Eating disorders and insulin-dependent diabetes mellitus

The eating disorders anorexia nervosa and bulimia nervosa have been reported to occur in Type I diabetes mellitus. Although prevalence estimates vary, the most rigorous studies yield rates similar to the population at large. Intentional insulin omission is more common, especially in young diabetic women, and at times may indicate an eating disorder in Type I diabetic patients. Both diagnosable eating disorders and intentional insulin omission are associated with worse glycemic control and higher rates of secondary diabetic complications. Recognition of these conditions, followed by carefully coordinated treatment involving both diabetes care providers and mental health providers, is necessary to improve treatment outcome.

Implicit and explicit memory for shape, body weight, and food-related words in patients with anorexia nervosa and nondieting controls

Twelve patients with anorexia nervosa and 12 control participants watched a series of 64 words. There were 4 word types: anorexia related, positive, negative, and neutral. The last 3 types were anorexia unrelated. Anorexia-related words had the same affective valence as the neutral control words. Next, the participants completed an explicit memory test (cued recall) and an implicit memory test (word stem completion). Results showed a strong explicit memory bias for anorexia-related words for patients with anorexia nervosa but not for nondieting controls. There was no evidence for a similar bias in implicit memory. Results are discussed in the context of cognitive biases in psychopathology.

[Two sides of patients with eating disorders. One wants to get better, the other resists]

Anorexia and bulimia nervosa patients often require long-term treatment. The efficacy of different treatment approaches is insufficiently known, and for many years well-defined treatment goals were lacking. However, treatment studies are being published, or are under way. In this paper, the authors attempt to summarize the current state-of-knowledge in the field of eating disorder treatment.

Neuroendocrine, appetitive and behavioural responses to d-fenfluramine in women recovered from anorexia nervosa

BACKGROUND

Increased central serotonin (5-HT) function has been hypothesised to be a vulnerability trait in anorexia nervosa.

METHODS

Eighteen women with a history of DSM-III-R anorexia nervosa and 18 female controls were examined. The subjects had recovered weight and menstrual function. A placebo-controlled d-fenfluramine test was used. Subjects ingested d-fenfluramine or placebo and after three hours were offered a 'free' meal. The amounts eaten were recorded and plasma cortisol and prolactin levels were measured. Questionnaires related to eating attitudes and behaviour, to personality, and to mood were administered.

RESULTS

Unlike the control subjects, those recovered from anorexia nervosa did not show the expected appetite-suppressing responses to d-fenfluramine; their eating attitudes and behaviour were more restrained, 'negative' perfectionism was more pronounced, and post-meal plasma cortisol levels did not rise as expected.

CONCLUSIONS

Our results do not suggest that increased central 5-HT function is a trait marker in anorexia nervosa, but dysregulation in part of the central 5-HT system may be a vulnerability factor. The flattened post-meal response to cortisol in the subjects who had recovered from anorexia nervosa suggests that their hypothalamic pituitary--adrenal axis may be altered and deserves further investigation.

Anorexia nervosa and bulimia nervosa in children and adolescents: a review of the past 10 years

OBJECTIVE

To critically review the research in juvenile anorexia nervosa and bulimia nervosa over the past 10 years and highlight recent advances in normal development as it pertains to these disorders and their diagnosis, prevention, and treatment.

METHOD

Computerized search methods were combined with manual searches of the literature. A detailed review of the most salient articles is provided. Preference was given to studies involving children and adolescents that approached the subject from a developmental perspective.

RESULTS

The information from these studies is presented in a developmental framework. Research in eating disorders has progressed, but definitive longitudinal data are still absent from the literature. Research specific to treatment of child and adolescent eating disorders remains rare.

CONCLUSIONS

Data approaching eating disorders from a developmental perspective are available in only a few studies. Research is needed addressing normative data on the development of eating behavior and specific risk and resilience factors for pathology in specific developmental periods. Especially lacking are studies regarding the continuities and discontinuities of eating disturbances across the life span. Best documented are epidemiological studies of prevalence and incidence, long-term outcome in anorexia nervosa, and short-term treatment response in bulimia.

Videotape assessment of changes in aberrant meal-time behaviors in anorexia nervosa after treatment

This study compared meal-time behaviors in patients with anorexia nervosa to normal-weight controls and the effects of hospital treatment on these behaviors. Ten restricting-anorexics and six normal-weight controls were given a standard lunch and asked to eat the entire meal. Their behaviors were recorded via hidden camera. All participants were tested twice--anorexics before and after in-patient treatment, and controls at similar intervals. Videotapes of these sessions were analysed for occurrence and duration of eight categories of non-ingestive behaviors: food manipulation, food preparation, food moving, non-food manipulation, concealment, vigilance, passivity and physical activity. Food-ingestion patterns, including number of bites of food and switches between different kinds of food, were also recorded. Results indicated that anorexics spent significantly more time than controls in behaviors that were directly food-related, and exhibited more vigilance behavior. Pre-treatment anorexics spent significantly more time in these behaviors than did post-treatment anorexics. Few group differences or treatment effects were found in food-ingestion patterns, although there was an indication that both pre- and post-treatment anorexics avoided high-fat foods more than controls did. These results suggest that videotaping provides a useful technique for characterizing the behavior associated with eating disorders. Further studies should explore whether normalization of these behaviors is associated with a positive clinical outcome.

Does fluoxetine augment the inpatient treatment of anorexia nervosa?

OBJECTIVE

While pharmacological interventions are of established utility in bulimia nervosa, medications have no clear role in the treatment of anorexia nervosa. Because patients with anorexia nervosa frequently exhibit mood disturbances and symptoms of obsessive-compulsive disorder, the authors tested the utility of fluoxetine in the treatment of women participating in an inpatient program for anorexia nervosa.

METHOD

The authors conducted a randomized, placebo-controlled, double-blind, 7-week study of fluoxetine at a target daily dose of 60 mg in 31 women with anorexia nervosa receiving treatment for their eating disorder on a clinical research unit. Body weight and measures of eating behavior and psychological state were obtained at baseline and at termination.

RESULTS

There were no significant differences in clinical outcome on any measure between patients receiving fluoxetine and patients receiving placebo.

CONCLUSIONS

Fluoxetine does not appear to add significant benefit to the inpatient treatment of anorexia nervosa.

The slender ideal and eating disorders: an interdisciplinary "telescope" model

OBJECTIVE

This paper interprets eating disorders (including anorexia and bulimia) as one (nonfunctional) manifestation, in modern environments, of evolved psychological mechanisms which modulate the standard of feminine bodily attractiveness as a response to economic conditions.

METHOD

Published evidence from anthropology, sociology, and psychology was used to evaluate predictions that (1) where economic independence is possible, women favor a slender standard and (2) where women lack economic power, marriage tends to be favored and the standard becomes more curvaceous. These patterns were tested by correlating U.S. economic data with changing standards of bodily curvaceousness in Vogue and Playboy. Psychological and biological mechanisms by which the slender standard produces anorexia and bulimia were examined.

RESULTS

Published evidence and the empirical data suggest that the standard of bodily curvaceousness is determined by the economics of reproduction.

DISCUSSION

These ideas permit integration of the research on eating disorders in several disciplines and suggest many avenues for future enquiry.

[Anorectic and bulimic eating disorders--new developments. 1: Definitions, clinical manifestations and etiopathogenesis]

In western industrial countries, anorectic and bulimic eating disorders have appreciably increased in recent decades. For the most part, but not exclusively, the victims of such disorders are young women. The eating disorders may be understood as a failed attempt to resolve such problems as feelings of insecurity, anxiety and a lack of self-esteem. Anorexia nervosa continues to be a very serious illness with a high mortality rate. Numerous medical complications can be observed in anorexia nervosa and in bulimic eating disorders in normal-weight (bulimia nervosa) and overweight (binge eating disorder) patients. The etiology is multifactorial. Bulimic eating disorders (bulimia nervosa) in particular, whether in normal-weight or overweight patients, have recently been investigated scientifically.

[Anorectic and bulimic eating disorders--new developments. 2: Spectrum of evaluated therapy measures]

Therapeutic approaches to eating disorders--in particular the restrictive form of anorexia nervosa--should, in the first instance, be directed towards improving the patient's physical state of health. In addition, psychotherapeutic management of the interoceptive and emotional perception disturbances that are also usually present makes good sense (e.g. by cognitive behavioral therapy, video confrontation of the patient with her own appearance). On the other hand, disturbances in emotional expression also need to be addressed, and inadequate social skills improved. On an individual basis, the question must be investigated as to how far chronic stress, and/or major events in the patient's life are involved, or whether conflicts within the family or a partnership may be of significance for the initiation and maintenance of an eating disorder.

Body size estimation in anorexia nervosa patients: the significance of overestimation

Using the video distortion method on a life-size screen, we have studied body size estimation in 100 female restricting anorexia nervosa patients. About half of the patients were accurate in estimating their own body dimensions and only 20% clearly showed overestimation. We then tested whether differences in accuracy of estimation were related to scores on the following questionnaires: Eating Disorder Inventory; Body Attitude Test; and Symptom Checklist (SCL-90). Overestimators reported a more negative body attitude and a more "neurotic profile" on the SCL-90. These differences might have both prognostic and therapeutic implications.

Perceived control in eating disorders: relationship with reported sexual abuse

OBJECTIVE

Control issues appear to be central to the eating disorders. However, it is important to understand the generalizability of that link by explaining the role of life experiences that reduce levels of perceived control. This study examined the potential role of one such experience--reported sexual abuse.

METHOD

A group of 55 eating-disordered women completed the Eating Attitudes Test and a measure of perceived personal control (Locus of Control scale). They were also interviewed regarding a history of sexual abuse.

RESULTS

A reported history of sexual abuse was linked to a lower level of perceived personal control. A more external locus of control was associated with more severe eating psychopathology among abused women, particularly if the abuse was more severe. In contrast, there was no such association among the women who reported no history of sexual abuse.

CONCLUSIONS

Clinical work with eating-disordered women who report a history of sexual abuse may derive particular benefit from a focus on cognitions regarding personal control.

Anorexia nervosa in an Arab culture

The available literature indicates that anorexia nervosa is rare in Arab culture. We report 5 cases of anorexia nervosa: 3 female and 2 male patients. Two are UAE nationals, 2 are Omanis, and 1 is Sudanese. The occurrence of these cases is discussed in the context of sociocultural changes and the increasing westernization of the UAE society.

Is amenorrhea a critical criterion for anorexia nervosa?

The significance of amenorrhea as a criterion for anorexia nervosa was examined. Twelve nonamenorrheic women treated for anorexia were compared with 40 women meeting full DSM-IV criteria. The nonamenorrheic group displayed the same high levels of eating disorder, body-image disturbance, and psychopathology as the amenorrheic group, as measured by the following variables: body-size overestimation on the Image Marking Procedure; body distortion on the Body Distortion Questionnaire; eating disorder on the Eating Disorder Inventory; depression on the Beck Depression Inventory; psychopathology on the MMPI; and external locus of control on the Rotter Locus of Control Scale. Amenorrhea does not appear to be a useful criterion for distinguishing full-syndrome anorexia nervosa from partial-syndrome cases.

Comparison of habitual runners and anorexia nervosa patients

Psychological and physiological similarities have been proposed between habitual runners and anorexia nervosa patients.

METHOD

Twenty male runners, 20 female runners, and 17 anorexia nervosa patients were evaluated using several psychological measures (Minnesota Multiphasic Personality Inventory, Leyton Obsessional Inventory, and three measures of body image) and physiological measures (physical examination, anthropometric assessment, and exercise treadmill tests).

RESULTS

Anorexia nervosa patients had significantly more evidence of psychopathology on all the psychological measures than either group of runners. There were suggestive similarities between female runners and anorexics on some of the body image tests. Fat content was in the normal range for both groups of runners and low in the anorexia nervosa group. Abnormalities were seen on the treadmill tests in all three groups, but there were no statistically significant differences.

CONCLUSION

Despite hypothetical similarities, this study found that anorexia nervosa patients and habitual runners have few similar psychological or physiological features.

The variable manifestations and contextual meanings of anorexia nervosa: two case illustrations from Hong Kong

This paper discusses two Chinese anorexic patients with contrasting clinical presentations. Notwithstanding their difference with respect to the presence of the intense fear of becoming fat, their food refusal might arise from a similar sense of powerlessness which exaggerated rigid self-control and hampered self-definition at a critical phase of personal development. In order that early recognition and meaningful treatment may be facilitated, more attention to the variable manifestations and situated meanings of anorexia nervosa in different cultures is emphasized.

Body perception index: benefits, pitfalls, ideas

Estimates of body size are often expressed as a ratio of actual size [body perception index or BPI = (estimated size/actual size) x 100%]. In this article, we examine the possibility that overestimation of body size in patients with anorexia nervosa, as measured by the BPI, is due to their smaller body size rather than to their being anorexic. Using 50 mean body sizes derived from seven studies we investigated whether the error of estimation is a constant proportion of the body size to be estimated, as the use of the BPI assumes. A negative linear relation between BPI and actual body size was found, confirming that smaller size is associated with greater overestimation. However, although both groups showed a strong tendency to overestimate smaller sizes, anorexic subjects showed even greater overestimation than controls. Hence, overestimation of body size in AN can only partially be accounted for by the smaller body size of anorexic patients. Recommendations for future use of the BPI are put forward.

Eating behavior and pregnancy outcome

The association between clinical eating disorders, maternal body weight, shape, and eating concerns, and the birth of low-birth-weight infants (LBW; less than 2500 g) was investigated using a retrospective case-control study. Eighty-eight women delivering LBW infants were interviewed and then divided into two groups--those delivering term, small-for-gestational-age infants (SGA; 37 or more completed weeks, n = 34) and those delivering premature infants (less than 37 completed weeks, n = 54). There were 86 reference women (CTRL) matched for age, parity, and health insurance status, who delivered babies with birth weights greater than 2500 g. In the week postpartum, women delivering term SGA, premature (PREM), and CTRL infants were interviewed using a semistructured interview. One section of this interview included a modified version of the Eating Disorder Examination (EDE), which retrospectively generated, over the previous 12 months, diagnosis of an eating disorder and maternal "normative" weight and shape concerns. In the 3 months before pregnancy, 32% of SGA women, 9% PREM women, and 5% of reference women were diagnosed as having a clinical eating disorder. Women with a past history of an eating disorder had no greater risk of delivering a low-birth-weight infant. Women delivering SGA infants, reported elevated eating disorder psychopathology postdelivery (Eating Disorders Inventory, EDI) and more disturbances in eating behavior before and during pregnancy. Unique predictors for delivery of a LBW term SGA infant were: low maternal prepregnancy body weight, smoking, low maternal weekly weight gain, and elevated EDI (Bulimia subscale). Unique predictors for delivery of a LBW premature infant were: lower maternal occupational status, vomiting in pregnancy, and lower dietary restraint. Women with disordered eating were shown to be at greater risk of delivering term SGA infants. Predictors of term growth retardation are partly determined by maternal behavior.

The Eating Attitudes Test: comparative analysis of female and male students at the Public Ballet School of Berlin

Differentiated examination of eating attitudes and behaviours of female and male German ballet school students with particular reference to their age and analysis of common points with and differences from female Anorexia nervosa (A.n.) patients. The Eating Attitudes Test (EAT-40) was used. Male and female adolescent students of a ballet school and a high school as well as anorectic patients participated in this study. EAT totals exhibited by female and male ballet school students were higher with significance than those recorded from high school students. EAT totals > 30 were reached by 21.6% of female ballet school students but by no male ballet school student at all. In the context of certain EAT items, a number of differences are described between female ballet school students, on the one hand, and female A.n. patients, on the other. No case was identifiable which would satisfy ICD-10 criteria for Anorexia nervosa. Attitudes and behaviours of adolescent female and male ballet dancers toward eating and their own body should be judged with due consideration of their specific living conditions.

A case report of Usher's syndrome and anorexia nervosa

OBJECTIVE

This report describes the rare combination of anorexia nervosa, deafness, and visual impairment with a particular emphasis on management issues. To the author's knowledge, this is the first report of an eating disorder in a patient who is deaf with a visual impairment.

DISCUSSION

It describes the history of such a patient and the difficulties encountered in her treatment.

Outpatient group therapy for anorexia nervosa: a preliminary study

Group therapy is generally recognized as an important form of psychotherapy for anorexia nervosa patients, but there are few controlled studies of its effectiveness. The aim of the current study was to determine the effectiveness of cognitive-behavioural therapy (CBT) for the treatment of anorexia nervosa in outpatients. Twenty-six outpatients with anorexia nervosa, were assessed for depression (BDI, Beck Depression Inventory), eating psychopathology (EDI, Eating Disorders Inventory), eating attitudes (EAT, Eating Attitudes Test) and weight at the beginning and at the end of the treatment and at one year follow-up. Our results substantiate the effectiveness of the CBT approach as a treatment and also at one year follow-up. Good EAT scores were observed in 70% of our cases after the treatment and in 60% at follow-up. Further research should assess the effectiveness of therapeutic groups more intensively because of their economic advantages.