Eating disorders and antecedent anxiety disorders: a controlled study

We compared the prevalence and age of onset of adult and childhood anxiety disorders relative to the primary diagnosis in 68 women with anorexia nervosa (AN), 116 women with bulimia nervosa (BN), 56 women with major depression with no eating disorder (MD) and 98 randomly selected controls (RC) in order to determine whether antecedent anxiety disorders are plausible risk factors for AN and BN. Comorbid anxiety disorders were common in all three clinical groups (AN, 60%; BN, 57%; MD, 48%). In 90% of AN women, 94% of BN women and 71 % of MD women, anxiety disorders preceded the current primary condition (P=0.01), although panic disorder tended to develop after the onset of AN, BN or MD. In multivariate logistic regressions, the odds ratios (ORs) for overanxious disorder (OR=13.4) and obsessive-compulsive disorder (OR=11.8) were significantly elevated for AN. The ORs for overanxious disorder and social phobia were significantly elevated for BN (OR_OAD,=4.9; OR_SP=15.5) and MD (OR_OAD,=6.1; OR_SP=6.4). These data suggest that certain anxiety disorders are non-specific risk factors for later affective and eating disorders, and others may represent more specific antecedent risk factors.     

Measuring state trait properties of detail processing and global integration ability in eating disorders

Abstract

Objectives. Women with eating disorders (EDs) are reported to have strengths in local or detailed information processing and difficulties with coherence or global processing/integration. Methods. This study aimed to replicate these findings and additionally explore a global integration task which has not previously been reported for an ED group, the Fragmented Pictures Task (FPT). Two hundred and twenty-two women (50 with anorexia nervosa (AN), 48 with bulimia nervosa (BN), 35 recovered from AN and 89 controls (HC)) completed the Rey–Osterrieth Complex Figure Task (RCFT) to measure global/local processing strategies, the Group Embedded Figures Task (GEFT) to measure local processing and the FPT to measure global integration. Results. Superior detail processing skills (GEFT) and a tendency to utilise detail processing strategies (RCFT) were associated with having AN, BN and being in recovery from AN. Global integration difficulties (FPT) were only observed in acute AN, whereas participants in the BN and recovered group performed similarly to HCs. Conclusions. People currently ill with, and recovered from EDs are skilled at detail processing. The acute phase of AN is associated with difficulties in global integration.     

On the role of sadness in the psychopathology of anorexia nervosa

Recent models on the development and maintenance of eating disorders propose negative emotions to be important precursors for the occurrence of eating disorder symptomatology. In fact, previous research on bulimia nervosa (BN) and binge eating disorder provides evidence that negative emotions are an antecedent condition for binge eating. However, there is a lack of research examining the influence of negative emotions on restrictive eating and exercising in individuals with anorexia nervosa (AN). In an experimental study, women with AN (n=39) and BN (n=34) as well as a non-eating disordered control group (CG; n=34) watched a sadness-inducing film clip. Before and after the film clip participants rated their current desire to engage in dietary restriction (DTR) and desire to exercise (DTE). Main results reveal that DTR significantly increased after the film clip in women with AN only, while DTE decreased over time in all groups. Results are in line with the notion that negative emotions have a prominent influence on the core eating pathology in AN.     

Normal brain tissue volumes after long-term recovery in anorexia and bulimia nervosa.

BACKGROUND: Individuals who are ill with anorexia (AN) and bulimia nervosa (BN) often have increased cerebrospinal fluid (CSF) volumes and decreased total gray and white matter volumes. It is unclear whether such disturbances persist after recovery from an eating disorder. METHODS: Magnetic resonance imaging was performed on 40 women who were long-term recovered (>1 year no binging, purging, or restricting behaviors, normal weight, and menstrual cycles, not on medication) from restricting or binge/purging type AN or BN and 31 healthy control women (CW). Voxel-based morphometry (VBM) was used for data analysis. RESULTS: Recovered AN and BN subgroups were similar to CW in terms of cerebrospinal fluid (CSF) volume as well as total or regional gray or white matter volume. CONCLUSIONS: These findings suggest that structural brain abnormalities are reversible in individuals with eating disorders after long-term recovery.     

A comprehensive meta-analysis of the risk of suicide in eating disorders

Preti A, Rocchi MBL, Sisti D, Camboni MV, Miotto P. A comprehensive meta‐analysis of the risk of suicide in eating disorders. Objective: Past meta‐analyses on suicide in eating disorders included few available studies. Method: PubMed/Medline search for papers including sample n ≥ 40 and follow‐up ≥5 years: 40 studies on anorexia nervosa (AN), 16 studies on bulimia nervosa (BN), and three studies on binge eating disorder (BED) were included. Results: Of 16 342 patients with AN, 245 suicides occurred over a mean follow‐up of 11.1 years (suicide rate = 0.124 per 100 person‐years). Standardized mortality ratio (SMR) was 31.0 (Poisson 95% CI = 21.0–44.0); a clear decrease in suicide risk over time was observed in recent decades. Of 1768 patients with BN, four suicides occurred over a mean follow‐up of 7.5 years (suicide rate = 0.030 per 100 person‐years): SMR was 7.5 (1.6–11.6). No suicide occurred among 246 patients with BED (mean follow‐up = 5.3 years). Conclusion: AN and BN share many risk factors for suicide: the factors causing lower suicide rates per person‐year in BN compared to AN should be investigated.     

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Pharmacological Treatment of Eating Disorders

Abstract

Objectives. The treatment of eating disorders is a complex process that relies not only on the use of psychotropic drugs but should include also nutritional counselling, psychotherapy and the treatment of the medical complications, where they are present. In this review recommendations for the pharmacological treatment of eating disorders (anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED)) are presented, based on the available literature. Methods. The guidelines for the pharmacological treatment of eating disorders are based on studies published between 1977 and 2010. A search of the literature included: anorexia nervosa bulimia nervosa, eating disorder and binge eating disorder. Many compounds have been studied in the therapy of eating disorders (AN: antidepressants (TCA, SSRIs), antipsychotics, antihistaminics, prokinetic agents, zinc, Lithium, naltrexone, human growth hormone, cannabis, clonidine and tube feeding; BN: antidepressants (TCA, SSRIs, RIMA, NRI, other AD), antiepileptics, odansetron, d-fenfluramine Lithium, naltrexone, methylphenidate and light therapy; BED: antidepressants (TCA, SSRIs, SNRIs, NRI), antiepileptics, baclofen, orlistat, d-fenfluramine, naltrexone). Results. In AN 20 randomized controlled trials (RCT) could be identified. For zinc supplementation there is a grade B evidence for AN. For olanzapine there is a category grade B evidence for weight gain. For the other atypical antipsychotics there is grade C evidence. In BN 36 RCT could be identified. For tricyclic antidepressants a grade A evidence exists with a moderate-risk-benefit ratio. For fluoxetine a category grade A evidence exists with a good risk-benefit ratio. For topiramate a grade 2 recommendation can be made. In BED 26 RCT could be identified. For the SSRI sertraline and the antiepileptic topiramate a grade A evidence exists, with different recommendation grades. Conclusions. Additional research is needed for the improvement of the treatment of eating disorders. Especially for anorexia nervosa there is a need for further pharmacological treatment strategies.     

Mortality in eating disorders: A follow-up study of adult eating disorder patients treated in tertiary care, 1995–2010

Elevated mortality risk in anorexia nervosa has been established, but less is known about the outcomes of bulimia nervosa and binge eating disorder. In this follow-up study we determined mortality in adults (N=2450, 95% women) admitted to the eating disorder clinic of the Helsinki University Central Hospital in the period 1995–2010. Most of the patients (80.7%) were outpatients. For each patient four controls were selected and matched for age, sex and place of residence. The matching was taken into account by modelling end-point events using Cox's proportional hazard model. The hazard ratio (HR) for all-cause mortality was 6.51 (95% CI 3.46–12.26) in broad anorexia nervosa (AN), 2.97 (95% CI 1.90–4.65) in broad bulimia nervosa (BN), and 1.77 (95% CI 0.60–5.27) in binge eating disorder (BED). Mortality risk in broad AN was highest during the first years after admission but declined thereafter, while in broad BN the mortality risk started to rise two years after the first admission. The HR for suicide was elevated both in broad AN (HR 5.07; 95% CI 1.37–18.84) and in broad BN (HR 6.07; 95% CI 2.47–14.89). Results show that eating disorders are associated with increased mortality risk even when specialised treatment is available.     

Control over interfering memories in eating disorders

Introduction: Recent studies have suggested that patients suffering from either anorexia nervosa (AN) or bulimia nervosa (BN) exhibit abnormal performance in the ability to control cognitive interference in response selection. Method: We assessed the status of cognitive control in episodic memory by addressing the ability to inhibit interfering memories. To this end, we used the retrieval-practice paradigm, which allows for measuring both the beneficial and the detrimental effects of memory practice. The latter phenomenon, known as retrieval-induced forgetting (RIF), is thought to reflect an adaptive inhibitory mechanism aimed at reducing competition in memory retrieval. Twenty-seven healthy controls and 27 patients suffering from eating disorders (either AN or BN) performed a retrieval-practice paradigm and a control task addressing general reactivity and filled a self-report questionnaire on impulsivity. Results: No differences between patients and healthy controls were observed for the beneficial effects of practice. The same pattern also emerged for RIF. However, when patients with AN and BN were analyzed separately, a clear dissociation emerged: patients with AN displayed no hint of RIF, whereas patients with BN showed an intact memory suppression performance. No group differences emerged in the control task. Conclusions: Our findings suggest a specific impairment in the ability to suppress interfering memories in patients with AN, thus extending current evidence of cognitive control deficits in AN to episodic memory.     

Different Patterns of Emotional Eating and Visuospatial Deficits Whereas Shared Risk Factors Related with Social Support between Anorexia Nervosa and Bulimia Nervosa

Objective

Although it is thought that eating disorders result from the interplay of personal and sociocultural factors, a comprehensive model of eating disorders remains to be established. The aim of this study was to determine the extent to which the childhood factors and deficit in visuoperceptual ability contribute to eating disorders.

Methods

A total of 76 participants - 22 women with anorexia nervosa (AN), 28 women with bulimia nervosa (BN), and 26 healthy women of comparable age, IQ, and years of education - were examined. Neuropsychological tasks were applied to measure the visuoperceptual deficits, viz. the Rey-Osterrieth complex figure test and the group embedded figures test (GEFT). A questionnaire designed to obtain retrospective assessments of the childhood risk factors was administered to the participants.

Results

The women with both AN and BN were less likely to report having supportive figures in their childhood and poor copy accuracy in the Rey-Osterrieth test. The women with AN were more likely to report premorbid anxiety, childhood emotional undereating and showed poor performances in the GEFT. In the final model, the factors independently contributing to the case status were less social support in childhood as a common factor for both AN and BN, and childhood emotional undereating and poor ability in the low-level visuospatial processing for AN.

Conclusion

Our results suggest the disturbance in the food-emotion relationship and the deficit in low-level visuospatial processing in people with AN. Lower social support appears to contribute to an increase in vulnerability to both AN and BN.     

Moderators of post-binge eating negative emotion in eating disorders

The purpose of this study was to test the impact of two variables on post-binge eating negative emotion in a combined sample of women with anorexia nervosa (AN; n = 47) and bulimia nervosa (BN; n = 121). Participants completed two weeks of an ecological momentary assessment protocol during which they provided multiple daily ratings of overall negative affect and guilt and reported eating disorder behaviors including binge eating and self-induced vomiting. The results indicate that both overall negative affect and guilt exhibited a statistically significantly decrease in the hour immediately following binge eating episodes. The decrease in guilt, but not overall negative affect, was moderated by eating disorder diagnosis and the tendency to engage in self-induced vomiting. Specifically, individuals with BN reported a greater reduction in guilt than those with AN, and individuals who did not typically engage in self-induced vomiting reported more decreases in guilt than those who typically engaged in self-induced vomiting. This study extends the existing literature on the relationship between negative affect and eating disorder behaviors, suggesting guilt as a potentially relevant facet of negative affect in the maintenance of binge eating. In addition, the findings indicate that two individual differences, eating disorder diagnosis and self-induced vomiting, may influence the trajectory of guilt following binge eating episodes.     

Impaired Set-Shifting Ability in Patients with Eating Disorders, Which Is Not Moderated by Their Catechol-O-Methyltransferase Val158Met Genotype

The aim of this study was to examine the set-shifting ability in women with both anorexia nervosa (AN) and bulimia nervosa (BN) and to investigate whether it is contributed by the catechol-O-methyltransferase (COMT) Val158Met genotype. A total of 102 Korean participants-40 women with lifetime AN, 28 women with lifetime BN, and 34 healthy women of comparable age and intelligence quotient- were examined. A neuropsychological battery of tests was applied and blood samples were obtained for COMT Val158Met genotyping. Set-shifting impairments Trail Making Test (TMT, Part B) were found in patients with AN and BN, respectively. Furthermore, the eating disorders were also linked to deficits in attentional mechanisms (TMT, Part A) and motor skills (Finger Tapping Test). Finally, set-shifting and its link to eating disorders were not moderated by COMT Val158Met genotype.     

Comparison of regional cerebral blood flow in patients with eating disorders

We used single photon emission computed tomography (SPECT) with Tc-99m-HMPAO to examine the characteristics of regional cerebral blood flow (rCBF) in five patients with bulimia nervosa (BN), eight patients with anorexia nervosa (AN), and in nine healthy controls. The SPECT examinations were performed before and attar food intake stimulus, and the values of the corrected ratio (R) for rCBF in 10 cerebral cortical regions before (R_before) and after eating (R_after) were calculated. The asymmetry indices (AI) of the R values for the left and right side of each cortical region and the percent change from R_before to R_after (%change) were computed. In comparison with the other two groups, BN patients showed significantly higher R_before values in the bilateral inferior frontal and left temporal regions. The AN patients showed significantly lower R_before values in the left parietal region than the control group. There were no significant differences in R_after values among the three groups. The %change values in the AN group showed the greatest increase in 9 out of the 10 regions. In contrast to the positive values obtained from the 10 regions observed in the AN group, 5 out of the 10 regions in the BN group showed negative values. Among the three groups, significant differences in %change were observed on both sides of the inferior frontal, temporal, parietal, and occipital regions. These findings indicate that differences in cerebral function of BN and AN patients can be characterized through SPECT imaging.     

An epidemiological study of eating disorders in a northern area of Japan

Nadaoka T, Oiji A, Takahashi S, Morioka Y, Kashiwakura M, Totsuka S. An epidemiological study of eating disorders in a northern area of Japan. Scand 1996: 93: 305–310. © Munksgaard 1996. A total of 97 patients with eating disorders who visited the Department of Neuro-Psychiatry, Yamagata University Hospital, between 1978 and 1992 were studied. According to the diagnostic criteria of DSM-III-R, there were 48 cases of anorexia nervosa (AN), 38 cases of bulimia nervosa (BN) and 11 cases with both AN and BN. Both the number of patients and the ratio to all out-patients in each year increased four times during the period 1988–1992 compared to the previous period. With regard to their places of residence, the number of patients with AN and with BN from every district appeared to increase at almost the same rate, although the majority of the patients were from medium-sized cities. These findings may indicate that eating disorders are influenced by urbanization.     

Altered processing of rewarding and aversive basic taste stimuli in symptomatic women with anorexia nervosa and bulimia nervosa: An fMRI study

Functional magnetic resonance imaging (fMRI) studies have displayed a dysregulation in the way in which the brain processes pleasant taste stimuli in patients with anorexia nervosa (AN) and bulimia nervosa (BN). However, exactly how the brain processes disgusting basic taste stimuli has never been investigated, even though disgust plays a role in food intake modulation and AN and BN patients exhibit high disgust sensitivity. Therefore, we investigated the activation of brain areas following the administration of pleasant and aversive basic taste stimuli in symptomatic AN and BN patients compared to healthy subjects. Twenty underweight AN women, 20 symptomatic BN women and 20 healthy women underwent fMRI while tasting 0.292 M sucrose solution (sweet taste), 0.5 mM quinine hydrochloride solution (bitter taste) and water as a reference taste. In symptomatic AN and BN patients the pleasant sweet stimulus induced a higher activation in several brain areas than that induced by the aversive bitter taste. The opposite occurred in healthy controls. Moreover, compared to healthy controls, AN patients showed a decreased response to the bitter stimulus in the right amygdala and left anterior cingulate cortex, while BN patients showed a decreased response to the bitter stimulus in the right amygdala and left insula. These results show an altered processing of rewarding and aversive taste stimuli in ED patients, which may be relevant for understanding the pathophysiology of AN and BN.     

The incidence of eating disorders in a Danish register study: Associations with suicide risk and mortality

Our aim was to characterize the incidence rates and cumulative incidence of anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS), and examine associations among eating disorder diagnoses, suicide attempts, and mortality. Individuals born in Denmark between 1989 and 2006 were included (N = 966,141, 51.3% male). Eating disorders diagnoses (AN, broad AN, BN, EDNOS) were drawn from the Danish Psychiatric Central Research Register (PCRR) and Danish National Patient Register (NPR). Suicide attempts and deaths were captured in the NPR, the PCRR, and the Danish Civil Registration System (CRS). In females, AN had a peak hazard at approximately age 15 years, BN at 22 years, and EDNOS had an extended peak that spanned 18 years–22 years. Eating disorder diagnoses predicted a significantly higher hazard for death and suicide attempt compared with the referent of individuals with no eating disorders. In males, peak hazard for diagnosis was earlier than in females. The present study represents one of the largest and longest studies of eating disorder incidence and suicide attempts and death in both females and males. Eating disorders are accompanied by increased hazard of suicide attempts and death even in young adults.     

Decreased levels of serum brain-derived neurotrophic factor in female patients with eating disorders.

BACKGROUND: Several lines of evidence suggest that brain-derived neurotrophic factor (BDNF) plays a role in the regulation of eating behavior. Because of its role in eating behavior, which is especially relevant to eating disorders, BDNF is an attractive candidate for investigation of potential biological markers of eating disorders such as bulimia nervosa (BN) and anorexia nervosa (AN). METHODS: We enrolled 18 female patients with BN, 12 female patients with AN, and 21 age-matched female normal control subjects in this study. Eating-related psychopathology and depressive symptoms were evaluated using the Bulimic Investigatory Test, Edinburgh (BITE) and the Hamilton Depression Rating Scale (HDRS). Serum BDNF levels were measured by a sandwich enzyme-linked immunosorbent assay. RESULTS: Serum levels of BDNF in the patients with AN or BN were significantly (p<.0001) decreased compared with those of normal control subjects, and serum BDNF levels in the patients with AN were significantly (p=.027) lower than those in patients with BN. A significant positive correlation (r=.378, p=.006) between serum BDNF levels and body mass index in all of the subjects was detected. Furthermore, there was a significant positive correlation (r=.435, p=.015) between the BITE symptom scale score and HDRS in these patients. CONCLUSIONS: The present study suggests that BDNF may play a role in the pathophysiology of eating disorders.     

Obsessive-compulsive and eating disorders: comparison of clinical and personality features

Abstract   The aim of the present study was to determine whether anorexia nervosa (AN), bulimia nervosa (BN) and obsessive-compulsive disorder (OCD) share clinical and psychopathological traits. The sample consisted of 90 female patients (30 OCD; 30 AN; 30 BN), who had been consecutively referred to the Department of Psychiatry, University Hospital of Bellvitge, Barcelona. All subjects met DSM-IV criteria for those pathologies. The assessment consisted of the Maudsley Obsessive-Compulsive Inventory (MOCI), Questionnaire of obsessive traits and personality by Vallejo, Eating Attitudes Test-40 (EAT-40), Eating Disorder Inventory (EDI), and Beck Depression Inventory (BDI). ancova tests (adjusted for age and body mass index) and multiple linear regression models based on obsessive-compulsiveness, obsessive personality traits and perfectionism, as independent variables, were applied to determine the best predictors of eating disorder severity. On ancova several significant differences were found between obsessive-compulsive and eating-disordered patients (MOCI, P  < 0.001; EAT, P  < 0.001; EDI, P  < 0.001), whereas some obsessive personality traits were not eating disorder specific. A total of 16.7% OCD patients presented a comorbid eating disorder, whereas 3.3% eating disorders patients had an OCD diagnosis. In the eating disorder group, the presence of OC symptomatology was positively associated ( r  = 0.57, P  < 0.001) with the severity of the eating disorder. The results were maintained after adjusting for comorbidity. Although some obsessive-compulsive and eating disorder patients share common traits (e.g. some personality traits especially between OCD and AN), both disorders seem to be clinically and psychopathologically different.     

Interaction between serotonin transporter and dopamine D2/D3 receptor radioligand measures is associated with harm avoidant symptoms in anorexia and bulimia nervosa

Individuals with anorexia nervosa (AN) and bulimia nervosa (BN) have alterations of measures of serotonin (5-HT) and dopamine (DA) function, which persist after long-term recovery and are associated with elevated harm avoidance (HA), a measure of anxiety and behavioral inhibition. Based on theories that 5-HT is an aversive motivational system that may oppose a DA-related appetitive system, we explored interactions of positron emission tomography (PET) radioligand measures that reflect portions of these systems. Twenty-seven individuals recovered (REC) from eating disorders (EDs) (7 AN–BN, 11 AN, 9 BN) and nine control women (CW) were analyzed for correlations between [¹¹C]McN5652 and [¹¹C]raclopride binding. There was a significant positive correlation between [¹¹C]McN5652 binding potential (BP_{non displaceable(ND)}) and [¹¹C]Raclopride BP_ND for the dorsal caudate, antero-ventral striatum (AVS), middle caudate, and ventral and dorsal putamen. No significant correlations were found in CW. [¹¹C]Raclopride BP_ND, but not [¹¹C]McN5652 BP_ND, was significantly related to HA in REC EDs. A linear regression analysis showed that the interaction between [¹¹C]McN5652 BP_ND and [¹¹C]raclopride BP_ND in the dorsal putamen significantly predicted HA. This is the first study using PET and the radioligands [¹¹C]McN5652 and [¹¹C]raclopride to show a direct relationship between 5-HT transporter and striatal DA D2/D3 receptor binding in humans, supporting the possibility that 5-HT and DA interactions contribute to HA behaviors in EDs.     

An Association Study of the A218C Polymorphism of the Tryptophan Hydroxylase 1 Gene with Eating Disorders in a Korean Population: A Pilot Study

Objective

We examined the association between the tryptophan hydroxylase 1 (TPH1) gene and eating disorders focusing on obsessionality.

Methods

The sample included 62 women with a lifetime diagnosis of anorexia nervosa (AN) as well as 50 women with a lifetime diagnosis of bulimia nervosa (BN) recruited from specialist clinics for eating disorders and 131 healthy women in Korea. Blood samples were collected from all participants for the TPH1 genotyping. The patients were ad ministered the Korean version of the Eating Disorders Examination and obsessionality was conceptualized using measures of persistence, harm avoidance, and obsessive-compulsive symptoms.

Results

In the case-control comparisons, the frequency of the A/A genotype was increased in the patients with BN, but this difference was not significant after correcting for multiple testing. We found no effect of the TPH A218C polymorphism on obsessionality in the patients with AN or BN.

Conclusion

Although the present findings should be regarded as preliminary because of the small size of our sample, they suggest that the TPH1 gene may contribute to the genetic susceptibility to BN and be associated with the other unexplored traits of bulimic case status.     

The association between interpersonal problems and treatment outcome in the eating disorders: A systematic review

Abstract

Objective: To review systematically the eating disorder literature in order to examine the association between pre-treatment interpersonal problems and treatment outcome in people diagnosed with an eating disorder. Methods: Six relevant databases were searched for studies in which interpersonal problems prior to treatment were examined in relation to treatment outcome in patients diagnosed with anorexia nervosa (AN), bulimia nervosa (BN) or eating disorders not otherwise specified (EDNOS). Results: Thirteen studies were identified (containing 764 AN, 707 BN and 48 EDNOS). The majority of studies indicated that interpersonal problems at the start of therapy were associated with a detrimental treatment outcome. Conclusions: Individuals with a binge/purge-type of eating disorder may be particularly vulnerable to interpersonal issues and these issues may lead to poorer treatment recovery by reducing the individual's ability to engage in the treatment process on a functional level. The clinical and research implications are discussed.