Symptom development in bulimia nervosa: a comparison of women with and without a history of anorexia nervosa

Clinical utility of subtyping binge eating disorder by history of anorexia or bulimia nervosa in a treatment sample

OBJECTIVE

This study examined whether having a history of anorexia nervosa (AN) or bulimia nervosa (BN) is associated with response to treatment in adults with binge eating disorder (BED).

METHOD

Data from 189 adults diagnosed with BED who were randomly assigned to one of three group cognitive-behavioral (CBT) treatments were analyzed to compare those with and without a history of AN/BN.

RESULTS

A total of 16% of the sample had a history of AN/BN. The BED subgroup with a history of AN/BN presented with higher rates of mood disorders and greater eating-related symptom severity at baseline. Participants with a history of AN/BN also had higher global eating disorder (ED) symptoms at end of treatment (EOT), and more frequent objective binge-eating episodes at EOT and 12-month follow-up.

DISCUSSION

These findings suggest that in adults with BED, a history of AN/BN is predictive of greater eating-related symptom severity following group-based CBT and poorer short- and long-term binge-eating outcomes. These findings suggest that considering ED history in the treatment of adults with BED may be clinically useful.

Trait-level and momentary correlates of bulimia nervosa with a history of anorexia nervosa

OBJECTIVE

Some investigators have suggested subtyping bulimia nervosa (BN) by anorexia nervosa (AN) history. We examined trait-level and momentary eating-related and psychosocial factors in BN with and without an AN history.

METHOD

Interview, questionnaire, and ecological momentary assessment data of eating-related and psychological symptoms were collected from 122 women with BN, including 43 with (BN+) and 79 without an AN history (BN-).

RESULTS

Body mass index (kg/m(2) ) was lower in BN+ than BN- (p = 0.001). Groups did not differ on trait-level anxiety, shape/weight concerns, psychiatric comorbidity, or dietary restraint; or on momentary anxiety, dietary restriction, binge eating, purging, or exercise frequency, or affective patterns surrounding binge/purge behaviors. Negative affect increased prior to exercise and decreased thereafter in BN+ but not BN-, although groups did not statistically differ.

DISCUSSION

Results do not support formally subtyping BN by AN history. Exercise in BN+ may modulate negative affect, which could have important treatment implications.

Bulimia nervosa with history of anorexia nervosa: could the clinical subtype of anorexia have implications for clinical status and treatment response?

OBJECTIVE

To investigate whether the subtype of anorexia nervosa (AN) could influence the bulimic syndrome and treatment response in bulimia nervosa (BN) patients with a history of AN (BN/AN+).

METHOD

Seventy female BN patients were assessed for eating disorder, psychopathology and personality, and treated for 6 months.

RESULTS

BN/AN+ patients retained some traits of their past condition: lower body weight, higher perfectionism, and higher reward dependence. They also had more severe symptoms, longer evolution time, and worse response to treatment. A history of restricting AN was associated to higher age, longer evolution time, higher impulsivity, and greater tendency to use diet pills and diuretics. A history of binge-purging AN was associated to more severe vomiting, lower body dissatisfaction and less depressive symptoms, as well as better outcome.

DISCUSSION

The influence of the AN subtype in BN/AN+ patients is worthy of further study as it might have clinical implications.

Investigation of factors associated to crossover from anorexia nervosa restricting type (ANR) and anorexia nervosa binge-purging type (ANBP) to bulimia nervosa and comparison of bulimia nervosa patients with or without previous ANR or ANBP

OBJECTIVE

To characterize factors associated to diagnostic crossover from anorexia nervosa restricting type (ANR) and anorexia nervosa binge-purging type (ANBP) to bulimia nervosa (BN) and to compare BN individuals with initial ANR or ANBP to subjects with stable BN.

METHOD

Two hundred thirty-eight patients with current and lifetime diagnosis of AN or BN underwent diagnostic, psychopathological, and historical examinations by means of ad hoc clinical interviews and rating scales.

RESULTS

One hundred twenty-three individuals had a stable BN. Seventy patients had a diagnosis of ANR and 45 of ANBP at the time of disease onset; 24 ANR patients and 23 ANBP subjects developed BN, whereas 46 ANR patients and 22 ANBP subjects did not crossover. Although the rate of diagnostic crossover was higher in the ANBP group than in the ANR one, the difference was not statistically significant. Longer illness duration, higher maximum past body mass index (BMI), higher novelty seeking, and lower self-directedness resulted significantly associated to crossover from ANR to BN, whereas higher maximum past BMI, higher desired body weight, higher novelty seeking, and lower harm avoidance were significantly associated to crossover from ANBP to BN. As compared to stable BN subjects, BN patients with initial ANR exhibited lower minimum past BMI, lower desired body weight, higher drive for thinness, ascetism, and social insecurity scores; BN patients with initial ANBP exhibited lower minimum past BMI and decreased enteroceptive awareness scores.

CONCLUSIONS

Different clinical and personality factors seem to be associated to crossover from ANR and ANBP to BN. Moreover, BN with initial ANR seems to differ clinically from stable BN. These findings may have therapeutic and prognostic implications.

Revisiting differences in individuals with bulimia nervosa with and without a history of anorexia nervosa: Eating pathology, personality, and maltreatment

OBJECTIVE

Early research in subtyping bulimia nervosa (BN) by history of anorexia nervosa (AN) generally found more similarities than differences, but recent research and limitations of the early work suggest the need to revisit this approach. We examine differences between women with BN with and without a history of AN regarding eating pathology, personality, and childhood maltreatment.

METHOD

Participants were women (aged 18-55) recruited from the community and eating disorder clinics who met DSM-IV criteria for BN; 37 had a history of AN and 101 did not. Participants completed questionnaires related to eating disorder pathology, multidimensional perfectionism, multidimensional impulsivity, and childhood maltreatment.

RESULTS

Women with BN and a history of AN had higher levels of dietary restraint and purging and lower body mass indices as well as higher levels of all forms of childhood neglect and abuse. In contrast, no group differences were found for perfectionism or impulsivity dimensions.

CONCLUSION

The group differences in terms of eating pathology and maltreatment have clinical implications. Further research is needed regarding if and how a history of AN among those with BN may reflect different etiological pathways and predict different outcomes.

Should bulimia nervosa be subtyped by history of anorexia nervosa? A longitudinal validation

OBJECTIVE

To determine whether a past diagnosis of anorexia nervosa (AN) predicts longitudinal course and outcome among women with bulimia nervosa (BN).

METHOD

A subset (n = 176) of participants in the Longitudinal Study of Anorexia and Bulimia Nervosa who met DSM-IV criteria for BN either at study intake (n = 144) or during follow-up (n = 32; 4 had restricting AN at intake, 28 had binge/purge AN at intake) were included in this report. Over a median of 9 years, weekly eating disorder symptom data were collected from participants using the Longitudinal Interview Follow-up Examination, Eating Disorders Version.

RESULTS

While there were no between-group differences in likelihood of partial recovery, women with BN who had a history of AN were more likely to have a protracted illness, relapsing into AN during follow-up, compared to those with no AN history who were more likely to move from partial to full recovery.

CONCLUSION

Lifetime AN is an important prognostic indicator among women with BN and these longitudinal data would support the subtyping of BN on the basis of AN history.

History of anorexia nervosa in bulimic patients: its influence on body composition

OBJECTIVE

To analyze the body composition of a group of patients fulfilling DSM-IV criteria for bulimia nervosa (BN), comparing the patients who had a history of DSM-IV anorexia nervosa (AN) with those without such a history to determine (1) whether both groups differed in terms of body composition and (2) whether the differences between groups could be the consequence of the past condition.

METHODS

The sample consisted of 104 patients, 43 with prior AN (BN-AN group) and 61 without a history of AN (BN-nonAN). The patients were assessed using anthropometric and bioelectrical methods: height and weight, body circumferences, abdominal diameter, skinfold thickness, and body impedance analysis. In a later phase and to test the influence of current low weight on the results, two experimental groups were created: the first group was composed of the patients from the BN-AN group who had a normal body mass index (BMI range in this group, 20.1-23.4 kg/m2; n = 23); the second group consisted of 23 patients from the BN-nonAN group in the same BMI range. In both phases unpaired sample t tests were performed for statistical analysis.

RESULTS

More than 40% of the bulimic patients with a history of AN had a BMI less than 20. They had a lower percentage of body fat, lower muscle mass, and higher percentage of extracellular water. Nevertheless, most of these differences disappeared in the second phase of the analysis, when only the patients within a normal weight range were compared.

DISCUSSION

According to these results, a significant number of bulimic patients with a history of AN tend to retain some clinical traits of the past condition and could be viewed as remaining in a "subclinical anorexic status": they are thinner and seem to have less difficulties in maintaining low weight than patients without a history of AN. Nevertheless, in patients who have reached a normal weight after AN, all these differences disappear. This fact raises some important questions related to the boundaries between AN and BN, the shifting from one to another, or when AN patients really recover.

Bulimia nervosa: an update and treatment recommendations

Bulimia nervosa is a common eating disorder in adolescent women. Biological, psychological, and social factors are implicated in onset and important in treatment. Diagnosis of the syndrome, but not its subtypes, can be made well using the DSM-IV system. Screening tools, laboratory findings, and physical findings can be helpful in making the diagnosis. Comorbid disorders include affective disorders, addictive disorders, anxiety disorders, personality disorders, and anorexia nervosa. The etiology of bulimia nervosa is complex, with biologic, psychological, social, and family factors, which likely differ somewhat from patient to patient. Treatment, accordingly, should be comprehensive, individualized, and multifaceted. Many patients respond well to the use of an antidepressant, and cognitive-behavioral therapy is a useful approach for many patients. Combining these two treatments seems to be a good strategy. Environmental and family issues also need to be addressed. Many patients are treated insufficiently. More research on bulimia nervosa specific to adolescence is needed.

The validity of a short version of the Body Shape Questionnaire

This study investigated the 'construct validity' (which includes the extent to which a test conforms to predictions from previous observations) of a 14-item version of the Body Shape Questionnaire (BSQ) in 75 patients with psychogenic low weight and a history of full or partial anorexia nervosa (AN). Various predictions were confirmed, i.e. ratings on the BSQ (designed to measure concern about body image) were significantly correlated with ratings for the Eating Attitudes Test, the Bulimia Investigatory Test and the Beck Depression Inventory, and with the body mass index at referral. Also, the binge eating/purging subtype of AN was associated with increased body-image psychopathology. In contrast to a previous report using another questionnaire, this association was independent of body weight. The findings indicate that this shorter version of the BSQ can be used to assess body image psychopathology in patients with psychogenic low weight and to confirm an increased concern about body-image in the binge-eating/purging subtype of AN.