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

Exploring the Relationship Between Social Anxiety and Bulimic Symptoms: Mediational Effects of Perfectionism Among Females

Previous findings indicate that social anxiety and bulimia co-occur at high rates; one mechanism that has been proposed to link these symptom clusters is perfectionism. We tested meditational models among 167 female undergraduates in which maladaptive evaluative perfectionism concerns (MEPC; i.e., critical self-evaluative perfectionism) mediated the relationship between social anxiety and bulimic symptoms. Results from a first model indicated that MEPC mediated the relationship between fear of public scrutiny and bulimia symptoms. This indirect effect was significant above and beyond the indirect effects of maladaptive body-image cognitions and perfectionism specific to pure personal standards. A second model was tested with MEPC mediating the relationship between social interaction anxiety and bulimia symptoms. Similar results were obtained; however, in this model, a significant direct effect remained after partialing out the indirect effect of the mediators. Theoretical implications are discussed.

Treatment of obsessive-compulsive disorder complicated by comorbid eating disorders

PURPOSE

Eating disorders and obsessive-compulsive disorder (OCD) commonly co-occur, but there is little data for how to treat these complex cases. To address this gap, we examined the naturalistic outcome of 56 patients with both disorders, who received a multimodal treatment program designed to address both problems simultaneously.

METHODS

A residential treatment program developed a cognitive-behavioral approach for patients with both OCD and an eating disorder by integrating exposure and response prevention (ERP) treatment for OCD with ERP strategies targeting eating pathology. Patients also received a supervised eating plan, medication management, and social support. At admission and discharge, patients completed validated measures of OCD severity (the Yale-Brown Obsessive-Compulsive Scale--Self Report [Y-BOCS-SR]), eating disorder severity (the Eating Disorders Examination-Questionnaire), and depressive severity (the Beck Depression Inventory II [BDI-II]). Body mass index (BMI) was also measured. Paired-sample t-tests examined change on these measures.

MAIN RESULTS

Between 2006 and 2011, 56 individuals completed all study measures at admission and discharge. Mean length of stay was 57 days (SD = 27). Most (89%) were on psychiatric medications. Significant decreases were observed in OCD severity, eating disorder severity, and depression. Those with bulimia nervosa showed more improvement than those with anorexia nervosa. BMI significantly increased, primarily among those underweight at admission.

CONCLUSION

Simultaneous treatment of OCD and eating disorders using a multimodal approach that emphasizes ERP techniques for both OCD and eating disorders can be an effective treatment strategy for these complex cases.

Clinical characteristics and distinctiveness of DSM-5 eating disorder diagnoses: findings from a large naturalistic clinical database

BACKGROUND

DSM-IV eating disorder (ED) diagnoses have been criticized for lack of clinical utility, diagnostic instability, and over-inclusiveness of the residual category "ED not otherwise specified" (EDNOS). Revisions made in DSM-5 attempt to generate a more scientifically valid and clinically relevant system of ED classification. The aim with the present study was to examine clinical characteristics and distinctiveness of the new DSM-5 ED diagnoses, especially concerning purging disorder (PD).

METHODS

Using a large naturalistic Swedish ED database, 2233 adult women were diagnosed using DSM-5. Initial and 1-year follow-up psychopathology data were analyzed. Measures included the Eating Disorder Examination Questionnaire, Structural Eating Disorder Interview, Clinical Impairment Assessment, Structural Analysis of Social Behavior, Comprehensive Psychiatric Rating Scale, and Structured Clinical Interview for DSM-IV Axis I Disorders.

RESULTS

Few meaningful differences emerged between anorexia nervosa binge/purge subtype (ANB/P), PD, and bulimia nervosa (BN). Unspecified Feeding and Eating Disorders (UFED) showed significantly less severity compared to other groups.

CONCLUSIONS

PD does not appear to constitute a distinct diagnosis, the distinction between atypical AN and PD requires clarification, and minimum inclusion criteria for UFED are needed. Further sub-classification is unlikely to improve clinical utility. Instead, better delineation of commonalities is important.

Adolescents' perception of causes of obesity: unhealthy lifestyles or heritage?

PURPOSE

To evaluate adolescents' perception of the causes of obesity, with emphasis on differences according to nutritional status and socioeconomic position.

METHODS

We conducted qualitative research including 80 adolescents belonging to the 1993 Pelotas (Brazil) Birth Cohort Study, and their mothers. We classified adolescent boys and girls into four groups (girls-obese, girls-eutrophic, boys-obese, and boys-eutrophic) according to body mass index for age and sex, and systematically selected them according to family income at age 15 years. Research techniques included semistructured interviews and history of life. Topics covered in the interviews included early experiences with weight management, effect of weight on social relationships, family history, eating habits, and values.

RESULTS

Low-income obese adolescents and their mothers perceive obesity as a heritage, caused by family genes, side effects of medication use, and stressful life events. However, low-income eutrophic adolescents emphasize the role of unhealthy diets on obesity development. Among the high-income adolescents, those who are obese attribute it to genetic factors and emotional problems, whereas those who are eutrophic mention unhealthy diets and lack of physical activity as the main causes of obesity.

CONCLUSIONS

Perceptions of the causes of obesity in adolescents from a middle-income setting vary by gender, socioeconomic position, and nutritional status. Whereas some blame genetics as responsible for obesity development, others blame unhealthy diets and lifestyles, and others acknowledge the roles of early life experiences and family traditions in the process of obesity development.

Social anxiety and self-consciousness in binge eating disorder: associations with eating disorder psychopathology

OBJECTIVE

Research has consistently shown that anxiety disorders are common among individuals with eating disorders. Although social phobia has been found to be highly associated with eating disorders, less is known about social anxiety in individuals with binge eating disorder (BED). The present study examined associations between social anxiety and self-consciousness with body mass index (BMI) and eating disorder psychopathology in BED.

METHODS

Participants were 113 overweight or obese treatment-seeking men and women with BED. Participants were administered semistructural diagnostic clinical interviews and completed a battery of self-report measures.

RESULTS

Social anxiety was positively and significantly correlated with shape and weight concerns and binge eating frequency. After accounting for depressive levels, social anxiety and self-consciousness accounted for significant variance in eating, shape, and weight concerns and overall eating disorder global severity scores (Eating Disorder Examination). Social anxiety also accounted for significant variance in binge eating frequency after covarying for depressive levels. Social anxiety and self-consciousness were not significantly associated with BMI or dietary restraint.

DISCUSSION

Our findings suggest that greater social anxiety and heightened self-consciousness are associated with greater eating disorder psychopathology, most notably with greater shape and weight concerns and binge eating frequency in patients with BED. Social anxiety and self-consciousness do not appear to be merely functions of excess weight, and future research should examine whether they contribute to the maintenance of binge eating and associated eating disorder psychopathology.

Ghrelin signalling and obesity: at the interface of stress, mood and food reward

The neuronal circuitry underlying the complex relationship between stress, mood and food intake are slowly being unravelled and several studies suggest a key role herein for the peripherally derived hormone, ghrelin. Evidence is accumulating linking obesity as an environmental risk factor to psychiatric disorders such as stress, anxiety and depression. Ghrelin is the only known orexigenic hormone from the periphery to stimulate food intake. Plasma ghrelin levels are enhanced under conditions of physiological stress and ghrelin has recently been suggested to play an important role in stress-induced food reward behaviour. In addition, chronic stress or atypical depression has often demonstrated to correlate with an increase in ingestion of caloric dense 'comfort foods' and have been implicated as one of the major contributor to the increased prevalence of obesity. Recent evidence suggests ghrelin as a critical factor at the interface of homeostatic control of appetite and reward circuitries, modulating the hedonic aspects of food intake. Therefore, the reward-related feeding of ghrelin may reveal itself as an important factor in the development of addiction to certain foods, similar to its involvement in the dependence to drugs of abuse, including alcohol. This review will highlight the accumulating evidence demonstrating the close interaction between food, mood and stress and the development of obesity. We consider the ghrelinergic system as an effective target for the development of successful anti-obesity pharmacotherapies, which not only affects appetite but also selectively modulates the rewarding properties of food and impact on psychological well-being in conditions of stress, anxiety and depression.

Understanding the association of impulsivity, obsessions, and compulsions with binge eating and purging behaviours in anorexia nervosa

OBJECTIVE

To further refine our understanding of impulsivity, obsessions, and compulsions in anorexia nervosa (AN) by isolating which behaviours--binge eating, purging, or both--are associated with these features.

METHODS

We conducted regression analyses with binge eating, purging, and the interaction of binge eating with purging as individual predictors of scores for impulsivity, obsessions, and compulsions in two samples of women with AN (n = 1373).

RESULTS

Purging, but not binge eating, was associated with higher scores on impulsivity, obsessions, and compulsions. Purging was also associated with worst eating rituals and with worst eating preoccupations.

CONCLUSION

Our results suggest that purging, compared with binge eating, may be a stronger correlate of impulsivity, obsessions, and compulsions in AN.

Thinking about eating food activates visual cortex with reduced bilateral cerebellar activation in females with anorexia nervosa: an fMRI study

Background

Women with anorexia nervosa (AN) have aberrant cognitions about food and altered activity in prefrontal cortical and somatosensory regions to food images. However, differential effects on the brain when thinking about eating food between healthy women and those with AN is unknown.

Methods

Functional magnetic resonance imaging (fMRI) examined neural activation when 42 women thought about eating the food shown in images: 18 with AN (11 RAN, 7 BPAN) and 24 age-matched controls (HC).

Results

Group contrasts between HC and AN revealed reduced activation in AN in the bilateral cerebellar vermis, and increased activation in the right visual cortex. Preliminary comparisons between AN subtypes and healthy controls suggest differences in cortical and limbic regions.

Conclusions

These preliminary data suggest that thinking about eating food shown in images increases visual and prefrontal cortical neural responses in females with AN, which may underlie cognitive biases towards food stimuli and ruminations about controlling food intake. Future studies are needed to explicitly test how thinking about eating activates restraint cognitions, specifically in those with restricting vs. binge-purging AN subtypes.

The comorbidity between eating disorders and anxiety disorders: prevalence in an eating disorder sample and anxiety disorder sample

OBJECTIVE

To investigate the prevalence of comorbid eating and anxiety disorders in women presenting for inpatient and outpatient treatment of an eating disorder and women presenting for outpatient treatment of an anxiety disorder.

METHODS

The prevalence of comorbidity was investigated from a sample of 152 women, which included 100 women presenting for treatment of an eating disorder and 52 women presenting for treatment of an anxiety disorder.

RESULTS

Of women presenting for treatment of an eating disorder, 65% also met criteria for at least one comorbid anxiety disorder; 69% of these reported the onset of the anxiety disorder to precede the onset of the eating disorder. Of the anxiety disorders diagnosed, social phobia was most frequently diagnosed (42%) followed by post-traumatic stress disorder (26%), generalised anxiety disorder (23%), obsessive-compulsive disorder (5%), panic/agoraphobia (3%) and specific phobia (2%). We also found that 13.5% of women presenting for anxiety treatment also met criteria for a comorbid eating disorder. Furthermore, 71% (n = 5) reported the onset of the anxiety disorder to precede the onset of the eating disorder.

DISCUSSION

The results of this study suggest that the prevalence of eating and anxiety disorder comorbidity is high. The present research should improve the clinical understanding of the comorbidity between eating disorders and anxiety disorders. In particular, it is anticipated that this research will have significant aetiological and therapeutic implications especially with regard to improving the clinical effectiveness of psychological treatments for eating disorders and highlighting the importance of screening for eating pathology in the clinical assessment of anxiety disorders.

An examination of medical and psychological morbidity in adolescent males with eating disorders

The objective of this study was to examine the clinical profile of adolescent male patients presenting for eating disorder (ED) assessment over a 17-year period. A retrospective cohort study was completed. A total of 52 patients (8% of the total sample) were included in the study. The average age of patients was 14.7 years and the most common diagnosis observed was Eating Disorder Not Otherwise Specified (EDNOS). Rates of concurrent depression and anxiety were very high, as were rates of medical co-morbidity, including osteoporosis. Our study supports findings documented in previously published reports of males with eating disorders and adds to the limited knowledge base which targets adolescents specifically. Multi-center controlled trials are required to further investigate male-specific ED symptomatology, treatment courses, and outcomes.

Post-traumatic stress symptoms and childhood abuse categories in a national representative sample for a specific age group: associations to body mass index

BACKGROUND

Studies of specific groups such as military veterans have found that posttraumatic stress disorder (PTSD) is linked to adverse health outcomes including unhealthy weight. The aim of this study was to examine the relationship between PTSD symptoms, experiences of childhood trauma and weight in a community sample.

METHODS

A stratified random probability survey was conducted in Denmark by the Danish National Centre for Social Research between 2008 and 2009 with 2,981 participants born in 1984, achieving a response rate of 67%. The participants were interviewed with a structured interview with questions pertaining PTSD symptomatology, exposure to childhood abuse, exposure to potentially traumatizing events, height, and weight. Underweight was defined by a body mass index (BMI) <18.5, overweight was defined by a BMI ≥25 and <30 and obesity was defined by a BMI ≥30.

RESULTS

PTSD symptomatology and childhood abuse were significantly associated with both underweight and overweight/obesity. Childhood emotional abuse was especially associated with underweight, whereas sexual abuse and overall abuse were particularly associated with overweight/obesity.

CONCLUSION

These findings indicate that health care professionals may benefit from assessing PTSD and childhood abuse in the treatment of both overweight and underweight individuals.

Moderators of weight gain in the early stages of outpatient cognitive behavioral therapy for adults with anorexia nervosa

OBJECTIVE

Treatments for anorexia nervosa have relatively low levels of effectiveness. This prospective study examines the impact of patients' characteristics on their early responses to cognitive behavioral therapy (CBT) for anorexia nervosa.

METHOD

Patients' eating attitudes, body mass index, and comorbid characteristics at the outset of treatment were used to predict drop-out and changes in weight across the first 10 sessions of CBT. Forty anorexic patients (28 full syndrome and 12 atypical cases--body mass index range = 12.8-18.4) entered CBT for anorexia nervosa.

RESULTS

Early drop-outs (N = 6) had relatively low levels of anxiety at the beginning of therapy, but there were no other moderators. Weight gain was slower in the 6th to 10th sessions among patients with relatively unhealthy eating attitudes (restraint and shape concerns). Higher levels of anxiety at the start of treatment were associated with poorer weight gain across these first 10 sessions.

DISCUSSION

Early anxiety levels should be attended to closely in CBT for anorexia nervosa, with low levels indicating a high risk of drop-out and a greater need for engagement and motivational work, and high levels, indicating that clinicians should work explicitly with the patient on anxiety reduction techniques in order to enhance their level of early weight gain.

Coenzyme Q10 concentration in plasma and blood cells of juvenile patients hospitalized for anorexia nervosa

The antioxidant status of coenzyme Q10 (CoQ10) was investigated in plasma, erythrocytes, and platelets of juvenile patients with anorexia nervosa. Blood for analysis of the CoQ10 status was taken from 16 juvenile patients suffering from anorexia nervosa (restricting form) at the time point of admission to the hospital and at discharge after about 12 weeks. Plasma and blood cells isolated by a density gradient were stored at -84 °C until analysis. CoQ10 concentration and redox status were measured by high pressure liquid chromatography with electrochemical detection and internal standardization. The improvement of physical health during the hospital refeeding process was followed up by the body mass index (BMI). The antioxidant status of plasma CoQ10 in juvenile patients suffering from anorexia nervosa indicated no abnormalities in comparison to healthy controls. However, the decreased concentration of CoQ10 observed in platelets at the time point of hospital admission may represent mitochondrial CoQ10 depletion. This initial deficit improved during the hospital refeeding process. The platelet CoQ10 concentration showed a positive correlation to the BMI of the patients.

Eating-related anxiety in individuals with eating disorders

Although previous research has supported the importance of anxiety as an etiological and maintenance factor for eating disorders, the specific mechanisms are not well understood. The role of anxiety in the context of eating behavior is especially unclear. The purpose of this study was to identify anxiety-eliciting eating situations and anxiety management strategies patients use to mitigate anxiety experienced in the context of eating as determined by diagnostic groups and symptom patterns. Fifty-three eating disorder outpatients were administered the Eating and Anxiety Questionnaire (EAQ) and the Eating Disorder Diagnostic Scale. Ratings indicated significant anxiety in most eating situations, whereas management strategies were more limited yet regularly employed. Factor analysis of the EAQ revealed a 6-factor solution for anxiety management strategies and a 4-factor solution for anxiety-eliciting situations. These results indicate patients with eating disorders report high levels of anxiety associated with eating behaviors but utilize limited yet consistent anxiety management strategies. Effective intervention strategies for managing eating-related anxiety should be incorporated into treatment and may need to be specified for different diagnostic subgroups.

Is childhood OCD a risk factor for eating disorders later in life? A longitudinal study

BACKGROUND

It has been suggested that childhood obsessive-compulsive disorder (OCD) may be a risk factor for the development of an eating disorder (ED) later in life, but prospective studies are lacking. We aimed to determine the prevalence of ED at follow-up and clinical predictors in a longitudinal clinical sample of adolescents/young adults diagnosed with OCD in childhood.

METHOD

All contactable (n=231) young people with OCD assessed over 9 years at a national and specialist paediatric OCD clinic were included in this study. At follow-up, 126 (57%) young people and parents completed the ED section of the Developmental and Well-being Assessment. Predictors for ED were investigated using logistic regression.

RESULTS

In total, 16 participants (12.7%) had a diagnosis of ED at follow-up. Having an ED was associated with female gender and persistent OCD at follow-up. There was a trend for family history of ED being predictive of ED diagnosis. Five (30%) of those who developed an ED at follow-up had ED symptoms or food-related obsessions/compulsions at baseline. A difference in predictors for an ED versus other anxiety disorders at follow-up was identified.

CONCLUSIONS

This study provides initial evidence that baseline clinical predictors such as female gender and family history of ED might be specific to the later development of ED in the context of childhood OCD. Clinicians should be alert to ED subthreshold symptoms in young girls presenting with OCD. Future longitudinal studies are needed to clarify the relationship between childhood OCD and later ED.

Social cognition in bulimia nervosa: a systematic review

OBJECTIVE

Clinical accounts and previous evidence suggest that socio-emotional impairments may be present in people with bulimia nervosa (BN). The aim of this paper was to systematically review studies of social cognition, and to evaluate whether social cognitive deficits exist in BN.

METHOD

Keywords were identified using an existing model of social cognition (Green et al., 2007) [16], and used to search for relevant papers in three online databases. Records were then screened according to a priori inclusion/exclusion criteria.

RESULTS

Five papers reporting seven social cognition tasks were identified as pertinent to the review. All involved either theory of mind ability or emotional processing skills. Participants with BN had impaired performance on the Levels of Emotional Awareness Scale and showed greater attentional bias than controls on an emotional Stroop task. There were no overall group differences for any other tasks, although there were small differences for some specific test items.

CONCLUSIONS

Basic social cognition does not appear to be impaired in people with BN. Future research should make use of more complex, ecologically valid measures, and consider the relationship between task performance and everyday social functioning.

Insight in eating disorders: clinical and cognitive correlates

BACKGROUND

The aim of this study was to explore the extent of lack of insight and its components in eating disorders (EDs) and to investigate the relationship between insight and clinical and cognitive characteristics in this group.

METHOD

Seventy-five participants were enrolled in the study: 25 with anorexia nervosa (AN), 15 with bulimia nervosa (BN) and 35 healthy controls (HC). Insight was assessed with a modified version of the Schedule for the Assessment of Insight for EDs (SAI-ED) and multi-dimensional scaling (MDS) analysis was used to clarify the internal structure of the scale. Neuropsychological tests included the Trail Making Test (TMT), the Brixton Test and a Verbal Fluency Task.

RESULTS

Only a subgroup of AN patients (24%) had severe impairment of insight. Patients with the restricting type of AN (AN-R) had poorer overall insight than patients with the binge-purge type of the disorder (AN-B/P). More of the ED patients displayed a deliberate denial of illness rather than a lack of awareness of the illness. A regression model revealed that only performance in part B of the TMT (TMT-B) was a moderate predictor of insight level. No association was found between insight and other cognitive or clinical variables.

CONCLUSIONS

Impaired insight is a significant feature of some ED patients. Insight in EDs seems to be partially dependent on intact mental flexibility.

Modulation of fear/anxiety responses, but not food intake, following α-adrenoceptor agonist microinjections in the nucleus accumbens shell of free-feeding rats

This study investigated the effect of α-adrenoceptor agonists microinjected into the shell region of the accumbens nucleus (AcbSh) on feeding and anxiety-related behaviors in free-feeding rats. Male Wistar rats with a chronically implanted cannula into the AcbSh were unilaterally microinjected with either clonidine (CLON, α(2)-adrenoceptor agonist) or phenylephrine (PHEN, α(1)-adrenoceptor agonist) at the doses of 6 and 20 nmol and submitted to the elevated plus-maze (EPM), a pre-clinical test of anxiety. Immediately after the EPM test, the animals underwent food intake evaluation for 30 min. The data showed that rats microinjected with CLON (20 nmol/0.2 μl) into the AcbSh exhibited increased %Open arm time, which is compatible with an anxiolytic-like effect. The CLON-induced anxiolysis was corroborated by increased head-dipping and decreased stretched-attend posture, two ethologically derived behaviors which are fear/anxiety-motivated. The animal's locomotor activity was not changed by 20 nmol CLON microinjection into the AcbSh. However, neither dose of PHEN microinjected into the AcbSh was able to alter either the spatial-temporal or ethological variables representative of fear/anxiety and locomotion. Food intake was not altered by any dose of CLON and PHEN microinjected into the AcbSh, but the 20 nmol CLON microinjection induced increased motor activity in the feeding test. The data suggests that noradrenergic projections to the AcbSh may underlie fear/anxiety modulation through α(2)-adrenoceptor in the AcbSh, while feeding behavior was unaffected by noradrenergic modulation in the AcbSh of free-feeding rats. This article is part of a Special Issue entitled 'Anxiety and Depression'.

An experimental exploration of behavioral and cognitive-emotional aspects of intolerance of uncertainty in eating disorder patients

OBJECTIVE

Intolerance of uncertainty (IU) is an important concept in eating disorders (ED). Cognitive, emotional, and behavioral features of IU amongst individuals with and without ED were investigated.

METHOD

Participants completed the intolerance of uncertainty scale (IUS) and four versions of a data-gathering task varying in difficulty/uncertainty, and rated their Beads task experience.

RESULTS

ED groups had significantly higher IUS scores than healthy controls (HC). Bulimia Nervosa (BN) participants requested more cues than HC and Anorexia Nervosa (AN) participants before making decisions. ED groups found the task more distressing than HC participants, with those with BN feeling more uncertain and less confident in their decisions, and those with AN attributing greater importance in making the correct decision.

DISCUSSION

While both ED groups reported raised IUS scores only BN participants engaged in an elevated evidence requirement data gathering style. Future research might benefit from further exploration of the role of perseverative processes in BN.

Social appearance anxiety and bulimia nervosa

Social appearance anxiety is an unexplored concept in eating disorders (ED). It refers to social anxiety surrounding overall appearance, including body shape, and fear of negative evaluation by others. It is potentially relevant to those with bulimia nervosa (BN) as both social anxiety and body image disturbance are commonly experienced by patients. Thirty women with BN and forty healthy controls (HC) completed the Social Appearance Anxiety Scale (SAAS), a 16-item self-report questionnaire. ED cognitions and behaviours were assessed with the Eating Disorders Examination-Questionnaire. Women with BN have significantly higher SAAS scores than HC (z=-6.79, p<0.001). In BN, SAAS scores show significant positive correlation with global ED subscales and dietary restraint. In HC, SAAS scores are correlated with shape, weight, eating concern, and global eating disturbance subscales. Preliminary findings suggest the SAAS is potentially useful in future research concerning overall risk factors for eating disturbance and treatment outcome in BN.

Olanzapine use for the adjunctive treatment of adolescents with anorexia nervosa

OBJECTIVE

To examine assessment and treatment profiles of adolescent patients with anorexia nervosa and eating disorder not otherwise specified who received olanzapine as compared with an untreated matched sample.

METHOD

A retrospective, matched-groups comparison study was completed. Medical files of 86 female patients treated in the eating disorder program at the Children's Hospital of Eastern Ontario were examined. Patients treated with olanzapine were initially identified through chart review and then matched to a diagnosis, age, and, when possible, treatment group that served as the active comparator. Weight gain was examined in a sample of 22 inpatients.

RESULTS

Patients treated with olanzapine displayed greater evidence of psychopathology and medical compromise at the time of first assessment compared with those not treated. Rate of weight gain was not statistically different between groups when olanzapine was started during inpatient admissions. Medication effect on eating disorder cognitions could not be assessed given the presence of multiple confounders relating to treatment. Notable side effects included sedation and dyslipidemia in 56% of patients.

CONCLUSIONS

Despite our best attempts at matching olanzapine-treated subjects with a control sample, analysis revealed significant differences between groups, suggesting greater illness severity in those augmented with olanzapine. Given these inherent differences, we were unable to draw any firm conclusions regarding the potential efficacy of olanzapine. Factors associated with the prescription of adjunctive pharmacotherapy in this cohort appear to be linked to illness severity, acuity, and associated comorbidity. The observed side-effect profile indicates the need for more consistent predrug screening and for closer monitoring during treatment.

Successful Anterior Capsulotomy in Comorbid Anorexia Nervosa and Obsessive-Compulsive Disorder: Case Report

BACKGROUND AND IMPORTANCE:

State-of-the-art treatment of anorexia nervosa (AN) and obsessive-compulsive disorder (OCD) often proves ineffective. Both disorders have common features, and anterior capsulotomy is a last-resort treatment for OCD. We document the effect of bilateral anterior capsulotomy in a patient with comorbid AN and OCD.

CLINICAL PRESENTATION:

A 38-year-old woman with life-threatening, chronic, treatment-refractory AN and OCD underwent anterior capsulotomy. Psychiatric and neuropsychological evaluations at baseline and at follow-up document the severity and progress of the case. Bilateral anterior capsulotomy resulted in normalization of eating pattern and weight and a significant decrease of food-related and overall obsessive-compulsive symptoms. Psychiatric evaluations and exposure to food cues confirmed the clinical improvement that was evident immediately after surgery and sustained at 3-month follow-up.

CONCLUSION:

This case report suggests that bilateral anterior capsulotomy can be a therapeutic option for patients with comorbid AN and OCD. However, a well-controlled study is warranted.

Self-silencing and anger regulation as predictors of disordered eating among adolescent females

The main purpose of this study was to examine how self-silencing, emotional regulation, and body-esteem differentiated healthy eating from different patterns of disordered eating. A community sample of adolescent females was classified as either: 1) Restrained Eaters (n=104, M(age)=14.48); 2) Emotional Eaters (n=125, M(age)=14.52); or, 3) Healthy Eaters (n=396, M(age)=13.71). A discriminant function analysis revealed two significant functions. The first function differentiated the two disordered eating groups (i.e., the restrained and emotional eaters) from the healthy group, with the disordered eating groups scoring significantly higher on levels of self-silencing and anger regulation, and lower on body-esteem. The second function differentiated between the restrained and emotional eaters, with the emotional eaters reporting higher levels of externalized self-perception and anger, and lower levels of body-esteem. The results suggest that body-esteem and anger suppression were the most influential variables in differentiating between groups. The findings are discussed in terms of the implications for disordered eating prevention and treatment programs.

Animal models of eating disorder traits

Eating disorders, such as anorexia and bulimia nervosa, are psychiatric disorders that are likely determined by a complex interaction between genetic variations, developmental processes, and certain life events. Cross-species analysis of traits related to eating disorders may provide a way to functionally and systematically study neurobiological mechanisms underlying these disorders. Interspecies trait genetics may offer opportunities to identify common neurobiological mechanisms underlying eating disorder characteristics relevant to the initiation, progression, and/or maintenance of the disease, such as cognitive rigidity, increased anxiety levels, and behavioral hyperactivity. These can subsequently be tested directly by studying allelic variation in mice and human subjects and by applying methods that can modify gene expression levels in rodent models. Increasing our knowledge about these traits and their underlying neurobiological mechanisms will be relevant to develop new therapies for patients within the heterogeneous eating disorder populations. Novel mouse genetic and phenotyping tools offer a way to study these neurobehavioral traits under controlled environmental and genetic background conditions.

Comorbidity and age of onset of eating disorders in gay men, lesbians, and bisexuals

This study examines the prevalence of psychiatric disorders among lesbian, gay, and bisexual (LGB) men with eating disorders. A total of 388 white, black, and Latino LGB men and women were sampled from community venues. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses of anorexia, bulimia, and binge eating disorder were assessed using the World Health Organization's Composite International Diagnostic Interview. Gay and bisexual men with eating disorders were more likely to have an anxiety or substance abuse disorder than gay and bisexual men without eating disorders, whereas lesbian and bisexual women with eating disorders were more likely to have a mood disorder than lesbian and bisexual women without an eating disorder. For individuals diagnosed with an eating and anxiety or major depressive disorder, the onset of the psychiatric disorder was more likely to precede the onset of the eating disorder. Researchers should study potential explanations of the relationship between eating and psychiatric disorders among LGB men and women.

Anxiety in anorexia nervosa and its management using family-based treatment

Anorexia nervosa (AN) is characterized by its similarity to anxiety disorders, especially obsessive-compulsive disorder (OCD). Family-based treatment (FBT) has shown promising initial results for treatment of AN in adolescents, yet the precise mechanisms of action are unknown. We present a theoretical argument and model, suggesting that FBT may work via exposure (and habituation) to food and its consumption. First, we review the evidence for pathological anxiety in AN, and suggest a framework for identifying specific anxious triggers, emotions (fear and worry) and avoidance strategies. Second, we briefly review evidence indicating that cognitive-behavioural therapy (CBT) and specifically exposure in its various forms is most effective for treating anxiety disorders in youth. Third, we consider distinct approaches to exposure therapy based on the pattern of triggers, anxious emotions and avoidance. We conclude that the interventions utilized in FBT share clear similarities to exposure with response prevention, a type of exposure therapy commonly used with OCD, and may work via facilitating habituation to food and eating in one's natural environment. We also highlight how parents facilitate this process in between sessions by effectively coaching their children and facilitating naturalistic exposure to food and related triggers. Options for future research are considered.

Eating disorders, gene-environment interactions and epigenetics

This review describes the various subtypes of eating disorders and examines factors associated with the risk of illness. It considers evidence that the development and maintenance of eating disorders is due to gene-environment interactions (GxE) that alter genetic expression via epigenetic processes. It describes how environmental factors such as those associated with nutrition and/or stress may cause epigenetic changes which have transcriptional and phenotypic effects, which, in turn, alter the long term risk of developing an eating disorder. It reviews theoretical and practical issues associated with epigenetic studies in psychiatry and how these are relevant to eating disorders. It examines the limited number of epigenetic studies which have been conducted in eating disorders and suggests directions for further research. Understanding the relationship between epigenetic processes and the risk of an eating disorder opens possibilities for preventive and/or therapeutic interventions. For example, epigenetic changes associated with diet and weight may be reversible and those associated with cognitive processes may be accessible to pharmacological interventions.

Eating disorders: screening in the dental office

BACKGROUND

Eating disorders are serious illnesses that often are not detected by health care professionals. The author presents techniques that the oral health care professional (OHCP) can use to screen at-risk patients for eating disorders during routine preventive care appointments.

CONCLUSIONS

OHCPs often are the first health care professionals to encounter patients with undiagnosed eating disorders. Because early detection of eating disorders is challenging, screening tools can be helpful. Early detection of eating disorders, with appropriate referral, is associated with fewer dental and systemic adverse effects and a more favorable prognosis.

CLINICAL IMPLICATIONS

OHCPs are in an ideal position to screen patients for eating disorders. They can accomplish this via a valid, reliable, brief questionnaire and careful patient assessment.

Delineation of differential temporal relations between specific eating and anxiety disorders

This study examined the temporal sequencing of eating and anxiety disorders to delineate which anxiety disorders increase eating disorder risk and whether individuals with eating disorders are at greater risk for particular anxiety disorders. The sample was drawn from the Oregon Adolescent Depression Project. Temporal relations between specific eating and anxiety disorders were examined after controlling for relevant variables (e.g., mood disorders, other anxiety disorders) over 14 years. After excluding those with anorexia nervosa (AN) in adolescence (T1), OCD was the only T1 anxiety disorder to predict AN by age 30 (T4). No T1 anxiety disorder was associated with T4 bulimia nervosa (BN). Although T1 AN did not increase risk of any T4 anxiety disorder, T1 BN appeared to increase risk for social anxiety and panic disorders. Evidence that eating disorders may have differential relations to particular anxiety disorders could inform prevention and treatment efforts.

The role of the right parietal lobe in anorexia nervosa

BACKGROUND

Patients with anorexia nervosa (AN) overestimate their size despite being severely underweight. Whether this misperception echoes an underlying emotional disturbance or also reflects a genuine body-representation deficit is debatable. Current measures inquire directly about subjective perception of body image, thus distinguishing poorly between top-down effects of emotions/attitudes towards the body and disturbances due to proprioceptive disorders/distorted body schema. Disorders of body representation also emerge following damage to the right parietal lobe. The possibility that parietal dysfunction might contribute to AN is suspected, based on the demonstrated association of spatial impairments, comparable to those found after parietal lesion, with this syndrome.

METHOD

We used a behavioral task to compare body knowledge in severe anorexics (n=8), healthy volunteers (n=11) and stroke patients with focal damage to the left/right parietal lobe (n=4). We applied a psychophysical procedure based on the perception, in the dark, of an approaching visual stimulus that was turned off before reaching the observer. Participants had to predict whether the stimulus would have hit/missed their body, had it continued its linear motion.

RESULTS

Healthy volunteers and left parietal patients estimated body boundaries very close to the real ones. Conversely, anorexics and right parietal patients underestimated eccentricity of their left body boundary.

CONCLUSIONS

These findings are in line with the role the parietal cortex plays in developing and maintaining body representation, and support the possibility for a neuropsychological component in the pathogenesis of anorexia, offering alternative approaches to treatment of the disorder.

Leptin-deficient mice retain normal appetitive spatial learning yet exhibit marked increases in anxiety-related behaviours

RATIONALE

The individual's emotional state influences food intake in both humans and rodents. Moreover, specific cognitive processes regulating the salient aspects of food reward are also critical for ingestive behaviour. However, the molecular mechanisms underlying such influence remain unclear. Genetic mouse models thus are important tools in dissecting the molecular and pathophysiological processes which cause complex human diseases. Leptin, encoded by the ob gene, plays an important part in the energy homeostasis and is critical for the development of obesity.

OBJECTIVES

In these studies, we assess the impact of leptin on behaviours relevant to anxiety and appetitive learning.

METHODS

Anxiety-related behaviour was assessed in the light dark box and two tests of hyponeophagia. Spatial learning and behavioural flexibility by re-learning was assessed in an appetitive Y-maze task.

RESULTS

Leptin-deficient (ob/ob) mice displayed higher levels of anxiety-related behaviour in both anxiety tests. In the appetitive Y-maze task, leptin deficiency caused no deficit in learning or re-learning and acute restrained stress had no influence on the learning process.

CONCLUSIONS

These results emphasise that whilst leptin has previously been shown to modulate aversively motivated learning we found no difference between leptin-deficient mice and their controls in an appetitive learning task. Moreover, both groups showed behavioural flexibility under stressful conditions. On the other hand, leptin deficiency resulted in marked alterations in behaviours relevant to anxiety.

Does avoidant personality disorder impact on the outcome of treatment for bulimia nervosa?

OBJECTIVE

To examine the impact of avoidant personality disorder (AVPD) on bulimia nervosa (BN) treatment outcome over 3 years.

METHOD

Women with BN were participating in a randomized treatment trial. The sample was split into: AVPD (n = 37), other PD (n = 37), and no PD (n = 60). Eating disorder symptomatology, depressive symptoms and psychosocial functioning were examined at pretreatment and follow-up. Multiple regression was conducted to control for high axis I comorbidity.

RESULTS

There were no significant differences across the groups at pretreatment or follow-up on eating disorder symptoms. AVPD had worse depressive symptoms and psychosocial functioning at pretreatment which continued 3 years post-treatment. Multiple regression analyses revealed that the presence of any lifetime mood disorder contributed to these significant results.

DISCUSSION

These findings suggest AVPD is not a significant predictor of BN outcome. However, AVPD is associated with poorer psychiatric symptoms although much of this variance appears to be attributable to the lifetime presence of any mood disorder.

An investigation of the effect of body dissatisfaction on selective attention toward negative shape and weight-related information

OBJECTIVE

The aim of the present study was to investigate the effect of inducing body dissatisfaction on selective attention toward negative shape and weight-related information.

METHOD

A total of 54 female undergraduate university students were randomly allocated to one of three induction conditions: body dissatisfaction, negative mood, and neutral. Subsequently, participants' attentional bias toward negative shape/weight words was measured using a dot probe task.

RESULTS

Contrary to the hypotheses, participants in the body dissatisfaction condition did not demonstrate an increase in attention toward negative shape/weight words compared with the negative mood and neutral conditions. Indeed, it was the negative mood induction that resulted in significantly increased attention toward negative shape/weight words relative to the body dissatisfaction condition.

DISCUSSION

The finding that the negative mood (rather than the body dissatisfaction) induction triggered an attentional bias toward shape- and weight-related information is discussed in terms of the anxiety literature given the nature of the mood induction utilized. This finding might help to account for the high comorbidity between eating disorders and anxiety disorders and suggests the possible relevance of attentional training interventions designed for anxiety disorders in the treatment of eating disorders.

Eating disorders in patients with obsessive-compulsive disorder: prevalence and clinical correlates

OBJECTIVE

The objective is to evaluate the prevalence and associated clinical characteristics of eating disorders (ED) in patients with obsessive-compulsive disorder (OCD).

METHOD

This is a cross-sectional study comparing 815 patients with OCD. Participants were assessed with structured interviews and scales: SCID-I, Y-BOCS, Dimensional Y-BOCS, BABS, Beck Depression and Anxiety Inventories.

RESULTS

Ninety-two patients (11.3%) presented the following EDs: binge-eating disorders [= 59 (7.2%)], bulimia nervosa [= 16 (2.0%)], or anorexia nervosa [= 17 (2.1%)]. Compared to OCD patients without ED (OCD-Non-ED), OCD-ED patients were more likely to be women with previous psychiatric treatment. Mean total scores in Y-BOCS, Dimensional Y-BOCS, and BABS were similar within groups. However, OCD-ED patients showed higher lifetime prevalence of comorbid conditions, higher anxiety and depression scores, and higher frequency of suicide attempts than did the OCD-Non-ED group. Primarily diagnosed OCD patients with comorbid ED may be associated with higher clinical severity.

DISCUSSION

Future longitudinal studies should investigate dimensional correlations between OCD and ED.

Compulsivity in mouse strains homologous with chromosomes 7p and 15q linked to obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a severe anxiety disorder characterized by obsessions and compulsions. The core symptom of OCD is compulsivity, the inability to stop thinking or acting when you want to, despite being aware of the uselessness of the content or the adverse consequences. To initiate a systematic search for genetic mechanisms underlying the pathophysiology of compulsivity, a panel of chromosome substitution (CS) strains, derived from mice that suppress (C57BL/6J strain) or maintain (A/J strain) high levels of repetitive wheel running during 2 hr of daily limited food access, was screened for this compulsive behavior. Following the genetic screen, we found linkage between compulsive wheel running and mouse chromosomes 2, 6, and 7 that show overlap with recently identified human linkage regions for OCD on chromosomes 7p and 15q. In the overlapping (human/mouse) genomic region, the CRH receptor 2 (CRHR2) gene was tested in a human case-control study. An initial exploration in OCD cases versus controls failed to detect an association between four-candidate CRH2R SNP's within this homologous linkage region and OCD. Genetic fine mapping of compulsivity in mice provides new opportunities to reveal mechanisms underlying this significant psychiatric trait.

Patterns of co-morbidity of eating disorders and substance use in Swedish females

BACKGROUND

Little is known about the association of eating disorder subtypes across multiple categories of substance use in population-based samples. We examined the association between eating disorders and substance use in a large population-based sample.

METHOD

Female participants (n=13 297) were from the Swedish Twin Registry [Lichtenstein et al., Twin Research and Human Genetics (2006) 9, 875-882]. Substance use was examined in four defined groups - (1) anorexia nervosa (AN); (2) bulimia nervosa (BN); (3) AN and BN (ANBN); and (4) binge eating disorder (BED) as well as a referent group without eating disorder (no ED). Secondary analyses examined differences between restricting AN (RAN) and binge and/or purge AN (ANBP).

RESULTS

In general, eating disorders were associated with greater substance use relative to the referent. The AN group had significantly increased odds for all illicit drugs. Significant differences emerged across the RAN and ANBP groups for alcohol abuse/dependence, diet pills, stimulants, and polysubstance use with greater use in the ANBP group. Across eating disorder groups, (1) the BN and ANBN groups were more likely to report alcohol abuse/dependence relative to the AN group, (2) the ANBN group was more likely to report diet pill use relative to the AN, BN and BED groups, and (3) the BN group was more likely to report diet pill use relative to the no ED, AN and BED groups.

CONCLUSIONS

Eating disorders are associated with a range of substance use behaviors. Improved understanding of how they mutually influence risk could enhance understanding of etiology and prevention.

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.

Screening for eating disorders in a psychiatric outpatient population

BACKGROUND

Some studies have found "hidden" eating disorders in psychiatric patients. However, eating behaviour, weight, and body image concerns are usually weakly assessed among psychiatric patients.

OBJECTIVES

a) To analyse the prevalence of eating disorders (ED) in patients referred from primary care for psychiatric assessment; and b) to analyse the psychopathological variables associated with these disorders. Methods. Ninety-three patients underwent psychometric assessment using Derogatis' Symptom Checklist-90-R, the Rosenberg Self-Esteem Scale, the Perceived Stress Questionnaire, the Eating Attitudes Test-40 (EAT-40), the Bulimic Investigatory Test, Edinburgh (BITE), and the Body Dissatisfaction Scale of the Eating Disorders Inventory-2. The subsequent clinical assessment, applying DSM-IV-R criteria for ED, was conducted by means of interview with those patients whose scores on the EAT-40 and BITE were above the cut-off points.

RESULTS

The assessments confirmed one case of bulimia nervosa and three of unspecified eating disorder, these accounting for 1.07% and 3.22%, respectively.

CONCLUSION

The existence of hidden ED in psychiatric patients, especially as regards bulimic behaviour, and the correlation between eating disorder symptoms and different psychopathological variables make it important for clinicians to conduct a proper assessment when faced with "anxiety and depressive syndromes", which are a common feature of primary care referrals for psychiatric assessment.

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.

Interspecies comparisons of functional genetic variations and their implications in neuropsychiatry

Animal studies are important for the identification and functional characterization of the biological substrates underlying complex psychiatric disorders. However, novel insights into the relationship between the genome and behavior are needed for the development of fully valid translational models. Based on the notion that in different species, the same genes may independently give rise to alleles with similar functional and phenotypic effects, either under similar selection or through similar genomic mechanisms, we propose the use of genetic validity as a tool for identifying analogous pathology between animals and human neuropsychiatric disorders. Furthermore, the identification of copy number variants which disrupt entire genes, reinforces the notion that transgenic animals, such as knockouts or knock-ins, may provide unexpectedly valid disease models for psychiatric traits. To illustrate interspecies comparison of genetic variations in relation to neurobehavioral traits, examples are provided for the BDNF, COMT, and DISC1 genes in mouse and man. We propose that alignment of individual genetic variations with endophenotypes obtained from mice and across categories of neuropsychiatric disorders will provide an important step in translational research.

Type 1 Diabetes Among Adolescents

Purpose

The aim of this study was to examine the association between social anxiety and adherence to diabetes self-care and quality of life and to determine the effects of fear of hypoglycemia on these associations in adolescents with type 1 diabetes. It is hypothesized that (1) social anxiety will be negatively associated with adherence and quality of life and (2) that fear of hypoglycemia will mediate this relationship. It is also hypothesized that (3) girls will have higher social anxiety than boys.

Methods

Adolescents with type 1 diabetes were recruited during clinic visits at 2 international centers. Participants answered a survey containing questionnaires on social anxiety, behavioral adherence to the diabetes self-care regimen, quality of life, fear of hypoglycemia, and last hemoglobin A1C results.

Results

Seventy-six adolescents (33 boys, 43 girls), mean age 15.9 (1.44) years, participated. Social anxiety levels are not statistically different between genders. In boys, social anxiety is associated with worse diet and insulin injection adherence; no associations are found in girls. Social anxiety is positively correlated with poor quality of life in both genders. Fear of hypoglycemia mediates the relationship between social anxiety and insulin adherence in boys.

Conclusions

Findings suggest that social anxiety, which is common in general populations of adolescents, may interfere with behavioral adherence and quality of life among adolescents with type 1 diabetes. Screening and treatment of social anxiety may result in better adherence and increased quality of life.