A comparison of ever-married and never-married women with anorexia nervosa or bulimia nervosa

OBJECTIVE

The results of the scant research on anorexia nervosa and marriage suggest that married anorexics may exhibit more severely disordered eating. However, past research has not controlled for the greater age of married versus unmarried anorexics, and very little research has been conducted on marriage and women with bulimia nervosa. We investigated differences in disordered eating and clinical traits between ever-married and never-married women with anorexia nervosa or bulimia nervosa and statistically controlled for age.

METHOD

Adult women ages 20-45, who were assessed in an outpatient eating disorders clinic and diagnosed with anorexia nervosa (n = 91) or bulimia nervosa (n = 223), completed several measures of disordered eating and related traits at the point of initial evaluation.

RESULTS

In simple comparisons, ever-married women differed from their never-married peers with regard to several indices of symptom history and severity. However, after controlling for age, ever-married women differed only with regard to an earlier onset of menarche and, for women with bulimia nervosa, an earlier onset of sexual intercourse.

DISCUSSION

Results are discussed with regard to possible explanation and directions for future research.

Food cravings in women with a history of anorexia nervosa

OBJECTIVE

The objective of the present study was to determine the prevalence and characteristics of food cravings in women with a history of anorexia nervosa.

METHOD

One hundred one control women selected at random and 64 women with a diagnosis of anorexia nervosa 10 to 14 years earlier (cases) completed the Diagnostic Interview for Genetic Studies, a food craving questionnaire, the Temperament and Character Inventory and the Three-Factor Eating Questionnaire.

RESULTS

A similar proportion of cases and controls reported food cravings. A greater proportion of cases reported strong cravings with two or more features of intensity (p = .02). Cravings in the cases were more likely to be characterized by difficulty resisting the craved food (p = .0008), anxiety when the craved food was unavailable (p = .002), and a high frequency of occurrence (p = .001). The cases who craved were significantly more likely to have had lifetime BN (p = .02).

CONCLUSION

A similar prevalence of food craving in cases as in controls suggests that successful control of food intake and/or denial of hunger overrides dietary restriction as a precondition for craving in anorexia nervosa. A dysfunction in the serotonergic system, the provision of intermittent reinforcement by binge episodes, and/or frustration due to unsuccessful attempts at dietary restraint may mediate the association of cravings with the presence of lifetime bulimia.

[Gender issues and eating disorders]

Sexual problems are not specific for eating disorders. The etiology is complex and no one single causal facter has been identified. However, clinical as well as epidemiological studies have shown that eating disorders occur more commonly in females than males. The evidence that eating disorders are more common in females has resulted in the postulation that socio-cultural factors may be important. An important aspect of the socio-cultural position of women which may contribute to eating disorders is the conflict in roles. Clinical experience and research have shown the important role of sexual problems and traumas in the development of anorexia nervosa and bulimia. When compared to anorexics, bulimics reported greater sexual interest and activity.

A comparison of subgroups of inpatients with anorexia nervosa

OBJECTIVE

Classification of subgroups of people with anorexia nervosa has been in flux. It has not been clear whether anorexics who only purge should be grouped with pure restricters or with people who both binge and purge.

METHODS

We compared 27 restricting-type anorexics (RAN), 26 bulimic anorexics (BAN), and 34 restricting anorexics with purging behaviors (RAN-P). All subjects were underweight and recently admitted to a hospital. We excluded subjects who had not had a diagnosis of anorexia nervosa for at least 1 year duration.

RESULTS

The three groups of subjects had similar scores for Depression and Anxiety on the Beck Depression Inventory, the Spielberger State and Trait Anxiety Inventory, and on the EDI subscales aside from higher scores for BAN subjects on the Bulimia subscale.

DISCUSSION

These three subgroups of anorexia nervosa have similar degrees of dysphoric moods and core eating disorder symptoms when underweight and malnourished.

The psychological characteristics of patients suffering from anorexia nervosa and the nurse's role in creating a therapeutic relationship

This paper reviews research on the psychological characteristics of patients suffering from anorexia nervosa and that examining the therapeutic relationship. The former research suggests that anorexic patients possess a psychological profile characterized by: a phobia of weight gain and fear of loss of control; alexithymia and lack of introceptive awareness; mistrust of self and others; cognitive dysfunction; low self-esteem; and often the presence of starvation-induced depression. The latter strongly suggests that in order for a relationship to be therapeutic it needs to be characterized by: empathy; positive regard and acceptance; warmth; commitment; trust; genuineness; and be non-judgemental. The implications of these research findings regarding the nurse's role in forming a therapeutic relationship with anorexic patients is then discussed. It is seen that it is vital that nurses receive adequate education before working with such patients, and that their knowledge is regularly updated. Nurses should receive regular clinical supervision and support, in order to ensure that they are able to provide therapeutic care for such patients.

Hypothalamic-pituitary-adrenal axis function, psychopathological traits, and natural killer (NK) cell activity in anorexia nervosa

To evaluate the role of Hypothalamic-Pituitary-Adrenal (HPA) hormones and psychoneuroendocrine modulation on NK cell activity in Anorexia Nervosa (AN) we studied in 24 patients and 20 sex- and age-matched healthy controls, the spontaneous NK activity of peripheral blood mononuclear (PBM) cells and the susceptibility in vitro to cortisol or immune interferon or interleukin-2. NK cytotoxicity of PBM cells was measured in a direct non-radiometric 4h cytolytic assay using K562 cells as targets. HPA axis function was evaluated by IV ovine Corticotropin Releasing Hormone (o-CRH) administration. We did not find clear-cut abnormalities of NK cytotoxicities either in basal conditions or after exposure to challengers. The extent of cortisol-dependent inhibition was comparable in patients and controls. Significant inverse and direct correlations were found respectively between the spontaneous NK cell activity and baseline serum cortisol at 0800 h (r = -0.5; p < .02), and between IL-2 dependent boosting of NK cell cytotoxicity and ACTH, beta-endorphin or cortisol responses after o-CRH, expressed as areas under the curve (AUC) (r = 0.46, p < .05; r = 0.46, p < .05; and r = -0.48, p < .05, respectively). Correlations observed with AUC ratios yielded more significant results (r = 0.62; p < .01 and r = 0.51; p < .05 respectively). These data suggest a role for Proopiomelanocortin (POMC) derived peptides in the regulation of NK cell activity in AN, and multifaceted relationships between this particular immune function, on the one hand, and certain patterns of HPA axis function on the other.

Death themes in anorexia nervosa: dimensions for a reply to Jackson et al

OBJECTIVE

To provide a critical, theoretical response to some ideas argued initially by Jackson and Davidson (Int J Eat Dis, 5, 821-835, 1986). Those ideas developed an understanding of anorexia nervosa in terms of disturbed death ideation and the notion of the anorexia nervosa sufferer as a "survivor." This paper was intended to broaden the frame of reference for a consideration of the relationship between eating disorders and death ideation.

METHOD

The approach is a reflection on three domains of thinking about death and destructiveness, two within psychology, the third a perspective provided by philosophy. Specifically, early post-Freudian work, personal construct psychology, and the philosophical tradition that makes death generally significant in human life, that is, Existentialism, are discussed in terms of their illumination of the ideas under review.

RESULTS

The result is a series of speculative observations that constitute an argument that these three domains together provide a strong countercritical position to the idea of a universal, even a general significance of death, particularly etiologically, in anorexia nervosa.

DISCUSSION

The discussion suggests that the particular significance of death ideation in a multidimensional condition like anorexia nervosa must be derived in each particular case where it will sometimes be more, sometimes less significant, and, importantly, will mean something different to each individual sufferer.

[Opinions regarding the importance of body image disorders in the development and in the course of eating disorders]

The article presents a review of most important research results as well as opinions about the role and importance of body image disturbances in the development and the course of eating disorders. It also contains a review of definitions of body image, and techniques used in the evaluation of this type of disorders.

Family and individual therapy in anorexia nervosa. A 5-year follow-up

BACKGROUND

There is evidence that specific psychological treatments are effective in patients with eating disorders. Our goal was to determine by means of a controlled trial whether psychological treatments, previously found to be effective in anorexia nervosa, gave rise to enduring benefits.

METHODS

A 5-year follow-up was conducted on patients who had participated in a previous trial of family therapy for anorexia and bulimia nervosa. Family therapy or individual supportive therapy had been administered to 80 outpatients for 1 year beginning on discharge from hospital after weight restoration. The 80 patients had been subdivided into 4 prognostically homogeneous groups of which 2 turned out to be the most important: patients with early onset and short history of anorexia nervosa, and patients with late-onset anorexia nervosa. At the 5-year follow-up, the efficacy of the outpatient therapies was again assessed by the maintenance of weight, and the categories of general outcome and dimensions of clinical functioning defined by the Morgan-Russell scales.

RESULTS

Significant improvements were found in the group of 80 patients as a whole, mainly attributable to the natural outcome of anorexia nervosa, and most evident in the early onset and short history group, as expected. Within 2 of the prognostic groups, significant benefits attributable to previous psychological treatments were still evident, favoring family therapy for patients with early onset and short history of anorexia nervosa and favoring individual supportive therapy for patients with late-onset anorexia nervosa.

CONCLUSIONS

Much of the improvements found at a 5-year follow-up can be attributed to the natural outcome of the illness. Nevertheless, it was still possible to detect long-term benefits of psychological therapies completed 5 years previously.

A comparative study of defense styles of bulimic, anorexic and normal females

We have compared the defense styles of anorexic (N = 41), bulimic (N = 37) and normal females (N = 72) living in Paris, using the Bond Defense Style Questionnaire relating to 17 defenses: sublimation, anticipation, suppression, undoing, idealization, reaction formation, projection, passive aggression, acting out, isolation, devaluation, autistic fantasy, denial, displacement, dissociation, splitting and somatization. The objective of this study was to better understand the personality structure in terms of psychological defenses of adolescent girls and young women suffering from anorexia or bulimia nervosa (DSM-III-R). Data showed significant differences of psychological functioning between control subjects and eating disorder subjects, particularly for the projection, undoing and sublimation defenses. Anorexics differed from the bulimic females only on the passive aggression, isolation and devaluation defenses. These data are discussed in relation to the hypothesis that anorexics and bulimics can be situated on the same continuum ranging from normal to eating disorders with certain common psychological features as risk factors shared by the eating disorder females.

Anorexia nervosa in a 7-year-old girl

We report on a 7-year-old girl with anorexia nervosa and consider factors contributing to this early emergency. Cognitive differences in younger children can alter their understanding of this illness, so we chronicled this girl's treatment because it diverged from practices used with older patients. Accordingly, effective interventions in very young anorexics might require modifications of treatments used in postpubertal populations.

Paradox, persecution and the double game: psychotherapy in anorexia nervosa

OBJECTIVE

In anorexia nervosa, the interface between psychotherapy and effective physical management continues to arouse dissent. For this reason, theoretical underpinnings and their practical applications were explored.

METHOD

A selective review of the literature was based on the authors' clinical experience in hospital treatment settings.

RESULTS

The psychosomatic paradigm, the threat to life, the reward characteristics and the developmental trajectory of anorexia nervosa necessitate a particular form of integrated psychotherapy.

CONCLUSIONS

The approach is essentially that of self psychology but with an important departure which must be addressed in the therapeutic process. This is exemplifed in the paradox of persecution by refeeding and the curious double game that evolves.

The intellectual functioning of adolescents with anorexia nervosa and bulimia nervosa

The aim of this study was to investigate the intellectual functioning of a large group of eating disordered adolescents in order to test two hypotheses, viz, that the intellectual functioning of eating disordered adolescents conforms to the normal distribution, and that eating disordered adolescents do not perform better in verbal abilities than in nonverbal abilities. Standard intelligence tests were applied to 190 consecutive out- and inpatients with eating disorder diagnoses. The results were compared with those of a group of patients with other disorders, similar in age, sex, SES, and year of admission. The IQ of the eating disordered patients was significantly higher than that of patients in the comparison group. Patients in the comparison group and bulimic patients, but not anorexic patients, showed better nonverbal than verbal intellectual performance.

[A German version of the Eating Disorder Inventory EDI-2]

The paper presents a German version of the second revised edition of the Eating Disorder Inventory EDI-2 (Garner 1991). The EDI-2 is a self-rating inventory (self-report measure) with 91 items and 11 subscales designed for the assessment of attitudinal and behavioural dimensions relevant to anorexia and bulimia nervosa. It consists of the eight original subscales: drive for thinness, bulimia, body dissatisfaction, ineffectiveness, perfectionism, interpersonal distrust, interoception and maturity fears, and the three new subscales: asceticism, impulse regulation and social insecurity. The German EDI-2 was given to 71 patients with anorexia or bulimia nervosa, 30 patients with binge eating disorder, a control group of 186 women and a further control group of 102 men. In comparison to the female control group, patient groups showed significantly elevated means on all subscales. Item analysis revealed sufficient internal consistencies for all subscales except subscale 9 (asceticism) with Cronbachs alpha ranging from 0.58 to 0.90. Twelve of the 91 items showed poor item total scale correlations below 0.40. Factor analysis supported a six-factor-structure. Hence, the reliability and validity of the three new subscales was confirmed only partially. The use of the EDI-2 in therapy research and clinical practice is critically discussed.

[Psychoanalytically oriented treatment of anorexia nervosa. Methodology-related critical review of the literature using meta-analysis methods]

Psychodynamic approaches to treatment in anorexia nervosa (AN) remain influential. It is unclear, how a psychodynamic orientation influences outcome with this patient group. To our knowledge, there exists no systematic review (sensu Cochrane) of the subject.

METHODS

Extensive electronic and hand searches were conduced (updated in December 1995) to identify case reports and all longitudinal and comparison studies using "psychodynamic" treatment approaches, published in English, French and German. Case reports were examined for treatment "components". Group studies meeting operationalised criteria were independently rated for methodological quality, 12 aspects of treatment and its delivery (setting, type, orientation and focus) and therapy dose and duration. Effect sizes were calculated for post treatment and follow-up. Multiple regression analysis was used to identify outcome predictors.

FINDINGS

Six treatment comparison studies and seven follow-up studies met criteria. In most case reports and studies treatment included different settings and techniques and an explicit focus on the symptom. In the two studies directly comparing undifferentiated psychodynamic treatment and "treatment as usual" resp. With psychodynamically based disorder specific treatments the latter had better results. Outpatient treatment was as successful as inpatient treatment (in somewhat different populations). It was not possible to identify outcome predictors.

INTERPRETATION

"Psychodynamic" treatment in AN is more pragmatic and disorder orientated than generally acknowledged; patients seem to fare better in specialized treatment programmes delivered by experienced teams; less cachectic patients can be treated as outpatients by a specialized team. The exact contribution to treatment outcome of the psychodynamic orientation remains to be delineated. There is a great need for well designed and well presented treatment outcome studies.

[Are psychotropic drugs necessary for the treatment of anorexia and bulimia nervosa?]

This review summarises the results of psychopharmacological treatment studies on anorexia and, bulimia nervosa. Although several drugs have tested in patients with anorexia nervosa, the outcome of controlled studies has been disappointing. Trials of pharmacotherapy for bulimia nervosa have demonstrated that tricyclic antidepressants, monoamine oxidase inhibitors and selective serotonin reuptake inhibitors significantly reduce the frequency of binge eating and purging. In some cases, psychotherapists should accept the necessity of psychopharmacological intervention, although this does not imply a known biological cause of the eating disorder. However, the significance of antidepressant medication in the overall treatment of anorexia and bulimia nervosa remains unclear.

[Comparison of controlled psycho- and pharmacotherapy studies in bulimia and anorexia nervosa]

Controlled studies of psychological, pharmacological and combined treatments for bulimia and anorexia nervosa were examined. Only studies with random assignment to treatment groups were included. Outcome criteria differed for anorexia and bulimia nervosa. The bulimia nervosa studies were evaluated in a meta-analysis. The results of the abstinence and reduction rates as well as the magnitude of the effects confirm the superiority of psychological approaches to pharmacological treatment with antidepressants. The few combined treatment studies suggest the same results as for psychological treatment alone. Longer treatment duration turned out to be a positive predictor for the effects of purging and depression. As far as anorexia nervosa is concerned, there is a general and significant lack of controlled treatment studies. Since almost all of the existing psychological and pharmacological treatment studies involve additional treatment elements, a clear assignment to the treatment categories is difficult.

A controlled study of trait narcissism in anorexia and bulimia nervosa

INTRODUCTION

Many theories attribute anorexia and bulimia nervosa to "pathological narcissism," but this conception has not been adequately evaluated.

METHOD

We compared the scores of 90 eating disorder (ED) sufferers (23 anorexic restricters, 14 anorexic bingers, and 53 bulimics) with those of 36 psychiatric-control (PC) and 54 normal-control (NC) females on validated self-report scales measuring Narcissism, Affective Instability, Stimulus Seeking, Compulsivity, and Restricted Expression.

RESULTS

Narcissism scores of ED patients (whether restricters or bingers/purgers) consistently exceeded those of the PC and NC cases, suggesting that Narcissism does indeed load more heavily in the EDs than in other psychiatric disturbances. Conversely, Affective Instability was characteristic of all clinical cases (i.e., of EDs and PCs), Restricted Expression and Compulsivity were characteristic of restricters, and Stimulus Seeking was characteristic of bingers/purgers.

DISCUSSION

Results are consistent with the notion that different ED variants may reflect subtype-specific temperaments and/or adaptive styles acting-upon shared underlying narcissistic disturbances.

Catatonic syndrome preceded by symptoms of anorexia nervosa in a 14-year-old boy with arachnoid cyst

This paper reports a case of a 14-year-old boy with arachnoid cyst in the right parietal region, who was referred to the child psychiatry department due to anorexia nervosa. A few days after admission he developed nihilistic and guilt delusions and lapsed into catatonia. The diagnostic problems and relations between his various pathological conditions (anorexia, catatonia, organic brain lesion) are discussed in this paper.