Suicide and attempted suicide in eating disorders, obesity and weight-image concern

Suicide in anorexia nervosa and bulimia nervosa is a major cause of death. Meta-analyses have shown that individuals suffering from anorexia nervosa and bulimia nervosa commit suicide more often than their counterparts in the general population; also a few studies have suggested that suicide is the major cause of death among patients with anorexia nervosa, refuting the assumption that inanition generally threatens the life of these patients. Data concerning suicide in bulimia nervosa, on the other hand, are still scarce but suicide attempts are easily found among cohorts of patients with bulimia nervosa, which constitutes a risk factor for completed suicide. Suicidality in obesity and individuals with disturbed weight status has been reported. Both in the case of bulimia nervosa and obesity more long-term follow-up studies need to be completed before the risk of suicide for such disorders may be compared with that for anorexia nervosa.     

Suicide in anorexia nervosa: a meta-analysis

OBJECTIVE: Suicide is a major cause of death among subjects with anorexia nervosa, but the rate of suicide among this population is very often underestimated. We conducted a meta-analysis to compare data reported in representative studies of suicide in anorexia nervosa with data for the general population. METHOD: We searched the Index Medicus until 2002 through MedLine. We also searched the World Health Statistics Annual to ascertain the suicide rate in the age group 14-25 for specific years and country. RESULTS: We selected nine studies comprising 1,536 patients. Of these patients, 36 committed suicide. Results obtained for each study were processed together to calculate the mean figure for each year of suicides for 100,000 individuals suffering from anorexia nervosa. DISCUSSION: Our meta-analysis shows that suicide among patients with anorexia nervosa is more frequent when compared with the general population. All study analyses, except one, reported that the patients with anorexia nervosa committed suicide more often than their counterparts in the general population.     

The current status of treatment for anorexia nervosa and bulimia nervosa

A survey investigating the current status of treatment for anorexia nervosa and bulimia nervosa was distributed at the International Conference on Eating Disorders in 7988 and again in 1990. Respondents answered questions regarding treatments they had endorsed for their last patient with anorexia nervosa and for bulimia nervosa. One hundred and seven medical doctors and psychologists completed the survey in 1988 and 115 in 1990. The results indicate that: (1) less than 50% of the respondents believe there is a consensus regarding the treatment of eating disorders; (2) talking therapy is overwhelmingly endorsed for the treatment of both anorexia and bulimia nervosa; (3)there is a trend in clinical practice towards using drug therapy more frequently in treating patients with bulimia nervosa than in treating patients with anorexia nervosa; (4)physicians are more likely than psychologists to endorse drug therapy when treating patients with anorexia and for bulimia nervosa; and (5) about one third of the respondents endorse drug therapy for treating anorexia nervosa. © 1992 John Wiley & Sons, Inc.     

Taste function in patients with anorexia nervosa and bulimia nervosa

The sensitivity to sucrose, sodium hydrochloride, tartrate, and quinine was examined by a filter paper disc method in patients with anorexia nervosa and with bulimia nervosa. There were 20 of the 23 anorexia patients and 11 of the 13 bulimic patients who showed hypogeusia. There were 12 of the 23 anorexia patients and 8 of the 13 bulimia patients who showed dysgeusia. Seven anorexia patients were restudied when the treatments produced a weight gain to more than 85% of normal body weight. Taste function had improved substantially in all but still was subnormal. Serum zinc, iron, and triiodothyronine levels in these patients were depressed; however, none of these levels correlated with the taste recognition scores or dysgeusia scores. In conclusion, patients with anorexia nervosa and bulimia nervosa showed hypogeusia and/or dysgeusia, although the etiology of the taste dysfunction in these patients remains to be determined. These findings should be considered in the implications for treating these patients.     

Cognitive style of patients with anorexia nervosa and bulimia nervosa

Nine female patients with anorexia nervosa and 7 female patients with bulimia nervosa were assessed on the Matching Familiar Figures Test (MFFT). This study found that subjects with bulimia nervosa responded more quickly than did the anorexic subjects. Results such as these suggest that not only are bulimic patients more behaviorally impulsive than anorexic patients, they are also more cognitively impulsive. Patients with anorexia nervosa in contrast seemed to display a reflective cognitive style. Extreme cognitive styles may contribute to resistance in treatment and/or relapse in anorexia or bulimia nervosa. © 1995 by John Wiley & Sons, Inc.     

Changes in creatinine clearance during treatment of anorexia nervosa and bulimia nervosa

The improvement in renal clearance of creatinine in anorexia nervosa patients during treatment has been attributed to the increase in body weight. The body weight and creatinine clearance of 72 anorexia nervosa and 10 bulimia nervosa patients were studied during inpatient treatment. The anorexia nervosa patients gained an average of 4.5 kg, while the body weight of the bulimia nervosa patients was unchanged. Both groups showed a similar increase in weight-corrected creatinine clearance. The increase in creatinine clearance of eating disorder patients is associated with the cessation of the abnormal weight-controlling behaviors rather than weight gain.     

Is anorexia nervosa associated with elevated rates of suicide?

OBJECTIVES: The purpose of this study was to ascertain whether individuals with anorexia nervosa are more likely to commit suicide, as suggested by previously noted associations between anorexia nervosa and mood disorders. METHODS: Data from death records representing over 5 million women were examined, yielding 571 cases in which anorexia nervosa was mentioned as an existing condition. The women with anorexia were compared with 1713 control subjects matched for age, sex, and race. RESULTS: The percentage of suicides among those listed as having anorexia nervosa was only 1.4%, compared with 4.1% for the controls. CONCLUSIONS: These findings suggest that the suicide rate is not elevated among individuals currently suffering from anorexia nervosa.     

Gastric inhibitory polypeptide (GIP) in anorexia nervosa

Simultaneous glucose, insulin, and gastric inhibitory polypeptide (GIP) responses to meal stimulation were measured in five anorexia nervosa patients, eight bulimia patients with a past history of anorexia nervosa, and twenty-two healthy subjects. Although basal levels of GIP were similar, anorexia nervosa patients had an early and significantly higher (p <.05) mean peak GIP response than controls or bulimics with past anorexia nervosa. Mean peak insulin levels in anorexia nervosa patients did not differ significantly from those of control or bulimia/past anorexia nervosa patients, although anorexia nervosa patients had a nonsignificantly prolonged elevation of serum insulin. Glucose responses were not significantly different among the various groups. The exaggerated CIP response to meal stimulation with no significant difference in insulin levels suggests that the usual association between insulin and GIP is altered in anorexia nervosa. This is apparently a state-dependent abnormality since GIP responses in bulimia patients with a history of anorexia nervosa do not differ from healthy subjects. Altered GIP responses may contribute to the gastric hypomotility and acid secretion changes previously reported in low-weight anorexia nervosa patients.     

Body images in anorexia nervosa and bulimia nervosa

This study extends earlier research on body image disturbance in anorexia nervosa to the reactions of patients with bulimia nervosa. “Natural” procedures were employed, and normal comparison groups as well as those with anorexia nervosa or bulimia nervosa used adjective scales to rate “the self,” mirror images of themselves that were veridical, exaggerated for fatness or for thinness and adjusted to their ideal, and a television image they had adjusted to show how they feel and then how they think their body is. The different adjustments and ratings that were made in each condition question the validity of any single estimates of body size. Nevertheless, this multimethod approach to the cognitive and affective components of body image shows that those with anorexia nervosa and bulimia nervosa consistently emphasize their feelings of fatness.     

Racial and socioeconomic: Influences in anorexia nervosa and bulimia

Eight black and 120 white patients with anorexia nervosa or bulimia were compared with each other and with 21 black control patients. Biack and white patients with eating disorders were similar in demographic features (except for later age of onset in blacks), in clinical characteristics, and in course of illness. Both racial groups with eating disorders had a significantly higher socioeconomic status than control patients. A diagnosis of anorexia nervosa or bulimia can be confidently made independent of racial designation. Socioeconomic status appears to be a risk factor for development of anorexia nervosa or bulimia in both black and white populations.     

The role of pharmacotherapy in anorexia nervosa and bulimia

The purpose of this article is to review the basic pharmacology and the role of drugs that are used to treat anorexia nervosa and bulimia. The pharmacological treatment of eating disorders is based upon theoretical principles. The theoretical models include: (a) an illness secondary to other psychiatric disorders, (b) a disorder in the hypothalamic control of food intake, (c) a disorder of hypothalamic endocrine regulation, (d) a syndrome secondary to depressive illness, and (e) a disorder in the hypothalamic regulation of food intake. Theoretical models a, b, and c govern the choice of drug therapy for anorexia nervosa, and models d and e govern the choice of drug therapy for bulimia. Drugs used to treat anorexia nervosa and bulimia include tricyclic antidepressants and lithium carbonate. Chlorpromazine, metoclopramide, cyproheptadine, and clomiphene citrate have also been prescribed for the treatment of anorexia nervosa. Monoamine oxidase inhibitors are commonly prescribed to treat bulimia. Fenfluramine has the potential to be of therapeutic value in patients with bulimia. Although drug therapy plays a limited role in the treatment of eating disorders, drugs are commonly prescribed. Therefore, the nutritionist should be familiar with the basic pharmacology and the side effects related to drug therapy.     

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

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

Subtyping of bulimia nervosa

Several possible ways of subtyping bulimia nervosa are discussed. Two possibilities, subtyping bulimia nervosa by presence or absence of a history of anorexia nervosa or presence or absence of a history of obesity, both represent interesting approaches, but there is inadequate data to support either as a subclassifying system at this point. There is considerable interest in requiring purging behavior for the diagnosis of bulimia nervosa, or for subtyping bulimia nervosa into purging vs. non-purging types. Also the issue of bow to classify over-weight bulimic individuals by DSM-Ill-R criteria who do not purge remains controversial.     

Perception of hunger and satiety induced by 2-deoxy-D-glucose in anorexia nervosa and bulimia nervosa

The effect of intracellular glucopenia induced by 2-deoxy-D-glucose (2-DG) on changes in hunger ratings, blood glucose, plasms cortisol, and prolactin levels were examined in six female patients with primary anorexia nervosa, three patients with bulimia nervosa, and six age-and sex-matched volunteers. In the normal subjects, hunger ratings obtained by the linear visual analog technique increased significantly at 60 minutes after 2-DG infusion and remained elevated. In Patients with anorexia nervosa, however, hunger ratins paradoxically decreased significantly at 90 minutes. In normal subjects, the ingestion of a 20-minute lunch relieved hunger, but neither the anorexic patients nor bulimic patients felt satiety even after food intake. These results suggest that the perception of hunger induced by 2-DG in anorexia nervosa and that of satiety in anorexia nervosa and bulimia nervosa are disturbed.     

The psychiatric history of anorexia nervosa and bulimia nervosa: Weight concerns and bulimic symptoms in early case reports

British, French, American, German, and Italian historical medical reports on possible cases of anorexia nervosa and bulimia nervosa were critically reevaluated in order to trace the history of weight concerns, binge eating, and methods of food reversal like self-induced vomiting in these texts. It is argued that weight concerns are a new phenomenon in prolonged extreme fasting and has superseded traditional ascetic motivations for fasting from the first use of the term anorexia nervosa on. Binge eating, or bulimia as a symptom, on the other hand, has been known ever since ancient times; what is new here is its combination with methods of food reversal, which are motivated by concerns about weighing too much. This combination, bulimia nervosa (DSM-III-R), was first described in cases of primary anorexia and started becoming more frequent only in the 1940s. First accounts of possible cases of bulimia nervosa at normal body weight were published in the 1930s. Methodological problems of retrospective diagnosing and factors inherent to the history of medicine which might have influenced the history of medical writing about eating disorders are discussed.     

Oscillatory instability of body weight in alternating anorexia nervosa and bulimia nervosa

The present study was undertaken to clarify the longitudinal course, from adolescence to the age of 40, of weight fluctuations in a woman with alternating anorexia nervosa and bulimia nervosa. Although it has long been appreciated that a single person may fluctuate between states of binge eating and obesity on the one hand, and starvation on the other, few data exist regarding the nature and mechanism of this interrelationship. As opposed to the gradual linear increase in weight normally observed in human beings from early adulthood through middle-age, our patient with alternating bulimia nervosa and anorexia nervosa showed chronic weight oscillation of great magnitude. However, her weight oscillations were periodic, as opposed to chaotic, and oscillated around her ideal body weight of 137 pounds. Moreover, the frequency of major weight changes increased with time. It is possible that a fundamental dysregulation of the hypothalamic feeding apparatus, wherein the normal homeostatic system loses its stability so that periodic oscillatory behavior results, unites the syndromes of anorexia and bulimia nervosa in the same individual. Finally, the pathological weight dynamics observed in this case show similarities to the phenomenology and course of bipolar affective disorders.     

Metabolic changes in the brain of patients with anorexia and bulimia nervosa as detected by proton magnetic resonance spectroscopy.

OBJECTIVE: To investigate the brain of patients with anorexia and bulimia nervosa by localized proton magnetic resonance spectroscopy (1H-MRS) and to look for metabolic alterations. METHOD: Twenty patients with anorexia and bulimia nervosa were investigated by magnetic resonance imaging (MRI) and 1H-MRS in three regions of the brain. Age and sex-matched healthy subjects were investigated as controls. RESULTS: 1H-MRS revealed metabolic changes, such as a significant decrease of both myo-inositol and lipid compounds within the frontal white matter. The concentration of these compounds was further reduced with decreasing body mass index. Reduced lipid signals were also found in the occipital gray matter. In the cerebellum, the concentration of all metabolites including water, except lipids, was increased. DISCUSSION: The metabolic changes found in this study seem to be a consequence of nutritional deficiency. It has to be further investigated whether these findings have any relevance for brain function. 1H-MRS might serve as a valuable investigative tool to observe eating disorders as anorexia and bulimia nervosa and to follow the success of therapy.     

Excessive exercise in anorexia nervosa and bulimia nervosa: relation to eating characteristics and general psychopathology

OBJECTIVE: Excessive exercise is a well-known phenomenon in anorexia nervosa, but less is known about its role in bulimia nervosa. In addition, there is little evidence regarding the psychopathological processes that might act as predisposing, triggering, or maintaining factors for such exercise. The present study examined the presence of excessive exercise in different women with eating disorders, and its psychopathological correlates. METHODS: Case notes from 63 anorexia nervosa and 61 bulimia nervosa patients were examined. Two-way multivariate analyses of variance (diagnosis x use of excessive exercise) were used to determine the impact of the two factors upon eating characteristics (EAT-40 and BITE) and psychopathological symptoms (SCL-90-R). RESULTS: While high levels of depression were more likely among all patients who used excessive exercise, levels of anxiety and somatization were particularly high only among those anorexics who exercised excessively. DISCUSSION: Possible explanatory models are advanced to account for this pattern of findings, focusing on the possible use of exercise as an affect regulation strategy among anorexia nervosa patients. Further research is suggested to test and develop this model, and possible clinical implications are outlined.     

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.