Quality measures are reported on the CMS claim form just as any other service would be, except that no charge is billed for the reported measure. The time frame established for the reporting of these measures is July 1 through December 31 of this year. Although there are plans to continue the program in 2008, it is unclear whether funds will be available for a bonus in 2009, and the measures for 2008 will be different from those used in 2007.

To calculate the potential bonus amount when at least 3 measures are successfully reported, use your total Medicare income for the past 6 months. If you received $60,000 for treating Medicare patients from January 1 through May 31, for example, and Medicare income has been steady, expect a lump sum bonus of $900 in mid-2008.

How do I report an intervention?

Good news: You do not have to register to participate in PQRI; you need only report the selected quality measures each time you submit a claim for the patient service to which the quality measure applies. Criteria for reporting (and then receiving the bonus in mid-2008) for these quality measures are as follows:

• Select the quality measures that apply most often to your practice (see the TABLE)
  
• Enter the PQRI codes on block 24D of the CMS 1500 claim form with a $0.00 dollar amount; if your system does not allow this amount to be entered, change it to $0.01
  
• There must be a match between the acceptable CPT or ICD-9 code reported for the overall service with a CPT Category II or HCPCS “G” code designated as the quality measure, as listed in the Medicare specifications file (www.cms.hhs.gov/PQRI/15_MeasuresCodes.asp#TopOfPage)
  
• Apply any applicable allowed modifier that explains why the quality measure was not assessed:
  

• Measure title
  
• Description
  
• Instructions on reporting, including frequency, time frames, and applicability
  
• Numerator coding
  
• Definition of terms
  
• Coding instructions
  

The numerator part of the measure is represented by a CPT Category II code with or without a modifier. CPT code 1090F (presence or absence of urinary stress incontinence assessed) would be reported if the presence or absence of urinary incontinence was assessed, but a modifier 1P is placed in box 24E of the claim form if you have documented a medical reason why this was not assessed, or modifier 8P if it was not assessed but the reason was not documented.

TABLE

The Physician Quality Reporting Initiative: 10 measures may apply to ObGyn practice in 2007

Quality measures are reported on the CMS claim form just as any other service would be, except that no charge is billed for the reported measure. The time frame established for the reporting of these measures is July 1 through December 31 of this year. Although there are plans to continue the program in 2008, it is unclear whether funds will be available for a bonus in 2009, and the measures for 2008 will be different from those used in 2007.

To calculate the potential bonus amount when at least 3 measures are successfully reported, use your total Medicare income for the past 6 months. If you received $60,000 for treating Medicare patients from January 1 through May 31, for example, and Medicare income has been steady, expect a lump sum bonus of $900 in mid-2008.

How do I report an intervention?

Good news: You do not have to register to participate in PQRI; you need only report the selected quality measures each time you submit a claim for the patient service to which the quality measure applies. Criteria for reporting (and then receiving the bonus in mid-2008) for these quality measures are as follows:

• Select the quality measures that apply most often to your practice (see the TABLE)
  
• Enter the PQRI codes on block 24D of the CMS 1500 claim form with a $0.00 dollar amount; if your system does not allow this amount to be entered, change it to $0.01
  
• There must be a match between the acceptable CPT or ICD-9 code reported for the overall service with a CPT Category II or HCPCS “G” code designated as the quality measure, as listed in the Medicare specifications file (www.cms.hhs.gov/PQRI/15_MeasuresCodes.asp#TopOfPage)
  
• Apply any applicable allowed modifier that explains why the quality measure was not assessed:
  

• Measure title
  
• Description
  
• Instructions on reporting, including frequency, time frames, and applicability
  
• Numerator coding
  
• Definition of terms
  
• Coding instructions
  

The numerator part of the measure is represented by a CPT Category II code with or without a modifier. CPT code 1090F (presence or absence of urinary stress incontinence assessed) would be reported if the presence or absence of urinary incontinence was assessed, but a modifier 1P is placed in box 24E of the claim form if you have documented a medical reason why this was not assessed, or modifier 8P if it was not assessed but the reason was not documented.

TABLE

The Physician Quality Reporting Initiative: 10 measures may apply to ObGyn practice in 2007

Quality measures are reported on the CMS claim form just as any other service would be, except that no charge is billed for the reported measure. The time frame established for the reporting of these measures is July 1 through December 31 of this year. Although there are plans to continue the program in 2008, it is unclear whether funds will be available for a bonus in 2009, and the measures for 2008 will be different from those used in 2007.

To calculate the potential bonus amount when at least 3 measures are successfully reported, use your total Medicare income for the past 6 months. If you received $60,000 for treating Medicare patients from January 1 through May 31, for example, and Medicare income has been steady, expect a lump sum bonus of $900 in mid-2008.

How do I report an intervention?

Good news: You do not have to register to participate in PQRI; you need only report the selected quality measures each time you submit a claim for the patient service to which the quality measure applies. Criteria for reporting (and then receiving the bonus in mid-2008) for these quality measures are as follows:

• Select the quality measures that apply most often to your practice (see the TABLE)
  
• Enter the PQRI codes on block 24D of the CMS 1500 claim form with a $0.00 dollar amount; if your system does not allow this amount to be entered, change it to $0.01
  
• There must be a match between the acceptable CPT or ICD-9 code reported for the overall service with a CPT Category II or HCPCS “G” code designated as the quality measure, as listed in the Medicare specifications file (www.cms.hhs.gov/PQRI/15_MeasuresCodes.asp#TopOfPage)
  
• Apply any applicable allowed modifier that explains why the quality measure was not assessed:
  

• Measure title
  
• Description
  
• Instructions on reporting, including frequency, time frames, and applicability
  
• Numerator coding
  
• Definition of terms
  
• Coding instructions
  

The numerator part of the measure is represented by a CPT Category II code with or without a modifier. CPT code 1090F (presence or absence of urinary stress incontinence assessed) would be reported if the presence or absence of urinary incontinence was assessed, but a modifier 1P is placed in box 24E of the claim form if you have documented a medical reason why this was not assessed, or modifier 8P if it was not assessed but the reason was not documented.

TABLE

The Physician Quality Reporting Initiative: 10 measures may apply to ObGyn practice in 2007

One physician has written that good patient-doctor communication, like jazz, calls for improvisation.¹ We agree. And improvise we must when patients’ expectations for how we will communicate with them vary between visits and individuals.

For example, those who are ill may prefer that their doctor communicate with them in a way that is less important to those who are healthy. Patients with biomedical problems may have different preferences than persons with psychosocial problems. And older individuals may have communication desires that differ from those who are younger.^2-4

Do patients want cure or care, or both?

Depending on the reason for a visit—eg, biomedical or psychosocial—patient preferences may fit either the cure or the care dimension.

Cure dimension. On one hand, patients expect their doctor to be task-oriented and to find a cure for what ails them. They want an explanation of what is wrong and advice about possible treatments, and they want the doctor to do whatever is needed to get answers.⁵

Care dimension. On the other hand, patients may feel anxious and want reassurance. They expect the doctor to listen to their story and encourage them to disclose all health problems, concerns, and worries. They also expect friendliness and empathy. They want to be taken seriously. The extent to which the doctor shows this affect-oriented (and patient-centered) behavior will determine how fulfilled patients feel in their preference for care.^6,7

Why does it matter? Good communication serves a patient’s need to understand and to be understood.^6,8,9 And communication aimed at matching patient preferences enhances satisfaction with care, compliance with medical instructions, and health status.^10-13

How well do we assess patients’ communication preferences?

Patient-centered behavior is a necessary tool for discovering and fulfilling patients’ task-oriented (cure dimension) and affect-oriented (care dimension) communication preferences.^14-17 It’s important to know how well primary-care physicians interpret patients’ preferences for clinical encounters and if they respond in a manner that satisfies those expectations.

Reassuringly, patients indicate on surveys that their physicians do a fairly good job of interpreting their communication preferences and acting accordingly.^18-20 They also report that their desires and expectations from consultations are increasingly met.

There is always the worry, though, that physicians in certain positions—eg, non-gatekeeper roles or positions involving only part-time clinical responsibilities—would be challenged to assess patient preferences as accurately as others.²¹

The aim of our study

While it’s encouraging that physicians by and large understand their patients and communicate with them meaningfully, we wondered whether communication could improve further. Our purpose in this study was to gain detailed insight into patients’ preferences in physician communication and, through patients’ subjective perspectives and observed real practice consultations, learn how well physicians communicate according to those preferences.

Methods

Design

We derived physician data from the Second Dutch National Survey of General Practice (2001). This study was carried out in practices representative of Dutch general practice.²² We asked patients for permission to videotape consultations with the general practitioner (GP), and asked them to sign a consent form. Collected data were kept private as per regulations.

We videotaped consultations of 142 GPs (76.1% male) and 2784 patients (41.2% male). The number of patients cared for by each GP ranged between 17 and 21 (mean=19.6). Each patient was videotaped just once. We rated roughly 15 patient-consultations per GP (13–15, mean=14.8), excluding the first 3 to correct for possible bias because of the video camera. Before and immediately after the consultation, patients 18 years of age and older answered a questionnaire. We used data from 1787 patient consultations.

Patients rate their communication preferences

The patient questionnaire covered demographic characteristics (gender, age, education); health problems (psychosocial or not [ICPC-coded]);²³ overall health during the past 2 weeks (1=excellent, 2=very good, 3=good, 4=fair, 5=poor); and depressive feelings during the past 2 weeks (1=not at all, 2=slightly, 3=moderately, 4=quite a bit, 5=extremely) (COOP-WONCA charts²⁴).

We defined communication preferences as “the extent of importance patients attach to communication aspects.”²⁵ Patients’ preferences and the actual performance by the GP were measured using the conceptual framework of the QUOTE scale (quality of care through the patient’s eyes).^5,25

Before consultation, patients recorded how important they considered different aspects of communication for the coming visit (1=not important, 2=rather important, 3=important, 4=utmost important). Following consultation, they rated the GP’s performance in meeting their expectations for these aspects (1=not, 2=really not, 3=really yes, 4=yes).

Factor analysis of both the pre- and post-visit lists of questions on preference and performance revealed 2 relevant subscales: an affect-oriented scale of 7 communication aspects and a task-oriented scale of 6 communication aspects (Cronbach’s alpha between 0.74 and 0.89).

We also used communication aspects from the original 4-point scale to present 4 new categories that compared and contrasted preferences and relevance. These categories included: important and performed; important and not performed; not important and performed; not important and not performed. In the multilevel analysis, we included the 2 subscales using the original 4-point scale.

Socio-demographic and practice variables were derived from the GP questionnaires in the Second Dutch National Survey of General Practice (2001).

Video observations

Nine observers measured verbal behavior during the videotaped visits using the Roter Method of Interaction Process Analysis (RIAS²⁶), a well-documented, widely used system in the US and Netherlands. This observation system distinguishes both affect-oriented (socio-emotional) and task-oriented (instrumental) verbal behavior of doctors and patients, reflecting the care and cure dimensions, respectively. The RIAS categories are mutually exclusive and exhaustive.

Affect-oriented communication consists of personal remarks, agreements, concerns, reassurances, paraphrases, and disagreements.

Task-oriented talk includes asking questions, giving information, and (only GPs) counseling about medical/therapeutic and psychosocial, social context and lifestyle issues, and process-oriented talk (instructions, asking for understanding).

After finishing the RIAS-coding, we calculated the total numbers of affect-oriented and task-oriented verbal behaviors separately for GPs and patients.

The relevance and performance items and the RIAS-categories all measured the affect-oriented and task-oriented aspects.

We used the Noldus Observer-Video-Pro computer program for the observation study,²⁷ including measurement of consultation length. The interobserver reliabilities were good to excellent: between r=0.80 to r=0.95 per category, except for personal remarks (0.72).

Patient-centeredness measured in 3 ways

The observers, using a 5-point scale, also rated the extent to which GPs communicated in a patient-centered way in 3 areas: patient’s involvement in the problem-defining process; patient’s involvement in the decision-making process; and doctor’s overall responsiveness to the patient.

Based on ratings in these 3 areas, we determined an overall magnitude of patient-centeredness (Cronbach’s alpha=0.75). Observers and the responsible researcher met weekly to validate the quality of rating. The same was done for the RIAS coding.

Controlling variables

For GPs, controlling variables were gender, age, and number of full-time equivalents (FTEs) working. For patients, GP and patient gender were included in the variable “gender-dyad”—male GPs/male patients, male GPs/female patients, female GPs/male patients, female GPs/female patients. Other patient variables were age; education (low=no/primary school, middle=secondary school, high=higher vocational training/university); health problems: somatic or psychosocial (ICPC chapters); overall physical health and mental health during the past 2 weeks; and consultation length.

Data analysis

We used descriptive and multilevel analyses. The intra-class correlations of the affect-oriented and task-oriented communication and patient-centeredness were significant (between .05 and 0.23), which made it clear that consultations of the same GP did indeed exhibit a greater degree of similarity than the consultations of different GPs. Therefore, multilevel analyses were necessary to account for the clustering of patients with the same GP.²⁸ We applied a significance level of ≤0.05 (2-sided).

Results

Response rate

The overall patient response rate was 88%. Analysis of non-responders’ gender, age, and type of insurance showed no bias resulting from patients’ refusal.

GP response rate was 72.8%. Respondents were representative of all Dutch GPs with respect to gender, age, working hours, practice experience (mean=15.6 years, SD=8.3, range=1–32), and location (58% in an urban area). More GPs worked in a partnership or group practice than in a solo practice. We analyzed the influence of the practice type on doctor-patient communication and deemed it insignificant.

Study population

GP and patient characteristics appear in TABLE 1. Among patients, 22% had little education, 62% had an average education, and 16% had higher education. Nearly 10% had a psychosocial problem. GP-patient gender dyads were as follows: 32.1% male GP/male patient; 45.3% male GP/female patient; 6.9% female GP/male patient; 15.8% female GP/female patient.

TABLE 1
General practitioner and patient characteristics (N GPs=142, N patients=1787)

Preference and performance of communication aspects

GPs good with affect-oriented communication aspects. Patients considered 6 of 7 affect-oriented communication aspects as very important (87%–96%, TABLE 2). The item “Doctor was empathic to me” was less important (61%) than items like “Doctor listened well to me” (96%) and “Doctor took enough time for me” (93%). We noted only a few discrepancies between preference and performance of the GPs’ affect-oriented behavior. If patients said beforehand that a communication aspect was important, the doctors nearly always performed that aspect. For instance, 87% wanted enough attention from the doctor and received it, while 99% of all patients received GP’s attention, whether it was important to them or not.

GPs less successful with task-oriented communication aspects. Many patients wanted information, explanations, advice, and help with their problems (85%–94%, TABLE 2). Knowing the diagnosis was less important (77%) than, say, receiving advice on what to do and having details of treatment explained.

GPs also performed most of the task-oriented aspects, if patients considered these aspects important.

Subjectively, preferences for GP task-oriented behavior and perceived performance often went together, though more discrepancies were visible than with affect-oriented behavior. One fifth of patients said their problems were not helped, though they had said this was important. Similarly, GPs did not give a diagnosis to nearly 15% of patients who considered it important.

TABLE 2
Care vs cure-centered communication: Physicians fared better on the care side (N=1787)

GP communication varies by doctor gender, patient characteristics

GPs engaged less in affect-oriented than in task-oriented communication (48.6 and 70.0 utterances on average, respectively, P≤.001).

The more patients regarded affect-oriented talk by GPs as important, the more the GPs actually showed affective and patient-centered behavior (TABLE 3). Preferences for task-oriented behavior (question-asking, information-giving, and counseling) were mirrored in their doctors’ talk.

When taking into account other GP and patient characteristics, female doctors were more often affect-oriented as well as task-oriented when communicating with patients than were male doctors, especially with female patients. In consultations with older patients and those in poor health, the doctors were more affective than in consultations with younger and healthy patients.

TABLE 3
On observation, physician communication corresponded to patient preferences (N GPs=142, N patients=1787)

Discussion

Our study suggests most patients receive from their GPs the kind of communication they prefer in a consultation. In general, patients consider both affect- and task-oriented communication aspects important, and believe they are often performed. Our findings agree with most of the literature.^5,14,20 Furthermore, patients’ preferences are for the greater part reflected in the GPs’ observed communication during the visit, which agrees with one earlier study¹⁸ but not with others.^5,20

Patient preference for an affective doctor is very often met. GPs are generally considered attentive, friendly, frank, empathic, and good listeners. Patients seem satisfied in this respect. However, the task-oriented communication of the GPs is sometimes less satisfying. Contrary to patient preference, for example, GPs are not always able to make a diagnosis.

Observed physician behavior: patients usually get what they want. Looking at the relationship between preferences and actual GP communication, it appears that the more patients prefer an affective or caring doctor, the more they are likely to get an empathic, concerned, interested, and patient-centered doctor, especially when psychosocial problems are expressed. An affective GP was patient centered, involving patients in problem definition and decision making. This relationship between affective behavior and patient-centeredness was also found in earlier studies.^22,29 However, Swenson found that not all patients wanted the doctor to exhibit a patient-centered approach.³⁰

Likewise, the more patients prefer a task-oriented doctor, the better the chance they will have a doctor who explains things well, and who gives information and advice to their satisfaction. However, task-oriented doctors are usually less affective and less patient-centered when talking with patients. In view of the postulate that a doctor has to be curing as well as caring,⁶ doctors would be wise to give attention to both aspects.

GPs do improvise while communicating with patients. The study shows that GPs and patients working together can create the type of encounter both want. GPs are able to change their behavior in response to real-time cues they believe patients are giving in an encounter.

Physician gender often makes a difference. Our findings suggest that female doctors are more affective and task-oriented when talking with their patients than are male doctors, especially with female patients. In view of the steady increase of female doctors in general practice, this combined communication style may become more common in the future.

Psychosocial complaints prompt affective communication. Patients with a psychosocial problem are more likely to encounter an affective doctor than those with a biomedical problem. The growing number of psychosocial problems in the population may lead to a more affective communication.

Eventually the demand and the supply of affective communication may coincide. However, it is a challenge for every doctor to keep his or her mind open to both biomedical (task-oriented) and psychosocial (affective-oriented) information.³¹

Study caveats. Because we used scale scores for affect- and task-oriented preferences instead of the separate item scores for patient preferences, the reflection of preferences for GP communicative behavior might be somewhat overestimated. Likewise, we used total observation scores for affect- and task-oriented talk instead of the separate RIAS categories. More detailed measures of such communication aspects as empathy might give better insight into patient preferences.

Final thoughts on personal application. Primary care physicians would do well to take notice of patients’ preferences for communication. GPs in our study were often able to grasp what patients considered important to talk about, and there seemed to be only modest mismatches between patient expectations and physician behavior. To increase the quality of health care, consider asking patients at the end of a visit whether their preferences were met.

Acknowledgments

We acknowledge the participating general practitioners and patients, the observers of the videotaped consultations, and the Ministry of Health, Welfare and Sports for funding (for the greater part) the research project.

Correspondence
A. van den Brink-Muinen, PhD, NIVEL, PO Box 1568, 3500 BN Utrecht, The Netherlands; a.vandenbrink@nivel.nl

One physician has written that good patient-doctor communication, like jazz, calls for improvisation.¹ We agree. And improvise we must when patients’ expectations for how we will communicate with them vary between visits and individuals.

For example, those who are ill may prefer that their doctor communicate with them in a way that is less important to those who are healthy. Patients with biomedical problems may have different preferences than persons with psychosocial problems. And older individuals may have communication desires that differ from those who are younger.^2-4

Do patients want cure or care, or both?

Depending on the reason for a visit—eg, biomedical or psychosocial—patient preferences may fit either the cure or the care dimension.

Cure dimension. On one hand, patients expect their doctor to be task-oriented and to find a cure for what ails them. They want an explanation of what is wrong and advice about possible treatments, and they want the doctor to do whatever is needed to get answers.⁵

Care dimension. On the other hand, patients may feel anxious and want reassurance. They expect the doctor to listen to their story and encourage them to disclose all health problems, concerns, and worries. They also expect friendliness and empathy. They want to be taken seriously. The extent to which the doctor shows this affect-oriented (and patient-centered) behavior will determine how fulfilled patients feel in their preference for care.^6,7

Why does it matter? Good communication serves a patient’s need to understand and to be understood.^6,8,9 And communication aimed at matching patient preferences enhances satisfaction with care, compliance with medical instructions, and health status.^10-13

How well do we assess patients’ communication preferences?

Patient-centered behavior is a necessary tool for discovering and fulfilling patients’ task-oriented (cure dimension) and affect-oriented (care dimension) communication preferences.^14-17 It’s important to know how well primary-care physicians interpret patients’ preferences for clinical encounters and if they respond in a manner that satisfies those expectations.

Reassuringly, patients indicate on surveys that their physicians do a fairly good job of interpreting their communication preferences and acting accordingly.^18-20 They also report that their desires and expectations from consultations are increasingly met.

There is always the worry, though, that physicians in certain positions—eg, non-gatekeeper roles or positions involving only part-time clinical responsibilities—would be challenged to assess patient preferences as accurately as others.²¹

The aim of our study

While it’s encouraging that physicians by and large understand their patients and communicate with them meaningfully, we wondered whether communication could improve further. Our purpose in this study was to gain detailed insight into patients’ preferences in physician communication and, through patients’ subjective perspectives and observed real practice consultations, learn how well physicians communicate according to those preferences.

Methods

Design

We derived physician data from the Second Dutch National Survey of General Practice (2001). This study was carried out in practices representative of Dutch general practice.²² We asked patients for permission to videotape consultations with the general practitioner (GP), and asked them to sign a consent form. Collected data were kept private as per regulations.

We videotaped consultations of 142 GPs (76.1% male) and 2784 patients (41.2% male). The number of patients cared for by each GP ranged between 17 and 21 (mean=19.6). Each patient was videotaped just once. We rated roughly 15 patient-consultations per GP (13–15, mean=14.8), excluding the first 3 to correct for possible bias because of the video camera. Before and immediately after the consultation, patients 18 years of age and older answered a questionnaire. We used data from 1787 patient consultations.

Patients rate their communication preferences

The patient questionnaire covered demographic characteristics (gender, age, education); health problems (psychosocial or not [ICPC-coded]);²³ overall health during the past 2 weeks (1=excellent, 2=very good, 3=good, 4=fair, 5=poor); and depressive feelings during the past 2 weeks (1=not at all, 2=slightly, 3=moderately, 4=quite a bit, 5=extremely) (COOP-WONCA charts²⁴).

We defined communication preferences as “the extent of importance patients attach to communication aspects.”²⁵ Patients’ preferences and the actual performance by the GP were measured using the conceptual framework of the QUOTE scale (quality of care through the patient’s eyes).^5,25

Before consultation, patients recorded how important they considered different aspects of communication for the coming visit (1=not important, 2=rather important, 3=important, 4=utmost important). Following consultation, they rated the GP’s performance in meeting their expectations for these aspects (1=not, 2=really not, 3=really yes, 4=yes).

Factor analysis of both the pre- and post-visit lists of questions on preference and performance revealed 2 relevant subscales: an affect-oriented scale of 7 communication aspects and a task-oriented scale of 6 communication aspects (Cronbach’s alpha between 0.74 and 0.89).

We also used communication aspects from the original 4-point scale to present 4 new categories that compared and contrasted preferences and relevance. These categories included: important and performed; important and not performed; not important and performed; not important and not performed. In the multilevel analysis, we included the 2 subscales using the original 4-point scale.

Socio-demographic and practice variables were derived from the GP questionnaires in the Second Dutch National Survey of General Practice (2001).

Video observations

Nine observers measured verbal behavior during the videotaped visits using the Roter Method of Interaction Process Analysis (RIAS²⁶), a well-documented, widely used system in the US and Netherlands. This observation system distinguishes both affect-oriented (socio-emotional) and task-oriented (instrumental) verbal behavior of doctors and patients, reflecting the care and cure dimensions, respectively. The RIAS categories are mutually exclusive and exhaustive.

Affect-oriented communication consists of personal remarks, agreements, concerns, reassurances, paraphrases, and disagreements.

Task-oriented talk includes asking questions, giving information, and (only GPs) counseling about medical/therapeutic and psychosocial, social context and lifestyle issues, and process-oriented talk (instructions, asking for understanding).

After finishing the RIAS-coding, we calculated the total numbers of affect-oriented and task-oriented verbal behaviors separately for GPs and patients.

The relevance and performance items and the RIAS-categories all measured the affect-oriented and task-oriented aspects.

We used the Noldus Observer-Video-Pro computer program for the observation study,²⁷ including measurement of consultation length. The interobserver reliabilities were good to excellent: between r=0.80 to r=0.95 per category, except for personal remarks (0.72).

Patient-centeredness measured in 3 ways

The observers, using a 5-point scale, also rated the extent to which GPs communicated in a patient-centered way in 3 areas: patient’s involvement in the problem-defining process; patient’s involvement in the decision-making process; and doctor’s overall responsiveness to the patient.

Based on ratings in these 3 areas, we determined an overall magnitude of patient-centeredness (Cronbach’s alpha=0.75). Observers and the responsible researcher met weekly to validate the quality of rating. The same was done for the RIAS coding.

Controlling variables

For GPs, controlling variables were gender, age, and number of full-time equivalents (FTEs) working. For patients, GP and patient gender were included in the variable “gender-dyad”—male GPs/male patients, male GPs/female patients, female GPs/male patients, female GPs/female patients. Other patient variables were age; education (low=no/primary school, middle=secondary school, high=higher vocational training/university); health problems: somatic or psychosocial (ICPC chapters); overall physical health and mental health during the past 2 weeks; and consultation length.

Data analysis

We used descriptive and multilevel analyses. The intra-class correlations of the affect-oriented and task-oriented communication and patient-centeredness were significant (between .05 and 0.23), which made it clear that consultations of the same GP did indeed exhibit a greater degree of similarity than the consultations of different GPs. Therefore, multilevel analyses were necessary to account for the clustering of patients with the same GP.²⁸ We applied a significance level of ≤0.05 (2-sided).

Results

Response rate

The overall patient response rate was 88%. Analysis of non-responders’ gender, age, and type of insurance showed no bias resulting from patients’ refusal.

GP response rate was 72.8%. Respondents were representative of all Dutch GPs with respect to gender, age, working hours, practice experience (mean=15.6 years, SD=8.3, range=1–32), and location (58% in an urban area). More GPs worked in a partnership or group practice than in a solo practice. We analyzed the influence of the practice type on doctor-patient communication and deemed it insignificant.

Study population

GP and patient characteristics appear in TABLE 1. Among patients, 22% had little education, 62% had an average education, and 16% had higher education. Nearly 10% had a psychosocial problem. GP-patient gender dyads were as follows: 32.1% male GP/male patient; 45.3% male GP/female patient; 6.9% female GP/male patient; 15.8% female GP/female patient.

TABLE 1
General practitioner and patient characteristics (N GPs=142, N patients=1787)

Preference and performance of communication aspects

GPs good with affect-oriented communication aspects. Patients considered 6 of 7 affect-oriented communication aspects as very important (87%–96%, TABLE 2). The item “Doctor was empathic to me” was less important (61%) than items like “Doctor listened well to me” (96%) and “Doctor took enough time for me” (93%). We noted only a few discrepancies between preference and performance of the GPs’ affect-oriented behavior. If patients said beforehand that a communication aspect was important, the doctors nearly always performed that aspect. For instance, 87% wanted enough attention from the doctor and received it, while 99% of all patients received GP’s attention, whether it was important to them or not.

GPs less successful with task-oriented communication aspects. Many patients wanted information, explanations, advice, and help with their problems (85%–94%, TABLE 2). Knowing the diagnosis was less important (77%) than, say, receiving advice on what to do and having details of treatment explained.

GPs also performed most of the task-oriented aspects, if patients considered these aspects important.

Subjectively, preferences for GP task-oriented behavior and perceived performance often went together, though more discrepancies were visible than with affect-oriented behavior. One fifth of patients said their problems were not helped, though they had said this was important. Similarly, GPs did not give a diagnosis to nearly 15% of patients who considered it important.

TABLE 2
Care vs cure-centered communication: Physicians fared better on the care side (N=1787)

GP communication varies by doctor gender, patient characteristics

GPs engaged less in affect-oriented than in task-oriented communication (48.6 and 70.0 utterances on average, respectively, P≤.001).

The more patients regarded affect-oriented talk by GPs as important, the more the GPs actually showed affective and patient-centered behavior (TABLE 3). Preferences for task-oriented behavior (question-asking, information-giving, and counseling) were mirrored in their doctors’ talk.

When taking into account other GP and patient characteristics, female doctors were more often affect-oriented as well as task-oriented when communicating with patients than were male doctors, especially with female patients. In consultations with older patients and those in poor health, the doctors were more affective than in consultations with younger and healthy patients.

TABLE 3
On observation, physician communication corresponded to patient preferences (N GPs=142, N patients=1787)

Discussion

Our study suggests most patients receive from their GPs the kind of communication they prefer in a consultation. In general, patients consider both affect- and task-oriented communication aspects important, and believe they are often performed. Our findings agree with most of the literature.^5,14,20 Furthermore, patients’ preferences are for the greater part reflected in the GPs’ observed communication during the visit, which agrees with one earlier study¹⁸ but not with others.^5,20

Patient preference for an affective doctor is very often met. GPs are generally considered attentive, friendly, frank, empathic, and good listeners. Patients seem satisfied in this respect. However, the task-oriented communication of the GPs is sometimes less satisfying. Contrary to patient preference, for example, GPs are not always able to make a diagnosis.

Observed physician behavior: patients usually get what they want. Looking at the relationship between preferences and actual GP communication, it appears that the more patients prefer an affective or caring doctor, the more they are likely to get an empathic, concerned, interested, and patient-centered doctor, especially when psychosocial problems are expressed. An affective GP was patient centered, involving patients in problem definition and decision making. This relationship between affective behavior and patient-centeredness was also found in earlier studies.^22,29 However, Swenson found that not all patients wanted the doctor to exhibit a patient-centered approach.³⁰

Likewise, the more patients prefer a task-oriented doctor, the better the chance they will have a doctor who explains things well, and who gives information and advice to their satisfaction. However, task-oriented doctors are usually less affective and less patient-centered when talking with patients. In view of the postulate that a doctor has to be curing as well as caring,⁶ doctors would be wise to give attention to both aspects.

GPs do improvise while communicating with patients. The study shows that GPs and patients working together can create the type of encounter both want. GPs are able to change their behavior in response to real-time cues they believe patients are giving in an encounter.

Physician gender often makes a difference. Our findings suggest that female doctors are more affective and task-oriented when talking with their patients than are male doctors, especially with female patients. In view of the steady increase of female doctors in general practice, this combined communication style may become more common in the future.

Psychosocial complaints prompt affective communication. Patients with a psychosocial problem are more likely to encounter an affective doctor than those with a biomedical problem. The growing number of psychosocial problems in the population may lead to a more affective communication.

Eventually the demand and the supply of affective communication may coincide. However, it is a challenge for every doctor to keep his or her mind open to both biomedical (task-oriented) and psychosocial (affective-oriented) information.³¹

Study caveats. Because we used scale scores for affect- and task-oriented preferences instead of the separate item scores for patient preferences, the reflection of preferences for GP communicative behavior might be somewhat overestimated. Likewise, we used total observation scores for affect- and task-oriented talk instead of the separate RIAS categories. More detailed measures of such communication aspects as empathy might give better insight into patient preferences.

Final thoughts on personal application. Primary care physicians would do well to take notice of patients’ preferences for communication. GPs in our study were often able to grasp what patients considered important to talk about, and there seemed to be only modest mismatches between patient expectations and physician behavior. To increase the quality of health care, consider asking patients at the end of a visit whether their preferences were met.

Acknowledgments

We acknowledge the participating general practitioners and patients, the observers of the videotaped consultations, and the Ministry of Health, Welfare and Sports for funding (for the greater part) the research project.

Correspondence
A. van den Brink-Muinen, PhD, NIVEL, PO Box 1568, 3500 BN Utrecht, The Netherlands; a.vandenbrink@nivel.nl

One physician has written that good patient-doctor communication, like jazz, calls for improvisation.¹ We agree. And improvise we must when patients’ expectations for how we will communicate with them vary between visits and individuals.

For example, those who are ill may prefer that their doctor communicate with them in a way that is less important to those who are healthy. Patients with biomedical problems may have different preferences than persons with psychosocial problems. And older individuals may have communication desires that differ from those who are younger.^2-4

Do patients want cure or care, or both?

Depending on the reason for a visit—eg, biomedical or psychosocial—patient preferences may fit either the cure or the care dimension.

Cure dimension. On one hand, patients expect their doctor to be task-oriented and to find a cure for what ails them. They want an explanation of what is wrong and advice about possible treatments, and they want the doctor to do whatever is needed to get answers.⁵

Care dimension. On the other hand, patients may feel anxious and want reassurance. They expect the doctor to listen to their story and encourage them to disclose all health problems, concerns, and worries. They also expect friendliness and empathy. They want to be taken seriously. The extent to which the doctor shows this affect-oriented (and patient-centered) behavior will determine how fulfilled patients feel in their preference for care.^6,7

Why does it matter? Good communication serves a patient’s need to understand and to be understood.^6,8,9 And communication aimed at matching patient preferences enhances satisfaction with care, compliance with medical instructions, and health status.^10-13

How well do we assess patients’ communication preferences?

Patient-centered behavior is a necessary tool for discovering and fulfilling patients’ task-oriented (cure dimension) and affect-oriented (care dimension) communication preferences.^14-17 It’s important to know how well primary-care physicians interpret patients’ preferences for clinical encounters and if they respond in a manner that satisfies those expectations.

Reassuringly, patients indicate on surveys that their physicians do a fairly good job of interpreting their communication preferences and acting accordingly.^18-20 They also report that their desires and expectations from consultations are increasingly met.

There is always the worry, though, that physicians in certain positions—eg, non-gatekeeper roles or positions involving only part-time clinical responsibilities—would be challenged to assess patient preferences as accurately as others.²¹

The aim of our study

While it’s encouraging that physicians by and large understand their patients and communicate with them meaningfully, we wondered whether communication could improve further. Our purpose in this study was to gain detailed insight into patients’ preferences in physician communication and, through patients’ subjective perspectives and observed real practice consultations, learn how well physicians communicate according to those preferences.

Methods

Design

We derived physician data from the Second Dutch National Survey of General Practice (2001). This study was carried out in practices representative of Dutch general practice.²² We asked patients for permission to videotape consultations with the general practitioner (GP), and asked them to sign a consent form. Collected data were kept private as per regulations.

We videotaped consultations of 142 GPs (76.1% male) and 2784 patients (41.2% male). The number of patients cared for by each GP ranged between 17 and 21 (mean=19.6). Each patient was videotaped just once. We rated roughly 15 patient-consultations per GP (13–15, mean=14.8), excluding the first 3 to correct for possible bias because of the video camera. Before and immediately after the consultation, patients 18 years of age and older answered a questionnaire. We used data from 1787 patient consultations.

Patients rate their communication preferences

The patient questionnaire covered demographic characteristics (gender, age, education); health problems (psychosocial or not [ICPC-coded]);²³ overall health during the past 2 weeks (1=excellent, 2=very good, 3=good, 4=fair, 5=poor); and depressive feelings during the past 2 weeks (1=not at all, 2=slightly, 3=moderately, 4=quite a bit, 5=extremely) (COOP-WONCA charts²⁴).

We defined communication preferences as “the extent of importance patients attach to communication aspects.”²⁵ Patients’ preferences and the actual performance by the GP were measured using the conceptual framework of the QUOTE scale (quality of care through the patient’s eyes).^5,25

Before consultation, patients recorded how important they considered different aspects of communication for the coming visit (1=not important, 2=rather important, 3=important, 4=utmost important). Following consultation, they rated the GP’s performance in meeting their expectations for these aspects (1=not, 2=really not, 3=really yes, 4=yes).

Factor analysis of both the pre- and post-visit lists of questions on preference and performance revealed 2 relevant subscales: an affect-oriented scale of 7 communication aspects and a task-oriented scale of 6 communication aspects (Cronbach’s alpha between 0.74 and 0.89).

We also used communication aspects from the original 4-point scale to present 4 new categories that compared and contrasted preferences and relevance. These categories included: important and performed; important and not performed; not important and performed; not important and not performed. In the multilevel analysis, we included the 2 subscales using the original 4-point scale.

Socio-demographic and practice variables were derived from the GP questionnaires in the Second Dutch National Survey of General Practice (2001).

Video observations

Nine observers measured verbal behavior during the videotaped visits using the Roter Method of Interaction Process Analysis (RIAS²⁶), a well-documented, widely used system in the US and Netherlands. This observation system distinguishes both affect-oriented (socio-emotional) and task-oriented (instrumental) verbal behavior of doctors and patients, reflecting the care and cure dimensions, respectively. The RIAS categories are mutually exclusive and exhaustive.

Affect-oriented communication consists of personal remarks, agreements, concerns, reassurances, paraphrases, and disagreements.

Task-oriented talk includes asking questions, giving information, and (only GPs) counseling about medical/therapeutic and psychosocial, social context and lifestyle issues, and process-oriented talk (instructions, asking for understanding).

After finishing the RIAS-coding, we calculated the total numbers of affect-oriented and task-oriented verbal behaviors separately for GPs and patients.

The relevance and performance items and the RIAS-categories all measured the affect-oriented and task-oriented aspects.

We used the Noldus Observer-Video-Pro computer program for the observation study,²⁷ including measurement of consultation length. The interobserver reliabilities were good to excellent: between r=0.80 to r=0.95 per category, except for personal remarks (0.72).

Patient-centeredness measured in 3 ways

The observers, using a 5-point scale, also rated the extent to which GPs communicated in a patient-centered way in 3 areas: patient’s involvement in the problem-defining process; patient’s involvement in the decision-making process; and doctor’s overall responsiveness to the patient.

Based on ratings in these 3 areas, we determined an overall magnitude of patient-centeredness (Cronbach’s alpha=0.75). Observers and the responsible researcher met weekly to validate the quality of rating. The same was done for the RIAS coding.

Controlling variables

For GPs, controlling variables were gender, age, and number of full-time equivalents (FTEs) working. For patients, GP and patient gender were included in the variable “gender-dyad”—male GPs/male patients, male GPs/female patients, female GPs/male patients, female GPs/female patients. Other patient variables were age; education (low=no/primary school, middle=secondary school, high=higher vocational training/university); health problems: somatic or psychosocial (ICPC chapters); overall physical health and mental health during the past 2 weeks; and consultation length.

Data analysis

We used descriptive and multilevel analyses. The intra-class correlations of the affect-oriented and task-oriented communication and patient-centeredness were significant (between .05 and 0.23), which made it clear that consultations of the same GP did indeed exhibit a greater degree of similarity than the consultations of different GPs. Therefore, multilevel analyses were necessary to account for the clustering of patients with the same GP.²⁸ We applied a significance level of ≤0.05 (2-sided).

Results

Response rate

The overall patient response rate was 88%. Analysis of non-responders’ gender, age, and type of insurance showed no bias resulting from patients’ refusal.

GP response rate was 72.8%. Respondents were representative of all Dutch GPs with respect to gender, age, working hours, practice experience (mean=15.6 years, SD=8.3, range=1–32), and location (58% in an urban area). More GPs worked in a partnership or group practice than in a solo practice. We analyzed the influence of the practice type on doctor-patient communication and deemed it insignificant.

Study population

GP and patient characteristics appear in TABLE 1. Among patients, 22% had little education, 62% had an average education, and 16% had higher education. Nearly 10% had a psychosocial problem. GP-patient gender dyads were as follows: 32.1% male GP/male patient; 45.3% male GP/female patient; 6.9% female GP/male patient; 15.8% female GP/female patient.

TABLE 1
General practitioner and patient characteristics (N GPs=142, N patients=1787)

Preference and performance of communication aspects

GPs good with affect-oriented communication aspects. Patients considered 6 of 7 affect-oriented communication aspects as very important (87%–96%, TABLE 2). The item “Doctor was empathic to me” was less important (61%) than items like “Doctor listened well to me” (96%) and “Doctor took enough time for me” (93%). We noted only a few discrepancies between preference and performance of the GPs’ affect-oriented behavior. If patients said beforehand that a communication aspect was important, the doctors nearly always performed that aspect. For instance, 87% wanted enough attention from the doctor and received it, while 99% of all patients received GP’s attention, whether it was important to them or not.

GPs less successful with task-oriented communication aspects. Many patients wanted information, explanations, advice, and help with their problems (85%–94%, TABLE 2). Knowing the diagnosis was less important (77%) than, say, receiving advice on what to do and having details of treatment explained.

GPs also performed most of the task-oriented aspects, if patients considered these aspects important.

Subjectively, preferences for GP task-oriented behavior and perceived performance often went together, though more discrepancies were visible than with affect-oriented behavior. One fifth of patients said their problems were not helped, though they had said this was important. Similarly, GPs did not give a diagnosis to nearly 15% of patients who considered it important.

TABLE 2
Care vs cure-centered communication: Physicians fared better on the care side (N=1787)

GP communication varies by doctor gender, patient characteristics

GPs engaged less in affect-oriented than in task-oriented communication (48.6 and 70.0 utterances on average, respectively, P≤.001).

The more patients regarded affect-oriented talk by GPs as important, the more the GPs actually showed affective and patient-centered behavior (TABLE 3). Preferences for task-oriented behavior (question-asking, information-giving, and counseling) were mirrored in their doctors’ talk.

When taking into account other GP and patient characteristics, female doctors were more often affect-oriented as well as task-oriented when communicating with patients than were male doctors, especially with female patients. In consultations with older patients and those in poor health, the doctors were more affective than in consultations with younger and healthy patients.

TABLE 3
On observation, physician communication corresponded to patient preferences (N GPs=142, N patients=1787)

Discussion

Our study suggests most patients receive from their GPs the kind of communication they prefer in a consultation. In general, patients consider both affect- and task-oriented communication aspects important, and believe they are often performed. Our findings agree with most of the literature.^5,14,20 Furthermore, patients’ preferences are for the greater part reflected in the GPs’ observed communication during the visit, which agrees with one earlier study¹⁸ but not with others.^5,20

Patient preference for an affective doctor is very often met. GPs are generally considered attentive, friendly, frank, empathic, and good listeners. Patients seem satisfied in this respect. However, the task-oriented communication of the GPs is sometimes less satisfying. Contrary to patient preference, for example, GPs are not always able to make a diagnosis.

Observed physician behavior: patients usually get what they want. Looking at the relationship between preferences and actual GP communication, it appears that the more patients prefer an affective or caring doctor, the more they are likely to get an empathic, concerned, interested, and patient-centered doctor, especially when psychosocial problems are expressed. An affective GP was patient centered, involving patients in problem definition and decision making. This relationship between affective behavior and patient-centeredness was also found in earlier studies.^22,29 However, Swenson found that not all patients wanted the doctor to exhibit a patient-centered approach.³⁰

Likewise, the more patients prefer a task-oriented doctor, the better the chance they will have a doctor who explains things well, and who gives information and advice to their satisfaction. However, task-oriented doctors are usually less affective and less patient-centered when talking with patients. In view of the postulate that a doctor has to be curing as well as caring,⁶ doctors would be wise to give attention to both aspects.

GPs do improvise while communicating with patients. The study shows that GPs and patients working together can create the type of encounter both want. GPs are able to change their behavior in response to real-time cues they believe patients are giving in an encounter.

Physician gender often makes a difference. Our findings suggest that female doctors are more affective and task-oriented when talking with their patients than are male doctors, especially with female patients. In view of the steady increase of female doctors in general practice, this combined communication style may become more common in the future.

Psychosocial complaints prompt affective communication. Patients with a psychosocial problem are more likely to encounter an affective doctor than those with a biomedical problem. The growing number of psychosocial problems in the population may lead to a more affective communication.

Eventually the demand and the supply of affective communication may coincide. However, it is a challenge for every doctor to keep his or her mind open to both biomedical (task-oriented) and psychosocial (affective-oriented) information.³¹

Study caveats. Because we used scale scores for affect- and task-oriented preferences instead of the separate item scores for patient preferences, the reflection of preferences for GP communicative behavior might be somewhat overestimated. Likewise, we used total observation scores for affect- and task-oriented talk instead of the separate RIAS categories. More detailed measures of such communication aspects as empathy might give better insight into patient preferences.

Final thoughts on personal application. Primary care physicians would do well to take notice of patients’ preferences for communication. GPs in our study were often able to grasp what patients considered important to talk about, and there seemed to be only modest mismatches between patient expectations and physician behavior. To increase the quality of health care, consider asking patients at the end of a visit whether their preferences were met.

Acknowledgments

We acknowledge the participating general practitioners and patients, the observers of the videotaped consultations, and the Ministry of Health, Welfare and Sports for funding (for the greater part) the research project.

Correspondence
A. van den Brink-Muinen, PhD, NIVEL, PO Box 1568, 3500 BN Utrecht, The Netherlands; a.vandenbrink@nivel.nl

The Centers for Disease Control and Prevention (CDC) recently released an update to its treatment guidelines for sexually transmitted diseases, stating that fluoroquinolones are no longer recommended for treatment of gonococcal infections.¹ This change resulted from a progressive increase in the rate of resistance to quinolones among gonorrhea isolated from publicly funded treatment centers across the country.

The new advisory applies to all quinolones previously recommended: ciprofloxacin, ofloxacin, and levofloxacin.

Epidemiology. Gonorrhea remains common in the United States, with nearly 340,000 cases reported in 2005. Since it is under-reported, estimates are that more than 600,000 cases occur each year.²

Neisseria gonorrhoeae causes infection of the cervix, urethra, rectum, pharynx, and adnexa. It can also cause disseminated disease that can affect joints, heart, and the meninges.

Tracking the spread of resistant cases

Since the early 1990s, fluoroquinolones have been one of the recommended treatments for gonorrhea because of their availability as effective, single-dose oral regimens. Fluoroquinolone-resistant N gonorrhea began to emerge at the end of the century and has progressed rapidly since. FIGURE 1 illustrates the proportion of fluoroquinolone-resistant N gonorrhea from the CDC’s Gonococcal Isolate Surveillance Project (GISP) by year, from 1990 to 2006.

Resistance began to emerge first among gonorrhea isolates from men who have sex with men (MSM), and resistance rates among MSM continue to be higher than in heterosexual men (FIGURE 2).

Geographic trends. In 2000, the CDC recommended that quinolones should no longer be used to treat gonorrhea in persons who contracted the infection in Asia or the Pacific. In 2002, California was added to this list. In 2004, the recommendation against quinolone use was extended to all MSM in the US.

The new recommendation against general use is based on resistance surpassing 5% of total isolates.

FIGURE 1
Percentage of N gonorrhoeae isolates with intermediate resistance or resistance to ciprofloxacin

FIGURE 2
Progressive increase of fluoroquinolone resistance

Ceftriaxone, the default treatment of choice

The loss of quinolones as a recommended gonorrhea treatment leaves only ceftriaxone, 125 mg intramuscularly (IM), as the only readily available treatment for urogenital, anorectal, and pharyngeal gonorrhea. Cefixime 400 mg as a single dose is also recommended, but is not currently available in tablet form in the US. It is available as a suspension with 100 mg per 5 cc.

Other options

Possible oral options include cefpodoxime 400 mg or cefuroxime axetil 1 g. However, neither has the official endorsement of the CDC, and neither appears effective against pharyngeal infection.

Spectinomycin 2 g intramuscularly is recommended for those with cephalosporin allergy—but, like cefixime, it is not currently available in the US, and it also is not considered effective against pharyngeal infection.

Azithromycin 2 g orally as a single dose is currently effective against gonorrhea and is an option for those with cephalosporin allergies. The CDC discourages its widespread use because of concerns about resistance.

New information regarding the availability of spectinomycin and cefixime can be obtained from local health departments or the CDC’s sexually transmitted diseases web site (www.cdc.gov/std).³

Recommended regimens for treatment of gonorrhea

Associated conditions

Treat for chlamydia if chlamydial infection is not ruled out

The CDC continues to recommend concurrent treatment for chlamydia for all persons who have gonorrhea, unless coinfection has been ruled out.

Therapies for chlamydia include azithromycin 1 g as a single dose or doxycycline 100 mg twice a day for 7 days.

Pelvic inflammatory disease and epididymitis

The treatment of both pelvic inflammatory disease (PID) and epididymitis include an option of ceftriaxone 250 mg IM plus doxycycline for either 7 days (for epididymitis) or 10 days (for PID). There are several parenteral options for PID and disseminated gonorrhea; these can be found on the CDC’s STD web site.³

Should you always retest to ensure a cure?

It is still not necessary to retest patients who have had the recommended treatments. However, patients with persistent symptoms or rapidly recurring symptoms should be retested by cultures so that drug-resistance patterns can be checked if gonorrhea is documented.

Retest for recurrence

Consider retesting all treated patients after 3 to 6 months, since anyone with a sexually transmitted infection is at risk of being reinfected.

Summary

The ongoing challenges with the evolving resistance patterns of gonorrhea illustrate the importance of physicians accurately diagnosing gonorrhea, treating with recommended regimens, reporting positive cases to the local public health department, and assisting with partner evaluation and treatment.

The Centers for Disease Control and Prevention (CDC) recently released an update to its treatment guidelines for sexually transmitted diseases, stating that fluoroquinolones are no longer recommended for treatment of gonococcal infections.¹ This change resulted from a progressive increase in the rate of resistance to quinolones among gonorrhea isolated from publicly funded treatment centers across the country.

The new advisory applies to all quinolones previously recommended: ciprofloxacin, ofloxacin, and levofloxacin.

Epidemiology. Gonorrhea remains common in the United States, with nearly 340,000 cases reported in 2005. Since it is under-reported, estimates are that more than 600,000 cases occur each year.²

Neisseria gonorrhoeae causes infection of the cervix, urethra, rectum, pharynx, and adnexa. It can also cause disseminated disease that can affect joints, heart, and the meninges.

Tracking the spread of resistant cases

Since the early 1990s, fluoroquinolones have been one of the recommended treatments for gonorrhea because of their availability as effective, single-dose oral regimens. Fluoroquinolone-resistant N gonorrhea began to emerge at the end of the century and has progressed rapidly since. FIGURE 1 illustrates the proportion of fluoroquinolone-resistant N gonorrhea from the CDC’s Gonococcal Isolate Surveillance Project (GISP) by year, from 1990 to 2006.

Resistance began to emerge first among gonorrhea isolates from men who have sex with men (MSM), and resistance rates among MSM continue to be higher than in heterosexual men (FIGURE 2).

Geographic trends. In 2000, the CDC recommended that quinolones should no longer be used to treat gonorrhea in persons who contracted the infection in Asia or the Pacific. In 2002, California was added to this list. In 2004, the recommendation against quinolone use was extended to all MSM in the US.

The new recommendation against general use is based on resistance surpassing 5% of total isolates.

FIGURE 1
Percentage of N gonorrhoeae isolates with intermediate resistance or resistance to ciprofloxacin

FIGURE 2
Progressive increase of fluoroquinolone resistance

Ceftriaxone, the default treatment of choice

The loss of quinolones as a recommended gonorrhea treatment leaves only ceftriaxone, 125 mg intramuscularly (IM), as the only readily available treatment for urogenital, anorectal, and pharyngeal gonorrhea. Cefixime 400 mg as a single dose is also recommended, but is not currently available in tablet form in the US. It is available as a suspension with 100 mg per 5 cc.

Other options

Possible oral options include cefpodoxime 400 mg or cefuroxime axetil 1 g. However, neither has the official endorsement of the CDC, and neither appears effective against pharyngeal infection.

Spectinomycin 2 g intramuscularly is recommended for those with cephalosporin allergy—but, like cefixime, it is not currently available in the US, and it also is not considered effective against pharyngeal infection.

Azithromycin 2 g orally as a single dose is currently effective against gonorrhea and is an option for those with cephalosporin allergies. The CDC discourages its widespread use because of concerns about resistance.

New information regarding the availability of spectinomycin and cefixime can be obtained from local health departments or the CDC’s sexually transmitted diseases web site (www.cdc.gov/std).³

Recommended regimens for treatment of gonorrhea

Associated conditions

Treat for chlamydia if chlamydial infection is not ruled out

The CDC continues to recommend concurrent treatment for chlamydia for all persons who have gonorrhea, unless coinfection has been ruled out.

Therapies for chlamydia include azithromycin 1 g as a single dose or doxycycline 100 mg twice a day for 7 days.

Pelvic inflammatory disease and epididymitis

The treatment of both pelvic inflammatory disease (PID) and epididymitis include an option of ceftriaxone 250 mg IM plus doxycycline for either 7 days (for epididymitis) or 10 days (for PID). There are several parenteral options for PID and disseminated gonorrhea; these can be found on the CDC’s STD web site.³

Should you always retest to ensure a cure?

It is still not necessary to retest patients who have had the recommended treatments. However, patients with persistent symptoms or rapidly recurring symptoms should be retested by cultures so that drug-resistance patterns can be checked if gonorrhea is documented.

Retest for recurrence

Consider retesting all treated patients after 3 to 6 months, since anyone with a sexually transmitted infection is at risk of being reinfected.

Summary

The ongoing challenges with the evolving resistance patterns of gonorrhea illustrate the importance of physicians accurately diagnosing gonorrhea, treating with recommended regimens, reporting positive cases to the local public health department, and assisting with partner evaluation and treatment.

The Centers for Disease Control and Prevention (CDC) recently released an update to its treatment guidelines for sexually transmitted diseases, stating that fluoroquinolones are no longer recommended for treatment of gonococcal infections.¹ This change resulted from a progressive increase in the rate of resistance to quinolones among gonorrhea isolated from publicly funded treatment centers across the country.

The new advisory applies to all quinolones previously recommended: ciprofloxacin, ofloxacin, and levofloxacin.

Epidemiology. Gonorrhea remains common in the United States, with nearly 340,000 cases reported in 2005. Since it is under-reported, estimates are that more than 600,000 cases occur each year.²

Neisseria gonorrhoeae causes infection of the cervix, urethra, rectum, pharynx, and adnexa. It can also cause disseminated disease that can affect joints, heart, and the meninges.

Tracking the spread of resistant cases

Since the early 1990s, fluoroquinolones have been one of the recommended treatments for gonorrhea because of their availability as effective, single-dose oral regimens. Fluoroquinolone-resistant N gonorrhea began to emerge at the end of the century and has progressed rapidly since. FIGURE 1 illustrates the proportion of fluoroquinolone-resistant N gonorrhea from the CDC’s Gonococcal Isolate Surveillance Project (GISP) by year, from 1990 to 2006.

Resistance began to emerge first among gonorrhea isolates from men who have sex with men (MSM), and resistance rates among MSM continue to be higher than in heterosexual men (FIGURE 2).

Geographic trends. In 2000, the CDC recommended that quinolones should no longer be used to treat gonorrhea in persons who contracted the infection in Asia or the Pacific. In 2002, California was added to this list. In 2004, the recommendation against quinolone use was extended to all MSM in the US.

The new recommendation against general use is based on resistance surpassing 5% of total isolates.

FIGURE 1
Percentage of N gonorrhoeae isolates with intermediate resistance or resistance to ciprofloxacin

FIGURE 2
Progressive increase of fluoroquinolone resistance

Ceftriaxone, the default treatment of choice

The loss of quinolones as a recommended gonorrhea treatment leaves only ceftriaxone, 125 mg intramuscularly (IM), as the only readily available treatment for urogenital, anorectal, and pharyngeal gonorrhea. Cefixime 400 mg as a single dose is also recommended, but is not currently available in tablet form in the US. It is available as a suspension with 100 mg per 5 cc.

Other options

Possible oral options include cefpodoxime 400 mg or cefuroxime axetil 1 g. However, neither has the official endorsement of the CDC, and neither appears effective against pharyngeal infection.

Spectinomycin 2 g intramuscularly is recommended for those with cephalosporin allergy—but, like cefixime, it is not currently available in the US, and it also is not considered effective against pharyngeal infection.

Azithromycin 2 g orally as a single dose is currently effective against gonorrhea and is an option for those with cephalosporin allergies. The CDC discourages its widespread use because of concerns about resistance.

New information regarding the availability of spectinomycin and cefixime can be obtained from local health departments or the CDC’s sexually transmitted diseases web site (www.cdc.gov/std).³

Recommended regimens for treatment of gonorrhea

Associated conditions

Treat for chlamydia if chlamydial infection is not ruled out

The CDC continues to recommend concurrent treatment for chlamydia for all persons who have gonorrhea, unless coinfection has been ruled out.

Therapies for chlamydia include azithromycin 1 g as a single dose or doxycycline 100 mg twice a day for 7 days.

Pelvic inflammatory disease and epididymitis

The treatment of both pelvic inflammatory disease (PID) and epididymitis include an option of ceftriaxone 250 mg IM plus doxycycline for either 7 days (for epididymitis) or 10 days (for PID). There are several parenteral options for PID and disseminated gonorrhea; these can be found on the CDC’s STD web site.³

Should you always retest to ensure a cure?

It is still not necessary to retest patients who have had the recommended treatments. However, patients with persistent symptoms or rapidly recurring symptoms should be retested by cultures so that drug-resistance patterns can be checked if gonorrhea is documented.

Retest for recurrence

Consider retesting all treated patients after 3 to 6 months, since anyone with a sexually transmitted infection is at risk of being reinfected.

Summary

The ongoing challenges with the evolving resistance patterns of gonorrhea illustrate the importance of physicians accurately diagnosing gonorrhea, treating with recommended regimens, reporting positive cases to the local public health department, and assisting with partner evaluation and treatment.

Ms. G, age 39, has a body mass index (BMI) >35 kg/m² and is pursuing bariatric surgery to treat obesity. She is frustrated with dieting and describes a decade of unconscious nocturnal eating, including peanut butter and uncooked spaghetti.

This behavior began after her divorce 10 years ago. Initially she had partial recall of the nocturnal binges, but now describes full amnesia. Treatment for a depressive episode did not control her nocturnal eating.

Sleep-related eating disorder (SRED) can be associated with disrupted sleep, weight gain, and major chronic morbidity. In SRED—involuntary eating while asleep, with partial or complete amnesia—the normal suppression of eating during the sleep period is disinhibited. The disorder can be idiopathic, associated with medication use, or linked to other sleep disorders such as somnambulism (sleepwalking), restless legs syndrome (RLS), periodic limb movement disorder (PLMD), or obstructive sleep apnea (OSA).

SRED is more common in women than men; it usually begins in the third decade of life but can begin in childhood or middle age. About one-half of SRED patients also have a psychiatric illness, usually a mood disorder. Unremitting SRED may lead to psychopathology, as the onset of sleep-related eating usually precedes the onset of a psychiatric disorder by years.

SRED often is unrecognized, but it can be effectively identified and treated. This article examines how to:

• distinguish SRED from nocturnal eating syndrome (NES) and other disorders
• identify precipitating causes
• select effective pharmacologic therapy.

Box

Differentiating SRED from NES

Eating and sleeping—and disorders of each—are closely linked (Box).^1-4 SRED and night eating syndrome (NES) are 2 principal night eating disorders. SRED is characterized by inappropriately consuming food after falling asleep,⁵ whereas NES is characterized by hyperphagia after the evening meal, either before bedtime or after fully awakening during the night.⁶

To meet diagnostic criteria for SRED, patients must experience involuntary nocturnal eating and demonstrate at least 1 other symptom, such as:

• eating peculiar, inedible, or toxic substances
• engaging in dangerous behavior while preparing food (Table 1).

Level of consciousness. In both SRED and NES, patients demonstrate morning anorexia. However, patients with NES report being awake and alert during their nocturnal eating, whereas patients with SRED describe partial or complete amnesia. SRED patients with partial awareness often describe the experience as being involuntary, dream-like, and “out-of-control.” Interestingly, hunger is notably absent during most episodes in which patients have at least partial awareness.

Typically, patients cannot be awakened easily from a sleep-eating episode. In this regard, SRED resembles sleepwalking. Sleepwalking without eating often precedes SRED, but once eating develops it often becomes the predominant or exclusive sleepwalking behavior. This pattern has led many researchers to consider SRED a “sleepwalking variant disorder.”

Eating episodes in SRED are often characterized by binge eating, and many patients describe at least one episode per night.⁵ They usually eat high-calorie foods. The spectrum of cuisine is broad, ranging from dry cereal to hot meals that require more than 30 minutes to prepare. Patients treated at our sleep center report eating foods that are high in simple carbohydrates, fats, and—to a lesser extent—protein. Peanut butter—a preferred item—can lead to near-choking episodes when patients fall asleep with peanut butter in their mouths and wake up gasping for air. Alcohol consumption is rare.

SRED episodes can be hazardous, with risks of drinking or eating excessively hot liquids or solids, choking on thick foods, or receiving lacerations while using knives to prepare food. Patients may consume foods to which they are allergic or eat inedible or even toxic substances (Table 2).^5,7-9

Table 1

Differences between expressive and supportive psychotherapy

Table 2

Typical foods consumed while sleep-eating

Chain of consequences

Repeated nocturnal binge eating episodes can have multiple adverse health effects.^5,7 Patients often wake up with painful abdominal distention. Weight gain and subsequent increased BMI may compromise the control of medical complications such as diabetes mellitus, hyperlipidemia, hypertriglyceridemia, hypertension, OSA, and cardiovascular disease. Patients with SRED also report dental problems such as tooth chipping and increased incidence of caries.

Failure to control nocturnal eating can lead to secondary depressive disorders related to excessive weight gain. Moreover, SRED patients’ nighttime behaviors may disrupt their bed partners’ sleep and cause interpersonal and marital problems.

Untreated SRED is usually unremitting. In our experience, most patients describe suffering for years before seeking treatment. Many report that their symptoms have been dismissed by other physicians or wrongly attributed to a mood disorder. Not surprisingly, patients in obesity clinics and eating disorder groups regularly report SRED.

Multiple causes

Medication-induced. The commonly prescribed hypnotic zolpidem can induce SRED.^10,11 Sporadic cases of SRED have been reported with other psychotropics, such as tricyclic antidepressants, anticholinergics, lithium, triazolam, olanzapine, and risperidone.¹²

Life stressors. For a subgroup of patients, such as Ms. G, a life stressor such as a death or divorce precipitates the disorder. Others report SRED onset with cessation of cigarette smoking, ethanol abuse, or amphetamine/cocaine abuse.^5,7 Thus, SRED can be viewed as a “final common pathway disorder” that can be triggered by a variety of sleep disorders, medical-neurologic disorders, medications, and stress. It also can be idiopathic (Table 3).¹²

Table 3

Sleep disorders and medications associated with SRED

CASE CONTINUED: Reaching a diagnosis

Ms. G’s psychiatrist refers her to an accredited sleep center, where she is instructed to keep a diary of her eating and sleeping behaviors for 2 weeks. She returns to the center and undergoes overnight video polysomnography (PSG). During this test, Ms. G demonstrates recurrent confusional arousals arising from non-rapid eye movement sleep (NREM) and eating binges while asleep with no subsequent recall.

Sleep studies aid diagnosis

Diagnosing a patient with SRED requires taking a diligent history to:

• characterize nocturnal eating
• identify predisposing or precipitating factors
• differentiate the behavior from other sleep-related or eating disorders.

At our sleep center, we frequently ask patients and their families to track the patient’s sleep and nocturnal eating behavior 2 weeks before a clinic visit. These diaries help document sleep and eating patterns and assess the patient’s awareness and subsequent recall.

As described above, recurrent nighttime eating with full awareness and control would be best characterized as NES. How-ever, there is some debate as to the extent that SRED can manifest with substantial or full alertness and subsequent recall.¹³ SRED and NES might be at opposite poles of a pathology continuum, in which a sub-group of patients falls into a “gray area” of mixed SRED/NES features.^13,14

Self-induced emesis or other purging behavior usually is not seen in SRED. If a patient presents with this symptom, consider an alternate diagnosis such as bulimia nervosa. A patient with SRED may be diagnosed with a coexisting eating disorder, however, as long as the diagnostic features of the eating disorder are not associated with the nocturnal episodes of SRED.

Finally, at least 2 reports exist of a nocturnal dissociative disorder, in which a recurrent nocturnal “eating personality” emerges.⁷

Sleep laboratory testing. Overnight video PSG—recording the biophysiologic changes that occur during sleep—often is valuable in characterizing SRED and identifying other sleep disorders. To facilitate the eating behavior, we ask patients to bring to the sleep laboratory commonly consumed food to be placed within reach of their bed.

If the patient does eat during the study, we identify the sleep state (non-REM sleep or REM sleep) that precipitates the behavior. Confusional arousals, both with and without eating, usually arise from nonREM sleep.

In patients with SRED, PSG often helps to identify other sleep abnormalities that trigger arousal. Reversible disorders such as RLS, PLMD, and OSA or more subtle sleep disordered breathing are especially important to identify so they can be properly treated. Recently, PSG found rhythmic masticatory muscle activity in stages 1 and 2 non-REM sleep in 29 of 35 patients diagnosed with SRED.¹⁵

CASE CONTINUED: Adding medication

After diagnosing SRED, Ms. G’s psychiatrist initiates the anticonvulsant topiramate, 25 mg at bedtime. After the dose is gradually increased in 25-mg increments to 100 mg at bedtime, Ms. G achieves full control of recurrent nocturnal eating. She loses 40 pounds within the next 6 months.

Pharmacotherapy

SRED is treatable and a reversible cause of obesity. The choice of medication depends on:

• which form of SRED the patient exhibits (drug-induced or idiopathic)
• whether the patient has treatable comorbid conditions.

Temazepam. Switch patients whose SRED is triggered by zolpidem or another hypnotic to a different agent. We have had excellent success with temazepam, 15 to 30 mg at bedtime.

Topiramate. For idiopathic SRED or the sleepwalking variant of SRED, trials from 2 academic institutions suggest that off-label use of topiramate, 25 to 150 mg at bedtime, may be the treatment of choice.^16-18

Start topiramate at 25 mg, and increase in 25-mg increments every 5 to 7 days until the night eating episodes are eliminated. Paresthesias, visual symptoms, and (rarely) renal calculus are reported side effects.

Other medications. Other agents that have shown at least some benefit in patients with SRED include dopaminergic agonists, opiates, and clonazepam.¹⁴ Patients with SRED and a history of chemical dependency may respond to combined levodopa, trazodone, and bupropion (dopaminergic/noradrenergic antidepressant) therapy at bedtime.¹⁹ Also focus treatment on any coexisting sleep disorder, such as RLS or OSA.

Related resources

• American Obesity Association. www.obesity.org.
• American Insomnia Association. www.americaninsomniaassociation.org.
• Schenck CH. Paradox lost: midnight in the battleground of sleep and dreams. Minneapolis, MN: Extreme-Nights, LLC; 2006.

Drug brand names

• Bupropion • Wellbutrin
• Clonazepam • Klonopin
• Levodopa/carbidopa • Sinemet
• Lithium • Eskalith, Lithobid
• Olanzapine • Zyprexa
• Risperidone • Risperdal
• Temazepam • Restoril
• Topiramate • Topamax
• Trazodone • Desyrel
• Triazolam • Halcion
• Zolpidem • Ambien

Disclosures

Drs. Howell and Schenck report no financial relationships with any companies whose products are mentioned in this article or with manufacturers of competing products.

Dr. Crow has received grants or research support from Bristol-Myers Squibb and Pfizer Inc. and served as a consultant to Eli Lilly and Company.

Ms. G, age 39, has a body mass index (BMI) >35 kg/m² and is pursuing bariatric surgery to treat obesity. She is frustrated with dieting and describes a decade of unconscious nocturnal eating, including peanut butter and uncooked spaghetti.

This behavior began after her divorce 10 years ago. Initially she had partial recall of the nocturnal binges, but now describes full amnesia. Treatment for a depressive episode did not control her nocturnal eating.

Sleep-related eating disorder (SRED) can be associated with disrupted sleep, weight gain, and major chronic morbidity. In SRED—involuntary eating while asleep, with partial or complete amnesia—the normal suppression of eating during the sleep period is disinhibited. The disorder can be idiopathic, associated with medication use, or linked to other sleep disorders such as somnambulism (sleepwalking), restless legs syndrome (RLS), periodic limb movement disorder (PLMD), or obstructive sleep apnea (OSA).

SRED is more common in women than men; it usually begins in the third decade of life but can begin in childhood or middle age. About one-half of SRED patients also have a psychiatric illness, usually a mood disorder. Unremitting SRED may lead to psychopathology, as the onset of sleep-related eating usually precedes the onset of a psychiatric disorder by years.

SRED often is unrecognized, but it can be effectively identified and treated. This article examines how to:

• distinguish SRED from nocturnal eating syndrome (NES) and other disorders
• identify precipitating causes
• select effective pharmacologic therapy.

Box

Differentiating SRED from NES

Eating and sleeping—and disorders of each—are closely linked (Box).^1-4 SRED and night eating syndrome (NES) are 2 principal night eating disorders. SRED is characterized by inappropriately consuming food after falling asleep,⁵ whereas NES is characterized by hyperphagia after the evening meal, either before bedtime or after fully awakening during the night.⁶

To meet diagnostic criteria for SRED, patients must experience involuntary nocturnal eating and demonstrate at least 1 other symptom, such as:

• eating peculiar, inedible, or toxic substances
• engaging in dangerous behavior while preparing food (Table 1).

Level of consciousness. In both SRED and NES, patients demonstrate morning anorexia. However, patients with NES report being awake and alert during their nocturnal eating, whereas patients with SRED describe partial or complete amnesia. SRED patients with partial awareness often describe the experience as being involuntary, dream-like, and “out-of-control.” Interestingly, hunger is notably absent during most episodes in which patients have at least partial awareness.

Typically, patients cannot be awakened easily from a sleep-eating episode. In this regard, SRED resembles sleepwalking. Sleepwalking without eating often precedes SRED, but once eating develops it often becomes the predominant or exclusive sleepwalking behavior. This pattern has led many researchers to consider SRED a “sleepwalking variant disorder.”

Eating episodes in SRED are often characterized by binge eating, and many patients describe at least one episode per night.⁵ They usually eat high-calorie foods. The spectrum of cuisine is broad, ranging from dry cereal to hot meals that require more than 30 minutes to prepare. Patients treated at our sleep center report eating foods that are high in simple carbohydrates, fats, and—to a lesser extent—protein. Peanut butter—a preferred item—can lead to near-choking episodes when patients fall asleep with peanut butter in their mouths and wake up gasping for air. Alcohol consumption is rare.

SRED episodes can be hazardous, with risks of drinking or eating excessively hot liquids or solids, choking on thick foods, or receiving lacerations while using knives to prepare food. Patients may consume foods to which they are allergic or eat inedible or even toxic substances (Table 2).^5,7-9

Table 1

Differences between expressive and supportive psychotherapy

Table 2

Typical foods consumed while sleep-eating

Chain of consequences

Repeated nocturnal binge eating episodes can have multiple adverse health effects.^5,7 Patients often wake up with painful abdominal distention. Weight gain and subsequent increased BMI may compromise the control of medical complications such as diabetes mellitus, hyperlipidemia, hypertriglyceridemia, hypertension, OSA, and cardiovascular disease. Patients with SRED also report dental problems such as tooth chipping and increased incidence of caries.

Failure to control nocturnal eating can lead to secondary depressive disorders related to excessive weight gain. Moreover, SRED patients’ nighttime behaviors may disrupt their bed partners’ sleep and cause interpersonal and marital problems.

Untreated SRED is usually unremitting. In our experience, most patients describe suffering for years before seeking treatment. Many report that their symptoms have been dismissed by other physicians or wrongly attributed to a mood disorder. Not surprisingly, patients in obesity clinics and eating disorder groups regularly report SRED.

Multiple causes

Medication-induced. The commonly prescribed hypnotic zolpidem can induce SRED.^10,11 Sporadic cases of SRED have been reported with other psychotropics, such as tricyclic antidepressants, anticholinergics, lithium, triazolam, olanzapine, and risperidone.¹²

Life stressors. For a subgroup of patients, such as Ms. G, a life stressor such as a death or divorce precipitates the disorder. Others report SRED onset with cessation of cigarette smoking, ethanol abuse, or amphetamine/cocaine abuse.^5,7 Thus, SRED can be viewed as a “final common pathway disorder” that can be triggered by a variety of sleep disorders, medical-neurologic disorders, medications, and stress. It also can be idiopathic (Table 3).¹²

Table 3

Sleep disorders and medications associated with SRED

CASE CONTINUED: Reaching a diagnosis

Ms. G’s psychiatrist refers her to an accredited sleep center, where she is instructed to keep a diary of her eating and sleeping behaviors for 2 weeks. She returns to the center and undergoes overnight video polysomnography (PSG). During this test, Ms. G demonstrates recurrent confusional arousals arising from non-rapid eye movement sleep (NREM) and eating binges while asleep with no subsequent recall.

Sleep studies aid diagnosis

Diagnosing a patient with SRED requires taking a diligent history to:

• characterize nocturnal eating
• identify predisposing or precipitating factors
• differentiate the behavior from other sleep-related or eating disorders.

At our sleep center, we frequently ask patients and their families to track the patient’s sleep and nocturnal eating behavior 2 weeks before a clinic visit. These diaries help document sleep and eating patterns and assess the patient’s awareness and subsequent recall.

As described above, recurrent nighttime eating with full awareness and control would be best characterized as NES. How-ever, there is some debate as to the extent that SRED can manifest with substantial or full alertness and subsequent recall.¹³ SRED and NES might be at opposite poles of a pathology continuum, in which a sub-group of patients falls into a “gray area” of mixed SRED/NES features.^13,14

Self-induced emesis or other purging behavior usually is not seen in SRED. If a patient presents with this symptom, consider an alternate diagnosis such as bulimia nervosa. A patient with SRED may be diagnosed with a coexisting eating disorder, however, as long as the diagnostic features of the eating disorder are not associated with the nocturnal episodes of SRED.

Finally, at least 2 reports exist of a nocturnal dissociative disorder, in which a recurrent nocturnal “eating personality” emerges.⁷

Sleep laboratory testing. Overnight video PSG—recording the biophysiologic changes that occur during sleep—often is valuable in characterizing SRED and identifying other sleep disorders. To facilitate the eating behavior, we ask patients to bring to the sleep laboratory commonly consumed food to be placed within reach of their bed.

If the patient does eat during the study, we identify the sleep state (non-REM sleep or REM sleep) that precipitates the behavior. Confusional arousals, both with and without eating, usually arise from nonREM sleep.

In patients with SRED, PSG often helps to identify other sleep abnormalities that trigger arousal. Reversible disorders such as RLS, PLMD, and OSA or more subtle sleep disordered breathing are especially important to identify so they can be properly treated. Recently, PSG found rhythmic masticatory muscle activity in stages 1 and 2 non-REM sleep in 29 of 35 patients diagnosed with SRED.¹⁵

CASE CONTINUED: Adding medication

After diagnosing SRED, Ms. G’s psychiatrist initiates the anticonvulsant topiramate, 25 mg at bedtime. After the dose is gradually increased in 25-mg increments to 100 mg at bedtime, Ms. G achieves full control of recurrent nocturnal eating. She loses 40 pounds within the next 6 months.

Pharmacotherapy

SRED is treatable and a reversible cause of obesity. The choice of medication depends on:

• which form of SRED the patient exhibits (drug-induced or idiopathic)
• whether the patient has treatable comorbid conditions.

Temazepam. Switch patients whose SRED is triggered by zolpidem or another hypnotic to a different agent. We have had excellent success with temazepam, 15 to 30 mg at bedtime.

Topiramate. For idiopathic SRED or the sleepwalking variant of SRED, trials from 2 academic institutions suggest that off-label use of topiramate, 25 to 150 mg at bedtime, may be the treatment of choice.^16-18

Start topiramate at 25 mg, and increase in 25-mg increments every 5 to 7 days until the night eating episodes are eliminated. Paresthesias, visual symptoms, and (rarely) renal calculus are reported side effects.

Other medications. Other agents that have shown at least some benefit in patients with SRED include dopaminergic agonists, opiates, and clonazepam.¹⁴ Patients with SRED and a history of chemical dependency may respond to combined levodopa, trazodone, and bupropion (dopaminergic/noradrenergic antidepressant) therapy at bedtime.¹⁹ Also focus treatment on any coexisting sleep disorder, such as RLS or OSA.

Related resources

• American Obesity Association. www.obesity.org.
• American Insomnia Association. www.americaninsomniaassociation.org.
• Schenck CH. Paradox lost: midnight in the battleground of sleep and dreams. Minneapolis, MN: Extreme-Nights, LLC; 2006.

Drug brand names

• Bupropion • Wellbutrin
• Clonazepam • Klonopin
• Levodopa/carbidopa • Sinemet
• Lithium • Eskalith, Lithobid
• Olanzapine • Zyprexa
• Risperidone • Risperdal
• Temazepam • Restoril
• Topiramate • Topamax
• Trazodone • Desyrel
• Triazolam • Halcion
• Zolpidem • Ambien

Disclosures

Drs. Howell and Schenck report no financial relationships with any companies whose products are mentioned in this article or with manufacturers of competing products.

Dr. Crow has received grants or research support from Bristol-Myers Squibb and Pfizer Inc. and served as a consultant to Eli Lilly and Company.

Ms. G, age 39, has a body mass index (BMI) >35 kg/m² and is pursuing bariatric surgery to treat obesity. She is frustrated with dieting and describes a decade of unconscious nocturnal eating, including peanut butter and uncooked spaghetti.

This behavior began after her divorce 10 years ago. Initially she had partial recall of the nocturnal binges, but now describes full amnesia. Treatment for a depressive episode did not control her nocturnal eating.

Sleep-related eating disorder (SRED) can be associated with disrupted sleep, weight gain, and major chronic morbidity. In SRED—involuntary eating while asleep, with partial or complete amnesia—the normal suppression of eating during the sleep period is disinhibited. The disorder can be idiopathic, associated with medication use, or linked to other sleep disorders such as somnambulism (sleepwalking), restless legs syndrome (RLS), periodic limb movement disorder (PLMD), or obstructive sleep apnea (OSA).

SRED is more common in women than men; it usually begins in the third decade of life but can begin in childhood or middle age. About one-half of SRED patients also have a psychiatric illness, usually a mood disorder. Unremitting SRED may lead to psychopathology, as the onset of sleep-related eating usually precedes the onset of a psychiatric disorder by years.

SRED often is unrecognized, but it can be effectively identified and treated. This article examines how to:

• distinguish SRED from nocturnal eating syndrome (NES) and other disorders
• identify precipitating causes
• select effective pharmacologic therapy.

Box

Differentiating SRED from NES

Eating and sleeping—and disorders of each—are closely linked (Box).^1-4 SRED and night eating syndrome (NES) are 2 principal night eating disorders. SRED is characterized by inappropriately consuming food after falling asleep,⁵ whereas NES is characterized by hyperphagia after the evening meal, either before bedtime or after fully awakening during the night.⁶

To meet diagnostic criteria for SRED, patients must experience involuntary nocturnal eating and demonstrate at least 1 other symptom, such as:

• eating peculiar, inedible, or toxic substances
• engaging in dangerous behavior while preparing food (Table 1).

Level of consciousness. In both SRED and NES, patients demonstrate morning anorexia. However, patients with NES report being awake and alert during their nocturnal eating, whereas patients with SRED describe partial or complete amnesia. SRED patients with partial awareness often describe the experience as being involuntary, dream-like, and “out-of-control.” Interestingly, hunger is notably absent during most episodes in which patients have at least partial awareness.

Typically, patients cannot be awakened easily from a sleep-eating episode. In this regard, SRED resembles sleepwalking. Sleepwalking without eating often precedes SRED, but once eating develops it often becomes the predominant or exclusive sleepwalking behavior. This pattern has led many researchers to consider SRED a “sleepwalking variant disorder.”

Eating episodes in SRED are often characterized by binge eating, and many patients describe at least one episode per night.⁵ They usually eat high-calorie foods. The spectrum of cuisine is broad, ranging from dry cereal to hot meals that require more than 30 minutes to prepare. Patients treated at our sleep center report eating foods that are high in simple carbohydrates, fats, and—to a lesser extent—protein. Peanut butter—a preferred item—can lead to near-choking episodes when patients fall asleep with peanut butter in their mouths and wake up gasping for air. Alcohol consumption is rare.

SRED episodes can be hazardous, with risks of drinking or eating excessively hot liquids or solids, choking on thick foods, or receiving lacerations while using knives to prepare food. Patients may consume foods to which they are allergic or eat inedible or even toxic substances (Table 2).^5,7-9

Table 1

Differences between expressive and supportive psychotherapy

Table 2

Typical foods consumed while sleep-eating

Chain of consequences

Repeated nocturnal binge eating episodes can have multiple adverse health effects.^5,7 Patients often wake up with painful abdominal distention. Weight gain and subsequent increased BMI may compromise the control of medical complications such as diabetes mellitus, hyperlipidemia, hypertriglyceridemia, hypertension, OSA, and cardiovascular disease. Patients with SRED also report dental problems such as tooth chipping and increased incidence of caries.

Failure to control nocturnal eating can lead to secondary depressive disorders related to excessive weight gain. Moreover, SRED patients’ nighttime behaviors may disrupt their bed partners’ sleep and cause interpersonal and marital problems.

Untreated SRED is usually unremitting. In our experience, most patients describe suffering for years before seeking treatment. Many report that their symptoms have been dismissed by other physicians or wrongly attributed to a mood disorder. Not surprisingly, patients in obesity clinics and eating disorder groups regularly report SRED.

Multiple causes

Medication-induced. The commonly prescribed hypnotic zolpidem can induce SRED.^10,11 Sporadic cases of SRED have been reported with other psychotropics, such as tricyclic antidepressants, anticholinergics, lithium, triazolam, olanzapine, and risperidone.¹²

Life stressors. For a subgroup of patients, such as Ms. G, a life stressor such as a death or divorce precipitates the disorder. Others report SRED onset with cessation of cigarette smoking, ethanol abuse, or amphetamine/cocaine abuse.^5,7 Thus, SRED can be viewed as a “final common pathway disorder” that can be triggered by a variety of sleep disorders, medical-neurologic disorders, medications, and stress. It also can be idiopathic (Table 3).¹²

Table 3

Sleep disorders and medications associated with SRED

CASE CONTINUED: Reaching a diagnosis

Ms. G’s psychiatrist refers her to an accredited sleep center, where she is instructed to keep a diary of her eating and sleeping behaviors for 2 weeks. She returns to the center and undergoes overnight video polysomnography (PSG). During this test, Ms. G demonstrates recurrent confusional arousals arising from non-rapid eye movement sleep (NREM) and eating binges while asleep with no subsequent recall.

Sleep studies aid diagnosis

Diagnosing a patient with SRED requires taking a diligent history to:

• characterize nocturnal eating
• identify predisposing or precipitating factors
• differentiate the behavior from other sleep-related or eating disorders.

At our sleep center, we frequently ask patients and their families to track the patient’s sleep and nocturnal eating behavior 2 weeks before a clinic visit. These diaries help document sleep and eating patterns and assess the patient’s awareness and subsequent recall.

As described above, recurrent nighttime eating with full awareness and control would be best characterized as NES. How-ever, there is some debate as to the extent that SRED can manifest with substantial or full alertness and subsequent recall.¹³ SRED and NES might be at opposite poles of a pathology continuum, in which a sub-group of patients falls into a “gray area” of mixed SRED/NES features.^13,14

Self-induced emesis or other purging behavior usually is not seen in SRED. If a patient presents with this symptom, consider an alternate diagnosis such as bulimia nervosa. A patient with SRED may be diagnosed with a coexisting eating disorder, however, as long as the diagnostic features of the eating disorder are not associated with the nocturnal episodes of SRED.

Finally, at least 2 reports exist of a nocturnal dissociative disorder, in which a recurrent nocturnal “eating personality” emerges.⁷

Sleep laboratory testing. Overnight video PSG—recording the biophysiologic changes that occur during sleep—often is valuable in characterizing SRED and identifying other sleep disorders. To facilitate the eating behavior, we ask patients to bring to the sleep laboratory commonly consumed food to be placed within reach of their bed.

If the patient does eat during the study, we identify the sleep state (non-REM sleep or REM sleep) that precipitates the behavior. Confusional arousals, both with and without eating, usually arise from nonREM sleep.

In patients with SRED, PSG often helps to identify other sleep abnormalities that trigger arousal. Reversible disorders such as RLS, PLMD, and OSA or more subtle sleep disordered breathing are especially important to identify so they can be properly treated. Recently, PSG found rhythmic masticatory muscle activity in stages 1 and 2 non-REM sleep in 29 of 35 patients diagnosed with SRED.¹⁵

CASE CONTINUED: Adding medication

After diagnosing SRED, Ms. G’s psychiatrist initiates the anticonvulsant topiramate, 25 mg at bedtime. After the dose is gradually increased in 25-mg increments to 100 mg at bedtime, Ms. G achieves full control of recurrent nocturnal eating. She loses 40 pounds within the next 6 months.

Pharmacotherapy

SRED is treatable and a reversible cause of obesity. The choice of medication depends on:

• which form of SRED the patient exhibits (drug-induced or idiopathic)
• whether the patient has treatable comorbid conditions.

Temazepam. Switch patients whose SRED is triggered by zolpidem or another hypnotic to a different agent. We have had excellent success with temazepam, 15 to 30 mg at bedtime.

Topiramate. For idiopathic SRED or the sleepwalking variant of SRED, trials from 2 academic institutions suggest that off-label use of topiramate, 25 to 150 mg at bedtime, may be the treatment of choice.^16-18

Start topiramate at 25 mg, and increase in 25-mg increments every 5 to 7 days until the night eating episodes are eliminated. Paresthesias, visual symptoms, and (rarely) renal calculus are reported side effects.

Other medications. Other agents that have shown at least some benefit in patients with SRED include dopaminergic agonists, opiates, and clonazepam.¹⁴ Patients with SRED and a history of chemical dependency may respond to combined levodopa, trazodone, and bupropion (dopaminergic/noradrenergic antidepressant) therapy at bedtime.¹⁹ Also focus treatment on any coexisting sleep disorder, such as RLS or OSA.

Related resources

• American Obesity Association. www.obesity.org.
• American Insomnia Association. www.americaninsomniaassociation.org.
• Schenck CH. Paradox lost: midnight in the battleground of sleep and dreams. Minneapolis, MN: Extreme-Nights, LLC; 2006.

Drug brand names

• Bupropion • Wellbutrin
• Clonazepam • Klonopin
• Levodopa/carbidopa • Sinemet
• Lithium • Eskalith, Lithobid
• Olanzapine • Zyprexa
• Risperidone • Risperdal
• Temazepam • Restoril
• Topiramate • Topamax
• Trazodone • Desyrel
• Triazolam • Halcion
• Zolpidem • Ambien

Disclosures

Drs. Howell and Schenck report no financial relationships with any companies whose products are mentioned in this article or with manufacturers of competing products.

Dr. Crow has received grants or research support from Bristol-Myers Squibb and Pfizer Inc. and served as a consultant to Eli Lilly and Company.