Mark A. Blais

Mortality in eating disorders: a descriptive study.

OBJECTIVE We report rates and causes of death for a cohort of 246 eating-disordered women and provide descriptive information on their eating disorder and comorbid diagnoses. METHOD Data on mortality were collected as part of a longitudinal study of anorexia nervosa and bulimia nervosa, now in its 11th year. Other data sources included death certificates, autopsy reports, relative interviews, and a National Death Index search. RESULTS Seven deaths have occurred during the study, all among anorexic subjects with a history of binging and purging and with comorbid Axis I disorders. The crude mortality rate was 5.1%. The standardized mortality ratios for death (9.6) and suicide (58.1) were significantly elevated (p <. 001). CONCLUSIONS Anorexia nervosa is associated with a substantial risk of death and suicide. Features correlated with fatal outcome are longer duration of illness, binging and purging, comorbid substance abuse, and comorbid affective disorders.

Psychometric Properties of the Rosenberg Self-Esteem Scale: Overall and Across Demographic Groups Living Within the United States

The purpose of this study was twofold: (a) to evaluate the scaling assumptions and component structure of and present normative data for the Rosenberg Self-Esteem Scale (RSES) using a sample of US adults (N = 503), both overall and across demographic subgroups and (b) to provide new data regarding the relationship between the two RSES subcomponents of self-competence (SC) and self-liking (SL), and other demographic and clinical variables. As hypothesized, all psychometric tests supported the underlying structure of the RSES. Overall RSES scores varied significantly across age, racial and ethnic, education, employment status, income, and marital status groups. Furthermore, differences between SC and SL were also found across groups differing in gender, age, employment status, and marital status groups. The implications and limitations of this study are discussed, with an emphasis on clinical relevance.

Correlates of health-related quality of life in type 2 diabetes

Aims/hypothesisWe assessed the impact of medical comorbidities, depression, and treatment intensity on quality of life in a large primary care cohort of patients with type 2 diabetes.MethodsWe used the Health Utilities Index-III, an instrument that measures health-related quality of life based on community preferences in units of health utility (scaled from 0=death to 1.0=perfect health), in 909 primary care patients with type 2 diabetes. Demographic and clinical correlates of health-related quality of life were assessed.ResultsThe median health utility score for this population was 0.70 (interquartile range 0.39–0.88). In univariate analyses, older age, female sex, low socioeconomic status, cardiovascular disease, microvascular complications, congestive heart failure, peripheral vascular disease, chronic lung disease, depression, insulin use and number of medications correlated with decreased quality of life, while obesity, hypertension and hypercholesterolaemia did not. In multiple regression analyses, microvascular complications, heart failure and depression were most strongly related to decreased health-related quality of life, independently of duration of diabetes; in these models, diabetes patients with depression had a utility of 0.59, while patients without symptomatic comorbidities did not have a significantly reduced quality of life. Treatment intensity remained a significant negative correlate of quality of life in multivariable models.Conclusions/interpretationPatients with type 2 diabetes have a substantially decreased quality of life in association with symptomatic complications. The data suggest that treatment of depression and prevention of complications have the greatest potential to improve health-related quality of life in type 2 diabetes.

Development and Initial Validation of a Brief Mental Health Outcome Measure

Using a combination of classical test theory and Rasch item analysis, we developed a short scale designed to measure the effectiveness of mental health treatment across a wide range of mental health services and populations. Item development for the scale was guided by literature review and interviews with senior clinicians and with patients. Using 3 different samples consisting of inpatients, outpatients, and nonpatients, we reduced our initial item pool from 81 to 10 items. The 10-item scale had an alpha of .96 and showed strong correlations with commonly used measures of psychological well-being and distress. Our results suggest that the scale appears to measure a broad domain of psychological health. The scale appeared to lack ceiling and floor effects, and it discriminated between inpatients, outpatients, and nonpatients, suggesting the scale has excellent potential to be broadly responsive to a variety of treatment effects. In addition, the new scale proved to be sensitive to treatment changes in a sample of 20 psychiatric inpatients. Overall, the initial data suggest that we have developed a brief, sensitive outcome measure designed to have wide application across psychiatric and psychological treatments and populations.

Psychometric Evaluation and Normative Data for the Depression, Anxiety, and Stress Scales-21 (DASS-21) in a Nonclinical Sample of U.S. Adults

Health care professionals are coming under increased pressure to empirically monitor patient outcomes across settings as a means of improving clinical practice. Within the psychiatric and primary care communities, many have begun utilizing brief psychometric measures of psychological functioning to accomplish these goals. The purpose of this study was to evaluate the psychometric properties and clinical utility of the Depression, Anxiety, and Stress Scales—21-item version (DASS-21), and contribute normative data to facilitate interpretation using a sample of U.S. adults (N = 503). Item-scale convergence was generally supported, although assumptions of item-scale divergence were not met. Only 86%, 50%, and 43% of Depression, Anxiety, and Stress items, respectively, correlated significantly greater with their hypothesized scales than other scales. Internal consistency reliability was acceptable for all scales and comparable to existing research (αs = .91, .80, and .84 for Depression, Anxiety, and Stress, respectively). Scale-level correlations were greater than what has been reported elsewhere (range of rs = .68 to .73), and principal components analysis supported the extraction of only one component accounting for 47% of the item-level variance. However, confirmatory factor analysis (CFA) favored a three-factor structure when compared to a one-factor model. The implications for the health care professions are discussed.

Pregnancy: Outcome and impact on symptomatology in a cohort of eating‐disordered women

OBJECTIVE This study investigates both the impact of eating disorders (ED) on pregnancy outcome and the impact of pregnancy on cognitive and behavioral symptoms of EDs. METHOD Data on pregnancy outcome (live birth [LB], therapeutic abortion [TAB], and spontaneous abortion [SAB]) and ED symptomatology were collected as part of a large, prospective longitudinal study of anorexia nervosa (AN) and bulimia nervosa (BN). Data were gathered using a semistructured interview administered every 6 months to 246 subjects. RESULTS We identified 54 women who reported 82 pregnancies (46 LB, 25 TAB, and 11 SAB). Pregnancy outcome was not significantly related to any of the clinical variables studied. Women with BN showed a significant decrease in the severity of their ED symptoms during pregnancy, and this decrease was sustained through 9 months postpartum. Women with AN also demonstrated a significant reduction in ED symptoms, however, these symptoms returned to prepregnancy levels by 6 months postpartum. CONCLUSIONS Our prospective findings reveal an elevated TAB rate for ED women along with a general reduction in the severity of ED symptoms during pregnancy.

Clinician ratings of the five-factor model of personality and the DSM-IV personality disorders.

This study explored the associations among the domains of the five-factor model (FFM) of personality (neuroticism, extraversion, openness, agreeableness, and conscientiousness) and the DSM-IV personality disorders (PDs). Clinician ratings were obtained for both the DSM-IV PDs and the FFM on a sample of 100 PD patients. The correlational data showed that the DSM PDs were most strongly associated with the FFM domains of neuroticism, extraversion, and agreeableness. Factor analysis revealed four underlying factors that provided insights into qualities shared by subgroups of the DSM-IV PDs. The domain of neuroticism was associated with the borderline, avoidant, and dependent PDs (factor 1). The paranoid, avoidant, schizoid, and schizotypal PDs were negatively associated with the domain of agreeableness (factor 2). The domain of extraversion was positively associated with the narcissistic and histrionic PDs and negatively with schizoid PD (factor 3). The FFM conscientiousness and openness domains loaded onto a single factor and were positively associated with the obsessive-compulsive PD and negatively associated with the antisocial and borderline PDs. Exploring the relationships between these two personality systems will improve our conceptualization and understanding of the DSM PDs.

What predicts suicide attempts in women with eating disorders

BACKGROUND Suicide is a common cause of death in anorexia nervosa and suicide attempts occur often in both anorexia nervosa and bulimia nervosa. No studies have examined predictors of suicide attempts in a longitudinal study of eating disorders with frequent follow-up intervals. The objective of this study was to determine predictors of serious suicide attempts in women with eating disorders. METHOD In a prospective longitudinal study, women diagnosed with either DSM-IV anorexia nervosa (n = 136) or bulimia nervosa (n = 110) were interviewed and assessed for suicide attempts and suicidal intent every 6-12 months over 8.6 years. RESULTS Fifteen percent of subjects reported at least one prospective suicide attempt over the course of the study. Significantly more anorexic (22.1%) than bulimic subjects (10.9%) made a suicide attempt. Multivariate analyses indicated that the unique predictors of suicide attempts for anorexia nervosa included the severity of both depressive symptoms and drug use over the course of the study. For bulimia nervosa, a history of drug use disorder at intake and the use of laxatives during the study significantly predicted suicide attempts. CONCLUSIONS Women with anorexia nervosa or bulimia nervosa are at considerable risk to attempt suicide. Clinicians should be aware of this risk, particularly in anorexic patients with substantial co-morbidity.

Development of a Brief Screening Instrument: The HANDS

Background: The present study was designed to develop a briefer screening scale of approximately 10 items which maintained the validity of the Zung Self-Rating Depression Scale in a sample similar to that attending National Depression Screening Day (NDSD), as well as a more general audience. Methods: We first administered 70 items from a variety of existing rating scales to 40 subjects who answered an ad for depressed subjects and 55 who answered an ad for non-depressed subjects, all of whose diagnoses were confirmed by the Structured Clinical Interview for DSM-IV (SCID). Based on the correlation between each item and the diagnostic criterion, we reduced the number of items to 17 which we then administered to another 45 subjects who answered an ad similar to that used for NDSD and also underwent a SCID interview. Based on these results, we arrived at the final 10-item Harvard Department of Psychiatry/NDSD scale (HANDS) with the assistance of the item-response theory. The items are scored for frequency of occurrence of each symptom over the past 2 weeks. Total scores range from 0 to 30. Results: The 10-item scale (HANDS) has good internal consistency and validity: a cutpoint score of 9 or greater gave sensitivity of at least 95% in both studies. Although specificity was lower for all scales in the self-selected population, the HANDS performed at least as well as the 20-item Zung Scale, the 21-item Beck Depression Inventory-II and the 15-item Hopkins Symptom Depression Checklist. Conclusion: The 10-item HANDS performs as well as other widely used longer self-report scales and has the advantage of briefer administration time.

The Anxiety Sensitivity Index: Item Analysis and Suggestions for Refinement

Anxiety sensitivity is the fear of anxiety-related sensations, and is measured by the 16-item Anxiety Sensitivity Index (ASI; Reiss, Peterson, Gursky, & McNally, 1986). Despite the popularity and utility of the ASI in research, a number of studies have provided evidence for the inadequacy of several items, and item-to-scale correlations for the ASI have not been published. In this study, a converging set of analyses to evaluate the item adequacy and factor structure of the ASI was used. The results of these multiple analyses converged nicely suggesting that Items 1, 5, 7, 8, and 13 should be considered for removal from the instrument. The impact of removing these problematic items from the scale was explored through the reanalysis of data from 3 previously published studies that compared the original ASI with the new 11-item version (the ASI minus the 5 problematic items). The results of these analyses suggest that the 2 scales function comparably in many respects but that the new version may be a more precise measure of anxiety sensitivity. The 11-item ASI appears to tap 2 primary aspects of anxiety sensitivity: fears of somatic sensations of anxiety and fears of loss of mental control. Suggestions for further development of the ASI are offered.