Topiramate in the treatment of severe bulimia nervosa with comorbid mood disorders: a case series

OBJECTIVE: To report observations on the efficacy and tolerability of topiramate in a sample of five patients with severe symptoms of bulimia nervosa and comorbid mood and/or anxiety disorders. METHOD: Topiramate was added to other psychotropic medication under open-label conditions up to the maximum tolerated dose or until remission of the eating disorder was achieved. RESULTS: Topiramate almost completely eliminated binging and purging behavior in three of the five patients. Improvement was maintained throughout the period of follow-up for up to 18 months. One patient showed a partial, temporary response, and the fifth was intolerant of the drug and unable to complete an adequate trial. DISCUSSION: These results suggest strongly that the efficacy of topiramate in patients with bulimia nervosa with and without comorbid mood and anxiety disorders should be investigated more fully.     

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.     

Distinguishing Recovery from Remission in a Cohort of Bulimic Women: How Should Asymptomatic Periods Be Described?

Background: Empirical definitions of remission and recovery from eating disorders are needed to understand outcome data and compare results across studies. Method: 106 treatment-seeking women with bulimia nervosa, who had abstained from binging and purging for at least 4 weeks, were followed prospectively. Relapse was defined as at least 4 consecutive weeks of either binging and purging weekly or binging two or more times per week, regardless of purging. Recovery was differentiated from remission based on the probability of relapse. The minimum number of weeks after which the risk of relapse leveled off was used as the cut-off to distinguish between the two outcomes. Kaplan-Meier methods were used to estimate the weekly probability of relapse. Results: When defining remission as at least 4 weeks of being asymptomatic, a quarter of the women relapsed within 11 weeks. By 37 weeks, only 49% of the women remained asymptomatic (95% CI, 41–61). The probability of relapse was substantial for approximately a year after a woman ceased to binge and purge. Conclusion: Bulimia nervosa is an episodic disorder. As a conservative approach, periods of being asymptomatic that last less than 1 year should be labeled as remissions, not recoveries.     

Relationship between EDNOS and its subtypes and borderline personality disorder

OBJECTIVE: The purpose of this study was to assess the prevalence of eating disorder not otherwise specified (EDNOS) and four well-defined subtypes of this disorder found in a sample of female borderline patients. METHOD: The lifetime prevalence of EDNOS and its various subtypes among 233 female borderline patients and 46 female Axis II comparison subjects was assessed using the Structured Clinical Interview for DSM-III-R Axis I disorders. RESULTS: Thirty-three percent of female borderline patients met DSM-III-R criteria for EDNOS at some point in their lives. Of these 76 women, 20% reported a pattern of restricting without low weight, 37% reported a pattern of binging without purging, 37% reported a pattern of purging without binging, and 33% reported a pattern of low weight without loss of menses. However, less than 25% of these 76 borderline women had ever met criteria for anorexia nervosa or bulimia nervosa. CONCLUSIONS: The results of this study suggest that EDNOS is a separate cluster of eating disorders among borderline women, rather than a prodromal or residual form of a more clear-cut case of anorexia or bulimia nervosa.     

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.     

Barrett's esophagus in anorexia nervosa: A case report

Barrett's esophagus (BE) is a metaplastic lesion that may result from long‐lasting gastroesophageal reflux and it is an established precursor of esophageal adenocarcinoma. There are reports of an increased prevalence of BE, and eventually esophageal adenocarcinoma, in patients with eating disorders characterized by purging behaviors like those with bulimia nervosa (BN). Among patients with eating disorders, those affected by anorexia nervosa binging purging subtype (ANBP), are behaviorally very similar to those with BN, but to our knowledge there are no data in literature about BE in patients with ANBP. We present the case of a 37‐year‐old female with a 20‐year history of ANBP in comorbidity with bipolar disorder, who developed a BE requiring multi‐specialistic intervention. © 2014 Wiley Periodicals, Inc. (Int J Eat Disord 2015; 48:147–150)     

Topiramate treatment in bulimia nervosa patients: a randomized, double-blind, placebo-controlled trial

OBJECTIVE: The aim of the current study was to test the influence of topiramate on behavior, body weight, and health-related quality of life (HRQOL) in bulimic patients. METHOD: Thirty patients with bulimia nervosa were treated with topiramate in a 10-week randomized, double-blind, placebo-controlled study. The subjects were randomly assigned to receive topiramate (topiramate group [TG]; n = 30) or a placebo (control group [CG]; n = 30). Primary outcome measures were changes in the frequency of binging/purging, in body weight, and on the SF-36 Health Survey (SF-36) scales. RESULTS: In comparison to the CG group (according to the intent-to-treat principle), significant changes in the frequency of binging/purging (a > 50% reduction: TG, n = 11 [36.7%]; CG, n = 1 [3.3%]; p < .001), body weight (difference in weight loss between the two groups: 3.8 kg, 95% confidence interval [CI] = -5.4 to -2.1; p < .001), and SF-36 (all ps < .001) could be seen. All patients tolerated topiramate well. CONCLUSION: Topiramate appears to safe and effective in influencing the frequency of binging/purging, body weight, and HRQOL in bulimic patients.     

Predictors of rapid and sustained response to cognitive-behavioral therapy for bulimia nervosa.

OBJECTIVE: To examine characteristics of individuals who show a rapid and sustained response to cognitive-behavioral therapy (CBT) for bulimia nervosa (BN). METHOD: As part of a randomized clinical trial designed to dismantle CBT for BN, we compared 19 individuals who exhibited complete abstinence from binging and purging after only eight sessions of CBT and maintained abstinence throughout the duration of treatment and the 1-year follow-up interval, to 79 individuals who had a more variable response to treatment. Demographics, baseline clinical characteristics, lifetime comorbidity, and personality disorder symptoms and profiles from the Temperament and Character Inventory were examined. RESULTS: In univariate analyses, frequency of binging and purging at baseline, low scores on the Eating Disorders Inventory (EDI) Bulimia subscale, lower harm avoidance, and higher self-directedness were associated with rapid response. In multiple regression analyses, frequency of binging at baseline (OR = 0.87; 95% CI 0.77-0.98) and self-directedness (OR = 1.12; 95% CI 1.04-1.21) independently predicted rapid and sustained treatment response. CONCLUSION: Frequency of binging and the character quality of self-directedness may be useful predictors of those individuals who are likely to respond positively to a brief course of CBT for BN.     

Time course of symptom remission in eating disorders

OBJECTIVE: The study was carried out to test whether time to remission varies for different eating disorder symptoms. METHOD: Sixty-five patients (35 anorexic patients and 30 bulimic patients) treated with psychotherapy were interviewed 2 1/2 years after initial assessment. RESULTS: The anorexic physical symptoms remitted before the psychological symptoms of anorexia and bulimia nervosa, as did the bulimic behaviors: binging and purging. Nonpurging compensatory behavior and obsession with weight and shape were the last symptoms to remit. Differences between the anorexic and bulimic groups were found between the remission order of psychological symptoms. DISCUSSION: In spite of different treatments and symptoms between patients, the results support the notion of a common pattern in the process of change including a long and stepwise course. The results detail a template of the course to recovery for eating disorders.     

Purging behaviors and comorbidity as predictive factors of quality of life in anorexia nervosa

OBJECTIVE: This study examined the predictive factors for the physical and mental summary components (PCS and MCS) of quality of life (SF-36) in patients with anorexia nervosa. METHOD: Forty-seven patients with anorexia nervosa were studied. Assessment comprised psychiatric diagnosis by a clinical structured interview for Axis I disorders (SCID-I) and personality disorders (SCID-II), Clinical Global Impression (CGI), and Quality of Life (SF-36). RESULTS: Anorexia nervosa, restrictive type, was diagnosed in 73.9% of the patients and 51% of the patients presented with comorbidity on Axis I or Axis II or both. The predictive variables for the PCS were poor outcome in previous year, comorbidity on Axes I and II, and female gender. The predictive variables for the MCS were the presence of comorbidity in one or the other of the Axis I or II disorders and purging behaviors. DISCUSSION: The current study suggests the importance of comorbidity and purging behaviors in the quality of life of these patients with anorexia nervosa.     

Methylphenidate treatment for bulimia nervosa associated with a cluster B personality disorder

OBJECTIVES: Psychotherapy and antidepressant medication are helpful to many patients with bulimia nervosa (BN). However, a substantial number of bulimics respond poorly to such treatments. Recent studies suggest that many of the poor responders have cluster B personality disorders. In some ways, the symptomatology of bulimics who have a comorbid cluster B disorder resembles that of patients with attention deficit hyperactivity disorder (ADHD). In particular, individuals in both groups frequently have a high level of impulsivity. Such a resemblance raised the question of whether administration of methylphenidate (MPH), a drug used to treat ADHD, would have therapeutic effects in this subgroup of BN patients. METHODS: In a pilot study, we administered MPH to 2 patients with BN and cluster B traits and found beneficial effects. These patients had not responded to adequate trials of psychotherapy and selective serotonin reuptake inhibitors (SSRIs). RESULTS: MPH treatment was effective. Both Patients had decreased binging and purging. DISCUSSION: MPH may be useful for bulimics with cluster B personality disorder who respond poorly to conventional treatment. Further studies of MPH administration may be worthwhile. Due to the potential risks, however, clinical treatment with this agent is not recommended at this time.     

Repeated binge/purge cycles in bulimia nervosa: Role of glucose and insulin

The available data indicate that over half of patients with bulimia nervosa binge and purge daily with repetitions of the binge/purge cycle being common. An understanding of the biobehavioral mechanisms associated with frequent binge/purge cycles may aid the general conceptualization of bulimia nervosa including its development and maintenance. Binging and purging have demonstrable physiological effects that may be partially responsible for the repetition of binge/purge episodes. In the present study, the cephalic phase oversecretion of insulin and high insulin levels subsequent to purging were investigated as possible mediators of repeated binging and purging. Insulin and glucose levels of bulimic and nonbulimic women were measured in response to: thinking about food, the presence of food, while eating, and for the bulimic group, after purging. Bulimic subjects displayed a dramatic reduction in both insulin and glucose after purging the test meal. When these same subjects ate a subsequent meal that was not purged, they displayed elevations in insulin and glucose similar to those of the normal controls. The hypoglycemia resulting from purging appears to be partially responsible for the continuation of repeated binge/purge episodes.     

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.     

Personality disorder traits evident by early adulthood and risk for eating and weight problems during middle adulthood

OBJECTIVE: The current article investigates the association of personality disorder (PD) with the subsequent development of eating and weight problems. METHOD: Psychiatric interviews were administered to a community-based sample of 658 individuals at mean ages 14, 16, 22, and 33 years. RESULTS: Individuals with PD by age 22 were at an elevated risk for eating disorders at mean age 33 years. PDs were associated with risk for onset of binge eating, purging, daily dietary restriction, and obesity among individuals without a history of these problems. Borderline and histrionic PD symptoms were associated with recurrent binging and purging at mean age 33 years. Antisocial and schizotypal symptoms were associated with recurrent binging and obesity at mean age 33 years. Depressive PD symptoms were associated with recurrent binging and dietary restriction at mean age 33 years. CONCLUSION: PD symptoms, evident by early adulthood, may be associated with the risk for the development of eating and weight problems by middle adulthood.     

Plasma concentrations of leptin in a bulimic patient

Recently, the obese gene in the ob/ob mouse was cloned, along with its human homologue. The gene product leptin is important in the regulation of body weight. Excessive food intake during a binge might affect leptin synthesis. Alternatively, fluctuations in leptin synthesis might induce binge eating. Therefore, plasma leptin levels of a patient with bulimia nervosa were determined over a period of 48 hr in a natural setting. Amount, type, time of food intake, and binging and purging episodes were concomitantly assessed. Although binging and purging episodes were quite frequent, leptin levels remained stable and were neither related to food intake nor to binge episodes. © 1998 John Wiley & Sons, Inc. Int J Eat Disord 23: 459–463, 1998.     

Norms, normality, and clinical significant change: implications for the evaluation of treatment outcomes for eating disorders.

OBJECTIVE: The implications of the use of national norms of the Eating Disorders Inventory (EDI) are investigated. METHOD: A German version of the EDI was administered to a representative national sample (n = 650), a repeatedly measured community sample (n = 207), and a national inpatient sample with primary diagnoses of anorexia or bulimia nervosa (n = 959). Resulting scale distributions were compared with those of North American samples of the handbook. RESULTS: Normal ranges on several scales markedly differed when German community norms were used. When estimates of rates of clinical significant changes were based on German norms instead of on North American norms, rates were markedly lower for scales measuring core diagnostic features (e.g., binging/purging, Drive for Thinness) and higher for those measuring correlates (e.g., Maturity Fears, Interpersonal Distrust). DISCUSSION: Neglecting differences in national norms can lead to substantial misinterpretation of empirical findings in the diagnosis of eating disorders and the evaluation of treatment outcome.     

Suicide and attempted suicide in eating disorders, obesity and weight-image concern

Suicide in anorexia nervosa and bulimia nervosa is a major cause of death. Meta-analyses have shown that individuals suffering from anorexia nervosa and bulimia nervosa commit suicide more often than their counterparts in the general population; also a few studies have suggested that suicide is the major cause of death among patients with anorexia nervosa, refuting the assumption that inanition generally threatens the life of these patients. Data concerning suicide in bulimia nervosa, on the other hand, are still scarce but suicide attempts are easily found among cohorts of patients with bulimia nervosa, which constitutes a risk factor for completed suicide. Suicidality in obesity and individuals with disturbed weight status has been reported. Both in the case of bulimia nervosa and obesity more long-term follow-up studies need to be completed before the risk of suicide for such disorders may be compared with that for anorexia nervosa.     

Determinants and outcomes of serious attempted suicide: a nationwide study in Finland, 1996-2003

Suicide is among the 10 leading causes of death. Attempted suicide is 10-40 times more frequent than completed suicide and is the strongest single predictor of subsequent suicide. The current study population included all persons in Finland who were hospitalized with a diagnosis of attempted suicide between 1996 and 2003 (N = 18,199). Information on background variables and mortality was obtained by register linkage. The risk of repeated attempted suicide was 30% and the risk of suicide was 10%. The risks of repeated attempted suicide, completed suicide, and death from any cause were high immediately after discharge from the hospital. Analysis of competing causes of death revealed that while alcohol-related disorder was not associated with suicide, it markedly increased the risk of other violent death: The subdistribution hazards rate (SHR) was 2.61 (95% confidence interval (CI): 2.12, 3.21). Schizophrenia-related disorders (SHR = 1.87, 95% CI: 1.57, 2.21) and mood disorders (SHR = 1.72, 95% CI: 1.47, 2.01) were associated with the risk of suicide. The risks of suicide and all-cause mortality were extremely high immediately after hospitalization for attempted suicide.     

Familial and sociopsychopathological risk factors for suicide attempt in bulimic and in depressed women: prospective study

OBJECTIVE: This study was carried out to examine sociopsychopathological predictors of prospective observed suicide attempts in bulimic women purging type without comorbid major depression (BNG) at the time of study entry and in woman with major depression without comorbid eating disorder at the time of study entry (MDG). METHODS: Data from 28 BNG (age 23.5 +/- 3.6) and 126 MDG women (age 33.4 +/- 5.1) who had attempted suicide during 12 months' monitoring were compared. RESULTS: A univariate comparison of the two groups revealed various differences. Analysis of risk factors for suicide attempts using stepwise logistic regression was conducted separately for each group. The derived logistic models showed that patients from the BNG group had a history of higher incidence of sexual abuse in childhood, as well as abuse of laxatives and illicit drugs; they also lacked orientation in life, felt lonely despite family and friends, tended to direct their anger outward, and were unable to relax. CONCLUSIONS: Sociopsychopathological risk factors for suicide attempts in the BNG and MDG appear to vary.     

Sequencing of cognitive-behavioral treatments for bulimia nervosa

OBJECTIVE: This study investigated the efficacy of a stepped-care trial of brief group psychoeducation (PE) followed by individual cognitive-behavioral therapy (CBT) in the treatment of bulimia nervosa. METHOD: Fifty-six subjects first completed PE and were then randomly assigned to either a 16-week trial of CBT (PE + CBT) or to no further treatment follow-up (PE-alone). RESULTS: Compared to PE-alone, PE + CBT produced significantly greater reductions in the specific eating symptoms of binging and purging and significantly higher remission rates that were maintained over a 16-week follow-up. However, there were no differential treatment effects on measures of nonspecific psychopathology. Among PE + CBT subjects, remission in specific eating symptoms was associated with greatest improvements in non-specific psychopathology. The outcome of nonremitted PE + CBT subjects and PE-alone subjects was no different at posttreatment or follow-up. DISCUSSION: These results provide limited support for offering individual CBT to subjects once they have completed an initial trial of group PE.