J. psychiat.
Rev..
1975,
Vol.
12, pp. 59-68.
Pergamon
Press.
Printed
in Great
Britain.
MEASUREMENT OF APPETITE DISTURBANCES IN PSYCHIATRIC DISORDERS* R. G. ROBINSON,? P. R. MCHUGH$ and M. F. FOLSTEIN Cornell University Medical Center, New York Hospital, Westchester Division, White Plains, New York 10605 and Department of Psychiatry, University of Oregon Medical School, Portland, Oregon 97201, U.S.A. (Received8
Febtwmy 1974; iu reviscd,form 7 Nownber
1974)
INTRODUCTION
in feeding sufficient to change body weight accompany several mental disorders. Depressed patients often lose weight, manic patients often gain weight and considerable weight increase may complicate phenothiazine treatment in schizophrenia. Although it is a clinical presumption that the altered feeding is due to changes in the patient’s hunger or sense of appetite for food, there are no systematic studies of hunger in psychiatric patients. Some of the reasons for this involve arguments over just how to define such a subjective experience as hunger and then design an instrument to measure it. Recently, self-rating visual analogue scales have been employed to quantify such inner psychic states as emotions.1-3 These scales resolve the problem of definition by accepting both the patient’s own understanding of the meaning of such words as fear or depression, for his subjective experiences, and his own appreciation of the change of these emotions within him. Thus a visual analogue scale gives a quantitative score to a subjective feeling and also avoids arguments about the definition of that feeling. The scores may then be evaluated for reliability and validity in traditional ways and employed in clinical situations.3-5 JORDAN et aL4 and SILVERSTONE and STIINKARD~ have demonstrated that such scales can validly measure subjective appetite in normal people. In order to quantitatively study the role of hunger in the feeding changes of psychiatric patients a self rating visual analogue appetite scale was designed. The current study reports its reliability and validity in both normals and psychiatric patients as well as its application to the study of appetite in groups of psychiatric patients with alterations of feeding and body weight. ALTERATIONS
METHODS
Subjects were selected from the staff and the inpatient population of the New York Hospital-Westchester Division, a private University psychiatric hospital in White Plains, New York. See Table 1 for characteristics of the patient sample and diagnostic criteria. Only patients who clearly met the diagnostic criteria were chosen. * This study was partially supported by Grant 2 TO1 MHllOOO-06 from the National institute of Mental Health. t Currently Research Associate, National Institute of Mental Health, St. Elizabeth’s Hospital, Washington, D.C., U.S.A. $ Currently Professor and Chairman, Department of Psychiatry, University of Oregon Medical School, Portland, Oregon, U.S.A. 59
60
R. G. ROBINSON,P. R. MCHLJGI~and M. F. FOLSTEIN TABLE1. DESCRIPTIONOFEXPERIMENTAL SUBJECTS Staff
(&
Patients? Schizophrenics
10
Manics Endogenous
8 depressives
Neurotic-personality
6
disorders
8
Sex (13M) (5F)
Age (Median 30) (Range 2638)
6M 4F 4M 4F 4M 2F 4M 4F
Median 26 Range 17-45 Median 34 Range 2145 Median 45’ Range 23-56 Median 26 Range 17-45
* Statistically different from non-depressives p < 0.01. f The diagnostic criteria used were as follows: mania was diagnosed as an intermittent disorder characterized by inflated self attitude, possibly reflected in delusionary thinking, elated mood and increase in bodily activity; endogenous depression was diagnosed as an intermittent disorder characterized by self-depreciation, possibly reflected in delusionary thinking, sad mood and change of bodily functioning, such as motor retardation, or early morning awakening. Schizophrenia was diagnosed when the above criterion were not met but hallucinations and or delusions were present or when a change in life course was followed by personality dilapidation. Neurotic personality disorders were diagnosed when none of the above criterion were met and when major psychological symptoms could be attributed to environmental precipitants or a vulnerable character.
The visual analogue appetite scale (VAAS) was a slip of paper 100 x 40 mm on which there was a 100 mm line. Above this line was printed, “How is your appetite right now? A mark to the right indicates your greatest appetite and a mark to the left your poorest appetite.” Scores were determined by measuring the distance in millimeters from the left hand edge of the line to the patient’s mark. The date and time of testing were written on the slip immediately after the patient had completed it. The parameters used to measure food intake are described in the experiments below. Patients were weighed weekly, in the morning just after waking. Standard statistical methods were used to analyze the data. RESULTS
Validity experiments If the VAAS is a valid measure of hunger it should correlate with and predict the amount of subsequent food intake. Eighteen staff members were asked to rate their appetite before purchasing lunch at the hospital cafeteria and again after eating. The cost of their lunch was independently sought out. Both appetite score before the meal and the change in appetite score produced by the meal were found to correlate with its cost. (Fig. 1). All correlation coefficients are shown in Table 2. The validity in the patient group was determined by utilizing a standard diet. Ten patients (3 with affective disorders; 3 schizophrenics; 2 receiving > 1500 mg chlorpromazine/day; 4 with neurotic-personality disorders) were asked to eat only Carnation Instant Breakfast for three meals for 1 day. Patients marked an appetite slip before and after each meal and were allowed an unlimited supply of instant breakfast, As with normals, both VAAS score
MEASUREMENT OF APPETITEDISTURBANCES IN PSYCHIATRICDISORDERS VAAS
SCORE
BEFORE
MEAL
YS COST
OF
61
MEAL
l Initial experiment 0 Retest l 0
:
.
0
0
0
0
l
.
.
0
0’
l*
l
0
0
00 0
0
0
0
20 -
0
0
”
.20
”
.40
”
.60
”
.80
”
1.00
”
1.20
”
1.40
Cost of meal in dollars
FIG. I. Appetite (VAAS)
score before lunch vs cost of the meal in normals. Note the overlap of scores during the initial experiment and retest. TABLE 2. CORRELATIONCOEFFICIENTS
Staff VAAS before meal vs cost of meal Change of VAAS during meal vs cost of meal Test-retest during fast Patients VAAS before meal vs number of packets eaten Change of VAAS during meal vs number of packets eaten Average VAAS before all meals vs total number of packets eaten Test-retest during fast
R 0.77* 0.58p 0.92* 0.53.r 0.63’ 0.84* 0.92”
“p < 0.001. ? P < 0.005.
before the meal and amount of change in VAAS score produced by the meal correlated with the meal size (Fig. 2). Additionally the average VAAS score before the three instant breakfast meals showed a high correlation with the total daily intake. A valid measurement of appetite should change over time in an understandable way, Seven staff members and the 10 previously mentioned patients were asked to mark a VAAS slip each hour for 1 day. VAAS scores increased between meals and sharply decreased after meals. Hourly scores followed the same general pattern in all subjects. An individual example from a staff member is shown in Fig. 3. Previous investigators, utilizing self-rating analog scales, have also reported in normal subjects similar fluctuations in appetite throughout the day.6*7 ReliabilitJj experiments
If the VAAS is a reliable measure of appetite it should remain unchanged under constant conditions. Eighteen staff members and the 10 patients already described rated their
62
R. G. ROBINSON,I?. R. MCHUGH and M. F. FOLSTEIN IlEAN VAAS SCORE BEFORE hlEAL vs NUMBfR OF INSTANT BREAKFASTS CONSUI.\ED
o
/
I
j
I
I
I 2 3 4 Number of pdcketsconsumed
5
FIG. 2. Appetite (VAAS) score before meals vs number of packets of instant breakfast consumed patient group. See text for patient group composition. Bars indicate SEM.
VAAS
SCORE
vs ACTUAL
in a
TIME dinner
::
.
..: . j ‘ .
.
.
.
.
or 8
10
12 am
FIG. 3. Appetite fluctuations
appetite at a I-hr interval correlation (Table 2).
1 pm
2
.
.
4
6
at hourly intervals throughout indicate meals.
during
a fasting
8
10
12
Time
period.
the day in a normal subject. Vertical bars
The test-retest
scores showed
a high
63
MEASUREMENT OF APPETITE DISTURBANCES IN PSYCHIATRIC DISORDERS
Clinical studies Descriptions and numbers of patients used in the clinical studies are listed in Table I. Every patient marked a VAAS slip at noon each day prior to eating lunch for 3-12 weeks. Daily VAAS score was determined for each patient. Additionally, some patients marked VAAS slips at hourly intervals throughout the day for one or more days. Results will be presented for each diagnostic category. (I) Endogenous depression. Patients with endogenous depressions had the lowest VAAS scores of any diagnostic group (Table 3, Fig. 4). Three-week mean VAAS scores for each TABLE 3. MEAN WEEKLY APPETITESCORESFOR EACH DIAGNOSTIC CATEGORY
Week
Mania Schizophrenia high dose phenothiazine Schizophrenia low dose phenothiazine Neurotic-personality disorder Endogenous depression
1 Mean _____ Wkly. VAAS SEM 795 7
2 Mean
3 Mean
Wkly. VAAS SEM 815 7
Wkly. VAAS 793
SEM 7
4 Mean ______ Wkly. VAAS SEM -
5 Mean -___Wkly. VAAS SEM -
76%
7
789
4
78”
9
SO:
6
69
9
53
5
61
2
56
3
59
3
59
3
5 7
48 178
5 5
50 21s
6 2
53 -
7
50 -
6
Z$
For statistical calculations all VAAS scores were compared with those of the neurotic-personality group. * p < 0.02. tP < 0.01. 1 p < 0.005. pp -=C0.001.
disorder
patient and his medication regimen are shown in Fig. 5. Note the markedly low appetite scores of the entire group. Hourly VAAS slips revealed that patients with endogenous depressions, although their appetite scores were quantitatively lower than normals, had a normal pattern of appetite fluctuations. As an example, appetite scores during the illness and recovery period are illustrated in Fig. 6 for a single patient with endogenous depression. This example shows the same pattern of rises and falls in appetite from meal to meal as found in normals but with quantitative improvement during recovery. The markedly low VAAS scores in endogenous depressives were reflected in continuing weight loss during the 3-week test period (Fig. 7). (2) Mania. Manic patients and schizophrenic patients on high dose chlorpromazine had the highest group mean appetite scores (Table 3). Three-week mean VAAS scores plus medication regimen for each patient are shown in Fig. 5. Note that although three manic patients received chlorpromazine in dosages up to 600 mg/day in addition to lithium carbonate, the VAAS scores of these patients were indistinguishable from those manic patients who were receiving only lithium. As in patients with endogenous depression, the
64
R. G. RCWNSON, P. R. MCHUGH and M. F. FOLSTEIN
r
100
Schizophrenia, high dos$phenothiazine -
En$ogenousdepression
00 FIG. 4. Mean
weekly
appetite
Weeks in hospital
scores for separate diagnostic groups determined at lunchtime vs number of weeks in hospital. Bars indicate SEM.
MIAN WECK1.Y CATEGORY
I
Mania
20
0
I
VAAS
SCORES
“s
SchizophreniaI Neuroticpersonality disorder
Mania: l Lithium carbonate 0 Lithium carbonate + chlorpromazine Sshizophrenia: . Pheno!hiazine, 0 Chlorprorw:inc.
DIAGNOSTIC
:_
u
l
Endoyenaus depression -600mgiday
IGI: dsse; chlorpromazine;‘8M)myiday 1.509mgicby
Neurotic per sonaliiy disorder: Prrr medications only. nu phenothidzines
t ndogcrwu5
depression: l lmlpramine hydrochloride.. 300mqlday 0 I.ithiunl carbon& 4 Imiprdmlne
FIG.
5.
Three week mean appetite scores for individual patients with their medication are separated by diagnostic category.
regimen.
patients
MEASUREMENT OF APPETITEDISTURBANCES IN PSYCHIATRIC DLKNDERS VAAS
SCORE
vs ACTUAL
TIME dinner
lunch
:< /
? j: ..’~ .~
8
d
65
o Endogenous depression l
Recovered*
I
I
10
i
10
8
am ’ pm
Time
FIG. 6. Appetite (VAAS) scores at hourly intervals throughout the day in a patient with an endogenous depression and repeated during the recovery period. * Recovery period was defined as when the treating physician, staff, and the patient’s family all agreed that the patient was either completely well or greatly improved.
hourly pattern of appetite scores was the same as normals but in manic patients the scores were quantitatively higher. This increased appetite was reflected by a marked weight gain in these patients (Fig. 7).
high
dose phenothiazine
Schizophrenia, low dose phenothiazine
-5
0
I 1
I 2
Eidogenous I 3 Weeks in hospital
depression I 4
5
FIG. 7. Cumulative change in body weight during the test period. Weight change paralleled appetite scores.
(3) Schizophrenia. Schizophrenic patients receiving large amounts of phenothiazines, that is, greater than 1500 mg of chlorpromazine daily, formed, on the basis of their appetite
66
R. G.
ROBINSON, P. R. MCHUGH and M. F. FOLSTEIN
scores, a group distinct from those schizophrenic patients receiving low doses of phenothiazines, that is, less than 800 mg of chlorpromazine or 30 mg of trifluoperazine daily. This may be seen graphically in Fig. 5 where 3-week mean VAAS scores and medication regimen are shown for each patient. As a group, those patients being treated with high dose chlorpromazine had appetite scores as high as manic patients while those schizophrenics receiving low dose phenothiazines had mid-range appetite scores (Table 3). The hourly pattern of appetite scores, as with patients in other diagnostic categories, were not qualitatively different from normals but were quantitatively elevated in those patients receiving high dose phenothiazines. Patients receiving large amounts of chlorpromazine showed a marked weight gain equal to that of manic patients while those patients receiving low dose phenothiazines gained comparatively little weight during the same period (Fig. 7). (4) Neurotic-personality disorder. The VAAS scores of patients with neurotic-personality disorders were midrange as were normals and schizophrenic patients on low dose phenothiazines (Fig. 4). Three week mean VAAS scores for individual patients are shown in Fig. 5. The hourly pattern of appetite scores did not differ qualitatively or quantitatively from normals and the midrange appetites of patients with neurotic-personality disorders were reflected in the lack of weight change during the experimental period. DISCUSSION
This study was undertaken in an effort to investigate appetite disturbances in psychiatric patients using a method of self quantification of hunger. The visual analogue appetite scale, chosen for its ease and simplicity, was demonstrated to be a valid and reliable guide to appetite in human subjects. In both normals and psychiatric patients the VAAS score correlated with and partially predicted the size and cost of meals that were eaten. The VAAS score fluctuated in a rhythm around meals throughout the day and changed in the expected way from hour to hour before and after eating. The VAAS demonstrated that manic and schizophrenic patients on high doses of phenothiazines have increased appetites, patients with endogenous depressions have decreased appetites, and patients with neurotic personality disorders and schizophrenic patients on low doses of phenothiazines had appetite scores that fell between these extremes. These appetite findings were significant since changes in these patients’ body weights conformed with the differences in their VAAS scores (Fig. 7). Schizophrenic patients receiving high doses of chlorpromazine showed in this study a distinct phenomenon of marked increase in appetite. These patients were given high doses of chlorpromazine because they were the most severely ill being delusional with hallucinations. The question arises whether the elevated appetite is a result of the medication or the severity of the schizophrenic illness. There are two lines of evidence which tend to indicate that the chlorpromazine was responsible for the appetite disturbance. First, the more severely ill patient would be expected to be preoccupied with his delusions and distracted from hunger. But, in fact, the severely ill schizophrenics had much greater appetites than the milder schizophrenics who received only low doses of phenothiazines. Secondly, the VAAS scores of these patients became elevated only after they started receiving high doses of chlorpromazine and, if the phenothiazines were continued, remained elevated even when the patient was no longer so disturbed.
MEAsuREhlENTOF APPETITEDIWURBANCESIN PSYCHIATRIC DISORDERS
6-l
The observation that phenothiazines cause weight gain in schizophrenic patients, which is confirmed in the present study, is a well documented clinical phenomenon.*-l1 The mechanism by which phenothiazines cause weight gain, however, has been a matter of debate. Previous investigators, however, have hypothesized such mechanisms as fluid retention12 or decreased caloric need due to tranquillization and immobility. Although we cannot rule out the possibility of these other mechanisms contributing to weight gain, there was no clinical evidence in the current study to support any process other than increased appetite for food and a resultant increased food intake. Laboratory animals administered chlorpromazine both chronically and acutely have also increased their food intake and gained weight.13-l5 The cause of the increased appetite with phenothiazines is likely to be a direct central nervous system effect of the medication most likely due to the drugs effect on CNS biogenic amines.lGW1* The observation of increased appetite in schizophrenic patients receiving high doses of phenothiazines is a phenomenon that could be profitably studied further; particularly a search for a blocking agent to interrupt this increased appetite might assist in the study of the particular central nervous system mechanisms affected by this drug. The VAAS slip would be a useful clinical instrument in such a study. SUMMARY
A visual analogue scale was used for the self rating of appetite in 18 normals and 32 psychiatric patients. Appetite scores were shown to correlate with quantity of food intake, to fluctuate in the expected manner in relation to meals, and at an hourly interval to be a reliable measurement in both the normal and patient populations. Patients, chosen for their clarity of diagnosis, marked appetite slips either once/day for several weeks or once/hr for 1 or more days. All diagnostic groups showed the same general pattern of appetite scores changing in relation to meals. However, quantitative differences were found among different diagnostic groups. Schizophrenic patients receiving high doses of chlorpromazine and manic patients had the highest appetite scores, schizophrenic patients receiving low doses of phenothiazines and patients with neurotic personality disorders had appetite scores which ranked in the middle while patients with an endogenous depression had the lowest rank appetite scores. Both quantity of food intake and body weight change correlated with appetite scores. The elevation of appetite noted in schizophrenic patients receiving high doses of phenothiazines was thought to be an effect of the medication and to be mainly responsible for the marked weight gain. It was recommended that further research proceed along the lines of delineating central nervous system mechanisms involved in chlorpromazine induced hunger. AckrzOwZedgenzents-The authors would like to thank the nursing personnel of Hall 6W and Nichols Cottage and the volunteers at the New York Hospital, Westchester Division for their valuable help in data collection and analysis. We also gratefully acknowledge the help of Miss HELEN GOODELLwith manuscript editing and review. REFERENCES 1. AITKEN,R. C. Measurements of feelings using visual analogue scales. Proc. Roy. Sot. Med. 62,989,1969. 2. AITKEN, R. C., ZEALLEY,A. K. and ROSENTHAL,S. V. Psychological measures of emotion in chronic asthmatic patients. J. Ps@zosom. Res. 13,298, 1969.
68
R. G. ROBINSON,P. R. MCHUGH and M. F. FOLSTEIN
3. FOLSTEIN,M. F. and LURIA, R. Reliability, validity and clinical application of the visual analogue mood scale. P&zol. Med. In press. 4. JORDAN,H. A., WIELAND, W. F., ZEBLEY,S. P., STELLAR,E. and STUNKARD,A. J. Direct measurement of food intake in man: A method for the objective study of eating behavior. Psychosom. Med. 28,
836, 1966. 5. SILVERSTONE,J. T. and STUNKARD, A. J. The anorectic effect of dexamphetamine sulphate. Br. J. Pharmac. Chemother. 33,513, 1968. 6. STUNKARQ A. J. and Fox, S. The relationship of gastric motility and hunger. Psychosom. Med. 33,123, 1971. 7. BLOOM,P. B., FILION,R. D. L., STUNKARD,A. J., Fox, S. and STELLAR,E. Gastric and duodenal motility, food intake and hunger measured in man during a 24-hr period. Am. J. Dig. Dis. 15,719, 1970. 8. PLANANSKY,K. Changes in weight in patients receiving a “tranquilizing” drug. Psychiat. Qr. 32, 289, 1958. ___-.
9. CAFFEY,E. M. Experience with large scale interhospital co-operative research in chemotherapy. Am. J. Psychiat. 117,713, 1971. 10. CAFFEY,E. M. and KLE~, C. J. Side effects and laboratory findings during combined drug therapy of chronic schizophrenics. Dis. Nerv. Syst. 22, 370, 1961. 11. GORDON, H. L. and GROTH, C. Weight change during and after hospital treatment. Archs gen. Psychiat. 10,187, 1964. 12. SLET~N, I. W. and GERSHON,S. The effect of chlorpromazine on water and electrolyte balance. J. Nerv. Ment. Dis. 142,25, 1966. 13. Bovo, E. M. Chlorpromazine tolerance and physical dependence. 1. Pharmac. exp. Ther. 128,75, 1960. 14. REYNOLDS,R. W. and CARLISLE,H. J. The effect of chlorpromazine on food intake in the albino rat. J. Camp. Physiol. Psychol. 54,354, 1961. 15. STOLERMAN,I. P. Eating, drinking and spontaneous activity in rats after the administration of chlorpromazine. Neuropharmac. 9,405, 1970. 16. LE~OWITZ, S. F. and MILLER, N. E. Unexpected adrenergic effect of chlorpromazine: Eating elicited by injection into rat hypothalamus. Science 165, 609, 1969. 17. FIBINGER,H. C., ZIS, A. P. and MCGEER, E. G. Feeding and drinking deficits after 6-hydroxydopamine administration in the rat: Similarities to the lateral hypothalamic syndrome. Brain Res. 55, 135, 1973. 18. UNGERSTEDT,U. Adipsia and aphagia after 6-hydroxydopamine induced degeneration of the nigrostriatal dopamine system. Acta. Physiol. stand. Suppl. 367, 95, 1971.
Rev..
1975,
Vol.
12, pp. 59-68.
Pergamon
Press.
Printed
in Great
Britain.
MEASUREMENT OF APPETITE DISTURBANCES IN PSYCHIATRIC DISORDERS* R. G. ROBINSON,? P. R. MCHUGH$ and M. F. FOLSTEIN Cornell University Medical Center, New York Hospital, Westchester Division, White Plains, New York 10605 and Department of Psychiatry, University of Oregon Medical School, Portland, Oregon 97201, U.S.A. (Received8
Febtwmy 1974; iu reviscd,form 7 Nownber
1974)
INTRODUCTION
in feeding sufficient to change body weight accompany several mental disorders. Depressed patients often lose weight, manic patients often gain weight and considerable weight increase may complicate phenothiazine treatment in schizophrenia. Although it is a clinical presumption that the altered feeding is due to changes in the patient’s hunger or sense of appetite for food, there are no systematic studies of hunger in psychiatric patients. Some of the reasons for this involve arguments over just how to define such a subjective experience as hunger and then design an instrument to measure it. Recently, self-rating visual analogue scales have been employed to quantify such inner psychic states as emotions.1-3 These scales resolve the problem of definition by accepting both the patient’s own understanding of the meaning of such words as fear or depression, for his subjective experiences, and his own appreciation of the change of these emotions within him. Thus a visual analogue scale gives a quantitative score to a subjective feeling and also avoids arguments about the definition of that feeling. The scores may then be evaluated for reliability and validity in traditional ways and employed in clinical situations.3-5 JORDAN et aL4 and SILVERSTONE and STIINKARD~ have demonstrated that such scales can validly measure subjective appetite in normal people. In order to quantitatively study the role of hunger in the feeding changes of psychiatric patients a self rating visual analogue appetite scale was designed. The current study reports its reliability and validity in both normals and psychiatric patients as well as its application to the study of appetite in groups of psychiatric patients with alterations of feeding and body weight. ALTERATIONS
METHODS
Subjects were selected from the staff and the inpatient population of the New York Hospital-Westchester Division, a private University psychiatric hospital in White Plains, New York. See Table 1 for characteristics of the patient sample and diagnostic criteria. Only patients who clearly met the diagnostic criteria were chosen. * This study was partially supported by Grant 2 TO1 MHllOOO-06 from the National institute of Mental Health. t Currently Research Associate, National Institute of Mental Health, St. Elizabeth’s Hospital, Washington, D.C., U.S.A. $ Currently Professor and Chairman, Department of Psychiatry, University of Oregon Medical School, Portland, Oregon, U.S.A. 59
60
R. G. ROBINSON,P. R. MCHLJGI~and M. F. FOLSTEIN TABLE1. DESCRIPTIONOFEXPERIMENTAL SUBJECTS Staff
(&
Patients? Schizophrenics
10
Manics Endogenous
8 depressives
Neurotic-personality
6
disorders
8
Sex (13M) (5F)
Age (Median 30) (Range 2638)
6M 4F 4M 4F 4M 2F 4M 4F
Median 26 Range 17-45 Median 34 Range 2145 Median 45’ Range 23-56 Median 26 Range 17-45
* Statistically different from non-depressives p < 0.01. f The diagnostic criteria used were as follows: mania was diagnosed as an intermittent disorder characterized by inflated self attitude, possibly reflected in delusionary thinking, elated mood and increase in bodily activity; endogenous depression was diagnosed as an intermittent disorder characterized by self-depreciation, possibly reflected in delusionary thinking, sad mood and change of bodily functioning, such as motor retardation, or early morning awakening. Schizophrenia was diagnosed when the above criterion were not met but hallucinations and or delusions were present or when a change in life course was followed by personality dilapidation. Neurotic personality disorders were diagnosed when none of the above criterion were met and when major psychological symptoms could be attributed to environmental precipitants or a vulnerable character.
The visual analogue appetite scale (VAAS) was a slip of paper 100 x 40 mm on which there was a 100 mm line. Above this line was printed, “How is your appetite right now? A mark to the right indicates your greatest appetite and a mark to the left your poorest appetite.” Scores were determined by measuring the distance in millimeters from the left hand edge of the line to the patient’s mark. The date and time of testing were written on the slip immediately after the patient had completed it. The parameters used to measure food intake are described in the experiments below. Patients were weighed weekly, in the morning just after waking. Standard statistical methods were used to analyze the data. RESULTS
Validity experiments If the VAAS is a valid measure of hunger it should correlate with and predict the amount of subsequent food intake. Eighteen staff members were asked to rate their appetite before purchasing lunch at the hospital cafeteria and again after eating. The cost of their lunch was independently sought out. Both appetite score before the meal and the change in appetite score produced by the meal were found to correlate with its cost. (Fig. 1). All correlation coefficients are shown in Table 2. The validity in the patient group was determined by utilizing a standard diet. Ten patients (3 with affective disorders; 3 schizophrenics; 2 receiving > 1500 mg chlorpromazine/day; 4 with neurotic-personality disorders) were asked to eat only Carnation Instant Breakfast for three meals for 1 day. Patients marked an appetite slip before and after each meal and were allowed an unlimited supply of instant breakfast, As with normals, both VAAS score
MEASUREMENT OF APPETITEDISTURBANCES IN PSYCHIATRICDISORDERS VAAS
SCORE
BEFORE
MEAL
YS COST
OF
61
MEAL
l Initial experiment 0 Retest l 0
:
.
0
0
0
0
l
.
.
0
0’
l*
l
0
0
00 0
0
0
0
20 -
0
0
”
.20
”
.40
”
.60
”
.80
”
1.00
”
1.20
”
1.40
Cost of meal in dollars
FIG. I. Appetite (VAAS)
score before lunch vs cost of the meal in normals. Note the overlap of scores during the initial experiment and retest. TABLE 2. CORRELATIONCOEFFICIENTS
Staff VAAS before meal vs cost of meal Change of VAAS during meal vs cost of meal Test-retest during fast Patients VAAS before meal vs number of packets eaten Change of VAAS during meal vs number of packets eaten Average VAAS before all meals vs total number of packets eaten Test-retest during fast
R 0.77* 0.58p 0.92* 0.53.r 0.63’ 0.84* 0.92”
“p < 0.001. ? P < 0.005.
before the meal and amount of change in VAAS score produced by the meal correlated with the meal size (Fig. 2). Additionally the average VAAS score before the three instant breakfast meals showed a high correlation with the total daily intake. A valid measurement of appetite should change over time in an understandable way, Seven staff members and the 10 previously mentioned patients were asked to mark a VAAS slip each hour for 1 day. VAAS scores increased between meals and sharply decreased after meals. Hourly scores followed the same general pattern in all subjects. An individual example from a staff member is shown in Fig. 3. Previous investigators, utilizing self-rating analog scales, have also reported in normal subjects similar fluctuations in appetite throughout the day.6*7 ReliabilitJj experiments
If the VAAS is a reliable measure of appetite it should remain unchanged under constant conditions. Eighteen staff members and the 10 patients already described rated their
62
R. G. ROBINSON,I?. R. MCHUGH and M. F. FOLSTEIN IlEAN VAAS SCORE BEFORE hlEAL vs NUMBfR OF INSTANT BREAKFASTS CONSUI.\ED
o
/
I
j
I
I
I 2 3 4 Number of pdcketsconsumed
5
FIG. 2. Appetite (VAAS) score before meals vs number of packets of instant breakfast consumed patient group. See text for patient group composition. Bars indicate SEM.
VAAS
SCORE
vs ACTUAL
in a
TIME dinner
::
.
..: . j ‘ .
.
.
.
.
or 8
10
12 am
FIG. 3. Appetite fluctuations
appetite at a I-hr interval correlation (Table 2).
1 pm
2
.
.
4
6
at hourly intervals throughout indicate meals.
during
a fasting
8
10
12
Time
period.
the day in a normal subject. Vertical bars
The test-retest
scores showed
a high
63
MEASUREMENT OF APPETITE DISTURBANCES IN PSYCHIATRIC DISORDERS
Clinical studies Descriptions and numbers of patients used in the clinical studies are listed in Table I. Every patient marked a VAAS slip at noon each day prior to eating lunch for 3-12 weeks. Daily VAAS score was determined for each patient. Additionally, some patients marked VAAS slips at hourly intervals throughout the day for one or more days. Results will be presented for each diagnostic category. (I) Endogenous depression. Patients with endogenous depressions had the lowest VAAS scores of any diagnostic group (Table 3, Fig. 4). Three-week mean VAAS scores for each TABLE 3. MEAN WEEKLY APPETITESCORESFOR EACH DIAGNOSTIC CATEGORY
Week
Mania Schizophrenia high dose phenothiazine Schizophrenia low dose phenothiazine Neurotic-personality disorder Endogenous depression
1 Mean _____ Wkly. VAAS SEM 795 7
2 Mean
3 Mean
Wkly. VAAS SEM 815 7
Wkly. VAAS 793
SEM 7
4 Mean ______ Wkly. VAAS SEM -
5 Mean -___Wkly. VAAS SEM -
76%
7
789
4
78”
9
SO:
6
69
9
53
5
61
2
56
3
59
3
59
3
5 7
48 178
5 5
50 21s
6 2
53 -
7
50 -
6
Z$
For statistical calculations all VAAS scores were compared with those of the neurotic-personality group. * p < 0.02. tP < 0.01. 1 p < 0.005. pp -=C0.001.
disorder
patient and his medication regimen are shown in Fig. 5. Note the markedly low appetite scores of the entire group. Hourly VAAS slips revealed that patients with endogenous depressions, although their appetite scores were quantitatively lower than normals, had a normal pattern of appetite fluctuations. As an example, appetite scores during the illness and recovery period are illustrated in Fig. 6 for a single patient with endogenous depression. This example shows the same pattern of rises and falls in appetite from meal to meal as found in normals but with quantitative improvement during recovery. The markedly low VAAS scores in endogenous depressives were reflected in continuing weight loss during the 3-week test period (Fig. 7). (2) Mania. Manic patients and schizophrenic patients on high dose chlorpromazine had the highest group mean appetite scores (Table 3). Three-week mean VAAS scores plus medication regimen for each patient are shown in Fig. 5. Note that although three manic patients received chlorpromazine in dosages up to 600 mg/day in addition to lithium carbonate, the VAAS scores of these patients were indistinguishable from those manic patients who were receiving only lithium. As in patients with endogenous depression, the
64
R. G. RCWNSON, P. R. MCHUGH and M. F. FOLSTEIN
r
100
Schizophrenia, high dos$phenothiazine -
En$ogenousdepression
00 FIG. 4. Mean
weekly
appetite
Weeks in hospital
scores for separate diagnostic groups determined at lunchtime vs number of weeks in hospital. Bars indicate SEM.
MIAN WECK1.Y CATEGORY
I
Mania
20
0
I
VAAS
SCORES
“s
SchizophreniaI Neuroticpersonality disorder
Mania: l Lithium carbonate 0 Lithium carbonate + chlorpromazine Sshizophrenia: . Pheno!hiazine, 0 Chlorprorw:inc.
DIAGNOSTIC
:_
u
l
Endoyenaus depression -600mgiday
IGI: dsse; chlorpromazine;‘8M)myiday 1.509mgicby
Neurotic per sonaliiy disorder: Prrr medications only. nu phenothidzines
t ndogcrwu5
depression: l lmlpramine hydrochloride.. 300mqlday 0 I.ithiunl carbon& 4 Imiprdmlne
FIG.
5.
Three week mean appetite scores for individual patients with their medication are separated by diagnostic category.
regimen.
patients
MEASUREMENT OF APPETITEDISTURBANCES IN PSYCHIATRIC DLKNDERS VAAS
SCORE
vs ACTUAL
TIME dinner
lunch
:< /
? j: ..’~ .~
8
d
65
o Endogenous depression l
Recovered*
I
I
10
i
10
8
am ’ pm
Time
FIG. 6. Appetite (VAAS) scores at hourly intervals throughout the day in a patient with an endogenous depression and repeated during the recovery period. * Recovery period was defined as when the treating physician, staff, and the patient’s family all agreed that the patient was either completely well or greatly improved.
hourly pattern of appetite scores was the same as normals but in manic patients the scores were quantitatively higher. This increased appetite was reflected by a marked weight gain in these patients (Fig. 7).
high
dose phenothiazine
Schizophrenia, low dose phenothiazine
-5
0
I 1
I 2
Eidogenous I 3 Weeks in hospital
depression I 4
5
FIG. 7. Cumulative change in body weight during the test period. Weight change paralleled appetite scores.
(3) Schizophrenia. Schizophrenic patients receiving large amounts of phenothiazines, that is, greater than 1500 mg of chlorpromazine daily, formed, on the basis of their appetite
66
R. G.
ROBINSON, P. R. MCHUGH and M. F. FOLSTEIN
scores, a group distinct from those schizophrenic patients receiving low doses of phenothiazines, that is, less than 800 mg of chlorpromazine or 30 mg of trifluoperazine daily. This may be seen graphically in Fig. 5 where 3-week mean VAAS scores and medication regimen are shown for each patient. As a group, those patients being treated with high dose chlorpromazine had appetite scores as high as manic patients while those schizophrenics receiving low dose phenothiazines had mid-range appetite scores (Table 3). The hourly pattern of appetite scores, as with patients in other diagnostic categories, were not qualitatively different from normals but were quantitatively elevated in those patients receiving high dose phenothiazines. Patients receiving large amounts of chlorpromazine showed a marked weight gain equal to that of manic patients while those patients receiving low dose phenothiazines gained comparatively little weight during the same period (Fig. 7). (4) Neurotic-personality disorder. The VAAS scores of patients with neurotic-personality disorders were midrange as were normals and schizophrenic patients on low dose phenothiazines (Fig. 4). Three week mean VAAS scores for individual patients are shown in Fig. 5. The hourly pattern of appetite scores did not differ qualitatively or quantitatively from normals and the midrange appetites of patients with neurotic-personality disorders were reflected in the lack of weight change during the experimental period. DISCUSSION
This study was undertaken in an effort to investigate appetite disturbances in psychiatric patients using a method of self quantification of hunger. The visual analogue appetite scale, chosen for its ease and simplicity, was demonstrated to be a valid and reliable guide to appetite in human subjects. In both normals and psychiatric patients the VAAS score correlated with and partially predicted the size and cost of meals that were eaten. The VAAS score fluctuated in a rhythm around meals throughout the day and changed in the expected way from hour to hour before and after eating. The VAAS demonstrated that manic and schizophrenic patients on high doses of phenothiazines have increased appetites, patients with endogenous depressions have decreased appetites, and patients with neurotic personality disorders and schizophrenic patients on low doses of phenothiazines had appetite scores that fell between these extremes. These appetite findings were significant since changes in these patients’ body weights conformed with the differences in their VAAS scores (Fig. 7). Schizophrenic patients receiving high doses of chlorpromazine showed in this study a distinct phenomenon of marked increase in appetite. These patients were given high doses of chlorpromazine because they were the most severely ill being delusional with hallucinations. The question arises whether the elevated appetite is a result of the medication or the severity of the schizophrenic illness. There are two lines of evidence which tend to indicate that the chlorpromazine was responsible for the appetite disturbance. First, the more severely ill patient would be expected to be preoccupied with his delusions and distracted from hunger. But, in fact, the severely ill schizophrenics had much greater appetites than the milder schizophrenics who received only low doses of phenothiazines. Secondly, the VAAS scores of these patients became elevated only after they started receiving high doses of chlorpromazine and, if the phenothiazines were continued, remained elevated even when the patient was no longer so disturbed.
MEAsuREhlENTOF APPETITEDIWURBANCESIN PSYCHIATRIC DISORDERS
6-l
The observation that phenothiazines cause weight gain in schizophrenic patients, which is confirmed in the present study, is a well documented clinical phenomenon.*-l1 The mechanism by which phenothiazines cause weight gain, however, has been a matter of debate. Previous investigators, however, have hypothesized such mechanisms as fluid retention12 or decreased caloric need due to tranquillization and immobility. Although we cannot rule out the possibility of these other mechanisms contributing to weight gain, there was no clinical evidence in the current study to support any process other than increased appetite for food and a resultant increased food intake. Laboratory animals administered chlorpromazine both chronically and acutely have also increased their food intake and gained weight.13-l5 The cause of the increased appetite with phenothiazines is likely to be a direct central nervous system effect of the medication most likely due to the drugs effect on CNS biogenic amines.lGW1* The observation of increased appetite in schizophrenic patients receiving high doses of phenothiazines is a phenomenon that could be profitably studied further; particularly a search for a blocking agent to interrupt this increased appetite might assist in the study of the particular central nervous system mechanisms affected by this drug. The VAAS slip would be a useful clinical instrument in such a study. SUMMARY
A visual analogue scale was used for the self rating of appetite in 18 normals and 32 psychiatric patients. Appetite scores were shown to correlate with quantity of food intake, to fluctuate in the expected manner in relation to meals, and at an hourly interval to be a reliable measurement in both the normal and patient populations. Patients, chosen for their clarity of diagnosis, marked appetite slips either once/day for several weeks or once/hr for 1 or more days. All diagnostic groups showed the same general pattern of appetite scores changing in relation to meals. However, quantitative differences were found among different diagnostic groups. Schizophrenic patients receiving high doses of chlorpromazine and manic patients had the highest appetite scores, schizophrenic patients receiving low doses of phenothiazines and patients with neurotic personality disorders had appetite scores which ranked in the middle while patients with an endogenous depression had the lowest rank appetite scores. Both quantity of food intake and body weight change correlated with appetite scores. The elevation of appetite noted in schizophrenic patients receiving high doses of phenothiazines was thought to be an effect of the medication and to be mainly responsible for the marked weight gain. It was recommended that further research proceed along the lines of delineating central nervous system mechanisms involved in chlorpromazine induced hunger. AckrzOwZedgenzents-The authors would like to thank the nursing personnel of Hall 6W and Nichols Cottage and the volunteers at the New York Hospital, Westchester Division for their valuable help in data collection and analysis. We also gratefully acknowledge the help of Miss HELEN GOODELLwith manuscript editing and review. REFERENCES 1. AITKEN,R. C. Measurements of feelings using visual analogue scales. Proc. Roy. Sot. Med. 62,989,1969. 2. AITKEN, R. C., ZEALLEY,A. K. and ROSENTHAL,S. V. Psychological measures of emotion in chronic asthmatic patients. J. Ps@zosom. Res. 13,298, 1969.
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R. G. ROBINSON,P. R. MCHUGH and M. F. FOLSTEIN
3. FOLSTEIN,M. F. and LURIA, R. Reliability, validity and clinical application of the visual analogue mood scale. P&zol. Med. In press. 4. JORDAN,H. A., WIELAND, W. F., ZEBLEY,S. P., STELLAR,E. and STUNKARD,A. J. Direct measurement of food intake in man: A method for the objective study of eating behavior. Psychosom. Med. 28,
836, 1966. 5. SILVERSTONE,J. T. and STUNKARD, A. J. The anorectic effect of dexamphetamine sulphate. Br. J. Pharmac. Chemother. 33,513, 1968. 6. STUNKARQ A. J. and Fox, S. The relationship of gastric motility and hunger. Psychosom. Med. 33,123, 1971. 7. BLOOM,P. B., FILION,R. D. L., STUNKARD,A. J., Fox, S. and STELLAR,E. Gastric and duodenal motility, food intake and hunger measured in man during a 24-hr period. Am. J. Dig. Dis. 15,719, 1970. 8. PLANANSKY,K. Changes in weight in patients receiving a “tranquilizing” drug. Psychiat. Qr. 32, 289, 1958. ___-.
9. CAFFEY,E. M. Experience with large scale interhospital co-operative research in chemotherapy. Am. J. Psychiat. 117,713, 1971. 10. CAFFEY,E. M. and KLE~, C. J. Side effects and laboratory findings during combined drug therapy of chronic schizophrenics. Dis. Nerv. Syst. 22, 370, 1961. 11. GORDON, H. L. and GROTH, C. Weight change during and after hospital treatment. Archs gen. Psychiat. 10,187, 1964. 12. SLET~N, I. W. and GERSHON,S. The effect of chlorpromazine on water and electrolyte balance. J. Nerv. Ment. Dis. 142,25, 1966. 13. Bovo, E. M. Chlorpromazine tolerance and physical dependence. 1. Pharmac. exp. Ther. 128,75, 1960. 14. REYNOLDS,R. W. and CARLISLE,H. J. The effect of chlorpromazine on food intake in the albino rat. J. Camp. Physiol. Psychol. 54,354, 1961. 15. STOLERMAN,I. P. Eating, drinking and spontaneous activity in rats after the administration of chlorpromazine. Neuropharmac. 9,405, 1970. 16. LE~OWITZ, S. F. and MILLER, N. E. Unexpected adrenergic effect of chlorpromazine: Eating elicited by injection into rat hypothalamus. Science 165, 609, 1969. 17. FIBINGER,H. C., ZIS, A. P. and MCGEER, E. G. Feeding and drinking deficits after 6-hydroxydopamine administration in the rat: Similarities to the lateral hypothalamic syndrome. Brain Res. 55, 135, 1973. 18. UNGERSTEDT,U. Adipsia and aphagia after 6-hydroxydopamine induced degeneration of the nigrostriatal dopamine system. Acta. Physiol. stand. Suppl. 367, 95, 1971.
