Predictive validity of bulimia nervosa as a diagnostic category

Prospective Relations between Overeating, Loss of Control Eating, Binge Eating, and Depressive Symptoms in a School-Based Sample of Adolescents

A sample of 353 community adolescents (grades 9 to 12, 57.6 % female) participated in a 2-wave longitudinal study of eating behaviors (overeating, loss of control eating [LOC], and binge eating) and depression. The study addresses 4 hypotheses. (1) The prospective relations between eating behaviors and depressive symptoms will be reciprocal, with each predicting the other over time. (2) These relations will be stronger for girls than for boys. (3) These relations will be stronger for adolescents with high (not low) body mass index (BMI). (4) LOC will show incremental predictive utility in relation to depressive symptoms over and above overeating. Evidence supported reciprocal relations between binge eating and depressive symptoms and between overeating and depressive symptoms, but not between LOC and depressive symptoms. Sex and BMI did not substantially moderate these relations. Taken separately, overeating but not LOC predicted depressive symptoms. Taken together, neither predictor was significant controlling for the other. Results raise questions about the importance of LOC alone in predicting depressive symptoms in adolescence.

Depression, worry, and psychosocial functioning predict eating disorder treatment outcomes in a residential and partial hospitalization setting

This retrospective study explores depression, worry, psychosocial functioning, and change in body mass index (BMI) as predictors of eating disorder (ED) symptomatology and BMI at discharge and 1-year follow-up from a residential and partial hospitalization ED treatment center. Participants were 423 male and female patients receiving treatment at an ED treatment center. Results indicate significant improvement in ED symptomatology, psychological impairment, and change in BMI (in patients with anorexia nervosa) at treatment discharge and follow-up compared to treatment admission (ps < 0.001). Depression and worry predicted ED symptomatology and psychological impairment at discharge (ps < 0.05). Depression, worry, and psychosocial functioning predicted ED symptomatology and psychological impairment at 1-year follow-up (ps < 0.001). Change in BMI was not a significant predictor of outcome. Depression, worry, and psychosocial functioning each play a role in treatment outcomes and may help clarify who might benefit from treatment. Clinicians in ED treatment centers should consider these as areas of focus for improved outcomes.

An Interactive, Graphical Tool for Retrospectively Assessing Symptom Frequency and Severity: An Illustration With Eating Disorder Behaviors, Body Weight, and Stress

There are few assessments that gather valid, highly detailed data on short-term (i.e., weekly) symptom frequency/severity retrospectively. In particular, methodologies that provide valid data for research investigating symptom changes are typically prospective, expensive, and burdensome. The purpose of this study was to evaluate a new interactive and graphical assessment tool for gathering detailed information about eating-related symptom frequency/severity retrospectively over a 3-month period. A mixed eating disorder sample ( N = 113) recruited from the community provided symptom data once weekly for 12 weeks and completed the Interactive, Graphical Assessment Tool (IGAT) assessing eating disorder symptoms on three occasions to determine the test-retest and concurrent validity of the IGAT. The IGAT performed marginally better than other measures for retrospective symptom frequency assessment in the eating disorders and did so at a greater level of detail than other available tools. Future research should evaluate the IGAT with other behaviors of interest.

Personality psychopathology differentiates risky behaviors among women with bulimia nervosa

OBJECTIVE

Individuals with bulimia nervosa (BN) frequently endorse risky behaviors such as self-harm and substance use. However, no studies of BN to date have examined factors associated with engaging in individual or co-occurring risky behaviors. Given that individuals with BN often have personality psychopathology, which has been linked to symptoms and course of illness, this study sought to examine how personality may differentiate engagement in risky behaviors among BN individuals.

METHOD

A sample of 133 women with BN completed self-report measures of personality psychopathology at baseline, and then reported on bulimic and risky behaviors (e.g., substance misuse, self-harm) over 2 weeks using ecological momentary assessment. A series of hierarchical multiple regression analyses were conducted to examine the unique associations between state-level predictor variables (each risky behavior, e.g., substance misuse, and combination of risky behaviors, e.g., substance misuse plus self-harm) and trait-level personality constructs.

RESULTS

Substance misuse behavior, above and beyond all other risky behaviors, was significantly associated with higher scores on trait dissocial behavior (P = 0.004).

DISCUSSION

Substance misuse in BN has a unique association with dissocial behavior, a personality trait characterized by hostility, impulsivity, and entitlement. These results suggest that targeting personality variables may help facilitate more effective treatment of risky behaviors, including substance use in BN. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:681-688).

Comparing operational definitions of DSM-5 anorexia nervosa for research contexts

OBJECTIVE

DSM-5 anorexia nervosa (AN) criteria include several changes that increase reliance on clinical judgment. However, research contexts require operational definitions that can be applied reliably and that demonstrate validity. The present study evaluated different operational definitions for DSM-5 AN.

METHOD

DSM-5 AN criteria were applied to diagnostic interview data from 364 women varying two features: threshold for determining low weight for Criterion A (body mass index [BMI] <17.0 kg/m(2) vs. <18.5 kg/m(2)) and explicit endorsement of weight phobia (Criterion B explicit vs. inferred). Resulting groups of individuals with DSM-5 AN were compared on estimated frequency. In addition, AN groups were compared to non-eating disorder controls and individuals with an other specified feeding or eating disorder (OSFED) on external validators.

RESULTS

All operational DSM-5 definitions produced higher lifetime frequency estimates than reported for DSM-IV AN, with a particularly large increase associated with the broadest definition. All definitions produced significant differences in comparison to controls on external validators that were associated with medium to large effect sizes. Only definitions that required a lower weight threshold or explicit endorsement of weight phobia demonstrated significant differences compared to OSFED on external validators, and these were of small effect size. The specific combination of BMI <18.5 kg/m(2) with inferred weight phobia exhibited few meaningful distinctions from the OSFED group.

DISCUSSION

To balance inclusivity, syndromal reliability, and validity, an operational definition for DSM-5 AN in research contexts should define low weight as BMI <18.5 kg/m(2) and require measurable rather than inferred weight phobia.

The role of impulsivity, inattention and comorbid ADHD in patients with bulimia nervosa

Introduction

Little is known about the contribution of impulsivity, inattention and comorbid attention deficit/hyperactivity disorder (ADHD) in the development and maintenance of bulimia nervosa (BN). In particular, their specific contribution to disordered eating symptoms and whether they have additive effects to the general psychopathological burden remains unclear.

Methods

Fifty-seven female patients seeking treatment for BN and 40 healthy controls completed diagnostic questionnaires and interviews that investigated: a) ADHD, b) impulsivity, c) eating disorders and d) general psychopathology. Attentional processes and impulsivity were assessed by a comprehensive computer-based neuropsychological battery.

Results

Twenty-one percent of patients with BN met the clinical cut-off for previous childhood ADHD compared to 2.5% of healthy controls. Adult ADHD according to DSM IV was also more prevalent in patients with BN, with an odds ratio of 4.2. Patients with BN and previous childhood ADHD were more impulsive and inattentive than patients with BN alone. These patients also displayed more severely disordered eating patterns and more general psychopathological symptoms compared with those without ADHD. Severity of eating disorder symptoms was better explained by inattentiveness than by either impulsivity or hyperactivity.

Discussion

Our data suggest an elevated rate of former childhood and current ADHD-symptoms in treatment-seeking patients with BN. Stronger impulsivity and inattention associated with more severe neuropsychological deficits and eating disorder symptoms indicate an additive risk that is clinically relevant for these patients. Thus, clinicians should identify comorbid patients who might profit from additional ADHD-specific treatments.

Latent profile and latent transition analyses of eating disorder phenotypes in a clinical sample: a 6-year follow-up study

The DSM-IV classification of Eating Disorders (EDs) identifies clinical entities showing considerable overlap and diagnostic instability across time. Latent profile analysis (LPA) allows the identification of underlying groups of individuals according to their patterned responses across a set of features. LPA was applied to data regarding EDs symptoms of a clinical sample of 716 EDs patients, with a current DSM-IV diagnosis of threshold and subthreshold EDs. Latent transition analysis (LTA) was used to examine the longitudinal stability of the obtained profiles. The latent profiles were compared for psychopathological variables and long-term outcomes (recovery, relapse), based on a 6-year follow-up after a cognitive behavioural treatment. Five different phenotypes were identified: "severe binging", "moderate binging", "restricted eating", "binge and moderate purging", and "binge and severe purging". The relevance of this characterization was confirmed by the differences in terms of psychopathological features and outcomes. Over the long term, a three-profile solution was adopted, clustering the subjects into "binge eating", "binge eating and purging", and "restricted eating". Latent profiles showed a moderate stability over the 6-year period, with probability estimates of stability within status over time of 0.57 for "binge eating", 0.40 for "binge eating and purging", and 0.41 for "restricted eating". The implications for DSM 5 were discussed, and the relative high rate of transition within phenotypes confirmed the significant instability of EDs phenomenology.

Classification of feeding and eating disorders: review of evidence and proposals for ICD-11

Current classification of eating disorders is failing to classify most clinical presentations; ignores continuities between child, adolescent and adult manifestations; and requires frequent changes of diagnosis to accommodate the natural course of these disorders. The classification is divorced from clinical practice, and investigators of clinical trials have felt compelled to introduce unsystematic modifications. Classification of feeding and eating disorders in ICD-11 requires substantial changes to remediate the shortcomings. We review evidence on the developmental and cross-cultural differences and continuities, course and distinctive features of feeding and eating disorders. We make the following recommendations: a) feeding and eating disorders should be merged into a single grouping with categories applicable across age groups; b) the category of anorexia nervosa should be broadened through dropping the requirement for amenorrhoea, extending the weight criterion to any significant underweight, and extending the cognitive criterion to include developmentally and culturally relevant presentations; c) a severity qualifier "with dangerously low body weight" should distinguish the severe cases of anorexia nervosa that carry the riskiest prognosis; d) bulimia nervosa should be extended to include subjective binge eating; e) binge eating disorder should be included as a specific category defined by subjective or objective binge eating in the absence of regular compensatory behaviour; f) combined eating disorder should classify subjects who sequentially or concurrently fulfil criteria for both anorexia and bulimia nervosa; g) avoidant/restrictive food intake disorder should classify restricted food intake in children or adults that is not accompanied by body weight and shape related psychopathology; h) a uniform minimum duration criterion of four weeks should apply.

Understanding the association of impulsivity, obsessions, and compulsions with binge eating and purging behaviours in anorexia nervosa

OBJECTIVE

To further refine our understanding of impulsivity, obsessions, and compulsions in anorexia nervosa (AN) by isolating which behaviours--binge eating, purging, or both--are associated with these features.

METHODS

We conducted regression analyses with binge eating, purging, and the interaction of binge eating with purging as individual predictors of scores for impulsivity, obsessions, and compulsions in two samples of women with AN (n = 1373).

RESULTS

Purging, but not binge eating, was associated with higher scores on impulsivity, obsessions, and compulsions. Purging was also associated with worst eating rituals and with worst eating preoccupations.

CONCLUSION

Our results suggest that purging, compared with binge eating, may be a stronger correlate of impulsivity, obsessions, and compulsions in AN.

Empirical classification of eating disorders

Current diagnostic criteria for anorexia nervosa (AN) and bulimia nervosa (BN) account for a minority of individuals with clinically significant disorders of eating, raising concerns about the clinical utility of current definitions. This review examines evidence for the validity of current and alternative approaches to defining eating disorders and implications for draft criteria for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Although this review largely supports the predictive validity of distinctions among AN, BN, and the newly proposed binge eating disorder (BED), it also highlights that our tendency to "study what we define" has created a gap between the problems that people have and what we know about those problems. Future research on the causes and consequences of eating disorders should include more heterogeneous groups to enable identification of meaningful boundaries that distinguish between disorders based on etiological and predictive validity.

Outcome of dialectical behaviour therapy for concurrent eating and substance use disorders

AIM

The current study examined the preliminary efficacy of dialectical behaviour therapy (DBT) adapted for concurrent eating disorders (EDs) and substance use disorders (SUDs).

METHOD

A matched randomized controlled trial was carried out with 25 female outpatients diagnosed with concurrent ED and SUD. Participants randomized to the intervention condition received DBT, whereas those randomized to the control condition received treatment as usual (TAU), both for a period of 1 year. A series of measures related to disordered eating, substance use and depression were administered to the participants at the beginning of treatment and at 3, 6, 9 and 12 months into treatment, followed by 3-month and 6-month follow-up assessments.

FINDINGS

Participants randomized to the DBT condition evidenced a superior retention rate relative to their counterparts in the TAU condition at various study time points, including post-treatment (80% versus 20%) and follow-up (60% versus 20%). Due to the unexpected elevated dropout rates and the worsening of ED-SUD symptomatology in the TAU condition, recruitment efforts were terminated early. Results from the DBT condition revealed that the intervention had a significant positive effect on behavioural and attitudinal features of disordered eating, substance use severity and use, negative mood regulation and depressive symptoms. Finally, increases in participants' perceived ability to regulate and cope with negative emotional states were significantly associated with decreases in emotional eating and increases in levels of confidence in ability to resist urges for substance use.

CONCLUSION

Results suggest that the adapted DBT might hold promise for treating individuals with concurrent ED and SUD.

KEY PRACTITIONER MESSAGE

The current study is the first study to report positive effects of DBT on individuals with concurrent eating and substance use disorders. Although the results require replication and extension, they suggest that the DBT may be promising for this population. The results suggest that clinicians treating individuals with concurrent eating and substance use problems should be particularly cautious of poor treatment retention and treatment complications. The results bear upon the highly salient and important issue of whether individuals with concurrent substance use need to be excluded from research studies and treatment programmes.

Management of anorexia and bulimia nervosa: An evidence-based review

Anorexia nervosa and bulimia nervosa are primarily psychiatric disorders characterized by severe disturbances of eating behavior. Eating disorders are most prevalent in the Western culture where food is in abundance and female attractiveness is equated with thinness. Eating disorders are rare in countries like India. Despite a plethora of management options available to the mental health professionals, no major breakthrough has been achieved in recent years. Nutritional rehabilitation along with some form of re educative psychotherapy remains the mainstay of management of anorexia nervosa. In bulimia nervosa, both fluoxetine and cognitive behavior therapy have been found to be effective. Although the above-mentioned management options have been in use for decades, the active ingredient is still to be ascertained.

EXECUTIVE PERSONALITY TRAITS AND EATING BEHAVIOR

Eating disorders, such as anorexia, bulimia, and binge eating disorder, commonly involve a dysregulation of behavior (e.g., a lack or excess of inhibition and impulsive eating patterns) that is suggestive of prefrontal dysfunction. Functional neuro-imaging studies show that prefrontal-subcortical systems play a role in eating behavior and appetite in healthy individuals, and that people with eating disorders have altered activity in these systems. Eating behavior is often disturbed by illnesses and injuries that impinge upon prefrontal-subcortical systems. This study examined relationships between executive functioning and eating behavior in healthy individuals using validated behavioral rating scales (Frontal Systems Behavior Scale and Eating Inventory). Correlations demonstrated that increased dysexecutive traits were associated with disinhibited eating and greater food cravings. There was also a positive association with cognitive restraint of eating, suggesting that increased compensatory behaviors follow disinhibited eating. These psychometric findings reinforce those of other methodologies, supporting a role for prefrontal systems in eating.

Lifetime course of eating disorders: design and validity testing of a new strategy to define the eating disorders phenotype

BACKGROUND

Aetiological studies of eating disorders would benefit from a solution to the problem of instability of eating disorder symptoms. We present an approach to defining an eating disorders phenotype based on the retrospective assessment of lifetime eating disorders symptoms to define a lifetime pattern of illness. We further validate this approach by testing the most common lifetime categories for differences in the prevalence of specific childhood personality traits.

METHOD

Ninety-seven females participated in this study, 35 with a current diagnosis of restricting anorexia nervosa, 32 with binge/purging subtype of anorexia nervosa and 30 with bulimia nervosa. Subjects were interviewed by a newly developed EATATE Lifetime Diagnostic Interview for a retrospective assessment of the lifetime course of eating disorders symptoms and childhood traits reflecting obsessive-compulsive personality.

RESULTS

The data illustrate the extensive instability of the eating disorders diagnosis. Four most common lifetime diagnostic categories were identified that significantly differ in the prevalence of childhood traits. Perfectionism and rigidity were more common in groups with a longer duration of underweight status, longer episodes of severe food restriction, excessive exercising, and shorter duration of binge eating.

CONCLUSIONS

The assessment of lifetime symptoms may produce a more accurate definition of the eating disorders phenotype. Obsessive-compulsive traits in childhood may moderate the course producing longer periods of underweight status. These findings may have important implications for nosology, treatment and future aetiological studies of eating disorders.

Impulse control disorders in women with eating disorders

We compared symptom patterns, severity of illness, and comorbidity in individuals with eating disorders with and without impulse control disorders (ICD), and documented the temporal pattern of illness onset. Lifetime ICD were present in 16.6% of 709 women with a history of eating disorders. The most common syndromes were compulsive buying disorder and kleptomania. ICD occurred more in individuals with binge eating subtypes, and were associated with significantly greater use of laxatives, diuretics, appetite suppressants and fasting, and with greater body image disturbance, higher harm avoidance, neuroticism, cognitive impulsivity, and lower self-directedness. In addition, individuals with ICD were more likely to have obsessive-compulsive disorder, any anxiety disorder, specific phobia, depression, cluster B personality disorder, avoidant personality disorder, and to use psychoactive substances. Among those with ICD, 62% reported the ICD predated the eating disorder and 45% reported the onset of both disorders within the same 3-year window. The presence of a lifetime ICD appears to be limited to eating disorders marked by binge eating and to be associated with worse eating-related psychopathology, more pathological personality traits, and more frequent comorbid Axis I and II conditions. Untreated ICD may complicate recovery from eating disorders.

Outcomes of eating disorders: a systematic review of the literature

OBJECTIVE

The RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center systematically reviewed evidence on factors associated with outcomes among individuals with anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED) and whether outcomes differed by sociodemographic characteristics.

METHOD

We searched electronic databases including MEDLINE and reviewed studies published from 1980 to September, 2005, in all languages against a priori inclusion/exclusion criteria and focused on eating, psychiatric or psychological, or biomarker outcomes.

RESULTS

At followup, individuals with AN were more likely than comparisons to be depressed, have Asperger's syndrome and autism spectrum disorders, and suffer from anxiety disorders including obsessive-compulsive disorders. Mortality risk was significantly higher than what would be expected in the population and the risk of suicide was particularly pronounced. The only consistent factor across studies relating to worse BN outcomes was depression. A substantial proportion of individuals continue to suffer from eating disorders over time but BN was not associated with increased mortality risk. Data were insufficient to draw conclusions concerning factors associated with BED outcomes. Across disorders, little to no data were available to compare results based on sociodemographic characteristics.

CONCLUSION

The strength of the bodies of literature was moderate for factors associated with AN and BN outcomes and weak for BED.

Shared transmission of eating disorders and anxiety disorders

OBJECTIVE

Eating disorders have high comorbidity with mood, anxiety, and substance use disorders. Using twins from the population-based Minnesota Twin Family Study (MTFS), we examined comorbidity and shared transmission between eating pathology and these disorders.

METHOD

Female twins (N = 672), ages 16-18 years, completed structured clinical interviews assessing anorexia nervosa and bulimia nervosa (as described in the 4th ed. of the Diagnostic and Statistical Manual of Mental Disorders [DSM-IV; American Psychiatric Association, 1994]), as well as mood, anxiety, and substance use disorders (as described in the 3rd Rev. ed. of the Diagnostic and Statistical Manual of Mental Disorders [DSM-III-R]). Shared transmission was examined using a discordant monozygotic (MZ) twin design.

RESULTS

Significant comorbidity was found between eating disorders and major depression, anxiety disorders, and nicotine dependence. Within MZ twin pairs discordant for eating disorders (n = 14), non-eating-disordered cotwins demonstrated increased risk for anxiety disorders compared with controls. Similarly, within MZ twin pairs discordant for anxiety disorders (n = 52), non-anxiety-disordered cotwins demonstrated increased risk for eating disorders compared with controls.

DISCUSSION

Findings support shared transmission between eating disorders and anxiety disorders. However, the nature of this shared diathesis remains unknown.

Adolescents with bulimia nervosa and eating disorder not otherwise specified-purging only

OBJECTIVE

The purpose of the study was to better understand the phenomenology of bulimic symptomatology in an adolescent clinic sample.

METHOD

Adolescents with bulimia nervosa (BN; n = 36) and eating disorders not otherwise specified-purging but no objective bulimic episodes (EDNOS-P; n = 20) were compared on the Eating Disorder Examination (EDE), the Beck Depression Inventory (BDI), the Rosenberg Self-Esteem Scale (RSES), and the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS).

RESULTS

Subjects with EDNOS-P and BN were equivalent in terms of age and weight, but were less likely to have intact families. Nearly one half of EDNOS-P subjects purged exclusively outside of eating episodes in which they experienced a sense of loss of control. Although still at clinically significant levels, EDNOS-P subjects reported less concerns regarding weight, shape, and eating relative to BN. Groups were not significantly different on psychiatric comorbidity, but differed on self-esteem.

DISCUSSION

Results prompt reappraisal of current criteria of BN to encompass those who purge without binge eating.

Comorbidity of bipolar and eating disorders: distinct or related disorders with shared dysregulations?

BACKGROUND

The co-occurrence of bipolar and eating disorders, though of major clinical and public health importance, remains relatively unexamined.

METHODS

In reviewing the literature on this comorbidity, we compared bulimia, anorexia nervosa, bulimia nervosa, binge eating disorders and bipolar disorders on phenomenology, course, family history, biology, and treatment response.

RESULTS

Epidemiological studies show an association between subthreshold bipolar disorder and eating disorders in adolescents, and between hypomania and eating disorders, especially binge eating behavior, in adults. Of the clinical studies, most show that patients with bipolar disorder have elevated rates of eating disorders, and vice versa. Finally, the phenomenology, course, comorbidity, family history, and pharmacologic treatment response of these disorders show considerable overlap on all of these parameters. In particular, on phenomenologic grounds--eating dysregulation, mood dysregulation, impulsivity and compulsivity, craving for activity and/or exercise--we find many parallels between bipolar and eating disorders. Overall, the similarities between these disorders were more apparent when examined in their spectrum rather than full-blown expressions.

LIMITATIONS

Despite an extensive literature on each of these disorders, studies examining their overlap across all these parameters are relatively sparse and insufficiently systematic.

CONCLUSIONS

Nonetheless, the reviewed literature leaves little doubt that bipolar and eating disorders--particularly bulimia nervosa and bipolar II disorder--are related. Although several antidepressants and mood stabilizers have shown promise for eating disorders, their clinical use when these disorders co-exist with bipolarity is still very much of an art. We trust that this review will stimulate more rigorous research in their shared putative underlying psychobiologic mechanisms which, in turn, could lead to more rational targeted treatments.

Associations among aspects of impulsivity and eating factors in a nonclinical sample

OBJECTIVE

Impulsivity has been well documented as a factor in the behavior of eating-disordered populations and is likely to influence normal eating patterns as well. The current study attempted to clarify the relationship between the three elements of impulsivity (nonplanning, attentional, and motor) and the three factors of eating (cognitive restraint, disinhibition, and hunger) in a nonclinical sample.

METHOD

Data were collected from a sample (N = 112) of volunteer participants from the community who answered two self-report instruments related to impulsivity (the Barratt Impulsiveness Scale, Version 11) and eating (the Eating Inventory). Partial correlations were performed on the data to control for age, sex, and education. Cognitive restraint did not correlate with any element of impulsivity. Disinhibition was positively correlated with both attentional impulsivity (r = .40, p < .001) and motor impulsivity (r = .32, p < .01). Attentional impulsivity was also positively correlated with hunger (r = .24, p < .05).

DISCUSSION

The lack of association between cognitive restraint and impulsivity suggests that they are functionally distinct. Disinhibition is most closely associated with impulsivity, consistent with findings from clinical samples. Further clarification of the relationship between impulsivity and eating in nonclinical populations could facilitate a better understanding of the relationship between personality variables and normal eating behavior.

Review of studies evaluating psychotherapy in bulimia nervosa: The influence of research methods

The purpose of the study was to test if design and research methods of studies predict outcome results of bulimia nervosa. Fifty-seven articles on outcome of bulimia nervosa were found through MEDLINE and PSYCHINFO databases and 25 were included in the statistical analysis. Percentages of patients with a good outcome ranged from 24% to 74% with a mean of 51.1%. The variables best predicting outcome were time to follow-up and number of symptoms evaluated in definition of good outcome whereas dropout, design of studies, treatments, and sample characteristics did not predict significantly. The implications of these findings are discussed.

Self-reported competencies and problems among Swedish girls with eating disorders and a control sample, using the youth self-report

OBJECTIVE

To study self-reported competencies and problems in adolescent girls with eating disorders, anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS) compared to matched normal controls.

METHOD

The Youth Self-Report (YSR) was completed by 211 girls between 13 and 17 years of age with eating disorders and 211 controls matched for age, sex, and geographical area.

RESULTS

Girls with eating disorders scored lower on all competence scales and higher on most problem 'scales compared to controls. Type of diagnosis had no effect on competence scales, but BN-patients scored higher than AN- and EDNOS-patients on many problem scales. AN-bingers/purgers reported more problems than restrictors on somatic complaints, delinquent behaviour, and the externalizing dimension.

DISCUSSION

We conclude that the YSR gives important information concerning self-reported competencies and concomitant symptoms of general psychopathology in eating disordered adolescent girls.

Social anxiety and social comparison: differential links with restrictive and bulimic attitudes among nonclinical women

This study investigated the relationship of two social psychological constructs (social anxiety and social comparison) with bulimic and restrictive eating attitudes among nonclinical women. Eighty young women completed a measure of social anxiety (the Fear of Negative Evaluation Scale, FNE), a measure of social comparison (the Iowa-Netherlands Comparison Orientation Measure, INCOM), the Beck Depression Inventory (BDI), and the Eating Disorders Inventory (EDI). The results indicate a differential link between the two different social processes and the nature of eating psychopathology. Specifically, heightened social anxiety predicted drive for thinness, while levels of social comparison predicted bulimic attitudes. The findings support a model where the two social processes are each associated with different patterns of eating pathology.

Are eating disorders culture-bound syndromes? Implications for conceptualizing their etiology

The authors explore the extent to which eating disorders, specifically anorexia nervosa (AN) and bulimia nervosa (BN), represent culture-bound syndromes and discuss implications for conceptualizing the role genes play in their etiology. The examination is divided into 3 sections: a quantitative meta-analysis of changes in incidence rates since the formal recognition of AN and BN, a qualitative summary of historical evidence of eating disorders before their formal recognition, and an evaluation of the presence of these disorders in non-Western cultures. Findings suggest that BN is a culture-bound syndrome and AN is not. Thus, heritability estimates for BN may show greater variability cross-culturally than heritability estimates for AN, and the genetic bases of these disorders may be associated with differential pathoplasticity.

Assessment of eating disorders: comparison of interview and questionnaire data from a long-term follow-up study of bulimia nervosa

OBJECTIVE

This paper examines diagnostic agreement between interview and questionnaire assessments of women participating in a long-term follow-up study of bulimia nervosa.

METHODS

Women (N = 162) completed follow-up evaluations comprising questionnaires and either face-to-face or telephone interviews.

RESULTS

Consistent with previous research, rates of eating disorders were higher when assessed by questionnaire than when assessed by interview; however, rates of full bulimia nervosa were similar. Overall diagnostic agreement was adequate for eating disorders (kappa=.64) but poor for bulimia nervosa (kappa=.49), with greater agreement between questionnaires and telephone interviews (kappa's range: .67-.71) than between questionnaires and face-to-face interviews (kappa's range: .35-.58).

CONCLUSION

Findings support the possibility that increased rates of eating pathology on questionnaire assessments may be due, in part, to increased candor when participants feel more anonymous. Questionnaire assessments may not be inferior to interview assessments; they may reveal different aspects of disordered eating.

Outcome in patients with eating disorders: a 5-year study

BACKGROUND

Eating disorders are disabling, unpredictable, and difficult to treat. We did a prospective 5-year investigation of a representative sample of patients with eating disorders. Our aim was to identify predictors of outcome and to assess effects of available treatments.

METHODS

We prospectively investigated 95 patients with anorexia nervosa, 88 with bulimia nervosa, and 37 with eating disorders not otherwise specified (EDNOS), who sought treatment in Adelaide, South Australia. We divided patients into those who had, and had not, received treatment in specialist units and reached a safe body weight. Individuals were then further classified dependent on intensity of any treatment received. We assessed clinical symptoms, body-related attitudes, and psychosocial function.

FINDINGS

216 (98%) patients were available for follow-up after 5 years. Three patients with anorexia nervosa and two with EDNOS died. 65 (74%) bulimic, 29 (78%) EDNOS, and 53 (56%) anorexic patients had no diagnosable eating disorder. A small proportion of patients in every group had poor Morgan-Russell-Hayward scores at outcome. Final outcome was predicted by extent and intensity, but not duration, of initial symptoms in patients with anorexia nervosa, and by initial body-related attitudes and impaired psychosocial functioning in bulimia patients. We were unable to predict EDNOS outcome. Treatment did not affect outcome for any group.

INTERPRETATION

Deaths in the study confirm the serious nature of eating disorders. However, our results suggest that the efficacy of existing interventions is questionable.

Importance of size in defining binge eating episodes in bulimia nervosa

OBJECTIVE

This study sought to determine if amount of food consumed is important in defining binge eating episodes in individuals with bulimia nervosa (BN).

METHOD

Women (N = 30) with DSM-IV BN (OBN) and women (N = 25) who would have met DSM-IV criteria for BN except that their binge episodes were not objectively large (SBN) were recruited from the community. Subjects completed telephone interviews and questionnaires.

RESULTS

Results demonstrated no significant differences between women with OBN and SBN in levels of dietary restraint, disinhibition, or hunger; no significant differences in general psychopathology; and significant differences in frequency of binge/purge episodes and impulsiveness. Differences in impulsiveness remained after controlling for frequency of binge/purge episodes.

DISCUSSION

These results partially validate current diagnostic criteria for bulimia nervosa and elucidate one factor, impulsiveness, that may be important in understanding objective binge episodes in bulimia nervosa.

Eating disorders and substance use. An examination of behavioral associations

The association between the eating disorders of anorexia nervosa (AN) and bulimia nervosa (BN) and substance use disorder (SUD) has been widely investigated, however, our understanding of the relationship between the disorders remains unclear. Explanatory models have tended to focus on behaviors, yet, little is currently known about the patterns of association among disordered eating and substance use behaviors. In this exploratory study, a behavioral approach was used to investigate the cooccurrence of seven disordered eating and three substance use behaviors in women meeting current DSM-III-R criteria for AN (n=12), subthreshold AN (n=14), BN (n=29), and subthreshold BN (n=24). Results suggest that disordered eating behaviors are differentially associated with substance use behaviors. The most robust finding was that diuretic use positively predicted the current level of alcohol use regardless of diagnostic group. The findings for marijuana and tobacco use were less consistent. Results suggest that rather than being pervasive in all eating disordered women, higher levels of alcohol use may be found in those women who use diuretics.