Anorexie mentale : bases rationnelles pour l’hospitalisation en milieu psychiatrique

Hospitalisation in a psychiatry ward is one of the oldest treatments for anorexia nervosa (AN); however the therapeutic modalities and indications for inpatient care have evolved considerably over the last century. In this article, we will present the clinical arguments from the international literature that are used to determine the type of treatment ward in which patients with AN should be hospitalised. Then we will discuss our belief that ideally, all patients with AN needing hospitalisation should cared for in a specialised psychiatry department, even though patients are usually hospitalised because of somatic manifestations of the disorder. Finally, in order to illustrate our point, we present the example of our treatment program at the “Institut Mutualiste Montsouris” before concluding.     

Obsessive-compulsive neurosis and anorexia nervosa

A large number of anorexia nervosa patients manifest anancastic personality traits or obsessive-compulsive symptoms. The clinical characteristics and psychological data from nine female anorexia nervosa patients, characterized by obsessive-compulsive symptoms during the course of their illness, were compared with the data from sixteen anorexia nervosa patients without obsessive-compulsive features. Patients with obsessive-compulsive symptoms showed higher scores in general psychiatric symptoms and in anorectic behavior. Deficiencies in social adjustment were pronounced. The combination of marked obsessive-compulsive and anorectic behaviors seems to coincide with more severe disturbances and chronicity of the disease. The data from this study, which are consistent with the hypothesis that there is a strong relationship between anorexia nervosa and obsessive- compulsive neurosis, are discussed.     

Health and housing conditions in public sector housing estates

This article reports some of the findings of a study of health and housing conditions ina sample of households from eight different types of council housing areas in Gateshead.Controlling for age, there were found to be marked and consistent differences in self-reported health between individuals from different areas. For all age groups up to 65 years old, those living in “bad” housing areas reported poorer health, more long-standing illness, more recent illness and more symptoms of respiratory disease and depression. The clearest associations between poor health and bad housing emerged for the generally fittest age-groups (the under 25 years). For the people over 65 years the position was reversed, with those in “good” housing areas reporting poorer health, with the exception of recent illness. This is argued to be the result of local authority lettings policy, which gives priority to re-housing the less-fit elderly.Those in “bad” housing areas were also more likely to report housing defects which affected their health and to feel that their health could be improved by a change in their housing.The study found that “bad” council housing areas did not necessarily conform to thestereotype of non-traditional construction, or high-rise flats. Some consisted of traditionally built houses, while there was a sizeable representation among the “good” housing of system-built high-rise flats. The “bad” housing areas were marked off more by their location, their poor environment and the low quality of their construction.     

An Academic Clinician’s Perspective on the Care of the Geriatric Patient

This paper discusses the role that the personal history plays in a patient’s perception of his or her own illness in the light of the patient’s own personal history. It demonstrates the regrettable modern tendency to regards the patient as the “bearer of a disease” rather than as a human being with personal values and experiences into which their current illness needs to be integrated. I illustrate my point by an exchange between a student and an “attending” and the “attending” and the patient. It represents only one out of unfortunately many such instances in which the pressures of “managed care” and “efficiency” have made truly knowing the patient as an individual with life experiences and personal values much more difficult.     

Acquired pseudo eating disorder: An imitation or fabrication of anorexia nervosa

Acquired pseudo eating disorder is a condition characterized by the development or fabrication of symptoms corresponding to an eating disorder in a patient hospitalized for an unrelated medical illness, who has previously been exposed to a patient(s) with anorexia nervosa. Two adolescent patients developed an eating disorder during medical hospitalisation. Both acquired the condition while hospitalized for another reason (myelomeningocele and multiple sclerosis, respectively). The potential psychodynamics suggested the selection of an “eating disorder,” amenable to control, over the reality of a threatening illness that was experienced as being out of control. Thus, the new and dramatic symptoms appeared to serve as a defense against a pervasive underlying depression. The patient's loudly proclaimed “eating disorder” seemed to originate from the imitation of anorexia nervosa patients. Recognition of this hospital-acquired pseudo eating disorder and appropriate counseling resulted in rapid resolution of the symptoms. It is possible to identify a pseudo eating disorder developing during a hospitalization and differentiate it from “true” anorexia nervosa.     

Behavioural differences between twin and non-twin female sibling pairs discordant for anorexia nervosa

Despite the voluminous literature on anorexia nervosa, its aetiology remains an issue of speculation and debate. Family influences have long been considered important, but genetic factors only recently have attracted interest. We surveyed a consecutive sample of anorexia nervosa patients referred to our service and identified 11 patients who were members of a same-sex twin pair. To our surprise, in no instance was there evidence that the co-twin was concordant for the illness. This finding contrasts with other reports in the literature, and it aroused our interest in the effects of being a twin on susceptibility to the illness. The aim of the present study was to determine whether there were any significant differences in premorbid factors and in symptoms following the development of the illness in 11 twin anorexia nervosa females who were compared with 11 non-twin anorexic patients. The development of each patient was also contrasted with that of a sister. The development of each patient was elicited from the patient's mother by means of an interview schedule that contained questions relating to parental background, birth history, infancy, and adolescent development stages, as well as daughter's attitudes towards school, food, appearance, and weight-reducing behaviours, including eating, exercise, and sport. The findings suggest that there may be differences in clinical pictures presented by twin and non-twin anorexia nervosa patients that could influence response to treatment and outcome.     

Outpatient management of eating disorders in adults

Eating disorders are prevalent in the young adult female population. Given the serious medical, nutritional, and psychological risks associated with eating disorders, it is advisable that patients be seen within the framework of a multidisciplinary team. Psychotherapy is the most effective treatment modality for eating disorders and constitutes the core of mental health treatment. Although cognitive behavior therapy trials dominate the research literature on interventions for bulimia nervosa and binge-eating disorder, various modalities of psychotherapy have efficacy. Active weight management is also a key component of treatment for anorexia nervosa. Psychotropic medication therapy is not generally useful for the primary symptoms of anorexia nervosa, whereas it is moderately effective in the treatment of both bulimia nervosa and binge-eating disorder. Given the patient population at Massachusetts General Hospital, to which patients often present with serious and chronic symptoms, comorbid medical and psychiatric illness, and history of poor response to treatment, we have found a flexible and eclectic treatment approach most useful clinically.     

Are there gender differences in core symptoms,temperament, and short‐term prospective outcome in anorexia nervosa?

OBJECTIVE: The objective of this study was to compare symptoms, premorbid personality phenotypes, and short-term outcome between males and females with anorexia nervosa. METHOD: Symptom and personality ratings were obtained at the time of hospital admission, and outcome was assessed at discharge and again 1 year later. RESULTS: Gender effects were negligible at admission, with the exception of greater weight concern among females. Lifetime anxiety disorders and personality traits implicated in liability for anorexia nervosa were common among patients of both genders. Females had greater persistence of symptom morbidity over the 1-year follow-up. CONCLUSION: Although gender has little effect on the clinical features of anorexia nervosa, the illness runs a more protracted early course in females. Possible mechanisms underlying greater persistence of morbidity in females include sexual dimorphisms in brain neurotransmission, gender differences in attitudes regarding ideal body weight, and anxiety-related personality phenotypes associated with anorexia nervosa.     

Duration of illness predicts outcome for bulimia nervosa: a long-term follow-up study

OBJECTIVE: The purpose of this study was to investigate long-term outcome and prognosis in a bulimic and subthreshold bulimic sample. METHOD: In a follow-up study, 44 patients diagnosed with bulimia nervosa and subthreshold bulimia nervosa were contacted after an average follow-up period of 9 years. RESULTS: Results revealed that 72.7% (n = 32) of the participants were recovered at the time of follow-up. An investigation of prognostic variables showed that good outcome was associated with a shorter duration of illness, which was defined as the time between onset of symptoms and first treatment intervention. If participants were initially treated within the first few years of the illness, the probability of recovery was above 80%. However, if they were initially treated 15 years or more after the onset of the illness, the probability of recovery fell below 20%. DISCUSSION: This finding suggests that early identification of bulimia nervosa may be a very important factor in preventing a chronic eating disorder.     

“They (ARVs) are my life, without them I’m nothing”—experiences of patients attending a HIV/AIDS clinic in Johannesburg, South Africa

This paper is a part of a larger study that explores the “social complexity” of antiretroviral therapy (ART), in resource-limited environments. Drawing on in-depth interviews with a sample of 44 patients in an urban HIV/AIDS clinic in Johannesburg, South Africa, this paper examines how people with HIV/AIDS conceptualise their illness and its treatment in this context. The paper concludes that the fear of stigma plays a significant role in patients’ experiences throughout the disease trajectory. Yet, demonstrates that there are indications that ARVs are transforming the experience of living with HIV/AIDS and a process of normalisation is taking place. Despite the resource-limited context and, often, lack of family and community support, patients see the ARVs as ‘life saving’ and express their long-term commitment to adhere to the drug regimen as well as their trust in health professionals.     

Illness in breastfeeding infants relates to concentration of lactoferrin and secretory Immunoglobulin A in mother’s milk

Background and objectives: This study aims to better understand the relationship between immune compounds in human milk and infant health. We hypothesized that the concentration of immune compounds in milk would relate to infant illness symptoms according to two possible theoretical paradigms. In the ‘protective’ paradigm, high concentrations of immune compounds prevent infant illness. The converse, the ‘responsive’ framework, posits that concentrations of immune compounds are elevated in response to infection.Methodology: Milk samples (n = 110) and illness data were collected among the Toba of Argentina from 30 mother–infant dyads. Samples were assayed for two immune proteins, lactoferrin and secretory immunoglobulin A (sIgA). Generalized estimating equations were used to assess the relationship between immune composition of milk and symptoms of illness in infants.Results: Lactoferrin was positively associated with symptoms of illness in infants (odds ratios >1), both in the month preceding the sample collection and the subsequent month. sIgA was negatively associated with symptoms (odds ratios <1) in the preceding and subsequent months, an association which was particularly strong for gastrointestinal symptoms.Conclusions and implications: The two compounds investigated in our study had opposite relationships with symptoms of illness; the positive relationship between lactoferrin and illness lends support to our ‘responsive’ paradigm, and the negative relationship between sIgA and symptoms of illness was consistent with our ‘protective’ framework. That elevated lactoferrin is restricted to periods of illness suggests that there may be a cost to mother or infant associated with persistently elevated lactoferrin that is not incurred with elevated sIgA.     

Composantes neurosensorielles et hormonales dans l’anorexie mentale

Anorexia nervosa (AN) is often considered a multifactorial illness of unknown pathophysiology. Family and twin studies have consistently demonstrated that AN is strongly related to genetic factors. The probability of some genetic origin is 92%, genetic factors explaining around 20% of the variance. It must be remembered that 95% of the AN patients were girls or women, suggesting a role for gonadal hormonal systems and their effects on the brain and on cognitive functions. Most studies focused on the serotonin system, but other candidate genes have been suggested. At the present time, we have no evidence that women who develop AN have an adipose, metabolic, gonadal, pituitary, hypothalamic or some other dysfunctions that predispose them for the illness. It is suggested on the contrary that the symptoms of AN are physiological responses to starvation or to the response to altered body image and self-satisfaction. If this eating disorder is related to the fear of the alimentary desire of the patients, it will be easy to understand the plasma level of adiponectin, ghrelin and better understand a role for the low leptin level in the enhanced hunger. If we remember that almost 60% of these patients are engaged in a physical and mental hyperactivity, the abnormality in plasma level of cortisol, ACTH, and CRH. The decease in fat mass could explain why leptin level was low and low leptin level may explain the amenorrhea and the fall in LH, FSH, and LH–RH secretion. Moreover, anxiety, obsessive compulsive disorders and physical hyperactivity may be three interrelated factors, which could be related to serotonin and dopamine systems and in turn inhibit food intake.     

Insight into illness and outcome in anorexia nervosa

Thirty female subjects were followed up an average of 4.6 years after being hospitalized for anorexia nervosa. Insight into illness, symptoms, and treatment was rated for index hospitalization and assessed at follow up using the Schedule for Assessment of Insight. In addition, subjects were interviewed and assessed for level of function, symptoms of eating disorders, and the presence of significant psychopathology. The Insight Rating at index hospitalization was correlated with the Global Insight Score at follow up and with EAT score at follow up. Subjects with longer lengths of stay and greater increase in Body Mass Index during index hospitalization had higher levels of insight at both times of measurement. At followup, both Global Insight Score and assessment of subjects' ability to acknowledge illness were correlated with a variety of positive outcome measures, suggesting that insight may be an important therapeutic factor to consider in assessment and treatment of anorexia nervosa.     

Disordered eating: A defense against psychosis?

The authors present four cases suffering with either bulimia nervosa or anorexia nervosa in conjunction with a psychotic illness. In all cases there appeared to be a reciprocal relationship between the eating disorder and psychosis such that improvement in eating precipitated or exacerbated the psychotic symptoms. We suggest that disordered eating serves as a defense against psychosis. Difficulties in treating such patients are discussed. © 1998 by John Wiley & Sons, Inc. Int J Eat Disord 24: 329–333, 1998.     

Clinical presentation of anorexia nervosa in males: 24 new cases

As part of a larger prognostic study of anorexia nervosa, clinical features at presentation of 24 males with anorexia are described, and compared with a female group matched for date of admission. Data were extracted from the original case records and follow-up interview. The study confirms the view that males display the classical syndrome of anorexia nervosa, but differs from previous studies in several respects. Age at onset (mean 18.6 years) and at presentation (mean 20.2 years) is later, with a mean duration of illness at presentation of only 1.6 years. A premorbid tendency to obesity is confirmed; maximum weight loss during the illness amounted to 42% matched population mean weight (MPMW), and weight at presentation was 78.5% MPMW, somewhat higher than the female group. In keeping with earlier studies, hinging and vomiting were noted commonly, in around half of sufferers, but laxative abuse was less frequent and excessive exercising more frequent in males. Depressive and obsessional symptoms are common in both groups, and a strong family history of affective disorders and alcohol abuse was noted in over one third.© 1994 by John Wiley & Sons, Inc.     

Health-seeking strategies and sexual health among female sex workers in urban India: Implications for research and service provision

This paper presents and discusses selected findings from a study of health-seeking strategies in relation to sexual health among a group of female sex workers in Calcutta, India. Background information on sex work and sexually transmitted disease in Calcutta is followed by the presentation of findings pertaining to women's understandings of (sexual) health, treatment-seeking and service utilisation. In the urban context where health services are readily available, patterns of initial treatment-seeking are shown to be generally (biomedically) appropriate, but subsequent “non-compliant” therapeutic practices give cause for concern. Conventional approaches to the study of “health-seeking behaviour” are reviewed in the light of these findings and questions raised about the appropriateness of approaches that focus on initial choice of treatment type and/or assume processes of health-seeking to be determined primarily by cultural “beliefs” about illness. Inherent biomedical and culturalist biases in the orientation of such research are shown to produce an analytic neglect of the dual influences of material life conditions and people's perceptions of health, rather than illness, upon health-related strategies. Recommendations are made for operational research and policy formulation on the provision of effective sexual health services, and implications are drawn for the scope of interventions and applied research directed at improving sexual health.     

Infinitesimal risk as public health crisis: News media coverage of a doctor-patient HIV contact tracing investigation

Among the most prominent health or medical stories covered in 1994 by the Australian news media was that concerning an HIV positive hospital obstetrician and the attempt by the New South Wales Health Department to trace and test 149 women on whom he had operated. All press and television coverage of the issue was reviewed. The surface news narrative of the search for missing, “innocent” mothers potentially infected with a deadly and infectious illness is shown to serve as a “hard news” pretext enabling a wider major discourse to operate about a health system accused as being captive to gay and civil libertarian politics, allowing “guilty” doctors at high risk of HIV to endanger “innocent” patients. Expert consensus held that the women were at “infinitesimal risk” of acquiring HIV. However, media accounts of the investigation all but belied this, illustrating that the news media's framing of risk has more to do with its reproduction of moral outrage components than with “scientific” notions of calculable risk.     

Anorexia nervosa complicated by diabetes mellitus: The case for permissive hyperglycemia

The coexistence of Type 1 Diabetes Mellitus and anorexia nervosa results in an increased incidence of known diabetic complications such as retinopathy and nephropathy, presumably because blood glucose is difficult to control within the throes of comorbid anorexia nervosa. In addition, even when a diabetic patient with anorexia nervosa has committed to resolving his or her eating disorder, glucose control is again difficult and fraught with complexity and peril as will be highlighted in the following case report. Prudence dictates that strict glucose control is not indicated for the relatively short period of time that constitutes the early stage of refeeding in a patient with severe anorexia nervosa. Rather, “permissive hyperglycemia” may be the more optimal course to pursue, as a clinical strategy which is considerate of both the criticality of the refeeding treatment plan and of the long‐term nature of the diabetic illness. © 2014 Wiley Periodicals, Inc. (Int J Eat Disord 2014; 47:671–674)     

Bulimia nervosa with and without alcoholism: A comparative study in Japan

To characterize females with bulimia nervosa and alcoholism, this study compared the social and family backgrounds, as well as the clinical symptoms of alcoholics with bulimia and patients with bulimia only. The subjects were 22 Japanese female patients with both bulimia nervosa and alcoholism; the comparison group comprised 22 age-matched female patients with bulimia nervosa but without alcoholism. Patients with both bulimia and alcoholism had more borderline personality disorders and pathological symptoms such as stealing, suicide attempts, and liver injuries than the nonalcoholic comparison group. The subjects' average body weight was significantly less than that of the comparison group. Whereas the clinical characteristics of females with bulimia and alcoholism differ in many respects from those with bulimia only, it is suggested that alcoholic bulimia patients form a distinct clinical subgroup among patients with bulimia nervosa. © 1994 by John Wiley & Sons, Inc.