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Abstract Background Anorexia nervosa is a complex and highly variable disorder. Preventing patients from becoming resistant to treatments is fundamental since an important percentage develops a severe and enduring disorder; and because relapse is highly associated with psychiatric comorbidity, poor prognosis, and serious medical consequences due to malnutrition. Contemporary treatments for anorexia nervosa support the benefits of involving the family in treatment, and although the gold standard of family psychotherapy offers an excellent option for anorexia nervosa, that intervention is aimed at early stages, and therapeutic options for later stages of the disorder are reduced and not clearly established. Objective Expose the therapeutic effect of the protocol for severe and enduring cases of anorexia nervosa at relapse, used at the Clinic of Eating Behavior of the National Institute of Psychiatry, Ramón de la Fuente Muñiz, whose theoretical foundation is systemic therapy. Method To develop this case report, we carried out an in-depth review of the clinical records, and of the clinic attendance records of the case presented here. CARE clinical case report guidelines format were used. Results The case shows how a young woman, diagnosed with anorexia nervosa with clinical signs of severe and enduring anorexia nervosa (SE-AN), was able to achieve symptomatic remission after her parents, but not her, were administered the protocol for SE-AN. Discussion and conclusion Here we present an emblematic case showing the importance of getting the parents involved in the treatment of anorexia nervosa.
Resumen Antecedentes La anorexia nervosa es un trastorno complejo y muy variable. Evitar que los pacientes se vuelvan resistentes a los tratamientos es fundamental, pues un porcentaje importante desarrolla un trastorno grave y duradero; adicionalmente, la recaída está muy asociada con una alta comorbilidad psiquiátrica, un mal pronóstico y graves consecuencias médicas debido a la desnutrición. El tratamiento actual de la anorexia nervosa respalda los beneficios de involucrar a la familia en el tratamiento, y, aunque el estándar de oro en psicoterapia familiar ofrece una excelente opción para la anorexia nervosa, dicha intervención está orientada a etapas tempranas y las opciones para las etapas tardías del trastorno son reducidas, además de no estar claramente establecidas. Objetivo Exponer el efecto terapéutico del protocolo para casos graves y duraderos de anorexia nervosa en recaída, de la Clínica de Trastornos de la Conducta Alimentaria (CTA) del Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, cuya base teórica es la terapia sistémica. Método Para integrar este caso, realizamos una revisión a fondo del expediente clínico y de los registros asistenciales del caso que aquí presentamos. Se utilizó el formato de reporte de caso de las guías CARE. Resultados El caso muestra cómo una joven, con signos clínicos de anorexia nervosa grave y duradera (AN-GD), pudo lograr remisión sintomatológica después de que sus padres, pero no ella, recibieran tratamiento con el protocolo para AN-GD. Discusión y conclusión Aquí presentamos un caso emblemático que muestra la importancia de involucrar a los padres en el tratamiento de la anorexia nervosa.
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El objetivo de la presente investigación fue validar el instrumento en población mexicana femenina Body Shape Questionnaire (BSQ), creado con la finalidad de evaluar la insatisfacción corporal. Participaron 472 mujeres, 256 eran estudiantes (x‾ = 15.9, DE = 3.2) y conformaron el grupo control y 216 pacientes con Trastorno del Comportamiento Alimentario (TCA) (x‾ = 20.5, DE = 3.9) con un rango de edad de 13 a 30 años. Los resultados mostraron una excelente consistencia interna (a = .98), así como una estructura de 2 factores que explicaron el 63.8% de la varianza total. Estos fueron: 1) Malestar corporal normativo (α=.95) y 2) Malestar corporal patológico (α=.94). Respecto a la validez discriminante y predictiva, el BSQ mostró una buena capacidad de clasificar a individuos con TCA, en función de la insatisfacción corporal, y se observó que dicha capacidad es mayor cuando discrimina entre Anorexia, Bulimia y control (λ de Wilks = .485, χ²(gl=1)= 278.830, p≤ .001). Finalmente se exploraron 6 diferentes puntos de corte, de los cuales 110 fue el que demostró ser el más apropiado, de acuerdo a sus valores de sensibilidad (84.3%) y especificidad (84.4%). En conclusión el BSQ es un cuestionario de gran utilidad para detectar la insatisfacción corporal en mujeres mexicanas.
The aim of this study was to validate the instrument Body Shape Questionnaire (BSQ) in female Mexican population, created to assess body dissatisfaction. 472 women participated, 256 were students and formed the control group (x‾ = 15.9, DE = 3.2) and 216 patients with Eating Disorders (ED) (x‾ = 20.5, DE = 3.9) with an age range of 13 to 30 years. The results showed excellent internal consistency (a = .98) and a 2-factor structure that explained 63.8% of the total variance. These were: 1) normative body uncomfort (α=.95), and 2) pathological body uncomfort (α=.94). Regarding the discriminant and predictive validity, the BSQ showed good ability to classify individuals with eating disorders, depending on body dissatisfaction, noting that such capacity is greater when discriminating between Anorexia, Bulimia and control (λ de Wilks = .485, χ2(gl=1)= 278.830, p≤ .001). Finally we explored 6 different cut off points, of which the 110-was proved to be the most appropriate according to their values of sensitivity (84.3%) and specificity (84.4%). In conclusion, the BSQ is a useful questionnaire to detect body dissatisfaction in Mexican women.
ABSTRACT
La anorexia nervosa, la bulimia nervosa y los trastornos inespecíficos del comportamiento alimentario son alteraciones conductuales relacionadas al acto de comer y a la imagen corporal; han sido considerados como entidades estrechamente ligadas a la idolatría por la delgadez, aunque la historia revela que han existido desde tiempos remotos. Los trastornos de la conducta alimentaria han sido descritos desde diferentes perspectivas y, recientemente, se les ha comenzado a abordar con un enfoque científico. Su naturaleza y origen son complejos, con interacción de factores biológicos, psicológicos y sociales. Según la clasificación propuesta por la Asociación Psiquiátrica Americana en su Manual Diagnóstico y Estadístico de los Trastornos Mentales (DSM-IV-TR), los trastornos de la conducta alimentaria se dividen en específicos e inespecíficos. Los primeros comprenden a la anorexia y a la bulimia. En la presente revisión se inicia con una breve introducción y se abordan algunos aspectos psiquiátricos en torno al concepto, la epidemiología, la etiopatogenia, el diagnóstico diferencial, la evolución y generalidades del tratamiento de estos trastornos.
Anorexia nervosa, bulimia nervosa and the unspecific disorders of eating behavior are behavioral alterations associated with body image and the act of eating. These disorders have been considered as consequences of the idolatry to be thin, although history reveals they have existed for a long time. Eating disorders have been described from different perspectives and have recently been studied from a scientific perspective. Their complex nature and origin involves biological, psychological and social factors. According to the classification proposed by The American Psychiatric Association and found in the Diagnostic and Statistic Manual of Mental Disorders (DSM-IV-TR), eating disorders are divided into specific and unspecific disorders; anorexia and bulimia are included in the group of specific disorders. This paper reviews some of the psychiatric aspects about the concept, epidemiology, ethiopathogeny, differential diagnoses, evolution and generalities of eating disorders treatment.
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Abstract: The Eating Disorder Inventory (EDI) is a psychometric instrument developed by Garner et al. for the evaluation of psychological traits in patients with eating disorders. The questionnaire offers an integral evaluative approach that includes other psychological characteristics besides those of fear of fatness. It consists of 64 items in 8 subscales: 1) Drive for Thinness, 2) Bulimia, 3) Body Dissatisfaction, 4) Ineffectiveness, 5) Perfectionism, 6) Interpersonal Distrust, 7) Interoceptive Awareness, 8) Maturity Fears. The EDI is an instrument widely used for the exploration of eating disorders (ED). Nevertheless, the use of psychometric scales in a population other than the one in which they were originally developed, requires careful adaptation. Items should be phrased in a culturally significant way, and even after that, constructs still could have different meanings in different contexts. The factorial grouping of the EDI in open populations has been reported as different from the results in clinical samples. Also, Lee and cols. reported a low correlation of the EDI subscales that measure weight preoccupation and the General Health Questionnaire - 12, concluding that fear of fatness is not related with emotional distress in their sample. In Mexico City, Alvarez and Franco conducted a validation study, finding good reliability and discriminative power, and a factorial grouping close to the original. On the other hand, in a sample of teenage girls from a semi-rural area, the factorial grouping was very different. Although we already have data about the EDI's specificity and sensitivity in Mexican ED patients, there are no studies of the validity and reliability of the test in this population. Therefore, our main objective in this work was to validate the EDI in a sample of Mexican ED patients. Also, the score information provided could be used for comparison purposes with other clinical samples. A non-probabilistic sample was obtained of all subsequent patients attending the ED Clinic at the National Institute of Psychiatry Ramón de la Fuente (INPRF) in the period 1997 2002 (n=523). Patients were diagnosed according to DSM-IV criteria in a clinical interview. They also completed other questionnaires, such as the Symptom Check List (SCL90) and the Coopersmith's Self-esteem Inventory. According to diagnosis, the sample was composed of compulsive/purging type anorexia nervosa, 5.7%; restrictive anorexia nervosa, 8%; purging type bulimia nervosa 45.1% and eating disorders not otherwise specified 41.3%. Mean age was 19.9 years (s.d.=3.9), within a rank of 13 to 39 years. Mean age at the beginning of ED was 16 years (s.d.=3.1). Mean educational level was 12 years (s.d.=3), i.e. high-school level. The sample included single women 93.9%, married 4.8% and divorcees, 1.4%. Mean Body Mass Index was 21 (s.d. = 5.5). Participants completed the EDI, SCL90, and Coopersmith's self-esteem inventory during their first visit to the Clinic. They were assured of the voluntary nature and confidentiality of their participation. Completing the tests took them about 60 minutes. An internal reliability analysis was conducted, followed by a factorial analysis of main components with Varimax rotation. Pearson correlations were made to assess the concurrent validity of EDI and other instruments. Analysis of variance was employed to compare between diagnostic groups. Data were captured and analysed in the SPSS software, versión 10.0. The first step of the analysis was the item-total correlation, considering as valid correlations equal or over 0.28. This step eliminated 12 items that were not included in further analyses. Cronbach's alpha was 0.93. Most of the items in the Perfectionism subscale disappeared in this step. Second step was factorial analysis. We found 6 factors with a minimum of 3 items included with factorial charges equal or over .40. Then a second analysis was conducted with only the 40 items that had been grouped in the 6 factors. Factor 1 included items from Bulimia and Interoceptive Awareness; factor 2, from Drive for Thinness and Body Dissatisfaction; factor 3, from Interoceptive Awareness; factor 4, from Ineffectiveness; factor 5, from Maturity Fears; and factor 6, from Body Dissatisfaction. The resulting factorial structure explained 56% of total variance. Cronbach's alpha of the final version was 0.92. Correlation analysis showed a positive and significant correlation of EDI with SCL-90, and a negative and significant correlation of EDI with Coopersmith's self-esteem inventory. Comparisons between diagnostic groups showed that bulimia nervosa patients had the highest scores in the EDI. Patients with restrictive AN had the lowest scores in all sub-scales except for Maturity Fears. Bulimia nervosa and compulsive/purging type AN patients were different from restrictive AN and EDNOS patients in the total score of Interoceptive Awareness and Ineffectiveness subscales. Bulimia nervosa was different from the other groups in Bulimia and Drive for Thinness subscales. The results show that, in this sample, many of the EDI items have a poor correlation with the scale, and factorial grouping is different from the original. However, once non-correlated items are eliminated, a version of the EDI remains that is valid and reliable. Items from the Perfectionism subscale were eliminated because of low correlation with the rest of the EDI. This supports the findings in Bulgaria, rural Mexico, and Mexico City. Maturity Fears, which also had dubious results in other studies, grouped correctly in this sample, although it did not distinguish among diagnostic groups. Analysis of variance showed that subscales were able to differentiate the Bulimia nervosa patients. Also, most of the variance explained corresponded to the Bulimia subscale, suggesting that EDI can detect bulimic attitudes, and so is a useful complement to instruments that are more capable of detecting anorexia nervosa, such as the Eating Attitudes Test. However, this could also be an effect of the sample's composition, with more than half of it being bulimic patients. Another important segment of variance was explained by Interoceptive Awareness, Ineffectiveness and Maturity Fears subscales, psychological traits that are not necessarily related to ED. In this sample, psychological subscales correlated with eating and weight attitude subscales, showed that Mexican patients do present ED according to the way they are conceptualized in the DSM-IV. Our results show that the EDI is adequate for the evaluation of psychological traits of ED patients in Mexico. Perfectionism and Interpersonal Distrust subscales are an exception, that requires further investigation.