Emotion-focused psychotherapy for patients with panic disorder.

OBJECTIVE: Recent studies have suggested that most patients treated for panic disorder receive forms of psychotherapy other than cognitive behavior therapy, even though there is little information about the efficacy of such treatments or how they compare to proven active treatments. The authors compared one of these other forms, emotion-focused psychotherapy (given to 30 patients with panic disorder), to results obtained with recommended standard treatment (either cognitive behavior therapy [N=36] or imipramine [N=22]). The authors also compared emotion-focused psychotherapy to results obtained in subjects given pill placebo (N=24). METHOD: Subjects met DSM-IV criteria for panic disorder with no more than mild agoraphobia. Treatment consisted of approximately 3 months of weekly visits followed by 6 monthly maintenance visits. Assessments were conducted after each treatment phase and at a follow-up visit after 6 months of no treatment. RESULTS: Emotion-focused psychotherapy was less effective for symptoms of panic disorder than treatment with either cognitive behavior therapy or imipramine; results obtained with emotion-focused psychotherapy after the acute and maintenance phases were similar to those seen with placebo. Treatment expectations were not different among the different groups. Patients receiving emotion-focused psychotherapy had the highest completion rate. CONCLUSIONS: The results suggest that emotion-focused psychotherapy (a supportive form of psychotherapy) has low efficacy for the treatment of panic disorder. However, emotion-focused psychotherapy may be superior to medical management in helping patients stay in treatment.

Monitoring and enforcing cultural competence in Medicaid managed behavioral health care.

In recent years cultural competence has expanded beyond language provisions to include understanding and factoring into services provision the cultural perspectives clients may have that are different from the majority culture. The federal government requires state Medicaid programs to offer culturally competent services, but little is known about how states implement such mandates and monitor and enforce them. We reviewed the origins and implications of cultural competence mandates and conducted a brief case study of 5 states to learn about the implementation of cultural competence provisions in behavioral managed care contracts. We found that states and managed behavioral health organizations (MBHOs) vary in their definitions and implementation of standards to ensure mental health care access for vulnerable populations. Although states had a variety of oversight mechanisms, varying contractual requirements ranging from optional to required, vague contract language, no existing standardized indicators or definitions, and scant data on the cultural characteristics of the populations enrolled in Medicaid managed care hamper monitoring and enforcement of cultural competence by states. Implications for MBHOs, states, and the federal government, as well as services researchers, follow.

CSF oxytocin and vasopressin levels after recovery from bulimia nervosa and anorexia nervosa, bulimic subtype.

BACKGROUND: When ill, people with eating disorders have disturbances of the neuropeptides vasopressin and oxytocin. METHODS: To avoid the confounding effects of the ill state, we studied women who were recovered (more than 1 year, normal weight, and regular menstrual cycles, no bingeing or purging) from bulimia nervosa (rBN) or binge eating/purging-type anorexia nervosa (rAN-BN), and matched healthy control women. RESULTS: Vasopressin was elevated in rAN-BN and showed a trend towards elevation in rBN. In rBN, elevated cerebrospinal fluid vasopressin may be related to having a lifetime history of major depression. In comparison, cerebrospinal fluid oxytocin was normal in recovered subjects, but elevated levels in some rBN might be related to birth control pill use. CONCLUSIONS: These data confirm and extend the possibility that elevated cerebrospinal fluid vasopressin may be related to the pathophysiology of eating disorders, and/or a lifetime history of major depression.

Binge antecedents in obese women with and without binge eating disorder.

In this study, women with binge eating disorder (BED; n = 41) and weight- and age-matched comparison women without BED (NBED; n = 38) monitored their eating for 6 days, using handheld computers to measure mood, appetite, and setting at all eating episodes and comparison noneating episodes. Poor mood, low alertness, feelings of poor eating control, and craving sweets all preceded binge episodes for the BED group. An unanticipated finding was the frequent report of binge episodes in the comparison group; only feelings of poor eating control and craving sweets predicted binge episodes in this group. Binge eating NBED women tended to experience worse mood, less control, and more craving than other NBED women, contributing to evidence of the close relationship of binge eating and decrements in emotional and appetitive functioning.

Diagnosis of nonpsychotic patients in community clinics.

OBJECTIVE: Diagnosis-specific, proven efficacious treatments are a major recent advance in psychiatry. Appropriate use of such treatments presupposes patients who meet the diagnostic criteria and clinicians who have accurately diagnosed the target disorder and comorbid conditions. Since little is known about whether these prerequisites are commonly met, the authors conducted a study at two community treatment sites to determine the frequency of various axis I diagnoses and the concordance between the diagnoses recorded in patient charts and those obtained by a structured interview. Given that a DSM diagnosis may not be sufficient to understand a patient's problems, the authors also obtained ratings of interpersonal functioning. METHOD: The subjects were 164 nonpsychotic patients who were seen at a rural (N=114) or urban (N=50) community treatment facility. Raters trained to reliably use the Structured Clinical Interview for DSM-IV (SCID) conducted diagnostic interviews. Clinical charts were reviewed to obtain clinical diagnoses. Patients completed questionnaires regarding interpersonal functioning. RESULTS: Most (N=145, 88%) of the patients met the SCID criteria for a current axis I diagnosis, and 53% (N=87) met the criteria for two or more disorders. Clinical and SCID diagnoses had poor agreement. Evidence was found for interpersonal dysfunction. CONCLUSIONS: Most patients met the diagnostic criteria for conditions for which there are proven treatments; however, inaccurate diagnosis proved common. This barrier to optimal treatment could be ameliorated with the use of structured interviews for common diagnoses. Scores on social/interpersonal measures support the premise that DSM symptoms provide only part of the relevant information about patients' conditions.

Initial treatment engagement in a rural community mental health center.

The charts of patients who received an initial assessment at a rural mental health center were reviewed to identify patient, system, and clinical characteristics that predicted return to the center for at least one treatment visit in the following three months. Among 112 patients, the overall rate of return was 46 percent. Patients who were seen for assessment within one week of their initial request for services were significantly more likely to return, as were those who had lower scores on the Global Assessment of Functioning scale. Patients referred for assessment by agencies of social control were the least likely to return for treatment.

Anger attacks: correlates and significance of an underrecognized symptom.

BACKGROUND: Anger attacks over provocations described as trivial by the individual are an underrecognized symptom associated with aggressive acts. They are usually followed by guilt and regret. Anger attacks among mothers are an important problem because they are often directed at the woman's spouse and/or children. This study examines the prevalence and correlates of anger attacks in a psychiatric clinic for women who are either pregnant or up to 18 months postpartum. METHOD: Fifty consecutive consenting patients were assessed at initial presentation with the Structured Clinical Interview for DSM-IV Axis I Disorders, a modified Anger Attacks Questionnaire, self-reports of psychiatric symptoms and psychosocial variables, and clinician ratings. RESULTS: Thirty (60%) of 50 patients reported anger attacks. Of those with anger attacks, 76.7% worried about them, and 73.3% had tried to prevent them. Compared with women without anger attacks, those with anger attacks were significantly more likely to report higher state and trait anger (p < .001), have a diagnosis of unipolar depression (p < .01), report more aggression directed at immediate family, and avoid their children. Both groups displayed little angry affect in the interview, thus appearing similar at assessment. CONCLUSION: Anger attacks in response to children and spouse were common in this group of women and were associated with subjective distress. Because those with and without anger attacks appear similar at interview, inquiring about the presence of anger attacks is important to ensure that they become a focus of treatment.

How many donuts is a "binge"? Women with BED eat more but do not have more restrictive standards than weight-matched non-BED women.

Theories of disordered eating suggest that binge eating may occur as a response to violations of unrealistically restrictive dietary standards, but there are few direct comparisons of the dietary standards of binge eaters and nonbinge eaters. In this study, we asked obese women with Binge Eating Disorder (BED) and weight- and age-matched women without BED to report the minimum amount of each of eight foods they considered a "binge" and "out of control" to determine whether binge eaters had stricter dietary standards than women without BED. Women with BED did not consider smaller amounts of food a "binge" or "out of control" than did women without BED; however, binge eaters did report that their "typical" and "largest-ever" servings of each of the eight foods were larger than those reported by nonbinge eaters. This suggests that for this group of eating- disordered women, eating behaviors may be a more important intervention target than overly restrictive dietary standards.

The effect of perceived control over eating on the life satisfaction of women and men: results from a community sample.

OBJECTIVE: To test whether overweight, or perception of lack of control over eating, or both, contributed to the level of life satisfaction for women and men in a random sample of community-dwelling adults. METHOD: This study examined the effects of body mass index (BMI) and perceived control over eating on life satisfaction for women and men in a community-based sample of 1,069 women and 963 men. RESULTS: For women, both lack of perceived eating control and higher BMI were associated with less life satisfaction, and lack of control over eating was the more important predictor. For men, only lack of perceived eating control was associated with less life satisfaction. Furthermore, for both women and men, the contribution of eating control to life satisfaction was unaffected by BMI, that is, the life satisfaction of heavier people was not more affected by perceived control over eating than was the life satisfaction of lighter people. DISCUSSION: These findings suggest that psychological issues related to eating and weight can affect global aspects of well-being.

Alterations in serotonin activity and psychiatric symptoms after recovery from bulimia nervosa.

BACKGROUND: Women with bulimia nervosa (BN) have disturbances of mood and behavior and alterations of monoamine activity when they are bingeing and purging. It is not known whether these alterations are secondary to pathological eating behavior or traits that could contribute to the pathogenesis of BN. METHODS: To avoid the confounding effects of pathological eating behavior, we studied 30 women after long-term recovery (>1 year with no bingeing or purging, normal weight, and regular menstrual cycles) from BN. Subjects were compared with 31 healthy volunteer women. We assessed psychiatric diagnoses and symptoms to determine whether there was any persistent disturbance of behavior after recovery. We measured cerebrospinal fluid (CSF) levels of the major metabolites of serotonin (5-hydroxyindoleacetic acid [5-HIAA]), dopamine (homovanillic acid [HVA]), and norepinephrine (3-methoxy-4-hydroxyphenylglycol [MHPG]) as well as hormonal and behavioral response to m-chlorophenylpiperazine (m-CPP), a serotonin-specific agent. RESULTS: Women who were recovered from BN had mild to moderate negative moods and obsessions with perfectionism and exactness and exaggerated core eating disorder symptoms compared with healthy volunteer women. Recovered BN women had increased levels of CSF 5-HIAA compared with control women (117 +/- 33 vs 73 +/- 15 pmol/mL; P< or =.001) but normal CSF HVA and MHPG concentrations. Recovered BN women had an anxious and disorganized behavioral response to m-CPP but a normal hormonal response. CONCLUSIONS: Persistent serotonergic and behavioral abnormalities after recovery raise the possibility that these psychobiological alterations might be trait-related and contribute to the pathogenesis of BN.

A controlled family study of anorexia nervosa and bulimia nervosa: psychiatric disorders in first-degree relatives and effects of proband comorbidity.

BACKGROUND: We used contemporary family-epidemiological methods to examine patterns of comorbidity and familial aggregation of psychiatric disorders for anorexia and bulimia nervosa. METHODS: Direct interviews and blind best-estimate diagnostic procedures were used with diagnostically "pure" groups of probands with eating disorders and a matched control group. Lifetime prevalence rates of eating disorders, mood disorders, substance use disorders, anxiety disorders, and selected personality disorders were determined in female probands with restricting anorexia nervosa (n=26) or bulimia nervosa (n=47), control women (n=44), and first-degree biological relatives (n=460). RESULTS: Relatives of anorexic and bulimic probands had increased risk of clinically subthreshold forms of an eating disorder, major depressive disorder, and obsessive-compulsive disorder. Familial aggregation of major depressive disorder and obsessive-compulsive disorder was independent of that of anorexia nervosa and bulimia nervosa. These relatives also had increased risk of other anxiety disorders, but the mode of familial transmission was not clear-cut. The risk of substance dependence was elevated among relatives of bulimic probands compared with relatives of anorexic probands, and familial aggregation was independent of that of bulimia nervosa. The risk of obsessive-compulsive personality disorder was elevated only among relatives of anorexic probands, and there was evidence that these 2 disorders may have shared familial risk factors. CONCLUSIONS: There may be a common familial vulnerability for anorexia nervosa and bulimia nervosa. Major depressive disorder, obsessive-compulsive disorder, and substance dependence are not likely to share a common cause with eating disorders. However, obsessional personality traits may be a specific familial risk factor for anorexia nervosa.

Psychiatric disorders in women with bulimia nervosa and their first-degree relatives: effects of comorbid substance dependence.

OBJECTIVE: Women with bulimia nervosa (BN) and comorbid substance dependence often display impulsive behaviors. We assessed Axis I and II psychiatric diagnoses in their first-degree relatives in order to understand the etiological factors that may contribute to this subtype of BN. METHOD: We used contemporary family-epidemiological methodology to compare the lifetime prevalence of psychiatric disorders among 47 women with BN and 44 non-eating-disordered community control women, and their first-degree relatives (177 and 190, respectively). BN probands were stratified by the presence (n = 20) or absence (n = 27) of a lifetime history of alcohol and/or drug dependence. RESULTS: Social phobia, conduct disorder, and clusters B and C personality disorders were significantly more prevalent among BN probands with substance dependence than among BN probands without substance dependence or control women probands. Substance use disorders, social phobia, panic disorder, and cluster B personality disorders were significantly more prevalent among the relatives of BN probands with substance dependence than the relatives of the other two groups. DISCUSSION: Women with BN and substance dependence have problems with social anxiety, antisocial behavior, and a variety of personality disturbances, and come from families where there are problems with substance use disorders, anxiety, impulsivity, and affective instability. These data raise the possibility that a familial vulnerability for impulsivity and affective instability may contribute to the development of substance dependence in a subgroup of women with BN.

Relationship of depression, anxiety, and obsessionality to state of illness in anorexia nervosa.

OBJECTIVE: Depression, anxiety, and obsessionality frequently are present in underweight, malnourished patients with anorexia nervosa. It is less certain if these symptoms persist after recovery. Thus, we assessed these symptoms in anorexic women at three states of illness (underweight, short-term weight restored, and long-term weight restored) in comparison to a group of healthy women. METHOD: We used standardized self- and trained rater instruments to assess depression (Hamilton Depression Rating Scale and Beck Depression Inventory), anxiety (Spielberger State-Trait Anxiety Inventory and Hamilton Anxiety Rating Scale), and obsessions and compulsions (Yale-Brown Obsessive Compulsive Scale). RESULTS: A similar pattern was found for all symptoms. That is; scores for depression, anxiety, and obsessionality were most elevated in the underweight state. These symptoms improved with weight restoration. However, milder but significantly elevated symptoms persisted in long-term weight-restored anorexic women compared to healthy control women. DISCUSSION: These data suggest that malnutrition intensifies the severity of depression, anxiety, and obsessionality in anorexia nervosa. However, the fact that mild to moderate symptoms persisted after long-term weight restoration raises the possibility that such behaviors are related to the pathogenesis of this illness.

Anger attacks and treatment nonadherence in a perinatal psychiatry clinic.

Anger attacks are common in depressive disorders. High levels of anger have been associated with treatment nonadherence in medical and psychiatric patients. In this study we examined the relationship between anger attacks and treatment nonadherence in a perinatal psychiatry clinic that treats pregnant and postpartum women. Treatment adherence was examined by chart review. Patients with anger attacks at initial assessment were more likely to drop out of treatment than were patients without anger attacks at initial assessment (11/34 vs. 2/21; one-tailed Fisher's exact test p < .05). Treatment nonadherence among pregnant and postpartum women with anger attacks may be an important problem because of its impact on treatment outcome and because anger in depressed mothers is frequently directed at their children.

A double-blind, placebo-controlled trial of the effect of fluoxetine on dietary intake in overweight women with and without binge-eating disorder.

This study examined mechanisms by which fluoxetine may reduce energy consumption and body weight. Women with binge-eating disorder (BED; n = 38) and age- and weight-matched women without BED (n = 32) monitored their dietary intake and concurrently recorded mood variables on a hand-held computer for 6 d of baseline and for 6 d after being randomly assigned to receive placebo or fluoxetine (60 mg). Fluoxetine reduced eating more than did the placebo on days 4-6 of treatment. The frequency of episodes was not affected, suggesting that fluoxetine affects satiety, not hunger. Fluoxetine did not preferentially reduce carbohydrate intake, did not affect snack consumption as compared with meal consumption, and did not affect negative-mood eating more than positive-mood eating, nor did fluoxetine affect subjects' mood ratings. Benefits of fluoxetine were of approximately equal magnitude for women with and without BED. However, women who reported higher energy consumption at baseline were more responsive to fluoxetine than were women who reported lower energy consumption at baseline, and binge-eating status was associated with greater energy consumption at all time points, including baseline. Fluoxetine affects dietary intake within 4 d of its consumption, and if future research shows that this remains true on repeated applications, this drug may be useful for short periods when difficulty with overeating is anticipated, such as during vacations.

Bulimia nervosa and substance dependence: association and family transmission.

Alcohol and drug use disorders are common among women with bulimia nervosa (BN) and their family members. However, it is not known whether there is a familial relationship between BN and substance use disorders. We compared 47 women with BN and 44 non-eating-disordered community control women, and their first-degree relatives (177 and 190, respectively). BN probands were stratified by the presence (43%) or absence (57%) of lifetime alcohol and/or drug dependence. The first-degree relatives of substance-dependent BN probands had significantly higher lifetime rates of alcohol/drug dependence (38%), compared with relatives of nonsubstance-dependent BN probands (10%) or relatives of community controls (18%). These data suggest that BN and substance dependence are transmitted independently in families.

Weight changes in caregivers of Alzheimer's care recipients: psychobehavioral predictors.

Relationships of changes in body mass index (BMI) were examined with changes in psychobehavioral variables in spouse caregivers of individuals with Alzheimer's disease (n = 81) and matched spouses of controls (n = 86). Men caregivers had significantly greater BMI and obesity than men controls at both times. Over 15-18 months, women caregivers gained significantly more weight than did women controls. A trend for greater obesity occurred in women caregivers than in women controls at follow-up. Although weight gain was not related to psychobehavioral variables in controls, in men caregivers decreased perceived control and increased fat intake explained significant variance in weight gain. In women caregivers, increased anger control and increased calories explained weight gain. Such caregivers may be at risk for health problems.