The natural course of bulimia nervosa and eating disorder not otherwise specified is not influenced by personality disorders

OBJECTIVE: To examine prospectively the natural course of bulimia nervosa (BN) and eating disorder not otherwise specified (EDNOS) and to test the effects of personality disorder (PD) comorbidity on the outcomes. METHOD: Ninety-two female patients with current BN (N=23) or EDNOS (N=69) were evaluated at baseline enrollment in the Collaborative Longitudinal Personality Disorders Study (CLPS). Eating disorders (EDs) were assessed with the Structured Clinical Interview for DSM-IV Axis I Disorders. Personality disorders (PDs) were assessed with the Diagnostic Interview for DSM-IV PD (DIPD-IV). The course of BN and EDNOS was assessed with the Longitudinal Interval Follow-up Evaluation and the course of PDs was evaluated with the Follow-Along version of the DIPD-IV at 6, 12, and 24 months. RESULTS: Probability of remission at 24 months was 40% for BN and 59% for EDNOS. To test the effects of PD comorbidity on course, ED patients were divided into groups with no, one, and two or more PDs. Cox proportional regression analyses revealed that BN had a longer time to remission than EDNOS (p<.05). The number of PDs was not a significant predictor of time to remission, nor was the presence of Axis I psychiatric comorbidity or Global Assessment of Functioning scores. Analyses using proportional hazards regression with time-varying covariates revealed that PD instability was unrelated to changes in ED. CONCLUSIONS: BN has a worse 24-month course (longer time to remission) than EDNOS. The natural course of BN and EDNOS is not influenced significantly by the presence, severity, or time-varying changes of co-occurring PDs, co-occurring Axis I disorders, or by global functioning.     

Prevalence of eating disorders in female and male adolescents (14-15 years)

OBJECTIVE: The main aim of the present study is to establish the prevalence of eating disorders (ED) in adolescents of both genders. To our knowledge, such data have not previously been published using both DSM-IV and DSM-III-R criteria. METHOD: The study sample consisted of 1960 adolescents (1026 girls and 934 boys), 14-15 years of age. The participants completed the Survey for Eating Disorders (SEDs), including DSM-III-R and DSM-IV diagnoses for all subcategories of ED. RESULTS: Lifetime prevalence of any ED among girls was 17.9% anorexia nervosa (AN) 0.7%, bulimia nervosa (BN) 1.2%, binge eating disorder (BED) 1.5%, and EDs not otherwise specified (EDNOS) 14.6%. Corresponding numbers for boys for any ED is 6.5%, AN 0.2%, BN 0.4%, BED 0.9%, and EDNOS 5.0%. DISCUSSION: Our prevalence rates on AN, BN, and BED largely support previous school/community-based studies, while our figures on EDNOS were rather high. Generally, we found high numbers for boys with ED.     

General population-based epidemiological study of eating disorders in Norway

In a questionnaire-based study of eating disorders in a representative sample of the general female population of Norway, the lifetime prevalence of eating disorders was 8.7% with a point prevalence of 3.8%. The lifetime prevalence of binge eating disorder (BED) was 3.2%, bulimia nervosa (BN) 1.6%, and anorexia nervosa (AN) 0.4%. Eating disorders not otherwise specified (EDNOS) had a lifetime prevalence of 3.0%. Point prevalence of BED was 1.5%, BN 0.7%, AN 0.3%, and EDNOS 1.3%. © 1995 by John Wiley & Sons, Inc.     

Psychiatric comorbidity of eating disorders in men: a national study of hospitalized veterans

OBJECTIVE: This study examined eating disorders and their psychiatric comorbidity in a national sample of hospitalized male veterans. METHOD: Review of discharge summaries for 466,590 male patients from Veterans Affairs medical centers for fiscal year 1996 resulted in the identification of 98 men with a current ICD-9-CM diagnosis of an eating disorder. For the comorbidity analyses, eating disorder cases were matched with controls drawn randomly from the pool of male patients without an eating disorder, using age and race as matching variables. RESULTS: There was a high rate of comorbid substance use and mood disorder for men with anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS). Men with AN were also at high risk for comorbid schizophrenia/psychotic disorder, men with BN were at risk for comorbid personality disorder, and men with EDNOS were at special risk for comorbid organic mental disorder and schizophrenia/psychotic disorder. DISCUSSION: For each eating disorder, there was a distinct pattern of psychiatric comorbidity that deserves further study.     

Course and predictors of maternal eating disorders in the postpartum period

Objective:

To investigate course and predictors of eating disorders in the postpartum period.

Method:

A total of 77,807 women, participating in the Norwegian Mother and Child Cohort Study (MoBa), completed questionnaires during pregnancy including items covering DSM‐IV criteria for prepregnancy anorexia nervosa (AN), bulimia nervosa (BN), eating disorder not otherwise specified (EDNOS‐P), and binge eating disorder (BED). Additional questionnaires were completed at 18 and 36 months postpartum.

Results:

Proportions of women remitting at 18 months and 36 months postpartum were 50% and 59% for AN, 39% and 30% for BN, 46% and 57% for EDNOS‐P, and 45% and 42% for BED, respectively. However, disordered eating persisted in a substantial proportion of women meeting criteria for either full or subthreshold eating disorders. BN during pregnancy increased the risk for continuation of BN. BMI and psychological distress were significantly associated with course of BED.

Discussion:

This is the first large‐scale population‐based study on course of eating disorders in the postpartum period. The results indicated that disordered eating persists in a substantial proportion of women with prepregnancy eating disorders. Health care professionals working with women in this phase of life need to pay specific attention to eating disorder symptoms and behaviors. © 2013 by Wiley Periodicals, Inc. (Int J Eat Disord 2013)     

Predicting the outcome of eating disorders using structural equation modeling

OBJECTIVE: There is a need for models that predict accurately the course of mental disorders. METHOD: Eating-disordered female inpatients were assessed longitudinally at the beginning of treatment (t1), at the end of treatment (t2), at 2 or 3-year follow-up (t3), and at 6-year follow-up (t4). The sample consisted of 196 women with bulimia nervosa (BN) purging type, 103 women with anorexia nervosa (AN), and 68 women with binge eating disorder (BED; N=367). Confirmatory factor analysis and path analysis were used to predict the women's status at 6-year follow-up. RESULTS: The results for BN and BED show that the specific eating disorder pathology was influenced mainly by specific eating disorder pathology at earlier time points and not by non-eating-specific (general) psychopathology. Similarly, general psychopathology was influenced mainly by general psychopathology at earlier time points. For AN patients, both categories of psychopathology (eating specific and general) were relevant for the 6-year outcome. The potential impact of 14 factors on the level of pathology was estimated (a) at baseline (at the beginning of treatment), (b) during the course of illness (baseline controlled), and (c) on the 6-year outcome of eating disorders (baseline and course controlled). Although there were many correlations between potential factors and baseline pathology, there was only a limited number of significant correlations with the 6-year outcome. This effect was mediated largely by the level of general psychopathology. DISCUSSION: The models for outcome prediction based on structural equation modeling techniques were very similar for BN and BED. For both BN and BED, there were almost entirely separate predictions for the specific eating disorder on the one hand and non-eating-related (general) psychopathology on the other hand. This was true to a lesser degree for AN. CONCLUSIONS: The use of refined path analytic methods in follow-up studies on larger general populations will be helpful to increase our understanding of the course of illness of psychiatric disorders.     

An epidemiological study of eating disorders in Norwegian psychiatric institutions

Objective: The aim was to establish the prevalence of eating disorders in psychiatric patients. Method: The total inpatient (n = 8,942) and outpatient (n = 10,125) Norwegian psychiatric population was investigated with a staff-report questionnaire. Results: The prevalence of eating disorders in the inpatient population was 3.8% for women and 1.6% for men. In the outpatient population, the differentiated diagnoses anorexia nervosa (AN), bulimia nervosa (BN), and the comorbidity of AN + BN was 5.7%, 7.3%, and 1.6% for women, and 0.8%, 0.7%, and 0.3% for men (this could be reduced to AN and BN prevalences of 7.3% and 8.9% for women and 1.0% and 1.0% for men). Discussion: The level of the prevalence figures is in the expected area, thus the present study confirms earlier studies with smaller psychiatric populations. © 1995 by John Wiley & Sons, Inc.     

Fractures in patients with anorexia nervosa,bulimia nervosa,and other eating disorders--a nationwide register study

OBJECTIVE: To study fracture risk in patients with anorexia nervosa (AN), bulimia nervosa (BN), or eating disorders not otherwise specified (EDNOS). METHOD: Cohort study including all Danes diagnosed with AN (n = 2,149), BN (n = 1,294), or EDNOS (n = 942) between 1977 and 1998. Each patient was compared with three randomly drawn age- and gender-matched control subjects. RESULTS: Fracture risk was increased in AN after diagnosis compared to controls (incidence rate ratio: 1.98, 95% CI: 1.60-2.44), but not before. The increased fracture risk persisted more than 10 years after diagnosis. A significant increase in fracture risk was found before diagnosis in BN (1.31, 95% CI: 1.04-1.64), with a trend towards an increase after diagnosis (1.44, 95% CI: 0.93-2.22). EDNOS patients had a significant increase in fracture risk before (1.39, 95% CI: 1.06-1.81) and after diagnosis (1.77, 95% CI: 1.25-2.51). DISCUSSION: The increased fracture risk many years after diagnosis indicates permanent skeletal damage.     

Evaluating the treatment of eating disorders from the patient's perspective

OBJECTIVE: This study investigated the evaluation of treatment of eating disorders (EDs) from the patient's perspective in a large community based sample in the Netherlands. It investigated perceived helpfulness of different types of treatment. Furthermore it investigated which patient and treatment characteristics contribute to the evaluation of treatment. METHOD: The Eating Disorder Examination questionnaire was administered to 44 anorexia nervosa (AN), 43 bulimia nervosa (BN), 69 EDNOS (ED not otherwise specified), and 148 former ED patients. A questionnaire specifically designed for the purpose of this study addressing treatment history and patient's evaluation of their treatment was administered. RESULTS: There is a substantial patient and doctor delay in seeking and finding treatment. Treatment in specialized ED centers, self-help groups, and treatment with a partner were reported to be most helpful. Beneficial components of treatment reported in specialized ED centers refer to the communication skills of professionals, the therapist-patient working alliance, the contact with peers, and the focus of treatment on both ED symptoms as well as underlying issues. CONCLUSION: The patient's perspective on treatment of EDs does provide recommendations for the improvement of treatment of EDs that will facilitate clinical decision making and treatment planning.     

Eating disorders and health in elite women distance runners.

OBJECTIVES: To examine the presence of eating disorder syndromes in elite women distance runners in the United Kingdom and any associated differences in training, dieting, general health, and well-being. METHOD: Athletes were selected from the top of their respective ranking lists for all middle and long-distance races in 1996/1997. All running disciplines were included (track, road, cross-country, and fell/mountain running). Athletes were sent the Eating Disorders Examination Questionnaire and a questionnaire on demographics, athletic training, diet, and health. Of the 226 athletes identified, 181 (81%) completed and returned the questionnaires. RESULTS: Twenty-nine athletes (16%) had an eating disorder at the time of the study (7 had anorexia nervosa [AN], 2 had bulimia nervosa [BN], and 20 had eating disorders not otherwise specified [EDNOS]) and a further 6 had received previous treatment. Comparing the eating disorder group with the rest of the sample showed no difference in age, height, preferred race distance, or the number of hours/week spent training. However, they had a significantly lower body mass index (BMI), lower self-esteem, and poorer mental health. Current and past dieting were significantly more common in the eating disorder group. DISCUSSION: The levels of AN and EDNOS are higher than would be expected in similarly aged, nonathletic women. The demands for leanness rather than exercise intensity appear to be the main risk in these elite runners. The early detection and prevention of eating disorders in women athletes should have high priority.     

Empirical classification of eating disorders

Although the eating disorder nosology has become refined over the years, considerable problems remain. The purpose of the present study was to empirically examine eating disorder classification using a sample of treatment-seeking eating-disorder patients. One hundred and fifty-nine patients with diagnoses of anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder, not otherwise specified (EDNOS), were included in a cluster analysis using a variety of eating disorder variables. Findings revealed four clusters, with three clusters resembling AN, restricting type, BN, and binge-eating disorder (BED). The remaining cluster appeared to be a group of patients that were subthresholded in terms of symptom severity. Results also indicated a relatively poor fit between the empirically derived groupings and clinical diagnoses. The implications of these findings for both the current classification system and treatment considerations are discussed.     

Twelve-year course and outcome predictors of anorexia nervosa

OBJECTIVE: The current study presents the long-term course of anorexia nervosa (AN) over 12 years in a large sample of 103 patients diagnosed according to criteria in the 4th ed. of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). METHOD: Assessments were made at the beginning of therapy, at the end of therapy, at the 2-year follow-up, at the 6-year follow-up, and at the 12-year follow-up. Self-rating and an expert-rating interview data were obtained. RESULTS: The participation rate at the 12-year follow-up was 88% of those alive. There was substantial improvement during therapy, a moderate (in many instances nonsignificant) decline during the first 2 years posttreatment, and further improvement from 3 to 12 years posttreatment. Based on a global 12-year outcome score, 27.5% had a good outcome, 25.3% an intermediate outcome, 39.6% had a poor outcome, and 7 (7.7%) were deceased. At the 12-year follow-up 19.0% had AN, 9.5% had bulimia nervosa-purging type (BN-P), 19.0% were classified as eating disorder not otherwise specified (EDNOS). A total of 52.4% showed no major DSM-IV eating disorder and 0% had binge eating disorder (BED). Systematic-strictly empirically based-model building resulted in a parsimonious model including four predictors of unfavorable 12-year outcome explaining 45% of the variance, that is, sexual problems, impulsivity, long duration of inpatient treatment, and long duration of an eating disorder. CONCLUSION: Mortality was high and symptomatic recovery protracted. Impulsivity, symptom severity, and chronicity were the important factors for predicting the 12-year outcome.     

Personality disorders among subjects recovered from eating disorders

OBJECTIVE: Personality disorders are common in symptomatic eating disorders subjects. Because personality symptoms could be exaggerated by malnutrition or Axis I disorders, we studied women who had recovered from eating disorders for at least 1 year to see if personality disorder symptoms persisted in the well state. METHOD: Personality disorders were evaluated in 10 women recovered from anorexia nervosa (AN), 28 women recovered from bulimia nervosa (BN), and 16 women recovered from AN and BN, using the Structured Clinical Interview for DSM-III-R personality disorders. RESULTS: Fourteen of 54 subjects (26%) met the criteria for at least one personality disorder, such as self-defeating, obsessive-compulsive, or borderline personality disorder. Cluster B personality disorders were closely associated with bulimic subtypes. CONCLUSIONS: While a recovery from eating disorders may have an attenuating influence on the symptoms of personality disorders, such personality disorder diagnoses persist after recovery in some recovered subjects.     

The clinical features of EDNOS: Relationship to mood,health status and general functioning

Study purposeEating disorder not otherwise specified (EDNOS) remains poorly evaluated in terms of eating disorder features and relationship to mood, health status and general functioning. This study investigated the clinical profiles of a sample of EDNOS patients, and how they compared to patients with anorexia nervosa (AN) and bulimia nervosa (BN).MethodThe sample consisted of 178 patients. All completed the Eating Disorder Examination, Beck Depression Inventory, Work and Social Adjustment Scale and Sf-36. ANOVAs were conducted to explore group differences.ResultsNo differences were found for depression. No differences were found between BN and EDNOS on measures of health status and general functioning. AN patients reported greater role limitations due to physical health and experienced greater physical pain compared with BN or EDNOS patients, and reported poorer social functioning, lower vitality and higher functional impairment compared with EDNOS patients.ConclusionEDNOS patients are generally no less clinically impaired than those with BN. However AN patients may be more impaired in some aspects of general functioning compared with BN or EDNOS patients.     

Eating disorder symptomatology among ballet dancers

OBJECTIVE: The current study sought to compare eating disorder symptomatology among ballet dancers and individuals with restricting anorexia nervosa (RAN), bulimia nervosa (BN), and no eating pathology. METHOD: Twenty-nine female ballet dancers completed assessments and were compared with an archival dataset of 26 women with RAN, 47 women with BN, and 44 women with no eating pathology. Eating disorder diagnoses and behaviors were assessed with a semi-structured clinical interview, the Eating Disorder Inventory (EDI), and a weight history interview. RESULTS: Eighty-three percent of dancers met lifetime criteria for AN (6.9%), BN (10.3%), AN+BN (10.3%), or EDNOS (55.0%). Moreover, dancers looked more similar to eating-disordered individuals than to control individuals on measures of eating pathology. CONCLUSION: Despite previous emphasis on the pathology AN, the current findings suggest that dancers frequently engage in binge eating and purging behaviors. Moreover, it appears that their pathology is as severe as that of non-dancing women with eating disorders.     

Drug abuse in women with eating disorders

OBJECTIVE: Drug abuse in women with eating disorders has received relatively little attention. The frequency of drug use disorder (DUD) by specific drug type was examined in the current longitudinal study. METHOD: In a prospective study, women diagnosed with either anorexia nervosa (AN; n = 136) or bulimia nervosa (BN; n = 110), were interviewed and assessed for research diagnostic criteria (RDC) DUD every 6-12 months over 8.6 years. RESULTS: Forty-two (17%) women in the current longitudinal study had a lifetime history of DUD, with 19 prospective onsets over the course of the study (9 AN and 10 BN). The most commonly abused illicit drugs were amphetamines, cocaine, and marijuana, and rates of DUD did not differ between intake diagnoses of AN and BN. CONCLUSION: Drug abuse in women with eating disorders is an area of clinical concern and should be monitored routinely throughout the treatment process.     

The emergence and treatment of anorexia and bulimia nervosa. A comprehensive and practical model

The objective was to propose and describe a new bio-psycho-social model of emergence and maintenance of anorexia nervosa and bulimia nervosa, and demonstrate its application to treatment. An original model, based on literature review and our own clinical experience, was created. Therapeutic guidelines were derived from the theoretical model and applied in the treatment of 97 anorexia and bulimia nervosa patients presented at the eating disorders unit at Kaplan Hospital in Israel over 18 months. A team comprising a pediatrician, a child psychiatrist, a dietician, and trained nurses collaborated in a comprehensive systemic therapeutic approach involving parents, schools, and community agents. RESULTS: Ninety-one girls and six boys were treated in the eating disorder unit (55 had AN, 29 had BN and 13 had EDNOS). Thirty-seven patients were hospitalized and sixty were treated in the outpatient clinic. Mean hospitalization time of the first five patients was 108 days. Mean hospitalization time of the remaining 32 patients was reduced to 32 days. The mean number of outpatient clinic interventions was 12. At the one-year follow up, 74 patients were doing well in all respects. Fourteen patients still needed a lot of supervision in eating. Five are still hospitalized and four were lost to follow up. CONCLUSIONS: The proposed model proves to be more than just another theory in that it is successfully applied in treatment. Short systemic therapy is very effective. The longer the delay in drastic, aggressive treatment, the worse the prognosis. Extended hospitalization periods worsen the prognosis. Weakness of the parental unit is a strong indication for inpatient care. The longer the experience in treating eating disorders, the shorter the hospitalization and number of interventions.     

Features associated with excessive exercise in women with eating disorders

OBJECTIVE: Excessive exercise and motor restlessness are observed in a substantial number of patients with eating disorders. This trait has been studied extensively among animal models of activity anorexia nervosa (AN) and may hold particular interest as an endophenotype for AN. We explored features associated with excessive exercise across subtypes of eating disorders. METHOD: Participants were female probands and affected female relatives from the multi-site international Price Foundation Genetic Studies with diagnoses of AN, bulimia nervosa (BN), and both AN and BN or eating disorder not otherwise specified (ED-NOS) (N=1,857). Excessive exercise was defined based on responses to the Structured Interview for Anorexic and Bulimic Disorders (SIAB). RESULTS: Among the eating disorder diagnostic groups, excessive exercise was most common among the purging subtype of AN. Individuals who reported excessive exercise also reported lower minimum BMI, younger age at interview, higher scores on anxiety, perfectionism, and eating disorder symptom measures, more obsessions and compulsions, and greater persistence. CONCLUSION: Excessive exercise may be associated particularly with the purging subtype of AN as well as with a constellation of anxious/obsessional temperament and personality characteristics among women with eating disorders.     

Artificial sweetener use among individuals with eating disorders

Women with eating disorders report using large quantities of artificially sweetened products, but this has not been quantified. OBJECTIVE: The authors assessed the use of selected artificially sweetened low-calorie products among women with eating disorders compared with controls. METHOD: Thirty women with anorexia nervosa (18 with the restricting subtype [AN-R] and 12 with the binge/purge subtype [AN-B/P]), 48 women with bulimia nervosa (BN), and 32 healthy control women completed a survey of frequency and amount of consumption of chewing gum, artificially sweetened low-calorie beverages, and packets of artificial sweetener in the previous month. RESULTS: A greater proportion of women with AN-B/P and BN reported use of each product, compared with women with AN-R and control participants. Among product users, patients with eating disorders reported using greater amounts than controls. Among patients who reported binge eating and/or purging, the quantity of each product used was inversely correlated with body mass index (BMI). CONCLUSION: These data suggest an increased drive for sweet orosensory stimulation in women with AN and BN.