Relationship of depression, anxiety, and obsessionality to state of illness in anorexia nervosa

OBJECTIVE

Depression, anxiety, and obsessionality frequently are present in underweight, malnourished patients with anorexia nervosa. It is less certain if these symptoms persist after recovery. Thus, we assessed these symptoms in anorexic women at three states of illness (underweight, short-term weight restored, and long-term weight restored) in comparison to a group of healthy women.

METHOD

We used standardized self- and trained rater instruments to assess depression (Hamilton Depression Rating Scale and Beck Depression Inventory), anxiety (Spielberger State-Trait Anxiety Inventory and Hamilton Anxiety Rating Scale), and obsessions and compulsions (Yale-Brown Obsessive Compulsive Scale).

RESULTS

A similar pattern was found for all symptoms. That is; scores for depression, anxiety, and obsessionality were most elevated in the underweight state. These symptoms improved with weight restoration. However, milder but significantly elevated symptoms persisted in long-term weight-restored anorexic women compared to healthy control women.

DISCUSSION

These data suggest that malnutrition intensifies the severity of depression, anxiety, and obsessionality in anorexia nervosa. However, the fact that mild to moderate symptoms persisted after long-term weight restoration raises the possibility that such behaviors are related to the pathogenesis of this illness.

Treating eating-disorder patients in a managed care environment. Contemporary American issues and Canadian response

This article addresses the effect of managed care on the treatment of eating disorders. We review strategies for negotiating limitations that managed care reviewers place on treatment. Finally, this article reviews the experiences of a Canadian program that has 10 years of experience in providing low-cost day treatment. While change is frustrating and difficult, it is inevitable and can be rejuvenating. These changes offer opportunities for creative development of quality low-cost care. If we do not adjust to these conditions, patients will not get treatment that they need.

Bulimia nervosa and substance dependence: association and family transmission

Alcohol and drug use disorders are common among women with bulimia nervosa (BN) and their family members. However, it is not known whether there is a familial relationship between BN and substance use disorders. We compared 47 women with BN and 44 non-eating-disordered community control women, and their first-degree relatives (177 and 190, respectively). BN probands were stratified by the presence (43%) or absence (57%) of lifetime alcohol and/or drug dependence. The first-degree relatives of substance-dependent BN probands had significantly higher lifetime rates of alcohol/drug dependence (38%), compared with relatives of nonsubstance-dependent BN probands (10%) or relatives of community controls (18%). These data suggest that BN and substance dependence are transmitted independently in families.

Comparison of obsessions and compulsions in patients with anorexia nervosa and obsessive compulsive disorder

Patients with anorexia nervosa (n = 18) and patients with obsessive-compulsive disorder (OCD) (n = 16) had similar scores on the Yale-Brown Obsessive Compulsive Scale (19 + or - 9 vs. 22 + or - 6). This suggests that these disorders have similar magnitude of impairment from obsessions and compulsions; however, OCD patients endorsed a wide variety of obsessions and compulsions, whereas anorexics tended to endorse symptoms that were related to symmetry and order.

Neuropeptide abnormalities in anorexia nervosa

Starvation-induced alterations of neuropeptide activity probably contribute to neuroendocrine dysfunctions in anorexia nervosa. For example, CRH alterations contribute to hypercortisolemia and NPY alterations may contribute to amenorrhea. Alterations of these peptides as well as opioids, vasopressin, and oxytocin activity could contribute to other characteristic psychophysiological disturbances, such as reduced feeding, in acutely ill anorexics. Such neuropeptide disturbances could contribute to the vicious cycle that has been hypothesized to occur in anorexia nervosa. That is, the consequences of malnutrition perpetuate pathological behavior.

Short-term neuroendocrine effects of a large oral dose of monosodium glutamate in fasting male subjects

Fasting male subjects received each of four treatments on different days: a large oral dose of monosodium L-glutamate (MSG; 12.7 g), the MSG vehicle, an iv injection of TRH, or a high protein meal. Blood samples were drawn via an indwelling venous line before and at 20-min intervals after each treatment for 4 h. Plasma glutamate levels rose 11-fold within 1 h of MSG ingestion, but did not change appreciably with any of the other treatments. Plasma PRL levels rose 10-fold after TRH infusion and 2-fold after the protein meal, but did not rise significantly after MSG ingestion. No effects resulted from any of the treatments on plasma LH, FSH, testosterone, GH, or cortisol concentrations. Plasma levels of TSH, T4, and T3 showed minimal changes after any of the treatments except TRH; TRH elevated plasma TSH and T3 levels. Self-rating instruments of mood and side-effects revealed no treatment-related effects on mood or physical state for up to 48 h after each treatment. Together, these results suggest that acute pharmacological elevations of plasma glutamate levels in adult men produce minimal, if any, effects on hypothalamic or pituitary function.

Persistent perfectionism, symmetry, and exactness after long-term recovery from anorexia nervosa

OBJECTIVE

It is well recognized that patients with anorexia nervosa have perfectionistic and obsessive behaviors. This study investigated whether such behaviors persist after recovery.

METHOD

Twenty subjects who had recovered from anorexia nervosa were recruited for the study. They had been at normal weight and their menses had been regular for more than a year. These subjects were compared with 16 healthy women with the use of the Eating Disorder Inventory, the Frost Multidimensional Perfectionism Scale, and the Yale-Brown Obsessive Compulsive Scale.

RESULTS

The recovered anorexic patients had significantly higher scores than the comparison women on the measures of perfectionism on the Eating Disorder Inventory and on overall perfectionism on the Frost scale. Moreover, the recovered patients had higher scores on the Yale-Brown scale, with target symptoms suggesting that many had specific concerns with symmetry and exactness.

CONCLUSIONS

Certain characteristics of anorexia nervosa, such as a need for order and precision, persist after good outcome and recovery, raising the question of whether these behaviors are traits that contribute to the pathogenesis of this illness.

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.

Acute tryptophan depletion and increased food intake and irritability in bulimia nervosa

OBJECTIVE

Data suggest that serotonin activity is reduced in women at normal weight who have bulimia nervosa. The authors tested whether acute perturbations in serotonin activity could alter short-term eating behavior and mood.

METHOD

They examined the effect of acute tryptophan depletion in 10 women with and 10 women without bulimia nervosa.

RESULTS

Women with bulimia nervosa exhibited an increase in caloric intake and mood irritability after acute tryptophan depletion.

CONCLUSIONS

These results indicate that women with bulimia nervosa have an exaggerated or pathological response to transient alterations in serotonin activity.

Low discharge weight and outcome in anorexia nervosa

OBJECTIVE

Because recent limitations in health care coverage have resulted in shorter lengths of inpatient stay, many patients with anorexia nervosa are discharged while still underweight. The authors' goal was to determine whether anorectic patients who were underweight when they were discharged had a worse outcome and a higher rate of rehospitalization than those who had achieved normal weight at discharge.

METHOD

They assessed weight and height, eating disorder symptoms, and severity of depressive and anxiety symptoms in 22 women with anorexia nervosa at hospital admission and at follow-up a mean of 29 months after discharge.

RESULTS

Anorectic patients who were discharged while severely underweight reported significantly higher rates of rehospitalization and endorsed more symptoms than those who had achieved normal weight before discharge.

CONCLUSIONS

These data suggest that brief hospitalization for severely underweight women with anorexia may not be cost effective because the majority are rehospitalized.

Perfectionism in anorexia nervosa

Although it is well accepted that most patients with anorexia nervosa are perfectionistic, little work has been done in characterizing this behavior. Anorexics were assessed by two new multidimensional instruments that were designed to measure multiple aspects of perfectionism. Both scales confirm that underweight, malnourished patients with anorexia nervosa are perfectionistic. Importantly, elevated perfectionism scores, persisted after weight restoration. Anorexics experienced their perfectionism as self-imposed, and not as a response to other's expectations. Perfectionism is a dimension of the rigid, obsessive behaviors that may contribute to resistance to treatment and relapse in anorexia nervosa. Thus, these scales may be of value in assessing response to treatment.

Differences in weight gain between restrictor and bulimic anorectics

After admission for weight restoration, restrictor anorectics (n = 17) gained significantly less weight than bulimic anorectics (n = 17) in a 30-day period. However, these groups had similar caloric intake. Severity of illness was found to be a predictor of rate of weight gain for restrictor anorectics, but not for bulimic anorectics.

Premorbid onset of psychopathology in long-term recovered anorexia nervosa

It is recognized that patients with anorexia nervosa commonly have other psychiatric illnesses. No study, to our knowledge, has determined whether these other psychiatric disorders occur prior to the age of onset of anorexia nervosa. We obtained a retrospective history from 24 subjects who were long term (more than 1 year) recovered from anorexia nervosa. We found that 58% reported that they had the onset of one or more childhood anxiety disorder diagnoses at the age of 10 +/- 5 years old. This was 5 years before the mean age of onset of anorexia nervosa. The onset of depression was about 1 year before the onset of anorexia nervosa in about one half the subjects. Alcohol and substance abuse/dependency tended to occur after the onset of anorexia nervosa and only occurred in anorexic subjects who binged and/or purged. The early and common onset of childhood anxiety disorders in a substantial percentage of anorexics raises the possibility that childhood anxiety disorders herald the first behavioral expression of a biologic vulnerability in some subjects who develop anorexia nervosa.

Temperament in eating disorders

This study examined dimensional personality and temperamental characteristics in women with eating disorders. Clinical symptoms, personality, and temperament were examined in 30 women with anorexia nervosa (AN), 32 women with bulimia nervosa with no history of anorexia nervosa (BN), and 20 women with comorbid anorexia and bulimia nervosa (AB). Temperament differed markedly across the groups on the Tridimensional Personality Questionnaire (TPQ) with AN women showing greater reward dependence, BN women scoring higher on novelty seeking subscales, and AB women showing high harm avoidance. The TPQ subscales also displayed higher classification accuracy than other personality and symptom measures. Temperamental features are distinct across eating disorder subtypes. Temperament could reflect differential vulnerabilities for the development of specific eating disorder symptom clusters.

Laxative withdrawal and anxiety in bulimia nervosa

Symptoms of anxiety can be prominent during treatment of bulimia nervosa. Our experience is that bulimics who abuse laxatives have the most prominent symptoms of anxiety. We conducted ratings of anxiety in 23 bulimics who purge with laxatives and 17 who purge by vomiting. We found that the laxative-abusing group had higher levels of state but not trait anxiety and that they were more likely to be treated with medication for anxiety during hospitalization. These data suggest an association between laxatives and anxiety in bulimia nervosa.

Perfectionism in anorexia nervosa

Although it is well accepted that most patients with anorexia nervosa are perfectionistic, little work has been done in characterizing this behavior. Anorexics were assessed by two new multidimensional instruments that were designed to measure multiple aspects of perfectionism. Both scales confirm that underweight, malnourished patients with anorexia nervosa are perfectionistic. Importantly, elevated perfectionism scores, persisted after weight restoration. Anorexics experienced their perfectionism as self-imposed, and not as a response to other's expectations. Perfectionism is a dimension of the rigid, obsessive behaviors that may contribute to resistance to treatment and relapse in anorexia nervosa. Thus, these scales may be of value in assessing response to treatment.

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.

Twenty-four-hour food intake in patients with anorexia nervosa and in healthy control subjects

Ad libitum feeding over 24 hours was assessed in underweight restrictor anorectic (RAN) women (n = 8) and matched healthy control subjects (n = 9) in a relatively naturalistic laboratory setting. RAN consumed 828 +/- 210 kcal/day (20 +/- 6 kcal/kg/day); controls ingested 2274 +/- 564 kcal/day (41 +/- 13 kcal/kg/day). Expressed as macronutrient consumption, RAN, compared to healthy controls, ate less fat (13% vs 31%), more carbohydrate (73% vs 57%), and similar amounts of protein (14% vs 12%). RAN initiated fewer eating episodes than controls (4 vs 7). This study quantitatively confirms the growing body of evidence suggesting that RAN avoid fat-containing foods. Such persistent fat avoidance may significantly contribute to the difficulty RAN experience in gaining and maintaining body weight.

Defense style in women with eating disorders

A relatively new instrument, the Defense Style Questionnaire (DSQ), represents an efficient method by which to quantify an individual's psychological defense style. We administered the DSQ to 66 women hospitalized for anorexia nervosa, bulimia nervosa, or concurrent anorexia and bulimia nervosa. Contrary to our expectations, there were no consistent patterns of identifiable defense styles specific to these groups in qualitative, univariate, and multivariate analyses. The failure of the DSQ to demonstrate specificity across eating disorder subgroups suggests it is not informative in regard to the pathogenesis of these specific syndromes. In contrast, in a previous study, we found temperamental measures to be informative.

Acute tryptophan depletion in bulimia: effects on large neutral amino acids

Acute tryptophan depletion, which may reduce brain serotonin synthesis in humans, was evaluated in bulimic and normal subjects assessing its effects on the plasma ratio of tryptophan to the sum of the other large, neutral amino acids (TRP/sigma LNAA). Thirteen bulimic and 9 control women ingested an amino acid mixture containing either 2.3 g (control mixture) or 0 g of tryptophan (active mixture), in combination with 100 g of the other amino acids. Six healthy male volunteers were also studied, using a similar mixture containing 4.6 g of tryptophan. Bulimic and control women both experienced sizable reductions in the plasma TRP/sigma LNAA ratio, compared to baseline values, for both the active mixture (10% of baseline) or the control mixture (45% of baseline). For bulimic women, the active mixture produced a significant increase in fatigue and a trend toward increased anxiety and indecisiveness. The control mixture did not maintain baseline TRP/sigma LNAA ratios so we identified a control amino acid mixture that does not cause a drop in the plasma TRP/sigma LNAA ratio when ingested (4.6 g tryptophan in combination with 100 g of other amino acids). An oral, tryptophan-deficient amino acid mixture produced acute, substantial reductions in the plasma TRP/sigma LNAA ratio in all subjects, suggesting that the treatment should reduce brain tryptophan uptake and serotonin synthesis. A control mixture containing tryptophan was also identified that maintains the plasma TRP/sigma LNAA ratio at pretreatment values.

Characteristics of bulimic women with and without alcohol abuse

We compared the characteristics of hospitalized women with bulimia nervosa alone (N = 19) and with bulimia nervosa plus alcohol abuse (N = 13) using standard measures of depression, eating disorders, general psychiatric symptomatology, and temperament. Bulimic women with alcohol abuse had significantly higher lowest past weight, but did not differ from women with bulimia alone on age, age of onset of bulimia, current weight, and highest past weight. There were no differences in clinical symptoms of bulimia, depression, or general psychiatric symptomatology. On Cloninger's Tridimensional Personality Questionnaire (TPQ), bulimic women with alcohol abuse scored significantly higher on Total Novelty Seeking, on the Novelty Seeking Subscale Disorderliness, and on the Reward Dependence Subscale Attachment. Implications for understanding the relation between bulimia and substance abuse are discussed.

Prediction of reproductive status in women with bulimia nervosa by past high weight

It is not understood why disturbed menstrual function occurs in as many as 50% of women with bulimia nervosa who are at normal weight. The authors measured luteinizing hormone (LH), estradiol, and progesterone in 13 women with bulimia nervosa who were at normal weight and six normal comparison subjects. They found that the women with bulimia nervosa were likely to have abnormal 24-hour luteinizing hormone (LH) secretion if their current weight was less than 85% of their past high weight.

Cerebrospinal fluid TRH immunoreactivity in anorexia nervosa

Central nervous system (CNS) thyrotropin-releasing hormone (TRH) activity is of interest in patients with anorexia nervosa. First, anorexics have peripheral thyroid abnormalities that appear to be related to weight and nutritional status. Second, CNS TRH activity may effect many other physiologic systems that are known to be disturbed in patients with anorexia nervosa. We found that anorexic patients, when both underweight and studied after attaining goal weight, had significantly reduced CSF TRH concentrations in comparison to controls. These data suggest that weight gain or increased caloric intake, in contrast to its large effect on peripheral thyroid function, has relatively little effect on CNS TRH activity. The reason for reduced CSF TRH in goal weight anorexics is not known but could be trait related, a persistent defect slow to normalize after weight gain, or related to these patients still being at a weight lower than controls. Finally, in terms of CSF TRH concentrations, this study suggests that anorexia nervosa has a different pathophysiology than major depressive disorder.