Attachment security and existential distress among patients with advanced cancer.

BACKGROUND: Felt security in close relationships may affect individual adaptation responses to existential threat in severe illness. We examined the contribution of attachment security to demoralization, a state of existential distress involving perceived pointlessness and meaninglessness in advanced cancer. METHOD: A mixed cross-sectional sample of 382 patients with advanced cancer (mean age 59, 60% female) was recruited from outpatient oncology clinics. Participants completed self-report measures of attachment security, demoralization, depression, and physical symptom burden. We used multiple linear regression to analyze the association between attachment security and demoralization, controlling for demographic factors and symptom burden and tested whether attachment security moderated the association of symptom burden with demoralization. Separate analyses compared the contribution of the dimensions of attachment anxiety and attachment avoidance. RESULTS: The prevalence of clinically relevant demoralization was 35%. Demoralization was associated with lower attachment security (ß = -0.54, 95%CI: -0.62 to 0.46). This effect was empirically stronger for attachment anxiety (ß = 0.52, 95%CI: 0.44 to 0.60) compared to attachment avoidance (ß = 0.36, 95%CI: 0.27 to 0.45). Attachment security also significantly moderated the association of physical symptom burden with demoralization, such that with less attachment security, there was a stronger association between symptom burden and demoralization. CONCLUSION: Attachment security may protect from demoralization in advanced cancer. Its relative lack, particularly on the dimension of attachment anxiety, may limit adaptive capacities to deal with illness burden and to sustain morale and purpose in life. An understanding of individual differences in attachment needs can inform existential interventions for severely ill individuals.

Preliminary psychometrics of the Existential Distress Scale in patients with advanced cancer.

Existential distress is of clinical concern in patients with terminal illness. Although existential distress has been used to describe a broad spectrum of psychological disturbances, its narrower definition may be confined to distress that arises when the meaning and value of one's life is unclear, and is comorbid with feelings of loneliness and low self-worth. To promote further study, we developed and pilot-tested a 10-item Existential Distress Scale (EDS). Twenty-one patients with advanced cancer were recruited from a palliative care unit. Measures of existential distress, death anxiety, depression, performance status and physical symptom burden were collected. The EDS showed promising psychometric properties, including significant associations with death anxiety and depression. Thirty-eight per cent of the sample reported great or unbearable distress on at least one existential concern. The EDS may be administered to measure existential distress in patients with advanced cancer and clinicians may find the instrument useful to initiate a structured discussion about this symptom.

Natural history and predictors of disturbed eating behaviour in girls with Type 1 diabetes.

AIM: To determine the natural history and psychosocial predictors of disturbed eating behaviour in girls with Type 1 diabetes (T1D) over a 1-year period. METHODS: One hundred and six girls with T1D, 9-13 years of age at Time 1, completed a Children's Eating Disorder Examination (cEDE) interview at Time 1 and again 1 year later (Time 2). Potential Time 1 predictors of Time 2 disturbed eating behaviour were body mass index (BMI), self-esteem, depressive symptoms, attachment to parents, and parental eating attitudes. Glycated haemoglobin (HbA(1c)) was measured. RESULTS: Disturbed eating behaviour was reported by 14% (15/106) of girls at Time 1, and 17% (18/106) at Time 2, and persisted in 8/15 girls over 1 year. Lower self-esteem, higher BMI and more disturbed maternal eating attitudes at Time 1 accounted for 35% of the variance in Time 2 cEDE score, while higher BMI and more disturbed attachment to one's mother predicted new-onset disturbed eating behaviour at Time 2. Glycaemic control was not associated with or predicted by disturbed eating behaviour. CONCLUSIONS: There was only moderate stability in disturbed eating behaviour status over a 1-year period. In this preliminary study, disturbed eating behaviour was associated with and, to a lesser degree, predicted by physical, psychological and family factors. Although the long-term clinical course of the mild disturbances identified is not known, prevention and early intervention efforts in this high-risk medical group should begin in the pre-teen years, and should probably target multiple factors in order to prevent the persistence and worsening of disturbed eating behaviour and its medical sequelae.

Eating disorders in young women with type 1 diabetes. Prevalence, problems and prevention.

Disordered eating attitudes and behavior are common and persistent in adolescent and young adult females with type 1 diabetes, and are associated with impaired metabolic control and a higher risk of diabetes-related complications. Specific aspects of diabetes and its management, e.g. weight gain associated with initiation of insulin treatment or improved metabolic control, and dietary restraint, may trigger the body dissatisfaction and drive for thinness that accompany eating disturbances. Health care providers should be aware of the possible association between eating disturbances and diabetes, and also of the types of behavior, particularly insulin omission for weight loss, that are common in these young women. Therapy will depend on the severity of the eating disturbance. Group psychoeducation, incorporating a nondeprivational approach to eating, may prove effective, especially in those with milder degrees of eating and weight psychopathology.

Disordered eating behavior and microvascular complications in young women with insulin-dependent diabetes mellitus.

BACKGROUND: Insulin-dependent diabetes mellitus (IDDM) and eating disorders are relatively common among young women in North America. Their coexistence could lead to poor metabolic control and an increased risk of the microvascular complications of IDDM. METHODS: We studied 91 young women with IDDM at base line and four to five years later to determine the prevalence and persistence of disordered eating behavior (on the basis of self-reported eating and weight-loss practices, including the intentional omission or underdosing of insulin to control weight) and the association of such eating disorders with metabolic control, diabetic retinopathy, and urinary albumin excretion. At base line, the mean age of the young women was 15+/-2 years and the duration of diabetes was 7+/-4 years. RESULTS: At base line, 26 of 91 young women (29 percent) had highly or moderately disordered eating behavior, which persisted in 16 (18 percent) and improved in 10 (11 percent). Of the 65 women with normal eating behavior at base line (71 percent), 14 (15 percent) had disordered eating at follow-up. Omission or underdosing of insulin lose weight was reported by 12 of 88 young women (14 percent) at base line and 30 (34 percent) at follow-up (P=0.003). At base line, the mean (+/-SD) hemoglobin A(1c) value was higher in the group with highly disordered eating behavior (11.1+/-1.2 percent) than in the groups whose eating behavior was moderately disordered (8.9+/-1.7 percent) or nondisordered (8.7+/-1.6 percent, P<0.001). Disordered eating at base line was associated with retinopathy four years later (P=0.004), when 86 percent of the young women with highly disordered eating behavior, 43 percent of those with moderately disordered eating behavior, and 24 percent of those with nondisordered eating behavior had retinopathy. CONCLUSIONS: Disordered eating behavior is common and persistent in young women with IDDM and is associated with impaired metabolic control and a higher risk of diabetic retinopathy.

A prospective clinical study in humans of an endosseous dental implant partially covered with a powder-sintered porous coating: 3- to 4-year results.

A dental implant covered partially with a porous coating (EndoPore) developed at the University of Toronto was tested. This new implant is a tapered, truncated-cone endosseous root-form implant fabricated from Ti-6Al-4V. It utilizes a powder-sintered porous surface geometry over most of its length to promote three-dimensional bone ingrowth and implant stabilization. In this trial, three implants were placed in the anterior mandibles of 52 patients and were used subsequently as free-standing units to support an overdenture. Much shorter implants, shorter initial healing periods, and simpler surgical techniques than are customary with other implant designs were used. At the time of this report, all patients with implants had passed 3 years of function, and the cumulative implant success rate was 94.8%. Analysis of carefully standardized radiographs revealed a pattern of crestal bone loss similar to earlier published dog data. On a yearly basis, the mean bone loss was 0.43 mm in year 1, 0.17 mm in year 2, and 0.13 mm in year 3.

Psychiatric consultation for competency to refuse medical treatment. A retrospective study of patient characteristics and outcome.

Forty-one psychiatric consultations on medical-surgical inpatients for competency to refuse medical treatment were studied retrospectively. The competent (n = 16) and incompetent (n = 25) patients were compared in terms of demographic data, diagnoses, clinical variables, details about treatment refusal, and outcome following competency assessment. The incompetent patients tended to be men, the focus of more urgent requests, and to have refused operations. The incompetent patients tended to have organic brain syndromes; the competent patients had personality disorders, adjustment disorders, or no psychiatric diagnosis. Ultimate acceptance of treatment initially refused was common in both groups; differential psychiatric interventions were recommended. The process of psychiatric consultation appeared to facilitate acceptance of treatment initially refused.

Relationship of self-efficacy and binging to adherence to diabetes regimen among adolescents.

OBJECTIVE: To test the hypothesis that poorer adherence to diabetes care is related to four variables associated with self-concept in adolescents with diabetes: self-esteem, self-efficacy, depression, and binging behavior. In addition, we expected adolescent females to be less adherent to diabetes care. RESEARCH DESIGN AND METHODS: We recruited 193 consecutive patients (aged 13-18 yr) with insulin-dependent diabetes mellitus during their regular quarterly visit to a diabetes clinic in a large urban hospital. Participants completed the Rosenberg Self-Esteem Scale, the Children's Depression Inventory, an assessment of the frequency of binging in the past 3 mo, and parallel forms of an adherence scale and a self-efficacy scale that were developed for use in this study. RESULTS: Adolescents who reported lower adherence tended to report lower self-esteem (r = 0.45, P less than 0.001) and self-efficacy (r = 0.57, P less than 0.001), more depressive symptoms (r = -0.50, P less than 0.001), more binging (r = -0.36, P less than 0.001), and had higher HbA1c (r = -0.24, P less than 0.001) than those with higher adherence scores. Together, the psychological variables accounted for 50% of the variance in adherence. There was no sex difference in reported binging, but, as expected, adolescent females reported less adherence overall (F[7,184] = 2.5, P = 0.018). CONCLUSIONS: Treatment adherence in adolescents with insulin-dependent diabetes mellitus is associated with behavioral and psychological variables. These findings suggest that specific behavioral and cognitive interventions could be used to improve adherence in those individuals who lack confidence in their ability to perform diabetes-related tasks.

Effects of photoperiod, the pineal gland and the gonads on agonistic behavior in female golden hamsters (Mesocricetus auratus).

Four studies were conducted to determine the role of photoperiod, the pineal gland and the gonads in the regulation of intrasex agonistic behavior in female hamsters. In the first experiment animals maintained under Long or Short photoperiods were tested in same or opposite photoperiod pairs. Under both testing conditions, Short-day animals tended to exhibit a higher ratio of offensive to defensive behaviors, which was due primarily to a reduced level of defensive behavior in Short-day groups. In the second experiment animals under Long and Short photoperiods were tested following sham surgery or pinealectomy. Short-day sham animals exhibited the highest level of offensive behavior, the lowest level of defensive behaviors and the highest offensive/defensive ratio; pinealectomy eliminated the Short-day advantage. In the third experiment, Long-day animals receiving exogenous melatonin showed a higher level of agonistic responding than animals injected with control vehicle, indicating that Short-day effects are probably mediated through pineal melatonin. The results of the last experiment in which ovariectomy to Long-day animals was not able to mimic the effects of photoperiod or exogenous melatonin indicated that the photoperiod effects on aggression are probably not mediated through the gonads.