Binge/purge symptoms and comorbidity in adolescents with eating disorders

A systematic review of eating disorders and family functioning

The purpose of the current review was to address four questions: 1) Are there differences in family functioning or family environment among patients with different eating disorder (ED) diagnoses? 2) Are there differences in the perception of family functioning or family environment among different family members? 3) Is family functioning or family environment related to ED symptomatology? 4) Does family functioning or family environment change as a result of ED treatment? and 4a) If so, does this impact ED treatment outcome? Although most studies found no differences among ED diagnostic groups, those that did generally found worse family functioning among those with binge/purge symptoms than among those with the restricting subtype of anorexia nervosa. Differences in perceptions of family functioning among family members were found, with patients generally reporting worse functioning than their parents. Worse family functioning was generally found to be related to worse ED symptoms. The variety of treatment approaches and different assessments of outcome made it somewhat unclear whether family functioning consistently improves with ED treatment. More research is needed on family functioning and EDs, particularly in understudied groups such as males, and those with ED diagnoses other than anorexia nervosa or bulimia nervosa.

Bulimia Symptoms in Russian Youth: Prevalence and Association With Internalizing Problems

BACKGROUND

There has been limited research on bulimia symptoms in adolescents from the general population outside the United States. This study aimed to evaluate the prevalence of bulimia symptoms in Russian youth and explore the associations between a clinical level of self-reported probable bulimia nervosa (BN) and internalizing problems, binge drinking and functional impairment by gender.

METHODS

Data were collected from a representative sample of school students (N = 2,515, 59.5% female) from Northern Russia [age M (SD) = 14.89 ± 1.13 years]. Probable BN and internalizing psychopathology were assessed using self-report scales. Chi-square and independent sample t-tests were used to compare respondents' demographic characteristics and disordered eating behaviors. GLM multivariate analysis of covariance was used to assess the associations between probable BN, functional impairment and mental health problems (MHP) by gender.

RESULTS

Analyses showed that the 3-month prevalence of probable BN was higher in girls (3.9%) than in boys (1.2%). Probable BN was associated with depressive and anxiety symptoms, somatic anxiety, somatic complaints, binge drinking and functional impairment. Boys reported a higher level of problem scores in relation to probable BN.

CONCLUSIONS

Our findings suggest that bulimia symptoms are prevalent in Russian adolescents and are associated with MHP and functional impairment. Timely recognition of bulimia symptoms and associated MHP is important for early prevention and intervention strategies.

Low oxytocin levels are broadly associated with more pronounced psychopathology in anorexia nervosa with primarily restricting but not binge/purge eating behavior

OBJECTIVE

Anorexia nervosa (AN) is commonly associated with depression, anxiety, and deficits in socioemotional functioning. Basal levels of oxytocin, a neurohormone with antidepressant, anxiolytic, and prosocial properties, are low in women with AN. However, the relationship between oxytocin and psychopathology of AN/atypical AN has not been examined in individuals with primarily food restriction (AN/AtypAN-R) or those with restriction plus binge/purge behaviors (AN/AtypAN-BP) alone, which is important to further elucidate the neurobiology of different AN presentations. We investigated whether oxytocin levels are related to eating, affective, and socioemotional psychopathology in women with AN/AtypAN-R and separately AN/AtypAN-BP.

METHODS

In a cross-sectional study of 53 women with low-weight AN or atypical AN based on DSM-5 (AN/AtypAN-R: n=21, AN/AtypAN-BP: n=32), we obtained fasting serum oxytocin levels and self-report measures of psychopathology, including the Eating Disorder Examination-Questionnaire (EDE-Q), Beck Depression Inventory-IA (BDI), State-Trait Anxiety Inventory (STAI), and Toronto Alexithymia Scale (TAS-20).

RESULTS

In individuals with AN/AtypAN-R, oxytocin levels were negatively associated with eating psychopathology (EDE-Q Global Score: r=-0.49, p=0.024), depressive and anxiety symptoms (BDI Total Score: r=-0.55, p=0.009; STAI Trait Score: r=-0.63, p=0.002), and socioemotional symptoms (TAS-20 Difficulty Identifying Feelings Score: r=-0.49, p=0.023). In contrast, in those with AN/AtypAN-BP oxytocin levels were negatively associated with depressive symptoms only (BDI Total Score: r=-0.52, p=0.049).

CONCLUSIONS

These findings support the notion that AN/AtypAN-R and AN/AtypAN-BP might have divergent underlying neurobiology. Understanding these differences is crucial to develop targeted treatments for a population with high levels of chronicity, for which no specific pharmacological treatments are currently available.

CLINICAL TRIAL REGISTRATION

https://clinicaltrials.gov, identifier: NCT01121211.

Deep brain stimulation of the subcallosal cingulate for treatment-refractory anorexia nervosa: 1 year follow-up of an open-label trial

BACKGROUND

Anorexia nervosa is a life-threatening illness. Brain circuits believed to drive anorexia nervosa symptoms can be accessed with surgical techniques such as deep brain stimulation (DBS). Initial results suggest that DBS of the subcallosal cingulate is safe and associated with improvements in mood and anxiety. Here, we investigated the safety, clinical, and neuroimaging outcomes of DBS of the subcallosal cingulate in a group of patients during 12 months of active stimulation.

METHODS

We did this prospective open-label trial at the Department of Surgery of the University of Toronto (Toronto, ON, Canada). Patients were eligible to participate if they were aged 20-60 years and had a diagnosis of anorexia nervosa (restricting or binge-purging subtype) and a demonstrated history of chronicity or treatment resistance. Following a period of medical stabilisation, patients underwent surgery for DBS and received open-label continuous stimulation for the entire 1 year study duration. The primary outcome was safety and acceptability of the procedure. The secondary outcomes were body-mass index (BMI), mood, anxiety, affective regulation, and anorexia nervosa-specific behaviours at 12 months after surgery, as well as changes in neural circuitry (measured with PET imaging of cerebral glucose metabolism at baseline and at 6 and 12 months after surgery). This trial was registered with ClinicalTrials.gov, number NCT01476540.

FINDINGS

16 patients with treatment-refractory anorexia nervosa were enrolled between September, 2011, and January, 2014, and underwent DBS of the subcallosal cingulate between November, 2011, and April, 2014. Patients had a mean age of 34 years (SD 8) and average illness duration of 18 years (SD 6). Two patients requested that their devices be removed or deactivated during the study, although their reasons for doing so were poorly defined. The most common adverse event was pain related to surgical incision or positioning that required oral analgesics for longer than 3-4 days after surgery (five [31%] of 16 patients). Seven (44%) of 16 patients had serious adverse events, most of which were related to the underlying illness, including electrolyte disturbances. Average BMI at surgery was 13·83 (SD 1·49) and 14 (88%) of the 16 patients had comorbid mood disorders, anxiety disorders, or both. Mean BMI after 12 months of stimulation was 17·34 (SD 3·40; p=0·0009 vs baseline). DBS was associated with significant improvements in measures of depression (mean Hamilton Depression Rating Scale scores 19·40 [SD 6·76] at baseline vs 8·79 [7·64] at 12 months; p=0·00015), anxiety (mean Beck Anxiety Inventory score 38·00 [15·55] vs 27·14 [18·39]; p=0·035), and affective regulation (mean Dysfunction in Emotional Regulation Scale score 131·80 [22·04] vs 104·36 [31·27]; p=0·019). We detected significant changes in cerebral glucose metabolism in key anorexia nervosa-related structures at both 6 months and 12 months of ongoing brain stimulation.

INTERPRETATION

In patients with chronic treatment-refractory anorexia nervosa, DBS is well tolerated and is associated with significant and sustained improvements in affective symptoms, BMI, and changes in neural circuitry at 12 months after surgery.

FUNDING

Klarman Family Foundation Grants Program in Eating Disorders Research and Canadian Institutes of Health Research.

Investigating Cognitive Deficits as Risk Factors for Developing Eating Disorders During Adolescence

Adolescents with eating disorders (ED) suffer from deficits in executive functions and "theory of mind." It is unclear whether these indicate state or trait characteristics. We examined cognitive functioning in 150 adolescents, comparing those at high risk and those not at risk for ED. Deficits in set shifting and in theory of mind were found in all high-risk groups. Adolescents at high risk for bulimia were found to be higher in impulsivity and in theory of mind deficits, compared to adolescents at high risk for anorexia. These are trait characteristics rather than state vulnerabilities and preexist the development of ED.

Prevalence of abnormal liver function tests and comorbid psychiatric disorders among patients with anorexia nervosa and eating disorders not otherwise specified in the anorexia nervosa DSM-IV criteria

INTRODUCTION

Anorexia nervosa (AN) and eating disorders not otherwise specified (EDNOS) are on the rise in Singapore. Abnormal liver function tests have been reported for up to 12.2% of patients with AN. These patients are also known to present with comorbid psychiatric disorders. This study aims to investigate the correlation between body mass index (BMI) and the severity of abnormal liver function tests, and between BMI and the presence of comorbid psychiatric disorders.

METHODS

A retrospective cohort analysis of 373 patients diagnosed with AN or EDNOS at a tertiary hospital was performed. The clinical course of transaminitis and comorbid psychiatric disorders was correlated with the patient's BMI.

RESULTS

Patients with a BMI of ≥ 16.6 kg/m(2) at their first consult had a significantly lower risk of having comorbid psychiatric disorders (χ(2) = 32.08, p < 0.001). These patients were five times less likely to have comorbid psychiatric disorders as compared to patients from the other BMI groups (odds ratio [OR] 0.21). On the other hand, patients with a BMI of < 14.6 kg/m(2) had a significantly higher risk of having transaminitis (χ(2) = 72.5, p < 0.001). They were 11.1 times more likely to develop transaminitis as compared to patients with a BMI of ≥ 14.6 kg/m(2) (OR 11.05).

CONCLUSION

Severity of BMI can be used by clinicians as an indicator to assess for secondary psychiatric comorbidities and/or transaminitis during the first consultation. This could help reduce the morbidity and mortality rates in patients with AN or EDNOS.

Does Sex Matter in the Clinical Presentation of Eating Disorders in Youth?

PURPOSE

Eating disorders (EDs) impact both males and females, but little is known about sex differences in ED psychopathology and overall clinical presentation. This study compared demographic and clinical characteristics of child and adolescent males and females who presented for ED treatment.

METHODS

Participants included 619 youth (59 males and 560 females) ages 6-18 years who presented for treatment between 1999 and 2011.

RESULTS

Males presented for ED treatment at a significantly younger age (p < .001), earlier age of onset (p = .004), and were more likely to be nonwhite (p = .023). Females showed more severe ED pathology across the Eating Disorder Examination subscales (weight concern: p < .001; eating concern: p < .001; restraint: p = .001; and shape concern: p = .019) and global score (p < .001). Males were more likely to present with an ED other than anorexia nervosa or bulimia nervosa (p = .002). Females presented with significantly higher rates of mood disorders (p = .027) and had a lower average percent of expected body weight (p = .020). Males and females did not differ in duration of illness, prior hospitalization or treatment, binging and purging episodes, anxiety disorders, behavioral disorders, or self-esteem. All analyses were controlled for age.

CONCLUSIONS

Results indicate that further exploration into why the sexes present differently may be warranted. Developing ED psychopathology assessments that better capture nuances particular to males and reevaluating criteria to better categorize male ED diagnoses may allow for more targeted treatment.

The neurobiology of eating disorders--a clinical perspective

OBJECTIVE

To provide a neurobiological basis of eating disorders for clinicians and to enlighten how comparing neurobiology and eating disorders with neurobiology of other psychiatric illnesses can improve treatment protocols.

METHOD

A selective review on the neurobiology of eating disorders. The article focuses on clinical research on humans with consideration of the anatomical, neural, and molecular basis of eating disorders.

RESULTS

The neurobiology of people with eating disorders is altered. Many of the neurobiological regions, receptors, and chemical substrates that are affected in other mental illnesses also play an important role in eating disorders. More knowledge about the neurobiological overlap between eating disorders and other psychiatric populations will help when developing treatment protocols not the least regarding that comorbidity is common in patients with EDs.

CONCLUSION

Knowledge about the underlying neurobiology of eating disorders will improve treatment intervention and will benefit from comparisons with other mental illnesses and their treatments.

A case series investigation of association between co-morbid psychiatric disorder and the improvement in body mass index among patients with anorexia nervosa and eating disorder not otherwise specified of the anorexia nervosa type

BACKGROUND

Anorexia nervosa and eating disorder not otherwise specified* (not fulfilling Anorexia Nervosa DSM IV criteria) are increasing in Singapore. Patients with eating disorders may also present with other psychiatric disorders such as depression and anxiety. The paper aims to investigate the association of co-morbid psychiatric disorders with the improvement of body mass index (BMI) in these patients.

METHODS

A retrospective cohort analysis of 182 patients with anorexia and eating disorder not otherwise specified at a tertiary hospital was done. The clinical course of co-morbid psychiatric disorders was correlated with the improvement of body mass index.

RESULTS

109 patients were included in the analysis and the mean BMI on resolution of co-morbid psychiatric disorders was BMI 16.9. There is a significant association between the BMI groups and the resolution of co-morbid psychiatric disorders, χ2 = 10.2, p = .03. Patients in BMI group 5 (BMI 16.6 - 18.5) were noted to be significantly less likely to resolve their psychiatric co-morbidity compared to the other 4 groups. (OR = 0.323).

CONCLUSION

Patients with anorexia nervosa and eating disorders not otherwise specified were at increased risk of having co-morbid psychiatric disorders and the clinical course of co-morbid psychiatric disorders appeared to correlate with improved BMI. Specifically patients with BMI < 16.5 with co-morbid psychiatric disorders were more likely to recover from their co-morbid psychiatric disorder with nutritional rehabilitation than patients with a higher BMI.

Normative data for female adolescents with eating disorders on the Children's Depression Inventory

OBJECTIVE

Given the importance of assessing depressive symptoms and suicidal ideation in adolescents with eating disorders (EDs), the aim was to provide normative data on the Children's Depression Inventory (CDI) for female adolescents presenting for treatment of an ED.

METHOD

The data source was the Helping to Outline Paediatric Eating Disorders (HOPE) Project registry (N = 1000), a prospective, ongoing registry study comprising consecutive pediatric tertiary ED referrals. Females (N = 256; 12-17 years) with DSM-5 EDs completed the CDI at intake.

RESULTS

Results on the CDI revealed a pattern of increasing depressive scores with age and higher scores among patients with anorexic spectrum disorders. The prevalence of suicidal ideation was high and had the same pattern as CDI scores. The mean score on the CDI in the sample was higher than community samples and clinical samples of adolescents with post-traumatic stress disorder, obsessive compulsive disorder, and other clinical disorders.

DISCUSSION

Females adolescents with EDs are at high-risk of depression and suicidal ideation. These data provide information about variation in CDI scores to guide clinicians in interpretation of scores.

Eating problems in Irish children and adolescence - EPICA

OBJECTIVES

To examine eating concerns in a cohort of Irish adolescents.

METHODS

Students from a stratified random sample of post primary schools were screened using the EAT-26, the EDI-III and a study specific questionnaire.

RESULTS

A total of 3,031 students (mean age 14.74, range 12-19) enrolled in the study. The majority of respondents felt popular (91%), happy (75.2%) and perceived themselves to have a good quality of life (86.8%). Despite this, 32% of females dieted, 29.4% were dissatisfied with their bodies, and 10.8% scored above 20 on the EAT-26. Adolescents always on a diet reported a lower quality of life (QoL) X2(16, N=2,961) =144.43, p <.000, perceived themselves to be less popular X2(15, N=2,963) =53.26, p <.000 and less academically able X2(16, N=2,297) =43.96, p<.000, than those who never dieted. Comparing EPICA values to published norms, Irish males had significantly lower EAT scores, females had comparable total EAT-26 scores but significantly lower levels of dieting and higher levels of bulimic features and oral control. Girls in mixed schools had higher rates of body dissatisfaction F (1,2855) = 16.61, p <.001 and drive for thinness F (1,2860) = 11.78, p <.005 than girls attending same sex schools.

CONCLUSIONS

Weight and body image concerns were high among Irish adolescents, especially females, with higher than expected levels of bulimia and oral control scores on the EAT but lower scores on the dieting subscale. Females attending mixed sex schools appear most at risk of eating pathology.

Body-related social comparison and disordered eating among adolescent females with an eating disorder, depressive disorder, and healthy controls

The purpose of this study was to investigate the association between body-related social comparison (BRSC) and eating disorders (EDs) by: (a) comparing the degree of BRSC in adolescents with an ED, depressive disorder (DD), and no psychiatric history; and (b) investigating whether BRSC is associated with ED symptoms after controlling for symptoms of depression and self-esteem. Participants were 75 girls, aged 12–18 (25 per diagnostic group). To assess BRSC, participants reported on a 5-point Likert scale how often they compare their body to others’. Participants also completed a diagnostic interview, Eating Disorders Inventory-2 (EDI-2), Beck Depression Inventory-II (BDI-II), and Rosenberg Self-Esteem Scale (RSE). Compared to adolescents with a DD and healthy adolescents, adolescents with an ED engaged in significantly more BRSC (p ≤ 0.001). Collapsing across groups, BRSC was significantly positively correlated with ED symptoms (p ≤ 0.01), and these associations remained even after controlling for two robust predictors of both ED symptoms and social comparison, namely BDI-II and RSE. In conclusion, BRSC seems to be strongly related to EDs. Treatment for adolescents with an ED may focus on reducing BRSC.

Anorexia nervosa: towards an integrative neuroscience model

We reviewed the evidence for emotion-related disturbances in anorexia nervosa (AN) from behavioural, cognitive, biological and genetic domains of study. These domains were brought together within the framework of an integrative neuroscience model that emphasizes the role of emotion and feeling and their regulation, in brain organization. PsychInfo and Medline searches were performed to identify published peer-reviewed papers on AN within each domain. This review revealed evidence for 'Emotion', 'Thinking and Feeling' and 'Self-regulation' disturbances in AN that span non-conscious to conscious processes. An integrative neuroscience framework was then applied to develop a model of AN, from which hypotheses for empirical investigation are generated. We propose that AN reflects a core disturbance in emotion at the earliest time stage of information processing with subsequent effects on the later stages of thinking, feeling and self-regulation.

Risk Factors for Addictive Disorders: A Discriminant Analysis on 374 Addicted and 513 Nonpsychiatric Participants

Many common risk factors have been described in addictive disorders. Little is known about factors' respective contributions to discrimination of addicted and nonaddicted participants. Two large samples were compared including 513 nonpsychiatric participants and 374 addicted participants meeting the DSM–IV criteria for eating disorders, alcohol, or substance dependence. Twenty-six risk factors were assessed by interview or self-rating scales. A discriminant analysis determined the respective weight of each risk factor. One discriminant function emerged and characterized a depressive dimension. The results suggest that the different risk factors described in addiction could be related to a depressive dimension.

Longitudinal associations between externalizing behavior and dysfunctional eating attitudes and behaviors: a community-based study

This study investigated longitudinal associations between externalizing behavior and dysfunctional eating attitudes and behaviors. Participants were girls drawn from the community-based Minnesota Twin Family Study and assessed at ages 11, 14, and 17. Cross-sectional correlations indicated that the strength of the associations between externalizing behavior and dysfunctional eating attitudes and behaviors increased over time. Mixed-model analyses indicated that earlier externalizing behavior predicted increases in weight preoccupation, body dissatisfaction, and use of inappropriate compensatory behaviors. Earlier use of inappropriate compensatory behaviors predicted increases in externalizing behavior.

Clozapine/olanzapine-induced recurrence or deterioration of binge eating-related eating disorders

OBJECTIVE

To explore the association between eating disorders (EDs) prior to the use of clozapine/olanzapine (pre-clozapine/olanzapine EDs) and after initiation of these antipsychotics (post-clozapine/olanzapine EDs).

METHOD

Sixty-four consecutively admitted patients receiving clozapine/olanzapine were screened using the M-Composite International Diagnostic Interview (M-CIDI) to identify subjects with pre-clozapine/olanzapine EDs (DSM-IV criteria). We investigated post-clozapine/olanzapine EDs and binge eating behavior using the Questionnaire on Eating and Weight Patterns (QEWP) and used the Naranjo probability scale as objective causality assessment.

RESULTS

Post-clozapine/olanzapine EDs were significantly more frequent in patients with pre-clozapine/olanzapine EDs (5 of 6) when compared to patients without pre-clozapine/olanzapine EDs (4 of 58) [chi(2) = 26.29; df = 1; p < 0.001] [odds ratio (OR) 67.5; 95% CI: 6.3-725.8]. According to the Naranjo probability scale, recurrence or deterioration of EDs in patients with prior EDs was definitely (n = 1) or probably (n = 4) related to the intake of clozapine/olanzapine.

CONCLUSION

Clozapine/olanzapine may induce recurrence or deterioration of binge eating symptomatology or full-blown EDs in patients with prior EDs.

Symptom profile of major depressive disorder in women with eating disorders

OBJECTIVE

Based on the well-documented association between eating disorders (EDs) and affective disorders, the patterns of comorbidity of EDs and major depressive disorder (MDD) were investigated. The temporal relation between EDs and MDD onset was analyzed to determine differences in the course and nature of MDD when experienced prior to versus after the onset of the ED.

METHOD

Lifetime MDD and depressive symptoms were assessed in 1371 women with a history of ED. The prevalence of MDD was first explored across ED subtypes, and ages of onset of MDD and EDs were compared. Depressive symptoms were examined in individuals who developed MDD before and after ED onset.

RESULTS

The lifetime prevalence of MDD was 72.9%. Among those with lifetime MDD (n =963), 34.5% reported MDD onset before the onset of ED. Those who experienced MDD first reported greater psychomotor agitation (OR =1.53; 95%CI =1.14-2.06), and thoughts of own death (but not suicide attempts or ideation; OR =1.73; 95%CI =1.31-2.30). Among individuals who had MDD before ED, 26.5% had the MDD onset during the year before the onset of ED; 67% of individuals had the onset of both disorders within the same 3 year window.

CONCLUSION

Clinicians treating individuals with new-onset ED or MDD should remain vigilant for the emergence of additional psychopathology, especially during the initial 3 year window following the onset of the first disorder.

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.

Symptoms of anxiety and depression in Estonian medical students with sleep problems

High emotional stress in medical students has been observed in many studies. Our aim in this article was to assess the prevalence of symptoms of anxiety and depression among Estonian medical students and to find relationships between sleep complaints and emotional symptoms. The study group consisted of 413 medical students, ages 19-33 years, at the University of Tartu. Each was asked to complete two questionnaires: the Emotional State Questionnaire (EST-Q), containing 28 questions, and the Questionnaire on Sleep and Daytime Habits, with 25 questions. The anxiety and depression subscales from the EST-Q were applied. From the study group, 21.9% students had symptoms of anxiety, and 30.6% had symptoms of depression. The frequency of anxiety and depressive symptoms was higher in females. In regression and multiple regression analysis, we determined which sleep problems were related to emotional symptoms. The associations were different for men and women. In women, anxiety remained significantly related to waking up because of nightmares and feeling tired in the morning; depressive symptoms were related to difficulties in getting to sleep at night, waking up because of nightmares and nocturnal eating habits, daytime sleepiness, and sleepiness during school lessons. In men, significant relations were clear only for depression: difficulties in falling asleep at night before an exam and subjective sleep quality. The study demonstrated that a high percentage of medical students had emotional symptoms. We found that some sleep problems indicated underlying symptoms of anxiety and depression.

[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.

Alexithymia in female patients with eating disorders

Previous studies indicate that patients with eating disorders have alexithymic characteristics, as revealed by the Toronto Alexithymia Scale (TAS). The aim of the present study was to investigate the role of negative affect (anxiety and depression) in the relationship between eating disorders and alexithymia. In addition, we have evaluated whether the relationship between negative affect and alexithymia varies according to the type of eating disorder (anorexia and bulimia). Eighteen female patients and 16 female patients who met the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) diagnostic criteria for restrictive anorexia nervosa and bulimia nervosa, respectively, and 18 healthy female controls matched by age and education were submitted to Beck Depression Inventory and Spielberger State-Trait Anxiety Inventory to assess depression and anxiety and the Toronto Alexithymia Scale (TAS-20) and the Bermond Vorst Alexithymia Questionnaire (BVAQ) to evaluate alexithymic characteristics. The findings indicated that, although anorexic and bulimic patients showed higher alexithymia scores compared to controls, this result could be mainly related to negative affect. In fact, taking negative affect into account, anorexic and bulimic patients did not show higher TAS-20 and BVAQ scores compared to controls. The only variable useful to discriminate among anorexics, bulimics and controls is the perceived inability to experience emotional feelings, which is higher in anorexic patients compared to the other two groups.

Predictors of treatment response for suicidal youth referred for emergency psychiatric hospitalization

This study evaluated factors that predicted poor treatment response for 70 suicidal youth (ages 10 to 17 years; 67% African American) who received either multisystemic therapy (MST) or inpatient psychiatric hospitalization. Following treatment, suicidal youth were classified as either treatment responders or nonresponders based on caregiver or youth report of attempted suicide. Overall, female gender, depressive affect, parental control, caregiver psychiatric distress, and caregiver history of psychiatric hospitalization were associated with suicide attempts. However, controlling for other variables, only depressive affect and parental control predicted treatment nonresponse. These results suggest the need to adapt existing treatments for suicidal youth to better address problems relating to youth depression.

Partial eating disorders among adolescents: a review

PURPOSE

Many adolescents do not fulfill all the DSM-IV criteria's for anorexia nervosa and bulimia, but do nevertheless suffer from partial eating disorders (EDs). This review focuses on the definition, epidemiology and clinical aspects of these disorders.

METHODS

Search on Medline & PsycINFO, review of websites, screening of bibliographies of articles and book chapters.

RESULTS

There is still no consensus on the definition of these disorders, which cover a wide range of severity. Affected adolescents often suffer from physical and psychological problems owing to co-morbidity or as a consequence of their eating patterns: chronic constipation, dyspeptic symptoms, nausea, abdominal pain, fatigue, headaches, hypotension, menstrual dysfunction as well as dysthymia, depressive and anxiety disorders, or substance misuse and abuse. In comparison with those who are unaffected, adolescents with partial ED are at higher risk of evolving into full ED. However, most of them evolve into spontaneous remission. Adolescents with partial ED engaged, over a period of several months, in potentially unhealthy weight-control practices, suffering from intense fear of gaining weight and a disturbed body weight/image should be offered therapeutic support.

CONCLUSION

Future research should focus on the exact delineation of various subtypes of clinical presentations in partial ED and on evidence-based treatment and follow-up of these various situations.

Eating disorders symptomatology and inpatient treatment experience in eating-disordered subjects

OBJECTIVE

This study aimed to examine whether eating disorder (ED) subjects with and without a history of inpatient treatment differ in the severity of symptoms as measured by the Eating Disorders Inventory (EDI-1).

METHOD

In a sample of 222 women (66 women with anorexia nervosa, 126 women with bulimia nervosa, and 30 women with eating disorders not otherwise specified), the history of inpatient treatment was assessed and the EDI was administered.

RESULTS

Fifty percent of the participants had received previous inpatient treatment. The group with past inpatient treatment had significantly higher scores on the EDI subscales Body Dissatisfaction, Ineffectiveness, and Interpersonal Distrust than the group without inpatient treatment experience.

DISCUSSION

ED subjects with and without inpatient treatment showed different profiles on the EDI subscales. The fact that these two groups differ in specific ED symptoms may represent a bias in ED studies when samples with heterogeneous treatment contact history are recruited.

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.

Psychiatric disorders associated with risk for the development of eating disorders during adolescence and early adulthood

Longitudinal data were used to investigate whether anxiety, depressive, disruptive, personality, or substance use disorders are associated with risk for the development of eating disorders during adolescence or early adulthood. Psychiatric disorders were assessed among 726 youths from a random community sample during adolescence and early adulthood. Depressive disorders during early adolescence were associated with elevated risk for the onset of eating disorders, dietary restriction, purging behavior, and recurrent weight fluctuations after preexisting eating problems and other psychiatric disorders were controlled statistically. Disruptive and personality disorders were independently associated with elevated risk for specific eating or weight problems. The present findings suggest that depressive disorders during early adolescence may contribute to the development of eating disorders during middle adolescence or early adulthood.

Psychological characteristics of eating disorders as evidenced by the combined administration of questionnaires and two projective methods: the Tree Drawing Test (Baum Test) and the Sentence Completion Test

The objective of this study is to examine psychological/psychopathological characteristics of eating disorders and their subtypes through a combined administration of questionnaires and projective tests. Three questionnaires (Eating Disorder Inventory - 2, Social Adaptation Scale, Southern California University Eating Disorder Inventory - Revised) and two projective tests (the Tree Drawing Test [TDT, Baum Test], and the Sentence Completion Test [SCT]) were administered to 126 female patients between the ages of 15 and 30 years, with eating disorders according to DSM-IV criteria at our outpatient clinic, and to 54 sex- and age-matched control subjects. The purging subtypes of eating disorders (anorexia nervosa - binge-eating/purging type [ANBP] and bulimia nervosa - purging type [BNP]) were clearly differentiated from the controls, both by the questionnaires and the projective tests. Compared with the controls, ANBP/BNP showed more problematic profiles across the three questionnaires, drew smaller and poorer trees in TDT to a more left location on the drawing paper, and gave fewer positive, and more negative responses in SCT. In contrast, few significant differences were found between anorexia nervosa- restricting type (ANR) and the controls, and between ANBP and BNP. As a trend, however, ANR was consistently located between the controls and ANBP/BNP across the whole questionnaires and projective tests.

Bulimic symptoms in the Virginia Twin Study of Adolescent Behavioral Development: correlates, comorbidity, and genetics

BACKGROUND

This paper addresses bulimia symptoms in a large community sample of twins aged 8 to 17 years. We aim to identify environmental correlates of bulimia symptoms and relationships with other psychiatric disorder symptoms. The twin design allows examination of the structure of genetic and environmental effects.

METHODS

DSM-IIIR bulimia symptoms and consequential impairment were measured by interview in the first wave of the Virginia Twin Study of Adolescent Behavioral Development. Comorbidity with other psychiatric symptoms and environmental correlates were examined and the relative contributions of genes and environment were assessed using structural equation modeling.

RESULTS

An item-response theory model indicated that the range of bulimic symptoms represented a single underlying trait. Bulimia symptoms were more common in postmenarche girls and positively associated with body-mass index. Subdiagnostic symptomatology was associated with impairment in psychosocial functioning. Bulimia symptoms were strongly associated with other psychiatric disorders symptoms including anxiety and depression. Genetic model fitting identified strong additive genetic effects on the symptom score. Accounting for a potential violation of the equal environment assumption for identical and fraternal twins slightly reduced estimated genetic variance.

CONCLUSIONS

The pattern of comorbidity suggests overlap between bulimia symptoms and those of internalizing disorders. Substantial genetic variance (44%) was evident in the most conservative model.

"Diet pills" and major depression in the Canadian population

OBJECTIVE

To evaluate epidemiological associations between self-reported diet pill consumption and major depressive episodes (MDEs), using data from a large-scale, cross-sectional survey of the Canadian population.

METHODS

Data from the National Population Health Survey (NPHS) were used in this analysis. The NPHS interview included a brief version of the Composite International Diagnostic Interview (CIDI) depression section, known as the CIDI Short Form for Major Depression (CIDI-SFMD), as well as provision for self-reported medication use.

RESULTS

Approximately 0.5% of the population reported the use of diet pills. Diet pill use was more common among women than among men. At the time of data collection (1996-1997), the most commonly used medication was fenfluramine (since withdrawn from the market because of cardiovascular toxicity). The use of these medications was strongly associated with MDE: the annual prevalence among persons reporting use was 17.1% (95% CI, 8.6 to 25.6), approximately 4 times the underlying population rate.

CONCLUSIONS

Because the NPHS was a general health survey, and because self-reported exposure to these medications was relatively uncommon, the data did not permit a detailed multivariate analysis. These findings, however, indicate that depressive psychopathology is strongly associated with the use of appetite-suppressant medications.

Validating the Eating Disorder Inventory-2 (EDI-2) in Sweden

OBJECTIVE

To validate the Eating Disorder Inventory-2 (EDI-2) on a Swedish population by investigating differences between 1) young women with eating disorder symptoms (patients and non-patients), and normal controls and 2) patients with different eating disorder diagnoses, regarding symptom load and psychological characteristics. Another objective was to update EDI as a screening instrument

METHOD

Patients (n=194) with DSM-IV confirmed eating disorder diagnoses (anorexia nervosa AN; bulimia nervosa BN; eating disorder not otherwise specified, EDNOS) were compared vvith each other and with randomly selected and matched controls consisting of young women with self-reported eating disorder symptoms (n=51) and women without such symptoms (n=188).

RESULTS

In general, women vvith eating disorderproblems, whether or not they were patients, scored significantly higher on both symptoms and personality characteristics compared to normal controls. Patients with DSM verified eating disorders did not differ from women with self-reported eating disorders symptoms on body dissatisfaction, perfectionism and impulsiveness. Women with self-reported symptoms did not differ from women without symptoms on interpersonal distrust and maturity fears. Amongst the patient groups, BN patients scored highest, and AN patients lowest, on self-reported pathology. Most of the EDI-2 scales and all the three indexes had acceptable specificity and sensitivity.

CONCLUSION

EDI-2 discriminates well between women with eating disorder symptoms and normal controls, but responses from patients with AN should be interpreted with care. The EDI-2 indexes are especially recommended for screening purposes.

A comparison of male and female adolescents referred to an eating disorder program

OBJECTIVE

To compare gender-related psychopathology and psychiatric diagnoses in male and female adolescents referred to an adolescent eating disorder program.

METHOD

All adolescents presenting at the Eating Disorder Program at our hospital completed the semistructured Diagnostic Interview for Children and Adolescents-Revised (DICA-R) and self-report scales, including the Children's Depression Inventory (CDI), the Brief Symptom Inventory (BSI), the Eating Disorder Inventory (EDI-2), and the Family Assessment Measure (FAM-III), during their initial assessment. The 157 subjects (21 male, 136 female) were classified into Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) eating disorder (ED) subtypes and then recombined into male and female restricters (R) and ED-related groups: showing eating-related concerns but not having a DSM-IV diagnosis. We compared the male and female restricter groups and ED-related group on 5 specific psychological dimensions to examine comorbid psychiatric diagnosis, ED-specific and nonspecific psychopathology, EDI clinical and provisional subscales, and family functioning using multivariate analyses of covariance (MANCOVAs).

RESULTS

Males endorsed statistically significant lower drive for thinness and body dissatisfaction than did females. However, there are no representative norms for adolescent males on these variables. The ED-related group also endorsed statistically significant lower drive for thinness and body dissatisfaction (specific ED psychopathology) than did the ED-restricter groups. The males in both groups endorsed fewer EDI items than did their female counterparts, but the differences were not statistically significant. Comorbid psychiatric diagnoses of depression and anxiety in male and female restricters were common but did not distinguish the groups.

CONCLUSIONS

Our results suggest that male and female adolescents with EDs are clinically similar to each other and therefore resemble adults for lack of gender-specific effects on self-reported psychopathology, family functioning, and comorbid psychiatric disorders.