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The use and misuse of the SCOFF screening measure over two decades: a systematic literature review. Eat Weight Disord 2024; 29:29. [PMID: 38652332 PMCID: PMC11039549 DOI: 10.1007/s40519-024-01656-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 04/02/2024] [Indexed: 04/25/2024] Open
Abstract
PURPOSE The SCOFF questionnaire was designed as a simple, memorable screening tool to raise suspicion that a person might have an eating disorder. It is over 20 years since the creation of the SCOFF, during which time it has been widely used. Considering this, we wish to review the use of the SCOFF in peer-reviewed scientific journals, and to assess whether it is being used appropriately in the manner in which it was originally devised and tested. METHODS The Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) guidelines were followed, and all search strategies and methods were determined before the onset of the study. PubMed and Wiley Online Library were searched using the terms SCOFF and eating. Two reviewers were involved in the reviewing process. Criteria for appropriate use of the SCOFF were formalised with the tool's original authors. RESULTS 180 articles were included in the final review. 48 articles had used the SCOFF appropriately, 117 articles inappropriately and 15 articles had been mixed in the appropriateness of their use. CONCLUSION This systematic review highlights the inappropriate use of the SCOFF in diverse languages and settings. When used correctly the SCOFF has made a significant contribution to the understanding of eating disorders and its simplicity has been applauded and led to widespread use. However in over two-thirds of studies, the use of the SCOFF was inappropriate and the paper highlights how and in what way it was misused, Guidelines for the appropriate use of the SCOFF are stated. Future validation and avenues of research are suggested. LEVEL OF EVIDENCE Level I.
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Factors predicting long-term weight maintenance in anorexia nervosa: a systematic review. Eat Weight Disord 2024; 29:24. [PMID: 38582784 PMCID: PMC10998787 DOI: 10.1007/s40519-024-01649-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 03/03/2024] [Indexed: 04/08/2024] Open
Abstract
PURPOSE Eating disorder recovery is a poorly defined concept, with large variations among researchers' definitions. Weight maintenance is a key aspect of recovery that remains relatively underexplored in the literature. Understanding the role of weight maintenance may help guide the development of treatments. This paper aims to address this by (1) investigating the factors predicting long-term weight maintenance in anorexia nervosa (AN) patients; (2) exploring differences in predictive factors between adolescent and adult populations; and (3) exploring how weight maintenance is conceptualised in the literature. METHODS We conducted a systematic review following PRISMA guidelines to address our research questions. Five databases were searched and filtered according to our exclusion criteria. RESULTS From the search, 1059 studies were yielded, and 13 studies were included for review. A range of weight, biological and psychological factors were found to predict weight maintenance among these papers. BMI at admission and discharge from inpatient treatment was the most common predictor among the papers. Few studies investigated biological factors and mixed evidence was found for psychological factors. We found no observable differences between adult and adolescent populations. Finally, weight maintenance was defined and measured differently across studies. CONCLUSION This review's findings can help contribute to a well-rounded understanding of weight maintenance, and ultimately, of recovery. This can help support clinicians in tailoring interventions to improve long-term outcomes in AN. Future research should aim to replicate studies to better understand the relationship between the factors identified and weight maintenance. LEVEL I Systematic review.
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Specific psychological therapies versus other therapies or no treatment for severe and enduring anorexia nervosa. Cochrane Database Syst Rev 2023; 8:CD011570. [PMID: 37610143 PMCID: PMC10445422 DOI: 10.1002/14651858.cd011570.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
BACKGROUND Anorexia nervosa is a psychological condition characterised by self-starvation and fear or wait gain or other body image disturbance. The first line of treatment is specific psychological therapy; however, there is no consensus on best practice for treating people who develop severe and enduring anorexia nervosa (SEAN). Notably, there is no universal definition of SEAN. OBJECTIVES To evaluate the benefits and harms of specific psychological therapies for severe and enduring anorexia nervosa compared with other specific therapies, non-specific therapies, no treatment/waiting list, antidepressant medication, dietary counselling alone, or treatment as usual. SEARCH METHODS We used standard, extensive Cochrane search methods. The last search date was 22 July 2022. SELECTION CRITERIA We included parallel randomised controlled trials (RCTs) of people (any age) with anorexia nervosa of at least three years' duration. Eligible experimental interventions were any specific psychological therapy for improved physical and psychological health in anorexia nervosa, conducted in any treatment setting with no restrictions in terms of number of sessions, modality, or duration of therapy. Eligible comparator interventions included any other specific psychological therapy for anorexia nervosa, non-specific psychological therapy for mental health disorders, no treatment or waiting list, antipsychotic treatment (with or without psychological therapy), antidepressant treatment (with or without psychological therapy), dietary counselling, and treatment as usual as defined by the individual trials. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Our primary outcomes were clinical improvement (weight restoration to within the normal weight range for participant sample) and treatment non-completion. Results were presented using the GRADE appraisal tool. MAIN RESULTS We found two eligible studies, but only one study provided usable data. This was a parallel-group RCT of 63 adults with SEAN who had an illness duration of at least seven years. The trial compared outpatient cognitive behaviour therapy for SEAN (CBT-SEAN) with specialist supportive clinical management for SEAN (SSCM-SE) over eight months. It is unclear if there is any difference between the effect of CBT-SEAN versus SSCM-SE on clinical improvement at 12 months (risk ratio (RR) 1.42, 95% confidence interval (CI) 0.66 to 3.05) or treatment non-completion (RR 1.72, 95% CI 0.45 to 6.59). There were no reported data on adverse effects. The trial was at high risk of performance and detection bias. We rated the GRADE level of evidence as very low-certainty for both primary outcomes, downgrading for imprecision and risk of bias concerns. AUTHORS' CONCLUSIONS This review reports evidence from one trial that evaluated CBT-SEAN versus SSCM-SE. There was very low-certainty evidence of little or no difference in clinical improvement and treatment non-completion between the two therapies. There is a need for larger high-quality trials to determine the benefits of specific psychological therapies for people with SEAN. These should take into account the duration of illness as well as participants' previous experience with evidence-based psychological therapy for anorexia nervosa.
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Developments in Pb-210 methodologies to provide chronologies for environmental change. ENVIRONMENTAL GEOCHEMISTRY AND HEALTH 2023; 45:1173-1181. [PMID: 35318556 PMCID: PMC10060312 DOI: 10.1007/s10653-022-01215-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 01/27/2022] [Indexed: 06/14/2023]
Abstract
Chronologies generated from core profiles to apply dates to environmental changes commonly use the measurement of the activity of radionuclides deposited and stratified with physical environmental material. The most commonly reported nuclide to define chronologies covering the last 150 years is Pb-210, for which accepted data processing methodologies in the literature have focussed on the constant rate of supply (CRS) model and the more recently published Bayesian Plum model. This short communication describes a validation approach using defined sediment layers referred to as 'varve' counting, which provide known points of reference to account for uncertainty between generated dates from each model using published Pb-210 measurements. A significant improvement in the chronologies was observed when applying reference date corrections to the models. This was shown to be essential in providing confidence in reported datasets and accuracy of predicted chronologies, which will better inform the interpretation of environmental change, e.g. sedimentation rates, climate change, pollution pathways and land degradation. Generated chronologies from both the CRS and Plum methods showed good agreement with the established varve dates (typically < 4-year difference).
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Correction to: Disturbed families or families disturbed: a reconsideration. Eat Weight Disord 2022; 27:401. [PMID: 33864198 PMCID: PMC9172650 DOI: 10.1007/s40519-021-01185-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Abstract
BACKGROUND The relationship between anorexia nervosa (AN) and family disturbance has been a subject of debate since its first description. What began as a clear view of the pathologically disturbed family causing AN has become ever more complex over the decades. OBJECTIVE The aim of this review is to explore the literature to examine the changes and evolution of clinical opinion around family dysfunction and AN over the last 20 years. METHODS A narrative review of heterogeneous studies in peer-reviewed publications sourced from the major databases, including PubMed and ScienceDirect, to illuminate the topic of family distress and AN by highlighting the conflicting and complementary ways it has been studied. RESULTS This review has highlighted the complexity of the relationship between anorectic sufferers and their families. It has explored the literature about parental burden, emotions and cognitive mechanisms together with parental attitudes about weight and shape. It is clear that there is no consistent psycho-social pathology in families which has been shown to be causative. However, over the last twenty years, research has highlighted the distress and family dysfunction caused by having to look after an anoretic child with poor mentalisation skills, insecure attachment and emotion dysregulation. CONCLUSION The area has become clearer over the last 20 years; research suggests a bi-directional relationship between AN and family dysfunction, with difficult dynamics becoming entrenched within the family. This is best addressed, the consensus suggests, by specialist family therapy and carer skills interventions. Longitudinal research is needed to definitively answer the question with rigorous scientific certainty. EMB RATING Level V. LEVEL OF EVIDENCE Level I: Evidence obtained from: at least one properly designed randomized controlled trials; systematic reviews and meta-analyses; experimental studies. Level II: Evidence obtained from well-designed controlled trials without randomization. Level III: Evidence obtained from well-designed cohort or case-control analytic studies. Level IV: Evidence obtained from with multiple time series analysis such as case studies. Dramatic results in uncontrolled trials might also be regarded as this type of evidence. Level V: Opinions of respected authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.
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Self-esteem as a catalyst for change in adolescent inpatients with anorexia nervosa: a pilot randomised controlled trial. Eat Weight Disord 2022; 27:189-198. [PMID: 33713335 PMCID: PMC8860801 DOI: 10.1007/s40519-021-01161-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 01/20/2021] [Indexed: 12/04/2022] Open
Abstract
PURPOSE To determine the potential effectiveness of a six-session manualised self-esteem group using CBT approaches when given as an adjuvant to adolescent inpatients with Anorexia Nervosa (AN). METHODS Using a randomised controlled design, 50 girls aged 12-17 years with AN were assigned to either self-esteem group with treatment as usual (TAU) (n = 25) or TAU alone (n = 25). 50/78 (64%) consented to be randomised. Both groups completed self-report measures of self-esteem and eating disorder psychopathology at three time points to measure the potential effectiveness of the treatment. Qualitative feedback was collected to assess acceptability. RESULTS 29 participants completed the study: 15 self-esteem group with TAU, 14 TAU alone. Self-esteem group participants had greater improvement in all outcomes than TAU participants at all time points, the difference in self-report self-esteem at T2 is 1.12 (95% CI - 1.44-3.69; effect size = 0.21). Similar small effect sizes were found for the eating disorder psychopathology measure following completion of the intervention but not at four-week follow-up. Favourable qualitative feedback was gained. CONCLUSION These findings demonstrate that the self-esteem group supplements an intensive treatment package which also addresses elements of low self-esteem. The self-esteem group was beneficial for addressing self-esteem and acted as a catalyst for change in eating disorder psychopathology. Positive qualitative feedback indicated the intervention was acceptable to users. Self-esteem group is a potential new adjuvant treatment for AN. EMB RATING Level 1.
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Abstract
The decision concerning who is fit to practise medicine is rightly considered a serious one and universities hand this responsibility to a small number of senior clinicians. However, it is on patients that the doctor will practise and while all patients have a concept of what makes a good doctor, their views are never canvassed in the Final MB.
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The treatment demand for bulimia: a catchment area report of referral rates and demography. PSYCHIATRIC BULLETIN 2018. [DOI: 10.1192/pb.16.4.203] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In the light of proposals to change the system of providing NHS health care, it is important for future district or regional procurers to have reliable data on which to base their treatment ‘contracts’, bearing in mind not only current but also the potential demand of a mature market.
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A meta-analysis of the relation between therapeutic alliance and treatment outcome in eating disorders. Int J Eat Disord 2017; 50:323-340. [PMID: 28152196 DOI: 10.1002/eat.22672] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 12/12/2016] [Accepted: 12/12/2016] [Indexed: 12/11/2022]
Abstract
The therapeutic alliance has demonstrated an association with favorable psychotherapeutic outcomes in the treatment of eating disorders (EDs). However, questions remain about the inter-relationships between early alliance, early symptom improvement, and treatment outcome. We conducted a meta-analysis on the relations among these constructs, and possible moderators of these relations, in psychosocial treatments for EDs. Twenty studies met inclusion criteria and supplied sufficient supplementary data. Results revealed small-to-moderate effect sizes, βs = 0.13 to 0.22 (p < .05), indicating that early symptom improvement was related to subsequent alliance quality and that alliance ratings also were related to subsequent symptom reduction. The relationship between early alliance and treatment outcome was partially accounted for by early symptom improvement. With regard to moderators, early alliance showed weaker associations with outcome in therapies with a strong behavioral component relative to nonbehavioral therapies. However, alliance showed stronger relations to outcome for younger (vs. older) patients, over and above the variance shared with early symptom improvement. In sum, early symptom reduction enhances therapeutic alliance and treatment outcome in EDs, but early alliance may require specific attention for younger patients and for those receiving nonbehaviorally oriented treatments.
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Specific psychological therapies versus other therapies or no treatment for severe and enduring anorexia nervosa. Hippokratia 2015. [DOI: 10.1002/14651858.cd011570] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Rules of engagement: qualitative experiences of therapeutic alliance when receiving in-patient treatment for anorexia nervosa. Eat Disord 2014; 22:233-43. [PMID: 24392991 DOI: 10.1080/10640266.2013.867742] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Recent research has emphasised the importance of therapeutic alliance to treatment outcomes for anorexia nervosa. This study aimed to examine the experiences of service users in developing therapeutic alliance whilst in treatment for their eating disorders. This qualitative study, using purposive sampling, recruited a sample of service users receiving treatment at a national eating disorders service. In-depth interviews were audiotaped and transcribed, with transcriptions being subject to interpretative phenomenological analysis. Participants were eight adult women receiving tertiary level eating disorder treatment in a specialist setting. The text analysis produced four dominant categories: alliance as a key experience; being active, not passive; taboo talking; and first impressions count. The development of therapeutic alliance is a core component of treatment. This study identifies important areas that contribute to the successful cultivation of positive therapeutic alliance.
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Comparing drug detection in oral fluid and blood: data from a national sample of nighttime drivers. TRAFFIC INJURY PREVENTION 2014; 15:111-118. [PMID: 24345011 DOI: 10.1080/15389588.2013.796042] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE The National Roadside Survey is a study undertaken in the United States to determine the prevalence of alcohol and drugs in randomly selected drivers. Following the success of a 2006 pilot study, the 2007 survey incorporated, for the first time, the collection of biological specimens for drug analysis. This article compares the results obtained from blinded analyses of pairs of oral fluid and blood samples obtained from the same subject. METHODS During the 2007 survey, more than 7000 nighttime drivers were randomly stopped and surveyed for their self-reported drug use and were requested to donate an oral fluid specimen using the Quantisal (Immunalysis Corporation, Pomona, CA) device and a blood sample. Overall, 5869 oral fluid specimens were collected from nighttime drivers with 3236 corresponding blood samples. RESULTS Biological specimens were analyzed for a wide range of drugs. At nighttime, 14.4 percent of the drivers were positive for drugs in oral fluid, with just over half of those having marijuana present (7.6%). Of the 3236 pairs of specimens, 2676 were negative for all drugs, and 326 matched pairs of samples were both positive, out of which 247 (75.8%) were an exact match for all drug classes and 70 (21.5%) were positive for at least one common drug class. CONCLUSIONS Oral fluid and blood samples provided very similar information regarding recent drug intake by randomly tested drivers and oral fluid yielded a higher detection rate for one drug (cocaine) than blood. Oral fluid can be considered a reliable alternative to blood as a matrix for drug testing.
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Premature termination of treatment for anorexia nervosa: differences between patient-initiated and staff-initiated discharge. Int J Eat Disord 2014; 47:40-6. [PMID: 24323526 DOI: 10.1002/eat.22190] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/14/2013] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To investigate treatment drop-out by comparing clinical indicators of patients whose discharge was initiated by staff with those who initiated discharge themselves. METHOD Ninety participants with anorexia completed questionnaires at admission and four weeks into hospitalized treatment. Weight data was collected over this same period. At discharge, participants were categorized into completer (n = 38) or patient-initiated (n = 36) /staff-initiated (n = 16) premature termination groups. RESULTS Significant differences between staff-initiated and patient-initiated discharge groups were found at admission. Staff initiated groups were on average older (p = .035), and more likely to have had prior compelled treatment (p = .039). At 4 weeks those in the patient-initiated group had put on weight at a faster rate (p = .032) and reported a decrease in alliance (p = .017). At discharge, staff initiated discharge demonstrated greater time in treatment (p = .001), greater weight gain (p = .027), and a higher discharge BMI (p = .013). At discharge, staff-initiated drop-outs had comparable end-of-treatment outcomes to those who completed treatment as planned. DISCUSSION There are key differences between those who prematurely discharge themselves from treatment, compared to those who are prematurely discharged by clinical staff. Future research into drop-out needs to take into account and recognize these differences.
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Predicting premature termination of hospitalised treatment for anorexia nervosa: the roles of therapeutic alliance, motivation, and behaviour change. Eat Behav 2013; 14:119-23. [PMID: 23557806 DOI: 10.1016/j.eatbeh.2013.01.007] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Revised: 12/18/2012] [Accepted: 01/30/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVES This study aims to investigate treatment drop-out, and the associated roles of motivation, alliance, and behaviour change exhibited over the first four weeks of hospitalised treatment for anorexia. METHODS 90 participants meeting DSM-IV criteria for anorexia nervosa completed questionnaires at admission, and four weeks into treatment. Weight data was collected over this same time period. At the end of treatment, participants were categorised into completer or premature termination groups. RESULTS The overall rate of premature termination was 57.8%. Those who prematurely terminated treatment demonstrated lower discharge BMI (p<.0005), and weight gain (p<.0005) than those who completed. Therapeutic alliance proved significantly different between outcome groups at admission (p=.004). DISCUSSION End-of-treatment outcomes for those who do not complete treatment are invariably poor. Therapeutic alliance appears to be a particularly important factor in this area.
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The St George's eating disorders service meal preparation group for inpatients and day patients pursuing full recovery: a pilot study. EUROPEAN EATING DISORDERS REVIEW 2011; 20:218-24. [PMID: 21910164 DOI: 10.1002/erv.1134] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2010] [Revised: 02/18/2011] [Accepted: 04/22/2011] [Indexed: 11/07/2022]
Abstract
This naturalistic cohort study evaluates a meal cookery group-based occupational therapy intervention for adult inpatients and day patients with severe eating disorders. It also evaluates the Eating and Meal Preparation Skills Assessment (EMPSA) as an outcome measure, allowing clients pursuing recovery to rate ability and motivation to perform tasks related to preparing and eating 'normal' meals. Twenty-seven participants completed EMPSAs at their first, 10th and final sessions, plus 1 year later. The Ability subscale of EMPSA indicated significant improvements (p < 0.001) by the 10th session, which was maintained 1 year later. The Motivation subscale of EMPSA indicated no significant changes at the 10th session but highly significant improvements (p < 0.001) between the 10th and final session, which was maintained 1 year later. Internal consistency for EMPSA was demonstrated by Cronbach's alpha of 0.71 for Ability subscale and 0.95 for Motivation subscale. We conclude that the meal preparation group is effective and durable.
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Abstract
OBJECTIVE This article describes the three-stage development of the SCOFF, a screening tool for eating disorders. METHOD Study 1 details questionnaire development and testing on cases and controls. Study 2 examines reliability of verbal versus written administration in a student population. Study 3 validates the test as a screening tool in primary care. RESULTS The SCOFF demonstrates good validity compared with DSM-IV diagnosis on clinical interview. In the primary care setting it had a sensitivity of 84.6% and a specificity of 89.6%, detecting all true cases of anorexia nervosa and bulimia nervosa and seven of nine cases of EDNOS. Reliability between written and verbal versions of the SCOFF was high, with a kappa statistic of 0.82. DISCUSSION The SCOFF, which has been adapted for use in diverse languages, appears highly effective as a screening instrument and has been widely adopted to raise the index of suspicion of an eating disorder.
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Abstract
We report two cases of pathological ingestion of salt as a feature of anorexia nervosa, which we have previously termed "salinophagia." Both cases were young women with anorexia nervosa of the purging subtype and of sufficient severity to necessitate inpatient treatment. In both instances, excessive quantities of salt were ingested in the context of treatment programs requiring nutritional rehabilitation, and motivated by a wish to despoil the food and render it distasteful, to rob its ingestion of any hedonic qualities. In one instance, this behavior pattern was imitated by other patients on the unit. Having first briefly described salinophagia in 1999, the first author has received considerable correspondence from other specialists suggesting that this is not an isolated phenomenon. The issues of phenomenology and treatment are further discussed.
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Abstract
OBJECTIVE To describe the management of a woman with cerebral palsy and anorexia nervosa. METHOD We carried out a literature search and gained consent and a history from the patient. We explored the etiological and ethical issues raised in this case. RESULTS Etiological issues are raised, looking at the interaction between physical disability and self-image. Clinical and practical difficulties of caring for a patient with physical disability properly on an eating disorder unit are discussed, as well as ethical issues concerning mental capacity and the use of the mental health act in anorexia nervosa. CONCLUSION This case reminds us again that we can learn much from listening to patients. In this instance, service and operational policies on managing disabilities on the unit, were shaped by her input.
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Screening for eating disorders in primary care: EDE-Q versus SCOFF. Behav Res Ther 2008; 46:612-22. [PMID: 18359005 DOI: 10.1016/j.brat.2008.02.003] [Citation(s) in RCA: 166] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2007] [Revised: 02/02/2008] [Accepted: 02/05/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVE AND METHODS The comparative validity of the Eating Disorder Examination Questionnaire (EDE-Q) (22 items) and SCOFF (five items) in screening for cases of the more commonly occurring eating disorders was examined in a primary care sample of young adult women (n=257). Diagnoses were confirmed in a sub-group of interviewed participants (n=147). RESULTS Twenty-five cases, primarily variants of bulimia nervosa (BN) not meeting formal diagnostic criteria, were identified in the interviewed sample. An EDE-Q global score of >or= 2.80 yielded the optimal trade-off between sensitivity (Se) (0.80) and specificity (Sp) (0.80) (positive predictive value (PPV)=0.44), whereas a score of two or more positive responses on the SCOFF was optimal (Se=0.72, Sp=0.73, PPV=0.35). Validity coefficients for both measures varied as a function of participants' age and body weight, although these effects were more pronounced for the SCOFF. CONCLUSIONS Both measures performed well in terms of their ability to detect cases and to exclude non-cases of the more commonly occurring eating disorders in a primary care setting. The EDE-Q performed somewhat better than the SCOFF and was more robust to effects on validity of age and weight. These findings need to be weighed against the advantage of the SCOFF in terms of its brevity.
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Abstract
OBJECTIVE Bulimia nervosa is common and treatable. An association between bulimia and obstetric complications has been suggested, but sample size and absence of control have limited previous studies. Our aim was to determine if active bulimia nervosa affects obstetric outcome. METHODS This was a retrospective case-control comparison of obstetric complications in primigravidae previously treated for bulimia in a specialist eating disorder service. A cohort of 122 women with active bulimia during pregnancy was contrasted against 82 with quiescent bulimia, using structured interviews comprising the Eating Disorders Examination, Structured Clinical Interview for DSM-III-R, and systematic questions addressing obstetric complications. RESULTS Odds ratios (ORs) for postnatal depression, miscarriage, and preterm delivery were 2.8 (95% confidence interval [CI], 1.2-6.2), 2.6 (95% CI, 1.2-5.6) and 3.3 (95% CI, 1.3-8.8) respectively. Risk of unplanned pregnancy was markedly elevated (OR, 30.0; 95% CI, 12.8-68.7). Risk estimates were not explained by differences in adiposity, demographics, alcohol/substance/laxative misuse, smoking, or year of birth, but relative contributions of bulimic behaviors were not discerned. CONCLUSIONS Active bulimia during pregnancy is associated with postnatal depression, miscarriage, and preterm delivery. Bulimia may be a treatable cause of adverse obstetric outcome.
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A prospective study of changes in bone turnover and bone density associated with regaining weight in women with anorexia nervosa. Osteoporos Int 2005; 16:1955-62. [PMID: 16027954 DOI: 10.1007/s00198-005-1972-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2004] [Accepted: 06/02/2005] [Indexed: 10/25/2022]
Abstract
Anorexia nervosa (AN) is a condition of self-induced weight loss, associated with an intense fear of gaining weight. Previous studies have shown that bone density may increase with regaining and maintaining normal weight; however, relatively little is known about the changes in bone metabolism that occur during weight restoration. We describe the effect of weight restoration and maintenance of weight over 1 year on bone mineral density (BMD) and bone turnover. We recruited women from the eating disorders services at the South West London and St George's Mental Health NHS Trust, and the Priory and Charter Nightingale Hospitals in London, UK. Details of their AN, fracture history, menstrual history and exercise were obtained by interview and case note review. Morning samples of blood and second void urine were taken for biochemical analysis. BMD was measured by DXA at the lumbar spine (LS), femoral neck (FN), distal radius (RD) and total body bone mineral content (BMC). Patients then entered the treatment program, which includes re-feeding, dietary education and psychotherapy. Over a period of 42 months, we recruited 55 women who agreed to participate in this study and underwent baseline investigations. Of these, 15 (27%) subjects achieved and then maintained their target weight for the duration of the study. At baseline for all subjects (n=55) estradiol levels were lower than the normal reference ranges (both follicular and luteal phases) in 91% of the women. Bone specific alkaline phosphatase (BSAP) concentrations were lower than the premenopausal reference range in 55% of women, and urinary deoxypyridinoline (DPD) was above the premenopausal reference range in 78% of women. Baseline lumbar spine BMD was positively related to BMI (Pearson's r=0.29, P=0.04) and inversely related to bone turnover markers: urinary DPD (Pearson's r=-0.39, P=0.01 and serum BSAP (Pearson's r=-0.3, P=0.06). The 15 patients who regained and maintained weight were followed-up for a mean duration of 69 weeks (SD 7.3, range 54 to 84 weeks). Mean BMI increased from 14.2 (1.7) to 20.2 (0.77) kg/m2 and remained stable throughout follow-up. Menstruation resumed in 8 of the 15 women. Total body BMC and LS BMD increased significantly over the duration of follow-up (by 4.3% each), but FN BMD and distal radius remained stable. Lumbar spine bone area also increased significantly, whereas FN and distal radius did not. These changes were associated with a significant increase in BSAP (P=0.01), and a non-significant trend for a decrease in DPD (P=0.10). Our findings suggest that when women are at low body weight they are in a hypo-estrogenic state, which is associated with imbalance of bone turnover (high bone resorption and low bone formation). This is reversed with weight gain and persists as target weight is maintained and is associated with increases in BMC and BMD.
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Childhood onset neuropsychiatric disorders in adult eating disorder patients. A pilot study. Eur Child Adolesc Psychiatry 2005; 14:431-7. [PMID: 16341499 DOI: 10.1007/s00787-005-0494-3] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2005] [Indexed: 11/28/2022]
Abstract
BACKGROUND Autism spectrum disorders (ASD) have been suggested to be overrepresented in anorexia nervosa. This study aimed to explore the comorbidity of ASD and other childhood onset neuropsychiatric disorders (COND) [attention-deficit/hyperactivity disorder (AD/HD) and tic disorders] in a group of severe eating disorder (ED) patients. METHOD Thirty female ED patients from a specialist hospital clinic were examined on measures tapping into COND and personality disorders. RESULTS In our group of longstanding ED, 53% had at least one COND diagnosis; 23% had ASD, 17% had AD/HD, and 27% had a tic disorder. CONCLUSIONS These preliminary data suggest that COND may be common in patients with severe ED and should be kept in mind when treating these patients.
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Eating psychopathology in young non-clinical adults: a pilot study of the impact of parental personality. EUROPEAN EATING DISORDERS REVIEW 2005. [DOI: 10.1002/erv.625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
This study investigated whether a reported history of childhood sexual abuse (CSA) in morbidly obese adults is associated with a higher level of negative core beliefs (unconditional, schema-level representations regarding the self, the world, and others), and whether those beliefs are significantly associated with weight levels and weight fluctuation. A cross-sectional design was used, with comparative and correlational elements. The participants were 30 morbidly obese patients (age range=27-61years; body mass index [BMI] range=40.8-73.5), awaiting surgical intervention. Each completed standardized self-report measures of childhood traumatic experiences, core beliefs, and weight history. BMI was obtained from clinical interview. In terms of weight variables, the individuals with a reported history of sexual abuse (n=10) did not differ from those with no such history (n=20). However, those with a reported abuse history had higher levels of specific negative core beliefs. This group also showed more extensive associations between their BMI and their core beliefs than the nonabused group. Core beliefs, which are often associated with personality disorder pathology, were associated with the reported presence of a history of sexual abuse among the morbidly obese. The group differences (in levels of core beliefs and in their association with weight variables) suggest that there might be different mechanisms to explain weight levels in those obese patients who do or do not have a history of CSA. When psychological interventions are used in support of other treatments (e.g., surgery), they might be most productively targeted on those with such an abuse history.
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The prevalence of DSM-IV personality pathology among individuals with bulimia nervosa, binge eating disorder and obesity. Psychol Med 2003; 33:1311-1317. [PMID: 14580084 DOI: 10.1017/s0033291703007505] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND There are numerous reports of personality disorder pathology in different eating disorders. However, few studies have directly compared personality pathology in bulimia nervosa, binge eating disorder and obesity. The present study examines group differences in DSM-IV personality pathology, considering the potential utility of understanding personality disorders in terms of diagnosis and dimensional scores. METHOD Eating disorder diagnoses were established using the Eating Disorder Examination interview. Thirty-five bulimia nervosa patients, 15 binge eating disorder patients and 37 obese patients were assessed and compared on the International Personality Disorder Examination using categorical and dimensional personality disorder scores. RESULTS For most personality disorders, there was a dichotomy of binge eaters versus non-binge eaters. In contrast, there was a continuum of severity in borderline personality disorder pathology between the groups. The dimensional system of measurement of personality pathology allowed for clearer differentiation between the groups. CONCLUSION The study strongly indicates that personality disorder difficulties are present in patients who binge eat, while obese patients who do not binge eat display significantly less personality disorder pathology. Assessment of bulimia nervosa, binge eating disorder and obesity needs to address personality disorders and pathology. Dimensional markers of personality pathology can be used to supplement categorical diagnoses, providing information about the traits that underlie diagnosis.
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The SCOFF questionnaire and clinical interview for eating disorders in general practice: comparative study. BMJ 2002; 325:755-6. [PMID: 12364305 PMCID: PMC128378 DOI: 10.1136/bmj.325.7367.755] [Citation(s) in RCA: 139] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/28/2002] [Indexed: 11/04/2022]
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Abstract
OBJECTIVE To examine long-term changes in polycystic ovarian morphology in women with polycystic ovaries and bulimia nervosa after treatment of the latter condition. DESIGN Longitudinal follow-up study. SETTING Eating disorder unit of a university hospital. PATIENT(S) Eight women originally treated for bulimia nervosa (T(0)) who underwent ultrasonography up to 2 years after treatment (T(1)) and had a second ultrasonographic scan 9 years later (T(2)). INTERVENTION(S) Treatment of bulimia nervosa that combined cognitive behavioral therapy with insight-orientated psychotherapy. MAIN OUTCOME MEASURE(S) Ovarian morphology evaluated by ultrasonography, using the criteria of Adams to define polycystic ovaries; Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis of eating disorders. RESULT(S) At T(1), 7 women had recent bulimia and 1 was quiescent. The woman with quiescent disease had normal ovaries. Of the 7 bulimic women, 6 had polycystic ovaries and 1 had multifollicular morphology. At T(2), 5 women were bulimic, all of whom had polycystic ovaries. Three women had normal eating patterns and normal ovarian morphology. CONCLUSION(S) This study clearly shows a strong association between resolution of bulimia and changes in ovarian morphology, suggesting that changes in the former mirror changes in the latter. It also demonstrates normalization of ovarian morphology in previously polycystic ovaries.
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Do starvation diets lead to irreversible lung changes? EUROPEAN EATING DISORDERS REVIEW 2001. [DOI: 10.1002/erv.414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Abstract
METHOD We describe the cases of four patients with eating disorders in whom complex interactions occurred among religious faith, pathogenesis of the eating disorder, and clinical management. RESULTS In some of the cases, religious beliefs seemed to provide a containment of maladaptive behaviors, partly through prayer and through a sense of belonging to the religious community. In other cases, it proved difficult to separate the concept of a punitive God from the illness process. DISCUSSION The cases are discussed with reference to a limited empirical literature. Similarities are noted between some religious institutions and eating disorder treatment regimes. This paper explores management issues, including the use of pastoral counseling and the ethics of addressing religious beliefs in therapy. We note the benefits of a rapprochement between psychiatry and religion.
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Abstract
OBJECTIVE Previous studies suggest season of birth variation in eating disorders akin to those of psychoses. We studied season of birth variation in bulimia nervosa. METHOD Season of birth variation in 935 patients was examined after adjustment for population trends. Variation was also examined for subgroups by age and previous anorexia nervosa. RESULTS Season of birth did not differ significantly from population norms among bulimics (p >.30), contrasting with studies of other eating disorders. With a history of anorexia nervosa (n = 227), peak season of birth was in March (p <.05). This is consistent with previous studies and also with seasonal birth variation for psychoses. DISCUSSION Overall, we find no evidence of season of birth variation in bulimia nervosa, and suggest any positive findings be treated with caution. We discuss a number of confounding influences and argue that one explanation remains shared trait vulnerability between anorexia nervosa and psychoses.
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Abstract
BACKGROUND Deliberate blood-letting has been characterized as an alternative to purging behavior in bulimia. METHOD We describe a female healthcare worker with an 8-year history of restrictive anorexia nervosa, who initially presented with anemia, using blood-letting, cold baths, and starvation to control her mental state. RESULTS In contrast with the previous cases of bulimia, the aim of blood-letting in this case of anorexia nervosa was to achieve anemia. She compared the psychic correlates of anemia to emaciation, rather than to deliberate self-harm or purging. DISCUSSION We note that mainstream 19th century psychiatry prescribed "baths, blood-letting and diet" as a treatment of "madness."
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The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ (CLINICAL RESEARCH ED.) 1999; 319:1467-8. [PMID: 10582927 PMCID: PMC28290 DOI: 10.1136/bmj.319.7223.1467] [Citation(s) in RCA: 687] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abstract
OBJECTIVE We examined changes in sexual drive during weight restoration in patients with anorexia nervosa. METHODS Eleven women with anorexia nervosa prospectively completed the Sexual Daydreaming Questionnaire (SDQ) and the Hospital Anxiety and Depression Scale (HADS) at five time points during inpatient treatment involving weight restoration. SDQ and HADS scores were recorded every 4 weeks until 8 weeks after subjects had reached the mean matched population weight (MMPW), which was monitored against body mass index (BMI). Histories were 'taken for purging, self-cutting, childhood sexual abuse, and number of sexual partners. Repeated-measures analysis of variance, regression analyses, and t tests were performed. RESULTS BMI and sexual daydreaming were closely associated (p < .001). BMI and depression also achieved a statistically significant association (p = .046), with "caseness" for anxiety disorder throughout. Higher levels of sexual drive at MMPW seemed to be associated with purging, self-cutting, and childhood sexual abuse but not at low weight. Levels of sexual drive did not reflect previous sexual behavior. CONCLUSIONS An increase in sexual drive accompanies weight restoration in patients with anorexia nervosa, which is consistent with psychological and physiological explanations of altered sexuality. Transient depression is also associated with weight gain. Changes in sexuality should be considered in both recovery and treatment failure.
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Changes in plasma concentrations of leptin and body fat composition during weight restoration in anorexia nervosa. J Clin Endocrinol Metab 1999; 84:2257. [PMID: 10372743 DOI: 10.1210/jcem.84.6.5809-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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Abstract
An association between pruritus and eating disorders has been suggested. This study examined changes in pruritus during weight restoration in a homogeneous group of women with severe anorexia nervosa (n = 19), using a structured questionnaire, visual analogue scale, clinical examination and a range of serological markers. We demonstrated that itching is a clinical feature of anorexia nervosa, associated with low weight and resolving on weight restoration. Some 58% of the sample suffered pruritus at low weight in a stable hospital environment. There was a significant association between changes in body mass index and severity of pruritus (P = 0.033), with reduced itching on weight restoration. Pruritus occurred in the absence of abnormalities in thyroid, renal and hepatic function, serum androgens, oedema, dermatoses or compulsive washing. Scratching was manifest as 'scratch prurigo' in five cases. Where itching was present, it was experienced as severe. We discuss a variety of possible explanations, including psychopathology, endocrine factors, regional blood flow variation, eczema and the role of central opioid and serotonergic activity. We argue that anorexia nervosa should be considered in all patients at low weight presenting with pruritus, and pruritus should be considered to be a physical symptom of anorexia nervosa.
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Abstract
BACKGROUND Bulimia nervosa affects women at a peak age of reproductive functioning, but few studies have examined the impact of pregnancy on bulimia. AIM To examine the impact of pregnancy on symptoms of bulimia nervosa and associated psychopathology. METHOD Women actively suffering from bulimia nervosa during pregnancy (n = 94) were interviewed using the eating disorder examination (12th edn) and structured clinical interview for DSM-III-R, with additional structured questions. Behaviours were recorded at conception, each trimester and postnatally. Relative risks were calculated for prognostic factors. RESULTS Bulimic symptoms improved throughout pregnancy. After delivery, 57% had worse symptoms than pre-pregnancy, but 34% were no longer bulimic. Relapse was predicted by behavioural severity and persistence, previous anorexia nervosa ('Type II' bulimia), gestational diabetes and 'unplanned' pregnancy. Unplanned pregnancies were the norm, usually resulting from mistaken beliefs about fertility. 'Postnatal depression' was suggested in one-third of the sample, and in two-thirds of those with'Type II' bulimia, and was predicted by alcohol misuse, symptom severity and persistence. CONCLUSIONS Postnatal treatment intervention should focus on women 'at risk' of relapse, but all women with bulimia should be assessed for postnatal depression.
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Abstract
The authors present four cases suffering with either bulimia nervosa or anorexia nervosa in conjunction with a psychotic illness. In all cases there appeared to be a reciprocal relationship between the eating disorder and psychosis such that improvement in eating precipitated or exacerbated the psychotic symptoms. We suggest that disordered eating serves as a defense against psychosis. Difficulties in treating such patients are discussed.
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Abstract
We describe the management of multi-impulsive bulimia nervosa in a 27-year-old man. Inpatient treatment was attempted using a standardized focal-interpretative (psychodynamic) and cognitive-behavioral approach, with an emphasis on ward milieu. The value of this approach has been proved for female patients in the past. To our knowledge, this is the first report of its usage for a male with multi-impulsive bulimia, and the problems encountered highlight the impact of gender on behavioral symptoms, ward culture, and the predominantly female patient group.
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Diet-induced loss of cyclic ovarian function at normal body weight in a rodent model for bulimia nervosa. JOURNAL OF REPRODUCTION AND FERTILITY 1998; 112:217-23. [PMID: 9640260 DOI: 10.1530/jrf.0.1120217] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A bulimic rat model was used to test whether type and frequency of food intake mimicking that in human bulimia nervosa could disrupt oestrous cyclicity, induce an effect on glycoprotein (LH) structure, or affect both processes and if so, to determine whether any such effects were acute, or persisted after return to normal eating patterns. Voluntary hyperphagia was induced by offering female rats a varied and palatable choice of human food items--the 'cafeteria diet'. There were four groups: control (normal chow), obese (continuous cafeteria diet), post-obese (cafeteria diet, then fasted to reduce weight to that of controls) and binge (cafeteria alternated with normal diet every few days). Animals were maintained on these diets for 60 days (phase I). They were then given a GnRH challenge on day 2 of dioestrus of the cycle. Twenty-four hours later, half of the animals in each group were killed for assessment of effects on their reproductive organs. The remaining animals were returned to normal diets and kept for a further 40 days, when the GnRH challenge was repeated and the animals were killed 24 h later (phase II). All animals on the cafeteria diet in phase I exhibited significant disruption of oestrous cyclicity irrespective of body weight. LH released in response to the first GnRH challenge showed a prolonged half-life, and/or increased rate of secretion in the obese and post-obese groups but in the binge group the secretory/clearance properties resembled those of control animals. After the second GnRH challenge at the end of phase II, however, the LH of the binge group appeared to have different secretory or clearance characteristics, whereas that of the previously obese animals had returned to normal. These data show ovarian cyclicity was disrupted by hyperphagia and irregular eating, even at normal body weight. Relating ovarian function to pituitary output in terms of LH, the effects of the continuous cafeteria diet did not appear to persist in the animals that returned to normal diets, but in the binge group the effect, presumably of the diet manipulation, was manifested after return to a normal eating pattern. This finding suggests that irregular eating habits may exert a direct (and acute) effect on the ovary, but that effects on the pituitary (and LH glycoforms) take longer to be expressed, explaining many features of bulimia nervosa.
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Abstract
OBJECTIVE This report describes the rare combination of anorexia nervosa, deafness, and visual impairment with a particular emphasis on management issues. To the author's knowledge, this is the first report of an eating disorder in a patient who is deaf with a visual impairment. DISCUSSION It describes the history of such a patient and the difficulties encountered in her treatment.
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Abstract
We report a case of bulimia nervosa in a 21-year-old HIV-positive woman whose seropositivity provoked sustained motivation for recovery from her eating disorder. To the authors' knowledge, this is the first report of HIV-1 seropositivity leading to a clinical improvement in an eating disorder. We review the literature, in which the negative impact of seropositivity has been emphasized, and we explore the complex interaction between eating disorders and HIV-1 infection, considering both nutritional and psychological factors.
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Abstract
Measures of abnormal eating behaviour in 48 women referred for psychiatric assessment following an act of deliberate self-poisoning (subjects) were compared with those in 50 women attending an accident and emergency department following minor accidental injury (controls). Disordered eating behaviour was significantly more prevalent in the subject group, even when the effect of depression was removed. Four subjects fulfilled the diagnostic criteria for bulimia nervosa, but none of the subjects met the diagnostic criteria for anorexia nervosa. The prevalence of obesity was the same in both subject and control groups. The degree of abnormal eating was very strongly correlated with a measure of inwardly directed irritability in both subjects and controls, and was strongly associated with measures of impulsiveness, outwardly directed irritability and anxiety in subjects.
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Abstract
We report a case of anorexia nervosa in a 14-year-old girl following withdrawal of oral prednisolone used in the treatment of asthma. The patient exhibited depressed affect and disturbance of body image prior to onset of anorexia. To the authors' knowledge this is the first report of anorexia nervosa precipitated by steroid withdrawal. The pathogenesis is discussed with reference to recent literature, considering both the physiological and psychological impact of steroid withdrawal.
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