Risk factors for bulimia nervosa: a controlled study of parental psychiatric illness and divorce

The Relationship of Parental Personality Disorders with Offspring Eating Disorders at Childhood and Adolescence Age

This study aimed to investigate parents' PDs that could be associated with children and adolescents' EDs. We studied association of parental PDs with offspring EDs in age group 6-18 years in a nationally representative sample of Iranians with 27,111 children and adolescents and their parents. We used a multistage random cluster sampling method. We used Millon Clinical Multiaxial Inventory-Third Edition and Persian present and lifetime version of Kiddie Schedule for Affective Disorders and Schizophrenia to measure parental PDs and children and adolescents' EDs, respectively. We used descriptive statistics and binary logistic regression analysis methods to analyze the data. Maternal but not paternal PDs were significantly associated with EDs in offspring. Maternal antisocial, borderline, schizoid, histrionic, and compulsive PDs were significantly associated with EDs in offspring by 32.06, 4.66, 4.32, 3.15, and 1.71 odd ratios, respectively. Of EDs in offspring, anorexia nervosa and binge ED were significantly associated with maternal PDs.

Extreme Risk-Taking Behaviors in Patients With Eating Disorders

BACKGROUND

Patients with eating disorders (EDs) engage in different self-inflicted at-risk behaviors, including suicide, attempted suicide and non-suicidal self-injury. Our aim was to describe the occurrence and underlying motivations of non-suicidal extreme risk-taking behaviors in patients with EDs.

METHODS

Four cases from different treatment centers in Israel were analyzed.

RESULTS

All patients were females hospitalized in inpatient settings because of long lasting anorexia nervosa (AN) with either binge/purge or purging episodes (AN-B/P/AN-P), including in most cases both self-induced voting and laxative abuse. Case [1] was an adolescent also diagnosed with type 1 diabetes mellitus. She abused insulin, both omission and overdose, was highly suicidal, and suffered from comorbid oppositional behavior, depression and anxiety. Case [2] was a 24-years old woman, transitioning from restricting to AN with vomiting and laxative use during inpatient treatment. She was also diagnosed with attention deficit hyperactivity disorder, depression, anxiety, and suicidal thoughts. In hospital, she developed excessive water consumption, leading to very low urine concentrations and sodium levels, and one episode of loss of consciousness. Case [3] was in her late thirties, demonstrating particularly massive laxative abuse. She also suffered from alcohol addiction, sexual trauma, and one attempted suicide. During hospitalization she developed laxative-abuse-related rectal prolapse that was successfully operated. Nonetheless, after operation she resumed laxative abuse. Case [4] was a 23-year old pregnant women with highly active AN-B/P during pregnancy. She was hospitalized at 23 weeks of gestation following abdominal pressure. She only partly complied with inpatient treatment, discharged herself against medical advice after 5 weeks, and gave birth at week 34.

DISCUSSION

All cases were females with long-standing B/P type AN, often with multiple purging behaviors, other impulsive and non-impulsive comorbidities, and many environmental vulnerabilities. Different motivations were found for these extreme behaviors in addition to ED-related factors, mostly not related to suicide. The severity of the medical and psychological condition required multimodal medical and psychological inpatient interventions. The patients mostly did not comply with their treatment, showing considerable indifference to their grave medical condition.

Family-related non-abuse adverse life experiences occurring for adults diagnosed with eating disorders: a systematic review

BACKGROUND

Although previous reviews suggest a strong association between abuse and eating disorders, less is known about non-abuse adverse life experiences, such as parental mental illness or family discord, which occur frequently for this population. The aim of the current study was to identify family-related non-abuse adverse life experiences occurring for adults with eating disorders, and to establish whether they occur for people with anorexia nervosa, bulimia nervosa or binge-eating disorder more than the general population and other psychiatric populations.

METHOD

A systematic review of studies focusing on family-related non-abuse adverse life experiences and eating disorders was conducted in accordance with PRISMA guidelines. The search string was applied to four electronic databases including Psycinfo, PubMed/Medline, CINAHL Plus and EMBASE.

RESULTS

Of the 26 studies selected for inclusion, six types of family-related non-abuse adverse life experiences were identified: adverse parenting style; family disharmony; loss of a family member, relative or close person; familial mental health issues; family comments about eating, or shape, weight and appearance; and family disruptions. Findings provided tentative evidence for eating disorder specific (i.e. parental demands and criticism) and non-specific (i.e. familial loss and family disruptions) non-abuse adversities, with findings also suggesting that those with bulimia nervosa and binge-eating disorder were more impacted by loss, family separations and negative parent-child interactions compared to those with anorexia nervosa.

CONCLUSIONS

This review provides a clear synthesis of previous findings relating to family-related non-abuse adverse life experiences and eating disorders in adults. Implications for trauma-informed care in clinical practice were discussed (e.g. considering the impact of past life events, understanding the function of ED behaviours, reducing the risk of potential re-traumatisation).

Early childhood adversities and risk of eating disorders in women: A Danish register-based cohort study

OBJECTIVE

Previous studies evaluating the association between early childhood adversities and eating disorders have yielded conflicting results. The aim of this study is to examine the association between a range of adversities and risk of anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS) in 495,244 women.

METHOD

In this nationwide, register-based cohort study, nine types of early childhood adversity (family disruption, residential instability, placement in out-of-home care, familial death, parental somatic illness, parental psychiatric illness, parental disability, severe parental criminality, and parental substance use disorder) were defined and exposure during the first 6 years of life was determined. Hazard ratios for eating disorders were calculated using Cox regression.

RESULTS

Few adversities were significantly associated with AN, and for each, the presence of the adversity was associated with lower risk for AN. BN, and EDNOS were positively associated with several types of adversities. AN rates were unchanged or reduced by up to 54% by adversities, whereas rates of BN and EDNOS were unchanged or increased by adversities by up to 49 and 89%, respectively.

DISCUSSION

Our findings indicate that childhood adversities appear to be associated with an increased risk of BN and in particular EDNOS, whereas they seem to be either unassociated or associated with a decreased risk of AN.

Parental mental illness and eating disorders in offspring

OBJECTIVE

To investigate which parental mental illnesses are associated with eating disorders in their offspring.

METHOD

We used data from a record-linkage cohort study of 158,679 children aged 12-24 years at the end of follow-up, resident in Stockholm County from 2001 to 2007, to investigate whether different parental mental illnesses are risk factors for eating disorders in their offspring. The outcome measure was diagnosis of any eating disorder, either from an ICD or DSM-IV code, or inferred from an appointment at a specialist eating disorder clinic.

RESULTS

Mental illness in parents is a risk factor for eating disorders in female offspring (Adjusted Hazard Ratio (AHR) 1.57 (95% CI 1.42, 1.92), p < 0.0001). Risk of eating disorders is increased if there is a parental diagnosis of bipolar affective disorder (AHR 2.28 (95% CI 1.39, 3.72), p = 0.004), personality disorder (AHR 1.57 (95% CI 1.01, 2.44), p = 0.043) or anxiety/depression (AHR 1.57 (95% CI 1.32, 1.86), p < 0.0001). There is a lack of statistical evidence for an association with parental schizophrenia (AHR 1.41 (95% CI 0.96, 2.07), p = 0.08), and somatoform disorder (AHR 1.25 (95% CI 0.74, 2.13), p = 0.40). There is no support for a relationship between parental substance misuse and eating disorders in children (AHR 1.08 (95% CI 0.82, 1.43), p = 0.57).

DISCUSSION

Parental mental illness, specifically parental anxiety, depression, bipolar affective disorder, and personality disorders, are risk factors for eating disorders in their offspring.

We are family--parents, siblings, and eating disorders in a prospective total-population study of 250,000 Swedish males and females

OBJECTIVE

We examined how parental characteristics and other aspects of family background were associated with the development of eating disorders (ED) in males and females.

METHOD

We used register data and record linkage to create the prospective, total-population study the Stockholm Youth Cohort. This cohort comprises all children and adolescents who were ever residents in Stockholm County between 2001 and 2007, plus their parents and siblings. Individuals born between 1984 and 1995 (N = 249, 884) were followed up for ED from age 12 to end of 2007. We used Cox regression modeling to investigate how ED incidence was associated with family socioeconomic position, parental age, and family composition.

RESULTS

In total, 3,251 cases of ED (2,971 females; 280 males) were recorded. Higher parental education independently predicted a higher rate of ED in females [e.g., adjusted hazard ratio (HR) 1.69 (95% CI: 1.42, 2.02) for degree-level vs. elementary-level maternal education], but not in males [HR 0.73 (95% CI: 0.42, 1.28), p < 0.001 for gender interaction]. In females, an increasing number of full-siblings was associated with lower rate of ED [e.g., fully adjusted HR 0.92 (95% CI: 0.88, 0.97) per sibling], whereas an increasing number of half-siblings was associated with a higher rate [HR 1.05 (95% CI: 1.01, 1.09) per sibling].

DISCUSSION

The effect of parental education on ED rate varies between males and females, whereas the effect of number of siblings varies according to whether they are full or half-siblings. A deeper understanding of these associations and their underlying mechanisms may provide etiological insights and inform the design of preventive interventions.

Parental divorce and disordered eating: an investigation of a gene-environment interaction

OBJECTIVE

We investigated gene-environment interactions (GxE) for associations between parental divorce and disordered eating (DE).

METHOD

Participants were 1,810 female twins from the Michigan State University Twin Registry and the Minnesota Twin Family Study. The Minnesota Eating Behaviors Survey was used to assess DE. We tested for GxE by comparing the heritability of DE in twins from divorced versus intact families. It was hypothesized that divorce would moderate the heritability of DE, in that heritability would be higher in twins from divorced than twins from intact families.

RESULTS

As expected, the heritability of body dissatisfaction was significantly higher in twins from divorced than intact families. However, genetic influences were equal in twins from divorced and intact families for all other forms of DE.

DISCUSSION

Although divorce did not moderate heritability of most DE symptoms, future research should replicate GxEs for body dissatisfaction and identify factors underlying this unique relationship.

Parental psychopathology as a predictor of long-term outcome in bulimia nervosa patients

This paper sought to examine parental variables as predictors of long-term outcome in women with bulimia nervosa (BN). Participants were 94 treatment-seeking women with BN who were assessed at baseline, treatment end, and at follow-up (M=10.13 years). Participants reported rates of psychopathology and obesity in their mothers and fathers at baseline. The most frequently reported parental psychopathology was substance abuse in fathers. Chi-square analyses indicated that substance abuse in fathers was associated with poor treatment-end outcome in BN participants. Depression in mothers was associated with poor outcome at long-term follow-up, and obesity in mothers was associated with better outcome at long-term follow-up. A logistic regression analysis found that lifetime mood disorder in participants and severe depression in mothers were independent predictors of bulimic symptoms at long-term follow-up. The association between maternal severe depression and long-term outcome in BN suggests that specific parental variables may indicate longer course of BN.

Childhood body-focused behaviors and social behaviors as risk factors of eating disorders

BACKGROUND

The risk factors for adolescent eating disorders are poorly understood. It is generally agreed, however, that interactions with one's body and interactions with others are two important features in the development of anorexia and bulimia nervosa. Therefore, we assessed a variety of childhood body-focused behaviors and childhood social behaviors in eating-disordered patients as compared to non-eating-disordered subjects.

METHOD

We compared 50 female inpatients with eating disorders (anorexia or bulimia nervosa), 50 female inpatients with polysubstance dependence, and 50 nonpatient female control subjects with no history of eating or substance abuse disorders (all defined by DSM-IV criteria), using a semi-structured interview of our own design. We asked questions about (1) childhood body-focused behaviors (e.g. thumb-sucking) and body-focused family experiences (e.g. bodily caresses), and (2) childhood social behaviors (e.g. numbers of close friends) and family social styles (e.g. authoritarian upbringing).

RESULTS

Many body-focused measures, such as feeding problems, auto-aggressive behavior, lack of maternal caresses, and family taboos regarding nudity and sexuality, characterized eating-disordered patients as opposed to both comparison groups, as did several social behaviors, such as adjustment problems at school and lack of close friends. However, nail-biting, insecure parental bonding, and childhood physical and sexual abuse were equally elevated in both psychiatric groups.

CONCLUSION

It appears that eating-disordered patients, as compared to substance-dependent patients and healthy controls, show a distinct pattern of body-focused and social behaviors during childhood, characterized by self-harm, a rigid and 'body-denying' family climate, and lack of intimacy.

Expressed emotion, family environment, and parental bonding in bulimia nervosa: a 6-year investigation

As part of a prospective, long-term treatment study, 30 in-patients with bulimia nervosa (BN) were divided into groups with high and low expressed emotion (EE) family backgrounds according to the Camberwell Family Interview, and followed for a period of six years. The high EE group initially showed significantly more psychopathology than the low EE group. No group x time interactions were found, but the high EE group showed a worse outcome on the "conflict" and "organisation" subscales of the Family Environment Scale. They also showed significantly more eating disorder pathology according to the Eating Disorder Inventory (EDI) and the Structured Interview for anorexia nervosa (AN) and BN before treatment at discharge, after two years and, to some degree, even after six years. Depth of depression (Beck Depression Inventory) was significantly higher in the high EE group at admission (moderate depression), discharge and after the 6-year follow-up (still slight depression). The Parental Bonding Instrument (PBI) showed no differences between the high EE and low EE groups, but the individuals with "affectionless control" according to the PBI had more negative scores on three of the subscales of the Family Environment Scale (FES). In brief, the high EE individuals with BN were initially sicker and did not fully catch up over time in comparison with the symptomatic recovery of the low EE individuals. These data suggest that EE status upon admission to in-patient treatment is a relevant predictor of the severity and course of BN and depressive symptoms.

Investigation of quality of the parental relationship as a risk factor for subclinical bulimia nervosa

OBJECTIVE

Previous literature suggests a link between the quality of the parental relationship and disordered eating in offspring. We investigated the relationship between offspring pyschopathology and the parental relationship using a population-based twin registry that contained 766 complete twin pairs.

METHOD

We used reports of twin lifetime psychopathology from the twins and quality of parental relationship and parental lifetime psychopathology from both parents.

RESULTS

Poorer quality of the marital relationship predicted the presence of subclinical bulimia nervosa (SBN) using both mother's (odds ratio [OR] = 0.83, 95% confidence interval [CI]: 0.71-0.97) and father's (OR = 0.78, 95% CI: 0.62-0.97) reports. It also predicted the presence of generalized anxiety disorder (GAD) and alcohol dependence. SBN was still strongly predicted by the marital relationship when parental psychopathology was included as a covariate.

DISCUSSION

These results are supportive of the notion that a conflictual and distant marital relationship can, at least partially, act as an environmental risk factor for SBN.

Self-directed hostility and family functioning in normal-weight bulimics and overweight binge eaters

The aim of this study was to examine whether overweight binge eaters demonstrate similar perceptions of family interactions and views of the self as do normal-weight bulimics. We compared 37 obese binge eaters and 37 normal-weight bulimics to 38 normal-weight non-bulimic controls, and 10 overweight nonbulimic controls on the Bulimia Test (BULIT). Profile of Mood States (POMS), Structural Analysis of Social Behavior (SASB) Short Form, which includes measure of hostility of family interactions and self-directed hostility; the Family Interaction Survey (FIS), and a measure of history of physical and sexual abuse and familial psychopathology. Both normal-weight bulimics and overweight binge eaters differed from nonbulimic controls across all measures of symptomatology, family functioning, history of abuse, familial psychopathology, and self-directed hostility. Normal-weight bulimics demonstrated significantly higher BULIT scores and self-directed hostility than did overweight binge eaters. Post hoc analysis showed that among binge eaters and bulimics, self-directed hostility accounted for a significant percentage of the variance of BULIT scores when controlling for the effects of age, BMI, family hostility, and mood. The possible role of self-directed hostility in the maintenance of bulimic symptomatology is discussed.