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Introduction: Eating disordered patients (EDp) who binge-eat appear to present impulse control deficits that influence treatment outcome. The present bulimia nervosa (BN) study tests the function of brain areas involved in top-down control of behavior, associated with the anterior cingulate cortex (ACC), at the individual level., Methods: ACC activity was analyzed in two women with BN and one matched control with a reliable and simple cue imperative target paradigm for response anticipation and response conflict processing using an event-related functional magnetic resonance imaging (fMRI) design., Results: Patients showed meaningful ACC patterns of activation, less recruitment for response anticipation, and abnormal for response conflict, when they had to suppress an inappropriate response., Discussion: Preliminary evidence suggests a BN neurocognitive model of impaired executive control-related brain activity. Reliable fMRI paradigms may be clinically useful to determine ACC dysfunction in EDp, to inform treatment and track changes.

Objective: There is a paucity of evidence-based interventions for anorexia nervosa (AN). An innovative family-based treatment (FBT), developed at the Maudsley Hospital and recently put in manual form, has shown great promise for adolescents with AN. Unlike traditional treatment approaches, which promote sustained autonomy around food, FBT temporarily places the parents in charge of weight restoration. This aim of this open trial was to investigate the feasibility and effectiveness of delivering FBT at a site beyond the treatment's origin and manualization., Method: Twenty adolescents (ages 12-17) with AN or subthreshold AN were treated with up to 1 year of FBT using the published treatment manual. Outcome indices included the percentage of ideal body weight, menstrual status, the Eating Disorder Examination (EDE) subscales scores, and the Children's Depression Rating Scale-Revised score., Results: Of the 20 patients recruited, 15 (75%) completed a full course of treatment. Intent-to-treat analyses showed significant improvement over time in the percentage of ideal body weight (t = -4.46, p =.000), menstrual status (p =.002), EDE Restraint (z = -3.02, p =.003), EDE Eating Concern (z = -2.10, p =.04), but not in EDE Shape Concern or Weight Concern subscales or Children's Depression Rating Scale-Revised score., Conclusions: This open trial provides evidence that FBT can be successfully disseminated, replicating the high retention rates and significant improvement in the psychopathology of adolescent AN seen at the original sites.

The onset of eating disorder psychopathology is most common in the adolescent age group. Acute psychopathology or subsyndromal eating disorders are perhaps less intractable in these young patients. Subsyndromal eating disorders in children and adolescents are not only clinically significant in their present state, but may represent legitimate candidates for preventive efforts in light of: (i) a risk of progression from subthreshold anorexia nervosa (SAN) to AN or subthreshold bulimia nervosa (SBN) to BN; (ii) the detrimental effects on outcome of delaying treatment; and (iii) the refractory, severe nature of eating disorders once the diagnostic threshold is crossed. Moreover, children and adolescents with SAN and SBN may in fact be exhibiting early 'caseness' of these disorders. Given that AN is notoriously difficult to treat, and there are limited efficacy data for adolescent BN, attempts to disrupt these disorders in what is arguably their early phases is an important goal in preventing more chronic and treatment-resistant forms of these disorders. Future research should address whether the best interventions for SAN and SBN should be derived from the prevention or intervention fields.

Objective: This prospective observational study compared the effectiveness and acceptability of three commonly used regimens to reduce pain during first-trimester surgical abortion with local anesthesia., Method: Women undergoing suction curettage at less than 14 weeks gestation received preoperative ibuprofen and an intraoperative paracervical block. Participants then selected (1) no additional medication (local arm), (2) sublingual lorazepam (0.5 to 1 mg, approximately 20 min preoperatively) or (3) intravenous sedation with fentanyl and midazolam (doses from 50 to 125 microg of fentanyl and 1-2 mg of midazolam). Our primary outcome was intraoperative pain as measured on an 11-point verbal rating scale (0=no pain and 10=worst pain ever)., Results: Three-hundred thirty women were enrolled, 105 chose local, 106 opt for lorazepam and 119 picked intravenous sedation. Mean pain scores were 6.2 for local, 6.8 for lorazepam and 5.7 for intravenous sedation. Increased preoperative anxiety, depression and expected pain and a lower volume of local anesthesia used (10 mL vs. 20 mL) were positive predictors of intraoperative pain. Using multivariable analyses to control for these confounders, plus gestational age, alcohol use and body mass index, intravenous sedation was associated with a 0.86 point lower pain score (p<.005), and the local and lorazepam groups were not significantly different. Compared with the referent group (local), participants who received lorazepam were significantly less satisfied with pain control (23.8% vs. 6% unsatisfied; OR=1.93, 95% CI=1.13 to 3.26)., Conclusion: In women who self-selected their type of anesthesia, intravenous sedation using fentanyl and midazolam decreased pain with suction curettage under local anesthesia. Sublingual lorazepam as studied did not decrease pain compared with local anesthesia alone and was associated with more dissatisfaction with pain control.

Objective: Although depression is known to co-occur with anorexia nervosa (AN), there are few clear studies of mood in the context of weight gain treatment without the use of medication., Method: Twenty-one patients admitted consecutively to an inpatient clinical research unit normalized weight to at least 90% of ideal body weight (IBW). Depression was assessed at admission and weight normalization (pre-discharge) with the Beck Depression Inventory (BDI)., Results: Multivariate F tests showed BDI scores to be significantly improved across these two time points (BMI: F(2,20) = 166.58, p = 0.000; BDI: F(2,19) = 22.64, p = 0.000). Moreover, improvement in mood was also evident at partial weight restoration (80% IBW)., Conclusion: Patients with AN undergoing nutritional rehabilitation and psychotherapy on an inpatient unit present with significant depressive symptoms as measured by the BDI, and, with weight restoration, demonstrate statistically significant improvement in mood symptoms without the use of adjunctive medication. Data at partial weight restoration suggest that these results cannot be explained by improved mood related to anticipation of discharge., ((c) 2006 by Wiley Periodicals, Inc.)

The relationship between therapeutic alliance, therapist adherence to treatment protocol, and outcome was analyzed in a randomized trial of cognitive-behavioral therapy (CBT) and interpersonal psychotherapy for bulimia nervosa. Independent observers rated audiotapes of full-length therapy sessions. Purging frequency was the primary outcome variable. There were no significant therapist or Therapist x Treatment effects on outcome. Although results showed high levels of alliance and adherence across treatments, CBT was associated with greater adherence. Across treatments and time points, better adherence was associated with enhanced alliance. Treatment condition and baseline purging frequency, but not adherence, predicted outcome. Early alliance predicted posttreatment purging frequency. In temporal analyses, prior symptom change assessed early in treatment was significantly related to subsequent adherence at midtreatment.

Objective: The current study compared the agreement between the Eating Disorders Examination (EDE) and the Eating Disorders Examination-Questionnaire (EDE-Q) in the diagnosis and assessment of eating disorder pathology in a sample of women with anorexia nervosa., Method: First, a physician administered a clinical interview to each patient. Then, before hospital admission, all subjects were given the EDE-Q and the EDE interview., Results: Results indicate that agreement between the EDE and the EDE-Q on the individual items informing the overall diagnosis of anorexia nervosa ranges from low to moderate. Agreement for the overall diagnosis of anorexia nervosa and for the binge/purge subtype was more impressive. Although correlations between subscale scores as well as eating disorder behaviors were strong, higher levels of disturbance were consistently reported on the EDE-Q than on the EDE interview., Discussion: The pattern of findings suggests that the EDE-Q may be used in place of the interviewer-based measure when assessing overall diagnosis and subtype, as well as specific, well-defined features (vomiting/laxative use). However, there was a low level of agreement with respect to less-defined features, like binge eating, for which significantly higher frequencies were generated by the self-report questionnaire., ((c) 2005 by Wiley Periodicals, Inc.)

Objective: The purpose of this study was to describe a case series of children and adolescents (mean age = 14.5 years, SD = 2.3; range 9-18) with anorexia nervosa who received manualized family-based treatment for their eating disorder., Method: Forty-five patients with anorexia nervosa were compared pre- and post-treatment on weight and menstrual status., Results: After an average of 17 treatment sessions, patients were significantly improved on primary measures of outcome (body mass index and percentage of ideal body weight). Defining outcome categorically (Morgan-Russell outcome criteria), 56% (n = 25) had a good outcome (>85% ideal body weight and menses), 33% (n = 15) an intermediate outcome (>85% IBW and menses intermittent), and 11% (n = 5) responded poorly (<85% ideal body weight and no menses)., Conclusions: Findings provide preliminary support for the feasibility of an outpatient approach with active parental involvement in the treatment of children and adolescents with anorexia nervosa. However, randomized, controlled studies are needed to establish the relative efficacy of this family-based treatment approach.

Background: There are few reports that describe the manifestation of bulimia nervosa (BN) among adolescents. Moreover, none make reference to the comparative clinical manifestation of adolescent BN and adolescent anorexia nervosa. Nor are any reports available of how distinct partial-syndrome BN cases are from those that meet full diagnostic criteria for BN., Objectives: To describe 3 groups of adolescents, those with a full-syndrome eating disorder (BN and anorexia nervosa) or partial-syndrome BN, and to compare these groups along demographic, general psychopathology, and eating disorder variables., Design: The study population included 120 adolescents with eating disorders who were initially seen at The University of Chicago Eating Disorders Program, Chicago, Ill, for treatment. All participants completed an assessment prior to treatment., Measures: Weight and height were obtained from all participants. Participants also completed a baseline demographic questionnaire (eg, menstrual status, ethnicity, family status), Beck Depression Inventory, Rosenberg Self-Esteem Scale, and the Eating Disorder Examination., Results: Partial-syndrome BN cases are clinically quite similar to their full-syndrome counterparts. Only objective binge eating episodes and purge frequency distinguished BN and partial-syndrome BN cases. Anorexia nervosa cases, on the other hand, were quite distinct from BN and partial-syndrome BN cases on almost all variables., Conclusion: Early recognition and swift treatment of eating disorders in adolescents, regardless of whether a diagnostic threshold is met, are imperative because they will lead to early intervention thereby potentially improving eating disorder recovery rates.

Bleomycin is an antibiotic used in cancer chemotherapy for its ability to achieve both single- and double-strand cleavage of DNA through abstraction of the deoxyribose C4'-H. Magnetic circular dichroism (MCD) and X-ray absorption (XAS) spectroscopies have been used to study the interaction of the biologically relevant FeIIBLM complex with DNA. Calf thymus DNA was used as the substrate as well as short oligonucleotides, including one with a preferred 5'-G-pyrimidine-3' cleavage site [d(GGAAGCTTCC)2] and one without [d(GGAAATTTCC)2]. DNA binding to FeIIBLM significantly perturbs the FeII active site, resulting in a change in intensity ratio of the d d transitions and a decrease in excited-state orbital splitting (5Eg). Although this effect is somewhat dependent on length and composition of the oligonucleotide, it is not correlated to the presence of a 5'-G-pyrimidine-3' cleavage site. No effect is observed on the charge-transfer transitions, indicating that the H-bonding recognition between the pyrimidine and guanine base does not perturb Fe-pyrimidine backbonding. Azide binding studies indicate that FeIIBLM bound to either oligomer has the same affinity for N3-. Parallel studies of BLM structural derivatives indicate that FeIIiso-PEPLM, in which the carbamoyl group is shifted on the mannose sugar, forms the same DNA-bound species as FeIIBLM. In contrast, FeIIDP-PEPLM, in which the -aminoalanine group is absent, forms a new species upon DNA binding. These data are consistent with a model in which the primary amine from the -aminoalanine is an FeII ligand and the mannose carbamoyl provides either a ligand to the FeII or significant second-sphere effects on the FeII site; intercalation of the bithiazole tail into the double helix likely brings the metal-bound complex close enough to the DNA to create steric interactions that remove the sugar groups from interaction with the FeII. The fact that the FeII active site is perturbed regardless of DNA sequence is consistent with the fact that cleavage is observed for both 5'-GC-3' and nonspecific oligomers and indicates that different reaction coordinates may be active, depending on orientation of the deoxyribose C4'-H.

Chronic pelvic pain is difficult to diagnose and to treat [81] because of the multiple and often overlapping causes [82]. A systematic approach aids in the thorough evaluation and appropriate therapy. At the initial visit(s), a thorough history should be taken and complete physical examination performed. Screening for co-existing conditions, such as depression, narcotic dependency, and physical, sexual, or emotional abuse is crucial so these issues may be addressed immediately while additional causes for pelvic pain are evaluated. The relative likelihood of gastrointestinal, urologic, musculoskeletal, or gynecologic etiology must be considered to guide a more thorough initial evaluation. With gynecologic chronic pelvic pain, differentiation between hormonally responsive and nonresponsive conditions is helpful for diagnosis and treatment. Therapy can then be instituted or an appropriate referral made.

A stepped care approach would link different patient needs to therapeutic modalities that range from simple advice to intensive inpatient care. Brief methods, including self-help and psychoeducation, may be effective for a subset of patients with bulimia nervosa and binge eating disorder. Identifying this subset remains a challenge. It is unclear how patients who fail to respond to evidence-based, first-line treatments should be treated. Given the absence of data on effective treatment of anorexia nervosa (AN), discussion of a stepped care approach is speculative. Because AN typically demands expert and sustained treatment, the lower levels of stepped care models are inapplicable for these patients. A stepped care approach poses methodological challenges for clinical research and raises important clinical issues, such as when to switch from 1 level of treatment to another.

This study compared the relative short- and longer-term efficacy of therapist-guided and unguided use of a cognitive behavioral self-help manual for binge eating [Fairburn, C. G. (1995). Overcome binge eating. New York: The Guilford Press.] Forty women (82.5% with binge eating disorder) were randomized to one of the two treatment levels. Results indicate that both conditions represent viable means of treating binge eating. Overall, patients improved their eating behavior, eliminated any inappropriate compensatory behaviors, reduced their shape concern, weight concern, and other symptoms of eating-related psychopathology, and improved their general psychological functioning. The guided self-help condition was notably superior in reducing the occurrence of binge eating and its associated symptomatology, as well as lowering interpersonal sensitivity. A high degree of general psychopathology was a negative prognostic indicator. The implications for a stepped-care approach to treating binge eating are discussed.

This article extends the acute outcome findings from a study comparing psychological and pharmacological interventions for bulimia nervosa (B.T. Walsh et al., 1997) by examining 3 additional domains: predictive factors, therapeutic alliance, and time course of change. One hundred twenty women were randomized to cognitive-behavioral therapy (CBT), supportive psychotherapy (SPT) plus antidepressant medication or a placebo, or a medication-alone condition. Results indicate that high baseline frequencies of binge eating and vomiting, as well as a positive history of substance abuse or dependence, are negative prognostic indicators. Although a greater overall therapeutic alliance may increase the likelihood of remission, symptom change over the course of treatment may have as much of an impact on patient ratings of alliance as the reverse. CBT was significantly more rapid than SPT in reducing binge eating and vomiting frequencies.

Objective: Two treatments for bulimia nervosa have emerged as having established efficacy: cognitive-behavioral therapy and antidepressant medication. This study sought to address 1) how the efficacy of a psychodynamically oriented supportive psychotherapy compared to that of cognitive-behavioral therapy; 2) whether a two-stage medication intervention, in which a second antidepressant (fluoxetine) was employed if the first (desipramine) was either ineffective or poorly tolerated, added to the benefit of psychological treatment; and 3) if the combination of medication and psychological treatment was superior to a course of medication alone., Method: A total of 120 women with bulimia nervosa participated in a randomized, placebo-controlled trial., Results: Cognitive-behavioral therapy was superior to supportive psychotherapy in reducing behavioral symptoms of bulimia nervosa (binge eating and vomiting). Patients receiving medication in combination with psychological treatment experienced greater improvement in binge eating and depression than did patients receiving placebo and psychological treatment. In addition, cognitive-behavioral therapy plus medication was superior to medication alone, but supportive psychotherapy plus medication was not., Conclusions: At present, cognitive-behavioral therapy is the psychological treatment of choice for bulimia nervosa. A two-stage medication intervention using fluoxetine adds modestly to the benefit of psychological treatment.

In order to determine the clinical severity of bulimia nervosa and to measure symptomatic improvement during treatment, the behavioral and psychological features of the syndrome must be assessed. Focused semistructured interviews have recently been designed for this purpose, but such instruments can be time-consuming and costly. The present study compared the assessment of the key symptoms of bulimia nervosa using the Eating Disorder Examination with data obtained in self-report inventories and in patients' diaries of binge eating and purging. Results suggest that once the diagnosis has been established and patients have been instructed in the construct of a binge, the essential features of bulimia nervosa (frequency of binge eating and purging, and overconcern with body shape and weight) can be evaluated with self-report measures. These findings may be useful for the purposes of repeated assessment of progress and measurement of outcome in treatment studies.