The Impact of Alexithymia on Emotion Dysregulation in Anorexia Nervosa and Bulimia Nervosa over Time

Research supports that anorexia nervosa‐restricting subtype (AN‐R) and bulimia nervosa (BN) are associated with emotion regulation difficulties and alexithymia. However, the impact of diagnosis on the relationship between these constructs is less well understood. The purpose of the present study was to examine whether eating disorder diagnosis moderated the association between admission alexithymia and emotion regulation through discharge. Adult patients with AN‐R (n = 54) and BN (n = 60) completed assessments at treatment admission and discharge from a partial hospital program. Eating disorder diagnosis moderated the association between admission alexithymia levels and change in global emotion dysregulation, impulse control difficulties and access to emotion regulation strategies. At higher levels of admission alexithymia, there were no differences between AN‐R and BN on emotion dysregulation, whereas at lower levels of alexithymia, AN‐R patients demonstrated lower levels of emotion dysregulation. Results imply that difficulties with alexithymia appear to have a greater impact on emotion dysregulation for AN‐R patients. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.     

Purging Disorder: A Comparison to Established Eating Disorders with Purging Behaviour

This study is part of the larger Christina Barz Study, and it compared consecutively admitted patients with purging disorder (PurD; N = 225) with consecutively admitted patients with anorexia nervosa binge eating/purging subtype (AN‐bp; N = 503) and bulimia nervosa purging subtype (BN‐p; N = 756). Participants answered self‐rating questionnaires on admission, at the end of inpatient treatment, and in a 5‐year follow‐up. Patients with PurD reported lower severity of general psychopathology than patients with AN‐bp and lower severity of eating disorder symptoms than patients with AN‐bp and BN‐p on admission. Eating disorder symptoms of patients with PurD improved less during the course than of the comparison groups. Diagnostic perseverance was stronger in the PurD group than for patients with AN‐bp; mortality was higher than for patients with BN‐p. Predictors for better outcome differed for the groups. Our results provide new data about the long‐term course of patients with PurD and indicate clinical relevance of the disorder. Copyright © 2013 John Wiley & Sons, Ltd and Eating Disorders Association.     

Self‐Discrepancy and Eating Disorder Symptoms Across Eating Disorder Diagnostic Groups

This study examined self‐discrepancy, a construct of theoretical relevance to eating disorder (ED) psychopathology, across different types of EDs. Individuals with anorexia nervosa (AN; n = 112), bulimia nervosa (BN; n = 72), and binge eating disorder (BED; n = 199) completed semi‐structured interviews assessing specific types of self‐discrepancies. Results revealed that actual:ideal (A:I) discrepancy was positively associated with AN, actual:ought (A:O) discrepancy was positively associated with BN and BED, and self‐discrepancies did not differentiate BN from BED. Across diagnoses, A:O discrepancy was positively associated with severity of purging, binge eating, and global ED psychopathology. Further, there were significant interactions between diagnosis and A:O discrepancy for global ED psychopathology and between diagnosis and A:I discrepancy for binge eating and driven exercise. These results support the importance of self‐discrepancy as a potential causal and maintenance variable in EDs that differentiates among different types of EDs and symptom severity. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.     

Relapse in anorexia and bulimia nervosa—a 2.5‐year follow‐up study

Anorexia nervosa (AN) and bulimia nervosa (BN) not infrequently take a chronic course during which remission is followed by relapse, sometimes repeatedly. For AN as well as BN, substantial interindividual differences have been observed in long‐term course and relapse rates. Attempts to identify consistent predictors of relapse have not been very successful so far in both disorders. This paper presents the results of the German Project TR‐EAT, which served as the blueprint for the European collaboration COST Action B6. In Project TR‐EAT, the symptomatic status of eating‐disordered patients (AN, N = 233, BN, N = 422) was tracked after inpatient treatment over a 2.5‐year follow‐up period using the LIFE interview. The distribution of time to relapse for both disorders and possible predictors for relapse are investigated by means of discrete time survival analysis. Fifty‐eight per cent of the patients with AN and 74% of those with BN achieved partial remission before end of treatment, and thus were at risk for relapse. The relapse rates within 2.5 years were 32.6% for AN and 37.4% for BN. For both eating disorders, the highest risk of relapse was within the first 6 or 7 months after achieving partial remission, but the distribution of time to relapse differed between both. Desired weight, duration of illness, EDI scores, specialization of clinic and additional treatment during follow‐up were identified as predictors for AN. For BN, symptomatic status before relapse, motivation for treatment and additional treatment during follow‐up showed predictive value. Implications for care provision are discussed. Copyright © 2005 John Wiley & Sons, Ltd and Eating Disorders Association.     

Getting better byte by byte: a pilot randomised controlled trial of email therapy for bulimia nervosa and binge eating disorder

One hundred and ten people in an university population responded to emailed eating disorder questionnaires. Ninty‐seven fulfilling criteria for eating disorders (bulimia nervosa (BN), binge eating disorder (BED), EDNOS) were randomised to therapist administered email bulimia therapy (eBT), unsupported Self directed writing (SDW) or Waiting list control (WLC). Measures were repeated at 3 months. Diagnosis, Beck depression inventory (BDI) and Bulimia investigatory test (BITE) scores were recorded. Follow‐up rate was 63% and results must be interpreted cautiously. However significantly fewer participants who had received eBT or SDW fulfilled criteria for eating disorders at follow up compared to WLC. There was no significant difference between eBT and SDW in the analysis of variance (ANOVA), although in separate analyses, eBT was significantly superior to WLC (p < 0.02) and the difference for SDW approached significance (p = 0.06). BDI and BITE scores showed no significant change. For eBT participants there was a significant positive correlation between words written and improvement in BITE severity score. BN, BED and EDNOS can be treated via email. Copyright © 2007 John Wiley & Sons, Ltd and Eating Disorders Association.     

Personality traits and self‐injurious behaviour in patients with eating disorders

The interest in different aspects of personality and the neuropsychological basis for behaviour in eating disorder patients has increased over the last decade. The present study aims at exploring personality traits, self‐injurious behaviour (SIB) and suicide attempts in a group of severely ill eating disorder patients. Patients with eating disorders (N = 38) and age‐matched controls (N = 67) were examined concerning self‐reported personality traits by means of the Karolinska scales of personality (KSP). Psychosocial history and SIB was collected from medical records. Depression was rated by means of the Beck Depression Inventory (BDI). Results indicated significantly higher anxiety‐related and detachment traits in both anorexia nervosa (AN) and bulimia nervosa (BN) patients and higher hostility in BN patients than controls. No specific personality traits could be defined as typical for self‐injurious or suicidal behaviour. The AN group was lower than the BN group on scales measuring impulsivity, guilt and anxiety. Furthermore, presence of SIB and suicide attempts was more frequent among the BN patients. Copyright © 2008 John Wiley & Sons, Ltd and Eating Disorders Association.     

Methylation of the OXTR gene in women with anorexia nervosa: Relationship to social behavior

DNA methylation allows for the environmental regulation of gene expression and is believed to link environmental stressors to psychiatric disorder phenotypes, such as anorexia nervosa (AN). The oxytocin receptor (OXTR) gene is epigenetically regulated, and studies have shown associations between OXTR and social behaviours in various samples, including women with AN. The present study examined differential levels of methylation at various CG sites of the OXTR gene in 69 women with active AN (AN‐Active), 21 in whom AN was in remission (AN‐Rem) and 35 with no eating disorder (NED). Within each group, we explored the correlation between methylation and measures of social behaviour such as insecure attachment and social avoidance. Hypermethylation of a number of CG sites was seen in AN‐Active participants as compared with AN‐Rem and NED participants. In the AN‐Rem sample, methylation at CG27501759 was significantly positively correlated with insecure attachment (r = .614, p = .003, permutation Q = 0.008) and social avoidance (r = .588, p = .005, permutation Q = 0.0184). Our results highlight differential methylation of the OXTR gene among women with AN, those in remission from AN, and those who never had AN and provide some evidence of associations between OXTR methylation and social behaviour in women remitted from AN.     

Central and Peripheral Peptides Regulating Eating Behaviour and Energy Homeostasis in Anorexia Nervosa and Bulimia Nervosa: A Literature Review

A large body of literature suggests the occurrence of a dysregulation in both central and peripheral modulators of appetite in patients with anorexia nervosa (AN) and bulimia nervosa (BN), but at the moment, the state or trait‐dependent nature of those changes is far from being clear. It has been proposed, although not definitively proved, that peptide alterations, even when secondary to malnutrition and/or to aberrant eating behaviours, might contribute to the genesis and the maintenance of some symptomatic aspects of AN and BN, thus affecting the course and the prognosis of these disorders. This review focuses on the most significant literature studies that explored the physiology of those central and peripheral peptides, which have prominent effects on eating behaviour, body weight and energy homeostasis in patients with AN and BN. The relevance of peptide dysfunctions for the pathophysiology of eating disorders is critically discussed. Copyright © 2014 John Wiley & Sons, Ltd and Eating Disorders Association.     

Changes in eating disorder characteristics over the years

Since 1980, the diagnostic criteria of patients with eating disorders (ED) have changed over the years. Are these changes also expressed in the clinical features of the ED patients? A cross‐sectional sample was drawn consisting of 100 consecutive female patients' files diagnosed with anorexia nervosa (AN) and bulimia nervosa (BN) and bulimia nervosa and admitted at an inpatient unit from the first of January 1990, 2000, and 2010, respectively. Several reliable and well‐validated questionnaires (Eating Disorder Inventory, Body Attitude Test, Symptom Checklist, and the Beck Depression Inventory) were administered and scores were compared. The ratio AN/BN remained the same (65/35). No differences were found between the three cohorts except for depression, which increased over the years. This pattern is the same for the subsamples of anorexia nervosa and bulimia nervosa. Specific characteristics of eating disorder pathology did not change across time.     

The Functional Significance of Shyness in Anorexia Nervosa

The defining features of anorexia nervosa (AN) include disordered eating and disturbance in the experience of their bodies; however, many women with AN also demonstrate higher harm avoidance (HA), lower novelty seeking, and challenges with interpersonal functioning. The current study explored whether HA and novelty seeking could explain variation in disordered eating and social functioning in healthy control women ( n = 18), weight‐restored women with a history of AN (n = 17), and women currently‐ill with AN (AN; n = 17). Our results indicated that clinical participants (AN + weight‐restored women) reported poorer social skills than healthy control participants. Moreover, the relationship between eating disorder symptoms and social skill deficits was mediated by HA. Follow‐up analyses indicated that only the ‘shyness with strangers’ factor of HA independently mediated this relationship. Collectively, our results suggest a better understanding of shyness in many individuals with eating disorders could inform models of interpersonal functioning in AN. Copyright © 2015 John Wiley & Sons, Ltd and Eating Disorders Association.     

Affect consciousness and eating disorders. Short term stability and subgroup characteristics

The aim of the study was to analyse differences in observer rated affect consciousness (AC) between subgroups of patients diagnosed with eating disorders (N = 44; 30 with anorexia nervosa and 14 with bulimia nervosa), and a non‐clinical group (N = 40). Another aim was to study the short‐term stability of AC over 10–11 weeks of treatment and its relation to self‐reported eating pathology and general psychopathology. A moderate short‐term stability of AC was found but the levels were not correlated with eating pathology or psychopathology. No differences between the two diagnostic categories were found, but the eating disorder group as whole had significantly lower AC compared with a non‐eating disorder reference group. AC seems to be a moderately stable ability that differentiates patients diagnosed with eating disorders from a non‐clinical population. However, AC is not related to symptoms of eating disorder or general psychiatric symptoms in this group of patients. Copyright © 2011 John Wiley & Sons, Ltd and Eating Disorders Association.     

Food Addiction and Bulimia Nervosa

In individuals with obesity and binge eating disorder (BED), eating patterns can show addictive qualities, with similarities to substance use disorders on behavioural and neurobiological levels. Bulimia nervosa (BN) has received less attention in this regard, despite their regular binge eating symptoms. The Yale Food Addiction Scale (YFAS) was developed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnostic criteria for substance use disorders, and food addiction can be diagnosed when at least three addiction symptoms are endorsed and a clinically significant impairment or distress is present. Although the prevalence of food addiction diagnoses is increased in individuals with obesity and BED, recent studies which used the YFAS showed that there are also individuals with normal weight who can be classified as being ‘food addicted’. Based on self‐reported eating disorder symptoms, women with current (n = 26) or remitted (n = 20) BN, and a control group of women matched for age and body mass index (n = 63) completed the YFAS and other measures. Results revealed that all patients with current BN received a food addiction diagnosis according to the YFAS while only six (30%) women with remitted BN did. None of the women in the control group received a food addiction diagnosis. Results provide support for the notion that BN can be described as addiction‐like eating behaviour and suggest that food addiction most likely improves when BN symptoms remit. Copyright © 2014 John Wiley & Sons, Ltd and Eating Disorders Association.     

A Meta‐Analysis of Temperament in Eating Disorders

Although suggested as an important contributor to the development and maintenance of eating disorders, temperament has not previously been studied adopting a meta‐analytical approach. We therefore pooled data (N = 14 studies; N = 3315 cases, N = 3395 controls) on Cloninger's temperament traits (novelty seeking, harm avoidance, reward dependence and persistence) in anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED) and eating disorders not otherwise specified. Persistence was significantly higher than in the controls in all eating disorders except for BED the highest levels being observed in AN. Correspondingly, the highest effect sizes for harm avoidance were seen in AN. Novelty seeking was significantly elevated relative to the controls only in BN. Harm avoidance was significantly lower, and reward dependence was significantly higher in individuals who had recovered from AN than in those who remained ill. Future studies with a longitudinal design are needed to explore the temporal relationships between eating disorders and temperament traits. Copyright © 2014 John Wiley & Sons, Ltd and Eating Disorders Association.     

Temporal Discounting and the Tendency to Delay Gratification across the Eating Disorder Spectrum

Bulimia nervosa (BN) and binge eating disorder (BED) have been associated with poorer reward‐related inhibitory control, reflected by a reduced tendency to delay gratification. The opposite has been reported in anorexia nervosa (AN), but differences have not been directly compared across eating disorders (EDs). This study investigated self‐reported (Delaying Gratification Inventory) and task‐based (temporal discounting) inhibitory control in 66 women with an ED and 28 healthy controls (HCs). Poorer task‐based inhibitory control was observed in the BN compared with the AN group and poorer self‐reported inhibitory control in the BN and in the BED groups compared with the AN and the HC groups, suggesting that reward‐related inhibitory control varies across EDs. Symptom severity correlated with poorer self‐reported (but not task‐based) inhibitory control across the EDs. These data provide some support for transdiagnostic mechanisms and highlight the importance of addressing perceived loss of control in the treatment of EDs. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.     

Eating disorders and concurrent psychopathology: a reconceptualisation of clinical need through Rasch analysis

Therapies for anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED) and eating disorder not otherwise specified (EDNOS) take as their focus, perhaps of necessity, the eating disorder symptomatology. However, there is increasing evidence of comorbidity of psychopathological mechanisms (e.g. perfectionism, depression) with eating disorders which, left untreated, may diminish any therapeutic effects. Thus identifying the extent of comorbidity in an eating disorder population and assessing the relationship between psychopathological mechanisms and the eating disorder is important. Rasch analysis was applied to the findings from questionnaires (EDI‐2; SCL90‐R) completed by 105 female patients referred to an eating disorder unit. General psychopathology was found to be more indicative of ‘caseness’ than eating disorder psychopathology. In particular, interpersonal sensitivity, depression and mild interpersonal aspects of psychoticism emerged as important factors across eating disorders. The comorbidity of psychopathological mechanisms needs to be given consideration in the successful treatment of eating disorders. Copyright © 2007 John Wiley & Sons, Ltd and Eating Disorders Association.     

Clinical characteristics of early onset anorexia nervosa

The aim of the current paper is to evaluate clinical characteristics of 30 children with early onset anorexia nervosa (EO‐AN; age = 12.2 ± 1.6 years) compared with 30 patients with adolescent onset AN (AO‐AN; age = 15.9 ± 0.7 years) and 60 age‐matched healthy controls. Statistical analyses included one‐way analyses of variance with three planned comparisons and chi‐square tests. Compared with AO‐AN, EO‐AN patients displayed more restrictive eating behaviour (p = 0.038), received more tube‐feeding (p = 0.024), and had less problems with self‐esteem (p < 0.001) and perfectionism (p = 0.001). EO‐AN patients have similar eating disorder pathology (p = 0.183), body‐image distortion (p = 0.060), and number of hospitalizations (p = 0.358) as AO‐AN. Only a third of EO‐AN patients suffer from low self‐esteem. Overall, core AN pathology seems similar in EO‐AN and AO‐AN. However, EO‐AN patients show differences in their pathological eating behaviour and the need for tube‐feeding.     

Investigation of Oxytocin Secretion in Anorexia Nervosa and Bulimia Nervosa: Relationships to Temperament Personality Dimensions

Published studies suggested an implication of oxytocin in some temperament characteristics of personality. Therefore, we measured oxytocin secretion in 23 women with anorexia nervosa (AN), 27 with bulimia nervosa (BN) and 19 healthy controls and explored the relationships between circulating oxytocin and patients' personality traits. Plasma oxytocin levels were significantly reduced in AN women but not in BN ones. In healthy women, the attachment subscale scores of the reward dependence temperament and the harm avoidance (HA) scores explained 82% of the variability in circulating oxytocin. In BN patients, plasma oxytocin resulted to be negatively correlated with HA, whereas no significant correlations emerged in AN patients. These findings confirm a dysregulation of oxytocin production in AN but not in BN and show, for the first time, a disruption of the associations between hormone levels and patients' temperament traits, which may have a role in certain deranged behaviours of eating disorder patients. Copyright © 2015 John Wiley & Sons, Ltd and Eating Disorders Association.     

A longitudinal study on the association between facets of mindfulness and eating disorder symptoms in individuals diagnosed with eating disorders

Mindfulness‐based treatments for eating disorders could be improved by understanding how facets of mindfulness predict eating disorder symptoms over time. We examined whether facets of mindfulness predict eating disorder symptoms over time and vice versa. Individuals with an eating disorder diagnosis (N = 124; 87.9% diagnosed with anorexia nervosa) and an undergraduate sample (N = 290) completed measures of mindfulness at baseline. The clinical sample also completed these measures 1 month later. Individuals in the clinical sample had lower acting with awareness and higher observing than individuals in the undergraduate sample (ps < 0.002). In the clinical sample, higher body dissatisfaction prospectively predicted lower acting with awareness (p = 0.02). Lower acting with awareness prospectively predicted higher drive for thinness (p < 0.01) and bulimic symptoms (p < 0.01). Acting with awareness shows potential as a process that can be altered to effect positive outcomes on drive for thinness and bulimic symptoms.     

Demographic,psychiatric, and personality correlates of adults seeking treatment for disordered gambling with a comorbid binge/purge type eating disorder

Preliminary evidence suggests that binge/purge type eating disorders and gambling disorder may commonly co‐occur. However, this dual‐diagnosis population remains understudied. The present research examined the prevalence rates and correlates of binge/purge type eating disorders (i.e., bulimia nervosa, binge‐eating disorder, and anorexia nervosa binge/purge type) among adults seeking treatment for their gambling (N = 349). In total, 11.5% of the sample (n = 40) met criteria for a binge/purge type eating disorder, most commonly bulimia nervosa (n = 33). There was a higher preponderance of binge/purge type eating disorders in women. People with a comorbid binge/purge type eating disorder reported more days gambling, gambling‐related cognitive distortions, impulsivity, suicidality, and other current psychiatric comorbidities including addictive behaviours. These findings suggest that binge/purge type eating disorders in people seeking treatment for gambling may be more common than previously believed. Furthermore, the increased psychopathology among people with binge/purge type eating disorder and gambling disorder identify vulnerabilities of this dual‐diagnosed population that may require clinical attention.     

A serial study of gastric emptying in anorexia nervosa and bulimia

To determine the natural history of delayed gastric emptying of solid foods in anorexia nervosa (AN), gastric emptying was assessed by scintigraphy in 20 consecutive inpatients; eight had restrictive AN, ten had both AN and bulimia nervosa (BN), and two BN alone. Initial gastric half-emptying time (HET) exceeded 110 min (the upper limit of normal for the laboratory) in 16; their body mass index ranged from 11.7 to 18.1. HET showed a significant negative correlation with body mass (r = 0.71; p<0.001) but not age, duration of illness or use of psychotropic medication. Fourteen patients with prolonged emptying were retested; HET improved in nine of 12 retested at one month (p= 0.0005) but none showed a change in the lag phase of emptying. All four patients retested a further one to two months later achieved a HET < 110 min. Fourteen patients reached a body mass index of 16.3 during treatment and HET improved to better than 110 min in all but one of these. However, normalisation occurred while body mass was still subnormal (<20.3) and with amenorrhea still present. This study shows that delayed gastric emptying in AN improves quite rapidly as feeding recommences; thus the motility disturbance is secondary to restriction in food intake and is not fundamental to the disorder.