John F. Morgan

The SCOFF questionnaire and clinical interview for eating disorders in general practice: comparative study.

Standards 2 and 3 of the national service framework for mental health outline the need to improve health care for patients with anorexia nervosa and bulimia nervosa.1 Healthcare workers in primary care are at the forefront of screening and managing these disorders. Assessment tools available to primary healthcare professionals can take a long time to administer and may need to be interpretedby specialists2; this may limit improvements in care. A screening tool was developed, but only to facitate epidemiological research.3 The SCOFF questionnaire is a brief and memorable tool designed to detect eating disorders and aid treatment (see figure). It showed excellent validity in a clinical population and reliability in a student population. 4 5 We assessed the SCOFF questionnaire in primary care. We invited sequential women attenders (aged 18-50) at two general practices in southwest London to participate. We gave participants …

Prevalence of anxiety and depression in osteoarthritis: use of the Hospital Anxiety and Depression Scale as a screening tool

The aims of this study are to ascertain the prevalence of anxiety and depressive disorders in an outpatient population with osteoarthritis (OA), examine the interrelationships between severity of OA, pain, disability, and depression, and evaluate the Hospital Anxiety and Depression Scale (HADS) as a screening tool for this population. Patients with lower limb OA were evaluated with the Short Form McGill Pain and Present Pain Index Questionnaires, and a visual analogue scale, WOMAC Osteoarthritis Index-section C, and the HADS. Participants underwent a structured clinical interview by a liaison psychiatrist (AB). X-rays of affected joints were rated for disease severity. Fifty-four patients (42 females; mean age 63.3) were investigated. The prevalence of clinically significant anxiety and/or depression was 40.7% (95% confidence interval (CI), 27.6–55.0%). HADS was a good predictor of anxiety and depression with a sensitivity and specificity of 88% (95%CI, 64% to 99%) and 81% (95%CI, 65% to 92%), respectively. Pain correlated with HADS anxiety and depression scores (e.g. Rank correlation coefficients (Kendall’s tau-b) between total HADS scores and Pain VAS scores 0.29; p = 0.003). Disability was greater in patients with depression and/or anxiety (e.g. total HADS score; Kendall’s rank correlation coefficient tau-b = 0.26, p = 0.007) OA severity as determined by radiological score was not a good predictor for anxiety nor depression and only weakly associated with disability. Anxiety and depression are very common in OA patients. HADS anxiety was a better predictor of diagnosed anxiety than HADS depression was of diagnosed depression. HADS is a valid and reliable screening instrument for detecting mood disorder, but not a diagnostic tool or a substitute for asking about symptoms of depression. The interrelationship between mental health, pain and disability is strong. We should therefore adopt a multidisciplinary approach to the management of OA.

Risk of postnatal depression, miscarriage, and preterm birth in bulimia nervosa: retrospective controlled study.

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. BN = bulimia nervosa; CI = confidence interval; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; EDNOS = eating disorder not otherwise specified; GP = general practitioner; OR = odds ratio; PCOS = polycystic ovary syndrome; SCID = Structured Clinical Interview for DSM-III-R; SD = standard deviation.

Polycystic ovarian morphology and bulimia nervosa: a 9-year follow-up study

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.

Spiritual starvation?: a case series concerning christianity and eating disorders.

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.

Season of birth and bulimia nervosa

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.

Pouch Dilatation following Laparoscopic Adjustable Gastric Banding: Psychobehavioral Factors (Can Psychiatrists Predict Pouch Dilatation?)

Background: Laparoscopic adjustable gastric banding is increasingly being performed in morbidly obese individuals for weight loss. Some patients develop pouch dilatation as a postoperative complication that limits the utility of the procedure. Surgical variables are poor predictors of this complication. 5 patients from a series of 157 who underwent LAGB at a single center developed the condition. Methods: Psychiatric and surgical case-notes were analyzed retrospectively for the presence of operationally defined psychiatric disorders and compared to 10 controls from the same population. Results: Cases were significantly more likely to have past or current binge eating, emotionally triggered eating with reduced awareness of the link, a history of affective disorder, reduced sexual functioning and successful preoperative weight loss. No difference between groups was observed for compliance with orlistat, childhood sexual abuse, relationships with parents, history of bulimia nervosa, rate of band inflation or preoperative BMI. Conclusions: Psychological factors may be better predictors of pouch dilatation than biomedical variables. Disordered eating can be an attempt to modulate negative emotions. Pouch dilatation may be a consequence of this eating behavior.

Use of leucotomy for intractable anorexia nervosa: A long-term follow-up study

OBJECTIVE We studied the long-term outcomes of intractable anorexia nervosa treated with leukotomy and specialized psychotherapy over 20 years ago. METHOD All traceable subjects were interviewed using the Eating Disorders Examination (EDE) and the Structured Clinical Interview for DSM-III-R (SCID). They also completed questionnaires. Detailed histories were taken. RESULTS Four of five female subjects were traced. Their cases had been severe, with failure of previous intensive psychotherapy and now with high risk of death from terminal inanition. One patient had committed suicide, whereas the others enjoyed a reasonable quality of life. Persistent core psychopathology was evident, but patients had not succumbed to weight loss. All suffered depression and anxiety-related disorders, but endorsed their treatment, which had allowed sustained weight gain by release of appetitive behavior, provision of a license to change, and alleviation of phobic anxiety, allowing psychotherapeutic engagement. DISCUSSION We argue that these outcomes are relatively favorable and would not have been possible without this latter engagement in specialist psychotherapy to address burgeoning panic at unavoidable weight gain.

Costs of the police service and mental healthcare pathways experienced by individuals with enduring mental health needs

Background Substantial policy, communication and operational gaps exist between mental health services and the police for individuals with enduring mental health needs. Aims To map and cost pathways through mental health and police services, and to model the cost impact of implementing key policy recommendations. Method Within a case-linkage study, we estimated 1-year individual-level healthcare and policing costs. Using decision modelling, we then estimated the potential impact on costs of three recommended service enhancements: street triage, Mental Health Act assessments for all Section 136 detainees and outreach custody link workers. Results Under current care, average 1-year mental health and police costs were £10 812 and £4552 per individual respectively (n = 55). The cost per police incident was £522. Models suggested that each service enhancement would alter per incident costs by between −8% and +6%. Conclusions Recommended enhancements to care pathways only marginally increase individual-level costs.

Psychogenic Mania and Bereavement

Early notions of mania invoked a combination of psychogenic and organic factors, but psychogenic mania has not endured as a concept. We present a 37-year-old woman with an acute manic episode precipitated by the prolonged death of her husband from cancer. To our knowledge this is the first published account of ‘maniacal grief’ in the absence of pre-existing affective disorder, and with clear causal relations. Mania was clearly induced by the bereavement and we argue that the loss represented more than a non-specific life event. This case supports a re-examination of mania as potentially a ‘reactive’ or psychogenic phenomenon.