Catherine Boyd

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 12months. 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 wellknown measures of eating disorders, psychological dysfunction, general QOL and behaviour and body weight (p < 0.001). The QOL ED shows high reliability (Cronbachs 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.

Psychological features are important predictors of functional gastrointestinal disorders in patients with eating disorders

Objective. Gastrointestinal symptoms that occur without evidence of structural gastrointestinal disease are a well-recognized feature of patients with eating disorders (EDs). Despite this, the spectrum and predictors of specific functional gastrointestinal disorders (FGIDs), documented using standardized and validated questionnaires, have received little attention. The aims of the study were to describe the prevalence and type of FGIDs in patients suffering from anorexia nervosa (AN), bulimia nervosa (BN) and eating disorders not otherwise specified (EDNOS), and to determine the relationships between psychological features, eating-disordered attitudes and behaviours, demographic characteristics and the type and number of FGIDs present. Material and methods. A total of 101 consecutive female patients admitted to an eating disorder unit (AN 44%, BN 22%, EDNOS 34%, mean age 21 years) completed the Rome II modular questionnaire and a range of other validated self-reported questionnaires detailing illness history, psychological features and eating and exercise behaviour. Results. The criteria for at least one FGID were fulfilled by 98% of the sample. The most prevalent FGIDs were irritable bowel syndrome (IBS: 52%), functional heartburn (FH: 51%), functional abdominal bloating (31%), functional constipation (FC: 24%), functional dysphagia (23%) and functional anorectal pain disorder (FAno: 22%); 52% of the sample satisfied the criteria for at least three coexistent FGIDs. Psychological variables (somatization, neuroticism, state and trait anxiety), age and binge eating were significant predictors of specific, and ≥3 coexistent FGIDs. Other disordered eating characteristics, including body mass index, were not predictors. Conclusions. In patients with EDs, specific psychological traits predict FGID type and the presence of multiple coexistent FGIDs. These findings support the role of specific psychological features as important contributors to certain FGIDs.

Usefulness of amenorrhoea in the diagnoses of eating disorder patients

We investigated the usefulness of amenorrhoea as a criterion in eating disorder diagnoses. Menstrual history, eating disordered behavior and weight history of 251 female eating disorder inpatients were assessed on admission to hospital. Menstrual status of 88 (35%) could not be assessed (80 taking hormonal contraception, 5 ( < 16 years) had never menstruated, one hysterectomized, 2 postmenopausal). Of the remaining 163; 90 had secondary amenorrhoea (no periods for > 3 months), 19 irregular periods and 54 regular cycles. Some patients with recent changes in energy status, who warranted inpatient treatment for their eating disorder did not develop amenorrhoea until later during their admission. Menstrual disturbance is not limited to anorexia nervosa, 24% of patients with an eating disorder not otherwise specified (EDNOS) and 15% of bulimic patients had amenorrhoea/oligomenorrhoea on admission. The best predictors (82% cases, 83% noncases, R2 = 0.41) of secondary amenorrhoea at admission, were; current BMI ⩽ 18, and having rules for exercising. Menstrual status of women with an eating disorder diagnosis cannot always be assessed, is mostly measuring low body weight and exercise and is not useful in planning or initiating treatment. There is insufficient evidence to support the use of amenorrhoea as a criterion for any eating disorder.

Anxiety and feelings of medical students conducting their first gynecological examination.

We examined the anxiety of medical students when they conduct their first gynecological examination. The students (226) from two universities completed anonymous questionnaires providing measures of state and trait anxiety and anxiety and confidence feelings, before and after conducting their first bimanual and speculum examination. This took place during a structured, self-directed learning session and involved examination of a professional patient. Students state anxiety was significantly elevated immediately before and fell to below baseline levels after the examination (p < 0.001). Students’ reported feelings of increased confidence during the examination (p < 0.001). Students who had personally had a Pap smear test were most anxious before (p < 0.003) but during the examination, students who had experienced a gynecological exam felt less anxious (p < 0.002). The students experiencing the greatest decreases (before to after) in state anxiety were those who had never experienced sexual intercourse (p < 0.005). Most students (96%), particularly those who were more anxious during the examination (p < 0.001) and who experienced a greater decrease in anxiety from before to after the examination (p < 0.008) would recommend this method of learning to other students. In summary, medical students are anxious when they conduct their first gynecological examination, appear to be influenced by their personal experiences and appreciate methods of learning that reduce their anxiety.

Appearance and disappearance of functional gastrointestinal disorders in patients with eating disorders.

Background  Functional gastrointestinal disorders or ‘functional gastrointestinal disorder‐like’ symptoms (FGIDs) occur commonly in eating disorders (ED), but it is not known if these disorders are stable over time. The aims were to evaluate the turnover of FGIDs in patients with ED, and to relate this turnover to changes in body mass index (BMI), ED behaviors, and psychological variables.

Time since menarche, weight gain and body image awareness among adolescent girls: onset of eating disorders?

Background. Eating, body weight and shape feelings and behaviours of female adolescents in relation to the time since their first menstrual period were studied. Method. Three hundred sixty three female school students, aged 12–17 years participated in a cross-sectional computer survey. Results. There was a significant increase in body weight following menarche including a rapid rise from 7–12 months after menarche (47.4 kg, 95% CI 45.2–49.7, 56.9 kg 95% CI 54.0–59.8). Students did not immediately adjust their perception of body weight to incorporate this rapid rise. The discrepancy between actual and desired weight was greatest 7–12 and 13–24 months after menarche. Weight losing behaviours and associated feelings around body image increased significantly following menarche in adolescents of all body weights. Increases were related to body weight and time since menarche, but not to age. Binge eating commenced more than 6 months after menarche and purging behaviour after 12 months. Conclusion. Both time since menarche and increase in body weight following menarche are associated with increasing concerns about eating, body image and weight losing behaviour. Some young women develop eating disorders. Menarche and subsequent weight gain appear as a risk factor for the onset of eating disorders.

Functional gastrointestinal disorders in eating disorder patients: Altered distribution and predictors using ROME III compared to ROME II criteria

AIM To compare the prevalence of Functional gastrointestinal disorders (FGIDs) using ROME III and ROME II and to describe predictors of FGIDs among eating disorder (ED) patients. METHODS Two similar cohorts of female ED inpatients, aged 17-50 years, with no organic gastrointestinal or systemic disorders, completed either the ROME III (n = 100) or the ROME II (n = 160) questionnaire on admission for ED treatment. The two ROME cohorts were compared on continuous demographic variables (e.g., age, BMI) using Students t-tests, and on categorical variables (e.g., ED diagnosis) using χ(2)-tests. The relationship between ED diagnostic subtypes and FGID categories was explored using χ(2)-tests. Age, BMI, and psychological and behavioural predictors of the common (prevalence greater than 20%) ROME III FGIDs were tested using logistic regression analyses. RESULTS The criteria for at least one FGID were fulfilled by 83% of the ROME III cohort, and 94% of the ROME II cohort. There were no significant differences in age, BMI, lowest ever BMI, ED diagnostic subtypes or ED-related quality of life (QOL) scores between ROME II and ROME III cohorts. The most prevalent FGIDs using ROME III were postprandial distress syndrome (PDS) (45%) and irritable bowel syndrome (IBS) (41%), followed by unspecified functional bowel disorders (U-FBD) (24%), and functional heartburn (FH) (22%). There was a 29% or 46% increase (depending on presence or absence of cyclic vomiting) in functional gastroduodenal disorders because of the introduction of PDS in ROME III compared to ROME II. There was a 35% decrease in functional bowel disorders (FBD) in Rome III (excluding U-FBD) compared to ROME II. The most significant predictor of PDS was starvation (P = 0.008). The predictor of FH (P = 0.021) and U-FBD (P = 0.007) was somatisation, and of IBS laxative use (P = 0.025). Age and BMI were not significant predictors. The addition of the 6-mo duration of symptoms requirement for a diagnosis in ROME III added precision to many FGIDs. CONCLUSION ROME III confers higher precision in diagnosing FGIDs but self-induced vomiting should be excluded from the diagnosis of cyclic vomiting. Psychological factors appear to be more influential in ROME II than ROME III.

Lifetime and recent DSM and ICD psychiatric comorbidity of inpatients engaging in different eating disorder behaviours

OBJECTIVE: Previous studies investigating psychiatric comorbidity in eating disorder (ED) patients compared groups according to ED diagnoses. The current paper compared groups according to ED behaviours: self-induced vomiting, objective binge eating, excessive exercising, and to body mass index (BMI, kg/m2) for selected psychiatric comorbidity using two systems: Diagnostic and Statistical Manual of Mental Disorders —Fourth Edition (DSM-IV) and International Classification of Diseases —Tenth Revision (ICD-10) diagnoses. METHOD: Two hundred and twenty-six patients admitted for treatment in a specialised Eating Disorders Unit completed the Composite International Diagnostic Interview (CIDI). Lifetime and recent (12 months) psychiatric diagnoses were produced according to DSM-IV and ICD-10. Associations between presence of ED behaviours or BMI and psychiatric comorbidity were investigated. RESULTS: Eighty-eight percent of patients had a lifetime history (72% recent history) of at least one comorbid diagnosis (regardless of diagnostic system). Agreement between the systems was high for mood (affective) disorders and moderate for anxiety/somatoform disorders. Significantly more patients who vomit had lifetime and recent mood (affective) disorders (DSM-IV and ICD-10). Significantly more ‘vomiters’ had recent anxiety disorders (DSM-IV) and neurotic, stress-related and somatoform disorders (ICD-10) including post-traumatic stress disorder (PTSD; DSM-IV and ICD-10). More patients with BMI >17.5 kg/m2 had lifetime and recent mood (affective) disorders and lifetime PTSD (DSM-IV and ICD-10). The results for ‘excessive exercisers’ varied and appeared inconsistent. There were no differences in any disorders for objective binge eaters. DISCUSSION: Patients who induce vomiting have more psychiatric comorbidity than ‘non-vomiters’, both lifetime and recent, and may benefit from diagnostic recognition as a separate group, for example ‘vomiting’ or ‘purging’ ED, who can then receive specialist treatment for their comorbidity and associated problems.

Medical Students' Opinions of Chaperone use during Gynecological and Anorectal Examinations

The opinions of medical students on chaperone use during physical examinations of the male and female was studied. The students (157) had conducted their first gynecological or first anoredal and prostate examination. Fifty-one percent of students were female, 56% younger than 25 years of age, and 77% males and 73% females had experienced sexual intercourse. Data on the use of a chaperone during vaginal, anoredal, breast and musculoskeletal examinations when conducted by doctors and by students was collected by anonymous questionnaire. Most students feel a chaperone is necessary when students-in-training conduct vaginal (94%), anorectal (94%) or breast (89%) examinations. Fewer students feel a chaperone is necessary when doctors rather than students condud vaginal (41%), anoredal (22%) and breast (25%) examinations. Students were significantly more likely to feel a chaperone was necessary when a doctor of the opposite sex conducts vaginal (58%) and anorectal (34%) examinations, compared to a doctor of the same sex. Students who were male, 25 years or older or had not experienced sexual intercourse were significantly more likely to favour doctors using chaperones. The differences in responses of students of differing age, gender and sexual experience should be considered and discussed when students are learning invasive physical examinations.