General population-based epidemiological study of eating disorders in Norway

In a questionnaire-based study of eating disorders in a representative sample of the general female population of Norway, the lifetime prevalence of eating disorders was 8.7% with a point prevalence of 3.8%. The lifetime prevalence of binge eating disorder (BED) was 3.2%, bulimia nervosa (BN) 1.6%, and anorexia nervosa (AN) 0.4%. Eating disorders not otherwise specified (EDNOS) had a lifetime prevalence of 3.0%. Point prevalence of BED was 1.5%, BN 0.7%, AN 0.3%, and EDNOS 1.3%. © 1995 by John Wiley & Sons, Inc.     

Disgust sensitivity in eating disorders: a preliminary investigation

BACKGROUND: Disgust is a basic emotion that has been relatively neglected in psychiatry in general and in eating disorders in particular. Nevertheless, there are features of disgust and its more complex derivatives (e.g., shame) which suggest that disgust may have a role to play in eating disorders. METHOD: Seventy-four patients with a DSM-IV diagnosis of anorexia nervosa, bulimia nervosa, eating disorder not otherwise specified, and obese binge eater were compared with 15 control subjects on their levels of disgust sensitivity. RESULTS: Overall, eating disorder patients did not appear to be more sensitive to disgust-eliciting stimuli than comparison subjects, although there was a tendency for patients to be more disgusted by body products. However, drive for thinness and bulimia scores were related to higher levels of disgust sensitivity to food, death, and magical contagion. General psychopathology did not appear to be related to levels of disgust sensitivity. DISCUSSION: Although patients are not more sensitive than controls to the disgust-eliciting stimuli measured, disgust still has a positive relationship to eating disorder symptoms. Future studies will need to examine more precisely what this relationship might be.     

Atypical eating disorders.

Some patients with eating disorders have neither anorexia nervosa (A.N.) nor bulimia. Cases which do not rigorously meet the DSM-III-R criteria for anorexia nervosa or for bulimia are usually defined as "eating disorders N.O.S." Among them are patients with pathological characteristics very closely related to the above-mentioned categories. Others, however, although affected by an eating disorder, present a quite different clinical picture from either A.N. or bulimia. In a study of 80 eating disorder cases, only 45 met the strict definition of A.N. or bulimia. The other 35 were diagnosed as atypical eating disorders and are the focus of this presentation. 29 were classified as Eating Disorders N.O.S. and 6 as obesity. Co-morbidity, gender and age data, and clinical vignettes are presented.     

Predictors of bone mineral density in patients with eating disorders

OBJECTIVE: The objective of this study was to examine potential clinical predictors of bone density in patients with eating disorders. METHOD: We studied 137 women with anorexia nervosa, bulimia nervosa, or eating disorder not otherwise specified (NOS) after admission to the hospital. Clinical data of patients were collected by clinical interview and standardized questionnaires. Bone mineral density of the lumbar spine was measured by dual energy x-ray absorptiometry. RESULTS: Lumbar bone density was significantly correlated to present and past minimum weight even after correction for height and age. Other factors did not reach significance. CONCLUSION: Normalized present and past weight is the best predictor of lumbar bone density in patients with eating disorders. Factors like reduced caloric intake, binge eating, vomiting, menstrual status, and use of estrogen, laxatives, and nicotine seem to have no independent effect on bone density in this group of patients.     

Criterion validity of the multiaxial assessment of eating disorders symptoms

OBJECTIVE: The purpose of this investigation was to establish the criterion validity of the Multiaxial Assessment of Eating Disorders Symptoms (MAEDS). The MAEDS is a brief, comprehensive, self-report measure for the evaluation of eating disorders treatment outcome. It assesses six symptoms associated with eating disorders with subscales for binge eating, purgative behavior, avoidance of forbidden foods, restrictive eating, fear of fatness, and depression. METHOD: To establish criterion validity, we compared the subscale scores of the MAEDS across four eating disorder diagnoses, specified by subtype (bulimia nervosa, purging type; anorexia nervosa, binge-eating/purging type; anorexia nervosa, restricting type; and binge eating disorder). Participants who did not meet the full diagnostic criteria for an eating disorder, but who did meet criteria for a partial syndrome eating disorder, were grouped with the full eating disorder diagnostic subtypes. RESULTS: The criterion validity of the MAEDS was supported by the pattern of subscale scores for the different eating disorder diagnostic groups. Also, with few exceptions, persons diagnosed with anorexia nervosa, bulimia nervosa, and binge eating disorder, in comparison to subthreshold cases of anorexia nervosa, bulimia nervosa, and binge eating disorder, had equivalent scores on the subscales of the MAEDS. DISCUSSION: These findings support the criterion validity of the MAEDS and add to a growing literature that questions differences in severity of eating disorder symptoms in full syndrome versus partial syndrome cases.     

Caffeine intake in eating disorders

OBJECTIVE: The current study compares caffeine consumption in females with an eating disorder and females without an eating disorder. METHOD: Caffeine intake in three diagnostic groups (10 females with anorexia nervosa, 27 females with bulimia nervosa, and 42 females with binge eating disorder [BED]) was compared with caffeine intake in three comparison groups (n = 659 each). Data were obtained from a longitudinal study of Black and White girls. Three-day food records were examined for the years before the onset of the eating disorder, the onset year, and the years after the onset of the eating disorder. Data from the same years were used for the comparison groups. RESULTS: Caffeine intake increased over time between ages 9 and 19 years across all groups and this trend was not moderated by diagnostic status. For anorexia nervosa, relative to the non-eating disorder group, the proportional intake of caffeine from soda increased significantly before onset to onset to after onset and ingestion of chocolate-containing foods decreased sharply over time. CONCLUSION: Caffeine consumption in young girls with eating disorders differs from girls with no eating disorders only for anorexia nervosa, but not for bulimia nervosa or BED.     

The interrater reliability of physical signs in patients with eating disorders.

OBJECTIVE: To evaluate the interrater reliability of five common signs of eating disorders. METHODS: Eating disorder patients with anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified (ED-NOS), at various stages of recovery, were evaluated for the presence or absence of lanugo hair, acrocyanosis, parotid hypertrophy, hypercarotinemia, and Russell's sign. Patients were examined by two physicians with similar experience and training. Results are analyzed for reliability using the kappa statistic. RESULTS: Kappa scores were as follows, indicating marginal reproducibility of results: lanugo hair (kappa = 0.606), acrocyanosis (kappa = 0.014), parotid hypertrophy (kappa = 0.266), hypercarotinemia (kappa = 0.101) , and Russell's sign (kappa = 0.140). CONCLUSION: The interrater reliability for individual items ranged from poor to moderate. Overall, there is marginal interrater reliability for the five common signs of eating disorders assessed.     

Self-oriented perfectionism in eating disorders

OBJECTIVE: To assess perfectionism dimensions in eating disorders in comparison with other psychiatric disorders and subjects from the general population. METHOD: The Child and Adolescent Perfectionism Scale (CAPS), the Eating Disorders Inventory (EDI-2), and the Eating Attitudes Test (EAT) were administered to a group of 108 female eating-disordered patients (75 anorexia nervosa and 33 bulimia nervosa), to a group of 86 female psychiatric patients with anxiety (N = 32), depressive (N = 38), or adaptive disorders (N = 16), and to 213 healthy female participants. RESULTS: Both bulimic and anorexic patients scored higher on Self-Oriented Perfectionism (p < 0.001) than the other two groups but not on Socially-Prescribed Perfectionism (p = 0.054). Among patients with eating disorder, 17.6% obtained a score two standard deviations higher than the mean in the healthy comparison group on self-oriented perfectionism; this percentage was significantly higher than in the other two groups. The percentage of eating disorder patients with high socially-prescribed perfectionism was similar to that found in other psychiatric disorders. Moreover, self-oriented perfectionism was a predictor of an eating disorder. CONCLUSION: Self-oriented perfectionism is more specific to eating disorders than to depressive or anxiety disorders.     

Relationships between features associated with vomiting in purging-type eating disorders

OBJECTIVE: Vomiting is a pernicious symptom of eating disorders. We explored the relation between the symptom of vomiting and features of eating disorder course and severity, personality traits, and Axis I and II comorbidity in individuals with purging-type eating disorders. METHOD: The sample included participants from the multisite, international Price Foundation Genetic Studies, who had an eating disorder diagnosis (anorexia nervosa, bulimia nervosa, or eating disorder not otherwise specified) and had data available for the frequency of purging behaviors (n = 1,048). Axis I disorders, personality disorders, trait anxiety, perfectionism, and temperament and character dimensions were included as possible correlates. RESULTS: The presence of vomiting was associated with less regular laxative use, lower self-directedness, organization, personal standards, and higher novelty seeking. CONCLUSION: Vomiting remains a prevalent and potentially destructive symptom of eating disorders, with significant dental and medical morbidity. Our findings suggest that certain clinical and personality variables distinguish individuals with purging-type eating disorders who vomit from those who do not, although there were no marked differences in Axis I or II comorbidity. Specifically targeting treatment to decrease duration of exposure to this dangerous symptom continues to be an important clinical objective.     

Psychiatric comorbidity of eating disorders in men: a national study of hospitalized veterans

OBJECTIVE: This study examined eating disorders and their psychiatric comorbidity in a national sample of hospitalized male veterans. METHOD: Review of discharge summaries for 466,590 male patients from Veterans Affairs medical centers for fiscal year 1996 resulted in the identification of 98 men with a current ICD-9-CM diagnosis of an eating disorder. For the comorbidity analyses, eating disorder cases were matched with controls drawn randomly from the pool of male patients without an eating disorder, using age and race as matching variables. RESULTS: There was a high rate of comorbid substance use and mood disorder for men with anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS). Men with AN were also at high risk for comorbid schizophrenia/psychotic disorder, men with BN were at risk for comorbid personality disorder, and men with EDNOS were at special risk for comorbid organic mental disorder and schizophrenia/psychotic disorder. DISCUSSION: For each eating disorder, there was a distinct pattern of psychiatric comorbidity that deserves further study.     

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.     

Features associated with excessive exercise in women with eating disorders

OBJECTIVE: Excessive exercise and motor restlessness are observed in a substantial number of patients with eating disorders. This trait has been studied extensively among animal models of activity anorexia nervosa (AN) and may hold particular interest as an endophenotype for AN. We explored features associated with excessive exercise across subtypes of eating disorders. METHOD: Participants were female probands and affected female relatives from the multi-site international Price Foundation Genetic Studies with diagnoses of AN, bulimia nervosa (BN), and both AN and BN or eating disorder not otherwise specified (ED-NOS) (N=1,857). Excessive exercise was defined based on responses to the Structured Interview for Anorexic and Bulimic Disorders (SIAB). RESULTS: Among the eating disorder diagnostic groups, excessive exercise was most common among the purging subtype of AN. Individuals who reported excessive exercise also reported lower minimum BMI, younger age at interview, higher scores on anxiety, perfectionism, and eating disorder symptom measures, more obsessions and compulsions, and greater persistence. CONCLUSION: Excessive exercise may be associated particularly with the purging subtype of AN as well as with a constellation of anxious/obsessional temperament and personality characteristics among women with eating 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.     

Review of the prevalence and incidence of eating disorders

OBJECTIVE: To review the literature on the incidence and prevalence of eating disorders. METHODS: We searched Medline using several key terms relating to epidemiology and eating disorders and we checked the reference lists of the articles that we found. Special attention has been paid to methodologic problems affecting the selection of populations under study and the identification of cases. RESULTS: An average prevalence rate for anorexia nervosa of 0.3% was found for young females. The prevalence rates for bulimia nervosa were 1% and 0.1% for young women and young men, respectively. The estimated prevalence of binge eating disorder is at least 1%. The incidence of anorexia nervosa is 8 cases per 100,000 population per year and the incidence of bulimia nervosa is 12 cases per 100,000 population per year. The incidence of anorexia nervosa increased over the past century, until the 1970s. DISCUSSION: Only a minority of people who meet stringent diagnostic criteria for eating disorders are seen in mental health care.     

Season of birth and bulimia nervosa

OBJECTIVE: Previous studies suggest season of birth variation in eating disorders akin to those of psychoses. We studied season of birth variation in bulimia nervosa. METHOD: Season of birth variation in 935 patients was examined after adjustment for population trends. Variation was also examined for subgroups by age and previous anorexia nervosa. RESULTS: Season of birth did not differ significantly from population norms among bulimics (p >.30), contrasting with studies of other eating disorders. With a history of anorexia nervosa (n = 227), peak season of birth was in March (p <.05). This is consistent with previous studies and also with seasonal birth variation for psychoses. DISCUSSION: Overall, we find no evidence of season of birth variation in bulimia nervosa, and suggest any positive findings be treated with caution. We discuss a number of confounding influences and argue that one explanation remains shared trait vulnerability between anorexia nervosa and psychoses.     

Two-year prospective study of personality disorders in adults with longstanding eating disorders

OBJECTIVE: The current study had three objectives: to report the presence of personality disorders (PDs) in adults with longstanding eating disorders (EDs) at admission to inpatient treatment, and at 1 and 2-year follow-up; to compare the frequency of PDs in anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS); and to investigate whether recovered patients had lower frequency of PDs. METHOD: Seventy-four patients with a mean age of 30 years and long-lasting EDs were assessed with the Structured Clinical Interview for DSM-IV Axis-II disorders at admission to inpatient treatment, and at 1 and 2-year follow-up. RESULTS: At admission, 57 patients (77%) had one or more PDs, whereas 42 patients (57%) had one or more PDs at 2-year follow-up No statistically significant differences in frequencies of PDs among patients with AN, BN, and EDNOS were found. Recovered patients had a lower frequency of PDs (p < .01). DISCUSSION: At 2-year follow-up, there were substantial reductions in the frequency of PDs in patients with long-lasting EDs.     

Screening for eating disorders and high-risk behavior: caution

OBJECTIVE: The current study reviews the state of eating disorder screens. METHODS: Screens were classified by their purported screening function: identification of cases with (a) anorexia nervosa only; (b) bulimia nervosa only; (c) eating disorders in general; (d) partial syndrome, eating disorder not otherwise specified (EDNOS), or subclinical; (e) not a-d but at high risk. Information is presented on development, psychometric properties, and external validation (e.g., sensitivity, specificity, positive predictive values, and negative predictive values). RESULTS: Screens differ widely with regard to objective, psychometric properties and the validation methodology used. Most screens that identify cases are not appropriate for the identification of at-risk behaviors. Little data on the external validity of screens are available. DISCUSSION: Screens should be used with caution. A sequential procedure, in which subjects identified as being at risk during the first stage is followed by more specific diagnostic tests during the second stage, might overcome some of the limitations of the one-stage screening approach.     

Comorbidity of DSM-III-R eating disorders and personality disorders

The purpose of this study was to assess the relationship of eating disorders to personality disorders. Two hundred subjects were independently administered the Structured Clinical Interview for DSM-III-R (SCID) and the Personality Disorder Examination (PDE) face-to-face by two experienced clinicians. One hundred forty-six also completed the Personality Diagnostic Questionnaire-Revised (PDQ-R). Rates of personality disorder among patients with and without eating disorders were determined by each of the three instruments. Comorbidity between bulimia nervosa and anorexia nervosa and a conservative estimate of individual Axis II disorders was examined. Eating disorders with and without personality disorders were compared on age at onset and two measures of illness severity. Results indicate that the association, in general, between personality disorders and eating disorders varies by diagnostic method. Bulimia nervosa, however, is associated with borderline personality disorder and anorexia nervosa with avoidant personality disorder. Eating disorders with personality disorders are characterized by chronicity and low levels of functioning compared with eating disorders without personality disorders. © 1993 by John Wiley & Sons, Inc.     

Executive function in eating disorders: The role of state anxiety

Objective:

We examined the influence of depression and anxiety on executive function in individuals with a DSM‐IV diagnosis of anorexia nervosa‐restricting type, anorexia nervosa‐binge‐eating/purging type, bulimia nervosa, or eating disorder not otherwise specified.

Method:

We assessed 106 women after their inpatient treatment in an eating disorders program. All participants were nutritionally stable at the time of testing.

Results:

Thirty percent of the total sample showed impaired performance on one or more tests of executive function. No differences in executive function were observed among diagnostic groups. Anxiety scores accounted for significant variance in performance for all groups.

Discussion:

Executive function deficits were found in a minority of our sample, with significant variance in performance accounted for by self‐reported anxiety. State anxiety appears to contribute to diminished executive function in women with eating disorders. © 2013 by Wiley Periodicals, Inc. (Int J Eat Disord 2013)     

Prevalence of eating disorders in middle‐aged women

Objective: Little is known about the prevalence and correlates of eating disorders (ED) in middle‐aged women. Method: We mailed anonymous questionnaires to 1,500 Austrian women aged 40–60 years, assessing ED (defined by DSM‐IV), subthreshold ED, body image, and quality of life. We broadly defined “subthreshold ED” by the presence of either (1) binge eating with loss of control or (2) purging behavior, without requiring any of the other usual DSM‐IV criteria for frequency or severity of these symptoms. Results: Of the 715 (48%) responders, 33 [4.6%; 95% confidence interval (CI): 3.3–6.4%] reported symptoms meeting full DSM‐IV criteria for an ED [bulimia nervosa = 10; binge eating disorder = 11; eating disorder not otherwise specified (EDNOS) = 12]. None displayed anorexia nervosa. Another 34 women (4.8%; CI: 3.4–6.6%) displayed subthreshold ED. These women showed levels of associated psychopathology virtually equal to the women with full‐syndrome diagnoses. Discussion: ED appear common in middle‐aged women, with a preponderance of binge eating disorder and EDNOS diagnoses as compared to the “classical” diagnoses of anorexia and bulimia nervosa. Interestingly, middle‐aged women with even very broadly defined subthreshold ED showed distress and impairment comparable to women with full‐scale ED. © 2013 Wiley Periodicals, Inc. (Int J Eat Disord 2014; 47:320–324)