Chris Freeman

The dismantling of a myth: a review of eating disorders and socioeconomic status.

OBJECTIVE A key feature of the stereotype that exists of those groups and individuals most likely to develop an eating disorder relates to socioeconomic status. The prevailing wisdom about this relationship is that there is an increased prevalence of eating disorders in high socioeconomic groups. The aim of this paper is to assess the validity of this view and to examine the ways in which this stereotype was created. METHOD Articles written between the early 1970s and the early 1990s, which include assessment of socioeconomic status, are reviewed and the evidence for and against the stereotype is examined. RESULTS It was found that existing research fails to support this stereotype for eating disorders as a whole, that the relationship between anorexia nervosa and high socioeconomic status remains to be proved, and that there is increasing evidence to suggest that the opposite relationship may apply to bulimia nervosa. DISCUSSION The powerful influence of clinical impression, sources of bias in referral procedures, methodological problems in existing research, and the failure to adequately separate anorexia nervosa from bulimia nervosa when referring to common predisposing factors, are discussed in relation to why the stereotype exists.

Comparison of eating disorders and other dietary/weight groups on measures of perceived control, assertiveness, self-esteem, and self-directed hostility.

Anorexic and bulimic patients were compared to obese dieters, nonobese dieters, and normal controls on measures of perceived control, assertiveness, self-esteem, self-directed hostility, and psychiatric caseness. The anorexic and bulimic groups both scored significantly differently in the expected direction from the other three groups on all measures. There were no significant differences between the anorexic and bulimic groups and in turn, no significant differences among the obese, nonobese dieters, and normal controls. Results are in keeping with the notion that perceived control, low assertiveness, low self-esteem, and self-directed hostility are characteristics of eating disorder patients that differentiate them from individuals who display dietary/weight features, as well as from normal controls.

Anomalies in the Measurement of Changes in Total‐Body Bone Mineral by Dual‐Energy X‐Ray Absorptiometry During Weight Change

For an eating disorder study over a period of 1 year, we measured total‐body bone mineral using a Hologic QDR 1000W in a total of 157 subjects and observed anomalies that questioned the accuracy of such measurements. Using the recommended Enhanced software, a change in total bone mineral content (ΔBMC) correlated positively with a change in weight (ΔW; r = 0.66), but a loss of weight was associated with an increase in bone mineral areal density (BMD; r = 0.58), arising from a reduction in bone area (AREA). Both regressions were highly significant. The dominant factor in this relationship was a strong correlation between ΔAREA and ΔBMC, for all parts of the skeleton, r > 0.9, with a slope close to 1. This is implausible because bone area would not be expected to change. When Standard software was used, the slope of the ΔBMC/ΔW correlation was steeper, but the ΔBMD/ΔW regression became positive. An artefact of dual‐energy X‐ray absorptiometry processing was suspected, and phantom measurements were made. The phantom consisted of tissue‐equivalent hardboard cut and stacked to form cylinders corresponding to the head, trunk, arms, and legs of a standard man. The skeleton was constructed from layers of aluminium sheet as an approximation of the average shape, BMD, BMC, and AREA in each region. When aluminium thickness was varied, BMD thresholds were found, approximately 0.4 g/cm2 for the legs and 0.2 g/cm2 for the arms. Above these, bone area rose fairly rapidly toward a plateau. At higher skeletal densities, the relationships between measured and true BMDs were close to linear, but slopes were less than unity, so that changes would be underestimated by 10–30%. Increases of thickness of the soft tissue of the phantom lowered AREA slightly. Uniform fat proportion increases led to decreases in BMC and AREA, but lard wrapped in an annulus around the limbs led to spurious increases in BMC and AREA of a similar magnitude to those observed in vivo, while BMD fell slightly, although there had been no true change of bone variables. Similar results were obtained with lard around the limbs of a volunteer. Reanalysis of phantom scans using Standard software confirmed the software differences noted in vivo. The phantom measurements offer an explanation of the anomaly in vivo and demonstrate that, under different circumstances, change in both BMC and BMD can be wrongly recorded. We believe that no valid conclusions can be drawn from measurements by the Holgic QDR 1000W of bone changes during weight change.

Body mass index as an estimate of body fat.

Body mass index (BMI) was compared with percentage body fat (%Fat) measured by dual energy X-ray absorptiometry (DXA) in 233 adolescent schoolgirl volunteers and 179 adult female patients. Repeat measurements were made on 67 of the adolescents and 51 of the adults. The correlations between BMI and %Fat were established from the 300 adolescent measurements and the 230 adult measurements. Although highly significant relationships were found between BMI and %Fat, only 58% of the variance in %Fat in adolescents and 66% in adults could be predicted by BMI. At the 95% confidence levels, a BMI of 20 kg m-2 can correspond to a range of 18-33% body fat in adolescents and 13-32% in adults. Without any change in BMI, an adolescents percentage fat can change by as much as -3% to +7%. For an individual adult the same BMI can correspond to changes in fat of +/-5%. Since the strength of prediction of percentage body fat from BMI is poor, caution should be exercised in its use for eating disorders research.

Psychotherapy for bulimia: A controlled study

A psychotherapy study for bulimia is described. The preliminary results of a random allocation control trial comparing cognitive behaviour therapy, behaviour therapy and group psychotherapy with a waiting list control are presented. The results of the first 60 subjects in active treatment are shown. They indicate that all three treatments are effective in dramatically reducing the behavioural symptoms of the bulimia syndrome. There is evidence that cognitive therapy has a greater effect on symptoms of depression and self-esteem. No evidence is yet available on the longterm outcome of the three treatments.

Development and validation of the stirling eating disorder scales

The development and reliability/validity check of an 80-item, 8-scale measure for use with eating disorder patients is presented. The Stirling Eating Disorder Scales (SEDS) assess anorexic dietary behavior, anorexic dietary cognitions, bulimic dietary behavior, bulimic dietary cognitions, high perceived external control, low assertiveness, low self-esteem, and self-directed hostility. The SEDS were administered to 82 eating disorder patients and 85 controls. Results indicate that the SEDS are acceptable in terms of internal consistency, reliability, group validity, and concurrent validity.

Osteoporosis and normal weight bulimia nervosa— which patients are at risk?

This study assesses the degree of bone mineral loss in women with active DSM IIIR bulimia nervosa. The subjects in this study were 20 GP-referred female patients of normal weight who met criteria for bulimia nervosa and 16 healthy age, sex and weight matched controls. Dual energy X-ray densitometry of lumbar L1-L4 vertebrae was performed on all subjects. The patients with bulimia nervosa had a significantly lower mean lumbar bone mineral density (0.964 g/cm2) than the control group (1.043 g/cm2, p < 0.01). Within the patient group only subjects with a past history of anorexia nervosa had a significantly lower mean bone mineral density (BMD) than the controls. Small sample sizes limit the power of the study, however significant correlations were found between duration of amenorrhoea, low BMI and lumbar BMD. Bulimic patients do suffer from osteoporosis. Risk factors for this may be; a past history of anorexia nervosa, prolonged secondary amenorrhoea, and a persistently low body mass index.

Specificity of the salivary cortisol dexamethasone suppression test across psychiatric diagnoses

One hundred forty-eight psychiatric inpatients, 12 outpatients, and 17 normal controls were given the 1.0-mg overnight Dexamethasone Suppression Test (DST), with salivary cortisol concentrations being measured as the dependent variable. Based on the Structured Clinical Interview for DSM-III, the patients were diagnosed as having major depression with melancholia (n = 21), nonmelancholic major depression (n = 50), mania (n = 15), schizophrenia (n = 32), dementia (n = 6), substance dependence/abuse n = 18), and miscellaneous (n = 18). Neither the melancholic major depressives nor the entire group of major depressives had significantly higher salivary cortisol pre- or postdexamethasone as compared with all the other patients combined, nor did the melancholic patients have significantly higher cortisol than the nonmelancholic depressives. The inpatients as a group had significantly higher pre- and postdexamethasone cortisol values than the normal controls; cortisol values for the outpatients were intermediate between these two groups. Illness severity (in the depressives), length of time in hospital before the DST, and medication regimen were all unrelated to DST outcome. Thus, in this study, the salivary cortisol DST showed little clinical utility in discriminating major depressives with and without melancholia from other patients with a broad range of psychiatric diagnoses. The test did distinguish between hospitalized psychiatric patients and normal control subjects and between depressed inpatients and depressed outpatients, indicating that hospitalization-related variables contributed to DST outcome.

Electroconvulsive therapy in Scottish clinical practice: a national audit of demographics, standards, and outcome.

Objectives: Many of the commonly expressed concerns about the effectiveness of electroconvulsive therapy (ECT) have been addressed by scientific studies. However, this has done little to reassure service users and the public at large about its use in routine clinical practice. This 3-year study between 1997 and 1999 consisted of a series of audit cycles to systematically answer questions about ECT demographics and outcome across Scotland. Methods: Audit standards were agreed and each ECT clinic was visited at least twice to assess facilities and adherence to protocol as set down by the Royal College of Psychiatrists, UK. Demographics and outcome after ECT were measured during 2 9-month sample periods. Adequacy of teaching and supervision was assessed directly and by questionnaire. Results: Facilities and equipment at ECT centers were up to date and generally of a high standard. ECT was given at a rate of 142 treatments per 100,000, mainly to white adult patients suffering from a depressive disorder. The ratio of females to males was approximately 2 to 1, and ECT was not given disproportionately to the elderly. 76% of patients were of informal status and 82% gave informed consent, with the remaining 18% receiving treatment under the safeguards of the Mental Health (Scotland) Act 1984. There was a definite clinical improvement with treatment, defined as at least a 50% fall in the Montgomery Asberg Depression Scale, in 71% of those treated for depressive illness. 65% of those treated for a non -depressive psychosis were rated as at least ‘much improved’ on the Clinical Global Impression scale. Conclusions: ECT given in routine clinical settings across Scotland meets Royal College of Psychiatrists standards and is an effective treatment of the clear majority of patients.

DSM-III Melancholia: Do the criteria accurately and reliably distinguish endogenous pattern depression?

The Structured Clinical Interview for DSM-III (SCID), Newcastle Endogenous/Reactive Index, Feinberg-Carroll Discriminant Index, and Hamilton Depression Scale were used to assess 70 depressed patients in order to determine similarities and differences in symptom structure and severity in those patients with and without endogenous/melancholic depression. All patients with melancholia according to DSM-III had definite endogenous major depression by the Research Diagnostic Criteria (RDC), but only 20 out of 35 patients with RDC definite endogenous depression were DSM-III melancholic. There was a greater difference in symptom pattern between those patients with definite endogenous depression and those with probable or non-endogenous depression than there was between the melancholic and non-melancholic definite endogenous depressives. A prerequisite for the valid delineation of a nosological category is the establishment of good reliability for diagnostic criteria. Using SCID ratings of audiotaped interviews of 9 patients (5 with major depression), the 8 raters in this study achieved a kappa coefficient of 0.79, suggesting that the use of a structured interview can improve the reliability of DSM-III diagnoses. Interrater reliabilities for most of the individual DSM-III major depressive episode and melancholia items were reasonable, but some were low. The low reliabilities could be improved by redefinition of the items to reduce ambiguity and by development of a SCID glossary.