N-acetylcysteine in bulimia nervosa — Open-label trial

The objective of this 12-week open-label flexible-dose study was to preliminarily assess the effectiveness of N-acetylcysteine (NAC) in bulimia nervosa (BN). The primary outcome was binge-purge episode frequency. Eight individuals with BN by DSM-IV criteria received NAC, but only two completed the study. NAC was not associated with significant reductions in frequency of binge-purge episodes or measures of clinical severity, eating, or mood pathology. In this trial, NAC was ineffective in BN and was associated with a high discontinuation rate.     

Is sham feeding an animal model of bulimia?

Studies of sham-feeding animals are useful in dissociating the hedonic, orosensory effects of food in the mouth from the satiating and nutritive effects of food in the gut, an operational state highly analogous to binge eating with vomiting. Alteration of hedonic and postingestive responses to food may occur physiologically or may be conditioned; binge-like behavior can result when regulatory processes are sufficiently distorted by biological or environmental changes. An important role for satiety-inducing neuropeptides and central dopamine activity during binging is inferred from the model.     

Purging disorder: An ominous variant of bulimia nervosa?

OBJECTIVE: The current study evaluates the clinical significance and distinctiveness of purging disorder (PD), an eating disorder characterized by recurrent purging in the absence of objective binge episodes (OBE) among normal-weight individuals. METHOD: Women with PD (n = 37), bulimia nervosa (BN; n = 39), or no eating disorder (n = 35) completed clinical assessments. Women with PD (n = 23) and BN (n = 25) completed 6-month follow-up assessments. RESULTS: Compared with controls, both eating-disordered groups reported significantly higher eating, Axis I, and Axis II pathology. Compared with BN, PD was associated with significantly lower eating concerns, disinhibition, and hunger. At 6-month follow-up, rates of remission did not differ significantly between PD and BN, and crossover between disorders was rare. CONCLUSION: PD appears to be a clinically significant and potentially distinctive eating disorder.     

Are there subgroups of bulimia nervosa based on comorbid psychiatric disorders?

OBJECTIVE: The current study sought to determine whether there are subtypes of bulimia nervosa (BN) differentiated by comorbid psychiatric disorders. METHOD: Data on comorbid psychiatric diagnoses in female relatives of probands and controls in the Collaborative Study of the Genetics of Alcoholism (COGA) who met criteria for BN (as outlined in the 3rd Rev. ed. of the Diagnostic and Statistical Manual of Mental Disorders) were analyzed using latent class analysis. Resulting latent classes were compared on a variety of variables related to impulsive behaviors and psychological functioning. RESULTS: The best-fitting solution, a two-class model, yielded one class (72%) characterized by substance dependence, depression, antisocial personality disorder (ASPD), and anxiety disorders, and another characterized by depression. The highly comorbid class had more suicidality, more daily smokers, sought help for emotional problems, and had lower Global Assessment of Functioning (GAF) scores compared with those in the comorbid depression only class. DISCUSSION: Latent class findings suggest the existence of two classes of BN differentiated by substance dependence, impulsive behaviors, and poorer psychological functioning.     

Is major depressive disorder or dysthymia more strongly associated with bulimia nervosa?

OBJECTIVE: Research on adult samples has found that the comorbidity between depression and eating disorders exceeds the comorbidity of any other Axis I disorder and eating disorders. Few studies have investigated the specific associations of major depression versus dysthymia with eating disorders. METHOD: This sample consisted of 937 adolescents who were repeatedly assessed until the age of 24. RESULTS: Analyses revealed that dysthymia was a stronger correlate with bulimia than major depression, even while controlling for other mood disorders and a history of depression and dysthymia. CONCLUSIONS: The presence of dysthymia in adolescence might be a possible risk factor for the development of bulimia nervosa.     

Is bulimia nervosa a heterogeneous disorder? Lessons from the history of medicine

What causes bulimia nervosa? Most authorities would respond that this question cannot be answered simply, in that bulimia nervosa has a multifactorial etiology in which psychological, sociocultural, biological, and other factors combine in different ways in different individuals to produce the syndrome. In other words, it has seemed axiomatic to many of us that bulimia nervosa is far too complex and heterogeneous to permit a simple, reductionistic explanation. However, a minority of researchers have argued, against the weight of opinion, that the etiology of bulimia may ultimately be explained more simply. Notable among these individuals are Drs. Harrison Pope and James Hudson, who are well known for their research on eating disorders in recent years. Accordingly, we have asked Drs. Pope and Hudson to present this “minority position,” as an exercise that may help to bring into relief the facts and philosophies behind some of the current controversies regarding the nature of bulimia nervosa. We are also pleased to present an equally thought-provoking counterpoint on the heterogeneity of bulimia authored by P. J. V. Beumont of the University of Sydney, well known for his distinguished record of scholarly research in this field.     

Treatment of bulimia nervosa: Where are we and where are we going?

OBJECTIVE: The purpose of this article is to review the extant treatment literature on bulimia nervosa and to offer suggestions for future research directions. METHOD: The available treatment studies regarding both pharmacotherapy and psychotherapy are reviewed. RESULTS: Both pharmacotherapy and psychotherapy appear to play a role in the treatment of bulimia nervosa; however, available data suggest that cognitive behavioral therapy remains the treatment of choice. CONCLUSION: Additional work is clearly indicated regarding assisted and unassisted self-help. An enhanced form of CBT and the integrative cognitive-affective therapy both deserve further study. New approaches need to be piloted. More research is needed on treatment modeling.     

Which comes first in the pathogenesis of bulimia nervosa: dieting or bingeing?

OBJECTIVE: Clinical experience has indicated that dieting usually precedes the onset of binge eating in the development of bulimia nervosa (BN). However, data confirming this in nonclinical, representative samples are lacking. METHOD: Using results obtained from the National Women's Study (NWS), we were able to determine the chronological relationship between age of onset of significant dieting (attempting to lose 15 lbs) and onset of bingeing in 85 respondents who met DSM-III-R criteria for BN. These respondents were a subset of over 3,000 female adult U.S. women who completed a random telephone interview (averaging 40 min and including screenings for rape, sexual molestation, aggravated assault, posttraumatic stress disorder [PTSD], and BN). RESULTS: We found that the age of first serious attempt to diet preceded the age of first binge in 46% of cases. There were no significant differences in histories of victimization experiences among the groups. First binge preceded first serious diet in 37% of cases, and these behaviors occurred during the same age in 17% of cases. DISCUSSION: These data confirm that dieting is more likely to precede binge eating, although binge eating precedes significant dieting in a substantial proportion of bulimic respondents.     

Bulimia nervosa: Friend or foe? The pros and cons of bulimia nervosa

OBJECTIVE: The aim of the current study was to use a qualitative approach to investigate the attitude of people with bulimia nervosa (BN) to their illness. METHOD: Patients with BN were asked to write two letters to their bulimia, one addressing it as a friend and the other addressing it as an enemy. We used a coding scheme to classify themes in letters of people with anorexia nervosa (AN) to group together themes expressed by those with BN. We revised the coding scheme to include themes that were not present in the letters of people with AN. RESULTS: There were both similarities and differences in the themes described by AN and BN patients. Two positive themes (BN allowing the individuals to eat and not get fat and BN as a way of dealing with boredom) and two negative themes (shame or low self-esteem resulting from BN and obsessive thoughts of weight and shape) were added to the coding scheme to account for these differences. DISCUSSION: The positive and negative aspects of BN differ in some important ways from those expressed by patients with AN. The meaning of these differences is discussed with reference to the wider symptom pattern of BN compared with AN and their importance with reference to motivation for change is outlined.     

Why the high rate of dropout from individualized cognitive-behavior therapy for bulimia nervosa?

OBJECT: To investigate predictors of dropout from cognitive-behavior therapy for bulimia nervosa. METHOD: Pretreatment assessment measures were examined including the Eating Disorder Inventory-2, Body Satisfaction Questionnaire, Beck Depression Inventory, Beck Hopelessness Scale, the Locus of Control of Behavior Scale, and demographic and behavioral measures. RESULTS: Forty-three percent (n = 14) of clients with a DSM-IV diagnosis of bulimia nervosa dropped out of treatment prematurely. No differences were found between treatment completers and dropouts with respect to the initial severity of bulimia-related symptoms. Noncompleters were, however, found to have significantly higher depression and hopelessness scores as well as elevated levels of external locus of control. Discriminate analysis showed that these variables resulted in a 90% prediction accuracy of individuals who prematurely dropped out of treatment. DISCUSSION: Results suggest a need to focus treatment directly on factors such as hopelessness and depression in addition to standard bulimia procedures to ensure clients are able to engage in therapy.     

Binge eating before the onset of dieting: a distinct subgroup of bulimia nervosa?

OBJECTIVE: While most individuals with bulimia nervosa begin dieting prior to the onset of binge eating, some individuals begin binge eating prior to dieting. The purpose of this study was to assess the differences between these two groups. METHODS: Participants (N = 120) in a treatment study for bulimia nervosa were separated into two groups (Binge First vs. Diet First) based on the ages they reported for the onset of binge eating and of dieting and then compared across a number of variables. RESULTS: Individuals in the Binge First group reported higher weight, higher shape and weight concern, lower age of onset of eating disorder symptoms, and an altered relationship of binge eating to vomiting when compared to individuals in the Diet First group. DISCUSSION: The differences between the two groups suggest that there may be subgroups of individuals with purging bulimia nervosa and that individuals in the Binge First group more closely resemble individuals with binge eating disorder than do those in the Diet First group.     

Does the frequency of anxiety and depressive disorders differ between diagnostic subtypes of anorexia nervosa and bulimia?

OBJECTIVE: The objective of the present work is to determine whether the prevalence of depressive and anxiety disorders varies in subgroups of eating disorders (ED) according to age, ED duration, mode of care provision, and body mass index (BMI). METHOD: Using the Mini International Neuropsychiatric Interview (MINI), the frequency of anxiety and depressive disorders was evaluated in 271 ED participants. Their prevalence was compared in subgroups of anorexics (AN-R and AN-BN) and bulimics (BN), both before and after controlling for potential confounding variables. RESULTS: Current or lifetime comorbidity of anxiety and depressive disorders did not differ between AN-R and AN-BN groups. Social phobia, panic disorders, and obsessive-compulsive disorder (OCD) were significantly more frequent in AN-BN and AN-R groups. Panic disorder was more frequent in the BN group. CONCLUSION: Several confounding factors, in particular those identified in the present study, may explain previous conflicting results on the frequency of anxiety and depressive disorders in ED. Nevertheless, the study confirmed that OCD is more frequent in AN, even after controlling for confounding factors.