Fatigue mood as an indicator discriminating between anorexia nervosa and bulimia nervosa

In order to clarify the differences in mood states between anorexia and bulimia nervosa, the Profile of Mood States (POMS) with tension-anxiety, depression, anger-hostility, vigour, fatigue and confusion scales was administered to 32 female patients with anorexia nervosa (age range 14 to 32 years, mean age 20 years), 49 female patients with bulimia nervosa (age range 15 to 33 years, mean age 23 years) and 410‘normal’ female subjects (age range 14 to 35 years, mean age 23 years). The scores on the depression, fatigue and confusion scales for both anorexia and bulimia nervosa and those on the tension-anxiety and anger-hostility scales for bulimia nervosa were significantly higher than those for the control subjects. The score on the fatigue scale for bulimia nervosa was significantly higher than that for anorexia nervosa. Moreover, the result of the multiple logistic regression analysis including all of the POMS scales indicated that the fatigue scale significantly discriminated between the two disorders. Fatigue mood appears to be a principal indicator for differentiating between the two disorders.     

Bulimia nervosa and abnormal cardiac repolarization

OBJECTIVE: Eating disorders (ED) are thought to be risk factors for sudden death, and arrhythmias are one of the major causes of sudden death in ED patients. Late potentials (LPs) are a predictor of arrhythmias and can be measured using signal-averaged electrocardiography (SAECG). We examined arryhthmogenicity by LPs in ED patients. METHODS: We performed SAECG on 48 female ED patients [21 with anorexia nervosa (AN) and 27 with bulimia nervosa (BN)] and on 20 healthy women. An LP was judged positive if two or more of the following criteria were fulfilled: QRS duration >120 ms, root-mean-square voltage <20 microV, and a high-frequency, low-amplitude duration >38 ms. We compared the occurrence of LPs among subgroups. RESULTS: Compared with the controls, BN patients with a history of AN had significantly more SAECG abnormalities. CONCLUSIONS: BN patients with a history of AN may be prone to ventricular arrhythmias.     

Altered processing of rewarding and aversive basic taste stimuli in symptomatic women with anorexia nervosa and bulimia nervosa: An fMRI study

Functional magnetic resonance imaging (fMRI) studies have displayed a dysregulation in the way in which the brain processes pleasant taste stimuli in patients with anorexia nervosa (AN) and bulimia nervosa (BN). However, exactly how the brain processes disgusting basic taste stimuli has never been investigated, even though disgust plays a role in food intake modulation and AN and BN patients exhibit high disgust sensitivity. Therefore, we investigated the activation of brain areas following the administration of pleasant and aversive basic taste stimuli in symptomatic AN and BN patients compared to healthy subjects. Twenty underweight AN women, 20 symptomatic BN women and 20 healthy women underwent fMRI while tasting 0.292 M sucrose solution (sweet taste), 0.5 mM quinine hydrochloride solution (bitter taste) and water as a reference taste. In symptomatic AN and BN patients the pleasant sweet stimulus induced a higher activation in several brain areas than that induced by the aversive bitter taste. The opposite occurred in healthy controls. Moreover, compared to healthy controls, AN patients showed a decreased response to the bitter stimulus in the right amygdala and left anterior cingulate cortex, while BN patients showed a decreased response to the bitter stimulus in the right amygdala and left insula. These results show an altered processing of rewarding and aversive taste stimuli in ED patients, which may be relevant for understanding the pathophysiology of AN and BN.     

Fast psychomotor functioning in underweight anorexia nervosa patients

To explore whether underweight anorexia nervosa patients show psychomotor differences relative to normal controls, 32 female hospitalised patients, aged between 14 and 25 years, were compared with 32 healthy, normal weight controls, matched for sex, age and educational level. Using computerised analysis of writing and drawing behaviour, reaction times and movement times and their different components were analysed, while cognitive and motor demands were manipulated in five drawing and copying tasks. Anorexia nervosa patients were, compared to normal weight controls, significantly faster in a drawing task and showed shorter reaction times in copying tasks. Movement times did not differ significantly between the two groups. In the most complex copying task, a significant group×complexity interaction for reaction time (patients shorter) and reinspection time (patients longer) was found. Patients also made more errors than controls. The finding of a consistent pattern of shorter reaction times in underweight anorexia nervosa patients seems to run contrary to previous findings of disturbed cognitive functioning (i.e. impaired attention) in these patients. The differences seem to be related to cognitive factors more than to motor (executive) components.     

High-fat taste challenge reveals altered striatal response in women recovered from bulimia nervosa: A pilot study

Objectives. Individuals with anorexia nervosa (AN) and bulimia nervosa (BN) tend to have disordered thinking and eating behaviours in regards to fat containing foods. This is the first study to investigate neuronal pathways that may contribute to altered fat consumption in eating disordered patients. Methods. We used functional magnetic resonance imaging (fMRI) to compare responses to a high-fat cream stimulus, water, and a non-caloric viscous stimulus (CMC) to control for response to viscosity in individuals recovered from AN (N = 15), BN (N = 14) and a healthy control sample (CW, N = 18). Results. An interaction analysis (ANOVAR) comparing the three groups (AN, BN, CW) and the three conditions (cream, CMC, water) revealed significant differences in the left anterior ventral striatum (AVS). A post hoc analysis displayed a higher magnitude of response for the contrast cream/water in BN compared to AN or CW and for the contrast CMC/water in BN compared to AN. Conclusions. BN showed an exaggerated AVS response for the cream/water contrast in comparison to AN or CW. Moreover, BN showed an exaggerated AVS response for the CMC/water contrast in comparison to AN. These findings support the possibility that BN have an altered hedonic and/or motivational drive to consume fats.     

Prefrontal brain metabolites in short-term weight-recovered adolescent anorexia nervosa patients

Various neuroimaging techniques have revealed morphological and functional alterations in anorexia nervosa (AN), although few spectroscopic magnetic resonance studies have examined short-term weight-recovered AN patients. Subjects were 32 female adolescent patients (between 13 and 18 years old) seen consecutively in our department and who met DSM-IV diagnostic criteria for AN. All of them had received a minimum of six months of treatment and were short-term weight-recovered (for one to three months) with a body mass index ranging from 18 to 23. A group of 20 healthy female volunteer controls of similar age were also included. All subjects were assessed with psychopathological scales and magnetic resonance spectroscopy. Total choline (Cho) (p = 0.007) and creatine (Cr) (p = 0.008) levels were significantly higher in AN patients than in controls. AN patients receiving psychopharmacological treatment with SSRIs (N = 9) had metabolite levels similar to control subjects, but patients without this treatment did not. The present study shows abnormalities in brain neurometabolites related to Cho compounds and Cr in the prefrontal cortex in short-term weight-recovered adolescent AN patients, principally in patients not undergoing psychopharmacological treatment. More studies with larger samples are necessary to test the generalizability of the present results.     

Puberty,sexual development and eating disorders in adolescent outpatients

This study examined puberty and psychosexual state in a clinical sample of adolescents attending for assessment because of eating disorders (ED). A total of 57 adolescents (girls) aged 14–21 years (mean age 16.9 years) having either anorexia nervosa (AN) or bulimia nervosa (BN) were studied by semi-structured interviews and structured self-report questionnaires considering the timing of menarche, dating and attitudes to sexuality. The age at menarche did not differ statistically significantly between AN and BN. It was significantly lower in the BN group than in the normal population, but no statistically significant difference was found between the AN group and normal population. The general attitudes to sexuality were more negative in the AN group than in the BN group. In the AN group, there were also fewer dating experiences and interest in dating than in the BN group. After controlling for the effect of age, age at menarche and duration of ED, negative attitudes to sexuality and no dating experiences were still best predicted by AN. The results suggest different ways of coping with the developmental challenges in sexuality in AN and BN during adolescence.     

Cardiac regulation in bulimia nervosa

Heart rate and vagal tone were assessed during sleep and bed rest conditions in nine patients with bulimia nervosa (BN), six patients with concomitant anorexia nervosa and bulimia nervosa (AN + BN) and five control subjects. During bed rest conditions AN + BN patients had significantly lower heart rates than BN or control subjects. During sleep, the heart rate differed significantly for all three groups. The AN + BN group had a significantly lower heart rate than either the BN or control groups and the BN group had a significantly lower heart rate than controls. On the other hand, measures of vagal tone, based on respiratory sinus arrhythmia, were significantly elevated in both patient groups compared to controls. These findings suggest that the bradycardia during sleep in BN patients may be primarily due to hypervagal activity, but the greater bradycardia demonstrated in those patients with both AN and BN may result from hypervagal activity coupled with reduced sympathetic activity.     

Good outcome of adolescent onset anorexia nervosa after systematic treatment

We studied the intermediate to long-term outcome of childhood and adolescent onset anorexia nervosa (AN), in a sample that had received systematic treatment based on close cooperation between parents, paediatric department and child and adolescent psychiatry. Of 55 female AN-patients, 51 were examined 3.5-14.5 years after treatment start. The material includes all AN-patients under 18 years in one county that received inpatient treatment and almost all that received outpatient treatment, during the time period 1986-1998. Forty-two (82%) subjects had no eating disorder (ED) at follow-up, one (2%) had AN, one (2%) bulimia nervosa (BN) and seven (14%) had less severe ED (EDNOS). Except the one with BN, none had bulimic symptoms. There was no mortality. Twenty (41%) had one or more other axis-1 psychiatric diagnoses at follow-up. Depression and anxiety disorders were most frequent. Psychosocial functioning assessed by Global Assessment of Functioning (GAF) was fairly good; mean 73+/-SD14 for symptoms and mean 77+/-SD13 for functioning. Only 48% were satisfied with life, compared to 83% in a normal population sample. Our conclusion is that the eating disorder outcome was good. However, in accordance with other studies, many subjects had other psychiatric problems at follow-up.     

Characteristic prefrontal blood volume patterns when imaging body type,high-calorie food,and mother–child attachment in childhood anorexia nervosa: A near infrared spectroscopy study

The aim of this study was to investigate the prefrontal activation in childhood anorexia nervosa (AN) patients when imaging symptom-provocative factors such as body type, high-calorie food, and attachment between mother and child. The prefrontal activations during each task, in terms of blood volume changes, were measured by near infrared spectroscopy. Twelve females with childhood AN (mean age, 14.4 years old) and 13 age-matched healthy female controls (mean age, 14.3 years old) participated in this study. Both groups showed increased prefrontal blood volume when viewing images of each symptom-provocative factor. Unexpectedly, there was no significant difference in the prefrontal blood volume increases between the control group and the childhood AN group when viewing images of slender and obese body types and high-calorie food. On the other hand, images of mother–child attachment resulted in significantly greater increases in prefrontal blood volume in the childhood AN group than in the control group. These results indicated that prefrontal activation in AN might be associated with imaging attachment between mother and child, but not associated with imaging body type or high-calorie food.     

A comprehensive meta-analysis of the risk of suicide in eating disorders

Preti A, Rocchi MBL, Sisti D, Camboni MV, Miotto P. A comprehensive meta‐analysis of the risk of suicide in eating disorders. Objective: Past meta‐analyses on suicide in eating disorders included few available studies. Method: PubMed/Medline search for papers including sample n ≥ 40 and follow‐up ≥5 years: 40 studies on anorexia nervosa (AN), 16 studies on bulimia nervosa (BN), and three studies on binge eating disorder (BED) were included. Results: Of 16 342 patients with AN, 245 suicides occurred over a mean follow‐up of 11.1 years (suicide rate = 0.124 per 100 person‐years). Standardized mortality ratio (SMR) was 31.0 (Poisson 95% CI = 21.0–44.0); a clear decrease in suicide risk over time was observed in recent decades. Of 1768 patients with BN, four suicides occurred over a mean follow‐up of 7.5 years (suicide rate = 0.030 per 100 person‐years): SMR was 7.5 (1.6–11.6). No suicide occurred among 246 patients with BED (mean follow‐up = 5.3 years). Conclusion: AN and BN share many risk factors for suicide: the factors causing lower suicide rates per person‐year in BN compared to AN should be investigated.     

Personality disorders in anorexia nervosa and bulimia nervosa

Two self-report questionnaires (MCMI and BSI) designed to measure personality disorder (PD) according to DSM-III (R) criteria were administered to patients with a diagnosis of anorexia nervosa (AN) (n = 19), bulimia nervosa (BN) (n = 16), or both diagnoses (AN + BN) (n = 9), both before and after treatment for the eating disorder. The main finding was that self-reported Personality Disorder (PD) diagnoses are not stable enduring characteristics among this group of eating disorder patients. A high rate of PD diagnoses occurred in all patient groups at admission (93%) and at discharge (79%). Both MCMI and BSI scales were subject to significant change following treatment. A high prevalence of borderline personality disorder was found in patients with BN. Changes in depression and self-esteem scores correlated most strongly with changes in schizoid, schizotypal, histrionic and narcissistic scales. Assessment of PD using self-report measures should be interpreted with caution in acutely symptomatic patients with eating disorders.     

Decreased levels of serum brain-derived neurotrophic factor in female patients with eating disorders.

BACKGROUND: Several lines of evidence suggest that brain-derived neurotrophic factor (BDNF) plays a role in the regulation of eating behavior. Because of its role in eating behavior, which is especially relevant to eating disorders, BDNF is an attractive candidate for investigation of potential biological markers of eating disorders such as bulimia nervosa (BN) and anorexia nervosa (AN). METHODS: We enrolled 18 female patients with BN, 12 female patients with AN, and 21 age-matched female normal control subjects in this study. Eating-related psychopathology and depressive symptoms were evaluated using the Bulimic Investigatory Test, Edinburgh (BITE) and the Hamilton Depression Rating Scale (HDRS). Serum BDNF levels were measured by a sandwich enzyme-linked immunosorbent assay. RESULTS: Serum levels of BDNF in the patients with AN or BN were significantly (p<.0001) decreased compared with those of normal control subjects, and serum BDNF levels in the patients with AN were significantly (p=.027) lower than those in patients with BN. A significant positive correlation (r=.378, p=.006) between serum BDNF levels and body mass index in all of the subjects was detected. Furthermore, there was a significant positive correlation (r=.435, p=.015) between the BITE symptom scale score and HDRS in these patients. CONCLUSIONS: The present study suggests that BDNF may play a role in the pathophysiology of eating disorders.     

Dialectical behaviour therapy and an added cognitive behavioural treatment module for eating disorders in women with borderline personality disorder and anorexia nervosa or bulimia nervosa who failed to respond to previous treatments. An open trial with a 15-month follow-up

There is evidence from case studies suggesting that adapted dialectical behavior therapy (DBT) for borderline personality disorder (BPD) and eating disorders (ED) might improve disorder related complaints. Twenty-four women with BPD (9 with comorbid anorexia nervosa [AN] and 15 with bulimia nervosa [BN]), who already had failed to respond to previous eating-disorder related inpatient treatments were consecutively admitted to an adapted inpatient DBT program. Assessment points were at pre-treatment, post-treatment, and 15-month follow-up. At follow-up, the remission rate was 54% for BN, and 33% for AN. Yet 44% of women with AN crossed over to BN and one woman additionally met the criteria of AN. For women with AN, the mean weight was not significantly increased at post-treatment, but had improved at follow-up. For women with BN, the frequency of binge-eating episodes was reduced at post-treatment as well as at follow-up. Self-rated eating-related complaints and general psychopathology, as well as ratings on global psychosocial functioning, were significantly improved at post-treatment and at follow-up. Although these findings support the assumption that the adapted DBT inpatient program is a potentially efficacious treatment for those who failed to respond to previous eating-disorder related inpatient treatments, remission rates and maintained eating-related psychopathology also suggest that this treatment needs further improvement.     

Interhemispheric functional connectivity in anorexia and bulimia nervosa

The functional interplay between hemispheres is fundamental for behavioral, cognitive, and emotional control. Anorexia nervosa (AN) and bulimia nervosa (BN) have been largely studied with brain magnetic resonance imaging (MRI) in relation to the functional mechanisms of high‐level processing, but not in terms of possible inter‐hemispheric functional connectivity anomalies. Using resting‐state functional MRI (fMRI), voxel‐mirrored homotopic connectivity (VMHC) and regional inter‐hemispheric spectral coherence (IHSC) were studied in 15 AN and 13 BN patients and 16 healthy controls (HC). Using T1‐weighted and diffusion tensor imaging MRI scans, regional VMHC values were correlated with the left‐right asymmetry of corresponding homotopic gray matter volumes and with the white matter callosal fractional anisotropy (FA). Compared to HC, AN patients exhibited reduced VMHC in cerebellum, insula, and precuneus, while BN patients showed reduced VMHC in dorso‐lateral prefrontal and orbito‐frontal cortices. The regional IHSC analysis highlighted that the inter‐hemispheric functional connectivity was higher in the ‘Slow‐5’ band in all regions except the insula. No group differences in left–right structural asymmetries and in VMHC vs. callosal FA correlations were significant in the comparisons between cohorts. These anomalies, not explained by structural changes, indicate that AN and BN, at least in their acute phase, are associated with a loss of inter‐hemispheric connectivity in regions implicated in self‐referential, cognitive control and reward processing. These findings may thus gather novel functional markers to explore aberrant features of these eating disorders.     

Long-term outcome of residential treatment for anorexia nervosa and bulimia nervosa

We analyzed results from surveys of respondents who had completed ≥ 30 days of treatment at Monte Nido Residential Treatment Program over a 10 year period. Participants with anorexia nervosa (AN; n = 66) and bulimia nervosa (BN; n = 52) completed the Eating Disorders Inventory-2 (EDI-2), the Beck Depression Inventory (BDI), and a structured eating disorder assessment at admission and follow-up. Mean duration between discharge and last follow-up was 4.6 years and 3.8 years for AN and BN respectively. For AN there were significant improvements in BMI, BDI, 10 of 11 EDI-2 subscales, and frequencies of bingeing and purging. For BN there were significant improvements in BDI, all EDI subscales, and frequencies of bingeing and purging. Eighty-nine percent of AN graduates and 75% of BN graduates had good or intermediate outcomes. Using linear regression, the best model contained the single variable, discharge BMI, which predicted 23% of the variance explaining full recovery from AN (p ≤ .02). For BN, the best model contained vomiting frequency and the bulimia subscale score of the EDI-2 at discharge, which accounted for 37% of the variance explaining full recovery from BN (p ≤ .02). The great majority of patients showed significant improvement at long-term follow-up after this program of residential treatment. In addition, these results underscore the importance of weight gain for AN patients and cessation of bulimic symptoms for BN patients when predicting long-term recovery.     

The incidence of eating disorders in a Danish register study: Associations with suicide risk and mortality

Our aim was to characterize the incidence rates and cumulative incidence of anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS), and examine associations among eating disorder diagnoses, suicide attempts, and mortality. Individuals born in Denmark between 1989 and 2006 were included (N = 966,141, 51.3% male). Eating disorders diagnoses (AN, broad AN, BN, EDNOS) were drawn from the Danish Psychiatric Central Research Register (PCRR) and Danish National Patient Register (NPR). Suicide attempts and deaths were captured in the NPR, the PCRR, and the Danish Civil Registration System (CRS). In females, AN had a peak hazard at approximately age 15 years, BN at 22 years, and EDNOS had an extended peak that spanned 18 years–22 years. Eating disorder diagnoses predicted a significantly higher hazard for death and suicide attempt compared with the referent of individuals with no eating disorders. In males, peak hazard for diagnosis was earlier than in females. The present study represents one of the largest and longest studies of eating disorder incidence and suicide attempts and death in both females and males. Eating disorders are accompanied by increased hazard of suicide attempts and death even in young adults.     

Neuroendocrine and psychopathological measures in anorexia nervosa: Resemblances to primary affective disorders

Clinical and biochemical data suggest a link between anorexia nervosa (AN) and primary affective disorders (PAD). In 14 female patients, aged 15–40 years, with 7-month to 11-year histories of AN, we studied circadian cortisol periodicity, response to the dexamethasone suppression test (DST), and plasma levels of β-endorphin and β-lipotropin before and after desimipramine therapy. Possible correlations were sought among neuroendocrine impairments, weight loss, and depressive symptomatology. Impaired circadian cortisol periodicity, blunted DST response, and increased β-endorphin plasma levels, observed in a subgroup of patients, could not be related to weight loss, either before or after therapy. Instead, a trend toward a relationship between neuroendocrine impairments and depressive symptoms was observed before and after treatment.     

Long-term outcome of 151 cases of anorexia nervosa

ABSTRACT One hundred and fifty-one patients (140 females - 11 males) with anorexia nervosa (AN) from three departments (child psychiatry, psychiatry, and internal medicine) were re-examined 4–22 years (average 12.5 years) after their first contact with the Rigshospital in Copenhagen. During the years 1960–76 the number of referrals was on the increase, and relatively more patients were treated in the psychiatric departments at the end than at the beginning of the period. Mean age was 16.6 years at onset, 19.0 years at primary contact. Mean weight loss was 32 %. Mean duration of treatment was 12 months. Differences between the three departments concern especially age, sex, and duration of treatment. Mean age at follow-up was 31.0 years (range 16–63 years) for surviving probands. Follow-up information originated from semi-structured personal interviews (in 80 % of surviving probands) together with register data on all probands, supplemented by extensive hospital data. Nine patients (6 %), including six who committed suicide, died on the average 7.3 years after primary contact (average age 27.1 years). The mortality rate was 0.5 % per year. At follow-up one fourth of the surviving probands had AN and one fourth suffered from other psychiatric disorders, while one half were free from mental illness. There were no significant differences in outcome between the three departments. As a whole, the group experienced a social decline. It is concluded that a substantial part of this group of AN patients had a poor prognosis with a tendency towards chronicity, despite relatively long and intensive treatment, but, on the other hand, about one half of the probands seemed to be healthy and well functioning.     

Eating disorders and antecedent anxiety disorders: a controlled study

We compared the prevalence and age of onset of adult and childhood anxiety disorders relative to the primary diagnosis in 68 women with anorexia nervosa (AN), 116 women with bulimia nervosa (BN), 56 women with major depression with no eating disorder (MD) and 98 randomly selected controls (RC) in order to determine whether antecedent anxiety disorders are plausible risk factors for AN and BN. Comorbid anxiety disorders were common in all three clinical groups (AN, 60%; BN, 57%; MD, 48%). In 90% of AN women, 94% of BN women and 71 % of MD women, anxiety disorders preceded the current primary condition (P=0.01), although panic disorder tended to develop after the onset of AN, BN or MD. In multivariate logistic regressions, the odds ratios (ORs) for overanxious disorder (OR=13.4) and obsessive-compulsive disorder (OR=11.8) were significantly elevated for AN. The ORs for overanxious disorder and social phobia were significantly elevated for BN (OR_OAD,=4.9; OR_SP=15.5) and MD (OR_OAD,=6.1; OR_SP=6.4). These data suggest that certain anxiety disorders are non-specific risk factors for later affective and eating disorders, and others may represent more specific antecedent risk factors.