Eating disorders

Anorexia nervosa and bulimia nervosa are primarily psychiatric disorders characterized by severe disturbances of eating behaviour. Anorexia nervosa has been well documented in pre-pubertal children. Eating disorders are most prevalent in the Western cultures where food is in abundance and for females attractiveness is equated with thinness. Eating disorders are rare in countries like India. As Western sociocultural ideals become more widespread one may expect to see an increase in number of cases of eating disorders in non-Western societies. Etiological theories suggest a complex interaction among psychological, sociocultural, and biological factors. Patients with anorexia nervosa manifest weight loss, fear of becoming fat, and disturbances in how they experience their body weight and shape. Patients with bulimia nervosa present with recurrent episodes of binge eating and inappropriate methods of weight control such as self-induced vomiting, and abuse of diuretics and laxatives. Major complications of eating disorders include severe fluid and electrolyte disturbances and cardiac arrhythmias. The most common cause of death in anorexia nervosa is suicide. Management requires a team approach in which different professionals work together. Individual and family psychotherapy are effective in patients with anorexia nervosa and cognitive-behavioral therapy is effective in bulimia nervosa. Pharmacotherapy is not universally effective by itself. Patients with eating disorders suffer a chronic course of illness. The pediatrician plays important role in early diagnosis, management of medical complications, and psychological support to the patient and the family.

Analyzing the relation between self-esteem and eating disorders: differential effects of self-liking and self-competence

Research in the past has demonstrated an association between low self-esteem and eating disorders. Recent research on self-esteem has shown, however, that self-esteem is composed of two distinct factors--self-liking and self-competence. The present study examined the relation between these two self-esteem factors and both eating disorders and eating disturbed cognitions. A total of 51 female participants from a high-risk population were clinically interviewed to identify the eating disorder and administered a series of questionnaires that included a measure of self-liking and self-competence. A strong relationship was found between self-liking and eating disorders, but no relationship was found between self-competence and eating disorders.

Frequency of recovery from anorexia nervosa of a cohort patients re-evaluated on a long-term basis following intensive care

The need to treat the acute onset of anorexia nervosa in a specialty unit is well known, but nevertheless, even "clinically recovered" patients show a high rate of relapse. The aim of our study was to re-evaluate various clinical (hemoglobin, transferrin, insulin-like growth factor I, TSH, PRL, gonadotropins and 17 beta-estradiol) and psychiatric [semistructured interview, Eating Disorder Inventory (EDI) Test] parameters in 19 female anorexic patients hospitalized in our department from 1983 to 1993 (with a 9-year median prior to the present study) for the treatment of anorexia nervosa, and to compare these results with those of a previous follow-up performed on the same subjects in 1993. In the present evaluation, no significant variation was found among the clinical, nutritional and hormonal parameters when compared to those of the first follow-up in which all parameters had improved with the exception of the PRL levels, which were significantly low. Meanwhile, the percentage of patients with spontaneous menses increased significantly from 50% to 70%, while the number of patients on psychopharmacological therapy decreased significantly throughout the study. Furthermore the percentage of patients with altered (severe or mild) EDI profiles decreased to 50%. This study emphasizes the positive prognostic role of hospitalization and intensive care in a cohort of anorexic patients. The present study, in addition to demonstrating both a general maintenance of body weight acquired over the years, albeit in the lower normal range, and an increase in the percentage of patients with a regular menstrual cycle, also highlights the persistence of psychiatric abnormalities in a large number of patients, even in those diagnosed as "clinically recovered", thus suggesting the need for long-term psychiatric care.

Subjective body-image dimensions in normal and anorexic adolescents

The subjective body dimensions of adolescent anorexic patients and adolescents from the general population were studied by means of a new technique that combines certain characteristics of the 'body-site estimation' and the 'whole-image adjustment' procedures. The technique used (Subjective Body Dimensions Apparatus-SBDA) reveals the individual's idea of the size of the different parts of his/her body, and produces a life-size global silhouette. Eighty-five female anorexic patients (ages 12 to 18) were compared with 427 adolescents from the general population. The technique showed acceptable test-retest stability. The comparison group overestimated their thorax, waist and hips, and anorexic patients overestimated all parts of their body but their thorax, waist and hips especially. For all parts of the body, the anorexic group showed greater overestimation (p < .0001) than the comparison group.

Earliest recollections in anorexia and bulimia

Earliest Recollections (ER) are very useful as they reveal information about a person's main aims and lifestyle, according to the Individual Psychology assumption of the inner coherence of the personality. This paper looks at the utility of analyzing ER in psychopathological research, diagnosis and therapy. Its purpose is to compare particular ER in a group of anorectic outpatients, a group of bulimic outpatients and in a control group. The results provide further evidence that ER are a useful instrument to identify various aspects of family dynamics, particular pathological nuclei which are often of the borderline type. They can also help to overcome the initial hostility towards any therapy that is often present in anorectic and assist the therapist early on in drawing a mental picture of the premises for understanding the lifestyle of the subject both as a child, and now as a patient.

The role of the central nervous system in the psychoneuroendocrine disturbances of anorexia and bulimia nervosa

It has been well-recognized that starvation in anorexia and bulimia nervosa causes endocrine disturbances. Such disturbances may help understand why many people with eating disorders cannot easily reverse their illness since people with eating disorders often enter a downward spiraling circle with malnutrition sustaining and perpetuating the desire for more weight loss and dieting. Symptoms, such as obsessions and dysphoric mood, and altered appetitive behavior, may be exaggerated by neuropeptide alterations and thus contribute to this downward spiral. While neuropeptide disturbances do not appear to be a permanent feature or cause or anorexia nervosa, these disturbances are strongly entrenched, and are not easily corrected by improved nutrition or short-term weight normalization. This suggests that therapy should be sustained for months after nutritional normalization.

Randomized trial of measures of body fat versus body weight in the treatment of anorexia nervosa

OBJECTIVE

To determine whether treatment goals based on body weight or body fat assessed by anthropometrics caused a larger reduction in the Eating Disorder Examination (EDE) over 3 months during the treatment of anorexia nervosa (AN).

METHODS

Randomized trial comparing the use of body weight versus measures of body fat by anthropometrics, with the EDE as the outcome measure. Of 23 patients enrolled, 11 subjects who met diagnostic criteria for AN (DSM-IV) and received outpatient treatment from the Eating Disorders clinic of a university teaching hospital completed the study.

RESULTS

Comparison of the 2 methods by independent t-tests, verified by Mann-Whitney and Sign tests, suggests no difference (p = 0.33). Due to the small sample size, statistical significance could not be assured. A cross-sectional survey of 48 clinic users found the majority of patients preferred to be followed by skinfold measurements and felt they were more helpful than weight.

DISCUSSION

Regardless of which measurement is used, if the clinic staff firmly believe that a method is more helpful and more useful, it is likely that the patients will find it acceptable.

Eating disorders: progress and problems

Recent research on Anorexia Nervosa and Bulimia Nervosa has yielded an increasingly detailed understanding of the range of biological and psychological abnormalities associated with these eating disorders. Inherited vulnerabilities, cultural pressures, and adverse individual and family experiences all appear to contribute to the onset of extreme dieting, binge eating, and purging. Once initiated, these behaviors give rise to multiple physiological disturbances, some of which may serve to perpetuate the illness. Although there have been substantial advances in the management of Bulimia Nervosa, the goal of offering effective treatment to all individuals with eating disorders remains elusive. This article reviews current thinking on the etiology and treatment of the two major eating disorders and a related syndrome, Binge Eating Disorder.

Impact of a history of physical and sexual abuse in eating disordered and asymptomatic subjects

The present study aimed to explore the impact of sexual and/or physical abuse among eating disordered patients (ED) and asymptomatic subjects. A total of 86 patients with anorexia nervosa, 69 patients with bulimia nervosa and 81 asymptomatic subjects were assessed. Among ED, we did not find a significant association between abuse experiences and the severity of the eating disorder, or between abuse and dissociative symptoms. Among ED, self-destructive behaviour appears to be the most important predictor of a history of sexual and/or physical abuse. In contrast, in the asymptomatic group, the score on the Dissociation Questionnaire is the only significant predictor of reported abuse experiences.

Coming alive: the psychotherapeutic treatment of patients with eating disorders

OBJECTIVE

To describe a dynamic psychotherapeutic approach specifically developed for women with eating disorders.

METHOD

The developmental origins and psychological disturbances associated with eating disorders are outlined based on a review of the literature and the authors' observations. Principles from contemporary psychodynamic theories that focus on subjectivity and intersubjectivity are applied to the treatment of women with eating disorders and are illustrated with clinical vignettes. Theoretical models employed include intersubjective and relational theory, self psychology, and feminist psychodynamic theory.

RESULTS

Relative unresponsiveness to a child's subjective experience and to child-initiated cues are thought to contribute to psychological disturbances among women with eating disorders. These disturbances include impairment in the sense of effectiveness, in the capacity to appreciate and tolerate emotions, and in the continuity and cohesiveness of self-experience. Self-imposed starvation, binge-purge episodes, and excessive exercise may act as psychic organizers in women with these vulnerabilities. An active psychotherapeutic approach with sustained interest in the patient's authentic subjective experience promotes the identification, organization, and integration of emotional experience and the consolidation of a more differentiated sense of self.

CONCLUSION

In the psychotherapeutic treatment of women with eating disorders, a therapeutic posture of sustained empathic enquiry contributes to the patient's curiosity about her own subjective world. Feeling understood in a therapeutic relationship and feeling assisted in organizing and understanding one's subjective experience contributes to the gradual unfolding of the psychological sense of self.

"A body to die for": eating disorders and body-image distortion in women

This article presents an overview of anorexia nervosa, bulimia, and eating disorders not otherwise specified (including binge eating disorder) and their psychological and medical complications. Also included are strategies that enhance the communication process with patients who may be in denial or reluctant to share fears and concerns. Some of the most important points for readers to keep in mind are their own hidden prejudices about size, weight and shape. The eating disorders of anorexia nervosa and bulimia have reached epidemic proportions in our population today, especially among adolescent and adult women. Often, these disorders go undiagnosed (and thus untreated) because patients rarely disclose their symptoms to their physician, therapist or dietitian.

Thin line: managing care for adolescents with anorexia and bulimia

Anorexia nervosa ranks third among common chronic disorders in adolescents, surpassed only by asthma and obesity. Unfortunately, recent changes in health care and insurance have resulted in fewer resources for these vulnerable clients Anorexia and bulimia are best managed by a treatment team, but frequently it is the nurse who manages much of the eating-disordered client's care, especially when there is no available team, or when the nurse is the primary care provider or therapist. Nurses can and do care for adolescents with anorexia and bulimia. All it takes is commitment, knowledge, and networking.

Food aversions in eating disorders

The food aversions of a group of anorexia nervosa patients, bulimia nervosa patients, and no eating disordered individuals (controls) were compared. An open questionnaire was used to obtain data on the eating aversions of each of the three populations. The foodstuffs were placed in categories according to their nutritional value. They were also converted into nutrients, and the average value for each population was calculated. With the exception of the 'legumes' and 'dry fruits' categories, the degree of aversion towards the other food groups detected in the individuals with eating disorders was significantly greater than that detected in controls. Aversion towards food with a high protein content (meat, fish, milk and eggs) was characteristic of patients with eating disorders and is a source of clinical problems, which are discussed in this article.

[Male anorexia nervosa patients in long-term follow-up]

Despite an increasing number of studies on the long-term course of anorexia nervosa, male patients only play a subordinate role in the majority of investigations. Thus, one section of a more comprehensive study aimed at describing possible differences in the disease course of male and female patients. Total assessment after a mean of 12 years revealed a clearly increased mortality rate of more than 20% in 10 of the male patients examined (as well as 2 male anorexia nervosa patients with an additional physical condition). The male survivors had a better prognosis than the females patients. Male anorectics were in better physical condition than their female counterparts at the time of follow-up. On the Morgan Russell scale, food intake, psychosexual and social state showed a more favorable development in male than in female patients. Male patients had a more favorable course regarding psychosocial integration but a similar course as female patients regarding eating disorder symptoms. The results are discussed theoretically and clinically. Further studies with a larger random selection of patients should be carried out.

[Course and prognosis of anorexia nervosa: catamnesis of 41 patients]

The purpose of the following study was a multidimensional assessment of the course of anorexia nervosa. In our follow-up-study we were able to examine 41 out of 51 patients meeting DMS-111 R criteria for anorexia nervosa in our department at a mean follow-up of 5.3 years. At the first evaluation the patients were characterized by an early age of onset (mean 14.2 years), no or very little previous psychiatric treatment, and restrictive eating habits (72.5%); the mean age was 15.2 years. At the time of follow-up, the physical outcome was unfavourable for 50% of the patients; one patient had died. The psychosocial outcome was less favourable for 60%. Against the background of a neurotic structure, social and sexual disturbances were found although the patient's weight was often normal. Depressive symptoms and a "slimness ideal" were found among a large number of patients, just as much as the fear of gaining weight--which prove to be a reliable indicator for the continuation of an eating disorder. A multidimensional evaluation facilitates an assessment of the determinants of prognosis. Previous psychiatric treatment and low body weight were associated with an unfavourable, mention of problems/disturbances in the family environment with a good somatic outcome. Outpatient treatment indicates a favourable psychosocial outcome.

Personality disorders in patients with eating disorders in Japan

We assessed the prevalence of personality disorders (PD) using the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) in 36 patients with restricting anorexia nervosa, 30 patients with anorexia nervosa and bulimia nervosa, and 42 patients with bulimia nervosa. Of the 108 patients, 51% met the criteria for at least one PD. The patients with PD had more severe clinical features in terms of bulimic behaviors, concurrent depressive, anxious, and obsessive-compulsive symptoms, and psychopathology related to eating disorders compared to the patients without any PD. The patients with PD, especially borderline PD, also had more severe global functioning and greater numbers of suicidal attempts and hospital admissions. We compare these results with those reported in the Western world and discuss them cross-culturally.

Long-term outcome of children and adolescents with anorexia nervosa: study of comorbidity

Eighty-seven children and adolescents with anorexia nervosa, admitted to the Gaslini Department of Child Neurology and Psychiatry between 1976 and 1990, were followed up after a mean of 9.6 years. Outcome measures included the Morgan Russell Outcome Schedule as modified by Jeammet. Outcome was good in 43 (53%) cases, intermediate in 27 (34%) cases, and negative in 11 (14%) cases. No deaths occurred. Based on the Jeammet assessment schedule, the most significant items predicting outcome were insight; sexual, familial, and social relationships; and mental state. Gender of patients and early disease onset did not seem to be predictive measures. Poor outcome was associated with a severe initial clinical picture and length of in-patient treatment. In regard to comorbidity, mood and personality disorders seemed to be negative prognostic indicators, whereas anxiety disorders did not show prognostic value.

The meaning of body image for women with eating disorders

OBJECTIVE

To propose a theoretical model accounting for the meaning and function of body image disturbances for individuals with eating disorders. This model departs from available conceptualizations of body image focused on attractiveness and emphasizes the role of body image preoccupations in the regulation of self-esteem and affect.

METHOD

This model was developed on the basis of the author's clinical observations and the available empirical research.

RESULTS

Three main functions of body image are described. The first one, "affiliation," consists of using one's appearance in the establishment of interpersonal relationships, both at the level of friendship and romance. The second function, "avoidance," consists of using one's body image to avoid abuse, be it psychological, physical, or sexual. The third function, "expression," consists of using one's body image to communicate to the self and others one's capacity for accomplishment or one's inner feelings of dejection.

CONCLUSION

This model is designed to be a therapeutic tool within body image therapy. Body image therapy can be most effective when focused on the unique meaning of body image for each individual patient.