Eating Disorder Examination-Questionnaire as a measure of change in patients with bulimia nervosa

OBJECTIVE: The current study evaluated the agreement between the Eating Disorder Examination and the Eating Disorder Examination-Questionnaire in assessing eating disorder pathology in a sample of women with bulimia nervosa. METHOD: Patients with broadly defined bulimia nervosa were enrolled in a double-blind, placebo-controlled treatment study of fluoxetine, with and without guided self-help. The current study presents information from 50 patients with data from both the EDE and EDE-Q at study entry and treatment termination. RESULTS: The EDE and EDE-Q produced more similar scores for compensatory behaviors (vomiting/laxative use) than complex eating-disordered features (binge eating/importance of shape and weight) at the pretreatment and posttreatment assessments, and for change during the study. DISCUSSION: The EDE and EDE-Q are highly correlated for many of the behavioral and attitudinal features of bulimia nervosa. There is substantial variability in agreement for individual patients, but on average, the EDE and EDE-Q will yield similar assessments of eating disorder symptoms and change in symptoms over time.     

Chewing and spitting out food among eating-disordered patients

OBJECTIVE: The symptom of chewing and spitting out food (CHSP) is fairly common among patients with eating disorders. The purpose of this study is to examine the associations of the symptom in patients with eating disorders. METHOD: Patients who reported CHSP were compared with those who did not. The relationship between CHSP and other symptoms was assessed by logistic regression analysis. RESULTS: CHSP was found in 22% of patients. Patients with anorexia nervosa and eating disorder not otherwise specified who reported CHSP showed more severe eating-related pathology. This was not so for bulimia nervosa patients with CHSP who differed only in reporting greater distortion of body image. Binging was not related to CHSP in any of the diagnostic groups. DISCUSSION: CHSP is a common symptom in all groups of patients with eating disorders. The symptom may serve different functions for different patients, depending on diagnosis.     

Relationship of gender and eating disorder symptoms to reported cravings for food: construct validation of state and trait craving questionnaires in Spanish

Using confirmatory factor analysis, we cross-validated the factor structures of the Spanish versions of the State and Trait Food Cravings Questionnaires (FCQ-S and FCQ-T; ) in a sample of 304 Spanish college students. Controlling for eating disorder symptoms and food deprivation, scores on the FCQ-T were higher for women than for men, but no sex differences were observed on the FCQ-S. Eating disorder symptomatology was predictive of trait cravings, whereas food deprivation was predictive state cravings. Trait cravings, but not state cravings, were more strongly associated to symptoms of anorexia and bulimia nervosa than with other psychopathology. We suggest that cravings can be conceptualized as multidimensional motivational states and that our data support the hypothesis that food cravings are strongly associated with symptoms of bulimia nervosa.     

Bulimic symptoms, cognitions, and body dissatisfaction in women with major depressive disorder

OBJECTIVE: The goals of this study were to assess eating disorder symptoms in depressed women with no history of eating disturbance and to evaluate the clinical significance of these symptoms relative to those reported by women with bulimia spectrum disorder. METHOD: Participants were 63 women with major depressive disorder (MDD) (n = 19), bulimia spectrum disorder (n = 20), or no history of MDD or eating disorder (n = 24). Measures included diagnostic interviews and self-report questionnaires designed to assess diagnostic criteria for bulimia nervosa, subthreshold eating disorder symptoms, dysfunctional attitudes about appearance, and body dissatisfaction. RESULTS: There were no significant differences between depressed and bulimic women on shape concerns, appearance overvaluation, or body dissatisfaction. Depressed women endorsed significantly more subthreshold eating disorder symptoms, dysfunctional attitudes about appearance, and body dissatisfaction than did control subjects. DISCUSSION: Eating disorder symptoms may be associated with depression in women in the absence of comorbid eating disorder diagnoses.     

Comparison of DSM-III and DSM-III-R bulimia nervosa classifications for psychopathology and other eating behaviors

Although recent studies on bulimia nervosa have yielded lower incidence rates for the disorder when using the DSM-IIIR, rather than the DSM-III criteria, none measured differences in emotional disturbances between those bulimics who meet the revised criteria and those who do not. Young women (50 ballet dancers and 56 nondancers) from a larger study on the complications of amenorrhea were grouped into three categories; nonbulimics, DSM-III bulimics, and DSM-IIIR (revised criteria) bulimics. Women were surveyed for eating disturbance, concurrent psychopathology, past histories of anorexia nervosa, and family history of emotional and eating disorders. Differences between bulimic groups were found for nondancers, as DSM-IIIR bulimics scored significantly higher than nonbulimics on measures of bulimic thought and behaviors, depression, and emotional disturbance. In addition, a significantly higher proportion of DSM-IIIR bulimics than nonbulimics reported that they had had anorexia nervosa in the past and that they had relatives with bulimia nervosa. For dancers, other than the measure of interpersonal distrust, no significant differences were found between the three groups. Results of the study indicate that bulimia nervosa as defined by the revised criteria (DSM-IIIR) is associated with more emotional problems than is bulimia nervosa according to the DSM-III.     

Binge eating before the onset of dieting: a distinct subgroup of bulimia nervosa?

OBJECTIVE: While most individuals with bulimia nervosa begin dieting prior to the onset of binge eating, some individuals begin binge eating prior to dieting. The purpose of this study was to assess the differences between these two groups. METHODS: Participants (N = 120) in a treatment study for bulimia nervosa were separated into two groups (Binge First vs. Diet First) based on the ages they reported for the onset of binge eating and of dieting and then compared across a number of variables. RESULTS: Individuals in the Binge First group reported higher weight, higher shape and weight concern, lower age of onset of eating disorder symptoms, and an altered relationship of binge eating to vomiting when compared to individuals in the Diet First group. DISCUSSION: The differences between the two groups suggest that there may be subgroups of individuals with purging bulimia nervosa and that individuals in the Binge First group more closely resemble individuals with binge eating disorder than do those in the Diet First group.     

Food Addiction in Eating Disorders: A Cluster Analysis Approach and Treatment Outcome

Background: A first approach of a phenotypic characterization of food addiction (FA) found three clusters (dysfunctional, moderate and functional). Based on this previous classification, the aim of the present study is to explore treatment responses in the sample diagnosed with Eating Disorder(ED) of different FA profiles. Methods: The sample was composed of 157 ED patients with FA positive, 90 with bulimia nervosa (BN), 36 with binge eating disorder (BED), and 31 with other specified feeding or eating disorders (OSFED). Different clinical variables and outcome indicators were evaluated. Results: The clinical profile of the clusters present similar characteristics with the prior study, having the dysfunctional cluster the highest ED symptom levels, the worse psychopathology global state, and dysfunctional personality traits, while the functional one the lowest ED severity level, best psychological state, and more functional personality traits. The dysfunctional cluster was the one with lowest rates of full remission, the moderate one the higher rates of dropouts, and the functional one the highest of full remission. Conclusions: The results concerning treatment outcome were concordant with the severity of the FA clusters, being that the dysfunctional and moderate ones had worst treatment responses than the functional one.     

Electrolyte and other blood serum abnormalities in normal weight bulimia nervosa: evidence for sampling bias

OBJECTIVE: Sampling bias due to research settings might be responsible for reported high prevalence rates of electrolyte and serum abnormalities in bulimia nervosa. The aim of this study was to investigate the prevalence of electrolyte and other serum abnormalities in bulimia nervosa patients with normal weight seeking treatment in a community mental health center. METHOD: Diagnostic evaluations and laboratory tests were done for a consecutive series of 31 patients meeting DSM-III-R criteria for bulimia nervosa. RESULTS: The duration and clinical severity of the eating disorder were considerable and psychiatric comorbidity was high. None of the subjects showed electrolyte abnormalities. Hypomagnesemia was found in 9.7% and hypoalbuminemia in 6.4% of the population. The severity of the abnormalities was modest. DISCUSSION: The results suggest that previous reports on electrolyte abnormalities in bulimia nervosa were affected by sampling bias. Based on the results, there is no indication to perform routinely laboratory studies in ambulatory patients with normal weight.     

Temperament in eating disorders

This study examined dimensional personality and temperamental characteristics in women with eating disorders. Clinical symptoms, personality, and temperament were examined in 30 women with anorexia nervosa (AN), 32 women with bulimia nervosa with no history of anorexia nervosa (BN), and 20 women with comorbid anorexia and bulimia nervosa (AB). Temperament differed markedly across the groups on the Tridimensional Personality Questionnaire (TPQ) with AN women showing greater reward dependence, BN women scoring higher on novelty seeking subscales, and AB women showing high harm avoidance. The TPQ subscales also displayed higher classification accuracy than other personality and symptom measures. Temperamental features are distinct across eating disorder subtypes. Temperament could reflect differential vulnerabilities for the development of specific eating disorder symptom clusters. © 1995 by John Wiley & Sons, Inc.     

Outpatient management of eating disorders in adults

Eating disorders are prevalent in the young adult female population. Given the serious medical, nutritional, and psychological risks associated with eating disorders, it is advisable that patients be seen within the framework of a multidisciplinary team. Psychotherapy is the most effective treatment modality for eating disorders and constitutes the core of mental health treatment. Although cognitive behavior therapy trials dominate the research literature on interventions for bulimia nervosa and binge-eating disorder, various modalities of psychotherapy have efficacy. Active weight management is also a key component of treatment for anorexia nervosa. Psychotropic medication therapy is not generally useful for the primary symptoms of anorexia nervosa, whereas it is moderately effective in the treatment of both bulimia nervosa and binge-eating disorder. Given the patient population at Massachusetts General Hospital, to which patients often present with serious and chronic symptoms, comorbid medical and psychiatric illness, and history of poor response to treatment, we have found a flexible and eclectic treatment approach most useful clinically.     

Patients admitted to hospital with anorexia nervosa and bulimia nervosa: Psychopathology,weight gain,and attitudes toward treatment

Ten percent of patients assessed at Toronto General Hospital Eating Disorder Centre require admission to hospital. In a comparative study of 100 consecutive admissions, differences in weight, eating disorder symptoms, and psychopathology between inpatients and outpatients were most apparent in the group with bulimia nervosa. Patients admitted with anorexia nervosa and with bulimia nervosa also had a longer duration of illness compared to outpatients. At discharge the anorexic patients weighed approximately 85% of ideal body weight. After a mean follow-up period of 2 years, 50% of patients were in the “good” outcome category, vshereas 16% were rated as having a “poor” outcome. Patient attitudes to various components of the program did not appear to influence outcome.     

Comorbidity of body dysmorphic disorder and eating disorders: severity of psychopathology and body image disturbance

OBJECTIVE: The current study examined comorbidity and clinical correlates of eating disorders in a large sample of individuals with body dysmorphic disorder (BDD). METHOD: Two hundred individuals with DSM-IV (4th ed. of the Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: American Psychiatric Association; 1994) BDD completed reliable interviewer-administered and self-report measures, including diagnostic assessments and measures of body image, symptom severity, delusionality, psychosocial functioning, quality of life (QOL), and history of psychiatric treatment. RESULTS: A total of 32.5% of BDD subjects had a comorbid lifetime eating disorder: 9.0% had anorexia nervosa, 6.5% had bulimia nervosa, and 17.5% had an eating disorder not otherwise specified. Comparisons of subjects with a comorbid lifetime eating disorder (n = 65) and subjects without an eating disorder (n = 135) indicated that the comorbid group was more likely to be female, less likely to be African American, had more comorbidity, and had significantly greater body image disturbance and dissatisfaction. There were no significant group differences in BDD symptom severity, degree of delusionality, or suicidal ideation or attempts. Functioning and QOL were notably poor in both groups, with no significant between-group differences. However, a higher proportion of the comorbid eating disorder group had been hospitalized for psychiatric problems. This group had also received a greater number of psychotherapy sessions and psychotropic medications. CONCLUSION: Eating disorders appear relatively common in individuals with BDD. BDD subjects with a comorbid eating disorder differed on several demographic variables, had greater comorbidity and body image disturbance, and had received more mental health treatment than subjects without a comorbid eating disorder. These findings have important implications for the assessment and treatment of these comorbid body image disorders.     

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.     

Quality of life and eating disorders

Objective: Eating disorders (EDs) can have a serious impact on various life domains and may lead to physical, mental and social impairment and consequently to poor quality of life (QOL). This study compared the QOL of ED patients and former ED patients in a large community based sample to the QOL of a normal reference group and to the QOL of patients with mood disorders. Differences between ED diagnostic groups were examined. The study investigated what factors contribute to QOL.Methods: A generic health-related quality of life questionnaire, the Short Form-36 (SF-36), and the Eating Disorder Examination-Questionnaire were administered to 156 ED patients – 44 anorexia nervosa patients, 43 bulimia nervosa patients, 69 eating disorder not otherwise specified patients – and 148 former ED patients.Results: ED patients reported significantly poorer QOL than a normal reference group. No differences were found between the diagnostic groups. Former ED patients still had poorer QOL than a normal reference group. ED patients reported significantly poorer QOL than patients with mood disorders. Self esteem contributed most to QOL.Conclusion: EDs have a severe impact on many domains of QOL. Therefore QOL needs to be addressed in effectiveness research and clinical practice.     

Characterization of eating disordered behavior in obese binge eaters

In the present study, the Eating Disorder Examination (EDE), a clinical interview designed to characterize the psychopathohgy specific to eating disorders, was administered to 17 obese women seeking treatment for binge eating problems. Subjects also completed questionnaires to assess binge severity, depression, and weight history. Obese binge eaters obtained EDE subscale scores that did not differ from those reported for normal weight bulimia nervosa patients on the Overeating, Shape Concern, Weight Concern, and Eating Concern Sub-scales of the EDE; however, bulimia nervosa patients had higher scores on the EDE Restraint Subscale. Questionnaire data indicated that obese binge eaters had considerable depressive symptomatology and that early onset obesity, frequent weight losses, and family histories of obesity were common. These findings suggest that obese binge eaters and bulimia nervosa patients have similar levels of eating disorders psychopathohgy, but that future research directly comparing overweight and normal weight patients is needed.     

The epidemiology of bulimia nervosa: Two community studies

Recent studies of American college students suggest that the syndrome bulimia is common and that individual elements of the condition are even more widespread. In Britain, two community-based studies of the related syndrome bulimia nervosa have been reported. In the first, 499 women who fulfilled diagnostic criteria for bulimia nervosa were identified with the help of a women's magazine. These women closely resembled bulimia nervosa patients attending psychiatric hospitals. Although more than half reported that they wanted medical help, less than one-third had discussed their eating difficulties with a doctor and only 2.5% were currently receiving treatment. The second study investigated the eating habits and attitudes of 369 attenders at a family planning clinic. Of these, 20.9% reported current episodes of “binge-eating”; 2.9% currently used vomiting as a means of weight control; and 1.9% fulfilled diagnostic criteria for bulimia nervosa. Comparison of the two samples indicates that people with bulimia nervosa are prone to have been both overweight and underweight in the past. They also have more disturbed attitudes toward food, eating, body weight, and body shape and a considerably higher degree of psychological disturbance. These studies suggest that bulimia nervosa constitutes a significant undetected source of psychiatric morbidity. The service implications of these findings have yet to be examined.     

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.     

Social adjustment over 10 years following diagnosis with bulimia nervosa

OBJECTIVE: The authors sought to describe social adjustment among women diagnosed with bulimia nervosa more than a decade earlier. METHOD: A cohort of women who were diagnosed with bulimia nervosa between 1981 and 1987 were located and invited to participate in follow-up assessments. RESULTS: Although the current sample demonstrated considerable improvement in disordered eating behaviors and social adjustment, measures of social adjustment suggested continued impairment in interpersonal relationships and only a modest association with eating disorder outcome. DISCUSSION: Continued difficulties in social adjustment may reflect an underlying vulnerability from which disordered eating developed. Treatments for bulimia nervosa may benefit from including interpersonal skills training.     

Clinical and personality correlates of body size overestimation in anorexia nervosa and bulimia nervosa

A video camera technique was used to assess perceived actual and ideal size in patients with a restricting type of anorexia nervosa (n = 17), bulimia nervosa patients with previous anorexia (n = 23), bulimia nervosa patients with no previous anorexia (n = 24), phobic controls (n = 18), and normals (n = 33). Bulimic patients with previous anorexia demonstrated a significantly greater tendency to overestimate their actual body size (p <.05) than subjects in the restricting anorexic or control groups. Previously anorexic bulimics also demonstrated more overall clinical and personality disturbance than any of the other groups (p <.01). Body size overestimation and dissatisfaction were strongly associated with the duration and severity of the eating disturbance in previously anorexic bulimics but there were no clear relationships between clinical or personality disturbances and body size distortions in the restricting anorexic or never-anorexic bulimic groups. Results are discussed with respect to the importance of refining diagnostic criteria for subtypes of anorexia and bulimia nervosa. Multitrait-multimethod methodologies are recommended for purposes of elucidating “body image disturbance” and its importance in the etiology and maintenance of eating disorders.     

Duration of illness predicts outcome for bulimia nervosa: a long-term follow-up study

OBJECTIVE: The purpose of this study was to investigate long-term outcome and prognosis in a bulimic and subthreshold bulimic sample. METHOD: In a follow-up study, 44 patients diagnosed with bulimia nervosa and subthreshold bulimia nervosa were contacted after an average follow-up period of 9 years. RESULTS: Results revealed that 72.7% (n = 32) of the participants were recovered at the time of follow-up. An investigation of prognostic variables showed that good outcome was associated with a shorter duration of illness, which was defined as the time between onset of symptoms and first treatment intervention. If participants were initially treated within the first few years of the illness, the probability of recovery was above 80%. However, if they were initially treated 15 years or more after the onset of the illness, the probability of recovery fell below 20%. DISCUSSION: This finding suggests that early identification of bulimia nervosa may be a very important factor in preventing a chronic eating disorder.