Bulimia related to affective disorder by family history and response to the dexamethasone suppression test

Comparative efficacy and acceptability of selective serotonin reuptake inhibitor antidepressants for binge eating disorder: A network meta-analysis

Background: There are several selective serotonin reuptake inhibitor (SSRI) antidepressants currently used to treat binge eating disorder (BED), but the efficacy and acceptability of these antidepressants are still controversial. Therefore, we designed a network meta-analysis (NMA) to compare the efficacy and acceptability of different SSRI antidepressants for the treatment of BED.

Methods: Four databases including PubMed, Embase, the Cochrane Library, and Web of Science were systematically searched for the eligible randomized controlled trials (RCTs) for the treatment of patients with BED. The analysis was performed with Stata16 software.

Results: 9 RCTs were included in this NMA. The results of the study showed that compared with placebo, sertraline and fluoxetine could significantly reduce the frequency of binge eating. Fluoxetine was shown to be the drug with the greatest reduction in Hamilton Rating Scale for Depression (HAMD) score. Besides, all SSRI antidepressants were ineffective in losing weight. In addition, all the investigated antidepressants were found to be well acceptable in regards to the acceptability reflected by the dropout rate.

Conclusion: As far as both efficacy and acceptability were concerned, fluoxetine might be the best choice.

The dexamethasone suppression test in bulimic outpatients without major depression

Recent studies have examined the effectiveness of the dexamethasone suppression test (DST) in the evaluation of bulimia. In a series of 18 female bulimic outpatients without major depression, 9 (50%) failed to suppress on the DST. No significant difference was found between suppressors and nonsuppressors in personal and family histories of affective disorder, levels of anxious and depressive symptoms, psychoactive substance abuse, and severity of abnormal eating-related behaviours. In contrast, non-suppression was significantly associated with low weight. There is a trend to differentiate non-suppressors from suppressors in the current diagnosis of anorexia nervosa and in past history of anorexia nervosa. Seven patients received fluvoxamine for 8 weeks. Five patients were suppressors and showed a significant decrease in the frequency of their binges while the 2 non-suppressors did not improve. These preliminary results suggest that DST non-suppression might be typical of bulimic patients with anorexia nervosa and that pretreatment DST results might predict the response of bulimic behaviour to treatment with fluvoxamine.

Family Relations and Psychopathology: Examining Depressive and Bulimic Symptomatology

Despite early theories suggesting that family dysfunction (FD) may cause disordered eating, FD has been linked with other disorders and is a non-specific risk factor for disordered eating. We examined one potential model of the way FD relates to disordered eating, drawing on research that identified depression as a risk factor for bulimia. We examined whether depression symptoms (DEPs) partially mediated the relationship between family cohesion (as a measure of FD) and bulimic symptoms (BNs) using a sample of 215 never-married college women under age 20. Perceptions that one's family was less cohesive (or more disengaged) was associated with increased DEPs and BNs. Moreover, DEPs partially mediated the influence of cohesion on BNs through a significant indirect effect. Both family systems in general and treatment of mood difficulties may be important considerations in the prevention of disordered eating, and prevention efforts that include family relationships should be experimentally explored.

Suicidal behavior and depression in adolescents with eating disorders

BACKGROUND

Eating disorders are associated with an increased risk of suicide.

AIM OF THE STUDY

To examine suicidal behavior and depression in adolescents with eating disorders, and to identify risk factors associated with suicidal ideation and attempted suicide.

METHODS

Forty-six Israeli adolescent girls with anorexia nervosa or bulimia nervosa completed a self-report battery at the time of assessment or treatment. Suicide attempts and suicidal ideation were investigated in relation to clinical (e.g. body mass index, purging) and psychological (e.g. body dissatisfaction) features of the eating disorders, as well as depression. Twenty-four percent of the subjects had attempted suicide, and 65% reported suicidal thoughts. Fifty-eight percent were moderately to severely depressed.

FINDINGS

The risk of attempted suicide was associated with depression, a history of sexual abuse and longer duration of illness, but it was moderated by hospital treatment. Suicidal ideation was related only to depression.

CONCLUSIONS

The results of this study emphasize the importance of treating aggressively depression in adolescents with eating disorders. Depression seems to amplify illness severity. Currently, strategies for treating eating disorders focus more on the eating disorder behaviors and less on depression. We suggest investing more resources in detecting and treating the co-morbid depression.

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.

Neurobiology of addiction. An integrative review

Evidence that psychoactive substance use disorders, bulimia nervosa, pathological gambling, and sexual addiction share an underlying biopsychological process is summarized. Definitions are offered for addiction and addictive process, the latter being the proposed designation for the underlying biopsychological process that addictive disorders are hypothesized to share. The addictive process is introduced as an interaction of impairments in three functional systems: motivation-reward, affect regulation, and behavioral inhibition. An integrative review of the literature that addresses the neurobiology of addiction is then presented, organized according to the three functional systems that constitute the addictive process. The review is directed toward identifying candidate neurochemical substrates for the impairments in motivation-reward, affect regulation, and behavioral inhibition that could contribute to an addictive process.

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.

Food intake and mood in anorexia nervosa and bulimia

It is clear that patients with anorexia nervosa and bulimia have disturbances of mood, and it is likely that the mood disturbances bear an important relationship to the disturbances of eating behavior. We have as many questions, however, about the relationship between mood and eating behavior in these syndromes as we have answers. Although patients with anorexia nervosa and bulimia are frequently depressed, they fail to exhibit many of the biological characteristics of typical depressive illness, suggesting that these eating disorders are probably not simply variants of depression. Patients with bulimia appear to binge in response to dysphoric emotional states and to derive some transient relief from their bingeing. But it is unclear what facet or facets of the binge produce the alteration in emotional state, and thereby may serve to reinforce the behavior. A more detailed examination of this issue may significantly advance our understanding of the relationship between mood and food in eating disorders.

[Comorbidity between eating disorders and mood disorders: review]

OBJECTIVE

Comorbidity between eating disorders (ED) and mood disorders is a major issue when evaluating and treating patients with anorexia nervosa (AN) or bulimia nervosa (BN). In the literature, estimated comorbidity rates of mood disorders in subjects with ED differ widely across studies. Obviously, it is difficult to compare results from various sources because of differences in methods of assessment of depressive symptoms and in diagnostic criteria for both ED and mood disorders. Furthermore, few studies have included control groups, and, since mood disorders are among the most frequent psychiatric disorders in women--with an average estimated lifetime prevalence of 23.9 % (Kessleret al., 1994)--, it is not clear, yet, whether mood disorders are more common among women with an ED (AN or BN) than among women from the community. The only review articles we found on the relationships between ED and mood disorders survey different types of arguments in favour of a link between both categories of disorders, including symptoms, personal and family comorbidity, overlap in biological findings, and treatment results, but do not review in detail available comorbidity data. The aim of this paper is to conduct a critical literature review on studies assessing the prevalence of mood disorders in subjects with an ED (AN or BN). In the first part, we will discuss methodological issues relevant to comorbidity studies between ED and mood disorders, and select the most reliable studies. In the second part, taking into account these methodological considerations raised, we summarize the findings of these studies.

METHOD

We performed a manual and computerized search (Medline) for all published studies on comorbidity between ED and AD, limiting our search to the 1985-2002 period, in order to get sufficiently homogeneous diagnostic criteria for both categories of disorders.

RESULTS

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

DISCUSSION

We reviewed numerous studies here and conclude simply that there are many arguments in favor of elevated rates of MD in ED subjects, but there is no convincing evidence yet. Many questions are left unanswered or have conflicting responses. Our review highlights the need for further studies, which should address several requisites: comorbidity studies should be designed with this as a specific goal, rather than as a secondary aim within other types of studies (such as treatment studies, follow-up studies, etc.). Kendler et al. (1991) state that individuals with two disorders are more likely to present for treatment than individuals with one, therefore, comorbidity rates (which are not in agreement with a special etiologic relationship between BN and depression) may be exaggerated in clinical population results. New studies should include control subjects, matched (at least) for sex and age with ED subjects. Studies should evaluate prevalence of all types of MD in order to yield comparable estimates of MD in general. Comorbidity studies should be conducted on both current and recovered patients, compared to subjects from the community. It is still necessary to demonstrate specificity of findings, i.e. that early onset MD are of specific etiological importance to ED and do not simply increase the risk of later psychopathology in general. Studies should be conducted on larger samples, and all diagnostic subgroups should be considered (restrictive and bulimic anorexics, bulimics with and without history of AN, with or without purging). Multivariate comparisons should be performed, taking into account subject age, sex (if men are included), in- and outpatient status, course of illness, and other possibly relevant variables. Thus, more reliable estimates of the frequency of MD in subjects with ED could provide us with valuable etiologic, therapeutic and prognostic information.

Comorbidité entre les troubles du comportement alimentaire et les troubles anxieux Première partie : revue méthodologique

The objective of our work is to conduct a critical literature review on studies assessing the prevalence of anxiety disorders (AD) in subjects with eating disorders (ED) (anorexia nervosa and bulimia nervosa). In the first part (this paper), we will discuss methodological issues relevant to comorbidity studies between ED and AD.

METHOD

We performed a manual and computerised search (Medline) for all published studies on comorbidity between ED and AD, limiting our search to the 1985-2002 period, in order to get sufficiently homogeneous diagnostic criteria for both categories of disorders (most often RDC, DSM III, DSM Ill-R, or DSM IV criteria).

RESULTS

We review methodological issues regarding population sources, general methodological procedures, diagnostic criteria for ED and AD, diagnostic instruments, age of subjects and course of the eating disorder.

DISCUSSION

We give implications for reviewing the results of published studies and planing future research.

Psychiatric comorbidity in anorexia and bulimia nervosa: nature, prevalence, and causal relationships

Eating disorders are complex, multifactorially determined phenomena. When individuals with eating disorders present for treatment with comorbid conditions, case conceptualization is further complicated and, as a result, it may be difficult to determine optimal psychological or pharmacological treatment. This article reviews the evidence of the association between eating disorders (anorexia nervosa [AN] and bulimia nervosa [BN]) and Axis I depression, obsessive-compulsive disorder (OCD), substance abuse, and Axis II personality disorders, for the purposes of increasing awareness about the different options for case conceptualization. Although other diagnoses comorbid with eating disorders are of interest to clinicians (e.g., posttraumatic stress disorder [PTSD] and social phobia), their comprehensive review is currently premature due to a lack of empirical scrutiny. Finally, future directions for research, including suggestions for the use of particular assessment tools and more sophisticated research designs, are discussed.

Comorbidity between eating disorders and anxiety disorders: a review

OBJECTIVE

We conducted a critical literature review on studies assessing the prevalence of anxiety disorders (AD) in subjects with eating disorders (ED) (anorexia nervosa and bulimia nervosa). In the first part, we discuss methodological issues relevant to comorbidity studies between ED and AD. In the second part, taking into account these methodological considerations raised, we summarize the findings of these studies.

METHOD

We performed a manual and computerized search (Medline) for all published studies on comorbidity between ED and AD, limiting our search from 1985-2001 to get sufficiently homogeneous diagnostic criteria for both categories of disorders.

RESULTS

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

DISCUSSION

We discuss the results taking into account the methodological problems observed. We give guidelines for reviewing the results of published studies and planing future research.

Treatment of bulimia with antidepressants

Bulimia is a syndrome of compulsive binge eating that is often associated with serious morbidity and usually resistant to existing psychological or pharmacological treatments. We report use of tricyclic antidepressants in eight bulimic patients, six of whom obtained moderate or marked reduction of their eating binges within 2-4 weeks. This preliminary observation suggests that antidepressants may be of value in treating bulimia and adds to the evidence linking bulimia with affective disorder.

Blunted cardiovascular and catecholamine stress reactivity in women with bulimia nervosa

Cardiovascular and catecholamine responses to mental stressors were investigated in women with bulimia nervosa (BN) and in healthy control subjects. Fifteen women with BN and 15 control subjects completed psychosocial questionnaires before laboratory testing, where they were exposed to an interpersonally based speech stressor and a serial math task. Blood pressure, heart rate, epinephrine, norepinephrine and, via impedance cardiography, systolic time intervals, cardiac output and total peripheral resistance were measured at rest and during stress. Results indicated that BN was associated with blunted sympathetic activation in response to mental stress, indicated by increased pre-ejection period responses and blunted systolic blood pressure, heart rate and epinephrine responses. In contrast, women with BN had elevated cortisol levels when compared with control women. In addition, despite equivalent performance between groups, bulimic women reported feeling significantly more confused, frustrated, inadequate and dissatisfied with their performance during tasks. Psychosocial questionnaires also indicated that women with BN perceived more stress, had worse coping skills, lower self-esteem and sense of mastery, reported less social support, had worse mood, had greater anxiety and were more depressed when compared with control women. These results are interpreted as reflecting physiological and psychological profiles indicative of distress vs. active effort coping in BN.

Eating disorder symptomatology in major depression

This study evaluated the relationship between eating disorder symptomatology and severity of depression in depressed outpatients before and after antidepressant treatment and assessed the effect of treatment on eating disorder symptomatology. One hundred thirty-nine outpatients (82 women and 57 men) with major depressive disorder (MDD) filled out the eating disorder inventory (EDI) before and after 8 weeks of treatment with fluoxetine 20 mg/day. Diagnoses of MDD and possible comorbid eating disorders were made with the Structured Clinical Interview for DSM-III-R-Patient Edition. Several EDI subscales correlated significantly with severity of depression both at baseline and endpoint. Additionally, all EDI subscales showed a statistically significant decrease following fluoxetine treatment, and changes in depression severity following treatment were significantly related to changes in EDI bulimia, ineffectiveness, perfectionism, and interpersonal distress subscale scores. These results suggest that several symptoms characteristic of eating disordered patients are linked to the severity of depressive symptoms. Decreases in eating disorder symptomatology following antidepressant treatment may be related to changes in depressive symptoms.

Neurobiological and psychopharmacological basis in the therapy of bulimia and anorexia

1. Eating disorders can be found in several psychiatric pathologies: schizophrenia, delusional disorder (somatic type), bipolar disorders, major depressive disorder, borderline personality disorder, generalized anxiety disorder, body dysmorphic disorder, somatization disorder and conversion disorder. 2. Although their clinical features have been defined, relatively little is known about the role of neurobiological patterns in the pathogenesis of these disorders. Several CNS neurotransmitters and neuromodulators are involved in the regulation of eating behavior in animals and have been implicated in symptoms such as depression and anxiety often observed in patients with eating disorders. The authors will review some studies on NA, DA, 5-HT, beta-endorphins, CRH, VP, OT, CCK, NPY and PYY involved in eating disorders. Furthermore, we will highlight some of the studies on drug therapy of eating disorders taking into account the effects of these agents on neurotransmitters and neuromodulators. 3. Antidepressant drugs have long been used for anorexia nervosa and bulimia, these disorders been claimed to be affective equivalent. Antidepressant agents seem to be effective in reducing the frequency of binge-eating episodes, purging behavior and depressive symptomatology. It is notable that antidepressant agents have been proved to be effective in patients with chronic bulimic symptoms, even in cases persisting for many years and in patients who had repeatedly failed courses of alternative therapeutic approaches. In all of the positive studies, antidepressant agents appeared effective even in bulimic subjects who did not display concomitant depression. 4. Few controlled studies on use of medications for anorexia nervosa have been published. Central serotonergic receptor-blocking compounds such as cyproheptadine cause marked increase in appetite and body weight. Zinc supplementation or cisapride could be a therapeutic option in addition to psychological and other approaches in anorexia nervosa. 5. There is no therapy as yet which is fully effective in alimentary disorders. Psychotropic drugs give some relief from symptoms, but they cannot cure the disorders. An integrated approach, either pharmacological or psychological, is still recommendable.

Biological correlates of binge eating

Eating disorders are associated with numerous biological perturbations; however, sorting out cause from effect is difficult. Neuroendocrine and metabolic abnormalities are seen in both anorexia nervosa and bulimia nervosa, but they have not been described in binge eating disorder, in which neither starvation nor compensatory behaviors are present. Although these findings may reflect biologic differences among subgroups of binge eaters, an alternative explanation is that many of the biological correlates of binge eating are the result of metabolic derangement secondary to starvation and/or purging. The identification of binge eating disorder provides an opportunity to study the causes and concomitants of binge eating in the absence of compensatory behaviors.

Compulsive eating, obsessive thoughts of food, and their relation to assertiveness and depression in women

Fifty-three self-defined compulsive eaters recruited from weight loss programs and a college population and prescreened to eliminate probable anorexics and bulimics participated in this study. They completed the Three Factor Eating Questionnaire, Beck Depression Inventory, Compulsive Eating Scale, Eating Obsessive-Compulsive Questionnaire, Personal Assertion Analysis, and provided demographic information. Participants had high scores for compulsive eating and disinhibition and low scores for depression. The best predictors of compulsive eating were disinhibition and obsessive thoughts of food, which accounted for 61% of the variance. Twenty-one percent of the sample reported a history of sexual abuse. Thirty-one percent of the sample were classified as medically obese, yet 49% perceived themselves to be moderately to very overweight.

Co-morbidity of eating disorders and substance abuse review of the literature

The comorbidity of eating disorders and substance use and abuse has frequently been reported in the past 15 years. To date, however, no synthesis of this literature exists. Here, 51 studies reporting on these associations are reviewed. Studies of substance use and abuse in eating disordered women are considered, as are studies of eating disorders among women classified as substance abusers. The rates of substance abuse among eating disordered women are also examined. This review indicates that associations are stronger with bulimia, and "bulimic" behaviors, than with anorexia nervosa. Analogously, bulimic anorectics report more substance use and abuse than restricters. The prevalence of drug abuse was not found to differ between the relatives of bulimics and anorectics. Several mechanisms explaining the eating disorder-substance use/abuse link are considered, and suggestions for future research made.

Food preferences, eating patterns, and physical activity among adolescents: correlates of eating disorders symptoms

PURPOSE

Food preferences, eating patterns, and physical activity patterns were examined in a cohort of adolescent females and males participating in a longitudinal study of the developmental antecedents of eating disorders.

METHODS

All adolescents (n = 1494) in grades seven through ten in an entire school district completed a survey about their dieting behaviors, eating, and exercise patterns.

RESULTS

Principal components analysis showed similar factor structures for food preferences and eating patterns among males and females. Gender differences were present in physical activity patterns. Sports participation was correlated with healthy food preference and was a significant predictor of eating disorders symptoms. Junk food preference was marginally inversely related to eating disorders symptoms in females. Preference for other types of foods and reported intake of foods were not related to eating disorders symptoms. The percent of variance in risk score accounted for by dietary intake and physical activity patterns was small.

CONCLUSIONS

Psychological and social/environmental variables may explain a larger proportion of the variance in eating disorders risk than the dietary and physical activity variables examined in this study. Implications for understanding the etiology and behavioral expression of eating disorders are discussed.

The use of electroconvulsive therapy in patients with intractable anorexia nervosa

The history of the treatment of anorexia nervosa includes the majority of psychological and somatic therapies devised by psychiatrists, psychologists, and general physicians. We review the history of one of these treatments, electrical convulsive therapy (ECT), and discuss three patients treated with ECT for primary anorexia nervosa. Two had a positive response to this treatment, one did not. She later responded favorably to a course of treatment with fluoxetine.

Adoption and eating disorders: a high-risk group?

Between 1975 and 1985, 3.8% of patients referred to the Maudsley Hospital with anorexia and bulimia were adoptees. This exceeds the rate of adoption (1.5%) in the general population matched for year of birth. The 18 adoptees with eating disorders had significantly more associated behavioural disturbance and lower academic achievement than the 18 matched controls, and different precipitating factors.

Alpha-1-acid glycoprotein in major depressive and eating disorders

Plasma alpha 1-acid glycoprotein (AGP) levels were measured in 49 subjects with major depressive disorder, 15 subjects with anorexia nervosa and 18 subjects with bulimia nervosa, together with age- and sex-matched controls. AGP levels were elevated in depression and bulimia compared to controls. They were particularly elevated in depressed subjects who proved unresponsive to treatment with a standard course of antidepressants. In the depressed subjects, elevated AGP levels returned to control levels after treatment whether or not treatment was successful. There was a correlation between AGP and post-dexamethasone plasma cortisol levels in depression but not in bulimia and a correlation with age in depressed subjects only. There was no correlation between AGP values and tritiated imipramine binding parameters. Further studies are suggested to explore the issue of whether variations in AGP level are responsible for the abnormalities in platelet 5HT uptake and tritiated imipramine binding that have been reported in depression or for treatment non-response.

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

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

Comparison of regional brain metabolism in bulimia nervosa and affective disorder assessed with positron emission tomography

Women with bulimia often present with symptoms of depression in addition to bingeing and purging behavior. Brain metabolism in eight women with bulimia nervosa was compared to that in eight women with major affective disorder and eight normal women, using positron emission tomography and 18-fluoro-2-deoxyglucose. Normal women have higher right than left cortical metabolic rates and active basal ganglia. Bulimics lost the normal right activation in some areas, but maintained basal ganglia activity. Depressives retained right hemisphere activation, but had decreased metabolism in basal ganglia. This suggests that although women with bulimia frequently present with symptoms of depression, the pathophysiologic changes associated with bulimia differ from major effective disorder.

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

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

The role of serotonin in eating disorders

Recent pharmacological studies have more precisely characterised the nature of the inhibitory effect of brain serotonin (5-hydroxytryptamine) on feeding behaviour. Thus, the brain sites and receptors involved have been identified, and a possible physiological role of endogenous serotonin in controlling natural patterns of eating and nutrient selection has been defined. The medial hypothalamus is believed to be a critical location in the mediation of serotonin's action. Specifically, the paraventricular and ventromedial nuclei are known to be involved in controlling energy balance, while the suprachiasmatic nucleus determines circadian patterns of eating. Serotonergic stimulation of these 3 nuclei with exogenous serotonin or drugs that release endogenous serotonin, preferentially reduces carbohydrate intake in naturally feeding animals through satiety mechanisms involved in the termination of feeding. This phenomenon is mediated by serotonin and possibly serotonin receptors, in contrast to serotonin autoreceptors which potentiate feeding possibly by inhibiting serotonin release. The activity of serotonergic function in the medial hypothalamus exhibits a circadian rhythm which is characterised by a peak at the beginning of the active cycle when the motivation to eat is strongest and is triggered by deficits in energy stores. At this time, carbohydrate is found to be the naturally preferred macronutrient, and it appears that serotonin becomes most activated under these conditions to terminate the carbohydrate-rich meal, possibly by activating satiety neurons localised in the medial hypothalamus. In this process, serotonin may interact antagonistically with noradrenaline (norepinephrine) and its alpha 2-noradrenergic receptors that normally function to enhance carbohydrate intake at the onset of the natural feeding cycle. Moreover, while inducing satiety for carbohydrate, serotonin may also play a role in switching the animal's preference towards protein. The regulation of this macronutrient is closely linked to that of carbohydrate, and it is normally preferred in the second meal of the natural feeding cycle. Most of the pharmacological evidence to date generally supports the hypothesis that disturbances in serotonin function occur in eating disorders. Decreases in plasma tryptophan, urinary 5-hydroxyindoleacetic acid (5-HIAA), platelet serotonin binding and basal cerebrospinal fluid 5-HIAA in anorexia nervosa normalise upon weight restoration and appear to be starvation effects. These alterations in serotonergic function may however perpetuate the symptomatology of anorexia nervosa once the illness is set in motion. Some drugs which in part affect serotonergic function facilitate weight gain in conjunction with an integrated psychotherapeutic and behavioural programme. Patients with bulimia nervosa, regardless of the presence of anorexia nervosa or major depression, who have been relatively weight stable and free of binge/vomit episodes for at least 3 weeks, have significantly blunted prolactin responses to the serotonin agonists. These findings indicate that post-synaptic responsiveness in hypothalamic-pituitary serotonergic pathways is reduced in bulimia. Similar alterations in other serotonin pathways at or above the level of the hypothalamus may contribute to binge eating and other behavioural symptoms in bulimic patients. The clinical response to several psychotropic agents known to potentiate serotonergic transmission further substantiates a serotonin dysregulation hypothesis of bulimia nervosa.(ABSTRACT TRUNCATED AT 400 WORDS)

Luteinizing hormone and cortisol responses to naloxone in normal weight women with bulimia

The present study was undertaken in order to establish whether alterations in the endogenous opioid control of luteinizing hormone (LH) and ACTH/cortisol secretion occur in bulimic women with normal body weight and normal menstrual cycles. For this purpose, the capability of the opioid antagonist naloxone (4 mg injected as an intravenous bolus at time 0, plus 10 mg infused over 2 hr) to increase the circulating levels of LH and cortisol was tested in nine bulimic women and in nine age- and weight-matched normal controls. All women were tested on the 22nd day of a normal menstrual cycle. Two days later, a control test with normal saline (NaCl 0.9%) instead of naloxone was performed. The basal levels of LH and cortisol were similar in the bulimic and normal subjects and were not modified by the administration of normal saline. In contrast, the administration of naloxone significantly increased plasma LH and cortisol levels in all subjects, with peak LH responses at 30 min and peak cortisol responses at 60 min. The naloxone-induced LH and cortisol increases were significantly higher in the bulimic women than in the normal controls. These data indicate the presence of an increased opioid inhibitory tone in the control of LH and ACTH/cortisol secretion in normal weight bulimic women with normal menstrual cycles.

Adolescent dual diagnosis: a 12-step transformational model

A structured model inpatient treatment program for multiple-diagnosed treatment-resistant adolescents is described. The chemical dependence disease model of Predisposition+Drug+Enabling System=Disease provides the fundamental theoretical approach. This model is elaborated and used similarly for psychiatric disorders, with examples presented. The role of psychiatric evaluation for pharmacological interventions is outlined. The psychotherapeutic treatment focuses on a commitment to abstinence as the goal. A "psychology of commitment" is described using a reframing of traditional psychotherapeutic approaches. This approach is used in conjunction with the first five steps of Alcoholics Anonymous as an empowering therapeutic model. The role of defenses, denial, confrontation, and cognitive distortions is described. The value of this approach as a neutral ground for discussion using concepts from traditional Freudian therapy, self-psychology, cognitive and learning therapies, and rational emotive therapy is elaborated.

Specificity of the salivary cortisol dexamethasone suppression test across psychiatric diagnoses

One hundred forty-eight psychiatric inpatients, 12 outpatients, and 17 normal controls were given the 1.0-mg overnight Dexamethasone Suppression Test (DST), with salivary cortisol concentrations being measured as the dependent variable. Based on the Structured Clinical Interview for DSM-III, the patients were diagnosed as having major depression with melancholia (n = 21), nonmelancholic major depression (n = 50), mania (n = 15), schizophrenia (n = 32), dementia (n = 6), substance dependence/abuse n = 18), and miscellaneous (n = 18). Neither the melancholic major depressives nor the entire group of major depressives had significantly higher salivary cortisol pre- or postdexamethasone as compared with all the other patients combined, nor did the melancholic patients have significantly higher cortisol than the nonmelancholic depressives. The inpatients as a group had significantly higher pre- and postdexamethasone cortisol values than the normal controls; cortisol values for the outpatients were intermediate between these two groups. Illness severity (in the depressives), length of time in hospital before the DST, and medication regimen were all unrelated to DST outcome. Thus, in this study, the salivary cortisol DST showed little clinical utility in discriminating major depressives with and without melancholia from other patients with a broad range of psychiatric diagnoses. The test did distinguish between hospitalized psychiatric patients and normal control subjects and between depressed inpatients and depressed outpatients, indicating that hospitalization-related variables contributed to DST outcome.

Bulimia, tricyclic antidepressants, and mania

Anorexia nervosa and bulimia are common conditions that are difficult to treat effectively. Psychopharmacologic agents, particularly tricyclic antidepressants, are now being used as adjunctive therapy in bulimia. The case of a 15-year-old girl with bulimia who was treated with imipramine and had a severe (and first) manic episode is presented. The complication of drug-induced mania observed in patients treated with tricyclic antidepressants is discussed.

An empirical assessment of bulimic patients using multiple measures

This paper examines personality and clinical assessment data from bulimic patients and from a control group of normal volunteer subjects. Thirty-eight bulimic females representing consecutive admissions to an outpatient treatment program were administered a battery of tests including the MMPI, FIRO-B, Beck Depression Inventory, Moos Family Environment Scale, Bem Sex Role Inventory, and Conte Borderline Syndrome Index. Twenty-six normal females also completed this testing battery. As expected, bulimics differed from normals on several clinical scales, including the MMPI, Beck Depression Inventory, and Conte Borderline Syndrome Index. More importantly, however, were the results of the cluster analysis of the bulimic MMPI scores which demonstrated two clearly defined subtypes of bulimia: a mildly disturbed group that shows developmental conflicts and adjustment difficulties, and a severely disturbed group that displays low ego strength and characteristics suggesting an Axis II personality disturbance. The other testing measures failed to reach significance levels. Implications for assessment and treatment are explored in the context of these results.

Cardiac regulation in bulimia nervosa

Heart rate and vagal tone were assessed during sleep and bed rest conditions in nine patients with bulimia nervosa (BN), six patients with concomitant anorexia nervosa and bulimia nervosa (AN + BN) and five control subjects. During bed rest conditions AN + BN patients had significantly lower heart rates than BN or control subjects. During sleep, the heart rate differed significantly for all three groups. The AN + BN group had a significantly lower heart rate than either the BN or control groups and the BN group had a significantly lower heart rate than controls. On the other hand, measures of vagal tone, based on respiratory sinus arrhythmia, were significantly elevated in both patient groups compared to controls. These findings suggest that the bradycardia during sleep in BN patients may be primarily due to hypervagal activity, but the greater bradycardia demonstrated in those patients with both AN and BN may result from hypervagal activity coupled with reduced sympathetic activity.

The DST and TRH test in bulimia nervosa

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

The dexamethasone suppression test in bulimia nervosa

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

Bingeing behavior and plasma amino acids: a possible involvement of brain serotonin in bulimia nervosa

It has been suggested that bingeing and vomiting behavior may be an attempt to suppress hunger or reduce dysphoria. Theoretically, such relationships could involve a mechanism whereby bingeing and vomiting change plasma amino acids which, in turn, enhance brain serotonin-mediated satiety and/or improvement in mood. This hypothesis is based on data showing that the intake of dietary carbohydrates increases the uptake of tryptophan (TRP), the precursor of serotonin, into the brain by increasing the plasma TRP ratio (the ratio of the plasma TRP concentration to the summed concentrations of other amino acids that compete with TRP for brain uptake). Plasma prolactin (PRL) release might reflect the activation of this system. We found that an increase in the TRP ratio during bingeing and vomiting was associated with satiety (i.e., cessation of bingeing and vomiting), but not change in mood. In other words, bulimic subjects who developed an increased plasma TRP ratio during bingeing and vomiting had fewer cycles of bingeing and vomiting and a greater increase in plasma PRL than did subjects who did not develop an increase in the plasma TRP ratio. This study raises the possibility that an increase in the TRP ratio may be associated with the termination of bingeing and vomiting, perhaps due to its effects on brain serotonin metabolism.

Involvement of serotonin system in bulimia

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