42 results
66 A Recurrent Pattern of Posterior Vermis-Predominant Cerebellar Hypoplasia (Not Dandy-Walker) Occurring with Psychosis-Schizophrenia
- Alison C. Leslie, William B. Dobyns, Mitchell P. Ward
-
- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 850-851
-
- Article
-
- You have access Access
- Export citation
-
Objective:
Schizophrenia (SCZ) is a neuropsychiatric disorder with strong genetic heritability and predicted genetic heterogeneity, but limited knowledge regarding the underlying genetic risk variants. Classification into phenotype-driven subgroups or endophenotypes is expected to facilitate genetic analysis. Here, we report a teen boy with chronic psychosis and cerebellar hypoplasia (CBLH) and analyze data on 16 reported individuals with SCZ or chronic psychosis not otherwise specified associated with cerebellar hypoplasia to look for shared features.
Participants and Methods:We evaluated an 18-year-old boy with neurodevelopmental deficits from early childhood and onset of hallucinations and other features of SCZ at 10 years who had mild vermis-predominant CBLH on brain imaging. This prompted us to review prior reports of chronic psychosis or SCZ with cerebellar malformations using paired search terms including (1) cerebellar hypoplasia, Dandy-Walker malformation, Dandy-Walker variant, or mega-cisterna magna with (2) psychosis or SCZ. We found reports of 16 affected individuals from 13 reports. We reviewed clinical features focusing on demographic information, prenatal-perinatal history and neuropsychiatric and neurodevelopmental phenotypes, and independently reviewed brain imaging features.
Results:All 17 individuals had classic psychiatric features of SCZ or chronic psychosis as well as shared neurodevelopmental features not previously highlighted including a downward shift in IQ of about 20 points, memory impairment, speech-language deficits, attention deficits and sleep disturbances. The brain imaging findings among these individuals consistently showed posterior vermis predominant CBLH with variable cerebellar hemisphere hypoplasia and enlarged posterior fossa (a.k.a. mega-cisterna magna). None had features of classic DWM.
Conclusions:In 17 individuals with chronic psychosis or SCZ and cerebellar malformation, we found a high frequency of neurodevelopmental disorders, a consistent brain malformation consisting of posterior vermis-predominant (and usually symmetric) CBLH, and no evidence of prenatal risk factors. The consistent phenotype and lack of prenatal risk factors for CBLH leads us to hypothesize that psychosis or schizophrenia associated with vermis predominant CBLH comprises a homogeneous subgroup of individuals with chronic psychosis/schizophrenia that is likely to have an underlying genetic basis. No comprehensive targeted gene panel for CBLH has yet been defined, leading us to recommend trio-based exome sequencing for individuals who present with this combination of features.
Health Technology Agency insights: informing modification of a qualitative benefit risk framework for Health Technology Reassessment of prescription medications
- Mary Alison Maloney, Lisa Schwartz, Daria O'Reilly, Mitchel Levine
-
- Journal:
- International Journal of Technology Assessment in Health Care / Volume 35 / Issue 5 / 2019
- Published online by Cambridge University Press:
- 16 September 2019, pp. 384-392
-
- Article
- Export citation
-
Objectives
This study's intent was to determine if a qualitative benefit risk framework could be used or modified to further enable Health Technology Reassessment (HTR) of prescription medicine recommendations. The purpose of this research was to understand Canadian Health Technology Agency assessors past experiences and insights to inform any modifications to the Universal Methodology for Benefit−Risk Assessment (UMBRA) qualitative framework. The UMBRA framework consists of an eight-step process, used during the assessment phase, to aid in decision making and dissemination.
MethodsA qualitative descriptive study was conducted and included a purposeful, criterion-based sample of eight assessors who had participated in Health Technology Assessment (HTA) or HTR for prescription medicines or in qualitative decision-making frameworks.
ResultsParticipant interviews lead to four common themes: “adoption of a qualitative benefit risk framework,” “data (either too much or not enough),” “importance of incorporating stakeholder values,” and “feasibility of the UMBRA framework.” Methodological challenges with HTR were highlighted including the lack of clinical outcome data and the ability to compare clinically relevant meaningful differences. The implementation of a ranking or weighing process found within the UMBRA framework was not favored by half of the participants.
ConclusionsResearch participants did not consider all steps of the UMBRA framework to be transferable to the assessment phase of HTR given the need for simplicity, resource efficiency, and stakeholder input throughout the process. The assessor experiences and insights and the resultant key themes can be used in future research to aid in the development of a qualitative recommendation framework for HTR.
DRUG DISINVESTMENT FRAMEWORKS: COMPONENTS, CHALLENGES, AND SOLUTIONS
- Mary Alison Maloney, Lisa Schwartz, Daria O'Reilly, Mitchel Levine
-
- Journal:
- International Journal of Technology Assessment in Health Care / Volume 33 / Issue 2 / 2017
- Published online by Cambridge University Press:
- 13 July 2017, pp. 261-269
-
- Article
- Export citation
-
Objectives: Value assessments of marketed drug technologies have been developed through disinvestment frameworks. Components of these frameworks are varied and implementation challenges are prevalent. The objective of this systematic literature review was to describe disinvestment framework process components for drugs and to report on framework components, challenges, and solutions.
Methods: A systematic literature search was conducted using the terms: reassessment, reallocation, reinvestment, disinvestment, delist, decommission or obsolescence in MEDLINE, EMBASE, NLM PubMed, the Cochrane Library, and CINAHL from January 1, 2000, until November 14, 2015. Additional citations were identified through a gray literature search of Health Technology Assessment international (HTAi) and the International Network of Agencies for Health Technology Assessment (INAHTA) member Web sites and from bibliographies of full-text reviewed manuscripts.
Results: Sixty-three articles underwent full text review and forty were included in the qualitative analysis. Framework components including disinvestment terms and definitions, identification and prioritization criteria and methods, assessment processes, stakeholders and dissemination strategies, challenges, and solutions were compiled. This review finds that stakeholders lack the political, administrative, and clinical will to support disinvestment and that there is not one disinvestment framework that is considered best practice.
Conclusions: Drug technology disinvestment components and processes vary and challenges are numerous. Future research should focus on lessening value assessment challenges. This could include adopting more neutral framework terminology, setting fixed reassessment timelines, conducting therapeutic reviews, and modifying current qualitative decision-making assessment frameworks.
Contributors
-
- By Mitchell Aboulafia, Frederick Adams, Marilyn McCord Adams, Robert M. Adams, Laird Addis, James W. Allard, David Allison, William P. Alston, Karl Ameriks, C. Anthony Anderson, David Leech Anderson, Lanier Anderson, Roger Ariew, David Armstrong, Denis G. Arnold, E. J. Ashworth, Margaret Atherton, Robin Attfield, Bruce Aune, Edward Wilson Averill, Jody Azzouni, Kent Bach, Andrew Bailey, Lynne Rudder Baker, Thomas R. Baldwin, Jon Barwise, George Bealer, William Bechtel, Lawrence C. Becker, Mark A. Bedau, Ernst Behler, José A. Benardete, Ermanno Bencivenga, Jan Berg, Michael Bergmann, Robert L. Bernasconi, Sven Bernecker, Bernard Berofsky, Rod Bertolet, Charles J. Beyer, Christian Beyer, Joseph Bien, Joseph Bien, Peg Birmingham, Ivan Boh, James Bohman, Daniel Bonevac, Laurence BonJour, William J. Bouwsma, Raymond D. Bradley, Myles Brand, Richard B. Brandt, Michael E. Bratman, Stephen E. Braude, Daniel Breazeale, Angela Breitenbach, Jason Bridges, David O. Brink, Gordon G. Brittan, Justin Broackes, Dan W. Brock, Aaron Bronfman, Jeffrey E. Brower, Bartosz Brozek, Anthony Brueckner, Jeffrey Bub, Lara Buchak, Otavio Bueno, Ann E. Bumpus, Robert W. Burch, John Burgess, Arthur W. Burks, Panayot Butchvarov, Robert E. Butts, Marina Bykova, Patrick Byrne, David Carr, Noël Carroll, Edward S. Casey, Victor Caston, Victor Caston, Albert Casullo, Robert L. Causey, Alan K. L. Chan, Ruth Chang, Deen K. Chatterjee, Andrew Chignell, Roderick M. Chisholm, Kelly J. Clark, E. J. Coffman, Robin Collins, Brian P. Copenhaver, John Corcoran, John Cottingham, Roger Crisp, Frederick J. Crosson, Antonio S. Cua, Phillip D. Cummins, Martin Curd, Adam Cureton, Andrew Cutrofello, Stephen Darwall, Paul Sheldon Davies, Wayne A. Davis, Timothy Joseph Day, Claudio de Almeida, Mario De Caro, Mario De Caro, John Deigh, C. F. Delaney, Daniel C. Dennett, Michael R. DePaul, Michael Detlefsen, Daniel Trent Devereux, Philip E. Devine, John M. Dillon, Martin C. Dillon, Robert DiSalle, Mary Domski, Alan Donagan, Paul Draper, Fred Dretske, Mircea Dumitru, Wilhelm Dupré, Gerald Dworkin, John Earman, Ellery Eells, Catherine Z. Elgin, Berent Enç, Ronald P. Endicott, Edward Erwin, John Etchemendy, C. Stephen Evans, Susan L. Feagin, Solomon Feferman, Richard Feldman, Arthur Fine, Maurice A. Finocchiaro, William FitzPatrick, Richard E. Flathman, Gvozden Flego, Richard Foley, Graeme Forbes, Rainer Forst, Malcolm R. Forster, Daniel Fouke, Patrick Francken, Samuel Freeman, Elizabeth Fricker, Miranda Fricker, Michael Friedman, Michael Fuerstein, Richard A. Fumerton, Alan Gabbey, Pieranna Garavaso, Daniel Garber, Jorge L. A. Garcia, Robert K. Garcia, Don Garrett, Philip Gasper, Gerald Gaus, Berys Gaut, Bernard Gert, Roger F. Gibson, Cody Gilmore, Carl Ginet, Alan H. Goldman, Alvin I. Goldman, Alfonso Gömez-Lobo, Lenn E. Goodman, Robert M. Gordon, Stefan Gosepath, Jorge J. E. Gracia, Daniel W. Graham, George A. Graham, Peter J. Graham, Richard E. Grandy, I. Grattan-Guinness, John Greco, Philip T. Grier, Nicholas Griffin, Nicholas Griffin, David A. Griffiths, Paul J. Griffiths, Stephen R. Grimm, Charles L. Griswold, Charles B. Guignon, Pete A. Y. Gunter, Dimitri Gutas, Gary Gutting, Paul Guyer, Kwame Gyekye, Oscar A. Haac, Raul Hakli, Raul Hakli, Michael Hallett, Edward C. Halper, Jean Hampton, R. James Hankinson, K. R. Hanley, Russell Hardin, Robert M. Harnish, William Harper, David Harrah, Kevin Hart, Ali Hasan, William Hasker, John Haugeland, Roger Hausheer, William Heald, Peter Heath, Richard Heck, John F. Heil, Vincent F. Hendricks, Stephen Hetherington, Francis Heylighen, Kathleen Marie Higgins, Risto Hilpinen, Harold T. Hodes, Joshua Hoffman, Alan Holland, Robert L. Holmes, Richard Holton, Brad W. Hooker, Terence E. Horgan, Tamara Horowitz, Paul Horwich, Vittorio Hösle, Paul Hoβfeld, Daniel Howard-Snyder, Frances Howard-Snyder, Anne Hudson, Deal W. Hudson, Carl A. Huffman, David L. Hull, Patricia Huntington, Thomas Hurka, Paul Hurley, Rosalind Hursthouse, Guillermo Hurtado, Ronald E. Hustwit, Sarah Hutton, Jonathan Jenkins Ichikawa, Harry A. Ide, David Ingram, Philip J. Ivanhoe, Alfred L. Ivry, Frank Jackson, Dale Jacquette, Joseph Jedwab, Richard Jeffrey, David Alan Johnson, Edward Johnson, Mark D. Jordan, Richard Joyce, Hwa Yol Jung, Robert Hillary Kane, Tomis Kapitan, Jacquelyn Ann K. Kegley, James A. Keller, Ralph Kennedy, Sergei Khoruzhii, Jaegwon Kim, Yersu Kim, Nathan L. King, Patricia Kitcher, Peter D. Klein, E. D. Klemke, Virginia Klenk, George L. Kline, Christian Klotz, Simo Knuuttila, Joseph J. Kockelmans, Konstantin Kolenda, Sebastian Tomasz Kołodziejczyk, Isaac Kramnick, Richard Kraut, Fred Kroon, Manfred Kuehn, Steven T. Kuhn, Henry E. Kyburg, John Lachs, Jennifer Lackey, Stephen E. Lahey, Andrea Lavazza, Thomas H. Leahey, Joo Heung Lee, Keith Lehrer, Dorothy Leland, Noah M. Lemos, Ernest LePore, Sarah-Jane Leslie, Isaac Levi, Andrew Levine, Alan E. Lewis, Daniel E. Little, Shu-hsien Liu, Shu-hsien Liu, Alan K. L. Chan, Brian Loar, Lawrence B. Lombard, John Longeway, Dominic McIver Lopes, Michael J. Loux, E. J. Lowe, Steven Luper, Eugene C. Luschei, William G. Lycan, David Lyons, David Macarthur, Danielle Macbeth, Scott MacDonald, Jacob L. Mackey, Louis H. Mackey, Penelope Mackie, Edward H. Madden, Penelope Maddy, G. B. Madison, Bernd Magnus, Pekka Mäkelä, Rudolf A. Makkreel, David Manley, William E. Mann (W.E.M.), Vladimir Marchenkov, Peter Markie, Jean-Pierre Marquis, Ausonio Marras, Mike W. Martin, A. P. Martinich, William L. McBride, David McCabe, Storrs McCall, Hugh J. McCann, Robert N. McCauley, John J. McDermott, Sarah McGrath, Ralph McInerny, Daniel J. McKaughan, Thomas McKay, Michael McKinsey, Brian P. McLaughlin, Ernan McMullin, Anthonie Meijers, Jack W. Meiland, William Jason Melanson, Alfred R. Mele, Joseph R. Mendola, Christopher Menzel, Michael J. Meyer, Christian B. Miller, David W. Miller, Peter Millican, Robert N. Minor, Phillip Mitsis, James A. Montmarquet, Michael S. Moore, Tim Moore, Benjamin Morison, Donald R. Morrison, Stephen J. Morse, Paul K. Moser, Alexander P. D. Mourelatos, Ian Mueller, James Bernard Murphy, Mark C. Murphy, Steven Nadler, Jan Narveson, Alan Nelson, Jerome Neu, Samuel Newlands, Kai Nielsen, Ilkka Niiniluoto, Carlos G. Noreña, Calvin G. Normore, David Fate Norton, Nikolaj Nottelmann, Donald Nute, David S. Oderberg, Steve Odin, Michael O’Rourke, Willard G. Oxtoby, Heinz Paetzold, George S. Pappas, Anthony J. Parel, Lydia Patton, R. P. Peerenboom, Francis Jeffry Pelletier, Adriaan T. Peperzak, Derk Pereboom, Jaroslav Peregrin, Glen Pettigrove, Philip Pettit, Edmund L. Pincoffs, Andrew Pinsent, Robert B. Pippin, Alvin Plantinga, Louis P. Pojman, Richard H. Popkin, John F. Post, Carl J. Posy, William J. Prior, Richard Purtill, Michael Quante, Philip L. Quinn, Philip L. Quinn, Elizabeth S. Radcliffe, Diana Raffman, Gerard Raulet, Stephen L. Read, Andrews Reath, Andrew Reisner, Nicholas Rescher, Henry S. Richardson, Robert C. Richardson, Thomas Ricketts, Wayne D. Riggs, Mark Roberts, Robert C. Roberts, Luke Robinson, Alexander Rosenberg, Gary Rosenkranz, Bernice Glatzer Rosenthal, Adina L. Roskies, William L. Rowe, T. M. Rudavsky, Michael Ruse, Bruce Russell, Lilly-Marlene Russow, Dan Ryder, R. M. Sainsbury, Joseph Salerno, Nathan Salmon, Wesley C. Salmon, Constantine Sandis, David H. Sanford, Marco Santambrogio, David Sapire, Ruth A. Saunders, Geoffrey Sayre-McCord, Charles Sayward, James P. Scanlan, Richard Schacht, Tamar Schapiro, Frederick F. Schmitt, Jerome B. Schneewind, Calvin O. Schrag, Alan D. Schrift, George F. Schumm, Jean-Loup Seban, David N. Sedley, Kenneth Seeskin, Krister Segerberg, Charlene Haddock Seigfried, Dennis M. Senchuk, James F. Sennett, William Lad Sessions, Stewart Shapiro, Tommie Shelby, Donald W. Sherburne, Christopher Shields, Roger A. Shiner, Sydney Shoemaker, Robert K. Shope, Kwong-loi Shun, Wilfried Sieg, A. John Simmons, Robert L. Simon, Marcus G. Singer, Georgette Sinkler, Walter Sinnott-Armstrong, Matti T. Sintonen, Lawrence Sklar, Brian Skyrms, Robert C. Sleigh, Michael Anthony Slote, Hans Sluga, Barry Smith, Michael Smith, Robin Smith, Robert Sokolowski, Robert C. Solomon, Marta Soniewicka, Philip Soper, Ernest Sosa, Nicholas Southwood, Paul Vincent Spade, T. L. S. Sprigge, Eric O. Springsted, George J. Stack, Rebecca Stangl, Jason Stanley, Florian Steinberger, Sören Stenlund, Christopher Stephens, James P. Sterba, Josef Stern, Matthias Steup, M. A. Stewart, Leopold Stubenberg, Edith Dudley Sulla, Frederick Suppe, Jere Paul Surber, David George Sussman, Sigrún Svavarsdóttir, Zeno G. Swijtink, Richard Swinburne, Charles C. Taliaferro, Robert B. Talisse, John Tasioulas, Paul Teller, Larry S. Temkin, Mark Textor, H. S. Thayer, Peter Thielke, Alan Thomas, Amie L. Thomasson, Katherine Thomson-Jones, Joshua C. Thurow, Vzalerie Tiberius, Terrence N. Tice, Paul Tidman, Mark C. Timmons, William Tolhurst, James E. Tomberlin, Rosemarie Tong, Lawrence Torcello, Kelly Trogdon, J. D. Trout, Robert E. Tully, Raimo Tuomela, John Turri, Martin M. Tweedale, Thomas Uebel, Jennifer Uleman, James Van Cleve, Harry van der Linden, Peter van Inwagen, Bryan W. Van Norden, René van Woudenberg, Donald Phillip Verene, Samantha Vice, Thomas Vinci, Donald Wayne Viney, Barbara Von Eckardt, Peter B. M. Vranas, Steven J. Wagner, William J. Wainwright, Paul E. Walker, Robert E. Wall, Craig Walton, Douglas Walton, Eric Watkins, Richard A. Watson, Michael V. Wedin, Rudolph H. Weingartner, Paul Weirich, Paul J. Weithman, Carl Wellman, Howard Wettstein, Samuel C. Wheeler, Stephen A. White, Jennifer Whiting, Edward R. Wierenga, Michael Williams, Fred Wilson, W. Kent Wilson, Kenneth P. Winkler, John F. Wippel, Jan Woleński, Allan B. Wolter, Nicholas P. Wolterstorff, Rega Wood, W. Jay Wood, Paul Woodruff, Alison Wylie, Gideon Yaffe, Takashi Yagisawa, Yutaka Yamamoto, Keith E. Yandell, Xiaomei Yang, Dean Zimmerman, Günter Zoller, Catherine Zuckert, Michael Zuckert, Jack A. Zupko (J.A.Z.)
- Edited by Robert Audi, University of Notre Dame, Indiana
-
- Book:
- The Cambridge Dictionary of Philosophy
- Published online:
- 05 August 2015
- Print publication:
- 27 April 2015, pp ix-xxx
-
- Chapter
- Export citation
Distinguishing Friend from Foe: Law and Policy in the Age of Battlefield Biometrics
- Alison Mitchell
-
- Journal:
- Canadian Yearbook of International Law / Annuaire canadien de droit international / Volume 50 / 2013
- Published online by Cambridge University Press:
- 09 March 2016, pp. 289-330
- Print publication:
- 2013
-
- Article
- Export citation
-
In the space of just over ten years, the collection and use of biometric data in the context of international military operations has gone from being virtually unheard of to being an everyday occurrence. The Canadian and US armed forces operating in Afghanistan, for example, have together collected the digital fingerprints, eye scans, and digital photographs of more than 2.5 million Afghans. The introduction of biometrics technology to warfare has undoubtedly increased the security of the armed forces that use it and made it easier for them to kill or capture their enemies. Its effectiveness, reliability, and convenience have all been praised. Due in part to its novelty, however, law and policy relating to the use of biometrics in conflict situations remain underdeveloped. This underdevelopment poses considerable risks for the already vulnerable populations who are being subjected to these programs, potentially including violations of their right to privacy, misuse of their personal data, or their misidentification as enemies or threats. This article weighs these benefits and risks associated with biometrics technology. It analyzes the extent to which law and policy already govern the collection and use of biometrics by armed forces at both the domestic and international levels. It explores why the United States and Canada — the two states whose armed forces appear to be the most heavily engaged in the collection of biometric data abroad — have adopted such different policies with respect to the use of biometrics. It explains why the current international legal and policy vacuum in relation to battlefield biometrics is unacceptable and concludes that the time to discuss best practices is now. Ten non-legally binding guidelines are proposed for consideration and potential adoption by states.
Contributing Authors
-
- By Caroline (Cal) Baier-Anderson, Larry Binning, Dominique Brossard, Alvin J. Bussan, Anthony J. Cavalieri, Jason R. Cavatorta, Jed Colquhoun, José Falck-Zepeda, Gregory D. Graff, Stewart M. Gray, The Rev. Lowell E. Grisham, Russell Groves, Michelle Mauthe Harvey, Molly M. Jahn, Shelley Jansky, Jiming Jiang, Nicholas Kalaitzandonakes, Keith Kelling, Deana Knuteson, Peggy G. Lemaux, Marty D. Matlock, William H. Meyers, Paul D. Mitchell, William Muir, Pamela Ronald, Matt Ruark, Eric S. Sachs, Mark K. Sears, Erin Silva, Walter R. Stevenson, Alison Van Eenennaam, Jeffrey D. Wolt, Jeff Wyman, David Zilberman
- Edited by Jennie S. Popp, University of Arkansas, Molly M. Jahn, University of Wisconsin, Madison, Marty D. Matlock, University of Arkansas, Nathan P. Kemper, University of Arkansas
-
- Book:
- The Role of Biotechnology in a Sustainable Food Supply
- Published online:
- 05 June 2012
- Print publication:
- 31 January 2012, pp xiv-xviii
-
- Chapter
- Export citation
Roman Inscriptions 2001–2005
- Alison E. Cooley, Stephen Mitchell, Benet Salway
-
- Journal:
- The Journal of Roman Studies / Volume 97 / November 2007
- Published online by Cambridge University Press:
- 08 March 2010, pp. 176-263
- Print publication:
- November 2007
-
- Article
- Export citation
-
This paper surveys work relating to Roman inscriptions published during the period 2001–2005. The main aims are to signal important newly discovered inscriptions, significant reinterpretations of previously published texts, new trends in the scholarship on the subject and recent studies drawing heavily on epigraphic sources, as well as to report on the progress of major publishing projects.
Plate section
- C. Laird Birmingham, University of British Columbia, Vancouver, Pierre J. V. Beumont, University of Sydney
-
- Book:
- Medical Management of Eating Disorders
- Published online:
- 18 December 2009
- Print publication:
- 23 September 2004, pp -
-
- Chapter
- Export citation
17 - Information for family and friends
- C. Laird Birmingham, University of British Columbia, Vancouver, Pierre J. V. Beumont, University of Sydney
-
- Book:
- Medical Management of Eating Disorders
- Published online:
- 18 December 2009
- Print publication:
- 23 September 2004, pp 257-259
-
- Chapter
- Export citation
-
Summary
AN is a disease, like asthma is a disease. It is not dieting, a strong wish to be thin, or malingering. People afflicted with AN have within their minds two realities. One reality is a normal and healthy one. Just like you and I, those who suffer from AN want to be happy, healthy, and normal. The other reality is best understood as a phobia, a state of immense fear and concern. In AN, the phobia is that of loss of control, leading to obesity. Just like a phobia of going outside, AN has far-reaching implications. The phobia of personal obesity leads to changes in exercise, eating, unusual behaviors, and AN almost constant state of fear, anxiety, and inability to cope with life. The weight loss that results from this phobic state can be life-threatening.
What causes anorexia nervosa?
Anorexia is a disease that occurs in about one in 100–200 women and about two in 1000 men. The onset of AN is preceded by weight loss. The weight loss may have occurred for any reason, e.g. dieting, travel, diarrhea, or after surgery. AN also requires a certain genetic make-up. AN cannot occur in those who do not have a genetic predisposition to the disease. Even with a genetic predisposition and weight loss, other factors, such as social, environmental, family, or psychological stressors, may be necessary for the disease to manifest itself.
3 - History, examination, and investigations
- C. Laird Birmingham, University of British Columbia, Vancouver, Pierre J. V. Beumont, University of Sydney
-
- Book:
- Medical Management of Eating Disorders
- Published online:
- 18 December 2009
- Print publication:
- 23 September 2004, pp 24-47
-
- Chapter
- Export citation
-
Summary
Special considerations for history taking in eating disorder patients
Leave your office to meet the patient and observe their behavior with those who have accompanied them. Note their state of affect and ability to walk, then gait, weakness, and unsteadiness.
Certain elements of the history, such as those related to abuse or sexual issues, may best be left to a subsequent interview when rapport has been developed.
Instruct the patient to change in a private area, to keep on their underwear, and to wear the gown open to the back. Examining the patient while fully dressed may lead to failure to observe the degree of emaciation and other physical signs. It is preferable to perform the physical examination in the presence of a female trusted by the patient. Do not do rectal, pelvic, or breast examination as part of an eating disorder assessment physical examination.
Mental status examination
General appearance and behavior
Does the patient appear physically unwell, anxious, or depressed? Is he or she emaciated, or are they wearing clothes that obscure their figure? Is the patient restless? Many anorexic patients are unable to sit still or even sit, even when asked to do so, and continually jiggle their feet.
Speech
Is the patient communicative, or do they answer only briefly and reluctantly. Does the patient set out to justify their reasons for dieting? Do they avoid eye contact when asked potentially confrontational questions about eating, exercise, vomiting, or laxative abuse?
4 - Medical manifestations by system
- C. Laird Birmingham, University of British Columbia, Vancouver, Pierre J. V. Beumont, University of Sydney
-
- Book:
- Medical Management of Eating Disorders
- Published online:
- 18 December 2009
- Print publication:
- 23 September 2004, pp 48-85
-
- Chapter
- Export citation
-
Summary
The medical symptoms and signs of AN and, although less serious, of other eating disorders are part of the illness, and hence it is more appropriate to think of them as medical manifestations rather than merely complications. Although the disorder usually starts in adolescence, its course is often prolonged; AN patients may be ill for many years, and the majority of severely ill AN patients are in early or mid adult life. Hence, AN is a matter of concern for adult physicians as well as for pediatricians and adolescent medicine specialists. Figure 4.1 shows a mnemonic that is useful for remembering the physical signs of eating disorders.
Manifestations result from starvation or from the behaviors adopted to induce it. They are not indicative of underlying pathology. The inexperienced clinician who undertakes unnecessary investigations to exclude all possible causes for each abnormal finding is doing the patient a disservice by delaying appropriate treatment. Rather, all clinicians should be aware of the wide range of physical abnormalities that are commonly found in anorexic patients (Table 4.1). Many of these abnormalities, such as decreased serum concentrations of gonadotropins and steroid sex hormones, alterations to the peripheral metabolism of thyroid hormone, and raised circulating concentrations of cortisol and growth hormone, are best regarded as physiological adaptations to the state of starvation and do not require treatment. However, some medical complications are not only clinically important but are also life-threatening; these require special attention.
7 - Medical and nutritional therapy
- C. Laird Birmingham, University of British Columbia, Vancouver, Pierre J. V. Beumont, University of Sydney
-
- Book:
- Medical Management of Eating Disorders
- Published online:
- 18 December 2009
- Print publication:
- 23 September 2004, pp 128-170
-
- Chapter
- Export citation
15 - Nursing patients with anorexia nervosa
- C. Laird Birmingham, University of British Columbia, Vancouver, Pierre J. V. Beumont, University of Sydney
-
- Book:
- Medical Management of Eating Disorders
- Published online:
- 18 December 2009
- Print publication:
- 23 September 2004, pp 245-249
-
- Chapter
- Export citation
-
Summary
Introduction
Caring for patients with dieting disorders can be one of the most challenging and rewarding roles for nurses. However, even for the most experienced clinician, it can also be frustrating, anxiety-provoking, and emotionally draining, and nurses must be aware of the potential for burnout and emotional over- or underinvolvement.
Nurses become many things to a patient with AN, most essentially someone who is familiar with the patient's feelings, ideas, emotions, routines, rituals, and behaviors. Nurses need to be skilled in recognizing and interpreting the physiological and psychological signs, symptoms, and complications of the disorder. It is imperative that they develop AN empathic, non-judgmental approach, and that they maintain clear professional boundaries — yet a nurse's job is to challenge fixed and unrealistic beliefs and to assist in the development of motivation to change, so it is necessary to form a strong and trusting bond. As well, nurses provide information, act as role models, and support the patient and their family through the recovery process.
In order to fulfill this challenging and difficult role, nurses need education, clinical supervision, support from management and administration, collaboration and communication with other nursing colleagues, and recognition from other members of the treatment team that the nurse's role is valuable and vital.
16 - The role of the dietitian
- C. Laird Birmingham, University of British Columbia, Vancouver, Pierre J. V. Beumont, University of Sydney
-
- Book:
- Medical Management of Eating Disorders
- Published online:
- 18 December 2009
- Print publication:
- 23 September 2004, pp 250-256
-
- Chapter
- Export citation
-
Summary
A team approach is vital for effective treatment of eating disorders. The specialist clinical dietitian, as part of the team, is the most qualified person to provide accurate education about nutrition, weight gain, weight maintenance, the resumption of normal eating, and the nutritional methods of avoiding the refeeding syndrome.
Nutrition treatment is not as simple as applying AN educational formula and handing out a diet sheet. Nutrition intervention is complex, and eating disorder patients are resistant to nutritional treatment. Compliance may be reduced by perceived coercion, psychiatric comorbidities such as borderline personality disorders, self-harm, and suicidality, and ethical issues such as the need to report at-risk children to the law. Dietary change may be dependent on the patient's psychological progress.
The objectives of this chapter are to:
Review the range of dietetic interventions that are professionally acceptable to dietitians.
List some methods of dealing with the emotional issues that are likely to occur during treatment.
Promote self-care (supervision) for all dietitians working with eating disordered patients.
Discuss distinctions between specialist and non-specialist dietitians.
Clinical boundaries
Discuss the therapeutic limitations of nutrition counseling and make clear the need for concurrent psychotherapy at the first interview.
Professional boundaries
Work as a member of a team: before initiating any nutrition intervention, make certain that a doctor is following the patient medically on a regular basis and that psychological therapy is being carried out by a qualified practitioner. Emphasize the link between the patient's eating disorder and their emotional health in the dietetic sessions. Set AN upper limit of six dietetic sessions with a patient who is not engaged in a psychological intervention. This is to avoid clouding the dietetic intervention with emotional issues, to encourage psychological treatment, and to protect the patient against inadequate treatment.
[…]
5 - The clinician's response to common physical complaints
- C. Laird Birmingham, University of British Columbia, Vancouver, Pierre J. V. Beumont, University of Sydney
-
- Book:
- Medical Management of Eating Disorders
- Published online:
- 18 December 2009
- Print publication:
- 23 September 2004, pp 86-112
-
- Chapter
- Export citation
-
Summary
Many of the physical symptoms of AN arerelated directly to the effects of semi-starvation, while other physical symptoms areassociated mainly with behavioral problems such as excessive exercising, vomiting, and purging. Table 5.1 lists the most common physical manifestations in AN. Table 5.2 lists the physical manifestations most commonly found in BN.
Edema
Case
A 25-year-old female gains 10 kg in seven days. She is extremely anxious and agitated and threatens to discharge herself against medical advice. The nurse asks you why she has gained so much weight.
Comment
During feeding, edema occurs due to volume depletion, low metabolic rate, behaviors such as vomiting and laxative, enema, and diuretic use, which cause the body to have high circulating hormones that promote the retention of fluid. Antidiuretic hormone is secreted by the pituitary, renin is secreted by the kidney, angiotension is formed in the blood, and aldosterone is produced by the adrenal gland. The amount of fluid that might be retained in a patient is impossible to predict, but it is often 3—5 kg of water. The fluid retention is much greater in patients with a history of binge—purge behavior or diuretic use.
If the patient is suspected of having edema, apply steady, firm pressure with the pad of your thumb over the skin covering the lower tibia, just about the ankle. After 15 seconds, a small pit will appear if edema is present.
PART V - AREAS OF SPECIAL INTEREST
- C. Laird Birmingham, University of British Columbia, Vancouver, Pierre J. V. Beumont, University of Sydney
-
- Book:
- Medical Management of Eating Disorders
- Published online:
- 18 December 2009
- Print publication:
- 23 September 2004, pp 235-238
-
- Chapter
- Export citation
-
Summary
Introduction
This section of the book is directed at a more selective audience than Parts I–IV. First, it deals with the specific roles that general practitioners, nurses, and dietitians play in the management of patients with AN and other eating disorders. Second, it provides a brief section on the essential information that should be given to patients, their families, and their friends. Third, it draws conclusions about the possible future direction of clinical work in eating disorders and to the possibility of prevention programs with AN appraisal of risk factors.
2 - The behavioral disorders
- C. Laird Birmingham, University of British Columbia, Vancouver, Pierre J. V. Beumont, University of Sydney
-
- Book:
- Medical Management of Eating Disorders
- Published online:
- 18 December 2009
- Print publication:
- 23 September 2004, pp 19-23
-
- Chapter
- Export citation
-
Summary
Dieting (restricting) and purging forms of anorexia nervosa
The diagnostic criteria that have been prescribed for AN and the other eating disorders have varied only slightly over the years, and the present form (see Tables 1.3–1.6) is essentially similar to when the disorders were first described. It is important to stress that these descriptions are simply lists of symptoms and signs that are commonly associated and that point to a similarity of course of others. They are not true definitions of an illness entity as is found in many instances elsewhere in medicine, i.e. an explanatory portrayal of etiological factors, pathology and physiopathology, derived manifestations, and a course of progression. Instead, they merely note physical, psychological, and behavioral features without a clear appreciation of their interrelationship. The most characteristic of the features of an eating disorder are the behavioral disturbances that the patient displays; it is these features that will be described here.
Anorexic behaviors, although all directed at either decreasing energy intake or increasing energy expenditure, are not uniform (Table 2.1). Some patients employ only the restrictive behaviors commonly associated with “normal” dieting, such as undereating, refusal of high-energy foods, and strenuous exercise. This is the “dieting” or “restricting” form of the illness; these patients differ from normal mainly in the extent of these behaviors and their inability to desist. Other patients also use vomiting and laxative or diuretic abuse. The presentation, then, is of the “purging” form of AN.
14 - The role of the general practitioner
- C. Laird Birmingham, University of British Columbia, Vancouver, Pierre J. V. Beumont, University of Sydney
-
- Book:
- Medical Management of Eating Disorders
- Published online:
- 18 December 2009
- Print publication:
- 23 September 2004, pp 239-244
-
- Chapter
- Export citation
-
Summary
With the current shift in focus from tertiary services to primary and secondary services, and with estimates that up to 5% of women presenting to (or registered with) a general practitioner have AN eating disorder, the general practitioner's (GP) role in identifying, treating, and managing people with eating disorders is becoming increasingly important. In addition, it is particularly concerning that, because eating disorders are frequently concealed or denied, up to 50% of cases go unrecognized in a clinical setting. On a practical level, secondary prevention has been associated with improved outcome and reduced chronicity.
For patients with partial- and full-syndrome disorders, the most effective role that a GP can take is the role of care coordinator or case manager. As Keks notes, “There is no consensus as to what constitutes case management; [however] on AN individual patient level it means the coordination of care for patients who require a number of services from different providers.”
In some cases, the GP's main goal will be to build rapport and motivation for change before arranging referral to other health professionals for treatment. In other instances, where additional training has been undertaken, the GP may feel comfortable with taking on AN extended role. Alternatively, the GP may wish to limit actual practice to medical management but to take responsibility for coordinating associated services. AN essential component of every GP's role is the identification of the disorder as it presents in various developmental or formative stages.
List of contributors
- C. Laird Birmingham, University of British Columbia, Vancouver, Pierre J. V. Beumont, University of Sydney
-
- Book:
- Medical Management of Eating Disorders
- Published online:
- 18 December 2009
- Print publication:
- 23 September 2004, pp xii-xiii
-
- Chapter
- Export citation
9 - Prepubertal children and younger adolescents
- C. Laird Birmingham, University of British Columbia, Vancouver, Pierre J. V. Beumont, University of Sydney
-
- Book:
- Medical Management of Eating Disorders
- Published online:
- 18 December 2009
- Print publication:
- 23 September 2004, pp 184-204
-
- Chapter
- Export citation
-
Summary
Based on the physical, psychological, and developmental characteristics of childhood and adolescence, significant differences and similarities may be expected from the adult population. This summary focuses on the negative biological effects and sequelae of eating disorders in children and adolescents. These may encompass effects on growth and pubertal development, and medical complications of different organ systems, including morbidity and mortality. All organs are affected by the protein-calorie malnutrition associated with AN. Similarly, the malnutrition seen with BN results in medical sequelae. Table 9.1 lists the medical complications commonly associated with eating disorders in children and adolescents. In addition, investigations and measurement strategies to assess the medical impact of eating disorders are discussed.
Adolescence may be defined using many different parameters. Chronological age is used most widely in the literature. For the purpose of this chapter, the terms “adolescent” and “youth” will refer to the age group between 11 and 19 years of age. From the philosophical point of view, adolescence may be defined as a time of change that encompasses not only biological changes but also major psychological and social adjustments.
A vast literature related to medical complications in patients with eating disorders already exists for the adult population, serving as AN excellent source of reference for developing adolescents. Some of the previously highlighted differences between these two groups may be categorized based on the physiological hallmarks of adolescent development.