Axes I and II comorbidity and treatment experiences in eating disorder subjects

Research on feeding and eating disorders in India: A narrative review

Despite growing evidence of their prevalence, research on feeding and eating disorders (FEDs) in India has been sporadic. This narrative review aimed to summarize the research on FED in India and set priorities for future research and translation of evidence. An electronic search was conducted in the MEDLINE, PsycINFO, and Google Scholar databases to identify relevant English peer-reviewed articles from April 1967 to July 2023. The extracted data from these studies included author names, publication year, research location, type of intervention (for interventional studies), nature of comparator treatments, and main outcomes or findings. We found a rising trend in the prevalence of EDs in India. Adolescent age group, female sex, higher socioeconomic status, family history of mental illness or disordered eating, and borderline personality pattern were risk factors for EDs. For feeding disorders (FDs), childhood age group, malnutrition, pregnancy, psychosis, intellectual disability (ID), and obsessive-compulsive disorder (OCD) were putative risk factors. Both physical and psychiatric comorbidities were common in FEDs. Culture appears to exert a pathoplastic effect on symptom presentation in FEDs; an illustrative example is the documented nonfat phobic variant of anorexia nervosa (AN) in India. Research on management has focused on using assessment tools, investigations to rule out medical comorbidities, psychosocial and family-based psychotherapies, nutritional rehabilitation, pharmacotherapy, and neuromodulation approaches. Whereas the publication output on FEDs in India has increased over the last decade, it remains an under-researched area, with a striking paucity of original research. Future research priorities in FEDs include conducting country-wide registry-based studies to offer real-world insights, longitudinal research to identify culturally relevant risk factors, and developing brief, culturally sensitive diagnostic instruments for FEDs in the Indian context. This will help generate locally relevant epidemiological data on FEDs and inform treatment and prevention strategies.

An investigation of the dual continua model of mental health in the context of eating disorder symptomatology using latent profile analysis

OBJECTIVE

The dual continua model of mental health suggests that mental well-being and mental illness are two distinct continua that are interrelated in their contributions to overall mental health. This study investigated the dual continua model in individuals with eating disorder symptoms.

METHOD

Female university students (N = 346) completed measures of mental well-being, eating disorder symptomatology, clinical impairment and psychological distress. Confirmatory factor and latent profile analyses were used to derive underlying mental health profiles.

RESULTS

Results revealed two oblique factors representing the mental well-being and eating disorder symptomatology constructs and four unique mental health profiles that were partially consistent with the dual continua model emerged: 'flourishing', 'vulnerable', 'partially symptomatic and content', and 'languishing'. The derived mental health profiles had unique characteristics described by psychological distress and clinical impairment.

CONCLUSIONS

The results did not provide conclusive evidence for the dual continua model as they could also be interpreted in a manner consistent with the unidimensional approach. While the dual continua model is a promising avenue to understand mental health in a way that looks beyond symptoms, these results caution against its rapid adoption and encourage future research to understand how eating disorder symptomatology and positive mental health assets contribute to overall mental health.

Sleep Pathologies and Eating Disorders: A Crossroad for Neurology, Psychiatry and Nutrition

The intricate connection between eating behaviors and sleep habits is often overlooked in clinical practice, despite their profound interdependence. Sleep plays a key role in modulating psychological, hormonal and metabolic balance and exerting an influence on food choices. Conversely, various eating disorders may affect sleep continuity, sometimes promoting the development of sleep pathologies. Neurologists, nutritionists and psychiatrists tend to focus on these issues separately, resulting in a failure to recognize the full extent of the clinical conditions. This detrimental separation can lead to underestimation, misdiagnosis and inappropriate therapeutic interventions. In this review, we aim to provide a comprehensive understanding of the tangled relationship between sleep, sleep pathologies and eating disorders, by incorporating the perspective of sleep experts, psychologists and psychiatrists. Our goal is to identify a practical crossroad integrating the expertise of all the involved specialists.

Testing intrusive thoughts as illness pathways between eating disorders and obsessive-compulsive disorder symptoms: a network analysis

Obsessive-compulsive disorder (OCD) and eating disorders (EDs) frequently co-occur. Intrusive thoughts are a mechanism that may maintain this comorbidity. This study used network analysis to identify central ED-related intrusive thoughts and tested which intrusive thoughts connected ED and OCD symptoms. Two cross-sectional graphical LASSO networks were computed using a sample of 353 non-clinical participants (mean age = 35.38, SD = 9.9, 40% female, 81.6% Caucasian) with elevated disordered eating symptoms. Model 1 included just ED-related intrusive thoughts, and Model 2 included ED-related intrusive thoughts, ED, and OCD symptoms. In Model 1, we found that thoughts about one's bodily appearance (i.e., looking horrible, getting fat, gaining weight) were most central. In Model 2, we found that desire to lose weight, eating in secret, and shape dissatisfaction were most central. We identified one illness pathway (i.e., difficulty concentrating due to thoughts of food/calories) connecting intrusive thoughts, ED symptoms, and OCD symptoms. However, intrusive thoughts did not bridge ED and OCD symptoms. Hence, we found some evidence that ED-related intrusive thoughts may contribute to ED and OCD symptoms based on thought content and frequency. However, other aspects of intrusive thoughts should be considered to ascertain whether they do in fact significantly contribute to ED and OCD comorbidity. Prevention efforts targeting ED-related intrusive thoughts may attenuate ED and OCD symptoms among subclinical individuals.

Psychiatric Comorbidity Among Eating Disorders and Obsessive-Compulsive Disorder and Underlying Shared Mechanisms and Features: An Updated Review

Eating disorders (EDs) are highly comorbid with obsessive-compulsive disorder (OCD), with comorbidity rates as high as 41%. In the current review, we summarize the literature regarding the prevalence of ED-OCD comorbidity. We also identify and review the literature assessing shared features (i.e., shared characteristics or symptoms) and mechanisms (i.e., variables that may explain ED or OCD symptoms) of EDs and OCD. Potential shared features of EDs and OCD include age of onset, course of illness, obsessions, compulsions and ritualistic behaviors, and thought action fusion. Shared mechanisms that may explain ED-OCD comorbidity include genetic and neurobiological mechanisms, anxiety and fear, repetitive negative thinking, perfectionism, intolerance of uncertainty, distress tolerance, and impulsivity. Based on these shared features and mechanisms, a theoretical conceptualization of ED and OCD comorbidity is developed, and outline considerations for assessment, differential diagnosis, treatment, and future research regarding ED-OCD comorbidity are described.

The experience of healthcare professionals treating adolescents with eating disorders in psychiatric and pediatric inpatient units for adolescents: A qualitative study

OBJECTIVES

The recommended treatment for Eating Disorders (EDs) is multidisciplinary and multimodal. Nonetheless, the complex linkage of the different disciplines involved is not necessarily simple. We analyzed the experience of healthcare professionals faced with psychiatric and psychological symptoms in adolescents with EDs in two "multidisciplinary" inpatient units embedded predominantly in different paradigms - one pediatric and one psychiatric.

METHODS

Qualitative analysis of 20 healthcare staff members' interviews from different professional backgrounds working in inpatient units for EDs in Montreal (Canada) and Paris (France).

RESULTS

The "Complex patients" theme discusses the need for a global approach to the multiplicity of symptoms presented by these patients. "Management and its limits" describes the daily management of psychiatric symptoms in both units. "Psychiatry and Adolescent medicine: from opposition to collaboration" describes the different levels at which these disciplines work together and how this cooperation may be evolving.

CONCLUSIONS

The complex entanglement intrinsic in EDs of the patients' somatic, psychosocial, psychiatric, and adolescent problems requires collaboration between disciplines, but the modalities of this collaboration are multiple and evolve non-linearly in specialized treatment units. A multilevel approach must be offered, with the degree of collaboration (multidisciplinary, interdisciplinary and transdisciplinary) appropriate to the complexity of each adolescent's issues.

Broad and Narrow Transdiagnostic Risk Factors in Eating Disorders: A Preliminary Study on an Italian Clinical Sample

Eating disorders are multifaceted psychopathologies and the transdiagnostic approach is currently considered a useful framework to understand their complexity. This preliminary study aimed to investigate both broad (i.e., intolerance of uncertainty and emotion dysregulation) and narrow (i.e., extreme body dissatisfaction) transdiagnostic risk factors underlying eating disorders. 50 Italian female patients seeking treatment for an eating disorder were involved (M_age = 31.6 years ± 12.8, 18–65). They completed self-report measures assessing emotion regulation difficulties, intolerance of uncertainty, extreme body dissatisfaction, general psychological distress, and eating disorder symptomatology. To explore whether the abovementioned transdiagnostic factors predicted patients’ psychological distress and eating disorder symptoms, two linear regressions were performed. Emotion dysregulation emerged as the only significant predictor of distress, while extreme body dissatisfaction was the only significant predictor of overall eating disorder symptomatology. Then, to analyze the differences between patients with anorexia nervosa and bulimia nervosa in intolerance of uncertainty and emotion regulation problems, t-tests were conducted. The two groups differed significantly in intolerance of uncertainty levels only, with higher scores obtained by patients with anorexia nervosa. Overall, our findings suggest that emotion dysregulation and extreme body dissatisfaction may be relevant constructs in eating disorders in general, while intolerance of uncertainty may be more involved in restrictive eating disorders. The clinical implications of such results are discussed.

Intolerance of uncertainty and maladaptive perfectionism as maintenance factors for eating disorders and obsessive-compulsive disorder symptoms

OBJECTIVE

Eating disorders (EDs) are highly comorbid with obsessive-compulsive disorder (OCD). In order to develop treatments which better address commonly comorbid ED and OCD symptoms, it is important to identify potential shared mechanisms. Two potential shared mechanisms are maladaptive perfectionism and intolerance of uncertainty (IU). We aimed to assess how maladaptive perfectionism and IU may contribute to the maintenance of ED and OCD symptoms in individuals with EDs.

METHODS

In the current study (N = 168 individuals with an ED), we analysed cross-sectional and prospective path models of maladaptive perfectionism and IU as maintenance factors of ED and OCD symptoms.

RESULTS

We found that IU was associated with both ED and OCD symptoms, and maladaptive perfectionism was associated with ED symptoms. We also found that maladaptive perfectionism and IU prospectively predicted OCD symptoms, but not ED symptoms.

CONCLUSIONS

Overall, these findings suggest that it may be beneficial to target both maladaptive perfectionism and IU in individuals with a current ED diagnosis in order to prevent the development of OCD symptoms.

Negative beliefs about the self prospectively predict eating disorder severity among undergraduate women

Social anxiety disorder (SAD) and eating disorders (EDs) are highly comorbid. Negative self-portrayal, or 'perceived flaws in the self,' is a key feature of SAD and consists of three self-critical aspects that are presumed to be flawed: social competence, physical appearance, and signs of anxiety. Negative self-portrayal has yet to be studied among EDs, despite research suggesting that individuals with EDs have a greater negative self-image and self-criticism. The identification of negative self-portrayal as a shared risk factor for SAD and EDs may have important implications for both prevention and treatment. The current study (N = 300 undergraduate women) aimed to extend negative self-portrayal theory to the EDs. We found that several aspects of negative self-portrayal were related to ED severity and that physical appearance concerns predicted subsequent ED severity. In a cross-sectional model of shared vulnerability, we found that physical appearance concerns were a shared correlate of SAD and ED symptoms. In a prospective shared vulnerability model, we found that (a) physical appearance prospectively predicted ED severity and (b) symptoms of SAD prospectively predicted all aspects of negative self-portrayal. Concerns about flaws in appearance should be targeted in the treatment of EDs, as this aspect of negative self-portrayal was shown to predict subsequent ED severity. Future research should further investigate the theory of negative self-portrayal as it pertains to EDs.

Eating disorders and posttraumatic stress disorder

PURPOSE OF REVIEW

Childhood maltreatment is associated with all types of eating disorders. We provide a systematic review of the recent literature on comorbid posttraumatic stress disorder (PTSD) in patients with eating disorders, and focus on prevalence, relationship with symptom severity, operating mechanisms and treatment.

RECENT FINDINGS

The prevalence of comorbid PTSD in patients with eating disorders ranges from 9 to 24%, with research suggesting that comorbid PTSD is associated with more severe eating disorder symptoms. Maladaptive emotional regulation strategies may mediate the relationship between PTSD and eating disorders. Two pilot studies provide preliminary evidence that concurrent cognitive behavior therapy (CBT) for PTSD and eating disorders may be beneficial and that repetitive transcranial magnetic stimulation (rTMS) could be helpful in the treatment of PTSD in some eating disorder patients.

SUMMARY

PTSD is a common comorbidity in patients with eating disorders and impacts the severity of their eating disorder symptoms. However, there is little research into concurrent treatments for PTSD and eating disorders. Difficulties in emotional regulation may be a common mechanism in both disorders.

[Integrated Complex Treatment for Extreme Anorexia Nervosa; An Interdisciplinary Treatment Concept of the University Hospital Zurich]

Integrated Complex Treatment for Extreme Anorexia Nervosa; An Interdisciplinary Treatment Concept of the University Hospital Zurich Abstract. The serious physical mental and psychosocial morbidity due to anorexia nervosa is often perceived by sufferers as less serious than from their environment. Doctors and other healthcare professionals are therefore confronted with the difficulty that urgent medical treatment is considered as unnecessary or even threatening by those affected. Although patients with anorexia nervosa usually wish to improve their condition, they are usually only able to tolerate treatment aimed at normalizing eating behavior and gaining weight in response to high external pressure. In view of this situation, an interdisciplinary team with experience in these treatments is required to treat these patients. Close cooperation is necessary to ensure a supporting treatment framework.

Hospitalization Outcomes and Comorbidities of Bulimia Nervosa: A Nationwide Inpatient Study

Objective To evaluate inpatient outcomes and the prevalence of psychiatric and medical comorbidities in bulimia nervosa. Methods We used the Nationwide Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project (HCUP). We identified bulimia nervosa as the primary diagnosis and medical and psychiatric comorbidities using ICD-9-CM codes. The differences in comorbidities were quantified using the Chi-square (χ2) test, and a multinomial logistic regression model was used to quantify associations among comorbidities (odds ratio (OR)). Results The sample consisted of 3,319 inpatient admissions with bulimia nervosa between 2010-2014. Overall, 88% patients were younger than 40 years of age (p < 0.001). Bulimia nervosa was seen in a higher proportion of females (92.5%). The mean inpatient stay was 9.15 days and had a variable trend, whereas inpatient charges have been increasing (p < 0.001), averaging $34,398 (USD). The odds of having a longer hospitalization > 7 days (median) was seen in patients with comorbid fluid/electrolyte disorders (OR = 1.816; p < 0.001) and comorbid depression (OR = 1.745; p < 0.001). The most prevalent psychiatric comorbidities were psychosis (52.4%), followed by depression (23.5%). Females had three times higher odds of comorbid diabetes (OR = 3.374; p < 0.001), hypertension (OR = 2.548; p-value < 0.001), comorbid depression (OR = 1.670; p = 0.002), and drug abuse (OR = 2.008; p < 0.001). Conclusion Our study established psycho-socio-demographic characteristics, hospitalization outcomes, and comorbidities of bulimia nervosa patients. We believe that medical and psychiatric comorbidities of bulimia nervosa should be carefully investigated by clinicians as they can further complicate the management of bulimia nervosa and result in adverse inpatient outcomes.

Associations between ADHD and eating disorders in relation to comorbid psychiatric disorders in a nationally representative sample

The objective of this study was to examine whether previously observed associations of attention-deficit/hyperactivity disorder (ADHD) with eating disorders (EDs) are at least partially attributable to other underlying psychopathology. Data came from 4719 participants aged 18-44 years in the National Comorbidity Survey Replication and the National Survey of American Life. DSM-IV diagnoses were assessed using the World Health Organization Composite International Diagnostic Interview. Multinomial logistic regression assessed associations between DSM-IV lifetime and past-12 month diagnoses of ADHD with EDs in unadjusted models and in models adjusted for demographic variables and other psychopathology. Lifetime ADHD was strongly and significantly associated with lifetime bulimia nervosa (BN), binge eating disorder (BED), and any ED in unadjusted models, but not with anorexia nervosa or subthreshold BED. After adjusting for demographic variables and psychiatric comorbidities, all associations of lifetime ADHD with EDs were substantially attenuated, and only the association of ADHD with BN remained statistically significant. Similar results were found using past-12 month diagnoses. These results suggest that previously observed associations of ADHD with EDs might be due - at least in part - to additional psychiatric disorders that are often comorbid with both ADHD and EDs.

Psychiatric comorbidity and maternal distress among adolescent eating disorder patients: A comparison with substance use disorder patients

High rates of comorbidity are found among eating disorder (ED) patients, which may negatively affect treatment outcome and prognosis. However, there is a shortage of studies in Spain using clinician administered interviews to assess rates of comorbidity among these patients, particularly in adolescents. This study aimed to evaluate Axis I psychiatric diagnoses in adolescent patients with an ED and to compare them with patients with a distinct disorder with adolescent onset, substance use disorder (SUD) patients. Considering that maternal psychological distress is another factor involved in ED prognosis, a secondary aim was to examine the relationship between patient's psychological variables and maternal distress (depression and anxiety). The cross-sectional study included 50 ED patients, 48 SUD patients, and their mothers. More than half of the patients received a diagnosis for a comorbid disorder. Internalizing problems were more common among EDs and externalizing disorders were the most common comorbidities among SUDs, similar to findings from other countries. Maternal distress was associated with higher levels of depression and symptom severity in patients. No differences in distress were found between mothers of patients with a comorbid diagnosis and those without. Elevated anxiety or depression in mothers did not increase the likelihood of patients having a particular primary diagnosis. In short, while both ED and SUD patients presented high rates of comorbidity, the types of comorbid diagnoses were specific to each group. Assessing for the presence of comorbid disorders and targeting maternal psychological distress may guide treatment interventions and improve patient prognosis.

Schedule for personality assessment from notes and documents (SPAN-DOC): Preliminary validation, links to the ICD-11 classification of personality disorder, and use in eating disorders

BACKGROUND

The underlying core of personality is insufficiently assessed by any single instrument. This has led to the development of instruments adapted for written records in the assessment of personality disorder.

AIMS

To test the construct validity and inter-rater reliability of a new personality assessment method.

METHOD

This study (four parts) assessed the construct validity of the Schedule for Personality Assessment from Notes and Documents (SPAN-DOC), a dimensional assessment from clinical records. We examined inter-rater reliability using case vignettes (Part 1) and convergent validity in three ways: by comparison with NEO Five-Factor Inventory in 130 Korean patients (Part 2), with agreed ICD-11 personality severity levels in two populations (Part 3) and determining its use in assessing the personality status in 90 British patients with eating disorders (Part 4).

RESULTS

Internal consistency (alpha = .90) and inter-rater reliability (intraclass correlation coefficient ≥ .88) were satisfactory. Each factor in the five-factor model of personality was correlated with conceptually valid SPAN-DOC variables. The SPAN-DOC domain traits in those with eating disorders were categorized into 3 clusters: self-aggrandisement, emotionally unstable, and anxious/dependent.

CONCLUSIONS

This study provides preliminary support for the usefulness of SPAN-DOC in the assessment of personality disorder. Copyright © 2016 John Wiley & Sons, Ltd.

Prevalence and comorbidity of eating disorders among a community sample of adolescents: 2-year follow-up

The previous literature about comorbidity between eating disorders (ED) and other DSM-IV psychiatric disorders in adolescence has employed cross-sectional studies with clinical samples, where the comorbid disorders were diagnosed retrospectively. The present study aims to overcome these limitations by the analysis of comorbidity in a community population during 2-year follow-up. A semi-structured interview was applied to a teenager sample. Firstly, a cross-sectional and non-randomized study on psychiatric morbidity was conducted with 993 teenagers between the ages of 12 and 16 from five schools. Secondly, 326 students between 14 and 17 years old of one school were reassessed 2 years later in order to detect ED new cases and find associations with previous psychiatric disorders. The ED prevalence was 3.6%. Cross-sectional analysis revealed that 62.9% of individuals with an ED had comorbid disorders: anxiety disorders (51.4%), Attention Deficit Hyperactivity Disorder (31.4%), oppositional defiant disorder (11.4%), and obsessive compulsive disorder (8.6%). Prospective longitudinal analysis showed an ED incidence rate of 2.76% over the course of 2 years. 22.2% of new cases had received previous psychiatric diagnoses, of which all were anxiety disorders. Thus, ED exhibited a high comorbidity rate among adolescent populations and anxiety disorders were the most common comorbid diagnosis.

Anorexia Nervosa und Bulimia Nervosa: Ein Individuationsversuch?

Zusammenfassung. Theoretischer Hintergrund: Verschiedene Theorien thematisieren Konflikte um Autonomie, Autarkie und Kontrolle in der Ätiologie von Essstörungen. Fragestellung: Diese Studie untersucht die bisher kaum empirisch überprüfte Hypothese zu einem hohen Autonomie-, Autarkie- und Kontrolle-Motiv im Zusammenhang mit Essstörungen. Methode: Insgesamt 270 ProbandInnen ohne und mit den Essstörungen Anorexia Nervosa (AN), Bulimia Nervosa (BN), Binge Eating Disorder (BED) und remittierten Essstörungen (REC) beantworteten den Fragebogen zur Analyse Motivationaler Schemata (FAMOS). Ergebnisse: ProbandInnen mit Essstörungen berichteten ein höheres Autonomie-, Autarkie- und Kontrolle-Motiv als ProbandInnen ohne Essstörungen. Außerdem zeigten sich Unterschiede in den Motiven zwischen den Essstörungsdiagnosen. Schlussfolgerungen: Die Studienergebnisse deuten auf einen Zusammenhang zwischen einem ausgeprägten Autonomie-, Autarkie- und Kontrolle-Motiv und Essstörungen hin, der für die Therapie von Essstörungen relevant sein könnte.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders

OBJECTIVES

This clinical practice guideline for treatment of DSM-5 feeding and eating disorders was conducted as part of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Clinical Practice Guidelines (CPG) Project 2013-2014.

METHODS

The CPG was developed in accordance with best practice according to the National Health and Medical Research Council of Australia. Literature of evidence for treatments of anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), other specified and unspecified eating disorders and avoidant restrictive food intake disorder (ARFID) was sourced from the previous RANZCP CPG reviews (dated to 2009) and updated with a systematic review (dated 2008-2013). A multidisciplinary working group wrote the draft CPG, which then underwent expert, community and stakeholder consultation, during which process additional evidence was identified.

RESULTS

In AN the CPG recommends treatment as an outpatient or day patient in most instances (i.e. in the least restrictive environment), with hospital admission for those at risk of medical and/or psychological compromise. A multi-axial and collaborative approach is recommended, including consideration of nutritional, medical and psychological aspects, the use of family based therapies in younger people and specialist therapist-led manualised based psychological therapies in all age groups and that include longer-term follow-up. A harm minimisation approach is recommended in chronic AN. In BN and BED the CPG recommends an individual psychological therapy for which the best evidence is for therapist-led cognitive behavioural therapy (CBT). There is also a role for CBT adapted for internet delivery, or CBT in a non-specialist guided self-help form. Medications that may be helpful either as an adjunctive or alternative treatment option include an antidepressant, topiramate, or orlistat (the last for people with comorbid obesity). No specific treatment is recommended for ARFID as there are no trials to guide practice.

CONCLUSIONS

Specific evidence based psychological and pharmacological treatments are recommended for most eating disorders but more trials are needed for specific therapies in AN, and research is urgently needed for all aspects of ARFID assessment and management.

EXPERT REVIEWERS

Associate Professor Susan Byrne, Dr Angelica Claudino, Dr Anthea Fursland, Associate Professor Jennifer Gaudiani, Dr Susan Hart, Ms Gabriella Heruc, Associate Professor Michael Kohn, Dr Rick Kausman, Dr Sarah Maguire, Ms Peta Marks, Professor Janet Treasure and Mr Andrew Wallis.

Personality disorders in eating disorder not otherwise specified and binge eating disorder: a meta-analysis of comorbidity studies

A meta-analysis was conducted to identify the proportion of comorbid personality disorders (PDs) in patients with eating disorder not otherwise specified (EDNOS) and binge eating disorder (BED). A search identified 20 articles in the period of 1987 to 2010. For EDNOS and BED, the comorbid proportions for any PD were 0.38 and 0.29, respectively; for cluster C PDs, 0.38 and 0.30, respectively (avoidant PD, 0.18 and 0.12, and obsessive-compulsive PD, 0.11 and 0.10, respectively); and for cluster B PDs, 0.25 and 0.11, respectively (borderline, 0.12 and 0.10). This pattern converged with findings on anorexia nervosa and bulimia nervosa, except being lower. Because the comorbidity profiles for EDNOS and BED were highly similar, their underlying PD pathology seems similar. Few moderators were significant, except for interviews yielding lower estimates than that of questionnaires. The variance statistic for any PD comorbidity was wide for EDNOS and narrow for BED, thus partly supporting BED as a distinct eating disorder category and EDNOS as a potentially more severe condition than BED.

Personality factors and eating disorders: self-uncertainty

The International Personality Disorder Examination interview (IPDE) was used to examine common features of personality amongst eating disorder (ED) patients. Female inpatients (N=155), aged 18 to 45, BMI<30 kg/m(2), were interviewed. Items present in ≥ 25% of patients were analysed by factor analysis. Five factors emerged - 'interpersonal anxiety', 'instability', 'self-uncertainty', 'obsessionality' and 'perfectionism' accounting for 62% of the variance. Patients with BMI, <18.5 kg/m(2) had significantly greater 'interpersonal anxiety' factor scores. Patients who purged had higher 'interpersonal anxiety', 'instability', and 'perfectionism' factor scores. Differences between ED diagnostic groups were accounted for by body weight and purging. Increasing age was weakly associated with improvement in 'self-uncertainty' and 'instability' scores. This study separates obsessionality and perfectionism, possibly reflecting ED patients' 'need for control', and introduces a new factor 'self-uncertainty' which reflects their poor self-concept. The contribution of this factor structure to development and duration of illness should be studied.

Axis-I comorbidity is linked to prospective instability of diagnoses within eating disorders

BACKGROUND

Eating disorders (ED) are classified into Anorexia Nervosa, Bulimia Nervosa, and eating disorder not otherwise specified. Prospectively, the diagnostic instability within ED is high, but it is not clear which factors may account for this instability. So far, there is no evidence of whether psychiatric comorbidity may play a role in ED diagnostic crossover. We sought to determine possible influences of comorbidities of axis I and II on diagnostic crossover within ED.

METHODS

Longitudinal data of 192 female patients were collected. All patients had a diagnosis of a current ED at study entry (baseline, T0). Diagnoses were re-established both 12 months (T1) and 30 months (T2) after T0. Comorbid psychiatric diagnoses were grouped into axis I and axis II according to DSM-IV.

RESULTS

Patients with instable ED diagnoses had lifetime axis-I comorbidity more frequently than patients with stable ED diagnoses (χ2 = 4.74, df = 1, p < 0.05). Post-hoc exploratory tests suggested that the effect was mainly driven by affective disorders like major depression. There was no difference for axis-II comorbidity between stable and instable diagnostic profiles.

CONCLUSIONS

Following previous reports of diagnostic crossover in ED, the present investigation points to an influence of a life-time psychiatric comorbidity, in particular of axis I, on follow-up diagnoses of ED. Comorbid affective disorders like major depression might facilitate a switching between clinical phenotypes. The understanding of mechanisms and causes of the symptoms fluctuation will be subject of future studies.

Prevalence, comorbidities and outpatient treatment of anorexia and bulimia nervosa in German children and adolescents

OBJECTIVE

This study aimed at investigating the prevalence, psychiatric comorbidity and outpatient treatment in a sample of German children and adolescents with eating disorders (EDs).

METHOD

Data of a large German statutory health insurance company were analysed and outpatients aged between 10 and 21 years with an ED diagnosis in 2009 were identified.

RESULTS

Of 248,558 insured children and adolescents, 1,404 patients (79.9 % females, mean age: 16.7; SD: 3.3 years) matched the inclusion criteria. The large majority of patients with anorexia nervosa (AN) and bulimia nervosa (BN) were females (94.7 and 92.7 %), on which we focus in the following analyses. The prevalence in females was 0.28 % (AN) and 0.20 % (BN). Psychiatric comorbidity was diagnosed in 59.8 % (AN) and 64.1 % (BN) of patients, respectively. Most patients were treated with psychotherapy (AN: 75.7 %, BN: 78.5 %), 16.4 % (AN) and 20.2 % (BN) of our patients received pharmacotherapy with either antidepressants or antipsychotics. 23.5 % (AN) and 21.1 % (BN) received no treatment with psychotherapy, antidepressants or antipsychotics.

DISCUSSION

This naturalistic study suggests that in young ED outpatients, EDs seem to be underdiagnosed and treatment does not necessarily comply with current guidelines. Therefore, dissemination of state-of-the-art knowledge on diagnosis and treatment in children and adolescents with EDs constitutes an important educational goal.

Perceived body weight, eating and exercise problems of different groups of women

OBJECTIVE

To compare prevalence of problems with body weight, eating and exercise (past or present) of female psychiatric inpatients with routine care, gynaecological and obstetric female outpatients, and eating disorder inpatients.

METHOD

One thousand and thirty-eight females aged 18-55 years from routine care (n=99), gynaecological (n=263) and obstetric (n=271) outpatient clinics, and eating disorder (n=223) and general psychiatric units (n=182) participated. Participants self-reported past or current problems with weight, eating and exercise using a short survey. A sub-sample of women completed the Eating and Exercise Examination (EEE) which includes the Quality of Life for Eating Disorders (QOL ED).

RESULTS

The prevalence of self-reported problems controlling weight (52%), disordered eating and eating disorders (43%) for the psychiatric patients was significantly greater than for the routine care and gynaecological and obstetrics outpatients. The psychiatric group had a significantly higher mean body mass index (BMI) of 27.3 kg/m(2) (standard deviation (SD)=6.7) and prevalence of self-reported obesity (28%) than the other groups.

CONCLUSION

Treatment of women with psychiatric problems should include assessment and concurrent attention to body weight, eating disorder and exercise problems in association with appropriate medical, psychiatric, psychological and medication treatment of their presenting disorder.

Dopamine-system genes, childhood abuse, and clinical manifestations in women with Bulimia-Spectrum Disorders

OBJECTIVE

We explored interaction effects involving polymorphisms of targeted dopamine system genes and selected forms of childhood abuse (sexual, physical and emotional) acting upon severity of binge-eating and psychopathological symptoms in women with Bulimia-Spectrum Disorders (BSDs).

METHODS

Women diagnosed with a BSD (n = 216) were assessed for childhood traumata, eating-disorder (ED) symptoms, and selected psychopathological features (sensation seeking, impulsivity, compulsivity and affective instability), and then provided blood samples for genotyping of main polymorphisms of dopamine-2 receptor (DRD2), dopamine transporter (DAT1) and catechol o-methyltransferase (COMT) genes.

RESULTS

Sensation Seeking was elevated in carriers of the low-function allele of the DRD2 Taq1A polymorphism who also reported childhood sexual abuse, relative to that in individuals showing other combinations of alleles and abuse exposures. In addition, carriers of a low-function allele of COMT scored higher on compulsivity, lower on impulsivity, and marginally lower on frequency of binge-eating than did individuals in whom the allele was absent.

DISCUSSION

Our results suggest that genes acting within the dopamine system may contribute, either directly or indirectly (i.e., in interaction with traumatic childhood experiences), to variations in the presentation of comorbid traits and, possibly, of bulimic symptoms.

Disordered eating attitudes in Egyptian antipsychotic naive patients with schizophrenia

OBJECTIVES

The study aimed to test in a sample of Egyptian antipsychotic naive patients the hypotheses that the disordered eating attitudes co-occur with schizophrenia in a higher frequency than would be expected by chance in the general population and that the disordered eating comorbidity would be associated with more severe schizophrenia psychopathology. Previous studies have been mostly concerned with the impact of the antipsychotics. Studies relating abnormal eating behavior to the schizophrenia psychopathology rather than to its treatment are lacking.

METHOD

In this case-control cross-sectional study, 50 consecutive antipsychotic naive patients, newly attending the psychiatric outpatient clinic, University Hospital, Zagazig, Egypt, with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnosis of schizophrenia, were assessed by the Positive and Negative Syndrome Scale and compared with 50 nonpsychiatric controls using the Eating Attitudes Test (EAT40).

RESULTS

Patients with schizophrenia had an EAT40 mean score (23.4 ± 7.8) higher than that of controls (19.7 ± 7.2) (P = .015). Prevalence of disordered eating (defined by a score of ≥ 30 on the EAT40) in these patients was higher than in the control group (30% vs 12%, P = .027). Comparison between schizophrenia patients with and without disordered eating showed no significant differences in demographic and a number of clinical variables, but they differed in their scores on lifestyle characteristics and anthropometric measures. The group of patients with disordered eating had also higher scores on total and all scale factors but not on the negative symptom scale.

CONCLUSIONS

Data of this study show, perhaps for the first time, that "disordered" eating attitudes, as measured by the EAT40, are higher in a group of Egyptian patients with schizophrenia than in controls. However, the lack of difference between patients with and without disordered eating in terms of demographic and a number of clinical characteristics fail to explain the hypothesis that schizophrenia with disordered eating is a distinct subtype of schizophrenia. Data indicate, on the other hand, that the presence of disordered eating behavior in patients with schizophrenia is associated with the expression of more active psychotic symptoms.

Guided self-help as the first step for bulimic symptoms: implementation of a stepped-care model within specialized psychiatry

OBJECTIVE

This study describes the implementation and effectiveness of the first step, guided self-help (GSH), in a clinical setting, of a stepped-care model of cognitive behavior therapy for patients with bulimic symptoms.

METHOD

Eighty-nine patients participated.

RESULTS

In the intent to-treat analyses, the effect sizes were small to moderate (0.25-0.66). However, the effect sizes were substantially larger (0.44-1.66) for the patients who completed all the GSH sessions (45%). The majority of noncompleters stayed within psychiatric services. Supplementary treatments were mostly directed towards comorbid conditions, especially depression. Those discontinuing treatment in advance where characterized by more lifetime diagnoses and higher ratings on the restraint subscale of the EDE-Q.

DISCUSSION

GSH within specialized psychiatry might be effective for about 30% of the patients. There is no indication of patients losing their confidence in psychiatric services by being offered GSH as the first treatment.

Prevalence of personality disorders and their clinical correlates in outpatient adolescents with anorexia nervosa

OBJECTIVE

To evaluate personality disorder (PD) comorbidity and its clinical correlates in a sample of adolescents with anorexia nervosa (AN) and to compare them with similar studies on adults.

METHODS

One hundred one female AN outpatients (16-18 years old)-57 with AN restrictive type and 44 with AN binge-purging type-and 71 age-matched, healthy, female participants were assessed using the Structured Clinical Interview for DSM-IV Axis II Disorders. Five selected clinical variables of AN severity were also assessed.

RESULTS

Overall, 24.8% of AN outpatients had one or more PD compared with 4.2% of the control participants (p < .001). PDs most frequently found in AN outpatients were avoidant, borderline, and obsessive-compulsive. Associations were found between AN binge-purging type and borderline PD and between AN restrictive type and obsessive-compulsive PD. AN outpatients with a PD had an earlier age of onset of AN (mean [standard deviation {SD}] = 15.4 [1.2] versus 16.1 [0.9], p = .002), lower lifetime lowest BMI (mean [SD] = 14.8 [1.5] versus 15.6 [1.3], p = .01), and more hospital admissions for AN (mean [SD] = 1.4 [0.9] versus 0.3 [0.6], p < .001) compared with those without PDs.

CONCLUSIONS

Associations were found between AN and PDs in adolescents similar to those found in adults. The presence of a PD is associated with a greater severity of AN. PD assessment of adolescent AN patients may permit a more accurate diagnosis and better treatment planning.

Suicide attempts in anorexia nervosa subtypes

OBJECTIVE

The risk for suicide attempts is elevated in anorexia nervosa (AN), yet we know little about the relation between suicide and personality in this group. We explored the prevalence of lifetime suicide attempts in women with AN and compared those who had and had not attempted suicide on eating disorder symptoms, general psychopathology, and personality both relative to a healthy control group and then across AN subtypes.

METHOD

One hundred four outpatients with restricting AN, 68 outpatients with purging AN, and 146 comparison individuals participated in the study.

RESULTS

The prevalence of suicide attempts differed significantly across the 3 groups (P = .003), with 0% in the controls, 8.65% in the restricting AN group, and 25.0% in the purging AN group. Depression measures were elevated in those with suicide attempts. Within the restricting AN group, those who attempted suicide scored significantly higher on Phobic Anxiety, measured by means of the Symptom Checklist-Revised, than those who did not (P = .001).

CONCLUSION

The presence of purging and depressive symptoms in individuals with AN should increase vigilance for suicidality; and among restrictors, greater anxiety may index greater suicide risk.

General psychopathology in anorexia nervosa: the role of psychosocial factors

The aim of the present study was to investigate psychosocial correlates of comorbid psychopathology. Data were collected from a total of 90 female inpatients with anorexia nervosa (AN). Higher levels of general psychopathology were detected in depression, interpersonal sensitivity, obsessive-compulsive and anxiety subscales of the Symptom Checklist (SCL)-90. Regression analysis also revealed that higher levels of psychopathology across SCL-90 subscales in AN patients are significantly associated with an earlier age of onset of the condition, higher levels of anorectic psychopathology as measured by Eating Disorders Examination, lower self-esteem as measured by Multidimensional Self-Esteem Inventory and social support levels as measured by Quality of Social Network and Social Support Questionnaire. Considering the high levels of general psychopathology in people with AN, routine clinical practice should aim for a comprehensive assessment of such. Given the strong association between psychosocial factors such as self-esteem, social support and general psychopathology, psychological therapies could play an important role in facilitating emotional recovery.

An approach to sub-grouping the eating disorder population: adding attachment and coping style

OBJECTIVE

To investigate whether clinically meaningful sub-groups of patients can be identified by clustering eating disorder features, attachment and coping styles.

METHOD

165 patients completed the Eating Disorder Examination (EDE), Attachment Style Questionnaire (ASQ) and Utrecht Coping List (UCL). Cluster analysis was used to identify sub-groups across the sample.

RESULTS

Four clusters were identified. Cluster one had low levels of eating disorder behaviours and the most severe attachment and coping difficulties. Cluster two had high levels of dietary restriction and exercise, and a fearful/avoidant attachment style. Cluster three had high levels of binge eating and vomiting, and few attachment and coping difficulties. Cluster four had low levels of eating disorder features and positive attachment and coping styles.

CONCLUSIONS

Clustering participants on the basis of eating disorder features, attachment and coping yields four sub-groups appearing to have clinical face validity.

The epidemiology of eating disorders in six European countries: results of the ESEMeD-WMH project

Few data are available to estimate the prevalence of eating disorders (EDs) and their correlates in the community. This paper reports data on EDs obtained in the framework of the ESEMeD project, aimed at investigating the prevalence of non-psychotic mental disorders in six European countries (Belgium, France, Germany, Italy, the Netherlands and Spain), using a new version of the Composite International Diagnostic Interview. The ESEMeD study was a general population cross-sectional household survey. In total, 21,425 respondents aged 18 or older provided data for the project between January 2001 and August 2003. A subsample (N=4139) underwent a detailed investigation on EDs. Lifetime estimated prevalence of anorexia nervosa, bulimia nervosa, binge eating disorder, sub-threshold binge eating disorder, and any binge eating were 0.48%, 0.51%, 1.12%, 0.72%, and 2.15%, respectively, and they were 3-8 times higher among women for all EDs. However, since people under 18 were excluded from this study, our prevalence should be taken as lower-bound estimate of real frequencies. Indeed, cumulative lifetime prevalence analysis showed that the majority of eating disorders had their initial onset between 10 and 20 years of age. Role impairment and comorbidity with other mental disorders were highly common, yet only small proportions of patients with a lifetime diagnosis of EDs requested medical treatment. It still has to be proven whether early diagnostic identification and access to specialized care can reduce the burden caused by these disorders.

The relationship between eating disorder not otherwise specified (EDNOS) and officially recognized eating disorders: meta-analysis and implications for DSM

Eating disorder not otherwise specified (EDNOS) is the most prevalent eating disorder (ED) diagnosis. In this meta-analysis, the authors aimed to inform Diagnostic and Statistical Manual of Mental Disorders revisions by comparing the psychopathology of EDNOS with that of the officially recognized EDs: anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). A comprehensive literature search identified 125 eligible studies (published and unpublished) appearing in the literature from 1987 to 2007. Random effects analyses indicated that whereas EDNOS did not differ significantly from AN and BED on eating pathology or general psychopathology, BN exhibited greater eating and general psychopathology than EDNOS. Moderator analyses indicated that EDNOS groups who met all diagnostic criteria for AN except for amenorrhea did not differ significantly from full syndrome cases. Similarly, EDNOS groups who met all criteria for BN or BED except for binge frequency did not differ significantly from full syndrome cases. Results suggest that EDNOS represents a set of disorders associated with substantial psychological and physiological morbidity. Although certain EDNOS subtypes could be incorporated into existing Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) categories, others-such as purging disorder and non-fat-phobic AN-may be best conceptualized as distinct syndromes. (PsycINFO Database Record (c) 2009 APA, all rights reserved).

Does prior psychotherapy experience affect the course of cognitive-behavioural group therapy for social anxiety disorder?

OBJECTIVE

To examine whether and how different patterns of psychotherapy history (no prior therapy, successful therapy experience, and unsuccessful therapy experience) affect the outcome of future treatment among patients undergoing cognitive-behavioural group therapy for social anxiety disorder.

METHOD

Fifty-seven patients with varying histories of psychotherapy participating in cognitive-behavioural group treatment for social anxiety disorder were included in the study. Symptom severity (including anxiety, depression, self-efficacy, and global symptom severity) was assessed at pre- and posttreatment. A therapist-rated measure of patient therapy engagement was included as a process variable.

RESULTS

First-time therapy patients showed more favourable pretreatment variables and achieved greater benefit from group therapy. Among patients with unsuccessful therapy experience, substantial gains were attained by those who were able to actively engage in the therapy process. Patients rating previous therapies as successful could benefit the least and tended to stagnate. Possible explanations for group differences and clinical implications are discussed.

CONCLUSIONS

Prior psychotherapy experience affects the course of cognitive-behavioural group therapy in patients with social phobias. While patients with negative therapy experience may need extensive support in being and remaining actively engaged, those rating previous therapies as successful should be assessed very carefully and may benefit from a major focus on relational aspects.

Profile of 50 women with midlife-onset eating disorders

The aim of this study was to present a detailed profile of 50 women eating disorder (ED) inpatients who reported first ED onset at age 40 or above. We assessed patients' sociodemographics, severity-of-illness, comorbid diagnoses, personality profiles, and short-term treatment outcomes. Compared to patients of more traditional young adult ages, results revealed unique features of midlife-onset ED inpatients, including less severe and less common self-reported ED symptomology measured by the EDI-2; a predominance of pure restricting behaviors and rarity of bulimia; similar rates of co-occurring depression and anxiety but of less severity; fewer substance use disorders with a predominance of sedating/calming substance usage; many fewer Cluster C diagnoses on Axis II; substantially greater histories of sexual abuse; and different MMPI-2 profiles emphasizing much greater denial. The corresponding needs among midlife-onset ED inpatients for specialized assessment and treatment interventions are considered.

Repetitive transcranial magnetic stimulation in bulimia nervosa: preliminary results of a single-centre, randomised, double-blind, sham-controlled trial in female outpatients

BACKGROUND

Bulimia nervosa (BN) is often associated with depressive symptoms and treatment with antidepressants has shown positive effects. A shared deficient serotonergic transmission was postulated for both syndromes. The left dorsolateral prefrontal cortex was argued to regulate eating behaviour and to be dysfunctional in eating disorders.

METHODS

Fourteen women meeting DSM-IV criteria for BN were included in a randomised placebo-controlled double-blind trial. In order to exclude patients highly responsive to placebo, all patients were first submitted to a one-week sham treatment. Randomisation was followed by 3 weeks of active treatment or sham stimulation. As the main outcome criterion we defined the change in binges and purges. Secondary outcome variables were the decrease of the Hamilton Depression Rating Scale (HDRS), the Beck Depression Inventory (BDI) and the Yale-Brown Obsessive Compulsive Scale (YBOCS) over time.

RESULTS

The average number of binges per day declined significantly between baseline and the end of treatment in the two groups. There was no significant difference between sham and active stimulation in terms of purge behaviour, BDI, HDRS and YBOCS over time.

CONCLUSION

These preliminary results indicate that repetitive transcranial magnetic stimulation (rTMS) in the treatment of BN does not exert additional benefit over placebo. A larger number of patients might clarify a further role of rTMS in the treatment of BN.

Specific and nonspecific comorbidity in anorexia nervosa

OBJECTIVE

This article reports lifetime Axis I and II comorbidity in women with anorexia nervosa (AN), and ascertains specific and nonspecific comorbidity in AN compared to clinical samples of women with bulimia nervosa (BN) or major depression (DEP).

METHOD

Outpatient AN (n = 56), BN (n = 132), and DEP (n = 100) samples were assessed using Structured Clinical Interviews I and II for DSM-III-R. Baseline data were compared using univariate statistics and logistic regression.

RESULTS

In the AN sample as a whole, specific elevations were found for prevalences of obsessive compulsive disorder. The AN-binge eating purging subtype (AN-BP) and the BN sample had elevated prevalences of Cluster B personality disorders. Cluster C prevalences were elevated across samples.

CONCLUSION

Evidence of AN-specific, eating disorder-specific, and nonspecific comorbidity illustrates the heterogeneity in AN. Further research is need to examine the relative impact of specific and nonspecific comorbidity in AN subtypes and AN as a whole.

Links between eating disorder symptom severity and psychiatric comorbidity

Patients with eating disorders (ED) frequently exhibit additional psychiatric disorders. This study aimed to examine whether psychiatric comorbidity in ED patients is associated with increased severity of ED symptoms in a sample of 277 women with a current ED (84 anorexia nervosa, 152 bulimia nervosa, 41 eating disorders not otherwise specified). Psychiatric comorbidity of Axes I and II was determined using the Structured Clinical Interview (SCID) for DSM-IV. Severity of ED-related symptoms was assessed using interviewer-rated scales from the Structured Interview for Anorexia and Bulimia Nervosa (SIAB). Affective and anxiety-related disorders of both axes were linked with increased intensity of weight- and appearance-related fears and concerns. Frequency of binge-eating and frequency of purging both were associated with Axis I anxiety disorders, substance-related disorders, and Cluster B personality disorders. Frequency of dieting was related to anxiety disorders on both axes. Multivariate analyses revealed that Axis I anxiety disorders were more closely linked with severity of ED symptoms than affective or substance-related disorders. The results showed that psychiatric comorbidity of both axes is linked with increased severity of ED symptoms and that there are associations between specific ED symptoms and specific forms of comorbidity.

Post-traumatic stress disorder in women with eating disorders

OBJECTIVE

The aim of the study was to assess the frequency of co-morbid post-traumatic stress disorders (PTSD) in women with eating disorders (ED).

METHOD

277 women aged 17 to 50 with a current DSM-IV ED were included. 84 were diagnosed with anorexia nervosa (AN), 152 with bulimia nervosa (BN) and 41 with ED not otherwise specified (EDNOS). Structured Clinical Interviews (SCID-I and SCID-II) were performed.

RESULTS

Sixty-eight participants (24.5%) reported unwanted sexual experiences (USE). Fifty-two participants (18.8%) reported some form of childhood sexual abuse (CSA). Four participants (1.4%) met the criteria for PTSD according to the Diagnostic and Statistical Manual-IV (DSM-IV). Participants with a history of USE did not differ from those without USE with regard to ED diagnosis, but were diagnosed more often with any Axis I or Axis II disorder.

CONCLUSIONS

The prevalence of PTSD in this sample of women with ED was low (1.4%), despite a USE rate of 24.5%.

Clinical epidemiology of eating disorders: results from the Sesto Fiorentino study

BACKGROUND

It is speculated that clinical samples do not fully reflect the characteristics of eating disorders (EDs) as they are in the general population, especially in their lowest range of severity. The present article reports the prevalence of EDs in a community sample aged >14 years, their clinical and psychopathological features, and their course and outcome on naturalistic grounds.

METHODS

The Sesto Fiorentino Study is a three-phase community-based survey where 2,355 out of 2,500 people representative of the population aged >14 years living in Sesto Fiorentino were evaluated by their own general practitioner using the Mini International Neuropsychiatric Interview plus six additional questions. All those who had positive results plus a probability sample of the non-cases were re-interviewed by psychiatrists using the Florence Psychiatric Interview. The subjects who reported ED symptoms were subsequently administered the Eating Disorder Examination (12th edition).

RESULTS

Overall, the lifetime prevalence of EDs was 1.21%. More precisely, 0.42% had anorexia nervosa, 0.32% bulimia nervosa, 0.32% binge eating disorder and 0.32% eating disorder not otherwise specified. All the subjects suffering from an ED fulfilled diagnostic criteria for at least another DSM-IV axis I psychiatric disorder. At the moment of the interview, conducted a few years (average 7 years) after the onset of the disorder, 50% had fully recovered from EDs, 26.9% were currently affected by an ED, 23.1% showed a persistent body image disturbance and/or the presence of compensatory behaviours.

CONCLUSIONS

Community surveys conducted by clinicians may provide useful additional information on the psychopathological features, natural course and outcome of these disorders on naturalistic grounds.

An attempt to understand the paradox of anorexia nervosa without drive for thinness

The "atypical" subgroup of women with anorexia nervosa not characterized by drive for thinness (DT) was studied. The study group comprised 151 anorectic patients (restrictor anorectics [AN-R], n=74; binge-purging anorectics [AN-BP], n=77). Subjects completed the following self-administered questionnaires: Eating Disorder Inventory-2 (EDI-2), Temperament and Character Inventory (TCI), State-Trait Anger Expression Inventory (STAXI), and Beck Depression Inventory (BDI). Patients were subdivided into three groups on the basis of body mass index (BMI) and DT score: AN-I with a BMI<15 and DT<7 (n=24); AN-II with a BMI>15 and DT<7 (n=34); and AN-III with a BMI<17.5 and DT>7 (n=93). Patients belonging to the AN-III group had a more severe disorder and form of psychopathology based on their scores on several scales. No association emerged between personality disorders and any single subgroup. Three hypotheses emerge: (1) some patients (about 38%) deny DT and provide negative answers on the questionnaires; (2) patients without DT (even when malnourished) seem to show less severe psychopathologic and personality traits; and (3) patients without DT answer questions honestly, but they have developed a character structure that enables them to feel negative and ego-dystonic emotions regarding their condition. Implications for treatment are discussed.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

DISCUSSION

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

Clinical, psychological and personality features related to age of onset of anorexia nervosa

BACKGROUND

To investigate the relationship between age of onset and clinical and personality features of patients with anorexia nervosa (AN).

SAMPLING AND METHOD

We assessed 250 outpatients with AN with the Temperament and Character Inventory, the Eating Disorder Inventory 2, the Beck Depression Inventory and the Body Shape Questionnaire. The patients were subdivided into 3 groups: early (n=73), intermediate (n=96) and late onset (n=81), based on age of onset of symptoms.

RESULTS

The early-onset group shows higher body dissatisfaction, maturity fear, impulsivity and asceticism than the other 2 groups. This group shows a greater character fragility, as described in particular by a lower self-directedness, than the other 2 groups.

CONCLUSIONS

Even several years after the onset of the disorder, early-onset subjects affected by AN seem characterized by a more disturbed personality, with a higher body dissatisfaction than late-onset subjects affected by AN and a pursuit of thinness based on an ascetic drive.

Symptom severity and treatment course of bulimic patients with and without a borderline personality disorder

There are contradictory results concerning the frequency of borderline personality disorder (BPD) in bulimic patients and its impact on eating pathology and treatment outcome. We evaluated 240 patients with bulimia nervosa using EDI-2, SIAB and SCL-90-R. Only a minority of patients had a BPD (13.8%). There were no differences in binging or purging behaviour between patients with and without BPD, but borderline patients had significantly more feelings of ineffectiveness and more disturbances in interoceptive awareness. Bulimic patients with BPD showed significantly more general psychopathology. Although, BPD patients started with higher levels of pathology, there were similar reductions of symptoms over the course of treatment in both groups. Psychotherapy in bulimic patients with a BPD has to focus not only on eating pathology but also on aspects that are caused by the severe personality disturbance.

Clinical, psychological, and personality correlates of asceticism in anorexia nervosa: from saint anorexia to pathologic perfectionism

This study investigated the personality and clinical correlates of asceticism in 154 anorectic patients. Multiple linear regression models showed that asceticism was related to angry temperament, high control over anger, perfectionism, maturity fears, and number of vomiting episodes per week. These results suggest that the self-discipline and hypercontrol of anorectic patients are related to a temperament prone to angry feelings in subjects with a fear of becoming adult and with a trait of pathologic perfectionism.

Body dysmorphic disorder and other clinically significant body image concerns in adolescent psychiatric inpatients: prevalence and clinical characteristics

BACKGROUND

This study assessed prevalence and clinical correlates of body dysmorphic disorder (BDD), eating disorders (ED), and other clinically significant body image concerns in 208 consecutively admitted adolescent inpatients. It was hypothesized that adolescents with BDD would have higher levels of depression, anxiety, and suicidality. Adolescents with eating disorders were expected to have higher levels of depression, anxiety, and trauma-related symptoms. Trauma-related symptoms were also examined in relation to BDD, in the absence of specific hypotheses.

METHOD

Participants completed the Body Dysmorphic Disorder Questionnaire (BDDQ) and reliable and valid self-report measures of suicidality, depression, anxiety, post-traumatic stress disorder (PTSD), dissociation, and sexual preoccupation/distress. Prevalence of BDD, eating disorders, and other clinically significant body image concerns was determined, and clinical correlates were examined.

RESULTS

6.7% (n = 14) of participants met DSM-IV criteria for definite (n = 10) or probable (n = 4) DSM-IV BDD, 3.8% (n = 8) met criteria for an eating disorder, and 22.1% (n = 46) had clinically significant shape/weight concerns (SWC) that did not clearly meet criteria for BDD or an eating disorder. Both the BDD and SWC groups scored significantly higher than the group with no significant body image concerns (no BDD/ED/SWC group) on measures of anxiety and suicidality. The BDD, SWC, and ED groups all had significantly higher levels of depression than the no BDD/ED/SWC group. Only the SWC group scored significantly higher than the no BDD/ED/SWC group on measures of PTSD, dissociation, and sexual preoccupation/distress.

CONCLUSIONS

A high proportion of participants had clinically significant body image concerns or a body image disorder. These concerns/disorders were associated with higher levels of depression, anxiety, and suicidality. In addition, the group concerned with body shape or weight had significantly greater symptoms of PTSD, dissociation, and sexual preoccupation/distress. These relatively common body image concerns and disorders deserve further study in adolescents.

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.