CSF oxytocin in anorexia nervosa and bulimia nervosa: clinical and pathophysiologic considerations

Oxytocin is a hypothalamic neuropeptide with both centrally and peripherally directed pathways. Data from experimental animals indicate that oxytocin impairs consolidation of aversively conditioned behaviors and is released after feeding or experimental gastric distension. The authors report that the mean CSF oxytocin level of five underweight women with restricting anorexia, but not 12 underweight bulimic anorexic women or 35 normal-weight women with bulimia nervosa, was significantly lower than the level of 11 control subjects. Restricting anorexic patients' low CSF oxytocin levels may reflect their persistently low food intake, and this behavior may exacerbate their tendency for perseverative preoccupation with adverse consequences of food intake.     

Self-forgiveness in anorexia nervosa and bulimia nervosa

This study investigated whether low levels of self-forgiveness were associated with eating disorder symptomatology. Participating women (N = 51) had diagnoses of anorexia nervosa, bulimia nervosa, or no eating disorder diagnosis. They completed 3 measures of self-forgiveness. Women with eating disorders had lower levels of self-forgiveness compared with control participants. Results suggest that incorporating self-forgiveness interventions into current eating disorder treatments should be evaluated in future research as they might enhance clinical outcomes.     

Stealing in anorexia nervosa and bulimia nervosa

Only recently stealing behaviour has been noticed as a symptom of anorexia nervosa and bulimia nervosa. Reviewing our sample of 63 patients we discuss the incidence and motivation of kleptomania. In 24% of our patients stealing behaviour was reported which is a definitely high rate compared to literature. Among the intentions for stealing behaviour we found: Stealing as conversion of revenge, self-assertiveness compensation of binge-eating or stealing as achievement. The differential motivation of stealing should be considered in legal consequences.     

Emotional eating in anorexia nervosa and bulimia nervosa

ObjectivesThe relationship between emotional states and eating behaviors is complex, and emotional eating has been identified as a possible factor triggering binge eating in bulimia nervosa (BN) and binge eating disorder. Few studies considered emotional eating in patients with anorexia nervosa.MethodsThe present study evaluated the clinical correlates of emotional eating in 251 eating-disordered (EDs) subjects (70 AN restricting type, 71 AN binge eating/purging type, 110 BN purging type) and in a group of 89 healthy control subjects. Subjects were assessed by means of a clinical interview (Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) and several self-reported questionnaires, including the Emotional Eating Scale (EES).ResultsNo significant differences were found between the 3 EDs groups in terms of EES total score, and all patients with ED showed higher EES scores compared with control subjects. Emotional eating was associated with subjective binge eating in AN binge eating/purging type and with objective binge eating in patients with BN. Among patients with AN restricting type, emotional eating was associated with restraint, but this association was lost when controlling for fear of loss of control over eating, which was the principal determinant of restraint.ConclusionEmotional eating and fear of loss of control over eating are significantly associated with specific eating attitudes and behaviors, according to the different diagnoses. Emotional eating is a relevant psychopathologic dimension that deserves a careful investigation in both anorectic and bulimic patients.     

Pain sensitivity in anorexia nervosa and bulimia nervosa

Pain threshold was measured with short heat stimuli using a contact thermode in 19 patients with anorexia nervosa, 20 patients with bulimia nervosa, and 21 control subjects. Both patient groups had significantly elevated pain thresholds compared with the control subjects. In the total sample, no substantial covariation could be demonstrated among pain threshold and clinical, physiological, metabolic, or psychological data. However, in separate regression analyses pain threshold correlated significantly (negatively) with local skin temperature in the anorectic patients and almost significantly (positively) with body weight in the bulimic patients. This finding suggests that the reduced pain sensitivity in the two kinds of eating disorders might have different causes.     

Pharmacotherapy for anorexia nervosa and bulimia nervosa

Psychotherapy is the treatment of choice for both anorexia nervosa and for bulimia nervosa. However, many patients are also treated by pharmaceutical drugs. For the clinician it is difficult to choose pharmacotherapy, because the drugs may not be licensed, because of pharmacodynamic problems due to underweight or purging behaviour, or because of comorbidity. The present review summarises the current knowledge on pharmacotherapy for anorexia nervosa and bulimia nervosa considering the available guidelines. In general, the knowledge based on studies is insufficient for anorexia nervosa. Up to now, there is no proof of efficacy for any antidepressant or atypical antipsychotic with respect to weight gain; atypical antipsychotics may be helpful for ruminating or excessive motor hyperactivity. For bulimia nervosa antidepressants are the pharmacotherapy of first choice. Long-term effects, however, are still unknown.     

Personality disorders in anorexia nervosa and bulimia nervosa

Two self-report questionnaires (MCMI and BSI) designed to measure personality disorder (PD) according to DSM-III (R) criteria were administered to patients with a diagnosis of anorexia nervosa (AN) (n = 19), bulimia nervosa (BN) (n = 16), or both diagnoses (AN + BN) (n = 9), both before and after treatment for the eating disorder. The main finding was that self-reported Personality Disorder (PD) diagnoses are not stable enduring characteristics among this group of eating disorder patients. A high rate of PD diagnoses occurred in all patient groups at admission (93%) and at discharge (79%). Both MCMI and BSI scales were subject to significant change following treatment. A high prevalence of borderline personality disorder was found in patients with BN. Changes in depression and self-esteem scores correlated most strongly with changes in schizoid, schizotypal, histrionic and narcissistic scales. Assessment of PD using self-report measures should be interpreted with caution in acutely symptomatic patients with eating disorders.     

The endocrinology of anorexia nervosa and bulimia nervosa

Considerable evidence exists of hypothalamic dysfunction in patients with anorexia nervosa and bulimia nervosa. This dysfunction is reflected in disturbances of endocrine function including abnormalities of gonadotropin, growth hormone, and corticotropin-releasing hormone secretion. Whereas these disturbances are generally reversed with nutritional rehabilitation and weight restoration, it is not evident to what extent nutritional factors are the primary etiology or whether they unmask an otherwise existing but compensated central disturbance. Similarly, endocrine disturbances may be a final common pathway in which disturbances of diet, weight, activity, stress, and mood as well as hypothalamic dysfunction are expressed.     

Cognitive flexibility in anorexia nervosa and bulimia nervosa.

The aim of this study was to determine if there are differences in cognitive flexibility in anorexia nervosa and bulimia nervosa. Fifty-three patients with an eating disorder (34 with anorexia nervosa and 19 with bulimia nervosa) and 35 healthy controls participated in the study. A battery of neuropsychological tests for cognitive flexibility was used, including Trail Making B, the Brixton Test, Verbal Fluency, the Haptic Illusion Test, a cognitive shifting task (CatBat) and a picture set test. Using exploratory factor analysis, four factors were obtained: 1: Simple Alternation; 2: Mental Flexibility; 3: Perseveration; and 4: Perceptual Shift. Patients with anorexia nervosa had abnormal scores on Factors 1 and 4. Patients with bulimia nervosa showed a different pattern, with significant impairments in Factors 2 and 4. These findings suggest that differential neuropsychological disturbance in the domain of mental flexibility/rigidity may underlie the spectrum of eating disorders.     

Medical complications of anorexia nervosa and bulimia nervosa

PURPOSE OF REVIEW: This review focuses on recent publications concerning medical complications in patients with eating disorders, including anorexia nervosa and bulimia nervosa. RECENT FINDINGS: Recent literature continues to reflect that multiple organ systems are frequently affected by eating disorders. The literature underscores the frequently cited risk of premature death in those with anorexia nervosa. A plethora of dermatologic changes have been described, some signaling serious underlying pathophysiology, such as purpura, which indicates a bleeding diathesis. Much of the literature continues to delineate the fact that diabetic patients with eating disorders are at high risk of developing diabetic complications. Gastrointestinal complications can be serious, including gastric dilatation and severe liver dysfunction. Acrocyanosis is common, and patients with anorexia nervosa are at risk of various arrhythmias. Low-weight patients are at high risk for osteopenia/osteoporosis. Nutritional abnormalities are also common, including sodium depletion and hypovolemia, hypophosphatemia and hypomagnesemia. Resting energy expenditure, although very low in low-weight patients, increases dramatically early in refeeding. SUMMARY: Medical complications are common and often serious in patients with eating disorders, particularly those with anorexia nervosa.     

Gonadotropin response to LH-RH in anorexia nervosa and bulimia

Serum LH and FSH levels before and after stimulation with LH-RH were measured in 9 patients with bulimia, 7 with a restricting subtype and 6 with a bulimic subtype of anorexia nervosa. All patients with anorexia nervosa and 5 (56%) patients with bulimia showed amenorrhea for at least 5 months, while 4 (44%) of the bulimic patients showed oligomenorrhea. Mean basal levels of LH and FSH were low in patients with restricting and bulimic anorexia nervosa, but were normal in patients with bulimia. The response of LH and FSH to LH-RH was impaired in approximately half of the patients with the two subtypes of anorexia nervosa, whereas it was normal in all but one patient with bulimia. These results suggest that bulimic patients with amenorrhea or oligomenorrhea have hypothalamic dysfunctions, which do not appear to be due solely to low weight or to metabolic changes resulting from binge eating, vomiting or purgative use.     

Hypothalamic-pituitary-gonadal function in anorexia nervosa and bulimia

Patients with anorexia nervosa (AN) exhibit neuroendocrine abnormalities that may result solely from emaciation or may reflect defective endocrine mechanisms which are intrinsic to disordered eating even in the absence of starvation. To distinguish these possibilities, we have studied indices of hypothalamic-pituitary-gonadal (HPG) function in 9 patients with AN, 12 normal weight patients with bulimia and recent or current oligomenorrhea, and 8 normal weight controls. Measurement of 24-hour luteinizing hormone (LH) secretion with 30-min sampling revealed significantly fewer LH secretory spikes and a trend toward lower mean 24-hour LH levels in both bulimic and anorectic patients than in controls. Stimulation with gonadotropin releasing hormone produced elevated LH responses in the bulimic group and blunted LH responses in the anorectic group. Stimulation with estradiol revealed diminished LH augmentative responses and a trend toward diminished follicle stimulating hormone augmentative responses among bulimic as well as AN patients compared to controls. In each instance, the bulimic group tended to show within-group heterogeneity, with some individuals falling within the AN range. These findings suggest that HPG axis abnormalities in eating disordered patients cannot entirely be attributed to emaciation and that factors other than subnormal weight contribute to disturbed hypothalamic-pituitary functioning in these patients.     

EEG-monitored sleep in anorexia nervosa and bulimia

We compared the EEG-monitored sleep of 8 women with anorexia nervosa and 16 normal weight women with bulimia to that of 14 normal women. The patients with anorexia nervosa spent less time asleep and spent less of their sleep time in Stage 1. The sleep of the normal weight patients with bulimia was remarkably similar to that of the controls. These data suggest that most patients with anorexia nervosa and bulimia do not exhibit the type of sleep disturbances characteristic of patients with major depressive illness.     

CSF oxytocin and vasopressin levels after recovery from bulimia nervosa and anorexia nervosa, bulimic subtype.

BACKGROUND: When ill, people with eating disorders have disturbances of the neuropeptides vasopressin and oxytocin. METHODS: To avoid the confounding effects of the ill state, we studied women who were recovered (more than 1 year, normal weight, and regular menstrual cycles, no bingeing or purging) from bulimia nervosa (rBN) or binge eating/purging-type anorexia nervosa (rAN-BN), and matched healthy control women. RESULTS: Vasopressin was elevated in rAN-BN and showed a trend towards elevation in rBN. In rBN, elevated cerebrospinal fluid vasopressin may be related to having a lifetime history of major depression. In comparison, cerebrospinal fluid oxytocin was normal in recovered subjects, but elevated levels in some rBN might be related to birth control pill use. CONCLUSIONS: These data confirm and extend the possibility that elevated cerebrospinal fluid vasopressin may be related to the pathophysiology of eating disorders, and/or a lifetime history of major depression.     

Hypothalamic-pituitary-adrenal-cortical activity in anorexia nervosa and bulimia

We studied hypothalamic-pituitary-adrenal-cortical (HPA) activity in nine underweight women with anorexia nervosa, 12 women of normal body weight with bulimia, and nine control subjects. The measures of HPA activity were the pattern of plasma cortisol secretion over 24 hr and the responses of plasma cortisol to dexamethasone suppression and to low dose ACTH stimulation. The patients with anorexia nervosa had significantly elevated 24 hr concentrations of plasma cortisol compared to the controls and showed significantly less cortisol suppression following dexamethasone. There was no difference between patients with anorexia nervosa and controls in the rise in plasma cortisol following ACTH. On most measures of HPA activity, the normal weight patients with bulimia were indistinguishable from the controls. These results suggest that HPA activity is normal in most patients of normal body weight with bulimia and that the psychological and behavioral disturbances common to both anorexia nervosa and bulimia are, in the absence of significant weight loss, insufficient to produce major alterations in HPA activity.     

Diagnostic crossover in anorexia nervosa and bulimia nervosa: implications for DSM-V

OBJECTIVE: The Diagnostic and Statistical Manual of Mental Disorders (DSM) is designed primarily as a clinical tool. Yet high rates of diagnostic "crossover" among the anorexia nervosa subtypes and bulimia nervosa may reflect problems with the validity of the current diagnostic schema, thereby limiting its clinical utility. This study was designed to examine diagnostic crossover longitudinally in anorexia nervosa and bulimia nervosa to inform the validity of the DSM-IV-TR eating disorders classification system. METHOD: A total of 216 women with a diagnosis of anorexia nervosa or bulimia nervosa were followed for 7 years; weekly eating disorder symptom data collected using the Eating Disorder Longitudinal Interval Follow-Up Examination allowed for diagnoses to be made throughout the follow-up period. RESULTS: Over 7 years, the majority of women with anorexia nervosa experienced diagnostic crossover: more than half crossed between the restricting and binge eating/purging anorexia nervosa subtypes over time; one-third crossed over to bulimia nervosa but were likely to relapse into anorexia nervosa. Women with bulimia nervosa were unlikely to cross over to anorexia nervosa. CONCLUSIONS: These findings support the longitudinal distinction of anorexia nervosa and bulimia nervosa but do not support the anorexia nervosa subtyping schema.