Relationships between features associated with vomiting in purging-type eating disorders

One size does not fit all: Exploring how the five-factor model facets predict disordered eating behaviours among adolescent and young adult males and females

There is a wealth of research that has highlighted the relationship between personality and eating disorders. It has been suggested that understanding how subclinical disordered eating behaviours are uniquely associated with personality can help to improve the conceptualization of individuals with eating disorders. This study aimed to explore how the facets of the Five-Factor Model (FFM) predicted restrictive eating, binge eating, purging, chewing and spitting, excessive exercising and muscle building among males and females. An online survey assessing disordered eating behaviours, FFM and general psychopathology was completed by 394 females and 167 males aged between 16 and 30 years. Simultaneous equations path models were systematically generated for each disordered eating behaviour to identify how the FFM facets, body dissatisfaction and age predicted behaviour. The results indicated that each of the six disordered behaviours were predicted by a unique pattern of thinking, feeling and behaving. Considerable differences between males and females were found for each path model, suggesting differences between males and females in the personality traits that drive disordered eating behaviours. It was concluded that it is important to take personality into account when treating males and females who engage in disordered eating behaviours.

Relationship between irregular diet and risk of esophageal cancer: A meta-analysis

Background: Associations between irregular diet and the risk of esophageal cancer remain unclear. The current meta-analysis was performed to determine whether the presence of irregular diet increases the risk of esophageal cancer.

Methods: The data from PubMed, Cochrane Libraries, and Embase up to 23 January 2022 were included in our analysis to identify studies that investigated associations between irregular diet and the risk of esophageal cancer. Summary relative risk (RR) and 95% confidence intervals (CIs) were calculated using a random-effects model.

Results: Five cohort studies and one case-control study investigating associations between irregular diet and the risk of esophageal cancer were included. None of the articles demonstrated publication bias. The summary RR was 4.181 (95% CI 2.196–7.960, I² = 66.1%, p = 0.011). In the subgroup analysis, we found significant heterogeneity in the Non-disease-causing group, nurse group and Asian group. The above three that produce heterogeneity may be the source of heterogeneity in the results of this study.

Conclusion: The current meta-analysis indicates that irregular diet increase the risk of esophageal cancer.

Trial registration: (https://www.crd.york.ac.uk/prospero/), (PROSPERO, CRD42022306407)

Eating disorders and the risk of developing cancer: a systematic review

PURPOSE

Evidence concerning eating disorders as risk toward developing cancer is sparse. Energy restriction might be cancer protective, while malnutrition, vomiting, laxative and substance use might stimulate cancer development. We examined whether individuals with an eating disorder (not restricted to anorexia nervosa) had a different risk of developing cancer.

METHODS

A systematic search on Medline and Embase until 28th April 2020 identified relevant human original research publications, including all populations and all cancer types.

RESULTS

From 990 records, 6 case reports and 9 cohorts were included. Some cohorts found a decreased breast (3/5 studies) or cervical (1/2) cancer risk, while an increased esophageal (2/3), liver (1/1), brain (1/1 in men) and respiratory (2/4) cancer risk, but other cancer risks were non-significant, and an increased mortality overall (1/2), from breast (1/1), female genital (1/1) and skin (1/1) cancer in eating disorder patients. The case reports further described esophageal cancer and leukemia. No clear statistical differences in cancer risk were found depending on eating disorder type, perhaps due to the small sample size (n = 1783 for other than anorexia nervosa).

CONCLUSIONS

The literature on eating disorders and cancer risk is sparse with many gaps. Hormonal changes, sexual activity, nutritional status, vomiting and concomitant tobacco/alcohol abuse may explain increased/decreased cancer risk. Future large studies (now 1-366 cancer cases) that also include men (now 4.7%), bulimia nervosa (now 3.8%) and several cancer sites (now mainly breast cancer) are needed and should foresee longer follow-up time (now 5.4-15.2 years) and extensive confounder adjustment (now only age and sex).

LEVEL OF EVIDENCE

Level I, systematic review.

Childhood trauma determines different clinical and biological manifestations in patients with eating disorders

PURPOSE

There is a significant relationship between childhood trauma and the development of an eating disorder in adolescence or adulthood, possibly influenced by circulating levels of inflammatory parameters. The main objective is to identify and describe a subgroup of patients with eating disorders and a history of trauma in childhood or adolescence with differential clinical features.

METHODS

An observational study on a sample of 55 patients who met the diagnostic criteria for any DSM-5 eating disorder was carried out. Inflammatory parameters in white blood cells were examined. Patients underwent different assessments, including clinical and personality scales.

RESULTS

Patients with a history of trauma had higher scores in the delirious and narcissistic items of the Millon Clinical Multiaxial Inventory (MCMI-II) (p < 0.05) and a higher score in the paranoid item of the SCID-5 Personality Disorders Version (SCID-5-PD) (p < 0.05). Patients with distinguishing personality features were grouped according to the Childhood Trauma Questionnaire sexual subscale. Tumor necrosis alpha (TNF-α) showed a significant association with childhood trauma history.

CONCLUSIONS

There is a profile of patients with eating disorders who have increased activity in the inflammatory pathways that, if identified precociously, can benefit from specifically aimed interventions.

LEVEL OF EVIDENCE

Level V, observational study.

The Anorexia Nervosa Genetics Initiative (ANGI): Overview and methods

BACKGROUND

Genetic factors contribute to anorexia nervosa (AN); and the first genome-wide significant locus has been identified. We describe methods and procedures for the Anorexia Nervosa Genetics Initiative (ANGI), an international collaboration designed to rapidly recruit 13,000 individuals with AN and ancestrally matched controls. We present sample characteristics and the utility of an online eating disorder diagnostic questionnaire suitable for large-scale genetic and population research.

METHODS

ANGI recruited from the United States (US), Australia/New Zealand (ANZ), Sweden (SE), and Denmark (DK). Recruitment was via national registers (SE, DK); treatment centers (US, ANZ, SE, DK); and social and traditional media (US, ANZ, SE). All cases had a lifetime AN diagnosis based on DSM-IV or ICD-10 criteria (excluding amenorrhea). Recruited controls had no lifetime history of disordered eating behaviors. To assess the positive and negative predictive validity of the online eating disorder questionnaire (ED100K-v1), 109 women also completed the Structured Clinical Interview for DSM-IV (SCID), Module H.

RESULTS

Blood samples and clinical information were collected from 13,363 individuals with lifetime AN and from controls. Online diagnostic phenotyping was effective and efficient; the validity of the questionnaire was acceptable.

CONCLUSIONS

Our multi-pronged recruitment approach was highly effective for rapid recruitment and can be used as a model for efforts by other groups. High online presence of individuals with AN rendered the Internet/social media a remarkably effective recruitment tool in some countries. ANGI has substantially augmented Psychiatric Genomics Consortium AN sample collection. ANGI is a registered clinical trial: clinicaltrials.govNCT01916538; https://clinicaltrials.gov/ct2/show/NCT01916538?cond=Anorexia+Nervosa&draw=1&rank=3.

Associations between dimensions of anorexia nervosa and obsessive-compulsive disorder: An examination of personality and psychological factors in patients with anorexia nervosa

OBJECTIVE

Anorexia nervosa (AN) and obsessive-compulsive disorder (OCD) are highly comorbid. However, the factors that account for this comorbidity are poorly understood. We examined the core dimensions of AN and OCD and psychological and personality factors shared by both disorders.

METHOD

In path analyses (N = 732 women with either current AN or recovered from AN), we examined which factors were uniquely and independently associated with the core dimensions of AN and OCD. We also examined recovery from AN as a moderator.

RESULTS

When individuals with AN reported greater concern over mistakes, they endorsed more severity in both AN and OCD core dimensions. These unique associations existed above and beyond all other transdiagnostic personality and psychological factors and regardless of AN recovery status.

CONCLUSIONS

Concern over mistakes partially accounts for severity in the core dimensions of both AN and OCD. Concern over mistakes may represent an important target in the aetiology of AN and OCD.

Improving prediction of eating-related behavioral outcomes with zero-sensitive regression models

Objective

Outcome variables gauging the frequency of specific disordered eating behaviors (e.g., binge eating, vomiting) are common in the study of eating and health behaviors. The nature of such data presents several analytical challenges, which may be best addressed through the application of underutilized statistical approaches. The current study examined several approaches to predicting count-based behaviors, including zero-sensitive (i.e., zero-inflated and hurdle) regression models.

Method

Exploration of alternative models to predict eating-related behaviors occurred in two parts. In Part 1, participants (N = 524; 54% female) completed the Eating Disorder Examination-Questionnaire and Daily Stress Inventory. We considered the theoretical basis and practical utility of several alternative approaches for predicting the frequency of binge eating and compensatory behaviors, including ordinary least squares (OLS), logistic, Poisson, negative binomial, and zero-sensitive models. In Part 2, we completed Monte Carlo simulations comparing negative binomial, zero-inflated negative binomial, and negative binomial hurdle models to further explore when these models are most useful.

Results

Traditional OLS regression models were generally a poor fit for the data structure. Zero-sensitive models, which are not limited to traditional distribution assumptions, were preferable for predicting count-based outcomes. In the data presented, zero-sensitive models were useful in modeling behaviors that were relatively rare (laxative use and vomiting, 9.7% endorsed) along with those that were somewhat common (binge eating, 33.4% endorsed; driven exercise, 40.7% endorsed). Simulations indicated missing data, sample size, and the number of zeros may impact model fit.

Discussion

Zero-sensitive approaches hold promise for answering key questions about the presence and frequency of common eating-related behaviors and improving the specificity of relevant statistical models. Hurdle models may also be appropriate when theoretically justified.

Emotional eating and temperamental traits in Eating Disorders: A dimensional approach

Growing evidence shows that temperamental features and emotional dysregulation are linked to Eating Disorders (EDs). Aim of this study was to explore the possible relationship between temperament and emotional eating (EE) from a dimensional standpoint, and the association of specific temperamental dimensions with overeating triggered by specific emotions. We enrolled 253 women with Anorexia Nervosa, Bulimia Nervosa and Binge Eating Disorder. Of those, 189 (74.7%), 73 (28.8%), and 80 (31.6%) reported binge eating, purging, or restrictive behaviors, respectively (the categories are not mutually exclusive). Participants completed the Emotional Eating Scale (EES), the Temperament and Character Inventory, the Eating Disorder Examination Questionnaire (EDE-Q) and the Symptom Checklist 90-Revised (SCL-90-R). Higher Persistence scores were found in the Restriction group, while the Binge group reported lower Persistence and higher Novelty Seeking scores. The Purge group showed lower Reward Dependence, Self Directedness and Cooperativeness scores. Patients with Purge also reported lower BMI and higher scores on EDE-Q restriction and eating concern subscales as well as higher scores for all SCL 90-R subscales. Patterns of association between temperamental traits and specific emotions were found in each group. Therefore, some temperamental features could be considered predictors of specific associations between emotions and the tendency to eat.

Associations between eating disorder symptoms and suicidal ideation through thwarted belongingness and perceived burdensomeness among eating disorder patients

BACKGROUND

Suicidal ideation is relatively common among people with eating disorders (EDs). The Interpersonal-Psychological Theory of Suicide holds that suicidal ideation has two proximal causes: thwarted belongingness and perceived burdensomeness. It is unknown which ED symptoms are positively associated with suicidal ideation, and whether thwarted belongingness and perceived burdensomeness explain those associations.

METHOD

We tested two parallel mediation models to determine whether current and lifetime ED symptoms were positively related to suicidal ideation through thwarted belongingness and perceived burdensomeness among ED patients (n=98), controlling for current depression. In each model, ED symptoms and depression were predictors, thwarted belongingness and perceived burdensomeness were mediators, and suicidal ideation was the outcome.

RESULTS

The first model included current symptoms; current body dissatisfaction (ab=0.04, 95% CI [0.01, 0.06]) and fasting (ab=0.12, 95% CI [0.01, 0.22]) were indirectly related to increased suicidal ideation through higher burdensomeness, controlling for depression. The second model included lifetime symptoms; lifetime fasting (ab=0.18, 95% CI [0.07, 0.29]) was indirectly related to increased suicidal ideation through higher burdensomeness, controlling for depression.

LIMITATIONS

The sample size prevented the use of latent variables for thwarted belongingness and perceived burdensomeness, and the cross-sectional data prevented testing for bidirectional relations among ED symptoms, thwarted belongingness, perceived burdensomeness, and suicidal ideation.

CONCLUSIONS

Results underscore the importance of exploring transdiagnostic ED symptoms, including body dissatisfaction and fasting in particular, that may intensify burdensomeness and thereby contribute to suicidal ideation over and above depressive symptoms in this high-risk population.

Predictors of Dropout by Female Obese Patients Treated with a Group Cognitive Behavioral Therapy to Promote Weight Loss

OBJECTIVE

To investigate predictors of dropout from a group cognitive behavioral therapy (CBT) intervention for overweight or obese women.

METHODS

119 overweight and obese Japanese women aged 25-65 years who attended an outpatient weight loss intervention were followed throughout the 7-month weight loss phase. Somatic characteristics, socioeconomic status, obesity-related diseases, diet and exercise habits, and psychological variables (depression, anxiety, self-esteem, alexithymia, parenting style, perfectionism, and eating attitude) were assessed at baseline. Significant variables, extracted by univariate statistical analysis, were then used as independent variables in a stepwise multiple logistic regression analysis with dropout as the dependent variable.

RESULTS

90 participants completed the weight loss phase, giving a dropout rate of 24.4%. The multiple logistic regression analysis demonstrated that compared to completers the dropouts had significantly stronger body shape concern, tended to not have jobs, perceived their mothers to be less caring, and were more disorganized in temperament. Of all these factors, the best predictor of dropout was shape concern.

CONCLUSION

Shape concern, job condition, parenting care, and organization predicted dropout from the group CBT weight loss intervention for overweight or obese Japanese women.

Risk of oesophageal cancer among patients previously hospitalised with eating disorder

•

There are case reports of oesophageal cancer in patients with eating disorders.

•

We followed up a cohort of patients hospitalised previously with eating disorders.

•

These patients were at significantly increased risk of oesophageal cancer.

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All cancers were squamous cell carcinomas in females with prior anorexia nervosa.

•

Indirect evidence suggests confounding by established risk factors.

Background

It has been suggested that the risk of oesophageal adenocarcinoma might be increased in patients with a history of eating disorders due to acidic damage to oesophageal mucosa caused by self-induced vomiting practiced as a method of weight control. Eating disorders have also been associated with risk factors for squamous cell carcinoma of the oesophagus, including alcohol use disorders, as well as smoking and nutritional deficiencies, which have been associated with both main sub-types of oesophageal cancer. There have been several case reports of oesophageal cancer (both main sub-types) arising in patients with a history of eating disorders.

Methods

We used linked records of hospitalisation, cancer registration and mortality in Scotland spanning 1981–2012 to investigate the risk of oesophageal cancer among patients with a prior history of hospitalisation with eating disorder. The cohort was restricted to patients aged ≥10 years and <60 years at the date of first admission with eating disorder. Disregarding the first year of follow-up, we calculated indirectly standardised incidence ratios using the general population as the reference group to generate expected numbers of cases (based on age-, sex-, socio-economic deprivation category-, and calendar period-specific rates of disease).

Results

After exclusions, the cohort consisted of 3617 individuals contributing 52,455 person-years at risk. The median duration of follow-up was 13.9 years. Seven oesophageal cancers were identified, as compared with 1.14 expected, yielding a standardised incidence ratio of 6.1 (95% confidence interval: 2.5–12.6). All were squamous cell carcinomas arising in females with a prior history of anorexia nervosa.

Conclusions

Patients hospitalised previously with eating disorders are at increased risk of developing oesophageal cancer. Confounding by established risk factors (alcohol, smoking, and nutritional deficiency) seems a more likely explanation than acidic damage through self-induced vomiting because none of the incident cases of oesophageal cancer were adenocarcinomas, and because the study cohort had higher than background rates of hospitalisation with alcohol-related conditions and chronic obstructive pulmonary disease.

Temperament and emotional eating: a crucial relationship in eating disorders

Specific personality traits are related to Eating Disorders (EDs) specific and general psychopathology. Recent studies suggested that Emotional Eating (EE) is a common dimension in all EDs, irrespective of binge eating. The present study was aimed to explore the relationship of temperamental features with EE and eating symptomatology in a sample of EDs patients, adjusting for general psychopathology. One hundred and sixty six female patients were enrolled at the Eating Disorders Outpatient Clinic of the Careggi Teaching-Hospital of Florence. Participants completed the emotional eating scale, the temperament and character inventory, the eating disorder examination questionnaire and the symptom checklist 90-revised. Novelty seeking and self directedness showed significant correlations with EE after adjustment for general psychopathology. Patients with binge eating displayed significant associations between EE and novelty seeking and self directedness. Among patients without binge eating, no significant correlation between EE and temperamental features was observed. Specific temperamental features are associated to EE in EDs. A clear, different pattern of association in patients with different eating attitudes and behavior was found. Considering that treatments of EDs are largely based on psychotherapeutic interventions, focused on emotions and cognitions, the present data provide some hints which could be helpful for the development of more appropriate psychotherapeutic strategies.

Factors associated with recovery from anorexia nervosa

Previous studies of prognostic factors of anorexia nervosa (AN) course and recovery have followed clinical populations after treatment discharge. This retrospective study examined the association between prognostic factors--eating disorder features, personality traits, and psychiatric comorbidity--and likelihood of recovery in a large sample of women with AN participating in a multi-site genetic study. The study included 680 women with AN. Recovery was defined as the offset of AN symptoms if the participant experienced at least one year without any eating disorder symptoms of low weight, dieting, binge eating, and inappropriate compensatory behaviors. Participants completed a structured interview about eating disorders features, psychiatric comorbidity, and self-report measures of personality. Survival analysis was applied to model time to recovery from AN. Cox regression models were used to fit associations between predictors and the probability of recovery. In the final model, likelihood of recovery was significantly predicted by the following prognostic factors: vomiting, impulsivity, and trait anxiety. Self-induced vomiting and greater trait anxiety were negative prognostic factors and predicted lower likelihood of recovery. Greater impulsivity was a positive prognostic factor and predicted greater likelihood of recovery. There was a significant interaction between impulsivity and time; the association between impulsivity and likelihood of recovery decreased as duration of AN increased. The anxiolytic function of some AN behaviors may impede recovery for individuals with greater trait anxiety.

Temporal sequence of comorbid alcohol use disorder and anorexia nervosa

Women with eating disorders have a significantly higher prevalence of substance use disorders than the general population. The goal of the current study was to assess the temporal pattern of comorbid anorexia nervosa (AN) and alcohol use disorder (AUD) and the impact this ordering has on symptomatology and associated features. Women were placed into one of three groups based on the presence or absence of comorbid AUD and the order of AN and AUD onset in those with both disorders: (1) AN Only, (2) AN First, and (3) AUD First. The groups were compared on psychological symptoms and personality characteristics often associated with AN, AUD, or both using general linear models. Twenty-one percent of women (n=161) with AN reported a history of AUD with 115 reporting AN onset first and 35 reporting AUD onset first. Women with binge-eating and/or purging type AN were significantly more likely to have AUD. In general, differences were found only between women with AN Only and women with AN and AUD regardless of order of emergence. Women with AN and AUD had higher impulsivity scores and higher prevalence of depression and borderline personality disorder than women with AN Only. Women with AN First scored higher on traits commonly associated with AN, whereas women with comorbid AN and AUD displayed elevations in traits more commonly associated with AUD. Results do not indicate a distinct pattern of symptomatology in comorbid AN and AUD based on the temporal sequence of the disorders.

An examination of early childhood perfectionism across anorexia nervosa subtypes

OBJECTIVE

To examine childhood perfectionism in anorexia nervosa (AN) restricting (RAN), purging (PAN), and binge eating with or without purging (BAN) subtypes.

METHOD

The EATATE, a retrospective assessment of childhood perfectionism, and the eating disorder inventory (EDI-2) were administered to 728 AN participants.

RESULTS

EATATE responses revealed general childhood perfectionism, 22.3% of 333 with RAN, 29.2% of 220 with PAN, and 24.8% of 116 with BAN; school work perfectionism, 31.2% with RAN, 30.4% with PAN, and 24.8% with BAN; childhood order and symmetry, 18.7% with RAN, 21.7% with PAN, and 17.8% with BAN; and global childhood rigidity, 42.6% with RAN, 48.3% with PAN and 48.1% with BAN. Perfectionism preceded the onset of AN in all subtypes. Significant associations between EDI-2 drive for thinness and body dissatisfaction were present with four EATATE subscales.

DISCUSSION

Global childhood rigidity was the predominate feature that preceded all AN subtypes. This may be a risk factor for AN.

Purging behavior in anorexia nervosa and eating disorder not otherwise specified: a retrospective cohort study

Purging behavior in eating disorders is associated with medical risks. We aimed to compare remission rates in purging and non-purging females with anorexia nervosa (AN) and eating disorder not otherwise specified (EDNOS) in a large retrospective single center cohort. A total of 339 patients with AN and 266 patients with EDNOS were included in the study. The proportion of subjects with purging behavior at least once a week during the last 3 months was similar in the two groups: 22% in AN and 24% in EDNOS. Remission was defined by a goal weight ≥85% of ideal body weight and no reported purging behavior in the last 6 months. The median time from onset to remission for patients with AN was 7 years for the non-purging vs. 11 years for the purging patients. The purging AN patients with both vomiting and laxative abuse displayed the poorest course. Among EDNOS patients, the time to remission was also significantly longer for purging patients compared to non-purging patients. Thus, in line with previous studies, we found that purging behavior is associated with delayed time to remission in treatment-seeking AN and EDNOS patients. This study provides evidence to support the retention of the diagnostic sub-typing in AN.

The use of multiple methods of compensatory behaviors as an indicator of eating disorder severity in treatment-seeking youth

OBJECTIVE

This study investigated the use and frequency of multiple methods of compensatory behaviors and how they relate to eating-related and general psychopathology for youth with eating disorders (ED).

METHOD

Participants were 398 referrals to a pediatric ED treatment program (91.2% female; M age = 14.9 ± 2.2). ANOVA and chi-square tests compared participants reporting multiple methods of compensatory behaviors, single method of compensatory behaviors, and no compensatory behaviors on measures of ED and general psychopathology. Partial correlations examined associations between compensatory behavior, frequency and severity of ED and general psychopathology.

RESULTS

Participants reporting multiple methods of compensatory behaviors had significantly greater ED and general psychopathology than the other groups (ps < .001). Frequency of compensatory behaviors was associated with ED psychopathology (partial r = .14; p = .007) but not with general psychopathology.

DISCUSSION

Engaging in multiple methods of compensatory behaviors is related to greater ED and general psychopathology, whereas frequency is only related to greater ED symptom severity.

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.

Latent class analysis of eating and impulsive behavioral symptoms in Taiwanese women with bulimia nervosa

OBJECTIVE

The implications of impulsivity in its relationship with binge-eating or purging behaviors remain unclear. This study examined the patterns of eating behaviors and co-morbid impulsive behaviors in individuals with bulimia nervosa n optimally homogeneous classes using latent class analysis (LCA).

METHODS

All participants (n=180) were asked to complete a series of self-reported inventories of impulsive behaviors and other psychological measures. Information regarding the lifetime presence of symptoms of eating disorder was assessed by clinical interviews. LCA was conducted using eating disorder symptoms, impulsive behaviors, and the number of purging methods.

RESULTS

Three latent classes of bulimic women were identified. These were women who exhibited relatively higher rates of purging, symptoms of impulsive behavior, and multiple purging methods (17.8%), women who used no more than one purging method with a low occurrence of impulsive behavior (41.7%), and women who showed higher rates of purging behaviors and the use of multiple purging methods with a low rate of impulsive behavior (41.7%). The impulsive sub-group had comparable severity of eating-related measures, frequency of binge-eating, and higher levels of general psychopathology than that of the other two sub-groups.

CONCLUSION

This study provides empirical support for the existence of an impulsive subgroup with distinctive features among a non-Western group of BN patients. This study also suggests that mechanisms other than impulse dysregulation may exist for the development of binge-eating and purging behaviors in bulimia nervosa patients, or the mechanisms contributing to binge-eating and impulsive behaviors may be different.

Regulating satiety in bulimia nervosa: the role of cholecystokinin

PURPOSE

Individuals with bulimia nervosa (BN) report altered perceptions in hunger, fullness, and satiety. This article reviews the role of cholecystokinin (CCK), a satiety-producing hormone, in the regulation of binge eating in those who suffer from BN.

CONCLUSION

Studies have shown that CCK is decreased in individuals with BN when compared with healthy controls. Decreased CCK functioning may contribute to impaired satiety and thus binge eating in this patient population. Depending on the macronutrient composition of food choices, CCK release can be differentially influenced. For instance, protein is a potent stimulator of a CCK response. Eating more protein-rich meals increases the release of CCK, increasing satiety and ending a meal.

PRACTICE IMPLICATIONS

Knowledge of CCK functioning and the utility of manipulating the macronutrient composition of meals may inform standard behavioral treatment strategies for those who suffer from BN.

Genetic association of recovery from eating disorders: the role of GABA receptor SNPs

Follow-up studies of eating disorders (EDs) suggest outcomes ranging from recovery to chronic illness or death, but predictors of outcome have not been consistently identified. We tested 5151 single-nucleotide polymorphisms (SNPs) in approximately 350 candidate genes for association with recovery from ED in 1878 women. Initial analyses focused on a strictly defined discovery cohort of women who were over age 25 years, carried a lifetime diagnosis of an ED, and for whom data were available regarding the presence (n=361 ongoing symptoms in the past year, ie, 'ill') or absence (n=115 no symptoms in the past year, ie, 'recovered') of ED symptoms. An intronic SNP (rs17536211) in GABRG1 showed the strongest statistical evidence of association (p=4.63 × 10(-6), false discovery rate (FDR)=0.021, odds ratio (OR)=0.46). We replicated these findings in a more liberally defined cohort of women age 25 years or younger (n=464 ill, n=107 recovered; p=0.0336, OR=0.68; combined sample p=4.57 × 10(-6), FDR=0.0049, OR=0.55). Enrichment analyses revealed that GABA (γ-aminobutyric acid) SNPs were over-represented among SNPs associated at p<0.05 in both the discovery (Z=3.64, p=0.0003) and combined cohorts (Z=2.07, p=0.0388). In follow-up phenomic association analyses with a third independent cohort (n=154 ED cases, n=677 controls), rs17536211 was associated with trait anxiety (p=0.049), suggesting a possible mechanism through which this variant may influence ED outcome. These findings could provide new insights into the development of more effective interventions for the most treatment-resistant patients.

Prevalence and correlates of self-induced vomiting as weight-control strategy among adolescents in Taiwan

AIMS

This study was designed to assess the prevalence and correlates of self-induced vomiting to control body weight among adolescents in Taiwan.

BACKGROUND

Over the past decades, the rate of obesity among children in Taiwan has nearly tripled. Educational authorities have devoted considerable effort to prevent the increase in childhood obesity.

DESIGN

An observational exploratory design to investigate the problem of using unhealthy weight-reduction strategy.

METHODS

This study consists of a cross-sectional study aimed at collecting national representative data. We chose 120 representative schools using a three-stage stratified systematic sampling design with probability proportionate to the size of the population in Taiwan. Participants consisted of 8673 girls and 7043 boys, aged 10-18 old.

RESULTS

Of the participants, 13% reported using self-induced vomiting, the prevalence being highest in participants aged 10-12 (15·9%) and lowest in participants aged 16-18 (7·5%). Several factors were significantly and positively associated with the use of self-induced vomiting as a weight-loss strategy, specifically subjects who (1) watched television, used computer, surfed the Internet or played video games for greater than or equal to two hours/day, (2) consumed fried food every day and (3) ate night-time snacks every day (odds ratio = 1·55, 2·10 and 1·51, respectively; p < 0·05). Eating breakfast every day and sleeping for more than eight hours a day were both protective factors against the use of self-induced vomiting to control body weight (odds ratio = 0·43 and 0·86, respectively; p < 0·05).

CONCLUSIONS

Self-induced vomiting was prevalent among adolescents who had tried to lose weight; sedentary lifestyle, shorter sleep length and unhealthy eating habits may contribute significantly to this behaviour among these adolescents.

RELEVANCE TO CLINICAL PRACTICE

School nurses who are helping adolescents lose weight should also pay attention to the possibility they are using self-induced vomiting as a weight-control strategy.

Absence of association between specific common variants of the obesity-related FTO gene and psychological and behavioral eating disorder phenotypes

Extensive population-based genome-wide association studies have identified an association between the FTO gene and BMI; however, the mechanism of action is still unknown. To determine whether FTO may influence weight regulation through psychological and behavioral factors, seven single-nucleotide polymorphisms (SNPs) of the FTO gene were genotyped in 1,085 individuals with anorexia nervosa (AN) and 677 healthy weight controls from the international Price Foundation Genetic Studies of Eating Disorders. Each SNP was tested in association with eating disorder phenotypes and measures that have previously been associated with eating behavior pathology: trait anxiety, harm-avoidance, novelty seeking, impulsivity, obsessionality, compulsivity, and concern over mistakes. After appropriate correction for multiple comparisons, no significant associations between individual FTO gene SNPs and eating disorder phenotypes or related eating behavior pathology were identified in cases or controls. Thus, this study found no evidence that FTO gene variants associated with weight regulation in the general population are associated with eating disorder phenotypes in AN participants or matched controls.

Impact of broadening definitions of anorexia nervosa on sample characteristics

Practical limitations and sample size considerations often lead to broadening of diagnostic criteria for anorexia nervosa (AN) in research. The current study sought to elucidate the effects of this practice on resultant sample characteristics in terms of eating disorder behaviors, psychiatric comorbidities, temperament and personality characteristics, and heritability point estimates. Three definitions of AN were created: meeting all Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) criteria for AN (AN-DSM-IV), meeting all DSM-IV criteria except criterion D, amenorrhea, (AN-noD), and broadening DSM-IV AN criteria by allowing a higher body mass index value, eliminating criterion D, and allowing less stringent body weight concerns (AN-Broad). Using data from the Swedish Twin Registry, 473 women fit one of the three definitions of AN. Women with AN-DSM-IV reported significantly more eating disorder behaviors than women with AN-Broad. Women with AN-noD reported more comorbid psychiatric disorders than women with AN-DSM-IV and AN-Broad. Temperament and personality characteristics did not differ across the three groups. Heritability point estimates decreased as AN definition broadened. Broadening the diagnostic criteria for AN results in an increased number of individuals available for participation in research studies. However, broader criteria for AN yield a more heterogeneous sample with regard to eating disorder symptoms and psychiatric comorbidity than a sample defined by narrower criteria.

Assessment of dental fear and anxiety levels in eating disorder patients undergoing minor oral surgery

PURPOSE

The aim of the present study was to evaluate the levels of dental fear and anxiety in women with eating disorders (EDs) scheduled for oral surgery.

PATIENTS AND METHODS

A total of 61 patients with EDs, an identical number of age-, gender-, and education-matched healthy controls, and 2 consecutive, randomly selected, clinical and nonclinical samples each consisting of 220 female subjects were included in the present study. The participants completed the demographic and clinical forms, as well as the modified dental anxiety scale (MDAS) and dental fear survey (DFS) before the surgical procedure.

RESULTS

The mean scores of the MDAS and DFS for the study population correlated negatively with age and positively with a previous unpleasant experience related to dentistry (P < .01 for both). Patients with EDs had significantly greater mean scores on the MDAS than the clinical and nonclinical groups (P < .05 for both). Their mean scores on the DFS were significantly greater than those for the nonclinical participants (P < .05). A significant difference was found in the DFS subscale "fear of specific situations and stimuli" compared with the healthy matched controls and clinical and nonclinical subjects (P < .05 for all).

CONCLUSION

The results of our study have shown that patients with EDs can be more sensitive to the auditory, visual, and contact stimuli of the oral surgery procedures under local anesthesia. They also had greater levels of dental fear and anxiety than routine clinical patients and randomly selected subjects from a nonclinical environment.

Life beyond the eating disorder: education, relationships, and reproduction

OBJECTIVE

We investigated the sociodemographic characteristics in women with and without lifetime eating disorders.

METHOD

Participants were from a multisite international study of eating disorders (N = 2,096). Education level, relationship status, and reproductive status were examined across eating disorder subtypes and compared with a healthy control group.

RESULTS

Overall, women with eating disorders were less educated than controls, and duration of illness and age of onset were associated with educational attainment. Menstrual status was associated with both relationship and reproductive status, but eating disorder subtypes did not differ significantly from each other or from healthy controls on these dimensions.

DISCUSSION

Differences in educational attainment, relationships, and reproduction do exist in individuals with eating disorders and are differentially associated with various eating disorder symptoms and characteristics. These data could assist in educating patients and family members about long-term consequences of eating disorders.

The significance of repetitive hair-pulling behaviors in eating disorders

We studied the relation between intrusive and repetitive hair pulling, the defining feature of trichotillomania, and compulsive and impulsive features in 1,453 individuals with anorexia nervosa and bulimia nervosa. We conducted a series of regression models examining the relative influence of compulsive features associated with obsessive-compulsive disorder, compulsive features associated with eating disorders, trait features related to harm avoidance, perfectionism, and novelty seeking, and self harm. A final model with a reduced sample (n = 928) examined the additional contribution of impulsive attributes. One of 20 individuals endorsed hair pulling. Evidence of a positive association with endorsement of compulsive behavior of the obsessive-compulsive spectrum emerged. Hair pulling may be more consonant with ritualistic compulsions than impulsive urges in those with eating disorders.

Specific eating disorder clusters based on social anxiety and novelty seeking

While social avoidance and distress (SAD), a key aspect of social phobia related to behavioral inhibition, is high in different eating disorders (EDs), novelty seeking (NS) is mainly linked to bulimic disorders. Since heterogeneity in NS levels (low/high) exists in social phobia and in about 55% of ED with a highly disturbed personality, we examined ED types based on SAD and NS and their relationships to eating and comorbid features. Scores of 825 ED women on SAD and NS were submitted to cluster analysis. Five clinically differentiated ED clusters emerged: two without SAD (45%) and three with high SAD and low (13%), mid (34%), high NS (8%) levels. High vs. low SAD groups showed greater eating and social impairment, ineffectiveness, ascetism, suicide attempts, and lower education. Among SAD clusters, "SAD-low NS" had the lowest rate of binge eating, vomit, substance use, stealing and compulsive buying, whereas "SAD-high NS" presented the opposite pattern. However, no differences across SAD clusters were found with regard to ED diagnostic category distribution or history of treatment. Findings show that SAD-ED types present heterogeneity of NS and greater severity.

Is season of birth related to disordered eating and personality in women with eating disorders?

We assessed the relation between season of birth and eating disorder symptoms and personality characteristics in a sample of 880 women with eating disorders and 580 controls from two Price Foundation Studies. Eating disorder symptoms were assessed using the Structured Interview of Anorexic and Bulimic Disorders and the Structured Clinical Interview for DSM-IV. Personality traits were assessed using the Temperament and Character Inventory and the Frost Multidimensional Perfectionism Scale. Date of birth was obtained from a sociodemographic questionnaire. No significant differences were observed 1) in season of birth across eating disorder subtypes and controls; nor 2) for any clinical or personality variables and season of birth. We found no evidence of season of birth variation in eating disorders symptoms or personality traits. Contributing to previous conflicting findings, the present results do not support a season of birth hypothesis for eating disorders.

Association study of 182 candidate genes in anorexia nervosa

We performed association studies with 5,151 SNPs that were judged as likely candidate genetic variations conferring susceptibility to anorexia nervosa (AN) based on location under reported linkage peaks, previous results in the literature (182 candidate genes), brain expression, biological plausibility, and estrogen responsivity. We employed a case-control design that tested each SNP individually as well as haplotypes derived from these SNPs in 1,085 case individuals with AN diagnoses and 677 control individuals. We also performed separate association analyses using three increasingly restrictive case definitions for AN: all individuals with any subtype of AN (All AN: n = 1,085); individuals with AN with no binge eating behavior (AN with No Binge Eating: n = 687); and individuals with the restricting subtype of AN (Restricting AN: n = 421). After accounting for multiple comparisons, there were no statistically significant associations for any individual SNP or haplotype block with any definition of illness. These results underscore the importance of large samples to yield appropriate power to detect genotypic differences in individuals with AN and also motivate complementary approaches involving Genome-Wide Association (GWA) studies, Copy Number Variation (CNV) analyses, sequencing-based rare variant discovery assays, and pathway-based analysis in order to make up for deficiencies in traditional candidate gene approaches to AN.

Substance use disorders in women with anorexia nervosa

OBJECTIVE

We examined prevalence of substance use disorders (SUD) in women with: (1) anorexia nervosa (AN) restricting type (RAN); (2) AN with purging only (PAN); (3) AN with binge eating only (BAN); and (4) lifetime AN and bulimia nervosa (ANBN). Secondary analyses examined SUD related to lifetime purging behavior and lifetime binge eating.

METHOD

Participants (N = 731) were drawn from the International Price Foundation Genetic Studies.

RESULTS

The prevalence of SUD differed across AN subtypes, with more in the ANBN group reporting SUD than those in the RAN and PAN groups. Individuals who purged were more likely to report substance use than those who did not purge. Prevalence of SUD differed across lifetime binge eating status.

DISCUSSION

SUD are common in AN and are associated with bulimic symptomatology. Results underscore the heterogeneity in AN, highlighting the importance of screening for SUD across AN subtypes.

Childhood anxiety associated with low BMI in women with anorexia nervosa

OBJECTIVE

Extremely low body mass index (BMI) values are associated with increased risk for death and poor long-term prognosis in individuals with anorexia nervosa (AN). The present study explores childhood personality characteristics that could be associated with the ability to attain an extremely low BMI.

METHODS

Participants were 326 women from the Genetics of Anorexia Nervosa (GAN) Study who completed the Structured Interview for Anorexia Nervosa and Bulimic Syndromes and whose mother completed the Child Behavioral Checklist and/or Revised Dimensions of Temperament Survey.

RESULTS

Children who were described as having greater fear or anxiety by their mothers attained lower BMIs during AN (p < 0.02). Path analysis in the GAN and a validation sample, Price Foundation Anorexia Nervosa Trios Study, confirmed the relation between early childhood anxiety, caloric restriction, qualitative food item restriction, excessive exercise, and low BMI. Path analysis also confirmed a relation between childhood anxiety and caloric restriction, which mediated the relation between childhood anxiety and low BMI in the GAN sample only.

CONCLUSION

Fearful or anxious behavior as a child was associated with the attainment of low BMI in AN and childhood anxiety was associated with caloric restriction. Measures of anxiety and factors associated with anxiety-proneness in childhood may index children at risk for restrictive behaviors and extremely low BMIs in AN.

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.

Self-induced vomiting in eating disorders: Associated features and treatment outcome

Self-induced vomiting is adopted by people with a variety of eating disorders (ED) to control body shape and weight. We tested the prevalence, the associated features and the role on treatment outcome of self-induced vomiting in 152 ED patients consecutively admitted to an inpatient cognitive-behavioral treatment (CBT), based on the transdiagnostic CBT for ED. The Eating Disorder Examination, together with the Beck Depression Inventory, the State-Trait Anxiety Inventory and the Temperament and Character Inventory were recorded at entry and at end of treatment. Self-induced vomiting was reported in 35.5% of cases, and 21.1% had multiple purging with vomiting. Individuals with vomiting and those with multiple purging had significantly higher BMI and a higher frequency of bulimic episodes, but individuals with multiple purging were also characterized by higher levels of depression, longer ED duration, more severe ED psychopathology and lower self-directness. Individuals with vomiting had higher eating concern and novelty seeking compared with those without purging behaviors. However, the three groups had similar dropout rates and outcomes in response to inpatient CBT, in keeping with the transdiagnostic theory of EDs.

Nausea and vomiting of pregnancy in women with bulimia nervosa and eating disorders not otherwise specified

OBJECTIVE

To explore the prevalence of pregnancy-related nausea (PN) and vomiting (PV), and hyperemesis gravidarum (HG), in women with bulimia nervosa (BN) and EDNOS purging subtype (EDNOS-P).

METHOD

Pregnant women (38,038) enrolled in the Norwegian Mother and Child Cohort Study had questionnaire-based information on eating disorder diagnosis and PN, PV, and HG. We estimated the odds for PN, PV, and HG using logistic regression.

RESULTS

Women with BN, purging subtype, but not women with BN, nonpurging subtype, had statistically significant higher odds of PN and PV compared to women without eating disorders. The EDNOS-P group showed significantly higher odds of PV. The odds of HG did not differ significantly between those with and without an eating disorder, or across eating disorder subtypes.

CONCLUSION

Our results suggest that eating disorders marked by the symptom of purging are associated with increased odds of PN and PV.

Anger expression in eating disorders: clinical, psychopathological and personality correlates

The goals of the study were to compare anger expressions in individuals with eating disorders and healthy controls, and to explore the relation among eating disorder symptoms, comorbid psychopathology, personality traits, and impulsive behaviours. Participants comprised 135 eating disorder patients consecutively admitted to our unit and 103 healthy controls. Assessment measures included the Eating Disorders Inventory 2 (EDI-2), Bulimic Investigatory Test Edinburgh (BITE), Symptom Checklist-Revised (SCL-90-R), Social Avoidance Distress Scale (SAD), Temperament and Character Inventory-Revised (TCI-R), State-Trait Anger Expression Inventory 2 (STAXI-2), and other clinical and psychopathological indices. In the control group also the General Health Questionnaire-28 (GHQ-28) was also used. Women with eating disorders obtained significantly higher mean scores than controls on all STAXI-2 scales except for Anger Control. When various purging methods were assessed independently, the frequency of laxative use was associated with anger suppression. Eating disorder symptoms and specific personality traits were positively associated with different forms of anger expression. Finally, patients with higher scores on anger suppression were more likely to report self-harming behaviors. Eating disorder patients may have inadequate anger expression and deficits in coping with anger and frustration. Furthermore, different purging methods may be related to different facets of anger.

Shared and unique risk factors between lifetime purging and objective binge eating: a twin study

BACKGROUND

Objective binge eating (OBE) and self-induced vomiting (SIV) occur and co-occur across a range of eating disorders but the extent to which the risk factors for these two behaviours overlap is unclear. Examination of this overlap was the focus of the current report.

METHOD

A population of female Australian twins (n=1002), mean age 35 years (s.d.=2.11, range 28-40), participated in three waves of data collection and were assessed for lifetime disordered eating with a semi-structured interview at wave 3 and a self-report questionnaire at wave 1; risk factors were assessed via a self-report at waves 1 and 3.

RESULTS

Non-shared environmental influences were the largest contributor to the variance of both OBE and SIV, with a more modest contribution of genetic influences. Between 5% and 14% of the environmental risk factors for OBE and SIV were shared and 27-100% of genetic risk factors were shared. SIV initiation was predicted by higher neuroticism and novelty seeking and lower maternal and paternal care, whilst lower levels of perceived paternal care, higher lifetime BMI, and a wider BMI range predicted OBE initiation. Retrospective correlates associated with both SIV and OBE onset were parental comments about weight, whilst higher levels of parental conflict, expectations and criticism was associated with OBE onset only.

CONCLUSIONS

The substantial extent of non-overlap between risk factors for SIV and OBE suggests that each of these behavioural disturbances warrants future investigation in its own right, not only when they occur in conjunction with each other.

Family, peer, and media predictors of becoming eating disordered

OBJECTIVE

To identify predictors of becoming eating disordered among adolescents.

DESIGN

Prospective cohort study.

SETTING

Self-report questionnaires.

SUBJECTS

Girls (n = 6916) and boys (n = 5618), aged 9 to 15 years at baseline, in the ongoing Growing Up Today Study (GUTS). Main Exposures Parent, peer, and media influences.

MAIN OUTCOME MEASURES

Onset of starting to binge eat or purge (ie, vomiting or using laxatives) at least weekly.

RESULTS

During 7 years of follow-up, 4.3% of female subjects and 2.3% of male subjects (hereafter referred to as "females" and "males") started to binge eat and 5.3% of females and 0.8% of males started to purge to control their weight. Few participants started to both binge eat and purge. Rates and risk factors varied by sex and age group (<14 vs > or =14 years). Females younger than 14 years whose mothers had a history of an eating disorder were nearly 3 times more likely than their peers to start purging at least weekly (odds ratio, 2.8; 95% confidence interval, 1.3-5.9); however, maternal history of an eating disorder was unrelated to risk of starting to binge eat or purge in older adolescent females. Frequent dieting and trying to look like persons in the media were independent predictors of binge eating in females of all ages. In males, negative comments about weight by fathers was predictive of starting to binge at least weekly.

CONCLUSIONS

Risk factors for the development of binge eating and purging differ by sex and by age group in females. Maternal history of an eating disorder is a risk factor only in younger adolescent females.

The genetics of anorexia nervosa collaborative study: methods and sample description

OBJECTIVE

Supported by National Institute of Mental Health (NIMH), this 12-site international collaboration seeks to identify genetic variants that affect risk for anorexia nervosa (AN).

METHOD

Four hundred families will be ascertained with two or more individuals affected with AN. The assessment battery produces a rich set of phenotypes comprising eating disorder diagnoses and psychological and personality features known to be associated with vulnerability to eating disorders.

RESULTS

We report attributes of the first 200 families, comprising 200 probands and 232 affected relatives.

CONCLUSION

These results provide context for the genotyping of the first 200 families by the Center for Inherited Disease Research. We will analyze our first 200 families for linkage, complete recruitment of roughly 400 families, and then perform final linkage analyses on the complete cohort. DNA, genotypes, and phenotypes will form a national eating disorder repository maintained by NIMH and available to qualified investigators.

Temporal patterns of recovery across eating disorder subtypes

OBJECTIVE

To compare patterns of recovery in individuals with index episodes of anorexia nervosa (AN) and bulimia nervosa (BN).

METHOD

Using Kaplan-Meier methods and Cox proportional hazards models, comparisons were conducted that were conditional on duration of eating disorder from onset and included a conservative recovery criterion of 3 asymptomatic years. Data collection was retrospective and from two of the international Price Foundation genetic studies on 901 individuals with eating disorders.

RESULTS

Using Kaplan-Meier methods, 11% of those with index AN and 10% of those with index BN met recovery criteria at 10 years. At 15 years, 16% of those with index AN and 25% of those with index BN met recovery criteria. In a Cox proportional hazards model the index BN group had three times the rate of recovery at 10-14 years (p=0.01) than the index AN group.

CONCLUSIONS

Initially the probability of recovery was greater for those with index AN, but as the duration of the eating disorder lengthened those with BN had higher probabilities of recovery. Replication of these results with prospective data using similarly stringent recovery criteria and methods is required to confirm trends.

Contribution of the serotoninergic system to anxious and depressive traits that may be partially responsible for the phenotypical variability of bulimia nervosa

Eating disorders (ED), such as anorexia nervosa (AN) and bulimia nervosa (BN), are complex psychiatric phenotypes influenced by both genetic and environmental factors. We investigated the genetic contribution of four single nucleotide polymorphisms (SNPs) within the serotonin receptor 5HT2C and two sequence variants within the serotonin transporter SLC6A4 to different ED-related psychopathological symptoms in a total sample of 82 ED patients. All patients were diagnosed according to DSM-IV criteria and underwent diagnostic and psychopathological assessments by means of structured clinical interviews and rating scales. We detected significant evidence of association between the -995A/-759T/-697C/Cys23 haplotype of the 5HT2C gene and different anxious and depressive subscales of the SCL90-R instrument, that included Somatization (p = 0.029), Obsessive-Compulsiveness (p = 0.021), Depression (p = 0.032), Anxiety (p = 0.004), Hostility (p = 0.028), Phobic Anxiety (p = 0.029) and Paranoid Ideation (p = 0.008), in BN patients. We also observed a strong association between the 5HTTLPR polymorphism of the SLC6A4 gene and Anxiety in the same group of BN patients (p = 0.004). However, no epistatic effects between the 5HT2C and SLC6A4 genes on the different anxious and depressive subscales were observed. Our preliminary data suggest that the serotoninergic system contributes to the different psychopathological symptoms that may be partially responsible for the phenotypical variability within the bulimic phenotype.

Features associated with diet pill use in individuals with eating disorders

We investigated the relation between diet pill use and eating disorder subtype, purging and other compensatory behaviors, body mass index (BMI), tobacco and caffeine use, alcohol abuse or dependence, personality characteristics, and Axis I and Axis II disorders in 1,345 participants from the multisite Price Foundation Genetics Studies. Diet pill use was significantly less common in women with restricting type of AN than in women with other eating disorder subtypes. In addition, diet pill use was associated with the use of multiple weight control behaviors, higher BMI, higher novelty seeking, and the presence of anxiety disorders, alcohol abuse or dependence, and borderline personality disorder. Findings suggest that certain clinical and personality variables distinguish individuals with eating disorders who use diet pills from those who do not. In the eating disorder population, vigilant screening for diet pill use should be routine clinical practice.

Links between eating disorder symptom severity and psychiatric comorbidity

Patients with eating disorders (ED) frequently exhibit additional psychiatric disorders. This study aimed to examine whether psychiatric comorbidity in ED patients is associated with increased severity of ED symptoms in a sample of 277 women with a current ED (84 anorexia nervosa, 152 bulimia nervosa, 41 eating disorders not otherwise specified). Psychiatric comorbidity of Axes I and II was determined using the Structured Clinical Interview (SCID) for DSM-IV. Severity of ED-related symptoms was assessed using interviewer-rated scales from the Structured Interview for Anorexia and Bulimia Nervosa (SIAB). Affective and anxiety-related disorders of both axes were linked with increased intensity of weight- and appearance-related fears and concerns. Frequency of binge-eating and frequency of purging both were associated with Axis I anxiety disorders, substance-related disorders, and Cluster B personality disorders. Frequency of dieting was related to anxiety disorders on both axes. Multivariate analyses revealed that Axis I anxiety disorders were more closely linked with severity of ED symptoms than affective or substance-related disorders. The results showed that psychiatric comorbidity of both axes is linked with increased severity of ED symptoms and that there are associations between specific ED symptoms and specific forms of comorbidity.

Is body checking in the eating disorders more closely related to diagnosis or to symptom presentation?

Body checking behaviours and cognitions are seen as underlying the core pathology of eating disorders-the over-evaluation of eating, shape and weight. While it has been demonstrated that levels of behaviours and cognitions differentiate eating-disordered women from non-eating-disordered women, little is known with regard to how these findings relate to diagnostic group. This study aimed to determine whether body checking cognitions and behaviours are best understood with regard to diagnostic category or symptom presentation. Eighty-four eating-disordered women (with diagnoses of anorexia nervosa, bulimia nervosa, binge eating disorder or other Eating Disorders Not Otherwise Specified) completed measures of body checking behaviours and cognitions and eating psychopathology. Results showed that different aspects of body checking were more closely associated with diagnosis and with symptom presentation. Anorexia nervosa and binge-eating-disorder patients had particularly low levels of body checking behaviours and some related cognitions. However, the belief that body checking allows one to be accurate in knowing one's weight was associated with binging and vomiting behaviours, rather than diagnosis. Future directions for research include understanding the links between body checking phenomena and neurological features. Clinical implications are discussed.