How should DSM-V classify eating disorder not otherwise specified (EDNOS) presentations in women with lifetime anorexia or bulimia nervosa?

OBJECTIVE

Anorexia nervosa (AN) and bulimia nervosa (BN) are marked by longitudinal symptom fluctuations. DSM-IV-TR does not address how to classify eating disorder (ED) presentations in individuals who no longer meet full criteria for these disorders. To consider this issue, we examined subthreshold presentations in women with initial diagnoses of AN and BN.

METHOD

A total of 246 women with AN or BN were followed for a median of 9 years; weekly symptom data were collected at frequent intervals using the Longitudinal Interval Follow-up Evaluation of Eating Disorders (LIFE-EAT-II). Outcomes were ED presentations that were subthreshold for 3 months, including those narrowly missing full criteria for AN or BN, along with binge eating disorder (BED) and purging disorder.

RESULTS

During follow-up, most women (77.6%) experienced a subthreshold presentation. Subthreshold presentation was related to intake diagnosis (Wald chi2=8.065, df=2, p=0.018). Individuals with AN most often developed subthreshold presentations resembling AN; those with BN were more likely to develop subthreshold BN. Purging disorder was experienced by half of those with BN and one-quarter of those with AN binge/purge type (ANBP); BED occurred in 20% with BN. Transition from AN or BN to most subthreshold types was associated with improved psychosocial functioning (p<0.001).

CONCLUSIONS

Subthreshold presentations in women with lifetime AN and BN were common, resembled the initial diagnosis, and were associated with modest improvements in psychosocial functioning. For most with lifetime AN and BN, subthreshold presentations seem to represent part of the course of illness and to fit within the original AN or BN diagnosis.

The effects of dose and repeated administration on the longer-term hypophagia produced by amphetamine in rats

Rats are hypophagic approximately 1-3 and 13-27h after receiving amphetamine (2.0mg/kg). This study examined how these short- and longer-term phases of hypophagia were affected by repeated administration of different amphetamine doses. Throughout eight five-day tests, the rats could lever press for food pellets for 1-hour periods beginning every three hours. On test day 1, the rats were treated with saline, and on test day 3, they were treated with a dose of amphetamine. Across tests, for one group, treatment on day 3 alternated between 0.0 (saline) and 0.5mg/kg amphetamine; for a second, group treatment on day 3 alternated between 1.0 and 2.0mg/kg amphetamine; and for a third group, treatment on day 3 was always 1.0mg/kg amphetamine. The patterns of food intake following day 1 saline and day 3 treatment were compared. Short-term food intake was abolished by 0.5, 1.0, and 2.0mg/kg amphetamine, and no tolerance was observed to this effect. Longer-term hypophagia was produced by 1.0 and 2.0 but not by 0.5mg/kg. Tolerance to longer-term hypophagia was seen when 1.0mg/kg alone was used as the day 3 treatment, but not when 1.0 and 2.0mg/kg were alternated across tests as the day 3 treatment. Short- and longer-term hypophagia were dissociated by threshold doses for elicitation and by differential tolerance. Occasional receipt of a higher amphetamine dose may sometimes increase the longer-term hypophagia produced by a lower dose.

Locusts as model organisms in which to study immunogen-induced anorectic behaviour

When injected into adult or nymphal Locusta that have been deprived of food for 2h, immunogens such as laminarin and bacterial LPS can induce an almost immediate dose-dependent state of anorexia for at least 1h. Such anorexia is a component of a medley of physiological and behavioural changes called collectively 'sickness behaviour' that occurs in a wide range of animals in response to infection or immune challenge. Sub-optimal amounts of injected laminarin allow some locusts to feed, but with a longer latency than in controls, although the length of the first meal is unaffected. The feeding behaviour of fifth instar nymphs is more sensitive to laminarin than that of adults, but both stages respond to amounts of immunogen that are lower than those required to activate the phenoloxidase cascade. Injection of adipokinetic hormone (AKH) before the period of food deprivation prevents the anorexigenic action of the laminarin in adults but not in nymphs. It is argued that the effect of the AKH may be indirect, through its lipid-mobilising action. The insecticide pymetrozine increases the latency to feed but also reduces the length of the first meal, and its anorexigenic activity is not affected by injection of AKH. The present data support the concept that laminarin-induced anorexia involves a central lack of motivation to eat, rather than a 'stop eating' signal. Others have shown that the mechanism of action of pymetrozine involves the serotonergic system and can be blocked by mianserin, so it is intriguing that in the present study injection of mianserin prior to that of laminarin modulates the anorexigenic effect of the immunogen. This suggests that biogenic amines are involved in the control of appetitive behaviour in locusts, as they are in vertebrates. The possible usefulness of the locust model in studying sickness-induced anorexia is discussed briefly.

Age-dependence of alpha-MSH-induced anorexia

Long-term regulation of energy balance involves two major trends: first age-related obesity develops in the middle-aged, later it is followed by anorexia of aging (sarcopenia and/or cachexia). A dynamic balance between orexigenic and anorexigenic neuropeptides is essential for the regulation of energy homeostasis. Special imbalances of neuropeptide effects may be assumed corresponding to different age-periods. Anorexia induced by acute alpha-MSH (alpha-melanocyte stimulating hormone; endogenous melanocortin agonist) injections was analyzed in male Wistar rats aged 6-9 weeks (juvenile), 3-4 months (young adult), 6 or 12 months (two middle-aged groups), 18 months (aging) and 24-26 months (old). Alpha-MSH injected through a preimplanted intracerebroventricular (ICV) cannula (compared with saline injection) dose-dependently suppressed spontaneous food intake and also re-feeding following 24-h fasting, but the rate of suppression varied between age-groups. An ICV injection of 5 microg alpha-MSH attenuated the 2-h re-feeding by 21.9+/-3.2% in juvenile rats, strongly (68.7+/-2.5%) suppressed it in young adults, the suppression became progressively weaker in the two middle-aged groups (55.7+/-4.9%, vs. 26.4+/-4.9%, respectively), but it turned extreme in aging (94.7+/-4.2%) and old (74.3+/-4.5%) rats. Body composition also changed with age: unlike the tibialis anterior muscle, the epididymal and retroperitoneal fat pads increased until middle-age and remained large even in old animals, while the measured indicator of muscle mass decreased in the oldest group. The food intake suppressing and body weight decreasing effects of a 7-day-long ICV infusion of 1 microg/h alpha-MSH were weakest in the 12-month-old and most pronounced in the 24 month-old rats. In conclusion, responsiveness to the anorexic effect of alpha-MSH varies with age, with a nadir of the curve in the middle-aged, and a peak in the aging and old animals. This age-related nadir of melanocortin-responsiveness may promote obesity in middle-aged rats, while the tendency for anorexia and incipient sarcopenia of old (still obese) rats may result from age-related melanocortin-hypersensitivity rather than from adiposity.

Impact of cultural and linguistic factors on symptom reporting by patients with cancer

BACKGROUND

Patient reporting of the severity and impact of symptoms is an essential component of cancer symptom management and cancer treatment clinical trials. In multinational clinical trials, cultural and linguistic variations in patient-reported outcomes instruments could confound the interpretation of study results.

METHODS

The severity and interference of multiple symptoms in 1433 cancer patients with mixed diagnoses and treatment status from the United States, China, Japan, Russia, and Korea were measured with psychometrically validated language versions of the M. D. Anderson Symptom Inventory (MDASI). Mixed-effect ordinal probit regression models were fitted to the pooled data to compare the magnitude of the effect of "country" (nation and linguistic factors) with between-subjects effects on symptom reporting, adjusted for patient and clinical factors (age, sex, performance status, and chemotherapy status).

RESULTS

For the pooled sample, fatigue, disturbed sleep, distress, pain, and lack of appetite were the most severe patient-reported MDASI symptoms. The magnitude of the variance of the country random effects was only one-fourth to one-half of the interpatient variation (sigma(2) = 0.23-0.46) for all symptoms, except nausea and vomiting.

CONCLUSIONS

Cultural and linguistic variations in symptom reporting among the five language versions of the validated MDASI were limited. Ordinal probit modeling provided a simple mechanism for accounting for cultural and linguistic differences in patient populations. The equivalence among MDASI translations in this study suggests that symptom ratings collected from various cultural and language groups using the MDASI can be interpreted in a similar way in oncology practice, clinical trials, and clinical research.

[Perception of social rank and submissive behavior in eating disorders]

OBJECTIVE

The aim of this paper is to study the social behavior in patients with eating disorders, in particular the presence of low social ranking and high submissive behavior. We also considered the relationship between these factors and the presence of some personality traits and pathological eating behaviors.

METHOD

We performed a case-control study on 249 young women (124 controls and 125 eating disorders subjects). Eating disorders were diagnosed as anorexia nervosa, bulimia nervosa and eating disorders non otherwise specified. The patients underwent a routine assessment by means of a diagnostic interview and some self-reported questionnaires. All the subjects (cases and controls) also completed two scales for the assessment of social ranking and submissive behaviors. The two questionnaires were translated from English with the back-translation method.

RESULTS

The two scales were valid and reliable in their Italian version. We observed a significant difference between cases and controls: social ranking was lower in cases, and submissive behavior was lower in controls. Social ranking had an inverse relationship with submissive behavior both in cases and controls, and a significant correlation was found with other interpersonal aspects (ineffectiveness, interpersonal sensitivity) and with some pathological traits and behaviors, like self-injurious behavior.

CONCLUSION

Our study shows that features of low social ranking and submissive behavior are common in eating disorders subjects. These features could represent a risk factor for the development of an eating disorder or, on the contrary, represent a consequence of an eating disorder. A useful therapeutic approach to these disorders could be focused on shifting from submissive to assertive behavior.

Psychological predictors of body image dissatisfaction in women suffering from eating discorders

The objective of the present study was to identify factors influencing body image dissatisfaction in female patients with anorexia and bulimia nervosa. 61 women, aged 16 to 31, (M = 21.69; SD = 3.85) filled questionnaires evaluating dissatisfaction with their body (Body Dissatisfaction Scale by Garner & al., 1984), attitudes about the body (Body Attitude Test by Probst & al., 1995), avoidance with regard to body image (Body Image Avoidance Questionnaire by Rosen & al., 1991), negative mood states (Hospital Anxiety and Depression Scale by Zigmond and Snaith, 1983) as well as self-esteem (Self-Esteem Inventory by Coopersmith, 1984). Negative appreciation of body size, symptoms of depression, grooming and weighting, lack of familiarity with one's own body, as well as low self-esteem in general, could predict the body image dissatisfaction among eating disordered women. The fact of knowing the most important determinants of body image could give indications for the prevention of the cognitive distortions concerning body image.

Consent in cyberspace: Internet-based research involving young people

Social networking sites such as MySpace and virtual communities such as on-line support groups can be a rich source of data for researchers. These sites can be an effective way of reaching and researching young people in order to address their particular health needs. Internet-based research is also potentially risky and exploitative. There is some guidance for conducting research online, but there are no detailed or universally accepted ethics guidelines for research of webspaces such as MySpace or virtual communities in which young people participate. One question that arises is--If MySpace is a public webspace, can research be done without consent? In this paper I investigate ethical issues surrounding young people's consent in cyber research. I identify issues that help determine whether consent is needed, offer suggestions for dealing with consent in cyberspace and add my voice to the call for a resource of case studies--indispensible in the development of guidelines and the education of researchers and research ethics committees.

The contribution of social factors to undereating in older adults with cancer

Inadequate nutrient intake is common in cancer patients and is associated with poor outcomes. Social factors may contribute to inadequate nutrient intake, although they have not been studied. The purpose of this study was to investigate social factors that may contribute to undereating in older adults with cancer. Participants included 30 patients, 17 women and 13 men, aged 70-99 years, who were diagnosed with pancreatic, colon, breast, lymphoma, skin, and head and neck cancers. Both participants and caregivers interpreted weight loss as a positive health outcome of cancer. Furthermore, some patients who had lost weight worked to keep the weight off by going on special diets. Patients and caregivers imbued certain foods with health-promoting qualities without corroborating scientific evidence. Cancer- and treatment-related alterations in self-identity due to changes in their bodies, in taste, and in the manner in which they must eat caused cancer patients to experience frustration and embarrassment, which led to reduced nutritional intake. Despite their compromised nutritional status, patients did not discuss food and eating habits with their physicians. Behaviors and attitudes of patients and caregivers may lead to negative changes in eating behaviors beyond the cancer itself or its treatment or sequelae. Many of these behaviors are potentially modifiable with appropriate education, communication, and intervention.

[Cognitive aspects of women's body image and eating disorders]

BACKGROUND

The authors presents basics of theoretical knowledge connected with cognitive aspects women's body image in Poland. The authors also presents results of research connected with the same subject.

MATERIAL AND METHODS

The study involved 111 women divided into groups - adolescents and young women and women with eating disorders (anorexia and bulimia nervosa). The study methods included the Contour Drawing Rating Scale (CDRS) by Thompson and Gray.

RESULTS AND CONCLUSIONS

The statistical tests indicate differences in the cognitive dimension of body image (between ideal and real self) among adolescent and young women, and women with eating disorders.

Anorexia-cachexia syndrome: a systematic review of the role of dietary polyunsaturated Fatty acids in the management of symptoms, survival, and quality of life

To provide a systematic review on the clinical utility of anti-inflammatory polyunsaturated fatty acids (PUFAs) in cancer-associated anorexia-cachexia syndrome (ACS), clinical trials involving eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) for the management of ACS were identified in the medical literature using MEDLINE (1966 to October 2006) and EMBASE (1980 to October 2006). Review Manager 4.1 was used to compare trials based on outcome measures of interest, including weight change, lean muscle mass change, survival, and quality of life (QoL). Seven randomized controlled trials (RCTs) were identified. Various outcome measures were used in each study. Variability in study populations, dose of EPA and DHA, and standardized scales did not allow for analysis using Review Manager 4.1. Therefore, trials were summarized based on their individual outcomes. Except for one trial showing a positive effect on weight, none of the trials found a clinically or statistically significant difference in outcome measures reviewed. EPA and DHA alone have not shown significant clinical effect in altering weight, lean muscle mass, survival, or QoL in patients with ACS associated with cancer.

[The influence of stereotypes on obesity perception]

BACKGROUND AND OBJECTIVES

The prejudice biases the categorization processes, which implies assigning particular characteristics beyond the objective data available. The stereotype occupies the categorical content by adding what is lacking to what we little know. From a mere physical datum ("he/she is fat") we categorize the obese individual on the basis of our own believes, intimately fusing the stereotype and categorization. SETTING, POPULATION, AND INTERVENTIONS: We included 138 students and 47 patients with anorexia or bulimia that assigned qualifying adjectives of the personality of obese people by using a list of epithets. This same list was provided to 49 obese patients in order to be used to define their own personality.

RESULTS

We analyzed the most frequently used epithets and the corresponding scales of personality by applying the X2 test to determine the differences between the adjectives and the scales in the samples. We considered a p value<0.05 as being statistically significant, by using the SPSS v.13 software. Obese people define their personality very differently than the control group and the group of patients does. While obese people more frequently use "positive" adjectives, the other groups tend to use adjectives with more "negative" connotations. It seems that the stereotypes introduce a perception bias regarding the personality characteristics. The fear to overweight-obesity or the fact of "weight gaining" of patients would explain some of the findings of this work. Patients attribute obese people some personality characteristics altogether more negative than those attributed by the people in the control group.

CONCLUSIONS

Knowing the influence of the stereotypes on obesity perception is essential to approach the patient with no prejudice regarding his/her treatment. The personality characteristics attributed to obese people are far from how these people really perceive themselves.

Neurobiology of anorexia and bulimia nervosa

Anorexia nervosa (AN) and bulimia nervosa (BN) are related disorders of unknown etiology that most commonly begin during adolescence in women. AN and BN have unique and puzzling symptoms, such as restricted eating or binge-purge behaviors, body image distortions, denial of emaciation, and resistance to treatment. These are often chronic and relapsing disorders, and AN has the highest death rate of any psychiatric disorder. The lack of understanding of the pathogenesis of this illness has hindered the development of effective interventions, particularly for AN. Individuals with AN and BN are consistently characterized by perfectionism, obsessive-compulsiveness, and dysphoric mood. Individuals with AN tend to have high constraint, constriction of affect and emotional expressiveness, ahendonia and asceticism, whereas individuals with BN tend to be more impulsive and sensation seeking. Such symptoms often begin in childhood, before the onset of an eating disorder, and persist after recovery, suggesting they are traits that create a vulnerability for developing an ED. There is growing acknowledgement that neurobiological vulnerabilities make a substantial contribution to the pathogenesis of AN and BN. Considerable evidence suggests that altered brain serotonin (5-HT) function contributes to dysregulation of appetite, mood, and impulse control in AN and BN. Brain imaging studies, using 5-HT specific ligands, show that disturbances of 5-HT function occur when people are ill, and persist after recovery from AN and BN. It is possible that a trait-related disturbance of 5-HT neuronal modulation predates the onset of AN and contributes to premorbid symptoms of anxiety, obsessionality, and inhibition. This dysphoric temperament may involve an inherent dysregulation of emotional and reward pathways which also mediate the hedonic aspects of feeding, thus making these individuals vulnerable to disturbed appetitive behaviors. Restricting food intake may become powerfully reinforcing because it provides a temporary respite from dysphoric mood. Several factors may act on these vulnerabilities to cause AN to start in adolescence. First, puberty-related female gonadal steroids or age-related changes may exacerbate 5-HT dysregulation. Second, stress and/or cultural and societal pressures may contribute by increasing anxious and obsessional temperament. Individuals with AN may discover that reduced dietary intake, by reducing plasma tryptophan availability, is a means by which they can modulate brain 5-HT functional activity and anxious mood. People with AN enter a vicious cycle which accounts for the chronicity of this disorder because caloric restriction results in a brief respite from dysphoric mood. However, malnutrition and weight loss, in turn, produce alterations in many neuropeptides and monoamine function, perhaps in the service of conserving energy, but which also exaggerates dysphoric mood. In summary, this article reviews findings in brain chemistry and neuroimaging that shed new light on understanding the psychopathology of these difficult and frustrating disorders.

Taste intensity and hedonic responses to simple beverages in gastrointestinal cancer patients

Changes in the taste of food have been implicated as a potential cause of reduced dietary intake among cancer patients. However, data on intensity and hedonic responses to the four basic tastes in cancer are scanty and contradictory. The present study aimed at evaluating taste intensity and hedonic responses to simple beverages in 47 anorectic patients affected by gastrointestinal cancer and in 55 healthy subjects. Five suprathreshold concentrations of each of the four test substances (sucrose in black current drinks, citric acid in lemonade, NaCl in unsalted tomato juice, and urea in tonic water) were used. Patients were invited to express a judgment of intensity and pleasantness ranging from 0 to 10. Mean intensity scores directly correlated with concentrations of sour, salty, bitter, and sweet stimuli, in both normals and those with cancer. Intensity judgments were higher in cancer patients with respect to sweet (for median and high concentrations, P<0.05), salty (for all concentrations, P<0.05), and bitter tastes (for median concentration, P<0.01). Hedonic function increased with the increase of the stimuli only for the sweet taste. A negative linear correlation was found between sour, bitter, and salty concentrations and hedonic score. Both in cancer patients and in healthy subjects, hedonic judgments increased with the increase of the stimulus for the sweet taste (r=0.978 and r=0.985, P=0.004 and P=0.002, respectively), and decreased for the salty (r=-0.827 and r=-0.884, P=0.084 and P=0.047, respectively) and bitter tastes (r=-0.990 and r=-0.962, P=0.009 and P=0.001, respectively). For the sour taste, the hedonic scores remained stable with the increase of the stimulus in noncancer controls (r=-0.785, P=0.115) and decreased in cancer patients (r=-0.996, P=0.0001). The hedonic scores for the sweet taste and the bitter taste were similar in cancer patients and healthy subjects, and these scores were significantly higher in cancer patients than in healthy subjects for most of the concentrations of the salty taste and all the concentrations of the sour taste. The present study suggests that cancer patients, compared to healthy individuals, have a normal sensitivity, a normal liking for pleasant stimuli, and a decreased dislike for unpleasant stimuli. Moreover, when compared to controls, they show higher hedonic scores for middle and high concentrations of the salty taste and for all concentrations of the sour taste. Further studies are needed to evaluate whether these changes observed in cancer patients translate into any alteration in dietary behavior and/or food preferences.

Grooming, scratching and feeding: role of response competition in acute anorectic response to rimonabant in male rats

RATIONALE

Although the CB1 receptor antagonist/inverse agonist rimonabant acutely suppresses food intake in rodents, the behavioural specificity of this effect remains unclear.

OBJECTIVES

To profile the behavioural effects of rimonabant in a free-feeding context.

MATERIALS AND METHODS

Videoanalysis was employed to characterise the effects of acute rimonabant (1.5 and 3.0 mg/kg, IP) on the behaviour of non-deprived male rats exposed to palatable mash. Data were also collected on post-treatment weight gain, and, as prolonged appetite suppression has been found after single dosing with compounds of this series, rats were reassessed (drug-free) for food intake 7 days after initial testing.

RESULTS

Both doses of rimonabant not only decreased mash consumption (44-55%) but also reduced 24-h weight gain. Although videoanalysis confirmed the inhibitory effects of rimonabant on feeding behaviour, it also revealed concurrent reductions in locomotion, rearing and sniffing as well as substantial (up to tenfold) and dose-dependent increases in grooming and scratching. Timecourse analyses further revealed that rimonabant dose-dependently induced frequent episodes of atypical scratching that waned over the test but which were succeeded by prolonged and behaviourally disruptive grooming. Finally, as groups did not differ in mash consumption on retest, any prolonged anorectic effect of acute rimonabant dissipates within 7 days of treatment.

CONCLUSIONS

The anorectic response to rimonabant in male rats would appear to be due largely to response competition. This parsimonious conclusion is supported by the less profound (although still significant) increases in scratching and grooming observed in rats treated with a sub-anorectic dose (0.5 mg/kg) of the compound.