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.     

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.     

A comparison of early family life events amongst monozygotic twin women with lifetime anorexia nervosa, bulimia nervosa, or major depression

OBJECTIVES: To investigate the differential profile of early family life events associated with lifetime anorexia nervosa (AN), bulimia nervosa (BN), and major depression (MD). METHOD: Only data from the monozygotic twins (n = 622) were examined from a community sample of female twins who had participated in three waves of data collection. Eating disorder and MD diagnoses were ascertained from the Eating Disorder Examination at Wave 3 and interview at Wave 2 respectively. Early family events were ascertained from self-report measures at Waves 1 and 3. Two case control designs were used, including a comparison of women: (1) who had lifetime AN, BN, MD, and controls, and (2) twin pairs discordant for either AN, BN, or MD (where the unaffected cotwin formed the control group). RESULTS: Across the two types of designs, compared to controls, both AN and BN were associated with more comments from the family about weight and shape when growing up. AN was uniquely associated with higher levels of paternal protection while BN was associated with higher levels of parental expectations. CONCLUSION: While some overlap among early life events was indicated, especially related to parental conflict and criticism, there was evidence to support some degree of nonoverlap among life events associated with AN, BN, and MD.     

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.     

Personality traits after recovery from eating disorders: Do subtypes differ?

OBJECTIVE: We compared individuals recovered from anorexia (AN) and bulimia nervosa (BN) to determine characteristics that are shared by or distinguish eating disorder (ED) subtypes. METHOD: Sixty women recovered for > or = 1 year from AN or BN were compared with 47 control women (CW). Assessments included the Yale-Brown-Cornell Eating Disorder Scale, the Spielberger State-Trait Anxiety Inventory, the Beck Depression Inventory, the Yale-Brown Obsessive Compulsive Scale, the Temperament and Character Inventory, and Structured Clinical Interviews for DSM-IV. RESULTS: Individuals recovered from an ED had similar scores for mood and personality variables that were significantly higher than the scores for CW. Few recovered subjects had Cluster B personality disorder. Most individuals recovered within 6 years of their ED onset. A latent profile analysis identified an "inhibited" and "disinhibited" cluster based on personality traits. CONCLUSION: A wide range of symptoms persist after recovery and do not differ between subtypes of ED. These findings may aid in identifying traits that create vulnerabilities for developing an ED.     

Specific and nonspecific comorbidity in anorexia nervosa

OBJECTIVE: This article reports lifetime Axis I and II comorbidity in women with anorexia nervosa (AN), and ascertains specific and nonspecific comorbidity in AN compared to clinical samples of women with bulimia nervosa (BN) or major depression (DEP). METHOD: Outpatient AN (n = 56), BN (n = 132), and DEP (n = 100) samples were assessed using Structured Clinical Interviews I and II for DSM-III-R. Baseline data were compared using univariate statistics and logistic regression. RESULTS: In the AN sample as a whole, specific elevations were found for prevalences of obsessive compulsive disorder. The AN-binge eating purging subtype (AN-BP) and the BN sample had elevated prevalences of Cluster B personality disorders. Cluster C prevalences were elevated across samples. CONCLUSION: Evidence of AN-specific, eating disorder-specific, and nonspecific comorbidity illustrates the heterogeneity in AN. Further research is need to examine the relative impact of specific and nonspecific comorbidity in AN subtypes and AN as a whole.     

Pain perception in recovered bulimia nervosa patients

OBJECTIVE: Decreased pain sensitivity is found in individuals who are ill with bulimia nervosa (BN). The purpose of this study is to determine whether altered pain perception persists after recovery from bulimia nervosa (RBN). METHODS: Eleven women who were recovered from BN for more than 1 year were compared with 15 healthy volunteer women. The participants received two pain evaluations--thermal pain stimulation (TPS), which evaluates threshold and tolerance to heat, and the submaximal effort tourniquet test (SETT), which assesses threshold and tolerance to ischemic pain induced by inflation of a blood pressure cuff. RESULTS: Compared with the controls, the RBN women showed elevated pain threshold as measured with the SETT and a tendency to elevated pain threshold on the TPS. DISCUSSION: Decreased pain sensitivity persists after recovery from BN and may reflect altered modulatory function in this illness.     

Poor social comparison and the tendency to submissive behavior in anorexia nervosa

OBJECTIVE: The aim of this study was to confirm an association between low social rank (SR) and anorexia nervosa (AN), and to test the hypotheses that low SR is (a) present after recovery from the illness, (b) mediates an association between increased childhood interpersonal adversity (CIA) and AN. METHOD: Participants were 18 women with active AN, 13 recovered women, and 16 healthy controls. General and specific psychopathology, childhood adversity, and indices of SR were assessed using self-report measures. RESULTS: Low SR was observed in both the active and the recovered AN groups and was a significant mediator in the relationship between CIA and AN status. CONCLUSION: CIA may contribute to the risk of developing AN via its impact on the development of low SR. The latter may be a shared risk factor for AN and affective disorder, and could be a useful therapeutic target.     

Changes in weight and body image over time in women with eating disorders

BACKGROUND: This study examined the changes in body image and weight in young women with an adolescent eating disorder, relative to women without an eating disorder (noED). METHOD: Three diagnostic groups, anorexia nervosa (AN; n = 10), bulimia nervosa (BN; n = 27), and binge eating disorder (BED; n = 42) and three comparison groups (noED; n = 659 each) were compared on body mass index (BMI) and self-reported current body size, ideal body size, and weight dissatisfaction. Dependent variables were examined 2 and 1 year before the onset, the onset year, and 1 and 2 years after the onset of the eating disorder in a model that was adjusted for ethnicity and BMI. RESULTS: BMI was lower in the AN group at all time points except 2 years before onset. AN girls evidenced a significantly stronger relation between BMI and current self-ratings and weight dissatisfaction than noED girls. BMI did not differ between the BN group and the noED group. Girls with BN reported larger current body sizes and greater weight dissatisfaction across all time points. The BED group had higher BMI than the noED group across time. BED girls reported greater current body size ratings and weight dissatisfaction than the noED girls. Girls with AN, BN, or BED did not differ from the noED girls on body ideal ratings. DISCUSSION: Body weight seems to influence perception of body size more so for girls with AN than for noED girls. No support was found for an accelerated weight gain over time for BN. Weight may increase over time for the BED group relative to the noED group, but larger studies are needed. Across all three groups, ideal body size appears to be unrelated to diagnostic status. Rather, the risk for developing an eating disorder appears to arise from size overestimation and related weight dissatisfaction.     

Review

Abstract

Neuroanatomical and functional studies in the eating disorders (ED) are reviewed. Typically, anorexia nervosa (AN) is associated with cerebral spinal fluid spaces enlargement which generally recover as a function of re-feeding. However, specific cortical areas fail to correct in weight restored anorectic patients suggesting trait-related abnormalities. Functional changes in AN associated with starvation reverse with weight recovery, however, reduced 5-HT2A receptor binding may be fundamental to the pathophysiology of AN since this remains after long term weight restoration. Structural studies of bulimia nervosa (BN) provide evidence of brain atrophy, in the absence of significant weight loss but potentially related to chronic dietary restriction. Functional investigations reveal reduced thalamic and hypothalamic serotonin transporter availability in BN which increases with longer illness duration. Thus, BN is associated with substantial structural and functional alterations despite normal weight. Recent advances in neuroimaging techniques and their interpretation are increasing our understanding of normal processes in the control of food intake including neuroanatomical correlates of hunger and satiety. Taken together with the structural and functional changes observed in the ED, neuroimaging provides a powerful platform to identify the underlying trait-related pathophysiological mechanisms in the aetiology and maintenance of AN and BN.     

Eating Disorders Examination versus Eating Disorders Examination-Questionnaire in adolescents with full and partial-syndrome bulimia nervosa and anorexia nervosa

OBJECTIVE: The current study compared the Eating Disorders Examination (EDE) and the Eating Disorders Examination-Questionnaire (EDE-Q) in adolescents with eating disorders. METHOD: Adolescents (N = 70) with bulimia nervosa (BN; n = 21), partial-syndrome BN (PBN; n = 25), and anorexia nervosa (AN; n = 24) were assessed with the EDE and EDE-Q. RESULTS: Moderate to high correlations were found on all four subscales within and between diagnostic groups. The discrepancy between the EDE and EDE-Q was significantly greater in BN relative to PBN and AN for the Eating Concern subscale. Objective binge episode (OBE) frequency in BN and subjective binge episode (SBE) frequency in BN and PBN were higher with the EDE compared with the EDE-Q. Self-induced vomiting was highly correlated between the two measures. DISCUSSION: Adolescents with BN, PBN, and AN exhibited strong correspondence between the EDE interview and questionnaire formats. However, this consistency was not as pronounced for BN as it was for PBN and AN. The current study lends preliminary credibility to the use of the EDE-Q in adolescent eating disorder samples.     

Subjective binge eating with compensatory behaviors: A variant presentation of bulimia nervosa

Objectives:

To determine whether a variant bulimic‐type presentation, whereby one meets criteria for bulimia nervosa (BN) except that binge eating episodes are not objectively large (i.e., “subjective bulimia nervosa,” SBN), has comparable clinical severity to established eating disorders, particularly BN.

Method:

Treatment‐seeking adults with BN (N = 112), SBN (N = 28), anorexia nervosa restricting type (AN‐R) (N = 45), and AN‐binge/purge type (AN‐B/P) (N = 24) were compared.

Results:

Overall, SBN could not be meaningfully distinguished from BN. SBN and BN had equivalent eating pathology, depression and anxiety symptoms, low quality of life, impulsivity, Axis I comorbidity, and lifetime psychiatric history, and comparable clinical severity to AN‐R and AN‐B/P.

Discussion:

Individuals with SBN, differing from BN only by the smaller size of their binge eating episodes, had a form of eating disorder comparable in clinical severity to threshold AN and BN and warranting clinical attention. Health professionals and the community require greater awareness of this variant to optimize detection, treatment‐seeking, and outcomes. © 2012 by Wiley Periodicals, Inc. (Int J Eat Disord 2013)     

Prevalence and utility of DSM-IV eating disorder diagnostic criteria among youth

OBJECTIVE: To examine the prevalence and utility of DSM-IV eating disorder (ED) criteria and anorexia (AN), bulimia (BN), and binge eating disorder (BED) among adolescents. METHOD: An ethnically diverse population-based sample of 4,746 public middle and high school students completed anthropometric measures and Project EAT survey items. RESULTS: Many youth endorsed body shape perception disturbance (41.5% female; 24.9% male), undue influence of body shape/weight on self-esteem (36.4% female; 23.9% male), and compensatory behavior (9.4% female; 13.5% male). Prevalence among females and males, respectively, was: AN = 0.04%, 0%; BN = 0.3%, 0.2%; BED = 1.9%, 0.3%. Analyses of individual criteria showed high sensitivity and negative predictive values for each disorder and corresponding criteria, low specificity for several AN (27.8%) and BN (32.0%) criteria, and low positive predictive values (0.06-40.2%). CONCLUSION: Body disparagement and compensatory behaviors indicate eating disturbance, despite low prevalence of EDs. Diagnostic classification may be clinically useful, but is complicated for use in epidemiological populations.     

Time trends in the incidence of eating disorders: a primary care study in the Netherlands

OBJECTIVE: This Dutch epidemiological study used primary care-based data to examine changes in the incidence of eating disorders in the 1990s compared to the 1980s. METHOD: A nationwide network of general practitioners, serving a representative sample of the total Dutch population, recorded newly diagnosed patients with anorexia nervosa (AN) and bulimia nervosa (BN) in their practices during 1985-1989 and 1995-1999. RESULTS: The overall incidence of AN was stable (from 7.4 to 7.7 per 100,000). However, the incidence among 15-19-year-old females increased significantly (from 56.4 to 109.2 per 100,000). The incidence rate of BN decreased nonsignificantly from 8.6 to 6.1 per 100,000. CONCLUSION: The time trend of an increasing AN incidence among the high risk group continued to the end of the past century. The BN incidence did not rise as was expected.     

Rapid recovery from anorexia nervosa after a life‐threatening episode with severe thrombocytopenia: Report of three cases

We report the cases of three patients with anorexia nervosa (AN) who each recovered rapidly after experiencing a life‐threatening episode with severe thrombocytopenia. All three cases were the typical restricting‐type of AN, occurring in adolescence. They refused to be admitted to a hospital until their general condition had been severely deteriorated. Their lowest platelet counts were 2.9, 4.6, and 2.3 × 10⁴/mm³, respectively. Apparent hemorrhagic tendencies, such as purpura, gingival and nasal bleeding, and gastrointestinal bleeding were observed. The bone marrow examination showed apparent hypoplasia in two patients. No evidence of disseminated intravascular coagulation or autoantibody to platelets was detected. The platelet counts recovered rapidly by water and nutritional supplementation. The recovery from the AN itself was excellent in all three patients without specific psycho‐ therapy. © 1999. John Wiley & Sons, Inc. Int J Eat Disord 25:113–118, 1999.     

Requiring remission of undue influence of weight and shape on self-evaluation in the definition of recovery for bulimia nervosa

OBJECTIVE: The current study evaluated the concurrent validity of requiring remission of undue influence of weight and shape on self-evaluation (undue influence) in defining recovery from bulimia nervosa (BN). METHODS: Three groups completed the Beck Depression Inventory, the Mood and Anxiety Symptom Questionnaire, the Body Shape Questionnaire, and the Social Adjustment Scale: 31 women were fully recovered from BN (FR), 28 women had no behavioral symptoms of BN (partially recovered [PR]), and 59 matched non-eating-disordered controls (MC). RESULTS: The PR group had more pathologic scores on depression, anxiety, body dissatisfaction, and social adjustment compared with both the FR and MC groups, which did not differ from each other. DISCUSSION: These findings suggest that including remission of cognitive symptoms in a standardized definition of recovery may prove to be clinically useful in establishing reliable prognostic indicators. Future research should evaluate the role played by cognitive symptoms in triggering relapse.     

Eating disorder symptomatology and substance use disorders: Prevalence and shared risk in a population based twin sample

Objective:

Research shows a significant association between eating disorders (ED) and substance use disorders (SUD). The objective of this study is to examine the prevalence, chronology, and possibility of shared familial risk between SUD and ED symptomatology.

Method:

Subjects included 1,206 monozygotic and 877 dizygotic adult female twins. ED symptomatology included anorexia (AN) and bulimia nervosa (BN) diagnosis, symptoms associated with diagnostic criteria, and BN symptom count. SUD included alcohol, illicit drug, and caffeine abuse/dependence. Generalized estimated equation modeling was used to examine phenotypic associations, and Choleksy decompositions were used to delineate the contribution of genes and environment to comorbidity.

Results:

There were no significant differences between SUD prevalence in women with AN and BN. Women with BN reported BN preceded SUD development while the reverse was true for AN. Twin analyses showed possible familial overlap between BN symptomatology and all SUD examined.

Discussion:

Results suggest an important difference in the chronology of EDs and SUDs. Women with BN may be turning to substances to dampen bulimic urges. Women with AN may be engaging in substance use initially in an effort to lose weight. Results also suggest familial factors contribute to the comorbidity between BN and SUD. © 2010 by Wiley Periodicals, Inc. (Int J Eat Disord 2010;)     

Eating-related concerns,mood, and personality traits in recovered bulimia nervosa subjects: a replication study

OBJECTIVE: Limited data suggest that eating-related concerns and behaviors, disturbances in mood, and altered temperament persist following recovery from bulimia nervosa (BN). METHOD: In order to replicate and extend such findings, 11 women who were long-term recovered from BN (>1 year with no binging, purging, or restricting behaviors, normal weight, and regular menstrual cycles) were compared with 15 healthy volunteer women on the Eating Disorders Invertory-2 (EDI-2), the Beck Depression Inventory, the State Trait Anxiety Inventory, and the Multidimensional Personality Questionnaire (MPQ). RESULTS: Compared with the control women, the recovered BN women showed elevated levels of the EDI-2 subscales of Drive for Thinness, Body Dissatisfaction, Ineffectiveness, Perfectionism, and Social Insecurity, greater depression and anxiety, elevated levels of the MPQ Stress Reaction dimension and the higher-order factor of Negative Emotionality, and lower levels of the MPQ Well Being and Closeness dimensions. DISCUSSION: Core eating and weight-related concerns, dysphoric affect, social discomfort, and personality traits indicative of perfectionism persist following long-term recovery from BN.     

A follow-up study of 33 subdiagnostic eating disordered women

Thirty-three female subjects with subdiagnostic DSM-III-R anorexia nervosa (SAN) and/or subdiagnostic bulimia nervosa (SBN) were reinterviewed 24 to 52 months (mean 41 months) after seeking treatment for an eating disorder. Subjects were administered a semi structured interview by telephone and assessed for level of functioning, eating disorder symptoms, course of illness, and treatment sought. During the course of the follow-up, 15 (46%) subjects went on to meet full DSM-III-R criteria for AN and/or BN. At follow-up, 4 (12%) met full DSM-III-R criteria for AN and/or BN, 22 (67%) were subdiagnostic, and 6 (18%) had recovered. The high percentage of subdiagnostic women that eventually develop full DSM-III-R criteria for AN and/or BN and the low rates of recovery at 2 to 4 years suggest that the current diagnostic criteria may be too restrictive. © 1993 by John Wiley & Sons, Inc.     

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.