Suicide and attempted suicide in anorexia nervosa and bulimia nervosa

Suicide in anorexia nervosa and bulimia nervosa is a major cause of death. Risk factors for suicide and attempted suicide (which in many cases results in successful suicide) in anorexia nervosa include: purging type, chronic disease, and during treatment, obsessive symptoms and drug abuse, major depression, and for anorexia nervosa low body mass index (BMI) at presentation. In anorexia nervosa suicide has been considered the first cause of death and attempted suicide is a serious threat to these individuals. Data concerning suicide in bulimia nervosa has still scarce whereas attempted suicides are easily found in clinical histories of patients. No doubt suicidal behavior is underestimated amongst patients with anorexia nervosa and bulimia nervosa. An effort to reconcile with subject of suicide and a better evaluation of these patients' psychopathology should improve suicide prevention strategies amongst these individuals.     

Suicide in anorexia nervosa: a meta-analysis

OBJECTIVE: Suicide is a major cause of death among subjects with anorexia nervosa, but the rate of suicide among this population is very often underestimated. We conducted a meta-analysis to compare data reported in representative studies of suicide in anorexia nervosa with data for the general population. METHOD: We searched the Index Medicus until 2002 through MedLine. We also searched the World Health Statistics Annual to ascertain the suicide rate in the age group 14-25 for specific years and country. RESULTS: We selected nine studies comprising 1,536 patients. Of these patients, 36 committed suicide. Results obtained for each study were processed together to calculate the mean figure for each year of suicides for 100,000 individuals suffering from anorexia nervosa. DISCUSSION: Our meta-analysis shows that suicide among patients with anorexia nervosa is more frequent when compared with the general population. All study analyses, except one, reported that the patients with anorexia nervosa committed suicide more often than their counterparts in the general population.     

Is anorexia nervosa associated with elevated rates of suicide?

OBJECTIVES: The purpose of this study was to ascertain whether individuals with anorexia nervosa are more likely to commit suicide, as suggested by previously noted associations between anorexia nervosa and mood disorders. METHODS: Data from death records representing over 5 million women were examined, yielding 571 cases in which anorexia nervosa was mentioned as an existing condition. The women with anorexia were compared with 1713 control subjects matched for age, sex, and race. RESULTS: The percentage of suicides among those listed as having anorexia nervosa was only 1.4%, compared with 4.1% for the controls. CONCLUSIONS: These findings suggest that the suicide rate is not elevated among individuals currently suffering from anorexia nervosa.     

The current status of treatment for anorexia nervosa and bulimia nervosa

A survey investigating the current status of treatment for anorexia nervosa and bulimia nervosa was distributed at the International Conference on Eating Disorders in 7988 and again in 1990. Respondents answered questions regarding treatments they had endorsed for their last patient with anorexia nervosa and for bulimia nervosa. One hundred and seven medical doctors and psychologists completed the survey in 1988 and 115 in 1990. The results indicate that: (1) less than 50% of the respondents believe there is a consensus regarding the treatment of eating disorders; (2) talking therapy is overwhelmingly endorsed for the treatment of both anorexia and bulimia nervosa; (3)there is a trend in clinical practice towards using drug therapy more frequently in treating patients with bulimia nervosa than in treating patients with anorexia nervosa; (4)physicians are more likely than psychologists to endorse drug therapy when treating patients with anorexia and for bulimia nervosa; and (5) about one third of the respondents endorse drug therapy for treating anorexia nervosa. © 1992 John Wiley & Sons, Inc.     

Dating People with Anorexia Nervosa and Bulimia Nervosa: Attitudes and Beliefs of University Students

ABSTRACT

Attitudes and beliefs about dating people with eating disorders were investigated in men and women using a questionnaire administered to 752 university students. Students believed that people with anorexia nervosa and bulimia nervosa had a difficult time dating, dates would involve conflict, and dating would be a negative experience. Students were more comfortable in casual interactions than more serious dating activities with people with anorexia nervosa and bulimia nervosa. Men were somewhat comfortable dating people with anorexia nervosa or bulimia nervosa, but less so for obesity. Most students believed dating people with anorexia nervosa and bulimia nervosa would not be a positive experience, and men Stigmatized people with eating disorders differently, than did women.     

Knowledge about eating disorders in the community

One-hundred and forty-nine subjects (80 females and 69 males) were asked about their knowledge of anorexia and bulimia nervosa, the source of their knowledge, and the ways in which their knowledge of these disorders may have affected their attitudes towards eating, dieting, and related behaviors. Almost all subjects had heard of anorexia nervosa, whereas bulimia nervosa was less well known, particularly among males. Knowledge of anorexia nervosa was more detailed than that for bulimia nervosa. The mass media were the major sources of subjects' information about these disorders. Over one-third of females reported that their knowledge concerning anorexia and bulimia nervosa had affected their own eating or related attitudes in some way. The importance of the media in both promoting and preventing eating disorders is discussed.     

Males with anorexia nervosa: a controlled study of eating disorders in first-degree relatives

OBJECTIVE: To compare lifetime rates of full and partial anorexia nervosa and bulimia nervosa in first-degree relatives of males with anorexia nervosa and in relatives of never-ill comparison subjects. METHODS: Rates of eating disorders were obtained for 747 relatives of 210 probands from personal structured clinical interviews and family history. Best-estimate diagnoses were determined blind to proband diagnosis and pedigree status. RESULTS: Full and partial syndromes of anorexia nervosa aggregated in female relatives of ill probands. For the full syndrome of anorexia nervosa, the crude relative risk was 20.3 among female relatives and for partial syndrome anorexia nervosa, the crude relative risk was 3.3. In contrast, bulimia nervosa was relatively uncommon among relatives of ill probands. CONCLUSION: Although anorexia nervosa in males is exceedingly rare, there is a pattern of familial aggregation that is highly similar to that observed in recent family studies of affected females. On the basis of these findings, there is no evidence that familial-genetic factors distinguish the occurrence of anorexia nervosa in the two sexes.     

On the emergence of bulimia nervosa as a syndrome a historical view

A review of the anorexia nervosa literature suggests that bulimia as a symptom has been known throughout the past century, but that bulimia as a syndrome is of recent origin, around 1940, when it occurred in connection with anorexia nervosa. Comments indicating concern over body shape are infrequent in case reports before the forties, but afterwards become the rule. It is hypothesized that changes in the cultural and economic conditions, such as the rising prosperity after the Depression Years, promoted an increased concern over body weight and recruited not only more, but also women of a psychologically different composition from the traditional anorexia nervosa patient, into dieting. This situation exposed more females to the risk of developing anorexia nervosa and those with a particular vulnerability, for example a tendency for affective instability, to the risk of developing bulimia nervosa. Similar dynamics might have promoted the unfolding of the bulimia nervosa syndrome in the late fifties and sixties.     

Anorexia nervosa following gastroplasty in the male: Two cases

The first stage in the development of anorexia nervosa involves voluntary restriction of food intake, that is, diet. Marked weight loss, impairment in body image, and deterioration of health ensue. Anorexia nervosa is much more prevalent among women than men. Its etiology and presentation are mostly similar for both sexes. Certain features, such as greater premorbid obesity and sexual identity concerns, are thought to be more prevalent in male patients. We present 2 male patients who had undergone gastroplasty for morbid obesity and subsequently developed anorexia nervosa. Both evinced signs of identity confusion. Neither one of the patients underwent psychiatric evaluation before surgery. The cases described illustrate that anorexia nervosa may succeed acute and marked weight loss following gastroplasty. This emphasizes the need for a psychiatric assessment before bariatric surgery, and should alert clinicians to search for elements that may predispose vulnerable individuals to a risk of developing anorexia nervosa. © 1996 by John Wiley & Sons, Inc.     

Outcomes of eating disorders: a systematic review of the literature

OBJECTIVE: The RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center systematically reviewed evidence on factors associated with outcomes among individuals with anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED) and whether outcomes differed by sociodemographic characteristics. METHOD: We searched electronic databases including MEDLINE and reviewed studies published from 1980 to September, 2005, in all languages against a priori inclusion/exclusion criteria and focused on eating, psychiatric or psychological, or biomarker outcomes. RESULTS: At followup, individuals with AN were more likely than comparisons to be depressed, have Asperger's syndrome and autism spectrum disorders, and suffer from anxiety disorders including obsessive-compulsive disorders. Mortality risk was significantly higher than what would be expected in the population and the risk of suicide was particularly pronounced. The only consistent factor across studies relating to worse BN outcomes was depression. A substantial proportion of individuals continue to suffer from eating disorders over time but BN was not associated with increased mortality risk. Data were insufficient to draw conclusions concerning factors associated with BED outcomes. Across disorders, little to no data were available to compare results based on sociodemographic characteristics. CONCLUSION: The strength of the bodies of literature was moderate for factors associated with AN and BN outcomes and weak for BED.     

Subtyping of bulimia nervosa

Several possible ways of subtyping bulimia nervosa are discussed. Two possibilities, subtyping bulimia nervosa by presence or absence of a history of anorexia nervosa or presence or absence of a history of obesity, both represent interesting approaches, but there is inadequate data to support either as a subclassifying system at this point. There is considerable interest in requiring purging behavior for the diagnosis of bulimia nervosa, or for subtyping bulimia nervosa into purging vs. non-purging types. Also the issue of bow to classify over-weight bulimic individuals by DSM-Ill-R criteria who do not purge remains controversial.     

The development and validation of the body shape questionnaire

Concerns about body shape are common among young women in Western cultures, and, in an extreme form, they constitute a central feature of the eating disorders anorexia nervosa and bulimia nervosa. To date there has been no satisfactory measure of such concerns. A self-report instrument, the Body Shape Questionnaire (BSQ) has therefore been developed. The items that constitute this measure were derived by conducting semistructured interviews with various groups of women including patients with anorexia nervosa and bulimia nervosa. The BSQ has been administered to three samples of young women in the community as well as to a group of patients with bulimia nervosa. The concurrent and discriminant validity of the measure have been shown to be good. The BSQ provides a means of investigating the role of concerns about body shape in the development, maintenance, and treatment of anorexia nervosa and bulimia nervosa.     

Racial and socioeconomic: Influences in anorexia nervosa and bulimia

Eight black and 120 white patients with anorexia nervosa or bulimia were compared with each other and with 21 black control patients. Biack and white patients with eating disorders were similar in demographic features (except for later age of onset in blacks), in clinical characteristics, and in course of illness. Both racial groups with eating disorders had a significantly higher socioeconomic status than control patients. A diagnosis of anorexia nervosa or bulimia can be confidently made independent of racial designation. Socioeconomic status appears to be a risk factor for development of anorexia nervosa or bulimia in both black and white populations.     

Factors associated with suicidal behaviors in a large French sample of inpatients with eating disorders

OBJECTIVE: The objective of the present study was to identify factors associated with suicidal behaviors among patients with eating disorders. METHOD: A large database including sociodemographic and clinical characteristics of 1,009 consecutive patients hospitalized for an eating disorder in Paris, France, was examined. Data gathered upon admission to hospital were analyzed to identify factors associated with a history of suicide attempt or current suicidal ideation, among the whole sample as well as among each subtype of eating disorder. RESULTS: Among the whole sample, the factor most strongly associated with suicide attempt or suicidal ideation was the diagnostic category, with the highest odds ratio for bulimia nervosa followed by anorexia nervosa of the binging/purging subtype. Among diagnostic subgroups, the strongest factors were drug use, alcohol use, and tobacco use. CONCLUSION: Suicide risk should be monitored carefully among patients with eating disorders, paying particular attention to combinations of risk factors.     

The cognitive behavioural model for eating disorders: a direct evaluation in children and adolescents with obesity

OBJECTIVE: The cognitive behavioural model of bulimia nervosa [Fairburn, C.G., Cooper, Z., & Cooper, P.J. (1986). The clinical features and maintenance of bulimia nervosa. In K.D. Brownell, and J.P. Foreyt (Eds.), Handbook of eating disorders: physiology, psychology and treatment of obesity, anorexia and bulimia (pp. 389-404). New York: Basic Books.] provides the theoretical framework for cognitive behaviour therapy of Bulimia Nervosa. For a long time it was assumed that the model can also be used to understand the mechanism of binge eating among obese individuals. The present study aimed to test whether the specific hypotheses derived from the cognitive behavioural theory of bulimia nervosa are also valid for children and adolescents with obesity. METHOD: The prediction of the model was tested using structural equation modeling. Data were collected from 196 children and adolescents. RESULTS: In line with the model, the results suggest that a lower self-esteem predicts concerns about eating, weight and shape, which in turn predict dietary restraint, which then further is predictive of binge eating. DISCUSSION: The findings suggest that the mechanisms specified in the model of bulimia nervosa is also operational among obese youngsters.     

Neuropsychological correlates of dieting disorders

Various studies have suggested that patients with anorexia nervosa may have cognitive deficits on neuropsychological examination. A battery of tests was administered to 35 patients (34 female, 1 male), diagnosed as suffering from anorexia nervosa (n = 20) or bulimia nervosa (n = 15) during the early stages of admission to a specialized eating disorders unit. Results revealed no significant differences between the anorexia nervosa and bulimia nervosa patients on any of the intellectual, neuropsychological, or academic-related tasks that were administered. There was no evidence of cognitive deficits in certain patient groups when compared with theoretical norms.     

Cognitive style of patients with anorexia nervosa and bulimia nervosa

Nine female patients with anorexia nervosa and 7 female patients with bulimia nervosa were assessed on the Matching Familiar Figures Test (MFFT). This study found that subjects with bulimia nervosa responded more quickly than did the anorexic subjects. Results such as these suggest that not only are bulimic patients more behaviorally impulsive than anorexic patients, they are also more cognitively impulsive. Patients with anorexia nervosa in contrast seemed to display a reflective cognitive style. Extreme cognitive styles may contribute to resistance in treatment and/or relapse in anorexia or bulimia nervosa. © 1995 by John Wiley & Sons, Inc.     

Season of birth and bulimia nervosa

OBJECTIVE: Previous studies suggest season of birth variation in eating disorders akin to those of psychoses. We studied season of birth variation in bulimia nervosa. METHOD: Season of birth variation in 935 patients was examined after adjustment for population trends. Variation was also examined for subgroups by age and previous anorexia nervosa. RESULTS: Season of birth did not differ significantly from population norms among bulimics (p >.30), contrasting with studies of other eating disorders. With a history of anorexia nervosa (n = 227), peak season of birth was in March (p <.05). This is consistent with previous studies and also with seasonal birth variation for psychoses. DISCUSSION: Overall, we find no evidence of season of birth variation in bulimia nervosa, and suggest any positive findings be treated with caution. We discuss a number of confounding influences and argue that one explanation remains shared trait vulnerability between anorexia nervosa and psychoses.     

Age of onset in eating disorders

This paper presents age of onset data for anorexia nervosa and bulimia nervosa, derived from a sample of 323 patients referred to a tertiary referral center. Patients had anorexia nervosa (n = 39), bulimia nervosa (n = 173), or bulimia nervosa with a history of anorexia nervosa (n = 173). While the pattern of onset of anorexia nervosa and bulimia nervosa is similar up to age 25, there is a significant excess of new cases of anorexia nervosa beyond this point. Significantly, age of onset was constant for both anorexia nervosa and bulimia regardless of whether they occurred in isolation (anorexia or bulimia alone) or in concert in the same individual (bulimia with a history of anorexia nervosa).