The use of selective serotonin reuptake inhibitors in eating disorders

The introduction of selective serotonin reuptake inhibitors (SSRIs), which are, in general, safer and more easily tolerated than conventional antidepressants, has had a profound effect on the treatment of affective illnesses and obsessive-compulsive disorder (OCD). A number of symptoms associated with eating disorders overlap those of depression and OCD, suggesting a theoretical and practical case for evaluating the SSRIs in the treatment of anorexia nervosa, bulimia nervosa, binge-eating disorder, and obesity. Despite the expectations for SSRIs in the treatment of eating disorders, clinical investigations have yielded mixed results. In this paper, results from clinical studies of SSRIs (with and without concomitant psychotherapy) in the treatment of anorexia and bulimia nervosa, binge eating disorder, and obesity are reviewed, directions for future research are suggested, and practical recommendations for the clinician are provided.

Eating disorders revisited. I: Anorexia nervosa

Anorexia nervosa is a serious psychiatric illness with a high morbidity and a significant lifetime mortality. Recurring themes in such patients centre on issues of self-worth and control. Treatment is difficult and prolonged, and may require hospitalisation. Therapy focuses on altering the misperceptions that patients have of themselves, both psychologically and physically. A multi-disciplinary team based in a specialised unit provides the treatment of choice, but if this is not available, a consistent, supportive relationship with an individual therapist familiar with the condition will be beneficial. Successful outcome should be based not simply on body weight but also on the resolution of anorexic thinking.

Eating disorders and adolescents: an overview of a maladaptive behavior

TOPIC

Eating disorders among the adolescent population are a serious health problem. The author provides an overview of anorexia nervosa and bulimia nervosa.

PURPOSE

To present information on eating disorders that includes DSM-IV criteria and typical profiles of the client. Current hypotheses about the etiology of eating disorders, medical complications, treatment approaches, morbidity and mortality data research, and outcome research of treatment are reviewed. Research, treatment, and educational considerations for nursing care are discussed.

SOURCES

Published literature, clinical experience.

CONCLUSIONS

Advanced practice nurses are particularly suited for working with adolescents because of their holistic approach to client care. Inconsistencies and gaps in the knowledge base of eating disorders regarding incidence, etiology, treatment approaches, pharmacology, and outcome are areas for future nursing research.

[A case of parotidomegaly associated with eating disorders (anorexia/bulimia)]

A case of parotidomegaly associated with anorexia is described, and the psychoneurological and etiopathogenetic theories of main feed disorders (anorexia/bulimia) are discussed. Particularly, a rare pathology of maxillofacial interest is presented: parotidomegaly associated with anorexia. The diagnosis and differential diagnosis of this pathology is discussed.

[Mortality of anorexia nervosa in Denmark 1970-1987]

Eight hundred and fifty-three patients were admitted to psychiatric institutions in Denmark with anorexia nervosa between 1970 and 1986. Based on register information, 50 deaths were recorded during a mean follow-up period of 7.8 years. Amongst these, five were males and 45 females. The standardized mortality ratio (SMR) was 9.1 in both sexes. The SMR was maximal during the first year after index admission. Suicide was the dominant cause of death amongst subjects who died from unnatural causes (18 of 22 cases). Among those who died from natural causes (24 subjects), 13 individuals died from anorexia nervosa, and 11 individuals died from other illnesses.

Evaluation of a programme of adapted physical activity for ED patients

The importance of work focused on body experience in the therapy of Eating Disorders is widely acknowledged. Even so, few researches have been devoted to this aspect. This paper describes the employment of adapted physical activity as part of a residential cure programme for 96 eating disorder patients. The chief aims of this programme relate to individual identity, relations with others, the body, and getting patients to build themselves a correct image of physical activity. The wide variety of working tools includes both individual and group activities: movement exercise, adapted sports, dancing, expressive activities, relaxation. The following are used to evaluate results: individual and group talks, specific observation scales, and video recordings of some meetings. As shown by other authors, the observations indicate that controlled physical activities can be usefully integrated into an eating disorders cure project.

The significance of body size estimation in eating disorders: its relationship with clinical and psychological variables

OBJECTIVE

To assess the relationship between body size estimation on the one hand and clinical and psychological variables on the other.

METHOD

Body size estimation was tested with the video distortion method on a life-size screen in normal women (n = 45) and compared to a total of 189 female eating disorder patients (100 with restricting anorexia nervosa, 41 with binging/purging anorexia nervosa, 48 with bulimia nervosa). The subjects' cognitive responses (what they think they really look like), affective responses (what they feel they look like), and optative responses (what they want to look like) were correlated with clinical parameters (including body composition) and with the scores on a series of self-report questionnaires assessing general psychological well-being and body experience.

RESULTS

No significant relationship was found between the body size estimations and the clinical variables. The cognitive and affective responses showed a moderate relationship with self-reported body attitude. Body dissatisfaction was negatively correlated with the optative response (desired body size).

DISCUSSION

This study contributes to the construct validity of the video distortion method. Body size estimation includes more than just a perceptual task. Hence, the narrow notion of body image should be replaced by the more complex construct of "body experience," the multidimensionality of which should be addressed in both research and treatment of eating-disordered patients.

Scope and significance of posttraumatic symptomatology among women hospitalized for an eating disorder

OBJECTIVE

To examine posttraumatic symptomatology among women with eating disorders.

METHOD

A sample of 294 women diagnosed as having anorexia nervosa (n = 121), bulimia nervosa (n = 103), or eating disorder-not otherwise specified (n = 70) completed a version of the posttraumatic stress disorder (PTSD) Symptom Scale along with instruments measuring specific eating disorder symptomatology and comorbid psychopathology.

RESULTS

Of the total sample, 154 (52%) reported current symptomatology consistent with PTSD. However, severity of PTSD symptomatology was unrelated to either type or eating disorder or severity of either anorexic or bulimic symptomatology. Severity of PTSD symptoms was significantly associated with depression, anxiety, and dissociative experiences.

DISCUSSION

The findings suggest that PTSD symptomatology is common and an important clinical variable among women with eating disorders, although apparently it is not directly related to the eating disorder per se.

Feeding laboratory studies in patients with eating disorders: a review

OBJECTIVE

The authors review the available literature on feeding lab studies in individuals with anorexia nervosa, bulimia nervosa, and binge eating disorder.

METHOD

Studies were grouped by the research groups which have conducted such studies since these studies have tended to cluster in certain research settings, using specific methodologies at each sites.

RESULTS

The results of this review indicate that although there are several inherent limitations in this type of research, various groups of investigators have demonstrated that eating disorder patients will engage in pathological eating behaviors in structured laboratory settings and that results can be obtained fairly consistently. Also interesting clinically significant differences have emerged across groups. Subtle differences in technique, such as the instructions regarding eating behavior, probably result in different behavioral responses.

DISCUSSION

Feeding laboratory studies provide useful information that can validate, suggest, or challenge established clinical assumptions and diagnostic criteria. However, there are limitations to these methodologies.

Pregnancy and early parenthood: factors in the development of anorexia nervosa?

Most psychologic and social theories of anorexia focus on the developmental pressures that challenge adolescent girls. Pregnancy, which causes profound physical, emotional, and cognitive changes, could represent an amplification of these developmental pressures. In this case study, pregnancy is suggested as a possible contributor to the development of anorexia in a 17-year-old female. Although she has other factors associated with the development of anorexia, the psychological and physical changes of pregnancy appear to be the crucial changes which precipitated anorexia nervosa.

Experiential cognitive therapy in anorexia nervosa

The paper details the characteristics of Experiential Cognitive Therapy (ECT), a relatively short-term, integrated, patient-oriented approach that focuses on individual discovery. Its novelty is the use of Virtual Reality, a new technology that could play an important role in clinical psychology, since it enables ECT to address both body experience disturbances and motivation for change, two key topics in the treatment of anorexia nervosa. All the phases of ECT are described with reference to an actual clinical case: a 22-year-old female anorectic patient.

Differential hemispheric involvement in anorexia nervosa

Hemispheric function was assessed in 22 restricting anorexia nervosa (AN) female subjects and 22 normal female controls. Two verbal and two visuospatial tasks and a set of psychopathological tests were administered. The failure of the "classic" lateralization tests to reveal the expected left hemisphere dominance or a right hemisphere deficit in AN group, as compared to controls, is counterbalanced by the tendency of the psychopathological tests to prove the neuropsychological hypothesis of the present study. Neuropsychological interpretation of psychopathological data, however, does not constitute direct evidence and so further studies and more sophisticated techniques are needed.

Stress, coping, and crisis support in eating disorders

OBJECTIVE

Recent research has supported the role of stress in the development and maintenance of eating disorders. However, coping and crisis support, important aspects of this stress process, have received little systematic attention. The cognitive-transactional approach to coping emphasizes the importance of the relationship between the individual and the particular problematic situation and yet most studies investigating coping in eating disorders have failed to measure situation-specific coping.

METHOD

The present study used semistructured interviews to measure coping and crisis support in response to severe events and/or marked difficulties in 12 women with anorexia nervosa (AN), 21 women with bulimia nervosa (BN), and 21 women without an eating disorder (non-ED).

RESULTS

Women with eating disorders were more likely to use cognitive avoidance or cognitive rumination and were less likely to downplay their problems. In addition, BN subjects were more likely to blame themselves and were less likely to receive crisis support from a core-tie. Overall, women with eating disorders were less likely to be masterful in response to crises than women without eating disorders.

DISCUSSION

It is concluded that women with eating disorders are less effective in their coping than women without eating disorders.

Hunger sensation: a chronobiometric approach to its within-day and intra-day recursivity in anorexia nervosa restricting type

Hunger sensation (HS) is a perception with a daily (circadian) and within-day (ultradian) recursive pattern. In human beings, circadian repeatability was investigated by means of the Single Cosinor method, while the ultradian recursivity was investigated by means of the spectral analysis, both applied to the 24-h HS profile (orexigram). Orexigrams were provided by each subject investigated, who self-rated her subjective orectic stimulus (OS) (from 1 to 10 hunger units) every half hour. The study was performed in 19 female patients aged 13-52 newly diagnosed as in the first episode of Anorexia Nervosa Restricting Type, with a BMI below 18.7. The control group consisted of 10 clinically healthy women aged 21 to 52 years with a BMI from 23 to 25. Two types of orexigrams were found. The first was characterized by a low profile with negligible ultradian variability, in which the HS circadian rhythm (CR) was still detectable, but the power spectrum (PS) was composed of unusual ultradian components associated with a very diminished amplitude for the circadian harmonics. The second was characterized by an almost regular profile, in which the ultradian variability was clearly detectable, the CR regularly fluctuated, and the PS was almost regularly composed. These findings indicate that anorectic patients (AP) can be recognized by their orexigram as "hyporectic", or "eurectic". Therefore, the term "anorexia" seems to be appropriate for AP who exhibit the first type of orexigram (anorectic aphagia nervosa), whereas the second identifying those who could be defined as suffering from "eurectic aphagia nervosa".

Personality features and expressed concerns of adolescents with eating disorders

Differences between adolescent females diagnosed with either anorexia nervosa (n = 26) or bulimia nervosa (n = 30) were investigated using the Millon Adolescent Personality Inventory (MAPI; Millon, Green, & Meagher, 1982). About half of the total sample displayed an inhibited (avoidant) personality style. Anorexics scored higher than did bulimics on the Respectful (Compulsive) personality scale. Expressed concerns over self-concept, personal esteem, and sexual acceptance were common in the total sample. The behavioral correlates of MAPI score profiles indicated that few bulimics, and none of the anorexics, were likely to exhibit problems with impulse control, societal conformity, and scholastic achievement. Results are compared with clinical observations of adolescents with eating disorders and findings for adult eating-disordered samples.

Dating people with anorexia nervosa and bulimia nervosa: attitudes and beliefs of university students

Attitudes and beliefs about dating people with eating disorders were investigated in men and women using a questionnaire administered to 752 university students. Students believed that people with anorexia nervosa and bulimia nervosa had a difficult time dating, dates would involve conflict, and dating would be a negative experience. Students were more comfortable in casual interactions than more serious dating activities with people with anorexia nervosa and bulimia nervosa. Men were somewhat comfortable dating people with anorexia nervosa or bulimia nervosa, but less so for obesity. Most students believed dating people with anorexia nervosa and bulimia nervosa would not be a positive experience, and men stigmatized people with eating disorders differently than did women.

Neuropsychological consequences of extreme weight loss and dietary restriction in patients with anorexia nervosa

This study examined the effects of weight loss and nutritional status on the cognitive performance of patients with anorexia nervosa. The intellectual, memory, attentional, verbal fluency and visuospatial abilities of 34 females with anorexia were compared to that of 31 normal weight-for-height females. Group differences in anxiety and depression were found but neither variable was related to the cognitive performance of patients with anorexia. Moreover, nutritional status and weight loss bore little relationship to the cognitive scores of the patient group. Overall, patients with anorexia were found to be deficient in their ability to recall meaningful prose and visuospatial information. The failure to find many cognitive deficits in this sample may reflect the fact that few patients with anorexia exhibited frank nutritional deficiencies.

Diagnosis and treatment of an adolescent with comorbid type 1 diabetes mellitus and anorexia nervosa

The authors describe the successful treatment of a 17-year-old female with comorbid type 1 diabetes mellitus and anorexia nervosa within the context of a residential program in a tertiary care facility. Assessment and treatment of the complex combinations of the psychological and medical symptoms involved in this patient required the interaction of medical, psychological, and nutritional services. Diagnostic and treatment challenges are discussed.

The contributions of self psychology to the treatment of anorexia and bulimia

This article reviews the contribution of self psychology to the treatment and understanding of anorexia and bulimia. It tries to show that the unique conceptualization of self, selfobject relations, and this theory's conceptualization of resistance and defenses constitutes a therapeutic stance which especially fits the therapeutic needs of eating-disordered patients. Clinical vignettes illuminate three main issues exemplifying the opportunities and dilemmas that this new development in psychoanalytic theory brings to the fore in the treatment of eating disorders: (1) empathy with deeds and attitudes of the patient that the therapist finds difficult to empathize with; (2) empathic understanding "from within" from an experience-near stance vs. experience-distant interpretation "from without"; (3) self, selfobject relations with food and as a result of progress in therapy, with human beings.

Civil commitment of the anorexic patient

Involuntary commitment appears to be an infrequently used intervention with anorexic patients, in part because of clinicians' uncertainty about its applicability to this population. In contrast to overtly suicidal patients, anorexic patients typically fail to express an intent to harm themselves, although their actions may result in severe harm. Examination of the language of civil commitment statutes, however, suggests that when the behavior of anorexic patients endangers their lives, they will usually be committable under grave disability standards. This appears to comport with the practices of experts in the treatment of anorexia, and with practices in other countries as well. Involuntary commitment should be used as an approach of last resort, when patients decline voluntary hospitalization and their physical safety is at risk. Moreover, civil commitment should probably also be limited to circumstances in which therapeutic gain is likely from hospitalization. Many severely ill anorexic patients will lack competence to make treatment decisions on their own behalf, allowing involuntary feeding and other procedures to take place, if necessary. Civil commitment is a tool that can legitimately be used in emergent situations with anorexic patients.

The eating disorders as addiction: a psychobiological perspective

A number of theories have been proposed to explain the substantial comorbidity between the eating disorders and the substance-related disorders. Among them is the claim that self-starvation--exacerbated by excessive exercising--is itself an addiction to the body's endogenous opioids. While efforts have also been made to identify an "addictive personality," attempts to establish whether eating-disordered patients share these characteristics have met with mixed success. The present study was designed to determine the degree to which anorexic and bulimic patients display addictive personality characteristics, and whether these traits are useful in predicting the severity of the patient's weight preoccupation and their degree of excessive exercising. Results confirmed that both anorexic and bulimic patients had high scores on the Addiction Scale of the Eysenck Personality Questionnaire, and that addictiveness and obsessive-compulsiveness were related simultaneously to weight preoccupation and excessive exercising in both patient groups. Findings are discussed within the framework of the auto-addiction opioid theory, and they highlight the similarities and differences in the personality structure of the eating-disorder subtypes.

Plasma concentrations of interleukin-1 beta, interleukin-6 and tumor necrosis factor-alpha in anorexia and bulimia nervosa

Plasma interleukin-1 beta (Il-1 beta) interleukin-6 (Il-6) and tumor necrosis factor-alpha (TNF-alpha) concentrations were measured in 26 women with Anorexia Nervosa (AN), nine of the restricted type (AN-R) and 17 of the binge-eating/purging type (AN-BP), in 24 women with Bulimia Nervosa (BN) and in 26 healthy age- and sex-matched controls. Concentrations of the cytokines were measured at the beginning of the study before starting any treatment and then after 1 and 3 months of combined cognitive-behavioral and pharmacological therapy (fluoxetine for AN-R and AN-BP, amineptine for AN-BP and BN, and fluvoxamine for BN). Basal values of Il-1 beta, Il-6 and TNF-alpha, were the same in patients and controls and did not change during treatments, in spite of the improvement of the mental disorders. This seems to exclude the possibility that alterations of basal plasma cytokine secretion are involved in the etiopathogenesis of AN and BN.