A study of 'crisis cards' in a community psychiatric service.

OBJECTIVE: 'Crisis cards' state patients' treatment details and preferences in anticipation of a later occasion when the patient might be too ill to express them directly. We assessed the feasibility of introducing 'crisis cards', or a collaborative form of them, 'joint crisis plans', into a sectorized community psychiatric service. METHOD: All patients with a psychosis and at high risk of crisis were invited to participate. Follow-up examined patients' satisfaction and how the cards were used. RESULTS: In total, 106 eligible patients were identified and offered a card, and 40% agreed to participate. Patients with an affective psychosis, past suicide attempts and less frequent admissions were over-represented among those who agreed to take part. Patients chose to include a wide range of information. For participants, admissions fell by 30% in the follow-up year. CONCLUSION: Crisis cards serve both a 'manifest', practical function (to provide important information when the patient is too ill to do so) and a 'latent' psychological one (positive effects on the patient's attitude to self, their illness and treatment, and their relationship with the clinical team).

Care-giving and the impact on carers of a community mental health service. PRiSM Psychosis Study. 6.

BACKGROUND: We examined: care-giving activities in a population-based sample of carers of sufferers from psychotic disorders; putative determinants of care-giving; and changes in care-giving in an intensive community psychiatric service. METHODS: In the PRiSM interview sample 170 people had a carer; 124 were interviewed. Care-giving activities, dissatisfaction with these, and carers' General Health Questionnaire (GHQ) scores were measured. Patient and illness characteristics were examined as predictors of the carer measures. The carer measures were reassessed for 62 carers after two years in two service sectors, one with an intensive community service, the other with a standard service. RESULTS: Overall, 36% of carers were engaged in no, or only occasional care-giving activities. Fifty per cent expressed no dissatisfaction with their care-giving role. Patient and illness characteristics predicted care-giving poorly. Carers in the intensive community treatment sector did not experience significantly different care-giving demands or distress than those in the standard sector. CONCLUSIONS: A significant proportion of carers of sufferers from psychosis do not engage in common care-giving activities, and are not dissatisfied with their role. An intensive community service did not affect the impact of the illness on carers.

Caring for relatives with serious mental illness: the development of the Experience of Caregiving Inventory.

The aim of this study was to develop a practical, comprehensive, and valid self-report measure of the experience of caring for a relative with a serious mental illness. The notion of caregiver "burden' was rejected; instead caregiving was conceptualised within a 'stress-appraisal-coping' framework. A 66-item version of the Experience of Caregiving Inventory (ECI) was derived from analyses of responses from 626 caregivers, and then tested on an independent sample of 63 relatives of patients with schizophrenia recently in acute care. The extent to which the ECI complied with the stress-coping model was tested, especially the degree to which it, in association with coping, predicted psychological morbidity in carers. Ten sub-scales with good internal consistency resulted from our analyses, eight negative (difficult behaviours; negative symptoms; stigma; problems with services; effects on the family; the need to provide backup; dependency; loss) and two positive (rewarding personal experiences; good aspects of the relationship with the patient). The ECI, in conjunction with coping style, predicted a large proportion of the variance in the General Health Questionnaire (GHQ). We concluded that the ECI taps salient dimensions of caregiving distinct from, although linked with, coping and psychological morbidity. It has potential as a useful outcome measure for interventions aimed at promoting caregiver well-being.

A controlled trial of a counselling intervention for caregivers of relatives with schizophrenia.

The effectiveness of short-term interventions to reduce caregiver 'burden' has not been clearly demonstrated. This study assessed the value of six weekly sessions of counselling for key relatives of patients with schizophrenia. The counselling had educational and problem-solving components and was conducted in the family home in the absence of the patient. A randomised controlled design was used. The subjects were the principal caregivers of patients consecutively admitted to acute psychiatric care. Assessments were made pre-treatment and at 3 and 6 months. Of 63 relatives recruited, 47 completed all phases of the study. Relatives in the intervention group reported that they were better able to understand the patient and had a more positive relationship. There were no differences between the intervention and control groups on negative aspects of caregiving or in coping style. Relatives who received the counselling reported slightly greater psychological morbidity at follow-up. However, they all said they would recommend it to others. We concluded that a brief, intensive counselling intervention was of modest benefit to caregivers. Some modifications are suggested.

Counseling caregivers of relatives with schizophrenia: themes, interventions, and caveats.

As part of a controlled study of the effectiveness of a counseling program for family caregivers of patients with schizophrenia, we conducted a comprehensive examination of the process. The particular foci were on themes that arose during sessions, principal therapeutic interventions offered, and caveats for counselors working in the field. The most striking finding was the diverse range of themes, covering personal, coping, family, and social aspects of the caregiving experience. This required a correspondingly broad array of interventions. The implications are clear: confining counseling for caregivers to such traditional dimensions as education or attempts to reduce emotional expressiveness denies them the opportunity to deal with other equally relevant concerns.

A controlled trial of cisapride in anorexia nervosa.

To determine the efficacy of cisapride, 10 mg three times daily, in improving gastric emptying, reducing distress during meals, and facilitating weight gain in anorexia nervosa, we conducted an 8-week, randomized, double-blind, placebo-controlled trial on 29 inpatients. Measures included scintigraphic gastric emptying studies at 0, 2, 4, and 8 weeks; subjective distress during meals measured by visual analogue scales; self-rating of degree of global improvement in symptoms associated with eating at end of study; and weight measured weekly. Gastric emptying improved significantly but equally in both groups over the study period. Yet subjective measures were better in the cisapride group; they rated themselves as more hungry (p = .02) and more improved on the global measure of change in symptoms (p = .02). Even so, the cisapride group did not gain more weight. The correlation between gastric emptying and weight gain was modest (r = .30; p = .11), and between gastric emptying and the subjective measures, virtually absent.

Osteoporosis in anorexia nervosa: the influence of peak bone density, bone loss, oral contraceptive use, and exercise.

Anorexia nervosa occurs early in life and predisposes to osteoporosis. Exercise may be protective. We asked: (1) Does failure to attain peak bone density contribute to the deficit in bone density? (2) Does oral contraceptive use protect against osteoporosis? (3) Is any protective effect of exercise confined to weight-bearing sites? Areal bone density (g/cm2) and body composition were measured by dual x-ray absorptiometry in 65 patients with anorexia nervosa and 52 controls. Comparing the 12 patients with primary amenorrhea and the 37 patients with secondary amenorrhea, bone density (mean +/- SEM) at the lumbar spine was 0.88 +/- 0.04 versus 1.06 +/- 0.03 (P = 0.001), respectively. Bone density at the femoral neck was 0.80 +/- 0.04 versus 0.92 +/- 0.03 (P < 0.05), respectively. These values differed before, but not after, adjusting for the respective duration of illness (73.0 +/- 10.3 versus 34.1 +/- 4.8 months, P < 0.001) and fat-free mass (31.6 +/- 1.3 versus 35.4 +/- 0.5 kg, P < 0.01). Bone density at the lumbar spine in the 16 patients with 31.8 +/- 8.3 months of contraceptive exposure was higher than in the 49 patients with no contraceptive exposure (1.14 +/- 0.05 versus 1.02 +/- 0.02 P < 0.02) but was lower than in controls (1.14 +/- 0.05 versus 1.27 +/- 1.02, P < 0.01). No protective effect of contraceptive exposure was detectable at the femoral neck.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: In Australia, a group of 65 patients with anorexia nervosa were studied. The diagnosis was based on DSM-III-R criteria. A total of 12 patients had primary amenorrhea. Of the 53 patients with secondary amenorrhea, 16 had taken oral contraceptives during a illness. A total of 19 patients were exercisers. 52 premenopausal healthy women volunteers with no illnesses known to affect bone were studied as the control group. Total-body and regional bone density (lumbar spine, L2-4, femoral neck, Ward's triangle, and intertrochanteric regions) were measured by dual x-ray absorptiometry. The 65 patients with anorexia nervosa had significantly lower bone density (lumber spine 1.05 +or- 0.02 gm/sq cm, femoral neck 0.91 +or- 0.02 gm/sq cm), weight (43.3 +or- 0.9 kg), fat mass (7.01 +or- 0.57 kg), and fat-free (lean) mass (34.89 +or- 0.53 kg) than controls (all p 0.001), even after adjustments for differences in age (24.4 +or- 1.0 years, and height, 162.5 +or- 0.8 cm). In the 12 patients with primary amenorrhea, the reduction in bone density at the lumbar spine and femoral neck was greater than the reduction at the corresponding sites in the 37 patients with secondary amenorrhea (p = 0.001 and p = 0.04, respectively). A total of 16 patients took oral contraceptives for 61 +or- 9% of the duration of their illness whose mean bone density at the lumbar spine was greater than in the 49 patients without contraceptive exposure (p 0.01) but less than in controls (p 0.01). The 19 patients who exercised vigorously had higher bone density at the proximal femoral sites than sedentary patients. Patients with anorexia nervosa commencing around puberty may be at greater risk for fractures because they have lower bone density. A protective effect of oral contraceptives was found at the spine; a protective effect of weight-bearing exercise was found at the proximal femur. Thus, estrogen replacement therapy may be an important therapeutic option in this illness.

Attitudes of medical professionals towards patients with eating disorders.

A questionnaire examining attitudes to patients with eating disorders was completed by 352 medical and nursing staff in a general hospital. Patients with eating disorders were less liked than patients with schizophrenia and were seen as responsible for their illness almost to the same degree as recurrent overdose takers. Factor analysis showed a first factor in which patients with eating disorders were construed as vulnerable to external pressures (from others, the media) while also self-inducing their illness, and this was associated with treatment recommendations for education, urging the patient to take self-control and psychotherapy. The professions differed significantly in attitudes.

Neuropsychological impairment in anorexia nervosa: before and after refeeding.

Neuropsychological measures were administered to 18 patients with anorexia nervosa shortly after admission to hospital and again after substantial weight gain. These patients were compared with a group of 18 normal weight controls, also tested on two occasions, who were matched for age, sex, and estimated premorbid IQ. At low weight, impairment was evident on tests of attentional-perceptual-motor functions and on tests of visuospatial construction and problem-solving. Learning was less affected. Refeeding resulted in significant improvements in performance.

Potential regulators of feeding behavior in anorexia nervosa.

We recruited 10 patients with anorexia nervosa and 6 age- and height-matched control subjects. Basal and postprandial concentrations of glucose, insulin, cholesterol, amino acids, gastrin, and pancreatic polypeptide (PP) were measured in response to a standard mixed meal. The only satiety signal that was significantly different between the anorectic group and the control group was PP (P less than 0.001). Tryptophan-LNAA and tyrosine-LNAA ratios were not significantly different in the two groups; however, there was a trend toward a lower tryptophan-LNAA ratio in the anorectic group. Gastrin concentrations were significantly decreased in the anorectic group (P less than 0.001) as were basal insulin concentrations (P less than 0.05). Decreased gastrin concentrations may play a role in the gastric symptoms associated with anorexia nervosa. Previous findings that PP release is diminished in obesity, together with the present findings of PP increase in anorexia nervosa, suggest that this peptide may play a role in appetite control mechanisms.

Anorexia nervosa: outcome and prognostic factors after 20 years.

Forty-one patients with anorexia nervosa, admitted to the Maudsley Hospital between 1959 and 1966, were followed up after a mean of 20 years. An assessment of general outcome (based on the Morgan-Russell scales) yielded three outcome categories: 'good' (n = 12), 'intermediate' (n = 13) and 'poor' (n = 15). Six patients (15%) had died from causes related to anorexia nervosa; at least 15% had developed bulimia nervosa. There was a general consistency between the follow-up at 20 years and that previously conducted five years after admission, although with a few individual patients there were serious prognostic errors at the earlier follow-up. A poorer outcome was associated with a later age of onset, a history of neurotic and personality disturbances, disturbed relationships in the family and a longer duration of illness.

Body image satisfaction, dieting beliefs, and weight loss behaviors in adolescent girls and boys.

Body image and weight loss beliefs and behaviors were assessed in 341 female and 221 male high school students. Estimates of body dissatisfaction varied depending on the measurement strategy used. Despite having similar weight distributions around the expected norm, girls were significantly more dissatisfied with their bodies than boys. Body Mass Index was positively related to body dissatisfaction in girls and boys, while higher exercise levels were related to higher body satisfaction in boys. Nearly two-thirds of girls and boys believed being thinner would have an impact on their lives, but the majority of girls believed this would be positive while the majority of boys believed this would be negative. Thirteen percent of female subjects reported using one or more extreme weight loss behavior at least weekly. Beliefs regarding the effectiveness of different weight loss measures were assessed. Weight loss behaviors in this Australian sample appear similar to comparable U.S. samples.

The dexamethasone suppression test in anorexia nervosa. The influence of weight, depression, adrenocorticotrophic hormone and dexamethasone.

When 20 female anorexic in-patients were investigated with weekly DSTs, 10 had an abnormal result at initial testing. There was no identifiable relationship between severity of weight loss and DST status; % ideal body weight was no different between suppressors and non-suppressors. There was no consistent relationship between normalisation of the DST response and weight gain. Depressive symptoms were common, with half the patients scoring 20 or more on the HRSD. Plasma ACTH concentrations before and after the DST were normal. There was a significant negative correlation between plasma dexamethasone concentrations and pre- and post-dexamethasone plasma cortisol concentrations.

A serial study of gastric emptying in anorexia nervosa and bulimia.

To determine the natural history of delayed gastric emptying of solid foods in anorexia nervosa (AN), gastric emptying was assessed by scintigraphy in 20 consecutive inpatients; eight had restrictive AN, ten had both AN and bulimia nervosa (BN), and two BN alone. Initial gastric half-emptying time (HET) exceeded 110 min (the upper limit of normal for the laboratory) in 16; their body mass index ranged from 11.7 to 18.1. HET showed a significant negative correlation with body mass (r = 0.71; p less than 0.001) but not age, duration of illness or use of psychotropic medication. Fourteen patients with prolonged emptying were retested; HET improved in nine of 12 retested at one month (p = 0.0005) but none showed a change in the lag phase of emptying. All four patients retested a further one to two months later achieved a HET less than 110 min. Fourteen patients reached a body mass index of 16.3 during treatment and HET improved to better than 110 min in all but one of these. However, normalisation occurred while body mass was still subnormal (less than 20.3) and with amenorrhea still present. This study shows that delayed gastric emptying in AN improves quite rapidly as feeding recommences; thus the motility disturbance is secondary to restriction in food intake and is not fundamental to the disorder.

An evaluation of family therapy in anorexia nervosa and bulimia nervosa.

A controlled trial comparing family therapy with individual supportive therapy in anorexia nervosa and bulimia nervosa was undertaken. Eighty patients (57 with anorexia nervosa; 23 with bulimia nervosa) were first admitted to a specialized unit to restore their weight to normal. Before discharge, they were randomly allocated to family therapy or the control treatment (individual supportive therapy). After one year of psychological treatment, they were reassessed, using body weight, menstrual function, and ratings on the Morgan and Russell scales. Family therapy was found to be more effective than individual therapy in patients whose illness was not chronic and had begun before the age of 19 years. A more tentative finding was the greater value of individual supportive therapy in older patients. To our knowledge, this is the first controlled trial of family therapy in anorexia nervosa and clarifies the specific indications for this treatment.