Phenomenologic relationship of eating disorders to major affective disorder

Comparative efficacy and acceptability of selective serotonin reuptake inhibitor antidepressants for binge eating disorder: A network meta-analysis

Background: There are several selective serotonin reuptake inhibitor (SSRI) antidepressants currently used to treat binge eating disorder (BED), but the efficacy and acceptability of these antidepressants are still controversial. Therefore, we designed a network meta-analysis (NMA) to compare the efficacy and acceptability of different SSRI antidepressants for the treatment of BED.

Methods: Four databases including PubMed, Embase, the Cochrane Library, and Web of Science were systematically searched for the eligible randomized controlled trials (RCTs) for the treatment of patients with BED. The analysis was performed with Stata16 software.

Results: 9 RCTs were included in this NMA. The results of the study showed that compared with placebo, sertraline and fluoxetine could significantly reduce the frequency of binge eating. Fluoxetine was shown to be the drug with the greatest reduction in Hamilton Rating Scale for Depression (HAMD) score. Besides, all SSRI antidepressants were ineffective in losing weight. In addition, all the investigated antidepressants were found to be well acceptable in regards to the acceptability reflected by the dropout rate.

Conclusion: As far as both efficacy and acceptability were concerned, fluoxetine might be the best choice.

The Complicated Relationship between Dieting, Dietary Restraint, Caloric Restriction, and Eating Disorders: Is a Shift in Public Health Messaging Warranted?

The origins of theories specifying dietary restraint as a cause of eating disorders can be traced to the 1970s. This paper will present an overview of the origins of dietary restraint theories and a brief historical review of evidence will be summarized. Recent research will be presented, including the results from the CALERIE Phase 1 study, as well as CALERIE Phase 2, which were NIH-sponsored randomized controlled trials. CALERIE 2 provided a test of the effect of two years of caloric restriction (CR) on the development of eating disorder syndromes and symptoms in comparison to a control group that did not alter eating behavior or body weight. The intervention was effective for inducing a chronic (two-year) reduction in total energy expenditure and increased dietary restraint but did not increase symptoms of eating disorders. The results of this recent investigation and other studies have not provided experimental support for conventional dietary restraint theories of eating disorders. These findings are discussed in terms of potential revisions of dietary restraint theory, as well as the implications for a paradigm shift in public health messaging related to dieting.

The Mediating Effect of Negative Appearance Evaluation on the Relationship Between Eating Attitudes and Sociocultural Attitudes Toward Appearance

OBJECTIVE

Body-image disturbance and eating disorders are significant physical and mental health problems in China. Attitudes toward the body are thought to work in conjunction with other established risk factors for dietary pathology, which include body dissatisfaction, dieting, and negative effects. Negative appearance evaluation may be valuable for extending our understanding of measuring factors and potential causal relationships associated with body image and eating problems. Therefore, this study aimed to determine the association between negative appearance evaluation and a combination of eating attitudes and sociocultural attitudes toward appearance and the mediating effect of negative appearance evaluation on the relationship between eating attitudes and sociocultural attitudes toward appearance.

METHODS

We invited 339 Chinese adults to undergo the Eating Attitudes Test (EAT-26), the Fear of Negative Appearance Evaluation Scale (FNAES), and the Sociocultural Attitudes toward Appearance (SATAQ-3) scale, and used AMOS 24.0 for model construction and mediating effects testing.

RESULTS

There was a significant positive correlation between EAT-26 scores and FNAES (p < 0.001) and SATAQ-3 scores (p < 0.001), and all dimensions except internalization general were significantly positively correlated (p < 0.05). There was a significant positive correlation between FNAES and SATAQ-3 scores for all dimensions (p < 0. 01). There was no significant direct effect of eating attitude on sociocultural attitude toward appearance; however, there was a significant mediating effect of fear of negative appearance evaluation.

CONCLUSION

Our results demonstrate that negative appearance evaluation fully mediates the relationship between eating attitudes and sociocultural attitudes toward appearance. An individual's attitude toward eating affects negative body perceptions and thus their perception of their own body shape. Our exploration of the specific effects of eating attitudes on body perception provides a psychological basis for guidance and developing interventions regarding attitudes toward the body.

The Prevalence of Impulse Control Disorders and Behavioral Addictions in Eating Disorders: A Systematic Review and Meta-Analysis

Aim: Individuals with eating disorders (EDs) may present with impulse control disorders (ICDs) and behavioral addictions (BAs), which may result in additional suffering and treatment resistance. However, the prevalence of ICDs and BAs in EDs has not been systematically examined. Therefore, this systematic review and meta-analysis aimed to assess the prevalence of ICDs and BAs in ED samples. Methods: A comprehensive electronic database search of the peer-reviewed literature was conducted in the following online databases: MEDLINE, PsycINFO, Embase, and CINAHL from their inception to May 2021. We restricted review eligibility to research studies reporting prevalence for ICDs or BAs in individuals with diagnosed EDs. The outcome for this review was the prevalence of ICDs or BAs in individuals with EDs. A series of random-effects meta-analyses were performed on eligible studies to estimate the pooled proportions and 95% confidence intervals (CIs). Results: Thirty-five studies met the inclusion criteria, including a total of 9,646 individuals identified as having an ED, 18 of these studies specifically examined ICDs/BAs in AN, BN, and BED. Random-effects pooled estimates demonstrated that the comorbid prevalence of any ICD was 22%. The prevalence of comorbid pathological/compulsive buying was highest (19%), followed by kleptomania (18%), pathological internet use (12%), intermittent explosive disorder (4%), trichotillomania (3%), and gambling disorder (2%). In addition, the prevalence of stealing/shoplifting behaviors was 30% in those with EDs. Conclusion: This is the first meta-analysis on the comorbid prevalence of EDs and ICDs/BAs. We found a moderate prevalence for these comorbid conditions, with approximately one out of five individuals with an ED also displaying a comorbid ICD/BA. Although causal inferences cannot be drawn, the numbers strongly suggest that clinical screening/monitoring of ICDs/BAs should be part of the clinical routine in cohorts with EDs. ED settings need either the capacity to manage these disorders or adequate access to relevant services. Further investigations are needed to reveal common underlying pathomechanisms. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier: CRD42020202044.

Bulimia and major affective disorder: experience with 105 patients

Several lines of evidence suggest that bulimia - the syndrome of compulsive binge-eating - may be related to major affective disorder. First, high rates of major affective disorder have been found both among bulimic patients and their relatives. Second, neuroendocrine abnormalities, similar to those found in major affective disorder, have been reported in bulimia. Finally, several antidepressant medications have been shown to be effective in the treatment of bulimia.

To investigate further the relationship between bulimia and major affective disorder, we evaluated 105 consecutive patients (101 women, 4 men), meeting DSM III criteria for bulimia, referred to our center, for the following: (1) rates of current or past major affective disorder and other psychiatric disorders, by DSM III criteria, using the NIMH Diagnostic Interview Schedule (n = 105); (2) family history of psychiatric disorders among first-degree relatives, by DSM III criteria (n = 101); (3) response to the 1 mg oral overnight dexamethasone suppression test (DST) with postdexamethasone plasma cortisol level measured at 16 00 h (n = 43); and (4) response to open trials of antidepressant medications, front several different classes - particularly tricyclic antidepressants, monoamine oxidase (MAO) inhibitors, and trazodone (n = 50).

The results of these studies were as follows: (1) the bulimic patients displayed a 77% lifetime prevalence rate of major affective disorder by DSM III criteria; (2) the morbid risk for major affective disorder among the firstdegree relatives of the bulimic probands was 0.29, similar to the 0.19 morbid risk found among the first-degree relatives of 40 probands with bipolar disorder, but significantly higher than the 0.03 morbid risk found among the first-degree relatives of 46 schizophrenic probands (P<0.001); (3) the bulimic patients showed a 40% rate of nonsuppression to the DST (16 00 h postdexamethasone plasma cortisol Level≥5.0 mcg/dl), significantly higher than the 9% rate of nonsuppression found among 22 normal control subjects (P<0.02); and (4) after one or more trials of antidepressant medications, 38% of the bulimic patients achieved a remission of symptoms (cessation of bingeeating episodes), 34% achieved a marked response (75-99% reduction in the frequency of binge-eating episodes), 16% achieved a moderate response (50-74% reduction in the frequency of binge-eating episodes), and 12% had no response (less than a 50% reduction in the frequency of binge-eating episodes).

Thus, on each of the four indices evaluated, patients with bulimia were similar to patients with major affective disorder, but were distinguishable from patients with other psychiatric disorders and from normal Controls. These results are consistent with the hypothesis that bulimia may be closely related to major affective disorder.

Psychiatric comorbidity of bulimia nervosa inpatients: relationship to clinical variables and treatment outcome

Experimental evidence suggesting that psychiatric comorbidity has important clinical and prognostic implications in bulimia nervosa has mostly been based on outpatient studies investigating a selection of co-existing psychopathological features with rather unstructured and not standardized diagnostic instruments. Using structured instruments (SCID-P, MDCL) for the diagnoses of DSM III-R axis I disorders and clinical interviews for the diagnosis of DSM III-R axis II disorders in 24 hospitalized bulimics, the present study demonstrated that more than half of the patients had two or three axis I disorders in addition to bulimia nervosa and almost half of the patients met criteria of at least one personality disorder. Subgroups of patients classified according to the type of psychiatric comorbidity did not differ significantly with respect to clinical features; regarding measures of hospital behavior therapy outcome. However, the findings provided evidence for a negative impact of anxiety disorder in addition to bulimia nervosa on the improvement of bulimic behavior and possibly also on self-rated depression.

Kleptomania: characteristics of 12 cases

A review of the literature showed that there is no good systematic study of a series of rigorously diagnosed “kleptomaniac” persons, other than those referred by the courts for expert opinions. This applies in particular to German-speaking and other European countries. We therefore report here on the phenomenology, demographics, psychopathology, family histories, treatment histories, behaviour therapy oriented analyses, and treatment results of 12 individuals meeting Diagnostic and Statistical Manual (DSM)-III-R criteria for kleptomania. All patients described an uncontrollable impulse to steal and a reduction in anxiety or tension during or after the act. All had at least one further psychiatric diagnosis. Although the kleptomaniac symptomatology did not seem to be part of these other disorders, the extent of stealing corresponded (positively or negatively) to other psychiatric symptoms such as depressive feelings, excessive urges to eat or migraine attacks. Microanalysis of the act of theft, as well as the preceding and following events (explored by applying behaviour therapy oriented analysis) showed intraindividually consistent, but inter-individually differing triggering factors. There was no evidence of correlation with obsessive-compulsive disorders, but some indications that kleptomania may be associated with affective disorders in terms of an “affective spectrum disorder”. According to a broader definition of “multi-impulsive-disorder” (analogous to Lacey and Evans or Fichter et al), one third of the patients might be diagnosed as “bi-impulsive disorder”. Eight of the 12 patients could be investigated at a mean follow-up time of 2 years after discharge showing favourable results. In conclusion, kleptomaniac behaviour seems to be multiconditionally caused and sustained.

Gender Differences and Comorbidities in U.S. Adults with Bipolar Disorder

Background: Past studies have evaluated the association of various comorbidities with bipolar disorder. This study analyzes differences in the prevalence and association of medical and psychiatric comorbidities in bipolar patients by gender. Methods: A retrospective analysis was conducted using the Nationwide Inpatient Sample (2010–2014). Using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes, we narrowed the study population to comprise those with a primary diagnosis of bipolar disorder and then obtained information about comorbidities. The differences in comorbidities by gender were quantified using chi-square tests and the logistic regression model (odds ratio (OR)). Results: Hypertension (20.5%), asthma (12.5%) and hypothyroidism (8.1%) were the top medical comorbidities found in bipolar patients. Migraine and hypothyroidism were seen three times higher in females (OR = 3.074 and OR = 3.001; respectively). Females with bipolar disorder had higher odds of comorbid inflammatory disorders like asthma (OR = 1.755), Crohn’s disease (OR = 1.197) and multiple sclerosis (OR = 2.440) compared to males. Females had a two-fold higher likelihood of comorbid post-traumatic stress disorder (PTSD) (OR = 2.253) followed by personality disorders (OR = 1.692) and anxiety disorders (OR = 1.663) compared to males. Conclusion: Women with bipolar disorder have a much higher medical comorbidity burden than men and may highly benefit from an integrated team of physicians to manage their condition and improve their health-related quality of life.

[Depressive symptoms during anorexia nervosa: State of the art and consequences for an appropriate use of antidepressants]

OBJECTIVE

Depressive comorbidity is often associated with anorexia nervosa (AN), and antidepressant medication is widely used although it does not rely on any convincing data in the scientific literature. Our objectives were: to summarize the epidemiological, physiological, psychopathological literature about the relation between AN and manifestations of depression, and to focus on the clinical trial data assessing the use of antidepressant medication in AN in order to clarify the strategy for the use of antidepressant in AN during adolescence.

METHOD

A manual computerised search (Medline) was performed for relevant published studies assessing the association between depressive signs or Major Depressive Disorder (MDD) and AN. Another manual computerised search (Medline) listed clinical trials assessing antidepressant in AN.

RESULTS

On the one hand, depressive symptoms are common during the course of AN and could have different meaning. Indeed, firstly, we can distinguish symptoms that are inherent to AN and which can be mistaken for depressive signs (for instance: low self-esteem, reduced social contacts). Secondly, long-term undernourishment can be held responsible for numerous psychological distortions, including anxiety and depression symptoms such as insomnia, impaired concentration, or social isolation. Thirdly, the natural course of AN can also lead to "depressive moments", in particular when switching to a "purging type" AN, or when recovery mobilizes control and narcissistic issues. On the other hand, MDD is also highly prevalent among AN patients and is a negative prognosis factor. Thus, it is complex to differentiate MDD from isolated depressive symptoms that could be inherent of the AN symptomatology which raises the question of the role of antidepressant medication in treatment of depression in AN. No significant benefit of antidepressant medication in AN has been shown in clinical trials, and according to international guidelines it should be prescribed only as a second-line treatment, after appropriate refeeding, and in case of an authentic depressive disorder. Those data appear to be in contradiction with the frequent use of those drugs in clinical practice.

DISCUSSION

Nevertheless, clinical trials assessing antidepressant treatment in AN suffer from methodological weakness concerning the size of the sample, the choice of the population or the evaluation criterion. This lack of proof must raise our vigilance concerning antidepressant medication in AN but should not categorically prevent the clinician from using it when necessary. We do believe that there are some indications for prescribing antidepressant in patients with AN. The clinical challenge lies in the differentiation of the depressive symptoms that are transitory and likely to improve without medication from those that signal the presence of an MDD. Three criterion could be indicative of MDD: familial history of mood disorder, as it is a major risk factor for MDD among relatives; the chronology of appearance of both disorders, when MDD pre-exists AN; a few specific symptoms cannot be attributed to undernourishment or reactive depressive signs, such as morning insomnia, daily variation of depressive symptoms, suicidal attempts or ideation and guilt ideation. Thus, in integrating the data from the literature review, we propose a pragmatic therapeutic strategy for the use of an antidepressant in AN during adolescence that lies in 3 main categories for depressive manifestations in AN: therapeutic emergencies: when an obvious and severe MDD is comorbid to AN, immediate antidepressant would be required; isolated and non-specific depressive sign: no medication would be relevant as they are supposed to improve with refeeding and psychotherapeutic support; intermediary patterns which is probably the most frequent situation. In the last case, it would be relevant to abstain from prescribing medication in first line, but an antidepressant medication should be quickly considered in the presence of one (or several) criterion listed above and its persistence despite refeeding. The general medical state of this fragile population of patients should be evaluated (standard blood test, ECG) before and during treatment.

Mood disorders in eating disorder patients: Prevalence and chronology of ONSET

OBJECTIVES

In a clinical population, we estimated the frequency of mood disorders among 271 patients suffering from Anorexia Nervosa (AN) and Bulimia Nervosa (BN) in comparison to a control group matched for age and gender.

METHOD

The frequency of mood disorders was measured using the Mini International Neuropsychiatric Interview (MINI), DSM-IV version.

RESULTS

Mood disorders were more frequent among eating disorder (ED) patients than among controls, with a global prevalence of the order of 80% for each ED group. The majority of the mood disorders comorbid with ED were depressive disorders (MDD and dysthymia). The relative chronology of onset of these disorders was equivocal, because mood disorders in some cases preceded and in others followed the onset of the eating disorders.

LIMITATIONS

Our sample was characterized by patients with severe ED and high comorbidities, and thus do not represent the entire population of AN or BN. This also may have resulted in an overestimation of prevalence.

CONCLUSION

Mood disorders appear significantly more frequently in patients seeking care for ED than in controls. These results have implications for the assessment and treatment of ED patients, and for the aetio-pathogenesis of these disorders.

Comparative Prevalence of Eating Disorders in Obsessive-Compulsive Disorder and Other Anxiety Disorders

Objective. The purpose of this study was to compare the prevalence of comorbid eating disorders in Obsessive-Compulsive Disorder (OCD) and other common anxiety disorders. Method. 179 patients from the same geographical area with a diagnosis of OCD or an anxiety disorder were divided into two groups based on their primary diagnosis. The prevalence of a comorbid eating disorder was calculated in both groups. Results. There was no statistically significant difference in the prevalence of comorbid eating disorders between the OCD and other anxiety disorders group. Conclusions. These results suggest that the prevalence of comorbid eating disorders does not differ in anxiety disorders when compared with OCD. However, in both groups, it remains statistically higher than that of the general population.

Automatic identification of Web-based risk markers for health events

BACKGROUND

The escalating cost of global health care is driving the development of new technologies to identify early indicators of an individual's risk of disease. Traditionally, epidemiologists have identified such risk factors using medical databases and lengthy clinical studies but these are often limited in size and cost and can fail to take full account of diseases where there are social stigmas or to identify transient acute risk factors.

OBJECTIVE

Here we report that Web search engine queries coupled with information on Wikipedia access patterns can be used to infer health events associated with an individual user and automatically generate Web-based risk markers for some of the common medical conditions worldwide, from cardiovascular disease to sexually transmitted infections and mental health conditions, as well as pregnancy.

METHODS

Using anonymized datasets, we present methods to first distinguish individuals likely to have experienced specific health events, and classify them into distinct categories. We then use the self-controlled case series method to find the incidence of health events in risk periods directly following a user's search for a query category, and compare to the incidence during other periods for the same individuals.

RESULTS

Searches for pet stores were risk markers for allergy. We also identified some possible new risk markers; for example: searching for fast food and theme restaurants was associated with a transient increase in risk of myocardial infarction, suggesting this exposure goes beyond a long-term risk factor but may also act as an acute trigger of myocardial infarction. Dating and adult content websites were risk markers for sexually transmitted infections, such as human immunodeficiency virus (HIV).

CONCLUSIONS

Web-based methods provide a powerful, low-cost approach to automatically identify risk factors, and support more timely and personalized public health efforts to bring human and economic benefits.

Anorexia and Depression: Depressive Comorbidity in Anorexic Adolescents

Frequently, depression is a concomitant pathology in anorexia nervosa. To verify this, we carried out a comparative case/control study with 50 anorexic patients, restricting-type (ANP), 50 depressed patients (DP) and 50 non-patients (NP), aged between 13 and 16. We used the Rorschach Test and the Minnesota Multiphasic Personality Inventory (MMPI) and compared the results to parent's observations collected from the Achenbach Child Behavior Checklist (CBCL). Results showed two clearly different groups among participants: ANP with depression (36%) and ANP without depression (64%). This seems to indicate that depression is not a core element in anorexic disorders. However, we also observed a significant increase in the MMPI scale 2, which was probably related to starvation and weight loss. We confirmed the absence of general anxiety in the ANP group and obtained differences between depressive symptoms and those derived from coping deficit disorders. The discussion emphasizes the importance of using several tests to reduce bias in results and conclusions.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

DISCUSSION

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

Delineation of differential temporal relations between specific eating and anxiety disorders

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

Associations between the serotonin-1A receptor C(-1019)G polymorphism and disordered eating symptoms in female adolescents

The purpose of this study was to examine the relationship between the C(-1019)G polymorphism of the serotonin-1A receptor gene and eating behavior in female adolescents. A total of 204 post-menarche, adolescent women, aged 16-17 years, were recruited from two neighboring high schools in Seoul. Polymerase chain reaction (PCR) was used to isolate and examine the C(-1019)G polymorphism in the serotonin-1A receptor genes (rs6295) of all participants. The Bulimia Investigatory Test, Edinburgh (BITE) and the Eating Attitude Test-26 (EAT-26) were administered to all participants. The total score of the EAT-26 differed significantly among the three genotype groups [CC, CG, GG (F = 4.844, p = 0.009)]. Both the EAT-26 (F = 9.69, p = 0.002) and the BITE (F = 5.22, p = 0.023) scores were higher in the participants who were G allele carriers than in the non-carrier group. The dieting subscale of the EAT-26 was higher among the G allele carriers (F = 12.941, p < 0.001), and these results were maintained even after adjusting for depression and anxiety. These findings suggest that the C(-1019)G polymorphism in the 5-HT1A receptor gene is associated with disordered eating symptoms in Korean female adolescents.

Patterns of maternal feeding and child eating associated with eating disorders in the Norwegian Mother and Child Cohort Study (MoBa)

The impact of eating disorders on maternal feeding practices and children's eating behaviors is not well understood. In the prospective Norwegian Mother and Child Cohort Study (MoBa), we compared self-reported feeding behavior in mothers with anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), and no eating disorders (No ED) as well as child eating behaviors and psychological symptoms. The sample comprised 13,006 women and their children from a prospective population-based study of 100,000 births throughout Norway. Eating disorder status was measured 6 months prior to pregnancy and during pregnancy. Maternal feeding, child eating, and psychological variables were reported by mothers when their child was 36 months old. Mothers with BN and BED were more likely to report restrictive feeding styles and child eating problems than mothers without eating disorders. Regarding the pressure to eat feeding style, no significant differences emerged across groups. Differences in self-reported feeding styles and children's eating behavior exist between mothers with and without eating disorders. Longitudinal follow-up will assist in determining the implications of feeding style on later growth trajectories and development.

Anxiety, Alexithymia, and Depression as Mediators of the Association between Childhood Abuse and Eating Disordered Behavior in African American and European American Women

This study evaluated structural equation models of the associations among family functioning, childhood abuse, depression, anxiety, alexithymia, and eating disorder symptomatology in a sample of 412 European American and 192 African American female undergraduates. Additionally, the specific roles of anxiety, depression, and alexithymia as mediators were assessed. Each of these variables was a significant mediator of the association between childhood abuse and disordered eating. Finally, a test of invariance between the African American and European American subsamples was significant, highlighting the need for additional cross-cultural eating disorder research.

Interactions between eating disorders and drug abuse

To examine the relationship between drug abuse and eating disorders in a longitudinal sample. In a prospective study, women diagnosed with either DSM-IV anorexia nervosa (n = 136) or bulimia nervosa (n = 110) were interviewed and assessed for research diagnostic criteria drug use disorder (DUD) every 6-12 months over 8.6 years. Contrary to expectation, DUD did not influence recovery from either eating disorder. Multivariate analyses indicated that alcohol use and suicide attempts over the course of the study, as well as hospitalization for an affective disorder before the study, predicted DUD in anorexia nervosa. For bulimia nervosa, multivariate predictors included the severity of alcohol use and the severity of bulimic symptoms over the course of the study, and a hospitalization before study entry for a nonaffective disorder. Drug abuse in women with eating disorders is an area of clinical concern and should be monitored routinely.

Gender-related differences in individuals seeking treatment for kleptomania

OBJECTIVE

Understanding variations in disease presentation in men and women is clinically important as differences may reflect biological and sociocultural factors and have implications for prevention and treatment strategies. Few empirical investigations have been performed in kleptomania, particularly with respect to gender-related influences.

METHODS

From 2001--2007, 95 adult subjects (n=27 [28.4%] males) with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-defined kleptomania were assessed on sociodemographics and clinical characteristics, including symptom severity, comorbidity, and functional impairment, to identify gender-related differences.

RESULTS

Men and women showed substantial symptom severity and functional impairment. Compared with affected men, women with kleptomania were more likely to be married (47.1% vs 25.9%; P=.039), have a later age at shoplifting onset (20.9 vs 14 years of age; P=.001), steal household items (P<.001), hoard stolen items (P=.020), and have an eating disorder (P=.017) and less likely to steal electronic goods (P<.001) and have another impulse-control disorder (P=.018).

CONCLUSION

Kleptomania is similarly associated with significant impairment in women and men. Gender-related differences in clinical features and co-occurring disorders suggest that prevention and treatment strategies incorporate gender considerations.

The combined presence of obsessive compulsive behaviors in males and females with eating disorders account for longer lengths of stay and more severe eating disorder symptoms

The goal of this study was to analyze the impact of obsessive compulsive behaviors (OCB) in eating disorder males and females admitted for residential treatment in terms of length of stay and severity of symptoms. Patients (N=384) were separated into four groups based on gender and the score obtained for the Maudsley Obsessive-Compulsive Inventory at admission. The instrument used to assess severity of eating disorder symptoms was the Eating Disorder Inventory (EDI-2) at admission and discharge. The results showed that the presence of comorbid OCB in eating disordered males and females account for longer length of stay (LOS) and an increased severity of eating disorder symptoms. Clinically, these findings point to the need for development of more targeted residential programs that are equipped for and adept at treating the comorbid eating disorder/OCB patient population.

Neurobiology of addiction. An integrative review

Evidence that psychoactive substance use disorders, bulimia nervosa, pathological gambling, and sexual addiction share an underlying biopsychological process is summarized. Definitions are offered for addiction and addictive process, the latter being the proposed designation for the underlying biopsychological process that addictive disorders are hypothesized to share. The addictive process is introduced as an interaction of impairments in three functional systems: motivation-reward, affect regulation, and behavioral inhibition. An integrative review of the literature that addresses the neurobiology of addiction is then presented, organized according to the three functional systems that constitute the addictive process. The review is directed toward identifying candidate neurochemical substrates for the impairments in motivation-reward, affect regulation, and behavioral inhibition that could contribute to an addictive process.

Comorbidity studies of eating disorders and mood disorders. Critical review of the literature

OBJECTIVE

We conducted a critical literature review of studies assessing the prevalence of mood disorders (MD) in subjects with eating disorders (ED; anorexia nervosa and bulimia nervosa). In the first part of this article, we discuss methodological issues relevant to comorbidity studies between ED and MD. In the second part, we summarize the findings of these studies in light of the methodological considerations raised.

METHOD

A manual computerised search (Medline) was performed for all published studies on comorbidity between ED and MD. In order to have sufficiently homogeneous diagnostic criteria for both categories of disorders, this search was limited to articles published between 1985 and 2006.

RESULTS

Too few studies include control groups, few studies compared diagnostic subgroups of ED subjects, and results are scarce or conflicting.

DISCUSSION

The results are discussed in the light of the methodological problems observed. The implications when reviewing the results of published studies and planning future research are set out.

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

OBJECTIVE

To critically review the literature examining the co-morbidity between eating disorders and anxiety disorders.

METHOD

A review of the literature on the co-morbidity between anorexia nervosa, bulimia nervosa and eating disorders not otherwise specified and the anxiety disorders of OCD, PTSD, social anxiety, GAD, panic and agoraphobia.

RESULTS

Of the empirical studies undertaken, it is clear that anxiety disorders are significantly more frequent in subjects with eating disorders than the general community. Researchers have shown that often anxiety disorders pre-date eating disorders, leading to a suggestion that early onset anxiety may predispose individuals to developing an eating disorder. To date however, the research presents strikingly inconsistent findings, thus complicating our understanding of eating disorder and anxiety co-morbidity. Furthermore, despite indications that eating disorder prevalence amongst individuals presenting for anxiety treatment may be high, there is a distinct lack of research in this area.

DISCUSSION

This review critically examines the available research to date on the co-morbidity of eating disorders and anxiety disorders. Some of the methodological limitations of previous research are presented, in order to highlight the issues which warrant further scientific investigation in this area.

Food intake and mood in anorexia nervosa and bulimia

It is clear that patients with anorexia nervosa and bulimia have disturbances of mood, and it is likely that the mood disturbances bear an important relationship to the disturbances of eating behavior. We have as many questions, however, about the relationship between mood and eating behavior in these syndromes as we have answers. Although patients with anorexia nervosa and bulimia are frequently depressed, they fail to exhibit many of the biological characteristics of typical depressive illness, suggesting that these eating disorders are probably not simply variants of depression. Patients with bulimia appear to binge in response to dysphoric emotional states and to derive some transient relief from their bingeing. But it is unclear what facet or facets of the binge produce the alteration in emotional state, and thereby may serve to reinforce the behavior. A more detailed examination of this issue may significantly advance our understanding of the relationship between mood and food in eating disorders.

Comorbidity of eating disorders with bipolar disorder and treatment implications

OBJECTIVES

To review the scientific evidence examining the comorbidity among eating disorders and bipolar disorder (BD).

METHODS

We reviewed all published English-language studies addressing the comorbidity of anorexia nervosa, bulimia, bulimia nervosa, and binge eating disorder in patients with BD and studies of comorbidity of BD in patients with eating disorders. In addition, we discuss the pharmacologic treatment implications from reviewed studies of agents used in BD and eating disorders.

RESULTS

Community and clinical population studies of the lifetime prevalence rates of eating disorders in patients with BD, and of BD in patients with eating disorders, particularly when subthreshold and spectrum manifestations of these disorders are included, indicate high rates of comorbidity among these illnesses.

CONCLUSIONS

Pharmacologic treatment approaches to patients with BD and a co-occurring eating disorder require examination of the possible adverse effects of the treatment of each syndrome on the other and attempts to manage both syndromes with agents that might be beneficial to both.

[Comorbidity between eating disorders and mood disorders: review]

OBJECTIVE

Comorbidity between eating disorders (ED) and mood disorders is a major issue when evaluating and treating patients with anorexia nervosa (AN) or bulimia nervosa (BN). In the literature, estimated comorbidity rates of mood disorders in subjects with ED differ widely across studies. Obviously, it is difficult to compare results from various sources because of differences in methods of assessment of depressive symptoms and in diagnostic criteria for both ED and mood disorders. Furthermore, few studies have included control groups, and, since mood disorders are among the most frequent psychiatric disorders in women--with an average estimated lifetime prevalence of 23.9 % (Kessleret al., 1994)--, it is not clear, yet, whether mood disorders are more common among women with an ED (AN or BN) than among women from the community. The only review articles we found on the relationships between ED and mood disorders survey different types of arguments in favour of a link between both categories of disorders, including symptoms, personal and family comorbidity, overlap in biological findings, and treatment results, but do not review in detail available comorbidity data. The aim of this paper is to conduct a critical literature review on studies assessing the prevalence of mood disorders in subjects with an ED (AN or BN). In the first part, we will discuss methodological issues relevant to comorbidity studies between ED and mood disorders, and select the most reliable studies. In the second part, taking into account these methodological considerations raised, we summarize the findings of these studies.

METHOD

We performed a manual and computerized search (Medline) for all published studies on comorbidity between ED and AD, limiting our search to the 1985-2002 period, in order to get sufficiently homogeneous diagnostic criteria for both categories of disorders.

RESULTS

Too few studies include control groups and few studies have compared diagnostic subgroups of ED subjects, with scarce or conflicting results.

DISCUSSION

We reviewed numerous studies here and conclude simply that there are many arguments in favor of elevated rates of MD in ED subjects, but there is no convincing evidence yet. Many questions are left unanswered or have conflicting responses. Our review highlights the need for further studies, which should address several requisites: comorbidity studies should be designed with this as a specific goal, rather than as a secondary aim within other types of studies (such as treatment studies, follow-up studies, etc.). Kendler et al. (1991) state that individuals with two disorders are more likely to present for treatment than individuals with one, therefore, comorbidity rates (which are not in agreement with a special etiologic relationship between BN and depression) may be exaggerated in clinical population results. New studies should include control subjects, matched (at least) for sex and age with ED subjects. Studies should evaluate prevalence of all types of MD in order to yield comparable estimates of MD in general. Comorbidity studies should be conducted on both current and recovered patients, compared to subjects from the community. It is still necessary to demonstrate specificity of findings, i.e. that early onset MD are of specific etiological importance to ED and do not simply increase the risk of later psychopathology in general. Studies should be conducted on larger samples, and all diagnostic subgroups should be considered (restrictive and bulimic anorexics, bulimics with and without history of AN, with or without purging). Multivariate comparisons should be performed, taking into account subject age, sex (if men are included), in- and outpatient status, course of illness, and other possibly relevant variables. Thus, more reliable estimates of the frequency of MD in subjects with ED could provide us with valuable etiologic, therapeutic and prognostic information.

Associations among postpartum depression, eating disorders, and perfectionism in a population-based sample of adult women

OBJECTIVE

The current study investigated associations among eating disorders, depressive symptoms during pregnancy and postpartum, and perfectionism in a population-based sample of women.

METHOD

Females who reported > or = 1 pregnancy (N = 1,119) completed questionnaires assessing perfectionism, eating disorder symptomatology, and depression during pregnancy and postpartum. Information regarding participants' history of major depressive disorder (MDD) was also available from structured psychiatric interviews completed during a previous wave of data collection.

RESULTS

Depressive symptoms during pregnancy and postpartum were high among women with a history of eating disorders. Both binge eating disorder (BED) and bulimia nervosa (BN) were positively associated with symptoms of postpartum depression (PPD), even when lifetime MDD was controlled. However, logistic regression indicated that women with a history of BN and BED are at particular risk of developing PPD symptomatology. Linear regression analyses conducted with the subset of the sample who endorsed a PPD screening item suggested that the severity of PPD symptomatology may be attributable to Concern Over Mistakes, a specific aspect of perfectionism.

CONCLUSION

These results highlight the importance of assessing specific features of perfectionism. In addition, they suggest that women with BN, BED, or high Concern over Mistakes may be at particular risk of developing PPD symptoms, and could benefit from prenatal screening.

Hippocampal volume and cognitive function in anorexia nervosa

We hypothesised that hippocampal volume would be reduced in underweight anorexia nervosa (AN) and associated with impaired hippocampus-dependent cognitive function. Hippocampal and whole brain volumes were measured in 16 women with AN and 16 matched healthy women using magnetic resonance imaging (MRI) and a manual tracing method. Participants also completed the Doors and People Test of hippocampus-dependent memory and an IQ test. After adjustment for total cerebral volume, there was significant bilateral reduction in hippocampal volume in the AN group (8.2% right; 7.5% left). There was no evidence of impaired hippocampus-dependent cognitive function and no evidence of a relationship between hippocampal volume and clinical features of AN. The reduced hippocampal volume in anorexia nervosa is not associated with changes in cognitive function. To understand the cause and consequence of hippocampal size and function, it will be important to integrate endocrine, neuropsychological and neuroimaging studies.

Presence of muscle dysmorphia symptomology among male weightlifters

Limited research exists on muscle dysmorphia (MD) in men and in nonclinical populations. The current study evaluated types of body image disturbance among 237 male weightlifters. Latent class analysis of 8 measures of body image disturbance revealed 5 independent types of respondents: Dysmorphic, Muscle Concerned, Fat Concerned, Normal Behavioral, and Normal. One-way analysis of variance of independent measures of body image disturbance and associated psychopathology confirmed significant differences between groups. The Dysmorphic group reported a pattern of body image disturbance consistent with MD by displaying a high overall level of body image disturbance, symptoms of associated psychopathology, steroid use, and appearance-controlling behavior. Findings generally supported classifying MD as a subtype of body dysmorphic disorder and an obsessive-compulsive spectrum disorder. Implications for studying body image disturbance in male weightlifters, and further evaluation of the MD diagnostic criteria are discussed.

Aggressiveness, anger and eating disorders: a review

Anger and aggressive behaviours, especially those self-directed, are frequent in subjects suffering from anorexia nervosa and bulimia nervosa. They increase the complexity of the clinical features, change the prognosis and cause a more difficult management of these disorders. In order to elucidate the complex relationships between eating disorders, anger and aggressiveness, the history of traumatic experiences, the prevalence of dissociative, obsessive, impulsive and compulsive symptoms, as well as the role of severe personality disorders in subjects suffering from anorexia nervosa, bulimia nervosa and self-injurious behaviours are considered. In the final section of this paper, a model exploring such a relationship in the light of the undefined sense of self is described.

The developmental association between eating disorders symptoms and symptoms of depression and anxiety in juvenile twin girls

OBJECTIVE

We investigated the role of genetic and environmental factors in the developmental association among symptoms of eating disorders, depression, and anxiety syndromes in 8-13-year-old and 14-17-year-old twin girls.

METHODS

Multivariate genetic models were fitted to child-reported longitudinal symptom data gathered from clinical interview on 408 MZ and 198 DZ female twin pairs from the Virginia Twin Study of Adolescent Behavioural Development (VTSABD).

RESULTS

Model-fitting revealed distinct etiological patterns underlying the association among symptoms of eating disorders, depression, overanxious disorder (OAD), and separation anxiety disorder (SAD) during the course of development: 1) a common genetic factor influencing liability to all symptoms - of early and later OAD, depression, SAD, and eating symptoms; 2) a distinct genetic factor specifically indexing liability to early eating disorders symptoms; 3) a shared environmental factor specifically influencing early depression and early eating disorders symptoms; and 4) a common environmental factor affecting liability to symptoms of later eating disorders and both early and later separation anxiety.

CONCLUSIONS

These results suggest a pervasive genetic effect that influences liability to symptoms of over-anxiety, separation anxiety, depression, and eating disorder throughout development, a shared environmental influence on later adolescent eating problems and persistent separation anxiety, genetic influences specific to early eating disorders symptoms, and a shared environmental factor influencing symptoms of early eating and depression.

Pilot treatment program for shoplifting in eating disorders

OBJECTIVE

There are no established treatment programs for shoplifting in eating disorder patients. Our objective was to observe the effect of an established behavioural treatment program in a series of eating disorder patients.

METHODS

Patients with eating disorders who shoplift voluntarily took part in an 8-week behavioral treatment program at the Elizabeth Fry Society of Greater Vancouver, British Columbia. They completed assessments at the first session, last session, and at 1 and 6 months post intervention.

RESULTS

Six patients enrolled in the study and three patients completed the treatment program. Only one patient reported a decrease in shoplifting frequency. All subjects reported an increase in self-esteem and ability to control shoplifting impulses.

DISCUSSION

Our findings suggest that behavioral therapy may be effective in treating shoplifting in eating disorders, but that longer sessions and follow-up may be necessary to show benefit. A randomized control trial with longer-term follow-up is needed to determine whether there is a benefit.

Comorbidity of bipolar and eating disorders: distinct or related disorders with shared dysregulations?

BACKGROUND

The co-occurrence of bipolar and eating disorders, though of major clinical and public health importance, remains relatively unexamined.

METHODS

In reviewing the literature on this comorbidity, we compared bulimia, anorexia nervosa, bulimia nervosa, binge eating disorders and bipolar disorders on phenomenology, course, family history, biology, and treatment response.

RESULTS

Epidemiological studies show an association between subthreshold bipolar disorder and eating disorders in adolescents, and between hypomania and eating disorders, especially binge eating behavior, in adults. Of the clinical studies, most show that patients with bipolar disorder have elevated rates of eating disorders, and vice versa. Finally, the phenomenology, course, comorbidity, family history, and pharmacologic treatment response of these disorders show considerable overlap on all of these parameters. In particular, on phenomenologic grounds--eating dysregulation, mood dysregulation, impulsivity and compulsivity, craving for activity and/or exercise--we find many parallels between bipolar and eating disorders. Overall, the similarities between these disorders were more apparent when examined in their spectrum rather than full-blown expressions.

LIMITATIONS

Despite an extensive literature on each of these disorders, studies examining their overlap across all these parameters are relatively sparse and insufficiently systematic.

CONCLUSIONS

Nonetheless, the reviewed literature leaves little doubt that bipolar and eating disorders--particularly bulimia nervosa and bipolar II disorder--are related. Although several antidepressants and mood stabilizers have shown promise for eating disorders, their clinical use when these disorders co-exist with bipolarity is still very much of an art. We trust that this review will stimulate more rigorous research in their shared putative underlying psychobiologic mechanisms which, in turn, could lead to more rational targeted treatments.

Psychoactive substance consumption in eating disorders

Research investigating the comorbidity between eating disorders and substance-use disorders have reported positive but contrasting results. The aim of this study was to further explore this association by studying patterns of consumption of the entire range of psychoactive substances (alcohol, specific drugs, prescribed psychotropics) in a large sample (N=271) of eating-disorder DSM-IV subtypes. Results show that subjects suffering from anorexia of the restrictive type show significantly less drug-consumption behaviors and alcohol abuse and/or dependence disorders than purging anorexic and bulimic subjects. No difference was found in the total consumption of psychotropics among the four groups of eating disorders. However, more than half of eating-disorder subjects are regular consumers of psychotropics. Among these regular consumers, bulimics self-prescribe and increase their doses of psychotropics significantly more than anorexics. Features of impulsivity that are associated with purging and bulimic behaviors could play a specific role in these patterns of comorbidity and account for such differences.

Role of fluoxetine in anorexia nervosa

OBJECTIVE

To evaluate the efficacy of fluoxetine in the treatment of anorexia nervosa.

DATA SOURCES

Literature obtained through searching MEDLINE (1966-January 2003).

DATA SYNTHESIS

Studies conducted on the efficacy of fluoxetine in treating anorexia nervosa have conflicting results. Study design and methodology should be carefully evaluated.

CONCLUSIONS

Fluoxetine played a role in the reduction of symptoms of obsessive-compulsive disorder and depression in anorexic patients. While psychotherapy, nutritional therapy, and behavioral therapy should be the mainstays of treatment, fluoxetine should be considered as an option to prevent relapse or to treat associated symptoms of anorexia nervosa following adequate weight restoration as a part of maintenance therapy and not as a primary or acute therapy. Although fluoxetine appears to be promising for the treatment of patients with anorexia nervosa, further studies need to be performed with a larger sample size and/or better design.

Depression influences the EDI scores in anorexia nervosa patients

AIM

To study the influence of the severity of depression on the eating disorder's inventory (EDI) scores in anorexia nervosa (AN) patients.

METHOD

We compared by variance analysis the EDI scores from three groups of AN patients: 55 patients having a major depression (as assessed by a Beck's depression inventory (BDI) >/= 16); 77 patients having a less severe depression (BDI < 16); 32 patients with mild or non-existent depression (BDI </= 7) and the EDI scores from a control group of 29 French healthy young women.

RESULTS

Higher EDI scores were elicited in the more severely depressed AN patients than in the less- or non-depressed AN patients (P < 0.01). In non-depressed AN patients, none of the scores was different from those of the control group. This was particularly true for the scores "Slimness wish", "bulimia", "body image dissatisfaction", "perfectionism" and "fear of maturity". The non-depressed restrictive AN patients had no score which differ from healthy controls.

DISCUSSION

The present results suggested that the EDI scores are clearly influenced by the severity of depression. Among the psychopathological and behavioural traits assessed with the EDI, only a few were not related to depressive symptoms: "feeling of inefficiency" and "distrust in interpersonal relations".

Kleptomania in impulse control disorders, obsessive-compulsive disorder, and bipolar spectrum disorder: clinical and therapeutic implications

This paper aims to critically review currently available data on kleptomania and to analyze the possible future evolution of clinical research and therapeutic strategies.

Comorbidity between eating disorders and anxiety disorders: a review

OBJECTIVE

We conducted a critical literature review on studies assessing the prevalence of anxiety disorders (AD) in subjects with eating disorders (ED) (anorexia nervosa and bulimia nervosa). In the first part, we discuss methodological issues relevant to comorbidity studies between ED and AD. In the second part, taking into account these methodological considerations raised, we summarize the findings of these studies.

METHOD

We performed a manual and computerized search (Medline) for all published studies on comorbidity between ED and AD, limiting our search from 1985-2001 to get sufficiently homogeneous diagnostic criteria for both categories of disorders.

RESULTS

Too few studies include control groups and few studies have compared diagnostic subgroups of ED subjects, with scarce or conflicting results.

DISCUSSION

We discuss the results taking into account the methodological problems observed. We give guidelines for reviewing the results of published studies and planing future research.

Anorexia nervosa: obsessive-compulsive disorder, obsessive-compulsive personality disorder, or neither?

Anorexia nervosa (AN) is a severe and often chronic disorder with uncertain aetiology and poor prognosis. New approaches to the understanding of the disorder are needed in order to aid the development of more effective treatments. Several authors have suggested that AN has a considerable overlap with obsessive-compulsive disorder (OCD) and that this may reflect common neurobiological, genetic, or psychological elements. However, more recent studies have suggested that AN may have a closer relationship with obsessive-compulsive personality traits such as those found in obsessive-compulsive personality disorder (OCPD). In this paper, evidence for links between the three conditions is reviewed, suggestions for further research are outlined and possible implications for the treatment of AN are presented.

Disordered eating and substance use in an epidemiological sample: I. Associations within individuals

OBJECTIVE

This study examined the strength of associations between disordered eating and eating disorders and substance use and substance use disorders (SU/SUDs) in an epidemiological sample.

METHODS

672 adolescent girls and 718 women completed structured interviews of lifetime eating disorders and substance use and misuse, as well as self-reported current disordered eating attitudes and behaviors.

RESULTS

Although effect sizes were small, eating attitudes and disorders were associated modestly with nicotine, alcohol, and drug use, and with nicotine dependence in adolescent girls. Alcohol use and misuse were related to eating attitudes and pathology in women. SU/SUDs were associated with restricting and bulimic behaviors and no prominent differences in associations were observed between substance classes. In contrast to findings in clinical populations, these community-based results were positive but generally weak, suggesting there is no strong, overarching relationship between eating and substance use problems.

DISCUSSION

These results have implications for the addiction model of eating disorders.

A supplemental interview for forms of "affective spectrum disorder"

OBJECTIVE

Recent evidence suggests that a number of psychiatric and medical conditions may be members or candidate members of a larger family of conditions, which we have termed "affective spectrum disorder (ASD)." In order to facilitate further research into this concept, we drafted seven interview modules, using the format of the Structured Clinical Interview for DSM-III-R (SCID), designed to diagnose the following psychiatric and medical disorders: irritable bowel syndrome, narcolepsy, Tourette's disorder, migraine, fibromyalgia, chronic fatigue syndrome, and kleptomania.

METHOD

Published operational diagnostic criteria for these seven disorders were sought in the literature. Questions in SCID format were then drafted in accordance with these operational criteria. Draft modules were then sent to experts familiar with each of the disorders and suggestions and revisions from these experts incorporated into the final modules.

RESULTS

The complete supplemental interview is presented with this report. Preliminary experience with this interview in more than 100 patients tentatively suggests that it is reliable for diagnosing the disorders in question; however, a formal test-retest reliability assessment is still required.

CONCLUSIONS

It is hoped that this supplemental interview, used in conjunction with the SCID, will be helpful in further studies of the epidemiology, pathogenesis, and treatment of these possible forms of affective spectrum disorder.