The association of anxiety disorders and obsessive compulsive personality disorder with anorexia nervosa: evidence from a family study with discussion of nosological and neurodevelopmental implications

BACKGROUND

To investigate the association of anorexia nervosa with anxiety disorders through use of a case-control family study design.

METHOD

Lifetime prevalence of anxiety disorders and obsessive compulsive personality disorder was determined among 574 first-degree relatives of 152 probands with anorexia nervosa and compared to rates observed among 647 first-degree relatives of 181 never-ill control probands.

RESULTS

Adjusting for comorbidity of the same illness in the proband, relatives of probands with anorexia nervosa, had a significantly higher prevalence of generalized anxiety, obsessive compulsive disorder, separation anxiety disorder, social phobia, panic disorder, and obsessive compulsive personality disorder compared to relatives of never-ill control probands.

CONCLUSION

Anorexia nervosa may share familial liability factors in common with various anxiety phenotypes. In suggesting that a transmitted propensity for anxiety is a key aspect of vulnerability in anorexia nervosa, the findings point to research developments in the affective neurosciences, specifically the neurocircuitry of fear and anxiety, as a heuristic framework in which to interpret aspects of premorbid temperamental anxieties and clinical symptoms.

Patterns of menstrual disturbance in eating disorders

OBJECTIVE

To describe menstrual disturbance in eating disorders (ED).

METHOD

We describe menstrual history in 1,705 women and compare eating, weight, and psychopathological traits across menstrual groups.

RESULTS

Menstrual dysfunction occurred across all eating disorder subtypes. Individuals with normal menstrual history and primary amenorrhea reported the highest and lowest lifetime body mass index (BMI), respectively. Normal menstruation and oligomenorrhea groups reported greater binge eating, vomiting, and appetite suppressant use. Amenorrhea was associated with lower caloric intake and higher exercise. Harm avoidance, novelty seeking, perfectionism, and obsessionality discriminated among menstrual status groups. No differences in comorbid Axis I and II disorders were observed.

CONCLUSION

Menstrual dysfunction is not limited to any eating disorder subtype. BMI, caloric intake, and exercise were strongly associated with menstrual function. Menstrual status is not associated with comorbidity. Menstrual irregularity is an associated feature of all ED rather than being restricted to AN only.

The application of exposure therapy and D-cycloserine to the treatment of anorexia nervosa: a preliminary trial

OBJECTIVE

Novel approaches to the treatment of anorexia nervosa (AN) are needed. This preliminary study examined the utility and safety of an exposure therapy intervention and D-cycloserine (DCS) in a population of patients with AN.

METHOD

Eleven participants completed a series of 6 laboratory meals, including pre- and post-exposure test meals and four exposure sessions. Participants were randomly assigned to receive either DCS or placebo in double-blind fashion before each of the 4 exposure sessions. These results were compared to data from a previously studied group of patients who received treatment as usual.

RESULTS

Total caloric intake increased significantly from the baseline meal session to the post-test meal session in the patients who received the exposure therapy intervention. Caloric intake did not increase significantly in the comparison group.

CONCLUSION

These data suggest that an exposure therapy intervention specifically focused on meal consumption may be helpful in increasing intake of a test meal.

Childhood-onset bipolar disorder: Evidence for increased familial loading of psychiatric illness

OBJECTIVE

To determine whether childhood-onset bipolar disorder (BP) is associated with an increased psychiatric family history compared with adolescent-onset BP.

METHOD

Semistructured psychiatric interviews were conducted for 438 youth with BP spectrum disorders. To evaluate the effects of age at onset and psychiatric family history, the sample was divided into childhood-onset BP (age and BP onset <12 years; n = 192), adolescents with early-onset BP (age > or =12 years and BP onset <12 years; n = 136), and adolescents with late-onset BP (age and BP onset > or =12 years; n = 110). Lifetime family history of psychiatric illness was ascertained for first- and second-degree relatives through both direct interview of caretakers and the Family History Screen.

RESULTS

After significant demographic and clinical factors were controlled for, children and adolescents with childhood-onset BP showed higher percentages of positive first-degree family history for depression, anxiety, attention-deficit/hyperactivity, conduct, and substance dependence disorders and suicidal behaviors compared with adolescents with late onset. Subjects with childhood-onset BP also showed elevated familial loading for depression and attention-deficit/hyperactive disorder in second-degree relatives.

CONCLUSIONS

These data support a model that postulates a higher density of familial risk for a broad range of psychopathology in childhood-onset BP.

Symptom profile of major depressive disorder in women with eating disorders

OBJECTIVE

Based on the well-documented association between eating disorders (EDs) and affective disorders, the patterns of comorbidity of EDs and major depressive disorder (MDD) were investigated. The temporal relation between EDs and MDD onset was analyzed to determine differences in the course and nature of MDD when experienced prior to versus after the onset of the ED.

METHOD

Lifetime MDD and depressive symptoms were assessed in 1371 women with a history of ED. The prevalence of MDD was first explored across ED subtypes, and ages of onset of MDD and EDs were compared. Depressive symptoms were examined in individuals who developed MDD before and after ED onset.

RESULTS

The lifetime prevalence of MDD was 72.9%. Among those with lifetime MDD (n =963), 34.5% reported MDD onset before the onset of ED. Those who experienced MDD first reported greater psychomotor agitation (OR =1.53; 95%CI =1.14-2.06), and thoughts of own death (but not suicide attempts or ideation; OR =1.73; 95%CI =1.31-2.30). Among individuals who had MDD before ED, 26.5% had the MDD onset during the year before the onset of ED; 67% of individuals had the onset of both disorders within the same 3 year window.

CONCLUSION

Clinicians treating individuals with new-onset ED or MDD should remain vigilant for the emergence of additional psychopathology, especially during the initial 3 year window following the onset of the first disorder.

Phenomenology of children and adolescents with bipolar spectrum disorders

CONTEXT

Children and adolescents who present with manic symptoms frequently do not meet the full DSM-IV criteria for bipolar I disorder (BP-I).

OBJECTIVE

To assess the clinical presentation and family history of children and adolescents with BP-I, bipolar II disorder (BP-II), and bipolar disorder not otherwise specified (BP-NOS).

DESIGN

Subjects and their primary caretaker were assessed by semistructured interview, and family psychiatric history was obtained from interview of the primary caretaker.

SETTING

Outpatient and inpatient units at 3 university centers.

PARTICIPANTS

A total of 438 children and adolescents (mean +/- SD age, 12.7 +/- 3.2 years) with BP-I (n = 255), BP-II (n = 30), or BP-NOS (n = 153).

MAIN OUTCOME MEASURES

Lifetime psychiatric history and family history of psychiatric disorders.

RESULTS

Youth with BP-NOS were not diagnosed as having BP-I primarily because they did not meet the DSM-IV duration criteria for a manic or mixed episode. There were no significant differences among the BP-I and BP-NOS groups in age of onset, duration of illness, lifetime rates of comorbid diagnoses, suicidal ideation and major depression, family history, and the types of manic symptoms that were present during the most serious lifetime episode. Compared with youth with BP-NOS, subjects with BP-I had more severe manic symptoms, greater overall functional impairment, and higher rates of hospitalization, psychosis, and suicide attempts. Elevated mood was present in 81.9% of subjects with BP-NOS and 91.8% of subjects with BP-I. Subjects with BP-II had higher rates of comorbid anxiety disorders compared with the other 2 groups and had less functional impairment and lower rates of psychiatric hospitalization than the subjects with BP-I.

CONCLUSIONS

Children and adolescents with BP-II and BP-NOS have a phenotype that is on a continuum with that of youth with BP-I. Elevated mood is a common feature of youth with BP-spectrum illness.

Are there gender differences in core symptoms, temperament, and short-term prospective outcome in anorexia nervosa?

OBJECTIVE

The objective of this study was to compare symptoms, premorbid personality phenotypes, and short-term outcome between males and females with anorexia nervosa.

METHOD

Symptom and personality ratings were obtained at the time of hospital admission, and outcome was assessed at discharge and again 1 year later.

RESULTS

Gender effects were negligible at admission, with the exception of greater weight concern among females. Lifetime anxiety disorders and personality traits implicated in liability for anorexia nervosa were common among patients of both genders. Females had greater persistence of symptom morbidity over the 1-year follow-up.

CONCLUSION

Although gender has little effect on the clinical features of anorexia nervosa, the illness runs a more protracted early course in females. Possible mechanisms underlying greater persistence of morbidity in females include sexual dimorphisms in brain neurotransmission, gender differences in attitudes regarding ideal body weight, and anxiety-related personality phenotypes associated with anorexia nervosa.

Psychotic symptoms in pediatric bipolar disorder and family history of psychiatric illness

BACKGROUND

Few studies have examined the specificity and non-specificity in patterns of familial loading for presentation of psychotic symptoms in pediatric bipolar disorder (BP).

METHODS

Diagnostic assessment of 263 pediatric BP probands included lifetime history of psychotic symptoms as well as longitudinal follow-up; family history of psychiatric illness was determined for 1st degree relatives.

RESULTS

Pediatric BP probands with lifetime history of psychosis had a higher percentage of positive family history of anxiety disorders and suicide attempts as compared to probands with no history of psychosis.

DISCUSSION

Familial loading for a spectrum of internalizing disorders is associated with presentation of psychotic symptoms in pediatric BP.

Smoking in eating disorders

OBJECTIVE

Smoking has been reported as an appetite and weight control method in eating disorders; however, few studies have explored patterns of smoking across subtypes of eating disorders. The aim of this paper was to explore the patterns and prevalence of smoking behavior in 1,524 women from two of the multisite Price Foundation Genetic studies.

METHOD

Smoking behavior was assessed in 306 individuals with anorexia nervosa-restricting type (RAN), 186 with anorexia nervosa-purging type (PAN), 180 with anorexia nervosa and bulimia nervosa (ANBN), 107 with anorexia nervosa-binging type (BAN), 71 individuals with purging type-bulimia nervosa (PBN), and 674 female community controls. We compared smoking prevalence and smoking behaviors across eating disorder (ED) subtypes and in comparison to controls using the Fagerstrom Test of Nicotine Dependence (FTND).

RESULTS

Overall, women with eating disorders reported higher rates of smoking and greater nicotine dependence than controls. Women with binge/purge subtypes of eating disorders reported the highest rates of smoking of all of the subtypes. Smoking in eating disorders was related to impulsive personality traits.

CONCLUSIONS

Women with eating disorders appear to be at increased risk for smoking, particularly those who binge eat and/or purge and display impulsive personality characteristics. Given the high prevalence, the impact of ongoing smoking on maintenance of eating disorders symptoms is worthy of both clinical and research attention.

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.

Child comorbidity, maternal mood disorder, and perceptions of family functioning among bipolar youth

OBJECTIVE

To examine the association between youth comorbid psychiatric disorders, maternal mood disorder, and perceptions of family cohesion and conflict among youth diagnosed with pediatric bipolar disorder (PBD).

METHOD

Three hundred eighty-nine bipolar youths and their parents completed a diagnostic interview and instruments assessing family psychiatric history and functioning. Family functioning was assessed with the Family Adaptability and Cohesion Scales-II and the Conflict Behavior Questionnaire.

RESULTS

The presence of a maternal mood disorder was associated with lower family cohesion. The presence of a youth externalizing disorder with or without a co-occurring anxiety disorder was also associated with lower family cohesion as well as higher family conflict. Furthermore, the negative relationship between maternal mood disorder and family functioning was stronger in the presence of a youth externalizing disorder.

CONCLUSIONS

Youth comorbidity and maternal mood disorders appear to be associated with worse family functioning among bipolar youths. Family-based treatments with bipolar youths may need to integrate treatment of youth comorbidity and address maternal mood disorder for optimal results.

Pediatric bipolar disease: current and future perspectives for study of its long-term course and treatment

AIM AND METHODS

Findings from recent long-term, prospective longitudinal studies of the course, outcome and naturalistic treatment of adults with bipolar illness are highlighted as background for long-term developmental study of pediatric bipolar illness.

RESULTS

Accumulating knowledge of bipolar illness in adults underscores a high risk for multiple recurrences through the lifespan, significant medical morbidity, high rates of self-harm, economic and social burden and frequent treatment resistance with residual symptoms between major episodes. At present, there is no empirical foundation to support any assumption about the long-term course or outcome of bipolar illness when it arises in childhood or adolescence, or the effects of conventional pharmacotherapies in altering its course and limiting potentially adverse outcomes. The proposed research articulates specific descriptive aims that draw on adult findings and outlines core methodological requirements for such an endeavor.

CONCLUSIONS

Innovations in the description and quantitative analysis of prospective longitudinal clinical data must now be extended to large, systematically ascertained pediatric cohorts recruited through multicenter studies if there is to be a meaningful scientific advance in our knowledge of the enduring effects of bipolar illness and the potential value of contemporary approaches to its management.

Features associated with laxative abuse in individuals with eating disorders

OBJECTIVE

Laxative abuse is common in patients with anorexia and bulimia nervosa and has been associated with longer duration of illness, suicide attempts, impulsivity, and greater eating and general psychopathology. We explored the extent to which laxative abuse was associated with specific psychopathological features across eating disorder subtypes.

METHODS

Participants were 1021 individuals from the multisite, International Price Foundation Genetic Studies. Axis I disorders, personality disorders and traits, and obsessive compulsive features were assessed.

RESULTS

Laxative abuse was associated with worse eating disorder and general psychopathology and higher prevalence of borderline personality disorder (BPD). Symptom level analyses revealed that specific features of BPD, including suicidality and self-harm, feelings of emptiness, and anger, were most strongly associated with laxative abuse.

CONCLUSIONS

The function of laxative abuse may differ across individuals with eating disorders, alternatively serving as a method of purging and a form of self-harm.

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.

Clinical course of children and adolescents with bipolar spectrum disorders

CONTEXT

Despite the high morbidity associated with bipolar disorder (BP), few studies have prospectively studied the course of this illness in youth.

OBJECTIVE

To assess the longitudinal course of BP spectrum disorders (BP-I, BP-II, and not otherwise specified [BP-NOS]) in children and adolescents.

DESIGN

Subjects were interviewed, on average, every 9 months for an average of 2 years using the Longitudinal Interval Follow-up Evaluation.

SETTING

Outpatient and inpatient units at 3 university centers.

PARTICIPANTS

Two hundred sixty-three children and adolescents (mean age, 13 years) with BP-I (n = 152), BP-II (n = 19), and BP-NOS (n = 92).

MAIN OUTCOME MEASURES

Rates of recovery and recurrence, weeks with syndromal or subsyndromal mood symptoms, changes in symptoms and polarity, and predictors of outcome.

RESULTS

Approximately 70% of subjects with BP recovered from their index episode, and 50% had at least 1 syndromal recurrence, particularly depressive episodes. Analyses of weekly mood symptoms showed that 60% of the follow-up time, subjects had syndromal or subsyndromal symptoms with numerous changes in symptoms and shifts of polarity, and 3% of the time, psychosis. Twenty percent of BP-II subjects converted to BP-I, and 25% of BP-NOS subjects converted to BP-I or BP-II. Early-onset BP, BP-NOS, long duration of mood symptoms, low socioeconomic status, and psychosis were associated with poorer outcomes and rapid mood changes. Secondary analyses comparing BP-I youths with BP-I adults showed that youths significantly more time symptomatic and had more mixed/cycling episodes, mood symptom changes, and polarity switches.

CONCLUSIONS

Youths with BP spectrum disorders showed a continuum of BP symptom severity from subsyndromal to full syndromal with frequent mood fluctuations. Results of this study provide preliminary validation for BP-NOS.

The relation among perfectionism, obsessive-compulsive personality disorder and obsessive-compulsive disorder in individuals with eating disorders

OBJECTIVE

Perfectionism and obsessionality are core features of eating disorders (ED), yet the nature of their relation remains unknown. Understanding the relation between these traits may enhance our ability to identify relevant behavioral endophenotypes for ED.

METHOD

Six-hundred seven individuals with anorexia and bulimia nervosa from the International Price Foundation Genetic Study were assessed for perfectionism, obsessive-compulsive personality disorder (OCPD), and obsessive-compulsive disorder (OCD).

RESULTS

No differences were found across ED subtypes in the prevalence of OCPD and OCD, nor with the association between OCD and OCPD. Perfectionism scores were highest in individuals with OCPD whether alone or in combination with OCD.

CONCLUSION

Perfectionism appears to be more closely associated with obsessive-compulsive personality symptoms rather than OCD. The pairing of perfectionism with OCPD may be a relevant core behavioral feature underlying vulnerability to ED.

Selection of eating-disorder phenotypes for linkage analysis

Vulnerability to anorexia nervosa (AN) and bulimia nervosa (BN) arise from the interplay of genetic and environmental factors. To explore the genetic contribution, we measured over 100 psychiatric, personality, and temperament phenotypes of individuals with eating disorders from 154 multiplex families accessed through an AN proband (AN cohort) and 244 multiplex families accessed through a BN proband (BN cohort). To select a parsimonious subset of these attributes for linkage analysis, we subjected the variables to a multilayer decision process based on expert evaluation and statistical analysis. Criteria for trait choice included relevance to eating disorders pathology, published evidence for heritability, and results from our data. Based on these criteria, we chose six traits to analyze for linkage. Obsessionality, Age-at-Menarche, and a composite Anxiety measure displayed features of heritable quantitative traits, such as normal distribution and familial correlation, and thus appeared ideal for quantitative trait locus (QTL) linkage analysis. By contrast, some families showed highly concordant and extreme values for three variables-lifetime minimum Body Mass Index (lowest BMI attained during the course of illness), concern over mistakes, and food-related obsessions-whereas others did not. These distributions are consistent with a mixture of populations, and thus the variables were matched with covariate linkage analysis. Linkage results appear in a subsequent report. Our report lays out a systematic roadmap for utilizing a rich set of phenotypes for genetic analyses, including the selection of linkage methods paired to those phenotypes.

Linkage analysis of anorexia and bulimia nervosa cohorts using selected behavioral phenotypes as quantitative traits or covariates

To increase the likelihood of finding genetic variation conferring liability to eating disorders, we measured over 100 attributes thought to be related to liability to eating disorders on affected individuals from multiplex families and two cohorts: one recruited through a proband with anorexia nervosa (AN; AN cohort); the other recruited through a proband with bulimia nervosa (BN; BN cohort). By a multilayer decision process based on expert evaluation and statistical analysis, six traits were selected for linkage analysis (1): obsessionality (OBS), age at menarche (MENAR), and anxiety (ANX) for quantitative trait locus (QTL) linkage analysis; and lifetime minimum body mass index (BMI), concern over mistakes (CM), and food-related obsessions (OBF) for covariate-based linkage analysis. The BN cohort produced the largest linkage signals: for QTL linkage analysis, four suggestive signals: (for MENAR, at 10p13; for ANX, at 1q31.1, 4q35.2, and 8q13.1); for covariate-based linkage analyses, both significant and suggestive linkages (for BMI, one significant [4q21.1] and three suggestive [3p23, 10p13, 5p15.3]; for CM, two significant [16p13.3, 14q21.1] and three suggestive [4p15.33, 8q11.23, 10p11.21]; and for OBF, one significant [14q21.1] and five suggestive [4p16.1, 10p13.1, 8q11.23, 16p13.3, 18p11.31]). Results from the AN cohort were far less compelling: for QTL linkage analysis, two suggestive signals (for OBS at 6q21 and for ANX at 9p21.3); for covariate-based linkage analysis, five suggestive signals (for BMI at 4q13.1, for CM at 11p11.2 and 17q25.1, and for OBF at 17q25.1 and 15q26.2). Overlap between the two cohorts was minimal for substantial linkage signals.

Association of multiple DRD2 polymorphisms with anorexia nervosa

To investigate whether the dopaminergic system plays a role in the etiology of anorexia nervosa (AN) via the dopamine D2 receptor, we investigated association and transmission disequilibrium at seven single-nucleotide polymorphisms (SNPs) spanning about 75 kbp of the gene DRD2. We studied 191 probands with a DSM-IV diagnosis of AN, 457 parents and affected relatives with a DSM-IV eating disorder diagnosis, and 98 unrelated, female, normal weight controls. The -141 C/- insertion/deletion (-141 Indel), previously shown to affect DRD2 transcription efficiency, and multiple exon seven polymorphisms, one of which has previously been shown to affect DRD2 transcript stability, exhibited statistically significant association with diagnosis in haplotype transmission disequilibrium and in haplotype case : control analyses. Significant linkage disequilibrium between the -141 Indel and two exon seven SNPs (939Y and 957Y) was observed over a distance of >50 kbp in the AN probands but not in the controls. Genetically transmitted variation in D2 dopamine receptor expression mediated by functional polymorphisms affecting transcription and translation efficiency may play a role in vulnerability to AN.

The future of treatment research in anorexia nervosa

In spite of much being written on the treatment of anorexia nervosa (AN), and the well-documented long-term morbidity of this illness, treatment effects have been little investigated. The current article considers the prospects for treatment research, taking note of the formidable challenges that lie ahead for the design, implementation, and interpretation of controlled clinical trials, and highlighting opportunities for effectiveness studies. In the light of increasing evidence of the role played by biologic susceptibility factors in AN, the potential future contribution to treatment research of advances in pharmacogenetics and molecular neuroscience also receives comment.

Symptom fluctuation in eating disorders: correlates of diagnostic crossover

OBJECTIVE

The course of anorexia nervosa often includes the emergence of bulimic symptoms and a crossover to the full syndrome of bulimia nervosa. However, clinicians' ability to predict who will develop bulimia nervosa is limited. The converse phenomenon, crossover from bulimia nervosa to anorexia nervosa, has not been investigated as thoroughly. The authors identified factors that are associated with crossover from anorexia nervosa to bulimia nervosa and from bulimia nervosa to anorexia nervosa.

METHOD

All participants were from the International Price Foundation Genetic Study. Two groups were studied. The first comprised 88 individuals with an initial diagnosis of anorexia nervosa, of whom 32 developed bulimia nervosa. The second included 350 individuals with bulimia nervosa, of whom 93 developed anorexia nervosa. Several variables, including DSM-IV axis I and II disorders and personality traits, were evaluated as potential predictors of crossover.

RESULTS

For the majority of affected individuals, crossover occurred by the fifth year of illness. A low level of self-directedness was associated with crossover in both directions. Other factors differed by diagnosis: high parental criticism was associated with crossover from anorexia nervosa to bulimia nervosa, whereas alcohol abuse/dependence and a low level of novelty seeking were associated with crossover from bulimia nervosa to anorexia nervosa.

CONCLUSIONS

Low self-directedness may be associated with diagnostic instability in general, whereas other specific factors are related to the direction of diagnostic crossover. These results indicate that personality and family characteristics may influence the course of eating disorders and may be informative for planning interventions.

Managing the chronic, treatment-resistant patient with anorexia nervosa

OBJECTIVE

To describe the psychopathology of chronic, treatment-resistant anorexia nervosa, as well as a paradigm for its clinical management.

METHOD

The foundation of the approach integrates clinical experience, empirical psychological findings, and a conceptual understanding of developmental and phenomenologic aspects of the illness.

RESULTS

Elements of the management paradigm take account of the compensatory nature of illness chronicity. The inherent risks of treating these patients in the customary way are described, along with therapist countertransference that must be anticipated and effectively considered.

DISCUSSION

The chronically ill patient requires a unique approach to care, one that minimizes the risk of iatrogenic effects of rapid weight restoration or failure to appraise the deleterious influences of therapist countertransference.

Personality characteristics of women before and after recovery from an eating disorder

BACKGROUND

Previous studies of personality characteristics in women with eating disorders primarily have focused on women who are acutely ill. This study compares personality characteristics among women who are ill with eating disorders, recovered from eating disorders, and those without eating or other Axis I disorder pathology.

METHOD

Female participants were assessed for personality characteristics using the Temperament and Character Inventory (TCI): 122 with anorexia nervosa (AN; 77 ill, 45 recovered), 279 with bulimia nervosa (BN; 194 ill, 85 recovered), 267 with lifetime histories of both anorexia and bulimia nervosa (AN + BN; 194 ill, 73 recovered), 63 with eating disorder not otherwise specified (EDNOS; 31 ill, 32 recovered), and 507 without eating or Axis I disorder pathology.

RESULTS

Women ill with all types of eating disorders exhibited several TCI score differences from control women, particularly in the areas of novelty-seeking, harm avoidance, self-directedness, and cooperativeness. Interestingly, women recovered from eating disorders reported higher levels of harm avoidance and lower self-directedness and cooperativeness scores than did normal control women.

CONCLUSIONS

Women with eating disorders in both the ill and recovered state show higher levels of harm avoidance and lower self-directedness and cooperativeness scores than normal control women. Although findings suggest that disturbances may be trait-related and contribute to the disorders' pathogenesis, additional research with more representative community controls, rather than our pre-screened, normal controls, is needed to confirm these impressions.

Personality in men with eating disorders

OBJECTIVE

This study compares personality variables of men with eating disorders to women with eating disorders.

METHOD

Data were obtained from an international study of the genetics of eating disorders. Forty-two male participants were age-band matched at 1:2 ratio to females from the same study. Personality features were compared between males and females controlling for diagnostic subgroup.

RESULTS

Males with eating disorders appear to be slightly less at risk for perfectionism, harm avoidance, reward dependence, and cooperativeness than females. Few differences were found when diagnostic subgroup was considered.

CONCLUSION

Observed differences in personality variables may help explain the difference in incidence and prevalence of eating disorders in men and women.

Chart review of the impact of attention-deficit/hyperactivity disorder comorbidity on response to lithium or divalproex sodium in adolescent mania

PURPOSE

Although adolescent onset of bipolar disorder is common, the optimal treatment approach for mania in this age group remains understudied. Comorbid attention-deficit/hyperactivity disorder (ADHD) has been reported to predict lithium resistance in adolescents with bipolar disorder. Little is known about response to dival-proex sodium in adolescents with bipolar disorder comorbid with ADHD. This study was conducted to evaluate comparative response rates to lithium and divalproex sodium in adolescent mania with and without this comorbidity.

METHOD

Medical records were reviewed for 42 patients (ages 12-19 years) who were hospitalized for acute mania and discharged with a diagnosis of DSM-III-R or DSM-IV bipolar disorder on either lithium (N = 29) or divalproex sodium (N = 13) treatment. A clinician blinded to treatment status rated improvement on the basis of abstracted notes in each case utilizing the Clinical Global Impressions Scale modified for use in bipolar illness (CGI-BP). Response was defined as a discharge CGI-BP overall change score of 1 or 2 (much or very much improved). Data were collected from January 1992 through May 1999.

RESULTS

36/42 (85.7%) patients presented with mixed mania, and 14/41 (34.1%) patients had a history of ADHD. The overall response rate was 80.9% (34/42). 92.6% (25/27) of patients without ADHD were responders versus 57.1% (8/14) of subjects with comorbid ADHD (p =.007). There were no significant differences in response rates for lithium versus divalproex sodium in subjects with and without ADHD.

CONCLUSION

These retrospective data suggest overall equivalent response rates for lithium and divalproex sodium in predominantly mixed adolescent mania. However, a history of ADHD was associated with a significantly diminished acute response to both divalproex sodium and lithium as a primary treatment for the manic phase of bipolar disorder.