Cognitive-behavioural therapy for adolescents with bulimic symptomatology: the acceptability and effectiveness of internet-based delivery.

BACKGROUND: The evidence base for the treatment of adolescents with bulimia nervosa (BN) is limited. AIMS: To assess the feasibility, acceptability, and clinical outcomes of a web-based cognitive-behavioural (CBT) intervention for adolescents with bulimic symptomatology. METHOD: 101 participants were recruited from eating disorders clinics or from beat, a UK-wide eating disorders charity. The programme consisted of online CBT sessions ('Overcoming Bulimia Online'), peer support via message boards, and email support from a clinician. Participants' bulimic symptomatology and service utilisation were assessed by interview at baseline and at three and six months. Participants' views of the treatment package were also determined. RESULTS: There were significant improvements in eating disorder symptoms and service contacts from baseline to three months, which were maintained at six months. Participants' views of the intervention were positive. CONCLUSIONS: The intervention has the potential for use as a first step in the treatment of adolescents with bulimic symptomatology.

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

UNLABELLED: 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.

Ethnicity and outcome of psychosis.

BACKGROUND: An excess of psychotic illness in Black people has been found in cross-sectional studies. Little is known about the outcome of psychosis in different ethnic groups in the UK. AIMS: To compare the incidence, nature and long-term outcome of psychosis in different ethnic groups. METHOD: A five-year, prospective study of an epidemiological cohort of people with a first contact for psychosis. RESULTS: Age-standardised incidence rates for schizophrenia and non-affective psychosis were higher for Black and Asian people than Whites. Stability of diagnosis and course of illness were similar in all ethnic groups. During the fifth year, Black people were more likely than others to be detained, brought to hospital by the police and given emergency injections. CONCLUSIONS: The nature and outcome of psychotic illness is similar in all ethnic groups but Black people experience more adverse contacts with services later in the course of illness.

New variant Creutzfeldt-Jakob disease: psychiatric features.

BACKGROUND: An apparently new variant of Creutzfeldt-Jakob disease (CJD), new variant CJD (nvCJD), was identified in the UK in 1996. There have now been 21 cases of nvCJD in the UK and one in France. Psychiatric symptoms are prominent in the initial presentation in these cases. METHODS: Cases of nvCJD are identified mainly by direct referral from neurologists and neuropathologists. Detailed clinical information was obtained by review of case notes and interviewing patients' relatives. We report the psychiatric features of the first 14 cases on nvCJD in the UK. Psychiatric notes were examined in all 13 of these cases who were seen by a psychiatrist. RESULTS: Eight cases were women. All 14 cases had early psychiatric features and in nine, the first symptom was psychiatric. 13 cases were seen by a psychiatrist and the majority were diagnosed as suffering from depression or depression secondary to organic disease. Two cases suffered from first-rank symptoms suggestive of psychotic illness and transient delusions and auditory or visual hallucinations occurred in the majority. All cases were referred to a neurologist as the illness evolved and neurological signs developed. INTERPRETATION: Psychiatric symptoms are a consistent early clinical feature in nvCJD. Analysis of the psychiatric symptoms does not suggest specific features that readily allow distinction from more common psychiatric disorders, although the occurrence of associated persistent sensory symptoms may raise the possibility of this diagnosis. Neurological signs, including ataxia, involuntary movements and cognitive impairment developed in all cases and the evolution of increasing neurological deficits is likely to remain critical to the clinical diagnosis of nvCJD.

First-onset psychotic illness: patients' and relatives' satisfaction with services.

BACKGROUND: Despite the growth in patient satisfaction studies, scant attention has been paid to the satisfaction of patients with a first episode of psychotic illness soon after presentation to services. We were particularly interested in any ethnic differences in satisfaction at this seminal stage in patient care. METHOD: Using multi-item questionnaire, face-to-face interviews were conducted with patients and relatives 12 months after first contact with psychiatric services. Relatives were also questioned on support and advice issues related to after-care. RESULTS: Most patients and relatives were generally satisfied with the treatment, and with the 'humane' qualities of psychiatric staff, but were less satisfied with the 'hotel' aspects of hospital care. Patients, and particularly relatives, were most concerned about levels of information and advice received. Relatives were dissatisfied with after-care. There were no significant differences between Black and other patients, but some differences between their relatives. Patients born abroad were significantly more satisfied than those born in Britain, irrespective of ethnicity. Compulsory detention under the Mental Health Act was also significant in determining low satisfaction for patients and especially for their relatives. CONCLUSIONS: For improved care in the community patients and their relatives need to be seen as partners in care rather than as passive recipients. The issue of information-giving by psychiatric services demands serious attention. Black patients and their relatives were not especially likely to be dissatisfied.

Pathways to care for patients with a first episode of psychosis. A comparison of ethnic groups.

BACKGROUND: It is reported that patients from ethnic minority groups, in particular Afro-Caribbeans, are more likely to enter less desirable pathways to psychiatric care. We aimed to determine whether ethnicity significantly affected time to presentation, type of first contact, rates of compulsory admission and police and primary care involvement, in patients with their first episode of psychosis. METHOD: As part of a prospective epidemiological study, patients and their carers were interviewed using a semi-structured questionnaire to trace the various persons and agencies seen en route to their first contact with psychiatric services. RESULTS: While compulsory admission was more likely for Black patients, the excess was less striking than in previous studies. Black patients were no more likely than other patients to have police involvement. The most important factors in avoiding an adverse pathway were having a supportive family member or friend and the presence of a general practitioner to assist in gaining access to psychiatric services. CONCLUSIONS: The routes to psychiatric services for first onset patients are different to those for chronic patients. Variables associated with social support were more important than ethnicity in determining pathways to care. Police involvement and compulsory admissions were strongly associated with the absence of GP involvement and the absence of help-seeking by a friend or relative. It may be that ethnicity becomes an important variable after the patient has come into contact with psychiatric services.

Bulimia nervosa: 5-year social outcome and relationship to eating pathology.

From an original sample of 50 patients, 32 female patients with bulimia nervosa were followed up for a minimum length of 5 years. Standardized interviews were employed to assess eating attitudes and behavior as well as social status both at entry and at completion of the follow-up period. All participants completed the Social Problem Questionnaire at follow-up. Social outcome was found to parallel eating disorder outcome. Being in a satisfactory stable relationship was associated with good eating disorder outcome. Being in a stable relationship was not related to eating disorder outcome. Good outcome was also associated with higher occupational social class, and having a fulfilling social life and job.

Incidence of psychotic illness in London: comparison of ethnic groups.

OBJECTIVE: To compare annual incidences of psychosis in people from different ethnic groups as defined in the 1991 census. SETTING: Catchment area of district psychiatric hospital. DESIGN: All people aged 16 to 54 years who made contact with a wide range of community and hospital services between 1 July 1991 and 30 June 1992 were screened for psychotic symptoms. Patients with such symptoms were interviewed face to face to collect information on demography, ethnic group, psychiatric history and symptoms, drug use, and how care had been sought. A key informant, usually a close relative, was also interviewed. MAIN OUTCOME MEASURES: Age standardised incidence of schizophrenia and non-affective psychosis according to the ninth edition of the International Classification of Diseases in each ethnic group. RESULTS: Ninety three patients took part, of whom 38 were assigned a certain or very likely diagnosis of schizophrenia (15 in white population, 14 in black, seven in Asian, and two in others). The age standardised annual incidence of schizophrenia was 2.2 (95% confidence interval 1.5 to 2.9) per 10,000 of the population. The incidence ratio for schizophrenia in all ethnic minority groups compared with the white population was 3.6 (1.9 to 7.1); the corresponding figure for non-affective psychosis was 3.7 (2.2 to 6.2). CONCLUSIONS: Raised incidences of schizophrenia were not specific to the African Caribbeans, which suggests that the current focus on schizophrenia in this population is misleading. Members of all ethnic minority groups were more likely to develop a psychosis but not necessarily schizophrenia. The personal and social pressures of belonging to any ethnic minority group in Britain are important determinants in the excess of psychotic disorders found.

Bulimia nervosa: a 5-year follow-up study.

Fifty patients with bulimia nervosa were followed up for a minimum length of 5 years. Standardized interviews, observer-rated instruments and self-rated questionnaires were employed both at entry and at completion of the follow-up period. After tracing, the positive response rate was 72%; one patient had died. At the time of follow-up 31% of those traced had made a complete recovery and 25% still fulfilled diagnostic criteria for bulimia nervosa. Judged on behavioural symptoms 47.2% of responders had a 'good' outcome. Good outcome was associated with fewer social problems, higher social class, and a significant improvement in eating attitudes at follow-up. All outcome groups reported a reduction of interference by symptoms in other areas of life, and an improvement in mood state. No factors, including those described in previous studies, were identified which predicted outcome.

Abnormal eating attitudes in London schoolgirls--a prospective epidemiological study: outcome at twelve month follow-up.

The occurrence and course of eating disorder in a large representative population of 15-year-old London schoolgirls has been assessed using a two-stage survey methodology. Attempts to control weight were common and often transient. Dieting was in the great majority of girls found to be a benign practice without progression to more extreme concerns about food and weight. However, a small proportion of dieters did become cases and formed the majority of new cases found at follow-up. The relative risk of dieters becoming cases was eight times that of non-dieters. Many factors conventionally associated with eating disorder were associated more with attempting weight control than caseness. These included pre-morbid personality, pre-morbid obesity and family weight pathology. Other factors, including social class, career choice and psychosexual development, had no association either with attempting weight control or caseness.

Abnormal eating attitudes in London schoolgirls--a prospective epidemiological study: factors associated with abnormal response on screening questionnaires.

One thousand and ten unselected London state schoolgirls were screened by questionnaire to identify an 'at risk' cohort displaying abnormal eating attitudes and two control cohorts, one with probable general psychiatric morbidity, one without. Members of all cohorts were assessed at interview for the presence of eating disorder and for putative risk factors implicated in the development of anorexia nervosa. A prevalence rate of 0.99% was detected for clinical eating disorder and 1.78% for the partial syndrome of eating disorder. Factors specifically associated with abnormal eating attitudes were identified, in particular, current or past overweight, history of amenorrhoea and perceived stress in school and social life. Some commonly accepted risk factors for eating disorders were discovered to be associations with general psychiatric morbidity. These were perceived parental pressure to eat more, taking exercise to lose weight, perceived stress at home and reporting a family history of anxiety or depression. Other well reported putative risk factors for eating disorder, including social class, birth order, age at menarche, obsessional personality and weight related career choice were not associated specifically with abnormal eating attitudes in schoolgirls. These findings represent cross-sectional data at entry into a prospective epidemiological study.

Physical illness. A risk factor in anorexia nervosa.

Reports have appeared in the literature suggesting an association between physical illness and the later development of anorexia nervosa. The histories of 326 patients with anorexia nervosa were examined for physical illness. A higher rate of severe physical illness was found in this group when compared with controls suggesting that it should be regarded as a risk factor for anorexia nervosa. No statistically significant differences were found when illness was examined by time in relation to onset of anorexia, system involved, or when subjects were stratified by age. Possible explanations for the observed association are discussed.

Mood changes in bulimia nervosa.

Daily measurement of mood, and the occurrence of specific eating behaviours, were assessed concurrently over an eight-week period in a sample of 50 patients meeting diagnostic criteria for bulimia nervosa. Results of observer-rated scales of mood showed a significant reduction of scores, whereas self-assessment of mood showed no change over the study period. Negative mood states, although not severe, were more marked when the specific behavioural symptoms of binge-eating, vomiting, or purging occurred, and they increased as abnormal eating behaviours accumulated. It is suggested that the accompanying dysphoric mood states of bulimia nervosa are likely to be a secondary manifestation related to the presence of abnormal eating symptoms, and that they do no constitute a primary depressive illness.

Bouffée délirante: an examination of its current status.

Bouffée délirante is an historic and unique French diagnostic term for a short-lived psychosis. The key diagnostic features are acute, floridly psychotic symptoms with complete remission. Its use in a Paris hospital has been examined, and it appears that the term is declining in popularity. A case-controlled study indicated that the diagnosis is likely to be given to migrants on first admission. A re-diagnosis of case summaries indicated no particular correspondence of bouffée délirante to any one ICD category. However, the usefulness of having a special diagnostic term for psychosis with a good outcome is discussed.