Mark Berelowitz

Do adolescents with eating disorder not otherwise specified or full-syndrome bulimia nervosa differ in clinical severity, comorbidity, risk factors, treatment outcome or cost?

OBJECTIVE We wanted to know whether adolescents with eating disorder not otherwise specified (EDNOS) differ from those with bulimia nervosa (BN) in clinical features, comorbidity, risk factors, treatment outcome or cost. METHOD Adolescents with EDNOS (n = 24) or BN (n = 61) took part in a trial of family therapy versus guided self-care. At baseline, eating disorder symptoms, risk factors, and costs were assessed by interview. Patients were reinterviewed at 6 and 12 months. RESULTS Compared with EDNOS, BN patients binged, vomited and purged significantly more, and were more preoccupied with food. Those with EDNOS had more depression and had more current and childhood obsessive-compulsive disorder. 66.6% of EDNOS versus 27.8% of BN patients were abstinent from bingeing and vomiting at 1 year. Diagnosis did not moderate treatment outcome. Costs did not differ between groups. CONCLUSION EDNOS in adolescents is not trivial. It has milder eating disorder symptoms but more comorbidity than BN.

Comparison of specialist and nonspecialist care pathways for adolescents with anorexia nervosa and related eating disorders

OBJECTIVE To explore the role of specialist outpatient eating disorders services and investigate how direct access to these affects rates of referral, admissions for inpatient treatment, and continuity of care. METHOD Services beyond primary care in Greater London retrospectively identified adolescents who presented with an eating disorder over a 2-year period. Data concerning service use were collected from clinical casenotes. RESULTS In areas where specialist outpatient services were available, 2-3 times more cases were identified than in areas without such services. Where initial outpatient treatment was in specialist rather than nonspecialist services, there was a significantly lower rate of admission for inpatient treatment and considerably higher consistency of care. DISCUSSION Developing specialist outpatient services with direct access from primary care is likely to lead to improvements in treatment and reduce overall costs.

Why do adolescents with bulimia nervosa choose not to involve their parents in treatment

BackgroundAlthough the use of family therapy for adolescents with anorexia nervosa is well established, there has been limited research into the efficacy of family therapy in adolescents with bulimia nervosa (BN). No previous research has investigated why individuals with BN do or do not involve their parents in treatment. This is an exploratory study aimed at determining whether there are any differences between these individuals in terms of eating disorder symptomatology, psychopathology, familial risk factors, patients’ perception of parental expressed emotion (EE) and family functioning.MethodsParticipants were 85 adolescents with BN or Eating Disorder Not Otherwise Specified, recruited to a randomised controlled evaluation of the cost-effectiveness of cognitive-behavioural guided self-care vs. family therapy. Participants were interviewed regarding the history of their eating disorder and completed self-report measures.ResultsPatients who did not involve their parents in treatment were significantly older, had more chronic eating disorder symptoms, exhibited more co-morbid and impulsive behaviours and rated their mothers higher in EE. However, they did not have more severe eating disorder symptomatology.ConclusionsThese preliminary findings, although in need of replication with a larger sample and limited by the attrition rate in some of the self-report measures, indicate that patients who did not involve their parents in treatment may perceive their mothers as having a more blaming and negative attitude towards the patient’s illness. Public awareness about BN needs to be raised, focusing on reducing the stigma and negative views attached to this illness.

Risk factors, correlates, and markers in early-onset bulimia nervosa and EDNOS

OBJECTIVE This study aimed to investigate the specific risk factors, correlates, and markers associated with the development of symptomatology of early-onset BN and subclinical BN. METHOD Two semi-structured interviews were used to examine symptomatology and antecedent factors of bulimic symptoms in a sample of British adolescents. RESULTS Adolescents with early-onset eating pathology were significantly more likely to report an earlier age of menarche than those developing the disorder at the typical age, and were found to have a different pathway of symptom development. DISCUSSION Increased awareness of this may help identify those particularly at risk for developing an early-onset of eating pathology.

Sexually abused girls: patterns of psychopathology and exploration of risk factors

Abstract.This paper studies the patterns of psychopathology in sexually abused girls. It also explores some environmental risk factors for psychopathology including abuse characteristics and environmental experiences. The data are derived from the baseline assessment of 81 sexually abused girls referred to the London Child Sexual Abuse Psychotherapy Outcome Study (collaborative Tavistock and Maudsley project). Data about abuse were collected from the parent or foster parent using a standardised, semi-structured interview format. The girls’ psychopathology was assessed using the Kiddie-SADS schedule. Widespread and serious psychopathology in sexually abused girls attending a psychotherapy clinic previously reported in a smallscale study was confirmed; so, too, was the extent of comorbidity and impairment of psychosocial functioning. Further, a significant association was found between children looked after away from home and high rates of Separation Anxiety Disorder. No such significant associations were found for Major Depressive Disorder nor impairment of functioning. Multivariate prediction analysis revealed that significant predictors of Major Depressive Disorder consisted of seriousness of abuse, the abuser not being a parent figure, and the abuse not being recent; the only significant predictor of Separation Anxiety Disorder was that the abuser was not a parent figure; finally, impairment of general functioning was strongly predicted by the greater seriousness of abuse and also by the abuser/s not being a parent figure. Theoretical explanations advanced for the reported associations have a sense of face validity: that girls abused by strangers will be at risk of developing Separation Anxiety Disorders; that serious sexual abuse is followed by the development of a Major Depressive Disorder and a high level of impairment of social functioning.

Behavioural psychopathology of child sexual abuse in schoolgirls referred to a tertiary centre : A North london study

Abstract The sexually abused girls in this study were a sub-sample of a group of girls referred to a Regional Centre for Psychotherapy for the whole of London, North Thames. An inclusion criterion was that they were psychologically symptomatic and so it is likely that they were more problematic cases causing concern in their locality. The control clinical group consisted of referrals to local Child and Family consultation services, were an opt-in matched sample and not a total clinic referral sample. In addition, the reasons for referral covered both child disorder and family problems. It is, therefore, important to bear in mind the differences between these two groups. Certain clear cut findings have emerged from this study. No disorders specific to child sexual abuse in girls were identified but the extent and severity of the disturbance in the sexually abused sample was most striking. In these girls an event (CSA), together with referral because of emotional symptoms, was associated with enhanced severity of disorder and comorbidity particularly with reference to a cluster of disorders comprising post-traumatic stress disorder, depressive disorder, anxiety disorders (general and separation), social phobias and reactive attachment disorder. In the community clinic sample the identified disorders were mainly those of separation anxiety disorders and adjustment. Wide comorbidity was common in the sexual abuse sample and also severity of impairment was notable when compared to the clinic sample. However, because of the selected nature of the abuse group the findings are not generalisable beyond the population from which they emerged. The view is advanced that there are strong grounds for exploring the utility of psychodynamic psychotherapy in similar samples of sexually abused girls. These findings are discussed in the light of the current literature.

Motivation to change in recent onset and long-standing bulimia nervosa: Are there differences?

REASON FOR THE STUDY: Little is known about how motivation to change evolves over the course of an eating disorder. The present study compared ‘stage of change’ and motivation, confidence and readiness to change in two groups of patients with bulimia nervosa (BN), adolescents with a short duration of illness and adults with a long duration of illness. METHOD: Patients completed the Severity of eating disorder symptomatology scale, Hospital Anxiety and Depression Scale and measures of stage of change and motivation, readiness and confidence to change their bulimic symptomatology at pre-treatment.MAIN FINDINGS: Short- and long duration groups did not differ in illness severity, comorbidity, stage of change, motivation, readiness, and confidence to change. There were, however, some differences between groups in terms of the relationship between motivational measures, illness severity, duration and comorbidity. CONCLUSIONS: There seem to be more similarities than differences between adolescents with short duration of illness and those with well-established BN in terms of their motivation to change.

Borderline personality disorder: study in adolescence.

The study of the presentation, symptomatology and family characteristics of an exclusively adolescent sample of patients with borderline personality disorder (BPD) was undertaken. Twenty-four cases of borderline personality disorder, 20 females, 4 males, identified using chart review and meeting the criteria of the Diagnostic Interview for Borderlines (DIB) and DSM III-R, were matched with psychiatric controls. Adolescents with borderline personality disorder were found to have high rates of affective symptomatology with Axis I diagnosis of major depressive disorder - MDD (DSM-III-R), and high rates of interpersonal psychopathology, i.e., manipulation, devaluation, and a pervasive sense of boredom. The latter seem to be characteristic as for adults with borderline personality disorder. The families were particularly angry and volatile.

Management of the Really Sick Child or Adolescent with Anorexia Nervosa in Hospital: The Role of Child and Adolescent Mental Health Services

Assessment and management of the problems of an adolescent with anorexia nervosa admitted to a paediatric ward requires substantial knowledge and skill. Challenges for the eating disorder specialist are many. Paediatric and general adolescent psychiatric staff may be unfamiliar with the condition and require support in its management. Nutritional treatment of the patient may be complicated by sabotaging behaviours, and compulsory treatment may be required. The family needs to be included and supported. Medication may be helpful but can also be risky in a severely physically compromised patient. The development of protocols to guide local practice in the different services involved can help the management of these complex problems.

Palestine: the assault on health and other war crimes: Personal view was one sided and unhelpful

EDITOR—I have lived and worked as a doctor in Israel. I have little sympathy for the government of Ariel Sharon, and I have had the privilege of meeting Yitzhak Rabin, as well as many other Israelis who were and are committed to peace. But I am dismayed by Summerfields comments and appalled by the BMJ s decision to publish them.1 The BMJ and Summerfield have …