoms. The diagnosis is made on the patients' own descriptions of their symptoms. Criteria laid out by Ackner and ICD-9 are closely adhered to. The findings of the study are compared with those of Shorvon's 66 cases and similarities are found. Depersonalization symptoms described by Mayer-Gross are reviewed. That depersonalization itself appears to have an affective aspect and a somatic aspect is noted, and an explanation for both aspects is attempted. The resistance to various treatment is confirmed.

Diminished responsibility--a psychiatric viewpoint

Diminished responsibility is based on the notion that mental disorder may make a person only partially accountable for his act in the killing of another person. For this plea to succeed it has to be shown that an accused has to be suffering from such an abnormality of mind that his responsibility for the action is substantially diminished. As these concepts of abnormality of mind and criminal responsibility do not fit easily into psychiatric classification of mental disorders, nine senior psychiatrists who regularly attend court as expert witnesses were surveyed and their viewpoints about mental abnormality and diminished responsibility were elected.

A cross-cultural study of the possession-trance in Singapore

Possession-trance is a common culture-bound syndrome in Singapore. The characteristic features as seen in 36 young men of the three different ethnic communities are described. At follow-up four to five years later, none of the 26 who could be contacted showed any evidence of mental illness. The psychopathology of the possession-trance is discussed.

Interband transitions in aggregated copper films

The optical properties of aggregated copper films have been studied in the spectral range from 200 to 1000 nm. Although it is well known that these films exhibit an anomalous absorption in the visible region attributed by many authors to collective oscillations of electrons in the particles forming the films, not much interest has been shown in the study of interband transitions occurring in these aggregated films. The results of the present work indicate that interband transitions are also found in copper in aggregated form, and that their effects cannot be ignored in the analysis of the optical properties of island films.

Work performance of rehabilitated psychiatric patients--a comparative study

View Road Hospital (VRH) was commissioned on 1st August 1975 with the main objective of providing intensive rehabilitation and training for male long-stay mental patients from Woodbridge Hospital. The aim was to train and prepare them for work outside the hospital. This paper examines the work performance of the 38 patients who have been phased out to work since the commissioning. A matched group of 38 male patients undergoing similar rehabilitative schemes in Woodbridge Hospital and placed in similar open employment was selected for comparison. Contrary to expectation, the VRH patients did not perform significantly better than the Woodbrige Hospital's patients. Some of the probable reasons for this discrepancy, and their implications for psychiatric rehabilitative services in general, are discussed.