Mortality and Its Predictors in Severe Bulimia Nervosa Patients

Acquired Capability for Suicide: An Evolutionary Concept Analysis

While virtually all suicide attempters experience ideations, not all who think about suicide will attempt or die by suicide. The ideation-to-action framework has led to new theories distinguishing suicide ideators from suicide attempters. The framework suggests that suicide progresses on a spectrum of thoughts and behaviors with different identifiers and explanations. The concept of acquired capability for suicide (ACS), conceptualized by the Interpersonal Psychological Theory of Suicide, is the first to explain the movement from ideation to action. This concept analysis of ACS is timely and relevant for greater clarification of the role ACS has in the movement from ideation to action. Rodgers' evolutionary concept analysis method is used. The six-step evolutionary method highlights the concept's attributes, antecedents, and consequences and provides a basis for further inquiry and development rather than a final definition.

Issues around food in mixed families of adolescent girls with bulimia nervosa: A qualitative study with photo-elicitation

OBJECTIVES

Bulimia nervosa (BN) is a common psychiatric disorder among adolescent girls with potentially significant complications. Family relationships play a major role in the development and progression of this disorder. Studies in migrant populations suffering from eating disorders show contrasting results depending on the generation of migrants: first generation migrants have fewer eating disorders than the native population, while the prevalence of this disorder is more important than the latter among second and third generation migrants. In our clinical experience, we have frequently encountered so-called "mixed" families, which are families composed of one migrant parent and one non-migrant parent. Research focusing on this kind of family is scarce which is why we chose to explore their dynamic.

METHODS

This study explored the issues around food and family relationships of adolescent girls suffering from BN, a topic that, to date, has not yet been studied. Ten interviews were conducted with five adolescent girls with BN between the ages of 16 and 20 and their parents, using photo-elicitation to enrich the collected data.

RESULTS

The results were organized around two axes: (1) identity issues around food, that is the assimilation process described by both parents and adolescents concerning family meals and food habits, and how the adolescents struggle to manage this interbreeding; and (2) transmission issues with the consequences the migrant parent has to deal with to transmit his/her cultural identity with food while being far away from the homeland, and the difficulties between this parent and his/her child to share this heritage. Both issues, identity and transmission, appear to be central among these families.

CONCLUSIONS

Our results suggest a difficulty in mentalizing identity issues in adolescent girls; the function of appeasement around non-mentalized tensions was highlighted. In our opinion, in this particular context, BN acts as a means of expressing the difficulty of their mixed culture. This enables it to draw some clinical implications, especially using mentalization-based therapy which has already shown efficacy in adolescents with borderline personality disorder and ED.

Description of patients with eating disorders by general practitioners: a cohort study and focus on co-management with depression

BACKGROUND

International guidelines often state that general practitioners (GPs) provide early management for most patients with eating disorders (EDs). GP management of EDs has not been studied in France. Depressive disorders are often a comorbidity of EDs. The aims of this study were to describe in France the characteristics of people with all subcategories of EDs (Anorexia Nervosa, Bulimia Nervosa, ED Not Otherwise Specified) managed by their GPs and to study the management temporality between depression and all subcategories of EDs.

METHODS

Retrospective cohort study of patients with EDs visiting French GPs. Data collected from 1994 through 2009 were extracted from the French society of general electronic health record. A descriptive analysis of the population focused on depression, medication such as antidepressants and anxiolytics, and the management temporality between depression and EDs.

RESULTS

1310 patients aged 8 years or older were seen at least once for an ED by a GP participating in the database out of 355,848 patients, with a prevalence rate of 0.3%. They had a mean age of 35.19 years, 82.67% were women. 41.6% had anorexia nervosa, 26.4% bulimia nervosa, and 32% an ED not otherwise specified. Overall, 32.3% had been managed at least once for depression, and 18.4% had been prescribed an antidepressant of any type at least once. Benzodiazepines had been prescribed at least once for 73.9% of the patients treated for depression. Patients with an ED seen regularly by their GP ("during" profile) received care for depression more frequently than those with other profiles. 60.9% had a single visit with the participating GP for their ED Treatment and management for depression did not precede care for EDs.

CONCLUSIONS

Data extracted from the French society of general practice were the only one available in France in primary care about EDs and our study was the only one on this topic. The frequency of visits for EDs was very low in our general practice-based sample. Depressive disorders were a frequent comorbidity of EDs. GPs could manage common early signs of depression and EDs, especially if they improved their communication skills and developed collaborative professional management.

Laxative Abuse Is Associated With a Depleted Gut Microbial Community Structure Among Women and Men With Binge-Eating Disorder or Bulimia Nervosa: The Binge Eating Genetics Initiative

OBJECTIVE

This study assessed the associations of binge eating, compensatory behaviors, and dietary restraint with the composition and diversity of the intestinal microbiota among participants with binge-eating disorder or bulimia nervosa.

METHODS

We analyzed data from 265 participants aged 18 to 45 years with current binge-eating disorder or bulimia nervosa enrolled in the Binge Eating Genetics Initiative study. We evaluated the associations of binge-eating frequency; presence/absence and frequency of vomiting, laxative use, and compulsive exercise; and dietary restraint with abundances of gut microbial genera, species, and diversity (Shannon diversity, Faith phylogenetic diversity, and Peilou's evenness) from 16S rRNA gene sequencing. General linear regression models adjusted for potential confounders, including age and current body mass index, were used to test associations; p values were corrected for the false discovery rate.

RESULTS

The normalized abundance of four genus- and species-level gut microbes and three diversity indices were lower among Binge Eating Genetics Initiative participants who reported any laxative use compared with those who reported no laxative use. Vomiting frequency was positively associated with the normalized abundance of the genus Escherichia-Shigella , a potential pathobiont, although the association was attenuated to nonsignificance after adjustment for age, body mass index, and binge-eating episodes.

CONCLUSIONS

Laxative use was highly and uniformly predictive of a reduced gut microbial diversity including potential commensals and pathobionts, and should be assessed and accounted for in all future studies of eating disorders and the gut microbiota. Future studies should collect data on specific medications-particularly laxatives-and dietary intake to obtain unbiased estimates of the effect of eating disorders on the gut microbiota and identify potential downstream clinical implications.Trial Registration:ClinicalTrials.gov identifier: NCT04162574 .

Mortality in anorexia nervosa and bulimia nervosa: A population-based cohort study in Taiwan, 2002-2017

OBJECTIVE

To investigate natural- and unnatural-cause mortality at different follow-up time points in Taiwanese patients with anorexia nervosa (AN) and bulimia nervosa (BN).

METHOD

In this longitudinal cohort study, 330,393 patients, including 2143 patients with AN, 13,590 with BN, and 20 times as many respective non-AN and non-BN patients, were followed up for 16 years. We performed conditional Cox regression survival analysis to examine the risk of mortality in the AN and BN groups relative to the comparison group.

RESULTS

A total of 1242 patients died, including 101 and 343 patients with AN and BN, respectively. Mortality rates for AN and BN were 5.42 and 2.90 deaths per 1000 person-years, respectively. Compared with the non-AN group, the AN group had a significantly higher risk of both natural- and unnatural-cause mortality, and the BN group had a significantly higher risk of unnatural-cause mortality. Suicide was the most common cause of death, and suicide risk was significantly higher in both the AN and BN groups. All-cause mortality risk was the highest at the beginning of follow-up and markedly declined in the AN group. In the BN group, all-cause mortality risk was lower but stable at follow-up. The risk of unnatural-cause mortality remained high throughout the follow-up period for both the groups.

CONCLUSIONS

Early detection and treatment for associated physical problems in patients with AN are crucial. Regular monitoring for unnatural-cause mortality events (mainly suicide) in AN and BN over time is also crucial.

PUBLIC SIGNIFICANCE

AN had a significantly higher risk of both natural- and unnatural-cause mortality and BN had a significantly higher risk of death from unnatural causes. All-cause mortality risk was highest at the beginning of follow-up in AN, but unnatural-cause mortality risk remained high throughout the follow-up period for both groups. Our findings imply that early detection and treatment in AN and regular monitoring for unnatural-cause mortality events in AN and BN are crucial.

Binge-eating disorder with and without lifetime anorexia nervosa: A comparison of sociodemographic and clinical features

OBJECTIVE

To compare individuals who have experienced binge-eating disorder (BED) and anorexia nervosa (AN) (BED AN+) to those who have experienced BED and not AN (BED AN-).

METHOD

Participants (N = 898) met criteria for lifetime BED and reported current binge eating. Approximately 14% had a lifetime diagnosis of AN. Analyses compared BED AN+ and BED AN- on sociodemographic variables and clinical history.

RESULTS

The presence of lifetime AN was associated with more severe eating disorder symptoms, including earlier onset, more frequent, more chronic, and more types of eating disorder behaviors over the lifetime, as well as a higher lifetime prevalence of bulimia nervosa (BN). Participants with lifetime AN reported being more likely to have received treatments for BED or BN, had significantly lower minimum, current, and maximum BMIs, had more severe general anxiety, and were significantly more likely to be younger and female. In the full sample, the lifetime prevalence of unhealthy weight control behaviors was high and treatment utilization was low, despite an average 15-year history since symptom onset. Gastrointestinal disorders and comorbid anxiety, depression, and attention-deficit/hyperactivity disorder symptoms were prevalent.

DISCUSSION

Individuals fared poorly on a wide array of domains, yet those with lifetime AN fared considerably more poorly. All patients with BED should be screened for mental health and gastrointestinal comorbidities and offered referral and treatment options.

PUBLIC SIGNIFICANCE

Individuals experiencing binge-eating disorder have severe symptomology, but those who have experienced binge-eating disorder and anorexia nervosa fare even more poorly. Our study emphasizes that patients with binge-eating disorder would benefit from being screened for mental health and gastrointestinal comorbidities, and clinicians should consider history of unhealthy weight control behaviors to inform treatment and relapse prevention.

Effects of social media on body dissatisfaction in junior high school girls in Japan

AIMS

Body dissatisfaction (BD) is a serious problem related to the incidence of eating disorders. Social media (SM) use is known to be associated with BD. With a view to preventing the incidence of eating disorders, this study aimed to investigate the association between SM and BD, particularly, the role of SM in the encouragement of thinness and its relationship with adolescent girls' BD.

METHODS

Junior high school girls aged 12-15 in Japan completed the Body Shape Questionnaire (BSQ), Eating Attitudes Test-26, Bulimic Investigatory Test Edinburgh, Depression Self-Rating Scale for Children, and SM usage. Participants were classified into two groups based on their BSQ cut-off score.

RESULTS

Overall, 161 students were recruited (44 participants with BD; 117 without BD). The BD group used SM more than the non-BD group (χ² (1) = 4.61, p = .032). The frequency of following SM accounts related to thinness was significantly higher in the BD group than in the non-BD group (χ² (1) = 7.76, p = .005). The association between BD and following SM accounts focused on thinness was the most important (adjusted OR = 3.82; 95 % CI: 1.05-13.89).

CONCLUSIONS

The risks of SM use increasing BD in adolescent girls should be considered to prevent mental disorders, including eating disorders.

Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature

BACKGROUND

Eating disorders (EDs) are potentially severe, complex, and life-threatening illnesses. The mortality rate of EDs is significantly elevated compared to other psychiatric conditions, primarily due to medical complications and suicide. The current rapid review aimed to summarise the literature and identify gaps in knowledge relating to any psychiatric and medical comorbidities of eating disorders.

METHODS

This paper forms part of a rapid review) series scoping the evidence base for the field of EDs, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/Medline were searched for English-language studies focused on the psychiatric and medical comorbidities of EDs, published between 2009 and 2021. High-level evidence such as meta-analyses, large population studies and Randomised Control Trials were prioritised.

RESULTS

A total of 202 studies were included in this review, with 58% pertaining to psychiatric comorbidities and 42% to medical comorbidities. For EDs in general, the most prevalent psychiatric comorbidities were anxiety (up to 62%), mood (up to 54%) and substance use and post-traumatic stress disorders (similar comorbidity rates up to 27%). The review also noted associations between specific EDs and non-suicidal self-injury, personality disorders, and neurodevelopmental disorders. EDs were complicated by medical comorbidities across the neuroendocrine, skeletal, nutritional, gastrointestinal, dental, and reproductive systems. Medical comorbidities can precede, occur alongside or emerge as a complication of the ED.

CONCLUSIONS

This review provides a thorough overview of the comorbid psychiatric and medical conditions co-occurring with EDs. High psychiatric and medical comorbidity rates were observed in people with EDs, with comorbidities contributing to increased ED symptom severity, maintenance of some ED behaviours, and poorer functioning as well as treatment outcomes. Early identification and management of psychiatric and medical comorbidities in people with an ED may improve response to treatment and overall outcomes.

Retention, engagement, and binge-eating outcomes: Evaluating feasibility of the Binge-Eating Genetics Initiative study

OBJECTIVE

Using preliminary data from the Binge-Eating Genetics Initiative (BEGIN), we evaluated the feasibility of delivering an eating disorder digital app, Recovery Record, through smartphone and wearable technology for individuals with binge-type eating disorders.

METHODS

Participants (n = 170; 96% female) between 18 and 45 years old with lived experience of binge-eating disorder or bulimia nervosa and current binge-eating episodes were recruited through the Recovery Record app. They were randomized into a Watch (first-generation Apple Watch + iPhone) or iPhone group; they engaged with the app over 30 days and completed baseline and endpoint surveys. Retention, engagement, and associations between severity of illness and engagement were evaluated.

RESULTS

Significantly more participants in the Watch group completed the study (p = .045); this group had greater engagement than the iPhone group (p's < .05; pseudo-R2 McFadden effect size = .01-.34). Overall, binge-eating episodes, reported for the previous 28 days, were significantly reduced from baseline (mean = 12.3) to endpoint (mean = 6.4): most participants in the Watch (60%) and iPhone (66%) groups reported reduced binge-eating episodes from baseline to endpoint. There were no significant group differences across measures of binge eating. In the Watch group, participants with fewer episodes of binge eating at baseline were more engaged (p's < .05; pseudo-R2 McFadden  = .01-.02). Engagement did not significantly predict binge eating at endpoint nor change in binge-eating episodes from baseline to endpoint for both the Watch and iPhone groups.

DISCUSSION

Using wearable technology alongside iPhones to deliver an eating disorder app may improve study completion and app engagement compared with using iPhones alone.

What can we learn about eating disorder mortality from eating disorder diagnoses at initial assessment? A Danish nationwide register follow-up study using record linkage, encompassing 45 years (1970-2014)

Increased risk for premature mortality is well established for women and girls diagnosed with anorexia nervosa (AN), but less is known for other types of eating disorder (ED), and especially the mortality outcome for boys and men is under-studied. In this registry-based observational epidemiological study, we included all people appearing in the Danish Psychiatric Central Research Register with an eating disorder (ED) diagnosis in the time period from Jan 1,1970 to Dec 31, 2014 (N: 22,633). For each patient four controls without ED were selected, matched for age, sex and place of residence (N: 90486). In all 802 people with ED died over 255762.6 person-years of observation. Standardized mortality ratio (SMR) for all-cause mortality and suicide mortality was significantly increased for all ED-diagnoses in women. The SMRs for men were similar, but only reached significance for the diagnoses AN and unspecified ED. Mortality by natural causes and accidents was significantly increased in most ED-diagnoses in women. The unequal female-to-male ratio in this, and most other studies of ED-patients, suggests that boys and men with ED have unmet needs.

Mortality in males as compared to females treated for an eating disorder: a large prospective controlled study

PURPOSE

To report on the mortality of DSM-IV eating disorders and predictors of premature death in males compared to females after inpatient treatment.

METHODS

Crude mortality rate (CMR) and standardized mortality ratio (SMR) were computed for a large sample of males aged at treatment 16-61 years [N = 66 anorexia nervosa (AN), 52 bulimia nervosa (BN), 70 eating disorder not otherwise specified (ED-NOS)] and females aged 14-65 years (N = 2066 AN, 1880 BN, 1350 ED-NOS). In addition, a survival analysis and Cox regression analyses for identifying predictors of death were computed.

RESULTS

CMRs for males and females, respectively, were 15% and 5% in AN, 8% and 3% in BN, and 4% and 3% in ED-NOS. Compared to the general population, mortality was elevated in males with AN (SMR = 4.93) and in all female diagnostic groups (AN, BN, ED-NOS). No significant sex differences for SMR emerged in any diagnostic group. Compared to females with AN or BN, males with AN or BN showed a shorter survival time after onset (survival analysis). Being male, and having AN, increased the risk of premature death.

CONCLUSION

Mortality in inpatients with eating disorder is high, especially in AN. Males appear to have about the same outcome in terms of mortality as females with AN, BN, and ED-NOS. However, long-term survival was shorter in males with AN or BN compared to females. The need for intensive treatment in both males and females with an eating disorder remains an important issue.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

Effectiveness of integrated treatment for eating disorders in Spain: protocol for a multicentre, naturalistic, observational study

INTRODUCTION

Eating disorders (EDs) are complex pathologies which require equally complex treatment strategies. These strategies should be multidisciplinary, personalised interventions, performed in appropriate settings along a healthcare continuum from inpatient to community care. Personalisation, and the complexity of levels of care and interventions make evaluation of treatments difficult. The present study aims to measure the effectiveness of a complex treatment programme for EDs which includes hospitalisation, day hospital and outpatient settings. Our purpose is to assess the complete therapeutic process of each patient through all these levels of care, capturing the multiplicity of trajectories that a programme of these characteristics involves.

METHODS AND ANALYSIS

This protocol describes a multicentre, naturalistic, observational study. All patients starting between November 2017 and October 2020 in a healthcare network for EDs in Spain are being invited to participate. The first phase of intensive change monitoring to November 2020 is followed by lower intensity follow-up until October 2025. In the first phase progress of all participants is assessed every 3 weeks using specific measures for ED and the Clinical Outcomes Routine Evaluation system, a family of instruments specifically designed to measure change in psychotherapy. In the second phase data collection will happen quarterly. Both cross-sectional and longitudinal analyses will be conducted, with a special focus on patterns and predictors of change studied through multilevel linear models.

ETHICS AND DISSEMINATION

The study has been approved by the Research Bioethics Committee of the University of Barcelona (no. IRB00003099) and the ethical committee of ITA Mental Health, the organisation to which all participating centres belong. Dissemination will be in papers for peer-reviewed research journals and to clinicians working with ED.

TRIAL REGISTRATION NUMBER

NCT04127214.

Emotion dysregulation and suicidality in eating disorders

OBJECTIVE

Suicidality in eating disorders (EDs) is high, and identification of therapeutically targetable traits associated with past, current, and future suicidality is of considerable clinical importance. We examined overall and ED subtype-specific associations among suicidal ideation, suicide attempts, and general and specific aspects of emotion dysregulation in a large sample of individuals with ED, at presentation for treatment and 1-year follow-up.

METHOD

Using registry data from 2,406 patients, scores on the Difficulties in Emotion Dysregulation Scale (DERS) at initial registration were examined as predictors of recent suicidal ideation and self-report lifetime suicide attempts. Associations were examined in the full sample and in each ED subtype. In 406 patients, initial DERS scores were examined as predictors of suicidality at 1-year follow-up.

RESULTS

Overall DERS was associated with suicidal ideation and suicide attempts, even when adjusting for ED psychopathology and current depression. Perceived lack of emotion regulation strategies showed unique associations with suicidal ideation and suicide attempts, both in the full sample and in most ED subtypes. Initial DERS was also associated with follow-up suicidal ideation and suicide attempts, although this association did not remain when adjusting for past suicidality.

DISCUSSION

Results suggest that emotion dysregulation may be a potential mechanism contributing to suicidality in EDs, beyond the effects of ED psychopathology and current depression. Although the prevalence of suicidality differs across ED subtypes, emotion dysregulation may represent a risk trait for future suicidality that applies transdiagnostically. Results support addressing emotion dysregulation in treatment in order to reduce suicidality.

Case Report: Unexpected Remission From Extreme and Enduring Bulimia Nervosa With Repeated Ketamine Assisted Psychotherapy

Background: Bulimia nervosa is a disabling psychiatric disorder that considerably impairs physical health, disrupts psychosocial functioning, and reduces overall quality of life. Despite available treatment, less than half of sufferers achieve recovery and approximately a third become chronically ill. Extreme and enduring cases are particularly resistant to first-line treatment, namely antidepressants and cognitive behavioral therapy, and have the highest rate of premature mortality. Here, we demonstrate that in such cases, repeated sessions of ketamine assisted psychotherapy (KAP) is an effective treatment alternative for improving symptoms. Case Presentation: A 21-year-old woman presented with extreme and enduring bulimia nervosa. She reported recurrent binge-eating and purging by self-induced vomiting 40 episodes per day, which proved refractory to both pharmacological and behavioral treatment at the outpatient, residential, and inpatient level. Provided this, her physician recommended repeated KAP as an exploratory and off-label intervention for her eating disorder. The patient underwent three courses of KAP over 3 months, with each course consisting of six sessions scheduled twice weekly. She showed dramatic reductions in binge-eating and purging following the first course of treatment that continued with the second and third. Complete cessation of behavioral symptoms was achieved 3 months post-treatment. Her remission has sustained for over 1 year to date. Conclusions: To our knowledge, this is the first report of repeated KAP used to treat bulimia nervosa that led to complete and sustained remission, a rare outcome for severe and enduring cases, let alone extreme ones. Additionally, it highlights the degree to which KAP can be tailored at the individual level based on symptom severity and treatment response. While its mechanism of action is unclear, repeated KAP is a promising intervention for bulimia nervosa that warrants future research and clinical practice consideration.

An Examination of the Interpersonal Theory of Suicide's Tenets among Women with Bulimic-Spectrum Pathology

Objective: Suicide attempts and self-injurious behaviors (SIBs) are known to be elevated among people with bulimia nervosa (BN). The aim of the current study was to examine the Interpersonal-Psychological Theory of Suicide (IPTS) as a framework for understanding, assessing, and mitigating suicidal behavior among women with BN. The IPTS suggests that for individuals to enact lethal suicide attempts, they must have both the desire to die (consisting of thwarted belongingness and perceived burdensomeness) as well as the capability to die (often acquired through repeated exposure to provocative or painful experiences).Method: Two-hundred and four women with eating disorders, the majority of whom met criteria for a current DSM-IV diagnosis of BN, completed measures from which proxies for IPTS variables were formed. Bivariate correlations and multiple regressions tested main effects and interactions of study variables. Tests of the difference between dependent correlations probed differential associations between study variables and suicidal ideation versus suicidal behavior.Results and Conclusions: Results yielded considerable but not unalloyed support for the theory, with desire to die variables (particularly perceived burdensomeness) more strongly associating with suicidal ideation than behavior, and the opposite holding true regarding capability. These findings suggest that the IPTS may provide a useful framework for understanding, assessing, and mitigating suicide risk among individuals with BN.

Pharmacological treatment of eating disorders, comorbid mental health problems, malnutrition and physical health consequences

The pharmacological treatment of patients with an eating disorder (ED) often includes medications to treat their ED, comorbid mental health problems, malnutrition and the physical health problems resulting from it. The currently approved pharmacological treatment options for EDs are limited to fluoxetine for bulimia nervosa (BN) and - in some countries - lisdexamfetamine for binge eating disorder (BED). Thus, there are no approved pharmacological options for anorexia nervosa (AN), even though study results for olanzapine and dronabinol are promising. Topiramate might be an additional future option for the treatment of BN and BED. Selective serotonin reuptake inhibitors (SSRI), mirtazapine and bupropion could be considered for the treatment of comorbid unipolar depression. However, AN and BN are contraindications for bupropion. For ED patients with a manic episode, we recommend olanzapine in AN and risperidone in BN and BED; whereas for bipolar depression, olanzapine (plus fluoxetine) seems appropriate in AN and lamotrigine in BN and BED. Acute anxiety or suicidality may warrant benzodiazepine treatment with lorazepam. Proton-pump inhibitors, gastroprokinetic drugs, laxatives and hormones can alleviate certain physical health problems caused by EDs. Therapeutic drug monitoring, pharmacogenomic testing, a more restrictive use of "pro re nata" (PRN) medication, an interdisciplinary treatment approach, shared decision making (SDM) and the formulation of common treatment goals by the patients, their family or carers and clinicians could improve treatment success and safety. Novel genetic, immunological, microbiome and brain imaging research as well as new pharmacological developments like the use of psychedelics, stimulants, novel monoaminergic drugs, hormone analogues and drugs which enhance the effects of psychotherapy may extend our therapeutic options in the near future.

Long-term outcome of inpatients with bulimia nervosa-Results from the Christina Barz Study

OBJECTIVE

To assess the long-term outcome and identify outcome predictors in a very large sample of inpatients treated for bulimia nervosa (BN).

METHOD

Out of a total of 2,033 patients admitted consecutively to specialized treatment, 1,351 patients (mean age at treatment 25.94) were assessed for follow-up on average 11 (SD 6) years after admission. Also a very long-term (21 years) subsample (N = 147; mean age 25.92) was defined. Bivariate and logistic regression analyses identified predictors of poor outcome.

RESULTS

For more than 70% of the patients follow-up information could be gathered. Severity of eating disorder (ED) and other symptoms decreased over time but remained higher than in healthy controls, using published normative data. Remission rate was 38% after 11 years and 42% in the subsample after 21 years. Out of the total sample of N = 2,033 patients, 49 had died (2.4%). Persistent BN was found in 14.2% and the most frequent crossover was to ED not otherwise specified. Predictors of poor outcome were fewer follow-up years, higher drive for thinness, higher age at treatment, and less global functioning.

DISCUSSION

Based on clinical indicators, patients presented with a high level of ED and psychiatric symptomatology. With less than half of the patients remitted after 22 years, efforts are needed to improve treatment outcome.

Predictors of Suicide Attempts in Individuals with Eating Disorders

OBJECTIVE

Although suicide is a major cause of mortality for individuals with eating disorders (EDs), researches about potential factors predicting suicide attempts in ED are insufficient. We sought to identify factors associated with suicide attempts in ED.

METHOD

A total of 899 patients with ED were assessed via structured interviews. To compare demographic and clinical characteristics of those who had attempted suicide with those who had not, we used chi-square tests and independent t tests for categorical and continuous variables, respectively. Then, binary logistic regression was conducted to identify factors associated with a history of suicide attempt.

RESULTS

Among ED patients, 20.8% reported a history of suicide attempts. Among the whole sample, the diagnostic category was the most significant factor. History of self-mutilating behavior, hospitalization history, comorbid depression, and impulse regulation were also important factors associated with suicide attempt. Within the subgroup, comorbid anxiety disorder, depression, and BMI in anorexia nervosa and hospitalization history, history of self-mutilating behavior, comorbid depression, illness duration, and poor impulse regulation in bulimia nervosa were significant factors associated with suicide attempt.

CONCLUSIONS

Because modifying risk factors of suicide attempt is important for preventing completed suicide, clinicians should carefully evaluate and monitor the risk factors of suicide attempt.

Suicide attempts in eating disorder subtypes: a meta-analysis of the literature employing DSM-IV, DSM-5, or ICD-10 diagnostic criteria

BACKGROUND

Quantification of suicidal risk in specific populations is important for the adoption of targeted prevention and harm reduction measures. Though there remains little systematic evidence, risk of suicide attempts for bulimia nervosa (BN) and binge-purging anorexia nervosa (AN-bp) appears higher than restrictive AN (AN-r); risk in binge eating disorder (BED) is still unclear. The aim of this meta-analysis was to compare proportions of suicide attempts in eating disorder (ED) subgroups.

METHODS

A literature search using combinations of key-words for ED and suicide attempts was performed. Studies reporting proportions of suicide attempters in at least two ED groups, diagnosed according to DSM-IV or -5 and ICD-10 diagnostic criteria were considered. ED subgroups were analyzed in pairs using a binary random effect model for proportions. Publication bias, meta-regression, and sensitivity analyses were performed.

RESULTS

In BN, attempted suicide was more frequent (21%) than in AN (12.5%), but the difference was statistically significant only when BN was compared with AN-r (9-10%). In BED, the proportion of suicide attempts was as high as in AN (10-12%).

CONCLUSIONS

Though limited by heterogeneity across the studies in terms of methodology and aims, inability to control for relevant confounding variables, exclusion of ED not otherwise specified, this study supports suicide attempts as a major issue in EDs, especially in binge-purging subtypes, i.e. BN and AN-bp. Similar suicidal proportions were observed in AN and BED. The reasons for a greater proportion of attempted suicide in binge/purging subtypes need to be explored in future studies.

Acipimox Administration With Exercise Induces a Co-feedback Action of the GH, PP, and PYY on Ghrelin Associated With a Reduction of Peripheral Lipolysis in Bulimic and Healthy-Weight Czech Women: A Randomized Study

Objective: Anti-lipolytic drugs and exercise are enhancers of growth hormone (GH) secretion. Decreased circulating free fatty acids (FFA) have been proposed to exert ghrelin-GH feedback loop after administration of an anti-lipolytic longer-acting analog of nicotinic acid, Acipimox (OLB, 5-Methylpyrazine-2-carboxylic acid 4-oxide, molecular weight of 154.1 Da). OLB administration strongly suppresses plasma FFA during exercise. Neuroendocrine perturbations of the adipose tissue (AT), gut, and brain peptides may be involved in the etiopathogenesis of eating disorders including bulimia nervosa (BN) and anorexia nervosa. BN is characterized by binge eating, self-induced vomiting or excessive exercise. Approach: To test the hypothesis that treatment with OLB together with exercise vs. exercise alone would induce feedback action of GH, pancreatic polypeptide (PP), peptide tyrosine tyrosine (PYY), and leptin on ghrelin in Czech women with BN and in healthy-weight Czech women (HW). The lipolysis rate (as glycerol release) in subcutaneous abdominal AT was assessed with microdialysis. At an academic medical center, 12 BN and 12 HW (the control group) were randomized to OLB 500 mg 1 h before a single exercise bout (45 min, 2 W/kg of lean body mass [LBM]) once a week vs. identical placebo over a total of 2 weeks. Blood plasma concentrations of GH, PP, PYY, leptin, ghrelin, FFA, glycerol, and concentrations of AT interstitial glycerol were estimated during the test by RIA utilizing ¹²⁵I-labeled tracer, the electrochemiluminescence technique (ECLIA) or colorimetric kits. Results: OLB administration together with short-term exercise significantly increased plasma GH (P < 0.0001), PP (P < 0.0001), PYY, and leptin concentrations and significantly decreased plasma ghrelin (P < 0.01) concentrations in both groups, whereas short-term exercise with placebo resulted in plasma ghrelin (P < 0.05) decrease exclusively in BN. OLB administration together with short-term exercise significantly lowered local subcutaneous abdominal AT interstitial glycerol (P < 0.0001) to a greater extent in BN. Conclusion: OLB-induced suppression of plasma ghrelin concentrations together with short-term exercise and after the post-exercise recovering phase suggests a potential negative co-feedback of GH, PP, PYY, and leptin on ghrelin secretion to a greater extent in BN. Simultaneously, the exercise-induced elevation in AT interstitial glycerol leading to a higher inhibition of peripheral lipolysis by OLB in BN. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT03338387.

The QTc interval and risk of cardiac events in bulimia nervosa: A long-term follow-up study

OBJECTIVE

An association between bulimia nervosa (BN) and prolonged corrected QT interval (QTc) in the electrocardiogram has been suggested, but results of previous studies are conflicting, and the risk of cardiac events in patients with BN has yet to be investigated.

METHOD

We estimated mean QTc interval and relative risk of borderline (QTc >440 ms) and prolonged QTc (QTc >460 ms) between adult women with BN (N = 531) and healthy controls (N = 123). In follow-up analyses, we investigated the risk of a primary endpoint (syncope, ventricular tachycardia, and cardiac arrest) and all-cause mortality in patients with BN (N = 702) compared with a population-based cohort derived from the Danish Civil Register (N = 7,020).

RESULTS

Mean QTc did not differ between patients with BN and controls. Relative risk of borderline prolonged QTc was 2.3 (p = 0.28). The number of patients and controls with prolonged QTc was small, and the risk did not differ between patients with BN and controls. Median follow-up was 10.6 years. Although there appeared to be increased risks after 5 years of follow-up, long-term risks of the primary endpoint (Hazard ratio [HR] = 1.4, p = 0.37) and all-cause mortality (HR = 1.7, p = .28), respectively, were not increased in patients with BN compared to a population-based cohort.

DISCUSSION

Mean QTc did not differ between patients with BN and healthy controls, and the risk of prolonged QTc was not increased in patients with BN. There was no difference in the long-term risk of cardiac events, and long-term all-cause mortality did not differ significantly between patients with BN and a population-based cohort.

The Science Behind the Academy for Eating Disorders' Nine Truths About Eating Disorders

OBJECTIVE

In 2015, the Academy for Eating Disorders collaborated with international patient, advocacy, and parent organizations to craft the 'Nine Truths About Eating Disorders'. This document has been translated into over 30 languages and has been distributed globally to replace outdated and erroneous stereotypes about eating disorders with factual information. In this paper, we review the state of the science supporting the 'Nine Truths'.

METHODS

The literature supporting each of the 'Nine Truths' was reviewed, summarized and richly annotated.

RESULTS

Most of the 'Nine Truths' arise from well-established foundations in the scientific literature. Additional evidence is required to further substantiate some of the assertions in the document. Future investigations are needed in all areas to deepen our understanding of eating disorders, their causes and their treatments.

CONCLUSIONS

The 'Nine Truths About Eating Disorders' is a guiding document to accelerate global dissemination of accurate and evidence-informed information about eating disorders. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Long-term outcome of anorexia nervosa: Results from a large clinical longitudinal study

OBJECTIVE

Assessment of the long-term outcome of anorexia nervosa (AN) in a very large sample of inpatients (N = 1,693) and identification of predictors for poor outcome.

METHOD

Over 25 years (mean 10 years), consecutively admitted inpatients of a specialized hospital were followed. A subsample of 112 patients with 20-year follow-up was defined. Bivariate comparisons and logistic regression analysis identified risk factors of poor outcome.

RESULTS

Body mass index (BMI) increased during the follow-up period. Eating behavior as well as general psychopathology improved but did not reach the level of healthy controls. Remission was found in 30% (total sample) and in 40% (20-year follow-up subsample). Crossover from AN to binge-eating disorder or obesity was rare. The predictors of a negative course of illness included lower BMI at admission; a higher score on the Eating Disorder Inventory Maturity Fears subscale at admission; fewer follow-up years; and higher age at admission. The main diagnostic crossover occurred from AN to eating disorder not otherwise specified. Motherhood was related to better outcome.

DISCUSSION

Many patients with very severe AN recover from their illness but AN also shows considerable long-term negative consequences. Over long time periods, survivors show improvement but better treatments for severe cases are still needed. Predictors of outcome included symptom severity, chronicity, and length of follow-up but not psychiatric comorbidity.

Diagnosis-specific self-image predicts longitudinal suicidal ideation in adult eating disorders

OBJECTIVE

Eating disorders (ED) are prevalent, serious illnesses with elevated mortality, mainly attributable to suicide. Predictors of suicidality include binge/purge symptomatology, impulsivity, and psychiatric comorbidity, as well as personality factors. Recent research has also shown self-image (the Structural Analysis of Social Behavior, SASB, model) to predict manifest suicide attempts in ED, and the study explored suicide risk prediction to increase knowledge of warning signs and intervention targets.

METHOD

Participants were adult ED patients registered in the Stepwise clinical database (N = 1537) with anorexia nervosa (AN), bulimia nervosa (BN), binge-eating disorder (BED), or other specified feeding and eating disorder (OSFED). The SASB self-image questionnaire was used in stepwise regressions to predict 12-month suicidal ideation, both self- and clinician-rated, in models both excluding and including baseline clinical variables.

RESULTS

Validation analyses showed fair correspondence between outcome variables as well as with suicide attempts. Different variables predicted suicidality in different diagnoses, over and above baseline clinical variables in all but one regression model. Low Self-protection was important in AN and BN, high Self-control in AN, and high Letting go of the self in BN. For BED, self-blame explained variance, and in OSFED, lack of self-love.

DISCUSSION

Findings are in line with research showing differential self-image-based prediction of important outcomes in ED, with noteworthy consistencies across diagnoses and suicidality variables. Strengths included the large sample, and limitations pertained to measures, attrition and Type II error risk. Replication is needed, but findings are consistent with some previous work and offers clinical and research implications.

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.

Detecting eating disorder patients in a general practice setting: a systematic review of heterogeneous data on clinical outcomes and care trajectories

PURPOSE

The incidence and prevalence of eating disorders (ED) is low in general practice (GP) settings. Studies in secondary care suggest that the general practitioner has an important role to play in the early detection of patients with EDs. The aim of this study was to describe the effect (clinical outcomes and care trajectory) of screening for EDs among patients in general practice settings.

METHODS

A systematic review was conducted on Medline, PsycINFO, CINAHL, Embase and WOS. The studies included were to have been carried out in a primary care setting, with screening explicitly performed in GP practices and follow-up information.

RESULTS

Ten studies met the inclusion criteria. For all ED patients, there was an increase in the frequency of consultations in GP setting, referrals to psychiatric resources and drug prescriptions such as antidepressants, following screening procedures. Clinical outcomes remained unclear and heterogeneous. One study focused on the course and outcome of ED patients identified by screening in the GP setting and reported recovery for anorexia nervosa (AN) and BN in more than half of the cases, after 4.8 years of mean follow-up. In this study, early age at detection predicted better recovery.

CONCLUSION

Most of the literature on the role of the GP in screening for and managing EDs consists of opinion papers and original studies designed in a secondary care perspective. The impact of systematically screening for EDs in a primary care setting is not clarified and requires further investigation in collaborative cohort studies with a patient-centered approach, and outcomes focused on symptoms.

Mortality in eating disorders - results of a large prospective clinical longitudinal study

OBJECTIVE

To report on long-term mortality in anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), and eating disorder not otherwise specified (ED-NOS), causes of death, and predictors of early death.

METHOD

A large sample of consecutively admitted inpatients (N = 5,839) was followed-up on vital status through the German civil registry office. Of these patients 1,639 were treated for AN, 1,930 for BN, 363 for BED, and 1,907 for ED-NOS. Data from the main inpatient hospital treatment were applied to bivariate and multivariate Cox regression analyses on survival time from onset of eating disorder to death or end of observation. Standardized mortality ratios (SMR) were computed matched for age, gender, and person-years.

RESULTS

SMR were 5.35 for AN, 1.49 for BN, 1.50 for BED, 2.39 for narrowly defined ED-NOS, and 1.70 for widely defined ED-NOS. Patients with AN died earlier than patients with BN, BED, or ED-NOS who did not differ. A diagnosis of AN, chronicity, later age of onset, not living in a relationship, and an irregular type of discharge from index inpatient treatment were major predictors of a shorter time to death. Suicidality was a univariate predictor of a shorter time to death in BN only. AN patients mostly died from natural causes related to their eating disorder.

DISCUSSION

Mortality in AN is excessive and considerably higher than in BN, BED, and ED-NOS.

Does specialization of treatment influence mortality in eating disorders?--A comparison of two retrospective cohorts

Eating disorders (EDs) are psychiatric disorders associated with high morbidity and mortality. It is well established that patients with anorexia nervosa (AN) have an increased risk of premature death, whereas mortality data are lacking for the other EDs. This study aimed to establish mortality rates in a sample of ED patients (n=998) with a mean follow-up of 12 years. This was compared to previous data from the same catchment area before a multidisciplinary centre was established. The standardized mortality ratio (SMR) was calculated. To compare the two cohorts, adjusted crude ratios were calculated with the confounding variables: body mass index (BMI), age at referral and diagnosis. In the latest cohort the SMR for AN was 2.89 vs 11.16 in the time before our specialization. SMR for bulimia nervosa (BN) and for eating disorder not otherwise specified (EDNOS) in the latest cohort were 2.37 and 1.14 respectively. When comparing two retrospective cohorts it is not possible to draw a definite conclusion, however the present study supports that integrating a somatic unit in a multidisciplinary centre may have a favourable influence on mortality in AN.

Risk of suicide among female adolescents with eating disorders: a longitudinal population-based study

PURPOSE

Suicide is a major cause of death among individuals with eating disorders. This study examined risk of suicide among females with eating disorders based on population-based military data.

METHODS

Data on diagnoses of eating disorders from the pre-induction screening for psychopathology and diagnoses assigned during military service were merged with data on later suicide from the nationwide Israeli Death Registry. We identified 1,356 females with eating disorders and compared their risk of suicide to a population-based control group of females without eating disorders over a mean follow-up period of 8.5 ± 5.34 years.

RESULTS

Females with eating disorders had a higher rate of suicide (0.22 %, n = 3) compared to females without eating disorders (0.03 %, n = 166). Having a moderate-severe eating disorder was associated with increased risk of suicide (RR = 12.50, 95 % CI = 3.86-38.09), whereas none of the females diagnosed as having a mild eating disorder died by suicide.

CONCLUSIONS

Females with moderate-severe eating disorders are at risk of suicide and should be monitored for suicidal intent.

Cognition and the risk of eating disorders in Spanish adolescents: the AVENA and AFINOS studies

Eating disorders (ED) can arise from a combination of biological and psychological factors. Some studies suggest that intellectual factors might be important in the development of ED, although the evidence is still scarce. The aim of this study was to examine the association between cognition measurements (cognitive performance and academic achievement) and the risk of developing ED in adolescents considering their weight status. The sample consisted of 3,307 adolescents (1,756 girls), aged 13-18.5 years, who participated in the AVENA (n = 1,430; 783 girls) and AFINOS (n = 1,877; 973 girls) studies. Cognitive performance was measured by the TEA test in the AVENA study, and academic achievement was self-reported in the AFINOS study. ED risk was evaluated in both studies by using the SCOFF questionnaire. Body mass index was calculated to classify adolescents as non-overweight or overweight (including obesity). Overweight adolescents showed a higher risk of developing ED than non-overweight ones in both studies. In the AVENA study, overweight boys with low performance in reasoning ability showed increased risk of ED (p = 0.05). In the AFINOS study, overweight boys with low academic performance in physical education and non-overweight girls with low academic achievement in all the areas analyzed showed higher risk of ED than their peers (all p < 0.05).

CONCLUSION

No association between cognitive performance and ED risk was found in adolescents, while academic achievement was associated with ED risk, especially in non-overweight girls. The non-cognitive traits that accompany academic achievement could influence the likelihood of developing ED in these girls.

Suicide attempts and mortality in eating disorders: a follow-up study of eating disorder patients

OBJECTIVE

The aim of this study is to explore the prevalence of hospital-treated suicide attempts in a large clinical population of eating disorder patients.

METHOD

Follow-up study of adults (N=2462, 95% women, age 18-62 years) admitted to the Eating Disorder Clinic of Helsinki University Central Hospital in the period 1995-2010. For each patient, four controls were selected and matched for age, sex and place of residence. The end point events were modeled using Cox's proportional hazard model, taking matching into account.

RESULTS

We identified 156 patients with eating disorder (6.3%) and 139 controls (1.4%) who had required hospital treatment for attempted suicide. Of them, 66 (42.3%) and 37 (26.6%) had more than one attempt. The rate ratio (RR) for suicide attempt in patients with eating disorder was 4.70 [95% confidence interval (CI) 1.41-15.74]. In anorexia nervosa, RR was 8.01 (95% CI 5.40-11.87), and in bulimia nervosa, it was 5.08 (95% CI 3.46-7.42). In eating disorder patients with a history of suicide attempt, the risk of death from any cause was 12.8%, suicide being the main cause in 45% of the deaths.

CONCLUSION

Suicide attempts and repeated attempts are common among patients with eating disorders. Suicidal ideation should be routinely assessed from patients with eating disorders.

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.

Self-image and suicide in a Swedish national eating disorders clinical register

OBJECTIVE

Using a prospective design, to examine the relation between self-image (assessed using the Structural Analysis of Social Behavior) and suicide attempts/completions in women with anorexia nervosa-restricting type (ANR), anorexia nervosa-binge/purge type (ANBP), bulimia nervosa (BN), binge eating disorder (BED), and eating disorder not otherwise specified (EDNOS); and to assess whether these self-image variables add unique predictive value to suicide when considering other baseline predictors.

METHOD

Women (N=2269) aged 12 to 45 (M=22.1) presenting to specialist eating disorders clinics in Sweden between 2005 and 2009 were identified through the Stepwise Eating Disorders Quality Register. Data on age, body mass index, eating disorder severity (Eating Disorder Examination-Questionnaire scores), psychiatric comorbidity, global assessment of functioning, and self-image were abstracted from Stepwise and included as baseline predictors or covariates. Suicide information (prior attempt and attempt/completion after Stepwise registration) was obtained from the National Patient Register and Cause of Death Register.

RESULTS

Prevalence of detected suicide attempts/completions over the study period was 9.2%. Negative self-image variables were associated with prior suicide attempts in ANR and EDNOS and later suicide attempts/completions in women with BN. In a stepwise Cox proportional hazards model, only low self-affirmation predicted time to suicide attempts/completions in women with BN when accounting for age and prior suicide attempt.

CONCLUSION

Assessing self-image might assist with identifying women with BN at elevated risk for suicide.

Purging disorder: a pathway to death? A review of 11 cases

OBJECTIVE

With data from the Christina-Barz-Study, we report mortality rates and predictors of death in purging disorder (PurD) as well as additional information concerning the fatal cases.

METHOD

The study was conducted with 225 consecutively admitted inpatients during the years 1999-2005. About 9 years later, fatal cases were identified by local registration office records. The standardised mortality ratio (SMR) was calculated through mortality tables of the Federal Office of Statistics, Germany. To identify predictors of death, survival analyses were performed. Spouses, relatives or doctors of the deceased were consulted by interview or questionnaire for further information of pathogenesis and circumstances of death.

RESULTS

Six of the 225 sample individuals could not be located for the follow-up. Eleven of 219 former inpatients had died during the follow-up interval. The crude mortality rate was 5.0%. The SMR was 3.90 [95% confidence interval (2.05; 7.21)]. Age at admission and presence of one or more co-morbid somatic illnesses at admission were factors associated with a shorter time period until death.

DISCUSSION

Our data indicate that there is a higher number of deaths within the study population than expected. Paying particular attention to age and the severity of co-morbid somatic symptoms could improve the outcome of patients with PurD.

The current status of suicide and self-injury in eating disorders: a narrative review

The aim of this paper is to review recent literature on suicide and self-injury in eating disorders (ED) including anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). Among psychiatric diagnoses, EDs are associated with increased mortality rates, even when specialized treatment is available. Of the mortalities that are reported in individuals with EDs, suicide is among the most commonly reported causes of death. Additionally, suicidal and non-suicidal self-injurious behaviors occur frequently in this clinical population. A literature search was undertaken using the databases of Medline/PubMed and PsycInfo to identify papers describing suicidality in individuals with ED diagnoses. The authors identified studies and review articles published between 2005-2013 (inclusive) that describe the relationship between EDs and suicide, and associated behaviors including self-injurious behaviors, or non-suicidal self-injury (NSSI). The initial search resulted in 1095 papers that met the a priori search criteria. After careful review, 66 papers were included. The majority of papers described clinical cohorts that were studied longitudinally. The diagnosis described most frequently in selected studies was AN. There are limited current data about the prevalence of suicide and NSSI among individuals with EDs. Among the published studies that focus specifically on the relationship between EDs and suicidality, most describe AN in more detail than other EDs. Nonetheless, rates of mortality, and specifically rates of suicide, are undeniably high in ED populations, as are the rates of self-harm. Therefore, it is critical for clinicians and caretakers to carefully evaluate these patients for suicide risk and to refer promptly for appropriate treatment.

Mortality in eating disorders: a follow-up study of adult eating disorder patients treated in tertiary care, 1995-2010

Elevated mortality risk in anorexia nervosa has been established, but less is known about the outcomes of bulimia nervosa and binge eating disorder. In this follow-up study we determined mortality in adults (N=2450, 95% women) admitted to the eating disorder clinic of the Helsinki University Central Hospital in the period 1995-2010. Most of the patients (80.7%) were outpatients. For each patient four controls were selected and matched for age, sex and place of residence. The matching was taken into account by modelling end-point events using Cox's proportional hazard model. The hazard ratio (HR) for all-cause mortality was 6.51 (95% CI 3.46-12.26) in broad anorexia nervosa (AN), 2.97 (95% CI 1.90-4.65) in broad bulimia nervosa (BN), and 1.77 (95% CI 0.60-5.27) in binge eating disorder (BED). Mortality risk in broad AN was highest during the first years after admission but declined thereafter, while in broad BN the mortality risk started to rise two years after the first admission. The HR for suicide was elevated both in broad AN (HR 5.07; 95% CI 1.37-18.84) and in broad BN (HR 6.07; 95% CI 2.47-14.89). Results show that eating disorders are associated with increased mortality risk even when specialised treatment is available.

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).