Somatic Disorders

Abuse and neglect during childhood appear to be associated with poor physical health just as early abuse affects adult emotional health, a meta-analysis of studies involving more than 40,000 people shows.

The object of the meta-analysis was to assess the evidence on the relationship between abuse in childhood and physical health outcomes, and to examine the role of variables such as specific health outcomes, gender, and type of abuse.

“Although the consequences of childhood sexual abuse have been explored extensively in the psychiatric literature, other forms of abuse such as physical abuse, emotional abuse, or neglect have important effects on well-being in adulthood, although their unique effect is just beginning to be understood,” wrote Holly L. Wegman, of Wake Forest University, Winston-Salem, N.C., and Cinnamon Stetler, Ph.D., of Furman University, Greenville, S.C. (Psychosomatic Med. 2009;71:805-12).

The researchers conducted a systematic review of 24 studies involving 48,801 individuals. From each study, data were coded for the following variables: health outcome, sex, average age of sample, type of abuse (physical, sexual, emotional, neglect), method used to assess abuse (self-report or objective method), and method used to assess health outcome (self-report or objective method). The meta-analysis yielded a small to medium weighted mean effect size (Cohen's d = 0.42, 95% confidence interval 0.39-0.45) for the association between childhood abuse and physical disorders in adulthood.

Neurologic and musculoskeletal disease showed the strongest association with childhood abuse, followed by respiratory, cardiovascular, and gastrointestinal disorders.

Nineteen of the 24 studies used self-report methods, which the researchers said “are subject to reporting biases that could introduce unreliability and adult magnitude of the relationship between child abuse and adult health.” Despite the potential for bias, no significant difference was found between the two groups in the strength of the association between early abuse and adult health outcomes.

Another potential source of bias is the overrepresentation of females in the study; 16 of the studies had an entirely female sample. The association between abuse and later physical disorders was stronger among the female-only studies (d = 0.66) than among the mixed-gender samples (0.49), but this finding may reflect the male underrepresentation.

The researchers noted that the association between childhood maltreatment and later health problems appeared to be comparable to the child abuse and psychological disorders correlation found in previous studies (Child Maltreat. 1996;1:6-16; J. Psychol. 2001;135:17-36; Clin. J. Pain 2005;21:398-405).

Ms. Wegman and Dr. Stetler speculated that neurologic and musculoskeletal problems might have the largest effects because “these are the types of conditions that persist as direct effects of the physical abuse in childhood.” Child abuse victims might be at a greater risk for respiratory, cardiovascular, and gastrointestinal problems because they are more likely than their nonabused counterparts to engage in dangerous health behaviors, such as smoking and excessive alcohol consumption, they said.

The meta-analysis contributes to the research on the relationship between childhood maltreatment and adult health problems, but it also highlights gaps in the literature. Studies that are more representative in terms of gender and age groups, more objective in methodogy, and more specific about types of abuse are needed to pinpoint the relationship between abuse and health outcomes.

Abuse and neglect during childhood appear to be associated with poor physical health just as early abuse affects adult emotional health, a meta-analysis of studies involving more than 40,000 people shows.

The object of the meta-analysis was to assess the evidence on the relationship between abuse in childhood and physical health outcomes, and to examine the role of variables such as specific health outcomes, gender, and type of abuse.

“Although the consequences of childhood sexual abuse have been explored extensively in the psychiatric literature, other forms of abuse such as physical abuse, emotional abuse, or neglect have important effects on well-being in adulthood, although their unique effect is just beginning to be understood,” wrote Holly L. Wegman, of Wake Forest University, Winston-Salem, N.C., and Cinnamon Stetler, Ph.D., of Furman University, Greenville, S.C. (Psychosomatic Med. 2009;71:805-12).

The researchers conducted a systematic review of 24 studies involving 48,801 individuals. From each study, data were coded for the following variables: health outcome, sex, average age of sample, type of abuse (physical, sexual, emotional, neglect), method used to assess abuse (self-report or objective method), and method used to assess health outcome (self-report or objective method). The meta-analysis yielded a small to medium weighted mean effect size (Cohen's d = 0.42, 95% confidence interval 0.39-0.45) for the association between childhood abuse and physical disorders in adulthood.

Neurologic and musculoskeletal disease showed the strongest association with childhood abuse, followed by respiratory, cardiovascular, and gastrointestinal disorders.

Nineteen of the 24 studies used self-report methods, which the researchers said “are subject to reporting biases that could introduce unreliability and adult magnitude of the relationship between child abuse and adult health.” Despite the potential for bias, no significant difference was found between the two groups in the strength of the association between early abuse and adult health outcomes.

Another potential source of bias is the overrepresentation of females in the study; 16 of the studies had an entirely female sample. The association between abuse and later physical disorders was stronger among the female-only studies (d = 0.66) than among the mixed-gender samples (0.49), but this finding may reflect the male underrepresentation.

The researchers noted that the association between childhood maltreatment and later health problems appeared to be comparable to the child abuse and psychological disorders correlation found in previous studies (Child Maltreat. 1996;1:6-16; J. Psychol. 2001;135:17-36; Clin. J. Pain 2005;21:398-405).

Ms. Wegman and Dr. Stetler speculated that neurologic and musculoskeletal problems might have the largest effects because “these are the types of conditions that persist as direct effects of the physical abuse in childhood.” Child abuse victims might be at a greater risk for respiratory, cardiovascular, and gastrointestinal problems because they are more likely than their nonabused counterparts to engage in dangerous health behaviors, such as smoking and excessive alcohol consumption, they said.

The meta-analysis contributes to the research on the relationship between childhood maltreatment and adult health problems, but it also highlights gaps in the literature. Studies that are more representative in terms of gender and age groups, more objective in methodogy, and more specific about types of abuse are needed to pinpoint the relationship between abuse and health outcomes.

Abuse and neglect during childhood appear to be associated with poor physical health just as early abuse affects adult emotional health, a meta-analysis of studies involving more than 40,000 people shows.

The object of the meta-analysis was to assess the evidence on the relationship between abuse in childhood and physical health outcomes, and to examine the role of variables such as specific health outcomes, gender, and type of abuse.

“Although the consequences of childhood sexual abuse have been explored extensively in the psychiatric literature, other forms of abuse such as physical abuse, emotional abuse, or neglect have important effects on well-being in adulthood, although their unique effect is just beginning to be understood,” wrote Holly L. Wegman, of Wake Forest University, Winston-Salem, N.C., and Cinnamon Stetler, Ph.D., of Furman University, Greenville, S.C. (Psychosomatic Med. 2009;71:805-12).

The researchers conducted a systematic review of 24 studies involving 48,801 individuals. From each study, data were coded for the following variables: health outcome, sex, average age of sample, type of abuse (physical, sexual, emotional, neglect), method used to assess abuse (self-report or objective method), and method used to assess health outcome (self-report or objective method). The meta-analysis yielded a small to medium weighted mean effect size (Cohen's d = 0.42, 95% confidence interval 0.39-0.45) for the association between childhood abuse and physical disorders in adulthood.

Neurologic and musculoskeletal disease showed the strongest association with childhood abuse, followed by respiratory, cardiovascular, and gastrointestinal disorders.

Nineteen of the 24 studies used self-report methods, which the researchers said “are subject to reporting biases that could introduce unreliability and adult magnitude of the relationship between child abuse and adult health.” Despite the potential for bias, no significant difference was found between the two groups in the strength of the association between early abuse and adult health outcomes.

Another potential source of bias is the overrepresentation of females in the study; 16 of the studies had an entirely female sample. The association between abuse and later physical disorders was stronger among the female-only studies (d = 0.66) than among the mixed-gender samples (0.49), but this finding may reflect the male underrepresentation.

The researchers noted that the association between childhood maltreatment and later health problems appeared to be comparable to the child abuse and psychological disorders correlation found in previous studies (Child Maltreat. 1996;1:6-16; J. Psychol. 2001;135:17-36; Clin. J. Pain 2005;21:398-405).

Ms. Wegman and Dr. Stetler speculated that neurologic and musculoskeletal problems might have the largest effects because “these are the types of conditions that persist as direct effects of the physical abuse in childhood.” Child abuse victims might be at a greater risk for respiratory, cardiovascular, and gastrointestinal problems because they are more likely than their nonabused counterparts to engage in dangerous health behaviors, such as smoking and excessive alcohol consumption, they said.

The meta-analysis contributes to the research on the relationship between childhood maltreatment and adult health problems, but it also highlights gaps in the literature. Studies that are more representative in terms of gender and age groups, more objective in methodogy, and more specific about types of abuse are needed to pinpoint the relationship between abuse and health outcomes.

SEATTLE – Sleep disturbances during pregnancy increase the risk of adverse perinatal outcomes such as gestational diabetes and cesarean delivery, according to an overview of research presented at the annual meeting of the Associated Professional Sleep Societies.

“Sleep disturbances are common during pregnancy,” said Bilgay Izci Balserak, Ph.D., of the University of Glasgow (Scotland) Sleep Centre. “The majority of pregnant women experience some level of sleep disturbance, especially in the third trimester of pregnancy.”

A 2007 poll conducted by the National Sleep Foundation, Washington, found that 84% of pregnant women reported experiencing sleep problems at least a few nights per week, she noted. This compared with 67% of all women surveyed.

Altered sleep during pregnancy stems from a variety of hormonal, physiologic, and psychological factors, according to Dr. Balserak. These factors can affect sleep directly, as in the case of progesterone causing sedation, or indirectly, as in the case of heartburn or nocturia causing awakenings.

The sleep disturbances seen during pregnancy include both nocturnal perturbations (poor sleep quality, insomnia, and frequent awakenings) and daytime symptoms (fatigue and daytime sleepiness), she noted.

Pregnancy-related changes can also trigger frank sleep disorders or exacerbate preexisting ones, such as restless legs syndrome, sleep-disordered breathing, and parasomnias.

The acute sleep loss or fragmented sleep that results from sleep disturbances “can cause adverse perinatal outcomes,” she said.

Retrospective and prospective studies, for example, have shown that pregnant women with sleep-disordered breathing have a two- to fivefold increased risk of developing gestational diabetes after body mass index is taken into account (Am. J. Respir. Crit. Care Med. 2007;175:A996, and Sleep 2009;32:A320-1).

Other research has linked sleep disturbances to birth outcomes. For instance, compared with women with a total sleep time of at least 7 hours in late pregnancy, women with a total sleep time of less than 6 hours or 6-6.9 hours have sharply elevated odds of cesarean delivery (odds ratios, 4.5 and 3.7, respectively) (Am. J. Obstet. Gynecol. 2004;191:2041-6). Women sleeping less than 6 hours also have longer labor, on average, than those sleeping at least 7 hours (29 vs. 18 hours).

Several studies have found correlations between unfavorable sleep parameters in late pregnancy and elevated levels of depressive symptoms, both at that time and in the early postpartum period, she noted.

In a study that was conducted among women in the third trimester of pregnancy that used the Center for Epidemiologic Studies-Depression (CES-D) scale, relative to their nondepressed counterparts (those with a CES-D score less than or equal to 15), depressed women (CES-D score of 16 or greater) had a greater frequency of sleep disturbances overall, as well as a longer latency to sleep onset, greater difficulty in maintaining sleep, poorer sleep quality, and less sleep time (J. Perinat. Neonatal Nurs. 2007;21:123-9).

“Early recognition, management, and treatment of sleep disturbances are important to prevent adverse perinatal outcomes,” Dr. Balserak asserted. However, she added, there are currently no practice parameters when it comes to screening for and managing sleep disturbances during pregnancy.

“Regarding management, nonpharmacologic interventions should be considered as the first choice, including lifestyle modifications and cognitive-behavioral therapy strategies,” she recommended.

Providers should encourage women to adopt healthy lifestyle behaviors, such as daily exercise, that may improve sleep, Dr. Balserak said. And they should counsel women about measures to address specific symptoms disrupting sleep, such as modifying eating habits to reduce heartburn.

“If pharmacological treatment is necessary, it should be used with caution due to potential side effects on the fetus,” she concluded.

Dr. Balserak reported that she had no conflicts of interest in association with her presentation.

Altered sleep during pregnancy stems from various hormonal, physiologic, and psychological factors.

Source Dr. Balserak

Several studies have found correlations between unfavorable sleep parameters in late pregnancy and elevated levels of depressive symptoms.

Source Nathan Gleave/iStockphoto.com

SEATTLE – Sleep disturbances during pregnancy increase the risk of adverse perinatal outcomes such as gestational diabetes and cesarean delivery, according to an overview of research presented at the annual meeting of the Associated Professional Sleep Societies.

“Sleep disturbances are common during pregnancy,” said Bilgay Izci Balserak, Ph.D., of the University of Glasgow (Scotland) Sleep Centre. “The majority of pregnant women experience some level of sleep disturbance, especially in the third trimester of pregnancy.”

A 2007 poll conducted by the National Sleep Foundation, Washington, found that 84% of pregnant women reported experiencing sleep problems at least a few nights per week, she noted. This compared with 67% of all women surveyed.

Altered sleep during pregnancy stems from a variety of hormonal, physiologic, and psychological factors, according to Dr. Balserak. These factors can affect sleep directly, as in the case of progesterone causing sedation, or indirectly, as in the case of heartburn or nocturia causing awakenings.

The sleep disturbances seen during pregnancy include both nocturnal perturbations (poor sleep quality, insomnia, and frequent awakenings) and daytime symptoms (fatigue and daytime sleepiness), she noted.

Pregnancy-related changes can also trigger frank sleep disorders or exacerbate preexisting ones, such as restless legs syndrome, sleep-disordered breathing, and parasomnias.

The acute sleep loss or fragmented sleep that results from sleep disturbances “can cause adverse perinatal outcomes,” she said.

Retrospective and prospective studies, for example, have shown that pregnant women with sleep-disordered breathing have a two- to fivefold increased risk of developing gestational diabetes after body mass index is taken into account (Am. J. Respir. Crit. Care Med. 2007;175:A996, and Sleep 2009;32:A320-1).

Other research has linked sleep disturbances to birth outcomes. For instance, compared with women with a total sleep time of at least 7 hours in late pregnancy, women with a total sleep time of less than 6 hours or 6-6.9 hours have sharply elevated odds of cesarean delivery (odds ratios, 4.5 and 3.7, respectively) (Am. J. Obstet. Gynecol. 2004;191:2041-6). Women sleeping less than 6 hours also have longer labor, on average, than those sleeping at least 7 hours (29 vs. 18 hours).

Several studies have found correlations between unfavorable sleep parameters in late pregnancy and elevated levels of depressive symptoms, both at that time and in the early postpartum period, she noted.

In a study that was conducted among women in the third trimester of pregnancy that used the Center for Epidemiologic Studies-Depression (CES-D) scale, relative to their nondepressed counterparts (those with a CES-D score less than or equal to 15), depressed women (CES-D score of 16 or greater) had a greater frequency of sleep disturbances overall, as well as a longer latency to sleep onset, greater difficulty in maintaining sleep, poorer sleep quality, and less sleep time (J. Perinat. Neonatal Nurs. 2007;21:123-9).

“Early recognition, management, and treatment of sleep disturbances are important to prevent adverse perinatal outcomes,” Dr. Balserak asserted. However, she added, there are currently no practice parameters when it comes to screening for and managing sleep disturbances during pregnancy.

“Regarding management, nonpharmacologic interventions should be considered as the first choice, including lifestyle modifications and cognitive-behavioral therapy strategies,” she recommended.

Providers should encourage women to adopt healthy lifestyle behaviors, such as daily exercise, that may improve sleep, Dr. Balserak said. And they should counsel women about measures to address specific symptoms disrupting sleep, such as modifying eating habits to reduce heartburn.

“If pharmacological treatment is necessary, it should be used with caution due to potential side effects on the fetus,” she concluded.

Dr. Balserak reported that she had no conflicts of interest in association with her presentation.

Altered sleep during pregnancy stems from various hormonal, physiologic, and psychological factors.

Source Dr. Balserak

Several studies have found correlations between unfavorable sleep parameters in late pregnancy and elevated levels of depressive symptoms.

Source Nathan Gleave/iStockphoto.com

SEATTLE – Sleep disturbances during pregnancy increase the risk of adverse perinatal outcomes such as gestational diabetes and cesarean delivery, according to an overview of research presented at the annual meeting of the Associated Professional Sleep Societies.

“Sleep disturbances are common during pregnancy,” said Bilgay Izci Balserak, Ph.D., of the University of Glasgow (Scotland) Sleep Centre. “The majority of pregnant women experience some level of sleep disturbance, especially in the third trimester of pregnancy.”

A 2007 poll conducted by the National Sleep Foundation, Washington, found that 84% of pregnant women reported experiencing sleep problems at least a few nights per week, she noted. This compared with 67% of all women surveyed.

Altered sleep during pregnancy stems from a variety of hormonal, physiologic, and psychological factors, according to Dr. Balserak. These factors can affect sleep directly, as in the case of progesterone causing sedation, or indirectly, as in the case of heartburn or nocturia causing awakenings.

The sleep disturbances seen during pregnancy include both nocturnal perturbations (poor sleep quality, insomnia, and frequent awakenings) and daytime symptoms (fatigue and daytime sleepiness), she noted.

Pregnancy-related changes can also trigger frank sleep disorders or exacerbate preexisting ones, such as restless legs syndrome, sleep-disordered breathing, and parasomnias.

The acute sleep loss or fragmented sleep that results from sleep disturbances “can cause adverse perinatal outcomes,” she said.

Retrospective and prospective studies, for example, have shown that pregnant women with sleep-disordered breathing have a two- to fivefold increased risk of developing gestational diabetes after body mass index is taken into account (Am. J. Respir. Crit. Care Med. 2007;175:A996, and Sleep 2009;32:A320-1).

Other research has linked sleep disturbances to birth outcomes. For instance, compared with women with a total sleep time of at least 7 hours in late pregnancy, women with a total sleep time of less than 6 hours or 6-6.9 hours have sharply elevated odds of cesarean delivery (odds ratios, 4.5 and 3.7, respectively) (Am. J. Obstet. Gynecol. 2004;191:2041-6). Women sleeping less than 6 hours also have longer labor, on average, than those sleeping at least 7 hours (29 vs. 18 hours).

Several studies have found correlations between unfavorable sleep parameters in late pregnancy and elevated levels of depressive symptoms, both at that time and in the early postpartum period, she noted.

In a study that was conducted among women in the third trimester of pregnancy that used the Center for Epidemiologic Studies-Depression (CES-D) scale, relative to their nondepressed counterparts (those with a CES-D score less than or equal to 15), depressed women (CES-D score of 16 or greater) had a greater frequency of sleep disturbances overall, as well as a longer latency to sleep onset, greater difficulty in maintaining sleep, poorer sleep quality, and less sleep time (J. Perinat. Neonatal Nurs. 2007;21:123-9).

“Early recognition, management, and treatment of sleep disturbances are important to prevent adverse perinatal outcomes,” Dr. Balserak asserted. However, she added, there are currently no practice parameters when it comes to screening for and managing sleep disturbances during pregnancy.

“Regarding management, nonpharmacologic interventions should be considered as the first choice, including lifestyle modifications and cognitive-behavioral therapy strategies,” she recommended.

Providers should encourage women to adopt healthy lifestyle behaviors, such as daily exercise, that may improve sleep, Dr. Balserak said. And they should counsel women about measures to address specific symptoms disrupting sleep, such as modifying eating habits to reduce heartburn.

“If pharmacological treatment is necessary, it should be used with caution due to potential side effects on the fetus,” she concluded.

Dr. Balserak reported that she had no conflicts of interest in association with her presentation.

Altered sleep during pregnancy stems from various hormonal, physiologic, and psychological factors.

Source Dr. Balserak

Several studies have found correlations between unfavorable sleep parameters in late pregnancy and elevated levels of depressive symptoms.

Source Nathan Gleave/iStockphoto.com

Zolpidem, a frequently prescribed sleep aid, suppresses nocturnal awakenings that are an important CNS response to acid reflux events.

By enabling users to sleep through reflux events, the drug has the unintended effect of increasing esophageal exposure to stomach acid. This in turn opens the door to gastroesophageal reflux disease (GERD) complications such as erosive esophagitis, stricture formation, Barrett's esophagus, and esophageal adenocarcinoma, said Dr. Gregg Gagliardi of Thomas Jefferson University, Philadelphia, and his associates.

This finding is especially concerning because epidemiologic studies suggest that sleep disturbances occur in as many as 75% of patients who have frequent heartburn. If they take the sleep aid to manage their sleep disturbances, they may unwittingly worsen their heartburn.

In addition, almost 30% of patients with sleep disturbances are thought to have undiagnosed GERD, and those who use zolpidem to manage their sleep disturbances may exacerbate reflux events and induce esophageal complications, the investigators noted (Clin. Gastroenterol. Hepatol. 2009;7:948-52).

Normally, these nocturnal events trigger awakening or arousal from sleep, which leads to a swallow reflex. This initiates peristalsis and exposure of the esophageal mucosa to saliva rich in bicarbonate. The saliva neutralizes the acid content in the esophagus and the peristalsis clears the acid through to the stomach. Suppressing this protective mechanism may lead to prolonged acid exposure and mucosal injury over time.

The researchers performed a double-blind, placebo-controlled trial to examine the issue in 15 GERD patients and 8 normal control subjects. The study was supported in part by AstraZeneca Pharmaceuticals LP.

Each study subject underwent separate sleep studies at a 2-week interval after taking zolpidem (Ambien, Sanofi-Aventis) or a matching placebo. A transnasal esophageal pH catheter with a sensor placed 5 cm above the lower esophageal sphincter recorded reflux events and the acid clearance time for each event, while polysomnography recorded reflux-associated arousals and awakenings.

In both the subjects with GERD and the healthy control subjects who had taken placebo, a nocturnal acid reflux event caused arousal or awakening 89% of the time. In contrast, after they had taken zolpidem, reflux events caused arousal or awakening only 40% of the time.

Among the control subjects, the mean time until acid was cleared from the esophagus during reflux episodes was 1.15 seconds after they had taken placebo, compared with 15.67 seconds after they had taken zolpidem.

Exposure time also was dramatically increased among the GERD subjects. The mean time until acid was cleared from the esophagus was 37.8 seconds after they had taken placebo, compared with 363.3 seconds after they had taken zolpidem.

When this exposure time is multiplied by the number of reflux events over the course of the entire sleep period, it has significant ramifications for the development of erosive esophagitis, strictures, Barrett's esophagus, and esophageal cancer, the researchers noted.

Suppression of the arousal reflex was most marked early in the evening for both GERD subjects and controls, perhaps because zolpidem has a relatively short duration of action. However, reflux events are most common early in the evening.

It is possible that other CNS depressants or psychotropic medications may exert similar effects on nighttime arousals as zolpidem did in this study. The use of such sleep aids is increasing in the United States, Dr. Gagliardi and his colleagues noted. “If this effect of blunted arousals or awakenings by hypnotics is substantiated, this would suggest caution in the use of sleep aids without first considering GERD as an etiologic factor in patients with complaints of disturbed sleep,” they added.

This study was limited by its small sample size, with just 23 subjects. However, the researchers attempted to counterbalance this drawback by analyzing each reflux event rather than each subject.

Dr. Gagliardi's associate, Dr. Karl Doghramji, also of Thomas Jefferson University, is a consultant for Sanofi-Aventis. No other conflicts of interest were reported.

Zolpidem, a frequently prescribed sleep aid, suppresses nocturnal awakenings that are an important CNS response to acid reflux events.

By enabling users to sleep through reflux events, the drug has the unintended effect of increasing esophageal exposure to stomach acid. This in turn opens the door to gastroesophageal reflux disease (GERD) complications such as erosive esophagitis, stricture formation, Barrett's esophagus, and esophageal adenocarcinoma, said Dr. Gregg Gagliardi of Thomas Jefferson University, Philadelphia, and his associates.

This finding is especially concerning because epidemiologic studies suggest that sleep disturbances occur in as many as 75% of patients who have frequent heartburn. If they take the sleep aid to manage their sleep disturbances, they may unwittingly worsen their heartburn.

In addition, almost 30% of patients with sleep disturbances are thought to have undiagnosed GERD, and those who use zolpidem to manage their sleep disturbances may exacerbate reflux events and induce esophageal complications, the investigators noted (Clin. Gastroenterol. Hepatol. 2009;7:948-52).

Normally, these nocturnal events trigger awakening or arousal from sleep, which leads to a swallow reflex. This initiates peristalsis and exposure of the esophageal mucosa to saliva rich in bicarbonate. The saliva neutralizes the acid content in the esophagus and the peristalsis clears the acid through to the stomach. Suppressing this protective mechanism may lead to prolonged acid exposure and mucosal injury over time.

The researchers performed a double-blind, placebo-controlled trial to examine the issue in 15 GERD patients and 8 normal control subjects. The study was supported in part by AstraZeneca Pharmaceuticals LP.

Each study subject underwent separate sleep studies at a 2-week interval after taking zolpidem (Ambien, Sanofi-Aventis) or a matching placebo. A transnasal esophageal pH catheter with a sensor placed 5 cm above the lower esophageal sphincter recorded reflux events and the acid clearance time for each event, while polysomnography recorded reflux-associated arousals and awakenings.

In both the subjects with GERD and the healthy control subjects who had taken placebo, a nocturnal acid reflux event caused arousal or awakening 89% of the time. In contrast, after they had taken zolpidem, reflux events caused arousal or awakening only 40% of the time.

Among the control subjects, the mean time until acid was cleared from the esophagus during reflux episodes was 1.15 seconds after they had taken placebo, compared with 15.67 seconds after they had taken zolpidem.

Exposure time also was dramatically increased among the GERD subjects. The mean time until acid was cleared from the esophagus was 37.8 seconds after they had taken placebo, compared with 363.3 seconds after they had taken zolpidem.

When this exposure time is multiplied by the number of reflux events over the course of the entire sleep period, it has significant ramifications for the development of erosive esophagitis, strictures, Barrett's esophagus, and esophageal cancer, the researchers noted.

Suppression of the arousal reflex was most marked early in the evening for both GERD subjects and controls, perhaps because zolpidem has a relatively short duration of action. However, reflux events are most common early in the evening.

It is possible that other CNS depressants or psychotropic medications may exert similar effects on nighttime arousals as zolpidem did in this study. The use of such sleep aids is increasing in the United States, Dr. Gagliardi and his colleagues noted. “If this effect of blunted arousals or awakenings by hypnotics is substantiated, this would suggest caution in the use of sleep aids without first considering GERD as an etiologic factor in patients with complaints of disturbed sleep,” they added.

This study was limited by its small sample size, with just 23 subjects. However, the researchers attempted to counterbalance this drawback by analyzing each reflux event rather than each subject.

Dr. Gagliardi's associate, Dr. Karl Doghramji, also of Thomas Jefferson University, is a consultant for Sanofi-Aventis. No other conflicts of interest were reported.

Zolpidem, a frequently prescribed sleep aid, suppresses nocturnal awakenings that are an important CNS response to acid reflux events.

By enabling users to sleep through reflux events, the drug has the unintended effect of increasing esophageal exposure to stomach acid. This in turn opens the door to gastroesophageal reflux disease (GERD) complications such as erosive esophagitis, stricture formation, Barrett's esophagus, and esophageal adenocarcinoma, said Dr. Gregg Gagliardi of Thomas Jefferson University, Philadelphia, and his associates.

This finding is especially concerning because epidemiologic studies suggest that sleep disturbances occur in as many as 75% of patients who have frequent heartburn. If they take the sleep aid to manage their sleep disturbances, they may unwittingly worsen their heartburn.

In addition, almost 30% of patients with sleep disturbances are thought to have undiagnosed GERD, and those who use zolpidem to manage their sleep disturbances may exacerbate reflux events and induce esophageal complications, the investigators noted (Clin. Gastroenterol. Hepatol. 2009;7:948-52).

Normally, these nocturnal events trigger awakening or arousal from sleep, which leads to a swallow reflex. This initiates peristalsis and exposure of the esophageal mucosa to saliva rich in bicarbonate. The saliva neutralizes the acid content in the esophagus and the peristalsis clears the acid through to the stomach. Suppressing this protective mechanism may lead to prolonged acid exposure and mucosal injury over time.

The researchers performed a double-blind, placebo-controlled trial to examine the issue in 15 GERD patients and 8 normal control subjects. The study was supported in part by AstraZeneca Pharmaceuticals LP.

Each study subject underwent separate sleep studies at a 2-week interval after taking zolpidem (Ambien, Sanofi-Aventis) or a matching placebo. A transnasal esophageal pH catheter with a sensor placed 5 cm above the lower esophageal sphincter recorded reflux events and the acid clearance time for each event, while polysomnography recorded reflux-associated arousals and awakenings.

In both the subjects with GERD and the healthy control subjects who had taken placebo, a nocturnal acid reflux event caused arousal or awakening 89% of the time. In contrast, after they had taken zolpidem, reflux events caused arousal or awakening only 40% of the time.

Among the control subjects, the mean time until acid was cleared from the esophagus during reflux episodes was 1.15 seconds after they had taken placebo, compared with 15.67 seconds after they had taken zolpidem.

Exposure time also was dramatically increased among the GERD subjects. The mean time until acid was cleared from the esophagus was 37.8 seconds after they had taken placebo, compared with 363.3 seconds after they had taken zolpidem.

When this exposure time is multiplied by the number of reflux events over the course of the entire sleep period, it has significant ramifications for the development of erosive esophagitis, strictures, Barrett's esophagus, and esophageal cancer, the researchers noted.

Suppression of the arousal reflex was most marked early in the evening for both GERD subjects and controls, perhaps because zolpidem has a relatively short duration of action. However, reflux events are most common early in the evening.

It is possible that other CNS depressants or psychotropic medications may exert similar effects on nighttime arousals as zolpidem did in this study. The use of such sleep aids is increasing in the United States, Dr. Gagliardi and his colleagues noted. “If this effect of blunted arousals or awakenings by hypnotics is substantiated, this would suggest caution in the use of sleep aids without first considering GERD as an etiologic factor in patients with complaints of disturbed sleep,” they added.

This study was limited by its small sample size, with just 23 subjects. However, the researchers attempted to counterbalance this drawback by analyzing each reflux event rather than each subject.

Dr. Gagliardi's associate, Dr. Karl Doghramji, also of Thomas Jefferson University, is a consultant for Sanofi-Aventis. No other conflicts of interest were reported.

SEATTLE – Returning military veterans who have posttraumatic stress disorder often also have sleep disturbances that may provide an alternative, stigma-free entry into medical care, Anne Germain, Ph.D., said at the annual meeting of the Associated Professional Sleep Societies.

About 1.6 million people have been deployed to Afghanistan and Iraq as part of the current combat operations in those countries, noted Dr. Germain, an assistant professor of psychiatry at the University of Pittsburgh.

Roughly one-third have been deployed multiple times.

“We know that the risk of PTSD increases with each deployment,” she said. “So whatever estimates we have right now for PTSD, we are likely to see an increase with the number of deployments and duration of tours.”

Deployment has been associated with an increased prevalence of PTSD, Dr. Germain noted.

For example, 5% of Army personnel meet criteria for PTSD before deploying to Iraq, compared with almost 13% after their return (N. Engl. J. Med. 2004;351:13-22).

Three other psychiatric disorders–anxiety, depression, and alcohol misuse–also become more prevalent after deployment.

“All of these disorders are associated with stigma,” she observed. “Despite the military's best effort to destigmatize mental health difficulties post deployment, a lot of people will refuse or be very hesitant to seek care for these conditions.”

However, all of the disorders are also associated with sleep disturbances, including insomnia, irregular sleep-wake schedules, and hypersomnia.

“Sleep disturbances may actually provide an entry into care that is not stigmatizing, that is more socially acceptable, that gets people to seek help first,” she said.

“And once they are in treatment, maybe we can address these other psychiatric difficulties.”

When it comes to the pathogenesis of PTSD and sleep disturbances in returning military personnel, research has implicated both physical and psychological exposures during deployment, according to Dr. Germain.

Her team is specifically investigating the role of blast exposure in a new study that has thus far enrolled 25 military veterans returning from Iraq or Afghanistan who reported sleep difficulties.

Preliminary analyses showed the returnees were an average age of 28 years, and 92% were men. Forty percent had been exposed to a blast during their deployment.

The prevalence of PTSD was higher in the group exposed to blasts than in the nonexposed group (90% vs. 67%).

The groups had nearly equal, moderate levels of insomnia as measured by mean scores on the Insomnia Severity Index, or ISI (16.5 vs. 16.0), and the same poor sleep quality as measured by mean scores on the Pittsburgh Sleep Quality Index, or PSQI (10.7 vs. 10.7).

“These veterans are well within the realm for clinically significant sleep disturbance,” she observed. “Those are levels of sleep disturbances that we treat.”

However, the blast-exposed group had a higher level of disruptive nocturnal behaviors, such as nightmares of traumatic events or dream enactments involving kicking or punching, as measured by mean scores on the PSQI Addendum (PSQI-A), which assesses sleep disturbances associated with PTSD (6.6 vs. 3.9).

“What this means is unclear at this time,” Dr. Germain commented. “But it's definitely something that we want to follow up, because the treatments for these types of sleep disturbances are very different from those that we typically use for insomnia, for example.”

Blast-exposed and -nonexposed returnees were similar in terms of sleep diary and polysomnography measures. However, she noted, the polysomnography data might have been confounded by the high prevalence of PTSD.

“When veterans with PTSD sleep in the sleep lab, they sleep much better. They feel safe; there is somebody watching them,” she explained.

“So usually they catch up on sleep a little bit, and their sleep efficiency is better.”

Dr. Germain cautioned that definitive study results will require a larger sample size, as well as follow-up to assess the course of the sleep disturbances and PTSD, and the impact of treatment in the blast-exposed and -nonexposed groups.

“I'm especially interested in looking at how sleep may play a role in the development of some of those mental health difficulties or adjustment difficulties–not just PTSD, but other difficulties, too, such as depression–and in looking at the role of sleep in recovery as well,” she said.

Dr. Germain reported that she had no conflicts of interest in association with her presentation.

When veterans with PTSD sleep in the lab, they sleep much better. They feel safe; somebody is watching them.

Source DR. GERMAIN

SEATTLE – Returning military veterans who have posttraumatic stress disorder often also have sleep disturbances that may provide an alternative, stigma-free entry into medical care, Anne Germain, Ph.D., said at the annual meeting of the Associated Professional Sleep Societies.

About 1.6 million people have been deployed to Afghanistan and Iraq as part of the current combat operations in those countries, noted Dr. Germain, an assistant professor of psychiatry at the University of Pittsburgh.

Roughly one-third have been deployed multiple times.

“We know that the risk of PTSD increases with each deployment,” she said. “So whatever estimates we have right now for PTSD, we are likely to see an increase with the number of deployments and duration of tours.”

Deployment has been associated with an increased prevalence of PTSD, Dr. Germain noted.

For example, 5% of Army personnel meet criteria for PTSD before deploying to Iraq, compared with almost 13% after their return (N. Engl. J. Med. 2004;351:13-22).

Three other psychiatric disorders–anxiety, depression, and alcohol misuse–also become more prevalent after deployment.

“All of these disorders are associated with stigma,” she observed. “Despite the military's best effort to destigmatize mental health difficulties post deployment, a lot of people will refuse or be very hesitant to seek care for these conditions.”

However, all of the disorders are also associated with sleep disturbances, including insomnia, irregular sleep-wake schedules, and hypersomnia.

“Sleep disturbances may actually provide an entry into care that is not stigmatizing, that is more socially acceptable, that gets people to seek help first,” she said.

“And once they are in treatment, maybe we can address these other psychiatric difficulties.”

When it comes to the pathogenesis of PTSD and sleep disturbances in returning military personnel, research has implicated both physical and psychological exposures during deployment, according to Dr. Germain.

Her team is specifically investigating the role of blast exposure in a new study that has thus far enrolled 25 military veterans returning from Iraq or Afghanistan who reported sleep difficulties.

Preliminary analyses showed the returnees were an average age of 28 years, and 92% were men. Forty percent had been exposed to a blast during their deployment.

The prevalence of PTSD was higher in the group exposed to blasts than in the nonexposed group (90% vs. 67%).

The groups had nearly equal, moderate levels of insomnia as measured by mean scores on the Insomnia Severity Index, or ISI (16.5 vs. 16.0), and the same poor sleep quality as measured by mean scores on the Pittsburgh Sleep Quality Index, or PSQI (10.7 vs. 10.7).

“These veterans are well within the realm for clinically significant sleep disturbance,” she observed. “Those are levels of sleep disturbances that we treat.”

However, the blast-exposed group had a higher level of disruptive nocturnal behaviors, such as nightmares of traumatic events or dream enactments involving kicking or punching, as measured by mean scores on the PSQI Addendum (PSQI-A), which assesses sleep disturbances associated with PTSD (6.6 vs. 3.9).

“What this means is unclear at this time,” Dr. Germain commented. “But it's definitely something that we want to follow up, because the treatments for these types of sleep disturbances are very different from those that we typically use for insomnia, for example.”

Blast-exposed and -nonexposed returnees were similar in terms of sleep diary and polysomnography measures. However, she noted, the polysomnography data might have been confounded by the high prevalence of PTSD.

“When veterans with PTSD sleep in the sleep lab, they sleep much better. They feel safe; there is somebody watching them,” she explained.

“So usually they catch up on sleep a little bit, and their sleep efficiency is better.”

Dr. Germain cautioned that definitive study results will require a larger sample size, as well as follow-up to assess the course of the sleep disturbances and PTSD, and the impact of treatment in the blast-exposed and -nonexposed groups.

“I'm especially interested in looking at how sleep may play a role in the development of some of those mental health difficulties or adjustment difficulties–not just PTSD, but other difficulties, too, such as depression–and in looking at the role of sleep in recovery as well,” she said.

Dr. Germain reported that she had no conflicts of interest in association with her presentation.

When veterans with PTSD sleep in the lab, they sleep much better. They feel safe; somebody is watching them.

Source DR. GERMAIN

SEATTLE – Returning military veterans who have posttraumatic stress disorder often also have sleep disturbances that may provide an alternative, stigma-free entry into medical care, Anne Germain, Ph.D., said at the annual meeting of the Associated Professional Sleep Societies.

About 1.6 million people have been deployed to Afghanistan and Iraq as part of the current combat operations in those countries, noted Dr. Germain, an assistant professor of psychiatry at the University of Pittsburgh.

Roughly one-third have been deployed multiple times.

“We know that the risk of PTSD increases with each deployment,” she said. “So whatever estimates we have right now for PTSD, we are likely to see an increase with the number of deployments and duration of tours.”

Deployment has been associated with an increased prevalence of PTSD, Dr. Germain noted.

For example, 5% of Army personnel meet criteria for PTSD before deploying to Iraq, compared with almost 13% after their return (N. Engl. J. Med. 2004;351:13-22).

Three other psychiatric disorders–anxiety, depression, and alcohol misuse–also become more prevalent after deployment.

“All of these disorders are associated with stigma,” she observed. “Despite the military's best effort to destigmatize mental health difficulties post deployment, a lot of people will refuse or be very hesitant to seek care for these conditions.”

However, all of the disorders are also associated with sleep disturbances, including insomnia, irregular sleep-wake schedules, and hypersomnia.

“Sleep disturbances may actually provide an entry into care that is not stigmatizing, that is more socially acceptable, that gets people to seek help first,” she said.

“And once they are in treatment, maybe we can address these other psychiatric difficulties.”

When it comes to the pathogenesis of PTSD and sleep disturbances in returning military personnel, research has implicated both physical and psychological exposures during deployment, according to Dr. Germain.

Her team is specifically investigating the role of blast exposure in a new study that has thus far enrolled 25 military veterans returning from Iraq or Afghanistan who reported sleep difficulties.

Preliminary analyses showed the returnees were an average age of 28 years, and 92% were men. Forty percent had been exposed to a blast during their deployment.

The prevalence of PTSD was higher in the group exposed to blasts than in the nonexposed group (90% vs. 67%).

The groups had nearly equal, moderate levels of insomnia as measured by mean scores on the Insomnia Severity Index, or ISI (16.5 vs. 16.0), and the same poor sleep quality as measured by mean scores on the Pittsburgh Sleep Quality Index, or PSQI (10.7 vs. 10.7).

“These veterans are well within the realm for clinically significant sleep disturbance,” she observed. “Those are levels of sleep disturbances that we treat.”

However, the blast-exposed group had a higher level of disruptive nocturnal behaviors, such as nightmares of traumatic events or dream enactments involving kicking or punching, as measured by mean scores on the PSQI Addendum (PSQI-A), which assesses sleep disturbances associated with PTSD (6.6 vs. 3.9).

“What this means is unclear at this time,” Dr. Germain commented. “But it's definitely something that we want to follow up, because the treatments for these types of sleep disturbances are very different from those that we typically use for insomnia, for example.”

Blast-exposed and -nonexposed returnees were similar in terms of sleep diary and polysomnography measures. However, she noted, the polysomnography data might have been confounded by the high prevalence of PTSD.

“When veterans with PTSD sleep in the sleep lab, they sleep much better. They feel safe; there is somebody watching them,” she explained.

“So usually they catch up on sleep a little bit, and their sleep efficiency is better.”

Dr. Germain cautioned that definitive study results will require a larger sample size, as well as follow-up to assess the course of the sleep disturbances and PTSD, and the impact of treatment in the blast-exposed and -nonexposed groups.

“I'm especially interested in looking at how sleep may play a role in the development of some of those mental health difficulties or adjustment difficulties–not just PTSD, but other difficulties, too, such as depression–and in looking at the role of sleep in recovery as well,” she said.

Dr. Germain reported that she had no conflicts of interest in association with her presentation.

When veterans with PTSD sleep in the lab, they sleep much better. They feel safe; somebody is watching them.

Source DR. GERMAIN

A cognitive-behavioral therapy intervention delivered via the Internet significantly reduced insomnia severity and contributed to overall sleep improvement in a study of 44 adults, according to a report in the Archives of General Psychiatry.

The 9-week intervention reduced the number of nighttime awakenings and improved sleep efficiency to a similar degree as has been reported for face-to-face CBT, self-help bibliotherapy, group therapy, telephone therapy, and pharmacotherapy, said Lee M. Ritterband, Ph.D., of the University of Virginia Health System, Charlottesville, and his associates.

“An effective and inexpensive Internet intervention would expand treatment options for large numbers of adults with insomnia, especially those whose geographical location prohibits access to relevant care, and could be a substantive first-line treatment choice,” they noted. Although traditional CBT is one of the most effective treatments for insomnia, its availability is “severely limited,” in part because of a lack of trained clinicians, the uneven geographical distribution of trained clinicians, and the cost of treatment.

Dr. Ritterband and his colleagues assessed the feasibility and efficacy of a fully automated Internet-based intervention called SHUTi (Sleep Healthy Using the Internet).

SHUTi provides instruction on going to bed only when sleepy, getting out of bed when unable to sleep, and returning only when sleep is imminent. The program advises patients to avoid sleep-incompatible activities in the bedroom such as watching television, to forgo daytime napping, and to arise at the same hour every day. Patients also are instructed to improve their sleep hygiene by avoiding nicotine, caffeine, and alcohol before bedtime. SHUTi also addresses “unhelpful” beliefs and thoughts, such as the notion that people absolutely need 8 hours of sleep every night or excessive concern about the consequences of insomnia.

Participants fill out the Insomnia Severity Index (ISI) online and complete weekly sleep diaries. That information is then used to individually tailor recommendations for the coming week, all of which is computed automatically using algorithms developed specifically for SHUTi.

The intervention uses graphics and animation as well as text, and it includes quizzes, brief games, and vignettes to deliver information, Dr. Ritterband and his colleagues said (Arch. Gen. Psychiatry 2009;66:692-8).

They compared insomnia outcomes between 22 insomnia patients randomly assigned to the SHUTi intervention and 22 control patients who were wait-listed to participate in the program.

The mean age of participants was 45 years; they had had sleep problems for an average of more than 10 years, and at the time of enrollment they reported disruptive sleep more than 5 nights per week.

The intervention group showed marked improvement in insomnia severity at the conclusion of the program as well as 6 months later, while the control group showed little change. Sixteen of the intervention subjects (73%) were judged to be in remission by ISI score, compared with none of the control subjects.

“It is important to highlight that the treatment effect sizes found using this Internet intervention, which was delivered with no human support and at a relatively low cost, are comparable to those found in face-to-face studies,” the investigators said.

They also pointed out that this intervention might expand treatment options for adults whose geographical location prohibits access to care.

However, Dr. Ritterband and his colleagues added that their study sample was “small, relatively homogeneous, well educated, and restricted to individuals with primary insomnia and no comorbidities. Future studies should enroll larger and more heterogeneous samples to improve the generalizability of the findings.”

No relevant conflicts of interest were reported. The study was supported by a grant from the National Institute of Mental Health, National Institutes of Health.

The Sleep Healthy Using the Internet (SHUTi) intervention advises patients to arise at the same hour every day.

Source ©Karen Winton/iStockphoto.com

A cognitive-behavioral therapy intervention delivered via the Internet significantly reduced insomnia severity and contributed to overall sleep improvement in a study of 44 adults, according to a report in the Archives of General Psychiatry.

The 9-week intervention reduced the number of nighttime awakenings and improved sleep efficiency to a similar degree as has been reported for face-to-face CBT, self-help bibliotherapy, group therapy, telephone therapy, and pharmacotherapy, said Lee M. Ritterband, Ph.D., of the University of Virginia Health System, Charlottesville, and his associates.

“An effective and inexpensive Internet intervention would expand treatment options for large numbers of adults with insomnia, especially those whose geographical location prohibits access to relevant care, and could be a substantive first-line treatment choice,” they noted. Although traditional CBT is one of the most effective treatments for insomnia, its availability is “severely limited,” in part because of a lack of trained clinicians, the uneven geographical distribution of trained clinicians, and the cost of treatment.

Dr. Ritterband and his colleagues assessed the feasibility and efficacy of a fully automated Internet-based intervention called SHUTi (Sleep Healthy Using the Internet).

SHUTi provides instruction on going to bed only when sleepy, getting out of bed when unable to sleep, and returning only when sleep is imminent. The program advises patients to avoid sleep-incompatible activities in the bedroom such as watching television, to forgo daytime napping, and to arise at the same hour every day. Patients also are instructed to improve their sleep hygiene by avoiding nicotine, caffeine, and alcohol before bedtime. SHUTi also addresses “unhelpful” beliefs and thoughts, such as the notion that people absolutely need 8 hours of sleep every night or excessive concern about the consequences of insomnia.

Participants fill out the Insomnia Severity Index (ISI) online and complete weekly sleep diaries. That information is then used to individually tailor recommendations for the coming week, all of which is computed automatically using algorithms developed specifically for SHUTi.

The intervention uses graphics and animation as well as text, and it includes quizzes, brief games, and vignettes to deliver information, Dr. Ritterband and his colleagues said (Arch. Gen. Psychiatry 2009;66:692-8).

They compared insomnia outcomes between 22 insomnia patients randomly assigned to the SHUTi intervention and 22 control patients who were wait-listed to participate in the program.

The mean age of participants was 45 years; they had had sleep problems for an average of more than 10 years, and at the time of enrollment they reported disruptive sleep more than 5 nights per week.

The intervention group showed marked improvement in insomnia severity at the conclusion of the program as well as 6 months later, while the control group showed little change. Sixteen of the intervention subjects (73%) were judged to be in remission by ISI score, compared with none of the control subjects.

“It is important to highlight that the treatment effect sizes found using this Internet intervention, which was delivered with no human support and at a relatively low cost, are comparable to those found in face-to-face studies,” the investigators said.

They also pointed out that this intervention might expand treatment options for adults whose geographical location prohibits access to care.

However, Dr. Ritterband and his colleagues added that their study sample was “small, relatively homogeneous, well educated, and restricted to individuals with primary insomnia and no comorbidities. Future studies should enroll larger and more heterogeneous samples to improve the generalizability of the findings.”

No relevant conflicts of interest were reported. The study was supported by a grant from the National Institute of Mental Health, National Institutes of Health.

The Sleep Healthy Using the Internet (SHUTi) intervention advises patients to arise at the same hour every day.

Source ©Karen Winton/iStockphoto.com

A cognitive-behavioral therapy intervention delivered via the Internet significantly reduced insomnia severity and contributed to overall sleep improvement in a study of 44 adults, according to a report in the Archives of General Psychiatry.

The 9-week intervention reduced the number of nighttime awakenings and improved sleep efficiency to a similar degree as has been reported for face-to-face CBT, self-help bibliotherapy, group therapy, telephone therapy, and pharmacotherapy, said Lee M. Ritterband, Ph.D., of the University of Virginia Health System, Charlottesville, and his associates.

“An effective and inexpensive Internet intervention would expand treatment options for large numbers of adults with insomnia, especially those whose geographical location prohibits access to relevant care, and could be a substantive first-line treatment choice,” they noted. Although traditional CBT is one of the most effective treatments for insomnia, its availability is “severely limited,” in part because of a lack of trained clinicians, the uneven geographical distribution of trained clinicians, and the cost of treatment.

Dr. Ritterband and his colleagues assessed the feasibility and efficacy of a fully automated Internet-based intervention called SHUTi (Sleep Healthy Using the Internet).

SHUTi provides instruction on going to bed only when sleepy, getting out of bed when unable to sleep, and returning only when sleep is imminent. The program advises patients to avoid sleep-incompatible activities in the bedroom such as watching television, to forgo daytime napping, and to arise at the same hour every day. Patients also are instructed to improve their sleep hygiene by avoiding nicotine, caffeine, and alcohol before bedtime. SHUTi also addresses “unhelpful” beliefs and thoughts, such as the notion that people absolutely need 8 hours of sleep every night or excessive concern about the consequences of insomnia.

Participants fill out the Insomnia Severity Index (ISI) online and complete weekly sleep diaries. That information is then used to individually tailor recommendations for the coming week, all of which is computed automatically using algorithms developed specifically for SHUTi.

The intervention uses graphics and animation as well as text, and it includes quizzes, brief games, and vignettes to deliver information, Dr. Ritterband and his colleagues said (Arch. Gen. Psychiatry 2009;66:692-8).

They compared insomnia outcomes between 22 insomnia patients randomly assigned to the SHUTi intervention and 22 control patients who were wait-listed to participate in the program.

The mean age of participants was 45 years; they had had sleep problems for an average of more than 10 years, and at the time of enrollment they reported disruptive sleep more than 5 nights per week.

The intervention group showed marked improvement in insomnia severity at the conclusion of the program as well as 6 months later, while the control group showed little change. Sixteen of the intervention subjects (73%) were judged to be in remission by ISI score, compared with none of the control subjects.

“It is important to highlight that the treatment effect sizes found using this Internet intervention, which was delivered with no human support and at a relatively low cost, are comparable to those found in face-to-face studies,” the investigators said.

They also pointed out that this intervention might expand treatment options for adults whose geographical location prohibits access to care.

However, Dr. Ritterband and his colleagues added that their study sample was “small, relatively homogeneous, well educated, and restricted to individuals with primary insomnia and no comorbidities. Future studies should enroll larger and more heterogeneous samples to improve the generalizability of the findings.”

No relevant conflicts of interest were reported. The study was supported by a grant from the National Institute of Mental Health, National Institutes of Health.

The Sleep Healthy Using the Internet (SHUTi) intervention advises patients to arise at the same hour every day.

Source ©Karen Winton/iStockphoto.com

In Sweden's general population, the subcategory of functional dyspepsia known as postprandial distress syndrome is associated with anxiety, Dr. Pertti Aro and his colleagues reported in an article appearing in the July issue of Gastroenterology.

In contrast, the other subcategory of functional dyspepsia–epigastric pain syndrome–is not associated with anxiety, wrote Dr. Aro of the Karolinska Institutet, Stockholm, and his associates.

The two distinct syndromes were delineated in the Rome III diagnostic criteria for functional dyspepsia. Postprandial distress syndrome includes one or more symptoms of bothersome postprandial fullness and early satiation, while epigastric pain syndrome includes unexplained epigastric pain and/or burning. Both occur in patients with no evidence of structural disease that could explain the symptoms.

Because little is known about the epidemiology of “these newly defined syndromes,” Dr. Aro and his associates undertook a population-based assessment of risk factors for them. They hypothesized that psychological distress (anxiety and depression) would be a risk factor for one or both subtypes of functional dyspepsia.

The Kalixanda study examined a representative sample drawn from 21,610 adults residing in Kalix and Haparanda, two neighboring communities in northern Sweden. A total of 1,001 people agreed to undergo esophagogastroduodenoscopy, including biopsy and Helicobacter pylori culturing, to rule out organic disease as the cause of their symptoms.

They also completed the extended Abdominal Symptom Questionnaire, the Hospital Anxiety and Depression Scale (HADS), and provided a complete medical history and demographic data.

At endoscopy, 157 subjects (15%) were deemed to have functional dyspepsia. A total of 52 had epigastric pain syndrome, 122 had postprandial distress syndrome, and 17 had both disorders.

Major anxiety (HADS score of 11 or higher) was associated with functional dyspepsia, but depression was not. When functional dyspepsia was broken down into the two subtypes, anxiety was associated with postprandial distress syndrome but not with epigastric pain syndrome.

In addition, another 157 subjects were found to have “uninvestigated” dyspepsia, a category separate from functional dyspepsia. Both minor anxiety (HADS scores of 8-10) and major anxiety, but not depression, were associated with this form of dyspepsia.

“Whether antianxiety agents have any role in management of dyspepsia is unknown but worthy of further testing,” the researchers wrote.

“To our knowledge, this is the first population-based study in a randomly selected adult population to evaluate risk factors for functional dyspepsia using the Rome III definition, with careful exclusion of organic disease by upper endoscopy,” they said.

The question of whether psychological factors cause functional dyspepsia is a controversial one. Some studies have found that psychological illness not only is associated with but also is a predictor of such a diagnosis, and one study reported that treatment with a combination of an anxiolytic and an antidepressant provided short-term improvement in dyspepsia symptoms.

However, other studies have found no such link or have reported that antianxiety medications have no effect on functional dyspepsia.

“Our results are consistent with the hypothesis that functional dyspepsia is causally linked to anxiety but not to depression. … However, it is also conceivable that having upper gastrointestinal symptoms drives increased anxiety.

“Alternatively, another factor such as a common genetic link could explain the coexistence of anxiety and dyspepsia in the population. … The search for common pathways that induce anxiety and dyspepsia now needs greater attention,” Dr. Aro and his colleagues wrote.

This study was supported in part by AstraZeneca Research and Development, Mölndal, Sweden.

In Sweden's general population, the subcategory of functional dyspepsia known as postprandial distress syndrome is associated with anxiety, Dr. Pertti Aro and his colleagues reported in an article appearing in the July issue of Gastroenterology.

In contrast, the other subcategory of functional dyspepsia–epigastric pain syndrome–is not associated with anxiety, wrote Dr. Aro of the Karolinska Institutet, Stockholm, and his associates.

The two distinct syndromes were delineated in the Rome III diagnostic criteria for functional dyspepsia. Postprandial distress syndrome includes one or more symptoms of bothersome postprandial fullness and early satiation, while epigastric pain syndrome includes unexplained epigastric pain and/or burning. Both occur in patients with no evidence of structural disease that could explain the symptoms.

Because little is known about the epidemiology of “these newly defined syndromes,” Dr. Aro and his associates undertook a population-based assessment of risk factors for them. They hypothesized that psychological distress (anxiety and depression) would be a risk factor for one or both subtypes of functional dyspepsia.

The Kalixanda study examined a representative sample drawn from 21,610 adults residing in Kalix and Haparanda, two neighboring communities in northern Sweden. A total of 1,001 people agreed to undergo esophagogastroduodenoscopy, including biopsy and Helicobacter pylori culturing, to rule out organic disease as the cause of their symptoms.

They also completed the extended Abdominal Symptom Questionnaire, the Hospital Anxiety and Depression Scale (HADS), and provided a complete medical history and demographic data.

At endoscopy, 157 subjects (15%) were deemed to have functional dyspepsia. A total of 52 had epigastric pain syndrome, 122 had postprandial distress syndrome, and 17 had both disorders.

Major anxiety (HADS score of 11 or higher) was associated with functional dyspepsia, but depression was not. When functional dyspepsia was broken down into the two subtypes, anxiety was associated with postprandial distress syndrome but not with epigastric pain syndrome.

In addition, another 157 subjects were found to have “uninvestigated” dyspepsia, a category separate from functional dyspepsia. Both minor anxiety (HADS scores of 8-10) and major anxiety, but not depression, were associated with this form of dyspepsia.

“Whether antianxiety agents have any role in management of dyspepsia is unknown but worthy of further testing,” the researchers wrote.

“To our knowledge, this is the first population-based study in a randomly selected adult population to evaluate risk factors for functional dyspepsia using the Rome III definition, with careful exclusion of organic disease by upper endoscopy,” they said.

The question of whether psychological factors cause functional dyspepsia is a controversial one. Some studies have found that psychological illness not only is associated with but also is a predictor of such a diagnosis, and one study reported that treatment with a combination of an anxiolytic and an antidepressant provided short-term improvement in dyspepsia symptoms.

However, other studies have found no such link or have reported that antianxiety medications have no effect on functional dyspepsia.

“Our results are consistent with the hypothesis that functional dyspepsia is causally linked to anxiety but not to depression. … However, it is also conceivable that having upper gastrointestinal symptoms drives increased anxiety.

“Alternatively, another factor such as a common genetic link could explain the coexistence of anxiety and dyspepsia in the population. … The search for common pathways that induce anxiety and dyspepsia now needs greater attention,” Dr. Aro and his colleagues wrote.

This study was supported in part by AstraZeneca Research and Development, Mölndal, Sweden.

In Sweden's general population, the subcategory of functional dyspepsia known as postprandial distress syndrome is associated with anxiety, Dr. Pertti Aro and his colleagues reported in an article appearing in the July issue of Gastroenterology.

In contrast, the other subcategory of functional dyspepsia–epigastric pain syndrome–is not associated with anxiety, wrote Dr. Aro of the Karolinska Institutet, Stockholm, and his associates.

The two distinct syndromes were delineated in the Rome III diagnostic criteria for functional dyspepsia. Postprandial distress syndrome includes one or more symptoms of bothersome postprandial fullness and early satiation, while epigastric pain syndrome includes unexplained epigastric pain and/or burning. Both occur in patients with no evidence of structural disease that could explain the symptoms.

Because little is known about the epidemiology of “these newly defined syndromes,” Dr. Aro and his associates undertook a population-based assessment of risk factors for them. They hypothesized that psychological distress (anxiety and depression) would be a risk factor for one or both subtypes of functional dyspepsia.

The Kalixanda study examined a representative sample drawn from 21,610 adults residing in Kalix and Haparanda, two neighboring communities in northern Sweden. A total of 1,001 people agreed to undergo esophagogastroduodenoscopy, including biopsy and Helicobacter pylori culturing, to rule out organic disease as the cause of their symptoms.

They also completed the extended Abdominal Symptom Questionnaire, the Hospital Anxiety and Depression Scale (HADS), and provided a complete medical history and demographic data.

At endoscopy, 157 subjects (15%) were deemed to have functional dyspepsia. A total of 52 had epigastric pain syndrome, 122 had postprandial distress syndrome, and 17 had both disorders.

Major anxiety (HADS score of 11 or higher) was associated with functional dyspepsia, but depression was not. When functional dyspepsia was broken down into the two subtypes, anxiety was associated with postprandial distress syndrome but not with epigastric pain syndrome.

In addition, another 157 subjects were found to have “uninvestigated” dyspepsia, a category separate from functional dyspepsia. Both minor anxiety (HADS scores of 8-10) and major anxiety, but not depression, were associated with this form of dyspepsia.

“Whether antianxiety agents have any role in management of dyspepsia is unknown but worthy of further testing,” the researchers wrote.

“To our knowledge, this is the first population-based study in a randomly selected adult population to evaluate risk factors for functional dyspepsia using the Rome III definition, with careful exclusion of organic disease by upper endoscopy,” they said.

The question of whether psychological factors cause functional dyspepsia is a controversial one. Some studies have found that psychological illness not only is associated with but also is a predictor of such a diagnosis, and one study reported that treatment with a combination of an anxiolytic and an antidepressant provided short-term improvement in dyspepsia symptoms.

However, other studies have found no such link or have reported that antianxiety medications have no effect on functional dyspepsia.

“Our results are consistent with the hypothesis that functional dyspepsia is causally linked to anxiety but not to depression. … However, it is also conceivable that having upper gastrointestinal symptoms drives increased anxiety.

“Alternatively, another factor such as a common genetic link could explain the coexistence of anxiety and dyspepsia in the population. … The search for common pathways that induce anxiety and dyspepsia now needs greater attention,” Dr. Aro and his colleagues wrote.

This study was supported in part by AstraZeneca Research and Development, Mölndal, Sweden.

SAN DIEGO – The prevalence of headache disorders in patients referred to a sleep lab for sleep-disordered breathing was 70% and consisted primarily of morning headache, a study of more than 200 patients showed.

A relationship between headache disorders and sleep disorder has been described anecdotally in the medical literature for several decades, but this marks the largest-known prospective study to evaluate the association, Dr. Timothy M. Quast reported during a poster session at an international conference of the American Thoracic Society.

“There have been very few studies done on this topic,” said Dr. Quast of the Walter Reed Army Medical Center, Washington. “The ones that we did find were small, of 50-80 patients. We wanted to find out if there was something to this association, or if this is something anecdotal that's just been repeated for decades.”

He and his associates asked 219 consecutive patients undergoing an overnight polysomnography for diagnostic purposes to complete a brief questionnaire to evaluate whether or not headache disorders were present. Respondents who were affected by headache disorders were asked to complete a more detailed questionnaire to diagnose and characterize the condition.

After all patients underwent poly-somnography, the researchers conducted follow-up phone calls at 1- and 3-month intervals to evaluate compliance with their continuous positive airway pressure machine and the effect of CPAP on a comorbid headache disorder.

The mean age of the 219 patients was 44 years old, their mean body mass index was 30.4 kg/m

A total of 154 patients (70%) had a headache disorder present and 65 did not. Morning headache was most common type of headache disorder (55%), followed by tension type headache (49%), migraine headache (32%), and chronic daily headache (16%).

No polysomnography features were predictive of headache disorder, a finding that surprised Dr. Quast. “The patients who had headaches had better sleep indices,” he said. “They had less respiratory disturbances, woke up less frequently, and had fewer hypopneas or apneas. They didn't move as much in terms of periodic leg movement syndrome, and they actually had higher mean oxygen saturation levels. That's counterintuitive.”

The researchers also found that CPAP therapy appeared to improve headache symptoms among patients who were compliant with their CPAP machines. “This is another reason that patients need to be compliant with their CPAP, because their headache might actually go away,” he commented.

Patients with a headache disorder tended to be younger, compared with their counterparts who did not have a headache disorder. They also reported being were more depressed based on responses to the Patient Health Questionnaire-9 and more tired based on responses to the Epworth Sleepiness Scale. “There's something breaking out here, but we did not have the power to determine what makes these subpopulations different from one another,” Dr. Quast said.

He estimated that a study of at least 500 patients will be required to further elucidate the findings.

For now, he said, the clinical implications of the current findings are that if you have a patient that complains of waking up with a headache in the morning, “that's highly predictive of sleep disordered breathing, and that person should undergo a sleep study,” advised Dr. Quast, who had no conflicts to disclose.

To watch a video interview of Dr. Quast, go to www.youtube.com/ClinPsychNews

If a patient reports waking up with a headache, 'that's highly predictive of sleep disordered breathing.' DR. QUAST

SAN DIEGO – The prevalence of headache disorders in patients referred to a sleep lab for sleep-disordered breathing was 70% and consisted primarily of morning headache, a study of more than 200 patients showed.

A relationship between headache disorders and sleep disorder has been described anecdotally in the medical literature for several decades, but this marks the largest-known prospective study to evaluate the association, Dr. Timothy M. Quast reported during a poster session at an international conference of the American Thoracic Society.

“There have been very few studies done on this topic,” said Dr. Quast of the Walter Reed Army Medical Center, Washington. “The ones that we did find were small, of 50-80 patients. We wanted to find out if there was something to this association, or if this is something anecdotal that's just been repeated for decades.”

He and his associates asked 219 consecutive patients undergoing an overnight polysomnography for diagnostic purposes to complete a brief questionnaire to evaluate whether or not headache disorders were present. Respondents who were affected by headache disorders were asked to complete a more detailed questionnaire to diagnose and characterize the condition.

After all patients underwent poly-somnography, the researchers conducted follow-up phone calls at 1- and 3-month intervals to evaluate compliance with their continuous positive airway pressure machine and the effect of CPAP on a comorbid headache disorder.

The mean age of the 219 patients was 44 years old, their mean body mass index was 30.4 kg/m

A total of 154 patients (70%) had a headache disorder present and 65 did not. Morning headache was most common type of headache disorder (55%), followed by tension type headache (49%), migraine headache (32%), and chronic daily headache (16%).

No polysomnography features were predictive of headache disorder, a finding that surprised Dr. Quast. “The patients who had headaches had better sleep indices,” he said. “They had less respiratory disturbances, woke up less frequently, and had fewer hypopneas or apneas. They didn't move as much in terms of periodic leg movement syndrome, and they actually had higher mean oxygen saturation levels. That's counterintuitive.”

The researchers also found that CPAP therapy appeared to improve headache symptoms among patients who were compliant with their CPAP machines. “This is another reason that patients need to be compliant with their CPAP, because their headache might actually go away,” he commented.

Patients with a headache disorder tended to be younger, compared with their counterparts who did not have a headache disorder. They also reported being were more depressed based on responses to the Patient Health Questionnaire-9 and more tired based on responses to the Epworth Sleepiness Scale. “There's something breaking out here, but we did not have the power to determine what makes these subpopulations different from one another,” Dr. Quast said.

He estimated that a study of at least 500 patients will be required to further elucidate the findings.

For now, he said, the clinical implications of the current findings are that if you have a patient that complains of waking up with a headache in the morning, “that's highly predictive of sleep disordered breathing, and that person should undergo a sleep study,” advised Dr. Quast, who had no conflicts to disclose.

To watch a video interview of Dr. Quast, go to www.youtube.com/ClinPsychNews

If a patient reports waking up with a headache, 'that's highly predictive of sleep disordered breathing.' DR. QUAST

SAN DIEGO – The prevalence of headache disorders in patients referred to a sleep lab for sleep-disordered breathing was 70% and consisted primarily of morning headache, a study of more than 200 patients showed.

A relationship between headache disorders and sleep disorder has been described anecdotally in the medical literature for several decades, but this marks the largest-known prospective study to evaluate the association, Dr. Timothy M. Quast reported during a poster session at an international conference of the American Thoracic Society.

“There have been very few studies done on this topic,” said Dr. Quast of the Walter Reed Army Medical Center, Washington. “The ones that we did find were small, of 50-80 patients. We wanted to find out if there was something to this association, or if this is something anecdotal that's just been repeated for decades.”

He and his associates asked 219 consecutive patients undergoing an overnight polysomnography for diagnostic purposes to complete a brief questionnaire to evaluate whether or not headache disorders were present. Respondents who were affected by headache disorders were asked to complete a more detailed questionnaire to diagnose and characterize the condition.

After all patients underwent poly-somnography, the researchers conducted follow-up phone calls at 1- and 3-month intervals to evaluate compliance with their continuous positive airway pressure machine and the effect of CPAP on a comorbid headache disorder.

The mean age of the 219 patients was 44 years old, their mean body mass index was 30.4 kg/m

A total of 154 patients (70%) had a headache disorder present and 65 did not. Morning headache was most common type of headache disorder (55%), followed by tension type headache (49%), migraine headache (32%), and chronic daily headache (16%).

No polysomnography features were predictive of headache disorder, a finding that surprised Dr. Quast. “The patients who had headaches had better sleep indices,” he said. “They had less respiratory disturbances, woke up less frequently, and had fewer hypopneas or apneas. They didn't move as much in terms of periodic leg movement syndrome, and they actually had higher mean oxygen saturation levels. That's counterintuitive.”

The researchers also found that CPAP therapy appeared to improve headache symptoms among patients who were compliant with their CPAP machines. “This is another reason that patients need to be compliant with their CPAP, because their headache might actually go away,” he commented.

Patients with a headache disorder tended to be younger, compared with their counterparts who did not have a headache disorder. They also reported being were more depressed based on responses to the Patient Health Questionnaire-9 and more tired based on responses to the Epworth Sleepiness Scale. “There's something breaking out here, but we did not have the power to determine what makes these subpopulations different from one another,” Dr. Quast said.

He estimated that a study of at least 500 patients will be required to further elucidate the findings.

For now, he said, the clinical implications of the current findings are that if you have a patient that complains of waking up with a headache in the morning, “that's highly predictive of sleep disordered breathing, and that person should undergo a sleep study,” advised Dr. Quast, who had no conflicts to disclose.

To watch a video interview of Dr. Quast, go to www.youtube.com/ClinPsychNews

If a patient reports waking up with a headache, 'that's highly predictive of sleep disordered breathing.' DR. QUAST

Women with bulimia nervosa appear to have deficient activity in frontostriatal regulatory circuits of the anterior cingulate cortex, as assessed on functional MRI.

This subnormal activation likely contributes to their greater than normal impulsivity in eating and other behaviors, said Dr. Rachel Marsh and associates at the New York State Psychiatric Institute, New York (Arch. Gen. Psych. 2009;66:51–63).

They assessed 20 women recruited from an eating disorders clinic and 20 healthy control subjects matched for body mass index and age (average, 26 years). All underwent fMRI imaging while performing the Simon spatial incompatibility task to compare differences between the group in brain activation patterns associated with self-regulatory control.

The bulimia patients made significantly more errors on the task than did controls, and their accuracy decreased further over time. Those with the most severe bulimia symptoms made the most errors.

Compared with controls, bulimia patients showed deficits in the activation of circuits in the brain's left side (the inferolateral prefrontal cortex and the left lenticular nucleus) and in the right side (the ventral and dorsal anterior cingulate cortex, the putamen, and the caudate nucleus).

“Deficient cortical activation likely accounted for their more impulsive, error-prone performances, compared with controls,” the authors wrote. “These deficits may be caused by previously reported decreases in serotonin metabolism in frontal cortices in [bulimics].”

The differences between the groups were independent of IQ, depression, and ADHD rating instruments.

Women with bulimia nervosa appear to have deficient activity in frontostriatal regulatory circuits of the anterior cingulate cortex, as assessed on functional MRI.

This subnormal activation likely contributes to their greater than normal impulsivity in eating and other behaviors, said Dr. Rachel Marsh and associates at the New York State Psychiatric Institute, New York (Arch. Gen. Psych. 2009;66:51–63).

They assessed 20 women recruited from an eating disorders clinic and 20 healthy control subjects matched for body mass index and age (average, 26 years). All underwent fMRI imaging while performing the Simon spatial incompatibility task to compare differences between the group in brain activation patterns associated with self-regulatory control.

The bulimia patients made significantly more errors on the task than did controls, and their accuracy decreased further over time. Those with the most severe bulimia symptoms made the most errors.

Compared with controls, bulimia patients showed deficits in the activation of circuits in the brain's left side (the inferolateral prefrontal cortex and the left lenticular nucleus) and in the right side (the ventral and dorsal anterior cingulate cortex, the putamen, and the caudate nucleus).

“Deficient cortical activation likely accounted for their more impulsive, error-prone performances, compared with controls,” the authors wrote. “These deficits may be caused by previously reported decreases in serotonin metabolism in frontal cortices in [bulimics].”

The differences between the groups were independent of IQ, depression, and ADHD rating instruments.

Women with bulimia nervosa appear to have deficient activity in frontostriatal regulatory circuits of the anterior cingulate cortex, as assessed on functional MRI.

This subnormal activation likely contributes to their greater than normal impulsivity in eating and other behaviors, said Dr. Rachel Marsh and associates at the New York State Psychiatric Institute, New York (Arch. Gen. Psych. 2009;66:51–63).

They assessed 20 women recruited from an eating disorders clinic and 20 healthy control subjects matched for body mass index and age (average, 26 years). All underwent fMRI imaging while performing the Simon spatial incompatibility task to compare differences between the group in brain activation patterns associated with self-regulatory control.

The bulimia patients made significantly more errors on the task than did controls, and their accuracy decreased further over time. Those with the most severe bulimia symptoms made the most errors.

Compared with controls, bulimia patients showed deficits in the activation of circuits in the brain's left side (the inferolateral prefrontal cortex and the left lenticular nucleus) and in the right side (the ventral and dorsal anterior cingulate cortex, the putamen, and the caudate nucleus).

“Deficient cortical activation likely accounted for their more impulsive, error-prone performances, compared with controls,” the authors wrote. “These deficits may be caused by previously reported decreases in serotonin metabolism in frontal cortices in [bulimics].”

The differences between the groups were independent of IQ, depression, and ADHD rating instruments.

KEYSTONE, COLO. – Red flags for disturbed eating behavior in adolescent girls with type 1 diabetes include a persistently high glycosylated hemoglobin level, frequent episodes of diabetic ketoacidosis, and behaviors such as skipping insulin doses or underdosing in order to control weight, according to one expert.

Another warning sign is a pattern of skipping breakfast and/or lunch, followed by binge eating throughout the evening, Rita Temple-Trujillo said at a conference on the management of diabetes in youth. Distress about body weight and shape is also common among affected individuals, but it's a nonspecific indicator.

“It's rare that I see girls who don't have concern about body image. We're a weight-obsessed culture,” said Ms. Temple-Trujillo, a clinical social worker at the Barbara Davis Center for Childhood Diabetes, which cosponsored the conference with the University of Colorado and the Children's Diabetes Foundation at Denver.

Pressed by a physician in the audience for a few quick screening questions to help zero in on disturbed eating behavior in adolescent girls with diabetes, Ms. Temple-Trujillo's fellow panelist, Dr. Denis Daneman, suggested asking the following:

▸ Are you manipulating your insulin by omission or by changing the dose in order to control your weight?

▸ Are you dieting at the moment to control your weight?

▸ Are you exercising specifically to control your weight?

▸ Are you doing any other things specifically to control your weight?

“Those four questions, if you get honest answers, will probably give you most of the information you need,” said Dr. Daneman, professor and chair of the department of pediatrics at the University of Toronto and pediatrician-in-chief at the Hospital for Sick Children there.

But getting honest answers is a challenge because diabetic youths with disturbed eating behaviors feel great shame and a reluctance to disclose the details, according to Ms. Temple-Trujillo.

KEYSTONE, COLO. – Red flags for disturbed eating behavior in adolescent girls with type 1 diabetes include a persistently high glycosylated hemoglobin level, frequent episodes of diabetic ketoacidosis, and behaviors such as skipping insulin doses or underdosing in order to control weight, according to one expert.

Another warning sign is a pattern of skipping breakfast and/or lunch, followed by binge eating throughout the evening, Rita Temple-Trujillo said at a conference on the management of diabetes in youth. Distress about body weight and shape is also common among affected individuals, but it's a nonspecific indicator.

“It's rare that I see girls who don't have concern about body image. We're a weight-obsessed culture,” said Ms. Temple-Trujillo, a clinical social worker at the Barbara Davis Center for Childhood Diabetes, which cosponsored the conference with the University of Colorado and the Children's Diabetes Foundation at Denver.

Pressed by a physician in the audience for a few quick screening questions to help zero in on disturbed eating behavior in adolescent girls with diabetes, Ms. Temple-Trujillo's fellow panelist, Dr. Denis Daneman, suggested asking the following:

▸ Are you manipulating your insulin by omission or by changing the dose in order to control your weight?

▸ Are you dieting at the moment to control your weight?

▸ Are you exercising specifically to control your weight?

▸ Are you doing any other things specifically to control your weight?

“Those four questions, if you get honest answers, will probably give you most of the information you need,” said Dr. Daneman, professor and chair of the department of pediatrics at the University of Toronto and pediatrician-in-chief at the Hospital for Sick Children there.

But getting honest answers is a challenge because diabetic youths with disturbed eating behaviors feel great shame and a reluctance to disclose the details, according to Ms. Temple-Trujillo.

KEYSTONE, COLO. – Red flags for disturbed eating behavior in adolescent girls with type 1 diabetes include a persistently high glycosylated hemoglobin level, frequent episodes of diabetic ketoacidosis, and behaviors such as skipping insulin doses or underdosing in order to control weight, according to one expert.

Another warning sign is a pattern of skipping breakfast and/or lunch, followed by binge eating throughout the evening, Rita Temple-Trujillo said at a conference on the management of diabetes in youth. Distress about body weight and shape is also common among affected individuals, but it's a nonspecific indicator.

“It's rare that I see girls who don't have concern about body image. We're a weight-obsessed culture,” said Ms. Temple-Trujillo, a clinical social worker at the Barbara Davis Center for Childhood Diabetes, which cosponsored the conference with the University of Colorado and the Children's Diabetes Foundation at Denver.

Pressed by a physician in the audience for a few quick screening questions to help zero in on disturbed eating behavior in adolescent girls with diabetes, Ms. Temple-Trujillo's fellow panelist, Dr. Denis Daneman, suggested asking the following:

▸ Are you manipulating your insulin by omission or by changing the dose in order to control your weight?

▸ Are you dieting at the moment to control your weight?

▸ Are you exercising specifically to control your weight?

▸ Are you doing any other things specifically to control your weight?

“Those four questions, if you get honest answers, will probably give you most of the information you need,” said Dr. Daneman, professor and chair of the department of pediatrics at the University of Toronto and pediatrician-in-chief at the Hospital for Sick Children there.

But getting honest answers is a challenge because diabetic youths with disturbed eating behaviors feel great shame and a reluctance to disclose the details, according to Ms. Temple-Trujillo.