Psychiatric comorbidity and Eating Disorder Inventory (EDI) profiles in eating disorder patients

Intolerance of uncertainty and repetitive negative thinking: transdiagnostic moderators of perfectionism in eating disorders

Perfectionism has been identified as a vulnerability and maintenance factor across eating disorders (EDs). Additionally, research has found that intolerance of uncertainty (IU) and repetitive negative thinking (RNT) moderate the relationship between perfectionism and psychopathology. Despite this evidence, few studies have examined if these factors specifically moderate ED severity. This study aimed to fill this gap by investigating the moderating effect of IU and RNT on the relationship between perfectionism and ED symptoms, as well as the predictive power of these factors on identifying participants with clinically significant ED symptoms. 331 treatment-seeking adults from a university-affiliated community clinic and 264 undergraduate students completed measures to assess ED symptoms, RNT, perfectionism and IU. 147 participants (24.7% of the total sample) had clinically significant levels of ED symptoms as determined by the Eating Disorder Questionnaire Short-Form (EDE-QS). Multiple linear regressions found significant associations between ED symptoms and both the IU*perfectionism interaction (p < .001) and the RNT*perfectionism interaction (p < .001). A binary logistic regression identified that both the IU*perfectionism interaction (p = .03) and the RNT*perfectionism interaction (p = .001) predicted clinically significant EDE-QS scores. The findings indicate that both IU and RNT moderate the relationship between perfectionism and ED symptoms and build on previous literature recognising transdiagnostic contributors to ED symptomatology.

A network analysis of eating disorder, PTSD, major depression, state-trait anxiety, and quality of life measures in eating disorder patients treated in residential care

BACKGROUND

The network approach in the eating disorder (ED) field has confirmed important links between EDs and posttraumatic stress disorder (PTSD) symptoms. However, studies including comorbid symptoms are scarce, which limits our understanding of potentially important connections. We hypothesised that anxiety, depression and poor quality of life (QOL) would provide a more complete picture of central, maintaining factors.

METHODS

Network analysis using R was performed in 2178 adult ED patients (91% female) admitted to residential treatment. Assessments included the ED Examination Questionnaire (EDEQ), the Eating Disorders Inventory (EDI-2), the PTSD Checklist for DSM-5 (PTSD clusters (PCL-5)), the Patient Health Questionnaire (PHQ-9), the Spielberger State-Trait Anxiety Scale (STAI), and the ED QOL Scale (EDQOL), which measure symptoms of EDs, PTSD, major depression, state-trait anxiety, and QOL, respectively.

RESULTS

EDI-2 ineffectiveness showed the highest centrality (expected influence) followed by EDI-2 interoceptive awareness, STAI state anxiety, EDEQ shape concern, EDQOL psychological subscale, and PTSD cluster D (hyperarousal) symptoms. Eating Disorder Quality of Life psychological and physical-cognitive subscales and PHQ-9 major depressive, STAI state anxiety and PCL-5 PTSD cluster E (negative alterations in mood and cognition) symptoms showed the highest bridge expected influence, suggesting their interactive role in maintaining ED-PTSD comorbidity.

CONCLUSIONS

This is the first network analysis of the interaction between ED and PTSD symptoms to include the comorbid measures of depression, anxiety, and QOL in a large clinical sample of ED patients. Our results indicate that several symptom clusters are likely to maintain ED-PTSD comorbidity and may be important targets of integrated treatment.

Omega-3 as an adjuvant in the treatment eating and psychological symptoms in patients with anorexia nervosa: a systematic review and meta-analyses

BACKGROUND

This study was carried out to assess the effects of omega-3 supplementation as an adjunct treatment for eating and psychological symptoms in patients with anorexia nervosa.

METHODS

We conducted a systematic review of the literature using the terms 'anorexia nervosa' AND 'Fatty Acids, Omega-3'. Five randomised controlled trials with a total of 144 participants, published between 2003 and 2022, were included.

RESULTS

The effects of supplementation of omega-3 on anxiety were standardised mean difference (SMD) 0.79, 95% confidence interval (CI) -0.08 to 1.66; p = 0.08; I² = 3%; two studies, 33 participants; moderate quality of evidence. For depression, the supplementation of omega-3 was SMD: 0.22, 95% CI: -0.50 to 0.93; p = 0.18; I² = 45%; two studies, 33 participants; moderate quality of evidence. For obsessive-compulsive disorder, the supplementation of omega-3 was SMD: -0.22, 95% CI: -0.70 to 2.25; p = 0.36; I² = 0%; three studies, 32 participants; low quality of evidence.

CONCLUSION

This research showed that regardless of dose, time or, if associated with other components, the use of omega-3 supplementations as an adjuvant treatment showed no evidence of effect in eating and psychological symptoms in patients with anorexia nervosa.

Efficacy and tolerance of second-generation antipsychotics in anorexia nervosa: A systematic scoping review

INTRODUCTION

Second-generation antipsychotics (SGAs) are frequently prescribed for the treatment of resistant anorexia nervosa. However, few clinical trials have been conducted so far and no pharmacological treatment has yet been approved by the Food and Drug Administration. The aim of this paper is to conduct a systematic scoping review exploring the effectiveness and safety of atypical antipsychotics in anorexia nervosa (AN).

METHOD

We conducted a systematic scoping review of the effectiveness and tolerability of SGAs in the management of AN. We included articles published from January 1, 2000, through September 12, 2022 from the PubMed and PsycInfo databases and a complementary manual search. We selected articles about adolescents and adults treated for AN by four SGAs (risperidone, quetiapine, aripiprazole or olanzapine). This work complies with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews (PRIMA-ScR) and was registered in the Open Science Framework (OSF) repository.

RESULTS

This review included 55 articles: 48 assessing the effectiveness of SGAs in AN and 7 focusing only on their tolerability and safety. Olanzapine is the treatment most frequently prescribed and studied with 7 randomized double-blind controlled trials. Other atypical antipsychotics have been evaluated much less often, such as aripiprazole (no randomized trials), quetiapine (two randomized controlled trials), and risperidone (one randomized controlled trial). These treatments are well tolerated with mild and transient adverse effects in this population at particular somatic risk.

DISCUSSION

Limitations prevent the studies both from reaching conclusive, reliable, robust, and reproducible results and from concluding whether or not SGAs are effective in anorexia nervosa. Nonetheless, they continue to be regularly prescribed in clinical practice. International guidelines suggest that olanzapine and aripiprazole can be interesting in severe or first-line resistant clinical situations.

Symptom association between social anxiety disorder, appearance anxiety, and eating disorders among Chinese University students: A network analysis to conceptualize comorbidity

Background

Incidences of social anxiety disorder (SAD), appearance anxiety, and eating disorders (ED) show an increased prevalence among young people. However, symptoms' associations between these disorders have not been investigated in depth. Network analysis is an approach that can be used to explain the relationship(s) between symptoms of different psychological disorders. Using network analysis, this study aimed to explore the association and potential interacting mechanisms between SAD, appearance anxiety, and ED.

Methods

This study included 96,218 University students from Jilin Province, China. SAD, appearance anxiety and ED were assessed using the Social Anxiety Subscale of the Self-Consciousness Scale (SASS), the Appearance Anxiety Scale Brief Version (AASBV), and the Sick, Control, One, Fat, Food questionnaire (SCOFF), Chinese versions. Network analysis was employed to investigate the symptom associations, while the stability of the network model was analyzed using statistical measures.

Results

The prevalence of ED among the total sample was 38% (95% CI: 38.1-38.8%), while this figure was 31.2% (95% CI: 30.7-31.6%) in males and 43.6% (95% CI: 43.2-44.0%) in females. Additionally, the total score of SAD was significantly higher in females (11.83 ± 5.37) than it in males (10.02 ± 5.46) (P < 0.001). While the total score of appearance anxiety was also different significantly in gender (39.21 ± 9.49 in females vs. 38 ± 9.42 in males) (P < 0.001). Results showed that ED was associated with all three aspects of appearance anxiety, including "appearance concern," "appearance satisfaction," and "wish for good looks." Appearance anxiety and SAD were also associated; specifically, symptoms of "appearance satisfaction" were significantly associated with the symptoms "easily talk to strangers" and "appearance concern", which was also significantly associated with "embarrassed". Compared with males, females showed significantly stronger associations with appearance anxiety symptoms, while ED symptoms were associated with "troubled by being watched" and "appearance concern".

Conclusion

Appearance anxiety was associated with both ED and SAD symptoms. ED may have a potential relationship with SAD, affecting appearance anxiety indirectly. Significant differences were found among males and females in symptom associations between appearance anxiety and SAD. This study therefore clarified that young people should have body-positive interventions and challenge the normative body image discourse, which may help alleviate symptoms of SAD and ED.

Emotional Eating and Perfectionism as Predictors of Symptoms of Binge Eating Disorder: The Role of Perfectionism as a Mediator between Emotional Eating and Body Mass Index

(1) Background: Perfectionism has been linked to eating disorders and might be a risk factor for the appearance of eating pathologies. The aims of this study are (a) to verify the relationship between perfectionism, emotional eating (EE), binge eating (BE), and body mass index (BMI); (b) to identify the variables that predict BE symptoms and BMI; (c) to study the role of perfectionism as a mediator between EE and BMI. (2) Methods: 312 adult participants answered a cross-sectional survey that included the Multidimensional Perfectionism Scale, the Emotional Eater Questionnaire (EEQ), the Binge Eating Scale (BES), and a sociodemographic questionnaire including BMI. (3) Results: The results suggest a direct correlation between EE, BE, and BMI, showing that EE is a powerful predictor of BE symptoms and BMI. Furthermore, two dimensions of perfectionism have a mediator role between EE and BMI, specifically doubts and actions and concern over mistakes: the presence of these two components of perfectionism reverses the relationship between EE and BMI. (4) Conclusions: These results have significant implications for the understanding of the two different (pathological) eating patterns: intake restriction and overeating and should be considered in intervention programs.

Are Adherence to the Mediterranean Diet, Emotional Eating, Alcohol Intake, and Anxiety Related in University Students in Spain?

Research has suggested that university students are at risk from certain unhealthy habits, such as poor diet or alcohol abuse. At the same time, anxiety levels appear to be higher among university students, which may lead to high levels of emotional eating. The aim of this study was to analyze the degree of adherence to the Mediterranean diet (AMD), emotional eating, alcohol intake, and anxiety among Spanish university students, and the interrelationship of these variables. A total of 252 university students filled out the Mediterranean Diet Quality Index (KIDMED) questionnaire for Mediterranean diet adherence, an Alcohol Use Disorders Identification Test, a State-Trait Anxiety Inventory and the Emotional Eater Questionnaire. We analyzed descriptive data, a t-test and analysis of variance (ANOVA) for differences, a Pearson correlation, and multiple regression tests. Results showed low levels of AMD among university students (15.5%) and considerable levels of emotional eating (29%) and anxiety (23.6%). However, levels of alcohol dependence were low (2.4%). State-anxiety was a predictor of the emotional eater score and its subscales, and sex also was predictive of subscale guilt and the total score. However, AMD was predicted only by trait-anxiety. These models accounted for between 1.9% and 19%. The results suggest the need for the implementation of educational programs to promote healthy habits among university students at risk.

Olanzapine in the treatment of anorexia nervosa: a systematic review

Anorexia nervosa, with the highest mortality rate among psychiatric diseases, is characterized by low body mass index, fear of weight gain, and disturbed body image. Even though multiple drugs have been proposed for the treatment of anorexia nervosa, current treatment modalities include nutritional support and psychotherapy. In this study, our aim is to analyze the efficiency and possible adverse effects of olanzapine, an atypical anti-psychotic drug, in the treatment of anorexia nervosa. The studies investigating the efficiency and possible adverse effects of olanzapine in anorexia nervosa have been searched by using 3 databases (Embase, PubMed, and Cochrane Library). DerSimonian-Laird random effects meta-analyses have been used in the statistical analysis. Effect of olanzapine treatment in accordance with the duration and dosage of drug have been analyzed by the determination of 95% confidence intervals (p value < 0.05 is considered as statistically significant). Despite the presence of some contradictory studies, olanzapine treatment has been found beneficial in anorexia nervosa. In addition, analysis reveals that statistically significant beneficial effect of olanzapine treatment is used at high doses and for short duration. Possible side effects include neuroleptic malignant syndrome, hypoglycemia, and heart block in patients suffering from anorexia nervosa. Even though there is obvious need for more comprehensive further studies, current literature favors olanzapine treatment. The efficiency of olanzapine is considered to be related to changes in dopaminergic and serotonergic system in anorexic patients both in terms of neurotransmitter levels and receptor activity.

Role of antidepressants in the treatment of adults with anorexia nervosa

Introduction:

Anorexia nervosa (AN) is a severe psychiatric disorder that is difficult to treat and is associated with frequent relapses and high mortality rates. Psychiatric symptomatology (eg, depression, anxiety, obsessive-compulsive disorder/behaviors) are common comorbidities. This review provides current information about safety and efficacy of antidepressant therapy for management of AN in adults.

Methods:

A literature review of randomized controlled trials, open-label studies, and case reports with adults or adults/adolescents was conducted. PubMed and Medline were searched using anorexia management and treatment, antidepressants, selective serotonin reuptake inhibitors (SSRIs), fluoxetine, sertraline, citalopram, and mirtazapine in AN, relapse prevention in AN, and psychotropic medications in AN.

Results:

The role and utility of antidepressants in AN were published in double-blind, placebo-controlled studies; open-label trials; and a retrospective study. Antidepressants should not be used as sole therapy for AN although their use for confounding symptomatology makes discerning efficacy difficult as they are given together with other therapies. Neurobiological changes due to starvation and AN itself complicate results interpretation. For safety, tricyclic antidepressants and monoamine oxidase inhibitors are not recommended, and bupropion is contraindicated. Use of SSRIs during acute treatment lacks efficacy. Use of SSRIs—primarily fluoxetine and to some extent citalopram, sertraline, or mirtazapine—may aid in relapse prevention and improvement of psychiatric symptomatology in weight-restored anorexic patients.

Discussion:

Health care professionals should use clinical judgment regarding fluoxetine or possibly citalopram, sertraline or mirtazapine as adjunctive treatment to psychotherapy for relapse prevention, improvement of depressive and anxiety symptoms, and/or obsessive-compulsive behaviors unresolved with nutritional rehabilitation and psychotherapy.

'I can't accept that feeling': Relationships between interoceptive awareness, mindfulness and eating disorder symptoms in females with, and at-risk of an eating disorder

Mindfulness based therapies (MBTs) for eating disorders show potential benefit for outcomes yet evidence is scarce regarding the mechanisms by which they influence remission from symptoms. One way that mindfulness approaches create positive outcomes is through enhancement of emotion regulation skills. Maladaptive emotion regulation is a key psychological feature of all eating disorders. The aim of the current study was to identify facets of emotion regulation involved in the relationship between mindfulness and maladaptive eating behaviours. In three cross-sectional studies, clinical (n=39) and non-clinical (n=137 and 119) female participants completed: 1) the Eating Disorder Inventory (EDI) eating specific scales (drive-for-thinness and bulimia) and the EDI psychological symptom scales (emotion dysregulation and interoceptive deficits); and 2) mindfulness, impulsivity, and emotion regulation questionnaires. In all samples mindfulness was significantly and inversely associated with EDI eating and psychological symptom scales, and impulsivity. In non-clinical samples interoceptive deficits mediated the relationship between mindfulness and EDI eating specific scales. Non-acceptance of emotional experience, a facet of interoceptive awareness, mediated the relationship between mindfulness and eating specific EDI scores. Further investigations could verify relationships identified so that mindfulness based approaches can be optimised to enhance emotion regulation skills in sufferers, and those at-risk, of eating disorders.

Psychiatric comorbidity in women and men with eating disorders results from a large clinical database

Psychiatric comorbidity is common in patients with eating disorders (ED), but prevalence estimates are heterogeneous, probably due to methodological differences between studies (population, diagnostic method, sampling procedure etc.) and a few studies include men. The aim of this study is to investigate psychiatric DSM-IV Axis I comorbidity in a large sample of adult patients, both males and females, with the whole spectrum of DSM-IV ED diagnoses. Initial presentation assessment data on 11,588 adult men and women presenting to specialist ED clinics in Sweden between 2008 and 2012 were extracted from a large clinical database. Diagnostics were based on semi-structured interviews (SCID-I) and the Structured Eating Disorder Interview (SEDI). Seventy-one percent of the patients with ED had at least one other Axis I disorder. The most common type of diagnosis was anxiety disorders (53%), where generalized anxiety disorder was the most common diagnosis. The highest levels of comorbidity were found for women with Binge Eating Disorder (BED) and men with Bulimia Nervosa (BN). Findings are consistent with previous research showing a high prevalence of psychiatric comorbidity in both men and women with ED. The small gender differences observed seem negligible compared to the general similarity in comorbidity.

The impact of comorbid depressive and anxiety disorders on severity of anorexia nervosa in adolescent girls

We examined the impact of comorbid depression and anxiety disorders on the severity of anorexia nervosa (AN) in adolescent girls. Adolescent girls with AN (N = 88) were divided into one group with and another group without comorbid disorders, and selected subjective and objective measures of illness severity were compared between the two groups. The comorbid group had significantly higher scores than the noncomorbid group for all four subscales and total scores of the Eating Disorders Examination as well as for all Eating Disorders Inventory-2 subscales, except for bulimia. The comorbid group also had significantly more suicide attempts and hospitalizations compared with the noncomorbid group. There were no significant group differences for the lowest ever body mass index, duration of AN symptoms, and age at AN onset. Our findings suggest that AN with comorbid depression and anxiety disorder is a more severe clinical variant of the disorder, especially with respect to severity of psychological symptoms and suicide risk.

Perfectionism and sense of coherence among patients with eating disorders

BACKGROUND

There is a substantial body of research on eating disorders and perfectionism. Also there are several studies on eating disorders and sense of coherence (SOC), but studies regarding all three subjects are sparse. Perfectionism and the degree of SOC are considered central and aggravating aspects of psychiatric conditions, not least in relation to eating disorders.

AIMS

The present study aimed to describe the relationship between perfectionism as operationalized by Garner in the Eating Disorder Inventory-2 and SOC as defined by Antonovsky in the SOC-29 scale. The hypothesis was that SOC should be negatively associated with perfectionism.

METHODS

Data from the two self-measuring instruments collected from 95 consecutively recruited eating disorder outpatients were analysed with descriptive and inferential statistics.

RESULTS

The patients in the present study scored consistently with other Swedish eating disorder samples on the Perfectionism subscale in the Eating Disorder Inventory-2 (EDI-P) and on the SOC-29, indicating a higher degree of perfectionism and weaker SOC than normal population groups. Perfectionism was significantly correlated to SOC. The correlation was negative, confirming the study hypothesis. The hypothesis was further confirmed in a subgroup analysis comparing patients with different degrees of SOC related to their EDI-P scores.

CONCLUSIONS

Perfectionism is associated with SOC in patients with eating disorders.

CLINICAL IMPLICATIONS

The clinical implications derived from the study could be a recommendation to focus on the SOC in patients with an eating disorder with the hope of lowering the patients' perfectionism as well.

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.

Correlates of Eating Disorder in Middle-Aged and Older Adults

Objective: This study aims to investigate: (a) the association of eating disorders with childhood sexual abuse and recent stressful life events; (b) the coexistence of eating disorders and other common psychiatric disorders; and (c) the impact of eating disorders on obesity, medical conditions, and health service utilization. Method: We conducted secondary data analyses based on population-based study, which consists of a nationally representative sample of 2,870 community-dwelling adults aged 50 and above, interviewed in 2006 to 2007. Results and conclusion: The 12-month prevalence of eating disorders was 2.61%. Multivariate analyses revealed that eating disorders were more common among younger age groups, women, and those who reported stressful life events. In addition, eating disorders were significantly related to anxiety disorders, agoraphobia, panic disorder, obesity, and cancer. Discussion: This study supports the notion that eating disorders in older adults are associated with a number of psychosocial, psychiatric, and medical conditions.

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.

Dimensional measures of personality as a predictor of outcome at 5-year follow-up in women with bulimia nervosa

Dimensional models are commonly used as a supplement to the categorical model within the field of personality disorders. The purpose of this study was to examine personality dimensions as predictors of 5-year outcomes among women with bulimia nervosa. One hundred and thirty-four women with bulimia nervosa participated in a randomised psychotherapy treatment trial. Data was available for 109 out of the 134 participants at follow-up. Outcomes were the presence of any eating disorder (past year), the presence of a mood disorder episode (past year), and the global assessment of functioning at 5-year follow-up. Self-directedness was the only predictor of any eating disorder diagnosis (past year) at 5-year follow-up. Asceticism significantly predicted the presence of a mood disorder episode (past year) at 5 years. Borderline personality disorder symptoms predicted global functioning at 5 years. These results suggest that high self-directedness at pre-treatment may offer potential prognostic information regarding eating disorder status 5 years post-treatment. Furthermore, no single measure predicted outcome for all variables (any eating disorder diagnosis, a mood disorder episode (past year), or global functioning) at 5-year follow-up. This suggests that a comprehensive personality assessment using multiple measures is desirable for predicting outcomes.

Personality pathology comorbidity in adult females with eating disorders

Personality pathology is examined in 100 female in-patients diagnosed with eating disorders. The Eating Disorder Inventory-II and the NEO-PI-R were self-administered and personality pathology was assessed using a structured interview. Clinicians additionally evaluated patients' global functioning. The results indicated sizeable personality disorder comorbidity, and two dimensions of personality pathology, for example, an internalizing and an externalizing factor, could be identified. Patients' global functioning was primarily associated with dimensions of personality pathology, but not with eating disorder symptoms. Assessment and therapeutic interventions should focus on this co-occurring pathology in order to improve patients' functioning.

Role of the neurotrophin network in eating disorders' subphenotypes: body mass index and age at onset of the disease

Eating disorders (ED) are severe psychiatric diseases that most likely result from, and are sustained by socio-cultural, psychological and biological factors. We explored whether members of the neurotrophin family are disease-modifying factors of quantitative traits, potentially contributing to the outcome or prognosis of the disease. We studied lifetime minimum and maximum body mass index (minBMI and maxBMI) and age at onset of the disease in a sample of 991 ED patients from France, Germany, Italy and Spain and analysed 183 genetic variants located in 10 candidate genes encoding different neurotrophins and their receptors. We used a hierarchical model approach to include prior genetic knowledge of the specific and found that variants in CNTF, in its receptor CNTFR, and in NTRK2 were significantly associated with a lower age at onset of the ED. In addition, one variant in NTRK1 was associated with a higher minBMI. The results suggest that for these two subphenotypes, CNTF, CNTFR, NTRK1 and NTRK2 might act as disease-modifying factors and add preliminary evidence to the global hypothesis that EDs are the result of complex interactions and reciprocal controls between the immune, endocrine and central nervous systems.

Emotion avoidance in patients with anorexia nervosa: initial test of a functional model

OBJECTIVE

This study aimed to evaluate emotion avoidance in patients with anorexia nervosa (AN) and to examine whether emotion avoidance helps to explain (i.e., mediates) the relation between depressive and anxiety symptoms and eating disorder (ED) psychopathology in this group.

METHOD

Seventy-five patients with AN completed questionnaires to assess study variables. Rates of emotion avoidance were compared to published data, and regression models were used to test the hypothesis that emotion avoidance mediates the relation between depressive and anxiety symptoms and ED psychopathology in AN.

RESULTS

Patients with AN endorsed levels of emotion avoidance that were comparable to or higher than other psychiatric populations and exceeded community controls. As predicted, emotion avoidance significantly explained the relations of depressive and anxiety symptoms to ED psychopathology.

DISCUSSION

Findings confirm that emotion avoidance is present in patients with AN and provide initial support for the idea that anorexic symptoms function, in part, to help individuals avoid aversive emotional states.

Sexual functioning in women with eating disorders

OBJECTIVE

To describe sexual functioning in women with eating disorders.

METHOD

We assessed physical intimacy, libido, sexual anxiety, partner status, and sexual relationships in 242 women from the International Price Foundation Genetic Studies relative to normative data.

RESULTS

Intercourse (55.3%), having a partner (52.7%), decreased sexual desire (66.9%), and increased sexual anxiety (59.2%) were common. Women with restricting and purging anorexia nervosa had a higher prevalence of loss of libido than women with bulimia nervosa and eating disorder not otherwise specified (75%, 74.6%, 39%, and 45.4%, respectively). Absence of sexual relationships was associated with lower minimum lifetime body mass index (BMI) and earlier age of onset; loss of libido with lower lifetime BMI, higher interoceptive awareness and trait anxiety; and sexual anxiety with lower lifetime BMI, higher harm avoidance and ineffectiveness. Sexual dysfunction in eating disorders was higher than in the normative sample.

DISCUSSION

Sexual dysfunction is common across eating disorders subtypes. Low BMI is associated with loss of libido, sexual anxiety, and avoidance of sexual relationships.

Trait anxiety in children and adolescents with anorexia nervosa

In this study of trait anxiety in children and adolescents with anorexia nervosa, a consecutive series of 23 newly admitted children and adolescents with anorexia nervosa was studied by use of the State-Trait-Anxiety-Inventory, the Eating Disorders Inventory (EDI), the Social Phobia and Anxiety Inventory for Children (SPAI-C), and a structured psychiatric interview (DIPS: Diagnostisches Interview bei psychischen Störungen). In addition, clinical diagnoses were taken from the files. Trait anxiety was significantly increased at the time of admission and social phobia was present in a large proportion of the patients. Specific eating disorder psychopathology as measured by the EDI was significantly associated with trait anxiety. There were no clinical diagnoses (according to the International Classification of Diseases - Tenth Revision) of anxiety disorders. Features of anxiety are very common in young patients with anorexia nervosa and closely linked to specific psychopathology. Anxiety disorders need careful evaluation in these patients.

Abnormal eating attitudes in Mexican female students: a study of prevalence and sociodemographic-clinical associated factors

The objective of the study was to determine the prevalence of abnormal eating attitudes (AEA) in Mexican high school and university students in the city of San Luis Potosí, Mexico. By means of a transversal study with a weighted, random and multistage sampling process, we analyzed a representative sample of female students (N= 2006). The instrument was the Eating Disorder Inventory-2 (EDI-2), validated in Mexican population and a questionnaire of sociodemographic data. The prevalence of AEA was 12.6% and its frequency was significantly higher in high school than in university students. AEA cases were uniformly distributed among public and private institutions and a highly significant relationship between substances consumption and AEA was observed. A logistic regression model for AEA was obtained. Therefore, a profile of highly AEA was built based on sociodemographic data and a solid instrument validated in Mexican population, which can be employed as a screening and secondary prevention tool to design public health programs.

A cross-cultural comparison of the Eating Disorder Inventory

OBJECTIVE

A systematic analysis of data collected with the Eating Disorder Inventory (EDI) was made.

METHOD

A literature search identified 94 sources in which the mean values of the EDI or EDI-2 subscales were reported, comprising 310 samples differing by sex, age, diagnosis, language, ethnicity, or some other relevant attribute. The total number of respondents was 43,722, from 25 different countries, having used the EDI in one of the 16 languages (1-94).

RESULTS

The factorial structure of the aggregate means of the EDI subscales, for both clinical versus nonclinical and Western versus non-Western samples, was almost identical suggesting generalizability across languages and cultures. Non-Western participants scored higher than Western participants on virtually all EDI subscales, both in normal and eating-disordered samples. It was shown that age is a risk factor when someone is already diagnosed with an eating disorder but, in the general population, increasing age reduces the likelihood of being afflicted by eating disorders.

DISCUSSION

Symptoms of eating disorders are more pronounced in non-Western than in Western samples.

Eating disorders and associated psychiatric comorbidity in elderly Canadian women

This study examined the prevalence of disordered eating symptomatology and their associations with socio-demographic characteristics and health indicators in a nationally representative sample of Canadian women aged 50 years and older. The study also examined associations of disordered eating symptomatology with comorbid mood disorders, anxiety disorders and alcohol dependence. The study was based on secondary data analysis of the Canadian Community Health Survey, cycle 1.2. About 2.6% of women 50-64 years old and 1.8% of women 65 years or older reported disordered eating symptomatology. These women exhibited elevated frequencies of dieting behaviors and preoccupation with food intake and body shape. Disordered eating symptomatology was positively associated with stress level and negatively associated with physical health. Similar to findings in younger women, risk of eating disorders was strongly associated with mood and anxiety disorders. Results indicate that the risk of having eating disorders is a lifelong concern. Hence, older women should be screened for symptoms of disordered eating and associated psychiatric comorbidity.

Blood levels of brain-derived neurotrophic factor correlate with several psychopathological symptoms in anorexia nervosa patients

BACKGROUND

Evidence of a role of brain-derived neurotrophic factor (BDNF) in the pathophysiology of eating disorders (ED) has been provided by association studies and by murine models. BDNF plasma levels have been found altered in ED and in psychiatric disorders that show comorbidity with ED.

AIMS

Since the role of BDNF levels in ED-related psychopathological symptoms has not been tested, we investigated the correlation of BDNF plasma levels with the Symptom Checklist 90 Revised (SCL-90R) questionnaire in a total of 78 ED patients.

METHODS

BDNF levels, measured by the enzyme-linked immunoassay system, and SCL-90R questionnaire, were assessed in a total of 78 ED patients. The relationship between BDNF levels and SCL-90R scales was calculated using a general linear model.

RESULTS

BDNF plasma levels correlated with the Global Severity Index and the Positive Symptom Distress Index global scales and five of the nine subscales in the anorexia nervosa patients. BDNF plasma levels were able to explain, in the case of the Psychoticism subscale, up to 17% of the variability (p = 0.006).

CONCLUSION

Our data suggest that BDNF levels could be involved in the severity of the disease through the modulation of psychopathological traits that are associated with the ED phenotype.

The Role of Exercise Dependence for the Relationship between Exercise Behavior and Eating Pathology

Our study examined the potential mediating or moderating effect of exercise dependence on the exercise—eating pathology relationship. Female university students ( N = 330) completed Internet-based self-report measures of exercise behavior, exercise dependence, and eating pathology. Exercise dependence served as a mediator for the relationship between exercise and eating pathology. This unidirectional causal model suggests that an individual's pathological motivation or compulsion to exercise is the critical mediating component in the exercise—eating pathology relationship. The best target for removing the link between exercise behavior and eating pathology may be reformulating exercise dependence symptoms.

Association of NTRK3 and its interaction with NGF suggest an altered cross-regulation of the neurotrophin signaling pathway in eating disorders

Eating disorders (EDs) are complex psychiatric diseases that include anorexia nervosa and bulimia nervosa, and have higher than 50% heritability. Previous studies have found association of BDNF and NTRK2 to ED, while animal models suggest that other neurotrophin genes might also be involved in eating behavior. We have performed a family-based association study with 151 TagSNPs covering 10 neurotrophin signaling genes: NGFB, BDNF, NTRK1, NGFR/p75, NTF4/5, NTRK2, NTF3, NTRK3, CNTF and CNTFR in 371 ED trios of Spanish, French and German origin. Besides several nominal associations, we found a strong significant association after correcting for multiple testing (P = 1.04 x 10(-4)) between ED and rs7180942, located in the NTRK3 gene, which followed an overdominant model of inheritance. Interestingly, HapMap unrelated individuals carrying the rs7180942 risk genotypes for ED showed higher levels of expression of NTRK3 in lymphoblastoid cell lines. Furthermore, higher expression of the orthologous murine Ntrk3 gene was also detected in the hypothalamus of the anx/anx mouse model of anorexia. Finally, variants in NGFB gene appear to modify the risk conferred by the NTRK3 rs7180942 risk genotypes (P = 4.0 x 10(-5)) showing a synergistic epistatic interaction. The reported data, in addition to the previous reported findings for BDNF and NTRK2, point neurotrophin signaling genes as key regulators of eating behavior and their altered cross-regulation as susceptibility factors for EDs.

Contribution of the serotoninergic system to anxious and depressive traits that may be partially responsible for the phenotypical variability of bulimia nervosa

Eating disorders (ED), such as anorexia nervosa (AN) and bulimia nervosa (BN), are complex psychiatric phenotypes influenced by both genetic and environmental factors. We investigated the genetic contribution of four single nucleotide polymorphisms (SNPs) within the serotonin receptor 5HT2C and two sequence variants within the serotonin transporter SLC6A4 to different ED-related psychopathological symptoms in a total sample of 82 ED patients. All patients were diagnosed according to DSM-IV criteria and underwent diagnostic and psychopathological assessments by means of structured clinical interviews and rating scales. We detected significant evidence of association between the -995A/-759T/-697C/Cys23 haplotype of the 5HT2C gene and different anxious and depressive subscales of the SCL90-R instrument, that included Somatization (p = 0.029), Obsessive-Compulsiveness (p = 0.021), Depression (p = 0.032), Anxiety (p = 0.004), Hostility (p = 0.028), Phobic Anxiety (p = 0.029) and Paranoid Ideation (p = 0.008), in BN patients. We also observed a strong association between the 5HTTLPR polymorphism of the SLC6A4 gene and Anxiety in the same group of BN patients (p = 0.004). However, no epistatic effects between the 5HT2C and SLC6A4 genes on the different anxious and depressive subscales were observed. Our preliminary data suggest that the serotoninergic system contributes to the different psychopathological symptoms that may be partially responsible for the phenotypical variability within the bulimic phenotype.

D2 dopamine receptor (DRD2) gene Taq1A polymorphism and the eating-related psychological traits in eating disorders (anorexia nervosa and bulimia) and obesity

OBJECTIVE

Food is considered a reinforcing agent, like a variety of substances such as alcohol and other drugs of abuse that produce pleasure. Psychopathological traits related to food intake are demonstrated in eating disorders as in obesity with different genetic aspects for these diseases. Recently, the prevalence of TaqA1 allele has been associated to alcohol, drug abuse and carbohydrate preference. For this reason, the aim of this study was to evaluate if the presence of A1 allele, in eating disorders and obesity, is associated with some particular psycho-pathological characteristics.

METHODS

We studied the presence of TaqA1 in Italian subjects affected by obesity (n=71), anorexia (n=28), bulimia (n=20) and in control group (n=54). The Eating Disorders Inventory (EDI test) was used to evaluate the psychological profiles. Patients without alcohol and drugs abuse were selected (>125 ml/day).

RESULTS

The A1+ allele, both in A1/A1 and A1/A2 genotypes, was not differently distributed among disease groups; on the contrary two EDI subscales (Drive for thinness and Ineffectiveness) resulted associated with A1+ allele without effect of the eating disease or obesity.

CONCLUSION

These results confirm that the presence of A1+ allele is not simply related to body weight but the A1+ allele might be a marker of a genetic psychological condition in people with high risk to develop pathological eating behaviour.

Perfectionism and eating disorders: Current status and future directions

The literature examining the relation between perfectionism and eating disorders was reviewed and content and methodological comparisons were made with the perfectionism literature in anxiety disorders and depressive disorders. A PsychInfo search using the key words "perfectionism/perfect/perfectionistic," "anorexia," "bulimia," and "eating disorders" was performed and the generated list of papers was supplemented based on a review of reference lists in the papers. A total of 55 papers published between 1990 and 2005 were identified that assessed perfectionism among individuals with diagnosed eating disorders. The key research questions were distilled from these publications and empirical findings were summarized for each question, followed by a comparison with perfectionism papers in the anxiety and depressive disorder literatures. Also, key research design methodological parameters were identified and comparisons made across the three literatures: eating disorders, anxiety disorders, depressive disorders. The current review concludes with conceptual and methodological recommendations for researchers interested in perfectionism and eating disorders.

Psychiatric comorbidities of female inpatients with eating disorders

OBJECTIVE

We analyze 27 point-prevalent DSM-IV Axis I comorbidities for eating disorder inpatients.

METHODS

The sample included 2436 female inpatients treated between January 1, 1995, and December 31, 2000, for primary DSM-IV diagnoses of anorexia, bulimia, and eating disorder not otherwise specified. Analyses were multivariate analysis of variance and multinomial logistic regression; sociodemographics and severity-of-illness measures were controlled.

RESULTS

Ninety-seven percent of patients evidenced > or = 1 comorbid diagnoses; 94% evidenced comorbid mood disorders, largely unipolar depression, with no differences across eating disorders; 56% evidenced anxiety disorders, with no differences across eating disorders; and 22% evidenced substance use disorders, with significant differences across eating disorders (p < .0001). Five specific diagnoses differed across eating disorders. Alcohol abuse/dependence was twice as likely with bulimia (p < .0001); polysubstance abuse/dependence three times as likely with bulimia (p < .0001); obsessive-compulsive disorder twice as likely with restricting and binge/purge anorexia (p < .01); posttraumatic stress disorder twice as likely with binge-purge anorexia (p < .05); schizophrenia/other psychoses three times more likely with restricting anorexia (p < .05) and two times with binge-purge anorexia (p < .05).

CONCLUSIONS

New findings emerged: extremely high comorbidity regardless of eating disorder, ubiquitous depression across all eating disorders, no difference in overall rate of anxiety disorders across eating disorders, greater posttraumatic stress disorder in binge-purge anorexia, more psychotic diagnoses in anorexia. Certain previous findings were confirmed: more obsessive-compulsive disorder in anorexia; more substance use in bulimia; and a replicated comorbidity rank-ordering for eating disorder patients: mood, anxiety, and substance use disorders, respectively.

Personality traits after recovery from eating disorders: do subtypes differ?

OBJECTIVE

We compared individuals recovered from anorexia (AN) and bulimia nervosa (BN) to determine characteristics that are shared by or distinguish eating disorder (ED) subtypes.

METHOD

Sixty women recovered for > or = 1 year from AN or BN were compared with 47 control women (CW). Assessments included the Yale-Brown-Cornell Eating Disorder Scale, the Spielberger State-Trait Anxiety Inventory, the Beck Depression Inventory, the Yale-Brown Obsessive Compulsive Scale, the Temperament and Character Inventory, and Structured Clinical Interviews for DSM-IV.

RESULTS

Individuals recovered from an ED had similar scores for mood and personality variables that were significantly higher than the scores for CW. Few recovered subjects had Cluster B personality disorder. Most individuals recovered within 6 years of their ED onset. A latent profile analysis identified an "inhibited" and "disinhibited" cluster based on personality traits.

CONCLUSION

A wide range of symptoms persist after recovery and do not differ between subtypes of ED. These findings may aid in identifying traits that create vulnerabilities for developing an ED.

Psychiatric comorbidity in children and adolescents

PURPOSE OF REVIEW

This review critically discusses recent research findings on psychiatry comorbidity in children and adolescent persons.

RECENT FINDINGS

Several epidemiological studies have confirmed previous findings in relation to the high rates of psychiatric comorbidity in children and adolescents. In particular, psychiatric comorbidity has been detected in children with substance abuse, and with conduct and oppositional defiant, anxiety and attention deficit-hyperactivity disorders. These studies have also investigated the impact comorbidity has on symptom presentation, outcome and service utilization. Although the presence of concurrent psychiatric disorders in children and adolescents is well established, there has been limited research on the need for different treatment modalities in children suffering from more than one disorder.

SUMMARY

It is widely accepted that children and adolescents frequently present with more than one psychiatric diagnosis. The substantial variation in psychiatric comorbidity found in the literature may be due to the different methods of data collection as well as to the classification system used. Whether children and adolescents fulfil diagnostic criteria for a mixed condition (International Classification of Diseases-10) or multiple disorders (Diagnostic and Statistical Manual of Mental Disorders-IV), it is important that the concurrent psychopathology be recognized and treated.