5-HTTLPR moderates the relation between changes in depressive and bulimic symptoms in adolescent girls: a longitudinal study

Objective

Depression and bulimia both are associated with low serotonin levels. We examined whether the serotonin transporter gene (5‐HTTLPR) moderates the relation between depressive and bulimic symptoms over time.

Method

Fifty adolescent girls with no current or past Axis I disorder were genotyped for the 5‐HTTLPR gene. Twice, 6 months apart, participants completed self‐report measures of depressive symptoms and bulimic symptoms.

Results

The association between change in depressive symptoms and change in bulimic symptoms over time was significantly stronger in girls who are homozygous for the short 5‐HTTLPR allele than for girls with at least one long allele.

Discussion

This finding is consistent with previous studies documenting a relation between depressive and bulimic symptoms in adolescents. Few studies, however, considered the possible role of serotonin linking both disorders. Gaining a better understanding of developmental effects of low serotonin could help to identify high‐risk individuals and provide effective prevention and intervention. © 2010 by Wiley Periodicals, Inc. Int J Eat Disord 2011     

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.     

Impulsivity, dietary control and the urge to binge in bulimic syndromes.

OBJECTIVE: Naturalistic studies on sufferers of bulimic syndromes suggest that binge episodes are often precipitated by episodes of dietary restraint. However, evidence also implies that binge eating may, in certain psychopathological contexts, have less direct connection with dietary control factors. Applying an 8- to 22-day experience-sampling procedure in individuals with bulimic syndromes, we explored possible moderating effects of trait impulsivity upon the ongoing association between cognitive dietary control and binge eating. METHOD: Fifty-one women with bulimia spectrum eating disorders provided periodic daily observations on cognitive control over eating, urges to binge, and binge episodes. Impulsivity was assessed by self-report questionnaire. Hierarchical linear modeling techniques were used to assess relationships of interest. RESULTS: Urge to Binge was higher (on average) prior to eating binges than at comparable times on binge-free days, and thus seemed to signal the potential for binge eating. More importantly, scores on Urge to Binge and Dietary Control covaried systematically over time in most participants, but were desynchronous in highly impulsive individuals. CONCLUSIONS: Binge eating is closely linked to dietary control in most bulimic individuals, but this may be less typical of individuals showing marked impulsivity. We discuss factors that may explain the disconnection between Dietary Control and Urge to Binge in impulsive binge eaters as well as the implications of such factors for the management of bulimic patients with marked impulsivity.     

Impulsivity ratings in bulimia nervosa: Relationship to binge eating behaviors

Although impulsive behavioral patterns are often described by patients with bulimia nervosa, there has been little formal evaluation of the relationship between impulsivity and eating-related symptomatology in this disorder. In this controlled outpatient study, ratings on the Barratt Impulsivity Scale were significantly elevated in 20 women with bulimia nervosa in comparison to 20 healthy female volunteers. Frequency of binge eating episodes was not significantly correlated with impulsivity ratings. Although these results indicate increased prevalence of impulsive behavioral style in patients with bulimia nervosa, impulsivity per se does not appear to be a predictor of symptom severity as reflected in frequency of bulimic episodes. © 1994 by John Wiley & Sons, Inc.     

Serotonin and Bulimia Nervosa

Serotonin (5HT) is one of several neuromodulators of feeding. Experimentally reducing 5HT activity in animals increases food intake, while increasing 5HT activity has the opposite effect. Studies suggest that women with bulimia nervosa show signs of reduced 5HT activity, which may be related to binge eating. Data supporting the theory that reduced central nervous system 5HT activity may play a role in the pathophysiology of bulimia nervosa is reviewed. Disturbances of 5HT activity and the relationship to other psychopathology in bulimia nervosa, such as depression, substance abuse, and impulsivity, are also reviewed.     

Specificity in the relationship between depressive and eating disorder symptoms in remitted and nonremitted women.

OBJECTIVE: There is a strong association between eating disorders and depression. However, because both eating disorder symptoms and depression are multifactorial, this study explored the relationship between these two disorders in women with eating disorders and women in remission. METHOD: Two hundred and eight (mostly female) volunteers with a history of eating disorders participated. They completed a self-report questionnaire of eating disorder symptoms, the Short Evaluation for Eating Disorders (SEED), and a questionnaire measuring depression, the Beck Depression Inventory (BDI). RESULTS: According to the SEED, 57 volunteers were classified as being in remission and 151 were classified as being ill. Those who were in remission were significantly less depressed overall than those who were still ill with 72% of the former falling in the "not depressed" or "mildly depressed" categories and 73% of the latter falling in the "moderately" or "severely depressed" categories. Factor analyses of the SEED and BDI identified three subscales of eating disorder symptoms (dietary restriction, bulimia, and body mass index [BMI]/menstruation) and two subscales of depression (cognitive and somatic/affective). Dietary restriction and bulimia, but not BMI/menstruation, were uniquely associated with the cognitive symptoms of depression. However, none of the eating disorder symptoms were uniquely associated with the somatic/affective symptoms of depression. DISCUSSION: Although eating disorders and depression share considerable comorbidity, a specific association is restricted to that between the cognitive and behavioral symptoms of eating disorders and the cognitive symptoms of depression.     

Impulsivity as an underlying factor in the relationship between disordered eating and sexual behavior

OBJECTIVE: Previous research has reported associations between bulimia nervosa (BN), increased sexual activity, and impulsivity. However, most studies have examined these topics separately and have not examined the role of impulsivity in associations between bulimic and sexual behaviors. The current study sought to examine relationships between disordered eating, sexual behaviors, and impulsivity, as well as to investigate impulsivity as a third variable in these relationships. METHOD: The participants were 500 female undergraduate students from a large midwestern university who completed self-report questionnaires of binge eating, the use of compensatory behavior, sexual behavior, and impulsivity. RESULTS: Compensatory behavior, but not binge eating, was significantly correlated with sexual experiences. Partial correlations indicated that impulsivity is a third variable that partially underlies this relationship. CONCLUSION: Compensatory behaviors and increased sexual activity likely represent risky behaviors that are influenced by impulsivity levels.     

Three studies on the factorial distinctiveness of binge eating and bulimic symptoms among nonclinical men and women

OBJECTIVE: According to DSM-IV's proposed nosology, binge eating disorder is separable from bulimia nervosa. The basis for separation rests with compensatory behaviors (e.g., induced vomiting)-people with bulimia nervosa engage in compensatory behaviors, whereas those with binge eating disorder do not. We addressed the validity of this nosology. METHODS: In three studies on 2,015 young men and women, we used factor-analytic techniques to assess whether bulimic and binge eating symptoms are separable in men and women. Results and Discussion Results of the three studies converged: Although binge eating symptoms may be distinct from bulimic symptoms among young men, the two syndromes are factorially inseparable among young women. Nosologic and sociocultural implications are noted.     

Impulsivity and compulsivity in bulimia nervosa

OBJECTIVE: A primary objective of the current article is to investigate the relationship between impulsivity and compulsivity in patients with bulimia nervosa (BN). A second goal is to explore the relationship between impulsivity and compulsivity and related psychiatric problems. METHOD: Two-hundred four females with BN completed several measures of impulsivity and compulsivity as well as measures of personality, substance use, eating pathology, and depression. RESULTS: Participants reported considerable variability on measures of impulsivity and compulsivity and these scores were positively correlated with each other. Impulsive-compulsive groups differed in personality, substance use, eating, and depression. CONCLUSION: These findings suggest that impulsivity and compulsivity can coexist in BN patients and that both traits may provide useful information about comorbid problems in women with BN.     

Relationship of the eating disorders to depression biological similarities and differences

Behavioral signs and symptoms and biological similarities present in anorexia nervosa, bulimia nervosa, and depressive disorder have been the spur for a variety of investigations comparing the eating disorders with affective disorder. These studies have examined and compared the phenomenology, family history, and neuroendocrinology of these disorders. A review of all the pertinent studies does not allow one to conclude that the eating disorders are a form of affective disorder.     

Body shape concerns in bulimia nervosa

Overconcern with shape and weight is considered a primary feature of the psychopathology of bulimia nervosa and was included as a diagnostic criterion in DSM- III-R. In order to test the significance of shape and weight concern in bulimia nervosa, we administered the Body Shape Questionnaire (BSQ) to 78 outpatients with bulimia nervosa and three comparison groups: 14 women with seasonal affective disorder (SAD), 10 acquaintances of patients, and 32 normal controls. Women with bulimia nervosa had significantly higher mean BSQ scores than did other subject groups. Other self-report measures of body shape concern, eating attitudes, and depression were correlated with BSQ score. Furthermore, all patients had BSQ scores greater than the average score of the normal control group. These data support the continued inclusion of body shape and weight overconcern as a diagnostic criterion for bulimia nervosa but suggest that “overconcern” should be interpreted as “above average” rather than “outside the normal range”.     

Test meal intake in obese binge eaters in relation to impulsivity and compulsivity

OBJECTIVE: Studies have linked increased impulsivity and compulsivity with bulimia nervosa (BN). Less is known about this relationship in binge eating disorder (BED). METHOD: Seventy-nine overweight participants (28 male, 65 females) were classified as BED (n = 22), BE (Subthreshold BED, not meeting full criteria for BED) (n = 21), and non-BED (n = 36). Following an 8-hr fast, participants completed psychological scales to assess impulsivity, compulsivity, and depression. They then consumed a liquid test meal until extremely full. RESULTS: Test meal intake (TMI) was significantly greater for both BED and BE than non-BED participants. Impulsivity and depression scores were significantly higher in BED and BE than in non-BED participants. Men had significantly higher compulsivity scores than women. Impulsivity correlated significantly with TMI, accounting for 16% of the variance. CONCLUSION: There was greater impulsivity in BED and BE, compared with non-BED. Moreover, impulsivity was the best predictor of TMI, and may play a larger role in BE than previously realized.     

Impulsivity as a risk factor for eating disorder behavior: assessment implications with adolescents

OBJECTIVE: The aims of the current study were to determine if impulsivity serves as a risk factor for eating disorder behavior and to examine whether different risk outcomes are obtained depending on the assessment strategy used to measure impulsivity. METHOD: Three independent studies are reported, each of which examined the relationship of impulsivity and eating disorder behavior in a prospective longitudinal design with adolescent subjects recruited from both public and private schools. Individuals displaying eating disorder behavior at initial assessments were not included in the analyses, to ensure that we were testing the role of impulsivity in the onset of eating disorder behavior. RESULTS: Trait impulsivity, measured with traditional personality scales, failed to predict the onset of eating disorder behavior in all three studies. However, when behavioral constructs associated with impulsivity, such as delinquency or substance abuse, were examined, they significantly predicted the onset of eating disorder behavior in most of the analyses conducted. DISCUSSION: These results provide moderate support for the idea that impulsivity serves as a risk factor for the onset of eating disorder behavior. However, this is only true when more objective behavioral measures were utilized.     

Eating disorders, dieting, and the accuracy of self-reported weight

OBJECTIVE: This study investigated the accuracy of self-reported weight and height in individuals with an eating disorder (i.e., anorexia nervosa [AN] and bulimia nervosa [BN]) and in individuals without an eating disorder (i.e., dieters and nondieters). METHOD: Self-reported and measured weights and heights were obtained from the eating disorder sample (n = 81) and the college student sample (n = 163) and were compared within and between the groups. RESULTS: Eating disorder patients were extremely accurate at self-reporting their weight. However, there was a significant difference in accuracy between AN and BN patients. AN patients slightly overreported their weight, whereas BN patients slightly underreported their weight. Both dieters and nondieters significantly underreported their weight. However, dieters significantly underreported their weight to a greater degree than did the nondieters. DISCUSSION: The implications of these subgroup differences and their specificity to weight reporting are discussed with reference to the accuracy of self-reported height.     

Seasonal variations in eating disorder subtypes in Japan

OBJECTIVE: This study estimated the degree of seasonal changes in eating disorder subtypes in Japan. METHOD: A Japanese version of the Seasonal Pattern Assessment Questionnaire (SPAQ) was mailed to 228 outpatients with eating disorders in Kyoto (latitude 35 degrees 01' N). Ninety responses were analyzed. The mean of the global seasonality score (GSS) in the SPAQ and the comorbidity rate of seasonal affective disorder (SAD) and subsyndromal-SAD in each subtype were used as indices of seasonality. RESULTS: The mean (8.2) of the GSS of the bulimia nervosa (BN) group and the sum (43%) of the comorbidity rates of SAD and subsyndromal-SAD in the BN group were significantly higher than those in the nonclinical comparison group. DISCUSSION: The seasonality of BN in Kyoto is the highest among eating disorder subtypes, although lower than that in North America. This finding suggests that light therapy could be useful for Japanese BN patients.     

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.     

Personality pathology in purging disorder and bulimia nervosa

Objective:

To compare levels of personality pathology in women with purging disorder (PD), bulimia nervosa (BN), and controls and to compare women with PD and BN on associations between personality pathology and shared eating disorder features.

Method:

Women with BN (n = 73), PD (n = 48), and controls (n = 64) completed interviews and self‐report questionnaires.

Results:

BN and PD were associated with significantly greater personality pathology compared to controls. Cluster C symptoms and trait anxiety were greater in BN compared to PD, but groups did not differ on Cluster B symptoms or impulsivity. Subjective binge episodes were associated with anxious and impulsive personality traits in PD but not BN. Purging in PD was associated with trait anxiety, while purging in BN was associated with impulsivity.

Discussion:

Although BN and PD share eating disorder features and personality disturbance, some of the underlying associations between these eating disorder and personality features differ between groups. © 2011 by Wiley Periodicals, Inc.     

Relationships between perfectionism and specific disordered eating behaviors

OBJECTIVE: Perfectionism has been reported as a specific risk factor for anorexia nervosa and bulimia nervosa, but not binge eating disorder. This study examined whether these differences are due to differential associations between perfectionism and specific eating disorder behaviors. METHOD: Participants (N = 2,482) completed the eating disorders inventory perfectionism scale and a questionnaire assessing eating disorder symptoms. RESULTS: Perfectionism was associated with an array of disordered eating behaviors in women. However, associations were strongest for fasting and purging. Further, the association between binge eating and perfectionism was statistically mediated by fasting. In men, perfectionism was significantly associated only with fasting, and this association was greater than associations with other disordered eating behaviors. CONCLUSION: Results explain why previous studies have reported weak or inconsistent associations between perfectionism and binge eating and may inform etiological models of EDNOS characterized by fasting or purging.     

Schema-level cognitions in patients with binge eating disorder: a case control study

OBJECTIVE: This study examined the schema-level cognitions (core beliefs) of patients with binge eating disorder to determine whether these patients differ from those with bulimia nervosa. A case control method (matching groups for age and body mass index [BMI]) was used, to avoid the confounding factors that are found in most studies of this sort. METHOD: All clinical women were recruited from a specialist eating disorder clinic. The index group consisted of 25 women with DSM-IV diagnoses of binge eating disorder, who were compared with a clinical group of 25 women with bulimia nervosa and a group of 25 women with no eating disorder. Groups were closely matched for age and BMI. Each participant completed a well-validated measure of core beliefs. RESULTS: Although the binge eating disorder group had a range of more negative core beliefs than nonclinical women, the differences between the clinical groups were much smaller. The binge eating disorder group had more negative core beliefs than the bulimia nervosa group in many areas. However, the bulimia nervosa group was distinguished by having the highest level of abandonment beliefs, and this difference may account for the difference in the presence of purging behaviors. CONCLUSIONS: Levels of abandonment beliefs seem to be crucial in understanding the behavioral differences between these clinical groups--particularly the absence of purging behaviors. However, the relevance of these beliefs to treatment outcome and to other aspects of psychopathology remains to be established.     

Early trauma,dissociation, and late onset in the eating disorders

Although the majority of patients with anorexia nervosa and bulimia nervosa develop these disorders in their teens and 20s, some patients develop an eating disorder in their 30s, 40s, or 50s. We present a subgroup of patients with the following pattern of symptoms and historical detail: (1) severe sexual and physical abuse by family members; (2) relatively good premorbid professional and marital adjustment (considering later difficulties) though characterized by (3) hypomania, binge eating, and morbid obesity. A pronounced shift in eating behaviors follows (4) medical trauma (e.g., injury, cancer, surgery) that occurs after age 30, interrupts previous hypomanic adaptation, and leads to severe restriction, purging, and dramatic weight loss (e.g., 100 lb). Although only one patient met full criteria for anorexia nervosa, weight loss and starvation were serious enough to provoke further medical crises in all patients. Finally, (5) during both weight loss and weight restoration patients demonstrated significant dissociative disturbance, including dissociated mood and personality states (i.e., multiple personality disorder), self-destructive behavioral episodes repeating early trauma, and avoidance of food as a way to manage PTSD symptoms. © 1995 by John Wiley & Sons, Inc.