Hypothalamic-pituitary-adrenal-axis hyperactivity in bulimia

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.

Neuroendocrine Profile in the Night Eating Syndrome

Night eating syndrome (NES) has recently been getting more attention as a recognized eating disorder. NES is characterized by a delay in the circadian pattern of food intake, associated with morning anorexia, evening hyperphagia, awakenings from sleep with ingestion of food, depressed mood, and obesity. Although the behavioral characteristics of NES were first described in 1955, the neuroendocrine characteristics have only been described recently. Researchers have examined several hormones that appear to differ in night eaters compared to controls, including melatonin, leptin, and cortisol. Researchers have more recently examined the hypothalamic-pituitary-adrenal axis in more detail, with emphasis on corticotrophin releasing hormone. Further studies have examined ghrelin, growth hormone, prolactin, and IGF-1, with differences observed in the circadian pattern of these hormones in those with NES compared to controls. Despite increasing interest in the neuroendocrine profile of night eating behavior, the biological basis of NES is still not well understood.

Sex differences in the effects of chronic stress and food restriction on body weight gain and brain expression of CRF and relaxin-3 in rats

This study investigated sex-specific effects of repeated stress and food restriction on food intake, body weight, corticosterone plasma levels and expression of corticotropin-releasing factor (CRF) in the hypothalamus and relaxin-3 in the nucleus incertus (NI). The CRF and relaxin-3 expression is affected by stress, and these neuropeptides produce opposite effects on feeding (anorexigenic and orexigenic, respectively), but sex-specific regulation of CRF and relaxin-3 by chronic stress is not fully understood. Male and female rats were fed ad libitum chow (AC) or ad libitum chow and intermittent palatable liquid Ensure without food restriction (ACE), or combined with repeated food restriction (60% chow, 2 days per week; RCE). Half of the rats were submitted to 1-h restraint stress once a week. In total, seven weekly cycles were applied. The body weight of the RCE stressed male rats significantly decreased, whereas the body weight of the RCE stressed female rats significantly increased compared with the respective control groups. The stressed female RCE rats considerably overate chow during recovery from stress and food restriction. The RCE female rats showed elevated plasma corticosterone levels and low expression of CRF mRNA in the paraventricular hypothalamic nucleus but not in the medial preoptic area. The NI expression of relaxin-3 mRNA was significantly higher in the stressed RCE female rats compared with other groups. An increase in the expression of orexigenic relaxin-3 and misbalanced hypothalamic-pituitary-adrenal axis activity may contribute to the overeating and increased body weight seen in chronically stressed and repeatedly food-restricted female rats.

Cortisol responses on the dexamethasone suppression test among women with Bulimia-spectrum eating disorders: associations with clinical symptoms

INTRODUCTION

Evidence associates Bulimia Nervosa (BN) with altered functioning of the hypothalamic-pituitary-adrenal (HPA) axis, but the clinical implications of such alterations need to be better understood. We contrasted cortisol responses to the dexamethasone suppression test (DST) in bulimic and non-eating disordered women and examined relationships among DST cortisol responses, eating symptoms and co-morbid disturbances.

METHOD

Sixty women with Bulimia Spectrum (BS) Disorders (either BN or normal weight Eating Disorder NOS with regular binge eating or purging) and 54 non-eating disordered women of similar age and body mass index participated in a 0.5 mg DST, and completed interviews and questionnaires assessing eating symptoms and co-morbid psychopathology.

RESULTS

Compared with the normal-eater group, the BS women demonstrated significantly less DST suppression. Among BS women, DST non-suppression was associated with more severe depression, anxiety and eating preoccupations.

CONCLUSIONS

Our findings show BS women to show less DST suppression compared to normal eater women, and results link extent of non-suppression, in BS individuals, to severity of depression, anxiety and eating preoccupations.

Neurobiological and psychopathological variables related to emotional instability: a study of their capability to discriminate patients with bulimia nervosa from healthy controls

OBJECTIVE

To analyze the capability of a set of neurobiological and psychopathological variables to discriminate bulimia nervosa (BN) patients from healthy controls.

METHOD

Seventy-five female patients with purging BN and 30 healthy controls were compared for psychopathology (impulsivity, borderline personality traits, depressive symptoms and self-defeating personality traits) and neurobiological parameters reflecting hypothalamic-pituitary-adrenal axis activity (morning serum cortisol before and after dexamethasone) and monoamine activity (24-hour urinary excretion of norepinephrine, serotonin, dopamine, and their main metabolites: 3-methoxy-4-hydroxyphenylglycol, 5-hydroxyindoleacetic acid, and homovanillic acid). Furthermore, the relationships between the 2 sets of variables were compared in the 2 samples.

RESULTS

BN patients displayed higher impulsivity, more severe depressive features, and more borderline and self-defeating personality traits than controls. The 4 psychopathological variables were strongly interrelated in patients, whereas only depressive features correlated with self-defeating personality traits in controls. Patients had lower 24-hour excretion of serotonin and dopamine than controls, as well as lower ability to suppress cortisol. The relations between the biochemical and the psychopathological variables were only significant in the BN patients, but not in the control group. When discriminant analysis methods were applied, patients and controls differed for psychopathology (impulsive behaviors and borderline personality traits) and biological parameters (baseline cortisol and dopamine excretion), but when the variables were analyzed together, the differences in neurobiological parameters appeared as mediated by the psychopathological status.

DISCUSSION

Our results suggest that hypothalamic-pituitary-adrenal axis activity, dopamine activity and other biological parameters are worthy of further study as potential dimensional markers of BN, although they seem to depend on the psychopathological status of the patients, in such a way that the psychopathological items associated with emotional instability (impulsivity and borderline personality traits) seem to be more reliable as clinical markers at the time being.

Hostility and helper T-cells in patients with bulimia nervosa

OBJECTIVE

The study aimed to analyze the correlation between lymphocyte counts and several psychopathological variables associated with psychological instability (depression, hostility, impulsivity, self-defeating personality traits, and borderline personality symptoms) in patients with bulimia nervosa (BN).

METHOD

Sixty BN patients were assessed, using specific scales for eating pathology, general psychopathology, impulsivity, depression, and borderline personality features. Lymphocyte and lymphocyte subset counts were performed. Plasma cortisol at 8:00, before and after administration of 1 mg of dexamethasone at 23:00, was determined. The influence of body weight, and the use of tobacco, alcohol, and caffeine was controlled. The relationship between each isolated variable and the number of immune cells was analyzed. In a second step, supplementary post-hoc analysis of the variables was introduced to confirm the accuracy of the psychopathological assessment.

RESULTS

Hostility was negatively correlated with the number of helper T-cells (CD4+). Patients with high hostility had lower CD4+ cell counts and lower CD4+/CD8+ ratios. In the post-hoc control study, hostility was significantly related with other "interpersonal" items.

CONCLUSIONS

These results support the idea that hostility, as an expression of disturbed interpersonal relationships, could play a role as a modulator of immune activity in patients with BN.

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.

Sleep in eating disorders

Sleep research on eating disorders has addressed two major questions: (1) the effects of chronic starvation in anorexia nervosa and of rapidly fluctuating eating patterns in bulimia nervosa on the sleep regulating processes and (2) the search for a significant neurobiological relationship between eating disorders and major depression. At present, the latter question appears to be resolved, since most of the available evidences clearly underline the notion that eating disorders (such as anorexia and bulimia nervosa) and affective disorders are two distinct entities. Regarding the effects of starvation on sleep regulation, recent research in healthy humans and in animals demonstrates that such a condition results in a fragmentation of sleep and a reduction of slow wave sleep. Although several peptides are supposed to be involved in these regulatory processes (i.e. CCK, orexin, leptin), their mode of action is still poorly understood. In opposite to these experimentally induced sleep disturbances are the findings that the sleep patterns in eating disorder patients per se do not markedly differ from those in healthy subjects. However, when focusing on the so-called restricting anorexics, who maintain their chronic underweight by strictly dieting, the expected effects of malnutrition on sleep can be ascertained. Furthermore, at least partial weight restoration results in a 'deepening' of nocturnal sleep in the anorexic patients. However, our knowledge about the neurobiological systems (as well as their circadian pattern of activity) that transmit the effects of starvation and of weight restoration on sleep is still limited and should be extended to metabolic signals mediating sleep.

Hypothalamic-pituitary-adrenal axis in the night eating syndrome

The typical neuroendocrine characteristics of the night eating syndrome have previously been described as changes in the circadian rhythm by an attenuation in the nocturnal rise of the plasma concentrations of melatonin and leptin and an increased circadian secretion of cortisol. The aim of this study was to test the hypothesis that night eaters have an overexpressed hypothalamic-pituitary-adrenal axis with an attenuated response to stress. Five female subjects with the night-eating syndrome and five sex-, age-, and weight-matched controls performed a 120-min corticotropin-releasing hormone (CRH) test (100 microg iv). Blood samples were drawn intravenously for measurements of the plasma concentrations of ACTH and cortisol. The results showed that, in night eaters compared with controls, the CRH-induced ACTH and cortisol response was significantly decreased to 47 and 71%, respectively. In conclusion, disturbances in the hypothalamic-pituitary-adrenal axis with an attenuated ACTH and cortisol response to CRH were found in subjects with night-eating syndrome.

Women with eating disorder tendencies display altered cardiovascular, neuroendocrine, and psychosocial profiles

OBJECTIVE

Cardiovascular, neuroendocrine, and psychosocial profiles were investigated in women with eating disorder tendencies, but who had never met clinical criteria for an eating disorder, and in healthy controls.

METHODS

Twenty-six women who scored in the highest distribution of the Eating Disorder Inventory bulimia subscale (HEDI women) and 27 women who scored in the lowest distribution (LEDI women) completed psychosocial questionnaires, underwent a speech reactivity task for measures of blood pressure and heart rate reactivity, and also underwent 24-hour ambulatory blood pressure monitoring and urinary neuroendocrine collection.

RESULTS

The HEDI women exhibited increased blood pressure and heart rate reactivity to the speech task and increased 24-hour urinary cortisol, but decreased 24-hour urinary norepinephrine compared with LEDI women. There were no overall group differences in 24-hour ambulatory blood pressure levels, but negative mood and tension were associated with greater systolic blood pressures for all women. Finally, HEDI women reported greater depressive symptoms and anxiety, lower self-esteem and sense of mastery, less social support, poor coping skills, and greater emotional impact of daily stressors relative to LEDI women.

CONCLUSIONS

These results indicate that the same pattern of neuroendocrine and psychosocial profiles seen in prior studies of bulimia nervosa are also present in women with eating disorder tendencies.

Eating disorder in women admitted to hospital following deliberate self-poisoning

Measures of abnormal eating behaviour in 48 women referred for psychiatric assessment following an act of deliberate self-poisoning (subjects) were compared with those in 50 women attending an accident and emergency department following minor accidental injury (controls). Disordered eating behaviour was significantly more prevalent in the subject group, even when the effect of depression was removed. Four subjects fulfilled the diagnostic criteria for bulimia nervosa, but none of the subjects met the diagnostic criteria for anorexia nervosa. The prevalence of obesity was the same in both subject and control groups. The degree of abnormal eating was very strongly correlated with a measure of inwardly directed irritability in both subjects and controls, and was strongly associated with measures of impulsiveness, outwardly directed irritability and anxiety in subjects.

Lipoprotein metabolism following gastroplasty in obese women

In order to elucidate the long-term alterations in cholesterol transport and esterification as a part of the changes in the carbohydrate and lipoprotein metabolism subsequent to calorific restriction, 15 obese women were investigated before and after treatment with vertical banded gastroplasty. Insulin resistance and production, lipid levels in plasma, lipoproteins and the lecithin: cholesterol acyl transferase (LCAT) rate were assessed. There was a 60% decrease in mean calorific intake six months after surgery. A slight hyperglycaemia was almost normalized concomitant with a reduction of serum insulin and C-peptide after 1 year. The very low density lipoprotein (VLDL) level was unchanged. The high density lipoprotein (HDL) levels tended to rise after 1 year, when there was a significant increase of the HDL-2 subfraction. The lipid levels in the lipoprotein fractions showed a rise in mean HDL-2 cholesterol. Both the molar and fractional rates of LCAT were decreased. These results suggest that long-term calorific restriction reduces insulin resistance and production, and lowers VLDL levels and VLDL and cholesterol synthesis. However, the low density lipoprotein cholesterol levels are unchanged, probably because of a decrease in the previously elevated fractional cholesterol removal.

Coexistence of bulimia nervosa and mania: a literature review and case report

A literature review of the relationship between bulimia and affective disorder showed that the evidence from empirical research and case report studies suggests that a sizeable subgroup of bulimics suffer from bipolar disorder as well as bulimia and may benefit from antimanic medications such as lithium. A case report is presented of a bulimic patient with manic symptoms who was successfully treated with lithium. However, the use of lithium should be avoided with any patient who is purging, since it may exacerbate the loss of intracellular potassium, thereby increasing the risk of cardiac toxicity.

Disturbances in the hypothalamo-pituitary-adrenal and other neuroendocrine axes in bulimia

Disturbances in the hypothalamo-pituitary-adrenal (HPA) and other endocrine axes were assessed in 24 women with bulimia and healthy controls. Overnight blood samples for measuring nocturnal plasma cortisol, prolactin (PRL), growth hormone (GH), luteinizing hormone (LH), and follicle stimulating hormone (FSH) were obtained at 30-min intervals. A 1.5 mg dexamethasone suppression test (DST) and a TRH-test were performed. Patients were monitored closely while their nutritional intake was recorded over 21 days. Compared with healthy controls, nocturnal cortisol plasma levels were not elevated in the bulimics. There was a trend toward insufficient cortisol suppression in the DST in patients with bulimia, which was most pronounced in patients with signs of restricted caloric intake. Plasma dexamethasone levels were significantly reduced in bulimics compared with healthy controls. There was a trend for blunted thyrotropin stimulating hormone (TSH) responses to thyrotropin releasing hormone (TRH) in bulimia. The prolactin response to TRH was significantly reduced in bulimics with a history of anorexia nervosa. Plasma LH and plasma FSH were significantly reduced in bulimics with signs of reduced caloric intake [low T3, high levels of beta-hydroxy-butyric acid (BHBA), reduced daily caloric intake, high number of fasting days] as compared with healthy controls. Bulimics with high BHBA levels had significantly reduced nocturnal prolactin plasma levels. Results show that multiple neuroendocrine disturbances exist in bulimia in a milder form than in anorexia nervosa. Evidence for the impact of caloric intake on endocrine functions is presented. Endocrine dysfunctions in our bulimic sample did not show a positive association with the presence of depressive symptoms.

Early family experiences of women with bulimia and depression

This study characterizes the early family experiences of 30 women with bulimia nervosa and 15 women with major depression, and compares them with 100 women controls, with particular emphasis placed on parental rearing practices, family conflict resolution, sexual mistreatment, problematic childhood indicators, and childhood separation experiences. There is little research on these patient populations in relation to their childhood experiences, and thus, it is difficult to identify markers for women at risk for these disorders. The findings show that there are significant differences between the experiences these women had growing up and those of the control group, and a profile of children at risk based upon the study indicators is presented.

HPA axis disturbance in obsessive-compulsive disorder

Twenty nondepressed outpatients with DSM-III obsessive-compulsive disorder entered a 10-week placebo-controlled study of clomipramine and underwent a 1-mg dexamethasone suppression test (DST) at baseline; 11 had a repeat DST at the end of treatment: Nonsuppression was rare. When compared to 82 previously described outpatients with panic disorder studied in a similar fashion, OCD patients had postdexamethasone cortisol values that were substantially lower and more stable over time. Results within the OCD group closely resembled those from a group of never-ill controls.

Neuroendocrine probes as biological markers of affective disorders: new directions

Numerous endocrine abnormalities are found in depressive illness and, among these, several have been proposed as useful markers in diagnosis, prediction of treatment response, monitoring treatment outcome or in understanding of etiology. This paper reviews five endocrine systems--the hypothalamic-pituitary-adrenal axis, hypothalamic-pituitary-thyroid axis, growth hormone regulation, prolactin regulation and pineal function, in which such abnormalities have been reported. The dexamethasone suppression test (DST) results are affected by a variety of other diseases and confounding conditions. Furthermore, variability in dexamethasone availability has recently been shown to be an important factor, influencing post-DST cortisol levels. Refined tests, taking into account all these factors, or alternative tests of hypothalamic-pituitary-adrenal function may lead to improved clinical utility. Pineal function is now the focus of considerable investigation. Low nocturnal output of melatonin is found in unipolar and bipolar affective disorder and is normalized by treatment with antidepressant drugs which block re-uptake of noradrenaline. These findings support the hypothesis of noradrenergic abnormality in depression. In seasonal affective disorder there is evidence for a phase delay in the melatonin rhythm which may be a key factor in the seasonal disorder. Effective light therapy causes a phase advance in the abnormal melatonin rhythm. Whether the normalization of the melatonin rhythm is instrumental in producing the antidepressant effect is yet to be determined. There are wide spread neuroendocrine abnormalities in depressive illness. These abnormalities encompass many different pituitary hormones, as well as the pineal.(ABSTRACT TRUNCATED AT 250 WORDS)

The significance of HPA axis disturbance in panic disorder

Agoraphobic and panic disorder patients underwent 1-mg Dexamethasone Suppression Tests (DST) before, during, and after an 8-week trial of diazepam, alprazolam, or placebo. Previously described, never-ill controls underwent similar testing. At baseline, 21 of 82 (25.6%) panic disorder and 5 of 38 (13.2%) controls were nonsuppressors. This difference grew more marked with multiple testing over a 2-month period; 18 of 44 (40.9%) panic disorder patients were nonsuppressors on at least 1 of 3 tests compared with only 5 of 35 (14.3%) controls (p = 0.006). DST results were related to severity, but not to the presence or absence, of depressive syndromes. Control for plasma dexamethasone levels left highly significant differences in postdexamethasone cortisol across diagnostic groups. Neither DST results nor plasma dexamethasone levels changed in concert with clinical change, and type of treatment had little differential effect on these measures. Nor did DST results predict subsequent course when active treatment was extended by 6 months. However, DST results during the initial 8 weeks of treatment were strongly related to relapse when medications were tapered, even though this occurred 6 months after the last DST.

Eating disorders in a general practice population. Prevalence, characteristics and follow-up at 12 to 18 months

Attenders to four South London group general practices were screened using the Eating Attitudes Test (EAT), after which all high scorers and a random selection of low scorers were approached for interview. General practitioners (GPs) were given details on a random half of high-scoring patients with the aim of assessing intervention for revealed and hidden psychopathology. Twelve to 18 months later all high scorers on the EAT were followed up by post to measure change in behaviour and attitudes. Practice records were examined to determine the doctor's knowledge of the patient and any intervention that had occurred. It was found that 1.1% of women had bulimia nervosa and 2.8% a partial-syndrome eating disorder. No cases of anorexia nervosa were found. Cases of bulimia nervosa and partial syndromes were similar in being: mainly female, of higher social class, in the normal weight range but with considerable weight fluctuation in the past, more likely to have had a history of menstrual irregularity, and frequently psychologically troubled with more past psychiatric contact. Over the follow-up period there was some change along a spectrum of normal dieting to the full syndrome, although only one subject with bulimia nervosa recovered significantly. Although the GPs were unaware of the eating pathology and their intervention was minimal, most had documented their patients' psychological distress.

The DST and TRH test in bulimia nervosa

Abnormal neuroendocrine responses have been found in depression and eating disorders. It remains unclear whether these reflect an underlying shared biology or epiphenomena. To evaluate this further, we conducted the 1 mg DST and the TSH response to 500 micrograms i.v. TRH in normal-weight bulimics and controls. Bulimics (n = 18) demonstrated significantly more DST non-suppression (45%) than controls (18%; n = 20). In the bulimic group, non-suppressors were significantly thinner than suppressors, but did not differ from them on any measure of depression. Bulimics (n = 19) and controls (n = 12) responded similarly without blunting on the TSH response to TRH. These data suggest that DST non-suppression may be related to non-specific variables such as weight. Bulimics do not demonstrate TSH blunting as found in some depressed patients. These tests do not support evidence for a biological link between these disorders.

Neuroendocrine profile in bulimia nervosa

The neuroendocrinology of bulimia nervosa has only recently been investigated, with initial research suggesting some biological overlap with both anorexia nervosa (AN) and depression. Similarities among AN, depression, and bulimia include a nonsuppressed Dexamethasone Suppression Test and an abnormal growth hormone (GH) response to thyrotropin-releasing hormone (TRH). Bulimics and anorectics both tend to have a delayed thyrotropin (TSH) response to TRH and elevated basal GH levels. Bulimics, however, have a normal GH response to clonidine, a nonblunted TSH response to TRH, low basal prolactin (PRL) levels, and may have an exaggerated PRL response to TRH. Unpublished data suggest bulimics may have a gonadotropin profile distinct from either AN or depression, as well as a variety of other endocrinopathies. Although many of these abnormalities may reflect malnutrition despite normal weight, other factors that are as yet unidentified are likely to be contributing to the neuroendocrine abnormalities seen in bulimia.

The dexamethasone suppression test in bulimia nervosa

In a study of the dexamethasone suppression test (DST) in patients with bulimia nervosa, a non-suppression rate of about 50% was found. The only clinical correlates of DST non-suppression were a previous history of weight loss and/or of anorexia nervosa. These results suggest that DST non-suppression in these subjects may be a trait rather than a state marker of anorexia nervosa.

The dexamethasone suppression test for Japanese with eating disorders

A one-mg oral overnight dexamethasone suppression test (DST) was conducted on 22 inpatients with eating disorders. To confirm that the dexamethasone tablets had been ingested, we measured the plasma concentrations of dexamethasone the next morning (at 0900 hr after DST). The diagnosis of anorexia nervosa and bulimia was made according to the criteria for DSM-III, respectively. Of the 22 patients with eating disorders, 16 satisfied the criteria for anorexia nervosa and 6 for bulimia. The DST was carried out within 2 weeks of hospitalization on each patient. The subjects were given 1 mg of dexamethasone in the evening (at 2300 hr) and blood samples were collected the following day (at 0900, 1600 and 2100 hr, respectively). The plasma cortisol and dexamethasone levels were concurrently determined by RIA. The criterion for non-suppression was a failure to suppress the plasma cortisol levels below 5.0 micrograms/dl in any one of the three samples. All but one patient with bulimia had ingested the dexamethasone. Thirteen (62%) of 21 patients with eating disorders were nonsuppressors. We found a significant positive correlation between the plasma cortisol levels at 1600 hr or 2100 hr and a decrease in ideal body weight (n = 16, r = 0.613, p less than 0.05; r = 0.75, p less than 0.01, respectively) and a significant inverse relationship between the plasma dexamethasone levels at 0900 hr and the plasma cortisol levels at 1600 hr was recognized (n = 21, r = 0.631, p less than 0.01). These results suggest that the blood dexamethasone levels as well as body weight might contribute to the abnormalities of DST seen in patients with eating disorders.

Involvement of serotonin system in bulimia

Platelet 3H-imipramine binding was investigated in 8 patients affected by bulimia according to DSM III criteria, and in 7 healthy volunteers. The Bmax +/- SD (fmol/mg protein) was 356 +/- 53 in patients, and 1144 +/- 134 in controls. The Kd +/- SD (nM) was 1.35 +/- 0.44 in patients, and 1.90 +/- 0.72 in controls. There was a significant difference (p less than 0.0001) in Bmax values in the two groups, whereas no significant difference was observed in Kd values. This study suggests the possible involvement of the indoleamine system in bulimia.

Sleep EEG in bulimia

To evaluate the sleep electroencephalogram (EEG) characteristics of bulimia, all-night sleep EEGs were performed on 11 women meeting DSM-III criteria for bulimia. Comparison groups consisted of young women outpatients with major depression (n = 44) and young normal women (n = 20). The sleep EEGs of the bulimic patients were largely indistinguishable from those of the normal controls, except for a trend toward increased rapid eye movement (REM) density in the first REM period among the bulimic subjects. No differences in any sleep EEG measure were observed between bulimic patients with major depression and those without affective disorder. By contrast, the outpatients with major depression displayed marked sleep continuity disturbances, as well as significantly increased REM intensity and REM density, as compared to normal controls. Implications of these results with respect to the hypothesis that bulimia is related to major affective disorder are discussed.

Thyrotropin, prolactin, and growth hormone responses to thyrotropin-releasing hormone in anorexia nervosa and bulimia

Serum thyrotropin (TSH), prolactin (PRL), and growth hormone (GH) levels were measured before and after stimulation with thyrotropin-releasing hormone (TRH) in 10 patients with bulimia, 7 with features of the restricting subtype of anorexia nervosa, and 6 with bulimic subtype of anorexia nervosa. The mean basal levels of TSH, PRL, and GH did not differ among the three groups. A delayed TSH response was found in 86% of the restricting anorectics, 80% of the bulimic anorectics, and 22% of the bulimics. The PRL response was normal in all patients, with no significant difference among the three groups. Elevated basal GH levels were found in 29% of the restricting anorectics, 33% of the bulimic anorectics, and 33% of the bulimics. An abnormal GH increase after TRH stimulation was observed in 50% of the restricting anorectics, 20% of the bulimic anorectics, and 13% of the bulimics. These results suggest that some patients with bulimia, and some with anorexia nervosa, have a hypothalamic dysfunction. These neuroendocrine abnormalities do not appear to be due solely to low weight or to metabolic changes resulting from binge eating and are not associated with depressive symptoms.

The dexamethasone suppression test in healthy controls

We have summarized the results of 53 studies which examined the dexamethasone suppression test in normal controls. Only 3.6% of 687 0800 hr postdexamethasone cortisol levels were above 5 micrograms/dl. Corresponding figures for 1600 hr and 2300 hr cortisol levels were 7.4% (85/1144) and 6.3% (28/434), respectively. Neither the type of assay (competitive protein binding or radioimmunoassay) nor mean/median age of the subjects was associated with non-suppression rates.

Hypothalamic-pituitary-adrenal-cortical activity in anorexia nervosa and bulimia

We studied hypothalamic-pituitary-adrenal-cortical (HPA) activity in nine underweight women with anorexia nervosa, 12 women of normal body weight with bulimia, and nine control subjects. The measures of HPA activity were the pattern of plasma cortisol secretion over 24 hr and the responses of plasma cortisol to dexamethasone suppression and to low dose ACTH stimulation. The patients with anorexia nervosa had significantly elevated 24 hr concentrations of plasma cortisol compared to the controls and showed significantly less cortisol suppression following dexamethasone. There was no difference between patients with anorexia nervosa and controls in the rise in plasma cortisol following ACTH. On most measures of HPA activity, the normal weight patients with bulimia were indistinguishable from the controls. These results suggest that HPA activity is normal in most patients of normal body weight with bulimia and that the psychological and behavioral disturbances common to both anorexia nervosa and bulimia are, in the absence of significant weight loss, insufficient to produce major alterations in HPA activity.

[Factors interfering with the dexamethasone suppression test]

The interpretation of the dexamethasone suppression test in endocrinology and psychiatry depends on several variables. False-positive results can be caused by stress, weight loss, alcohol withdrawal, treatment with diphenylhydantoin, phenobarbital, rifampicin, carbamazepine and lithium. Therapy with spironolactone, naloxone, alpha 1-mimetic agents and estrogen can be responsible for an increase in plasma-cortisol concentration. False-negative results are seen in patients with liver disease and can also result from therapy with benzodiazepines at high dosages, indomethacin and possibly methadone and ketoconazole.

The depressive symptoms of bulimia nervosa

Standardised measures of mental state were used to compare patients with bulimia nervosa with those with major depressive disorder. The two groups were found to be similar in terms of severity of psychiatric disturbance, as measured by the Montgomery & Asberg Scale and the Present State Examination. Noteworthy symptomatic differences were a greater frequency of obsessional ruminations and anxiety amongst the first group, and a greater frequency of depressed mood, apparent sadness, and suicidal ideation amongst the second. Discriminant function analyses revealed that the two patient groups had a different pattern of symptoms. Examination of the character of the psychiatric symptoms of patients with bulimia nervosa suggests that the anxiety and depressive symptoms are likely to be secondary to the eating disorder itself, rather than of primary significance.

Plasma immunoreactive beta-endorphin in bulimics

The plasma beta-endorphin response to glucose ingestion was compared in 8 bulimics and 8 controls. The bulimics demonstrated a sustained elevation of plasma beta-endorphin unrelated to glucose ingestion throughout the 5-hour study period. It is hypothesized that such an elevation of beta-endorphin is the result of stress and that it may play an important role in the perpetuation of the binge-vomiting cycle.

Weight loss causes neuroendocrine disturbances: experimental study in healthy starving subjects

A variety of endocrine dysfunctions have been reported for anorexia nervosa, protein caloric malnutrition, and depression. The effect of reduced caloric intake and weight loss on endocrine functions was assessed in an experiment with five healthy female subjects during an initial baseline phase, a 3-week phase of complete food abstinence, weight gain to the original level, and a final baseline phase. During fasting, disturbances in hypothalamic-pituitary-adrenal function were observed, with elevated plasma cortisol levels, increase in the number of secretory episodes, increase in cortisol plasma half-life, and insufficient suppression following 1.5 mg dexamethasone. While all dexamethasone suppression tests (DSTs) were normal at baseline, 7 of 14 DSTs showed insufficient suppression in the fasting phase. During fasting, basal thyroid-stimulating hormone (TSH) values were lowered and the TSH response to thyrotropin-releasing hormone (TRH) was blunted. The plasma level of growth hormone (GH) over 24 hours was elevated during fasting and administration of the alpha 2-adrenergic receptor agonist clonidine resulted in a subnormal GH response after restoration of original body weight. One of the five subjects showed increased irritability, distress, anxiety, and depression as measured by various psychological scales. The results show that reduced caloric intake, weight loss, or catabolic state have powerful effects on several endocrine systems. The specificity of measures of endocrine disturbances (DST, TRH tests, and clonidine tests) as biological markers for certain types of depression must be questioned, and the metabolic state should be given more consideration in future studies.

Characteristics of patients with bulimia only, bulimia with affective disorder, and bulimia with substance abuse problems

Characteristics of patients with a diagnosis of bulimia only (N = 46), bulimia with a history of affective disorder (N = 34), and bulimia with a history of substance abuse (N = 34) were compared. Results showed that compared to patients with bulimia only or with bulimia and affective disorders, patients with bulimia and substance abuse experienced a higher rate of diuretic use to control weight, financial and work problems, stealing before and after the onset of the eating disorder, previous psychiatric inpatient treatment, and greater amount of alcohol use after the onset of the eating disorder. Both the substance abuse group and affective disorder group showed a higher incidence of attempted suicide, more social problems, and greater overall treatment rate than the bulimia only group. There were no significant differences among groups in their family histories.

EEG-monitored sleep in anorexia nervosa and bulimia

We compared the EEG-monitored sleep of 8 women with anorexia nervosa and 16 normal weight women with bulimia to that of 14 normal women. The patients with anorexia nervosa spent less time asleep and spent less of their sleep time in Stage 1. The sleep of the normal weight patients with bulimia was remarkably similar to that of the controls. These data suggest that most patients with anorexia nervosa and bulimia do not exhibit the type of sleep disturbances characteristic of patients with major depressive illness.

The effect of weight loss and inappropriate plasma dexamethasone levels on the DST

Recent studies from different research groups have raised fundamental questions about the postulated specificity of the dexamethasone suppression test (DST) for endogenous depression. Findings in 116 psychiatric inpatients and 24 semi-starved healthy volunteers underline the importance of weight loss as a factor affecting DST results. A study of 160 DSTs in 93 psychiatric inpatients further revealed a significant negative correlation of plasma cortisol and plasma dexamethasone levels 10 hours after oral administration of 1 mg of dexamethasone. These results suggest a decisive effect of the pharmacokinetics of dexamethasone, at least on the 1-mg DST.

Neuroendocrine changes in depression

Biological research in depression has concentrated on 'endogenous' depressions and over the past 30 years has been guided by the amine theory. Neuroendocrine abnormalities in depression have been reported for over 20 years and include changes in the hypothalamic-pituitary-adrenal and thyroid axes, in growth hormone and prolactin secretion. As neurotransmitters regulate neuroendocrine secretion, inter-relationships between neurochemical and neuroendocrine abnormalities may provide a window for understanding the pathophysiology of depression. The availability of these biological markers for depression opens new possibilities for research in psychiatric diagnosis and for management.

Metabolic and endocrine indices of starvation in bulimia: a comparison with anorexia nervosa

Fifteen patients with bulimia (DSM-III) and 22 patients with anorexia nervosa (10 "restricters" and 12 "vomiters") were compared with 24 age- and sex-matched healthy controls. Serial blood samples were collected between 8:30 and 9:30 a.m. with patients in supine and standing positions. Elevated blood values of beta-hydroxybutyric acid and free fatty acids were observed in the majority of patients with bulimia and anorexia nervosa. These data indicate that many patients with bulimia showed the metabolic signs of starvation at the time of the study, a finding supported by the symptoms of endocrine adaptation to starvation, namely low triiodothyronine and a decreased noradrenaline response to an orthostatic test in many of these patients.

Diagnostic heterogeneity and the DST in consecutive psychiatric admissions

There is uncertainty about the clinical usefulness of the dexamethasone suppression test (DST). It is also unclear whether there are advantages to a 1-mg or 2-mg DST. Eighty-three consecutive psychiatric inpatients were randomly given a 1-mg or 2-mg DST within the first week of admission. Sensitivity, specificity, and diagnostic confidence are reported for this group, and also in combination with those for 119 semi-consecutive psychiatric admissions. Although rates of nonsuppression were consistently higher in patients with affective disorders than in patients with other diagnoses, the diagnostic confidence of the DST for major depression in a diverse and unselected patient population was not greater than the prevalence of the disorder. The DST does not appear to be useful for clinical diagnostic decision-making. Nonetheless, the DST may still be an important biological marker in neuroendocrine psychiatric research.

The significance of the neurotic symptoms of bulimia nervosa

The significance of the neurotic symptoms of bulimia nervosa is a subject of current debate. In the present paper, data are reported on changes in these symptoms during the course of psychological treatment directed at the eating disorder itself. A significant association was found between outcome in terms of eating habits and the severity of neurotic symptoms after treatment. There was no association between outcome and the pre-treatment level of neurotic symptoms. These findings suggest that the neurotic symptoms are likely to constitute a secondary psychological reaction.