Predictors of binge eating in restrictive anorexia nervosa patients in Italy

The transition from restrictive anorexia nervosa to binging and purging: a systematic review and meta-analysis

Numerous studies addressed the topic of behavioral and symptomatic changes in eating disorders. Rates of transition vary widely across studies, ranging from 0 to 70.8%, depending on the diagnoses taken into account and the study design. Evidence shows that the specific transition from restrictive-type anorexia nervosa (AN-R) to disorders involving binging and purging behaviors (BPB) is related to a worsening of the clinical picture and worse long-term outcomes. The aim of this systematic review and meta-analysis is to focus on this specific transition, review existing literature, and summarize related risk factors. Medline and PsycINFO databases were searched, including prospective and retrospective studies on individuals with AN-R. The primary outcome considered was the rate of onset of BPB. Twelve studies (N = 725 patients) were included in the qualitative and quantitative analysis. A total of 41.84% (95% CI 33.58-50.11) of patients with AN-R manifested BPB at some point during follow-up. Risk factors for the onset of BPB included potentially treatable and untreatable factors such as the family environment, unipolar depression and higher premorbid BMI. These findings highlight that patients with AN-R frequently transition to BPB over time, with a worsening of the clinical picture. Existing studies in this field are still insufficient and heterogeneous, and further research is needed. Mental health professionals should be aware of the frequent onset of BPB in AN-R and its risk factors and take this information into account in the treatment of AN-R. LEVEL OF EVIDENCE: Evidence obtained from a systematic review and meta-analysis, Level I.

Refeeding syndrome in patients with anorexia nervosa - case reports

Introduction: Refeeding syndrome RS is a life-threatening acute hormonal and metabolic disorder that occurs in patients with moderate or severe malnutrition as a result of improperly administered nutritional therapy.

Material and method: The aim of this study is to describe the cases of two female patients suffering from anorexia nervosa, who developed a refeeding syndrome after starting nutritional therapy. Additionally, the available literature was reviewed in order to characterize the issue, including negative consequences and prevention of the refeeding syndrome.

Results: In both cases, the development of the refeeding syndrome was found in the patients, resulting from the excessive supply of energy and nutritional substrates in a short time, preceded by a previous, months long period of starvation and exhaustion of the organism (both patients had a decrease in the body mass index - BMI - to the value of about 14 kg / m2). In patient 1, the symptoms concerned mainly the cardiovascular system: a significant increase in the concentration of N-terminal B-type natriuretic propeptide (NT-proBNP) and tachycardia, as well as a decrease in the concentration of inorganic phosphates and hypokalemia. On the other hand, in the case of patient 2, symptoms such as confusion or deep disturbances of consciousness, which led to hospitalization in the intensive care unit, dominated the clinical picture.

Conclusions: Refeeding syndrome may develop during nutritional rehabilitation, especially in the case of a sudden, inadequately planned supply of nutrients. Particular care should be taken in patients with extremely low BMI when reintroducing nutrition.

The presented case reports draw attention to the possibility of cardiological complications and mental disorders of the realimentation syndrome, and indicate the behavior of patients (eating excessive food) that may lead to the development of the refeeding syndrome.

The role of self-esteem in the treatment of patients with anorexia nervosa - A systematic review and meta-analysis

OBJECTIVE

We aimed to provide a comprehensive overview of the role of self-esteem in the treatment of patients with anorexia nervosa (AN). Specifically, our objectives were to investigate the differences in self-esteem between individuals with AN and healthy controls, or individuals with other eating disorders, and to examine self-esteem as an outcome, predictor, moderator, and mediator in AN treatment.

METHOD

The databases PsycINFO, PSYNDEXplus, Ovid MEDLINE®, and ProQuest were searched for studies published from 1990 to 2018. To estimate aggregated effect sizes, we performed random-effects meta-analyses.

RESULTS

A screening of 1,596 abstracts and 203 full-texts identified 68 relevant publications. Results suggest a significantly lower global self-esteem in individuals with AN than in healthy controls (d = -1.90, p < .001). In contrast, global self-esteem of AN and bulimia nervosa (BN) patients was found to be comparable (d = 0.05, p = .529). It might be specific to AN patients that negative self-evaluations may not affect scholastic and professional abilities. Significantly moderate self-esteem increases were observed in treated AN patients at the end of treatment (d = 0.56, p < .001), short-term (d = 0.50, p < .001), and long-term (d = 0.75, p < .001) follow-up. Self-esteem did not predict end of treatment remission-or weight-related outcome and treatment dropout. However, small to moderate predictive effects were detected on short-term (r = .15, p = .007) and long-term remission or weight (r = .33, p = .017). Finally, first indications point to self-esteem as a mediator in adult AN inpatient treatment.

DISCUSSION

The review provides insights relevant for theory, research, and practice. Implications concern the overall support for transdiagnostic approaches and the recommendation to consider low initial self-esteem for decisions on after-care.

Social cognition in children at familial high-risk of developing an eating disorder

Objective: Diagnosis of an eating disorder (ED) has been associated with differences in social cognition. To date research investigating social cognition and ED has mainly employed patient and recovered samples. It is therefore unclear whether differences in social cognition are present prior to onset of ED, potentially contributing to development, or whether differences observed are a consequence of the disorder. We aimed to further explore whether individuals at high-risk for ED present social cognition characteristics previously found in ED groups.

Methods: Our sample was drawn from a population-based cohort, the Avon Longitudinal Study of Parents and Children (ALSPAC). Data on maternal ED behaviors over the lifetime were collected through in-depth clinical interviews (n = 1128) conducted using the Structured Clinical Interview for DSM disorders (SCID), and were used to categorize mothers according to ED behaviors over the lifetime: Restricting and Excessive Exercising (n = 58), Purging (n = 70), Binge-eating (n = 72), Binging and Purging (n = 66), no ED (n = 862). High-risk status of children was determined using these maternal lifetime behavioral phenotypes. Children at high-risk (maternal ED exposure) were compared to children at low-risk (born to mothers with no ED) on three measures of social cognition: the Social Communication Disorders Checklist (SCDC) (n = 922), the faces subtest of the Diagnostic Analysis of Non-Verbal Accuracy (DANVA) (n = 722), and the Emotional Triangles Task (n = 750).

Results: Children at high-risk for ED showed poorer performance on measures of social cognition compared to children at low-risk. Maternal lifetime binge-eating, and maternal lifetime binging and purging were associated with poorer social communication in children (OR: 2.4, 95% CI: 1.0, 5.7, p = 0.05; and OR: 2.7, 95% CI: 1.1, 6.5, p = 0.03 respectively). Maternal binging and purging was also found to be associated with differential facial emotion processing and poorer recognition of fear from social motion cues (B: −0.7, 95% CI: −1.1, −0.2, p = 0.004).

Discussion: Children at high-risk for ED showed slight differences in some areas of social cognition when compared to children at low-risk. Characteristic patterns in social cognition are present in children at high-risk for ED, particularly among children whose mothers have binge-eating and purging behaviors over the lifetime. Our findings support the hypothesis that these differences may be part of an intermediate phenotype for ED: perhaps contributing to development, or perhaps indexing a shared liability with psychiatric disorders characterized by abnormal social cognition.

Puberty as a critical risk period for eating disorders: a review of human and animal studies

This article is part of a Special Issue "Puberty and Adolescence". Puberty is one of the most frequently discussed risk periods for the development of eating disorders. Prevailing theories propose environmentally mediated sources of risk arising from the psychosocial effects (e.g., increased body dissatisfaction, decreased self-esteem) of pubertal development in girls. However, recent research highlights the potential role of ovarian hormones in phenotypic and genetic risk for eating disorders during puberty. The goal of this paper is to review data from human and animal studies in support of puberty as a critical risk period for eating disorders and evaluate the evidence for hormonal contributions. Data are consistent in suggesting that both pubertal status and pubertal timing significantly impact risk for most eating disorders in girls, such that advanced pubertal development and early pubertal timing are associated with increased rates of eating disorders and their symptoms in both cross-sectional and longitudinal research. Findings in boys have been much less consistent and suggest a smaller role for puberty in risk for eating disorders in boys. Twin and animal studies indicate that at least part of the female-specific risk is due to genetic factors associated with estrogen activation at puberty. In conclusion, data thus far support a role for puberty in risk for eating disorders and highlight the need for additional human and animal studies of hormonal and genetic risk for eating disorders during puberty.

Motor inhibition and cognitive flexibility in eating disorder subtypes

Anorexia Nervosa (AN) and Bulimia Nervosa (BN) are complex Eating Disorders (EDs). Even if are considered two different diagnostic categories, they share clinical relevant characteristics. The evaluation of neurocognitive functions, using standardized neuropsychological assessment, could be a interesting approach to better understand differences and similarities between diagnostic categories and clinical subtypes in EDs thus improving our knowledge of the pathophisiology of EDs spectrum. This study explored cognitive flexibility and motor inhibition in patients with AN considering both Restricter and Binge/Purge subtypes, patients with BN and healthy comparisons subjects (HC). Intra-Extra Dimentional Set shifting Test and Stop Signal Task, selected from CANTAB battery, were administered to analyzed set-shifting and motor inhibition respectively. AN patients showed a deficient motor inhibition compared to HC, while no evidence for impaired motor inhibition was found in BN patients; a significant relationship between commission errors in the Stop Signal Task and attentional impulsiveness was found. Moreover, no difference in set-shifting abilities was found comparing all clinician groups and HC. So our results indicated no cognitive impairment in these two cognitive functions in BN patients, while AN and BN showed different performances in motor inhibition. A similar cognitive profile was found in other obsessive compulsive spectrum disorders. Finally, the paper suggests a new interactive approach for the study of cognitive profile in psychiatric disorders; it might be more useful since it is more closely related to the executive functions complexity.

An investigation of the joint longitudinal trajectories of low body weight, binge eating, and purging in women with anorexia nervosa and bulimia nervosa

OBJECTIVES

To describe the longitudinal course of three core eating disorder symptoms-low body weight, binge eating, and purging-in women with anorexia nervosa (AN) and bulimia nervosa (BN) using a novel statistical approach.

METHOD

Treatment-seeking women with AN (n = 136) or BN (n = 110) completed the Eating Disorders Longitudinal Interval Follow-Up Evaluation interview every 6 months, yielding weekly eating disorder symptom data for a 5-year period. Semiparametric mixture modeling was used to identify longitudinal trajectories for the three core symptoms.

RESULTS

Four individual trajectories were identified for each eating disorder symptom. The number and general shape of the individual trajectories was similar across symptoms, with each model including trajectories depicting stable absence and stable presence of symptoms as well as one or more trajectories depicting the declining presence of symptoms. Unique trajectories were found for low body weight (fluctuating presence) and purging (increasing presence). Conjunction analyses yielded the following joint trajectories: low body weight and binge eating, low body weight and purging, and binge eating and purging.

DISCUSSION

The course of individual eating disorder symptoms among patients with AN and BN is highly variable. Future research identifying clinical predictors of trajectory membership may inform treatment and nosological research.

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.

Psychiatric comorbidities among female adolescents with anorexia nervosa

This study investigated current comorbid Axis I diagnoses associated with Anorexia Nervosa (AN) in adolescents. The sample included 101 female adolescents treated at a psychiatric unit for primary DSM-IV diagnoses of AN. 73.3% of the AN patients were diagnosed as having a current comorbidity of at least one comorbid Axis I diagnosis, with no differences across AN subtypes. Mood disorders (60.4%) were most commonly identified, followed by the category anxiety disorders without obsessive-compulsive disorders (OCD) (25.7%), OCD (16.8%) and substance use disorders (7.9%). Two specific diagnoses differed across the two subtypes of AN. Substance use disorder was 18 times, and the category anxiety disorder without OCD was three times as likely to co-occur with AN binge-eating disorder and purging type than with AN restricting type. Clinicians should be alerted to the particularly high rate of psychiatric comorbidities in adolescents suffering from AN.

Psychological and weight-related characteristics of patients with anorexia nervosa-restricting type who later develop bulimia nervosa

Background

Patients with anorexia nervosa-restricting type (AN-R) sometimes develop accompanying bulimic symptoms or the full syndrome of bulimia nervosa (BN). If clinicians could predict who might change into the bulimic sub-type or BN, preventative steps could be taken. Therefore, we investigated anthropometric and psychological factors possibly associated with such changes.

Method

All participants were from a study by the Japanese Genetic Research Group for Eating Disorders. Of 80 patients initially diagnosed with AN-R, 22 changed to the AN-Binge Eating/Purging Type (AN-BP) and 14 to BN for some period of time. The remaining 44 patients remained AN-R only from the onset to the investigation period. Variables compared by ANOVA included anthropometric measures, personality traits such as Multiple Perfectionism Scale scores and Temperament and Character Inventory scores, and Beck Depression Inventory-II scores.

Results

In comparison with AN-R only patients, those who developed BN had significantly higher current BMI (p < 0.05) and maximum BMI in the past (p < 0.05). They also scored significantly higher for the psychological characteristic of parental criticism (p < 0.05) and lower in self-directedness (p < 0.05), which confirms previous reports, but these differences disappeared when the depression score was used as a co-variant. No significant differences were obtained for personality traits or depression among the AN-R only patients irrespective of their duration of illness.

Conclusion

The present findings suggest a tendency toward obesity among patients who cross over from AN-R to BN. Low self-directedness and high parental criticism may be associated with the development of BN by patients with AN-R, although the differences may also be associated with depression.