Comorbidity between eating disorders and anxiety disorders: a review

Mediation of symptom changes during inpatient treatment for eating disorders: the role of obsessive-compulsive features

The present study examined the relative contributions of changes in obsessive-compulsive symptoms among eating-disorder patients with (n = 254) and without (n = 254) obsessive-compulsive disorder (OCD) to eating-disorder symptom improvement observed with inpatient treatment. Consistent with hypothesis, multilevel mediation analyses revealed that improvements in OCD symptoms over time accounted for significant variance in the improvements in eating-disorder symptoms over time, with stronger mediation evident among eating-disorder patients with comorbid OCD (percent mediated; P(M) = 22.5%) compared to those without OCD (P(M) = 12.2%). However, decreases in eating-disorder symptoms over time fully mediated improvements in OCD symptoms over time, and this mediated pathway did not vary substantially as a function of comorbid OCD status. The theoretical and treatment implications of these findings for conceptualizing the relationship between eating disorders and OCD are discussed.

Body dysmorphic disorder: some key issues for DSM-V

Body dysmorphic disorder (BDD), a distressing or impairing preoccupation with an imagined or slight defect in appearance, has been described for more than a century and increasingly studied over the past several decades. This article provides a focused review of issues pertaining to BDD that are relevant to DSM-V. The review presents a number of options and preliminary recommendations to be considered for DSM-V: (1) Criterion A may benefit from some rewording, without changing its focus or meaning; (2) There are both advantages and disadvantages to adding a new criterion to reflect compulsive BDD behaviors; this possible addition requires further consideration; (3) A clinical significance criterion seems necessary for BDD to differentiate it from normal appearance concerns; (4) BDD and eating disorders have some overlapping features and need to be differentiated; some minor changes to DSM-IV's criterion C are suggested; (5) BDD should not be broadened to include body integrity identity disorder (apotemnophilia) or olfactory reference syndrome; (6) There is no compelling evidence for including diagnostic features or subtypes that are specific to gender-related, age-related, or cultural manifestations of BDD; (7) Adding muscle dysmorphia as a specifier may have clinical utility; and (8) The ICD-10 criteria for hypochondriacal disorder are not suitable for BDD, and there is no empirical evidence that BDD and hypochondriasis are the same disorder. The issue of how BDD's delusional variant should be classified in DSM-V is briefly discussed and will be addressed more extensively in a separate article.

[Social phobia in anorexia nervosa: evolution during the care]

CONTEXT

The links between anorexia nervosa (AN) and anxiety disorders, and particularly social phobia, are little known. However, social phobia occurs frequently in AN. Some studies have shown reduction in anxious and depressive symptomatology in AN with re-nutrition. But, to our knowledge, no work has examined the evolution of social phobia symptoms during re-nutrition in AN.

OBJECTIVES

To specify the links between AN, nutritional state, and social phobia.

METHOD

The population consisted of 2 samples and the analysis was conducted using the SPSS11.5. Sample 1 (N=24 AN) was evaluated on admission and on leaving the hospital. Our evaluation used the body mass index (BMI), the Liebowitz scale, the Mini International Neuropsychiatric Interview (MINI), and the Yale-Brown Obsessive Compulsive Scale for Eating Disorders scale (Y-BOCS-ED) respectively to evaluate or diagnose the state of malnutrition, social anxiety symptomatology, social phobia in Diagnostic and Statistical Manual-4 (DSM-IV) and anorexic symptomatology. Sample 2 (N=60) was assessed at the end of the hospitalization and then 6, 12 and 18 months later. We used the BMI, Liebowitz scale, MINI, and Eating Disorders Inventory (EDI) to assess anorexic symptomatology. In addition, the Morgan-Russell outcome assessment schedule (MR schedule) was used to assess the total clinical state of the patients.

RESULTS

Social anxiety symptomatology and actual diagnosis decreased throughout the treatment. However, regardless of the point at which the patient received care, there was no correlation between social phobia and nutritional state, as indicated by BMI. A correlation existed between social phobia and AN symptomatology, and between social phobia and total clinical state, during the out-patient care.

CONCLUSION

A component of AN-social phobia comorbidity is still questionable. Is it linked to the clinical state of the subjects (question of an additional effect of under nutrition and cognition), or even to AN? Others indicators of under nutrition are of interest and warrant further evaluations. We therefore feel that a diagnosis of social phobia can only be confirmed after an acute state of AN, thus allowing for preferential treatments. Others studies must be conducted in order to continue to explore the links between social phobia and AN.

Evidence-Based Assessment of Child Obsessive Compulsive Disorder: Recommendations for Clinical Practice and Treatment Research

Obsessive-compulsive disorder (OCD) presents heterogeneously and can be difficult to assess in youth. This review focuses on research-supported assessment approaches for OCD in childhood. Content areas include pre-visit screening, diagnostic establishment, differential diagnosis, assessment of comorbid psychiatric conditions, tracking symptom severity, determining psychosocial functioning, and evaluating clinical improvement. Throughout this review, similarities and differences between assessment approaches geared towards clinical and research settings are discussed.

Eating disorders and multi-level models of emotion: an integrated model

This paper examines the relationship between emotions, depression and eating disorders. Initially, a review is undertaken of the current state of the research and clinical literature with regard to emotional factors in eating disorders. This literature is then integrated within a version of the multi-level model of emotion proposed by Power and Dalgleish. The aim of this paper is to incorporate a basic emotions, multi-modal perspective into developing a new emotions-based model that offers a theoretical understanding of psychological mechanisms in eating disorders. Within the new Schematic Propositional Analogical Associative Representation System model applied to eating disorders, it is argued that the emotions of anger and disgust are of importance in eating disorders and that the eating disorder itself operates as an inhibitor of emotions within the self. It is hoped that the development of a multi-levelled model of eating disorders will allow for the construction of number of specific testable hypotheses that are relevant to future research into the psychological treatment and understanding of eating disorders.

The validity of virtual environments for eliciting emotional responses in patients with eating disorders and in controls

This article explores the efficacy of virtual environments representing situations that are emotionally significant to patients with eating disorders (ED) to modify depression and anxiety levels both in these patients and in controls. Eighty-five ED patients and 108 students were randomly exposed to five experimental virtual environments (a kitchen with low-calorie food, a kitchen with high-calorie food, a restaurant with high-calorie food, a restaurant with low-calorie food, and a swimming-pool) and to one neutral environment. In the interval between the presentation of each situation, anxiety and depressed mood were assessed. Results of several repeated measures analyses demonstrated that patients show higher levels of anxiety and a more depressed mood after eating, especially high-calorie food, and after visiting the swimming pool than in the neutral room. In contrast, controls only show higher levels of anxiety in the swimming pool. In the rest of the situations they presented a similar mood state as in the neutral room. We concluded that virtual reality is a useful vehicle for eliciting similar emotional reactions to those one would expect in real life situations. Thus, this technology seems well suited for use in experimental studies as well as in evaluative and therapeutic contexts.

The epidemiology of eating disorders in six European countries: results of the ESEMeD-WMH project

Few data are available to estimate the prevalence of eating disorders (EDs) and their correlates in the community. This paper reports data on EDs obtained in the framework of the ESEMeD project, aimed at investigating the prevalence of non-psychotic mental disorders in six European countries (Belgium, France, Germany, Italy, the Netherlands and Spain), using a new version of the Composite International Diagnostic Interview. The ESEMeD study was a general population cross-sectional household survey. In total, 21,425 respondents aged 18 or older provided data for the project between January 2001 and August 2003. A subsample (N=4139) underwent a detailed investigation on EDs. Lifetime estimated prevalence of anorexia nervosa, bulimia nervosa, binge eating disorder, sub-threshold binge eating disorder, and any binge eating were 0.48%, 0.51%, 1.12%, 0.72%, and 2.15%, respectively, and they were 3-8 times higher among women for all EDs. However, since people under 18 were excluded from this study, our prevalence should be taken as lower-bound estimate of real frequencies. Indeed, cumulative lifetime prevalence analysis showed that the majority of eating disorders had their initial onset between 10 and 20 years of age. Role impairment and comorbidity with other mental disorders were highly common, yet only small proportions of patients with a lifetime diagnosis of EDs requested medical treatment. It still has to be proven whether early diagnostic identification and access to specialized care can reduce the burden caused by these disorders.

Cognitive-behavioural therapy for individuals with bulimia nervosa and a co-occurring substance use disorder

A significant percentage of individuals with bulimia nervosa (BN) also can be diagnosed with a co-occurring substance use disorder (SUD). Although studies have addressed the frequency of overlap between the disorders, etiology and shared personality traits, limited research is available about the treatment of these comorbid patients. Adapting cognitive-behaviour therapy (CBT) to serve as an integrated treatment for patients with both BN and a SUD is a viable option, as studies of CBT suggest that this form of treatment is efficacious for both disorders independently. The shared strategies in CBT for BN and SUDs facilitate the development of a combined treatment for individuals with both disorders with the addition of modules designed to address some common features of these disorders, such as motivation, difficulty with interpersonal relationships, reward sensitivity and impulsivity. Future research should begin to evaluate the efficacy of an integrated CBT in treating individuals with BN and a SUD.

Emotional perception in eating disorders

OBJECTIVE

It remains an open question whether there are basic emotional perception and emotional processing deficits in eating disorders (ED). The aim of this study was to explore deficits in emotional perception in restrictive anorexia nervosa (AN-R) and bulimia nervosa (BN), using visual emotional stimuli.

METHOD

Thirty-four patients with ED (19 with BN and 15 with AN-R) were compared with 25 controls. Visual stimuli from the international affective picture system were used.

RESULTS

Patients with AN-R showed increased fear when confronted with stimuli containing anger, whereas patients with BN showed a tendency towards decreased fear. There were no other fundamental differences in the emotional perception of fear, happiness, sadness, and anger.

DISCUSSION

The finding of increased fear when exposed to the emotion of anger might be attributed to introversion and conflict avoidance of anorectic patients. No other basic deficiency of emotional perception was found.

Interspecies genetics of eating disorder traits

Family and twin studies have indicated that genetic factors play a role in the development of eating disorders, such as anorexia and bulimia nervosa, but novel views and tools may enhance the identification of neurobiological mechanisms underlying these conditions. Here we propose an integrative genetic approach to reveal novel biological substrates of eating disorder traits analogous in mouse and human. For example, comparable to behavioral hyperactivity that is observed in 40-80% of anorexia nervosa patients, inbred strains of mice with different genetic backgrounds are differentially susceptible to develop behavioral hyperactivity when food restricted. In addition, a list of characteristics that are relevant to eating disorders and approaches to their measurement in humans together with potential analogous rodent models has been generated. Interspecies genetics of neurobehavioral characteristics of eating disorders has the potential to open new roads to identify and functionally test genetic pathways that influence neurocircuits relevant for these heterogeneous psychiatric disorders.

Is there a relationship between parental self-reported psychopathology and symptom severity in adolescents with anorexia nervosa?

The current study aimed to screen for indications of psychopathology displayed by the parents of adolescents diagnosed with Anorexia Nervosa (AN), and examine the relationship between severity of adolescent eating disorder symptoms and parental psychopathology. Sixty female adolescents diagnosed with DSM-IV-TR AN (restricting-type and binge-purge-type) were administered the Eating Disorder Examination (EDE) and parents completed the Symptom Checklist 90-Revised (SCL-90-R). As compared to established non-patient norms, both fathers and mothers of adolescents with AN reported greater levels of obsessive compulsive behaviors, hostility, depression, and anxiety as measured by the SCL-90-R. In addition, duration of AN was positively associated with hostility scores in fathers, and global EDE scores were associated with hostility in mothers. While parental scores on the SCL-90 were elevated as compared to community samples, results of this study do not support a direct influence of parental psychopathology on symptom severity of adolescent AN. Increasing rates of hostility scores in parents with increased duration of AN may represent either a response to the presence of the disorder or be a maintaining factor for AN.

Anxiety, Alexithymia, and Depression as Mediators of the Association between Childhood Abuse and Eating Disordered Behavior in African American and European American Women

This study evaluated structural equation models of the associations among family functioning, childhood abuse, depression, anxiety, alexithymia, and eating disorder symptomatology in a sample of 412 European American and 192 African American female undergraduates. Additionally, the specific roles of anxiety, depression, and alexithymia as mediators were assessed. Each of these variables was a significant mediator of the association between childhood abuse and disordered eating. Finally, a test of invariance between the African American and European American subsamples was significant, highlighting the need for additional cross-cultural eating disorder research.

Influence of overanxious disorder of childhood on the expression of anorexia nervosa

OBJECTIVE

Childhood anxiety often precedes the onset of anorexia nervosa (AN) and may mark a liability to the emergence of an eating disorder for some women. This study investigates the prevalence of overanxious disorder (OAD) among women with AN and explores how OAD impacts AN symptoms and personality traits.

METHOD

Participants were 637 women with AN who completed an eating disorders history, the Structured Clinical Interview for DSM-IV Axis I Disorders, and assessments for childhood anxiety, eating disorder attitudes, and associated personality traits.

RESULTS

Of 249 women (39.1%) reporting a history of OAD, 235 (94.4%) met criteria for OAD before meeting criteria for AN. In comparison to those without OAD, women with AN and OAD self-reported more extreme personality traits and attitudes and they engaged in more compensatory behaviors.

CONCLUSION

Among individuals with AN, those entering AN on a pathway via OAD present with more severe eating disorder pathology.

Neurobiology of anorexia and bulimia nervosa

Anorexia nervosa (AN) and bulimia nervosa (BN) are related disorders of unknown etiology that most commonly begin during adolescence in women. AN and BN have unique and puzzling symptoms, such as restricted eating or binge-purge behaviors, body image distortions, denial of emaciation, and resistance to treatment. These are often chronic and relapsing disorders, and AN has the highest death rate of any psychiatric disorder. The lack of understanding of the pathogenesis of this illness has hindered the development of effective interventions, particularly for AN. Individuals with AN and BN are consistently characterized by perfectionism, obsessive-compulsiveness, and dysphoric mood. Individuals with AN tend to have high constraint, constriction of affect and emotional expressiveness, ahendonia and asceticism, whereas individuals with BN tend to be more impulsive and sensation seeking. Such symptoms often begin in childhood, before the onset of an eating disorder, and persist after recovery, suggesting they are traits that create a vulnerability for developing an ED. There is growing acknowledgement that neurobiological vulnerabilities make a substantial contribution to the pathogenesis of AN and BN. Considerable evidence suggests that altered brain serotonin (5-HT) function contributes to dysregulation of appetite, mood, and impulse control in AN and BN. Brain imaging studies, using 5-HT specific ligands, show that disturbances of 5-HT function occur when people are ill, and persist after recovery from AN and BN. It is possible that a trait-related disturbance of 5-HT neuronal modulation predates the onset of AN and contributes to premorbid symptoms of anxiety, obsessionality, and inhibition. This dysphoric temperament may involve an inherent dysregulation of emotional and reward pathways which also mediate the hedonic aspects of feeding, thus making these individuals vulnerable to disturbed appetitive behaviors. Restricting food intake may become powerfully reinforcing because it provides a temporary respite from dysphoric mood. Several factors may act on these vulnerabilities to cause AN to start in adolescence. First, puberty-related female gonadal steroids or age-related changes may exacerbate 5-HT dysregulation. Second, stress and/or cultural and societal pressures may contribute by increasing anxious and obsessional temperament. Individuals with AN may discover that reduced dietary intake, by reducing plasma tryptophan availability, is a means by which they can modulate brain 5-HT functional activity and anxious mood. People with AN enter a vicious cycle which accounts for the chronicity of this disorder because caloric restriction results in a brief respite from dysphoric mood. However, malnutrition and weight loss, in turn, produce alterations in many neuropeptides and monoamine function, perhaps in the service of conserving energy, but which also exaggerates dysphoric mood. In summary, this article reviews findings in brain chemistry and neuroimaging that shed new light on understanding the psychopathology of these difficult and frustrating disorders.

Taste-dependent sociophobia: when food and company do not mix

Using a combination of the paradigm of conditioned taste aversion (CTA) and of the paradigm of social interactions, we report here that in the rat, eating while anxious may result in long-term alterations in social behavior. In the conventional CTA, the subject learns to associate a tastant (the conditioned stimulus, CS) with delayed toxicosis (an unconditioned stimulus, UCS) to yield taste aversion (the conditioned response, CR). However, the association of taste with delayed negative internal states that could generate CRs that are different from taste aversion should not be neglected. Such associations may contribute to the ontogenesis, reinforcement and symptoms of some types of taste- and food-related disorders. We have recently reported that a delayed anxiety-like state, induced by the anxiogenic drug meta-chlorophenylpiperazine (mCPP), can specifically associate with taste to produce CTA. We now show that a similar protocol results in a marked lingering impairment in social interactions in response to the conditioned taste. This is hence a learned situation in which food and company do not mix well.

Linguistic analyses of natural written language: unobtrusive assessment of cognitive style in eating disorders

OBJECTIVE

Linguistic style analysis is introduced as a method of nonreactive measurement of cognitive style in individuals with eating disorders (ED).

METHOD

A journaling exercise was implemented on an ED inpatient unit. Thirty-four written essays collected from an unselected sample of 11 patients were analysed with the Linguistic Inquiry and Word Count, with regard to predefined text categories. At each session, self-report of participant well-being and session impact were assessed.

RESULTS

Compared to essays from a student control group, and message-board entries of individuals who had recovered from an anorexia nervosa (AN), the inpatient journals displayed the highest rates of self-related words, negative emotion words, and the lowest rate of positive emotion words. Inpatients used more anxiety words and fewer words that refer to social processes and eating concerns than individuals who had recovered from an AN. Associations were found between linguistic categories, prewriting well-being, and postwriting evaluation.

CONCLUSION

Linguistic style analysis offers insights into cognitive styles, and provides a promising approach for their unobtrusive measurement in ED.

The genetics of anorexia nervosa

Anorexia nervosa is a perplexing illness marked by low body weight and persistent fear of weight gain. Anorexia nervosa has the highest mortality rate of any psychiatric disease. Historically, anorexia nervosa was viewed as a disorder primarily influenced by sociocultural factors; however, over the past decade, this perception has been challenged. Family studies have consistently demonstrated that anorexia nervosa runs in families. Twin studies have underscored the contribution of additive genetic factors to the observed familial aggregation. With these bodies of literature as a starting point, we evaluate critically the current state of research on molecular genetic studies of anorexia nervosa and provide guidance for future research.

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.

The relationship of body dysmorphic disorder and eating disorders to obsessive-compulsive disorder

Body dysmorphic disorder (BDD) and eating disorders are body image disorders that have long been hypothesized to be related to obsessive-compulsive disorder (OCD). Available data suggest that BDD and eating disorders are often comorbid with OCD. Data from a variety of domains suggest that both BDD and eating disorders have many similarities with OCD and seem related to OCD. However, these disorders also differ from OCD in some ways. Additional research is needed on the relationship of BDD and eating disorders to OCD, including studies that directly compare them to OCD in a variety of domains, including phenomenology, family history, neurobiology, and etiology.

Treatment responses of inpatient eating disorder women with and without co-occurring obsessive-compulsive disorder

We analyzed the influence of co-occurring obsessive-compulsive disorder (OCD) on response to eating disorder (ED) treatment among 2,971 female inpatients. We assessed treatment response using Eating Disorder Inventory-2 and DSM-IV ED criteria. Multivariate analyses included sociodemographics, illness severity, and co-occurring Axis I/II diagnoses. ED inpatients with OCD had greater ED severity than those without OCD. However, no differences occurred in short- and intermediate-term ED outcomes. Patients with and without OCD evidenced the same degree of change in EDI-2 scores admission-to-discharge and discharge-to-one-year; and 93% of patients both with and without OCD no longer evidenced a DSM-IV ED diagnosis one-year post-discharge. Results suggest that with co-occurring OCD treated using evidence-based interventions ED inpatients with and without OCD may have similar prognoses.

The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication

BACKGROUND

Little population-based data exist on the prevalence or correlates of eating disorders.

METHODS

Prevalence and correlates of eating disorders from the National Comorbidity Replication, a nationally representative face-to-face household survey (n = 9282), conducted in 2001-2003, were assessed using the WHO Composite International Diagnostic Interview.

RESULTS

Lifetime prevalence estimates of DSM-IV anorexia nervosa, bulimia nervosa, and binge eating disorder are .9%, 1.5%, and 3.5% among women, and .3% .5%, and 2.0% among men. Survival analysis based on retrospective age-of-onset reports suggests that risk of bulimia nervosa and binge eating disorder increased with successive birth cohorts. All 3 disorders are significantly comorbid with many other DSM-IV disorders. Lifetime anorexia nervosa is significantly associated with low current weight (body-mass index <18.5), whereas lifetime binge eating disorder is associated with current severe obesity (body-mass index > or =40). Although most respondents with 12-month bulimia nervosa and binge eating disorder report some role impairment (data unavailable for anorexia nervosa since no respondents met criteria for 12-month prevalence), only a minority of cases ever sought treatment.

CONCLUSIONS

Eating disorders, although relatively uncommon, represent a public health concern because they are frequently associated with other psychopathology and role impairment, and are frequently under-treated.

Comorbidity studies of eating disorders and mood disorders. Critical review of the literature

OBJECTIVE

We conducted a critical literature review of studies assessing the prevalence of mood disorders (MD) in subjects with eating disorders (ED; anorexia nervosa and bulimia nervosa). In the first part of this article, we discuss methodological issues relevant to comorbidity studies between ED and MD. In the second part, we summarize the findings of these studies in light of the methodological considerations raised.

METHOD

A manual computerised search (Medline) was performed for all published studies on comorbidity between ED and MD. In order to have sufficiently homogeneous diagnostic criteria for both categories of disorders, this search was limited to articles published between 1985 and 2006.

RESULTS

Too few studies include control groups, few studies compared diagnostic subgroups of ED subjects, and results are scarce or conflicting.

DISCUSSION

The results are discussed in the light of the methodological problems observed. The implications when reviewing the results of published studies and planning future research are set out.

Mediating social anxiety and disordered eating: the role of expressive suppression

Social anxiety and disordered eating frequently overlap, and evidence suggests that emotional suppression may be an important mediating factor. The present study examines the relationships among social anxiety, emotional suppression, and disordered eating in a non-clinical sample of 160 undergraduate women. Participants completed self-report measures for social anxiety, disordered eating, expressive suppression, depression, and negative affect. Results from mediation analyses indicate that the relationship between social anxiety and disordered eating is fully mediated by expressive suppression. Findings are consistent with a displacement theory in which unexpressed negative affect is shifted towards the body, thereby promoting symptoms of disordered eating.

The co-morbidity of eating disorders and anxiety disorders: a review

OBJECTIVE

To critically review the literature examining the co-morbidity between eating disorders and anxiety disorders.

METHOD

A review of the literature on the co-morbidity between anorexia nervosa, bulimia nervosa and eating disorders not otherwise specified and the anxiety disorders of OCD, PTSD, social anxiety, GAD, panic and agoraphobia.

RESULTS

Of the empirical studies undertaken, it is clear that anxiety disorders are significantly more frequent in subjects with eating disorders than the general community. Researchers have shown that often anxiety disorders pre-date eating disorders, leading to a suggestion that early onset anxiety may predispose individuals to developing an eating disorder. To date however, the research presents strikingly inconsistent findings, thus complicating our understanding of eating disorder and anxiety co-morbidity. Furthermore, despite indications that eating disorder prevalence amongst individuals presenting for anxiety treatment may be high, there is a distinct lack of research in this area.

DISCUSSION

This review critically examines the available research to date on the co-morbidity of eating disorders and anxiety disorders. Some of the methodological limitations of previous research are presented, in order to highlight the issues which warrant further scientific investigation in this area.

Does the frequency of anxiety and depressive disorders differ between diagnostic subtypes of anorexia nervosa and bulimia?

OBJECTIVE

The objective of the present work is to determine whether the prevalence of depressive and anxiety disorders varies in subgroups of eating disorders (ED) according to age, ED duration, mode of care provision, and body mass index (BMI).

METHOD

Using the Mini International Neuropsychiatric Interview (MINI), the frequency of anxiety and depressive disorders was evaluated in 271 ED participants. Their prevalence was compared in subgroups of anorexics (AN-R and AN-BN) and bulimics (BN), both before and after controlling for potential confounding variables.

RESULTS

Current or lifetime comorbidity of anxiety and depressive disorders did not differ between AN-R and AN-BN groups. Social phobia, panic disorders, and obsessive-compulsive disorder (OCD) were significantly more frequent in AN-BN and AN-R groups. Panic disorder was more frequent in the BN group.

CONCLUSION

Several confounding factors, in particular those identified in the present study, may explain previous conflicting results on the frequency of anxiety and depressive disorders in ED. Nevertheless, the study confirmed that OCD is more frequent in AN, even after controlling for confounding factors.

Dietary restriction changes behaviours in brain-derived neurotrophic factor heterozygous mice: role of serotonergic system

Accumulating evidence has suggested that brain-derived neurotrophic factor (BDNF) plays a role in eating behaviours, and that BDNF-heterozygous (+/-) mice exhibit abnormal behaviours (e.g. obesity, anxiety and aggression). The present study was undertaken to determine whether or not dietary restriction (DR) alters the behaviours in BDNF(+/-) mice, as DR has been shown to exert a number of beneficial effects on the brain. Eight-week-old male wild-type (+/+) and BDNF(+/-) mice were divided into two groups, ad libitum (AL) diet group and DR group, for 16 weeks. After carrying out a behavioural evaluation, we determined the BDNF mRNA levels, as well as mRNA levels for subtypes (5-HT(1A), 5-HT(1B), 5-HT(2A) and 5-HT(2C)) of the 5-HT receptor and 5-HT transporter (5-HTT), protein levels of BDNF and concentrations of 5-HT and 5-HIAA in the hypothalamus, hippocampus and frontal cortex. DR significantly ameliorated behaviours including obesity, anxiety and aggression in BDNF(+/-) mice. The concentrations of 5-HT and 5-HIAA in the frontal cortex, and 5-HT in the hippocampus, of BDNF(+/-) mice were significantly lower than those of wild-type mice. Interestingly, DR significantly increased the levels of 5-HT and 5-HIAA in the frontal cortex of BDNF(+/-) mice. These findings suggest that DR may alter the behaviours in BDNF(+/-) mice, and that the 5-HT system may be implicated in the beneficial effects of DR on these behaviours.

Management of psychiatric comorbidity in anorexia nervosa and bulimia nervosa

The eating disorders anorexia nervosa and bulimia nervosa present with comorbidity in a number of important areas, including depression, bipolar disorder, anxiety disorders (obsessive-compulsive disorder, panic disorder, social anxiety disorder and other phobias, and post-traumatic stress disorder) and substance abuse. The most important principle of treating comorbidity in these conditions is the recognition of the effect of starvation and unstable eating on both the diagnosis and response to treatment of the comorbidity. This article reviews the identification of the most common areas of comorbidity and describes treatment approaches for these conditions. When it occurs, clinicians should treat comorbidity in patients with eating disorders in the usual fashion, but must remain aware that the disturbed eating itself will negatively affect response to treatment.

Two-three-year stability and interrelations of bulimotypic indicators and depressive and anxious symptoms in middle-aged women

OBJECTIVE

There is a paucity of research examining eating disorder symptoms among middle-aged women.

METHOD

This prospective study assessed the stability of bulimic symptoms and 5 associated variables (perfectionism, depressive symptoms, self-esteem, anxiety symptoms, and perceived weight status) in a sample of 150 middle-aged women (mean age = 45.19 years) over a 2.5-year time period. In addition, interrelations among bulimic, anxiety, and depressive symptoms were assessed.

RESULTS

Results suggested that all 6 bulimia-related variables remained significantly stable over 2.5 years. In addition, notable relations between Time 1 and Time 2 variables emerged (e.g., anxious symptoms at Time 1 predicted bulimic symptoms at Time 2).

CONCLUSION

Thus, the results indicate that bulimic symptoms exist in middle-aged women, and that they remain relatively stable over a 2.5-year time period. Clinical implications for middle-aged women with eating disorder symptoms are discussed.

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.

Gender differences in the progression of co-morbid psychopathology symptoms of eating disordered patients

This study examined the utility of the Personality Assessment Inventory (PAI) in screening for comorbid psychopathology in eating disordered males and females undergoing residential treatment. The PAI, a self-administered screening tool containing 344 items to provide information on 11 clinical constructs, was administered at admission and discharge to 181 patients, 154 females and 27 males. Average age was 26.88 years (SD=9.35) and average length of stay was 58.31 days (SD=39.94). The results showed that both male and female patients exhibit several comorbid disorders at admission to residential treatment and the severity of these symptoms was statistically significantly reduced over the course of treatment. When comparing differences among genders, the results show that females present with more psychopathology symptoms at the start of treatment but make better progress than males in reducing these symptoms over time. When comparing patients across eating disorder diagnoses, subjects with bulimia displayed more severe comorbid symptomatology as compared to those with anorexia or other eating disorders. A thorough clinical assessment of eating disordered patients including comorbid psychopathology disorders is relevant for clinical diagnosis, treatment planning, and perhaps ultimately the outcome of treatment.

Neurobiology of anorexia nervosa: clinical implications of alterations of the function of serotonin and other neuronal systems

Recent evidence suggests that genetic and neurobiologically mediated mechanisms contribute to the etiology of anorexia nervosa (AN). Serotonin neuronal systems, in particular, may create vulnerabilities related to pathological feeding, anxiety and obsessions, and extremes of impulse control, that make individuals susceptible to developing an eating disorder, perhaps in combination with environmental stressors.

Fear of negative evaluation and the development of eating psychopathology: a longitudinal study among nonclinical women

OBJECTIVE

We replicated the cross-sectional relationship between restrictive eating attitudes and a fear of being negatively evaluated by others and tested whether negative evaluation fears longitudinally predict changes in eating attitudes over a 7-month period.

METHOD

During the first week of an academic year, and again during Week 33, 143 female students completed the Fear of Negative Evaluation Scale (FNE), the Rosenberg Self-Esteem Scale (RSE), the Hospital Anxiety and Depression Scale (HADS), and the three eating scales of the Eating Disorders Inventory (EDI).

RESULTS

The exclusive link between heightened negative evaluation fears and restrictive eating attitudes was replicated cross-sectionally. However, the longitudinal model predicting the development of restriction was nonsignificant. In contrast, alongside depression, negative evaluation fears predicted an increase in bulimic attitudes, whereas self-esteem predicted an increase in body dissatisfaction.

DISCUSSION

The findings support a model whereby individuals with heightened fears of negative evaluation may use restrictive pathology to raise their status among peers. If this mechanism of dealing with negative evaluation fears is not sufficient in the long term, individuals may develop bulimic symptoms to deal with their negative evaluation fears.

Stress and weight gain in parents of cancer patients

OBJECTIVE

To investigate the effects of chronic stress on weight changes and related behavioral changes in parents with a child who had just been diagnosed with cancer compared to parents with healthy children.

DESIGN

Longitudinal case-control study with assessments occurring over a three-month period following the child's diagnosis of cancer.

SUBJECTS

In total, 49 parents of healthy children and 49 parents of cancer patients aged 19-58.

MEASUREMENTS

Body weight, diet, physical activity, self-reported mood and stress.

RESULTS

Parents of cancer patients were more likely to gain weight, and experienced significantly greater weight gain over the 3 months than parents of healthy children. The magnitude of weight gain was related to the degree of psychological distress that the parents experienced. Parents of cancer patients reported lower levels of physical activity and lower caloric intake than parents of healthy children, with the most marked differences between groups occurring in the area of physical activity.

CONCLUSION

Findings suggest that a major stressor, such as a child's diagnosis of cancer, is associated with weight gain. Further research is needed to determine how long these weight gains persist and whether other types of stress also produce weight gains. Such studies should focus not only on the effect of stress on eating behavior but also on physical activity.

Capacity and competence in child and adolescent psychiatry

Capacity and competence in the field of child and adolescent psychiatry are complex issues, because of the many different influences that are involved in how children and adolescents make treatment decisions within the setting of mental health. This article will examine some of the influences which must be considered, namely: developmental aspects, the paradoxical relationship between the need for autonomy and participation and the capacity of children, family psychiatry, and the duty of care towards children and adolescents. The legal frameworks relevant to consideration of consent and competence will be briefly considered, as well as some studies of children's consent, participation and competence. A case vignette will be used as a focus to consider the complexity of the issue of competence in child and adolescent psychiatry, in the particular mental disorder of anorexia nervosa.

Depression, anxiety, and obsessionality in long-term recovered patients with adolescent-onset anorexia nervosa

Anorexia nervosa (AN) is frequently associated with symptoms of depression, anxiety, and obsessive-compulsive behavior which also develop secondary to semistarvation. It is less certain if these symptoms persist after recovery. A few studies have already reported on high prevalence rates of anxious, depressive, and obsessive features in long-term recovered patients with AN, but several of these so called "long-term" recovered patients had only maintained weight restoration for six to twelve months. The aim of this study was to determine whether depressive, anxious, and obsessive-compulsive symptoms persist in truly long-term recovered patients (BMI 20.3+/-2.5 kg/m(2)) who no longer had any eating disorder symptoms (including weight phobia) for at least 3 years. Seventeen subjects of an AN sample (n=39) previously described in a 10-year follow-up met our strict criteria of at least 3 years of complete recovery of AN. In comparison to 39 age-, sex-, and occupation-matched healthy subjects without a history of psychiatric or eating disorder, long-term recovered patients had higher levels of depressive (p=0.002), anxious (p=0.006), and obsessive-compulsive (p=0.015) features but did not differ with regard to psychiatric morbidity and psychosocial adaptation. In conclusion, depressive, anxious, and obsessive-compulsive symptoms may be personality traits in subjects with former adolescent anorexia nervosa.

Predictive factors of social disability in anorexic and bulimic patients

OBJECTIVES

The purpose of this study was to determine whether subjects suffering from anorexia nervosa (AN) or bulimia nervosa (BN) would demonstrate more severe social disability than a control group; and whether social disability could be best explained as a function of the eating disorder itself or as a function of comorbid anxiety or depressive disorders.

METHOD

Subjects were 166 AN subjects, 105 BN subjects and 271 control subjects matched for age, sex and socio-economic status. Prevalence of anxiety or depressive disorders was assessed (through the Mini International Neuropsychiatric Interview), and social functioning was measured (through the Groningen scale).

RESULTS

The majority of AN and BN subjects demonstrated social disability in the "social role" (leisure time, time spent with friends) and the "occupational role" (work or educational activities). A regression analysis was employed to uncover predictive factors of social disability. Eating disorders (AN and BN), anxiety disorders and depression accounted for a large portion of social disability.

DISCUSSION

Anxiety and depressive disorders appear to play an important role in the type of social disability demonstrated in eating disorder patients. Therapeutic implications are discussed.

Panic-agoraphobic spectrum in obese binge eaters

OBJECTIVE

This study investigated the frequency of the panic-agoraphobic spectrum symptoms in a sample of obese subjects affected by Binge Eating Disorder (BED) vs controls.

METHOD

Fifty obese with BED were matched by age, sex and marital status to twenty-five normal weight controls. The Structured Clinical Interview For Panic-Agoraphobic Spectrum--SCI-PAS was administered to all participants.

RESULTS

Obese subjects with BED presented significantly higher frequencies of typical and atypical panic symptoms (82% vs 8%, p<0.0001), agoraphobia (58% vs 12%, p=0.002) and reassurance orientation (56% vs 8%, p=0.001) than controls.

DISCUSSION

BED frequently co-occurs with other major psychiatric disorders, traditionally assessed using categorical methods of classification of mental disorders. The spectrum of the subthreshold, atypical and partial symptoms of full-blown mental disorders, often neglected by categorical approach, may also affect subjective well-being and functioning as full-blown disorders. The identification of the subthreshold symptomatology may have relevant implications for the response to treatment and the outcome of the eating disorder.

The contribution of anxiety and food restriction on physical activity levels in acute anorexia nervosa

OBJECTIVE

Excessive exercise is present in 40%-80% of anorexia nervosa (AN) patients. Hyperactivity often plays a role in developing and maintaining AN and represents an obstacle to weight gain in refeeding. Interconnections among caloric restriction, psychopathology, and physical activity in humans with AN are poorly investigated.

METHODS

Physical activity and food restriction during the last 3 months and status of body image/slimness ideal were assessed by the Structured Interview of Anorexia and Bulimia Nervosa (SIAB) in 30 adolescent patients with acute AN at admission to inpatient treatment. Anxiety, depression, and obsessive-compulsiveness were assessed with the Symptom Check-List-90-Revised (SCL-90-R). A regression model based on the independent variables body mass index, food reduction, body image/slimness ideal, anxiety, depression, and obsessive-compulsiveness was calculated to determine the relevant prediction variables of physical activity.

RESULTS

The regression model explained 64% (R(2) = .64, p = .000) of the variance of physical activity. Only food restriction (p = .006) and anxiety (p = .004) contributed significantly to the variance.

DISCUSSION

Our results indicate that anxiety symptoms and food restriction synergistically contribute to increased levels of physical activity in the acute phase of AN.