Differentiating purging and nonpurging bulimia nervosa and binge eating disorder

The Gut Microbiome and Metabolomics Profiles of Restricting and Binge-Purging Type Anorexia Nervosa

Alterations in the gut microbiome and fecal metabolites have been detected in anorexia nervosa (AN), but differences in those profiles between restricting AN (ANR) and binge-purging AN (ANBP) type have not been explored. We made a secondary analysis of our previous data concerning microbiome and metabolomics profiles of 17 ANR women, six ANBP women and 20 healthy controls (HC). Twelve fecal metabolites differentiating ANR patients, ANBP patients and HC were identified. Both patient groups showed decreased intra-individual bacterial richness with respect to healthy controls (HC). Compared to ANR subjects, ANBP patients had a significant increase in relative abundances of Bifidobacterium, Bifidobacteriaceae, Bifidobacteriales, and Eubacteriacae and a significant decrease in relative abundances of Odoribacter, Haemophilus, Pasteurellaceae, and Pasteurellales. The heatmaps of the relationships of selected fecal metabolites with microbial families showed different structures among the three groups, with the heatmap of ANBP patients being drastically different from that of HC, while that of ANR patients resulted more similar to HC. These findings, although preliminary because of the relatively small sample size, confirm the occurrence of different gut dysbiosis in ANR and ANBP and demonstrate different connections between gut microorganisms and fecal metabolites in the two AN types.

Polaprezinc (Zinc-L-Carnosine Complex) as an Add-on Therapy for Binge Eating Disorder and Bulimia Nervosa, and the Possible Involvement of Zinc Deficiency in These Conditions: A Pilot Study

BACKGROUND

Zinc plays an important role in appetite regulation. L-Carnosine, an endogenous dipeptide, may also regulate eating behavior via its histaminergic and antiglutamatergic properties. Polaprezinc (zinc-L-carnosine complex) is a medication for gastric ulcers. A small case series reported successful treatment of binge eating with add-on polaprezinc.

METHODS

This was an open trial of add-on polaprezinc in patients with binge eating disorder (BED; n = 22) or bulimia nervosa (BN; n = 7) receiving antidepressants. A 4-week baseline period was followed by a 16-week polaprezinc treatment at 150 mg/d (containing 34 mg zinc and 116 mg L-carnosine) in addition to ongoing psychotropic medications. We also assessed their zinc status via a laboratory index and zinc deficiency-related symptoms.

RESULTS

At the study end, both conditions showed a significant reduction in the 4-week frequency of combined objective and subjective binge eating episodes, the 4-week frequency of days when at least 1 such episode occurred (only in BED), several aspects of eating disorder psychopathology (rated by the Eating Disorder Examination-Questionnaire), and comorbid depressive symptoms (rated by the 16-item Quick Inventory of Depressive Symptomatology [Self-Report]). Serum copper/zinc ratio decreased from 1.4 to 1.1 on average in both conditions. All patients had multiple zinc deficiency-related symptoms at baseline that substantially improved after polaprezinc treatment. Overall, the effectiveness of polaprezinc was greater in BED patients than in BN patients, with minor adverse effects.

CONCLUSIONS

These findings offer preliminary evidence for the effectiveness of polaprezinc in treating BED and BN and suggest the involvement of zinc deficiency in these conditions.

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.

The impact of DSM-5 on the diagnosis and severity indicator of eating disorders in a treatment-seeking sample

OBJECTIVE

To examine the impact of the DSM-5 on the diagnoses and severity indicators of eating disorders, we conducted a comparative study on the classification of eating disorders including subtypes of anorexia nervosa (AN) between the DSM-IV and DSM-5 criteria. In addition, we studied the association of the DSM-5 severity criteria and clinical variables.

METHOD

Participants were 304 outpatients, aged 16-45 years, with eating disorders, diagnosed using semi-structured clinical interviews and the eating disorder examination questionnaire (EDE-Q). The severity of AN, bulimia nervosa (BN), and binge-eating disorder (BED) was rated from mild to extreme using the DSM-5 severity criteria.

RESULTS

The DSM-5 remarkably reduced the number of diagnoses in the residual category from 37.5% to 9.2% and effectively differentiated the diagnostic groups in eating disorder psychopathology. Unexpectedly, however, the scores of all the EDE-Q subscales significantly decreased as severity ratings increased in the DSM-5 AN. Furthermore, while the AN binge-eating/purging group reported significantly lower severity ratings than the AN restricting group, the former displayed more severe eating disorder psychopathology than the latter. In the BN and BED groups, the level of eating concern increased as severity ratings increased, but the severity groups did not differ on other eating pathology variables.

DISCUSSION

The DSM-5 effectively reduced the reliance on residual categories and differentiated the diagnostic groups in eating disorder psychopathology. However, our findings show limited support for the DSM-5 severity specifiers for eating disorders. It is necessary to test additional clinical or functional variables for severity specifiers across eating disorders.

Purging behaviors and therapeutic prognosis of women with eating disorders treated in a healthcare context

Background/Objective: The evidence on efficacy of cognitive-behavioral interventions in Eating Disorders (ED) still shows inconclusive results with respect to the role of purging behaviors, more so in uncontrolled situations. Evolution of ED patients with and without purging behavior was studied 30 months after start of a multicomponent treatment. Method: 162 women (87 purging, 75 non-purging) treated in outpatient or hospitals + outpatient care units in Spain participated. The evaluation instruments were: BSQ, EAT-40, EDI, STAI, BDI and BITE. Results: At the beginning of the treatment, participants with purging behavior showed higher bulimic symptomatology, more body dissatisfaction, drive for thinness, perfectionism and ineffectiveness, anxiety and depressive symptomatology. After thirty months, intervention produced improvement in ED characteristics, emotional alterations and personal development variables, in both groups, but less in patients with no purging behavior. The effect of intervention was stronger in purging patients and variables with larger effect size: body dissatisfaction, bulimic symptomatology and anxiety. Conclusions: Purging behaviors must be considered in the design of these treatments with a view to prognosis.

Influence of Weight on Shared Core Symptoms in Eating Disorders

In terms of the transdiagnostic model of eating disorders, Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Binge Eating Disorder (BED) share the same distinctive psychopathology. However, empirical evidence showing similarities between these eating disorder diagnoses for core symptoms is scarce, and the role of weight status is unclear. Data from a total of 168 female participants were collected between April 2004 and April 2008, at an outpatient unit specialized in eating disorder treatment. Core symptoms of eating disorders were measured via self-report questionnaires. In particular, women with BED and BN showed similar patterns of core symptomatology compared with AN. However, when body mass index (BMI) was considered in the analyses, there were no differences between the three diagnostic groups in relation to body image. Differences in eating behavior are not solely triggered by weight differences, whereas body image disturbances are a transdiagnostic phenomenon among EDs and should also be considered in the treatment of BED.

Loneliness mediates the relationship between emotion dysregulation and bulimia nervosa/binge eating disorder psychopathology in a clinical sample

Emotion dysregulation has been linked to binge eating disorder (BED) and bulimia nervosa (BN) although the mechanisms by which it affects BN/BED psychopathology are unclear. This study tested loneliness as a mediator between emotion dysregulation and BN/BED psychopathology. A treatment-seeking sample of 107 women with BN or BED was assessed for loneliness (UCLA Loneliness Scale), emotion dysregulation (Difficulties in Emotion Regulation Scale), and BN/BED psychopathology (Eating Disorder Examination) before treatment. Hierarchical linear regressions and bootstrapping mediation models were run. Greater overall emotion dysregulation was associated with greater BN/BED psychopathology, mediated by loneliness (95 % CI 0.03, 0.09). Emotion dysregulation, however, did not mediate between loneliness and BN/BED psychopathology (95 % CI −0.01, 0.01). Targeting loneliness may effectively treat emotional aspects of BN/BED in women.

The association of "food addiction" with disordered eating and body mass index

INTRODUCTION

The contribution of an addictive process to elevated body mass index (BMI) and disordered eating is an area of growing interest. Yet, little is known about how "food addiction" may be related to disordered eating and obesity. The ability of addictive-like eating to account for eating pathology not captured by traditional eating disorders is unknown. No prior research has examined the association of "food addiction" with bulimia nervosa (BN). Finally, little is understood about the association of "food addiction" with patterns of dieting and weight gain. The current study was conducted to address these gaps in the literature.

MATERIAL AND METHODS

Participants (N=815) were recruited from online advertisements nationwide and completed measures related to "food addiction", BMI, weight history, and disordered eating.

RESULTS

Addictive-like eating was associated with elevated current and lifetime highest BMI, weight cycling, and eating pathology. The prevalence of "food addiction" was higher in participants with BN than in those with binge eating disorder (BED). "Food addiction" continued to be related to clinically relevant variables, especially elevated BMI, even when participants did not meet criteria for BED or BN. The co-occurrence of "food addiction" with eating disorders appears to be associated with a more severe variant of eating pathology.

DISCUSSION

An addictive-type response to highly palatable food may be contributing to eating-related problems, including obesity and eating disorders. BN relative to BED appears to be more strongly associated with "food addiction." Additionally, the concept of "food addiction" appears to capture clinically relevant information in participants who do not meet criteria for either BN or BED. Further examination of "food addiction" may be important in understanding the mechanisms underlying certain types of problematic eating behavior.

Purging behavior modulates the relationships of hormonal and behavioral parameters in women with eating disorders

BACKGROUND/AIMS

There is ample consensus that there is a neurophysiological basis for eating disorders (ED). Traits of personality translate into behavioral traits, purging being a well-defined transversal example. The direct implication of steroid hormones on ED has seldom been studied, despite their effects on behavior.

METHODS

After psychological interview analysis, 57 ED female patients (31 purgative and 26 nonpurgative) and 17 female controls were studied. Metabolic parameters and analysis of androgen, estrogen and glucocorticoid hormones were determined in parallel to the psychopathological profile (EDI-2 and SCL-90-R) and anthropometric measurements.

RESULTS

Psychometric tests showed clear differences between ED and controls, but there were few hormonal-metabolic significant differences. In purgative ED there were repeated (significant) positive correlations with corticosteroid-binding globulin (CBG) and negative correlations with sex hormone-binding globulin (SHBG) versus eating and general psychopathology. In nonpurging ED there were positive correlations for deoxycortisol, free fatty acids and albumin and negative for aspartate aminotransferase and psychopathological traits.

CONCLUSION

The data suggest that CBG/corticosteroids and sexual hormones/SHBG are involved in purging behavior and its psychopathology and severity scores. Correlations of selected psychometric data and the CBG/SHBG levels in purging may eventually result in clinical markers. This approach may provide additional clues for understanding the pathogenesis of ED.

Bulimia nervosa-nonpurging subtype: closer to the bulimia nervosa-purging subtype or to binge eating disorder?

OBJECTIVE

DSM-5 has dropped subtyping of bulimia nervosa (BN), opting to continue inclusion of the somewhat contentious diagnosis of BN-nonpurging subtype (BN-NP) within a broad BN category. Some contend however that BN-NP is more like binge eating disorder (BED) than BN-P. This study examines clinical characteristics, eating disorder symptomatology, and Axis I comorbidity in BN-NP, BN-P, and BED groups to establish whether BN-NP more closely resembles BN-P or BED.

METHOD

Women with BN-P (n = 29), BN-NP (n = 29), and BED (n = 54) were assessed at baseline in an outpatient psychotherapy trial for those with binge eating. Measures included the Structured Clinical Interviews for DSM-IV, Eating Disorder Examination, and Eating Disorder Inventory-2.

RESULTS

The BN-NP subtype had BMIs between those with BN-P and BED. Both BN subtypes had higher Restraint and Drive for Thinness scores than BED. Body Dissatisfaction was highest in BN-NP and predicted BN-NP compared to BN-P. Higher Restraint and lower BMI predicted BN-NP relative to BED. BN-NP resembled BED with higher lifetime BMIs; and weight-loss clinic than eating disorder clinic attendances relative to the BN-P subtype. Psychiatric comorbidity was comparable except for higher lifetime cannabis use disorder in the BN-NP than BN-P subtype

DISCUSSION

These results suggest that BN-NP sits between BN-P and BED however the high distress driving inappropriate compensatory behaviors in BN-P requires specialist eating disorder treatment. These results support retaining the BN-NP group within the BN category. Further research is needed to determine whether there are meaningful differences in outcome over follow-up.

Loss of control over eating: a description of the eating disorder/obesity spectrum in women

GOALS

This study aimed to analyse the association, commonalities and differences between obesity and eating disorders (ED).

METHOD

A total of 150 female patients [50 obese with bulimia nervosa (OB + BN), 50 obese with binge eating disorders (OB + BED), 50 obese without eating disorders (OB)] and 50 female healthy-eating/weight control (CG) volunteers participated in this study.

ASSESSMENT

All participants were assessed by the Eating Disorders Inventory-2 (EDI-2), the Symptom Checklist-Revised (SCL-90-R) and the Temperament and Character Inventory-Revised.

RESULTS

In general, all the groups differed significantly and showed linear trends (OB + BN > OB + BED > OB > CG) on general and eating psychopathology (SCL-90-R and EDI-2). Regarding personality traits, statistically significant differences across all four groups were found on Harm Avoidance and Self-Directedness. Whereas some symptoms were shared in extreme weight conditions, others were specifically related to ED.

CONCLUSIONS

The presence of binge and purge symptomatology in obese patients is clinically relevant. These findings help to understand the relationship between Obesity and ED.

Cognitive behaviour therapy response and dropout rate across purging and nonpurging bulimia nervosa and binge eating disorder: DSM-5 implications

BACKGROUND

With the imminent publication of the new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), there has been a growing interest in the study of the boundaries across the three bulimic spectrum syndromes [bulimia nervosa-purging type (BN-P), bulimia nervosa-non purging type (BN-NP) and binge eating disorder (BED)]. Therefore, the aims of this study were to determine differences in treatment response and dropout rates following Cognitive Behavioural Therapy (CBT) across the three bulimic-spectrum syndromes.

METHOD

The sample comprised of 454 females (87 BED, 327 BN-P and 40 BN-NP) diagnosed according to DSM-IV-TR criteria who were treated with 22 weekly outpatient sessions of group CBT therapy. Patients were assessed before and after treatment using a food and binging/purging diary and some clinical questionnaires in the field of ED. "Full remission" was defined as total absence of binging and purging (laxatives and/or vomiting) behaviors and psychological improvement for at least 4 (consecutive).

RESULTS

Full remission rate was found to be significantly higher in BED (69.5%) than in both BN-P (p < 0.005) and BN-NP (p < 0.001), which presented no significant differences between them (30.9% and 35.5%). The rate of dropout from group CBT was also higher in BED (33.7%) than in BN-P (p < 0.001) and BN-NP (p < 0.05), which were similar (15.4% and 12.8%, respectively).

CONCLUSIONS

Results suggest that purging and non-purging BN have similar treatment response and dropping out rates, whereas BED appears as a separate diagnosis with better outcome for those who complete treatment. The results support the proposed new DSM-5 classification.

Pathological gambling in eating disorders: prevalence and clinical implications

OBJECTIVE

Pathological gambling (PG) and eating disorders (ED) rarely co-occur. We explored the prevalence of lifetime PG in ED, compared severity of ED symptoms, personality traits, and psychopathological profiles across individuals with ED and PG (ED+PG) and without PG (ED-PG). Finally, we assessed the incremental predictive value of gender on the presentation of a comorbid PG.

METHOD

A total sample of 1681 consecutively admitted ED patients (1576 females and 105 males), participated in the current study (25 ED+PG and 1656 ED-PG). All participants were diagnosed according to DSM-IV criteria. Assessment measures included the Symptom Checklist and the Temperament and Character Inventory-Revised, as well as other clinical and psychopathological indices.

RESULTS

The observed lifetime prevalence of PG was 1.49%. ED subtype was associated with lifetime PG (p=.003), with PG being more frequent in binge eating disorder (5.7%). ED+PG was more prevalent in males than in females (16% vs. 1.26%, respectively). Additionally, ED+PG patients exhibited more impulsive behaviours, lower impulse regulation and higher novelty seeking. Best predictors of ED+PG were novelty seeking (OR 1.030, p=.035), sex (OR 3.295, p=.048) and BMI (OR 1.081, p=.005).

CONCLUSIONS

Some personality traits (novelty seeking), being male and higher BMI are strongly related to the presence of lifetime PG in specific ED subtypes (namely binge eating disorder).

From disordered eating to addiction: the "food drug" in bulimia nervosa

The high prevalence of substance abuse in individuals with bulimia nervosa (BN) and the pervasive symptom substitution in many types of drug addiction suggest that a number of substances--including food--can impair an individual's self-control, even in the presence of negative consequences. Nonetheless, the neurobiological similarities between BN and drug addiction are not clearly established. This review explores how the specific eating patterns seen in BN (binge eating and purging, with intermittent dietary restriction) are particularly addictive and differentiate BN from other eating disorders and obesity. A number of peripheral and central biological aberrations seen in BN may result in altered reward sensitivity in these individuals, particularly through effects on the dopaminergic system. Neurobiological findings support the notion that BN is an addictive disorder, which has treatment implications for therapy and pharmacological manipulations.

Lifetime obesity in patients with eating disorders: increasing prevalence, clinical and personality correlates

OBJECTIVES

The aims of our study were to examine the lifetime prevalence of obesity rate in eating disorders (ED) subtypes and to examine whether there have been temporal changes among the last 10 years and to explore clinical differences between ED with and without lifetime obesity.

METHODS

Participants were 1383 ED female patients (DSM-IV criteria) consecutively admitted, between 2001 and 2010, to Bellvitge University Hospital. They were assessed by means of the Eating Disorders Inventory-2, the Symptom Checklist-90-Revised, the Bulimic Investigatory Test Edinburgh and the Temperament and Character Inventory-Revised.

RESULTS

The prevalence of lifetime obesity in ED cases was 28.8% (ranging from 5% in anorexia nervosa to 87% in binge-eating disorders). Over the last 10 years, there has been a threefold increase in lifetime obesity in ED patients (p < .001). People with an ED and obesity had higher levels of childhood and family obesity (p < .001), a later age of onset and longer ED duration; and had higher levels of eating, general and personality symptomatology.

CONCLUSIONS

Over the last 10 years, the prevalence of obesity associated with disorders characterized by the presence of binge episodes, namely bulimic disorders, is increasing, and this is linked with greater clinical severity and a poorer prognosis.

Binge eating, purging and non-purging compensatory behaviours decrease from adolescence to adulthood: A population-based, longitudinal study

BACKGROUND

Subclinical forms of eating disorders (ED) are highly prevalent, but relatively little is known about age trends, gender differences and distinctions among symptoms. This study investigates age trends and gender difference in binge eating, purging and non-purging compensatory behaviours (CB) and the relationship of such behaviours to psychosocial problems.

METHODS

Data from the national representative longitudinal study "Young in Norway" (ages 14-34 years) were analysed using χ(2) tests, logistic random intercept models and analyses of covariance.

RESULTS

For both genders, a decrease was found in the prevalence of CB from age 14-16 years to 23 years and over. For binging, however, a significant decrease was found only for females, whose binge eating also declined more markedly over time than did males'. A significant gender difference was detected for purging, with females at higher risk. Purging was related to particularly serious symptoms of psychosocial problems: Those who purged had significantly higher levels of appearance dissatisfaction, anxiety and depressive symptoms, alcohol consumption, self-concept instability and loneliness than those with symptoms of other forms of disordered eating.

CONCLUSIONS

Individuals affected by purging need to be targeted as a high-risk group. The distinction in severity among the subclinical ED may indicate the need for the reformulation of the eating disorder not otherwise specified category in the Diagnostic and Statistical Manual of Mental Disorders-V.

Empirical classification of eating disorders

Current diagnostic criteria for anorexia nervosa (AN) and bulimia nervosa (BN) account for a minority of individuals with clinically significant disorders of eating, raising concerns about the clinical utility of current definitions. This review examines evidence for the validity of current and alternative approaches to defining eating disorders and implications for draft criteria for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Although this review largely supports the predictive validity of distinctions among AN, BN, and the newly proposed binge eating disorder (BED), it also highlights that our tendency to "study what we define" has created a gap between the problems that people have and what we know about those problems. Future research on the causes and consequences of eating disorders should include more heterogeneous groups to enable identification of meaningful boundaries that distinguish between disorders based on etiological and predictive validity.