Early psychopathological signs in bulimia nervosa. A retrospective comparison of the period of puberty in bulimic and control girls

While bulimia nervosa (BN) typically begins in girls during late adolescence, puberty and associated developmental changes have been linked to negative body image and onset of a variety of psychological problems. This study aimed to identify early psychopathological signs, which could have marked the period of puberty in subjects whom later developed BN. In a case control study, we compared 49 girls with BN according to DSM-IV, aged between 18 and 20 years, to 49 girls of the same age, who were free of any past or current psychiatric diagnosis. Psychiatrists or clinical psychologists, using a semi-structured clinical interview including retrospective assessment of the emotional and behavioural changes that had occurred in puberty evaluated both groups. Before the onset of a clinical eating disorder, the subjects with BN presented significantly more often than controls weight related concerns, attitudes of withdrawal and social isolation, and negative changes in their body image and self-image, as well as in their relationships with siblings and peers. The results suggest that early psychological distress precedes the onset of an eating disorder in many cases, and that prevention efforts should be directed towards peripubertal psychopathology.

Alexithymia and depression in eating disorders

We compared alexithymia and depression ratings for non-hospitalized women meeting DSM-IV criteria for anorexia nervosa (n=32) and bulimia nervosa (n=32) to ratings for healthy women (n=74). Alexithymia was evaluated by the Toronto Alexithymia Scale (TAS-20) and depression by the Hospital Anxiety and Depression Scale (HAD). TAS and HAD scores were significantly higher in anorexic compared to bulimic patients, although these two scales were significantly and positively correlated (r=0.53, P=0.001). After taking depression into account as a confounding variable, rates of alexithymia did not vary according to the type of eating disorder (anorexia or bulimia).

Absence of cognitive impairment at long-term follow-up in adolescents treated with ECT for severe mood disorder

OBJECTIVE

Cognitive functions of adolescents treated with ECT for mood disorder were evaluated at long-term follow-up.

METHOD

At an average of 3.5 years (SD=1.7) after the last ECT, 10 subjects treated during adolescence with bilateral ECT for severe mood disorder completed a clinical and cognitive evaluation, including the California Verbal Learning Test and Squire's Subjective Memory Questionnaire. The same assessments were given to 10 psychiatric comparison subjects matched for sex, age, and diagnosis.

RESULTS

All cognitive test scores of the patients treated with ECT were similar to those of the comparison subjects and did not differ from norms from the community. Six of the 10 ECT-treated patients reported having had memory losses immediately after the ECT course, but only one complained of subjective memory impairment at follow-up.

CONCLUSIONS

The results suggest that adolescents given ECT for severe mood disorder do not suffer measurable cognitive impairment at long-term follow-up.

[Manic-depressive disorders in adolescence. Lithium treatment]

FIRST INTENTION PREVENTION: Lithium is the first intention preventive treatment for bipolar disorders. It the most effective choice in this indication and provides the most benefit for the patient, particularly the young patient still in the process of maturation.

SURVEILLANCE

Serum lithium must be monitored regularly. It is important for the clinician to be aware of different factors which can modify serum levels, including disease states or iatrogenic effects related to co-prescriptions. PATIENT INFORMATION: Long-term compliance and surveillance, and thus treatment efficacy, depend greatly on the quality of the information provided to the patient and his/her family.

[Manic-depressive conditions in adolescents. Epidemiological and clinical aspects]

EPIDEMIOLOGY CONTEXT: The prevalence of maniac depressive disorders is similar in adolescents and adults, i.e. about 1% with a 1:1 sex-ratio. Risk is higher in families with a diseased member and early episodes of mood disorders are probably correlated with the genotypic severity or the presence of a unique susceptibility gene. HIGHLY VARIABLE CLINICAL SIGNS: Until recent years, the highly variable clinical expression with rapid changes in mood, bipolar states, variable somatic, behavioral or addictive symptomatology, cognition disorders, and disturbed ideation or hallucinations, probably contributed to our poor understanding of juvenile forms of the disease. EARLY MANAGEMENT: Early diagnosis and psychiatric care is crucial due to the short-, mid- and long-term risk of unfavorable or even fatal consequences. Indeed, while still in the process of structuralization, the predisposed personality is particularly reactive to positive or negative events. It is most difficult to achieve flexibility once a restrictive organization of the personality has been installed. In addition, these families often have a painful past and lack sufficient capacity to successfully deal with the stress of emotions and conflicts occurring in the future adult during the self-identification and independence-seeking processes. This familial situation points out the importance of implicating the family and close friends in the treatment strategy as a complement to drug therapy and psychotherapy proposed to the adolescent.

Obsessive-compulsive symptoms as a correlate of severity in the clinical presentation of eating disorders: measuring the effects of depression

Obsessive-compulsive symptoms have been related to severity in the clinical presentation of eating disorders, whereas the impact of depression on the correlations between their severity and the severity of eating disorders has not been investigated. This paper assesses the effects of depression in 42 adolescent patients who met DSM-IV criteria for anorexia nervosa or bulimia nervosa by using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), the Eating Disorder Inventory (EDI) and the Beck Depression Inventory (BDI). The results indicate that patients who show elevated obsessionality and compulsivity on the Y-BOCS display a significantly higher degree of disturbed attitudes and behaviours concerning eating than patients with limited obsessionality and compulsivity. However, when the effects of depression are considered, all the differences found disappear. Our study suggests that depression is more directly associated with the severity of eating disorders than obsessive-compulsive symptoms and that the intensity of obsessive-compulsive symptoms in eating disorders is influenced by the intensity of depression. The relations between obsessive-compulsive symptoms, depression and eating disorders are not known. Even so this study highlights the importance of assessing depression when using obsessive and compulsive symptoms as a correlate of severity in the clinical presentation of eating disorders.

Bulimia nervosa and autoimmunity

The autoantibodies that react with dopamine and serotonin are of interest in the study of bulimia nervosa. These neurotransmitters play an important role in appetite control, sexual and social behavior, and stress responses, all of which form a part of the clinical picture of bulimia nervosa. Are these autoantibodies involved in the serotoninergic hypofunctioning present in bulimia nervosa? Are they a part of an immunity regulation system essential for the cerebral system's homeostasis? To address these questions, 31 bulimic females (diagnosed according to DSM-III-R criteria) were compared with 10 control subjects (matched to the patients for sex, age, and demographic/psychosocial features). Measurement of the activity of natural autoantibodies reacting with dopamine, dopamine-beta-hydroxylase and serotonin was performed by an enzyme-linked immunosorbent assay (ELISA) for typical immunoglobulins (IgG, IgM, IgA). All of the autoantibodies of the IgG type were lower in the bulimic group than in the control group, a difference that was statistically significant for IgG anti-serotonin and IgG anti-dopamine. There was a trend for the amount of IgM anti-dopamine to be lower in patients than in controls. Dopamine and serotonin are specific components of brain cells. It can therefore be hypothesized that these antigens acting with autoantibodies could be the antigenic cerebral targets reacting with 'anti-brain' antibodies. The study of these specific autoantibodies provides information about the immunological characteristics that may be related to brain disturbances.

[Eating disorders. Osteoporosis and infertility after anorexia nervosa]

EATING DISORDERS: The development of somatic complications observed in patients with eating disorders depends both on the duration of the clinical course and on the gravity of the symptoms and psychological factors. It would thus appear advisable to obtain a complete endocrine (gonadotropic, thyroid, hypothalamo-hypophyseal-adrenal) work-up which could be repeated every year after the patient has controlled the behavior disorder. Two aspects of these complications predominate: osteoporosis and infertility. OSTEOPOROSIS: A common finding after anorexia nevrosa, osteoporosis can lead to multiple, sometimes spontaneous, fractures. Bone mass can be assessed with biphotonic absorptiometry. The indication for estroprogestogen prophylaxis is debatable, depending on the patient's psychological profile, but also because efficacy has not always been demonstrated. Third-generation biphosphonates appear to offer promising results. INFERTILITY: Among a population of women consulting for infertility, a non-negligible percentage have infraclinical manifestations of anorexia nevrosa. The question of prescribing estroprogestogens, which would allow normal cycles and a certain vaginal trophicity, is often raised. We advocate a dose coordination between endocrinologists, infertility specialists and psychiatrists in order to better define the precise modalities of a given treatment aimed at regulating hypothalamo-pituitary function or favoring procreation.

[Eating disorders. Prepubertal anorexia nervosa]

AN UNCOMMON CONDITION: Anorexia nevrosa in the prepubertal period occurs more frequently in boys than common anorexia nevrosa and is characterized by rapid major weight loss more so than by signs of bulimia. ASSOCIATED SIGNS: Depression and volitional disorders are frequently observed together with growth retardation which portends poor prognosis. The patient's personal history (eating disorders during infancy are often found) is an essential factor together with psychiatric conditions in the parents who often have major narcissistic fragility.

[Eating disorders. Anorexia nervosa in adolescents]

EPIDEMIOLOGICAL DATA

Anorexia nevrosa is mainly observed in young women in the 15-24 year age range. The incidence is 1 to 2% in the general population of female adolescents. The sex ratio is 9 girls for 1 boy.

SYMPTOM TRIAD

Three symptoms predominate in anorexia nevrosa: weight loss, anorexia, amenorrhea. Weight loss results from restrictive eating behavior and not from a loss of appetite.

CLINICAL DIAGNOSIS

Diagnosis is clinical and confirmed by an analysis of the underlying psychological conflicts which involve difficulty in accepting the female identity and in assuming self-sufficiency outside the family. The clinician should evaluate the quality of the familial environment, particularly the mother-daughter and father-daughter relationship as well as the social environment (school, friends) which is also needed to apprehend the global situation. Physical examination and laboratory tests are aimed at rapidly eliminating any differential diagnosis and to quantify the weight loss and its rate, and identify any nutritional disorders.

ETIOLOGY

Anorexia nevrosa is not a truly structured psychopathological disorder but rather a loss of a stable organization of Self, with a highly vulnerable narcissistic element and precarious neurotic defences.

CLINICAL COURSE

The risk of poor outcome is very real, sometimes life threatening. The treatment of choice is to implement analytical management as soon as possible, but outside acute episodes.

[Suicidal behavior and borderline states in adolescence. Thoughts on a dependence problem]

The process of self destruction in suicidal behavior for borderline patients seems to have a breaking function of filiation which has to live in mortify parental desire- or non-desire, both of them reflect a lack of investment. It tries to reach a part of the adolescent's body, figuration place of filial alienation, neither in a death desire, but in will rebirth.

[Bulimia and autoimmunity]

In the first part of this study, we investigated the rate of natural autoantibodies, in a sample of 31 female inpatients with bulimia nervosa according to DSM III-R criteria. The control (age and sex matched) group consisted in high school students including 10 females without eating disorders, depressive disorder or immunological disease. We investigated especially natural autoantibodies reacting with compounds of the central nervous system (Dopamine, Dopamine beta Hydroxylase, Serotonin). Our first conclusion is that there is a lower level of these natural auto-antibodies among female patients with bulimia nervosa. In the second part of the study, we have especially investigated the correlation between impulsivity in bulimia nervosa and the rate of natural autoantibodies against serotonin.

[Manic-depressive psychoses in adolescence. Influence of life change events. Study of family dynamics]

A sample of 38 adolescents hospitalized for a major depressive episode melancholic type or a manic episode during the course of a bipolar disorder (according to the DSM III-R Criteria) was examined with particular emphasis on precipating life events and family relationships. Psychosocial stressors in the year preceding onset of the affective disorder were found in a very high proportion of cases (about 80%). Stressors are most often severe. All of these stressors have to do with loss or threat of loss, particularly the most frequent one: the sentimental failure. Analyzing results of a familial dynamic questionnaire, we showed in the MDD sample the prevalence of two psychopathological index: maternal rejection, parental dysharmony.

[Pharmacologic treatment of bulimia]

The rationale for pharmacological treatment of bulimia nervosa is summarized and a review of controlled therapeutic trials shows contradictory results. A number of antidepressant agents (tricyclics: imipramine, desipramine, amitriptyline; IMAO: phenelzine, isocarboxazide; trazodone; fluoxetine) appear more effective than placebo in double-blind controlled trials of 6 to 16 weeks. In similar studies, other antidepressants (mianserine, fluvoxamine) are ineffective. Improvement reported is often incomplete and the low percentage of patients totally abstinent at the end of treatment appears of poor pronostic value for long-term outcome. Methodological limitations of existing studies are discussed, and some psychopathological factors to consider in the assessment of therapeutic response are proposed.

Therapeutical management of depression during adolescence

Our model of reference remains essentially the psychoanalytic theory of psychic functioning which has permitted us to have a general outlook on the individual: taking into account the genetic and biological aspects of mental functioning, cognitive capacities, requirements concerning learning, as well as the role of affectivity such as is organized through interactions with the environment throughout the patient's life. We suggest that the therapeutical management of depression in adolescence is related to the psychopathology of the patient, especially when there are narcissistic dimensions.