Assessment of ego state in anorexia nervosa and bulimia nervosa.

To clarify the effects of ego states on anorexia nervosa (AN) and bulimia nervosa (BN), the questionnaire of the Tokyo University Egogram (TEG) with critical parent, nurturing parent, adult, free child and adapted child scales was administered to 32 female AN patients aged 14 to 32 years (mean age 20 years) and 49 female BN patients aged 14 to 33 years (mean age 23 years). The scores on the critical parent and adapted child scales for AN were significantly lower than those for BN. A multiple logistic regression analysis including all of the TEG scales, age, duration of illness and education showed that the adapted child scale significantly discriminated between AN and BN. The adaptive ego state is suggested for differentiating between the two disorders.     

Effect of mood states on QT interval and QT dispersion in eating disorder patients

Aim:  Prolonged QT interval and QT dispersion have been reported in patients with eating disorders. Although the factors that cause prolongation remain unclear, mood states such as anxiety have been reported to influence QT interval and dispersion, probably via the autonomic nervous system. Therefore the aim of the present paper was to investigate mood effect on prolonged QT interval and QT dispersion.
Method:  The subjects were 47 female anorexia nervosa (AN) and 48 female bulimia nervosa (BN) patients. In all of the patients, serum electrolyte levels were normal. QT interval and QT dispersion were measured from 12-lead electrocardiographic recordings. Mood states in each patient were measured using a Profile of Mood States (POMS) evaluation, and the patients were divided into high- and low-score groups for each POMS subscale. The differences in QT variables were compared between the two groups for each subscale.
Results:  In the BN group, QT interval and QT dispersion in the high depression score group were significantly longer than those in the low depression score group, and QT dispersion was significantly greater in the high anxiety score group than in the low anxiety score group. In addition, QT interval and QT dispersion were significantly correlated with depression scores. In the AN group there were no significant differences in QT interval or QT dispersion between the high- and low-score groups for any POMS subscale.
Conclusions:  BN patients with worse states of depression or anxiety had longer QT intervals and larger QT dispersion. In BN patients, mood disturbance might increase the risk of arrhythmias.     

Temperament, character and suicide attempts in anorexia nervosa, bulimia nervosa and major depression.

OBJECTIVE: We examined the relation between personality traits as measured by the Temperament and Character Inventory (TCI) and a reported history of suicide attempts in women with anorexia nervosa, bulimia nervosa and major depression. METHOD: We compared the prevalence and severity of suicide attempts in women with anorexia nervosa (n = 68), bulimia nervosa (n = 152) and major depression with no history of an eating disorder (n = 59), and we examined the relation between the TCI scales and suicide attempts. RESULTS: Comparable numbers of women across the three groups had attempted suicide. The temperament dimension of high persistence and the character dimensions of low self-directedness and high self-transcendence were associated with a reported history of suicide attempts. CONCLUSION: Suicide attempts are equally common in women with eating disorders and women with depression. Whether the observed association between temperament and suicide attempts reflects correlates, causal factors or sequelae of suicide attempts is unknown.     

Anorexia nervosa and bulimia nervosa: A meta-analysis of executive functioning

ObjectiveResearch investigating the link between eating disorder (ED) diagnosis and executive dysfunction has had conflicting results, yet no meta-analyses have examined the overall association of ED pathology with executive functioning (EF).MethodEffect sizes were extracted from 32 studies comparing ED groups (27 of anorexia nervosa, 9 of bulimia nervosa) with controls to determine the grand mean effect on EF. Analyses included effects for individual EF measures, as well as an age-based subgroup analysis.ResultsThere was a medium effect of ED diagnosis on executive functioning, with bulimia nervosa demonstrating a larger effect (Hedges’s g = −0.70) than anorexia nervosa (g = −0.41). Within anorexia nervosa studies, subgroup analyses were conducted for age and diagnostic subtype. The effect of anorexia nervosa on EF was largest in adults; however, subgroup differences for age were not significant.ConclusionsAnorexia and bulimia nervosa are associated with EF deficits, which are particularly notable for individuals with bulimia nervosa. The present analysis includes recommendations for future studies regarding study design and EF measurement.     

Epidemiology of anorexia nervosa and bulimia nervosa in Bornholm County,Denmark, 1970–1989

In a retrospective study of anorexia nervosa and bulimia nervosa, potential cases were traced, studied, and diagnosed according to ICD-10. Forty-two cases were found in Bornholm County, comprising the island of Bornholm in Denmark, in a population of 47,000 from 1970 to 1989. Less than half of these cases (n= 16) were registered in Danish psychiatric case registers, and 35% (n= 14) could be found only by search in primary care. The incidence rates were stable during most of the study period, but a significant increase occurred during the last 5 years. The prevalence rates, determined by counting the number of cases in the population year by year, also increased during the late part of the study period. In 1989 the incidence rate of the high-risk group of females 10 to 24 years of age was 136 per 100,000 for anorexia nervosa and 45 per 100,000 for bulimia nervosa, and the prevalence rate was 222 per 100,000 for anorexia nervosa and 89 per 100,000 for bulimia nervosa.     

CSF beta-endorphin and dynorphin in bulimia nervosa.

OBJECTIVE: Preclinical and clinical evidence suggests that central opioid dysfunction may play a role in the pathophysiology of the eating disorders. In particular, endogenous opioids are known to regulate feeding behavior, mood, perception, and neuroendocrine function, all of which are disturbed in patients with eating disorders. Although low concentrations of CSF beta-endorphin have been reported in low-weight patients with anorexia nervosa, central opioid activity in normal-weight patients with bulimia nervosa has not been reported. The authors therefore measured CSF concentrations of beta-endorphin and dynorphin in drug-free female patients with DSM-III-R-defined bulimia nervosa and normal comparison subjects. METHOD: After 4 days of a low monoamine diet and overnight bed rest, CSF was obtained (12-26 cc) from 11 women with bulimia and 17 normal comparison subjects (eight women and nine men). RESULTS: The women with bulimia had significantly lower CSF concentrations of beta-endorphin than did the female comparison subjects. However, CSF concentrations of dynorphin were not significantly different in patients and female or male comparison subjects. beta-Endorphin concentrations were inversely correlated with Beck Depression Inventory scores and the depression subscale of the Eating Disorders Inventory. CONCLUSIONS: These data support a role for central opiates in the mediation of the pathophysiology of the signs and symptoms of bulimia nervosa, although it is impossible to rule out the effects of depression on the results.     

Anorexia nervosa and affective disorders: a controlled family history study

Analysis of family history information from a prospectively studied group of 40 young female patients with anorexia nervosa and 23 normal control female subjects of similar age showed more depression and substance use disorders in first- and second-degree relatives of anorexia nervosa patients. Further, the pedigrees of the patients differed significantly from those of the control subjects in the higher frequency of depression and substance use disorders in consecutive generations and in the family "loading" of these disorders. These findings, consistent with previous reports, add to the growing evidence of an association between anorexia nervosa and familial risk for affective and related disorders.     

An evaluation of family therapy in anorexia nervosa and bulimia nervosa

A controlled trial comparing family therapy with individual supportive therapy in anorexia nervosa and bulimia nervosa was undertaken. Eighty patients (57 with anorexia nervosa; 23 with bulimia nervosa) were first admitted to a specialized unit to restore their weight to normal. Before discharge, they were randomly allocated to family therapy or the control treatment (individual supportive therapy). After one year of psychological treatment, they were reassessed, using body weight, menstrual function, and ratings on the Morgan and Russell scales. Family therapy was found to be more effective than individual therapy in patients whose illness was not chronic and had begun before the age of 19 years. A more tentative finding was the greater value of individual supportive therapy in older patients. To our knowledge, this is the first controlled trial of family therapy in anorexia nervosa and clarifies the specific indications for this treatment.     

Insulin sensitivity in patients with anorexia nervosa and bulimia

Insulin sensitivity was studied using the euglycemic insulin clamp technique in 5 female patients with anorexia nervosa and 4 females with bulimia. The results were compared with those of 15 male patients with non-insulin-dependent diabetes mellitus. Euglycemic insulin clamp is performed for 2 h using the Biostator, during which time insulin was infused at a rate of 0.77 mU kg-1 min-1. Fasting plasma glucose and immunoreactive insulin tended to be lower in patients with anorexia nervosa than in those with bulimia (69.8 +/- 6.7 vs 75.9 +/- 7.7 mg/dl, and 5.9 +/- 2.0 vs 9.8 +/- 3.4 U/ml). The mean metabolic clearance rate (MCR) was 9.2 +/- 3.9 ml kg-1 min-1 for patients with anorexia nervosa, 5.1 +/- 2.2 ml kg-1 min-1 for patients with bulimia, and 3.8 +/- 0.3 ml kg-1 min-1 for patients with diabetes mellitus. However, one anorectic had a significantly high MCR. One anorectic and 3 bulimics had a significantly low MCR. These results suggest that insulin sensitivity varied in patients with anorexia nervosa, whereas it tended to decrease in some patients with bulimia but not to the same degree as in patients with diabetes mellitus.     

Perinatal factors and the risk of developing anorexia nervosa and bulimia nervosa

CONTEXT: Few prospective studies to date have investigated the role of obstetric complications in anorexia nervosa, and no study to our knowledge exists for this in bulimia nervosa. OBJECTIVE: To explore the role of obstetric complications in the development of eating disorders. DESIGN: A blind analysis of the obstetric records of a sample of subjects with anorexia nervosa, with bulimia nervosa, and normal subjects was performed. All of the subjects included in the study belong to the same population birth cohort and were born in the 2 obstetric wards of Padua Hospital, Padua, Italy, between January 17, 1971, and December 30, 1979. SETTINGS AND PARTICIPANTS: Part of the sample of subjects with eating disorders and all of the controls took part in a prevalence study carried out in 2 randomly selected areas of Padua. In addition, all of the subjects with anorexia nervosa and bulimia nervosa of the same birth cohort who were referred to an outpatient specialist unit were included. The final sample comprised 114 subjects with anorexia nervosa, 73 with bulimia nervosa, and 554 control subjects. RESULTS: Several complications, such as maternal anemia (P = .03), diabetes mellitus (P = .04), preeclampsia (P = .02), placental infarction (P = .001), neonatal cardiac problems (P = .007), and hyporeactivity (P = .03), were significant independent predictors of the development of anorexia nervosa. The risk of developing anorexia nervosa increased with the total number of obstetric complications. In addition, an increasing number of complications significantly anticipated the age at onset of anorexia nervosa (P = .03). The obstetric complications significantly associated with bulimia nervosa were the following: placental infarction (P = .10), neonatal hyporeactivity (P = .005), early eating difficulties (P = .02), and a low birth weight for gestational age (P = .009). Being shorter for gestational age significantly differentiated subjects with bulimia nervosa from both those with anorexia nervosa (P = .04) and control subjects (P = .05). CONCLUSIONS: A significantly higher risk of eating disorders was found for subjects with specific types of obstetric complications. An impairment in neurodevelopment could be implicated in the pathogenesis of eating disorders.     

Predictive validity of bulimia nervosa as a diagnostic category

OBJECTIVE: The authors sought to investigate the predictive validity of bulimia nervosa as a diagnostic category. METHOD: More than 10 years after they appeared as patients with bulimia nervosa, 177 women (participation rate=79.7%) completed follow-up assessments. RESULTS: Among the women with a current eating pathology, most engaged in recurrent binge eating and purging. Anorexia nervosa and binge eating disorder were relatively uncommon. Eating disorder outcome was significantly related to the presence of mood, substance use, and impulse control disorders but not to the presence of anxiety disorders. CONCLUSIONS: These results support the validity of bulimia nervosa as a diagnostic category that is distinct from anorexia nervosa. Furthermore, these results suggest that bulimic symptoms are associated with disorders involving distress and disinhibition.     

High rates of comorbid OCD in patients with bulimia nervosa

There have been several suggestions in the literature that anorexia nervosa and bulimia nervosa, and obsessive-compulsive disorder (OCD) may be related. To assess in a controlled fashion the incidence and lifetime prevalence of OCD in patients with bulimia nervosa, we administered portions of the Structured Clinical Interview for DSM-III-R (SCID) to 25 females with a primary diagnosis of bulimia nervosa. We also assessed current obsessive-compulsive symptomatology using the YBOCS, Symptom Checklist 90-R, and the Maudsley Obsessive Compulsive Inventory. After excluding core bulimic symptoms, the lifetime prevalence of OCD was 32%; an additional 24% met Subthreshold criteria for OCD at some point in their lives. Core anorexia/bulimia nervosa symptoms to ensure that bulimic symptoms would not create a false-positive for OCD. Again, After excluding core bulimic symptoms, the mean score on the YBOCS score on the YBOCS obsessions subscale was 12.0 ± 11.6 and on the compulsions subscale was 5.04 ± 4.75. Scores for both YBOC scales range from 0 to 20. While this is somewhat less than that reported previously for OCD patients, it is considerably greater than that found in normals. These data provide further support for the link between OCD and the eating disorders.     

Risk factors for anorexia nervosa: three integrated case-control comparisons

BACKGROUND: Many risk factors have been implicated in the development of anorexia nervosa. Little is known about their relative contributions, nor in most cases is it clear whether they are specific to anorexia nervosa or risk factors for all eating disorders or for psychiatric disorder in general. METHODS: We used a case-control design involving the comparison of 67 female subjects with a history of anorexia nervosa with 204 healthy control subjects, 102 subjects with other psychiatric disorders, and 102 subjects with bulimia nervosa. A broad range of risk factors was assessed by interview. RESULTS: The subjects with anorexia nervosa and the healthy controls differed in their exposure to most of the putative risk factors. There was no greater exposure to factors that increased the likelihood of dieting, once the influence of other classes of risk factors had been taken into account. Premorbid perfectionism and negative self-evaluation were especially common and more so than among the general psychiatric controls. Parental obesity and an early menarche, together with parental psychiatric disorder, distinguished those with bulimia nervosa from those with anorexia nervosa. CONCLUSIONS: There appears to be a broad range of risk factors for anorexia nervosa and bulimia nervosa, some of which are shared with other psychiatric disorders. Factors that increase the likelihood of dieting seem to have more important influence as risk factors for bulimia nervosa than anorexia nervosa. Perfectionism and negative self-evaluation appear to be particularly common and characteristic antecedents of both eating disorders.     

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.     

Bulimia nervosa, childbirth, and psychopathology

OBJECTIVE: To examine whether having a baby following treatment for bulimia nervosa places women at increased risk for continuing or relapsing eating disorders or major depression. METHODS: Subjects were women who had participated in a large randomized controlled trial evaluating cognitive behavior therapy for bulimia nervosa, who were prospectively followed-up over 5 years. At follow-up assessments (at least yearly), life charts were completed with patients and childbirth was recorded. The presence of eating disorders and major depressive disorder was assessed using the Structured Interview for DSM-III-R. RESULTS: Childbirth was not specifically associated with increased symptomatology. This was found for both eating disorders and major depression in the same year as childbirth and for the year following childbirth. CONCLUSION: Childbirth is not specifically associated with symptomatology following treatment for bulimia nervosa.     

Eating disorder symptoms among Japanese female students in 1982, 1992 and 2002

To study transcultural differences in eating disorders, we examined eating disorder symptoms and point prevalence of eating disorders among Japanese female students in 1982, 1992 and 2002. In 1982, 1992 and 2002, a total of 10,499 Japanese female students, aged 16–23 years, were asked to complete a self-administered questionnaire. Diagnosis of an eating disorder was made on the basis of DSM-IV criteria. On almost all measures, there were significant increases of a disordered attitude about fear of gaining weight, body perception disturbance and problematic eating behaviors over time. The point prevalence of anorexia nervosa, bulimia nervosa and eating disorder not otherwise specified significantly increased over time. These results suggest that the prevalence of eating disorder symptoms and the point prevalence of eating disorders were increasing among Japanese female students in 2002. Changing socio-cultural factors in Japan may explain the dramatic increase of eating disorders over time.     

A controlled study of phenomenology and family history in outpatients with bulimia nervosa

We administered structured diagnostic interviews and family history evaluations to 69 outpatient women meeting the new DSM-III-R criteria for bulimia nervosa. This group was compared with 50 women with DSM-III bulimia, 24 women with major depression, and 28 nonpsychiatric control women, all recruited during previous studies. On both phenomenologic and family history assessments, the women with DSM-III-R bulimia nervosa closely resembled the women with DSM-III bulimia, and both groups differed significantly from controls in their prevalence of personal and familial major mood disorders. These data support a relationship between bulimia nervosa and major mood disorders, consistent with that suggested by studies of bulimia assessed by earlier diagnostic criteria.     

Resting-state synchrony between anterior cingulate cortex and precuneus relates to body shape concern in anorexia nervosa and bulimia nervosa

Cortical areas supporting cognitive control and salience demonstrate different neural responses to visual food cues in patients with eating disorders. This top-down cognitive control, which interacts with bottom-up appetitive responses, is tightly integrated not only in task conditions but also in the resting-state. The dorsal anterior cingulate cortex (dACC) is a key node of a large-scale network that is involved in self-referential processing and cognitive control. We investigated resting-state functional connectivity of the dACC and hypothesized that altered connectivity would be demonstrated in cortical midline structures involved in self-referential processing and cognitive control. Seed-based resting-state functional connectivity was analyzed in women with anorexia nervosa (N=18), women with bulimia nervosa (N=20) and age matched healthy controls (N=20). Between group comparisons revealed that the anorexia nervosa group exhibited stronger synchronous activity between the dACC and retrosplenial cortex, whereas the bulimia nervosa group showed stronger synchronous activity between the dACC and medial orbitofrontal cortex. Both groups demonstrated stronger synchronous activity between the dACC and precuneus, which correlated with higher scores of the Body Shape Questionnaire. The dACC-precuneus resting-state synchrony might be associated with the disorder-specific rumination on eating, weight and body shape in patients with eating disorders.     

The epidemiology of eating disorders in Fyn County, Denmark, 1977-1986.

The occurrence of anorexia nervosa and bulimia in Fyn County, Denmark is described. Incidence was estimated from national and local registers. The DSM-III-R criteria of one or both eating disorders were met by 104 patients. The incidence of anorexia nervosa for females 10 to 24 years of age was 11.0 per 100,000 per year. In the same population, the incidence of bulimia was 5.5 per 100,000 per year. Prevalence was estimated from questionnaires to and interviews with general practitioners. There were 193 cases; the prevalence of anorexia nervosa was estimated at 1:780 (patient years/total population years), and the prevalence of bulimia at 1:1480, in the high-risk population: females 15-19 years of age. Sixty percent of the anorexia nervosa patients, but only 30% of the bulimia patients, were admitted to hospital; this is an important difference in regard to estimation of occurrence from registers.     

Eating Disorder Inventory in Sweden: description, cross-cultural comparison, and clinical utility

The Eating Disorder Inventory is one of very few tests for anorexia nervosa and bulimia nervosa that measures not only symptoms but also psychological characteristics believed to be central in these disorders. This study of 425 patients and control subjects showed that patients had markedly higher scores than controls and recovered patients on all eight scales. Individuals with bulimia nervosa scored higher on a few of the scales than those with anorexia nervosa, as did binge eaters at all weights compared with those who only restricted eating. Comparison with Canadian subjects showed several differences in normal controls. Since the technical properties of our Swedish version of the EDI were excellent, these differences may be meaningful rather than artifacts of the translation. Finally, the analyses indicated that the EDI may be useful for purposes of screening for eating disorders, and possibly for differential diagnosis.