Evaluating new severity dimensions in the DSM-5 for bulimic syndromes using mixture modeling

Androgens impact on psychopathological variables according to CPRS, and EDI 2 scores: In women with bulimia nervosa, and eating disorder not otherwise specified

Bulimia nervosa (BN) is characterized by binge eating, compensatory behavior, over-evaluation of weight and shape, which often co-occur with symptoms of anxiety and depression. Depression is the most common comorbid diagnosis in women with eating disorders. The role of androgens in the pathophysiology of depression has been recognized in recent years. However, the research on psychopathological comorbidity and androgen levels in bulimic disease is sparse. This study aimed to investigate, if there were any correlations between the androgens, testosterone (T), dehydroepiandrosterone sulphate (DHEAS), androstenedione (A4), 5α-dihydrotestosterone, (5α-DHT), and test scores of psychopathological variables, in women with bulimia nervosa (BN), eating disorder not otherwise specified of purging subtype (EDNOS-P) assessed by CPRS, and EDI 2. Women with DSM-IV diagnosis of BN (n = 36), EDNOS-P (n = 27), and healthy control subjects (n = 58) evaluated for fifteen psychopathological variables, i.a. depressive symptoms, impulsivity, personal traits, as well as serum androgen levels. All women were euthyroid, and polycystic ovarian syndrome (PCOS) diagnosis was excluded. Although androgen levels were almost equal for all three groups, significant correlations between core psychopathological symptoms (9/15) of bulimia nervosa and the most potent endogenous androgen, 5α-DHT, was found only in the EDNOS-P group. The role of 5α-DHT in women is not fully elucidated. Both animal and human studies have shown that the brain is able to locally synthesize steroids de novo and is a target of steroid hormones. Maybe these results can be interpreted in the light of differences in androgen receptor variability, metabolism and origin of T and 5α-DHT.

Body image as a multidimensional concept: A systematic review of body image facets in eating disorders and muscle dysmorphia

Body image disturbance is core to the psychopathology of eating disorders (EDs), and related disorders such as muscle dysmorphia (MD). Global measures of body image fail to quantify specific aspects of body image disturbance that characterizes EDs, and may be differentially associated to outcomes. The aim of this systematic review was to provide an overview of specific body image facets and synthesize findings from controlled studies that compared clinical ED/MD and control-comparison groups in body image disturbance. One-hundred sixty-seven studies met inclusion criteria, and reported on comparisons among 30,584 individuals in 28 body image facets, which were more broadly grouped into evaluative, perceptual, cognitive-affective and motivational categories for the purpose of the present review. Effect sizes were calculated as Cohen's d for every comparison between ED and control groups. Body dissatisfaction (evaluative category) was the most prevalent facet assessed across studies (62 %), and differences between clinical and control groups were the largest in this category, especially for bulimia nervosa (d = 1.37). Scarcity of studies with male and MD clinical samples, and use of single-item and non-validated measures, should encourage development of instruments for body image facets pertinent to EDs and MD that can be validly applied across gender.

Where does purging disorder lie on the symptomatologic and personality continuum when compared to other eating disorder subtypes? Implications for the DSM

OBJECTIVES

To assess the clinical significance and distinctiveness of purging disorder (PD) from other eating disorder (ED) diagnoses.

METHOD

Participants included 3127 women consecutively admitted to an ED treatment centre (246 PD, 465 anorexia nervosa restrictive [AN-R], 327 AN-binge purging [AN-BP], 1436 bulimia nervosa [BN], 360 binge eating disorder [BED], 177 atypical AN and 116 unspecified feeding or eating disorder [UFED]) who were diagnosed according to DSM-5 criteria. Additionally, 822 control participants were recruited from the community. All participants completed measures assessing ED symptoms (EDI-2), general psychopathology (SCL-90-R) and personality (TCI-R).

RESULTS

Patients with PD, when compared to controls, scored significantly higher on the EDI-2 and SCL-90-R, and most TCI-R dimensions. Most of the significant differences between PD and the other ED diagnoses emerged between PD and AN-R, followed by Atypical-AN, UFED, AN-BP and BED, with patients with PD typically reporting higher scores on the EDI-2 and SCL-90-R subscales. Significant differences between PD and BN were also present, but to a lesser extent. The findings for personality varied amongst the different ED diagnoses.

CONCLUSIONS

PD is a clinically significant disorder, which seems to be more similar to BN than it is to AN and the other ED subtypes.

Mixture Modeling to Characterize Anorexia Nervosa: Integrating Personality and Eating Disorder Psychopathology

BACKGROUND: Efforts to examine alternative classifications (e.g., personality) of anorexia nervosa (AN) using empirical techniques are crucial to elucidate diverse symptom presentations, personality traits, and psychiatric comorbidities. AIMS: The purpose of this study was to use an empirical approach (mixture modeling) to test an alternative classification of AN as categorical, dimensional, or hybrid categorical-dimensional construct based on the co-occurrence of personality psychopathology and eating disorder clinical presentation. METHODS: Patients with AN (N = 194) completed interviews and questionnaires at treatment admission and 3-month follow-up. Mixture modeling was used to test whether indicators best classified AN as categorical, dimensional, or hybrid. RESULTS: A four-latent class, one-latent dimension mixture model that was variant across groups provided the best fit to the data. Results suggest that all classes were characterized by low self-esteem and self-harming and suicidality tendencies. Individuals assigned to Latent Class 2 (LC2; n = 21) had a greater tendency toward being impulsive and easily angered and having difficulties controlling anger compared with those in LC1 (n = 84) and LC3 (n = 66). Moreover, individuals assigned to LC1 and LC3 were more likely to have a poor outcome from intensive treatment compared with those in LC4 (n = 21). Findings indicate that the dimensional aspect within each class measured frequency of specific eating disorder behaviors but did not predict treatment outcomes. CONCLUSIONS: These results emphasize the complexity of AN and the importance of considering how facets of clinical presentation beyond eating disorder behaviors may have different treatment and prognostic implications.

Association of etiological factors across the extreme end and continuous variation in disordered eating in female Swedish twins

BACKGROUND

Accumulating evidence suggests that many psychiatric disorders etiologically represent the extreme end of dimensionally distributed features rather than distinct entities. The extent to which this applies to eating disorders (EDs) is unknown.

METHODS

We investigated if there is similar etiology in (a) the continuous distribution of the Eating Disorder Inventory-2 (EDI-2), (b) the extremes of EDI-2 score, and (c) registered ED diagnoses, in 1481 female twin pairs at age 18 years (born 1992-1999). EDI-2 scores were self-reported at age 18. ED diagnoses were identified through the Swedish National Patient Register, parent-reported treatment and/or self-reported purging behavior of a frequency and duration consistent with DSM-IV criteria. We differentiated between anorexia nervosa (AN) and other EDs.

RESULTS

The heritability of the EDI-2 score was 0.65 (95% CI 0.61-0.68). The group heritabilities in DeFries-Fulker extremes analyses were consistent over different percentile-based extreme groups [0.59 (95% CI 0.37-0.81) to 0.65 (95% CI 0.55-0.75)]. Similarly, the heritabilities in liability threshold models were consistent over different levels of severity. In joint categorical-continuous models, the twin-based genetic correlation was 0.52 (95% CI 0.39-0.65) between EDI-2 score and diagnoses of other EDs, and 0.26 (95% CI 0.08-0.42) between EDI-2 score and diagnoses of AN. The non-shared environmental correlations were 0.52 (95% CI 0.32-0.70) and 0.60 (95% CI 0.38-0.79), respectively.

CONCLUSIONS

Our findings suggest that some EDs can partly be conceptualized as the extreme manifestation of continuously distributed ED features. AN, however, might be more distinctly genetically demarcated from ED features in the general population than other EDs.

Drive for thinness provides an alternative, more meaningful, severity indicator than the DSM-5 severity indices for eating disorders

OBJECTIVE

To assess an alternative trans-diagnostic indicator for severity based on drive for thinness (DT) for anorexia nervosa (AN), bulimia nervosa (BN), binge-eating disorder (BED), and other specified feeding or eating disorder (OSFED), and to compare this new approach to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) severity categories for EDs.

METHOD

A total of 2,811 ED [428 AN-restrictive (AN-R), 313 AN-binge purging (AN-BP), 1,340 BN, 329 BED, 154 OSFED/atypical AN (AT), and 223 OSFED/purging disorder (PD)] patients were classified using: (a) The DSM-5 severity categories and (b) a DT categorisation. These severity classifications were then compared based on ED symptoms, general psychopathology, personality, and impulsive behaviours.

RESULTS

For the DSM-5 categories, most ED patients fell into the 'mild' to 'moderate' categories. Using the DT categories, AN patients were mainly represented in the 'low' DT category, and BN, OSFED/AT, and PD in the 'high' DT category. The clinically significant findings were stronger for the DT than the DSM-5 severity approach (medium-to-large effect sizes). AN-BP and AN-R provided the most pronounced effects.

CONCLUSION

Our findings question the clinical value of the DSM-5 severity categorisation, and provide initial support for an alternative DT severity approach for AN. HIGHLIGHTS : This study assessed an alternative trans-diagnostic drive for thinness (DT) severity. Category for all eating disorder (ED) sub-types, and then compared this to the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) severity indices for EDs. ED symptoms, general psychopathology, personality, and impulsive behaviours were assessed using both classifications in a total of 2,811 female patients diagnosed with EDs. Clinically significant findings were stronger for the DT than the DSM-5 severity category (medium-to-large effect sizes); there was differentiation of the anorexia nervosa (AN) patients into mainly 'low' DT, and bulimia nervosa (BN) spectrum patients into mainly 'high' DT, vs. most patients were clustered in the 'mild-to-moderate' DSM-5 categories. Our findings provide initial support for an alternative trans-diagnostic DT severity category that may be more clinically meaningful than the DSM-5 severity indices for EDs.

A cluster analysis of purging disorder: Validation analyses with eating disorder symptoms, general psychopathology and personality

OBJECTIVES

To assess the natural grouping of Purging Disorder (PD) patients based on purging symptomatology and to evaluate the derived classes (a) against each other and (b) to a control group on a range of clinical and psychological measures.

METHOD

Participants included 223 PD women consecutively admitted to a tertiary ED treatment centre and 822 controls. Purging behaviours (self-induced vomiting, laxative and diuretic use) were used as indicators, while the EDI-2 (ED symptoms), the SCL-90-R (general psychopathology), and the TCI-R (personality traits) were used as validators.

RESULTS

Three distinct PD clusters emerged: Cluster 1 (only self-induced vomiting), Cluster 2 (self-induced vomiting and laxative use) and Cluster 3 (all purging methods). Significant differences between Cluster 1 and Cluster 3 were found for the EDI-2 drive for thinness and perfectionism subscales, and the TCI-persistence scale. All clusters differed significantly from the controls on all the EDI-2 and the SCL-90-R scales, but findings for the TCI-R scales were less consistent.

CONCLUSIONS

This study adds to a growing literature on the validity and distinctiveness of PD and provides evidence of dimensional symptom differences amongst PD clusters.

A review of purging disorder through meta-analysis

Although a growing body of research has examined Purging Disorder (PD), there remains a lack of conclusive evidence regarding the diagnostic validity of PD. This meta-analysis compared PD to DSM-5 eating disorders (i.e., Anorexia Nervosa [AN], Bulimia Nervosa [BN], and Binge Eating Disorder [BED]) and controls. A comprehensive literature search identified 38 eligible studies. Group differences on indicators of course of illness and both general and eating psychopathology were assessed using standardized effect sizes. Results supported the conceptualization of PD as a clinically significant eating disorder, but findings were less clear regarding its distinctiveness from other eating disorder diagnoses. More specifically, PD significantly differed from BN and BED in natural course of illness (g = .40-.54), and PD significantly differed from AN in treatment outcome (g = .27), with PD characterized by a better prognosis. Overall, PD was more similar to AN and BED on many dimensional measures of general and eating-related psychopathology, though PD was less severe than BN in most of these domains. PD, BN, and BED groups also evidenced similar frequencies of subjective binge episodes (SBEs), yet PD evidenced less frequent SBEs than AN. There is a clear need for future studies of PD to assess validators that have not been reported comprehensively in the literature, such as mortality, medical morbidity, and course of illness. Additionally, empirical classification studies are needed to inform future classifications of PD, particularly with regard to categorical differences between PD and other eating disorders. (PsycINFO Database Record

Affect-based profiles of bulimia nervosa: The utility and validity of indicators assessed in the natural environment

Theoretical conceptualizations of bulimia nervosa (BN) emphasize the role of emotion dysregulation in the development and maintenance of symptoms, which has been supported by ecological momentary assessment studies. Given the importance of affective disturbances in BN, this study aimed to classify a sample of adult women with BN (N = 130) based on primarily momentary affective indicators, including negative and positive affect, negative and positive affective lability, and depression. Participants completed baseline assessments followed by a two-week ecological momentary assessment protocol. Latent profile analysis revealed four groups: (1) a "stable normal" group characterized by low affective lability and intensity; (2) a "stable depressed" group characterized by low affective lability and higher affect intensity; (3) an "unstable normal" group characterized by higher affective lability but lower affect intensity; and (4) an "unstable depressed" group characterized by higher affective lability and intensity. The stable depressed group evidenced the highest levels of eating psychopathology, borderline personality traits, and childhood trauma history, while the stable normal group generally evidenced the lowest levels of psychopathology. The findings demonstrate significant heterogeneity in the topography of affect experienced by individuals with BN, and suggest that chronic, intense negative affect may be particularly important to address in treatment.

The validity of DSM-5 severity specifiers for anorexia nervosa, bulimia nervosa, and binge-eating disorder

OBJECTIVE

The DSM-5 includes severity specifiers (i.e., mild, moderate, severe, extreme) for anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating disorder (BED), which are determined by weight status (AN) and frequencies of binge-eating episodes (BED) or inappropriate compensatory behaviors (BN). Given limited data regarding the validity of eating disorder (ED) severity specifiers, this study examined the concurrent and predictive validity of severity specifiers in AN, BN, and BED.

METHOD

Adults with AN (n = 109), BN (n = 76), and BED (n = 216) were identified from previous datasets. Concurrent validity was assessed by measures of ED psychopathology, depression, anxiety, quality of life, and physical health. Predictive validity was assessed by ED symptoms at the end of the treatment in BN and BED.

RESULTS

Severity categories did not differ in baseline validators, though the mild AN group evidenced greater ED symptoms compared to the severe group. In BN, greater severity was related to greater end of treatment binge-eating and compensatory behaviors, and lower likelihood of abstinence; however, in BED, greater severity was related to lower ED symptoms at the end of the treatment.

DISCUSSION

Results demonstrated limited support for the validity of DSM-5 severity specifiers. Future research is warranted to explore additional validators and possible alternative indicators of severity in EDs.

Male clinical norms and sex differences on the Eating Disorder Inventory (EDI) and Eating Disorder Examination Questionnaire (EDE-Q)

OBJECTIVE

Evidence indicates that males account for a significant minority of patients with eating disorders (EDs). However, prior research has been limited by inclusion of small and predominantly non-clinical samples of males. This study aimed to (1) provide male clinical norms for widely used ED measures (Eating Disorder Examination Questionnaire [EDE-Q] and Eating Disorder Inventory-3 [EDI-3]) and (2) examine sex differences in overall ED psychopathology.

METHOD

Participants were 386 male and 1,487 female patients with an ED diagnosis aged 16 years and older who completed the EDE-Q and EDI-3 upon admission to a residential or partial hospital ED treatment program.

RESULTS

Normative data were calculated for the EDE-Q (global and subscales) and the EDI-3 (drive for thinness, body dissatisfaction, and bulimia). Analyses of variance (ANOVAs) used to examine sex, ED diagnosis, and their interaction in relation to overall ED psychopathology revealed a consistent pattern of greater severity among females for ED psychopathology.

DISCUSSION

This study provides clinical norms on the EDE-Q and the EDI-3 for males with clinically diagnosed EDs. It is unclear whether the greater severity observed in females reflects qualitative differences in ED presentation or true quantitative differences in ED severity. Additional research examining the underlying nature of these differences and utilizing male-specific ED measures with clinical samples is warranted.

Incremental validity of weight suppression in predicting clinical impairment in bulimic syndromes

Research has shown that weight suppression (WS; the difference between a person's highest and current body weight in pounds) is a robust predictor of weight gain and eating-disorder (ED) symptoms among individuals with bulimic syndromes. Given the important prognostic role that WS plays in ED course and outcome, we hypothesized that WS would represent a clinically useful indicator of impairment for bulimic syndromes. We further posited that WS would demonstrate incremental validity above-and-beyond other proposed indicators in explaining clinical impairment in bulimic syndromes. Participants were community-recruited adults (N = 101; 80.2% female) with full-threshold (n = 51) or subthreshold (n = 50) bulimia nervosa. Other indicators of impairment included body mass index, frequency of inappropriate compensatory behaviors, lifetime history of any internalizing disorder, and multiple purging. Clinical impairment was assessed with the clinical impairment assessment (CIA). Hierarchical linear regression tested whether WS added to the explanation of CIA score variance above-and-beyond other indicators of bulimic-syndrome impairment. WS was significantly associated with clinical impairment (p = .011), but did not demonstrate incremental validity over other independent variables in predicting CIA scores. WS explained an additional 1.7% of the variance in CIA scores above-and-beyond other variables and the independent effect of WS on CIA scores represented a medium-sized effect (Cohen's d = 0.521). Results suggested that WS may be an indicator of ED-related clinical impairment. Inquiring about WS could be an informative component of routine bulimic-syndrome assessment, given that WS explains some of the variance in clinical impairment in bulimic syndromes.

Application of structural equation mixture modeling to characterize the latent structure of eating pathology

OBJECTIVE

Several theoretical models describe the structure of eating disorders (EDs), and a burgeoning empirical literature has sought to identify whether eating pathology is conceptualized best as categorical (presence or absence of disorder), dimensional (continuous), or a hybrid of categories and dimensions.

METHODS

This study used structural equation mixture modeling (SEMM) to identify the latent structure of EDs. Items from the Eating Pathology Symptoms Inventory (EPSI) were administered to individuals with EDs (N = 344). Select EPSI scales and body mass index were indicators in subsequent SEMM analyses. The Inventory of Depression and Anxiety Symptoms (IDAS), ED diagnoses, and select demographic variables were used as validators using chi-square or MANOVA.

RESULTS

Categorical models fit the data better than latent dimensional or hybrid models. Latent profile 1 (LP1) was non-fat-phobic restricting anorexia nervosa; LP2, an obese, binge-eating class; LP3, non-purging bulimia nervosa; LP4, fat-phobic restricting anorexia nervosa; and LP5, multiple purging bulimia nervosa. External validation analyses indicated that LP4 and LP5 had the highest non-ED-related psychopathology.

DISCUSSION

These findings indicate that there is substantial variability in the phenomenology of traditional DSM-based ED categories across latent profiles, and highlight the salience of certain ED phenotypes that have been debated in the literature. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:542-550).

Characterizing severe and enduring anorexia nervosa: An empirical approach

Targeted approaches for the treatment of severe and enduring anorexia nervosa (SE-AN) have been recommended, but there is no consensus definition of SE-AN to inform research and clinical practice. This study aimed to take initial steps toward developing an empirically based definition of SE-AN by characterizing associations among putative indicators of severity and chronicity in eating disorders. Patients with AN (N = 355) completed interviews and questionnaires at treatment admission and discharge; height and weight were assessed to calculate body mass index (BMI). Structural equation mixture modeling was used to test whether associations among potential indicators of SE-AN (illness duration, treatment history, BMI, binge eating, purging, quality-of-life) formed distinct subgroups, a single group with one or more dimensions, or a combination of subgroups and dimensions. A three-factor (dimensional), two-profile (categorical) mixture model provided the best fit to the data. Factor 1 included eating disorder behaviors; Factor 2 comprised quality-of-life domains; Factor 3 was characterized by illness duration, number of hospitalizations, and admission BMI. Profiles differed on eating disorder behaviors and quality-of-life, but not on indicators of chronicity or BMI. Factor scores, but not profile membership, predicted outcome at discharge from treatment. Data suggest that patients with AN can be classified on the basis of eating disorder behaviors and quality-of-life, but there was no evidence for a chronic subgroup of AN. Rather, indices of chronicity varied dimensionally within each class. Given that current definitions of SE-AN rely on illness duration, these findings have implications for research and clinical practice.

How useful is the DSM-5 severity indicator in bulimia nervosa? A clinical study including a measure of impairment

The severity criterion used in DSM-5 for bulimia nervosa (BN) was investigated in 214 individuals referred for treatment at a regional eating disorders service in the UK. In addition to comparing eating disorder symptoms, impairment secondary to these symptoms was also assessed. According to guidance in DSM-5, 94 individuals were classified as mild (43.9%), 70 as moderate (32.7%), 32 as severe (15.0%), and 8 as extreme (3.7%) levels of BN severity. Due to small numbers in the latter two groups, it was necessary to combine these to form one 'severe/extreme' group. Analyses on these three groups suggested no group effect on demographic variables but differences were seen on measures of eating pathology, psychological distress, and psychosocial impairment between the mild group and other groups. Individuals in the moderate and severe/extreme groups scored comparably on most measures of pathology and impairment. The results are broadly consistent with past studies on community samples although together question the demarcation between moderate and more severe groups of individuals with BN.

The dimensional nature of eating pathology: Evidence from a direct comparison of categorical, dimensional, and hybrid models

Eating disorders are conceptualized as categorical rather than dimensional in the current major diagnostic system (Diagnostic and Statistical Manual of Mental Disorders; 5th ed.; American Psychiatric Association, 2013) and in many previous studies. However, previous research has not critically evaluated this assumption or tested hybrid models (e.g., modeling latent variables with both dimensional and categorical features). Accordingly, the current study directly compared categorical, dimensional, and hybrid models for eating pathology in a large, population-based sample. Participants included 3,032 female and male twins (ages 9-30 years) from the Michigan State University Twin Registry. The Minnesota Eating Behaviors Survey was used to assess disordered eating symptoms including body dissatisfaction, weight preoccupation, binge eating, and compensatory behaviors. Results showed that dimensional models best fit the data in the overall sample as well as across subgroups divided by sex and pubertal status (e.g., prepubertal vs. postpubertal). It is interesting to note that the results favored more categorical models when using a case-control subset of our sample with participants who either endorsed substantial eating pathology or no/little eating pathology. Overall, findings provide support for a dimensional conceptualization of eating pathology and underscore the importance of using community samples to capture the full range of severity of eating pathology when investigating questions about taxonomy. (PsycINFO Database Record

Speaking of That: Terms to Avoid or Reconsider in the Eating Disorders Field

Inspired by an article on 50 terms that, in the interest of clarity in scientific reasoning and communication in psychology, psychiatry, and allied fields, "should be avoided or at most be used sparingly and only with explicit caveats,"(1) we propose a list of terms to avoid or think twice about before using when writing for the International Journal of Eating Disorders (IJED). Drawing upon our experience as reviewers or editors for the IJED, we generated an abridged list of such terms. For each term, we explain why it made our list and what alternatives we recommend. We hope that our list will contribute to improved clarity in scientific thinking about eating disorders, and that it will stimulate discussion of terms that may need to be reconsidered in our field's vocabulary to ensure the use of language that is respectful and sensitive to individuals who experience an eating disorder.

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.

The role of loss of control eating in purging disorder

OBJECTIVE

Purging Disorder (PD), an Other Specified Feeding or Eating Disorder (APA, 2013), is characterized by recurrent purging in the absence of binge eating. Though objectively large binge episodes are not present, individuals with PD may experience a loss of control (LOC) while eating a normal or small amounts of food. The present study sought to examine the role of LOC eating in PD using archival data from 101 women with PD.

METHOD

Participants completed diagnostic interviews and self-report questionnaires. Analyses examined the relationship between LOC eating and eating disorder features, psychopathology, personality traits, and impairment in bivariate models and then in multivariate models controlling for purging frequency, age, and body mass index.

RESULTS

Across bivariate and multivariate models, LOC eating frequency was associated with greater disinhibition around food, hunger, depressive symptoms, negative urgency, distress, and impairment.

DISCUSSION

LOC eating is a clinically significant feature of PD and should be considered in future definitions of PD. Future research should examine whether LOC eating better represents a dimension of severity in PD or a specifier that may impact treatment response or course.

Comparing operational definitions of DSM-5 anorexia nervosa for research contexts

OBJECTIVE

DSM-5 anorexia nervosa (AN) criteria include several changes that increase reliance on clinical judgment. However, research contexts require operational definitions that can be applied reliably and that demonstrate validity. The present study evaluated different operational definitions for DSM-5 AN.

METHOD

DSM-5 AN criteria were applied to diagnostic interview data from 364 women varying two features: threshold for determining low weight for Criterion A (body mass index [BMI] <17.0 kg/m(2) vs. <18.5 kg/m(2)) and explicit endorsement of weight phobia (Criterion B explicit vs. inferred). Resulting groups of individuals with DSM-5 AN were compared on estimated frequency. In addition, AN groups were compared to non-eating disorder controls and individuals with an other specified feeding or eating disorder (OSFED) on external validators.

RESULTS

All operational DSM-5 definitions produced higher lifetime frequency estimates than reported for DSM-IV AN, with a particularly large increase associated with the broadest definition. All definitions produced significant differences in comparison to controls on external validators that were associated with medium to large effect sizes. Only definitions that required a lower weight threshold or explicit endorsement of weight phobia demonstrated significant differences compared to OSFED on external validators, and these were of small effect size. The specific combination of BMI <18.5 kg/m(2) with inferred weight phobia exhibited few meaningful distinctions from the OSFED group.

DISCUSSION

To balance inclusivity, syndromal reliability, and validity, an operational definition for DSM-5 AN in research contexts should define low weight as BMI <18.5 kg/m(2) and require measurable rather than inferred weight phobia.

Hyperphagie boulimique : évolution des concepts et critères diagnostiques actuels (DSM V)

L’individualisation des troubles alimentaires dans le sens d’un excès d’alimentation s’est faite très tardivement par rapport aux troubles dits restrictifs. les critères de la boulimie ont été pour la première fois décrits par Russell en 1976. les troubles alimentaires se sont divisés en Anorexie mentale avec deux sous-types (restrictif et purgatif) et Boulimie dite « normopondérée ». Tous les autres tableaux cliniques qui ne remplissaient pas la totalité des critères d’un de ses deux troubles entraient dans la catégorie des troubles alimentaires non spécifiés « Eating Disorders not Otherwise Specified ou EDNOS » dans le DSM IV TR. Ces catégories ne semblaient pas pertinentes pour décrire l’ensemble de la pathologie et il est apparu nécessaire de les refondre. les critères de diagnostic tels qu’ils étaient proposés ne permettaient pas de décrire des formes modérées de ces troubles et de pouvoir rendre compte du degré de sévérité du symptôme ou de l’existence de stratégies de contrôle du poids. les classifications se sont faites de façon empirique. Parallèlement à ces classifications (DSM IV TR, CIM 10), différents travaux se sont appliqués à prendre en compte une plus grande diversité de symptômes avec en particulier la description du syndrome d’alimentation nocturne « Night Eating Syndrome ou NES ». Le DSM V a intégré ces travaux et a reconnu comme trouble l’hyperphagie boulimique « binge eating disorder » qui se définit comme l’ingestion de grandes quantités de nourriture sur une courte période avec sentiment de perte de contrôle ce qui le différencie du phénomène plus courant de l’hyperphagie qui est associé à moins de problèmes physiques et psychologiques. La conséquence de ces désordres liés à l’excès de nourriture sont le surpoids et surtout l’obésité avec ses conséquences somatiques. Le fait d’avoir une description clinique précise de ces troubles permet de leur appliquer des thérapeutiques pertinentes. les propositions de traitement doivent absolument tenir compte des caractéristiques cliniques et psychologiques des sujets.

Incorporating dimensions into the classification of eating disorders: three models and their implications for research and clinical practice

OBJECTIVE

Given renewed interest in dimensional approaches in psychiatric nosology, we review evidence for the utility of including dimensions of eating disorder (ED) psychopathology, comorbid psychopathology, and neurobiology in the classification of EDs.

METHOD

We searched on-line databases and reference lists of published papers for articles on dimensional methods in psychiatric classification, with an emphasis on EDs.

RESULTS

ED classification may be enhanced by including dimensional assessments. Specifically, some ED features appear to exist on a continuum with normality, and dimensional measures of ED severity are likely to have utility in clinical contexts. Furthermore, accumulating data support the validity of ED classification schemes that incorporate dimensions of comorbid psychopathology. Finally, neurobiological dimensions have gained increasing notice across the psychiatric literature and may be particularly salient to the classification of EDs.

DISCUSSION

An approach to ED classification that incorporates multiple dimensional measures may have the greatest utility for advancing ED treatment.