Hans W. Hoek

Incidence, prevalence and mortality of anorexia nervosa and other eating disorders.

Purpose of review The purpose of this review is to evaluate the recent literature on the incidence and prevalence of and mortality associated with eating disorders. Recent findings General-practice studies show that the overall incidence rates of anorexia nervosa remained stable during the 1990s, compared with the 1980s. Some evidence suggests that the occurrence of bulimia nervosa is decreasing. Anorexia nervosa is a common disorder among young white females, but is extremely rare among black females. Recent studies confirm previous findings of the high mortality rate within the anorexia nervosa population. Summary The incidence of anorexia nervosa is around eight per 100 000 persons per year. An upward trend has been observed in the incidence of anorexia nervosa in the past century till the 1970s. The most substantial increase was among females aged 15–24 years, for whom a significant increase was observed from 1935 to 1999. The average prevalence rates for anorexia nervosa and bulimia nervosa among young females are 0.3 and 1%, respectively. Only a minority of people with eating disorders, especially with bulimia nervosa, are treated in mental healthcare.

Should We Expand the Toolbox of Psychiatric Treatment Methods to Include Repetitive Transcranial Magnetic Stimulation (rTMS)? A Meta-Analysis of the Efficacy of rTMS in Psychiatric Disorders

OBJECTIVE Repetitive transcranial magnetic stimulation (rTMS) is a safe treatment method with few side effects. However, efficacy for various psychiatric disorders is currently not clear. DATA SOURCES A literature search was performed from 1966 through October 2008 using PubMed, Ovid Medline, Embase Psychiatry, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, and PsycINFO. The following search terms were used: transcranial magnetic stimulation, TMS, repetitive TMS, psychiatry, mental disorder, psychiatric disorder, anxiety disorder, attention-deficit hyperactivity disorder, bipolar disorder, catatonia, mania, depression, obsessive-compulsive disorder, psychosis, posttraumatic stress disorder, schizophrenia, Tourettes syndrome, bulimia nervosa, and addiction. STUDY SELECTION Data were obtained from randomized, sham-controlled studies of rTMS treatment for depression (34 studies), auditory verbal hallucinations (AVH, 7 studies), negative symptoms in schizophrenia (7 studies), and obsessive-compulsive disorder (OCD, 3 studies). Studies of rTMS versus electroconvulsive treatment (ECT, 6 studies) for depression were meta-analyzed. DATA EXTRACTION Standardized mean effect sizes of rTMS versus sham were computed based on pretreatment-posttreatment comparisons. DATA SYNTHESIS The mean weighted effect size of rTMS versus sham for depression was 0.55 (P < .001). Monotherapy with rTMS was more effective than rTMS as adjunctive to antidepressant medication. ECT was superior to rTMS in the treatment of depression (mean weighted effect size -0.47, P = .004). In the treatment of AVH, rTMS was superior to sham treatment, with a mean weighted effect size of 0.54 (P < .001). The mean weighted effect size for rTMS versus sham in the treatment of negative symptoms in schizophrenia was 0.39 (P = .11) and for OCD, 0.15 (P = .52). Side effects were mild, yet more prevalent with high-frequency rTMS at frontal locations. CONCLUSIONS It is time to provide rTMS as a clinical treatment method for depression, for auditory verbal hallucinations, and possibly for negative symptoms. We do not recommend rTMS for the treatment of OCD.

Auditory verbal hallucinations predominantly activate the right inferior frontal area.

The pathophysiology of auditory verbal hallucinations (AVH) is largely unknown. Several functional imaging studies have measured cerebral activation during these hallucinations, but sample sizes were relatively small (one to eight subjects) and findings inconsistent. In this study cerebral activation was measured using fMRI in 24 psychotic patients while they experienced AVH in the scanner and, in another session, while they silently generated words. All patients were right handed and diagnosed with schizophrenia, schizo-affective disorder or psychotic disorder not otherwise specified. Group analysis for AVH revealed activation in the right homologue of Brocas area, bilateral insula, bilateral supramarginal gyri and right superior temporal gyrus. Brocas area and left superior temporal gyrus were not activated. Group analysis for word generation in these patients yielded activation in Brocas and Wernickes areas and to a lesser degree their right-sided homologues, bilateral insula and anterior cingulate gyri. Lateralization of activity during AVH was not correlated with language lateralization, but rather with the degree to which the content of the hallucinations had a negative emotional valence. The main difference between cerebral activity during AVH and activity during normal inner speech appears to be the lateralization. The predominant engagement of the right inferior frontal area during AVH may be related to the typical low semantic complexity and negative emotional content.

Epidemiology, course, and outcome of eating disorders

Purpose of review To review the recent literature about the epidemiology, course, and outcome of eating disorders in accordance with the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Recent findings The residual category ‘eating disorder not otherwise specified’ (EDNOS) was the most common DSM-IV eating disorder diagnosis in both clinical and community samples. Several studies have confirmed that the DSM-5 criteria for eating disorders effectively reduce the proportion of EDNOS diagnoses. The lifetime prevalence of DSM-5 anorexia nervosa among women might be up to 4%, and of bulimia nervosa 2%. In a cross-national survey, the average lifetime prevalence of binge eating disorder (BED) was 2%. Both anorexia nervosa and bulimia nervosa are associated with increased mortality. Data on long-term outcome, including mortality, are limited for BED. Follow-up studies of BED are scarce; remission rates in randomized controlled trials ranged from 19 to 65% across studies. On a community level, 5-year recovery rates for DSM-5 anorexia nervosa and bulimia nervosa are 69 and 55%, respectively; little is known about the course and outcome of BED in the community. Summary Applying the DSM-5 criteria effectively reduces the frequency of the residual diagnosis EDNOS, by lowering the threshold for anorexia nervosa and bulimia nervosa, and adding BED as a specified eating disorder. Course and outcome studies of both anorexia nervosa and bulimia nervosa show that no significant differences exist between DSM-5 and DSM-IV definitions.

The incidence and prevalence of anorexia nervosa and bulimia nervosa in primary care

General practitioners using DSM-III criteria have studied the incidence and prevalence of anorexia nervosa and bulimia nervosa in a large (N = 151,781) representative sample of the Dutch population. The incidence rate for anorexia nervosa is 6.3 and for bulimia nervosa 9.9 per year per 100,000 population. The prevalence of bulimia nervosa is three times higher in larger cities than in smaller urbanized or rural areas, while anorexia nervosa is found with almost equal frequency in areas with a different degree of urbanization.

Incidence of schizophrenia among ethnic minorities in the Netherlands : A four-year first-contact study

There is only one previous report on the first-contact incidence of schizophrenia among immigrants in the Netherlands, which was based on a small number of cases, particularly for second generation immigrants. We conducted another two-year first-contact incidence study in the same geographical area, combined the data of both studies and compared risks over all four years. The incidence of schizophrenia was increased for all first generation non-Western immigrants. The risk was particularly high for second generation immigrants: the age- and gender-adjusted incidence rate ratio was 5.8 (95% CI, 2.9-11.4) for Moroccans, 2.9 (1.6-5.0) for Surinamese, 2.3 (1.0-5.4) for Turks, and 3.5 (1.8-6.8) for immigrants from other non-Western countries.

Incidence and outcomes of bulimia nervosa : a nationwide population-based study

BACKGROUND Little is known about the epidemiology of bulimia nervosa outside clinical settings. We report the incidence, prevalence and outcomes of bulimia nervosa using for the first time a nationwide study design. METHOD To assess the incidence and natural course and outcomes of DSM-IV bulimia nervosa among women from the general population, women (n=2881) from the 1975-79 birth cohorts of Finnish twins were screened for lifetime eating disorders using a two-stage procedure consisting of a questionnaire screen and the Structured Clinical Interview for DSM-IV (SCID). Clinical recovery was defined as 1-year abstinence from bingeing and purging combined with a body mass index (BMI) 19 kg/m2. RESULTS The lifetime prevalence of DSM-IV bulimia nervosa was 2.3%; 76% of the women suffered from its purging subtype and 24% from the non-purging subtype. The incidence rate of bulimia nervosa was 300/100000 person-years at the peak age of incidence, 16-20 years, and 150/100000 at 10-24 years. The 5-year clinical recovery rate was 55.0%. Less than a third of the cases had been detected by health-care professionals; detection did not influence outcome. After clinical recovery from bulimia nervosa, the mean levels of residual psychological symptoms gradually decreased over time but many women continued to experience significantly more body image problems and psychosomatic symptoms than never-ill women. CONCLUSIONS Few women with bulimia nervosa are recognized in health-care settings. Symptoms of bulimia are relatively long-standing, and recovery is gradual. Many clinically recovered women experience residual psychological symptoms after attaining abstinence from bingeing and purging.

Acute dystonia induced by drug treatment

Acute dystonia induced by drug treatment can be a side effect of treatment with antipsychotic drugs and other drugs, and it may occur at an early stage of treatment.1 2 Acute dystonia is often frightening and may seriously disturb the relationship between the doctor and the patient. Therefore, every doctor who prescribes dopamine blocking agents should be familiar with the prevalence of and the risk factors for acute dystonia and should know how to prevent and treat the condition. #### Summary points Acute dystonia induced by drug treatment can be caused by antipsychotic, antiemetic, and antidepressant drugs Acute dystonia caused by drug treatment can seriously disturb the relationship between doctor and patient and should be prevented Patients who develop abnormal positioning or muscle spasms within seven days of starting drug treatment or of a rapid increase in the dose of a drug may be diagnosed with acute, drug induced dystonia Biperiden 5 mg should be administered intramuscularly to treat the condition; this is nearly always effective within 20 minutes Risk factors for acute, drug induced dystonia include young age, male sex, use of cocaine, and a history of acute dystonia Drug induced dystonia can be prevented either by adding, during the first four to seven days of treatment, anticholinergic drugs to treatment with antipsychotic drugs or by starting treatment with atypical antipsychotics We searched Medline and Embase for the period 1980-98 using the key terms extrapyramidal syndromes, dyskinesia, dystonia, movement disorders, side effects, and antipsychotics, and we checked the reference lists of the articles that we identified. This information supplemented our own research into extrapyramidal side effects induced by antipsychotic drugs.3–5 Acute dystonia induced by antipsychotic drugs is described as “sustained abnormal postures or muscle spasms that develop within seven days of starting or rapidly raising the dose of …

Can Low-Frequency Repetitive Transcranial Magnetic Stimulation Really Relieve Medication-Resistant Auditory Verbal Hallucinations? Negative Results from a Large Randomized Controlled Trial

BACKGROUND Several studies have applied low-frequency repetitive transcranial magnetic stimulation (rTMS) directed at the left temporoparietal area (TP) for the treatment of auditory verbal hallucinations (AVH), but findings on efficacy are inconsistent. Furthermore, recent functional magnetic resonance imaging (fMRI) studies indicate that the left TP is not a general focus of activation during the experience of AVH. The aims of this study are twofold: to investigate the effects of rTMS on AVH in a double blind, randomized, sham-controlled study; and to investigate whether the efficacy can be improved when rTMS is guided by individual fMRI scans of hallucinatory activation. METHODS Sixty-two patients with medication-resistant AVH were randomized over three conditions: rTMS targeted at the area of maximal hallucinatory activation calculated from individual fMRI scans during AVH, rTMS directed at the left TP, and sham treatment. Repetitive TMS was applied during 15 sessions of 20 min each, at 1 Hz and 90% of the individual motor threshold. The severity of AVH and other psychotic symptoms were monitored during treatment and 3-month follow-up, with the Auditory Hallucination Rating Scale, the Positive and Negative Syndrome Scale, and the Psychotic Symptom Rating Scales. RESULTS The effects of fMRI-guided rTMS and left TP rTMS on the severity of AVH were comparable to those of sham treatment. No differences in severity of general psychotic symptoms were found among the three treatment conditions. CONCLUSIONS Low-frequency rTMS administered to the left TP or to the site of maximal hallucinatory activation is not more effective for medication-resistant AVH than sham treatment.

Validity and Utility of Subtyping Anorexia Nervosa

OBJECTIVE The purpose of this article is to review the available literature that addresses the predictive validity and utility of subtyping patients with anorexia nervosa (AN) into binge/purge and restrictor subtypes. METHOD Literature was reviewed including studies that compared individuals with subtype diagnoses on clinical and outcome variables as well as more recent research examining the frequency of diagnostic crossover. RESULTS Several studies found that in general the binge/purge subtype patients have more psychopathology, tend to be older, and tend to have a worse outcome. More recent studies which have examined diagnostic crossover suggest that the rate of crossover from the restrictor subtype to the binge/purge subtype is substantial. Crossover from the binge/purge to the restrictor subtype appears to occur less commonly. There is also literature documenting crossover from AN to bulimia nervosa (BN) and a small literature looking at crossover from BN to AN. DISCUSSION The results of this article suggest that although there is generally progression from restrictor AN to binge/purge AN to BN in a sizeable number of patients, other crossover patterns can be seen as well and the amount of crossover is quite large. This suggests a lack of predictive validity for subtypes.